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Communique

Weekly Communique # 14

16 July, 2020

WEEK IN REVIEW

This week we experienced a shift in the level of alert among the clinicians who form Australia’s frontline healthcare response to COVID-19, particularly in Victoria.

As our colleagues rally, we will continue to update guidance weekly to ensure that all Australian clinicians have access to clear, consistent, evidence-based guidance based on up-to-the minute research during the pandemic. We are extremely grateful to members of the Taskforce who volunteer their time week-in and week-out to make this happen.

RECOVERY trial: Hydroxychloroquine arm preprint results
The Taskforce notes the publication of the preprint results of the RECOVERY trial on 15 July that concluded that hydroxychloroquine was not associated with reductions in 28-day mortality in patients hospitalised with COVID-19, but was associated with an increased length of hospital stay and increased risk of progressing to invasive mechanical ventilation or death. We are currently incorporating these results in the guidelines.

Dexamethasone in pregnancy/breastfeeding, children and adolescents
This week the Taskforce’s special populations panels issued guidance on Dexamethasone in pregnant or breastfeeding women, and in children and adolescents (noting that these are interim recommendations awaiting complete reporting of the RECOVERY trial).

Upgraded evidence for continuing ACEIs/ARBs
At present, no randomised trials have investigated the benefits of continuing or stopping ACEIs/ARBs in patients with COVID-19. Despite the very low certainty evidence that continued use of concomitant ACEIs/ARBs increases or decreases mortality or disease severity in patients with COVID-19, there is high certainty evidence of harm if ACEIs/ARBs are stopped abruptly in patients who are already receiving them. Stopping these medications could lead to acute heart failure or unstable blood pressure. The Taskforce has strengthened its recommendation around continuation of these medications in people with COVID-19 (see recommendation summary below).

Working in partnership with our Consumer Panel
Drawing on advice from the Consumer Panel, the guidelines have been updated to incorporate a statement on the use of language around pregnancy and perinatal care:

“The Taskforce recognises that individuals have diverse gender identities. Terms such as pregnant person, childbearing people and parent can be used to avoid gendering birth, and those who give birth, as feminine. However, because women are also marginalised and oppressed in most places around the world, we have continued to use the terms woman, mother or maternity. When we use these words, it is not meant to exclude those who give birth and do not identify as women.”

The Taskforce Consumer Panel is co-convened with our Community Partner, the Consumers Health Forum of Australia.

 


QUICK STATISTICS

COVID-19 research pipeline

  • 12,829 studies published or registered in Cochrane COVID-19 Study Register, 861 added this week
  • 1,327 randomised controlled trials registered (data from Covid-nma site), 101 added this week
  • 28 randomised controlled trials published (data from Covid-nma site), 2 added this week
  • 1,664 systematic reviews registered in PROSPERO, 69 added this week

 


NEW OR UPDATED RECOMMENDATIONS

Version 13.0

Dexamethasone for pregnant or breastfeeding women

Conditional recommendation

  • Consider using dexamethasone 6 mg daily intravenously or orally for up to 10 days in pregnant or breastfeeding women with COVID-19 who are receiving oxygen (including mechanically ventilated patients).

*Interim awaiting complete reporting: This recommendation will be revisited when more complete and detailed reporting of this comparison of the RECOVERY trial is made available. 

Conditional recommendation against

  • Do not routinely use dexamethasone to treat COVID-19 in pregnant or breastfeeding women who do not require oxygen.

*Interim awaiting complete reporting: Antenatal corticosteroids should still be used for fetal lung maturation in pregnant women at risk of preterm birth who also have COVID-19. Dexamethasone should still be used for other evidence-based indications in pregnant and breastfeeding women who have COVID-19. This recommendation will be revisited when more complete and detailed reporting of this comparison of the RECOVERY trial is made available.

Dexamethasone for children or adolescents

Conditional recommendation

  • Consider using dexamethasone daily intravenously or orally for up to 10 days in children and adolescents with COVID-19 who are receiving oxygen (including mechanically ventilated).

* Interim awaiting complete reporting: A dose of 6 mg daily was used for adults; the protocol stated a dose of 0.15 mg/kg/day to a maximum of 6 mg/day for children but it is unclear how many children were included in the trial. This recommendation will be revisited when more complete and detailed reporting of this comparison of the RECOVERY trial is made available.

Conditional recommendation against

  • Do not routinely use dexamethasone to treat COVID-19 in children or adolescents who do not require oxygen.

* Interim awaiting complete reporting: Dexamethasone should still be used for other evidence-based indications in children or adolescents who have COVID-19. This recommendation will be revisited when more complete and detailed reporting of this comparison of the RECOVERY trial is made available.

ACEIs/ARBs in patients with COVID-19 

Recommended

  • In patients with COVID-19 who are receiving ACEIs/ARBs, there is currently no evidence to deviate from usual care and these medications should be continued unless contraindicated.

Steroids for people with asthma or COPD and COVID-19 

The evidence base for the recommendation regarding steroids for people with asthma or COPD and COVID-19 has been updated with no change to the strength or direction of the recommendation.

Consensus recommendation

  • Use inhaled or oral steroids for the management of people with co-existing asthma or COPD and COVID-19 as you would normally for viral exacerbation of asthma or COPD. Do not use a nebuliser.

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

 


CLINICAL FLOWCHARTS

Five 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 UPDATED

Changes to flowcharts this week reflect: 

  • Improved clarity on the strength and direction of living recommendations
  • Hyperlinks from each living recommendation to the summary of evidence and evidence-to-decision considerations in MAGICapp

 


 EVIDENCE UNDER REVIEW


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

  • Hydroxychloroquine NEW
  • Darunavir/cobicistat NEW
  • Disease-modifying treatments for pregnant woman
  • Disease-modifying treatments for children and adolescents
  • Disease-modifying treatments for people requiring palliative care and frail older people
  • Cardiac arrest
  • ECMO in pregnancy
  • Rooming-in of mothers and newborns

 


NEW TOPICS & 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 updated each week and available here.

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

 


PARTNER UPDATES

NPS MedicineWise
NPS MedicineWise has just published two new podcasts:

  • Episode 8 – NPS MedicineWise CEO Steve Morris speaks with the head of the TGA John Skerritt about how the TGA is supporting clinicians and consumers during the COVID-19 pandemic.
  • Episode 9 – Steve Morris speaks with Chris Freeman, National President of the Pharmaceutical Society of Australia (PSA) about how pharmacists have responded and adapted to the COVID-19 pandemic, navigated medicines access challenges and enabled continuity of care, and the importance of taking care of their own health and wellbeing. Listen here.

Cochrane

This week Cochrane published an update for the review Convalescent plasma or hyperimmune immunoglobulin for people with COVID‐19. Originally published May 15, this is the first update to this Living review. Read the full review.
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