Please keep them coming! Covid is changing but it's not going away--but information about it is dwindling.
I'm so glad you utilized your plan and have come through this. Wondering if your test ever turned positive.
It's like flu now--where even uptodate says (re: flu) don't wait for the fairly useless rapid tests--treat if clinical suspicion is high.
Your approach to avoiding infection while living life is just so spot on--and it's just so helpful as we navigate the new normal of an infectious disease that knows no seasonality yet.
Personally, I look at JWeiland and the PMC model (weekly) to get a sense of circulating levels and weigh my own risks/benefits.
I just tried to reach out to a high risk patient who was seen in the ED, actually diagnosed with Covid and sent home with no Paxlovid...it's the norm but why?
Thank you for all you do and please thank the artists.
Hi Jan, thanks for your support and encouragement! It does take a good amount of time "clipping" these articles and then synthesizing each month, but I'll keep it up. Do you remember those "clipper" things that had a razor and could be used for saving choice newspaper/magazine articles/paragraphs? I miss those days, as an older family member used to keep me posted this way!
My rapid test was equivocal, but like I said the viral dose I received before the first family member tested positive was assuredly large. I'm glad UpToDate has switched over to the "treat with high index of suspicion" model we often use with flu... my office has rapid flu A, flu B, and Covid testing, but nothing is 100% accurate. These rapid tests are now available in a 3 in 1 swab at most pharmacies for A LOT cheaper than medical offices charge as I'm sure you know.
JWeiland continues to be a rockstar. He should write a Substack already!
And yes, I struggle with the counter narrative that antiviral treatment is not worth it all the time, from patients and clinicians.
Uptodate hasn’t officially switched over to high clinical suspicion yet for COVID treatment--I kind of doubt they will but as we know testing is not perfect.
They have for flu.
I did reach the patient who was grateful for Paxlovid and very upset with the ED…
Please keep these coming. It’s reassuring to have a factual and timely resource and I appreciate your investment in compiling it. And the artists are inspiring!
Curious how long you took the paxlovid for (8 days)? It all seems like a guessing game other than likely that 5 days is not enough (and it's difficult and expensive to get more)
Hi Robin, cost and availability are definite issues with Paxlovid. I had an extra supply left over from an overseas trip, so you are correct about the duration. Was really happy to finish that as the taste was oppressively disgusting. It did not seem worth taking based on symptoms being so mild, but as you know I was betting on lower viral loads and better clearance, for long Covid and other collateral damage reduction. The game - often inscrutable from the outside, but well studied internally.
I have seen studies showing lower rebound rates in immunocompromised patients taking longer courses, assume it would be the same for everyone else, wish there were studies and more info on the actual optimal duration!
Paxlovid worked great for me (I'm old, so no way I wasn't taking it) but I got the rebound which was annoying although not serious. I can tell you that a York peppermint patty every 6 hours does a pretty good job killing the taste. One of my church friends, who is 81, tells me that 1-2 tsp of Atomic Fireball Whiskey on the same schedule works, too. Or maybe it just makes you not care, I dunno. Thank you for a great series
The best synopsis of Covid 2024 I have read! Thank you so much for all you do to educate and inform us. Easy to see where your daughter gets her artistic talent!!
Thanks Patti! I struggle to pare these down in terms of studies and word counts, but I figure at the end of the day people want more from long form newsletters on Substack. And yes, like grandmother like granddaughter! It is a true pleasure to watch them paint together.
Very much appreciate your continuing excellent work, and artwork!
As a non-physician, do you have any advice for approaching a cautious, wary internist about prescribing “preemptive” Paxlovid and metformin? Or must I rely on “urgent” care facilities?
I understand the caution from the internist... as far as I know there are no RCTs evaluating Paxlovid + metformin together versus placebo, or versus one or the other yet. Most physicians are not prescribing both together, myself included, but I do offer knowns and unknowns to my patients and let them decide. Feel free to print out my "self treatment plan" linked above in the case report, as it is well referenced. It is only a showing of my own cards though, and not medical advice to others per se.
