Regeneron. 1) does your ED give it, 2) if so does your hospital have any?

[Dr Mantis Toboggan]

1) yes
2) no

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[bravotwozero]

the privately owned freestandings I work at give it. As for the hospital EDs, none of them do but we put in a computer order to refer them, and someone calls them to schedule an infusion at their outpatient infusion center.

 

[Dr Mantis Toboggan]

the privately owned freestandings I work at give it. As for the hospital EDs, none of them do but we put in a computer order to refer them, and someone calls them to schedule and infusion at their outpatient infusion center.

Nice. I fear the private clinics and freestanding giving it are going to be experiencing severe supply issues given the recent change to central planning for distribution.

 

[deleted1077312]

No worry though because equity or something

 

[thegenius]

1) yes
2) I don't know

 

[Rockinacoustic]

Yes and Yes (is it on shortage?)

 

[panscan]

Yes and yes.

We were actually encouraged recently to give it more. Now almost anyone qualifies for it.

Unvaccinated patients come in every day requesting “the infusion”. Makes me rage.

You won’t get a highly effective vaccine and take some responsibility, but you’ll wait 5 hours in the WR, expose all of us, for something that probably won’t even help you? It’s absolute garbage.

 

[deleted6669]

Yes and Yes

 

[emergentmd]

Our FSER gives it, has had great results, and from our limited appx 500 infusions have all done well. There have not been one pt who came back with Covid pneumonia that was infused early on.

Biden's restrictions has hurt the supply chain when there was no shortage issues. If getting Regen was so difficulty and supply threatened, then we never saw it. It seems like this is all a political ploy to get more people vaccinated.

Why fix something that was working well and label it a supply issue.

 

[TheComebacKid]

There are certain criteria in order for them to receive it. Need to have some comorbidities, need to be discharged, can't admit them etc. If I remember correctly it's a level 2C recommendation to give it to these higher risk groups to decrease risk of hospitalization, but I have no sense if it actually works. We give it in the ED at one of the sites we work at. What's more frustrating is that the oncologists will send them to the ED to get these infusions now, instead of just having them do it outpatient, which is really awful.

 

[Dr Mantis Toboggan]

Yes and Yes (is it on shortage?)

Oh yeah. The move to central planning for distribution has frozen my hospital out it appears.

 

[Dr Mantis Toboggan]

Yes and yes.

We were actually encouraged recently to give it more. Now almost anyone qualifies for it.

Unvaccinated patients come in every day requesting “the infusion”. Makes me rage.

You won’t get a highly effective vaccine and take some responsibility, but you’ll wait 5 hours in the WR, expose all of us, for something that probably won’t even help you? It’s absolute garbage.

Definitely cognitive dissonance to refuse the experimental vaccine but take the experimental infusion.

 

[Jabbed]

Yes and yes.

I hate it. It's high cost, low value care that's putting money in the pockets of DeSantis and the like. Almost no institution is giving it according to the indications in the non-pre-specified subgroup analysis (covid positive, antibody negative). And now there's a fear of "what happens if I don't give this patient regeneron and get sued".

 

[thegenius]

Yes and yes.

We were actually encouraged recently to give it more. Now almost anyone qualifies for it.

Unvaccinated patients come in every day requesting “the infusion”. Makes me rage.

You won’t get a highly effective vaccine and take some responsibility, but you’ll wait 5 hours in the WR, expose all of us, for something that probably won’t even help you? It’s absolute garbage.

I agree with this sentiment...but I'm not sure I've ever admitted someone who has gotten that outpatient regeneron mAB cocktail. Maybe I have...but if I have it's pretty rare.

But yea...I agree they sit in our ER for 4 hours potentially infecting everyone and they don't have the common decency to get a vaccine.

 

[GenericWhiteGuy]

Yes.
Yes.

But I absolutely refuse to order it for any patient I see in the ED. I have had patients wait for 4 hours in waiting room because some other provider referred them to my ED and used the “Sorry, based on my interpretation of the literature I see no benefit and will not order this today”. I actually did this to some hospital executives family member and they emailed me directly asking me why I didn’t order it (And here is a reminder of what a good boss is - forwarded email to my director and he went to bat due to some non clinical suit questioning my care including referring them to HR and CEO and I just found out said person is on suspension)

good review of the literature here:

RECOVERY Trial: The REGN-COV Antibody Cocktail in COVID19 - REBEL EM - Emergency Medicine Blog

Does a monoclonal antibody cocktail of casirivimab/imdevimab reduce mortality in patients hospitalized with COVID?

rebelem.com

 

[Dr Mantis Toboggan]

Yes.
Yes.

