Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV

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Drug-Drug Interactions

Drug Interactions between Integrase Inhibitors and Other Drugs

Last Updated: October 17, 2017; Last Reviewed: October 17, 2017

Table 18d. Drug Interactions Between Integrase Strand Transfer Inhibitors and Other Drugs

This table provides information on known or predicted pharamacokinetic interactions between INSTIs (DTG, EVG, or RAL) and non-ARV drugs. EVG is always coadministered with COBI. Recommendations for managing a particular drug interaction may differ depending on whether a new ARV drug is being initiated in a patient on a stable concomitant medication or if a new concomitant medication is being initiated in a patient on a stable ARV regimen. The magnitude and significance of drug interactions are difficult to predict when several drugs with competing metabolic pathways are prescribed concomitantly.

Table 18d. Drug Interactions Between Integrase Strand Transfer Inhibitors and Other Drugs
Concomitant Drug Class/Name INSTI Effect on INSTI or Concomitant Drug Concentrations Dosing Recommendations and Clinical Comments
Acid Reducers
Al, Mg,
+/-
Ca-Containing Antacids


Please refer to the Miscellaneous Drugs section of this table for recommendations on use with other polyvalent cation products (e.g., Fe, Ca supplements, multivitamins).
DTG DTG AUC ↓ 74% if given simultaneously with antacid

DTG AUC ↓ 26% if given 2 hours before antacid
Give DTG at least 2 hours before or at least 6 hours after antacids containing polyvalent cations.
EVG/c EVG AUC ↓ 40%–50% if given simultaneously with antacid

EVG AUC ↓ 15%–20% if given 2 hours before or after antacid; ↔ with 4-hour interval
Separate EVG/c/TDF/FTC and antacid administration by more than 2 hours.
RAL Al-Mg Hydroxide Antacid:
  • RAL Cmin ↓ 49% to 63%
CaCO3 Antacid:
  • RAL (400 mg BID) Cmin ↓ 32%
  • RAL (1200 mg once daily) Cmin ↓ 48% to 57%
Do not coadminister RAL and Al-Mg hydroxide antacids. Use alternative acid reducing agent.

With CaCO3 Antacids:
  • RAL 1200 mg once daily: Do not coadminister
  • RAL 400 mg BID: No dose adjustment or separation necessary
H2-Receptor Antagonists EVG/c No significant effect No dose adjustment.
Proton Pump Inhibitors (PPIs) DTG No significant effect No dose adjustment.
EVG/c No significant effect No dose adjustment.
RAL RAL AUC ↑ 37% and Cmin ↑ 24% No dose adjustment.
Anticoagulants and Antiplatelets
Apixaban EVG/c ↑ apixaban expected Coadministration is not recommended. Consider alternative antiretroviral (e.g., an unboosted INSTI) or warfarin. If coadministration is necessary, reduce apixaban dose by 50% and monitor for apixaban toxicity.
Betrixaban EVG/c ↑ betrixaban expected Coadministration is not recommended. Consider alternative antiretroviral (e.g., an unboosted INSTI) or warfarin.
Dabigatran EVG/c ↑ dabigatran expected

Dabigatran AUC ↑ 110%–127% with COBI 150 mg alone
Coadministration is not recommended. Consider alternative antiretroviral (e.g., another INSTI) or warfarin.
Edoxaban EVG/c ↑ edoxaban expected Coadministration is not recommended. Consider alternative antiretroviral (e.g., an unboosted INSTI) or warfarin.
Rivaroxaban EVG/c ↑ rivaroxaban expected Coadministration is not recommended. Consider alternative antiretroviral (e.g., an unboosted INSTI) or warfarin.
Ticagrelor EVG/c ↑ ticagrelor expected Avoid concomitant use.
Vorapaxar EVG/c ↑ vorapaxar expected Avoid concomitant use.
Warfarin EVG/c ↑ or ↓ warfarin possible Monitor INR and adjust warfarin dose accordingly.
Anticonvulsants
Carbamazepine DTG DTG AUC ↓ 49% Increase DTG dose to 50 mg BID in treatment-naive or treatment-experienced, INSTI-naive patients.

