Covid and the elderly and Paxlovid

[EKS]

My almost 86yo mother has covid.  She is in generally good health, no risk factors other than being elderly (she is thin, not immunocompromised, and does not have diabetes, for example).  She is 5x vaccinated including the bivalent booster.  She also had a very mild case of covid over the summer.

Her doctor does not seem to be a fan of Paxlovid, but at the moment I don't know why.

Am I nuts in thinking that she should be taking Paxlovid?  

Any information, experience, or opinions you may have about the Paxlovid thing or covid in the elderly in general would be much appreciated.

[Pawz4me]

An 87 yo relative was diagnosed with Covid a couple of weeks ago. Has underlying heart issues (stents and one unresolved blockage). They have only had one Covid vaccine, which was right after the first one was available (so a long time ago). The doc who saw them didn't prescribe Paxlovid. But it had been at least three, and possibly four, days since onset of symptoms. The only thing I could figure out was that maybe the doc thought it was too late for Paxlovid to help? They have recovered okay at this point. Energy level is not back to normal, but getting there.

[Katy]

So one of my sisters just had it. She couldn’t stand the taste the medicine left in her mouth, it was a vomit-inducing rotten taste for hours. She quit after 3 days, had a rebound case with worse symptoms than before the medication. 

[Eos]

My mother took it at 93 last summer, fully vaxxed and boosted.  She did start it pretty quick, had a very mild case and no lasting issues.  We all thought it was a good idea.

[Spryte]

My 83 yr old FIL is in a nursing home, and has Covid. The day he was diagnosed, they started him on Paxlovid, as it’s the protocol the nursing home follows — every Covid positive resident is given Paxlovid (unless contraindicated). 

I hope your mother has a mild case and improves quickly.

[prairiewindmomma]

Paxlovid gave me significant GI distress and after my course of treatment ended, I got much sicker as the virus could then replicate freely. I went from feeling relatively fine to needing regular breathing treatments for over a week.

It’s not a cure-all, by any means. Would I have been sicker without it, maybe? I had had four vaccines at the time I got COVID. It seems like all Paxlovid did was delay COVID symptoms by a week plus wear me out with frequent trips to the bathroom.

Edited February 22, 2023 by prairiewindmomma

[MEmama]

My in laws both currently have Covid. FIL is still recovering from a stroke last spring, is obese and has diabetes, MIL's health is similar. Neither were offered Paxlovid by their doctor, but MIL wants ivermectin (eyeroll) lol. Both seem to have had mild cases and be on the rebound.

[Mrs Tiggywinkle Again]

Most doctors here are not prescribing Paxlovid if the risk profile isn’t high.  Nursing home patients are still getting it, probably due to institutionalization automatically giving someone a higher risk profile. 
(they were consistently prescribing it up until about six months ago, so I would assume the research findings have changed some with no longer having a Covid naive population)

Edited February 22, 2023 by Mrs Tiggywinkle Again

[kbutton]

My 90 year old grandmother did not use Paxlovid and did all right. She takes a lot of meds that would've made it tricky. I was kind of worried, but it all turned out well.

[Pam in CT]

I took it myself in June 2022 (full vax, not yet bivalent booster) when my symptoms > what I considered mild (I had fever and chills and could.not.get.warm for 36 hours even with heating pads and hot water bottles).  My doctor kinda-sorta advised against (because the rebound case issue was beginning to arise) but I kinda-sorta insisted. I got the yucky mouth taste, which was definitely weird; and I continued to RAT-test positive for like a zillion days which was irritating, but my actual COVID symptoms cleared within 2 days. It may have prolonged by positivity but on balance I was glad I took it and **if I had those kinds of symptoms** I would take it again. Others in my family have not had that level of symptoms.

Both my mother (MA, July 2022) and my FIL (NY, Dec 2022) were advised by their doctors to take it.  My mother opted not to (very mild symptoms) and my FIL initially declined it, got much worse and was hospitalized, took it, and turned around pretty quickly once he was on it. He too then continued to RAT-test positive for like a zillion days.

Who knows how my own and my FIL's symptoms would have progressed had we NOT taken it.  That's the thing, we only ever know about the downsides and side effects of the road TAKEN, not the road not taken.

