ACMT Toxicology Visual Pearl: Sink or Swim
What type of mothball floats in both water and saturated salt solution?
- Camphor
- Naphthalene
- Paradichlorobenzene
- Sodium Hypochlorite
Extracorporeal Treatment Options in Poisoned Patients
Background
Caring for a patient that is critically-ill secondary to a toxic ingestion is complicated and, in severe cases, extracorporeal treatments (ECTRs) may be considered. The most commonly used ECTRs are intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT), but ECTRs also include exchange transfusion, hemoperfusion, liver dialysis, and therapeutic plasma exchange. Finding and evaluating the supporting literature for these treatment modalities in a timely manner is not feasible in most situations. In order to assist in this effort, the EXtracorporeal Treatments In Poisoning (EXTRIP) workgroup has reviewed and provided free, evidence-based recommendations regarding the use of ECTRs for many common toxins and toxicants [1]. These recommendations can be found in a summarized format on the EXTRIP website and the links to their comprehensive reviews are published on PubMed with direct links on their website. This international workgroup is made up of experts in toxicology, nephrology, emergency medicine, pediatrics, pharmacology, critical care, and more. An excellent example of this resource is their review and recommendations on ECTRs for poisoning secondary to beta-adrenergic antagonists (BAAs).
Evidence
The EXTRIP workgroup included 76 publications in this comprehensive review on the use of ECTRs in BAA poisoning [2]. They evaluated pharmacokinetic/toxicokinetic data for a total of 334 patients poisoned with various BAAs, of which ~90% of the data was published prior to 1990 and does not necessarily represent the improved clearance of these medications with modern ECTR modalities. Based on this evidence, they deemed atenolol, nadolol, and sotalol as dialyzable BAAs. They also reviewed case reports/series of 37 patients with BAA toxicity and made recommendations for those agents with sufficient evidence. Based on the above data, the EXTRIP group recommends iHD over CRRT in patients severely poisoned with atenolol or sotalol and kidney impairment. They make no recommendation for or against ECTR in patients severely poisoned with atenolol or sotalol with normal kidney function and they recommend against ECTR in patients severely poisoned with propranolol.
Bottom Line
- Some toxic ingestions may require invasive treatment strategies (e.g., ECTRs) but a comprehensive review of the literature may not be possible
- The EXTRIP website is an excellent resource to assess if patients should receive emergent ECTRs due to specific toxins
- Hemodialysis is recommended in severely symptomatic patients poisoned with atenolol or sotalol and with impaired kidney function
Want to learn more about EM Pharmacology?
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
References:
- Ghannoum M, Nolin TD, Lavergne V, Hoffman RS, EXTRIP workgroup. Blood purification in toxicology: nephrology’s ugly duckling. Adv Chronic Kidney Dis. 2011;18(3):160-166. doi: 10.1053/j.ackd.2011.01.008. PMID: 21531321.
- Bouchard J, Shepherd G, Hoffman RS, et al. Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup. Crit Care. 2021;25(1):201. doi: 10.1186/s13054-021-03585-7. PMID: 34112223.
SAEM Clinical Image Series: Eye Pain
A 59-year-old gentleman experiencing homelessness with a history of hepatocellular carcinoma, hepatitis C, alcohol use disorder, and tobacco dependence presented to the emergency department (ED) with severe, worsening right eye pain, blurry vision, swelling, redness, and purulent discharge after scraping his upper face on concrete during a mechanical fall two weeks prior. Of note, his partner presented to the ED at the same time with a necrotic infection of the breast as well as multiple skin lesions reportedly due to insect bites.
Human Trafficking in the ED – What you need to know
Human trafficking is a devastating crime, where a human being’s labor is exploited through force, fraud, or coercion, for someone else’s profit (1). For survivors, connecting to support in the community can be incredibly difficult, and may come at the expense of their personal safety (1, 2).
The emergency department (ED) is a rare exception, with some studies estimating that over 60% of trafficked persons will present at some point during their exploitation to the ED (3). Unfortunately, less than 5% of emergency physicians report feeling confident in their ability to identify a trafficked person, citing confusion around patient characteristics and their role as a provider (4).
By learning more about human trafficking, ED providers can better prepare themselves to identify and provide appropriate support to those who experience human trafficking.
