Should Repatha be Held When Starting Paxlovid?
Yes, Repatha (evolocumab) should be temporarily held during the 5-day course of Paxlovid (nirmatrelvir/ritonavir) treatment due to potential drug-drug interactions with ritonavir.
Mechanism of Interaction
- Paxlovid contains ritonavir, a potent inhibitor of cytochrome P450 3A4 (CYP3A4), which can significantly affect the metabolism of many medications, including cardiovascular drugs 1, 2
- Ritonavir is included in Paxlovid specifically to boost nirmatrelvir levels by inhibiting its metabolism, but this also affects other medications metabolized through similar pathways 1
- Even though Paxlovid is only a 5-day course, the inhibition of CYP3A4 is rapid and potent, creating a high potential for drug-drug interactions 1
Management Approach for Repatha
- Repatha (evolocumab) is a PCSK9 inhibitor administered every 2 weeks or monthly, making it feasible to temporarily pause without significant impact on long-term lipid management 2
- The short 5-day course of Paxlovid means that Repatha can be safely held during this period and resumed after completion of COVID-19 treatment 1
- Missing a single dose of Repatha during the Paxlovid treatment period poses minimal risk to cardiovascular outcomes compared to the potential risks of drug interactions 2, 3
Balancing COVID-19 Treatment Benefits vs. Risks
- Paxlovid has demonstrated significant effectiveness in reducing hospitalization by 39% and death by 61% in real-world data, making it an important treatment option for COVID-19 patients 4
- The benefit of Paxlovid in preventing progression to severe COVID-19 outweighs the temporary interruption of lipid-lowering therapy 4, 5
- Proper management of potential drug-drug interactions must balance the benefit of nirmatrelvir/ritonavir to prevent severe disease with the risk of adverse events 2
Practical Recommendations
- If Repatha is due during the 5-day Paxlovid course, delay the Repatha injection until after completing the full course of Paxlovid 1, 3
- If Repatha was recently administered, it's still safe to start Paxlovid as needed, since the interaction concern is primarily about concurrent administration 2
- Resume regular Repatha dosing schedule after completing the 5-day course of Paxlovid 1
- No dosage adjustment is needed for Repatha after resuming - simply continue with the regular dosing schedule 3
Important Considerations
- This recommendation applies specifically to the short 5-day course of Paxlovid used for COVID-19 treatment 1
- The temporary holding of Repatha is a precautionary measure to minimize potential drug interactions 2
- Document the temporary interruption of Repatha in the patient's medical record and ensure they understand when to resume their regular schedule 3