The management of COVID-19 is dynamic and changes as new variants emerge. Thus far, Omicron has the greatest number of gene mutations. It is unaffected by most therapeutic antibodies and effectively evades humoral immunity gained from prior infection or vaccination.[7] Thus, new therapies and adjusted protocols have been adopted.[7,8,9]
Sotrovimab is a monoclonal antibody administered as a 1-hour outpatient intravenous infusion within 10 days of mild or moderate symptom onset in patients at high risk for severe COVID-19 progression. A 1-hour observation period after the infusion is required to ensure good tolerance. The US Food and Drug Administration has updated the emergency use authorization for sotrovimab, which is no longer authorized to treat COVID-19 in any US region owing to the Omicron BA.2 subvariant.[10]
Remdesivir is a broad-spectrum antiviral that requires intravenous infusion for 3-5 consecutive days within 7 days of mild or moderate symptom onset in patients at high risk for severe COVID-19 progression. It can be administered in an outpatient or inpatient setting, depending on symptom severity and patient feasibility. In an inpatient setting, remdesivir and dexamethasone are recommended for those who require supplemental oxygen.
Baricitinib and dexamethasone can be administered, in addition to remdesivir, to patients with rapidly worsening hypoxia and systemic inflammation. This inpatient Janus kinase (JAK1/JAK2) inhibitor and corticosteroid combination therapy is discontinued at discharge.
Tocilizumab and dexamethasone can be administered, in addition to remdesivir, within 24 hours of admission to an intensive care unit (ICU) for COVID-19 complications. This inpatient monoclonal antibody and corticosteroid combination therapy is discontinued at discharge.
In patients who require oxygen supplementation, dexamethasone should be stopped after 10 days to prevent adverse events from prolonged corticosteroid use.[8,9] Baricitinib is administered orally and may be continued for up to 14 days with renal dosing adjustments.[8,9] Tocilizumab inhibits interleukin-6 and is a single-dose intravenous infusion; a second dose may be given 8 hours later if there is no appreciable clinical improvement.[8,9] In addition, supportive care and prevention of further transmission with a 5-day isolation followed by wearing a mask for the next 5 days are recommended for all symptomatic patients found to be positive for the COVID-19 Omicron variant.
The patient in this case was admitted for correction of her electrolyte abnormalities and fluid resuscitation. She was also found to be positive for COVID-19 by rRT-PCR and received remdesivir. She was placed on isolation precautions. The hematology/oncology service was consulted regarding the patient's history of lymphoma and current lymphopenia, and no further intervention was recommended because her abnormal white blood cell count was attributed to COVID-19. Throughout her hospitalization, she received a consistent carbohydrate diet and sliding-scale insulin for diabetes management. Upon discharge, she was scheduled for outpatient follow-up with her primary care provider.
Editor's Note: The discussion in this Case Challenge applies to COVID-19 diagnosis and treatment recommendations as of April 19, 2022. This scenario will not be regularly updated, and users are encouraged to find the latest information in Medscape's COVID-19 Resource Center.
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