What's New in the Guidelines
Last Updated: April 20, 2023
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:
April 20, 2023
Pregnancy, Lactation, and COVID-19 Therapeutics
A new section has been added to provide guidance on the use of Panel-recommended therapies in pregnant or lactating patients with COVID-19. A new table summarizes the recommendations for each drug. The section includes the rationale behind these recommendations and potential safety concerns for fetuses and for infants who receive breast milk from individuals who are taking COVID-19 therapies.
Therapeutic Management of Nonhospitalized Adults With COVID-19
This section has been updated to clarify the goals of therapeutic management for nonhospitalized patients and discuss the limitations of the data that inform the Panel's recommendations. Currently, the Panel’s recommendations reflect the available data on the benefits of using antiviral therapies to prevent progression to severe COVID-19. The Panel will consider the potential benefits of therapies for other outcomes, such as symptom recovery, as those data emerge.
Data from the PANORAMIC trial have been added to the rationale for molnupiravir. The Panel also expanded the subsection on viral rebound and symptom recurrence to discuss the rebounds that have been reported after patients have completed therapy with molnupiravir and ritonavir-boosted nirmatrelvir (Paxlovid).
Therapeutic Management of Hospitalized Adults With COVID-19
The Panel currently recommends using dexamethasone as the primary immunomodulator for all patients who require high-flow nasal canula oxygen, noninvasive ventilation, mechanical ventilation, or extracorporeal membrane oxygenation. A second immunomodulator (e.g., baricitinib, tocilizumab) should be added to dexamethasone for the treatment of these patients. These minor changes are reflected in both Table 2b and the Panel’s rationale.
Oxygenation and Ventilation for Adults
The Panel updated the rationale for the recommendations with information from recent studies. In addition, the recommendations and rationale for using neuromuscular blocking agents in mechanically ventilated adults with moderate to severe acute respiratory distress syndrome were streamlined, and 1 of the recommendations was removed.
This section includes information from the PANORAMIC trial, an open-label randomized controlled trial that enrolled nonhospitalized adults with COVID-19 during a period when the Omicron variant was circulating. Molnupiravir plus usual care did not reduce the occurrence of the primary composite outcome of hospitalization or death compared to usual care alone, but participants in the molnupiravir arm reported recovering from COVID-19 an estimated 4 days earlier. Because this was an open-label trial, these findings are less reliable than those from a placebo-controlled trial. The Panel continues to recommend molnupiravir as an alternative therapy to ritonavir-boosted nirmatrelvir or remdesivir.
The Panel summarized the recently published data from the TOGETHER trial on the use of pegylated interferon lambda in nonhospitalized patients with COVID-19. This trial showed a reduction in the occurrence of the primary composite outcome of observation in an emergency department for >6 hours or hospitalization among patients who received interferon lambda. However, because interferon lambda is not available in the United States, the Panel is not able to make a recommendation for or against use of this agent. Table 4d has been updated to include a description of the results from the TOGETHER trial.
Janus Kinase Inhibitors
The title for this section has been changed from Kinase Inhibitors: Janus Kinase Inhibitors and Bruton’s Tyrosine Kinase Inhibitors to Janus Kinase Inhibitors. Information on agents that are not recommended for the treatment of COVID-19, including the Janus kinase inhibitor ruxolitinib and Bruton’s tyrosine kinase inhibitors, has been removed from the section.
This section now includes information from the REMAP-CAP trial, which demonstrated that treatment with interleukin (IL)-6 receptor antagonists improved survival among severely and critically ill patients with COVID-19 after 180 days. Information on agents that are not recommended for the treatment of COVID-19, including the anti-IL-6 monoclonal antibody siltuximab, has been removed from the section.