Table 3.
Overview of recommended therapies for SARS-CoV-2 infection.
| Medication and dose | ||
|---|---|---|
| Antiviral therapy | Indication | Important comments and considerations for CLD and LT recipients |
| Remdesivir (Veklury) 200 mg on day 1 followed by 100 mg on days 2 and 3 (intravenous). |
Prevention of severe COVID-19 in at-risk patients (within 7 days of symptom onset). | Monitoring liver parameters, eGFR. Usage in patients with an eGFR of <30 only if the potential benefits outweigh the risks. No significant DDI is expected. |
| Nirmatrelvir/ritonavir (Paxlovid) 300 mg (2 tablets)/100 mg (1 tablet) twice daily for 5 days (per os) |
Prevention of severe COVID-19 in at-risk patients (within 5 days of symptom onset). | Monitoring liver parameters and eGFR#, not recommended in advanced cirrhosis, caution in LT because of DDI. |
| Molnupiravir (Lagevrio) 800 mg (4 tablets) twice daily for 5 days (per os) |
Prevention of severe COVID-19 in at-risk patients (within 5 days of symptom onset). | Contraindicated in pregnancy and in women of childbearing potential not using effective contraception, no significant DDIs are expected. Monitoring liver parameters, eGFR#. |
| mAbs Sotrovimab (Xevudy) 500 mg (intravenous) Bebtelovimab 175 mg (intravenous) Tixagevimab/cilgavimab (Evusheld) 150 mg/150 mg or 300 mg/300 mg (intramuscular) – only approved for pre-exposure prophylaxis |
Prevention of severe COVID-19 in at-risk patients (unvaccinated individuals or individuals without detectable serological response to vaccination. Treatment within 72 hours but no longer than 7 days after symptom onset (post exposure prophylaxis). Recommendations are based on the current knowledge of the in vitro activities of available mAbs against the circulating SARS-CoV-2 variants and subvariants. |
Monitoring for hypersensitivity reactions.Consider SARS-CoV-2 variants (e.g. sotrovimab is not recommended if omicron BA.2 is dominant). Serology (antibody) assessment is not essential in immunocompromised patients. |
|
Immunomodulatory therapies | ||
| Dexamethasone 6 mg for 10 days (per os or intravenous) |
Treatment of COVID-19 WHO ≥5 (oxygen demand) | Monitoring liver parameters. HBsAg/anti-HBc test, prophylactic NAs in HBsAg-positive patients, adjust immunosuppression in LT. |
| Janus kinase 1/2 inhibitor Baricitinib (Olumiant) 4 mg per day for 14 days (per os) |
COVID-19 WHO ≥5 (oxygen demand) in addition to dexamethasone | Dose adjustment if eGFR <60, not recommended if eGFR is <15. Monitoring of eGFR, liver parameters. HBsAg/anti-HBc test, prophylactic NAs in HBsAg-positive patients, adjust immunosuppression in LT, no combination with anti-IL-6. |
| IL-6 receptor antagonist tocilizumab (Actemra) 8 mg/kg (<65 kg = 400 mg, up to 90 kg = 600 mg, >90 kg = 800 mg) as a single dose (intravenous). |
COVID-19 WHO 6-9 (High-flow oxygen demand, NIV) in addition to dexamethasone | Monitoring liver parameters. HBsAg/anti-HBc test, prophylactic NAs in HBsAg-positive patients, adjust immunosuppression in LT, no combination with JAKI, contraindicated in patients with absolute neutrophil count <2,000/μl; active tuberculosis. |
DDI, drug-drug interactions; eGFR, estimated glomerular filtration rate; JAKI, Janus kinase inhibitor; LT, liver transplantation; mAbs, monoclonal antibodies; NAs, nucleos(t)ide analogues.
#
Because of limited experience outside clinical trials.