ACP releases living practice points on COVID-19 treatment in outpatient settings

The ACP has released living, rapid practice points summarizing the best available evidence on the treatment of adults with confirmed mild or moderate COVID-19 in an outpatient setting.

“Management of COVID-19 in the outpatient setting continues to evolve as new data emerges on SARS-CoV-2 variants and the availability of newer treatments,” ACP President Ryan D. Mire, MD, MACP, said in a press release. “These living practice points will be a valuable clinical resource for physicians and the rest of the health care community in treating patients in the outpatient setting, as most COVID-19 cases are now managed as outpatients.”

The practice points, developed by the ACP’s Scientific Medical Policy Committee and published in Annals of Internal Medicine, recommend that physicians consider the following treatments for patients with confirmed mild to moderate COVID-19 in the outpatient setting:

• Lagevrio (molnupiravir, Merck) for patients who are within 5 to 7 days of the onset of symptoms and at high risk for progressing to severe disease;
• Paxlovid (nirmatrelvir-ritonavir, Pfizer) for patients who are within 5 days of the onset of symptoms and at high risk for progressing to severe disease; and
• Veklury (remdesivir, Gilead Sciences) for patients who are within 7 days of the onset of symptoms and at high risk for progressing to severe disease.

ACP advised against the use of:

• azithromycin, chloroquine, hydroxychloroquine, ivermectin, lopinavir-ritonavir combination therapy, nitazoxanide, convalescent plasma, ciclesonide and fluvoxamine; and
• certain monoclonal antibodies, including casirivimab-imdevimab combination therapy, regdanvimab or sotrovimab, unless it is considered effective against a COVID-19 variant or subvariant.

The practice points are based on a review of 26 randomized studies evaluating COVID-19 outpatient treatment effectiveness, with sample sizes ranging from 18 to 5,607 participants (47.1% women).

Amir Qaseem, MD, PhD, MHA, FACP, vice president of clinical policy and the Center for Evidence Reviews at ACP, and colleagues concluded that nirmatrelvir-ritonavir probably reduces all-cause mortality and hospital admissions.

Additionally, the researchers found that molnupiravir may reduce both all-cause mortality and COVID-19 mortality, while remdesivir may improve recovery time.

The researchers acknowledged that some of the reviewed treatments could be used as adjunctive therapy, but the studies in the current analysis only examined them as the primary treatment. All studies were also conducted before omicron became the dominant circulating variant.

Qaseem and colleagues noted that the practice points do not provide clinical advice on the comparative effectiveness of the highlighted treatments, and that COVID-19 treatment initiation should be personalized and based on a decision-making approach that includes factoring in the patient’s characteristics and preferences, as well as potential harms and benefits.

The researchers emphasized that the highlighted treatments are not recommended for asymptomatic patients with COVID-19, and patients should meet the criteria for all reviewed treatment before it is started. They concluded that more research into pharmacological and biological treatments of COVID-19 in outpatient settings “is needed, particularly as new variants emerge for which less is known about susceptibility to new and existing treatments.”

References:

• ACP issues rapid, living practice points on treating COVID-19 patients in outpatient settings. https://www.acponline.org/acp-newsroom/acp-issues-rapid-living-practice-points-on-treating-covid-19-patients-in-outpatient-settings. Published Nov. 29, 2022. Accessed Nov. 29, 2022.
• Qaseem A, et al. Ann Intern Med. 2022;doi:10.7326/M22-2249.