 

I'm very glad it's in the toolkit; and also, probably would only advise it for folks who are actually experiencing significant symptoms, not "just in case."

 

 

 

Edited February 22, 2023 by Pam in CT
eta wrong years... it's all been one long blur since march 2020...

[lmrich]

My mom (85) has  a mild heart condition and could not take paxlovid. She took another antiviral and recovered without hospitalization (a trip to the ER). My dad who is 90 and no conditions got paxlovid and recovered faster than my mom. 

[LucyStoner]

2 hours ago, EKS said:

My almost 86yo mother has covid.  She is in generally good health, no risk factors other than being elderly (she is thin, not immunocompromised, and does not have diabetes, for example).  She is 5x vaccinated including the bivalent booster.  She also had a very mild case of covid over the summer.

Her doctor does not seem to be a fan of Paxlovid, but at the moment I don't know why.

Am I nuts in thinking that she should be taking Paxlovid?  

Any information, experience, or opinions you may have about the Paxlovid thing or covid in the elderly in general would be much appreciated.

Did she take Paxlovid when she had it over the summer?  

[stephanier.1765]

My elderly mother had Covid in June, took Paxlovid and ended up with rebound symptoms. She had Covid again in January and this time decided not to do Paxlovid. It seemed to us that she recovered more quickly without it but that could be just the difference in strains. My heart goes out to you all because this is a hard decision.

[Ausmumof3]

https://www.abc.net.au/radio/programs/coronacast/do-antivirals-increase-your-risk-of-rebound-covid/102003218

Yesterday’s coronacast was on the topic, just in case there’s anything new or helpful in there. (There is a transcript so you can skim read instead of listening if that’s easier)

[gardenmom5]

wrong side of middle age, immune compromised.

Had paxlovid - I question how helpful it was.

My ND gave me a bunch of other stuff to take to strengthen my immune system.

[wathe]

6 hours ago, EKS said:

My almost 86yo mother has covid.  She is in generally good health, no risk factors other than being elderly (she is thin, not immunocompromised, and does not have diabetes, for example).  She is 5x vaccinated including the bivalent booster.  She also had a very mild case of covid over the summer.

Her doctor does not seem to be a fan of Paxlovid, but at the moment I don't know why.

Am I nuts in thinking that she should be taking Paxlovid?  

Any information, experience, or opinions you may have about the Paxlovid thing or covid in the elderly in general would be much appreciated.

In short, because the state of the evidence for paxlovid for vaccinated  people remains very, very poor, and it's very reasonable to conclude that she likely won't benefit.

You've caught me right before work.  I'll respond more fully later.

Edited February 22, 2023 by wathe

[Acadie]

1 hour ago, gardenmom5 said:

My ND gave me a bunch of other stuff to take to strengthen my immune system.

Would love to hear what your ND recommended if you're up for sharing. 

If not, no need to reply and I'm sending all good wishes to you and yours 💜

[EKS]

6 hours ago, LucyStoner said:

Did she take Paxlovid when she had it over the summer?  

No, she just had a sore throat for two days.  She never even tested positive.  My father was sick at the same time and did test positive so I am assuming that my mother had it too.  Anyway no Paxlovid for either of them.

[KSera]

3 hours ago, wathe said:

In short, because the state of the evidence for paxlovid for vaccinated  people remains very, very poor, and it's very reasonable to conclude that she likely won't benefit.

You've caught me right before work.  I'll respond more fully later.

I haven't had a chance to read beyond the abstract yet, but do you have any thoughts on the recent study of Paxlovid out of Israel? 75% of the participants were considered "adequate" vaccination status. I need to read the whole thing still to figure out how that is defined. Here's a chart of results, though:

 

Boy, I'm really going to have to go read the whole thing now, because some of this is confusing:

 

Pubmed link: https://pubmed.ncbi.nlm.nih.gov/35653428/

 

eta: Oh, I understand the second chart now. I misunderstood what it was showing the odds ratio for. It was for whether someone received Paxlovid or not, not for their outcome on Paxlovid. The conclusion was that Paxlovid was helpful, particularly in people with risk factors, and that effect was independent of vaccination status, but not nearly as impactful as vaccine status. There are some potential confounding factors, but it's a better study IMO than the EPIC-HR one.

