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doi: 10.1111/j.1365-2796.2010.02301.x Drug–drug interactions in the treatment of HIV infection: focus on pharmacokinetic enhancement through CYP3A inhibition F. Josephson MedicalProductsAgency,Uppsala,Sweden Abstract.JosephsonF. (Medical ProductsAgency,Upp- sala, Sweden). Drug–drug interactions in the treat- ment of HIV infection: focus on pharmacokinetic enhancement through CYP3A inhibition (Review- Symposium).J InternMed2010;268: 530–539. The aim of this review is to discuss the effect of phar- macokinetic drug–drug interactions (DDIs) in the an- tiretroviral treatment of HIV infection. In particular, butnot exclusively,DDIsdue to thecytochromeP450 3A (CYP3A) inhibitor ritonavir, which is used to in- crease antiretroviral drug exposure – a technique known as pharmacokinetic enhancement or ‘ritona- virboosting’ –willbereviewed.Theemphasisherewill be on the treatment of important co-morbidities com- mon in patients with HIV, including dyslipidaemia, hypertension, tuberculosis and opiate dependence, as well as on the potentially life-threatening interac- tion between ritonavir and inhalational steroids, and on the effect of acid-reducing agents on some antiret- roviral drugs. Finally, further developments with re- gard to theuse of CYP3A-blocking agents to augment theefficacyofantiviral therapywillbediscussed. Keywords: cobicistat, CYP3A, drug interaction, HIV, ritonavir. Introduction Givenourunderstandingof thediseaseandtheavail- able therapies, infection with human immunodefi- ciency virus (HIV) currently requires lifelong therapy. Combinations of three active drugs from at least two classes are recommended in most cases. The most commonly used combination regimens include two nucleoside analogue inhibitors of reverse transcrip- tase (NRTIs) incombinationwitheitheranon-nucleo- side inhibitor of reverse transcriptase (NNRTI) or an HIV protease inhibitor (PI) (Table 1). The potential for clinically relevantdrug–drug interactions (DDIs)with the NRTIs is limited andmainly restricted to interac- tions between the NRTIs themselves; though, there are some exceptions to this rule. With regard to the NNRTIs, all three drugs currently approved in the European Union (efavirenz, nevirapine and etravi- rine) are inducers of cytochrome P450 (CYP450) en- zymes and may in some cases cause clinically rele- vant decreases in exposure to co-treating agents that undergoCYP450-dependentmetabolism [1–3]. Addi- tionally, they are metabolized by several different CYP450 enzymes, and co-treatment with potent he- patic enzyme inducers, such as rifampicin, may in turn cause lowered NNRTI exposure. The generally recommended PIs, including atazanavir, lopinavir anddarunavir, arealmost exclusivelymetabolizedby CYP4503A (CYP3A) and thereby biotransformed into inactive metabolites [4–6]. To a varying extent, they are themselves inhibitors of CYP3A, and some are also inducers of hepatic drug-metabolizing enzymes. Furthermore, and of crucial importance, all first-line recommended PI regimens include co-administra- tion of the CYP3A inhibitor ritonavir to increase the pharmacokinetic exposure to the active PI through increased bioavailability and decreased clearance (lopinavir is co-formulated with ritonavir). This prac- tice of pharmacokinetic enhancement is termed ‘ri- tonavir boosting’ and has been shown to increase the potencyandgreatlyaugment thebarrier to resistance ofPI-basedantiretroviral therapy [7]. CYP3A, however, is not only responsible for the metabolism of PIs, but is also the predominant en- zyme for drug metabolism in general. Its substrates include many important drugs used in a wide range of therapeutic fields. Thus, ritonavir boosting creates a plethora of putative, clinically relevant DDIs, as illustrated inTable2. In addition toNRTIs, NNRTIs andPIs, other currently available drugs include the entry inhibitors enfuvir- tide andmaraviroc, and the integrase inhibitor ralte- gravir. The former drugshave relatively limiteduse in Europe at present. Raltegravir, however, is a very po- tent drug with a wide therapeutic index and is