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Bai F, Beringheli T, Vitaletti V, Santoro A, Molà F, Copes A, Gemignani N, Pettenuzzo S, Castoldi R, Varisco B, Nardo R, Lundgren LB, Ligresti R, Sala M, Albertini L, Augello M, Biasioli L, Bono V, Rovito R, Bini T, Passarella S, Orfeo NV, Monforte AD, Marchetti G. Clinical Outcome and 7-Day Virological Clearance in High-Risk Patients with Mild-Moderate COVID-19 Treated with Molnupiravir, Nirmatrelvir/Ritonavir, or Remdesivir. Infect Dis Ther 2024; 13:1589-1605. [PMID: 38829439 DOI: 10.1007/s40121-024-00994-3] [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: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION We compared the effectiveness and virological clearance (VC) at day 7 (T7) post-treatment with molnupiravir, nirmatrelvir/ritonavir, and remdesivir in SARS-CoV-2-infected patients at high risk (HR) for clinical progression. METHODS We conducted a retrospective study enrolling HR patients with mild-to-moderate COVID-19 (Jan-Oct 2022) treated with nirmatrelvir/ritonavir or molnupiravir or 3 days of remdesivir. We investigated clinical recovery at T7 (resolution of symptoms for ≥ 72 h or all-cause death), VC at T7 (PCR/antigenic negative nasopharyngeal swab), and median time to VC (days from symptom onset to the first negative swab). Factors associated with VC were investigated by logistic regression. RESULTS In the study, 92/376 (43.8%) patients received molnupiravir, 150/376 (24.7%) nirmatrelvir/ritonavir, and 134/376 (31.5%) remdesivir. Forty-nine (13%) patients were unvaccinated or incompletely vaccinated. Patients treated with nirmatrelvir/ritonavir were younger and presented immunodeficiencies more frequently; remdesivir was used more commonly in patients hospitalized for other diseases. A high proportion of patients obtained clinical recovery without differences among the therapies (97.5% for molnupiravir, 98.3% for nirmatrelvir/ritonavir, and 93.6% for remdesivir); 12 (3.7%) patients died. Nirmatrelvir/ritonavir was associated with a higher proportion of T7 VC and a shorter time to VC compared to molnupiravir/remdesivir, also after adjustment for age and immunodeficiency (AOR 0.445 RDV vs. NMV-r, 95% CI 0.240-0.826, p = 0.010; AOR 0.222 MNP vs. NMV-r, 95% CI 0.105-0.472, p < 0.001). CONCLUSIONS SARS-COV-2 antiviral treatments are an excellent therapeutic strategy in HR patients. Nirmatrelvir/ritonavir showed a higher proportion of VC as early as 7 days after treatment, confirming its likely superiority in indirect comparisons.
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Affiliation(s)
- Francesca Bai
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy.
| | - Tomaso Beringheli
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Virginia Vitaletti
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Andrea Santoro
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Francesco Molà
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Alessandro Copes
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Nicole Gemignani
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Sofia Pettenuzzo
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Roberto Castoldi
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Benedetta Varisco
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Riccardo Nardo
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Lorenzo Brando Lundgren
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Riccardo Ligresti
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Matteo Sala
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Lorenzo Albertini
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Matteo Augello
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Lorenzo Biasioli
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Valeria Bono
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Roberta Rovito
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Teresa Bini
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | | | | | - Antonella d'Arminio Monforte
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - Giulia Marchetti
- Clinic of Infectious Diseases, Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, University of Milan, Via A. Di Rudinì, 8, 20142, Milan, Italy
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Abu-Ahmad W, Arbel R, Wolff Sagy Y, Battat E, Sergienko R, Friger M, Yaron S, Serby D, Zucker R, Hammerman A, Bitan HD, Peretz A, Lavie G, Netzer D. Effectiveness and Safety of Molnupiravir in the Intended-Use Population: an Observational Cohort Study. Clin Microbiol Infect 2024:S1198-743X(24)00298-2. [PMID: 38942382 DOI: 10.1016/j.cmi.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/20/2024] [Accepted: 06/19/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVES Previous research reported inconsistent results on the efficacy of molnupiravir in treating COVID-19. Moreover, efficacy was not assessed in the intended-use population (IUP), as defined by the FDA. Therefore, we aimed to evaluate the effectiveness and safety of molnupiravir for the treatment of COVID-19 in the IUP. METHODS We conducted a retrospective cohort study on all IUP in Israel's Clalit Health Services (CHS) from Jan. 16, 2022, to Feb. 16, 2023. The effectiveness outcome was the incidence of hospitalization or death due to COVID-19, and the safety outcome was the incidence of all-cause mortality within 35 days of SARS-CoV-2 infection. Cox-proportional hazard models were used to analyze the data after 1:5 propensity score matching. RESULTS 49,515 patients met the eligibility criteria. Of them, 3,957 molnupiravir-treated patients were matched to 19,785 untreated patients. In molnupiravir-treated patients, 70 out of 3,957 (5.1 per 10,000 person-days) experienced COVID-19-related hospitalization or death, compared to 699 out of 19,785 untreated patients (10.4 per 10,000 person-days); RR: 0.50, (95% CI: 0.39-0.64). All-cause mortality was also lower in the treated group, with 41 out of 3,957 (3.0 per 10,000 person-days) experiencing mortality compared to 414 out of 19,785 untreated patients (6.1 per 10,000 person-days); RR: 0.50 (0.36-0.68). CONCLUSIONS In a real-world cohort of IUP, molnupiravir therapy was associated with a significant reduction in hospitalizations or deaths due to COVID-19 and all-cause mortality.
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Affiliation(s)
- Wiessam Abu-Ahmad
- Braun School of Public Health, Hebrew University-Hadassah, Jerusalem, Israel; Branch of Planning and Strategy, Clalit Health Services, Tel Aviv, Israel.
| | - Ronen Arbel
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel; Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Yael Wolff Sagy
- Branch of Planning and Strategy, Clalit Health Services, Tel Aviv, Israel
| | - Erez Battat
- Branch of Planning and Strategy, Clalit Health Services, Tel Aviv, Israel
| | - Ruslan Sergienko
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Michael Friger
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shlomit Yaron
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel
| | - Danielle Serby
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel
| | - Roy Zucker
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel
| | - Ariel Hammerman
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel
| | - Hadar Duskin Bitan
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel
| | - Alon Peretz
- Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel; School of Public Health, University of Haifa, Haifa, Israel
| | - Gil Lavie
- Branch of Planning and Strategy, Clalit Health Services, Tel Aviv, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Doron Netzer
- Adelson School of Medicine, Ariel University Israel; Community Medical Services Division, Clalit Health Services, Tel-Aviv, Israel
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Yan L, Bui D, Li Y, Rajeevan N, Rowneki M, Berry K, Argraves S, Huang Y, Hynes DM, Cunningham F, Huang GD, Aslan M, Ioannou GN, Bajema KL. Identifying Veterans Who Benefit From Nirmatrelvir-Ritonavir: A Target Trial Emulation. Clin Infect Dis 2024:ciae202. [PMID: 38864601 DOI: 10.1093/cid/ciae202] [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: 12/09/2023] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Nirmatrelvir-ritonavir is recommended for persons at risk for severe coronavirus disease 2019 (COVID-19) but remains underutilized. Information on which eligible groups are likely to benefit from treatment is needed. METHODS We conducted a target trial emulation study in the Veterans Health Administration comparing nirmatrelvir-ritonavir treated versus matched untreated veterans at risk for severe COVID-19 who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from April 2022 through March 2023. We measured incidence of any hospitalization or all-cause mortality at 30 days. Outcomes were measured for the entire cohort, as well as among subgroups defined by 30-day risk of death or hospitalization, estimated using an ensemble risk prediction model. RESULTS Participants were 87% male with median age 66 years and 16% unvaccinated. Compared with matched untreated participants, those treated with nirmatrelvir-ritonavir (n = 24 205) had a lower 30-day risk for hospitalization (1.80% vs 2.30%; risk difference [RD], -0.50% points [95% confidence interval {CI}: -.69 to -.35]) and death (0.11% vs 0.30%; RD, -0.20 [95% CI: -.24 to -.13]). The greatest reductions in combined hospitalization or death were observed in the highest risk quartile (RD -2.85 [95% CI: -3.94 to -1.76]), immunocompromised persons (RD -1.91 [95% CI: -3.09 to -.74]), and persons aged ≥75 years (RD -1.16 [95% CI: -1.73 to -.59]). No reductions were observed in the 2 lowest risk quartiles or persons younger than 65 years. CONCLUSIONS Nirmatrelvir-ritonavir was effective in reducing 30-day hospitalization and death in older veterans, those at highest predicted risk for severe outcomes, and immunocompromised groups. Benefit was not observed in younger veterans or groups at lower predicted risk for hospitalization and death.
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Affiliation(s)
- Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - David Bui
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Stephanie Argraves
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
| | - Yuan Huang
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety-Pharmacy Benefit Management (PBM) Services, Hines, Illinois, USA
| | - Grant D Huang
- Office of Research and Development, Veterans Health Administration, Washington D.C., USA
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP CERC), Veterans Affairs Connecticut Health Care System, West Haven, Connecticut, USA
- Office of Research and Development, Veterans Health Administration, Washington D.C., USA
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Divisions of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Kristina L Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Butt AA, Yan P, Shaikh OS. Nirmatrelvir/ritonavir or Molnupiravir for treatment of non-hospitalized patients with COVID-19 at risk of disease progression. PLoS One 2024; 19:e0298254. [PMID: 38843201 PMCID: PMC11156403 DOI: 10.1371/journal.pone.0298254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/21/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND In randomized controlled trials, Nirmatrelvir/ritonavir (NMV/r) and Molnupiravir (MPV) reduced the risk of severe/fatal COVID-19 disease. Real-world data are limited, particularly studies directly comparing the two agents. METHODS Using the VA National COVID-19 database, we identified previously uninfected, non-hospitalized individuals with COVID-19 with ≥1 risk factor for disease progression who were prescribed either NMV/r or MPV within 3 days of a positive test. We used inverse probability of treatment weights (IPTW) to account for providers' preferences for a specific treatment. Absolute risk difference (ARD) with 95% confidence intervals were determined for those treated with NMV/r vs. MPV. The primary outcome was hospitalization or death within 30 days of treatment prescription using the IPTW approach. Analyses were repeated using propensity-score matched groups. RESULTS Between January 1 and November 30, 2022, 9,180 individuals were eligible for inclusion (6,592 prescribed NMV/r; 2,454 prescribed MPV). The ARD for hospitalization/death for NMV/r vs MPV was -0.25 (95% CI -0.79 to 0.28). There was no statistically significant difference in ARD among strata by age, race, comorbidities, or symptoms at baseline. Kaplan-Meier curves did not demonstrate a difference between the two groups (p-value = 0.6). Analysis of the propensity-score matched cohort yielded similar results (ARD for NMV/r vs. MPV -0.9, 95% CI -2.02 to 0.23). Additional analyses showed no difference for development of severe/critical/fatal disease by treatment group. CONCLUSION We found no significant difference in short term risk of hospitalization or death among at-risk individuals with COVID-19 treated with either NMV/r or MPV.
