What are the treatment recommendations for Covid-19?

Treatment Recommendations for COVID-19

The treatment of COVID-19 should be tailored according to disease severity, with corticosteroids strongly recommended for patients requiring oxygen or ventilatory support, while patients with mild disease who don't require supplemental oxygen should receive supportive care and possibly antiviral therapy if at high risk for progression. 1

Disease Classification and Initial Assessment

• COVID-19 severity is classified as mild, moderate, severe, or critical based on clinical presentation and oxygen requirements 1
• Mild illness: symptoms without respiratory distress or abnormal imaging 1
• Moderate illness: lower respiratory disease with SpO2 ≥94% on room air 1
• Severe illness: SpO2 <94% on room air, PaO2/FiO2 <300 mmHg, respiratory rate >30 breaths/min, or lung infiltrates >50% 1
• Critical illness: requiring ICU admission or mechanical ventilation, may include ARDS or septic shock 1

Treatment Recommendations by Disease Severity

For Non-Hospitalized Patients (Mild Disease)

• Remdesivir is indicated for non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease 2
• Treatment should be initiated as soon as possible after diagnosis 2
• For high-risk patients, consider anti-SARS-CoV-2 monoclonal antibodies if available 1
• Avoid routine antibiotics unless there is clinical suspicion of bacterial infection 1

For Hospitalized Patients Not Requiring Oxygen

• Supportive care is the mainstay of treatment 3, 4
• Corticosteroids are NOT recommended for patients not requiring supplemental oxygen 1
• Remdesivir may be considered, though no definitive recommendation is made for this group 1
• The recommended treatment duration with remdesivir is 5 days 2

For Hospitalized Patients Requiring Oxygen (Non-ICU)

• Corticosteroids (dexamethasone 6 mg daily) are strongly recommended 1
• Consider IL-6 receptor antagonist monoclonal antibody therapy 1
• Remdesivir may be considered (no definitive recommendation) 1
• Prophylactic-dose anticoagulation is recommended 1
• For patients on antiplatelet therapy for previous stroke, continue antiplatelet therapy and add prophylactic-dose LMWH 1

For Critically Ill Patients (ICU/Requiring Mechanical Ventilation)

• Corticosteroids are strongly recommended 1
• Consider IL-6 receptor antagonist if COVID-19-related inflammation is present 1
• Remdesivir is not recommended for patients requiring invasive mechanical ventilation 1
• Therapeutic anticoagulation should be considered based on individual risk assessment 1
• Low tidal volume ventilation, prone positioning for refractory hypoxemia 1

Specific Therapeutic Agents

Corticosteroids

• Dexamethasone 6 mg daily for up to 10 days is recommended for patients requiring oxygen or ventilatory support 1
• Provides mortality benefit in patients requiring oxygen (26.2% vs 23.3%) and mechanical ventilation (41.4% vs 29.3%) 1
• NOT recommended for patients not requiring oxygen (may increase mortality) 1

Remdesivir

• FDA-approved for treatment of COVID-19 in adults and pediatric patients (≥1.5 kg) 2
• Adult dosing: 200 mg IV on day 1, followed by 100 mg IV daily 2
• Pediatric dosing (1.5 kg to <40 kg): weight-based dosing 2
• Duration: 5 days for non-ventilated patients; may extend to 10 days if no improvement 2
• Not recommended for patients requiring invasive mechanical ventilation 1

Anticoagulation

• All hospitalized COVID-19 patients should receive some form of anticoagulation 1
• For patients on oral anticoagulation for atrial fibrillation, consider switching to therapeutic dose LMWH or UFH during hospitalization 1
• For new-onset atrial fibrillation in hospitalized patients, therapeutic-dose parenteral anticoagulation is suggested 1

Medications NOT Recommended

• Hydroxychloroquine (strong recommendation against) 1
• Lopinavir-ritonavir (strong recommendation against) 1
• Azithromycin (conditional recommendation against) 1
• Colchicine for hospitalized patients (conditional recommendation against) 1
• Interferon-β (conditional recommendation against) 1

Supportive Care and Management of Complications

• Routine antibiotics are NOT recommended unless there is clinical evidence of bacterial infection 1
• For patients requiring oxygen, consider high-flow nasal cannula or CPAP for hypoxemic respiratory failure without immediate indication for intubation 1
• Early rehabilitation care should be implemented when patients are stable 1
• Psychological support and mental health interventions are recommended for anxiety, fear, and depression 1

Special Considerations

• For patients with hematological malignancies or immunocompromised status, treatment may include monoclonal antibodies, convalescent plasma, or other specific therapies 1
• For patients with COVID-19 associated mucormycosis, liposomal amphotericin B is the primary therapy of choice 1
• Patients with COVID-19 associated fungal infections require specific antifungal therapies 1

Common Pitfalls to Avoid

• Delaying corticosteroid therapy in patients requiring oxygen 1
• Using corticosteroids in patients not requiring oxygen 1
• Routine use of antibiotics without evidence of bacterial infection 1
• Delaying intubation when non-invasive respiratory support fails 1
• Overlooking the need for anticoagulation in hospitalized patients 1