4 ms·

Most of the interactions can be managed, but I think the message got out among primary care docs there are drug interactions and so they get scared to prescribe

by reureu 4y ago

Most of the interactions can be managed, but I think the message got out among primary care docs there are drug interactions and so they get scared to prescribe it. There are relatively few meds that are absolutely contraindicated, while there's a large list of meds that require some dose adjustment or holding the med for a few days. This is an issue with the ritonavir in the paxlovid, which has been extensively used in HIV treatment -- so, this isn't a new issue that we know nothing about. And then I've heard from too many patients their doctor doesn't think they need it because they're not that sick, so it's not worth managing the drug interactions. Unfortunately, paxlovid needs to be started within five days of symptom onset, but most patients aren't going to be hospitalized within those first five days. Given the lack of monoclonal antibodies, the potential mutagenic effect of molupiravir, and the less-than-steller impact of remdesivir... if I or someone I loved got covid, I'd be jumping on paxlovid since there aren't many other options right now.

nradov 4y ago
What if that someone you love is young and in good health? Paxlovid has some significant side effects and is only recommended for patients at high risk of severe COVID-19 due to advanced age or other risk factors. https://www.paxlovidhcp.com/ https://www.paxlovidhcp.com/
- MrMan 4y ago
  yeah people in my house hold are getting covid a couple of times a year and are constantly exposed to it at school and work and we are all vaccinated but dont take any other medications for covid.
- reureu 4y ago
  I think this is where many providers get mixed up. It's for "mild-to-moderate" COVID-19 (i.e., "you're not sick enough yet" isn't at play, because then you have "mild" covid which is exactly what paxlovid is indicated for) who are at "high risk for progression to severe COVID-19." According to the CDC, risk factors that make you at "high risk" include being over 50, having a mood disorder (including anxiety and depression), being obese or overweight, being physically inactive, being a current or former smoker, or having asthma: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html#anchor_1618433687270 https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/... Most Americans would check one of those boxes, even the healthy and young among us. And some of those (e.g., "physically inactive") are pretty ill-defined that you could argue even more fit in that category. Just saying you're anxious about covid outcomes should qualify you for paxlovid because anxiety is a risk factor. Many of the infectious disease doctors I work with think that paxlovid should be offered to virtually everybody because it seems to decrease your viral load (this could decrease the chance of onward transmission), there may be a decrease in risk of long covid, it may shorten your symptom duration, and there aren't many other treatment options if you get sicker. So, short of being on one of the medications that's absolutely contraindicated, their opinion is generally if you want paxlovid you should get it. So if your doctor is saying you don't need it or don't qualify, and you want to take it, I would find a different doctor or use a telemedicine provider.
victor9000 4y ago
The medical system in the US is optimized to get people in, bill them, and get them out; that's it. Managing drug interactions is a long tail process that requires critical thinking, which is not an incentiviced activity. Plenty of startups have failed thinking that they could succeed if their products resulted in improvements to quality of care.
- reureu 4y ago
  I dunno, the NIH literally suggests using this website to check for interactions: https://covid19-druginteractions.org/checker https://covid19-druginteractions.org/checker Managing drug interactions for paxlovid isn't much more complicated than inputting meds into a web form and looking at the color of the box that pops up after. I think most providers can handle that if they know these tools exist and get past the reflex of "paxlovid has drug interactions, you don't want to take it." Managing drug interactions is part of ordering medications, and if it's really taking that much time (i.e., the EHR isn't just doing all the work for you), then it'd result in a higher E&M code when it's billed out. Medication management, in some cases, can also be billed and reimbursed by the pharmacist. So, totally agree that the US medical system is optimized for billing. I don't think those of us in the US should be ok with that, and I don't think it's an excuse in this case to not prescribe paxlovid to patients who want it and would qualify for it.
  - victor9000 4y ago
    Sure, in the abstract it is straight forward, but you quickly run into data gaps when considering multiple medications. Particularly in the context of comorbidities.
shadowgovt 4y ago
> Most of the interactions can be managed By whom? Medical professionals are overwhelmed, so you can't hospitalize these patients to monitor their compliance. And this is, in the large, not a demographic you can trust for maximal patient compliance.
- reureu 4y ago
  By the medical professional who is prescribing paxlovid. When I wrote "can be managed", I mean the health care provider tells the patient to either stop taking their other meds for 5-7 days, to reduce the dose, or to look out for symptoms and call them if they have certain issues. Not be hospitalized to watch for side effects. You can look for yourself at the list of common meds, and the ones that are absolutely contraindicated are relatively few: https://www.covid19treatmentguidelines.nih.gov/therapies/antivirals-including-antibody-products/ritonavir-boosted-nirmatrelvir--paxlovid-/paxlovid-drug-drug-interactions/ https://www.covid19treatmentguidelines.nih.gov/therapies/ant... One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending. The patient and provider have aligned interests, it's just a matter of ensuring the provider is making sure the patient understands what's going on. The provider should be doing that in all of their encounters, so that's nothing specific to paxlovid.
  - shadowgovt 4y ago
    > One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending. I suspect you haven't worked with elderly patients. I help a relative manage his care. I keep having to hide the DayQuil so he doesn't take it alongside his arthritis medication and overdose on acetamenophin. He "knows" he's not supposed to, but it doesn't click when the pills are in his hand and his nose is running (because he took it for decades prior to the arthritis prescription and deeply-ingrained habits are not easily replaced). He definitely tells the doctor he understands, and the doctor believes him, but it's not like the doctor is in any way responsible for verifying that information. Drug interactions are way past the maximum complexity capacity of the median patient at high risk for death by COVID.
    - 4y ago

by reureu 4y ago

nradov 4y ago

What if that someone you love is young and in good health? Paxlovid has some significant side effects and is only recommended for patients at high risk of severe COVID-19 due to advanced age or other risk factors. https://www.paxlovidhcp.com/ https://www.paxlovidhcp.com/