But I absolutely refuse to order it for any patient I see in the ED. I have had patients wait for 4 hours in waiting room because some other provider referred them to my ED and used the “Sorry, based on my interpretation of the literature I see no benefit and will not order this today”. I actually did this to some hospital executives family member and they emailed me directly asking me why I didn’t order it (And here is a reminder of what a good boss is - forwarded email to my director and he went to bat due to some non clinical suit questioning my care including referring them to HR and CEO and I just found out said person is on suspension)

good review of the literature here:

RECOVERY Trial: The REGN-COV Antibody Cocktail in COVID19 - REBEL EM - Emergency Medicine Blog

Does a monoclonal antibody cocktail of casirivimab/imdevimab reduce mortality in patients hospitalized with COVID?

rebelem.com

I mean that article is about a study in admitted patients. It is thought to prevent admission in non-hospitalized patients and recommended by the NIH etc.

 

[HemorrhagicShock]

Yes.
Yes.

But I absolutely refuse to order it for any patient I see in the ED. I have had patients wait for 4 hours in waiting room because some other provider referred them to my ED and used the “Sorry, based on my interpretation of the literature I see no benefit and will not order this today”. I actually did this to some hospital executives family member and they emailed me directly asking me why I didn’t order it (And here is a reminder of what a good boss is - forwarded email to my director and he went to bat due to some non clinical suit questioning my care including referring them to HR and CEO and I just found out said person is on suspension)

I'm sort of interested. This seems like a unicorn situation these days, where an ER doc and director actually have the upper hand with a family member of a relatively high-level exec.

I'd imagine the CEO would side with the exec and his/her family, resulting in yet another hit to the political capital your group has going forward (and potentially adding to a variety of factors that de-stabilize a contract).

Was this is a low-level exec that was already disliked within the hospital? How did HR get involved and what was the reason for the suspension over this case? Telling a physician how to do their job?

 

[GenericWhiteGuy]

I mean that article is about a study in admitted patients. It is thought to prevent admission in non-hospitalized patients and recommended by the NIH etc.

But this is the only study I know of with some statistically teased out “positive outcome” for monoclonal antibodies and this let them extrapolate ( and take a big leap IMO) to give it people not requiring admission. I would hope you as a doc are keeping up on the literature before giving your patients any drug….

 

[GenericWhiteGuy]

I'm sort of interested. This seems like a unicorn situation these days, where an ER doc and director actually have the upper hand with a family member of a relatively high-level exec.

I'd imagine the CEO would side with the exec and his/her family, resulting in yet another hit to the political capital your group has going forward (and potentially adding to a variety of factors that de-stabilize a contract).

Was this is a low-level exec that was already disliked within the hospital? How did HR get involved and what was the reason for the suspension over this case? Telling a physician how to do their job?

I got a zoom meeting with ceo, Ed director and mid level exec where I received a direct apology and was told how they are following the policy of violating rules about opening a family members chart on EMR to its full effect and then had a private apology from CEO after exec logged off. Hopefully it doesn’t blow back on the ED but doesn’t seem like it now …

 

[Apollyon]

I would hope you as a doc are keeping up on the literature before giving your patients any drug….

That's rather insulting.

 

[Dr Mantis Toboggan]

That's rather insulting.

But this is the only study I know of with some statistically teased out “positive outcome” for monoclonal antibodies and this let them extrapolate ( and take a big leap IMO) to give it people not requiring admission. I would hope you as a doc are keeping up on the literature before giving your patients any drug….

What can I say, I enjoy human experimentation…

Seriously, the data on Regeneron which was released demonstrating a reduction in hospitalizations etc is currently enough for me to recommend this therapy. Granted the article isn’t out yet and some might choose to wait until it is released etc. I suppose my bias is always more to try and prevent badness when I can so I give it for now based on what I know. That approach is supported by the NIH AND Joe Rogan so it works for me.

