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Therapeutics for people with COVID-19

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1 Recommendations

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

1.2 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 (see section 2).

1.3 Baricitinib is recommended as an option for treating COVID-19 in adults, subject to it receiving a marketing authorisation in Great Britain for this indication.

1.4 Casirivimab plus imdevimab is not recommended, within its marketing authorisation, for treating acute COVID-19 in adults.

1.5 Molnupiravir is not recommended, within its marketing authorisation, for treating mild to moderate confirmed COVID-19 in adults who have at least 1 risk factor for developing severe COVID-19.

1.6 Remdesivir is not recommended, within its marketing authorisation, for treating COVID-19 in:

  • people aged at least 4 weeks and weighing at least 3 kg with pneumonia who need supplemental oxygen (low- or high-flow oxygen or other non-invasive ventilation) at start of treatment

  • young people weighing at least 40 kg and adults who do not need supplemental oxygen and have an increased risk for progression to severe COVID-19.

1.7 Sotrovimab is not recommended, within its marketing authorisation, for treating symptomatic acute COVID-19 in people aged 12 years and over and weighing at least 40 kg who:

  • do not need oxygen supplementation and

  • have an increased risk for progression to severe COVID-19.

1.8 Tixagevimab plus cilgavimab is not recommended, within its marketing authorisation for treating COVID-19 in adults who do not require supplemental oxygen and who are at increased risk of progressing to severe COVID-19.

1.9 People may be offered treatment from supplies already purchased by the Department of Health and Social Care before this guidance was published under the interim clinical commissioning policies, if clinicians consider it an appropriate option for people with COVID-19.

Why the committee made these recommendations

People with COVID-19 who have a high risk for progression to severe COVID-19 are offered treatments to stop their symptoms worsening. Usually, people would be offered nirmatrelvir plus ritonavir, sotrovimab, remdesivir or molnupiravir. These treatments are recommended through the NHS interim clinical commissioning policy on antivirals or neutralising monoclonal antibodies for people with COVID-19 who are not in hospital. An independent advisory group report commissioned by the Department of Health and Social Care defines who has an increased risk.

People in hospital with severe COVID-19 are offered different treatments based on their oxygen needs. For people who need supplemental oxygen, NICE's rapid guideline on managing COVID-19 recommends corticosteroids. For people who are having corticosteroids and who need supplemental oxygen, the NHS secondary care interim clinical commissioning policy and NICE's managing COVID‑19 guideline recommend, in certain circumstances, tocilizumab, off-label (outside of marketing authorisation in Great Britain) use of baricitinib, or remdesivir. They also recommend nirmatrelvir plus ritonavir, sotrovimab or remdesivir for people who have no, or low, oxygen needs and a high risk for progression to severe disease.

This evaluation reviews the clinical and cost effectiveness of baricitinib, casirivimab plus imdevimab, molnupiravir, nirmatrelvir plus ritonavir, remdesivir, sotrovimab, tixagevimab plus cilgavimab and tocilizumab as treatment options for COVID-19.

Most of the clinical evidence is from studies done before the Omicron variant of SARS-CoV-2 (the virus that causes COVID-19). So there are significant uncertainties in the clinical evidence. There is some clinical evidence suggesting that baricitinib, molnupiravir, nirmatrelvir plus ritonavir, remdesivir and tocilizumab are effective at treating COVID-19. But, it is highly uncertain whether casirivimab plus imdevimab, sotrovimab and tixagevimab plus cilgavimab (all neutralising monoclonal antibodies) are effective against the Omicron variant.

The cost-effectiveness estimates are highly dependent on hospitalisation and mortality rates. These rates are lower with the Omicron wave than earlier variants in the pandemic. Lower rates increase the cost-effectiveness estimates.

Nirmatrelvir plus ritonavir and tocilizumab are recommended because the likely cost-effectiveness estimates are within what NICE usually considers an acceptable use of NHS resources. Baricitinib is recommended subject to it receiving a marketing authorisation in Great Britain for this indication.

Casirivimab plus imdevimab, molnupiravir, remdesivir, sotrovimab and tixagevimab plus cilgavimab are not recommended because the likely cost-effectiveness estimates are higher than what NICE usually considers an acceptable use of NHS resources.