COVID Updates: A Podcast with Peter Chin-Hong and Lona Mody

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:06

And Alex, who do we have with us today?

Alex 00:07

We are delighted to welcome back Lona Mody, who is a geriatrician, translational infectious disease researcher, and professor at the University of Michigan and the Ann Arbor Va. Lona, welcome back to GeriPal.

Lona 00:21

It’s great to be here. Thank you.

Alex 00:23

And we’re delighted to welcome Peter Chin-Hong, who is an infectious disease physician and medical educator, professor at UCSF and associate dean for regional campuses. Peter, welcome to the GeriPal Podcast.

Peter 00:36

A pleasure to be on Alex and Eric.

Eric 00:39

Alex, we haven’t had a COVID podcast in a long time. Is that right?

Alex 00:42

It’s been a minute.

Eric 00:44

Been a minute.

Eric 00:45

So today we’re going to be talking about COVID updates, and I’m super excited. We’ve got a lot to cover from thinking about COVID boosters, to where we are with potential treatments. But before we do, we always start off with a song request. Who has a song request. Is it you, Peter?

Peter 01:02

I do have a song request. I want to hear Kelly Clarkson, and I want to hear her sing. Well, not Kelly herself, but Catch My Breath. And the reason why I’m choosing is because it’s respiratory virus season and we don’t want our patients to catch their breath.

Eric 01:21

I love this because Peter gave such a great list of potential songs. All good ones. Yeah. I was voting for Cough Syrup. That was a great one. [laughter]

Alex 01:32

That one would have been quite the challenge. This one’s a little bit more straightforward, I think.

Eric 01:36

Cough syrup, though, I’m not sure. I think it may have been the way the kids take cough syrup. Not really.

Alex 01:41

I think that was the meaning, too. I got that as well. Waiting for the cough syrup to wear off.

Alex 01:47

Little bit different from the way that we mean.

Eric 01:51

So wise choice. Wise choice on this.

Alex 01:53

Wise choice. Here’s a little bit.

Alex 01:56

(singing)

Eric 03:00

That was great.

Peter 03:02

Bravo.

Lona 03:04

Awesome. It was fantastic.

Eric 03:06

I did hear her once in Central park when I lived in New York. She was, like, playing, and I did not go in to pay for it. I just listened outside. That was my only piece.

Alex 03:14

Kelly, amazing singer. I remember that early American Idol is so good. Yeah, I had to take that down about two octaves to see it. Thank you, Peter.

Eric 03:29

Lona, I am not sure you remember this, but over four years ago, March, mid March of 2020, we did a podcast on a novel respiratory virus that was coming out of Wuhan. And we asked questions like, what should we be calling this? COVID. SARS. COV2. And, man, things have changed since that first time that we had you on to talk about COVID over the last four years, huh?

Lona 03:57

Yes, it has been four years. Over four years, and it seems like so much has happened. We all have grown so much. The virus has changed so much. The world has changed so much. So, yeah, it’s a good reflection. We know so much now than before.

Speaker 5 04:13

Yeah.

Eric 04:14

And I mean, I’m just reflecting because, like, it feels like back in early 2020, like, it was almost like we were dealing with another virus. Like, Alex and I did some virtual palliative care in New York when the first kind of wave hit New York, and holy smokes, like, the people that we were seeing were so sick. And then when it came to San Francisco again, that. That first year, diffuse lung injuries that we’re seeing, everything else, like, it was devastating.

And four years later, it almost feels like we’re dealing with a different virus. And I know that’s probably a stupid statement of me. I probably get a lot of feedback on that statement, but I’d love to hear kind of how you think, both of you, how you think. Where are we with COVID right now? Just from a virus perspective, not treatments or vaccines yet. Peter, does it feel different to you?

Peter 05:07

It feels different, but it also feels the same. The way it feels different is that your neighbor, your cousin, the person at work, isn’t getting as sick in terms of being debilitated anymore or not being as fearful. But it feels the same in that I was on call a lot over the summer, and I took care of a lot of people behind those hospital walls. And, you know, some people are still getting very sick.

It’s not the same universal age groups anymore, but there’s a select group, kind of like influenza almost. And when you look at the numbers, actually last year in 2023, even though we’re in a recovery phase, there were more than 75,000 deaths. So I think that dissonance or that disconnect is a little bit, you know, disconcerting to me.

