COVID-19 Treatment Resources for Healthcare Providers

Key point:

Effective outpatient treatment for patients with mild-to-moderate COVID-19 and at high risk for severe illness is available and should be offered to all eligible patients, with the primary goals of reducing hospitalizations and deaths.

Overview of COVID-19 Antivirals:

The following medications are FDA approved or under EUA for the outpatient treatment of COVID-19:

The following medications are FDA approved or under EUA for the pre-exposure prophylaxis (PReP) of COVID-19:

Pemgarda (pemivibart) (PDF)

Introduction:

COVID-19 treatments can help prevent severe illness in eligible patients.
Eligibility depends on exposure status, symptoms, and risk factors for severe disease. These risk factors include but are not limited to age over 50 years, being unvaccinated or not up to date on COVID-19 vaccinations, or having specific medical conditions.
CDPH recommends that providers prescribe nirmatrelvir/ritonavir (Paxlovid) to non-hospitalized, symptomatic, and eligible patients. Remdesivir (Veklury) should be considered when nirmatrelvir/ritonavir (Paxlovid) is clinically contraindicated, and molnupiravir (Lagevrio) may be considered if remdesivir is impractical and Paxlovid is clinically contraindicated.

COVID-19 Therapeutics Frequently Asked Questions

Which outpatient treatment should I choose for my patient?

Please use the resources below when deciding which treatment option to prescribe. There are several factors that may affect the treatment option selected for a specific patient. While not a complete list of contraindications, the following should be noted.

Nirmatrelvir/ritonavir (Paxlovid):

Drug-drug interaction potential, primarily due to the ritonavir component.
Different dosing required for moderate renal impairment. Not recommended for patients with severe hepatic or renal impairment.
Given the presence of ritonavir, nirmatrelvir/ritonavir may increase the risk of HIV-1 resistance to HIV protease inhibitors in individuals with uncontrolled or undiagnosed HIV-1.

Remdesivir (Veklury):

Not recommended in pediatric patients (greater than 28 days old) with eGFR less than 30 mL/min or in full-term neonates (at least 7 days to less than or equal to 28 days old) with serum creatinine greater than or equal to 1 mg/dL.

Molnupiravir (Lagevrio):

Not authorized for use in patients less than 18 years of age because it may affect bone and cartilage growth.
Not recommended for use in pregnant or breastfeeding individuals due to potential fetal harm.

COVID-19 Therapeutics Decision Aids

Nirmatrelvir/ritonavir (Paxlovid) information:

Molnupiravir (Lagevrio) information:

Remdesivir (Veklury) information:

How can I check drug-drug interactions with nirmatrelvir/ritonavir (Paxlovid) and other therapeutics?

Use the consultative pharmacist or COVID-19 treatments team in your facility or health system or use one of the resources below:

University of Liverpool COVID-19 drug interaction checker

Note: use generic drug names

Pfizer's Paxlovid drug checker
IDSA Management of Drug Interactions With Nirmatrelvir/Ritonavir (Paxlovid®): Resource for Clinicians (PDF)

Are available antivirals effective against new variants?

Yes.

Viruses continuously mutate as they circulate among the population, creating new variants. COVID-19 therapeutic products vary in their vulnerability to new variants depending on their mechanism of action.

The National Center Advancing Translational Sciences maintains an OpenData Portal (NIH.gov) tracking COVID-19 therapeutics activity against SARS-CoV-2 variants.

Does a patient need a positive COVID-19 test in order to be prescribed nirmatrelvir/ritonavir (Paxlovid) or molnupiravir (Lagevrio)?

Yes, for pharmacists.
The California Business and Professions Code (BPC) 4052.04 states a pharmacist may furnish COVID-19 oral therapeutics following a positive test for SARS-CoV-2. Pharmacy staff may also find additional assessment and treatment information at CDPH Resource Guide for Pharmacies. Note: Emergency Use Authorization (EUA) for the emergency use of Lagevrio (molnupiravir) does not list pharmacists as authorized prescribers.

No, for all other authorized prescribers.
On February 1, 2023, the Food and Drug Administration (FDA) revised the scope of emergency use authorizations (EUAs) for both nirmatrelvir/ritonavir (Paxlovid) and molnupiravir (Lagevrio) to no longer require positive results of direct SARS-CoV-2 viral testing before prescribing. Patients must have a current diagnosis of symptomatic COVID-19. Clinical judgement regarding symptoms and exposure may be used when testing is not available.

As of May 25, 2023, Paxlovid is approved by the FDA for adults, thus prescribing is up to clinical discretion.

For the most current prescribing guidelines, see CDC Interim Clinical Considerations for COVID-19 Treatment in Outpatients.

Are anti-SARS-CoV-2 outpatient treatments safe for pediatric, geriatric, pregnant, and other specific populations?

