The National Institutes of Health updated guidance on use of dexamethasone and substitutes in critically ill patients, and on ensuring surrogate decision makers are identified.
The National Institutes of Health (NIH) on July 30, 2020 made updates on use of corticosteroids in treatment of COVID-19 and on approaches to care of the crtically ill, including considerations for advance planning to its dynamic COVID-19 Treatment Guidelines. The guidelines are updated as soon as published data and other authoritative information become available. Following are highlights of the recent updates.
The recommendations in these NIH COVID-19 Treatment Guidelines are based on scientific evidence and expert opinion. Each recommendation includes two ratings: a letter (A, B, or C) that indicates the strength of the recommendation and a Roman numeral (I, II, or III) that indicates the quality of the evidence that supports the recommendation.
NIH Update on Corticosteroid Treatment. The recommendations in this section have been updated to allow the use of alternative corticosteroids (ie, hydrocortisone, methylprednisolone, prednisone) in situations where dexamethasone may not be available.
NIH Corticosteroid Treatment Revisions. Based on preliminary data from the RECOVERY trial the COVID-19 Treatment Guidelines Panel recommends using dexamethasone 6 mg per day for up to 10 days for the treatment of COVID-19 in patients who are mechanically ventilated (AI) and in patients who require supplemental oxygen but who are not mechanically ventilated (BI).
NIH Corticosteroid Update. The Panel recommends against using dexamethasone for the treatment of COVID-19 in patients who do not require supplemental oxygen (AI). If dexamethasone is not available, the Panel recommends using alternative glucocorticoids such as prednisone, methylprednisolone, or hydrocortisone (see Guidelines/Additional Considerations for dosing recommendations) (AIII).
NIH Rationale for Updated Corticosteroid Recommendation. The RECOVERY trial, a multicenter, randomized, open-label study in hospitalized patients with COVID-19, showed lower mortality among patients randomized to receive dexamethasone than among those who received standard of care.
NIH Update to Care of Critically Ill Patients: Goals of Care/Advance Care Planning. The Goals of Care subsection has been expanded to include information on advance care planning, with emphasis on the importance of identifying surrogate decision makers for critically ill patients with COVID-19.
NIH Update to Advance Care Planning/Goals. The advance care plans and the goals of care for all critically ill patients must be assessed at admission and regularly thereafter. This is an essential element of care for all patients. Information on palliative care for patients with COVID-19 can be found at the National Coalition for Hospice and Palliative Care website.
NIH Update: Advance Care Planning/Goals. To guide shared decision-making in cases of serious illness, advance care planning should include identifying existing advance directives that outline a patient’s preferences and values. Specialty palliative care teams can facilitate communication among all parties.
NIH Update: Advance Care Planning/Goals. Surrogate decision makers should be identified for all critically ill patients with COVID-19 at admission. Infection-control policies for COVID-19 often limit direct communication with the surrogate decision makers; most surrogates will not be physically present when discussing treatment options with clinicians. Many decision-making discussions will occur via telecommunication.
