Why is Thor’s Hammer, Molnupiravir, Considered a 4th Line Option for COVID-19?

Authors:
Amanda Applegate, PharmD, BCACP
Mary Beth Dameron, PharmD, BCACP

Reviewers:
Daniel B. Chastain, Pharm.D., BCIDP, AAHIVP
J. Dillon Frazier, Pharm.D.
Jacklyn Gries, PharmD
Nora Sharaya, PharmD, BCPS, BCACP

Citation:
RJayk Bernal A, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for Oral Treatment of Covid-19 in Nonhospitalized Patients. N Engl J Med 2022; 386(6):509-520

The Problem

As the COVID-19 pandemic raged, it filled hospital beds, overwhelming healthcare systems worldwide. A critical factor in reducing the global impact of COVID-19 has been treatments that could prevent hospitalizations.  While vaccinations are a cornerstone in preventing hospitalization and death, until now, only intravenous treatments have been available, which are challenging to administer and difficult to access. Two novel oral antiviral agents were granted emergency use authorization (EUA) by the U.S. Food and Drug Administration (FDA) for the treatment of mild to moderate COVID-19 in late December 2021.¹  Although it is named after Thor’s hammer, Mjölnir, molnupiravir (Lagevrio^TM, Merck) was given a last place (4^th line) recommendation by the National Institutes of Health (NIH) COVID-19 Treatment Guideline Panel.  What gives?