What is the current CDC recommended treatment for severe COVID-19?

Current CDC-Recommended Treatment for Severe COVID-19

For hospitalized adults with severe COVID-19 (SpO2 ≤94% on room air or requiring supplemental oxygen), the standard of care is corticosteroids combined with baricitinib, with remdesivir considered only for patients on oxygen therapy but not mechanical ventilation. 1

Definition of Severe COVID-19

Severe illness is defined as patients with SpO2 ≤94% on room air, including those on supplemental oxygen, oxygen through a high-flow device, or non-invasive ventilation. 1

First-Line Treatment Algorithm

Corticosteroids (Foundation of Therapy)

• Administer dexamethasone 6 mg daily for 10 days to all patients with severe COVID-19 requiring oxygen therapy. 1, 2
• This reduces all-cause mortality by 3% and decreases mechanical ventilation requirements with moderate certainty evidence. 1, 2
• Critical error: Never initiate corticosteroids before oxygen requirement develops, as this worsens outcomes and delays viral clearance during the viral phase. 2, 3

Add Baricitinib to Corticosteroids

• Baricitinib 4 mg daily (or appropriate renal dosing) for up to 14 days or until hospital discharge should be added to corticosteroids. 1
• Baricitinib demonstrates the most benefit in patients with severe COVID-19 on high-flow oxygen/non-invasive ventilation at baseline. 1
• Limited data suggest mortality reduction even among patients requiring mechanical ventilation. 1

Add IL-6 Receptor Blockers for High Inflammatory Markers

• Administer tocilizumab or sarilumab for patients with CRP ≥100 mg/L or elevated IL-6 who are on oxygen support. 1, 2
• This reduces mortality particularly at higher CRP levels with moderate certainty evidence. 1, 2
• Should be given with systemic corticosteroids; specific timing during hospitalization is not specified. 1

Remdesivir: Limited Role

When to Consider Remdesivir

• For patients receiving oxygen therapy but NOT on invasive mechanical ventilation, consider 5 days of remdesivir treatment. 1
• This is a weak recommendation with moderate evidence quality. 1
• For patients with critical COVID-19 on mechanical ventilation, do NOT use remdesivir, as it shows no benefit on survival or other patient-important outcomes. 1

Remdesivir Dosing (If Used)

• Loading dose: 200 mg IV on day 1, followed by 100 mg IV daily for days 2-10. 4
• For hospitalized patients not requiring invasive mechanical ventilation/ECMO: 5 days total duration. 4
• For patients requiring invasive mechanical ventilation/ECMO: 10 days total duration. 4

Alternative JAK Inhibitor if Baricitinib Unavailable

• If baricitinib is unavailable, ruxolitinib or tofacitinib may be considered only with corticosteroids, though evidence is weaker. 1
• Most well-informed patients would decline these alternatives given uncertainty of benefit. 1

Supportive Care Requirements

Respiratory Support

• Immediately provide oxygen therapy, non-invasive ventilation (NIV), or invasive mechanical ventilation (IMV) as clinically indicated. 1
• For patients receiving high-flow nasal cannula (HFNC) or NIV, concurrent awake prone positioning is recommended for >12 hours if no contraindication exists. 1

Monitoring Requirements

• Perform hepatic laboratory testing before starting and during remdesivir treatment. 4
• Determine prothrombin time before starting remdesivir and monitor during treatment. 4
• Monitor for secondary bacterial infections aggressively. 2, 3
• Closely monitor D-dimer levels and coagulation parameters given increased thromboembolic risk. 2, 3

Treatments to AVOID

Hydroxychloroquine

• Do NOT use hydroxychloroquine, as it increases risk of death and invasive mechanical ventilation without improving outcomes. 2, 3
• Evidence shows no significant differences in viral clearance, clinical progression, or hospital length of stay, with increased adverse events. 1

Lopinavir/Ritonavir

• Do NOT use lopinavir/ritonavir, as it provides no benefit and increases risk of diarrhea and nausea/vomiting. 2, 3
• May not reduce severe conversion rate or improve important outcomes. 1

Special Populations

Elderly Patients (≥80 years)

• Reduce all COVID-19 medications to 1/2 of standard adult doses due to deteriorated liver and kidney function. 2, 3
• Review all prescriptions to minimize polypharmacy and prevent drug-drug interactions. 2, 3
• For mild COVID-19 in elderly patients, consider early high-titer convalescent plasma therapy. 1

Pediatric Patients

• Remdesivir dosing for children <40 kg: 5 mg/kg loading dose on day 1, then 2.5 mg/kg daily. 4
• Remdesivir dosing for children ≥40 kg: Same as adult dosing (200 mg day 1, then 100 mg daily). 4
• Remdesivir was well tolerated in pediatric compassionate use with 88% showing decreased oxygen requirements. 5

Common Pitfalls

• Using corticosteroids too early (before oxygen requirement) worsens outcomes. 2, 3
• Continuing remdesivir in patients on mechanical ventilation provides no benefit. 1
• Failing to add baricitinib to corticosteroids misses the synergistic benefit demonstrated in severe disease. 1
• Not monitoring for secondary infections in elderly patients who have significantly higher infection susceptibility. 2, 3