COVID-19: The Importance of Early Treatment

How do we treat patients with critical illness due to COVID-19? I’d like to share how my team had to use nearly every medication class in the COVID-19 armamentarium to treat a patient with life-threatening illness, and how this underscores the importance of starting treatment early and correctly.

Patient Case
A few months ago, a 30-year-old male with severe obesity—who was not vaccinated against SARS-CoV-2 infection—presented to our emergency department with a chief complaint of progressive shortness of breath over the preceding week. He stated that it was originally not his plan to seek medical care for his symptoms, but he ultimately became so unwell that he decided to go to the emergency department for care.

Upon presentation, he was noted to have hypoxemia with an oxygen saturation of 80%, tachycardia with a heart rate of 120 beats per minute, and tachypnea with a respiratory rate of 35 breaths per minute. This patient ultimately tested positive for SARS-CoV-2.

Clinical Progression
Given his severe clinical presentation, this patient was quickly intubated, put on invasive mechanical ventilation, and transferred to the medical ICU, which is where I work. In the medical ICU, we simultaneously administered remdesivir, anticoagulation, corticosteroids, and tocilizumab.

Had this patient required less oxygen and had his clinical course not escalated so quickly, we would have followed the National Institutes of Health COVID-19 treatment guidelines of starting with remdesivir or corticosteroids (or the combination of the two) and then adding a second immunomodulatory agent (eg, baricitinib or tocilizumab) as his oxygen demands increased.

However, this patient was so ill that we did not have time to use these therapies in a stepwise fashion. Rather, we had to quickly use everything we could to optimize treatment combinations with agents that had complementary mechanisms of action—regardless of trial and error of previous agents and combinations.

Despite administering these therapies and performing aggressive ventilatory maneuvers, this patient’s clinical condition continued to worsen, and he soon developed severe acute respiratory distress syndrome. Based on this, we tried more conventional critical care interventions, including prone positioning, positive end-expiratory pressure maneuvers, antibiotics (in case there was a bacterial superinfection), nitric oxide, and neuromuscular blockade. All these failed to halt his respiratory decline, and we ultimately had to put the patient on venovenous extracorporeal membrane oxygenation (VV ECMO).

Clinical Improvement
It was a stormy course for this patient. But at about 3 weeks on VV ECMO, his lungs gradually started to recover, and he survived to ECMO decannulation. Unfortunately, he was left with lingering effects of critical illness, including neuromuscular weakness and delirium. Slowly, those conditions improved. After aggressive physical therapy and ventilator weaning, we were happy to announce that, after 2 months in the hospital, he was fit enough to go home back to his family.

The patient came back to see us a few weeks after and walked with us for a few rounds of the ICU. He is one of the many success stories we’ve had throughout the pandemic.

Reflection
This patient presented late after symptom onset and with such severe symptoms that he was not a candidate for outpatient COVID-19 treatments. Based on when this patient became infected with SARS-CoV-2, had he presented sooner, when his disease course was milder, he could have potentially received treatment with an oral antiviral agent (within 5 days of symptom onset) or monoclonal antibody (within 7 days of symptom onset).

If this patient had presented as a high-risk outpatient during the current wave of omicron subvariants, we could have administered an oral antiviral agent or a 3-day course of IV remdesivir.

To me, this patient’s case also underscores the importance of COVID-19 vaccination, especially in patients with comorbidities, to prevent progression to severe illness and hospitalization.

To learn more about the optimal use of antiviral agents, monoclonal antibodies, and anti-inflammatories/immunomodulators for COVID-19, see the modules on COVID-19: Which Drug, When, and Why?

Your Thoughts?
What combinations of COVID-19 therapeutics have you used successfully in critically ill patients with COVID-19? Answer the polling question and join the conversation by posting a comment.