What are the treatment options for symptoms of a new COVID-19 strain?

COVID-19 Symptom Management

For symptomatic COVID-19 patients, implement supportive care with paracetamol for fever, honey or short-term opioids for distressing cough, controlled breathing techniques for dyspnea, and consider remdesivir for hospitalized patients or high-risk non-hospitalized patients, while monitoring for clinical deterioration that may require treatment escalation. 1, 2

Clinical Presentation

The typical symptoms of COVID-19 include:

• Fever remains the most characteristic symptom, occurring in approximately 88% of confirmed cases 3, 4
• Cough (typically dry), fatigue, and dyspnea are common respiratory manifestations 3
• Nasal congestion, runny nose, or other upper respiratory symptoms may occur with or without the classic triad 3
• Dyspnea is the only symptom significantly associated with severe disease (OR 2.43,95% CI: 1.52-3.89), making it a critical warning sign requiring immediate attention 4

Initial Assessment and Risk Stratification

Immediately evaluate patients for signs of severe disease:

• Shortness of breath, moist rales in lungs, weakened breath sounds, or altered mental status indicate potential severe pneumonia 3
• Patients with comorbidities, frailty, impaired immunity, or reduced ability to cough are at higher risk for severe pneumonia and require closer monitoring 1
• Establish treatment escalation plans early, as COVID-19 patients may deteriorate rapidly and require urgent hospital admission 1

Pharmacological Symptom Management

Fever and General Symptoms

• Recommend paracetamol for fever and other symptoms that antipyretics would help treat, continuing only while symptoms persist 1
• Advise patients to drink fluids regularly to avoid dehydration, with a maximum of 2 liters per day 1

Cough Management

• Start with simple measures first: encourage patients to avoid lying on their back as this makes coughing ineffective 1
• Use honey for patients aged over 1 year as an initial approach 1
• For distressing cough unresponsive to simple measures, use short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1

Dyspnea Management

• Implement controlled breathing techniques including proper positioning, pursed-lip breathing, and relaxing/dropping shoulders to reduce hunched posture from anxiety 1
• For end-of-life patients with moderate to severe breathlessness, use morphine sulfate immediate-release or modified-release with concomitant antiemetic and regular stimulant laxative 1

Antiviral Therapy: Remdesivir

Remdesivir is the FDA-approved antiviral for COVID-19 treatment in specific populations 2:

Indications

• Hospitalized patients of any severity 2
• Non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease, including hospitalization or death 2

Dosing

For adults and pediatric patients ≥40 kg:

• Loading dose: 200 mg IV on Day 1 2
• Maintenance: 100 mg IV once daily from Day 2 2

For pediatric patients 1.5 kg to <40 kg:

• Weight-based dosing applies (refer to specific weight-based tables) 2

Treatment Duration

• Hospitalized patients on invasive mechanical ventilation/ECMO: 10 days total 2
• Hospitalized patients not requiring invasive support: 5 days, extendable to 10 days if no clinical improvement 2
• Non-hospitalized high-risk patients: 3 days total, initiated within 7 days of symptom onset 2

Monitoring Requirements

• Perform hepatic laboratory testing before starting and during treatment as clinically appropriate 2
• Assess prothrombin time before starting and monitor as needed 2
• Discontinue if ALT >10× upper limit of normal, or if ALT elevation accompanied by signs/symptoms of liver inflammation 2

Administration Precautions

• Administer via IV infusion over 30-120 minutes 2
• Slower infusion rates (up to 120 minutes) can prevent hypersensitivity reactions 2
• Monitor patients during infusion and observe for at least one hour after completion for hypersensitivity signs 2
• Must be administered in settings with immediate access to medications for treating severe reactions and ability to activate emergency medical services 2

Respiratory Support

Oxygen Therapy Principles

• Provide supplemental oxygen to maintain peripheral blood oxygenation >90-96% 5, 6
• Use non-rebreather masks when possible to minimize aerosol generation 7
• Be aware that all oxygen delivery devices (nasal cannulas, simple face masks, venturi masks) have aerosol-generating potential requiring appropriate PPE 7

