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Database of Antiretroviral Drug Interactions

Interactions between Cardiovascular medications and Antiretrovirals

Interactions with Amiodarone
Antiretroviral (ARV)Dose of ARVDose of AmiodaroneEffect on ARV LevelsEffect on Amiodarone LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase amiodarone levelsIncreased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias)Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust amiodarone as indicated

Atazanavir/cobicistat755
(others)(Evotaz)
--- Not studied; may increase amiodarone levels Possible increased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias) Inhibition of CYP3A4 by cobicistat

Use with caution; monitor amiodarone adverse effects. Consider obtaining ECG and monitoring amiodarone levels

Darunavir161
(DRV)(Prezista)
---Not studied; may increase amiodarone levelsIncreased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias)Inhibition of CYP450 3A4 by darunavir

Use with caution. Monitor for amiodarone toxicity. Consider ECG and amiodarone drug level monitoring.

Darunavir/cobicistat757
(Prezcobix)
--- Not studied; may increase amiodarone levels Possible increased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias) Inhibition of CYP3A4 by cobicistat

Use with caution. Monitor for amiodarone toxicity. Consider ECG and amiodarone drug level monitoring

Elvitegravir/cobicistat699
(Genvoya, Stribild)
---Not studied; may increase amiodarone levelsPossible increased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias) Inhibition of CYP3A4 by cobicistat

Use with caution; monitor amiodarone adverse effects. Consider obtaining ECG and monitoring amiodarone levels.

Antiretroviral (ARV)Dose of ARVDose of AmiodaroneEffect on ARV LevelsEffect on Amiodarone LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase amiodarone levelsPossible increased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmiasInhibition of CYP3A4 by ritonavir

Do not coadminister with saquinavir/ritonavir or tipranavir/ritonavir. Others use with caution; monitor amiodarone adverse effects. Consider obtaining ECG and monitoring amiodarone levels.

Indinavir314
(IDV)(Crixivan)
800 mg TID200 mg QD- Amiodarone levels: increased 44%Increased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias)Inhibition of CYP450 3A4 by indinavir

Monitor and adjust amiodarone as indicated; amiodarone dose reduction may be necessary

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
---Not studied; may increase amiodarone levelsIncreased amiodarone effects (eg, cardiac arrhythmias, hypotension)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Use with caution. Monitor ECG and adjust amiodarone as indicated

Nelfinavir24
(NFV)(Viracept)
- - - Not studied; may increase amiodarone levelsIncreased amiodarone effects (eg, hypotension, bradycardia, cardiac arrhythmias)Inhibition of CYP450 3A4 by nelfinavir

Monitor and adjust amiodarone as indicated

Ritonavir55
(RTV)(Norvir)
---Not studied; may increase amiodarone levelsIncreased amiodarone effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by ritonavir

Do not coadminister

Tipranavir154
(TPV)(Aptivus)
--Not studiedNot studied; may increase amiodarone levelsIncreased amiodarone effects (eg, cardiac arrhythmias, hypotension)Inhibition of CYP450 3A4 by tipranavir/ritonavir

Monitor and adjust amiodarone as indicated

"-" indicates that there are no data available
Interactions with Amlodipine
Antiretroviral (ARV)Dose of ARVDose of AmlodipineEffect on ARV LevelsEffect on Amlodipine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Indinavir313
(IDV)(Crixivan)
800 mg Q12H with 100 mg ritonavir Q12H on days 8-265 mg QD on days 1-7 and 20-26No significant changeAmlodipine AUC: increased 89.8%; Cmax: increased 89%Increased amlodipine effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 by indinavir and ritonavir

Use lower starting dose and titrate to effect

"-" indicates that there are no data available
Interactions with Apixaban
Antiretroviral (ARV)Dose of ARVDose of ApixabanEffect on ARV LevelsEffect on Apixaban LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727
(ATV)(Reyataz)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Atazanavir/cobicistat727
(others)(Evotaz)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Darunavir727
(DRV)(Prezista)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Darunavir/cobicistat727
(Prezcobix)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Elvitegravir/cobicistat699
(Genvoya, Stribild)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Antiretroviral (ARV)Dose of ARVDose of ApixabanEffect on ARV LevelsEffect on Apixaban LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase apixaban levelsPotential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4

Avoid coadministration. Use alternative anticoagulant

Fosamprenavir727
(FPV)(Lexiva)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Lopinavir/ritonavir727
(LPV/r)(Kaletra)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Ritonavir727
(RTV)(Norvir)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Saquinavir727
(SQV)(Fortovase, Invirase)
---Not studied; may increase levels of apixaban.Potential for increased risk of bleedingInhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

Tipranavir
(TPV)(Aptivus)
--- Not studied; may increase levels of apixaban. Potential for increased risk of bleeding Inhibition of apixaban metabolism via CYP3A4.

Avoid coadministration. Consider alternative anticoagulant

Alternative Agents:
dabigatran

"-" indicates that there are no data available
Interactions with Atenolol
Antiretroviral (ARV)Dose of ARVDose of AtenololEffect on ARV LevelsEffect on Atenolol LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir
(ATV)(Reyataz)
400 mg QD on days 1-1150 mg QD on days 7-11 and 19-23Atazanavir AUC: no significant change; Cmax: no significant change; Cmin: decreased 26%Atenolol AUC: increased 25%; Cmax: increased 34%; Cmin: no significant change--

No dose adjustment necessary

"-" indicates that there are no data available
Interactions with Avanafil
Antiretroviral (ARV)Dose of ARVDose of AvanafilEffect on ARV LevelsEffect on Avanafil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat727
(Genvoya, Stribild)
-- No effect expectedNot studied; may increase avanafil levels --

Avoid coadministration

Elvitegravir/ritonavir-boosted protease inhibitor727
-- No effect expected Not studied; may increase avanafil levels --

Avoid coadministration

"-" indicates that there are no data available
Interactions with Bepridil
Antiretroviral (ARV)Dose of ARVDose of BepridilEffect on ARV LevelsEffect on Bepridil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase bepridil levelsIncreased bepridil effectsInhibition of CYP450 3A4 by amprenavir

Do not coadminister

Darunavir161
(DRV)(Prezista)
---Not studied; may increase bepridil levelsIncreased bepridil effectsInhibition of CYP450 3A4 by darunavir

Do not coadminister

Elvitegravir/cobicistat
(Genvoya, Stribild)
--- Not studied; may increase bepridil concentrations Possible increased bepridil effects (hypotension, cardiac arrhythmias)-

Use with caution and monitor for adverse effects. Consider therapeutic drug monitoring.

