What is the approach to Covid-19 treatment based on disease severity?

COVID-19 Treatment Approach by Disease Severity

Treatment of COVID-19 should be stratified by disease severity, with systemic corticosteroids and appropriate anticoagulation forming the cornerstone for hospitalized patients requiring oxygen, while avoiding hydroxychloroquine and lopinavir-ritonavir which provide no benefit. 1

Mild Disease (Non-Hospitalized Patients)

Symptomatic Management

• Provide symptomatic treatment for all patients with mild, uncomplicated respiratory tract infections 2
• These patients typically do not require hospitalization and can be managed in the outpatient setting 2

Antiviral Therapy for High-Risk Patients

• For non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression to severe disease, initiate remdesivir (VEKLURY) within 7 days of symptom onset 3
• The recommended treatment duration is 3 days for non-hospitalized high-risk patients 3
• Dosing for adults and pediatric patients ≥40 kg: 200 mg IV loading dose on Day 1, followed by 100 mg IV once daily on Days 2-3 3

Considerations for Immunosuppressed Patients

• For patients on immunosuppressive therapy (e.g., DMARDs), consider case-by-case modifications of immunosuppressant medications 1
• Be aware that immunosuppressants may mask COVID-19 symptoms such as fever, and IL-6 inhibitors/JAK inhibitors decrease acute phase response regardless of clinical course 1

Pneumonia (Moderate Disease)

General Approach

• Continue symptomatic treatment as the foundation 2
• Some guidelines suggest considering chloroquine/hydroxychloroquine or lopinavir-ritonavir, though these should be avoided based on higher-quality evidence showing no benefit and potential harm 1

Traditional Chinese Medicine Options

• For patients in settings where TCM is available, consider "three CPMs and three decoctions" (JHQG granules, LHQW capsules/granules, XBJ injection, QFPD decoction, HSBD decoction, XFBD decoction) based on syndrome differentiation 2
• These may reduce severe conversion rates and improve symptoms when combined with usual care 2

Severe Disease (Hospitalized, Requiring Oxygen)

Immediate Respiratory Support

• Provide aggressive respiratory support immediately: oxygen therapy via nasal cannula or mask for patients with PaO2/FiO2 <300 mmHg 2
• If respiratory distress or hypoxemia does not improve within 1-2 hours, escalate to high-flow nasal cannula (HFNC) or non-invasive ventilation (NIV) 2
• For patients receiving HFNC or NIV, implement awake prone positioning for >12 hours daily if no contraindications exist 2, 1

Corticosteroid Therapy

• Administer systemic corticosteroids (dexamethasone) for all severe COVID-19 patients requiring supplementary oxygen or ventilatory support 1
• This represents a strong recommendation with moderate evidence quality 2

Anticoagulation

• Provide appropriate anticoagulation for all hospitalized patients 1
• Monitor actively for signs of thromboembolism including stroke, deep vein thrombosis, pulmonary embolism, or acute coronary syndrome 2
• For patients with atrial fibrillation, use therapeutic anticoagulation regardless of CHA2DS2-VASc score 1

Immunomodulatory Therapy

• Consider IL-6 receptor antagonist monoclonal antibody treatment (tocilizumab) for patients with evidence of systemic inflammation and elevated inflammatory markers 2, 1
• This is particularly important for patients with high IL-6, IL-8, or TNF-α levels 2

Antiviral Therapy

• For hospitalized severe patients, administer remdesivir 200 mg IV loading dose on Day 1, followed by 100 mg IV once daily 3
• Treatment duration: 5 days for patients not requiring invasive mechanical ventilation/ECMO; may extend up to 10 days if no clinical improvement 3

Monitoring and Supportive Care

• Perform hepatic laboratory testing before starting and during remdesivir treatment 3
• Determine prothrombin time before starting remdesivir and monitor as clinically appropriate 3
• Consider serial procalcitonin measurement to guide antibiotic therapy decisions, especially in critically ill patients 1
• Measure high-sensitivity troponin daily and provide continuous ECG monitoring for patients with suspected myocardial injury 2

Traditional Chinese Medicine Adjuncts

• For severe COVID-19, consider XBJ injection for "overabundant heat in both Qifen and Yingfen" syndrome 2
• HSBD decoction may be used for "epidemic toxin blocking lung" syndrome 2
• TCM treatment may reduce adverse events by shortening application time and total dose of antivirals or corticosteroids 2

Critical Disease (Requiring Mechanical Ventilation/ECMO)

Advanced Respiratory Support

• If condition does not improve after 1-2 hours of HFNC or NIV, proceed immediately to invasive mechanical ventilation (IMV) 2
• Consider extracorporeal membrane oxygenation (ECMO) if available and indicated 2

Extended Antiviral Treatment

• For patients requiring invasive mechanical ventilation and/or ECMO, extend remdesivir treatment to 10 days total duration 3
• Dosing remains 200 mg IV loading dose on Day 1, followed by 100 mg IV once daily 3

Continued Corticosteroids and Anticoagulation

• Maintain systemic corticosteroids throughout critical illness 1
• Continue appropriate anticoagulation with close monitoring 1

Complication Management

• Actively monitor for and immediately treat complications including thromboembolism, myocardial injury, acute coronary syndrome, and secondary infections 2
• Evaluate hemorrhage risk immediately after admission for all adolescent and adult patients 2

Treatments to Avoid

Ineffective Antivirals

• Do not use hydroxychloroquine alone or in combination with azithromycin - strongly recommended against due to no benefit and increased risk of death, adverse effects, and QT prolongation 2, 1
• Do not use lopinavir-ritonavir - strongly recommended against due to lack of efficacy 1

Antibiotic Stewardship

• Restrict antibiotics in mild-to-moderately ill patients, especially those with low initial procalcitonin levels (<0.25 ng/mL) 1
• Do not provide routine antifungal prophylaxis 1
• Overuse of antibiotics without bacterial co-infection contributes to antimicrobial resistance 1

Special Populations

Immunocompromised Patients

• For patients with hematological malignancies, consider early use of monoclonal antibodies and convalescent plasma 1
• Anti-SARS-CoV-2 monoclonal antibodies are recommended for pre-exposure prophylaxis in unimmunized patients at risk for severe COVID-19 1

Patients on Immunosuppressants

• Do not routinely reduce or discontinue immunosuppressants in asymptomatic patients unless they are COVID-19 positive 2
• For liver transplant recipients, reduction of immunosuppressant or discontinuation of mycophenolate is not recommended unless COVID-19 positive 2

Renal Impairment

• No dosage adjustment of remdesivir is required for any degree of renal impairment, including patients on dialysis 3
• Remdesivir may be administered without regard to timing of dialysis 3

Critical Pitfalls to Avoid

• Patients with initially mild symptoms may experience sudden worsening - close monitoring is essential 1
• Do not delay respiratory support escalation; if no improvement within 1-2 hours, advance to next level of support 2
• Avoid high-dose chloroquine due to safety concerns including severe rhabdomyolysis, prolonged QTc, and ventricular tachycardia 2
• Do not use medications with high risk of drug-drug interactions when alternatives exist; use minimum effective doses for shortest duration 2