As Covid surges again, killing about 1,500 Americans each week, medical researchers are trying to understand why so few people take Paxlovid, a drug that is surprisingly effective at preventing serious illness and death from the disease. .
A study of one million high-risk people with Covid found that only about 15 percent of those who were eligible to receive the drug were taking it. If half of eligible patients had received Paxlovid, 48,000 deaths could have been prevented, the authors of the study, conducted by the National Institutes of Health, concluded.
It’s not because people don’t know about the drug (most do), but rather the reluctance seems to come from doctors concerned about interactions with other medications and from people who fear a possible rebound case or metallic aftertaste.
Regional differences offer a clue: Acceptance is highest in Democratic strongholds in the Northeast and Pacific Northwest regions of the United States and lowest in deep red areas such as Florida and Indiana. However, no careful study has clarified why so few people used the drug, which reduced the risk of death by 73 percent for high-risk patients in the NIH study.
“I don’t know why there is such variability and why acceptance isn’t greater across the board,” said Dr. Josh Fessel, senior clinical adviser on the National Institutes of Health team that studied the drug’s use. “If you can take Paxlovid and do so within the recommended time frame, the chance of death or hospitalization is significantly reduced. That’s a big problem”.
Covid deaths have risen since September to around 1,200 to 1,300 deaths per week, inching up to around 1,500 per week in December. Researchers say they will most likely continue to rise unless more people receive Covid vaccines and updated antiviral treatments.
Dr. Fessel said that over the course of the entire NIH study of one million people, about 10 percent of high-risk patients eligible for Paxlovid took it, although the rate rose to about 15 percent toward the end of the study period in early 2023. In total, the NIH authors estimated that about 135,000 hospitalizations and 48,000 deaths could have been avoided if half of the patients eligible to receive the antiviral had received it.
Paxlovid, manufactured by Pfizer, is a two-drug treatment that must be taken within five days of the onset of Covid symptoms to quell viral spread within the body. It was approved for adults at high risk of severe Covid, which tends to include people aged 65 and over and people with diabetes, obesity, asthma and other conditions.
The reasons for not prescribing or taking it have varied: Doctors balk at the long list of drugs that should not be mixed with Paxlovid, including common medications intended to lower blood pressure or prevent blood clots. Patients tend to complain about the metallic aftertaste of the drug. Many stop the medication in the early days of Covid, when symptoms tend to be milder, avoiding the possibility of limiting early viral growth.
“They want to wait and see if things get worse, but waiting and seeing is not effective,” said Dr. David Gifford, chief medical officer of the American Health Care Association, which represents nursing homes. People think, “It’s just a cold and I’ll ride it out,” he said. “And that has to change”.
Price has also become a factor. The federal government has provided the five-day course of drugs at no cost in the months since its initial emergency authorization in December 2021 (the Food and Drug Administration fully approved the drug in May). Federal officials still have more than a million free doses to be sent to pharmacies and the drug will be free through 2024 for Medicaid and Medicare patients. But in recent weeks, officials have turned distribution of the drug over to Pfizer, which has priced it at about $1,400 per course, though private insurers are expected to cover a portion of the price and Pfizer is offering co-pay assistance. .
No study has analyzed the effect of handover. The NIH study period ended early last year. It found wide regional variation in Paxlovid use, with up to 50 percent of eligible patients receiving the drug in Utah and the northeast and northwest regions of the United States. However, rates fell near zero in Southeastern states and parts of the lower Midwest.
The NIH’s Dr. Fessel said he would be curious to see whether concerns about the so-called Paxlovid rebound contributed. The concern has been that the drug initially attenuates symptoms and then leads to a second stage of the disease.
In a recent review of studies, the Centers for Disease Control and Prevention found “no consistent association” with Paxlovid use and Covid rebound. Studies show that rebound can also occur without treatment.
Denis Nash, a professor of epidemiology at the City University of New York, has also been studying the use of Paxlovid. In a much smaller study, his team also found that absorption of the drug was nearly 14 percent, although lower among some, including 7 percent among black people and almost 11 percent among those with disabilities. lower income levels.
He said his team worked on a nationally representative survey of 4,000 people to dig deeper (the results have not yet been published or peer-reviewed). An interesting finding, she said, was that awareness of Paxlovid was high: About 80 percent of respondents said they knew it was available.
However, respondents showed a lack of recognition of their own risk: Only about a third of people over 65 were considered at high risk for severe Covid, even though the CDC considers everyone in that age group age are high risk. The finding was similar for patients with asthma or diabetes, although half of overweight or obese patients recognized their risk.
“People don’t necessarily perceive themselves as at risk,” Dr. Nash said.
Another recent study found that starting Paxlovid very early, or on the first day of symptoms, improved the chances of survival or avoiding hospitalization, compared with starting the drug a day or two later.
Studies have also looked at the use of another antiviral drug, molnupiravir, made by Merck, which was less effective and used less frequently. Gilead, which makes the antiviral infusion remdesivir, is also studying a Covid antiviral pill called obeldesivir and plans to seek FDA approval. The NIH is studying another antiviral option, ensitrelvir, from the company Shinogi, which also appears to reduce the duration of the illness.
Researchers have also reported low use of Paxlovid in nursing homes, given the risk patients face of serious illness or death. About one in four nursing home residents received an antiviral prescription to treat Covid by the end of 2022, according to a study. The data showed that the rate increased to about a third of nursing home residents in May 2023, said one of the study’s authors, Brian McGarry, an assistant professor of medicine at the University of Rochester.
After that, federal officials stopped asking about Paxlovid use in their weekly nursing home Covid questionnaire.
“I think things are a little better,” Dr. McGarry said, “but at the same time, facilities are now dealing with Covid, in addition to RSV and the flu.”
