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Database of Antiretroviral Drug Interactions

Interactions between Gastrointestinal secretion and motility agents and Antiretrovirals

Interactions with Antacids
Antiretroviral (ARV)Dose of ARVDose of AntacidsEffect on ARV LevelsEffect on Antacids LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
- - Decreased amprenavir levels- - Decreased amprenavir bioavailability

Separate dosing by at least 1 hour

Atazanavir/cobicistat755
(others)(Evotaz)
--Not studied; likely decreased atazanavir levels---

Separate administration of atazanavir/cobicistat and antacids by a minimum of 2 hours.

Delavirdine88
(DLV)(Rescriptor)
300 mg x 1 dose-Delavirdine AUC: decreased 41%Not studiedDecreased delavirdine effectsDecreased absorption of delavirdine

Separate antacid dose by at least 1 hour before or 2 hours after delavirdine

Dolutegravir641
(Tivicay)
50 mg x 1Maalox given simultaneously as dolutegravirDolutegravir AUC: decreased 74%; Cmin: decreased 74%---

Do not coadminister simultaneously. Administer dolutegravir 2 hours before or 6 hours after antacids.

Dolutegravir641
(Tivicay)
50 mg x 1Maalox given 2 hours after dolutegravirDolutegravir AUC: decreased 26%; Cmin: decreased 30% -Potentially decreased dolutegravir effectiveness -

Administer dolutegravir 2 hours before or 6 hours after antacids.

Antiretroviral (ARV)Dose of ARVDose of AntacidsEffect on ARV LevelsEffect on Antacids LevelsPotential Clinical EffectsMechanism of InteractionManagement
Efavirenz90
(EFV)(Sustiva)
400 mg x 1 dose30 mL x 1 doseNo significant change- - -

No dose adjustment necessary

Elvitegravir697
(Vitekta)
150 mg-Elvitegravir AUC decreased 40-50% if given simultaneously with an antacid and a boosted protease inhibitor. Elvitegravir AUC decreased 15-20% if given simultaneously with boosted PI, but antacid was separated by 2 hours. No change in AUC if elvitegravir given simultaenously with boosted PI and antacid is separated by 4 hours. -Potentially decreased elvitegravir effectiveness if given simultaneously with boosted PI and antacidChelation of integrase inhibitors by divalent cations

When giving elvitegravir with a boosted PI, separate antacids by at least 2 hours.

Elvitegravir/cobicistat623
(Genvoya, Stribild)
150 mg elvitegravir with 100 mg ritonavir x 120 mL x 1 4 hours before elvitegravirNo significant change---

No dose adjustment necessary

Elvitegravir/cobicistat623
(Genvoya, Stribild)
50 mg elvitegravir with 100 mg ritonavir x 120 mL x 1 given 4 hours after elvitegravirNo significant change---

No dose adjustment necessary

Elvitegravir/cobicistat623
(Genvoya, Stribild)
50 mg elvitegravir with 100 mg ritonavir x 120 mL x 1 given 2 hours before elvitegravirNo significant change---

No dose adjustment necessary

Elvitegravir/cobicistat623
(Genvoya, Stribild)
50 mg elvitegravir with 100 mg ritonavir x 120 mL given 2 hours after elvitegravirElvitegravir AUC: decreased 20%; Cmin: decreased 20%---

Separate elvitegravir from antacids by at least 2 hours

Antiretroviral (ARV)Dose of ARVDose of AntacidsEffect on ARV LevelsEffect on Antacids LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/ritonavir-boosted protease inhibitor707
--Elvitegravir AUC decreased 40-50% if administered simultaneously with antacid. AUC decreased 15-20% if antacid administered 2 hours before or after elvitegravir. No change in AUC if antacid administered 4 hours before or after elvitegravir.-Potential for decreased effects of EVG if antacid administered within +/- 2 hours.-

Separate administration of EVG and antacid by more than 2 hours.

