Anti-COVID-19 drugs, COVID-19 and anesthetics - The challenge for anesthesiologists.

Dear Editor,

The world is battling against the novel virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing the coronavirus disease 2019 (COVID-19). Various preventive and curative strategies are being followed with limited success.[1] This COVID-19 pandemic has open the pandora for pharmacologic agents being used on experimental and compassionate grounds for COVID-19 management.[2] Many drugs are being used are like using old weapons for the new enemy. Till date, no definite therapy has been confirmed for management of COVID-19.

With the COVID-19 ongoing, patients may require surgical interventions - elective or emergency. At times, many of these patients would be receiving various drug therapy for COVID-19 or had received in the recent past. In the absence of any data related to the duration for the complete systemic recovery after COVID-19, it is not feasible to decide for a safe interval before surgical intervention after contacting COVID-19. Not only the individual action of drugs on the body, but the anti-COVID-19 drugs may also interact with anesthetic and analgesic drugs. This ‘ drug-drug, drug-body systems, and disease-body systems’ become crucial to understand for an anesthesiologist for an optimal uneventful perioperative care.

We read with interest the article on drugs used for COVID-19 and their interaction with anesthetic agents.[3] The limitations remain the review is an extrapolation of the existing non-COVID literature. Most of these drugs have been used in the past for other non-COVID clinical indications. The literature is grossly lacking for such interactions in COVID-19 patients undergoing surgical intervention under anesthesia. It needs to be emphasized that drug interactions in real-time in the human being are just not based on pharmacokinetics but also pharmacodynamics of the drug and impact on physiology due to disease. On this background, the interaction of drugs may be affected by underlying systemic physiological and pathological changes invoked by the COVID-19 infection and Long COVID concerns. It has been reported that in almost one-fifth of patients have multiorgan involvement and more and more systemic manifestations are being reported especially in severe illness.[4]

The multisystemic effect of the impact of COVID-19 also includes cardiac conduction abnormalities due to infection, inflammation, hypoxia, and electrolyte abnormalities.[5] Similarly, the effect of coronavirus on neurological function includes myalgia, altered sensorium, cerebral edema, delirium, and encephalopathy.[4] The respiratory impact of COVID-19 is well known. Ritonavir inhibits CYP3A4 which is important for the metabolism of drugs like fentanyl and midazolam. So, co-administration of these drugs have the possibility of potentially fatal respiratory depression or prolonged sedation. The present paper justifies the interaction of anti-COVID-19 drugs and anesthetic drugs for risk of the exaggerated effect of opioids and benzodiazepines due to altered metabolism because of a drug interaction. But it needs to be remembered, that is just not drug interaction, but also the underlying neurological impact and respiratory dysfunction of COVID-19 may have an additive effect on sedation and respiratory function.

To conclude, it’s just not the drug-drug interaction but the perioperative care should consider “anti-COVID-19 drug-anesthetic and analgesic drug-patient-virus and its manifestations” interaction in a holistic way.

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Conflicts of interest

There are no conflicts of interest.