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Anti-HIV Drug Interactions

A Guide to the Interactions Found Between Anti-HIV Drugs and Common HIV-Related Therapies

August 2004

Interactions Table (K-P)

A | B-D | E-I | R | S-Z

Kaletra (lopinavir/ritonavir) plus ...
Kaletra is a single pill containing 2 anti-HIV drugs, lopinavir and ritonavir. References below indicate which drug contained in Kaletra is specifically altered in combinations.
Amiodarone May increase amiodarone level in blood. Checking amiodarone level in blood is recommended.
Amprenavir Decreases lopinavir level by 15% and increases amprenavir trough level about 2-fold in blood. Amprenavir dose may be reduced to 750 mg twice a day or less. However, optimal dose is unclear.
Astemizole Should not be used together. Increases risk of side effects.
Atorvastatin Should be used together with great caution. Increases active atorvastatin level about 6-fold and atorvastatin metabolite by 2.5 times in blood and may increase risk of side effects.
Atovaquone Decreases atovaquone level in blood. Atovaquone dose may have to be increased.
Bepridil May increase bepridil level in blood. Checking bepridil level in blood is recommended.
Carbamazepine Should be used together with great caution. May decrease lopinavir level in blood.
Cisapride Should not be used together. Increases risk of side effects.
Clarithromycin Increases clarithromycin level in blood. Clarithromycin dose should be decreased for people with kidney dysfunction.
Cyclosporine May increase cyclosporine level in blood. Checking cyclosporine level in blood is recommended.
ddI or ddI EC ddI or ddI EC should be taken 1 hour before or 2 hours after taking Kaletra. ddI and ddI EC should be taken on an empty stomach, and Kaletra should be taken with a meal.
Delavirdine May increase lopinavir level in blood. Needs further study.
Dexamethasone Should be used together with great caution. May decrease lopinavir level in blood.
Dihydroergotamine Should not be used together. Increases risk of side effects.
Disulfiram/metronidazole Should be used together with Kaletra oral solution with caution. Alcohol in Kaletra oral solution may increase risk of side effects.
Efavirenz Decreases lopinavir level by about 25% (trough by about 33%). Kaletra dose should be increased to 4 capsules twice a day.
Ergonovine Should not be used together. Increases risk of side effects.
Ergotamine Should not be used together. Increases risk of side effects.
Ethinyl estradiol Should not be used together. Decreases ethinyl estradiol level by 42% in blood. Use another form of contraception.
Felodipine Should be used together with caution. May increase felodipine level in blood. Check for side effects.
Food Increases lopinavir level in blood. Kaletra should be taken with food.
Fosamprenavir Significantly decreases fosamprenavir level in blood. Also increases risk of side effects. Appropriate dose adjustments not yet established.
