We provide interim support on the appropriate use of investigational medicines for the treatment and prevention of COVID-19.
Our aim is to bring together the best available evidence, and the latest on clinical trial development, to support hospital healthcare professionals when considering available treatment options for patients with COVID-19.
Medical management of hospitalised adults with COVID-19
1. Critical COVID-19 is defined by WHO/CMO as acute respiratory distress syndrome (ARDS), sepsis, septic shock or other conditions that would normally require the provision of life-sustaining therapies, such as mechanical ventilation (invasive or non-invasive)
or vasopressor therapy
2. Severe COVID-19 is defined by WHO/CMO as any of the following:
- oxygen saturation < 90% on room air; however this threshold is arbitrary and should be interpreted cautiously when used for determining which patients should be offered systemic corticosteroids. For example, clinicians must use their judgement to determine whether a low oxygen saturation is a sign of severity or is normal for a given patient suffering from chronic lung disease. Similarly, a saturation above 90–94% on room air may be abnormal if the clinician suspects that this number is on a downward trend. Generally, if there is any doubt, the panel suggested erring on the side of considering the illness as severe (WHO ‘Corticosteroids for COVID-19’).
- respiratory rate > 30 breaths per minute in adults and children > 5 years old; ≥ 60 in children less than 2 months; ≥ 50 in children 2–11 months, ≥ 40 in children 1–5 years old
- signs of severe respiratory distress (i.e. accessory muscle use, inability to complete full sentences; and in children, very severe chest wall indrawing, grunting, central cyanosis, or presence of any other general danger signs.
3. Patients receiving supplementary oxygen are likely to benefit from dexamethasone based on results from the RECOVERY study [CTAG expert opinion]
4. Stop on discharge. Dexamethasone 5.94mg (1.8mL of 3.3mg/mL) intravenously once daily may be used only where tablets or oral solution are not appropriate. Dexamethasone should be avoided in pregnancy and breastfeeding women; an alternative corticosteroid regimen is prednisolone 40mg orally once daily or hydrocortisone 80 mg intravenously twice daily (a longer low dose duration can be considered for patients with septic shock).
5. Remdesivir 200mg intravenously on Day 1 followed by 100mg intravenously until Day 5. Remdesivir should not be used in patients with eGFR < 30 mL/min or ALT levels > 5 times the upper limit of normal at baseline. Check SPC for full cautions and contraindications. In England, access to remdesivir is subject to Blueteq registration. Access in Scotland, Northern Ireland and Wales is subject to any further country specific guidance.
6. The results of the SOLIDARITY trial and the associated meta-analysis have not yet been subject to peer review. Results from SOLIDARITY found remdesivir did not reduce the risk of death in the population treated, or in any subgroup of entry characteristics.
The totality of evidence however suggests that there may be a small treatment effect of remdesivir in hospitalised patients requiring oxygen, especially early in disease course. This benefit does not appear to extend to patients who are mechanically ventilated.
This small effect size could be taken into account in individual patient decisions around initiation and discontinuation of treatment.
(v2.2; 02 December 2020)