Remarks

• See Section 6 regarding identifying patients at high risk for hospitalization.
• Several therapeutic options are available: see decision support tool that displays benefits and harms of nirmatrelvirritonavir, molnupiravir and remdesivir among patients at high risk of hospitalization.
• The longer term harms of molnupiravir remain unknown in the absence of clinical evidence, both for individual patients and at the population level. These include potential mutagenesis, emergence of resistance, and emergence of new variants (see Mechanism of action section).
• Use of molnupiravir should be accompanied by mitigation strategies such as avoiding the drug in younger adults, children and pregnant patients, active pharmacovigilance programmes, and monitoring viral polymerase and spike sequences (see Justification section).
• The GDG considered that nirmatrelvir-ritonavir represents a superior choice to molnupiravir (due to greater reduction in hospitalization and because of safety concerns with molnupiravir.
• The GDG considered that remdesivir represents a superior choice to molnupiravir because it possibly has a greater reduction in hospitalization in high-risk patients.

Practical info Route, dosage and duration: Additional considerations are available in three summaries of practical issues (molnupiravir for COVID-19, administration of molnupiravir for COVID-19, safety and monitoring for patients receiving molnupiravir for COVID-19). Here follows a brief summary of the key points:

• The recommended dose for molnupiravir is 800 mg tablet every 12 hours daily for 5 days, as per the regimen evaluated in large trials informing the recommendation.
• Administration should be as early as possible in the time course of the disease. In the included studies, molnupiravir was administered within 5 days of disease onset.