What can I do to be ready in the ED?
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Just the Facts – Human Trafficking
What is Human Trafficking?
Human trafficking always involves 3 components –an act, a means, and a purpose.
- The “act” refers to the role a trafficker is playing in exploiting the person
- The “means” refers to the use of force, fraud, or coercion to exploit a person
- The “purpose” is what type of labor they are exploited for (1)
Often human trafficking will overlap with other crimes such as assault, domestic violence, rape, and child abuse (5). Of note, anyone under the age of 18 engaged in commercial sex is considered to be sex trafficked regardless of whether a means is present, as they cannot provide consent.
How many people are affected?
Human trafficking is widespread, but is often undetected, making true estimates of size difficult.
For example, human trafficking prevalence estimates may fail to account for survivors who do not recognize they are being exploited or are afraid to disclose (6, 7).
Who is trafficked?
While no identity is spared, there are certain populations that are at greater risk. These may include:
- People of color
- Children in welfare and juvenile justice systems
- Runaway and homeless youth
- Children working in agriculture
- Indigenous patients
- Migrant laborers
- Foreign national domestic workers
- Patients with limited English
- Patients with disabilities
- Members of the LGBTQ community
- Patients with limited education
- Patients who use substances (6,8)
Why are they targeted?
The only thing all trafficked persons have in common is their vulnerability (1). Trafficking determinants can be conceptualized as “push” and “pull” factors. Push factors lead people to away from their current situation to trafficking (e.g., abuse, poverty, family conflict). Pull factors, drive an individual to something new that increases the risk of trafficking (e.g., income, housing, access to substances) (9, 10).
Who are the traffickers?
In the same way that anyone can be trafficked, anyone can be a trafficker.
Traffickers may be well known in the community, recruiting victims from places of employment or education (1). They may be a family member. They may also lure at-risk individuals by acting as a romantic partner, or by providing emotional affirmation, financial assistance, and material goods (1).
How do traffickers coerce survivors?
A number of tactics can be employed by traffickers, each tailored to the individual survivor but can include any combination of the following (1).
- Physical violence
- Sexual violence
- Emotional violence
- Withholding basic needs (food, water, shelter)
- Intimidation
- Coercion and threats
- Economic coercion
- Social isolation
Specific situations to be wary of:
- Runaway or homeless youth – greater incidence of “survival sex,” where sexual acts are exchanged for basic necessities (1, 11)
- Recent immigrants – withholding documentation/ fear of deportation are used as powerful coercion tactic (1, 5, 6)
What are some of the health consequences of Human Trafficking (6)?
- Physical abuse (traumatic injury, chronic pain)
- Sexual abuse (sexually transmitted infections, pregnancy)
- Emotional abuse (post-traumatic stress disorder, suicide ideation)
- Poor living conditions (malnutrition, dehydration, exposure injuries)
- Substance use, overdose
- Death
10 Common Misconceptions of Human Trafficking
Click to view full-size images
Guide for Emergency Department Providers
What are the primary goals of an ED visit with a potentially trafficked patient?
- Address the acute presenting illness or injury
- Establish the ED as a haven from trauma or exploitation
- Offer additional resources, if appropriate and available
The goal of the visit is NOT to elicit a disclosure.
Your role as a provider is not to investigate or confirm the presence of trafficking, but to respect the autonomy of the patient in front of you, meet their healthcare needs, and empower them to seek additional support on their terms.
What steps should I take during my encounter?
- Capitalize on the same “trauma-informed” principles used to care for survivors of intimate partner violence and child maltreatment.
- Encounter tips (1, 6, 12)
- Separate the potential victim from accompanying persons
- If difficult, ask the patient to move to another room for an x-ray or routine test.
- Use a trained interpreter when required
- Foster trust and establish rapport
- Use education about rights and resources as an empowerment tool (12)
- Providing nonjudgmental education around violence and safety can normalize the sharing of information and open discussion (12)
- Be patient
- Always get consent before proceeding with any next steps (physical exam, diagnostic tests, and involvement of other providers)
Click for full-size images
Red flags For Human Trafficking (1, 13)
| Patient Indicators | Companion Indicators |
|---|---|
| Delayed presentation | Refuses to leave |
| Discrepancy between history and clinical presentation | Insists on translating or speaking for the patient |
| Scripted/memorized history | Controlling, interrupting |
| Hypervigilance, fearful | Has patient’s documents in their possession |
| Cannot produce identification | Employer demanding access to medical information |
| Work-related injury with unsafe conditions | |
| Fearful attachment to a cell phone (often used for communication and tracking) |
Red flags for pediatric patients (1, 14)
- Accompanied by unrelated, non-guardian adults
- Material possessions you reasonably doubt they would be able to afford
- Truancy or running away
- Multiple sexual “partners”
What are the next steps after my assessment?
