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    The SARS-CoV2 virus has been the scourge of the modern world for the last two years. New variants like omicron inject a sense of urgency to finding treatments for those infected. Important among these is an effective oral therapy which can be used to minimize hospitalizations and deaths.

    Not too long ago, I wrote about the development by Merck Pharmaceuticals (the maker of ivermectin) of an oral COVID-19 treatment called molnupiravir. Molnupiravir inhibits coronavirus replication inside the body by inserting errors in viral genetic code. As more and more faulty genetic material is produced, it causes an “error catastrophe” that prevents viral reproduction completely.

    At the time, clinical trials were reporting a 50 percent decrease in severe disease in COVID patients taking molnupiravir compared to placebo. Since then, Merck’s drug has slipped somewhat: Current evidence has modified the effectiveness against SARS-CoV2 down to 30 percent.

    Given the lackluster results at present with molnupiravir, an alternative was needed. This comes in the form of a Pfizer combination drug known as Paxlovid. Paxlovid is a combination of the experimental drug nirmatrelvir and the HIV med ritonavir. The ritonavir allows nirmatrelvir to remain active in the body at higher concentrations for a longer period of time.

    Like molnupiravir, Paxlovid also stops viral replication, but in a different way. It acts by binding to enzymes called proteases. Without protease, reproduction can’t occur. The new drug may also have additional applications for future outbreaks of related viruses like SARS and other coronaviruses.

    An ongoing study called EPIC-HR (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients) originally published results showing an 85 percent reduction in hospitalization and 100 percent decrease in deaths in those taking Paxlovid compared to placebo. Even later data increased effectiveness to 89 percent if taken in the first three days of symptoms, 88 percent in the first five days, even against the omicron variant. Adverse reactions include headaches and muscle aches.

    If approved, a dose of 300 mg of nirmatrelvir and 100 mg of ritonavir would be given twice a day for five days. As with many antiviral drugs, treatment should begin at the first sign of symptoms or after a suspected exposure.

    The newly-developed drugs won’t be cheap, costing at least several hundred dollars per treatment. Compared to hospital costs or even intravenous infusions of monoclonal antibodies or remdesivir (FDA approved), it’s still a bargain. Pfizer expects to produce 80 million courses of therapy by the end of 2022. Of course, ivermectin is still a cheap and effective alternative, according to the physicians of the Front Line COVID Critical Care Alliance.

    In the next year, expect a number of other new COVID drugs emerging. Hopefully, one or more will pan out to be effective strategies against the pandemic virus.

    Joe Alton MD

    Joe Alton MD

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