Indinavir Increases indinavir trough level by about 4 times in blood. Currently under study; however, indinavir dose should be reduced to no more than 600 mg twice a day if used together.
Itraconazole Increases itraconazole level in blood. Itraconazole dose should not exceed 200 mg/day.
Ketoconazole Increases ketoconazole level by 3 times in blood. Ketoconazole dose should not exceed 200 mg/day.
Lidocaine (systemic) May increase lidocaine level in blood. Checking lidocaine level in blood is recommended.
Lovastatin Should not be used together. Increases risk of side effects.
Methadone Decreases methadone level by 53% in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Methylergonovine Should not be used together. Increases risk of side effects.
Midazolam Should not be used together. Increases risk of side effects.
Nelfinavir Decreases lopinavir level in blood. Kaletra dose may need to be increased. Optimal dose is under study.
Nevirapine Decreases lopinavir level in blood. Kaletra dose should be increased to 4 capsules twice a day.
Nicardipine Should be used together with caution. May increase nicardipine level in blood. Check for side effects.
Nifedipine Should be used together with caution. May increase nifedipine level in blood. Check for side effects.
Phenobarbital Should be used together with great caution. May decrease lopinavir level in blood.
Phenytoin Should be used together with great caution. May decrease lopinavir level in blood.
Pimozide Should not be used together. Increases risk of side effects.
Pravastatin Increases pravastatin level in blood. No dose adjustment recommended.
Quinidine May increase quinidine level in blood. Checking for quinidine level in blood is recommended.
Rapamycin May increase rapamycin level in blood. Checking for rapamycin level in blood is recommended.
Rifabutin Increases rifabutin level by 5.7-fold. Rifabutin dose should be changed to 150 mg every other day or 3 times a week. Check for side rifabutin effects.
Rifampin Should not be used together. Decreases lopinavir level by 75% in blood.
Saquinavir (Fortovase) Increases saquinavir trough level by about 3-fold. Saquinavir dose may be reduced to 800 mg twice a day. Optimal dose is under study.
Sildenafil Should be used together with caution. Increases sildenafil level in blood. Sildenafil dose should be reduced to no more than 25 mg every 48 hours.
Simvastatin Should not be used together. Increases risk of side effects.
St. John's Wort Should not be used together. May decrease lopinavir level in blood.
Tacrolimus May increase tacrolimus level in blood. Checking for tacrolimus level in blood is recommended.
Tedalafil Should be used together with caution. May increase tedalafil level in blood.
Tenofovir Increases tenofovir level by about 30% and decreases lopinavir level 15% in blood. No dose adjustment currently recommended.
Triazolam Should not be used together. Increases risk of side effects.
Vardenafil Should be used together with caution. May increase vardenafil level in blood.
Warfarin May affect warfarin level in blood. Check INR.

