4.1. Therapeutic indications

Paxlovid is indicated for the treatment of COVID‑19 in adults who do not require supplemental oxygen and who are at increased risk for progression to severe COVID‑19 (see section 5.1).

4.2. Posology and method of administration

Paxlovid is nirmatrelvir tablets co-packaged with ritonavir tablets.

Nirmatrelvir must be coadministered with ritonavir. Failure to correctly coadminister nirmatrelvir with ritonavir will result in plasma concentrations of nirmatrelvir that will be insufficient to achieve the desired therapeutic effect.

Posology

The recommended dosage is 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) all taken together orally twice daily every 12 hours for 5 days. Paxlovid should be given as soon as possible after positive results of direct SARS-CoV-2 viral testing and within 5 days of onset of symptoms even if baseline COVID-19 symptoms are mild.

A missed dose should be taken as soon as possible and within 8 hours of the scheduled time, and the normal dosing schedule should be resumed. If more than 8 hours has elapsed, the missed dose should not be taken and the treatment should resume according to the normal dosing schedule.

If a patient requires hospitalisation due to severe or critical COVID-19 after starting treatment with Paxlovid, the patient should complete the full 5-day treatment course at the discretion of his/her healthcare provider.

Special populations

Paediatric population

The safety and efficacy of Paxlovid in paediatric patients younger than 18 years of age have not yet been established.

Elderly

No dosage adjustment is currently recommended for elderly patients.

Renal impairment

No dosage adjustment is needed in patients with mild renal impairment [estimated glomerular filtration rate (eGFR) ≥ 60 to < 90 mL/min].

In patients with moderate renal impairment (eGFR ≥ 30 to < 60 mL/min) or with severe renal impairment (eGFR < 30 mL/min) including those requiring haemodialysis, the dosage of Paxlovid should be reduced as shown in Table 1. Paxlovid should be administered at approximately the same time each day for 5 days. On days patients with severe renal impairment undergo haemodialysis, the Paxlovid dose should be administered after haemodialysis (see section 5.2).

Table 1: Recommended dose and regimen for patients with renal impairment

Renal function

Days of treatment

Dose and dose frequencya

Moderate renal impairment

(eGFR ≥ 30 to < 60 mL/min)

Days 1-5

150 mg nirmatrelvir (one 150 mg tablet) with 100 mg ritonavir (one 100 mg tablet) twice daily

Severe renal impairment

(eGFR < 30 mL/min) including those requiring haemodialysisb

Day 1

300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) once

Days 2-5

150 mg nirmatrelvir (one 150 mg tablet) with 100 mg ritonavir (one 100 mg tablet) once daily

Abbreviation: eGFR=estimated glomerular filtration rate.

a. Paxlovid should be administered at approximately the same time each day for 5 days.

b. On days of hemodialysis, the Paxlovid dose should be administered after hemodialysis.

Special attention for patients with severe renal impairment

Healthcare providers should pay special attention to dosing instructions for patients with severe renal impairment and alert the patient that the daily dose pack provided may contain more nirmatrelvir and ritonavir tablets than needed for accurate dosing in these patients.

Therefore, patients with severe renal impairment should be alerted that two tablets of nirmatrelvir with one tablet of ritonavir should be taken once on day 1 followed by one tablet of nirmatrelvir with one tablet of ritonavir once daily on days 2 to 5.

Special attention for patients with moderate renal impairment

Healthcare providers should pay special attention to dosing instructions for patients with moderate renal impairment and alert the patient that the daily dose pack provided may contain more nirmatrelvir and ritonavir tablets than needed for accurate dosing in these patients.

Therefore, patients with moderate renal impairment should be alerted that only one tablet of nirmatrelvir with one tablet of ritonavir should be taken every 12 hours for 5 days.

The remaining tablets should be disposed of in accordance with local requirements (see section 6.6).

Hepatic impairment

No dosage adjustment of Paxlovid is needed for patients with either mild (Child-Pugh Class A) or moderate (Child-Pugh Class B) hepatic impairment.

No pharmacokinetic or safety data are available regarding the use of nirmatrelvir or ritonavir in subjects with severe (Child-Pugh Class C) hepatic impairment, therefore, Paxlovid is contraindicated in patients with severe hepatic impairment (see sections 4.3 and 5.2).

Concomitant therapy with ritonavir- or cobicistat-containing regimen

No dosage adjustment is needed; the dose of Paxlovid is 300 mg/100 mg twice daily for 5 days.

Patients diagnosed with human immunodeficiency virus (HIV) or hepatitis C virus (HCV) infection who are receiving ritonavir- or cobicistat-containing regimen should continue their treatment as indicated.

Method of administration

For oral use.

Paxlovid can be taken with or without food (see section 5.2). The tablets should be swallowed whole and not chewed, broken or crushed.

4.3. Contraindications

Paxlovid is contraindicated in patients:

- with a history of clinically significant hypersensitivity to the active substances (nirmatrelvir/ritonavir) or to any of the excipients listed in section 6.1.

- with severe hepatic impairment.

Paxlovid is also contraindicated with medicinal products that are highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life‑threatening reactions. Paxlovid is also contraindicated with medicinal products that are potent CYP3A inducers where significantly reduced plasma nirmatrelvir/ritonavir concentrations may be associated with the potential for loss of virologic response and possible resistance. Medicinal products listed in Table 2 and Table 3 (section 4.5) are a guide and not considered a comprehensive list of all possible medicinal products that may be contraindicated with Paxlovid.

Table 2: Medicinal products that are contraindicated for concomitant use with nirmatrelvir/ritonavir

Medicinal product class

Medicinal products within class

Clinical comments

Interactions that result in increased concentrations of concomitant medicinal product as Paxlovid inhibits their CYP3A4 metabolic pathway

Alpha1‑adrenoreceptor antagonist

alfuzosin

Increased plasma concentrations of alfuzosin may lead to severe hypotension.

Antianginal

ranolazine

Potentially increased plasma concentrations of ranolazine may result in serious and/or life-threatening reactions.

Anticancer agents

neratinib

venetoclax

Increased plasma concentrations of neratinib which may increase the potential for serious and/or life‑threatening reactions including hepatotoxicity.

Increased plasma concentrations of venetoclax which may increase the risk of tumour lysis syndrome at the dose initiation and during the dose-titration phase.

