As I understand it, part of the issue is that Paxlovid interacts with a large number of other medications. This is a problem because people at high risk of dying from Covid tend to have preexisting medical conditions, and thus are more likely to take medications that interact with Paxlovid.
Most of the interactions can be managed, but I think the message got out among primary care docs there are drug interactions and so they get scared to prescribe it. There are relatively few meds that are absolutely contraindicated, while there's a large list of meds that require some dose adjustment or holding the med for a few days. This is an issue with the ritonavir in the paxlovid, which has been extensively used in HIV treatment -- so, this isn't a new issue that we know nothing about.
And then I've heard from too many patients their doctor doesn't think they need it because they're not that sick, so it's not worth managing the drug interactions. Unfortunately, paxlovid needs to be started within five days of symptom onset, but most patients aren't going to be hospitalized within those first five days.
Given the lack of monoclonal antibodies, the potential mutagenic effect of molupiravir, and the less-than-steller impact of remdesivir... if I or someone I loved got covid, I'd be jumping on paxlovid since there aren't many other options right now.
The medical system in the US is optimized to get people in, bill them, and get them out; that's it. Managing drug interactions is a long tail process that requires critical thinking, which is not an incentiviced activity. Plenty of startups have failed thinking that they could succeed if their products resulted in improvements to quality of care.
Managing drug interactions for paxlovid isn't much more complicated than inputting meds into a web form and looking at the color of the box that pops up after. I think most providers can handle that if they know these tools exist and get past the reflex of "paxlovid has drug interactions, you don't want to take it."
Managing drug interactions is part of ordering medications, and if it's really taking that much time (i.e., the EHR isn't just doing all the work for you), then it'd result in a higher E&M code when it's billed out. Medication management, in some cases, can also be billed and reimbursed by the pharmacist.
So, totally agree that the US medical system is optimized for billing. I don't think those of us in the US should be ok with that, and I don't think it's an excuse in this case to not prescribe paxlovid to patients who want it and would qualify for it.
Sure, in the abstract it is straight forward, but you quickly run into data gaps when considering multiple medications. Particularly in the context of comorbidities.
Medical professionals are overwhelmed, so you can't hospitalize these patients to monitor their compliance. And this is, in the large, not a demographic you can trust for maximal patient compliance.
By the medical professional who is prescribing paxlovid. When I wrote "can be managed", I mean the health care provider tells the patient to either stop taking their other meds for 5-7 days, to reduce the dose, or to look out for symptoms and call them if they have certain issues. Not be hospitalized to watch for side effects. You can look for yourself at the list of common meds, and the ones that are absolutely contraindicated are relatively few:
https://www.covid19treatmentguidelines.nih.gov/therapies/ant...
One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending. The patient and provider have aligned interests, it's just a matter of ensuring the provider is making sure the patient understands what's going on. The provider should be doing that in all of their encounters, so that's nothing specific to paxlovid.
> One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending.
I suspect you haven't worked with elderly patients.
I help a relative manage his care. I keep having to hide the DayQuil so he doesn't take it alongside his arthritis medication and overdose on acetamenophin. He "knows" he's not supposed to, but it doesn't click when the pills are in his hand and his nose is running (because he took it for decades prior to the arthritis prescription and deeply-ingrained habits are not easily replaced). He definitely tells the doctor he understands, and the doctor believes him, but it's not like the doctor is in any way responsible for verifying that information.
Drug interactions are way past the maximum complexity capacity of the median patient at high risk for death by COVID.
I spent a decade working in a nursing home before becoming an epidemiologist, so definitely have worked with elderly patients. Not to mention my own experiences with elderly family members.
> but it's not like the doctor is in any way responsible for verifying that information.
Yeah, that's the exact point. Everybody does things that the doctor says they shouldn't, but that doesn't mean we withhold care as a result.
People stop antibiotics before the scripts are done. People smoke and drink too much, some even drink and drive. People don't take their blood pressure or cholesterol or even HIV meds as prescribed. Some people take half a pill because the pill they were prescribed is "too big" -- people are weird and do all kinds of things.
Paxlovid is no different. The provider can be checking drug interactions, making adjustments as needed and counseling the patient. That's their job. They can't babysit the patient all of the time. If it's clear the patient doesn't understand and can't care for themselves, then there are larger conversations to be had.
My point is that deciding not to prescribe a medication to a qualifying patient because it generally has too many drug interactions and patients can't be trusted with their health is not ok. Patients don't need to understand that ritonavir is a protease inhibitor that was incidentally found to inhibit cytochrome P450-3A4, which subsequently boosts the levels of many other medications. They just need to know to stop taking their cholesterol pill for the next week. That's all. Some, like your elderly relative, may not be able to follow that direction. But there are millions of high risk people who are able to do that, and shouldn't be denied care based on the assumption they're incompetent.
Didn't we restrict Sudafed because people can cook it into meth and change the painkiller regiment because of opioid addiction? I don't think the rule "we don't refrain from prescribing a drug because some users won't be able to use it responsibly" is universal.
Yes, there are levels of controlled substances based on, among other things, their abuse potential. That's not what we're talking about here because paxlovid is not a controlled substance.
If you're going to construct a new strawman argument, don't make up quotes that I never wrote. I also have a lot of thoughts about how controlled substance laws create problems and harm patients. But I'll stick to the main point of this thread: paxlovid drug interactions are easily checked and managed for the majority of patients, and should not be a reason for providers to reflexively deny prescription requests for it.
What if that someone you love is young and in good health? Paxlovid has some significant side effects and is only recommended for patients at high risk of severe COVID-19 due to advanced age or other risk factors.
I think this is where many providers get mixed up. It's for "mild-to-moderate" COVID-19 (i.e., "you're not sick enough yet" isn't at play, because then you have "mild" covid which is exactly what paxlovid is indicated for) who are at "high risk for progression to severe COVID-19."
According to the CDC, risk factors that make you at "high risk" include being over 50, having a mood disorder (including anxiety and depression), being obese or overweight, being physically inactive, being a current or former smoker, or having asthma:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/...
Most Americans would check one of those boxes, even the healthy and young among us. And some of those (e.g., "physically inactive") are pretty ill-defined that you could argue even more fit in that category. Just saying you're anxious about covid outcomes should qualify you for paxlovid because anxiety is a risk factor.
Many of the infectious disease doctors I work with think that paxlovid should be offered to virtually everybody because it seems to decrease your viral load (this could decrease the chance of onward transmission), there may be a decrease in risk of long covid, it may shorten your symptom duration, and there aren't many other treatment options if you get sicker. So, short of being on one of the medications that's absolutely contraindicated, their opinion is generally if you want paxlovid you should get it.
So if your doctor is saying you don't need it or don't qualify, and you want to take it, I would find a different doctor or use a telemedicine provider.
yeah people in my house hold are getting covid a couple of times a year and are constantly exposed to it at school and work and we are all vaccinated but dont take any other medications for covid.
There are renal dosing standards for paxlovid. So if you have not-great kidneys, they just give you a different dose. Covid can also cause kidney damage, and kidney issues are associated with worse outcomes from covid. So, it's all a bit of a double edged sword.
