Intended for healthcare professionals

Rapid response to:

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

Interventions Population Disease severity Non-severe Severe Critical Oxygen saturation <90% on room air Signs of pneumonia Requires life sustaining treatment Acute respiratory distress syndrome Sepsis Septic shock Absence of signs of severe or critical disease This recommendation applies only to people with these characteristics: Patients with confirmed covid-19 Corticosteroids Recommendation against (weak) Recommendation in favour (strong) Casirivimab and imdevimab Recommendation in favour (conditional) Recommendation in favour (conditional) Recommendation in favour (strong) Remdesivir Recommendation against (weak) Lopinavir-ritonavir Recommendation against (strong) Hydroxychloroquine Recommendation against (strong) Ivermectin Recommendation against (except in clinical trials) IL-6 receptor blockers Interleukin-6 receptor blockers Neutralising monoclonal antibodies For those with highest risk of hospitalisation The panel recommended that the intervention should be reserved for those at a risk above 10% of being hospitalised for COVID-19. Typical characteristics of people at high risk include: Lack of vaccination Older people Immunodeficiency Chronic diseases such as diabetes For those with seronegative status Assessed by accurate and rapid testing The benefits of casirivimab and imdevimab are only observed in patients with seronegative status. This requires rapid identification through point of care testing with performance characteristics similar to the reference standard test used in the RECOVERY trial 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

Monoclonal antibodies

Suggested regimen Casirivimab and imdevimab One off dose 1200-2400 mg Casirivimab and imdevimab One off dose 2400-8000 mg – total dose – total dose Intravenous or subcutaneuous Intravenous People with non-severe disease People with severe or critical disease
Recommendation 1Usual supportive careMonoclonal antibodiesorPatients withnon-severe covid-19We suggest treatment with casirivimab and imdevimab,for those at highest risk of hospitalisationStrongAll 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 2Usual supportive careMonoclonal antibodiesorPatients with severeand critical covid-19We suggest treatment with casirivimab and imdevimab,if the patient has seronegative statusStrongAll 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

IL-6 receptor blockers

Suggested regimen Tocilizumab Max 800mg 8mg per kg Intravenous Intial dose over 1 hour or Sarilumab 400mg Intravenous Intial dose over 1 hour A second dose may be administered after 12 to 48 hours
Recommendation 1Usual supportive careIL-6 receptor blockersorPatients with severeand critical covid-19We recommend treatment with IL-6 receptor blockers(tociluzimab 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

Ivermectin

No suggested regimen Trials used variable dosing strategies
Recommendation 1Usual supportive careIvermectinorPatients with covid-19at any severityWe recommend not using ivermectin in patients withcovid-19 except in the context of a clinical trialStrongAll 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

Hydroxychloroquine

Suggested regimen Hydroxychloroquine 800 to 1600mg Oral On the first day then Hydroxychloroquine 200 to 800mg Oral Daily for 5 to 21 days 1 to 3 divided doses 1 to 2 divided doses
Recommendation 1Usual supportive careHydroxychloroquineorPatients with covid-19at any severityWe recommend against administeringhydroxychloroquine or chloroquineStrongAll 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

Lopinavir-ritonavir

Suggested regimen Lopinavir 800mg Oral Daily Ritonavir 200mg Oral Daily Combinedwith Divided intotwo doses
Recommendation 1Usual supportive careLopinavir-ritonavirorPatients with covid-19at any severityWe recommend against administeringlopinavir-ritonavirStrongAll 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