Ketoconazole (Nizoral) plus ...
Alcohol May increase risk of nausea, vomiting and low blood pressure.
Alprazolam Should be used together with caution. May increase level of alprazolam in blood.
Amphotericin B May interfere with the activity of amphotericin B.
Amprenavir Increases amprenavir level by 31% and increases ketoconazole level by 44% in blood. Impact of interaction is uncertain.
Antacids Should be taken 2 hours apart, otherwise may decrease ketoconazole level in blood.
Astemizole Should not be used together*. Increases risk of side effects.
Cimetidine Should be taken 2 hours apart, otherwise may decrease ketoconazole level in blood.
Cisapride Should not be used together*. Increases risk of side effects.
Clonazepam Should be used with caution. May increase clonazepam level in blood.
Corticosteroids May decrease corticosteroid level in blood.
Cyclosporine Should be used together with caution. May increase cyclosporine level in blood. Check cyclosporine level and adjust dose accordingly.
ddI Should be taken 2 hours apart, otherwise ddI buffering agents may significantly decrease ketoconazole level in blood.
Delavirdine Increases delavirdine level by 50% in blood.
Diazepam Should be used together with caution. May increase diazepam level in blood.
Digoxin May increase digoxin level in blood. Digoxin level should be carefully checked.
Famotidine Should be taken 2 hours apart, otherwise may decrease ketoconazole level in blood.
Fosamprenavir Should be used together with great caution. Increases risk of serious side effects. Do not exceed 400 mg of ketoconazole if fosamprenavir used alone, or 200 mg if boosted with ritonavir.
Glipizide May increase risk of low blood sugar level.
Glyburide May increase risk of low blood sugar level.
Indinavir Increases indinavir level by 68% in blood. Decrease indinavir dose to 600 mg 3 times/day.
Isoniazid Should not be used together*. Decreases ketoconazole level in blood.
Kaletra Increases ketoconazole level by 3 times in blood. Ketoconazole dose should not exceed 200 mg/day.
Loratadine Increases loratadine level by 300% in blood.
Methylprednisolone Should be used together with caution. May increase methylprednisolone level in blood. Check blood level of cyclosporine and adjust dose accordingly.
Miconazole Should be used together with great caution. May lead to severe hypoglycemia (low blood sugar).
Midazolam Should not be used together*. Increases midazolam level in blood.
Nelfinavir Increases nelfinavir level by 35% in blood. No dose adjustment recommended.
Nevirapine Should not be used together. Significantly decreases ketoconazole level in blood.
Omeprazole Should be used together with caution. Decreases ketoconazole and increases omeprazole level in blood.
Phenytoin Should be used together with caution. May affect ketoconazole and phenytoin levels in blood. Check phenytoin and ketoconazole levels and adjust dose accordingly.
Prednisolone May increase prednisolone level in blood.
Ranitidine Should be taken 2 hours apart, otherwise may decrease ketoconazole level in blood.
Rifabutin May decrease ketoconazole level in blood.
Rifampin Should not be used together*. Significantly decreases ketoconazole level in blood.
Ritonavir Should be used together with caution. Significantly increases ketoconazole level in blood. Ketoconazole dose should not exceed 200 mg/day.
Saquinavir (Fortovase) Significantly increases saquinavir level in blood. However, no dose adjustment recommended.
Saquinavir (Invirase) Significantly increases saquinavir level in blood. However, no dose adjustment recommended.
Tacrolimus Should be used together with caution. May increase tacrolimus level in blood. Check tacrolimus level.
Tedalafil Should be used together with caution. Increases tedalafil level in blood. Tedalafil dose should not exceed 10 mg in a 72 hour period.
Testosterone May decrease testosterone level in blood, especially when ketoconazole is used at higher doses.
Tolbutamide May increase risk of low blood sugar level.
Trazodone Increases trazodone level in blood. Trazodone dose may need to be reduced.
Triazolam Should not be used together*. Increases triazolam level in blood.
Trimetrexate May affect trimetrexate and/or ketoconazole level in blood.
Vardenafil Should be used together with caution. Increases vardenafil level in blood. If taking ketoconazole 400 mg/day, vardenafil dose should not exceed 2.5 mg/day. If taking ketoconazole 200 mg/day, vardenafil dose should not exceed 5 mg/day.
Warfarin Should be used together with caution. May increase prothrombin (coagulation) time and increase anticoagulant effects. Check warfarin dose closely.

