Nirmatrelvir and risk of hospital admission or death in adults with covid-19: emulation of a randomized target trial using electronic health records
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj-2022-073312 (Published 11 April 2023) Cite this as: BMJ 2023;381:e073312
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Dear Editor
Today's news report of 5 deaths from the XBB.1.16 variant of covid-19 is a wake-up call for the use of measures such as antiviral medication (exemplified by paxlovid) to mitigate the risk of hospitalisation or death from COVID-19 infection. According to the news report, "The deaths that we see[are] nearly all in the elderly...."[1]. In view of that news report it would be useful to ascertain the exact ages of the patients who died, and whether or not they had comorbidities.
The study by Xie et al tells us that paxlovid confers a 1.55% absolute reduction in the risk of hospitalsation (95% Confidence Interval 1.28% to 1.79%) following COVID-19 infection in patients aged 65 or more. Among patients with 5 or more risk factors for worsening of COVID-19 infection the absolute risk reduction amounts to 2.16%(95% CI 1.61 to 2.78).
The effectiveness of paxlovid (in mitigating the risk of hospitalisation) is maintained in those who are not vaccinated, and in those who are vaccinated, and in those who have received a booster dose.
In the elderly, hospitalisation for covid 19 incurs a huge cost in personal well being and in the risk of nosocomial infection, let alone deterioration in functional status. The latter may ultimately lead to transfer to a nursing home, thereby compounding the financial cost, and loss of independence and self esteem. Some of these costs are quantifiable but others are not. Whether quantifiable or not these hospitalisation-related costs probably far exceed the cost of a course of paxlovid medication.
References
[1] Booth R., Thomas R. Five die with Arcturus variant in UK as strain spreads globally. Independent 24/April/2023
[2] Xie Y., Bowe B., Al-Aly Z. Nirmatrelvir and risk of hospital admission or death in adults with covid-19: emulation of a randomized target trial using electronic health records. BMJ 2023;381:e073312
Competing interests: No competing interests
Re: Nirmatrelvir and risk of hospital admission or death in adults with covid-19: emulation of a randomized target trial using electronic health records
Dear Editor,
The important question whether nilmatrelvir reduces mortality from Covid-19 infection remains unanswered. Is it safe to assume that it does not? Until mortality data is presented separately, one certainly may be tempted to assume that nilmatrelvir does not reduced death in Covid infections, neither in immunised, not in unimmunised. Had it been otherwise, it is likely that the authors would have presented the finding in the paper, clearly, in a separate table. As the data is not presented separately, another question remains unanswered: does it prevent hospitalisations? It is possible that neither hospital admission nor death separately reach statistical significance and this is why they are presented lumped together as 'hospital admission or death'? The authors should put the matter to rest by publishing the data for death and for admission separately, stratified by immunisation status. Until the data is presented separately, it is possible that here in Australia we keep spending 1200.00 AUD per treatment course for unproven benefit.
Those of us a bit long in the tooth, still remember the oseltamivir (Tamiflu) affair, where the UK Government stockpiled nearly half a billion GBP worth of oseltamivir, only to be later denounced as a 'shocking waste of taxpayer money'. In order to help public health decision making, I plead with the authors to publish the data for hospitalisation and death separately.
Competing interests: No competing interests