Researchers at the University of Rochester and Harvard University analyzed data reported to Medicare by the nursing homes under special pandemic regulations. The study showed that only about 25 percent of residents with covid-19 were prescribed any antiviral medication between May of 2021 and December 2022. The study, supported by funding from the National Institutes of Health and the National Institute on Aging, was published online Friday by JAMA.
Nursing homes could have done better getting the treatments to patients, especially once the Paxlovid pill was widely available starting in the second quarter of 2022, the study said. Monoclonal antibody treatments available earlier required transfusions into the bloodstream, making the treatments more challenging to administer. Another antiviral tablet to treat covid-19 authorized by the Food and Drug Administration is Lagevrio from Merck, which is not as effective as Paxlovid.
“The massive underuse of Paxlovid particularly in nursing homes almost certainly led to a lot of avoidable mortality,” said Michael Barnett, a clinician and professor of health management and policy at the Harvard School of Public Health.
At the time the FDA authorized it in December 2021, the key clinical trial found that Paxlovid reduced the risk of death and hospitalization by 88 percent for people with the greatest risk factors, including the elderly and those with underlying medical conditions. A more recent study analyzing outcomes in a Veterans Affairs database found that Paxlovid reduced the risk of death by 47 percent and hospitalization by 24 percent.
The researchers on the new nursing home analysis noted in interviews that some clinicians may have been unfamiliar with antiviral treatments during the study period. Patients also may have been discouraged by reports of a coronavirus “rebound” that can occur even after the pills knock down the infection initially. President Biden was the highest-profile patient to suffer the rebound. But the drug has been shown to be highly protective for elderly people.
The nursing home industry trade association said that facilities encountered difficulties with both supply and prescribing guidance for physicians. “Nursing home staff are committed to working with physicians, pharmacists, and family members to protect residents from severe outcomes due to covid-19 with every available tool, including therapeutic treatments,” said David Gifford, chief medical officer for the American Health Care Association and National Center for Assisted Living.
“However, nursing homes faced substantial challenges in accessing these medications as well as convincing physicians to prescribe them. The lesson to be learned here is that public health officials must prioritize our nation’s most vulnerable and provide clear guidance to health care professionals, especially during a pandemic.”
The FDA approved Paxlovid for people at high risk of severe covid-19 symptoms: the elderly and people with obesity, diabetes and other serious conditions. A three-pill dose must be taken twice a day for five days. The treatment must begin within five days after symptoms appear. There are some downsides. The pills are large and leave a metallic taste in the mouth. Another common side effect is diarrhea. It also has a negative interaction with some other drugs, including blood thinners, which are commonly prescribed to elderly people.
But the researchers said that it would be worth pausing blood thinners for a few days during a course of Paxlovid to reduce the risk of death or hospitalization from covid-19. “Almost all nursing home residents are over the age of 50, and they have multiple chronic conditions. This is exactly the population” one “would think is the intended demographic for these types of medications,” said Brian McGarry, a professor at the University of Rochester department of medicine and a specialist in aging.
Facilities with an affiliated geriatrician did a better job of getting antivirals to infected residents than did nursing homes without one, indicating a possible knowledge gap in some of the locations. Nonprofits also performed better than for-profits. Residents on Medicaid and non-White residents also received the drugs at lower rates.
In all, 40 percent of nursing homes reported not having any residents who received antiviral medications, the study showed. “A lot goes onto the shoulders of clinicians not staying on top of the guidelines, and for disparities, of not having access to the sort of high-quality providers who have clinicians who are up to date,” McGarry said.