“Paxlovid is a miracle drug,” says a primary care doc whom I know, “because it is a miracle when I can prescribe it. Anyone who is sufficiently vulnerable to serious consequences from COVID-19 is already on drugs that have interactions with Paxlovid.” The other docs with whom I’ve talked about this drug, especially cardiologists, are generally negative regarding the drug. In their view, it will interact badly with other drugs, have bad side effects, and/or result in SARS-CoV-2 attacking the patient as soon as he/she/ze/they stops taking Paxlovid.
Chinks in the miracle drug’s armor are beginning to be described in our otherwise cheerleading media. Example from the NYT, March 25:
Certain medications or supplements, including painkillers, statins and even St. John’s Wort, may have adverse interactions with Paxlovid. So you may be advised to hold off on taking them for a week while being treated, Dr. Gandhi said. But for some medications, like drugs that regulate heart rhythm, abstaining for a week may not be possible. In those cases, your doctor may recommend molnupiravir for Covid-19 instead.
From Yale, where they understand medicine if not accounting, “13 Things To Know About Paxlovid, the Latest COVID-19 Pill”:
The FDA authorized Paxlovid for people ages 12 and older who weigh at least 88 pounds. But in order to qualify for a prescription, you must also have had a positive COVID-19 test result and be at high risk for developing severe COVID-19.
That means you must either have certain underlying conditions (including cancer, diabetes, obesity, or others) or be 65 or older (more than 81% of COVID-19 deaths occur in in this group). The more underlying medical conditions a person has, the higher their risk for developing a severe case of COVID-19, according to the CDC.
Since Paxlovid is cleared by the kidneys, dose adjustments may be required for patients with mild-to-moderate kidney disease, explains Dr. Topal. “For patients with severe kidney disease—or who are on dialysis—or those with severe liver disease, Paxlovid is not recommended; the levels of the drug can become too high and could cause increased side effects,” he says.
There is a long list of medications Paxlovid may interact with, and in some cases, doctors may not prescribe Paxlovid because these interactions may cause serious complications.
The list of drugs that Paxlovid interacts with includes some organ anti-rejection drugs that transplant patients take, as well as more common drugs like some used to treat heart arrhythmias. Paxlovid also decreases the metabolism of anticoagulants, or blood thinners, that many older adults depend on, driving up levels of those medications in the body to a point where they are unsafe, Dr. Topal explains.
It also interacts with cholesterol-lowering medications like Lipitor, but that’s less challenging for patients to overcome. “If you stop taking your Lipitor for five days, nothing bad is going to happen,” he adds.
If you are pregnant or breastfeeding, the FDA recommends discussing your options and specific situation with your health care provider, since there is no experience using the drug in these populations. If you could become pregnant, it’s recommended that you use effective barrier contraception or do not have sexual activity while taking Paxlovid.
So the ideal Paxlovid patient is morbidly obese with the blood pressure and heart health of a 22-year-old tennis star.
Pfizer wants you to take your Paxlovid every day… “FDA rebukes Pfizer CEO’s suggestion to take more Paxlovid if COVID-19 symptoms return”:
The FDA rebuked Pfizer CEO Albert Bourla’s proposed solution to reports that some patients experienced a relapse of COVID-19 symptoms after treatment with the company’s antiviral Paxlovid.
After reports said some patients who took Paxlovid rebounded and started feeling symptoms again, the CEO told Bloomberg that patients can take another course, “like you do with antibiotics.”
“There is no evidence of benefit at this time for a longer course of treatment … or repeating a treatment course of Paxlovid in patients with recurrent COVID-19 symptoms following completion of a treatment course,” John Farley, M.D., director of the Office of Infectious Diseases, said in a post.
Science is complex!
