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Lo CM, Chen WH, Tsai MY, Lu HI, Hsiao YH, Chuang KH, Chen Y, Wu HF, Huang KT, Wang YH. A case report of drug interaction between co-packaged nirmatrelvir-ritonavir and tacrolimus causing hyponatremia in a lung transplant recipient. J Cardiothorac Surg 2024; 19:132. [PMID: 38491538 PMCID: PMC10941613 DOI: 10.1186/s13019-024-02599-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/05/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) infection in lung transplant recipients can be lethal owing to the use of immunosuppressants. Antiviral agents may be administered to these patients. Co-packaged nirmatrelvir-ritonavir is a new agent currently being used in combination. CASE PRESENTATION In this report, we present a case of a 64-year-old woman, a lung transplant recipient, who experienced hyponatremia and showed a high serum tacrolimus concentration following the administration of the co-packaged nirmatrelvir-ritonavir combination. CONCLUSION Although the nirmatrelvir-ritonavir and tacrolimus combination is not contraindicated, other treatment strategies should be considered first, if available, and the dose of tacrolimus should be reduced when using the nirmatrelvir-ritonavir combination. In cases where combination therapy is necessary, serum tacrolimus levels should be closely monitored in lung transplant recipients. Documentation of more such reports is important to identify drug interactions between nirmatrelvir-ritonavir and other agents, with the aim of preventing severe adverse effects.
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Affiliation(s)
- Chien-Ming Lo
- Division of Thoracic and Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC.
| | - Wei-Hsun Chen
- Division of Thoracic and Cardiovascular Surgery, Linko Chang Gung Memorial Hospital, Linkou, Taiwan, ROC
| | - Meng-Yun Tsai
- Division of Chest, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Hung-I Lu
- Division of Thoracic and Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Yu-Hsin Hsiao
- Division of Thoracic and Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Kai-Hao Chuang
- Division of Thoracic and Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Hsuan-Feng Wu
- Division of Chest, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Kuo-Tung Huang
- Division of Chest, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Yi-Hsi Wang
- Division of Chest, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
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Aggarwal NR, Beaty LE, Bennett TD, Fish LE, Jacobs JR, Mayer DA, Molina KC, Peers JL, Richardson DB, Russell S, Varela A, Webb BJ, Wynia MK, Xiao M, Carlson NE, Ginde AA. Real-world use of nirmatrelvir-ritonavir in COVID-19 outpatients during BQ.1, BQ.1.1., and XBB.1.5 predominant omicron variants in three U.S. health systems: a retrospective cohort study. Lancet Reg Health Am 2024; 31:100693. [PMID: 38500962 PMCID: PMC10945426 DOI: 10.1016/j.lana.2024.100693] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/15/2023] [Accepted: 01/26/2024] [Indexed: 03/20/2024]
Abstract
Background Ritonavir-boosted Nirmatrelvir (NMV-r), a protease inhibitor with in vitro activity against SARS-CoV-2, can reduce risk of progression to severe COVID-19 among high-risk individuals infected with earlier variants, but less is known about its effectiveness against omicron variants BQ.1/BQ.1.1/XBB.1.5. We sought to evaluate effectiveness of NMV-r in BQ.1/BQ.1.1/XBB.1.5 omicron variants by comparing hospitalisation rates to NMV-r treated patients during a previous omicron phase and to contemporaneous untreated patients. Methods We conducted a retrospective observational cohort study of non-hospitalised adult patients with SARS-CoV-2 infection using real-world data from three health systems in Colorado and Utah, and compared hospitalisation rates in NMV-r-treated patients in a BA.2/BA.2.12.1/BA.4/BA.5 variant-predominant (first) phase (April 3, 2022-November 12, 2022), with a BQ.1/BQ.1.1/XBB.1.5 variant-predominant (second) phase (November 13, 2022-March 7, 2023). In the primary analysis, we used Firth logistic regression with a two-segment (phase) linear time model, and pre-specified non-inferiority bounds for the mean change between segments. In a pre-specified secondary analysis, we inferred NMV-r effectiveness in a cohort of treated and untreated patients infected during the second phase. For both analyses, the primary outcome was 28-day all-cause hospitalisation. Subgroup analyses assessed treatment effect heterogeneity. Findings In the primary analysis, 28-day all-cause hospitalisation rates in NMV-r treated patients in the second phase (n = 12,061) were non-inferior compared to the first phase (n = 25,075) (198 [1.6%] vs. 345 [1.4%], adjusted odds ratio (aOR): 0.76 [95% CI 0.54-1.06]), with consistent results among secondary endpoints and key subgroups. Secondary cohort analyses revealed additional evidence for NMV-r effectiveness, with reduced 28-day hospitalisation rates among treated patients compared to untreated patients during a BQ.1/BQ.1.1/XBB.1.5 predominant phase (198/12,061 [1.6%] vs. 376/10,031 [3.7%], aOR 0.34 [95% CI 0.30-0.38), findings robust to additional sensitivity analyses. Interpretation Real-world evidence from major US healthcare systems suggests ongoing NMV-r effectiveness in preventing hospitalisation during a BQ.1/BQ.1.1/XBB.1.5-predominant phase in the U.S, supporting its continued use in similar patient populations. Funding U.S. National Institutes of Health.
