Doctors Aren’t Prescribing Paxlovid Often Enough. Here’s Why.

Forbes Innovation Healthcare Doctors Aren’t Prescribing Paxlovid Often Enough. Here’s Why. Judy Stone Senior Contributor Opinions expressed by Forbes Contributors are their own. I am an Infectious Disease specialist and author of Resilience: One Family's Story of Hope and Triumph over Evil and of Conducting Clinical Research, the essential guide to the topic Following Click to save this article.

You'll be asked to sign into your Forbes account. Got it Jan 9, 2024, 12:00pm EST Share to Facebook Share to Twitter Share to Linkedin The drug Paxlovid against Covid 19 from the manufacturer Pfizer Photo by Fabian Sommer/picture ... [+] alliance via Getty Images dpa/picture alliance via Getty Images Covid 19 infections and deaths have been steadily increasing in recent weeks, now reaching 1500 deaths/week.

We have antiviral drugs that still protect against severe infection and death, yet practitioners are prescribing them too infrequently. Why? Since 2021, Paxlovid (nirmatrelvir/ritonavir) has been the drug of choice for mild to moderate Covid 19. The FDA issued an Emergency Use Authorization (EUA) after studies showed that “Paxlovid significantly reduced the proportion of people with Covid 19 related hospitalization or death” by 88% compared to placebo.

The study was in patients with one or more risk factors for progression or who were at least 60 years old and unvaccinated. Similarly, a review of more than 1 million electronic health records in the National Covid Cohort Collaborative showed that Paxlovid reduced hospitalizations by 26% and deaths by 78%.

Results were not broken down by prior vaccination status. Paxlovid was prescribed to only 9.7% of those eligible for treatment. Researchers estimate 48,000 deaths could have been prevented if its uptake were 50%. There were regional differences in prescriptions for Paxlovid. Despite having Covid and being at high risk, only a quarter of nursing home residents received antivirals in one study.

Lower treatment rates were seen in for profit centers and those with higher shares of Medicaid and non White residents. Disturbingly, more than 40% of the nursing homes never prescribed any antivirals. Most studies agree as to the benefit in unvaccinated people. But in a small study of those who were already hospitalized, had other serious medical problems, and had been previously vaccinated, no benefit to Paxlovid was found.

MORE FOR YOU How Samsung’s Galaxy S24 Ultra Will Change Smartphones Forever SEC Issues Sudden Warning As Bitcoin ETF Race Primes Crypto For A 17 Trillion Earthquake Boosting The Price Of Ethereum XRP And Solana Trump Arrives In Court For Jan 6 Criminal Case Hearing Here s What To Watch For In a recent study , providers failed to give two thirds of eligible patients prescriptions for Paxlovid.

Notably, an emergency room visit had a five times lower odds of treatment. So did covid testing just done through a lab—where there was no apparent follow up of positive results. Some data has also suggested that Paxlovid might reduce the incidence of long Covid, though there are conflicting thoughts about this.

Long Covid appears to plague up to 20% of patients following an acute infection. In a study of 281, 793 Covid patients by Ziyad Al Aly and colleagues last year, Paxlovid was associated with 26% less risk of long Covid in unvaccinated people. A recent small study from UCSF in vaccinated individuals found no benefit in reducing long Covid.

Since the EUA in 2021, guidelines have routinely recommended treating relatively high risk individuals. These include people older than 50, those with diabetes, cancer, heart or kidney disease, or who are immunocompromised. In my chats with community groups and my free weekly Covid newsletter , I have recommended acutely ill, high risk people ask their physicians for an antiviral and metformin.

The recommendation for metformin is based on Carolyn Bramante’s study showing a 41% reduction in the incidence of long Covid, with an absolute decrease of 4·1%, compared with placebo, when started within the first three days and continued for 14 days. During this past month’s surge in Covid 19, several people told me that their physician or nurse practitioner refused their specific request to prescribe antivirals, prompting this review.

Reasons for refusal have varied. The most common has been that the patient “wasn’t sick enough.” This reflects a lack of knowledge or understanding of when antivirals should be prescribed. In an email interview, Ziyad Al Aly, MD, chief of research and development at VA St. Louis Health Care System, suggests that “the nation is falling into complacency about Covid and long Covid,” fueling the undertreatment.

Other reasons were that “not enough is known about the drug” and that it has too many side effects (nausea, diarrhea, and a metallic taste). Some medications which are contraindicated with Paxlovid, like statins, could be stopped for the few days needed for Covid 19 treatment. Alternatively, patients could be given molnupiravir, an alternative antiviral.

Practitioners are overly concerned about possible rebound covid symptoms. The CDC found no clear association between treatment and rebound and recommended that the concern not deter treatment . Other practitioners did not understand that an EUA allowed the drug to be prescribed or mistakenly believed it was restricted to those with serious lung disease.

The FDA fully approved Paxlovid in May 2023. Short term metformin was denied by some practitioners because “it’s just for diabetes,” even though the reference was provided to the practitioner and metformin is inexpensive and rarely has serious side effects . Other people did not encounter problems with their provider and promptly received requested prescriptions.

Occasionally, it was given to those embarking on international travel to have as a standby medication. A recent study specifically looked at prescribing gaps among high risk adults with Covid, finding less than a third received antivirals. The rate was similarly poor, even for those over 65 or having asthma.

Being unvaccinated and having chronic kidney disease resulted in lower odds of treatment! Co author Matt Levy, Ph.D., hypothesized via email that “treatment may not be prioritized due to overall lower numbers of hospitalizations and deaths compared to earlier in the pandemic.” As noted earlier, “there may not be a perceived need to treat (among patients or providers)” if someone has only mild to moderate symptoms.

Patients and physicians should review this list of underlying conditions which increase the risk of severe Covid. Disparities in treatment are likely to grow as the government stops covering the cost of treatment, and Pfizer plans to charge $1390 per 5 day course . For now, it is still “free” through Medicare and Medicaid.

The level of ignorance or confusion is surprising given the magnitude of the pandemic and the efforts to educate. Al Aly concluded, Paxlovid is “a lifeline that prevents much of the ill effects of the infection. But far too many chose to navigate the rough waters of Covid infection without this lifeline.

[It is] Illogical and complacent.” Follow me on Twitter or LinkedIn . Check out my website or some of my other work here . Judy Stone Editorial Standards Print Reprints & Permissions.