Summary of COVID-19 medicines guidance: Critical care

Diane Bramley, Highly Specialist Pharmacist Medicines Information, Guy's and St Thomas' NHS Foundation TrustPublished Last updated See all updates

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and critical care.

Our advice is constantly reviewed as the pandemic situation evolves.

Whilst we have tried to ensure that the information on this page is complete, please report a concern if you feel anything is omitted or inaccurate.

To see our professional guidance summaries for other clinical areas, click here
Advice in this area includes:

NICE: COVID-19 rapid guideline: managing COVID-19 (NG 191)

Published 23 March 2021, updated 2 September 2021

This comprehensive guideline covers the management of COVID-19 for children, young people and adults in all care settings. Within the section on treatment within the hospital setting there is guidance on escalating and de-escalating treatment and delivering care on critical care and respiratory support units. Therapeutic guidance and evidence overviews are provided on the use of antibiotics (not to be used unless evidence of bacterial co-infection), azithromycin (not to be used as a treatment for COVID-19), colchicine (not to be used), corticosteroids, low molecular weight heparin, remdesivir, tocilizumab, and sarilumab.

SPS/ NHSI: Providing patient information leaflets following COVID-19 treatment.

Published 31 March 2021.

Following treatment for COVID-19 with tocilizumab, sarilumab, or steroids, clinicians should provide suitable patient information leaflets at discharge. Leaflets for discharging a patient after treatment for COVID-19, patients discharged after treatment with corticosteroids and patients discharged after treatment with tocilizumab or sarilumab are provided,

NHSE/I: Interim Clinical Commissioning Policy: Sarilumab for critically ill patients with COVID-19 pneumonia (adults) and Interim Clinical Commissioning Policy: Tocilizumab for critically ill patients with COVID-19 pneumonia (adults) 

Published 17 February 2021

Following NICE reviews of the evidence to support the use of sarilumab and tocilizumab in the treatment of COVID-19 NHSE/I has issued interim commissioning policies for each medicine.

  • Eligible patients for tocilizumab include those patients who have received or require treatment with a course of dexamethasone (or equivalent)  and have a C-reactive protein level of at least 75mg/L; and an oxygen saturation of <92% on room air or requirement for supplemental oxygen OR if the patient has not received an IL-6 inhibitor for COVID-19 during this admission and is within 24-48 hours of commencement of respiratory support (highflow nasal oxygen, continuous positive airway pressure (CPAP) or non-invasive ventilation, or invasive mechanical ventilation).
  • Patients are ineligible for tocilizumab if they are known to be hypersensitive to the medicine, Caution is advised if patient has an infection that might be made worse by tocilizumab, has raised transaminase levels (> 5 times upper limit of normal), a pre-existing treatment or condition that results in ongoing immunosuppression.
  • Eligible patients for sarilumab include those treated with respiratory support (high-flow nasal oxygen, continuous positive airway pressure (CPAP) or non-invasive ventilation, or invasive mechanical ventilation) and less than 24 hours have elapsed since commencement of respiratory support and who have not already been treated during this episode with tocilizumab or another IL-6 inhibitor
  • Patients are ineligible for sarilumab if they are known to be hypersensitive to the medicine, have an infection that might be made worse by sarilumab, has raised transaminase levels (> 5 times upper limit of normal and caution if > 1.5 times upper limit of normal), baseline platelet count < 50×109 /L, a pre-existing treatment or condition that results in ongoing immunosuppression.
  • The recommended dose of tocilizumab is 8mg/kg (up to a maximum of 800mg) to be administered as an intravenous infusion.  A second dose should not be considered given the uncertainty of evidence of additional benefit and the need to maximise available supply
  • The recommended dose of sarilumab is 400mg to be given as a once-only intravenous infusion.
  • No adverse interactions with corticosteroids or remdesivir are expected.

MHRA. CAS Alert:  Corticosteroids in the treatment of suspected or confirmed COVID-19

Issued 3 Sept 2020

Based on the results of the REMAP-CAP trial for hydrocortisone and a meta-analysis of corticosteroids (that included results from 7 RCTs including REMAP-CAP and the RECOVERY study of dexamethasone). The MHRA has advised that corticosteroids have been demonstrated to have a clear place in the management of patients with severe or critical COVID-19 disease (as defined by WHO – definitions provided within CAS) but should not be used in patients with non-severe disease. It is stated the guidance applies primarily to patients who are hospitalised and receiving supplemental oxygen but may apply to some non-hospitalised patients.

