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COVID-19

Therapy for Non-Hospitalized Patients


Key Points Updated 1-26-23
  • Outpatient antiviral COVID-19 therapeutics are widely available but underused. This is especially true in communities of color, low-income communities, and in long term care facilities.
  • The majority of adults and some children with symptomatic COVID-19 are eligible for antiviral treatment. This includes people who are not up to date with COVID vaccinations, people in a racial or ethnic minority group, people with disabilities and common underlying health conditions including obesity, depression, smoking (former or present), and physical inactivity. See CDC Risk Factors for Severe COVID-19.
  • Antiviral treatment of outpatients at risk for severe COVID-19 reduces their risk of hospitalization and death. Recent studies of Paxlovid in highly COVID-19 immune populations demonstrate significant reductions in hospitalizations and deaths among patients 18 and older who had risk factors for severe disease with the largest benefits in unvaccinated patients and in patients who are ≥65 years-old and/or immunocompromised (regardless of vaccination/previous infection).
    • Studies have also shown that Paxlovid may reduce the risk of developing post-COVID symptoms and also decreases SARS-CoV-2 viral load faster compared with people not treated.
  • Three antiviral therapies are available Paxlovid, IV remdesivir (Veklury), and molnupiravir (Lagevrio). Monoclonal antibodies are no longer available for treatment.
    • Paxlovid is the preferred treatment for most adults and children (12 years of age and older weighing at least 40 kg).
      • Paxlovid has been shown to be safe, including in fragile, elderly people.
      • Many commonly used medications can be safely co-administered with Paxlovid despite potential for drug-drug interaction. Guidance is available on simple steps (such as brief suspension or dose reduction) to avoid significant interactions with commonly prescribed medications.
  • High risk patients co-infected with influenza and COVID-19 should be treated for both viruses. Co-infection is associated with more severe illness. There are no clinically significant drug-drug interactions between the antiviral agents or immunomodulators that are used to prevent or treat COVID-19 and the antiviral agents that are used to treat influenza.
  • The potential for COVID-19 rebound or mild side effects is NOT a reason to avoid treatment. Rebound occurs in the minority of people treated with COVID-19 therapeutics and is typically mild. Rebound can also occur in people who are not treated.

Recommended actions for providers

  • Ensure patients with suspected COVID-19 are tested. Self-tests are acceptable.
  • Enable pathways for symptomatic individuals who test positive for SARS-CoV-2 to connect to a prescriber as soon as possible within 5 days of symptom onset for evaluation for treatment. Patients should be told that a new law enacted Sept 25, 2022 requires all health plans in California to cover out-of-network care for patients seeking COVID-19 therapeutics evaluation with no cost sharing to patients.
  • Have a low threshold to prescribe COVID-19 therapeutics given the broad range of individuals who are at higher risk for severe COVID-19 who may benefit from COVID-19 outpatient treatment.
    • Call the CA COVID-19 Provider Therapeutics Warmline at 1-866-268-4322 (866-COVID-CA) to receive free and confidential consultation including drug-drug interactions or any other COVID-19 treatment or testing questions. Healthcare providers of any experience can call to speak with a clinician or pharmacist. Available Monday-Friday 6am-5pm; voicemail messages left after hours will be returned the next business day.
    • If you are unable to provide a timely service to your patients with COVID-19, refer them to a prescribing pharmacy, test to treat program, or DPH Telehealth service. Information for the public about these options is available at the DPH patient webpage ph.lacounty.gov/covidmedicines or call 1-833-540-0473.

Quick Links

Provider Therapeutics Warmline: 1-866-268-4322 (866-COVID-CA)

  • Monday-Friday: 6 am – 5 pm.
  • Voicemail messages left after hours will be returned on the next business day.

