Since SARS-CoV2 was recognised as the cause of COVID-19 in 2020, there have been significant changes in the virus and the therapeutic landscape has evolved rapidly, including with the introduction of the highly effective vaccination programme.
Cases of severe COVID-19 pneumonia are very rare except in unvaccinated individuals. Even in those with poor prognostic indicators, the disease is usually mild in vaccinated individuals. In a small group of patients their response to vaccine may be suboptimal and affect outcomes. This is usually seen in patients on B cell depleting agents like rituximab, but this does not apply to all systemic anti-cancer treatments (SACT), nor all monoclonal agents, as it is dependent on the mechanism of action and the specific immunological pathway affected.
Management is broadly divided into:
There are two licensed monoclonal antibodies but Ronapreve® is not considered to be effective against Omicron, so is not currently used. Sotrovimab has reduced in vitro efficacy against Omicron variant BA.2, and currently there are no published clinical data on clinical outcomes with BA.2, or the currently dominant strains of BA.4 and BA.5. These data are likely to evolve.
The UK has four nations commissioned documents for COVID-19 therapeutics which divide patients into three groups. See here for a brief overview of the therapeutic management of each of these groups, with more detail provided below.
Group 1: Hospitalised due to acute COVID-19 infection refers to those with respiratory compromise due to COVID-19 pneumonitis which is currently rare in a vaccinated patient.
Group 2: Hospitalised not due to COVID-19 infection is aimed at COVID-19 acquired in hospital in high risk groups, or where COVID-19 may destabilise a pre-existing condition. It is not for asymptomatic patients, or patients whose symptoms are already improving, or where symptom duration is greater than 5-7 days.
Group 3: Community non-hospitalised and in a defined high risk group will largely have been identified and informed that they are within this group via letters from the Scottish Government. It is not the same as the previous "shielding group", although patients may have been in both. It is not for asymptomatic patients, or symptoms which are improving. The eligibility criteria are pre-defined in the commissioning document which GGC prescribers are not able to change. Patients self-refer by phone (information on NHS inform) for triage and if they fit eligibility criteria they will be prescribed and supplied with treatment via a specified network of community pharmacies.
You must be clear which of the above group your patient falls into to decide on the appropriate therapeutic option, then follow the relevant link for details.
Guideline reviewed: 26/10/2022
Page last updated: 01/09/2023
