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Database of Antiretroviral Drug Interactions

All Interactions with Elvitegravir/cobicistat (Genvoya, Stribild)

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Alfuzosin623
(Uroxatral)
----Potentially increased alfuzosin effects (e.g. hypotension)-

Do not coadminister

Amiodarone699
--Not studied; may increase amiodarone levels-Possible increased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias) Inhibition of CYP3A4 by cobicistat

Use with caution; monitor amiodarone adverse effects. Consider obtaining ECG and monitoring amiodarone levels.

Amitriptyline
(Elavil)
-- Not studied; Increased levels of amitriptyline expected- Possible increased risk of amitriptyline adverse effects-

Initiate amitriptyline low dose and titrate according to response, adverse effects, and/or drug levels

Antacids623
(Maalox, Mylanta, Riopan, Milk of Magnesia, others)
20 mL given 2 hours after elvitegravir50 mg elvitegravir with 100 mg ritonavir x 1-Elvitegravir AUC: decreased 20%; Cmin: decreased 20%--

Separate elvitegravir from antacids by at least 2 hours

Antacids623
(Maalox, Mylanta, Riopan, Milk of Magnesia, others)
20 mL x 1 4 hours before elvitegravir150 mg elvitegravir with 100 mg ritonavir x 1-No significant change--

No dose adjustment necessary

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Antacids623
(Maalox, Mylanta, Riopan, Milk of Magnesia, others)
20 mL x 1 given 2 hours before elvitegravir50 mg elvitegravir with 100 mg ritonavir x 1-No significant change--

No dose adjustment necessary

Antacids623
(Maalox, Mylanta, Riopan, Milk of Magnesia, others)
20 mL x 1 given 4 hours after elvitegravir50 mg elvitegravir with 100 mg ritonavir x 1-No significant change--

No dose adjustment necessary

Apixaban699
--Not studied; may increase levels of apixaban.-Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Atazanavir651, 645, 639
(ATV)(Reyataz)
300 mg QDElvitegravir 85 mg QD with COBI 150 mg QDAtazanavir Cmax: decreased 24%; Cmin: decreased 20%Elvitegravir AUC: increased 17%; Cmax: decreased 16%; Cmin: increased 83%Potentially decreased or increased elvitegravir, cobicistat and/or atazanavir effects-

Do not coadminister

Atorvastatin717
--Not studied; expected increase in atorvastatin levels-Possible increased atorvastatin effects-

Initiate with low dose and titrate slowly; monitor for adverse effects

Avanafil727
(Stendra)
--Not studied; may increase avanafil levels No effect expected--

Avoid coadministration

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Bepridil
-- Not studied; may increase bepridil concentrations- Possible increased bepridil effects (hypotension, cardiac arrhythmias)-

Use with caution and monitor for adverse effects. Consider therapeutic drug monitoring.

Boceprevir623
(Victrelis)
-150/150 mg Not studied---

Do not coadminister

Bosentan699
-- Not studied; Possible increased bosentan levels---

If patient has been on elvitegravir/cobicistat for more than 10 days, start with bosentan dose of 62.5 mg daily or every other day. If patient is currently on bosentan and requires use of elvitegravir/cobicistat, stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Buprenorphine727
(Suboxone)(Buprenex)
--Norbuprenorphine AUC decreased 80%Tipranavir/ritonavir Cmin decreased 19-40%Possible decreased buprenoprhine effects. Possible loss of antiviral efficacy with tipranavir/ritonavir.-

Monitor viral load and consider monitoring tipranavir level

Buprenorphine625
(Suboxone)(Buprenex)
16-24 mg with 4-6 mg naloxone-Buprenorphine AUC; increased 35%; Cmin: increased 66%; Norbuprenorphine AUC: increased 42%; Cmax: increased 24%; Cmin: increased 57%. Naloxone: no significant change.No significant change--

No dose adjustment necessary

Bupropion705
(Zyban)(Wellbutrin)
-- Not studied; potential decrease in bupropion levels- Potential decreased bupropion effectiveness-

Monitor bupropion response and adverse effects, titrate dose.

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Buspirone707
(Buspar)
-- Not studied; possible increased buspirone levels- Potential increased risk of buspirone adverse effects-

Start with low dose buspirone and titrate accordingly. Monitor for side effects.