Antiarrhythmics

amiodarone,

bepridil,

dronedarone,

encainide,

flecainide,

propafenone,

quinidine

Potentially increased plasma concentrations of amiodarone, bepridil, dronedarone, encainide, flecainide, propafenone and quinidine may result in arrhythmias or other serious adverse effects.

Antibiotic

fusidic acid

Increased plasma concentrations of fusidic acid and ritonavir.

Anti-gout

colchicine

Increased plasma concentrations of colchicine may result in serious and/or life-threatening reactions in patients with renal and/or hepatic impairment.

Antihistamines

astemizole,

terfenadine

Increased plasma concentrations of astemizole and terfenadine may result in serious arrhythmias from these agents.

Antipsychotics/neuroleptics

lurasidone,

pimozide

quetiapine

Increased plasma concentrations of lurasidone and pimozide result in serious and/or life‑threatening reactions.

Increased plasma concentrations of quetiapine may lead to coma.

Benign prostatic hyperplasia agents

silodosin

Increased plasma concentrations of benign prostatic hyperplasia agent.

Cardiovascular agents

eplerenone,

ivabradine

Increased plasma concentrations of cardiovascular agents.

Ergot derivatives

dihydroergotamine,

ergonovine,

ergotamine,

methylergonovine

Increased plasma concentrations of ergot derivatives leading to acute ergot toxicity, including vasospasm and ischaemia.

GI motility agent

cisapride

Increased plasma concentrations of cisapride, thereby increasing the risk of serious arrhythmias from this agent.

Immunosuppressants

voclosporin

Increased plasma concentrations of immunosuppressant.

Lipid-modifying agents

HMG-CoA reductase inhibitors

Microsomal triglyceride transfer protein (MTTP) inhibitor

lovastatin,

simvastatin

lomitapide

Increased plasma concentrations of lovastatin and simvastatin resulting in increased risk of myopathy, including rhabdomyolysis.

Increased plasma concentrations of lomitapide.

Migraine medications

eletriptan,

ubrogepant

Increased plasma concentrations of migraine medications.

Mineralocorticoid receptor antagonists

finerenone

Increased plasma concentrations of mineralocorticoid receptor antagonist.

Opioid antagonists

naloxegol

Increased plasma concentrations of opioid antagonist.

PDE5 inhibitors

avanafil,

vardenafil

sildenafil (Revatio®) when used for pulmonary arterial hypertension (PAH)

Increased plasma concentrations of avanafil and vardenafil.

Increased plasma concentrations of sildenafil can potentially result in visual abnormalities, hypotension, prolonged erection and syncope.

Sedative/hypnotics

triazolam,

oral midazolama

Increased plasma concentrations of triazolam and oral midazolam can increase risk of extreme sedation and respiratory depression.

Serotonin receptor 1A agonists/serotonin receptor 2A antagonists

flibanserin

Increased plasma concentrations of serotonin receptor 1A agonist/serotonin receptor 2A antagonist.

Vasopressin receptor antagonists

tolvaptan

Increased plasma concentrations of vasopressin receptor antagonist.

Interactions that result in decreased concentrations of nirmatrelvir/ritonavir as the concomitant medicinal products induce Paxlovid's CYP3A4 metabolic pathway

Anticonvulsants

carbamazepinea,

phenobarbital,

phenytoin,

primidone

Decreased plasma concentrations of nirmatrelvir/ritonavir may lead to loss of virologic response and possible resistance.

Anticancer agents

enzalutamide

Decreased plasma concentrations of nirmatrelvir/ritonavir may lead to loss of virologic response and possible resistance.

Antimycobacterials

rifampicin, rifapentine

Potentially decreased plasma concentrations of nirmatrelvir/ritonavir may lead to loss of virologic response and possible resistance.

Cystic fibrosis transmembrane conductance regulator potentiators

lumacaftor/ivacaftor

Potentially decreased plasma concentrations of nirmatrelvir/ritonavir may lead to loss of virologic response and possible resistance.

Herbal products

St. John's Wort (Hypericum perforatum)

Potentially decreased plasma concentrations of nirmatrelvir/ritonavir may lead to loss of virologic response and possible resistance.

a. See section 5.2, Interaction studies conducted with nirmatrelvir/ritonavir.

4.4. Special warnings and precautions for use

Risk of serious adverse reactions due to interactions with other medicinal products

Initiation of Paxlovid, a CYP3A inhibitor, in patients receiving medicinal products metabolised by CYP3A or initiation of medicinal products metabolised by CYP3A in patients already receiving Paxlovid, may increase plasma concentrations of medicinal products metabolised by CYP3A.

Initiation of medicinal products that inhibit or induce CYP3A may increase or decrease concentrations of Paxlovid, respectively.

These interactions may lead to:

• Clinically significant adverse reactions, potentially leading to severe, life-threatening or fatal events from greater exposures of concomitant medicinal products.

• Clinically significant adverse reactions from greater exposures of Paxlovid.

• Loss of therapeutic effect of Paxlovid and possible development of viral resistance.

Severe, life-threatening, and fatal adverse reactions due to drug interactions have been reported in patients treated with Paxlovid.

See Table 1 for medicinal products that are contraindicated for concomitant use with nirmatrelvir/ritonavir (see section 4.3) and Table 2 for potentially significant interactions with other medicinal products (see section 4.5). Potential for interactions should be considered with other medicinal products prior to and during Paxlovid therapy; concomitant medicinal products should be reviewed during Paxlovid therapy and the patient should be monitored for the adverse reactions associated with the concomitant medicinal products. The risk of interactions with concomitant medications during the 5-day treatment period for Paxlovid should be weighed against the risk of not receiving Paxlovid.

Coadministration of Paxlovid with calcineurin inhibitors and mTOR inhibitors

Consultation of a multidisciplinary group (e.g., involving physicians, specialists in immunosuppressive therapy, and/or specialists in clinical pharmacology) is required to handle the complexity of this coadministration by closely and regularly monitoring immunosuppressant blood concentrations and adjusting the dose of the immunosuppressant in accordance with the latest guidelines (see section 4.5).

Hypersensitivity reactions

Anaphylaxis, hypersensitivity reactions, and serious skin reactions (including toxic epidermal necrolysis and Stevens-Johnson syndrome) have been reported with Paxlovid (see section 4.8). If signs and symptoms of a clinically significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue Paxlovid and initiate appropriate medications and/or supportive care.

