A living WHO guideline on drugs for covid-19 · WHO convened an international guideline development panel with 28 individuals,ofwhom24werecontentexperts(clinicians,methodologists,

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A living WHO guideline on drugs for covid-19Bram Rochwerg, 1, 2, a, c Reed AC Siemieniuk, 1, 2, a, * Thomas Agoritsas, 1, 3, 4, *, b François Lamontagne, 5, *, b

Lisa Askie, 6 Lyubov Lytvyn, 1, * Arnav Agarwal, 7, * Yee-Sin Leo, 8, a, b, c Helen Macdonald, 9, * Linan Zeng, 1,*Wagdy Amin, 10, a, c Erlina Burhan, 11, a, c Frederique Jacquerioz Bausch, 12, a, c Carolyn S Calfee, 13, b, c

Maurizio Cecconi, 14, a, b, c Duncan Chanda, 15, a, c Bin Du, 16, a, c Heike Geduld, 17, a, b, c Patrick Gee, 18, a, b, c

Nerina Harley, 19, c Madiha Hashimi, 20, a, c Beverly Hunt, 21, c Sushil K Kabra, 22, a, c Seema Kanda, 23, a, b, c

Leticia Kawano-Dourado, 24, a, b, c Yae-Jean Kim, 25, a, b, c Niranjan Kissoon, 26, a, b, c Arthur Kwizera, 27, a, b, c

ImeldaMahaka, 28, a, cHelaManai, 29, a, b, cGretaMino, 30, a, c Emmanuel Nsutebu, 31, a, cNatalia Pshenichnaya, 32,a, cNida Qadir, 33, a, b, c Saniya Sabzwari, 34, a, c Rohit Sarin, 35, a, b, cManu Shankar-Hari, 36, cMichael Sharland, 37,a, c Yinzhong Shen, 38, a, b, c Shalini Sri Ranganathan, 39, a, c Joao P Souza, 40, a, cMiriam Stegemann, 41, c An DeSutter, 42, c Sebastian Ugarte, 43, a, c Sridhar Venkatapuram, 44, a, c Vu Quoc Dat, 45, a, c Dubula Vuyiseka, 46, a,c Ananda Wijewickrama, 47, a, c Brittany Maguire, 48, * Dena Zeraatkar, 1, * Jessica J Bartoszko, 1, * Long Ge, 1,49, * Romina Brignardello-Petersen, 1, * Andrew Owen, 50, * Gordon Guyatt, 1, 2, * Janet Diaz, 6, *, d

Michael Jacobs, 51, a, c, d Per Olav Vandvik4, 52, *, d

ABSTRACTCLINICAL QUESTIONWhat is the role of drug interventions in the treatmentof patients with covid-19?NEW RECOMMENDATIONIncreased attention on ivermectin as a potentialtreatment for covid-19 triggered this recommendation.The panel made a recommendation againstivermectin in patients with covid-19 regardless ofdisease severity, except in the context of a clinicaltrial.PRIOR RECOMMENDATIONS(a) a strong recommendation against the use ofhydroxychloroquine in patients with covid-19,regardless of disease severity; (b) a strongrecommendation against the use of lopinavir-ritonavirin patients with covid-19, regardless of diseaseseverity; (c) a strong recommendation for systemiccorticosteroids in patients with severe and criticalcovid-19; (d) a conditional recommendation againstsystemic corticosteroids in patients with non-severecovid-19, and (e) a conditional recommendationagainst remdesivir in hospitalised patients withcovid-19.HOW THIS GUIDELINE WAS CREATEDThis living guideline is from the World HealthOrganization (WHO) and provides up to date covid-19guidance to inform policy and practice worldwide.Magic Evidence Ecosystem Foundation (MAGIC)provided methodological support. A living systematicreview with network analysis informed therecommendations. An international guidelinedevelopment group (GDG) of content experts,clinicians, patients, an ethicist and methodologistsproduced recommendations following standards fortrustworthy guideline development using the Gradingof Recommendations Assessment, Development andEvaluation (GRADE) approach.UNDERSTANDING THE NEW RECOMMENDATIONThere is insufficient evidence to be clear to whatextent, if any, ivermectin is helpful or harmful in

treating covid-19. There was a large degree ofuncertainty in the evidence about ivermectin onmortality, need for mechanical ventilation, need forhospital admission, time to clinical improvement,and other patient-important outcomes. There ispotential for harm with an increased risk of adverseevents leading to study drug discontinuation.Applying pre-determined values and preferences, thepanel inferred that almost all well informed patientswould want to receive ivermectin only in the contextof a randomised trial, given that the evidence left avery high degree of uncertainty on important effects.UPDATESThis is a living guideline. It replaces earlier versions(4 September, 20 November, and 17 December 2020)and supersedes the BMJ Rapid Recommendations onremdesivir published on 2 July 2020. The previousversions can be found as data supplements. Newrecommendations will be published as updates tothis guideline.READERS NOTEThis is the fourth version (update 3) of the livingguideline (BMJ 2020;370:m3379). When citing thisarticle, please consider adding the update numberand date of access for clarity.This living guideline responds to emerging evidencefrom randomised controlled trials (RCTs) on existingandnewdrug treatments for covid-19. Although casenumbers are falling in some regions, they are risingin others. Vaccines are linked to falling case numbersand hospitalisations, but most people remainunvaccinated. It is unclear how long protectionfollowing vaccination or natural infection will last,or how this might alter with the emergence of newvariants. Therefore, the potential for drugs to treatpeople infected with covid-19 remains of interest andis the focus of this guideline. A linked guidelineaddresses the role of drugs in the prevention ofcovid-19 among people who are not infected.1

More than 3800 trials on covid-19 interventions havebeen registered or are ongoing (see section on

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For numbered affiliations see end ofarticle.

