Department of Family and Preventive Medicine, Emory University, Atlanta, GA (Dr. Kulshreshtha); Department of Pharmacy, Emory University Hospital Midtown/Emory University Hospital, Atlanta, GA (Dr. Sizemore); Department of Family Medicine, Michigan State University, East Lansing (Dr. Barry) akulshr@emory.edu
The authors reported no potential conflict of interest relevant to this article.
Some treatments should not be in your COVID-19 toolbox
High-quality studies are lacking for several other potential COVID-19 treatments. Some of these drugs are under investigation, with unclear benefit and with the potential risk of toxicity—and therefore should not be prescribed or used outside a clinical trial. See “Treatments not recommended for COVID-19,” page E14. 1-4,15-19,33-41
SIDEBAR Treatments not recommended for COVID-191-4,15-19,33-41
Fluvoxamine. A few studies suggest that the selective serotonin reuptake inhibitor fluvoxamine reduces progression to severe disease; however, those studies have methodologic challenges.33 The drug is not FDA approved for treating COVID.33
Convalescent plasma, given to high-risk outpatients early in the course of disease, can reduce progression to severe disease,34,35 but it remains investigational for COVID-19 because trials have yielded mixed results.34-36
Ivermectin. The effect of ivermectin in patients with COVID-19 is unclear because high-quality studies do not exist and cases of ivermectin toxicity have occurred with incorrect administration.39
Hydroxychloroquine showed potential in a few observational studies, but randomized clinical trials have not shown any benefit.15
Azithromycin likewise showed potential in a few observational studies; randomized clinical trials have not shown any benefit, however.15
Statins. A few meta-analyses, based on observational studies, reported benefit from statins, but recent studies have shown that this class of drugs does not provide clinical benefit in alleviating COVID-19 symptoms.16,17,37
Inhaled corticosteroids. A systematic review reported no benefit or harm from using an inhaled corticosteroid.18 More recent studies show that the inhaled corticosteroid budesonide used in early COVID-19 might reduce the need for urgent care38 and, in patients who are at higher risk of COVID-19-related complications, shorten time to recovery.19
Vitamins and minerals. Limited observational studies suggest an association between vitamin and mineral deficiency (eg, vitamin C, zinc, and vitamin D) and risk of severe disease, but high-quality data about this finding do not exist.40,41
Casirivimab + imdevimab [REGEN-COV2]. This unapproved investigational combination treatment was granted an EUA in 2020 for postexposure prophylaxis. The EUA was withdrawn in January 2022 because of the limited efficacy of casirivimab + imdevimab against the Omicron variant of SARS-CoV-2.
Postexposure prophylaxis. National guidelines1-4 recommend against postexposure prophylaxis with hydroxychloroquine, colchicine, inhaled corticosteroids, or azithromycin.
TABLE 27,11-25 and TABLE 326,42-46 provide additional information on treatments not recommended outside trials, or not recommended at all, for COVID-19.
Treatment during hospitalization
The NIH COVID-19 treatment panel recommends hospitalization for patients who have any of the following findings1:
Oxygen saturation < 94% while breathing room air
Respiratory rate > 30 breaths/min
A ratio of partial pressure of arterial O2 to fraction of inspired O2 (PaO2/FiO2) < 300 mm Hg
Lung infiltrates > 50%.
General guidance for the care of hospitalized patients:
Treatments that target the virus have the greatest efficacy when given early in the course of disease.
Anti-inflammatory and immunosuppressive agents help prevent tissue damage from a dysregulated immune system. (See TABLE 326,42-46)
The NIH panel,1 IDSA,2 and WHO3 recommend against dexamethasone and other corticosteroids for hospitalized patients who do not require supplemental oxygen.
Prone positioning distributes oxygen more evenly in the lungs and improves overall oxygenation, thus reducing the need for mechanical ventilation.
Remdesivir.Once a hospitalized patient does require supplemental oxygen, the NIH panel,1 IDSA,2 and WHO3 recommend remdesivir; however, remdesivir is not recommended in many other countries because WHO has noted its limited efficacy.42 Dexamethasone is recommended alone, or in combination with remdesivir for patients who require increasing supplemental oxygen and those on mechanical ventilation.
Baricitinib.For patients with rapidly increasing oxygen requirements, invasive mechanical ventilation, and systemic inflammation, baricitinib, a Janus kinase inhibitor, can be administered, in addition to dexamethasone, with or without remdesivir.47
