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Pharmacists: Outpatient COVID-19
Practical Insights for Pharmacists: Drug and Vaccine Considerations for Acute Outpatient COVID-19

Released: April 04, 2023

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Key Takeaways
  • COVID-19 reinfection and COVID-19 rebound are different entities and require different management strategies.
  • In most cases, drug—drug interactions with COVID-19 antivirals are manageable.

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

 

Does metformin help treat acute COVID-19?

There is no evidence to support using metformin as a treatment for acute COVID-19.

 

It has been studied because of its possible benefits related to its in vitro antiviral activity, anti-inflammatory activity, and antiviral activity. However, clinical trials using metformin as a treatment for acute COVID-19 in nonhospitalized patients has not proven a benefit.

 

The National Institutes of Health (NIH) COVID-19 Treatment Guideline panel recommends against the use of metformin for nonhospitalized patients with acute COVID-19 except in a clinical trial. If patients are receiving metformin for another indication (eg, type 2 diabetes) and develop acute COVID-19, they should continue their metformin as directed by their HCP.

 

Are corticosteroids beneficial in the treatment of nonhospitalized patients with acute COVID-19?

No, corticosteroids do not have a beneficial role in this patient population. In fact, use of dexamethasone in ambulatory patients with acute COVID-19 has been shown to worsen outcomes.

 

Similar to the question about metformin, patients who are receiving a corticosteroid for an underlying condition who develop acute COVID-19 should continue their corticosteroid as directed by their HCP.

 

Given the difference in efficacy seen in clinical trials of nirmatrelvir plus ritonavir and molnupiravir, should an HCP prescribe nirmatrelvir plus ritonavir for a patient even if drug—drug interactions exist with the patient’s other medications?

This depends on the specific drug in question, but in most cases, the answer is yes, nirmatrelvir plus ritonavir has stronger efficacy data to prevent hospitalizations and death in high-risk ambulatory patients with acute COVID-19.

 

In most cases, the drug—drug interactions between the patient’s chronic medications and a 5-day course of nirmatrelvir plus ritonavir can be managed and monitored when necessary. In cases where the drug—drug interaction could adversely affect the patient (eg, decreasing the efficacy of cancer chemotherapy), I would recommend using an alternative to nirmatrelvir plus ritonavir.

 

The NIH Treatment Guidelines list of concomitant medications show that the majority of drugs can either be safely coadministered, dose reduced, used with caution, or held during treatment, and only a small list of drugs are contraindicated for use in conjunction with nirmatrelvir plus ritonavir.

 

If a high-risk nonhospitalized patient has been treated with nirmatrelvir plus ritonavir several months earlier and now tests positive again for COVID-19, would you treat the patient again with nirmatrelvir plus ritonavir?

Yes, this new infection several months later would be considered a COVID-19 reinfection (not COVID-19 rebound) and a second course of oral antiviral therapy would be appropriate.

 

COVID-19 rebound is a recurrence of COVID-19 symptoms or a new positive test after having tested negative and typically occurs 2-8 days after the initial recovery. There is no specific recommendation for what to take for COVID-19 rebound symptoms, but this phenomenon continues to be studied and further guidance is likely forthcoming.

 

After a patient experiences an acute COVID-19 infection, how long should he or she wait before receiving a COVID-19 booster vaccine?

Although there is evidence of natural immunity after experiencing an acute COVID-19 infection, it is unknown how long it lasts. The CDC recommends delaying the next COVID-19 vaccine dose by 3 months after symptoms started or, in the case of an asymptomatic infection, when a first positive COVID-19 test was received.

 

It is important for people to receive any recommended COVID-19 vaccines after recovering from their acute COVID-19 infection to provide additional protection against a future COVID-19 infection.

 

What is the risk of blood clots with receipt of a COVID-19 vaccine?

It is important to understand that the risk of a serious blood clot, such as one that causes a stroke or myocardial infarction, is several-fold greater with a COVID-19 infection than with receipt of a COVID-19 vaccine. Thrombosis with thrombocytopenia syndrome (TTS) has been observed after vaccination with the Janssen vaccine but is extremely rare. The rate of TTS is approximately 3.8 cases per million vaccine doses administered whereas the rates of cerebral venous thrombosis and portal vein thrombosis associated with acute COVID-19 is estimated to be 42.8 per million people and 329.3 per million people, respectively.

 

Your Thoughts?

What questions do your patients ask about COVID-19 vaccination and acute COVID-19 treatment? Join the conversation by posting a comment below.