Help Ensure Access to Paxlovid for COVID-19

Please see the FDA announcement authorizing pharmacists to prescribe Paxlovid with certain limitations.

You play a key role in limiting treatment delays with Paxlovid (nirmatrelvir/ritonavir) for patients with COVID-19.

Help HIGH-risk patients start within the 5-day window.

Dispensing. Any type of positive COVID-19 test is enough to qualify for Paxlovid, even a home test. And the med is still no cost to patients.

Keep in mind, you do NOT have to obtain an estimated glomerular filtration rate (eGFR). Treat Paxlovid as you would any other Rx.

But if you get Paxlovid Rxs for patients with an eGFR of 30 to 59 mL/min/1.73 m2 and don’t have the 150 mg dose pack, continue to discard one AM and PM tab of nirmatrelvir from each card in the 300 mg pack.

Educate that Paxlovid is usually well tolerated. But “Paxlovid mouth”...a bitter, metallic, or unusual common. Reassure that it resolves after treatment...and frequent liquids or hard candy may help.

Don’t recommend a repeat course of Paxlovid for rare “COVID-19 rebound”...recurrent illness or a positive test within about a week of finishing. Advise 5 more days of isolation and a mask for 10 days.

Interactions. Ritonavir is a strong CYP3A4 and P-glycoprotein inhibitor. Use a checker, such as if your pharmacy software doesn’t include Paxlovid yet.

For example, don’t stop or decrease oral or inhaled steroids...despite labeled warnings that adding Paxlovid may increase risk of adrenal suppression. Five days of the combo isn’t likely a concern.

But recommend a different COVID-19 med (molnupiravir, etc) for patients using inhalers that contain salmeterol (Advair, etc)...Paxlovid may increase risk of CV effects (QT prolongation, tachycardia, etc).

Work with prescribers on direct oral anticoagulant interactions...based on the DOAC, dose, and indication. For instance, suggest reducing Eliquis (apixaban) for atrial fib to 2.5 mg bid during Paxlovid and for 3 days after. But avoid Paxlovid in patients on Xarelto (rivaroxaban).

Explain that Paxlovid may DECREASE efficacy of clopidogrel...ritonavir inhibits the conversion of clopidogrel to its active form.

Consider a different COVID-19 med for patients at high clot risk...such as coronary stent placement less than 6 weeks ago. But don’t generally worry about this interaction for other patients.

Go to our resource, Treatments of Interest for COVID-19, for more interaction checkers...and the role of other meds.


Key References

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Pharmacist's Letter. July 2022, No. 380702

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