Food and drug administration licensed Paxlovid (nirmatrelvir and ritonavir) in December 2021 for the cure of mild-to-reasonable COVID-19 in adults and pediatric sufferers (12 decades of age and more mature weighing at least 40 kg) with positive results of immediate SARS-CoV-2 viral testing who are also at superior threat for development to intense COVID-19, like hospitalization or dying.

Dr. John Farley

Paxlovid is now broadly readily available in group pharmacies. Despite the fact that the amount of COVID-19 hospitalizations has decreased drastically given that early 2022, some superior-risk individuals are continue to obtaining unwell adequate to call for medical center admission, and early treatment method with Paxlovid and other offered approved or authorised therapeutics could make a variance.

In this CDER Conversation, Dr. John Farley, director of the Office of Infectious Ailments, gives beneficial facts that can assist well being care providers in selection building pertaining to Paxlovid, the chosen remedy for the administration of non-hospitalized grownups with COVID-19, according to the Countrywide Institutes of Health COVID Remedy Guidelines.

What does “direct SARS-CoV-2 viral testing” signify? Do patients have to have a positive polymerase chain reaction (PCR) check to be treated with Paxlovid?

Direct SARS-CoV-2 viral tests are used to diagnose an infection by SARS-CoV-2, the virus that results in COVID-19. Direct SARS-CoV-2 viral assessments consist of two kinds of diagnostic tests for COVID-19:

  • Molecular assessments, this sort of as PCR tests, that detect the virus’s genetic substance.
  • Swift antigen diagnostic assessments that detect specific proteins from the virus.

There are quite a few rapid antigen assessments approved for home use. Patients in the authorized population who report a optimistic home take a look at end result from a quick antigen diagnostic test to their supplier are qualified for Paxlovid below the emergency use authorization (EUA). A favourable final result on a PCR examination also satisfies the requirement below the EUA to have a positive examination end result. Affirmation of a constructive house immediate antigen diagnostic exam with further immediate SARS-CoV-2 viral screening, these kinds of as a PCR, is not needed. Serologic checks are not thought of to be direct SARS-CoV-2 viral tests.

How should wellbeing care providers assess a individual for “high chance for development to critical COVID-19”?

Sufferers in the licensed inhabitants with a hazard factor for development to significant COVID-19 are qualified for Paxlovid below the EUA even if they are thoroughly vaccinated. Patients do not have to have a lot more than a single risk component to be deemed “high risk”.

We identify that chance elements have modified more than time, and that it is appropriate to take into account vaccination status in evaluating a patient’s risk for development to extreme COVID-19.

For additional details on healthcare circumstances and things related with increased chance for development to significant COVID-19, please take a look at the Facilities for Disorder Manage and Avoidance (CDC) website.

Are there tools to support well being care companies control potential drug-drug interactions?

Sure. Food and drug administration recently up-to-date the Simple fact Sheet for Wellbeing Care Providers for Paxlovid to deliver a lot more certain tips for some medicines. We also developed a Prescriber Affected individual Eligibility Screening Checklist. The checklist is supposed to support medical choice producing, and I believe it will be a useful addition to any prescriber’s “toolbox.”

Paxlovid consists of nirmatrelvir and ritonavir. Ritonavir is a potent inhibitor of cytochrome P450 3A. Possible drug-drug interactions are an vital thing to consider. Having said that, various frequently used medicines with opportunity interactions these types of as statins, oral contraceptives, and HIV medicines can be quickly managed under supplier supervision. Recommendations are presented in the Wellness Care Company Reality Sheet and the Eligibility Screening Checklist Instrument alongside with an alphabetized list of other medicines with most likely important drug interactions. 

Other assets relating to management of medicines with perhaps significant drug interactions with Paxlovid incorporate:

Is dose adjustment of Paxlovid required for patients with moderate renal impairment?

Yes. Paxlovid is now provided in two different dose packs, one for typical dosing and a person for reasonable renal impairment dosing.

