PAXLOVID Patient Eligibility Screening Checklist and Drug Interaction Tool

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Date of Birth

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PAXLOVID Patient Eligibility Screening Checklist Tool for Prescribers

This checklist is intended as an aid to support clinical decision making for prescribers. However, use of this checklist is not required to prescribe PAXLOVID under the EUA.

Please Check the box next to each statement indicating that it does apply to you. If you answer NO to ANY of the following questions, Please see Pharmacist.

Please check each box to confirm that the following statements apply to you. If you answer no to any of them, you must consult with pharmacist.

Positive SARS-CoV-2 test Confirmation in the last 5 daysAge 18 years OR > 12 years of age and weighing at least 40 kgSymptoms consistent with mild to moderate COVID-19 (No difficulty breathing)No known or suspected severe renal impairment (eGFR < 30 mL/min)No known or suspected severe hepatic impairment (Child-Pugh Class C)No history of clinically significant hypersensitivity reactions e.g., toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome] to the active ingredients (nirmatrelvir or ritonavir) or other components of the product.

Concomitant Medications

I currently take HMG-CoA reductase inhibitors (statins) for high cholesterol and have been counseled on the following to reduce possible side effects and drug interactions while taking Paxlovid.I do not take statins

If the patient is taking lovastatin or simvastatin, which are contraindicated with PAXLOVID coadministration, PAXLOVID can be given if the statin can be held 12 hours prior to the first dose of PAXLOVID treatment, held during the 5 days of treatment, and restarted 5 days after completing PAXLOVID. If the patient is taking atorvastatin or rosuvastatin, 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.

Additional info can be found at the following links:

1 https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html 2 ttps://www.covid19treatmentguidelines.nih.gov/overview/clinical- spectrum/#:~:text=Patients%20with%20mild%2Oillness%20may,on%20exertion%2C%20or%20abnormal%20i maging

Do you currently take Hormonal Contraceptives containing ethinyl estradiol? If so, you understand that it is advisable to consider an additional non-hormonal method of contraception during the 5 days of PAXLOVID treatment and until one menstrual cycle after stopping PAXLOVID.

I agree to the above statementI do not take hormonal contraception

PLEASE CHECK THE FOLLOWING BOX INDICATING THAT YOU ARE NOT TAKING ANY OF THE MEDICATIONS LISTED IN RED BELOW. If you are not sure, please consult with Pharmacist.

I take one or more medications listed in RED and I will consult with my physician.Patient is NOT taking any of the medications listed in RED but is taking one or more of the medications listed below in BLACK below, and dose adjustment, holding of medication, or increased monitoring is planned (additional resources which include instructions for managing specific drug interactions are included at the end of this document In addition, the patient's other medications not listed below have been checked for contraindications, the need for dose adjustment, or increased monitoring due to drug interactions with a strong CYP3A inhibitor such as ritonavir based on appropriate resources such as the prescribing information ofI confirm that I do not take any of the below medications and have consulted with pharmacist.

abemaciclib Anticancer drug ***
alfuzosin Alpha 1-adrenoreceptor antagonist XXX
aliskiren Cardiovascular agent ***
amiodarone Antiarrhythmic XXX
amlodipine Calcium channel blocker ***
apalutamide Anticancer drug XXX
avanafil PDE5 inhibitor ***
bedaquiline Antimycobacterial ***
betamethasone Systemic corticosteroid ***
bosentan Endothelin receptor antagonist ***
budesonide Systemic corticosteroid ***
bupropion Antidepressant ***
carbamazepine Anticonvulsant XXX
ceritinib Anticancer drug ***

