A CT scan contains more than 12,000 free doses of baxlovid to treat COVID, but few people take it.  Here's why

A CT scan contains more than 12,000 free doses of baxlovid to treat COVID, but few people take it. Here’s why

Thousands of doses of free COVID antivirals are available in Connecticut. But few patients are prescribed medication.

According to Public Health Commissioner Manisha Gothani, who was approved earlier this year under an emergency use authorization, Pfizer’s Paxlovid and Moderna molnupiravir are the first outpatient treatments available to fight COVID.

“So far, all the treatments we’ve had that have developed over the past two years have been the things you have to be in the hospital to receive,” she said. “This is our first advance, and it’s an oral medication, people can go to the pharmacy and get it.”

Jothani said the drugs represent a shift in how the country is fighting the pandemic. While prevention remains critical, Jothani said it’s also important to keep hospitalizations low.

“The real impact is how this will affect the delivery of health care and our health care systems,” she said. “The end point is the number of people in hospital.”

When it was first approved, antiviral drugs were hard to come by. Recently, federal officials set up so-called test-to-treat sites where a patient can take a COVID test and, if positive, be prescribed treatment at the same site.

As of last week, federal authorities have sent 12,700 doses of Baxlovid and 20,612 doses of molnopiravir to Connecticut health care providers, including hospitals, pharmacies and urgent care centers. Medicines paid by the federal government are free to patients.

The problem is that few people take it. Doctors are reluctant to prescribe them, and patients, upon hearing about side effects, are reluctant to take them.

Both drugs are most effective if taken early in the course of the disease. Gothany said molnupiravir has fewer drug interactions, but is less effective. Paxlovid is considered more effective, but it has a large number of interactions with other drugs.

This has resulted in doctors, especially those in urgent care settings, being reluctant to prescribe them.

Drugs are lifesavers, according to Dr. Julian Neves III, MD and assistant professor at the University of Connecticut School of Medicine.

“It can be a life-saving treatment, especially with high-risk individuals,” he said, although he understands that reluctance. “Things happen so quickly that it takes some time for clinicians and the public to become comfortable with any new treatment regimen.”

Robert Wood of Shelton, for example, began experiencing cold symptoms on Good Friday. The home test was positive and his doctor’s office was closed, so he decided to get an antiviral from a local clinic.

“Participants did a polymerase chain reaction (PCR) test that was positive,” Wood said. “The doctor said she can’t prescribe an antiviral, and if my symptoms get worse, I should go to the ER. I developed symptoms at the age of 76. The doctor handed me an antiviral paper to educate me on whether I should go to the emergency room.”

Wood said he “felt like visiting this place was a lost trip.”

One Doctor’s Perspective

John Ianaroni used to work in a private practice, but is now semi-retired, working part-time in an urgent care center.

When it comes to COVID antivirals like Pfizer’s Paxlovid, a Monroe resident said he was “cautious” to prescribe them.

“Abuse is not the word. Just very careful,” he said. “I think a lot of clinicians are being careful, especially people in urgent care settings.”

The issue, he said, is drug interactions. Antivirals tend to interact negatively with many drugs–50 percent of commonly prescribed medications, by one estimate.

Outpatient doctors have no prior relationships with their patients, and those with a COVID infection may not remember all of their prescribed medications.

“The issue of interaction is the biggest problem,” he said. “The list of interactions is enormous.”

Another concern is side effects. While the vast majority of people tolerate antiviral medications well, there are a few who experience nausea and diarrhea.

Iannaron said he has heard of a small number of patients who, due to “vomiting and diarrhoea, had to be hospitalized for intravenous fluids because of the medication.”

A doctor cannot really predict which patient will experience significant side effects. Some suffer from dry mouth.

“If you don’t really know the patient, you certainly don’t want the treatment to be worse than the disease,” Yanaroni said.

It all hit the house when his mother, 95-year-old Elinor Ianaroni, started experiencing COVID symptoms.

“She’s had mild symptoms the whole time, and she’s feeling better now, just a little tired,” he said.

She was fully vaccinated and doubly boosted, but her doctor son wanted to be safe, so after a positive home test, Iannarones went to urgent care.

In the end, the elder Ianaroni did not take antiviral drugs.

