With the emergence of the more highly transmissible omicron variant it became clear in December (as noted by the AP) that all of us will have a date at some point with some variant of SARS-CoV-2:
“All of us have a date with omicron,” said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. “If you’re going to interact with society, if you’re going to have any type of life, omicron will be something you encounter, and the best way you can encounter this is to be fully vaccinated.”
After receiving my fourth jab and returning to St. Louis to begin rounding on inpatient cardiology consults at SLU Hospital I have been very careful while in the hospital. I wear an N95 (Kimberly Clark) 99% of the time when in health care facilities.
For two years I and the former eternal fiancee’ had been carefully and successfully avoiding COVID but lately based on our highly vaccinated state and the reduction in virulence of the new variants we had loosened up.
Outside the hospital I stopped wearing a mask except in rare cases. Last week after finishing inpatient rounding I went to several indoor events at which the vast majority of participants were unmasked. I realized I was increasing my chances of catching COVID-19 but given my super quadrivaccinated state and the seeming inevitability of avoiding the illness without living a cloistered and/or masked existence I felt ready for my date.
Monday night I attended an event at the Historic Schlafly Tap Work which I could not resist. It was a concert by the Ariana String Quartet on the Art of the Brew. Each piece the Quartet played was based on a Schlafly brew introduced by the beer maker’s brewmaster. Around 30 mostly un-masked beer and music loving individuals gathered in a medium-sized room in folding chairs scattered at nice intervals with really high ceilings to listen for about 90 minutes.
I judged this exposure as higher risk than I typically endure without a mask but Wednesday night at a medical dinner I attended I judged the risk as really high. We were all gathered in a small room (with the only door frequently shut) sitting right next to each other at a table. I began counting down the days until I could consider myself COVID-free.
Symptoms: Are they from COVID?
Unfortunately two days later in the after noon I began feeling very fatigued. The fatigue continued the next day accompanied by a mild scratchiness in my upper airway. the weakness and malaise became progressively worse as the day wore on. By mid-day I tried to take a walk and after two blocks was exhausted. I took a COVID rapid antigen test which was negative.
I thought about going for walk in park in afternoon but the process of getting ready for the walk exhausted me. I took the inhalers Advair and albuterol through the day as my chest felt heavy and congested along with shortness of breath that felt like asthma
The next day, I awoke at 3 AM with intense sneezing and nasal congestion which intensified over the next hour and became associated with a particularly nasty headache. I took 30 mg of the decongestant pseudophed, a zicam tablet, my nasal steroid inhaler and ibuprofen. I couldn’t sleep so I watched an episode of Better Call Saul.
I retested myself again (15 hours after my initial negative test) for COVID and this time it was positive.
When I awoke later Sunday morning I felt pretty bad-extremely weak, bad headache, congested, chest tightness, shortness of breath on exertion. These symptoms worsened throughout the day and were accompanied by my first fever along with tachycardia in the evening.
To Take Paxlovid or Not?
In the morning I pondered whether to take Paxlovid. I wrote in detail about this very effective oral treatment for COVID-19, focusing on its drug-drug interactions here.
The FDA has an EUA for Paxlovid based on seeing an 89% reduction in the risk of hospitalization and death in a well done randomized clinical trial. It is free right now and it has efficacy against Omicron. It is indicated for:
nonhospitalized patients with mild to moderate COVID-19 aged ≥12 years and weighing ≥40 kg who are at high risk of disease progression;
I had all of the four factors in the above statement.
Mild, Moderate or Severe?
NPR published a nice article on the nuances of the terms mild, moderate and severe disease.
Basically as long your breathing/oxygenation is not impaired you are in the mild category but you can feel very horrible for multiple days and it won’t feel that mild.
So what does a mild case look like? A mild case could mean barely any symptoms and a quick return to feeling normal. But so-called mild cases aren’t always … well, mild. The National Institutes of Health guidelines for treatment categorize mild COVID as” [i]ndividuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but who do not have shortness of breath, dyspnea (difficult or labored breathing), or abnormal chest imaging.”NPR.org
I checked my oxygen saturation, of course, multiple times (using my handy dandy Circul ring.) Early in the day of my diagnosis my O2 saturation was 98% and my pulse was 75 BPM. However late in the evening when I felt absolutely horrible and my temperature rose to 99.8 degrees* and my pulse to 104 BPM my oxygen saturation was hovering between 93 and 95%.
Earlier in the pandemic I wrote about pulse oximeters for home measurement of oxygen saturation, something I recommend for everyone. This NEJM graphic from 2020 emphasizes an O2 saturation of 94% as a differentiator of moderate from severe illness. Please note that treatment recommendations have changed dramatically in 2 years.
Because I am old (>65 years) I am automatically considered high risk.
Paxlovid On Board
Thus, when I decided to pull the trigger on Paxlovid and sent a my chart message to my internist I immediately received a call back from the covering nurse practitioner. By the time she called I had checked with various pharmacies on their Paxlovid supplies. Interestingly, there were none at Walgreen’s but they nicely referred me to a nearby CVS who had the drug.
Appropriately she asked about symptoms and test positivity. Most importantly she looked closely at the drugs I was taking for interactions with Paxlovid as these are (as I have written) legion.
I knew that she would ask me to stop taking the rosuvastatin I am taking. I was surprised when she told me that the inhaled Advair I take was also on the interaction list (more on that in another post.) The prescription was sent within 30 minutes to my local CVS. CVS requires that someone other than you pick up the prescription and that they come with a mask on.
Within 8 hours of my positive rapid antigen test I took my first dose (3 pills) of the Paxlovid. So far the only side effect has been a very strong metallic taste in my mouth. My daughter, the internist, indicates this is common. Thus far I have had none of the diarrhea that some experience as a side effect.
I am now midway through Day 3 of significant symptoms and feeling much better with no fever or headache. I began the Paxlovid 24 hours ago. Being a skeptical scientist I cannot say with certainty whether the improvement is due to a) tincture of time (i.e. the disease would have gotten better with or without the treatment b) Paxlovid or c) placebo.
I can say that I wish my date with COVID-19 had never happened and I fervently hope that I will have no further encounters.
*N.B. for a great discussion on the normal temperature range I recommend my early pandemic post entitled ” In The Time of Coronavirus What Should Be Considered A Normal Temperature And What Is A Fever?“
N.B The rapid antigen test I utilized was iHealth