Hepatotoxicity

Hepatic transaminase elevations, clinical hepatitis and jaundice have occurred in patients receiving ritonavir. Therefore, caution should be exercised when administering Paxlovid to patients with pre-existing liver diseases, liver enzyme abnormalities or hepatitis.

HIV resistance

As nirmatrelvir is coadministered with ritonavir, there may be a risk of HIV-1 developing resistance to HIV protease inhibitors in individuals with uncontrolled or undiagnosed HIV-1 infection.

Excipients

Lactose

Nirmatrelvir tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Sodium

Nirmatrelvir and ritonavir tablets each contain less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium‑free'.

4.5. Interaction with other medicinal products and other forms of interaction

Paxlovid (nirmatrelvir/ritonavir) is a strong inhibitor of CYP3A and an inhibitor of CYP2D6, P-gp and OATP1B1. Coadministration of Paxlovid with medicinal products that are primarily metabolised by CYP3A and CYP2D6 or are transported by P-gp or OATP1B1 may result in increased plasma concentrations of such medicinal products and increase the risk of adverse reactions.

Medicinal products that are extensively metabolised by CYP3A and have high first pass metabolism appear to be the most susceptible to large increases in exposure when coadministered with nirmatrelvir/ritonavir. Thus, coadministration of Paxlovid with medicinal products highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life‑threatening events is contraindicated (see Table 1, section 4.3).

In vitro study results showed nirmatrelvir may be inducer of CYP3A4, CYP2B6, CYP2C8, and CYP2C9. The clinical relevance is unknown. Based on in vitro data, nirmatrelvir has a low potential to inhibit BCRP, MATE2K, OAT1, OAT3, OATP1B3 and OCT2. There is a potential for nirmatrelvir to inhibit MDR1, MATE1, OCT1 and OATP1B1 at clinically relevant concentrations.

Ritonavir has a high affinity for several cytochrome P450 (CYP) isoforms and may inhibit oxidation with the following ranked order: CYP3A4 > CYP2D6. Ritonavir also has a high affinity for P‑glycoprotein (P-gp) and may inhibit this transporter. Ritonavir may induce glucuronidation and oxidation by CYP1A2, CYP2C8, CYP2C9 and CYP2C19 thereby increasing the biotransformation of some medicinal products metabolised by these pathways and may result in decreased systemic exposure to such medicinal products, which could decrease or shorten their therapeutic effect.

Coadministration of other CYP3A4 substrates that may lead to potentially significant interaction should be considered only if the benefits outweigh the risks (see Table 2).

Nirmatrelvir/ritonavir is a CYP3A substrate; therefore, medicinal products that induce CYP3A may decrease plasma concentrations of nirmatrelvir and ritonavir and reduce Paxlovid therapeutic effect.

Medicinal products listed in Table 2 (section 4.3) and Table 3 are a guide and not considered a comprehensive list of all possible medicinal products that may interact with nirmatrelvir/ritonavir. The healthcare provider should consult appropriate references for comprehensive information.

Table 3: Interaction with other medicinal products and other forms of interaction

Medicinal product class

Medicinal product within class

(AUC change, Cmax Change)

Clinical comments

Alpha1‑adrenoreceptor antagonist

↑alfuzosin

↑tamsulosin

Increased plasma concentrations of alfuzosin may lead to severe hypotension and is therefore contraindicated (see section 4.3).

Avoid concomitant use with Paxlovid.

Amphetamine derivatives

↑methylphenidate, ↑dexamfetamine

Ritonavir dosed as an antiretroviral agent is likely to inhibit CYP2D6 and as a result is expected to increase concentrations of amphetamine and its derivatives. Careful monitoring of adverse effects is recommended when these medicines are coadministered with Paxlovid.

Analgesics

↑buprenorphine (57%, 77%),

↑norbuprenorphine (33%, 108%)

↑fentanyl

↑hydrocodone

↑oxycodone

↑meperidine

↓methadone (36%, 38%)

↓morphine

The increases of plasma levels of buprenorphine and its active metabolite did not lead to clinically significant pharmacodynamic changes in a population of opioid tolerant patients. Adjustment to the dose of buprenorphine may therefore not be necessary when the two are dosed together.

Ritonavir dosed as a pharmacokinetic enhancer inhibits CYP3A4 and as a result is expected to increase the plasma concentrations of these medicines. Careful monitoring of therapeutic and adverse effects (including respiratory depression) is recommended when fentanyl, hydrocodone, oxycodone, or meperidine is concomitantly administered with Paxlovid. If concomitant use with Paxlovid is necessary, consider a dosage reduction of the narcotic analgesic and monitor patients closely at frequent intervals. Refer to the individual SmPC for more information.

Increased methadone dose may be necessary when coadministered with ritonavir dosed as a pharmacokinetic enhancer due to induction of glucuronidation. Dose adjustment should be considered based on the patient's clinical response to methadone therapy.

Morphine levels may be decreased due to induction of glucuronidation by coadministered ritonavir dosed as a pharmacokinetic enhancer.

Antianginal

↑ranolazine

Due to CYP3A inhibition by ritonavir, concentrations of ranolazine are expected to increase. The concomitant administration with ranolazine is contraindicated (see section 4.3).

Antiarrhythmics

↑amiodarone, ↑dronedarone, ↑flecainide, ↑propafenone, ↑quinidine

↑digoxin

↑disopyramide

Ritonavir coadministration is likely to result in increased plasma concentrations of amiodarone, dronedarone, flecainide, propafenone and quinidine and is therefore contraindicated (see section 4.3).

This interaction may be due to modification of P-gp mediated digoxin efflux by ritonavir dosed as a pharmacokinetic enhancer.

Caution is warranted and therapeutic concentration monitoring is recommended for antiarrhythmic if available.

Antiasthmatic

↓theophylline (43%, 32%)

An increased dose of theophylline may be required when coadministered with ritonavir, due to induction of CYP1A2.

Anticancer agents

enzalutamide

↑afatinib

↑abemaciclib

↑apalutamide

↑ceritinib

↑dasatinib, ↑nilotinib, ↑vincristine, ↑vinblastine

↑encorafenib

↑fostamatinib

↑ibrutinib

↑neratinib

↑venetoclax

Coadministration contraindicated due to potential loss of virologic response and possible resistance (see section 4.3).

