What's New in the Guidelines
Last Updated: May 31, 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:
May 31, 2022
Four new sections were added to the Guidelines to discuss the unique aspects of managing critically ill children with COVID-19 or multisystem inflammatory syndrome in children (MIS-C). The new sections are:
- Introduction to Critical Care Management of Children With COVID-19
- Extracorporeal Membrane Oxygenation for Children
- Hemodynamic Considerations for Children
- Oxygenation and Ventilation for Children
Since the last update, the results from several large randomized controlled trials that evaluated the use of antiplatelet therapy in hospitalized patients with COVID-19 have been published. Additionally, a randomized controlled trial evaluated a 35-day course of rivaroxaban after hospital discharge in patients with COVID-19 who were at risk of experiencing thromboembolic events.
After reviewing the results of these studies, the Panel provides the following recommendations:
- The Panel recommends against the use of antiplatelet therapy to prevent COVID-19 progression or death in noncritically ill patients (BIIa).
- There is insufficient evidence for the Panel to recommend either for or against antiplatelet therapy in critically ill patients with COVID-19.
- The Panel recommends against routinely continuing venous thromboembolism (VTE) prophylaxis for patients with COVID-19 after hospital discharge, except in a clinical trial (AIII).
- For patients who are at high risk for VTE and low risk for bleeding, there is insufficient evidence to recommend either for or against continuing anticoagulation after hospital discharge unless another indication for VTE prophylaxis exists.
The rationale for the Panel’s recommendations is discussed in this section. A new table summarizes the data from randomized controlled trials that evaluated the use of antiplatelet therapy in hospitalized patients with COVID-19.
The Panel made a number of updates to these sections, including:
- The rationale in Oxygenation and Ventilation for Adults was revised to include data from recent clinical trials.
- The Panel updated the recommendations and rationale for empiric broad-spectrum antibiotics in Pharmacologic Interventions for Critically Ill Patients.
- The Infection Control and Acute Kidney Injury and Renal Replacement Therapy sections have been archived.
The rationale in this section and the information in Table 4a incorporate new data from clinical trials, including trials that investigated different doses of dexamethasone for the treatment of COVID-19.
This section includes results from the COLCOVID trial, an open-label, multicenter, randomized trial that evaluated the use of colchicine in hospitalized adults with COVID-19. After reviewing the results of the trial, the Panel continues to recommend against the use of colchicine for the treatment of hospitalized patients with COVID-19 (AI).
The Panel updated the information on the use of COVID-19 vaccines in patients with cancer and their close contacts. This section also discusses using tixagevimab plus cilgavimab (Evusheld) as pre-exposure prophylaxis (PrEP) in these patients and the potential drug-drug interactions between ritonavir-boosted nirmatrelvir (Paxlovid) and certain chemotherapeutic agents.
Special Considerations in Solid Organ Transplant, Hematopoietic Stem Cell Transplant, and Cellular Immunotherapy Candidates, Donors, and Recipients
The Panel added COVID-19 vaccination recommendations for potential organ and stem cell donors, and for close contacts of transplant and cellular immunotherapy candidates and recipients. This section also discusses using tixagevimab plus cilgavimab as PrEP in transplant candidates and recipients and the potential drug-drug interactions between ritonavir-boosted nirmatrelvir and certain immunosuppressants that are used in these patients.
May 13, 2022
The guidance on identifying and managing drug-drug interactions has moved to a new section of the Guidelines, entitled Drug-Drug Interactions Between Ritonavir-Boosted Nirmatrelvir (Paxlovid) and Concomitant Medications. The Ritonavir-Boosted Nirmatrelvir (Paxlovid) section retains the general description of ritonavir-boosted nirmatrelvir, the Panel’s recommendations for using this regimen, and a discussion of the clinical data that support those recommendations.
This section has been updated to acknowledge reports of SARS-CoV-2 viral rebound and the recurrence of COVID-19 symptoms in patients who completed a 5-day course of ritonavir-boosted nirmatrelvir. The frequency and clinical implications of these events are not yet known.
Drug-Drug Interactions Between Ritonavir-Boosted Nirmatrelvir (Paxlovid) and Concomitant Medications
Many commonly used medications can be safely coadministered with ritonavir-boosted nirmatrelvir despite its drug-drug interaction potential. In some cases, however, drug-drug interactions with ritonavir-boosted nirmatrelvir may lead to serious or life-threatening drug toxicities. This new section highlights the importance of evaluating a patient’s medication regimen for potential drug-drug interactions before prescribing ritonavir-boosted nirmatrelvir. However, because ritonavir-boosted nirmatrelvir is the only highly effective oral antiviral for the treatment of COVID-19, drug-drug interactions that can be safely managed should not preclude the use of this regimen.
The section provides guidance on management strategies and a variety of resources that clinicians can use to identify potential interactions between ritonavir-boosted nirmatrelvir and concomitant medications.
This section also includes 2 quick reference lists:
- Box 1 lists examples of commonly prescribed medications that can be safely coadministered with ritonavir-boosted nirmatrelvir.
- Box 2 lists medications with clinically significant interactions with ritonavir-boosted nirmatrelvir. The list is divided into categories of medications that:
- Should not be coadministered with ritonavir-boosted nirmatrelvir;
- Can be withheld temporarily, if clinically appropriate;
- May be continued with dose adjustments, if clinically appropriate; or
- May be continued while the patient is monitored for adverse effects.
Prioritization of Anti-SARS-CoV-2 Therapies for the Treatment and Prevention of COVID-19 When There Are Logistical or Supply Constraints
The Panel updated this section to highlight that this prioritization guidance should be used ONLY when logistical or supply constraints limit the availability of therapies. The Panel emphasizes that when there are no supply or logistical constraints, therapies for the prevention or treatment of SARS-CoV-2 infection can be prescribed for any eligible individual as recommended in these Guidelines.