Carbamazepine623
(others)(Tegretol)
--Not studied; Possible increased carbamazepine levelsPotential decreased elvitegravir and cobicistat concentrationsPotentially decreased elvitegravir/cobicistat effects-

Consider alternative anticonvulsant

Carbamazepine707
(others)(Tegretol)
-- Not studied; possible increased levels of carbamazepine Potential decreased levels of elvitegravir and cobicistat Potential loss of antiretroviral efficacy-

Consider alternative anticonvulsant

Cisapride623
(Propulsid)
----Potentially increased cisapride effects (e.g. cardiac arrhythmias)-

Do not coadminister

Citalopram705
(Celexa)
--Not studied; may increase citalopram levels-Possible increased SSRI adverse effects-

Initiate therapy with lowest citalopram dose. Monitor citalopram response and titrate dose according to efficacy and adverse effects.

Clarithromycin639, 623
(Biaxin)
--Not studied; Potentially increased effectsNot studied; Potentially increased effects--

No dose adjustment necessary if patients CrCl > 60 mL/min. Reduce clarithromycin dose by 50% if CrCl is between 50-60 mL/min. Do not coadminster if CrCl < 50 mL/min.

Alternative Agents:
Azithromycin

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Clonazepam623
(others)(Klonapin)
----Potentially increased clonazepam effects-

More frequent clinical monitoring is recommended

Cyclosporine721
(Neoral, Sandimmune)
-- Not studied; may increase cyclosporine levels- Possible increased cyclosporine toxicity Inhibition of CYP450 3A4 by cobicistat

Initiate lower dose of immunosuppressant; monitor concentrations and toxicity, consult with specialist, and adjust dose as necessary

Dabigatran701
(Pradaxa)
--Not studied; may increase dabigatran levels-Potential for increased risk of bleedingInhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Dabigatran727
(Pradaxa)
--Not studied; may increase dabigatran levels-Potential for increased risk of bleedingInhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Daclatasvir747
(Daklinza)
----- Inhibition of CYP3A4

Decrease daclatasvir dose to 30 mg daily

Darunavir639, 633
(DRV)(Prezista)
600 mg BIDElvitegravir 150 mg QD with COBI 150 mg BIDNo significant changeNo significant change (compared to historical controls)Potentially decreased or increased elvitegravir, cobicistat and/or darunavir effects-

Do not coadminister

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Darunavir643, 639
(DRV)(Prezista)
600 mg BID with RTV 100 mg BID125 mg QDDarunavir Cmin: decreased 17%Elvitegravir Cmin: increased 18%Potentially decreased or increased elvitegravir, cobicistat and/or darunavir effects-

Do not coadminister

Darunavir643, 633
(DRV)(Prezista)
800 mg QDElvitegravir 150 mg QD with COBI 150 mg QDDarunavir AUC: no significant change; Cmin: decreased 21%Elvitegravir AUC: decreased 20%; Cmin: decreased 52% Cobicistat AUC: decreased 15-20%Potentially decreased or increased elvitegravir, cobicistat and/or darunavir effects-

Do not coadminister

Dasabuvir, Ombitasvir/Paritaprevir/Ritonavir727
(Viekira)
----Increase AUC of HCV agentsDuplicate boosting effect via CYP3A4 inhibition

Do not coadminister

Desipramine623
(Norpramin)
50 mg150 mg cobicistatDesipramine AUC: increased 65%-Increased desipramine effects-

Initiate low dose desipramine and titrate dose according to efficacy and adverse effects.

Dexamethasone699
(Decadron)
--- Not studied; may decrease levels of elvitegravir and cobicistat Possible loss of antiviral efficacy-

Use with caution; monitor viral load if extended dexamethasone use.

