- Use of low molecular weight or unfractionated heparin recommended depending on the situation
- Antivitamin K and DOACs are not recommended 
- Effects of some drugs may be reduced in effect by combination with enzyme inhibitors like lopinavir

Anticoagulants and antiplatelet drugs

- Statin toxicity can be increased by additive effects in combination with lopinavir
- Monitoring is necessary and statin dosage may have to be reduced
- Pravastatin is least prone to interactions

Lipid lowering drugs

- Sartans and diuretics not prone to significant pharmacokinetic interactions
- Combinations of calcium channel blockers (CCBs) with lopinavir/r can increase the plasma exposure of CCBs
- Combinations of beta blockers with lopinavir/r or hydroxychloroquine can increase the plasma exposure of beta blockers
- Contraindication of use of the beta blocker metoprolol with lopinavir/r

Anti-hypertensives

- Increased plasma exposure of eplerenone in combination with lopinavir/r
- Replacement of eplerenone with spironolactone is worth consideration

Drugs in heart failure

- Ivabradine is extensively metabolized by CYP3A4 and have significant interactions with lopinavir/r so such use is contraindicated
- Interactions between the two may cause severe bradycardia

Drugs in angina pectoris

- Lopinavir/r increases the exposure of quinidine and propafenone (class I AADs or sodium channel blockers) which could cause cardiac disorders
- ECG monitoring required
- Class III AADs (or potassium channel blockers) like amiodarone are contraindicated in combination with lopinavir/r due to an increased risk of torsade de pointes

Anti-arrhythmic drugs

- Lopinavir/r can cause hyperglycemia
- Hydroxychloroquine can worsen hypoglycemia
- Exposure of sulphonylureas can be reduced by ritonavir
- Exposure and concentration of gliptins can be increased by lopinavir/r
- Case by case assessment of COVID-19 patients is necessary when considering oral anti-diabetics 

Oral anti-diabetics

- Anticoagulants and antiplatelet drugs
- Lipid lowering drugs
- Anti-hypertensives
- Drugs in heart failure
- Drugs in angina pectoris
- Anti-arrhythmic drugs
- Oral anti-diabetics

Rutgers University

- antipyretics and analgesics
- drugs in cardiovascular diseases
- drugs in infectious diseases
- anti cancer drugs
- drugs in transplantation and autoimmune diseases
- drugs in neuropsychiatric diseases
- drugs in respiratory diseases

Assessment and Management of the Risk of Drug-Drug Interactions with Other Widely Used Drugs

- Anticancer treatment must be suspended for patients with COVID-19 in ICU
- Highly cytotoxic chemotherapy should be avoided in COVID-19 infection
- Possible additive cardiotoxicity between protein kinase inhibitors and hydroxychloroquine, azithromycin or lopinavir
- Many anticancer drugs can inhibit or induce CYPs which can change the bioavailability or elimination of lopinavir/r, hydroxychloroquine, favipiravir, or remdesivir

Anti-Cancer drugs: cytotoxic, targeted therapy

- When co-administered with hydroxychloroquine, calcineurin inhibitors and m-TOR inhibitors can cause QT prolongation
- Increased exposure of hydroxychloroquine with ciclosporin
- Must reduce dose of lopinavir/r with immunosuppressants due to its strong inhibition of CYP3A, OATP1B1, and OATP1B3 to prevent nephrotoxicity and neurotoxicity  
- Therapeutic drug monitoring needed in combination with lopinavir/r
- Baricitinib may increase immunosuppression in combination with immunosuppressants 
- Combination of anakinra and methotrexate or TNF-alpha not recommended 

Drugs in organ transplantation and autoimmune disease

Antidepressants:
- Do not combine citalopram or escitalopram with hydroxychloroquine due to risk of torsades de pointes by increasing the QT interval

Anxiolytics:
- Use of hydroxyzine with hydroxychloroquine is contraindicated due to the torsadogenic risk

Antipsychotics:
- Increased torsadogenic potential of most neuroleptics with hydroxychloroquine but combination not contraindicated

Addiction medication:
- Methadone not recommended with hydroxychloroquine due to dose dependent cardiotoxicity like torsades de pointes

Anti migraines:
- Use of azithromycin is contraindicated with ergot derivatives, ergotamine and dihydroergotamine

Antiepileptics: 
- Risk of interactions from old anticonvulsants including but not limited to phenytoin and phenobarbital due to enzyme inducing effects

Drugs in neuropsychiatric diseases

Anti-asthmatics:
- Ritonavir was show to increase the plasma exposure of fluticasone by more than 100 times and thus this combination should be avoided
- Strong CYP3A4 inhibitors like lopinavir/r can increase exposure of budesonide and salmeterol
- Increased salmeterol exposure can lead to QT prolongation and palpitations
- Theophylline exposure may be altered by lopinavir/r so both must be used with caution

Learn Before

Related

Learn After