Berlin – Once again, experts from the German Society for Internal Intensive Care and Emergency Medicine (DGIIN) have updated the guideline on the inpatient treatment of COVID-19 patients. (DGIIN) have updated the guideline for the inpatient therapy of COVID-19 patients together with 15 other professional associations. For the first time, monoclonal antibodies and Janus kinase (JAK) inhibitors are listed as available drug therapy options that have been shown to reduce mortality in randomised controlled trials. There are also new recommendations for thrombosis prophylaxis and anticoagulation. In addition, the guideline recommends prone positioning also in awake patients.
Prone positioning also for awake patients
„Even in awake patients who receive high-dose oxygen therapy via a nasal tube or who are ventilated non-invasively, prone positioning should be performed,“ says Professor Stefan Kluge, MD, member of the board of the DGIIN and coordinator of the guideline. Physicians have repeatedly observed during the pandemic that COVID patients lie down on their stomachs themselves and that this improves the oxygen supply. A large prospective randomised study was able to show that the frequency of later intubations is reduced if abdominal positioning is already performed during this phase of the disease. „This is an important new finding that may help to avoid intubation and mechanical ventilation,“ says Kluge.
The updated guideline also provides new recommendations on drug therapy for COVID-19. „It has been shown that in the early phase of COVID-19 disease, in which the body has not yet formed antibodies, so-called monoclonal antibodies have a positive influence on the course of the disease and mortality. These monoclonal antibodies have a neutralising effect on the SARS-CoV-2 virus,“ explains Jakob Malin, MD, representative of the German Society for Infectious Diseases, who also contributed to the update of the guideline. Virus-neutralising monoclonal antibodies have the ability to prevent virus entry into the cell by interacting with the SARS-CoV-2 spike protein. The guideline therefore recommends implementing therapy with the combination of the SARS-CoV-2 specific monoclonal antibodies casirivimab and imdevimab in hospitalised COVID-19 patients who have not yet shown their own immune response to the infection and have no or at most a low-flow oxygen requirement.
Also new is that the guideline recommends the use of Janus kinase (JAK) inhibitors. The use of this immunomodulatory therapy approach is included in the recommendations for the first time. JAK inhibitors have an anti-inflammatory effect. Studies show a survival advantage when JAK inhibitors are used in hospitalised patients without oxygen requirement or with a maximum of low-flow oxygen treatment.
Thrombosis prophylaxis and therapeutic anticoagulation in hospitalised patients
People with severe COVID-19 can develop thromboses, which in turn can cause lung failure or pulmonary embolism. Therefore, COVID-19 patients who are hospitalised receive standard therapy for thrombosis prophylaxis. „It has always been under discussion whether standard thromboprophylaxis with heparin is sufficient to prevent thrombosis. Therefore, in the revision of the guideline, we have also updated the recommendations on thrombosis treatment,“ says Professor Christian Karagiannidis, MD, President of the DGIIN. The new recommendations now include that in the early phase of hospitalised, non-intensive care COVID-19 patients with an increased risk of thrombosis should be treated.
-patients with an increased risk of thrombosis can be considered for therapeutic anticoagulation, provided they have a low risk of bleeding. In intensive care patients, on the other hand, therapeutic anticoagulation should not be given in the absence of evidence of thrombosis or embolism, as the risk of severe bleeding complications increases significantly here.
Collaboration with the CEOsys research consortium
„The update of the guideline for the treatment of COVID-19 inpatients provides many new insights for everyday medical treatment,“ says Professor Nicole Skoetz, MD, from the COVID-19 Evidence Ecosystem (CEOsys) research consortium, which accompanied the guideline update. The CEOsys project is funded by the German Federal Ministry of Education and Research as part of the Network University Medicine (NUM). „The guideline is also an example of the systematic exchange between the different disciplines of medical science in order to provide patients with the best possible care, to achieve a joint approach to pandemic control and to arrive at a systematic review of evidence,“ says Skoetz. The focus is on patient safety combined with the goal of avoiding additional harm from therapies. „Through the consistent critical analysis of a large number of drug therapy approaches for the treatment of COVID-19 (colchicine, ivermectin, convalescent plasma, etc.), we can now also issue a catalogue of negative recommendations, i.e. recommendations against certain therapies,“ Kluge summarises the results of the guideline update.