COVID-19 treatment planning in general practice
Page last updated: 10am, 3 April 2023.
GPs play a crucial role in supporting patients to prepare for potential COVID-19 infection.
There are several different treatments available in Australia and more may be approved in future. Some treatments are available in community pharmacies with a prescription, while others are only available in hospital-based clinics.
GPs can currently prescribe the following medications that are listed on the Pharmaceutical Benefits Scheme (PBS):
- Paxlovid® (nirmatrelvir + ritonavir) – an oral antiviral medication
- Lagevrio® (molnupiravir) – an oral antiviral medication
- Evusheld™ (tixagevimab and cilgavimab) – an intra-muscular injection for the prevention (pre-exposure prophylaxis) of COVID-19
These treatments can significantly reduce the risk of hospitalisation and death in high-risk patients. However, they are not suitable for everyone, and prescribing GPs need to work with individual patients to determine whether they are suitable.
On this page:
- Which treatment should GPs prescribe?
- Tips for prescribers
- Pre-infection planning
- When to refer to hospital clinics
- Resources and more information
Which treatment should GPs prescribe?
Paxlovid vs Lagevrio
Paxlovid reduces risk of severe disease by 90 per cent (source: New England Journal of Medicine). Every effort should be made to prescribe Paxlovid if it is suitable for the patient.
Lagevrio reduces risk of severe disease by 30 per cent. It is a good alternative for lower risk patients if Paxlovid is not suitable. Please note that on 7 December 2022, the National Clinical Evidence Taskforce made a recommendation against routine use of molnupiravir for the treatment of COVID-19.
To receive Paxlovid or Lagevrio, patients must be COVID-positive, symptomatic, not in hospital and within 5 days of infection. These medications are not to be prescribed for patients prophylactically, or as a delayed “back pocket” prescription. Confirmation of infection can be by conversation between a patient and their GP.
Contraindications are listed on HealthPathways Melbourne and on the product information for Paxlovid (.pdf) and Lagevrio (.pdf). These documents are available on the Therapuetic Goods Administration website. The Liverpool tool for interactions is useful for working out drug interactions and medication changes.
Evusheld is an intra-muscular (IM) injection for the prevention (pre-exposure prophylaxis) of COVID-19 in eligible people. Victoria was allocated a limited supply of Evusheld through the National Medical Stockpile; however, this tock expires on 31 December 2022 and it is highly unlikely that further stock will be available from the stockpile in 2023. Therefore, from January 2023 access will be up to individual hospitals to consider making available.
GP should consider prescribing Evusheld for severely immunocompromised individuals not expected to mount an adequate immune response to COVID-19 vaccination or due to underlying medical conditions or treatments that compromise the body’s immune system.
Tips for prescribers
Paxlovid is the drug of choice but there are several significant and potentially severe drug interactions and issues for those with impaired renal function. Approximately 25 per cent of eligible patients will not be able to be prescribed Paxlovid.
The Liverpool tool for interactions is useful for working out drug interactions and medication changes. It uses a traffic light system to highlight interactions and how to manage them. Many contraindicated medications can be withheld or reduced for the period of Paxlovid prescription. For further advice call the Victorian COVID-19 therapies PBS prescriber helpline on (03) 8290 3801.
Refer higher risk patients who cannot take Paxlovid to hospital clinics for remdesivir. Visit COVID-19 Treatment Referrals on HealthPathways Melbourne to find out where and how to refer. Lagevrio is an alternative for lower risk patients and has fewer interactions; however, it has much lower efficacy (around 30 per cent compared to 90 per cent for Paxlovid).
Use the RACGP’s eGFR table – also available as a .pdf – to determine whether or not Paxlovid is recommended for your patient. There is no hard and fast rule for the recency of the eGFR, although in the past 6 months is generally considered OK. This period could be shortened or lengthened using your clinical judgement about stability and risk factors for renal disease. If the patient is high risk and there is no recent eGFR or doubt about stability, refer them to a hospital clinic.
