Nirmatrelvir increases blood tacrolimus concentration in COVID-19 patients as determined by UHPLC-MS/MS method

- OBJECTIVE: Transplant recipi-ents have a higher risk of SARS-CoV-2 infection owing to the use of immunosuppressive drugs like tacrolimus (FK506). FK506 and nirmatrelvir (NMV) (an anti-SARS-CoV-2 drug) are metabo-lized by cytochrome P450 3A4 and may have po-tential drug-drug interactions. It is important to determine the effect of NMV on FK506 concen-trations.PATIENTS AND METHODS: Following pro-tein precipitation from blood, FK506 and its in-ternal standard (FK506-13C,2d4) were detected by ultra-high performance liquid chromatography/ tandem mass spectrometry (UHPLC-MS/MS). Total 22 blood samples (valley concentrations) from two coronavirus disease 2019 (COVID-19) patients were collected and analyzed for FK506 concentrations. RESULTS: Blood levels of FK506 (0.5-100 ng/ mL) showed good linearity. The UHPLC-MS/MS method was validated with intra-and inter-batch accuracies of 104.55-107.85%, and 99.52-108.01%, respectively, and precisions of < 15%. Mean blood FK506 concentration was 12.01 ng/mL (range, 3.15-33.1 ng/mL). Five-day co-administration with NMV increased the FK506 concentrations from 3.15 ng/mL to 33.1 ng/mL, returning to 3.36 ng/mL after a 9-day-washout.CONCLUSIONS: We developed a simple quantification method for therapeutic drug mon- itoring of FK506 in patients with COVID-19 us-ing UHPLC-MS/MS with protein precipitation. We found that NMV increased FK506 blood con-centration 10-fold. Therefore, it is necessary to re-consider co-administration of FK506 with NMV.