What are the current inpatient protocols for patients admitted with COVID-19, including the use of Dexamethasone (corticosteroid), Remdesivir (antiviral medication), Baricitinib (Janus kinase inhibitor), pulmonary treatments, anticoagulation, and other additional measures?

Current Inpatient COVID-19 Treatment Protocols

Corticosteroid Therapy: Dexamethasone

All hospitalized COVID-19 patients requiring supplemental oxygen, noninvasive ventilation, or mechanical ventilation should receive dexamethasone 6 mg daily for up to 10 days, as this represents the single most important mortality-reducing intervention. 1, 2, 3

• Dexamethasone reduces mortality by 3% absolute risk reduction in patients requiring oxygen support 3
• The mortality benefit is time-sensitive, so do not delay initiation once oxygen is required 3
• Critical pitfall to avoid: Do NOT administer corticosteroids to hospitalized patients not requiring supplemental oxygen, as there is no mortality benefit and potential harm 1, 3
• Continue for the full 10-day course even if oxygen is discontinued earlier 1

Anticoagulation Strategy

All hospitalized COVID-19 patients should receive prophylactic-dose anticoagulation unless absolute contraindications exist. 4, 1, 2, 3

• Low molecular weight heparin (LMWH) is preferred over unfractionated heparin due to lack of routine monitoring requirements and decreased healthcare worker exposure 2
• Standard prophylactic dosing: enoxaparin 40 mg daily subcutaneously 4
• For patients with obesity (BMI >30 kg/m²), consider 50% dose increase (e.g., enoxaparin 40 mg twice daily or 0.5 mg/kg twice daily) 4
• For critically ill ICU patients, intermediate-dose LMWH can be considered in high-risk patients 4
• Do not change anticoagulant regimen based solely on D-dimer levels 4, 2
• Check platelet count, coagulation parameters, and renal/hepatic function before starting and monitor during treatment 4

Special Anticoagulation Scenarios

• For patients with new-onset atrial fibrillation during hospitalization, start therapeutic-dose parenteral anticoagulation irrespective of CHA2DS2-VASc score 4
• For patients already on anticoagulation for atrial fibrillation, continue therapeutic anticoagulation 4, 2
• For patients on dual antiplatelet therapy (DAPT) for acute coronary syndrome, continue DAPT and add prophylactic-dose anticoagulation 2

Post-Discharge Anticoagulation

• Consider extended-duration thromboprophylaxis for 14-30 days post-discharge in high-risk patients (advanced age, ICU stay, cancer, prior VTE, severe immobility, D-dimer >2 times upper limit of normal, IMPROVE VTE score ≥4) 4
• Use LMWH or a DOAC (rivaroxaban or betrixaban) for extended prophylaxis 4

Remdesivir

Remdesivir should be considered for hospitalized patients not requiring invasive mechanical ventilation, but is NOT recommended for patients on invasive mechanical ventilation or ECMO. 1, 3, 5

Dosing for Adults and Pediatric Patients ≥40 kg:

• Loading dose: 200 mg IV on Day 1 5
• Maintenance dose: 100 mg IV once daily from Day 2 5
• Duration: 5 days for non-ventilated patients (may extend to 10 days if no clinical improvement); 10 days for those requiring invasive mechanical ventilation/ECMO 5
• Administer via IV infusion over 30-120 minutes 5

Monitoring Requirements:

• Perform hepatic laboratory testing before starting and during treatment 5
• Assess prothrombin time before starting and monitor as clinically appropriate 5
• No dosage adjustment needed for renal impairment, including dialysis patients 5

Baricitinib (JAK Inhibitor)

Baricitinib combined with remdesivir and dexamethasone can be considered for hospitalized patients requiring oxygen support, with similar efficacy to dexamethasone plus remdesivir but potentially fewer adverse events. 4, 6