Digoxin727, 623
(others)(Lanoxin)
0.5 mg150 mg cobicistatCmax increase 41% and AUC no significant change---

Use with caution; monitor levels and digoxin adverse effects

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Disopyramide699
(Norpace, Norpace CR)
-- Not studied; may increase disopyramide levels- Potential increased risk of disopyramide adverse effects-

Use with caution; monitor for disopyramide toxicity

Dronedarone699
(Multaq)
-- Not studied; may increase dronedarone levels- Possible increased risk of dronedarone adverse effects-

Use with caution; monitor for dronedarone toxicity

Efavirenz639
(EFV)(Sustiva)
----Potentially decreased or increased elvitegravir, cobicistat and/or efavirenz effects-

Do not coadminster

Elbasvir/grazoprevir733, 727
(Zepatier)
----Potentially increased elbasvir/grazoprevir AUCExpected CYP450 inhibition by cobicistat

Coadministration not recommended. Minimal or no data to guide interaction.

Ergotamine623
(Cafergot, Ergot derivatives)(Cafergot, others)
----Potentially increased ergot effects (e.g. ergot toxicity, peripheral vasospasm, ischemia)-

Do not coadminister

Escitalopram705
(Lexapro)
-- Not studied; potential increased SSRI levels- Possible increase in SSRI adverse effects-

Initiate escitalopram therapy with lowest dose. Monitor escitalopram response and titrate according to efficacy and adverse effects

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Ethinyl estradiol/norgestimate623
(others)(Ortho Tri-Cyclen)
0.18/0.215/0.250 mcg norgestimate150/150 mgNorgestimate AUC: increased 126%; Cmin: increased 167%; Ethinyl estradiol AUC: decreased 25%; Cmin: decreased 44%-Increased norgestimate effects; decreased ethinyl estradiol effects-

Use with caution; alternate form of contraception recommended

Ethosuximide
-- Not studied; possible increased levels of ethosuximide---

Monitor for psychiatric side effects of ethosuximide

Etravirine647, 639
(ETR)(Intelence)
200 mg BID with ritonavir 100 mg QDElvitegravir 150 mg QDNo significant changeNo significant changePotentially decreased or increased elvitegravir, cobicistat and/or etravirine effects-

Do not coadminister

Everolimus727
(Zortress, Afintor)
-- Not studied; may increase everolimus levelsNo effect expectedIncreased everolimus effects (e.g. excessive immunosuppression) Inhibition of CYP450 3A4 by cobicistat

Monitor sirolimus levels and adjust dose as indicated

Famotidine623
(Pepcid)
40 mg given 12 hours after elvitegravir150/150 mg-Elvitegravir Cmin: increased 18%--

No dose adjustment necessary

Famotidine623
(Pepcid)
40 mg given simultaneously with elvitegravir150/150 mg-No significant change--

No dose adjustment necessary

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Flecainide699
(Tambocor)
-- Not studied; may increase flecainide levels.- Possible increased risk of flecainide adverse effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity. Consider therapeutic drug monitoring

Fluoxetine705
(Prozac)
--Not studied; potential for increased fluoxetine levels-Possible increased risk of fluoxetine adverse effects-

Start with lowest fluoxetine dose. Monitor response and titrate dose according to efficacy and adverse effects

Fluticasone699
(Advair, Flonase, Aerobid)
-- Not studied; possible increased fluticasone levels- Possible increased fluticasone effects (eg, Cushing's syndrome, adrenal suppression)-

Consider using alternative corticosteroid such as beclomethasone

Alternative Agents:
Beclomethasone

Fluvoxamine705
---Not studied; possible increase or decreased levels of elvitegravirPotential decreased elvitegravir effects-

Consider alternative antidepressant

Fosamprenavir653, 639
(FPV)(Lexiva)
700 mg BID with ritonavir 100 mg BIDElvitegravir 125 mg QDNo significant changeNo significant changePotentially decreased or increased elvitegravir, cobicistat and/or fosamprenavir effects-

Do not coadminister

Itraconazole623
(Sporanox)(Sporanox)
--Potentially increased effectsPotentially increased effects--

Avoid itraconazole > 200 mg daily and monitor itraconazole concentrations with coadministration.

