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Gottlieb RL, Kalil AC. True DisCoVeRy of COVID-19 Disease Burden Versus Speculated Antiviral Cardiovascular Risk Requires a Control Group. Clin Infect Dis 2024; 79:392-394. [PMID: 38552189 DOI: 10.1093/cid/ciae172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/28/2024] [Indexed: 08/17/2024] Open
Affiliation(s)
- Robert L Gottlieb
- Department of Internal Medicine, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Dallas, Texas, USA
- Department of Internal Medicine, Burnett School of Medicine at Texas Christian University (TCU), Fort Worth, Texas, USA
- Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Choi MH, Wan EYF, Wong ICK, Chan EWY, Chu WM, Tam AR, Yuen KY, Hung IFN. Comparative effectiveness of combination therapy with nirmatrelvir-ritonavir and remdesivir versus monotherapy with remdesivir or nirmatrelvir-ritonavir in patients hospitalised with COVID-19: a target trial emulation study. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00353-0. [PMID: 39025098 DOI: 10.1016/s1473-3099(24)00353-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Remdesivir (Veklury, Gilead Sciences, Foster City, CA, USA) and nirmatrelvir-ritonavir (Paxlovid, Pfizer, New York, NY, USA) were reported to improve the outcome of patients with mild-to-moderate COVID-19 symptoms. Preclinical data suggest that nirmatrelvir-ritonavir might be more effective than remdesivir alone or in combination with nirmatrelvir-ritonavir for people at high risk of severe COVID-19. We aimed to assess the safety and effectiveness of combining remdesivir and nirmatrelvir-ritonavir compared with using each drug alone for adults hospitalised with COVID-19. METHODS In this target trial emulation study, we used electronic health records of patients aged 18 years or older who received either combination treatment of nirmatrelvir-ritonavir and remdesivir or monotherapy of either drug between March 16 and Dec 31, 2022, within 5 days of hospitalisation for COVID-19 in Hong Kong. Inverse probability of treatment weighting was applied to balance baseline patient characteristics across the treatment groups. The primary outcome was all-cause mortality. Cox proportional hazards regression adjusting weighting was used to compare the risk of all-cause mortality, intensive care unit (ICU) admission, or ventilatory support for 90 days of follow-up between groups. FINDINGS Between March 16 and Dec 31, 2022, 18 196 participants were identified from electronic health records and assigned to receive remdesivir (n=4232), nirmatrelvir-ritonavir (n=13 656), or nirmatrelvir-ritonavir and remdesivir (n=308). By applying an inverse probability of treatment weighting, a weighted sample composed of 18 410 recipients of nirmatrelvir-ritonavir and remdesivir combination treatment, 18 178 recipients of remdesivir monotherapy, and 18 287 recipients of nirmatrelvir-ritonavir monotherapy was obtained. After a median follow-up of 84 days (IQR 45-90), risk of mortality was lower in patients who received nirmatrelvir-ritonavir monotherapy (hazard ratio [HR] 0·18 [95% CI 0·15 to 0·20]; absolute risk reduction [ARR] -16·33% [95% CI -16·98 to -15·68]) or remdesivir and nirmatrelvir-ritonavir combination therapy (HR 0·66 [95% CI 0·49 to 0·89]; ARR -6·52% [95% CI -7·29 to -5·74]) than in patients who received remdesivir monotherapy. Similar results were observed for ICU admission or ventilatory support (nirmatrelvir-ritonavir monotherapy: HR 0·09 [95% CI 0·07 to 0·11]; ARR -10·04% [95% CI -10·53 to -9·56]; combination therapy: HR 0·68 [95% CI 0·42 to 1·12]; ARR -3·24% [95% CI -3·84 to -2·64]). Compared with combination therapy, nirmatrelvir-ritonavir monotherapy was associated with lower risk of mortality (HR 0·27 [95% CI 0·20 to 0·37]; ARR -9·81% [95% CI -10·39 to -9·24]) and ICU admission or ventilatory support (HR 0·13 [95% CI 0·08 to 0·22]; ARR -6·80% [95% CI -7·22 to -6·39]). INTERPRETATION Our study highlighted the potential for reduced risk of mortality, ICU admission, or the need for ventilatory support in patients hospitalised with COVID-19 treated with nirmatrelvir-ritonavir as a monotherapy compared with treatment regimens based on nirmatrelvir-ritonavir and remdesivir combination therapy or remdesivir monotherapy. Further randomised controlled trials are needed to support the validity of the current results. FUNDING The Health and Medical Research Fund Commissioned Research on COVID-19. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ming Hong Choi
