Popular COVID-19 Drug May Interact With Common Heart Medications

Paxlovid is an oral antiviral that’s used to fight coronavirus infections by stopping the virus’s progress inside the physique.

The overview paper urges well being programs to inform sufferers with coronary heart illness who’re utilizing COVID-19 of potential drug interactions.

Sufferers with coronary heart illness who’ve symptomatic COVID-19 are often treated with nirmatrelvir-ritonavir (Paxlovid) to avoid progression to severe disease; however, it may interfere with several previously prescribed drugs. A review paper recently published in the Journal of the American College of Cardiology investigates the possible drug-drug interactions (DDIs) between Paxlovid and routinely used cardiovascular medications, as well as potential methods to reduce severe side effects.

“Awareness of the presence of drug-drug interactions of Paxlovid with common cardiovascular drugs is key. System-level interventions by integrating drug-drug interactions into electronic medical records could help avoid related adverse events,” said Sarju Ganatra, MD, director of the cardio-oncology program at Lahey Hospital and Medical Center in Burlington, Massachusetts, and the senior author of the review.

“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 health care team, particularly pharmacists, can prove to be extremely valuable. However, a health care provider’s fundamental understanding of the drug-drug interactions with cardiovascular medications is key.”

https://www.youtube.com/watch?v=Okay-dr_jq_RJY
Dr. Ganatra discusses the potential drug-drug interactions between Paxlovid and generally used cardiovascular medicines. Credit score: American School of Cardiology

Paxlovid was authorised by the US Meals and Drug Administration for emergency use in December 2021 as an oral antiviral agent for the remedy of symptomatic, non-hospitalized folks with delicate to reasonable COVID-19 an infection who’re at excessive threat of progressing to extreme illness. Sufferers with coronary heart illness and different threat elements, together with as diabetes, hypertension, power kidney illness, and smoking, account for a major proportion of the high-risk group for whom Paxlovid is beneficial.

Paxlovid, in keeping with the authors, has been demonstrated to be extraordinarily useful in sufferers with pre-existing coronary heart illness, but it surely has appreciable DDIs with routinely used cardiovascular medicine, emphasizing the significance of all medical doctors being aware of these DDIs. As a result of medical information on DDI-related antagonistic occasions is restricted, the authors used current data and information on how therapies like Paxlovid usually work together with different medicines to offer steerage on potential interactions and the related seemingly penalties primarily based on the diploma of interplay.

The overview supplies an in-depth overview of a wide range of cardiovascular medicines used to deal with many types of coronary heart illness. 5 of a very powerful cardiovascular drug interactions with Paxlovid to pay attention to embrace:

• Antiarrhythmic brokers

  • Antiarrhythmic brokers are used to handle irregular coronary heart rhythms. Many of those medicine are metabolized in a means that will increase plasma levels when co-administered with Paxlovid. While it may be possible to start Paxlovid after 2-2.5-day temporary discontinuation of the antiarrhythmic agents, this may not be feasible from a practical standpoint. Clinicians are advised to consider alternative COVID-19 therapies and avoid co-administration of these agents with Paxlovid. Sotalol, another antiarrhythmic agent, is renally cleared and does not interact with Paxlovid.

• Antiplatelet agents and anticoagulants

  • Antiplatelet agents are used for the treatment of coronary artery disease, particularly if a patient has received a stent. Aspirin and prasugrel are safe to co-administer with Paxlovid. There is an increased risk of blood clots when Paxlovid is given alongside clopidogrel and an increased risk of bleeding when given with ticagrelor. When possible, these agents should be switched to prasugrel. If patients have contraindication to taking prasugrel, then co-administration of Paxlovid should be avoided and alternative COVID-19 therapies should be considered.
  • Anticoagulants or blood thinners used to treat or prevent blood clots, such as warfarin may be co-administered with Paxlovid but require close monitoring of clotting factors in bloodwork. The plasma levels of all direct oral anticoagulants increase when co-administered with Paxlovid, therefore dose adjustment or temporary discontinuation and use of alternative anticoagulants may be required.

• Certain statins

  • Co-administration of simvastatin or lovastatin with Paxlovid can lead to increased plasma levels and subsequent muscle weakness (myopathy) and rhabdomyolysis, a condition in which the breakdown of muscle tissue releases a damaging protein into the bloodstream. These agents should be stopped prior to initiation of Paxlovid. A dose reduction of atorvastatin and rosuvastatin is reasonable when co-administered with Paxlovid. The other statins are considered safe when given along with Paxlovid.

• Ranolazine

  • Plasma concentration of ranolazine used to treat angina and other heart-related chest pain is exponentially increased in the presence of CPY450 inhibitors like Paxlovid, thereby increasing the risk of clinically significant QT prolongation and torsade de pointes (a type of arrhythmia). Co-administration of Paxlovid is therefore contraindicated. Temporary discontinuation of ranolazine is advised if prescribing Paxlovid.

• Immunosuppressive agents

  • The plasma levels of immunosuppressive agents prescribed for patients who have undergone heart transplantation exponentially rise to toxic levels when co-administered with Paxlovid. Temporary reduction of dosing of immunosuppressive agents would require frequent monitoring and be logistically difficult. Therefore, alternative COVID-19 therapies should be considered in these patients.

The authors conclude awareness and availability of other COVID-19 therapies enable clinicians to offer alternative treatment options to patients who are unable to take Paxlovid due to DDIs.

Reference: “Cardiovascular Drug Interactions With Nirmatrelvir/Ritonavir in Patients With COVID-19” by Sonu Abraham, Anju Nohria, Tomas G. Neilan, Aarti Asnani, Anu Mariam Saji, Jui Shah, Tara Lech, Jason Grossman, George M. Abraham, Daniel P. McQuillen, David T. Martin, Paul E. Sax, Sourbha S. Dani, and Sarju Ganatra, 12 October 2022, Journal of the American College of Cardiology.
DOI: 10.1016/j.jacc.2022.08.800