What is the first line treatment for a 63-year-old patient with Covid-19 (Coronavirus disease 2019) and mild to moderate symptoms, with or without underlying health conditions such as hypertension, diabetes, or cardiovascular disease?

First-Line Treatment for COVID-19 in a 63-Year-Old Patient

For a 63-year-old with mild-to-moderate COVID-19, initiate nirmatrelvir/ritonavir (Paxlovid) 300 mg/100 mg orally twice daily for 5 days as soon as possible after diagnosis and within 5 days of symptom onset, as this is FDA-approved specifically for adults at high risk for progression to severe disease. 1

Immediate Antiviral Therapy

• Start Paxlovid (nirmatrelvir 300 mg [two 150 mg tablets] with ritonavir 100 mg [one 100 mg tablet]) twice daily for 5 days, taken with or without food 1
• Treatment must begin within 5 days of symptom onset, even if baseline symptoms are mild 1
• Critical requirement: Nirmatrelvir must be co-administered with ritonavir—failure to do so results in insufficient plasma levels and therapeutic failure 1
• Complete the full 5-day course to maximize viral clearance and minimize SARS-CoV-2 transmission 1

Pre-Treatment Medication Review (Essential Safety Step)

• Before prescribing Paxlovid, review ALL current medications to identify potentially severe, life-threatening, or fatal drug-drug interactions, as ritonavir is a strong CYP3A inhibitor 1
• Determine which concomitant medications require dose adjustment, temporary interruption, or additional monitoring 1
• Do not co-administer with drugs highly dependent on CYP3A for clearance where elevated concentrations cause serious reactions 1
• Avoid potent CYP3A inducers that could reduce nirmatrelvir/ritonavir levels and cause loss of virologic response 1

Dose Adjustments for Comorbidities

If the patient has renal impairment:

• Normal renal function (eGFR ≥60 mL/min): Standard dose 300 mg/100 mg twice daily 1
• Moderate impairment (eGFR 30-59 mL/min): Reduce to 150 mg nirmatrelvir/100 mg ritonavir twice daily for all 5 days 1
• Severe impairment (eGFR <30 mL/min): Give 300 mg/100 mg once on Day 1, then 150 mg/100 mg once daily on Days 2-5 1

If the patient has hepatic impairment:

• Mild-to-moderate (Child-Pugh A or B): No dose adjustment needed 1
• Severe (Child-Pugh C): Paxlovid is not recommended 1

Age-related dosing considerations:

• For patients 60-80 years old, consider that deteriorated hepatic and renal clearance may require closer monitoring, though FDA labeling does not specify age-based dose reductions for Paxlovid 2, 3, 4

Symptomatic Management

For fever and discomfort:

• Advise paracetamol (acetaminophen) for fever and associated symptoms while they persist 5
• Paracetamol is preferred over NSAIDs until more evidence is available 5
• Do not use antipyretics solely to reduce body temperature 5
• Ensure adequate hydration with regular fluid intake (no more than 2 liters per day) 5

For distressing cough:

• Consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution only if cough is significantly distressing 5

For breathlessness (if present):

• Implement controlled breathing techniques: pursed-lip breathing (inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds) 5
• Position patient sitting upright and leaning forward with arms bracing to improve ventilatory capacity 5
• Relaxing and dropping shoulders reduces anxiety-induced hunched posture 5

Monitoring and Escalation Criteria

If the patient has diabetes, hypertension, or cardiovascular disease:

• These comorbidities increase risk of severe COVID-19, ICU admission, and mortality 6, 7, 8
• Continue existing RAAS inhibitors (ACE inhibitors/ARBs) and cardiovascular medications unless contraindications develop—withdrawing these medications causes more harm than benefit 9
• Monitor for disease progression more vigilantly, as diabetes increases mortality risk (relative risk 2.78) and hypertension increases mortality risk (relative risk 2.39) 8

Establish clear escalation criteria:

• Monitor oxygen saturation—if patient requires supplemental oxygen, this signals progression to moderate-severe disease requiring different management 5, 2
• Watch for worsening breathlessness, respiratory rate >30/min, or oxygen saturation <90-94% 5

Critical Pitfalls to Avoid

• Do not delay Paxlovid initiation—efficacy depends on starting within 5 days of symptom onset 1
• Do not use corticosteroids (dexamethasone) in mild-to-moderate COVID-19 without oxygen requirement—early corticosteroid use worsens outcomes and delays viral clearance 2, 3, 4
• Do not overlook drug interactions—ritonavir causes potentially fatal interactions with many common medications 1
• Do not stop existing cardiovascular medications (especially RAAS inhibitors) in patients with hypertension or cardiovascular disease, as this causes more complications than COVID-19 itself 9
• Do not assume mild symptoms will remain mild—patients aged 63 with comorbidities can deteriorate rapidly and require urgent hospitalization 2

Alternative Antiviral Options (If Paxlovid Contraindicated)

If Paxlovid cannot be used due to drug interactions or contraindications:

• Consider remdesivir, though this typically requires healthcare facility administration 5
• Molnupiravir may be considered as an alternative oral antiviral 5
• Anti-SARS-CoV-2 monoclonal antibodies if available and patient is seronegative 5