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Communique

Communique # 44

24 May, 2021

WEEK IN REVIEW

UPDATES TO THE LIVING GUIDELINE

New recommendations

Baricitinib upgraded to a conditional recommendation
The Disease-Modifying Treatment and Chemoprophylaxis Panel has reviewed the latest evidence for baricitinib and determined that in hospitalised adults with COVID-19 who require supplemental oxygen, baricitinib probably reduces the risk of death.

As a result, the Taskforce has made the following conditional recommendation:

Consider using baricitinib for adults hospitalised with COVID-19 who require supplemental oxygen, high-flow oxygen and/or non-invasive ventilation.
In patients hospitalised with COVID-19 who require supplemental oxygen, baricitinib probably reduces the risk of death. Because of this, the Taskforce gives a conditional recommendation for baricitinib both within and outside the context of a randomised trial.

Given the uncertainty regarding the effectiveness of bariticinib in patients who require mechanical ventilation, further evidence is required to inform care in this population.

Evidence comes from two randomised trials—one that compared baricitinib plus remdesivir with remdesivir alone in 1033 adults hospitalised with suspected COVID-19, and one that compared baricitinib with standard care in 1525 adults with mild to severe COVID-19.

Baricitinib is a Janus kinase (JAK) inhibitor, and commonly used to treat arthritis.

Hydroxychloroquine plus azithromycin changes to Do Not Use
The Taskforce has revised the previous guidance advising that hydroxychloroquine plus azithromycin should only be used to treat COVID-19 in the context of randomised trials to recommending that azithromycin is not used to treat COVID-19.

There is currently limited evidence about the effect of hydroxychloroquine plus azithromycin on patient-relevant outcomes in the treatment of COVID-19. However, when used individually, neither of these treatments has demonstrated improvements in clinical outcomes.

Lenzilumab added to list of ‘only in clinical trials’
The Taskforce has reviewed the latest evidence for lenzilumab and concluded that there is insufficient evidence to recommend its use outside the context of a randomised trial with appropriate ethical approval.

Updated recommendations

  • Remdesivir for adults
  • Tocilizumab for adults
  • Lopinavir-ritonavir
  • Bromhexine hydrochloride
  • Ivermectin
  • Nitazoxanide

Further details about these recommendations and additional updates are below.

Consumer Panel continuing to enhance the guideline with lived experience insights
Last week the Consumer Panel reviewed the preferences and value statements for:

  • ‘Do Not Use’ recommendations
  • ‘Not recommended outside of clinical trials’ recommendations
  • Hydroxychlororquine as post-exposure prophylaxis
  • VTE prophylaxis in adults
  • Timing of surgery following COVID-19 infection

The Panel provided overall endorsement of the recommendations with minor but meaningful edits to the preferences and values statements.

The Consumer Panel is co-convened with the Consumers Health Forum of Australia (CHF)

Victorian Government commits to Phase Two Living Evidence Program
Last Thursday’s Victorian budget announcement included $4 million in funding for the Australian Living Evidence Consortium’s Phase Two four-year program to develop a world-leading, end-to-end evidence system to enable frontline clinicians to stay continually up-to-date with the latest research.

The Consortium includes Australia’s leading guideline developers in stroke, diabetes, kidney disease, heart disease and musculoskeletal conditions and was the foundation for the establishment of the Taskforce.

The Victorian Government’s commitment will form part of a national funding partnership that is envisaged between State and Territory Governments, the Commonwealth Government and major philanthropic donors that include the Ian Potter Foundation and the Lord Mayor’s Charitable Foundation.

 

QUICK STATISTICS

COVID-19 research pipeline

  • 61,153 studies published or registered in Cochrane COVID-19 Study Register, 2,880 added this fortnight
  • 2,960 randomised controlled trials registered (data from Covid-nma site), 50 added this fortnight
  • 4,095 systematic reviews registered in PROSPERO, 134 added this fortnight
  • 297 randomised controlled trials published (data from Covid-nma site), 19 added this fortnight

 

LIVING GUIDELINES

Australian guidelines for the clinical care of people with COVID-19: Version 39.0

NEW RECOMMENDATIONS

  • Baracitinib

Consider using baracitinib for adults hospitalised with COVID-19 who require supplemental oxygen, high-flow oxygen and/or non-invasive ventilation.

  • Hydroxychloroquine plus azithromycin

Do not use for the treatment of COVID-19.

  • Lenizilumab

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

UPDATED RECOMMENDATIONS

  • Remdesivir for adults, Tocilizumab for adults, Lopinavir-ritonavir, Bromhexine hydrochloride, Ivermectin, Nitazoxanide

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

  • Disease-modifying treatments ‘do not use’

A statement has been added to the ‘Preferences and Values’ of disease-modifying treatments not recommended for the treatment of COVID-19 following review by the Consumer Panel.

  • Disease-modifying treatments ‘not recommended outside of clinical trials’

A statement has been added to the ‘Preferences and Values’ of disease-modifying treatments ‘not recommended for use outside of clinical trials’ following review by the Consumer Panel.

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
  • 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:

  • Baracitinib added as a ‘conditional recommendation’
  • Addition of lenzilumab to ‘only in clinical trials’
  • Hydroxychloroquine plus azithromycin added to ‘do not use’

 

EVIDENCE UNDER REVIEW

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

  • Aerosol generating procedures and behaviours
  • Camostat mesilate NEW
  • Angiotensin II type 2 receptor agonist (C21) NEW
  • Bromhexine hydrochloride
  • Colchicine
  • Corticosteroids
  • Hydroxycloroquine
  • Immunoglobulin plus methylprednisolone
  • Post-exposure hydroxychloroquine prophylaxis
  • Proxalutimide
  • Sarilumab
  • Sofosbuvir-lepidasvir
  • Care of people with post acute COVID-19

 

NEWS & EVENTS

Cochrane
This week a new visual abstract and podcast were added to the Cochrane review exploring international travel-related control measures to contain the COVID-19 pandemic; view the visual abstract, listen to the podcast, or read the full review on the Cochrane Library.

Cochrane and the Taskforce were also featured in a recent article in Nature about the challenges of evidence synthesis during the COVID-19 pandemic, ‘How COVID broke the evidence pipeline’.

Murray PHN Webinar: Long COVID Symptoms – Management of long term effects
Taskforce Senior Evidence Officer and Primary and Chronic Care Panel Methods Chair, Dr Samantha Chakraborty is joining presenters from the UK’s Royal College of General Practitioners and the National Institute for Health and Care Excellence (NICE) to provide an update on Long COVID symptoms and what we know so far.
Date: Thursday, 27 May 2021
Time: 7:00pm – 8.30pm AEST
Location: online
The interactive webinar will be facilitated by Dr Norman Swan, and will draw on experiences from the UK and Australia as well as provide an opportunity for questions and answers with the expert panel.
For more information, go to the registration page.

 

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