What is the treatment approach for SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)?

Treatment Approach for SARS-CoV-2 (COVID-19)

For patients with COVID-19, a combination of systemic glucocorticoids and tocilizumab is recommended for those requiring oxygen therapy, as this approach reduces disease progression and mortality. 1

Treatment Based on Disease Severity

Non-hospitalized Patients

• For non-hospitalized patients with SARS-CoV-2 infection, there is currently no evidence to support the initiation of immunomodulatory therapy 1
• In patients at high risk for severe COVID-19 with symptom onset <5 days or who are still seronegative, monoclonal antibodies against SARS-CoV-2 spike protein should be considered 1
• Remdesivir is FDA-approved for non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease 2
• Early antiviral treatment significantly reduces the risk of disease progression 3

Hospitalized Patients Not Requiring Oxygen

• For hospitalized patients who do not require oxygen therapy, there is no evidence to support the initiation of immunomodulatory therapy to treat COVID-19 1
• Routine deferral of chemotherapy in all asymptomatic SARS-CoV-2 positive patients with hematological malignancies is not advisable, with treatment decisions based on individual risk-benefit assessment 1

Hospitalized Patients Requiring Oxygen

• In patients requiring supplemental oxygen, non-invasive or mechanical ventilation, systemic glucocorticoids should be used as they decrease mortality; most evidence concerns dexamethasone 1
• The combination of glucocorticoids and tocilizumab should be considered since it reduces disease progression and mortality 1
• The combination of glucocorticoids with baricitinib or tofacitinib could be considered as it might decrease disease progression and mortality 1
• Remdesivir is FDA-approved for hospitalized patients with COVID-19 2

Severe COVID-19 with ARDS

• For COVID-19-related ARDS, lung-protective ventilation strategies are recommended, including low tidal volume ventilation (4-8 mL/kg), targeting plateau pressures <30 cm H₂O, and implementing higher PEEP (>10 cm H₂O) 4
• Prone positioning for 12-16 hours is recommended for mechanically ventilated patients with moderate to severe ARDS 4
• A conservative fluid strategy is recommended rather than liberal fluid management 4

Medications to Avoid or Use with Caution

• Hydroxychloroquine should be avoided for treating any stage of SARS-CoV-2 infection since it does not provide additional benefit to standard care and could worsen prognosis, particularly if co-prescribed with azithromycin 1
• There is no robust evidence to support the use of anakinra or canakinumab at any disease stage 1
• There is no robust evidence to support the use of low-dose colchicine at any disease stage 1
• In patients without hypogammaglobulinemia and with symptom onset >5 days, there is robust evidence against the use of convalescent plasma 1

Special Populations

Patients with Rheumatic and Musculoskeletal Diseases

• In patients with rheumatic and musculoskeletal diseases, continuing JAK2-inhibitors and TKI/BTKi during COVID-19 is recommended 1
• Ensure clinical and virological resolution of COVID-19 before resuming chemotherapy in patients with rheumatic diseases 1

Patients with Hematological Malignancies

• Patients with hematological malignancies, particularly lymphoproliferative disorders, are at higher risk for severe COVID-19 1
• Cellular therapy (HSCT, CAR-T) should be deferred in patients with COVID-19 or asymptomatic SARS-CoV-2 infection 1

Diagnostic Considerations

• SARS-CoV-2 molecular NAT assays are recommended for diagnosis, targeting at least two distinct viral gene sequences 1
• Lower respiratory tract fluid sampling is recommended in patients with symptoms/signs of lower respiratory tract infection and negative nasopharyngeal swab tests 1
• Testing for other pathogens should be performed in symptomatic patients with negative SARS-CoV-2 tests to rule out superinfection, which is a common complication 1

Treatment Pitfalls and Caveats

• The "hit early-hit hard" principle with antivirals is crucial, as early administration can shorten the course of clinical illness and reduce viral shedding 1, 3
• Immunosuppression reduction should be considered carefully, as possible disadvantages like immune reconstitution syndrome may occur 1
• High-dose steroids are generally associated with prolonged viral shedding in respiratory viral infections, but low-dose steroids (<1 mg/kg/day) have shown benefit in COVID-19 1, 4
• Empiric antimicrobial/antibacterial agents should be considered for mechanically ventilated COVID-19 patients with respiratory failure, with daily assessment for de-escalation 4

The treatment of COVID-19 continues to evolve as new evidence emerges. The approach should be tailored based on disease severity, with early intervention with antivirals in high-risk patients and appropriate immunomodulatory therapy for those requiring oxygen support.