April 14, 2020

IDSA publishes guidelines on treatment and management of patients with COVID-19

The Infectious Diseases Society of America (IDSA) has published guidelines intended to support patients, clinicians and other health-care professionals in their decisions about treatment and management of patients with COVID-19.

According to the IDSA, a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists was formed to develop these evidence-based rapid guidelines. The IDSA added that the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations.  

The IDSA noted that recommendations are labeled as “strong” or “conditional” based on the GRADE methodology. It added that the word “recommend” indicates strong recommendations and “suggest” indicates conditional recommendations. Meanwhile, in situations where promising interventions were judged to have insufficient evidence of benefit to support their use and with potential appreciable harms or costs, the expert panel recommended their use in the context of a clinical trial. Further, the guideline panel used the word “only” in recommendations about therapeutic agents with higher uncertainty and/or more potential for harm. According to the IDSA, these recommendations acknowledge the current “knowledge gap” and aim at avoiding premature favorable recommendations for potentially ineffective or harmful interventions.

 The IDSA guideline panel has agreed on the following seven treatment recommendations: 

  1. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends hydroxychloroquine/chloroquine in the context of a clinical trial. (Knowledge gap)
  2. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends hydroxychloroquine/chloroquine plus azithromycin only in the context of a clinical trial. (Knowledge gap)
  3. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends the combination of lopinavir/ritonavir only in the context of a clinical trial. (Knowledge gap)
  4. Among patients who have been admitted to the hospital with COVID-19 pneumonia, the IDSA guideline panel suggests against the use of corticosteroids. (Conditional recommendation, very low certainty of evidence)
  5. Among patients who have been admitted to the hospital with  acute respiratory distress syndrome (ARDS) due to COVID-19, the IDSA guideline panel recommends the use of corticosteroids in the context of a clinical trial. (Knowledge gap)
  6. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends tocilizumab only in the context of a clinical trial. (Knowledge gap)
  7. Among patients who have been admitted to the hospital with COVID-19, the IDSA guideline panel recommends COVID-19 convalescent plasma in the context of a clinical trial. (Knowledge gap)

In the guidelines, the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for COVID-19. 

The panel determined that when an explicit trade-off between the highly uncertain benefits and the known putative harms of these therapeutic agents were considered, a net positive benefit was not reached and could possibly be negative (risk of excess harm). The panel acknowledges that enrolling patients in randomized clinical trials  might not be feasible for many frontline providers due to limited access and infrastructure. 

“Should lack of access to clinical trials exist, we encourage setting up local or collaborative registries to systematically evaluate the efficacy and safety of drugs to contribute to the knowledge base. Each clinician can play a role in advancing our understanding of this disease through a local registry or other data collection efforts”, the panel remarked.

SOURCE: Infectious Diseases Society of America
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