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
Tocilizumab. A monoclonal antibody and interleukin (IL)-6 inhibitor, tocilizumab is also recommended in addition to dexamethasone, with or without remdesivir.48 Tocilizumab should be given only in combination with dexamethasone.49 Patients should receive baricitinib or tocilizumab—not both. IDSA recommends tofacitinib, with a prophylactic dose of an anticoagulant, for patients who are hospitalized with severe COVID-19 but who are not on any form of ventilation.50
Care of special populations
Special patient populations often seek primary care. Although many questions remain regarding the appropriate care of these populations, it is useful to summarize existing evidence and recommendations from current guidelines.
Children. COVID-19 is generally milder in children than in adults; many infected children are asymptomatic. However, infants and children who have an underlying medical condition are at risk of severe disease, including multisystem inflammatory syndrome.51
The NIH panel recommends supportive care alone for most children with mild-to-moderate disease.1 Remdesivir is recommended for hospitalized children ≥ 12 years who weigh ≥ 40 kg, have risk factors for severe disease, and have an emergent or increasing need for supplemental oxygen. Dexamethasone is recommended for hospitalized children requiring high-flow oxygen, noninvasive ventilation, invasive mechanical ventilation, or extracorporeal membrane oxygenation. Molnupiravir is not authorized for patients < 18 years because it can impede bone and cartilage growth.
There is insufficient evidence for or against the use of monoclonal antibody products for children with COVID-19 in an ambulatory setting. For hospitalized children, there is insufficient evidence for or against use of baricitinib and tocilizumab.
Continue to: Patients who are pregnant
