Right patient, right time key to Paxlovid benefit

A new study helps confirm that the antiviral should be given early and only to those at high risk of severe disease.

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Early antiviral treatment for people at high risk of developing severe covid is key, according to one infectious diseases expert.

The results of a new trial, published in the New England Journal of Medicine earlier this month, has sparked some confusion and concern when Paxlovid was found to be no better than placebo at treating covid signs and symptoms in some vaccinated patients.

The trial, which included almost 1300 patients, saw patients with a confirmed case of covid receive twice-daily doses of Paxlovid or a placebo for five days.

The research also found Paxlovid also performed similar to placebo when the 636 patients at high-risk of developing severe covid were compared to the 649 patients without risk factors for severe covid.

Associate Professor Paul Griffin, an infectious diseases physician and microbiologist from the University of Queensland, said the findings reinforced what we have known about the prevention and management of covid for a long time.

“[This study] highlights patient selection and early initiation [of oral antivirals] remains key. We know there’s likely to be much less benefit if you start [antivirals] late or use them in people that are low risk,” he told The Medical Republic.  

Professor Griffin felt the new findings aligned with the most recent changes to eligibility criteria for oral covid treatments, which were introduced last month. The Pharmaceutical Benefits Advisory Committee recommend Paxlovid be used in the first instance in adults aged 70 years and older with mild or moderate covid, as well as in patients aged 50 years or older with additional risk factors.

Molnupiravir, which PBAC noted was less effective than Paxlovid, is now only recommended in people with contraindications for Paxlovid.

The challenge, according to Professor Griffin, is effectively communicating the guidelines and decision-making process to health professionals and the public.

“A lot of people are critical of a lot of these recommendations, thinking we’re holding [onto] something that’s highly effective because it’s expensive, or we don’t have enough [supply]. People need to understand the role of these medicines, [which are] both viable options.

“We need to explain to people that it’s simple the fact that [taking the antivirals] doesn’t seem to make much of a difference if you’re not high risk, because your chance of getting really sick from covid is now so low that we’re not going to achieve anything by giving you these medications,” he told TMR.

Misinformation about covid treatments is still rife, Professor Griffin explained.

“I’ve recently come across quite a few patients where they were told that medication [like Paxlovid] is only for when you get more severe disease, so they missed the opportunity for early initiation, which is designed to prevent you from progressing to more severe disease.

“Waiting until you get more symptoms is exactly the wrong way to use these medications.”

Professor Griffin emphasised the importance of patients at higher risk working with their GPs to develop a plan around how testing and medications can be accessed if they start displaying symptoms.

This is timely advice, with new Pfizer research released today showing 74% of Australians at higher risk of serious illness do not have a “covid plan”, and that 44% would not routinely contact their GP if they tested positive for covid.

These findings came from the fourth covid community sentiment index, where 1000 members of the public and 100 GPs were surveyed. The research was commissioned by Pfizer Australia.  

“Now is the time to check your eligibility [for antiviral treatment] and make a plan with your GP,” said Dr Daniel Nour, founder of Street Side Medics, in a statement released by Pfizer.

“If you do test positive, don’t wait for worsening symptoms, contact your GP straight away.”

RATs and combination tests (for covid, RSV and influenza) were still of value, Professor Griffin said, provided they were used appropriately as a complement to laboratory-based testing.

“We don’t want people to assume if you have symptoms and a negative RAT that you’re fine. That’s when we need people to understand the role of PCT testing, which is a more sensitive way of looking for covid as well as other viruses. [You need to] regard yourself as potentially positive until you get a PCR test.”

New England Journal of Medicine 2024, online 3 April