Pan American Health Organization · 1st edition, 2022
PAHO guidance on rational use of COVID-19 therapeutics tailored to vaccination status, resource constraints and variant prevalence in the Americas
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2022
- Audience
- Clinicians, public-health decision-makers, national programmes in Latin America and the Caribbean
- Evidence
- GRADE-rated recommendations based on WHO living guideline and regional expert panel consensus
- Reviewed
- 18 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO guidance document provides region-specific considerations for implementing WHO recommendations on COVID-19 therapeutics in Latin America and the Caribbean. It addresses antivirals (nirmatrelvir-ritonavir, molnupiravir, remdesivir), monoclonal antibodies (casirivimab/imdevimab, sotrovimab, bamlanivimab), immunomodulators (tocilizumab, baricitinib, corticosteroids), and fluvoxamine for both mild/moderate and severe/critical disease.
The document emphasizes that therapeutic decisions must account for vaccination status, variant prevalence (particularly Omicron’s resistance to certain monoclonal antibodies), resource availability, route of administration, cost, and patient-specific risk factors. PAHO’s expert panel prioritizes increasing vaccination coverage whilst providing a tiered risk stratification system to allocate scarce therapeutics to immunocompromised patients and unvaccinated individuals aged ≥75 years or ≥65 years with comorbidities. All recommendations are GRADE-rated, with evidence certainty ranging from very low to high depending on the intervention.
The guidance strongly discourages use of casirivimab/imdevimab and sotrovimab in settings where Omicron predominates due to reduced in vitro efficacy. For severe/critical disease, corticosteroids and tocilizumab remain the foundation of care, with conditional recommendations for baricitinib and casirivimab/imdevimab (in seronegative patients only). The document includes detailed tables on dosing, administration, safety profiles, and implementation considerations tailored to resource-limited settings.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Nirmatrelvir 150 mg/ritonavir 100 mg orally is strongly recommended for non-severe COVID-19 patients at highest risk of hospitalisation; contraindicated with amiodarone, rifampicin and rivaroxaban due to drug interactions
- Molnupiravir 800 mg orally twice daily is conditionally recommended for high-risk patients when other options unavailable; administer within 5 days of symptom onset; contraindicated in pregnancy and children <18 years
- Casirivimab/imdevimab (1,200–2,400 mg IV) and sotrovimab (500 mg IV) should NOT be used where Omicron variant predominates due to reduced efficacy demonstrated by in vitro data
- Tier 1 priority for therapeutics: immunocompromised patients regardless of vaccination status, OR unvaccinated individuals ≥75 years, OR unvaccinated ≥65 years with clinical risk factors (obesity BMI >30, diabetes, cardiovascular/lung/kidney disease)
- Dexamethasone 6 mg daily for ≤10 days remains standard for severe/critical disease; tocilizumab 8 mg/kg IV (max 800 mg) reduces mortality by 24 per 1,000 patients (high certainty evidence)
- Baricitinib 4 mg daily orally for 14 days is conditionally recommended for severe disease with eGFR ≥60 ml/min/1.73 m²; should not be given simultaneously with tocilizumab
- Remdesivir 200 mg IV day 1, then 100 mg IV days 2–3 is conditionally recommended for non-severe high-risk patients; administer within 7 days of symptom onset; monitor transaminases
- All monoclonal antibodies carry theoretical risk of anaphylaxis; patients require monitoring during infusion and ≥1 hour post-administration
Groups of individuals at high risk for hospitalisation due to COVID-19
Table extracted from the guideline
| Tier | Risk group |
|---|---|
| 1 | Immunocompromised individuals who are not expected to mount adequate immune response to COVID-19 vaccine or SARS-CoV-2 infection, regardless of vaccination status; OR unvaccinated individuals at increased risk of severe illness (anyone ≥75 years or ≥65 years with additional clinical risk factors) |
| 2 | Unvaccinated individuals at increased risk of severe disease not included in tier 1 (anyone ≥65 years with clinical risk factors) |
Source: Pan American Health Organization, Considerations on the Use of Antivirals, Monoclonal Antibodies, and Other Interventions for the Management of COVID-19 Patients in Latin America and the Caribbean. Reproduced in summary form.