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Affiliation(s)
- Adeel Ajwad Butt
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- Weill Cornell Medicine, New York, New York, United States of America
- Weill Cornell Medicine Qatar, Doha, Qatar
- Hamad Medical Corporation, Doha, Qatar
| | - Peng Yan
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
| | - Obaid S. Shaikh
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
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Richmond DiBello J, Raziano VT, Liu X, Puenpatom A, Peebles K, Khan NF, Hill DD. Molnupiravir Use Among Patients with COVID-19 in Real-World Settings: A Systematic Literature Review. Infect Dis Ther 2024; 13:1177-1198. [PMID: 38743192 PMCID: PMC11128428 DOI: 10.1007/s40121-024-00976-5] [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: 03/15/2024] [Accepted: 04/08/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Molnupiravir (MOV) is an oral antiviral for the treatment of individuals with mild-to-moderate COVID-19 and at high risk of progression to severe disease. Our objective was to conduct a systematic literature review (SLR) of evidence on the effectiveness of MOV in reducing the risk of severe COVID-19 outcomes in real-world outpatient settings. METHODS The SLR was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and using pre-determined population, intervention, comparison, outcome, time, and study design inclusion criteria. Eligible studies were published between January 1, 2021, and March 10, 2023, and evaluated the real-world effectiveness of MOV compared to no treatment in reducing the risk of severe COVID-19 outcomes among outpatients ≥ 18 years of age with a laboratory-confirmed diagnosis of SARS-CoV-2 infection. RESULTS Nine studies from five countries were included in the review. The size of the MOV-treated group ranged from 359 to 7818 individuals. Omicron variants of SARS-CoV-2 were dominant in all study periods. Most studies noted differences in the baseline characteristics of the MOV-treated and untreated control groups, with the treated groups generally being older and with more comorbidities. Eight studies reported that treatment with MOV was associated with a significantly reduced risk of at least one severe COVID-19 outcome in at least one age group, with greater benefits consistently observed among older age groups. CONCLUSIONS In this SLR study, treatment with MOV was effective in reducing the risk of severe outcomes from COVID-19 caused by Omicron variants, especially for older individuals. Differences in the ages and baseline comorbidities of the MOV-treated and control groups may have led to underestimation of the effectiveness of MOV in many observational studies. Real-world studies published to date thus provide additional evidence supporting the continued benefits of MOV in non-hospitalized adults with COVID-19.
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Affiliation(s)
- Julia Richmond DiBello
- Biostatistics and Research Decision Sciences (BARDS), Epidemiology, Merck & Co., Inc., Rahway, NJ, USA
| | - Valerie T Raziano
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, USA.
- Merck & Co., Inc., 351 N Sumneytown Pike, North Wales, PA, 19454, USA.
| | - Xinyue Liu
- Biostatistics and Research Decision Sciences (BARDS), Epidemiology, Merck & Co., Inc., Rahway, NJ, USA
| | - Amy Puenpatom
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, USA
| | - Kathryn Peebles
- Biostatistics and Research Decision Sciences (BARDS), Epidemiology, Merck & Co., Inc., Rahway, NJ, USA
| | - Nazleen F Khan
- Biostatistics and Research Decision Sciences (BARDS), Epidemiology, Merck & Co., Inc., Rahway, NJ, USA
| | - Deanna D Hill
- Biostatistics and Research Decision Sciences (BARDS), Epidemiology, Merck & Co., Inc., Rahway, NJ, USA
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Mesfin YM, Blais JE, Kibret KT, Tegegne TK, Cowling BJ, Wu P. Effectiveness of nirmatrelvir/ritonavir and molnupiravir in non-hospitalized adults with COVID-19: systematic review and meta-analysis of observational studies. J Antimicrob Chemother 2024:dkae163. [PMID: 38817046 DOI: 10.1093/jac/dkae163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/05/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE To determine the effectiveness of nirmatrelvir/ritonavir and molnupiravir among vaccinated and unvaccinated non-hospitalized adults with COVID-19. METHODS Observational studies of nirmatrelvir/ritonavir or molnupiravir compared to no antiviral drug treatment for COVID-19 in non-hospitalized adults with data on vaccination status were included. We searched MEDLINE, EMBASE, Scopus, Web of Science, WHO COVID-19 Research Database and medRxiv for reports published between 1 January 2022 and 8 November 2023. The primary outcome was a composite of hospitalization or mortality up to 35 days after COVID-19 diagnosis. Risk of bias was assessed with ROBINS-I. Risk ratios (RR), hazard ratios (HR) and risk differences (RD) were separately estimated using random-effects models. RESULTS We included 30 cohort studies on adults treated with nirmatrelvir/ritonavir (n = 462 279) and molnupiravir (n = 48 008). Nirmatrelvir/ritonavir probably reduced the composite outcome (RR 0.62, 95%CI 0.55-0.70; I2 = 0%; moderate certainty) with no evidence of effect modification by vaccination status (RR Psubgroup = 0.47). In five studies, RD estimates against the composite outcome for nirmatrelvir/ritonavir were 1.21% (95%CI 0.57% to 1.84%) in vaccinated and 1.72% (95%CI 0.59% to 2.85%) in unvaccinated subgroups.Molnupiravir may slightly reduce the composite outcome (RR 0.75, 95%CI 0.67-0.85; I2 = 32%; low certainty). Evidence of effect modification by vaccination status was inconsistent among studies reporting different effect measures (RR Psubgroup = 0.78; HR Psubgroup = 0.08). In two studies, RD against the composite outcome for molnupiravir were -0.01% (95%CI -1.13% to 1.10%) in vaccinated and 1.73% (95%CI -2.08% to 5.53%) in unvaccinated subgroups. CONCLUSIONS Among cohort studies of non-hospitalized adults with COVID-19, nirmatrelvir/ritonavir is effective against the composite outcome of severe COVID-19 independent of vaccination status. Further research and a reassessment of molnupiravir use among vaccinated adults are warranted. REGISTRATION PROSPERO CRD42023429232.
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Affiliation(s)
- Yonatan M Mesfin
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Immunity & Global Health, Murdoch Children's Research Institute (MCRI), Parkville, VIC, Australia
| | - Joseph E Blais
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administration Region, Hong Kong, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
| | - Kelemu Tilahun Kibret
- Global Centre for Preventive Health and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Teketo Kassaw Tegegne
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Benjamin J Cowling
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administration Region, Hong Kong, China
| | - Peng Wu
- School of Public Health, LKS Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, The University of Hong Kong, Hong Kong Special Administration Region, Hong Kong, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, New Territories, Hong Kong Special Administration Region, Hong Kong, China
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Wang H, Wei Y, Hung CT, Lin G, Jiang X, Li C, Jia KM, Yam CHK, Chow TY, Ho JYE, Wang Y, Zhao S, Guo Z, Li K, Yang A, Mok CKP, Hui DSC, Yeoh EK, Chong KC. Association of nirmatrelvir-ritonavir with post-acute sequelae and mortality in patients admitted to hospital with COVID-19: a retrospective cohort study. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00217-2. [PMID: 38710190 DOI: 10.1016/s1473-3099(24)00217-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Studies have established the short-term efficacy of nirmatrelvir-ritonavir in managing COVID-19, yet its effect on post-COVID-19 condition, especially in patients admitted to hospital, remains understudied. This study aimed to examine the effect of nirmatrelvir-ritonavir on post-COVID-19 condition among patients admitted to hospital in Hong Kong. METHODS This retrospective cohort study used real-world, territory-wide inpatient records, vaccination records, and confirmed COVID-19 case data from the Hong Kong Hospital Authority and Department of Health, The Government of the Hong Kong Special Administrative Region. Patients aged 18 years and older who tested positive for SARS-CoV-2 between March 11, 2022, and Oct 10, 2023, and who were admitted to hospital with COVID-19 were included. The treatment group included patients prescribed nirmatrelvir-ritonavir within 5 days of symptom onset, excluding those prescribed molnupiravir within 21 days, and the control group had no exposure to either nirmatrelvir-ritonavir or molnupiravir. The outcomes were post-acute inpatient death and 13 sequelae (congestive heart failure, atrial fibrillation, coronary artery disease, deep vein thrombosis, chronic pulmonary disease, acute respiratory distress syndrome, interstitial lung disease, seizure, anxiety, post-traumatic stress disorder, end-stage renal disease, acute kidney injury, and pancreatitis). These outcomes were evaluated starting at 21 days after the positive RT-PCR date in each respective cohort constructed for the outcome. Standardised mortality ratio weights were applied to balance covariates, and Cox proportional hazards regression was used to investigate the relationship between nirmatrelvir-ritonavir and outcomes. FINDINGS 136 973 patients were screened for inclusion, among whom 50 055 were eligible and included in the analysis (24 873 [49·7%] were female and 25 182 [50·3%] were male). 15 242 patients were prescribed nirmatrelvir-ritonavir during acute COVID-19 and 23 756 patients were included in the control group; 11 057 patients did not meet our definition for the exposed and unexposed groups. Patients were followed up for a median of 393 days (IQR 317-489). In the nirmatrelvir-ritonavir group compared with the control group, there was a significantly lower hazard of post-acute inpatient death (hazard ratio 0·62 [95% CI 0·57-0·68]; p<0·0001), congestive heart failure (0·70 [0·58-0·85]; p=0·0002), atrial fibrillation (0·63 [0·52-0·76]; p<0·0001), coronary artery disease (0·71 [0·59-0·85]; p=0·0002), chronic pulmonary disease (0·68 [0·54-0·86]; p=0·0011), acute respiratory distress syndrome (0·71 [0·58-0·86]; p=0·0007), interstitial lung disease (0·17 [0·04-0·75]; p=0·020), and end-stage renal disease (0·37 [0·18-0·74]; p=0·0049). There was no evidence indicating difference between the groups in deep vein thrombosis, seizure, anxiety, post-traumatic stress disorder, acute kidney injury, and pancreatitis. INTERPRETATION This study showed extended benefits of nirmatrelvir-ritonavir for reducing the risk of post-acute inpatient death as well as cardiovascular and respiratory complications among patients admitted to hospital with COVID-19. Further research is essential to uncover the underlying mechanisms responsible for these observed negative associations and to devise effective strategies for preventing the onset of post-acute sequelae. FUNDING Health and Medical Research Fund, Research Grants Council theme-based research schemes, and Research Grants Council Collaborative Research Fund.
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Affiliation(s)
- Huwen Wang
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yuchen Wei
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chi Tim Hung
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Guozhang Lin
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Xiaoting Jiang
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Conglu Li
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Katherine Min Jia
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Carrie Ho Kwan Yam
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Tsz Yu Chow
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Janice Ying-En Ho
- Division of Landscape Architecture, Department of Architecture, Faculty of Architecture, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yawen Wang
- Division of Landscape Architecture, Department of Architecture, Faculty of Architecture, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Shi Zhao
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; School of Public Health, Tianjin Medical University, Tianjin, China
| | - Zihao Guo
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kehang Li
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Aimin Yang
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Chris Ka Pun Mok
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - David S C Hui
- S H Ho Research Centre for Infectious Diseases, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eng Kiong Yeoh
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Ka Chun Chong
- Centre for Health Systems and Policy Research, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
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8
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Wu JY, Liu MY, Lee MC, Hung KC, Hsu WH, Tsai YW, Liu TH, Huang PY, Chuang MH, Tseng SC, Lu CY, Lai CC. The clinical outcomes and effectiveness of antiviral agents among underweight patients with COVID-19. Expert Rev Anti Infect Ther 2024; 22:343-352. [PMID: 38178687 DOI: 10.1080/14787210.2024.2303017] [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: 07/15/2023] [Accepted: 12/13/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES This study investigated the outcomes of underweight patients with COVID-19 and the effectiveness of antiviral agents in this population. METHODS A retrospective cohort study using theTriNetX research network was conducted. Propensity score matching (PSM) was employed to balance the first cohort involving COVID-19 patients with underweight and normal-weight. In the second cohort, underweight patients receiving antiviral agents and untreated individuals were matched using PSM. The primary outcome was a composite of all-cause hospitalization and death during the 7-30-day follow-up period. RESULTS After PSM, the first cohort including each group of 13,502 patients with balanced baseline characteristics were identified for comparing the outcome of patients with underweight and normal weight. The underweight group had a higher risk of the composite primary outcome than those with normal weight (hazard ratio [HR], 1.251; 95% confidence interval [CI], 1.132-1.382). The second cohort included each 884 underweight patients with and without receiving antivirals.Compared with untreated patients, those receiving antiviral treatment had a lower risk of composite primary outcomes (HR, 0.426; 95% CI, 0.278-0.653). CONCLUSION Underweight status may be associated with a higher risk of all-cause hospitalization and death in patients with COVID-19.Among underweight patients, antiviral agents demonstrated clinically beneficial effects.