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
---Not studied; may increase bepridil levelsIncreased bepridil effects (hypotension, cardiac arrhythmias)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Do not coadminister

Ritonavir55
(RTV)(Norvir)
---Not studied; may increase bepridil levelsIncreased bepridil effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by ritonavir

Do not coadminister

Tipranavir
(TPV)(Aptivus)
---Not studied; may increase bepridil levelsIncreased bepridil effects (hypotension, cardiac arrhythmias)Inhibition of CYP450 3A4 by tipranavir/ritonavir

Do not coadminister

"-" indicates that there are no data available
Interactions with Bosentan
Antiretroviral (ARV)Dose of ARVDose of BosentanEffect on ARV LevelsEffect on Bosentan LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727, 699
(ATV)(Reyataz)
--Expected decreased atazanavir levels-Possible loss of antiviral efficacy-

Do not coadminister bosentan with unboosted atazanavir

Darunavir727
(DRV)(Prezista)
----Possible increased bosentan effects-

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Elvitegravir/cobicistat699
(Genvoya, Stribild)
--- Not studied; Possible increased bosentan levels--

If patient has been on elvitegravir/cobicistat for more than 10 days, start with bosentan dose of 62.5 mg daily or every other day. If patient is currently on bosentan and requires use of elvitegravir/cobicistat, stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; likely increased levels of bosentanIncreased bosentan toxicityInhibition of bosentan metabolism via CYP3A4

If patient has been on elvitegravir with a ritonavir boosted protease inhibitor for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires the use of elvitegravir with a ritonavir boosted PI, stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Fosamprenavir727
(FPV)(Lexiva)
----Possible increased bosentan effects-

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Antiretroviral (ARV)Dose of ARVDose of BosentanEffect on ARV LevelsEffect on Bosentan LevelsPotential Clinical EffectsMechanism of InteractionManagement
Indinavir727
(IDV)(Crixivan)
----Possible increased bosentan effects-

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Lopinavir/ritonavir727, 467
(LPV/r)(Kaletra)
400/100 mg BID125 mg BIDLopinavir AUC: decreased 14%; Ritonavir AUC:decreased 17%Bosentan AUC: increased 422%; Cmax: increased : 512%Increased bosentan effectsInhibition of CYP450 3A4 by lopinavir/ritonavir

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Nelfinavir727
(NFV)(Viracept)
---- Possible increased bosentan effects-

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Ritonavir
(RTV)(Norvir)
---- Possible increased bosentan effects-

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

Saquinavir727
(SQV)(Fortovase, Invirase)
---- Possible increased bosentan effects-

Start low and titrate bosentan to effect. If patient has been on protease inhibitor (other than unboosted atazanavir) for more than 10 days, start bosentan at 62.5 mg daily or every other day. If patient is currently on bosentan and requires a PI (other than unboosted atazanavir), stop bosentan for at least 36 hours prior to initiating ART. Wait 10 days and then resume bosentan starting with 62.5 mg daily or every other day.

"-" indicates that there are no data available
Interactions with Clopidogrel
Antiretroviral (ARV)Dose of ARVDose of ClopidogrelEffect on ARV LevelsEffect on Clopidogrel LevelsPotential Clinical EffectsMechanism of InteractionManagement
Etravirine405
(ETR)(Intelence)
----Possibly decreased clopidogrel effectsActivation of clopidogrel to its active metabolites may be decreased by etravirine

Avoid combination; consider alternative agents

"-" indicates that there are no data available
Interactions with Dabigatran
Antiretroviral (ARV)Dose of ARVDose of DabigatranEffect on ARV LevelsEffect on Dabigatran LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727
(ATV)(Reyataz)
---Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Atazanavir/cobicistat755, 727
(others)(Evotaz)
--- Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Darunavir727
(DRV)(Prezista)
---Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Darunavir/cobicistat727
(Prezcobix)
---Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Elvitegravir/cobicistat701
(Genvoya, Stribild)
---Not studied; may increase dabigatran levelsPotential for increased risk of bleedingInhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Antiretroviral (ARV)Dose of ARVDose of DabigatranEffect on ARV LevelsEffect on Dabigatran LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat727
(Genvoya, Stribild)
---Not studied; may increase dabigatran levelsPotential for increased risk of bleedingInhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Elvitegravir/ritonavir-boosted protease inhibitor701
---Not studied; may increase dabigatran levelsPotential for increased risk of bleedingInhibition of dabigatran metabolism via CYP3A4

No adjustment necessary if CrCl > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Fosamprenavir727
(FPV)(Lexiva)
--- Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Lopinavir/ritonavir727
(LPV/r)(Kaletra)
---Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Ritonavir727
(RTV)(Norvir)
--- Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Saquinavir727
(SQV)(Fortovase, Invirase)
--- Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

Tipranavir727
(TPV)(Aptivus)
--- Not studied; may increase dabigatran levels Potential for increased risk of bleeding Inhibition of dabigatran metabolism via CYP3A4

No dose adjustment if CrCL > 50 ml/min. Avoid concomitant use if CrCl < 50ml/min.

"-" indicates that there are no data available
Interactions with Digoxin
Antiretroviral (ARV)Dose of ARVDose of DigoxinEffect on ARV LevelsEffect on Digoxin LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir/cobicistat755, 727
(others)(Evotaz)
---Not studied; may increase digoxin levels Possible increased risk of digoxin toxicity-

Digoxin dose may need to be decreased. Monitor digoxin level and adjust digoxin dose based on clinical signs and drug levels.

