Question of the week
Treating COVID-19 in older adults comes with unique challenges, especially when practitioners must balance comorbidities and current medications. In this case, practitioners weigh in on which antivirals are most appropriate and share insights on emerging treatments that could benefit patients like this one.
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Patient Profile:
• 65-year-old male
• Reports of fever, cough, fatigue, and mild shortness of breath for 2
days
History:
• Atrial fibrillation
• BMI: 32.1
• Hypertension
• Hypercholesterolemia
Current Medications:
• Rivaroxabana 20 mg/day
• Amiodaronea 400 mg/day
• Amlodipine 10 mg/day
• Simvastatina 20 mg/day
Current Status:
• Mild COVID-19 Symptoms for 2 days (fever up to 101°F, dry cough,
and generalized fatigue)
• Reports mild shortness of breath, especially during exertion
• Noticed a loss of taste and smell since yesterday
Questions for consult
1. Which antiviral would you recommend for this patient? Why?
2. Are you aware of any treatments in the pipeline that would be beneficial in treating a patient like this? Please explain.
Consults
Key takeaways about COVID-19 treatment in older adults:
- Consider drug interactions and comorbidities
Avoid the use of Paxlovid to treat patients with complex medication regimens (e.g., anticoagulants, statins, or amiodarone) due to challenging drug interactions. - Tailor antiviral use to symptom severity and risk
Mildly symptomatic patients may be managed with supportive care, while higher-risk patients could benefit from alternatives like Remdesivir or Molnupiravir (Lagevrio), even if efficacy is slightly lower. - New treatments remain limited and experimental
While some investigational antivirals and monoclonal antibodies exist, most practitioners are not currently relying on pipeline therapies to treat COVID-19 in older adult patients.
Infectious Disease/HIV
"Remdesivir would be the best choice. The drug interactions with Paxlovid would be difficult to manage. Molnupiravir is less effective. I am not aware of new antivirals in the pipeline."
Internal Medicine
"Because of the presence of atrial fibrillation and the need for ongoing Anticoagulation and due to drug-drug interactions, Paxlovid should be withheld. If it were only simvastatin, that was of concern; it could reasonably be held. Therefore, Lagevrio would be the drug of choice. JAK 2 inhibitors, iminosugars (especially MON-DNJ/UV-4B), Nsp15 inhibitors, and monoclonal antibodies like meplazumab remain understudied."
Family Practice
"Would not recommend an antiviral with this presentation. Mild symptoms and symptomatic treatment initially should be sufficient. Also, his medications make antivirals (Paxlovid) difficult. Of course, with any worsening, then he should go to the ER. Not aware of any new medications upcoming."
Internal Medicine
"Given he is high risk and symptomatic and several meds that would need adjustments if we used Paxlovid, I would suggest Lagevrio as the meds would not have to be adjusted. However, its efficacy is less than Paxlovid. Might consider monoclonal antibodies. If Paxlovid is used, you would have to stop the statin and either stop or adjust Xarelto. Would have to stop the amiodarone as well. Not aware of any new meds at this time."
Internal Medicine
"Could use Paxlovid, but clinically I have seen better response to short course Decadron, and DayQuil NyQuil. Paxlovid has never been shown to shorten the course of COVID or impact mortality. It did decrease the risk of hospitalization, but that was during the omicron version of this virus. Saw a lot of hospitalization then, but current strain rarely causes severe disease, so don’t feel you can really translate that previous data to current treatment."
To explore more peer insights on managing COVID-19 treatment in older adults, or share your own approach, read the full case on Healthcasts.
