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

Treatment for COVID-19

For hospitalized COVID-19 patients requiring supplemental oxygen, initiate systemic corticosteroids (dexamethasone 6 mg daily for 10 days) and appropriate anticoagulation immediately, while avoiding hydroxychloroquine and lopinavir-ritonavir which provide no benefit. 1

Treatment Based on Disease Severity and Setting

Non-Hospitalized Patients with Mild-to-Moderate COVID-19 at High Risk for Progression

• Initiate antiviral therapy as early as possible after symptom onset, ideally within the first few days, as early treatment reduces viral load, shortens illness duration, and decreases progression to severe disease 2, 3

• Remdesivir is FDA-approved for non-hospitalized patients with mild-to-moderate COVID-19 who are at high risk for progression to severe disease, including hospitalization or death 3

  • Dosing for adults and pediatric patients ≥40 kg: 200 mg IV loading dose on Day 1, then 100 mg IV daily
  • Treatment duration: 3 days for non-hospitalized patients 3

• Anti-SARS-CoV-2 monoclonal antibodies are recommended for pre-exposure prophylaxis in unimmunized patients at risk for severe COVID-19 1

• The "hit early-hit hard" principle is critical: mathematical modeling demonstrates that antiviral dosing at the earliest possible time (presymptomatic phase before peak viral load) is the only way to meaningfully reduce viral area under the curve 2

Hospitalized Patients Not Requiring Invasive Mechanical Ventilation or ECMO

• Systemic corticosteroids (dexamethasone 6 mg daily for 10 days) are strongly recommended for all patients requiring supplemental oxygen 1

  • This reduces mortality by approximately 3% based on the RECOVERY trial 2
  • Critical caveat: Corticosteroids are detrimental when used in earlier viral phases without oxygen requirement 2

• Remdesivir for hospitalized patients:

  • Adults and pediatric patients ≥40 kg: 200 mg IV loading dose on Day 1, then 100 mg IV daily
  • Treatment duration: 5 days (may extend up to 10 days if no clinical improvement) 3
  • Initiate as soon as possible after diagnosis 3

• Therapeutic anticoagulation is recommended for all hospitalized patients 1

• Consider IL-6 receptor antagonists (tocilizumab or sarilumab), especially in patients with evidence of systemic inflammation 1

• High-flow nasal oxygen or continuous positive airway pressure should be considered in patients with hypoxemic respiratory failure 1

Hospitalized Patients Requiring Invasive Mechanical Ventilation and/or ECMO

• Dexamethasone 6 mg daily for 10 days remains the cornerstone of treatment 2, 1

• Remdesivir treatment duration: 10 days for patients requiring invasive mechanical ventilation and/or ECMO 3

• Anti-IL-6 therapy (tocilizumab, sarilumab) or anti-IL-1 therapy (anakinra) if worsening despite dexamethasone 2

• Therapeutic anticoagulation unless contraindicated 1

Special Population Considerations

Patients with Hematological Malignancies or Immunocompromised

• Early use of anti-SARS-CoV-2 monoclonal antibodies is recommended due to prolonged viral replication in immunocompromised hosts 2

• Convalescent plasma may be considered in seronegative patients 2

• Do not routinely reduce or discontinue immunosuppressants in asymptomatic patients unless COVID-19 positive 2

• Remdesivir may be particularly useful in patients with prolonged viral replication 2

Patients on Anticoagulation for Other Indications

• Atrial fibrillation: Continue therapeutic anticoagulation regardless of CHA2DS2-VASc score if hospitalized 1

• Peripheral artery disease: Continue antiplatelet therapy if on prophylactic-dose anticoagulation; individualize if on therapeutic-dose anticoagulation 1

Critical Monitoring Requirements

Before and During Treatment

• Hepatic laboratory testing must be performed before starting remdesivir and monitored during treatment as clinically appropriate 3

• Prothrombin time should be determined before starting remdesivir and monitored during treatment 3

• Serial procalcitonin measurement should be considered in hospitalized patients, especially critically ill or ICU patients under mechanical ventilation, to guide antibiotic therapy decisions 1

Treatments to Definitively AVOID

• Hydroxychloroquine (alone or with azithromycin) is strongly contraindicated—provides no benefit 1

• Lopinavir-ritonavir is strongly contraindicated—provides no benefit 1

• Routine antifungal prophylaxis is not recommended in COVID-19 patients 1

• Antibiotics should be restricted in mild-to-moderately ill patients, especially those with low initial procalcitonin levels (<0.25 ng/mL), to prevent antimicrobial resistance 1

Critical Pitfalls to Avoid

• Do not delay antiviral treatment: Time from illness onset to antiviral therapy is statistically significantly associated with disease severity; shorter time to treatment correlates with milder illness 2

• Do not use corticosteroids in patients not requiring oxygen: This causes harm rather than benefit 2

• Do not overlook sudden deterioration: Patients with initially mild symptoms may experience sudden worsening; close monitoring is essential 1

• Remdesivir administration requirements: May only be administered in settings where healthcare providers have immediate access to medications for severe infusion/hypersensitivity reactions and ability to activate emergency medical services 3

• Immunosuppressants may mask fever: IL-6 inhibitors and JAK inhibitors decrease acute phase response regardless of clinical course 1

• Antibiotic overuse: Inappropriate antibiotic use in COVID-19 patients without bacterial co-infection contributes significantly to antimicrobial resistance 1