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Lamivudine (3TC, Epivir) plus ...
Abacavir Decreases 3TC level by 15% in blood. No dose adjustment recommended.
ddC Should not be used together. Decreases anti-HIV activity.
Nelfinavir Increases 3TC level by 10% in blood. No dose adjustment recommended.
TMP/SMX Increases 3TC level by 44% in blood. No dose adjustment recommended. Check for 3TC side effects.

Methadone plus ...
Abacavir May decrease methadone level in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
AZT Increases AZT level by 43% in blood. Check for AZT side effects.
ddI or ddI EC Decreases ddI level by 60% in blood.
Efavirenz Decreases methadone level by 52% in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Kaletra Decreases methadone level by 53% in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Nelfinavir Decreases methadone level in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Nevirapine Decreases methadone level by about 60% in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Rifabutin May decrease effectiveness of methadone. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Rifampin May decrease effectiveness of methadone. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Ritonavir Decreases methadone level by about 40% in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.

Nelfinavir (Viracept) plus ...
3TC Increases 3TC level by 10% in blood. No dose adjustment recommended.
Amiodarone Should not be used together*. Increases risk of side effects.
Amprenavir Increases nelfinavir level by 15% in blood. No dose adjustment recommended.
Astemizole Should not be used together*. Increases risk of side effects.
Atorvastatin Should be used together with great caution. May increase atorvastatin level in blood.
Azithromycin Should be used together with caution. Increases azithromycin level in blood. No dose adjustment recommended, but check for hearing and liver side effects.
AZT Decreases AZT level by 35% in blood. No dose adjustment recommended.
Carbamazepine Should be used together with caution. May decrease nelfinavir level in blood.
Cisapride Should not be used together*. Increases risk of side effects.
ddI or ddI EC Nelfinavir should be taken 2 hours before or after taking ddI or ddI EC. Nelfinavir should be taken with food, and ddI and ddI EC should only be taken on an empty stomach.
Dihydroergotamine Should not be used together*. Increases risk of side effects.
Delavirdine Increases nelfinavir level by about 95% but decreases nelfinavir active metabolite by about 45% in blood. Decreases delavirdine level by about 40%. No data exist to guide dose adjustments.
Ergonovine Should not be used together*. Increases risk of side effects.
Ergotamine Should not be used together*. Increases risk of side effects.
Ethinyl estradiol Should not be used together. Decreases ethinyl estradiol level by 47% in blood. Use another form of contraception.
Fluvastatin May interact somewhat with nelfinavir. No dose adjustment currently recommended.
Food Increases nelfinavir level in blood. Nelfinavir should be taken with food.
Indinavir Increases indinavir level by 51% and increases nelfinavir level by 83% in blood. Increase indinavir dose to 1,000 mg every 8 hours or boost indinavir with ritonavir.
Kaletra Decreases lopinavir level in blood. Kaletra dose may need to be increased. Optimal dose is under study.
Ketoconazole Increases nelfinavir level by 35% in blood. No dose adjustment recommended.
Lovastatin Should not be used together. Increases lovastatin level in blood.
Methadone Decreases methadone level in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Methylergonovine Should not be used together*. Increases risk of side effects.
Midazolam Should not be used together*. Increases risk of side effects.
Nevirapine Modestly decreases nelfinavir level in blood. No dose adjustment recommended.
Norethindrone Should be used together with caution. Decreases norethindrone level by 18% in blood.
Phenobarbital Should be used together with caution. May decrease level of nelfinavir in blood.
Phenytoin Should be used together with caution. May increase rate of metabolism of phenytoin. Check phenytoin level and adjust dose accordingly.
Pimozide Should not be used together*. Increases risk of side effects.
Quinidine Should not be used together*. Increases risk of side effects.
Rifabutin Should be used together with caution. Increases rifabutin and decreases nevirapine level in blood. Reduce rifabutin dose by ½ and use nevirapine at 1,250 mg twice a day.
Rifampin Should not be used together*. Decreases nelfinavir level by 82% in blood.
Ritonavir Increases ritonavir level by 9% and increases nelfinavir level by 152% in blood. Alternate doses under study include nelfinavir at 500–750 mg + ritonavir 400 mg twice a day.
Saquinavir (Fortovase) Increases nelfinavir level 18% and increases saquinavir level 4 times in blood. Saquinavir dose may be reduced to 800 mg 3 times a day or 1,200 mg twice a day.
Saquinavir (Invirase) Increases saquinavir level by 4 times and increases nelfinavir level by 18% in blood. Saquinavir dose may be reduced to 800 mg 3 times a day or 1,200 mg twice a day.
Sildenafil Should be used together with caution. Increases sildenafil level in blood. Sildenafil dose should be reduced to no more than 25 mg every 48 hours.
Simvastatin Should not be used together. Increases simvastatin level in blood.
St. John's Wort Should not be used together. May decrease nelfinavir level in blood.
Tedalafil Should be used together with caution. May increase tedalafil level in blood.
Triazolam Should not be used together*. Increases risk of side effects.
Vardenafil Should be used together with caution. May increase vardenafil level in blood.