Correspondence to: Bram [email protected] or MichaelJacobs [email protected]

Additional material is published onlineonly. To view please visit the journalonline

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emerging evidence2). Among these are large national andinternationalplatformtrials (suchasRECOVERY,WHOSOLIDARITY,DISCOVERY, REMAP-CAP and ACTIV) that recruit large numbersof patients in many countries, with a pragmatic and adaptivedesign.3 4 These platform trials are currently investigating andreporting on numerous interventions, including antiviralmonoclonal antibodies and immunomodulators. This rapidlyevolving evidence landscape requires trustworthy interpretationand expeditious clinical practice guidelines to inform cliniciansand health care decision-makers.

A living network meta-analysis associated with this guideline willincorporate new trial data as the evidence base increases andallowsfor analysis of comparative effectiveness of multiple covid-19treatments.5 This network meta-analysis and other relatedpublications are included in box 1. We also use additional relevantevidence on safety, prognosis, and patient values and preferencesrelated to covid-19 treatments to inform the living guidance.

Box 1: Linked resources in this BMJ Rapid Recommendations cluster

• Siemieniuk RAC, Rochwerg B, Agoritsas T, et al. A living WHO guidelineon drugs for covid-19 [Update 3]. BMJ 2020;370:m3379

• World Health Organization. Therapeutics and COVID-19. Livingguideline. 31 March 2021. https://www.who.int/publica-tions/i/item/therapeutics-and-covid-19-living-guideline.

• MAGICapp (https://app.magicapp.org/#/guideline/nBkO1E)‐ Expanded version of the methods, processes, and results with

multilayered recommendations, evidence summaries, and decisionaids for use on all devices

• Siemieniuk RAC, Bartoszko JJ, Ge L, et al. Drug treatments for covid-19:living systematic review and network meta-analysis [Update 3]. BMJ2020;370:m2980, doi:10.1136/bmj.m2980

• Izcovich A, Siemieniuk RAC, Bartoszko JJ, et al. Adverse effects ofremdesivir, hydroxychloroquine, and lopinavir/ritonavir when usedfor COVID-19: systematic review and meta-analysis of randomizedtrials. Preprint available at: https://www.medrxiv.org/con-tent/10.1101/2020.11.16.20232876v1

What triggered this version of the guideline?This is the fourth version of this guideline, and it addresses the useof ivermectin in patientswith covid-19. Itwas triggered by increasedinternational attention on ivermectin as a potential treatment.

How to use this guidelineThis is a living guideline, so the recommendations included herewill be updated, and new recommendations will be added for otherdrugs for covid-19. The infographic provides a summary of therecommendations and includes links to the MAGICapp for moredetails on the evidence and rationale for the recommendation, aswell as patient decision aids. Box 2 outlines key methodologicalaspects of the guideline process.

Box 2: How this living guideline was created (see MAGICapp for fulldetails https://app.magicapp.org/#/guideline/nBkO1E)

This guideline was developed by WHO and the MAGIC Evidence EcosystemFoundation (MAGIC), with support from The BMJ. It is driven by an urgentneed for trustworthy and living guidance to rapidly inform policy andpractice worldwide during the covid-19 pandemic. WHO has partneredwith MAGIC for their methodologic support in the development anddissemination of living guidance for covid-19 drug treatments, in the formof BMJ Rapid Recommendations, to provide patients, clinicians, andpolicy makers with up to date, evidence based, and user friendlyguidelines.

Standards,methods, andprocesses for living and trustworthyguidanceThe panel produced the recommendations following standards fortrustworthy guideline development using the GRADE (Grading ofRecommendations Assessment, Development and Evaluation) approach,in compliance with the WHO Handbook for Guideline Development 2ndEdition,6 the Institute of Medicine, and the Guideline InternationalNetwork (G-I-N).7 Details are provided in the WHO guideline(https://www.who.int/publications/i/item/therapeutics-and-covid-19-living-guideline) and MAGICapp (https://app.magicapp.org/#/guide-line/nBkO1E).Selection and support of the panelFor the ivermectin recommendation, WHO convened an internationalguideline development panel (GDG) with 34 individuals, of whom 28 werecontent experts (clinicians, methodologists, scientists) and four werepatients who had survived covid-19. The methods chair (methodologicalexpertise) and a clinical chair (content expertise) guided the paneldiscussions. Panel members were invited by WHO, after consultationwith the methods chair and MAGIC, with the aim of achieving gender,geography, expertise, and patient representation balance in the panel.No relevant conflict of interest was identified for any panel member.As recommended by the WHO handbook, the panel aimed to create arecommendation based on consensus but elected, at the beginning ofthe first panel meeting, to call a vote if a consensus could not be reached.These procedures proved unnecessary for this recommendation.Guideline perspective, outcomes, and values and preferencesThe target audience for this guidance consists primarily of clinicians, butsecondarily of patients and healthcare decision makers. The panelconsidered an individual patient perspective but also took account ofcontextual factors (such as resources, feasibility, acceptability, equity)to accommodate global re-use and adaptation for countries andhealthcare systems.During a pandemic, access to healthcare may vary over time and betweendifferent countries. The panel defined covid-19 by clinical severity, andmutually exclusive definitions are provided in box 3.There were insufficient published data to provide the GDG with aninformative systematic review of studies describing patients’ experiencesor values and preferences on treatment decisions for covid-19 drugtreatments. The GDG therefore relied on their own judgments of whatwell informed patients would value after carefully balancing the benefits,harms, and burdens of treatment and their subsequent treatmentpreferences. The GDG included four patient representatives who hadlived experience with covid-19.The GDG agreed that the following values and preferences would berepresentative of those of typical well-informed patients:• Most patients would be reluctant to use a medication for which the

