What works for the treatment of COVID-19 infection for people who are not in the hospital?


A: It’s been a minute since we updated you about COVID-19 treatments.

This will take a couple of posts, but let’s start with patients who do not need to be hospitalized (called outpatients or ambulatory patients). There are still more questions than answers, but let’s go through the evidence. In short, the bamlanivimab/etesevimab combo may be useful but not readily available, the jury is out on ivermectin, hydroxychloroquine definitely doesn’t help, and good ol’ TLC is still the mainstay of treatment. Buckle up, y’all, this is a long one.

➡️Monoclonal antibody therapy: This type of therapy provides infusions of laboratory made antibodies that are like the ones your body would make if you had the #COVID-19 infection. These target the spike protein of the SARS-CoV-2 virus. The US Food and Drug Administration (FDA) has issued emergency use authorizations for several monoclonal antibody treatments:

amlanivimab, the combination of casirivimab and imdevimab, and the combination bamlanivimab and etesevimab. These treatments are not available to everyone, but are authorized for use in people diagnosed with mild to moderate COVID-19 (for example, they don’t need to be in the hospital) and who are at high risk of developing severe disease (for example, are 65 years of age or over or have certain high risk medical conditions like diabetes or kidney disease).

The Infectious Diseases Society of America (IDSA) and the US National Institutes of Health (NIH) both have guidelines on treatment of COVID-19 and weighed in on the monoclonal antibodies. The NIH guidelines say there is insufficient evidence to recommend for or against the use of bamlanivimab or the combination of casirivimab and imdevimab. The studies focus heavily on disease-oriented outcomes (DOEs), rather than patient-oriented outcomes (POEs). DOEs are things like the amount of virus detected and POEs are things that people actually care about in their lives, like how often someone is hospitalized or dies from a disease. While DOEs are interesting and may help guide future clinical research, they aren’t very helpful for patients and their clinicians to make decisions (for that, we need POEs!). Bamlanivimab by itself and casirivimab/imdevimab have preliminary data showing that they can reduce the amount of virus detected but there wasn’t enough data to really know if they reduce important things like hospitalization, emergency room visits, or death. More studies are in process and we will certainly have more evidence on these treatments.
But… (drum roll please!)…both the NIH and IDSA recommend the use of the combination bamlanivimab and etesevimab for outpatients at high risk of severe disease. Treatment should be started as soon as possible after being diagnosed with COVID-19 and within 10 days of symptom onset. Bamlanivimab/etesevimab has more of those POEs than the other monoclonal antibodies treatment. Early data shows a decrease in absolute mortality rates and hospitalizations. Because of the larger sample size and more events, the data for bamlanivimab/etesevimab is stronger than for the other monoclonal antibodies. In lab studies, it looks like bamlanivimab/etesevimab has activity against the B.1.1.7 variant but have markedly reduced activity against the B.1.351 variant. Bamlanivimab/etesevimab is in very short supply and not available in a lot of places.

➡️Ivermectin: This is a medication used to treat parasite infections. It has been shown in labs (in vitro) to inhibit the virus from copying itself in cell cultures, but the concentration needed for ivermectin to work in the lab was 100x higher than those approved for use in people (yikes!). A bunch of studies have been done looking at ivermectin efficacy in treating COVID-19, but these studies have some pretty huge problems limiting their usefulness. These problems include too few people, different doses, lack of blinding, study participants getting other meds at the same time or not having a comparison group, and different severity of illness. Though some of the studies suggested there may be benefit, the studies are too flawed and too small. The IDSA recommends against using ivermectin outside of a clinical trial and the NIH says there is insufficient evidence to recommend for or against the use of ivermectin. We need way better designed studies to be able to know if this helps.

➡️Hydroxychloroquine: This medicine is used to treat autoimmune diseases, like lupus or rheumatoid arthritis, and just flat out doesn’t work for COVID-19. Both the NIH and IDSA recommend against using hydroxychloroquine for the treatment of COVID-19. Hydroxychloroquine (with and without the antibiotic azithromycin) has been looked at in a ton of studies. In well-designed studies, there is no improvement in rates of death, need for mechanical ventilation (like breathing tubes), or need for hospitalization.

➡️Antibiotics: Antibiotics treat bacterial infections and do not have any benefit for viral infections, like COVID-19. Antibiotics may be helpful if someone develops a bacterial infection (like a bacterial pneumonia) in addition to their COVID-19 infection.

If you do get COVID-19, talk with your primary care clinician about treatment options and what is right for you. Because so much is still unknown, your clinician can talk to you about the risks and benefits of any possible options and help you make a decision that is right for you. They can also talk about ways to take care of yourself, like staying hydrated, sleeping, over the counter medicines that might help for pain or fever, and what things to watch out for.

For those who love digging through the data, check out these links! You can find the NIH and IDSA recommendations, as well as evidence tables, summaries of the available studies, and more. It’s a nerd’s dream.

NIH COVID-19 Treatment Guidelines

IDSA Guidelines on Treatment of COVID-19

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