ATS releases interim guidance on management of COVID-19

The American Thoracic Society has released new guidance on how to approach treatment of COVID-19 during the global pandemic.

Despite the lack of hard evidence, the ATS international task force reported that guidance was necessary as the number of new COVID-19 cases continues to climb. Therefore, the document, which is open access and available to the public, contains suggestions rather than recommendations, according to a press release.

Although the guidance contains suggestions relevant for all patients with COVID-19, including outpatients as well as critically ill patients, the focus remains on those hospitalized with COVID-19 pneumonia.

The main suggestions include performing prone ventilation in patients who have refractory hypoxemia and COVID-19 pneumonia, or acute respiratory distress syndrome, and considering extracorporeal membrane oxygenation in patients who have refractory hypoxemia, COVID-19 pneumonia or ARDS and have failed prone ventilation.

The task force also makes no suggestion regarding the prescribing of hydroxychloroquine or chloroquine to outpatients with COVID-19 or hospitalized patients with COVID-19 who have no evidence of pneumonia. However, they suggest prescribing the drug for hospitalized patients who have COVID-19 pneumonia only if all of the following criteria are met: shared decision-making in which the patient is informed about possible benefits and side effects; data can be collected for interim comparisons of patients who received hydroxychloroquine or chloroquine vs. those who did not; the disease is severe enough to warrant investigational therapy; and the drug is not in short supply.

Noting that the evidence regarding the use of hydroxychloroquine and chloroquine is unclear, Kevin C. Wilson, MD, chief of guidelines and documents at the ATS, stated that the task force suggests that if the drug is prescribed, it should be done in the context of data collection and research.

“We believe that in urgent situations like a pandemic, we can learn while treating by collecting real-world data,” he said in the release. “There are in vitro studies that suggest that hydroxychloroquine and chloroquine have activity against SARS-CoV-2019, the virus that causes COVID-19. There are also several controlled trials from China and France, but they all have serious flaws and inconsistent findings. Even interim analyses of data from institutions that are using hydroxychloroquine and chloroquine are inconsistent. Thus, the bottom line is, whether hydroxychloroquine or chloroquine confer benefits to patients with COVID-19 are unanswered questions.”

Additionally, the task force makes no suggestion for or against the use of remdesivir (Gilead Science), lopinavir/ritonavir, tocilizumab (Actemra, Genentech) or systemic corticosteroids in patients with COVID-19 and evidence of pneumonia.

“Empirical evidence, particularly randomized trials, are desperately needed to guide therapy. Supportive care remains the mainstay of treatment and social distancing remains an important part of prevention. The suggestions provided in this document will be periodically reevaluated as new evidence emerges and modified accordingly,” the task force wrote in the guidance.

Reference:

ATS. Guidance document on COVID-19. Available at: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/covid-19-guidance.pdf. Accessed April 6, 2020.

Disclosures: Wilson reports he is co-developer of the Convergence of Opinion on Recommendations and Evidence (CORE) process that is utilized in the guidance document. The other authors report no relevant financial disclosures.