This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and infection and infectious diseases.
This page has been put together rapidly in relation to the COVID-19 pandemic.
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:
NHS England/NHS Improvement: Clinical management of persons admitted to hospital with suspected COVID-19 infection.
Last updated: 19 March 2020
- Those with underlying medical conditions (diabetes mellitus (any type), chronic respiratory disease, chronic cardiovascular disease including hypertension or severe immunosuppression (as per Green Book definition) are significantly more likely to progress to complicated illness.
- Consider empirical antimicrobial treatment in line with NICE pneumonia guidance, lower respiratory tract infection (LRTI) guidelines and sepsis guidelines.
- High-dose corticosteroids should not be routinely given to treat viral pneumonia or ARDS. Low-dose corticosteroids may be given if indicated for another reason.
- Although intravenous immunoglobulin (IVIg) is used in up to 70% of cases of septic shock, its routine use in COVID-19 is not recommended.
Last updated: 23 April 2020
- Provides guide to differentiating between Covid-19 pneumonia and bacterial pneumonia.
- If bacterial infection is suspected the first choice antibiotic is a 5-day course of doxycycline with amoxicillin as an alternative. Rationale being that Mycoplasma pneumoniae and Staph. aureus are more likely to be secondary causes during the Covid-19 pandemic.
- Dual antibiotics are not recommended. For more complex clinical scenarios (incl suspicion of atypical pathogens) refer to NICE guideline on community-acquired pneumonia.
- Do not offer a corticosteroid unless patient has another indication for use such as asthma or COPD
Published 1 May 2020 (Updated 9 October 2020)
Provides guidance on empirical antibiotic regimens for hospitalised adults with community acquired moderate or severe pneumonia, and for suspected hospital-acquired pneumonia (incl if MRSA suspected or confirmed). Update in October was to amend cefuroxime dose in adults
Published date: 5 June 2020
This review comprises 3 studies of remdesivir (2 placebo-controlled RCTs and an observational study) and a meta-analysis of the 2 RCTs.
Remdesivir is associated with clinical improvements in some outcomes (reducing supportive measures including mechanical ventilation and time to recovery in patients with mild or moderate, or severe COVID-19 disease who are on supplemental oxygen treatment.) but not yet in reducing mortality.
No statistically significant differences were found serious adverse events although fewer were reported with remdesivir compared with placebo). In one RCT more treatment discontinuations were reported with remdesivir compared with placebo due to adverse events.
It is suggested that the following factors should be taken into consideration when using remdesivir as a treatment option for patients with COVID-19: timing of initiation of treatment at the onset of symptoms, disease severity (this includes the need for oxygen support, non-invasive ventilation, invasive ventilation or organ support, most of the patients in the studies had severe COVID-19) and the underlying clinical status of the patient and age.
NHS England/NHS Improvement: Interim Clinical Commissioning Policy: Remdesivir for patients hospitalised with COVID-19 (adults and children 12 years and over) Version 2 [added 6 November 2020]
Last updated 6 November 2020
- This policy sets out the interim clinical commissioning position for the use of remdesivir for patients with COVID-19 and has updated to reflect the improved supply position in the UK and to reflect the latest available evidence, including the results of the World Health Organisation’s Solidarity Trial.
Issued 6 November 2020
- This Alert outlines the criteria to be applied to patients being considered for remdesivir in light of an improvement in supplies but still including a recommendation to limit to a 5-day course in appropriate patients.
NICE: COVID 19 rapid evidence summary: Anakinra for COVID-19 associated secondary haemophagocytic lymphohistiocytosis [ES26]
Published date: 21 May 2020
In this review no studies were found that considered the effectiveness, safety or cost effectiveness of anakinra in adults and children with secondary haemophagocytic lymphohistiocytosis (SHLH) triggered by SARS-CoV-2 or a similar coronavirus.
However overall NICE conclude:
- anakinra has been used (off label) for cytokine storm syndromes triggered by other viruses (such as herpes viruses), including sHLH, and is reported to be relatively well tolerated, with a favourable safety profile.
- caution is advised when using immunomodulating therapies in critically ill people with known or suspected infections because they increase the risk of infectious complications. However, it has been proposed that anakinra may be an option if such a treatment is considered necessary because it has a relatively short half-life and can be discontinued quickly if an adverse effect or concern for worsening infection arises.
- anakinra can be given intravenously (off label) or subcutaneously and has a large therapeutic window.
- when anakinra is effective for cytokine storm syndromes, it reportedly works within 2 or 3 days
Published date: 29 June 2020
NICE assessed evidence from 5 observational studies published in peer reviewed journals but concluded that there is no direct evidence to support taking vitamin D supplements to specifically prevent or treat COVID-19.
