Since we published this resource in April, many new resources have become available. Please share these resources with your colleagues. They include:
- COVID-19 Therapeutics Locator shows locations for monoclonal antibodies Evusheld and bebtelovimab.
- CDC Health Advisory Network update emphasizing that steroids are NOT indicated for patients with mild to moderate COVID-19 not requiring supplemental oxygen. Antibiotics should not be prescribed for COVID-19 patients without a specific bacterial indication.
- A handy clinician Paxlovid checklist to help screen for eligibility and drug interactions
- A new Paxlovid provider Fact Sheet.
- A new Outpatient COVID-19 Therapeutic Clinical Implementation Guide
- A new CDC patient guide to COVID-19 Therapeutics
- OHA COVID Therapeutic resource
May 9, 2022 CDC verbally commented on the observed phenomenon of recurring COVID symptoms and viral loads after a course of Paxlovid. They, FDA and others are following the events and evaluating the situation. CDC does not recommend a second course of Paxlovid for relapsing symptoms, though Pfizer’s messaging does not discourage a second course. Pfizer is reporting 1 in 3000 courses of Paxlovid treatment are associated with recurring symptoms, while 0.2% of patients in their trial had rebounding viral loads after therapy. There was discussion of early treatment blunting the immune response or possibly natural history of the infection. More to come on this.
We now have a QR code for this and all our clinician alerts. You can also find those at multco.us/health-officer/clinician-alerts.
Request to Clinicians
Outpatient SARS-CoV-2 anti-viral and monoclonal therapies can be life saving for high-risk individuals. They require initiation early in the disease course to be effective. High priority for the antiviral therapy should be given to populations disproportionately affected by the COVID pandemic and those at highest risk for severe outcomes. There ARE courses of treatment available locally. Use of these available medications now may lead to increased supplies and easier patient access in the future.
We are asking clinicians to:
- Consider how to identify high risk patients eligible for treatment early in their COVID-19 disease course. Communicating with your highest risk patients before they contract COVID may encourage them to test early and reach out to you for early treatment.
- Create pathways to expeditiously prescribe treatment and facilitate access to available medications.
- See below for more information about therapeutics access, treatment eligibility and prescribing information for each drug.
Many primary care / medical homes have systems in place to provide COVID therapeutics. See below for information about some of these resources. If you are interested in signing up to order COVID-19 antiviral or monoclonal antibody medications, email the OHA COVID Therapeutics Team at OHA.firstname.lastname@example.org
Treatment is indicated for outpatients with a positive SARS-CoV-2 PCR or antigen test, in the first 5-7 days of symptoms, who have mild to moderate COVID-19 and are at high risk for severe disease. If supplies are limited, use the NIH tier system to further prioritize by vaccination status and age. Early treatment can prevent progression to more severe disease and may prevent hospitalization and death. Early data suggests the same effectiveness for the BA.2 Omicron subvariant.
Drug supply is free from the federal government. Individual sites may charge fees for testing, clinical consultation or drug administration fees. Uninsured patients may be charged and funding is being sought to address these gaps.
- Retail pharmacies / clinics / hospital systems - See treatment locator, enter the zipcode & click on “Locations to fill a prescription.” Patients or providers should call sites to make sure that they have supply on hand before going in-person. In addition to both oral medications being available at some local pharmacies, many retail pharmacies have received supplies of antiviral therapy.
- Some FQHC and Tribal clinics have received HRSA supplies of COVID therapeutics. These sites may have access or may be developing systems to rapidly enroll new patients, but otherwise will not have therapeutic courses for the general public. See below for regional information.
- Individual clinics and providers: OHA, the Oregon Medical Board and Oregon Board of Pharmacy have collaborated to streamline the process for providers and clinics with a dispensing license to obtain and dispense antiviral therapy. It is not too late to sign up for a dispensing license: See Application for Registration as a Dispensing Physician or Physician Assistantomb.oregon.gov/dispensing for information about steps in the dispensing process that can be delegated. Here is a link to the application.
- Test to Treat is the federal program that provides oral antiviral therapy to sites that can provide testing, same-day appointments, clinical consultation, a pharmacy partner, and access for uninsured. You or your patient can use the Test to Treat program and locator or call center at 1-800-232-0233. There are currently fewer than 10 sites within 30 miles of the metro area but more sites are being added.
- Health systems, FQHCs and some other clinics have obtained and are dispensing monoclonal antibodies for COVID treatment and Evusheld for pre-exposure prophylaxis for high risk individuals.
If you are interested in signing up to order COVID-19 antiviral or monoclonal antibody medications, send an email to the OHA COVID Therapeutics Team at OHA.email@example.com. After OHA receives your request, they will send an email providing a link to the OHA COVID-19 Therapeutics Registration Survey. Once that is completed and you have received approval, they will get you set up to begin ordering.
COVID-19 therapeutics resources
Regional Medical Home networks
Multnomah County Health Centers have some COVID-19 therapeutics for their panel patients. County residents without a medical home can rapidly access care: see this handout for new patients. They should call as early as possible in their course of illness and say that they currently have COVID-19.
Virginia Garcia Memorial Health Center has opened a new facility at 232 SE 7th Ave., Hillsboro. It has COVID-19 services including therapeutics available to all Washington County residents and Virginia Garcia patients. No insurance required. Appointments or by calling 503-601-7400 are required and can be made on-line through links from the COVID services page or by calling 503-601-7400.
