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Communique

Communique # 40

18 March, 2021

WEEK IN REVIEW

UPDATES TO THE LIVING GUIDELINE

New recommendation for tocilizumab in children or adolescents
Further to the Taskforce’s recent recommendation for the conditional use of tocilizumab for adults (25 February 2021), the Paediatric and Adolescent Care Panel have reviewed the evidence in the context of this special population, also consulting with members of the Expert Advisory Group in rheumatology, immunotherapy and paediatric infectious diseases.

Based on the likely mortality benefit in adult patients and because tocilizumab is already used for other indications in children and adolescents, the Taskforce makes the following conditional recommendation:

Consider using tocilizumab for the treatment of COVID-19 in children and adolescents who require supplemental oxygen, particularly where there is evidence of systemic inflammation.

There is no established dose for tocilizumab for the treatment of acute COVID-19 in children and adolescents. Although no children were enrolled in the included trials, the Taskforce notes the RECOVERY trial is recruiting children and adolescents with PIMS-TS for their tocilizumab trial.

Ivermectin remains ‘only in clinical trials’ recommendation
The Disease Modifying and Chemoprophylaxis Panel have incorporated the evidence from three new studies (Mohan et al., Shah Bukhari et al., Gonzalez et al.) into the body of evidence for ivermectin and concluded that there remains significant uncertainty whether ivermectin is more effective and safer than standard care in treating patients with COVID-19.

As a result of this uncertainty, the Taskforce recommendation remains:

Do not use ivermectin for the treatment of COVID-19 outside of randomised trials with appropriate ethical approval.

Ivermectin should still be considered for other evidence-based indications in people who have COVID-19.

Trials are needed in special populations, including children and adolescents, pregnant and breastfeeding women, older people living with frailty and those receiving palliative care. Until further evidence is available, do not use ivermectin to treat COVID-19 in these populations unless they are eligible to be enrolled in trials.

Evidence informing this recommendation is now based on 10 randomised trials that compares ivermectin with standard care in over 800 adults with COVID-19. The Taskforce is currently reviewing one additional study comparing ivermectin with placebo (López-Medina et al.) and will update the recommendation as appropriate in a future version of the guidelines.

Four more treatments added to list of ‘only in clinical trials’
The Disease-Modifying Treatment and Chemoprophylaxis Panel has reviewed the latest evidence for:

  • Anakinra
  • Ivermectin + doxycycline
  • Nitazoxanide
  • Zinc

The Taskforce concludes that there is insufficient evidence to recommend their use outside the context of a randomised trial with appropriate ethical approval.

Further details about these recommendations and additional updates are below.

IPC Healthcare worker consultation recruitment to continue
Thank you to all Taskforce members and stakeholders who promoted our recent campaign calling for frontline healthcare workers to participate in a series of consultations to provide feedback on the implementability of draft infection prevention and control (IPC) recommendations.

We now have a diverse pool of more than 40 volunteer participants but will continue to recruit suitable healthcare workers to ensure appropriate representation from all disciplines and settings.

We are particularly seeking:

  • nurses working in aged care; and
  • general practitioners and other allied health providers working in primary care.

For further information or to apply click here.

Reconstituted Consumer Panel now includes lived experience
The Taskforce, together with Consumers Health Forum of Australia (CHF), has finalised the constitution of the 2021 Consumer Panel which now includes consumers and carers with  lived experience of COVID-19 as well as those experiencing post acute COVID-19 symptoms.

We welcome:

  • Mya Cubitt
  • Chris Lassig
  • Joanne Muller
  • Sophie Noble
  • Elle Peters-Wisniak
  • Nicholas Wood
  • Lynda Condon

We also welcome back Eleanor Horton and Rebecca Randall who will continue to co-chair the panel.

The first meeting will be held next Wednesday and we look forward to the panel’s collective experiences shaping the guidelines as they review the preferences and values statements for all recommendations.

 

QUICK STATISTICS

COVID-19 research pipeline

  • 49,899 studies published or registered in Cochrane COVID-19 Study Register, 2,667 added this fortnight
  • 2,691 randomised controlled trials registered (data from Covid-nma site), 49 added this fortnight
  • 3,544 systematic reviews registered in PROSPERO, 138 added this fortnight
  • 223 randomised controlled trials published (data from Covid-nma site), 14 added this fortnight

 

LIVING GUIDELINES

Australian guidelines for the clinical care of people with COVID-19: Version 36.0

NEW RECOMMENDATIONS

  • Tocilizumab for children or adolescents

Consider using tocilizumab for the treatment of COVID-19 in children and adolescents who require supplemental oxygen, particularly where there is evidence of systemic inflammation.

