What is the comparative efficacy of Remdesivir (Veklury) versus Paxlovid (Nirmatrelvir/Ritonavir) in the inpatient setting?

From the Guidelines

Paxlovid (Nirmatrelvir/Ritonavir) is generally considered a superior choice to Remdesivir in the inpatient setting, due to its greater reduction in hospitalization and practical advantages over intravenous administration. When considering the treatment of COVID-19 in the inpatient setting, the choice between Remdesivir and Paxlovid depends on several factors, including the patient's clinical status, potential drug interactions, and the practicality of administration.

• Remdesivir is administered intravenously, which may pose practical challenges in the inpatient setting, particularly for patients with limited vascular access or those requiring prolonged treatment 1.
• Paxlovid, on the other hand, is an oral medication, which may offer advantages in terms of ease of administration and reduced need for intravenous access.
• The WHO guideline on drugs for COVID-19 suggests that Nirmatrelvir/Ritonavir represents a superior choice to Remdesivir due to its greater reduction in hospitalization and practical advantages over intravenous administration, provided that the intended recipient is not using other drugs that interact with Nirmatrelvir/Ritonavir 1.
• It is essential to consider potential drug interactions and contraindications when selecting between Remdesivir and Paxlovid, as Nirmatrelvir/Ritonavir may interact with other medications, such as ritonavir-boosted antiretrovirals.
• In terms of efficacy, Paxlovid has been shown to have a greater reduction in hospitalization compared to Remdesivir, making it a preferred option in the inpatient setting, particularly for patients at high risk of progression to severe COVID-19 1.
• Ultimately, the choice between Remdesivir and Paxlovid should be individualized based on the patient's specific clinical needs, potential drug interactions, and the availability of these medications in the inpatient setting.

From the Research

Comparative Efficacy of Remdesivir and Paxlovid

There are no direct comparative studies between Remdesivir (Veklury) and Paxlovid (Nirmatrelvir/Ritonavir) in the provided evidence. However, the efficacy of Paxlovid in the treatment of COVID-19 is well-documented:

• Paxlovid has been shown to reduce the risk of hospitalization and death in COVID-19 patients 2, 3.
• A meta-analysis found that Paxlovid significantly reduced hospitalization (RR = 0.53; 95% CI: 0.24-0.69, p < 0.001) and all-cause mortality (RR = 0.36; 95% CI: 0.27-0.50, p < 0.001) compared to the control group 2.
• A target trial emulation study found that Paxlovid reduced the risk of hospitalization by 39% (95% CI [36%, 41%]; p < 0.001) and reduced the risk of death by 61% (95% CI [55%, 67%]; p < 0.001) 3.
• Paxlovid has also been shown to be effective in reducing the viral load and shortening the disease course of COVID-19 4, 5.

Efficacy of Paxlovid Compared to Other Treatments

Paxlovid has been compared to other treatments, such as Azvudine:

• A retrospective study found that Paxlovid had a shorter recovery time, a higher degree of rise in lymphocytes, and a faster recovery of the immune system compared to Azvudine 6.
• However, Azvudine may be preferable for patients with malnutrition or cirrhotic hypoproteinemia, as it does not decrease total protein levels as much as Paxlovid 6.

Limitations

The provided evidence does not include direct comparative studies between Remdesivir and Paxlovid, and the studies on Paxlovid have some limitations, such as:

• The studies were mostly observational or retrospective, which may be subject to bias 2, 3, 4, 6.
• The studies had varying populations, settings, and outcomes, which may limit the generalizability of the results 2, 3, 4, 6, 5.