August 6, 2022

We haven’t run the numbers for a bit. Where are we? About 100-120,000 new cases of Covid being reported daily in the US. This is about four times the low spot of late spring when we were down to about 30,000 cases daily and about a tenth of the peak of omicron this past January when we were at nearly a million new cases a day. Is the current number accurate? Probably not as health departments are not as timely or as exacting with their data reporting and because the majority of home test diagnosed cases aren’t reported and counted correctly due to all the barriers that stand in the way of that data collection. Deaths are going up again. We’re up from about 300-400 deaths a day a month ago to about 650 deaths a day nationwide. That’s nowhere near what we had earlier in the pandemic but it’s still a significant increase over the last few weeks, likely reflective of the increase in cases as omicron BA 5 continues to spread with its pesky habit of getting around our various immunities, both natural and vaccine derived.

Assuming that we stay even at roughly 650 deaths daily, that’s nearly 20,000 deaths a month or about 235,000 deaths a year. That’s enough to enshrine Covid as the third leading cause of death in the US for some time to come, bested only by cancer and heart disease (both about 600,000 a year) and roughly ten times the usual flu death rate which usually hovers somewhere between 20,000 and 30,000 annually. So, if Covid is here to stay in an endemic fashion, it’s still a problem not to be taken lightly and my best advice to everyone is to keep getting those boosters as they come down the pike, just like you keep getting flu shots. I’m not convinced that we’re at the end of the road yet. I still think we’ve got a nasty little surprise or two coming.

Has the availability of Paxlovid, the antiviral drug combination which if taken early in the infection, made a major difference in the mortality and morbidity statistics? I honestly don’t know. It certainly hasn’t hurt. There’s a bit of misinformation about Paxlovid floating around out there. First off, it’s not a prophylactic. If you go to a wedding and you find out later that the person across the table from you had Covid and decided to come any way, taking the drug won’t protect you from infection. It’s only for those who are actually actively infected. If you are infected and you’re young and healthy and your symptoms are mild like a bad cold, should you take it? It won’t hurt but it’s probably not necessary. It’s probably best used by those who are starting to get slightly more symptomatic such as fever or worsening cough, especially if they are at risk for severe complications from age or from other underlying health issues or immune deficiencies. For it to be helpful, it has to be taken within four or five days of the start of symptoms and it’s a five day course. It’s standard dosing unless you have kidney function issues requiring a lower dose. It doesn’t have a lot of side effects. There is some talk about Paxlovid rebound – a worsening of symptoms following finishing a course for a few days, but it’s unclear if this is a real issue or not. Will I take it if I get infected again? Won’t hurt, might help, can’t think of a major reason not to.

The problem with Paxlovid, indeed with all medications within American health care, is that the general population thinks of them as magic. Feel bad? Take a pill and presto changeo the miracle happens and you’re back to normal. The problem is that health, disease and pharmacology are a lot more complex than that. (That’s why pharmacy school is a four year program after college). Drugs are controlled doses of poisons – substances designed to alter your physiology in one way or another. They don’t do the same thing in all people. One of the dirty little secrets of pharmacy is that pretty much all drugs don’t work in between 5-25% of people because of genetic variations in physiology. They don’t do the same things in the same person at different times in the life span due to alterations in body composition over time. They can interact with each other in highly complex ways that no one understands. There has never been a controlled trial of a human being with more than three medications circulating in their system at once. It’s too complicated to study using those sorts of rigorous scientific methods so when someone takes ten, fifteen, twenty-two different medications daily, we haven’t a clue what’s actually going on. We’re just making our best guesses.

I’m going to reduce four years of pharmacy school down to a couple of paragraphs to help explain some of these concepts. There are two basic things to consider. Pharmacokinetics and pharmacodynamics. Pharmacokinetics are the movement of drugs through the body and pharmacodynamics are the body’s biologic response to the drugs once they reach their destination. Pharmacokinetics are affected by four basic processes. The first is absorption. Most drugs are administered as pills and enter the stomach and pass into the intestine for digestion. The chemicals are then taken up across the intestinal lining and enter the blood stream. As the gut is one of the earliest body systems on an evolutionary scale, it works pretty well most of our lives and absorption doesn’t change a lot with age. There are some exceptions. First, some pills come with capsules and coatings that require stomach acid to properly disintegrate and a lot of older people, due to changes in the stomach and reflux, take a lot of antacids which may keep this from happening properly. Second, there are some specific categories of medicines not taken up as well as the transport systems in the gut deteriorate with age – these include positively charged ions such as iron and magnesium and vitamin B12.

Our second pharmacokinetic system is known as distribution. Drugs, like other chemicals, either prefer to dissolve in water or in fat/oil (hydrophilic or lipophilic). The body has both of these available. Water in the circulation and lead muscle tissue and we all know about fat. As we get older the proportion of fat to water tends to increase meaning that hydrophilic drugs have less volume to dissolve in and so their circulating concentrations go up and the lipophilic drugs have more volume meaning they are going to stick around longer in the body and clear less effectively leading to much longer half lives. I always had a problem understanding this when I took second year pharmacology in med school so if you have no idea what I’m talking about, you’re not alone.

Lastly, we have metabolism, the changing of drugs from one form to another, usually by the liver, in preparation for either use by the body or to become an inert form or a form which can be cleared from the body – something that slows with age and, of course, excretion, where the drug leaves the body either from being moved from the blood stream into the urine through kidney function (declining with age) or by the lower part of the GI tract. Paxlovid is subject to all of these processes as much as any other drug. It is eliminated in the urine so in those with renal dysfunction, it doesn’t cross through the kidneys quickly enough leading to toxic buildup which is why it must be administered in lower doses. It also interferes in the metabolism of several other common drugs and those drugs often need to be held while taking Paxlovid. Your pharmacist can advise you.

As one gets older or develops health conditions where you’re on routine medications, one of the best things you can do for yourself is choose a single pharmacy to fill your prescriptions and make friends with your pharmacist. Their scope of practice is quite broad and they are the experts at catching interactions between medications and other medications related problems, but to really do it, they have to know you and your whole med list. When you’re filling things at three different pharmacies, no one is able to see the whole picture and catch things early. With the number of patients I see, the complexity of their medical problems, and the numbers of medications they take, I rely whole heartedly on the pharmacists I work with to help keep me on the straight and narrow, or to at least keep me from killing too many of them.

And there you have it. I’ve just saved you $80,000 in pharmacy school tuition. Hopefully you’ll use some of that cost savings to take care of yourselves and buy a little gas for the car so you can go get your boosters as they become available.