Nevirapine (Viramune) plus ...
Amiodarone Should be used together with caution. May decrease amiodarone level in blood.
Amoxicillin May increase risk of rashes and Stevens Johnson Syndrome. Requires careful monitoring.
Amprenavir May decrease amprenavir level in blood. If boosting amprenavir with ritonavir, increase ritonavir to 200 mg twice a day.
Carbamazepine Should be used together with caution. May decrease carbamazepine level in blood.
Cimetidine Should be used together with caution. May slightly increase nevirapine level in blood.
Cisapride Should be used together with caution. May decrease cisapride level in blood.
Clarithromycin Decreases clarithromycin level by 30% and increases nevirapine level by 26% in blood. Consider using alternatives to clarithromycin.
Clonazepam Should be used together with caution. May decrease clonazepam level in blood.
Cyclophosphamide Should be used together with caution. May decrease cyclophosphamide level in blood.
Cyclosporin Should be used together with caution. May decrease cyclosporin level in blood.
Dihydroergotamine Should be used together with caution. May decrease dihydroergotamine level in blood.
Dicumarol Should not be used together*. May increase dicumarol level in blood.
Diltiazem Should be used together with caution. May decrease diltiazem level in blood.
Disopyramide Should be used together with caution. May decrease disopyramide level in blood.
Efavirenz Decreases efavirenz level by 22% in blood. Efavirenz dose may need to be increased to 800 mg once a day.
Ergonovine Should be used together with caution. May decrease ergonovine level in blood.
Ergotamine Should be used together with caution. May decrease ergotamine level in blood.
Erythromycin Should be used together with great caution. May increase risk of liver toxicity.
Ethinyl estradiol Should not be used together. Decreases ethinyl estradiol level in blood. Use another form of contraception.
Ethosuximide Should be used together with caution. May decrease ethosuximide level in blood.
Fentanyl Should be used together with caution. May decrease fentanyl level in blood.
Indinavir Decreases indinavir level by 27% in blood. Indinavir dose should be increased to 1,000 mg 3 times a day or 800 mg twice daily if boosted with ritonavir.
Itraconazole Should be used together with caution. May decrease itraconazole level in blood. Itraconazole dose may need to be increased.
Kaletra Decreases Kaletra level in blood. Kaletra dose should be increased to 4 capsules twice a day.
Ketoconazole Should not be used together. Significantly decreases ketoconazole level in blood.
Lidocaine (systemic) Should be used together with caution. May decrease lidocaine level in blood.
Methadone Decreases methadone level by about 60% in blood. Check for methadone withdrawal symptoms and adjust methadone dose accordingly.
Methylergonovine Should be used together with caution. May decrease methylergonovine level in blood.
Nelfinavir Modestly decreases nelfinavir level in blood. No dose adjustment recommended.
Nifedipine Should be used together with caution. May decrease nifedipine level in blood.
Norethindrone Decreases norethindrone level in blood. Use another form of contraception.
Prednisone May increase risk of rash.
Rifabutin Should be used together with caution. May significantly affect rifabutin level in blood.
Rifampin Should not be used together. Decreases nevirapine level in blood.
Ritonavir Decreases ritonavir level by 11% in blood. No dose adjustment recommended.
Saquinavir (Fortovase) Decreases saquinavir level by 24% in blood. Saquinavir may require ritonavir boosting.
Saquinavir (Invirase) Decreases saquinavir level by 27% in blood. Saquinavir may require ritonavir boosting.
Sirolimus Should be used together with caution. May decrease sirolimus level in blood.
Steroids May increase rate of metabolism of steroids.
St. John's Wort Should not be used together. May decrease nevirapine level in blood.
Tacrolimus Should be used together with caution. May decrease tacrolimus level in blood.
TMP/SMX Should not be initiated together for the first 4–6 weeks. May increase risk of rashes.
Voriconazole Should be used together with caution. May increase nevirapine side effects and decrease effectiveness of voriconazole.
Warfarin Should be used together with great caution. Interaction is complex. Warfarin level in blood should be checked carefully.

Oral contraceptives
See section on Ethinyl estradiol.

Pentamidine (Pentam) plus ...
Adefovir Should not be used together*. Increases risk of kidney toxicity.
Amphotericin B Should be used together with great caution. May increase risk of kidney toxicity.
Anticancer drugs May increase risk of anemia.
AZT May increase risk of anemia.
Cidofovir Should not be used together*. Increases risk of kidney toxicity.
ddC Should be used with great caution. May increase risk of peripheral neuropathy and pancreatitis.
ddI or ddI EC May increase risk of pancreatitis.
d4T May increase risk of pancreatitis.
Foscarnet Should be used with caution. May increase risk of kidney toxicity. Check closely.
Ganciclovir Should be used together with great caution. May increase risk of bone marrow toxicity.
Interferon-alfa May increase risk of bone marrow toxicity.
Tenofovir Should not be used together*. May increase risk of side effects.

