What medications are given to COVID-19 positive patients?

Medications for COVID-19 Positive Patients

For non-hospitalized COVID-19 positive patients with mild disease and risk factors for progression, nirmatrelvir-ritonavir (Paxlovid) or remdesivir should be initiated within 5-7 days of symptom onset, while hospitalized patients requiring supplemental oxygen should receive dexamethasone combined with remdesivir, and those with severe disease may benefit from adding tocilizumab or baricitinib. 1, 2

Treatment Based on Disease Severity

Non-Hospitalized Patients (Mild-to-Moderate Disease)

For outpatients at risk of severe COVID-19 with symptom onset <5 days:

• Antiviral therapy is the priority - nirmatrelvir-ritonavir (Paxlovid), remdesivir, or molnupiravir should be considered 1, 3
• Monoclonal antibodies against SARS-CoV-2 spike protein should be considered in patients at risk of severe disease, particularly if symptom onset is <5 days or patients remain seronegative 1
• No immunomodulatory therapy is indicated for non-hospitalized patients with mild disease 1
• Hydroxychloroquine should be avoided as it provides no benefit and may worsen prognosis, particularly when combined with azithromycin 1

Hospitalized Patients Not Requiring Oxygen

• No immunomodulatory therapy is currently supported by evidence for hospitalized patients who do not require supplemental oxygen 1
• Supportive care remains the standard 1

Hospitalized Patients Requiring Supplemental Oxygen

This is the critical treatment tier where immunomodulation becomes essential:

• Dexamethasone (systemic glucocorticoids) is mandatory - reduces 28-day mortality (21.6% vs 24.6% with usual care; age-adjusted rate ratio 0.83) 1, 4, 3
• Combination of glucocorticoids plus tocilizumab (IL-6 receptor inhibitor) should be considered as it reduces disease progression and mortality 1
• Remdesivir improves time to recovery from 15 to 11 days and should be administered 2, 4
• Baricitinib or tofacitinib (JAK inhibitors) combined with glucocorticoids could be considered as they may decrease disease progression and mortality 1, 3

Severe/Critical COVID-19 (ARDS, Mechanical Ventilation, Septic Shock)

For patients with the most severe disease:

• Dexamethasone remains essential 1
• Remdesivir should be continued 1, 2
• Add second immunosuppressant if COVID-19-related inflammation is present: tocilizumab or sarilumab (anti-IL-6 agents) are preferred 1
• Casirivimab/imdevimab may be considered in seronegative patients on non-invasive ventilation (no data for invasive mechanical ventilation) 1

Medications to AVOID

Critical pitfalls in COVID-19 treatment:

• Hydroxychloroquine/chloroquine should be avoided at any disease stage - no additional benefit and potential harm, especially with azithromycin 1
• Anakinra and canakinumab (IL-1 inhibitors) lack robust evidence 1
• Low-dose colchicine has no robust evidence at any disease stage 1
• Convalescent plasma has robust evidence against its use in patients without hypogammaglobulinemia and symptom onset >5 days 1, 4
• Dexamethasone should NOT be used in mild COVID-19 or patients not requiring oxygen 1

Special Considerations for Immunosuppressed Patients

For patients on chronic immunosuppression (e.g., IBD, rheumatic diseases):

• Following SARS-CoV-2 exposure: temporarily stop immunosuppressants (tacrolimus, cyclosporine, mycophenolate, azathioprine), non-IL-6 biologics, and JAK inhibitors pending negative test or 2 weeks symptom-free observation 1
• With documented COVID-19: stop or withhold methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors regardless of severity 1
• Hydroxychloroquine and sulfasalazine may be continued 1
• IL-6 receptor inhibitors may be continued in select circumstances as part of shared decision-making 1
• NSAIDs should be stopped in patients with severe respiratory symptoms 1

Restarting Therapy Post-COVID-19

For patients recovering from COVID-19:

• Uncomplicated infections: consider restarting DMARDs, immunosuppressants, biologics, and JAK inhibitors within 7-14 days of symptom resolution 1
• Asymptomatic but PCR-positive: consider restarting treatments 10-17 days after positive PCR result 1
• Severe COVID-19: timing should be individualized case-by-case 1

Emerging and Investigational Therapies

Agents with insufficient evidence or under investigation:

• GM-CSF inhibitors (mavrilimumab, otilimab, lenzilumab) - evolving evidence, no formal recommendation yet 1
• Interferons (alpha, beta, lambda, kappa) - insufficient evidence 1
• Other immunomodulators (leflunomide, eculizumab, cyclosporine, non-SARS-CoV-2 IVIg) - insufficient evidence 1

Key Clinical Pearls

Important considerations for optimal outcomes:

• Timing is critical - antivirals and monoclonal antibodies are most effective when given within 5-7 days of symptom onset 1, 4
• Check drug interactions using the Liverpool COVID-19 drug interaction tool (www.covid19-druginteractions.org) before prescribing 5
• Remdesivir pharmacokinetics are not significantly affected by renal impairment, though metabolite accumulation occurs; this is not considered clinically significant 2
• Supportive care remains fundamental - oxygen therapy, fluid management, and anticoagulation measures are essential 6, 7, 4