Guidelines
Treatment

Treatment

Hospitalized Patients

The medications that have been reviewed, but due to lack of evidence, these medications are not currently recommended for the treatment of COVID-19

Revision History

  • 03/15/2020
    • General treatment options, dosing, and monitoring
  • 03/19/2020
    • Testing guidance for asymptomatic and symptomatic patients
    • Added therapeutic options based on severity using scale and laboratory monitoring for patients with COVID-19
    • Updated dosing for hydroxychloroquine
    • Corticosteroids: use of steroids in patients with severe disease could be considered as part of the supportive care regimen for patients with ARDS on a case-by-case basis
    • ACEi/ARB: advised against adding/removing beyond in standard practice
    • NSAIDs: no evidence for against the management of fever with NSAIDs
    • Guidance for use of nebulized respiratory medications
    • Removed chloroquine, ribavirin, atazanavir/ritonavir, atazanavir/cobicistat, darunavir/cobicistat
    • Added Tocilizumab
    • Post-exposure prophylaxis for patients and health care workers
  • 03/21/2020
    • Added: Discharge patients should be offered supportive care (anti-pyretics, MDI, etc.)
  • 03/25/2020
    • Updated treatment options based on severity score:
      • Severity score 1: removed hydroxychloroquine, lopinavir/ritonavir, darunavir/ritonavir
      • Severity score 2-3: no change
      • Severity score ≥ 4: Remdesivir for eligible patients first, if not: hydroxychloroquine. Removed combination of hydroxychloroquine plus lopinavir/ritonavir or darunavir/ritonavir
    • Lower dose glucocorticoids (equivalent to methylprednisolone 1-2 mg/kg/day for 3-5 days or ≤0.5-1 mg/kg/day methylprednisolone for ≤ 7 days) have been recommended after careful consideration of risks and benefits.
    • Azithromycin: insufficient evidence to recommend the use of azithromycin in addition to hydroxychloroquine
    • ECG monitoring at baseline for all hospitalized patients
  • 03/31/2020
    • Revised the duration of treatment
      • Severity score: 2-3: changed from 10 days to 5-7 days
      • Severity score ≥ 4: changed from 10-14 days to 7-10 days
    • Corticosteroids: early initiation of lower dose glucocorticoids (equivalent to methylprednisolone 1-2 mg/kg/day for 3-5 days or ≤0.5-1 mg/kg/day methylprednisolone for ≤ 7 days) have been recommended for patients with refractory shock and/or ARDS
    • Removed darunavir/ritonavir
    • Added Sarilumab with criteria for use
  • 4/15/2020
    • Added: statement regarding use of off-label experimental therapies with only in vitro data
    • Added recommendation against use of ivermectin
    • Added anticoagulation pathway
    • Added guidance on cardiac monitoring
    • Added additional steroid guidance and chart with risk factors for CRS
    • Added restriction to ID for lopinavir/ritonavir
    • Revised daily monitoring parameters
  • 4/20/2020
    • Added statement regarding use of micronutrients, Zinc and Vitamin C
  • 4/27/2020
    • Removed lopinavir/ritonavir from algorithm
    • Added comment regarding use of hydroxychloroquine
    • Updated remdesivir information for compassionate use
  • 4/29/2020
    • Updated anticoagulation algorithm, removal of ROTEM
    • Added statement regarding use of tPA
  • 5/12/2020
    • Removed hydroxychloroquine from algorithm
  • 5/18/2020
    • Added guidance for outpatient anticoagulation
    • Removed cardiac monitoring for patients receiving hydroxychloroquine
    • Removed statement regarding empiric initiation of experimental/investigational therapies for severity score ≥ 4
    • Included information on remdesivir emergency use authorization
    • Included information on convalescent plasma
  • 5/26/2020
    • Clarification of outpatient anticoagulation recommendations
  • 6/4/2020
    • Updated allocation information on remdesivir
  • 6/9/2020
    • Updated DOH link to request remdesivir for State of Florida (outside of CFDS)
  • 6/18/2020
    • Addition of low-dose dexamethasone recommendation
    • Removal of remdesivir compassionate use information
    • Edited remdesivir allocation information
  • 6/30/2020
    • Added warning against use of hydroxychloroquine
    • Modified IL6 antagonist recommendation to include use for severity score ≥ 2
    • Updated remdesivir access process
  • 7/3/2020
    • Removal of sarilumab from algorithm
    • Updated tocilizumab recommendation to include use for severity score ≥ 3
