Brand name: Crixivan

Generic name: indinavir sulfate (indinavir), or IDV

Class: Protease inhibitor (PI)

Manufacturer: Merck and Co.,, (800) 850-3430

AWP: $548.12/month for 180 400 mg capsules

Standard Dose: STANDARD DOSE: Rarely used by itself (two 400 mg capsules every eight hours with no food or a low-fat snack). Almost always boosted with Norvir, both twice daily: 800 mg with 100 mg Norvir or 800 mg with 200 mg Norvir (all doses taken with food and with plenty of water to avoid kidney sludge or stones). Avoid grapefruit juice and vitamin C (more than one gram a day). Take missed dose as soon as possible, unless it is closer to the time of your next dose. Do not double up on your next dose. Drink lots of non-caffeinated fluids throughout the day if you are taking Crixivan to help reduce the risk of kidney stones. Also available in 100 mg, 200 mg, and 333 mg capsules.

Potential side effects and toxicity: Headache, fatigue or weakness, malaise (general ill feeling), nausea, diarrhea, stomach pain, loss of appetite, yellowing of skin/eyes, changed skin color, dry mouth/sore throat, taste changes, painful urination, indigestion, joint pain, hives, and liver toxicity. Itchy/dry skin, ingrown toe nails, and hair loss are unique to Crixivan. Kidney stones, which may lead to more serious problems, can also occur -- if pain develops in the middle to lower stomach or the back, or if there is blood in the urine, call your health care provider immediately. An increase in bilirubin (a test of liver function) has been reported, but it is not associated with liver problems. It may sometimes cause yellowing of the skin or eyes. Crixivan has also been associated with hemolytic anemia (premature destruction of red blood cells) and it should be stopped once the anemia is diagnosed. See chart for potential drug class side effects.

Potential drug interactions: PIs interact with many other drugs. See the package insert for the most complete list. Tell your provider or pharmacist about all medications, herbs, and supplements you are taking or thinking of taking, prescribed or not. Do not take with alfuzosin, Revatio, Tambocor (flecainide), Rythmol (propafenone), Cordarone (amiodarone), oral Versed (midazolam), triazolam, rifampin, pimozide, garlic supplements, or the herb St. John's wort. Do not use Advicor, Altoprev, Livalo, Mevacor (lovastatin), Simcor, Vytorin, or Zocor (simvastatin) for the treatment of high cholesterol. Cholesterol-lowering alternatives are Crestor, Lescol, Lipitor, and Pravacol (pravastatin), but should be used with caution and started at the lowest dose possible; monitor closely for increased side effects from these medications. Not recommended in combination with Reyataz. Reduce Crixivan to 600 mg every eight hours when taken with Rescriptor, itraconazole (200 mg twice a day), or ketoconazole (200 mg once a day). The dose of Mycobutin should be reduced to 150 mg daily or 300 mg three times a week and Crixivan dose increased to 1,000 mg every eight hours or use Norvir-boosted dose when taken together. Cialis, Levitra, and Viagra levels are increased; doses should not exceed 10 mg Cialis or 2.5 mg Levitra per 72 hours, or 25 mg Viagra per 48 hours. Effectiveness of birth control pills may be decreased; consider the use of alternative or additional contraception. Additional monitoring may be required when taking Coumadin (warfarin) or calcium channel blockers (such as Norvasc, Procardia, and others). Use caution with anti-convulsants: Tegretol (carbamazepine), phenobarbital, and Dilantin (phenytoin). Crixivan may decrease levels of methadone and methadone may need to be increased, but withdrawal rarely occurs. Also, increased levels of trazodone can occur with Crixivan. Increased levels of the inhaled and nasal sprays with fluticasone (found in Advair, Flonase, and Flovent) can occur with Crixivan; use only if the benefits outweigh the risks, and monitor for signs of Cushing's syndrome (increased fat in the abdomen, fatty hump between the shoulders, rounded face, red/purple stretch marks on the skin, bone loss, possible high blood pressure, and sometime diabetes). Alternatives should be considered, particularly for long-term use. Use with caution with bosentan, salmeterol, immunosuppressants (including transplant drugs), and colchicine; use lower dose of colchicine. Use of the hepatitis C drug Victrelis (boceprevir) along with a Norvir-boosted PI can potentially reduce the effectiveness of both drugs -- combined use is not recommended.

More information: Very rarely used. Drink at least 48 oz. of fluids daily, preferably water or clear liquids (soda pop doesn't count!) to decrease the chances of kidney stones. Don't forget to drink more water in summer or with increased sweating. Large amounts of coffee or alcohol can increase risk of stones due to increased dehydration. Stones may continue after stopping Crixivan. Store in original container and keep dry. See package insert for more complete information on potential side effects and interactions.

Doctor's Comments

Crixivan deserves our undying gratitude for having saved many lives in the late '90s, but it's now a drug of purely historical importance. Side effects included kidney stones or kidney failure, diabetes, lipid changes, dry skin, chapped lips, ingrown toenails, and possibly body-shape changes (the dreaded "Crix belly," for example). When taken without Norvir boosting, its dosing schedule was unforgiving and complex; when boosted by Norvir, it just became more toxic. Avoid it.

-- Joel Gallant, M.D., M.P.H.

Activist's Comments

This miracle drug will go down in history as a game changer. People went from just staying alive to living with HIV. Although at the time, it was too many horse pills, too much water to drink, and still all kinds of side effects, but we dealt with it. Today, it is very rarely used, only by those still on it from back in the day who think "if it ain't broke, don't fix it!" I convinced someone three months ago to switch off of it to a newer regimen, and he thanked me two months later, as it really was a difficult regimen, both in managing side effects and pill burden. Thanks, Crixivan, you'll always be remembered for that crossroads.

-- Joey Wynn

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