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Nirmatrelvir and Ritonavir (Monograph)

Brand name: Paxlovid
Drug class: Coronavirus (COVID-19)

Medically reviewed by Drugs.com on Feb 10, 2025. Written by ASHP.

Warning

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are cautioned that a combined regimen of ritonavir-boosted nirmatrelvir is not an approved treatment for coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in pediatric patients 12 years of age or older, but rather, is being investigated for and is currently available under an FDA emergency use authorization (EUA) for the treatment of mild to moderate COVID-19 in this population. The American Society of Health-System Pharmacists, Inc. makes no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to the information contained in the accompanying monograph, and specifically disclaims all such warranties. Readers of this information are advised that ASHP is not responsible for the continued currency of the information, for any errors or omissions, and/or for any consequences arising from the use of the information contained in the monograph in any and all practice settings. Readers are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug's actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Warning

  • Ritonavir is a strong CYP3A inhibitor and can increase exposure of certain concomitant medications, resulting in potentially severe, life-threatening, or fatal events.

  • Prior to prescribing ritonavir-boostednirmatrelvir, review all medications taken by the patient to assess potential drug-drug interactions and determine if dose adjustment, interruption, and/or additional monitoring is needed for any concomitant therapies.

  • Consider the benefit of ritonavir-boosted nirmatrelvir treatment in reducing hospitalization and death, and whether the risk of potential drug-drug interactions for an individual patient can be appropriately managed.

Introduction

Antiviral agent; nirmatrelvir is a SARS-CoV-2 main protease (Mpro) inhibitor and ritonavir is a potent inhibitor of CYP3A isoenzyme. Ritonavir decreases metabolism and increases plasma concentrations of nirmatrelvir.

Uses for Nirmatrelvir and Ritonavir

Coronavirus Disease 2019 (COVID-19)

Nirmatrelvir with low-dose ritonavir (ritonavir-boosted nirmatrelvir) is FDA-labeled for the treatment of mild-to-moderate COVID-19 in adults who are at high risk for progression to severe COVID-19, including hospitalization or death.

Ritonavir-boosted nirmatrelvir is also authorized under an emergency use authorization (EUA) for the treatment of mild to moderate COVID-19 in pediatric patients (≥12 years of age weighing ≥40 kg) who are at high risk for progression to severe COVID-19, including hospitalization or death.

Not approved for use as pre-exposure or post-exposure prophylaxis for the prevention of COVID-19.

May be prescribed for an individual patient by physicians, advanced practice registered nurses, and physician assistants that are licensed or authorized under state law to prescribe drugs; the combination therapy also may be prescribed for an individual patient by a state-licensed pharmacist under certain conditions.

The Infectious Diseases Society of America (IDSA) suggests a 5-day treatment course of ritonavir-boosted nirmatrelvir, dosed based on renal function, starting within 5 days of symptom onset over no ritonavir-boosted nirmatrelvir treatment in nonhospitalized patients with mild to moderate COVID-19 who are at high risk of progression to severe disease. Patients with mild to moderate COVID-19 who are hospitalized for reasons other than COVID-19 and who are at high risk of progression to severe disease may also receive ritonavir-boosted nirmatrelvir.

Use of ritonavir-boosted nirmatrelvir early in the disease process when viral loads are high confers maximum benefit; therefore, it is critical to make a rapid diagnosis and treat nonhospitalized patients with COVID-19 early in the disease course.

Case reports suggest that some patients who have completed a 5-day course of ritonavir-boosted nirmatrelvir and have recovered can experience viral rebound (i.e., a recurrence of symptoms or a new positive viral test after having tested negative). There is currently no evidence that additional treatment for COVID-19 is needed for COVID-19 rebound. Based on currently available data, CDC states that patient monitoring continues to be the most appropriate management for such patients.

Nirmatrelvir and Ritonavir Dosage and Administration

General

Pretreatment Screening

Dispensing and Administration Precautions

Other General Considerations

Administration

Oral Administration

Administer orally without regard to food.

Swallow tablets whole; do not chew, break, or crush.

Must administer nirmatrelvir in conjunction with low-dose ritonavir at the same time twice daily. Ritonavir is a pharmacokinetic enhancer that improves the pharmacokinetic profile of nirmatrelvir.

Paxlovid is available as a 5-day dose pack of 10 blister cards; each blister card contains a single dose (one or two 150-mg nirmatrelvir tablets and one 100-mg ritonavir tablet).

If a dose of ritonavir-boosted nirmatrelvir is missed by ≤8 hours, take the prescribed dose as soon as possible. If a dose is missed by >8 hours, administer prescribed dose at the next scheduled time; do not administer an additional dose to replace the missed dose.

