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The British Columbia COVID-19 Therapeutics Committee provides guidance on the most current research on the use of therapies in the management of COVID-19.

Clinical guidance

Clinical Reference Group Recommendations: Therapies for COVID-19

UPDATED: January 13, 2021 

The British Columbia COVID-19 Therapeutics Committee (CTC) meets regularly to discuss the most current research on the use of therapies in the management of COVID-19.

Evidence for the role of various therapies for the prevention or treatment of COVID-19 is quickly emerging and represents a rapidly evolving area of research.

While positive results for a small number of treatments are being published, the efficacy, safety and role in therapy for most pharmacological treatments for COVID-19 remain unknown. Currently, international bodies such as the World Health Organization (WHO), recommend that unproven pharmacological therapies for COVID-19 not be used outside of clinical trials. Within British Columbia, the use of unproven COVID-19 drug therapies outside of clinical trials is NOT recommended. Participation in clinical trials allows for ethical evaluation of the efficacy and safety of potential agents, minimizes inconsistencies in usage that is harmful to the clinical community and the public, and protects the drug supply chain.  It is recognized that there may be extenuating individual circumstances where clinicians decide to use such therapies when clinical trials are unavailable. In settings where unproven therapies are used, the WHO has provided a standardized case report form for data collection to ensure that there is contribution to scientific research and the clinical community.

In circumstances where practice-changing results become available, such data should carefully be interpreted with particular attention to effect size, applicability, safety and practical issues of incorporating the evidence into practice that are specific to patients in British Columbia. The recommendations listed below have been written with careful consideration of these points.

These recommendations apply to hospitalized and non-hospitalized adult patients with confirmed or suspected COVID-19. Find recommendations for Multisystem Inflammatory Syndrome in Children (MIS-C) and COVID-19.     

Recommendations for Specific Therapies:
  1. Corticosteroids
    Dexamethasone 6 mg IV/PO q24h for up to 10 days is strongly recommended (RECOVERY trial), unless higher doses are clinically indicated.** Hydrocortisone 50 mg IV q6h is recommended as an alternative (REMAP-CAP trial). If dexamethasone and hydrocortisone are not available, methylprednisolone 32 mg IV q24h or prednisone 40 mg PO daily are recommended.

  2. Tocilizumab
    Tocilizumab 8 mg/kg IV (single dose; up to maximum 800 mg) is recommended (REMAP-CAP) for patients requiring life support due to confirmed COVID-19.  This includes high-flow oxygen support (e.g., Optiflow) if flow rate > 30 L/min and FiO2 > 0.4 OR invasive or non-invasive ventilation OR vasopressor or inotropic support.  Tocilizumab must be administered within 24 hours of the initiation of life support measures. Patients admitted to hospital for more than 14 days with symptoms of COVID-19 should not receive tocilizumab for this indication. Tocilizumab should only be initiated when life support is required because of COVID-19 rather than other causes (such as bacterial infection, pulmonary embolism, etc).

  3. Remdesivir
    Remdesivir has not demonstrated benefit in survival, progression to ventilation or length of hospital stay and remains uncertain with respect to shortening time to recovery by 5 days. The World Health Organization (WHO) has issued a conditional recommendation against the use of remdesivir in hospitalized COVID-19 patients. Further evaluation in approved clinical trials is strongly encouraged. If remdesivir is used outside of clinical trials, full disclosure of risks and benefits with consideration of patient values and preferences are necessary, as it is not considered standard of care. Furthermore, it should be restricted to hospitalized patients requiring supplemental oxygen but not requiring non-invasive or invasive mechanical ventilation.

  4. Lopinavir / Ritonavir (Kaletra®)
    Lopinavir/ritonavir is not recommended for treatment of COVID-19.  Lopinavir/ritonavir is not recommended for prophylaxis of COVID-19 outside of approved randomized-controlled trials.

  5. Chloroquine or Hydroxychloroquine
    Chloroquine or hydroxychloroquine (with or without azithromycin) is not recommended for treatment or prophylaxis of COVID-19.

  6. Oseltamivir
    Oseltamivir is not recommended for treatment or prophylaxis of COVID-19.

  7. Ribavirin and Interferon
    Interferon IV/SC is not recommended for the treatment of COVID-19.  Ribavirin/Interferon (Inhaled) is not recommended outside of approved clinical trials.

  8. Colchicine 
    Colchicine is not recommended for treatment or prophylaxis of COVID-19 outside of approved randomized-controlled trials.

  9. Ascorbic Acid and Vitamin D
    Ascorbic acid and Vitamin D are not recommended for treatment or prophylaxis of COVID-19 outside of approved randomized-controlled trials.

  10. Biologics/Small Molecules (Anakinra, Baricitinib, Ruxolitinib)
    Biologics/Small Molecules (Anakinra, Baricitinib, Ruxolitinib)  are not recommended for treatment or prophylaxis of COVID-19 outside of approved randomized-controlled trials.

  11. Passive Immunotherapies (Convalescent Plasma#/IVIG)
    Convalescent Plasma#/IVIG is not recommended for treatment or prophylaxis of COVID-19 outside of approved randomized-controlled trials.

  12. Monoclonal Antibodies/Antibody Cocktails
    Monoclonal Antibodies/Antibody Cocktails (e.g. bamlanivimab) are not recommended for treatment or prophylaxis of COVID-19 outside of approved randomized-controlled trials.

  13. Antibiotics
    Antibiotics should be initiated based on local institutional antibiograms and sensitivities if bacterial infection is suspected.

  14. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
    Acetaminophen is recommended preferentially for symptomatic management of COVID-19 but do not recommend against the use of NSAIDs such as ibuprofen. 

  15. Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs)
    Patients on ACE inhibitors and ARBs are recommended to continue these agents as indicated and not cease therapy solely on the basis of COVID-19.

  16. Venous Thromboembolism (VTE) prophylaxis
    Enoxaparin 30 mg SC bid is suggested as the preferred dose for VTE prophylaxis in critically ill patients with COVID-19. Enoxaparin 30 mg SC bid should be considered for VTE prophylaxis in hospitalized ward-based patients with COVID-19. This dose was selected to reduce incident VTE and potentially save health care resources with patient transport and minimize risk of COVID-19 transmission to staff and others. Suggest even higher doses of enoxaparin for hospitalized patients with weight above 100 kg or BMI above 40 kg/m2.

  17. SSRIs
    SSRIs are not recommended for treatment or prophylaxis of COVID-19 outside of approved randomized-controlled trials.
            
  18. Other investigational therapies
    Other investigational agents including arbidol, ASC09, azvudine, baloxavir marboxil/favipiravir, camostat mesylate, darunavir/cobicistat, camrelizumab, famotidine, ivermectin, niacin, thymosin, natural health products, and traditional Chinese medicines are not recommended for treatment or prophylaxis of COVID-19 due to lack of data, lack of availability, or both.

# Denotes that a clinical trial of named therapy is currently planned or underway in British Columbia:
*Recommendations are consistent with guidelines from the World Health Organization (WHO), the Surviving Sepsis Campaign (SSC) (a joint initiative of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM)), the Public Health Agency of Canada (PHAC), the Canadian Critical Care Society (CCCS), the Association of Medical Microbiology and Infectious Diseases Canada (AMMI), and The Australian and New Zealand Intensive Care Society (ANZICS).

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