Ask the Pharmacist

Q) I heard that pharmacists are now allowed to prescribe that antiviral medication for people at risk if they catch COVID. Is this true, and if so, how will this work?

A) Yes, that is correct. Effective December 12, 2022, Ontario pharmacists are now legally allowed to prescribe the anti-viral Paxlovid to qualifying patients without the need for them to contact their doctor.

As a quick reminder (check our past articles for more detailed information on this drug), Paxlovid is an antiviral medication specific for the COVID virus. This differs from antibiotics that many are accustomed to taking for other illnesses to treat a bacterial infection such as step throat. A five-day course of Paxlovid has been shown to lower the chances of requiring hospitalization by 51% regardless of whether an individual has been previously infected or vaccinated.

In clinical trials conducted in 2021 on unvaccinated individuals, the drug reduced the risk of serious illness and death by a staggering 89% when compared to a placebo. In short, the drug works when given in a timely manner, and that latter part has proven to be a challenge. The drug must be started within 5 days of symptom onset for it to be fully effective. This is challenging given the number of people who do not have a family doctor or be able to reach theirs in a timely fashion. This is reflected in the fact that as of late September, Health Canada had distributed enough doses to treat more than 700,000 people with 100’s of thousands of more doses apparently on the way, yet the provinces have given out only a small fraction of this medication to patients.

Given how jam packed our hospitals currently are as we continue through the tridemic (one of the names given to this current surge in cases of influenza, RSV and COVID), it seems prudent to improve access for a medication that should help keep COVID ill from getting sick enough to require hospitalization.

As such, it makes sense for pharmacies to help with this solution seeing as though most are open for longer hours and more days than doctors’ offices. To be eligible to receive Paxlovid, there are certain criteria that must be met. The first is that the patient must have tested positive for the virus. This can be done with an at-home rapid antigen test and the individual does not have to provide proof that they have done so. The honour system reigns supreme here, as does common sense. All drugs can have side effects. Why would anyone take that risk without knowing there was at least the potential for benefit to be gained. Paxlovid is specific for COVID. There is no indication for its use in the flu, RSV or other viruses or bacterial infections.

Secondly, the drug works by stopping the virus from reproducing. Thus, it is far more effective when given at the beginning of an infection than after the virus has run wild. As such, the individual must be seeking treatment within 5 days of when they first noticed any symptoms including mild ones such as a runny nose. Your testing day does not matter as obviously most of us will have been sick for some time before we decide to shove a swab halfway up our nose.

Lastly, the drug is being reserved for those who will most benefit from it, i.e. those who are most likely to get severely ill. This list includes:

  • Anyone over the age of 60, regardless of how many times or how recently they have received a vaccination or previously contracted the virus. This age group, even those without any other risk factors such as another disease, should be strongly considered for Paxlovid therapy.
  • Anyone between the ages of 18 and 59 who are at a higher risk of a severe COVID-19 infection. This group requires further clarification as to who falls into this higher risk category. It’s a lengthy list:
  • Those who have inadequate immunity from either a vaccine or a previous infection. You fall into this group if:
    1. You are either unvaccinated or never completed the initial primary series (i.e. the first 2 doses before we started adding booster injections).
    2. You completed the primary series but it has been longer than 6 months since this was completed. If you have not had a booster dose or COVID infection within the last 6 months, then your immunity has waned and you are eligible.
    3. Regardless of vaccination status, anyone between those ages who has a disease or takes a medication that impairs their immune system. This too is a lengthy list, but in the interest of being thorough and having people fully informed, you can view the following details:

A) Individuals receiving dialysis, such as hemodialysis or peritoneal dialysis.
B) Recipients of solid-organ transplant who are taking immunosuppressive therapy.
C) Individuals receiving active treatment, such as chemotherapy, targeted therapies or immunotherapy, for solid tumour or hematologic malignancies.
D) Recipients of chimeric antigen receptor (CAR)-T-cell therapy or hematopoietic stem cell transplant, who received transplantation within the past two years or who are taking immunosuppression therapy.
E) Individuals with moderate to severe primary immunodeficiency, such as DiGeorge syndrome or Wiskott-Aldrich syndrome.
F) Individuals who have experienced HIV with AIDS-defining illness in the last 12 months before starting their vaccine series or severe immune compromise with CD4 count <200 cells/uL or CD4 percentage <15%, or without HIV viral suppression.
G) Individuals receiving active treatment with the following categories of immunosuppressive therapies:
i. Anti-B cell therapies such as monoclonal antibodies targeting CD19, CD20 and CD22.
ii. High-dose systemic corticosteroids.
iii. Alkylating agents.
v. Antimetabolites.
v. Tumour-necrosis factor (TNF) inhibitors and other biologic agents that are                           significantly immunosuppressive.

H) Individuals with any of the following diseases (note this is not the entire list):
(a) cancer,
(b) cerebrovascular disease,
(c) chronic kidney disease,
(d) chronic liver diseases, where the disease is cirrhosis, non-alcoholic fatty liver disease, alcoholic liver disease or autoimmune hepatitis,
(e) chronic lung diseases, where the disease is bronchiectasis, chronic obstructive pulmonary disease, interstitial lung disease, pulmonary hypertension or pulmonary embolism,
(f) cystic fibrosis,
(g) diabetes mellitus, type 1 or type 2,
(h) disabilities such as Down syndrome, learning, intellectual or developmental disabilities, ADHD, cerebral palsy, congenital disabilities or spinal cord injuries,
(i) heart conditions such as cardiomyopathies, coronary artery disease, heart failure and similar conditions,
(j) HIV infection,
(k) mental health disorders, where the disorder is a mood disorder, including depression, or a schizophrenia spectrum disorder,
(l) obesity,
(m) pregnancy or recent pregnancy,
(n) primary immunodeficiency diseases,
(o) smoking, current or former,
(p) solid organ or blood stem cell transplant,
(q) tuberculosis, and
(r) use of corticosteroids or other immunosuppressive medication; (“comorbodités”)

When calling your pharmacy to discuss the Paxlovid, be prepared to answer some questions to determine your eligibility. As well, if the pharmacy you are calling is not aware of all of your medications, please have a list prepared or a number they can call to find out so the pharmacist can review the numerous medication interactions with Paxlovid. It is best to not request the pharmacy to contact your physician for this list as sometimes there are challenges getting in contact with their offices. If the pharmacist has detected a medication that interacts with Paxlovid, you may be asked to temporarily stop taking or alter the dose of some of your drugs. As well, there are certain people who should not take Paxlovid.

All in all, prescribing this drug is a lengthy process and does take time so be prepared to wait for a couple of hours before the prescription is ready to be picked up (but not by you of course as you should stay at home and keep the rest of us safe!) or delivered. The medication as well as the consultation services are provided free of charge by our government so you will not need to pay anything. For more information about this or any other health related questions, contact your pharmacist.