Written by Mary Marschner
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To reduce hospitalizations of patients with mild to moderate COVID, treat with nirmatrelvir-ritonavir or remdesivir. To shorten the duration of COVID symptoms, azithromycin, favipiravir, molnupiravir, umifenovir, or corticosteroids may help, but they are not standard of care.
The latest for COVID-19 treatment
COVID-19 continues to circulate and cause primary care visits as well as hospitalizations. However, the virus has evolved significantly and is now a different illness than the original strain, so it is important to re-evaluate the effectiveness of our treatment options.
In mild to moderate COVID‑19, this systematic review and Bayesian network meta‑analysis included 187 RCTs (166,230 patients, studied through June 2023) comparing drug treatments vs. standard care/placebo. Primary outcomes included hospital admission and symptom duration. Nirmatrelvir‑ritonavir reduced hospitalizations by 25 per 1,000 (95%CI 28 – 20 fewer; moderate certainty), and remdesivir by 21 per 1,000 (95%CI 28 – 7 fewer). Molnupiravir and systemic corticosteroids may also reduce admissions (low certainty). Azithromycin, favipiravir, molnupiravir, umifenovir, and corticosteroids shortened symptom duration (3-5 days; moderate-high certainty). Only lopinavir‑ritonavir increased adverse event-related discontinuation.
This study is limited by time, and it doesn’t have the ability to look at combination therapies. How does nirmatrelvir-ritonavir + steroids vs. nirmatrelvir-ritonavir + azithromycin help with hospitalization and symptoms? Also, COVID-19 continues to mutate, and this analysis looked at studies ending two years ago, which makes it a bit less relevant in my mind. Given the overall acuity and hospitalization of patients who get COVID is low, should we be focusing more on symptom management?
How does this change my practice?
This study affirms my practice when treating mild/moderate COVID with nirmatrelvir-ritonavir. Remdesivir is limited to hospital use, because of IV administration and cost, while molnupiravir is more expensive than nirmatrelvir-ritonavir and isn’t frequently used. As for decreasing symptom duration, I don’t regularly use steroids or azithromycin, and they are not standard of care now.
Editor’s note: As a caution, if you prescribe nirmatrelvir-ritonavir, be careful of drug interactions. ~Clay Smith
Source
Drug treatments for mild or moderate covid-19: systematic review and network meta-analysis. BMJ. 2025 May 29;389:e081165. doi: 10.1136/bmj-2024-081165. PMID: 40441732
