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Do Young Vaccinated COVID Patients Need Antivirals?

December 21, 2023

Please read this announcement about upgrades to JournalFeed (CME, Amal Mattu, new website)! We also need to do a price increase due to rising costs. Price changes started Dec. 1, 2023 for new subscribers and on Jan 1, 2024 for current subscriber auto-renewals. If cost is a barrier for you, please read the announcement. We want to help! ~Clay Smith

Written by Christian Gerhart

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In this retrospective cohort study of COVID-vaccinated patients aged 18-50 years old, there was a significant reduction in all cause hospital visits, hospitalization and death within 30 days among patients who received nirmatrelvir/ritonavir (NMV/r, aka Paxlovid) for symptomatic COVID-19 infection, particularly among those with cancer and/or cardiovascular disease, compared to propensity matched controls who did not receive NMV/r. 

Paxlovid in the vaccinated?
Data support the use of NMV/r in unvaccinated patients with COVID. The data to guide providers when caring for COVID-vaccinated patients and younger patients with COVID is less robust. This study used the TriNetX database, a multicenter research network, to identify 86,119 individuals who met inclusion criteria of non-hospitalized individuals who were vaccinated against COVID and were between 18-50 years old. Within this group they identified the 2,547 patients who received NMV/r and then performed propensity matching to make the control population of 2,547 patients from the database as similar as possible. They found an odds ratio of 0.683 (95%CI 0.54–0.86, p=0.001) for the primary outcome of all-cause ED visit, hospitalization, or death among patients who received NMV/r for symptomatic COVID-19 infection compared to propensity matched controls. This would correlate to a number needed to treat (NNT) of 47 to prevent an ED visit, hospitalization or death. They found a stronger correlation favoring the treatment group among patients with cancer (NNT 45), cardiovascular disease (NNT 30), or both of these conditions (NNT 16). There was no statistically significant effect among patients without serious comorbidities or among patients with chronic lower respiratory tract disorders such as asthma and COPD.  

How does this change my practice?
Although this was a well-done cohort study it is observational in nature and probably shouldn’t change practice on its own. That being said, the NIH already strongly recommends treating non-hospitalized patients with COVID who have high risk conditions with NMV/r, assuming there are no significant contraindications or drug-drug interactions. This study seems to support that recommendation, even in younger patients who are vaccinated. It was interesting that patients with chronic lower respiratory tract disorders such as asthma and COPD did not seem to benefit in this study, whereas those with malignancy and cardiac conditions did. Hopefully future studies will be able to further delineate which patient populations derive the most benefit from this medication.

Editor’s note: We will cover another article on antivirals for COVID-19 tomorrow that only showed benefit among the most vulnerable patients. It seems NMV/r is most helpful in those with serious health problems. ~Clay Smith

Oral Nirmatrelvir and Ritonavir for Coronavirus Disease 2019 in Vaccinated, Nonhospitalized Adults Aged 18-50 Years. Clin Infect Dis. 2023;77(9):1257-1264. doi:10.1093/cid/ciad400. 

What are your thoughts?