Originally posted at The CT Insider
The half-hour training a few days ago on Paxlovid, the new “game-changer” treatment for people with COVID-19, covered the nuts and bolts that medical staff at Community Health Center Inc. needed to know.
Unsaid were some big questions now that CHC and other large Connecticut health care providers have started to see shipments of the Pfizer drug. How exactly will docs decide who gets the medication once public awareness, and demand, mushroom?
Yes, it’s true that people who decided not to be vaccinated will likely be among the chosen few to receive the life-saving treatment ahead of vaccinated patients. Simply put, they are more likely to develop deadly symptoms — exactly what Paxlovid prevented in 88 percent of patients in clinical trials.
Dr. Veena Channamsetty, the CHC medical director, and Dr. Marwan Haddad, director of the statewide clinic’s Center for Key Populations, didn’t need to mention that to their colleagues. It goes without saying.
“In medicine we do not punish,” Haddad said to me Friday, less than a week after CHC received its first 100 courses of the treatment.
For now, Paxlovid in some parts of the country is seeing huge demand that early shipments can’t satisfy. In Connecticut, for reasons that seem perplexing, uptake has been slower for the roughly 3,000 courses of the treatment that have arrived in the state since Christmas week, when the Food and Drug Administration gave emergency authorization.
“None of the facilities have used 100 percent of their allocations and there is no shortage of Paxlovid,” state Department of Public Health spokesman Chris Boyle said in an email late Thursday.
How can that be, for a drug that could help perhaps half or even more of all the patients who develop COVID? The short answer is, awareness and the limits of the drug. A patient must start taking it within five days of the first symptoms — not within five days of a positive test, Haddad reminded his colleagues.
It must go to patients at high risk of developing severe or deadly cases of coronavirus disease, typically over 60 and with at least one of the many underlying conditions that raise the risk, such as active cancer, obesity and chronic lung disease.
Going over the list of conditions in the training at CHC, which serves people insured by Medicaid and other low-income populations, “I keep saying this is every single one of our patients for the most part,” Haddad said.
If a patient shows severe symptoms such as a low blood oxygen level or needs hospitalization for the illness, it’s too late. Paxlovid won’t help. And it can’t be given to people taking several kinds of medications including some heart drugs and some antidepressants.
So, speed matters, extreme caution matters and awareness by the public matters. As with the vaccine, rapid tests, ventilators and so many other resources connected with COVID, we will see an acutely high demand and a scarcity of the product until manufacturing catches up.
The first COVID treatment pills
The nation has ordered 20 million courses of the treatment, which is 30 pills of two different medications taken over five days.
“It’s a very important piece of the strategy to control and to live with COVID as we move forward,” said Haddad, an AIDS treatment expert who is also chairman of the HIV Medicine Association, having filled a vacancy created when Dr. Rochelle Walensky became head of the U.S. Centers for Disease Control and Prevention.
He added, “This is the first oral medication that we have that if you do get COVID, we can treat it.”
Paxlovid works by inhibiting the activity of proteins that allow the coronavirus to multiply in the body. It’s more effective in tests than monoclonal antibody treatments, which must be given intravenously, and which don’t work effectively against the omicron variant.
Another question unspoken at the Community Health Center training: How many of the 9,900 people in Connecticut who have perished in the COVID pandemic, and the 883,000 Americans and 5.66 million in the world, might have been spared a death sentence if Paxlovid had been available at, say, the end of 2020?
We can’t know that number, of course. We can only move forward, and that’s what they’re doing at CHC, with a very practical guide for the medical staff to start prescribing Paxlovid to Connecticut patients.
Crucial to the workflow: Don’t wait for the patients who are developing early symptoms to take a PCR test, or even a rapid antigen test at a testing site.
“Use your clinical judgment but obviously you can take their word for the fact that the rapid test was taken at home and the result was positive,” Haddad told his colleagues.
And if you have a patient in the clinic testing for COVID, be ready, Dr. Channamsetty, the medical director, advised. “Keep them there on site if they’re positive because you will need to dispense the Paxlovid right then and there, but you kind of want to pre-identify and go through the eligibility before that happens.”
Access for all, for now
Those are the practical steps for doctors and nurses, yet another protocol to learn, and fast. In the big picture, the rollout of this drug, and a similar one by Merck, represents, for docs on the front lines, a chance — an an obligation — to create a new world order for a corner of medicine.
Haddad has seen it in AIDS drugs.
“This is all a very exciting time and a new time for this,” he said, “when we’ve got to figure out how to get these medications to the people who need them.”
Access is never far from the conversation especially at a clinic that serves hundreds of thousands of low-income people, many with chronic health conditions. For now, Paxlovid is free for patients, purchased by U.S. taxpayers, with allocations controlled by federal agencies.
Will it stay that way?
“Pfizer is committed to working toward equitable access to PAXLOVID for all people, aiming to deliver safe and effective antiviral therapeutics as soon as possible and at an affordable price,” the company said in a written release.
The distribution of vaccinations and treatments remains a global problem. “I really hope we look at mechanisms for increased access across the world,” Haddad told me.
If the scourge of COVID brings any good, it may be as a tipping point in awareness of the crisis of health care access — not that anyone needed a reminder.