What is the treatment for Coronavirus disease (COVID-19)?

Treatment for COVID-19

The recommended treatment for COVID-19 should be initiated as soon as possible after diagnosis of symptomatic COVID-19, with a stepwise approach based on disease severity to reduce progression to severe disease and mortality. 1

Disease Severity Classification

COVID-19 severity is categorized as:

• Mild: Various symptoms without respiratory distress
• Moderate: Lower respiratory disease and SpO2 ≥94% on room air
• Severe: SpO2 <94% on room air
• Critical: Requires ICU admission or mechanical ventilation

Treatment Approach by Disease Severity

Non-Hospitalized Patients (Mild-to-Moderate Disease)

For patients at high risk for progression to severe disease:

1. Antiviral therapy:

   • Nirmatrelvir-ritonavir: 300 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days 1
   • Remdesivir: 200 mg IV on Day 1, followed by 100 mg IV daily for 2 additional days (total 3 days) 1, 2
   • Must be initiated within 7 days of symptom onset 1, 2

2. Supportive care:

   • Adequate hydration
   • Symptomatic treatment for fever and pain
   • Close monitoring for clinical deterioration

Hospitalized Patients Not Requiring Mechanical Ventilation

1. Oxygen therapy:

   • Target SpO2 ≥94% (or 90-96% in patients at risk of hypercapnic respiratory failure) 1
   • Delivery methods include low-flow nasal cannula, high-flow nasal cannula (HFNC), or non-invasive ventilation (NIV) as needed 1

2. Pharmacological therapy:

   • Remdesivir: 200 mg IV on Day 1, followed by 100 mg IV daily for 4 additional days (total 5 days) 1, 2
   • Corticosteroids (for patients requiring oxygen): Dexamethasone 6 mg daily for up to 10 days 1
   • Anticoagulation: Prophylactic dose for all hospitalized patients 1
   • IL-6 receptor antagonists (tocilizumab): For patients with elevated inflammatory markers 1

3. Positioning:

   • Consider awake prone positioning for patients on HFNC or NIV 1

Hospitalized Patients Requiring Mechanical Ventilation/ECMO

1. Ventilation strategies:

   • Low tidal volume ventilation 1
   • ECMO for refractory hypoxemia

2. Pharmacological therapy:

   • Remdesivir: 200 mg IV on Day 1, followed by 100 mg IV daily for up to 9 additional days (total 10 days) 1, 2
   • Corticosteroids: Dexamethasone 6 mg daily for up to 10 days 1
   • Anticoagulation: Prophylactic dose with consideration of intensified prophylaxis for additional risk factors 1
   • IL-6 receptor antagonists (tocilizumab): For patients with elevated inflammatory markers 1

Special Considerations

Pediatric Patients

For pediatric patients weighing 1.5 kg to less than 40 kg, remdesivir dosing should be weight-based:

• For patients less than 28 days old: 2.5 mg/kg loading dose, then 1.25 mg/kg daily 2
• For patients at least 28 days old: 5 mg/kg loading dose, then 2.5 mg/kg daily 2

Renal Impairment

No dosage adjustment of remdesivir is recommended in patients with any degree of renal impairment, including patients on dialysis 2

Monitoring

• Perform hepatic laboratory testing before starting remdesivir and during treatment 2
• Determine prothrombin time before starting remdesivir and monitor during treatment 2
• Monitor for infusion-related reactions 2

Rehabilitation and Follow-up

1. Early rehabilitation:

   • Pulmonary rehabilitation training for impaired pulmonary function
   • Breathing exercises
   • Gradual increase in physical activity 1

2. Follow-up:

   • Schedule virtual follow-up 1-2 weeks after diagnosis 1
   • Monitor for long-term complications and adjust treatment plan as needed

Important Caveats

• Treatment should be initiated as early as possible after diagnosis for optimal outcomes 3, 1
• The "hit early-hit hard" principle with antivirals is crucial as they are most effective when administered shortly after symptom onset 3
• Antiviral drugs administered early can shorten the course of clinical illness and reduce viral shedding 3
• Corticosteroids should NOT be used in patients not requiring oxygen 1
• Remdesivir is the only FDA-approved antiviral agent specifically for COVID-19 treatment 2, 4
• Psychological support should be provided for patients with serious COVID-19 1

The treatment of COVID-19 continues to evolve as new evidence emerges. This approach represents the current best practice based on the most recent and highest quality evidence available.