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COVID19 : When to Treat
COVID-19 in Inpatient Care: When to Treat?

Released: October 31, 2024

Expiration: October 30, 2025

Cristina Mussini
Cristina Mussini, MD
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Key Takeaways
  • Risk-based treatment: Prioritize COVID-19 treatments for patients with high risk of severe disease, especially those who are immunocompromised.
  • Antiviral timing: If using antivirals, early intervention is essential.

COVID-19 in Inpatient Care: When to Treat?
Consider a patient who is young, in their late thirties, and immunocompromised due to a recent kidney transplant. This individual presents to the hospital with mild COVID-19 symptoms but is at high risk for severe disease progression. Do we treat them with antivirals? When do we treat, and do we prioritize certain therapies over others? How do we manage the risk of drug–drug interactions with immunosuppressive therapy?

These are the kinds of pressing questions we face in inpatient COVID-19 management. COVID-19 is here to stay, and while it may present as mild in many cases, it remains a substantial threat to many patients, such as those who are immunocompromised. In this commentary, I’ll explore the critical questions in treating hospitalized COVID-19 patients, including whom to treat and which therapies to prioritize.

COVID-19’s Persistent Impact on Healthcare
COVID-19–associated morbidity and mortality have lessened thanks to vaccination and variants that, since Omicron, seem to replicate more in the upper respiratory tract and less in the lungs. But COVID-19 continues to impact hospital resources and treatment planning. In Italy, for example, we still dedicate beds to patients with COVID-19, though we are no longer testing universally.

In many cases, hospitalized patients with COVID-19 are admitted for reasons unrelated to the virus—such as acute surgical needs—yet COVID-19 adds another layer of complexity to their care. Sometimes, COVID-19 is just a “cherry on top,” with the “cake” of underlying conditions being the true driver of their hospitalization.

Understanding Patient Risk Factors for Severe Disease
When deciding whether to treat COVID-19 in hospitalized patients, a key consideration is the patient’s risk for severe disease. Older adults, especially those over 65 years of age, are at increased risk, yet not all elderly patients require treatment; treatment decisions may depend on whether their comorbidities change their prognosis more than their COVID-19.

For immunocompromised patients—regardless of age—the equation changes. These patients may be young, but they are at increased risk for severe COVID and poor outcomes such as intensive care unit (ICU) admission. In addition, the risk for complications increases the longer the patient is hospitalized. Other factors can also worsen prognosis, such as comorbidities like diabetes or obesity.

Therefore, when someone presents with COVID-19 and is immunocompromised due to transplant, cancer, end-stage kidney disease, or dialysis, we must consider treatment. Even if their COVID-19 vaccinations are up to date, their immune response will not match that of immunocompetent patients, placing them at higher risk for poor outcomes.  

In clinical trials, the antivirals nirmatrelvir/ritonavir and remdesivir reduced hospitalizations. But in people already hospitalized, our goal should be to avoid severe pneumonia, avoid ICU admission, and especially avoid acquiring a nosocomial infection in the ICU. Early antiviral treatment can be critical to prevent progression.

Choosing the Right Treatment: Antivirals
In choosing an antiviral, both nirmatrelvir/ritonavir and remdesivir are effective when started early, but we must evaluate each patient’s needs. For example, nirmatrelvir/ritonavir is easy to administer, but the ritonavir component can pose challenges in the inpatient setting; drug–drug interactions with ritonavir might make it unsuitable for transplant patients on antirejection drugs. In addition, some hospitalized patients may be unable to take oral medication. In these situations, intravenous remdesivir may be a choice that avoids drug interactions and supports patients who are unable to take pills. It can also be administered regardless of whether the patient requires oxygen.

Irrespective of which antiviral is started, early intervention is vital, particularly for immunocompromised patients or those admitted for other conditions but who are at high risk of severe COVID-19 progression. For immunocompromised individuals who contract COVID-19—particularly if they’ve been infected within the last 7 days—we treat with antivirals as soon as they are admitted; we do not wait.

Monoclonal Antibodies: Where Will They Fit?
Unlike with antivirals, which are approved for COVID-19 treatment, the role of monoclonal antibodies in COVID-19 care is evolving as variants change. Earlier monoclonal antibodies had their place in treatment during early waves, but they are no longer selective for the variants that are currently circulating. Currently, 2 next-generation monoclonal antibodies—pemivibart and sipavibart—are under investigation or have emergency use authorization as preexposure prophylaxis for SARS-COV-2 infection in the United States, but they are not available in the European Union. [CODER: Please link to https://clinicaloptions.com/activities/infectious-disease/role-of-mab-in-covid-19:-q&a/100004278/content]

Your Thoughts?
The COVID-19 landscape in inpatient care has evolved, yet many questions and complexities remain, particularly when balancing risk, treatment efficacy, and even cost. What challenges do you face in deciding on COVID-19 treatment for hospitalized patients? Are there specific guidelines or practices you find particularly helpful? Share your experiences and insights in the comments below.