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Opinion | The under-prescribing of Paxlovid may be our biggest covid policy failure

Paxlovid - Drug
Thought Leader: Leana Wen
January 16, 2024

The United States suffers from a litany of policy failures in the response to covid-19. Low vaccine uptake in vulnerable populations such as nursing homes remains a major problem, as does the lack of investment in local and state public health infrastructure.

But one deficiency stands out above the rest: The antiviral medication Paxlovid is highly effective at preventing severe illness and death, yet the usage rate is staggeringly low. Only about 15 percent of high-risk individuals who contract the coronavirus are prescribed the drug.

This unfortunate statistic would be wholly unacceptable for other serious ailments. Imagine if fewer than 1 in 6 people with bacterial pneumonia received antibiotics, or if fewer than 1 in 6 people with heart attacks received aspirin. Those therapies are considered standard of care. So is antiviral treatment for high-risk covid patients.

The evidence in favor of Paxlovid use is strong. According to research from the Centers for Disease Control and Prevention, people who took the antiviral pills were 51 percent less likely to be hospitalized compared with those who didn’t. A 2023 study from the Kaiser Permanente health system found that when taken within five days of symptoms emerging, Paxlovid was nearly 80 percent effective at preventing hospitalization or death.

A new National Institutes of Health study involving more than 1 million patients supports this. The paper, which is online but not yet peer-reviewed, reports that Paxlovid reduces mortality from covid-19 by 73 percent, but it also found that the medication was prescribed to less than 10 percent of eligible, high-risk individuals between December 2021 and February 2023. If uptake were 50 percent, nearly 48,000 deaths could have been prevented during that time.

The conclusion is clear: If the primary goal is to reduce covid-associated deaths, which currently reach almost 1,000 a week, then increasing Paxlovid use should be a top priority.

Those concerned about long covid should also be pushing for antiviral treatment. One study from Veterans Affairs found that use of Paxlovid reduced the incidence of post-covid symptoms by 26 percent. Another paper just published by the CDC provides an additional justification for the medication: Antiviral treatment represses viral replication, and increased treatment with Paxlovid averts onward coronavirus transmission and decreases risk to others.

With such compelling rationale for its use, why isn’t Paxlovid prescribed more? I think it’s because health professionals and patients alike are misjudging the drug’s risk-benefit calculation. They are overemphasizing the treatment’s potential risk while underestimating the seriousness of covid.

I often hear from clinicians that they are hesitant to prescribe Paxlovid because of its side effects, especially the possibility of “rebound” symptoms. Though it’s true that some patients who receive the antiviral might experience a recurrence of symptoms a week or so after they initially improve, two recent systematic reviews by the CDC and the Food and Drug Administration found no consistent association tying Paxlovid use to rebound. Rebound appears to occur with and without Paxlovid at comparable rates. Other side effects from the drug, such as nausea, diarrhea and metallic aftertaste, might be annoying, but they are temporary. Surely, they are minor compared with the specter of hospitalization — or worse.

Some clinicians might also balk at how the pills interact with other medications their patients are on. The FDA estimates that as many as half of VA and Medicare enrollees are taking medications or have conditions that cause trouble alongside Paxlovid. But the FDA also says that most of these interactions can be managed. For instance, someone taking certain cholesterol medications can stop them temporarily. Those truly ineligible for Paxlovid should consider the two alternative antiviral agents: molnupiravir and remdesivir.

Federal health officials have already worked to remove some access barriers to Paxlovid, but they need to do a lot more, especially around clinician education. A national initiative targeting health professionals should emphasize the importance of early treatment. Clinicians shouldn’t be waiting to initiate antivirals until symptoms worsen. Paxlovid works best when given early in the course of illness; in fact, it is no longer useful once someone is ill enough to be hospitalized.

Insurers and hospital systems can also change their policies and workflows to flag patients eligible for Paxlovid. Clinicians should have to justify each time they choose not to prescribe antiviral therapies to patients 65 and older and to those with chronic medical conditions that predispose them to severe illness from covid-19.

Finally, the FDA should provide explicit instructions to allow doctors to issue “just in case” prescriptions. High-risk patients who are traveling and are concerned about accessing treatment should be able to take antivirals with them so that they can initiate treatment as soon as they test positive.

It’s remarkable that science has delivered exceptional breakthroughs that have dramatically reduced severe illness and death from the coronavirus. The great tragedy is our continuing failure to take advantage of these advances.

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