Main ContentManagement of Patients with Suspected SARS-CoV-2 (COVID-19)
Last update: September 9, 2021
The backbone of the treatment strategy for COVID-19 is good quality supportive care as in any viral pneumonia. Certain therapies have shown benefit for COVID-19 and are included in the recommendations below, including inpatient and outpatient treatments. This page will be updated continually as new evidence emerges and based on the availability of treatment regimens.
Management of Hospitalized Patients with COVID-19
Patient Admitted on Nasal Cannula |
Disposition: Consider admission to intensive care unit if older than 65 years of age with a new oxygen requirement, D-dimer > 1,000 ng/L, or RR > 22 breaths/min |
Fluids | Conservative fluid management strategy |
Medications | Evaluate for enrollment in clinical trials |
| Antimicrobials | Consider empiric antibiotics for bacterial pneumonia while COVID-19 results are pending |
| Corticosteroids | Initiate dexamethasone for patients requiring O2; do not continue on discharge |
| Bronchodilators | If needed, use metered dose inhalers and avoid nebulized therapies. |
Coagulopathy | See Anticoagulation Dosing Recommendations for COVID-19 Patients. |
O2 Supplement | Target SpO2 >90%. If oxygen requirement increases to 5 L, call primary team and ICU for evaluation. |
| Consider high-flow nasal cannula at 15 – 30 LPM with surgical mask over patient’s face. |
Patient Admitted to Intensive Care Unit |
Fluids | Conservative fluid management strategy such as daily net neutral fluid balance in patients without evidence of shock |
Medications | Evaluate for enrollment in clinical trials |
| Antimicrobials | Consider empiric antibiotics for bacterial pneumonia while COVID-19 results are pending |
| Corticosteroids | Initiate dexamethasone for patients requiring O2 or mechanical ventilation |
Coagulopathy | See Anticoagulation Dosing Recommendations for COVID-19 Patients. |
O2 /Mechanical Ventilation | Target SpO2 >92%. Consider HFNC at 15-30LPM with surgical mask over patients face. |
| Once intubated, maintain plateau pressures < 30cm H20. Low Vt and high PEEP strategies are controversial. |
| If PaO2/FiO2 < 150, consider early proning and use of paralytics. |
| If PaO2/FiO2 remains < 150 after proning and paralysis, consider cautious use of inhaled vasodilators and ECMO consult. |
Clinical trials
Information about ongoing or potential clinical trials at UMMC can be found in our Clinical Trials database.
Additional comments
- Early intubation for hypoxemic respiratory failure is no longer required.
Agents not recommended for COVID-19 treatment
The agents listed below have no evidence supporting the use for treatment of COVID-19 but can be used for alternative diagnoses or in the context of clinical trials. * = drugs with low supply (recent shortage or currently on allocation) – contact pharmacy with questions.
- HIV protease inhibitors (more on lopinavir/ritonavir below): darunavir, atazanavir
- H2-receptor blockers: famotidine*, cimetidine
- Supplements: zinc*, ascorbic acid*, vitamin D
- Miscellaneous: hydroxychloroquine, IVIG*, interferon, azithromycin, cetirizine, ivermectin
Treatment Information
Approved Therapies |
| Drug | Dose and Duration | Comments |
Remdesivir (Veklury) - Direct acting antiviral
- Allocation decisions made on an individual basis
| Adult - 200 mg IV x 1 followed by 100 mg IV q24h
Pediatric - <40 kg: 5 mg/kg IV load followed by 2.5 mg/kg IV q24h
- ≥40kg: Refer to adult dosing
Duration: 5 days or until no longer hypoxic | FDA approved for patients >12 years old weighing >40 kg. Available through emergency use authorization for pediatric patients <12 years old and/or <40 kg. Pediatric criteria: - Peds ID must be consulted for the use of remdesivir.
- Remdesivir is recommended for children 12-15 years old with risk factors for severe disease and are requiring oxygen.
- Remdesivir is recommended for children ≥16 years old who are requiring oxygen regardless of risk factors.
Adult criteria: - Adult ID must be consulted for the use of remdesivir.
- Requires O2 sat ≤94% or oxygen supplementation
- Low-flow nasal cannula
- High-flow nasal cannula within 24 hours of being placed on oxygen
- No benefit seen in patients who are already mechanically ventilated
Monitoring: - Requires baseline eGFR and ALT
- Contraindicated with ALT > 10x UNL
A/E: Increased ALT/AST.
|
Corticosteroids
Dexamethasone - Initiate in patients requiring mechanical ventilation or oxygen
- Do not start in patients not requiring oxygen
| Adult Preferred: Dexamethasone 6-10 mg IV/PO* daily Duration: 10 days or until no longer hypoxic | Decreased mortality shown in the RECOVERY trial Not recommended for the treatment of non-hospitalized or non-hypoxic patients Pediatric considerations: Corticosteroids are recommended in pediatric patients who require mechanical ventilation, high flow oxygen, non-invasive ventilation, ECMO. They are not routinely recommended for patients only on low flow oxygen. Adult considerations: Corticosteroids are recommended for all patients requiring oxygen. Additional assessment - Monitor blood sugar
- Elevations in WBC can occur with corticosteroid use
|
Investigational Therapies |
Convalescent Plasma | Only available through clinical trials | |
Tocilizumab (Actemra) - Adjunctive agent that targets IL-6
- Sarilumab can be used as a substitute for tocilizumab if out of stock. See information below.
| Adult 8 mg/kg IV x1 dose - Use total body weight for dosing
- Doses will be rounded to the nearest available full vial (80 mg, 200 mg, 400 mg vials)
- Max dose = 800 mg
Pediatric Insufficient evidence for tocilizumab in hospitalized children with COVID or MIS-C.
