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Opinion The Checkup With Dr. Wen: Do not wait to take Paxlovid if you are eligible

A box of Pfizer's Paxlovid antiviral medication is displayed in a warehouse in Shoham, Israel, on Jan. 18. (Kobi Wolf/Bloomberg News)

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Imagine that you have contracted a disease that is killing hundreds of Americans every day. There are pills you can take that will significantly reduce your chance of death. Side effects are minimal — mostly limited to an upset stomach. And taking the treatment can keep you out of the hospital and allow you to recover at home.

That’s the case with Paxlovid, the antiviral pill for covid-19. Initial research found that in high-risk individuals, Paxlovid reduced hospitalization and death by nearly 90 percent. A real-world study of more than 100,000 patients in Israel found that among people 65 and over, Paxlovid cut the rate of hospitalization by a factor of four and the likelihood of death by a factor of five.

Yet Paxlovid remains vastly underutilized. Recent data from the Centers for Disease Control and Prevention also shows massive racial disparities in Paxlovid prescribing. From April to July, Black patients were 36 percent less likely to receive Paxlovid compared with White patients. Among those 65 to 79 years old, White individuals were 44 percent more likely to receive Paxlovid than Black patients.

What accounts for the underuse of an effective and safe medication? I think a lot has to do with misconceptions — among the public and medical professionals.

Callum from New Mexico wrote that his nearly 80-year-old grandparents were told by their doctor that they didn’t need Paxlovid because they only had mild symptoms. “How severe do symptoms need to get?” he asks. “My grandfather is a former smoker with lung disease and my grandmother has diabetes.”

Callum hit the nail on the head. His grandparents should not wait to take Paxlovid. By virtue of their age alone, they are eligible. They also have chronic medical conditions that make them susceptible to severe illness.

The point of taking Paxlovid is to prevent progression to more serious symptoms. Eligible individuals with mild symptoms shouldn’t wait. In fact, Paxlovid is most effective when started early in the course of illness and needs to be initiated within five days from the onset of symptoms. If someone is so ill that they need to be hospitalized, they are no longer eligible for the treatment.

Unfortunately, there is a common misconception that infected people should adopt a “wait and see” approach. This is not prudent. People 65 and older, and others with underlying medical conditions that predispose them to severe illness, should not hesitate to take Paxlovid.

A major reason I have heard people cite for holding off on Paxlovid is concern for rebound symptoms. It is true that some people who take the pills, including President Biden, experience a recurrence of symptoms after appearing to clear their infection. As I have previously written, Paxlovid rebound is annoying, but hardly a reason to avoid a medication that could save you a trip to the hospital or worse.

Interestingly, a recent JAMA Network Open study found that the rebound phenomenon is also present in 44 percent of patients who did not take Paxlovid. It’s possible that the waxing and waning of symptoms is part of illness from covid-19, with or without the antiviral.

“I’m 68 with hypertension and breast cancer,” Mary from Wisconsin wrote. “I haven’t had covid yet, but I asked my doctor what I should do if I get it this winter. I was told I shouldn’t take Paxlovid because I’m on lovastatin [a cholesterol medication]. Do you agree?”

I don’t, because that’s not the guidance from the Food and Drug Administration. The FDA has a helpful checklist to look for medication interactions. Those taking lovastatin should stop using it 12 hours before taking Paxlovid. They can restart it five days after finishing the antiviral treatment.

Some clinicians might not be aware of this. If that’s the case, you take a look at the FDA checklist and bring it to your next doctor’s visit. Everyone should have a plan for what happens if they have covid, including knowing whether you are eligible for Paxlovid and whether you might need to adjust other medications while on it.

What about younger people who do not have significant medical conditions? These individuals are not eligible for Paxlovid, and indeed, the Israeli study found no benefit in reducing hospitalization or death for individuals under 65.

However, a new Veterans Affairs study, online but not yet peer-reviewed, found a 25 percent reduction in long-covid symptoms for those who took Paxlovid. These findings should prompt more research into whether younger individuals would also benefit from the antiviral. In the meantime, it strengthens the case for everyone eligible to take it.

