Oral antiviral treatment in patients with systemic rheumatic disease at risk for development of severe COVID-19: a case series

Oral Antiviral Treatment for COVID-19 in Patients With Systemic Autoimmune Rheumatic Diseases

“…Nevertheless, our impression is that COVID-19 outcomes in patients receiving oral antivirals seem to be better than those previously reported among other high-risk SARD patients with breakthrough infection and particularly among those not fully vaccinated individuals infected with pre-Omicron variants 1,7 . Similar are the findings in another case series published by Fragoulis et al where no high-risk SARD patient taking MP or NM/R progressed to severe COVID-19 requiring hospitalization and, more importantly, no deaths were reported 8 . However, these anticipated differences between up-to-date vaccinated patients with and without oral antiviral treatment for breakthrough infections may have been recently mitigated given that the majority of patients with SARD and additional vaccine doses seem to recover uneventfully even without oral antiviral prophylaxis during the current Omicron wave, as Saxena et al demonstrated in an cohort of lupus patients 9 .…”

“…Although in our case series, a definite COVID-19 rebound cannot be supported due to lack of SARS-CoV-2 testing, the overall clinical picture in Case 1 and 2 was highly indicative. Fragoulis et al reported that COVID-19 relapsed in 2/31 participants within 1 month after NM/R initiation and negative antigen tests in between, raising the concern whether treatment with immunosuppressive/immunomodulatory drugs could be somehow related 8 . A recent preprint study, examining the rates and relative risks of a composite COVID-19 rebound outcome (infections, symptoms and hospitalizations) after oral antiviral treatment among 92 million patients from a multicenter nationwide database in the US, found that COVID-19 rebound occurred both after NM/R and MP 13 .…”

ERN ReCONNET points to consider for treating patients living with autoimmune rheumatic diseases with antiviral therapies and anti-SARS-CoV-2 antibody products

“…Literature data have shown that antiviral drugs have been also used in immunocompromised patients, usually at the doses and durations as recommended for the general population. Although the evidence is not strong and data collected are heterogeneous even regarding the different periods of the pandemic (i.e., alpha to delta variants and no vaccines; delta variant, vaccination ongoing; rise of omicron variant, primary vaccination cycle likely complete; emergence of new omicron subvariants, booster vaccination ongoing; summarised in Table I), globally, the data on safety and efficacy are encouraging (29,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46) (summarised in Tables III and IV). For this reason, the rationale for this PtC is to emphasise that having an ARD does not contraindicate the use of antiviral drugs and that they may be considered in case of mild to moderate COVID-19.…”

Coronavirus Disease-2019 in the Immunocompromised Host

“…One challenge with the use of antiviral therapy is that the kinetics of viral replication necessitate prompt therapy in order to ensure an adequate outcome 53 ; there is no clear evidence that replication is more rapid in immunocompromised hosts, despite the possibility due to impaired innate and cellular immunity. In one series of 31 ARD patients treated with nirmatrelivir/ritonavir (29) and molnupilavir during the first 5 days of COVID-19 diagnosis, no patients were hospitalized, but most (94%) were fully vaccinated 54 , and no comparator arm was studied. Little efficacy data is available for remdesivir in immunocompromised hosts; a case study suggested that remdesivir can reduce viral load in immunocompromised patients with persistent infections 55 .…”