Dosage

Pediatric Patients

Treatment of Mild to Moderate COVID-19 in Patients at Risk for Progression
Oral

≥12 years of age weighing ≥40 kg: FDA EUA permits use of 300 mg of nirmatrelvir (two 150-mg tablets) orally twice daily in conjunction with 100 mg of ritonavir (one 100-mg tablet) orally twice daily for 5 days. Complete full 5-day treatment course.

Dosage adjustment required in patients with moderate renal impairment. (See Renal Impairment under Dosage and Administration.)

Initiate therapy as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset even if baseline symptoms are mild.

If hospitalization occurs due to progression to severe or critical COVID-19 after initiation of ritonavir-boosted nirmatrelvir therapy, treatment course may be continued per the clinician's discretion.

Adults

Treatment of Mild to Moderate COVID-19 in Patients at Risk for Progression
Oral

300 mg of nirmatrelvir (two 150-mg tablets) orally twice daily in conjunction with 100 mg of ritonavir (one 100-mg tablet) orally twice daily for 5 days. Complete full 5-day treatment course.

Dosage adjustment required in patients with moderate renal impairment. (See Renal Impairment under Dosage and Administration.)

Initiate therapy as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset even if baseline symptoms are mild.

If hospitalization occurs due to progression to severe or critical COVID-19 after initiation of ritonavir-boosted nirmatrelvir therapy, treatment course may be continued per the clinician's discretion.

Special Populations

Hepatic Impairment

Mild or moderate hepatic impairment (Child-Pugh class A or B): No dosage adjustment of ritonavir-boosted nirmatrelvir necessary.

Severe hepatic impairment (Child-Pugh class C): Pharmacokinetic profile and safety of nirmatrelvir and ritonavir not established; ritonavir-boosted nirmatrelvir not recommended in such patients.

Renal Impairment

Moderate renal impairment (eGFR 30 to <60 mL/minute): Reduce nirmatrelvir dosage to 150 mg twice daily in conjunction with ritonavir 100 mg twice daily for 5 days. Prescribing clinicians must specify the numeric dose of nirmatrelvir and ritonavir (e.g., 150 mg nirmatrelvir with 100 mg ritonavir for patients with moderate renal impairment) on prescriptions and should counsel patients about renal dosing instructions. When dispensing ritonavir-boosted nirmatrelvir for patients with moderate renal impairment, only dispense the dose pack that contains 150 mg nirmatrelvir and 100 mg ritonavir. If this lower strength dose pack is unavailable for dispensing to patients with moderate renal impairment, the pharmacist should refer to the document entitled “Important Paxlovid EUA dispensing information for patients with moderate renal impairment”.

Mild renal impairment (eGFR 60 to <90 mL/minute): No dosage adjustment necessary.

Severe renal impairment (eGFR <30 mL/minute): Appropriate dosage not established; use not recommended in such patients.

Geriatric Patients

No specific dosage recommendations.

Cautions for Nirmatrelvir and Ritonavir

Contraindications

Warnings/Precautions

Serious Adverse Reactions Due to Drug Interactions

Nirmatrelvir must be used in conjunction with ritonavir. Failure to administer nirmatrelvir with the recommended dosage of ritonavir will result in subtherapeutic nirmatrelvir concentrations and inadequate virologic response. Consider the cautions, precautions, contraindications, and drug interactions associated with nirmatrelvir and ritonavir.

Concomitant use of ritonavir-boosted nirmatrelvir with certain drugs is contraindicated or requires particular caution. Concomitant use with some drugs may result in clinically important adverse effects, including severe, life-threatening, or fatal events, due to higher exposures of the concomitant drug or higher exposures of nirmatrelvir and/or ritonavir. Concomitant use with other drugs may result in drug interactions leading to loss of therapeutic effect of ritonavir-boosted nirmatrelvir and possible development of viral resistance.

Ritonavir is a strong CYP3A inhibitor, which may lead to greater exposure of certain concomitant medications, resulting in potentially severe, life-threatening, or fatal events. (See Boxed Warning.)

Hypersensitivity Reactions

Hypersensitivity reactions, including anaphylaxis, reported. Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome reported in patients receiving ritonavir.

Immediately discontinue treatment if signs and symptoms of a clinically significant hypersensitivity reaction or anaphylaxis develop and initiate appropriate treatment and/or supportive care.

Hepatotoxicity

Hepatotoxicity (i.e., elevations in serum aminotransferase concentrations, clinical hepatitis, jaundice) reported in patients receiving ritonavir.

Use ritonavir with caution in patients with preexisting liver disease, liver enzyme abnormalities, or hepatitis.

HIV-1 Resistance Development

Because nirmatrelvir is coadministered with ritonavir, cross-resistance to HIV protease inhibitors (HIV PIs) may occur in individuals with uncontrolled or undiagnosed HIV-1 infection.

