What older people need to know about taking PaxlovidThank you for reading this post, don't forget to subscribe!
A new variant of the coronavirus is circulating, the most transmissible to date. Hospitalizations of infected patients are increasing. And the elderly have accounted for nearly 90 percent of U.S. deaths from Covid-19 in recent months, the most since the pandemic began.
What does this mean for people aged 65 and over infected with Covid for the first time or those experiencing re-infection? The message from infectious disease experts and geriatricians is clear: seek treatment with antiviral therapy that remains effective against new Covid variants.
The first-choice therapy, experts say, is Paxlovid, an antiviral treatment for people with mild to moderate Covid who are at high risk of becoming seriously ill from the virus. All adults 65 and older fall into this category. If people cannot tolerate the drug – potential complications with other drugs must be carefully evaluated by a medical professional – two alternatives are available.
“There is a lot of evidence that Paxlovid can reduce the risk of catastrophic events that can follow Covid infection in the elderly,” said Dr. Harlan Krumholz, professor of medicine at Yale University.
In the meantime, develop a plan for what you will do if you get Covid. Where will you seek care? What if you can’t get to your doctor quickly, a common problem? You must act quickly, as Paxlovid must be started no later than five days after the onset of symptoms. Will you need to adjust your medication regimen to protect yourself from potentially dangerous drug interactions?
“The time to understand all of this is before you get Covid,” said Dr. Alison Weinman, an infectious disease expert at Henry Ford Hospital in Detroit.
Being prepared proved extremely important when I caught Covid in mid-December and went to the ER for a prescription. Being 67 years old, with blood cancer and an autoimmune disease, I am at increased risk of becoming severely ill from the virus. But I take a blood thinner that can have life-threatening interactions with Paxlovid.
Luckily the urgent care center could see my electronic medical record and a doctor’s note there said it was safe for me to stop the blood thinner and get the treatment. (I had consulted my oncologist beforehand.) So I left with a prescription for Paxlovid and within a day my headache and chills were gone.
Right before I got Covid I was reading iimportant study of nearly 45,000 patients age 50 and older treated for Covid between January and July 2022 at Mass General Brigham, a large health system in Massachusetts. Twenty-eight percent of patients were prescribed Paxlovid, which received emergency use authorization for mild to moderate Covid from the FDA in December 2021; 72% were not. All were outpatients.
Unlike other studies, most of the patients in this one had been vaccinated. Still, Paxlovid conferred a remarkable advantage: those who took it were 44% less likely to be hospitalized with severe Covid-related illnesses or die. Among those who received fewer than three doses of the vaccine, these risks were reduced by 81%.
A few months earlier, research of Israel confirmed the efficacy of Paxlovid—the brand name for a combination of nirmatrelvir and ritonavir—in elderly people infected with the omicron strain of Covid that emerged in late 2021. (The original study establishing the effectiveness of Paxlovid was conducted while delta strain was predominant and included only unvaccinated patients.) In patients 65 and older, most of whom were vaccinated or had previously had Covid, hospitalizations were reduced by 73% and deaths by 79%.
However, several factors have hindered the use of Paxlovid among older people, including doctors’ concerns about drug interactions and patients’ concerns about possible “ricochet” infections and side effects.
Dr. Christina Mangurian, associate dean for faculty and academic affairs at the UC San Francisco School of Medicine, faced several of these issues when both of her parents contracted Covid in July, an episode she recounted in a recent JAMA article.
First, her father, 84, was told at a virtual medical appointment by a doctor he didn’t know that he couldn’t take Paxlovid because he was on a blood thinner — a decision that was later reversed by his primary care physician. Her mother, 78, was then told in a separate virtual meeting to take an antibiotic, steroids and over-the-counter drugs instead of Paxlovid. Once again, her primary care physician stepped in and offered a prescription.
In both cases, Mangurian said, the doctors her parents first saw didn’t seem to understand who should receive Paxlovid and under what conditions. “It shows a major deficit in how information about this therapy is being disseminated to frontline providers,” she told me in a phone conversation.
Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, agrees. “Every day I hear from people who are misinformed by their doctors or nurse hotlines. They are generally told that you cannot get Paxlovid until you are seriously ill – which is the exact opposite of what is recommended. Why aren’t we doing more to educate the medical community?”
The potential for drug interactions with Paxlovid is a serious concern, especially in older patients with multiple medical conditions. More than 120 drugs are marked for interactions and each case should be evaluated taking into account individual conditions as well as kidney and liver function.
The good news, experts say, is that most potential interactions can be managed either by temporarily stopping the drug while taking Paxlovid or by reducing the dose.
“A little bit of additional work is needed, but there are resources and systems available that can help practitioners understand what they need to do,” said Brian Izetts, a professor in the University of Minnesota College of Pharmacy.
In nursing homes, patients and families should ask to speak with consultant pharmacists if they are told that antiviral therapy is not recommended, Isetts suggested.
About 10 percent of patients cannot take Paxlovid because of potential drug interactions, according to Dr. Scott Dryden-Peterson, medical director of Covid Outpatient Care for Mass General Brigham. For them, Veklury (remdesivir), antiviral infusion therapy given on three consecutive days is a good option, although sometimes difficult to arrange. Also, Lagevrio (molnupiravir)another antiviral pill, may help shorten the duration of symptoms.
Many older people worry that after taking Paxlovid they will get a rebound infection — a sudden resurgence of symptoms after the virus seems to have cleared. But in the vast majority of cases, “the rebound is very mild and the symptoms — usually a runny nose, nasal congestion and sore throat — go away within a few days,” said Dr. Rajesh Gandhi, an infectious disease physician and professor of medicine at Harvard Medical School. .
Gandhi and other doctors I spoke to said the risk of not treating Covid in the elderly is far greater than the risk of re-illness.
Paxlovid side effects include a metallic taste in the mouth, diarrhea, nausea, and muscle pain, among others, but serious complications are uncommon. “Continuously, people tolerate the drug really well,” said Dr. Caroline Harada, associate professor of geriatrics at the University of Alabama-Birmingham School of Medicine, “and feel better very quickly.”
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