Prescribing two medications at the same time does not feel like much effort to me, as many of my patients unfortunately have to take 5-10 medicines daily anyway. I always use the University of Liverpool Medication Interaction checker with Paxlovid, and there is no concern as of this writing with combining these two meds from a drug metabolism perspective. https://www.covid19-druginteractions.org/checker
Once again, talk to you doctor, and feel free to cite the science, but acknowledge a little leap of faith in the absence of that necessary RCT.
Urgent care will only prescribe Paxlovid I'm guessing, and sometimes this needs to be requested after an initial dismissal.
Well this has been a stupendous series from the start. I really appreciate the focus on actionable, primary care type studies. It reinforces the guidance we get about staying up to date with vaccines and taking antivirals, but also sees the different game and players in 2024 like you said.
And what tremendous artists-in-residence you have shared with us! The painting for this month is outstandingly good! The play of light and shadow is kinetic, and the epic clouds and winter fields might symbolize the power of nature, with the house and fence showing our human efforts to create structure and order in the vast incomprehensible world?
Kind of like science itself!
OK enough amateur art criticism, please accept my thanks for your writing, and extend my appreciation to the artists.
Grant! What a fun comment, and I would say your art appreciation skills are "stupendous," too. I'm glad you have not found this series too heavy handed or fearmongering, but rather a highlight show of the counternarratives revealed by ongoing Covid science and inquiry.
As you know I'm on the front lines of patient care, not research... so what I present here is hopefully of more relevance to real people trying to figure out what to do.
I'll pass you compliments on to the artists! Love the word "kinetic." Need to figure a way to use that one more! Happy New Year :)
Thanks CBA👌 I’m hopefully not too biased with my selection of articles, as I do try to stick to good journals and less dogmatic voices here, without iconoclastic or political interference. Keep you posted if the evidence changes the Covid prevention and treatment narrative.
Your posts are invaluable, gorgeously illustrated (wow, Grandma’s is glorious—I love how the artistic gift is traveling down the generations), and what a lovely gift of a booklet on top of it. Can’t wait to download it.
Very sorry to learn of your spoiled Thanksgiving, but glad to know you and yours came through OK. Thank you, science!
On metformin: Glad to see it is helpful, as it comes in liquid form, and Pax does not. I’m going to talk with my PCP about that, as it’s a big worry not to be able to swallow the Pax pills, which appear are still the main line of defense, correct?
Very concerning to learn of the shortage of peds MDs. It is awful to think we are coming into an extremely anti-science, anti-expert period given all the health and public health needs we have.
On the vax timing calculation: I remember when you first cranked out the specifics and wondered again when you have time to sleep. (Glad, BTW, to see you are following your own napping, etc. advice after COVID!) I still don’t understand the math, which is my problem, solely, but what leaps out to me is this: “vaccine-induced protection levels, which peak in the first month post-vaccination before declining over subsequent months.” This suggests to me that, all things being equal, getting the vax a month before a time of anticipated higher virus levels/chances for exposure, could make sense . It is hard to time that way in the real world, I suspect, but is it worth bearing in mind?
Thank you for everything, and may you and yours have a happy and healthy new year.
Hi Susan, happy new year to you, too! I don’t think there is a higher compliment than “glorious” so I’ll be sure to pass that on to the artist!
Yes the ID Society and NIH guidelines recommend paxlovid as first line treatment, and I don’t think metformin has made the official consensus list yet… not sure why as there has been at least one good quality RCT supporting its use, safety, etc. No need to read these guidelines as they are pretty long, but the official stuff:
And to be honest I don’t quite get the mathematical underpinnings of the 9/15 Covid vaccination optimized date either, but I included it more for the YLE graphic that is based on the math for people with recent infections. I agree with you that it makes sense to individualize the choice based on unique risk factors, what’s actually going on with COVID rates, family structure/school aged kids, grandparents , weddings etc!
Thank you for such a complete and informative evidence based summary. I find all of your articles invaluable and appreciate how you blend them with your clinical experience. Please tell both artists that I enjoy their work very much and that they have brought joy to my life. Both artists have significant artistic gifts. Happy New Year!
