Evolving Real-World Effectiveness of Monoclonal Antibodies for Treatment of COVID-19 : A Cohort Study

Abstract

Background: Treatment guidelines and U.S. Food and Drug Administration emergency use authorizations (EUAs) of monoclonal antibodies (mAbs) for treatment of high-risk outpatients with mild to moderate COVID-19 changed frequently as different SARS-CoV-2 variants emerged.

Objective: To evaluate whether early outpatient treatment with mAbs, overall and by mAb product, presumed SARS-CoV-2 variant, and immunocompromised status, is associated with reduced risk for hospitalization or death at 28 days.

Design: Hypothetical pragmatic randomized trial from observational data comparing mAb-treated patients with a propensity score-matched, nontreated control group.

Setting: Large U.S. health care system.

Participants: High-risk outpatients eligible for mAb treatment under any EUA with a positive SARS-CoV-2 test result from 8 December 2020 to 31 August 2022.

Intervention: Single-dose intravenous mAb treatment with bamlanivimab, bamlanivimab-etesevimab, sotrovimab, bebtelovimab, or intravenous or subcutaneous casirivimab-imdevimab administered within 2 days of a positive SARS-CoV-2 test result.

Measurements: The primary outcome was hospitalization or death at 28 days among treated patients versus a nontreated control group (no treatment or treatment ≥3 days after SARS-CoV-2 test date).

Results: The risk for hospitalization or death at 28 days was 4.6% in 2571 treated patients and 7.6% in 5135 nontreated control patients (risk ratio [RR], 0.61 [95% CI, 0.50 to 0.74]). In sensitivity analyses, the corresponding RRs for 1- and 3-day treatment grace periods were 0.59 and 0.49, respectively. In subgroup analyses, those receiving mAbs when the Alpha and Delta variants were presumed to be predominant had estimated RRs of 0.55 and 0.53, respectively, compared with 0.71 for the Omicron variant period. Relative risk estimates for individual mAb products all suggested lower risk for hospitalization or death. Among immunocompromised patients, the RR was 0.45 (CI, 0.28 to 0.71).

Limitations: Observational study design, SARS-CoV-2 variant presumed by date rather than genotyping, no data on symptom severity, and partial data on vaccination status.

Conclusion: Early mAb treatment among outpatients with COVID-19 is associated with lower risk for hospitalization or death for various mAb products and SARS-CoV-2 variants.

Primary funding source: None.

Visual Abstract.. Real-World Effectiveness of Monoclonal Antibodies for Treatment of COVID-19.

Treatment guidelines and emergency use authorizations for monoclonal antibodies (mAbs) for treatment of COVID-19 have changed frequently as different SARS-CoV-2 variants have emerged. This study evaluated whether early outpatient treatment with mAbs is associated with reduced risk for hospitalization or death at 28 days.

Appendix Figure.. CONSORT (Consolidated Standards of Reporting Trials) diagram of selection of patients classified as treated or nontreated, based on time between a positive SARS-CoV-2 test result and treatment with mAb therapy.

The bottom section depicts 1:2 propensity score matching of treated and nontreated patients. mAb = monoclonal antibody.

Figure 1.. Kaplan–Meier plot of the probability of freedom from hospitalization or death over 28-day follow-up for treated patients and nontreated matched control patients.

The analysis reflects a 2-day treatment grace period from the date of a positive SARS-CoV-2 test result to monoclonal antibody treatment.

Figure 2.. Kaplan–Meier plot of the probability of freedom from hospitalization or death over 28-day follow-up for treated patients and nontreated matched control patients, stratified by immunocompromised status.

The analysis reflects a 2-day treatment grace period from the date of a positive SARS-CoV-2 test result to monoclonal antibody treatment.