The Latest in Critical Care, 2/26/24 (Issue #31)

Tenecteplase for stroke after 4.5 hours; Lumbar drains after SAH; Covid update; Patient complexity going up

Covid Update: Two new drugs for mild-moderate symptoms; Fluvoxamine RCT; Covid “brain fog”

Paxlovid improves outcomes for the elderly and other people at high risk for severe Covid, but the best available data suggest it doesn’t meaningfully help healthier, younger people. Two new drugs do appear to reduce mild-moderate Covid symptoms, but won’t be available in the U.S. anytime soon.

Simnotrelvir, a new compound, was tested against placebo in a phase 2–3 randomized trial among 1,208 patients with mild to moderate Covid-19 in China. Patients receiving simnotrelvir got better faster (by about a day and a half), had greater declines in viral load (and presumably less shedding, although transmissibility was not tested). There were no serious adverse events; 4% experienced hypertriglyceridemia, and 2% experienced neutropenia. The drug is available in China, but there is no known pending FDA application.

Another new compound called ensitrelvir, marketed as Xocova under an emergency use authorization in Japan, reduces symptoms by about one day, and appeared to improve smell and taste more quickly than placebo, along with reducing viral positivity. Phase 3 trials are still ongoing.

Will there even be a market for these new drugs in the United States, where most people at lower risk for severe Covid now forgo yearly vaccination or testing during illness, and where the CDC has decided to meet Americans where they are by curtailing recommended isolation to (in essence) ‘until you start to feel a little better’?

In other Covid news:

Fluvoxamine 100 mg bid, after showing promise in an improvised randomized trial in the late Delta era, was not shown to speed recovery from mild-to-moderate Omicron-era Covid, among 1,175 people in a randomized trial published in JAMA. 

Persistent symptoms of Covid affect an estimated 65 million people worldwide, but so-called “long Covid” has proven to be very difficult to define or study productively. A new Danish study helps place the concept of post-Covid “brain fog” in context with sequelae from other illnesses. Patients (n=120) who experienced severe Covid-19 in 2020 and 2021 (Delta era) were prospectively followed post-discharge and compared with 125 controls who had been hospitalized for myocardial infarctions or pneumonia, and 100 non-hospitalized healthy controls. When compared to healthy controls, people who had recovered from severe Covid had lower scores on cognitive testing and other psychiatric and neurologic tests. However, the decreases in cognitive scores after severe Covid were similar to declines seen in patients after hospitalization for myocardial infarction or pneumonia. Read in JAMA Network Open