Hi Stef - I hear your concern loud and clear. There are some similarities and some real differences between HIV and SARS CoV-2. I'm going to do a post about this instead of answering this comment, hang in there :)
Thank you for such a thoughtful post. What are your thoughts about Vitamin D either around COVID or increasing in winter... or this could be another post entirely
Hi Laurie and thanks for reading :) A post this morning on Your Local Epidemiologist summed this up quite well:
"Vitamin D? Very low vitamin D levels can reduce your ability to deal with respiratory infections, but this level of deficiency is very uncommon in high-income nations like the United States. A recent meta-analysis of randomized controlled trials found that vitamin D supplementation did not impact respiratory illness among subgroups. Only when data were pooled was a small effect (1%) noted, which is unlikely to have clinical relevance."
So in general it's probably best to keep Vitamin D levels in normal range, but not great as a treatment acutely. If you feel like reading some posts I wrote about this (that are entirely too long, sorry!) here are the links:
Very clear. Very thoughtful. Very helpful. Very much appreciated. Thank you. When the rains fade, and the sun shines, (here in CA), it is easy to believe that the world is safe. But always good to have the Reminder, and a Game Plan.
Thank you Mary! I wanted to keep this short, but it's just impossible to say anything useful without expanding the word count... so I'm glad you still found it clear and helpful. I could go for some sun shine here in Philly today, gray and raining and cold so it fit the subject at hand ;)
Thanks for this excellent update. New subscriber here, and don't know if you wrote previously about what is most important when other people in the house have Covid. My nephew's wife got Covid, and they kept all the windows open, and it was 60 degrees inside the apartment. That seemed excessive to me. That isolation, masking, and a fan running with some outside air should be enough. Also, I just learned that the price of Paxlovid has gone from free to $1400, which is a huge inhibitor for people to take it. For those of us on Medicare, there is a program to still get it free until the end of the year. But those people under Medicare age seem to be out of luck.
Ventilation really is key with Covid transmission, and the amount of viruses we breathe in initially can make or break whether we develop a full on Covid illness. This concept is referred to as "viral dose" and while I'm not an epidemiologist, I think that as a concept it has been validated in terms of who gets sick and who doesn't. But once converted to an infection the initial "dose" of virus does not necessarily predict the severity of disease.
That being said, as a family doc I treat entire families, and I've been keeping an eye on who gets the sickest in the family. While there are many different risk factors among individual family members that might predict severity of illness... it just seems like the people who get sick secondarily in the home often get "sicker." Would need to look this up and see if any actual evidence supports this hunch.
And finally Pfizer does run a program called PAXCESS, which I have not tried personally but I think it can provide free courses of treatment for the uninsured, perhaps contingent upon income (?). I would definitely check it out as part of a game plan if concerns about costs and coverage :
Yes, we have signed up for this program. But it is only for people on Medicare or Medicaid or uninsured. Don't know about people on work-covered insurance plans.
Thank you! I take a medication which needs to be monitored on Paxlovid--and it's hard to stop--but I've talked to my PCP about it: I would definitely want Paxlovid and as long as we're making people access it via the healthcare system, and it's so under utilized, we are missing a huge opportunity to help people.
I'm hoping the oral remdesivir--which was fast tracked over a year ago--gets approved soon as it doesn't interact with so many medications.
Liverpool drug interaction checker is so strict, the ISDA and epocrates are less stringent about some of the drug interactions. That said, in a busy hectic environment, and with some pharmacists getting an alert when prescribing, there are barriers to treatment.
Thanks Jan, and some really good points here. I also find the Liverpool Med Checker to be of higher alarm levels than other sources. I suppose this is in line with my way of practicing cautiously, but can potentially close some doors for people who could have made a few little tweaks of small risk to take Paxlovid. And I am very frustrated with the delay in getting oral remdesevir on shelves! It makes a non-conspiracy theorist start to wonder about conspiracies!
Thanks also for the IDSociety link, I'm going to review that again. Interestingly they list the Liverpool link first, too!
