Inpatient Management

Inpatient Management

Risk Factors for Severe COVID-19 Disease

  • Age > 55

  • Pre-existing pulmonary disease

  • Chronic kidney disease

  • Diabetes with A1c > 7.6%

  • History of hypertension

  • History of cardiovascular disease

  • Use of biologics for immune suppression

  • History of transplant or other immunosuppression

  • All patients with HIV (regardless of CD4 count)

  • Healthcare personnel with significant aerosolizing exposure

  • Respiratory rate > 24

  • Heart rate > 125 bpm

  • SpO2 < 90% on room air

  • D-dimer > 1 mcg/mL (1000 ng/mL)

  • CPK > 2 x ULN

  • CRP > 10 mg/dL (100 mg/L)

  • LDH > 245 units/L

  • Elevated troponin

  • Admission absolute lymphocyte count < 0.8

  • Ferritin > 500 ug/L

Clinical Trials

There are no active inpatient clinical trials at this time

General Treatment Considerations

  1. Steroids should be limited to 10 days in most patients. There is little evidence to support their use beyond this in Covid-19. Nearly all published studies evaluating steroids in severe and critically ill patients capped treatment durations near 10 days, regardless of degree of clinical improvement.
  2. If no improvement at 10 days, reevaluate risk v. benefit, especially if patient is receiving another immunosuppressive agent. The benefit of continuing steroids in this situation is unclear with high risk
    • Consider stopping/weaning steroids and monitoring clinical status with a repeat CRP in 2-3 days if concern for rebound inflammation.

Note: Dexamethasone does not need to be tapered in most patients for Covid-19 due to its long biological half-life (36 – 72hr)

  1. Observational studies demonstrate improved mortality when steroids are given to those with CRP >15 – 20, no or unclear benefit with CRP 10-15, and the potential for harm if CRP is <10.
  2. Consider obtaining baseline CRP and avoid escalating immunosuppression if CRP is trending down.