MrMan 4y ago
yeah people in my house hold are getting covid a couple of times a year and are constantly exposed to it at school and work and we are all vaccinated but dont take any other medications for covid.
reureu 4y ago
I think this is where many providers get mixed up. It's for "mild-to-moderate" COVID-19 (i.e., "you're not sick enough yet" isn't at play, because then you have "mild" covid which is exactly what paxlovid is indicated for) who are at "high risk for progression to severe COVID-19." According to the CDC, risk factors that make you at "high risk" include being over 50, having a mood disorder (including anxiety and depression), being obese or overweight, being physically inactive, being a current or former smoker, or having asthma: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html#anchor_1618433687270 https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/... Most Americans would check one of those boxes, even the healthy and young among us. And some of those (e.g., "physically inactive") are pretty ill-defined that you could argue even more fit in that category. Just saying you're anxious about covid outcomes should qualify you for paxlovid because anxiety is a risk factor. Many of the infectious disease doctors I work with think that paxlovid should be offered to virtually everybody because it seems to decrease your viral load (this could decrease the chance of onward transmission), there may be a decrease in risk of long covid, it may shorten your symptom duration, and there aren't many other treatment options if you get sicker. So, short of being on one of the medications that's absolutely contraindicated, their opinion is generally if you want paxlovid you should get it. So if your doctor is saying you don't need it or don't qualify, and you want to take it, I would find a different doctor or use a telemedicine provider.

victor9000 4y ago

The medical system in the US is optimized to get people in, bill them, and get them out; that's it. Managing drug interactions is a long tail process that requires critical thinking, which is not an incentiviced activity. Plenty of startups have failed thinking that they could succeed if their products resulted in improvements to quality of care.

reureu 4y ago
I dunno, the NIH literally suggests using this website to check for interactions: https://covid19-druginteractions.org/checker https://covid19-druginteractions.org/checker Managing drug interactions for paxlovid isn't much more complicated than inputting meds into a web form and looking at the color of the box that pops up after. I think most providers can handle that if they know these tools exist and get past the reflex of "paxlovid has drug interactions, you don't want to take it." Managing drug interactions is part of ordering medications, and if it's really taking that much time (i.e., the EHR isn't just doing all the work for you), then it'd result in a higher E&M code when it's billed out. Medication management, in some cases, can also be billed and reimbursed by the pharmacist. So, totally agree that the US medical system is optimized for billing. I don't think those of us in the US should be ok with that, and I don't think it's an excuse in this case to not prescribe paxlovid to patients who want it and would qualify for it.
- victor9000 4y ago
  Sure, in the abstract it is straight forward, but you quickly run into data gaps when considering multiple medications. Particularly in the context of comorbidities.

shadowgovt 4y ago

> Most of the interactions can be managed By whom? Medical professionals are overwhelmed, so you can't hospitalize these patients to monitor their compliance. And this is, in the large, not a demographic you can trust for maximal patient compliance.

reureu 4y ago
By the medical professional who is prescribing paxlovid. When I wrote "can be managed", I mean the health care provider tells the patient to either stop taking their other meds for 5-7 days, to reduce the dose, or to look out for symptoms and call them if they have certain issues. Not be hospitalized to watch for side effects. You can look for yourself at the list of common meds, and the ones that are absolutely contraindicated are relatively few: https://www.covid19treatmentguidelines.nih.gov/therapies/antivirals-including-antibody-products/ritonavir-boosted-nirmatrelvir--paxlovid-/paxlovid-drug-drug-interactions/ https://www.covid19treatmentguidelines.nih.gov/therapies/ant... One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending. The patient and provider have aligned interests, it's just a matter of ensuring the provider is making sure the patient understands what's going on. The provider should be doing that in all of their encounters, so that's nothing specific to paxlovid.
- shadowgovt 4y ago
  > One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending. I suspect you haven't worked with elderly patients. I help a relative manage his care. I keep having to hide the DayQuil so he doesn't take it alongside his arthritis medication and overdose on acetamenophin. He "knows" he's not supposed to, but it doesn't click when the pills are in his hand and his nose is running (because he took it for decades prior to the arthritis prescription and deeply-ingrained habits are not easily replaced). He definitely tells the doctor he understands, and the doctor believes him, but it's not like the doctor is in any way responsible for verifying that information. Drug interactions are way past the maximum complexity capacity of the median patient at high risk for death by COVID.
  - 4y ago