Table 2b. Therapeutic Management of Adults Hospitalized for COVID-19 Based on Disease Severity
Last Updated: December 28, 2022
|Disease Severity||Recommendations for Antiviral or Immunomodulator Therapy||Recommendations for Anticoagulant Therapy|
|Hospitalized for Reasons Other Than COVID-19||Patients with mild to moderate COVID-19 who are at high risk of progressing to severe COVID-19a,b||See Therapeutic Management of Nonhospitalized Adults With COVID-19.||For patients without an indication for therapeutic anticoagulation: |
|Hospitalized but Does Not Require Oxygen Supplementation||All patients||The Panel recommends against the use of dexamethasone (AIIa) or other systemic corticosteroids (AIII) for the treatment of COVID-19.c|
|Patients who are at high risk of progressing to severe COVID-19a,b||Remdesivird (BIII)|
|Hospitalized and Requires Conventional Oxygene||Patients who require minimal conventional oxygen||Remdesivirf (BIIa)||For nonpregnant patients with D-dimer levels above the ULN who do not have an increased bleeding risk: |
|Most patients||Use dexamethasone plus remdesivirf (BIIa). If remdesivir cannot be obtained, use dexamethasone (BI).|
|Patients who are receiving dexamethasone and who have rapidly increasing oxygen needs and systemic inflammation||Add PO baricitinibg or IV tocilizumabg to 1 of the options above (BIIa).|
|Hospitalized and Requires HFNC Oxygen or NIV||Most patients||Promptly start 1 of the following, if not already initiated: ||For patients without an indication for therapeutic anticoagulation: |
|Hospitalized and Requires MV or ECMO||Most patients||Promptly start 1 of the following, if not already initiated: |
|Each recommendation in the Guidelines receives 2 ratings that reflect the strength of the recommendation and the quality of the evidence that supports it. See Guidelines Development for more information.|
a For a list of risk factors, see the CDC webpage Underlying Medical Conditions Associated With Higher Risk for Severe COVID-19.
b Ritonavir-boosted nirmatrelvir (Paxlovid) has not been studied in hospitalized patients. The FDA EUA for ritonavir-boosted nirmatrelvir allows for its use in hospitalized patients with mild to moderate COVID-19 (i.e., not requiring supplemental oxygen) who are at high risk for progression to severe COVID-19 and who are within 5 days of symptom onset.
c Corticosteroids that are prescribed for an underlying condition should be continued.
d 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).
e Conventional oxygen refers to oxygen supplementation that is not HFNC oxygen, NIV, MV, or ECMO.
f If these patients progress to requiring HFNC oxygen, NIV, MV, or ECMO, the full course of remdesivir should still be completed.
g If PO baricitinib and IV tocilizumab are not available or not feasible to use, PO tofacitinib can be used instead of PO baricitinib (BIIa), and IV sarilumab can be used instead of IV tocilizumab (BIIa).
h Contraindications for the use of therapeutic anticoagulation in patients with COVID-19 include a platelet count <50 x 109/L, Hgb <8 g/dL, the need for dual antiplatelet therapy, bleeding within the past 30 days that required an ED visit or hospitalization, a history of a bleeding disorder, or an inherited or active acquired bleeding disorder.
i If a JAK inhibitor or an anti-IL-6 receptor mAb is not readily available, start dexamethasone while waiting for the additional immunomodulator to be acquired. If neither of the other immunomodulators can be obtained, use dexamethasone alone.
j Clinicians may consider adding remdesivir to 1 of the recommended immunomodulator combinations in patients who require HFNC oxygen or NIV, including immunocompromised patients. The Panel recommends against the use of remdesivir without immunomodulators in these patients (AIIa).
Key: CDC = Centers for Disease Control and Prevention; ECMO = extracorporeal membrane oxygenation; ED = emergency department; EUA = Emergency Use Authorization; FDA = Food and Drug Administration; HFNC = high-flow nasal cannula; Hgb = hemoglobin; ICU = intensive care unit; IL = interleukin; IV = intravenous; JAK = Janus kinase; mAb = monoclonal antibody; MV = mechanical ventilation; NIV = noninvasive ventilation; the Panel = the COVID-19 Treatment Guidelines Panel; PO = oral; ULN = upper limit of normal