Should you take Paxlovid if you Test Positive?

We seem to have entered a new normal for COVID.  COVID doesn't seem to be leaving anytime soon, and people continue to get infected.  However, symptoms are generally manageable and mild, and hospitalizations and deaths are still quite low.  Politics aside, compare when President Trump got COVID (had a drop in oxygen, was seriously ill, had to be hospitalized and did well due to multiple treatments not yet available to the public) to President Biden's recent COVID illness (mild symptoms, taking Paxlovid available to everyone, stayed in the White House and continued to work).  While COVID is still around, we have truly come a long way, mostly due to vaccines, boosters, and treatments like Paxlovid.  Thus, with many people still getting COVID; patients, friends, and family are asking me about taking Paxlovid when they test positive.  

 
First, it is important to note that one should not take Paxlovid if they don't have symptoms.  I generally don't recommend testing for COVID unless you have symptoms.  If you decide to test for personal reasons (want to visit an at-risk friend who requests that you test before visiting) and test positive; other than masking and staying away from at-risk people, I wouldn't do anything unless symptoms develop.  
 
Second, it's important to understand how Paxlovid works.  It is actually two medications: the main one stops COVID from spreading and getting worse, and the second one is an HIV medication designed to block the breakdown of the first one to increase its levels in the body.  While there is good evidence that Paxlovid prevents hospitalizations and death in at-risk individuals, there is no evidence that it actually makes you feel better. 
 
Third, one needs to look at the downsides of Paxlovid.  First, the component that is the HIV drug in Paxlovid interacts with a lot of other medications, so some medicines (like cholesterol lowering drugs) need to be stopped.  Second, Paxlovid does have some side effects- primarily metallic taste and stomach upset.  However, more importantly, there is a clear phenomena which may occur in up to 20% of patients where patients improve from COVID and test negative, only to get sick again and test positive again. (The actual number is not known.  Early reports from studies were around 2%, but what I and other doctors are seeing appear closer to 10-20%).  This happened to both Dr. Fauci and more recently President Biden. Exactly why this happens is unclear, but the biggest downside of Paxlovid is that it can make you symptomatic (and contagious) for longer. 
 
In summary, Paxlovid decreases hospitalization and severe complications for high-risk COVID patients, but at the expense of some side effects, medication interactions, and more importantly prolonging illness in as many as 20% of patients. Because of this, I am really only recommending Paxlovid for symptomatic high risk patients.  High risk patients include those over 65, or those under 65 with high risk diseases such as diabetes, heart disease, and anything that can compromise the immune system, like cancer treatment.  If you don't have these risk factors, you should probably not take Paxlovid.  Also, Paxlovid should be taken within 5 days of symptoms to work.  So, for someone who it is not clear whether taking Paxlovid is worth it, you can always wait a few days and see how your symptoms develop before you and your doctor make a decision about taking Paxlovid. 
Author
Matthew L. Mintz, MD, FACP

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