What is the treatment for SARS (Severe Acute Respiratory Syndrome) COVID-19 (Coronavirus Disease 2019)?

Treatment of COVID-19

For COVID-19, treatment is primarily supportive care with disease severity-based interventions: remdesivir for hospitalized patients and high-risk outpatients, dexamethasone 6 mg daily for up to 10 days for those requiring oxygen, and anti-SARS-CoV-2 monoclonal antibodies for high-risk patients with mild-to-moderate disease. 1, 2

Initial Assessment and Testing

• Test all patients for SARS-CoV-2 before treatment initiation 3
• If positive and treatment can be delayed, consider postponing therapy by 10-14 days (except for urgent situations) 3
• If negative but high clinical suspicion exists, repeat testing after 24 hours as RT-PCR sensitivity is approximately 70% 3
• Before starting treatment, perform hepatic laboratory testing and assess prothrombin time; monitor as clinically appropriate during therapy 2

Treatment by Disease Severity

Mild-to-Moderate COVID-19 (Non-Hospitalized, High-Risk Patients)

For outpatients at high risk for progression (unvaccinated, immunocompromised, elderly, multiple comorbidities):

• Anti-SARS-CoV-2 monoclonal antibodies are the primary recommendation, especially for unvaccinated individuals or those with impaired immune response 1
• Initiate treatment within 7 days of symptom onset 2
• Recommended treatment duration is 3 days 2
• If monoclonal antibodies are unavailable, high-titer convalescent plasma within 72 hours of symptom onset is recommended 1
• Nirmatrelvir/ritonavir (oral antiviral) can be considered as an alternative 1
• Molnupiravir may be used when other options are unavailable 1

Moderate COVID-19 (Hospitalized, Requiring Oxygen)

For patients requiring supplemental oxygen but not mechanical ventilation:

• Dexamethasone 6 mg daily for up to 10 days or until hospital discharge 1, 4
• Remdesivir: 200 mg loading dose on Day 1, followed by 100 mg daily maintenance doses (for patients ≥40 kg) 2
• Recommended treatment duration is 5 days; may extend up to 5 additional days (total 10 days) if no clinical improvement 2
• Initiate treatment as soon as possible after diagnosis 2

Severe/Critical COVID-19 (Mechanical Ventilation/ECMO)

For patients requiring invasive mechanical ventilation and/or ECMO:

• Dexamethasone 6 mg daily for up to 10 days 1, 4
• Remdesivir may have limited benefit in critically ill patients on mechanical ventilation 1
• Recommended total treatment duration with remdesivir is 10 days 2
• Triple therapy with interferon β-1b, lopinavir/ritonavir, and ribavirin may be considered to reduce severe conversion rate (weak recommendation) 3
• Tocilizumab (anti-IL-6) may be beneficial for cytokine release syndrome 3, 5

Essential Supportive Care Measures

All patients require comprehensive supportive management:

• Oxygen supplementation to maintain SpO2 >90-96% 1
• Thromboprophylaxis with anticoagulation 1
• Careful fluid management 1
• Monitor for and treat co-infections or superinfections 1
• Adequate nutrition and fluid support to ensure water-electrolyte balance 3
• Monitor vital signs (heart rate, pulse oxygen saturation, respiratory rate, blood pressure) 3
• Monitor blood routine, CRP, PCT, organ function (liver enzymes, bilirubin, myocardial enzymes, creatinine, urea nitrogen), coagulation function, and arterial blood gas analysis 3

Oxygen Therapy Escalation

Progressive oxygen support based on clinical response:

• Nasal cannula or mask oxygen (initial flow rate 5 L/min, titrate to target) 3
• High-flow nasal oxygen therapy (HFNO) 3
• Non-invasive ventilation (NIV) 3
• Invasive mechanical ventilation 3
• ECMO should be considered for refractory hypoxemia unresponsive to protective lung ventilation 3

Special Populations

Immunocompromised Patients

• Pre-exposure prophylaxis with long-acting monoclonal antibodies for unimmunized immunocompromised patients at risk for severe COVID-19 1
• Post-exposure prophylaxis with monoclonal antibodies for high-risk immunocompromised patients (unvaccinated, vaccine non-responders) 1
• Consider longer treatment duration with antivirals 1

Elderly Patients (>65 Years)

• Minimize steroid exposure due to increased risk of severe COVID-19 complications 3
• Consider reducing doses of daunorubicin and PEGylated asparaginase during induction treatment 3
• Early treatment with high-titer convalescent plasma can be considered for elderly patients with mild COVID-19 3

Pediatric Patients

• Dosing is weight-based for patients weighing 1.5 kg to less than 40 kg 2
• For patients ≥40 kg, use adult dosing 2

Corticosteroid Use: Critical Considerations

Corticosteroids should be used judiciously:

• Only for patients requiring supplemental oxygen 1, 4
• Methylprednisolone 40-80 mg daily may be considered for rapid disease progression or severe illness; total daily dose should not exceed 2 mg/kg 3
• Avoid in mild cases without oxygen requirement 3
• Systemic glucocorticoid use requires caution due to potential adverse effects 3

Antibiotic Therapy

Antibiotics are NOT routinely recommended:

• Avoid blind or inappropriate use of antibacterial drugs 3
• Only use when bacterial co-infection is clinically suspected 3
• For mild patients with suspected bacterial infection: amoxicillin, azithromycin, or fluoroquinolones 3
• For severe patients: empirical broad-spectrum coverage until pathogen identified, then de-escalate 3

Antiviral Considerations

Current evidence for specific antivirals:

• Remdesivir is the primary antiviral with FDA approval 2
• No dosage adjustment needed for any degree of renal impairment, including dialysis 2
• Alpha-interferon atomization inhalation (5 million U twice daily) can be considered (weak recommendation) 3
• Lopinavir/ritonavir (2 capsules twice daily) can be considered (weak recommendation) 3
• Antivirals should be initiated before peak viral replication for optimal outcomes 5
• Ribavirin may be beneficial as add-on therapy but ineffective as monotherapy 5

Rehabilitation and Mental Health

Early rehabilitation is essential:

• Implement rehabilitation care as soon as possible, parallel with disease treatment 3
• For stable oxygenation and hemodynamics, initiate passive and active activities to promote sputum drainage and pulmonary rehabilitation 3
• Pulmonary rehabilitation training for impaired lung function and potential fibrosis 3
• Non-drug treatments: Baduanjin, Tai-chi, 6-character breathing exercise, posture management, breathing exercise management 3

Mental health support:

• Psychological counseling, mental health education, cognitive behavioral therapy, mindfulness training, and group intervention for anxiety, fear, depression, and somatization symptoms 3
• Continue mental health support after hospital discharge with follow-up 3

Key Clinical Pitfalls to Avoid

• Do not delay oxygen therapy in patients with respiratory distress 3
• Do not use corticosteroids in patients not requiring oxygen 3, 4
• Do not routinely prescribe antibiotics without evidence of bacterial co-infection 3
• Do not miss the early treatment window for antivirals and monoclonal antibodies 1, 2, 5
• Do not discontinue chronic immunosuppressive therapy in rheumatic disease patients without consultation, as some agents may be beneficial 3
• Monitor for thromboembolic complications and provide prophylaxis 1