The treatment and management of COVID-19 combines both supportive care, which includes treatment to relieve symptoms, fluid therapy, oxygen support as needed, and a growing list of approved medications. Highly effective vaccines have reduced mortality related to SARS-CoV-2; for those awaiting vaccination, as well as for the estimated millions of immunocompromised persons who are unlikely to respond robustly to vaccination, treatment remains important. Some people may experience persistent symptoms or disability after recovery from the infection, known as long COVID, but there is still limited information on the best management and rehabilitation for this condition.
Most cases of COVID-19 are mild. In these, supportive care includes medication such as paracetamol or NSAIDs to relieve symptoms (fever, body aches, cough), proper intake of fluids, rest, and nasal breathing. Good personal hygiene and a healthy diet are also recommended. As of April 2020 the U.S. Centers for Disease Control and Prevention (CDC) recommended that those who suspect they are carrying the virus isolate themselves at home and wear a face mask. As of November 2020 use of the glucocorticoid dexamethasone had been strongly recommended in those severe cases treated in hospital with low oxygen levels, to reduce the risk of death. Noninvasive ventilation and, ultimately, admission to an intensive care unit for mechanical ventilation may be required to support breathing. Extracorporeal membrane oxygenation (ECMO) has been used to address respiratory failure, but its benefits are still under consideration. Some of the cases of severe disease course are caused by systemic hyper-inflammation, the so-called cytokine storm.
Although several medications have been approved in different countries as of April 2022, not all countries have these medications. Patients with mild to moderate symptoms who are in the risk groups can take nirmatrelvir/ritonavir (marketed as Paxlovid) or remdesivir, either of which reduces the risk of serious illness or hospitalization. In the US, the Biden Administration COVID-19 action plan includes the Test to Treat initiative, where people can go to a pharmacy, take a COVID test, and immediately receive free Paxlovid if they test positive. In November 2021, the UK approved the use of molnupiravir as a COVID treatment for vulnerable patients recently diagnosed with the disease.
Several experimental treatments are being actively studied in clinical trials. Others were thought to be promising early in the pandemic, such as hydroxychloroquine and lopinavir/ritonavir, but later research found them to be ineffective or even harmful, like fluvoxamine, a cheap and widely available antidepressant; In December 2020, two monoclonal antibody-based therapies were available in the United States, for early use in cases thought to be at high risk of progression to severe disease./ The antiviral remdesivir has been available in the U.S., Canada, Australia, and several other countries, with varying restrictions; it is not recommended for people needing mechanical ventilation and has been discouraged altogether by the World Health Organization (WHO), due to limited evidence of its efficacy.
The WHO, the Chinese National Health Commission, the UK National Institute for Health and Care Excellence, and the United States' National Institutes of Health, among other bodies and agencies worldwide, have all published recommendations and guidelines for taking care of people with COVID-19. As of 2020 Intensivists and pulmonologists in the U.S. have compiled treatment recommendations from various agencies into a free resource, the IBCC.
General support Taking over-the-counter drugs such as paracetamol or ibuprofen, drinking fluids, taking honey to ease a cough, and resting may help alleviate symptoms.
Medications
In the early months of the pandemic, many ICU doctors faced with the virus ventured to prescribe conjectured treatments because of the unprecedented circumstances. The standard of care for most intractable illnesses is that, as it develops over years, doctors build a body of research that tests various theories, compares and contrasts dosages, and measures one drug's power against another.
Antiviral development for SARS-CoV-2 has been disappointing. In January 2020, research into potential treatments started, and several antiviral drugs were in clinical trials. In February 2020 with 'no known effective' treatments, the WHO recommended volunteers take part in trials of the effectiveness and safety of potential treatments. Antiviral medications were tried in people with severe disease. As of March 2020 several medications were already approved for other uses or were already in advanced testing. As of April 2020 trials were investigating whether existing medications could be used effectively against the body's immune reaction to SARS-CoV-2 infection. As of May 2020 several antiviral drugs were under investigation for COVID-19, though none had been shown to be clearly effective on mortality in published randomized controlled trials.
As of February 2021, in the European Union, the use of dexamethasone and remdesivir were authorized. Corticosteroids like dexamethasone have shown clinical benefit in treating COVID-19. As of February 2021, the monoclonal antibody therapies bamlanivimab/etesevimab and casirivimab/imdevimab were found to reduce the number of hospitalizations, emergency room visits, and deaths. and both combination drugs received emergency use authorization by the US Food and Drug Administration (FDA).
As of February 2021 there were Emergency Use Authorizations for baricitinib, bamlanivimab, bamlanivimab/etesevimab, and casirivimab/imdevimab.
