ISMP Warns of Dosing Errors Linked to Paxlovid

Patients with renal impairments are particularly vulnerable to Paxlovid dosing errors, the ISMP reports

The COVID-19 treatment Paxlovid has been linked to numerous reports of medication mistakes, which could have been avoided, according to medication safety experts.

The Institute for Safe Medication Practices (ISMP) issued a new warning on July 1, aimed at pharmacists and healthcare providers, following reports of dozens of Paxlovid dosing errors.

Paxlovid (nirmatrelvir and ritonavir) is a drug prescribed to treat mild to moderate COVID-19 in people who are at risk for progression to severe COVID-19, including hospitalization or death. The drug is currently available in tablet form in two blister pack configurations, with different dosing and a specific blister pack for patients who have moderate renal impairment and cannot take the full dose.

The ISMP indicates it has received reports involving errors from prescribing or dosing the wrong strength, improper renal dosing, or self-administration errors. Errors often involve improper renal dosing, such as prescribing or dispensing Paxlovid to patients with severe renal impairment. Pharmacists are supposed to remove one tablet from the dual blister pack for renal patients. Some pharmacists were not removing the second tablet, according to the ISMP.

Other errors included patient self-administration errors; taking the wrong number of tablets or taking the tablets at the wrong time.

The ISMP is alerting both healthcare professionals and pharmacists about the risk of errors, noting that 87% of prescriptions were dispensed by pharmacists.

The group is calling for improved education for prescribers and pharmacists about the reduced-dose blister package for patients with moderate renal impairment and who should receive this dosing.

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Doctors and pharmacists should ensure the medication configuration is easy for patients to select two of the 150 mg tablets to make up a 300 mg dose. Guidance should also be provided for Paxlovid in the prescribing systems, according to the ISMP warning.

Additionally, the institute recommends pharmacists use screening checklist tools available from the U.S. Food and Drug Administration to identify significant drug interactions. They should also avoid instructing patients which pills to take based on tablet or blister color to avoid dosing misunderstandings, the ISMP advises.

Patients should be educated with clear explanations about the label on the blister pack and pharmacists and health care providers should make sure patients know which tablets to take and when to remove each tablet just prior to taking the dose.

“ISMP is emphasizing the need to educate patients using the teach back method, since blister pack instructions can be quite confusing,” said ISMP President Rita K. Jew. “Providing patients with the Paxlovid Fact Sheet for Patients, Parents, and Caregivers is a requirement and provides printed instructions to follow; if patients have questions they should contact their pharmacist.”


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