Fosamprenavir727, 130, 241
(FPV)(Lexiva)
1400 mg x 1 dose30 mL x 1 doseAmprenavir Cmax: decreased 35%; AUC: decreased 18%; Cmin: no significant changeNot studied--

Give FPV simultaneously with (or at least 2 hours before or 1 hour after) antacids.

Raltegravir525
(RAL)(Isentress)
400 mg x 1Maalox Extra StrengthRaltegravir AUC: no significant change; Cmax: increased 53%; Cmin: decreased 65%---

No dose adjustment necessary

Rilpivirine567
(RPV)(Edurant)
----Potentially decreased rilpivirine effectsDecreased gastric acidity leading to impaired drug solubility and absorption

Administer antacids either at least 2 hours before or at least 4 hours after rilpivirine.

Tipranavir154
(TPV)(Aptivus)
500 mg BID with 200 mg ritonavir BID20 mLTipranavir AUC: decreased 27%; Cmax: decreased 25%-Decreased tipranavir effects-

Separate antacids from tipranavir by at least 2 hours

Zalcitabine85
(ddC)(Hivid)
1.5 mg x 130 ml x 1Zalcitabine AUC: decreased 25%Not studiedDecreased zalcitabine absorption-

Administer zalcitabine 1 hour before or 2 hours after antacid

"-" indicates that there are no data available
Interactions with Cimetidine
Antiretroviral (ARV)Dose of ARVDose of CimetidineEffect on ARV LevelsEffect on Cimetidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Amprenavir60
(APV)(Agenerase)
--Not studied; may increase amprenavir levels--Inhibition of CYP450 3A4 by cimetidine

Consider alternative agents

Alternative Agents:
Famotidine Nizatidine Ranitidine

Atazanavir240
(ATV)(Reyataz)
----May decrease atazanavir effectsPossible decreased GI absorption

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Delavirdine88
(DLV)(Rescriptor)
--Not studied; may decrease delavirdine absorption-Decreased delavirdine effectsDecreased absorption of delavirdine

Consider alternative agents

Alternative Agents:
Famotidine Nizatidine Ranitidine

Indinavir16
(IDV)(Crixivan)
400 mg x 1 dose600 mg Q12No significant change---

No dose adjustment necessary

Nevirapine95
(NVP)(Viramune)
--Cmin: increased 21%--Inhibition of CYP450 3A4 by cimetidine

No dose adjustment necessary

Zalcitabine85
(ddC)(Hivid)
--Not studiedNot studiedIncreased zalcitabine effectsInhibition of renal tubular secretion by cimetidine

Consider alternative agents

Alternative Agents:
Famotidine Nizatidine Ranitidine

"-" indicates that there are no data available
Interactions with Esomeprazole
Antiretroviral (ARV)Dose of ARVDose of EsomeprazoleEffect on ARV LevelsEffect on Esomeprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir240
(ATV)(Reyataz)
----Decreased atazanavir effectsDecreased GI absorption

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 blockers

Fosamprenavir389
(FPV)(Lexiva)
1400 mg BID x 14 days20 mg QD x 21 daysNo significant changeEsomeprazole AUC: increased 55%; Cmax: no significant change--

No dose adjustment necessary

Fosamprenavir389
(FPV)(Lexiva)
700 mg BID with 100 mg ritonavir BID x 14 days20 mg QD x 21 daysNo significant changeNo significant change--

No dose adjustment necessary

"-" indicates that there are no data available
Interactions with Famotidine
Antiretroviral (ARV)Dose of ARVDose of FamotidineEffect on ARV LevelsEffect on Famotidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir240
(ATV)(Reyataz)
----May decrease atazanavir effectsPossible decreased GI absorption

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir
(ATV)(Reyataz)
300 mg QD with 100 mg ritonavir20 mg BID on d 11-17 (simultaneous administration with morning atazanavir/ritonavir)No significant change---

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir
(ATV)(Reyataz)
300 mg QD with 100 mg ritonavir QD with tenofovir on d 11-1720 mg BID on d 11-17Atazanavir AUC: decreased 41%-Decreased atazanavir effects-

