WHO Guideline on drugs Casirivimab and Imdevimab for Covid-19 treatment

This WHO Therapeutics and COVID-19: living guideline now includes two recommendations regarding the combination of neutralizing monoclonal antibodies, Casirivimab and Imdevimab: a conditional recommendation in favour of use in non-severe patients (the condition being patients’ risk of severe disease: patients at highest risk represent good candidates for use of the intervention); and a conditional recommendation in favour of use in the severe and critically ill (the condition being seronegative status).

Casirivimab and imdevimab (neutralizing monoclonal antibodies)

Conditional recommendation

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For patients with non-severe COVID-19

WHO suggest treatment with casirivimab and imdevimab, conditional to those at highest risk of hospitalization.

Whereas casirivimab and imdevimab achieves a substantial reduction in the relative risk of hospitalization, the absolute benefit will be trivial or unimportant in absolute terms for all but those at highest risk for which the intervention should be reserved.

The panel identified a risk beyond 10% of being hospitalized for COVID-19 to represent a threshold at which most people would want to be treated with casirivimab and imdevimab.

In the absence of credible tools to predict risk for hospitalization in people infected with COVID-19, typical characteristics of people at highest risk include lack of vaccination, older people, or those with immunodeficiencies and/or chronic diseases (e.g. diabetes).

For patients with severe or critical COVID-19

WHO suggest treatment with casirivimab and imdevimab, under the condition that the patient has seronegative status.

With benefits of casirivimab and imdevimab observed only in patients with seronegative status, clinicians will need to identify these patients by credible tests available at the point of care to appropriately apply this recommendation (see Evidence to Decision section).

Treatment with casirivimab and imdevimab is in addition to the current standard of care, which includes corticosteroids and IL-6 receptor blockers.

WHO severity definitions

Critical COVID-19 – Defined by the criteria for acute respiratory distress syndrome (ARDS), sepsis, septic shock, or other conditions that would normally require the provision of life-sustaining therapies such as mechanical ventilation (invasive or non-invasive) or vasopressor therapy.
Severe COVID-19 – Defined by any of:

Oxygen saturation < 90% on room air;
in adults, signs of severe respiratory distress (accessory muscle use, inability to complete full sentences, respiratory rate > 30 breaths per minute), and, in children, very severe chest wall indrawing, grunting, central cyanosis, or presence of any other general danger signs (inability to breastfeed or drink, lethargy or reduced level of consciousness, convulsions) in addition to the signs of pneumonia.