• Scott Dryden-Peterson, Andy Kim, Arthur Y Kim, Ellen C Caniglia, Inga T Lennes, Rajesh Patel, Lindsay Gainer, Lisa Dutton, Elizabeth Donahue, Rajesh T Gandhi, Lindsey R Baden, and Ann E Woolley.
• Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and Botswana Harvard AIDS Institute, Gaborone, Botswana (S.D.).
• Ann. Intern. Med. 2023 Jan 1; 176 (1): 778477-84.

BackgroundIn the EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients) trial, nirmatrelvir plus ritonavir led to an 89% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. The clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain.ObjectiveTo assess whether nirmatrelvir plus ritonavir reduces risk for hospitalization or death among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages.DesignPopulation-based cohort study analyzed to emulate a clinical trial using inverse probability-weighted models to account for anticipated bias in treatment.SettingA large health care system providing care for 1.5 million patients in Massachusetts and New Hampshire during the Omicron wave (1 January to 17 July 2022).Patients44 551 nonhospitalized adults (90.3% with ≥3 vaccine doses) aged 50 years or older with COVID-19 and no contraindications for nirmatrelvir plus ritonavir.MeasurementsThe primary outcome was a composite of hospitalization within 14 days or death within 28 days of a COVID-19 diagnosis.ResultsDuring the study period, 12 541 (28.1%) patients were prescribed nirmatrelvir plus ritonavir, and 32 010 (71.9%) were not. Patients prescribed nirmatrelvir plus ritonavir were more likely to be older, have more comorbidities, and be vaccinated. The composite outcome of hospitalization or death occurred in 69 (0.55%) patients who were prescribed nirmatrelvir plus ritonavir and 310 (0.97%) who were not (adjusted risk ratio, 0.56 [95% CI, 0.42 to 0.75]). Recipients of nirmatrelvir plus ritonavir had lower risk for hospitalization (adjusted risk ratio, 0.60 [CI, 0.44 to 0.81]) and death (adjusted risk ratio, 0.29 [CI, 0.12 to 0.71]).LimitationPotential residual confounding due to differential access to COVID-19 vaccines, diagnostic tests, and treatment.ConclusionThe overall risk for hospitalization or death was already low (1%) after an outpatient diagnosis of COVID-19, but nirmatrelvir plus ritonavir reduced this risk further.Primary Funding SourceNational Institutes of Health.

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