Summary of COVID-19 medicines guidance: Infection and infectious diseases

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 (currently under review to reflect changes to case definition for Covid-19)

  • 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.

NICE: COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community

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

NICE: COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital

Published 1 May 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).

 

NICE: COVID 19 rapid evidence summary: Remdesivir for treating hospitalised patients with suspected or confirmed COVID-19 [ES24]

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.

 

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

 

NICE: COVID-19 rapid evidence summary: vitamin D for COVID-19 

[ES28]

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.

 

NHS England/NHS Improvement: Provision of tuberculosis services

Last updated 26 March 2020

  • Childhood vaccination programmes are continuing, including neonatal BCG. Therefore, maternity providers should continue to vaccinate for BCG before discharge of mother and baby.
  • To reduce person-to-person contact a blood test (IGRA) can be used for contact tracing instead of the TST/Mantoux test.

 

NICE: COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19

Evidence summary [ES23]

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.

NICE. COVID-19 rapid evidence summary: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19

Evidence summary [ES25]

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.

NHS: Patient information – ibuprofen for adults

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.

NICE. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. Evidence summary [ES24]

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 10 July 2020 

Key messages

There are no antiviral medicines approved to treat or prevent human coronaviruses. There is no published randomised controlled trial evidence that any treatment beyond best supportive care delivers improved outcomes for patients with COVID-19

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

Updated to provide details of RECOVERY study

 

MHRA. CAS Alert:   Dexamethasone in the treatment of COVID-19: Implementation and management of supply for treatment in hospitals

Issued 16 Jun 2020

Based on the results of the Recovery trial the MHRA has advised that dexamethasone has been demonstrated to have a clear place in the management of hospitalised patients with COVID-19. Clinicians should therefore consider dexamethasone for the management of hospitalised patients with COVID-19 who require oxygen or ventilation.

 

  • The recommended regimen in adults is 6mg (either orally or by injection) once daily for 10 days.
  • However if pregnant or breast feeding prednisolone (40mg daily orally) or hydrocortisone (80mg twice daily by injection) should be used instead of dexamethasone.
  • Gastroprotection should be provided in line with local clinical guidance
  • If the patient is discharged from hospital before the recommended 10-day course is complete, the corticosteroid should be stopped on discharge
  • Dexamethasone has the potential to reduce levels of remdesivir and therefore caution should be applied in patients receiving both treatments.

 

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 30 June 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.

Updated to provide details of the RECOVERY study

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 (16th July 2020): resources updated on the page as indicate by red text.