Any next steps should always be determined by the patient
- Referrals (social work, case manager or discharge specialist, local advocacy services) (6, 15)
- Human Trafficking Hotline
- USA – National Human Trafficking Hotline at 1-888-373-7888
- Canada – Canadian Human Trafficking Hotline at 1-833-900-1010
- Consider offering admission if unsafe to discharge
- Clear and accurate documentation (may be relevant to future legal proceedings)
- Consider notifying security if appropriate (6)
Unless local criteria for mandatory reporting are met, Police should only be contacted at the explicit instruction of the patient (6, 16).
Interested in advocacy?
Consider implementing an ED and institutional protocol for human trafficking. A complete protocol guide is available through HEAL Trafficking.
References
- Alpert EJ, Ahn R, Albright E et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in a Healthcare Setting. Boston, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine.
- Human Trafficking. Public Safety Canada, Government of Canada. 2019.
- Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2013;23(1):61–91.
- Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Heal. 2015;3:1–9. PMID: 25688343
- Canada’s Human Trafficking Laws. British Columbia Public Health Agency. 2014.
- Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016;68(4):501-508.e1. PMID: 27130802
- Global Report on Trafficking in Persons [Internet]. New York; 2014. Available from: https://www.unodc.org/res/cld/bibliography/global-report-on-trafficking-in-persons_html/GLOTIP_2014_full_report.pdf
- 2021 Trafficking in Persons Report – United States Department of State [Internet]. U.S. Department of State; 2021. Available from: https://www.state.gov/reports/
2021-trafficking-in-persons- report/ - Macias Konstantopoulos W, Ahn R, Alpert EJ, Cafferty E, McGahan A, Williams TP, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. J Urban Health. 2013. PMID: 24151086
- Calhoun C. Push and pull factors. Oxford Dictionary. Soc Sci Oxford Univ Press. 2002;
- Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011. PMID: 20799134
- PEARR Tool Trauma-Informed Approach to Victim Assistance in Health Care Settings. Dignity Health, in partnership with HEAL Trafficking and Pacific Survivor Center. 2019.
- Identifying Victims of Human Trafficking: What to look for in a healthcare setting. National Human Trafficking Resource Center. The Polaris Project.
- Tracy EE, Konstantopoulos WMI. Human trafficking: A call for heightened awareness and advocacy by obstetrician-gynecologists. Obstet Gynecol. 2012. PMID: 22525917
- Meshkovska B, Siegel M, Stutterheim SE, Bos AER. Female sex trafficking: Conceptual issues, current debates, and future directions. J Sex Res. 2015. PMID: 25897567
- Zimmerman C BR. Caring for Trafficked Persons: Guidance for Health Providers. Health Providers. Geneva, Switzerland: International Organization for Migration. 2009.
Trick of the Trade: DIY Nasal Snot Aspirator
Nasal congestion is a common symptom of upper respiratory tract infections, such as bronchiolitis, in newborns and infants. Because newborns are obligate nose breathers, any congestion presents a challenge during feeding and sleeping. These infants become frustrated when they cannot breathe while feeding and tend to have disturbed sleep when their nasal passages are occluded. This often leads to dehydration and irritability. Although the infant bulb syringe (above) can often alleviate the congestion, other commercial products may be able to more forcefully clean out the nasal mucus (e.g., NoseFrida, Bubzi Nasal Aspirator).
Trick of the Trade: DIY Nasal Snot Aspirator
In the Emergency Department, you may encounter families who may not have the resources to purchase or be aware of commercial aspiration devices for children. The concept behind our DIY Nasal Snot Aspirator is to allow the caregiver to suction the child’s nose using the negative pressure generated from the caregiver’s own mouth. The left video demonstrates how the NoseFrida works, and the right video demonstrates our DIY Nasal Snot Aspirator. Note that the specimen trap serves as the protective “filter”, or barrier, between the child’s suctioned mucus and the caregiver’s mouth. Thanks to Stephany Landry, RN, BSN for sharing this trick of the trade.