Thank you again! I do have one question - what's the shelf life of Paxlovid? And one comment. I have a sister - in - law who swears by gargling with saltwater... for just about anything. 😄 Her musical daughter wrote this song for her mother, Saltwater Cures. (It was used in a movie, but the song was originally a tribute to her mother.) It's only 2 minutes... your saline nasal spray brought it to mind.
Gemma - what a beautiful song! I absolutely love it, and it brought a couple salt water tears to my eyes. There are so many talented musicians out there, and the songs they create are a shimmering collection of light in the world. Thanks for sharing, so much.
I think there is some decent evidence for gargling with salt water, especially for pharyngitis. I don't know of any harms, and this analysis I found via quick search presents an interesting non-Western medicine take from India:
Excellent--love the cope ahead, and I plan to do many of the same things. What are your thoughts about discontinuing an anticoagulant to take Paxlovid? It seems counterintuitive given the prothrombotic effects of Covid.
Hi Carole - thanks for stopping in. I've decreased the dosage of Eliquis in certain high risk patients so they could take Paxlovid, especially after the IV remdesevir option dried up. Of course this discussion would have to be individualized with a doctor, weighing risks and benefits of everything... but the prothrombotic effects of Covid are certain so I hear where you are coming from. Molnupiravir is another decent option for high risk individuals who can't shift meds like certain anticoagulants... and I've seen it work quite well in 70-90 year olds I've prescribed it to. Unlike Paxlovid, it has really been proven to reduce the duration of symptoms, too.
Great and timely post for me. Just was diagnosed with Covid last Friday and finished the course of Paxlovid yesterday. I didn’t know about the metformin- would it still be worth it for me to start taking it today and through the next 7 days?
Excellent article. Unfortunately, about 3 weeks too late for me. I came down with what I thought were cold symptoms on Jan 2, and by Jan 6 I realized it was something more so I did the rapid test. Positive result was evident in 3 minutes!. Did a telehealth visit and the clinician prescribed Paxlovid (reluctantly, since I was already 4 days into symptoms). When the pharmacy called (2 days later!) and informed me the prescription finally in but was NOT COVERED and it would be $1600 out of pocket, I was already a week into the illness and figured I would ride it out. But happy to have this info for next time.
I agree with what Jan listed below, and sorry the pharmacy did not give that option... I don't think many know about it, and I just recently learned of it myself as this has been coming up. Sounds like you are doing fine either way, like most people these days! Glad to hear it. Just a hardcore game plan, not the mainstream so no worries this time around.
Thank you for the time and care you took to put this together. It is always helpful to get a trusted, knowledgeable view like yours. I’m also interested to understand better your thinking about taking metformin as well as Paxlovid.
As an aside, I wish, for those of us who are not able to swallow the pills, that Paxlovid would become available in an emulsifiable form. I know there is an infusion alternative (remdesivir, I want to say?), but it appears that will be very hard to obtain from my health system.
PS, for those who raised the issue of payment for Paxlovid, though I wasn’t able to ascertain for sure, it looks like it will continue to be covered under Part D, but of course, even if so, the vagaries of the formularies will be there.
Good points Susan, and figuring out coverage is always a nightmare when time is of the essence. You bring up a really good point that I should add to this post - pregaming your insurance coverage and ultimate cost of Paxlovid. I'll drop a link in now, thank you!
Thank you for taking the time to share this. I appreciate how carefully you examine every angle.
Do you have suggestions for how one might approach their family physician or urgent care to ask for metformin? Or how to self-advocate for 10 day pax? (I guess the next obstacle is getting insurance to cover it.)
Is your plan to take metformin and pax simultaneously?
I've been trying to sort out which I should prioritize, as a 57yo with several lower tier risk factors. (I'm mainly concerned about LC. As a pwME, I can't go there.)
Feel free to copy and paste this article to your doctor - I tried to keep it chock full of references from good journals like Lancet, JAMA, NEJM etc. I don't think it's unreasonable, although I realize almost no one is doing this, or even aware of the COVID-OUT trial. You could politely ask your doctor if they are aware of these studies?
I would definitely prioritize Paxlovid for myself, especially if GI side effects get to be a bit much on the combination!
