Test to Treat and the New Oral Antivirals

Like so many others, I have family members who have chosen not to get vaccinated against COVID-19. We’ve had many respectful conversations about the reasons I support vaccination, but in the end they didn’t change their opinions. I carried a nagging concern for their health as well as worry for the many nurses who might be required to care for the unvaccinated.

Until recently, there were limited options beyond vaccination to keep patients with COVID-19 out of the hospital, adding to the burden of an overburdened healthcare system. Those options were for medications administered intravenously, making it more difficult to access them quickly. But in January 2022, the Food and Drug Administration (FDA) gave emergency use authorization (EUA) to two new oral antiviral medications. These two medications can be a game changer for those at high risk of infection – such as the unvaccinated who contract COVID-19 – if they are treated early in their course of illness. So, I was beyond happy to hear about the U.S. Department of Health and Human Services’ new program “Test to Treat,” which provides free early treatment with these antivirals for those who contract COVID-19 and for those who are at high risk. The program includes a direct allocation of antiviral pills to participating clinics, centers and facilities.

About ‘Test to Treat’

The Test to Treat program is run by the U.S. Department of Health and Human Services and allows people who test positive for COVID-19 to be seen and treated at hundreds of local pharmacy-based clinics and federally qualified community health centers. The program also includes treatment for patients who need long-term care. Patients who are at high risk for developing severe disease are assessed by a qualified healthcare provider who can prescribe oral antiviral pills on the spot.

The key to the success of Test to Treat is early treatment, especially for the unvaccinated and those with underlying conditions. Even if a person is not feeling symptoms yet, but knows they have been exposed, they should get tested and treated right away. If the course of illness is interrupted early – within the first three to five days of exposure/symptom onset – the chances of preventing serious illness and hospitalization are very high. Additional benefits of early treatment include reducing the duration of illness and the spread of the disease. The goal is to minimize the possibility of overwhelming the healthcare system.

Approved Oral Antivirals for the Test to Treat Program

Currently, two medications, Pfizer’s Paxlovid: nirmatrelvir + ritonavir and Merck’s Lagevrio: molnupiravir, have received an EUA from the FDA to treat patients with COVID-19. Both medications work by inhibiting the virus’s ability to replicate in the body. Both have clinically significant adverse effects and cautions for use, so it’s important to understand these medications before prescribing or administering them.

Paxlovid

Paxlovid is a combination medication composed of nirmatrelvir and ritonavir. Nirmatrelvir is a SARS-CoV-2 main protease inhibitor, while ritonavir is a CYP3A inhibitor included to increase the plasma levels of nirmatrelvir. Ritonavir has no effect on SARS-CoV-2 by itself; it was previously used as an HIV-1 protease inhibitor. In clinical trials, this medication has been up to 90% effective in the treatment of patients with COVID-19.

The dosage of Paxlovid is two 150 mg tablets (300 mg) nirmatrelvir with one 100 mg tablet ritonavir taken orally twice a day for five days. The medication needs to be started as soon as possible after COVID-19 diagnosis and within five days of symptom onset, with or without food. The dose must be reduced for moderate renal impairment.

The medication is not recommended for treatment of patients requiring hospitalization due to severe or critical COVID-19. The patient must be at least 12 years of age and weigh more than 88 pounds. The medication should not be used as pre-exposure or post-exposure prophylaxis to prevent COVID-19. Paxlovid should not be taken for more than five consecutive days.

As a healthcare provider, you should inform patients that Paxlovid may interact with some medications and is contraindicated for use with some other medications due to its impact on the CYP3A receptor site. Obtain a complete medication list from your patient including nonprescription medications and herbal supplements. It is very important to check the patient's medication list for any possible clinically significant medication interactions. The provider will need to decide if Paxlovid is appropriate compared with an authorized alternative treatment. This decision includes whether your patient should hold, change or reduce the dosage of their other medications while taking Paxlovid or if additional monitoring may be needed.

The most common adverse effects of Paxlovid are impaired sense of taste, diarrhea, high blood pressure and muscle aches.

Lagevrio

Lagevrio (molnupiravir) works by inhibiting SARS-CoV-2 replication and is for patients 18 years of age or older. As with Paxlovid, Lagevrio must be started as soon as possible after diagnosis of COVID-19 and within five days of symptom onset. It should not be used for more than five consecutive days, or for pre-exposure or post-exposure prophylaxis for prevention of COVID-19. Lagevrio cannot be used to treat patients with COVID-19 who require hospitalization. However, if a patient does require hospitalization after starting treatment with Lagevrio, they may complete the full five-day treatment course with the approval of their healthcare provider. This medication is approximately 30% effective for the treatment of patients with COVID-19.

The dosage of Lagevrio is 800 mg (four 200 mg capsules) taken orally every 12 hours for five days, with or without food. It is important to complete the full five-day treatment course. The most common adverse effects are diarrhea, nausea and dizziness.

The important cautions for healthcare providers and those administering the medication include advising individuals of childbearing age to use contraception during the full course of treatment and for at least four days after the last dose of Lagevrio. You should also advise sexually active individuals with partners of childbearing age to use contraception during treatment and for at least three months after the last dose of this medication. As noted earlier, this medication should not be given to patients younger than 18, since the medication may affect bone and cartilage growth. Breastfeeding is not recommended during treatment and for four days after the final dose.

Conclusion

Vaccination remains the best option for preventing COVID-19 and hospitalization. But now a treatment option is finally available and being made readily accessible to those who are not or cannot get vaccinated. The new oral antivirals, Paxlovid and Lagevrio, and the Test to Treat program provide not only treatment for patients with COVID-19 and those at high risk for severe infection, but also hope for families and for nurses and others who will possibly not have to care for additional hospitalized patients.

Paxlovid and Molnupiravir Dosage, Adverse Effects and Patient Teaching

Are you ready to tell other nurses about these new treatment options?