- Bajema, Kristina L;
- Berry, Kristin;
- Streja, Elani;
- Rajeevan, Nallakkandi;
- Li, Yuli;
- Mutalik, Pradeep;
- Yan, Lei;
- Cunningham, Francesca;
- Hynes, Denise M;
- Rowneki, Mazhgan;
- Bohnert, Amy;
- Boyko, Edward J;
- Iwashyna, Theodore J;
- Maciejewski, Matthew L;
- Osborne, Thomas F;
- Viglianti, Elizabeth M;
- Aslan, Mihaela;
- Huang, Grant D;
- Ioannou, George N
Background
Information about the effectiveness of oral antivirals in preventing short- and long-term COVID-19-related outcomes in the setting of Omicron variant transmission and COVID-19 vaccination is limited.Objective
To measure the effectiveness of nirmatrelvir-ritonavir and molnupiravir for outpatient treatment of COVID-19.Design
Three retrospective target trial emulation studies comparing matched cohorts of nirmatrelvir-ritonavir versus no treatment, molnupiravir versus no treatment, and nirmatrelvir-ritonavir versus molnupiravir.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 or molnupiravir pharmacotherapy.Measurements
Incidence of any hospitalization or all-cause mortality at 30 days and from 31 to 180 days.Results
Eighty-seven percent of participants were male; the median age was 66 years, and 18% were unvaccinated. Compared with matched untreated control participants, those treated with nirmatrelvir-ritonavir (n = 9607) had lower 30-day risk for hospitalization (22.07 vs. 30.32 per 1000 participants; risk difference [RD], -8.25 [95% CI, -12.27 to -4.23] per 1000 participants) and death (1.25 vs. 5.47 per 1000 participants; RD, -4.22 [CI, -5.45 to -3.00] per 1000 participants). Among persons alive at day 31, reductions were seen in 31- to 180-day incidence of death (hazard ratio, 0.66 [CI, 0.49 to 0.89]) but not hospitalization (subhazard ratio, 0.90 [CI, 0.79 to 1.02]). Molnupiravir-treated participants (n = 3504) had lower 30-day and 31- to 180-day risks for death (3.14 vs. 13.56 per 1000 participants at 30 days; RD, -10.42 [CI, -13.49 to -7.35] per 1000 participants; hazard ratio at 31 to 180 days, 0.67 [CI, 0.48 to 0.95]) but not hospitalization. A difference in 30-day or 31- to 180-day risk for hospitalization or death was not observed between matched nirmatrelvir- or molnupiravir-treated participants.Limitation
The date of COVID-19 symptom onset for most veterans was unknown.Conclusion
Nirmatrelvir-ritonavir was effective in reducing 30-day hospitalization and death. Molnupiravir was associated with a benefit for 30-day mortality but not hospitalization. Further reductions in mortality from 31 to 180 days were observed with both antivirals.Primary funding source
U.S. Department of Veterans Affairs.