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

There are practitioners throughout the world who are using various unproven therapies. In the setting of a pandemic, it is not just one or a few individuals with a rare clinical disorder, but many with a common novel disease. Without ethically conducted clinical trials, the true efficacy and safety of investigational agents are largely unknown. Any inconsistencies in usage may also lead to confusion amongst clinicians and the public. Additionally, there are limited supplies of many of these agents. This results in limited supplies of therapies for patients with established indications for existing drugs.

There are currently no novel agents specifically developed and approved for treatment of COVID-19, but certain treatments have shown positive results. Concomitantly, several well-designed studies have shown various therapies to have no effect or pose safety concerns. Even though significant progress has been made to evaluate COVID-19 therapies through high-quality randomized controlled trials, the majority of published evidence still comes from observational studies. Where applicable and feasible, we support enrolment into clinical trials to address knowledge gaps.

The recommendations provided by the BC COVID-19 Therapeutics Committee on specific therapies for COVID-19 are based on the current best available evidence.

These recommendations apply to hospitalized and non-hospitalized adult patients with confirmed or suspected COVID-19.   

1. Corticosteroids
   Recommendation: Dexamethasone 6 mg IV/PO q24h for up to 10 days is strongly recommended for patients requiring mechanical ventilation and recommended for hospitalized patients requiring supplemental oxygen (RECOVERY trial). If dexamethasone is not available, methylprednisolone 30 mg IV q24h or prednisone 40 mg PO q24h are the preferred alternatives.  If dexamethasone supplies are limited, they should be reserved for critically ill patients.
   
2. Lopinavir / Ritonavir (Kaletra®)
   Recommendation: Recommend against the use of lopinavir/ritonavir^# outside a randomized-controlled trial.
3. Remdesivir
   Recommendation: Recommend against the use of remdesivir^# outside a randomized-controlled trial. Remdesivir shortened time to clinical recovery but failed to show survival benefit in the ACTT-1 trial. Remdesivir is currently not approved by Health Canada.
4. Chloroquine or Hydroxychloroquine
   Recommendation: Chloroquine or hydroxychloroquine (with or without azithromycin) is not recommended for treatment of COVID-19 in hospitalized patients. Chloroquine or hydroxychloroquine^# (with or without azithromycin) is not recommended for treatment of outpatients with mild infections outside of approved randomized-controlled trials. Chloroquine or hydroxychloroquine (with or without azithromycin) is not recommended for prophylaxis of COVID-19.
5. Oseltamivir
   Recommend against the use of oseltamivir unless suspected or confirmed influenza infection.
6. Ribavirin and Interferon
   Recommendation: Recommend against the use of ribavirin and/or interferon outside of a randomized-controlled trial.
7. Colchicine 
   Recommend against the use of colchicine^# for treatment or prophylaxis outside a randomized-controlled trial.
   
8. Ascorbic Acid
   Recommendation: Recommend against the use of ascorbic acid for treatment or prophylaxis outside a randomized-controlled trial.
   
9. Tocilizumab and Sarilumab
   Recommendation: Recommend against the use of tocilizumab or sarilumab^# outside a randomized-controlled trial. If considered on an individual basis in patients with cytokine storm, it should only be done so with expert consultation (Infectious Diseases and Hematology/Rheumatology).
10. Convalescent Plasma
    Recommendation: Recommend against the use of convalescent plasma^# outside a randomized-controlled trial.
11. Intravenous Immunoglobulin G (IVIG)
    Recommendation: Recommend against the use of IVIG outside a randomized-controlled trial.
12. Antibiotics
    Recommendations: If bacterial infection is suspected, antibiotics should be initiated based on local institutional antibiograms and sensitivities. 
13. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
    Recommendation: Recommend acetaminophen use preferentially for symptomatic management of COVID-19 but do not recommend against the use of NSAIDs such as ibuprofen. 
14. Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs)
    Recommendation: Recommend that patients on ACE inhibitors and ARBs continue these agents as indicated and not cease therapy solely on the basis of COVID-19.
15. Venous Thromboembolism (VTE) prophylaxis
    Recommendation: Suggest enoxaparin 30 mg SC bid as the preferred dose for VTE prophylaxis in critically ill patients with COVID-19. Consider enoxaparin 30 mg SC bid as the preferred dose 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.
    
16. Other investigational therapies
    Recommendation: Recommend against any other investigational agent, including including arbidol, ASC09, azvudine, baloxavir marboxil/favipiravir, camostat mesylate, darunavir/cobicistat, camrelizumab, ivermectin, niacin, thymosin, natural health products, and traditional Chinese medicines due to lack of data, lack of availability, or both.