The COVID-19 Textbook

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CHAPTER 15 • Treatment of COVID-19 in Adults

hospitalized for unrelated reasons, and there may be a lower threshold to hospitalize elderly, frail, or chronically ill individuals. In this situation, therapeutic management of COVID-19 is more similar to nonhospitalized patients than to hospitalized patients with hypoxemia and severe disease. Remde sivir should be considered for patients at high risk for progression to severe disease. 4,23 These patients should not receive corticosteroids for the treatment of COVID-19 because of potential harm in those who do not require oxygen. 4,20 Patient With Supplemental Oxygen Requirement, Not on High-Flow Nasal Cannula Oxygen or Noninvasive Ventilation Remdesivir has been approved by the FDA for use in hospitalized patients with COVID-19 and is recommended for patients who are hospitalized with severe COVID-19. 4 In patients who have more than a minimal supplemental oxygen requirement, dexamethasone is usually added because of its demonstrated benefit in reducing mortality. 4,20 If patients are already receiving dexamethasone but are experiencing rapid increases in oxygen requirement and have evidence for systemic inflammation (eg, elevated C-reactive protein), addition of a second immunomodulatory drug, such as baricitinib or tocilizumab, is recommended. 4 Patient on High-Flow Nasal Cannula Oxygen or Noninvasive Ventilation These patients should receive dexamethasone plus either baricitinib or tocilizumab. 4 If neither ba ricitinib nor tocilizumab are available, an alternative Jak inhibitor (tofacitinib) or IL-6 antagonist (sarilumab) may be used instead. Remdesivir should be added, particularly if the patient is early in the course of infection or immunosuppressed (because ongoing viral replication is more likely in such patients). Patient on Mechanical Ventilation or Extracorporeal Membrane Oxygenation Pharmacologic options in this group are similar to those in the preceding group. In addition to medications, patients require critical supportive care using approaches such as those implemented in patients without COVID-19 (eg, patients with acute respiratory distress syndrome). Similar to patients on high-flow oxygen by nasal cannula and noninvasive mechanical ventilation, patients on mechanical ventilation or ECMO reflect a group with a severe systemic inflammatory response to the virus and the trial data for the use of adjunctive immunomodulator therapy are even stronger in this group. Dexamethasone and either baricitinib or tocilizumab should be initiated as early as possible in the clinical management of patients with rapid progression of pulmonary/systemic illness. 4 If remdesivir was initiated earlier in a patient’s hospital course prior to the need for mechani cal ventilation or ECMO, then the treatment course is typically continued. However, remdesivir is generally not initiated in patients on mechanical ventilation or ECMO as trial data have not shown a benefit. 22 Management of Cardiac Complications Because of COVID-19 Patients hospitalized with COVID-19 may develop cardiac disease. Evaluation for cardiac mani festations is now routine. Cardiac abnormalities can include myocardial injury, myocarditis, stress cardiomyopathy, acute coronary syndrome, arrhythmias, and conduction disease. Several factors go into the baseline assessment. Cardiac troponin levels are mildly elevated in a large fraction of hospitalized patients with COVID-19. Marked rise in troponin levels during illness suggest acute myocarditis or acute coronary syndrome. An electrocardiogram (ECG) should also be obtained to assess ST segment and T-wave morphology reflective of myocardial injury or ischemia, as well as the PR segment and QRS morphology for evidence of conduction disease. Further cardiac diagnostic evaluation is based on patient-specific presentation and whether the results of testing will alter clinical management. For patients with new-onset heart failure symp toms, arrhythmias, or ECG changes, further evaluation with echocardiography may be indicated to assess for evidence of systolic dysfunction. For patients with evidence of myocardial ischemia such as troponin elevation or ST segment/T-wave derangements, further evaluation for coronary disease may be warranted with cardiac stress testing or coronary computed tomographic angiography or invasive angiography. Treatment follows typical management strategies, independent of the presence of COVID-19.

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