Lopinavir/ritonavir

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Sick sinus syndrome following off-label use: case report A 67-year-old man developed sick sinus syndrome while receiving off-label treatment with lopinavir/ritonavir for Coronavirus disease 2019 (COVID-19). The man presented with fever and cough for one week. His medical history was significant for ex-smoker, hypertension, hyperlipidaemia, gout, stable ischaemic heart disease (IHD) with angina last year and elective percutaneous coronary intervention. He had been prescribed with a week’s treatment of amoxicillin/clavulanic acid [Co-amoxiclav]. As his fever continued, he again visited to the clinic, was subsequently diagnosed with COVID-19. His body temperature was 38°C. Initial findings showed mild thrombocytopenia and lymphopenia. Baseline ECG was normal sinus rhythm with first-degree atrioventricular block. On day 3, he had mild haemoptysis with saturations of 93-95% on room air. He was initiated on off-label lopinavir/ritonavir 400mg/100mg twice daily [route not stated]. Subsequently, he was transferred to an ICU for closer monitoring and initiation of awake prone therapy. He was concurrently initiated on IV piperacillin/tazobactam for empirical coverage of bacterial superinfection. In the ICU, repeat ECG showed intermittent sinus pauses and junctional escape rhythm, but he remained normotensive. Transthoracic ECG showed preserved cardiac function and no regional wall motion abnormalities or significant pericardial effusion. Several days after supportive measures, he developed transient junctional escape rhythm of 35 beats/min with hypotension. He required emergency transcutaneous pacing with transition to IV dopamine infusion of 5 lg/kg/min. No obvious reversible causes of sick sinus syndrome were found. A multidisciplinary discussion concluded that lopinavir–ritonavir was the likely cause of the sick sinus syndrome. The man’s treatment with lopinavir/ritonavir was discontinued. Within 48h of lopinavir/ritonavir discontinuation, the bradycardic episodes resolved and he was extubated. Furthermore, he was discharged from the ICU. He was last seen in the infectious disease outpatient clinic and reported no symptoms suggestive of bradycardia. Wang LY-T, et al. COVID-19 treatment with lopinavir-ritonavir resulting in sick sinus syndrome: A case report. European Heart Journal - Case Reports 4: no pagination, No. 803520826 1, Oct 2020. Available from: URL: http://doi.org/10.1093/ehjcr/ytaa171

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Reactions 12 Dec 2020 No. 1834

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