Clinical Practice Guideline: Recommendations on the In-hospital Treatment of Patients with COVID-19

Abstract

Background: The mortality of COVID-19 patients who are admitted to a hospital because of the disease remains high. The implementation of evidence-based treatments can improve the quality of care.

Methods: The new clinical practice guideline is based on publications retrieved by a systematic search in the Medline databases via PubMed and in the Cochrane COVID-19 trial registry, followed by a structured consensus process leading to the adoption of graded recommendations.

Results: Therapeutic anticoagulation can be considered in patients who do not require intensive care and have an elevated risk of thromboembolism (for example, those with D-dimer levels ≥ 2 mg/L). For patients in intensive care, therapeutic anticoagulation has no benefit. For patients with hypoxemic respiratory insufficiency, prone positioning and an early therapy attempt with CPAP/noninvasive ventilation (CPAP, continuous positive airway pressure) or high-flow oxygen therapy is recommended. Patients with IgG-seronegativity and, at most, low-flow oxygen should be treated with SARS-CoV-2-specific monoclonal antibodies (at present, casirivimab and imdevimab). Patients needing no more than low-flow oxygen should additionally be treated with janus kinase (JAK) inhibitors. All patients who need oxygen (low-flow, high-flow, noninvasive ventilation/CPAP, invasive ventilation) should be given systemic corticosteroids. Tocilizumab should be given to patients with a high oxygen requirement and progressively severe COVID-19 disease, but not in combination with JAK inhibitors.

Conclusion: Noninvasive ventilation, high-flow oxygen therapy, prone positioning, and invasive ventilation are important elements of the treatment of hypoxemic patients with COVID-19. A reduction of mortality has been demonstrated for the administration of monoclonal antibodies, JAK inhibitors, corticosteroids, tocilizumab, and therapeutic anticoagulation to specific groups of patients.

Figure 1

Possible escalation of device-based therapy in case of acute respiratory insufficiency due to COVID-19 *Initial setting: CPAP (10 mbar); NIV (PEEP 5–10 mbar + 6–10 mbar); target: Vt<9 mL/kg RR, respiratory rate; O2, oxygen therapy; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; DNI, do not intubate; FiO2, fraction of inspired oxygen; NIV, non-invasive ventilation“ PaO2, arterial partial pressure of oxygen in mm Hg; PEEP, positive end-expiratory pressure; SpO2, oxygen saturation in the blood; Vt, tidal volume

Figure 2

Overview of the recommendations for drug therapy for COVID-19, according to disease severity *¹ WHO clinical progression scale (34) *² Data refer to the overall group of disease severity evaluated in randomized controlled trials (WHO scale). Effects in specific subgroups may differ. *³ If same-day determination of the serostatus is not possible, patients with inadequate immunization (one vaccination, no vaccination or severe immunosuppression) may be treated with approved antibody drugs or antibody drugs recommended by the European Medicines Agency (EMA) within 72 hours for a maximum of 7 days after symptom onset (expert consensus). Green = recommended drugs; red = not recommended drugs JAK inhibitors, janus kinase inhibitors; NIV, noninvasive ventilation, CPAP, continuous positive airway pressure, CI, confidence interval