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If you’re an immunocompromised patient, you recognize just how important it is to have every mechanism of defense you can against COVID-19. A common treatment is Paxlovid, an antiviral pill that can be prescribed to those high-risk for severe COVID-19.
Its importance is underscored by the fact that Evusheld, a preventive antibody treatment for the infection, is no longer recommended due to its declining efficacy against new variants.
However, some patients have reported doctors not prescribing Paxlovid due to potential side effects or contraindications (circumstances that suggest the drug shouldn’t be used). As with all things, it’s critical to be as informed as possible about your options and to know when it’s worth seeking a second medical opinion.
“There are really very few reasons why doctors should not be prescribing Paxlovid to patients at risk,” says Jeffrey D. Klausner, MD, MPH, Clinical Professor of Medicine, Population, and Public Health Sciences in the Keck School of Medicine of the University of Southern California. “There’s even some data — not the strongest data, but some — suggesting that shortening the duration of infection with Paxlovid may reduce the likelihood of long COVID.”
You should speak to your doctor about Paxlovid because it’s highly likely they’ll prescribe it to you if you’re infected with COVID-19 and are immunocompromised or over the age of 65. However, here are five reasons why you might not be prescribed Paxlovid.
1. Allergic Reactions
Just like with the COVID-19 vaccine, your doctor will consider if you have any allergies to the ingredients used in Paxlovid. According to the U.S. Food and Drug Administration (FDA), contraindications to this drug include a history of clinically significant hypersensitivity reactions to the active ingredients (nirmatrelvir and ritonavir) or any other components.
As with many other medications, anaphylaxis and other hypersensitivity reactions have been reported even after a single dose of Paxlovid, but they’re rare. Tell your doctor if you’ve experienced any allergic reactions to medication before.
You should stop taking Paxlovid and alert your physician at the first sign of a skin rash, hives or other skin reactions, difficulty with swallowing or breathing, swelling (i.e. of the lips, tongue, face, throat, etc.), or any other symptoms of an allergic reaction, per the FDA.
2. Drug Interactions
Your doctor may tell you that Paxlovid could interfere with a medication you take, but in most cases, this won’t rule out the antiviral pill.
“Some of the more common ones are anticoagulants [blood thinners] like rivaroxaban or apixaban, common blood pressure medications like amlodipine, and some other medications like statins that should be held,” says Alexander R. Peck, DO, a rheumatologist at Pacific Arthritis Care Center in Los Angeles.
In cases like this, your doctor may recommend reducing the dose of your medication. However, among the top 100 prescribed drugs, only two — rivaroxaban and salmeterol (an asthma and COPD medication) — have interactions so severe that Paxlovid should be avoided altogether, per the Infectious Diseases Society of America.
“Common medications like anti-cholesterol drugs can safely be stopped for seven to 10 days,” says Dr. Klausner. “Many people can also have blood thinners stopped for a few days.”
Generally, Paxlovid does not interfere with medications commonly used in the treatment of arthritis. The Infectious Disease Society of America does note that Paxlovid may cause increased toxicity of oral steroids, but in this case, your doctor can consider reducing the dose. (No other specific adjustments are recommended.)
“The real frequency of drug-to-drug interactions is very low and, from a public health perspective, it’d be much, much better to get more people treated with Paxlovid than worry about the rare drug-drug interactions,” says Dr. Klausner.
3. Underlying Conditions
In addition to the medication you take, certain underlying conditions may prevent your doctor from prescribing you Paxlovid.
“Paxlovid does need to be metabolized in the kidneys, so I wouldn’t use it if someone has renal impairment or kidney dysfunction,” says Dr. Peck. Paxlovid is also not recommended for those with severe liver impairment, since safety data is not available for these patients, per the FDA.
4. Side Effects
It’s possible your doctor may take into account potential adverse reactions of Paxlovid, such as altered taste, diarrhea, hypertension, and muscle pain — but most of these are quite rare and don’t outweigh the benefits of the drug.
