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c19early.org COVID-19 treatment researchEnsitrelvirEnsitrelvir (more..)
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Efficacy and safety of Ensitrelvir in asymptomatic or mild to moderate COVID-19: a systematic review and meta-analysis of randomized controlled trials

Ul Haq et al., Infection, doi:10.1007/s15010-025-02582-0, PROSPERO CRD42024572306, Jul 2025
https://c19early.org/ulhaq.html
49th treatment shown to reduce risk in July 2023, now with p = 0.028 from 7 studies.
No treatment is 100% effective. Protocols combine treatments.
6,000+ studies for 175 treatments. c19early.org
Meta-analysis of 6 RCTs with 2,793 participants showing significantly lower viral load with ensitrelvir. However, treatment was associated with significant adverse effects including decreased HDL levels, elevated triglycerides, increased bilirubin, more headaches, and higher overall treatment-emergent adverse events.
Currently there are 7 ensitrelvir studies and meta analysis shows:
OutcomeImprovement
Mortality24% higher [-83‑805%]
Ventilation158% higher [-40‑1012%]
ICU admission97% lower [-3585978‑100%]
Hospitalization34% lower [3‑55%]
Ul Haq et al., 31 Jul 2025, peer-reviewed, 11 authors, trial PROSPERO CRD42024572306.
Efficacy and safety of Ensitrelvir in asymptomatic or mild to moderate COVID-19: a systematic review and meta-analysis of randomized controlled trials
Muhammad Zain Ul Haq, Saad Ashraf, Muhammad Shahmeer Ullah Shah, Samia Aziz Sulaiman, Ayesha Shaukat, Muhammad Ahsan Ansari, Areeba Aamir Ali Basaria, Laveeza Fatima, Humza Saeed, Aman Goyal, Mohamed Daoud
Infection, doi:10.1007/s15010-025-02582-0
Introduction Since late 2019, COVID-19 has had a catastrophic impact on public health. Ensitrelvir, a new antiviral targeting the SARS-CoV-2 main protease, has reduced viral replication and disease severity. This meta-analysis and systematic review assessed Ensitrelvir's efficacy and safety in patients with mild-to-moderate COVID-19 symptoms. Methods A comprehensive search was conducted in PubMed (Medline), Scopus, Embase, and CENTRAL up to July 2024 to retrieve randomized controlled trials (RCTs) comparing Ensitrelvir to placebo in adults with mild to moderate, RT-PCRconfirmed COVID-19. Outcomes were assessed at standardized time points, with viral RNA measured at day 4. Mean differences (MD) for continuous outcomes and risk ratios (RR) for binary outcomes, both with 95% confidence intervals (CIs), were calculated using the Mantel-Haenszel random-effects model. Efficacy outcomes included SARS-CoV-2 viral RNA, while safety outcomes included HDL, triglycerides, bilirubin, AST, headache, diarrhea, TEAEs, TRAEs, serious TEAEs, and treatment discontinuation. The quality of the included RCTs was assessed with the Cochrane Risk of Bias 2 (ROB2) tool. Results The analysis included six RCTs with 2,793 participants: 1,860 received Ensitrelvir and 933 were given a placebo. Ensitrelvir gave significant results for reduced viral RNA levels of SARS-CoV-2 [MD: -1.35; 95% CI -1.58 to -1.13; p < 0.01] and the incidence of lower cholesterol levels [RR: 8.83; 95% CI 4.05 to 19.27; p < 0.01] compared to the placebo group. However, it was associated with increased risks of decreased HDL levels, elevated triglycerides, increased bilirubin, more headaches, and a higher overall occurrence of treatment-emergent adverse events. Conclusion Ensitrelvir effectively reduces viral load in COVID-19 patients, but its safety profile raises concerns due to significant adverse effects. The benefits must be carefully weighed against the risks, and further research is needed to confirm its role in treatment and to find ways to mitigate these adverse effects.
