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Antiviral Medications

 

Sample policies: Paxlovid (nirmatrelvir/ritonavir) and Lagevrio (molnupiravir).

Two oral antivirals, Paxlovid (nirmatrelvir with ritonavir) and Lagevrio (molnupiravir) are available for the treatment of our nursing facility residents with mild to moderate COVID-19 illness and are at risk for progression to severe illness, including hospitalization and death.

  • Paxlovid is FDA-approved and is the preferred treatment.
  • Molnupiravir received FDA-EUA (emergency use authorization).

High risk conditions of nursing facility residents that could increase the risk of progression to severe COVID-19 include:

  • Older age (over 50 years)
  • Chronic kidney disease
  • Diabetes mellitus, Type 1 and Type 2
  • Immunosuppressive disease or immunosuppressive treatment
  • Cardiovascular disease, cerebrovascular disease
  • Dementia
  • Physical Inactivity
  • Chronic lung disease, asthma
  • Cirrhosis, alcoholic liver disease, autoimmune hepatitis, non-alcoholic fatty liver disease
  • Sickle cell disease
  • Neurodevelopmental disorders such as cerebral palsy
  • Having a medical device such as gastrostomy, tracheostomy, or positive pressure ventilation not related to COVID-19
  • Obesity or overweight (BMI greater than 25)
  • Cancer, hematologic malignancy

Inclusion Criteria for Paxlovid Treatment:

  • The resident weighs at least 40 kg (80 pounds).
  • The resident is 12 years or older.
  • The resident has positive test results of SARS-CoV-2 by rapid antigen or PCR, OR the resident has been diagnosed with COVID-19 based on symptoms consistent with COVID-19 disease secondary to high-risk transmission and contact in a facility outbreak (Clinical diagnosis made without COVID-19 test).
  • Symptom onset or positive COVID-19 test within 5 days.
  • The resident can swallow tablets whole.
  • The resident does not have:
    • hypoxia with pulse oximetry less than 90%, newly requiring oxygen supplementation due to severe COVID-19 illness.
    • a higher requirement for oxygen, for residents on chronic oxygen therapy for a non-COVID condition.
    • severe renal impairment with GFR less than 30 ml/minute.
    • severe liver impairment (Child-Pugh Class C).

Paxlovid Dose Adjustment for Renal Function (eGFR)

  • Residents with GFR greater than or equal to 60 ml/minute should receive the standard dose of Paxlovid – 2 nirmatrelvir tablets (=300 mg) and 1 ritonavir 100 mg, taken together, twice a day for five days.
  • Residents with GFR 30 to 60 ml/minute should receive the renal dose of Paxlovid – 1 nirmatrelvir tablet (150 mg) and 1 ritonavir 100 mg, taken together, twice a day for five days.

Paxlovid Medication Interactions & Adjustments

Potentially significant drug interactions with Paxlovid must be cleared before starting Paxlovid. We suggest using the Liverpool Interaction Checker.

  • Review carefully the resident’s medication regimen profile, including over the counter and herbal medications.
  • Consult with the facility pharmacist consultant or the vendor pharmacist.
  • The prescriber can use management strategies to benefit the resident with Paxlovid. For example:
    • It may be clinically appropriate to hold certain medications, such as holding statins for 7 to 10 days.
    • Reducing the dose of anti-coagulants or switching to another anticoagulant without potential drug interaction with Paxlovid.

PAXCESS Program

All patients on Medicare or Medicaid are eligible for a voucher to pay for Paxlovid.  Before the patient is prescribed and charged for the medication, the patient must be enrolled in the program. For more information or to enroll, go to PAXCESSPatientPortal.com.

Alternative Antiviral Treatment: Molnupiravir

  • For residents with severe renal impairment, GFR less than 30 ml/minute.
  • For residents when there is no management strategy possible to allow prescribing of Paxlovid with an absolute contraindication to co-administer drugs (such as amiodarone or quetiapine).
  • Resident must be 18 years or older.
  • Dose: 200 mg capsules, 4 capsules (=800 mg) taken whole by mouth every 12 hours for five days for a total of 40 capsules.

Discontinue oral antiviral therapy if the resident’s condition has progressed to Severe COVID-19.

See ASPR COVID-19 Outpatient Therapeutics Clinical Decision Aid