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir239
(ATV)(Reyataz)
300 mg QD with ritonavir 100 mg QD on d 1-20 (simultaneous administration)40 mg BID on d 11-20Atazanavir AUC: decreased 18%; Cmax: no significant change; Cmin: decreased 28%Not studiedDecreased atazanavir effectsInhibition of atazanavir absorption by famotidine

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir155
(ATV)(Reyataz)
400 mg atazanavir with 100 mg ritonavir on d 11-2040 mg Q12H on d 11-20Atazanavir AUC: no significant change; Cmax: no significant change; Cmin: decreased 14%(compared to 300 mg atazanavir with 100 mg ritonavir QD)- - Inhibition of atazanavir absorption by famotidine

For treatment-naive patients, atazanavir 400 mg QD can be used if dosed 2 hrs before or 10 hours after the H2-blocker or atazanavir 300 mg with ritonavir 100 mg QD can be used. For treatment-experienced patients, atazanavir 300 mg with ritonavir 100 mg QD can be used if dosed at least 2 hs before and at least 10 hours after the H2-blocker.

Antiretroviral (ARV)Dose of ARVDose of FamotidineEffect on ARV LevelsEffect on Famotidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir
(ATV)(Reyataz)
400 mg on d 1-6, d 7-12 (10 hr after, 2 hrs before famotidine)40 mg QD on d 7-12Atazanavir Cmin: decreased 31%-Decreased atazanavir effectsInhibition of atazanavir absorption by famotidine

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir239
(ATV)(Reyataz)
400 mg QD40 mg Q12HAtazanavir AUC: decreased 38%; Cmax: decreased 42%; Cmin: decreased 40%Not studiedDecreased atazanavir effectsInhibition of atazanavir absorption by famotidine

For treatment-naive patients, atazanavir 400 mg QD can be used if dosed 2 hrs before or 10 hours after the H2-blocker or atazanavir 300 mg with ritonavir 100 mg QD can be used.For treatment-experienced patients, atazanavir 300 mg with ritonavir 100 mg QD can be used if dosed at least 2 hs before and at least 10 hours after the H2-blocker.

Atazanavir
(ATV)(Reyataz)
400 mg QD on d 1-12 (simultaneous administration)40 mg BID on d 7-12Atazanavir AUC: decreased 41%; Cmax: decreased 47%; Cmin: decreased 42%-Decreased atazanavir effectsInhibition of atazanavir absorption by famotidine

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir/cobicistat727
(others)(Evotaz)
--Not studied; Potential decrease in atazanavir levels-Potential loss of antiviral efficacy-

Give atazanavir/cobicistat simultaneously with or ≥10 hours after H2 receptor antagonists (H2RA). If using TDF with H2RA in an ART-experienced patient, increase atazanavir dose to 400 mg (plus cobicistat 150 mg). Do not exceed an H2RA dose equivalent to famotidine 40 mg BID in ART-naive patients or 20 mg BID in ART experienced patients.

Delavirdine88
(DLV)(Rescriptor)
- - Not studied; may decrease delavirdine absorption- Decreased delavirdine effectsDecreased absorption of delavirdine

Avoid chronic coadministration

Alternative Agents:
Local antacids

Efavirenz90
(EFV)(Sustiva)
400 mg x 1 dose40 mg x 1 doseNo significant change- - -

No dose adjustment necessary

Antiretroviral (ARV)Dose of ARVDose of FamotidineEffect on ARV LevelsEffect on Famotidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat623
(Genvoya, Stribild)
150/150 mg40 mg given 12 hours after elvitegravirElvitegravir Cmin: increased 18%---

No dose adjustment necessary

Elvitegravir/cobicistat623
(Genvoya, Stribild)
150/150 mg40 mg given simultaneously with elvitegravirNo significant change---

No dose adjustment necessary

Raltegravir445
(RAL)(Isentress)
400 mg BID20 mg QD given 2 hours before raltegravirRaltegravir AUC: increased 45%; Cmax: increased 60%--Possibly due to increased bioavailability due to increased gastric pH

No dose adjustment necessary

Rilpivirine567
(RPV)(Edurant)
150 mg x 140 mg x 1 taken 12 hours before rilpivirineNo significant change---

No dose adjustment necessary

Rilpivirine567
(RPV)(Edurant)
150 mg x 140 mg x 1 taken 2 hours before rilpivirineRilpivirine AUC: decreased 76%; Cmax: decreased 85%-Decreased rilpivirine effectsDecreased gastric acidity leading to impaired drug solubility and absorption

Administer H2-antagonist by at least 12 hours before rilpivirine or at least 4 hours after rilpivirine.

Rilpivirine567
(RPV)(Edurant)
150 mg x 140 mg x 1 taken 4 hours after rilpivirineRilpivirine Cmax: increased 21%---

No dose adjustment necessary

"-" indicates that there are no data available
Interactions with Lansoprazole
Antiretroviral (ARV)Dose of ARVDose of LansoprazoleEffect on ARV LevelsEffect on Lansoprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir727, 390
(ATV)(Reyataz)
400 mg QD60 mg QD x 2 dosesAtazanavir AUC: decreased 94%; Cmax: decreased 91%; half-life: no significant change-Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir/cobicistat727
(others)(Evotaz)
-- Not studied; Potential decrease in atazanavir levels---

Administer proton pump inhibitor at least 12 hours before atazanavir/cobicistat. Proton pump inhibitors should not exceed a dose equivalent to omeprazole 20 mg daily in protease inhibitor naive patients. Proton pump inhibitors are not recommended in protease inhibitor experienced patients.

"-" indicates that there are no data available
Interactions with Loperamide
Antiretroviral (ARV)Dose of ARVDose of LoperamideEffect on ARV LevelsEffect on Loperamide LevelsPotential Clinical EffectsMechanism of InteractionManagement
Didanosine84
(ddI)(Videx)
300 mg (buffered formulation) x 1 dose4 mg Q6H x 1 dayDidanosine AUC: no significant change; Cmax: decreased 23%Not studied--

No dose adjustment necessary

Tipranavir154
(TPV)(Aptivus)
750 mg BID with 200 mg ritonavir BID x 21 doses16 mg x 1 doseTipranavir Cmin: decreased 26%Loperamide AUC: decreased 51%; Cmax: decreased 61%--

Dose adjustment not established

Zalcitabine85
(ddC)(Hivid)
1.5 mg x 1 dose4 mg 16 hours before zalcitabine, 2 mg at 10 hours and 4 hours before zalcitabine, and 2 mg 2 hours after zalcitabine doseNot reportedNot reported--

No dose adjustment necessary

"-" indicates that there are no data available
Interactions with Metoclopramide
Antiretroviral (ARV)Dose of ARVDose of MetoclopramideEffect on ARV LevelsEffect on Metoclopramide LevelsPotential Clinical EffectsMechanism of InteractionManagement
Didanosine84
(ddI)(Videx)
300 mg (buffered formulation) x 1 dose10 mg x 1 doseNo significant changeNot studied--

No dose adjustment necessary

Zalcitabine85
(ddC)(Hivid)
1.5 mg x 1 dose10 mg 1 hour before, 10 mg 4 hours after zalcitabine doseZalcitabine AUC: decreased 16-21%Not studied--