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Affiliation(s)
- Neil R. Aggarwal
- Department of Medicine, Division of Pulmonary Sciences and Critical Care, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Laurel E. Beaty
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, 80045, USA
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, 80045, USA
| | - Lindsey E. Fish
- Division of General Internal Medicine, Denver Health and Hospital and University of Colorado School of Medicine, Denver, CO, 80204, USA
| | - Jason R. Jacobs
- Pulmonology and Critical Care Medicine Research, Intermountain Health, Murray, UT, 84107, USA
| | - David A. Mayer
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, 80045, USA
| | - Kyle C. Molina
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Jennifer L. Peers
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Douglas B. Richardson
- Division of General Internal Medicine, Denver Health and Hospital and University of Colorado School of Medicine, Denver, CO, 80204, USA
| | - Seth Russell
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, 80045, USA
| | - Alejandro Varela
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, 80045, USA
| | - Brandon J. Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Salt Lake City, UT, 84107, USA
| | - Matthew K. Wynia
- Department of Medicine, Division of Pulmonary Sciences and Critical Care, University of Colorado School of Medicine, Aurora, CO, 80045, USA
- Department of Health Systems Management and Policy, University of Colorado Center for Bioethics and Humanities, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, 80045, USA
| | - Mengli Xiao
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, 80045, USA
| | - Nichole E. Carlson
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, 80045, USA
| | - Adit A. Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
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Chen PY, Wang JT, Chang SC. Antiviral therapy of coronavirus disease 2019 (COVID-19). J Formos Med Assoc 2024; 123 Suppl 1:S47-S54. [PMID: 37661527 DOI: 10.1016/j.jfma.2023.08.029] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/05/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has reached a turning point. The non-pharmaceutical interventions for preventing COVID-19 are lifting. Vaccination uptake is increasing in general, but this strategy is continuously challenged by the rapid evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Of note, the Omicron subvariants spread globally for at least one year, and the most recently developed subvariants show strong immune evasion to preexisting immunity, either from previous infection, vaccination or both. Therefore, early and appropriate antiviral agents to treat patients at risk for severe COVID-19 or death is crucial to decrease morbidities and mortalities, to restore the healthcare capacities and to facilitate a return to the new normal. Current antiviral therapy for COVID-19 consist of neutralizing monoclonal antibodies (mAbs) and direct antiviral agents. Each agent has been proved for early ambulatory treatment of COIVD-19, but suffer from variable effectiveness and limitations due to patients' comorbidities, drug properties, or antiviral resistance. Besides, some specific mAbs are indicated for prophylaxis of COVID-19 before or after close contact with confirmed COVID-19 patients. This review article summarizes the evidence and unmet needs of the currently available antiviral agents for management of COVID-19 in the context of the Omicron subvariants.
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Affiliation(s)
- Pao-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Institutes of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan.
