On Monday this week (11 July), millions of Australians became eligible for the oral COVID-19 antiviral treatments molnupiravir (Lagevrio) and nirmatrelvir plus ritonavir (Paxlovid), with eligibility criteria widening significantly. 

Federal Minister for Health and Aged Care Mark Butler announced the changes following recommendations from the Pharmaceutical Benefits Advisory Committee (PBAC) based on the latest evidence on the effectiveness and safety of the medicines, usage data and the changing epidemiology of COVID-19.

So far, there have been 86,500 supplies of COVID-19 antivirals through the Pharmaceutical Benefits Scheme (PBS).

The PSA advocated for eligibility criteria changes for the oral treatments, and welcomed the PBAC recommendation along with Minister Butler’s funding decision.

Here’s what pharmacists need to know about the changes.

1. Access has widened to include all patients aged 70 and over

All Australians 70 years of age and over can now access antivirals through the PBS if they test positive to COVID-19 through a rapid antigen test (RAT) or PCR test.

Patients 70 and over can access and commence treatment while asymptomatic, said Deputy Chief Medical Officer Professor Michael Kidd in the Primary Care COVID-19 update webinar, held on 12 July.

‘These treatments need to be commenced within 5 days of symptoms starting, but some people can become gravely unwell within 5 days,’ he said.

‘We also know that in some elderly people, the symptoms may be masked, especially for those who have cognitive decline or dementia.’ 

Some patients are not aware they are eligible to receive antivirals or they do not understand the importance of timely initiation, PSA National President Dr Fei Sim told the webinar. 

These conversations should be had with all patients 70 and over – at every opportunity.

‘Every time you’re engaging with a patient, whether you’re giving a vaccination, or they’re coming in for an over-the-counter medicine or to fill in their prescription for their regular medicine: have that conversation with them,’ she added.

Amelia Richardson MPS, a community pharmacist based in Kadina, South Australia, has dispensed COVID-19 antivirals to patients before and after the eligibility widened.

In her experience, patients are more aware of the increased accessibility to the COVID-19 vaccine winter dose than they are of changes to antiviral eligibility criteria. 

However, given her pharmacy is next door to a respiratory clinic, this offers a gateway to improved awareness.

‘If we retrieve a script from the car of an [eligible] PCR patient, we could share that there are options available for them if they do test positive,’ she said.

2. The new eligibility criteria cover more chronic conditions

Access to antivirals was extended to patients aged 50 years and over with two or more risk factors for severe disease, along with Aboriginal or Torres Strait Islander patients 30 and over with two or more risk factors. A further category of patient – immunocompromised patients 18 years and over – continue to be eligible to access antivirals. 

Eligibility has also been broadened to include people who have chronic respiratory issues, such as chronic obstructive pulmonary disease or moderate to severe asthma. 

Other risk factors include:

• neurological conditions such as stroke or dementia
• demyelinating conditions such as multiple sclerosis, or Guillain-Barré syndrome
• obesity, or type 1 or type 2 diabetes
• congestive heart failure, coronary artery disease and cardiomyopathy 
• kidney failure or cirrhosis of the liver
• living remotely with reduced access to healthcare.

Pharmacists should encourage patients with comorbidities to be pre-assessed by a GP. This includes patients who may previously have been told their health conditions weren’t severe enough to be eligible, such as those with moderate asthma.

On Monday, Ms Richardson dispensed her first Paxlovid prescription to a patient who fell under the new criteria. Aged 59, the patient has diabetes and a chronic respiratory condition. To be eligible for antiviral treatment, the patient had to have at least one symptom of COVID-19.

A family member collected the medicine on the patient’s behalf, with Ms Richardson  providing counselling over the phone, including dosage instructions of 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) taken together orally every 12 hours for 5 days.

‘I encourage [patients] to drink a lot of water, rest, and if they experience severe shortness of breath or any more severe symptoms, to call an ambulance,’ she said

3. Eligible, symptomatic patients with a negative RAT should get a PCR test

The Australian Health Protection Principal Committee (AHPPC) recommends at-risk patients who are symptomatic, but have returned a negative RAT get an immediate PCR test to enable access to antivirals.

With this week’s reduction in the reinfection window from 12 to 4 weeks, more people are likely to test positive for COVID-19. Any patients with symptoms 4 weeks after infection should get tested for COVID-19 immediately, said NSW Health.

The end of the free RAT program on 31 July could put vulnerable patients at risk, however.

‘With most states and territories adopting advice from the AHPPC to move from a 3-month to a 28-day immunity period, access to testing will be vital, especially for vulnerable groups who’ve relied on the concessional program,’ Dr Sim said. 

‘[The] PSA fully supports an extension of the concessional RAT program to make sure that our most vulnerable have continued access to testing when it’s needed.’

4. Eligible patients need access to antivirals ASAP

While antivirals are very effective, they only work if people can gain access to them in a timely manner, Dr Sim warned. Antivirals should be in stock, on your shelf and ready to use, she said.

‘We know that currently, through conversations with major wholesalers through the [National Pharmaceutical Services Association] that in general, we do have enough antivirals,’ Dr Sim said. 

‘In some jurisdictions, we’ve received reports that they may appear out of stock, but we do have enough stock in Australia to enable mobilisation for people to access antivirals.

‘Have that conversation with your wholesalers, really understand your terms with the wholesalers, and have the antivirals on hand.’

Since funding for the COVID-19 Home Medicines Service ceased on 30 June, pharmacists also need to consider other same-day delivery options to ensure patients receive their medicines as soon as possible. This could include charging the patient for the cost of delivery from a courier if needed.

5. Patients with COVID-19 should still not enter a pharmacy

Patients should not present to healthcare settings, including GP practices or community pharmacies, when they are symptomatic or have tested positive for COVID-19.

‘We need to work together to protect our frontline health workers because this is going to be a long fight against COVID-19,’ Dr Sim said.

Pharmacists should offer contactless options for people collecting antivirals who are allowed to leave home. Close contacts should be reminded of their legal obligation to wear a mask in the pharmacy.

For more information on supplying COVID-19 antivirals, including ensuring access in rural and remote settings, listen to the  Primary Care COVID-19 update webinar recording.