Paxlovid vs Remdesivir vs Monoclonal Antibody: What are the Differences?
If you are confused about the recommendations made by different professional groups for the COVID-19 pandemic, you've come to the right place.
Most people with COVID-19 will experience a mild illness, and they’ll be able to take care of themselves at home. But some—especially those with underlying health conditions—could benefit from one of several COVID-19 treatments. Some of these are available in pill form and others are given intravenously or by injection—and all of them must be prescribed by a health care provider.
BQ.1.1 is a new Omicron subvariant descended from Omicron BA.5. BQ.1.1, along with its sister variant BQ.1, accounts for around 62.8% of new COVID-19 cases in the U.S. (CDC). Are the current treatment options still relevant?In this article, we will do a roundup and cover 3 popular anti-viral treatments i.e. Remdesivir, Paxlovid and Monoclonal Antibodies.
Remdesivir (Veklury)What is it? The antiviral treatment remdesivir, sold under the brand name Veklury, was the first COVID-19 therapy to get full FDA approval, and, so far, it's still the only one. Although originally used in COVID-19 patients only after they were hospitalized, new data suggests it can be helpful in outpatients who become infected and who are at high risk for severe disease. It is meant for people who have a current COVID-19 infection.
When it was authorized:
How you take it: Via injection or IV and administered only in a health care setting by a health care professional. For outpatients, the treatment is a three-day course of infusions that must be initiated within seven days of symptom onset.
Side effects: Nausea is the most common side effect. Hypersensitivity, including infusion-related and anaphylactic reactions, has been observed following treatment. There is insufficient data on the safety of using remdesivir in pregnant women or women who are breastfeeding; patients should speak with their health care provider.
How it works: Administered intravenously to patients who are in the hospital or in an ambulatory setting, the drug inserts itself into new viral genes to block replication of the virus, shortening the time it takes seriously ill patients to recover. A number of experts believe that the drug may work best early in the course of an infection.
How well it works: 87% reduction in risk of hospitalization in non-hospitalized patients given a three-day course, according to a study published in The New England Journal of Medicine in December 2021.
What else you should know: For hospitalized patients, research in early 2020 showed that
the therapy reduced length of stay (the number of days in the
hospital) from 15 days to 12. However, questions have been raised
about remdesivir’s trial results for hospitalized patients. In late
2021, the World Health Organization (WHO) recommended against
remdesivir after releasing data that showed disappointing results. Still, many U.S. hospitals continue to provide this medication.
This is one of two NIH-preferred therapies (after Paxlovid) for COVID-19.
More information: Gilead remdesivir fact sheet for patients.
Paxlovid and COVID-19
How to Get Paxlovid Without a Medical Doctor
In March 2022, the Biden administration launched the Test to Treat initiative. The initiative’s goal was to allow people to be tested for COVID-19 at
pharmacies or health centers that have an on-site clinic, like CVS
MinuteClinic. If you had a positive test, you’d then receive an antiviral
prescription at the pharmacy before leaving the building.
While well-intentioned, there were many roadblocks that made the Test to Treat initiative difficult to roll out. One big barrier was the fact that most pharmacies don’t have clinics in the same building. In late May 2022, there were only about 2,500 Test to Treat locations in the entire U.S. This left many Americans still struggling to get a prescription from their healthcare providers in enough time to benefit from Paxlovid.
In response to this, the FDA updated Paxlovid’s EUA in July 2022. This change allows pharmacists to prescribe Paxlovid directly to people who have tested positive for COVID-19. This means that you might be able to head over to your local pharmacy for the medication without having to make other stops along the way. Keep in mind that not all pharmacies may offer this service.
- Your current health records, which must be less than a year old (either electronic or printed records are fine)
- Your most recent liver and kidney function tests, which must be less than a year old
- A complete list of all medications that you take, including any over-the-counter (OTC) medications, vitamins, and supplements
How much will Paxlovid cost?
