Treatment Prescribed to Few Infected Patients With Underlying Conditions
Click to Enlarge: A: Percentage of veterans receiving any COVID-19 pharmacotherapy. B: Pharmacotherapies prescribed among treated veterans. Regions are based on VISNs. West includes VISNs 19 to 22; Midwest: 10, 12, 15, 23; Northeast: 1, 2, 4, 5; South: 6 to 9, 16, 17. Error bars indicate 95% CIs for proportions; VISN, Veterans Integrated Services Network. Source: JAMA Network Open
PORTLAND, OR — When antiviral agents and monoclonal antibodies were first authorized for use at the beginning of the year, few of them were prescribed at the VA, according to a new study.
That meant that many veterans with risk factors for severe COVID-19 did not receive treatment, according to the report in JAMA Network Open. The research, led by the VA Portland, OR, Health Care System and the Oregon Health and Sciences University, also found that veterans from minority racial and ethnic groups were less likely to receive any pharmacotherapy.1
“Older adults and individuals with medical comorbidities are at increased risk for severe COVID-19,” the report noted. “Several pharmacotherapies demonstrated to reduce the risk of COVID-19-related hospitalization and death have been authorized for use.”
The study team, which also included participation from the VA Ann Arbor, MI, Healthcare System; the VA Center for Medication Safety in Hine, IL; the VA Puget Sound Health Care System in Seattle and the VA Connecticut Health Care System in West Haven, said that led to its effort to describe factors associated with receipt of outpatient COVID-19 pharmacotherapies at the VA.
The cohort study involved 111,717 VHA outpatients with clinical risk factors for severe COVID-19 who tested positive for SARS-CoV-2 during January and February 2022. Of those, only 3.8% received outpatient pharmacotherapy. “Black veterans and Hispanic veterans were less likely to receive treatment, whereas older veterans with a higher number of underlying conditions were more likely to receive treatment,” the authors wrote, adding, “These findings suggest that during a two-month period when four anti-SARS-CoV-2 pharmacotherapies were authorized for use, few eligible veterans received treatment.”
The study estimated the odds of receiving any COVID-19 pharmacotherapy, including sotrovimab, nirmatrelvir boosted with ritonavir, molnupiravir or remdesivir. About 16,500 courses of sotrovimab, nirmatrelvir and molnupiravir were allocated across the VA during the research period.
Participants had a median age of 60, and 86.4% were male. In terms of racial/ethnic background, 9.6% were Hispanic, 20.9% were Black, and 68% were white.
The rate of receiving the pharmacotherapy was 3.1% in January and 7.1% in February, the study noted.
Click to Enlarge: a) Includes sotrovimab, nirmatrelvir, molnupiravir, and remdesivir.
b) A total of 4233 veterans who received any COVID-19 pharmacotherapy out of 111 717 veterans testing positive for SARS-CoV-2 were included. Models were limited to veterans with complete data for all included covariates.
c) All models adjusted for age, sex, race, and ethnicity. Additional covariates did not change the adjusted odds ratio by at least 5% and were therefore not included in the final models. Source: JAMA Network Open
The study also reported results for a subset of 56, 285 veterans with documented COVID-19-related symptoms in the 30 days preceding a positive SARS-CoV-2 test. Of those, 5.5% received any COVID-19 pharmacotherapy. While untreated veterans had a median age of 60 and a median of three underlying medical conditions, those receiving treatment were more likely to:
- Be older (aged 65 to 74 years vs. 50 to 64 years: adjusted odds ratio [aOR], 1.66 [95% CI, 1.52-1.80];
- Be aged at least 75 years vs. 50 to 64 years: aOR, 1.67 [95% CI, 1.53-1.84]) and
- Have a higher number of underlying conditions (at least five conditions vs. one to two conditions: aOR, 2.17 [95% CI, 1.98-2.39]).
Black Veterans Undertreated
“Compared with white veterans, Black veterans (aOR, 0.65 [95% CI, 0.60-0.72]) were less likely to receive treatment; and compared with non-Hispanic veterans, Hispanic veterans (aOR, 0.88 [95% CI, 0.77-0.99]) were less likely to receive treatment,” the authors advised.
The incidence of COVID-19 in the United States was at its highest in January 2022, and 82% of intensive care unit hospital beds were occupied. At that point, nearly 900 000 COVID-19-related deaths had occurred since the pandemic began.
Background information in the report noted that older adults and patients with underlying medical conditions such as chronic kidney disease, diabetes and obesity are at increased risk for severe outcomes including hospitalization or death.
The U.S. Food and Drug Administration has granted emergency-use authorization to several neutralizing monoclonal antibodies and antivirals for patients with mild to moderate COVID-19 who are at high risk for progression to severe disease.
“Most recently, these include EUA for nirmatrelvir boosted with ritonavir and molnupiravir in late December 2021 and remdesivir for outpatient use in January 2022,” the authors explained. “Although these therapies have been demonstrated in clinical trials to be effective in reducing the short-term risk of hospitalization or death among unvaccinated individuals, early limited drug supply, the requirement for prompt recognition of symptomatic disease and linkage to treatment, logistical barriers to administration, and the need for clinician and public awareness of therapeutic options have hampered widespread use.”
At the VA, COVID-19 pharmacotherapies allocated by the federal government are distributed across 156 VA pharmacies by the Pharmacy Benefits Management Services (PBM). “This national distribution system serving a population with a majority of older adults with a high burden of underlying conditions who are frequently at increased risk for severe COVID-19 provides a unique opportunity to evaluate how these therapies have been allocated to at-risk patients infected with SARS-CoV-2, including among minority racial and ethnic groups for whom reach of novel pharmacotherapies in the general US population is often unequal,” the researchers pointed out. “Thus, we sought to describe rates and factors associated with prescription of outpatient COVID-19 pharmacotherapies during January and February 2022 when sotrovimab, a monoclonal antibody active against circulating Omicron SARS-CoV-2 variants at the time and antivirals nirmatrelvir, molnupiravir, and remdesivir were authorized for use.”
The study also found variation in use of the pharmacotherapies across VISNs and that veteran in rural areas were somewhat more likely to receive treatment.
“Although U.S. veterans are a highly rural population, many VA facilities allocated anti-SARS-CoV-2 pharmacotherapies are also located in rural areas,” the authors wrote. “Rural veterans in our study, in addition to being older, male, and non-Hispanic white, also had more underlying conditions than their urban counterparts.”
They added that veterans testing positive for SARS-CoV-2 lived within a relatively close distance of a dispensing facility, “and we did not observe a meaningful difference between treated and untreated persons, suggesting that relative to other factors, physical distance may not have been a substantial barrier to treatment. However, veterans living farther from VA facilities are more likely to engage in VA care, which may have contributed to better ascertainment of prescriptions in this group and a higher observed likelihood of treatment among rural veterans.”
- Bajema KL, Wang XQ, Hynes DM, et al. Early Adoption of Anti–SARS-CoV-2 Pharmacotherapies Among US Veterans With Mild to Moderate COVID-19, January and February 2022. JAMA Netw Open. 2022;5(11):e2241434. doi:10.1001/jamanetworkopen.2022.41434
