Fig. 3: Anti-inflammatory and antiviral agents for COVID-19 including dose adjustment for kidney function impairment.

The immunosuppressive therapies dexamethasone and tocilizumab can be used without dose adjustments in patients with kidney disease, including those with kidney failure. However, the anti-inflammatory agent baricitinib must be administered at reduced doses in patients with estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m². In the case of antivirals used to treat SARS-CoV-2 infection, molnupiravir can be used without dose adjustments and remdesivir, although currently not recommended for use in patients with eGFR < 30 ml/min/1.73 m², has been reportedly used in patients across the spectrum of kidney dysfunction, including in patients with kidney failure who require kidney replacement therapy (KRT). By contrast, nirmatrelvir–ritonavir is contraindicated in patients with eGFR <30 ml/min/1.73 m² and, given its potential to increase exposure to calcineurin inhibitors (CNIs) and mammalian target of rapamycin (mTOR) inhibitors, must be used with extreme caution in recipients of solid organ transplants, and only if CNI and/or mTOR levels can be monitored closely. The asterisk indicates that in patients with eGFR 30–59 ml/min/1.73 m², the dose of nirmatrelvir is reduced by 50% but the ritonavir dose remains unchanged.