Coronavirus Disease 2019 (COVID-19) Medication

Updated: Sep 16, 2021
  • Author: David J Cennimo, MD, FAAP, FACP, FIDSA, AAHIVS; Chief Editor: Michael Stuart Bronze, MD  more...
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Medication

Medication Summary

Remdesivir was the first drug approved by the FDA for treating the SARS-CoV-2 virus. It is indicated for treatment of COVID-19 disease in hospitalized adults and children aged 12 years and older who weigh at least 40 kg. [21]  The broad-spectrum antiviral is a nucleotide analog prodrug. Full approval was preceded by the US FDA issued an EUA (emergency use authorization) on May 1, 2020 to allow prescribing of remdesivir for severe COVID-19 (confirmed or suspected) in hospitalized adults and children prior to approval. [149]  Upon approval of remdesivir in adults and adolescents, the EUA was updated to maintain the ability for prescribers to treat pediatric patients weighing 3.5 kg to less than 40 kg or children younger than 12 years who weigh at least 3.5 kg. [22]   

Investigational treatments include other antiviral agents, vaccines, immunomodulators, monoclonal antibodies, convalescent plasma, and antithrombotics. Several of the above therapies and vaccines have been granted emergency use authorization by the FDA.

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Vaccines

Class Summary

The FDA has granted emergency use authorization for the vaccines listed below.

COVID-19 vaccine, mRNA-Pfizer (BNT-162b2 [Pfizer])

December 11, 2020: Emergency use authorization (EUA) issued by FDA for active immunization to prevent COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals aged ≥16 years. Administered IM as a 2-dose series 3 weeks apart. 

COVID-19 vaccine, mRNA-Moderna (MRNA-1273 [Moderna])

December 18, 2020: Emergency use authorization (EUA) issued by FDA for active immunization to prevent COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals aged ≥18 years. Administered IM as a 2-dose series 1 month apart. 

COVID-19 vaccine, viral vector-Janssen (Ad26.COV2.S [Johnson & Johnson])

February 27, 2021: Emergency use authorization (EUA) issued by FDA for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in individuals aged ≥18 years. Administered IM as a single dose. 

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Monoclonal Antibodies

Class Summary

Recombinant neutralizing human IgG1-kappa monoclonal antibodies (mAb) exert their effect by binding to various sites on the SARS-CoV-2 spike protein. All are indicated for mild-to-moderate COVID-19 disease in adults and adolescents who are at high risk for progressing to severe COVID-19 and/or hospitalization.

Casirivimab/imdevimab (REGEN-COV)

FDA granted EUA November 21, 2020. Casirivimab and imdevimab IV solution are each supplied in individual single-dose vials and are admixed in the same IV bag. May also be administered SC when an IV infusion is not feasible. In July 2021, the EUA updated to include use as postexposure prophylaxis for individuals at high risk of progression to severe COVID-19, including hospitalization or death, and are not fully vaccinated or are not expected to mount an adequate immune response. 

Sotrovimab

FDA granted EUA May 26, 2021. Binds to conserved epitope of the spiked protein of SARS-CoV-1 and SARS-CoV-2, thereby indicating unlikelihood of mutational escape. 

Etesevimab

FDA granted EUA February 9, 2021. Etesevimab can only be used with bamlanivimab by admixing each dose within the same IV bag. Etesevimab and bamlanivimab bind to different but overlapping epitopes in the receptor-binding domain of the S-protein. In clinical trials, bamlanivimab and etesevimab administered together resulted in fewer treatment-emergent variants relative to bamlanivimab administered alone. However, the proportion of SARS-CoV-2 variants of concern (VOCs) with reduced susceptibility to bamlanivimab plus etesevimab (P.1, B.1.351, and B.1.617) sequenced from U.S. residents continues to grow. As of June 11, at least 10 states have ceased using this combination and recommend prescribing casirivimab plus imdevimab or sotrovimab.

Bamlanivimab

FDA granted EUA November 9, 2020. Owing to the increase in variants of concern (VOC) in the United States, monoclonal antibodies that have gained emergency use authorization have been tested to evaluate activity against VOCs. As of March 24, 2021, distribution has ceased of bamlanivimab alone. Consider use of etesevimab plus bamlanivimab, casirivimab plus imdevimab, or sotrovimab in outpatients who qualify for monoclonal antibodies.

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Corticosteroids

Class Summary

NIH guidelines for COVID-19 recommends use of dexamethasone to reduce mortality in hospitalized patients who are mechanically ventilated or those requiring supplemental oxygen without mechanical ventilation. [380]  These recommendations are based on results of the RECOVERY trial. [23]  

If dexamethasone is unavailable, use alternant glucocorticoids (eg, prednisone, methylprednisolone, or hydrocortisone). [380]  

Dexamethasone

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and reducing capillary permeability; stabilizes cell and lysosomal membranes.

Prednisone (Deltasone)

Consider use if dexamethasone is unavailable. Available as oral formulation. 

Methylprednisolone (A-Methapred, DepoMedrol, Medrol)

Consider use if dexamethasone is unavailable. Available as IV formulation.

Hydrocortisone

Consider use if dexamethasone is unavailable. Available as oral or IV formulations.

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Antiviral Agents

Class Summary

Remdesivir is the first drug approved by the FDA for COVID-19.

Remdesivir (Veklury)

Adenosine nucleotide prodrug that distributes into cells, where it is metabolized to form the pharmacologically active nucleoside triphosphate metabolite. Inhibits SARS-CoV-2 RNA-dependent RNA polymerase (RdRp), which is essential for viral replication. It is indicated. It is indicated for treatment of COVID-19 disease in hospitalized adults and children aged 12 years and older who weigh at least 40 kg. An EUA is approved for pediatric patients weighing 3.5 kg to less than 40 kg or children younger than 12 years who weigh at least 3.5 kg. 

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Immunomodulators

Class Summary

Immunomodulators plus other treatment modalities (eg, remdesivir, glucocorticoids) may be considered for hospitalized patients with severe COVID-19 to blunt the hyperinflammation caused by cytokine release.

Tocilizumab (Actemra)

June 24, 2021: Emergency use authorization (EUA) issued by the FDA for treatment of coronavirus disease 2019 (COVID-19) in hospitalized adults and pediatric patients (aged >2 years) who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or ECMO.

Baricitinib (Olumiant)

November 19, 2020: Emergency use authorization (EUA) issued by the FDA for use, in combination with remdesivir, for treatment of suspected or laboratory confirmed coronavirus disease 2019 (COVID-19) in hospitalized patients aged ≥2 years who require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). The EUA was revised in July 2021 to allow use with or without remdesivir.

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