Put inhaled and oral COVID-19 treatments in perspective

This topic will discuss the new trial about using Inhaled steroids, oral colchicine and fluvoxamine for treating COVID-19...
Abdelwahab Ward, BS Pharm, PharmD

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

  1. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. Available at: https://www.covid19treatmentguidelines.nih.gov.
  2. Ramakrishnan S., D V., et al. (2021). Inhaled budesonide in the treatment of early COVID-19 illness: a randomised controlled trial. medRxiv 2021.02.04.21251134.
  3. Jean-Claude Tardif, et al. Efficacy of Colchicine in Non-Hospitalized Patients with COVID-19. medRxiv 2021.01.26.21250494
  4. Lenze EJ, Mattar C, Zorumski CF, et al. Fluvoxamine vs Placebo and Clinical Deterioration in Outpatients With Symptomatic COVID-19: A Randomized Clinical Trial. JAMA. 2020;324(22):2292-2300.
Abdelwahab Ward, BS Pharm, PharmD