Anti-SARS-CoV-2 Monoclonal Antibodies | COVID-19 Treatment Guidelines

Read information about anti-SARS-CoV-2 monoclonal antibodies and COVID-19.

www.covid19treatmentguidelines.nih.gov

 

[thegenius]

But this is the only study I know of with some statistically teased out “positive outcome” for monoclonal antibodies and this let them extrapolate ( and take a big leap IMO) to give it people not requiring admission. I would hope you as a doc are keeping up on the literature before giving your patients any drug….

We hope that you are also up to date on every single drug you prescribe too. Every one.

 

[HemorrhagicShock]

What? You mean you all don't live on the bleeding edge of evidence-based medicine?!

 

[thegenius]

I actually give myself a 30 minute timeout to review all the current literature every time I order a med in the ED. Evidence can change, you know? Kind of sucks for those kids and adults who want tylenol...I have to look at all the relevant literature before giving it.

 

[Arcan57]

Yes and yes.

I hate it. It's high cost, low value care that's putting money in the pockets of DeSantis and the like. Almost no institution is giving it according to the indications in the non-pre-specified subgroup analysis (covid positive, antibody negative). And now there's a fear of "what happens if I don't give this patient regeneron and get sued".

A buddy of mine caught a board complaint for not giving it in the ED to a patient with 4 or 5 days of symptoms who got the infusion the next morning. Hospital did service recovery on patient.

 

[lucid_leprechaun]

A buddy of mine caught a board complaint for not giving it in the ED to a patient with 4 or 5 days of symptoms who got the infusion the next morning. Hospital did service recovery on patient.

I mean Regeneron reeks of TPA literature. Pharma studies showing marginal benefit in a subgroup for “hospital encounters.” I mean sometimes the answer is don’t just do something, stand there. Expensive therapies with unclear benefit just to pad the company profits. Antibodies given after the majority of people already have their own is suspect even theoretically. Unless you’re doing antibody testing on all patients you’re wasting a ton of money IMO.

 

[Birdstrike]

A buddy of mine caught a board complaint for not giving it in the ED

I had a board complaint filed against me for results of a test someone else ordered. My name was inadvertently put on the study as the ordering doctor, when I didn't order it. The study showed a tumor.

I had proof I never ordered the test. I had proof of who the ordering doctor was. The patient was still convinced I ordered it. The board complaint was filed against me and not the ordering doctor. Unlike a lawsuit, which is just two lawyers fighting over an insurance company's money, this lady didn't want money. Board complaints can't win a patient money. She wanted my license revoked, my career taken away and my life ruined, essentially.

I won, but it took seven months to clear it up. So, I know how terrible these board complaints can be, even when totally baseless.

 

[Arcan57]

I had a board complaint filed against me for results of a test someone else ordered. My name was inadvertently put on the study as the ordering doctor, when I didn't order it. The study showed a tumor.

I had proof I never ordered the test. I had proof of who the ordering doctor was. The patient was still convinced I ordered it. The board complaint was filed against me and not the ordering doctor. Unlike a lawsuit, which is just two lawyers fighting over an insurance company's money, this lady didn't want money. Board complaints can't win a patient money. She wanted my license revoked, my career taken away and my life ruined, essentially.

I won, but it took seven months to clear it up. So, I know how terrible these board complaints can be, even when totally baseless.

Yeah, they are. Heaven help you if you don't realize how serious it is when you get that letter in the mail. They can be filed by anyone, for any reason, and unlike in a suit some states don't give any specifics about what is being alleged. Lawyer up and produce some response that simultaneously portrays you as having the compassion of Mother Theresa, the wisdom of Solomon, and the patience of Job. Then you hope that nobody on the board is in a bad mood when they receive your reply.

Also malpractice attorneys like to use them as fact finding. As such, they tend to get filed rather quickly after the inciting even so that by the time the investigation wraps up there's still plenty of time on statute of limitations.

 

[Birdstrike]

Also malpractice attorneys like to use them as fact finding. As such, they tend to get filed rather quickly after the inciting even so that by the time the investigation wraps up there's still plenty of time on statute of limitations.

