ArticleJournal of medical toxicology : official journal of the American College of Medical Toxicology2023
Tacrolimus Drug-Drug Interaction with Nirmatrelvir/Ritonavir (Paxlovid™) Managed with Phenytoin.
Article in Journal of medical toxicology : official journal of the American College of Medical Toxicology, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 20 papers.
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Who cites it
20 citing papers in PubMed, 32 citations in OpenAlex.
- Delayed Drug-Drug Interaction Between Antiviral Drugs and Tacrolimus in a Pancreatic Islet Transplant Recipient With SARS-CoV-2 Pneumonia.Therapeutic drug monitoring · 2025Article
- Design, Synthesis, and Biological Evaluation of Peptidomimetic Tetrahydropyrrole Spirodihydroindolones as SARS-CoV-2 3CL Protease Inhibitors.ACS medicinal chemistry letters · 2025Article
- A Case Report of Successful Use of Phenytoin/Fosphenytoin in a Pediatric Kidney Transplant Recipient With Nirmatrelvir/Ritonavir-Induced Tacrolimus Allograft Injury.Pediatric transplantation · 2025Article
- Cardiovascular adverse effects of antiviral therapies for COVID-19: Evidence and plausible mechanisms.Acta pharmacologica Sinica · 2025Review
- Paxlovid (Nirmatrelvir/Ritonavir)-Induced Tacrolimus Toxicity in Organ Transplant Recipients - A Review on Drug Interactions Involving CYP3A Enzymes.Current drug safety · 2025Review
- Pharmacovigilance of Drug-Drug Interactions with Nirmatrelvir/Ritonavir.Infectious diseases and therapy · 2024Article
- Nirmatrelvir/ritonavir treatment of patients with COVID-19 taking tacrolimus: case series describing the results of drug-drug interactions.The Journal of international medical research · 2024Article
- Ritonavir: 25 Years' Experience of Concomitant Medication Management. A Narrative Review.Infectious diseases and therapy · 2024Review
- Introducing urea into tirapazamine derivatives to enhance anticancer therapy.National science review · 2024Article
- Prevention and treatment strategies for kidney transplant recipients in the context of long-term existence of COVID-19.Frontiers in medicine · 2024Review
- Case report and literature review: management of Paxlovid (nirmatrelvir/ritonavir)-induced acute tacrolimus toxicity in a patient with systemic lupus erythematosus.Frontiers in pharmacology · 2024Article
- Pharmacokinetic Interactions of Paxlovid Involving CYP3A Enzymes and P-gp Transporter: An Overview of Clinical Data.Current drug metabolism · 2024Review
- Design, synthesis and biological evaluation of novel 3C-like protease inhibitors as lead compounds against SARS-CoV-2.Future medicinal chemistry · 2024Article
- Safety Profile of Paxlovid in the Treatment of COVID-19.Current pharmaceutical design · 2024Article
- Case report: Paralytic ileus resulted from nirmatrelvir/ritonavir-tacrolimus drug-drug interaction in a systemic lupus erythematosus patient with COVID-19.Frontiers in pharmacology · 2024Article
- Monitoring tacrolimus toxicity following Paxlovid administration in a liver transplant patient.Practical laboratory medicine · 2023Article
- Response to Comment on "Tacrolimus Drug-Drug Interaction with Nirmatrelvir/Ritonavir (Paxlovid™) Managed with Phenytoin".Journal of medical toxicology : official journal of the American College of Medical Toxicology · 2023Article
- Comment on "Tacrolimus Drug-Drug Interaction with Nirmatrelvir/Ritonavir (Paxlovid™) Managed with Phenytoin".Journal of medical toxicology : official journal of the American College of Medical Toxicology · 2023Article
- Tacrolimus toxicity due to enzyme inhibition from ritonavir.The American journal of emergency medicine · 2023Article
- Case report: Supratherapeutic tacrolimus concentrations with nirmatrelvir/ritonavir in a lung transplant patient: a case report using Rifampin for reversal.Frontiers in pharmacology · 2023Article
Corrections and comments
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Authors and funding
3 authors at 1 institution in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionThe novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) pandemic has had a significant impact on communities and health systems. The Federal Drug Administration (FDA) authorized Pfizer's nirmatrelvir/ritonavir (Paxlovid™) through an EUA for the treatment of mild to moderate cases of COVID-19 at high risk for progression to severe disease. Patients with a history of transplant who test positive for COVID-19 are considered high risk because of their immunosuppression and are therefore candidates for nirmatrelvir/ritonavir. CASE REPORT: This is a case of a 67-year-old female with a past medical history of orthotopic heart transplant who received tacrolimus as part of her immunosuppressive regimen. She originally presented with complaints of dyspnea and cough for several days in the setting of COVID-19. The patient was started on nirmatrelvir/ritonavir due to her high risk for progression to severe disease. Four days after starting nirmatrelvir/ritonavir, she presented to the ED for slowed speech, fatigue, weakness, and loss of appetite. Upon admission she was found to have a supratherapeutic tacrolimus level of 176.4 ng/mL and an acute kidney injury. In this case, phenytoin was used as a CYP3A4 inducer to quickly decrease the tacrolimus level to within therapeutic range.
conclusionThis case highlights the strong and important drug-drug interaction between tacrolimus and nirmatrelvir/ritonavir leading to toxic levels of tacrolimus. It also demonstrates the utility and effectiveness of phenytoin as a "rescue" medication for tacrolimus toxicity.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.