“She’s taking medication, which could have interacted with baxlovid, and of course there was concern about side effects of nausea, vomiting and diarrhea,” John Yanaroni said. “My mom received monoclonal antibodies intravenously at the Saint Vincent ED Center.”

How does Baxiloid work

Xiaobo Zhong, professor of pharmacology and toxicology at Ocon University’s School of Pharmacy, and three doctoral students — Roxana Munshi, Giulia Migliorati and Jing Jin — explained that baxiloid is actually a combination of two things.

“Baxlovid has two components,” Jane said. “One is ritonavir and the other is nimatelvir.”

Nirmaterlvir is what actually fights the coronavirus. Ritonavir allows the body to better process the medication. The goal is for nirmatrilvir to reach the lung cells, where it fights the replication of the virus.

But your liver gets in the way, as it metabolizes nirmatelvir and flushes it out of the system. This is where ritonavir comes in. This drug is designed to “inhibit the metabolism of the liver” so that nirmatilvir can “get into the lung cell to help prevent infection with the virus,” Jane said.

But ritonavir affects an enzyme in the liver that many other drugs depend on, which means that “basically people have a reduced ability to metabolize a lot of other drugs that people commonly use.”

For example, if you are taking medicine to keep your blood sugar low, ritonavir can make it less effective.

Or the opposite may happen. Munshi said that some drugs “can reduce the effectiveness of the antiviral activity of baxlovid by decreasing its concentration in the blood serum.”

Your doctor may suggest that you stop taking the medicine for the five days while you are taking this medicine. But Zhong said “some drugs you can’t stop.” Some drugs, “when stopped immediately, cause withdrawal syndrome, and also make people feel very sick.”

Migliorati advised that patients not only talk to their doctors, but also pharmacists.

There are healthy levels of skepticism. “With so many Americans on different types of medication, it can make prescribing medication very complex and could potentially require a professional in many cases,” she said. “So I understand that hesitation.”

sick and then sick again

Kate Giannilli, of Trumbull, got COVID, was prescribed Paxlovid, felt better and then started getting sick again.

“After feeling a little better each day, I was exhausted all day Friday and just got back into the groove, but did the antigen test Friday night,” she said. “I was shocked when my COVID line showed up before the solution reached the line of control.”

Gothany said the patients in Giannelli’s case represent “a small subset of people whose symptoms go away. When they stop the medication, the symptoms come back.”

This reaction — a relapse of COVID after the five-day antiviral course — has been shown in clinical trials, but not initially published.

This is one reason patients are reluctant to take the drug, Jothani said.

“There are some people I’ve heard say, ‘Well, if this is going to happen, why bother taking it anyway? “

However, Giannelli said she was happy with the prescription, despite the return of symptoms.

“I still tested positive immediately and resumed isolation,” she said. “It’s very frustrating, but I’m still glad I took Baxlovid.”

Education value

Not all antivirals are left on the shelves.

“We’re seeing 55 percent of hospital-grade baxiloid being used,” Jothany said.

The difference is the level of comfort. The drugs used in Baxlovid have been known to HIV professionals for decades, and Gothany said it will take some time for the rest of the medical establishment to rest.

“Some of the people get comfortable and say, ‘Well, I can describe this. “They feel comfortable knowing how to do it,” she said.

Side effect stories may be exaggerated. Chung said the drug was “well tolerated,” and Jothany argued that it’s hard to know what the drug causes and what the virus causes.

“It’s a balance, isn’t it? Because people are vomiting from COVID. This is happening from COVID,” she said. We don’t know it’s the drug that does this, but people associate it that way. But we don’t know for sure, is that just the natural history of what’s going to happen to you anyway? “

For this reason, Jothany said, it is important for the state to educate clinicians and patients about the risks and benefits of COVID treatments. In the end, she said, it’s a matter of risk versus reward.

“I don’t think people should describe things they don’t feel comfortable describing, because their license is at stake, their name is at stake, and they should have a right to say, ‘I won’t describe,'” said Gothany. “Now, what I’m going to argue in this situation is, you can get relief, you can get an education. That’s what we’re trying to do. We’re trying to educate people. We’re trying to show them that it’s not scary.”

2022-05-08 11:31:30

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