Serum concentrations may be increased due to Breast Cancer Resistance Protein (BCRP) and acute P-gp inhibition by ritonavir. The extent of increase in AUC and Cmax depends on the timing of ritonavir administration. Caution should be exercised in administering afatinib with Paxlovid (refer to the afatinib SmPC). Monitor for ADRs related to afatinib.

Serum concentrations may be increased due to CYP3A4 inhibition by ritonavir.

Coadministration of abemaciclib and Paxlovid should be avoided. If this coadministration is judged unavoidable, refer to the abemaciclib SmPC for dose adjustment recommendations. Monitor for ADRs related to abemaciclib.

Apalutamide is a moderate to strong CYP3A4 inducer and this may lead to a decreased exposure of nirmatrelvir/ritonavir and potential loss of virologic response. In addition, serum concentrations of apalutamide may be increased when coadministered with ritonavir resulting in the potential for serious adverse events including seizure. Concomitant use of Paxlovid with apalutamide is not recommended.

Serum concentrations of ceritinib may be increased due to CYP3A and P-gp inhibition by ritonavir. Caution should be exercised in administering ceritinib with Paxlovid. Refer to the ceritinib SmPC for dose adjustment recommendations. Monitor for ADRs related to ceritinib.

Serum concentrations may be increased when coadministered with ritonavir resulting in the potential for increased incidence of adverse events.

Serum concentrations of encorafenib may be increased when coadministered with ritonavir which may increase the risk of toxicity, including the risk of serious adverse events such as QT interval prolongation. Coadministration of encorafenib and ritonavir should be avoided. If the benefit is considered to outweigh the risk and ritonavir must be used, patients should be carefully monitored for safety.

Coadministration of fostamatinib with ritonavir may increase fostamatinib metabolite R406 exposure resulting in dose-related adverse events such as hepatotoxicity, neutropenia, hypertension or diarrhoea. Refer to the fostamatinib SmPC for dose reduction recommendations if such events occur.

Serum concentrations of ibrutinib may be increased due to CYP3A inhibition by ritonavir, resulting in increased risk for toxicity including risk of tumour lysis syndrome. Coadministration of ibrutinib and ritonavir should be avoided. If the benefit is considered to outweigh the risk and ritonavir must be used, reduce the ibrutinib dose to 140 mg and monitor patient closely for toxicity.

Serum concentrations may be increased due to CYP3A4 inhibition by ritonavir.

Concomitant use of neratinib with Paxlovid is contraindicated due to serious and/or life-threatening potential reactions including hepatotoxicity (see section 4.3).

Serum concentrations may be increased due to CYP3A inhibition by ritonavir, resulting in increased risk of tumour lysis syndrome at the dose initiation and during the ramp-up phase (see section 4.3 and refer to the venetoclax SmPC). For patients who have completed the ramp-up phase and are on a steady daily dose of venetoclax, reduce the venetoclax dose by at least 75% when used with strong CYP3A inhibitors (refer to the venetoclax SmPC for dosing instructions).

Anticoagulants

↑apixaban

↑dabigatrana (194%, 233%)

↑rivaroxaban (153%, 53%)

↑vorapaxar

warfarin,

↑↓S-warfarin (9%, 9%),

↓↔R-warfarin (33%)

Combined P-gp and strong CYP3A4 inhibitors increase blood levels of apixaban and increase the risk of bleeding. Dosing recommendations for coadministration of apixaban with Paxlovid depend on the apixaban dose. Refer to the apixaban SmPC for more information.

Increased bleeding risk with dabigatran. Depending on dabigatran indication and renal function, reduce dose of dabigatran or avoid concomitant use. Refer to the dabigatran SmPC for further information.

Inhibition of CYP3A and P-gp lead to increased plasma levels and pharmacodynamic effects of rivaroxaban which may lead to an increased bleeding risk. Therefore, the use of ritonavir is not recommended in patients receiving rivaroxaban.

Serum concentrations may be increased due to CYP3A inhibition by ritonavir. The coadministration of vorapaxar with Paxlovid is not recommended (refer to the vorapaxar SmPC).

Induction of CYP1A2 and CYP2C9 lead to decreased levels of R-warfarin while little pharmacokinetic effect is noted on S‑warfarin when coadministered with ritonavir. Decreased R-warfarin levels may lead to reduced anticoagulation, therefore it is recommended that anticoagulation parameters are monitored when warfarin is coadministered with ritonavir.

Anticonvulsants

carbamazepinea

phenobarbital, phenytoin, primidone

↓divalproex, ↓lamotrigine

Carbamazepine is strong CYP3A4 inducer, and this may lead to a decreased exposure of nirmatrelvir and ritonavir and potential loss of virologic response. Concomitant use of carbamazepine with Paxlovid is contraindicated (see section 4.3).

Coadministration contraindicated due to potential loss of virologic response and possible resistance (see section 4.3).

Ritonavir dosed as a pharmacokinetic enhancer induces oxidation by CYP2C9 and glucuronidation and as a result is expected to decrease the plasma concentrations of anticonvulsants. Careful monitoring of serum levels or therapeutic effects is recommended when these medicines are coadministered with ritonavir.

Antidepressants

↑amitriptyline, ↑fluoxetine, ↑imipramine, ↑nortriptyline, ↑paroxetine, ↑sertraline

↑desipramine (145%, 22%)

Ritonavir dosed as an antiretroviral agent is likely to inhibit CYP2D6 and as a result is expected to increase concentrations of imipramine, amitriptyline, nortriptyline, fluoxetine, paroxetine or sertraline.

Careful monitoring of therapeutic and adverse effects is recommended when these medicines are concomitantly administered with antiretroviral doses of ritonavir.

The AUC and Cmax of the 2-hydroxy metabolite were decreased 15% and 67%, respectively. Dosage reduction of desipramine is recommended when coadministered with ritonavir.

Antifungals

↑ketoconazole (3.4-fold, 55%)

↑itraconazolea

↓voriconazole (39%, 24%)

Ritonavir inhibits CYP3A-mediated metabolism of ketoconazole. Due to an increased incidence of gastrointestinal and hepatic adverse reactions, a dose reduction of ketoconazole should be considered when coadministered with ritonavir.

Ritonavir dosed as a pharmacokinetic enhancer inhibits CYP3A4 and as a result is expected to increase the plasma concentrations of itraconazole. Careful monitoring of therapeutic and adverse effects is recommended when itraconazole is coadministered with ritonavir.

