Treatments for mild/moderate Covid outpatients; resource links

30 Jan 2022

Treatment options and prophylaxis on Provider Dashboard

By: Matthew Tanner, PharmD, BCPS, pharmacy clinical coordinator

Salem Health has two options (and a third, pending) to treat mild/moderate COVID for patients that do not require hospitalization.

First-line is Paxlovid (oral, x5 days) given within 5 days
Second line is Sotrovimab (a monoclonal antibody), given within 10 days, currently reserved for patients who are not Paxlovid candidates
Third line (pending) is Molnupiravir (oral x 5 days) given within 5 days

These therapies are on allocation from OHA. We have a fair number of doses of Paxlovid, but the supply of Sotrovimab is extremely limited, so we are limiting sotrovimab patients who are Tier 1 or Tier 2 on the NIH Suggested Patient Prioritization table.

A pre-exposure prophylaxis option is available for patients unable to receive the vaccines or who are severely immunocompromised called Evusheld (Tixagevimab and Cilgavimab) which is two IM injections repeated every 6 months.

A dashboard (AMB Provider Dashboard, see below) shows which meds are available for each of the NIH risk tiers.

More detail about each drug:

First-line therapy:
- Paxlovid (nirmtrelvir boosted by ritonavir) – a SARS-CoV-2 protease inhibitor that is taken orally BID x5 days available from the Salem Health Retail Pharmacy
  - Reduces the probability of death or admission due to COVID by 88% (from 6.3 to 0.8%), NNT = 18
  - Must be within 5 days of symptom onset
  - Many drug interactions (see a partial list at this link)
  - Renal dosing (for GFR of 30 to 60, not authorized for GFR less than 30, not studied in Child-Pugh C hepatic failure
  - Order form available if your clinic isn’t on Epic: www.salemhealth.org/paxlovid
Second-line therapy:
- Sotrovimab – a monoclonal antibody which binds to the spike protein of SARS-CoV-2, given as an IV infusion over an hour x1 dose at Salem Health Infusion Clinic.
  - Reduces the probability of death or hospitalization for greater than 24 hours if given within 5 days by 85% (from 7% to 1%), NNT = 17
  - Must be within 10 days of symptom onset
  - Cannot give vaccine for 90 days, otherwise no drug interactions
  - Very limited supply, patients must be at the highest risk (Tier 1 & 2 on this link) AND not be Paxlovid candidates
Third-line therapy (pending):
- Molnupiravir – an antiviral agent that causes RNA transcription errors and inhibits viral replication.
  - Reduces the probability of all-cause mortality or all-cause hospitalization if given within 5 days from by 30% (from 9.7% to 6.8%), NNT = 35
  - Must be within 5 days of symptom onset
  - May cause fetal harm, do not use during pregnancy, pump and dump during lactation and effective birth control for 4 days after therapy (women) and 3 months after therapy (men)
  - Most available of all of the therapies at the moment

Pre-exposure prophylaxis available through the Infusion Clinic:

Evusheld (Tixagevimab and Cilgavimab) – combination monoclonal antibody given as IM injection x1, repeat every 6 months for patients who are immune-suppressed or who cannot tolerate the vaccine.
- Reduces the probability of first instance of COVID infection by 77% (from 1% for placebo to 0.2% for Evusheld) with no severe illness for Evusheld patients (compared to 0.1% for patients who received placebo).

Relevant links:

Please contact Matt Tanner (503-814-9960 or matthew.tanner@salemhealth.org) or AJ Sowles (andrew.sowles@salemhealth.org) if you have any questions.