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric Yuk Fai Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China; Aston Pharmacy School, Aston University, Birmingham, UK; School of Pharmacy, Medical Sciences Division, Macau University of Science and Technology, Macau Special Administrative Region, China
| | - Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China; Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
| | - Wing Ming Chu
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Anthony Raymond Tam
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kwok Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ivan Fan Ngai Hung
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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Mozaffari E, Chandak A, Chima-Melton C, Kalil AC, Jiang H, Lee E, Der-Torossian C, Thrun M, Berry M, Haubrich R, Gottlieb RL. Remdesivir is Associated with Reduced Mortality in Patients Hospitalized for COVID-19 Not Requiring Supplemental Oxygen. Open Forum Infect Dis 2024; 11:ofae202. [PMID: 38894848 PMCID: PMC11182948 DOI: 10.1093/ofid/ofae202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/10/2024] [Indexed: 06/21/2024] Open
Abstract
Background Remdesivir has demonstrated benefit in some hospitalized patients with coronavirus disease 2019 (COVID-19) on supplemental oxygen and in nonhospitalized patients breathing room air. The durability of this benefit across time periods with different circulating severe acute respiratory syndrome coronavirus 2 variants of concern (VOC) is unknown. This comparative effectiveness study in patients hospitalized for COVID-19 and not receiving supplemental oxygen at admission compared those starting remdesivir treatment in the first 2 days of admission with those receiving no remdesivir during their hospitalization across different VOC periods. Method Using a large, multicenter US hospital database, in-hospital mortality rates were compared among patients hospitalized for COVID-19 but not requiring supplemental oxygen at admission between December 2020 and April 2022. Patients receiving remdesivir at hospital admission were matched 1:1 to those not receiving remdesivir during hospitalization, using propensity score matching. Cox proportional hazards models were used to assess 14- and 28-day in-hospital mortality rates or discharge to hospice. Results Among the 121 336 eligible patients, 58 188 remdesivir-treated patients were matched to 17 574 unique patients not receiving remdesivir. Overall, 5.4% of remdesivir-treated and 7.3% in the non-remdesivir group died within 14 days, and 8.0% and 9.8%, respectively, died within 28 days. Remdesivir treatment was associated with a statistically significant reduction in the in-hospital mortality rate compared with non-remdesivir treatment (14-day and 28-day adjusted hazard ratios [95% confidence interval], 0.75 [0.68-0.83] and 0.83 [0.76-0.90], respectively). This significant mortality benefit endured across the different VOC periods. Conclusions Remdesivir initiation in patients hospitalized for COVID-19 and not requiring supplemental oxygen at admission was associated with a significantly reduced in-hospital mortality rate. These findings highlight a potential survival benefit when clinicians initiated remdesivir on admission across the dominant variant eras of the evolving pandemic.