Coadministration of voriconazole and ritonavir dosed as a pharmacokinetic enhancer should be avoided, unless an assessment of the benefit/risk to the patient justifies the use of voriconazole.

Anti-gout

↑colchicine

Concentrations of colchicine are expected to increase when coadministered with ritonavir. Life-threatening and fatal drug interactions have been reported in patients treated with colchicine and ritonavir (CYP3A4 and P-gp inhibition).

Concomitant use of colchicine with Paxlovid is contraindicated (see section 4.3).

Antihistamines

↑fexofenadine

↑loratadine

Ritonavir may modify P-gp mediated fexofenadine efflux when dosed as a pharmacokinetic enhancer resulting in increased concentrations of fexofenadine.

Ritonavir dosed as a pharmacokinetic enhancer inhibits CYP3A and as a result is expected to increase the plasma concentrations of loratadine. Careful monitoring of therapeutic and adverse effects is recommended when loratadine is coadministered with ritonavir.

Anti-HIV protease inhibitors

↑atazanavir (86%, 11-fold)

↑darunavir (14-fold)

Ritonavir increases the serum levels of atazanavir as a result of CYP3A4 inhibition. For further information, physicians should refer to the SmPC for atazanavir.

Ritonavir increases the serum levels of darunavir as a result of CYP3A inhibition. Darunavir must be given with ritonavir to ensure its therapeutic effect. For further information, refer to the SmPC for darunavir.

Anti-HIV

↑efavirenz (21%)

↑maraviroc (161%, 28%)

↓zidovudine (25%, ND)

A higher frequency of adverse reactions (e.g., dizziness, nausea, paraesthesia) and laboratory abnormalities (elevated liver enzymes) have been observed when efavirenz is coadministered with ritonavir.

Ritonavir increases the serum levels of maraviroc as a result of CYP3A inhibition. Maraviroc may be given with ritonavir to increase the maraviroc exposure. For further information, refer to the SmPC for maraviroc.

Ritonavir may induce the glucuronidation of zidovudine, resulting in slightly decreased levels of zidovudine. Dose alterations should not be necessary.

Anti-infectives

↓atovaquone

↑clarithromycin (77%, 31%)

↓14-OH clarithromycin metabolite (100%, 99%)

delamanid

↑erythromycin

↑fusidic acid

sulfamethoxazole/trimethoprim

Ritonavir dosed as a pharmacokinetic enhancer induces glucuronidation and as a result is expected to decrease the plasma concentrations of atovaquone. Careful monitoring of serum levels or therapeutic effects is recommended when atovaquone is coadministered with ritonavir.

Due to the large therapeutic window of clarithromycin no dose reduction should be necessary in patients with normal renal function. Clarithromycin doses greater than 1 g per day should not be coadministered with ritonavir dosed as a pharmacokinetic enhancer. For patients with renal impairment, a clarithromycin dose reduction should be considered: for patients with creatinine clearance of 30 to 60 ml/min the dose should be reduced by 50%, for patients with creatinine clearance less than 30 ml/min the dose should be reduced by 75%.

No interaction study is available with ritonavir only. In a healthy volunteer drug interaction study of delamanid 100 mg twice daily and lopinavir/ritonavir 400/100 mg twice daily for 14 days, the exposure of the delamanid metabolite DM‑6705 was 30% increased. Due to the risk of QTc prolongation associated with DM-6705, if coadministration of delamanid with ritonavir is considered necessary, very frequent ECG monitoring throughout the full delamanid treatment period is recommended (see section 4.4 and refer to the delamanid SmPC).

Ritonavir dosed as a pharmacokinetic enhancer inhibits CYP3A4 and as a result is expected to increase the plasma concentrations of erythromycin. Careful monitoring of therapeutic and adverse effects is recommended when erythromycin is coadministered with ritonavir.

Ritonavir coadministration is likely to result in increased plasma concentrations of both fusidic acid and ritonavir and is therefore contraindicated (see section 4.3).

Dose alteration of sulfamethoxazole/trimethoprim during concomitant ritonavir therapy should not be necessary.

Antimycobacterial

↑bedaquiline

↑rifabutin (4-fold, 2.5-fold)

↑25-O-desacetyl rifabutin metabolite (38-fold, 16-fold)

rifampicin, rifapentine

No interaction study is available with ritonavir only. Due to the risk of bedaquiline related adverse events, coadministration should be avoided. If the benefit outweighs the risk, coadministration of bedaquiline with ritonavir must be done with caution. More frequent electrocardiogram monitoring and monitoring of transaminases is recommended (refer to the bedaquiline SmPC).

Due to the large increase in rifabutin AUC, reduction of the rifabutin dose to 150 mg 3 times per week may be indicated when coadministered with ritonavir as a pharmacokinetic enhancer.

Rifampicin and rifapentine are strong CYP3A4 inducers, and this may lead to a decreased exposure of nirmatrelvir/ritonavir and potential loss of virologic response. Concomitant use of rifampicin and rifapentine with Paxlovid is contraindicated (see section 4.3).

Antiparasitic agent

↓albendazole

Significant decreases in plasma concentrations of albendazole and its active metabolite may occur due to induction by ritonavir, with a risk of decreased albendazole efficacy. Clinical monitoring of therapeutic response and possible adjustment of albendazole dosage during treatment with Paxlovid and following discontinuation is recommended.

Antipsychotics

↑lurasidone, ↑pimozide

↑quetiapine

↑clozapine

↑haloperidol, ↑risperidone, ↑thioridazine

Due to CYP3A inhibition by ritonavir, concentrations of lurasidone and pimozide are expected to increase. The concomitant administration with lurasidone and pimozide is contraindicated (see section 4.3).

Due to CYP3A inhibition by ritonavir, concentrations of quetiapine are expected to increase. Concomitant administration of Paxlovid and quetiapine is contraindicated as it may increase quetiapine-related toxicity (see section 4.3).

If coadministration is necessary, consider reducing the clozapine dose and monitor for adverse reactions.

Ritonavir is likely to inhibit CYP2D6 and as a result is expected to increase concentrations of haloperidol, risperidone and thioridazine. Careful monitoring of therapeutic and adverse effects is recommended when these medicines are concomitantly administered with antiretroviral doses of ritonavir.

Benign prostatic hyperplasia agents

↑silodosin

Coadministration contraindicated due to potential for postural hypotension (see section 4.3).