Speaker 5 05:58

Yeah.

Eric 05:59

Why do you think there is such disconnect?

Peter 06:02

I think there is because of. Well, the virus has evolved suddenly. Well, the virus always evolves with the variants, but we’ve evolved even more in terms of getting more immune as a population. So there’s a big force field in society. So that’s changed. And we don’t see hospitals being strained as much anymore. You don’t see body bags, you know, not the same sort of heightened impact on society, but you are seeing some people who are still ill. And I think that disconnect is why people don’t often think of themselves being at risk in the same way, which is more variable in 2024 than in previous years.

Eric 06:48

How are you thinking about Lona?

Lona 06:50

Yeah, I think I remember in the early few months the amount of stress that I personally experienced because all of my research has been older adults, nursing home population and the deaths that nursing homes experienced was simply devastating. There were stories about multiple people on the same ward, same unit, all of a sudden having COVID 19 and unfortunately not making it. The impact on. The impact on families. I think that was. That probably deeply impacted me more than I thought it would, considering that there were no early answers. So that was one thing, that early phase that I personally went through, along with several people in that industry.

I remember the happiest day was certainly when the vaccine news came out, and I probably jumped several times in my office that, you know, finally we have some good news that are going that’s going to make a difference. I was really happy that day. And then, of course, other treatments and other sort of medications and such came out. We saw the worst and the best of humanity in those times in terms of call schedules, people stepping up or people worried and stressed out. So that was a big portion of the first couple of years of COVID in my life personally. But after that, I think people have become used to the virus.

I had heard several virologists mention the same thing as Peter was mentioning that now the immunity is over. 90% of the US population is immune, has some sort of antibodies to the virus. And that’s probably the reason that people feel the need to move forward and not be held back anymore with the worries that are related to the virus. So I think that’s how I’m thinking about it right now. Clearly, scientifically speaking, we need to learn much more than what we know right now about the virus, about the transmission, about the treatment and about the long term sort of implications of a global world that we are in.

Eric 08:58

Yeah, I also wonder around that disconnect, how much of it is like we all kind of went through in our own ways some type of trauma, especially early on. That trauma may have been caring for patients who were sicker from respiratory virus than I often have ever seen. I know, Peter, again, the work that you do is different than the work that I do. But like in the nursing home setting, just the sheer amount of how sick people came. And we had Darrell Owens on one of our podcasts very early on we had a nursing home director who basically everybody else called in stopped working in the nursing home. So he was doing everything.

Remember that podcast, Alex? Especially in these nursing facilities where you get to know patients over time. And then they were just devastated. In 2020, I do have to say, working still being in a nursing facility, it does actually feel like I have seen people get. And again, this is like these, these n of 1. But like, I am just not as worried when my patients are getting COVID now as I was in 2020. And I think a lot of that is maybe my belief that, you know, immunity works, that this is not a novel virus. Our body is adapting and kind of getting used to this and seeing it over and again. Maybe part of that is just denial based on our own forms of trauma.

Alex 10:23

That we all experience trying to get beyond it. And we should mention treatment. The treatments have improved dramatically since the beginning of the pandemic.

Eric 10:32

And we got vaccines. So how about we talk about that? So we have vaccines. I was super excited. I posted my Twitter pictures of me getting my vaccines. Number one shot, number two shot, number three shot. This year I have not yet gotten my COVID vaccine. Yes, part of it double two weeks ago, flu shot.

Alex 10:58

And you got double COVID, like north, same arm.

Eric 11:03

Well, part of it is they. I didn’t sign up for both, so they wouldn’t give me both at the same time. And part of it is like, man, I kind of also like, I don’t think it’s harmful, but I’m 49, okay? For my listeners, I’m 49 years old. I am not sure there’s a lot of evidence that it’s that beneficial. Like, if you look at other guidelines outside of the US like the UK, they actually don’t recommend a healthy 49 year old to get the COVID vaccine. So where are we right now with COVID Lona? Should I call it Boost? Like, what’s the proprietor covered? Boosters, yearly Covered shots. Like what’s the terminology? Since I asked you that same question about terminology in March of 2020, I call them boosters.

