A new variant of the coronavirus is circulating, the most transmissible so far. The hospitalizations of the infected are increasing. And older adults account for nearly 90 percent of US deaths from covid-19 in recent months, the largest share since the pandemic began.
What does this mean for people aged 65 and over who get covid for the first time or for those who get a repeat infection?
The message from infectious disease experts and geriatricians is clear: seek treatment with antiviral therapy that remains effective against the new covid variants.
The therapy of first choice, experts said, is Paxlovid, an antiviral treatment for people with mild to moderate covid who are at high risk of becoming seriously ill from the virus. All adults age 65 and older fall into that category. If people cannot tolerate the drug — potential complications with other drugs need to be carefully evaluated by a doctor — two alternatives are available.
“There is a lot of evidence that Paxlovid can reduce the risk of catastrophic events that can follow covid infection in older individuals,” said Dr. Harlan Krumholz, a professor of medicine at Yale University.
In the meantime, develop a plan for what you will do if you get covid. Where will you seek assistance? What if you can’t get in quickly to see your doctor, a common problem? You need to act fast as Paxlovid needs to be started no later than five days after the onset of symptoms. Will you need to adjust your medication regimen to protect yourself from potentially dangerous drug interactions?
“The time to understand all of this is before you get covid,” said Dr. Allison Weinmann, an infectious disease expert at Henry Ford Hospital in Detroit.
Being prepared proved essential when I caught covid in mid-December and went to the ER for a prescription. Because I’m 67 years old, with blood cancer and an autoimmune disease, I’m at a high risk of becoming very ill from the virus. But I take a blood thinner which can have life threatening interactions with Paxlovid.
Fortunately, the urgent care center was able to see my electronic health record and a note from the doctor said it was safe for me to stop the blood thinner and receive treatment. (I had consulted with my oncologist beforehand.) So, I walked away with a prescription of Paxlovid, and within a day my headaches and chills were gone.
Just before I fell ill with covid, I had read a major study of nearly 45,000 patients age 50 and older treated for covid between January and July 2022 at Mass General Brigham, a large health care system in Massachusetts. 28% of patients were prescribed Paxlovid, which had received an emergency use authorization for mild to moderate covid from the FDA in December 2021; 72% were not. All were outpatients.
Unlike other studies, most of the patients in this one had been vaccinated. However, Paxlovid did confer one notable benefit: Those who took it were 44% less likely to be hospitalized for serious covid-related illnesses or to die. Among those who received fewer than three doses of the vaccine, those risks were reduced by 81%.
A few months earlier, a study conducted in Israel had confirmed the efficacy of Paxlovid – the trade name for a combination of nirmatrelvir and ritonavir – in older adults infected with the omicron strain of covid, which emerged in late 2021. (The original study establishing l efficacy of Paxlovid was conducted while the delta strain was prevalent and included only unvaccinated patients.) In patients 65 years of age and older, most of whom were vaccinated or had previously contracted covid, hospitalizations are been reduced by 73% and deaths by 79%.
However, several factors have hindered the use of Paxlovid among the elderly, including physician concerns about drug interactions and patient concerns about possible “rebound” infections and side effects.
Dr. Christina Mangurian, vice dean for faculty and academic affairs at the University of California-San Francisco School of Medicine, experienced many of these problems when both of her parents contracted covid in July, an episode she recounted in a recent JAMA article.
First, her father, 84, was told in a virtual doctor’s appointment by a doctor that he didn’t know he couldn’t take Paxlovid because he was on a blood thinner — a decision later overturned by his primary care physician. Then, her 78-year-old mother was told, in a separate virtual appointment, to take an antibiotic, steroid, and over-the-counter medication instead of Paxlovid. Again, her primary care doctor stepped in and offered a prescription.
In both cases, Mangurian said, the doctors his parents saw for the first time seemed to misunderstand who should take Paxlovid and under what conditions. “This points to a serious deficit in terms of how information about this therapy is disseminated to frontline health care providers,” she told me in a telephone conversation.
Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, agrees. “Every day I hear from people who are misinformed by their doctors or nurse call lines. Typically, they are told that you cannot take Paxlovid until you are seriously ill, which is the exact opposite of what is recommended. Why aren’t we doing more to educate the medical community?”
The potential for drug interactions with Paxlovid is a significant concern, especially in older patients with multiple medical conditions. More than 120 drugs have been reported for interactions and each case must be evaluated, taking into account an individual’s condition, as well as kidney and liver function.
The good news, experts say, is that most potential interactions can be managed by temporarily stopping a drug while you’re taking Paxlovid or reducing your dose.
“It takes a little more work, but there are resources and systems in place that can help practitioners understand what they should be doing,” said Brian Isetts, a professor in the University of Minnesota College of Pharmacy.
In nursing homes, patients and families should ask to speak to consultant pharmacists if they are told antiviral therapy is not recommended, Isetts suggested.
About 10 percent of patients cannot take Paxlovid due to potential drug interactions, according to Dr. Scott Dryden-Peterson, medical director of outpatient covid therapy for Mass General Brigham. For them, Veklury (remdesivir), an antiviral infusion therapy given for three consecutive days, is a good, if sometimes difficult to organize, option. Additionally, Lagevrio (molnupiravir), another antiviral pill, can help shorten the duration of symptoms.
Many older adults worry that after taking Paxlovid they may get a rebound infection, a sudden flare-up of symptoms after the virus seems to have run its course. But in the vast majority of cases, “the rebound is very mild and the symptoms — usually a runny nose, nasal congestion and sore throat — go away within a few days,” said Dr. Rajesh Gandhi, an infectious disease physician and professor of medicine at Harvard Medical School.
Gandhi and other doctors I spoke to said the risk of not treating covid in the elderly is far greater than the risk of rebound disease.
Paxlovid side effects include a metallic taste in the mouth, diarrhea, nausea, and body aches, among others, but serious complications are rare. “Consistently, people tolerate the drug very well,” said Dr. Caroline Harada, an associate professor of geriatrics at the University of Alabama-Birmingham Heersink School of Medicine, “and feel better very quickly.”
We’re eager to hear from readers the questions you’d like answered, the problems you’ve experienced with your care, and the advice you need to deal with the healthcare system. Visit khn.org/columnists to submit your requests or suggestions.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three major operational programs of the KFF (Kaiser Family Foundation). KFF is a gifted non-profit organization that provides information on health issues to the nation.
USE OUR CONTENT
This story is free to republish (details).