Infectious Diseases I

Disease

Severity

Remdesivir

Dexamethasonea

Baricitinib

Tocilizumabb

Anticoagulation

High-flow

oxygen device

or noninvasive

ventilation

requirement

Recommended

in combination

with

dexamethasone

Recommended as

preferred therapy

with or without

remdesivir

Promptly add either agent

(rating recommendation/

evidence level: baricitinib

AI; tocilizumab BIIa)

to dexamethasone ±

remdesivir in most patients

For patients without

an indication

for therapeutic

anticoagulation:

Prophylactic dose

of heparin, unless

contraindicated (AI)

For patients on

therapeutic dose of

heparin in non-ICU

setting and transferred

to ICU, switch to

prophylactic dose

of heparin, unless

another indication

for therapeutic

anticoagulation (BIII)

Mechanical

ventilation or

extracorporeal

membrane

oxygenation

requirement

N/A

Recommmeded

to be

administered to

all patients (AI).

Promptly add either agent

(Rating recommendation/

Evidence level: baricitinib

BIIa; tocilizumab BIIa) to

dexamethasone in most

patients

aAlternative corticosteroids at equivalent glucocorticoid dose may be considered.

bAlthough approximately 33% of REMAP-CAP and RECOVERY patients received a second dose of tocilizumab at the treating physician’s discretion, evidence to

support repeat dosing is insufficient.

N/A = No recommendation provided.

Information from: National Institutes of Health (NIH); COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines.

Previously available at www.covid19treatmentguidelines.nih.gov/about-the-guidelines/table-of-contents/. RECOVERY Collaborative Group. Tocilizumab in patients

Gordon AC, Mouncey PR, et al. Interleukin-6 receptor antagonists in critically ill patients with Covid-19. N Engl J Med 2021;384:1491-502. Ely EW, Ramanan AV,

Kartman CE, et al. Efficacy and safety of baricitinib plus standard of care for the treatment of critically ill hospitalised adults with COVID-19 on invasive mechanical

Consortium. Remdesivir and three other drugs for hospitalised patients with COVID-19: final results of the WHO Solidarity randomised trial and updated meta-analyses.

Patient Case

pital for refractory hypoxemic respiratory failure despite maximal MV support. S.B. is being evaluated

for venovenous ECMO. She is quickly transferred to the MICU for evaluation. S.B. is initiated on dexa-

methasone 6 mg intravenously once daily, and her analgesia-sedative regimen is modified to maintain deep

sedation in anticipation of starting continuous neuromuscular blockade. S.B. is receiving norepinephrine at

10 mcg/minute, which continues to be tapered to maintain a mean arterial pressure greater than 65 mm Hg.

S.B. is being considered for remdesivir, which is in ample supply at your institution. Which best describes

the current guideline recommendations for remdesivir in patients with COVID-19 requiring MV?

Patients Hospitalized with Coronavirus Disease 2019 (continued)