360 View of COVID Drugs
Coronavirus affects a range of ages differently with treatment recommendations based on health status and severity. While SARS-CoV was discovered as a novel virus without standard treatment guidelines, the CDC has utilized the latest research data and provided guidance to healthcare providers managing patients with COVID. It is important to note that these recommendations are mainly focused on adults and are typically based on the individual’s hospitalization status. There’s little data on children, as they typically experience mild COVID symptoms.
Why Should Payers Care About This?
COVID-19 has presented unique circumstance transforming the nature of many jobs from low to high risk. This risk increase is directly caused by the potential for virus exposure by workers. According to the National Conference of State Legislators, 28 states and Puerto Rico have extended workers’ compensation coverage to include COVID-19 as a work-related illness. Eleven, states have enacted legislation creating a presumption of coverage for various types of workers such as first responders, healthcare workers and more. Under these conditions, it is important for payers to understand the various therapies available in the market, their cost, and how to effectively manage them. This article is the first step by Prodigy to provide information to its clients to help them understand this landscape.
To help our clients prepare, Prodigy has created a comprehensive COVID Drug Management Program that includes clinical management, cost controls, patient, and peer intervention. Prodigy’s first objective is to ensure that our clients can provide a complaint and cost-effective pharmacy program for their employees. To learn more, contact our PharmDs pharmd@prodigyrx.com.
Highlight of Commonly Used Therapy
Below, we have highlighted commonly used courses of therapy for COVID-19 including current recommendations by the CDC and the NIH Treatment Guideline Panel when applicable. The list is not exhaustive with several drug products not included because they are still investigational and/or are not commonly used. Prescribers look at a variety of factors before selecting a drug product based on the clinical needs of the patient. Nothing in this article or this entire site, regardless of the published date, should ever be used as a substitute for direct medical advice from a qualified clinician.
Traditional Drugs – treat general health and chronic conditions such as hypertension, cholesterol, cold, etc. Below is a list of traditional drugs used to treat COVID-19.
Oxygen is used when patients have difficulty breathing and may advance to needing mechanical ventilators for respiratory support.
Corticosteroids, like Dexamethasone, are used to open the airways and help patients breathe better. These drugs are used when supplemental oxygen is in place and act to reduces potential inflammation and increases flow of oxygen.
Fluvoxamine is an antidepressant taken orally at home. According to a large study published in the Lancet Global Health in October 2021, it significantly reduced the risk of hospitalization in some COVID-19 patients who were unvaccinated, with serious underlying health problems and at risk of severe illness. NIH Treatment Guidelines Panel does not recommend for or against the use of fluvoxamine for the treatment of COVID-19.
Hydroxychloroquine and chloroquine are a commonly used antimalarial drug that interfere with the pathway that takes the virus into the body and blocks its receptors. While this medication has cardiovascular and gastrointestinal side effects, some studies show that hydroxychloroquine +/- azithromycin was successful treating both hospitalized and non-hospitalized COVID patients. However, the CDC and the NIH Treatment Guidelines Panel recommends against the use of chloroquine or hydroxychloroquine and/or azithromycin for the treatment of COVID-19 in hospitalized patients and in non-hospitalized patients.
Ivermectin is an antiparasitic drug that has been has the capability of repleting respiratory viruses like SAR-COV2 from docking on human cell membranes. Due to its additional anti-inflammatory abilities, Ivermectin has been a commonly prescribed medication in the outpatients setting. The use of Ivermectin has sparked controversy among practitioners due to apparent lack of evidence. It is important to note that the treatment guidelines from the Infectious Diseases Society of America (IDSA), CDC and NIH recommend against the use of Ivermectin due to lack of evidence from adequately powered, well-designed, and well-conducted clinical trials.
Specialty Drugs treat complex and rare diseases such as cancer, multiple sclerosis and hemophilia. These drugs are sometimes protein-based and quite expensive. Specialty drugs used to treat coronavirus can be broken into two groups: antivirals and monoclonal antibodies.
Antiviral Drugs help the body prevent or treat infections by certain viruses, like coronavirus.
Veklury (Remdesivir) is administered intravenously to prevent the risk of disease progression in high-risk patients. It works by disrupting replication of the virus. Remdesivir reduces virus levels in the lungs and, as a result, reduce lung damage. It is approved by the FDA for both adults and pediatric patients above 12 years of age. This medication is safe in pregnant patients and those with renal insufficiency.