Nice looong piece but worth it. :~) Though I think with the respiratory "season", it good to be prepared for anything. Especially Influenza and RSV, was surprised that hospitalized RSV older Px have more severe case than those with COVI-19 or Influenza, though they are less frequent. https://www.cdc.gov/mmwr/volumes/72/wr/mm7240a2.htm
Certainly not fond of the idea 10 day course of Paxlovid. I would feel better with more science behind it. At any rate, it's not cheap but you can get help with it.
Agreed KB, thanks for the links. The 5 versus 10 is still quite contentious, and you are not wrong for being hesitant, although if the 5 days is too short, this might also favor antiviral resistance, similar to antibiotic courses that don't finish the job. Once again I tried to frame this from a personal vantage point, and it does take a few leaps of intuition and speculation, realizing that RCT data on long covid and subtle problems that might not show up for 5-10 years will never be there.
I do appreciate your point of view and there really isn't a baking recipe book to go by on for this. I have read reports that shorter courses are not inferior in some cases and Redesivir started out with multiple days and wound up with a shorter course of three days. Ultimately, the body's defense system has to finish the job though.
Thank you for this. I’m going to keep it with my “health stuff” so I can find it fast when I or someone I know needs it. I’ve had Covid once so far, tested positive twice on the first day I had symptoms, and got a telemedicine visit & Paxlovid prescription later that day. That first week, I felt like I’d been gently run over by a train. It took a second week to get my energy back. I’d take Paxlovid again in a heartbeat. I’ll ask my PCP about adding metformin - if Covid and I cross paths again.
Hi Liz, and I kind of wrote this to consolidate my own thoughts, so I'm glad it's potentially useful for you, too. I shouldn't laugh but the "gently run over by a train" description is hard to picture! Your PCP might not be offering the metformin unless prompted. It's not a consensus recommendation yet but does have solid peer review from the Lancet behind its publication. Best of (prepared) luck out there!
I posted this earlier but deleted and am reposting because I was too verbose. ;) Have you prescribed Pax for an elderly but otherwise healthy person on a long term, low dose of clonazepam, with a dose adjustment? The guidelines are equivocal -some say this is a major interaction, others that a dose adjustment or change to a different benzo is sufficient. I manage my parent’s care and am trying to keep their Covid plan in mind if and when I need it (obviously I would talk to their doctor, etc.). Thank you for such an informative post!
Hi Lindsey, thanks for stopping by and much respect for helping to manage your parents' care. I need to do a better job of this, and I'm always impressed when a family member advocates for and helps another... it's a great part of "family medicine" actually.
In terms of the clonazepam question, I pretty much go by the Liverpool med check website which is public domain. Here is what they state regarding clonazepam, and maybe this helps?
I would weigh factors like the patient's baseline mental status, other medications that might cause sedation, and risk of falling with higher/somewhat unpredictable levels of clonazepam. Thanks for understanding I can't give your mother any specific advice, but you have a good grasp of the vagaries between different sources. It's just as hard for us as clinicians who balance competing risks!
Thank you so much for this helpful and kind response! Learning how to help navigate their care has been a real experience, as I am an informed consumer but not a healthcare worker. This is very helpful in that it helps me consider which risks to discuss with my parent’s providers or pharmacists if/when this situation might arise (I’m in a state with a centralized Paxlovid rx program). I find it fascinating and reassuring that the Liverpool guideline is so transparent and clear about the differences in the US guidance and theirs, for example, and about the level of evidence available. I appreciate this detail because it likely helps providers with nuanced decision making. On another note, I signed up as a paid subscriber today and didn’t leave this in the “notes” because I was between clients but I will publicly shout out my thanks now. As I said, I’m not a HCW but worked in a public facing, healthcare adjacent human services role in a hospital setting during the pandemic’s eruption and early days. Information from people like you, Dr. Jetelina and Dr. McBride were lifelines to me and my colleagues during the most challenging time of our careers. I have since moved into a slightly different role within human services for family and personal reasons but will never forget those times and how much you and other scientists helped see us through.
I am suspect everyone reading this newsletter feels the same gratitude, but I just want to say that I really have no words to thank you for the time you have dedicated to what is a true public service. It takes many hours to write thoughtfully and well, and you do this out of kindness and dedication. Hence my subscriptions to all three of you! Thank you so much for all you do!