Darunavir161
(DRV)(Prezista)
600 mg BID with ritonavir 100 mg BID0.4 mg-Digoxin AUC: increased 36%; Cmax: increased 15%--

Digoxin dose may need to be decreased. Monitor digoxin level and adjust digoxin dose based on clinical signs and drug levels.

Darunavir/cobicistat757
(Prezcobix)
--- Not studied; may increase digoxin levels Possible increased risk of digoxin toxicity -

Digoxin dose may need to be decreased. Monitor digoxin level and adjust digoxin dose based on clinical signs and drug levels.

Elvitegravir/cobicistat727, 623
(Genvoya, Stribild)
150 mg cobicistat0.5 mg-Cmax increase 41% and AUC no significant change--

Use with caution; monitor levels and digoxin adverse effects

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase digoxin levelsPossible increased risk of digoxin toxicity-

Use with caution; monitor levels and digoxin adverse effects

Ritonavir385, 386
(RTV)(Norvir)
200 mg BID x 15 days0.4 mg x 1 doseNot studiedDigoxin AUC (0-8 hr): increased 29%; AUC (0-72 hr): increased 22%; clearance: decreased 30%; half-life: increased 43%Increased digoxin effectsPossible inhibition of P-gp by ritonavir

Digoxin dose may need to be decreased. Monitor digoxin level and adjust digoxin dose based on clinical signs and drug levels.

Saquinavir75
(SQV)(Fortovase, Invirase)
1000 mg BID with 100 mg ritonavir BID x 16 days0.5 mg x 1-Digoxin AUC: increased 49%; Cmax: increased 27%Increased digoxin levels-

Digoxin dose may need to be decreased. Monitor digoxin level and adjust digoxin dose based on clinical signs and drug levels.

"-" indicates that there are no data available
Interactions with Diltiazem
Antiretroviral (ARV)Dose of ARVDose of DiltiazemEffect on ARV LevelsEffect on Diltiazem LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - May increase diltiazem levelsIncreased diltiazem effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust diltiazem as indicated

Atazanavir
(ATV)(Reyataz)
400 mg QD on days 1-11180 mg QD on days 7-11 and 19-23No significant changeDiltiazem AUC: increased 125%; Cmax: increased 198%; Cmin: decreased 59%Increased diltiazem effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 by atazanavir

Reduce diltiazem dose by 50%. ECG monitoring is recommended.

Atazanavir/cobicistat727
(others)(Evotaz)
--- Not studied. Unboosted atazanavir increases diltiazem levels therefore a greater effect is expected when boosted with ritonavir or cobicistat.--

Decrease diltiazem dose by 50% and monitor ECG.

Efavirenz90
(EFV)(Sustiva)
600 mg QD x 15 days240 mg QD x 21 daysNo significant changeDiltiazem AUC: decreased 69%; Cmax: decreased 60%; Cmin: decreased 63%Decreased diltiazem effectsInduction of CYP450 by efavirenz

May need to titrate diltiazem to clinical effect

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase levels of diltiazemPotential increased risk of diltiazem adverse effects-

If using elvitegravir with ritonavir-boosted atazanavir, decrease diltiazem dose 50% and monitor ECG. For elvitegravir with other ritonavir boosted protease inhibitors, use diltiazem with caution.

Indinavir313
(IDV)(Crixivan)
800 mg Q12H with 100 mg ritonavir Q12H on days 8-26120 mg QD on days 1-7 and 20-26No significant changeDiltiazem AUC: increased 26.5%; Cmax: increased 24.9%; Desacetyldiltiazem AUC: increased 102%; Desmethyldiltiazem AUC: decreased 27%Increased diltiazem effects (eg, hypotension, heart block)Possible inhibition of CYP450 3A4 by indinavir and ritonavir

Use lower starting dose and titrate to effect

"-" indicates that there are no data available
Interactions with Disopyramide
Antiretroviral (ARV)Dose of ARVDose of DisopyramideEffect on ARV LevelsEffect on Disopyramide LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir/cobicistat755
(others)(Evotaz)
---Not studied; may increase disopyramide levels Potential increased risk of disopyramide adverse effects -

Use with caution; monitor for disopyramide toxicity

Darunavir/cobicistat757
(Prezcobix)
---Not studied; may increase disopyramide levelsPotential increased risk of disopyramide adverse effects -

Use with caution; monitor for disopyramide toxicity

Elvitegravir/cobicistat699
(Genvoya, Stribild)
--- Not studied; may increase disopyramide levels Potential increased risk of disopyramide adverse effects-

Use with caution; monitor for disopyramide toxicity

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase disopyramide levelsPotential increased risk of disopyramide adverse effects-

Use with caution; monitor for disopyramide toxicity

"-" indicates that there are no data available
Interactions with Dofetilide
Antiretroviral (ARV)Dose of ARVDose of DofetilideEffect on ARV LevelsEffect on Dofetilide LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir316
(APV)(Agenerase)
---Not studied; may increase dofetilide levels-Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust dofetilide as indicated

Dolutegravir691
(Tivicay)
---Not studied; may increase dofetilide levelsPotential increased dofetilide toxicityDTG may increase plasma concentrations of drugs eliminated by OCT2 or MATE1

Contraindicated - do not coadminister

Indinavir316
(IDV)(Crixivan)
- - - Not studied; may increase dofetilide levelsIncreased defetilide effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by indinavir

Monitor and adjust dofetilide as indicated

Nelfinavir316
(NFV)(Viracept)
- - - Not studied; may increase dofetilide levelsIncreased dofetilide effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by nelfinavir

Monitor and adjust dofetilide as indicated

"-" indicates that there are no data available
Interactions with Dronedarone
Antiretroviral (ARV)Dose of ARVDose of DronedaroneEffect on ARV LevelsEffect on Dronedarone LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat699
(Genvoya, Stribild)
--- Not studied; may increase dronedarone levels Possible increased risk of dronedarone adverse effects-

