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Updated Adult and Adolescent ARV Guidelines

The Adult and Adolescent ARV Guidelines were updated on February 12, 2013. 

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

Drug Interactions

Drugs That Should Not Be Used With Antiretroviral Agents

(Last updated:2/12/2013; last reviewed:2/12/2013)

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Table 14. Drugs That Should Not Be Used With Antiretroviral Agents
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This table only lists drugs that should not be co-administered at any dose and regardless of ritonavir (RTV) boosting. See Tables 15 and 16 for more detailed pharmacokinetic (PK) interaction data.

Drug Categories

Antiretroviral Agentsa,b

Cardiac Agents

Lipid- Lowering Agents

Antimyco-bacterials

Gastro-intestinal Drugs

Neuroleptics

Psycho-tropics

Ergot Derivatives (vasoconstrictors) 

Herbs

Anti-retroviral Agents

Others 
ATV +/− RTV amiodarone
dronedarone		 lovastatin
simvastatin 		rifampin
rifapentinec		 cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergonovine
ergotamine
methylergonovine		 St. John’s wort ETR
NVP		 alfuzosin
irinotecan
salmeterol
sildenafil for PAH
DRV/r amiodarone
dronedarone		 lovastatin
simvastatin		 rifampin
rifapentinec		 cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergonovine
ergotamine
methylergonovine		 St. John’s wort none alfuzosin
salmeterol
sildenafil for PAH
FPV +/− RTV amiodarone
dronedarone
flecainide
propafenone		 lovastatin
simvastatin		 rifampin
rifapentinec		 cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergonovine
ergotamine
methylergonovine		 St. John’s wort ETR alfuzosin
salmeterol
sildenafil for PAH
LPV/r amiodarone
dronedarone		 lovastatin
simvastatin		 rifampind
rifapentinec		 cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergonovine
ergotamine
methylergonovine		 St. John’s wort none alfuzosin
salmeterol
sildenafil for PAH
SQV/r amiodarone
dronedarone
dofetilide
flecainide
lidocaine
propafenone
quinidine 		lovastatin
simvastatin		 rifampind
rifapentinec		 cisapridee pimozide midazolamf
triazolam
trazodone		 dihydroergotamine
ergonovine
ergotamine
methylergonovine

St. John’s wort

garlic supplements

 none alfuzosin
salmeterol
sildenafil for PAH
TPV/r amiodarone
dronedarone
flecainide
propafenone
quinidine		 lovastatin
simvastatin		 rifampin
rifapentinec		 cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergonovine
ergotamine
methylergonovine		 St. John’s wort ETR alfuzosin
salmeterol
sildenafil for PAH
EFV none none  rifapentinec cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergonovine
ergotamine
methylergonovine		 St. John’s wort other NNRTIs none
ETR none none rifampin
rifapentinec		 none none  none  none  St. John’s wort unboosted PIs ATV/r, FPV/r, or TPV/r
other NNRTIs		 carbamazepine
phenobarbital
phenytoin
clopidogrel
NVP none none  rifapentinec none  none  none  none  St. John’s wort ATV +/− RTV
other NNRTIs		 ketoconazole
RPV none none rifabutin
rifampin
rifapentinec		 proton pump inhibitors none none  none  St. John’s wort other NNRTIs carbamazepine
oxcarbazepine
phenobarbital
phenytoin
MVC none none  rifapentinec none none none none St. John’s wort none none
EVG/COBI/TDF/FTC none lovastatin
simvastatin		 rifabutin
rifampin
rifapentinec		 cisapridee pimozide midazolamf
triazolam		 dihydroergotamine
ergotamine
methylergonovine		 St. John’s wort All other ARVs alfuzosin
sildenafil for PAH
a DLV, IDV, NFV, and RTV (as sole PI) are not included in this table. Refer to the appropriate FDA package insert for information regarding DLV-, IDV-, NFV-, and RTV (as sole PI)-related drug interactions.
b Certain listed drugs are contraindicated on the basis of theoretical considerations. Thus, drugs with narrow therapeutic indices and suspected metabolic involvement with CYP450 3A, 2D6, or unknown pathways are included in this table. Actual interactions may or may not occur in patients.
c HIV-infected patients treated with rifapentine have a higher rate of tuberculosis (TB) relapse than those treated with other rifamycin-based regimens. Therefore an alternative agent to rifapentine is recommended.
d A high rate of Grade 4 serum transaminase elevation was seen when a higher dose of RTV was added to LPV/r or SQV or when double-dose LPV/r was used with rifampin to compensate for rifampin’s induction effect and therefore, these dosing strategies should not be used.
e The manufacturer of cisapride has a limited-access protocol for patients who meet specific clinical eligibility criteria.
f Use of oral midazolam is contraindicated. Parenteral midazolam can be used with caution as a single dose and can be given in a monitored situation for procedural sedation.

Suggested alternatives to:
• Lovastatin, simvastatin: Fluvastatin, pitavastatin, and pravastatin (except for pravastatin with DRV/r) have the least potential for drug-drug interactions (see Table 15a). Use atorvastatin and rosuvastatin with caution; start with the lowest possible dose and titrate based on tolerance and lipid-lowering efficacy.
• Rifampin: Rifabutin (with dosage adjustment, see Tables 15a and 15b)
• Midazolam, triazolam: temazepam, lorazepam, oxazepam

Key to Abbreviations: ATV +/- RTV = atazanavir +/- ritonavir, ATV/r = atazanavir/ritonavir, COBI = cobicistat, CYP = cytochrome P, DLV = delavirdine, DRV/r = darunavir/ritonavir, EFV = efavirenz, ETR = etravirine, EVG = elvitegravir, FDA = Food and Drug Administration, FPV +/- RTV = fosamprenavir +/- ritonavir, FPV/r = fosamprenavir/ritonavir, IDV = indinavir, LPV/r = lopinavir/ritonavir, MVC = maraviroc, NFV = nelfinavir, NNRTI = non-nucleoside reverse transcriptase inhibitor, NVP = nevirapine, PAH = pulmonary arterial hypertension, PI = protease inhibitor, PK = pharmacokinetic, RPV = rilpivirine, RTV = ritonavir, SQV = saquinavir, SQV/r = saquinavir/ritonavir, TB = tuberculosis, TPV/r = tipranavir/ritonavir