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Affiliation(s)
- Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mei-Yuan Liu
- Department of Nutrition, Chi Mei Medical Center, Tainan, Taiwan
- Department of Nutrition and Health Sciences, Chang Jung Christian University, Tainan, Taiwan
- Department of Food Nutrition, Chung Hwa University of Medical Technology, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy & Science, Tainan, Taiwan
| | - Mei-Chuan Lee
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, Chi Mei Medical Centre, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Wan-Hsuan Hsu
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ya-Wen Tsai
- Center of Integrative Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ting-Hui Liu
- Department of Psychiatry, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Yu Huang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Min-Hsiang Chuang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Shu-Ching Tseng
- Department of Examination Room, Chi Mei Medical Center, Tainan, Taiwan
| | - Chih-Ying Lu
- Department of General Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Chih-Cheng Lai
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
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9
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Cha-Silva AS, Gavaghan MB, Bergroth T, Alexander-Parrish R, Yang J, Draica F, Patel J, Garner DA, Stanford RH, Meier G, McLaughlin JM, Nguyen JL. Effectiveness of Nirmatrelvir-Ritonavir for the Prevention of COVID-19-Related Hospitalization and Mortality: A Systematic Literature Review. Am J Ther 2024; 31:e246-e257. [PMID: 38691664 PMCID: PMC11060058 DOI: 10.1097/mjt.0000000000001744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND Nirmatrelvir/ritonavir (NMV/r) is an oral antiviral drug used to treat mild-to-moderate coronavirus disease 2019 (COVID-19) in patients aged 12 years or older at high risk of progression to severe disease (eg, hospitalization and death). Despite being the preferred option for outpatient treatment in the majority of countries worldwide, NMV/r is currently underutilized in real-world clinical practice. AREAS OF UNCERTAINTY As numerous real-world studies have described patient outcomes following treatment with NMV/r, this systematic literature review provides a comprehensive summary of evidence on NMV/r effectiveness against hospitalization and mortality further organized by clinically meaningful categories, such as acute versus longer-term follow-up, age, underlying health conditions, and vaccination status, to help inform health care decision making. DATA SOURCES We searched Embase and PubMed (December 22, 2021-March 31, 2023) and congress abstracts (December 1, 2021-December 31, 2022) for reports describing NMV/r effectiveness. THERAPEUTIC ADVANCES In total, 18 real-world studies met final selection criteria. The evidence showed that NMV/r significantly reduced postinfection risk of all-cause and COVID-19-related hospitalization and mortality in both acute (≤30 days) (21%-92%) and longer-term (>30 days) (1%-61%) follow-up. The reduction in postinfection risk was higher when treatment was received within 5 days of symptom onset. Real-world effectiveness of NMV/r treatment was observed regardless of age, underlying high-risk conditions, and vaccination status. CONCLUSION The systematic literature review findings demonstrated the effectiveness of NMV/r against hospitalization and mortality during the Omicron period among individuals at high risk of progression to severe COVID-19 disease.
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Affiliation(s)
| | | | | | | | - Jingyan Yang
- Pfizer, New York, NY
- Institute for Social and Economic Research and Policy, Columbia University, New York, NY; and
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10
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Hammond J, Fountaine RJ, Yunis C, Fleishaker D, Almas M, Bao W, Wisemandle W, Baniecki ML, Hendrick VM, Kalfov V, Simón-Campos JA, Pypstra R, Rusnak JM. Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with Covid-19. N Engl J Med 2024; 390:1186-1195. [PMID: 38598573 PMCID: PMC11156287 DOI: 10.1056/nejmoa2309003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Nirmatrelvir in combination with ritonavir is an antiviral treatment for mild-to-moderate coronavirus disease 2019 (Covid-19). The efficacy of this treatment in patients who are at standard risk for severe Covid-19 or who are fully vaccinated and have at least one risk factor for severe Covid-19 has not been established. METHODS In this phase 2-3 trial, we randomly assigned adults who had confirmed Covid-19 with symptom onset within the past 5 days in a 1:1 ratio to receive nirmatrelvir-ritonavir or placebo every 12 hours for 5 days. Patients who were fully vaccinated against Covid-19 and who had at least one risk factor for severe disease, as well as patients without such risk factors who had never been vaccinated against Covid-19 or had not been vaccinated within the previous year, were eligible for participation. Participants logged the presence and severity of prespecified Covid-19 signs and symptoms daily from day 1 through day 28. The primary end point was the time to sustained alleviation of all targeted Covid-19 signs and symptoms. Covid-19-related hospitalization and death from any cause were also assessed through day 28. RESULTS Among the 1296 participants who underwent randomization and were included in the full analysis population, 1288 received at least one dose of nirmatrelvir-ritonavir (654 participants) or placebo (634 participants) and had at least one postbaseline visit. The median time to sustained alleviation of all targeted signs and symptoms of Covid-19 was 12 days in the nirmatrelvir-ritonavir group and 13 days in the placebo group (P = 0.60). Five participants (0.8%) in the nirmatrelvir-ritonavir group and 10 (1.6%) in the placebo group were hospitalized for Covid-19 or died from any cause (difference, -0.8 percentage points; 95% confidence interval, -2.0 to 0.4). The percentages of participants with adverse events were similar in the two groups (25.8% with nirmatrelvir-ritonavir and 24.1% with placebo). In the nirmatrelvir-ritonavir group, the most commonly reported treatment-related adverse events were dysgeusia (in 5.8% of the participants) and diarrhea (in 2.1%). CONCLUSIONS The time to sustained alleviation of all signs and symptoms of Covid-19 did not differ significantly between participants who received nirmatrelvir-ritonavir and those who received placebo. (Supported by Pfizer; EPIC-SR ClinicalTrials.gov number, NCT05011513.).
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Affiliation(s)
- Jennifer Hammond
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Robert J Fountaine
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Carla Yunis
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Dona Fleishaker
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Mary Almas
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Weihang Bao
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Wayne Wisemandle
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Mary Lynn Baniecki
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Victoria M Hendrick
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Veselin Kalfov
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - J Abraham Simón-Campos
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - Rienk Pypstra
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
| | - James M Rusnak
- From Global Product Development, Pfizer, Collegeville, PA (J.H.); Global Product Development, Pfizer, Groton, CT (R.J.F.); Global Product Development, Pfizer, Lake Mary (C.Y.), and Global Product Development, Pfizer, Tampa (J.M.R.) - both in Florida; Global Product Development, Pfizer, Lexington, KY (D.F.); Global Product Development, Pfizer, New York (M.A., W.B., R.P.); Global Product Development, Pfizer, Lake Forest, IL (W.W.); Early Clinical Development, Pfizer, Cambridge, MA (M.L.B.); Pfizer, Sandwich, United Kingdom (V.M.H.); the Specialized Hospital for Active Treatment of Pneumo-Phthisiatric Diseases, Haskovo, Bulgaria (V.K.); and Méchnikov Project, Köhler and Milstein Research, Anahuac-Mayab University, Mérida, Mexico (J.A.S.-C.)
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11
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Miyawaki A, Kitajima K, Iwata A, Sato D, Tsugawa Y. Physician characteristics associated with antiviral prescriptions for older adults with COVID-19 in Japan: an observational study. BMJ Open 2024; 14:e083342. [PMID: 38490659 PMCID: PMC10946352 DOI: 10.1136/bmjopen-2023-083342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/22/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES Although guidelines recommend antiviral therapy for outpatients with COVID-19 who are at high risk of progressing to severe conditions, such as older adults, many patients do not receive appropriate treatment. Little is known, however, about the physician factors associated with the prescription of guideline-recommended antiviral therapy for patients with COVID-19. DESIGN A cross-sectional study. SETTING Data including outpatient visits in primary care clinics in Japan from April to August 2023. PARTICIPANTS We analysed 30 953 outpatients aged ≥65 years treated with COVID-19 (mean (SD) age, 75.0 (7.6) years; 17 652 women (57.0%)) in 1394 primary care clinics. OUTCOME MEASURES The primary outcome was the prescription of guideline-recommended antivirals (ie, nirmatrelvir-ritonavir or molnupiravir), adjusted for patient characteristics, months of visits and regions. RESULTS Antiviral prescriptions were concentrated among a small proportion of physicians; for example, the top 10% of physicians that had the largest number of nirmatrelvir-ritonavir prescriptions accounted for 92.4% of all nirmatrelvir-ritonavir prescriptions. After adjusting for potential confounders, physicians with higher patient volumes were more likely to prescribe guideline-recommended antivirals to their patients (adjusted OR (aOR) for high vs low volume, 1.76; 95% CI 1.31 to 2.38; adjusted p<0.001). We found no evidence that the likelihood of guideline-recommended antiviral prescription differed based on physicians' gender (aOR for women vs men, 1.24; 95% CI 0.88 to 1.74; adjusted p=0.48) or age (aOR for 45-59 vs <45 years, 1.16; 95% CI 0.87 to 1.54; adjusted p=0.48; aOR for ≥60 vs <45 years, 0.88; 95% CI 0.66 to 1.16; adjusted p=0.48). These patterns were similar when examining nirmatrelvir-ritonavir and molnupiravir separately. CONCLUSIONS Our findings suggest that provider-level factors, such as the clinical experience of treating the patients with COVID-19, play an important role in the appropriate prescription of antiviral medications for COVID-19 in the primary care setting.
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Affiliation(s)
- Atsushi Miyawaki
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | | | | | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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12
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Szabó D, Crowe A, Mamotte C, Strappe P. Natural products as a source of Coronavirus entry inhibitors. Front Cell Infect Microbiol 2024; 14:1353971. [PMID: 38449827 PMCID: PMC10915212 DOI: 10.3389/fcimb.2024.1353971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/01/2024] [Indexed: 03/08/2024] Open
Abstract
The COVID-19 pandemic has had a significant and lasting impact on the world. Four years on, despite the existence of effective vaccines, the continuous emergence of new SARS-CoV-2 variants remains a challenge for long-term immunity. Additionally, there remain few purpose-built antivirals to protect individuals at risk of severe disease in the event of future coronavirus outbreaks. A promising mechanism of action for novel coronavirus antivirals is the inhibition of viral entry. To facilitate entry, the coronavirus spike glycoprotein interacts with angiotensin converting enzyme 2 (ACE2) on respiratory epithelial cells. Blocking this interaction and consequently viral replication may be an effective strategy for treating infection, however further research is needed to better characterize candidate molecules with antiviral activity before progressing to animal studies and clinical trials. In general, antiviral drugs are developed from purely synthetic compounds or synthetic derivatives of natural products such as plant secondary metabolites. While the former is often favored due to the higher specificity afforded by rational drug design, natural products offer several unique advantages that make them worthy of further study including diverse bioactivity and the ability to work synergistically with other drugs. Accordingly, there has recently been a renewed interest in natural product-derived antivirals in the wake of the COVID-19 pandemic. This review provides a summary of recent research into coronavirus entry inhibitors, with a focus on natural compounds derived from plants, honey, and marine sponges.