Probenecid (Benemid, ColBenemid) plus ...
Acetaminophen Should be used together with caution. Increases acetaminophen level in blood.
Acyclovir Increases acyclovir level in blood. Impact of interaction is uncertain.
Aspirin Should be used together with caution. Decreases activity of probenecid.
AZT Should be used together with caution. Increases AZT level by 106% in blood. Check for AZT side effects.
Benzodiazepines Increases benzodiazepine level in blood.
Bumetadine Should not be used together. Probenecid decreases the effectiveness of bumetadine.
Captopril Should be used together with caution. May increase captopril level in blood.
Cidofovir Needs to be taken together to decrease risk of kidney toxicity.
Cilastatin Should be used together with caution. May increase cilastatin level in blood and increase risk of side effects.
Ciprofloxacin Should be used together with caution. May increase ciprofloxacin level in blood and increase risk of side effects.
Cisplatin Should be used together with caution. May increase cisplatin level in blood and increase risk of side effects.
Clofibrate Should be used together with caution. May increase clofibrate level in blood and increase risk of side effects.
Dapsone Should be used together with caution. May increase dapsone level in blood and increase risk of side effects.
ddC Significantly increases ddC level in blood. Check for toxicity and consider lower ddC dose.
Famotidine Should be used together with caution. Significantly increases famotidine level in blood.
Furosemide May increase risk of inner ear poisoning (ototoxicity).
Ganciclovir Should be used together with caution. May increase ganciclovir level in blood and increase risk of side effects.
Indomethacin Should be used together with caution. Increases indomethacin level in blood. May allow for lower indomethacin dose.
Imipenem Should be used together with caution. May increase imipenem level in blood and increases risk of side effects.
Ketamine Should be used together with caution. Increases ketamine level in blood.
Ketoprofen Should not be used together. Increases ketoprofen level in blood and increases risk of side effects.
Lorazepam Should be used together with caution. Increases lorazepam level in blood.
Meclofenamate Increases meclofenamate level in blood.
Methotrexate Should be used together with caution. Increases methotrexate level in blood and increases risk of side effects.
Naproxen Should be used together with caution. Increases naproxen level in blood.
Penicillin Should be used together with caution. Increases penicillin level 2–4 times in blood and increases risk of side effects.
Pyrazinamide Should be used together with caution. Decreases activity of probenecid.
Rifabutin Should be used together with caution. May increase rifabutin level in blood and increase risk of side effects.
Rifampin Should be used together with caution. May increase rifampin level in blood and increase the risk of side effects.
Sulfonamide Increases sulfonamide level in blood.
Sulindac Increases sulindac level in blood and decreases activity of probenecid.
Theophylline May increase theophylline level in blood.
Thiopental Should be used together with caution. Increases thiopental level in blood.

Pyrimethamine (Daraprim) plus ...
AZT Should be used together with caution. May increase risk of bone marrow toxicity.
Dapsone May increase risk of bone marrow toxicity.
Ethionamide May increase risk of side effects from other anti-TB drugs like pyrazinamide.
Interferon-alfa May increase risk of bone marrow toxicity.
Lorazepam May increase risk of liver toxicity.
Sulfonamides Should be used together with caution. May increase risk of bone marrow toxicity.
TMP/SMX Should be used together with caution. May increase risk of bone marrow toxicity.


Interpreting Directions

Should not be used together
The risk of side effects from a combination is too high for the two medications to be used together.

An asterisk (*) following this phrase means the side effects may be life-threatening.

Should be used together with caution
The risk of side effects from a combination is possible, but not highly common.

Should be used together with great caution
The risk of side effects from a combination is possible, and though not common may be serious if they occur.




  
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