Updates

  • Evusheld not currently authorized for use until further notice (1-26-23). The FDA has revised the Emergency Use Authorization for Evusheld (tixagevimab/cilgavimab) to limit its use to when the combined frequency of non-susceptible SARS-CoV-2 variants nationally is less than or equal to 90%. Per the most recent CDC Nowcast data, non-susceptible SARS-CoV-2 variants are projected to be more than 90% of current infections nationally. See FDA announcement.
  • CDC Webinar: Updates to COVID-19 Testing and Treatment for the Current SARS-CoV-2 Variants-Recorded on 1-24-23. View archived recording | See slides
  • CA Provider Therapeutics Warmline support now available. Beginning 1-9-23, health care providers can call 1-866-268-4322 (866-COVID-CA) to receive free and confidential consultation on COVID-19 testing and treatment. The COVID-19 Therapeutics Warmline is a real-time resource available to all California health care providers and is managed by the University of California, San Francisco (UCSF) National Clinician Consultation Center.
  • Assistance available in implementing Test to Treat programs. The COVID-19 Test to Treat Equity ECHO can assist clinics and community-based sites in implementation of their own Test & Treat programs. This program will consist of:
    • CA Statewide Webinar – 2nd Wednesday of each month, 12-1pm PT A monthly webinar with presentations by expert faculty and a moderated Q&A panel discussion with subject matter experts. Register for the CA Statewide webinar
    • Southern California Test and Treat ECHO Sessions-- 3rd Wednesday of each month, 12-1pm PT. A more intimate, small group Q&A session with hands-on clinical discussion and technical support with multi-disciplinary expert panelists. Register for the Southern CA sessions
  • A positive COVID-19 test is no longer required to prescribe remdesivir. In December 2022, the FDA revised the Veklury (remdesivir) labeling to remove having a positive SARS-CoV-2 viral test result from the indication. See Veklury (remdesivir) label
  • CDPH Health Alert: Reminder to Lower Barriers to Prescribing COVID-19 Therapeutics to Mitigate Impact of COVID-19 (12-2-22, reposted from 11-27-22). There is an ample supply, but treatments are underused – especially among populations disproportionately impacted by COVID-19. CDPH states that providers should have a low threshold to prescribe COVID-19 therapeutics given the broad range of individuals who are at higher risk for severe COVID-19 and can benefit from COVID-19 treatment. See CAHAN.
  • Bebtelovimab is no longer authorized in the US because it is not expected to neutralize Omicron subvariants BQ.1 and BQ.1.1. Providers are asked to retain their supplies in the event that variants susceptible to bebtelovimab become more prevalent in the future. See FDA announcement.
  • New service for Community Care Facilities: Facilities that have 3 or more patients with COVID symptoms and a positive test can request the DPH mobile therapeutics service. See flyer - English | Spanish
  • Shelf Life Extensions have been granted for certain lots of Evusheld, Bebtelovimab and Paxlovid

Please be sure to review the major changes section of the FDA provider fact sheets periodically to review any new updates.

Who should receive outpatient therapy for COVID-19?
Clinicians should prescribe COVID-19 treatment to the extent possible to outpatients who meet all of the following:
  • Test positive for SARS-CoV-2 (with PCR or antigen test, including self-tests)
  • Have symptoms consistent with mild or moderate COVID-19 illness
  • Are within 5 days of symptoms onset for Paxlovid and molnupirivir or 7 days of symptom onset for IV remdesivir
  • Have one or more risk factors for severe COVID-19 including:
    • Age over 50 years, especially those 65 and older, regardless of the presence of a medical condition
    • Being unvaccinated or not being up to date on COVID-19 vaccinations
    • Being in a racial or ethnic minority group
    • Having common underlying health conditions and behaviors such as physical inactivity, obesity, depression, smoking (former or present), and disabilities. See CDC comprehensive discussion.

For more information, see the CDC webpage Interim Clinical Considerations for COVID-19 Treatment in Outpatients.

To view the IDSA COVID-19 Risk Continuum graphic see Understanding Risk for Severe COVID-19 webpage.