Use alternative anticonvulsant for INSTI-experienced patients with known or suspected INSTI resistance.
EVG/c Carbamazepine AUC ↑ 43%

EVG AUC ↓ 69% and Cmin ↓ >99%

↓ COBI expected
Contraindicated.
RAL ↓ or ↔ RAL possible Coadministration is not recommended.
Phenobarbital Phenytoin DTG ↓ DTG possible Coadministration is not recommended.
EVG/c ↓ EVG/c expected Contraindicated.
RAL ↓ or ↔ RAL possible Coadministration is not recommended.
Ethosuximide EVG/c ↑ ethosuximide possible Clinically monitor for ethosuxamide toxicities.
Oxcarbazepine DTG, EVG/c ↓ INSTI possible

↓ cobicistat possible
Consider alternative anticonvulsant.
Antidepressants/Anxiolytics/Antipsychotics
Also see Sedative/Hypnotics section below.
Bupropion EVG/c ↑ or ↓ bupropion possible Titrate bupropion dose based on clinical response.
Buspirone EVG/c ↑ buspirone possible Initiate buspirone at a low dose. Dose reduction may be necessary.
Fluvoxamine EVG/c ↑ or ↓ EVG possible Consider alternative antidepressant or ARV.
Lurasidone EVG/c ↑ lurasidone expected Contraindicated.
Pimozide EVG/c ↑ pimozide expected Contraindicated.
Quetiapine EVG/c ↑ quetiapine AUC expected Initiation of Quetiapine in a Patient Receiving EVG/c:
  • Start quetiapine at the lowest dose and titrate up as needed. Monitor for quetiapine efficacy and adverse effects.
Initiation of EVG/c in a Patient Receiving a Stable Dose of Quetiapine:
  • Reduce quetiapine dose to 1/6 of the original dose, and closely monitor for quetiapine efficacy and adverse effects.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Citalopram, escitalopram, fluoxetine, paroxetine, sertraline
EVG/c ↔ EVG

↔ sertraline
No dose adjustment necessary.
↑ other SSRI possible Initiate with lowest dose of SSRI and titrate dose carefully based on antidepressant response.
RAL ↔ RAL

↔ citalopram

↔ SSRI expected
No dose adjustment necessary.
DTG ↔ DTG

↔ citalopram

↔ SSRI expected
No dose adjustment necessary.
Tricyclic Antidepressants (TCAs)
Amitriptyline, desipramine, doxepin, imipramine, nortriptyline
EVG/c Desipramine AUC ↑ 65% Initiate with lowest dose of TCA and titrate dose carefully.
↑ TCA expected Initiate with lowest dose of TCA and titrate dose carefully based on antidepressant response and/or drug levels.
Trazodone EVG/c ↑ trazodone possible Initiate with lowest dose of trazodone and titrate dose carefully.
Antifungals
Isavuconazole EVG/c ↑ isavuconazole expected

↑ EVG and COBI possible
If coadministered, consider monitoring isavuconazole concentrations and assess virologic response.
Itraconazole EVG/c ↑ itraconazole expected

↑ EVG and COBI possible
Consider monitoring itraconazole level to guide dosage adjustments. High itraconazole doses (>200 mg/day) are not recommended unless dose is guided by itraconazole levels.
Posaconazole EVG/c ↑ EVG and COBI possible

↑ posaconazole possible
If coadministered, monitor posaconazole concentrations.
Voriconazole EVG/c ↑ voriconazole expected

↑ EVG and COBI possible
Risk/benefit ratio should be assessed to justify use of voriconazole. If administered, consider monitoring voriconazole level. Adjust dose accordingly.
Antihyperglycemics
Saxagliptin EVG/c ↑ saxagliptin expected Limit saxagliptin dose to 2.5 mg once daily.
Dapagliflozin/ Saxagliptin EVG/c ↑ saxagliptin expected Do not coadminister, as this coformulated drug contains 5 mg of saxagliptin.
Antimycobacterials
Clarithromycin EVG/c ↑ clarithromycin possible

