When should Paxlovid (nirmatrelvir/ritonavir) be initiated in an elderly patient with a cardiac condition and asthma diagnosed with COVID-19?

From the Guidelines

Paxlovid should be initiated as soon as possible after COVID-19 diagnosis in an elderly patient with cardiac conditions and asthma, ideally within 5 days of symptom onset. The standard adult dosage is nirmatrelvir 300 mg (two 150 mg tablets) with ritonavir 100 mg (one tablet), taken together twice daily for 5 days. Dose adjustment is necessary for patients with moderate renal impairment (eGFR 30-60 mL/min), reducing to nirmatrelvir 150 mg with ritonavir 100 mg twice daily. Paxlovid is particularly beneficial for this patient population as elderly individuals and those with underlying conditions like cardiac disease and asthma face higher risks of severe COVID-19 outcomes, as noted in studies such as 1. The medication works by inhibiting viral replication, reducing viral load and potentially preventing progression to severe disease.

Before initiating treatment, a thorough medication review is essential as ritonavir can interact with many cardiac medications, including certain statins, antiarrhythmics, and anticoagulants, as discussed in 1. Some medications may need temporary discontinuation or dose adjustment during the 5-day Paxlovid course. Patients should be monitored for side effects including altered taste, diarrhea, increased blood pressure, and muscle aches. It's also important to consider the management of cardiovascular conditions during the COVID-19 pandemic, as outlined in studies like 1 and 1, which provide guidance on the care of patients with acute myocardial infarction and other cardiovascular conditions during this time.

Key considerations for the management of elderly patients with cardiac conditions and asthma include:

• Close monitoring for signs of cardiac complications, such as myocarditis or arrhythmias, as discussed in 1
• Adjustment of medications as needed to minimize interactions with Paxlovid, as noted in 1
• Management of asthma symptoms and potential exacerbations, taking into account the patient's underlying condition and the potential impact of COVID-19 on respiratory function. Overall, the initiation of Paxlovid in elderly patients with cardiac conditions and asthma should be guided by the principles of minimizing morbidity, mortality, and improving quality of life, as supported by the most recent and highest quality evidence, such as 1.

From the FDA Drug Label

The 5-day treatment course of PAXLOVID should be initiated as soon as possible after a diagnosis of COVID-19 has been made, and within 5 days of symptom onset even if baseline COVID-19 symptoms are mild

• Initiation of Paxlovid: The treatment course should be started as soon as possible after COVID-19 diagnosis and within 5 days of symptom onset.
• Considerations for Elderly Patients with Cardiac Conditions and Asthma:
  • Before prescribing Paxlovid, review all medications to assess potential drug-drug interactions with a strong CYP3A inhibitor like Paxlovid.
  • Determine if concomitant medications require a dose adjustment, interruption, and/or additional monitoring.
  • 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.
• Key Consideration: Paxlovid is indicated for the treatment of mild-to-moderate COVID-19 in adults at high risk for progression to severe COVID-19, including hospitalization or death 2.

From the Research

Timing of Paxlovid Initiation in Elderly Patients with Cardiac Conditions and Asthma

• The ideal timing for initiating Paxlovid (nirmatrelvir/ritonavir) in elderly patients with cardiac conditions and asthma diagnosed with COVID-19 is within 5 days of symptom onset, as indicated by studies 3, 4, 5, 6, 7.
• A study published in 2024 found that Paxlovid treatment within 10 days of onset can shorten the disease course of COVID-19 by reducing the viral load 3.
• Another study from 2023 demonstrated that Paxlovid reduced the duration of hospitalization and viral shedding time in elderly patients with COVID-19, with no serious adverse events reported 4.
• A case report from 2022 showed that Paxlovid administration in an elderly patient with COVID-19 caused by the Omicron BA.2.0 variant improved symptoms and prevented severe disease 6.
• A systematic review and meta-analysis published in 2024 found that Paxlovid significantly reduced hospitalization, all-cause mortality, and intensive care unit admission in COVID-19 patients, with a shorter hospital length of stay and polymerase chain reaction negative conversion time compared to the control group 7.

Considerations for Elderly Patients with Cardiac Conditions and Asthma

• Elderly patients with cardiac conditions and asthma may be at higher risk for severe COVID-19 and may benefit from early initiation of Paxlovid 4, 5, 6.
• The presence of comorbidities, such as cardiac conditions and asthma, should be taken into account when deciding on the timing of Paxlovid initiation 4, 5.
• Close monitoring of patients with cardiac conditions and asthma is recommended during Paxlovid treatment to minimize potential adverse events 4, 6.