Use with caution; monitor for dronedarone toxicity

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase dronedarone levelsPossible increased risk of dronedarone adverse effects-

Do not coadminister

"-" indicates that there are no data available
Interactions with Felodipine
Antiretroviral (ARV)Dose of ARVDose of FelodipineEffect on ARV LevelsEffect on Felodipine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Darunavir161
(DRV)(Prezista)
---Not studied; may increase felodipine levelsIncreased felodipine effects (hypotension, bradycardia)Inhibition of CYP450 3A4 by darunavir/ritonavir

Monitor and adjust felodipine as indicated

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
- - - Not studied; may increase felodipine levelsIncreased felodipine effects (hypotension, bradycardia)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Monitor and adjust felodipine as indicated

"-" indicates that there are no data available
Interactions with Flecainide
Antiretroviral (ARV)Dose of ARVDose of FlecainideEffect on ARV LevelsEffect on Flecainide LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir/cobicistat755
(others)(Evotaz)
---Not studied; may increase flecainide levels. Possible increased risk of flecainide adverse effects (eg, cardiac arrhythmias) -

Use with caution. Monitor for toxicity. Consider therapeutic drug monitoring

Darunavir/cobicistat757
(Prezcobix)
---Not studied; may increase flecainide levels. Possible increased risk of flecainide adverse effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity. Consider therapeutic drug monitoring

Elvitegravir/cobicistat699
(Genvoya, Stribild)
--- Not studied; may increase flecainide levels. Possible increased risk of flecainide adverse effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity. Consider therapeutic drug monitoring

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase flecainide levels.Possible increased risk of flecainide adverse effects-

Do not coadminister

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
- - - Not studied; may increase flecainide levelsIncreased flecainide effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Do not coadminister

Ritonavir55
(RTV)(Norvir)
---Not studied; may increase flecainide levelsIncreased flecainide effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by ritonavir

Do not coadminister

Tipranavir154
(TPV)(Aptivus)
---Not studied; may increase flecainide levelsIncreased flecainide effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by tipranavir/ritonavir

Do not coadminister

"-" indicates that there are no data available
Interactions with Lidocaine
Antiretroviral (ARV)Dose of ARVDose of LidocaineEffect on ARV LevelsEffect on Lidocaine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- Systemic lidocaine- Not studied; may increase lidocaine levelsIncreased lidocaine effectsInhibition of CYP450 3A4 by amprenavir

Monitor and adjust lidocaine as indicated

Atazanavir/cobicistat755
(others)(Evotaz)
---Not studied; may increase lidocaine levels.--

Use with caution. Monitor adverse effects and consider therapeutic drug monitoring.

Darunavir161
(DRV)(Prezista)
-Systemic lidocaine-Not studied; may increase lidocaine levelsIncreased lidocaine effectsInhibition of CYP450 3A4 by darunavir

Monitor and adjust lidocaine as indicated

Darunavir/cobicistat757
(Prezcobix)
---Not studied; may increase lidocaine levels.--

Use with caution. Monitor adverse effects and consider therapeutic drug monitoring.

Elvitegravir/cobicistat699
(Genvoya, Stribild)
--- Not studied; may increase lidocaine levels--

Use with caution. Monitor adverse effects and consider therapeutic drug monitoring.

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase effects of lidocainePotential increased risk of lidocaine adverse effects-

Do not coadminister with saquinavir/ritonavir. Use with caution with other protease inhibitors; monitor for lidocaine toxicity.

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
-Systemic lidocaine-Not studied; may increase lidocaine levelsIncreased lidocaine effectsInhibition of CYP450 3A4 by lopinavir/ritonavir

Use with caution. Monitor and adjust lidocaine as indicated

"-" indicates that there are no data available
Interactions with Metoprolol
Antiretroviral (ARV)Dose of ARVDose of MetoprololEffect on ARV LevelsEffect on Metoprolol LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat623
(Genvoya, Stribild)
----Potentially increased metoprolol effects-

Use with caution; titrate to effect

Elvitegravir/cobicistat623
(Genvoya, Stribild)
----Potentially increased metoprolol effects-

Initiate beta-blocker at low dose, titrate to effect while monitoring for potentially increased side effects

"-" indicates that there are no data available
Interactions with Mexiletine
Antiretroviral (ARV)Dose of ARVDose of MexiletineEffect on ARV LevelsEffect on Mexiletine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir/cobicistat755
(others)(Evotaz)
---Not studied; may increase mexiletine levels Potential increased risk of mexiletine adverse effects-

Use with caution; monitor for mexiletine toxicity

Darunavir/cobicistat757
(Prezcobix)
--- Not studied; may increase mexiletine levels Potential increased risk of mexiletine adverse effects -

Use with caution; monitor for mexiletine toxicity

Elvitegravir/cobicistat
(Genvoya, Stribild)
--- Not studied; may increase levels of mexiletine- Potential increased risk of mexiletine adverse effects

Use with caution; monitor for mexiletine toxicity

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase levels of mexiletinePotential increased risk of mexiletine adverse effects-

Use with caution; monitor for mexiletine toxicity

"-" indicates that there are no data available
Interactions with Nicardipine
Antiretroviral (ARV)Dose of ARVDose of NicardipineEffect on ARV LevelsEffect on Nicardipine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase nicardipine levelsIncreased nicardipine effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust nicardipine as indicated

Darunavir161
(DRV)(Prezista)
---Not studied; may increase nicardipine levelsIncreased nicardipine effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 by darunavir

Monitor and adjust nicardipine as indicated

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
- - - Not studied; may increase nicardipine levelsIncreased nicardipine effects (eg, hypotension, cardiac arrhythmias)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Monitor and adjust nicardipine as indicated