The following factors should NOT be reasons to withhold COVID-19 treatment:

  • Being fully or partially vaccinated
  • Having a history of prior SARS-CoV-2 infection
  • Presence of only mild disease. Patients with mild symptoms are included in criteria for outpatient treatment according to the FDA EUA and NIH recommendations.
  • A lack of recent renal or liver function tests. The FDA EUA does not require assessment of laboratory results.

Clinicians should have a low threshold to prescribe COVID-19 therapeutics given the broad range of individuals who are at higher risk for severe COVID-19 and can benefit from COVID-19 treatment.

Outpatient Treatments for COVID-19

Three antiviral therapies are currently FDA approved or authorized for outpatient treatment of COVID-19 infection and recommended by the NIH COVID-19 Treatment Guidelines Panel. They are not approved for pre- or post-exposure prophylaxis. Importantly, they retain full activity against the current variant mix in California.

Antiviral Medication (in order of preference) FDA Status Mode/duration of Administration Start time from symptom onset Age/Weight Fact sheet/Webpage
1. Paxlovid FDA EUA Oral twice daily for 5 days ≤5 days Age ≥12 who weigh ≥40kg Providers
Patient/caregivers
2. Remdesivir FDA Approved IV infusion daily for 3 days ≤7 days Adults and children age ≥28 days who weigh ≥3kg Providers
Patients
3. Molnupiravir FDA EUA Oral twice daily for 5 days ≤5 days Adults ≥18 (not recommended in pregnancy) Providers
Patient/caregivers
HHS Side-by-Side Overview of Therapeutics
See Side-by-Side Overview of Therapeutics for additional information.
Paxlovid

Paxlovid (nirmatrelvir 300 mg with ritonavir 100 mg), given within 5 days of symptom onset, is the preferred treatment for adults and pediatric patients (12 years of age and older weighing at least 40 kg) with symptomatic COVID-19 and risk factors for progression. It is taken orally twice a day for 5 days.

Studies have shown that Paxlovid:

  • Reduces the risk for hospitalization and death by 50-88% among unvaccinated people and by 45–50% among vaccinated or previously infected people.1,2,3 Recent studies in highly COVID-19 immune populations conducted during omicron circulation show significant reductions in hospitalizations among patients aged 18 and older with risk factors for severe disease (see Table below).
  • May decrease the risk of developing post-COVID symptoms. 4,5,6,7 The extent and scale of impact that long COVID may have on individual and population health are yet to be revealed and may be quite significant.
  • Decreases SARS-CoV-2 viral load faster compared with people not treated, suggesting the potential for decreased transmission and isolation time for test-result-based isolation protocols.1
  • Has been shown to be safe, including in older adults.1,8 Risks are minimal, especially when weighed against benefits.

Most commonly used medications can be safely co-administered with Paxlovid

The potential for COVID-19 rebound is not a reason to avoid prescribing Paxlovid

  • COVID-19 rebound is the term used to describe a recurrence of symptoms and/or SARS CoV-2 antigen positivity which can occur between 2 and 8 days after initial recovery. The etiology of this phenomenon is not known. Recent small studies suggest that rebound may happen when people have a strong immune response to COVID-19; neither the development of resistance nor the absence of neutralizing antibody were likely causes of rebound 9, 10
  • Rebound has been observed in the minority of patients treated with Paxlovid or molnupiravir11,12 It also occurs in patients who did not receive COVID-19 therapeutics 13,14 A preprint by Deo et al found that 1 out of 8 people who did not receive COVID-19 therapy experienced rebound. Those that rebounded were more likely to be older. Among those that rebounded, only 10% had symptoms.
  • Rebound is typically mild. Recent studies suggest that patients who experience rebound have an extremely low probability of developing severe COVID-19. Retreatment is not currently recommended.
FDA Paxlovid Patient Eligibility Checklist
FDA Paxlovid patient eligibility checklist PDF
Paxlovid Prescribing Provider Tool
Paxlovid Prescribing Provider Tool Word Document