Authors and Affiliations Muhammad Zain Ul Haq
References
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Mukae, Yotsuyanagi, Ohmagari, Efficacy and safety of Ensitrelvir in patients with mild-to-moderate coronavirus disease 2019: the phase 2b part of a randomized, placebo-controlled, phase 2/3 study, Clin Infect Dis, doi:10.1093/cid/ciac933
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Nobori, Fukao, Kuroda, Efficacy of Ensitrelvir against SARS-CoV-2 in a delayed-treatment mouse model, J Antimicrob Chemother, doi:10.1093/jac/dkac257
Ohmagari, Yotsuyanagi, Doi, Efficacy and safety of Ensitrelvir for asymptomatic or mild COVID-19: an exploratory analysis of a multicenter, randomized, phase 2b/3 clinical trial, Influenza Other Respir Viruses, doi:10.1111/irv.13338
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Shimizu, Sonoyama, Fukuhara, Kuwata, Matsuo et al., A phase 1 study of Ensitrelvir fumaric acid tablets evaluating the safety, pharmacokinetics and food effect in healthy adult populations, Clin Drug Investig, doi:10.1007/s40261-023-01309-z
Shimizu, Sonoyama, Fukuhara, Kuwata, Matsuo et al., Safety, tolerability, and pharmacokinetics of the novel antiviral agent Ensitrelvir fumaric acid, a SARS-CoV-2 3CL protease inhibitor, in healthy adults, Antimicrob Agents Chemother, doi:10.1128/aac.00632-22
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Yotsuyanagi, Ohmagari, Doi, Efficacy and safety of 5-day oral Ensitrelvir for patients with mild to moderate COVID-19 the SCORPIO-SR randomized clinical trial, JAMA Netw Open, doi:10.1001/jamanetworkopen.2023.54991
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DOI record: { "DOI": "10.1007/s15010-025-02582-0", "ISSN": [ "0300-8126", "1439-0973" ], "URL": "http://dx.doi.org/10.1007/s15010-025-02582-0", "abstract": "<jats:title>Abstract</jats:title>\n <jats:sec>\n <jats:title>Introduction</jats:title>\n <jats:p>Since late 2019, COVID-19 has had a catastrophic impact on public health. Ensitrelvir, a new antiviral targeting the SARS-CoV-2 main protease, has reduced viral replication and disease severity. This meta-analysis and systematic review assessed Ensitrelvir’s efficacy and safety in patients with mild-to-moderate COVID-19 symptoms.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Methods</jats:title>\n <jats:p>A comprehensive search was conducted in PubMed (Medline), Scopus, Embase, and CENTRAL up to July 2024 to retrieve randomized controlled trials (RCTs) comparing Ensitrelvir to placebo in adults with mild to moderate, RT-PCR–confirmed COVID-19. Outcomes were assessed at standardized time points, with viral RNA measured at day 4. Mean differences (MD) for continuous outcomes and risk ratios (RR) for binary outcomes, both with 95% confidence intervals (CIs), were calculated using the Mantel–Haenszel random-effects model. Efficacy outcomes included SARS-CoV-2 viral RNA, while safety outcomes included HDL, triglycerides, bilirubin, AST, headache, diarrhea, TEAEs, TRAEs, serious TEAEs, and treatment discontinuation. The quality of the included RCTs was assessed with the Cochrane Risk of Bias 2 (ROB2) tool.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Results</jats:title>\n <jats:p>The analysis included six RCTs with 2,793 participants: 1,860 received Ensitrelvir and 933 were given a placebo. Ensitrelvir gave significant results for reduced viral RNA levels of SARS-CoV-2 [MD: − 1.35; 95% CI − 1.58 to − 1.13; p &lt; 0.01] and the incidence of lower cholesterol levels [RR: 8.83; 95% CI 4.05 to 19.27; p &lt; 0.01] compared to the placebo group. However, it was associated with increased risks of decreased HDL levels, elevated triglycerides, increased bilirubin, more headaches, and a higher overall occurrence of treatment-emergent adverse events.</jats:p>\n </jats:sec>\n <jats:sec>\n <jats:title>Conclusion</jats:title>\n <jats:p>Ensitrelvir effectively reduces viral load in COVID-19 patients, but its safety profile raises concerns due to significant adverse effects. 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Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. Lancet. 2023;401(10373):281–93. https://doi.org/10.1016/S0140-6736(22)02597-1.", "volume": "401", "year": "2023" }, { "key": "2582_CR25", "unstructured": "Research C for DE and. Assessing COVID-19-related symptoms in outpatient adult and adolescent subjects in clinical trials of drugs and biological products for COVID-19 prevention or treatment. February 22, 2024. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/assessing-covid-19-related-symptoms-outpatient-adult-and-adolescent-subjects-clinical-trials-drugs. 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Please send us corrections, updates, or comments. c19early involves the extraction of 200,000+ datapoints from thousands of papers. Community updates help ensure high accuracy. Treatments and other interventions are complementary. All practical, effective, and safe means should be used based on risk/benefit analysis. No treatment or intervention is 100% available and effective for all current and future variants. We do not provide medical advice. Before taking any medication, consult a qualified physician who can provide personalized advice and details of risks and benefits based on your medical history and situation. IMA and WCH provide treatment protocols.
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