NIH Updates Guidelines for the Treatment of COVID-19

covid-19 treatment

In a March 24 YouTube video, Dr. Jeffrey VanWingen, a family physician in Michigan, demonstrates how to wipe down your groceries to avoid potential fomite spread (coronavirus infection via high-touch surfaces). Dr. VanWingen’s video got more than 26 million views.

Four months later, Emmanuel Goldman, a virologist at Rutgers University, published an article “Exaggerated Risk of Transmission of COVID-19 by Fomites” in the July 2020 online issue of The Lancet. In the article, Goldman questions the real-life applicability of fomite spread studies: “chance of transmission through inanimate surfaces is minimal, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze (within 1 – 2 h).” 

So, who has it right here? The family doctor from Michigan? Or the virologist from New Jersey? More important, in our homes, public spaces, and workplaces, whose COVID-prevention and treatment guidelines should we follow? 

The surface spread debate is just one in a seemingly evolving set of information around the prevention, treatment, and after-treatment of COVID-19. Or, as the U.S. National Institutes for Health (NIH) posts on its website—in bold, red font–“COVID-19 is an emerging, rapidly evolving situation.” 

What’s New from the National Institute for Health (NIH) on the Treatment of COVID-19?

In October 2020, the NIH issued two new and two updated COVID-19 guidelines for providers, patients, and policy experts. 

The NIH distinguishes between “new” (previously unpublished by NIH) and “updated” guidelines (published but amended based on new clinical data). New or amended, all guidelines are approved by the NIH COVID-19 Treatment Guidelines Panel, and individual clinical recommendations are ranked via a three-point, lettered, and numeric scale. 

For example, in its October 22-released guidelines for our overlapping influenza and COVID seasons, the Panel recommends testing for both viruses (flu and coronavirus) in all hospitalized patients with acute respiratory illness. This testing recommendation is assigned an AIII score, with “A” signifying a “strong” recommendation and “III” indicating that this recommendation is based “on expert opinion” (see complete table below). 

Other NIH influenza-COVID guidelines include clinical protocols for testing, treatments, and indications for drugs such as corticosteroids, including potential drug interactions. 

New: Pharmacological Management and COVID Treatment for HIV Patients

On October 9, 2020, the NIH published two new sections. Based on the evolving research, this dyad of recommendations addresses two key areas: the pharmacological management of patients with COVID-19; and the treatment of COVID-19 patients with co-occurring Human Immunodeficiency Virus (HIV). 

In Section 1, the pharmacological guidelines are specific to the corresponding patient cohort, and the four patient cohorts (presented in the color-coded graphic) are ranked by disease severity. For example, in Patient Group 1 (patients who are not hospitalized or hospitalized but do not require supplemental oxygen), the NIH COVID Panel does not recommend dexamethasone. Instead, the Panel refers clinicians to its anti-viral therapy page for remdesivir indications in this particular group of moderately ill patients. By contrast, for Patient Group 4 (those hospitalized and require invasive mechanical ventilation or ECMO), the Panel recommends dexamethasone at specified dosages and duration. 

New: Treating Patients With HIV

The NIH’s special considerations for the treatment of COVID-19 in HIV patients are the same as those for the general population, and persons with HIV are eligible and recruitable for COVID-related clinical trials. Clinicians are advised to pay careful attention to potential drug-drug interactions and overlapping toxicities and consult with an HIV specialist before adjusting ARV medications. 

Updated: Severity of Illness Categories, 12 Considerations and Special Considerations for Children 

In its October 9 updated COVID guidelines, the NIH Panel groups adult patients into five distinct groups according to the severity of illness. The groups range from adults who test positive but are asymptomatic or pre-symptomatic (Group 1) to patients who present for care in respiratory failure, septic shock, or multiple organ dysfunction (Group 5). These categories also apply to pregnant patients. However, these NIH- defined disease categories cannot be used as the sole criteria to define the COVID-19 illness categories among pediatric patients. 

Update: Post-Treatment of COVID-19 Patients

The October 9 updates include a subsection on COVID-survivor patients–including milder and more severe cases—who, post-treatment, continue to suffer symptoms such as fatigue, joint pain, chest pain, palpitations, shortness of breath, anxiety, depression, and psychiatric distress. 

Again, these updates are based on emerging science, and the NIH acknowledges that “more research is needed to better understand the pathophysiology and clinical course of these post-infection sequelae and to identify management strategies for patients.”

Update: General Treatment Consideration for Patients with Comorbid Conditions and Special Considerations for Children

On October 9, the NIH also updated its 12 general considerations, including critical-care guidelines and potential drug interactions for patients with underlying or comorbid conditions. Also, the NIH provides an updated section, “Special Considerations for Children.” 

Now, back to that issue of fomites or surface spread of the coronavirus. In a recently published Wired article, “It’s Time to Talk about COVID-19 and Surfaces Again,” the health journalist concludes: “Nearly a year into the COVID-19 pandemic, it’s time to ask: What do we know now?” 

For clinicians and the general public, the NIH’s regularly updated clinical guidelines—including its extensive list of published, peer-reviewed clinical studies—is an excellent place to get the latest evidence-based prevention strategies and clinical recommendations. 

Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion