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A Pocket Guide to Adult HIV/AIDS Treatment
February 2006 edition |
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Drug Table 1.
TOP
Antiretroviral Agent Characteristics
| Drug Name |
Form |
Food Effects |
Liver Failure Dosing |
Toxicity (main toxicity in italics)
|
| Nucleoside Reverse Transcriptase Inhibitors (NRTIs) |
Abacavir
(ABC, Ziagen) |
300 mg tab; (see also: Trizivir); 20 mg/mL po soln. |
300 mg bid |
No effect |
Standard |
Usual |
Hyper-sensitivity:
fever, rash, GI sx, dyspnea§¶¶ |
Combivir
(CBV) |
AZT 300 mg +
3TC 150 mg (tab) |
1 bid |
No effect |
Fixed formulation not recommended |
Usual |
AZT side effects§ |
Didanosine
(Videx EC;
ddI)† |
125, 200, 250, and 400 mg EC caps†† |
½ hr before
or 2 hr after
meal
Separate
dosing of
ATV, TPV/r |
>60 kg
200 mg/d
<60 kg
125 mg/d |
>60 kg
125 mg/d
<60 kg
100 mg/d |
>60 kg
125
mg/d
<60 kg
75
mg/d¶ |
Usual |
Pancreatitis,
peripheral
neuropathy, GI
intolerance § |
| EC Caps |
400 mg qd |
250 mg qd |
| with TDF |
250 mg/d |
200 mg/d |
Emtricitabine
(Emtriva, FTC) |
200 mg cap |
200 mg qd |
No effect |
200 mg q72 h |
200 mg
q96 h |
Usual |
Minimal§
HBV flare» |
Lamivudine
(Epivir; 3TC) |
150, 300 mg
tab (see also:
Combivir &
Trizivir); 10 mg/mL
po soln. |
150 mg bid or 300 mg qd |
No effect |
150 mg x 1 then 100
mg/d |
150 mg x 1
then 25-50
mg/kg/d |
Usual |
Minimal§
HBV flare» |
| Epzicom |
3TC 300 mg +
ABC 600 mg |
1 qd
|
No effect |
Fixed formulation not recommended in renal failure |
Usual |
ABC
hyper-sensitivity
HBV flare» |
Stavudine
(Zerit; d4T) † |
15, 20, 30, 40 mg cap;
1 mg/mL po soln. |
Wt >60 kg: 40 mg bid
Wt <60 kg: 30 mg bid |
No effect |
>60 kg 20 mg q 12 h
<60 kg
15mg q
12 h |
>60 kg 20 mg q 24 h
<60 kg 15 mg q 24 h |
>60 kg
20 mg q 24 h
<60 kg
20 mg q 24 h¶ |
Usual |
Peripheral
neuropathy,
pancreatitis,
lipoatrophy,
ascending
paresis (rare)§ |
Tenofovir
(Viread, TDF) |
300 mg tab
(see also: Truvada)
|
300 mg qd |
Take with
meal |
300 mg
q 48 hr |
300 mg 2
days/wk |
300 mg q 7
days¶ |
Usual |
Minimal. Renal
toxicity (rare)§
HBV flare» |
| Trizivir (TZV) |
AZT 300 mg +
3TC 150 mg +
ABC 300 mg (tab) |
1 bid |
No effect |
Fixed formulation not recommended in
renal failure |
Usual |
Hyper-sensitivity-reaction (ABC), bone marrow suppression (AZT), GI Intolerance (AZT)§
HBV flare» |
| Truvada |
TDF 300 mg +
FTC 200 mg |
1 qd |
No effect |
Fixed formulation not recommended in
renal failure |
Usual |
Minimal.
Renal toxicity,
HBV flare» |
Zidovudine
(Retrovir, AZT) |
100 cap, 300
mg tab; (see
also: Combivir &
Trizivir)
10 mg/ mL IV soln.
