Antivirals work by targeting specific proteins on the SARS-CoV-2 virus to prevent virus replication within the host cell.
The oral antivirals nirmatrelvir with ritonavir (Paxlovid), molnupiravir (Lagevrio) and the intravenous antiviral remdesivir (Veklury) are available for:
For IV remdesivir, patients can visit ExpressCare or call 212-COVID19 (212-268-4319) or 311 for a treatment evaluation and to schedule an infusion appointment if indicated through NYC Health + Hospitals.
Select Outpatient COVID-19 Treatment Resources:
Patient Assistance Programs
Patient assistant programs have been developed to help ensure uninsured and underinsured patients have continued and timely access to critical COVID-19 oral antiviral treatments.
Counsel your patients on these programs when prescribing antivirals and help them enroll or provide them with the necessary information to do so to avoid unnecessary costs or delays in treatment.
Provider resources and patient education materials can be found at Pfizer: Paxlovid Access.
Currently, most people who have insurance coverage through Medicare will need to enroll in Pfizer’s patient assistance program (Paxcess) to access Paxlovid at no cost through 2024. If they do not enroll, they may have to pay for it out-of-pocket and will not be reimbursed.
Information on coverage and patient assistance programs will continue to be updated in the HHS COVID-19 Therapeutics Transition Guide.
In clinical trials, antivirals as an outpatient therapy reduce the risk of hospitalization and death by 88% with Paxlovid, 87% with remdesivir, and 30% with molnupiravir. In real-world studies, antivirals significantly reduced the risks of hospitalization and death among high-risk non-hospitalized patients during periods of Omicron and Omicron-variants circulation, including among highly vaccinated populations. (Lin, 2023; Amani, 2023)
Antivirals are available for people who are diagnosed with COVID-19, even if they have been vaccinated.
Oral antivirals are available for people who meet all of the following conditions:
Intravenous Veklury (remdesivir) is approved for people who meet all of the following conditions:
Providers can use HHS's COVID-19 Decision Support Tool (PDF, September 2023) to support their clinical decisions.
Oral antiviral treatment must be administered within five days of symptom onset, but it is most effective the sooner patients begin. Treatment should be offered to any eligible patient at higher risk for severe COVID-19, regardless of vaccination status (Shaw, 2022).
Paxlovid is the preferred treatment for eligible patients ages 12 years and older.
Paxlovid can alter the concentrations of other drugs, so it is important to assess for potential drug-drug interactions. Approved label includes a boxed warning with instructions for prescribers. Several resources are available on steps that can be taken to avoid significant interactions with commonly prescribed medications, such as brief suspension or dose reduction of other medications. Do not prescribe Paxlovid for patients who are taking rivaroxaban or salmeterol; avoid it in patients with severe renal impairment (eGFR <30).
Paxlovid is not recommended for patients with severe kidney (eGFR <30 mL/min) or liver (Child-Pugh Class C) impairment.
Special renal dose packs (Paxlovid 150 mg; 100 mg) are available for patients with moderate renal impairment (eGFR ≥30 to <60 mL/min).
Patients on ritonavir- or cobicistat-containing HIV or HCV regimens should continue their treatment as indicated.
The following resources are available to assess and manage potential drug-drug interactions:
The following strategies can facilitate the use of Paxlovid in special populations:
Lagevrio should be prescribed for patients ages 18 years and older for whom alternative FDA-authorized COVID-19 treatment options are not accessible or clinically appropriate.
Lagevrio is not recommended during pregnancy. Prescribing providers should advise individuals of childbearing potential to use effective contraception correctly and consistently for the duration of treatment and for four days after the last dose of Lagevrio.
Breastfeeding is not recommended during treatment and for four days after the last dose of Lagevrio. A lactating individual may consider interrupting breastfeeding and pumping and discarding breast milk during this time.
Men of reproductive potential who are sexually active with women of childbearing potential should use a reliable method of contraception correctly and consistently during treatment and for at least three months after the last dose.
Veklury (remdesivir) is available for adults and children 28 days and older. It is administered daily for 3 consecutive days via intravenous infusion and treatment should start within 7 days of symptoms onset.
Therapy is contraindicated for patients with a history of clinically significant hypersensitivity reactions to its active ingredients or any other components of the product.
Prior to initiating treatment with Veklury, the FDA recommends performing liver function and prothrombin time tests as clinically appropriate and repeating these tests during treatment as clinically indicated.
For more information, see the Veklury Label Sheet (PDF)
COVID-19 rebound is the term used describe a recurrence of symptoms or SARS CoV-2 antigen positivity, which can occur between 2 and 8 days after initial recovery. Recent studies suggest that patients who experience rebound have an extremely low probability of developing severe COVID-19. Retreatment is not currently recommended. The potential for COVID-19 rebound after antiviral treatment is not a reason to avoid prescribing.
People with rebound can transmit to others, and patients should re-isolate for at least 5 days from the recurrence of symptoms per CDC guidance. It is important to advise your patients that COVID-19 rebound does not represent a failure of treatment or resistance.
Prescribing Oral Antiviral Therapy
Paxlovid and Lagevrio are available in pharmacies throughout NYC. Visit the federal COVID-19 Treatment Locator to find the nearest location, including pharmacies participating in the Pfizer Paxcess Patient Assistance program. Clinicians should recommend to patients that they call ahead to their pharmacy to confirm availability of their prescribed oral antiviral medication and whether there will be a co-pay or other charges.
Oral antivirals can only be prescribed by a physician, advanced practice registered nurse or physician assistant. Paxlovid can also be prescribed by pharmacists with certain limitations (PDF). For more information on prescribing Paxlovid, see the Paxlovid Eligibility Screening Checklist for Prescribers (PDF) and the Pharmacist Paxlovid Prescribing Guide (PDF).
Access to Intravenous Antiviral Therapy (Remdesivir)
Veklury can be given in skilled nursing facilities, home health care settings and outpatient facilities such as infusion centers as long as severe hypersensitivity reactions, such as anaphylaxis, can be managed.
Facilities and providers that see large numbers of immunosuppressed patients (such as transplant and oncology centers), high-risk pediatric populations, or other patients for whom Paxlovid may not be clinically appropriate are encouraged to offer Veklury in the outpatient setting. This can be done in collaboration with tertiary care centers.
Patients can also visit ExpressCare or call 212-COVID19 (212-268-4319) or 311 for a treatment evaluation and to schedule an appointment for remdesivir infusions if indicated through NYC Health + Hospitals.
Patient Education on Antivirals
People at increased risk of severe COVID-19 and their caregivers should be advised:
Patients who do not have a health provider or are uninsured can be referred to: