Brand name: Reyataz

Generic name: atazanavir sulfate (atazanavir), or ATV

Class: Protease inhibitor (PI)

Manufacturer: Bristol-Myers Squibb,, (800) 321-1335

AWP: $1,219.09/month for 300 mg capsules; $1,257.09/month for 200 mg capsules

Standard Dose: One 300 mg capsule plus 100 mg Norvir, once daily (this dose must be used if taking Viread or Truvada, or if pregnant), or two 200 mg capsules (without Norvir), once daily for treatment-naïve adults; take with food. If pregnant and on Viread or Truvada, take Reyataz 400 mg plus Norvir 100 mg, once daily. It is also recommended in combination with Norvir for children 6 years or older. Reyataz capsules should not be opened and mixed with food or nutritional supplements. Swallow capsules whole. Also available in 100 mg and 150 mg capsules. 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.

Potential side effects and toxicity: Dizziness and lightheadedness; possible jaundice (yellowing of the skin or eyes), not related to liver damage, but report to your medical provider right away. Other side effects may include rash, kidney stones, and elevated liver enzymes, a sign of liver damage (more common in people with hepatitis B or C). Reyataz should not be taken by treatment-experienced patients on hemodialysis. Reyataz is the only PI that doesn't increase lipid levels, but higher lipid levels may be seen if Reyataz is boosted with Norvir. See chart for potential drug class side effects.

Potential drug interactions: PIs interact with many other drugs. See 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. Medications used to treat acid reflux (GERD) and heartburn, like proton pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs), can lower the levels of Reyataz. Treatment-experienced people cannot take Reyataz with PPIs. Treatment-naïve people can take a PPI in a dose comparable to Prilosec OTC 12 hours before Reyataz/Norvir. H2RAs like Pepcid may be taken (no more than 20 mg twice a day if treatment-experienced or 40 mg twice a day if treatment-naïve, or equivalent doses) at the same time as Reyataz/Norvir with food (before the H2RA has started to work) or at least 10 hours later. If taking with Viread or Truvada and an H2RA, you must take the 400 mg Reyataz/100 mg Norvir dose with food. When taking Reyataz without Norvir, dose can be taken at least two hours before and at least 10 hours after an H2RA. Reyataz should be taken two hours before or one hour after antacids (Rolaids, Tums, etc.). Do not take with alfuzosin, Revatio, rifampin, Camptosar, oral Versed, Halcion, pimozide, Crixivan, or St. John's wort. Do not use Advicor, Altoprev, Livalo, Mevacor, Simcor, Vytorin, or Zocor. Alternatives are Crestor, Lescol, Lipitor, and Pravacol, but should be used with caution and started at the lowest dose possible; monitor closely for increased side effects from these medications. Must be taken two hours before or one hour after Videx EC (unless taking Videx EC with Viread). Treatment-naïve people should take 400 mg Reyataz/Norvir (100 mg) when taking with Sustiva, but treatment-experienced people should not take Reyataz with Sustiva. Viread decreases the levels of Reyataz and Reyataz increases Viread levels, which could increase adverse events. Monitor for Viread-associated adverse events. Reyataz can be taken unboosted with Epzicom if Norvir is not indicated or not tolerated. Use the heart medications bepridil, Cordarone, quinidine, and lidocaine cautiously. Monitoring may be required when used with Coumadin. Increases levels of fluticasone in Advair, Flonase, and Flovent); 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 sometimes diabetes). Effectiveness of birth control pills may be decreased; consider the use of alternative or additional contraception. Oral contraception should contain no more than 30 mcg of ethinyl estradiol if taking Reyataz without Norvir and at least 30 mcg if taken with Norvir. Use caution when using itraconazole or ketoconazole. Vfend is not recommended. Monitor for Reyataz side effects when taking with Noxafil. Reducing dose and frequency of rifabutin to 150 mg every other day or three times a week is recommended. Use caution with Tegretol, phenobarbital, and Dilantin. 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. Calcium channel blockers should be monitored. A lower dose of trazodone is recommended. Use with caution with bosentan, salmeterol, and immunosuppressants, and use lower dose of colchicine. Use with Norvir when taking buprenorphine. Monitor before sedation. Reyataz can decrease the effects of Malarone. 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: Norvir-boosted Reyataz is recommended by the U.S. HIV treatment guidelines for people starting HIV therapy for the first time. It's set to be combined with the booster drug cobicistat (see cobicistat). A built-in cobicistat booster would both eliminate Norvir and reduce pill burden. Many people who started out with unboosted Reyataz continued to do as well as those on boosted Reyataz, but many folks are still concerned about data showing that unboosted use is associated with a higher risk of treatment failure. See the package insert (revised October 2011) for more complete information on potential side effects and interactions.

Doctor's Comments

The first of the "kindler, gentler PIs," Reyataz was shown to be as effective as Kaletra for initial therapy, with less diarrhea and lipid elevations. It also has the most convenient dosing of any PI. Although I always prefer to boost Reyataz with Norvir, it is the only PI I would consider prescribing without boosting, because resistance to Reyataz doesn't cause cross-resistance to other PIs. Because of an interaction with tenofovir, Reyataz must be boosted when taken with Viread or Truvada, and if taken with Sustiva or Atripla, an even higher dose of Reyataz should be used (400 mg plus 100 mg Norvir). Reyataz needs an acidic environment for absorption; it can't be taken with most proton pump inhibitors, and strict dosing separation is required with other stomach acid reducers, such as H2 blockers and antacids. It's probably better to just avoid Reyataz if you're taking medications for reflux or ulcers. Reyataz also increases indirect bilirubin, which for most is a harmless lab abnormality, but for others, can result in yellowing of the eyes and/or skin. These side effects are harmless but unattractive, and most people who develop them elect to change drugs.

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

Activist's Comments

If you don't have to take acid reflux drugs and you really need to take a vacation from Norvir boosting, this may be the drug for you! Crowned as the first "once-a-day PI," Reyataz should have been a blockbuster, but due to the list of complications with some drugs, it never gained a strong foothold in certain areas of the country. And with eerie side effects for some, like yellowing of the eyes, folks switch off of it quickly, never to return; but, it has great tolerability and no lipid or other lab problems.

-- Joey Wynn

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