Yes. That's what my lawyer told me, also. It's basically a way to get a free expert review. If you get a finding against you, they're off to the races in a suit against you, armed with the board finding. Then, if you're cleared, they know they have no case against you, but they haven't had to spend a penny to determine that. I'm not sure if the doc that actually did order the study eventually got targeted or not.

Anyways, back to the scheduled programming of Regeneron.

 

[DoctwoB]

https://www.nejm.org/doi/full/10.1056/NEJMoa2109682

Looks to be quite effective in preventing symptomatic infection in the post-exposure prophylaxis setting. Less clear in the post-infection setting, though may be some benefit in the seronegative population (though even is is in the pre-delta era, unclear effectiveness with delta).

Still incredibly frustrating the cognitive dissonance between non-vaxxers who will get this. The above trial randomized 750 people to the antibody cocktail. There is more real world data, but it is not monitored int he way that vaccines are. It could have a 1 in 2000 risk of killing you outright, and we probably wouldn't know about it. The vaccine studies randomized 10s of thousands with real world monitoring data on hundrends of millions or billions of people.

 

[lucid_leprechaun]

https://www.nejm.org/doi/full/10.1056/NEJMoa2109682

Looks to be quite effective in preventing symptomatic infection in the post-exposure prophylaxis setting. Less clear in the post-infection setting, though may be some benefit in the seronegative population (though even is is in the pre-delta era, unclear effectiveness with delta).

Still incredibly frustrating the cognitive dissonance between non-vaxxers who will get this. The above trial randomized 750 people to the antibody cocktail. There is more real world data, but it is not monitored int he way that vaccines are. It could have a 1 in 2000 risk of killing you outright, and we probably wouldn't know about it. The vaccine studies randomized 10s of thousands with real world monitoring data on hundrends of millions or billions of people.

Better than the previous data for sure. But holy **** imagine implementing this and what the cost would be

 

[turkeyjerky]

https://www.nejm.org/doi/full/10.1056/NEJMoa2109682

Looks to be quite effective in preventing symptomatic infection in the post-exposure prophylaxis setting. Less clear in the post-infection setting, though may be some benefit in the seronegative population (though even is is in the pre-delta era, unclear effectiveness with delta).

Still incredibly frustrating the cognitive dissonance between non-vaxxers who will get this. The above trial randomized 750 people to the antibody cocktail. There is more real world data, but it is not monitored int he way that vaccines are. It could have a 1 in 2000 risk of killing you outright, and we probably wouldn't know about it. The vaccine studies randomized 10s of thousands with real world monitoring data on hundrends of millions or billions of people.

Yeah, in an unvaccinated, seronegative population. Please don't extrapolate this to vaccinated gomers. Different patient populations.

Also, absolute risk reduction of 0.5% to prevent an ED visit or hospital admission. So, assuming $1200/dose (probably low-end), 240k to prevent an ER visit or hospitalization. (Based on my experience, likely 1/3 of patients coming to the ER w/ known covid get admitted. I think about 25% of admitted patients are ICU-level. So we're talking about 2.8M to prevent an ICU admission.)

 

[southerndoc]

Yeah, in an unvaccinated, seronegative population. Please don't extrapolate this to vaccinated gomers. Different patient populations.

Also, absolute risk reduction of 0.5% to prevent an ED visit or hospital admission. So, assuming $1200/dose (probably low-end), 240k to prevent an ER visit or hospitalization. (Based on my experience, likely 1/3 of patients coming to the ER w/ known covid get admitted. I think about 25% of admitted patients are ICU-level. So we're talking about 2.8M to prevent an ICU admission.)

No way do we admit 1/3 of our COVID patients.

 

[BoardingDoc]

No way do we admit 1/3 of our COVID patients.

Agreed. I'd say more like 1 in 10 are getting admitted in my neck of the woods.

 

[turkeyjerky]

Agreed. I'd say more like 1 in 10 are getting admitted in my neck of the woods.

I was referring to the specific population of patients already diagnosed w/ covid as an outpatient, then coming to the ER a number of days later. In my experience, roughly 1/3 of these are whiny 'why do I still feel sick' people, 1/3 were sent in by their PCP or OB for a PE workup (universally negative or not indicated), and 1/3 have disease progression meriting admission.