• The combination of baricitinib plus remdesivir showed similar mechanical ventilation-free survival compared to dexamethasone plus remdesivir (87.0% vs 87.6% at day 29), but dexamethasone was associated with significantly more adverse events 6
• Baricitinib is particularly useful when corticosteroid side effects are a concern 6
• The RECOVERY trial and meta-analysis support baricitinib use in hospitalized patients 4
• Typical duration: up to 14 days 7, 8

IL-6 Receptor Antagonists as Alternative Immunomodulation

• Consider tocilizumab or sarilumab for patients with increasing oxygen requirements AND evidence of systemic inflammation (CRP ≥75 mg/L) 2, 3
• Most beneficial when added to corticosteroids within 24 hours of requiring noninvasive or invasive ventilatory support 2
• Reduces combined endpoint of mechanical ventilation or death (OR 0.74,95% CI 0.72-0.88) 2
• Do NOT use IL-6 receptor antagonists for patients not requiring supplemental oxygen 2

Pulmonary/Respiratory Support

High-flow nasal cannula (HFNC) or noninvasive CPAP should be considered for patients with hypoxemic acute respiratory failure without immediate indication for invasive mechanical ventilation. 1, 2

Monitoring Strategy:

• Monitor oxygen saturation at least twice daily, with target SpO2 no higher than 96% if supplemental oxygen is required 3
• Monitor respiratory rate at least twice daily, as this is often the earliest sign of deterioration before oxygen desaturation occurs 3
• Do not delay intubation when noninvasive respiratory support fails or signs of exhaustion appear 3

Treatments NOT Recommended

The following therapies should NOT be used for COVID-19: 1, 2, 3

• Hydroxychloroquine: Strongly recommended against in all COVID-19 patients 1, 2, 3
• Azithromycin: Do not use unless documented bacterial coinfection exists 1, 2, 3
• Lopinavir-ritonavir: Strongly recommended against 1, 2, 3
• Colchicine: Not recommended for hospitalized patients 1, 3
• Interferon-β: Not recommended for hospitalized patients 1, 3
• Routine antibiotics: Only use when clinical suspicion of bacterial infection exists 1, 3

Treatment Algorithm by Oxygen Requirement

Patients NOT Requiring Supplemental Oxygen:

• Prophylactic-dose anticoagulation (LMWH preferred) 1, 3
• Do NOT give corticosteroids 1, 3
• Monitor oxygen saturation and respiratory rate at least twice daily 3

Patients Requiring Supplemental Oxygen (Low-Flow):

• Dexamethasone 6 mg daily for up to 10 days 1, 2, 3
• Prophylactic-dose anticoagulation 1, 2, 3
• Consider remdesivir (200 mg loading, then 100 mg daily for 5 days) 5
• Consider baricitinib as alternative to dexamethasone if side-effect profile favors it 6

Patients Requiring High-Flow Oxygen or Noninvasive Ventilation:

• Dexamethasone 6 mg daily for up to 10 days 1, 2, 3
• Prophylactic-dose anticoagulation (consider intermediate-dose in ICU patients) 4, 2
• Consider adding IL-6 receptor antagonist if CRP ≥75 mg/L and within 24 hours of requiring ventilatory support 2, 3
• Consider remdesivir 5

Patients Requiring Invasive Mechanical Ventilation or ECMO:

• Dexamethasone 6 mg daily for up to 10 days 1, 2, 3
• Prophylactic to intermediate-dose anticoagulation 4
• Do NOT use remdesivir 1, 3
• Consider adding IL-6 receptor antagonist or other immunosuppressant if COVID-19-related inflammation persists despite dexamethasone 3
• Remdesivir duration if started before intubation: complete 10-day course 5

Additional Measures

Infection Prevention:

• Do not use routine antibiotics unless clinical evidence of bacterial infection exists 1, 3

Rehabilitation and Supportive Care:

• Initiate early rehabilitation care when patients are stable 1
• Provide psychological support and mental health interventions for anxiety, fear, and depression 1

Thrombosis Management:

• For confirmed VTE, use treatment-dose LMWH in the inpatient setting and transition to DOACs for post-discharge management 4
• Treatment duration for VTE: at least 3 months 4