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Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

Drug Interactions

Drugs That Should Not Be Used With Antiretroviral Agents

(Last updated: April 8, 2015; last reviewed: April 8, 2015)

Table 18. Drugs That Should Not Be Used With Antiretroviral Agents

This table only lists drugs that should not be coadministered at any dose and regardless of RTV or COBI enhancing. See Tables 19 and 20 for more detailed PK interaction data.

Table 18. Drugs That Should Not Be Used With Antiretroviral Agents
ARV Agentsa,b Cardiac Agents Lipid-Lowering Agents Antimyco-bacterial Agents Antiepileptic Agents Neurologic Agents Herbs HCV Agentsc  Other Agents
ATV 
+/−
RTV or COBI
Dronedarone
Ranolazine
Lovastatin
Simvastatin
Rifampin
Rifapentined
None Lurasidone
Midazolame

Pimozide

Triazolam
St. John’s wort Boceprevir
Simeprevir
Alfuzosin
Cisapridef
Ergot derivatives
Irinotecan
Salmeterol
Sildenafil for PAH
DRV/c
or
DRV/r
Dronedarone
Ranolazine
Lovastatin
Simvastatin
Rifampin
Rifapentined
 None Lurasidone
Midazolame 

Pimozide 

Triazolam

St. John’s wort
Boceprevir
Dasabuvir
Ombitasvir
Paritaprevir

Simeprevir 
Alfuzosin
Cisapridef
Ergot derivatives
Salmeterol
Sildenafil for PAH
FPV
+/−
RTV
Dronedarone
Flecainide
Propafenone
Ranolazine
Lovastatin
Simvastatin
Rifampin
Rifapentined
None Lurasidone
Midazolame
Pimozide
Triazolam
St. John’s wort Boceprevir
Dasabuvir
Ombitasvir 
Paritaprevir 
Simeprevir
Alfuzosin
Cisapridef
Ergot derivatives
Salmeterol
Sildenafil for PAH
LPV/r Dronedarone
Ranolazine
Lovastatin
Simvastatin
Rifamping
Rifapentined
None Lurasidone
Midazolame
Pimozide
Triazolam
St. John’s wort Boceprevir
Dasabuvir
Ombitasvir 
Paritaprevir 
Simeprevir
Alfuzosin
Cisapridef
Ergot derivatives
Salmeterol
Sildenafil for PAH
SQV/r Amiodarone
Dofetilide
Dronedarone
Flecainide
Lidocaine
Propafenone
Quinidine
Ranolazine
Lovastatin
Simvastatin
Rifamping
Rifapentined
None Lurasidone
Midazolame
Pimozide
Trazodone
Triazolam
Garlic supplements 
St. John’s wort
Boceprevir
Dasabuvir
Ombitasvir
Paritaprevir 
Simeprevir
Alfuzosin
Cisapridef
Ergot derivatives
Salmeterol
Sildenafil for PAH
TPV/r Amiodarone
Dronedarone
Flecainide
Propafenone
Quinidine
Ranolazine
Lovastatin
Simvastatin
Rifampin
Rifapentined
None Lurasidone
Midazolame
Pimozide
Triazolam
St. John’s wort