Wow, that is humbling and so, so kind of you, thank you! All of us with public facing work, especially through the early phases of the pandemic, have an unspoken bond forged in dark times. I appreciate your contributions in human service!
I'm so glad that I am able to contribute to the conversation around health, and around Covid in particular for the past 2.5 years here. I regret that I was not able to add my voice earlier, but I had a lot going on! ( https://mccormickmd.substack.com/p/that-little-souvenir-of-a-terrible ). I would stay up late with my wife, also a doc, learning as much as we could about this novel nightmare... I found Katelyn Jetelina, Lindsey Marr, and Eric Topol particularly helpful, but also scoured the journals and med-Twitter. Like you I am so grateful for all the scientists, researchers, and clinicians who sacrificed their time and lives to bring us to the better times we currently inhabit. And I'm forever grateful to everyone who kept the supply chains going, the food on the shelves, the fabric of our society together. And I'm grateful to those who sheltered in place when we were poised to have Covid otherwise rip through an unvaccinated world. I could go on...
I wish you and your parents well, and I do think the University of Liverpool interaction website is an amazing, free reference for the world. I've used it continually, and find that they've updated things as speculation is replaced with better nuance and pharmacokinetics!
Keep in touch and thanks again for a fun comment before bed :)
Hi Stef - I hear your concern loud and clear. There are some similarities and some real differences between HIV and SARS CoV-2. I'm going to do a post about this instead of answering this comment, hang in there :)
Thank you for such a thoughtful post. What are your thoughts about Vitamin D either around COVID or increasing in winter... or this could be another post entirely
Hi Laurie and thanks for reading :) A post this morning on Your Local Epidemiologist summed this up quite well:
"Vitamin D? Very low vitamin D levels can reduce your ability to deal with respiratory infections, but this level of deficiency is very uncommon in high-income nations like the United States. A recent meta-analysis of randomized controlled trials found that vitamin D supplementation did not impact respiratory illness among subgroups. Only when data were pooled was a small effect (1%) noted, which is unlikely to have clinical relevance."
So in general it's probably best to keep Vitamin D levels in normal range, but not great as a treatment acutely. If you feel like reading some posts I wrote about this (that are entirely too long, sorry!) here are the links:
https://mccormickmd.substack.com/p/how-much-vitamin-d-should-i-be-taking
https://mccormickmd.substack.com/p/how-much-vitamin-d-should-i-be-taking
Very clear. Very thoughtful. Very helpful. Very much appreciated. Thank you. When the rains fade, and the sun shines, (here in CA), it is easy to believe that the world is safe. But always good to have the Reminder, and a Game Plan.
Thank you Mary! I wanted to keep this short, but it's just impossible to say anything useful without expanding the word count... so I'm glad you still found it clear and helpful. I could go for some sun shine here in Philly today, gray and raining and cold so it fit the subject at hand ;)
Agree this is very clear and helpful. I appreciate the suggestions as talking points, especially as most appointment windows are pretty tight.
SO true. "Here's some Paxlovid if you want. Call if you develop shortness of breath or severe symptoms," right?
Thanks for this excellent update. New subscriber here, and don't know if you wrote previously about what is most important when other people in the house have Covid. My nephew's wife got Covid, and they kept all the windows open, and it was 60 degrees inside the apartment. That seemed excessive to me. That isolation, masking, and a fan running with some outside air should be enough. Also, I just learned that the price of Paxlovid has gone from free to $1400, which is a huge inhibitor for people to take it. For those of us on Medicare, there is a program to still get it free until the end of the year. But those people under Medicare age seem to be out of luck.
Hi Mary, welcome aboard (and many thanks!). Your story supports the prime importance of ventilation. I wrote this a while back:
https://mccormickmd.substack.com/p/clean-air-good-ventilation-and-co2
Ventilation really is key with Covid transmission, and the amount of viruses we breathe in initially can make or break whether we develop a full on Covid illness. This concept is referred to as "viral dose" and while I'm not an epidemiologist, I think that as a concept it has been validated in terms of who gets sick and who doesn't. But once converted to an infection the initial "dose" of virus does not necessarily predict the severity of disease.