Hi Tara, many thanks from me and I’ll pass on the compliments to the artists☺️
I think clinical experience is important as we increasingly turn over decisions to non-clinical entities, AI, and politicians. Thanks for supporting us humans who actually do the work and see the patients!
Happy New Year, and I hope 2025 is bright and healthy for you!
I was at urgent care twice with my teen…the 27th and 29th. Viral illness (possibly RSV; they do not test for it and strep, covid, and flu were negative…twice) that led to a ruptured eardrum. Not a good Christmas gift. Not a mask to be found except on us. I watched people disregard the “please take a mask if you are experiencing respiratory symptoms” sign and cough, sneeze, and snot all over the waiting room and triage room. No masks on any nurses, medical assistants, or on the MD and PA we saw.
I admit, after well over a year of going to well checks and a breast health clinic and an orthopedist, and urgent cares during sick season and seeing zero masks on providers and employees, I wonder if I am the ridiculous one. I mean, they seem not to be fearful of breathing in contagious illness. And surely, they are exposed to high viral loads all day…and don’t get sick?
I hope your teen is feeling a bit better now, ADWH. I feel the exact same about being one black mask in a sea of naked medical faces. And I am in medical settings relentlessly with my elderly parent. It.does.not.make.sense.
He is, Donna! Thank you! Unfortunately, now we have to go back to the pediatrician to follow-up. I truly despise being in medical offices during sick season. 😭
Me too. I’ve been there in just about every wave. Do masks work? I’m still a Novid despite swimming in it most of the time—hell yeah masks (and all the other Swiss cheese mitigations) work! Good luck out there!
When I spoke to the pharmacist yesterday about Paxlovid, she begged me to instruct the patient with COVID to wear a mask, saying that no one does and they all get sick.
I thought, maybe you could mask…
I also feel nuts as the lone mask in medical settings and I have to mentally psych myself to wear one.
When Jon Stewart got COVID for the first time this year, he said “not a fan”— so I mentally say that when I feel weird.
I just bought a Readimask to wear during an MRI next week. I have put it off for months because I just hate going into to medical places. And I get angry that providers are not masking.
Thanks for stopping by and for your story here. I don’t get it either. I used to get sick 5-7 times a year from patient care before the pandemic, even though I was one of the weird ones who would wear a surgical mask while seeing patients with fever or suspected flu. N95 for TB. But since I’ve been masking, zero work related infections and therefore none spread to my patients either. I know it’s a burden to wear a mask, but accepting burdens as part of a calling to be a healthcare clinician is part of the damn job. I apologize on behalf of the system that’s supposed to be keeping people safe as well as trying to help them when vulnerable/sick.
I love all your posts, but especially the COVIDlandia ones. You are part of a very rare breed of family med docs who pay such close attention to all things COVID, and it is much appreciated. I’m very glad to hear you made it through your first infection relatively unscathed. And major kudos to both artists! They add a bit of joy to these serious subjects. HNY, doc! 🎉🥳
Thanks Amy, and you know I value your first person accounts of living with LC, as well as the humanism and fun you bring to you writing! Maybe adding our voices to the crowd will help some people! HNY to you too! 🥳
Lots of clippings and, no one person can possibly track all of it. I barely use 10% of the material I come across. Admittedly, I was taken aback by the "extra days" of Paxlovid. I recall extra days didn't produce significant improvement over the 5 days in clinical trials (IIRC). Besides, how would you be able to prescribe extra days for Px? Just asking questions, no judgement, you know me.
As for your artist in residence, you are paying her the royalties fees, right? (LOL)
Hi KB! Happy new year 🎊 The 13 yo artist-in-residence gets room and board and a small stipend for her work! This month’s artist gets a big hug, she won’t accept royalties ☺️
The Paxlovid duration of treatment is still being worked out, though only approved for 5. It doesn’t seem to work for well established long covid in patients who have had symptoms for a long time and are treated with 15 days. But that RCT did establish safety of 15 days tx. If you follow Dr. Al-Aly you are more likely to think 5 days not enough:
And then there is this anecdote from that article , not worth much scientifically but quite interesting:
“ Sikka recommends Paxlovid to any COVID-19 patient who qualifies for the drug, including all those 60 and older. He said he is intrigued by using the antiviral for longer than the approved 5-day course, and said he has seen evidence in his patients that 10 days is a better course of treatment. Sikka said he has treated 900 patients with a 10-day course of Paxlovid, and has recorded no long COVID cases in that group. He has not yet published those results in a study.