Calcium channel antagonist

↑amlodipine, ↑diltiazem, ↑nifedipine, ↑verapamil

Ritonavir dosed as a pharmacokinetic enhancer or as an antiretroviral agent inhibits CYP3A4 and as a result is expected to increase the plasma concentrations of calcium channel antagonists. Careful monitoring of therapeutic and adverse effects is recommended when these medicines are concomitantly administered with ritonavir.

Cardiovascular agents

↑eplerenone

↑ivabradine

↑aliskiren, ↑ticagrelor, ↑vorapaxar

↓clopidogrel

↑cilostazol

↑mavacamten

Coadministration with eplerenone is contraindicated due to potential for hyperkalaemia (see section 4.3).

Coadministration with ivabradine is contraindicated due to potential for bradycardia or conduction disturbances (see section 4.3).

Avoid concomitant use with Paxlovid.

Coadministration is likely to result in decreased plasma concentrations of the active metabolite of clopidogrel.

Dosage adjustment of cilostazol is recommended. Refer to the cilostazol SmPC for more information.

Coadministration with mavacamten may increase mavacamten plasma concentration and increase the risk of heart failure. Discontinue mavacamten for the duration of Paxlovid treatment. Resumption of mavacamten within 5 days of completing Paxlovid may result in higher exposure of mavacamten. Refer to the mavacamten SmPC for more information.

Corticosteroids primarily metabolized by CYP3A

↑betamethasone, ↑budesonide, ↑ciclesonide, ↑fluticasone, ↑methylprednisolone, ↑mometasone, ↑triamcinolone

↑dexamethasone

Coadministration with corticosteroids (all routes of administration) of which exposures are significantly increased by strong CYP3A inhibitors can increase the risk for Cushing's syndrome and adrenal suppression. However, the risk of Cushing's syndrome and adrenal suppression associated with short-term use of a strong CYP3A4 inhibitor is low.

Alternative corticosteroids including beclomethasone and prednisone should be considered.

Ritonavir dosed as a pharmacokinetic enhancer or as an antiretroviral agent inhibits CYP3A and as a result is expected to increase the plasma concentrations of dexamethasone. Careful monitoring of therapeutic and adverse effects is recommended when dexamethasone is concomitantly administered with ritonavir.

Corticosteroids

↑prednisolone (28%, 9%)

Careful monitoring of therapeutic and adverse effects is recommended when prednisolone is concomitantly administered with ritonavir. The AUC of the metabolite prednisolone increased by 37 and 28% after 4 and 14 days ritonavir, respectively.

Cystic fibrosis transmembrane conductance regulator potentiators

lumacaftor/ivacaftor

↑ivacaftor,

↑elexacaftor/ tezacaftor/ivacaftor, ↑tezacaftor/ivacaftor

Coadministration contraindicated due to potential loss of virologic response and possible resistance (see section 4.3).

Reduce dosage when coadministered with Paxlovid. Refer to the individual product SmPC for more information.

Dipeptidyl peptidase 4 (DPP4) inhibitors

↑saxagliptin

Dosage adjustment of saxagliptin is recommended. Refer to the saxagliptin SmPC for more information.

Endothelin antagonists

↑bosentan

Coadministration of bosentan and ritonavir may increase steady-state bosentan Cmax and AUC.

Ergot derivatives

↑dihydroergotamine, ↑ergonovine, ↑ergotamine, ↑methylergonovine

Ritonavir coadministration is likely to result in increased plasma concentrations of ergot derivatives and is therefore contraindicated (see section 4.3)

HCV direct acting antiviral

↑glecaprevir/pibrentasvir

Serum concentrations may be increased due to P-gp, BCRP and OATP1B inhibition by ritonavir. Concomitant administration of glecaprevir/pibrentasvir and Paxlovid is to be avoided due to an increased risk of ALT elevations associated with increased glecaprevir exposure.

Herbal products

St. John's Wort (Hypericum perforatum)

Coadministration contraindicated due to potential loss of virologic response and possible resistance (see section 4.3).

HMG-CoA reductase inhibitors

↑lovastatin, ↑simvastatin

↑atorvastatin, ↑rosuvastatina

↑fluvastatin, ↑pravastatin,

Since increased concentrations of lovastatin and simvastatin may predispose patients to myopathies, including rhabdomyolysis, the combination of these medicinal products with ritonavir is contraindicated (see section 4.3).

Discontinue use of lovastatin and simvastatin at least 12 hours prior to initiation of Paxlovid, during the 5 days of Paxlovid treatment and for 5 days after completing Paxlovid.

Consider temporary discontinuation of atorvastatin and rosuvastatin during treatment with Paxlovid. Atorvastatin and rosuvastatin do not need to be held prior to or after completing Paxlovid

The metabolism of pravastatin and fluvastatin is not dependent on CYP3A, and interactions are not expected with ritonavir. If treatment with an HMG-CoA reductase inhibitor is indicated, pravastatin or fluvastatin is recommended.

Hormonal contraceptive

↓ethinylestradiol (40%, 32%)

Due to reductions in ethinylestradiol concentrations, barrier or other non‑hormonal methods of contraception should be considered during the 5 days of Paxlovid treatment and until one menstrual cycle after stopping Paxlovid. Ritonavir is likely to change the uterine bleeding profile and reduce the effectiveness of estradiol-containing contraceptives.

Immunosupressants

↑voclosporin

Calcineurin inhibitors: ↑cyclosporine, ↑tacrolimus

mTOR inhibitors: ↑everolimus, ↑sirolimus

Coadministration contraindicated due to potential for acute and/or chronic nephrotoxicity (see section 4.3).

Avoid concomitant use of calcineurin inhibitors and mTOR inhibitors during treatment with Paxlovid.

Dose adjustment of the immunosuppressant and close and regular monitoring for immunosuppressant concentrations and immunosuppressant-associated adverse reactions is are recommended during and after treatment with Paxlovid. Refer to the individual immunosuppressant SmPC and latest guidelines for further information and obtain expert consultation of a multidisciplinary group (see section 4.4).

Janus kinase (JAK) inhibitors

↑tofacitinib

↑upadacitinib

Dosage adjustment of tofacitinib is recommended. Refer to the tofacitinib SmPC for more information.

Dosing recommendations for coadministration of upadacitinib with Paxlovid depends on the upadacitinib indication. Refer to the upadacitinib SmPC for more information.

