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Interactions between Nutritional supplements/herbs and Antiretrovirals
Antiretroviral (ARV) | Dose of ARV | Dose of Calcium carbonate | Effect on ARV Levels | Effect on Calcium carbonate Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Bictegravir759 (Biktarvy) | 50 mg x 1 | 1200 mg x 1 | If administered simultaneously in the fasted state Cmax decreased 42%; AUC decreased 33%. If administered simultaneously in the fed state Cmax decreased 10%; AUC increased 3%. | Not studied | Potential loss of antiviral efficacy | - | Bictegravir should be administered simultaenously with calcium carbonate supplements, with food. |
Dolutegravir685, 641 (Tivicay) | 50 mg x 1 | 1200 mg | Dolutegravir AUC decreased ~39% if taken together, fasting conditions. No significant change in dolutegravir AUC if taken 2 hours before calcium carbonate or if taken simultaneously with food. | - | Potential decreased dolutegravir effectiveness if taken in fasted state | - | Administer dolutegravir 2 hours before or 6 hours after calcium-containing supplements. Alternatively, administer dolutegravir simulatenously with calcium supplements and with food. |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Echinacea | Effect on ARV Levels | Effect on Echinacea Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Lopinavir/ritonavir527 (LPV/r)(Kaletra) | 400/100 mg BID x 29.5 days | 500 mg TID x 28 days | No significant change | - | - | - | No dose adjustment necessary |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Ferrous fumarate | Effect on ARV Levels | Effect on Ferrous fumarate Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Bictegravir759 (Biktarvy) | 50 mg x 1 | 324 mg x 1 | If administered simultaneously in the fasted state Cmax decreased 71%; AUC decreased 63%. If administered simultaneously in the fed state Cmax decreased 25%; AUC decreased 16%. | Not studied | Potential loss of antiviral efficacy | - | Bictegravir should be administered simultaenously with iron supplements, with food. Monitor for virologic efficacy. |
Dolutegravir687 (Tivicay) | 50 mg | 324 mg | Dolutegravir AUC decreased 54% when administered simultaneously with ferrous fumarate, fasting conditions. No significant change in dolutegravir AUC if given simultaneously with ferrous fumarate, with food or if given 2 hours after ferrous fumarate. | - | Potentially decreased dolutegravir effectiveness if given with iron. | Chelation of dolutegravir by divalent cations | Administer dolutegravir 2 hours before or 6 hours after medicines with divalent cations (Ca++, Fe++). Alternatively, dolutegravir can be taken simultaneously with iron supplements, with food. |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Garlic | Effect on ARV Levels | Effect on Garlic Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Saquinavir75, 172 (SQV)(Fortovase, Invirase) | 1200 mg (soft gel caps) TID with food x 4 days | Garlic capsules (3.6 mg/caplet) BID on days 5-24 | Saquinavir AUC: decreased 51%; Cmax: decreased 54%; Cmin: decreased 49%After a 10 day garlic washout period, pharmacokinetic values returned to only 60-70% of baseline | Not studied | Decreased saquinavir effects | Possible induction of gut mucosal CYP450 3A4 by garlic; P-glycoprotein effects are also possible | Avoid garlic supplements when saquinavir is used either boosted or unboosted.
