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 remarkably effective at preventing severe illness and death from the disease.
A study of a million high-risk people with Covid found that only about 15% of those eligible for the drug took it. If half of eligible patients in the United States had taken Paxlovid during the study period, 48,000 deaths could have been avoided, 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 the reluctance seems to come from doctors worried about interactions with other drugs and from people wary of a possible case of rebound or the metallic aftertaste.
Regional differences offer a clue, with the highest spread in Democratic strongholds of the Northeast and Pacific Northwest regions of the United States and the lowest in deep red areas, including Florida and Indiana. Yet no careful study has clarified why so few people have used the drug, which reduced the risk of death by 73% for high-risk patients in the NIH study.
“I don’t know why there is such variability and why absorption isn’t higher across the board,” said Dr. Josh Fessel, senior clinical advisor to the National Institutes of Health team that studied the drug’s use. “If you can take Paxlovid and you take it within the recommended time period, the chance of death or hospitalization is significantly reduced. This is a big problem.
Covid deaths have increased since September to around 1,200-1,300 deaths per week, rising to around 1,500 per week in December. Researchers say they will most likely continue to increase unless more people receive updated Covid vaccines and antiviral treatments.
Dr. Fessel said that over the course of the entire million-person NIH study, about 10% of high-risk patients eligible for Paxlovid took it, although the rate rose to about 15% toward the end of the period study in early 2023. Overall, the NIH authors estimated that about 135,000 hospitalizations and 48,000 deaths could have been prevented if half of the patients eligible to receive the antiviral had received it.
Paxlovid, made by Pfizer, is a two-drug treatment intended to be taken within five days of the onset of Covid symptoms to reverse viral spread within the body. It was approved for adults at high risk for severe Covid, which tends to include people aged 65 and older and people with diabetes, obesity, asthma and other conditions.
The reasons not to prescribe or take it are varied: Doctors object to the long list of drugs not to mix with Paxlovid, including common drugs intended to lower blood pressure or prevent blood clots. Patients tend to complain about the metallic aftertaste of the drug. Many give up on the drug in the early days of Covid, when symptoms tend to be milder, ignoring 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, medical director of the American Health Care Association, which represents nursing homes. People think, “‘It’s just a cold and I’ll tough it out,'” he said. “And that needs to change.”
Price also became a factor. The federal government provided the five-day course of the drugs free of charge in the months following 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 drug doses at pharmacies, and the drug will be free through 2024 for Medicaid and Medicare patients. But in recent weeks, officials have turned the drug’s distribution over to Pfizer, which has priced it at about $1,400 a shot, though private insurers are expected to cover some of the price and Pfizer is offering assistance with the ticket.
No studies have examined the effect of transfer. The NIH study period ended early last year. Wide regional variation in the use of Paxlovid has been found, with approximately 50% of eligible patients receiving the drug in Utah and the Northeastern and Northwest regions of the United States. However, rates have fallen to near zero in Southeastern states and parts of the lower Midwest.
Dr. Fessel, of the NIH, said he would be curious to see whether concerns about the so-called Paxlovid rebound contributed. The fear is that the drug initially alleviates the 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” between Paxlovid use and Covid relapse. Studies show that rebound can occur even without treatment.
Denis Nash, a professor of epidemiology at the City University of New York, has also studied the use of Paxlovid. In a much smaller study, his team also found that drug absorption was nearly 14%, although lower among some, including 7% among people of color and nearly 11% among those with 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, with about 80% of respondents saying they knew it was available.
However, respondents showed a lack of recognition of their own risk: only about a third of people over the age of 65 consider themselves at high risk of severe Covid, even though the CDC considers everyone in that age group to be at high risk. age. The result was similar for patients with asthma or diabetes, although half of the overweight or obese patients recognized their risk.
“People don’t necessarily perceive themselves at risk,” Dr. Nash said.
Another recent study found that taking Paxlovid very early, or on the first day symptoms appear, improves your chances of surviving or avoiding hospitalization, compared to taking the drug a day or two later .
The studies also looked at the use of another antiviral drug, molnupiravir, made by Merck, which was less effective and is 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 yet another antiviral option, ensitrelvir, from the Shionogi company that also appears to shorten the duration of the disease.
Researchers also reported low use of Paxlovid in nursing homes, given the risk patients face of serious illness or death. Around one in four care home residents will have received an antiviral prescription to treat Covid by the end of 2022, a study found. The data showed the rate rose to closer to a third of care home residents by May 2023, said one study author, Brian McGarry, an assistant professor of medicine at the University of Rochester.
Federal officials subsequently stopped asking questions about Paxlovid use in their weekly Covid questionnaire in nursing homes.
“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, in addition to influenza.”