Outpatient Treatment Options for COVID 19

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Updated January 1st 2023

 

Outpatient management strategies continue to evolve – Data informing outpatient coronavirus disease 2019 (COVID-19) management strategies continue to evolve, particularly in the setting of emerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variants; the approach described here is based upon a rapidly developing evidence base. Clinicians should take into account the individual patient's clinical and social circumstances as well as the available resources when considering treatment options. 

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Outpatient management appropriate for majority of patients – Outpatient management is appropriate for most patients with COVID-19. When possible, we favor a coordinated care management program that includes initial risk stratification, clinician telehealth visits, a dedicated outpatient respiratory clinic, and a close relationship with a local emergency department (ED). 

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Initial evaluation; evaluation of acuity and risk stratification – On initial evaluation, we assess risk factors for severe disease dyspnea severity and duration (and oxygenation status of those with dyspnea, if that information is available), overall level of acuity, and the patient’s home setting to determine who warrants an in-person evaluation at an outpatient clinic or in the ED. The additional criteria we use to make this determination are not fixed and will vary by institution, region, and over time as resource availability and treatment options evolve. 

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We typically refer patients with one or more of the following features to the ED for further management and likely hospital admission:

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•Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in complete sentences)

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•Oxygen saturation on room air of ≤90 percent, regardless of severity of dyspnea

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•Concerning alterations in mentation (eg, confusion, change in behavior, difficulty in rousing) or other signs and symptoms of hypoperfusion or hypoxia (eg, falls, hypotension, cyanosis, anuria, chest pain suggestive of acute coronary syndrome)

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We refer patients for evaluation in an outpatient clinic if they have one or more of the following features without any of the preceding features:

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•Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94 percent

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•Mild dyspnea in a patient with any risk factors for severe disease

 

•Moderate dyspnea in any patient

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•Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but not severe enough to require ED referral

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The decision to refer patients for hospital admission or manage at home depends upon several factors, including their requirement for supplemental oxygen, an assessment of their overall acuity level, and hospital resources and capacity.

 

Other patients can generally remain at home for management without in-person evaluation if they can reliably report worsened symptoms and can self-isolate for the anticipated duration of illness. Some outpatients may be candidates for COVID-19-specific therapy, if available. We generally do not schedule routine telehealth follow-up visits for patients managed at home, although we reach out to those patients about whom we have concerns (eg, older adults who live alone, individuals who may not be able to reliably self-report worsening of symptoms) by telephone as our resources permit.

 

Outpatient COVID-19-specific therapy

 

•Adults who are at increased risk for severe disease due to comorbidities and/or vaccination status – For individuals who have symptomatic mild to moderate COVID-19 (ie, no hypoxia) and are at increased risk for progression to severe disease due to advanced age, comorbidities, and/or vaccination status, we recommend early treatment with nirmatrelvir-ritonavir rather than no therapy. Such individuals include:

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-Adults ≥65 years, regardless of vaccination history

-Adults of any age with an immunocompromising condition, regardless of vaccination history or prior receipt of pre-exposure prophylaxis

-Immunocompetent adults of any age who have multiple risk factors for progression to severe disease, regardless of vaccination history

-Immunocompetent adults >50 years who have not been vaccinated, regardless of risk factors

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Nirmatrelvir-ritonavir can reduce the risk of COVID-19-associated hospitalization and death, and the expected benefit of treatment in these patients is likely substantial. 

 

When supplies of and resources for COVID-19-specific therapy are limited, we prioritize treatment for immunocompromised individuals who are likely to have a suboptimal response to vaccination and unvaccinated or incompletely vaccinated individuals who have the highest risk for progression to severe disease.

 

•Other adults – We do not routinely use COVID-19-specific therapy for immunocompetent adults aged ≤64 years who are up to date with recommended COVID-19 vaccinations and who have no other risk factors for progression to severe disease. In such patients, the overall risk of progression to severe disease is low enough that the absolute benefit of treatment may not outweigh any potential risk of harm (eg, medication adverse effects, drug-drug interactions, risk of "rebound COVID-19" requiring extension of the isolation period).

 

We also do not use COVID-19-specific therapy for individuals without any risk factors for severe disease, or for individuals who have asymptomatic SARS-CoV-2 infection.

 

●Administration of nirmatrelvir-ritonavir – Nirmatrelvir-ritonavir should be administered as soon as possible and within five days after symptom onset.

 

•Dose – For patients with normal renal function (estimated glomerular filtration rate [eGFR] ≥60 mL/min), the dose is nirmatrelvir 300 mg-ritonavir 100 mg orally twice daily for five days. For patients with moderate kidney impairment (eGFR 30 to 59 mL/min), the dose is nirmatrelvir 150 mg-ritonavir 100 mg orally twice daily for five days. It is not authorized for patients with severe kidney impairment. 

 

•Interactions – Prior to prescribing nirmatrelvir-ritonavir, clinicians should review all medications and assess potential drug interactions using an online tool. Although many medications have interactions with nirmatrelvir-ritonavir, some interactions may be mitigated by holding or dose-reducing the co-medication, and some interactions only warrant monitoring. Specific drug interactions can be checked through the Lexicomp Drug Interaction tool or the drug interaction checker from the University of Liverpool. 

 

•Rebound – Viral rebound with or without mild recurrent symptoms occurs in a minority of patients following initial improvement with nirmatrelvir-ritonavir and warrants extension of the isolation period. We advise patients of this possibility, but for patients at risk for progression to severe disease, the potential benefits of treatment greatly outweigh any potential inconvenience from rebound. 

 

●Alternative treatment options – If nirmatrelvir-ritonavir is not available or appropriate, remdesivir is an alternative option; it requires three intravenous (IV) doses over three days. 

 

Monoclonal antibodies 

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Anti-SARS-CoV-2 monoclonal antibodies used to be alternative options for COVID-19-specific therapy [52-54]. However, monoclonal antibodies have variable activity against the different SARS-CoV-2 variants, and there are no monoclonal antibodies with activity against the increasingly prevalent Omicron sublineages BQ.1 and BQ1.1 in the United States. Thus, bebtelovimab is no longer authorized for use to treat COVID-19 in the United States

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Please note the treatments for COVID 19 are evolving day to day, so please call our office for any updates or questions.

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References: UpToDate accessed December 31st 2022

COVID-19 VACCINE UPDATE FOR SBPA PATIENTS