Time Course of the Interaction Between Oral Short-Term Ritonavir Therapy with Three Factor Xa Inhibitors and the Activity of CYP2D6, CYP2C19, and CYP3A4 in Healthy Volunteers.

Publication date: Feb 23, 2024

We investigated the effect of a 5-day low-dose ritonavir therapy, as it is used in the treatment of COVID-19 with nirmatrelvir/ritonavir, on the pharmacokinetics of three factor Xa inhibitors (FXaI). Concurrently, the time course of the activities of the cytochromes P450 (CYP) 3A4, 2C19, and 2D6 was assessed. In an open-label, fixed sequence clinical trial, the effect and duration of a 5-day oral ritonavir (100 mg twice daily) treatment on the pharmacokinetics of three oral microdosed FXaI (rivaroxaban 25 ug, apixaban 25 ug, and edoxaban 50 ug) and microdosed probe drugs (midazolam 25 ug, yohimbine 50 ug, and omeprazole 100 ug) was evaluated in eight healthy volunteers. The plasma concentrations of all drugs were quantified using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods and pharmacokinetics were analysed using non-compartmental analyses. Ritonavir increased the exposure of apixaban, edoxaban, and rivaroxaban, but to a different extent the observed area under the plasma concentration-time curve (geometric mean ratio 1. 29, 1. 46, and 1. 87, respectively). A strong CYP3A4 inhibition (geometric mean ratio > 10), a moderate CYP2C19 induction 2 days after ritonavir (0. 64), and no alteration of CYP2D6 were observed. A CYP3A4 recovery half-life of 2. 3 days was determined. This trial with three microdosed FXaI suggests that at most the rivaroxaban dose should be reduced during short-term ritonavir, and only in patients receiving high maintenance doses. Thorough time series analyses demonstrated differential effects on three different drug-metabolising enzymes over time with immediate profound inhibition of CYP3A4 and only slow recovery after discontinuation. EudraCT number: 2021-006643-39.

Concepts Keywords
100mg Cyp2d6
Cyp2c19 Cyp3a4
Daily Drugs
Pharmacokinetics Factor
Volunteers Fxai


Type Source Name
disease VO time
drug DRUGBANK Ritonavir
disease VO dose
disease MESH COVID-19
drug DRUGBANK Rivaroxaban
drug DRUGBANK Apixaban
drug DRUGBANK Edoxaban
drug DRUGBANK Midazolam
drug DRUGBANK Yohimbine
drug DRUGBANK Omeprazole

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