Can Practice Guidelines for COVID-19 Inpatient Drug Therapies Be Trusted?

Female doctor in protective suit consoling senior patient. Elderly man with oxygen mask is lying on bed in intensive care unit during COVID-19 crisis. They are in hospital ward.
Are clinical guidelines developed during the pandemic for COVID-19 inpatient drug therapies “trustworthy” by National Academy of Medicine standards?

During the COVID-19 pandemic, clinicians need swift and urgent guidance to manage affected patients and forestall transmission. But few clinical practice guidelines (CPGs) developed for pharmacologic treatments in hospitalized patients with COVID-19 meet National Academy of Medicine standards for trustworthy guidelines, according to a systematic review recently published in JAMA Network Open.

Researchers in Canada searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials and screened all titles and abstracts of citations for guidelines eligible for review. All 32 CPGs included in the review covered pharmacologic treatment in COVID-19 and were investigator-led and sponsored or produced by a national or international scientific organization or a government or nongovernment organization related to global health.

The investigators found that most of the CPGs were of low quality. Few CPGs (1) reported funding sources or conflicts of interest; (2) included a methodologist; (3) described a search strategy or study selection process; or {4) synthesized evidence. Although 14 CPGs (43.8%) made recommendations or suggestions for or against treatments, only 6 (18.8%) rated confidence in the quality of the evidence; 6 (18.8%) described potential benefits and harms; and 5 (15.6%) included a methodologist and graded the strength of recommendations. Just 7 CPGs (21.9%) reported funding sources and 12 (37.5%) divulged conflicts of interest.

According to investigators, the chaos and urgency surrounding COVID-19 surely contributed to the deficiencies found in the CPGs, but strong methodologic standards for CPGs are critical to avoid promotion of useless or potentially harmful treatments and the squandering of precious health care resources. Certain strategies could enhance the development of trustworthy CPGs, even in a pandemic, they asserted, suggesting that: (1) CPG panels should include a methodologist such as an epidemiologist, biostatistician, or health services researcher; (2) collaborations of multidisciplinary participants from at least 2 World Health Organization regions could pool their expertise to produce fewer but better-quality CPGs; and (3) journal editors and peer reviewers could require the use of CPG appraisal tools at the time of submission to assure the publication of high-quality guidelines.

The authors acknowledge certain limitations to their review, including: they confined their search to CPGs published in peer-reviewed journals; they did not verify guideline methodology; and they did not determine whether CPGs were assessed for quality at the time of submission. Nevertheless, the findings are important. “These points highlight the need for high publication standards even in the unique circumstances posed by a pandemic,” the researchers cautioned.


Burns KEA, Laird M, Stevenson J, et al. Adherence of clinical practice guidelines for pharmacologic treatments of hospitalized patients with COVID-19 to trustworthy standards: a systematic review. JAMA Netw Open. Published online December 1, 2021. doi:10.1001/jamanetworkopen.2021.36263