This article was medically reviewed by Dr. Ellen Hirsh.
Since the start of the pandemic, the global medical community has been working on vaccines and drug treatments for COVID-19, and they’ve made significant advances against the disease. Several vaccine and treatment options are available now. Among healthcare providers and the public, understanding is replacing fear, and there’s an increasing expectation that we’ll soon be able to manage COVID-19 much more like influenza, and less like a public health emergency.
But it’s been a costly struggle to get to this point. According to the World Health Organization, we’ve recently exceeded 485 million total cases and 6.1 million deaths globally due to COVID-19. Fortunately, several positive factors now support an optimistic outlook. One is that in New Jersey, our full vaccination rate is relatively high at 74.5%, and our daily case rate has dropped from 37,000 on January 5, 2022, to under 1,000 per day currently.
The Infectious disease specialists at ID Care understand COVID-19 treatment options and are an important source of current information and insight as we move into this more hopeful phase of the pandemic. In this blog, Dr. Ellen Hirsh provides a guide to the latest FDA-authorized COVID-19 treatments and drugs to address every stage of the disease, from vaccines and antiviral medications to long COVID support groups:
- Pre-exposure prophylaxis is for uninfected people who have not been exposed to COVID-19.
- Post-exposure prophylaxis is for uninfected high-risk individuals who have been exposed, to prevent the virus from reproducing and causing symptoms.
- Early infection treatment is for the first 5-7 days of the disease, targeting the virus when it is present and active.
- Later infection treatment focuses on the complications remaining after the virus has left the body, including those who experience long COVID, or post-COVID conditions.
Along with updates on virus variants, herd immunity, and testing recommendations, this information can help you make the best healthcare decisions to protect yourself and your loved ones as we enter year three of life with COVID-19.
COVID-19 Treatments and Drugs
Are there FDA-authorized drugs to treat COVID-19 infection? The answer is yes. Several have emergency use authorization (EUA), which represent the FDA’s permission to expedite the availability and use of a drug before its full FDA review process is completed, and only where the known and potential benefits are greater than the potential risks. This is for cases where the drug shows a high likelihood of safety and effectiveness, and an emergency such as a pandemic means that waiting for the usual process to run its course would be too costly in lives. Emergency use authorization is considered very carefully by the FDA and is not applied to experimental or poorly understood drugs.
Generally, the treatment approach and medicines used for COVID-19 are classified by 1 of 4 stages of the disease’s progression:
1. Pre-Exposure Prophylaxis
Vaccines & Boosters
Pre-exposure prophylaxis is preventative treatment, and for most people, the first and most important step is simply vaccination. Typically, your first vaccine shots are called primary immunizations, or a primary series. After some months, later shots are called boosters. The primary series will generate immunity about two weeks after your last dose. Boosters work without delay because your body has already been taught to make these specific antibodies.
“Anybody with a normally functioning immune system who can get vaccinated, should get vaccinated against COVID-19” advises Dr. Hirsh, adding that “it’s the best preventative available, and it’s been used safely in many millions of people worldwide.”
Vaccine and booster recommendations vary by age and risk groups, so the term fully vaccinated means different things for different people. Dr. Hirsh warns that “to avoid confusion, we are now using the term up to date, which means you’ve received all the vaccine and booster shots currently recommended specifically for you.”
Vaccine and Booster Recommendations
Note: only Pfizer is FDA-approved for use in children under 18 — adults may choose Moderna or Pfizer:
- Children under age 12 should get 2 primary vaccine doses 3 weeks apart, with no booster.
- Children aged 12 to 17 should get a 2-dose primary series, 3-8 weeks apart, followed by a booster 5 months later.
- Adults aged 18 to 50 should get a 2-dose primary series (Pfizer is given 3-8 weeks apart and Moderna is given 4-8 weeks apart. The second dose should be spaced out as much as possible to decrease risk and increase efficacy.), followed by a booster in 5 months.
- People with compromised immune systems should get a 3-dose primary series, followed by booster shots.
- Now everyone 50 and over is eligible for a fourth shot if they so desire.
The second method of pre-exposure prophylaxis is administration of a drug called Evusheld, a 2-shot preventative series of 2 different monoclonal antibodies for people in high-risk groups whose immune systems can’t respond or tolerate the vaccine. Essentially, it is injecting antibodies directly instead of having the vaccine spur antibody production, with a similar protective effect.
2. Post-Exposure Prophylaxis
Since October of 2021, some people in high-risk groups who’ve been exposed to COVID-19 may have been prescribed the monoclonal antibody Sotrovimab in a single 500 mg infusion to prevent infection. However, as of late March 2022, authorization to use this drug in certain areas, including New Jersey, has been rescinded. This is due to the Omicron BA.2 subvariant displacing BA.1 to account for more than 50% of cases in these areas, and Sotrovimab has proven ineffective at treating BA.2. Fortunately, alternative medicines are expected to be effective for post-exposure prophylaxis against Omicron BA.2.
