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

Last Updated: April 20, 2023

Table 2b. Therapeutic Management of Hospitalized Adults With COVID-19
Disease SeverityRecommendations for Antiviral or Immunomodulator TherapyRecommendations for Anticoagulant Therapy
Clinical ScenarioRecommendation
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,bSee Therapeutic Management of Nonhospitalized Adults With COVID-19.For patients without an indication for therapeutic anticoagulation:
  • Prophylactic dose of heparin, unless contraindicated (AI); (BIII) for pregnant patients
Hospitalized but Does Not Require Oxygen SupplementationAll patientsThe 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,bRemdesivird (BIII)
Hospitalized and Requires Conventional OxygenePatients who require minimal conventional oxygen Remdesivird,f (BIIa)For nonpregnant patients with D-dimer levels above the ULN who do not have an increased bleeding risk:
  • Therapeutic dose of heparinh (CIIa)
For other patients:
  • Prophylactic dose of heparin, unless contraindicated (AI); (BIII) for pregnant patients
Most patientsUse 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 inflammationAdd PO baricitinibg (BIIa) or IV tocilizumabg (BIIa) to 1 of the options above.
Hospitalized and Requires HFNC Oxygen or NIVAll patientsDexamethasone should be administered to all patients (AI). If the patient has not already received a second immunomodulator, promptly add 1 of the following (listed in order of preference):
  • PO baricitinibg,i (AI)
  • IV tocilizumabg,i (BIIa)
Add remdesivir to 1 of the options above in certain patients (CIIa).j 		For patients without an indication for therapeutic anticoagulation:
  • Prophylactic dose of heparin, unless contraindicated (AI); (BIII) for pregnant patients
For patients who are started on a therapeutic dose of heparin in a non-ICU setting and then transferred to the ICU, the Panel recommends switching to a prophylactic dose of heparin, unless there is another indication for therapeutic anticoagulation (BIII).
Hospitalized and Requires MV or ECMOAll patientsDexamethasone should be administered to all patients (AI). If the patient has not already received a second immunomodulator, promptly add 1 of the following (listed in alphabetical order):
  • PO baricitinibg,i (BIIa)
  • IV tocilizumabg,i (BIIa)
Each recommendation in the Guidelines receives a rating for the strength of the recommendation (A, B, or C) and a rating for the evidence that supports it (I, IIa, IIb, or III). 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., those who do not require supplemental oxygen) who are at high risk of progressing 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 baricitinib or tocilizumab are not readily available, start dexamethasone while waiting for the additional immunomodulator to be acquired. If other immunomodulators cannot be obtained or are contraindicated, 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 patients who are immunocompromised. 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; IV = intravenous; MV = mechanical ventilation; NIV = noninvasive ventilation; the Panel = the COVID-19 Treatment Guidelines Panel; PO = oral; ULN = upper limit of normal