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Ketoconazole623
(Nizoral)
200 mg BID150 mg elvitegravir with 100 mg ritonavir-Elvitegravir AUC: increased 48%; Cmin: increased 67%Increased elvitegravir and ketoconazole effects-

Avoid if possible, avoid ketoconazole > 200 mg daily

Ledipasvir/sofosbuvir713
--Increased ledipasvir levels expectedIncreased tenofovir levels expectedPotential increased tenofovir and ledipasvir adverse effectsPotentiation of effect occurs in ritonavir or cobicistat boosted regimens

Do not coadminister

Lidocaine699
(Xylocaine)
-- Not studied; may increase lidocaine levels---

Use with caution. Monitor adverse effects and consider therapeutic drug monitoring.

Lopinavir/ritonavir649, 639
(LPV/r)(Kaletra)
400/100 mg BIDElvitegravir 125 mg QDNo significant changeElvitegravir AUC; increased 75%; Cmax: increased 52%; Cmin: increased 139%Potentially decreased or increased elvitegravir, cobicistat and/or lopinavir effects-

Do not coadminister

Lovastatin623
(Mevacor)
----Potentially increased lovastatin effects (e.g. myopathy, rhabdomyolysis)-

Do not coadminister

Alternative Agents:
Atorvastatin Pravastatin

Methadone625
(Dolophine)
80-120 mg150 mg/150 mgNo significant changeNo significant change--

No dose adjustment necessary

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Methylprednisolone699
(Solu-medrol, Depo-medrol)
-- Not studied; may increase levels of methyprednisolone- Possible increased risk of adrenal insufficiency and Cushing's syndrome-

Do not co-administer

Metoprolol623
(others)(Lopressor)
----Potentially increased metoprolol effects-

Use with caution; titrate to effect

Metoprolol623
(others)(Lopressor)
----Potentially increased metoprolol effects-

Initiate beta-blocker at low dose, titrate to effect while monitoring for potentially increased side effects

Mexiletine
-- Not studied; may increase levels of mexiletine-- Potential increased risk of mexiletine adverse effects

Use with caution; monitor for mexiletine toxicity

Midazolam623
(Versed)
----Potentially increased midazolam effects (e.g. prolonged sedation, altered mental status, respiratory depression)-

Parenteral midazolam can be used with caution when given as a single dose in a monitored situation for procedural sedation; chronic midazolam administration (oral or intravenous) should be avoided.

Nevirapine639
(NVP)(Viramune)
----Potentially decreased or increased elvitegravir, cobicistat and/or nevirapine effects-

Do not coadminister

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Norgestimate/ethinyl estradiol715
0.180/0.215/ 0.250 norgestimate once daily with 0.025 ethinyl estradiol once daily150/150 mgNorgestimate AUC increased 2.6-fold. Ethinyl estradiol AUC decreased 25% and Cmin decreased 44%-Potential increased risk of progestin adverse effects (insulin resistance, dyslipidemias, acne, venous thromboembolism)-

Weigh risks and benefits of coadministration and consider alternative contraceptive method.

Omeprazole623
(Prilosec)
20 mg given 12 hours after elvitegravir150/150 mg-No significant change--

No dose adjustment necessary

Omeprazole623
(Prilosec)
20 mg given 2 hours before elvitegravir150 mg/150 mg-No significant change--

No dose adjustment necessary

Omeprazole623
(Prilosec)
40 mg given 2 hours before elvitegravir50 mg elvitegravir with 100 mg ritonavir-No significant change--

No dose adjustment necessary

Oxcarbazepine623
(Oxtellar, Trileptal)
--- Not studied; Potentially decreased elvitegravir and cobicistat levelsPotential loss of antiretroviral efficacy-

Consider alternative anticonvulsants

Paroxetine705
(Paxil)
-- Not studied; may increase paroxetine levels- Possible increased risk of paroxetine adverse effects-

Initiate paroxetine at lowest dose. Monitor response and titrate dose according to efficacy and adverse effects

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Phenobarbital623
(others)(Luminal)
--- Not studied; Potentially decreased elvitegravir cobicistat levelsPotential loss of antiretroviral efficacy-

Consider alternative anticonvulsants

Phenytoin
(Dilantin)
--- Not studied; Potentially decreased elvitegravir and cobicistat levelsPotential loss of antiretroviral efficacy-

Consider alternative anticonvulsants

Pimozide623
(Orap)(Orap)
----Potentially increased pimozide effects (e.g. cardiac arrhythmias)-

Do not coadminster

Posaconazole623
(Noxafil)
--Potentially increased effectsPotentially increased effects--

Monitor posaconazole concentrations with coadministration

Prednisolone
(others)
--Not studied; may increase prednisolone levels-Possibly increased prednisolone effects (adrenal insufficiency, Cushing’s syndrome).-

Do not coadminister

Propafenone
(Rythmol)
-- Not studied; may increase propafenone levels-Increased propafenone effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity.

