Table 5e. Characteristics of Immunomodulators
Last Updated: February 29, 2024
- The information in this table is derived from data on the use of these drugs for FDA-approved indications or from clinical trials that evaluated their use in patients with COVID-19.
- For dose modifications in patients with organ failure or those who require extracorporeal devices, please refer to product labels or EUAs, when available.
- There are currently not enough data to determine whether certain medications can be safely coadministered with therapies for the treatment of COVID-19. When using concomitant medications with similar toxicity profiles, consider performing additional safety monitoring.
- The potential additive, antagonistic, or synergistic effects and the safety of using certain combination therapies for the treatment of COVID-19 are unknown. Clinicians are encouraged to report AEs to the FDA MedWatch program.
- For drug-drug interaction information, please refer to product labels and visit the Liverpool COVID-19 Drug Interactions website.
- For the Panel’s recommendations on using the drugs listed in this table, please refer to the drug-specific sections of the Guidelines; Therapeutic Management of Nonhospitalized Adults With COVID-19; Therapeutic Management of Hospitalized Adults With COVID-19; Therapeutic Management of Hospitalized Children With COVID-19; and Pregnancy, Lactation, and COVID-19 Therapeutics.
Drug Name | Dosing Regimens | Adverse Events | Monitoring Parameters | Drug-Drug Interaction Potential | Comments |
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Corticosteroid (Systemic) Recommended by the Panel for the treatment of COVID-19 in certain hospitalized patients. | |||||
Dexamethasone | Dose for Adults With COVID-19
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Janus Kinase Inhibitors Recommended by the Panel for the treatment of COVID-19 in certain hospitalized patients. | |||||
Baricitinib | FDA-Approved Doses for COVID-19 in Adults Aged ≥18 Years, per eGFR2 ≥60 mL/min/1.73 m2
30 to <60 mL/min/1.73 m2
15 to <30 mL/min/1.73 m2
<15 mL/min/1.73 m2
FDA EUA Dose for Children Aged 9–17 Years3
FDA EUA Doses for Children Aged 2 to <9 Years, per eGFR3 ≥60 mL/min/1.73 m2
30 to <60 mL/min/1.73 m2
<30 mL/min/1.73 m2
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Availability
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Tofacitinib | Dose for COVID-19 in Clinical Trials
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Interleukin-6 Inhibitors (Anti-Interleukin-6 Receptor Monoclonal Antibodies) Recommended by the Panel for the treatment of COVID-19 in certain hospitalized patients. | |||||
Sarilumab | Dose for COVID-19 in Clinical Trials
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Availability
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Tocilizumab | FDA-Approved Dose for COVID-19 in Hospitalized Adults
FDA EUA Doses for COVID-19 in Hospitalized Children Body Weight ≥30 kg
Body Weight <30 kg
For All Doses
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Availability
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Cytotoxic T-Lymphocyte–Associated Antigen 4 Agonist Recommended by the Panel for the treatment of COVID-19 in certain hospitalized patients. | |||||
Abatacept | Dose for COVID-19 in Clinical Trials
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Availability
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Tumor Necrosis Factor–Alpha Inhibitor Recommended by the Panel for the treatment of COVID-19 in certain hospitalized patients. | |||||
Infliximab | Dose for COVID-19 in Clinical Trials
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| Availability
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Anti-C5a Monoclonal Antibody Received an FDA EUA for the treatment of COVID-19 when it is administered within 48 hours of MV or ECMO. There is insufficient evidence for the Panel to recommend either for or against its use. | |||||
Vilobelimab | FDA EUA Dose for COVID-19 in Hospitalized Adults Receiving MV or ECMO
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| Availability
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Interleukin-1 Inhibitors Anakinra: Received an FDA EUA for the treatment of COVID-19 in certain hospitalized adults. There is insufficient evidence for the Panel to recommend either for or against its use. Canakinumab: The Panel recommends against the use of canakinumab for the treatment of COVID-19, except in a clinical trial. | |||||
Anakinra | FDA EUA Dose for COVID-19 in Hospitalized Patients Aged ≥18 Years
Dose for Patients With CrCl <30 mL/min
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Canakinumab | Dose for COVID-19 in Clinical Trials
FDA-Approved Dose for Systemic JIA
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| Availability
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Corticosteroids (Inhaled) There is insufficient evidence for the Panel to recommend either for or against the use of inhaled corticosteroids for the treatment of COVID-19. | |||||
Budesonide (Inhaled) | Dose for COVID-19 in Clinical Trials
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Ciclesonide (Inhaled) | Dose for COVID-19 in Clinical Trials
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Fluticasone (Inhaled) | Dose for COVID-19 in Clinical Trials
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Key: AE = adverse event; ALC = absolute lymphocyte count; ALT = alanine transaminase; ANC = absolute neutrophil count; AST = aspartate aminotransferase; BAR = baricitinib; BMP = basic metabolic panel; BP = blood pressure; CBC = complete blood count; CD4 = CD4 T lymphocyte; COPD = chronic obstructive pulmonary disease; CrCl = creatinine clearance; CVA = cerebral vascular accident; CYP = cytochrome P450; DEX = dexamethasone; DILI = drug-induced liver injury; DVT = deep vein thrombosis; ECMO = extracorporeal membrane oxygenation; eGFR = estimated glomerular filtration rate; EUA = Emergency Use Authorization; FDA = Food and Drug Administration; GDH-PQQ = glucose dehydrogenase pyrroloquinoline quinone; GI = gastrointestinal; HBV = hepatitis B virus; Hgb = hemoglobin; HSR = hypersensitivity reaction; HSV = herpes simplex virus; HTN = hypertension; ICU = intensive care unit; IL = interleukin; IV = intravenous; JIA = juvenile idiopathic arthritis; MDI = metered dose inhaler; MI = myocardial infarction; MV = mechanical ventilation; NaCl = sodium chloride; NIV = noninvasive ventilation; NMBA = neuromuscular blocking agent; OAT = organic anion transporter; the Panel = the COVID-19 Treatment Guidelines Panel; PE = pulmonary embolism; PLT = platelet count; PO = oral; SUBQ = subcutaneous; TB = tuberculosis; TNF = tumor necrosis factor |
References
- Randomised Evaluation of COVID-19 Therapy (RECOVERY). Low-cost dexamethasone reduces death by up to one third in hospitalised patients with severe respiratory complications of COVID-19. 2020. Available at: https://www.recoverytrial.net/news/low-cost-dexamethasone-reduces-death-by-up-to-one-third-in-hospitalised-patients-with-severe-respiratory-complications-of-covid-19. Accessed January 23, 2024.
- Baricitinib (Olumiant) [package insert]. Food and Drug Administration. 2022. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/207924s006lbl.pdf.
- Food and Drug Administration. Fact sheet for healthcare providers: Emergency Use Authorization (EUA) of baricitinib. 2022. Available at: https://www.fda.gov/media/143823/download.
- Guimarães PO, Quirk D, Furtado RH, et al. Tofacitinib in patients hospitalized with COVID-19 pneumonia. N Engl J Med. 2021;385(5):406-415. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34133856.
- REMAP-CAP Investigators. Effectiveness of tocilizumab, sarilumab, and anakinra for critically ill patients with COVID-19: the REMAP-CAP COVID-19 immune modulation therapy domain randomized clinical trial. medRxiv. 2021;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2021.06.18.21259133v2.
- Sivapalasingam S, Lederer DJ, Bhore R, et al. Efficacy and safety of sarilumab in hospitalized patients with COVID-19: a randomized clinical trial. Clin Infect Dis. 2022;75(1):e380-e388. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35219277.
- Sarilumab (Kevzara) [package insert]. Food and Drug Administration. 2018. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761037s001lbl.pdf.
- REMAP-CAP Investigators. Interleukin-6 receptor antagonists in critically ill patients with COVID-19. N Engl J Med. 2021;384(16):1491-1502. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33631065.
- Food and Drug Administration. Fact sheet for healthcare providers: Emergency Use Authorization for Actemra (tocilizumab). 2021. Available at: https://www.fda.gov/media/150321/download.
- Tocilizumab (Actemra) [package insert]. Food and Drug Administration. 2022. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/125276s138lbl.pdf.
- O’Halloran JA, Ko ER, Anstrom KJ, et al. Abatacept, cenicriviroc, or infliximab for treatment of adults hospitalized with COVID-19 pneumonia: a randomized clinical trial. JAMA. 2023;330(4):328-339. Available at: https://pubmed.ncbi.nlm.nih.gov/37428480.
- Abatacept (Orencia) [package insert]. Food and Drug Administration. 2021. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/125118s240lbl.pdf.
- Infliximab (Remicade) [package insert]. Food and Drug Administration. 2021. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/103772s5401lbl.pdf.
- Food and Drug Administration. Fact sheet for healthcare providers: Emergency Use Authorization for Gohibic. 2023. Available at: https://www.fda.gov/media/166824/download.
- Food and Drug Administration. Fact sheet for healthcare providers: Emergency Use Authorization for Kineret. 2022. Available at: https://www.fda.gov/media/163075/download.
- Caricchio R, Abbate A, Gordeev I, et al. Effect of canakinumab vs placebo on survival without invasive mechanical ventilation in patients hospitalized with severe COVID-19: a randomized clinical trial. JAMA. 2021;326(3):230-239. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34283183.
- Hepprich M, Mudry JM, Gregoriano C, et al. Canakinumab in patients with COVID-19 and type 2 diabetes - a multicentre, randomised, double-blind, placebo-controlled trial. EClinicalMedicine. 2022;53:101649. Available at: https://www.ncbi.nlm.nih.gov/pubmed/36128334.
- Canakinumab (Ilaris) [package insert]. Food and Drug Administration. 2020. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/125319s100lbl.pdf.
- Ramakrishnan S, Nicolau DV Jr, Langford B, et al. Inhaled budesonide in the treatment of early COVID-19 (STOIC): a Phase 2, open-label, randomised controlled trial. Lancet Respir Med. 2021;9(7):763-772. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33844996.
- Yu LM, Bafadhel M, Dorward J, et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet. 2021;398(10303):843-855. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34388395.
- Clemency BM, Varughese R, Gonzalez-Rojas Y, et al. Efficacy of inhaled ciclesonide for outpatient treatment of adolescents and adults with symptomatic COVID-19: a randomized clinical trial. JAMA Intern Med. 2022;182(1):42-49. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34807241.
- Boulware DR, Lindsell CJ, Stewart TG, et al. Inhaled fluticasone furoate for outpatient treatment of COVID-19. N Engl J Med. 2023;389(12):1085-1095. Available at: https://www.ncbi.nlm.nih.gov/pubmed/37733308.