10 mg/ mL po soln. |
300 mg bid
200 mg tid |
No effect |
300 mg bid |
300 mg qd |
100 mg tid |
Usual |
Peripheral
neuropathy,
stomatitis§ |
| Protease Inhibitors (PIs) |
Atazanavir
(Reyataz,
ATV) |
100, 150, and 200 mg capsules |
400 mg qd; ATV 300 mg/RTV 100 mg qd. Boosting is often preferred and is required if ATV is combined with TDFor EFV |
Take with
food. Avoid
concurrent
buffered
ddl,
antacids. |
Standard |
CPS* 7-9:
300 mg
qd
CPS* >9*:
Avoid |
Benign increase in indirect bilirubin, GI
intolerance, transaminitis, prolongation of QTc (caution with conduction defects or drugs that do this)‡‡ |
Fosamprenavir
†† (FPV, Lexiva) |
700 mg tabs |
1400 mg bid or
700 mg/RTV 100 mg bid or
1400 mg/RTV 200 mg qd |
No effect |
Standard |
CPS* 5-8:
700 mg
bid
CPS* >9:
Avoid |
Rash, GI
intolerance, transaminitis,
headache,
hepatitis ‡‡ |
Indinavir (IDV,
Crixivan) |
200, 333, 400 mg caps |
800 mg q 8h; separate buffered ddI ≥ 1 hr
IDV 400 mg/RTV 400 mg bid or #
IDV 800 mg/RTV 100-200 mg bid # |
1 hr before
or 2 hr after
meal unless
with RTV |
Standard |
600 mg
q8h |
GI intolerance
nephrolithiasis,
transaminitis, benign increase
in indirect
bilirubin ‡‡ |
Lopinavir/
Ritonavir
(LPV/r)
(Kaletra) |
200/50 mg tabs ; LPV 80 mg + RTV 20 mg/mL
po soln †† |
400 mg LPV + 100 mg RTV (2 tabs) bid
Soln: 5 mL bid |
No effect |
Standard |
§§ |
Transaminitis, GI intolerance
(esp. diarrhea),
asthenia ‡‡ |
Nelfinavir
(NFV,
Viracept) |
250, 625 mg tabs
50 mg/g powder |
1250 mg bid or
750 mg tid |
Take with
high fat
meal |
Standard |
§§ |
GI intolerance, diarrhea, transaminitis ‡‡ |
Ritonavir (RTV,
Norvir) |
100 mg caps
600 mg/ 7.5 mL
po soln |
600 mg q12h #; separate ddI ≥ 2 h |
Food
improves GI
tolerance |
Standard |
§§ |
GI intolerance,
paresthesia,
transaminitis, taste
perversion ‡‡ |
Saquinavir††
(SQV, Invirase) |
200 mg caps
500 mg tabs |
SQV 1000 mg bid + RTV 100 bid ††
SQV 2000 mg qd + RTV 100 mg qd †† |
Take within 2 hours of meal |
Standard |
§§ |
GI intolerance,
transaminitis ‡‡ |
Tipranavir
(TPV, Aptivus) |
250 mg caps |
500 mg bid with RTV 200 mg bid |
Take TPV and RTV with food |
Standard |
CPS B or C: Avoid |
Hepatotoxicity - monitor ALT, skin rash, GI intoerlance, multiple drug interactions |
| Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) |
Delavirdine
(DLV, Rescriptor) |
100, 200 mg tabs |
400 mg tid |
No effect |
Standard |
§§ |
Rash |
Efavirenz †††
(EFV, Sustiva) |
50, 100, 200 mg
caps,
600 mg tabs |
600 mg hs |
Avoid high
fat meal |
Standard |
§§ |
CNS x 2-3
wks, rash,
hepatitis, false + cannibinoid test |
Nevirapine
(NVP,
Viramune) |
200 mg tabs
50 mg/5 mL po susp. |
200 mg qd x14 days, then 200 mg bid |
No effect |
Standard |
Standard;
give post
dialysis |
Avoid |
Rash, hepatitis;
hepatic necrosis
esp women with
CD4 >250 in
first 6 wks |
| Fusion Inhibitors |
Enfuvirtide
(ENF, Fuzeon,
T-20) |
90 mg singleuse
vials to be
reconstituted with 1.1 mL H20 |