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Affiliation(s)
- Dávid Szabó
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Andrew Crowe
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Cyril Mamotte
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Padraig Strappe
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Curtin Medical School, Curtin University, Bentley, WA, Australia
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13
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Huang X, Tan X, Xie X, Jiang T, Xiao Y, Liu Z. Successful salvage of a severe COVID-19 patient previously with lung cancer and radiation pneumonitis by mesenchymal stem cells: a case report and literature review. Front Immunol 2024; 15:1321236. [PMID: 38380312 PMCID: PMC10876893 DOI: 10.3389/fimmu.2024.1321236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/04/2024] [Indexed: 02/22/2024] Open
Abstract
During the COVID-19 pandemic, elderly patients with underlying condition, such as tumors, had poor prognoses after progressing to severe pneumonia and often had poor response to standard treatment. Mesenchymal stem cells (MSCs) may be a promising treatment for patients with severe pneumonia, but MSCs are rarely used for patients with carcinoma. Here, we reported a 67-year-old female patient with lung adenocarcinoma who underwent osimertinib and radiotherapy and suffered from radiation pneumonitis. Unfortunately, she contracted COVID-19 and that rapidly progressed to severe pneumonia. She responded poorly to frontline treatment and was in danger. Subsequently, she received a salvage treatment with four doses of MSCs, and her symptoms surprisingly improved quickly. After a lung CT scan that presented with a significantly improved infection, she was discharged eventually. Her primary disease was stable after 6 months of follow-up, and no tumor recurrence or progression was observed. MSCs may be an effective treatment for hyperactive inflammation due to their ability related to immunomodulation and tissue repair. Our case suggests a potential value of MSCs for severe pneumonia that is unresponsive to conventional therapy after a COVID-19 infection. However, unless the situation is urgent, it needs to be considered with caution for patients with tumors. The safety in tumor patients still needs to be observed.
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Affiliation(s)
- Xiaohua Huang
- Department of Hematology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Hematology, Dongzhimen Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Xin Tan
- Department of Rehabilitation Medicine, Southern Theater General Hospital, Guangzhou, China
| | - Xiuwen Xie
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tingshu Jiang
- Department of Respiratory and Critical Care Medicine, Yantai Yuhuangding Hospital, Yantai, China
| | - Yang Xiao
- Department of Hematology, Shenzhen Qianhai Shekou Pilot Free Trade Zone Hospital, Shenzhen, China
| | - Zenghui Liu
- Department of Hematology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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14
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Shen Y, Robertson MM, Kulkarni SG, Puzniak L, Zamparo JM, Allen KE, Porter TM, Qasmieh SA, Grov C, Srivastava A, Zimba R, McLaughlin JM, Nash D. Oral COVID-19 Antiviral Uptake Among a Highly Vaccinated US Cohort of Adults With SARS-CoV-2 Infection Between December 2021 and October 2022. Open Forum Infect Dis 2024; 11:ofad674. [PMID: 38344131 PMCID: PMC10854389 DOI: 10.1093/ofid/ofad674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/19/2023] [Indexed: 02/18/2024] Open
Abstract
Background We described the oral nirmatrelvir/ritonavir (NMV/r) and molnupiravir (MOV) uptake among a subgroup of highly vaccinated adults in a US national prospective cohort who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between 12/2021 and 10/2022. Methods We estimate antiviral uptake within 5 days of SARS-CoV-2 infection, as well as age- and gender-adjusted antiviral uptake prevalence ratios by antiviral eligibility (based on age and comorbidities), sociodemographic characteristics, and clinical characteristics including vaccination status and history of long coronavirus disease 2019 (COVID). Results NMV/r uptake was 13.6% (95% CI, 11.9%-15.2%) among 1594 participants, and MOV uptake was 1.4% (95% CI, 0.8%-2.1%) among 1398 participants. NMV/r uptake increased over time (1.9%; 95% CI, 1.0%-2.9%; between 12/2021 and 3/2022; 16.5%; 95% CI, 13.0%-20.0%; between 4/2022 and 7/2022; and 25.3%; 95% CI, 21.6%-29.0%; between 8/2022 and 10/2022). Participants age ≥65 and those who had comorbidities for severe COVID-19 had higher NMV/r uptake. There was lower NMV/r uptake among non-Hispanic Black participants (7.2%; 95% CI, 2.4%-12.0%; relative to other racial/ethnic groups) and among individuals in the lowest income groups (10.6%; 95% CI, 7.3%-13.8%; relative to higher income groups). Among a subset of 278 participants with SARS-CoV-2 infection after 12/2021 who also had a history of prior SARS-CoV-2 infection, those with (vs without) a history of long COVID reported greater NMV/r uptake (22.0% vs 7.9%; P = .001). Among those prescribed NMV/r (n = 216), 137 (63%; 95% CI, 57%-70%) reported that NMV/r was helpful for reducing COVID-19 symptoms. Conclusions Despite proven effectiveness against severe outcomes, COVID-19 antiviral uptake remains low among those with SARS-CoV-2 infection in the United States. Further outreach to providers and patients to improve awareness of COVID-19 oral antivirals and indications is needed.
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Affiliation(s)
- Yanhan Shen
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
| | - McKaylee M Robertson
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
| | - Sarah G Kulkarni
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
| | | | | | | | | | - Saba A Qasmieh
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
| | - Christian Grov
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Community Health and Social Sciences, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
| | - Avantika Srivastava
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
| | - Rebecca Zimba
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
| | | | - Denis Nash
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, New York, USA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York, USA
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15
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Anand ST, Vo AD, La J, Brophy M, Do NV, Fillmore NR, Branch-Elliman W, Monach PA. Risk of severe coronavirus disease 2019 despite vaccination in patients requiring treatment with immune-suppressive drugs: A nationwide cohort study of US Veterans. Transpl Infect Dis 2024; 26:e14168. [PMID: 37966134 DOI: 10.1111/tid.14168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/29/2023] [Accepted: 10/01/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Patients taking immune-suppressive drugs are at increased risk of severe coronavirus disease 2019 (COVID-19), not fully ameliorated by vaccination. We assessed the contributions of clinical and demographic factors to the risk of severe disease despite vaccination in patients taking immune-suppressive medications for solid organ transplantation (SOT), rheumatoid arthritis (RA), inflammatory bowel disease (IBD), or psoriasis. METHODS Veterans Health Administration electronic health records were used to identify patients diagnosed with RA, IBD, psoriasis, or SOT who had been vaccinated against severe acute respiratory syndrome coronavirus 2, were subsequently infected, and had received immune-suppressive drugs within 3 months before infection. The association of severe (defined as hypoxemia, mechanical ventilation, dexamethasone use, or death) versus non-severe COVID-19 with the use of immune-suppressive and antiviral drugs and clinical covariates was assessed by multivariable logistic regression. RESULTS Severe COVID-19 was more common in patients with SOT (230/1011, 22.7%) than RA (173/1355, 12.8%), IBD (51/742, 6.9%), or psoriasis (82/1125, 7.3%). Age was strongly associated with severe COVID-19, adjusted odds ratio (aOR) of 1.04 (CI 1.03-1.05) per year. Comorbidities indicating chronic brain, heart, lung, or kidney damage were also associated with severity, aOR 1.35-2.38. The use of glucocorticoids was associated with increased risk (aOR 1.66, CI 1.39-2.18). Treatment with antivirals was associated with reduced severity, for example, aOR 0.28 (CI 0.13-0.62) for nirmatrelvir/ritonavir. CONCLUSION The risk of severe COVID-19 despite vaccination is substantial in patients taking immune-suppressive drugs, more so in patients with SOT than in patients with inflammatory diseases. Age and severe comorbidities contribute to risk, as in the general population. Oral antivirals were very beneficial but not widely used.
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Affiliation(s)
- Sonia T Anand
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Austin D Vo
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Jennifer La
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
| | - Mary Brophy
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Nhan V Do
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Nathanael R Fillmore
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Westyn Branch-Elliman
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- VA Boston Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA
| | - Paul A Monach
- VA Boston Cooperative Studies Program, Boston, Massachusetts, USA
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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16
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Wilcock AD, Kissler S, Mehrotra A, McGarry BE, Sommers BD, Grabowski DC, Grad YH, Barnett ML. Clinical Risk and Outpatient Therapy Utilization for COVID-19 in the Medicare Population. JAMA HEALTH FORUM 2024; 5:e235044. [PMID: 38277170 PMCID: PMC10818223 DOI: 10.1001/jamahealthforum.2023.5044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Importance Multiple therapies are available for outpatient treatment of COVID-19 that are highly effective at preventing hospitalization and mortality. Although racial and socioeconomic disparities in use of these therapies have been documented, limited evidence exists on what factors explain differences in use and the potential public health relevance of these differences. Objective To assess COVID-19 outpatient treatment utilization in the Medicare population and simulate the potential outcome of allocating treatment according to patient risk for severe COVID-19. Design, Setting, and Participants This cross-sectional study included patients enrolled in Medicare in 2022 across the US, identified with 100% Medicare fee-for-service claims. Main Outcomes and Measures The primary outcome was any COVID-19 outpatient therapy utilization. Secondary outcomes included COVID-19 testing, ambulatory visits, and hospitalization. Differences in outcomes were estimated based on patient demographics, treatment contraindications, and a composite risk score for mortality after COVID-19 based on demographics and comorbidities. A simulation of reallocating COVID-19 treatment, particularly with nirmatrelvir, to those at high risk of severe disease was performed, and the potential COVID-19 hospitalizations and mortality outcomes were assessed. Results In 2022, 6.0% of 20 026 910 beneficiaries received outpatient COVID-19 treatment, 40.5% of which had no associated COVID-19 diagnosis within 10 days. Patients with higher risk for severe disease received less outpatient treatment, such as 6.4% of those aged 65 to 69 years compared with 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]) and 6.4% of White patients compared with 3.0% of Black patients (aOR, 0.56 [95% CI, 0.54-0.58]). In the highest COVID-19 severity risk quintile, 2.6% were hospitalized for COVID-19 and 4.9% received outpatient treatment, compared with 0.2% and 7.5% in the lowest quintile. These patterns were similar among patients with a documented COVID-19 diagnosis, those with no claims for vaccination, and patients who are insured with Medicare Advantage. Differences were not explained by variable COVID-19 testing, ambulatory visits, or treatment contraindications. Reallocation of 2022 outpatient COVID-19 treatment, particularly with nirmatrelvir, based on risk for severe COVID-19 would have averted 16 503 COVID-19 deaths (16.3%) in the sample. Conclusion In this cross-sectional study, outpatient COVID-19 treatment was disproportionately accessed by beneficiaries at lower risk for severe infection, undermining its potential public health benefit. Undertreatment was not driven by lack of clinical access or treatment contraindications.
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Affiliation(s)
| | - Stephen Kissler
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ateev Mehrotra
- Harvard Medical School, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Yonatan H. Grad
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Michael L. Barnett
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Schilling WHK, Jittamala P, Watson JA, Boyd S, Luvira V, Siripoon T, Ngamprasertchai T, Batty EM, Cruz C, Callery JJ, Singh S, Saroj M, Kruabkontho V, Ngernseng T, Tanglakmankhong N, Tubprasert J, Abdad MY, Madmanee W, Kouhathong J, Suwannasin K, Pagornrat W, Piaraksa N, Hanboonkunupakarn P, Hanboonkunupakarn B, Poovorawan K, Potaporn M, Srisubat A, Loharjun B, Taylor WRJ, Chotivanich V, Chotivanich K, Imwong M, Pukrittayakamee S, Dondorp AM, Day NPJ, Teixeira MM, Piyaphanee W, Phumratanaprapin W, White NJ. Antiviral efficacy of molnupiravir versus ritonavir-boosted nirmatrelvir in patients with early symptomatic COVID-19 (PLATCOV): an open-label, phase 2, randomised, controlled, adaptive trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:36-45. [PMID: 37778363 PMCID: PMC7615401 DOI: 10.1016/s1473-3099(23)00493-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Molnupiravir and ritonavir-boosted nirmatrelvir are the two leading oral COVID-19 antiviral treatments, but their antiviral activities in patients have not been compared directly. The aim of this ongoing platform trial is to compare different antiviral treatments using the rate of viral clearance as the measure of antiviral effect. METHODS PLATCOV is an open-label, multicentre, phase 2, randomised, controlled, adaptive pharmacometric platform trial running in Thailand, Brazil, Pakistan, and Laos. The component of the trial reported here was conducted in the Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. We recruited low-risk adult patients aged 18-50 years with early symptomatic COVID-19 (<4 days of symptoms). Eligible patients were randomly assigned using block randomisation via a centralised web app to one of seven treatment groups: molnupiravir, ritonavir-boosted nirmatrelvir, casirivimab-imdevimab, tixagevimab-cilgavimab, favipiravir, fluoxetine, or no study drug. The no study drug group comprised a minimum proportion of 20% of patients at all times, with uniform randomisation ratios applied across the active treatment groups. Results for the concurrently randomised molnupiravir, ritonavir-boosted nirmatrelvir, and no study drug groups are reported here. The primary endpoint was the rate of oropharyngeal viral clearance assessed in a modified intention-to-treat population, defined as patients with more than 2 days of follow-up. Safety was assessed in all participants who took at least one dose of the medication. The viral clearance rate was derived under a Bayesian hierarchical linear model fitted to the log10 viral densities in standardised duplicate oropharyngeal swab eluates taken daily over 1 week (18 measurements). Treatment groups with a probability of more than 0·9 that viral clearance was accelerated by more than 20% compared with no drug entered a non-inferiority comparison (with a 10% non-inferiority margin) compared with the platform's current most effective drug. This ongoing trial is registered at ClinicalTrials.gov, NCT05041907. FINDINGS Between June 6, 2022, and Feb 23, 2023, 209 patients in Thailand were enrolled and concurrently randomly assigned to molnupiravir (n=65), ritonavir-boosted nirmatrelvir (n=59), or no study drug (n=85). 129 (62%) of the patients were female and 80 (38%) were male. Relative to the no study drug group, the rates of viral clearance were 37% (95% credible interval 16-65) faster with molnupiravir and 84% (54-119) faster with ritonavir-boosted nirmatrelvir. In the non-inferiority comparison, viral clearance was 25% (10-38) slower with molnupiravir than ritonavir-boosted nirmatrelvir. Molnupiravir was removed from the study platform when it reached the prespecified inferiority margin of 10% compared with ritonavir-boosted nirmatrelvir. Median estimated viral clearance half-lives were 8·5 h (IQR 6·7-10·1) with ritonavir-boosted nirmatrelvir, 11·6 h (8·6-15·4) with molnupiravir, and 15·5 h (11·9-21·2) with no study drug. Viral rebound occurred more frequently following nirmatrelvir (six [10%] of 58) compared with the no study drug (one [1%] of 84; p=0·018) or the molnupiravir (one [2%] of 65; p=0·051) groups. Persistent infections following molnupiravir had more viral mutations (three of nine patients had an increased number of single nucleotide polymorphisms in samples collected at 7 or more days compared with those at baseline) than after nirmatrelvir (zero of three) or no study drug (zero of 19). There were no adverse events of grade 3 or worse, or serious adverse events in any of the reported treatment groups. INTERPRETATION Both molnupiravir and ritonavir-boosted nirmatrelvir accelerate oropharyngeal SARS-CoV-2 viral clearance in patients with COVID-19, but the antiviral effect of ritonavir-boosted nirmatrelvir was substantially greater. Measurement of oropharyngeal viral clearance rates provides a rapid and well tolerated approach to the assessment and comparison of antiviral drugs in patients with COVID-19. It should be evaluated in other acute viral respiratory infections. FUNDING Wellcome Trust through the COVID-19 Therapeutics Accelerator.
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Affiliation(s)
- William H K Schilling
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Podjanee Jittamala
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - James A Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Simon Boyd
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Viravarn Luvira
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tanaya Siripoon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth M Batty
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Cintia Cruz
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James J Callery
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Shivani Singh
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Manisaree Saroj
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Varaporn Kruabkontho
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thatsanun Ngernseng
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nuttakan Tanglakmankhong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jaruwan Tubprasert
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mohammad Yazid Abdad
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Wanassanan Madmanee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jindarat Kouhathong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kanokon Suwannasin
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Watcharee Pagornrat
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nattaporn Piaraksa
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Borimas Hanboonkunupakarn
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kittiyod Poovorawan
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Manus Potaporn
- Department of Medical Services, Ministry of Public Health, Nonthaburi, Thailand
| | - Attasit Srisubat
- Department of Medical Services, Ministry of Public Health, Nonthaburi, Thailand
| | - Bootsakorn Loharjun
- Department of Medical Services, Ministry of Public Health, Nonthaburi, Thailand
| | - Walter R J Taylor
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Kesinee Chotivanich
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sasithon Pukrittayakamee
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mauro M Teixeira
- Clinical Research Unit, Center for Advanced and Innovative Therapies, Universidade Federal de Minas Gerais, Belp Horizonte, Brazil
| | - Watcharapong Piyaphanee
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Weerapong Phumratanaprapin
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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18
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Durstenfeld MS, Peluso MJ, Lin F, Peyser ND, Isasi C, Carton TW, Henrich TJ, Deeks SG, Olgin JE, Pletcher MJ, Beatty AL, Marcus GM, Hsue PY. Association of nirmatrelvir for acute SARS-CoV-2 infection with subsequent Long COVID symptoms in an observational cohort study. J Med Virol 2024; 96:e29333. [PMID: 38175151 PMCID: PMC10786003 DOI: 10.1002/jmv.29333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Oral nirmatrelvir/ritonavir is approved as treatment for acute COVID-19, but the effect of treatment during acute infection on risk of Long COVID is unknown. We hypothesized that nirmatrelvir treatment during acute SARS-CoV-2 infection reduces risk of developing Long COVID and rebound after treatment is associated with Long COVID. We conducted an observational cohort study within the Covid Citizen Science (CCS) study, an online cohort study with over 100 000 participants. We included vaccinated, nonhospitalized, nonpregnant individuals who reported their first SARS-CoV-2 positive test March-August 2022. Oral nirmatrelvir/ritonavir treatment was ascertained during acute SARS-CoV-2 infection. Patient-reported Long COVID symptoms, symptom rebound and test-positivity rebound were asked on subsequent surveys at least 3 months after SARS-CoV-2 infection. A total of 4684 individuals met the eligibility criteria, of whom 988 (21.1%) were treated and 3696 (78.9%) were untreated; 353/988 (35.7%) treated and 1258/3696 (34.0%) untreated responded to the Long COVID survey (n = 1611). Among 1611 participants, median age was 55 years and 66% were female. At 5.4 ± 1.3 months after infection, nirmatrelvir treatment was not associated with subsequent Long COVID symptoms (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.80-1.64; p = 0.45). Among 666 treated who answered rebound questions, rebound symptoms or test positivity were not associated with Long COVID symptoms (OR: 1.34; 95% CI: 0.74-2.41; p = 0.33). Within this cohort of vaccinated, nonhospitalized individuals, oral nirmatrelvir treatment during acute SARS-CoV-2 infection and rebound after nirmatrelvir treatment were not associated with Long COVID symptoms more than 90 days after infection.
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Affiliation(s)
- Matthew S. Durstenfeld
- Division of Cardiology at ZSFG and Department of Medicine, University of California, San Francisco (UCSF), USA
| | | | - Feng Lin
- Department of Epidemiology and Biostatistics, UCSF, USA
| | | | - Carmen Isasi
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine
| | | | | | - Steven G. Deeks
- Division of HIV, Infectious Disease, & Global Medicine, UCSF, USA
| | | | | | - Alexis L. Beatty
- Department of Epidemiology and Biostatistics and Division of Cardiology, Department of Medicine, UCSF, USA
| | | | - Priscilla Y. Hsue
- Division of Cardiology at ZSFG and Department of Medicine, University of California, San Francisco (UCSF), USA
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19
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Sandin R, Veenstra DL, Vankelegom M, Dzingina M, Sullivan SD, Campbell D, Ma C, Harrison C, Draica F, Wiemken TL, Mugwagwa T. Budget impact of oral nirmatrelvir/ritonavir in adults at high risk for progression to severe COVID-19 in the United States. J Manag Care Spec Pharm 2023; 29:1290-1302. [PMID: 38058141 PMCID: PMC10776264 DOI: 10.18553/jmcp.2023.29.12.1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Nirmatrelvir/ritonavir (NMV/r) is indicated for the treatment of mild-to-moderate COVID-19 in adults who are at high risk for progression to severe COVID-19. NMV/r has also been authorized for emergency use by the US Food and Drug Administration for the treatment of mild-to-moderate COVID-19 in pediatric patients (aged 226512 years and weighing at least 40 kg) who are at high risk for progression to severe COVID-19. Understanding the budget impact of introducing NMV/r for the treatment of adults with COVID-19 is of key interest to US payers. OBJECTIVE To estimate the annual budget impact of introducing NMV/r in a US commercial health plan setting in the current Omicron COVID-19 era. METHODS A budget impact model was developed to assess the impact of NMV/r on health care costs in a hypothetical 1-million-member commercial health insurance plan over a 1-year period in the US population; clinical and cost inputs were derived from published literature with a focus on studies in the recent COVID-19 era that included vaccinated population and predominance of the Omicron variant. In the base-case analysis, it was assumed the only effect of NMV/r was a reduction in incidence (not severity) of hospitalization or death; its potential effect on post-COVID conditions was assessed in a scenario analysis. Outcomes included the number of hospitalizations, total cost, per patient per year (PPPY) costs, and per member per month (PMPM) costs. Sensitivity and scenario analyses were conducted to assess uncertainty around key model inputs. RESULTS An estimated 29,999 adults were eligible and sought treatment with oral antiviral for COVID-19 over 1 year. The availability of NMV/r was estimated to reduce the number of hospitalizations by 647 with a total budget impact of $2,733,745, $91 PPPY, and $0.23 PMPM. NMV/r was cost saving when including post-COVID conditions with a -$1,510,780 total budget impact, a PPPY cost of -$50, and a PMPM cost of -$0.13. Sensitivity analyses indicated results were most sensitive to the risk of hospitalization under supportive care, risk of hospitalization with NMV/r treatment and cost of NMV/r. CONCLUSIONS Treatment with NMV/r in the current COVID-19 era is estimated to result in substantial cost offsets because of reductions in hospitalization and modest budget impact to potential overall cost savings.
