Doctors have said that self-medication is dangerous, especially in these times that the pandemic is still in our midst. Just because someone recommended a certain type of medication does not mean it’s effective and safe, not unless they are doctors.
Dr. Edsel Maurice Salvaña, Adult Infectious Disease Specialist, Director, Institute of Molecular Biology and Biotechnology, National Institutes of Health, University of the Philippines Manila, said that medications for Covid-19 are meant to decrease mortality or morbidity from the disease’s effects, where the highest mortality happens in the most vulnerable population. He said that we are lucky because of the presence of vaccines, which has decreased mortality by at least 90 percent.
Medications for Covid-19, he said, are meant for mild or moderate cases but with high risk of progression and for those with severe disease. “But more importantly, not all people need medication. About 99 percent of those who are vaccinated with breakthrough infection will recover from Covid-19 without the need for medication. Only symptomatic treatment should be okay,” he explained.
Right now, Dr. Salvaña said the focus of treatment are those in the high- and medium-risk categories, particularly the unvaccinated 60-year-olds and above and anyone with comorbidities, those above 60 years old who are vaccinated, the 20 to 59-year-olds who are unvaccinated, and those with comorbidities and are vaccinated.
Dr. Salvaña said there are three types of medications: the antivirals (which kill the virus and prevent it from replicating), immunomodulators (steroids and some monoclonal antibodies that target the immune response), and monoclonal antibodies, or direct-acting monoclonal antibodies, which were not discussed.
As per US NIH guidelines, which look at people outside the hospitals, Dr. Salvaña said there are four medications that work for patients who do not require hospitalization or supplemental oxygen—Ritonavir-boosted Nirmatrelvir or Paxlovid; Sotrovimab, the antiviral monoclonal antibody that is not available here; Remdesivir, used only for severe disease but now being used for mild to moderate disease and people with risk of progression, and Molnupiravir, which, is the lowest in terms of preference and in preventing hospitalization.
He said the IV-infused Remdesivir is a broad-spectrum antiviral, an RNA-dependent RNA polymerase inhibitor. For mild to moderate high-risk patients, it is given only for three days, and should be given within seven days of symptom onset. This, however, should be used with caution for patients with hepatic and renal disease.
One of the first trials that showed Remdesivir works was published in the New England Journal of Medicine, Dr. Salvaña said. It showed a decrease in the time to recovery for patients given Remdesivir and more likely to have clinical improvement but no difference in mortality.
Paxlovid is made up of two drugs: Nirmatrelvir (two 150 mg tablets) and Ritonavir (one 100 mg tablet), used for confirmed Covid-19 with mild disease and with high risk progression, and reduces hospitalization by 88 percent. All three tablets are taken together twice daily for five days for mild to moderate and in vulnerable population, and need to start within five days from symptom onset. “The biggest problem is that Ritonavir reacts with a lot of drugs, especially statins and has to be adjusted renally for severe impairment, may induce HIV drug resistance, and should not be used beyond five days or for prophylaxis,” he said.
Using Paxlovid, hospitalization or death was 88-percent lower versus placebo, and early trials showed no effect in hospitalized patients, is not recommended for severe disease, and should not be used longer than five days.
Molnupiravir, on the other hand, was the first effective oral drug against Covid-19 for confirmed Covid-19 cases with mild disease and high risk of progression, and reduces hospitalization by 31 percent. Four capsules should be taken for five days and started from five days of symptom onset. “Really no major issues in terms of side effects but should be avoided for use in pregnant women, and not to be used beyond five days or for prophylaxis,” Dr. Salvaña again noted.
The use of Dexamethasone (a steroid used only for severe/critical cases and before vaccination), the earliest drug proven to decrease mortality, resulted in 28-day mortality for those under invasive mechanical ventilation or oxygen but not for those receiving respiratory support. “If you’re not severe, don’t take it. As we all know, steroids are a double-edged sword since it can reduce immunity to other diseases,” he added.
Meanwhile, Tocilizumab showed clear benefits in reducing the risk of death, with data showing that patients under Tocilizumab were more likely to be discharged from the hospital alive within 28 days, at least in patients with severe disease, including those receiving non-invasive respiratory support.
The target for endemic diseases in general, Dr. Salvaña said, is a mortality rate of less than 0.1 percent. As such, for patients in the vulnerable population, the residual risk of death after vaccination goes down from 10 percent to 1 percent. This can be brought down further to 0.1 percent through medications.
However, there is a need for more evidence, he said, for vaccinated people because trials were done on unvaccinated people. He added the emergence of resistance is possible because these are RNA viruses. “Again, these medications should be used properly since not all people need treatment. Those who need treatment are the high-risk ones,” he noted.
But medications are really very important for those who can’t get vaccinated for medical reasons. Dr. Salvaña said this is their chance to increase their survival, but medications’ most important effect is that it is another layer in terms of preventing death and bringing down those in the high-risk level to an even lower level to that of the seasonal flu. When that happens, the focus can be shifted to other chronic illnesses like diabetes, heart problems, cancer, and others that were neglected during the lockdowns. People can have themselves screened so they can undergo medical management with their doctors.
“What is essential now is that with vaccines and medications, we minimize the societal impact of Covid-19, and we can exit the pandemic since these decrease mortalities from Covid-19 to near that of the flu,” he said.
Reference: https://businessmirror.com.ph/2022/02/16/covid-19-medicines-to-help-phl-exit-from-pandemic/
