3児の親さん薬剤師のブログ

とある薬剤師です。感染症治療を考える素材をちょこっと提供。noteもあります https://note.com/twin1980

COVID-19 Management Guidelinesって何があるの?

 

なかなか治療選択が増えないCOVID-19。

 

レムデシビル以外はどうなのか?

 

note.com

 

メジャーなものとして、NIHとIDSAがあります。 

 

 

NIHを少し復習。

抗ウイルス薬の選択肢が増えて欲しいですが、

開発は簡単でなく、ACTT2のような、抗ウイルス薬 + 抗免疫薬など組み合わせたが進むと思われます。血漿も期待できますが、大量に作成できない欠点が辛いです。

 

Antivirals

 

  • On the basis of preliminary clinical trial data, the COVID-19 Treatment Guidelines Panel (the Panel) recommends the investigational antiviral agent remdesivir for the treatment of COVID-19 in hospitalized patients with severe disease defined as SpO2 ≤94% on ambient air (at sea level), requiring supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation (BI).
    • Remdesivir is not approved by the FDA. It is available through an FDA emergency use authorization, in clinical trials, or through an emergency access program for children and pregnant patients.
  • The Panel does not recommend remdesivir for the treatment of mild or moderate COVID-19 outside of a clinical trial (AIII).
  • There are insufficient clinical data to recommend either for or against using chloroquine or hydroxychloroquine for the treatment of COVID-19 (AIII).
  • The Panel recommends against using high-dose chloroquine (600 mg twice daily for 10 days) for the treatment of COVID-19 (AI).
  • Except in the context of a clinical trial, the Panel recommends against the use of the following drugs for the treatment of COVID-19:
    • The combination of hydroxychloroquine plus azithromycin (AIII) because of the potential for toxicities.
    • Lopinavir/ritonavir (AI) or other HIV protease inhibitors (AIII) because of unfavorable pharmacodynamics and negative clinical trial data.
Immune-Based Therapy

  • There are insufficient data to recommend either for or against the use of COVID-19 convalescent plasma or SARS-CoV-2 immune globulins for the treatment of COVID-19 (AIII).
  • The COVID-19 Treatment Guidelines Panel (the Panel) recommends against the use of non-SARS-CoV-2-specific intravenous immune globulin (IVIG) for the treatment of COVID-19, except in the context of a clinical trial (AIII). This should not preclude the use of IVIG when it is otherwise indicated for the treatment of complications that arise during the course of COVID-19.
  • There are insufficient data to recommend either for or against the use of the following agents for the treatment of COVID-19 (AIII):
  • Interleukin-1 inhibitors (e.g., anakinra)
  • Interleukin-6 inhibitors (e.g., sarilumab, siltuximab, tocilizumab)
  • Except in the context of a clinical trial, the Panel recommends against the use of other immunomodulators, such as:
  • Interferons (AIII), because of the lack of efficacy in treatment of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) and toxicity.
  • Janus kinase inhibitors (e.g., baricitinib) (AIII), because of their broad immunosuppressive effect.

 

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs):

  • Persons with COVID-19 who are prescribed ACE inhibitors or ARBs for cardiovascular disease (or other indications) should continue these medications (AIII).
  • The COVID-19 Treatment Guidelines Panel (the Panel) recommends against the use of ACE inhibitors or ARBs for the treatment of COVID-19 outside of the setting of a clinical trial (AIII).

Corticosteroids

For Critically Ill Patients with COVID-19:

  • The Panel recommends against the routine use of systemic corticosteroids for the treatment of mechanically ventilated patients with COVID-19 without acute respiratory distress syndrome (ARDS)(AIII).
  • For mechanically ventilated patients with ARDS, there is insufficient evidence to recommend for or against the use of systemic corticosteroids (CI).
  • For adults with COVID-19 and refractory shock, the Panel recommends using low-dose corticosteroid therapy (i.e., shock reversal) over no corticosteroids (BII).

For Hospitalized, Non-Critically Ill Patients with COVID-19:

  • The Panel recommends against the routine use of systemic corticosteroids for the treatment of COVID-19 in hospitalized patients, unless they are in the intensive care unit (AIII).

For Patients on Chronic Corticosteroids:

  • Oral corticosteroid therapy used prior to COVID-19 diagnosis for another underlying condition (e.g., primary or secondary adrenal insufficiency, rheumatological diseases) should not be discontinued (AIII). On a case-by-case basis, supplemental or stress-dose steroids may be indicated (AIII).
  • Inhaled corticosteroids used daily for patients with asthma and chronic obstructive pulmonary disease for control of airway inflammation should not be discontinued in patients with COVID-19 (AIII).

Pregnancy Considerations:

  • The antenatal corticosteroids betamethasone and dexamethasone are known to cross the placenta and therefore are generally reserved for when administration is required for fetal benefit (BIII). Other systemic corticosteroids do not cross the placenta, and pregnancy is not a reason to restrict their use if otherwise indicated (CIII).
  • The American College of Obstetricians and Gynecologists recommends against offering antenatal corticosteroids for fetal benefit in the late preterm period (34 0/7 weeks–36 6/7 weeks) because the benefits of antenatal corticosteroids in the late preterm period are less well established (CIII).
  • Modifications to care for these patients may be individualized, weighing the neonatal benefits of antenatal corticosteroid use with the risks of potential harm to the pregnant patient (CIII).

HMG-CoA Reductase Inhibitors (Statins):

  • Persons with COVID-19 who are prescribed statin therapy for the treatment or prevention of cardiovascular disease should continue these medications (AIII).
  • The Panel recommends against the use of statins for the treatment of COVID-19 outside of the setting of a clinical trial (AIII).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):

  • Persons with COVID-19 who are taking NSAIDs for a co-morbid condition should continue therapy as previously directed by their physician (AIII).
  • The Panel recommends that there be no difference in the use of antipyretic strategies (e.g., with acetaminophen or NSAIDs) between patients with or without COVID-19 (AIII).