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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Krohmer E, Rohr BS, Stoll F, Gümüs KS, Bergamino M, Mikus G, Sauter M, Burhenne J, Weiss J, Meid AD, Czock D, Blank A, Haefeli WE. Influence of a Short Course of Ritonavir Used as Booster in Antiviral Therapies Against SARS-CoV-2 on the Exposure of Atorvastatin and Rosuvastatin. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07538-w. [PMID: 38112932 DOI: 10.1007/s10557-023-07538-w] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Early antiviral treatment with nirmatrelvir/ritonavir is recommended for SARS-CoV-2-infected patients at high risk for severe courses. Such patients are usually chronically ill and susceptible to adverse drug interactions caused by ritonavir. We investigated the interactions of short-term low-dose ritonavir therapy with atorvastatin and rosuvastatin, two statins commonly used in this population. METHOD We assessed exposure changes (area under the concentration-time curve (AUC∞) and maximum concentration (Cmax)) of a single dose of 10 mg atorvastatin and 10 mg rosuvastatin before and on the fifth day of ritonavir treatment (2 × 100 mg/day) in healthy volunteers and developed a semi-mechanistic pharmacokinetic model to estimate dose adjustment of atorvastatin during ritonavir treatment. RESULTS By the fifth day of ritonavir treatment, the AUC∞ of atorvastatin increased 4.76-fold and Cmax 3.78-fold, and concurrently, the concentration of atorvastatin metabolites decreased to values below the lower limit of quantification. Pharmacokinetic modelling indicated that a stepwise reduction in atorvastatin dose during ritonavir treatment with a stepwise increase up to 4 days after ritonavir discontinuation can keep atorvastatin exposure within safe and effective margins. Rosuvastatin pharmacokinetics were only mildly modified; ritonavir significantly increased the Cmax 1.94-fold, while AUC∞ was unchanged. CONCLUSION Atorvastatin doses should likely be adjusted during nirmatrelvir/ritonavir treatment. For patients on a 20-mg dose, we recommend half of the original dose. In patients taking 40 mg or more, a quarter of the dose should be taken until 2 days after discontinuation of nirmatrelvir/ritonavir. Patients receiving rosuvastatin do not need to change their treatment regimen. TRIAL REGISTRATION EudraCT number: 2021-006634-39. DRKS00027838.
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Affiliation(s)
- Evelyn Krohmer
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Brit Silja Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Felicitas Stoll
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Katja S Gümüs
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Mariano Bergamino
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Max Sauter
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wee LE, Tay AT, Chiew C, Young BE, Wong B, Lim R, Lee CL, Tan J, Vasoo S, Lye DC, Tan KB. Real-world effectiveness of nirmatrelvir/ritonavir against COVID-19 hospitalizations and severe COVID-19 in community-dwelling elderly Singaporeans during Omicron BA.2, BA.4/5, and XBB transmission. Clin Microbiol Infect 2023; 29:1328-1333. [PMID: 37331509 PMCID: PMC10275656 DOI: 10.1016/j.cmi.2023.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVES Real-world data on continued effectiveness of nirmatrelvir/ritonavir against hospitalization and severe COVID-19 in the context of widespread booster mRNA vaccine uptake and more immune-evasive Omicron sub-variants are lacking. We conducted a retrospective cohort study in adult Singaporeans aged ≥60 years presenting to primary care with SARS-CoV-2 infection, during waves of Omicron BA.2/4/5/XBB transmission. METHODS Binary logistic regression was used to estimate the effect of treatment (receiving nirmatrelvir/ritonavir) on outcomes (hospitalization, severe COVID-19). Additional sensitivity analyses, including inverse-probability-of-treatment-weighting-adjusted analysis and adjustment using overlap weights, were performed to account for observed differences in baseline characteristics among treated/untreated cohorts. RESULTS We included 3959 nirmatrelvir/ritonavir recipients and 139 379 untreated controls. Almost 95% received ≥3 doses of mRNA vaccines; 5.4% had preceding infection. Overall 26.5% of infections occurred during the Omicron XBB period and 1.7% were hospitalized. On multivariable logistic regression, receipt of nirmatrelvir/ritonavir was independently associated with lower odds of hospitalization (adjusted odds ratio [aOR] = 0.65, 95% CI = 0.50-0.85). Consistent estimates were obtained after inverse-probability-of-treatment-weighting adjustment (aOR for hospitalization = 0.60, 95% CI = 0.48-0.75) and adjustment using overlap weights (aOR for hospitalization = 0.64, 95% CI = 0.51-0.79). Although receipt of nirmatrelvir/ritonavir was associated with lower odds of severe COVID-19, it was not statistically significant. DISCUSSION Outpatient usage of nirmatrelvir/ritonavir was independently associated with reduced odds of hospitalization amongst boosted older community-dwelling Singaporeans during successive waves of Omicron transmission, including Omicron XBB; however, it did not significantly reduce the already low risk of severe COVID-19 in a highly vaccinated population.
