South Florida Sun-Sentinel (Sunday)
How common is Paxlovid rebound?
Home treatment for COVID-19 is causing some to develop symptoms after taking drug
Michael Rodin knows just how President Joe Biden feels having a rebound from Paxlovid, the antiviral used to fight COVID-19.
The 85-year-old Rodin thought he was in the clear after he took Paxlovid, recovered from COVID, and received a negative test result. Two days later, he was sicker than previously with a fever he couldn’t shake. Sure enough, a test showed his COVID infection had returned.
Rodin says his experience with Paxlovid mirrors about a dozen others in his retirement community in Boynton Beach. It also happens to be why health providers are asking for more research on why some patients treated for the coronavirus with Paxlovid experience a second round of the disease shortly after recovering.
The drug, developed by Pfizer, became available for home treatment in the U.S. in December to anyone at high risk for developing severe COVID-19.
In July, the Food and Drug Administration (FDA) updated the Emergency Use Authorization for Paxlovid to allow for pharmacists to prescribe it to patients. If you test positive for the coronavirus and are eligible, you can take the pills at home within the first five days and lower your chances of going to the hospital.
It is not entirely clear why some people develop a COVID19 rebound two to eight days after taking Paxlovid, and others don’t. But there are some theories as to what is triggering the rebound: Paxlovid works by suppressing the virus that causes COVID-19. So, it is possible that the five-day course simply isn’t long enough and leaves enough virus in people’s bodies to reemerge days later.
Dr. Ashish K. Jha, White House COVID-19 response coordinator, estimates rebound occurs in about
5-8% of people who take Paxlovid. But Rodin and friends believe the percentage is higher based on the experience of their small Boynton Beach community.
“It irks me that Dr. Jha said a rebound is rare,” Rodin said. “That’s not what we have been seeing in the community.” Neighbor Jeff Reisch, 70, agrees. “The rate of rebound is much higher than that. It’s probably 20% in these older retirement communities,” Reisch said.
Reisch said he and his wife Lucy came down with COVID-19 after international travel. They live in Rodin’s community of Valencia Sound. Lucy had no symptoms with her initial infection and only tested herself because her husband had a high fever and sore throat. She took Paxlovid for five days as a precaution. Then, three days after a negative result, new symptoms came on — a cough, runny nose, sneezing. Sure enough, she tested herself again and it came back positive. In those few days in between, Lucy had mixed with the neighbors, some went on to become infected, too.
“They did studies with taking Paxlovid for five days and I think they should have done seven days,” Reisch said. “And, with this rebound so prevalent, you really need to do 10 days of isolation if you take Paxlovid.”
More research is needed
Some experts have called for studies into extending Paxlovid treatments to be prioritized. In Pfizer’s clinical trials, 1% to 2% of people taking Paxlovid saw a rebound case.
A study done in June by researchers from the University of California, San Diego School of Medicine, found in some individuals, not enough of the medication was getting to infected cells in the allotted time. They concluded for those people, Paxlovid may need to be taken longer.
The second time around isn’t usually worse
Most people aren’t getting sicker with their rebound infection, but for some people the virus affects them differently the second time: They may have a sore throat, cough or even a fever that they didn’t have the first time.
President Biden has had a loose cough with his second bout with
COVID-19.
He returned a positive test only days after testing negative for COVID for which he had taken a five-day course of the antiviral medication.
A CDC report issued in May said most people who had symptoms during a rebound improved on their own in an average of three days.
“There is currently no evidence that additional treatment is needed with Paxlovid or other anti-SARSCoV-2 therapies in cases where
COVID-19 rebound is suspected,” the report says.
Dr. Alexandria Beranger, ChenMed national director of quality and patient experience, said she has prescribed Paxlovid to hundreds of patients as have other doctors at Chen Med, a chain of primary care centers for seniors. While some patients have had Paxlovid rebound, most haven’t, she said. “Everyone responds differently. If they do rebound, we don’t repeat Paxlovid. We just treat the symptoms.”
‘Paxlovid saved me’
Despite the potential to rebound, Beranger and Calvo say Paxlovid works for its intended purpose: to keep people with COVID out of the hospital.
The seniors in Boynton Beach believe they fared better by taking Paxlovid than had they toughed out the virus without the antiviral medication.
“Paxlovid saved me,” said Reich. “I had 103.5 fever, my oxygen level was at 91, I felt like I had strep throat,” he said. “By the second day, I was feeling better. I would have been in the hospital without it.” Dr. Aldo Calvo, medical director of the ambulatory division at Broward Health, said he continues to recommend Paxlovid because it is easy to take at home and keeps people out of the hospital. “Even if we find out certain people are more prone to rebound effects, they should still consider it as a first-line treatment,” he said. “It could just be that certain people need to take it another two or three days. All of this is being studied.”
Beranger said with her patients who are mostly seniors, the risk-benefit is favorable for Paxlovid. “I am more fearful of COVID landing them in the hospital. I want them to recover safely at home.”
For anyone who experiences a rebound, the CDC advises people “restart isolation” for five days. Pfizer recommends reporting your rebound experience on its portal for adverse events associated with Paxlovid.
There is a long list of medications Paxlovid may interact with, which is why Bob Zobel, 73, turned to an alternate treatment when he contracted COVID.
Zobel said his doctor recommended monoclonal antibodies instead of Paxlovid. And after he saw his Boynton Beach neighbors getting rebound cases, he felt more comfortable with that option. His wife, who also tested positive for COVID, opted for the monoclonal antibodies, too.
Bebtelovimab is the only monoclonal antibody left that works against BA.5.
“They came to our house, gave us an injection, and after a day or two we were feeling better,” Zobel said. “By day seven or eight, we were testing negative. So for those who aren’t able to take Paxlovid or are afraid of rebound, there is another option.”