"With 10 days you test negative faster, you become less contagious, and symptoms are reduced faster," Sikka said. Sikka said such dosing is left up to provider discretion, and until RCTS are conducted, won't become widespread.”
Good interview, she’s great. She hits the main theories for LC pathology, of course there are more but impressive memory nonetheless for an interview. She does a good job mediating the longer antiviral treatment for LC prevention mixed bag.
Those other LC mechanisms at the bottom of this post, but I know you already know these!
Thanks Arthur! I find little blocks of time in between life responsibilities and stresses, and just feel compelled to keep writing. I think it’s become my favorite hobby so I’m glad it’s well received. Happy New Year to you, too!
Yes, please do continue the Covidlandia posts! It's getting a lot harder to find this information, especially distilled into such a readable summary. I really appreciate the time and thought you put into these, and the actionable information + your analysis make this series invaluable. Thanks for all you do!
Ok, will do, thank you Michele! I agree it’s harder to find good sources as we all get sick of Covid, and with Covid… I like TWiV clinical update podcast (although I would answer some of the listener questions differently at times), CIDRAP, NEJM journal watch, and Medpage today as sources… and Eric Topol still throws out some links though less long form writing anymore about Covid.
Thank you very much! Let’s keep touring Covidlandia when we can! (“We” ;). It’s going to be important to find the plentitude of beauty in this new year. We can do it. Thanks for your help. (I admire the artists!)
Thanks Donna, we will get by with a little help from our friends, going to try with a little help from our friends, and I’m thankful for all my virtual friends here on Substack/Examined! Happy new year, and I’ll keep these coming.
Ryan, sorry to hear about your recent COVID infection. I, too, was a Novid until Christmas, when I was infected by a family member. My PCP wouldn't prescribe Paxlovid since I didn't "fit the criteria" - thankfully, my symptoms were mild, but like you I am mainly concerned about long Covid. I'll be focusing on resting for the next month and avoiding any strenuous workouts.
I already had an appointment with my PCP scheduled for mid-January to discuss some other non-Covid concerns, but curious if there is anything in general that you would advise people to talk about with their physician after a recent infection?
BTW, if you ever decide to move to Washington state, please let us know. I will be first in line to sign-up at your practice. It is refreshing to see that there are physicians who are still taking Covid seriously instead of dismissing it as just another cold/flu.
Hi Lindsay, it’s really impossible to avoid infection completely if you have kids or family! Glad you’re doing OK it seems. Most people do. I think just getting back into exercise intuitively and slower than you think is all I recommend. Just don’t want to trigger post, exertional, malaise, or muscle damage if susceptible. and then the usual mantra is like good sleep, healthy food, etc. I’ve been doing well getting back into exercise it seems, but a family member not so much, so she is taking it more slowly. Best of luck and thanks for the vote of confidence!
Please keep them coming! Covid is changing but it's not going away--but information about it is dwindling.
I'm so glad you utilized your plan and have come through this. Wondering if your test ever turned positive.
It's like flu now--where even uptodate says (re: flu) don't wait for the fairly useless rapid tests--treat if clinical suspicion is high.
Your approach to avoiding infection while living life is just so spot on--and it's just so helpful as we navigate the new normal of an infectious disease that knows no seasonality yet.
Personally, I look at JWeiland and the PMC model (weekly) to get a sense of circulating levels and weigh my own risks/benefits.
I just tried to reach out to a high risk patient who was seen in the ED, actually diagnosed with Covid and sent home with no Paxlovid...it's the norm but why?
Thank you for all you do and please thank the artists.
