Is molnupiravir a wise investment? Reassessing COVID-19 treatment strategies

We were greatly intrigued by the systematic review and meta-analysis conducted by Sun et al.,1 which investigated the efficacy of molnupiravir in patients with COVID-19. As we find ourselves in an era where the Omicron variant prevails, and the majority of patients present with mild symptoms, it is imperative to re-evaluate our priorities in COVID-19 drug research. With potentially billions being invested in the development of novel drugs indicated for COVID-19 such as molnupiravir, we must now contemplate whether our focus should shift towards medications that have the potential to reduce mortality associated with COVID-19.

The systematic review and meta-analysis reported by Sun et al.1 provided compelling evidence of the efficacy of molnupiravir in reducing the risk of hospitalization (pooled relative risk:  0.63; 95% CI: 0.47–0.85) and shortening the time to symptom resolution (pooled mean differences:   −2.91 days; 95% CI: −3.66 to −2.16) in COVID-19 patients. These findings offer promise in terms of managing hospital admissions and alleviating symptomatic burden. However, it is important to acknowledge that the systematic review did not demonstrate a significant reduction in all-cause mortality, raising questions about the overall impact of molnupiravir on severe outcomes. Furthermore, considering molnupiravir's status as the first oral, direct-acting antiviral against SARS-CoV-2, the review did not find a significant effect on the rate of and time to viral clearance. Although the drug's primary mechanism of action is to introduce errors in viral RNA replication, potentially leading to viral mutagenesis, its ability to hasten viral clearance may be limited.²