Equipment Needed: DIY nasal snot aspirator
- Left: Little Sucker Aspirator [Amazon]
- Middle: Short suction tubing
- Right: Mucous specimen trap, 40 cc [Amazon]
Description of the Trick
- Suction tubing: Attach one end to the Little Sucker Aspirator and the other end to the short connector port on the specimen trap.
- Instill some saline drops into the child’s nose.
- Insert the aspirator tip of your contraption into the child’s nostril.
- Have the caregiver suck out through the “straw” attached on top of the specimen trap.
Disclosures
The authors and ALiEM do not have any affiliation with any of these device companies.
SAEM Clinical Image Series: Pediatric Rash
A 17-month-old girl with a history of eczema presents to the pediatric emergency department for evaluation of a rash. The rash is different from her usual eczema, developed three days prior to presentation, and is described as red with yellow crusting. Her mother also noticed blistering in her groin and under her axilla. She has associated fussiness and decreased feeding, but no fever.
Vitals: T 37.7°C; HR 161; BP 115/75; RR 24; O2 sat 100% on room air General: Fussy but consolable Eyes: No conjunctival erythema or discharge Mouth: Yellow crusting and fissuring surrounding mouth; no intra-oral lesions Neck: No nuchal rigidity Cardiovascular: Tachycardic with regular rhythm; no murmurs Respiratory: Normal rate; normal breath sounds Abdomen: Non-tender to palpation; non-distended; normal bowel sounds Neurologic: Alert Skin: Diffusely erythematous; scaling rash over the face with areas of yellow crusting; erythematous areas with blistering/desquamation to the anterior trunk, axilla, and inguinal regions Complete blood count (CBC) and comprehensive metabolic panel (CMP) unremarkable. Staphylococcal scalded skin syndrome caused by impetigo. This case describes a patient with a rash, blistering/desquamation of axilla and groin, and systemic symptoms consistent with staphylococcal scalded skin syndrome (SSSS). Clinical features of SSSS include erythema to intertriginous areas, rapid progression of erythema, and systemic symptoms such as fever, irritability, and poor oral intake. Mucous membranes are not typically involved. Physical exam findings include perioral crusting and fissuring (seen in photo), blanching erythema, desquamation, shallow skin erosions, and a positive Nikolsky sign. SSSS is caused by exfoliative toxin A (ETA) and exfoliative toxin B (ETB), two exotoxins produced by certain strains of S. aureus. ETA and ETB cause the breakdown of keratinocyte adhesions within the epidermis, leading to desquamation. Infection with S. aureus at any site can cause SSSS, including bacterial conjunctivitis, wound/skin infection, staphylococcal pneumonia, pyomyositis, septic arthritis, and endocarditis. SSSS is more common in children, a phenomenon thought to be due to a lack of protective antibodies against staphylococcal antigens. The diagnosis of SSSS is clinical but can be confirmed with histopathology. In this case, the extensive yellow, crusting lesions of the face suggest impetigo, a superficial skin infection predominantly caused by S. aureus, as the etiology of SSSS. Children with eczema are at increased risk of impetigo due to disruption of the normal skin barrier. Complications of SSSS include fluid losses due to extensive skin breakdown, electrolyte abnormalities, sepsis, and death. Penicillinase-resistant penicillins (oxacillin, nafcillin) or first- or second-generation cephalosporins. Clindamycin monotherapy should be avoided due to high rates of resistance. Management of SSSS in most cases also includes hospitalization for IV antibiotics and supportive care. In patients with significant skin involvement, admission to either an ICU or burn unit is warranted for close monitoring and wound care.
Take-Home Points
Oral Antivirals for Treatment of Mild-Moderate COVID-19 Infection
Background
Two new oral agents were given Emergency Use Authorization to be used in patients with mild-moderate COVID-19 at high risk of progression to severe infection, molnupiravir and nirmatrelvir/ritonavir (Paxlovid) [1,2]. Prior to this authorization, most evidence-based COVID therapies were parenteral and required significant healthcare resources to coordinate and administer.
