LAC DPH Health Advisory: Availability of Therapeutics for Treatment and Pre-exposure Prophylaxis of COVID-19 February 11, 2022 anti-SARS-CoV-2, COVID-19, LAHAN, molnupiravir, monoclonal antibodies, NIH, Paxlovid, Providers, remdesivir, sotrovimab, Therapies, Treatment Guidelines Panel 1177 Key Messages Four therapies are available to treat mild to moderate COVID-19 in individuals at high risk for progression to severe disease to reduce their risk of hospitalization and death. Treatment should be given as soon as possible after symptom onset and within specific time frames. Providers should proactively educate their patients at high risk for severe COVID-19 disease about the availability of effective, time-sensitive, outpatient therapy should they become symptomatic and test positive. Providers should consider prescribing pre-exposure prophylaxis with Evusheld (tixagevimab plus cilgavimab) to their highest-risk patients such as those who are moderately to severely immunocompromised. Background Information Treatment of high-risk patients with mild to moderate COVID-19 infection Paxlovid (ritonavir-boosted nirmatrelvir), sotrovimab, remdesivir, and molnupiravir are anti-SARS-CoV-2 therapies that are effective against the Omicron variant and are recommended for the treatment of nonhospitalized patients with mild to moderate COVID-19 who are at high risk of disease progression. The NIH COVID-19 Treatment Guidelines Statement on Therapies for High-Risk, Nonhospitalized Patients With Mild to Moderate COVID-19 lists these therapies in order of preference: 1) Paxlovid; 2) sotrovimab; and 3) remdesivir. Molnupiravir should only be used when the other options are not available or cannot be used. These treatments should be started as soon as possible after diagnosis and within 5 days of symptom onset for Paxlovid and molnupiravir, 7 days for remdesivir, and 10 days for sotrovimab. Supplies of Paxlovid and sotrovimab remain limited. Note: casirivimab plus imdevimab and bamlanivimab plus etesevimab are no longer authorized for use in the United States because they are not effective against the Omicron variant. When deciding which treatment is best for a particular patient, providers should consider the time from symptom onset, the availability of the treatment, the feasibility of administering parenteral medications, the potential for significant drug-drug interactions, and other clinical factors. The NIH Treatment Guidelines Panel has provided guidance on how to prioritize patients for these treatments when their availability is limited; see NIH Statement on Patient Prioritization for Outpatient Therapies. The panel prioritized patients at risk based on 4 key elements: age, vaccination status, immune status, and clinical factors. Pre-exposure prophylaxis Evusheld is a combination of two long-acting anti-SARS-CoV-2 monoclonal antibodies (tixagevimab plus cilgavimab) administered via intramuscular injection that is authorized for pre-exposure prophylaxis (PrEP) to prevent COVID-19 infection. It is authorized for adults and children 12 years of age and older weighing at least 40 kg who are not currently infected with SARS-CoV-2 and who have not had a known recent exposure to an individual infected with SARS-CoV-2 and either: Who have moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments and may not mount an adequate immune response to COVID-19 vaccination or For whom vaccination with any available COVID-19 vaccine, according to the approved or authorized schedule, is not recommended due to a history of severe adverse reaction (e.g., severe allergic reaction) to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s). Actions Requested of Providers Identify patients who are eligible for PrEP with Evusheld. Provide these patients with information and offer or refer for Evusheld. See the Evusheld point of contact list on the Procuring medication for your patientsdrop-down section of the DPH therapeutics webpage. Facilities interested in becoming an Evusheld provider are encouraged to contact DPH-Therapeutics@ph.lacounty.gov. Identify patients who are at high risk for progression to severe COVID-19 before they become infected. Provide them with information about the availability of treatment options and the need to get a COVID-19 viral test immediately if they develop symptoms. If they test positive, instruct them on how to contact your practice for a prescription or referral for treatment. Carefully review the fact sheet for health providers before prescribing these treatments to ensure that the patient’s condition warrants treatment, that there are no drug interactions, and that there are no contraindications. Because supplies of both Paxlovid and sotrovimab are limited, treatment should be prioritized as outlined in the NIH COVID-19 Treatment Guidelines. Supplies remain adequate for remdesivir and molnupiravir at this time. Refer to the DPH Monoclonal and antiviral therapy for nonhospitalized patients webpage for additional information, including location and contact information of sites where product is available and other resources. The U.S. Department of Health and Human Services COVID 19 Therapeutics Locator can also be used to identify sites were Paxlovid, molnupiravir and Evusheld are available and to check daily stock on hand. Additional Resources For Healthcare Providers NIH COVID-19 Treatment Guidelines Fact Sheets for Healthcare Providers on Evusheld | Paxlovid | Sotrovimab | Remdesivir | Molnupiravir LAC DPH provider webpage COVID-19 Monoclonal & Antiviral Therapy for NonhospitalizedPatients CDPH webpage SARS-CoV-2 Antiviral Therapeutics For Patients LAC DPH Medicine to Treat and Prevent COVID-19 CDC Treatments Your Healthcare Provider Might Recommend if You Are Sick Further Questions For questions related to Evusheld, Paxlovid, or molnupiravir, please contact DPH-Therapeutics@ph.lacounty.gov For questions related to sotrovimab, please contact laemsadutyofficer@dhs.lacounty.gov Remdesivir can be ordered directly from the manufacturer: vekluryhcp.com This communication was sent by Seira Kurian, MD, MPH, COVID-19 Therapeutics Lead, Los Angeles County Department of Public Health To view a printable PDF of this communication and other LAHAN communications, please visit publichealth.lacounty.gov/lahan. 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