COVID Therapeutics (Dr. Lam)

what is the strongest risk factor for severe COVID 19

age (>60 years)

person to person considered predominant mode of transmission, likely via respiratory droplets from coughing, sneezing, or talking (t/f)

true

virus rarely cultured in respiratory sample >9 days after symptoms onset (t/f)

true

multiple studies describe a correlation between reduced infectivity with decreases In viral loads and rises in neutralizing antibodies (t/f)

true

symptoms may appear 2-14 days after exposure to the virus (t/f)

true

Anosmia & hypogeusia are symptoms of what

covid 19

onset is gradual

cough

fever

dyspnea

headache

myalgia

change in/loss of taste or smell

people >50

covid 19

age > 18years , 12-17 years and weghing >40kg

use within 5 days of symptoms onset

renal dosing if eGFR 30-59

5 days course

oral

Nirmatrelvir + Ritonavir (Paxlovid)

use within 7 days of symptoms

IV

Age >12 years

3 days course

remdesivir

use within 5 days of symptoms onset

do not use in pregnant women

Age >18 years

oral

5 day course

Molnupiravir

in high risk, nonhospitalized participants, 3 day course of remdesivir prevented COVID 19 related medically attended visits hospitalization or death (t/f)

true

Remdesivir warning and precautions

• hypersentivity reactions

• transaminase elevation

Phenytoin, carbamazepine, and rifampin, decrease/increase paxlovid

decrease

hold to avoid increased levels of lovastatin, simvastatin, atorvastatin, rosuvastatin, bosentan (t/f)

true

1. Initiating treatment in the appropriate window is an important consideration for COVID-19 treatments. How long can a patient have had symptoms of mild-to-moderate COVID-19 in order to receive either molnupiravir (LagevrioTM) or nirmatrelvir + ritonavir (Paxlovid®)?

1. 3 days or less

2. 5 days or less

3. 7 days or less (Remdesivir)

4. 10 days or less

2

1. Which oral antiviral medication is approved for treatment against COVID-19 in adults aged ≥18 years old?

1. Baloxavir

2. Dexamethasone

3. Molnupiravir

4. Nirmatrelvir + ritonavir

3

1. What is the difference in treatment duration for outpatient use of remdesivir vs. inpatient use of remdesivir? 

Remdesivir outpatient use duration = 3 days

Remdesivir inpatient use duration = 5 days (not on IMV/EMCO), 10 days (extended if not improving or on IMV/EMCO)

1. PS, 14-year-old boy (70 kg) presents to the clinic with signs and symptoms of a “cold” (mild HA and low-grade fever of 100.8ᵒF) that started 2 days ago. Rapid testing results showed positivity for SARS-CoV-2. He has NKDA and does not take any medications. His renal function is WNL. His pediatrician wants to prescribe PS an oral antiviral medication and asks for your recommendation. Which treatment would you recommend for PS who is diagnosed as having mild COVID-19 symptoms?

1. Baloxavir

2. Dexamethasone

3. Molnupiravir

4. Nirmatrelvir + ritonavir

4

1. Which antiviral medication has demonstrated teratogenicity in animal studies and should not be used in pregnant women with mild-to-moderate COVID-19 symptoms? 

Molunpiravir

1. Which antiviral medications should not be used at its recommended standard dose in patients with moderate-to-severe renal function (eGFR <30 mL/min)? 

1. Bebtelovimab

2. Molnupiravir

3. Nirmatrelvir + ritonavir

4. Remdesivir

3

1. List 3 advantages and disadvantages of remdesivir.

Advantages: ages ≥ 12 yr and ≥ 40 kg, administer within 7 days of symptom onset, 3 day IV infusion, no renal dose adjustment 

Disadvantages: must be administered in a healthcare setting or by home infusion, C/I in history of significant hypersensitivity reactions, nausea, must D/C if ALT >10x ULN (↑ALT/AST)

1. (True / False): Contraception precautions should be taken when taking molnupiravir.

true

1. List 3 advantages and disadvantages of nirmatrelvir + ritonavir (Paxlovid®).

Advantages: ages ≥ 18 yr & 12-17 yr and weighing ≥ 40 kg, oral administration, high efficacy & preferred oral tx 

Disadvantages: high potential for DDIs with ritonavir (CYP3A4 inhibitor, must hold atorvastatin/rosuvastatin), nirmatrevir requires renal dosing & cannot be used with eGFR < 30 mL/min, cannot be used beyond 5 days of symptom onset

1. What is the treatment duration for nirmatrelvir + ritonavir and molnupiravir? 

5 days

1. Which antiviral treatment for COVID-19 infection has potential for drug-drug interactions? Which cytochrome P450 substrate does this medication inhibit?

Nirmatrevir + ritonavir → potent CYP3A4 inhibitor (RTV) & P-glycoprotein

because of ritonavir

1. Which pivotal clinical trial led to the EUA status (and FDA approval) of nirmatrelvir + ritonavir for outpatient use in persons with mild-to-moderate COVID-19 symptoms? 

EPIC-HR

1. Which pivotal clinical trial expanded the access of remdesivir for outpatient use in persons with mild-to-moderate COVID-19 symptoms? 