Lona 11:50

Right? They are covered boosters, but you know, I think we can vary. I don’t know what Peter calls.

Peter 11:55

Well, I think the CDC wants us to call it yelly shots. But you’re right, Luna. I mean, I think colloquially everyone calls it a booster because most people have gotten tons of shots before, so. And the WOOD booster suggests what it’s supposed to do, which is to remind the immune system that what the virus looks like. So for some people they need more reminders. Other people probably don’t need as or it isn’t as urgent that they get that reminder. So that’s kind of where we are.

Eric 12:29

And then what vaccines do we have right now? We have three FDA approved vaccines. Is that right?

Peter 12:35

Yeah. So we have three FDA approved vaccines. Two are similar to MRNA, Pfizer and Moderna based on KP2, one of the Flirt variants, descendants of JN1 all Omicron and Novavax, a traditional protein subunit vaccine based on JN1 because it’s more traditional. They had to decide the formula a few months before Pfizer and Moderna did.

Eric 13:02

So they’re targeting similar but different strains.

Peter 13:06

They’re all targeting the same similar thing. Jan1 was what emerged last winter and January, then spewed a bunch of children out, including these hypertransmissible variants over the summer with the prefix of kp, not Kaiser Permanente. And because MRNA vaccine someone nimbly manufacture, they can say hey, let’s just make a vaccine based on what’s currently circulating. Because the thing in the winter coming up might be more closely derived from that. But turns out that Jan1 and its family are all very similar. So if you got Novavax or if you get Pfizer Moderna, you would probably get the same benefit.

Eric 13:53

All right, if. If I was talking to my dad, trying to convince him to get a COVID booster, should I convince them to get Norovax? Should I focus on KP2 with MRNA’s? Does it not matter at all?

Peter 14:06

It probably doesn’t matter. Although I must say that Novavax does have a fan club. They have a. I mean the fans of Novavax have a Facebook page. They advocated for it to come out earlier. So there’s a big sort of cache around novavax. And the reason why is because it’s more traditional. They were no head to head studies, but in the Novak studies they tend to have a fewer side effects Just mildly fewer. Again, not compared to each other. And you know, I think there’s a lot of still people talking about MRNA vaccines. Although personally, if you come back to your question, what you’d recommend to your dad, I would say either is fine. But one of my older relatives had just a really severe reaction to an MRNA shot early on and he got myocarditis, which was very, very rare in an older person. He’s in his 80s.

Speaker 5 15:04

Yeah.

Peter 15:06

Then he, you know, he talked to me, I said, try the Novax. And he tried it and you know, not that it’s again an N of one.

Speaker 5 15:15

Yeah.

Peter 15:16

But he’s continuing to get no vaccine updates.

Eric 15:19

Do both of them make you feel like not so great the day after or like, is there any difference or is it the more we use it, you know, you know that post COVID MRNA shot, like you don’t feel great for a day.

Peter 15:34

I think that because they’re so spaced out now, a lot of the side effects that we’ve seen like in adolescent males with myocarditis happened after the second shot.

Speaker 5 15:45

Yeah.

Peter 15:46

Because people are getting further apart. It’s not less of that one, two punch. So that’s my hypothesis around that. But yeah, you aren’t hearing people talk about sort of serious side effects anymore. People are talking about, you know, some people. Oh, it wiped me out. Oh, I get on Friday because I want to make sure that over the weekend I can sleep on Saturday.

Speaker 5 16:08

Yeah.

Eric 16:09

Lona, thoughts from your perspective. Do you have any preference when you’re thinking about it? Let’s say for nursing home patients, older.

Lona 16:18

Adults, I think most we use Moderna much more than Novavax and leave it on the patients for their preference. Some patients do have a strong, some strong feelings against the MRNA vaccines, in which case I think the protein based vaccines come in really, really handy. But overall we largely use MRNA vaccine. I have used Moderna or all of mine and in my family I do okay with the vaccine, which means that I probably am not mounting enough response. My husband is that kind of a person who’ll take it on a Friday and he’ll say, okay, I can sleep it up on the weekend. So within the same, you know, we all differ in how we respond to these vaccines, but overall they have been pretty mild.

