Trends, variation, and clinical characteristics of recipients of antiviral drugs and neutralising monoclonal antibodies for covid-19 in community settings

How to cite: Amelia C A Green, Helen J Curtis, Rose Higgins, Linda Nab, Viyaasan Mahalingasivam, Rebecca M Smith, Amir Mehrkar, Peter Inglesby, Henry Drysdale, Nicholas J DeVito, Richard Croker, Christopher T Rentsch, Krishnan Bhaskaran, John Tazare, Bang Zheng, Colm D Andrews, Seb C J Bacon, Simon Davy, Iain Dillingham, David Evans, Louis Fisher, George Hickman, Lisa E M Hopcroft, William J Hulme, Jon Massey, Orla McDonald, Jessica Morley, Caroline E Morton, Robin Y Park, Alex J Walker, Tom Ward, Milan Wiedemann, Chris Bates, Jonathan Cockburn, John Parry, Frank Hester, Sam Harper, Ian J Douglas, Stephen J W Evans, Ben Goldacre, Laurie A Tomlinson, Brian MacKenna. Trends, regional variation and clinical characteristics of recipients of antivirals and neutralising monoclonal antibodies for non-hospitalised COVID-19: a descriptive cohort study of 23.4 million people in OpenSAFELY. BMJ Medicine 2023;2:e000276.

Abstract

Background

From December 16th 2021, antivirals and neutralising monoclonal antibodies (nMABs) were available to treat high-risk non-hospitalised patients with COVID-19 in England.

Aims

To ascertain patient eligibility status and describe coverage of antiviral drugs and neutralising monoclonal antibodies (nMAB) as treatment for COVID-19 in community settings in England.

Methods

With the approval of NHS England we conducted a retrospective cohort study using routine clinical data from 23.4m people in the OpenSAFELY-TPP database, approximately 40% of England’s population. We implemented national eligibility criteria and generated descriptive statistics with detailed clinical, demographic and geographic breakdowns for patients receiving an antiviral or nMAB.

Results

93,870 outpatients with COVID-19 were identified between 11 December 2021 and 28 April 2022 to be at high risk of severe outcomes and therefore potentially eligible for antiviral or nMAB treatment (or both). Of these patients, 19,040 (20%) received treatment (sotrovimab, 9,660 (51%); molnupiravir, 4,620 (24%); paxlovid, 4,680 (25%); casirivimab/imdevimab, 50 (<1%); and remdesivir, 30 (<1%)). The proportion of patients treated increased from 9% (190/2,220) in the first week of treatment availability to 29% (460/1,600) in the latest week. The proportion treated varied by high risk group, being lowest in those with liver disease (16%; 95% confidence interval 15% to 17%); by treatment type, with sotrovimab favoured over molnupiravir and paxlovid in all but three high risk groups (Down’s syndrome (35%; 30% to 39%), rare neurological conditions (45%; 43% to 47%), and immune deficiencies (48%; 47% to 50%)); by age, ranging from ≥80 years (13%; 12% to 14%) to 50-59 years (23%; 22% to 23%); by ethnic group, ranging from black (11%; 10% to 12%) to white (21%; 21% to 21%); by NHS region, ranging from 13% (12% to 14%) in Yorkshire and the Humber to 25% (24% to 25%) in the East of England); and by deprivation level, ranging from 15% (14% to 15%) in the most deprived areas to 23% (23% to 24%) in the least deprived areas. Groups that also had lower coverage included unvaccinated patients (7%; 6% to 9%), those with dementia (6%; 5% to 7%), and care home residents (6%; 6% to 7%).

Conclusions

Using the OpenSAFELY platform, we were able to identify patients with covid-19 at high risk of severe outcomes who were potentially eligible to receive treatment and assess the coverage of these new treatments among these patients. In the context of a rapid deployment of a new service, the NHS analytical code used to determine eligibility could have been over-inclusive and some of the eligibility criteria not fully captured in healthcare data. However targeted activity might be needed to resolve apparent lower treatment coverage observed among certain groups, in particular (at present): different NHS regions, ethnic groups, people aged ≥80 years, those living in socioeconomically deprived areas, and care home residents.