Pediatric:

Nirmatrelvir/ritonavir (Paxlovid): Authorized for use in children 12 years and older and weighing at least 40kg who are at risk of disease progression under the Paxlovid EUA (PDF).
Remdesivir (Veklury): Approved for use in pediatric (28 days of age and older weighing at least 3 kilograms) outpatients who are at risk of disease progression. For pediatric dosing, see Veklury prescriber information (PDF).
Molnupiravir (Lagevrio): Authorized for use in individuals 18 years and older due to its potential impact on bone and cartilage development. For more information, see molnupiravir (Lagevrio) Fact sheet for Healthcare Providers (PDF).

Geriatric:

Multiple studies have shown that treatments are safe in the elderly without increased rates of adverse effects. Whenever possible, elderly patients should be encouraged to treat COVID-19 given the high-risk of progression to severe disease based on age alone.

Pregnant and/or breastfeeding:

Nirmatrelvir/ritonavir (Paxlovid): There is insufficient data on drug-associated risk of maternal or fetal outcomes. However, observational studies of ritonavir use in pregnant individuals have not shown an increase in major birth defects.
Remdesivir (Veklury) There is insufficient data on drug-associated risk of maternal or fetal outcomes. However, observational studies of Remdesivir use in pregnant and/or breastfeeding individuals have not shown an increase in major birth defects or other adverse events.
Molnupiravir (Lagevrio): Not recommended in pregnant or breastfeeding individuals given mutagenic potential to cause fetal harm.

Special populations:

For more information on other specific populations, see CDC Special Clinical Considerations.

What should I do when a patient has known or suspected kidney or liver disease?

There is no requirement to check creatinine levels in order to prescribe nirmatrelvir/ritonavir (Paxlovid). However, the eGFR is relevant if the patient has known kidney disease. For patients with kidney or liver disease, the Paxlovid dosing recommendations are as follows:

eGFR ≥30 to 60 mJ/min: Nirmatrelvir 150 mg (one 150-mg tablet) with RTV 100 mg (one 100-mg tablet) twice daily for 5 days.
eGFR <30 mL/m in: Not recommended.
Severe Hepatic Impairment (Child-Pugh Class C): Not recommended.

For more information, see the Paxlovid Fact Sheet for Healthcare Providers (PDF).

Can pharmacists prescribe COVID-19 oral therapeutics?

The California Business and Professions Code (BPC) 4052.04 states that pharmacists may furnish COVID-19 oral therapeutics following a positive test for SARS-CoV-2. Please use the following resources for details regarding the definition of COVID-19 oral therapeutics, clinical guidelines, notification to primary care providers, documentation requirements, etc.:

BPC 4052.04 will remain in effect only until January 1, 2025, and will be repealed as of that date. Note: Emergency Use Authorization (EUA) for the emergency use of Lagevrio (molnupiravir) does not list pharmacists as authorized prescribers.

Is it permissible to have a standing order for nirmatrelvir/ritonavir (Paxlovid) prescription and to have a registered nurse (RN) conduct the assessment?

Yes, an RN can assess the patient based on a standing workflow/order. Depending on the clinic workflow, the RN can either 1) sign and enter the provider's name or 2) route the note to that provider who will then add a note that the case has been reviewed and the nirmatrelvir/ritonavir (Paxlovid) order has been approved.

Are there any medications that help prevent COVID-19 in immunocompromised patients?

In March 2024, Pemgarda (pemivibart), a monoclonal antibody, gained EUA by the FDA for pre-exposure prophylaxis (PrEP) of COVID-19 in adults and adolescents (12 years of age and older weighing at least 40 kg):

who are not currently infected with SARS-CoV-2 and who have not had a recent exposure to an individual infected with SARS-CoV-2 AND
who have moderate-to-severe immune compromise.

Pemgarda is commercially available in the U.S. through authorized specialty distributions. Healthcare providers can obtain Pemgarda by contacting their primary vendor or contacting Invivyd: 1-800-890-3385 or email medinfo@invivyd.com.

What are the best practices for long-term care facilities?

According to the CDC, residents of long-term care facilities are “at increased risk, making up less than 1% of the U.S. population but accounting for more than 35% of all COVID-19 deaths."

Best practices for long term care facilities are available below:

Additional Resources:

Treatment-Resources-for-Providers COVID-19 Treatment Resources for Healthcare Providers

COVID-19 Treatment Resources for Healthcare Providers

Overview of COVID-19 Antivirals:

Introduction:

Which outpatient treatment should I choose for my patient?

How can I check drug-drug interactions with nirmatrelvir/ritonavir (Paxlovid) and other therapeutics?

Are available antivirals effective against new variants?

Does a patient need a positive COVID-19 test in order to be prescribed nirmatrelvir/ritonavir (Paxlovid) or molnupiravir (Lagevrio)?

Are anti-SARS-CoV-2 outpatient treatments safe for pediatric, geriatric, pregnant, and other specific populations?

What should I do when a patient has known or suspected kidney or liver disease?

Can pharmacists prescribe COVID-19 oral therapeutics?

Is it permissible to have a standing order for nirmatrelvir/ritonavir (Paxlovid) prescription and to have a registered nurse (RN) conduct the assessment?

Are there any medications that help prevent COVID-19 in immunocompromised patients?

What are the best practices for long-term care facilities?

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Overview of COVID-19 Antivirals:

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