What is the treatment approach for patients with low-risk COVID-19 (Coronavirus Disease 2019)?

Treatment Approach for Low-Risk COVID-19 Patients

For patients with low-risk COVID-19, supportive care focusing on symptom management is the primary treatment approach, with antiviral therapy (nirmatrelvir/ritonavir) reserved for those with risk factors for progression to severe disease.

Supportive Care for Symptom Management

Managing Cough

• Encourage patients to avoid lying on their back as this makes coughing ineffective 1
• Use simple measures first, including honey (for patients aged over 1 year) 1
• For distressing cough, consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1
• Controlled breathing techniques including positioning, pursed-lip breathing, and breathing exercises may help 1

Managing Fever

• Advise patients to drink fluids regularly to avoid dehydration (no more than 2 liters per day) 1
• Fever is typically most common around five days after exposure to infection 1

General Management

• Put treatment escalation plans in place as patients may deteriorate rapidly and need urgent hospital admission 1
• Discuss risks, benefits, and possible outcomes of treatment options with patients and their families 1
• Document any advance care plans or advance decisions to refuse treatment 1
• Instruct patients on who to contact if symptoms worsen (e.g., NHS 111 online) 1

Antiviral Therapy for At-Risk Patients

Nirmatrelvir/Ritonavir (Paxlovid)

• Indicated for mild-to-moderate COVID-19 in adults at high risk for progression to severe disease 2
• Risk factors include: diabetes, overweight (BMI >25), chronic lung disease, chronic kidney disease, current smoker, immunosuppressive disease or treatment, cardiovascular disease, hypertension, sickle cell disease, neurodevelopmental disorders, active cancer, medically-related technological dependence, or age ≥60 years 2
• Treatment should be initiated as soon as possible after diagnosis and within 5 days of symptom onset 2
• Standard dosage: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), taken together twice daily for 5 days 2
• Dose adjustment required for patients with renal impairment 2
• Significant drug interactions must be assessed before prescribing due to ritonavir's strong CYP3A inhibition 2

Special Considerations

Immunocompromised Patients

• Effects of immunosuppression on COVID-19 development have not been fully established 1
• For immunosuppressed COVID-19-negative patients, no adjustment of immunosuppressant dose is necessary in advance 1
• For immunosuppressed COVID-19-positive patients 1:
  • Steroids or immunosuppressants can be used when potential benefits outweigh risks
  • Consider minimizing high-dose steroids while maintaining sufficient dose to avoid adrenal insufficiency
  • In cases of pneumonia aggravation, lymphopenia, and persisting fever, consider reducing or discontinuing azathioprine or mycophenolate
  • Calcineurin inhibitors may be reduced but should not be discontinued

Hospital Visits and Procedures

• Patients should minimize hospital visits to decrease infection risk 1
• Non-emergency procedures should be postponed for COVID-19 positive patients 1
• Consider remote medical support when possible 1

Discharge Criteria

• Two consecutive negative RT-PCR tests from respiratory tract samples 1
• Temperature returned to normal for more than 3 days 1
• Respiratory symptoms significantly improved 1
• Significant absorption of pulmonary chest lesions on CT imaging 1

Important Cautions

• Avoid hydroxychloroquine/chloroquine as evidence does not support their use and may increase mortality 3
• Do not use combinations of three or more antiviral drugs simultaneously 1
• Be aware that older patients or those with comorbidities, frailty, impaired immunity, or reduced ability to cough are more likely to develop severe pneumonia 1
• Patients may deteriorate rapidly, requiring close monitoring and prompt escalation of care when needed 1

Remember that most patients with COVID-19 have mild or moderate disease, with only 5-10% progressing to severe or life-threatening disease 4. Early identification of deterioration and appropriate supportive care remain the cornerstones of management for low-risk patients.