Hi Jan, thanks for your support and encouragement! It does take a good amount of time "clipping" these articles and then synthesizing each month, but I'll keep it up. Do you remember those "clipper" things that had a razor and could be used for saving choice newspaper/magazine articles/paragraphs? I miss those days, as an older family member used to keep me posted this way!
My rapid test was equivocal, but like I said the viral dose I received before the first family member tested positive was assuredly large. I'm glad UpToDate has switched over to the "treat with high index of suspicion" model we often use with flu... my office has rapid flu A, flu B, and Covid testing, but nothing is 100% accurate. These rapid tests are now available in a 3 in 1 swab at most pharmacies for A LOT cheaper than medical offices charge as I'm sure you know.
JWeiland continues to be a rockstar. He should write a Substack already!
And yes, I struggle with the counter narrative that antiviral treatment is not worth it all the time, from patients and clinicians.
Happy New Year!
Uptodate hasn’t officially switched over to high clinical suspicion yet for COVID treatment--I kind of doubt they will but as we know testing is not perfect.
They have for flu.
I did reach the patient who was grateful for Paxlovid and very upset with the ED…
Please keep these coming. It’s reassuring to have a factual and timely resource and I appreciate your investment in compiling it. And the artists are inspiring!
Thanks PJJ! Will do, and very happy you like the artwork, too. I will try to keep these updates relevant to what I do in primary care.
Curious how long you took the paxlovid for (8 days)? It all seems like a guessing game other than likely that 5 days is not enough (and it's difficult and expensive to get more)
Hi Robin, cost and availability are definite issues with Paxlovid. I had an extra supply left over from an overseas trip, so you are correct about the duration. Was really happy to finish that as the taste was oppressively disgusting. It did not seem worth taking based on symptoms being so mild, but as you know I was betting on lower viral loads and better clearance, for long Covid and other collateral damage reduction. The game - often inscrutable from the outside, but well studied internally.
I have seen studies showing lower rebound rates in immunocompromised patients taking longer courses, assume it would be the same for everyone else, wish there were studies and more info on the actual optimal duration!
I'll have to dig up those studies, as that would really be good to prove beyond the intuitive. Thank you!
Pfizer will share them if you ask
Please share those studies if you find them!
Paxlovid worked great for me (I'm old, so no way I wasn't taking it) but I got the rebound which was annoying although not serious. I can tell you that a York peppermint patty every 6 hours does a pretty good job killing the taste. One of my church friends, who is 81, tells me that 1-2 tsp of Atomic Fireball Whiskey on the same schedule works, too. Or maybe it just makes you not care, I dunno. Thank you for a great series
The best synopsis of Covid 2024 I have read! Thank you so much for all you do to educate and inform us. Easy to see where your daughter gets her artistic talent!!
Thanks Patti! I struggle to pare these down in terms of studies and word counts, but I figure at the end of the day people want more from long form newsletters on Substack. And yes, like grandmother like granddaughter! It is a true pleasure to watch them paint together.
Very much appreciate your continuing excellent work, and artwork!
As a non-physician, do you have any advice for approaching a cautious, wary internist about prescribing “preemptive” Paxlovid and metformin? Or must I rely on “urgent” care facilities?
Thanks for all you do!
Hi Robert and many thanks!
I understand the caution from the internist... as far as I know there are no RCTs evaluating Paxlovid + metformin together versus placebo, or versus one or the other yet. Most physicians are not prescribing both together, myself included, but I do offer knowns and unknowns to my patients and let them decide. Feel free to print out my "self treatment plan" linked above in the case report, as it is well referenced. It is only a showing of my own cards though, and not medical advice to others per se.
Prescribing two medications at the same time does not feel like much effort to me, as many of my patients unfortunately have to take 5-10 medicines daily anyway. I always use the University of Liverpool Medication Interaction checker with Paxlovid, and there is no concern as of this writing with combining these two meds from a drug metabolism perspective. https://www.covid19-druginteractions.org/checker
Once again, talk to you doctor, and feel free to cite the science, but acknowledge a little leap of faith in the absence of that necessary RCT.
