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Insights for Pharmacists: Outpatient Treatment
Practical Insights for Pharmacists: FAQs on Treatment of Acute Outpatient COVID-19

Released: October 21, 2022

Expiration: October 20, 2023

Renslow Sherer
Renslow Sherer, MD
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Key Takeaways

  • Use of oral and IV antiviral agents in the outpatient setting requires risk stratification, determination of symptom duration, and consideration of patient-specific factors prior to prescribing
  • Treatments in the order of preference are nirmatrelvir plus ritonavir and remdesivir, and alternative treatments in selected patients are bebtelovimab and molnupiravir

In this commentary, Renslow Sherer, MD, addresses the most important questions asked by healthcare professionals in a series of recent webinars on principles of outpatient COVID-19 management.

How do you respond to a symptomatic patient who tests positive for SARS-CoV-2 and would like to be prescribed an antiviral but is at low risk for progression to severe disease from COVID-19?
Patients who are not at high risk of progressing to severe disease from their COVID-19 are not indicated for treatment with an IV or oral antiviral agent. There is no evidence from clinical trial data that low-risk patients benefit from use of IV or oral antivirals.

Also, there is a limited supply of these agents both within the United States and globally, and priority should be placed on reserving COVID-19 antivirals for the patients who need them most. The National Institutes of Health have a prioritization table for this reason.

If your patient with mild renal dysfunction has fluctuating estimated glomerular filtration (eGFR) rates with a most recent value >60 mL/min, can the patient receive full-dose nirmatrelvir plus ritonavir for COVID-19 treatment?
For patients with an eGFR ≥30 to <60 mL/min, nirmatrelvir plus ritonavir has renal dosing recommendations due to increased systemic exposure to nirmatrelvir.

Patients with an eGFR >60 mL/min can safely receive full-dose nirmatrelvir plus ritonavir. Because it is only a 5-day treatment course, it would be safe to use the higher dose in a patient with mild renal dysfunction who had a recent eGFR value >60 mL/min.

Is remdesivir used in the hospital setting only?
Remdesivir is an IV infusion that is indicated both for certain hospitalized patients with COVID-19 and for high-risk ambulatory patients with COVID-19.

When prescribed for ambulatory patients with mild to moderate COVID-19, it is administered as a 3-day IV infusion, and this is often done through an infusion center within a health system. However, this can be administered in the home by a home infusion company, if that is something that can be arranged within the remdesivir treatment window. Remember that remdesivir is indicated for outpatient treatment of COVID-19 if started within 7 days of symptom onset.

What are the contraceptive recommendations for women of reproductive potential for whom molnupiravir is prescribed?
The issue of contraception applies to both men and women of reproductive potential who are being prescribed molnupiravir for their acute COVID-19 infection.

The Emergency Use Authorization for molnupiravir advises assessment of pregnancy in women of childbearing potential prior to prescribing. Women who receive molnupiravir should use a reliable method of contraception during the 5-day treatment course and for 4 days after the last dose of molnupiravir.

Men who are sexually active with partners of childbearing potential should use a reliable method of contraception during the 5-day treatment course and for 3 months after the last dose of molnupiravir.

Your Thoughts?
How often do you prescribe antiviral agents for your ambulatory patients with COVID-19? Join the conversation by posting a comment below.