Step-by-step guide to treating covid

4 minute read

Guidelines for primary care and emergency physicians treating covid now include the latest research.

As Australia prepares to scrap compulsory isolation for covid patients and Victoria declares residents are no longer mandated to report a positive test, the pandemic is far from over. 

With an average of more than 5000 cases still being reported every day in Australia (as of October 4), frontline health professionals like GPs continue to see presentations across the covid spectrum. 

The National COVID-19 Clinical Evidence Taskforce has released a flowchart to provide clinicians with detailed guidance on treating patients with mild to severe symptoms. 

Recommendations for eight drugs for adults who don’t need supplemental oxygen, and another six for those who do, are outlined in the chart, which is published on the taskforce’s website. 

A further 10 drugs have been labelled “do not use”, including hydroxychloroquine, aspirin, azithromycin, interferon B-1a and ivermectin. The experts also recommend clinicians “do not routinely use” dexamathasone (or any other systemic corticosteroid) to treat covid in adults who do not require oxygen. 

The flowchart suggests doctors consider treating adults with mild covid who have one or more risk factors for disease progression, with the combination medicine casirivimab/imdevimab (Ronapreve, Roche), within a week of symptom onset. However, in patients infected with Omicron variants BA.1, BA.2, BA.4 or BA.5, the recommendations advise only considering Ronapreve “where other treatments are not suitable or available”, as the limited evidence available suggests reduced efficacy against these variants.

Inhaled corticosteroids can also be used within two weeks of symptom onset. 

In unvaccinated adults who have mild covid and one or more risk factors for disease progression, doctors can also consider using one of the following, antiviral agents remdesivir (Veklury, Gilead Sciences) or nirmatrelvir plus ritonavir (Paxlovid, Pfizer) or combined monoclonal antibody treatment tixagevimab plus cilgavimab (Evusheld, AstraZeneca). 

Remdesivir can be given within a week of symptom onset, while nirmatrelvir plus ritonavir and tixagevimab plus cilgavimab must be given within five days. 

Experts recommend considering all treatments, except for casirivimab/imdevimab and inhaled corticosteroids, for patients with mild covid who are immunocompromised and who are at a particularly high risk of severe disease, due to advanced age and multiple risk factors. 

They also agreed that the antiviral agent molnupiravir (Lagevrio, Merck) could be used in unvaccinated adults with one or more risk factors for disease progression, those who are immunocompromised or those who are at a particularly high risk of severe disease, if other treatments are not suitable or available. 

In patients with severe to critical covid, who need supplemental oxygen, the only treatment strongly recommended is systemic corticosteroids. These patients should be treated with intravenous or oral dexamethasone for up to 10 days. 

The antiviral agent remdesivir was conditionally recommended for adults who required supplemental oxygen but not hospitalised patients who required non-invasive or invasive ventilation. 

The taskforce provided more extensive guidelines on the suggested therapies for neonates, children and adolescents, pregnancy and perinatal care, patients on chemotherapy and for venous thromboembolism prophylaxis. 

For patients receiving ACE inhibitors or ARBs for the treatment of hypertension, the guidelines strongly recommend continuing these medications unless contraindicated. 

The authors backed the use of inhaled or oral steroids as usual in patients with asthma and COPD, but not nebulisers. They also advised women taking menopausal hormone therapy and oestrogen-containing contraception to continue as usual. 

In response to reported increase in harms, the guidelines conditionally recommended against elective surgery within eight weeks of recovery from acute covid. The taskforce also conditionally recommended multisystem pre-operative assessment of people who subsequently undergo surgery.  

Dozens of therapies have been recommended against, except in appropriately controlled clinical trials, including metformin, doxycycline, vitamin C, vitamin D analogues, opaganib, ensovibep and zinc. 

The full list of recommendations, as well as the latest updates, can be found on the taskforce’s website. 

MJA 2022, online 3 October   

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