In my most recent COVID post, I touched on the dismissive phrasing of "We don't need to worry about COVID as much now, because we have treatments!" It's often used as a reason to dismiss my appeals for people to get their vaccine or wear masks or test frequently.
It's not that simple. Just like many of you, I have many friends and friends' loved ones who have caught COVID in the past few weeks. I have received multiple questions about monoclonal antibodies and Paxlovid this week, treatments people were hoping to rely on if they were infected with COVID-19. The following are outpatient treatments, used if you test positive but don't yet need to go the hospital.
Monoclonal Antibodies: No longer used. Omicron is not affected by any of the monoclonal antibodies (including the most recent sotrovimab), so those are no longer offered and the Emergency Use Authorizations have been withdrawn.
HOWEVER: Evusheld (tixagevimab+cilgavimab) are monoclonal antibodies currently authorized for pre-exposure prophylaxis against COVID-19 in patients with immunocompromise. It is not given for people who already have COVID-19. If you have a condition or are taking medication that compromises your immune system, you should ask your doctor about this.
Paxlovid (Nirmatrelvir-ritonavir, made by Pfizer): Effective at reducing duration of symptoms and preventing hospitalization (89% effective if started with 5 days of COVID-19 symptoms starting). Of note, one of its components (ritonavir) interacts with the CYP3A enzyme group, which means it may interact with several medications if you're on them (including certain antipsychotic medications, certain statins, and certain anti-seizure medications, among others; and St. John's Wort). It is processed by the kidneys (which may require a reduced dose or it may not be able to be used at all depending on the severity). It is also only authorized for folks who are at higher risk for progressing to severe disease. Paxlovid was a challenge to obtain during the initial Omicron surge earlier this year because there was such a limited supply that pharmacies quickly ran out. During the lull in cases, we did the right thing and restocked. However, I just heard from a patient on 5/16/22 that their physician could not prescribe Paxlovid because their pharmacy ran out, so they received molnupiravir instead. Hopefully Pfizer gets moving and restocks soon (some of the ingredients take a long time to make, unfortunately, so it's not solely a distribution issue) because it IS a good medication despite all that I've said here, and I have prescribed it a few times and I am happy to continue to do so.
You may have heard of Paxlovid rebound, in which people get treated with the medication for its authorized 5 days, and then symptoms return shortly after. This is an overall rare occurrence so far (noted in 2% of participants in the initial trials, though it was also 1.5% of the placebo group), and seems to be only with certain subvariants of Omicron. It is thought that maybe the antiviral works so quickly that the immune system doesn’t have a chance to kick in, so once the drug is done, any lingering virus can rally. At this time, if symptoms return, you do qualify for re-treatment! I’m sure there will be more to come on this, including maybe a longer course of treatment.
Molnupiravir (made by Merck): Another oral treatment, unfortunately only 30% effective at reducing duration of symptoms or preventing hospitalizations. Even if it's not effective, any help against COVID-19 duration is still something!
Remdesivir: An antiviral medication that inhibits viral replication in SARS-CoV-2, and an IV infusion that, in the outpatient setting, is given for three days (which requires you to go to an office or infusion center three days in a row, which can sometimes be challenging for those without their own transportation).
The latter three are the mainstays of treatment in the outpatient setting. If you've read this blog before, you know there is no evidence to support use of hydroxychloroquine, ivermectin, azithromycin, or any vitamin infusion in treatment of COVID-19. There is also not much evidence to support the use of steroids in the outpatient setting when not requiring extra supplemental oxygen.
If you end up in the hospital, based on your combination of symptoms you will likely be treated with some combination of steroids, remdesivir, and the addition of vitamin C, D, and zinc (for which the evidence is not very strong, but are used as adjunct medications - not sole treatment).
As you can see, we do have some options, but they each have their limitations either medicinally or socially. They may have contraindications or aspects that make it more difficult to prescribe. In some cases, a patient may not qualify for them. Not to mention it will not be long before insurance companies make this harder.
This is why these should be thought of as another layer of protection. Vaccines have very few contraindications (in fact, they just approved the booster for kids 5-11). I know many parents are anxiously awaiting a vaccine for kids under 5 (hopefully this summer, though we all wish they would expedite the process and not wait for both companies' products).
Treatments for COVID-19 are still coming (there is at least one new monoclonal antibody on the horizon), but Congress has decided to let funding for COVID-19 relief lapse. Which means we will not be getting more treatments in an accessible way, and there will be less money for tests and supplies. The problem is that this pandemic is NOT over and we still need these things! A pandemic response does not work without the funding behind it. Call your representatives and demand that they fund COVID-19 relief! In addition, please get vaccinated, mask up in crowds or in close proximity to people, ventilate your spaces, and test frequently. I welcome your questions.