Long-acting beta‑adrenoceptor agonists

↑salmeterol

Ritonavir inhibits CYP3A4 and as a result a pronounced increase in the plasma concentrations of salmeterol is expected. Therefore, avoid concomitant use with Paxlovid.

Microsomal triglyceride transfer protein (MTTP) inhibitors

↑lomitapide

CYP3A4 inhibitors increase the exposure of lomitapide, with strong inhibitors increasing exposure approximately 27‑fold. Due to CYP3A inhibition by ritonavir, concentrations of lomitapide are expected to increase. Concomitant use of Paxlovid with lomitapide is contraindicated due to potential for hepatotoxicity and gastrointestinal adverse reactions (refer to the lomitapide SmPC) (see section 4.3).

Migraine medications

↑eletriptan

↑ubrogepant

↑rimegepant

Coadministration of eletriptan within at least 72 hours of Paxlovid is contraindicated due to potential for serious adverse reactions including cardiovascular and cerebrovascular events (see section 4.3).

Coadministration of ubrogepant with Paxlovid is contraindicated due to potential for serious adverse reactions (see section 4.3).

Avoid concomitant use with Paxlovid.

Mineralocorticoid receptor antagonists

↑finerenone

Coadministration contraindicated due to potential for serious adverse reactions including hyperkalaemia, hypotension, and hyponatremia (see section 4.3).

Muscarinic receptor antagonists

↑darifenacin

The darifenacin daily dose should not exceed 7.5 mg when coadministered with Paxlovid. Refer to the darifenacin SmPC for more information.

Neuropsychiatric agents

↑suvorexant

↑aripiprazole, ↑brexpiprazole, ↑cariprazine, ↑iloperidone, ↑lumateperone, ↑pimavanserin

Avoid concomitant use of suvorexant with Paxlovid.

Dosage adjustment of aripiprazole, brexpiprazole, cariprazine, iloperidone, lumateperone, and pimavanserin is recommended. Refer to the individual SmPC for more information.

Opioid antagonists

↑naloxegol

Coadministration contraindicated due to the potential for opioid withdrawal symptoms (see section 4.3).

PDE5 inhibitors (Erectile dysfunction agents)

↑avanafil (13-fold, 2.4-fold)

↑sildenafil (11-fold, 4-fold), ↑tadalafil (124%, ↔)

↑vardenafil (49-fold, 13-fold)

Concomitant use of avanafil with Paxlovid is contraindicated (see section 4.3) because a safe and effective avanafil dosage regimen has not been established.

Dosage adjustment is recommended for use of sildenafil or tadalafil with Paxlovid. Concomitant use of sildenafil or tadalafil for the treatment of erectile dysfunction with ritonavir dosed as an antiretroviral agent or as a pharmacokinetic enhancer should be made with caution and and with increased monitoring for adverse reactions. Sildenafil doses should not exceed 25 mg in 48 hours and tadalafil doses should be reduced to no more than 10 mg every 72 hours. Refer to individual product SmPC for more information.

Concomitant use of vardenafil with Paxlovid is contraindicated (see section 4.3).

PDE5 inhibitors (Pulmonary hypertension agents)

↑sildenafil (Revatio®)

↑tadalafil (Adcirca®)

Coadministration of sildenafil with Paxlovid is contraindicated due to the potential for sildenafil associated adverse events, including visual abnormalities, hypotension, prolonged erection, and syncope (see section 4.3).

Avoid concomitant use of tadalafil with Paxlovid.

sGC stimulators (Pulmonary hypertension agents)

↑riociguat

Dosage adjustment is recommended for riociguat. Refer to the riociguat SmPC for more information.

Sedatives/hypnotics

↑oral (1430%, 368%) and parenteral midazolama

↑triazolam (> 20-fold, 87%)

↑alprazolam (2.5-fold, ↔)

↑buspirone, ↑clonazepam, ↑clorazepate, ↑diazepam, ↑estazolam, ↑flurazepam

↑zolpidem (28%, 22%)

Midazolam is extensively metabolised by CYP3A4. Coadministration with Paxlovid may cause a large increase in the concentration of midazolam.

Plasma concentrations of midazolam are expected to be significantly higher when midazolam is given orally. Therefore, Paxlovid should not be coadministered with orally administered midazolam (see section 4.3), whereas caution should be used with coadministration of Paxlovid and parenteral midazolam. Data from concomitant use of parenteral midazolam with other protease inhibitors suggests a possible 3 – 4 fold increase in midazolam plasma levels. If Paxlovid is coadministered with parenteral midazolam, it should be done in an intensive care unit (ICU) or similar setting which ensures close clinical monitoring and appropriate medical management in case of respiratory depression and/or prolonged sedation. Dosage adjustment for midazolam should be considered, especially if more than a single dose of midazolam is administered.

Ritonavir coadministration is likely to result in increased plasma concentrations of triazolam and is therefore contraindicated (see section 4.3)

Alprazolam metabolism is inhibited following the introduction of ritonavir. Caution is warranted during the first several days when alprazolam is coadministered with ritonavir dosed as an antiretroviral agent or as a pharmacokinetic enhancer, before induction of alprazolam metabolism develops.

Ritonavir dosed as a pharmacokinetic enhancer or as an antiretroviral agent inhibits CYP3A and as a result is expected to increase the plasma concentrations of buspirone, clonazepam, clorazepate, diazepam, estazolam, and flurazepam. A dose decrease may be needed for these medicinal products when coadministered with Paxlovid and careful monitoring of therapeutic and adverse effects is recommended when concomitantly administered with Paxlovid.

Zolpidem and ritonavir may be coadministered with careful monitoring for excessive sedative effects.

Serotonin receptor 1A agonists/ serotonin receptor 2A antagonists

↑flibanserin

Coadministration contraindicated due to potential for hypotension, syncope, and CNS depression (see section 4.3).

Smoke cessation

↓bupropion (22%, 21%)

Bupropion is primarily metabolised by CYP2B6. Concurrent administration of bupropion with repeated doses of ritonavir is expected to decrease bupropion levels. These effects are thought to represent induction of bupropion metabolism. However, because ritonavir has also been shown to inhibit CYP2B6 in vitro, the recommended dose of bupropion should not be exceeded. In contrast to long-term administration of ritonavir, there was no significant interaction with bupropion after short‑term administration of low doses of ritonavir (200 mg twice daily for 2 days), suggesting reductions in bupropion concentrations may have onset several days after initiation of ritonavir coadministration.

