Infectious Disease

COVID-19 rebounds like Biden’s ‘should not dissuade’ patients from taking Paxlovid

August 01, 2022

2 min read

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Adalja reports no relevant financial disclosures.

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President Joe Biden tested positive for SARS-CoV-2 again on Monday, the White House announced — the third day in a row he tested positive after testing negative for 3 days last week.

Biden, who is fully vaccinated and has received two boosters, has a case of so-called “rebound” COVID-19, which has been reported in some patients after being treated with Paxlovid. He first tested positive on July 21 and experienced “very mild” symptoms, according to the White House.

IDN0822Paxlovid_Rebound_Graphic_01_WEB

Joe Biden

“It’s unclear how common this effect is,” Amesh A. Adalja, MD, senior scholar at Johns Hopkins Center for Health Security, told Healio. “It was not seen as an issue in the clinical trials but the real-world experience with the drug seems to suggest that this is something that occurs with some level of frequency.”

Adalja explained that a rebound “is not a reinfection — it is the same virus that the initial infection was caused by” and said there are reports of transmission occurring from people experiencing a rebound.

One preprint study examining the rates of COVID-19 rebound in patients treated with Paxlovid and molnupiravir found that among 13,644 adults, the 7-day and 30-day COVID-19 rebound rates after treatment were 3.53% and 5.4% for SARS-CoV- 2 infections, 2.31% and 5.87% for symptoms, and 0.44% and 0.77% for hospitalizations.

Another study published in Clinical Infectious Diseases assessed the outcomes of 483 high-risk patients treated for COVID-19 with a 5-day oral regimen of Paxlovid. Among them, two patients (0.4%) required hospitalization by day 30, four (0.8%) experienced rebound symptoms — which were “generally mild” — and all illnesses resolved without additional treatment.

“Why this is occurring is still something that needs an answer,” Adalja said.

The researchers of the second study said one explanation could be “the resumption of SARS-CoV-2 viral replication following completion of therapy, triggering a secondary immune-mediated response that manifests as recurrence of clinical symptoms.” They reported that all four patients with rebound symptoms had comorbidities, which can complicate recoveries.

“It could be that the drug lowers viral load, which then rebounds when the drug is not present because, perhaps, the immune response is blunted with the drug in the early stage,” Adalja said. “Nevertheless, the drug is working perfectly well at doing what it was designed to do: prevent severe disease.”

The CDC issued a health advisory about the recurrence of symptoms in late May. It said that “a brief return of symptoms may be part of the natural history of SARS-CoV-2 infection in some persons, independent of treatment with Paxlovid and regardless of vaccination status.”

It said limited information available from case reports suggests that people treated with Paxlovid who experience COVID-19 rebound have had mild illness and that there is currently no evidence that additional treatment is needed with Paxlovid or other anti-SARS-CoV-2 therapies in cases where COVID-19 rebound is suspected.

The White House is following this advice and wrote in a statement that because Biden is experiencing mild symptoms, “there is no reason to reinitiate treatment at this time.”

“Reports about rebound should not dissuade high-risk individuals from taking this life-saving drug,” Adalja said.

References:

COVID-19 rebound after Paxlovid treatment. https://emergency.cdc.gov/han/2022/han00467.asp. Posted May 24, 2022. Accessed Aug 1, 2022.

Ranganath N, et al. Clin Infect Dis. 2022;doi:10.1093/cid/ciac481.

Wang L, et al. medRXiv. 2022;doi:10.1101/2022.06.21.22276724

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