  • 7/14/2020
    • Modified remdesivir criteria for use
  • 8/5/2020
    • Revised remdesivir criteria for use
    • Updated multi-state convalescent plasma inclusion criteria
    • Removal of HERO study details as trial has stopped enrollment
    • Addition of statement regarding insufficient data on use of tocilizumab
  • 8/25/2020
    • Updated convalescent plasma criteria based on FDA’s EUA announcement
  • 9/3/2020
    • Updated verbiage regarding remdesivir criteria for use
  • 10/27/2020
    • Updated remdesivir information to reflect changes in regulatory requirements based on FDA approval of remdesivir on 10/22/20
    • Removed tocilizumab and recommended against routine use
  • 11/12/2020
    • Added bamlanivimab
  • 11/19/2020
    • Added NIH and IDSA recommendations and references for use of bamlanivimab in outpatients
  • 11/24/2020
    • Reviewed available data and EUA information on baricitinib
  • 12/3/2020
    • Added casirivimab/imdevimab
  • 12/22/2020
    • Revised language regarding baricitinib
  • 1/7/2021
    • Updated verbiage regarding use of ivermectin
  • 1/12/2021
    • Added tocilizumab back into treatment algorithm
  • 2/4/2021
    • Included information on colchicine for non-hospitalized patients
  • 2/9/2021
    • Modified tocilizumab recommendation to include only patients with severity score ≥3
    • Updated convalescent plasma EUA criteria
  • 2/11/2021
    • Updated EUA information on convalescent plasma
    • Added EUA information for bamlanivimab/etesevimab combination
    • Added additional links to ivermectin
  • 2/18/2021
    • Updated information on convalescent plasma severity score recommendations based on EUA
  • 3/02/2021
    • Updated inpatient and outpatient anticoagulation algorithm
  • 3/10/2021
    • Added additional study evaluating ivermectin
    • Updated information and recommendations on MABs
  • 3/25/2021
    • Updated criteria for use for remdesivir to include option to use in patients on high flow oxygen
    • Updated information and recommendations on MABs
  • 4/20/2021
    • Updated guideline recommendations on MABs
    • Included FDA EUA updates and information on the revoked EUA for bamlanivimab monotherapy
  • 5/3/2021
    • Updated tocilizumab criteria to reflect provider restrictions
  • 5/25/2021
    • Updated EUA requirements for MABs
  • 5/27/2021
    • Updated bamlanivimab-etesevimab information on distribution to the state of Florida
  • 6/3/2021
    • Modified recommendation for use of COVID-19 convalescent plasma
  • 6/7/2021
    • Updated FDA EUA information for casirivimab/imdevimab: new dosing and route of administration
  • 6/15/2021
    • Clarified language regarding scientific basis for avoiding routine use of remdesivir in patients on room air or mechanical ventilation
    • Removed statement about insufficient data for baricitinib and the warning against use of baricitinib with corticosteroids
    • Updated FDA EUA information for new MAB, Sotrovimab
  • 6/25/2021
    • Updated information regarding distribution of bamlanivimab-etesevimab in the U.S.
  • 07/13/2021
    • Updated tocilizumab to reflect EUA and results of the RECOVERY trial
  • 07/29/2021
    • Added bradycardia and hypotension to Adverse Effects for remdesivir
    • Updated baricitinib information to reflect update to EUA
  • 8/5/2021
    • Updated EUA criteria for casirivimab-imdevimab for use in post-exposure prophylaxis
    • Added guidance on utility of IL6 levels
  • 8/17/2021
    • Updated recommendations on use of colchicine in non-hospitalized patients and addressed inpatient use
    • Updated ivermectin studies-no change to overall recommendation for use
    • Updated baricitinib drug information to warn against initiation for low ALC, ANC, or Hgb
  • 8/24/2021
    • Edited information on baricitinib labs for imitation of therapy (ALC <200 cells/µL instead of <500 cells/µL)
  • 8/30/2021
    • Edited information to include tofacitinib and sarilumab as alternatives to baricitinib and tocilizumab in cases of supply issue
  • 10/04/2021
    • Updated monoclonal antibody information to reflect renewed availability of bamlanivimab/etesevimab and to incorporate post-exposure prophylaxis
  • 11/16/2021
    • Edited inpatient anticoagulation algorithm
    • Added chart on preferred outpatient therapies
    • Added information on fluvoxamine

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Adapted from the AdventHealth Orlando Antimicrobial Stewardship Program