From the guideline
Verbatim
“The PAHO panel emphasized that countries should direct their efforts toward increasing coverage of the full vaccination schedule in order to effectively and safely reduce viral transmission, severe cases, and SARS-CoV-2-associated mortality.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
This PAHO guidance arrives at a critical juncture for Georgia as we transition COVID-19 management from emergency response to sustainable integration within our universal health coverage programme. The tiered risk stratification system—prioritizing immunocompromised patients and unvaccinated elderly—aligns well with Georgia's capacity to implement targeted interventions, as demonstrated by our hepatitis C micro-elimination approach and our diabetes management protocols. I would stress to Georgian clinicians the absolute necessity of screening for drug interactions before prescribing nirmatrelvir-ritonavir, given the high prevalence of cardiovascular disease and polypharmacy in our older population; ritonavir's contraindication with amiodarone and other common medications requires systematic checking that may exceed current outpatient workflow capacity. The realistic implementation challenge is the 5–10 day therapeutic window: our current COVID-19 diagnostic pathways, which were designed for surveillance rather than urgent treatment initiation, will require redesign to enable same-day or next-day prescribing decisions in ambulatory settings, particularly in rural areas where access to both diagnostics and specialist consultation remains limited.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 18 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia has demonstrated capacity for rapid therapeutic guideline adoption through its national hepatitis C elimination programme and COVID-19 vaccination rollout. This PAHO guidance is directly relevant because Georgia faces similar constraints to Latin American settings: limited supplies of novel antivirals, Omicron predominance since early 2022, variable vaccination coverage (particularly in older adults and rural populations), and need to prioritize scarce resources. The tiered risk stratification system can be adapted by Georgia’s National Centre for Disease Control and Public Health to allocate nirmatrelvir-ritonavir and molnupiravir when available through international procurement mechanisms. Georgian clinicians should note that the drug interaction profiles—particularly ritonavir with cardiovascular medications widely used in the elderly population—require careful screening. Implementation will require strengthening outpatient diagnostic pathways to enable treatment within 5–10 days of symptom onset, and establishing infusion capacity for monoclonal antibodies at regional level, though the latter may be deprioritized given Omicron’s dominance and cost-effectiveness considerations.
Questions this guideline answers
Quick answers
Which COVID-19 therapeutic should be first-line for an unvaccinated 70-year-old diabetic patient presenting 3 days after symptom onset?
Nirmatrelvir 150 mg/ritonavir 100 mg orally has a strong recommendation for this high-risk patient (Tier 1: unvaccinated ≥65 years with clinical risk factors). Check for drug interactions with any antiarrhythmic drugs, rifampicin, or rivaroxaban before prescribing. If nirmatrelvir-ritonavir is unavailable or contraindicated, molnupiravir 800 mg twice daily or remdesivir 200 mg IV day 1 then 100 mg days 2–3 are conditional alternatives, all administered within 5–10 days of symptom onset.
Can I still use casirivimab/imdevimab or sotrovimab now that Omicron is the dominant variant?
No. PAHO advises against using casirivimab/imdevimab or sotrovimab in countries where Omicron predominates due to in vitro data showing substantially reduced efficacy. These monoclonal antibodies should only be considered if viral genotyping confirms a susceptible (non-Omicron) variant, which is impractical in most settings. Prioritize oral antivirals (nirmatrelvir-ritonavir or molnupiravir) instead.
What defines an immunocompromised patient eligible for Tier 1 therapeutic prioritization?
Tier 1 immunocompromised patients include: those within 1 year of B-cell-depleting therapies (rituximab, ocrelizumab), recipients of CAR T-cell or stem-cell transplant with graft-versus-host disease, patients with haematologic malignancies on active therapy, lung transplant recipients, solid organ transplant recipients within 1 year or recently treated for rejection, patients with severe combined immunodeficiencies, and untreated HIV with CD4 <50 cells/mm³. These patients should receive therapeutics regardless of vaccination status.
What is the evidence quality and mortality benefit for tocilizumab in severe COVID-19?
Tocilizumab has HIGH certainty evidence (8,455 patients in 20 trials) showing reduction of 24 deaths per 1,000 patients with severe disease (baseline risk 16%). Administer as single IV dose of 8 mg/kg up to maximum 800 mg, with possible second dose 12–48 hours later. Check neutrophil/platelet counts and transaminases before starting. Monitor for infections given immunosuppression, especially when combined with corticosteroids.
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Quality & accreditation
Other guidelines on this topic
- Guidance for Developing Status Profiles on Communicable Diseases to Further Progress toward Their Elimination in the Region of the Americas
- Guidelines for the Care of Adult Patients with Severe or Critical COVID-19 in the Americas. Abridged version, 4th edition
- Guidelines for the Prophylaxis and Management of Patients with Non-severe COVID-19 in Latin America and the Caribbean
- Living Systematic Review of Therapeutic Options for Post COVID-19 Condition, 11 January 2023
- Prevention and management of heat-related illness at mass gatherings: risk assessment tool
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2022
- Status
- Current
- Published
- 2022-01-01
- Languages
- English, Spanish
- Scope
- COVID-19 therapeutics for mild, moderate, severe and critical disease
- Audience
- Clinicians, public-health decision-makers, national programmes in Latin America and the Caribbean
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE-rated recommendations based on WHO living guideline and regional expert panel consensus
- Record history
- Created 18 Oct 2026 · updated 18 Oct 2026 · next check Apr 2027
Pan American Health Organization. Considerations on the Use of Antivirals, Monoclonal Antibodies, and Other Interventions for the Management of COVID-19 Patients in Latin America and the Caribbean. Washington, D.C.: PAHO; 2022. (PAHO/IMS/EIH/COVID-19/22-0012).GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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