COVID-19 drug Paxlovid may react poorly with certain heart medications, cardiologists warn
Nirmatrelvir-ritonavir (NMVr), sold by Pfizer under the name Paxlovid, is commonly prescribed to treat symptomatic COVID-19 patients, including patients who present with prior cardiovascular disease (CVD).
NMVr is safe and effective for COVID-19 patients with CVD, but there is a chance that it could have an adverse interaction with other common heart medications. A team of specialists evaluated these potential drug-drug interactions (DDIs), sharing their findings in the Journal of the American College of Cardiology.[1]
“Awareness of the presence of drug-drug interactions of Paxlovid with common cardiovascular drugs is key,” senior author Sarju Ganatra, MD, a cardiologist with Lahey Hospital and Medical Center in Burlington, Massachusetts, said in a prepared statement from the American College of Cardiologyb (ACC). “System-level interventions by integrating drug-drug interactions into electronic medical records could help avoid related adverse events. The prescription of Paxlovid could be incorporated into an order set, which allows physicians, whether it be primary care physicians or cardiology providers, to consciously rule out any contraindications to the co-administration of Paxlovid. Consultation with other members of the healthcare team, particularly pharmacists, can prove to be extremely valuable.”
Ganatra et al. tracked potential DDIs between NMVr and a wide variety of cardiovascular medications. These are five of the team’s key findings:
1. How antiarrhythmic agents may interact with NMVr/Paxlovid
While sotalol can be safely given to patients at the same time as NMVr, many other antiarrhythmic medications—including amiodarone, dofetilide, flecainide, dronedarone, propafenone and quinidine—can increase plasma levels when prescribed at the same time as NMVr. The researchers recommended considering alternative COVID-19 therapies or withholding the antiarrhythmic agent temporarily so that NMVr can be administered.
2. How antiplatelet agents and anticoagulants may interact with NMVr/Paxlovid
Aspirin and prasugrel can both be safely given to patients at the same time as NMVr, but that is not true for all antiplatelet agents. Patients given clopidogrel and NMVr at the same time face an increased risk of a blood clot, for example, and patients given ticagrelor and NMVr could experience a bleeding event.
Most anticoagulants such as warfarin, meanwhile, can be given to patients at the same time as NMVr, but they should be monitored closely. A dose adjustment may also be needed, the authors added, depending on how the anticoagulant affects plasma levels.
Also, patients taking rivaroxaban who are unable to stop taking it should not be treated with NMVr. If a patient is able to stop taking rivaroxaban temporarily, it should be withheld for two to three days before NMVr treatment begins and an alternative anticoagulant should be taken instead of rivaroxaban while the patient is on NMVr.
3. How statins may interact with NMVr/Paxlovid
Simvastatin and lovastatin should not be given to patients at the same time as NMVr, the researchers noted, due to a heightened risk of myopathy and rhabdomyolysis. Those specific agents should be stopped before a patient is given NMVr.
Atorvastatin and rosuvastatin can each be co-administered with NMVr if the statin dose is reduced. Other statins appear to be perfectly safe to give to a patient at the same time as NMVr.
4. How ranolazine may interact with NMVr/Paxlovid
Ranolazine, a medication typically prescribed to treat angina or chest pain, should be discontinued before a patient is treated with NMVr. Taking the two medications at once can increase a patient’s risk of an arrhythmia.
5. How immunosuppressive agents may interact with NMVr/Paxlovid
If a patient is taking an immunosuppressive agent—after undergoing a heart transplant, for instance—they should not be treated with NMVr, because the combination can cause plasma levels to rise dramatically. Alternative COVID-19 treatments are recommended.
Final thoughts on NMVr use in cardiac patients
“The importance of medication reconciliation before initiation of NMVr cannot be overemphasized to avoid serious DDIs,” the document’s authors concluded. “Dose adjustment or discontinuation of cardiovascular medications may be required for the duration of NMVr treatment and three to five days after completion. If co-administration of NMVr with certain cardiovascular medications is not advisable or if their temporary discontinuation is impractical, NMVr should be avoided, and other treatments used.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.