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What's New in the Guidelines

Last Updated: August 8, 2022

The Coronavirus Disease 2019 (COVID-19) Treatment Guidelines is published in an electronic format that can be updated in step with the rapid pace and growing volume of information regarding the treatment of COVID-19.

The COVID-19 Treatment Guidelines Panel (the Panel) is committed to updating this document to ensure that health care providers, patients, and policy experts have the most recent information regarding the optimal management of COVID-19 (see the Panel Roster for a list of Panel members).

New Guidelines sections and recommendations and updates to existing Guidelines sections are developed by working groups of Panel members. All recommendations included in the Guidelines are endorsed by a majority of Panel members (see Guidelines Development for additional details on the development process).

Major revisions to the Guidelines within the past month are as follows:

August 8, 2022

Special Considerations in People Who Are Immunocompromised

Individuals who are immunocompromised may have a higher risk of progressing to severe disease or death from COVID-19 than the general population. The Panel added a new section to the Guidelines to discuss some unique considerations for the prevention and management of COVID-19 in these patients.

This section covers methods of preventing SARS-CoV-2 infection, including vaccinating patients and their close contacts against COVID-19 and using tixagevimab plus cilgavimab (Evusheld) as pre-exposure prophylaxis (PrEP). It also discusses considerations for clinicians who manage patients with COVID-19 who are immunocompromised. Key considerations include consulting with specialists before stopping or reducing doses of immunosuppressive drugs, promptly initiating antiviral drugs or anti-SARS-CoV-2 monoclonal antibodies in patients with mild to moderate disease, managing concomitant medications and drug-drug interactions, and monitoring for secondary infections.

Clinical Management of Children

The Panel added 3 new sections to the Guidelines that focus on the therapeutic management of COVID-19 in children. Because there are currently no results available from clinical trials that evaluated the treatment of COVID-19 in children, and because data from observational studies are limited, the Panel’s recommendations for children are based largely on safety and efficacy data from clinical trials in adults. The recommendations take the child’s risk of disease progression into consideration; this risk assessment is based on the limited available data for children with COVID-19.

The new sections include:

The Panel also revised Special Considerations in Children to include recent epidemiologic data on COVID-19 and information on the risk factors for severe COVID-19 in children.

Clinical Spectrum of SARS-CoV-2 Infection

This section includes information regarding breakthrough SARS-CoV-2 infections in people who are vaccinated against COVID-19. It also includes updated epidemiologic and clinical information on persistent symptoms and other conditions after acute COVID-19.

Prevention of SARS-CoV-2 Infection

The Panel updated this section to include 2 new revisions to the Food and Drug Administration (FDA) Emergency Use Authorization (EUA) for tixagevimab plus cilgavimab (Evusheld). The updates include a warning about the potential risk of cross-hypersensitivity between COVID-19 vaccines and Evusheld and a new recommendation for repeat dosing of tixagevimab 300 mg plus cilgavimab 300 mg every 6 months (BIIb), as authorized by the updated EUA.

Therapeutic Management of Nonhospitalized Adults With COVID-19

The Panel briefly discusses the recent case reports of viral rebound, with or without recurrence of symptoms, after a course of ritonavir-boosted nirmatrelvir (Paxlovid) has been completed. To date, these rebounds have not been associated with progression to severe COVID-19. The Panel notes that longer treatment courses of ritonavir-boosted nirmatrelvir are not authorized based on the current EUA, and there are insufficient data on the efficacy of administering a second course.

This update also includes a review of recent observational data showing that corticosteroids confer no benefits and may potentially cause harm in patients with COVID-19 who do not require supplemental oxygen. The Panel stresses that the use of corticosteroids in nonhospitalized patients with COVID-19 is not recommended (AIIb).

Therapeutic Management of Hospitalized Adults With COVID-19

The Panel revised this section based on recent clinical trial data on the use of remdesivir or baricitinib in hospitalized patients with COVID-19. The Panel’s recommendations are categorized by a patient’s disease severity and specific clinical scenario. The Panel also updated the rationale for these recommendations.

Key updates to this section include:
  • For patients who are hospitalized for reasons other than COVID-19 and who are found to have mild to moderate COVID-19 and a high risk of disease progression, the Panel recommends following its recommendations for treating nonhospitalized patients with COVID-19.
  • For patients who require oxygen supplementation through a high-flow nasal cannula or noninvasive ventilation (NIV), the Panel recommends the use of a combination of 2 immunomodulators (either dexamethasone plus baricitinib [AI] or dexamethasone plus tocilizumab [BIIa]). If baricitinib, tofacitinib, tocilizumab, or sarilumab cannot be obtained, the Panel recommends starting dexamethasone while waiting for an additional immunomodulator to be acquired.
  • For patients who require mechanical ventilation or extracorporeal membrane oxygenation (ECMO) and who have not initiated 1 of the recommended immunomodulator combinations, the Panel recommends promptly starting either dexamethasone plus baricitinib (BIIa) or dexamethasone plus tocilizumab (BIIa). If the second immunomodulator is not available, dexamethasone should be started while waiting for the second agent.

Kinase Inhibitors: Janus Kinase Inhibitors and Bruton’s Tyrosine Kinase Inhibitors

This section references the recent approval of baricitinib by the FDA for the treatment of COVID-19 in hospitalized adults who require supplemental oxygen, NIV, mechanical ventilation, or ECMO. Minor revisions have been made to the Panel’s rationale for the use of kinase inhibitors for the treatment of COVID-19. A new clinical data table summarizes the results of key randomized controlled trials.

Minor Updates to the Guidelines

Minor updates were made to the following Guidelines sections: