A new variant of the coronavirus is circulating, the most transmissible to date, with hospitalizations on the rise. And older adults account for nearly 90% of the COVID-19 deaths in the United States in recent months, the largest share since the start of the pandemic.
What does this mean for people 65 and older who get covid for the first time, or who experience a second infection?
The message from infectologists and geriatricians is clear: use antiviral therapy, which continues to be effective against new variants.
Experts say the first-choice therapy is Paxlovid, an antiviral treatment for people with mild to moderate covid at high risk of severe illness.
All adults age 65 and over fall into this category. If people cannot tolerate the drug (a medical provider must carefully evaluate possible drug interactions), 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 people,” said Dr. Harlan Krumholz, a professor of medicine at Yale University.
In the meantime, it is convenient to have an action plan. Where to seek care? What if the GP is not available quickly? Paxlovid must be started no later than five days after the onset of symptoms.
“The time to know all of this is before you get it,” said Dr. Allison Weinmann, an infectious disease specialist at Henry Ford Hospital in Detroit.
A study of 45,000 outpatients age 50 and older treated for covid between January and July 2022 at Mass General Brigham, a large Massachusetts health system, showed the efficacy of Paxlovid. 28% of patients were prescribed the drug, which had received emergency use authorization for mild to moderate covid from the FDA in December 2021; 72% did not take it.
Unlike other studies, most of the patients in this one had been vaccinated. Still, Paxlovid conferred a notable advantage: Those who took it were 44% less likely to be hospitalized with serious covid-related illness or to die.
A few months earlier, a study from Israel had confirmed the efficacy of Paxlovid, the trade name for a combination of nirmatrelvir and ritonavir, in older people infected with the omicron strain, which emerged in late 2021. (The original study that established the effectiveness The Paxlovid trial was performed while the delta strain was prevalent and included only unvaccinated patients).
In patients 65 years or older, most of whom had been vaccinated or previously had covid, hospitalizations fell by 73% and deaths by 79%.
Still, several factors have hampered the use of Paxlovid among older adults, including concerns from doctors about drug interactions, and from patients about potential “rebound” infections and side effects.
Dr. Christina Mangurian, vice dean for academic affairs at the University of California-San Francisco School of Medicine, encountered several of these problems when her parents contracted covid in July, an episode she recounted in a recent JAMA article.
First, a doctor her 84-year-old father didn’t know told her in a virtual doctor’s appointment that she couldn’t take Paxlovid because she was taking a blood thinner, a decision her primary care doctor later reversed.
Then her 78-year-old mother was told, in another virtual appointment, to take an antibiotic, steroids and over-the-counter medication instead of Paxlovid. Once again, her primary care physician stepped in and she wrote him a prescription.
Mangurian said that in both cases, the virtual doctors did not know when to recommend Paxlovid. “This points to a huge deficit in terms of how information about this therapy is disseminated to frontline medical providers,” he said 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 nurses. In general, they are told that they cannot have Paxlovid until they are seriously ill, just the 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 major concern, especially in older patients with multiple medical conditions. More than 120 medications have been highlighted, and each case must be evaluated, taking into account the person’s conditions, as well as kidney and liver function.
The good news, experts say, is that most potential interactions can be controlled, either by temporarily stopping a drug while taking Paxlovid, or by reducing the dose.
“It takes a little bit of extra work, but there are resources and systems out there that can help practitioners figure out what to do,” said Brian Isetts, a professor at the University of Minnesota School of Pharmacy.
In nursing homes, patients and families should ask to speak with consulting pharmacists if they are told antiviral therapy is not recommended, Isetts suggested.
About 10% of patients cannot take Paxlovid because of possible drug interactions, according to Dr. Scott Dryden-Peterson, medical director of outpatient therapy for COVID at Mass General Brigham.
For these patients, Veklury (remdesivir), an antiviral infusion therapy given for three consecutive days, is a good option, though sometimes difficult to manage. Also, Lagevrio (molnupiravir), another antiviral pill, can help shorten the duration of symptoms.
Many older adults fear that they will have a rebound infection after taking Paxlovid. But in the vast majority of cases, “the rebound is very mild and the symptoms, usually runny nose, nasal congestion and sore throat, go away within a few days,” said Dr. Rajesh Gandhi, an infectologist and professor of medicine at Harvard Medical School.
Gandhi and other doctors say the risk of not treating covid in older adults is far greater than the risk of rebound disease.
Paxlovid side effects include a metallic taste in the mouth, diarrhea, nausea, and muscle 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 quickly.”
KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth journalism on health. It is one of the three main programs of KFF, a non-profit organization that analyzes the problems of health and public health in the nation.