Treatment for patients hospitalized with COVID-19 is continuously evolving. Some medications have proven beneficial over the past year, while others have fallen out of favor. Here we review the most recent guidelines as of August 2021. 

In short, it is recommended to continue home maintenance medications, provide supportive care for non-severe cases of COVID, and, if severely ill, consider dexamethasone, remdesivir, and/or tocilizumab depending on the patient’s oxygen needs. 

NIH recommends continuing home medications for hospitalized patients. This includes ACE inhibitors, ARBs, statins, and aspirin. NSAIDs can also be continued unless there is another reason for discontinuation such as heart failure, renal failure, or GI bleed. Acetaminophen is preferred as an antipyretic in hospitalized COVID patients.

Nebulized medications should be avoided due to the risk of aerosolizing the virus; metered-dose inhalers are preferred when possible. 

VTE prophylaxis (low molecular weight heparin preferred) should be initiated for all hospitalized COVID patients due to the hypercoagulability risk in COVID-19. 

There is less certainty about continuing immunosuppressants such as prednisone or biologic agents while hospitalized for COVID-19. Use must be determined after considering patient-specific factors. 

In the treatment of COVID-19 for hospitalized patients, non-severe cases should be provided with supportive care only. 

For severe cases, treatment is stratified by supplemental oxygen needs. NIH guidelines recommend the following: 

• Patients on room air: 
  • Evidence does not support the use of dexamethasone or remdesivir unless there is a strong likelihood of disease progression, in which case remdesivir can be considered.
• Patients requiring minimal supplemental oxygen:
  • Remdesivir
  • Add dexamethasone if requiring increasing amount of supplemental oxygen
  • Use dexamethasone alone if remdesivir cannot be used or is unavailable
• Patients requiring high-flow device or noninvasive ventilation: 
  • Use dexamethasone, or dexamethasone plus remdesivir.
  • If recently hospitalized with rapidly increasing oxygen needs and inflammation, may add baricitinib or tocilizumab to one of the above options
• Patients requiring IMV or ECMO: 
  • Dexamethasone for most patients
  • If within 24 hours of admission to ICU: dexamethasone plus tocilizumab 

Most guidelines also recommend enrollment in clinical trials for eligible patients, which promotes continued research and makes new treatments available to patients. A list of active trials can be found at clinicaltrials.gov. 

Note: This page is NOT Actively updated so please refer to NIH/CDC and other organizations for the most up to date clinical guideline information.

This article was written by Eva Carlson, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP

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