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Paxlovid may reduce the chance of long Covid. Why don’t doctors prescribe it more?

Experts who study and treat long Covid agree that Paxlovid seems to lower the risk of lingering symptoms. Some long Covid patients regret not taking it.
Photo Illustration: A Paxlovid box
Justine Goode / Getty Images

A consensus has emerged among experts who study and treat long Covid: Paxlovid seems to reduce the risk of lingering symptoms among those eligible to take it.

The idea is intuitive, experts say. Paxlovid prevents the coronavirus from replicating, so researchers think it may also reduce the risk of an infection causing inflammation or organ damage, which in turn can lead to chronic illness.

Clinical observations and a large study published in March support that theory. Among the 282,000 people in the study who were eligible for Paxlovid, the drug was associated with a 26% lower risk of long Covid. 

“Research definitely backs up that it helps prevent lingering symptoms — it helps prevent long Covid,” said Ashley Drapeau, director of the Long Covid Clinic at the GW Center for Integrative Medicine.

Some patients who took Paxlovid during their illness also seem to have less severe long Covid symptoms overall than those who did not, according to Drapeau. 

But doctors who treat people for active Covid infections say they aren’t widely prescribing Paxlovid, since the medication interacts with several common drugs and is only approved for people vulnerable to severe illness — older adults and people with underlying medical conditions.

Data from the Veterans Affairs St. Louis Health Care System indicates that just 30% of patients who qualify for Paxlovid are being prescribed it, said Dr. Ziyad Al-Aly, the system’s chief of research and development. 

Research from Helix, a genomic data company, similarly showed that around one-third of nonhospitalized adults at risk of severe Covid were prescribed an antiviral from February to June. 

“It’s really unfortunate that people are not prescribing it enough, especially going into the winter season,” said Al-Aly, who authored the March study.

“It’s kind of like when a vaccine is available and people are not using it,” he added. “It’s really, profoundly sad.”

Some long Covid patients regret not taking Paxlovid 

Reta Greenier, a 61-year-old special education teacher in Saint David, Maine, said she asked her doctor for Paxlovid shortly after testing positive for Covid in August 2022. At the time, she said, she had a cough, a slight fever and fatigue.

“I said, ‘I heard there’s a medicine out there now that you can take that will make this less severe,’” she recalled. “I didn’t know much about long Covid at that point. In fact, I don’t think I knew about it at all.”

But Greenier’s doctor told her he didn’t know enough about Paxlovid to feel comfortable writing her a prescription, she said, despite several factors that made her eligible: her age, weight and a history of asthma. Her doctor did not respond to a request for comment.

Since then, Greenier said, she has had long Covid symptoms including painful constipation and a combination of dizziness and an elevated heart rate that makes her feel like she might pass out. In June, she said, she called her attorney’s office and asked to update her will.

“I thought I was dying,” she said.

Greenier said she can only work part-time now, and wonders whether she would be back full-time if she had taken Paxlovid.

Drapeau said many of her long Covid patients report that they weren’t offered Paxlovid or were told by their health care provider that they didn’t need it. 

“Many of my patients come to me and say, ‘If only I had taken the Paxlovid …’” she said.

Why aren’t more people taking Paxlovid?

Drapeau said doctors probably don’t consider long Covid as a primary risk factor when deciding whether to prescribe Paxlovid.

“They’re thinking, ‘How can I prevent this person from being in the hospital?’” she said. “Versus, ‘How can I prevent them having lingering symptoms that are going to cause major debility in their life?’”

Doctors, for their part, cite a few other reasons: Paxlovid interacts negatively with some anti-seizure and heart medications, as well as certain drugs that lower blood pressure or cholesterol. The medication can also have side effects, such as diarrhea, nausea and a metallic taste in the mouth. 

Doctors also weigh how severe a person’s symptoms were the last time they got Covid, if this is not their first infection.

“In general, if you had mild symptoms the first time, you’re probably going to have mild symptoms again, and Paxlovid often makes people feel worse,” said Dr. Geoffrey Mount Varner, an emergency room physician in Virginia and Maryland. 

To a lesser extent, doctors see Paxlovid’s potential “rebound” effect as a deterrent as well. A small study found that less than 1% of Covid patients saw their symptoms come back one to two weeks after taking Paxlovid. Other research that’s yet to be peer-reviewed found that 6% of a group of 11,300 Covid patients saw symptoms rebound in the month after they took the medication.

But Al-Aly said concerns about rebounds and side effects are overblown. 

“You may have malaise again or fever, but it’s all in the acute phase,” he said. “It usually gets better a few days later, and in the long term is inconsequential.”

A potential treatment option for long Covid?

Paxlovid is taken twice daily, in sets of three pills, for five days. It’s the National Institutes of Health’s preferred treatment for mild to moderate Covid and has been approved since December 2021. 

At first, doctors touted Paxlovid as a breakthrough: The drug lowered the risk of severe illness and death from Covid by 89% in a clinical trial, and reduced the risk of hospitalization by 51% in a real-world study.

In the spring and summer of 2022, Paxlovid made up a much larger share of prescriptions filled at pharmacies than it did over the same period this year, according to GoodRx’s prescription tracker. Now, the weekly share of Paxlovid prescriptions is about the same as last October.

Some experts think the drug might even improve symptoms for patients who already struggle with long Covid. As the theory goes, Paxlovid may help clear lingering virus or viral proteins in the body that continuously aggravate the immune system.

But researchers are still evaluating that application of the drug. The NIH’s RECOVER Initiative is giving people Paxlovid for up to 25 days to see if it improves their long Covid symptoms. The first participant in that study was enrolled in July. Studies at the Yale School of Medicine and Karolinska Institutet in Sweden are also investigating Paxlovid as a potential long Covid treatment.

Dr. Benjamin Abramoff, director of the Post-COVID Assessment and Recovery Clinic at Penn Medicine, said he recommends Paxlovid for people with long Covid who get reinfected.

“I’ve had a couple patients report improvement through that process,” he said. “Even if they’re not necessarily high risk, I think there’s a lot of benefit for many of our patients who have significant long Covid symptoms.”

Another unanswered question is whether young, healthy people might benefit from Paxlovid. Though doctors don’t have evidence of that yet, Drapeau said there’s reason to believe the drug could reduce the risk of long Covid even for people without underlying risk factors.

“It makes sense to me that we give it to a wider population,” she said.