At the end of 2021, a year after the coronavirus vaccines were approved, Pfizer announced that it had an effective treatment for covid ready. Paxlovid showed in clinical trials that it could reduce hospitalizations of patients with the most serious prognosis by 89%. It seemed the ideal complement to immunization for the most vulnerable people and whose lives are most at risk from the virus: those over 60 with other pathologies. But since it was acquired in February, its use has been residual in Spain.
The Government, like most of those around it, rushed to buy it shortly after it was Approves the European Medicines Agency. She acquired 344,000 treatments for a figure that is subject to confidentiality clauses; the Council of Ministers that approved the purchase granted an extraordinary credit of 253.4 million euros to the Ministry of Health for this expense (mainly) and others related to the response to the pandemic. In the United States (which also bought much more, which usually lowers the price), each treatment was set at $530. With this reference, in Spain the treatments would have cost about 164 million euros (at the exchange rate for February), although the figure is probably higher, given the country’s lower price negotiation capacity.
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 that have been purchased, which would mean around 13,000 treatments. “It is a disaster that medicines that we have all paid for and that can save many lives are not used,” Rodrigo Abad, a family doctor from Asturias, said last week at the national congress of the Spanish Society of Primary Care Physicians (Semergen ), to which EL PAÍS attended invited by the organization.
In Abad’s opinion, the scarce prescription is fundamentally due to two reasons: the lack of knowledge that many Primary Care doctors have of the drug and the multiple interactions with others. In the package insert he warns that almost fifty preparations should not be taken simultaneously. “But of these, only about a dozen are commonly used and could often be left off for the duration of Paxlovid treatment,” he explained in a Pfizer-sponsored talk.
The drug, which is the sum of two antivirals (nirmatrelvir and ritonavir), is indicated precisely for people with a higher risk of a poor evolution of covid: those over 60 years of age, frequently with comorbidities, which makes it more likely that they are taking any of the drugs with which it cannot be combined. According to Jesús Sierra, from the Spanish Society of Hospital Pharmacy, it is not always easy to withdraw a treatment to introduce Paxlovid, which has to be taken within five days of the symptoms to be effective. “If, for example, you are taking statins for cholesterol, which are very common, there is no time to eliminate the drug and start with Paxlovid,” he says.
In a context in which covid infections are becoming milder, diagnoses have also been relaxed. People who have symptoms do not always go to the doctor, many times they do a simple antigen test at home and it is very possible that in these first five days they have not even been to their GP.
In addition to these barriers to its use, there are others pointed out by Roger Paredes, head of the infectious diseases service at the Trias i Pujol Hospital in Badalona: “It is being underused compared to other countries for various reasons. One is the circuit that has been 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 falls by the wayside and does not get to receive it”.
All these difficulties, those consulted agree, mean that the family doctor rarely resorts to this treatment, even in cases in which it would be potentially beneficial for the patient. “With vaccines there are fewer and fewer serious cases. The perception in the consultation is surely that very few have a poor prognosis. A doctor who in his day to day prescribes all kinds of drugs receives a new one, antiviral, which does not have much tradition, with many problems of interactions, and it is difficult for him to stop to examine them to prescribe it, which is very understandable. This means that in the end we have many hospitalizations that could have been avoided,” says Paredes.
Real effectiveness of the drug
Beyond clinical trials, nirmatrelvir, one of the components of Paxlovid, has shown very good real-world results. A study conducted in Israel and published in September in New England Journal of Medicine it showed 81% efficacy in people over 65 years of age, most of them vaccinated and infected with the omicron variant (the trials were mainly done with the delta variant in unvaccinated people). Among those who received the pills, the hospitalization ratio was 15 people per 100,000 inhabitants, while among those who did not, it reached 59 per 100,000 inhabitants. In younger people it has not given significant results, but it is not a medicine that is indicated for them.
With the older population vaccinated, hospitalization rates have dropped dramatically from before the shots. This means that in order to avoid hospitalization it is necessary to administer pills to many more patients, which increases the costs of the treatment, compared to its real effectiveness. It would need to be prescribed to a large number of infected for it to have a significant reducing effect on the number of hospitalizations. Just the opposite of what is happening in Spain.
The result is that there are more than 300,000 purchased treatments that in theory began to expire at the beginning of next year. Faced with this possibility, Pfizer reports that the expiration date has been updated to go from one year to 18 months, which would give more time before having to throw them away, but provided that the rate of prescriptions accelerated enormously: at present it would take more than 10 years to spend all of them. However, it is not uncommon to update the expiration date to avoid waste. “The active principle of a batch is reviewed and if it is maintained, its useful life is extended. We’ve been doing it for a decade the tamiflu [del que se hizo un gran acopio para combatir la gripe A]”, assures Jesus Sierra.
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