Outpatient Treatment Options for COVID 19
Updated April 9th 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.
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).
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.
We typically refer patients with one or more of the following features to the ED for further management and likely hospital admission:
Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in complete sentences)
Oxygen saturation on room air of ≤90 percent, regardless of severity of dyspnea
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)
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:
Mild dyspnea in a patient with an oxygen saturation on room air between 91 to 94 percent
Mild dyspnea in a patient with any risk factors for severe disease
Moderate dyspnea in any patient
Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but not severe enough to require ED referral
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:
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
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.
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
Please note the treatments for COVID 19 are evolving day to day, so please call our office for any updates or questions.
COVID-19 VACCINE UPDATE FOR SBPA PATIENTS
COVID-19 BOOSTER VACCINATION
Updated April 30th 2023
FDA amends emergency use authorization for COVID-19 vaccines: The FDA amended the emergency use authorization for the bivalent Pfizer-BioNTech and Moderna COVID-19 vaccines resulting in a simplified vaccination schedule for most individuals. This amendment authorizes the bivalent vaccines available since September 2022 to be used for all doses (primary vaccination and boosters) for individuals 6 months of age and older. Most individuals who have already received a single dose of the bivalent vaccine are not currently eligible for another dose.
However, individuals can receive an additional dose of a bivalent COVID-19 vaccine if they are:
Immunocompromised and it has been at least 2 months since receiving a bivalent COVID-19 vaccine. For immunocompromised individuals 6 months through 4 years old, eligibility for an additional dose will depend on the vaccine previously received.
Ages 65 and older if it has been at 4 months since receiving a bivalent COVID-19 vaccine.
Please refer to the CDC website for more information about the COVID-19 booster vaccine.
As the guidelines for COVID-19 booster vaccination continue to evolve, if you have questions about if the booster vaccine is right for you, please contact us at SBPA to discuss further.