ANTIVIRAL DECISION MAKING TOOL FOR COVID-19 PATIENTS Patient has confirmed COVID-19 PLUS is symptomatic PLUS not requiring oxygen
Consider INH budesonide 800mcg BD if patient able to manage a turbuhaler AND not already on inhaled or systemic steroids.
Do they meet the clinical risk criteria for antiviral therapy? See table at the bottom of the chart
NO
YES YES
Symptom onset ≤ 5 days ago
CrCl ≤ 30 mL/min OR Childs-Pugh C cirrhosis OR pregnant?
Consider Paxlovid
Nirmatrelvir/Ritonavir 300mg/100mg BD PO 5 days
Symptom onset ≤ 7 days ago
Dose adjust if CrCl 30-59 mL/min Nirmatrelvir/Ritonavir 150mg/100mg BD PO 5 days
NO
YES
NO
NO
YES
Ensure drug-drug interactions have been checked Click here for the Liverpool Interactions Checker Paxlovid is only available from selected community pharmacies. Consider Remdesivir for inpatient use OR discharge with Paxlovid script to selected pharmacy to be couriered to patient.
Non-dialysis & CrCl < 30 mL/min
Dialysis (HD or PD)
Cirrhosis Childs-Pugh C
Pregnancy < 12/40 gestation
Pregnancy ≥ 12/40 gestation
Paxlovid or Remdesivir are NOT recommended.
Consider INH budesonide 800mcg BD if patient able to manage a turbuhaler AND not already on inhaled or systemic steroids.
Consider Remdesivir
200mg IV on Day 1 followed by 100mg IV on Days 2 and 3 if already inpatient and expected ≥2 days of admission Reduced course can be considered if CrCl < 30 mL/min and not on dialysis 200mg IV on Day 1 followed by 100mg IV on Day 2 (i.e. omit Day 3 dose) ALT must be < 275 U/L and monitor LFTs daily during treatment. Do not admit to hospital specifically for Remdesivir. Contact the on call ID / COVID SMO if any questions. CLINICAL RISK CRITERIA FOR ANTIVIRAL THERAPY Group 1 - Severely immunocompromised and not expected to reliably mount an adequate immune response to COVID-19 vaccination • • • • • • • •
Solid organ transplant especially if needing ↑immunosuppression, on mycophenolate, rejection in the last 12 months Bone marrow transplant in the last 24 months or if GVHD requiring multimodal immunosuppressive therapy CAR-T cell therapy in the last 24 months Treated B-cell malignancy e.g. myeloma, CLL, lymphoma - within 6 months Advanced HIV with CD4 < 200 Hypogammaglobulinaemia (IgG < 3) incl. those on replacement Primary immunodeficiency assoc. with severe B-cell or combined cellular defects Other conditions felt to have profound immunocompromise (case by case)
Group 2 - Patient has at least FIVE of the following risk factors below (or case by case decision by ID or COVID SMO) • • • • • • • • • • • • • • • •
Maori or Pacific ethnicity Age ≥ 65 years Age ≥ 50 years PLUS single vaccinated only OR 2nd dose < 7 days or > 6 months prior Immunosuppression (any degree) Chronic kidney disease incl. dialysis patients Chronic lung or airways disease Cardiovascular disease Chronic liver disease Chronic neurological impairment or neuromuscular disease Severe haematological disorders Diabetes mellitus Active malignancy Severe mental illness Pregnancy Current smoker BMI ≥ 35