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Affiliation(s)
- Essy Mozaffari
- Medical Affairs, Gilead Sciences, Foster City, California, USA
| | | | - Chidinma Chima-Melton
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of California–Los Angeles Health, Torrance, California, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Heng Jiang
- Evidence & Access, Certara, Paris, France
| | - EunYoung Lee
- Medical Affairs, Gilead Sciences, Foster City, California, USA
| | | | - Mark Thrun
- Medical Affairs, Gilead Sciences, Foster City, California, USA
| | - Mark Berry
- Medical Affairs, Gilead Sciences, Foster City, California, USA
| | | | - Robert L Gottlieb
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Dallas, Texas, USA
- Department of Internal Medicine, Burnett School of Medicine at TCU, Fort Worth, Texas, USA
- Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas, USA
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Mozaffari E, Chandak A, Gottlieb RL, Chima-Melton C, Kalil AC, Sarda V, Der-Torossian C, Oppelt T, Berry M, Amin AN. Treatment of patients hospitalized for COVID-19 with remdesivir is associated with lower likelihood of 30-day readmission: a retrospective observational study. J Comp Eff Res 2024; 13:e230131. [PMID: 38420658 PMCID: PMC11044956 DOI: 10.57264/cer-2023-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 02/14/2024] [Indexed: 03/02/2024] Open
Abstract
Aim: This observational study investigated the association between remdesivir treatment during hospitalization for COVID-19 and 30-day COVID-19-related and all-cause readmission across different variants time periods. Patients & methods: Hospitalization records for adult patients discharged from a COVID-19 hospitalization between 1 May 2020 to 30 April 2022 were extracted from the US PINC AI Healthcare Database. Likelihood of 30-day readmission was compared among remdesivir-treated and nonremdesivir-treated patients using multivariable logistic regression models adjusted for age, corticosteroid treatment, Charlson comorbidity index and intensive care unit stay during the COVID-19 hospitalization. Analyses were stratified by maximum supplemental oxygen requirement and variant time period (pre-Delta, Delta and Omicron). Results: Of the 440,601 patients discharged alive after a COVID-19 hospitalization, 248,785 (56.5%) patients received remdesivir. Overall, remdesivir patients had a 30-day COVID-19-related readmission rate of 3.0% and all-cause readmission rate of 6.3% compared with 5.4% and 9.1%, respectively, for patients who did not receive remdesivir during their COVID-19 hospitalization. After adjusting for demographics and clinical characteristics, remdesivir treatment was associated with significantly lower odds of 30-day COVID-19-related readmission (odds ratio 0.60 [95% confidence interval: 0.58-0.62]), and all-cause readmission (0.73 [0.72-0.75]). Significantly lower odds of 30-day readmission in remdesivir-treated patients was observed across all variant time periods. Conclusion: Treating patients hospitalized for COVID-19 with remdesivir is associated with a statistically significant reduction in 30-day COVID-19-related and all-cause readmission across variant time periods. These findings indicate that the clinical benefit of remdesivir may extend beyond the COVID-19 hospitalization.
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Affiliation(s)
| | | | - Robert L Gottlieb
- Baylor University Medical Center, Dallas, TX 75246, USA
- Baylor Scott & White Heart & Vascular Hospital, Dallas, TX USA, 75226
- Baylor Scott & White The Heart Hospital, Plano, TX 75093, USA
- Baylor Scott & White Research Institute, Dallas, TX 75204, USA
| | | | - Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE 68198, USA
| | | | | | | | - Mark Berry
- Gilead Sciences, Foster City, CA, 94404, USA
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Mozaffari E, Chandak A, Amin AN, Gottlieb RL, Kalil AC, Sarda V, Berry M, Brown G, Okulicz JF, Chima-Melton C. Racial and Ethnic Disparities in COVID-19 Treatments in the United States. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-01942-0. [PMID: 38409487 DOI: 10.1007/s40615-024-01942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