That being said, as a family doc I treat entire families, and I've been keeping an eye on who gets the sickest in the family. While there are many different risk factors among individual family members that might predict severity of illness... it just seems like the people who get sick secondarily in the home often get "sicker." Would need to look this up and see if any actual evidence supports this hunch.
And finally Pfizer does run a program called PAXCESS, which I have not tried personally but I think it can provide free courses of treatment for the uninsured, perhaps contingent upon income (?). I would definitely check it out as part of a game plan if concerns about costs and coverage :
https://www.paxlovid.com/paxcess
Yes, we have signed up for this program. But it is only for people on Medicare or Medicaid or uninsured. Don't know about people on work-covered insurance plans.
Thank you! I take a medication which needs to be monitored on Paxlovid--and it's hard to stop--but I've talked to my PCP about it: I would definitely want Paxlovid and as long as we're making people access it via the healthcare system, and it's so under utilized, we are missing a huge opportunity to help people.
I'm hoping the oral remdesivir--which was fast tracked over a year ago--gets approved soon as it doesn't interact with so many medications.
Liverpool drug interaction checker is so strict, the ISDA and epocrates are less stringent about some of the drug interactions. That said, in a busy hectic environment, and with some pharmacists getting an alert when prescribing, there are barriers to treatment.
https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/management-of-drug-interactions-with-nirmatrelvirritonavir-paxlovid/
Thanks again for a detailed post--it's a topic I've thought about a lot also.
Thanks Jan, and some really good points here. I also find the Liverpool Med Checker to be of higher alarm levels than other sources. I suppose this is in line with my way of practicing cautiously, but can potentially close some doors for people who could have made a few little tweaks of small risk to take Paxlovid. And I am very frustrated with the delay in getting oral remdesevir on shelves! It makes a non-conspiracy theorist start to wonder about conspiracies!
Thanks also for the IDSociety link, I'm going to review that again. Interestingly they list the Liverpool link first, too!
Thank you again! I do have one question - what's the shelf life of Paxlovid? And one comment. I have a sister - in - law who swears by gargling with saltwater... for just about anything. 😄 Her musical daughter wrote this song for her mother, Saltwater Cures. (It was used in a movie, but the song was originally a tribute to her mother.) It's only 2 minutes... your saline nasal spray brought it to mind.
https://youtu.be/RYkUU_3sRNY?si=5gWMXYRh5QS-gYm5
Gemma - what a beautiful song! I absolutely love it, and it brought a couple salt water tears to my eyes. There are so many talented musicians out there, and the songs they create are a shimmering collection of light in the world. Thanks for sharing, so much.
I think there is some decent evidence for gargling with salt water, especially for pharyngitis. I don't know of any harms, and this analysis I found via quick search presents an interesting non-Western medicine take from India:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528968/
Most ENT's would agree with saline irrigation and gargles. I'll try to ask one next time we talk...
Excellent--love the cope ahead, and I plan to do many of the same things. What are your thoughts about discontinuing an anticoagulant to take Paxlovid? It seems counterintuitive given the prothrombotic effects of Covid.
Hi Carole - thanks for stopping in. I've decreased the dosage of Eliquis in certain high risk patients so they could take Paxlovid, especially after the IV remdesevir option dried up. Of course this discussion would have to be individualized with a doctor, weighing risks and benefits of everything... but the prothrombotic effects of Covid are certain so I hear where you are coming from. Molnupiravir is another decent option for high risk individuals who can't shift meds like certain anticoagulants... and I've seen it work quite well in 70-90 year olds I've prescribed it to. Unlike Paxlovid, it has really been proven to reduce the duration of symptoms, too.
Great and timely post for me. Just was diagnosed with Covid last Friday and finished the course of Paxlovid yesterday. I didn’t know about the metformin- would it still be worth it for me to start taking it today and through the next 7 days?
I'm going to reach out to you now.
Excellent article. Unfortunately, about 3 weeks too late for me. I came down with what I thought were cold symptoms on Jan 2, and by Jan 6 I realized it was something more so I did the rapid test. Positive result was evident in 3 minutes!. Did a telehealth visit and the clinician prescribed Paxlovid (reluctantly, since I was already 4 days into symptoms). When the pharmacy called (2 days later!) and informed me the prescription finally in but was NOT COVERED and it would be $1600 out of pocket, I was already a week into the illness and figured I would ride it out. But happy to have this info for next time.