This post is a mixture of half truths. Yes Paxlovid has interactions with an insanely lost list of drugs including statins because it includes,by design, the well known drug Ritonavir which inhibits cytochrome P450, a liver enzyme that degrades a large number of drugs. It does this so the active ingrediant in Paxlovid can stay around long enough to work. (By the way grapefruit juice also imhibits P450, so people on Statins probably shouldn’t eat grapefruit.) But if you have a good doctor who understands what is going on with Ritonavir, he or she would simply lower the dose or temporarily stop for 6 days that other drug. It’s all about tradeoffs: if the risk of getting covid is severe enough for a patient, my medical friends say you monitor the patient after you temporarily take them off their statin or whatever. In paticular, a former student of mine who is a clinical pharmecoligist says the real problem is that most doctors (and he teaches medical students) aren’t really as knowledgeable about pharmecology as they should be and therefore don’t understand how to deal with drug interactions as well as they should. Pharmecists are often a better choice ironically enough. In a nutshell, the problem with this post (like a lot of your posts on Covid) is that you want to throw the baby out with the bath water because the government is often so stupid.
I’ll give you another example of something you should just stop doing: there is *no* question that properly wearing an n95 grade mask lowers the risk of getting Covid considerably, crappy masks or wearing them incorrectly, not so much. Instead of you stressing in any post about masks that despite the government stupidities: “Remember however, N95 grade masks work, wear them if you are in a high risk situation or are at high risk personally – but please wear them correctly.” you come across as being more interested in making fun of masks because the government rules are, I grant you often stupid and just theatre.
If only we had a body to handle the disinformation and had proper authorities to amend Phil’s posts.
We could remind people that masks work (despite studies to the contrary let alone two years of experience on the ground) and ensure that government never comes across as stupid.
Ah, sweet dreams…
Besides that, it’s not so easy to actually obtain the Paxlovid. Within a few days of developing symptoms, you need to get a prescription and find a place that has the drug. CVS putatively has a test-to-treat program which supposedly streamlines the process, but the pharmacist at my CVS didn’t know of any CVS’s that had operational test-to-treat programs. Getting a prescription is, in practice, not always easy. Getting hold of your Primary Care Physician if you happen to develop symptoms on a Friday can be an all day undertaking.
Due to my brutal history with long covid, I was able to talk my doctor into prescribing me Paxlovid even though I am, strictly speaking, probably not eligible. (48, reasonable BMI
It was a huge pain to get, as ERs and Urgent Care’s won’t prescribe it (at least in California last week; this seems to be a moving target). I had to call my primary care guy and do a tele-health visit, and apparently the pharmacy gave him (and my friend’s doctor who was also sick) a bunch of grief about it.
It’s hard to say how the disease would have progressed through my post-covid, triply vaxxed body without the Paxlovid, but it felt like the vaccines weren’t doing crap against this variant. Until I got the Paxlovid, the severity of the illness over time tracked pretty closely to that of my bout of original Covid in 2020. Subjectively, it was different with some different symptoms, but you know the old adage about stepping in the same river twice.
If there were side effects, other than the absolutely unshakable disgusting taste in my mouth all day and night, they would have been impossible to sort out from the symptoms of COVID. A day or two on Paxlovid and my fever broke and the rest of my symptoms, except for brain fog, started to abate.
I’m nine days in and finished the Paxlovid a couple of days ago. Feeling much better, but worried about long term cognitive effects. Hopefully this episode won’t reintroduce any of the long covid symptoms that have been fading over the last year.
I’m glad I had the Paxlovid because this variant went for my brain and lungs, this time seemingly bypassing my gut. I don’t want another couple years of long covid. Happy to answer questions.
A drug discovery expert gets to try Paxlovid: https://www.science.org/content/blog-post/personal-paxlovid-update. tl;dr: it made his saliva taste like tonic water but his symptoms were controlled.
You may have just ruined tonic water for me for a while.
Paxlovid tastes truly terrible in saliva (and his observations mirror mine exactly, it fades between doses, and I always managed to swallow it without it dissolving in my mouth)