What are the treatment options for COVID-19?

COVID-19 Treatment

For hospitalized COVID-19 patients requiring oxygen or ventilatory support, administer dexamethasone 6 mg daily for up to 10 days, as this provides a mortality benefit; avoid corticosteroids in patients not requiring oxygen, as they may be harmful. 1

Treatment by Disease Severity

Mild Disease (SpO2 ≥94% on room air, no respiratory distress)

Non-hospitalized high-risk patients:

• Initiate remdesivir within 7 days of symptom onset for patients at high risk of progression to severe disease 2
• Treatment duration: 3 days total 2
• Dosing: 200 mg IV loading dose on Day 1, then 100 mg IV daily maintenance (adults and pediatric patients ≥40 kg) 2
• Consider anti-SARS-CoV-2 monoclonal antibodies if available for high-risk patients 1

Symptomatic management:

• Honey for cough (patients >1 year old) 3
• For distressing cough: short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 3
• Encourage patients to avoid lying on their back, as this makes coughing ineffective 3
• Controlled breathing techniques including positioning, pursed-lip breathing, and breathing exercises 3
• Regular fluid intake to avoid dehydration (no more than 2 liters per day) for fever management 3

Moderate to Severe Disease (SpO2 <94% on room air, requiring oxygen)

Corticosteroid therapy (FIRST-LINE):

• Dexamethasone 6 mg daily for up to 10 days 1
• This provides a 3% reduction in mortality in patients requiring oxygen therapy 3
• Critical pitfall: Do NOT use corticosteroids in patients not requiring oxygen, as detrimental effects have been observed 3, 1

Antiviral therapy:

• Remdesivir for hospitalized patients not requiring mechanical ventilation 1, 2
• Treatment duration: 5 days initially; may extend up to 10 days total if no clinical improvement 2
• Dosing: 200 mg IV loading dose on Day 1, then 100 mg IV daily (adults and pediatric patients ≥40 kg) 2

Anticoagulation:

• Prophylactic-dose anticoagulation for all hospitalized patients requiring oxygen 1

Respiratory support:

• Consider high-flow nasal cannula or CPAP for hypoxemic respiratory failure without immediate indication for intubation 1
• Do NOT delay intubation when non-invasive respiratory support fails 1

Critical Disease (Requiring mechanical ventilation/ECMO)

Corticosteroids:

• Dexamethasone 6 mg daily for up to 10 days 1
• Mortality benefit demonstrated in patients requiring mechanical ventilation 1

Remdesivir:

• Treatment duration: 10 days total for patients requiring invasive mechanical ventilation and/or ECMO 2
• Same dosing as above 2

Immunomodulatory therapy:

• Consider tocilizumab or sarilumab (anti-IL-6 agents) if worsening despite dexamethasone 3
• Consider anakinra (anti-IL-1) as alternative 3

Anticoagulation:

• Continue prophylactic-dose anticoagulation 1
• Monitor for thromboembolism (stroke, DVT, PE, acute coronary syndrome) 3

Treatments to AVOID

Do NOT use the following (no benefit or potential harm):

• Hydroxychloroquine 1
• Lopinavir-ritonavir 1
• Azithromycin 1
• Colchicine 1
• Interferon-β 1
• Routine antibiotics without clinical suspicion of bacterial infection 3, 1

Special Populations

Immunocompromised patients (hematological malignancies, transplant recipients):

• Consider anti-SARS-CoV-2 monoclonal antibodies if available 3, 1
• Convalescent plasma may be considered 3
• Antiviral treatment may be useful in patients with prolonged viral replication 3
• Long-acting anti-SARS-CoV-2 monoclonal antibodies (AZD7442) for high-risk patients 3

Essential Monitoring and Care Planning

Before and during treatment:

• Perform hepatic laboratory testing before starting and during remdesivir therapy 2
• Determine prothrombin time before starting and monitor during remdesivir therapy 2
• Monitor high-sensitivity troponin and continuous ECG for suspected myocardial injury 3
• Monitor blood pressure, heart rate, and fluid balance 3

Treatment escalation planning:

• Establish treatment escalation plans immediately, as patients may deteriorate rapidly and need urgent hospital admission 3
• Document advance care plans and do-not-resuscitate decisions for patients with pre-existing advanced comorbidities 3
• Identify patients at higher risk: older age, comorbidities, frailty, impaired immunity, or reduced ability to cough and clear secretions 3

Rehabilitation and Supportive Care

Early rehabilitation:

• Implement rehabilitation care as soon as patients are stable 1
• Pulmonary rehabilitation training for potential impaired pulmonary function 3
• Non-drug treatments: Tai Chi, breathing relaxation training, mindfulness training, cognitive behavioral therapy 3

Psychological support:

• Provide mental health interventions for anxiety, fear, depression, and somatization symptoms 3, 1
• Psychological counseling and mental health education 3

Critical Pitfalls to Avoid

• Never delay corticosteroid therapy in patients requiring oxygen 1
• Never use corticosteroids in patients not requiring oxygen 1
• Never use routine antibiotics without evidence of bacterial infection 1
• Never delay intubation when non-invasive respiratory support fails 1
• Never overlook anticoagulation in hospitalized patients 1
• Never administer remdesivir by any route other than IV infusion 2