Patient with COVID-19 on Paxlovid (nirmatrelvir/ritonavir) has lost voice and sore throat since Thursday without fever; what management and supportive care are recommended?

Management of COVID-19 Patient on Paxlovid with Voice Loss and Sore Throat

Continue the Paxlovid as prescribed for the full 5-day course and provide supportive care for the laryngitis symptoms, as voice loss (laryngitis) is a common upper respiratory manifestation of COVID-19 that does not contraindicate antiviral therapy. 1

Paxlovid Continuation

• Complete the full 5-day course of nirmatrelvir/ritonavir (300 mg/100 mg twice daily) regardless of symptomatic improvement, as early discontinuation may increase risk of viral rebound and the medication must be taken for the entire duration to achieve optimal efficacy 1, 2

• The patient appropriately received Paxlovid since they were within the 5-day window from symptom onset (started Thursday, went to urgent care presumably within days), which is the critical treatment window 1, 2

• Do not stop Paxlovid due to voice loss or sore throat, as these are expected COVID-19 symptoms that the antiviral is treating, not adverse effects of the medication 3, 1

Supportive Care for Voice Loss and Sore Throat

Voice Rest and Laryngitis Management

• Advise complete voice rest or minimal voice use to allow vocal cord inflammation to resolve, as laryngitis is a common manifestation of viral upper respiratory infections including COVID-19 3

• Encourage the patient to communicate through writing, texting, or whispering minimally rather than forcing voice production

• Explain that voice loss typically resolves within 1-2 weeks as the viral infection clears, and the Paxlovid will help accelerate viral clearance 1

Sore Throat Relief

• Recommend paracetamol (acetaminophen) for throat pain and any associated fever, as this is preferred over NSAIDs for COVID-19 patients until more safety data is available 3

• Advise regular fluid intake to maintain hydration and soothe the throat, but limit to no more than 2 liters per day to avoid overhydration 3

• Consider honey (for patients over 1 year old) as a simple, effective measure for throat irritation and associated cough 3

• Warm salt water gargles may provide symptomatic relief for sore throat

Positioning and Breathing

• Encourage the patient to avoid lying flat on their back, as this position makes coughing ineffective and can worsen respiratory symptoms 3

• Recommend sitting upright or leaning forward with arms bracing a surface, as these positions improve ventilatory capacity and reduce airway obstruction 3

Monitoring for Complications

Red Flags Requiring Urgent Reassessment

• Monitor for progression to severe breathlessness, chest pain, confusion, or inability to maintain hydration, as these indicate potential progression to severe COVID-19 requiring hospitalization 3

• Be aware that older patients or those with comorbidities, frailty, or impaired immunity are at higher risk of developing severe pneumonia that could lead to respiratory failure 3

• Watch for signs of secondary bacterial infection, though co-infections are uncommon (occurring in <5% of COVID-19 cases) 3

Paxlovid-Specific Monitoring

• Counsel the patient about common Paxlovid side effects including dysgeusia (altered taste) and diarrhea, which occur more frequently than placebo but rarely require discontinuation 2

• If the patient is on any chronic medications, ensure drug-drug interactions were checked using the Liverpool COVID-19 Drug Interaction Tool before Paxlovid was prescribed, as ritonavir is a potent CYP3A4 inhibitor 2, 4, 5

• For patients with renal impairment (eGFR 30-60 mL/min), verify the dose was appropriately reduced to 150 mg nirmatrelvir with 100 mg ritonavir twice daily 2

Symptom Rebound Awareness

• Inform the patient that approximately 10-33% of patients may experience symptom rebound after completing the standard 5-day course, though this does not indicate treatment failure 6

• If rebound occurs (typically 2-8 days after completing treatment), symptoms are generally mild and self-limited, though the patient should contact their provider for reassessment 6

• Some evidence suggests extended courses (7-8 days) may reduce rebound frequency, but this is not currently standard practice and should only be considered in consultation with infectious disease specialists 6

Isolation and Infection Control

• The patient must continue isolation per public health recommendations during and after Paxlovid treatment, as the medication treats the infection but does not immediately eliminate infectiousness 2

• Advise the patient to isolate for at least 5 days from symptom onset and until fever-free for 24 hours without antipyretics, with continued precautions through day 10 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for sore throat and voice loss in COVID-19, as bacterial co-infection is rare (<5% of cases) and antibiotics should only be used if there is clear evidence of bacterial superinfection 3

• Do not use corticosteroids routinely for COVID-19 symptoms unless the patient develops severe disease requiring hospitalization, as steroids may exacerbate viral infection in mild-to-moderate cases 3

• Do not recommend NSAIDs as first-line therapy for symptom relief; paracetamol is preferred until more safety data on NSAIDs in COVID-19 is available 3

• Do not stop Paxlovid early even if symptoms improve, as the full 5-day course is necessary to prevent viral rebound and ensure optimal outcomes 1, 2