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Quetiapine699
(Seroquel)
--Not studied; potential increased quetiapine AUC-Possible increased risk of quetiapine adverse effects-

For patients currently on elvitegravir/cobicistat: initiate quetiapine at lowest possible dose. Titrate accordingly and monitor for adverse effects. If patient already on quetiapine and requiring new elvitegravir/cobicistat: reduce queitapine to 1/6 of original dose. Titrate and monitor efficacy and adverse effects

Quinidine699
(others)(Quindex)
--Not studied; may increase quinidine levels-Possible increased quinidine effects (e.g. cardiac arrhythmias) Inhibition of CYP450 3A4 by cobicistat

Use with caution. Monitor for toxicity.

Rifabutin639, 623
(Mycobutin)
150 mg every other day150 mg/150 mg25-O-rifabutin AUC: increased 625%; Cmin: increased 494% (compared to 300 mg rifabutin alone)Elvitegravir AUC: decreased 21%; Cmin: decreased 67%Increased rifabutin effects-

Do not coadminister; consider alternative antiretrovirals.

Rifampin639, 623
(Rifampicin)(Rifadin)
--- Expected decrease in elvitegravir and cobicistat levelsPotential loss of antiretroviral efficacyInduction of CYP450 by rifampin

Do not coadminister; consider alternative antiretrovirals

Rifapentine
(Priftin)
--- Expected significant decrease in elvitegravir and cobicistat levels Potential loss of antiretroviral efficacy-

Do not coadminister

Rivaroxaban703
(Xarelto)
-- Not studied; may increase rivaroxaban levels- Potential for increased risk of bleeding Inhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Rosuvastatin639
(Crestor)
10 mg x 1Elvitegravir 150 mg QD with COBI 150 mg QDRosuvastatin AUC: increased 38%; Cmax: increased 89%No significant changePotentially increased rosuvastatin effects-

Initiate rosuvastatin at lowest dose and titrate carefully. Monitor for adverse effects.

Sertraline705
(Zoloft)
--Not studied; may increase sertraline levels -Possible increased risk of sertraline adverse effects-

Initiate sertraline at lowest dose. Monitor response and titrate according to efficacy and adverse effects

Sildenafil727, 623
(Viagra)
--Not studied; may increase sildenafil levelsNo effect expectedPotentially increased sildenafil effects (eg, hypotension, priapism)-

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Simeprevir679
(Olysio)
-- Not studied; possible increased simeprevir levels- Potential increased simeprevir toxicity Inhibition of CYP450 3A4 by cobicistat

Avoid coadministration

Simvastatin623
(Zocor)
----Potentially increased simvastatin effects (e.g. myopathy, rhabdomyolysis)-

Do not coadminister

Sirolimus727
(Rapamycin)(Rapamune)
--Not studied; may increase sirolimus levelsNo effect expectedIncreased sirolimus effects (eg, excessive immunosuppression)Inhibition of CYP450 3A4 by cobicistat

Monitor and adjust sirolimus dose as indicated

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Sofosbuvir/velpatasvir751
(Epclusa)
400 mg /100 mg150 mg/150 mg (with emtricitabine and TDF)Sofosbuvir AUC increased 24%. Velpatasvir AUC increased 19%; Cmax increased 37%.Elvitegravir Cmax decreased 13%--

No dose adjustment necessary

Sofosbuvir/velpatasvir751
(Epclusa)
400 mg /100 mg150 mg/ 150mg (with emtricitabine and TAF)Sofosbuvir Cmax increased 23%; AUC increased 37%. Velpatasvir Cmax increased 30%; AUC increased 50%; Cmin increased 60%. Elvitegravir AUC decreased 7%--

No dose adjustment necessary

St. John's Wort623
(Hypericum perforatum)
----Potentially decreased elvitegravir and cobicistat effects Induction of CYP450 3A4 by St. John's Wort