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Affiliation(s)
| | | | | | | | | | | | - Cuiying Ma
- Health Economics & Outcomes Research Ltd, Cardiff, Wales, UK
| | - Cale Harrison
- Health Economics & Outcomes Research Ltd, Cardiff, Wales, UK
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20
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Park HR, Yoo MG, Kim JM, Bae SJ, Lee H, Kim J. Effectiveness of Molnupiravir Treatment in Patients with COVID-19 in Korea: A Propensity Score Matched Study. Infect Chemother 2023; 55:490-499. [PMID: 38014730 PMCID: PMC10771951 DOI: 10.3947/ic.2023.0087] [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: 09/13/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND The MOVe-OUT (efficacy and safety of molnupiravir [MK-4482] in non-hospitalized adult participants with COVID-19 [MK-4482-002]) trial reported that the administration of molnupiravir in unvaccinated patients with coronavirus disease 2019 (COVID-19) before the Omicron epidemic showed a preventive effect of 31% against hospitalization and death. However, studies on the preventive effect of molnupiravir against progression to severe disease and death in patients with COVID-19 during the Omicron epidemic are limited. This study aimed to evaluate the preventive effect of molnupiravir against severe/critical illness or death and death in Korean patients with COVID-19 who were vaccinated mostly during the Omicron epidemic. MATERIALS AND METHODS This study used large-scale retrospective cohort data to select patients with COVID-19 who were either treated or not treated with molnupiravir, between August 2022 and March 2023, at a ratio of 1 : 4 using the propensity score matching method. In total, 762,768 patients comprised the non- administered group, and 190,692 patients comprised the molnupiravir-administered group. The preventive effect of molnupiravir against severe/critical illness or death and death was analyzed using logistic regression analysis. RESULTS The preventive effect of molnupiravir against severe/critical illness or death and death, represented by the odds ratio (OR) and 95% confidence interval (CI), in the molnupiravir-administered and non-administered group was (OR: 0.714; CI: 0.667 - 0.764) and (OR: 0.749; CI: 0.682 - 0.823), respectively. As age increased, the preventive effect against severe/critical illness or death and death increased. The preventive effect against severe/critical illness or death at ≥60 years was (OR: 0.669; CI: 0.624 - 0.717), at ≥70 years was (OR: 0.614; CI: 0.570 - 0.661), and at ≥80 years was (OR: 0.563; CI: 0.515 - 0.615). The preventive effect against death at ≥60 years was (OR: 0.729; CI: 0.663 - 0.802), at ≥70 years was (OR: 0.676; CI: 0.612 - 0.747), and at ≥80 years was (OR: 0.622; CI: 0.554 - 0.698). CONCLUSION Although molnupiravir showed a relatively weak preventive effect against severe/critical illness or death (29%) and death (25%) among patients with COVID-19, it exhibited a stronger protective effect in older patients than in younger patients. In particular, the preventive effect against severe/critical illness or death (44%) and death (38%) in those aged ≥80 years was pronounced. This study strongly suggests that molnupiravir administration can alleviate the burden on the medical system, and treat patients with COVID-19 effectively by reducing its progression to severe disease and death.
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Affiliation(s)
- Hye Rim Park
- Patient Management Team, Central Disease Control Headquarters for COVID-19, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Min-Gyu Yoo
- Patient Management Team, Central Disease Control Headquarters for COVID-19, Korea Disease Control and Prevention Agency, Cheongju, Korea
- Division of Public Health Emergency Response Research, Bureau of Public Health Emergency Preparedness, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Jong Mu Kim
- Patient Management Team, Central Disease Control Headquarters for COVID-19, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Soon Jong Bae
- Patient Management Team, Central Disease Control Headquarters for COVID-19, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Hyungmin Lee
- Patient Management Team, Central Disease Control Headquarters for COVID-19, Korea Disease Control and Prevention Agency, Cheongju, Korea
- Division of Emerging Infectious Disease, Bureau of Infectious Disease Risk Response, Korea Disease Control and Prevention Agency, Cheongju, Korea
- Division of Vaccine-Prevetable Diseases Control and National Immunization Program, Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Jungyeon Kim
- Patient Management Team, Central Disease Control Headquarters for COVID-19, Korea Disease Control and Prevention Agency, Cheongju, Korea
- Division of Emerging Infectious Disease, Bureau of Infectious Disease Risk Response, Korea Disease Control and Prevention Agency, Cheongju, Korea
- Division of Clinical Research, Center for Emerging Virus Research, National Institute of Infectious Disease, Korea Disease Control and Prevention Agency, Cheongju, Korea.
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21
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Ioannou GN, Berry K, Rajeevan N, Li Y, Mutalik P, Yan L, Bui D, Cunningham F, Hynes DM, Rowneki M, Bohnert A, Boyko EJ, Iwashyna TJ, Maciejewski ML, Osborne TF, Viglianti EM, Aslan M, Huang GD, Bajema KL. Effectiveness of Nirmatrelvir-Ritonavir Against the Development of Post-COVID-19 Conditions Among U.S. Veterans : A Target Trial Emulation. Ann Intern Med 2023; 176:1486-1497. [PMID: 37903369 PMCID: PMC10620954 DOI: 10.7326/m23-1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND COVID-19 has been linked to the development of many post-COVID-19 conditions (PCCs) after acute infection. Limited information is available on the effectiveness of oral antivirals used to treat acute COVID-19 in preventing the development of PCCs. OBJECTIVE To measure the effectiveness of outpatient treatment of COVID-19 with nirmatrelvir-ritonavir in preventing PCCs. DESIGN Retrospective target trial emulation study comparing matched cohorts receiving nirmatrelvir-ritonavir versus no treatment. SETTING Veterans Health Administration (VHA). PARTICIPANTS Nonhospitalized veterans in VHA care who were at risk for severe COVID-19 and tested positive for SARS-CoV-2 during January through July 2022. INTERVENTION Nirmatrelvir-ritonavir treatment for acute COVID-19. MEASUREMENTS Cumulative incidence of 31 potential PCCs at 31 to 180 days after treatment or a matched index date, including cardiac, pulmonary, renal, thromboembolic, gastrointestinal, neurologic, mental health, musculoskeletal, endocrine, and general conditions and symptoms. RESULTS Eighty-six percent of the participants were male, with a median age of 66 years, and 17.5% were unvaccinated. Baseline characteristics were well balanced between participants treated with nirmatrelvir-ritonavir and matched untreated comparators. No differences were observed between participants treated with nirmatrelvir-ritonavir (n = 9593) and their matched untreated comparators in the incidence of most PCCs examined individually or grouped by organ system, except for lower combined risk for venous thromboembolism and pulmonary embolism (subhazard ratio, 0.65 [95% CI, 0.44 to 0.97]; cumulative incidence difference, -0.29 percentage points [CI, -0.52 to -0.05 percentage points]). LIMITATIONS Ascertainment of PCCs using International Classification of Diseases, 10th Revision, codes may be inaccurate. Evaluation of many outcomes could have resulted in spurious associations with combined thromboembolic events by chance. CONCLUSION Out of 31 potential PCCs, only combined thromboembolic events seemed to be reduced by nirmatrelvir-ritonavir. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- George N Ioannou
- Research and Development and Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, and Division of Gastroenterology, University of Washington, Seattle, Washington (G.N.I.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (K.B.)
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut (Y.L.)
| | - Pradeep Mutalik
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut (N.R., P.M.)
| | - Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut (L.Y.)
| | - David Bui
- Veterans Affairs Portland Health Care System, Portland, Oregon (D.B.)
| | - Francesca Cunningham
- Veterans Affairs Center for Medication Safety - Pharmacy Benefit Management (PBM) Services, Hines, Illinois (F.C.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon; Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon; and Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care (CIVIC), Veterans Affairs Portland Healthcare System, Portland, Oregon (M.R.)
| | - Amy Bohnert
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (A.B.)
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (E.J.B.)
| | - Theodore J Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, and Schools of Medicine and Public Health, Johns Hopkins University, Baltimore, Maryland (T.J.I.)
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center; Department of Population Health Sciences, Duke University School of Medicine; and Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina (M.L.M.)
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Department of Radiology, Stanford University School of Medicine, Stanford, California (T.F.O.)
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.M.V.)
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, and Department of Medicine, Yale School of Medicine, New Haven, Connecticut (M.A.)
| | - Grant D Huang
- Office of Research and Development, Veterans Health Administration, Washington, DC (G.D.H.)
| | - Kristina L Bajema
- Veterans Affairs Portland Health Care System, and Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon (K.L.B.)
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22
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Zibat A, Zhang X, Dickmanns A, Stegmann KM, Dobbelstein AW, Alachram H, Soliwoda R, Salinas G, Groß U, Görlich D, Kschischo M, Wollnik B, Dobbelstein M. N4-hydroxycytidine, the active compound of Molnupiravir, promotes SARS-CoV-2 mutagenesis and escape from a neutralizing nanobody. iScience 2023; 26:107786. [PMID: 37731621 PMCID: PMC10507161 DOI: 10.1016/j.isci.2023.107786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 07/27/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023] Open
Abstract
N4-hydroxycytidine (NHC), the active compound of the drug Molnupiravir, is incorporated into SARS-CoV-2 RNA, causing false base pairing. The desired result is an "error catastrophe," but this bears the risk of mutated virus progeny. To address this experimentally, we propagated the initial SARS-CoV-2 strain in the presence of NHC. Deep sequencing revealed numerous NHC-induced mutations and host-cell-adapted virus variants. The presence of the neutralizing nanobody Re5D06 selected for immune escape mutations, in particular p.E484K and p.F490S, which are key mutations of the Beta/Gamma and Omicron-XBB strains, respectively. With NHC treatment, nanobody resistance occurred two passages earlier than without. Thus, within the limitations of this purely in vitro study, we conclude that the combined action of Molnupiravir and a spike-neutralizing antagonist leads to the rapid emergence of escape mutants. We propose caution use and supervision when using Molnupiravir, especially when patients are still at risk of spreading virus.
