Intended for healthcare professionals

Practice Rapid Recommendations

A living WHO guideline on drugs for covid-19

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3379 (Published 04 September 2020) Cite this as: BMJ 2020;370:m3379
Visual summary of recommendation Last updated 10 Nov 2023
Interventions Population Disease severity Non-severe Severe Critical Requires life sustaining treatment Acute respiratory distress syndrome Sepsis Septic shock Absence of signs Risk of admissionto hospital: of severe or critical disease This recommendation applies only to people with these characteristics: Patients with confirmed covid-19 Oxygen saturation <90% on room air Signs of pneumonia Strong recommendations in favour Weak or conditional recommendations in favour Weak or conditional recommendations against Strong recommendations against Lopinavir-ritonavir Casirivimab and imdevimab Sotrovimab Hydroxychloroquine Colchicine Ivermectin Convalescentplasma Corticosteroids Ruxolitinib and tofacitinib Should be considered only if neither baricitinib nor IL-6 receptor blockers are available Remdesivir Remdesivir Molnupiravir Mitigation strategies to reduce potential harms should be implemented Remdesivir Molnupiravir Mitigation strategies to reduce potential harms should be implemented Molnupiravir Nirmatrelvirand ritonavir Nirmatrelvirand ritonavir Remdesivir Remdesivir All three may be combined IL-6 receptor blockers Corticosteroids Baricitinib M M M L L L Use the interactive multiple comparison tool to compare and choose treatments for patients at moderate or high risk of hospital admission Fluvoxamine Fluvoxamine Only in research settings The panel inferred that most patients would want to receive fluvoxamine only in the context of a randomised trial, given the uncertainty around potential benefits and the possibility of harms Convalescentplasma Only in research settings The panel inferred that most patients would want to receive convalescent plasma only in the context of a randomised trial, given the uncertainty around potential benefits and the possibility of harms There are also several practical issues related to the use of convalescent plasma, including but not limited to: Collection of plasma Storage and distribution of plasma Infusion of convalescent plasma into recipients Identification and recruitment of potential donors Only in research settings The panel inferred that most patients would want to receive ivermectin only in the context of a randomised trial, given the uncertainty around potential benefits and the possibility of harms Ivermectin Only in research settings The panel inferred that most patients would want to receive VV116 only in the context of a randomised trial, given the uncertainty around potential benefits and the possibility of harms VV116 UPDATE New recommendation UPDATE Ivermectin is no longer recommended for people with non-severe disease, even in research settings Nirmatrelvirand ritonavir H H H UPDATE The following recommendations for people with non-severe disease are now stratified by how likely it is for someone to be admitted to hospital Nirmatrelvir and ritonavir Remdesivir Molnupiravir UPDATE Low L Patients at low risk of hospital admission (0.5%)Includes people who are neither moderate nor high risk. Most patients are at low risk Moderate M Patients at moderate risk of hospital admission (3%)Includes people: over 65 years old with obesity with diabetes with active cancer with disabilities with comorbidities of chronic disease with chronic kidney or liver disease with chronic cardiopulmonary disease High H Patients at high risk of hospital admission (6%)Includes people who have: been diagnosed with immunodeficiency syndromes been diagnosed with immunodeficiency syndromes autoimmune illness, and are receiving immunosuppressants undergone sold organ transplant and are receiving immunosuppressants Signs of severe respiratory distress In adults: Accessory muscle use Inability to complete full sentences Respiratory rate > 30 breaths per minute In children: Very severe chest wall indrawing Grunting Central cyanosis Inability to breastfeed or drink Reduced level of consciousness Lethargy Convulsions

Corticosteroids

Corticosteroids Suggested regimen Acceptable alternative regimens Dexamethasone 6 mg Oral or intravenous Hydrocortisone 50 mg Intravenous Every 8 hours for 7-10 days Daily for7-10 days Every 6 hours for 7-10 days Methylprednisolone 10 mg Intravenous Daily for7-10 days Prednisone 40 mg Oral
Recommendation 1Supportive careCorticosteroidsorPatients withnon-severe covid-19We suggest no corticosteroidsStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone
Recommendation 2Supportive careCorticosteroidsorPatients with severe orcritical covid-19We recommend corticosteroidsStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone

Interleukin-6 (IL-6) receptor blockers

Suggested regimen Tocilizumab Max 800 mg 8 mg per kg Intravenous Initial dose over 1 hour or Sarilumab 400 mg Intravenous Initial dose over 1 hour A second dose may be administered after 12 to 48 hours
Recommendation 1Supportive careIL-6 receptor blockersorPatients with severe orcritical covid-19We recommend treatment with IL-6 receptor blockers(tocilizumab or sarilumab)StrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone

Janus kinase (JAK) inhibitors

Suggested regimen Baricitinib 4 mg Oral Daily Ruxolitinib 5 mg Oral Twice daily Tofacitinib 10 mg Oral Twice daily For 14 days or until hospital discharge
Recommendation 1Supportive careBaricitiniborPatients with severe orcritical covid-19We recommend treatment with baricitinibStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone
Recommendation 2Supportive careRuxolitiniborPatients with severe orcritical covid-19We suggest not using ruxolitinibStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone
Recommendation 3Supportive careTofacitiniborPatients with severe orcritical covid-19We suggest not using tofacitinibStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone

Nirmatrelvir and ritonavir

Suggestedregimen Nirmatrelvir and ritonavir Nirmatrelvir 300 mg Ritonavir 100 mg Oral Every 12 hoursfor 5 days Nirmatrelvir and ritonavir Nirmatrelvir 150 mg Ritonavir 100 mg Oral Every 12 hoursfor 5 days With renalinsufficiencyGFR 30-59 ml/min
Recommendation 1Supportive careNirmatrelvir and ritonavirorNon-severe covid-19,high admission riskWe recommend nirmatrelvir and ritonavir, for those athigh risk of hospital admissionStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone
Recommendation 2Supportive careNirmatrelvir and ritonavirorNon-severe covid-19,moderate admission riskWe suggest nirmatrelvir and ritonavir, for those atmoderate risk of hospital admissionStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likelywant the intervention to the right. Benefitswould outweigh harms for almost everyone
Recommendation 3Supportive careNirmatrelvir and ritonavirorNon-severe covid-19,low admission riskWe suggest no nirmatrelvir and ritonavir, for thoseat low risk of hospital admissionStrongAll or nearly all informed people would likelywant the intervention to the left. Benefitswould outweigh harms for almost everyoneWeakMost people would likely want the interventionto the left. Benefits would outweigh harms forthe majority, but not for everyoneWeakMost people would likely want the interventionto the right. Benefits would outweigh harmsfor the majority, but not for everyoneStrongAll or nearly all informed people would likely