Edited February 23, 2023 by KSera

[gardenmom5]

6 hours ago, Acadie said:

Would love to hear what your ND recommended if you're up for sharing. 

If not, no need to reply and I'm sending all good wishes to you and yours 💜

When I can think

Vitamin c, zinc, more etc

[TCB]

@EKS

Please do not make a decision based on anecdotal evidence in this thread. I’m afraid it’s late right now and I’m too tired to recall details, but Dr Daniel Griffin on the TWIV podcasts discusses recent data on Paxlovid. The last time I listened he was recommending it for older people. I believe it can be prescribed up to 5 days after symptom onset, but is best if within the first 3 days. A 3 day course of Remdesivir is also an option with similar efficacy to Paxlovid I think.

This is a serious matter that can potentially reduce someone’s chances of hospitalization or death and I don’t think just putting in one’s two cents worth, without any apparent knowledge of the data, is a good thing to do. 

Edited February 23, 2023 by TCB

[TCB]

Just now, TCB said:

Please do not make a decision based on anecdotal evidence in this thread. I’m afraid it’s late right now and I’m too tired to recall details, but Dr Daniel Griffin on the TWIV podcasts discusses recent data on Paxlovid. The last time I listened he was recommending it for older people. I believe it can be prescribed up to 5 days after symptom onset, but is best if within the first 3 days. A 3 day course of Remdesivir is also an option with similar efficacy to Paxlovid I think.

This is a serious matter that can potentially reduce someone’s chances of hospitalization or death and I don’t think just putting in one’s two cents worth, without any apparent knowledge of the data, is a good thing to do. 

ETA I believe that several recent studies have found a similar incidence of rebound in both people who took Paxlovid and those who didn’t. It seems to be a feature of the disease rather than the treatment.

[EKS]

7 hours ago, TCB said:

Please do not make a decision based on anecdotal evidence in this thread.

I appreciate hearing about people's experiences here, but in the end it's going to be up to her and her doctor. 

And the clock is running out on starting Paxlovid at this point.  I can't even get her to take Tylenol to help with her fever and discomfort.  It took two days before she even looked for it, and when she found it, she discovered that it expired in 2014!  I suggested that my father could go get more, but was told that he didn't plan to go to the store until the next day.  I pointed out that he should go to the store then because who knows if he would still be healthy the next day.  (Another issue is that they have been taking no precautions to keep him from getting sick, and he is 92 and immunocompromised.)

No one listens to me.  

[TCB]

49 minutes ago, EKS said:

I appreciate hearing about people's experiences here, but in the end it's going to be up to her and her doctor. 

And the clock is running out on starting Paxlovid at this point.  I can't even get her to take Tylenol to help with her fever and discomfort.  It took two days before she even looked for it, and when she found it, she discovered that it expired in 2014!  I suggested that my father could go get more, but was told that he didn't plan to go to the store until the next day.  I pointed out that he should go to the store then because who knows if he would still be healthy the next day.  (Another issue is that they have been taking no precautions to keep him from getting sick, and he is 92 and immunocompromised.)

No one listens to me.  

I hope they recover very quickly. It is good to hear people’s experiences but there’s so much information swirling around and it’s hard to keep it straight. I posted last night when I was tired and a bit grumpy so I apologize for being strident. 

[wathe]

@EKS

I'm back.  Sorry to post and run earlier.

Re evidence:

We have exactly one RTC on paxlovid for vaccinated people, EPIC-SR.  It was halted for futility and never formally published.  Results were communicated by press release.

All of the other studies on vaccinated people are observational cohort studies.  Many of them show a correlation with paxlovid and decreased hospitalization for covid in older patients (exact age range depends on the study).  But these need to be interpreted with a extreme caution.  Observational studies cannot eliminate confounders.  These studies show that older people who were prescribed paxlovid did better than those who weren't, but that might not be because of the drug.  Another way to put it is that these studies showed that patients who seek paxlovid do better than those who don't. Which I didn't need a study to know!  Pts who seek paxlovid tend to be those who have social determinants of health in their favour; they are well organized/supported enough to acknowledge covid sx, test, be aware that paxlovid exists, seek care, have had blood drawn in the past 3 months or get blood drawn, get to a pharmacy that stocks paxlovid --- all within a 5 days window.  Those same favourable social determinants of health mean that they were going to do better anyway, whether they got paxlovid or not.  Those whose social determinants of health are against them tend not to be able to pull it off, and because of those same social determinant of health,  they were going to do worse anyway, whether they got paxlovid or not.  Authors of observational studies do their best to erase confounders with fancy math and statistical manipulation, but it's not actually possible.

