Monday, July 18, 2022

Pharmacists can now prescribe Paxlovid

 - Jennifer Middleton, MD, MPH

The United States (US) Food and Drug Administration (FDA) recently modified its Emergency Use Authorization (EUA) for nirmatrelvir/ritonavir (Paxlovid) to "authorize state-licensed pharmacists to prescribe Paxlovid to eligible patients, with certain limitations to ensure appropriate patient assessment and prescribing." Although some physician organizations have previously expressed concern with expanding pharmacists' scope of practice, others argue that increased access to Paxlovid is necessary

Nirmatrelvir/ritonavir must be started within 5 days of symptom onset, and its EUA applies to outpatient adults at high risk for severe COVID-19 illness. It is effective at reducing the risk of hospitalization or death, with a number needed to treat (NNT) of 18 in unvaccinated persons, with early non-peer-reviewed data demonstrating efficacy in vaccinated persons as well. When first approved, supplies and access were limited, but now plenty of nirmatrelvir/ritonavir is available to meet demand, which has been increasing in the US as COVID-19 surges again. The challenge for many patients is access to a prescription within the short 5 day window; COVID-19 tests, especially home test kits, may not be positive on the first day or two of symptoms, and prescribing requires time to review medical records for underlying liver and kidney disease as well as medication lists for nirmatrelvir/ritonavir's many drug-drug interactions.

The FDA encourages patients seeking nirmatrelvir/ritonavir after a positive COVID-19 test to first "consider seeking care from their regular health provider" or look for a Test-to-Treat location nearby. If seeking nirmatrelvir/ritonavir from a state-licensed pharmacist, patients should bring records of liver and kidney labwork that are less than 1 year old along with a comprehensive list of their medications and supplements.

Pharmacists' expertise can benefit patients and physicians. This 2021 FPM article reviews how in-office pharmacists can help with medication safety reviews, assist with tobacco cessation, and improve diabetes and hypertension control. "Interventions that involve pharmacists" increase medication adherence in patients with multiple chronic health conditions. Compared to physicians, pharmacists' management of warfarin results in improved INR readings and safety outcomes, and pharmacists can safely manage uncomplicated urinary tract infections (UTIs). The Choosing Wisely campaign urges us to "[not] continue medications at transitions of care without a pharmacist...performing a comprehensive medication review."

The AAFP recognizes these benefits of collaborative agreements with pharmacists, but it also warns about fragmentation of care when pharmacist prescribing is decoupled from a patient's primary care physician. Ensuring adequate communication with primary care offices when a pharmacist prescribes nirmatrelvir/ritonavir will be necessary to minimize the risk of this fragmentation. Looking beyond the COVID-19 pandemic, family physicians should think creatively about how to maximize collaboration opportunities with pharmacists, especially since, on average, patients access their community pharmacists much more frequently than their primary care physician.