The pill Paxlovid, used to treat coronavirus disease (COVID-19), is seen in boxes at the Misericordia hospital in Grosseto, Italy, February 8, 2022.
Jennifer Lorenzini | Reuters
The Food and Drug Administration’s independent advisory panel on Thursday recommended full approval of Pfizer’s Covid-19 antiviral pill Paxlovid for high-risk 16-1 adults, but pointed to potentially harmful drug interactions.
Treatment is recommended for people over 50 or those suffering from a variety of conditions, such as high blood pressure or diabetes, that put them at higher risk of ending up in hospital or dying from Covid.
The FDA first made Paxlovid available for emergency use in high-risk individuals ages 12 and older in December 2021. Pfizer submitted an application for full approval of the drug in June 2022, but the FDA extended its review deadline for the application in December 2022.
The agency generally follows the advice of its advisory committees, but is not obliged to do so. A final decision will be made in May.
“I would say that along with oxygen, Paxlovid has probably been and continues to be the most important treatment tool during this epidemic,” said Richard Murphy, chief of infectious diseases at Veterans Affairs White River Junction Medical Center.
The panel relied on three of Pfizer’s mid- to late-stage clinical trials of Paxlovid, which enrolled more than 6,000 patients in 21 countries.
A study called EPIC-HR looked at high-risk adults who were unvaccinated and had no prior Covid infection. The study found that Paxlovid reduced the risk of hospitalization or death by 86% in adults treated within five days of symptom onset and by 89% in those treated within three days of symptom onset, such a review of the company’s data by the FDA.
“I found the efficacy data clear and compelling,” said Dr. Sankar Swaminathan, chief of the Department of Infectious Diseases at the University of Utah School of Medicine.
However, the advisors agreed that serious side effects due to drug-drug interactions or DDIs are an important safety issue with Paxlovid.
Photo taken on July 31, 2022 shows a health worker taking a swab sample from a woman to test for the Covid-19 coronavirus at a swab collection center in Guangzhou, southern Guangdong province. About a third of people with Covid will experience recovery in their symptoms regardless of whether they have been treated with the antiviral Paxlovid, according to a study published online on Tuesday.
St. | AFP | Getty Images
“I just want to emphasize that we underscore the importance of risk reduction for the prescriber, primary care provider, physician and other prescribers in relation to drug-drug interactions,” said Dr. David Hardy, associate clinical professor of medicine at the University of Southern California.
“That’s where I think we could get in trouble, I should say where they would get in trouble if they prescribe this drug without knowing well what ritonavir does to other drugs,” he said. Paxlovid consists of two antiviral drugs, ritonavir and nirmatrelvir.
Interactions with other drugs
More than half of Paxlovid-eligible Medicare and Veterans Affairs patients take medications that have drug-drug interactions with Paxlovid, according to an FDA review of safety surveillance data. About 74% of Paxlovid prescriptions came from adult primary care physicians who may not have experience managing possible adverse drug interactions, the FDA review added.
The FDA said its Office of Surveillance and Epidemiology had recorded 271 reports of serious adverse events potentially related to drug-drug interactions with Paxlovid through the end of January, including 147 hospitalizations. The most common drugs causing problems are immunosuppressants, which are commonly used to treat HIV and organ transplant patients, according to the FDA.
But Swaminathan noted that drug interactions should be “responsive and minimized.” FDA officials said at the beginning of the meeting that they could potentially be addressed by adjusting the dose of certain drugs, increasing patient monitoring, and ensuring product labeling informs prescribers and patients about potential drug interactions.
Paxlovid consists of two separate medicines packaged together and is designed to reduce the risk of hospitalization or death from Covid. Nirmatrelvir blocks a key enzyme the Covid virus needs to replicate, while ritonavir boosts the first drug’s ability to fight infection.
Patients take Paxlovid within five days of onset of Covid symptoms to reduce the risk of hospitalization or death. To complete a full cycle of the drug, patients must take three Paxlovid pills twice a day for five days.
According to federal data, more than 12 million cycles of Paxlovid have been shipped to pharmacies in the United States, and 1.3 million doses are available nationwide. About 10 million patients in the US and 14 million worldwide have been treated with the drug, according to Jim Rusnak, Pfizer’s chief development officer for internal medicine.
Paxlovid’s sales rose to $18.9 billion in 2022, the first year it was available, but Pfizer expects sales to fall 58% this year to $8 billion.
The only vote against Paxlovid came from Terry Gillespie, a patient advocate from Plainfield, Illinois. Gillespie expressed concern that doctors didn’t know when to prescribe the drug, noting they had had Covid infection four to five times, “but never once” Paxlovid was offered.
“I don’t feel like doctors really know how to use it,” Gillespie said.
After the vote, Swaminathan also noted that he has a “worryingly large number of patients” whose doctors are advising them not to take Paxlovid for fear of renewed Covid cases. Then patients see their Covid symptoms or a positive test after initially recovering.
“I am concerned that there is not a good understanding in the medical community and patients are actually being discouraged from taking an effective drug that could save their lives,” he said
Reports of these cases surfaced shortly after Paxlovid launched in 2021, with President Joe Biden and his former chief medical adviser Dr. Anthony Fauci appeared to have recovered from Covid after taking the antiviral cocktail before testing positive again.
Swaminathan said there is “dramatic acceptance” in the media that Paxlovid causes rebound cases and is “potentially worse” than what you had before taking the drug, although there is a lack of data to support this belief.
dr Lindsey Baden, the panel chair and director of Brigham and Women’s Hospital, added that new data suggests the rebound cases caused by Paxlovid “are not the biology of what’s going on.”
“Until recently, even some of the data shared today helped me understand what that means. So we’re seeing real-time data that’s systematic and informative,” Baden said.
An FDA review of Pfizer’s clinical trials found that overall rebound rates ranged from 10% to 16%, “with no evidence of a higher rate of symptom rebound or moderate symptom rebound” in patients taking Paxlovid compared were given a placebo. This is also independent of the patient’s risk of serious illness or whether the Omicron variant or an earlier strain is dominant, according to the agency’s staff.