Lacidipine/lopinavir/ritonavir/metoprolol interaction
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Multiple interactions (first report) leading to bradycardia, hypotension and AV block: case report A 51-year-old man developed bradycardia, hypotension and complete antrioventricular (AV) block during concomitant treatment with lopinavir/ritonavir and metoprolol and lacidipine [routes not stated]; these reactions were attributed to an interaction between lopinavir/ritonavir and metoprolol, and between lopinavir/ ritonavir and lacidipine. The man, who had a history of hypertension and ischaemic myocardiopathy, was receiving daily lacidipine 2mg, metoprolol 100mg, ramipril, levothyroxine sodium, rosuvastatin and aspirin. Following possible exposure to HIV, he started receiving lopinavir/ritonavir 400/100mg twice daily and tenofovir disoproxil fumarate/emtricitabine for 1 month. Forty-eight hours after starting lopinavir/ ritonavir, he presented with vasovagal syncope. Additionally, he had severe hypotension and bradycardia. An ECG revealed a complete AV block. The man received isoprenaline, and returned to normal sinus rhythm. Lopinavir/ritonavir, metoprolol, ramipril and lacidipine were withdrawn. On day 4, he started receiving raltegravir. Lacidipine and ramipril were readministered on day 7, and metoprolol was restarted on day 9. Further analysis found that he was an intermediate metaboliser of CYP2D6 and a CYP3A normal metaboliser. Author comment: "[T]he AV block and the hypotension in this case was primarily associated with co-administration of the lopinavir/ritonavir combination with metoprolol and lacidipine." Puech R, et al. Extreme bradycardia due to multiple drug-drug interactions in a patient with HIV post-exposure prophylaxis containing lopinavir-ritonavir. British Journal of Clinical Pharmacology 71: 621-623, No. 4, Apr 2011. Available from: 803052819 URL: http://dx.doi.org/10.1111/j.1365-2125.2010.03849.x - France
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Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports associated with an interaction between ritonavir and lacidipine, or ritonavir/lopinavir and lacidipine, or ritonavir and metoprolol, or ritonavir/lopinavir and metoprolol. The WHO ADR database contained no reports associated with the concomitant use of ritonavir and lacidipine, or ritonavir/ lopinavir and lacidipine. The WHO ADR database contained two reports associated with the concomitant use of ritonavir and metoprolol, and two reports associated with the concomitant use of ritonavir/lopinavir and metoprolol.
0114-9954/10/1347-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
Reactions 16 Apr 2011 No. 1347
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