90 mg (1 mL) SQ q12h into upper arm,
anterior or abdomen (rotate sites). |
N/A |
Standard |
Usual
Dose |
Site reactions |
† |
The
combination of ddI & d4T “should be used in pregnant
women only when the potential benefit clearly outweighs the
potential risk.” Efavirenz should be avoided in first
trimester of pregnancy and used with caution in women with reproductive
potential. Avoid APV liquid in pregnancy. |
†† |
The following are no longer available: buffered ddI, lopinovir/r 133/33 mg cap, amprenavir, or Fortovase. |
‡ |
Drug change or dose change could be considered on a case-by-case basis noting the risk of resistance with underdosing. |
** |
Capsule
is the preferred formulation due to high propylene glycol in
the po solution; po soln contraindicated in pregnancy. |
§ |
Class adverse reaction: lactic acidosis with steatosis (see Drug Table 2). Most common with d4T, ddl, and AZT. |
# |
See Drug Table 4 for dosing recommendations when using dual PI, PI plus NRTI, or dual PI plus NNRTI. |
¶ |
Give post dialysis |
* |
CPS = Child Pugh Score |
¶¶ |
Registry for hypersensitivity 1-800-270-0425 |
§§ |
More frequent monitoring required. Drug change or dose change could be considered on a case-by-case basis noting the risk of resistance with underdosing. |
††† |
Efavirenz should be avoided in first trimester of pregnancy and used with caution in women with reproductive potential. Avoid APV liquid in pregnancy. |
‡‡ |
Class adverse effects include lipodystrophy with hyperglycemia, fat redistribution, hyperlipidemia, and possible increased bleeding with hemophilia. ATV does not cause hyperlipidemia. All PIs may cause elevated transaminases (see Drug Table 2). |
» |
3TC, FTC, and TDF; Risk of flare of chronic HBV if discontinued. |
Drug Table 2.
TOP
Antiretroviral Agents, Class Adverse Reactions
| Reaction |
Lactic acidosis |
Hepatoxicity |
Hyperglycemia |
Fat redistribution |
Hyperlipidemia |
Rash |
| Definition |
Lactic acid >2 mmol/mL usually >5
mmol/mL |
Gr III = AST/ALT 5-10
X ULN
GR IV = AST/ALT > 10
x ULN |
Fasting glucose
>126 mg/dL |
Fat
accumulation,
Lipoatrophy |
See Adult ART Table 5 |
DRESS* (NVP, ABC)
SJS, TEN (NVP, EFV, DLV)
ABC hypersensitivity |
| Frequency |
1.3% NRTI recipients
with median onset at
4 mo. |
NRTIs: d4T, ddI, AZT (lactic
acidosis)
PIs: (15-30%)
NVP: 11% in first 6 wks in
women with baseline CD4
>250; possible hepatic
necrosis and death
NNRTI: (8-15%) |
3-17% with PIs |
4-50% |
--- |
ABC hypersensitivity: 5-8%, 90% in 1st 6 wks
EFV, NVP: 8-16% most in 1st 6 wks
|
| Agents |
NRTIs: d4T+ddI>d4T>
ddI>AZT; rare with
3TC, ABC, FTC or TDF |
NRTI: Lactic acidosis with steatosis
NVP: Hepatic necrosis
PIs, NNRTIs: transaminitis
|
PIs |
Fat accumulation: PIs
Lipoatrophy: NRTIs
esp. d4T
Also occurs without
antiretrovirals |
PI: esp. RTV; not noted
with ATV and reduced
frequency with FPV |
NNRTI: NVP > EFV & DLV
PIs: FPV, increased risk with sulfa allergy.
