Emerging evidence reveals that COVID-19 antiviral therapies may pose severe cardiovascular risks, urging caution in treating vulnerable patients.
Dr. Liji Thomas, MD – News Medical
A recent review published in the journal Acta Pharmacologica Sinica discusses the cardiovascular adverse effects associated with antiviral drugs used to treat COVID-19.
Remdesivir
Remdesivir is a prodrug that converts to an analog of the nucleotide adenosine, thereby disrupting viral replication. The vasodilation activity of adenosine can induce the release of catecholamines like epinephrine, thereby increasing the risk of ventricular tachycardia, ventricular fibrillation, and atrial fibrillation.
When administered intravenously, remdesivir can trigger QT prolongation and the potentially deadly arrhythmia torsade de pointes. Thus, continuous heart monitoring is essential for COVID-19 patients being treated with remdesivir, especially those with pre-existing cardiac disease or electrolyte abnormalities.
Paxlovid
Paxlovid, which consists of nirmatrelvir and ritonavir, may cause bradycardia and sinus dysfunction. However, it remains unclear which component of Paxlovid is responsible and what mechanisms are involved in this adverse side effect.
The toxicity of Paxlovid, when combined with tacrolimus, an immunosuppressant, has been reported in several cases. Paxlovid may also increase the risk of bleeding when used in combination with ticagrelor, warfarin, or rivaroxaban.
Paxlovid may also interact with other drugs to cause skeletal muscle breakdown and myopathy.
Molnupiravir
Esterases in host plasma activate molnupiravir to its active antiviral nucleoside analog EIDD-1931. Molnupiravir can increase oxidant stress, which may cause tissue damage. However, like Paxlovid, the use of molnupiravir can reduce the risk of severe COVID-19, particularly among those with diabetes and patients 65 years of age and older.
Conclusions
The potential cardiovascular side effects of COVID-19 therapeutics must be carefully considered before prescribing these agents to high-risk patients. Despite reported observations of cardiotoxicity, additional studies are needed to differentiate the cardiovascular effects of SARS-CoV-2 infection from those of antivirals.
MEA Comment
All antiviral drugs have side-effects and some drugs in this group have the potential to cause serious side effects.
This review has looked at cardiovascular side effects in particular and the findings need to be given special consideration when prescribing an antiviral drug to anyone with existing heart disease.
Dr Charles Shepherd,
Trustee and Hon. Medical Adviser to the ME Association,
Member of the 2018-2021 NICE Guideline Committee,
Member of the 2002 Independent Working Group on ME/CFS
Further information
- The Lancet: SARS-CoV-2 Antivirals and Long Covid | 12/09/2024
- NHS Treatment Covid and eligibility criteria | 12/07/2022