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Drug Interactions between ashwaganda and nirmatrelvir / ritonavir

This report displays the potential drug interactions for the following 2 drugs:

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Interactions between your drugs

Moderate

ritonavir ashwagandha

Applies to: nirmatrelvir / ritonavir and ashwaganda

MONITOR: Concomitant use of ashwagandha with other agents that are known to induce hepatotoxicity may theoretically increase the risk of hepatotoxicity. There are case reports of adverse effects on liver functions associated with ashwagandha use. In a case report, a 20-year-old man in Japan developed liver dysfunction and hyperbilirubinemia after using ashwagandha in combination with multiple antianxiety drugs. In additional case reports, three men and two women, age range 21 to 62 years who reportedly took supplements containing 450 to 1,350 mg ashwagandha daily over the course of one week to four months when signs of liver injury, such as jaundice, pruritus, nausea, lethargy, abdominal discomfort, and hyperbilirubinemia, appeared.

MANAGEMENT: Liver function tests should be monitored, and patients should be advised to report any symptoms such as abdominal pain, jaundice, dark urine, light stools, fever, or unusual fatigue.

References (6)
  1. (2024) "Product Information. Ashwagandha (ashwagandha)." Now Foods, 1
  2. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health Office of Dietary Supplements Ashwagandha https://www.nccih.nih.gov/health/ashwagandha
  3. inagaki k, mori n, honda y, takaki k, tsuji k (2017) "A case of drug-induced liver injury with prolonged severe intrahepatic cholestasis induced by Ashwagandha" Kanzo, 58, p. 448-454
  4. Bjornsson HK, Bjornsson ES, Avula B, Khan IA, Jonasson JG (2020) "Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network" Liver Int, 40, p. 825-829
  5. Lubarska M, Halasinski P, Hryhorowicz S, et al. (2023) "Liver Dangers of Herbal Products" Int J Environ Res Public Health, 20, p. 3921
  6. Ireland PJ, Hardy T, burt ad, Donnelly MC (2021) "Drug-induced hepatocellular injury due to herbal supplement ashwagandha" J R Coll Surg Edinb, 51, p. 363-365

Drug and food interactions

Moderate

ritonavir food

Applies to: nirmatrelvir / ritonavir

ADJUST DOSING INTERVAL: Administration with food may modestly affect the bioavailability of ritonavir from the various available formulations. When the oral solution was given under nonfasting conditions, peak ritonavir concentrations decreased 23% and the extent of absorption decreased 7% relative to fasting conditions. Dilution of the oral solution (within one hour of dosing) with 240 mL of chocolate milk or a nutritional supplement (Advera or Ensure) did not significantly affect the extent and rate of ritonavir absorption. When a single 100 mg dose of the tablet was administered with a high-fat meal (907 kcal; 52% fat, 15% protein, 33% carbohydrates), approximately 20% decreases in mean peak concentration (Cmax) and systemic exposure (AUC) were observed relative to administration after fasting. Similar decreases in Cmax and AUC were reported when the tablet was administered with a moderate-fat meal. In contrast, the extent of absorption of ritonavir from the soft gelatin capsule formulation was 13% higher when administered with a meal (615 KCal; 14.5% fat, 9% protein, and 76% carbohydrate) relative to fasting.

MANAGEMENT: Ritonavir should be taken with meals to enhance gastrointestinal tolerability.

References (1)
  1. (2001) "Product Information. Norvir (ritonavir)." Abbott Pharmaceutical

Therapeutic duplication warnings

No warnings were found for your selected drugs.

Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum.

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Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

Further information

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