COVID-19 treatments in Colorado: A guide to antivirals and antibodies

The National Institutes of Health last week advised doctors to try an antiviral pill first for their high-risk COVID-19 patients, but whether that’s the right treatment option depends on your health and what you can find quickly.

In Colorado, high-risk people who contract the virus have access to two drugs given intravenously and two different pills to try to prevent severe illness. All but one can be used in people 12 and older, as long as they have a positive COVID-19 test and have mild or moderate symptoms.

The NIH guidelines advise that doctors first consider Paxlovid, an antiviral pill made by Pfizer, for their patients who aren’t severely ill but are at a high risk of getting to that point. If that isn’t an option, the agency recommended monoclonal antibodies, the antiviral drug remdesivir, and, finally, Merck’s pill molnupiravir, which showed lower effectiveness in clinical trials.

In practice, patients may not have a menu of drugs to choose from. Colorado has received only a few hundred doses of monoclonal antibodies each week this year, and the pills are still difficult to find even as manufacturing ramps up. The shortages pose a particular problem because patients have a limited window for treatment.

The best option for you depends on how high your risk is, whether you take other medications and what’s available in your area, said Dr. Michael Roshon, vice president of physician residencies and research operations at Penrose-St. Francis Health Services.

“It’s driven by your individual risk,” he said.

Below is a guide to the treatment options for high-risk patients:

Paxlovid

Paxlovid targets an enzyme the virus needs to reproduce. If taken within five days after symptoms start, it reduces the odds of hospitalization or death by about 88%.

The U.S. Food and Drug Administration authorized it for COVID-19 patients 12 and older who have a compromised immune system or another condition that puts them at risk for severe disease, such as:

• Age 65 or older
• Obesity or overweight
• Pregnancy
• Chronic kidney disease
• Diabetes
• Heart disease or high blood pressure
• Chronic lung disease, including moderate or severe asthma
• Sickle cell disease
• Neurodevelopmental disorders (such as cerebral palsy) or complex genetic conditions
• Reliance on medical technology (such as a breathing tube or feeding tube)

Paxlovid has a long list of interactions with other drugs, including those for seizures and certain heart problems, so a doctor needs to carefully go over the medications and supplements you use before prescribing it. It also isn’t recommended for people with severe liver or kidney disease.

Monoclonal antibodies

These are lab-created versions of substances that the body creates to fight the virus that causes COVID-19.

Given early, they can reduce the odds that a high-risk person will be hospitalized or die by up to 85%. They aren’t particularly convenient, though, because they have to be given intravenously within the first 10 days after symptoms start.

Until recently, the state allowed people to attest that they qualify as high risk. That’s no longer the case, Roshon said, because two of the three available antibody products don’t work well against the omicron variant, and Colorado only gets a few hundred doses of the remaining option, sotrovimab. (Other states also don’t get nearly enough to treat everyone who could benefit.)

Now, the state health department recommends providers only write prescriptions for people who have compromised immune systems or two other risk factors, Roshon said.

Given the limited supply, it makes sense to reserve the drugs for the people at the highest risk, particularly since lower-risk people tend to do relatively well with an omicron infection, he said. Because the supply of the antiviral pills isn’t as tight, patients seeking those only need one risk factor.

“When we were dealing with the alpha variant or delta, we had multiple monoclonal antibodies that would help,” he said. “We simply don’t have enough to go around, so we have to be judicious.”

Remdesivir

This is perhaps the least convenient option, because COVID-19 patients have to get the antiviral drug intravenously on three consecutive days, with the first treatment within seven days after symptoms start.

The FDA authorized remdesivir for people hospitalized with COVID-19, but doctors can choose to prescribe it “off-label.” Studies have found it reduces the risk of hospitalization or death by about 87%.

Molnupiravir

Molnupiravir induces mutations in the virus until it becomes nonfunctional.

It’s not recommended for patients who are pregnant, and the NIH advises men who have a partner who could become pregnant to use reliable contraception for three months afterward. Breastfeeding patients should discard any milk pumped while receiving the drug and for four days afterward.

Unlike the other medications, this one is only recommended for people 18 and older because of concerns about bone and cartilage growth. It also has a lower effectiveness than the other options, reducing the risk of hospitalization or death by about 30%, if taken within the first five days of symptoms.

Some scientists also are worried that people taking the drug could accidentally spread versions of the virus with mutations, giving new variants a chance to take off.

Options for hospitalized patients

Monoclonal antibodies and the two antiviral pills aren’t effective once patients are sick enough to be hospitalized. Remdesivir may be helpful for people who need low levels of supplemental oxygen, though its effectiveness still drops after a person has been sick for 10 days,  according to the NIH guidelines for hospitalized COVID patients.

If a patient needs a high level of supplemental oxygen or is placed on a ventilator, the main option is dexamethasone, or a similar steroid. Some patients also get other drugs to suppress the immune system, but it’s not clear how much of an advantage that offers over steroids alone.

After the first five to 10 days, most patients have cleared the virus out of their system, but some develop a dangerous immune reaction that puts them in the hospital, Roshon said. (Some patients take longer to clear the virus, especially if they have compromised immune systems.) At that point, fighting inflammation is the priority, he said.

“All the antivirals in the world won’t help you after that,” he said.

Source: Read Full Article