COVID-19 Treatment Recommendations
For outpatients with mild COVID-19 who are at high risk for progression, initiate nirmatrelvir/ritonavir (Paxlovid) or molnupiravir as soon as possible after diagnosis and within 5 days of symptom onset. 1
Treatment Stratified by Disease Severity
Mild COVID-19 (Outpatient)
High-risk patients require early antiviral therapy:
Initiate nirmatrelvir/ritonavir (Paxlovid) or molnupiravir within 5 days of symptom onset for patients with risk factors including age >60 years, obesity, diabetes, cardiovascular disease, chronic lung disease, immunosuppression, or active malignancy 1
Anti-SARS-CoV-2 monoclonal antibodies should be considered if available and active against circulating variants 1
Remdesivir can be considered for high-risk patients within 7 days of symptom onset 1
Do NOT use corticosteroids in patients not requiring supplemental oxygen, as they can be harmful in this phase 1, 2
Symptomatic management:
Use paracetamol (acetaminophen) for fever and associated symptoms, but avoid using antipyretics solely to reduce body temperature 2
Maintain regular fluid intake (no more than 2 liters daily) to prevent dehydration 2
For distressing cough, consider simple linctus or honey; reserve codeine linctus, codeine phosphate, or morphine sulfate oral solution only for cough significantly impacting quality of life 2
Employ non-pharmacological breathing techniques including pursed-lip breathing, forward-leaning position, and breathing retraining for breathlessness 2
Moderate COVID-19 (Hospitalized, Requiring Oxygen)
Dexamethasone 6 mg daily for 10 days is the cornerstone of therapy and reduces mortality in patients requiring supplemental oxygen 1, 3
Additional therapies:
Remdesivir is recommended for hospitalized patients not on mechanical ventilation 1
For seronegative patients, consider casirivimab/imdevimab or convalescent plasma 1
If worsening despite dexamethasone with COVID-19-related inflammation, add a second immunosuppressant such as anti-IL-6 agents (tocilizumab or sarilumab) 1
Anticoagulation prophylaxis is strongly recommended for all hospitalized patients; consider intensified prophylaxis with therapeutic dose low molecular weight heparin (LMWH) in patients with additional risk factors (obesity, known thrombophilia, elevated D-dimers) 1, 3
Severe/Critical COVID-19 (ICU, High-Flow Oxygen, or Mechanical Ventilation)
Dexamethasone is strongly recommended and has proven mortality benefit 1, 3
Immunomodulation:
Addition of a second immunosuppressant is recommended if COVID-19-related inflammation is present, with anti-IL-6 agents (tocilizumab, sarilumab) preferred over other options 1
For seronegative patients on non-invasive ventilation, casirivimab/imdevimab may be considered 1
Antiviral considerations:
- Remdesivir may be considered, though evidence is mixed for critically ill patients; the European Respiratory Society suggests against its use for patients requiring invasive mechanical ventilation 1
Respiratory support:
High-flow nasal cannula (HFNC) or noninvasive CPAP is suggested for patients with hypoxemic acute respiratory failure without immediate indication for invasive mechanical ventilation 1
Patients with severe hypoxemia or high respiratory rate should undergo intubation and invasive ventilation 3
Treatments NOT Recommended
Avoid these interventions as they lack benefit or cause harm:
Hydroxychloroquine is strongly recommended against due to null benefit-risk balance and increased mortality 1, 4
Azithromycin should not be used in the absence of bacterial infection 1
Lopinavir-ritonavir is strongly recommended against due to no clinical benefit and high adverse event rate 1, 4
Special Populations and Considerations
Immunocompromised patients:
Pre-exposure prophylaxis with long-acting anti-SARS-CoV-2 monoclonal antibodies is recommended for unvaccinated or high-risk patients with hematological malignancies 1
Post-exposure prophylaxis with monoclonal antibodies for high-risk individuals not expected to mount adequate immune response to vaccination 1
Traditional Chinese Medicine integration:
- For patients in regions where TCM is practiced, "three CPMs and three decoctions" (Jinhua Qinggan granules, Lianhua Qingwen capsules/granules, Xuebijing injection, Qingfei Paidu decoction, Huashi Baidu decoction, Xuanfei Baidu decoction) combined with usual care can reduce severe conversion rates 5
Rehabilitation and Mental Health
Initiate rehabilitation as soon as oxygenation and hemodynamics are stable:
All patients should be screened for rehabilitation needs including physical deconditioning, respiratory, cognitive, and mental health disorders before discharge 5
Provide education on breathing control techniques (high side lying, forward lean sitting, pursed lip breathing) and gradual resumption of activities 5
Mental health support is essential:
More than 60% of COVID-19 patients experience anxiety and depression 5
For mild symptoms, use breath relaxation training, mindfulness training, and Tai Chi 5
For moderate to severe symptoms, combine medication with psychotherapy and cognitive behavioral therapy 5
Common Pitfalls to Avoid
Critical timing errors:
Do not delay antiviral therapy in high-risk outpatients; efficacy depends on administration within 5 days of symptom onset 1
Do not use corticosteroids in patients not requiring oxygen, as this can worsen outcomes 1, 2
Monitoring failures:
Actively monitor for thromboembolism signs (stroke, deep vein thrombosis, pulmonary embolism, acute coronary syndrome) and initiate appropriate diagnostic pathways immediately if suspected 5
For patients with suspected myocardial injury, repeat high-sensitivity troponin measurements daily with continuous ECG monitoring 5
Drug interactions:
- Nirmatrelvir/ritonavir has serious drug interaction risks; review all medications, supplements, and herbal products before prescribing 1