(First of two parts)
In the past several days, some readers have asked us about the new antiviral drug molnupiravir, and how it compares with ivermectin.
Last week, the United States-based pharmaceutical Merck announced the interim results of their clinical trial showing that COVID-19 patients who are considered high-risk (elderly or those with at least one comorbid disease), when given a five-day course of molnupiravir capsules, can cut by half the risk of being hospitalized, and perhaps significantly more, the risk of dying from the infection.
The clinical trial has not been completed yet as originally planned, but based on the interim analysis—usually done in many clinical trials as it reaches the midway point—the patient group which took molnupiravir, when compared with patients who took a placebo treatment, showed highly significant benefits, such that an independent data monitoring committee recommended the trial be already stopped.
This is indeed welcome news, but we need to stress that this was just based on a press release coming from the company.
It’s best to wait for the final publication of the detailed clinical trial results after being thoroughly peer reviewed.
We’re sure, though, that the company did not exaggerate any of the results they announced.
Same maker
It’s perhaps just a coincidence that both ivermectin and molnupiravir originate from the same company.
It’s perhaps not by chance that Merck was not very enthusiastic in endorsing ivermectin, the patent of which has already expired, in the prevention and treatment of COVID-19.
In February, Merck issued a statement that there was no evidence to support the effectiveness of ivermectin against COVID-19.
At just about the same time, the US government was already discussing plans to reserve $1.2 billion worth of molnupiravir, depending on the results of the then ongoing clinical trial.
If we were also the Merck chief executive officer, we’d probably be compelled to issue such a statement discrediting its own homegrown drug with already many generic comanufacturers, and which could directly compete with a new drug in which the company is investing a hefty sum.
It would have been well-appreciated, though, if the company disclosed their investment in molnupiravir when they issued their statement on ivermectin. This is in line with the guidelines on disclosure of potential conflicts of interest which all pharmaceutical companies, practitioners, researchers and other stakeholders are supposed to make when they issue public statements about a certain drug or treatment.
The positive anticipation of favorable results with a single randomized clinical trial (RCT) may be reasonably based for a promising new drug like molnupiravir, but we wondered why the same degree of enthusiastic acceptance could not be offered to ivermectin—an old, tried-and-tested drug for safety, with more than two dozen independent RCTs indicating its effectiveness in preventing COVID-19, and treating the infection both in early and more advanced stages.
The two are entirely different molecules, but they both work in preventing replication or multiplication of the virus. The earlier they’re given, the more beneficial they would be for the COVID-19 patient.
Both can be considered part of the early treatment regimen for COVID-19 which can be taken at home.
We have time and again emphasized that this is the big chink in our antipandemic armor—we sorely have a big gap in our early treatment armamentarium.
Replication stage
Molnupiravir is recommended to be taken by mouth for five days, while ivermectin is recommended to be taken for three days in mild cases, five days in moderate cases, and up to a week or longer in severe and critical cases.
There’s no indication at the moment that molnupiravir would still be beneficial beyond the replication stage of the disease, when the diffuse inflammation triggered by the virus or so-called cytokine storm phase has already set in.
In fact, another clinical trial evaluating molnupiravir in hospitalized patients with relatively more severe disease (MOVe-IN trial) was terminated prematurely in April because of insufficient clinical benefits compared to placebo or dummy pills.
It’s pretty much like the hydroxycholoroquine (HCQ) miscalculation. It’s effective as early treatment, and perhaps for prevention, but the big trials evaluating it in hospitalized patients with relatively more advanced disease showed dismal results. Hence, it was unfairly labeled as ineffective, and potentially harmful for COVID-19 patients.
We’re glad for molnupiravir that it didn’t suffer the same fate as HCQ, thanks to the unwavering support of Merck.
Since some clinical trials suggest that ivermectin may still reduce deaths even in patients already manifesting severe inflammation, it is postulated that beyond its antiviral effect, it might also have an anti-inflammatory effect.
Ivermectin appears to work on multiple sites, compared to the single viral-replication site molnupiravir is effective in.
The prices of both are likely to be miles apart. Ivermectin costs around P27 per tablet, while molnupiravir is expected to cost nowhere near that price.
The $1.2 billion the US government reserved for is good for 1.7 million courses, which translate to roughly P35,000 per course of 20 capsules of 400 milligram per capsule given at two capsules twice a day for five days. The cost of treatment per day is P7,000 for the four capsules.
Hence, we may consider molnupiravir to be the Lamborghini of ivermectin. When you drive a Lamborghini in a bumper-to-bumper traffic, there’s really nothing more you could expect from it than when you just drive your good old Toyota.
Priced compassionately
In fairness to Merck, they announced that they would price it more compassionately for developing and underdeveloped countries including the Philippines.
The company has committed to implement a “tiered pricing approach” based on the income classification by the World Bank of the countries’ capacity to finance their health response to the pandemic.
We hope that Merck is looking at less than a fifth of the price they have in mind for First World countries.
Being familiar with the pricing model of multinational companies, we’re sure they’ll still have ample margins with this discounted pricing.
Drugs like ivermectin and molnupiravir are intended for use in the community to prevent mild and moderate cases from worsening into more complicated diseases that will require hospitalization.
They can help diffuse the congestion in the health-care system that happens every time we have a surge of cases.
With this early treatment regimen, we may still have outbreaks in the community every now and then, but it can be handled better without exhausting the health-care system. Ergo, no need for stringent lockdowns, provided the standard health protocols are followed.
So, even expensive treatments like molnupiravir may be well worth it if you consider the stiffer price we’re directly and indirectly paying with stringent quarantines and lockdowns.
(To be continued next week)