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Affiliation(s)
- Liang En Wee
- National Centre for Infectious Diseases, Singapore, Singapore; Duke-NUS Graduate Medical School, National University of Singapore, Singapore, Singapore; Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.
| | | | - Calvin Chiew
- National Centre for Infectious Diseases, Singapore, Singapore; Ministry of Health, Singapore, Singapore
| | - Barnaby Edward Young
- National Centre for Infectious Diseases, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
| | - Betty Wong
- Ministry of Health, Singapore, Singapore
| | - Ruth Lim
- Ministry of Health, Singapore, Singapore
| | | | - Joyce Tan
- Ministry of Health, Singapore, Singapore
| | - Shawn Vasoo
- National Centre for Infectious Diseases, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - David Chien Lye
- National Centre for Infectious Diseases, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kelvin Bryan Tan
- Ministry of Health, Singapore, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Low EV, Pathmanathan MD, Chidambaram SK, Kim WR, Lee WJ, Teh ZW, Appannan MR, Zin SM, Zin FM, Amin SBM, Ismail M, Samad AA, Peariasamy KM. Real-world nirmatrelvir-ritonavir outpatient treatment in reducing hospitalization for high-risk patients with COVID-19 during Omicron BA.4, BA.5 and XBB subvariants dominance in Malaysia: A retrospective cohort study. Int J Infect Dis 2023; 135:77-83. [PMID: 37567557 DOI: 10.1016/j.ijid.2023.08.003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/22/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVE To determine if nirmatrelvir-ritonavir 300mg/100mg treatment for 5 days in high-risk outpatients with mild to moderate COVID-19 symptoms was associated with a reduction in hospitalization, intensive care unit (ICU) admission, and death. METHODS This 1:1 propensity score matched cohort study from 647 public health clinics in Malaysia included all patients with COVID-19 with positive tests aged 18 years and older, who were eligible for nirmatrelvir-ritonavir treatment within 5 days of illness from July 14, 2022, to November 14, 2022. The exposed group was patients with COVID-19 initiated with nirmatrelvir-ritonavir treatment, whereas those not initiated with the drug served as the control group. Data was analyzed from July 14, 2022 to December 31, 2022. RESULTS A total of 20,966 COVID-19 high-risk outpatients (n = 10,483 for nirmatrelvir-ritonavir group and n = 10,483 for control group) were included in the study. Nirmatrelvir-ritonavir treatment was associated with a 36% reduction (adjusted hazard ratio 0.64 [95% CI 0.43, 0.94]) in hospitalization compared with those not given the drug. There was a single ICU admission for the control group and one death each was reported in the nirmatrelvir-ritonavir and control group, respectively. CONCLUSIONS Nirmatrelvir-ritonavir treatment was associated with reduced hospitalization in high-risk patients with COVID-19 even in highly vaccinated populations.
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Affiliation(s)
- Ee Vien Low
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1 Jalan Setia Murni U13/52, Seksyen U13, 40170 Shah Alam, Selangor, Malaysia.