evidence left high uncertainty regarding effects on the outcomes theyconsider important. This was particularly so when evidence suggestedtreatment effects, if they exist, are small and the possibility ofimportant harm remains.

• In an alternative situation with larger benefits and less uncertaintyregarding both benefits and harms, more patients would be inclinedto choose the intervention.

Although the GDG focused on an individual patient perspective, theyalso considered a population perspective in which feasibility,acceptability, equity, and cost are important considerations.Sources of evidenceTo create recommendations, the panel relied on evidence synthesisedin a living network meta-analysis led by MAGIC.5 While the investigatorsresponsible for the meta-analyses rate the certainty of the evidence, thisis re-assessed independently by the guideline panel.Derivation of absolute effects for drug treatmentsThe control arm of the WHO SOLIDARITY trial, performed across a widevariety of countries and geographical regions, was identified by the GDGas generally representing the most relevant source of evidence forbaseline risk estimates for mortality and mechanical ventilation. Therationale for selecting the WHO SOLIDARITY trial was to reflect the overallprognosis of the global population for which the WHO guideline

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recommendations are made. However, the SOLIDARITY trial only enrolspatients who are hospitalised with covid-19. Given ivermectin has beenproposed for use and is often studied in outpatients, on this occasion,the panel used the median of risk in the standard care arms of theincluded trials for baseline risk estimates for these outcomes. Whenapplying the evidence to a particular patient or setting, for any medicationwith a convincing effect, clinicians should consider the individual’s riskof mortality and need for mechanical ventilation. In view of the studydesigns, the GDG determined that for other outcomes using the medianor mean of all patients randomised to usual care across the includedstudies would provide the most reliable estimate of baseline risk.Of note, baseline risks, and thus absolute effects, may vary significantlygeographically and over time. As such, users of this guideline may preferestimating absolute effects by using local event rates.

Who do the recommendations apply to?This guideline applies to all patientswith covid-19. For somedrugs,such as corticosteroids, recommendations differ based on theseverity of covid-19disease. TheGDGelected touse theWHOseveritydefinitions basedon clinical indicators, adapted fromWHOcovid-19severity categorisation (see box 3).8 These definitions avoid relianceonaccess tohealthcare to definepatient subgroups. The infographicillustrates these threedisease severity groups andkey characteristicsto apply in practice.

Box 3: WHO definitions of disease severity for covid-19

• Critical covid-19—Defined by the criteria for acute respiratory distresssyndrome (ARDS), sepsis, septic shock, or other conditions that wouldnormally require the provision of life sustaining therapies such asmechanical ventilation (invasive or non-invasive) or vasopressortherapy.

• Severe covid-19—Defined by any of:‐ Oxygen saturation 30 breaths per minute in adults and children >5

years old, ≥60 breaths/min in children 90-94% is abnormal, and can be an early sign of severedisease, if the patient is on a downward trend. Generally, if there is anydoubt, the panel suggested erring on the side of considering the illnessas severe.

The guidanceIvermectinIvermectin is relatively inexpensive and accessible, and somecountrieshavealreadywitnessed itswidespreaduse in the treatmentof covid-19; in other countries, there is increasing pressure to doso. Ivermectin is an antiparasitic agent that interferes with nerveandmuscle function of helminths throughbinding glutamate-gatedchloride channels.9 We currently lack persuasive evidence of amechanism of action for ivermectin in covid-19; any observedclinical benefit would be unexplained.

Evidenceunderpinning the recommendation comes from the linkedsystematic review and network meta-analysis.5 Compared withprevious drugs evaluated as part of this living guideline (see below),currently there are far fewer RCT data available for ivermectin. Theexisting data on ivermectin also have a substantially higher degreeof uncertainty, with included trials having enrolled substantiallyfewer patients with far fewer events, across multiple small trials.The evidence is outlined in box 4.

Box 4: Ivermectin trial data

The LNMA pooled data from 16 RCTs with 2407 participants.5 Of theincluded trials, 75% examined patients with non-severe disease and 25%included both severe and non-severe patients. A number of the includedtrials did not report on our outcomes of interest. Of the trials, 25% werepublished in peer-reviewed journals, 44% were available as preprintsand 31% were completed but unpublished (table 1). We excluded anumber of quasi-RCTs. None of the included RCTs enrolled children under15 or pregnant women but there is no rationale to suggest they wouldrespond differently.Although 16 RCTs contributed to the evidence summary informing thisdrug, only five directly compared ivermectin with standard care andreported mortality.10 -14 Of these five RCTs, two were at high risk of bias,due to inadequate blinding.10 11 One of these two trials also startedenrolling and randomising patients before the protocol being publiclyposted, another factor that contributes to an increased risk of bias.10The potential impact of risk of bias is exemplified by subgroup analysesfor mortality based on trial risk of bias. As shown in the forest plot (fig1), the pooled estimate across all five RCTs that directly compareivermectin with standard care suggests a reduction in mortality withivermectin, but this effect is not apparent if we consider only the trialsat low risk of bias (which together contribute nearly two thirds of theevidence).