"-" indicates that there are no data available
Interactions with Nifedipine
Antiretroviral (ARV)Dose of ARVDose of NifedipineEffect on ARV LevelsEffect on Nifedipine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase nifedipine levelsIncreased nifedipine effects (hypotension, heart block)Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust nifedipine as indicated

Darunavir161
(DRV)(Prezista)
---Not studied; may increase nifedipine levelsIncreased nifedipine effects (hypotension, bradycardia)Inhibition of CYP450 3A4 by darunavir/ritonavir

Monitor and adjust nifedipine as indicated

Delavirdine88
(DLV)(Rescriptor)
- - - Not studied; may increase nifedipine levelsIncreased nifedipine effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 and 2C9 by delavirdine

Monitor and adjust nifedipine as indicated

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
- - - Not studied; may increase nifedipine levelsIncreased nifedipine effects (eg, hypotension, cardiac arrhythmias)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Monitor and adjust nifedipine as indicated

"-" indicates that there are no data available
Interactions with Nimodipine
Antiretroviral (ARV)Dose of ARVDose of NimodipineEffect on ARV LevelsEffect on Nimodipine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase nimodipine levelsIncreased nimodipine effects (eg, hypotension, heart block)Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust nimodipine as indicated

"-" indicates that there are no data available
Interactions with Propafenone
Antiretroviral (ARV)Dose of ARVDose of PropafenoneEffect on ARV LevelsEffect on Propafenone LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir/cobicistat755
(others)(Evotaz)
--- Not studied; may increase propafenone levels Increased propafenone effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity.

Darunavir/cobicistat757
(Prezcobix)
--- Not studied; may increase propafenone levels Increased propafenone effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity.

Elvitegravir/cobicistat
(Genvoya, Stribild)
--- Not studied; may increase propafenone levelsIncreased propafenone effects (eg, cardiac arrhythmias)-

Use with caution. Monitor for toxicity.

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase propafenone levelsPotential increased risk of propafenone adverse effects-

Do not coadminister with saquinavir, tipranavir, or fosamprenavir. Use with other PIs with caution; monitor for propafenone toxicity

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
- - - Not studied; may increase propafenone levelsIncreased propafenone effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Do not coadminister

Ritonavir55
(RTV)(Norvir)
---Not studied; may increase propafenone levelsIncreased propafenone effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by ritonavir

Do not coadminister

Tipranavir154
(TPV)(Aptivus)
---Not studied; may increase propafenone levelsIncreased propafenone effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by tipranavir/ritonavir

Do not coadminister

"-" indicates that there are no data available
Interactions with Quinidine
Antiretroviral (ARV)Dose of ARVDose of QuinidineEffect on ARV LevelsEffect on Quinidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias, exacerbation of heart failure)Inhibition of CYP450 3A4 by amprenavir

Monitor and adjust quinidine as indicated

Atazanavir/cobicistat755
(others)(Evotaz)
--- Not studied; may increase quinidine levels Possible increased quinidine effects (e.g. cardiac arrhythmias) Inhibition of CYP450 3A4 by cobicistat

Use with caution. Monitor for toxicity.

Darunavir161
(DRV)(Prezista)
---Not studied; may increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias, exacerbation of heart failure)Inhibition of CYP450 3A4 by darunavir

Use with caution. Monitor and adjust quinidine as indicated

Darunavir/cobicistat757
(Prezcobix)
---Not studied; may increase quinidine levels Possible increased quinidine effects (e.g. cardiac arrhythmias) Inhibition of CYP450 3A4 by cobicistat

Use with caution. Monitor for toxicity.

Delavirdine88
(DLV)(Rescriptor)
- - - Not studied; may increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 and 2C9 by delavirdine

Do not coadminister

Antiretroviral (ARV)Dose of ARVDose of QuinidineEffect on ARV LevelsEffect on Quinidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat699
(Genvoya, Stribild)
---Not studied; may increase quinidine levelsPossible increased quinidine effects (e.g. cardiac arrhythmias) Inhibition of CYP450 3A4 by cobicistat

Use with caution. Monitor for toxicity.

Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase levels of quinidinePossible increased quinidine effects (e.g. cardiac arrhythmias)Inhibition of CYP450 3A4 by ritonavir

Use with caution; monitor for quinidine toxicity

Indinavir16
(IDV)(Crixivan)
400 mg x 1 dose200 mg x 1 doseAUC: increased 10%Not studied--

No dose adjustment necessary

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
- - - Not studied; may increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias)-

Monitor and adjust quinidine as indicated

Nelfinavir24
(NFV)(Viracept)
- - - May increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by nelfinavir

Do not coadminister

Ritonavir55
(RTV)(Norvir)
---Not studied; may increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by ritonavir

Do not coadminister

Tipranavir154
(TPV)(Aptivus)
---Not studied; may increase quinidine levelsIncreased quinidine effects (eg, cardiac arrhythmias)Inhibition of CYP450 3A4 by tipranavir/ritonavir

Do not coadminister

"-" indicates that there are no data available
Interactions with Ranolazine
Antiretroviral (ARV)Dose of ARVDose of RanolazineEffect on ARV LevelsEffect on Ranolazine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir709
(ATV)(Reyataz)
--Not studied; may increase atazanavir levelsNot studied; may increase ranolazine levelsPotential increased ranolazine adverse effects (e.g. prolonged QT, cardiac arrythmias).-

Do not coadminister

Darunavir709
(DRV)(Prezista)
--Not studied; may increase darunavir levelsNot studied; may increase ranolazine levelsPotential increased ranolazine adverse effects (e.g. prolonged QT, cardiac arrythmias).-

Do not coadminister

Fosamprenavir709
(FPV)(Lexiva)
--Not studied; may increase fosamprenavir levelsNot studied; may increase ranolazine levelsPotential increased ranolazine adverse effects (e.g. prolonged QT, cardiac arrythmias).-