↑ COBI possible
CrCl 50−60 mL/min:
  • Reduce clarithromycin dose by 50%
CrCl <50 mL/min:
  • EVG/c is not recommended
Rifabutin DTG Rifabutin (300 mg Once Daily):
  • DTG AUC ↔ and Cmin ↓ 30%
No dose adjustment necessary.
EVG/c Rifabutin 150 mg Every Other Day with EVG/c Once Daily Compared to Rifabutin 300 mg Once Daily Alone:
  • ↔ rifabutin AUC
  • 25-O-desacetyl-rifabutin AUC ↑ 625%
  • EVG AUC ↓ 21%, Cmin ↓ 67%
Do not coadminister.
RAL RAL AUC ↑ 19%, Cmin ↓ 20% No dose adjustment necessary.
Rifampin DTG Rifampin with DTG 50 mg BID Compared to DTG 50 mg BID Alone:
  • DTG AUC ↓ 54%, Cmin ↓ 72%
Rifampin with DTG 50 mg BID Compared to DTG 50 mg Once Daily Alone:
  • DTG AUC ↑ 33%, Cmin ↑ 22%
Dose:
  • DTG 50 mg BID (instead of 50 mg once daily) for patients without suspected or documented INSTI mutation.

Alternative to rifampin should be used in patients with certain suspected or documented INSTI-associated resistance substitutions. Consider using rifabutin.
EVG/c Significant ↓ EVG and COBI expected Contraindicated.
RAL RAL 400 mg:
  • RAL AUC ↓ 40%, Cmin ↓ 61%
Rifampin with RAL 800 mg BID Compared to RAL 400 mg BID Alone:
  • RAL AUC ↑ 27%, Cmin ↓ 53%
Dose:
  • RAL 800 mg BID, instead of 400 mg BID
Do not coadminister RAL 1200 mg once daily with rifampin.

Monitor closely for virologic response or consider using rifabutin as an alternative rifamycin.
Rifapentine DTG Significant ↓ DTG expected Do not coadminister.
EVG/c Significant ↓ EVG and COBI expected Do not coadminister.
RAL Rifapentine 900 mg Once Weekly:
  • RAL AUC ↑ 71%, Cmin ↓ 12%
Rifapentine 600 mg Once Daily:
  • RAL Cmin ↓ 41%
For once-weekly rifapentine, use standard RAL 400 mg BID doses.

Do not coadminister with once-daily rifapentine.
Cardiac Medications
Antiarrhythmics
Amiodarone, bepridil, digoxin, disopyramide, dronedarone, flecainide, systemic lidocaine, mexilitine, propafenone, quinidine
EVG/c ↑ antiarrhythmics possible

Digoxin Cmax ↑ 41% and no significant change in AUC
Use antiarrhythmics with caution. Therapeutic drug monitoring, if available, is recommended for antiarrhythmics.
Bosentan EVG/c ↑ bosentan possible In Patients on EVG/c ≥10 Days:
  • Start bosentan at 62.5 mg once daily or every other day based on individual tolerability.
In Patients on Bosentan Who Require EVG/c:
  • Stop bosentan ≥36 hours before EVG/c initiation. At least 10 days after initiation of EVG/c, resume bosentan at 62.5 mg once daily or every other day based on individual tolerability.
Beta-blockers
(e.g., metoprolol, timolol)
EVG/c ↑ beta-blockers possible Beta-blocker dose may need to be decreased; adjust dose based on clinical response.

Consider using beta-blockers that are not metabolized by CYP450 enzymes (e.g., atenolol, labetalol, nadolol, sotalol).
Calcium Channel Blockers (CCBs) EVG/c ↑ CCBs possible Coadminister with caution. Titrate CCB dose and monitor for CCB efficacy and toxicities.