Fig 1 | Forest plot showing direct comparison of ivermectin versus standard carefor mortality with subgroup analysis by risk of bias

This finding increases the degree of uncertainty regarding the true effectof ivermectin on mortality. Consistent with the direct evidence, a similarphenomenon is observed with the indirect evidence comparing ivermectinwith standard care (via comparisons against hydroxychloroquine andlopinavir-ritonavir). The indirect evidence suggesting a reduction inmortality with ivermectin is driven almost entirely by one study which isat high risk of bias due to a lack of detailed description of blinding orrandomisation and the lack of a publicly available study protocol (figurenot shown).15

In addition to concerns related to risk of bias, there are serious concernsrelated to imprecision for the outcome of mortality. According to GRADE,imprecision is evaluated based on both a confidence interval approachand an evaluation of information size (event number), ensuring there isadequate information on which to make informed judgments.16 In thiscase, despite confidence intervals that suggest benefit with ivermectin,

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the information size is very low. For mortality (and ignoring the concernsrelated to risk of bias discussed above), there were nine deaths acrossall 511 patients randomised to ivermectin (1.76%) and 22 deaths acrossall 404 patients randomised to standard care (5.45%). This is an extremelysmall number of events on which to base conclusions, and far below theoptimal information size. Furthermore, the evidence informing thiscomparison is from multiple small trials, adding to the risk ofunrecognised imbalances in study arms. Given the strong likelihood thatchance may be playing a role in the observed findings, the panel believedthere was very serious imprecision, further lowering the overall certaintyin findings.

Understanding the recommendation on ivermectinWe recommend not to use ivermectin in patients with covid-19except in the context of a clinical trial, regardless of disease severityor duration of symptoms.

Balance of benefit and harm—For most important outcomes, thepanel considered the evidence to be of very low certainty. Acombination of serious risk of bias and very serious imprecisioncontributed to very low certainty of evidence for mortality, despitea point estimate and confidence interval that appear to suggestbenefit with ivermectin (box 4). The picture was similar for otherimportant outcomes, including mechanical ventilation, hospitaladmission, duration of hospitalisation, and viral clearance. Thevery low certainty of evidence was a critical factor in therecommendation. Ivermectin may have little or no effect on time toclinical improvement (low certainty evidence) and may increasethe risk of adverse effects leading to drug discontinuation (lowcertainty evidence). A recommendation to only use a drug in thesetting of a clinical trials is appropriate when there is very lowcertainty evidence and future research has a large potential forreducing uncertainty about the effects of the intervention and fordoing so at reasonable cost.

Subgroup analyses indicated no effect modification based on dose.We were unable to examine subgroups based on patient age orseverity of illness due to insufficient trial data. Therefore, weassumed similar effects in all subgroups.

Values and preferences—The GDG inferred that almost allwell-informedpatientswouldnotwant to receive ivermectin, giventhe evidence left a veryhighdegree of uncertainty in effect on criticaloutcomes and there was a possibility of harms, such as adverseevents associated with treatment. The panel did not expect therewould bemuch variation amongpatients in values andpreferenceswhen it came to this intervention.

Resource implications, feasibility, equity, andhuman rights—Althoughthe cost of ivermectin may be low per patient, the GDG panel raisedconcerns about diverting attention and resources away from carelikely to provide a benefit such as corticosteroids in patients withsevere covid-19 and other supportive care interventions. Also, useof ivermectin for covid-19 would divert supply away frompathologies forwhich it is clearly indicated, potentially contributingto drug shortages, especially for helminth control and eliminationprogrammes. If corticosteroids are used in the treatment of covid-19,empiric treatment with ivermectin may still be considered in areaswhere strongyloidiasis is endemic, albeit not for treatment ofcovid-19 itself.

Hydroxychloroquine (published 17 December 2020)The recommendationaddressinghydroxychloroquinewas informedby results from a systematic review and network meta-analysis thatpooled data from 30 RCTs with 10 921 participants. Of note, none ofthe included RCTs enrolled children or adolescents under the age

of 19 years. Given this, the applicability of this recommendation tochildren is currently uncertain.

Understanding the recommendation on hydroxychloroquineWe recommend against using hydroxychloroquine or chloroquinein addition to usual care for the treatment of patients with covid-19,regardless of disease severity or duration of symptoms (strongrecommendation).

Balance of benefit andharm—Hydroxychloroquine and chloroquineprobably do not reduce mortality or mechanical ventilation andmay not reduce duration of hospitalisation. The evidence does notexclude the potential for a small increased risk of death andmechanical ventilation with hydroxychloroquine. The effect onother less important outcomes—including time to symptomresolution, admission to hospital, and duration of mechanicalventilation—remains uncertain.

Hydroxychloroquine may increase the risk of diarrhoea and nauseaor vomiting, a finding consistentwith evidence from its use in otherconditions. Diarrhoea and vomiting may increase the risk ofhypovolaemia, hypotension, and acute kidney injury, especially insettings where healthcare resources are limited. Whether and towhat degree hydroxychloroquine increases the risk of cardiactoxicity, including life threatening arrhythmias, when used inpatients with covid-19 is uncertain.

