Investigators who tracked the use of COVID-19 medications in nursing homes describe prescribing patterns that “fluctuated dramatically” over time, shedding new light on the ups and downs of clinical care during the pandemic.
Data came from the electronic health records of 11 nursing home chains in the United States between Jan 1, 2018, and March 31, 2022. Records represented over 59,000 unique residents. Investigators identified medications that were approved for treating COVID-19-related conditions or known to be used off-label for COVID-19 during the study period.
Shifting evidence base, availability
The researchers observed general increases and decreases in COVID-19 medication use after Food and Drug Administration actions, such as the issuing and revoking of emergency use approvals and medication use approvals. However, the uptake of some authorized medications was lower than expected, likely due to a shifting evidence base and availability of the drugs, the researchers said. Similarly, off-label use of some drugs continued after evidence of inefficacy.
Overall, there were 48 National Institutes of Health guidelines posted from April 21, 2020, to March 24, 2022, the investigators reported. This presented a major challenge for prescribers as they attempted to remain current and incorporate the rapidly changing guidelines in clinical practice, Andrew R. Zullo, PharmD, PhD, of Brown University in Providence, RI, and colleagues wrote.
Clinical practice “lag time”
“[We] found that medication use did not always reflect what the NIH guidelines recommended at a particular time, likely due to the lag time typically necessary to implement new guidance in clinical practice,” the authors explained.
The use of nirmatrelvir co-packaged with ritonavir (Paxlovid), for example, made up only 21.3% of orders involving one of its two components, ritonavir, in the first quarter of 2022, despite Paxlovid’s emergency use authorization in December, 2021. In comparison, ritonavir use alone rose sharply after the Paxlovid EUA, even though ritonavir alone was not recommended by NIH guidelines during the study period.
Also of note, and contrary to the researchers’ hypothesis, remdesivir (Veklury) was not commonly used in U.S. nursing homes throughout the study period, despite authorization for use in non-hospital settings, including nursing homes. A key reason could be its high cost and low availability, they theorized.
Most commonly used meds
Overall, the antibiotic azithromycin and the steroid dexamethasone were the most common COVID-19-related medications used during the study period. These were followed by the immunosuppressive and anti-parasite drug hydroxychloroquine and the off-label anti-parasite drug ivermectin.
“Providers should continue to diligently modify their prescribing as new evidence accrues,” the researchers concluded.
Full findings were published in JAMDA.
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