Paxlovid package information

  • Standard packaging for patients with normal renal function:
    • 300 mg nirmatrelvir;100 mg ritonavir - Each carton contains 30 tablets divided in 5 daily-dose blister cards.
    • Each blister card contains 4 nirmatrelvir tablets (150 mg each) and 2 ritonavir tablets (100 mg each). Nirmatrelvir tablets and ritonavir tablets are supplied in separate blister cavities within the same child-resistant blister card.
  • New packaging option for patients with reduced renal function: See Dear Healthcare Provider Letter
    • 150 mg nirmatrelvir; 100 mg ritonavir - Each carton contains 20 tablets divided in 5 daily-dose blister cards.
    • Each blister card contains 2 nirmatrelvir tablets (150 mg each) and 2 ritonavir tablets (100 mg each). Nirmatrelvir tablets and ritonavir tablets are supplied in separate blister cavities within the same child-resistant blister card.

Paxlovid sample prescriptions

  • Prescription for patients with normal renal function
  • Prescription for patients with reduced renal function
Thumbnail of COVID-19 Rebound PDF
FAQs for patients - COVID-19 Rebound:
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FDA: Letter of authorization | FAQs on the EUA  | FDA letter: new medication packaging for patients with moderate renal impairment  |  Fact sheet for health providers  |  Fact sheet for patient/caregivers

Other resources: Pharmacist Authority to Prescribe

Remdesivir

Remdesivir (Veklury) is the only treatment approved for children under 12 years of age. It is given as an IV infusion for a total of 3 days initiated as soon as possible and within 7 days of symptom onset.

In clinical trials, remdesivir reduced the risk of hospitalization or death by 87% among high-risk unvaccinated patients with COVID-19 treated within 7 days of symptom onset (Gottlieb, 2021).

Given the emergence of variants resistant to mAbs, providing remdesivir in the outpatient setting may be of particular importance for facilities and providers that see large numbers of immunosuppressed patients such as transplant and oncology centers, or high-risk pediatric populations. Providers are encouraged to order remdesivir to have on hand for patients unable to take Paxlovid.

  • FDA approved for the treatment of COVID-19 in adults and pediatric patients (28 days of age and older weighing at least 3 kilograms) who are:
    • Hospitalized, or
    • Not hospitalized and have mild-moderate COVID-19 and are at high risk for progression to severe COVID-19, including hospitalization and death.
      Note: In December 2022, the FDA revised the remdesivir labeling to remove having a positive SARS-CoV-2 viral test result from the indication.
  • For information regarding purchasing or how to access remdesivir, please email remdesivir@amerisourcebergen.com, or call 1-800-746-6273 or reach out directly to your AmerisourceBergen representative.
  • CMS has created the Healthcare Common Procedure Coding System (HCPCS) code J0248 for reimbursement when administered in an outpatient setting. This code is available for use by all payers and is effective for dates of service on or after December 23, 2021. Additional information is available here.

FDA: Press release FDA approval for children | Information for providers vekluryhcp.com | Information for patients wwwwww.veklury.com

Molnupiravir

Molnupiravir (Lagevrio) is authorized as an alternative therapy when Paxlovid and remdesivir are not available, feasible to use, or clinically appropriate. It is given as 800 mg (four 200 mg capsules) taken orally every 12 hours for 5 days. Treatment started as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset.

  • Molnupiravir is a nucleoside analogue that inhibits SARS-CoV-2 replication by viral mutagenesis.
  • Due to concern for side effects and decreased risk reduction compared to other available medications, molnupiravir should only be used if other treatments are not available or not clinically appropriate.
  • Several studies have shown a risk reduction in severe disease after molnupiravir treatment with the most significant benefit in those at highest risk or elderly (≥75 years of age). In addition, there is evidence of more rapid symptom resolution and viral load reductions in people treated with molnupiravir. See table below.
  • Use in adults 18 and older only. Not recommended in pregnancy. If the provider and patient choose to use the product during pregnancy, it is advised that the patient be registered in the Merck Pregnancy Surveillance Program.
  • Females of childbearing potential should use a reliable method of contraception correctly and consistently, as applicable, for the duration of treatment and for 4 days after the last dose of molnupiravir.
  • Males of reproductive potential who are sexually active with females of childbearing potential should use a reliable method of contraception correctly and consistently during treatment and for at least 3 months after the last dose.
  • Providers should carefully review the Fact sheet for health providers before prescribing to ensure that the patient’s condition warrants treatment, that there are no drug interactions, and that there are contraindications to therapy.
FDA Molnupiravir Patient Eligibility Checklist
FDA Molnupiravir patient eligibility checklist PDF

