Weighing risks when considering a Paxlovid prescription for patients with renal impairment
Paxlovid (nirmatrelvir/ritonavir) has proven highly effective at reducing the severity of COVID-19, especially when taken in the earliest stages of an infection (within five days after clinical presentation). Current guidelines reduce the dosage of nirmatrelvir in the presence of mild-moderate renal impairment (eGFR 30–60 mL/min/1.73 m2), but due to a lack of data, suggest no treatment recommendation for those with more severe kidney dysfunction (eGFR <30 mL/min, as seen typically when the serum creatinine is >2 mg/dL).?
Doctors are asking, "What is the right approach when I don't know or haven't documented the renal function of a new patient with COVID-19 infection?" Doctors also realize that patients with more severe renal dysfunction are at the highest risk of developing more severe complications from COVID-19.?
A July 2022 article in Clinical Journal of the American Society of Nephrology addresses how to manage risk in a patient with COVID-19 and chronic kidney disease [CKD] or kidney transplant. The authors concluded that despite the minimal data on using and dosing Paxlovid in such patients, they should still be treated with Paxlovid. They suggest that patients with advanced CKD (eGFR <30 mL/min per 1.73 m2) and those receiving dialysis who contract COVID-19 should be offered low-dose nirmatrelvir/ritonavir regimens. There are additional drug-drug-interaction caveats for patients on immunosuppressive therapies, especially kidney transplant patients.
Sources:
- Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD, Clinical Journal of the American Society of Nephrology
- Paxlovid Use for COVID-19 May Be Feasible in Advanced CKD, Renal & Urology News
- Fact Sheet for Healthcare Providers: Emergency Use Authorization for PaxlovidTM, FDA