COVID-19 therapy: What works? What doesn’t? And what’s on the horizon?
Here is the latest evidence on the efficacy and safety of treatments that are FDA approved or authorized, in clinical trials, or not recommended to combat COVID-19.
PRACTICE RECOMMENDATIONS
› Use antivirals (eg, molnupiravir, nirmatrelvir packaged with ritonavir [Paxlovid], and remdesivir) and monoclonal antibody agents (eg, bebtelovimab) effective against the circulating Omicron variant, to treat symptoms of mild-to-moderate COVID-19 illness. C
› Treat severely ill hospitalized COVID-19 patients who require supplemental oxygen with dexamethasone, alone or in combination with remdesivir, to produce better outcomes. B
› Consider administering baricitinib or tocilizumab, in addition to dexamethasone with or without remdesivir, to COVID-19 patients with rapidly increasing oxygen requirements. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Bebtelovimab was recently given an EUA. It is a next-generation antibody that neutralizes all currently known variants and is the most potent monoclonal antibody against the Omicron variant, including its BA.2 subvariant.31 However, data about its activity against the BA.2 subvariant are based on laboratory testing and have not been confirmed in clinical trials. Clinical data were similar for this agent alone and for its use in combination with other monoclonal antibodies, but those trials were conducted before the emergence of Omicron.
In your decision-making about the most appropriate therapy, consider (1) the requirement that monoclonal antibodies be administered parenterally and (2) the susceptibility of the locally predominating viral variant.
Other monoclonal antibody agents are in the investigative pipeline; however, data about them have been largely presented through press releases or selectively reported in applications to the FDA for EUA. For example, preliminary reports show cilgavimab coverage against the Omicron variant14; so far, cilgavimab is not approved for treatment but is used in combination with tixagevimab for PreP—reportedly providing as long as 12 months of protection for patients who are less likely to respond to a vaccine.32
Corticosteroids. Guidelines recommend against dexamethasone and other systemic corticosteroids in outpatient settings. For patients with moderate-to-severe symptoms but for whom hospitalization is not possible (eg, beds are unavailable), the NIH panel recommends dexamethasone, 6 mg/d, for the duration of supplemental oxygen, not to exceed 10 days of treatment.1
Patients who were recently discharged after COVID-19 hospitalization should not continue remdesivir, dexamethasone, or baricitinib at home, even if they still require supplemental oxygen.
Continue to: Some treatments should not be in your COVID-19 toolbox
