Active COVID-19 Clinical Pathway – All Settings – COVID-19 Treatment Recommendations

Active COVID-19 Clinical Pathway – All Settings

COVID-19 Treatment Recommendations

  • Antiviral therapies (remdesivir and nirmatrelvir-ritonavir) are most effective when initiated as early as possible after illness onset
  • Maximum treatment durations for remdesivir, dexamethasone and baricitinib are listed.
  • Treatment should be stopped once child is well enough to be discharged.
Non-Hospitalized Children
  Antiviral Treatment Immunomodulator Anticoagulation Comments
High-Risk Condition
  • < 12 yrs or < 40 kg
    • Supportive care
 Not recommended None
  • Remdesivir is not routinely recommended and not available at CHOP for outpatients.
  • For very high-risk children and/or those unable to receive Paxlovid, admission for remdesivir administration can be considered on a case-by-case basis in discussion with relevant subspecialists and ID.
  • ≥ 12 yrs old and ≥ 40 kg
    • Consider Paxlovid within 5 days of symptom onset:
      • Nirmatrelvir 300 mg
        2 × 150 mg tablets
      • and
      • Ritonavir 100 mg
        1 × 100 mg tablet
        BID × 5 days
    • Dosing adjustment in renal impairment: eGFR 30 – < 60 mL/min
      • Nirmatrelvir 150 mg
        1 × 150 mg tablets
      • and
      • Ritonavir 100 mg
        1 × 100 mg tablet
        BID × 5 days
    • eGFR < 30 mL/min or HD
No High-Risk Condition Supportive care  
Hospitalized Children with Mild/Moderate Illness
  Antiviral Treatment Immunomodulator Anticoagulation Comments
High-Risk Underlying Condition
  • Consider remdesivir
    • 5 mg/kg IV loading dose on day 1
      Max 200 mg
    • followed by
    • 2.5 mg/kg IV daily × 2 days
      Max 100 mg
  • For infants 1.5 kg – < 3 kg
Not recommended Anticoagulation per COVID-19 Recommendations  
No High-Risk Underlying Condition Supportive care
Hospitalized Children with Severe Illness
  Antiviral Treatment Immunomodulator Anticoagulation Comments
Conventional Oxygen
  • Remdesivir
    • 5 mg/kg IV loading dose on day 1
      Max 200 mg
    • followed by
    • 2.5 mg/kg IV daily on days 2–5
      Max 100 mg
  • For infants 1.5 kg – < 3 kg
Consider adding dexamethasone for adolescents with rapidly increasing oxygen needs Anticoagulation per COVID-19 Recommendations  
Hospitalized Children with Critical Illness
  Antiviral Treatment Immunomodulator Anticoagulation Comments
Non-Invasive Mechanical Ventilation/High-Flow Oxygen
  • Remdesivir
    • Not routinely recommended
    • May consider on a case-by-case basis early in disease symptoms < 10 days
  • Dexamethasone
    • 0.15 mg/kg/dose q24hr for up to 10 days
    • Max 6 mg
  • Not rapidly improving with steroids within 24 hrs, consider adding baricitinib or tocilizumab
    • First-line: Baricitinib
      • 2–8 yrs
        2 mg once daily PO × 14 days
      • ≥ 9 yrs
        4 mg once daily PO × 14 days
    • Alternative: Tocilizumab
      • < 30 kg
        12 mg/kg IV as a single dose
      • ≥ 30 kg
        8 mg/kg as a single dose
 Anticoagulation per COVID-19 Recommendations
  • Review tocilizumab or baricitinib prescribing steps.
  • Consider ID consult if considering use of tocilizumab or baricitinib.
  • Higher doses of dexamethasone may be considered on a case-by-case basis for children with ARDS per CHOP formulary.
  • There are limited data for dosing baricitinib in children < 2 yrs old. Recommend discussion with ID and clinical pharmacy on a case by case basis.
Mechanical Ventilation or ECMO Remdesivir
Not recommended
  • Dexamethasone
    • 0.15 mg/kg/dose q24hr for up to 10 days
    • Max 6 mg
  • Not rapidly improving with steroids within 24 hrs, consider adding baricitinib or tocilizumab
    • First-line: Baricitinib
      • 2–8 yrs
        2 mg once daily PO × 14 days
      • ≥ 9 yrs
        4 mg once daily PO × 14 days
    • Alternative: Tocilizumab
      • < 30 kg
        12 mg/kg IV as a single dose
      • ≥ 30 kg
        8 mg/kg as a single dose
 Anticoagulation per COVID-19 Recommendations

See CHOP formulary for complete dosing information.