Urgent care will only prescribe Paxlovid I'm guessing, and sometimes this needs to be requested after an initial dismissal.
Well this has been a stupendous series from the start. I really appreciate the focus on actionable, primary care type studies. It reinforces the guidance we get about staying up to date with vaccines and taking antivirals, but also sees the different game and players in 2024 like you said.
And what tremendous artists-in-residence you have shared with us! The painting for this month is outstandingly good! The play of light and shadow is kinetic, and the epic clouds and winter fields might symbolize the power of nature, with the house and fence showing our human efforts to create structure and order in the vast incomprehensible world?
Kind of like science itself!
OK enough amateur art criticism, please accept my thanks for your writing, and extend my appreciation to the artists.
Grant! What a fun comment, and I would say your art appreciation skills are "stupendous," too. I'm glad you have not found this series too heavy handed or fearmongering, but rather a highlight show of the counternarratives revealed by ongoing Covid science and inquiry.
As you know I'm on the front lines of patient care, not research... so what I present here is hopefully of more relevance to real people trying to figure out what to do.
I'll pass you compliments on to the artists! Love the word "kinetic." Need to figure a way to use that one more! Happy New Year :)
This is a marvelous summation of our current situation. Thank you again for being the voice of reason in a wasteland of profiteering and politics.
Thanks CBA👌 I’m hopefully not too biased with my selection of articles, as I do try to stick to good journals and less dogmatic voices here, without iconoclastic or political interference. Keep you posted if the evidence changes the Covid prevention and treatment narrative.
Your posts are invaluable, gorgeously illustrated (wow, Grandma’s is glorious—I love how the artistic gift is traveling down the generations), and what a lovely gift of a booklet on top of it. Can’t wait to download it.
Very sorry to learn of your spoiled Thanksgiving, but glad to know you and yours came through OK. Thank you, science!
On metformin: Glad to see it is helpful, as it comes in liquid form, and Pax does not. I’m going to talk with my PCP about that, as it’s a big worry not to be able to swallow the Pax pills, which appear are still the main line of defense, correct?
Very concerning to learn of the shortage of peds MDs. It is awful to think we are coming into an extremely anti-science, anti-expert period given all the health and public health needs we have.
On the vax timing calculation: I remember when you first cranked out the specifics and wondered again when you have time to sleep. (Glad, BTW, to see you are following your own napping, etc. advice after COVID!) I still don’t understand the math, which is my problem, solely, but what leaps out to me is this: “vaccine-induced protection levels, which peak in the first month post-vaccination before declining over subsequent months.” This suggests to me that, all things being equal, getting the vax a month before a time of anticipated higher virus levels/chances for exposure, could make sense . It is hard to time that way in the real world, I suspect, but is it worth bearing in mind?
Thank you for everything, and may you and yours have a happy and healthy new year.
Hi Susan, happy new year to you, too! I don’t think there is a higher compliment than “glorious” so I’ll be sure to pass that on to the artist!
Yes the ID Society and NIH guidelines recommend paxlovid as first line treatment, and I don’t think metformin has made the official consensus list yet… not sure why as there has been at least one good quality RCT supporting its use, safety, etc. No need to read these guidelines as they are pretty long, but the official stuff:
https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
And to be honest I don’t quite get the mathematical underpinnings of the 9/15 Covid vaccination optimized date either, but I included it more for the YLE graphic that is based on the math for people with recent infections. I agree with you that it makes sense to individualize the choice based on unique risk factors, what’s actually going on with COVID rates, family structure/school aged kids, grandparents , weddings etc!
Hope you have great night!
Thank you for such a complete and informative evidence based summary. I find all of your articles invaluable and appreciate how you blend them with your clinical experience. Please tell both artists that I enjoy their work very much and that they have brought joy to my life. Both artists have significant artistic gifts. Happy New Year!
Hi Tara, many thanks from me and I’ll pass on the compliments to the artists☺️
I think clinical experience is important as we increasingly turn over decisions to non-clinical entities, AI, and politicians. Thanks for supporting us humans who actually do the work and see the patients!