Do not coadminister

Lopinavir/ritonavir709
(LPV/r)(Kaletra)
--Not studied; may increase lopinavir levelsNot studied; may increase ranolazine levelsPotential increased ranolazine adverse effects (e.g. prolonged QT, cardiac arrythmias).-

Do not coadminister

Saquinavir709
(SQV)(Fortovase, Invirase)
--Not studied; may increase saquinavir levelsNot studied; may increase ranolazine levelsPotential increased ranolazine adverse effects (e.g. prolonged QT, cardiac arrythmias).-

Do not coadminister

Tipranavir709
(TPV)(Aptivus)
---Not studied; may increase ranolazine levelsPotential increased ranolazine adverse effects (e.g. prolonged QT, cardiac arrythmias).-

Do not coadminister

"-" indicates that there are no data available
Interactions with Rivaroxaban
Antiretroviral (ARV)Dose of ARVDose of RivaroxabanEffect on ARV LevelsEffect on Rivaroxaban LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727
(ATV)(Reyataz)
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

Darunavir727
(DRV)(Prezista)
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

Elvitegravir/cobicistat703
(Genvoya, Stribild)
--- Not studied; may increase rivaroxaban levels Potential for increased risk of bleeding Inhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Elvitegravir/ritonavir-boosted protease inhibitor703
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; use alternative anticoagulant

Fosamprenavir727
(FPV)(Lexiva)
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

Antiretroviral (ARV)Dose of ARVDose of RivaroxabanEffect on ARV LevelsEffect on Rivaroxaban LevelsPotential Clinical EffectsMechanism of InteractionManagement
Lopinavir/ritonavir727
(LPV/r)(Kaletra)
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

Ritonavir727
(RTV)(Norvir)
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

Saquinavir727
(SQV)(Fortovase, Invirase)
---Not studied; may increase rivaroxaban levelsPotential for increased risk of bleedingInhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

Tipranavir727
(TPV)(Aptivus)
--- Not studied; may increase rivaroxaban levels Potential for increased risk of bleeding Inhibition of rivaroxaban metabolism via CYP3A4

Avoid concomitant use; consider alternative anticoagulant

Alternative Agents:
dabigatran

"-" indicates that there are no data available
Interactions with Sildenafil
Antiretroviral (ARV)Dose of ARVDose of SildenafilEffect on ARV LevelsEffect on Sildenafil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir739, 60, 727
(APV)(Agenerase)
---Not studied; may increase sildenafil levelsPotentially increased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by amprenavir

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Atazanavir739, 727
(ATV)(Reyataz)
----Potentially increased sildenafil effects (eg, hypotension, priapism)-

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Darunavir739, 297, 727, 161
(DRV)(Prezista)
400 mg BID with ritonavir 100 mg BID25 mg x 1Not studiedSildenafil Cmax: decreased 38%; Cmin: no significant change; AUC: no significant change (compared to sildenafil 100 mg x 1 without darunavir/ritonavir)Increased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by darunavir/ritonavir

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Elvitegravir/cobicistat727, 623
(Genvoya, Stribild)
--No effect expectedNot studied; may increase sildenafil levelsPotentially increased sildenafil effects (eg, hypotension, priapism)-

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Elvitegravir/ritonavir-boosted protease inhibitor727
--No effect expectedSildenafil levels increased when co-administered with boosted protease inhibitorsIncreased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by ritonavir

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Antiretroviral (ARV)Dose of ARVDose of SildenafilEffect on ARV LevelsEffect on Sildenafil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Etravirine405
(ETR)(Intelence)
-50 mg x 1- Sildenafil AUC: decreased 57%; Cmax: decreased 45%Decreased sildenafil effectsInduction of CYP450 3A4 by etravirine

No dose adjustment necessary

Indinavir254, 16, 299
(IDV)(Crixivan)
800 mg TID25 mg x 1 doseIndinavir AUC: increased 11%; Cmax: increased 48%Sildenafil AUC: increased 340%; Cmax: increased 300% (Levels exceeded those achieved by a 100 mg single dose)Increased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by indinavir

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
---Not studied; may increase sildenafil levelsIncreased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Initiate sildenafil at 25 mg QOD-QD; adjust dose as indicated; not recommended to exceed 25 mg in a 48 hour period

Nelfinavir24
(NFV)(Viracept)
---Not studied; may increase sildenafil levelsIncreased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by nelfinavir

Initiate sildenafil at 25 mg QOD-QD; adjust dose as indicated; not recommended to exceed 25 mg in a 48 hour period

Nelfinavir298
(NFV)(Viracept)
1250 mg Q12H25 mg x 1Not studiedNo significant change--

No dose adjustment necessary

Rilpivirine567
(RPV)(Edurant)
75 mg QD50 mg x 1No significant changeNo significant change--

No dose adjustment necessary

Ritonavir55, 301
(RTV)(Norvir)
300 mg, 400 mg and 500 mg BID on days 2, 3 and 4-8100 mg x 1 dose-Sildenafil AUC: increased 1000%; Cmax: increased 290%; Tmax: delayed 3 hoursIncreased sildenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by ritonavir

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

Saquinavir75
(SQV)(Fortovase, Invirase)
1200 mg TID x 8 days100 mg x 1-Sildenafil AUC: increased 210%; Cmax: increased 140%Increased sildenafil effects (eg, headache, flushing, priapism)Inhibition of CYP450 3A4 by saquinavir

For erectile dysfunction, initiate sildenafil 25 mg every 48 hours and monitor for adverse effects. Manufacturer recommends not to exceed dose of 25 mg every 48 hours. Do not coadminister if using sildenafil for pulmonary arterial hypertension.

