There are 3 antiviral medications shown to benefit outpatients who get COVID-19. The goal is to reduce “progression to severe illness, hospitalization, and death” (JAMA September 29, 2023).
Paxlovid (generic name is nirmatrelvir-ritonavir) is an effective antiviral taken by mouth twice a day for 5 days. It reduces the risk of “hospitalization or death by 86%” (JAMA 2023).
It is recommended for patients with a “high risk for progression to severe COVID-19 and who are within 5 days of symptom onset” (JAMA 2023).
Paxlovid has drug interactions with a number of medications. Fortunately, they can be managed. It is considered safe to use during pregnancy.
Paxlovid is not recommended for patients with severe kidney disease and is not approved for children.
Paxlovid is the preferred antiviral for most adult patients with COVID-19. The next recommended option, when Paxlovid cannot be used or is unavailable, is Veklury (remdesivir).
Veklury reduces “hospitalization or death by 87% compared with placebo“ (JAMA 2023). Unlike Paxlovid, it may be given to patients as young as “28 days, weighing at least 3kg, who are at high risk for progression to severe COVID-19 and within 7 days of symptom onset …” (JAMA 2023).
Veklury must be given IV once a day for 3 days. It may not be accessible for all patients and, because of the need for IV infusion, may be unacceptable to others.
The third antiviral option is Lageviro (molnupiravir), which is given by mouth twice a day for 5 days. It reduces “hospitalization or death by 30% compared with placebo;” thus, it is less effective than the first two options (JAMA 2023).
It is for adults age 18 and older who are at risk of “progression to severe COVID-19 and within 5 days of onset of symptoms, and for whom alternative treatment options are not available or appropriate” (JAMA 2023).
It should not be used during pregnancy; patients who could become pregnant are advised to use birth control.
These medications have shown benefit in unvaccinated patients, and there is good evidence for effectiveness in vaccinated patients. For example, Paxlovid reduced hospitalizations by 73% in vaccinated patients.
The bottom line is that outpatients age 50 or older, “younger patients with” pre-existing chronic medical disorders or obesity, and “immunocompromised individuals of any age” should be treated with an antiviral medication whether or not they are vaccinated (JAMA 2023).
After treatment there can be a rebound of symptoms. This also occurs in untreated patients. Luckily, “severe illness has not been observed” (JAMA 2023). Patients with rebound symptoms do not need additional doses, with the exception of of patients who are severely immunocompromised.
Do not rely solely on this blog to make your healthcare decisions. It is intended for educational purposes only. You should consult a physician before making a decision about the best option for your care.
This blog is based on an excellent review on the topic by Chew K, Malani P, Gandhi R. published online in JAMA on September 29, 2023. doi:10.1001/jama.2033.19542
Peter M. Hartmann, MD
Family Medicine & Psychiatry