  • Anakinra, Nitazoxanide, Ivermectin + doxycycline, Zinc

Do not use for the treatment of COVID-19 outside of randomised trials with appropriate ethical approval.

UPDATED RECOMMENDATIONS

  • Ivermectin

Updated evidence base with no change to the strength or direction of the recommendation

  • Sarilumab

Updated evidence base with no change to the strength or direction of the recommendation

  • Mode of birth, Rooming-in

Reference to a recently published WHO scientific brief was added to the evidence summary. There was no change to the evidence, strength or direction or recommendation.

  • Breastfeeding

References to a recently published systematic review and WHO scientific brief were added to the evidence summary. There was no change to the evidence, strength or direction of recommendation.

  • Skin-to-skin contact

References to a recently published systematic review and WHO scientific brief were added to the evidence summary. There was no change to the evidence, strength or direction of recommendation.

  • Delayed umbilical cord clamping

References to a recently published prospective observational study and WHO scientific brief were added to the evidence summary. There was no change to the evidence, strength or direction of recommendation.

The Taskforce is continually monitoring research to update recommendations as new evidence emerges.

 

CLINICAL FLOWCHARTS

11 clinical flowcharts have been developed by the Taskforce to cover:

  • Assessment for suspected COVID-19
  • Management of adults with mild COVID-19 UPDATED
  • Management of adults with moderate to severe COVID-19 UPDATED
  • Management of adults with severe to critical COVID-19 UPDATED
  • Respiratory support for adults with severe to critical COVID-19
  • Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment
  • Management of people with COVID-19 who are receiving palliative care
  • Care of people who experience symptoms post acute COVID-19 UPDATED
  • Preparedness for CPR during the COVID-19 pandemic
  • CPR for adults with COVID-19 in healthcare settings
  • Basic life support for adults in the community during the pandemic

Changes to flowcharts this week include:

  • Addition of anakinra, ivermectin plus doxycycline, nitzoxanide and zinc to ‘only in clinical trials’
  • Several changes to post COVID chart including new references, inclusion of children into background and text revision to symptoms and signs
  • Updated guidance regarding supportive anti-infectious therapy

 

EVIDENCE UNDER REVIEW

We are currently reviewing evidence to develop recommendations and flowcharts to guide practice in areas including:

  •  Budesonide NEW
  •  Clarithromycin NEW
  •  Face masks
  •  Eye protection
  •  Levels of ventilation
  •  Portable air cleaning devices
  •  Reduction in patient occupancy
  •  Bamlanivimab + etesevimab
  •  Enisamium
  •  Vitamin C
  •  Ivermectin
  •  Convalescent plasma
  •  Favipiravir
  •  Post-exposure hydroxychloroquine prophylaxis
  •  Immunoglobulin plus methylprednisolone
  •  Care of people with post acute COVID-19

 

NEWS & EVENTS

Cochrane

Cochrane has recently published the following systematic review: COVID‐19 and its cardiovascular effects: a systematic review of prevalence studies. It concludes that cardiometabolic comorbidities are common in people who are hospitalised with a severe COVID‐19 infection. The most frequent cardiovascular complications are cardiac arrhythmias, heart failure and arterial and venous occlusive events. Laboratory biomarkers may help identify those at greater risk of developing cardiovascular complications and of death.

The full list of Cochrane Reviews and related content from the Cochrane Library relating to the COVID-19 pandemic can be found here.

NPS MedicineWise

In this recent podcast NPS MedicineWise CEO Adj A/Prof Steve Morris is joined by the head of the Therapeutic Goods Administration (TGA) Adj Prof John Skerritt to discuss the latest information on COVID-19 vaccination in Australia. They also look at how the TGA decides which vaccines to approve in terms of both safety and efficacy, and how potential adverse events from the vaccines will be monitored as the vaccine is rolled out.

 

NEW TOPICS AND QUESTIONS

It is a core mission of the Taskforce to engage with frontline clinicians to rapidly identify and address priority clinical questions.

Each week we collect suggestions for new clinical questions or topics for consideration by the Taskforce. A document that lists all of the suggested questions, topics and new patient groups that we have received to date is available here.

Please encourage your clinical colleagues to provide their insights via the website.

Topics