Subgroup analyses indicated no effect modification based onseverity of illness (comparingeither critical versus severe/non-severeor non-severe versus critical/severe) or age (comparing those aged

RCTs enrolled children or adolescents under the age of 19 years, sothe applicability of this recommendation to children is uncertain.

Understanding the recommendation on lopinavir-ritonavirWe recommend against using lopinavir-ritonavir in addition tousual care for the treatment of patients with covid-19, regardless ofdisease severity and duration of symptoms (strongrecommendation).

Balance of benefit and harm—The GDG panel found a lack ofevidence that lopinavir-ritonavir improved patient-importantoutcomes such as reduced mortality, need for mechanicalventilation, time to clinical improvement, and others. For mortalityand need for mechanical ventilation, this was based on moderatecertainty evidence; for the other outcomes, this was based on lowor very low certainty evidence.

There was low certainty evidence that lopinavir-ritonavir mayincrease the risk of diarrhoea and nausea or vomiting, a findingconsistent with the indirect evidence evaluating its use in patientswith HIV infection. Diarrhoea and vomiting may increase the riskof hypovolaemia, hypotension, and acute kidney injury, especiallyin settings where healthcare resources are limited. There was anuncertain effect on viral clearance and acute kidney injury.

Subgroupanalysis indicatednoeffectmodificationbasedonseverityof illness (comparing either critical versus severe/non-severe ornon-severe versus critical/severe) or age (comparing those aged

Practical issues—Its use is contraindicated in those with liverdysfunction (ALT >5 times normal at baseline) or renal dysfunction(eGFR

the woman’s clinical condition, her wishes and those of herfamily, and available healthcare resources.

• Endemic infections thatmayworsenwith corticosteroids shouldbe considered. For example, for Strongyloides stercoralishyperinfection associated with corticosteroid therapy, diagnosisor empiric treatment may be considered in endemic areas ifsteroids are used.

Balance of benefit and harm—Systemic corticosteroidsmay increasethe risk of 28 day mortality (low certainty evidence; relative risk1.22 (95% CI 0.93 to 1.61); absolute effect estimate 39 more per 1000patients (95%CI 12 fewer to 107more)). The certainty of the evidencefor this specific subgroup was downgraded due to seriousimprecision (that is, the evidence does not allow to rule out amortality reduction) and risk of bias due to lack of blinding. Theeffects of systemic corticosteroids on other outcomes are describedin the summary of findings (infographic and links to MAGICapp).

Values and preferences—The weak or conditional recommendationwas driven by likely variation in patient values and preferences.The panel judged that most individuals with non-severe illnesswould decline systemic corticosteroids. However, many may wantthem after shared decision making with their treating physician.

Resource implications, feasibility, equity, and human rights—To helpguarantee access to systemic corticosteroids for patientswith severeand critical covid-19, it is reasonable to avoid their administrationto patients who, given the current evidence, do not seem to deriveany benefit from this intervention

Uncertainties, emerging evidence, and future researchThe guideline recommendations for covid-19 therapeuticsdemonstrate remaining uncertainties concerning treatment effectsfor all outcomes of importance to patients. There is also a need forbetter evidence onprognosis and values andpreferences of patientswith covid-19. Here we outline key uncertainties for ivermectinidentified by the GDG, adding to those for corticosteroids in the firstversion, remdesivir in the second version, and hydroxychloroquineand lopinavir-ritonavir in the third version of the living guideline.These uncertainties may inform future research—that is, theproduction of more relevant and reliable evidence to inform policyand practice. We also outline emerging evidence in the rapidlychanging landscape of trials for covid-19.

IvermectinGiven the very low certainty in estimates for most critical outcomesof interest, the GDG felt that further high quality clinical trialsexamining this drugwouldbe essential before any recommendationfor use as part of clinical care. This includes further RCTs examiningboth inpatients and outpatients, patients with varying diseaseseverities, and using different ivermectin dosing regimens. Thefocus of these studies should be on outcomes important to patientssuch as mortality, quality of life, need for hospitalisation, need forinvasive mechanical ventilation and time to clinical or symptomimprovement. Also, a better characterisation of potential harmswith ivermectin in patients with covid-19 is important.

Hydroxychloroquine and lopinavir-ritonavirAlthough some uncertainty remains, the GDG panel felt that furtherresearchwasunlikely touncover a subgroupof patientswhowouldbenefit from hydroxychloroquine or lopinavir-ritonavir on the mostimportant outcomes (mortality, mechanical ventilation) given theconsistent results in trials across disease severity and location.

RemdesivirRemaining uncertainties include effects on:

• Critical outcomes of interest, particularly those that impactresource allocation, such as the need for mechanical ventilation,duration of mechanical ventilation, and duration ofhospitalisation

• Specific subgroups, such as different severities of illness,different time (days) since onset of illness, children and olderadults, pregnant women, duration of therapy

• Long term outcomes (such as 1-year endpoint) examiningmortality or long term quality of life

• Long term safety and rare but important side effects• Patient-reported outcomes such as symptom burden• Outcomes when used in combination with other agents such as,

but not limited to, corticosteroids

• Impact on viral shedding, viral clearance, patient infectivity.CorticosteroidsRemaining uncertainties include effects on:

• Long term mortality and functional outcomes in covid-19survivors

• Patients with non-severe covid-19 (that is, pneumonia withouthypoxaemia)

• Whenused in combinationwith additional therapies for covid-19,such as novel immunomodulators. It will become increasinglyimportant to ascertain how these interact with systemiccorticosteroids. All investigational therapies for severe andcritical covid-19 (including remdesivir) should be comparedwithsystemic corticosteroids or evaluated in combination withsystemic corticosteroids versus systemic corticosteroids alone

• Immunity and the risk of a subsequent infection, which mayaffect the risk of death after 28 days

• By different steroid preparation, dosing, and optimal timing ofdrug initiation.