NRTI: ABC* |
| Risk Factors |
Prolonged use NRTI
(esp d4T)
Female, pregnancy,
obesity, ribavirin,
metformin |
HCV or HBV infection,
ETOH, male sex
NVP: baseline CD4>250 in
female, >400 in male |
Pre-existing glucose
intolerance |
No clear risks defined |
Risk for CVD: HBP,
smoking, obesity, genes,
prior MI/stroke, diabetes,
age |
ABC: genetic predisposition
NNRTI: 1st 12 wks
Female
|
| Sx |
GI (abd pain, anorexia,
nausea, vomiting),
wasting, dyspnea,
cardiac arrhythmias |
Most common: asymptomatic  ALT/AST due to all PIs and NNRTIs
NVP: may cause letahl hepatonecrosis
Note: indirect bilirubin with IDV or ATV is clinically
inconsequential but may cause jaundice |
Polyuria, polydipsia,
polyphagia, weight loss |
Fat
accumulation: abd (visceral), buffalo hump,
breasts, lipomas
Fat atrophy: face,
extremities, buttocks |
Cardiovascular disease with stroke or MI/angina.
Triglycerides >2000
mg/dL - pancreatitis |
Common: MP rash
Severe: Stevens-Johnson
synd, TEN#, DRESS *
NVP: hepatonecrosis with fever, rash, and/or GI sx 1st 16 weks
ABC hypersensitivity: ≥ 2 systems involved 1st 6 wks |
| Lab |
Lactate >2 mmol/mL;
life-threatening if >10
mmol/mL |
LFTs; liver biopsy is usually
not helpful. |
Fasting glucose >126
mg/dL |
Appearances is best "lab test", CT scan, MRI, waist and hip measurement,
Bioelectric Impedence Analysis,
DEXA, ultrasound |
triglycerides
cholesterol, LDL
cholesterol |
Eosinophilia: variable |
| Treatment |
Lactate 2-5 mmol/mL
+ Sx: D/C NRTI if sx
severe
Lactate level is 5-10
mmol/mL: D/C NRTIs.
Lactate >10 mmol/mL
(medical emergency):
D/C NRTIs +
supportive care
(ventilator, dialysis, IV
HCO3)
IV thiamine or
riboflavin (?)
Post recovery: use low risk NRTIs (3TC, FTC, TDF) or avoid class
|
Hypersensitivity reactions
to ABC or NVP (fever,
eosinophilia, rash, systemic
response usually in first 6-18
wks): D/C drug immediately
and do not rechallenge
Asymptomatic elevations of
LFT (<10 X ULN): repeat LFTs q 1-2 wks
Symptomatic or elevations of LFT (>5-10 X ULN) or hyperlactatemia or hypersensitivity (ABC or NVP): D/C ART or change regimen.
Some "treat through" asymptomatic ALT>10x ULN. ALT may return to baseline or persist; liver biopsy usually not helpful. |
Use standard diabetes
treatment with diet and
exercise
Preferred hypoglycemics
are metformin or
thiazolidinedione
D/C PI only if
uncontrolled
hyperglycemia |
D/C d4T, ddI, AZT for fat atrophy
Cosmetic surgery
Exercise?
Change PI to ATV or
NNRTI
Lipoatrophy: D/C d4T |
NECP guidelines (pg 29):
• General †
• LDL cholesterol
Statins
• Triglycerides fibrate |
Most rashes do not require drug
discontinuation
D/C drug if blisters, bullae, mucous membranes involved, fever, elevated ALT/AST
Withdraw NNRTI if severe; mucous membrane involvement (SJS); blisters or bullae, epidermal necrosis (TEN), systemic reaction (fever, arthralgia, myalgias)
Treatment: IV fluids, antipyretics, pain management, care in burn unit. Role of steroids not clear. Do not rechallenge
NVP and ABC: rash as component of DRESS* or ABC hypersensitivity or NVP hepatonecrosis reaction: D/C drug and supportive care |
Monitor
During
Therapy |
None |
LFTs at baseline and q 3-6 mo
NVP: LFTs at wks 0,2,4,8,12, 16 then q 3 mo |
Fasting glucose
baseline, at 3-6 mo, then yearly. |
Appearance |
Fasting lipid profile at
baseline, at 3-6 mo post HAART initiation, then yearly. |
Appearance |
*DRESS: (Drug
Rash, Eosinophilia, & Systemic Symptoms) Life threatening complication
that is seen with NVP and ABC - usually in the first 6 weeks of therapy.