The following dose regimens for adults are recommended

  • The recommended regimen in adults is dexamethasone 6mg (orally or by injection) once daily for 7-10 days or hydrocortisone 50mg (by injection) three times daily for 7 -10 days. Treatment should stop if discharged from hospital within 10 days.
  • A longer low-dose hydrocortisone regimen (lasting up to 28 days) may be considered for use in patients with septic shock.
  • Prescribers are referred to relevant SPC for use in children, pregnancy or breastfeeding women.
  • Co- prescription of a PPI should be considered for gastroprotection according to local policies
  • Interaction advice wrt to remdesivir updated to state: “Coadministration has not been studied but based on metabolism and clearance a clinically significant interaction is unlikely”

 

Royal College of Anaesthetists/ Association of anaesthetistsCovid-19 potential anaesthetic drug list

Published 17 April 2020

Provides a brief overview of key facts for:

  • anaesthetics (thiopental, isoflurance, etomidate and hyperbaric 2% prilocaine)
  • neuromuscular blocking drugs (vecuronium, suxamethonium and pancuronium)
  • analgesics (clonidine, oxycodone, tramadol, pethidine, diclofenac, ketorolac and parecoxib)
  • phenylephrine

Royal College of Anaesthetists/ Association of anaesthetists

Guidance on potential changes to anaesthetic drug usage and administration during pandemic emergency pressures 

Published 2 April 2020 (but now archived)

Advice on potential mitigating actions to reduce impact of increase in demand for medicines used in anaesthesia and critical care. Recommendations include:

  • Work with pharmacy to develop safe ways to use all the contents of drug vials/ ampoules eg through sharing vials
  • Use inhalational anaesthesia for maintenance and restrict use of propofol for maintenance where possible
  • Provides list of alternative medicines/ techniques which could be considered if there are insufficient supplies of first line drugs for induction, neuromuscular blockade (RSI and routine), maintenance, analgesia (short and long-acting), non-opioid analgesia, sedation and transfer, vasopressor (bolus and infusion).

Royal College of Anaesthetists/ Association of anaesthetists

Guidance on adaptations to standard UK critical care medication prescribing and administration practices during pandemic emergency pressures

Published 2 April 2020 (but now archived)

Advice on potential mitigating actions to reduce impact of increase in demand for medicines used in anaesthesia and critical care. Recommendations include:

  • Critical Care and Departments of Anaesthesia should work together to review and reallocate medicine stock supplies from areas where clinical demand has reduced
  • Prepare to adapt and guide local practice, where demand for certain products is high.
  • Consider combining sedatives (eg midazolam and morphine, propofol and alfentanil) following discussion with pharmacists.
  • Regularly review whether intravenous medicines can be changed to an alternative route, particularly enteral
  • Consider bolus dosing/administration of medicines where possible (eg magnesium, certain antibiotics).
  • Provides alternative drug options and clinical advice when first line drug supplies are insufficient to meet demand for sedation, neuromuscular blockade/ paralysis, vasopressors/ vasoactive drugs, non-opioid analgesia/ anti-pyretic, hypoglycaemics, antibiotics, stress ulcer prophylaxis.

 

 

Change history

  1. Resources checked and information remains correct
  1. Updated resource: 10 August 2021 NICE: COVID-19 rapid guideline: managing COVID-19 (NG 191)
  1. Link updated for report a concern
  1. Resources checked and information remains correct
  1. Updated to include new guidance from NICE on azithromycin, remdesivir and colchicine
  1. Updated to reflect availability of NICE Guideline on managing COVID-19 in all healthcare settings with any superseded guidance deleted. Also added availability of discharge information for patients treated with corticosteroids, tocilizumab or sarilumab.
  1. Updated to reflect changes in NHSE/I eligibility criteria for sarilumab and tocilizumab
  1. Updated to include detail of the NHSE/I interim commissioning policies for sarilumab and tocilizumab
  1. Published