increasingly used not only in treatment-experienced 530 ª 2010 The Association for the Publication of the Journal of Internal Medicine Review | but also in treatment-naive patients. Of interest, sig- nificant DDIs are not commonly associated with ral- tegravir, and it may be a valuable option when DDIs arecomplicating thechoiceofantiretroviral agents. Ritonavir Ritonavir is itself a PI and was one of the first drugs in this class to be approved for the treatment of HIV. At therapeutic doses (400–600 mg twice daily), it is, however, arguably the least well-tolerated PI, with side effects including severe gastrointestinal symp- toms, as well as increased plasma levels of choles- terol and triglycerides [8, 9]. As mentioned previ- ously, ritonavir is also a very strong inhibitor of CYP3A. At considerablymore tolerable, though byno means side effect–free, doses of 100 mg once or twice daily, which are used for ritonavir boosting, hepatic CYP3A activity is blocked by >80% and presystemic CYP3A even more so, using midazolam or alfentanil as a probe [10, 11]. Near-maximal CYP3A blockade is seen at doses as low as 50 mg [12]. Ritonavir boosting increases the area under the concentra- tion–time curve (AUC) 5- to 80-fold, depending on which ‘therapeutic’ PI is boosted. The highest values are seen for substances suchas darunavir and lopin- avir. The bioavailability of these agents in the ab- sence of ritonavir is very low as a result of presystem- ic metabolism, and therapeutic exposure cannot be reached in the absence of profound CYP3A blockade [4, 5, 13–15]. The DDI potential of ritonavir-boosted PI drug regi- mens is complicated by the fact that ritonavir is not only a strong net inhibitor of CYP3A but is also a po- tent pregnane X receptor activator. It is therefore an inducer of a number of clinically important drug- metabolizing enzymes, including CYP1A2, CYP2C9, CYP2C19, CYP3A and glucuronyl transferases [8, 11].Furthermore, it isan inducer aswell as an inhibi- tor of transmembrane drug transporter p-glycopro- tein [16, 17]. At therapeutic but not boosting doses, it is also a significant inhibitor of CYP2D6 [8]. Owing to the capacity of ritonavir (as well as some of the thera- peutic PIs) to induce hepatic enzymes, the spectrum of clinically relevant potential DDIs with ritonavir- boosted PI regimens is not restricted to the risk of substantially increased drug exposure and toxicity because of CYP3A inhibition, but also in some cases includes the possibility of decreased exposure and therapeutic efficacy because of the induction of other hepatic enzymes. PI and statin therapy Co-treatment with lipid-lowering therapy is common amongstpatients treated forHIV infection.Dyslipida- emia is frequent in thegeneralpopulationandmaybe more so amongst individuals with HIV, regardless of treatment [18]. Also, several antiretroviral agents are associated with alterations in plasma lipids. Of importance,most PIs, including ritonavir at boosting doses, may cause increased total cholesterol, Table 1 Examples of recommended and alternative first-line antiretroviral treatment regimens (e.g. see European AIDS Clinical Societyguidelines,availableathttp://www.europeanaidsclinicalsociety.org/guidelines.asp) NNRTI-basedregimens MajorpharmacokineticDDIpotential NRTI NRTI NNRTI abacavir + lamivudine + efavirenz tenofovir + emtricitabine + efavirenz Reducedexposure toco-treatingagentsbecauseof inductionof drug-metabolizingenzymes.ReducedexposuretoNNRTIbecauseof enzyme inductionbyco-treatingagent. PI-basedregimens NRTI NRTI PI ⁄ ritonavir (r) abacavir + lamivudine + atazanavir ⁄ r abacavir + lamivudine + darunavir ⁄ r tenofovir + emtricitabine + atazanavir ⁄ r tenofovir + emtricitabine + darunavir ⁄ r Increasedexposure toco-treatingagentsbecauseofCYP3A inhibition. Reducedexposure toco-treatingagentsbecauseof inductionof drug-metabolizingenzymes. Integrase inhibitor (II)-basedregimensNRTI NRTI II tenofovir + emtricitabine + raltegravir F. Josephson | Review-Symposium: Drug–drug interactions in the treatment of HIV infection ª 2010 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 268; 530–539 531 