What are the recommended oral treatments for Covid-19?

Recommended Oral Treatments for COVID-19

Nirmatrelvir/ritonavir (Paxlovid) is the preferred oral treatment for COVID-19 in high-risk adults, showing an 89% reduction in hospitalization and death when initiated within 5 days of symptom onset. 1, 2

First-Line Therapy: Nirmatrelvir/ritonavir (Paxlovid)

Indications

• Mild-to-moderate COVID-19 in adults at high risk for progression to severe disease
• Must be initiated within 5 days of symptom onset
• Risk factors include: diabetes, overweight (BMI >25), chronic lung disease, chronic kidney disease, cardiovascular disease, hypertension, immunosuppression, age ≥60 years, and others

Standard Dosing

• 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet)
• Take all three tablets together twice daily for 5 days
• Can be taken with or without food

Dose Adjustments for Renal Impairment

• Moderate renal impairment (eGFR 30-60 mL/min): 150 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days
• Severe renal impairment (eGFR <30 mL/min): 300 mg nirmatrelvir with 100 mg ritonavir once on day 1, then 150 mg nirmatrelvir with 100 mg ritonavir once daily for days 2-5

Important Considerations

• Drug interactions are a major concern - ritonavir is a potent CYP3A4 inhibitor
• Review all patient medications prior to prescribing
• Contraindicated with drugs highly dependent on CYP3A for clearance where elevated concentrations could lead to serious reactions
• Not recommended in severe hepatic impairment (Child-Pugh Class C)

Alternative Oral Treatments

Molnupiravir

• For adults ≥18 years with mild-to-moderate COVID-19 at high risk for progression
• When Paxlovid is not available or contraindicated due to drug interactions
• Less effective than Paxlovid (30% vs 89% reduction in hospitalization/death)
• Contraindicated in pregnancy and children
• Should be initiated within 5 days of symptom onset 3, 4

Favipiravir

• Used in some countries for mild to moderate COVID-19
• Dosing varies by country guidelines:
  • Japanese guidelines: 3600 mg (1800 mg BID) on day 1, then 1600 mg (800 mg BID) for up to 14 days
  • Russian guidelines: Weight-based dosing, generally 1600 mg BID on day 1, then 600 mg BID for days 2-10
  • Saudi guidelines: 1600 mg BID on day 1, then 600 mg BID for 7-10 days 5

Special Populations

Patients with Hematological Malignancies

For patients with hematological malignancies and COVID-19, recommended treatments include:

1. Anti-SARS-CoV-2 monoclonal antibodies
2. Remdesivir
3. Nirmatrelvir/ritonavir
4. Molnupiravir 5

Management of Symptoms

For symptomatic management of COVID-19:

• Cough: Consider honey (for patients >1 year), codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution if distressing
• Fever: Paracetamol is preferred over NSAIDs
• Breathlessness: Controlled breathing techniques, proper positioning, and breathing retraining 5

Common Pitfalls to Avoid

1. Delayed initiation: Treatment must begin within 5 days of symptom onset for maximum effectiveness
2. Missing drug interactions: Always check for potential interactions before prescribing nirmatrelvir/ritonavir
3. Inappropriate dosing in renal impairment: Adjust dose according to renal function
4. Not considering alternative treatments: When nirmatrelvir/ritonavir is contraindicated, consider alternatives promptly
5. Overlooking symptom management: Comprehensive care includes managing symptoms alongside antiviral therapy

Remember that oral COVID-19 treatments are intended to reduce the risk of hospitalization and death in high-risk individuals, not for prevention or treatment of mild disease in low-risk patients.