JJ 20 Outpatient Medications for COVID-19

With the COVID Omicron wave, we are assessing a lot of COVID patients, but the vast majority are not so sick - and they can usually go home. Nonetheless, the numbers are so huge that, even though they do not seem to be getting as sick as Alpha and Delta patients, that denominator is so high that the number of patients requiring hospitalization and/or ICU admission is still significant. And most would agree that the key to preventing a generalized healthcare system meltdown is to prevent hospitalizations and ICU admissions. We also, as usual, want to curb morbidity and mortality. When I tell COVID patients I am discharging from the ED to isolate, keep well hydrated, monitor their oxygen saturation and take acetaminophen or ibuprofen – almost universally they ask “is that all you’re going to offer me? Aren’t you going to give me a prescription?” In this Journal Jam podcast we dig deep into the science of FDA-approved outpatient medications for COVID, and discuss our philosophies of prescribing experimental medications without robust evidence during a time when we are desperate to save lives, reduce morbidity and decrease hospitalizations when COVID is changing so rapidly. Three critical appraisal masters chime in: Infectious Disease specialist Dr. Andrew Morris who you have almost certainly heard before on EM Cases, my EM colleague at North York General and SREMI researcher Dr. Rohit Mohindra, and my Journal Jam co-conspirator, Dr. Justin Morgenstern...



8 outpatient COVID medications in 4 categories covered in this Journal Jam podcast

The biologics - neutralizing monoclonal antibodies - the “mabs”



* Sotrovimab 500mg IV x1

* Evusheld (tixagevimab + cilgavimab) for pre-exposure prophylaxis ≥12 y/o



The nucleoside analogs - the “virs”



* Remdesivir 200mg IV on day 1, then 100mg IV daily x 2 days

* Molnupiravir

* Paxlovid (nirmatrelvir and ritonavir)



The SSRIs



* Fluvoxamine 50mg po daily titrated to 100mg po tid x 15 days



The inhaled coriticosteroids



* Budesonide 800 μg bid x 14 days

* Ciclesonide 600 μg bid x 14 days



Ontario COVID-19 Drugs and Biologics Clinical Practice Guidelines Working Group: Therapeutic Management of  Patients with COVID-19

Ontario COVID-19 Drugs and Biologics Clinical Practice Guidelines Working Group: Therapeutic Management of Adult Patients with COVID-19, January 2022

Additional FOAMed resources on outpatient medications for COVID-19

First10EM deep dives:



* COVID therapy: monulpinavir

* COVID therapy: Neutralizing monoclonal antibodies

* COVID therapy: Paxlovid

* Remdesivir: The evidence

* COVID therapy updates: Fluvoxamine 

* Inhaled corticosteroids in COVID-19





References for outpatient medications for COVID-19

Neutralizing monoclonal antibodies

Gupta A, Gonzalez-Rojas Y, Juarez E, Crespo Casal M, Moya J, Falci DR, Sarkis E, Solis J, Zheng H, Scott N, Cathcart AL, Hebner CM, Sager J,