Lopinavir/ritonavir/prednisone

Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 78-year-old woman developed knee osteonecrosis during off-label therapy with lopinavir/ritonavir for COVID-19. Further, she experienced worsening of knee osteonecrosis during treatment with prednisone for bronchospasm [not all dosages and routes stated; times to reaction onsets not stated].

The woman presented with increased swelling and pain in the right knee, one month after first symptoms of COVID-19. She also reported symptoms of parasympathetic post-COVID syndrome. She had arthrosis and meniscus degeneration in both knees, which mainly affected her left knee. Anamnesis revealed that she had been treated with off-label hydroxychloroquine and lopinavir/ritonavir for the COVID-19 infection, with oxygen supplementation. Two weeks post discharge, the right knee pain worsened. In addition, she experienced a mild increase in dyspnoea; hence, she started receiving oral prednisone 165mg over 9 days for bronchospasm. One week later, she was found to have local swelling on the internal side of the knee. MRI revealed a broken internal meniscus, which was dislodged to femorotibial recess; a chronic sprain in collateral internal ligament, as well as oedema secondary to osteochondral damage in condyle surface, with collapse of the anterior segment of the condyle. She was diagnosed with osteonecrosis of the internal condyle of the right knee. Total knee replacement was advised.

While awaiting surgery (at the time of reporting; delayed due to the pandemic), the woman received increased doses of tapentadol and salicylic acid, and she was given home exercises to strengthen her muscles. Her pain and swelling decreased within 1 month. She continued to walk using a cane, though with increased pain and instability. The treatment with off-label therapy lopinavir/ritonavir was thought to have caused the knee osteonecrosis, while prednisone was felt to have worsened the knee osteonecrosis.