Refer to Table 18a for diltiazem + ATV/r recommendations.
Dofetilide DTG ↑ dofetilide expected Contraindicated.
Eplerenone EVG/c ↑ eplerenone expected Contraindicated.
Ranolazine EVG/c ↑ ranolazine expected Contraindicated.
Ivabradine EVG/c ↑ ivabradine expected Contraindicated.
Corticosteroids
Beclomethasone
Inhaled or intranasal
EVG/c ↔ expected No dose adjustment necessary.
Budesonide, Ciclesonide, Fluticasone, Mometasone
Inhaled or intranasal
EVG/c ↑ glucocorticoid possible Coadministration can result in adrenal insufficiency and Cushing’s syndrome. Do not coadminister unless potential benefits of inhaled or intranasal corticosteroid outweigh the risks of systemic corticosteroid adverse effects. Consider an alternative corticosteroid (e.g., beclomethasone).
Betamethasone, Budesonide
Systemic
EVG/c ↑ glucocorticoids possible
↓ PI possible
Coadministration can result in adrenal insufficiency and Cushing’s syndrome. Do not coadminister unless potential benefits of systemic budesonide outweigh the risks of systemic corticosteroid adverse effects.
Dexamethasone
Systemic
EVG/c ↓ EVG and COBI possible Consider an alternative corticosteroid for long-term use or alternative ART. If coadministration is necessary, monitor virologic response to ART.
Prednisone, Prednisolone
Systemic
EVG/c ↑ prednisolone possible Coadministration may be considered if the potential benefits outweigh the risks of systemic corticosteroid adverse effects. If coadministered, monitor for adrenal insufficiency and Cushing’s syndrome.
Betamethasone, Methylprednisolone, Prednisolone, Triamcinolone
Local injections, including intra-articular, epidural, or intra-orbital
EVG/c ↑ glucocorticoids expected Do not coadminister. Coadministration may result in adrenal insufficiency and Cushing’s syndrome.
Hepatitis C Direct Acting Antivirals
Daclatasvir DTG ↔ daclatasvir No dose adjustment necessary.
EVG/c ↑ daclatasvir Decrease daclastavir dose to 30 mg once daily.
RAL No data No dose adjustment necessary.
Dasabuvir + Ombitasvir/ Paritaprevir/r DTG No data No dosing recommendations at this time.
EVG/c No data Do not coadminister.
RAL RAL AUC ↑ 134% No dose adjustment necessary.
Elbasvir/ Grazoprevir DTG ↔ elbasvir

↔ grazoprevir

↔ DTG
No dose adjustment necessary.
EVG/c ↑ elbasvir, grazoprevir expected Coadministration is not recommended.
RAL ↔ elbasvir

↔ grazoprevir

RAL ↔ with elbasvir

RAL AUC ↑ 43% with grazoprevir
No dose adjustment necessary.
Glecaprevir/ Pibrentasvir DTG, RAL No significant effect No dose adjustment necessary.
EVG/c Glecaprevir AUC ↑ 3-fold

Pibrentasvir AUC ↑ 57%

EVG AUC ↑ 47%
No dose adjustment necessary.
Ledipasvir/ Sofosbuvir EVG/c/ TDF/FTC ↑ TDF and ↑ ledipasvir expected Do not coadminister.
EVG/c/ TAF/FTC ↔ EVG/c/TAF/FTC expected No dose adjustment necessary.
DTG, RAL ↔ DTG or RAL No dose adjustment necessary.
Simeprevir DTG ↔ expected No dose adjustment necessary.
EVG/c ↑ simeprevir expected Coadministration is not recommended.
RAL ↔ expected No dose adjustment necessary.
Sofosbuvir All INSTIs ↔ expected No dose adjustment necessary.
Sofosbuvir/ Velpatasvir All INSTIs ↔ expected No dose adjustment necessary.
Sofosbuvir/ Velpatasvir/ Voxilaprevir EVG/c When Given with Sofosbuvir/Velpatasvir/Voxilaprevir (400/100/100 mg) + Voxilaprevir 100 mg:
  • Sofosbuvir AUC ↑ 22%
  • ↔ velpatasvir
  • Voxilaprevir AUC ↑ 2-fold
No dose adjustment necessary.
DTG, RAL ↔ expected No dose adjustment necessary.
Herbal Products
St. John’s Wort DTG ↓ DTG possible Do not coadminister.
EVG/c ↓ EVG and COBI possible Contraindicated.
Hormonal Therapies
Hormonal Contraceptives DTG, RAL ↔ ethinyl estradiol, norgestimate, and DTG or RAL No dose adjustment necessary.
EVG/c Norgestimate AUC, Cmax, and Cmin ↑ >2-fold

Ethinyl estradiol AUC ↓ 25% and Cmin ↓ 44%
The effects of increases in progestin (norgestimate) are not fully known and can include insulin resistance, dyslipidemia, acne, and venous thrombosis. Weigh the risks and benefits of the drug, and consider alternative contraceptive method.
↑ drospirenone possible Clinical monitoring is recommended, due to the potential for hyperkalemia.
Menopausal Hormone Replacement Therapy DTG, RAL With estradiol or conjugated estrogen (equine and synthetic): ↓ estrogen possible

↔ drospirenone, medroxyprogesterone, or micronized progesterone expected
No dose adjustment necessary.
EVG/c ↓ estrogen possible

