Our Experience with Paxlovid

A seemingly rapid response, but admittedly an N of 1

My son, a former preemie who was born at 26 weeks who has cardiac and pulmonary disease, caught COVID. While he is 18 years old now, he has a history of being severely ill with viral infections, even requiring ICU admissions (for RSV and for influenza A). His cardiologist of course blames his lungs and his pulmonologist (lung doctor) blames his heart. Personally, I think it’s the combination of the two. But whatever the biological reason, he gets sicker than most. I’ve spent many nights giving him breathing treatments and watching his oxygen levels, trying to decide when we should head to the emergency room or if we can leg it out at home. Even now as a young adult with a cold he is sicker than most. It seems he has very little reserve when it comes to viral illnesses.

It started with Oliver saying he felt a little unwell. A mild headache and sore throat, but his COVID antigen test was negative. He had a known close exposure, so we were on the lookout. He woke up the next day with a bad headache, stuffed up nose, and he didn’t look good. At all. His antigen test was positive before the fluid reached the control mark. 

Sigh.

Because of his history, I wanted him to start Paxlovid, the antiviral medications nirmatrelvir plus ritonavir, as soon as possible. Nirmatrelvir prevents COVID-19 from replicating and ritonavir boosts the levels of nirmatrelvir. I knew the data showed significant reduction in hospitalization for people who were not vaccinated. It was unknown how Paxlovid might help someone who was vaccinated but at higher risk for severe outcomes with COVID-19, like Oliver, but it was now authorized for use for those at high risk of complications, whether vaccinated or not. I didn’t want to wait a few days to see if he became sicker and besides, with antivirals, generally the earlier you start, the better.

This is how I approach medical situations where the evidence isn’t clear. How will I feel if we choose decision A (start Paxlovid) and my son has a complication? How will I feel if we decline decision A (not take Paxlovid) and my son has a complication? I would kick myself if we didn’t start it or if we’d waited and he became much sicker. If he needed to be hospitalized, I would never forgive myself.

I explained this to Oliver. As he had no contraindications to taking the medication and, most importantly, being the person who experiences how he feels with viral infections and being very unkeen to be hospitalized, he also wanted to start Paxlovid. He hates swallowing pills, so him saying he wanted the medication told me he felt like crap.

Fortunately, my health plan had just started our large-scale Paxlovid rollout. As Oliver has bronchopulmonary dysplasia (lung disease of prematurity), he qualified by our guidelines, so there was no argument needed about starting. We were appropriately advised there was no data for those who are vaccinated and as such, if it made him feel sick, to stop it. I was able to get the medication by 3 pm in the afternoon, which was amazing. Our insurance even covered home delivery (they had started same day delivery for COVID-related medications, but I was stunned it actually worked).

If I consider Oliver’s first sign of COVID was the night before his positive test when he felt unwell, but still had a negative antigen test, then he started Paxlovid less than 24 hours after the onset of symptoms and about 8 hours after his positive antigen test. I am not sure it can be more ideal than that.

Getting him to take the medication was initially a bit of a chore. The pills are large and he says they taste awful and of course when you feel like shit that makes things harder.

That night he was really ill. He had a fever, headache, and congestion. He looked terrible. I was in his room every 1-2 hours checking his oxygen saturation and heart rate. He looked like typical Oliver with a bad virus, a deflated balloon. I was expecting days of this and if he never dropped his oxygen saturation I would consider that a win. But by noon it was as if someone waved a magic wand. He rose out of bed like Lazarus, said he was hungry, and devoured 10 taquitos. He also cleaned up after himself without me asking! (This, dear reader, can only mean he felt 100% better). He looked amazing. Like he had never been sick. 

He couldn’t believe it. I couldn’t believe it! 

Taking the pills became a lot easier, because he felt better and he also felt like they were working. Amazing how that helps! Also, he says they are easier to swallow with juice (for whatever that’s worth), something about less aftertaste.

And that was it. He had a minor case of the sniffles for a few days, but totally normal energy levels. He was bored. And, even more impressively, his antigen test that had been brightly positive turned negative on day 3. And we checked again on day 4 and 5. Still negative. He had no side effects from the Paxlovid either.

The data for people who are unvaccinated shows that not only did the risk of hospitalization drop dramatically with Paxlovid, 88.9% if started within 3 days of symptoms and 87.8% if started within 5 days, but viral load decreased faster as well. That data is from this study in NEJM. But what does this mean for my son who was vaccinated and received his booster early December? 

It’s possible that Paxlovid did nothing for him, meaning he would have improved this quickly regardless. Maybe being about 4 months from his booster meant something medically. But my previous experience with him and viral illnesses makes this scenario seem unlikely as the only reason for his brief course of illness. He was really ill the first night, so it seemed like we were headed for at least a typical Oliver illness. And around 24 hours after the first dose all of his symptoms, with the exception of a stuffy nose, vanished. The timing fits with the Paxlovid helping.

And a negative Antigen test on day 3? Not impossible without Paxlovid, but in someone who had symptoms 72 hours before it seems unlikely. Here too it seems likely that Paxlovid helped.

While I can’t know for sure, and of course this is an n of 1, I think he had the best possible response to Paxlovid and I wonder how much of that was due to starting the medication less than 24 hours after the onset of symptoms?

I am looking forward to the data on Paxlovid for those who have been vaccinated, but for now, based on my n of 1, it seems Paxlovid was very helpful for my 18 year old son with cardiac and pulmonary risk factors and a history of bad outcomes with viral infections. And while we likely won’t have data for a while, I am really curious about him reverting to a negative antigen test so quickly. This obviously reduces the risk of transmission to others, but it does make you think about the potential impact of early use of Paxlovid for avoiding long COVID as one study indicated that the level of RNA early in the course of illness is a risk factor. Hopefully we’ll have better data on this soon.

Until more studies are in, I would suggest knowing if you qualify for Paxlovid medically now and if you do, consider how in your health setting you might access it, so in a future scenario if you do test positive for COVID, you can enact your plan for getting it quickly. It is easier to make these plans when you feel well. You can read more about Paxlovid here, and the site also lists the drug interactions (there are a few). If you have any risk of kidney disease, kidney function testing may be needed to start. Obviously, if you have COVID lugging yourself to the lab for blood work is less than ideal, so it might be worth seeing if you need that updated in your medical record.

This doesn’t mean we shouldn’t wear masks and do everything else to protect ourselves from COVID, but it is exciting to have something like Paxlovid and I am looking forward to seeing more data so I can reframe Oliver’s experience as either luck (he was always going to get better quickly) or a real effect from the drug.