Economic evaluation of oral nirmatrelvir-ritonavir for COVID-19 in higher risk outpatients

Journal article

Importance: Nirmatrelvir-ritonavir is an oral antiviral recommended for treating highrisk individuals with COVID-19 in the community. However, there remains uncertainty over its cost-effectiveness in largely vaccinated populations and subgroups defined by age and clinical risk.

Objective: To compare the cost-effectiveness of nirmatrelvir-ritonavir versus usual care based on the UK Platform Adaptative trial of NOvel antiviRals for eArly treatMent of COVID-19 In the Community (PANORAMIC) trial.

Design: A within-trial cost-utility analysis was conducted using data from the PANORAMIC trial and linked routine healthcare data from December 8, 2021 to September 30, 2024, adopting a UK National Health Service (NHS) and personal social services perspective over six months.

Setting: UK NHS.

Participants: Community-dwelling adults (aged ≥50 or 18-49 with comorbidities).

Intervention: Oral nirmatrelvir-ritonavir.

Main outcome and measures: Cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of nirmatrelvir-ritonavir versus usual care.

Results: There were 1736 participants randomised to receive nirmatrelvir-ritonavir plus usual care, and 1768 to usual care alone; the mean age was 55 years, 68.6% were female, and 98.6% were vaccinated. Nirmatrelvir-ritonavir was cost-effective, on average, lower total costs (£124, 95%CI –1207 to 1455) and higher QALYs (0.0110, 95%CI 0.0062 to 0.0170) over six months compared to usual care (ICER £10897 per QALY). Nirmatrelvir-ritonavir had a 0.65 probability of being costeffective at a £20,000 per QALY cost-effectiveness threshold, indicating decision uncertainty. The intervention remained cost-effective in most sensitivity analyses and prespecified subgroups, although several subgroup analyses were based on small sample sizes and should be interpreted as exploratory. 

Conclusion and relevance: In this economic evaluation of nirmatrelvir-ritonavir for COVID-19, cost-effectiveness varied by age, comorbidity and vaccination status. Subgroup findings should be interpreted with caution, but targeted prescribing for atrisk adults aged 18-64 years, those aged 65-69, and adults aged 75 years and above, particularly those with comorbidities and not recently vaccinated, was likely to provide the greatest health system value. Cost-effectiveness was not observed in low-risk adults aged 50-64 years, those aged 70-74 years, or in unvaccinated or recently vaccinated individuals.

Authors: Png, ME; Harris, V; Yu, L-M; Little, P; Hobbs, R

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: American Medical Association
• Journal: Jama Network Open
• Volume: 9
• Issue: 5
• Article number: e2612381
• Publication date: 2026-05-06
• Acceptance date: 2026-01-06
• DOI: 10.1001/jamanetworkopen.2026.12381
• EISSN: 2574-3805
• Language: English