Contraindications exist between ritonavir/nirmatrelvir and some CV medications
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There are drug-drug interactions between the COVID-19 treatment ritonavir/nirmatrelvir and various classes of commonly used CV medications, according to a review paper.
The review document, published in the Journal of the American College of Cardiology, provides an overview of the contraindications of ritonavir/nirmatrelvir (Paxlovid, Pfizer) across common antiplatelets/anticoagulants, lipid-lowering agents, antianginal drugs, antihypertensive agents, antiarrhythmic drugs, HF therapies, pulmonary hypertension therapies, immunosuppressive agents and anti-inflammatory drugs.
“Patients with CV risk factors and CVD are at a high risk of developing adverse events from COVID-19 and as a result have a higher likelihood of receiving ritonavir/nirmatrelvir,” Sarju Ganatra, MD, director of the cardio-oncology program at Lahey Hospital and Medical Center in Burlington, Massachusetts, told Healio. “Ritonavir/nirmatrelvir was originally shown to be beneficial for unvaccinated patients. However, we did a follow-up real-world study and demonstrated that it is beneficial for high-risk vaccinated patients as well such as those with heart disease (Ganatra S, et al. Clin Infect Dis. 2022. 2022;doi: 10.1093/cid/ciac673/6672670).
“We should not be deterred from considering ritonavir/nirmatrelvir as a potential treatment for COVID-19,” Ganatra told Healio. “However, co-administration of ritonavir/nirmatrelvir with medications commonly used to manage CV conditions can potentially cause significant drug-drug interactions and may lead to severe adverse effects. It is crucial to be aware of such interactions and make appropriate adjustments in the medication regimen to avoid any harm.”
In December, the FDA issued an expanded use authorization for ritonavir/nirmatrelvir, making it the first available oral antiviral treatment for COVID-19.
In a press release, the ACC highlighted the top five ritonavir/nirmatrelvir contraindications clinicians should look out for.
Antiarrhythmic agents
When administered alongside ritonavir/nirmatrelvir, many antiarrhythmic drugs can increase plasma levels and temporary discontinuation may not be feasible. Therefore, the document recommends alternative COVID-19 therapies and avoidance of coadministration of these agents with ritonavir/nirmatrelvir.
The researchers noted that sotalol, an antiarrhythmic agent that is renally cleared, does not interact with ritonavir/nirmatrelvir.
Antiplatelet agents and anticoagulants
Aspirin and prasugrel are safe to coadminister alongside ritonavir/nirmatrelvir, according to the document.
The researchers wrote there is an increased risk for thrombus when ritonavir/nirmatrelvir is coadministered with clopidogrel and an increased risk for bleeding when given alongside ticagrelor (Brilinta, AstraZeneca). Researchers recommended that patients taking these medications be switched to prasugrel. If other contraindications inhibit the use of prasugrel, alternative COVID-19 therapies to ritonavir/nirmatrelvir may be considered.
Warfarin and direct oral anticoagulants may be coadministered alongside ritonavir/nirmatrelvir but may necessitate close monitoring. Dose adjustment, temporary discontinuation or alternative anticoagulants may be required.
Statin therapy
Concomitant simvastatin or lovastatin with ritonavir/nirmatrelvir may increase plasma levels, myopathy and rhabdomyolysis, so these agents should be stopped prior to ritonavir/nirmatrelvir initiation, according to the document.
Reduced doses of atorvastatin and rosuvastatin may be considered when administered alongside ritonavir/nirmatrelvir.
Other statins are considered safe, according to the document.
Antianginal drugs
Researchers reported that ranolazine coadministered with ritonavir/nirmatrelvir was associated with increased risk for clinically significant QT prolongation and torsades de pointes. Ranolazine is therefore contraindicated, and temporary discontinuation may be advised.
Immunosuppressive agents
Immunosuppressive agents prescribed for patients who underwent heart transplantation may cause increased plasma levels when administered alongside ritonavir/nirmatrelvir. Researchers recommended use of alternative COVID-19 therapies to ritonavir/nirmatrelvir rather than dose reduction of immunosuppressive agents.
“We believe it’s important for providers and hospitals to create system-level interventions such as building in these interactions in the EMR system to alert the clinicians/prescribers to ensure patients get the right treatment and we can avoid potentially harmful drug-drug interactions,” Ganatra told Healio. “We hope [our article] will be helpful for clinicians to understand such interactions and also to make point-of-care decisions.”
Please see the review document for full details on the contraindications of ritonavir/nirmatrelvir with various classes of CV medications.
Reference:
- COVID-19 drug Paxlovid may interact with common heart medications. https://www.acc.org/About-ACC/Press-Releases/2022/10/12/17/14/COVID19-Drug-Paxlovid-May-Interact-with-Common-Heart-Medications. Published Oct. 12, 2022. Accessed Oct. 12, 2022.
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