Some people experience a “Paxlovid rebound” after taking the antiviral pill for COVID. Here’s what you need to know.

Paxlovid is Pfizer’s antiviral drug to treat COVID-19. (Reuters/Wolfgang Rathai/Illustration)

Some people experience a “Paxlovid rebound” after taking the antiviral pill for COVID.  Here’s what you need to know.

When the antiviral drug Paxlovid was approved in 2021 to treat COVID-19, doctors began to notice a puzzling trend among some of the patients taking it: a case of the virus rebounding. After treatment, some people recover and test negative for the virus, only to test positive or have symptoms reappear a few days later. The “Paxlovid bounce,” as it’s known, received a lot of media attention when President Biden and First Lady Jill Biden, as well as Dr. Anthony Fauci and Rochelle Walensky, director of the Centers for Disease Control and Prevention, all experienced it last year after taking the drug.

Scientists aren’t sure why this rebound effect occurs after taking Paxlovid, but here are a few things we do know.

What is Paxlovid? How it works?

Paxlovid is an oral antiviral pill that can be prescribed to people who get sick with COVID-19 and are at risk of developing severe disease. These may be people who have not been vaccinated, the elderly, or people with other illnesses, such as cancer or diabetes. The drug, developed by Pfizer, could protect these high-risk patients from needing hospitalization. Those who are vaccinated but are at risk of severe outcomes from COVID-19 may also benefit from taking Paxlovid.

US regulators granted Paxlovid emergency use authorization in December 2021. Today, the drug is available only with a prescription from a doctor or pharmacist. Anyone 12 years of age and older who weighs at least 88 pounds and is at high risk of serious illness is eligible for the drug. However, patients with severe kidney disease – or who are on dialysis – or people with severe liver disease should not take it. The drug can also interact with other drugs, such as those that treat high cholesterol, high blood pressure, and migraines, so patients taking these drugs should avoid taking Paxlovid.

Like many antiviral drugs, Paxlovid works best when taken early in the illness. The CDC recommends that treatment be started within the first five days of the onset of symptoms. Once a person is prescribed the drug, they will take three Paxlovid pills twice a day for five days, for a full course that adds up to 30 pills.

Antiviral therapy consists of a combination of two oral antiviral drugs—nirmatrelvir and ritonavir—that work together to stop the viral replication process. By reducing a person’s viral load, the drug reduces the severity of their symptoms.

in clinical trials, which were conducted when the Delta variant was prevalent, found that Paxlovid reduced the risk of hospitalization or death by 89% in high-risk people. Since its approval, many clinical trials conducted around the world have also confirmed its high level of protection against hospitalization and death.

As Omicron is a variant with strong immunity evasion that has rendered many antibody treatments are ineffective, vaccine experts worry that Paxlovid will also lose its effectiveness. Fortunately, that doesn’t seem to be the case. According to recent research, the drug continues to offer significant protection against hospitalization and death and may also offer significant benefit even to vaccinated patients diagnosed with COVID-19.

However, other studies have found no evidence of benefit from Paxlovid people under 65 years of age.

“I don’t think we should be pushing Paxlovid on every 20-year-old who gets COVID or every 35-year-old who’s healthy,” Dr. Bruce Farber, chief of public health and epidemiology at Northwell Health, on the largest health system in New York State, Yahoo News said. “But in those who are at high risk, those who are elderly, those who have not been vaccinated, those who have co-morbidities, those who are immunosuppressed, [for] these people [it] can make a significant difference.”

In addition to protecting high-risk patients from severe disease, Paxlovid can reducing the risk of symptoms of prolonged COVIDfound a November survey conducted by the Department of Veterans Affairs.

What is Paxlovide rebound?

The CDC defines a Paxlovid rebound as occurring when, after completing the full five-day course of treatment, a person either experiences a recurrence of symptoms or tests positive after testing negative for COVID-19. According to the CDC, this rebound effect usually occurs between two and eight days after the initial recovery. But recovery, the agency said, does not mean a person was resistant to Paxlovid, nor does it mean they have been reinfected with the virus. Additionally, the CDC said that cases of Paxlovid rebound are usually mild and resolve within a few days, and there is no evidence that additional treatments are needed for these patients.

Despite Paxlovid’s efficacy even in the Omicron setting, the drug is underused in the US and other parts of the world. According to a report by London-based healthcare analytics firm Airfinity, American doctors only prescribed the drug in about 13% new cases of COVID-19. Experts said concern about the potential recovery of Paxlovid may be one reason this is happening.

Farber said another reason Paxlovid is underused has to do with the virus itself. “This virus is much less virulent, although it is more contagious,” he said, adding that the need for Paxlovid “has decreased.”

Scientists are still investigating why the rebound effect occurs when taking Paxlovid, and who is more likely to experience it. However, recent research has found that rebound can also occur in people who develop COVID-19 and do not take Paxlovid. Studies are underway to find out why this happens, Farber said.

“More recent data show that rebound also occurs in people recovering from COVID who did not receive Paxlovid, and it occurs at probably similar levels whether you are taking Paxlovid or not,” Farber said, adding that post-drug rebound events were originally thought to occur in approximately 5% of cases, but this study showed that it may happen more often than first thought. “More recent papers say it could be as common as 10 or 15 percent of the time,” he said.

What to do if you get a Paxlovid rebound

If someone’s symptoms return or they test positive after treatment with Paxlovid, the CDC advises following up on theirs isolation guide and quarantine again for five days. Isolation may end after this period if a person has been fever-free for 24 hours without using antipyretic drugs. The agency also recommends wearing a mask for 10 days after the onset of recovery symptoms.

CDC encourages doctors and patients to report cases of Paxlovid ricochet Pfizer Portal for drug-related adverse events.

Finally, Farber said that a Paxlovid recovery is still fairly uncommon, and that it shouldn’t deter people and their doctors from using the life-saving drug when needed.

“In theory, this could prolong their isolation. But I think [people] must understand that this can happen even without Paxlovid. So it really doesn’t become an important distinction whether they get it or not,” he said.

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