Do not coadminister

Tacrolimus727
(Prograf)
--Not studied; may increase tacrolimus levelsNo effect expectedIncreased tacrolimus effects (increased immunosuppression)Inhibition of CYP450 3A4 by cobicistat

Monitor and adjust tacrolimus as indicated

Tadalafil729, 727
--Not studied; may increase tadalafil levelsNo effect expectedPossible increased tadalafil effects (e.g. hypotension, priapism)-

If initiating tadalafil for pulmonary arterial hypertension in a patient already taking elvitegravir/cobicistat for >1 week: start tadalafil 20 mg once daily and increase to 40 mg as tolerated. If patient with PAH requires initiation of elvitegravir/cobicistat: Stop tadalafil 24 hours prior to starting ART. Wait one week, then initiate tadalafil at 20 mg orally once daily. May increase to 40 mg as tolerated. For erectile dysfunction initiate tadalafil 5 mg dose do not exceed 10 mg in 72 hours.

Telaprevir623
(Incivek)
------

Do not coadminister

Coadministered DrugDose of DrugDose of Elvitegravir/cobicistatEffect on Drug LevelsEffect on Elvitegravir/cobicistat LevelsPotential Clinical EffectsMechanism of InteractionManagement
Ticagrelor705
(Brilinta)
--Not studied; may increase effects of ticagrelor-Potential for increased risk of bleedingInhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Tipranavir655, 639
(TPV)(Aptivus)
500 mg BID with ritonavir 200 mg BIDElvitegravir 200 mg QDNo significant changeNo significant changePotentially decreased or increased elvitegravir, cobicistat and/or etravirine effects-

Do not coadminister

Trazodone699
(Desyrel)
-- Not studied; may increase trazodone levels- Possible increased trazodone adverse effects-

Initiate trazodone lowest dose. Monitor response and titrate according to efficacy and adverse effects.

Triamcinolone707
--Not studied; may increase triamcinolone levels-Possible increased risk of adrenal insufficiency and Cushing's syndrome-

Do not coadminister

Triazolam623
(Halcion)
----Potentially increased triazolam effects (e.g. prolonged sedation, altered mental status, respiratory depression)-

Do not coadminister

Vardenafil727
--Not studied; may increase vardenafil levelsNo effect expectedPossible increased vardenafil effects (e.g. hypotension, priapism) Inhibition of CYP450 3A4 by cobicistat

Initiate vardenafil 2.5 mg every 72 hours and monitor for adverse effects

Vorapaxar705
(Zontivity)
-- Not studied; may increase effects of vorapaxar- Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Voriconazole623
(VFend)
--Not studied; Potentially increased or decreased voriconazole levelsPotentially increased effects--

Monitor voriconazole concentrations with coadministration

Warfarin623
(Coumadin)
-- Not studied; may increase or decrease warfarin effects-Potential for over or under anticoagulation-

Monitor INR closely when pt is first initiating elvitegravir/cobicistat

"-" indicates that there are no data available
 623:Stribild [package insert]. Foster City, CA: Gilead Sciences, Inc.; August 2012.
 625:Bruce R, Winkle P, Custodio J, et al. Pharmacokinetics of cobicistat-boosted elvitegravir administered in combination with methadone or buprenorphine/naloxone [poster A-1250]. 52nd Interscience Conference on Antimicrobial Agents and Chemotherapy Sept 9-12, 2012. San Francisco, CA.
 633:Ramanathan S, Wang H, Szwarcberg J, Kearney BP. Safety/tolerability, pharmacokinetics and boosting of twice-daily cobicistat administered alone or in combination with darunavir or tipranavir [poster P08]. 13th International Workshop on Clinical Pharmacology of HIV Therapy; April 16-18, 2012. Barcelona, Spain.
 639:DHHS. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Feb 12, 2013.
 643:Mathias A, Shen G, Enejosa J, et al. Lack of pharmacokinetic interaction between ritonavir-boosted GS-9137 (elvitegravir) and darunavir/r [abstract TUPDB03]. 4th IAS Conference on HIV Pathogenesis and Treatment and Prevention. Sydney, Australia.
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