I’m traveling. Should I bring Paxlovid in case I get Covid?

And can you hook me up please?

One of the unspoken taboos of practicing medicine has been giving patients antibiotics upon request before they travel. But what about now, when they ask for the antiviral Paxlovid instead? Would stocking them up be such a bad idea? After all, getting Covid is still a roll of the dice in terms of disease severity, duration, and potential post-Covid conditions like brain fog, increased cardiovascular events, and shortness of breath to name just a few. Do people want to track down Paxlovid while on safari?

First some background on why prescribing an antiviral for a rainy day might feel taboo. Antibiotic overuse is a major problem. Consider the Z-pak. It’s designed for convenience. The very name seems destined for packing alongside your toothbrush and antacids. But physicians generally try not to acquiesce when asked for an antibiotic prescription just in case. Usually upper respiratory infections are viral, and people recover just fine without Z-paks. By practicing good antibiotic stewardship, we help reduce the emergence of antibiotic resistance, and possible side effects like diarrhea, or even C. difficile colitis. Rebuilding a balanced microbiome can take months.

But Paxlovid, an antiviral, is different.

First, when people think they might have Covid on vacation, they can test. The rapid antigen tests are at least 70% sensitive for picking up a true case. Unlike sinusitis, which is a judgement call, the emergence of a red line next to the control line is almost certainly Covid (especially when the person has symptoms).

Second, Paxlovid is relatively safe but needs to be crossreferenced against other medications the person is taking to avoid dangerous interactions. Wouldn’t it be better to do this in a relaxed way with your primary care doctor, instead of with a provider in a foreign country, who may or may not speak English well?

Third, side effects of Paxlovid are usually mild. They can include GI upset and a funky taste, but you’re already feeling crummy, so what’s another couple symptoms? Could be the med, could be the virus causing your discomfort.

Fourth, Paxlovid has been shown to reduce the incidence of long Covid. The few studies about this estimate somewhere between 20-40% risk reduction. Long Covid can be really debilitating, and occasionally disabling. I see it all the time, and many young-ish people have nasty lingering symptoms for months. The inconvenient truth about long Covid is that it is actually most common in the 30–50-year-old population. And so, when we only think of Paxlovid as a medication for older, sicker patients to keep them out of the hospital, we are missing a chance to significantly reduce the sequelae of infection for healthy people, too.

Fifth, Paxlovid does reduce the risk of severe disease and hospitalization. This is especially true in the higher risk and older populations.

Sixth, we should consider good antiviral stewardship, and Paxlovid resistance will emerge someday. But until we have some better options for prevention and treatment, preventing severe disease and millions more people suffering from post-Covid conditions seem like the most immediate imperatives. The Biden Administration (or White House if you prefer) followed up on the Trump era Operation Warp Speed by announcing 5 billion dollars for Project Next Gen last week. This essential program adds new funding and priority for nasal vaccines, pan-coronavirus vaccines, and monoclonal antibodies. Warp Speed helped get mRNA vaccines into arms in historically record time. Next Gen will hopefully be the project that truly gets us back to normal. The promised land.

Seventh, there is no shortage of Paxlovid.

A few other considerations. Treatment won’t necessarily reduce your symptoms of Covid, or make you feel better faster. You’re still going to miss a lot of your vacation. And if you are an ethical person, you should be isolating yourself for at least 5 days, and then wearing a mask for another 5 to reduce spread. How many people waiting in line at Disney are following CDC guidelines? How many really care anymore? But I digress.

The most important way to avoid ruining your hard-earned, well-planned, entirely deserved vacation is to suck it up and wear an N95 respirator in the airport, on the plane, and in dense high-risk situations. Our pride, impulse to conform socially, and false narrative that Covid is “just like a cold now” all need to be rationally addressed. Swallow pride. Social conformity is overrated, and being a maverick is cool 😎. Covid illness still sucks in the short, medium, and long term potentially. “Sucks” is not a medical term, but there are few suitable alternative words that could hit the mark twice in 1 paragraph.

DALL E imagining “a crowded airplane cabin full of sick passengers.” This is close to the density of a recent flight I took. Can I please have another small packet of pretzels?

In conclusion, it does not seem taboo for traveling patients to talk to their doctors about Paxlovid just in case. A relaxed review of medications and planning can be best done stateside and with someone who has your medical record. Thanks to rapid antigen tests for Covid (that can be packed alongside your shaving cream) there’s no guessing like with sinusitis and Z-paks. Paxlovid can reduce our risk of severe disease, hospitalization, death, and long Covid. There’s lots of it lying around these days, and good antiviral stewardship when weighed against benefits to the individual tips the scales towards offering treatment. There are newer, better options for durable prevention and treatment on the $5 billion horizon.

And even when Covid is truly just like a cold or flu someday, I think I’ll keep wearing my 3M Aura mask on the plane. Do you know how many vacations in my life were partially ruined by getting sick on the way there? I do.

Here’s to your safe travels. Cheers to healthy vacations that inspire awe and some old-fashioned joy in this struggling world.