COVID-19 Treatment Recommendations for Hospitalized Patients
For hospitalized COVID-19 patients, corticosteroids are strongly recommended for those requiring oxygen support, while IL-6 receptor antagonists should be added for patients with increasing oxygen needs. 1
Oxygen Support and Respiratory Management
- Supplemental oxygen should be initiated when SpO2 is persistently below 94%, with a target range of 88-95% 2
- For patients with hypoxemic acute respiratory failure without immediate indication for invasive mechanical ventilation, high-flow nasal cannula (HFNC) or noninvasive CPAP delivered through either a helmet or facemask is suggested 1
- Prone positioning should be considered in awake patients who remain hypoxemic despite supplemental oxygen, with close monitoring for signs of deterioration 2
- Intubation decisions should be based primarily on signs of respiratory distress rather than refractory hypoxemia alone 2
- For intubated patients with refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O), prone positioning for 12-16 hours is recommended 2
Pharmacological Management
Corticosteroids
- Strong recommendation for corticosteroids in patients requiring oxygen, noninvasive ventilation, or invasive mechanical ventilation 1
- Dexamethasone 6 mg daily for 10 days is the standard regimen, shown to reduce mortality in patients requiring oxygen support 1
- Do not use corticosteroids in hospitalized patients not requiring supplemental oxygen as there is no mortality benefit and potential harm 1
IL-6 Receptor Antagonists
- Tocilizumab is indicated for hospitalized COVID-19 patients who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO 3
- Suggested for patients with increasing oxygen requirements and evidence of systemic inflammation 1
- Not recommended for patients not requiring supplemental oxygen 1
- Should be administered alongside corticosteroids for optimal effect 3
Anticoagulation
- Strong recommendation to offer some form of anticoagulation to all hospitalized COVID-19 patients 1
- For patients already on anticoagulation for atrial fibrillation:
Antiviral Therapy
- Remdesivir:
- No definitive recommendation for patients not requiring invasive mechanical ventilation 1
- Suggested against for patients requiring invasive mechanical ventilation 1
- Should be administered as early as possible in the disease course when indicated 4
- Standard dosing: 200 mg IV loading dose on day 1, followed by 100 mg IV daily 4
Treatments NOT Recommended
- Hydroxychloroquine - strong recommendation against use 1
- Azithromycin - conditional recommendation against use in the absence of bacterial infection 1
- Lopinavir-ritonavir - strong recommendation against use 1
- Hydroxychloroquine and azithromycin in combination - conditional recommendation against use 1
- Colchicine - conditional recommendation against use 1
- Interferon-β - conditional recommendation against use 1
Special Considerations
- For patients with acute coronary syndrome and COVID-19, dual antiplatelet therapy is recommended to reduce risk of recurrent ACS or death 1
- For patients on dual antiplatelet therapy receiving prophylactic-dose anticoagulant for COVID-19, continuation of DAPT is suggested 1
- For patients with stroke history on antiplatelet therapy, continue antiplatelet therapy and add prophylactic-dose LMWH 1
Common Pitfalls and Caveats
- Hypoxemia in COVID-19 is often remarkably well tolerated and should not alone trigger intubation 5, 2
- Patients may require oxygen therapy for extended periods (median 8 days), resulting in longer hospitalization times (median 12 days) 6
- Persistent systemic inflammation with elevated CRP levels may continue until discharge or death 6
- Sharing one ventilator for multiple patients is not recommended due to safety concerns 2
- The prognosis for elderly patients with high oxygen requirements and treatment limitations is poor 7