Thousands of COVID-19 at-home pills hailed as 'game-changer' are sitting on pharmacy shelves in Wisconsin

Some Wisconsin pharmacies have hundreds of courses of COVID-19 antiviral pills sitting in supply, amid a "surprising" lack of demand for the at-home pills hailed as a game-changer in treating COVID-19.

Officials initially warned that supply of Paxlovid and molnupiravir, the two types of COVID-19 antiviral pills that became available in January, would be "extremely limited." But some pharmacies have hundreds of courses of the treatments in supply and have been filling few prescriptions for the treatments, even as COVID-19 cases surged.

"I figured like within a week or a couple days we'd be completely gone, but I have quite a supply still left," Matt Mabie, owner of Forward Pharmacy, which has several locations in the Madison area, said last month. "Demand's not there."

Other pharmacies, including Hometown Pharmacy and Hayat Pharmacy, have reported filling relatively few prescriptions for the pills since receiving their first shipments in mid-January. The Hometown Pharmacy in Sun Prairie, outside Madison, had filled fewer than 10 prescriptions as of Tuesday. It had around 400 courses of molnupiravir and 80 to 100 courses of Paxlovid in supply, owner and pharmacist Jason Buenger said.

"I think it's highly unlikely that all people that should be being prescribed it are being prescribed it," said Abbi Linde, director of clinical services for Hometown Pharmacy, which has nearly 70 locations across Wisconsin.

Wisconsin received its first shipment of the pills from the U.S. government in early January. As of Tuesday, the state had received more than 5,800 courses of Paxlovid and more than 20,800 courses of molnupiravir, which were distributed to pharmacies and hospitals across the state, according to Jennifer Miller, spokeswoman with the state Department of Health Services.

The pills, which can be taken at home, have been hailed by public officials and medical professionals as a game-changer in treating COVID-19 in the most at-risk patients, with the potential to save thousands of lives.

Clinical trials have shown Pfizer's Paxlovid to prevent hospitalization or death in nearly 90% of high-risk COVID-19 patients when taken within five days of symptoms beginning. Molnupirvair, developed by Merck and Ridgeback Biotherapeutics, appears to prevent severe COVID-19 about 30% of the time.

Both pills were cleared for emergency use by the Food and Drug Administration in December. To be eligible, a COVID-19 patient must be at high risk of severe illness from COVID-19. For the pills to work properly, they must be taken within five days of symptoms starting.

Miller, the DHS spokesperson, said the state does not have precise numbers of how many pills have gone to patients, but federal data suggest that hundreds, if not thousands, of courses of Paxlovid and well over 10,000 courses of molnupiravir are sitting on shelves in pharmacies and hospitals across Wisconsin.

'Nobody knows where to get it'

Pharmacists believe a number of reasons may be behind the low demand for the pills, including lack of awareness on the part of both providers and patients, a hard-to-navigate process to get the pills and the fact that the pills are new and still being studied.

Both pills also come with warnings. Paxlovid is not appropriate for people who have severe kidney problems or cirrhosis of the liver or who cannot interrupt medications that should not be taken at the same time. Some medications may not interact well with Paxlovid, including statins commonly taken by people with high cholesterol.

Molnupiravir is only for use in adults and should not be taken during pregnancy because of the potential for birth defects.

Some Hometown pharmacies have been getting phone calls from doctors unsure how to prescribe the drugs, Linde said.

"I think there is some confusion, both on the prescribing side and on the patient side, about who should have it and where you can get it," she said. 

Only certain pharmacies and hospitals in the state have the medications. That can make it difficult for physicians and patients to know where to go for the pills. Last month, DHS published a map on its website of locations that have received shipments of either or both of the antiviral pills. However, some locations with available pills seem to be missing from the map.

"I think part of it is an awareness issue. Nobody knows where to get it," Linde said.

For patients, the process to get the pills, which require a prescription, can be difficult to navigate and complete within the five-day window from when symptoms begin. Patients must test positive for COVID-19 before they get a prescription. The whole process could involve a trip to a testing site, a doctor's office and a pharmacy before the patient finally takes the medication.

"Some of it's timing," said Mabie, the Forward Pharmacy owner. "Some people aren't getting their positive results back until Day 3 or 4. ... Now you've got to reach out to your doctor."

Rapid tests and virtual doctor visits can help high-risk patients more quickly get a prescription.

Dimmy Sokhal, a pharmacist with Hayat Pharmacy, said for the process to work, "everyone has to be proactive."

"It's important for people to catch it [their infection] early on and reach out to their primaries," Sokhal said.

Some patients may be reluctant to take a new drug that is still being studied, some physicians said.

The Froedtert & the Medical College of Wisconsin health network has dispensed the drugs to about 200 patients who were identified and referred to a Froedtert program that ranks eligible patients based on risk factors and then offers them one of the treatments, according to a Froedtert official.  

But most of the more than 800 patients to whom Froedtert has offered one of the pills have not responded or have declined, hospital officials said late last month.

"I think the biggest factor is patients making their own decisions to not accept the medications for whatever reason – they don't feel ill enough to need medication, they're not comfortable with taking an experimental medication," said Dr. J. Njeri Wainaina, medical director for the Froedtert & Medical College of Wisconsin antimicrobial stewardship program.

On Tuesday, federal data showed that Froedtert locations had over 1,400 courses of molnupiravir available and less than 60 of Paxlovid. Dr. Mark Lodes, with Froedtert & MCW, said that under federal guidelines, the health system is generally offering patients Paxlovid first.

The U.S. National Institutes of Health recommends Paxlovid as the top preference for treating high-risk COVID-19 patients.

Less incentive to expand antivirals access

Linde said she would like to have the antiviral pills available in all Hometown Pharmacy locations across the state, but that there is little incentive to do so when demand is so low and pharmacies are losing money dispensing them. She said the reimbursement rate to pharmacies for dispensing the pills is generally less than $1, sometimes not enough to cover the cost of the label.

She said dispensing the COVID-19 pills can be "quite the process" when pharmacists have to assess patients to make sure they don't have any conditions that would make the drug inappropriate or aren't taking any medications that could interact poorly with it.

"It's our liability as well," she said. "The pharmacist is just double checking everything, making sure that the dose makes sense and then sometimes calling a doctor and making sure it's what they meant."

While physicians, physician assistants and nurse practitioners may prescribe the pills, pharmacists may not. Some pharmacists have called for that to change. They say pharmacies, some of which are already conducting COVID-19 testing, would be well-placed to follow up with positive patients about the possibility of antivirals.

"It makes sense for us to then provide treatment as well," Linde said.

Sokhal is not in a rush to have pharmacists prescribe the pills. She thinks it would make sense, but maybe later, once the pills have been on the market for longer and more is known about their safety and any potential negative effects.

"I just want to be sure we're being safe instead of rushing into it," she said.

Buenger, the owner of the Hometown Pharmacy in Sun Prairie, thinks it would help with access if pharmacists could prescribe the pills, but said pharmacists would need access to a full list of patients' medications and other medical information for the process to run smoothly.

Sarah Volpenhein is a Report for America corps reporter who focuses on news of value to underserved communities for the Milwaukee Journal Sentinel. Email her at svolpenhei@gannett.com. Please consider supporting journalism that informs our democracy with a tax-deductible gift to this reporting effort at JSOnline.com/RFA.