Comparison
| Nirmatrelvir/ritonavir [3] | Molnupiravir [4] | |
|---|---|---|
| Mechanism |
Protease inhibitor leadings to interruption of viral replication Ritonavir has no role in treating COVID-19, it is only included to boost levels of nirmatrelvir via CYP3A4 inhibition |
Increased frequency of RNA mutations and impaired replication [5] |
| Efficacy vs Placebo (Hospitalization or Death) | 0.8% vs 6.3% (CI -7.21 to -4.03) | 6.8% vs 9.7% (CI -5.9 to -0.1) |
| Drug Interactions | CYP3A4 inducers, inhibitors, and substrates
May decrease efficacy of hormonal contraceptives, non-hormonal contraceptives should be considered Contraindicated medications include: amiodarone, carbamazepine, clozapine, colchicine, dihydroergotamine, dronedarone, flecainide, lovastatin, ranolazine, sildenafil, simvastatin Many other important interactions exist so care should be taken to assess all medication interactions |
N/A |
| Cost* | Patient: $0
US government: $530 [6] |
Patient: $0 US Government: $700 [7] |
| Dose | 300 mg/100 mg BID for 5 days
Must be started within 5 days of symptom onset |
800 mg BID for 5 days
Must be started within 5 days of symptom onset |
| Notes | Approved for patients ≥ 12 years old AND ≥ 40 kg
Not approved for inpatient initiation If patient is hospitalized, continuation is up to the discretion of the provider Not used as pre-/post-exposure prophylaxis |
Approved for patients ≥ 18 years
Not approved for inpatient initiation If patient is hospitalized, continuation is up to the discretion of the provider Not used as pre-/post-exposure prophylaxis |
| Renal/Hepatic Dose Adjustments | eGFR ≥30 to <60 mL/min: 150 mg/100 mg BID
eGFR <30 mL/min: Not recommended Child-Pugh class C: Not recommended |
None |
*Note: The US federal government has purchased 10 million doses of nirmatrelvir/ritonavir and 3 million doses of molnupiravir [8,9]. These supplies will be allocated to states and territories as needed and will be available to patients at no charge.
Evidence:
Nirmatrelvir/ritonavir (Paxlovid)
Paxlovid was evaluated in the EPIC-HR trial, which is not fully published at this time [3]. This was a phase 2/3, double-blinded, randomized placebo controlled trial including nonhospitalized, unvaccinated patients adults with mild-moderate COVID-19 within 5 days of symptom onset with at least 1 risk factor† for development of severe illness from COVID-19. Exclusion criteria included patients with a history of COVID-19 infection or COVID vaccination. Patients were given Paxlovid 300 mg/100 mg or placebo BID for 5 days. The primary outcome was hospitalization or death at day 28. The modified intention-to-treat1 (mITT1) group excluded patients who did not receive nor were expected to receive COVID-19 mAb treatment. In the mITT1 group, the primary outcome occurred in 0.8% of patients receiving Paxlovid vs 6.3% of patients in the placebo group (8/1039 vs 66/1046, CI -7.21 to -4.03).
These results appear quite robust with a fragility index of 37. Additionally, in patients with detectable COVID antibodies there was less of an impact of the study medication. However, these patients still appeared to have some benefit (0.2% vs 1.5%, CI -2.45 to -0.23) which suggests that vaccinated patients may still benefit from Paxlovid.
†Risk factors for progression to severe disease: BMI >25, chronic lung disease, asthma, chronic kidney disease, current smoker, immunosuppressive disease or immunosuppressive treatment, cardiovascular disease, hypertension, sickle cell disease, neurodevelopmental disorders, active cancer, medically-related technological dependence, or age >60 years
Molnupiravir
Molnupiravir was evaluated in the MOVe-OUT trial [10]. This was a phase 3, double-blinded, randomized, placebo controlled trial including nonhospitalized, unvaccinated adults with mild-moderate COVID-19 within 5 days of symptom onset with at least 1 risk factor‡ for development of severe illness from COVID-19. Exclusion criteria included anticipated hospitalization within 48 hours, eGFR <30 or dialysis dependent, pregnancy, and COVID vaccination. Patients were able to receive steroids but not monoclonal antibodies (mAbs) nor remdesivir. Patients were given molnupiravir 800 mg or placebo BID for 5 days. The primary outcome was hospitalization or death at 29 days. In the mITT population, the primary outcome occurred in 6.8% of patients in the study group vs 9.7% in the placebo group (48/709 vs 68/699, CI -5.9 to -0.1). Death occurred in 1 patient on molnupiravir and in 9 patients on placebo (0.1% vs 1.3%, RRR 89%, CI 14 to 99).
