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Oral antiviral treatment in patients with systemic rheumatic disease at risk for development of severe COVID-19: a case series
  1. George E Fragoulis1,
  2. Christos Koutsianas2,
  3. Kalliopi Fragiadaki1,
  4. Ilias Mariolis2,
  5. Stylianos Panopoulos1,
  6. Christina Tsalapaki2,
  7. Maria Pappa1,
  8. Theodoros Dimitroulas3,
  9. Maria G Tektonidou1,
  10. Dimitrios Vassilopoulos2,
  11. Petros P Sfikakis1
  1. 1 Joint Rheumatology Program, First Department of Internal Medicine, Propedeutic Clinic, “Laiko” hospital, National and Kapodistrian University of Athens, Athens, Greece
  2. 2 Joint Rheumatology Program, Second Department of Internal Medicine, “Hippokration” Hospital, National and Kapodistrian University of Athens, Athens, Greece
  3. 3 Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
  1. Correspondence to Dr George E Fragoulis, Joint Rheumatology program, First Department of Internal Medicine, Propedeutic clinic, “Laiko” hospital, National and Kapodistrian University of Athens, Athens, Greece; geofragoul{at}

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Significant advances have been made in the diagnosis and treatment of SARS-CoV-2 infection. Nevertheless, it seems that the virus and its mutations will be present in our lives for the years to come.1 People living with systemic rheumatic diseases (SRDs),2 especially those with certain characteristics and comorbidities such as coexisting lung disease, male gender and increasing age, are at increased risk for severe COVID-19.3

Despite vaccines have impeded the consequences of COVID-19,4 infections with adverse outcomes can occur in patients with SRD. To further decrease COVID-19 reated morbidity and mortality in high-risk patients, two oral antiviral therapies (molnupiravir and nirmatrelvir/ritonavir combination) have been approved for the outpatient treatment of patients at risk for progression to severe COVID-19.5

Both drugs have been shown to reduce COVID-19 related adverse outcomes. However, SRDs were not largely represented in the approval studies. Besides, due to interference of nirmatrelvir/ritonavir with cytochrome P450 enzymes, interactions with numerous drugs used in rheumatology, such as colchicine, cyclosporine, voclosporin, sildenafil, sirolimus, tacrolimus, bosentan and anticoagulants, should be checked to avoid possibly dangerous side …

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  • Handling editor Josef S Smolen

  • Twitter @FragoulisGeorge, @Dr_C_Koutsianas

  • GEF and CK contributed equally.

  • Contributors Study inception: PPS. Study design: GEF, PPS and DV. Data acquisition: GEF, CK, KF, CT, SP, IM, MP, MGT and TD. Drafting the manuscript: GEF, CK, KF, CT, SP, IM, MP, MT and TD. Revising the manuscript: PPS and DV.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.