↑ drospirenone possible

↑ oral medroxyprogesterone possible

↑ oral micronized progesterone possible
Adjust estrogen and progestin dose as needed based on clinical effects.
Gender-Affirming Hormone Therapy DTG, RAL ↔ estrogen expected No dose adjustment necessary.
DTG, EVG/c, RAL ↔ finasteride, goserelin, leuprolide acetate, spironolactone expected
EVG/c ↓ estradiol possible

↑ dutasteride possible
Adjust dutasteride dosage as needed based on clinical effects and endogenous hormone concentrations.
EVG/c ↑ testosterone possible Monitor masculinizing effects of testosterone and for adverse effects and adjust testosterone dose as necessary.
DTG, RAL ↔ testosterone expected No dose adjustment necessary.
HMG-CoA Reductase Inhibitors
Atorvastatin EVG/c ↑ atorvastatin AUC 2.6-fold and Cmax 2.3-fold Titrate statin dose carefully and use the lowest dose necessary while monitoring for toxicities. Do not exceed 20 mg atorvastatin daily.
Lovastatin EVG/c Significant ↑ lovastatin expected Contraindicated.
Pitavastatin, Pravastatin EVG/c No data No dosage recommendation
Rosuvastatin EVG/c Rosuvastatin AUC ↑ 38% and Cmax ↑ 89% Titrate statin dose carefully and use the lowest dose necessary while monitoring for toxicities.
Simvastatin EVG/c Significant ↑ simvastatin expected Contraindicated.
Immunosuppressants
Cyclosporine, Everolimus, Sirolimus, Tacrolimus EVG/c ↑ immunosuppressant possible Initiate with an adjusted immunosuppressant dose to account for potential increased concentration and monitor for toxicities. Therapeutic drug monitoring of immunosuppressant is recommended. Consult with specialist as necessary.
Narcotics/Treatment for Opioid Dependence
Buprenorphine
Sublingual, buccal, or implant
EVG/c Buprenorphine AUC ↑ 35%, Cmax ↑ 12%, and Cmin ↑ 66%

Norbuprenorphine AUC ↑ 42%, Cmax ↑ 24%, and Cmin ↑ 57%
No dose adjustment necessary. Clinical monitoring is recommended. When transferring buprenorphine from transmucosal to implantation, monitor to ensure buprenorphine effect is adequate and not excessive.
RAL ↔ observed (sublingual)

↔ expected (implant)
No dose adjustment necessary.
Methadone DTG No significant effect No dose adjustment necessary.
EVG/c No significant effect No dose adjustment necessary.
RAL No significant effect No dose adjustment necessary.
Neuroleptics
Perphenazine, Risperidone, Thioridazine EVG/c ↑ neuroleptic possible Initiate neuroleptic at a low dose. Decrease in neuroleptic dose may be necessary.
PDE5 Inhibitors
Avanafil EVG/c No data Coadministration is not recommended.
Sildenafil EVG/c ↑ sildenafil expected For Treatment of Erectile Dysfunction:
  • Start with sildenafil 25 mg every 48 hours and monitor for adverse effects of sildenafil.
For treatment of PAH:
  • Contraindicated.
Tadalafil EVG/c ↑ tadalafil expected For Treatment of Erectile Dysfunction:
  • Start with tadalafil 5-mg dose and do not exceed a single dose of 10 mg every 72 hours. Monitor for adverse effects of tadalafil.

For Treatment of PAH:
In patients on EVG/c >7 days:
  • Start with tadalafil 20 mg once daily and increase to 40 mg once daily based on tolerability.
In patients on tadalafil who require EVG/c:
  • Stop tadalafil ≥24 hours before EVG/c initiation. Seven days after EVG/c initiation, restart tadalafil at 20 mg once daily, and increase to 40 mg once daily based on tolerability.
Vardenafil EVG/c ↑ vardenafil expected Start with vardenafil 2.5 mg every 72 hours and monitor for adverse effects of vardenafil.
Sedative/Hypnotics
Clonazepam, Clorazepate, Diazepam, Estazolam, Flurazepam EVG/c ↑ benzodiazepines possible Dose reduction of benzodiazepine may be necessary. Initiate with low dose and clinically monitor.

Consider alternative benzodiazepines to diazepam, such as lorazepam, oxazepam, or temazepam.
Midazolam, Triazolam DTG With DTG 25 mg:
  • midazolam AUC ↔
No dose adjustment necessary.
EVG/c ↑ midazolam expected

↑ triazolam expected
Contraindicated. Do not coadminister triazolam or oral midazolam and EVG/c.

