COVID-19 Oral Antivirals


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glenn b. -

During supply shortages shouldn't we limit these to *unvaccinated* high-risk patients? The studies done on the unvaxxed. The already vaxxed should be considerated relatively low risk for hospitalization/death.

Reuben Strayer (@emupdates) -

That is what the New York State guidelines I mentioned recommend. Here are the prioritization criteria NYS has come up with:

Ryan A. -

As of this writing, whenever I click on the "full image" button I get an "access denied" error.

Reuben Strayer (@emupdates) -


tom f. -

Hello Reuben!
Excellent review. Short, clear, concise, informative, Brooklyn-like.
Hope all is not too chaotic at Maimonides.

tom fiero,
Ps; i finally caught covid last week

Ky H. -

Thank you for this update.

Michael O. -

There seems to be decent evidence for inhaled steroids in the treatment of COVID (including this However this is prohibitive due to cost. I have been trying to think of ways to decrease cost for these therapies and realized that steroid nasal sprays are $10-20 at most pharmacy locations. The cap of these allows for a 18 gauge needle to pass through and facilitates capture of the liquid when pumped. When mixed with a saline bullet this nebulizes well.

For Fluticasone 50 mcg/spray it takes 1.1 mL to get about 440 mcg
For Budesonide 32 mcg/spray it takes 1.75 mL to get 800 mcg

Nebulizers are available online for $40 to $60. Fluticasone is less expensive OTC and requires less volume. A single bottle would allow BID dosing for 7 days meaning for about $50 a patient could use this completely OTC strategy and based on the data hopefully decrease ED visits and Hospitalizations.

Do you know if anyone is doing this? I'd love to hear the thoughts from the EM:RAP COVID and Pharm experts!


Mel H. -

Michael I will ask Sean Nordt and the team about it

Anand S. -

Seems like data on inhaled steroids is mostly in terms of reducing cough - small benefit. No real reduction in terms of hospitalization or other important outcomes. I think if the patient's cough is really bad, this is a reasonable intervention (costs aside)

Andrew A. -


With paxlovid and "non-recommended" drugs such as calcium channel blockers,warfarin etc can we reduce these drugs by say 1/2 or what is the recommendation. Obviously with warfarin following the INR. Also if dose reduction is the recommendation, how long after the 5 day course should the reduction be continued (additional 24 hrs????). The warning by not contraindicated meds don't give any guidance.

Reuben Strayer (@emupdates) -

Hi Andrew, this is one of several thorny issues for prescribers. There is no guidance I'm aware of and I doubt there will be any guidance that applies broadly–the decision to hold or reduce a drug dose is going to depend on the individual patient and drug. For example, discontinuing a statin is probably not a big problem but discontinuing warfarin potentially is, and might be best done in collaboration with the patient's other clinicians.

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EM:RAP 2022 Breaking News January 6th: COVID-19 Oral Antivirals Full episode audio for MD edition 9:12 min - 11 MB - M4A