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COVID-19 Outpatient Therapeutics - Patient Eligibility Intake Form

IMPORTANT UPDATES:

Statement regarding Omicron Subvariants

11/21/22 Update: With the rapid increase in the circulation of certain SARS-CoV-2 Omicron subvariants in the United States, California, and our geographical region, the SHC COVID-19 Outpatient Therapeutics Team has decided to implement the following changes to our monoclonal antibody (mAb) therapies for the prophylaxis and treatment of COVID-19:

Pre-exposure prophylaxis [Evusheld]
- The subvariants BA.4.6, BA.2.75.2, BA.5.2.6, BF.7, BQ.1, and BQ.1.1 are likely to be resistant to tixagevimab plus cilgavimab (Evusheld). Certain SARS-CoV-2 viral variants may not be neutralized by Evusheld and may not be effective at preventing COVID-19 caused by these variants.
- Effective 11/21/22, SHC will halt the scheduling of new outpatient Evusheld appointments and close the Evusheld provider referral RedCap form
- Effective 11/23/22, SHC will halt ALL administrations of Evusheld for inpatient and outpatient areas.
- Patients who are eligible to receive Evusheld as PrEP should be informed of the following recommendations as preventative measures:
  - Receive a bivalent COVID-19 vaccine unless contraindicated due to a history of severe adverse reactions to a COVID-19 vaccine or any of its components.
  - Continue to take precautions (e.g. masking in public indoor areas) to avoid exposure.
Treatment [Bebtelovimab]
- The subvariants BQ.1 and BQ.1.1 are likely to be resistant to bebtelovimab. Certain SARS-CoV-2 viral variants may not be neutralized by bebtelovimab and may not be effective at treating COVID-19 caused by these variants.
- Effective 11/21/22, SHC will halt the administration of bebtelovimab.
- Based on the latest NIH COVID-19 Treatment Guidelines, the following therapeutics are expected to be active against these resistant subvariants and are available for the treatment of mild to moderate COVID-19 in non-hospitalized adults who are at high-risk of progressing to severe disease in order of preference:
  - ritonavir-boosted nirmatrelvir (Paxlovid)
  - remdesivir (Veklury) [IV infusion for 3 consecutive days]
  - molnupiravir (Lagevrio)

The COVID-19 Outpatient Therapeutics Team will continue to monitor this situation closely and provide updates. Our team will do our best to communicate information about these changes to patients. We ask for your assistance in informing your staff and patients. Thank you for your efforts in providing excellent care and evidence-based approaches to our patients.

Thank you,

The SHC COVID-19 Outpatient Therapeutics Team

Do NOT submit this form for hospitalized patients or compassionate use requests.

Do not leave anything blank. To ensure clinical eligibility, available drug supply, and appointment capacity, our current process requires that all requests be reviewed and approved by a clinical team member. Upon receipt of the pertinent clinical information, you will receive a response via email within 24-48 hours about approval status and possible next steps.

SHC reserves the right to select the infusion therapy based on medication supply and clinical data available at the time of the referral.

For questions, please email dl-shc-pharmacy-covid@stanfordhealthcare.org.

Is the patient currently admitted to the hospital?

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Yes

COVID-19 Outpatient Therapeutics - Patient Eligibility Intake Form

IMPORTANT UPDATES:

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