Emerging evidenceThe unprecedented volume of planned and ongoing studies forcovid-19 interventions—over 3000RCTs as of 1March 2021—impliesthatmore reliable and relevant evidencewill emerge to informpolicyand practice.2 An overview of registered and ongoing trials forcovid-19 therapeutics is available from the InfectiousDiseasesDataObservatory, through their living systematic review of covid-19clinical trial registrations2 and WHO website https://www.covid-nma.com/dataviz/. Concerning ivermectin and covid-19, more than66 RCTs planning to enrol more than 12 000 participants (range24-2724) are registered or ongoing.2

Although most of these studies are small and of variablemethodological quality, some large, international platform trials(such as RECOVERY, SOLIDARITY, and DISCOVERY) are betterequipped to provide robust evidence for several potential treatmentoptions. Such trials can also adapt their design, recruitmentstrategies, and selection of interventions based on new insights.

How patients were involved in the creation of this article

The guideline panel included four patients who have had covid-19. Theirperspectives were crucial in considering the values and preferences

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associated with ivermectin, hydroxychloroquine, lopinavir-ritonavir,remdesivir, and corticosteroids.

AUTHOR AFFILIATIONS1Department of Health ResearchMethods, Evidence and Impact, McMaster University,Hamilton, Ontario, Canada

2Department of Medicine, McMaster University, Hamilton, Ontario, Canada

3Division of General Internal Medicine & Division of Clinical Epidemiology, UniversityHospitals of Geneva, Geneva, Switzerland

4MAGIC Evidence Ecosystem Foundation, Oslo, Norway

5Université de Sherbrooke, Centre de recherche due CHU de Sherbrooke, Quebec,Canada

6World Health Organization, Geneva, Switzerland

7Department of Medicine, University of Toronto, Toronto, Ontario, Canada

8National Center for Infectious Diseases, Singapore

9, London, UK

10Ministry of Health and Population, Cairo, Egypt

11Infection Division, Department of Pulmonology and Respiratory Medicine, Faculty ofMedicine Universitas Indonesia

12Geneva University Hospital, Switzerland

13University of California, San Francisco, USA

14Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical andResearch Center - IRCCS, Via Manzoni 56, 20089 Rozzano (MI), Italy

15Adult Infectious Disease Centre, University Teaching Hospital, Lusaka, Zambia

16Peking Union Medical College Hospital, Beijing, China

17Division of EmergencyMedicine, Faculty ofMedicine and Health Sciences, StellenboschUniversity, Cape Town, South Africa

18USA

19Royal Melbourne Hospital and Epworth Healthcare, Melbourne , Australia

20Ziauddin University, Karachi, Pakistan

21St Thomas’ Hospital, London, UK

22All India Institute of Medical Sciences, New Delhi, India

23McMaster University (alumnus)

24Pulmonary Division, Heart Institute (InCor)- HCFMUSP, Medical School, University ofSao Paulo, São Paulo, Brazil and Research Institute, Hospital do Coração (HCor), SãoPaulo, Brazil

25SungkyunkwanUniversity School ofMedicine, SamsungMedical Center, Seoul, Republicof Korea

26Department of Paediatrics and Emergency Medicine, University of British Columbia,Vancouver, Canada

27Department of Anaesthesia and Critical Care, College of Health Sciences, MakerereUniversity, Kampala, Uganda

28Zimbabwe

29Emergency Medical Services, Faculty of Medicine, Tunis, Tunisia

30Alcivar Hospital in Guayaquil, Ecuador

31Sheikh Shakhbout Medical City, Abu Dhabi

32Central Research Institute of Epidemiology of Rospotrebnadzor, Moscow, Russia

33Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine,University of California Los Angeles, Los Angeles, California, USA

34Aga Khan University, Karachi, Pakistan

35National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India

36Guy’s and St Thomas’ NHS Foundation Trust, London, UK

37St. George’s University Hospital, UK

38Shanghai Public Health Clinical Center, Fudan University, Shanghai, China

39University of Colombo, Sri Lanka

40University of Sao Paulo, Brazil

41Charité - Universitätsmedizin Berlin, Germany

42University of Gent, Belgium

43Faculty of Medicine Andres Bello University, Indisa Clinic, Santiago, Chile);

44King’s College, London, UK

45Department of Infectious Diseases, Hanoi Medical University, Hanoi, Vietnam

46University of Stellenbosch, South Africa

47Ministry of Health, Sri Lanka

48Infectious Diseases Data Observatory (IDDO), Centre for Tropical Medicine and GlobalHealth, Nuffield Department of Medicine, University of Oxford, Oxford, UK

49Evidence Based Social Science Research Centre, School of Public Health, LanzhouUniversity, Lanzhou, China and the Department of Social Medicine and HealthManagement, School of Public Health, Lanzhou University, Lanzhou, China

50Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool,England

51Royal Free London NHS Foundation Trust

52Department of Health Economics and Health Management, Institute for Health andSociety, University of Oslo, Oslo, Norway

*. Not panelmember; resource formethodology, systematic review, and content support

aRemdesivir, hydroxychloroquine, and lopinavir-ritonavir panel member

bCorticosteroid panel member

civermectin panel member

dco-senior author

Funding: No specific funding was provided for this guideline, with MAGIC providing pro-bonocontributions and support to WHO in the context of the COVID-19 pandemic.

