CITRIC Centre for Clinical Best Practices, Aga Khan University, Karachi, Pakistan.
Department of Medicine, Aga Khan University, Karachi, Pakistan.
Glob Health Epidemiol Genom. 2022 Apr 20;2022:4240378. doi: 10.1155/2022/4240378. eCollection 2022.
The coronavirus disease 2019 (COVID-19) pandemic has presented as a therapeutic challenge for clinicians worldwide due to its rapid spread along with evolving evidence and understanding of the disease. Internationally, recommendations to guide the management of COVID-19 have been created and updated continuously by the WHO and CDC, which have been locally adapted by different countries. Similarly, Pakistan's National Command Operation Center (NCOC), in its national COVID-19 management strategy, generated guidelines for national implementation. Keeping the guidelines updated has proved challenging globally and locally. Here, we present a summary of the process to assess the evidence, including a time-restricted systematic review based on NCOC Clinical Management Guidelines for COVID-19 Infections v4 published on 11 December 2020 version, correlating it with current recommendations and with input one of the guidelines authors, particularly noting the methodological challenges.
We conducted a systematic review synthesizing global research on treatment options for COVID-19 hospitalized patients, limiting it to pharmacological interventions for hospitalized COVID-19 patients included in Pakistan's NCOC's national guidelines v4 published on 11 December 2020. Each treatment recommendation's strength and quality of evidence was assessed based on the grading of recommendations assessment, development, and evaluation (GRADE) methodology. These were then compared to the most current living WHO COVID-19 pharmacological treatment guidelines v7.1. One of the authors of the NCOC guidelines reviewed and commented on the findings as well.
We note that the data from our systematic review strongly supports corticosteroids use in treating severe and critically ill COVID-19 hospitalized patients correlating with WHO v7.1 guidelines 24 September 2021. However, evidence from our review and WHO v7.1 for the use of tocilizumab had some conflicting evidence, with data from our review until December 2020 supporting only a weak recommendation for its use, compared to the strong recommendation by the WHO for the use of tocilizumab in patients with severe or critical COVID-19 infection. Regarding the use of antibiotics and ivermectin use in treating COVID-19 hospitalized patients, data from our review and WHO v 7.1 recommend against their use.
Research data about the efficacy and safety of pharmacological interventions to treat hospitalized patients with COVID-19 are rapidly evolving, and based on it, the evidence for or against recommendations changes accordingly. Our study illustrates the challenges of keeping up with the evidence; the recommendations were based on studies up till December 2021, and we have compared our recommendations with the WHO v7.1, which showed some significant changes in the use of pharmacological treatment options.
由于 COVID-19 的快速传播以及对该疾病的认识不断发展，全球临床医生都面临着治疗方面的挑战。为此，世界卫生组织 (WHO) 和疾病控制与预防中心 (CDC) 不断制定和更新指导 COVID-19 管理的建议，并由不同国家进行本地化调整。同样，巴基斯坦国家指挥和运营中心 (NCOC) 在其国家 COVID-19 管理战略中制定了国家实施指南。在全球和本地范围内，不断更新指南都被证明具有挑战性。在这里，我们总结了评估证据的过程，包括根据 2020 年 12 月 11 日发布的 NCOC COVID-19 感染临床管理指南第 4 版进行的限时系统评价，以及与当前建议和其中一位指南作者的输入相关联，特别注意到方法学挑战。
我们进行了一项系统评价，综合了全球关于 COVID-19 住院患者治疗选择的研究，将其限制在纳入巴基斯坦 NCOC 国家指南第 4 版的 COVID-19 住院患者的药物干预措施。根据推荐评估、制定和评估 (GRADE) 方法学，评估每个治疗建议的强度和证据质量。然后将其与最新的世卫组织 COVID-19 药物治疗指南第 7.1 版进行比较。NCOC 指南的一位作者也对研究结果进行了审查和评论。
我们注意到，我们的系统评价数据强烈支持在治疗严重和危重症 COVID-19 住院患者中使用皮质类固醇，这与 2021 年 9 月 24 日世卫组织第 7.1 版指南一致。然而，我们的评价和世卫组织第 7.1 版关于使用托珠单抗的证据存在一些相互矛盾的证据，我们的评价数据直到 2020 年 12 月仅支持其使用的弱推荐，而世卫组织强烈推荐在严重或危重症 COVID-19 感染患者中使用托珠单抗。关于在治疗 COVID-19 住院患者中使用抗生素和伊维菌素，我们的评价和世卫组织第 7.1 版都不建议使用。
关于治疗 COVID-19 住院患者的药物干预措施的疗效和安全性的研究数据正在迅速发展，并且根据这些数据，建议的证据也相应变化。我们的研究说明了跟上证据的挑战；这些建议是基于截至 2021 年 12 月的研究，我们将我们的建议与世卫组织第 7.1 版进行了比较，后者显示在药物治疗选择的使用方面发生了一些重大变化。
