4 Therapeutics for COVID-19 | COVID-19 rapid guideline: managing COVID-19 | Guidance

4.1 Antivirals

Nirmatrelvir and ritonavir

There is a funding variation in place for nirmatrelvir plus ritonavir until 1 June 2025. See NICE's technology appraisal guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab.

4.1.1

Nirmatrelvir plus ritonavir is recommended as an option for treating COVID‑19 in adults, only if they:

do not need supplemental oxygen for COVID‑19 and
have any of the following:
- an increased risk for progression to severe COVID‑19, as defined in section 5 of NICE's technology appraisal guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab
- age 70 years and over
- a body mass index (BMI) of 35 kg/m² or more
- diabetes
- heart failure.
  
  This recommendation is from NICE's technology appraisal guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab. [13 April 2022, amended 29 March 2023 and 13 March 2024]

For a short explanation of why we made these recommendations, see the rationale section on nirmatrelvir and ritonavir.

Remdesivir

4.1.2

Consider a 3-day course of remdesivir for children and young people aged 12 to 17 who weigh at least 40 kg and adults with COVID-19 who:

do not need supplemental oxygen for COVID-19 and
are within 7 days of symptom onset and
are thought to be at high risk of progression to severe COVID-19. (NHS England's Interim Clinical Commissioning Policy on remdesivir and molnupiravir provides a list of people prioritised for treatment with antivirals.)

When assessing the person, take into account likely response to any vaccinations against COVID-19 they have already had, any comorbidities or risk factors, and whether their condition is deteriorating. [22 February 2022, amended 29 March 2023]

4.1.3

Consider a course of remdesivir (up to 5 days) for people who:

have COVID-19 pneumonia and
are in hospital and need low-flow supplemental oxygen.

The criteria for accessing remdesivir in the UK are outlined in NHS England's Interim Clinical Commissioning Policy on remdesivir for patients hospitalised due to COVID-19, which includes people who are significantly immunocompromised. [23 March 2021, amended 29 March 2023]

4.1.4

Do not use remdesivir for COVID-19 pneumonia in anyone in hospital and on high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), non-invasive mechanical ventilation or invasive mechanical ventilation, except as part of an ongoing clinical trial. [23 March 2021, amended 29 March 2023]

For a short explanation of why the panel made these recommendations, see the rationale section on remdesivir.

Full details of the evidence and the panel's discussion are in evidence review O: Early remdesivir.

Full details of the evidence and the panel's discussion are in evidence review P: Remdesivir for people in hospital.

Molnupiravir

4.1.5

Consider a 5-day course of molnupiravir for adults with COVID-19 who:

do not need supplemental oxygen for COVID-19 and
are within 5 days of symptom onset and
are thought to be at high risk of progression to severe COVID-19. (NHS England's Interim Clinical Commissioning Policy on remdesivir and molnupiravir provides a list of people prioritised for treatment with antivirals.)

When assessing the person, take into account their likely response to any vaccinations already given, any comorbidities or risk factors, and whether their condition is deteriorating. [23 March 2021, amended 29 March 2023]

4.1.6

Do not offer molnupiravir to children and young people aged under 18, or pregnant women. [23 March 2021, amended 29 March 2023]

For a short explanation of why the panel made these recommendations, see the rationale section on molnupiravir.

Full details of the evidence and the panel's discussion are in evidence review Q: Molnupiravir.

4.2 Sotrovimab

4.2.1

Sotrovimab is recommended as an option for treating COVID‑19 in adults and young people aged 12 years and over and weighing at least 40 kg, only if:

they do not need supplemental oxygen for COVID‑19 and
they have an increased risk for progression to severe COVID‑19, as defined in section 5 of NICE's technology appraisal guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab and
nirmatrelvir plus ritonavir is contraindicated or unsuitable.

Sotrovimab is only recommended if the company provides it according to the commercial arrangement.

This recommendation is from NICE's technology appraisal guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab. [27 January 2022, amended 29 March 2023 and 13 March 2024]

For a short explanation of why we made this recommendation, see the rationale section on sotrovimab.

4.3 Corticosteroids

4.3.1

Offer dexamethasone, or either hydrocortisone or prednisolone when dexamethasone cannot be used or is unavailable, to people with COVID‑19 who:

need supplemental oxygen to meet their prescribed oxygen saturation levels or
have a level of hypoxia that needs supplemental oxygen but who are unable to have or tolerate it.

Continue corticosteroids for up to 10 days unless there is a clear indication to stop early, which includes discharge from hospital or a hospital-supervised virtual COVID ward. [8 April 2021]

See box 1 on dosage information.

Box 1 Dosage information

Dosage in adults

Dexamethasone

6 mg orally once a day for 10 days (three 2 mg tablets or 15 ml of 2 mg/5 ml oral solution) or
6 mg intravenously once a day for 10 days (1.8 ml of 3.3 mg/ml ampoules [5.94 mg]).

For people able to swallow and in whom there are no significant concerns about enteral absorption, prescribe tablets. Only use intravenous administration when tablets or oral solutions are inappropriate or unavailable.

Suitable alternatives

Prednisolone: 40 mg orally once a day for 10 days.

Hydrocortisone: 50 mg intravenously every 8 hours for 10 days (0.5 ml of 100 mg/ml solution; powder for solution for injection or infusion is also available); this may be continued for up to 28 days for people with septic shock.

Dosage in pregnancy

Follow Royal College of Obstetrics and Gynaecology guidance.