Competing interests: All guideline panel members have completed the WHO interest disclosure form.All authors have completed the BMJ Rapid Recommendations interest of disclosure form. The WHO,MAGIC and The BMJ judged that no panel member had any financial conflict of interest. Professionaland academic interests are minimised as much as possible, while maintaining necessary expertise on

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the panel tomake fully informed decisions. MAGIC and TheBMJ assessed declared interests from otherco-authors of this publication and found no relevant conflicts of interests.

Provenance and peer review: This publication was commissioned by The BMJ in partnership withWHOand the MAGIC Evidence Ecosystem Foundation, in the context of the BMJ Rapid Recommendations.Pre-publication internal and external peer-review managed by WHO, and internal review at The BMJ.Post-publication review through rapid responses on bmj.com and through MAGICapp.

We thank all the following collaborators who contributed to this endeavour, as detailed in the WHOguidance (see link in box 1)

•World Health Organisation (WHO) Secretariat for Therapeutics and COVID-19

•WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group

• External reviewers for WHO

We also thank

• The living systematic review and networkmeta-analysis team, led by investigators Dr Reed Siemienukand Romina Brignardello-Petersen at McMaster University, Canada

• BMJ editorial team of Greg Cotton (technical editor), Navjoyt Ladher (head of education), and WillStahl-Timmins (data graphics designer) for their work on this living guideline publication in The BMJ

• Brittany Maguire, Philippe Guerin, and Sumayyah Rashan for providing up to date data on ivermectintrials from the Infectious Diseases Data Observatory (IDDO) living systematic review for covid-19 clinicaltrial registration (https://www.iddo.org/research-themes/covid-19/live-systematic-clinical-trial-review)

• Andrew Owen (University of Liverpool, UK) for contributions to subgroup analysis ofhydroxychloroquine by modelling expected serum concentrations over time

1 Lamontagne F, Agoritsas T, Siemieniuk R, etal. A living WHO guideline on drugs to preventcovid-19. BMJ 2021;372:n526doi: 10.1136/bmj.n526. pmid: 33649077

2 Maguire BJ, Guérin PJ. A living systematic review protocol for COVID-19 clinical trial registrations.Wellcome Open Res 2020;5:60. doi: 10.12688/wellcomeopenres.15821.1 pmid: 32292826

3 Pan H, Peto R, Karim Q, etal. Repurposed antiviral drugs for COVID-19–interimWHOSOLIDARITYtrial results.MedRxiv 2020

4 Horby P, Lim WS, Emberson JR, etalRECOVERY Collaborative Group. Dexamethasone inhospitalized patients with Covid-19. N Engl J Med 2021;384:693-704.doi: 10.1056/NEJMoa2021436 pmid: 32678530

5 Siemieniuk RA, Bartoszko JJ, Ge L, etal. Drug treatments for covid-19: living systematic reviewand network meta-analysis. BMJ 2020;370:m2980. doi: 10.1136/bmj.m2980 pmid: 32732190

6 Pan H, Peto R, Henao-Restrepo AM, etalWHO Solidarity Trial Consortium. Repurposed antiviraldrugs for Covid-19 - Interim WHO Solidarity Trial Results. N Engl J Med 2021;384:497-511.doi: 10.1056/NEJMoa2023184 pmid: 33264556

7 World Health Organization. Handbook for guideline development. 2008.https://www.who.int/publications/guidelines/handbook_2nd_ed.pdf?ua=1.

8 Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees PBoard of Trusteesof the Guidelines International Network. Guidelines International Network: toward internationalstandards for clinical practice guidelines. Ann Intern Med 2012;156:525-31.doi: 10.7326/0003-4819-156-7-201204030-00009 pmid: 22473437

9 World Health Organization. Clinical management of COVID-19: interim guidance. 2020.https://www.who.int/publications/i/item/clinical-management-of-covid-19.

10 MSDBV. Stromectol® (ivermectin). 2009. https://www.accessdata.fda.gov/drugsatfda_docs/la-bel/2009/050742s026lbl.pdf.

11 Kirti R, Roy R, Pattadar C, etal. Ivermectin as a potential treatment for mild tomoderate COVID-19– a double blind randomized placebo-controlled trial. MedRxiv 2021;

12 Niaee MS, Gheibi N, Namdar P, etal. Ivermectin as an adjunct treatment for hospitalized adultCOVID-19 patients: a randomized multi-center clinical trial. Research Square 2020;

13 Mohan A, Tiwari P, Suri T, etal. Ivermectin in mild and moderate COVID-19 (RIVET-COV): arandomized, placebo-controlled trial. Research Square 2021;

14 López-Medina E, López P, Hurtado IC, etal. Effect of ivermectin on time to resolution of symptomsamong adults with mild covid-19: a randomized clinical trial. JAMA 2021.doi: 10.1001/jama.2021.3071 pmid: 33662102

