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Covid-19 Outpatient Treatment in 2022. By Our Student Pharmacist, Connor Glasgow.

In the early stage of the Covid-19 pandemic, significant developments in containing, preventing, and mitigating spread of Covid-19 were at the forefront of healthcare development. This can be most obviously seen with the rapid production of effective vaccines and subsequent vaccination campaigns.

As of this month, approximately 63% of the population is vaccinated, and among the vaccinated population there is a sharp decline of hospitalizations and death due to Covid-19. That being said, due to variant strains such as Omicron, mild to moderate breakthrough cases are not uncommon and the need for effective outpatient therapy remains high.

This article will list available treatments and their place in therapy. It is of note that most prescription medications provided to treat Covid itself and not symptomatology are reserved for those who are at risk of developing severe symptoms.

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Novel oral antivirals:

  • Nirmatrelvir-ritonavir
    • First-line option for non-hospitalized patients
    • Inhibitor of Sars-Cov2 main protease and pharmacokinetic enhancer
    • Dose is two tablet regimen, 300 mg (nirmatrelvir) and 100 mg (ritonavir) twice a day for five days within five days of symptom onset
    • Contraindicated in patients on CYP3A4 metabolized medications with high risk of severe adverse effects and those with kidney function issues and an eGFR under 30ml/min
      • Caution in patients with hepatic impairment
      • Caution in patients with uncontrolled HIV due to resistance concerns
    • Requires renal adjustment to 150 mg-100 mg (respectively) twice daily if eGFR is between 30 and 60ml/min
    • Allowed for patients 12 and older with a body weight of 40 kg or more
  • Molnupravir
    • Second-line option for non-hospitalized patients
    • Cytidine nucleotide analog
    • Dose is 800 mg every 12 hours for five days
    • Contraindicated in pregnancy and for those under 18
      • Cartilage and bone toxicity reported in animal studies
      • No formal studies on pregnant patients or those under 18
      • Pregnancy test recommended before administration
    • No known drug interactions
      • Studies are limited
    • Seemingly well tolerated
      • Most common adverse events were diarrhea, dizziness, and nausea
      • Occurred in under 2% of patients
    • Specific variant coverage has not been studied
    • Generally considered lower efficacy compared to nirmatrelvir-ritonavir

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Monoclonal antibodies:

  • Sotrovimab
    • First-line for non-hospitalized patients in areas where Omicron is primary variant or Omicron is confirmed variant
    • Recombinant human IgG1 antibody binds to preserved epitope on Sars-Cov2 spike protein
    • Dose is single 500 mg IV infusion within 10 days of infection
    • Contraindicated in patients with history of hypersensitivity or those hospitalized
    • Reproductive effects not studied
    • Adverse reactions:
      • Diarrhea, rash, chills, and dizziness
    • Only drug interaction is with Covid-19 vaccine, which may reduce effectiveness
      • If previously vaccinated, must wait 90 days from vaccination to administer for treatment.
  • Casirivimab-indevimab
    • First-line for non-hospitalized patients in areas where Omicron is NOT primary variant or confirmed variant is NOT Omicron
    • Recombinant human IgG1 antibody binds to two seperate epitopes on Sars-Cov2 spike protein
    • Dose is 600-600 mg (respectively) single IV dose within 10 days of exposure
    • Contraindicated if hypersensitivity to drug product
    • Adverse reactions:
      • Nausea, vomiting, and pain at site of injection
    • Only drug interaction is with Covid-19 vaccine, which may reduce effectiveness
      • If previously vaccinated, must wait 90 days from vaccination to administer for treatment.
  • Bamlanivimab-etesevimab
    • First-line for non-hospitalized patients in areas where Omicron is NOT primary variant or confirmed variant is NOT Omicron
    • Recombinant human IgG1 antibody binds to two seperate epitopes on Sars-Cov2 spike protein
    • Dose is 700 mg and 1,400 mg (respectively) single IV dose as soon as possible following exposure
    • No current contraindications. Research is limited.
    • Adverse reactions:
      • Rash, dizziness, fever, and nausea
    • Only drug interaction is with Covid-19 vaccine, which may reduce effectiveness
      • If previously vaccinated, must wait 90 days from vaccination to administer for treatment.

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Parenteral antiviral:

  • Remdesivir
    • First-line option for both hospitalized and non-hospitalized patients
    • Adenosine triphosphate analog
    • Dose is 200 mg IV loading dose, then 100 mg IV for five days
    • Only contraindication is hypersensitivity to drug product
    • Adverse reactions
      • Nausea, rash, increased ALT/AST, and possible bradycardia
    • Efficacy can be reduced by concurrent administration of hydroxychloroquine
      • Combination is not recommended
    • Caution in patients with kidney function issues and eGFR under 30ml/min
    • Not recommended in patients with AST levels over 10 times ULN
    • While studies are small and preliminary, use in pregnant women is possible under physician guidance.

References:

  • Fact sheet for healthcare providers: Emergency use … (2021, December 22). Retrieved January 26, 2022, from https://www.fda.gov/media/155050/download
  • Fact sheet for healthcare providers: Emergency use … (2021, December 23). Retrieved January 26, 2022, from https://www.fda.gov/media/155054/download
  • Fact sheet for healthcare providers: Emergency use … (2021, November 30). Retrieved January 26, 2022, from https://www.fda.gov/media/149533/download
  • Fact sheet for healthcare providers: Emergency use … (2021, November 1). Retrieved January 26, 2022, from https://www.fda.gov/media/145611/download
  • Fact sheet for healthcare providers: Emergency use … (2022, January 1). Retrieved January 26, 2022, from https://www.fda.gov/media/145802/download
  • Fact sheet for healthcare providers: Emergency use … (2020, October 1). Retrieved January 26, 2022, from https://www.fda.gov/media/214787/download
  • COVID-19: Outpatient evaluation and management of acute illness in adults. UpToDate. (2022, January 24). Retrieved January 26, 2022, from https://www.uptodate.com/contents/covid-19-outpatient-evaluation-and-management-of-acute-illness-in-adults#!

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