• COVID-19 Therapeutics Comparison Table

    Updated April 27, 2022

    Outpatient Treatment Options for Patients with Moderate to Severe COVID-19
    who are at Increased Risk for Progression to Severe Disease

    (see more detailed therapies overview and therapeutics locator from HHS below)

     

    Veklury (Remdesivir)

    Molnupiravir

    Nirmatrelvir 300 mg with ritonavir 100 mg (Paxlovid)

    Monoclonal Antibodies

    Mechanism of Action

    RNA polymerase inhibitor—interferes with RNA virus replication  Nucleoside analog causing high rates of mutations resulting in reduced viral replication
    • Nirmatrelvir = SARS-CoV-2 main protease (Mpro) inhibitor
    • Ritonavir = HIV-1 protease inhibitor and CYP3A inhibitor

    Binds different regions of the spike protein of SARS-CoV-2 and prevents entry of the virus into cells.

     

    Indications
    for Use

    • Within 7 days of symptom onset
    • IV infusion for 3 days
      • Day 1: 200 mg IV
      • Days 2-3: 100 mg IV 
    • Within 5 days of symptom onset
    • Taken orally 2x day for 5 days
    • Within 5 days of symptom onset
    • Taken orally 2x day for 5 days
    • Treatment with Sotrovimab: within 10 days of symptom onset for all variants except Omicron BA.2
    • Single IV infusion: 500 mg  

    Eligible Populations

    • Pediatric patients 28 days of age and older weighing at least 3 kilograms (about 7 pounds) with positive results of direct SARS-CoV-2 viral testing, who are:
      • Hospitalized, or
      • Not hospitalized and have mild-to-moderate COVID-19 and are at high risk for progression to severe COVID-19, including hospitalization or death. 
    • Individuals aged 18 years and older
    • Not recommended unless other options are not available
    • Not recommended for individuals who are pregnant 
    • Individuals aged ≥12 years and weighing ≥40 kg
    • Individuals aged ≥12 years and weighing ≥40 kg who live in areas with high prevalence of the Omicron variant
    • Note: other monoclonal antibodies are authorized for use in children under 12

    Contraindications

     

     

     

     

    • Potential for infusion or anaphylactic reactions
    • Potential to increase ALT

     

     

     

     

     

     

    • Not recommended for individuals who are pregnant due to
      potential embryo-fetal toxicity. If no other options are available, can be prescribed following a discussion of benefits/risks
    • Individuals of childbearing age should use contraception to prevent pregnancy and individuals who are lactating should discontinue or pump and discard during and for four days after completing treatment.  

     

     

     

    • Significant and complex drug-drug interactions, primarily due to ritonavir.
    • A thorough review of all current medications including OTC and supplements should be performed before prescribing.
    • HIV drug resistance: use in individuals with uncontrolled or undiagnosed HIV infection may lead to HIV drug resistance
    • Liver/Kidney Damage: not recommended in patients with severe kidney or severe liver impairment. In patients with moderate renal impairment, a reduced paxlovid dose is needed.
    • Hormonal Contraceptives:  decrease hormonal contraception effectiveness, so patients will need to be counseled to use back up contraception

     

             Potential for infusion or
               anaphylactic reactions

    Other Key Information

    • Use of Remdesivir is approved for patients who are hospitalized for COVID-19
    • Recommendations for use in the outpatient setting are considered off-label
    • The only approved dosage form is Veklury for injection.
    • Molnupavir has the potential to result in creation of variants if not taken as indicated.
    • Patients should be counseled to take the medication as prescribed and to not stop medication before completing the dosing regimen
     
    • 3 authorized products for treatment:
      • Sotrovimab (not effective for Omicron BA.2 sub-variant)
      • Bebtelovimab
      • Bamlanivimab/etesevimab
      • Casirivimab/imdevimab
    • Sotrovimab and Bebtelovimab are the only products that retained effectiveness against the Omicron BA.1, BA.1.1 variants and should be used in areas of high transmission. Sotrovimab is not effective for Omicron BA.2 sub-variant.
    • The other products can be offered in areas where Delta is still dominant or when sotrovimab is contraindicated or unavailable

    NOTE: none of the therapeutics outlined above have been approved by the FDA. They are all available for use under Emergency Use Authorization during the public health emergency. Authorization may be revoked at anytime due to safety concerns or lack of effectiveness. Certain monoclonal antibody therapeutics can be given as pre/post exposure prophylaxis or via subcutaneous injections. More information can be found here: https://www.aafp.org/family-physician/patient-care/current-hot-topics/recent-outbreaks/covid-19/covid-19-clinical-resources/monoclonal-antibody-approved.html

    More detailed information can be in the EUA fact sheets for the products and from the NIH COVID-19 Treatment Guidelines: https://www.covid19treatmentguidelines.nih.gov/therapies/statement-on-therapies-for-high-risk-nonhospitalized-patients/

    HHS Resources: Therapies Overview and Therapeutics Locator