Parenteral midazolam can be used with caution in a closely monitored setting. Consider dose reduction, especially if more than one dose is administered.
Suvorexant EVG/c ↑ suvorexant expected Coadministration is not recommended.
Zolpidem EVG/c ↑ zolpidem expected Initiate zolpidem at a low dose. Dose reduction may be necessary.
Miscellaneous Drugs
Alfuzosin EVG/c ↑ alfuzosin expected Contraindicated.
Calcifediol EVG/c ↑ calcifediol possible Dose adjustment of calcifediol may be required, and serum 25-hydroxyvitamin D, intact PTH, and serum Ca concentrations should be closely monitored.
Cisapride EVG/c ↑ cisapride expected Contraindicated.
Colchicine EVG/c ↑ colchicine expected Do not coadminister in patients with hepatic or renal impairment.

For Treatment of Gout Flares:
  • Colchicine 0.6 mg for 1 dose, followed by 0.3 mg 1 hour later. Do not repeat dose for at least 3 days.

For Prophylaxis of Gout Flares:
  • If original dose was colchicine 0.6 mg BID, decrease to colchicine 0.3 mg once daily. If regimen was 0.6 mg once daily, decrease to 0.3 mg every other day.

For Treatment of Familial Mediterranean Fever:
  • Do not exceed colchicine 0.6 mg once daily or 0.3 mg BID.

Ergot Derivatives EVG/c ↑ dihydroergotamine, ergotamine, methylergonovine expected Contraindicated.
Dronabinol EVG/c ↑ dronabinol possible Monitor for dronabinol-related adverse effects.
Eluxadoline EVG/c ↑ eluxadoline possible Monitor for eluxadoline-related adverse effects.
Flibanserin EVG/c ↑ flibanserin expected Contraindicated.
Metformin DTG DTG 50 mg Once Daily + Metformin 500 mg BID:
  • Metformin AUC ↑ 79%, Cmax ↑ 66%
DTG 50 mg BID + Metformin 500 mg BID:
  • Metformin AUC↑ 2.4-fold, Cmax ↑ 2-fold
Start metformin at lowest dose and titrate based on glycemic control. Monitor for metformin adverse effects.

When starting/stopping DTG in patients on metformin, dose adjustment of metformin may be necessary to maintain optimal glycemic control and/or minimize adverse effects of metformin.
Polyvalent Cation Supplements
Mg, Al, Fe, Ca, Zn, including multivitamins with minerals

Note: Please refer to the Acid Reducers section in this table for recommendations on use with Al-, Mg-, and Ca-containing antacids.
All INSTIs ↓ INSTI possible

DTG ↔ when administered with Ca or Fe supplement simultaneously with food
If coadministration is necessary, give INSTI at least 2 hours before or at least 6 hours after supplements containing polyvalent cations, including but not limited to the following products: cation-containing laxatives; Fe, Ca, or Mg supplements; and sucralfate. Monitor for virologic efficacy.

DTG and supplements containing Ca or Fe can be taken simultaneously with food.

Many oral multivitamins also contain varying amounts of polyvalent cations; the extent and significance of chelation is unknown.
Salmeterol EVG/c ↑ salmeterol possible Do not coadminister, due to potential increased risk of salmeterol-associated cardiovascular events.
Key to Acronyms: Al = aluminum; ART = antiretroviral therapy; ARV = antiretroviral; AUC = area under the curve; BID = twice daily; Ca = calcium; CaCO3 = calcium carbonate; CCB = calcium channel blocker; Cmax = maximum plasma concentration; Cmin = minimum plasma concentration; COBI, c = cobicistat; CrCl = creatinine clearance; CYP = cytochrome P; DTG = dolutegravir; EVG = elvitegravir; Fe = iron; FTC = emtricitabine; GI = gastrointestinal; INR= international normalized ratio; INSTI = integrase strand transfer inhibitor; Mg = magnesium; PAH = pulmonary arterial hypertension; PI = protease inhibitor; PI/r = ritonavir-boosted protease inhibitor; PPI = proton pump inhibitor; PTH = parathyroid hormone; r = ritonavir; RAL = raltegravir; TDF = tenofovir disoproxil fumarate; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; Zn = zinc

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