Therapeutic management of non-hospitalized adults with COVID-19
An update from Alethea Turner, DO, FAAFP, Associate Director Family Medicine Residency Program, on vaccines, outpatient treatment indications, isolation and panel recommendations for all patients.
- Vaccines– A bivalent booster is recommended for everyone five years of age and older (two months after last booster/vaccine dose and approximately three months after last infection).
- Home isolation and masking recommendations can be reviewed in this link.
- Outpatient treatment options/indications
- Paxlovid appears to still be the most effective and readily available outpatient treatment option.
- It reduces hospitalization and mortality, especially among those 65 years of age and older (more than 80% of deaths from COVID-19 occur in this age group); also consider it for patients at high risk for developing complications/being hospitalized from COVID-19 (prevents hospitalization and death by 89% among high-risk individuals).
- Treatment must be started within 5 days of symptom onset; three pills two times a day for five days. Patients who are 12 years of age or older and weight 88 pounds or more can be prescribed Paxlovid.
- Dose adjustment is needed for low GFR (ordering in Epic clarifies this for you). It should not to be used to treat patients with severe liver disease.
- There are medications that can interact with Paxlovid(some of which will prevent you from prescribing it, but many may just require dose adjustments or a temporary pause of the medication. The Liverpool COVID-19 Interactions (covid19-druginteractions.org) website provides an easy interface and a print out option for patients.
- The most common side effect is bad taste in the mouth that resolves when the antibiotic course is done.
- Rebound– Pfizer study showed that approximately 2% of patients rebound; in real world, this is closer to 10-15%.
- Repeat COVID-19 symptoms within two to eight days of finishing Paxlovid
- Should retest on days two, three and four after completing Paxlovid and re-start isolation/masking if return to positive
- Repeat treatment not indicated
- Very rare that rebound causes hospitalization; more of a nuisance than anything
- Rebound– Pfizer study showed that approximately 2% of patients rebound; in real world, this is closer to 10-15%.
- Paxlovid appears to still be the most effective and readily available outpatient treatment option.
- Of note: HonorHealth Infusion Centers do not offer outpatient administration of Remdesivir.
- Recent updates: Bebtevlovimab is no longer available for treatment https://www.fda.gov/drugs/drug-safety-and-availability/fda-announces-bebtelovimab-not-currently-authorized-any-us-region
(NIH)Table 2a. Therapeutic management of non-hospitalized adults with COVID-19 – Last updated: Sept. 26, 2022
| Patient disposition | Panel’s recommendations |
| Does not require hospitalization or supplemental oxygen | For all patients:
· All patients should be offered symptom management (AIII). · The Panel recommends against the use of dexamethasonea or other systemic corticosteroids in the absence of another indication (AIIb). For patients who are at high risk of progressing to severe COVID-19b · Ritonavir-boosted nirmatrelvir (Paxlovid)c,d (AIIa) · Remdesivird,e (BIIa) Alternative therapies. For use only when neither of the preferred therapies are available, feasible to use, or clinically appropriate. Listed in alphabetical order: · Bebtelovimabf (CIII) · Molnupiravird,g,h(CIIa) |
| Discharged from hospital inpatient setting in stable condition, even if receiving supplemental oxygen | The Panel recommends against continuing the use of remdesivir (AIIa), dexamethasonea (AIIa), or baricitinib (AIIa) after hospital discharge. |
| Rating of recommendations: A = Strong; B = Moderate; C = Weak Rating of evidence: I = One or more randomized trials without major limitations; IIa = Other randomized trials or subgroup analyses of randomized trials; IIb = Nonrandomized trials or observational cohort studies; III = Expert opinion |
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| a There is currently a lack of safety and efficacy data on the use of dexamethasone in outpatients with COVID-19. Using systemic glucocorticoids in outpatients with COVID-19 may cause harm.
b For a list of risk factors, see the CDC webpage Underlying Medical Conditions Associated With Higher Risk for Severe COVID-19. When deciding whether to prescribe antiviral treatment (including an anti-SARS-CoV-2 mAb) to a patient who has been vaccinated, clinicians should be aware of the conditions associated with a high risk of disease progression. These conditions include older age, a prolonged amount of time since the most recent vaccine dose (i.e., >4–6 months), and a decreased likelihood of an adequate immune response to vaccination due to a moderate to severe immunocompromising condition or the receipt of immunosuppressive medications. The number and severity of the risk factors affects the level of risk. c Ritonavir-boosted nirmatrelvir has significant drug-drug interactions. Clinicians should carefully review a patient’s concomitant medications and evaluate potential drug-drug interactions. See Drug-Drug Interactions Between Ritonavir-Boosted Nirmatrelvir (Paxlovid) and Concomitant Medications for more information. d If a patient requires hospitalization after starting treatment, the full treatment course can be completed at the health care provider’s discretion. e Administration of remdesivir requires 3 consecutive days of IV infusion. f Bebtelovimab is active in vitro against all circulating Omicron subvariants, but there are no clinical efficacy data from placebo-controlled trials that evaluated the use of bebtelovimab in patients who are at high risk of progressing to severe COVID-19. Therefore, bebtelovimab should be used only when the preferred treatment options are not available, feasible to use, or clinically appropriate. g Molnupiravir appears to have lower efficacy than the preferred treatment options. Therefore, it should be used only when the preferred options are not available, feasible to use, or clinically appropriate. h The Panel recommends against the use of molnupiravir for the treatment of COVID-19 in pregnant patients unless there are no other options and therapy is clearly indicated (AIII). |
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