COVID-19 Antivirals Went Least to the Oldest: Outpatient Treatment Among Adults 65 and Up

Age is one of the strongest risk factors for being hospitalized or dying with COVID-19, and the risk keeps climbing with each decade.

• Adults 65 and older made up about two thirds of COVID-19 hospitalizations in October 2023–April 2024; those 75 and older, nearly half of hospitalizations and in-hospital deaths.
• In 2022, the COVID-19 death rate for people 65–74 was about 100 times, and for those 85 and older about 800 times, the rate among people 15–24.

Outpatient antivirals still work to prevent hospitalization and death, including since Omicron arrived in January 2022. Earlier studies suggested older adults seldom got them. This report looked at how use differs within the older population.

Image from the Centers for Disease Control and Prevention

The data

• Source: electronic health records from 28 U.S. health care systems in the National Patient-Centered Clinical Research Network (PCORnet) — covering 28,053,928 adults — for April 2022–September 2023.
• COVID-19 was identified by a positive lab test, a diagnosis code, or an outpatient COVID-19 treatment (nirmatrelvir-ritonavir or molnupiravir by mouth; remdesivir or a monoclonal antibody by IV). People already in hospital at diagnosis were excluded.
• The result: 393,390 outpatients aged 65 and older.
• Severe outcome meant hospitalization within 16 days, or death or discharge to hospice within 30 days.

Who got treated

Overall, 45.9% (180,522) received an outpatient antiviral within 30 days; 2.7% were hospitalized and 0.6% died or went to hospice.

• After adjustment for sex, race, ethnicity, comorbidities and neighborhood deprivation, people 75–89 had 1.17 times, and those 90 and older 1.54 times, the odds of going untreated compared with 65- to 74-year-olds.
• More comorbidities also meant less treatment: a comorbidity score of 1–2 or 3 or more raised the odds of going untreated (1.09 and 1.47).
• The oldest were somewhat more likely to get molnupiravir (4.5% vs 3.2%) or IV remdesivir (4.1% vs 0.8%) — not enough to close the gap.
• Results held when 62,910 patients identified only by a prescription were left out.

Treatment and outcomes: of 12,543 patients with severe outcomes, only 2,648 (21.1%) had received an antiviral, compared with 177,874 (46.7%) of 380,847 without.

Antiviral receipt and hospitalization by age group. Image from the Centers for Disease Control and Prevention

Why the oldest miss out

• Patients' reasons: symptoms seemed mild, they didn't know they were eligible, or no provider recommended it.
• Timing: seeking care late and missing the 5–7 day treatment window after symptoms start.
• Hurdles: getting tested, getting a prescription after a positive test, and getting the drug — each potentially a separate visit.
• Drug interactions: more illnesses and medicines with age may make patients and providers hesitate over nirmatrelvir-ritonavir, or over pausing other medications. But this cannot be the whole story: the age gap persisted after accounting for comorbidities, and the well-tolerated alternatives barely rose with age.
• Rebound worries, including having to isolate again — though a review found viral rebound equally common with or without treatment.

Limitations

1. People diagnosed on admission were excluded — though including them showed the same fall in oral antiviral use with age.
2. People without a recorded positive test or treatment were missed, which may vary by age.
3. The health systems were mostly urban and captured only a small share of cases, which may overstate treatment overall.
4. People with contraindications to nirmatrelvir-ritonavir could not be excluded.

What should happen

Antivirals are underused in older adults — most of all in the oldest, who face the highest risk. Priorities, especially for those 75 and older:

• vaccination and access to early, sensitive tests such as polymerase chain reaction testing;
• routinely discussing treatment with older adults who have mild or moderate COVID-19;
• starting antivirals within 5–7 days of symptoms for eligible people;
• tackling provider hesitancy, improving patient knowledge, and removing barriers to diagnosis and treatment.

Sources

Based on "Differences in COVID-19 Outpatient Antiviral Treatment Among Adults Aged ≥65 Years by Age Group — National Patient-Centered Clinical Research Network, United States, April 2022–September 2023," by Claire M. Quinlan, Melisa M. Shah, Carol E. DeSantis and colleagues, Morbidity and Mortality Weekly Report 73(39), Centers for Disease Control and Prevention; a work of the United States government in the public domain (corrected version). The source's abstract labels the age groups 65–75 and 76–89 where the rest of the report uses 65–74 and 75–89; its count of hospitalized people excluded (1,297,899) and its share receiving more than one treatment (1,818, "0.05%") do not fit its other figures, so those are left out.