Data suggests that medicine against COVID is prescribed ‘very little’

Ira Katz is working at her Atlanta pharmacy this cough season, seeing patients who need medication for respiratory viruses like COVID-19. He occasionally dispenses packets of Paxlovid, a drug designed to nip COVID in the bud. But there aren’t as many Paxlovid prescriptions as there could be.

In fact, national data suggests that the drug is prescribed “very little.” And with winter approaching, this is likely costing patients unnecessary hospitalizations and even deaths.

Some likely culprits: Weather and confusion. Screening everyone who is eligible to receive Paxlovid would take too much time and effort. And without a study, many medical workers still aren’t sure who qualifies.

“I think we are seeing a lot of doctors just stop, even though there are very clear indications that this drug is not only saving lives, but also saving hospital days and reducing the risk of COVID in the long term,” says Dr. Bronwen. Garner, an infectious disease specialist at Piedmont Atlanta Hospital.

Katz can empathize: Under a special federal pandemic rule, he could sign up to prescribe and dispense Paxlovid as a pharmacist, allowing customers to avoid having to see their doctor. But when he considers the complexity of possible drug interactions for some patients, he lets it slide.

‘It’s not hard to understand’

“It surprises me a bit; it’s not hard to understand,” says Dr. Davey Smith, a virologist and professor of medicine at the University of California, San Diego, who regularly prescribes Paxlovid. “There’s a pretty clear direction…but in a busy practice, people sometimes shrug and wonder, ‘Is this really worth my time wasting?

According to Smith, most primary care physicians are overworked and are not rewarded with a higher salary for studying, but for seeing many patients quickly.

When Paxlovid first hit the market just over a year ago, federal authorities thought it was such a breakthrough that they feared a flood of supplies. The antiviral for COVID was the first that could be taken at home in pill form. Studies revealed that it reduced the risk of hospitalization and death in unvaccinated people by 89 percent. The Food and Drug Administration (FDA) also authorized a second antiviral pill, Molnupiravir, whose estimated efficacy against hospitalization and death was 30 percent. Authorities strictly limited initial prescriptions of the drugs to the oldest and most vulnerable patients.

But production has ramped up and supplies are now plentiful, and still, the drugs only reach a small fraction of those who qualify, studies show.

A study in August by the Covid States Project of Northeastern, Harvard, Rutgers and Northwestern universities found that only 11 percent of COVID patients reported taking an antiviral pill. The study called that prescription rate “a tremendous missed opportunity.”

Even among those over 65, the percentage who took an antiviral pill was only 20 percent. Higher-income or male patients were more likely to receive it. The study cited confusion and a lack of clear guidance. A more recent study revealed that African-American and Hispanic patients were one-third less likely to receive Paxlovid than white patients.

Obstacles to prescription

Contrary to popular assumption, a wide variety of young adult patients can receive Paxlovid.

You have to make an effort to know the prescription guidelines. The FDA authorization for Paxlovid says the drug is only for COVID patients at “high risk” of progression to severe COVID, including hospitalization or death. For more details, the FDA refers readers to a list from the Centers for Disease Control and Prevention (CDC) of conditions that patients may have that place them at “high risk” for serious illness.

These range from the most obvious, such as asthma, to the most common, such as “physical inactivity”. The list includes dozens of conditions, including depression, “disabilities” — linked to another list — and obesity (190 pounds or more for a 5-foot-6 person).

An even greater bureaucratic barrier may be the factors that exclude patients from eligibility for Paxlovid.

There is a long list of drugs that patients should avoid mixing with Paxlovid. And there are conditions, such as severe kidney failure, that make a patient not need to take Paxlovid. For moderate kidney failure, a little Paxlovid may be fine, but doctors have to figure out the best dose.

Federal officials once thought the special program for pharmacists, called Test to Treat, would be a game changer and increase access to Paxlovid. But, like many pharmacists, Katz worries about how to get doctors’ notes or blood tests that show patients’ kidney health so he doesn’t misprescribe it.

“We have it; we have waived it,” Katz said of Paxlovid. “I know there is a protocol that allows us to prescribe and dispense it. But we prefer that it be your GP who recommends and refers you.”

Pharmacy chain CVS allows patients to check their eligibility for Paxlovid online, but appears to turn away patients without recent blood test records.

Address interactions

The cost of ignoring Paxlovid remains apparent. Even when other drugs have lost efficacy against new variants, Paxlovid in a recent CDC study reduced a person’s chance of hospitalization by 51 percent, regardless of vaccination status.

Garner sees indecisiveness even among doctors treating those most vulnerable to COVID. She works with transplant patients, who take drugs to suppress their immune systems. A COVID infection could devastate them.

Like Smith in San Diego, Garner has incorporated Paxlovid knowledge into his daily work. Virtually all of her patients also take drugs that interact with Paxlovid. But she doesn’t let that regulate them.

When they test positive for the COVID virus, Garner regularly receives calls from her primary care physicians, fearful of giving them Paxlovid. To address drug interactions, she and her colleagues have analyzed the drugs involved and created a protocol to alter patients’ drug regimens to make Paxlovid acceptable. They did it “because Paxlovid is so good – it’s so good – at preventing morbidity and mortality from COVID,” Garner said.

And when primary care physicians call asking if they should give Paxlovid, he said, “My answer, almost invariably, is yes.”