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COVID-19 Treatment Guidelines Updated

The COVID-19 Treatment Guidelines Panel last week updated its COVID-19 treatment guidelines, adding sections on pregnancy and lactation, revising information on therapeutic management of nonhospitalized and hospitalized adults, and making other major revisions.

A new section on pregnancy and lactation provides guidance on the use of Panel-recommended therapies in pregnant or lactating patients with COVID-19. The Panel recommends against withholding COVID-19 treatments or vaccination from pregnant or lactating individuals. A new table summarizes the recommendations for each therapy, and the document provides the rationale behind the recommendations and potential safety concerns for infants exposed in utero to COVID-19 agents and those who receive breast milk from individuals taking COVID-19 therapies. 

Also presented are the goals of therapeutic management for nonhospitalized patients with COVID-19 and the limitations of the data informing the Panel’s recommendations. Currently, the Panel’s recommendations reflect the available data on the benefits of using antiviral therapies to prevent progression to severe COVID-19. The Panel said it will consider the potential benefits of therapies for other outcomes, such as symptom recovery, as those data emerge. 

Data from the PANORAMIC trial have been added to the rationale for molnupiravir. The Panel also expanded the subsection on viral rebound and symptom recurrence to discuss the rebounds reported after patients have completed therapy with molnupiravir and ritonavir-boosted nirmatrelvir (Paxlovid). 

For patients hospitalized with COVID-19, the Panel currently recommends using dexamethasone as the primary immunomodulator for all patients who require high-flow nasal cannula oxygen, noninvasive ventilation, mechanical ventilation, or extracorporeal membrane oxygenation. A second immunomodulator (e.g., baricitinib, tocilizumab) should be added to dexamethasone for the treatment of these patients. These minor changes are reflected in both Table 2b of this section and in the Panel’s rationale. 

Other sections of the guidelines with major revisions are oxygenation and ventilation for adults, interferons (adding data from the TOGETHER trial), Janus kinase inhibitors (removing information on ruxolitinib and Bruton’s tyrosine kinase inhibitors, which are not recommended), and interleukin-6 inhibitors (including information from the REMAP-CAP trial).