| | - Mohan Dass Pathmanathan
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1 Jalan Setia Murni U13/52, Seksyen U13, 40170 Shah Alam, Selangor, Malaysia
| | - Suresh Kumar Chidambaram
- Department of Medicine, Sungai Buloh Hospital, Jalan Hospital, 47000, Sungai Buloh, Selangor, Malaysia
| | - Wee Ric Kim
- Digital Public Health Division (interim), Ministry of Health Malaysia, Blok F1, Complex F, 62000 Wilayah Persekutuan Putrajaya, Malaysia; Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, No.1 Jalan Setia Murni U13/52, Seksyen U13, 40170 Shah Alam, Selangor, Malaysia
| | - Wei Jia Lee
- Digital Public Health Division (interim), Ministry of Health Malaysia, Blok F1, Complex F, 62000 Wilayah Persekutuan Putrajaya, Malaysia
| | - Zhi Wei Teh
- Digital Public Health Division (interim), Ministry of Health Malaysia, Blok F1, Complex F, 62000 Wilayah Persekutuan Putrajaya, Malaysia
| | - Maheshwara Rao Appannan
- Digital Public Health Division (interim), Ministry of Health Malaysia, Blok F1, Complex F, 62000 Wilayah Persekutuan Putrajaya, Malaysia
| | - Shahanizan Mohd Zin
- Medical Development Division, Ministry of Health Malaysia, Block E1, Complex E, 62590 Wilayah Persekutuan Putrajaya, Malaysia
| | - Faizah Muhamad Zin
- Medical Development Division, Ministry of Health Malaysia, Block E1, Complex E, 62590 Wilayah Persekutuan Putrajaya, Malaysia
| | - Samha Bashirah Mohamed Amin
- Medical Development Division, Ministry of Health Malaysia, Block E1, Complex E, 62590 Wilayah Persekutuan Putrajaya, Malaysia
| | - Mastura Ismail
- Family Health Development Division, Ministry of Health Malaysia, Block E10, Complex E, 62590 Wilayah Persekutuan Putrajaya, Malaysia
| | - Azah Abdul Samad
- Section 7 Health Clinic, No.2 Persiaran Kayangan, Seksyen 7, 40000 Shah Alam, Selangor, Malaysia
| | - Kalaiarasu M Peariasamy
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1 Jalan Setia Murni U13/52, Seksyen U13, 40170 Shah Alam, Selangor, Malaysia
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Zhao Q, Zheng B, Han B, Feng P, Xia Z, Jiang H, Ying Y, Zhu J, Fei C, Xiang J, Shen L, Luo Q, Wu Y, Wusiman A, Xin C, Zhang M, Li G, Li X. Is Azvudine Comparable to Nirmatrelvir-Ritonavir in Real-World Efficacy and Safety for Hospitalized Patients with COVID-19? A Retrospective Cohort Study. Infect Dis Ther 2023; 12:2087-2102. [PMID: 37486556 PMCID: PMC10505125 DOI: 10.1007/s40121-023-00845-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION Azvudine and nirmatrelvir-ritonavir are more extensively used to treat COVID-19 in China due to their earlier approval by the National Medical Products Administration. However, there has been a scarcity of research directly comparing the clinical outcomes between azvudine and nirmatrelvir-ritonavir till now. We aimed to make a head-to-head comparison of the efficacy and safety of azvudine or nirmatrelvir-ritonavir in hospitalized patients with COVID-19 in China. METHODS This retrospective cohort study was conducted using data collected from Tongde Hospital of Zhejiang Province between December 2022 and January 2023. All-cause mortality, risk of progressing to a critical condition, proportion with nucleic-acid negative conversion (PNANC), time to first nucleic-acid negative conversion (TFNANC), length of hospital stay and incidence of adverse events were systematically assessed as outcomes. Multi-model regression analysis, propensity-score-matching analysis, subgroup analysis and several sensitivity analyses were applied to compare these outcomes. RESULTS This study included a total of 1571 hospitalized patients with COVID-19, among whom 272 received nirmatrelvir-ritonavir and 156 received azvudine. We found no significant differences in all-cause mortality (HR 1.41; 95% CI 0.56-3.56; P = 0.471), risk of progressing to critical COVID-19 (HR 1.67; 95% CI 0.78-3.60; P = 0.189), PNANC (HR 0.87; 95% CI 0.69-1.09; P = 0.220), length of stay (β - 0.82; 95% CI - 2.78 to 1.15; P = 0.414) and adverse event rate (3.21% vs. 4.41%, P = 0.538) between the two groups, although azvudine was slightly less effective than nirmatrelvir-ritonavir. Meanwhile, the azvudine group exhibited a significantly longer TFNANC (β 2.53; 95% CI 0.76-4.29; P = 0.005) than the nirmatrelvir-ritonavir group. Results were similar for propensity-score matching and multiple sensitivity analyses. CONCLUSION Azvudine probably possessed comparable efficacy and safety to nirmatrelvir-ritonavir, although it was less effective than nirmatrelvir-ritonavir for some outcomes.