Make a COVID treatment plan
Use CAT4 to find high risk patients. You could recall high-risk patients for a specific consultation to make a COVID treatment plan or do this opportunistically during an elective/non-urgent consultation. Example COVID treatment plan templates are available to download:
- Version A produced by North Western Melbourne Primary Health Network’s GP Adviser Dr Jeannie Knapp
- Version B produced by the Western Public Health Unit
Raise awareness in the practice
This could be through posters in the waiting room, an email/SMS campaign or using your website to explain how your practice manages appointments for COVID-19 treatments, and advising high-risk patients to speak to their GP.
Find out which local pharmacies are stocking COVID-19 medications
All pharmacies should now be able to get oral antivirals in within 24 hours. However, it is worth knowing if any local pharmacies always have stock. Victorian Supercare Pharmacies should all have stock on hand.
Evusheld is available in selected community and hospital pharmacies.
Educate patients on:
- how to access and use a rapid antigen test (RAT) – easy read instructions (.pdf) are available
- testing early – and when to have a PCR. For example: if a high-risk patient has COVID-19 symptoms but is returning negative RAT results, they should have an early PCR rather than wasting days waiting for a positive RAT.
- how to register their RAT result and why
- contacting their GP early if they test positive.
Accessing appointments for treatment
Providing appointments for high-risk patients can be challenging but it is time critical.
- Consider having some daily urgent telehealth appointments set aside for COVID positive patients, to prescribe antiviral treatments, if suitable.
- Provide training for your reception team to manage these urgent appointment requests.
- Have a plan for when you have no availability. GPs could consider referring COVID positive patients to general practice respiratory clinics for face-to-face COVID care.
- Know your local COVID care pathways.
Things to ask regarding patient
- Which medication is preferred for this patient?
- What are the contraindications and interactions?
- Can interacting medications be safely withheld?
- Does this patient have the cognitive ability to adjust the dose/withhold their existing mediation if prescribed Paxlovid?
- Is it available within the timeframe?
Writing the prescription and dispensing
- Consider adding the eGFR to Paxlovid prescriptions so the pharmacist knows it has been considered or call and speak to the pharmacist.
- Make sure all contact details are correct.
- Ensure the patient has a method to collect the medication.
When to refer to hospital-based clinics
Hospital-based infectious diseases clinics access COVID-19 medications through the National Medical Stockpile and use different criteria to the PBS. Each hospital service also has its own internal criteria.
Hospital-based clinics have access to remdesivir, which is the drug of choice for high-risk patients who cannot take Paxlovid.
GPs should consider referring to hospital-based clinics in the following situations:
- Patients who do not meet the PBS criteria but who you are concerned about
- High-risk patients who have a contraindication to Paxlovid
- High-risk pregnant and breastfeeding patients
- High-risk patients aged under 18
- High-risk patients at day 5 to 7 after infection
- Large outbreaks needing support, such as outbreaks in residential care facilities
Visit COVID-19 Treatment Referrals on HealthPathways Melbourne to find out where and how to refer.
For decision making resources and more information refer to:
- the Victorian Department of Health’s clinical decision making guide
- the National COVID-19 Evidence Taskforce’s decision tool available in the Clinical Flowcharts section
- the Liverpool tool for drug interactions
- RACGP resources including a prescribing workflow
- the Victorian COVID-19 therapies PBS prescriber helpline on (03) 8290 3801
- HealthPathways Melbourne
- our webinar held on 20 June 2022 (please note the PBS eligibility criteria for Paxlovid and Lagevrio have expanded since this webinar)
- our example COVID treatment plan template available in .rtf, .docx and .pdf formats
- CAT4 recipes to find and recall high-risk patients including:
- Identify ATAGI recommended groups due for a winter booster shot (.pdf)
- Identify Aboriginal and Torres Strait Islander patients aged over 50 years due for a winter booster shot (.pdf)
- Identify immunocompromised patients aged over 16 years due for a winter booster shot (.pdf)
- COVID-19 Vaccine Winter Booster 1a+ Identify immunocompromised of age due for a winter booster shot
- Identify at-risk patients and view their booster vaccine status
- Display count of patients who have received any of the COVID-19 vaccines administered at your practice