COVID-19 TRAINING FOR HEALTHCARE WORKERS 

COVID-19: Therapeutics 
Sophia Cohen, MD 
Matthew Strehlow, MD 
 
LEARNING OBJECTIVES 
At the end of this lecture, the learner will be able to: 
1. Recognize that the mainstays of treatment are supportive care and steroids 
2. Recognize that there are minimal proven therapeutics for COVID-19 patients 
3. Limit use of nebulizers because it can aerosolize virus  
 
LECTURE OVERVIEW 
I. Therapeutics 
II. Inhaled Bronchodilators 
III. Fluid Resuscitation 
IV. Vasopressors for Septic Shock 
 
I. THERAPEUTICS 
As of September 2020, the only proven therapy is steroids, all other treatments are investigational.   
It is important to recognize that the treatment of COVID-19 is frequently changing as we discover more 
information about it. 
1. Investigational agents 
● Ongoing clinical trials 
● All medications controversial due to uncertainty and or toxicity 
● There is insufficient evidence; therefore, do not use these medications routinely unless 
instructed by local healthcare agency or if enrolled in a clinical trial 
● Do not send patient home with any of these medications: 
o Hydroxychloroquine/Chloroquine 
▪ No clear benefit [1] 
 ▪ Can cause QTc prolongation which can lead to ventricular dysrhythmias 
and death [2] 
▪ If giving it for treatment, it is generally recommended patients stay in 
hospital to monitor QTc. Follow local guidelines. 
▪ Dosing:  
● Hydroxychloroquine (oral): 400 mg twice daily for 1 day, then 400 
mg daily for 4-7 days. Only continue if still hospitalized  
● Chloroquine (oral): 1 gram on day 1, then 500 mg daily for 4-7 days 
o Azithromycin with ​Hydroxychloroquine or Chloroquine 
▪ Can cause QTc prolongation which can lead to ventricular dysrhythmias 
and death [2] 
o Remdesivir 
▪ RNA dependent RNA polymerase inhibitor 
▪ Contact Gilead directly for use: compassionateaccess@gilead.com 
▪ RCT from China, 237 COVID + pts [3] 
● No change in mortality rate or clinical improvement  
▪ Study, 1,063 COVID positive patients, funded by drug company [4] 
● Trend towards mortality benefit  
● Faster time to recovery (median 11 vs. 15 days) 
o Lopinavir/ritonavir-protease inhibitors  
▪ No clear benefit [5] 
o Tocilizumab  
▪ Not readily available 
2. Antipyretics  
● Acetaminophen/Paracetamol 
o 1,000 mg every 6 hours as needed for fever [6] 
● Non-steroidal anti-inflammatory drugs (NSAIDs) 
o May be used [7] 
o Use with caution if patient has elevated creatinine on labs or known kidney 
disease   
3. Antibiotics 
● Begin empiric treatment for bacterial pneumonia for sick, febrile undifferentiated patient 
[8] 
 o Azithromycin and ceftriaxone or locally recommended treatment regimen for 
severe pneumonia 
o Continue if  
▪ Cannot do COVID-19 PCR testing -and/or- 
▪ Lobar consolidation on CXR  
● Incidence of bacterial co-infection in patients with COVID-19 is unknown at this time, 
however, it is estimated that bacterial co-infection is rare [9] 
● Avoid vancomycin as coinfection with MRSA is rare but kidney injury in COVID-19 patients 
is common. If MRSA coverage is needed, use linezolid or ceftaroline if available.  
4. Steroids 
● RECOVERY trial, RCT for COVID-19 patients [10]: 
o 2,104 patients given dexamethasone 6 milligrams once per day (IV or PO) for 10 
days compared to 4,321 patients who had usual care (No steroids) 
o Dexamethasone 
▪ Reduced deaths by 1/3 in ventilated patients (p=0.0003) 
▪ Reduced deaths by 1/5 in patients only getting oxygen (p=0.0021) 
▪ No benefit if patients didn’t need respiratory support (oxygen or 
ventilator) (p=0.14) 
● Also beneficial in patients who are also having an asthma or COPD exacerbation 
5. Convalescent Plasma  
● Mostly observational studies, yet to have a large randomized controlled trial 
● Studies inconsistent with dose, titer and timing of plasma administration 
● Dose: 1 or 2 units of plasma (200 or 250 milliliters per unit) 
● May be beneficial [11-14] 
○ Hospitalized covid-19 patients with respiratory distress or hypoxia, if given 
early in the disease course  
● Less beneficial [12, 14] 
○ Hospitalized covid-19 patients who are intubated with multi-organ failure  
○ If given later in disease course  
6. Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker  
● If patient was on this medication as an outpatient, you can continue it, but stop it if 
patient has an acute kidney injury or is hypotensive [15,16] 
7. DVT Prophylaxis in hospitalized patients  
 ● COVID-19 patients are hypercoagulable, therefore, DVT prophylaxis is recommended for 
hospitalized patients [8]. Follow your local protocol/guidelines. 
● Continue unless platelets < 30 x 10​9​/Liter 
 
