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Can you take sleeping pills with Paxlovid?

4 min read

Studies show that up to 76% of people who had mild COVID-19 report experiencing insomnia afterward [1.7.1, 1.7.4]. If you're on antiviral treatment, you might wonder, can you take sleeping pills with Paxlovid? The answer is complex and requires caution due to significant drug interactions.

Quick Summary

Taking sleeping pills with Paxlovid can be dangerous. The ritonavir component of Paxlovid blocks a key enzyme, CYP3A4, increasing concentrations of many sedatives to toxic levels. Some are strictly contraindicated, while others require dose adjustments.

Key Points

  • Ritonavir is the Culprit: The ritonavir in Paxlovid inhibits the CYP3A4 enzyme, causing other drugs to build up to toxic levels [1.6.2, 1.6.4].

  • Some Pills are Contraindicated: Sleeping pills like triazolam (Halcion®) and oral midazolam are strictly forbidden with Paxlovid [1.3.1, 1.8.4].

  • Caution with Common Prescriptions: Drugs like zolpidem (Ambien®) and certain benzodiazepines require a doctor's guidance as a dose adjustment is likely needed [1.5.4, 1.9.1].

  • OTC Antihistamines May Be Safer: Doxylamine and diphenhydramine are generally considered to have a lower risk of interaction for short-term use [1.5.2].

  • Prioritize Doctor's Advice: Always consult a healthcare professional before combining any sleep aid with Paxlovid to avoid potentially life-threatening reactions [1.2.2].

  • Non-Drug Options are Key: Improving sleep hygiene by avoiding caffeine, limiting screen time, and creating a relaxing routine is a safe and effective first step [1.5.5].

  • COVID-19 and Insomnia: Sleep disturbances are a very common symptom for those recovering from COVID-19, making this a frequent concern [1.7.1].

In This Article

Battling COVID-19 and Insomnia

Recovering from COVID-19 can be challenging, and sleep disturbances are a common complaint. Research has indicated a high prevalence of insomnia among those who have had COVID-19, with some studies showing that over 60% of survivors experience some form of insomnia [1.7.1, 1.7.2]. While you focus on recovery with an antiviral like Paxlovid, the lack of sleep can be debilitating. It's natural to consider a sleeping pill for relief, but this requires extreme caution. Paxlovid has a long list of drug interactions, and many common sleep aids are on it [1.3.1, 1.8.3].

The Science Behind the Interaction: Ritonavir and CYP3A4

Paxlovid consists of two medications: nirmatrelvir and ritonavir. While nirmatrelvir is the antiviral component that fights SARS-CoV-2, ritonavir's role is to boost its effectiveness [1.2.4]. Ritonavir is a strong inhibitor of a crucial liver enzyme called cytochrome P450 3A4 (CYP3A4) [1.6.2, 1.6.4]. This enzyme is responsible for metabolizing and clearing a wide variety of drugs from the body, including many common sedatives and hypnotics [1.4.1, 1.4.2].

When ritonavir inhibits CYP3A4, it prevents these other drugs from being broken down properly. This can cause their concentrations in the blood to rise to dangerously high levels, leading to an increased risk of serious, life-threatening, or even fatal adverse events like severe sedation and respiratory depression [1.2.1, 1.6.2]. Because of this, some sleeping pills are strictly contraindicated, meaning you should not take them with Paxlovid under any circumstances [1.3.1].

Sleeping Pills to Avoid with Paxlovid

Due to the potent CYP3A4 inhibition, several sedatives and hypnotics should not be taken with Paxlovid. Taking them together can lead to prolonged and excessive sedation, breathing difficulties, and other serious side effects [1.2.1].

Strictly Contraindicated:

  • Triazolam (Halcion®): This benzodiazepine is explicitly listed as a contraindicated drug. Its levels can increase significantly, posing a high risk [1.3.1, 1.8.4].
  • Oral Midazolam (Versed®): Another benzodiazepine that should not be taken with Paxlovid due to the risk of extreme sedation [1.3.1, 1.8.4].

Use with Caution or Dose Adjustment (Consult a Doctor):

  • Zolpidem (Ambien®): Paxlovid can increase zolpidem levels, leading to enhanced effects and potential toxicity. A dose reduction may be necessary, and it should only be used under a doctor's supervision [1.5.4, 1.9.1].
  • Benzodiazepines like Diazepam (Valium®) and Clonazepam (Klonopin®): Paxlovid can increase the blood levels of these drugs, heightening the risk of sedation and respiratory depression. A dose decrease and close clinical monitoring are often required if co-administration is necessary [1.2.1, 1.3.5].
  • Trazodone: Often used off-label for sleep, trazodone levels can be elevated by Paxlovid, increasing the risk of side effects like dizziness and low blood pressure. A dose reduction may be considered [1.10.1, 1.10.3].