"-" indicates that there are no data available
Interactions with Tadalafil
Antiretroviral (ARV)Dose of ARVDose of TadalafilEffect on ARV LevelsEffect on Tadalafil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727
(ATV)(Reyataz)
--- Not studied; potentially increased tadalafil effects (e.g. hypotension, priapism)--

Initiate tadalafil at 5 mg QD; adjust dose as indicated; not recommended to exceed 10 mg in 72 hour period

Darunavir161
(DRV)(Prezista)
---Not studied; may increase tadalafil levelsIncreased tadalafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by darunavir/ritonavir

Initiate tadalafil at 5 mg QD; adjust dose as indicated; not recommended to exceed 10 mg in 72 hour period

Elvitegravir/cobicistat729, 727
(Genvoya, Stribild)
--No effect expectedNot studied; may increase tadalafil levelsPossible increased tadalafil effects (e.g. hypotension, priapism)-

If initiating tadalafil for pulmonary arterial hypertension in a patient already taking elvitegravir/cobicistat for >1 week: start tadalafil 20 mg once daily and increase to 40 mg as tolerated. If patient with PAH requires initiation of elvitegravir/cobicistat: Stop tadalafil 24 hours prior to starting ART. Wait one week, then initiate tadalafil at 20 mg orally once daily. May increase to 40 mg as tolerated. For erectile dysfunction initiate tadalafil 5 mg dose do not exceed 10 mg in 72 hours.

Elvitegravir/ritonavir-boosted protease inhibitor731, 727
--No effect expectedTadalafil levels increased when administered with ritonavir-boosted protease inhibitors.Increased tadalafil effects (e.g. hypotension, priapism)Inhibition of CYP450 3A4 by ritonavir

If initiating tadalafil for pulmonary arterial hypertension (PAH) in a patient already taking elvitegravir/ritonavir/PI for >1 week: start tadalafil 20 mg once daily and increase to 40 mg as tolerated. If patient with PAH requires initiation of elvitegravir/ritonavir/PI: Stop tadalafil 24 hours prior to starting ART. Wait one week, then initiate tadalafil at 20 mg orally once daily. May increase to 40 mg as tolerated. For erectile dysfunction initiate tadalafil 5 mg dose do not exceed 10 mg in 72 hours.

Lopinavir/ritonavir727, 78
(LPV/r)(Kaletra)
---Not studied; may increase tadalafil levelsIncreased tadalafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Initiate tadalafil at 5 mg QD; adjust dose as indicated; not recommended to exceed 10 mg in 72 hour period

Alternative Agents:
Sildenafil, vardenafil

Antiretroviral (ARV)Dose of ARVDose of TadalafilEffect on ARV LevelsEffect on Tadalafil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Ritonavir388
(RTV)(Norvir)
200 mg BID20 mg x 1-Tadalafil AUC: increased 124%Increased tadalafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by ritonavir

Initiate tadalafil at 5 mg QD; adjust dose as indicated; not recommended to exceed 10 mg in 72 hour period

Ritonavir388
(RTV)(Norvir)
500 mg or 600 mg BID20 mg x 1-Tadalafil AUC: increased 32%, Cmax: decreased 30%Increased tadalafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by ritonavir

Initiate tadalafil at 5 mg QD; adjust dose as indicated; not recommended to exceed 10 mg in 72 hour period

Tipranavir154
(TPV)(Aptivus)
500 mg BID with 200 mg ritonavir BID x 110 mg x 1-Tadalafil AUC: increased 183%; Cmax decreased 22%-Inhibition of CYP450 by tipranavir/ritonavir (initial phase)

Titrate tadalafil to effect

Tipranavir154
(TPV)(Aptivus)
500 mg BID with 200 mg ritonavir BID x 17 doses10 mg x 1Tipranavir AUC: decreased 15%; Cmax: decreased 19%Tadalafil Cmax: decreased 30%-Induction of CYP450 by tipranavir/ritonavir

Titrate tadalafil to effect

"-" indicates that there are no data available
Interactions with Ticagrelor
Antiretroviral (ARV)Dose of ARVDose of TicagrelorEffect on ARV LevelsEffect on Ticagrelor LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727
(ATV)(Reyataz)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Atazanavir/cobicistat727
(others)(Evotaz)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Darunavir727
(DRV)(Prezista)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Darunavir/cobicistat727
(Prezcobix)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Elvitegravir/cobicistat705
(Genvoya, Stribild)
---Not studied; may increase effects of ticagrelorPotential for increased risk of bleedingInhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Antiretroviral (ARV)Dose of ARVDose of TicagrelorEffect on ARV LevelsEffect on Ticagrelor LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor705
---Not studied; may increase ticagrelor levelsPotential for increased risk of bleedingInhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; use alternative antiplatelet agent

Fosamprenavir727
(FPV)(Lexiva)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Lopinavir/ritonavir727
(LPV/r)(Kaletra)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Ritonavir727
(RTV)(Norvir)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Saquinavir727
(SQV)(Fortovase, Invirase)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding Inhibition of ticagrelor metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Tipranavir727
(TPV)(Aptivus)
--- Not studied; may increase effects of ticagrelor Potential for increased risk of bleeding-

Avoid concomitant use; consider alternative antiplatelet agent

"-" indicates that there are no data available
Interactions with Vardenafil
Antiretroviral (ARV)Dose of ARVDose of VardenafilEffect on ARV LevelsEffect on Vardenafil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Darunavir161
(DRV)(Prezista)
---Not studied; may increase vardenafil levelsIncreased vardenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by darunavir/ritonavir

Initiate vardenafil at 2.5 mg QD; adjust dose as indicated; not recommended to exceed 2.5 mg in 72 hour period

Elvitegravir/cobicistat727
(Genvoya, Stribild)
--No effect expectedNot studied; may increase vardenafil levelsPossible increased vardenafil effects (e.g. hypotension, priapism) Inhibition of CYP450 3A4 by cobicistat

Initiate vardenafil 2.5 mg every 72 hours and monitor for adverse effects

Elvitegravir/ritonavir-boosted protease inhibitor727
--No effect expectedNot studied; may increase vardenafil levelsPossible increased vardenafil effects (e.g. hypotension, priapism)Inhibition of CYP450 3A4 by ritonavir

Initiate vardenafil 2.5 mg every 72 hours and monitor for adverse effects

Indinavir16
(IDV)(Crixivan)
800 mg Q8H10 mg x 1 doseNot studiedVardenafil AUC: increased 16-fold; Cmax: increased 7-fold; half-life: increased 2-foldIncreased vardenafil effects (eg, hypotension, nausea, priapism, syncope)Inhibition of CYP450 3A4 by indinavir

Consider initiating vardenafil at lower dose and titrate to effect. Dose should not exceed 2.5 mg in any 24 hour period.