Peter 17:03

I just wanted to interject that there was a really interesting study at UCSF actually where by Eric Frother and Lisa Appel and others showing that the more side effects you had, the more robust the immune responses. But also if you didn’t have side effects you still had a good response.

Eric 17:21

So let me ask you a question, because back in December, years ago, when the new vaccine came out, I was super excited. Looking at the New England Journal studies, clearly effective in decreasing bad stuff from COVID in people who have never seen this novel virus before. We’re now three years later. We’ve probably all had some natural immunity. Most of us have had vaccines, 1, 2, 3 doses. What do we know about the evidence right now that yearly boosters in a population that’s no longer like this is no longer a novel virus, but a population that we’re seeing it? I probably saw it this summer and didn’t even know that my body saw it, just got rid of it. What do we know about the evidence?

Lona 18:16

I mean, I think we should probably have better RCTs, as you mentioned, but I feel that a yearly shot definitely is going to be useful and going to be beneficial to patients and all of us general public to reduce the circulation of new variants. So I do think that the virus evolves significantly enough for us to get our COVID shots or COVID boosters or whatever we want to call it at least once a year. I went through this doubt sometime in spring last year about the six monthly thing that’s going to happen. And I was like, I don’t see much in the community right now.

Do I really, really want it? And the only reason I took it is that I really don’t want to spend a day in bed. I just cannot afford that anymore. And that was probably the only reason I took it. So I think there is. I can understand public being skeptical about it, especially about the 6 monthly sort of shots that we probably will end up taking, or at least that would be the sort of the soft recommendation coming out.

Eric 19:21

So, Q. Six months, twice a year.

Peter 19:24

I mean, I think about the shot as. And I love the way that Luna put it too. You know, of course, serious disease, hospitalization and death. I think particularly in our older populations, there is some evidence that at least by antibodies, again, when I’m looking at T cells with cellular immunity, it declines the fastest within six months. And that’s why that six months thing came on board. But to tell you truth, the people I saw in the hospital, and it’s, you know, it’s corroborated by data too.

I would say pretty much 100% of the people I saw didn’t get a shot in the last year, even though they’ve gotten like a million shots in the beginning of the pandemic and they were all older in 75. So that’s another thing that I would think about and I worry about the every six months it has to be messaged appropriately because don’t forget the lowest hanging fruit. The eyes on the prize is really for the older patients to get it at least once a year and if you wanted to get the second after six months I’ll be great, like drink for the summer or something like that.

Eric 20:31

Well, it’s really interesting because this idea of low hanging fruit. So let’s. I mean if you look at the UK they do not recommend it for non older adults or non immunocompromised. They are not paying for yearly boosters for like a healthy 49 year old. So you would imagine, oh like they just, you know, they’re probably using a lot less of it. If you look at nursing home currently it looks like about half of their nursing home population have had a COVID booster this year.

Alex 21:01

So they recommend them for all and will pay for them but just in a narrow population.

Eric 21:07

We’re going to just look at this low hanging fruit target all of our messaging. Low hanging fruit us. Everyone over the age of six gets a COVID booster. You want more than one, we’ll give you more than one. Where are we with nursing home population? The group that probably is most at risk? I think it’s less than 20%.

Alex 21:27

At the same time, less than 20% are getting the annual boosters have gotten.

Eric 21:34

This year’s annual booster. If you look at last year, same thing, same thing between the two group. Significantly less people in the US in nursing homes got COVID boosters than the uk. And I wonder like part of that is like we’re different but part of that is like things are finite, we have finite resources. How much should we just target the people who are actually going to benefit from this versus constant messaging that everybody should be getting these COVID boosters which also feels like, well, do we really have the evidence for that? Thoughts? You could call me stupid for thinking about this, but I worry because I do think I would recommend it for every nursing home patient people who are immunocompromised. Even if we don’t have randomized controlled trial. The harm is so small and I’m fine with the antibody evidence. Peter, am I stupid?

Peter 22:30

Yes. He says you’re not stupid at all. You’re not stupid because the UK is not stupid. So I think there is some truth in what is a lot of truth in what you’re saying. The way I think about it is and it’s really tough this, this messaging. So first of all, historically, the flu vaccine was a targeted population vaccine. So very young and very old. And there is some evidence saying that when you make a vaccine universal that you can get more people in the. You know, again, I’m just quoting one study, more people in the who are actually needed to get it because there’s less confusion and more people are more vulnerable to have access it.

