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Paxlovid under-prescribed?

Sounds like a great tool for high-risk COVID sufferers. BTW, the statement that COVID is linked to hundreds of deaths a day appears increasingly misleading.

Unnecessary deaths

By German Lopez, NY Times

Covid is still linked to hundreds of deaths a day in the U.S. We have a treatment that could bring down those deaths: a prescribed pill called Paxlovid, which reduces the severity of a Covid infection, particularly among older and more vulnerable Americans.

Yet that treatment remains underused. Doctors prescribed it in about 45 percent of recorded Covid cases nationwide during the first two weeks of January, according to White House data. In some states, Paxlovid is given in less than 25 or even 20 percent of recorded cases. (Those are likely overestimates because cases are underreported.)

Why is Paxlovid still relatively untapped? Part of the answer lies in a lack of public awareness. Some Covid patients also may decide that they don’t need Paxlovid because they are already vaccinated, have had Covid before or are younger. (My colleagues explained why even mild cases often still warrant a dose of Paxlovid.) The political polarization of the virus plays a role, too: People in blue states are more likely to use Paxlovid than in red states.

Experts have increasingly pointed to another explanation for Paxlovid’s underuse: Doctors still resist prescribing it. Today’s newsletter will focus on that cause.

Physician resistance

Some doctors have concerns that are rooted in real issues with Paxlovid and inform their reluctance to prescribe it. But experts are unconvinced that those fears are enough to avoid prescribing Paxlovid altogether, especially to older and higher-risk patients.

“What I’m doing for a living is weighing the benefits and the risks for everything,” said Dr. Robert Wachter, the chair of the medicine department at the University of California, San Francisco. In deciding whether to prescribe Paxlovid, he said, the benefits significantly outweigh the risks.

Some of doctors’ doubts will sound familiar to regular readers of this newsletter. The medication is relatively new (in a field that typically takes years to adopt new treatments). They worry about side effects, including diarrhea, muscle pain and an altered sense of taste. They also point to “rebound” Covid cases, which can cause symptoms to come back after subsiding, as happened to Dr. Anthony Fauci and President Biden after they took Paxlovid. (Although Covid symptoms can rebound without Paxlovid.)

Doctors also sometimes believe that a patient is not sick enough to prescribe Paxlovid. But the point of Paxlovid is to prevent Covid from getting severe. The medication works best when prescribed in the first few days after a patient shows symptoms, so a doctor does not have time to wait to see how bad an infection gets.

Another concern topped a recent survey of medical professionals by the health care website Medscape: potential interactions between Paxlovid and a long list of other drugs. Doctors might see that their patients are on one of those medications and choose not to prescribe Paxlovid.

That justification is especially concerning to experts because it is more likely to be used to deny Paxlovid to older patients and those with other health conditions, since they are more likely to be on multiple medications. But these two groups are also among the most vulnerable to Covid hospitalization and death.

To avoid harmful drug interactions, experts said, doctors can temporarily get a patient off a medication or provide an alternative during a course of Paxlovid — something they already often do with other treatments. “This is not some extraordinary thing that physicians don’t know how to do,” said Dr. Ashish Jha, the White House Covid response coordinator.

Only two of the 100 most prescribed medications, rivaroxaban (typically prescribed for blood clots) and salmeterol (for lung disease), produce interactions so severe that Paxlovid should be avoided altogether, according to the Infectious Diseases Society of America.

Some doctors would also like to see more evidence for Paxlovid. The arc of Covid has changed since Paxlovid started rolling out by early 2022, with more widespread vaccinations and the emergence of new variants. Some physicians want data demonstrating which patients still benefit from the drug, said Dr. Lindsay Petty, an infectious disease doctor at the University of Michigan.

Wachter agreed that more data would be good, but argued that the existing studies show convincing evidence of Paxlovid’s benefit. “If you’re an impartial reader and sit down to look at the research and compare it to other research we used to decide people should take statins or have their blood pressure treated, Paxlovid feels like it’s in the same category,” he said.

Breaking through

The White House and health organizations are working to get more physicians to prescribe Paxlovid. They have made some progress in increasing use and closing gaps based on race and class, Jha said.

But with Covid still tied to hundreds of deaths and thousands of hospitalizations a day, those advances are slower than anyone would like. As with vaccines and boosters, it’s hard to see what will get more Americans to embrace one of the most effective treatments we have for Covid.

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