Many people shared experiences in which doctors told them they only needed the medication if their symptoms became severe. Daniel from Maryland, who is 82 and on immunosuppressing drugs, wrote: “My wife got covid, and then I tested positive a few days later. I only had a headache and sore throat, but while our doctor gave her Paxlovid because she was coughing, he told me I didn’t need it. I ended up telling him I had a cough just so that I could get the medicine. Was this the right thing to do?”
I hate to tell people that they should exaggerate their symptoms to their health-care providers, but Daniel did the right thing because he needed the prescription. Getting Paxlovid shouldn’t hinge on severity of symptoms. Rather, it should be based on the likelihood of the individual becoming seriously ill.
That’s because Paxlovid works by stopping viral replication. It is most effective when given early in the course of illness. In fact, it is not administered when someone is ill enough to require hospitalization.
If a patient had a bacterial infection, it’s not reasonable to withhold antibiotics until the infection worsens. This should be no different for patients vulnerable to severe covid.
Daniel should have been given Paxlovid based solely on his age, not to mention his immunocompromised status. He shouldn’t have to report a specific symptom and definitely shouldn’t wait until he becomes sicker. He should be prescribed the antiviral after testing positive to prevent disease progression.
Patients with reluctant providers can refer them to the National Institutes of Health’s coronavirus treatment guidelines, which unambiguously state that for high-risk individuals like Daniel, “treatment should be initiated as soon as possible and with 5 days of symptoms onset.”
Dru from Texas is 76 and also has autoimmune conditions. “I recently tested positive for covid and decided to take Paxlovid, which I obtained from an urgent-care doctor after being told ‘you don’t need it, you’ll be better without it’ by a CVS physician’s assistant. Three days after finishing it, I still tested positive and wanted to get a second course, but because I saw many articles stating that this would not be possible, I didn’t pursue it. Did I make the wrong decision?”
No, Dru didn’t. Research from the Centers for Disease Control and Prevention indicates that about half of infected people still test positive five to nine days after diagnosis. What Dru is experiencing is normal, and a second course is not needed.
A second course is also not recommended for people with “rebound” symptoms, such as Nancy from Colorado. “I took Paxlovid and felt better. Then, five days later I had the same symptoms of cough and congestion again. My doctor said I didn’t need it the second time around. I didn’t end up getting it. Should I have pushed harder?”
Nancy’s doctor was right. A recurrence of covid symptoms within a week or two of initial infection is common, both for patients who received Paxlovid and those who did not. The second time is unlikely to result in severe illness, and Paxlovid is not authorized for this purpose, though there might be circumstances in which it is prescribed. (Recall that Anthony S. Fauci, President Biden’s former chief medical adviser, received a second course of the antiviral when he developed rebound symptoms.)
This is a different from the situation raised by Karen from Washington: “Is there any issue with taking Paxlovid repeatedly if you are infected with covid multiple times in the course of a year?”
Assuming that someone has separate infections, it should not be a problem to take Paxlovid in each instance. Indeed, two or more infections in a year could become the norm for some people, given the prevalence and transmissibility of the coronavirus.
“You have talked about getting a ‘just in case’ prescription for Paxlovid from your physician,” Ivy Marie from New York wrote. “My doctor did this for me because we are going on a cruise soon. When I went to fill the prescription at the pharmacy, the pharmacist told me that this was insurance fraud. Is it?”
Does your pharmacist think that it’s insurance fraud to dispense an inhaler in case an asthmatic needs it? What about prescribing antibiotics in case someone with frequent sinusitis develops a bout of the infection? Perhaps this pharmacist is not aware that Paxlovid is no longer authorized under emergency use and instead has the same approval status as other medications. In any case, you could go to another pharmacy to get this “just in case” prescription filled.
Just as there is variation in practice among pharmacists, physicians have different views on the medication. “When my husband (age 68) got covid the first time, he was prescribed Paxlovid,” Martha from Massachusetts wrote. “When he got it a second time about six months later, doctors and pharmacists said Paxlovid could not be prescribed twice, so he couldn’t get it. But his sister who lives in Pennsylvania was able to get it both times she had covid. Can you explain this?”
The explanation goes back to why there are so many questions about the topic from readers, and why I’m writing another column to address it: There is widespread misunderstanding within the medical community about appropriate uses of Paxlovid. The federal government and state boards of medicine must do a better job providing up-to-date guidance to health-care providers. In the meantime, patients must take a proactive approach and advocate coronavirus treatment.
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