What is the next treatment for an elderly Covid-19 patient with a cough who cannot take Paxlovid (nirmatrelvir/ritonavir)?

Management of Elderly COVID-19 Patients with Cough When Paxlovid is Not an Option

For elderly COVID-19 patients with cough who cannot take Paxlovid, the next best treatment option is remdesivir, combined with supportive care including codeine for cough suppression and appropriate symptomatic management. 1

First-Line Alternative to Paxlovid

Remdesivir

• Recommended for hospitalized patients not requiring invasive mechanical ventilation
• Should be initiated as soon as possible after diagnosis
• Standard dosing for adults: 200mg IV loading dose on Day 1, followed by 100mg IV daily for 4 days
• For elderly patients, consider dose adjustment:
  • Ages 60-80: 3/4-4/5 of standard adult dosing
  • Ages >80: 1/2 of standard adult dosing 1
• Monitor hepatic function and prothrombin time before starting and during treatment 2
• Not recommended for patients already requiring invasive mechanical ventilation 1

Symptomatic Management for Cough

Cough Suppression

• First try simple measures: encourage patient to avoid lying on their back to make coughing more effective 1
• Consider honey for patients over 1 year of age 1
• For distressing cough, consider short-term use of:
  • Codeine linctus
  • Codeine phosphate tablets
  • Morphine sulfate oral solution 1

Positioning Techniques

• Sitting upright increases peak ventilation and reduces airway obstruction
• Leaning forward with arms bracing a chair or knees with upper body supported improves ventilatory capacity 1

Additional Supportive Care

Managing Fever

• Advise regular fluid intake (no more than 2L/day) to avoid dehydration
• Use paracetamol for fever and associated symptoms
• Avoid NSAIDs unless clearly indicated 1

Managing Breathlessness

• Implement controlled breathing techniques:
  • Pursed-lip breathing: inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds
  • Relaxing shoulders to reduce hunched posture from anxiety
  • Breathing retraining exercises 1

Special Considerations for Elderly Patients

Medication Management

• Reduce polypharmacy appropriately
• Adjust drug doses according to organ function and potential drug interactions
• Use medications with lowest risk of drug-drug interactions 1
• Use minimum effective doses for shortest duration 1

Monitoring and Prevention

• Closely monitor for potential complications:
  • Secondary infections (monitor respiratory pathogens)
  • Disseminated intravascular coagulation (monitor D-dimer and coagulation indicators)
  • Perform timely interventions for any complications 1

Important Caveats and Pitfalls

• Remdesivir must be administered intravenously, requiring appropriate healthcare setting
• Drug interactions are common in elderly patients - review all medications before starting any treatment
• Avoid lopinavir-ritonavir as evidence shows no benefit and potential for harm 1
• Elderly patients are more susceptible to adverse drug effects due to decreased liver and kidney function
• Ensure treatment escalation plans are in place as patients with COVID-19 may deteriorate rapidly 1
• Consider advance care plans or advance decisions to refuse treatment if applicable 1

By following this algorithm, clinicians can provide effective treatment for elderly COVID-19 patients with cough when Paxlovid is not an option, focusing on both antiviral therapy and symptomatic management to improve outcomes.