Zulfiqar Rana, MD, MPH, FACP

This article is for providers.

Guidelines

---

• CDC
• WHO
• Mass General

Treatment strategy for COVID-19

---

• Step 1 risk stratification
• Treatment based on risk
• Special considerations

Risk Stratification

---

Criteria for clinical severity of confirmed cases of COVID 19:

• Mild  (Hx, PE, Imaging)
  • MILD clinical symptoms: – fever less than 38°C, whether without cough, – no dyspnea, no gasping, – no chronic disease;
  • no imaging findings of pneumonia
• Moderate (Hx, PE, Imaging)
  • fever,
  • respiratory symptoms,
  • imaging findings suggestive of pneumonia
• Severe – any of the following:
  • respiratory distress, RR greater than 30 minute;
  • SPO to less than 93% at rest
  • PaO2/FiO2 < 300 mmHg
  • the rapid progression (greater than 50%) on CT imaging within 24 – 48 hours
• Critical – any of the following:
  • respiratory failure
  • needs mechanical assistance
  • shock
  • extra pulmonary organ failure
  • ICU is needed

Treatment

---

Mild – outpatient

• • Symptoms +
  • Infiltrates –
  • NO Hypoxia (oxygen saturation ≤94 percent on room air) OR Need for oxygenation or ventilatory support

– No treatment

– Monoclonal antibody The US Food and Drug Administration (FDA) issued EUAs for bamlanivimab and for the combination casirivimab-imdevimab for non-hospitalized COVID-19 patients with mild to moderate illness (eg, not requiring supplemental oxygen or, if on chronic supplemental oxygen, without an increased oxygen requirement) who have certain risk factors for severe disease [73,74]. These risk factors for adults (≥18 years) include any of the following:

• Body mass index (BMI) ≥35 kg/m²
•  Chronic kidney disease
•  Diabetes mellitus
•  Immunosuppression (immunosuppressive disease or treatment)
•  ≥65 years of age
•  ≥55 years of age and who have cardiovascular disease, and/or hypertension, and/or chronic obstructive pulmonary disease (or other chronic respiratory disease)

If either of these monoclonal antibodies are used, they are to be given as a single intravenous dose as soon as possible after a positive SARS-CoV-2 test, within 10 days of symptom onset.

Moderate

• Symptoms +
• Infiltrates +
• NO Hypoxia (oxygen saturation > 94 percent on room air) OR Need for oxygenation or ventilatory support

Severe

• Symptoms +
• Infiltrates +
• Hypoxia PRESENT (oxygen saturation ≤94 percent on room air) OR Need for oxygenation or ventilatory support

– Patients with severe disease but NOT on Oxygen

Remdesivir but NO dexamethasone

– Patients with severe disease but REQUIRING Oxygen

Remdesivir PLUS dexamethasone Alternatives to Dexamethasone include (MGH): – Hydrocortisone IV 50mg q8hrs (or q6h for refractory shock co-indication) – Methylprednisolone IV 30mg daily – Prednisone PO 40mg qd All patients admitted to inpatient for COVID-19 (including non-critically ill) should receive standard prophylactic anticoagulation with LMWH in the absence of any contraindications (active bleeding or platelet count less than 25,000); monitoring advised in severe renal impairment; abnormal PT or APTT is not a contraindication. 1. If CrCl >30mL/min – use Lovenox 40mg sc daily 2. If CrCl <30mL/min) – use UFH (see Dosing Guidelines). 3. In obese patients (BMI >40 kg/m2 or >120 kg), the recommended dose is 40 mg bid (for renal failure, see Dosing Guidelines) 4. If history of HIT or HITT, use non heparin alternative. 5. If anticoagulation is contraindicated, patients should have mechanical prophylaxis (eg: pneumo- boots).

Critical: ICU/ARDS/Ventilator/ shock/ organ failure/ CRS

• Ventilator settings
• Management of shock
• Management of organ failure
• Specific therapies