Merck & Co Inc.
If you just got sick with COVID-19 and you’re at high risk for a serious illness, there are two types of pills — scattered across US pharmacies — that can help keep you from getting worse. But doctors say the two pills are not equal.
These antiviral pills—Merck’s molnupiravir and Pfizer’s Paxlovid—help prevent the virus from spreading throughout the body if taken early in the course of the disease. Both were approved by the FDA in late December and are being distributed by the US government.
But molnupiravir is a much less effective drug and many doctors are hesitant to prescribe it. “It’s an alternative rather than a first-line drug, and I think that’s why the use is lower,” said Dr. Rajesh Gandhi of Mass General Hospital in Boston, who is helping develop guidelines for treating breast cancer. COVID-19 for the NIH and the IDSA, a medical society.
Both antivirals are five-day pill courses that can only be prescribed to someone who has tested positive for COVID and must be started within five days of developing symptoms.
Data reviewed by the FDA showed that molnupiravir was only 30% effective in reducing the risk of hospitalization with COVID-19. Paxlovid works much better and reduces the same risk by almost 90%. According to published data, antibody and antiviral infusion treatments also reduce the risk of serious disease more than molnupiravir. And molnupiravir carries reproductive risks, so it’s generally not recommended for patients who are pregnant or trying to conceive.
On the shortlist of four early COVID-19 treatments recommended by the government for patients before hospitalization, molnupiravir comes last — only to be used when the other treatments cannot be used.
The federal government has spent $2.2 billion on molnupiravir — and many doses go unused. Some pharmacies “are experiencing storage issues on molnupiravir and are not moving the product as quickly,” said Dr. Derek Eisnor, who leads the government’s distribution of COVID drugs, recently spoke with state health officials.
However, the other more effective drugs also have their drawbacks. Paxlovid pills have a long list of common medications that you can’t take because of potentially dangerous interactions. Getting intravenous drug infusions — as patients do for the other two authorized treatments — sometimes require you to go to a clinic multiple times. And many of these treatments are scarce.
So Gandhi says there’s still a place for molnupiravir in the current COVID treatment landscape: as “an alternative when one of those other drugs can’t be given due to drug interactions or feasibility issues.”
Trillium Health, a community health center in Rochester, NY, treats “many complicated patients, who have complex medication lists, whose medications can’t always be stopped,” says Dr. Bill Valenti, co-founder and staff physician.
The health center has found a use for molnupiravir and is prescribing it for more than a dozen patients, including Valenti’s 55-year-old patient John DeGrandis. “I’m a bit of his guinea pig at times,” jokes DeGrandis.
The first time DeGrandis got COVID was in the fall of 2020, before vaccines and treatments were available — and it felt like a really bad cold.
This month, when he got it again, there were approved drugs to treat mild COVID. “I think it’s better to treat than not to treat,” Valenti says, “So we went through the list.”
At the top of the list was Paxlovid — but Valenti ruled it out, as it could have some bad interactions with other drugs DeGrandis was taking.
Then there was a long waiting list for infusions, which could take a while to get. “That really wasn’t an option,” Valenti says, as the goal of early COVID treatments is to prevent the virus from spreading throughout the body.
That left molnupiravir – which was in abundance at the local pharmacy and easy to take at home. While it’s not as effective as the other options, “maybe we can compensate for that by giving it to him early in the course of his illness,” Valenti reasoned.
So DeGrandis filled his prescription at Walgreens and took four pills, twice a day, for five days. Did it help at the end of the course? Unclear, says DeGrandis, “I don’t know the difference. I honestly didn’t feel bad all the time. I was a little tired, but now I feel 100%.”
Valenti says these COVID pills are the first-generation tools doctors can use to treat COVID patients early. “These drugs are good for the time, especially because it took so little time to find something that was useful. But I think this is just the beginning of the treatment era,” he says.
Better medicines are being developed that take fewer pills and are more effective. For now, he will work with what he has.