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SUMMARY AND RECOMMENDATIONS
• A novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, China at the end of 2019; it has subsequently spread rapidly, resulting in a global pandemic. The disease is designated COVID-19, which stands for coronavirus disease 2019. The virus that causes COVID-19 is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
• The optimal approach to treatment of COVID-19 is uncertain. Our approach is based on limited data and evolves rapidly as clinical data emerge.
• Many patients with known or suspected COVID-19 have mild disease that does not warrant hospital-level care. Having such patients recover at home is preferred, as it prevents additional potential exposures in the health care setting and reduces burden on the health care system. Identification of patients who can be managed in the outpatient setting is discussed in detail elsewhere.
• The evaluation of hospitalized patients with documented or suspected COVID-19 should assess for features associated with severe illness and identify organ dysfunction or other comorbidities that could complicate potential therapy.
• Patients hospitalized with COVID-19 should receive pharmacologic prophylaxis for venous thromboembolism. COVID-19 has been associated with thromboembolic complications. This is discussed in detail elsewhere.
• There are minimal data informing the risks of non-steroidal anti-inflammatory drugs (NSAIDs) in the setting of COVID-19. We suggest acetaminophen as the preferred antipyretic agent, if possible (Grade 2C). If NSAIDs are needed, we use the lowest effective dose. We do not discontinue NSAIDs in patients who are on them chronically for other conditions if there are no other reasons to stop them.
• Specific concern for COVID-19 should not impact the decision to start or stop angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). People who are on an ACE inhibitor or ARB for another indication should not stop their medication.
• We make a point of continuing statins in hospitalized patients with COVID-19 who are already taking them.
Our approach to COVID-19-specific therapy in hospitalized patients depends on the severity of disease. Severe disease is characterized by hypoxia (O2 saturation ≤94 percent on room air) or need for oxygenation or ventilatory support.
• For patients with nonsevere disease, care is primarily supportive, with close monitoring for disease progression. When clinical trials for treatment of nonsevere disease are available, we prioritize those who have laboratory features associated with disease progression.
• For hospitalized patients with severe disease (ie, they have hypoxia) but who are not yet on oxygen, we suggest remdesivir, if available (Grade 2C). We suggest not using dexamethasone in such patients (Grade 2C).
• For hospitalized patients with severe disease who are receiving supplemental oxygen (including those who are on high-flow oxygen and noninvasive ventilation), we suggest low-dose dexamethasone and, if available, remdesivir (Grade 2C).
• For hospitalized patients with severe disease who require mechanical ventilation or extracorporeal membrane oxygenation, we recommend low-dose dexamethasone (Grade 1B). We suggest not routinely using remdesivir in this population (Grade 2C). Although it is reasonable to add remdesivir to dexamethasone in individuals who have only been intubated for a short time (eg, 24 to 48 hours), the clinical benefit of this is uncertain.
• If supplies of remdesivir are limited, we prioritize it for patients who are on low-flow oxygen supplementation at baseline. If dexamethasone is not available, other glucocorticoids at equivalent doses are reasonable alternatives.
• We generally do not use other agents off-label for treatment of COVID-19. In particular, we suggest not using hydroxychloroquine or chloroquine in hospitalized patients given the lack of clear benefit and potential for toxicity (Grade 2B). We also suggest not using lopinavir-ritonavir for COVID-19 therapy in hospitalized patients (Grade 2B).
• Patients with severe disease often need oxygenation support. Some patients may develop acute respiratory distress syndrome (ARDS) and warrant intubation with mechanical ventilation. This is discussed in detail elsewhere.

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