So somebody who is not in the system. But with that said, the way I say it is that everybody is allowed to get it. But I really want the people who are 65 and definitely over 75 to get this vaccine because they comprise over 90% of the population who are hospitalized with COVID in the United States and you know, from 2023 onwards. So I think that’s the way I put it. And of course the other benefits too, that decrease long COVID observational studies by 70% has a benefit of reducing infection if it matches the circling variance. Like if you get it now, you can kind of get six to eight weeks maybe of lower risk for holiday parties and things like that. So, you know, there are other benefits as well.

Speaker 5 24:09

Yeah.

Eric 24:10

So a lot of observational studies saying that it benefits. I want to highlight one thing you said too is like flu shots feel very different also because it’s a different virus. But I mean, part of the reason that we’re advocating for twice a year, sometimes even more like the most recent guidelines, you can get more than two shots a year for specific groups is that immunity or I want to say immunity. Right. We had Monica Gandhi on. She taught me the importance of there’s more than antibodies got T cells out there, but antibodies kind of what drop after like two months, like from an antibody response, we start seeing that wane. So when is the right timing that we should be giving these vaccines to our nursing home populations? Because we’re kind of in a lull. We’re going to start seeing it come back in November because it always does. It’s going to peak in December, early January and then it’s going to have that same cycle with the next late spring summer peak lona. Do I perfectly time it? Do I just jump on the bandwagon in September and give it?

Lona 25:22

I think September, October is a good timing to give just because that’s the time when families start making plans, start getting together in November and December and you want the immunity to be there. So I feel the fall timing is reasonably good. The main question is the next timing at the six months. If we do decide to go that route what is the good one? And I think we’ll need to see a couple of years of more pattern. I was looking at the curves from this past year and the spike was in June. CDC now collects data from nursing homes on COVID 19 and nursing homes there was a spike in June and I’m certain that the this is related to the community transmission around that time as well. Which brings us to a couple of different points regarding your original question.

One is that among the immunocompromised we should definitely. Among the elderly, we should definitely consider vaccine. Among us healthcare providers who care for the elderly, I think that is a good thing to protect ourselves and our patients. And there is a herd immunity that comes with that and probably is a tipping point that if enough people get the vaccine, then the downstream big outbreaks that we see probably will not be seen.

Eric 26:38

So you feel like it actually impacts transmission?

Lona 26:41

Yeah, I do feel that it does impact transmission to some extent. I don’t know, Peter, what do you feel about it?

Peter 26:47

I agree with you, Lona, because even if you just think about symptomatic infection, sure, the studies in households have not proven that it reduces transmission same way that say, you know, a flu vaccine or a time of flu. But, you know, if you reduce the person who is getting the vaccine from getting symptomatic infection, if it’s matching the variant circulating and you just got the vaccine, then you don’t have it to then transmit it to a vulnerable patient that you’re taking care of.

Eric 27:19

Oh yeah, I got one more question about vaccine because I want to go on the treatments too. Is that. Do you think we, we can do a randomized controlled trial of these vaccines, given what we know right now, to convince hesitant individuals that, hey, this does it. Because if you look at the observational studies, the effect size is quite large in these studies, so it shouldn’t take a monstrous trial. Am I truly to believe the observational studies?

Alex 27:51

So you’re assuming that the reason that rates are so low among older boosters and among nursing home residents is because of lack of information that we need a randomized trial?

Eric 28:02

Well, you got one person on this zoom call. I’m not going to call him out. Who has not yet had the COVID vaccine. And I do think that if I saw really good evidence that yearly vaccines in immunocompetent individuals who’ve seen COVID before, who’ve got shots before, for me, I do think so, because it kind of, you know, the alternative is like we’re just spending a lot of money on this thing that other countries are not recommending and that’s the other thing is that you’re seeing diversity. Most countries actually do not follow CDC guidelines. So the question is can we do a randomized controlled trial in the US of the vaccines?

Lona 28:39

Yeah, I’m not sure it is going to be ethical anymore to do an RCT of a vaccine. That has shown to be.