II. INHALED BRONCHODILATORS 
1. Indication:​ if bronchospasm is present (i.e. Chronic Obstructive Pulmonary Disease (COPD) or 
Asthma exacerbation) 
2. Medication:​ Albuterol and Ipratropium  
3. Route of Administration 
o Metered Dose Inhaler (MDI) 
▪ Preferred over nebulizer because ​MDI doesn’t aerosolize virus 
▪ 8 puffs are equivalent to 1 nebulizer treatment  
▪ 8 puffs with a spacer every 20 minutes, 4 breaths in between puffs (see video 
for demonstration) 
o Nebulization treatment 
▪ Higher risk of aerosolization of virus, increasing viral transmission, therefore, 
avoid if possible [17] 
▪ Use in negative pressure room, if not available, use in well ventilated room 
4. Albuterol​ dosing 
o Intermittent: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as 
needed  
-OR-  
o Continuous: 0.5 mg per kg per hour (maximum 15mg/hour) 
5. Ipratropium ​dosing 
o 0.25-0.5 mg every 20 minutes for 2-3 doses  
 
III. FLUID RESUSCITATION 
1. Fluid of choice: crystalloids (examples: normal saline, lactated ringer) 
2. Remember #1 problem in COVID-19 is hypoxemic respiratory failure, which can become worse 
when given fluids 
3. Initial Resuscitation of hypotensive COVID-19 patient​ [6,8] 
o Give fluid bolus: 500 mL 
 o Check for fluid responsiveness 
▪ Capillary refill 
▪ Skin temperature 
▪ Heart rate 
▪ Mental status 
▪ Lactate (if available) 
o If fluid responsive, repeat above steps 
o If not fluid responsive and still hypotensive, start vasopressors  
4. Post-resuscitation fluid management​ [6] 
o Target a​ ​normal fluid volume for patient 
o Lower amount of fluids  
o Avoid continuous fluids   
o If patient has a positive fluid balance, consider diuretics 
 
IV. VASOPRESSORS FOR SEPTIC SHOCK ​[6] 
1. Titrate vasopressors to a mean arterial pressure (MAP) of 60-65 mmHg 
2. Norepinephrine(NE)/Noradrenaline 
o 1​st​ line if available  
3. Vasopressin 
o Use if NE is not available 
o Add as 2​nd​ vasopressor if NE is at maximum dose 
4. Epinephrine (Adrenaline) 
o Use if NE and vasopressin not available or effective 
o Use as 3​rd​ vasopressor if NE and vasopressin are at maximum dose 
5. Dopamine 
o Only use if other vasopressors are not available 
 
SUMMARY 
I. Oral Therapeutics 
II. Inhaled Bronchodilators 
III. Fluid Resuscitation 
IV. Vasopressors for Septic Shock 
_____________________________________________________________________________ 
ADDITIONAL INFORMATION 
Asthma and COPD Treatments 
1. Asthma exacerbation  
o Steroids 
▪ Dexamethasone  
● 0.6mg/kg IV or by mouth (maximum 16mg); 2nd dose 24 hours later 
▪ Prednisone  
● 40-80mg/day in one or two divided doses for 5 days 

▪ Methylprednisolone  

● 1mg/kg IV every 4–6 hours 

o Albuterol/Ipratropium 
▪ See above in inhaled therapeutics  
o Magnesium 
▪ 25-75 mg/kg over 30 minutes (2-3 grams IV needed in most adults) 
o Epinephrine (adrenaline) -OR- Terbutaline 
▪ Consider if unresponsive to the above treatments  
▪ Epinephrine (adrenaline): ​0.01 mg/kg (max 0.5mg) of the 1 mg/mL 
concentration subcutaneous or intramuscular every 20 minutes for up to 3 
doses 
▪ Terbutaline​: 0.25 mg subcutaneous or intramuscular every 20 minutes for up 
to 3 doses 
2. COPD exacerbation  
o Steroids 
▪ Methylprednisolone 1-2 mg/kg IV daily  

▪ Prednisone 60 mg on day 1, then 40mg PO daily for 5 additional days 

o Albuterol/Ipratropium 
▪ See above in inhaled therapeutics  
o Antibiotics 
▪ Give if patient has pus in sputum, increased sputum production, or needs 
noninvasive positive pressure ventilation  
 ▪ Antibiotic choice per local recommendations. Example therapies are listed 
below. 
▪ Outpatient and healthy give a 3-5 day course of 
● Azithromycin -OR- 
● Doxycycline 
▪ Outpatient and unhealthy (​age >65 years, known cardiac disease, >3 
asthma/COPD exacerbations per year) 
● Levofloxacin, Moxifloxacin OR Amoxicillin/Clavulanate  
 
 
 
 
REFERENCES/SUGGESTED READING: 
1. Tang W, Cao Z, Han M. Hydroxychloroquine in patients mainly with mild to moderate 
COVID-19: an open-label, randomized, controlled trial. medRxiv 2020; published online May 7. 
DOI.;10(2020.04):10-20060558. 
https://www.medrxiv.org/content/10.1101/2020.04.10.20060558v2.full.pdf 
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Baía-da-Silva D, Guerra MV, Hajjar LA. Effect of high vs low doses of chloroquine diphosphate 
as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome 
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Apr 1;3(4):e208857-. 
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adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre 
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https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31022-9/fulltext 
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https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflam
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 https://doi.org/10.1182/blood.2020007079 
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