Should I use Paxlovid (nirmatrelvir/ritonavir) for COVID-19 (Coronavirus disease 2019)?

From the Guidelines

Paxlovid (nirmatrelvir/ritonavir) should be considered for the treatment of symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease. According to the most recent evidence from the Annals of Internal Medicine 1, the use of nirmatrelvir–ritonavir combination therapy is supported for the treatment of COVID-19 in high-risk individuals.

Key Points to Consider

• Paxlovid is most effective when started within 5 days of symptom onset.
• The standard regimen is two tablets of nirmatrelvir and one tablet of ritonavir taken together, twice daily for 5 days.
• Paxlovid can significantly reduce the risk of hospitalization and death in high-risk individuals by blocking a key enzyme the virus needs to replicate, thus reducing viral load and disease severity.
• However, Paxlovid isn't for everyone, as it can interact with many common medications and isn't recommended for those with severe kidney or liver disease.

Important Considerations

• Your doctor will need to review your medical history and current medications before prescribing Paxlovid.
• If prescribed, be sure to complete the full 5-day course, even if you start feeling better.
• Continue to follow isolation guidelines as you can still transmit the virus to others while taking Paxlovid.
• The evidence from the Annals of Internal Medicine 1 supports the use of Paxlovid in high-risk individuals, but it is essential to consult with a doctor to determine if it's appropriate for you.

From the FDA Drug Label

PAXLOVID which includes nirmatrelvir, a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) main protease (Mpro: also referred to as 3CLpro or nsp5 protease) inhibitor, and ritonavir, an HIV-1 protease inhibitor and CYP3A inhibitor, is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death. Initiate PAXLOVID treatment as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset.

Paxlovid (nirmatrelvir/ritonavir) is indicated for the treatment of mild-to-moderate COVID-19 in adults at high risk for progression to severe COVID-19.

• The treatment should be initiated as soon as possible after diagnosis and within 5 days of symptom onset 2.
• It is essential to review all medications taken by the patient to assess potential drug-drug interactions with Paxlovid and determine if concomitant medications require a dose adjustment, interruption, and/or additional monitoring 2.
• Consider the benefit of Paxlovid treatment in reducing hospitalization and death, and whether the risk of potential drug-drug interactions for an individual patient can be appropriately managed 2.

From the Research

Effectiveness of Paxlovid in Treating COVID-19

• Paxlovid has been shown to reduce the risk of hospitalization and death among patients with mild to moderate COVID-19 who are at risk for progression to severe disease 3, 4, 5.
• Studies have found that Paxlovid is effective in preventing hospitalization and death, including among vaccinated patients, and particularly among older patients 4, 5.
• The real-world effectiveness of Paxlovid has been demonstrated in several studies, with estimates suggesting a reduction in hospitalization risk of 39% 4 and a reduction in mortality risk of 61% 4.

Safety and Adverse Events

• Paxlovid has been found to be safe and effective in treating COVID-19 patients, with no significant differences in reported adverse events between patients treated within 5 days of onset and those treated more than 5 days after onset 6.
• However, some studies have reported cases of COVID-19 rebound after Paxlovid treatment, which may require additional treatment 7.

Treatment Guidelines

• Paxlovid is recommended for early-stage treatment of mild-to-moderate COVID-19 in patients at increased risk of progression to severe COVID-19 3, 4, 5.
• The treatment should be initiated within 5 days of symptom onset, but some studies suggest that it may still be effective when started more than 5 days after onset 6.
• Patients who experience a COVID-19 rebound after Paxlovid treatment may require additional treatment, such as proxalutamide 7.

Patient Characteristics

• Paxlovid has been found to be more effective in older patients, immunosuppressed patients, and patients with underlying neurological or cardiovascular disease 4, 5.
• However, disparities in Paxlovid treatment rates have been observed, with lower rates among black and Hispanic or Latino patients, and within socially vulnerable communities 4.