COVID-19 Treatment
Primary Treatment Strategy
The cornerstone of COVID-19 treatment is supportive care with disease severity-based targeted therapies: remdesivir for hospitalized patients and high-risk outpatients, dexamethasone 6 mg daily for up to 10 days for those requiring oxygen, and antiviral agents (nirmatrelvir/ritonavir) or monoclonal antibodies for high-risk patients with mild-to-moderate disease. 1, 2
Treatment Algorithm by Disease Severity
Mild-to-Moderate COVID-19 (Not Hospitalized, High-Risk for Progression)
For non-hospitalized patients with mild-to-moderate disease at high risk for progression:
Remdesivir 200 mg IV on Day 1, then 100 mg daily for 2 additional days (total 3 days) is indicated for patients with at least one risk factor for hospitalization (age ≥60 years, obesity, chronic lung disease, hypertension, cardiovascular disease, diabetes, immunocompromised state, chronic kidney/liver disease, cancer, sickle cell disease) 2
Nirmatrelvir/ritonavir (oral antiviral) can be considered as an alternative oral option 1, 3
Anti-SARS-CoV-2 monoclonal antibodies are recommended, especially for unvaccinated individuals or those with impaired immune response 1
Molnupiravir may be considered when other options are unavailable 1
High-titer convalescent plasma within 72 hours of symptom onset if monoclonal antibodies are unavailable 1
Supportive measures for low-risk mild disease:
- Avoid lying supine (makes coughing ineffective); use honey for cough (age >1 year); consider short-term codeine linctus, codeine phosphate, or morphine sulfate for distressing cough 3
- Maintain hydration with regular fluid intake (no more than 2 liters daily) 3
- Monitor closely as patients may deteriorate rapidly, requiring urgent hospital admission 3
Moderate COVID-19 (Hospitalized, Requiring Oxygen)
For hospitalized patients requiring supplemental oxygen:
Dexamethasone 6 mg daily for up to 10 days or until hospital discharge 1, 2, 4
Remdesivir 200 mg IV loading dose on Day 1, then 100 mg daily for 5 days total (may extend to 10 days if no clinical improvement) 2
Tocilizumab or sarilumab (IL-6 inhibitors) may be considered when condition deteriorates dramatically 5, 6
Baricitinib can be added in select cases 6
Severe/Critical COVID-19 (Invasive Mechanical Ventilation/ECMO)
For critically ill patients on mechanical ventilation or ECMO:
Dexamethasone 6 mg daily for up to 10 days remains the primary anti-inflammatory therapy 1, 4
Remdesivir 200 mg IV loading dose on Day 1, then 100 mg daily for 10 days total (though benefit may be limited in this population) 1, 2
Prone positioning for severely hypoxemic patients 4
Tocilizumab with close monitoring of vital signs 5
Essential Supportive Care Measures
All hospitalized patients require:
Oxygen supplementation to maintain SpO2 >90-96% 1
Prophylactic anticoagulation to prevent venous thromboembolism 5, 1, 6
Careful fluid management 1
Monitor and treat co-infections or superinfections 1
Continuous positive airway pressure (CPAP) for deteriorating patients not yet requiring intubation 6
Pediatric Dosing (Birth to <18 Years, ≥1.5 kg)
Remdesivir dosing for pediatric patients:
Neonates <28 days old (≥1.5 kg): 2.5 mg/kg loading dose Day 1, then 1.25 mg/kg daily 2
≥28 days old, 1.5 kg to <3 kg: 2.5 mg/kg loading dose Day 1, then 1.25 mg/kg daily 2
≥28 days old, 3 kg to <40 kg: 5 mg/kg loading dose Day 1, then 2.5 mg/kg daily 2
≥40 kg: Adult dosing (200 mg Day 1, then 100 mg daily) 2
Special Populations
Immunocompromised patients:
Pre-exposure prophylaxis with long-acting monoclonal antibodies for unimmunized immunocompromised patients 1
Post-exposure prophylaxis with monoclonal antibodies for high-risk immunocompromised patients (unvaccinated, vaccine non-responders) 1
Consider longer treatment duration with antivirals 1
For immunosuppressed COVID-19-positive patients, steroids or immunosuppressants can be used when benefits outweigh risks; consider minimizing high-dose steroids while maintaining sufficient dose to avoid adrenal insufficiency 3
In cases of pneumonia aggravation, lymphopenia, and persisting fever, consider reducing or discontinuing azathioprine or mycophenolate; calcineurin inhibitors may be reduced but not discontinued 3
Critical Monitoring Requirements
Before and during treatment:
Perform hepatic laboratory testing before starting remdesivir and monitor during treatment 2
Determine prothrombin time before starting remdesivir and monitor as clinically appropriate 2
Establish treatment escalation plans as patients may deteriorate rapidly 3
Older patients or those with comorbidities, frailty, impaired immunity, or reduced ability to cough are at higher risk for severe pneumonia 3
Treatments NOT Recommended
Avoid the following based on lack of efficacy:
Do not use combinations of three or more antiviral drugs simultaneously 5, 3
Lopinavir-ritonavir has shown less efficient treatment effects 7
Hydroxychloroquine/chloroquine combinations with azithromycin are not recommended 5, 7
Discharge Criteria
Patients may be discharged when:
- Two consecutive negative RT-PCR tests from respiratory tract samples 5, 3
- Temperature returned to normal for >3 days 5, 3
- Respiratory symptoms significantly improved 5, 3
- Significant absorption of pulmonary lesions on CT imaging 5, 3
Post-discharge: Home quarantine for 2 weeks with PCR testing at 2 and 4 weeks after discharge 5
Administration Requirements
Remdesivir must only be administered in settings where:
- Healthcare providers have immediate access to medications for severe infusion/hypersensitivity reactions including anaphylaxis 2
- Emergency medical system (EMS) can be activated as necessary 2
- Administer by intravenous infusion only; do not administer by any other route 2