†Lifestyle changes: d/c smoking, diet, weight reduction, exercise, tx HBP and diabetes.
# TEN: Toxic epidermal necrolysis
Drug Table 3. TOP
Antiretroviral Agents, Adverse Reactions: "Black Box Warnings"
| Agent |
Reaction |
| Abacavir |
• Fatal hypersensitivity reactions: do not restart
• Lactic acidosis and steatosis |
| Amprenavir |
Oral soln
contains large amounts of propylene glycol: avoid with renal
failure, hepatic failure, pregnancy, & metronidazole |
| Atazanavir |
None |
| Delavirdine |
None |
| Didanosine |
Fatal and nonfatal pancreatitis: do not restart
Lactic acidosis with steatosis
Fatal lactic acidosis when combined with stavudine in pregnancy |
| Efavirenz |
None |
| Emtricitabine |
Lactic acidosis with steatosis |
| Enfuvirtide |
None |
| Indinavir |
None |
| Lamivudine |
Lactic acidosis with steatosis; patients with HIV infection should receive only dosage and formulations appropriate for treatment of HIV. |
| Lopinavir |
None |
| Nelfinavir |
None |
| Nevirapine |
Hepatotoxicity including fulminant and cholestatic hepatitis & hepatic necrosis: monitor intensively in first 18 wks of therapy.
Severe, life-threatening skin reaction including toxic epidermal necrolysis (TEN), Stevens-Johnsson syndrome, etc.
Do not restart if there is serious liver injury or serious drug reaction. |
| Ritonavir |
Potentially serious drug interactions with nonsedating antihistamines, sedative hypnotics, antiarrhythmics, or ergot alkaloids. |
| Stavudine |
Lactic acidosis with steatosis
Fatal and non-fatal pancreatitis
Fatal lactic acidosis when combined with didanosine in pregnancy |
| Tenofovir |
Lactic acidosis and steatosis; discontinuation in pts with HBV co-infection may cause exacerbation of acute HBV |
| Tipranavir |
Hepatoxicity including clinical hepatitis and hepatic decomposition |
| Zalcitabine |
Severe peripheral neuropathy
Pancreatitis (rare)
Hepatic failure in patients with HBV infection (rare)
Lactic acidosis and steatosis |
| Zidovudine |
Hematologic toxicity: anemia & leucopenia
Lactic acidosis and steatosis |
Drug Table 4. TOP
Combination Antiretroviral Theraphy, Dose Adjustments
| |
RTV |
SQV |
NFV |
FPV |
LPV/r |
ATV |
NVP |
EFV |
| IDV |
IDV
400+
RTV 400
bid or
IDV/r
800/
100-200 bid |
ND |
IDV
1200
+ NFV
1250
bid |
IDV-SD,
APV-SD |
ND |
NR |
NVP-SD
IDV 1000
q8h |
EFV-SD
IDV- 1000
q8h or EFV SD/ IDV 800 bid/ RTV 200 bid |
| RTV |
--- |
SQV/r
1000/100
or
400/400
bid |
--- |
FPV/r
1400/200
qd or
700/100
bid |
co-formulated |
ATV/r
300/100
qd |
NVP-SD
RTV-SD |
EFV-SD
RTV-SD |
| SQV |
--- |
--- |
NFV-SD
+
SQV
1200
bid or SQV 800 tid |
ND |
SQV
1000 bid
+ LPV/r-
SD |
SQV 1200
+ATV 400 qd |
NVP-SD +
SQV/RTV
400/400
bid or
1000/100
bid |
EFV-SD +
SQV/RTV
400/400
bid |
| NFV |
--- |
--- |
--- |
ND |
ND |
ND |
NVP-SD
