ArticleTherapeutic advances in infectious disease
Prognostic factors in the selection of antivirals for COVID-19 in high-risk outpatients: A retrospective cohort study.
Article in Therapeutic advances in infectious disease. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Early oral antiviral treatment reduced disease progression and hospitalisation in high-risk COVID-19 outpatients. In practice, prescribing decisions were influenced by clinical risk, drug interaction concerns, and physician judgment, even in settings where guidelines prioritised nirmatrelvir/ritonavir. This study aimed to identify the patient characteristics that independently predicted oral antiviral selection. Objectives: To identify (1) independent predictors of nirmatrelvir/ritonavir versus molnupiravir prescribing, and (2) predictors of receiving any potent antiviral versus no potent antiviral, among high-risk COVID-19 outpatients. Design: Retrospective cohort study. Methods: Using data from Bhumibol Adulyadej Hospital in Bangkok, Thailand, this retrospective cohort study enrolled 450 COVID-19 outpatients between April 2022 and June 2023. Participants were randomly selected into three treatment groups of 150 each: nirmatrelvir/ritonavir, molnupiravir, and no antiviral. Multivariate logistic regression was applied to identify independent predictors of drug selection across demographics, comorbidities, and concomitant medications. Results: Treated patients were older than those who received no antiviral, with mean ages of 61.68 and 62.91 years in the nirmatrelvir/ritonavir and molnupiravir groups versus 43.89 years in the no-treatment cohort (p < 0.001). Comorbid disease was more prevalent in both antiviral groups. When nirmatrelvir/ritonavir and molnupiravir recipients were compared directly, concurrent statin use was the only variable that independently predicted a lower probability of nirmatrelvir/ritonavir being chosen (adjusted OR 0.46; 95% CI 0.27 to 0.79; p = 0.005). Conclusion: Older patients and those carrying a greater comorbidity burden were prioritised for antiviral treatment in this Thai outpatient cohort. Drug-drug interaction concerns, particularly between ritonavir and statins, drove physicians toward molnupiravir even when nirmatrelvir/ritonavir would otherwise have been the preferred agent. Systematic incorporation of pharmacist-conducted medication assessment before antiviral prescribing represents a practicable strategy for reducing avoidable drug substitution in high-risk patients.
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