Muristek
In Reply In our Viewpoint on COVID-19 therapeutics for nonhospitalized patients, we highlighted the fact that some medications are contraindicated and preclude use of the anti–SARS-CoV-2 protease inhibitor nirmatrelvir-ritonavir, whereas other medications require dose adjustment, close monitoring, or temporary discontinuation. We agree with Dr Farmakiotis that calcineurin inhibitors, such as tacrolimus or cyclosporine, should be stopped or markedly dose-reduced if a patient with COVID-19 is treated with nirmatrelvir-ritonavir, and that close monitoring of drug levels is essential. In fact, the University of Liverpool COVID-19 drug interaction website suggests an approach similar to that outlined by Farmakiotis, namely, that if drug monitoring is available, tacrolimus should be withheld and the cyclosporine dose be reduced by 80% during the 5-day nirmatrelvir-ritonavir course, followed by frequent measurements of calcineurin inhibitor drug levels to guide dose resumption. If managing the drug interaction with nirmatrelvir-ritonavir is not feasible, then it certainly makes sense to prescribe one of the alternative agents we discussed in our review.
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