Lagevrio (Molnupiravir) is given orally to prevent the replication of viruses by causing mutations in the virus. It is approved by the FDA to treat mild to moderate COVID-19 infection in people aged 18 years and older who are at risk for severe illness. It’s found to be more beneficial in non-hospitalized patients and has been shown to reduce the risk of hospitalization or death by approximately 50%. Its efficacy is highest when used within five days of symptom onset. However, Molnupiravir’s use should be limited to situations in which other COVID-19 treatments "are not accessible or clinically appropriate."
Paxlovid (Ritonavir – boosted Nirmatrelvir) is approved for the treatment of mild-to-moderate COVID-19 in patients ages 12 and older who are at increased risk for severe illness. It must be administered orally within five days of symptom onset to achieve maximum efficacy.
Monoclonal Antibodies (MABs) are protein-based drugs that bind to the surface of cells and other targets such as antigens in the body to help fight diseases.
Olumiant (Baricitinib) and Actemra (tocilizumab) given orally to patients who are concurrently on corticosteroids (dexamethasone) and are experiencing increasing oxygen needs and systemic inflammation. Working through different pathways, they both block and reduce inflammation from coronavirus virus infection.
Xevudy (Sotrovimab) is administered intravenously to patients within severe infection condition that require oxygen to neutralize the virus and diminish its effects. It has been shown to be highly effective against the Omicron strain.
Kevzara (Sarilumab) is an alternative to Actemra (tocilizumab) for patients with elevated markers of inflammation and rapidly increasing need for oxygen. Like Actemra, it can be administered in conjunction with a corticosteroid.
There is a long list of investigational MABs that are awaiting emergency use authorization (EUA) by the FDA. This will increase the number of MABs available to patients significantly. However, the FDA retains the right to expand or narrow the EUA anytime, based on current data. For example, the uptick of Omnicron caused the FDA to narrow the EUA for a handful of MABs.
Miscellaneous
Convalescent Plasma: during a coronavirus infection, the body produces antibodies to fight the infection. After recovering from the infection, those antibodies can be recovered from the blood plasma. In February 2021, the FDA reissued a narrowed emergency use authorization (EUA) for the use of convalescent plasma to treat immunocompromised hospitalized and non-hospitalized patients with COVID-19.
NSAIDs (Ibuprofen – Motrin, Naproxen – Aleve, Tylenol): NSAIDs are typically used for relief from symptoms such as aches and fever. Early in the pandemic, there were some concerns that NSAIDs were not safe for people with COVID-19. After analyzing several months of data, the CDC and the World Health Organization recommends taking medications such as ibuprofen or acetaminophen to relieve fever in patients with COVID-19. There is no evidence that ibuprofen has any negative effects for people with COVID-19.
Contributor(s)
Prathusha Grace Bethala, PharmD Candidate
References
Ahmed, M. H., & Hassan, A. (2020, October 31). Dexamethasone for the treatment of coronavirus disease (COVID-19): A Review. SN comprehensive clinical medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599121/
Merck and Ridgeback's investigational oral antiviral molnupiravir reduced the risk of hospitalization or death by approximately 50 percent compared to placebo for patients with mild or moderate COVID-19 in positive interim analysis of phase 3 study. Merck.com. (2021, October 1). Retrieved from https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/
U.S. Department of Health and Human Services. (2021, December 16). Hospitalized adults: Therapeutic management. National Institutes of Health. Retrieved February 4, 2022, from https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/hospitalized-adults--therapeutic-management/
U.S. Department of Health and Human Services. (2022, February 1). Nonhospitalized adults: Therapeutic management. National Institutes of Health. Retrieved February 2, 2022, from https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/nonhospitalized-adults--therapeutic-management/
U.S. Department of Health and Human Services. (2021, December 16). Oxygenation and ventilation. National Institutes of Health. Retrieved from https://www.covid19treatmentguidelines.nih.gov/management/critical-care/oxygenation-and-ventilation/
U.S. Department of Health and Human Services. (2021, December 16). Remdesivir. National Institutes of Health. Retrieved from https://www.covid19treatmentguidelines.nih.gov/therapies/antiviral-therapy/remdesivir/
U.S. Department of Health and Human Services. (2021, April 21). Special Considerations in Children. National Institutes of Health. Retrieved February 2, 2022, from https://www.covid19treatmentguidelines.nih.gov/special-populations/children/