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"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Ginkgo biloba | Effect on ARV Levels | Effect on Ginkgo biloba Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Lopinavir/ritonavir621 (LPV/r)(Kaletra) | 400/100 mg BID | 120 mg BID | No significant change | - | - | - | No dose adjustment necessary |
Raltegravir619 (RAL)(Isentress) | 400 mg x 1 | 120 mg BID | No significant change | Ginkgo biloba AUC: increased 21%; Cmax: increased 44% | - | Potential increase in raltegravir bioavailability | No dose adjustment necessary |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Ginseng | Effect on ARV Levels | Effect on Ginseng Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Indinavir446 (IDV)(Crixivan) | 800 mg Q8H | 1000 mg Q8H | No significant change | - | - | - | No dose adjustment necessary |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Milk thistle | Effect on ARV Levels | Effect on Milk thistle Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Darunavir613 (DRV)(Prezista) | - | 150 mg Q8H | Darunavir AUC: decreased 14%; Cmax: decreased 17%; Cmin: no significant change | - | - | - | No dose adjustment necessary |
Indinavir374 (IDV)(Crixivan) | 800 mg Q8H | 175 mg TID x 3 weeks | Indinavir AUC: no significant change; Cmin: decreased 25% | - | - | Unknown | No dose adjustment necessary |
Indinavir372 (IDV)(Crixivan) | 800 mg Q8H on days 1-30 | 450 mg TID on days 2-30 | No significant change | - | - | - | No dose adjustment necessary |
Indinavir373 (IDV)(Crixivan) | 800 mg TID x 4 doses on days 1, 2 and days 16 and 17 | 160 mg TID on days 3-17 | No significant effect | Not studied | - | - | No dose adjustment necessary |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Multiple vitamin | Effect on ARV Levels | Effect on Multiple vitamin Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Dolutegravir641 (Tivicay) | 50 mg x 1 | One-A-Day given simultaneously with dolutegravir | Dolutegravir AUC: decreased 33%; Cmin: decreased 32% | - | Potentially decreased dolutegravir effectiveness | - | Administer dolutegravir 2 hours before or 6 hours after multivitamins. |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of St. John's Wort | Effect on ARV Levels | Effect on St. John's Wort Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Amprenavir60 (APV)(Agenerase) | - | - | Not studied; may decrease amprenavir levels | Not studied | May decrease amprenavir effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister
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Atazanavir (ATV)(Reyataz) | - | - | Not studied; may decrease atazanavir levels | - | Decreased atazanavir effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister |
Darunavir161 (DRV)(Prezista) | - | - | Not studied; may decrease darunavir/ritonavir levels | - | Decreased darunavir/ritonavir effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister |
Dolutegravir691 (Tivicay) | - | - | Not studied; may decrease dolutegravir levels | - | Potentially decreased dolutegravir effectiveness | Induction of CYP450 3A4 by St. John's Wort | Contraindicated - do not coadminister |
Doravirine761 (Pifeltro, Delstrigo) | - | - | - | - | Potential loss of antiviral efficacy | - | Contraindicated. Use alternative agents. If discontinuing St. John's Wort, a minimum 4 week cessation period is recommended prior to initiating doravirine. |
Antiretroviral (ARV) | Dose of ARV | Dose of St. John's Wort | Effect on ARV Levels | Effect on St. John's Wort Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
Efavirenz90 (EFV)(Sustiva) | - | - | Not studied, may decrease efavirenz levels | - | Decreased efavirenz effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister
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Elvitegravir/cobicistat623 (Genvoya, Stribild) | - | - | - | - | Potentially decreased elvitegravir and cobicistat effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister |
Elvitegravir/ritonavir-boosted protease inhibitor691 | - | - | Expected decrease in elvitegravir, cobicistat, and protease inhibitor levels | - | Potentially decreased antiretroviral effects and efficacy | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister |
Indinavir173 (IDV)(Crixivan) | 800 mg Q8H | 300 mg TID (with meals) | Indinavir AUC: decrease 57+/-19% | Not studied | May decrease effect of indinavir; indinavir resistance | Possible induction of CYP450 3A4 by St. John's wort | Do not coadminister; active ingredient/quantity of hypericum varies between products and among individual tablets or capsules within the same product |
Lopinavir/ritonavir78 (LPV/r)(Kaletra) | - | - | Not studied; may decrease lopinavir/ritonavir levels | - | Decreased lopinavir/ritonavir effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister
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Nelfinavir173, 24 (NFV)(Viracept) | - | - | May decrease nelfinavir levels | - | Decreased nelfinavir effects | Induction of CYP450 3A4 by St. John's wort | Do not coadminister
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Nevirapine174 (NVP)(Viramune) | 200 mg BID | - | Clearance: increased 35% | - | Decreased nevirapine effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister
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Ritonavir55 (RTV)(Norvir) | - | - | Not studied; may decrease ritonavir levels | - | Decreased ritonavir effects | Induction of CYP450 3A4 by St. John's Wort | Do not coadminister
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Saquinavir254 (SQV)(Fortovase, Invirase) | - | - | May decrease saquinavir levels | - | Decreased saquinavir effects | Possible induction of CYP450 3A4 by St. John's Wort | Do not coadminister |
"-" indicates that there are no data available |
Antiretroviral (ARV) | Dose of ARV | Dose of Vitamin C | Effect on ARV Levels | Effect on Vitamin C Levels | Potential Clinical Effects | Mechanism of Interaction | Management |
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Indinavir383 (IDV)(Crixivan) | 800 mg Q8H x 4 doses | 1 g QD x 7 days | Indinavir AUC: no significant change; Cmin: decreased 32%; Cmax: decreased 20% | - | - | - | No dose adjustment necessary |
"-" indicates that there are no data available |