Eric 28:46

Why not? Most people don’t even take it.

Lona 28:49

Sure there are other designs that can be done. I’m not sure it is possible now in nursing homes for flu. As you know there are many sort of cluster randomized trials that are done for trivalent the different kinds of flu vaccines. That’s probably possible. Not sure if a randomized control trial would be approved from ethical bodies. They would certainly be very strong. But we would probably have to rely on other types of designs, study designs to make.

Eric 29:15

Peter, do you think.

Peter 29:17

I don’t think you’re going to get buying for randomized control trial for the reasons Luna mentioned but also because it’s going to be so effect expensive. I can imagine pharma or vaccine companies jumping on that bandwagon.

Eric 29:30

Oh they’re not good because we’re already giving it. Right. Like there’s no, there’s no economic reason to do a randomized control trial from a pharma company. You can only.

Peter 29:39

But there are trials. Well, they are small studies so far but you could like. I love the idea of looking at the flu models in nursing homes, for example, you know, quadrivalent or I mean the high dose flu vaccine or adjuvant flu vaccine. So there are new formulations coming out with a COVID shot like a flu and COVID together so you can look at those kinds of things within populations.

Eric 30:07

And I wonder since we have one vaccine targeting JN1 another targeting this KP2, I wonder if there’s any information to be gleaned by the difference in those two too.

Lona 30:19

I think they’re JN1 and JN2. Correct.

Peter 30:23

Peter, if I’m KP2 is the child of Jan1.

Speaker 5 30:29

Yeah.

Eric 30:30

Well I want to go to treatments because this brings up the other question.

Alex 30:32

About pathways before we go to treatments. Just thinking of our. I want to move on from Eric 49 year old person. Get back to our GeriPal audience. Older adults, people with serious illness. Can we talk briefly about people with serious illness? Is there a lag time to benefit for these vaccines? So for example, we have a hospice unit in our nursing home and those patients typically have days to weeks, maybe months left to live. Should they be getting the vaccine or do the harms, the short term harms, potential harms outweigh the risks for people with limited life expectancy.

Peter 31:08

Well, I can start. I really love to hear Luna’s take on this too. Well, I think the vaccine, there are very few harms right now, to tell you the truth. Particularly if somebody has had the vaccine successfully perform. You know, the longest it takes to get up to that top peak antibody is maybe two weeks, but probably in a few days if you’ve been experienced before.

Speaker 5 31:30

Yeah.

Peter 31:31

And it also helps against mi, stroke, some, but those are more long term things. But I think getting seriously ill can happen pretty soon after COVID. So I would say as an ID doc that I would offer vaccines to those individuals because I don’t want them to. I want them to preserve their quality of life, you know, in the period that they have.

Alex 31:57

Yeah, Lona.

Lona 31:59

Yeah, I don’t think I would necessarily withhold vaccines, you know, from patients, older adults who are in hospice. Ultimately it comes down to what does a quality of life mean. Some people feel that they are, they are doing fine right now and do not want to get COVID because in two months they have their grandchild, great grandchild’s graduation and they don’t want to risk anything in between. Just as an example. Example. So I, yeah, I may not be the person who makes a policy that, you know, they have to be or they have to reach a 70% target or those kinds of things. But I would not withhold it.

Eric 32:36

I think in practice a lot of us don’t do it for people who have less than two weeks to live because if, if anything, because I agree, I think the safety of these drugs is grind, but the possibility of feeling crappy for a day, just getting the shot, I do think we have to think about for our hospice patients.

Alex 32:53

So maybe less than two weeks. Maybe don’t recommend it. More than two weeks.

Eric 32:58

We’ll see if Peter thinks I’m stupid for that too.

Peter 33:01

No, no, I like the two week thing because from a scientific point of view, two weeks is also the time it takes you to get to that level.

Eric 33:08

Yeah. Okay.

Alex 33:11

Thank you, Alex.

Eric 33:12

Can I go to treatments?

Alex 33:13

Yes. To older adults or people with serious illness?

Eric 33:16

Older adults.

Alex 33:16

Not Eric, Widera.

Eric 33:17

Older adults.

Alex 33:19

I’m giving my co some grief.

Peter 33:21

Not a 49 year old.