“At first,” said Dr. Hirsh, “we were taking antibodies from people who had recovered from COVID, but now we can manufacture those antibodies in the lab. There’s no blood product involved at all, increasing its safety, and the extra antibodies help fight off infection.”
3. Early Infection Treatment for COVID-19
Once the virus has a foothold in your body and has begun to reproduce, you’re in the early infection stage. For vaccinated people not at high risk for complications, symptoms will likely be very mild. However, unvaccinated people and those in high-risk groups may require medication to interrupt the disease and reverse severe symptoms. These medications are generally restricted to be started in the first 5-7 days of illness
The following medications are authorized for treating early infection in high-risk patients or those hospitalized with COVID-19:
- Sotrovimab: monoclonal antibody, single 500 mg infusion, as an outpatient (NOTE: currently not authorized for Omicron BA.2/NJ)
- Bebtelovimab: monoclonal antibody, single 175 mg injection, outpatient basis
- Remdesivir: IV antiviral, 200 mg infusion on day 1, then 100 mg on days 2 and 3, inpatient
- Molnupiravir: oral antiviral, 800 mg (maximum) pill twice daily for 5 days, outpatient basis
- Paxlovid: oral antiviral, 150-300 mg pill twice daily for 5 days, outpatient basis
Although Sotrovimab is not effective on Omicron BA.2, it can still be a useful treatment option at this stage for previous COVID-19 variants and will produce antibodies to help fight the infection. In these cases, the drug can reduce hospitalization and death by over 80 percent if given within 7 days of a COVID-19 diagnosis.
“We’ve also been using the FDA-approved antiviral Remdesivir with hospitalized patients for a long time,” said Dr. Hirsh, “and it’s very safe and extremely effective. The two outpatient antiviral medications available now, Paxlovid and Molnupiravir, are both available under emergency use authorization.”
Paxlovid and Remdesivir are the mainstays at this stage. It is not advisable to start steroids at this time given another indication for its use, such as asthma or COPD. If you are already on steroids for another reason, they should be continued, but talk to your physician for specific recommendations for your situation. and it’s also important for patients to discontinue steroid use when taking either of them to avoid the drugs’ immunosuppressant effects.
Are there OTC Medications for Treating COVID-19?
If your symptoms are mild, over-the-counter non-prescription drugs may offer some relief, but they do not address the COVID virus.
“OTC medications will not treat COVID, but some can help alleviate the symptoms,” advises Dr. Hirsh, “so after you’ve informed your doctor of your COVID-19-positive status, there’s no reason to avoid trying these medicines, including non-steroidal anti-inflammatory drugs like ibuprophen.”
What About COVID & Antibiotics?
Many people wonder: are antibiotics effective in preventing or treating COVID-19?
Antibiotics can be effective against bacterial infections, but COVID-19 is a viral infection, so they won’t help to eliminate it. However, COVID-19 can cause viral pneumonia, which can irritate the airways, making the lungs more susceptible to subsequent bacterial infection, which may then require treatment with antibiotics.
Dr. Hirsh warns to never take antibiotics pre-emptively, because “if you take them upfront, you will not prevent bacterial pneumonia from happening, you’ll only create more antibiotic-resistant bacteria, which is a very bad idea.”
4. Later Infection Treatment
At this final stage in the disease’s progression, the virus is essentially gone, so antiviral medications are no longer useful. You’re basically dealing with leftover complications such as excessive lung inflammation and blood clots.
“When you come to the hospital with COVID-19,” advises Dr. Hirsh, “even if you’ve had no clots, we’ll give you medicine to prevent clots from forming, because they are a common complication, along with secondary bacterial infections.”
Inflammation can be a particular danger at this time, particularly in the lungs. With no virus remaining, the immunosuppressant effects of anti-inflammatory steroids are less of a concern, so they are a good choice to treat inflammation at this stage.
“Sometimes, corticosteroids alone are enough,” said Dr. Hirsh, “but the quicker you reduce inflammation in the lungs, the easier it is to breathe, and the less secondary scarring or fibrosis will remain in your lungs. Sometimes, though, an even stronger immunosuppressant is required.”
In these cases, physicians can resort to using medications that shut down the inflammation pathway. Currently, the most commonly used are drugs such as Tocilizumab, an IL-6 inhibitor, and Baricitinib, which is a JAK inhibitor. These interfere with different inflammatory pathways to suppress overstimulation. The concern with these medications is an increased risk of reactivating infections, so careful screening and monitoring is paramount:
- Tocilizumab (Actemra): max dosage is 800 mg through single intravenous infusion, but can be repeated once
- Baricitinib (Olumiant): dosage varies based on kidney function, administered in pill form, for up to 14 days.
Post-COVID Conditions, Treatment and Support Groups
Commonly known as long COVID, the medical community refers to COVID-19 related symptoms that persist for more than three months as post-COVID conditions. These can include all the usual symptoms, plus others such as anxiety, depression, and sleeplessness. In the worst cases, they can be debilitating and require targeted treatment.