ciclesonide Systemic corticosteroid ***
clarithromycin Anti-infective ***
clopidogrel Cardiovascular agent ***
clozapine Antipsychotic XXX
colchicine Anti-gout XXX
cyclosporine Immunosuppressant ***
dabigatran Anticoagulants ***
dasabuvir Hepatitis C direct acting antiviral ***
dasatinib Anticancer drug ***
dexamethasone Systemic corticosteroid ***
digoxin Cardiac glycoside ***
dihydroergotamine Ergot derivative XXX
diltiazem Calcium channel blocker ***
dronedarone Antiarrhythmic XXX
elbasvir/grazoprevir Hepatitis C direct acting antiviral ***
eletriptan Migraine medication XXX
elexacaftor/tezacaftor/ivacaftor Cystic fibrosis potentiator***
encorafenib Anticancer drug ***
eplerenone Cardiovascular agent XXX
ergotamine Ergot derivative XXX
erythromycin Anti-infective ***
everolimus Immunosuppressant ***
felodipine Calcium channel blocker ***
fentanyl Narcotic analgesic ***
finerenone Mineralocorticoid receptor antagonist XXX
flecainide Antiarrhythmic XXX
fluticasone Systemic corticosteroid ***
flibanserin Serotonin receptor 1A agonist/
serotonin receptor 2A antagonist XXX
glecaprevir/pibrentasvir Hepatitis C direct acting antiviral ***
hydrocodone Narcotic analgesic ***
ibrutinib Anticancer drug ***
isavuconazonium sulfate Antifungal ***
itraconazole Antifungal ***
ivabradine Cardiovascular agent XXX
ivacaftor Cystic fibrosis transmembrane
conductance regulator potentiator***
ivosidenib Anticancer drug ***
ketoconazole Antifungal ***

lidocaine (systemic) Antiarrhythmic ***
lomitapide Microsomal triglyceride transfer protein (MTTP) inhibitor XXX
lumacaftor/ivacaftor Cystic fibrosis transmembrane potentiator XXX
lurasidone Antipsychotic XXX
methadone Narcotic analgesic ***
methylergonovine Ergot derivative XXX
methylprednisolone Systemic corticosteroid ***
midazolam (administered parentally) Sedative/hypnotic ***
midazolam (oral) Sedative/hypnotic XXX
mometasone Systemic corticosteroid ***
naloxegol Opioid antagonist XXX
neratinib Anticancer drug ***
nicardipine Calcium channel blocker ***
nifedipine Calcium channel blocker ***
nilotinib Anticancer drug ***
ombitasvir/paritaprevir /ritonavir Hepatitis C direct acting antiviral ***
oxycodone Narcotic analgesic ***
pethidine Analgesic XXX
phenobarbital Anticonvulsant XXX
phenytoin Anticonvulsant XXX
pimozide Antipsychotic XXX
primidone Anticonvulsant XXX
propafenone Antiarrhythmic XXX
quetiapine Antipsychotic ***
quinidine Antiarrhythmic XXX
ranolazine Antianginal XXX
rifabutin Antimycobacterial ***
rifampin Antimycobacterial XXX
rifapentine Antimycobacterial ***
rimegepant Migraine medication ***
rivaroxaban Anticoagulant ***
salmeterol Long-acting beta-adrenoceptor agonist***
Sildenafil (when used for erectile dysfunction) PDE5 inhibitor ***
silodosin Benign prostatic hyperplasia agent XXX
sirolimus Immunosuppressant ***

sofosbuvir/velpatasvir/ voxilaprevir Hepatitis C direct acting antiviral ***
St. John’s Wort (hypericum perforatum) Herbal product XXX
suvorexant Neuropsychiatric agent ***
tacrolimus Immunosuppressant ***
tadalafil PDE5 inhibitor ***
tamsulosin Alpha 1-adrenoreceptor antagonist***
tezacaftor/ivacaftor Cystic fibrosis transmembrane regulator potentiator***
ticagrelor Cardiovascular agent ***
tolvaptan Vasopressin receptor antagonist XXX
trazodone Antidepressant ***
triamcinolone Systemic corticosteroid ***
triazolam Sedative/hypnotic XXX
ubrogepant Migraine medication XXX
vardenafil PDE5 inhibitor ***
venetoclax Anticancer drug ***
vinblastine Anticancer drug ***
vincristine Anticancer drug ***
voclosporin Immunosuppressant XXX
vorapaxar Cardiovascular agent ***
voriconazole Antifungal ***
warfarin Anticoagulant ***

In addition, the patient's other medications have been checked for contraindications, the need for dose adjustment, or increased monitoring due to drug interactions.

Additional information can be found at the following links:

PAXLOVID - Fact Sheet for Healthcare Providers: https://www.fda.gov/emergency-preparedness and-response/mcm-legal-regulatory-and-policy-framework/emergency-use- authorization#coviddrugs

Prescribing Information (Label/Package Insert) for Individual Drugs (Drugs@FDA): https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

University of Liverpool COVID-19 Drug Interactions: ittps://www.covid19-druginteractions.org/checker

NIH COVID-19 Treatment Guidelines:

https://www.covid19treatmentguidelines.nih.gov/therapies/antiviral-therapy/ritonavir-boosted- nirmatrelvir-paxlovid-/

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