NFV-SD |
EFV-SD
NFV-SD |
| FPV |
--- |
--- |
--- |
--- |
NR |
ND |
ND |
EFV-SD
FPV/r
1400/300
qd or
700/100
bid |
| LPV |
--- |
--- |
--- |
--- |
--- |
ND |
NVP-SD
LPV/r
533/133
bid |
EFV-SD
LPV/r
533/133 bid |
| ATV |
--- |
--- |
--- |
--- |
--- |
--- |
ND |
EFV-SD
+ ATV/r
300/100 qd |
| TPV** |
|
|
|
|
|
|
|
|
* Doses are in mg; ND = Inadequate data; NR = Not recommended; SD = Standard dose;
** TPV must be combined with RTV and should not be combined with any other PI
Drug Table 5. TOP
Drug Interactions: Contraindicated Combinations
| Class |
Contraindicated Agent |
ART Agents |
Alternatives |
| Ca++ channel blocker |
Bepridil |
RTV, ATV, FTV, TPV |
--- |
| Antiarrythmics |
Flecainide,
Propafenone |
RTV, LPV/r, TPV |
--- |
| Amiodarone, quinidine |
RTV, IDV, TPV |
--- |
| Lipid lowering |
Simvastatin, Lovastatin |
All PIs, DLV |
Pravastatin or
Fluvastatin, possibly
Atorvastatin,
Rosuvastatin |
| Antimycobacterials |
Rifampin |
All PIs;
all NNRTIs except
EFV |
Use Rifabutin* |
| Rifabutin |
DLV, SQV (unless used
with RTV) |
--- |
| Rifapentine |
All PIs, NVP, DLV, EFV |
Rifampin or rifabutin |
| Antihistamine |
Astemizole,
Terfenadine |
All PIs, DLV, EFV |
Loratadine,
Fexofenadine,
Cetirizine, or
Desloratidine |
| Antineoplastics |
Irinoteacan |
ATV |
--- |
| GI |
Cisapride |
All PIs, DLV, EFV |
--- |
H2 blockers, proton
pump inhibitors |
DLV, ATV |
--- |
| Neuroleptic |
Clozapine |
RTV |
--- |
| Pimozide |
All PIs |
--- |
| Psychotropic |
Midazolam†
Triazolam |
All PIs, DLV, EFV |
Temazepam,
Lorazepam |
| Alprazolam |
DLV |
| Ergot alkaloids |
Ergotamine |
All PIs, DLV, EFV |
Consider Sumatriptan |
| Herbs |
St. John's wort |
All PIs & EFV, DLV, NVP |
Alternative antidepressants |
| Miscellaneous |
Fluticasone |
RTV and all RTV/PI combinations |
|
* See Drug Table 7, pg 14 for Rifabutin and antiretroviral dose adjustments
† Midazolam may be used with caution as a single dose given for a procedure.
Drug Table 6. TOP
Drug Interactions: Nucleosides
| Drug |
AZT |
D4T |
ddI |
TDF |
| Methadone |
AZT AUC 43%;
no dose change; monitor for AZT toxicity |
d4T  27%;
no dose change |
--- |
No change in methadone or TDF levels |
| ddI |
--- |
Magnifies toxicity.
Use with caution |
--- |
ddI 44%
Pt>60 kg: 250 mg/d (ddI)
Pt<60 kg: 200 mg/d (ddI) |
| Ribavirin |
Inhibits AZT
activation; avoid
if possible |
No data |
Magnifies ddI
toxicity; avoid |
No data |
| ATV |
--- |
--- |
ddI EC: separate dosing due to food restrictions. |
Avoid concomitant
use unless ATV
combined with RTV. |
Cidofovir
Ganciclovir
Valgancyclovir |
Gancyclovir +
AZT marrow toxicity
Monitor CBC
|
--- |
--- |
Combinations
may decrease
CrCl |
| LPV/r |
No data |
No data |
No data |
TDF AUC 34%
Standard doses and monitor for TDF toxicity |
| TPV |
AZT AUC 31-42%
Right dose?
