Why High-Risk Veterans With COVID-19 Missed Antiviral Treatment, 2022

Image from CDC's report

Antiviral drugs — nirmatrelvir/ritonavir (Paxlovid) and remdesivir (Veklury), approved by the FDA, and molnupiravir (Lagevrio), authorized for emergency use — lower the risk of hospitalization and death when given within 5 days of symptoms to people with mild-to-moderate COVID-19 who are at high risk because of age or medical conditions. All three kept working against new variants, unlike monoclonal antibodies, which had lost activity by late 2022.

Yet they've been underused: studies found only about 24% of documented infections in the Veterans Health Administration (VA) treated with outpatient antivirals in 2022, and at most 34% in a large national research network — far below what risk factors would suggest. Why?

The study

Researchers reviewed VA patients who had been vaccinated, tested positive from March 1 to September 30, 2022, and had one of three conditions causing severe immune suppression: a solid organ transplant, chronic lymphocytic leukemia (CLL) or a plasma cell cancer.

From a random sample of untreated patients, the team read medical records until it had 110 who had truly received no antiviral and had mild-to-moderate illness at first evaluation.

Why they weren't treated

Among the 88 not offered an antiviral:

• For 24 of the mild cases, follow-up was only a phone call to report results and ask about symptoms, with no mention of treatment.
• 16 of the symptom-free infections were found by screening at hospitals, emergency departments, transplant clinics or before procedures.
• No one cited worry about "Paxlovid rebound" — symptoms briefly returning after treatment.

The records also undercount treatment: in 16.3% of cases reviewed, an antiviral had been given — often outpatient remdesivir, or a drug from a non-VA pharmacy — but was missed by the electronic search. Still, many eligible patients are never offered an antiviral.

What could help

• Educate patients, providers and the staff who make follow-up calls that mild COVID-19 in a high-risk person is a reason to treat, not to wait.
• Plan ahead: decide on possible antiviral treatment at the time of testing, or earlier.

Limits: these patients were at especially high risk, mostly male and mostly non-Hispanic White, and all in the VA, so results may differ elsewhere; chart review involves judgment, and notes may not reflect every conversation.

Sources

Based on Paul A. Monach, Sonia T. Anand, Nathanael R. Fillmore, Jennifer La and Westyn Branch-Elliman, "Underuse of Antiviral Drugs to Prevent Progression to Severe COVID-19 — Veterans Health Administration, March–September 2022," MMWR, volume 73, Centers for Disease Control and Prevention; a work of the United States government in the public domain.