COVID19 treatment

Death from COVID19 usually from cytokine storm and multi-organ failure (often resulting in secondary haemophagocytic lymphohistiocytosis).

NICE has risk factors for young people 12-16yrs:

  • Complex life limiting neurodisability

Otherwise you need 2 of the following to justify treatment in ill (hospitalised) patient:

  • Primary immunodeficiency:
  • Secondary immunodeficiency viz:
    • HIV with CD4 count less than 200 cells per mm3
    • solid organ transplant
    • stem cell transplant (HSCT) within 12 months, or with graft versus host disease (GVHD)
    • CAR-T cell therapy in last 24 months
    • induction chemotherapy for ALL etc
  • Immunosuppressive treatment:
    • chemotherapy within the last 3 months
    • cyclophosphamide within the last 3 months
    • corticosteroids greater than 2 mg per kg per day for 28 days in last 4 weeks
    • B-cell depleting treatment in the last 12 months
  • Other conditions:
    • high body mass index (BMI; greater than 95th centile)
    • severe respiratory disease (for example, cystic fibrosis or bronchiectasis with FEV1 less than 60%)
    • tracheostomy or long-term ventilation
    • severe asthma (paediatric intensive care unit [PICU] admission in 12 months)
    • neurodisability and/or neurodevelopmental disorders
    • severe cardiac/chronic kidney/liver disease
    • sickle cell disease or other severe haemoglobinopathy
    • trisomy 21
    • complex or chromosomal genetic or metabolic conditions associated with significant comorbidity, multiple congenital anomalies associated with significant comorbidity
    • bronchopulmonary dysplasia – decisions should be made taking into account degree of prematurity at birth and chronological age
    • infants less than 1 year with cyanotic CHD, or haemodynamically significant acyanotic CHD with history of prematurity, or those due for corrective surgery (to avoid complications or delay)


WHO recommends dexamethasone 150mcg/kg once daily for 10 days for severe/critical COVID19 disease, on basis of REACT metanalysis.

Severe defined as any of:

  • Sats <90%
  • Tachypnoea (>30 in over 5s, >40 over 2 etc)
  • Severe respiratory distress

Critical defined as ARDS, septic shock or anything else that would require critical care.


For Patients at ‘high risk’ of complications (as above, in particular immunocompromise) plus:

  • >4 weeks of age and at least 3kg 
  • Within 10 days of symptoms onset

NOT for patients requiring ventilatory support unless high risk, and not for ALT > 5x upper limit of normal .

5mg/kg loading dose on day 1, followed by 2.5mg/kg once a day for 4 days. May be extended to 10 days in immunocompromised.

Toculizimab is an option for pneumonitis.

Prophylaxis for high risk patients is available:

  • Remdesivir 3 days once daily infusions
  • Paxlovid (Nirmatrelvir +Ritonavir) 300/150mg BD for 5 days

Neutralising antibodies have also been tried but not in guidance.

Sotrovimab [NO LONGER AVAILABLE] – for 12-16yrs, pre-hospitalisation, PCR positive and onset of symptoms within previous 5 days. Not if new oxygen requirement or weight under 40kg. 1% vs 7% placebo hospitalisation or death (85% reduction).