Molnupiravir sample prescription:

FDA: Letter of authorization | FAQs on the EUA  | Fact sheet for health providers  |  Fact sheet for patient/caregivers

Summary of Effectiveness
Table: Summary of studies analyzing the effectiveness of oral antivirals during omicron
Study Population Drug Time analyzed Outcomes
Ganatra et al., 2022
  • 1,130 patients receiving nirmatrelvir/ritonavir and 1:1 propensity score matched controls
  • 18 yrs or older, fully vaccinated outpatients
 Paxlovid December – April 2022
  • 45% relative risk reduction in all-cause ED visits, hospitalizations, or death
  • 60% relative risk reduction in hospitalizations and 100% reduction in deaths
Najjar-Debbiny et al. 2022
  • 180,351 patients 18 years or older at high risk for severe COVID-19
  • 75.1% COVID-19 vaccinated
 Paxlovid January - February 2022
  • 46% risk reduction of hospitalizations or death
  • Most benefit in older patients, patients with cardiovascular disease, patients with neurological disease, and immunosuppressed patients
Najjar-Debbiny et al, 2022
  • 2,261 molnupiravir recipients matched with 2661 controls; with at least one RF for severe COVID-19 (≥60 or ≥18 with comorbidities)
  • 77.3% COVID-19 vaccinated
 Molnupiravir January-February 2022
  • Nonsignificant 17% risk reduction of composite outcome (severe disease/death)
  • Significant decrease in risk seen in subgroup analyses;
    • >75 years of age regardless of vaccination: HR= 0.54 (0.34–0.86)
    • females, regardless of vaccination: HR= 0.41 (0.22–0.77)
    • patients with inadequate COVID-19 vaccination HR=0.45 (0.25–0.82)
Arbel et al., 2022
  • 109,213 patients 40 years or older at high risk for severe disease (42,819 65 years or older)
  • 78% of patients had prior immunity (vaccination, prior infection, or hybrid immunity)
 Paxlovid January - March 2022
  • In 65 year or older patients:
  • 67% risk reduction of hospitalizations
  • 81% risk reduction of death
  • No significant benefit in younger adults
Dryden-Peterson et al., 2022 (pre-print)
  • 30,322 patients 50 years old or older
  • 87.2% vaccinated
 Paxlovid January - May 2022
  • 45% risk reduction of hospitalization
  • In unvaccinated individuals 84% risk reduction of hospitalization and death
Wong et al. 2022
  • 1,856 molnupiravir-receiving patients, 890 nirmatrelvir/ritonavir and 2,746 control patients
  • Hospitalized within 3 days before or after COVID diagnosis
 Paxlovid and molnupiravir
February -April 2022
  • 52% risk reduction of all-cause mortality with molnupiravir
  • 66% risk reduction of all-cause mortality with nirmatrelvir/ritonavir
Wong et al., 2022
  • 5,383 molnupiravir receiving patients and 6,464 nirmatrelvir/ritonavir
  • 1:10 propensity score matched controls
  • <50% vaccinated
  • Molnupiravir group older and higher % vaccinated vs. nirmatrelvir/ritonavir group
 Paxlovid and molnupiravir
February – June 2022
  • 24% risk reduction of all-cause mortality with molnupiravir
  • 66% risk reduction of all-cause mortality with nirmatrelvir/ritonavir
  • 24% reduced risk of hospitalization with nirmatrelvir/ritonavir
  • Similar effects of nirmatrelvir/ritonavir across vaccination status and age
Radcliffe et al. 2022
  • 122 solid organ transplant recipients
  • 49 (40%) received molnupiravir
  • 24 (20%) received sotrovimab
  • 48 (39%) untreated
  • 48% ≥3 doses of an mRNA vaccine series or two doses of Ad26.COV2.S
 Molnupiravir January – February 2022
  • 44% risk reduction of hospitalization or death
Butler et al. 2022
  • 25,529 molnupiravir plus usual care vs 12525 usual care alone
  • Outpatients ≥ 50 or ≥18 years with co-morbidities
  • Highly vaccinated group (94% overall had received ≥3 doses of COVID-19 vaccine)
 Molnupiravir December 2021-April 2022
  • 1% hospitalization or death in both groups (no difference) with a trend towards benefit in ≥65
  • Faster recovery in treatment group (median, 9 days vs. 15 days).
  • Faster reduction of viral load in treatment group (undetectable viral load by Day 5 8% molnupiravir vs. 3% usual care)
Pre-exposure prophylaxis

