To Paxlovid or Not?

Who benefits from the Covid antiviral drug Paxlovid, and how does it work?

Pam and Jon (who wish to remain anonymous for this story) are two former Chicagoans living in southern California. They took great care during the pandemic not to catch Covid-19. They masked, attended outdoor events only, and took all recommended shots and boosters.

But over Christmas 2022, their luck ran out; the couple tested positive for Covid. They contacted their respective doctors and asked about Paxlovid, the anti-viral emergency treatment for Covid. When their doctors prescribed it, Pam, 64, and Jon, 65, each took the recommended six pills daily, morning and evening, for five days. They recovered quickly, tested negative by the end of the medication’s course, and within a week resumed normal activities, albeit with masks.

But a few days later, Pam started to feel under the weather again. She retested for Covid, and discovered she had turned positive — again. She was in the throes of a rebound Covid infection and much sicker than before. “There was a few days’ window when I was feeling fine before I started getting symptoms again,” she says. “I didn’t want to believe that I was positive, so I think I tested three days in a row — all positive.”

What is Paxlovid?

Paxlovid, the current frontline treatment for Covid, is actually a combination of two drugs. “Paxlovid has two medications in it — one of which affects the virus and the other of which increases the level of that antiviral drug,” says Lisa Russell, MD, an infectious disease specialist at Sinai Chicago.

People need to start the treatment within five days of symptom onset — the earlier, the better.

The Food and Drug Administration (FDA) first approved Paxlovid under emergency authorization at the end of 2021, but in May, the FDA’s advisory committee voted to fully approve it for anyone over the age of 18 who is at high risk of severe illness and anyone with mild to moderate symptoms. As of July 2023, the government is still picking up the tab for Paxlovid, though eventually those who need it will have to go through insurance or fund the cost themselves.

Who needs Paxlovid?

During times when there are fewer Covid infections, as well as fewer Americans entering the hospital and dying of Covid, many wonder who should be taking this medication.

“You may not get much benefit if you’re fully vaxxed, healthy, and you don’t have other comorbidities. The likelihood that you’re going to be sick from this infection is low. On the other hand, if you have a fair amount of comorbidities, if you haven’t recently had a vaccine or a booster, you are increasing your risk of severe disease. At that point in time, it may make more sense for you to take the medication,” Russell says.

The Centers for Disease Control and Prevention (CDC) suggests that even healthy, vaccinated people without comorbidities or autoimmune issues benefit from Paxlovid if they are over age 65. However, if you take other medications, be sure to ask your doctor or pharmacist whether Paxlovid can interact with them. One common, unpleasant side effect is a strong metallic taste in your mouth during the course of the medication.

Another pro to consider: Paxlovid may decrease the likelihood of developing long Covid.

“It does seem like treatment with antivirals, whatever they are, limits people’s long Covid symptoms,” Russell says. She notes, however, that long Covid symptoms need to be better defined to truly study this issue.

Now that Paxlovid is widely available, Miranda Hart, MD, an internal medicine specialist and medical director with Erie Family Health Centers, says that places with high vaccination rates also tend to have more people taking Paxlovid.

In Hart’s experience, people ages 65 to 84 range tend to take Paxlovid more frequently. The rate goes down for people who are 85 or older, which has to do with the interactions that Paxlovid can have with other medications, Hart says. “It’s not an option for many people who are chronically ill with multiple medical problems, who are taking cardiac meds or things like that,” she says.

Gender plays a part, too. Hart says that about 58% of Paxlovid prescriptions go to women, although the reasons for that remain unclear. “It may be related to [their] interaction in the healthcare system and women’s willingness to take medication overall,” she says.

Pam, though, now wonders if the drug caused her rebound Covid. Russell says that even though Pam experienced a rebound Covid case, such cases have also happened to people who don’t take Paxlovid. More studies need to be done to determine whether the antiviral treatment contributes to them.

The FDA concurs. In one study, Covid symptoms recurred in people who had taken Paxlovid, as well as those who took placebos.

So what to do? Asked if they would take it if they contract Covid again, Pam and Jon answered simultaneously: “I would not,” Pam says. “I would,” Jon says.

As with most things Covid-related, more time — and more experience — will make things clearer.