EUA Requirements for Patient Monitoring and Mandatory FDA MedWatch Reporting

Safety and efficacy of ritonavir-boosted nirmatrelvir not established in pediatric patients; use in this population is authorized under an EUA.

Completion of FDA forms to report all medication errors and all serious adverse events potentially related to ritonavir-boosted nirmatrelvir in the EUA authorized population is mandatory. Consult the FDA fact sheet for instructions on reporting.

Specific Populations

Pregnancy

Nirmatrelvir: Data are insufficient to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Reduced fetal body weight observed in animal studies

Ritonavir: Published observational studies have not identified an increase in the risk of major birth defects when ritonavir was used in pregnant women. Published studies with ritonavir are insufficient to identify a drug-associated risk of miscarriage.

Estimated background risk of major birth defects and miscarriage in the indicated population unknown. COVID-19 in pregnancy is associated with adverse maternal and fetal outcomes, including preeclampsia, eclampsia, preterm birth, premature rupture of membranes, venous thromboembolic disease, and fetal death.

Lactation

Nirmatrelvir: Not known whether nirmatrelvir is distributed into human or animal milk or has effects on the breast-fed infant or milk production.

Ritonavir: Limited published data indicate that ritonavir is present in human milk. Not known whether ritonavir has effects on the breast-fed infant or milk production.

Consider developmental and health benefits of breast-feeding along with the mother’s clinical need for ritonavir-boosted nirmatrelvir and any potential adverse effects on the breast-fed child from the drug or from the underlying maternal condition.

Females with COVID-19 who are breast-feeding should follow clinical guidelines to avoid exposing the infant to the virus.

Females and Males of Reproductive Potential

Use of ritonavir may reduce efficacy of combined hormonal contraceptives; advise patients to use an effective alternative contraceptive method or an additional barrier method of contraception until completion of one additional menstrual cycle.

Pediatric Use

The FDA EUA permits use of ritonavir-boosted nirmatrelvir for the treatment of COVID-19 in certain pediatric patients ≥12 years of age weighing ≥40 kg. Use of ritonavir-boosted nirmatrelvir is not authorized for pediatric patients <12 years of age or those weighing <40 kg.

Safety and efficacy of ritonavir-boosted nirmatrelvir not established in pediatric patients.

Pharmacokinetics of ritonavir-boosted nirmatrelvir not evaluated in pediatric patients <18 years of age. EUA-recommended dosage of ritonavir-boosted nirmatrelvir is expected to result in plasma concentrations of the drugs in patients ≥12 years of age weighing ≥40 kg that are comparable to those observed in adults.

Geriatric Use

In an integrated data set of 1,578 patients who received nirmatrelvir and ritonavir, 10% were ≥65 years of age and 2% were ≥75 years of age. No overall differences in safety were seen between elderly and younger subjects; however, greater sensitivity of some older individuals cannot be ruled out.

Hepatic Impairment

Moderate hepatic impairment: Pharmacokinetics of nirmatrelvir not substantially altered following administration of ritonavir-boosted nirmatrelvir.

Severe hepatic impairment: Pharmacokinetic profile and safety of nirmatrelvir and ritonavir not studied.

Renal Impairment

Mild renal impairment (eGFR 60 to <90 mL/minute): Peak plasma concentrations or systemic exposure of nirmatrelvir increase by 30 or 24%, respectively, following administration of ritonavir-boosted nirmatrelvir.

Moderate renal impairment (eGFR 30 to <60 mL/minute): Peak plasma concentrations or systemic exposure of nirmatrelvir increase by 38 or 87%, respectively, following administration of ritonavir-boosted nirmatrelvir.

Severe renal impairment (eGFR <30 mL/minute): Peak plasma concentrations or systemic exposure of nirmatrelvir increase by 48 or 204%, respectively, following administration of ritonavir-boosted nirmatrelvir.

Common Adverse Effects

Most common adverse reactions (≥1%) include dysgeusia and diarrhea.

Drug Interactions

Consider drug interactions associated with both nirmatrelvir and ritonavir.

Ritonavir-boosted nirmatrelvir is a strong inhibitor of CYP3A, and an inhibitor of CYP2D6, P-gp, and OATP1B1. Co-administration of ritonavir-boosted nirmatrelvir with drugs that are primarily metabolized by CYP3A and CYP2D6 or are transported by P-gp or OATP1B1 may result in increased plasma concentrations of these drugs and increase the risk of adverse events. Co-administration of ritonavir-boosted nirmatrelvir with drugs highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life-threatening events is contraindicated.