Dosage for children with a greater than 44-week corrected gestational age

Dexamethasone: 150 micrograms/kg (as a base) orally, nasogastrically or intravenously once a day for 10 days (max 6 mg).
Prednisolone: 1 mg/kg orally, nasogastrically or intravenously once a day for 10 days (maximum 40 mg; doses can be rounded as per routine clinical practice).

Dosage for preterm babies with a corrected gestational age of less than 44 weeks

Seek specialist advice.

For more information on the management of children, follow the Royal College of Paediatrics and Child Health National guidance for the management of children in hospital with viral respiratory tract infections (2023).

For people able to swallow and in whom there are no significant concerns about enteral absorption, prescribe tablets. Only use intravenous administration when tablets or oral solutions are inappropriate or unavailable.

4.3.2

Do not use corticosteroids to treat COVID-19 in people who do not need supplemental oxygen. (People who need corticosteroids for another medical reason should still have them.) [8 April 2021, amended 20 April 2022]

For a short explanation of why the panel made these recommendations, see the rationale section on corticosteroids.

Full details of the evidence and the panel's discussion are in evidence review A: corticosteroids.

4.4 Casirivimab and imdevimab – for people hospitalised because of COVID-19

4.4.1

This recommendation has been deleted because the conditional marketing authorisation for casirivimab plus imdevimab for treating COVID‑19 was withdrawn. [13 March 2024]

4.5 Tocilizumab

4.5.1

Tocilizumab is recommended, within its marketing authorisation, as an option for treating COVID‑19 in adults who:

are having systemic corticosteroids and
need supplemental oxygen or mechanical ventilation.

Tocilizumab is only recommended if the company provides it according to the commercial arrangement.

This recommendation is from NICE's technology appraisal guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab.

The summary of product characteristics for tocilizumab specifies that it should only be offered when there is no evidence of a bacterial or viral infection (other than SARS-CoV-2) that might be worsened by tocilizumab. It also states that the efficacy of tocilizumab has not been established in the treatment of COVID-19 in people who do not have elevated C‑reactive protein levels. [8 April 2021, amended 29 March 2023 and 13 March 2024]

For a short explanation of why we made this recommendation, see the rationale section on tocilizumab.

4.6 Baricitinib

4.6.1

Consider baricitinib for people 2 years and over in hospital with COVID-19 who:

need supplemental oxygen for COVID-19 and
are having or have completed a course of corticosteroids such as dexamethasone, unless they cannot have corticosteroids and
have no evidence of infection (other than SARS-CoV-2) that might be worsened by baricitinib.

In March 2023, this was an off-label use of baricitinib. See NICE's information on prescribing medicines.

Baricitinib may be considered in people who meet the above criteria, and who cannot have tocilizumab. When there is clinical deterioration despite treatment with tocilizumab, it may be appropriate to add baricitinib.

Baricitinib is contraindicated in pregnancy and breastfeeding. The Royal College of Obstetricians and Gynaecologists has produced guidance on managing coronavirus infection in pregnancy. [6 May 2022, amended 29 March 2023]

For a short explanation of why the panel made this recommendation, see the rationale section on baricitinib.

Full details of the evidence and the panel's discussion are in evidence review L: baricitinib.

4.7 Antibiotics

4.7.1

Do not use antibiotics for preventing or treating COVID-19 unless there is clinical suspicion of additional bacterial co-infection. See the section on suspected or confirmed co-infection. See also the recommendations on azithromycin and doxycycline. [21 March 2021, amended 3 June 2021]

4.8 Azithromycin

4.8.1

Do not use azithromycin to treat COVID-19. [3 June 2021]

For a short explanation of why the panel made this recommendation, see the rationale section on azithromycin.

Full details of the evidence and the panel's discussion are in evidence review B: azithromycin.

4.9 Budesonide (inhaled)

4.9.1

Only use budesonide to treat COVID-19 as part of a clinical trial. (People already on budesonide for conditions other than COVID-19 should continue treatment if they test positive for COVID-19.) [3 November 2021]

For a short explanation of why the panel made this recommendation, see the rationale section on budesonide.

Full details of the evidence and the panel's discussion are in evidence review E inhaled budesonide.

4.10 Colchicine

4.10.1

Do not use colchicine to treat COVID-19. [27 May 2021, amended 1 December 2021]

For a short explanation of why the panel made this recommendation, see the rationale section on colchicine.

Full details of the evidence and the panel's discussion are in evidence review F: colchicine.

4.11 Doxycycline

4.11.1

Do not use doxycycline to treat COVID-19 in the community. [2 September 2021]

For a short explanation of why the panel made this recommendation, see the rationale section on doxycycline.

Full details of the evidence and the panel's discussion are in evidence review C: doxycycline.

4.12 Ivermectin

4.12.1

Do not use ivermectin to treat COVID-19 except as part of an ongoing clinical trial. [22 November 2021, amended 15 June 2022]

For a short explanation of why the panel made this recommendation, see the rationale section on ivermectin.

Full details of the evidence and the panel's discussion are in evidence review M: ivermectin.

4.13 Vitamin D

4.13.1

Do not use vitamin D to treat COVID-19 except as part of a clinical trial.

For existing UK guidance on taking vitamin D to maintain muscle and bone health, see NHS advice on vitamin D. [14 July 2022]

For a short explanation of why the panel made this recommendation, see the rationale section on vitamin D.

Full details of the evidence and the panel's discussion are in evidence review N: vitamin D.