At the end of 2021, a year after the approval of the coronavirus vaccines, Pfizer announced that it had an effective treatment for covid ready. Paxlovid has shown in clinical trials that it can reduce hospitalizations for patients with the most serious prognosis by 89%. It seemed the perfect complement to immunization for the most vulnerable people and whose lives are most threatened by the virus: those over 60 with other pathologies. But since it was acquired in February, its use in Spain has been residual.
The government, like most people around it, started buying it shortly after it was approved by the European Medicines Agency. It acquired 344,000 treatments for a figure subject to confidentiality clauses; The Council of Ministers, which approved the purchase, granted an emergency loan of €253.4 million to the Ministry of Health for this expenditure (mainly) and others related to the response to the pandemic. In the United States (which also bought a lot more, which usually lowers the price), each treatment was set at $530. With this reference, in Spain the treatments would cost around 164 million euros (at the February exchange rate), although the figure is likely to be higher given the country’s lower capacity to negotiate prices.
The Ministry of Health does not quantify how many of these drugs have been used so far, but several health sources put it at less than 5% of those purchased, which would mean about 13,000 treatments. “It is a disaster that the drugs that we have all paid for and that can save many lives are not being used,” said Rodrigo Abad, a family doctor from Asturias, last week at the national congress of the Spanish Society of Primary Care Physicians (Semergen ), which EL PAÍS attended at the invitation of the organization.
According to Abad, the scarce prescription is mainly due to two reasons: the lack of knowledge that many primary care physicians have about the drug and the multiple interactions with others. In its prospectus it warns that almost fifty preparations should not be taken at the same time. “But of these, only about a dozen are used frequently and can often be abandoned during Paxlovid treatment,” he explained in a Pfizer-sponsored talk.
The drug, which is a combination of two antivirals (nirmatrelvir and ritonavir), is indicated precisely for people at higher risk of developing badly from covid: those over 60, often with co-morbidities, making it more likely that you are taking one of the drugs with which it cannot be combined. According to Jesus Sierra of the Spanish Society of Hospital Pharmacy, it is not always easy to withdraw treatment to introduce Paxlovid, which must be taken within five days of symptoms to be effective. “If, for example, you’re taking statins for cholesterol, which are very common, there’s no time to get off the drug and start Paxlovid,” he says.
As covid infections become milder, diagnoses are also eased. People who have symptoms don’t always go to the doctor, many times they do a simple antigen test at home and it’s very possible that in those first five days they haven’t even seen their GP.
In addition to these obstacles to its use, there are others indicated by Roger Paredes, head of the infectious diseases service at Trias i Pujol Hospital in Badalona: “It is underused compared to other countries for various reasons. One is the scheme that is imposed in many autonomous communities: the doctor prescribes it, it has to be validated by a central pharmacist, the order is sent to the pharmacy, which takes a day to arrive. The patient has to do several procedures and often stays on the sidelines and doesn’t get it.”
All these difficulties, the consultees agree, mean that the family doctor rarely resorts to this treatment, even in cases where it would be potentially beneficial to the patient. “With vaccines, there are fewer and fewer serious cases. The understanding in the consultation is certainly that very few have a poor prognosis. A doctor who in his day prescribes all kinds of drugs gets a new one, an antiviral one that doesn’t have a lot of tradition, with a lot of interaction problems, and it’s hard for him to stop to review them to prescribe it, which is very understandable. That means we end up with a lot of hospitalizations that could have been avoided,” says Paredes.
Real effectiveness of the drug
Outside of clinical trials, nirmatrelvir, one of the components of Paxlovid, has shown very good results in the real world. A study conducted in Israel and published in September in New England Journal of Medicine showed 81% efficacy in people over 65 years of age, most of whom were vaccinated and infected with the omicron variant (trials were mainly done with the delta variant in unvaccinated people). Among those who received the pills, the rate of hospitalization was 15 per 100,000 population, while among those who did not, it was 59 per 100,000 population. In younger people, it has not produced significant results, but it is not a drug that is indicated for them.
As the older population has been vaccinated, hospitalization rates have dropped dramatically since before vaccines. This means that in order to avoid hospitalization, it is necessary to administer the pills to many more patients, which makes the treatment more expensive than its real effectiveness. It must be prescribed to a large number of infected people to have a significant reduction in the number of hospitalizations. The exact opposite of what is happening in Spain.
The result is that there are more than 300,000 purchased treatments that, in theory, begin to expire early next year. Faced with that possibility, Pfizer says the expiration date has been updated to go from one year to 18 months, which will give more time before you have to throw them away, but on the condition that the speed of prescriptions speeds up significantly : currently it would take more than 10 years to get through them all. However, it is not uncommon to update the expiration date to avoid loss. “The active principle of a batch is reviewed and if maintained, its useful life is extended. We’ve been doing it for a decade with tamiflu [del que se hizo un gran acopio para combatir la gripe A]”, assures Jesus Sierra.
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