Molnupiravir, nirmatrelvir-ritonavir, and remdesivir can be used in specific clinical situations for ambulatory patients with mild-to-moderate COVID-19, advises the Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP). The panel advises against use of azithromycin, chloroquine or hydroxychloroquine, ivermectin, nitazoxanide, lopinavir–ritonavir, casirivimab–imdevimab, regdanvimab, sotrovimab, convalescent plasma, ciclesonide, ciclesonide, and fluvoxamine in patients with mild-to-moderate COVID-19 in the outpatient setting.
SMPC based its recommendations on findings of a living, rapid review of studies of antiviral agents and antibodies tested in randomized controlled trials (RCTs) in the outpatient setting: “The 26 included studies collected data before the emergence of the Omicron variant. Nirmatrelvir–ritonavir and casirivimab–imdevimab probably reduced hospitalizations (1% vs. 6% [1 RCT] and 1% vs. 4% [1 RCT], respectively; moderate COE). Nirmatrelvir–ritonavir probably reduced all-cause mortality (0% vs. 1% [1 RCT]; moderate COE), and regdanvimab probably improved recovery (87% vs. 72% [1 RCT]; moderate COE). Casirivimab–imdevimab reduced time to recovery by a median difference of 4 days (10 vs. 14 median days [1 RCT]; high COE). Molnupiravir may reduce all-cause mortality, sotrovimab may reduce hospitalization, and remdesivir may improve recovery (low COE). Lopinavir–ritonavir and azithromycin may have increased harms, and hydroxychloroquine may result in lower recovery rates (low COE). Other treatments had insufficient evidence or no statistical difference in efficacy and safety versus placebo.”
The ACP’s 14 practice points include these 3 positive recommendations:
Practice Point 1: Consider molnupiravir to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 to 7 days of the onset of symptoms and at high risk for progressing to severe disease.
Practice Point 2: Consider nirmatrelvir–ritonavir combination therapy to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at high risk for progressing to severe disease.
Practice Point 3: Consider remdesivir to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 7 days of the onset of symptoms and at high risk for progressing to severe disease.