Optimize Outpatient COVID-19 Treatments in Your ED

You can reduce barriers to treating outpatients with COVID-19 who present to the emergency department.

COVID-19 is still leading to thousands of hospitalizations and hundreds of deaths per day in the US...but meds remain underutilized.

Continue to emphasize that treatment is available for patients at high risk of developing severe COVID-19 (diabetes, heart failure, obesity, etc)...regardless of vaccination status.

Plus risk of death increases with age...starting at around 50 and jumping again at 65. These patients see the most benefit from meds.

Choose oral nirmatrelvir/ritonavir (Paxlovid) first for most at-risk outpatients age 12 and up...even if symptoms are mild. Ensure it’s started within 5 days.

Nirmatrelvir/ritonavir still seems effective at preventing hospitalization and death...even with circulating variants. But recent data are observational or in vitro.

Reassure that “COVID-19 rebound” can happen in any patient...with OR without treatment. In either case, any symptoms seem mild.

Don’t prescribe a repeat course of nirmatrelvir/ritonavir for rebound. But it’s okay to use it again if patients get COVID-19 down the road.

Don’t let interactions deter nirmatrelvir/ritonavir use...most can be managed. Bookmark an interaction checker, such as COVID19-DrugInteractions.org.

But keep in mind that nirmatrelvir/ritonavir may need to be avoided with some meds...such as rivaroxaban or phenytoin.

Remdesivir (Veklury) seems similarly effective to nirmatrelvir/ritonavir and can be used in adults and kids down to 28 days old. But it’s a daily infusion for 3 days...so often isn’t practical.

Save oral molnupiravir (Lagevrio) as a last resort. It’s for patients age 18 and up...but is the least effective med and can’t be used in pregnancy.

Expect payer coverage of these meds to be a moving target with the COVID-19 health emergency ending in May.

Review our resource, Outpatient COVID-19 Treatment Options, for an algorithm to recommend the best med. Go to our COVID-19 Resource Hub  for charts and other tools.

Key References

  • https://www.covid19treatmentguidelines.nih.gov/ (3-1-23)
  • https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/outpatient-treatment-overview.html (3-1-23)
Hospital Pharmacist's Letter. March 2023, No. 390307

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