New Paxlovid Dose Pack Authorized by FDA
- The standard packaging that is currently in distribution: 300 mg nirmatrelvir;100 mg ritonavir - Each carton contains 30 tablets divided in 5 daily-dose blister cards. Each blister card contains 4 nirmatrelvir tablets (150 mg each) and 2 ritonavir tablets (100 mg each). Nirmatrelvir tablets and ritonavir tablets are supplied in separate blister cavities within the same child-resistant blister card.
- The new packaging option that will be in distribution later this month: 150 mg nirmatrelvir; 100 mg ritonavir - Each carton contains 20 tablets divided in 5 daily-dose blister cards. Each blister card contains 2 nirmatrelvir tablets (150 mg each) and 2 ritonavir tablets (100 mg each). Nirmatrelvir tablets and ritonavir tablets are supplied in separate blister cavities within the same child-resistant blister card.
At the same time, the CDC wrote, “a brief return of symptoms may be part of the natural history of [coronavirus] infection in some persons, independent of treatment with Paxlovid and regardless of vaccination status.”
The CDC said there is no evidence for more treatment in rebound cases, though people should isolate again for at least 5 days so they won’t pass COVID-19 to others.
People who have a rebound after taking Paxlovid can report their cases to Pfizer’s adverse event reporting page.
Paxlovid's Contraindications and Drug Interactions
Pfizer anti-COVID pill's interaction with common drugs will narrow its benefit, experts say | National Post:
The buzz around PAXLOVID™ has largely obscured one major downside of this treatment. Ritonavir can interact dangerously with a slew of commonly used medications, pumping up the potency of blood thinners, heart-arrhythmia therapies, epilepsy drugs and others. And the patients targeted for its use – those most at risk of serious COVID disease because of age and other health issues – are also the people most likely to be taking those “contraindicated” medications.
In some cases, the interactions could be managed, but it’s clear the problem will limit the pool of potential recipients, experts say. “It has a utility, it has a use,” said Dr. Gerald Evans, head of the Infectious Diseases Division of the Queen’s University medical school. “(But) I certainly would not call it a game-changer.” “A patient on blood thinners could end up with spontaneous bleeding in the gastrointestinal tract or brain”, noted Evans.
“Someone taking pills for hypertension might see their blood pressure fall so much they pass out”, said Dr. Andrew Hill, a pharmacology researcher at the U.K.’s Liverpool University. “There are all kinds of ways that PAXLOVID™ could cause serious harm,” he said.
Ritonavir is also used in HIV treatments, so there is a wealth of knowledge about those potential drug interactions. The U.S. Food and Drug Administration (FDA) product monograph for PAXLOVID™ lists over 100 drugs that it says should not be taken with the COVID pills, or whose use ought to be carefully monitored. The figure below lists a few of these drugs as well as liver enzymes whose functions are impacted by Ritonavir.
See Sections 4 and 7 of the FACT SHEET FOR HEALTHCARE PROVIDERS and a publication on JAMA by Ross et al. Pharmacists as prescribers may be a problem since they are not authorized to manage, deprescribe and be responsible for the OTHER drugs.
Bebtelovimab (Monoclonal Antibody)
|Credit: Design Cells/SPL|
The COVID-19 Treatment Guidelines Panel’s Statement on Therapies for High-Risk, Non-hospitalized Patients With Mild to Moderate COVID-19 (Last Updated: December 28, 2022)
Preferred therapies. Listed in order of preference:
- Ritonavir-boosted nirmatrelvir (Paxlovid)
Efficacy of Antiviral Agents against Omicron Subvariants BQ.1.1 and XBB | NEJM (Dec 2022)
Emergency warning signs
- Difficulty breathing
- Persistent pain or pressure in the chest
- Bluish lips or face
- New confusion or inability to arouse
Information provided in this article is for general informational purposes only. No content in the articles should ever be used as a substitute for medical advice from your doctor or other qualified clinician. Always seek the individual advice of your trusted health care provider with any questions you have regarding a medical condition.
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