On January 1-26-23 the FDA revised the Emergency Use Authorization for Evusheld (tixagevimab/cilgavimab) to limit its use to when the combined frequency of non-susceptible SARS-CoV-2 variants nationally is less than or equal to 90%. Based on this revision, Evusheld is not currently authorized for use in the U.S. until further notice by the Agency. See FDA announcement.

Evusheld is a combination of two long-acting anti-SARS-CoV-2 monoclonal antibodies administered via intramuscular injection. See CDC Pre-exposure Prophylaxis with Evusheld for more information.

Post-exposure prophylaxis
  • At this time there are no therapeutics authorized for post-exposure prophylaxis that are active against Omicron
Procuring medication for your patients
  • If you are interested in becoming a therapeutics provider, please contact  DPH-Therapeutics@ph.lacounty.gov.
  • This information is intended for medical providers. Information for the public is available here.
  • Patients who are unable to access oral COVID-19 therapeutics through their own provider or who do not have health insurance can be referred to a Test to Treat program or the DPH Public Health Call Center/Tele-Health service, which provides testing, consultation, and prescriptions. 1-833-540-0473 - open 7 days a week, 8:00 am-8:30 pm.

To search by zip code for locations that offer Test-to-Treat (testing, medical visits, and medication), use the federal Get medication for COVID-19 locator.

Patients who are unable to access oral COVID-19 therapeutics through their own provider or who do not have health insurance can be referred to a Test to Treat program or the DPH Public Health Call Center/Tele-Health service which provides testing, consultation, and prescriptions. 1-833-540-0473 - open 7 days a week 8:00 am-8:30 pm.

To search by zip code for locations that fill prescriptions use the federal Get medication for COVID-19 locator.

Patients who are unable to access oral COVID-19 therapeutics through their own provider or who do not have health insurance can be referred to a Test to Treat program or the DPH Public Health Call Center/Tele-Health service which provides testing, consultation, and prescriptions. 1-833-540-0473 - open 7 days a week 8:00 am-8:30 pm.

Facilities can order directly from manufacturer: vekluryhcp.com

Reimbursement and Billing

California’s Department of Health Care Services (DHCS) will still accept claims for individuals enrolled in the COVID-19 Uninsured Group Program. Individuals must apply for the COVID-19 Uninsured Group Program through a Medi-Cal Qualified Provider (QP). QPs are providers of the following programs: Presumptive Eligibility for Pregnant Women, Breast and Cervical Cancer Treatment Program, Hospital Presumptive Eligibility, and Child Health and Disability Prevention. Providers must submit applications via the COVID-19 Uninsured Group Application Portal. Providers can submit their COVID-19 testing, testing-related, and treatment claims to DHCS for claims processing.

