What are the treatment options for COVID-19 patients in the hospital?

Treatment Options for COVID-19 Patients in the Hospital

Hospitalized COVID-19 patients should receive treatment based on disease severity, with corticosteroids being the cornerstone therapy for those requiring oxygen support, along with appropriate respiratory support, anticoagulation, and consideration of IL-6 receptor antagonists for severe cases. 1, 2

Disease Classification and Treatment Algorithm

Disease severity guides treatment decisions:

• Mild disease: Symptoms without respiratory distress or abnormal imaging

  • Supportive care only 2
  • For high-risk patients: Consider anti-SARS-CoV-2 monoclonal antibodies if available 2

• Moderate disease: Lower respiratory disease with SpO2 ≥94% on room air

  • Prophylactic anticoagulation 2
  • Consider remdesivir (no strong recommendation for or against) 1
  • Avoid corticosteroids 1, 2

• Severe disease: SpO2 <94% on room air, requiring oxygen

  • Dexamethasone 6 mg daily for up to 10 days (strong recommendation) 1, 2
  • Consider IL-6 receptor antagonists (tocilizumab) 1, 3
  • Anticoagulation 1, 2
  • Appropriate oxygen delivery methods 1, 2

• Critical disease: Requiring ICU or mechanical ventilation

  • Dexamethasone 6 mg daily for up to 10 days 1, 2
  • IL-6 receptor antagonists (tocilizumab) 1, 3
  • Anticoagulation 1, 2
  • Consider HFNC or CPAP for hypoxemic respiratory failure 1, 2
  • Mechanical ventilation when non-invasive support fails 2, 4

Specific Therapeutic Agents

Corticosteroids

• Strong recommendation for dexamethasone 6 mg daily for 10 days in patients requiring oxygen or ventilatory support 1
• Mortality benefit is most significant in mechanically ventilated patients (41.4% vs 29.3%) and those requiring oxygen (26.2% vs 23.3%) 1
• Strong recommendation against corticosteroids in hospitalized patients not requiring oxygen 1

IL-6 Receptor Antagonists

• Conditional recommendation for tocilizumab in patients requiring oxygen or ventilatory support 1
• FDA-approved for hospitalized COVID-19 patients receiving systemic corticosteroids and requiring supplemental oxygen, non-invasive/invasive mechanical ventilation, or ECMO 3
• Conditional recommendation against use in patients not requiring oxygen 1

Anticoagulation

• Strong recommendation for some form of anticoagulation in all hospitalized patients 1
• For patients with atrial fibrillation requiring anticoagulation: Switch to therapeutic-dose LMWH or UFH if oral anticoagulation needs to be discontinued 1
• Consider therapeutic-dose anticoagulation for selected patients with high thrombotic risk 1

Respiratory Support

• Conditional recommendation for HFNC or CPAP delivered through helmet or facemask for hypoxemic respiratory failure without immediate indication for intubation 1, 2
• Timely tracheal intubation when non-invasive support fails 5, 4
• Oxygen supplementation to maintain SpO2 >90-96% 6, 7

Treatments NOT Recommended

• Strong recommendations against:

  • Hydroxychloroquine 1
  • Lopinavir-ritonavir 1

• Conditional recommendations against:

  • Azithromycin (unless bacterial infection is present) 1
  • Azithromycin and hydroxychloroquine combination 1
  • Colchicine 1
  • Interferon-β 1
  • Remdesivir in patients requiring invasive mechanical ventilation 1

Supportive Care

• Early mobilization when patients are stable 2, 8
• Psychological support for anxiety, fear, and depression 2
• Antibiotics only when there is clinical evidence of bacterial infection 1, 2
• Prone positioning for patients with severe hypoxemia 8
• Monitor for co-infections and treat appropriately 8

Common Pitfalls to Avoid

• Delaying corticosteroid therapy in patients requiring oxygen 2
• Using corticosteroids in patients not requiring oxygen 1, 2
• Routine use of antibiotics without evidence of bacterial infection 2
• Delaying intubation when non-invasive respiratory support fails 2, 5
• Overlooking the need for anticoagulation 1, 2
• Underestimating hypoxemia due to absence of dyspnea in some patients 7