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Reis G, Silva EASM, Silva DCM, Thabane L, Milagres AC, Ferreira TS, Dos Santos CVQ, Campos VHS, Nogueira AMR, de Almeida APFG, Callegari ED, Neto ADF, Savassi LCM, Simplicio MIC, Ribeiro LB, Oliveira R, Harari O, Forrest JI, Ruton H, Sprague S, McKay P, Guo CM, Rowland-Yeo K, Guyatt GH, Boulware DR, Rayner CR, Mills EJ. Effect of Early Treatment with Ivermectin among Patients with Covid-19. N Engl J Med 2022; 386:1721-1731. [PMID: 35353979 PMCID: PMC9006771 DOI: 10.1056/nejmoa2115869] [Citation(s) in RCA: 123] [Impact Index Per Article: 61.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of ivermectin in preventing hospitalization or extended observation in an emergency setting among outpatients with acutely symptomatic coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is unclear. METHODS We conducted a double-blind, randomized, placebo-controlled, adaptive platform trial involving symptomatic SARS-CoV-2-positive adults recruited from 12 public health clinics in Brazil. Patients who had had symptoms of Covid-19 for up to 7 days and had at least one risk factor for disease progression were randomly assigned to receive ivermectin (400 μg per kilogram of body weight) once daily for 3 days or placebo. (The trial also involved other interventions that are not reported here.) The primary composite outcome was hospitalization due to Covid-19 within 28 days after randomization or an emergency department visit due to clinical worsening of Covid-19 (defined as the participant remaining under observation for >6 hours) within 28 days after randomization. RESULTS A total of 3515 patients were randomly assigned to receive ivermectin (679 patients), placebo (679), or another intervention (2157). Overall, 100 patients (14.7%) in the ivermectin group had a primary-outcome event, as compared with 111 (16.3%) in the placebo group (relative risk, 0.90; 95% Bayesian credible interval, 0.70 to 1.16). Of the 211 primary-outcome events, 171 (81.0%) were hospital admissions. Findings were similar to the primary analysis in a modified intention-to-treat analysis that included only patients who received at least one dose of ivermectin or placebo (relative risk, 0.89; 95% Bayesian credible interval, 0.69 to 1.15) and in a per-protocol analysis that included only patients who reported 100% adherence to the assigned regimen (relative risk, 0.94; 95% Bayesian credible interval, 0.67 to 1.35). There were no significant effects of ivermectin use on secondary outcomes or adverse events. CONCLUSIONS Treatment with ivermectin did not result in a lower incidence of medical admission to a hospital due to progression of Covid-19 or of prolonged emergency department observation among outpatients with an early diagnosis of Covid-19. (Funded by FastGrants and the Rainwater Charitable Foundation; TOGETHER ClinicalTrials.gov number, NCT04727424.).
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Affiliation(s)
- Gilmar Reis
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Eduardo A S M Silva
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Daniela C M Silva
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Lehana Thabane
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Aline C Milagres
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Thiago S Ferreira
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Castilho V Q Dos Santos
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Vitoria H S Campos
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Ana M R Nogueira
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Ana P F G de Almeida
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Eduardo D Callegari
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Adhemar D F Neto
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Leonardo C M Savassi
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Maria I C Simplicio
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Luciene B Ribeiro
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Rosemary Oliveira
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Ofir Harari
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Jamie I Forrest
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Hinda Ruton
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Sheila Sprague
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Paula McKay
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Christina M Guo
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Karen Rowland-Yeo
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Gordon H Guyatt
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - David R Boulware
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Craig R Rayner
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
| | - Edward J Mills
- From the Research Division, Cardresearch-Cardiologia Assistencial e de Pesquisa (G.R., E.A.S.M.S., D.C.M.S., T.S.F., C.V.Q.S., V.H.S.C., M.I.C.S., L.B.R., R.O.), and the Department of Medicine, Pontifical Catholic University of Minas Gerais (G.R., E.A.S.M.S., D.C.M.S., C.V.Q.S., V.H.S.C.), Belo Horizonte, the Department of Public Health and Mental and Family Medicine, Ouro Preto Federal University, Ouro Preto (A.C.M., L.C.M.S.), the Public Health Care Division, Ibirité (A.C.M.), the Department of Public Health and the Family Medicine Fellowship Program, UNIFIPMoc, Montes Claros (A.M.R.N., A.P.F.G.A.), the Public Health Care Division, Brumadinho (E.D.C.), and the Public Health Fellowship Program, Governador Valadares Public Health Authority, Governador Valadares (A.D.F.N.) - all in Brazil; the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (L.T., S.S., P.M., G.H.G., E.J.M.), and Cytel (O.H., H.R., E.J.M.) and Platform Life Sciences (J.I.F., C.M.G., E.J.M.), Vancouver, BC - all in Canada; Certara, Princeton, NJ (K.R.-Y., C.R.R.); the Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis (D.R.B.); and Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia (C.R.R.)
