What is the treatment approach for COVID-19 (Coronavirus disease 2019)?

Treatment of COVID-19

The treatment of COVID-19 should be initiated as early as possible and stratified by disease severity, with antiviral therapy (remdesivir) for eligible patients, supportive care including oxygen therapy, prophylactic anticoagulation for hospitalized patients, and low-dose corticosteroids (dexamethasone) for those requiring supplemental oxygen. 1, 2

Risk Stratification and Initial Assessment

Before initiating treatment, assess disease severity and risk factors:

• Perform baseline testing including hepatic function, prothrombin time, D-dimer, and oxygen saturation before starting therapy 1, 3
• Identify high-risk patients including those over 65 years, with comorbidities (obesity, diabetes, cardiovascular disease), immunosuppression, or frailty 3, 4
• Measure oxygen saturation - levels below 90% indicate need for hospitalization and medical intervention 2

Treatment by Disease Severity

Mild COVID-19 (Non-Hospitalized, Low-Risk)

Supportive care is the cornerstone for mild disease:

• Avoid lying supine as this makes coughing ineffective; use positioning strategies including pursed-lip breathing and breathing exercises 4
• Manage cough with honey (for patients over 1 year), or consider short-term codeine linctus, codeine phosphate, or morphine sulfate oral solution for distressing cough 4
• Maintain hydration with regular fluid intake, limiting to no more than 2 liters daily 4
• Monitor for deterioration as patients can worsen rapidly; establish clear escalation plans and contact protocols 4
• Minimize hospital visits and consider remote medical support when possible 4

Moderate COVID-19 (Hospitalized, Requiring Oxygen)

For hospitalized patients not requiring mechanical ventilation:

• Initiate remdesivir as soon as possible after diagnosis: 200 mg IV loading dose on Day 1, followed by 100 mg IV daily for 5 days total (may extend to 10 days if no clinical improvement) 1, 2
• Administer prophylactic anticoagulation with low molecular weight heparin (LMWH) as soon as possible, adjusting dosage for renal function, weight, and bleeding risk 3
• Start low-dose dexamethasone if requiring supplemental oxygen, as this addresses the hyperinflammatory phase 2
• Provide oxygen therapy to maintain saturation above 90-96% 5
• Monitor inflammatory markers including C-reactive protein, D-dimer, and prothrombin time daily 2, 1

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

For patients requiring intensive care support:

• Extend remdesivir duration to 10 days for those requiring invasive mechanical ventilation and/or ECMO 1
• Intensify VTE prophylaxis with intermediate or half-therapeutic LMWH dosing once daily, or high-risk prophylactic LMWH twice daily, particularly for patients with BMI >30 kg/m², history of VTE, thrombophilia, or active cancer 3
• Escalate to therapeutic anticoagulation with LMWH if VTE develops; use unfractionated heparin in severe renal insufficiency 3, 2
• Continue corticosteroids (low-dose dexamethasone) for hyperinflammation 2
• Implement advanced respiratory support including prone positioning, high-flow nasal cannula, mechanical ventilation, or ECMO as needed 5, 6
• Avoid routine corticosteroids unless specifically indicated, as they may exacerbate viral infection and increase mortality in some contexts 3

Critical Therapeutic Principles

The "Hit Early, Hit Hard" Approach

Antiviral therapy must be initiated at the earliest possible timepoint:

• Viral load peaks early in infection, and antiviral efficacy is highest when administered presymptomatically or in early symptomatic phase 3
• Delayed antiviral therapy (beyond 4-5 days from symptom onset) has limited impact on viral load and disease progression 3
• Early treatment reduces viral shedding duration, infectiousness, and progression to severe disease 3, 2

Anticoagulation Strategy

All hospitalized COVID-19 patients require thromboprophylaxis:

• Standard prophylactic LMWH should be initiated immediately upon admission 3
• Monitor coagulation parameters including D-dimer, prothrombin time, and fibrinogen 2
• Escalate to therapeutic anticoagulation when D-dimer markedly increases, prothrombin time prolongs, and fibrinogen decreases (indicating DIC-like phase) 2
• Continue prophylaxis post-discharge for patients with persistent immobility, high inflammatory activity, or additional risk factors 3

Antimicrobial Stewardship

Avoid unnecessary antibiotic use:

• Do not routinely prescribe antibiotics for COVID-19, as this selects for resistant bacteria 3
• Reserve antibiotics for confirmed or highly suspected bacterial superinfection with positive cultures 3
• De-escalate therapy as soon as culture results allow 3
• Never combine three or more antiviral drugs simultaneously 4

Special Populations

Immunosuppressed Patients

Management requires careful balancing:

• Do not preemptively reduce immunosuppression in COVID-19-negative patients 4
• Consider minimizing high-dose steroids while maintaining sufficient dose to prevent adrenal insufficiency in COVID-19-positive patients 4
• Reduce or discontinue azathioprine or mycophenolate if pneumonia worsens, lymphopenia develops, or fever persists 4
• Reduce but do not discontinue calcineurin inhibitors 4

Pediatric Patients

Dosing adjustments are required:

• For neonates <28 days old (≥1.5 kg): remdesivir 2.5 mg/kg loading dose, then 1.25 mg/kg daily 1
• For infants ≥28 days old (1.5-40 kg): remdesivir 5 mg/kg loading dose, then 2.5 mg/kg daily 1
• Use only lyophilized powder formulation for patients weighing <40 kg 1

Monitoring and Complications

Vigilant monitoring prevents adverse outcomes:

• Assess for thromboembolism including stroke, deep vein thrombosis, pulmonary embolism, and acute coronary syndrome 3
• Monitor cardiac function with daily troponin, continuous ECG, blood pressure, heart rate, and fluid balance in suspected myocardial injury 3
• Screen for hepatotoxicity with baseline and serial hepatic function tests 1, 3
• Watch for infusion reactions during remdesivir administration; have emergency medications immediately available 1

Discharge Criteria

Patients may be discharged when:

• Two consecutive negative RT-PCR tests from respiratory samples are obtained 4
• Temperature normalizes for more than 3 days 4
• Respiratory symptoms significantly improve 4
• Chest CT shows significant absorption of pulmonary lesions 4

Common Pitfalls to Avoid

• Do not delay antiviral therapy waiting for test results if clinical suspicion is high - early treatment is critical 3
• Do not withhold anticoagulation due to theoretical bleeding concerns; thrombotic risk far exceeds bleeding risk in hospitalized COVID-19 patients 3, 2
• Do not use hydroxychloroquine, chloroquine, or lopinavir-ritonavir - these have been shown ineffective and potentially harmful 5, 3
• Do not administer remdesivir by any route other than IV infusion 1
• Do not assume mild disease will remain mild - establish clear monitoring and escalation protocols for all patients 4