What are the initial treatment recommendations for Covid-19 patients?

Initial Treatment Recommendations for COVID-19 Patients

For COVID-19 patients, the initial treatment should include systemic corticosteroids for those requiring supplementary oxygen or ventilatory support, and appropriate anticoagulation for all hospitalized patients, while avoiding hydroxychloroquine and lopinavir-ritonavir which have shown no benefit. 1

Treatment Based on Disease Severity

Mild to Moderate COVID-19 (Outpatients)

• Treatment should be initiated as soon as possible after diagnosis and within 7 days of symptom onset 2
• For non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease, remdesivir is recommended for a total treatment duration of 3 days 2
• For patients not at high risk, consider a case-by-case approach for DMARD modifications if the patient is on immunosuppressive therapy 1
• Anti-SARS-CoV-2 monoclonal antibodies are recommended for pre-exposure prophylaxis in unimmunized patients at risk for severe COVID-19 1

Moderate to Severe COVID-19 (Hospitalized, Not in ICU)

• Systemic corticosteroids (dexamethasone) are strongly recommended for patients requiring supplementary oxygen 1
• Anticoagulation is recommended for all hospitalized patients 1
• Consider high-flow nasal oxygen or continuous positive airway pressure in patients with hypoxemic respiratory failure 1
• Remdesivir is recommended for a treatment duration of 5 days; may be extended up to 10 days if no clinical improvement is observed 2
• IL-6 receptor antagonist monoclonal antibody treatment can be considered, especially in patients with evidence of systemic inflammation 1

Critical COVID-19 (ICU, Mechanical Ventilation, or ECMO)

• Systemic corticosteroids (dexamethasone) are strongly recommended 1
• Remdesivir is recommended for a total treatment duration of 10 days 2
• For patients with COVID-19-related inflammation, consider adding a second immunosuppressant such as anti-IL-6 (tocilizumab, sarilumab) or anti-IL-1 (anakinra) 1
• Therapeutic-dose anticoagulation should be considered 1

Specific Medications

Corticosteroids

• Dexamethasone is recommended for patients requiring oxygen or ventilatory support 1
• Decreases mortality in patients with severe or critical COVID-19 3
• Should not be used in mild disease without hypoxemia 1

Antivirals

• Remdesivir is FDA-approved for both hospitalized and non-hospitalized patients 2
• Dosing for adults and pediatric patients ≥40 kg: 200 mg IV loading dose on day 1, followed by 100 mg IV daily 2
• Pediatric dosing is weight-based for patients <40 kg 2
• Perform hepatic laboratory testing and assess prothrombin time before starting and during treatment 2

Anticoagulation

• Prophylactic-dose anticoagulation is recommended for all hospitalized patients 1
• Consider therapeutic-dose anticoagulation in patients with additional risk factors (obesity, known thrombophilia, intensive care treatment, or elevated D-dimers) 3
• For patients already on anticoagulants for conditions like atrial fibrillation, consider switching to therapeutic dose LMWH or UFH during hospitalization 1

Immunomodulators

• IL-6 inhibitors (tocilizumab, sarilumab) can be considered for patients with evidence of systemic inflammation who are worsening despite dexamethasone 1
• JAK inhibitors (baricitinib/tofacitinib) may be beneficial in selected patients with COVID-19-related inflammation 1

Special Considerations

Patients with Comorbidities

• For patients with atrial fibrillation, therapeutic anticoagulation is recommended regardless of CHA2DS2-VASc score if hospitalized 1
• In patients with peripheral artery disease, continue antiplatelet therapy if on prophylactic-dose anticoagulation; individualize decision if on therapeutic-dose anticoagulation 1
• For patients with hematological malignancies, follow specific recommendations including early use of monoclonal antibodies and convalescent plasma 1

Monitoring and Testing

• Perform hepatic laboratory testing in all patients before starting and during treatment with remdesivir 2
• Monitor prothrombin time before starting remdesivir and during treatment as clinically appropriate 2
• Consider serial procalcitonin measurement in hospitalized patients, especially in critically ill or ICU patients under mechanical ventilation, to guide antibiotic therapy decisions 1

Treatments to Avoid

• Hydroxychloroquine alone or in combination with azithromycin is strongly recommended against 1, 4
• Lopinavir-ritonavir is strongly recommended against 1
• Routine antifungal prophylaxis is not recommended in COVID-19 patients 1
• Antibiotics should be restricted in mild-to-moderately ill patients with COVID-19 infection, especially in those with low initial procalcitonin levels (<0.25 ng/mL) 1

Pitfalls and Caveats

• Delayed initiation of treatment can lead to worse outcomes; treatment should be started as soon as possible after diagnosis 2
• Overuse of antibiotics in COVID-19 patients without bacterial co-infection contributes to antimicrobial resistance 1
• Immunosuppressants may mask certain COVID-19 symptoms such as fever; IL-6 inhibitors and JAK inhibitors decrease acute phase response regardless of clinical course 1
• Patients with initially mild symptoms may experience sudden worsening; close monitoring is essential 1