Doctors in Hawaii are now prescribing antiviral pills for the treatment of symptomatic patients with mild to moderate COVID-19, but they must be considered at high risk and meet other criteria.
Two brands of antiviral pills are available at various pharmacies and health centers in the state with a doctor’s prescription: Paxlovid, which was developed by Pfizer, and Lagevrio, or molnupiravir, which was developed by Merck.
Both have been granted emergency use authorization for COVID-19 patients by the U.S. Food and Drug Administration. But both need to be prescribed and taken within a five-day window of the onset of symptoms.
Dr. Douglas Kwock, Hawaii Pacific Health’s vice president of medical affairs, said doctors have been prescribing the antiviral pills or therapeutics since January. They are available from Straub’s outpatient pharmacy and Wilcox Medical Center.
“Both of them are used for symptomatic COVID infections,” he said. “You have to have symptoms and have to have tested positive for COVID. They are not used for hospitalized patients, so this is only outpatient treatment.”
The purpose of the antiviral pills, he emphasized, is to prevent progression to severe infections, hospitalizations or deaths due to a coronavirus infection. They are not a cure for COVID-19. Nor are they for anyone simply exposed to the coronavirus.
“So I could say that the ones that we have treated, we have not had any progress to severe infection, hospitalizations or deaths,” he said. “So far, it’s been working out very well.”
Paxlovid is the more commonly prescribed of the two because studies have shown a higher level of effectiveness, but because of potential drug interactions, Lagevrio is available as an alternative.
Who is eligible
Paxlovid is available to patients ages 12 and older who weigh at least 88 pounds who are at high risk of severe illness from COVID-19. Lagevrio is for patients ages 18 and older.
Patients need to have tested positive for COVID-19 either with a PCR or antigen test in order to be considered.
They must also have high-risk conditions, which include obesity, diabetes, heart disease, lung disease, those undergoing cancer treatments or who are immunocompromised, according to Kwock.
“The treatment would involve a discussion with your primary care physician on whether you qualify or not, and even if you did, if it is something that would be beneficial,” he said. “The bottom-line treatment would involve a discussion with the primary care physician who is familiar with these considerations.”
With Paxlovid there is a long list of drug-to-drug interactions that need to be reviewed to make sure they do not interfere with the treatment. Patients should also tell doctors of any over-the-counter medicines, vitamins and supplements that they take.
Some common anti-cholesterol and anti-seizure medications, for instance, cause drug-to-drug interactions with Paxlovid.
“If a patient has kidney disease, depending on the severity, their dosage might have to be adjusted,” he said. “If it’s mild kidney disease, then it’s OK, but if it’s severe, then it would not be a recommendation to treat them with Paxlovid.”
Those who are pregnant, breastfeeding or planning to have children should also consult with their physicians about the best options. The FDA says Lagevrio is not recommended for use in pregnancy.
When to take them
Time is of the essence for antiviral pill treatments because they must be taken within a five-day window of developing symptoms. So for patients who are candidates, quick testing and diagnosis is vital.
“If they develop symptoms and are in that high-risk category, then, yes, you do want to get tested as soon as you can because you only have a five-day window to start that medication,” said Kwock.
Paxlovid is prescribed as three pills that need to be taken at the same time, twice a day for five days. With the Merck prescription, four pills need to be taken twice a day for five days.
The federal government has purchased millions of these antiviral pill treatments and distributed the first allotments to states and territories for free, and plans to send them directly to certain health centers as well. For now they are available free of charge.
How do they work?
Basically, the antiviral pills prevent the virus from replicating.
Paxlovid is actually made up of two medications packaged together: nirmatrelvir, which inhibits the coronavirus’ protein from replicating, and ritonavir, which enhances the former drug’s effectiveness.
Generally, Paxlovid is the first choice for the antiviral prescriptions, said Kwock, but molnupiravir is an alternative if a patient has potential drug-to-drug interactions or severe kidney disease that prevent them from taking the former.
According to Yale Medicine, a clinical trial showed Paxlovid resulted in an 89% reduction in the risk of hospitalization and death. By contrast, some studies suggested that Lagevrio, or molnupiravir, resulted in only a 30% reduction in the risk for hospitalization and death from COVID-19.
There are no major side effects due to the antiviral pills, according to Kwock. The most common ones for Lagevrio are nausea, dizziness and diarrhea. Possible side effects for Paxlovid, according to the FDA, include an altered sense of taste, high blood pressure and muscle aches.
The FDA says Paxlovid is not a substitute for vaccinations and boosters against COVID-19.
Kwock said patients who meet criteria are eligible for antiviral pill prescriptions regardless of vaccination status. He encourages those eligible and not yet vaccinated to get vaccinated against COVID-19.
Where to find them
President Joe Biden in his State of the Union speech in March announced the rollout of the “test-to-treat” program, in which Americans can get tested for the coronavirus at a pharmacy and, if positive, receive a prescription for antiviral pills on the spot at no cost.
In late March the White House announced the launch of COVID.gov, a new one-stop shop online to help with access to lifesaving tools such as vaccines, tests, treatments and masks. As part of that launch, a “test-to-treat” locator is now available to the public to find pharmacies and community health centers offering tests and antiviral treatments.
A recent search for Hawaii on the locator found more than 120 locations that fill prescriptions for either Paxlovid or Lagevrio with prescriptions, mostly at CVS Pharmacies, which operate as Longs Drugs in Hawaii.
The list also includes Adventist Health Castle, Waimanalo Health Center, Kokua Kalihi Valley, Queen’s Pharmacy in Honolulu, Waianae Coast Comprehensive Health Center, Kaiser Permanente locations, Molokai General Hospital and Hilo Medical Center, among others.
Only about a dozen locations, mostly CVS Pharmacies, however, were listed as places that offered testing, medical visits and medications in one location under the “test-to-treat” model.
“The vast majority of our stores are currently dispensing the FDA emergency use authorized COVID-19 antivirals Paxlovid and molnupiravir, and have the ability to fill prescriptions as received,” said CVS in a statement.
CVS said it offers a therapeutic locator at www.CVS.com/antiviral, which is searchable by ZIP code to find a nearby Longs Drugs that may be able to dispense antiviral prescription medications.
The state Department of Health has put out a public service announcement about oral antiviral treatments for COVID-19, and offers information at hawaiicovid19.com/covid-19-treatment.
COVID-19 PILL REQUIREMENTS
Pfizer’s Paxlovid
>> Must be at least 12 years or older and weight at least 88 pounds.
>> Must have a confirmed positive COVID PCR or antigen test.
>> Must be symptomatic.
>> Must be considered at high risk.
>> Includes three pills twice a day for five days.
>> Prescription only.
Merck’s Legevrio (molnupiravir)
>> Must be at least 18 years or older.
>> Must have a confirmed positive COVID-19 PCR or antigen test.
>> Must be symptomatic.
>> Must be considered at high risk.
>> Includes four pills twice a day for five days.
>> Prescription only.
Source: FDA fact sheets
Correction: A previous version of this story contained an incorrect spelling of Dr. Douglas Kwock’s name.