Sleeping Aid Interaction Comparison

Medication (Brand Name) Interaction with Paxlovid Recommendation
Triazolam (Halcion®) High risk of increased concentration and toxicity [1.3.1] Contraindicated - Do Not Use [1.8.4]
Oral Midazolam (Versed®) High risk of severe sedation and respiratory depression [1.2.1] Contraindicated - Do Not Use [1.8.4]
Zolpidem (Ambien®) Increased zolpidem levels and risk of toxicity [1.9.1] Requires medical consultation; dose reduction may be needed [1.5.4]
Clonazepam (Klonopin®) Increased benzodiazepine levels, risk of sedation [1.3.5] Requires medical consultation; dose reduction and monitoring needed [1.3.5]
Trazodone Increased trazodone levels and risk of side effects [1.10.1, 1.10.4] Requires medical consultation; consider holding or reducing dose [1.10.3]
Doxylamine (Unisom®) No significant interaction expected for short-term use [1.5.2] Generally considered a safer option, but consult pharmacist [1.5.2]
Diphenhydramine (Benadryl®) No significant interaction expected for short-term use [1.5.2] Generally considered a safer option, but consult pharmacist [1.5.2]

Potentially Safer Alternatives and Non-Pharmacological Options

While many prescription sleeping aids are problematic, some over-the-counter options may be safer. Antihistamines like doxylamine succinate (Unisom SleepTabs) and diphenhydramine (Benadryl) do not appear to have significant interactions with Paxlovid and can be considered for short-term use [1.5.2]. However, you should still consult your pharmacist or doctor before taking any new medication.

It's also highly beneficial to explore non-pharmacological strategies for improving sleep [1.5.5]:

  • Maintain a consistent sleep schedule: Go to bed and wake up around the same time each day.
  • Create a relaxing bedtime routine: Try reading a book, taking a warm bath, or listening to calming music.
  • Optimize your sleep environment: Ensure your bedroom is dark, quiet, and cool.
  • Avoid stimulants: Stay away from caffeine and alcohol, especially in the evening.
  • Limit screen time: Avoid TVs, computers, and smartphones for at least an hour before bed.

Conclusion: Always Consult Your Healthcare Provider

The most critical takeaway is that you must never start, stop, or adjust the dose of any medication without first consulting your doctor or pharmacist. The interaction between Paxlovid and sleeping pills can be severe [1.2.2]. Your healthcare provider can review all your current medications, assess the risks, and recommend the safest course of action to help you get the rest you need while safely treating COVID-19.

For more detailed information on drug interactions with Paxlovid, you can visit the FDA's Patient Emergency Use Authorization Fact Sheet.

Frequently Asked Questions

Paxlovid contains ritonavir, which blocks the CYP3A4 enzyme that your body uses to break down many medications, including certain sleeping pills. This can cause the sleeping pills to build up to dangerous levels in your system, leading to severe sedation and respiratory depression [1.6.2, 1.2.1].

You should not take Ambien (zolpidem) with Paxlovid without consulting your doctor. Paxlovid can increase Ambien levels, raising the risk of toxicity. Your doctor may need to adjust your dosage or recommend an alternative [1.5.4, 1.9.1].

Sleeping pills that are strictly contraindicated (forbidden) with Paxlovid include triazolam (Halcion®) and oral midazolam (Versed®) due to the risk of severe, life-threatening reactions [1.3.1, 1.8.4].

Tylenol PM contains diphenhydramine, an antihistamine. Diphenhydramine and another antihistamine, doxylamine, are generally considered to have a low risk of interaction with Paxlovid for short-term use. However, you should still confirm with your doctor or pharmacist before taking any new medication [1.5.2].

If you have taken a contraindicated medication with Paxlovid, you should contact your doctor or seek medical attention immediately. Watch for signs of excessive drowsiness, dizziness, or slowed breathing.

You should be cautious. For example, the herbal supplement St. John's Wort is contraindicated with Paxlovid [1.3.1]. While melatonin may have a lower risk, you must talk with your doctor before using any supplements to ensure safety [1.5.1].

Focus on non-medication strategies. Stick to a regular sleep schedule, make sure your bedroom is dark and quiet, avoid caffeine and alcohol, and do a relaxing activity like reading before bed [1.5.5]. These methods are safe and have no risk of drug interaction.

References

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Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice.