WWYD - covid antiviral in immunocompromised people question

June 27, 2024 2:05 PM

YANMY. TINMA. I have covid and was prescribed Lagevrio but I am hesitant to take it based on my specific situation and could use hive mind opinions. If you were in this situation how would you make this decision?

Paxlovid is contraindicated so she called in the other one. I am vaccinated and boosted but also had a recent course of rituximab so I am immunocompromised. I'm generally healthy otherwise.

I started 40 mg of Prednisone on day 1 of a positive home test which was 4 days after my spouse had symptoms then a confirmed positive home test. This is day 3 of 40mg Prednisone. Tomorrow I'll start three days of 20 mg then stop it most likely. I usually take 20mg for about 3 days for colds to jumpstart recovery. My rheumatologist knows and is good with this approach and trusts me to taper as needed. Rheumy knows that I jumped to 40mg for this covid situation.

I can't decide whether to actually take this antiviral. I don't feel awful. No fever at all. Mild to moderate myalgia. Significant fatigue. Mild sore throat and congestion. The headache the first 2 days was about as bad as any migraine I've had but I've had so many of them it's hard to call it a severe symptom. Occasional chest tightness but no shortness of breath. The fatigue is the most debilitating symptom.

This is my 3rd time with covid and I've never needed hospitalization. All 3 times I was immunocompromised but this is the first time I caught it so soon after freshly crashing my immune system.

I'm inclined to not take the medication unless I have more severe symptoms by day 5. It also says it can alter DNA which is pretty scary to me. Am I an idiot?

Reasons I am considering taking the antiviral: doctor recommended it. I don't want to be a long term incubator of the virus more likely to shed and infect others unknowingly which can be a thing for immunocompromised people with covid. Results for this version of covid antiviral suggest it doesn't prevent rates of hospitalization or death very well but it does reduce the course of illness by a few days. I would be ok with feeling back to myself sooner.

I'm not even sure why I am hesitating to take it except I don't want to take a medication I don't actually need. If my body can fend this off without help then I would imagine I'll have better natural antibodies anyway, right? Is having no fever a good sign that my body didn't think it was such a huge emergency, a bad sign that my body's ability to respond appropriately to an emergency invasion is broken, or a non-salient sign since anyone can have or not have fever with covid? I didn't actually see my doctor and she won't be able to answer these questions for several days but obviously I need to make this decision quickly so I'm hoping this post is allowed.

posted by crunchy potato to Science & Nature (8 answers total)

I bet others will come along with receipts, but if I recall correctly, I think there's a correlation, at least, between taking antivirals and lower incidence of long COVID. So that's why I would take it, myself.
posted by limeonaire at 2:18 PM on June 27 [5 favorites]

Best answer: Also, does your insurance have a nurse line you can call? That might be a good way to get another opinion.

The other reason I would do it is that I've read that COVID can in some cases persist longer and turn you into an incubator of the virus if you're immunocompromised, as you mentioned.
posted by limeonaire at 2:24 PM on June 27 [3 favorites]

I think there's a correlation, at least, between taking antivirals and lower incidence of long COVID

Unfortunately, the current best evidence - based on two studies released this year - is that Paxlovid does not reduce the risk of long Covid (study one, study two).
posted by Mr.Know-it-some at 2:37 PM on June 27 [3 favorites]

My hunch is that you're good w/o the antiviral. You're probably past the worst of the symptoms and you've got history indicating your body can deal with COVID. I believe the primary purpose of the antivirals was to prevent hospitalization & death, which they're effective at doing. Their efficacy for long COVID is mixed. Also suggest getting additional more qualified medical opinions.
posted by pappy at 2:41 PM on June 27 [1 favorite]

Best answer: A lot of the studies people are referencing are on paxlovid, and they aren't the same. Molnupiravir (lagevrio), which OP mentions, is much less effective and has been recently not doing well in tests. I would probably check with my doctor if it were me. Especially in combination with prednisone, which is also typically immunosuppressant, I (though not your doctor) would suggest you consider the possibility you aren't having symptoms not because your body has fought it off, but because your body doesn't even know it should be fighting yet (no immune response).
posted by Lady Li at 3:30 PM on June 27 [4 favorites]

Response by poster: Called the nurse line (thanks; I always forget that option) and also spoke to the pharmacist. Of course neither will take a firm position, but neither of them discouraged me from waiting to see if I continue to feel better before taking the molnupiravir.

Curious about Lady Li's comments as using Prednisone temporarily at onset of regular mild illnesses tends to shorten the course of the illness considerably, while reducing the risk of autoimmune flares. So much so that I had to research your comments to learn that it is suppressing the immune system because in my head it was doing something else I guess. Seems like an odd way to promote recovery but I feel better so much faster if I take it vs not taking it for whatever reason. Now I want to deep dive into how it helps me recover faster if it also suppresses immune response but this is probably not the time for that.

I don't recall ever having the "second wave which is also worse" flavor of covid but that doesn't mean I didn't. I did get bacterial pneumonia after fighting off an adenovirus while immunocompromised last year. Many people around here who get the current variant of covid also end up with strep or walking pneumonia so I guess that's reason enough to consider the antiviral even if I feel ok.

I think I'll message my doctor to verify the reasons for this Rx over paxlovid and verify my understanding of clinical decision making since this is the first time she's ever suggested taking the antiviral. Actually that isn't true but she didn't know within 5 days of symptom onset previously so she said it was too late to take it.

30% reduction in hospitalization or death doesn't seem worth it to me to take something that has potential genotoxicity but paxlovid would be ok. I could easily hold the medications she's concerned about interacting.
posted by crunchy potato at 4:01 PM on June 27 [1 favorite]

I doublechecked the contraindication between Paxlovid and Prednisone. It seems Paxlovid actually makes you absorb MORE Prednisone if taken together, which can mess up your Prednisone dosing. Other than that, they actually don't interact much. So IMHO, you SHOULD take the alternative antiviral for COVID. There's no reason to believe they'd interact, and even if they do, it's probably not a serious problem they'd be causing. Of course, I'm just a random Internet yahoo, not a doctor, and definitely NOT your doctor.
posted by kschang at 5:52 PM on June 27

If the antiviral-prescribing doctor is your rheumatologist, she knows your medical history and I think taking it would be a good idea; otherwise, call rheumy to confirm its appropriateness in your case.
posted by Iris Gambol at 12:36 AM on June 28 [1 favorite]