Table 2 Examples of drugs that undergo CYP3A-dependent metabolism, which are contraindicated or should be used with cautionwhen co-treatingwith a ritonavir-boosted PI (list based on the European SPC for Norvir� [8], but note that the list isnotexhaustive) Drugsundergoing CYP3A-dependent metabolism Comments Alpha-receptor blockers Detailsof themetabolismofother drugs in thisclass, suchas terazosinanddoxazocin,have notbeenreported; theymayalso beCYP3Asubstrates Alfuzosin Opiates CYP3Aisnot involved inmorphine metabolism Pethidine Fentanyl Anti-arrhythmics Therisksof co-administrationof QT-prolongingagentsthatare CYP3Asubstrates, together withstrongCYP3Ainhibitorssuch asritonavir,maybequite considerable Amiodarone Bepridil Quinidine Anticancer agents Notethatanumberofotheranticancer agentsarealsoCYP3Asubstrates Vincristine Vinblastine Anticonvulsants CYP3Aisnotprimarily involved in themetabolismofvalproicacid and lamotrigine Carbamazepine Antihistamines Cetirizine,whichhasconsiderable renal elimination,maybea preferredalternative Astemizole Terfenadine Calciumchannel antagonists See text.Themagnitudeof increasedexposureprobably variesbetweenagents.Therisksof co-administrationwith ritonavirmay behigherwithagents thataffect cardiacconductionat therapeuticdoses Table 2 (Continued) Drugsundergoing CYP3A-dependent metabolism Comments Amlodipine Felodipine Nifedipine Diltiazem Verapamil Gastrointestinal motilityagents Seeabove,anti-arrhythmics Cisapride Statins Seetext.Appropriatestatindepends onwhichboostedPI isused Simvastatin Lovastatin Atorvastatin Immunosuppressants Considerable increase in immunosuppressantexposure. Co-treatment ispossible,however, withcareful titrationanduseof therapeuticdrugmonitoring Cyclosporin Tacrolimus Everolimus PDE-5 inhibitors Co-treatwithcaution,using reduceddosesofPDE5inhibitors Sildenafil Tadalafil Vardenafil Benzodiazepines In contrast to the listed benzodiaze- pines,oxazepamdoesnotundergo CYP3A-dependentmetabolism Diazepam Flurazepam Midazolam Triazolam Flunitrazepam Inhaled corticosteroids Reported thatbeclometasonedoes notundergoCYP3A-dependent metabolism Fluticasone Mometasone Budesonide F. Josephson | Review-Symposium: Drug–drug interactions in the treatment of HIV infection 532 ª 2010 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 268; 530–539 decreasedHDLcholesteroland increased triglyceride levels [19]. The liability to interactwith ritonavir-boostedPIs var- ies between statins, and interestingly, also between PIs. With regard to elimination pathways, simvasta- tin, lovastatin and atorvastatin are metabolized by CYP3A. Thus, one would expect clinically relevant DDIs between these substances and ritonavir- boosted PI regimens. Indeed, when ritonavir and sa- quinavir were co-administered with simvastatin, the exposure to simvastatin acid increased 30-fold [20]. Thus, the combination of simvastatin and PIs is con- traindicated because of the risk of rhabdomyolysis, as is that of lovastatin and PIs by argument of anal- ogy. Exposure to atorvastatin when co-administered with a ritonavir-boosted PI only increases by three to sixfold, and exposure to the activemoiety even less so [4, 5, 20]. Although the use of atorvastatin together with ritonavir-boosted PIs is not recommended in all cases, titration froma lowstartingdoseunder careful monitoring is considered an acceptable strategy in cases of co-administration with, for example, ritona- vir-boosted lopinavir or darunavir. The difference be- tween the magnitudes of the increased exposure be- tween simvastatin and atorvastatin may result from the fact that the former is administered as a lactone prodrug and has a lower bioavailability because of presystemic CYP3A-mediated metabolism in the ab- sence of a strong CYP3A inhibitor [20, 21]. This illus- trates an important principle regarding DDIs due to ritonavir – that the greatest-fold increase in exposure may be seen for agents that normally have restricted bioavailability owing to presystemic metabolism. This principle will be further illustrated below, with regard to the interaction between inhalational corti- costeroidsandritonavir. Fluvastatin