Treatment

Tixagevimab-cilgavimab

Dexamethasone

Baricitinib

Tocilizumab

Remdesivir

Nirmatrelvir

Monoclonal Antibodies (Bebtelovimab)

Standard regimen

300 mg + 300 mg Cil

6 mg once daily for 14 days or hospital discharge

4 mg once daily for 14 days or hospital discharge

8 mg/kg once, second dose in 8 hours if no improvement

200 mg IV on day 1 followed by 100 mg once daily for 5 days

Nirmatrelvir 300 mg with ritonavir 100 mg administered together, twice daily for 5 days

175 mg as a single dose within 7 days of symptom onset.

CKD - without dialysis

No changes

No changes

2 mg for GFR 30-60; 1 mg for GFR 15-30

No changes

No changes

Nirmatrelvir 300 mg with ritonavir 100 mg on day 1 followed by Nirmatrelvir 150 mg and ritonavir 100 mg for the next four days when GFR < 30 [114]

No changes

CKD with dialysis

No changes

No changes

Use not recommended

No current recommendations. Some case studies have been reported with favorable outcomes [111,112]

No changes

Same dose as without dialysis but given on dialysis days following dialysis

No changes

Important drug interactions

Covid-19 vaccine, Efgartigimod alfa

Antibacterials and antifungals, calcineurin inhibitors, and desmopressin. More complete lists of medications can be found on CDC website.

Synergistic immune suppression is seen with other immune suppressive therapies

Synergistic immune suppression is seen with other immune suppressive therapies 

Chloroquine, Hydroxychloroquine

Ritonavir is a potent CYP3A4 inhibito. Important drugs to consider are statins, calcineurin inhibitors, estradiol contraceptives, and HIV treatments. Refer to Paxlovid FDA sheet for a more comprehensive list.

No known significant interactions

Transplant considerations

Given immune compromised state use of Tix/Cil in transplant patients is advisable especially in patients who were unable to receive a vaccine or those who did not mount an adequate immune response.

Earlier initiation of treatment in patients with Covid-19 is advised, transplant team should be notified and brought on for management following confirmation of infection 

Benefit of treatment in immune compromised patients needs to be heavily weighed against risks as significant immune suppression can result.

Benefit of treatment in immune compromised patients needs to be heavily weighed against risks as significant immune suppression can result.

Earlier initiation of treatment in patients with Covid-19 is advised, transplant team should be notified and brought on for management as early as possible following confirmation of infection.

Treatment should only be considered if remdesivir is unavailable per the American society of transplantation.

Some small studies have shown monoclonal antibodies to be effective in transplant patients. Earlier initiation of treatment in patients with Covid-19 is advised, transplant team should be notified and brought on for management as early as possible following confirmation of infection.

Adverse effects

Dizziness, fatigue, headache, insomnia, anaphylaxis (< 1%)

Adverse reactions to systemic steroids are extensive, an in depth analysis of side effects are available on the FDA insert

Elevated ALT and AST, Deep vein thrombosis, pulmonary embolis, septic shock, UTI, Thrombocythemia, Pneumonia, Tuberculosis

Elevated cholesterol, Constipation, neutropenia, increase ALT and AST, injection site reaction, infusion related reaction. Incidents that happened < 10% of the time can be found on the FDA package insert.

Increased serum glucose, Decreased creatinine clearance, increased serum creatinine

Hypertension, Diarrhea, Dysgeusia, Myalgia

Rash, Pruitus, Nausea, vomiting

Further considerations

Use of powder formulation to minimize concentration of SBECD is advised. Short overall duration of therapy is unlikely to lead to significant adverse outcomes, risks of clinical worsening should be weighed against benefits of treatment. 

A clinical trial is currently underway evaluating use in patients on dialysis. Clinicaltrials.gov Identifier is NCT05366192. At the time this article was submitted for publication the report had not been published yet.

As new strains develop efficacy will need to be reevaluated. Treatment should be reserved for only those who are most at risk and most likely to benefit. Other more well documented treatments should be used when available for patients who are not immune compromised.