Eric 33:22

I never know how to pronounce this one. Mole. New piv. I never use it. I’ve never used it. I’ve never seen it used. How do you pronounce it? Mol. New Peter.

Peter 33:34

Molnupiravir.

Eric 33:38

Is it something that we should still use if we’ve never used it?

Peter 33:43

There is still a place in the world for it. And I’ll tell you how I think about it. So of course everybody’s heard about Paxlovid. We’ll talk about that. Yeah, I think if you have access an infusion center, you can’t take Paxlovid because of the 120 potential drugs that people might be fearful of for drug interactions, then remdesivir infusion center is my next go to for three days. If you can’t get either of those two and somebody didn’t get vaccinated or you’re worried about them. A 30% benefit with mopiravir might be worth it to some people. So it’s well tolerated, you know, but got a 30% back.

Eric 34:26

I thought panoramic. Wasn’t panoramic. Negative. Was that another study that. Was that the UK panoramic study? They had like Paxlovid and Mal Nu, bit, whatever. Was that a negative study? Was that positive study? Do you know much about panoramic?

Peter 34:42

I don’t. I can’t remember the details about that study, to tell the truth. Except that, yeah, it didn’t show quite as much benefit as people thought. That. That’s my. That’s the punchline I remember.

Eric 34:54

Yeah, that’s my. Because it was Lancet last year. I think this comes to goes to Paxlovid is that. And potentially my concern, like with the vaccines too, is that the early on studies were pre omicron, pre. Most of us ever seeing this virus before and you look at like Paxlovid, epic, hr, the first one, high risk patients. Most of us have never been. Everybody not vaccinated. Great drug. Great drug, right? I would say it had a pretty good effect size. It looked like it really worked. Published when a couple months of completion showing in New England Journal showing it works. EPIC sr, standard risk patients, patients who’ve standard risk, not vaccinated or high risk with vaccination. Really no statistical difference between the two groups.

Peter 35:46

Well, it comes back to what you’ve been seeing before, from the beginning we started, which is that you, you know, I think the answer is yes and yes. Because when you look at, you know, panoramic or some or EPIC hsr, you’re mixing people both unvaccinated, vaccinated, younger, older, et cetera. Well, SR was mainly, you know, a younger group versus the pure original studies. So the answer is for the right patient, it’s still really worthwhile who, who.

Eric 36:18

Would be the right patient in your mind for Paxlovid?

Peter 36:21

Well, the people who I saw in the hospital who may not have been there.

Speaker 5 36:25

Yeah.

Peter 36:25

If they got Paxlovid, because none of them got Paxlovid either.

Eric 36:28

So older adults, high risk immunocompromised older adults, certainly nursing home patients. Is that right? Lona, would you agree?

Lona 36:39

I agree. And there is, although not RCTs that are observational studies, that the symptoms and the long term symptoms of COVID are fewer with Paxlovides. I would say that is, I can understand the public skepticism because of the newer studies and conflicting data. But I would say older adults immunocompromised, high risk of hospitalization, should probably get vaccinated.

Alex 37:02

Yeah.

Eric 37:04

And then again, I feel like this is another one. Like, man, it would be great to have more data, like more, you know, high grade data, high quality data, randomized controlled trials. But we’re just never going to get it because there’s no, there’s no incentive.

Alex 37:17

And I guess you mean incentive to the pharmaceutical.

Eric 37:20

I guess panoramic. We’re still waiting for panoramic Paxlovid study to come out.

Alex 37:25

Yeah.

Eric 37:25

No bet.

Eric 37:26

Pharmaceutical companies are not going to make money on this. They can only lose. I mean, Pfizer.

Peter 37:33

Yeah. So I mean, the way to summarize the way I think about Paxlovid is really the shoulds and the coulds. And again, it’s just like your discussion about vaccines. There are people who need it much more, but that’s getting lost in the average message. And that’s my concern.

Eric 37:51

Yeah, I think that’s my concern too. I guess one other question is like, nursing homes are a weird population. It’s not really inpatient. And an inpatient. We use a lot of remdesivir. Do we still use a lot of remdesivir? Is that like Peter, if you’re admitting.

Peter 38:06

Somebody 100% because you don’t know where they’re going.

