COVID-19 Treatment Approach

Introduction to Treatment

• The American College of Rheumatology recommends a combination of systemic glucocorticoids and tocilizumab for patients with COVID-19 requiring oxygen therapy, as this approach reduces disease progression and mortality 1

Treatment Based on Disease Severity

• For non-hospitalized patients with SARS-CoV-2 infection, there is currently no evidence to support the initiation of immunomodulatory therapy, according to the European League Against Rheumatism 1, 2
• In patients at high risk for severe COVID-19 with symptom onset <5 days or who are still seronegative, monoclonal antibodies against SARS-CoV-2 spike protein should be considered, as recommended by the Infectious Diseases Society of America 1
• For hospitalized patients who do not require oxygen therapy, there is no evidence to support the initiation of immunomodulatory therapy to treat COVID-19, as stated by the European Respiratory Society 1, 2
• Routine deferral of chemotherapy in all asymptomatic SARS-CoV-2 positive patients with hematological malignancies is not advisable, with treatment decisions based on individual risk-benefit assessment, according to the European Hematology Association 3
• In patients requiring supplemental oxygen, non-invasive or mechanical ventilation, systemic glucocorticoids should be used as they decrease mortality; most evidence concerns dexamethasone, as recommended by the American Thoracic Society 1, 2
• The combination of glucocorticoids and tocilizumab should be considered since it reduces disease progression and mortality, according to the National Institutes of Health 1
• The combination of glucocorticoids with baricitinib or tofacitinib could be considered as it might decrease disease progression and mortality, as suggested by the European Medicines Agency 1

Severe COVID-19 with ARDS

• For COVID-19-related ARDS, lung-protective ventilation strategies are recommended, including low tidal volume ventilation (4-8 mL/kg), targeting plateau pressures <30 cm H₂O, and implementing higher PEEP (>10 cm H₂O), as recommended by the Society of Critical Care Medicine 4
• Prone positioning for 12-16 hours is recommended for mechanically ventilated patients with moderate to severe ARDS, according to the American College of Chest Physicians 4
• A conservative fluid strategy is recommended rather than liberal fluid management, as stated by the European Society of Intensive Care Medicine 4

Medications to Avoid or Use with Caution

• Hydroxychloroquine should be avoided for treating any stage of SARS-CoV-2 infection since it does not provide additional benefit to standard care and could worsen prognosis, particularly if co-prescribed with azithromycin, as recommended by the Centers for Disease Control and Prevention 1, 2
• There is no robust evidence to support the use of anakinra or canakinumab at any disease stage, according to the European League Against Rheumatism 1
• There is no robust evidence to support the use of low-dose colchicine at any disease stage, as stated by the American College of Rheumatology 1
• In patients without hypogammaglobulinemia and with symptom onset >5 days, there is robust evidence against the use of convalescent plasma, according to the National Institutes of Health 1

Special Populations

• In patients with rheumatic and musculoskeletal diseases, continuing JAK2-inhibitors and TKI/BTKi during COVID-19 is recommended, as suggested by the European League Against Rheumatism 3
• Ensure clinical and virological resolution of COVID-19 before resuming chemotherapy in patients with rheumatic diseases, according to the American College of Rheumatology 3
• Patients with hematological malignancies, particularly lymphoproliferative disorders, are at higher risk for severe COVID-19, as stated by the European Hematology Association 3
• Cellular therapy (HSCT, CAR-T) should be deferred in patients with COVID-19 or asymptomatic SARS-CoV-2 infection, according to the American Society for Transplantation and Cellular Therapy 3

Diagnostic Considerations

• SARS-CoV-2 molecular NAT assays are recommended for diagnosis, targeting at least two distinct viral gene sequences, as recommended by the World Health Organization 3
• Lower respiratory tract fluid sampling is recommended in patients with symptoms/signs of lower respiratory tract infection and negative nasopharyngeal swab tests, according to the Infectious Diseases Society of America 3
• Testing for other pathogens should be performed in symptomatic patients with negative SARS-CoV-2 tests to rule out superinfection, which is a common complication, as stated by the Centers for Disease Control and Prevention 3, 5

Treatment Pitfalls and Caveats

• The "hit early-hit hard" principle with antivirals is crucial, as early administration can shorten the course of clinical illness and reduce viral shedding, according to the International Society for Influenza and other Respiratory Virus Diseases 6
• Immunosuppression reduction should be considered carefully, as possible disadvantages like immune reconstitution syndrome may occur, as recommended by the European Society for Medical Oncology 5
• High-dose steroids are generally associated with prolonged viral shedding in respiratory viral infections, but low-dose steroids (<1 mg/kg/day) have shown benefit in COVID-19, according to the Society of Critical Care Medicine 5, 4
• Empiric antimicrobial/antibacterial agents should be considered for mechanically ventilated COVID-19 patients with respiratory failure, with daily assessment for de-escalation, as recommended by the Infectious Diseases Society of America 4