Ask the Pharmacist

Q. I heard I can come to the pharmacy to pick up an anti-viral medication if I get Covid-19. What can you tell me about it?

A. As of April 12th, participating pharmacies can request an order of the publicly funded anti-viral medication called Paxlovid. Presently many stores in the area, do have some in stock although there are no guarantees in the future as to just how readily accessible this drug will be.

Paxlovid is a five-day kit comprised of two medications; nirmatrelvir 150mg which is a pink tablet and ritonavir 100mg which is a white tablet. Within the kit there are five blister cards, one for each treatment day. The dose of Paxlovid is 2 tablets of nirmatrelvir plus 1 tablet of ritonavir taken together twice daily (morning and evening) without regard to meals (i.e. 6 tablets in total each day).

This medication is still quite new on the market so the full side-effect profile may not be fully understood as of yet however, early findings show nausea, vomiting, diarrhea, taste disturbance, headache, high blood pressure and muscle aches as all possibilities. Not everyone will have access to the publicly funded anti-viral as it is being reserved for specific populations.

See below for the criteria set out by the Ontario Ministry of Health. The clinical criteria are that:

1. The individual has received a positive COVID-19 test result; and
2. The individual will be starting Paxlovid™ treatment within 5 days of symptom onset (i.e. you must have some symptoms); and
3. One of the following factors applies to the individual:
a. The individual is 18 years of age or older and is immunocompromised;
b. The individual is 70 years of age or older;
c. The individual is 60 years of age or older and has received less than three doses of a COVID-19 vaccine;
d. The individual is 18 years of age or older, has received less than three doses of COVID-19 vaccine, and has at least one of the following risk conditions:

• obesity
• diabetes
• heart disease, hypertension, congestive heart failure
• chronic respiratory disease (including cystic fibrosis)
• cerebral palsy
• intellectual and developmental disabilities
• sickle cell disease
• moderate or severe kidney disease
• moderate or severe liver disease
• pregnant and unvaccinated (zero doses)

e. The individual is assessed as being at higher risk of severe COVID19 based on their age, vaccination status, and risk conditions (excluding risks due to travel) by their prescriber.

You might be wondering why the average healthy person who is fully vaccinated, including a booster, would not be allowed access to this anti-viral medication. After all, we all know so many people that are getting infected with Covid, even those who are fully vaccinated and have had a booster to boot. It, on the surface, may not seem fair that those who have “followed the rules” should be denied access to this drug. However, there are valid medical reasons behind this decision and most of them are centered upon the fact that the vaccines have proven worth their weight in gold when it comes to keep people alive.

Though vaccinated individuals are getting Covid, the vaccines have greatly reduced the severity of the illness and thus their need for hospitalization. Note that the key word here is reduced. That means that fully vaccinated and ‘boostered’ people may still get ill enough to require medical help. However, more than likely this will be due to an underlying medical condition.

The unvaccinated or partially vaccinated people however may not be so lucky. It is this group of individuals that can far more frequently go from fairly mild symptoms to landing in the hospital just days later. As such, it is this same group that Paxlovid seems to provide some benefit.

There are three main reasons why Paxlovid will not be handed out to anybody and everybody that wishes it.

For starters, the supply of Paxlovid should be limited due to its limited supply and high cost. Though it will be publicly funded and will, therefore, cost the user nothing to acquire it, it is our provincial government that will, by funding this endeavour, mean that we will be paying for it in some way or another through our tax dollars. Given the current state of our deficit, we should only be spending tax dollars when there is a clear benefit to society.

Secondly, though this medication can greatly assist the mildly affected who are not fully vaccinated, it has proven ineffective for most other COVID positive cases. The drug works by preventing the virus from replicating (reproducing) and thus works well only in the initial stages of the virus before it really takes hold. As such, one of the guidelines for prescribing Paxlovid is that it must be started within FIVE days of the onset of symptoms. If your symptoms have already progressed to a degree that they are even moderate in nature (let alone severe), the drug is unlikely to benefit you much and there are other, better drugs at this stage, that can be used. Current studies also show no benefit for the fully vaccinated, boostered, healthy individuals even if the drug is given immediately after symptom onset. In fact, it can actually cause harm to the greater population as there is early evidence of resistance to Paxlovid, meaning the drug over time will be less effective the more often it is used.

Lastly, this is not a simple medication to prescribe. Though there is still much to learn about Paxlovid, it is already known that there are a plethora of drug interactions associated with this drug. Before you would receive Paxlovid, your pharmacist would have to do a thorough medical history and a review of your medications to ensure that it is safe for you to take. There is a very good chance that some of the medications that you regularly rely on will have to be reduced in dose or even stopped. This can play havoc with the conditions those drugs are supposed to be helping such as your cholesterol, breathing, sleep, blood pressure and many other common disease states. There are also some drugs that you might be taking that will prevent you from being prescribed Paxlovid due to the severity of the interaction regardless of whether the offending agent was discontinued immediately.

Because there is truly a long list of offending medications, we will not list them here but rest assured, if you do get a prescription for Paxlovid, your pharmacist will be able to assess that for you.

In short, Paxlovid will be yet another important tool in our fight against COVID, but only for a relatively small percentage of our population. For the rest of us, there are drugs such as remdesivir that are available in our hospitals should we run into trouble with the infection. For more information on this or any other health topics, contact your pharmacist.