Recently, on major social platforms, many people have said that they are "yang" again, with symptoms such as fever, cough, and sore throat. Hospital pharmacies are also receiving more and more calls from patients for antiviral treatment, especially in the case of recovery.
So, do I need to take antiviral drugs when I am infected with the new crown (including Fuyang) now? How should special groups such as the elderly, children, and pregnant women be treated?
In fact, in the mainland, the new crown has long been adjusted from "Category B and A" to "Category B and B". In fact, with the continuous mutation of the new coronavirus strain, its pathogenicity has decreased significantly compared with the early stage, and it is more similar to upper respiratory tract infection, mainly manifested as dry throat, sore throat, cough, fever, etc., and the fever is mostly moderate and low-grade fever. In addition, although the clinical presentation in children is similar to that of adults, there are relatively more cases of high fever. At present, the prognosis of most patients is still good, and critical illness is more likely to occur in the elderly, people with chronic underlying diseases, women in the third trimester of pregnancy and perinatal period, and obese patients.
For new crown patients, the first thing should be to ensure adequate nutritional intake, drink water regularly to avoid dehydration, and pay attention to water and electrolyte balance. Secondly, symptomatic treatment can be given, such as patients with high fever (generally more than 38.5°C) can be physically cooled and take antipyretic drugs; Patients with severe cough and expectorant can take cough and expectorant drugs; Patients diagnosed with bacterial infections should take antimicrobial drugs, but it is important to note that the new crown is a viral infection and should avoid blindly using antimicrobial drugs.
Small molecule oral drugs are currently the most important antiviral treatment regimens for new coronavirus infection, including nirmatrelvir/ritonavir (Paxlovid), azvudine, molnupiravir, sennotrelvir/ritonavir, deuteromedevir hydrobromide, leretgravir, atetegravir/ritonavir, etc., which are generally suitable for adult patients with mild and moderate symptoms and high-risk factors for progression to severe disease, and should be used as soon as possible, and it is advisable to use within 5~7 days of the first appearance of symptoms. In September 2022, the World Health Organization (WHO) updated its guidelines for the treatment of COVID-19, recommending systemic use of glucocorticoids in combination with baricitinib or IL-6 receptor blockers (e.g., tocilizumab) for patients with severe or critical COVID-19.
Treatment of the child
According to statistics, the course of COVID in most children is mild, and the mortality rate of children with COVID is much lower than that of adults, especially compared to elderly patients, and the number of hospitalizations is relatively small. For children with COVID, the type, number, and severity of comorbidities can influence drug treatment decisions. Most children with mild to moderate COVID do not develop more severe disease, so it is recommended to receive only supportive care, such as antipyretics, cough suppressants, expectorants, anti-allergy drugs, etc., which are commonly used in pediatrics, and should be treated symptomatically with water to avoid dehydration, pay attention to rest, and supplement nutrition.
In terms of drugs, it is forbidden to take molnupiravir for children infected with the new coronavirus, because it may affect the development of children's bones and joint cartilage, and it is forbidden under 18 years old. Other anti-COVID small molecule drugs should also be used with caution, and should be considered in combination with the child's vaccination status and his or her own underlying medical conditions. High-risk children (such as moderate or severe immunocompromise) can choose to take nirmatrelvir/ritonavir within 5 days of symptom onset for treatment at the age of 12~17 years old.
For intermediate-risk children, aged between 12~17 years, there is currently insufficient evidence to recommend or oppose any antiviral therapy. In addition, corticosteroids are not indicated for the treatment of non-hospitalized children, but they may be used in children with asthma and croup caused by viral infections. In children with acute laryngitis or tracheitis, glucocorticoids are preferred, and budesonide can be nebulized if they cannot be taken orally.
Maternal treatment
For pregnant women, the severity of the coronavirus, the risk of disease progression, and the safety of specific drugs for fetuses, infants, pregnant or lactating individuals should be considered. Although the overall risk of COVID is relatively low, the risk of severe disease in pregnant women is higher than that of non-pregnant women, and the risk of preterm birth and stillbirth in maternal patients is also a fact.
In general, the treatment and management of pregnant patients should be the same as that of non-pregnant patients, with supportive care preferred, plenty of rest, plenty of water to avoid dehydration, the use of a humidifier or inhaled steam to relieve nasal congestion, monitoring body temperature, and symptomatic treatment with appropriate antipyretics, cough suppressants, expectorants, and anti-allergy drugs. It is worth mentioning that maternal patients should pay attention to whether there is pregnancy toxicity when taking drugs, for example, the antipyretic drug ibuprofen is grade C before 30 weeks of pregnancy, and D after 30 weeks (the drug during pregnancy is divided into 5 grades A, B, C, D, and X, and the safety is gradually decreasing, and grade X is prohibited), at this time it is more appropriate to choose acetaminophen.
Antiviral therapy during pregnancy is a more important trade-off. Nirmatrelvir/ritonavir can be used as an option for antiviral therapy early in infection, and breastfeeding women receiving nirmatrelvir/ritonavir can still breastfeed. Leretgravir should only be used if the benefits outweigh the risks, and other anti-COVID small molecule drugs are generally not recommended. Molnupiravir is not recommended if there are no other options and the patient has indications for treatment and a clear benefit. Patients are not advised to breastfeed while taking molnupiravir and for 4 days after the last dose.