Thyroid hormone replacement therapy

levothyroxine

Post-marketing cases have been reported indicating a potential interaction between ritonavir containing products and levothyroxine. Thyroid-stimulating hormone (TSH) should be monitored in patients treated with levothyroxine at least the first month after starting and/or ending ritonavir treatment.

Vasopressin receptor antagonists

↑tolvaptan

Coadministration contraindicated due to potential for dehydration, hypovolemia and hyperkalaemia (see section 4.3).

Abbreviations: ALT=alanine aminotransferase, AUC=area under the curve; Cmax=maximum concentrations.

a. See section 5.2 Interaction studies conducted with nirmatrelvir/ritonavir.

4.6. Fertility, pregnancy and lactation

Women of childbearing potential/Contraception in males and females

There are limited human data on the use of Paxlovid during pregnancy to inform the drug-associated risk of adverse developmental outcomes, women of childbearing potential should avoid becoming pregnant during treatment with Paxlovid.

Use of ritonavir may reduce the efficacy of combined hormonal contraceptives. Patients using combined hormonal contraceptives should be advised to use an effective alternative contraceptive method or an additional barrier method of contraception during treatment and until after one complete menstrual cycle after stopping Paxlovid (see section 4.5).

Pregnancy

There are limited data from the use of Paxlovid in pregnant women. Paxlovid should be used during pregnancy only if the potential benefits outweigh the potential risks for the mother and the foetus.

Animal data with nirmatrelvir have shown developmental toxicity in the rabbit (lower foetal body weights) but not in the rat. There was no nirmatrelvir-related effect on foetal morphology or embryo-foetal viability at any dose tested in rat or rabbit embryo-foetal developmental toxicity studies. There were no nirmatrelvir-related adverse effects in a pre- and postnatal developmental study in rats (see section 5.3).

A large number (6100 live births) of pregnant women were exposed to ritonavir during pregnancy; of these, 2800 live births were exposed during the first trimester. These data largely refer to exposures where ritonavir was used in combination therapy and not at therapeutic ritonavir doses but at lower doses as a pharmacokinetic enhancer for other protease inhibitors, similar to the ritonavir dose used for nirmatrelvir/ritonavir. These data indicate no increase in the rate of birth defects compared to rates observed in population-based birth defect surveillance systems. Animal data with ritonavir have shown reproductive toxicity (see section 5.3).

Breast-feeding

In a clinical pharmacokinetics study, 8 healthy lactating women who were at least 12 weeks postpartum were administered 3 doses (steady-state dosing) of 300 mg/100 mg nirmatrelvir/ritonavir. Nirmatrelvir and ritonavir were excreted in breastmilk in small amounts, with a milk to plasma AUC ratio of 0.26 and 0.07, respectively. The mean (range) estimated daily infant dose (assuming average milk consumption of 150 mL/kg/day), was 1.8% (1.3-2.5%) and 0.2% (0.1-0.3%) of the maternal dose.

There are no available data on the effects of nirmatrelvir or ritonavir on the breast‑fed newborn/infant or on milk production. A risk to the newborn/infant cannot be excluded. Breast‑feeding should be discontinued during treatment with Paxlovid and for 48 hours after the last dose of Paxlovid.

Fertility

There are no human data on the effect of Paxlovid on fertility. No human data on the effect of nirmatrelvir on fertility are available. Nirmatrelvir produced no effects on fertility in rats (see section 5.3).

There are no human data on the effect of ritonavir on fertility. Ritonavir produced no effects on fertility in rats.

4.7. Effects on ability to drive and use machines

There are no clinical studies that evaluated the effects of Paxlovid on ability to drive and use machines.

4.8. Undesirable effects

Summary of the safety profile

The safety of Paxlovid was based on data from three phase 2/3 randomised, placebo-controlled trials in non‑hospitalised adult participants with a laboratory confirmed diagnosis of SARS-CoV-2 infection (see section 5.1).

• Study C4671005 (EPIC-HR) and Study C4671002 (EPIC-SR) investigated Paxlovid (nirmatrelvir/ritonavir 300 mg/100 mg) every 12 hours for 5 days in symptomatic participants with a laboratory confirmed diagnosis of SARS-CoV-2 infection. Participants were to present with mild-to-moderate COVID-19 at baseline.

• Study C4671006 (EPIC-PEP) investigated Paxlovid (nirmatrelvir/ritonavir 300 mg/100 mg) every 12 hours for 5 or 10 days in asymptomatic household contact of individuals with a recent diagnosis of SARS-CoV-2 infection. Participants were to have a negative SARS-CoV-2 result at baseline.

Across the three studies, 3,515 participants received a dose of Paxlovid and 2,585 participants received a dose of placebo. The most common adverse reactions (≥1% incidence in the Paxlovid group and occurring at a greater frequency than in the placebo group) were dysgeusia (5.9% and 0.4%, respectively) and diarrhoea (2.9% and 1.9%, respectively).

The safety profile of Paxlovid in participants with severe renal impairment, including those requiring haemodialysis, was consistent with the safety profile observed in the placebo‑controlled trials.

Tabulated summary of adverse reactions

The adverse reactions in Table 4 are listed below by system organ class and frequency. Frequencies are defined as follows: Very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); not known (frequency cannot be estimated from the available data).

Table 4: Adverse reactions with Paxlovid

System organ class

Frequency category

Adverse reactions

Immune system disorders

Uncommon

Hypersensitivity*

Rare

Anaphylaxis*

Nervous system disorders

Common

Dysgeusia, headache

Vascular disorders

Uncommon

Hypertension*

Gastrointestinal disorders

Common

Diarrhoea, nausea*

Uncommon

Vomiting, abdominal pain*

Skin and subcutaneous tissue disorders

Rare

Toxic epidermal necrolysis*, Stevens‑Johnson syndrome*

General disorders and administration site conditions

Rare

Malaise*

* Adverse drug reaction (ADR) identified post-marketing.

Paediatric population

The safety and efficacy of Paxlovid in paediatric patients have not been established.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Coronavirus Yellow Card Reporting site at https://coronavirus-yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Treatment of overdose with Paxlovid should consist of general supportive measures including monitoring of vital signs and observation of the clinical status of the patient. There is no specific antidote for overdose with Paxlovid.