INFORMATION FOR MEDICAL PROVIDERS


Information for Medical Providers

Who should receive outpatient therapy for COVID-19?

Individuals should be considered for outpatient therapy for COVID-19 if they meet the criteria below:

  • Are symptomatic with mild-moderate COVID-19 illness AND
  • Have a positive SARS-CoV-2 viral test result, AND
  • Are at high risk for progressing to severe COVID-19 and/or hospitalization

The Centers for Disease Control and Prevention (CDC) provides a list of risk factors for severe COVID-19. Some of the most important risk factors include (listed alphabetically): age (risk increases with each decade after age 50) , cancer, cardiovascular disease, chronic kidney disease, chronic lung disease, diabetes, immunocompromising conditions or receipt of immunosuppressive medications, obesity (body mass index ≥30), pregnancy, and sickle cell disease.

For a complete list of risk factors for disease progression, including information on the relative risk of severe disease, see the CDC webpage Underlying Medical Conditions Associated with High Risk for Severe COVID-19. Of note, the likelihood of developing severe COVID-19 increases when a person has multiple comorbidities.

How to prioritize patients for treatment if not enough medication is available for all ill persons?

Treatment should be prioritized in unvaccinated or incompletely vaccinated individuals and vaccinated individuals who are not expected to mount an adequate immune response (e.g., individuals who are immunocompromised or on immunosuppressive medications or individuals aged ≥65 years).

If supply remains limited after applying the above criteria, CDPH recommends additionally prioritizing high-risk patients with moderate illness as defined above in the following order:

  1.  Immunocompromised or on immunosuppressive medications
  2.  Incompletely vaccinated AND > 65 years of age with risk factors for severe disease
  3.  > 65 years of age with risk factors for severe disease

Molnupiravir is only authorized for use if alternative COVID-19 treatment options authorized by FDA are not accessible or are not clinically appropriate. In cases where Paxlovid or sotrovimab are not available for treatment and the patient is at high risk, consideration should be given to Remdesivir IV daily for three days or Molnupiravir can be considered.

NIH Prioritization

Tier Risk Group
1
  • Immunocompromised individuals not expected to mount an adequate immune response to COVID-19 vaccination or SARS-CoV-2 infection due to their underlying conditions, regardless of vaccine status (see Immunocompromising Conditions below); or
  • Unvaccinated individuals at the highest risk of severe disease (anyone aged ≥75 years or anyone aged ≥65 years with additional risk factors).
2
  • Unvaccinated individuals at risk of severe disease not included in Tier 1 (anyone aged ≥65 years or anyone aged <65 years with clinical risk factors)
3
  • Vaccinated individuals at risk of severe disease (anyone aged ≥65 years or anyone aged <65 with clinical risk factors)

Note: Vaccinated individuals who have not received a COVID-19 vaccine booster dose are likely at higher risk for severe disease; patients in this situation within this tier should be prioritized for treatment.

4
  • Vaccinated individuals at high risk of severe disease (anyone aged ≥75 years or anyone aged ≥65 years with clinical risk factors)

Note: Vaccinated individuals who have not received a COVID-19 vaccine booster dose are likely at higher risk for severe disease; patients in this situation within this tier should be prioritized for treatment.

For more information on NIH Prioritization Statement: https://www.covid19treatmentguidelines.nih.gov/therapies/statement-on-patient-prioritization-for-outpatient-therapies/

Decision Guide

For more information on guiding outpatient treatment decisions: COVID-19 Therapeutics Decision Aid (hhs.gov)

Overview of Monoclonal Antibody Treatments

Side by Side Therapeutic Overview

GSK’s Sotrovimab - Not Active Against BA.2
Type: Monoclonal Antibody
Minimum Order Requirement: 6 Doses of Sotrovimab
Administered: Intravenous – Treatment for Mild to Moderately ill Outpatients and Post Exposure Prophylaxis
Target Population: Exposed individuals that are at high risk for progression to severe COVID-19 symptoms. Effective against the omicron variant.

Lilly’s Bebtelovimab
Type: Monoclonal Antibody
Minimum Order Requirement: 5 doses of Bebtelovimab
Administered: Intravenous injection - Treatment for Mild to Moderately ill Outpatients and Post Exposure Prophylaxis
Target Population: Exposed individuals that are at high risk for progression to severe COVID-19 symptoms. Effective against the omicron variant.

Lilly’s Bamlanivimab plus Etesevimab (Bam- Ete) - Not Active Against Omicron
Type: Monoclonal Antibody
Minimum Order Requirements: 10 courses. One Bamlanivimab Treatment to 2 Etesevimab Treatments.
Administered: Intravenous – Treatment for Mild to Moderately ill Outpatients and Post Exposure Prophylaxis
Target Population: Exposed Individuals with access to infusion center or ER or residing in custodial care facilities with high level of care. Must be at high risk for progression to severe COVID-19 symptoms.

Regeneron Casirvimab plus Imdevimab (Regen-COV) - Not Active Against Omicron
Type: Monoclonal Antibody
Minimum Order Requirement: 12 Doses Regen-Cov
Administered: Intravenous – Treatment for Mild to Moderately ill Outpatients and Post Exposure Prophylaxis
Target Population: Exposed Individuals with access to infusion center or ER or residing in custodial care facilities with high level of care. Must be at high risk for progression to severe COVID-19 symptoms.

AstraZeneca’s Evusheld (AZD7442)
Type: Monoclonal Antibody and Pre-Exposure Prophylaxis
Minimum Order Requirements: 24 Courses per Case
Target Population: For individuals who have moderate to severe immunocompromised states and are not expected to mount an adequate response to vaccination or individuals for whom COVID-19 vaccination is contraindicated due to severe adverse reaction to vaccine. Must be at high risk for progression to severe COVID-19 symptoms.

 

Overview of Oral Antiviral Medication 

Oral Antiviral Medication is not authorized for treatment in patients requiring hospitalization due to severe or critical COVID-19.

 

Pfizer’s Paxlovid
Type: 
Oral antiviral
Minimum Order Requirement: 20 Courses
Target Population: COVID-19 patients 12 years of age and older with mild-moderate symptoms and are at high risk of developing severe COVID-19, including hospitalization or death.

Molnupiravir
Type: Oral Antiviral
Minimum Order Requirement: 20 Courses
Target Population: Adult COVID-19 patients with mild-moderate symptoms and are at high risk of developing severe COVID-19, including hospitalization or death. Also used for those who do not fall under the FDA authorization of alternative COVID-19 treatment options.

Providers should carefully review the fact sheet for healthcare providers (available both for Paxlovid and Molnupiravir) before prescribing either medication to ensure that the patient’s condition warrants treatment, that there are no drug interactions, and that there are no contraindications to therapy.

 

For additional resources please visit: https://rivcoph.org/coronavirus/Treatment/resources