The only way to eliminate confounders from a drug efficacy study is to do a double-blinded, randomized controlled trial.  Of which we have exactly one for vaccinated patients (EPIC -SR, above).  Which did not show benefit.  

Another issue with most of the trials and studies is that they tend to use disease-specific hospitalization (hospitalization for covid) as an endpoint.  Which means that non-covid hospitalizations due to paxlovid (like, say, for drug-drug interaction, or for worsening of chronic disease due to stopping regular meds that interact with paxlovid, or acute process like a stroke due to stopping or adjusting anticoagulant because it interacts with paxlovid) aren't captured.  Risk of harm from paxlovid treatment is missed.  

The Paxlovid story echos the Tamiflu story in a way that makes many of us uncomfortable.  EPIC-SR was pharma-funded and pharma-run.  Publishing it properly would not be in the drug company's financial best interest.  So they didn't.

Anyway, long story short:  It is very reasonable to conclude that paxlovid likely does not benefit vaccinated patients, and to prescribe very judiciously.  

My very EBM focused ED group is skeptical.  The litmus test/thought experiment of "would you recommend paxlovid to your own older, fully-vaccinated, immune-competent, otherwise well parents?" gets an answer of "probably not" from most of us.

Edited February 23, 2023 by wathe

[KSera]

2 hours ago, wathe said:

 The litmus test/thought experiment of "would you recommend paxlovid to your own older, fully-vaccinated, immune-competent, otherwise well parents?" gets an answer of "probably not" from most of us.

What if the thought experiment is shifted to your older, not particularly well parents?

[EKS]

Just an update:  My mother is feeling a bit better, and mentally she seems much more with it.  On the other hand my father is now sick.  And as I said above, he's immunocompromised and 92.  Ugh.

[prairiewindmomma]

21 minutes ago, EKS said:

Just an update:  My mother is feeling a bit better, and mentally she seems much more with it.  On the other hand my father is now sick.  And as I said above, he's immunocompromised and 92.  Ugh.

Sorry your dad is unwell.

Fwiw, we have used delivery services like DoorDash or Target or Walmart same day delivery to send OTC meds and easy to prepare foods to family out of state. For those very rural, we call their local pharmacy and they usually have a runner that can send things. 

[EKS]

44 minutes ago, prairiewindmomma said:

Sorry your dad is unwell.

Fwiw, we have used delivery services like DoorDash or Target or Walmart same day delivery to send OTC meds and easy to prepare foods to family out of state. For those very rural, we call their local pharmacy and they usually have a runner that can send things. 

They live on an island.  No delivery that I know about, but it could be that the pharmacy delivers.

We will definitely be having a conversation about how to get help if something like this happens again.

Edited February 24, 2023 by EKS

[whitestavern]

19 hours ago, TCB said:

ETA I believe that several recent studies have found a similar incidence of rebound in both people who took Paxlovid and those who didn’t. It seems to be a feature of the disease rather than the treatment.

Rebound in people not taking Paxlovid is rare and usually only lasts one day 

https://www.medpagetoday.com/meetingcoverage/croi/103220?xid=nl_mpt_DHE_2023-02-22&eun=g2149620d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily Headlines Evening 2023-02-22&utm_term=NL_Daily_DHE_dual-gmail-definition

 

[wathe]

4 hours ago, KSera said:

What if the thought experiment is shifted to your older, not particularly well parents?

Fully vaccinated and immune-competent, I would think hard, but still probably not.  More co-morbidities increase the risk of drug complications: potential drug-drug interactions, regular meds that would need to be stopped or adjusted, and renal failure. EPIC-SR included patients with  "at least one characteristic or underlying medical condition associated with an increased risk of developing severe illness from COVID-19 and were fully vaccinated against COVID-19 OR no characteristics associated with risk of severe COVID-19 and were unvaccinated". These were not low risk patients.

Not fully vaccianted, or immune-compromized, then yes.