What are the recommended anti-viral medications for the treatment of COVID-19?

From the Guidelines

Nirmatrelvir/ritonavir (Paxlovid) is the recommended anti-viral medication for the treatment of COVID-19 in patients with non-severe disease at high risk of hospitalization. This recommendation is based on the strongest and most recent evidence from a living WHO guideline on drugs for COVID-19, which suggests that nirmatrelvir/ritonavir should be used for patients with non-severe COVID-19 at high risk of hospitalization 1. The standard Paxlovid regimen is 300mg nirmatrelvir with 100mg ritonavir taken twice daily for 5 days, started within 5 days of symptom onset.

Some key points to consider when using Paxlovid include:

• Dose adjustments are needed for moderate kidney impairment
• Treatment should be initiated as early as possible after diagnosis, particularly for those with risk factors like advanced age, immunocompromise, or underlying health conditions
• Remdesivir is another effective option, administered intravenously as 200mg on day 1, followed by 100mg daily for 2 more days, and is typically used for hospitalized patients with severe disease
• Molnupiravir (800mg twice daily for 5 days) serves as an alternative when other antivirals aren't suitable, though it's less effective and contraindicated in pregnancy

It's worth noting that while remdesivir has been suggested as a treatment option for severe COVID-19, the evidence for its use is not as strong as that for nirmatrelvir/ritonavir, and its use should be considered on a case-by-case basis 1. However, the most recent and highest quality study recommends nirmatrelvir/ritonavir as the first-line treatment for COVID-19 in patients with non-severe disease at high risk of hospitalization 1.

From the FDA Drug Label

PAXLOVID which includes nirmatrelvir, a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) main protease (Mpro: also referred to as 3CLpro or nsp5 protease) inhibitor, and ritonavir, an HIV-1 protease inhibitor and CYP3A inhibitor, is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death. The recommended dosage for adults and pediatric patients weighing at least 40 kg is a single loading dose of VEKLURY 200 mg on Day 1 via intravenous infusion followed by once-daily maintenance doses of VEKLURY 100 mg from Day 2 via intravenous infusion.

The recommended anti-viral medications for the treatment of COVID-19 are:

• Nirmatrelvir (PAXLOVID): for mild-to-moderate COVID-19 in adults at high risk for progression to severe COVID-19.
• Remdesivir (VEKLURY): for hospitalized patients requiring invasive mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO) and for non-hospitalized patients diagnosed with mild-to-moderate COVID-19 who are at high risk for progression to severe COVID-19. Key points to consider when prescribing these medications include:
• Dosage and administration: follow the recommended dosage and administration instructions for each medication.
• Contraindications: be aware of the contraindications for each medication, such as history of clinically significant hypersensitivity reactions or co-administration with certain other drugs.
• Warnings and precautions: monitor patients for potential drug interactions, hypersensitivity reactions, and hepatotoxicity. 2 3

From the Research

Recommended Anti-Viral Medications for COVID-19

The following are recommended anti-viral medications for the treatment of COVID-19:

• Molnupiravir: a nucleoside analogue that can be used to treat mild to moderate COVID-19 in patients at risk for progression 4
• Nirmatrelvir-Ritonavir (Paxlovid): a combination of a SARS-CoV-2 main protease inhibitor and a human immunodeficiency virus type 1 protease inhibitor, which has been shown to reduce the risk of hospitalization and death in high-risk patients with COVID-19 4, 5, 6
• Sotrovimab: a monoclonal antibody that has been shown to be effective in preventing hospital admission and mortality attributable to COVID-19 7
• Remdesivir: an antiviral medication that has been shown to be effective in treating COVID-19 in outpatients at high risk of progression 8

Key Considerations for Anti-Viral Treatment

When considering anti-viral treatment for COVID-19, the following factors should be taken into account:

• Patient risk factors: patients with certain underlying health conditions, such as age ≥65 years, obesity, or immunosuppression, may be at higher risk for severe COVID-19 and may benefit from anti-viral treatment 4, 6
• Symptom onset: anti-viral treatment should be started within 5 days of symptom onset to be effective 4, 6
• Drug interactions: nirmatrelvir-ritonavir has a high potential for drug interactions due to the ritonavir component, which can inhibit the metabolism of other drugs 5
• Vaccination status: COVID-19 vaccination has been shown to be effective in preventing severe COVID-19 and reducing the risk of hospitalization and death, and should be prioritized in high-risk patients 7