Peter 38:13

And remember, most, remember when President Trump had COVID, everyone’s waiting for day seven because you kind of have mild symptoms at the beginning. And I think that’s another myth. My patient has mild symptoms, 85 years old, did maybe didn’t get the last booster, but look, it’s really mild. But remember, you don’t fall off the cliff until day seven. So you can’t really use that as a. And when people first come to the hospital, you don’t know where they’re going.

Eric 38:41

Okay. Now nursing homes, not really truly like community based outpatient, not really inpatient. Like, I think our nursing home still has a preference for remdesivir for when the patients get sick, which always confused me. Like, why aren’t we using Paxlovid? Because they are still technically outpatient, lona. Like, what should nursing homes be doing around?

Lona 39:03

I think the short, stiff populations are probably a little bit, you know, different than our long stay populations. But I have largely heard Paxlovid being used more than remdesivir in nursing homes.

Eric 39:16

Okay. Same thing with you, Peter.

Peter 39:19

People use Paxlovid more, but they’re also worried sometimes about drug interactions. I see. I would say many of these worries are sometimes unfounded. And, you know, I think working with a good pharmacist will help reassure you that, you know, it’s going to be okay. And I oftentimes advise people to have a paxlovid plan. So you kind of know what’s going to happen in case somebody needs paxlovid, but much easier to give than remdesivir.

Eric 39:49

All right, I got one last question. Alex, do you have any questions before I ask my question?

Alex 39:53

Last question. Yeah.

Eric 39:55

Magic wand. You had a magic wand, Right? Now we are in year what? Year four, year four of COVID What are you hoping in 2025, Lona? 2025. You got a magic wand. Has to be used in some regard regarding COVID. What would it be?

Lona 40:11

I’m hoping with a, with a magic wand that the virus gets even weaker and we have fewer spikes. Summer spikes and spikes.

Eric 40:21

Do you think that’s going to happen? Like it’s a coronavirus, right? Like it’s just going to constantly be around with us? I guess it’s a magic wand, so it doesn’t even matter.

Lona 40:29

Maybe the host gets stronger. Maybe the totality of the humanity is stronger in beating the virus. How is that?

Eric 40:36

I love it, Peter.

Peter 40:39

I’m going to be more existential about my magic wand, which is. Well, it’s not really existential, but my hope is that we have much more trust in science and medicine and less divisiveness and less misinformation about vaccines because it’s bleeding over into lots of other vaccines for kids, measles, et cetera. So that’s really my hope for 2025.

Eric 41:03

Alex, you got a hope?

Alex 41:05

I hope I can catch my breath at the end of this podcast.

Eric 41:08

Oh, no, that’s my line. Well, I will say actually, I got a hope. I actually do hope that in 2025 we’ll get some more kind of randomized controlled trial out there because I do think that the antidote to misinformation is actually evidence. So that would be my hope. Alex, Take my breath away. Wait, that’s not Take My Breath. What’s the title of the song?

Alex 41:31

That’s Top Gun.

Eric 41:32

That’s Top Gun.

Alex 41:33

That previous Top Gun.

Eric 41:36

Hatch my breath Serenade me as I drive my motorcycle with you in the back Alex.

Lona 41:42

It is a cities correct.

Speaker 6 41:44

I don’t want to be left behind Distance was a friend of of mine Catching breath in a web of lies I’ve spent most of my life Riding waves Playing acrobat Shadow boxing the other half learning how to react I’ve spent most of my time Catching my breath Letting it go Turning my cheek for the sake of the show now that you know this is my life I won’t be told what’s supposed to be right Catch my breath no one can hold me back I ain’t got time for that Catch my breath won’t don’t let them get me down it’s all so simple now.

Eric 42:48

Peter Lona, thank you for joining us on this podcast.

Peter 42:52

It was so fun. Thanks. Hopefully I can get Lona to paint me a watercolor of a COVID virus.

Lona 42:58

Oh, okay. I can send you a print. I can send you a print. You might like it.

Peter 43:02

Please do.

Eric 43:03

And to all of our listeners, thank you very much. Don’t forget, if you’re caring for nursing home patients, give them that booster this year no matter what you do for yourself. And thanks, everybody.

This episode is not CME eligible.