No dose adjustment necessary

"-" indicates that there are no data available
Interactions with Omeprazole
Antiretroviral (ARV)Dose of ARVDose of OmeprazoleEffect on ARV LevelsEffect on Omeprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir
(ATV)(Reyataz)
300 mg QD with 100 mg ritonavir QD on d 7-16 then 400 mg atazanavir QD with 100 mg ritonavir QD on d 17-2320 mg QD on d 17-23Atazanavir AUC: decreased 30%; Cmin: decreased 31%; Cmax: decreased 31%-Possibly decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir248, 240
(ATV)(Reyataz)
300 mg QD with ritonavir 100 mg QD x 20 d40 mg QD x 10 dAtazanavir AUC: decreased 76%; Cmax: decreased 72%; Cmin: decreased 78%-Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir
(ATV)(Reyataz)
300 mg QPM with 100 mg ritonavir QPM on d 7-16, 17-2320 mg QD on d 17-23Atazanavir AUC: decreased 42%; Cmax: decreased 39%, Cmin: decreased 46%-Possibly decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir240, 247
(ATV)(Reyataz)
300 mg with ritonavir 100 mg QD with 8 oz cola x 20 d40 mg QD x 10 dAtazanavir AUC: decreased 70%; Cmax: decreased 66%; Cmin: decreased 76%-Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir
(ATV)(Reyataz)
400 mg QD on d 1-1240 mg x 1 on d 7 and 20-Omeprazole AUC: increased 45%; Cmax: increased 24%Increased omeprazole effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Antiretroviral (ARV)Dose of ARVDose of OmeprazoleEffect on ARV LevelsEffect on Omeprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir240, 248
(ATV)(Reyataz)
400 mg QD with ritonavir 100 mg QD x 20 d40 mg QD x 10 dAtazanavir AUC: decreased 61%; Cmax: decreased 56%; Cmin: decreased 66%-Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir
(ATV)(Reyataz)
400 mg QD x 12 d40 mg QD x 5 dAtazanavir AUC: decreased 94%; Cmax: decreased 96%; Cmin: decreased 95%-Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir/cobicistat727
(others)(Evotaz)
-- Not studied; Potential decrease in atazanavir levels---

Administer proton pump inhibitor at least 12 hours before atazanavir/cobicistat. Proton pump inhibitors should not exceed a dose equivalent to omeprazole 20 mg daily in protease inhibitor naive patients. Proton pump inhibitors are not recommended in protease inhibitor experienced patients.

Darunavir161, 242
(DRV)(Prezista)
400 mg BID with ritonavir 100 mg BID20 mg QDNo significant change---

No dose adjustment necessary

Darunavir161
(DRV)(Prezista)
600 mg BID with ritonavir 100 mg BID40 mg x 1- Omeprazole AUC: decreased 42%; Cmax: decreased 34%- -

No dose adjustment necessary

Dolutegravir641
(Tivicay)
50 mg x 140 mg QDNo significant change ---

No dose adjustment necessary

Antiretroviral (ARV)Dose of ARVDose of OmeprazoleEffect on ARV LevelsEffect on Omeprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Elvitegravir/cobicistat623
(Genvoya, Stribild)
150 mg/150 mg20 mg given 2 hours before elvitegravirNo significant change---

No dose adjustment necessary

Elvitegravir/cobicistat623
(Genvoya, Stribild)
150/150 mg20 mg given 12 hours after elvitegravirNo significant change---

No dose adjustment necessary

Elvitegravir/cobicistat623
(Genvoya, Stribild)
50 mg elvitegravir with 100 mg ritonavir40 mg given 2 hours before elvitegravirNo significant change---

No dose adjustment necessary

Etravirine404, 405
(ETR)(Intelence)
100 mg x 140 mg QD x 11 daysEtravirine AUC: increased 41%; Cmax: increased 17%-- -

No dose adjustment necessary

Indinavir249
(IDV)(Crixivan)
800 mg or 800 mg with 200 mg ritonavir20 mg or 40 mg x 7 daysIndinavir AUC: decreased 47%; Cmin: decreased 55%Not studiedDecreased indinavir effects-

No dose adjustment necessary

Indinavir250, 251
(IDV)(Crixivan)
800 mg TID20-40 mg QDIndinavir AUC: decreased 25%-Decreased indinavir effectsDecreased gastric acidity may affect indinavir solubility and absorption

No dose adjustment necessary

Antiretroviral (ARV)Dose of ARVDose of OmeprazoleEffect on ARV LevelsEffect on Omeprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Lopinavir/ritonavir243
(LPV/r)(Kaletra)
400 mg/100 mg tabs BID on days 1-1540 mg QD on days 11-15Lopinavir: no significant change; Ritonavir: no significant changeNot studied--