In terms of other drugs, Brazil is only used during pregnancy if the benefits outweigh the harms, it is a large molecule drug, so generally only a small amount is thought to be secreted to the baby through milk, and patients can consider breastfeeding. The use of baricitinib also needs to consider the possible harm to the fetus, and nursing mothers should avoid breastfeeding during the drug and for 4 days after the last dose. Tocilizumab needs to be used with a trade-off. In addition, infliximab should only be considered if baricitinib and tocilizumab are unavailable or limited, but breastfeeding patients receiving infliximab may continue breastfeeding.
There is evidence that the coronavirus is not transmitted through breast milk, but this does not mean that nursing mothers do not spread the virus through things like coughing or sneezing while breastfeeding. The safest option is to pump milk and let someone who is not infected feed the baby. If a nursing mother insists on breastfeeding her baby herself, it is important to wash her hands before breastfeeding and wear a mask to take precautions.
Treatment of the elderly
Advanced age is the most important risk factor for severe COVID consequences. The risk of severe disease increases with age in older people, especially those aged 65 or older. In particular, older patients with pre-existing underlying medical conditions, including heart disease, lung disease, diabetes, or cancer, are more likely than patients of other ages to develop severe disease and even death.
The general treatment of the elderly is the same as that of adults, such as rest, hydration, nutrition, symptomatic treatment, etc. Dexamethasone or other systemic corticosteroids should not be used in patients with mild to moderate disease who do not require hospitalization or supplemental oxygen. For patients at high risk of progression to severe COVID, antiviral therapy should be initiated, and nirmatrelvir/ritonavir should be started as soon as possible within 5 days of symptom onset. Because the elderly often have multiple underlying diseases, they also take more drugs together. Drug-drug interactions need to be noted when administering antiviral therapy.
In fact, ritonavir is a strong cytochrome P450 (CYP) 3A4 inhibitor and P-glycoprotein (P-gp) inhibitor, and is used in combination with nirmatrelvir to increase blood concentrations so that its treatment of the virus is effective and sustainable. However, ritonavir may also increase blood levels of certain concomitant drugs, which may induce serious and even life-threatening drug toxicity. It is worth mentioning that the inhibitory effect of ritonavir on CYP3A4 will occur rapidly, and the maximum inhibitory effect usually occurs within 48 hours after taking ritonavir, in addition, after discontinuation of ritonavir, 70~90% of the inhibitory effect of CYP3A4 will gradually subside within 2~3 days, but it will take longer for the elderly.
Therefore, effective safety measures such as changing the treatment regimen, suspending the use of concomitant drugs, adjusting the dose, and monitoring for adverse effects may be required for safety reasons when elderly patients are taking drugs together. For example, the risks of the anti-epileptic drug carbamazepine, the cardiovascular drug amiodarone, and the anti-infective drug rifampicin will outweigh the potential benefits when combined with nirmatrelvir/ritonavir, and the treatment strategy needs to be changed in time. It is currently considered clinically appropriate to recommend molnupiravir, leretrelgravir, or deuterium remidevir hydrobromide in the early stages of infection in older patients at risk of drug interactions.
Treatment of other conditions
For patients with hepatic and renal insufficiency, it is recommended to give priority to molnupiravir or leretgravir for early treatment. Among them, patients with hepatic insufficiency need to pay attention to monitoring liver function indicators when using leretrelvir. For nirmatrelvir/ritonavir, nirmatrelvir is mainly excreted by the kidneys, ritonavir is mainly cleared by the hepatobiliary system, and the dose should be halved in patients with moderate kidney injury, and it is not recommended for patients with severe liver and kidney injury. Similarly, atetergravir/ritonavir is not recommended in patients with severe liver and kidney impairment.
In terms of new crown treatment, traditional Chinese medicine syndrome differentiation treatment can also be carried out according to the condition, and the common Chinese patent medicines include Huoxiang Zhengqi Capsule, Shufeng Jiedu Capsule, Jinhua Qinggan Granules, Lianhua Qingwen Capsules (granules), dampness and sepsis granules, Xuanlung sepsis granules, and cold and dampness dissipation granules, etc., which will not be repeated here.
The reality is that everyone can get infected with COVID more than once, and getting vaccinated and seeking effective treatment options can help reduce the risk of severe disease.
It is currently believed that when reinfected with the new coronavirus, the symptoms of patients are relatively mild, which is in line with immunological principles, but patients must not take it lightly, otherwise it may also lead to serious consequences. In fact, once infected with the coronavirus, the immune system responds, and this effect can protect the patient from reinfection for a period of several months or so, but this "protection" gradually weakens over time, that is, it is normal for reinfection to occur.
But even if reinfection occurs, the autoimmune system "helps" the patient to avoid severe symptoms or illness as much as possible. Studies have shown that the severity of a person's reinfection appears to be related to the severity of their initial infection. However, long COVID is more likely to occur after the first infection than after reinfection, such as feeling tired, coughing frequently, or difficulty sleeping, breathing, thinking, etc.
To sum up, the new crown is not terrible, and the recovery is not terrible, this is true for adults, and the same is true for special groups. In this regard, it is not advisable to let things go unchecked, and there is no need to be alarmist and honest. Remember: effective protection and standardized treatment are the first priority, and safe and rational drug use is the key.
Author: Shi Haoqiang, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine