Clinical Outcomes Following Treatment for COVID-19 With Nirmatrelvir/Ritonavir and Molnupiravir Among Patients Living in Nursing Homes

Abstract

ImportanceOlder patients living in nursing homes are at very high risk of mortality after getting COVID-19.ObjectiveTo evaluate outcomes following oral antiviral treatment for COVID-19 among nonhospitalized older patients living in nursing homes.Design, Setting, and ParticipantsThis is a territory-wide, retrospective cohort study conducted between February 16 and March 31, 2022, with the last follow-up date on April 25, 2022. Participants were patients with COVID-19 living in nursing homes in Hong Kong. Data analysis was performed from May to June 2022.ExposuresMolnupiravir, nirmatrelvir/ritonavir, or no oral antiviral treatment.Main Outcomes and MeasuresThe primary outcome was hospitalization for COVID-19, and the secondary outcome was risk of inpatient disease progression (ie, admission to intensive care unit, use of invasive mechanical ventilation, and/or death).ResultsOf 14 617 patients (mean [SD] age, 84.8 [10.2] years; 8222 women [56.2%]), 8939 (61.2%) did not use oral antivirals, 5195 (35.5%) used molnupiravir, and 483 (3.3%) used nirmatrelvir/ritonavir. Compared with patients who did not use oral antivirals, those who used molnupiravir and nirmatrelvir/ritonavir were more likely to be female and less likely to have comorbid illnesses and hospitalization in the past year. At a median (IQR) follow-up of 30 (30-30) days, 6223 patients (42.6%) were hospitalized and 2307 patients (15.8%) experienced inpatient disease progression. After propensity score weighting, both molnupiravir and nirmatrelvir/ritonavir were associated with a reduced risk of hospitalization (molnupiravir, weighted hazard ratio [wHR], 0.46; 95% CI, 0.37-0.57; P < .001; nirmatrelvir/ritonavir, wHR, 0.46; 95% CI, 0.32-0.65; P < .001) and inpatient disease progression (molnupiravir, wHR, 0.35; 95% CI, 0.23-0.51; P < .001; nirmatrelvir/ritonavir, wHR, 0.17; 95% CI, 0.06-0.44; P < .001). Nirmatrelvir/ritonavir was comparable to molnupiravir in achieving better clinical outcomes (hospitalization, wHR, 1.00; 95% CI, 0.75-1.33; P = .99; inpatient disease progression, wHR, 0.49; 95% CI, 0.20-1.20; P = .12).Conclusions and RelevanceIn this retrospective cohort study, the use of oral antivirals to treat COVID-19 was associated with a reduced risk of hospitalization and inpatient disease progression among patients living in nursing homes. The findings of this study of nursing home residents could be reasonably extrapolated to other frail older patients living in the community.

Safety and Effectiveness of Molnupiravir in Japanese Patients with COVID-19: Final Report of Post-marketing Surveillance in Japan

“…Furthermore, the mortality rate due to COVID-19 was 0.00% (0/2006) in outpatients and 1.08% (10/925) in inpatients. While a direct comparison is not possible owing to differences in patient backgrounds, such as inpatient to outpatient ratio, and proportion of patients with comorbidities, our findings are consistent with previous reports showing the effectiveness of molnupiravir in reducing severe COVID-19 outcomes in patients aged > 80 years ( 11 , 31 ).…”

Effectiveness of nirmatrelvir‐ritonavir on severe outcomes of COVID‐19 in the era of vaccination and Omicron: An updated meta‐analysis

“…The large differences in underlying study populations, outcome definitions and inclusion criteria can probably explain at least part of this heterogeneity. Some studies focused on specific patient groups such as patients with inflammatory bowel disease, 41 solid organ transplant patients, 42 patients with chronic respiratory disease, 44 systemic rheumatic disease, 55 diabetes, 47 hematological malignancy, 56,59 and long‐term facility residents 48,50 . Inclusion and exclusion criteria were not uniform across studies, and neither were outcome definitions, especially for the outcome of “disease progression.”…”

Clinical Manifestations and Outcomes of Older Patients with COVID-19: A Comprehensive Review

“…Figure 2 illustrates an overview of the treatment for patients with COVID-19 [ 34 ]. In non-hospitalized patients with mild-to-moderate illness, treatment typically involves symptom management combined with the administration of ritonavir-boosted nirmatrelvir (Paxlovid, Pfizer, New York, NY, USA) [ 35 - 37 ] or remdesivir [ 38 , 39 ]. Cases wherein these two drugs are unfeasible, molnupiravir may be considered [ 35 ].…”

“…In non-hospitalized patients with mild-to-moderate illness, treatment typically involves symptom management combined with the administration of ritonavir-boosted nirmatrelvir (Paxlovid, Pfizer, New York, NY, USA) [ 35 - 37 ] or remdesivir [ 38 , 39 ]. Cases wherein these two drugs are unfeasible, molnupiravir may be considered [ 35 ]. In a study [ 35 ] involving patients with COVID-19 residing in nursing homes with an average age of 84.8 years, both molnupiravir and paxlovid reduced hospitalizations, intensive care unit admissions, mortality, and the need for invasive mechanical ventilation (MV) compared to patients not treated with antiviral agents.…”

“…Cases wherein these two drugs are unfeasible, molnupiravir may be considered [ 35 ]. In a study [ 35 ] involving patients with COVID-19 residing in nursing homes with an average age of 84.8 years, both molnupiravir and paxlovid reduced hospitalizations, intensive care unit admissions, mortality, and the need for invasive mechanical ventilation (MV) compared to patients not treated with antiviral agents. Furthermore, initiating treatment within 5 days of symptom onset appears to offer greater risk reduction.…”