Cost Sharing

COVID-19 Therapeutics: Fees for Oral Antivirals

  1. Provider Assessment
    1. Bill insurance if/when available
    2. For uninsured and underinsured, encourage use of free, low-cost care (e.g., HRSA, State-run clinics)
    3. May share cost (full fee or co-pay) with patients
  2. Testing
    1. Encourage use of ICATT sites that provide free testing
      1. Most Walgreens and CVS T2T sites are enrolled in ICATT (working towards all sites)
      2. Otherwise non-ICATT sites may charge patients
      3. Patients are able to use (free) at-home test
  3. Medication
    1. Free for all. No cost sharing with patients
  4. Dispensing Fee
    1. No cost sharing with patients

COVID-19 Therapeutics: Fees for monoclonal antibodies

  1. Provider Assessment
    1. Bill insurance if/when available
    2. For uninsured and underinsured, encourage use of free, low-cost care (e.g., HRSA, State-run clinics)
    3. May share cost (full fee or co-pay) with patients
  2. Medication
    1. Free for all. No cost sharing allowable
  3. Administration Fee
    1. Bill insurance if/when available
    2. For uninsured and underinsured, encourage use of free, low-cost care (e.g. HRSA, State-run clinics)
    3. May share cost (full fee or co-pay) with patients

Resources

Resources and contact information

Contact Information

  • Call the California COVID-19 Provider Therapeutics Warmline at 1-866-268-4322 (866-COVID-CA) for clinical consultation regarding patient testing and treatment including management of drug-drug interactions.
  • For questions related to ordering Paxlovid or Molnupiravir please contact DPH-Therapeutics@ph.lacounty.gov.
References

1Hammond, Jennifer, et al. "Oral nirmatrelvir for high-risk, nonhospitalized adults with Covid-19." New England Journal of Medicine 386.15 (2022): 1397-1408.

2Ganatra, Sarju, et al. "Oral Nirmatrelvir and Ritonavir in Nonhospitalized Vaccinated Patients With Coronavirus Disease 2019 (COVID-19)." Clinical Infectious Diseases (2022).

3Paxlovid Associated with Decreased Hospitalization Rate Among Adults with COVID-19 — United States, April–September 2022 | MMWR (cdc.gov)

4Yan, Xie et al. Nirmatrelvir and the Risk of Post-Acute Sequelae of COVID-19"." MedRxiv Nov 3, 2022

5Sudre, Carole H., et al. "Attributes and predictors of long COVID." Nature medicine 27.4 (2021): 626-631.

6Al-Aly, Ziyad, et al. "High-dimensional characterization of post-acute sequelae of COVID-19." Nature 594.7862 (2021): 259-264.

7Peluso, Michael J., et al. "Early clues regarding the pathogenesis of long-COVID." Trends in Immunology (2022).

8Zhong, Weijie, et al. "The efficacy of paxlovid in elderly patients infected with SARS-CoV-2 omicron variants: Results of a non-randomized clinical trial." Frontiers in medicine 9 (2022).

9Epling, Brian P., et al. “Clinical, Virologic, and Immunologic Evaluation of Symptomatic Coronavirus Disease 2019 Rebound Following Nirmatrelvir/Ritonavir Treatment.” Clinical Infectious Diseases. October 6, 2022.

10Carlin, Alex F, et al. “ Virologic and Immunologic Characterization of Coronavirus Disease 2019 Recrudescence After Nirmatrelvir/Ritonavir Treatment”. Clinical Infectious Diseases. June 20, 2022.

11Ranganath, Nischal, et al. "Rebound Phenomenon After Nirmatrelvir/Ritonavir Treatment of Coronavirus Disease 2019 (COVID-19) in High-Risk Persons." Clinical Infectious Diseases (2022).

12Wang , Linsay et al., "COVID-19 Rebound after Paxlovid and Molnupiravir during January-June 2022. MedRxiv. June 2022.

13Smith DM, Li JZ, Moser C, et al. Recurrence of Symptoms Following a 2-Day Symptom Free Period in Patients With COVID-19. JAMA Netw Open. 2022;5(10):e2238867

14Deo, Rinki, et al., “Viral and Symptom Rebound in Untreated COVID-19 Infection”. MedRxiv.August 2022.



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