What is the treatment for individuals presenting with current Covid-19 symptoms?

Treatment for Individuals with Current COVID-19 Symptoms

For individuals presenting with current COVID-19 symptoms, treatment should focus on symptom management, with specific medications and interventions based on disease severity, while monitoring for clinical deterioration that may require hospital admission.

General Management Approach

• Put treatment escalation plans in place early, as patients with COVID-19 may deteriorate rapidly and require urgent hospital admission 1
• Discuss risks, benefits, and likely outcomes of treatment options with patients and their families to establish preferences about treatment and escalation plans 1
• For patients with pre-existing advanced comorbidities, determine if they have advance care plans or advance decisions to refuse treatment 1

Managing Specific Symptoms

Cough Management

• Encourage patients with cough to avoid lying on their back as this makes coughing ineffective 1
• Start with simple measures such as 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

Fever Management

• Be aware that fever typically peaks around five days after exposure to infection 1
• Advise patients to maintain adequate hydration (no more than 2 liters per day) 1
• Recommend paracetamol for fever and associated symptoms, continuing only while symptoms persist 1
• Do not use antipyretics solely to reduce body temperature 1
• Paracetamol is preferred over NSAIDs for patients with COVID-19 until more evidence is available 1

Breathlessness Management

• Implement controlled breathing techniques including:
  • Proper positioning (sitting upright to increase ventilation)
  • Pursed-lip breathing (inhaling through nose, exhaling slowly through pursed lips)
  • Relaxing shoulders to reduce hunched posture associated with anxiety
  • Leaning forward with arms bracing a chair to improve ventilatory capacity 1
• For moderate to severe breathlessness in end-of-life care, consider opioids with appropriate dosing based on prior opioid exposure 1

Treatment Based on Disease Severity

Mild COVID-19

• For non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for disease progression:
  • Initiate treatment as soon as possible after diagnosis and within 7 days of symptom onset 2
  • Remdesivir is recommended with a 3-day treatment course (200mg IV on day 1, followed by 100mg IV daily for 2 more days) 2
  • Consider anti-SARS-CoV-2 monoclonal antibodies for high-risk patients 1
  • Inhaled interferon β-1a may be considered 1

Moderate COVID-19 (requiring oxygen, saturation >90%)

• Remdesivir is recommended 1, 2
• Dexamethasone is recommended 1
• For seronegative patients, consider casirivimab/imdevimab or convalescent plasma 1

Severe COVID-19 (saturation <90-94%, respiratory rate >30/min)

• Dexamethasone is strongly recommended 1
• Remdesivir should be administered (200mg IV on day 1, followed by 100mg IV daily) 1, 2
• For patients with COVID-19-related inflammation who are worsening despite dexamethasone, consider adding a second immunosuppressant:
  • Anti-IL-6 (tocilizumab, sarilumab)
  • Anti-IL-1 (anakinra)
  • JAK inhibitor (baricitinib/tofacitinib) 1

Critical COVID-19 (ARDS, sepsis, mechanical ventilation)

• For patients requiring invasive mechanical ventilation or ECMO, the recommended remdesivir treatment duration is 10 days 2
• For hospitalized patients not requiring invasive mechanical ventilation or ECMO, the recommended treatment duration is 5 days, with possible extension up to 10 days if no clinical improvement 2
• Dexamethasone is strongly recommended 1

Special Considerations

Antibiotic Use

• While routine antibiotics are not recommended for mild COVID-19, they should be considered if bacterial superinfection cannot be ruled out, particularly in patients with deteriorating condition 1
• Appropriate antibiotics for community-acquired pneumonia include amoxicillin, azithromycin, or fluoroquinolones 1

Monitoring Requirements

• Perform hepatic laboratory testing before starting remdesivir and during treatment as clinically appropriate 2
• Assess prothrombin time before starting remdesivir and monitor as clinically appropriate 2
• For patients on potentially hepatotoxic medications, monitor liver tests twice weekly 1

Renal Impairment

• No dosage adjustment of remdesivir is recommended in patients with any degree of renal impairment, including those on dialysis 2

Pitfalls and Caveats

• Do not delay treatment initiation in high-risk patients, as early intervention is associated with better outcomes 2
• Be aware that older patients or those with comorbidities, frailty, impaired immunity, or reduced ability to cough are more likely to develop severe pneumonia, which could lead to respiratory failure and death 1
• Severe breathlessness often causes anxiety, which can further increase breathlessness, creating a vicious cycle 1
• Patients with mild symptoms may still have severe radiologic features and risk of sudden deterioration 1
• Off-label COVID-19 treatments should be withheld in cases of moderate-to-severe liver injury 1