Current treatment challenges in the COVID-19 pandemic

Infection with SARS-CoV-2, responsible for COVID-19, has spread all over the world since the beginning of 2020. Healthcare providers and researchers have been overwhelmed not only by the rapid diffusion of the disease resulting in a pandemic with more than 4 million cases of death, but also by the lack of therapeutic options. After more than 1 year, the knowledge on COVID-19 has increased thanks to the enormous effort of the scientific community. To date, some algorithms of management have been adopted. While asymptomatic or mildly symptomatic patients should receive only a symptom-based treatment and clinical monitoring when necessary, inpatients could be candidates for antiviral treatment due to fully symptomatic disease. Corticosteroid treatment should be limited to patients with severe disease, particularly those with respiratory failure or acute respiratory distress syndrome. Since the main clinical features of COVID-19 are hypoxemia and dyspnea, oxygen therapy remains the cornerstone of managing more severe cases. In this context, the first-line approach should be represented by low-flow oxygen delivery via a nasal cannula or, more frequently, via a face mask with a known fraction of inspired oxygen. When low-flow oxygen fails to significantly improve oxygen saturation, oxygen therapy using a high-flow nasal cannula is recommended. The current challenges in the treatment of COVID-19 include the need to define the role of convalescent plasma and monoclonal antibodies as well as to identify the optimal target and time for anticoagulation. In this review, we highlight the main aspects of these challenges in light of recent updates.