INTRODUCTION Racial and ethnic disparities in patient outcomes following COVID-19 exist, in part, due to factors involving healthcare delivery. The aim of the study was to characterize disparities in the administration of evidence-based COVID-19 treatments among patients hospitalized for COVID-19. METHODS Using a large, US hospital database, initiation of COVID-19 treatments was compared among patients hospitalized for COVID-19 between May 2020 and April 2022 according to patient race and ethnicity. Multivariate logistic regression models were used to examine the effect of race and ethnicity on the likelihood of receiving COVID-19 treatments, stratified by baseline supplemental oxygen requirement. RESULTS The identified population comprised 317,918 White, 76,715 Black, 9297 Asian, and 50,821 patients of other or unknown race. There were 329,940 non-Hispanic, 74,199 Hispanic, and 50,622 patients of unknown ethnicity. White patients were more likely to receive COVID-19 treatments, and specifically corticosteroids, compared to Black, Asian, and other patients (COVID-19 treatment: 87% vs. 81% vs. 85% vs. 84%, corticosteroids: 85% vs. 79% vs. 82% vs. 82%). After covariate adjustment, White patients were significantly more likely to receive COVID-19 treatments than Black patients across all levels of supplemental oxygen requirement. No clear trend in COVID-19 treatments according to ethnicity (Hispanic vs. non-Hispanic) was observed. CONCLUSION There were important racial disparities in inpatient COVID-19 treatment initiation, including the undertreatment of Black patients and overtreatment of White patients. Our new findings reveal the actual magnitude of this issue in routine clinical practice to clinicians, policymakers, and guideline developers. This is crucial to ensuring equitable and appropriate access to evidence-based therapies.
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Affiliation(s)
| | | | | | - Robert L Gottlieb
- Baylor University Medical Center, Dallas, TX, USA
- Baylor Scott & White Heart and Vascular Hospital, Dallas, TX, USA
- Baylor Scott & White The Heart Hospital, Plano, TX, USA
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | | | - Chidinma Chima-Melton
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, UCLA Health System, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
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Gottlieb RL, Paredes R. Oral and intravenous 1'-cyano-substituted adenosine-like antivirals for early COVID-19. THE LANCET. INFECTIOUS DISEASES 2024; 24:108-110. [PMID: 38006893 DOI: 10.1016/s1473-3099(23)00633-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 11/27/2023]
Affiliation(s)
- Robert L Gottlieb
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX 75246, USA; Baylor Scott & White Research Institute, Dallas, TX, USA; Texas A&M Health Science Center, Dallas, TX, USA; Burnett School of Medicine at TCU, Fort Worth, TX, USA.
| | - Roger Paredes
- Department of Infectious Diseases & Fundació Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain; IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain; Center for Global Health & Diseases, Department of Pathology, Case Western Reserve University, Cleveland, OH, USA
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Godwin PO, Polsonetti B, Caron MF, Oppelt TF. Remdesivir for the Treatment of COVID-19: A Narrative Review. Infect Dis Ther 2024; 13:1-19. [PMID: 38193988 PMCID: PMC10828241 DOI: 10.1007/s40121-023-00900-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024] Open
Abstract
Despite the wide availability of effective vaccines, COVID-19 continues to be an infectious disease of global importance. Remdesivir is a broad-spectrum antiviral and was the first US Food and Drug Administration-approved treatment for COVID-19. In clinical guidelines, remdesivir is currently the only recommended antiviral for use in hospitalized patients with COVID-19, with or without a supplemental oxygen requirement. It is also recommended for nonhospitalized patients with COVID-19 and hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who are at high risk of progression to severe disease. This narrative review explores the evidence for remdesivir across various clinical outcomes and evolution of clinical guidelines through a survey over time of randomized controlled trials, observational studies, and meta-analyses. Remdesivir, compared to standard of care, appears to improve survival and disease progression in a variety of patient populations with COVID-19 across a spectrum of disease severity and SARS-CoV-2 variant periods. Remdesivir also appears to improve time to clinical recovery, increase rate of recovery, and reduce time on supplemental oxygen and readmission rates. More recent large, real-world studies further support the early use of remdesivir in a range of patient populations, including those with immunocompromising conditions.
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Affiliation(s)
- Patrick O Godwin
- Department of Medicine, Division of Academic Internal Medicine, University of Illinois at Chicago, Chicago, IL, USA
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