COVID Treatment/Vaccine | MGH Covid Response

Covid Treatment

Paxlovid

COVID Treatment/Vaccine:

Last Updated March 2023

COVID-19 Therapeutics Guide for MGH Emergency Physicians

Think about COVID when patients present with symptoms (particularly less than 5 days for window of therapeutics)
Perform COVID Test and Creatinine/GFR on those who are potentially eligible for anti-virals .
1. Multiplex (Fluvid) tests have stopped. COVID-19 PCR test alone available
2. PCR test turnaround about 24-48 hrs.
3. Give handout on accessing results and they can then seek therapeutics
4. We might have LIMITED ID now tests for rare need for immediate results
You can treat based on a reported RAT + or close exposure + symptoms compatible with COVID.
Remember community pharmacies can do a treatment eligibility assessment and prescribe Paxlovid without a prescription.
If contraindications to use of Paxlovid or concerns about complex drug-drug interactions the ID team can support questions (eg eligible for Remdesivir)

ID will follow up and call all +ve Covid results until at least June 30, 2023.

Decision to Prescribe Paxlovid by ED Physician:

Full UofT/Waterloo Paxlovid Guide - Dec 2022 (14 pages)

Determine the Risk Level of Disease Progression

Potentially Eligible:

60 years or older
18 years and older, and immunocompromised*
18 – 59 years of age and are at a higher risk of severe COVID-19, this includes:
1. with clinical risk factors as per below risk** guidelines
2. Unvaccinated
3. Vaccinated but last COVID-19 vaccine dose was over 6 months ago

Those MOST LIKELY to benefit are those who are:

Unvaccinated or undervaccinated (<2 dose of mRNA vaccine)
Immunocompromised*
Over 60 with greater than 2 risk factors** with last vaccine greater than 6 months ago.

*Immunocompromised (immunosuppressed):

Having active treatment for solid tumor and hematologic malignancies
Received a solid organ transplant and are taking immunosuppressive therapy
Taking transplant-related immunosuppressive drugs
Received chimeric antigen receptor (CAR)-T- cell or hematopoietic stem cell transplant within 2 years of transplantation
Have a moderate or severe primary immunodeficiency (e.g., DiGeroge syndrome, Wiskott- Aldrich syndrome, common variable immunodeficiency, Good's syndrome, hyperIgE syndrome,advanced or untreated HIV infection)
Active treatment with high- dose corticosteroids – eg prednisone >=20mg od for >=2 week
Taking alkylating agents or antimetabolites (e.g .Cyclophosphamide, methotrexate, hydroxyurea)
Taking cancer chemotherapeutic agents classified as severely immunosuppressive
Taking tumor- necrosis factor (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory (e.g Humira, Remicade)
Other- Advanced/untreated HIV

**Risk factors for disease severity

Obesity (BMI >30)
Diabetes
Cerebral palsy
Heart disease, hypertension, congestive heart failure
Intellectual disability/cognitive impairment
Sickle cell disease
Chronic respiratory disease, including cystic fibrosis
Moderate or severe kidney disease (egfr <60ml/min)
Moderate or severe liver disease (e.g. Child Pugh Clas B or C cirrhosis)
Any other disease risk factors outside of this list deemed by the physician are valid and must be clearly documented at time of administration
Indigenous, racialized community

2. If patient potentially eligible, then evaluate for drug-drug interactions:

Many important drug-drug interactions to consider. Review Medication Interactions

Examples of common drug interactions and suggestions to manage for nirmatrelvir/ritonavir:

amlodipine- dose reduction by half
atorvastatin- hold dose until 2 days after completion of nirmatrelvir-ritonavir
clonazepam- hold dose until 2 days after completion
Oxycodone- dose reduction by 66%/change to hydromorphone

Pt on DOAC (rivaroxaban, apixaban,dabigatran, edoxaban): See Science Table Recommendations(easy to use visual algorithm)

Liverpool COVID 19 Drug interaction checking site (primary source for interaction checking)

UofT/Waterloo Paxlovid Guide full list of drug interactions - Dec 2022 (pages 5-14)

Quick List of drugs with significant interactions to Paxlovid- 1 page

Full List of drugs with significant interactions to Paxlovid- from monograph - 15 pages

3. If prescribing Paxlovid, check to see if needs to be renally adjusted dosing

Renal Dosing Dose reduction:

eGFR 30-59mL/min

Nirmatrelvir 150mg and ritonavir 100mg taken together bid x 5 day

eGFR < 30mL/min

Day 1 Nirmatrelvir 300mg and ritonavir 100mg
Day 2-5 Nirmatrelvir 150mg and ritonavir 100mg od

Full Chart on Renal Dosing for Paxlovid (including Dialysis): use Proposed Dosing Guidance

4. Counsel regarding adverse events

Side effects – most common side effect Paxlovid - GI: dysgeusia, diarrhea, vomiting, headache

5. Either write script or send to pharmacy

Pharmacies Near MGH Prescribing and Dispensing Antiviral Treatment:

Toronto East PharmasaveMedimost Pharmacy 2883 Danforth Ave
Main Drug Mart 2558 Danforth Ave
Thorncliffe Pharmacy 65 Overlea Blvd, Unit 106
Shoppers World Danforth 3003 Danforth Ave

Ask if you need any help! The ID Consult service is available as a resource.

Decision to Prescribe Remdesivir (intravenous antiviral) by ED Physician:

Indication: for individuals with mild to moderate COVID-19

symptoms who have a positive test for COVID-19, are at risk for severe outcomes and are able to receive treatment within seven days from the start of symptoms who can’t get Paxlovid

Remdesivir would be considered for the following: (consult ID/Medicine for admission- can't be given as out-patient)

1. Individuals taking essential medications (e.g. transplant rejection drugs) that cannot be co-administered with Paxlovid due to drug interactions, such as:

☐ Tacrolimus

☐ Cyclosporine

☐ Sirolimus

☐ Everolimus

☐ Rapamycin or other complex drug interaction based on Liverpool Drug Checker

2. AND have one of the following:

☐ A) Immunocompromised* or immunosuppressed individual

☐ B) Unvaccinated individuals (0 doses of any COVID-19 vaccine)

☐ Age equal or greater than 70 years

☐ Age equal or greater than 40 with 1 or more risk factors**

☐ Age equal or greater than 12 with 3 or more risk factors**

☐ Pregnant

☐ C) Individuals who have had 1 or 2 doses of a COVID-19 vaccine

☐ Age equal or greater than 70 with 1 or more risk factors**

☐ Age equal or greater than 20 with 3 or more risk factors**

Last Ontario Science Table Therapeutic Clinical Practice Guideline:

Simple to follow but extensive chart of Therapeutic options for all levels of COVID patients with level of evidence. Many options still not very available for our ED dept. due to supply issues. Not standard of care.

Ontario Science Table latest treatment chart CPG overview 2 pages (April 1/2022)

Monoclonal antibody (MAB) therapy

MGH ED nursing oriented review of MAB use at MGH ED

MGH ED COVID MAB orderset

MAB (Casirivimab and Imdevimab) Monograph - 26 pages (Jun 9, 2021)

Ontario Science Table MAB evidence review - 24 pages ( Jan 21, 2022)