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Agarwal A, Hunt B, Stegemann M, Rochwerg B, Lamontagne F, Siemieniuk RA, Agoritsas T, Askie L, Lytvyn L, Leo YS, Macdonald H, Zeng L, Alhadyan A, Muna AM, Amin W, da Silva ARA, Aryal D, Barragan FAJ, Bausch FJ, Burhan E, Calfee CS, Cecconi M, Chacko B, Chanda D, Dat VQ, De Sutter A, Du B, Freedman S, Geduld H, Gee P, Haider M, Gotte M, Harley N, Hashimi M, Hui D, Ismail M, Jehan F, Kabra SK, Kanda S, Kim YJ, Kissoon N, Krishna S, Kuppalli K, Kwizera A, Lado Castro-Rial M, Lisboa T, Lodha R, Mahaka I, Manai H, Mendelson M, Migliori GB, Mino G, Nsutebu E, Peter J, Preller J, Pshenichnaya N, Qadir N, Ranganathan SS, Relan P, Rylance J, Sabzwari S, Sarin R, Shankar-Hari M, Sharland M, Shen Y, Souza JP, Swanstrom R, Tshokey T, Ugarte S, Uyeki T, Evangelina VC, Venkatapuram S, Vuyiseka D, Wijewickrama A, Tran L, Zeraatkar D, Bartoszko JJ, Ge L, Brignardello-Petersen R, Owen A, Guyatt G, Diaz J, Kawano-Dourado L, Jacobs M, Vandvik PO. A living WHO guideline on drugs for covid-19. BMJ 2020; 370:m3379. [PMID: 32887691 DOI: 10.1136/bmj.m3379] [Citation(s) in RCA: 485] [Impact Index Per Article: 121.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Updates This is the fourteenth version (thirteenth update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline. Clinical question What is the role of drugs in the treatment of patients with covid-19? Context The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and underway. Emerging SARS-CoV-2 variants and subvariants are changing the role of therapeutics. What is new? The guideline development group (GDG) defined 1.5% as a new threshold for an important reduction in risk of hospitalisation in patients with non-severe covid-19. Combined with updated baseline risk estimates, this resulted in stratification into patients at low, moderate, and high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New pharmacokinetic evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation for ivermectin in patients with non-severe illness was updated in light of additional trial evidence which reduced the high degree of uncertainty informing previous guidance. A new recommendation was made against the antiviral agent VV116 for patients with non-severe and with severe or critical illness outside of randomised clinical trials based on one RCT comparing the drug with nirmatrelvir/ritonavir. The structure of the guideline publication has also been changed; recommendations are now ordered by severity of covid-19. About this guideline This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF on the WHO website, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact. Future recommendations Recommendations on anticoagulation are planned for the next update to this guideline. Updated data regarding systemic corticosteroids, azithromycin, favipiravir and umefenovir for non-severe illness, and convalescent plasma and statin therapy for severe or critical illness, are planned for review in upcoming guideline iterations.