Happy New Year, and I hope 2025 is bright and healthy for you!
Thanks for everything.
I was at urgent care twice with my teen…the 27th and 29th. Viral illness (possibly RSV; they do not test for it and strep, covid, and flu were negative…twice) that led to a ruptured eardrum. Not a good Christmas gift. Not a mask to be found except on us. I watched people disregard the “please take a mask if you are experiencing respiratory symptoms” sign and cough, sneeze, and snot all over the waiting room and triage room. No masks on any nurses, medical assistants, or on the MD and PA we saw.
I admit, after well over a year of going to well checks and a breast health clinic and an orthopedist, and urgent cares during sick season and seeing zero masks on providers and employees, I wonder if I am the ridiculous one. I mean, they seem not to be fearful of breathing in contagious illness. And surely, they are exposed to high viral loads all day…and don’t get sick?
I just cannot make it make sense.
I hope your teen is feeling a bit better now, ADWH. I feel the exact same about being one black mask in a sea of naked medical faces. And I am in medical settings relentlessly with my elderly parent. It.does.not.make.sense.
He is, Donna! Thank you! Unfortunately, now we have to go back to the pediatrician to follow-up. I truly despise being in medical offices during sick season. 😭
Me too. I’ve been there in just about every wave. Do masks work? I’m still a Novid despite swimming in it most of the time—hell yeah masks (and all the other Swiss cheese mitigations) work! Good luck out there!
When I spoke to the pharmacist yesterday about Paxlovid, she begged me to instruct the patient with COVID to wear a mask, saying that no one does and they all get sick.
I thought, maybe you could mask…
I also feel nuts as the lone mask in medical settings and I have to mentally psych myself to wear one.
When Jon Stewart got COVID for the first time this year, he said “not a fan”— so I mentally say that when I feel weird.
They DO get sick.
I just bought a Readimask to wear during an MRI next week. I have put it off for months because I just hate going into to medical places. And I get angry that providers are not masking.
Thanks for stopping by and for your story here. I don’t get it either. I used to get sick 5-7 times a year from patient care before the pandemic, even though I was one of the weird ones who would wear a surgical mask while seeing patients with fever or suspected flu. N95 for TB. But since I’ve been masking, zero work related infections and therefore none spread to my patients either. I know it’s a burden to wear a mask, but accepting burdens as part of a calling to be a healthcare clinician is part of the damn job. I apologize on behalf of the system that’s supposed to be keeping people safe as well as trying to help them when vulnerable/sick.
I love all your posts, but especially the COVIDlandia ones. You are part of a very rare breed of family med docs who pay such close attention to all things COVID, and it is much appreciated. I’m very glad to hear you made it through your first infection relatively unscathed. And major kudos to both artists! They add a bit of joy to these serious subjects. HNY, doc! 🎉🥳
Thanks Amy, and you know I value your first person accounts of living with LC, as well as the humanism and fun you bring to you writing! Maybe adding our voices to the crowd will help some people! HNY to you too! 🥳
That all means a lot to me coming from you. Thank you for making my day!
Hey Ryan,
Lots of clippings and, no one person can possibly track all of it. I barely use 10% of the material I come across. Admittedly, I was taken aback by the "extra days" of Paxlovid. I recall extra days didn't produce significant improvement over the 5 days in clinical trials (IIRC). Besides, how would you be able to prescribe extra days for Px? Just asking questions, no judgement, you know me.
As for your artist in residence, you are paying her the royalties fees, right? (LOL)
Hi KB! Happy new year 🎊 The 13 yo artist-in-residence gets room and board and a small stipend for her work! This month’s artist gets a big hug, she won’t accept royalties ☺️
The Paxlovid duration of treatment is still being worked out, though only approved for 5. It doesn’t seem to work for well established long covid in patients who have had symptoms for a long time and are treated with 15 days. But that RCT did establish safety of 15 days tx. If you follow Dr. Al-Aly you are more likely to think 5 days not enough:
https://www.cidrap.umn.edu/covid-19/does-paxlovid-prevent-long-covid-maybe-experts-suggest
And then there is this anecdote from that article , not worth much scientifically but quite interesting:
“ Sikka recommends Paxlovid to any COVID-19 patient who qualifies for the drug, including all those 60 and older. He said he is intrigued by using the antiviral for longer than the approved 5-day course, and said he has seen evidence in his patients that 10 days is a better course of treatment. Sikka said he has treated 900 patients with a 10-day course of Paxlovid, and has recorded no long COVID cases in that group. He has not yet published those results in a study.
