COVID-19 Treatment Recommendations for Hospitalized Patients

Oxygen Support and Respiratory Management

The European Respiratory Society suggests high-flow nasal cannula (HFNC) or noninvasive CPAP for patients with hypoxemic acute respiratory failure without immediate indication for invasive mechanical ventilation 1, 2

The European Respiratory Society strongly recommends corticosteroids in patients requiring oxygen, noninvasive ventilation, or invasive mechanical ventilation 3, 1
Dexamethasone 6 mg daily for 10 days is the standard regimen, shown to reduce mortality in patients requiring oxygen support 3, 1
The European Respiratory Society recommends against using corticosteroids in hospitalized patients not requiring supplemental oxygen as there is no mortality benefit and potential harm 3, 1

The European Respiratory Society suggests IL-6 receptor antagonists for patients with increasing oxygen requirements and evidence of systemic inflammation 1, 2
The European Respiratory Society recommends against using IL-6 receptor antagonists for patients not requiring supplemental oxygen 1

The European Respiratory Society and the American College of Chest Physicians strongly recommend offering some form of anticoagulation to all hospitalized COVID-19 patients 1, 4
For patients already on anticoagulation for atrial fibrillation, the American College of Chest Physicians suggests switching to therapeutic dose LMWH or unfractionated heparin if oral anticoagulation needs to be discontinued during hospitalization 4

The European Respiratory Society suggests against using remdesivir for patients requiring invasive mechanical ventilation 1

The European Respiratory Society and other societies strongly recommend against using hydroxychloroquine 1, 5
The European Respiratory Society conditionally recommends against using azithromycin in the absence of bacterial infection 1
The European Respiratory Society strongly recommends against using lopinavir-ritonavir 1

The American College of Chest Physicians recommends dual antiplatelet therapy for patients with acute coronary syndrome and COVID-19 to reduce risk of recurrent ACS or death 4
The American College of Chest Physicians suggests continuing dual antiplatelet therapy for patients on DAPT receiving prophylactic-dose anticoagulant for COVID-19 4
The American College of Chest Physicians recommends continuing antiplatelet therapy and adding prophylactic-dose LMWH for patients with stroke history on antiplatelet therapy 4

The American College of Physicians recommends that all hospitalized COVID-19 patients requiring supplemental oxygen, noninvasive ventilation, or mechanical ventilation should receive dexamethasone 6 mg daily for up to 10 days, as this represents the single most important mortality-reducing intervention in these patients 6
The European Society of Cardiology suggests that low molecular weight heparin (LMWH) is preferred over unfractionated heparin in the inpatient setting due to lack of routine monitoring requirements and decreased healthcare worker exposure 7

The European Respiratory Society recommends considering IL-6 receptor antagonists (tocilizumab or sarilumab) for patients with increasing oxygen requirements AND evidence of systemic inflammation (e.g., CRP ≥75 mg/L), as this therapy is most beneficial when added to corticosteroids in patients within 24 hours of requiring noninvasive or invasive ventilatory support 8
The treatment with IL-6 receptor antagonists reduces the combined endpoint of mechanical ventilation or death (OR 0.74, 95% CI 0.72-0.88) 8

The American College of Chest Physicians suggests monitoring renal function and platelet counts for anticoagulation decisions 7
The treatment algorithm for hospitalized patients requiring supplemental oxygen includes dexamethasone 6 mg daily and prophylactic-dose anticoagulation 6
For patients with increasing oxygen requirements and systemic inflammation, the algorithm includes adding an IL-6 receptor antagonist (if CRP ≥75 mg/L or other markers of inflammation) 8

The American Heart Association advises against changing anticoagulant regimen based solely on D-dimer levels 7