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Paxlovid and travellers

July 27th, 2022

Paxlovid®= combination of Nirmatrelvir (N) and Ritonavir (R)

Paxlovid is a COVID-19 medication that is a combination of two antiviral drugs. It is used for the treatment of early COVID-19 in persons who are severely immunosuppressed. The goal is to make COVID sufferers less likely to progress to severe COVID-19 which requires hospitalisation. In a trial undertaken in unvaccinated adults, it was found to be about 90% effective at stopping this severe progression.

Paxlovid has to be taken as soon as possible after the COVID-19 diagnosis, and definitely within the first 5 days. It only works in the early stages of COVID-19, when there is not much virus in the body. The N medication works by stopping the relatively large viral proteins that are being made in the infected cell from being cut up and assembled into new viruses – so you don’t get as many viruses causing damage in the body.  The R component stops the N medication being broken down in the liver so the N drug levels are boosted and do more work stopping the virus. If you take the medication too late, the damage has already occurred – that is why Paxlovid does not work if someone is already severely ill.

Paxlovid has a low incidence of side effects if recipients are chosen carefully, BUT it can cause problems if patients have weak kidneys or are taking drugs that interact with it. Many common drugs (like heart medication, blood thinners, pain killers e.g pethidine and feldene, diazepam, anti-epilepsy medication, and anti-cholesterol medications to name a few) dramatically increase the risk of side effects. There is more info here on the drug interactions: https://www.covid19-druginteractions.org/checker

Paxlovid was added to the Australian Pharmaceutical Benefits Scheme (PBS) on 1st May 2022.  Drugs on the PBS are available to Australians for about $40. The cost for a private (non-PBS) prescription is reported to be about $1000 for a 5-day course. In Australia, there is a limited supply of Paxlovid, so it has been requested that doctors do not supply this medication “off the PBS” or there will not be enough to go around to the patients who most need it. Giving it “off the PBS” means, for example, giving it to patients who are fully vaccinated and only have mild immunosuppression, if any. We don’t know yet if Paxlovid is helpful in this group of “standard risk” individuals. We have no evidence that it helps this standard risk population to get less symptoms, avoid hospital, avoid LongCOVID, or even to be less contagious. (The data is being collected and we may get further information in the future.)

According to Australian guidelines, the following groups are currently the only ones who are recommended to takePaxlovid after they are diagnosed with COVID-19[1]:

  • 70 years and older, regardless of risk factors and with or without symptoms
  • 50 years or older with 2 additional risk factors
  • Aboriginal or Torres Strait Islander, 30 years or older and with 2 additional risk factors.
  • Any patient over the age of 18 who is moderately to severely immunocompromised.

Risk factors for severe COVID-19diseaseinclude those with some types of cancer, those on some immunosuppressive drugs, and those with organ failure (heart/lung /liver/kidney), HIV, untreated high blood pressure, obesity, diabetes requiring medication, Downs syndrome, or sickle cell disease.

So in summary, Paxlovid is currently not recommended and not necessary for healthy vaccinated travellers in case they get COVID-19 while overseas.

Dr Deb Mills MBBS MPHTM

[1]https://www.health.gov.au/health-alerts/covid-19/treatments/oral

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