Written by Rachel Jennings
Spoon Feed
There are a variety of therapeutic agents available for use in outpatients with COVID-19. Each has advantages and disadvantages that can help you decide which medication is best for your patient.
Why does this matter?
Lots of progress has been made in therapeutics for non-hospitalized patients with COVID-19, but supply and access to treatment remain limited. As ED providers, we need to have knowledge of our options to provide appropriate care to our COVID patients that we are able to discharge.
Options for fighting COVID at home
Sotrovimab:
- What is it? A three anti-spike monoclonal antibody
- Who can use it? Patients with mild to moderate COVID-19 within 10 days of symptom onset
- Disadvantage: High demand, not always available
- Advantage: Approved for pregnancy, efficacious when compared to its competitors (bamlanivimab/ etesevimab and carisivimab/imdevimab). Its efficacy against omicron was far superior; thus, NIH has given it the big thumbs up.
- Addendum: This just in. Post amended late morning 3/30/22. Effectiveness is limited for the BA.2 omicron variant.
Nirmatrelvir-Ritonavir:
- What is it? Co-formulated antiviral
- Who can use it? Authorized for treatment of mild to moderate COVID-19 in adult and pediatric patients (>12) who are at high risk for progression and within 5 days of symptom onset.
- Disadvantage: CYP3A inhibitor, so will alter metabolism of other drugs. If using, must consult with experienced pharmacist prior to prescription (especially for those on antiarrhythmics or anticoagulation)
- Advantage: Oral dosing and high efficacy
- What is it? Antiviral
- Who can use it? High-risk, non-hospitalized patients that are within 7 days of symptom onset.
- Disadvantage: Necessitates IV infusion for 3 consecutive days
- Advantage: Lots of supply, could work for people in health care settings (eg SNFs), also approved for pregnancy
- What is it? Antiviral
- Who can use it: High-risk, non- hospitalized within 5 days of symptom onset, only if other authorized therapeutic options are not “accessible or clinically appropriate”
- Advantage: Oral
- Disadvantage: Lower efficacy, teratogenic
But which one is best?!
All have advantages and disadvantages; overall, with its high efficacy and availability for oral dosing, both in adults and pediatric patients, nirmatrevlir-ritonavir seems like our best bet. However, potential drug interactions will limit its use for many of our patients, and the drug has no track record in pregnant patients and is not yet approved for use in pregnancy.
Source
COVID-19 Therapeutics for Nonhospitalized Patients. JAMA. 2022 Feb 15;327(7):617-618. doi: 10.1001/jama.2022.0335.
Sotrovimab quickly losing eua in multiple states due to ba2 variant prevalence. Since this was written yesterday, might be with an update to note that Bebtelovimab is the new kid on the block and to look at evusheld.
As of 3/31:
Sotrovimab is not authorized at this time in the following states and territories:
Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont (Region 1) (as of 3/25/2022)
New Jersey, New York, Puerto Rico, and the Virgin Islands (Region 2) (as of 3/25/2022)
Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin (Region 5) (as of 3/30/2022)
Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau (Region 9) (as of 3/30/2022)
Alaska, Idaho, Oregon, and Washington (Region 10) (as of 3/30/2022)