COVID-19 Outpatient Therapeutics Clinical Decision Aid

February 2024

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Clinical Decision Aid for Ages 12+ Years

Adult or pediatric patients (ages 12 and older* weighing at least 40 kg) with mild to moderate COVID-19 and at high risk for progression to severe disease.

* Age requirement does not apply for Veklury (remdesivir)

Text Version of Clinical Decision Aid for Ages 12+ Years Flow Chart

Step 1
Is the patient hospitalized due to severe COVID-19?

Examples of severe COVID-19 symptoms include SpO2 ≤ 94%, respiratory failure, sepsis, and/or multiple organ dysfunction.¹

• If yes, continue to Step 6.
• If no, continue to Step 2.

Step 2
Symptom onset within the past 5–7 days?

• If yes, continue to Step 3.
• If no, continue to Step 6.

Step 3
Consider one of the following therapeutics:

• If Paxlovid (nirmatrelvir co-packaged with ritonavir) and Veklury (remdesivir) are clinically appropriate and feasible¹, continue to Step 4.
• If Paxlovid (nirmatrelvir co-packaged with ritonavir) and Veklury (remdesivir) are not available, feasible or clinically appropriate, consider one the following alternative therapies. Continue to Step 5.

Step 4
Paxlovid (nirmatrelvir co-packaged with ritonavir)^2,8 within 5 days of symptom onset if patient does not have severe renal impairment (eGFR <30mL/min) OR severe hepatic impairment (Child-Pugh Class C)

• eGFR ≥ 60mL/min: 300 mg nirmatrelvir taken with 100 mg ritonavir twice daily for 5 days
• eGFR ≥ 30mL/min to < 60 mL/min: 150 mg nirmatrelvir taken together with 100 mg ritonavir twice daily for 5 days
• Evaluate concomitant use of CYP3A inducers and medications with high dependency on CYP3A for clearance as these may be contraindicated^2,3,8

OR

Veklury (remdesivir)⁴ 200 mg IV x 1 dose on Day 1, 100 mg IV x 1 on Days 23 begun within 7 days of symptom onset

Prescribers must review and comply with the mandatory requirements outlined in the Paxlovid (nirmatrelvir co-packaged with ritonavir) EUA² or the Veklury Prescribing Information.⁴

• Continue to Step 6.

Step 5
Lagevrio (molnupiravir)⁵, if age 18 or over and not pregnant (if applicable). 800 mg by mouth every 12h for 5 days begun within 5 days of symptom onset.

• Lagevrio (molnupiravir)⁵ is not authorized for initiation of treatment in patients hospitalized due to COVID-19.
• Lagevrio (molnupiravir) can be administered via nasogastric (NG) or orogastric (OG) tube (12F or larger), refer to instructions within the EUA Fact Sheet, Section 2.3.
• Prescribers must review and comply with the mandatory requirements outlined in the Lagevrio (molnupiravir) EUA.⁶

COVID-19 convalescent plasma⁷ with high titers of anti-SARS-CoV-2 antibodies can also be considered for the treatment of COVID-19 in certain patients with immunosuppressive disease or receiving immunosuppressive treatment.

• Continue to Step 6.

Step 6
Treatment of symptoms, management per NIH¹ & CDC⁶ Guidelines

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¹NIH COVID-19 Treatment Guidelines Therapeutic Management of Nonhospitalized Adults With COVID-19
²Paxlovid EUA
³NIH's COVID-19 Treatment Guidelines Panel: Ritonavir-Boosted Nirmatrelvir (Paxlovid)
⁴Veklury (remdesivir) Prescribing Information
⁵Lagevrio EUA
⁶CDC Covid-19 Website
⁷Fact Sheet for Health Care Providers: EUA of COVID-19 Convalescent Plasma for Treatment of COVID-19
⁸Paxlovid Prescribing Information

Clinical Decision Aid for Pediatric Patients 28 Days of Age and Older

Pediatric patients 28 days of age and older weighing 3 kg to less than 40 kg with mild to moderate COVID-19 and at high risk for progression to severe disease.

Text Version of Clinical Decision Aid for Pediatric Patients 28 Days of Age and Older Flow Chart

Step 1
Symptom onset within the past 7 days?

• If yes, continue to Step 2.
• If no, continue to Step 3.

Step 2
Consider Veklury (remdesivir)*¹ begun ASAP within 7 days of symptom onset.

Pediatric patients 28 days of age and older and weighing 3 kg to less than 40 kg*: 5 mg/kg IV on Day 1, 2.5 mg/kg on Days 2–3

*Use only Veklury for Injection (supplied as 100 mg Lyophilized Powder in Vial).

Pediatric patients weighing 40 kg or greater: 200 mg IV x 1 dose on Day 1, 100 mg IV x 1 on Days 2–3

Step 3
Treatment of symptoms, management per NIH² & CDC³ Guidelines

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¹Veklury Prescribing Information.
²NIH COVID-19 Treatment Guidelines Therapeutic Management of Nonhospitalized Adults With COVID-19.
³CDC Covid-19 Website.