Boceprevir
Dasabuvir 
Ledipasvir
Ombitasvir
Paritaprevir
Simeprevir
Sofosbuvir
Alfuzosin
Cisapridef
Ergot derivatives
Salmeterol
Sildenafil for PAH
EFV None None Rifapentined  None None St. John’s wort Boceprevir
Dasabuvir
Ombitasvir
Paritaprevir
Simeprevir
None
ETR None None Rifampin
Rifapentined
Carbamazepine
Phenobarbital
Phenytoin
None St John’s wort Dasabuvir
Ombitasvir
Paritaprevir
Simeprevir
Clopidogrel
NVP None None Rifapentined None None St. John’s wort Dasabuvir
Ombitasvir
Paritaprevir 
Simeprevir
Ketoconazole
RPV None None Rifampin
Rifapentined
Carbamazepine
Oxcarbazepine
Phenobarbital
Phenytoin
None St. John’s wort Dasabuvir
Ombitasvir
Paritaprevir
Proton pump inhibitors
MVC None None Rifapentined None None St. John’s wort Dasabuvir
Ombitasvir
Paritaprevir 
None
EVG/c/TDF/FTC
or 
EVG + PI/r
Ranolazine Lovastatin
Simvastatin
Rifampin
Rifapentined
None Lurasidone
Pimozide
Midazolame
Triazolam
St. John’s wort EVG/c/TDF/FTC:
  • Boceprevir
  • Dasabuvir 
  • Ledipasvir
  • Ombitasvir
  • Paritaprevir 
  • Simeprevir
EVG + PI/r:
  • Refer to agents listed for the selected PI
Alfuzosin
Cisapridef
Ergot derivatives
Salmeterol
Sildenafil for PAH
DTG Dofetilide None Rifapentined None None St. John’s wort None None
a DLV, IDV, NFV, and RTV (as sole PI) are not included in this table. Refer to the appropriate FDA package insert for information regarding DLV-, IDV-, NFV-, and RTV (as sole PI)-related drug interactions.
b Certain listed drugs are contraindicated on the basis of theoretical considerations. Thus, drugs with narrow therapeutic indices and suspected metabolic involvement with CYP450 3A, 2D6, or unknown pathways are included in this table. Actual interactions may or may not occur in patients.
c HCV agents listed include only those that are commercially available at the publication of these guidelines.
d HIV-infected patients who received rifapentine as part of a treatment regimen for TB had a higher rate of TB relapse and acquired rifamycin resistance than those treated with other rifamycin-based regimens. Therefore an alternative agent to rifapentine is recommended for TB treatment.
e Use of oral midazolam is contraindicated. Single-dose parenteral midazolam can be used with caution and can be given in a monitored situation for procedural sedation.
f The manufacturer of cisapride has a limited-access protocol for patients who meet specific clinical eligibility criteria.
g A high rate of Grade 4 serum transaminase elevation was seen when a higher dose of RTV was added to LPV/r or SQV or when double-dose LPV/r was used with rifampin to compensate for rifampin’s induction effect; therefore, these dosing strategies should not be used.

 
Suggested alternatives to
  • Lovastatin, simvastatin: Fluvastatin, pitavastatin, and pravastatin (except for pravastatin with DRV/r) have the least potential for drug-drug interactions (see Table 19a). Use atorvastatin and rosuvastatin with caution; start with the lowest possible dose and titrate based on tolerance and lipid-lowering efficacy. 
  • Rifampin: Rifabutin (with dosage adjustment, see Tables 19a and 19b
  • Midazolam, triazolam: temazepam, lorazepam, oxazepam
 
Key to Acronyms: ARV = antiretroviral; ATV = atazanavir; COBI = cobicistat; CYP = cytochrome P; DLV = delavirdine; DRV/c = darunavir/cobicistat; DRV/r = darunavir/ritonavir; DTG = dolutegravir; EFV = efavirenz; ETR = etravirine; EVG = elvitegravir; EVG/c/TDF/FTC = elvitegravir/cobicistat/tenofovir/emtricitabine; FDA = Food and Drug Administration; FPV = fosamprenavir; FTC = emtricitabine; HCV = hepatitis C virus; IDV = indinavir; LPV/r = lopinavir/ritonavir; MVC = maraviroc; NFV = nelfinavir; NVP = nevirapine; PAH = pulmonary arterial hypertension; PI = protease inhibitor; PI/r = ritonavir-boosted protease inhibitor; PK = pharmacokinetic; RPV = rilpivirine; RTV = ritonavir; SQV = saquinavir; SQV/r = saquinavir/ritonavir; TB = tuberculosis; TDF = tenofovir disoproxil fumarate; TPV/r = tipranavir/ritonavir

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