Regional health systems providers and partners
(Kaiser) Northwest Permanente providers
Can connect patients with COVID-19 to the SCOT team (Specialized COVID-19 Outpatient Treatment) using an Epic referral order. This core team manages COVID-19 illness treatment for those with high medical risk who are unable to be treated safely with usual medication (example: Paxlovid). Paxlovid prescribing is now expanded to ALL clinicians of KPNW.
Can prescribe antivirals after competing education or send patients with COVID-19 to the PMG Virtual Sick Clinic (VSC) (971.326.8718 or Epic “mAb” Pool). Patients wanting access to Evusheld should be referred to VSC or the provider/clinic managing their immune compromising medication or condition.
Can send prescriptions for Paxlovid for qualified high risk patients to outpatient OHSU pharmacies (PPV and CHH2 being the most popular) or many retail pharmacies. Dispensing pharmacists will collaborate as needed. Supplies are monitored and prioritized within the NIH tier system. Other therapeutics require more complicated systems. See OHSU intranet.
Can send prescriptions for Paxlovid or molnupiravir for qualified high risk patients to outpatient Legacy apothecaries or to retail pharmacies. Legacy Medical Group PCPs can also refer to the clinical pharmacy team for oral treatments (and IV bebtelovimab in WA state only) through an Epic referral (REF COVID TREATMENT).
Current COVID-19 therapeutics
All information subject to change, check FDA fact sheets for the most up to date prescribing information
As of April 1, 2022, Sotrovimab is no longer in use in Oregon (or any US region) due to lack of effectiveness against BA.2 (our predominant variant).
Ritonavir-boosted nirmatrelvir (Paxlovid)
- FDA EUA authorized protease inhibitor for > 12 yrs > 40 kg
- Must be initiated within 5 days of symptom onset
- FDA provider fact sheet for Paxlovid - updated 4/14/22
- Reduced the risk of hospitalization or death by 88% compared to placebo in high risk non-hospitalized adults with laboratory-confirmed SARS-CoV-2 infection
- Many drug interactions. Use the on-line tool to screen for contraindications to Paxlovid use.
- Dosing: Tablets are supplied as: nirmatrelvir 150 mg & ritonavir 100 mg.
- Patients > 12 yrs and normal renal function take nirmatrelvir 300 mg (2 tabs) & ritonavir 100 mg (1 tab) all together twice daily with or without food.
- 4/14/22 A second dose pack presentation was authorized for patients with moderate renal impairment. For patients with eGFR ≥30 to <60 mL/min: request Nirmatrelvir 150 mg (1 tab) / RTV 100 mg PO (1 tab) twice daily
- Dose adjustments (ask patients for risk for renal or hepatic impairment) – all courses are twice daily for 5 days
- eGFR ≥60 mL/min: Nirmatrelvir 300 mg / RTV 100 mg PO
- eGFR ≥30 to <60 mL/min: Nirmatrelvir 150 mg/ RTV 100 mg PO
- eGFR <30 mL/min: Not recommended
- Severe Hepatic Impairment (Child-Pugh Class C): Not recommended
- Potential side effects include allergy, hepatotoxicity, altered sense of taste, diarrhea, high blood pressure, muscle aches and resistance to HIV medicine if untreated HIV infection.
- FDA approved nucleoside analog > 12 yrs & > 40 kg (EUA authorized for < 12 yrs and > 3.5 kg)
- Must be initiated within 7 days of symptom onset
- NIH Remdesivir Treatment Guidelines
- 3 consecutive days of intravenous (IV) remdesivir resulted in an 87% relative reduction in the risk of hospitalization or death compared to placebo in high risk outpatients with laboratory confirmed COVID-19.
- Dose: Adult dose 200 mg on Day 1, followed by once-daily maintenance doses of 100 mg from Day 2 administered only via intravenous infusion over 30 to 120 minutes. Not recommended in individuals with eGFR <30 mL/min.
- Potential side effects include allergy, hepatotoxicity, nausea & constipation.
- FDA EUA authorized nucleoside analogue for adults > 18 yrs
- Not recommended in pregnancy/lactation
- Considered third line treatment due to modest efficacy and potential risks
- Must be initiated within 5 days of symptom onset
- FDA fact sheet for Molnupiravir
- 30% reduction in hospitalization or death; 90% reduction in death
- Dose 800 mg (four 200 mg capsules) taken orally every 12 hours for 5 days, with or without food. No dose adjustment is required for renal or hepatic impairment.
- Potential side effects include allergies, diarrhea, nausea, and dizziness.
- EUA authorized monoclonal antibody for >12 years and > 40 kg as an alternative COVID-19 treatment option when other approved or authorized treatment is not accessible or clinically appropriate.
- Must be initiated within 7 days of symptom onset
- FDA EUA Fact Sheet
- Dose 175 mg given as a single intravenous injection over at least 30 seconds.
- Limited clinical data
- Potential side effects include allergy, infusion related reactions, itching and rash.
Thank you for your partnership
Christina Baumann, MD, MPH, Health Officer, Washington County
Teresa Everson, MD, MPH, Deputy Health Officer, Multnomah County
Ann M Loeffler, MD, Deputy Health Officer, Multnomah County
Sarah Present, MD, MPH, Health Officer, Clackamas County
Jennifer Vines, MD, MPH, Health Officer, Multnomah County