What is the recommended treatment for a 69-year-old female patient with COVID-19 (Coronavirus Disease 2019), assuming she is within the first 5 days of symptom onset and has no contraindications to medication, with consideration of her age and potential underlying health conditions such as hypertension or diabetes?

Treatment Prescription for COVID-19 in a 69-Year-Old Female

For a 69-year-old female with COVID-19 within 5 days of symptom onset, prescribe nirmatrelvir/ritonavir (Paxlovid) 300 mg/100 mg orally twice daily for 5 days, as this patient's age places her at high risk for progression to severe disease. 1, 2

Antiviral Treatment

Nirmatrelvir/ritonavir (Paxlovid) is the recommended first-line antiviral therapy for this patient based on her age-related high risk status. 1, 2

Dosing and Administration

• Standard dose: Nirmatrelvir 300 mg (two 150 mg tablets) with ritonavir 100 mg (one 100 mg tablet), all three tablets taken together twice daily for 5 days 2
• Timing: Initiate treatment as soon as possible after COVID-19 diagnosis and within 5 days of symptom onset 1, 2
• Administration: Take orally with or without food, at approximately the same time each day 2

Dose Adjustments for Renal Impairment

Before prescribing, assess renal function (eGFR): 2

• eGFR ≥60 mL/min: Standard dose (300 mg/100 mg twice daily for 5 days)
• eGFR 30-59 mL/min: Reduced dose of 150 mg/100 mg twice daily for 5 days 1, 2
• eGFR <30 mL/min: Day 1: 300 mg/100 mg once; Days 2-5: 150 mg/100 mg once daily 2

Critical Drug Interaction Assessment

Before prescribing Paxlovid, you must review ALL current medications due to ritonavir's potent CYP3A4 inhibition, which can cause serious or life-threatening drug interactions. 2, 3

Contraindicated medications (must not be co-administered): 2

• Drugs highly dependent on CYP3A for clearance where elevated concentrations cause serious reactions
• Potent CYP3A inducers that would reduce nirmatrelvir/ritonavir effectiveness

Management strategies for drug interactions: 3

• Temporarily pause interacting medications during the 5-day treatment course
• Adjust doses of comedications as needed
• Use the Liverpool COVID-19 drug interaction tool for comprehensive checking 1

Evidence Supporting Use

The WHO guideline provides a conditional recommendation for nirmatrelvir/ritonavir in patients at moderate-to-high risk of hospitalization, with high certainty evidence showing important reduction in hospitalization risk. 1 Recent real-world data demonstrates a 39% relative risk reduction in hospitalization and 61% reduction in death, with absolute risk reduction particularly pronounced in patients aged 65+ years. 4 Additional real-world evidence shows 86% reduction in 28-day all-cause mortality in severe hospitalized patients. 5

Symptomatic Management

Fever Control

• Paracetamol is preferred over NSAIDs for fever and symptom relief in COVID-19 patients 1, 6
• Advise taking paracetamol only while fever and symptoms are present, not solely to reduce body temperature 1, 6
• Ensure adequate hydration with regular fluid intake, limited to no more than 2 liters per day 1, 6
• Fever typically peaks around day 5 after exposure, requiring close monitoring during this period 1, 6

Cough Management

• Honey is recommended as first-line treatment for cough in adults 6
• Encourage patients to avoid lying flat on their back, as this makes coughing ineffective 6
• If cough becomes distressing despite simple measures, consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1, 6

Breathlessness Management

• Teach controlled breathing techniques, including pursed-lip breathing (inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds) 1, 6
• Positioning is crucial: sitting upright increases peak ventilation; leaning forward with arms bracing a chair or knees improves ventilatory capacity 1, 6
• Relaxing and dropping shoulders reduces anxiety-related hunched posture that worsens breathlessness 1, 6

Monitoring and Safety

Essential Monitoring Parameters

• Establish a treatment escalation plan immediately, as COVID-19 patients can deteriorate rapidly and require urgent hospital admission 6
• Monitor vital signs including heart rate, pulse oximetry, respiratory rate, and blood pressure 7
• Instruct the patient to seek immediate medical attention if she develops: 7
  • Worsening breathlessness
  • Persistent chest pain
  • Confusion or inability to stay awake
  • Oxygen saturation <94% on room air

Nutritional Support

• Ensure adequate nutritional support with protein-rich foods 6, 7
• Ideal energy intake: 25-30 kcal/(kg·day) 6, 7
• Protein intake: 1.5 g/(kg·day) 6, 7

Antibiotic Stewardship

• Avoid blind antibiotic use unless there is clear evidence of secondary bacterial infection 6, 7

Important Caveats

Hypersensitivity risk: Anaphylaxis, serious skin reactions (including toxic epidermal necrolysis and Stevens-Johnson syndrome), and other hypersensitivity reactions have been reported with Paxlovid. If signs of clinically significant hypersensitivity occur, immediately discontinue and initiate appropriate supportive care. 2

HIV-1 resistance concern: In individuals with uncontrolled or undiagnosed HIV-1 infection, Paxlovid use may lead to HIV-1 developing resistance to HIV protease inhibitors. 2

Hepatotoxicity: Hepatic transaminase elevations, clinical hepatitis, and jaundice have occurred in patients receiving ritonavir. 2

Not for prophylaxis: Paxlovid is not approved for pre-exposure or post-exposure prophylaxis for prevention of COVID-19. 2