What is the treatment plan for mild to severe Covid-19 symptoms?

Treatment Plan for COVID-19 Symptoms

For mild COVID-19 symptoms managed in the community, implement symptom-directed therapy with paracetamol for fever, honey or short-term codeine for distressing cough, controlled breathing techniques for dyspnea, and establish early treatment escalation plans as patients can deteriorate rapidly. 1

Initial Assessment and Planning

Establish a treatment escalation plan immediately upon diagnosis, as COVID-19 patients can deteriorate rapidly and require urgent hospital admission. 1 Document advance care plans for patients with pre-existing comorbidities and communicate clearly with patients about when to seek emergency care (e.g., NHS 111 online or equivalent). 1

Symptom-Specific Management

Fever Management

• Advise regular fluid intake to prevent dehydration, but limit to no more than 2 liters per day. 1
• Use paracetamol as the preferred antipyretic for fever accompanied by other symptoms requiring relief (myalgia, headache). 1 Continue only while symptoms persist.
• Do not use antipyretics solely to reduce body temperature without other symptomatic indications. 1
• Paracetamol is preferred over NSAIDs until more evidence emerges, though NSAIDs showed high perceived efficacy (>80%) for myalgia, arthralgia, and headache in provider surveys. 1, 2
• Be aware that fever typically peaks around day 5 after exposure. 1

Cough Management

• Encourage patients to avoid lying supine, as this position makes coughing ineffective and worsens symptoms. 1
• Start with honey (for patients over 1 year of age) as first-line simple therapy. 1
• For distressing cough, prescribe short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution to suppress coughing. 1
• Benzonatate was reported as highly utilized (83.9% of providers) and may be considered. 2
• Recognize that older patients, those with comorbidities, frailty, or impaired ability to clear secretions are at higher risk for progression to severe pneumonia and respiratory failure. 1

Breathlessness Management

Implement non-pharmacological breathing techniques as primary intervention: 1

• Pursed-lip breathing: Inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds to relieve dyspnea perception. 1
• Positioning strategies: Sit upright to increase peak ventilation; lean forward with arms bracing chair or knees to improve ventilatory capacity. 1
• Relaxation techniques: Drop shoulders to reduce anxiety-driven hunched posture. 1
• Breathing retraining with physiotherapist support (can be done remotely) to regain control and improve respiratory muscle strength. 1

For end-of-life patients with moderate-to-severe breathlessness: 1

• Opioid-naive patients able to swallow: Morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as needed, OR morphine sulfate modified-release 5 mg twice daily (maximum 30 mg daily). 1
• Patients already on opioids: Morphine sulfate immediate-release 5-10 mg every 2-4 hours as needed. 1
• Unable to swallow: Morphine sulfate 1-2 mg subcutaneously every 2-4 hours as needed; consider subcutaneous infusion via syringe driver starting at 10 mg over 24 hours if needed frequently. 1
• If eGFR <30 mL/min: Use equivalent doses of oxycodone instead of morphine. 1
• Always prescribe concomitant antiemetic (such as haloperidol) and regular stimulant laxative (such as senna). 1

Antibiotic Considerations

The evidence on empiric antibiotics is contradictory and requires clinical judgment:

• NICE guidelines recommend against blind or inappropriate use of antibacterial drugs in patients with mild or no symptoms. 1
• However, one expert opinion argues for empiric oral antibiotics (amoxicillin, azithromycin, or fluoroquinolones) if bacterial superinfection cannot be ruled out, given that bacterial co-infection occurs in approximately 40% of viral respiratory infections requiring hospitalization and COVID-19 patients cannot easily access routine clinical care. 1
• For severe patients, empirical antibacterial treatment should cover all possible pathogens against community-acquired pneumonia, with de-escalation once pathogens are clarified. 1
• In practice, reserve antibiotics for patients with clinical evidence of bacterial co-infection (high fever, productive cough with purulent sputum, elevated procalcitonin, focal consolidation on imaging). 3, 4

Antiviral Therapy

For non-hospitalized patients at high risk for progression:

• Remdesivir (VEKLURY) is FDA-approved for mild-to-moderate COVID-19 in non-hospitalized patients at high risk for progression. 5
• Initiate treatment as soon as possible after diagnosis and within 7 days of symptom onset. 5
• Recommended duration: 3 days for non-hospitalized patients. 5
• Dosing for adults ≥40 kg: Loading dose of 200 mg IV on Day 1, followed by 100 mg IV daily on Days 2-3. 5
• Perform hepatic laboratory testing and assess prothrombin time before starting and monitor during treatment. 5
• Remdesivir reduced COVID-19 severity in clinical trials and has emergency use authorization. 4

For hospitalized patients:

• Treatment duration: 5 days for those not requiring mechanical ventilation/ECMO; may extend up to 10 days if no clinical improvement. 5
• Treatment duration: 10 days for those requiring invasive mechanical ventilation and/or ECMO. 5

Corticosteroids

Corticosteroids (dexamethasone) are strongly recommended for hospitalized patients requiring supplemental oxygen to reduce mortality. 3, 4 However, they are not indicated for mild outpatient disease and carry risks including hyperglycemia, immunosuppression, and delayed viral clearance. 4

Common Pitfalls to Avoid

• Do not delay escalation of care: Lower respiratory symptoms and anxiety are the most challenging to manage; maintain a low threshold for escalating respiratory support. 3, 2
• Do not use hydroxychloroquine: The FDA has revoked authorization due to null benefit-risk balance, with no improvement in clinical outcomes and increased mortality. 4
• Do not routinely prescribe antibiotics without evidence of bacterial co-infection, as this contributes to antimicrobial resistance. 3, 4
• Do not use opioid patches in opioid-naive patients due to delayed onset and high morphine equivalence. 1
• Monitor for rapid deterioration: COVID-19 can progress from mild to severe within one week, particularly in vulnerable populations. 6, 4

Additional Supportive Measures

• Albuterol MDI showed high perceived efficacy (>80%) and was commonly used (80.6% of providers), particularly for patients with underlying asthma or reactive airway symptoms. 2
• Non-sedating antihistamines and nasal steroid spray showed high perceived efficacy for upper respiratory symptoms. 2
• Adequate hydration and rest remain cornerstones of supportive care. 1, 3