No dose adjustment necessary

Lopinavir/ritonavir243
(LPV/r)(Kaletra)
800 mg/200 mg tabs QD on days 1-1540 mg QD on days 11-15Lopinavir: no significant change; Ritonavir: no significant changeNot studied--

No dose adjustment necessary

Nelfinavir245
(NFV)(Viracept)
1250 mg BID x 8 days with 1 week washout period after 4 days40 mg QD x 4 daysNelfinavir AUC: decreased 36%; Cmax: decreased 37%; Cmin: decreased 39%;M8 AUC: decreased 92%; Cmax: decreased 89%; Cmin: decreased 75%-Decreased nelfinavir effects-

Do not coadminister

Raltegravir445
(RAL)(Isentress)
400 mg BID20 mg QDRaltegravir AUC: increased 39%; Cmax: increased 50%; Cmin: increased 24%- - Possibly due to increased bioavailability due to increased gastric pH

No dose adjustment necessary

Raltegravir444, 419
(RAL)(Isentress)
400 mg Q12H20 mg QD x 4 daysRaltegravir AUC: increased 212%; Cmin: increased 46%; Cmax: increased 315%- - Possibly due to increased bioavailability due to increased gastric pH

No dose adjustment necessary

Rilpivirine567
(RPV)(Edurant)
150 mg QD20 mg QDRilpivirine AUC: decreased 40%; Cmin: decreased 33%; Cmax: decreased 40%No significant changeDecreased rilpivirine effectsDecreased gastric acidity leading to impaired drug solubility and absorption

Do not coadminister

Alternative Agents:
H2-antagonists if administered at least 12 hours before rilpivirine or at least 4 hours after rilpivirine.

Saquinavir75, 246
(SQV)(Fortovase, Invirase)
1000 mg BID with 100 mg ritonavir BID on days 1-1540 mg QD on days 10-15Saquinavir AUC: increased 82%; Cmax: increased 75%; Cmin: increased 106%; Ritonavir: no significant effect- Increased saquinavir effectsPossibly due to increased saquinavir absorption

Monitor for increased saquinavir toxicity particularly GI symptoms, increased triglycerides or deep vein thrombosis

Alternative Agents:
H2-antagonists

"-" indicates that there are no data available
Interactions with Pantoprazole
Antiretroviral (ARV)Dose of ARVDose of PantoprazoleEffect on ARV LevelsEffect on Pantoprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir240, 727
(ATV)(Reyataz)
----Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

Atazanavir/cobicistat727
(others)(Evotaz)
-- Not studied; Potential decrease in atazanavir levels---

Administer proton pump inhibitor at least 12 hours before atazanavir/cobicistat. Proton pump inhibitors should not exceed a dose equivalent to omeprazole 20 mg daily in protease inhibitor naive patients. Proton pump inhibitors are not recommended in protease inhibitor experienced patients.

"-" indicates that there are no data available
Interactions with Rabeprazole
Antiretroviral (ARV)Dose of ARVDose of RabeprazoleEffect on ARV LevelsEffect on Rabeprazole LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir240
(ATV)(Reyataz)
----Decreased atazanavir effectsDecreased GI absorption of atazanavir due to reduced acidity

Do not coadminister PPIs with unboosted atazanavir. PPIs may be administered 12 hours before atazanavir when boosted with ritonavir or cobicistat, in treatment naive patients. Doses should not exceed the equivalent of omeprazole 20 mg daily. PPIs are not recommended for treatment experienced patients.