There is a copayment assistance program called Paxacess: it covers up to $1500: https://www.paxlovid.com/enroll-in-co-pay-program
I agree with what Jan listed below, and sorry the pharmacy did not give that option... I don't think many know about it, and I just recently learned of it myself as this has been coming up. Sounds like you are doing fine either way, like most people these days! Glad to hear it. Just a hardcore game plan, not the mainstream so no worries this time around.
Thank you, for this helpful information!
Thank you for the time and care you took to put this together. It is always helpful to get a trusted, knowledgeable view like yours. I’m also interested to understand better your thinking about taking metformin as well as Paxlovid.
As an aside, I wish, for those of us who are not able to swallow the pills, that Paxlovid would become available in an emulsifiable form. I know there is an infusion alternative (remdesivir, I want to say?), but it appears that will be very hard to obtain from my health system.
PS, for those who raised the issue of payment for Paxlovid, though I wasn’t able to ascertain for sure, it looks like it will continue to be covered under Part D, but of course, even if so, the vagaries of the formularies will be there.
Good points Susan, and figuring out coverage is always a nightmare when time is of the essence. You bring up a really good point that I should add to this post - pregaming your insurance coverage and ultimate cost of Paxlovid. I'll drop a link in now, thank you!
Thank you for taking the time to share this. I appreciate how carefully you examine every angle.
Do you have suggestions for how one might approach their family physician or urgent care to ask for metformin? Or how to self-advocate for 10 day pax? (I guess the next obstacle is getting insurance to cover it.)
Is your plan to take metformin and pax simultaneously?
I've been trying to sort out which I should prioritize, as a 57yo with several lower tier risk factors. (I'm mainly concerned about LC. As a pwME, I can't go there.)
Hi Dar - appreciate you reading it!
Feel free to copy and paste this article to your doctor - I tried to keep it chock full of references from good journals like Lancet, JAMA, NEJM etc. I don't think it's unreasonable, although I realize almost no one is doing this, or even aware of the COVID-OUT trial. You could politely ask your doctor if they are aware of these studies?
I would definitely prioritize Paxlovid for myself, especially if GI side effects get to be a bit much on the combination!
Nice looong piece but worth it. :~) Though I think with the respiratory "season", it good to be prepared for anything. Especially Influenza and RSV, was surprised that hospitalized RSV older Px have more severe case than those with COVI-19 or Influenza, though they are less frequent. https://www.cdc.gov/mmwr/volumes/72/wr/mm7240a2.htm
Certainly not fond of the idea 10 day course of Paxlovid. I would feel better with more science behind it. At any rate, it's not cheap but you can get help with it.
https://s2.washingtonpost.com/camp-rw/?trackId=5d5ff7f99bbc0f603edc5cc3&s=65b2d2de40c5a40373d382ea&linknum=2&linktot=51&linknum=2&linktot=51
Agreed KB, thanks for the links. The 5 versus 10 is still quite contentious, and you are not wrong for being hesitant, although if the 5 days is too short, this might also favor antiviral resistance, similar to antibiotic courses that don't finish the job. Once again I tried to frame this from a personal vantage point, and it does take a few leaps of intuition and speculation, realizing that RCT data on long covid and subtle problems that might not show up for 5-10 years will never be there.
I do appreciate your point of view and there really isn't a baking recipe book to go by on for this. I have read reports that shorter courses are not inferior in some cases and Redesivir started out with multiple days and wound up with a shorter course of three days. Ultimately, the body's defense system has to finish the job though.
Thank you for this. I’m going to keep it with my “health stuff” so I can find it fast when I or someone I know needs it. I’ve had Covid once so far, tested positive twice on the first day I had symptoms, and got a telemedicine visit & Paxlovid prescription later that day. That first week, I felt like I’d been gently run over by a train. It took a second week to get my energy back. I’d take Paxlovid again in a heartbeat. I’ll ask my PCP about adding metformin - if Covid and I cross paths again.
