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Zheng B, Tazare J, Nab L, Green AC, Curtis HJ, Mahalingasivam V, Herrett EL, Costello RE, Eggo RM, Speed V, Bacon SC, Bates C, Parry J, Cockburn J, Hester F, Harper S, Schaffer AL, Hulme WJ, Mehrkar A, Evans SJ, MacKenna B, Goldacre B, Douglas IJ, Tomlinson LA. Comparative effectiveness of nirmatrelvir/ritonavir versus sotrovimab and molnupiravir for preventing severe COVID-19 outcomes in non-hospitalised high-risk patients during Omicron waves: observational cohort study using the OpenSAFELY platform. Lancet Reg Health Eur 2023; 34:100741. [PMID: 37927438 PMCID: PMC10624988 DOI: 10.1016/j.lanepe.2023.100741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/06/2023] [Accepted: 09/14/2023] [Indexed: 11/07/2023]
Abstract
Background Timely evidence of the comparative effectiveness between COVID-19 therapies in real-world settings is needed to inform clinical care. This study aimed to compare the effectiveness of nirmatrelvir/ritonavir versus sotrovimab and molnupiravir in preventing severe COVID-19 outcomes in non-hospitalised high-risk COVID-19 adult patients during Omicron waves. Methods With the approval of NHS England, we conducted a real-world cohort study using the OpenSAFELY-TPP platform. Patient-level primary care data were obtained from 24 million people in England and were securely linked with data on COVID-19 infection and therapeutics, hospital admission, and death, covering a period where both nirmatrelvir/ritonavir and sotrovimab were first-line treatment options in community settings (February 10, 2022-November 27, 2022). Molnupiravir (third-line option) was used as an exploratory comparator to nirmatrelvir/ritonavir, both of which were antivirals. Cox proportional hazards model stratified by area was used to compare the risk of 28-day COVID-19 related hospitalisation/death across treatment groups. Findings A total of 9026 eligible patients treated with nirmatrelvir/ritonavir (n = 5704) and sotrovimab (n = 3322) were included in the main analysis. The mean age was 52.7 (SD = 14.9) years and 93% (8436/9026) had three or more COVID-19 vaccinations. Within 28 days after treatment initiation, 55/9026 (0.61%) COVID-19 related hospitalisations/deaths were observed (34/5704 [0.60%] treated with nirmatrelvir/ritonavir and 21/3322 [0.63%] with sotrovimab). After adjusting for demographics, high-risk cohort categories, vaccination status, calendar time, body mass index and other comorbidities, we observed no significant difference in outcome risk between nirmatrelvir/ritonavir and sotrovimab users (HR = 0.89, 95% CI: 0.48-1.63; P = 0.698). Results from propensity score weighted model also showed non-significant difference between treatment groups (HR = 0.82, 95% CI: 0.45-1.52; P = 0.535). The exploratory analysis comparing nirmatrelvir/ritonavir users with 1041 molnupiravir users (13/1041 [1.25%] COVID-19 related hospitalisations/deaths) showed an association in favour of nirmatrelvir/ritonavir (HR = 0.45, 95% CI: 0.22-0.94; P = 0.033). Interpretation In routine care of non-hospitalised high-risk adult patients with COVID-19 in England, no substantial difference in the risk of severe COVID-19 outcomes was observed between those who received nirmatrelvir/ritonavir and sotrovimab between February and November 2022, when Omicron subvariants BA.2, BA.5, or BQ.1 were dominant. Funding UK Research and Innovation, Wellcome Trust, UK Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.
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Affiliation(s)
- Bang Zheng
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - John Tazare
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Linda Nab
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Amelia Ca Green
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Helen J Curtis
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | | | - Emily L Herrett
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Ruth E Costello
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Rosalind M Eggo
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Victoria Speed
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Sebastian Cj Bacon
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | | | - John Parry
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | | | - Frank Hester
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Sam Harper
- TPP, TPP House, 129 Low Lane, Horsforth, Leeds LS18 5PX, UK
| | - Andrea L Schaffer
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - William J Hulme
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Amir Mehrkar
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Stephen Jw Evans
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Brian MacKenna
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Ben Goldacre
- Nuffield Department of Primary Care Health Sciences, Bennett Institute for Applied Data Science, University of Oxford, Oxford OX2 6GG, UK
| | - Ian J Douglas
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Laurie A Tomlinson
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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