Dosing: <30 kg = 12 mg/kg; ≥30 kg = 8 mg/kg (max 800 mg)
Duration: 1 dose | Mortality benefit shown in certain adult patient populations REMAP-CAP and RECOVERY trials; the FDA EUA for tocilizumab applies to patients 2 years of age and older. **Adults and peds ID MUST be consulted to use tocilizumab. Tocilizumab should only be used in combination with corticosteroids.** Inclusion Criteria: - Symptoms <10 days
- Hospitalized <48 hours
- Patients who are rapidly progressing and are requiring >4L nasal cannula
- CRP ≥7.5
Exclusion Criteria:
- Current bacterial or fungal co-infection
- Unlikely to survive >48 hours
- Mechanical ventilation
Risk/benefit discussion for pregnant women. A/E: Increased ALT/AST, infusion related reactions, hematologic dyscrasias, increased LDL, secondary infections |
Sarilumab (Kevzara) - Adjunctive agent that targets IL-6
- Substitute for tocilizumab if out of stock.
- Patients who meet inclusion criteria will undergo a secondary review for eligibility, and it does not guarantee receiving sarilumab. Given the limited supply, sarilumab allocation will be determined based on disease severity, risk factors, and overall clinical status.
| Adult 400 mg x 1 dose Pediatric Insufficient evidence for tocilizumab in hospitalized children with COVID or MIS-C. Duration: 1 dose | Mortality benefit shown in certain adult patient populations REMAP-CAP trial. **Adults and peds ID MUST be consulted to use sarilumab. Sarilumab should only be used in combination with corticosteroids.** Inclusion Criteria: - Symptoms <10 days
- Hospitalized <48 hours
- Patients who are rapidly progressing and are requiring >4L nasal cannula
- CRP ≥5
Exclusion Criteria: - Current bacterial or fungal co-infection
- Unlikely to survive >48 hours
- Mechanical ventilation
Risk/benefit discussion for pregnant women. A/E: Increased ALT/AST, infusion related reactions, hematologic dyscrasias, increased LDL, secondary infections |
Information on drug interactions and administration for patients who cannot swallow can be found at: http://www.covid19-druginteractions.org/
Management of Non-Hospitalized Patients with Mild-Moderate COVID-19
At this time, no therapies have shown a favorable risk/benefit profile for outpatient treatment of COVID-19, including corticosteroids, azithromycin, and ivermectin. The FDA has approved the REGEN-COV™ (casirivimab/imdevimab) monoclonal antibodies for the use in outpatient adult and pediatric patients with mild-moderate COVID-19 who are at high risk of disease progression. In addition, it can be used in high-risk patients with a COVID-19 exposure who are either not fully vaccinated or fully vaccinated but immunocompromised. The monoclonal antibodies should not be used for patients who are hospitalized with COVID-19, require oxygen therapy for COVID-19, or have an increase in baseline oxygen flow rate due to COVID-19.
The criteria defined by the EUA for both monoclonal antibodies are below and can easily be accessed using the SmartPhrase “.COVIDABINFSCREENING”: FOR TREATMENT OF MILD-MODERATE COVID-19 Initial Screening Criteria - Within 10 days from symptom-onset
- ≥12 years of age
- Weighs ≥40kgs /88lbs.
FOR POST-EXPOSURE PROPHYLAXIS (PEP) OF COVID-19 Vaccine Status - Vaccinated and immunocompromised*
- Unvaccinated
Initial Screening Criteria - Within 7 days of close contact
- ≥12 years of age
Weighs ≥40kgs /88lbs.
Patient must meet the 3 criteria above (for treatment PEP) PLUS 1 of the following risk factors for disease progression: 12-64 years of age AND have - Body mass index (BMI) ≥25 or BMI ≥85th percentile for their age and gender based on CDC growth charts, https://www.cdc.gov/growthcharts/clinical_charts.html
- Chronic kidney disease or
- Diabetes or
- Cardiovascular disease/hypertension (including congenital heart disease) or
- Chronic lung disease (COPD, mod-severe asthma, interstitial lung disease, cystitic fibrosis, pulmonary HTN) or
- Immunosuppressive disease* or
- Currently receiving immunosuppressive treatment (chemotherapy, transplant immunosuppressants, immune modulators such as Rituximab, etc.)
- Sickle cell disease or
- Neurodevelopmental disorders or other conditions that confer medical complexity or
- Medical-related technological dependence (tracheostomy, gastrostomy, or PPV not related to COVID-19) or
- Pregnant
*AIDS or CD4 count < 200, Complement deficiency, Grafts-Vs-Host disease (GVHD), HIV infection, Immunoglobulin deficiency/ Immunodeficiency, Immunosuppressive therapy (within the last 12 months), Leukemia, Lymphoma (Hodgkin’s/ Non-Hodgkin’s (NHL)), Metastatic cancer, Multiple Myeloma, Solid organ malignancy, Steroid therapy (within past 2 weeks), Bone marrow transplant (BMT) or peripheral stem cell transplant (PSCT), Solid organ transplant |
The monoclonal antibodies should not be used for patients who are hospitalized with COVID-19, require oxygen therapy for COVID-19, or have an increase in baseline oxygen flow rate due to COVID-19.
Currently UMMC only has access to REGEN-COV. If you are a UMMC provider and have a patient who you think may qualify for the monoclonal antibodies, please fill out the screening form (.COVIDABINFSCREENING) in Epic and send it to “P COVID-19 MONOCLONAL ANTIBODIES REQUEST”. Prior to sending the requests, please ensure the positive COVID-19 test is available to review in the chart.
Disclaimer
These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.