Rapid evidence reviews to inform COVID-19 treatment guidelines in South Africa

ABSTRACT

Introduction/ Background: In March 2020, the South African National Essential Medicines List Committee established a multidisciplinary expert panel to review emerging evidence for COVID-19 medicines quickly and systematically. Recommendations inform National Department of Health COVID-19 guidelines. We describe implementation of this rapid review mechanism and the impact of recommendations on medicines utilisation. Methods: A protocol was developed for conducting rapid reviews, including the formulation of pre-specified review question, search of at least 2 databases, data extraction and synthesis, evidence appraisal, and summarising key findings and recommendations (PROSPERO registration CRD42021286710). The COVID-nma initiative was engaged, using global evidence syntheses, adapted to local context. National Surveillance Centre medicines procurement data were analysed, monitoring the impact of the guidelines on medicine use. Pre-pandemic medicine use (2019) was compared to pandemic use (2020), as a ratio of utilisation per 1000 uninsured population for corticosteroids, azithromycin, colchicine, and vitamin C. Results: To date the committee have reviewed 26 medicines (for treatment and prevention of COVID-19) by conducting 52 rapid reviews (including updates and evidence summaries). Review of aggregate procurement data showed that utilisation of corticosteroids (that is recommended for hospitalised COVID-19 patients on oxygen), increased 1.6-fold across all 9 South African provinces. Colchicine and azithromycin (not recommended to treat COVID-19) use did not change. However, use of vitamin C (not recommended) increased 2.2-fold. Impact A generic rapid review protocol using GRADE principles and an explicit evidence-to-decision framework promoted adaptation of global evidence to develop robust and transparent guidelines. Medicines utilisation data, though, suggests that investment is needed to strengthen guideline implementation. Conclusion: Through extensive collaboration, the Department of Health managed therapeutic uncertainty by developing and implementing a rapid, robust, and transparent evidence-informed approach. However, the impact on clinical practice is uncertain, highlighting the need for more intensive investigation of patient-level prescribing data and engagement with healthcare providers.