15 Gonzalez JLB, González Gámez M, Enciso EAM, etal. Efficacy and safety of ivermectin andhydroxychloroquine in patients with severe COVID-19. A randomized controlled trial. MedRxiv2021;

16 Elgazzar A, Hany B, Youssef SA, etal. Efficacy and safety of ivermectin for treatment andprophylaxis of covid-19 pandemic. Research Square 2021;

17 Beigel JH, Tomashek KM, Dodd LE, etalACTT-1 Study Group Members. Remdesivir for thetreatment of Covid-19 - final report. N Engl J Med 2020.doi: 10.1056/NEJMoa2007764 pmid: 32445440

18 Spinner CD, Gottlieb RL, Criner GJ, etalGS-US-540-5774 Investigators. Effect of remdesivir vsstandard care on clinical status at 11 days in patients with moderate COVID-19. JAMA2020;324:1048-57. doi: 10.1001/jama.2020.16349 pmid: 32821939

19 Wang Y, Zhang D, Du G, etal. Remdesivir in adults with severe COVID-19: a randomised,double-blind, placebo-controlled, multicentre trial. Lancet 2020;395:1569-78.doi: 10.1016/S0140-6736(20)31022-9 pmid: 32423584

20 Schandelmaier S, Briel M, Varadhan R, etal. Development of the Instrument to assess theCredibility of Effect Modification Analyses (ICEMAN) in randomized controlled trials andmeta-analyses. CMAJ 2020;192:E901-6. doi: 10.1503/cmaj.200077 pmid: 32778601

21 Horby P, Lim WS, Emberson JR, etalRECOVERY Collaborative Group. Dexamethasone inhospitalized patients with Covid-19 - preliminary report. N Engl J Med 2020;doi: 10.1056/NEJMoa2021436. pmid: 32678530

22 Dequin PF, Heming N, Meziani F, etalCAPE COVID Trial Group and the CRICS-TriGGERSepNetwork. Effect of hydrocortisone on 21-day mortality or respiratory support among critically illpatients with COVID-19: a randomized clinical trial. JAMA 2020;324:1298-306.doi: 10.1001/jama.2020.16761 pmid: 32876689

23 Angus DC, Derde L, Al-Beidh F, etalWriting Committee for the REMAP-CAP Investigators. Effectof hydrocortisone on mortality and organ support in patients with severe COVID-19: theREMAP-CAP COVID-19 corticosteroid domain randomized clinical trial. JAMA 2020;324:1317-29.doi: 10.1001/jama.2020.17022 pmid: 32876697

24 Tomazini BM, Maia IS, Cavalcanti AB, etalCOALITION COVID-19 Brazil III Investigators. Effect ofdexamethasone on days alive and ventilator-free in patients with moderate or severe acuterespiratory distress syndrome and COVID-19: The CoDEX randomized clinical trial. JAMA2020;324:1307-16. doi: 10.1001/jama.2020.17021 pmid: 32876695

Appendix 3. Table of registered ongoing trials for remdesivir

Appendix 4. Table of registered ongoing trials for ivermectin

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https://www.iddo.org/research-themes/covid-19/live-systematic-clinical-trial-reviewhttps://www.who.int/publications/guidelines/handbook_2nd_ed.pdf?ua=1https://www.who.int/publications/i/item/clinical-management-of-covid-19https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/050742s026lbl.pdfhttps://www.accessdata.fda.gov/drugsatfda_docs/label/2009/050742s026lbl.pdfhttps://www.bmj.com/content/370/bmj.m3379/related#datasupphttps://www.bmj.com/content/370/bmj.m3379/related#datasupphttp://www.bmj.com/

Table 1 | Characteristics of included trials for ivermectin

Severity% MaleMean age (years)CountryNo of participantsRegistrationPublication statusStudy

Non-severe46.042.0Bangladesh72NRPublishedAhmed, 2020

Non-severe69.444.3Nigeria63ISRCTN40302986PreprintBabalola, 2021

Non-severe84.840.5Pakistan100NCT04392713PreprintBukhari, 2021

Non-severe50.026.0Spain24NCT04390022PublishedChaccour, 2020

Non-severe62.041.8Pakistan50NRPublishedChachar, 2020

Non-severe, severe70.357.1Egypt400NRPreprintElgazzar, 2020

Non-severe, severe72.352.5India115CTRI/2020/08/027225

PreprintKirti, 2021

Non-severe55.640.9Argentina45NCT004381884PreprintKrolewiecki, 2020

Non-severe58.839.6Bangladesh400NCT04523831Data from trialregistration

Mahmud, 2020

Non-severe88.835.3India157CTRI/2020/06/026001

PreprintMohan, 2021RIVET-COV

Non-severe, severe50.056.0Iran180IRCT20200408046987N1

PreprintNiaee, 2020

Non-severeNRNRLebanon~100ChiCTR2000033627Data from ameta-analysis

Raad, 2020

Non-severe, severeNRNRIran~103IRCT20111224008507N3

Data frommeta-analysis

Rezai, 2021

Non-severe80.939.5Israel94NCT04429711Data from authors(unpublished)

Schwartz, 2021

Non-severe40.537Colombia398NCT04405843Data from authors(unpublished)

Lopez, 2021

Severe62.253Mexico106NCT04391127PreprintGonzalez, 2021

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