Covid-19 Medications in Ambulatory Care

There has been important drug treatment recommendations for patients in primary ambulatory care that has been classified as ‘Non-severe’.

Furthermore, there has been reiteration of treatment as having no benefits and even harmful effects.

This brief review for primary care doctors summarise recommendations form:

WHO, BMJ Living guidelines, NICE-UK and CDC-USA as at 2022 August

(In addition hope you have seen the 2022 August MoH Sri Lanka criteria for primary care management of Covid patients- see at the end of this document )


Oral antivirals

Nirmatrelvir-ritonavir (Paxlovid) and Molnupiravir (Lageviro)

Recommended Antivirals for patients that

  • do not need supplemental oxygen for COVID-19 and
  • are within 5 days of symptom onset, and
  • are thought to be at high risk of progression to severe COVID-19

Non-severe covid-19 with highest admission risk – Strong recommendation

Non-severe covid-19, with low admission risk – Weak recommendation

(recommendation from WHO, BMJ, NICE, CDC)

Evidence from RCTs

The EPIC-HR trial demonstrated that starting ritonavir-boosted nirmatrelvir treatment in nonhospitalized adults with mild to moderate COVID-19 within 5 days of symptom onset reduced the risk of hospitalization or death through Day 28 by 89% compared to placebo.3,5  LINK

In the MOVe-OUT trial, molnupiravir reduced the rate of hospitalization or death by 30% compared to placebo.4  LINK

Molnupiravir was approved by the NMRC in 2021 October for use in Sri Lanka.

(Note: Searching the web it is seen that a five days course cost is approx. US$ 500 – 700 in the U.S. and in India Molnupiravir 5 day treatment will cost approx. Indian Rupees 2000)


Systemic Steroids

Not Recommended – For mild to moderate patients who are not on inhaled oxygen (WHO, BMJ)

Reason – Corticosteroids may increase the risk of 28-day mortality in patients with non-severe covid-1(One RCT with 1300 patients) CDC

The Panel recommends against the use of dexamethasone or other systemic glucocorticoids to treat outpatients with mild to moderate COVID-19 who do not require hospitalization or supplemental oxygen (AIIb). However, patients who are receiving dexamethasone or another corticosteroid for other indications should continue therapy for their underlying conditions as directed by their health care providers (AIII).

In the RECOVERY trial, the use of dexamethasone had no effect on mortality among hospitalized patients with COVID-19 who did not require supplemental oxygen. Large observational study of patients at Veterans Affairs hospitals reported no survival benefit for dexamethasone among patients with COVID-19 who did not require supplemental oxygen. Instead, these patients had an increased risk of 90-day mortality

Steroids – Benefits and harms – WHO

The panel made its recommendation on the basis of low certainty evidence suggesting a potential increase of 3.9% in 28-day mortality among patients with COVID-19 who are not severely ill. The certainty of the evidence for this specific subgroup was downgraded due to serious imprecision (i.e. the evidence does not allow to rule out a mortality reduction) and risk of bias due to lack of blinding. In making a conditional recommendation against the indiscriminate use of systemic corticosteroids, the panel inferred that most fully informed individuals with non-severe illness would not want to receive systemic corticosteroids, but many could want to consider this intervention through shared decision-making with their treating physician [161][6]. 

Strong recommendation for using Systemic Steroids for Severe or Critical Covid-19 Patients – WHO, BMJ

Oral Budesonide inhaler

People already on budesonide for conditions other than COVID-19 should continue treatment if they test positive for COVID-19.

Only use budesonide to treat COVID-19 as part of a clinical trial.

Evidence – Inhaled budesonide, can shorten the time it takes for people not admitted to hospital to recover from covid-19 by three days, a trial in people over 50 at greater risk of covid-19 and people aged over 65 has found.



Ivermectin

Not Recommend to use ivermectin, except in the context of a clinical trial.

A few new, relatively small trials were published since 2021. One key trial has since been retracted given concerns about research fraud. WHO, NICE, CDC


Vitamins

Vitamin D

Do not use vitamin D to treat COVID-19 except as part of a clinical trial.  – NICE 2022 July

Vit C, Zn

Insufficient data for https://www.covid19treatmentguidelines.nih.gov/therapies/supplements/

Antibiotics

Not Recommend

Azythromycin, Doxycycline

Fluvoxamine

Not Recommend to use fluvoxamine, except in the context of a clinical trial (recommended only in research settings) – WHO

Colchicine

Not Recommend to treatment with colchicine (strong recommendation against). – WHO


Update on assessment and management of adult Covid-19 patients in the OPD/ Primary care settings – MoH – 09-08-2022

COVID-OPD-23-2

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