"With 10 days you test negative faster, you become less contagious, and symptoms are reduced faster," Sikka said. Sikka said such dosing is left up to provider discretion, and until RCTS are conducted, won't become widespread.”
This is a challenging and complex issue. The answers are hard to come by and
I recall Dr Griffin saying something about being no longer contiguous after 5 days?Hopefully we are not developing AMR scenario with longer courses. I haven't seen any published studies by Sikka. From what I found, results are mixed and may depend on vaccination status. You might find this interesting. https://www.ama-assn.org/delivering-care/public-health/akiko-iwasaki-what-causes-long-covid-brain-fog-yale-paxlovid-study
Good interview, she’s great. She hits the main theories for LC pathology, of course there are more but impressive memory nonetheless for an interview. She does a good job mediating the longer antiviral treatment for LC prevention mixed bag.
Those other LC mechanisms at the bottom of this post, but I know you already know these!
https://mccormickmd.substack.com/p/october-highlights-from-covidlandia
I do think that a one size fit all is not going to cut. Occam's Razor will not apply here.
Ryan, you continue to amaze me with all you do in writing Examined and taking care of your patients at the same time; thank you.
Happy New Year to you and your family. Love the paintings.
Thanks Arthur! I find little blocks of time in between life responsibilities and stresses, and just feel compelled to keep writing. I think it’s become my favorite hobby so I’m glad it’s well received. Happy New Year to you, too!
Yes, please do continue the Covidlandia posts! It's getting a lot harder to find this information, especially distilled into such a readable summary. I really appreciate the time and thought you put into these, and the actionable information + your analysis make this series invaluable. Thanks for all you do!
Ok, will do, thank you Michele! I agree it’s harder to find good sources as we all get sick of Covid, and with Covid… I like TWiV clinical update podcast (although I would answer some of the listener questions differently at times), CIDRAP, NEJM journal watch, and Medpage today as sources… and Eric Topol still throws out some links though less long form writing anymore about Covid.
Thanks for your confidence!
Thank you very much! Let’s keep touring Covidlandia when we can! (“We” ;). It’s going to be important to find the plentitude of beauty in this new year. We can do it. Thanks for your help. (I admire the artists!)
Thanks Donna, we will get by with a little help from our friends, going to try with a little help from our friends, and I’m thankful for all my virtual friends here on Substack/Examined! Happy new year, and I’ll keep these coming.
Ryan, sorry to hear about your recent COVID infection. I, too, was a Novid until Christmas, when I was infected by a family member. My PCP wouldn't prescribe Paxlovid since I didn't "fit the criteria" - thankfully, my symptoms were mild, but like you I am mainly concerned about long Covid. I'll be focusing on resting for the next month and avoiding any strenuous workouts.
I already had an appointment with my PCP scheduled for mid-January to discuss some other non-Covid concerns, but curious if there is anything in general that you would advise people to talk about with their physician after a recent infection?
BTW, if you ever decide to move to Washington state, please let us know. I will be first in line to sign-up at your practice. It is refreshing to see that there are physicians who are still taking Covid seriously instead of dismissing it as just another cold/flu.
Hi Lindsay, it’s really impossible to avoid infection completely if you have kids or family! Glad you’re doing OK it seems. Most people do. I think just getting back into exercise intuitively and slower than you think is all I recommend. Just don’t want to trigger post, exertional, malaise, or muscle damage if susceptible. and then the usual mantra is like good sleep, healthy food, etc. I’ve been doing well getting back into exercise it seems, but a family member not so much, so she is taking it more slowly. Best of luck and thanks for the vote of confidence!