What is the current treatment approach for COVID-19 infection?

Current Treatment for COVID-19 Infection

For hospitalized COVID-19 patients requiring supplemental oxygen, dexamethasone 6 mg daily for 10 days combined with prophylactic anticoagulation forms the foundation of therapy, with tocilizumab added for those with high inflammatory markers receiving corticosteroids. 1, 2

Treatment Stratified by Disease Severity

Non-Hospitalized or Hospitalized Without Oxygen Requirements

• Do not initiate immunomodulatory therapy for patients who do not require supplemental oxygen, as corticosteroids cause harm without benefit in this population 3, 1
• For high-risk outpatients with mild COVID-19, initiate antiviral therapy within 5 days of symptom onset with nirmatrelvir/ritonavir (Paxlovid) as first-line or molnupiravir as an alternative 3, 1
• Anti-SARS-CoV-2 monoclonal antibodies should be considered for high-risk patients with symptom onset <5 days or those still seronegative 3

Hospitalized Patients Requiring Supplemental Oxygen

Core therapy consists of:

• Dexamethasone 6 mg daily for 10 days - this reduces mortality by 3% and represents the cornerstone of treatment 3, 1
• Prophylactic-dose anticoagulation with low molecular weight heparin preferred over unfractionated heparin for all hospitalized patients 1
• Remdesivir for 5 days can be considered for patients receiving oxygen therapy but not on invasive mechanical ventilation 3

Additional immunomodulation:

• Tocilizumab 8 mg/kg IV (maximum 800 mg) should be added for patients with high inflammatory markers (CRP ≥100 mg/L) who are already receiving corticosteroids, as this combination reduces mortality and progression to mechanical ventilation 3, 2
• The tocilizumab mortality benefit requires concomitant corticosteroid therapy - never give tocilizumab without corticosteroids 1
• For patients requiring high-flow oxygen or non-invasive ventilation, the combination of glucocorticoids with baricitinib or tofacitinib could be considered as it may decrease disease progression and mortality 3

Severe COVID-19 (Oxygen Saturation <90-94%, Respiratory Rate >30/min)

• Continue dexamethasone 6 mg daily 3
• Add tocilizumab if patient is seronegative and has high inflammatory markers 3
• Remdesivir can be considered 3
• If worsening despite dexamethasone with ongoing COVID-19-related inflammation, consider adding a second immunosuppressant: anti-IL-6 agents (tocilizumab, sarilumab), anti-IL-1 (anakinra), or JAK inhibitors (baricitinib/tofacitinib) 3

Critical COVID-19 (ARDS, Mechanical Ventilation, ECMO)

Respiratory support:

• Implement prone positioning for patients receiving invasive mechanical ventilation, as this reduces mortality 1
• For patients on high-flow nasal cannula or non-invasive ventilation, concurrent awake prone ventilation for >12 hours is recommended if no contraindications exist 3
• Use lung-protective ventilation with low tidal volumes and plateau pressure 4
• Progress from conventional oxygen therapy → high-flow nasal cannula → non-invasive ventilation → invasive mechanical ventilation → ECMO as needed based on clinical response within 1-2 hour intervals 3

Pharmacotherapy:

• Dexamethasone 6 mg daily remains essential 3
• Do not use remdesivir in mechanically ventilated patients - it has no survival benefit in this population 1
• Add tocilizumab or other anti-IL-6 agents if COVID-19-related inflammation is present 3
• Casirivimab/imdevimab can be considered in seronegative patients on non-invasive ventilation (no data for invasive mechanical ventilation) 3

Special Populations

Immunocompromised Patients

• Pre-exposure prophylaxis with long-acting anti-SARS-CoV-2 monoclonal antibodies is recommended for unvaccinated or high-risk immunocompromised patients not expected to mount adequate immune response 3, 1
• Post-exposure prophylaxis with anti-SARS-CoV-2 monoclonal antibodies for high-risk individuals (vaccine non-responders, haematological malignancy patients) 3, 1
• For haematological malignancy patients with mild COVID-19, consider anti-SARS-CoV-2 monoclonal antibodies, inhaled interferon beta-1a, molnupiravir, remdesivir, or ritonavir/nirmatrelvir 3

Critical Pitfalls to Avoid

• Never use hydroxychloroquine - it provides no benefit and may worsen prognosis, particularly when co-prescribed with azithromycin 3
• Do not use corticosteroids in patients not requiring oxygen - this causes harm 3, 1
• Avoid remdesivir in mechanically ventilated patients - no survival benefit exists 1
• Never give tocilizumab without concurrent corticosteroids - the mortality benefit requires combination therapy 1
• Do not use low-dose colchicine at any disease stage - no robust evidence supports its use 3
• Convalescent plasma should not be used in patients without hypogammaglobulinemia with symptom onset >5 days - robust evidence exists against its use 3

Supportive Care Essentials

• Close monitoring for signs of clinical deterioration including rapid progressive respiratory failure and shock 3
• Aggressive management of complications and secondary infections 3
• Treatment of underlying diseases and prevention of secondary infections 3
• Timely support of organ function 3
• Implement rehabilitation care as soon as oxygenation and hemodynamics are stable 1
• Provide psychological support for patients experiencing anxiety, fear, or depression 1