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Figure 2. Therapeutic Management of Adults Hospitalized for COVID-19 Based on Disease Severity

Therapeutic Management for Hospitalized Adults With COVID-19 Based on Disease Severity
a Corticosteroids that are prescribed for an underlying condition should be continued.
b If the patient progresses to requiring high-flow oxygen, NIV, MV, or ECMO, complete the full course of remdesivir (refer to Table A).
c Evidence suggests that the benefit of remdesivir is greatest when the drug is given early in the course of COVID-19 (e.g., within 10 days of symptom onset). Clinical trials have not demonstrated a mortality benefit for remdesivir, but a large, placebo-controlled trial showed that the use of remdesivir reduced time to clinical recovery in hospitalized patients. See Rationale for the Use of Remdesivir below. 
d Drugs are listed alphabetically. There are no studies that directly compare the use of baricitinib and tocilizumab, and there is insufficient evidence to recommend a drug or class of drug (i.e., JAK inhibitors, anti-IL-6 receptor mAbs) over the other. Treatment decisions should be based on local guidance, drug availability, and patient comorbidities.
e If baricitinib and IV tocilizumab are not available or not feasible to use, tofacitinib can be used instead of baricitinib (BIIa) and IV sarilumab can be used instead of IV tocilizumab (BIIa).
f Contraindications for the use of therapeutic anticoagulation in patients with COVID-19 include platelet count <50 x 109/L, Hgb <8 g/dL, the need for dual antiplatelet therapy, bleeding within the last 30 days that required an ED visit or hospitalization, a history of a bleeding disorder, or an inherited or active acquired bleeding disorder. This list is based on the exclusion criteria from clinical trials; patients with these conditions have an increased risk of bleeding.
g Either LMWH or UFH heparin can be used. In general, LMWH is preferred.
h The Panel recommends against the use of baricitinib in combination with tocilizumab for the treatment of COVID-19, except in a clinical trial (AIII). Because both baricitinib and tocilizumab are potent immunosuppressants, there is the potential for an additive risk of infection.
i The combination of dexamethasone plus remdesivir may be considered for patients who have recently been intubated (CIII). The Panel recommends against the use of remdesivir monotherapy in these patients (AIIa).
 
Key: ECMO = extracorporeal membrane oxygenation; ED = emergency department; Hgb = hemoglobin; ICU = intensive care unit; IL = interleukin; IV = intravenous; JAK = Janus kinase; LMWH = low-molecular-weight heparin; mAb = monoclonal antibody; MV = mechanical ventilation; NIV = noninvasive ventilation; the Panel = the COVID-19 Treatment Guidelines Panel; UFH = unfractionated heparin; ULN = upper limit of normal; VTE = venous thromboembolism