ASHP: Identify and Counsel Patients at High Risk for Severe COVID-19
By identifying patients at high risk for progressing to severe disease and counseling them on their treatment options, pharmacists empower patients to make informed decisions about their treatment.
Although managing COVID-19 has become largely routine, pharmacists should still be mindful when counseling patients at high risk of progressing to severe disease, defined as hospitalization or death. Importantly, counseling patients about the use of ritonavir and nirmatrelvir (Paxlovid; Pfizer) is a crucial role for pharmacists, according to a session at the American Society of Health-System Pharmacists (ASHP) Midyear 2024 meeting.
Between April 2023 and April 2024, an estimated 61,000 total COVID-19–related deaths occurred in the United States, or about 2% of total deaths. Furthermore, an estimated 824,000 hospitalizations occurred as a result of COVID-19 illness, demonstrating the significant burden the virus continues to have.In addition to acute illness, presenter Jeff Brock, PharmD, MBA, BCIDP, highlighted the chronic conditions that are also associated with COVID-19, including hypertension, diabetes, mental health conditions, heart failure, kidney disease, and some thrombotic events.
New variants continue to emerge, increasing the likelihood of surges. As of May 2024, Brock said the most common variants (90.9% of cases) were KP and JN omicron subvariants. Emergent variants, particularly variants of interest such as omicron parent lineages, may be associated with increased transmission rates, reduced antibody neutralization, and diagnostic detection failures. “It’s really important to understand these circulating variants and their impacts on our patients,” Brock said.
Symptoms of COVID-19 can include fever or chills, cough, dyspnea, fatigue, muscle aches, headache, sore throat, hoarse voice, congestion, nausea, and diarrhea. Emergency warning signs of more severe disease include trouble breathing; persistent chest pain or pressure; new mental confusion; inability to wake or stay awake; and discolored skin, lips, or nail beds. Illness persisting for more than a week also presents a greater risk for severe or critical illness. Brock emphasized that not only should pharmacists be aware of these symptoms, but they should educate patients so that they know when to seek medical care.
Although all patients should be aware of the common symptoms, identifying which patients are at the greatest risk is another role for pharmacists to play. The strongest risk factor is older age, defined as age 50 or older, and underlying medical conditions also heighten the risk. “Often 65 years and up is…referred to as older age,” Brock said. “But with respect to COVID-19, anybody 50 years of age or older is included in the high-risk category.”
Once patients have confirmed COVID-19, pharmacists should not only identify whether they are at heightened risk of severe disease, but should counsel them on treatment options, when appropriate. The use of ritonavir and nirmatrelvir can significantly lower patients’ risk of progressing to severe disease.
Nirmatrelvir is a peptidomimetic inhibitor of MPRO1, which is a critical protein for viral replication and is highly conserved across coronaviruses. Ritonavir inhibits CYP3A-mediated metabolism of nirmatrelvir, resulting in increased plasma concentrations and enhanced therapeutic effect. This treatment combination was used under Emergency Use Authorization during much of the COVID-19 pandemic, and was fully approved by the FDA in May 2023 for the treatment of mild-to-moderate COVID-19 in adults at high risk of progressing to severe disease.
Paxlovid (nirmatrelvir/ritonavir) was investigated in the EPIC-HR randomized clinical trial, and has also undergone real-world evidence studies. “Paxlovid demonstrated powerful efficacy in this trial versus placebo,” Brock said. “Relative risk reduction for Paxlovid was 86% compared to placebo, reducing hospitalization or death from any cause through day 28.” Real-world evidence studies have further supported these findings.
