Sample policies: Paxlovid (nirmatrelavir/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.

• monupiravir 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 less than 60 ml/minute should receive the renal dose of Paxlovid – 1 nirmatrelvir tablet (150 mg) and 1 ritanavir 100 mg, taken together, twice a day for five days.

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.

Alternative antiviral treatment: molnupivir

• For residents with severe renal impairment, GFR less than 30 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. 

The oral antivirals for COVID-19 are not for use in residents who have a new oxygen requirement for hypoxia or who have a higher oxygen need for a chronic condition. Paxlovid and Molnupiravir are for treatment of residents with mild to moderate COVID-19 illness at risk for progression to severe illness. These antivirals are not for the treatment of residents with severe or critical COVID-19.

Dexamethasone is not recommended for treatment of residents with mild to moderate COVID-19 (patients not on supplemental oxygen for hypoxia related to COVID-19).  Dexamethasone is only recommended for severely ill patients with COVID-19 who are on supplemental oxygen for hypoxia related to COVID-19. A meta-analysis study showed no benefit among patients treated with steroids who did not require oxygen or ventilatory support, and a non-statistically significant trend towards higher mortality.

Special circumstance use of dexamethasone in the skilled nursing facility

In nursing facilities, there may be a role for the use of dexamethasone for a resident with COVID-19 who is hypoxic with advance directives of “Do not transfer to Hospital." A discussion of risks and benefits of dexamethasone treatment in the nursing home by the Attending  Provider is recommended.

• Dexamethasone 6 mg oral daily for 10 days

Severe COVID-19 is associated with high D-dimer levels which appear to predict mortality. It is unknown whether antithrombotic treatments aimed at D-dimer thresholds improve outcomes. When possible, imaging confirmation of suspected VTE should be obtained to guide anticoagulation decisions.

VTE options include Apixaban 2.5mg bid, rivaroxaban 10mg daily or Enoxaparin SQ daily (prevention dose adjusted for weight). (Society of Critical Care Medicine).

Association Between COVID-19 and Thromboembolism

 COVID-19 has been associated with inflammation and a prothrombotic state, with increases in levels of fibrin, fibrin degradation products, fibrinogen, and D-dimer. In some studies, elevations in these markers have been associated with worse clinical outcomes. Studies have reported varying incidences of venous thromboembolism (VTE) in patients with COVID-19. A meta-analysis of studies of hospitalized patients with COVID-19 who received VTE prophylaxis found an overall VTE prevalence of 14.1% (95% CI, 11.6–16.9). The VTE prevalence was higher in studies that used ultrasound screening (40.3%; 95% CI, 27.0–54.3) than in studies that did not (9.5%; 95% CI, 7.5–11.7).

Guidelines for the use of antithrombotic therapy in patients with COVID-19 have been released by multiple organizations. The NICE guidelines state: “Consider a treatment dose of a low-molecular-weight heparin (LMWH) for young people and adults with COVID-19 who need low-flow oxygen and who do not have an increased bleeding risk. Results from clinical trials have provided further information on the safety and efficacy of different antithrombotic strategies for patients with COVID-19. 

Residents with COVID-19 illness who are already receiving anticoagulant or antiplatelet therapies for underlying conditions should continue their current medications unless significant bleeding or other contraindications are present. Before prescribing Paxlovid (nirmatrelvir-ritonavir) for mild to moderate COVID-19, the clinician must review any potential drug-drug interaction. There may not be a need to modify (such as aspirin), or it may be necessary to modify the anticoagulant (such as apixaban) or switch to another anticoagulant. 

Special circumstances for use of new anticoagulation for severe COVID-19 in the skilled nursing facility

Residents with SEVERE COVID-19 whose Advance Directives and goals of care discussion with their attending provider and nursing facility team are consistent with “treatment in place” at the nursing facility and no transfers to the hospital, may be considered for anticoagulation.  Refer to NIH guidelines on Chronic anticoagulant and antiplatelet therapy.