Introduction
It is identified in the literature that considerable proportion of
patients infected with severe acute respiratory syndrome corona virus-2
(SARS-CoV-2) are using combination of lopinavir (LPV) and ritonavir
(RTV) as first line antiviral therapy for the treatment of this pandemic
virus 1. It is also notable that many patients with
COVID-19 had multiple comorbidities and are vulnerable to polypharmacy2,3 which may in turn leads to DDIs due to taking
multiple medications. A recent clinical trial of LPV/RTV didn’t find
superiority of using this combination in COVID-19 patients4. Although many factors e.g. age, sex, comorbidities,
clinical features etc. might trigger the clinical outcomes, however, one
of the major contributing factors of these may be partly due to the DDIs
associated with COVID-19 patients due to having multiple comorbidities.
Being potent inhibitors of CYP3A4 enzyme, LPV/RTV can exert uniquely
powerful inhibiting effects of CYP3A4 substrate drugs, potentially
increased blood concentrations of substrate drugs which may leads to a
number of clinically significant DDIs 5,6.
Contrastingly, CYP3A4 inducer drugs may expedite the hepatic clearance
of LPV/RTV and may cause therapeutic failure leading to reduced
virologic control 7. Being acting as substrates of a
transporter protein called permeability glycoprotein (P-gp)8 known as efflux transporter, the pharmacokinetics
(PK) effects of LPV/RTV may also be affected by the co-prescription with
substrate, inhibitor or inducer drugs of P-gp and were predicted to
cause potential clinically significant DDIs.
However, the FDA prescribing information of LPV/RTV indicated that this
combination therapy is ‘contraindicated with drugs that are highly
dependent on CYP3A4 for clearance and for which elevated plasma
concentrations are associated with serious and/or life-threatening
reactions’. Also, it is ‘contraindicated with drugs that are potent
CYP3A4 inducers where significantly reduced lopinavir plasma
concentrations may be associated with the potential for loss of
virologic response and possible resistance and cross-resistance’9.
On the other hand, the Liverpool interactions group has provided
prescribing resources where they categorized the interactions of
experimental COVID-19 antiviral therapies as ‘contraindicated
medications’, ‘potential interactions requiring dose adjustment/close
monitoring’, ‘potential interactions of weak intensity’ or ‘no
clinically significant interactions 10.
Contraindicated medications should not be coadministered concurrently
due to potential life-threatening
ADRs.
Amid this emergency situations, details of the treatments provided in
COVID-19 patients and consequent clinical outcomes were not available
and was therefore unable to assess either the actual ADRs/drug toxicity
or potential clinically significant DDIs. It is also pertinent to noted
that while in many countries especially in developed countries, DDI
alert systems are functional, however, one of the major problems of
implementing DDIs assessment in clinical practice is that most
clinicians become fatigue to DDI alerts and majority of the time the
alerts are overridden due to too much warnings 11.
Therefore, the present study was aimed to predictively identify severe
DDIs pairs only predicted to cause life-threatening ADRs from
international resources so as to aware clinicians regarding the severity
of these interactions.