They therefore advise that all people should continue to follow UK Government advice on daily vitamin D supplementation to maintain bone and muscle health during the COVID-19 pandemic (ie everyone should consider taking 10 micrograms of vitamin D a day because they might not be getting enough from sunlight if they’re indoors most of the day). They also note that following appropriate testing and clinical management, people with vitamin D deficiency may also be prescribed higher therapeutic doses.
Published 14 April 2020
The available evidence suggests that, although the anti-inflammatory effects of NSAIDs reduce acute symptoms (such as fever), they may either have no effect on, or worsen, long-term outcomes, possibly by masking symptoms of worsening acute respiratory tract infection. Further evidence is needed to confirm this, and to determine whether these results also apply to infections such as COVID-19.
Published date: 21 May 2020
No evidence was found to suggest that people taking NSAIDs for a long-term condition should be advised to stop treatment in the context of COVID‑19. Stopping or switching NSAID treatment could have a negative impact on some people.
Last accessed 26 April 2020
- The Commission on Human Medicines has now confirmed that there is no clear evidence that using ibuprofen to treat symptoms such as a high temperature can make coronavirus (COVID-19) worse.
- You can take paracetamol or ibuprofen to treat the symptoms of coronavirus. We recommend that you try paracetamol first, it has fewer side effects than ibuprofen and is the safer choice for most people.
Published date: 21 May 2020
Despite biological plausibility for the role of ACEIs and ARBs in both increasing and decreasing the risk of COVID-19 and its complications, this evidence review has not found any observational or experimental data to support these hypotheses. However, the risks of stopping treatment with an ACEI or an ARB, such as worsening heart failure or hypertension, are well understood.
COVID-19 Therapeutics Advice & Support Group (CTAG): Position Statement: Use of investigational antiviral agents for COVID-19 in adults. Interim Support for hospital clinicians in England
Last updated 15 October 2020
Remdesivir is approved for the treatment of COVID-19 in adults and adolescents requiring supplemental oxygen and should used in line with the interim Clinical Commissioning Policy which sets out inclusion and exclusion criteria for the use of remdesivir in the UK
Investigative antiviral agents should be used in the context of a clinical trial
Provides details of RECOVERY, REMAP-CAP, ACTT, GS-5774, GS-5773 and SNG016 clinical trials of treatments (and schematic as to how the trials fit in terms of treatment setting and disease severity). Also provides details of ISARIC-CCP and GenOMICC observational trials and the expanded access programme for remdesivir
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”
Issued 03 Sep 2020
A summary of the evidence to support implementation of the CAS Alert above. Provides a visual representation of the results of the RECOVERY study of dexamethasone in hospitalised patients with COVID-19 who were on oxygen but not mechanical ventilation and patients who were on mechanical ventilation at the start of the study.
COVID-19 Therapeutics Advice & Support Group (CTAG): Position Statement: Use of investigational immunomodulatory agents for COVID-19 in adults. Interim Support for hospital clinicians in England
Last updated 15 Oct 2020
A subset of patients with COVID-19 experience an exaggerated host hyperinflammatory response associated with hypercytokinaemia following or associated with the initial viral response phase. This predominately affects the lung but can progress to multi-organ disease.
Several investigative immunomodulatory agents have potential to be repurposed for the management of COVID-19 associated hyperinflammation (including and not limited to anakinra, interferon-beta, tocilizumab, sarilumab, canakinumab and ruxolitinib). The evidence base for these agents and a number of others is described briefly.
There are no licenced immunomodulatory therapies to treat COVID-19 associated hyperinflammation. The standard of care in managing COVID-19 associated hyperinflammation is yet to be defined. Randomised controlled trials to address this are ongoing. RECOVERY, REMAP-CAP and COVACTA trials have got immunomodulatory arms incorporated into their design. Details of other proposed trials are also provided.
It is noted that the existing supplies of these medicines within the NHS supply chain are needed for patients receiving them for conventional indications and use outside of the context of a clinical trial will compromise the feasibility of the trial.
Suspected side effects to medicines used in coronavirus treatment should be reported via the Yellow Card COVID-19 reporting site: https://coronavirus-yellowcard.mhra.gov.uk
Updated to include new evidence and guidance on corticosteroids from WHO and letter from the CMO office. Additional advice from CTAG to consider dexamethasone in patients with a new oxygen requirement)
British HIV Association: Coronavirus (COVID-19) and HIV – Responses to common questions
Last updated 19 March 2020
- Recommended treatment with antiretrovirals should be continued at the same dose. Dose increases do not help protect against Covid-19 or make the infection less severe and could be harmful.
- Do not share antiretrovirals with anyone who has Covid-19 or is worried about catching it.
- The antiretrovirals used in PREP are not active against coronavirus
British Infection Association: Links to national guidance, academic publications and professional societies
- A series of links to useful resources about the treatment of Covid-19 but no specific advice
Administration update (6th November 2020): resources updated on the page as indicate by red text.