Paxlovid-Induced Symptomatic Bradycardia and Syncope

Abstract

Paxlovid (nirmatrelvir/ritonavir) is a game changer in the fight against COVID-19 due to its ease of administration and significant benefits of reducing progression to severe COVID-19, hospitalization, and death. Cardiac adverse events such as bradycardia and syncope are not known with this medication. We report a case of a 71-year-old patient who developed symptomatic bradycardia, syncopal episodes, and sinus pause after taking Paxlovid. Discontinuing medication and intravenous atropine helped to reverse the bradycardia and symptoms promptly. She did not require a pacemaker. We would like to report this possible association between Paxlovid and bradycardia. Until further information or studies are available, it is advised to promptly discontinue Paxlovid after any evidence of bradycardia and closely monitor for at least 40 hours in a hospital setting. The reported half-life (t 1/2) of the medication is 6.05 ± 1.79 hours and using 8 hours as a reference for the upper limit of t 1/2, around 97 % of the medication should be cleared off in about 40 hours (five half-lives).

Effectiveness and safety of azvudine in older adults with mild and moderate COVID-19: a retrospective observational study

“…A relatively high risk of drug-drug interaction has been reported with nirmatrelvir/ritonavir [ 48 ], which is worth noticing in older adults who are often receiving various medications for comorbidities. Nirmatrelvir/ritonavir is reported to be associated with TRAEs such as nausea, diarrhea, headache, running nose, and muscle ache [ 49 ], and several more severe TRAEs of nirmatrelvir/ritonavir (bradycardia and syncope) have been observed recently [ 50 ]. Few TRAEs of azvudine were previously reported [ 22 ], mainly headache, dizziness, increased aminotransferases, nausea, and increased D dimer levels [ 23 ].…”

Infection with COVID-19 Complicated by Sinus Arrest

“…Ganipisetti et al [ 10 ] reported a case of SA induced by nirmatrelvir/ritonavir administration for COVID-19 infection, with a significant correlation observed between the occurrence of SA and the medication administered. The half-life elimination of nirmatrelvir/ritonavir is approximately 6.05 ± 1.79 hours, with a metabolism rate of 94–97% after 5 half-lives [ 10 ]. The patient we report exhibited normal liver and kidney function, suggesting the absence of any metabolic disorders.…”

Paxlovid (Nirmatrelvir/Ritonavir): A new approach to Covid-19 therapy?

“…Fortunately, no serious complications occurred, and the pacemaker was removed after four days [80] . Furthermore, the potential of nirmatrelvir/ritonavir to interfere with normal sinoatrial node function has also been reported [81] .…”