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Affiliation(s)
- Arnav Agarwal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | - Beverly Hunt
- St Thomas’ Hospital, London, UK
- ivermectin and IL-6 receptor blocker panel member
| | - Miriam Stegemann
- Charité - Universitätsmedizin Berlin, Germany
- ivermectin and IL-6 receptor blocker panel member
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - François Lamontagne
- Université de Sherbrooke, Centre de recherche due CHU de Sherbrooke, Quebec, Canada
- Not panel member; resource for methodology, systematic review, and content support
- Corticosteroid panel member
| | - Reed Ac Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway
- Not panel member; resource for methodology, systematic review, and content support
- Corticosteroid panel member
| | - Lisa Askie
- World Health Organization, Geneva, Switzerland
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | - Yee-Sin Leo
- National Center for Infectious Diseases, Singapore
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Helen Macdonald
- The BMJ, London, UK
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Manzoni 56, 20089 Rozzano (MI), Italy
- Not panel member; resource for methodology, systematic review, and content support
| | - Linan Zeng
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | | | | | - Wagdy Amin
- Ministry of Health and Population, Cairo, Egypt
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | | | - Frederique Jacquerioz Bausch
- Geneva University Hospital, Switzerland
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Erlina Burhan
- Infection Division, Department of Pulmonology and Respiratory Medicine, Faculty of Medicine Universitas Indonesia
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Carolyn S Calfee
- University of California, San Francisco, USA
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Manzoni 56, 20089 Rozzano (MI), Italy
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
| | | | - Duncan Chanda
- Adult Infectious Disease Centre, University Teaching Hospital, Lusaka, Zambia
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Vu Quoc Dat
- Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - An De Sutter
- University of Gent, Belgium
- ivermectin and IL-6 receptor blocker panel member
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, China
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Stephen Freedman
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Canada
| | - Heike Geduld
- Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Patrick Gee
- USA
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | - Nerina Harley
- Royal Melbourne Hospital and Epworth Healthcare, Melbourne, Australia
- ivermectin and IL-6 receptor blocker panel member
| | - Madiha Hashimi
- Ziauddin University, Karachi, Pakistan
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - David Hui
- Stanley Ho Centre for Emerging Infectious Diseases, Chinese University of Hong Kong, China
| | | | | | - Sushil K Kabra
- All India Institute of Medical Sciences, New Delhi, India
- Department of Anaesthesia and Critical Care, College of Health Sciences, Makerere University, Kampala, Uganda
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Seema Kanda
- McMaster University (alumnus)
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Yae-Jean Kim
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Niranjan Kissoon
- Department of Paediatrics and Emergency Medicine, University of British Columbia, Vancouver, Canada
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | - Arthur Kwizera
- Department of Anaesthesia and Critical Care, College of Health Sciences, Makerere University, Kampala, Uganda
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | - Rakesh Lodha
- All India Institute of Medical Sciences, New Delhi, India
| | - Imelda Mahaka
- Zimbabwe
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Hela Manai
- Emergency Medical Services, Faculty of Medicine, Tunis, Tunisia
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Marc Mendelson
- Groote Schuur Hospital, University of Cape Town, South Africa
| | | | - Greta Mino
- Alcivar Hospital in Guayaquil, Ecuador
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Emmanuel Nsutebu
- Sheikh Shakhbout Medical City, Abu Dhabi
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | - Natalia Pshenichnaya
- Central Research Institute of Epidemiology of Rospotrebnadzor, Moscow, Russia
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Nida Qadir
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Shalini Sri Ranganathan
- University of Colombo, Sri Lanka
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | - Saniya Sabzwari
- Aga Khan University, Karachi, Pakistan
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Rohit Sarin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Manu Shankar-Hari
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- ivermectin and IL-6 receptor blocker panel member
| | - Michael Sharland
- St. George’s University Hospital, UK
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Yinzhong Shen
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Joao P Souza
- University of Sao Paulo, Brazil
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | | | | | - Sebastian Ugarte
- Faculty of Medicine Andres Bello University, Indisa Clinic, Santiago, Chile)
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Timothy Uyeki
- Influenza Division, U.S. Centers for Disease Control and Prevention, United States
| | | | - Sridhar Venkatapuram
- King’s College, London, UK
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Dubula Vuyiseka
- University of Stellenbosch, South Africa
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Ananda Wijewickrama
- Ministry of Health, Sri Lanka
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Lien Tran
- Infectious Diseases Data Observatory (IDDO), Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | - Jessica J Bartoszko
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | - Long Ge
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
- The BMJ, London, UK
- Not panel member; resource for methodology, systematic review, and content support
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, England
- Not panel member; resource for methodology, systematic review, and content support
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Not panel member; resource for methodology, systematic review, and content support
| | - Janet Diaz
- World Health Organization, Geneva, Switzerland
- Not panel member; resource for methodology, systematic review, and content support
- co-senior author
| | - Leticia Kawano-Dourado
- Pulmonary Division, Heart Institute (InCor)- HCFMUSP, Medical School, University of Sao Paulo, São Paulo, Brazil and Research Institute, Hospital do Coração (HCor), São Paulo, Brazil
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- Corticosteroid panel member
- ivermectin and IL-6 receptor blocker panel member
| | - Michael Jacobs
- Royal Free London NHS Foundation Trust
- Remdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member
- ivermectin and IL-6 receptor blocker panel member
- co-senior author
| | - Per Olav Vandvik
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway
- Department of Health Economics and Health Management, Institute for Health and Society, University of Oslo, Oslo, Norway
- Not panel member; resource for methodology, systematic review, and content support
- co-senior author
| |
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