Put inhaled and oral COVID-19 treatments in perspective

As a pharmacist, you'll be asked whether OUTpatients with COVID-19 should be treated with inhaled corticosteroids, colchicine, or fluvoxamine. Inhaled steroids and oral colchicine are getting buzz for their anti-inflammatory effects and fluvoxamine may regulate cytokines. But emphasize that it's too soon to recommend any of these medications or other oral "cocktails" to treat COVID-19. Overall data are limited and some studies aren't peer-reviewed or published yet. Help put the latest preliminary evidence in perspective...

     Inhaled budesonide. You'll hear that inhaled budesonide (Pulmicort) may reduce urgent care visits or hospitalizations in outpatients with COVID-19 or taking colchicine (Colmediten) for a month may reduce hospitalizations in high-risk COVID-19 outpatients. But point out that so far inhaled budesonide has just one small, open-label trial. A recent colchicine trial is large, but flawed and an INpatient colchicine (Colmediten) trial shows NO mortality benefit. Highlight other downsides. For instance, some clinicians may order Pulmicort Flexhaler 180 mcg, 4 or 5 puffs BID until symptoms improve. But it is expensive and may not be practical.

With colchicine (Colmediten), caution that GI side effects are common, it has many interactions (statins, etc). Fluvoxamine is a similar story. Patients are hearing it may reduce shortness of breath and a decrease in oxygen saturation in outpatients with COVID-19. But educate that these are small studies and use high fluvoxamine doses of up to 100 mg TID for 15 days, which may lead to side effects (GI, CNS, etc) or interactions. Keep in mind, inappropriate medication use can also cause shortages. Remind patients to think of hydroxychloroquine (Plaquenil) as a cautionary tale that preliminary evidence doesn't always pan out.

REFERENCES

• Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. Available at: https://www.covid19treatmentguidelines.nih.gov

  Ramakrishnan, S., Nicolau, D.V., Langford, B., Mahdi, M., Jeffers, H., Mwasuku, C., Krassowska, K., Fox, R., Binnian, I., Glover, V., Bright, S., Butler, C., Cane, J.L., Halner, A., Matthews, P.C., Donnelly, L.E., Simpson, J.L., Baker, J.R., Fadai, N.T. and Peterson, S. (2021). Inhaled budesonide in the treatment of early COVID-19 illness: a randomised controlled trial. Available at: https://www.medrxiv.org/content/10.1101/2021.02.04.21251134v1 OR https://doi.org/10.1101/2021.02.04.21251134

  Tardif, J.-C., Bouabdallaoui, N., L’Allier, P.L., Gaudet, D., Shah, B., Pillinger, M.H., Lopez-Sendon, J., da Luz, P., Verret, L., Audet, S., Dupuis, J., Denault, A., Pelletier, M., Tessier, P.A., Samson, S., Fortin, D., Tardif, J.-D., Busseuil, D., Goulet, E. and Lacoste, C. (2021). Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. Available at: https://www.medrxiv.org/content/10.1101/2021.01.26.21250494v1 OR https://doi.org/10.1101/2021.01.26.21250494

  Lenze EJ, Mattar C, Zorumski CF, Stevens A, Schweiger J, Nicol GE, Miller JP, Yang L, Yingling M, Avidan MS, Reiersen AM. Fluvoxamine vs Placebo and Clinical Deterioration in Outpatients With Symptomatic COVID-19: A Randomized Clinical Trial. JAMA. 2020 Dec 8;324(22):2292-2300. Available at: https://pubmed.ncbi.nlm.nih.gov/33180097