  • In people with moderate renal impairment (eGFR ≥30 to <60 mL/min), the dosage of Paxlovid is 150 mg nirmatrelvir (one 150 mg tablet) and 100 mg ritonavir (one 100 mg tablet) twice daily for five days.
  • Patients with mild renal impairment (eGFR ≥60 to <90 mL/min) should receive the standard dose of 300 mg nirmatrelvir (two 150 mg tablets) and 100 mg ritonavir (one 100 mg tablet) with all three tablets taken together orally twice daily for five days.
  • Paxlovid is not recommended at this time in patients with severe renal impairment (eGFR <30 mL/min).

Health care providers may rely on patient history and access to the patient’s health records to make an assessment regarding the likelihood of renal impairment. Providers may consider ordering a serum creatinine or calculating the estimated glomerular filtration rate (eGFR) for certain patients after assessment on a case-by-case basis.

How can I locate a community pharmacy that has Paxlovid in stock?

Paxlovid is now widely available at community pharmacies. The U.S. government maintains a locator tool for COVID-19 therapeutics that lists community pharmacies that have Paxlovid in stock. Use the search glass icon to enter the patient’s zip code. Pharmacies will be listed by proximity.

What do we know about the case reports of patients developing symptoms again after completing a course of Paxlovid?

FDA is aware of the reports of some patients developing recurrent COVID-19 symptoms after completing a treatment course of Paxlovid. In some of these cases, patients tested negative on a direct SARS-CoV-2 viral test and then tested positive again.

The benefit of a 5-day treatment course of Paxlovid was demonstrated in the clinical trial that supported the EUA. This study showed that among non-hospitalized patients at high risk of progression to severe disease, treatment with Paxlovid reduced the risk of hospitalization or death by 88%. Reductions in hospitalization and death were also demonstrated in clinical trials of other available approved (Veklury [remdesivir]) or authorized (Lagevrio [molnupiravir]) antiviral agents.

In light of these reports, additional analyses of the Paxlovid clinical trial data have been performed. In the Paxlovid clinical trial, some patients (range 1-2%) had one or more positive SARS-CoV-2 PCR tests after testing negative, or an increase in the amount of SARS-CoV-2 detected by PCR, after completing their treatment course. This finding was observed in patients treated with the drug as well as patients who received placebo, so it is unclear at this point that this is related to drug treatment. Additional analyses show that most of the patients did not have symptoms at the time of a positive PCR test after testing negative, and, most importantly, there was no increased occurrence of hospitalization or death or development of drug resistance.

These reports, then, do not change the conclusions from the Paxlovid clinical trial which demonstrated a marked reduction in hospitalization and death.

We are continuing to review data from clinical trials and will provide additional information as it becomes available. However, there is no evidence of benefit at this time for a longer course of treatment (e.g., 10 days rather than the 5 days recommended in the Provider Fact Sheet for Paxlovid) or repeating a treatment course of Paxlovid in patients with recurrent COVID-19 symptoms following completion of a treatment course.

In summary, Paxlovid reduces the risk of hospitalization and death for patients with mild-to-moderate COVID-19 at high risk of disease progression. Health care providers should consider treatment with Paxlovid or other approved or authorized therapeutics in accordance with the approved labeling or authorized Health Care Provider Fact Sheets. Patients who test positive for SARS-CoV-2 who have symptoms should discuss treatment options with their health care provider as soon as possible after testing positive. Health care providers and patients should refer to CDC recommendations regarding patient isolation, and should wear a mask and isolate if they have any symptoms regardless of whether or not they have been treated with an antiviral agent.

Thank you, Dr. Farley. Do you have any final remarks you’d like to share with health care providers about Paxlovid?

I would like to reiterate that Paxlovid is now widely available at community pharmacies. There is strong scientific evidence that it reduces the risk of hospitalization and death in patients with mild-to-moderate COVID-19 at high risk for progression to severe disease. It is also expected to be effective against the Omicron variant. For more information about the EUA for Paxlovid, including possible risks of use, the Fact Sheet for Health Care Providers, and Prescriber Patient Eligibility Checklist, please visit FDA’s Emergency Use Authorizations webpage.