Table 1.
Common drug–drug interactions and recommendations for use in patients with COVID-19
| Class of drug | Concerns | Recommendation | |
|---|---|---|---|
| Antiplatelets | P2Y12 inhibitors | Increased risk of bleeding | With fibrinolytics and patients with coagulopathy: clopidogrel is preferred |
| In patients receiving lopinavir/ritonavir, increased risk of bleeding with ticagrelor, and decreases antiplatelet activity with clopidogrel | Prasugrel is recommended with lopinavir/ritonavir | ||
| Glycoprotein IIb/IIIa Inhibitors | Increased risk of bleeding |
Their use should be restricted Can be considered if needed Abciximab is not recommended |
|
| Anticoagulants | LMWH | Increased risk of bleeding |
In patents with coagulopathy and with fibrinolytic therapy, LMWH is preferred (If angiography is going to be done within 24 h after fibrinolytic therapy, UFH is still the best option) |
| UFH | Increased risk of bleeding | If the patient is considered to be at high bleeding risk, UFH could be considered. | |
| Rivaroxaban |
In patients receiving lopinavir/ritonavir, increased risk of bleeding Interaction with tocilizumab |
Contraindicated with lopinavir/ritonavir Not recommended with tocilizumab |
|
| Apixaban |
In patients receiving lopinavir/ritonavir, increased risk of bleeding Interaction with tocilizumab |
Contraindicated/reduce dose by 50% with lopinavir/ritonavir Not recommended with Tocilizumab |
|
| Dabigatran | In patients receiving lopinavir/ritonavir, increased risk of bleeding | Use not recommended/suggested as an option, data lacking | |
| Edoxaban | In patients receiving lopinavir/ritonavir, increased risk of bleeding |
Stroke prevention in non-valvular AF: no dose adjustment VTE indication: reduce dose by 50% |
|
| Warfarin | In patients receiving lopinavir/ritonavir/tocilizumab, may reduce or increase INR | OAC of choice, monitor INR | |
| Fibrinolytics | Increased risk of bleeding | Tenecteplase is preferred | |
| Statins | Increased risk of hepatotoxicity | Monitor LFT | |
|
Increased effect with lopinavir/ritonavir Decreased effect with tocilizumab |
Reduce dose with lopinavir/ritonavir Monitor with tocilizumab |
||
| Beta-blockers | Increased risk of bradycardia, hypotension and AV block with concomitant use of protease inhibitors |
Metoprolol and bisoprolol are preferred Monitor BP and HR |
|
| ACEI/ARB/ARNI | Decreased effects of losartan and irbesartan with lopinavir/ritonavir |
Continuation of ACEI/ARB Monitor BP, SCr, and K |
|
| Increased effects of valsartan with lopinavir/ritonavir | |||
| Increased concentration of sacubitril with lopinavir/ritonavir | |||
| Mineralocorticoid antagonists | Increased risk of adverse effect with lopinavir/ritonavir |
Spironolactone is preferred Eplerenone is contraindicated Monitor serum electrolytes and SCr |
|
| Diuretics | Increase the concentration of indapamide with lopinavir/ritonavir |
Monitor BP, serum electrolytes for prevention of TdP Monitor BUN/SCr |
|
| Digoxin | Increased risk of toxicity | Monitor digoxin concentration | |
| Ivabradine | Increased risk of adverse effect with lopinavir/ritonavir | Do not co-administer with lopinavir/ritonavir | |
| Antiarrhythmics | Increased risk of QT prolongation and TdP with concomitant use of chloroquine/hydroxychloroquine |
Monitor ECG before initiation Maintain serum Mg > 2 and K > 4 mg/dL |
|
| Increased antiarrhythmic effects with protease inhibitors |
Lidocaine and quinidine are preferred. Monitor ECG and adjust dose if necessary Flecainide and propafenone are not recommended ECG, BP, LFT, and TFT should be monitored periodically with reduced dose of amiodarone |
||
ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor neprilysin inhibitor; AF: atrial fibrillation; AV: atrioventricular; BP: blood pressure; BUN: blood urea nitrogen; ECG: electrocardiogram; HR: heart rate; INR: international normalized ratio; LFT: liver function test; LMWH: low molecular weight heparin; OAC: oral anticoagulant; SCr: serum creatinine; TdP: torsade de pointes; TFT: thyroid function test; UFH: unfractionated heparin; VTE: venous thromboembolism