Alternative Agents:
H2 receptor antagonists

"-" indicates that there are no data available
Interactions with Ranitidine
Antiretroviral (ARV)Dose of ARVDose of RanitidineEffect on ARV LevelsEffect on Ranitidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Atazanavir240
(ATV)(Reyataz)
----May decrease atazanavir effectsPossible decreased GI absorption

Unboosted atazanavir 400 mg: give atazanavir 2 hrs before or 10 hours after H2-blocker. Single doses of H2-blockers should not exceed 20 mg of famotidine (or equivalent). Additionally, if treatment naive, total daily dose of H2 blocker should not exceed 40 mg of famotidine (or equivalent). Atazanavir 300 mg boosted with ritonavir or cobicistat: Give boosted atazanavir at same time as H2 blocker or 10 hours or more after. Total doses of H2 blocker should not exceed the equivalent of 40 mg BID famotidine (treatment naive) or 20 mg BID for (treatment experienced patients). If using tenofovir disoproxil fumarate, atazanavir, and H2 blocker in treatment experienced patient, increase atazanavir dose to 400 mg in addition to boosting with ritonavir or cobicistat.

Atazanavir/cobicistat727
(others)(Evotaz)
--Not studied; Potential decrease in atazanavir levels -Potential loss of antiviral efficacy -

Give atazanavir/cobicistat simultaneously with or ≥10 hours after H2 receptor antagonists (H2RA). If using TDF with H2RA in an ART-experienced patient, increase atazanavir dose to 400 mg (plus cobicistat 150 mg). Do not exceed an H2RA dose equivalent to famotidine 40 mg BID in ART-naive patients or 20 mg BID in ART experienced patients.

Darunavir161, 242
(DRV)(Prezista)
400 mg BID with ritonavir 100 mg BID150 mg BIDNo significant change---

No dose adjustment necessary

Delavirdine88
(DLV)(Rescriptor)
- - Not studied; may decrease delavirdine levels- Decreased delavirdine effectsDecreased absorption of delavirdine

Avoid chronic coadministration

Alternative Agents:
Local antacids

Didanosine244, 84
(ddI)(Videx)
375 mg (sachet) x 1 dose150 mg x 1 doseNo significant changeRanitidine AUC: decreased 16%; Cmax: no significant change-Inhibition of gastric acid slightly enhancing didanosine bioavailablity by reducing acid degradation

No dose adjustment necessary

Antiretroviral (ARV)Dose of ARVDose of RanitidineEffect on ARV LevelsEffect on Ranitidine LevelsPotential Clinical EffectsMechanism of InteractionManagement
Etravirine404, 405
(ETR)(Intelence)
100 mg x 1150 mg BID x 11 daysNo significant change- - -

No dose adjustment necessary

Fosamprenavir130, 241
(FPV)(Lexiva)
1400 mg x 1 dose300 mg x 1 doseAmprenavir AUC: decreased 30%; Cmax: decreased 51%; Cmin: no significant changeNot studiedDecreased amprenavir effects-

If concomitant use is necessary, give FPV at least 2 hours before H2 receptor antagonist. Consider boosting FPV with RTV.

Lopinavir/ritonavir243
(LPV/r)(Kaletra)
400 mg/100 mg BID on days 1-15150 mg QD on day 11No significant changeNot studied--

No dose adjustment necessary

Lopinavir/ritonavir243
(LPV/r)(Kaletra)
800 mg/200 mg tabs QD on days 1-15150 mg QD on day 11Lopinavir Cmin: decreased 35%; Ritonavir AUC: decreased 16%; Cmax: decreased 21%; Cmin: decreased 16%Not studied--

No dose adjustment necessary

Saquinavir44
(SQV)(Fortovase, Invirase)
600 mg x 1 dose150 mg x 2 dosesAUC: increased 67%; Cmax: increased 74%- - Inhibition of CYP450 3A4 by ranitidine

No dose adjustment necessary

"-" indicates that there are no data available
Interactions with Sucralfate
Antiretroviral (ARV)Dose of ARVDose of SucralfateEffect on ARV LevelsEffect on Sucralfate LevelsPotential Clinical EffectsMechanism of InteractionManagement
Dolutegravir689
(Tivicay)
--Not studied - may result in decreased dolutegravir concentrations-Potentially decreased dolutegravir effectiveness -

Administer dolutegravir 2 hours before or 6 hours after sucralfate.

"-" indicates that there are no data available
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