Concerns over vulnerable patients missing COVID-19 oral antivirals

GPs are reporting some at-risk COVID-19 patients have been unable to receive COVID-19 oral antiviral treatments in a timely way – even with a prescription.
 
The two oral antivirals are currently a key part of the Federal Government’s strategy to minimise the impact of COVID-19 on the most vulnerable patients, particularly among older people.
 
Both molnupiravir (sold as Lagevrio) and nirmatrelvir plus ritonavir (sold as Paxlovid), are part of the Pharmaceutical Benefits Scheme (PBS), and the Government recently announced a campaign to raise awareness of the treatments.  
 
However, RACGP Rural Chair Dr Michael Clements believes that patchy availability, despite being on the PBS, may be limiting prescriptions.
 
He says he has directly experienced issues accessing treatments for patients via the PBS through his practice on Magnetic Island and has also encountered less pronounced problems through his mainland practice in Townsville.
 
Pharmacy sources, including the Pharmaceutical Society of Australia, have told newsGP that the expense of the oral antivirals means pharmacies are likely to order on demand unless they expect to have a steady flow of prescriptions come through.
 
Dr Clements believes the problem is most acute in remote areas where pharmacies may not hold supplies of the oral antiviral at all.
 
‘I do hold fears, it’s not reasonable for some of these remote practices to have a holding stock of some of these very expensive medications just in case they’re needed,’ he told newsGP.
 
‘One of the troubles, I believe, is the pharmacy has to pay full price for the script and hold it on their shelf hoping that we’re going to write a script.
 
‘And if they don’t sell it, then they actually lose all that money so there’s a reluctance for places to hold on to too much stock. That has had an impact on us being able to prescribe.’
 
In an ongoing newsGP poll being conducted this week, more than 600 responses have so far been issued to a query about whether their patients have encountered problems accessing COVID antivirals after being prescribed them.
 
Of those who said they had prescribed the oral antivirals, more than one in three (36%) reported patients having issues with access.
 
The cost of the Paxlovid oral antiviral treatment is reportedly $1200 per course.
 
Dr Clements said he would support Government underwriting of the cost to ensure the supplies are shored up.
 
‘If I was a pharmacist, I’d be nervous too because I know that the tablets are expensive,’ he said.
 
‘If there’s a new tablet that comes out tomorrow that’s better, then we’re going to stop prescribing the older one, and then there’s a risk for that stock.’
 
In the PBS definition for the treatments, one of the high-risk factors is living in a remote area – defined as Modified Monash Model 5 and above – without easy access to ‘higher level’ healthcare.
 
The Department of Health (DoH) was approached by newsGP on Friday about the likelihood of underwriting the supply of antivirals in pharmacies should they not be used.
 
In the meantime, RACGP Vice President and Queensland Chair Dr Bruce Willett said he believes jurisdictional differences in approach to the antivirals can make a difference.
 
He points to changes to the Health Direct pathways in Queensland, which have only recently increased the emphasis on the use of antivirals. Other GPs in the state have reportedly been told that prescriptions needed to go through hospital health services.
 
Dr Willett said that given the tight time requirements for prescription, having ready supply on-hand is crucial.   
 
‘Pharmacies can generally have them there within 24–48 hours but that’s too long with these medications,’ he told newsGP.
 
Meanwhile, Professor Mark Morgan, Chair of RACGP Expert Committee – Quality Care (REC–QC), has stated that he believes more flexibility is needed.
 
‘I believe there should be scope for clinical judgment,’ he said. ‘If a patient has a particularly severe co-morbidity there should be an opportunity to prescribe antiviral treatments.’
 
Professor Morgan also pointed to different arrangements in place in different jurisdictions, which he says ‘make the whole thing very complicated’.
 
He is advocating for more input from data experts to help target the vulnerable patients most likely to benefit from the antivirals.
 
The Federal Minister for Health and Aged Care, Mark Butler, has previously confirmed he is seeking advice from DoH officials on the best way to reach at-risk patients in a timely way.

This week, Minister Butler also announced an independent review of Australia’s vaccine and treatment procurements, including the oral antivirals.
 
According to the latest figures, there have been 63,000 PBS prescriptions of the oral antivirals made by GPs and dispensed through community pharmacies to date.
 
The Government has ordered one million courses of nirmatrelvir plus ritonavir and 300,000 of molnupiravir so far.
 
Who is eligible in Australia?
According to PBS criteria, the drugs can be prescribed for those with mild-to-moderate COVID-19 confirmed by a PCR or rapid antigen test within five days of symptom onset, among the following patient groups:

• Those aged 65 or older, with two other risk factors for severe disease
• Those aged 75 or older with one other risk factor
• Those aged 50 and older who are of Aboriginal or Torres Strait Islander origin with two further risk factors for severe disease
• Those with moderate-to-severe immunocompromise

COVID-19 Lagevrio oral antivirals Paxlovid