"Test and treat" is a critical strategy for people and society returning to more normal activities.

Now that the early responses to the COVID-19 pandemic have — sort of — been met (ie, minimizing infection, spread, illness, and death with masks, testing, contact tracing, social distancing, and vaccines), we are now facing the challenge of treating acute COVID-19. (Treating long COVID is another significant challenge.)

The progression from public health mitigation and prevent strategies, to vaccines, to treatment, is something I'd described back in the summer of 2020 in various presentations and discussions. Fortunately, "test and treat" is now possible with the availability of effective treatments for acute COVID-19. And importantly, discussions I'd had with various people as early as the fall of 2020 indicated that being able to get treated for COVID-19 (even without a vaccine) would make people more willing to engage in more normal activities — that is, things that could put them at higher risk of getting infected.

The excellent news is that there are now five different outpatient treatments for people with acute COVID who are at high risk for severe disease. According to the NIH's COVID-19 Treatment Guidelines Panel, three of those options are preferred, with two others being alternatives if the first three are not available or clinically appropriate:

Preferred therapies for nonhospitalized patients with mild to moderate COVID-19 who are at high risk of progressing to severe disease (listed in order of preference) are:

  1. Paxlovid (nirmatrelvir 300 mg with ritonavir 100 mg) orally twice daily for 5 days, initiated as soon as possible and within 5 days of symptom onset in those aged ≥ 12 years and weighing ≥ 40 kg

  2. Sotrovimab 500 mg as a single intravenous (IV) infusion, administered as soon as possible and within 7 days of symptom onset in those aged ≥ 12 years and weighing ≥ 40 kg

  3. Remdesivir 200 mg IV on day 1, followed by remdesivir 100 mg IV once daily on days 2 and 3, initiated as soon as possible and within 7 days of symptom onset in those aged ≥ 12 years and weighing ≥ 40 kg

Alternative therapies, if none of the preferred therapies for high-risk, nonhospitalized patients are available, feasible to deliver, or clinically appropriate (listed in alphabetical order), are:

  • Bebtelovimab 175 mg as a single IV infusion, administered as soon as possible and within 7 days of symptom onset in those aged ≥12 years and weighing ≥40 kg

  • Molnupiravir 800 mg orally twice daily for 5 days, initiated as soon as possible and within 5 days of symptom onset in those aged ≥18 years

Fortunately, the availability of such treatments is increasing — as is the availability of tests for diagnosing COVID-19. To help raise awareness about the availability of treatments (and tests, vaccines, and masks), the COVID19.gov website was recently launched, and it includes information about how to locate COVID-19 treatments and a test and treat site. Hopefully the government will continue ramping up its support and public engagement for the critical "test and treat" part of its response to COVID.

Some clinicians may be concerned that individuals who haven't been vaccinated will also be resistant to receiving a treatment for COVID-19. However, I was recently told about research showing that this is not true; people who are vaccine resistant or hesitant do not seem to be more resistant to or unwilling to taking a medicine to treat COVID-19 than vaccinated people. (This study is being prepared for publication, and I will present more information about this research when it is available.)

While being "at high risk for progressing to serious disease" is clearly more likely in unvaccinated individuals, for vaccinated patients who become ill and are concerned about progressing to more serious illness, some of those treatments may be appropriate. However, like all medical decisions, the risks vs benefits need to be weighed for each individual and their living situation. For example, someone I know recently went through this calculation after being symptomatic for 3 days (ie, "feeling like crap") and then testing positive. They contacted their PCP and discussed treatment options. Because they had been vaccinated and weren't deemed to be at high risk — and were a bit wary of Paxlovid's side effects — they decided to forgo treatment. Interestingly, looking at WebMD's information about Paxlovid, the most commonly complained about side effect in the few patient reviews was a very unpleasant taste. Fortunately, that taste was reported to end after the 5 days of treatment, and some of the reviews include recommendations for alleviating it.

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About Dr Michael D. Miller

For more than 30 years, Michael D. Miller, MD has been working with large and small companies, government organizations, and patient advocates to improve access and affordability for treatments and innovations. His work has spanned many clinical, scientific, and policy areas, including autoimmune diseases, behavioral health, cancer, cell/gene therapies, diabetes, patents, reimbursements, and vaccines. He graduated from Williams College and Yale Medical School, has served on several nonprofit boards, and has spoken across the country on critical healthcare issues.

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