Definitely agree that newly diagnosed covid patients in the ER have a lower admit rate. However, if you guys are correct, it just means the c/b ratio of PEP-MABs is even worse.

 

[Airborne Flt Doc]

Yes, Basically anyone over 12 who has one comorbidity ( including just a BMI of >25 ) and onset symptoms / exposed to the covid 19 contact within 10 days

 

[Tenk]

We fax an order to pharmacy and they call patient for outpatient infusion.

 

[WilcoWorld]

A buddy of mine caught a board complaint for not giving it in the ED to a patient with 4 or 5 days of symptoms who got the infusion the next morning. Hospital did service recovery on patient.

Chasing satisfaction on folks who can't be satisfied...what a waste of time

 

[Arcan57]

Chasing satisfaction on folks who can't be satisfied...what a waste of time

Yeah, it’s a common belief perpetrated by people that see no difference between entertainment and medicine. The customer service view is that a customer you do good service recovery on actually becomes more loyal and enthusiastic compared to someone that never needed service recovery. In actuality, a doc that changes their plan after strongly advocating for a different plan isn’t viewed as a better doc. The initial impression of them as incompetent, stupid, or uncaring is still there. But now they’re also viewed as weak and to some people the weak are viewed as marks.

 

[Dred Pirate]

not in the ED - can't take up a bed for 4+ hours that is needed for one of the 40 people sitting in the lobby.
We can currently get it as far as I know - our outpatient pharmacy at an offsite clinic are dealing with it

 

[southerndoc]

not in the ED - can't take up a bed for 4+ hours that is needed for one of the 40 people sitting in the lobby.
We can currently get it as far as I know - our outpatient pharmacy at an offsite clinic are dealing with it

4+ hours? That's excessive. It's a 20 minute infusion followed by an hour observation time.

The time spent will likely prevent an additional patient coming back to your ER with hypoxemia sitting in the waiting room for hours. That's why I do it... it prevents admissions.

 

[Dred Pirate]

at end I am confusing it with BAM and that is where the four hour infusion is coming from

 

[Dr Mantis Toboggan]

at end I am confusing it with BAM and that is where the four hour infusion is coming from

BAM is 20 min now as well I believe.

 

[coachB]

4+ hours? That's excessive. It's a 20 minute infusion followed by an hour observation time.

The time spent will likely prevent an additional patient coming back to your ER with hypoxemia sitting in the waiting room for hours. That's why I do it... it prevents admissions.

I wouldn't consider a best case scenario of a NNT in the 30s as "likely"

 

[Jabbed]

BAM is 20 min now as well I believe.

Who is still doing bam??

 

[Dred Pirate]

Who is still doing bam??

We quit because of the resistance rates of delta.

 

[GeneralVeers]

I wouldn't consider a best case scenario of a NNT in the 30s as "likely"

Agreed, NNT of 30 is terrible. Especially when considering the loss of throughput by tying up a bed for 2 hours (at minimum). In an ideal world we'd have infinite beds and this would be reasonable.

 

[Dr Mantis Toboggan]

Who is still doing bam??

BAM is decent against Delta. It sucks against gamma which the CDC might be a thing in the spring. We give it because we give what the government lets us have.

 

[Goro]

Yeah, they are. Heaven help you if you don't realize how serious it is when you get that letter in the mail. They can be filed by anyone, for any reason, and unlike in a suit some states don't give any specifics about what is being alleged. Lawyer up and produce some response that simultaneously portrays you as having the compassion of Mother Theresa, the wisdom of Solomon, and the patience of Job. Then you hope that nobody on the board is in a bad mood when they receive your reply.

Also malpractice attorneys like to use them as fact finding. As such, they tend to get filed rather quickly after the inciting even so that by the time the investigation wraps up there's still plenty of time on statute of limitations.

Really?? Can we file Board complaints against the grifter docs who are bashing COVID vaccines in order to sell their quick cures??? Like Sherry Tenpenny, for example??

 

[bravotwozero]

Really?? Can we file Board complaints against the grifter docs who are bashing COVID vaccines in order to sell their quick cures??? Like Sherry Tenpenny, for example??

You absolutely can, and people have. The boards are starting to notice and going after people’s licenses.