In a recent speech, Biden said that at this point in the pandemic, “virtually every covid death in America is preventable.” Let that sink in a for second. We can save virtually everyone still dying from covid every day if we make use of available tools — including Paxlovid.

Ask Dr. Wen

Newsletter subscribers are invited to submit questions to Dr. Wen. Not a subscriber yet? Click here to sign up.

“My wife and I have had all the available covid-19 vaccinations and booster shots, including the bivalent booster. But this continued trend of newer and newer variants leads me to wonder if the pharma companies are rushing to develop new boosters too quickly to provide sufficient protection against the current virus. Maybe if they waited a month or two longer, they would have a more comprehensive and more effective booster that would successfully prevent more illness. What is your point of view on this? We can’t keep rushing to get the latest booster only to find that we have no protection against new variants that are already infecting people.” — Richard from New York

This is an excellent question that reflects the complexity of the moment we are in. You’re right; it would be ideal from a scientific viewpoint to have complete data that compares the effectiveness of an updated booster with previous versions of the vaccines. Such results might persuade more people to get the new booster.

The problem is timing. If we waited for these data, we might miss the window to forestall another surge. In addition, by the time the results come in, they might already be outdated, because the dominant variants may be different from the ones that the booster was initially tested on.

Health officials are constantly weighing these two competing factors. Ultimately, we need better vaccines that target a broader range of existing and future variants. All the more reason for Congress to fund the Biden administration’s request to develop better vaccines and treatments.

“When I get sick, my doctor makes me get a covid test before coming in. I’m really afraid what to do if I get covid. The doctors are so afraid of it. Will they treat me, or will I just be forced to stay home and die?” — Diana from South Carolina

Your doctor is probably asking patients to take a covid test before coming into the office to reduce the risk of transmitting the coronavirus to others — especially patients who might be medically vulnerable. Rest assured that you will be taken care of if you end up becoming infected yourself and need treatment. Emergency departments are required by law to treat every patient. Hospitals are very well-equipped to treat individuals with covid. Do not hesitate to seek emergency care if you are short of breath or otherwise experiencing severe and concerning symptoms from covid or any other illness.

“My daughter, 21, is vaccinated and boosted. She had a moderate covid infection at the end of September. She’s going to Rome for a month in late November and doesn’t want to get covid while overseas. Is it worth getting her bivalent booster before she goes, even though it will be less than three months since her infection?” – Maggie from Maryland

I think it’s important to clarify the purpose of vaccinations and continued boosters. The primary reason is to prevent severe illness. Your daughter is already extremely well-protected because of her age and having hybrid immunity from vaccination and recent recovery from covid.

Because she just had covid, she is also unlikely to get reinfected soon after. Her trip will begin two months after her infection and will be completed around the three-month window. Reinfection in this short time frame is uncommon.

A booster might give a little bit more protection against infection, or it might not, as she is already so well-protected. I would advise her to wait.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I’m reading

A large study out of South Africa published in the British Medical Journal of Sports Medicine shows that regular physical activity is associated with higher levels of protection against hospitalization among individuals who received coronavirus vaccines. Compared to vaccinated people with low-activity levels, those with moderate- and high-activity levels had a 1.4 and 2.8 times lower risk of hospitalization because of covid, respectively. The authors concluded that “physical activity enhances vaccine effectiveness against severe COVID-19 outcomes and should be encouraged by greater public health messaging.”

Yet another devastating consequence from the pandemic has been its impact on the worldwide fight against tuberculosis. The World Health Organization’s 2022 Global TB Report shows that more than 10 million people became ill from tuberculosis in 2021. This is a 4.5 percent increase from 2020 and represents the first time in almost two decades that the number of people with TB has increased. Deaths from TB are up, too, as is the percentage of drug-resistant tuberculosis.

Virologist Jesse Bloom wrote a thought-provoking piece in the New York Times that argues for stricter regulation of “gain of function” research. His point is that some aspects of virus research are so high risk that their benefit does not justify the potential harm. “In my view, there is no justification for intentionally making potential pandemic viruses more transmissible,” he writes. “The consequences of an accident could be too horrific, and such engineered viruses are not needed for vaccines anyway.”

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