Hi Liz, and I kind of wrote this to consolidate my own thoughts, so I'm glad it's potentially useful for you, too. I shouldn't laugh but the "gently run over by a train" description is hard to picture! Your PCP might not be offering the metformin unless prompted. It's not a consensus recommendation yet but does have solid peer review from the Lancet behind its publication. Best of (prepared) luck out there!
I posted this earlier but deleted and am reposting because I was too verbose. ;) Have you prescribed Pax for an elderly but otherwise healthy person on a long term, low dose of clonazepam, with a dose adjustment? The guidelines are equivocal -some say this is a major interaction, others that a dose adjustment or change to a different benzo is sufficient. I manage my parent’s care and am trying to keep their Covid plan in mind if and when I need it (obviously I would talk to their doctor, etc.). Thank you for such an informative post!
Hi Lindsey, thanks for stopping by and much respect for helping to manage your parents' care. I need to do a better job of this, and I'm always impressed when a family member advocates for and helps another... it's a great part of "family medicine" actually.
In terms of the clonazepam question, I pretty much go by the Liverpool med check website which is public domain. Here is what they state regarding clonazepam, and maybe this helps?
https://www.covid19-druginteractions.org/downloads/interaction_reports.pdf?interaction_ids%5B%5D=34574
I would weigh factors like the patient's baseline mental status, other medications that might cause sedation, and risk of falling with higher/somewhat unpredictable levels of clonazepam. Thanks for understanding I can't give your mother any specific advice, but you have a good grasp of the vagaries between different sources. It's just as hard for us as clinicians who balance competing risks!
Thank you so much for this helpful and kind response! Learning how to help navigate their care has been a real experience, as I am an informed consumer but not a healthcare worker. This is very helpful in that it helps me consider which risks to discuss with my parent’s providers or pharmacists if/when this situation might arise (I’m in a state with a centralized Paxlovid rx program). I find it fascinating and reassuring that the Liverpool guideline is so transparent and clear about the differences in the US guidance and theirs, for example, and about the level of evidence available. I appreciate this detail because it likely helps providers with nuanced decision making. On another note, I signed up as a paid subscriber today and didn’t leave this in the “notes” because I was between clients but I will publicly shout out my thanks now. As I said, I’m not a HCW but worked in a public facing, healthcare adjacent human services role in a hospital setting during the pandemic’s eruption and early days. Information from people like you, Dr. Jetelina and Dr. McBride were lifelines to me and my colleagues during the most challenging time of our careers. I have since moved into a slightly different role within human services for family and personal reasons but will never forget those times and how much you and other scientists helped see us through.
I am suspect everyone reading this newsletter feels the same gratitude, but I just want to say that I really have no words to thank you for the time you have dedicated to what is a true public service. It takes many hours to write thoughtfully and well, and you do this out of kindness and dedication. Hence my subscriptions to all three of you! Thank you so much for all you do!
Wow, that is humbling and so, so kind of you, thank you! All of us with public facing work, especially through the early phases of the pandemic, have an unspoken bond forged in dark times. I appreciate your contributions in human service!
I'm so glad that I am able to contribute to the conversation around health, and around Covid in particular for the past 2.5 years here. I regret that I was not able to add my voice earlier, but I had a lot going on! ( https://mccormickmd.substack.com/p/that-little-souvenir-of-a-terrible ). I would stay up late with my wife, also a doc, learning as much as we could about this novel nightmare... I found Katelyn Jetelina, Lindsey Marr, and Eric Topol particularly helpful, but also scoured the journals and med-Twitter. Like you I am so grateful for all the scientists, researchers, and clinicians who sacrificed their time and lives to bring us to the better times we currently inhabit. And I'm forever grateful to everyone who kept the supply chains going, the food on the shelves, the fabric of our society together. And I'm grateful to those who sheltered in place when we were poised to have Covid otherwise rip through an unvaccinated world. I could go on...
I wish you and your parents well, and I do think the University of Liverpool interaction website is an amazing, free reference for the world. I've used it continually, and find that they've updated things as speculation is replaced with better nuance and pharmacokinetics!
Keep in touch and thanks again for a fun comment before bed :)