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Affiliation(s)
- Arne Zibat
- Department of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Xiaoxiao Zhang
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, 53424 Remagen, Germany
- Department of Informatics, Technical University of Munich, 81675 Munich, Germany
| | - Antje Dickmanns
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
| | - Kim M. Stegmann
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
| | | | - Halima Alachram
- Department of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Rebecca Soliwoda
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
| | - Gabriela Salinas
- NGS Integrative Genomics Core Unit, Department of Human Genetics, University Medical Center Göttingen, 37077 Göttingen, Germany
| | - Uwe Groß
- Department of Medical Microbiology and Virology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Dirk Görlich
- Max Planck Institute for Multidisciplinary Sciences, 37077 Göttingen, Germany
| | - Maik Kschischo
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, 53424 Remagen, Germany
| | - Bernd Wollnik
- Department of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
- Cluster of Excellence "Multiscale Bioimaging: from Molecular Machines to Networks of Excitable Cells" (MBExC), University of Göttingen, 37075 Göttingen, Germany
| | - Matthias Dobbelstein
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
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23
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Wan EYF, Yan VKC, Wong ZCT, Chui CSL, Lai FTT, Li X, Wong CKH, Hung IFN, Lau CS, Wong ICK, Chan EWY. Effectiveness of molnupiravir vs nirmatrelvir-ritonavir in non-hospitalised and hospitalised patients with COVID-19: a target trial emulation study. EClinicalMedicine 2023; 64:102225. [PMID: 37753272 PMCID: PMC10518465 DOI: 10.1016/j.eclinm.2023.102225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/28/2023] Open
Abstract
Background Molnupiravir and nirmatrelvir-ritonavir have emerged as promising options for COVID-19 treatment, but direct comparisons of their effectiveness have been limited. This study aimed to compare the effectiveness of these two oral antiviral drugs in non-hospitalised and hospitalised patients with COVID-19. Methods In this target trial emulation study, we used data from a territory-wide electronic health records database on eligible patients aged ≥18 years infected with COVID-19 who were prescribed either molnupiravir or nirmatrelvir-ritonavir within five days of infection between 16 March 2022 and 31 December 2022 in the non-hospitalised and hospitalised settings in Hong Kong. A sequence trial approach and 1:1 propensity score matching was applied based on age, sex, number of COVID-19 vaccine doses received, Charlson comorbidity index, comorbidities, and drug use within past 90 days. Cox regression adjusted with patients' characteristics was used to compare the risk of effectiveness outcomes (all-cause mortality, intensive care unit (ICU) admission or ventilatory support and hospitalisation) between groups. Subgroup analyses included age (<70; ≥70 years); sex, Charlson comorbidity index (<4; ≥4), and number of COVID-19 vaccine doses received (0-1; ≥2 doses). Findings A total of 63,522 non-hospitalised (nirmatrelvir-ritonavir: 31,761; molnupiravir: 31,761) and 11,784 hospitalised (nirmatrelvir-ritonavir: 5892; molnupiravir: 5892) patients were included. In non-hospitalised setting, 336 events of all-cause mortality (nirmatrelvir-ritonavir: 71, 0.22%; molnupiravir: 265, 0.83%), 162 events of ICU admission or ventilatory support (nirmatrelvir-ritonavir: 71, 0.22%; molnupiravir: 91, 0.29%), and 4890 events of hospitalisation (nirmatrelvir-ritonavir: 1853, 5.83%; molnupiravir: 3037, 9.56%) were observed. Lower risks of all-cause mortality (absolute risk reduction (ARR) at 28 days: 0.61%, 95% CI: 0.50-0.72; HR: 0.43, 95% CI: 0.33-0.56) and hospital admission (ARR at 28 days: 3.73%, 95% CI: 3.31-4.14; HR: 0.72, 95% CI: 0.67-0.76) were observed in nirmatrelvir-ritonavir users compared to molnupiravir users. In hospitalised setting, 509 events of all-cause mortality (nirmatrelvir-ritonavir: 176, 2.99%; molnupiravir: 333, 5.65%), and 50 events of ICU admission or ventilatory support (nirmatrelvir-ritonavir: 26, 0.44%; molnupiravir: 24, 0.41%) were observed. Risk of all-cause mortality was lower for nirmatrelvir-ritonavir users than for molnupiravir users (ARR at 28 days: 2.66%, 95% CI: 1.93-3.40; HR: 0.59, 95% CI: 0.49-0.71). In both settings, there was no difference in the risk of intensive care unit admission or ventilatory support between groups. The findings were consistent across all subgroup's analyses. Interpretation Our analyses suggest that nirmatrelvir-ritonavir was more effective than molnupiravir in reducing the risk of all-cause mortality in both non-hospitalised and hospitalised patients. When neither drug is contraindicated, nirmatrelvir-ritonavir may be considered the more effective option. Funding HMRF Research on COVID-19, The Hong Kong Special Administrative Region (HKSAR) Government; Collaborative Research Fund, University Grants Committee, the HKSAR Government; and Research Grant from the Food and Health Bureau, the HKSAR Government; the Laboratory of Data Discovery for Health (D24H) funded by the AIR@InnoHK administered by Innovation and Technology Commission.
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Affiliation(s)
- Eric Yuk Fai Wan
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, Department of Family Medicine and Primary Care, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Vincent Ka Chun Yan
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
| | - Zoey Cho Ting Wong
- Li Ka Shing Faculty of Medicine, Department of Family Medicine and Primary Care, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Celine Sze Ling Chui
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, School of Nursing, The University of Hong Kong, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, School of Public Health, The University of Hong Kong, Hong Kong SAR, China
| | - Francisco Tsz Tsun Lai
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
| | - Xue Li
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carlos King Ho Wong
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Li Ka Shing Faculty of Medicine, Department of Family Medicine and Primary Care, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ivan Fan Ngai Hung
- Li Ka Shing Faculty of Medicine, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chak Sing Lau
- Li Ka Shing Faculty of Medicine, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian Chi Kei Wong
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Aston Pharmacy School, Aston University, Birmingham B4 7ET, UK
| | - Esther Wai Yin Chan
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D4H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- The University of Hong Kong, Shenzhen Institute of Research and Innovation, Shenzhen, China
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24
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Sommer I, Ledinger D, Thaler K, Dobrescu A, Persad E, Fangmeyer M, Klerings I, Gartlehner G. Outpatient Treatment of Confirmed COVID-19: A Living, Rapid Evidence Review for the American College of Physicians (Version 2). Ann Intern Med 2023; 176:1377-1385. [PMID: 37722115 PMCID: PMC10620953 DOI: 10.7326/m23-1626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Clinicians and patients want to know the benefits and harms of outpatient treatment options for the Omicron variant of SARS-CoV-2. PURPOSE To assess the benefits and harms of 22 different COVID-19 treatments. DATA SOURCES The Epistemonikos COVID-19 L·OVE platform, the iSearch COVID-19 portfolio, and the World Health Organization (WHO) COVID-19 Research Database from 26 November 2021 to 2 March 2023. STUDY SELECTION Two reviewers independently screened abstracts and full texts against a priori-defined criteria. DATA EXTRACTION One reviewer extracted the data and assessed the risk of bias and certainty of evidence (COE). A second reviewer verified the data abstraction and assessments. DATA SYNTHESIS Two randomized controlled trials and 6 retrospective cohort studies were included. Nirmatrelvir-ritonavir was associated with a reduction in hospitalization due to COVID-19 (for example, 0.7% vs. 1.2%; moderate COE) and all-cause mortality (for example, <0.1% vs. 0.2%; moderate COE). Molnupiravir led to a higher recovery rate (31.8% vs. 22.6%; moderate COE) and reduced time to recovery (9 vs. 15 median days; moderate COE) but had no effect on all-cause mortality (0.02% vs. 0.04%; moderate COE) and the incidence of serious adverse events (0.4% vs. 0.3%; moderate COE). Ivermectin had no effect on time to recovery (moderate COE) and resulted in no difference in adverse events compared with placebo (low COE). Sotrovimab resulted in no difference in all-cause mortality compared with no treatment (low COE). No eligible studies for all other treatments of interest were identified. LIMITATION Evidence for nirmatrelvir-ritonavir and sotrovimab is based on nonrandomized studies only. CONCLUSION Nirmatrelvir-ritonavir and molnupiravir probably improve outcomes for outpatients with mild to moderate COVID-19. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42023406456).
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Affiliation(s)
- Isolde Sommer
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Dominic Ledinger
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Kylie Thaler
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Andreea Dobrescu
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Emma Persad
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Martin Fangmeyer
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Irma Klerings
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria (I.S., D.L., K.T., A.D., E.P., M.F., I.K.)
| | - Gerald Gartlehner
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Krems, Austria; and RTI International, Research Triangle Park, North Carolina (G.G.)
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Şimşek-Yavuz S. COVID-19: An Update on Epidemiology, Prevention and Treatment, September-2023. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2023; 5:165-187. [PMID: 38633552 PMCID: PMC10986731 DOI: 10.36519/idcm.2023.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 04/19/2024]
Abstract
After a downward trend for more than 12 months, the incidence of COVID-19 has increased in the last months. Although COVID-19 is not as frequent as in the first years of the pandemic, case numbers are still very high, and it causes a significant number of deaths. COVID-19 is not seen with a predictable frequency, at least two times more deadly than the flu, continues as an epidemic, and has not reached the endemic level yet. Currently, the Omicron strains EG.5 and XBB.1.16 are dominant worldwide. Although BA.2.86 and FLip variants, including FL.1.5.1 are not widespread at the moment, both were shown to be highly immune-evasive and require close monitoring. Prevention of COVID-19 relies on vaccinations, surveillance, proper ventilation of enclosed spaces, isolation of patients, and mask usage. Currently, monovalent COVID-19 vaccines, including XBB.1.5 Omicron SARS-CoV-2, are recommended for both primary and booster vaccinations against COVID-19. Monovalent vaccines, including only original SARS-CoV-2 strain, and bivalent vaccines, including original virus plus BA4/5 variant, are no longer recommended against COVID-19. Booster vaccination with XBB.1.5 containing vaccine should be prioritized for patients at high risk for severe COVID-19. Bacillus Calmette-Guérin (BCG) vaccination does not seem to be effective in preventing COVID-19. At the current phase of the pandemic, nirmatrelvir/ritonavir, remdesivir, molnupiravir, sotrovimab (for patients from XBB.1.5 variant dominant settings), and convalescent plasma can be considered for the treatment of high-risk early-stage outpatients with COVID-19, while hospitalized patients with more severe disease can be treated with dexamethasone, anti cytokines including tocilizumab, sarilumab, baricitinib, and tofacitinib and antithrombotic agents including enoxaparin. Remdesivir oral analogues and ensitrelvir fumarate are promising agents for treating acute COVID-19, which are in phase trials now; however, ivermectin, fluvoxamine, and metformin were shown to be ineffective.