Nirmatrelvir and ritonavir are CYP3A substrates; therefore, drugs that induce CYP3A may decrease nirmatrelvir and ritonavir plasma concentrations and reduce therapeutic effect ofritonavir-boosted nirmatrelvir.

The following drug interactions are based on studies using ritonavir-boosted nirmatrelvir.

Drugs Affecting or Metabolized by Hepatic Microsomal Enzymes

CYP3A Inducers: Potential pharmacokinetic interaction with drugs that induce CYP3A (decreased plasma concentrations of nirmatrelvir and ritonavir, which may lead to reduced virologic response).

Substrates of CYP3A

Substrates of CYP3A: Potential pharmacokinetic interaction with drugs principally metabolized by CYP3A (increased plasma concentrations of drug metabolized by CYP3A). Concomitant use of nirmatrelvir and ritonavir with drugs highly dependent on CYP3A for metabolism and for which elevated plasma concentrations are associated with serious and/or life-threatening events is contraindicated. Concomitant use of nirmatrelvir and ritonavir with other CYP3A substrates may require dosage adjustment or additional monitoring.

Nirmatrelvir and Ritonavir Pharmacokinetics

Absorption

Bioavailability

Following oral administration of ritonavir-boosted nirmatrelvir, systemic exposure of nirmatrelvir increases in a less than dose proportional manner up to 750 mg (single dose) and up to 500 mg twice daily. Following administration of ritonavir-boosted nirmatrelvir twice daily for 10 days, steady-state concentrations of nirmatrelvir are attained on day 2 with approximately 2-fold accumulation.

Following oral administration of a single 300-mg dose of nirmatrelvir with 100 mg of ritonavir in healthy individuals, peak plasma concentrations of nirmatrelvir and ritonavir are achieved in 3 and 3.98 hours, respectively.

Food

Following coadministration of a suspension formulation of nirmatrelvir and ritonavir tablets with a high fat meal, mean peak plasma concentrations increased by approximately 15% and mean AUC increased by 1.6% relative to administration in a fasted state.

Distribution

Extent

Nirmatrelvir: Not known whether nirmatrelvir is distributed into human or animal milk.

Ritonavir: Limited published data indicate that ritonavir is present in human milk.

Plasma Protein Binding

Nirmatrelvir (when given with ritonavir) or ritonavir is 69 or 98–99% bound to plasma proteins, respectively.

Elimination

Metabolism

Nirmatrelvir is a CYP3A4 substrate but metabolic clearance is minimal when coadministered with ritonavir. Ritonavir is primarily metabolized by CYP3A4 and, by a lesser extent, CYP2D6.

Elimination Route

Following oral administration of a radiolabeled dose of nirmatrelvir suspension and ritonavir, 49.6% of the nirmatrelvir dose recovered in urine and 35.3% of the dose recovered in feces.

Half-Life

Nirmatrelvir: Following a single 300-mg dose of nirmatrelvir administered in conjunction with 100 mg of ritonavir, mean elimination half-life of nirmatrelvir is 6.05 hours in healthy individuals.

Ritonavir: Following a single 300-mg dose of nirmatrelvir administered in conjunction with 100 mg of ritonavir, mean elimination half-life of ritonavir is 6.15 hours in healthy individuals.

Specific Populations

Effects of age and sex on the pharmacokinetics of ritonavir-boosted nirmatrelvir not established.

Pharmacokinetics of ritonavir-boosted nirmatrelvir not evaluated in pediatric patients.

Based on adults with similar body weight to pediatric patients weighing ≥40 kg in the EPIC-HR clinical trial, the EUA-recommended dosage of ritonavir-boosted nirmatrelvir is expected to result in plasma concentrations in pediatric patients ≥12 years of age weighing ≥40 kg that are comparable to those observed in adults.

Systemic exposure is decreased in Japanese individuals compared with individuals from Western countries; however, the difference is not clinically significant.

Stability

Storage

Oral

Tablets

Blister packs containing nirmatrelvir and ritonavir tablets: 20–25°C (excursions permitted between 15–30ºC).

Actions

Advice to Patients

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Nirmatrelvir with Ritonavir

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Kit

150 mg nirmatrelvir; 100 mg ritonavir dose pack

Each blister card contains 2 tablets:

1 tablet, nirmatrelvir 150 mg

1 tablet, ritonavir 100 mg

300 mg nirmatrelvir; 100 mg ritonavir dose pack

Each blister card contains 3 tablets:

2 tablets, nirmatrelvir 150 mg

1 tablet, ritonavir 100 mg

Paxlovid™ (each carton contains 20 tablets divided in 10 blister cards)

Pfizer

Paxlovid™ (each carton contains 30 tablets divided in 10 blister cards)

Pfizer

AHFS DI Essentials™. © Copyright 2025, Selected Revisions February 10, 2025. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

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