“Paxlovid is a very safe medication,” says Dr. Klausner. “The only common side effect is a metallic taste, which goes away after people stop taking the medication.”
5. COVID-19 Severity
If you’re extremely sick with COVID-19, Paxlovid won’t be the right fit for you.
“The current emergency use authorization is only for mild to moderate COVID-19 in the outpatient setting,” says Dr. Peck. “It shouldn’t be used for someone who’s hypoxic [not getting enough oxygen] or who has severe COVID and needs emergency evaluation or hospitalization.”
In this case, a more common treatment route is remdesivir (an intravenous antiviral drug) or dexamethasone (a glucocorticoid medication that reduces inflammation) plus remdesivir, per the National Institutes of Health.
When to Seek a Second Opinion
There may be a number of other, less common reasons a doctor may not prescribe Paxlovid. It’s important to ask for the reasons why and seek a second opinion if needed.
“I could speculate that some doctors might think that if people clear the infection on their own, their post-infection immunity might be stronger, but that hasn’t been proven,” says Dr. Klausner. “There’s no benefit to ‘riding it out’ in anticipation of better immunity.”
You also shouldn’t be denied Paxlovid because of Omicron. Research shows that it’s still effective: In a December 2022 study of nearly 45,000 non-hospitalized adults aged 50 years or older who contracted COVID-19 during the Omicron wave, those who received a Paxlovid prescription were 44 percent less likely to be hospitalized or die from the infection than those who did not. Those who were incompletely vaccinated and took Paxlovid had an 81 percent lower risk.
Although the study didn’t look at Paxlovid’s efficacy against the most recent circulating variants (the research was conducted from January 1, 2022 to July 17, 2022), experts still believe it’s effective — “especially at reducing the progression to severe disease and decreasing hospitalization, which are the main reasons to take it,” says Dr. Peck.
It’s best to speak to your doctor about a Paxlovid game plan before you get infected. If they say they wouldn’t prescribe you Paxlovid and you don’t fully understand the reasons why, speak to a second physician.
“If it’s safe for you to get the medication as a high-risk patient and your doctor doesn’t want to prescribe it, you need to find another doctor,” says Dr. Klausner. “Doctors should be looking out for the best interest of their patients. By potentially denying people safe and effective medication, they’re not doing that.”
If there are valid circumstances that are giving your doctor pause when it comes to prescribing you Paxlovid, talk to your doctor about another option for an antiviral pill for COVID-19.
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Dryden-Peterson S, et al. Nirmatrelvir Plus Ritonavir for Early COVID-19 in a Large U.S. Health System. Annals of Internal Medicine. December 13, 2022. doi: https://doi.org/10.7326/M22-2141.
Fact Sheet for Healthcare Providers: Emergency Use Authorization for Paxlovid™. U.S. Food and Drug Administration. September 26, 2022. https://www.fda.gov/media/155050/download.
Important Prescribing and Dispensing Information. Pfizer. August 5, 2022. https://www.fda.gov/media/155071/download.
Interview with Alexander R. Peck, DO, a rheumatologist at Pacific Arthritis Care Center in Los Angeles
Interview with Jeffrey D. Klausner, MD, MPH, Clinical Professor of Medicine, Population, and Public Health Sciences in the Keck School of Medicine of the University of Southern California
Management of Drug Interactions With Nirmatrelvir/Ritonavir (Paxlovid®): Resource for Clinicians. Infectious Diseases Society of America. May 6, 2022. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/management-of-drug-interactions-with-nirmatrelvirritonavir-paxlovid/.
Table 2b. Therapeutic Management of Hospitalized Adults With COVID-19. COVID-19 Treatment Guidelines. National Institutes of Health. August 8, 2022. https://www.covid19treatmentguidelines.nih.gov/tables/therapeutic-management-of-hospitalized-adults/.