Updates to the Database of ARV Drug Interactions

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HIV Meds Updates Reference Table

October 5, 2012

Susa Coffey, MD, HIV InSite Medical Editor

Ian R. McNicholl, HIV InSite Pharmacy Editor

The following table summarizes recent additions to the HIV InSite Database of Antiretroviral Drug Interactions.For a full description of the updates, including references to the studies from which the data were derived, go to the database, click on a specific drug name, and search for the interacting agent.

Note: Numerous interactions between elvitegravir/cobicistat and other medications used for treatment of HIV infection have been identified. These interactions are compiled as a separate table at the bottom of this page.

New ARV Interactions (May-October 2012)
Drug One	Drug Two	Clinical Effects	Mechanisms	Management
Source: McNicholl I. HIV InSite Database of Antiretroviral Drug Interactions. University of California San Francisco: Center for HIV Information; 2012.
Atazanavir	Pitavastatin	Possibly increased pitavastatin effects		Start at lowest dosage and titrate to effect
Darunavir	Artemether			Dosage adjustment not established
Darunavir	Lumefantrine			Dosage adjustment not established
Darunavir	Milk thistle			No dosage adjustment necessary
Darunavir	Pitavastatin			Titrate pitavastatin to effect
Efavirenz	Ethinyl estradiol/norethindrone acetate			No dosage adjustment necessary
Etravirine	Artemether	Decreased antimalarial effects		Use with caution; avoid if possible
Etravirine	Lumefantrine	Decreased antimalarial effects		Use with caution; avoid if possible
Etravirine	Boceprevir	Decreased etravirine effects		Dosage adjustment not established; use with caution
Lopinavir/ritonavir	Gingko biloba			No dosage adjustment necessary
Raltegravir	Gingko biloba		Potential increase in raltegravir bioavailability	No dosage adjustment necessary

Drug Interactions with Elvitegravir/Cobicistat
Coadministered Drug	Dosage	Clinical Effects	Mechanisms	Management
Source: McNicholl I. HIV InSite Database of Antiretroviral Drug Interactions. University of California San Francisco: Center for HIV Information; 2012.
Alfuzosin		Potentially increased alfuzosin effects (eg, hypotension)		Do not coadminister
Antacids (Maalox, Mylanta, Riopan, Milk of Magnesia, Others)	20 mL given 2 hours after elvitegravir/50 mg elvitegravir with 100 mg ritonavir single dose 20 mL single dose 4 hours before elvitegravir/150 mg elvitegravir with 100 mg ritonavir single dose 20 mL single dose given 2 hours before elvitegravir /50 mg elvitegravir with 100 mg ritonavir single dose 20 mL single dose given 4 hours after elvitegravir/50 mg elvitegravir with 100 mg ritonavir single dose			Separate elvitegravir from antacids by at least 2 hours No dosage adjustment necessary No dosage adjustment necessary No dosage adjustment necessary
Boceprevir				Do not coadminister
Cisapride		Potentially increased cisapride effects (eg, cardiac arrhythmias)		Do not coadminister
Clarithromycin				Avoid combination if possible; Consider alternative agents Alternative Agents: Azithromycin
Desipramine	50 mg/150 mg cobicistat	Increased desipramine effects		Use with caution
Digoxin	0.5 mg/150 mg cobicistat			No dosage adjustment necessary; use with caution and monitor concentrations
Ergotamine		Potentially increased ergot effects (eg, ergot toxicity, peripheral vasospasm, ischemia)		Do not coadminister
Ethinyl estradiol/norgestimate	0.18/0.215/0.250 mcg norgestimate/150 mg elvitegravir/150 mg cobicistat	Increased norgestimate effects; decreased ethinyl estradiol effects		Use with caution; alternative form of contraception recommended
Famotidine	40 mg given 12 hours after elvitegravir/150 mg elvitegravir/150 mg cobicistat 40 mg given simultaneously with elvitegravir/150 mg elvitegravir/150 mg cobicistat			No dosage adjustment necessary No dosage adjustment necessary
Itraconazole				Avoid itraconazole >200 mg daily and monitor itraconazole concentrations with coadministration
Ketoconazole	200 mg BID/150 mg elvitegravir with 100 mg ritonavir	Increased elvitegravir and ketoconazole effects		Avoid if possible, avoid ketoconazole >200 mg daily
Lovastatin		Potentially increased lovastatin effects (eg, myopathy, rhabdomyolysis)		Do not coadminister
Metoprolol		Increased metoprolol effects		Use with caution; titrate to effect
Midazolam		Potentially increased midazolam effects (eg, prolonged sedation, altered mental status, respiratory depression)		Do not coadminister
Omeprazole	20 mg given 12 hours after elvitegravir/150 mg elvitegravir/150 mg cobicistat 20 mg given 2 hours before elvitegravir/150 mg elvitegravir/150 mg cobicistat 40 mg given 2 hours before elvitegravir/50 mg elvitegravir with 100 mg ritonavir			No dosage adjustment necessary No dosage adjustment necessary No dosage adjustment necessary
Pimozide		Potentially increased pimozide effects (eg, cardiac arrhythmias)		Do not coadminister
Posaconazole				Monitor posaconazole concentrations with coadministration
Rifabutin	150 mg every other day/150 mg elvitegravir/150 mg cobicistat	Increased rifabutin effects		Do not coadminister; consider alternative antiretrovirals
Rifampin		Decreased elvitegravir and cobicistat effects	Induction of CYP450 by rifampin	Do not coadminister; consider alternative antivirals
Rosuvastatin	10 mg/150 mg elvitegravir/150 mg cobicistat	Increased rosuvastatin effects		Avoid coadministration if possible
Sildenafil		Potentially increased sildenafil effects when used for pulmonary hypertension		Do not coadminister
Simvastatin		Potentially increased simvastatin effects (eg, myopathy, rhabdomyolysis)		Do not coadminister
St. John's Wort		Potentially decreased elvitegravir and cobicistat effects		Do not coadminister
Telaprevir				Do not coadminister
Triazolam		Potentially increased triazolam effects (eg, prolonged sedation, altered mental status, respiratory depression)
Voriconazole				Monitor voriconazole concentrations with coadministration

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