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Affiliation(s)
- Qinqin Zhao
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Bei Zheng
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Bing Han
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Pinpin Feng
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Zhongni Xia
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Hong Jiang
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Yin Ying
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Jun Zhu
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China
| | - Cheng Fei
- Department of Pharmacy, The 72nd Group Army Hospital of PLA, Huzhou, 313000, China
| | - Junlei Xiang
- Department of Pharmacy, Longquan People's Hospital, Longquan, 323700, China
| | - Lingli Shen
- Department of Pharmacy, Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, 311100, China
| | - Qiliang Luo
- Department of Pharmacy, Zhaotong Mental Health Center, Zhaotong, 657000, China
| | - Yinhuan Wu
- Department of Pharmacy, Ruian Fifth People's Hospital, Ruian, 325200, China
| | - Ayiguzhali Wusiman
- Department of Pharmacy, Fourth People's Hospital of Aksu Region, Aksu, 843000, China
| | - Chuanwei Xin
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China.
| | - Meiling Zhang
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China.
| | - Gonghua Li
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, No. 234 Gucui Road, Xihu District, Hangzhou, 310012, Zhejiang Province, China.
| | - Xiang Li
- School of Basic Medical Sciences and Forensic Medicine, Hangzhou Medical College, No. 8 Yikang Street, Lin'an District, Hangzhou, 311399, Zhejiang Province, China.
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Chen LH, Connor BA. Is standby therapy for Covid-19 a practical option for travellers? J Travel Med 2022; 29:taac111. [PMID: 36263880 PMCID: PMC9619438 DOI: 10.1093/jtm/taac111] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
International travel has resumed while the risk of SARS-CoV-2 persists, leading to consideration of medications that can treat or prevent Covid-19 when travellers become ill abroad. Nirmatrelvir-ritonavir, molnupiravir and tixagevimab-cilgavimab are available under Emergency Use Authorization or conditional approval. We discuss the potential application of these medications to protect travellers.
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Affiliation(s)
- Lin H Chen
- Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts, and Harvard Medical School, Boston, MA, USA
| | - Bradley A Connor
- Department of Medicine, Weill Cornell Medical College and the New York Center for Travel and Tropical Medicine, New York, NY, USA
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Singh AK, Singh A, Singh R, Misra A. An updated practical guideline on use of molnupiravir and comparison with agents having emergency use authorization for treatment of COVID-19. Diabetes Metab Syndr 2022; 16:102396. [PMID: 35051686 PMCID: PMC8755553 DOI: 10.1016/j.dsx.2022.102396] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Molnupiravir is a newer oral antiviral drug that has recently received emergency use authorization (EUA) in USA, UK and India. We aim to conduct an update on our previous systematic review to provide practical clinical guideline for using molnupiravir in patients with COVID-19. METHODS We systematically searched the electronic database of PubMed, MedRxiv and Google Scholar until January 5, 2022, using key MeSH keywords. RESULTS Final result of phase 3 study in 1433 non-hospitalized COVID-19 patients showed a significant reduction in composite risk of hospital admission or death (absolute risk difference, -3.0% [95% confidence interval {CI}, -5.9 to -0.1%]; 1-sided P = 0.02) although with a non-significant 31% relative risk reduction (RRR). RRR for death alone was 89% (95% CI, 14 to 99; P-value not reported). Number needed to treat to prevent 1 death or 1 hospitalization or death composite appears to be closely competitive to other agents having EUA in people with COVID-19. However, cost-wise molnupiravir is comparatively cheaper compared to all other agents. CONCLUSION Molnupiravir could be a useful agent in non-pregnant unvaccinated adults with COVID-19 who are at increased risk of severity including hospitalization. However, it is effective only when used within 5-days of onset of symptoms. A 5-days course seems to be safe without any obvious short-term side effects.
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Affiliation(s)
| | - Akriti Singh
- Jawaharlal Nehru Medical College & Hospital, Kalyani, West Bengal, India
| | - Ritu Singh
- G. D Hospital & Diabetes Institute, Kolkata, West Bengal, India
| | - Anoop Misra
- Fortis C-DOC Hospital for Diabetes & Allied Sciences, New Delhi, India; National Diabetes, Obesity and Cholesterol Foundation, New Delhi, India; Diabetes Foundation (India), New Delhi, India
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