COVID-19 Drugs: What to Know

Feb. 24, 2022 — These days, when doctors prescribe a treatment for a patient who’s positive for COVID-19, their list of options is longer than ever. That’s the good news.

But the abundance of options comes with many questions. Before deciding which of those treatments is best to keep you alive and perhaps even out of the hospital, it’s crucial for your doctor to consider many things, says Daniel C. DeSimone, MD, a consultant in infectious diseases and associate professor of medicine at Mayo Clinic.

First, how sick are you?

“Are they inpatient or outpatient?” he asks. “Symptomatic or asymptomatic? And what are their underlying risk factors that could put them at high risk of progression to severe disease?”

Is the drug available in the community, or scarce? And does the latest research suggest it’s working well against the latest COVID-19 variant?

“I wish it was easier,” DeSimone says of deciding which COVID-19 treatment is best, “but also wish I had the list about 2 years ago.”

Only one treatment, remdesivir (Veklury), has the full approval of the FDA. It works by blocking reproduction of the virus. But Many other treatments have emergency use authorizations from the FDA. The FDA has the authority to authorize the use of an unapproved product to treat a life-threatening disease.

COVID-19 Drug Decision Processes

Not everyone will need treatment, DeSimone says. Suppose a 20-year-old patient, healthy and vaccinated, has no other conditions and tests positive but has no symptoms or mild ones.

“More often than not, we would say hold off,” he says. “The patients we need to focus on [for treatment] are older age, with multiple risk factors for progression to severe disease, are immunocompromised, and have coexisting medical conditions.”

Guidelines from the Infectious Diseases Society of America, the National Institutes of Health, and other organizations recommend when treatments should be used, which ones, and in whom. The guidelines are updated as research emerges or as the FDA grants new emergency use authorizations or limits others.

Meanwhile, the FDA revised its emergency use authorization for two other monoclonal antibodies, limiting their use to COVID-19 infections not caused by the Omicron variant, saying they are highly unlikely to be effective for Omicron infections. These are REGEN-COV and bamlanivimab/etesevimab. The FDA said that other treatments, including Paxlovid, sotrovimab, and remdesivir, are expected to work against Omicron.

One other plus, according to Gandhi, is that “monoclonal antibodies in general are thought to be safe in pregnancy.” Monoclonal antibodies are given by IV.

A new option for outpatients is the antiviral drug remdesivir (Veklury), which already was authorized for hospitalized patients. It was authorized in late January by the FDA for outpatient use. Researchers found that patients getting the drug within 7 days of symptoms starting were 87% less likely to need hospitalization or to die.

Drug Therapies: Inpatients

For patients sick enough with COVID-19 to be hospitalized, DeSimone says, a 5-day course of IV remdesivir is often given.

“If you are requiring oxygen, that ups the stakes a little bit,” he says.

Last Resort List, Special Cases

Convalescent plasma, which first showed promise, is used less now. It involves using blood from people who have recovered from COVID-19 to help those infected recover. But the Infectious Diseases Society of America says it shouldn’t be used on hospitalized patients, and it also shouldn’t be used on non-hospitalized patients unless they are in a clinical trial.

“Early on, it showed promise,” DeSimone says. Now, “the thought is, now that we have these other therapies, it may not be adding much.” But in a small group, such as those who can’t make antibodies to a vaccine or infection, it can help, he says.

Another option for a small group of people is what’s known as “pre-exposure” treatment. The treatment, EvuSheld, combines two monoclonal antibodies (tixagevimab and cilgavimab). It is given to high-risk people before exposure, every 6 months. “This gives hope for those severely immunocompromised,” DeSimone says, the people who “have nothing to protect themselves and have a hard time fighting it off.”