Advanced Respiratory Support

• High-flow nasal oxygen (HFNO) is preferred for patients with higher oxygen support requirements 7
• Non-invasive positive pressure ventilation may be used but carries higher risk of nosocomial transmission; use special precautions to reduce aerosol formation 7
• Consider early intubation/mechanical ventilation for patients likely to progress to critical illness, multi-organ failure, or ARDS 7
• Extracorporeal Membrane Oxygenation (ECMO) may be considered for refractory hypoxemia unresponsive to protective lung ventilation 5

Immunomodulatory Therapy

For patients with rapid disease progression or severe illness:

• Consider methylprednisolone 40-80 mg per day (not exceeding 2 mg/kg daily) 5
• Use corticosteroids cautiously and typically for short periods (3-5 days) based on degree of dyspnea and chest imaging progression 5
• Avoid routine corticosteroid administration for viral pneumonia unless indicated for another condition or in a clinical trial 1

Infection Control and Isolation

Home Care for Mild Cases

• Well-ventilated single rooms (strongly preferred) 3
• Maintain bed distance of at least 1 meter from the patient 3
• Clean and disinfect household articles using 500 mg/L chlorine-containing disinfectant frequently every day 3
• Restrict patient activity and limit visits by relatives and friends 3
• Avoid sharing toothbrush, towel, tableware, bed sheets with patients 3
• When coughing or sneezing, wear a medical mask or cover with tissue/bent elbow, then clean hands immediately 3

Healthcare Worker Protection

• N95 masks should be worn in the same room with patients (strongly preferred) 3
• Maintain awareness of aerosol-generating procedures and use appropriate PPE 7
• Ensure compliance with standard precautionary guidelines during all medical procedures 1

Monitoring and Follow-up

• Perform regular (e.g., daily) follow-up through face-to-face visits or phone interviews to monitor symptom progression 3
• Monitor vital signs with regular assessment of blood routine, organ function, and chest imaging 5
• Agree with patients on follow-up frequency and monitor for new or worsening symptoms using both in-person and remote options 1

Nutritional Support

• Provide protein-rich foods with ideal energy intake of 25-30 kcal/(kg·d) 5
• For patients with nutrition risk scores <3 points: protein intake of 1.5 g/(kg·d) 5
• For patients with nutrition risk scores ≥3 points: increase protein through oral supplements 2-3 times daily (≥18g protein/time) 5

Additional Considerations

Antibiotic Use

• Avoid blind or inappropriate use of antibacterial drugs 5
• If bacterial infection cannot be ruled out, administer appropriate antibiotics 5
• For mild cases with suspected bacterial infection, consider antibiotics effective against community-acquired pneumonia (amoxicillin, azithromycin, or fluoroquinolones) 5

Gastrointestinal Protection

• Use H2 receptor antagonists or proton pump inhibitors in patients with gastrointestinal bleeding risk factors 5

Thromboembolism Prevention

• Evaluate risk of venous embolism and use low-molecular-weight heparin or heparin in high-risk patients without contraindications 5

Secretion Management

• For patients with dyspnea, cough, wheeze, and respiratory distress due to increased respiratory secretions, use selective (M1, M3) receptor anticholinergic drugs to reduce secretion and improve pulmonary ventilation 5

Critical Pitfalls to Avoid

• Avoid nebulized therapies; consider metered dose inhaler alternatives to minimize aerosol generation 7
• Do not delay treatment escalation for patients showing signs of deterioration 1
• Avoid use of opioid patches in opioid-naive patients due to time needed to reach steady state and high morphine equivalence 1
• Do not coadminister remdesivir with chloroquine phosphate or hydroxychloroquine sulfate due to potential antagonistic effects 2
• For immunocompromised patients or those with autoimmune liver disease, avoid rapid reduction or discontinuation of immunosuppressants; consider maintaining them rather than discontinuing 1