According to Dr. Hirsh, “patients who’ve been on a respirator may need pulmonary rehabilitation. Those with neurological problems may need neuro rehab. Some “long-haulers” need help with post-traumatic stress disorder. Fortunately, rehabilitation centers and support groups have begun addressing these post-COVID conditions, so help is available and increasing.”
For example, the Post-COVID Recovery Program at Robert Wood Johnson Hospital is open for enrollment. Located in New Brunswick, NJ, the Program focuses on evaluating COVID long-haulers and categorizing the different presentations of long COVID. Patient-centered support groups for post-COVID conditions can be found through the Centers for Disease Control (CDC) as well as local healthcare providers.
Seeking Medical Care for COVID-19
It is generally important to treat viral infections quickly, while the virus is still vulnerable. Waiting to treat COVID-19 when symptoms are severe may result in inflammation, lung scarring, and other serious complications of the virus. At that late stage, antiviral medicines won’t help.
Dr. Hirsh advises people with positive test results to “contact your primary care doctor for advice and treatment tailored to you and your situation. Don’t wait for problems with breathing when it may be too late.”
Testing for COVID-19
At-home, rapid antigen tests are not as sensitive as the polymerase chain reaction (PCR) tests you’d get at a doctor’s office, hospital, or lab. They tend to produce more false negative results, especially early in the disease’s progression, but are a convenient and useful tool.
There are three categories where home testing is recommended:
- If you have symptoms of COVID-19, take a test. If negative, repeat the test in 2 days to confirm you are not infected.
- If you’ve been exposed to someone with COVID-19, wait 5 days and then take a test. If negative, repeat the test in 2 days to confirm you are not infected. Avoid others during the waiting period to prevent potentially exposing them.
- If you plan to attend a large event such as a conference, wedding, or other big party, take a rapid test before you go. If positive, stay home. If negative but you still feel sick, stay home.
Which test you take depends on your specific situation. For example, travel authorities may require a negative PCR test and not accept an antigen test. For an event like a wedding, an antigen test is ok because it’s quick and tells if you’re contagious. “It’s adequate for that use.” said Dr. Hirsh. Either test, if positive, is adequate to diagnose for treatment purposes.
Treating COVID-19 Variants
After the original form of the virus thought to have emerged from the wild, COVID-19 has mutated several times, producing variants of the disease that differ in transmissibility and severity. These include Delta, later supplanted by Omicron BA.1, and now Omicron BA.2 (also known as stealth COVID).
According to Dr. Hirsh, “Certain viruses always mutate. They move, reproduce, recombine, and change at a genetic level.” For instance, with influenza there are new variants every year. We refer to small changes as “drifts”, and very large changes as “shifts”. Every year the vaccine is adjusted based on predicted variants and, over time, years of vaccinations give broader protection. Every century or so there is a large change, a shift, such as the 1918 Influenza pandemic, which can be much more disruptive and challenging.
“Not all these changes are a bad thing,” she added. “The Omicron variants are more transmissible than the prior Delta variant, so they spread much more quickly. However, Omicron tends to stay up in the upper airways, so it presents more like a cold and less like pneumonia, which is a good thing.”
So far, all COVID-19 variants can be detected by standard tests and countered well with existing vaccines and drug treatments.
Herd Immunity: Are We Close?
Herd immunity is the state where so many people are immune that the virus can’t find enough vulnerable people to infect, and it dies out. The percentage of immune people required to produce herd immunity is different for each virus, but generally requires a large percentage of the population to be vaccinated. For instance, for polio it is 80% and measles 95%. For COVID-19, it is not known.
As of this publishing date in New Jersey, Omicron BA.2 makes up about 25% to 35% of total cases, and it’s doubling rapidly. However, Dr. Hirsh is not concerned because the state’s total number of cases is declining: “We’re seeing fewer cases even though we have more-contagious variants. That’s a good sign that herd immunity is not too far off.”
ID Care’s Role in the COVID-19 Pandemic
When it comes to determining the best course of medication and other treatments for COVID-19, whether for straightforward cases or those fraught with complications, ID Care infectious disease doctors are uniquely positioned to offer guidance based on their specialized training, experience, and expertise.
According to Dr. Hirsh, “part of an infectious disease doctor’s role is staying up to date on the latest research, clinical trials, and medical literature, but also communicating directly with other medical professionals and the community.” This is especially true when existing medical literature is scarce, as it was at the beginning of the COVID-19 pandemic.
Over time, our understanding and treatment arsenal have grown. We’re now moving toward a brighter future in COVID-19 management, and infectious disease specialists remain a critical resource. With extensive hands-on experience, ID Care doctors can provide lifesaving guidance in emergent or hard-to-treat situations.
“Although pandemic protocols prevent ID Care from treating COVID-19 patients in our offices,” said Dr. Hirsh, “our long experience treating HIV/AIDS and other complex infectious diseases helps us understand the testing and treatment nuances that other doctors usually don’t have the opportunity to learn. As we consult with hundreds of organizations and individuals at home, in hospitals, and in other care facilities, our patients benefit from this deeper insight.”