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
Patients who are pregnant are at increased risk of severe COVID-19.52,53 The NIH states that, in general, treatment and vaccination of pregnant patients with COVID-19 should be the same as for nonpregnant patients.1
Pregnant subjects were excluded from several trials of COVID-19 treatments.54 Because Janus kinase inhibitors, such as baricitinib, are associated with an increased risk of thromboembolism, they are not recommended in pregnant patients who are already at risk of thromboembolic complications. Molnupiravir is not recommended for pregnant patients because of its potential for teratogenic effects.
The Society for Maternal-Fetal Medicine states that there are no absolute contraindications to the use of monoclonal antibodies in appropriate pregnant patients with COVID-19.55 Remdesivir has no known fetal toxicity and is recommended as a treatment that can be offered to pregnant patients. Dexamethasone can also be administered to pregnant patients who require oxygen; however, if dexamethasone is also being used to accelerate fetal lung maturity, more frequent initial dosing is needed.
Older people. COVID-19 treatments for older patients are the same as for the general adult population. However, because older people are more likely to have impaired renal function, renal function should be monitored when an older patient is being treated with COVID-19 medications that are eliminated renally (eg, remdesivir, baricitinib). Furthermore, drug–drug interactions have been reported in older patients treated with nirmatrelvir + ritonavir, primarily because of the effects of ritonavir. Review all of a patient’s medications, including over-the-counter drugs and herbal supplements, when prescribing treatment for COVID-19, and adjust the dosage by following guidance in FDA-approved prescribing information—ideally, in consultation with a pharmacist.
Immunocompromised patients. The combination product tixagevimab + cilgavimab [Evusheld] is FDA approved for COVID-19 PrEP, under an EUA, in patients who are not infected with SARS-CoV-2 who have an immune-compromising condition, who are unlikely to mount an adequate immune response to the COVID-19 vaccine, or those in whom vaccination is not recommended because of their history of a severe adverse reaction to a COVID-19 vaccine or one of its components.7
Continue to: Summing up