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
---Not studied; may increase vardenafil levelsIncreased vardenafil effects (eg, hypotension, priapism)Inhibition of CYP450 3A4 by lopinavir/ritonavir

Initiate vardenafil at 5 mg QD; adjust dose as indicated; not recommended to exceed 20 mg in a 48 hour period

Ritonavir741
(RTV)(Norvir)
600 mg BID5 mg daily-Vardenafil AUC increased 49-fold; Cmax increased 13-fold. T1/2 increased to 26 hours.Increased tadalafil effectsInhibition of CYP3A4

Initiate (and do not exceed) vardenafil 2.5 mg every 72 hours and monitor for adverse effects

"-" indicates that there are no data available
Interactions with Verapamil
Antiretroviral (ARV)Dose of ARVDose of VerapamilEffect on ARV LevelsEffect on Verapamil LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase levels of verapamilPotential increased risk of verapamil adverse effects-

Use with caution and monitor ECG

"-" indicates that there are no data available
Interactions with Vorapaxar
Antiretroviral (ARV)Dose of ARVDose of VorapaxarEffect on ARV LevelsEffect on Vorapaxar LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727
(ATV)(Reyataz)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Atazanavir/cobicistat727
(others)(Evotaz)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Darunavir727
(DRV)(Prezista)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Darunavir/cobicistat727
(Prezcobix)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Elvitegravir/cobicistat705
(Genvoya, Stribild)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Antiretroviral (ARV)Dose of ARVDose of VorapaxarEffect on ARV LevelsEffect on Vorapaxar LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor705
---Not studied; may increase vorapaxar levelsPotential for increased risk of bleedingInhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; use alternative antiplatelet agent

Fosamprenavir727
(FPV)(Lexiva)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Lopinavir/ritonavir727
(LPV/r)(Kaletra)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleedingInhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Ritonavir727
(RTV)(Norvir)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Saquinavir727
(SQV)(Fortovase, Invirase)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

Tipranavir727
(TPV)(Aptivus)
--- Not studied; may increase effects of vorapaxar Potential for increased risk of bleeding Inhibition of vorapaxar metabolism via CYP3A4

Avoid concomitant use; consider alternative antiplatelet agent

"-" indicates that there are no data available
Interactions with Warfarin
Antiretroviral (ARV)Dose of ARVDose of WarfarinEffect on ARV LevelsEffect on Warfarin LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - - Not studied; may increase warfarin effectsIncreased warfarin effects (eg, increased INR, increased risk of bleeding)Inhibition of CYP450 3A4 by amprenavir

Monitor INR and adjust warfarin as indicated

Darunavir161
(DRV)(Prezista)
600 mg BID with ritonavir 100 mg BID10 mg x 1- S-warfarin AUC: decreased 21%;Decreased warfarin effects (eg, decreased INR, increased risk of clotting)Induction of CYP450 3A4 by darunavir

Monitor INR and adjust warfarin as indicated

Delavirdine88
(DLV)(Rescriptor)
- - - Not studiedIncreased warfarin effects (eg, increased INR, increased risk of bleeding)Inhibition of CYP450 3A4 and 2C9 by delavirdine

Monitor INR and adjust warfarin as indicated

Efavirenz90
(EFV)(Sustiva)
---Not studied; may increase or decrease warfarin levelsIncreased or decreased warfarin effects (altered INR, increased risk of bleeding or clotting)Possible inhibition or induction of CYP450 by efavirenz

Monitor INR and adjust warfarin as indicated

Elvitegravir/cobicistat623
(Genvoya, Stribild)
--- Not studied; may increase or decrease warfarin effectsPotential for over or under anticoagulation-

Monitor INR closely when pt is first initiating elvitegravir/cobicistat

Antiretroviral (ARV)Dose of ARVDose of WarfarinEffect on ARV LevelsEffect on Warfarin LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor699
---Not studied; may increase warfarin levelsPotential increased risk of bleeding-

Monitor INR and adjust warfarin dose

Indinavir322
(IDV)(Crixivan)
800 mg Q8H x 12 days5 mg QD-Prothrombin complex activity increased from 25-35% to 53 and 43% at 10 and 25 days after indinavir discontinued in one patientIncreased warfarin effects (eg, increased INR, risk of bleeding)Inhibition of CYP450 by indinavir

Monitor INR and adjust warfarin as indicated

Lopinavir/ritonavir78
(LPV/r)(Kaletra)
---Not studied; may increase or decrease warfarin levelsIncreased or decreased warfarin effects (eg, altered INR, increased risk of bleeding or clotting)Possible inhibition of CYP450 by lopinavir/ritonavir

Monitor INR and adjust warfarin as indicated

Nevirapine95
(NVP)(Viramune)
----Possibly decreased warfarin effects (eg, altered INR, increased risk of clotting)-

Monitor INR and adjust warfarin as indicated

Ritonavir324
(RTV)(Norvir)
400 mg BID12.5 mg QD-INR: decreasedDecreased warfarin effects (eg, decreased INR, increased risk of clotting)Possible inhibition of CYP450 3A4, 2C9 and 1A2 by ritonavir

Monitor INR and adjust warfarin as indicated

Saquinavir323
(SQV)(Fortovase, Invirase)
600 mg TID x 8 weeks--Increased warfarin levels (INR increased from 2.1 to 4.24)Increased warfarin effects (eg, increased INR and risk of bleeding)Possible inhibition of CYP450 by saquinavir

Monitor INR and adjust warfarin as indicated

"-" indicates that there are no data available
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