Justin writes:
Daniel,
In episode number 978 you answered the question about stopping other medications as you start Paxlovid. The answer was very helpful and made a lot of sense. However, based on your answer, it seems the better question is when to restart medications that may interact with Paxlovid. As Paxlovid inhibits the metabolism of multiple other medications, how long does that effect last? In other words, if a medication is restarted for a patient before the Paxlovid has cleared from their system, could it cause a rise to toxic levels?
Kimona writes:
Hoping you can chime in on guidance re: COVID (+) elderly patients with underlying COPD and baseline oxygen sats of 90-94% and presenting with ‘relative’ hypoxia. We see a fair share of these patients and our ED providers will often give an initial dose of IV-Solumedrol, 60-125mg, as if treating a COPD exacerbation (despite current guidelines advising lower doses….!). As you recently reviewed, studies using ‘higher’ dose corticosteroids in Covid illness, had worse outcomes than the standard dosing of dexamethasone 6mg daily.
Firstly, it is not always clear what phase of Covid illness they are in, early viral vs later inflammatory, based on their vague history telling, symptoms of maybe just feeling a bit ‘weak’ for a while, and/or lack of home testing. But assuming that you have committed to using some steroid due to their COPD, should we be trying to keep this within the Dexa 6mg dosing range, which by my calculations would be prednisone 35-40mg at max? I feel like recent COPD guidelines have supported lower prednisone dosing, regardless.
Secondly, I do worry that we are also doing harm by even giving corticosteroids, especially if the patient is likely in the early viral phase of illness, despite also starting antivirals. I fear that very few providers dare avoid the steroids all-together, due to the COPD history. I’m not sure what my question really is, but would appreciate any commentary you can give to this conundrum.
Also, a little commentary re: Remdesivir IV treatment for those patients for whom Paxlovid may not be appropriate. I work at a small critical access hospital and have the benefit of reviewing some of the cost analysis of medications and re-imbursements. Both Medicare/Aid and many commercial insurances reimburse less than what our purchasing price is – now that Remdesivir is no longer provided by the gov/state under EUA, etc. Likewise for Tocilizumab, which is ridiculously expensive, and we have therefore chosen to not bring on-board. In the end, our mission is to do what is best for the patient – but there are yet more reasons why rural healthcare institutions are struggling to stay alive.
Thanks for all you do to help keep us mere mortals abreast on the latest and greatest!
Kimona
Laurie writes:
Good morning and thank you again for this invaluable resource.
First is in regards to testing – I work in a pediatric office in SF and we are considering moving from the Abbott ID Now to the Cepheid Xpert Xpress so we don’t need to stick so many swabs up these little ones’ noses. One concern I have is that the Cepheid literature states that it has a 100% PPA and 100% NPV. Is that possible? Seems suspect. If we just want to do COVID testing, can we trust the ID NOW in this current viral environment? The studies I’ve seen seem already out of date by the time they are published.. Any advice?
Second, In regards to the question in last week’s mailbag, about the perceived “punishment” for COVID testing. For the littles who are positive, and their parents, it is especially “punitive.” They can’t wear a “well fitting” mask so they are home for 10 days. (I’m not sure even a 12 yo can wear a well fitting mask, especially at lunch time!) And if there are multiple little kids in the same house and there is ongoing exposure, the parents may have to stay home for 20 days or more! This seems like this should change. Any advice/comments on this?
The third is a request – I am neither a PhD nor a surgeon, I am a busy pediatrician. I listen to these podcasts while driving with a dozen things in my head and I would love to see the figures but that would be dangerous! Sometimes I “blink” and miss something important. Would you mind giving us the 10 second take home point at the end of each sub-segment?
You guys are the best!
Thank you,
Laurie Schultz
Golden Gate Pediatrics
SF
Evan writes:
It has been reported that either a severe or mild case of Covid can lower IQ. Has these data been substantiated? Is there an additive diminishment with repeat Covid infections? Does the patient recover IQ?