Despite the above results, this may not be the positive trial it initially appears. First of all, for the primary outcome, the fragility index is 0, meaning that if 1 more patient in the study group experienced the primary outcome then it would have changed the statistical significance. Additionally, when the mITT analysis was adjusted for sex, the absolute risk reduction remained 2.8% but the confidence interval was not significant (-5.7 to 0.1). Lastly, in the subgroup analysis, there was no benefit in patients that had positive COVID antibody tests and there was a slight preference towards placebo over molnupiravir (3.7% vs 1.4%, ARR 2.3, CI -1.7 to 7.1). This suggests that vaccinated patients may not benefit from this therapy as much (or at all) as compared to unvaccinated patients.
‡Risk factors for progression to severe disease: age >60 years, active cancer, chronic kidney disease, COPD, BMI ≥30, heart failure, coronary artery disease, cardiomyopathy, or diabetes mellitus
Note: Both the EPIC-HR and MOVe-OUT studies were funded by their respective pharmaceutical company.
Bottom Line:
- Nirmatrelvir/ritonavir (Paxlovid) and molnupiravir are approved under FDA EUAs for patients with mild-moderate COVID infection at high risk of severe disease within 5 days of symptom onset
- Both medications appear to reduce death or hospitalization within a month, with most benefit likely to be experienced by unvaccinated patients
- Nirmatrelvir/ritonavir (Paxlovid) appears to be more effective but also has many more drug interactions and contraindications
Want to learn more about EM Pharmacology?
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
References:
- O’Shaughenessy J. Food and Drug Administration. Molnupiravir Emergency Use Authorization 108. December 23, 2021. https://www.fda.gov/media/155053/download
- O’Shaughenessy J. Food and Drug Administration. Nirmatrelvir/ritonavir Emergency Use Authorization 105. December 22, 2021. https://www.fda.gov/media/155049/download
- Nirmatrelvir/ritonavir. Package insert. Pfizer, Inc. 2021. https://www.fda.gov/media/155050/download
- Molnupiravir. Package insert. Merck Sharp & Dohme Corp. 2021. https://www.merck.com/eua/molnupiravir-hcp-fact-sheet.pdf
- Kabinger F, Stiller C, Schmitzová J, et al. Mechanism of molnupiravir-induced SARS-CoV-2 mutagenesis. Nat Struct Mol Biol. 2021;28(9):740-746. doi: 10.1038/s41594-021-00651-0. PMID: 34381216.
- Mishra M. U.S. to buy 10 mln courses of Pfizer’s COVID-19 pill for $5.3 bln. Reuters. Accessed January 12, 2022. https://www.reuters.com/business/healthcare-pharmaceuticals/us-govt-buy-10-mln-courses-pfizers-covid-19-pill-529-bln-2021-11-18/
- Willyard C. How antiviral pill molnupiravir shot ahead in the COVID drug hunt. Nature. Published online October 8, 2021. doi: 10.1038/d41586-021-02783-1. PMID: 34625735.
- Paxlovid (nirmatrelvir/PF-07321332 and ritonavir). U.S. Department of Health & Human Services: Office of the Assistant Secretary of Preparedness and Response. Updated: January 12, 2022. Accessed January 12, 2022. https://www.phe.gov/emergency/events/COVID19/investigation-MCM/Paxlovid/Pages/default.aspx
- Molnupiravir (MK-4482). U.S. Department of Health & Human Services: Office of the Assistant Secretary of Preparedness and Response. Updated: January 12, 2022. Accessed January 12, 2022. https://www.phe.gov/emergency/events/COVID19/investigation-MCM/molnupiravir/Pages/default.aspx
- Jayk Bernal A, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for oral treatment of covid-19 in nonhospitalized patients. N Engl J Med. Published online December 16, 2021. doi: 10.1056/NEJMoa2116044. PMID: 34914868.