Anticipatory deprescribing could allow more patients access to the antiviral Paxlovid.
Rising covid outbreaks in Australian residential aged care facilities have prompted a call for GPs to develop pre-emptive “covid antiviral action plans” to allow the potentially life-saving drugs to be started as soon as patients return a positive test.
Professor Dimity Pond, a GP with a special interest in aged care, says planning should also include the consideration of deprescribing to allow patients to access the covid antiviral nirmatrelvir-ritonavir (Paxlovid).
“This potentially has benefits beyond covid treatment, particularly for patients with polypharmacy,” she said.
“It’s a really good opportunity to have a rethink. There are too many people on too many medications they don’t necessarily need.”
Paxlovid is one of two oral antivirals currently approved for use in Australia but given its long list of drug-drug interactions and contraindications it has become the least prescribed, compared to the other drug molnupiravir (Lagevrio).
In a recent primary care covid response webinar, deputy chief medical officer Professor Michael Kidd revealed about 150,000 courses of Paxlovid and Lagevrio had been dispensed through community pharmacy on PBS authority. The prescriptions had been written by GPs or authorised nurse practitioners since they were made available through the national stockpile.
Of these, 123,000 prescriptions have been for Lagevrio and 27,000 for Paxlovid, Professor Kidd said. The federal government has secured one million courses of Paxlovid and 300,000 of Lagevrio.
Out of the 150,000, 96,000 have been for people aged 70 and above, 16,500 were for those in residential aged care facilities.
“We have seen a rise in the number of prescriptions being dispensed for residents in residential aged care facilities,” Professor Kidd said.
“We’ve got a rise in the number of facilities over the last week which have active outbreaks of covid-19. These treatments are proving to be lifesaving for many elderly people across the country.”
While Paxlovid has more drug-drug interactions and contraindications, research supports its greater effectiveness in minimising the length of hospital stays and preventing deaths in older people.
One Israeli study found it was associated with a 67% reduction in covid hospitalisations and an 81% reduction in mortality in patients aged 65 and older.
A JAMA article released last month looked at the issue of drug-drug interactions with Paxlovid in older adults using multiple medications, and found they were common in a population of older adults with polypharmacy.
“Many drug-drug interactions involved potentially inappropriate medications, which were candidate drugs for deprescribing,” the authors wrote.
“Because of these drug-drug interactions, many older adults with polypharmacy could not safely receive nirmatrelvir-ritonavir. Not all drug-drug interactions could be mitigated by simply holding or dose-reducing a medication.
“Some medications required anticipatory deprescribing to prevent adverse drug withdrawal events attributed to sudden stopping (e.g., benzodiazepines) or prolonged half-life (e.g., amiodarone).”
Professor Pond, a member of the RACGP’s Silver Book Expert Advisory Group, said anticipatory deprescribing where appropriate had her fullest support.
“Our bodies get more sensitive as we get older, and a lot of medications have a slight anticholinergic effect,” she said.
“Most GPs would know the major ones, but a lot of really commonly used medications have a small anticholinergic effect. And when you add all that up, that can have a really significant effect on your ability to think clearly and creates that brain fog. But it’s reversible.”
Professor Pond said with cases rising again in aged care facilities, it was important for GPs to be prepared for the inevitable calls that would come in relation to their patients. Having an action plan for each patient would allow for a seamless commencement of the most appropriate antiviral, she said.
“Part of that pre-approval in resi-care, because so many people have dementia, is to get consent from a family member or carer and that might have happened a month or two ago, so it’s worth double checking again.”
Professor Pond said developing a covid action plan was also a good opportunity to revisit patients’ medications, “and if in the process we got everyone off a few more medications, that would be a wonderful added bonus”.
“The gold standard is to have a look at the medications and maybe pick one or two that fairly uncontroversially need to be deprescribed,” she said.
“And then discuss it with the patient and or the family and get their input as to how they’d feel about us doing that. And then go really slowly with that, monitoring the side effects.
“I can talk to people in terms of not taking too many tablets, and a lot of people are aware that they’re taking a lot of tablets and agree it would be good to reduce how many they have to swallow each day.”
