You can help answer questions when patients with COVID-19 taking nirmatrelvir/ritonavir (Paxlovid) present to the hospital.
It’s too soon to say if patients taking nirmatrelvir/ritonavir should continue it on admission. It’s okay to complete the course...but you’ll likely need to use a patient’s home supply.
Ask patients if any of their home meds were stopped or adjusted due to interactions when nirmatrelvir/ritonavir was started. Include these details in your EHR’s home med section.
When starting meds in-house, consider using a checker, such as COVID19-DrugInteractions.org...especially if your EHR software doesn’t include nirmatrelvir/ritonavir yet.
For example, continue to use oral or inhaled steroids...despite labeled warnings that adding nirmatrelvir/ritonavir may increase risk of adrenal suppression. Five days of the combo isn’t likely a concern.
But stop nirmatrelvir/ritonavir if adding clopidogrel for a new stent or for other patients at high clot risk...ritonavir inhibits the conversion of clopidogrel to its active form.
Also stop nirmatrelvir/ritonavir if starting rivaroxaban...due to increased bleeding risk.
Point out that apixaban isn’t clear-cut. Manage based on dose and indication. For instance, if adding apixaban for VTE treatment, consider stopping nirmatrelvir/ritonavir.
At discharge, address any home meds that were stopped or adjusted when nirmatrelvir/ritonavir was started.
For example, if apixaban for atrial fib was reduced to 2.5 mg bid, increase back to 5 mg bid 3 days after completing the course.
Go to our resource, Treatments of Interest for COVID-19, for renal dose adjustments, other interaction checkers, etc.
- https://www.fda.gov/media/155050/download (6-27-22)
- https://www.covid19-druginteractions.org/checker (6-27-22)
- https://www.idsociety.org/globalassets/idsa/practice-guidelines/covid-19/treatment/idsa-paxlovid-drug-interactions-resource-5-6-22-v1.1.pdf (6-27-22)
- https://emergency.cdc.gov/han/2022/pdf/CDC_HAN_467.pdf (6-27-22)