|
--- |
TPV Cmin 44% with ddI EC
Separate by 2 hrs |
|
Drug Table 7. TOP
Drug Interactions: Combinations with NNRTIs or PIs Requiring Dose Modifications
| Class |
Agent |
ART |
| Antifungal |
Ketoconazole |
IDV: IDV 600 mg tid |
| RTV, LPV/r: Ketoconazole ≤ 200 mg/d, FPV ≤ 400 mg/d |
| NVP: Not recommended |
| Voriconazole |
Current use with RTV (≥ 400 mg/d) or EFV is contraindicated; no data for NNRTIs, NFV, ATV, TPV, FPV, LPV/r but bidirectional interacation anticipated; Monitor for toxicity; IDV is OK |
| Itraconazole |
IDV and TPV: Itraconazole dose ≤ 200 mg or monitor levels |
Oral
contraceptives |
--- |
Additional method of contraception recommended with: RTV, NFV, EFV, LPV/r, NVP, FPV. (IDV & ATV are OK) |
| No data for SQV |
| Anticonvulsants |
Phenobarbital,
Phenytoin,
Carbamazepine |
Avoid carbamazepine
+ IDV and phenytoin + LPV; all other combinations of NNRTIs
or PIs & designated anticonvulsants should be given with
caution and monitoring of anticonvulsant levels or consider
valproic acid |
| Methadone |
--- |
NVP and EFV may decrease methadone substantially; monitor for withdrawal
IDV has no interaction; other PIs may cause modest decrease in methadone levels and require monitoring for withdrawal
Methadone decreases buffered ddI levels - consider ddI EC (no interaction). |
| Antibiotics |
Clarithromycin |
RTV, LPV/r,TPV, DLV: Decrease clarithromycin dose in renal failure. |
| EFV, ATV: Consider alternative (e.g. Azithromycin) |
Erectile
dysfunction |
Sildenafil |
PIs + DLV: ≤ 25 mg q48 h |
| Vardenafil |
PIs + DLV: ≤ 2.5 mg/d |
| Tadalafil |
PIs + DLV: ≤ 10 mg q72 h |
| Antimycobacterials |
Rifabutin |
FPV 1400 mg bid + RBT 150 mg/d or 300 mg 3x/wk |
| ATV 400 mg/d + RBT 150 mg qod or 150 mg 3x/wk |
| EFV 600 mg/d + RBT 450-600 mg/d or 600 mg 3x/wk |
| IDV 1000 mg q 8h + RBT 150 mg/d or 300 mg 3x/wk |
| LPV/r 400/100 mg + RBT 150 mg qod or 3x/wk |
| NFV 1000 mg tid + RBT 150 mg/d or 300 mg 3x/wk |
| NVP standard + RBT standard |
| RTV 600 mg bid + RBT 150 mg qod or 150mg 3x/wk |
| RTV (maintain usual dose) + PI (standard dose) + RBT 150 mg qod or 3x/wk |
| Rifampin |
All PIs & NNRTIs contraindicated except EFV using standard doses of rifampin; consider EFV daily dose of 800 mg qd. |
| Lipid Lowering |
Lovastatin,
Simvastatin |
Avoid PIs and DLV; no data for EFV and NVP. |
| Atorvastatin |
Atorvastatin levels 480% - SQV/RTV, 70% - NFV, 9x - TPV, 150% - FPV, 590% - LPV/r; 43% EFV;
No data - IDV, ATV, NVP |
| Pravastatin |
Levels pravastatin 33% - LPV/r, 50% SQV/RTV;
No data for other PIs or NNRTIs |
| Miscellaneous |
Theophylline |
RTV: Monitor theophylline levels |
| Warfarin |
RTV, DLV, EFV: Monitor INR closely if given with any PI or NNRTI |
| Trazedone |
RTV: lowest dose + monitor CNS signs |
| Desipramine |
RTV: Consider desipramine dose reduction |
| Grapefruit juice |
IDV , SQV |
| Ca channel blockers |
ATV, FPV, RTV: contraindicated
Others: dose titration of Ca channel blockers + EKG monitoring
|
| Diltiazem |
All PIs: Reduce diltiazem dose 50% + monitor EKG |
ABC
Antacids |
TPV ABC levels 35-45%; ABC dose?
ATV and TPV levels ; give PI 2 hrs before or 1 hr after
|
| PPI |
ATV: Avoid PPI |
|
