IDSA recommends glucocorticoids, remdesivir for severe COVID-19
The Infectious Disease Society of America, or IDSA, updated their treatment guidelines for COVID-19 to recommend dexamethasone and remdesivir for treating hospitalized patients with severe disease.
“Our guidelines are intended to be a living document as we gather more data and learn more about what works for people with COVID-19,” Rajesh T. Gandhi, MD, FIDS, IDSA fellow and member of IDSA’s COVID-19 Treatment and Management Guidelines Expert Panel, chair-elect of the HIV Medicine Association, professor of medicine at Harvard Medical School and director of HIV Clinical Services and Education at Massachusetts General Hospital, said during a media briefing today. “Back in April, when we first issued these guidelines, there were really no medications that were known to be effective against COVID-19, but that has changed.”
One of the major changes to the guidelines focus on the use of glucocorticoids. The IDSA panel suggests the use of glucocorticoids for patients hospitalized with severe COVID-19 but recommends against their use in hospitalized patients who do not require supplemental oxygen due to hypoxemia.
The updated recommendations are based on study data, including results from the RECOVERY trial a randomized trial conducted in more than 6,000 hospitalized patients in the United Kingdom. The trial compared dexamethasone to usual care.
In the trial, researchers randomly assigned 2,104 participants to dexamethasone (6 mg daily for up to 10 days) and 4,321 to usual care to assess the outcomes of mortality and hospital discharge. The results demonstrated that 28-day mortality was 17% lower in the group that received dexamethasone than in the group that did not (RR = 0.83; 95% CI, 0.74-0.92) and that patients receiving dexamethasone were more likely to be discharged from the hospital (RR = 1.11; 95% CI, 1.04-1.19).
Additionally, a subgroup analyses of patients without hypoxia who were not receiving supplemental oxygen showed no benefit with dexamethasone and instead a trend toward harm when treating patients who were not on supplemental oxygen with dexamethasone (RR = 1.22; 95% CI, 0.86-1.75).
A second change to the guidelines was in regard to the use of remdesivir. According to Gandhi, the IDSA panel recommends the use of remdesivir for people hospitalized with severe COVID-19.
Preliminary results of the ACTT-1 study showed a trend toward a decline in mortality with remdesivir over no remdesivir at 14 days (HR = 0.70; 95% CI, 0.47-1.04). Moreover, a second study assessing remdesivir compared 5 and 10 days of treatment and found that the shorter course showed a trend toward reduced mortality (RR = 0.75; 95% CI, 0.51-1.12) and greater clinical improvement at 14 days (RR = 1.19; 95% CI, 1.01-1.40), although the IDSA notes this evidence is uncertain.
“We finally have medicines that work against severe COVID-19, and I think that's important,” Gandhi said. “Another point to make, though, is that there's much more to be done. These are not cures for COVID-19. They are advances against COVID-19.”
- IDSA. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/#toc-5. Accessed June 26, 2020.