As of July 2021, outpatient drugs budesonide and tocilizumab showed promising results in some patients but remained under investigation. As of July 2021, a large number of drugs had been considered for treating COVID-19 patients. As of November 2022, there was moderate-certainty evidence suggesting that dexamethasone, and systemic corticosteroids in general, probably cause a slight reduction in all-cause mortality (up to 30 days) in hospitalized patients with COVID‐19, the evidence was very uncertain at 120 days.
In March 2022, the BBC wrote, "There are now many drugs that target the virus or our body in different ways: anti-inflammatory drugs that stop our immune system overreacting with deadly consequences, anti-viral drugs that make it harder for the coronavirus to replicate inside the body and antibody therapies that mimic our own immune system to attack the virus"Coronavirus treatments: What progress is being made? BBC
The WHO recommendations on which medications should or should not be used to treat COVID-19 are continuously updated. As of July 2022, WHO strongly recommended for non-severe cases nirmatrelvir and ritonavir, and recommended conditionally Molnupiravir, Sotrovimab and Remdesivir. For severe cases WHO strongly recommended corticosteroids, IL-6 receptor blockers or Baricitinib and conditionally recommended casirivimab and imdevimab.
For patients in a life-threatening stage of the illness and in the presence of poor prognostic predictors, early antiviral treatment is essential.
Ineffective treatments As of 2020, several treatments had been investigated and found to be ineffective or unsafe, and are thus were not recommended for use; these include baloxavir marboxil, lopinavir/ritonavir, ruxolitinib, chloroquine, hydroxychloroquine, interferon β-1a, and colchicine. As of 2021, favipiravir and nafamostat had shown mixed results but were still in clinical trials in some countries.
During the early part of 2020 convalescent plasma, plasma from persons who recovered from SARS-CoV-2 infection, was frequently used with anecdotal successes in reports and small case series. Subsequent trials found no consistent evidence of benefit. Conflicting outcomes from trials can be understood by noting that they transfused insufficient therapeutic doses of CCP.
As of February 2021, in the United States, only remdesivir had FDA approval for certain COVID-19 patients, and while early research had suggested a benefit in preventing death and shortening illness duration, this was not borne out by subsequent trials.
On 16 April 2021, the FDA revoked the emergency use authorization (EUA) for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients.
As of July 2022, WHO strongly recommended against treating non-severe cases with convalescent plasma, hydroxychloroquine, lopinavir-ritonavir or colchicine and recommended conditionally against corticosteroids or ivermectin or fluvoxamine or nirmatrelvir and ritonavir WHO also strongly recommended against treating severe cases with hydroxychloroquine or lopinavir-ritonavir or Baricitinib and conditionally recommended against ruxolitinib or tofacitinib, ivermectin or convalescent plasma.
As of September 2022, oral treatment of outpatients with metformin, ivermectin, and fluvoxamine were found to be ineffective in a large randomized, controlled trial.
Adjuvant anticoagulation In general there is no good evidence that anticoagulants have any benefit in the treatment of COVID-19, other than poor quality evidence suggesting a possible effect on all-cause mortality.
Respiratory support
People seriously ill with COVID-19 may require respiratory support. Depending on the severity, oxygen therapy, mechanical ventilation, and intravenous fluids may be required.
Mechanical ventilation
Most cases of COVID-19 are not severe enough to require mechanical ventilation or alternatives, but a percentage of cases are. Some of the people acutely ill with COVID-19 experience deterioration of their lungs and acute respiratory distress syndrome (ARDS) and/or respiratory failure. Due to the high risk of death, urgent respiratory support including mechanical ventilation is often required in these people. Mechanical ventilation becomes more complex as ARDS develops in COVID-19 and oxygenation becomes increasingly difficult.
People who undergo mechanical ventilation are at risk of ventilator-associated lung injury or of worsening an existing lung injury, this damage is called ventilatory-induced lung injury (VILI). The mechanism of this injury is thought to be due to trauma to the lungs caused by aerated regions of the lungs being over swollen (overdistension of the aerated alveoli) and atelectrauma (force on the alveolar that could lead to lung collapse).
Ventilators capable of pressure control modes and optimal PEEP are needed to maximise oxygen delivery while minimising the risk of ventilator-associated lung injury and pneumothorax. An approach to enable the person to breathe spontaneously while being mechanically ventilated by adjusting the level of sedation and the respirator settings has been suggested, with the goal of reducing atrophy of the diaphragm. There is no clear evidence to suggest that enabling spontaneous breathing early while being mechanically ventilated is either beneficial or detrimental for the person's recovery.
Other approaches to mechanical ventilation including avoiding intubation using a high flow nasal cannula or bi-level positive airway pressure are under investigation; their effectiveness compared to intubation is not clear. Some doctors prefer staying with invasive mechanical ventilation when available because this technique limits the spread of aerosol particles compared to a high flow nasal cannula.
The administration of inhaled nitric oxide to people being ventilated is not recommended, and evidence around this practice is weak.
Extracorporeal membrane oxygenation