The World Health Organization (WHO) has released the fifth update to the living guidelines on drugs for the treatment of COVID-19. These updated guidelines were published in BMJ.
The Guideline Development Group (GDG) analyzed data from 4200 trials in order to determine “the role of drugs in COVID-19 treatment,” such that patients around the world are receiving the best evidence-based therapies.
The guidelines have been built on previous releases which strongly recommended the use of interleukin (IL)-6 receptor blockers and corticosteroids among patients with severe or critical SARS-CoV-2 infection. Patients with non-severe disease should not be administered these drugs.
In this addition to the living guidelines, the GDG advised that treatment with casirivimab-imdevimab should conditionally be administered to only adult patients with non-severe COVID-19 who are at increased risk for hospitalization or severe SARS-CoV-2 infection. With exception to those who are either immunosuppressed or have another significant risk factor for severe disease, the GDG recommended against treatment with casirivimab-imdevimab in children with SARS-CoV-2 infection because of the decreased risk for hospitalization among this patient population. In addition, the GDG recommended that patients who receive these drugs should be monitored for potential allergic reactions.
The GDG noted the lack of an established decision-making tool for assessing which patients are at increased risk for hospitalization. However, physicians should prioritize patients who are unvaccinated, those of older age, those who are immunosuppressed, and those with chronic conditions.
The evidence behind this recommendation is due to findings which showed decreased hospital admission and decreased time to clinical improvement in patients with non-severe SARS-CoV-2 infection. Among patients with severe (oxygen saturation <90%, signs of pneumonia, or severe respiratory distress) or critical (requires life sustaining treatment, acute respiratory distress syndrome, sepsis, or septic shock) SARS-CoV-2 infection, therapy with neutralizing monoclonal antibodies was found to be associated with a decreased risk of mortality as well as invasive mechanical ventilation.
The GDG also recommended systemic corticosteroids for the treatment of patients with severe or critical SARS-CoV-2 infection. Results of clinical trials included in their analysis showed evidence of a 3.4% decrease in 28-day mortality among this patient population (relative risk [RR], 0.79; 95% CI, 0.70-0.90). In addition, the GDG noted that findings from these trials showed an association between corticosteroid use and a decreased risk for invasive mechanical ventilation among patients with severe or critical SARS-Cov-2 infection (RR, 0.74; 95% CI, 0.59-0.93). However, they noted that the use of corticosteroids is less clear among populations that were under-represented in clinical trials, such as patients with tuberculosis, children, and those who were immunocompromised.
In patients with non-severe SARS-Cov-2 infection, the GDG recommended against treatment with corticosteroids as evidence from clinical trials showed corticosteroids may increase the risk for 28-day mortality (RR, 1.22; 95% CI, 0.93-1.61).
The GDG also recommended against treatment with remdesivir, lopinavir-ritonavir, hydroxychloroquine, and ivermectin in patients with COVID-19.
These guidelines are subject to change in response to ongoing research into the optimal management of patients with SARS-CoV-2 infection.
Rochwerg B, Agarwal A, Agoritsas T, et al. A living WHO guideline on drugs for covid-19. BMJ. 2020;370:m3379. doi:10.1136/bmj.m3379