Help Reduce Barriers 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.

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

Use the COVID-19 Therapeutic Locator to find local med supply.

Prescribe the Paxlovid 150 mg dose pack for patients with an estimated glomerular filtration rate (eGFR) of 30 to 59 mL/min/1.73 m2...instead of the 300 mg dose pack. Avoid Paxlovid with an eGFR below 30.

If you don’t have a recent eGFR, it’s okay to rely on your clinical judgment about the patient’s kidney function.

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 give 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 EHR 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 consider 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).

Manage direct oral anticoagulant (DOAC) interactions based on the DOAC, dose, and indication. For instance, reduce 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).

Be aware, 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 thrombosis 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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Prescriber's Letter. July 2022 No. 380702

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