These guidelines outline the available therapies for symptomatic hospitalised adult patients with COVID-19 within NHS Lothian. They are based on the guideline published by the National Institute for Health a Care Excellence (NICE) NG191  which were adopted by the Scottish Medicines Consortium and describes the local implementation. It will be updated if this is superseded or if the evidence base for these therapies changes significantly.

However, NHS Lothian has made several local adaptations and in some parts deviates from national guidelines. Some key differences between the NHS Lothian and the national guidelines are:

• Nirmatrelvir/ritonavir (Paxlovid®), molnupiravir (Lagevrio®), or remdesivir (Veklury®) will only be available for patients at increased risk for progression to severe COVID‑19, as defined in section 5 of NICE's technology appraisal guidance (TA878) on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab. A list of eligible conditions can also be found in this document.
• However, NHS Lothian will not expand the availability of nirmatrelvir/ritonavir (Paxlovid®) to additional groups currently defined by NICE beyond the above list (TA878).
• Furthermore, NHS Lothian will not automatically include the following criteria listed in TA878 for the use of remdesivir (Veklury®), molnupiravir (Lagevrio®) or nirmatrelvir/ritonavir (Paxlovid®):
  • • body mass index [BMI] greater than 30
    • diabetes mellitus
    • hypertension
  • Where the responsible consultant looking after any patient who falls into these categories wishes to pursue antiviral treatment a further discussion with the infectious diseases consultant on-call is required.
• A monoclonal antibody, sotrovimab, delivered intravenously is accepted for restricted use within the NHS in England, Scotland and Wales for the treatment of symptomatic adults, and adolescents (aged 12 years and over and weighing at least 40kg) with acute COVID-19 infection who do not require oxygen supplementation and who are at increased risk of progressing to severe COVID-19 infection. However, sotrovimab is not currently routinely available in Lothian.
• In NHS Lothian, for hospitalised adult inpatients not requiring oxygen with symptomatic COVID-19 nirmatrelvir/ritonavir (Paxlovid®) can be considered for eligible highest-risk patients as first-line therapy (see list of risk factors for progression to severe COVID‑19 in adults). Molnupiravir (Lagevrio®) will be offered to eligible highest-risk patients who cannot receive nirmatrelvir/ritonavir (Paxlovid®). For highest-risk patients not on oxygen, remdesivir (Veklury®) will generally only be offered if neither nirmatrelvir/ritonavir nor molnupiravir can be given.
• For all antivirals, some indications from NICE TA878 require specific approval by an infectious diseases consultant (see above and the remdesivir page for details).

These decisions have been made locally following review of the clinical evidence and cost-effectiveness predictions by Infectious Diseases Consultants, Medical Director (Acute), Director of Pharmacy, and has been supported by the Executive Leadership Team and Drugs and Therapeutics Committee.