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Affiliation(s)
- Serap Şimşek-Yavuz
- Department of Infectious Diseases and Clinical Microbiology, İstanbul University School of Medicine, İstanbul, Türkiye
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26
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Affiliation(s)
- Ashish K Jha
- Brown University School of Public Health, Providence, Rhode Island
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27
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Torti C, Olimpieri PP, Bonfanti P, Tascini C, Celant S, Tacconi D, Nicastri E, Tacconelli E, Cacopardo B, Perrella A, Buccoliero GB, Parruti G, Bassetti M, Biagetti C, Giacometti A, Erne EM, Frontuto M, Lanzafame M, Summa V, Spagnoli A, Vestri A, Di Perri G, Russo P, Palù G. Real-life comparison of mortality in patients with SARS-CoV-2 infection at risk for clinical progression treated with molnupiravir or nirmatrelvir plus ritonavir during the Omicron era in Italy: a nationwide, cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2023; 31:100684. [PMID: 37547273 PMCID: PMC10398591 DOI: 10.1016/j.lanepe.2023.100684] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 08/08/2023]
Abstract
Background Comparative data on mortality in COVID-19 patients treated with molnupiravir or with nirmatrelvir plus ritonavir are inconclusive. We therefore compared all-cause mortality in community-dwelling COVID-19 patients treated with these drugs during the Omicron era. Methods Data collected in the nationwide, population-based, cohort of patients registered in the database of the Italian Medicines Agency (AIFA) were used. To increase completeness of the recorded deaths and date correctness, a cross-check with the National Death Registry provided by the Ministry of the Interior was performed. We included in this study all patients infected by SARS-CoV-2 treated within 5 days after the test date and symptom onset between February 8 and April 30, 2022. All-cause mortalities by day 28 were compared between the two treatment groups after balancing for baseline characteristics using weights obtained from a gradient boosting machine algorithm. Findings In the considered timeframe, 17,977 patients treated with molnupiravir and 11,576 patients with nirmatrelvir plus ritonavir were included in the analysis. Most patients (25,617/29,553 = 86.7%) received a full vaccine course including the booster dose. A higher crude incidence rate of all-cause mortality was found among molnupiravir users (51.83 per 100,000 person-days), compared to nirmatrelvir plus ritonavir users (22.29 per 100,000 person-days). However, molnupiravir-treated patients were older than those treated with nirmatrelvir plus ritonavir and differences between the two populations were found as far as types of co-morbidities were concerned. For this reason, we compared the weight-adjusted cumulative incidences using the Aalen estimator and found that the adjusted cumulative incidence rates were 1.23% (95% CI 1.07%-1.38%) for molnupiravir-treated and 0.78% (95% CI 0.58%-0.98%) for nirmatrelvir plus ritonavir-treated patients (adjusted log rank p = 0.0002). Moreover, the weight-adjusted mixed-effect Cox model including Italian regions and NHS centers as random effects and treatment as the only covariate confirmed a significant reduced risk of death in patients treated with nirmatrelvir plus ritonavir. Lastly, a significant reduction in the risk of death associated with nirmatrelvir plus ritonavir was confirmed in patient subgroups, such as in females, fully vaccinated patients, those treated within day 2 since symptom onset and patients without (haemato)-oncological diseases. Interpretation Early initiation of nirmatrelvir plus ritonavir was associated for the first time with a significantly reduced risk of all-cause mortality by day 28 compared to molnupiravir, both in the overall population and in patient subgroups, including those fully vaccinated with the booster dose. Funding This study did not receive funding.
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Affiliation(s)
- Carlo Torti
- Department of Medical and Surgical Sciences, “Magna Graecia” University, Catanzaro, Italy
| | - Pier Paolo Olimpieri
- Italian Medicines Agency, Via del Tritone 181, 00187 Rome, Italy
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Bonfanti
- Fondazione IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, Monza, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, Udine University Hospital, Udine, Italy
| | - Simone Celant
- Italian Medicines Agency, Via del Tritone 181, 00187 Rome, Italy
| | - Danilo Tacconi
- Department of Specialised and Internal Medicine, Infectious Diseases Unit, San Donato Hospital, Arezzo, Italy
| | - Emanuele Nicastri
- National Institute for Infectious Disease Lazzaron Spallanzani, IRCCS, Via Portuense 292, 00149, Rome, Italy
| | - Evelina Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, 37129 Verona, Italy
| | - Bruno Cacopardo
- Department of Internal and Experimental Medicine, University of Catania School of Medicine, Catania, Italy
| | - Alessandro Perrella
- Division Emerging Infectious Disease and High Contagiousness, D. Cotugno Hospital, 80131 Naples, Italy
| | | | - Giustino Parruti
- Department of Medicine, Infectious Disease Unit, Pescara General Hospital, Pescara, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Carlo Biagetti
- Unit of Infectious disease Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Andrea Giacometti
- Azienda Ospedaliera Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Elke Maria Erne
- Department of Infectious Disease, Azienda Sanitaria dell’Alto Adige, Central Hospital of Bolzano, Italy
| | - Maria Frontuto
- Infectious Diseases Unit, A.O.R. San Carlo, Potenza, Italy
| | | | - Valentina Summa
- Italian Medicines Agency, Via del Tritone 181, 00187 Rome, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Giovanni Di Perri
- Department of Medical Sciences at the Unit of Infectious Diseases, University of Torino, Amedeo di Savoia Hospital, Torino, Italy
| | - Pierluigi Russo
- Italian Medicines Agency, Via del Tritone 181, 00187 Rome, Italy
| | - Giorgio Palù
- Italian Medicines Agency, Via del Tritone 181, 00187 Rome, Italy
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Yan L, Streja E, Li Y, Rajeevan N, Rowneki M, Berry K, Hynes DM, Cunningham F, Huang GD, Aslan M, Ioannou GN, Bajema KL. Anti-SARS-CoV-2 Pharmacotherapies Among Nonhospitalized US Veterans, January 2022 to January 2023. JAMA Netw Open 2023; 6:e2331249. [PMID: 37651140 PMCID: PMC10472184 DOI: 10.1001/jamanetworkopen.2023.31249] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Several pharmacotherapies have been authorized to treat nonhospitalized persons with symptomatic COVID-19. Longitudinal information on the use of these therapies is needed. Objective To analyze trends and factors associated with prescription of outpatient COVID-19 pharmacotherapies within the Veterans Health Administration (VHA). Design, Setting, and Participants This cohort study evaluated nonhospitalized veterans in VHA care who tested positive for SARS-CoV-2 from January 2022 through January 2023 using VHA and linked Community Care and Medicare databases. Exposures Demographic characteristics, underlying medical conditions, COVID-19 vaccination, and regional and local systems of care, including Veterans Integrated Services Networks (VISNs). Main Outcomes and Measures Monthly receipt of any COVID-19 pharmacotherapy (nirmatrelvir-ritonavir, molnupiravir, sotrovimab, or bebtelovimab) was described. Multivariable logistic regression was used to identify factors independently associated with receipt of any vs no COVID-19 pharmacotherapy. Results Among 285 710 veterans (median [IQR] age, 63.1 [49.9-73.7] years; 247 358 males [86.6%]; 28 444 Hispanic [10.0%]; 61 269 Black [21.4%] and 198 863 White [69.6%]) who tested positive for SARS-CoV-2 between January 2022 and January 2023, the proportion receiving any pharmacotherapy increased from 3285 of 102 343 veterans (3.2%) in January 2022 to 5180 of 21 688 veterans (23.9%) in August 2022. The proportion declined to 2194 of 10 551 veterans (20.8%) by January 2023. Across VISNs, the range in proportion of patients who tested positive who received nirmatrelvir-ritonavir or molnupiravir during January 2023 was 41 of 692 veterans (5.9%) to 106 of 494 veterans (21.4%) and 2.1% to 120 of 1074 veterans (11.1%), respectively. Veterans receiving any treatment were more likely to be older (adjusted odds ratio [aOR] for ages 65-74 vs 50-64 years, 1.18; 95% CI, 1.14-1.22; aOR for ages ≥75 vs 50-64 years, 1.19; 95% CI, 1.15-1.23) and have a higher Charlson Comorbidity Index score (aOR for CCI ≥6 vs 0, 1.52; 95% CI, 1.44-1.59). Compared with White veterans, Black veterans (aOR, 1.06; 95% CI, 1.02-1.09) were more likely to receive treatment, and compared with non-Hispanic veterans, Hispanic veterans (aOR 1.06; 95% CI, 1.01-1.11) were more likely to receive treatment. Conclusions And Relevance This study found that prescription of outpatient COVID-19 pharmacotherapies in the VHA peaked in August 2022 and declined thereafter. There were large regional differences in patterns of nirmatrelvir-ritonavir and molnupiravir use.
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Affiliation(s)
- Lei Yan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Elani Streja
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Yuli Li
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Nallakkandi Rajeevan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences; Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - Francesca Cunningham
- Pharmacy Benefit Management Services, Veterans Affairs Center for Medication Safety, Hines, Illinois
| | - Grant D. Huang
- Office of Research and Development, Veterans Health Administration, Washington, District of Columbia
| | - Mihaela Aslan
- Veterans Affairs Cooperative Studies Program Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Sciences University, Portland
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29
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Pierre V, Draica F, Di Fusco M, Yang J, Nunez-Gonzalez S, Kamar J, Lopez S, Moran MM, Nguyen J, Alvarez P, Cha-Silva A, Gavaghan M, Yehoshua A, Stapleton N, Burnett H. The impact of vaccination and outpatient treatment on the economic burden of Covid-19 in the United States omicron era: a systematic literature review. J Med Econ 2023; 26:1519-1531. [PMID: 37964554 DOI: 10.1080/13696998.2023.2281882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
AIMS To identify and synthesize evidence regarding how coronavirus disease 2019 (COVID-19) interventions, including vaccines and outpatient treatments, have impacted healthcare resource use (HCRU) and costs in the United States (US) during the Omicron era. MATERIALS AND METHODS A systematic literature review (SLR) was performed to identify articles published between 1 January 2021 and 10 March 2023 that assessed the impact of vaccination and outpatient treatment on costs and HCRU outcomes associated with COVID-19. Screening was performed by two independent researchers using predefined inclusion/exclusion criteria. RESULTS Fifty-eight unique studies were included in the SLR, of which all reported HCRU outcomes, and one reported costs. Overall, there was a significant reduction in the risk of COVID-19-related hospitalization for patients who received an original monovalent primary series vaccine plus booster dose vs. no vaccination. Moreover, receipt of a booster vaccine was associated with a lower risk of hospitalization vs. primary series vaccination. Evidence also indicated a significantly reduced risk of hospitalizations among recipients of nirmatrelvir/ritonavir (NMV/r), remdesivir, sotrovimab, and molnupiravir compared to non-recipients. Treated and/or vaccinated patients also experienced reductions in intensive care unit (ICU) admissions, length of stay, and emergency department (ED)/urgent care clinic encounters. LIMITATIONS The identified studies may not represent unique patient populations as many utilized the same regional/national data sources. Synthesis of the evidence was also limited by differences in populations, outcome definitions, and varying duration of follow-up across studies. Additionally, significant gaps, including HCRU associated with long COVID and various high-risk populations and cost data, were observed. CONCLUSIONS Despite evidence gaps, findings from the SLR highlight the significant positive impact that vaccination and outpatient treatment have had on HCRU in the US, including periods of Omicron predominance. Continued research is needed to inform clinical and policy decision-making in the US as COVID-19 continues to evolve as an endemic disease.
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Affiliation(s)
- Vicki Pierre
- Evidence Synthesis, Modeling & Communication, Evidera Inc., Bethesda, MD, USA
| | - Florin Draica
- Vaccine Clinical Research, Pfizer Inc., New York, NY, USA
| | | | - Jingyan Yang
- Vaccine Clinical Research, Pfizer Inc., New York, NY, USA
| | | | - Joanna Kamar
- Evidence Synthesis, Modeling & Communication, Evidera Inc., Bethesda, MD, USA
| | - Santiago Lopez
- Vaccine Clinical Research, Pfizer Inc., New York, NY, USA
| | - Mary M Moran
- Vaccine Clinical Research, Pfizer Inc., New York, NY, USA
| | | | - Piedad Alvarez
- Evidence Synthesis, Modeling & Communication, Evidera Inc., Bethesda, MD, USA
| | | | | | - Alon Yehoshua
- Vaccine Clinical Research, Pfizer Inc., New York, NY, USA
| | - Naomi Stapleton
- Evidence Synthesis, Modeling & Communication, Evidera Inc., Bethesda, MD, USA
| | - Heather Burnett
- Evidence Synthesis, Modeling & Communication, Evidera Inc., Bethesda, MD, USA
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