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Drug Interactions. Check COVID/COVID drug interactions. Drug combinations may have been assessed either by study or within the product label, or an interaction may have been predicted based on the metabolic profiles of the drugs. These drugs should not be coadministered.
- Box 1. Select Outpatient Medications Not Expected to Have Clinically Relevant Interactions With Ritonavir-Boosted Nirmatrelvir (Paxlovid)
- Medications That Have Clinically Relevant Drug-Drug Interactions With Ritonavir-Boosted Nirmatrelvir (Paxlovid)
- Identifying Drug-Drug Interactions
- Management Strategies for Drug-Drug Interactions
- Box 2. Select Outpatient Medications That Have Clinically Relevant Drug-Drug Interactions With Ritonavir-Boosted Nirmatrelvir (Paxlovid)
- Drug-Drug Interaction Considerations When Using Extended Courses of Ritonavir-Boosted Nirmatrelvir (Paxlovid)
- References
This list is primarily based on the most common medication searches by U.S. users on the Liverpool COVID-19 Drug Interactions website.
Box 1. Select Outpatient Medications Not Expected to Have Clinically Relevant Interactions With Ritonavir-Boosted Nirmatrelvir (Paxlovid) Medications Without Clinically Relevant Interactions
These medications may be coadministered without dose adjustment and without increased monitoring. This list is not inclusive of all noninteracting medications within each drug category.
Acid Reducers
•Famotidine
•Omeprazole
Clinicians should be aware that, in some cases, drug-drug interactions with ritonavir-boosted nirmatrelvir may lead to serious or life-threatening drug toxicities. The recommended treatment course of ritonavir-boosted nirmatrelvir for COVID-19 is 5 days. CYP3A4 inhibition occurs rapidly, with maximum inhibition occurring within 48 hours of ritonavir initiation.1 After treatment is completed and ritonavir is discontinued, 70% to 90% of CYP3A4 inhibition resolves within 2 to 3 days.2 The time to resolution of inhibition varies based on factors such as the patient’s age; therefore, resolution may take longer in some individuals, such as in adults of advanced age.
Ritonavir is also an inhibitor of CYP2D6, P-gp, and organic anion transporting polypeptide (OATP) 1B1. When used for longer durations or chronically, ritonavir may induce CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, and uridine diphosphate-glucuronyltransferase (UGT). See below for more information.
Quick reference lists:
Box 1 above lists select outpatient medications that are not expected to have clinically relevant interactions with ritonavir-boosted nirmatrelvir.
Box 2 below lists select outpatient medications that have clinically relevant drug-drug interactions with ritonavir-boosted nirmatrelvir.
Web-based drug-drug interaction checker:
Liverpool COVID-19 Drug Interactions website
Tables with guidance on managing specific drug-drug interactions:
Increasing monitoring for potential adverse events to the concomitant medication.
Adjusting the dose of the concomitant medication.
Temporarily withholding the concomitant medication.
Using an alternative to the concomitant medication.
The guidance in Box 2 is based on the drug-drug interaction potential of the FDA-approved 5-day course of ritonavir-boosted nirmatrelvir.
Not all medications that may interact with ritonavir-boosted nirmatrelvir are included in Box 2. Deviation from the recommended strategies may be appropriate in certain clinical scenarios.
Box 2. Select Outpatient Medications That Have Clinically Relevant Drug-Drug Interactions With Ritonavir-Boosted Nirmatrelvir (Paxlovid) Prescribe Alternative COVID-19 Therapy
For these medications, management strategies are not possible or feasible, or the risks outweigh the potential benefits.
Anticonvulsants
•Carbamazepine
The guidance in this document is based on the drug-drug interaction potential of the FDA-approved 5-day course of ritonavir-boosted nirmatrelvir.
Longer treatment courses may be utilized in certain cases (see Special Considerations in People Who Are Immunocompromised). Clinicians should be aware that the drug-drug interaction potential of ritonavir may change based on duration of treatment. Clinicians should be aware that:
•Induction properties6 may become clinically relevant when ritonavir is used for longer durations (i.e., ≥10 days) or chronically (e.g., in people who take HIV protease inhibitors).7 For example, induction of CYP2C9 and CYP2C19 may decrease warfarin and voriconazole concentrations, and induction of glucuronidation may decrease lamotrigine or valproic acid concentrations.
•The management strategies listed in Box 2 are based on the drug-drug interaction potential of a 5-day treatment course of ritonavir-boosted nirmatrelvir. These strategies may need to be modified wh...
Katzenmaier S, Markert C, Riedel KD, et al. Determining the time course of CYP3A inhibition by potent reversible and irreversible CYP3A inhibitors using a limited sampling strategy. Clin Pharmacol Ther. 2011;90(5):666-73. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21937987.
Stader F, Khoo S, Stoeckle M, et al. Stopping lopinavir/ritonavir in COVID-19 patients: duration of the drug interacting effect. J Antimicrob Chemother. 2020;75(10):3084-3086. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32556272.
Food and Drug Administration Center for Drug Evaluation and Research. Antimicrobial drugs advisory committee meeting. 2023. Available at: https://www.fda.gov/media/168508/download.
Food and Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. 2020. Available at: https://www.fda.gov/media/142368/download.
WARNING: SIGNIFICANT DRUG INTERACTIONS WITH PAXLOVID 1. PAXLOVID includes ritonavir, a strong CYP3A inhibitor, which may lead to greater exposure of certain concomitant medications, resulting in potentially severe, life-threatening, or fatal events.
Paxlovid Interactions. There are 665 drugs known to interact with Paxlovid (nirmatrelvir/ritonavir), along with 7 disease interactions, and 2 alcohol/food interactions. Of the total drug interactions, 247 are major, 379 are moderate, and 39 are minor. Does Paxlovid interact with my other drugs?
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Unless otherwise stated, interacting medications should be managed (held/dose reduced/extra monitoring) for 8 days from the first dose of Paxlovid. Very sensitive or narrow therapeutic index CYP3A4 drugs may need to be restarted 10 days after the first dose of Paxlovid) Antibiotics. Clarithromycin.
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Jun 1, 2023 · Updated on June 1, 2023. Key takeaways: Paxlovid (nirmatrelvir/ritonavir) is an oral antiviral medication that’s FDA approved to treat certain people who have mild to moderate COVID-19. Paxlovid interacts with many medications. Common examples are medications that treat high cholesterol, high blood pressure, and migraines.
Apr 2, 2024 · Interactions. FAQ. What is Paxlovid? Paxlovid is an antiviral medication used to treat COVID-19 to help decrease symptoms or avoid severe illness in certain patients. Paxlovid works by stopping the virus that causes COVID-19 (SARS-CoV-2) from multiplying. Paxlovid should be taken as soon as possible after diagnosis of COVID-19.
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