Management of nirmatrelvir/ritonavir and tacrolimus interaction in kidney transplant recipients infected by COVID-19: a three-case series

Abstract

Objectives Nirmatrelvir/ritonavir may cause a clinically relevant drug-drug interaction (DDI) with immunosuppressive drugs, such as tacrolimus, which may condition the use of this antiviral in transplant patients. We aimed to describe the management of this interaction. Methods Descriptive study in which renal transplant patients in treatment with nirmatrelvir/ritonavir and tacrolimus were included. They suspended tacrolimus the day before starting the antiviral treatment, and the decision to restart it was made based on their tacrolimus blood levels. Main variables studied to measure this DDI were tacrolimus blood concentration, dose adjustment and serum creatinine. Results Three patients were included. During the study, tacrolimus levels elevation did not have repercussion in the serum creatinine, that remained stable in all patients. No patient required hospitalisation or showed signs of rejection.Conclusions Our experience provides further evidence that this interaction should not be a contraindication to treatment with nirmatrelvir/ritonavir, and can be managed with close monitoring of tacrolimus levels.

Strategies to Mitigate the Drug-Drug Interaction between Nirmatrelvir/Ritonavir and Tacrolimus in Allogeneic Hematopoietic Stem Cell Transplant Recipients on Azole Antifungals: Results of a Case Series

“…There are six previous reports in 44 patients of strategies to mitigate this drug-drug interaction between NIM/r and tacrolimus limited only to solid organ transplant recipients, as summarized in Table 1 [16‒21]. Like the observations in the results from the strategies herein, they all support discontinuation of tacrolimus during NIM/r and the need for close, up to daily, monitoring of tacrolimus concentrations.…”

Abnormally Elevated Blood Tacrolimus Level Following the Concomitant Use of Nirmatrelvir/Ritonavir With Extended-Release Tacrolimus in a Post-lung Transplant Patient: A Case Report and a Literature Review

“…We reviewed the literature on organ transplant patients using TAC-ER in combination with NMV/r. Table 1 presents the background of post-solid organ transplant patients using TAC-ER in combination with NMV/r and Table 2 presents the blood TAC level course of these patients [ 20 - 23 ]. All patients using TAC-ER, except for the present patient, were post-kidney transplant patients.…”

Correspondence on ‘Management of nirmatrelvir/ritonavir and tacrolimus interaction in kidney transplant recipients infected by COVID-19: a three-case series’

“…We read with great interest the recent study conducted by Guzmán Cordero and Saez-Torres de Vicente,1 which reported how to manage patients treated with nirmatrelvir/ritonavir (brand name Paxlovid) and tacrolimus. The results hinted that nirmatrelvir/ritonavir combined with tacrolimus interaction could be controlled and achieve a good clinical effect.…”

“…Tacrolimus is mandatory in patients with chronic renal failure in the department of nephrology, especially in those who do not respond well to hormone use. Guzmán Cordero and Saez-Torres de Vicente1 published papers with profound guidance for us to manage chronic renal failure well with tacrolimus during the COVID-19 pandemic background.…”