Paxlovid, virüsün vücutta büyümesini önleyerek koronavirüs enfeksiyonlarıyla savaşmak için kullanılan oral bir antiviraldir.
İnceleme raporu, sağlık sistemlerini COVID-19 kullanan kalp hastalığı olan hastaları olası ilaç etkileşimleri hakkında bilgilendirmeye çağırıyor.
Semptomatik kalp hastalığı olan hastalar[{” attribute=””>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.”
Dr. Ganatra, Paxlovid ile yaygın olarak kullanılan kardiyovasküler ilaçlar arasındaki potansiyel ilaç-ilaç etkileşimlerini tartışıyor. Kredi: Amerikan Kardiyoloji Koleji
Paxlovid, ABD Gıda ve İlaç İdaresi tarafından Aralık 2021’de şiddetli hastalığa ilerleme riski yüksek olan hafif ila orta şiddette COVID-19 enfeksiyonu olan semptomatik, hastaneye yatırılmamış kişilerin tedavisi için oral bir antiviral ajan olarak acil kullanım için onaylandı. Kalp hastalığı ve diyabet, yüksek tansiyon, kronik böbrek hastalığı ve sigara içme gibi diğer risk faktörleri olan hastalar, Paxlovid’in yararlı olduğu yüksek risk grubunun önemli bir bölümünü oluşturur.
Yazarlara göre Paxlovid’in önceden kalp hastalığı olan hastalarda son derece yararlı olduğu kanıtlanmıştır, ancak rutin olarak kullanılan kardiyovasküler ilaçlarla önemli ölçüde DDI’lara sahiptir ve bu, tüm doktorların bu DDI’lara aşina olmasının önemini vurgulamaktadır. DDI ile ilişkili advers olaylara ilişkin klinik veriler sınırlı olduğundan, yazarlar, Paxlovid gibi tedavilerin tipik olarak diğer ilaçlarla nasıl etkileşime girdiğine dair mevcut bilgi ve verileri, potansiyel etkileşimler ve etkileşimin derecesine bağlı olarak ilişkili olası sonuçlar hakkında rehberlik sağlamak için kullandılar.
İnceleme, birçok kalp hastalığı formunu tedavi etmek için kullanılan çeşitli kardiyovasküler ilaçlara derinlemesine bir genel bakış sunmaktadır. Paxlovid ile dikkat edilmesi gereken en önemli kardiyovasküler ilaç etkileşimlerinden beşi şunları içerir:
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Antiaritmik ajanlar
- Anormal kalp ritimlerini yönetmek için antiaritmik ajanlar kullanılır. Bu ilaçların birçoğu artan bir şekilde metabolize edilir.[{” attribute=””>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.
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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.
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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.
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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.
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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