A new variant of the coronavirus is circulating, the most transmissible to date. Hospital admissions of infected patients are increasing. And older adults represent nearly 90% of US deaths from Covid-19 in recent months, the most since the pandemic began.
What does that mean for people 65 and older who are catching Covid for the first time or going through a repeat infection? The message from infectious disease experts and geriatricians is clear: find a treatment with antiviral therapy that remains effective against new Covid variants.
The therapy of choice, experts said, is Paxlovid, an antiviral treatment for people with mild to moderate Covid who are at high risk of becoming seriously ill from the virus. All adults age 65 and older fall into that category. If people cannot tolerate the medication – potential complications with other medications should be carefully assessed by a medical provider – two alternatives are available.
“There is a lot of evidence that Paxlovid can reduce the risk of catastrophic events that may follow infection with Covid in older individuals,” said Dr. Harlan Krumholz, professor of medicine at Yale University.
In the meantime, develop a plan for what you will do if you get Covid. Where will you seek care? What if you can’t get to your doctor quickly, a common problem? You must act quickly, as Paxlovid should be started no later than five days after the onset of symptoms. Do you need to adjust your medication regimen to protect against potentially dangerous drug interactions?
“The time to figure all this out is before you get Covid,” said Dr. Allison Weinmann, an infectious disease expert at Henry Ford Hospital in Detroit.
Being prepared proved essential when I got Covid in mid-December and went to the emergency room for a prescription. Because I am 67, have blood cancer and have an autoimmune disease, I am at increased risk of becoming seriously ill from the virus. But I take a blood thinner that can have life-threatening interactions with Paxlovid.
Fortunately, the ER was able to see my electronic medical record, and a doctor’s note there said it was safe for me to stop the blood thinner and get the treatment. (I consulted my oncologist beforehand.) So I walked away with a Paxlovid prescription, and within a day my headaches and chills were gone.
Just before I got Covid, I read a major study of nearly 45,000 patients ages 50 and older who were treated for Covid between January and July 2022 at Mass General Brigham, a major health system in Massachusetts. Twenty-eight percent of patients were prescribed Paxlovid, which received emergency use authorization from the FDA in December 2021 for mild to moderate Covid; 72% were not. All were ambulatory.
In contrast to other studies, most patients in this study were vaccinated. Still, Paxlovid offered a remarkable benefit: those who took it were 44% less likely to be hospitalized with serious Covid-related illnesses or die. In those who received fewer than three vaccine doses, those risks were reduced by 81%.
A few months earlier, a study from Israel had confirmed the efficacy of Paxlovid – the brand name for a combination of nirmatrelvir and ritonavir – in seniors infected with the omicron strain of Covid, which emerged in late 2021. (The original study that determined Paxlovid’s effectiveness had been conducted while the delta strain was widespread and included only unvaccinated patients.) In patients age 65 and older, most of whom had been vaccinated or had previously had Covid, hospitalizations at 73% and deaths at 79%.
Still, several factors have hindered the use of Paxlovid in older adults, including physicians’ concerns about drug interactions and patients’ concerns about possible “rebound” infections and side effects.
Dr. Christina Mangurian, vice dean for faculty and academic affairs at the University of California-San Francisco School of Medicine, encountered several of these issues when both her parents contracted Covid in July, an episode she chronicled in a recent JAMA article.
First, her father, 84, was told in a virtual medical appointment by a doctor he didn’t know he couldn’t take Paxlovid because he’s on a blood thinner – a decision that was later reversed by his GP. Then, in a separate virtual appointment, her mother, 78, was told to take an antibiotic, steroids and over-the-counter medication instead of Paxlovid. Again, her GP stepped in and offered a prescription.
In both cases, Mangurian said, the doctors who first saw her parents seemed to misunderstand who should receive Paxlovid and under what conditions. “This points to a major gap in how information about this therapy is being disseminated to frontline medical providers,” she told me in a phone call.
Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, agrees. “Every day I hear from people who have been misinformed by their doctor or the call-in nurses’ line. They are generally told that you cannot get Paxlovid until you are seriously ill – which is the exact opposite of what is recommended. Why aren’t we doing more to educate the medical community?”
The potential for drug interactions with Paxlovid is a major concern, especially in elderly patients with multiple medical conditions. More than 120 medications have been flagged for interactions, and each case must be evaluated taking into account an individual’s condition, as well as kidney and liver function.
The good news, experts say, is that most potential interactions can be managed, either by temporarily stopping a medication while taking Paxlovid or by lowering the dose.
“It takes a little extra work, but there are resources and systems that can help doctors figure out what to do,” says Brian Isetts, a professor at the University of Minnesota College of Pharmacy.
In nursing homes, patients and families should ask to speak to consultant pharmacists if they are told antiviral therapy is not recommended, Isetts suggested.
According to dr. Scott Dryden-Peterson, medical director of Covid outpatient therapy for Mass General Brigham, about 10% of patients cannot take Paxlovid due to potential drug interactions. For them, Veklury (remdesivir), an antiviral infusion therapy administered for three consecutive days, is a good option, although sometimes difficult to arrange. Also, Lagevrio (molnupiravir), another antiviral pill, can help shorten the duration of symptoms.
Many older adults worry that after taking Paxlovid they will get a rebound infection – a sudden flare-up of symptoms after the virus seems to have run its course. But in the vast majority of cases, “the rebound is very mild and the symptoms — usually runny nose, nasal congestion and sore throat — resolve within a few days,” said Dr. Rajesh Gandhi, an infectious disease physician and professor of medicine at Harvard Medical School.
Gandhi and other doctors I spoke to said the risk of failing to treat Covid in older adults far exceeds the risk of rebound disease.
Side effects of Paxlovid include a metallic taste in the mouth, diarrhoea, nausea and muscle aches, but serious complications are uncommon. “Consistently, people tolerate the drug very well,” says Dr. Caroline Harada, an associate professor of geriatrics at the University of Alabama-Birmingham Heersink School of Medicine, “and feel better quickly.”