SUMMARY AND RECOMMENDATIONS
●Indications for hospitalization – Many patients with known or suspected COVID-19 have mild disease that does not warrant hospital-level care. Having such patients recover at home is preferred, as it prevents additional potential exposures in the health care setting and reduces the burden on the health care system. Indications for hospitalization and identification of patients who can be managed in the outpatient setting are discussed in detail elsewhere. (See “COVID-19: Outpatient evaluation and management of acute illness in adults”, the section on ‘Determine if in-person evaluation warranted’.)
●Evaluation – The evaluation of hospitalized patients with documented or suspected COVID-19 should assess for features associated with severe illness and identify organ dysfunction or other comorbidities that could complicate potential therapy.
●Thromboprophylaxis – Patients hospitalized with COVID-19 should receive pharmacologic prophylaxis for venous thromboembolism. COVID-19 has been associated with thromboembolic complications. This is discussed in detail elsewhere.
●Antipyretics – We suggest acetaminophen for fever reduction in patients with COVID-19 rather than non-steroidal anti-inflammatory drugs (NSAID. This approach is the same as that in the general population. If NSAIDs are needed, we use the lowest effective dose. However, we do not discontinue NSAIDs in patients who are on them chronically for other conditions if there are no other reasons to stop them. Observational data do not indicate an association between NSAIDs and poor COVID-19 outcomes.
●Continuing chronic medications – Specific concern for COVID-19 should not impact the decision to start or stop angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). People who are on an ACE inhibitor or ARB for another indication should not stop their medication.
We continue statins in hospitalized patients with COVID-19 who are already taking them. We also continue aspirin unless there is a concern for bleeding risk.
●Approach to nonsevere disease – For patients with the nonsevere disease (O2 saturation >94 percent and no need for oxygenation or ventilatory support), care is primarily supportive, with close monitoring for disease progression. When clinical trials for the treatment of nonsevere disease are available, we prioritize those who have laboratory features associated with disease progression. Additionally, we evaluate whether patients with the nonsevere disease (ie, mild to moderate COVID-19) who are hospitalized for reasons other than COVID-19 would be eligible for monoclonal antibody therapy, as with certain high-risk outpatients.
●Approach to severe disease – For patients with severe disease (O2 saturation ≤94 percent on room air or need for oxygenation or ventilatory support), the approach to COVID-19-specific therapy depends on the level of support.
•For hospitalized patients with hypoxia who are not yet on oxygen, we suggest redeliver, if available (Grade 2C). We suggest not using dexamethasone in such patients (Grade 2C).
•For hospitalized patients who are receiving low-flow supplemental oxygen, we suggest low-dose dexamethasone and, if available, remdesivir (Grade 2C). For patients who have significantly elevated inflammatory markers (eg, C-reactive protein [CRP] level ≥75 mg/L) and escalating oxygen requirements despite dexamethasone, we suggest adding either baricitinib or tocilizumab on a case-by-case basis (Grade 2C). If supplies of tocilizumab or baricitinib are limited, we prioritize them for more severely ill patients on higher levels of oxygen support.
•For hospitalized patients who are receiving high-flow supplemental oxygen or non-invasive ventilation, we recommend low-dose dexamethasone (Grade 1B). For those who are within 24 to 48 hours of admission to an intensive care unit (ICU) or receipt of ICU-level care, we suggest either baricitinib or tocilizumab in addition to dexamethasone (Grade 2B). We also suggest adding remdesivir (Grade 2C); however, if supplies are limited, we prioritize remdesivir for patients who are on low-flow oxygen supplementation at baseline.
•For hospitalized patients with severe disease who require mechanical ventilation or extracorporeal membrane oxygenation, we recommend low-dose dexamethasone (Grade 1B). For those who are within 24 to 48 hours of admission to an ICU, we suggest adding tocilizumab to dexamethasone (Grade 2B). We suggest not routinely using remdesivir in this population (Grade 2C). Although it is reasonable to add remdesivir to dexamethasone in individuals who have only been intubated for a short time (eg, 24 to 48 hours), the clinical benefit of this is uncertain.
•If dexamethasone is not available, other glucocorticoids at equivalent doses are reasonable alternatives.
●Limited role for other therapies – We generally do not use other agents off-label for the treatment of COVID-19. In particular, we suggest not using hydroxychloroquine or chloroquine in hospitalized patients given the lack of clear benefit and potential for toxicity (Grade 2B). We also suggest not using lopinavir-ritonavir for COVID-19 therapy in hospitalized patients (Grade 2B). We suggest not routinely using convalescent plasma for hospitalized patients with severe disease outside a clinical trial because a clear clinical benefit has not been demonstrated (Grade 2B).
●Management of hypoxia – Patients with severe disease often need oxygenation support. Some patients may develop acute respiratory distress syndrome (ARDS) and warrant intubation with mechanical ventilation. This is discussed in detail elsewhere.
●Infection control – Infection control is an essential component of the management of patients with suspected or documented COVID-19.
COVID-19. Updates: https://oliviahospital.lk/covid-19/
