A Rare Cause of Refractory Vasodilatory Shock Due to Calcium Channel Blocker Toxicity from Drug-Drug Interaction Between Ritonavir-Boosted Nirmatrelvir (Paxlovid) And Manidipine

Herein, is a reported case of an 86-year-old woman, admitted due to complete atrioventricular block. During admission, she was diagnosed and treated with ritonavir-boosted nirmatrelvir (Paxlovid) for the coronavirus disease 2019 (COVID-19). Four days after initiating the treatment for COVID-19, an oral dose of 20 mg manidipine was administrated. Five hours later, the patient developed hypotension that eventually progressed to refractory shock requiring a maximum dose of 1.82 µg/kg/min of norepinephrine equivalent. Shock reversal dramatically improved within 17 hours after the cause of shock was diagnosed, and her having receiving specific treatment via intravenous calcium administration and high-dose insulin euglycemia therapy (HIE).