PINETREE

1. Initiating treatment in the appropriate window is an important consideration for COVID-19 treatments. How long can a patient have had symptoms of mild-to-moderate COVID-19 to receive remdesivir?

1. 3 days or less

2. 5 days or less

3. 7 days or less

4. 10 days or less

3

1. Which antiviral medication is administered via IV route to treat mild-to-moderate COVID-19 symptoms? 

Remdesivir

1. A 60-year-old woman presents with moderate COVID-19 symptoms and an at-home positive COVID-19 test result. Her current medications include albuterol 90 mcg, adalimumab 40 mg, and atorvastatin 80 mg. What are the most appropriate next steps when prescribing nirmatrelvir + ritonavir for this patient?

1. Wait 3-4 days before initiating nirmatrelvir + ritonavir and make no changes to her other medications.

2. Hold atorvastatin immediately and begin nirmatrelvir + ritonavir in 3-4 days.

3. Begin nirmatrelvir + ritonavir immediately and make no changes with her other medications.

4. Begin nirmatrelvir + ritonavir immediately and hold atorvastatin until 2-3 days after treatment completion.

4

1. A 58-year-old patient presents with a persistent cough, fever (38.6°C), sore throat, and fatigue for 5 and a half days. His polymerase chain reaction (PCR) test is positive for COVID-19. Given the timing of the patient’s symptoms, which antiviral therapy should be initiated and when?

1. Initiate nirmatrelvir + ritonavir immediately

2. Initiate nirmatrelvir + ritonavir in 2-3 days

3. Initiate molnupiravir immediately

4. Initiate molnupiravir in 2-3 days

5. Initiate remdesivir immediately

6. Initiate remdesivir in 2-3 days

5

1. VS, a 55-year-old female with obesity, hypertension, and dyslipidemia who takes atorvastatin 40 mg, losartan 50 mg, and hydrochlorothiazide 25 mg presents for a telehealth appointment. She has COVID-19 symptoms (runny nose, sore throat, fatigue, muscle aches, and a low-grade fever) and a positive rapid antigen test, which she took yesterday at the prompting of her spouse. Based on the NIH COVID-19 treatment guidelines, what would you recommend as a treatment for VS?

1. Nirmatrelvir plus ritonavir

2. Molnupiravir

3. Remdesivir

4. The patient does not meet indications for COVID-19 treatment

A

1. A patient is prescribed nirmatrelvir + ritonavir for a new COVID-19 infection. He is currently taking escitalopram. Which of the following actions should be taken regarding his escitalopram?

A. Hold the escitalopram for the duration of treatment plus an additional 2 days.

B. Substitute fluoxetine for escitalopram for the duration of treatment plus an additional 2 days.

C. Decrease the escitalopram dose by 50% for the duration of treatment plus an additional 2 days.

D. No changes are necessary; escitalopram can be continued unchanged.

D

1. WD, a 69-year-old man, is taking many medications including amiodarone, aspirin, rosuvastatin, losartan, and an MVI. He asks you, the future pharmacist, about his treatment using nirmatrelvir + ritonavir (Paxlovid®) if he develops COVID-19. You reply:

A. Yes, you can go ahead and take Paxlovid® as long as your COVID-19 symptoms are mild-to-moderate and within 3 days of symptom onset.

B. Yes, you can go ahead and take Paxlovid® as long as your COVID-19 symptoms are mild-to-moderate and within 5 days of symptom onset.

C. No, you cannot take Paxlovid® because there is a significant drug-drug interaction with amiodarone.

D. No, you cannot take Paxlovid® because there is a significant drug-drug interaction with rosuvastatin.

C

symptoms may appear 2-14 days after exposure to the virus for COVID (t/f)

true

COVID symptoms

anosmia

hypogeusia

gradual

change in loss of taste/smell

people >50

what are the treatment options for COVID 19

Nirmatrelvir + Ritonavir

Remdesivir

Molnupiravinir

which COVID med should be used within 5 days of symptoms

nirmatrelvir + ritonavir (paxlovid)

Molnupiravir

which COVID med should be used within 7 days of symptoms

remdesivir

which covid med is approved for age >12 years

remdesivir

which covid med is approved for age >18 or 12-17 years and weighing >40 kg

paxlovid

which covid med is not used in pregnancy

molnupiravir

common DDI with paxlovid

rivaroxaban

simvastatin

tacrolimus

glucocorticoids

adjust dose for paxlovid if eGFR <30 (t/f)

true

WHICH IS CONTRAINDICATED WITH PAXLOVID and decrease the efficacy of paxlovid

phenytoin

carbamazepine

rifampin

which drug increase the paxlovid and should be hold

lovastatin, simvastatin, atorvastatin, rosuvastatin, bosentan

hold atorvastatin and restart 2 days after completing paxlovid (t/f)

true

while taking and 4 days after completing molnupiravir course for contraception (t/f)

true

Nirmatrelvir + RTV (paxlovid) and molnupiravir (lagevrio) should be administered within how many days of symptoms

5 days

remdesivir (veklury) should be administered within how many days of symptoms

7 days