<b>Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19</b>. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT)

Falavigna, Maicon; Belli, Karlyse Claudino; Barbosa, Alexandre Naime; Zavascki, Alexandre Prehn; Nastri, Ana Catharina de Seixas Santos; Santana, Christiane Machado; Stein, Cinara; Gräf, Débora Dalmas; Cadegiani, Flavio Adsuara; Guimarães, Hélio Penna; Monteiro, José Tadeu; Ferreira, Juliana Carvalho; de Azevedo, Luciano Cesar Pontes; Magri, Marcelo Mihailenko Chaves; Sobreira, Marcone Lima; Dias, Maria Beatriz Gandra de Souza; de Oliveira, Maura Salaroli; Corradi, Mirian de Freitas Dal Ben; Rosa, Regis; Heinzelmann, Ricardo Souza; da Silva, Rosemeri Maurici; Belfort Junior, Rubens; Cimerman, Sergio; Colpani, Verônica; Veiga, Viviane Cordeiro; de Carvalho, Carlos Roberto Ribeiro

doi:10.1016/j.bjid.2022.102347

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Original Article • Braz J Infect Dis 26 (02) • 2022 • https://doi.org/10.1016/j.bjid.2022.102347 copy

Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT)

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background

Several therapies have been used or proposed for the treatment of COVID-19, although their effectiveness and safety have not been properly evaluated. The purpose of this document is to provide recommendations to support decisions about the drug treatment of outpatients with COVID-19 in Brazil.

Methods

A panel consisting of experts from different clinical fields, representatives of the Brazilian Ministry of Health, and methodologists (37 members in total) was responsible for preparing these guidelines. A rapid guideline development method was used, based on the adoption and/or adaptation of recommendations from existing international guidelines combined with additional structured searches for primary studies and new recommendations whenever necessary (GRADE-ADOLOPMENT). The rating of quality of evidence and the drafting of recommendations followed the GRADE method.

Results

Ten technologies were evaluated, and 10 recommendations were prepared. Recommendations were made against the use of anticoagulants, azithromycin, budesonide, colchicine, corticosteroids, hydroxychloroquine/chloroquine alone or combined with azithromycin, ivermectin, nitazoxanide, and convalescent plasma. It was not possible to make a recommendation regarding the use of monoclonal antibodies in outpatients, as their benefit is uncertain and their cost is high, with limitations of availability and implementation.

Conclusion

To date, few therapies have demonstrated effectiveness in the treatment of outpatients with COVID-19. Recommendations are restricted to what should not be used, in order to provide the best treatment according to the principles of evidence-based medicine and to promote resource savings by aboiding ineffective treatments.

Keywords
COVID-19; COVID-19 drug treatment; Guideline; SARS-CoV-2; Brazil; GRADE

Level	Definition	Implications
High	There is strong confidence that the true effect is close to the estimate.	It is unlikely that additional work will modify the confidence in the effect estimate.
Moderate	There is moderate confidence in the estimated effect.	Future work may change the confidence in the effect estimate and may even change the estimate.
Low	Confidence in the effect is limited.	Future work is likely to have a major impact on the confidence in the effect estimate.
Very low	Confidence in the effect estimate is very limited.There is an important degree of uncertainty in the findings.	Any effect estimate is uncertain.

Intended users	Strong	Conditional
Policymakers	The recommendation should be adopted as a health care policy in most situations.	Substantial debate and stakeholder involvement are required.
Patients	Most individuals would want the intervention to be indicated and only a small number would not accept this recommendation.	Most individuals would want the intervention to be indicated; however, a considerable number would not accept this recommendation.
Clinicians	Most patients should receive the recommended intervention.	The clinician should recognize that different choices will be appropriate for each patient to make a decision consistent with patient values and preferences.

Drug	Recommendation
Anticoagulants	Recommendation 1: We suggest against using anticoagulants in outpatients with suspected or confirmed COVID-19 (conditional recommendation, very low certainty in evidence).
Azithromycin	Recommendation 2: We recommend against using azithromycin in outpatients with suspected or confirmed COVID-19 (strong recommendation, moderate certainty in evidence).
Monoclonal antibodies	Recommendation 3: It was not possible to make a recommendation regarding the use of monoclonal antibodies in outpatients with suspected or confirmed COVID-19 (no recommendation, moderate certainty in evidence).
Budesonide	Recommendation 4: We suggest against using budesonide in outpatients with suspected or confirmed COVID-19 (conditional recommendation, low certainty in evidence).
Colchicine	Recommendation 5: We suggest against using colchicine in outpatients with suspected or confirmed COVID-19 (conditional recommendation, low certainty in evidence).
Systemic corticosteroids	Recommendation 6: We recommend against using corticosteroids in outpatients with suspected or confirmed COVID-19 (recommendation not graded).
Chloroquine / Hydroxychloroquine	Recommendation 7: We recommend against using chloroquine/ hydroxychloroquine, either alone or combined with azithromycin, in outpatients with suspected or confirmed COVID-19 (strong recommendation, moderate certainty in evidence).
Ivermectin	Recommendation 8: We suggest against using ivermectin in outpatients with suspected or confirmed COVID-19 (conditional recommendation, low certainty in evidence).
Nitazoxanide	Recommendation 9: We suggest against using nitazoxanide in outpatients with suspected or confirmed COVID-19 (conditional recommendation, very low certainty in evidence).
Convalescent plasma	Recommendation 10: We suggest against using convalescent plasma in outpatients with suspected or confirmed COVID-19 (conditional recommendation, moderate certainty in evidence).

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E-mail: bjid@bjid.org.br

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[1] ⁎Corresponding author at: Projeto Diretrizes, Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630 / 1015, Porto Alegre, RS, Brazil, Postal code: 90035-001. E-mail address: maicon@htanalyze.com (M. Falavigna).