Covid, antiviral Paxlovid: who is it for, the guidelines

Pfizer’s Paxlovid antiviral pill, a combination of the active ingredients nirmatrelvir and ritonavir, is “strongly recommended” by the World Health Organization for patients with Covid-19 who are not serious but are at higher risk of hospitalization, such as the unvaccinated, the elderly or immunosuppressed. The indication, published in ‘The BMJ’, comes from the WHO international experts of the Group for the development of the guidelines of the Geneva agency. In the same article, the specialists also formulate a “conditional (weak) recommendation” for the antiviral remdesivir in the same category of Covid sufferers. Read also Experts explain that, for patients in the groups listed, nirmatrelvir-ritonavir “is probably a better choice because it can prevent more hospitalizations than alternative therapies, has a lower risk of potential adverse effects than molnupiravir”, the other antiviral oral anti-Covid, “and is easier to administer than intravenous treatments such as remdesivir and monoclonal antibodies.” The use of Paxlovid is instead not recommended in low-risk Covid patients, because the benefits are not significant – the specialists point out – as well as in patients with severe Covid-19, because at the moment there are no experimental data on this category. “Antiviral drugs should be given as early as possible in the course of the disease,” the experts point out. However, the WHO group points out for these products some ‘nodes’ relating to “costs and resources”, which “could make access difficult in middle and low income countries”, and points out that “access to these drugs is linked to access to tests for the diagnosis of Sars-CoV-2, in particular to those for intercepting the infection at an early stage “. Finally, “uncertainty remains regarding the risk of resistance arising”. The recommendation for Paxlovid – explain the editors of the WHO guidelines in the British Medical Journal – is based on new data from two randomized controlled trials involving 3,100 patients. In these trials, it reads, “the moderate certainty evidence showed that nirmatrelvir-ritonavir reduced hospital admissions (84 fewer per 1,000 patients), the low-certainty evidence did not suggest any major difference in mortality and ‘High certainty evidence indicated little or no risk of adverse effects leading to drug discontinuation. “The conditional recommendation for remdesivir is based on new data from 5 randomized controlled trials involving 2,700 patients, and replaces a previous recommendation against ” use of the drug in all Covid patients regardless of the severity of the disease. WHO guidelines are progressively updated by the dedicated panel, with the methodological support of the Magic Evidence Ecosystem Foundation. Today’s recommendations add to previous conditional recommendations for the use of molnupiravir in high-risk patients with non-severe Covid-19; for the use of the monoclonal sotrovimab or casirivimab-imdevimab in selected patients, and against the use of convalescent plasma, ivermectin and hydroxychloroquine in Covid patients regardless of disease severity. For patients with severe forms, the United Nations Health Agency strongly recommends corticosteroids, with the addition of interleukin-6 (IL-6) receptor blockers or baricitinib.