is metabolized by CYP2C9, whereas pra- vastatin and rosuvastatin do not undergo significant CYP450-dependent metabolism [21]. Fluvastatin and pravastatin are considered first-line possibilities when a statin is needed in patients receiving ritona- vir-boosted PI therapy. However, pravastatin expo- sure was decreased by 50% when co-administered with saquinavir and ritonavir, presumably because of induction of metabolism [20], and recommended doses may often not be sufficiently efficacious. Also, contrary to expectation, when the interaction be- tween pravastatin and ritonavir-boosted darunavir was studied, an 81% increase in pravastatin expo- surewasseen,anduptofivefold increaseswerenoted in a subset of subjects [5]. To our knowledge, the mechanism of this interaction has not been clarified, but an effect of darunavir on the transmembrane transport of pravastatinhasbeen suggested [22]. An- other unexpected finding in the complex field of PI– statinDDIswas that ritonavir-boosted lopinavir dou- bled the exposure to rosuvastatin, and this is not readilyexplainedonthebasis of inhibitionofmetabo- lism [4]. However, it is considered that all statins are substrates of the OATP1B1 transmembrane trans- porter, which impacts their intracellular availability [21], and lopinavir was recently shown to inhibit this transporter at clinically relevant concentrations [23]. In summary, extrapolation of DDI data between sta- tins and PIs has turned out to be more difficult than initially expected, as multiple mechanisms other thanCYP3A inhibitionare involved,andtheseappear todifferbetweendrugs intheclass. PI and calcium channel antagonists There are numerous drugs in this important class, which are used for several common conditions, including hypertension, angina pectoris and cardiac arrhythmias. Most, if not all, calcium channel antag- onists are substrates for CYP3A; some are also sub- strates forp-glycoprotein [24]. Thus, increases incal- cium channel antagonist exposure may be expected when co-treating with ritonavir. However, the phar- macokinetic impact of ritonavir co-administration appears to have been studied for relatively few cal- cium channel blockers. Available data support the theoretical assumption of an interaction potential; though, the magnitude and clinical relevance of the effectmay vary betweenagents, e.g. becauseofdiffer- ing degrees of presystemicCYP3A-dependentmetab- olism and ⁄or the presence of alternative metabolic pathways. Co-administration of diltiazem or amlodi- pine together with indinavir in combination with ri- tonavir at a dose of 800 ⁄100 mg twice daily led to an increase in amlodipine exposure by a median of approximately 90%, whereas the increase in dil- tiazem exposure wasmoremoderate [24]. In general, if co-administeredwith ritonavir, dose titration of the calcium channel antagonist and careful monitoring of the response seem prudent. A useful strategy may be to chose alternative agents to calcium channel blockers with effects on cardiac conduction at thera- peuticdoses, ifpossible. Co-treatment with ritonavir and inhaled corticosteroids In the late 1990s, two case reports of patients treated with ritonavir developing Cushing’s syndrome, pre- sumably because of an interaction with nasally in- haled fluticasone, were published [25, 26]. To date, F. Josephson | Review-Symposium: Drug–drug interactions in the treatment of HIV infection ª 2010 The Association for the Publicationof the Journal of Internal Medicine Journal of Internal Medicine 268; 530–539 533 more than 30 cases of Cushing’s syndrome and ⁄or secondary adrenal insufficiency because of bronchi- ally or nasally administered fluticasone in combina- tion with ritonavir-boosted PI therapy have been re- ported. Some difficulties in diagnosis are noted in these case reports. According to one, the use of nasal fluticasone was not reported by the patient as he did not consider this over-the-counter drug to be ‘amedi- cine’ [26]. In other reports, the differential diagnosis of antiretroviral therapy–associated lipodystrophy was initially considered [27,28]. Like several other drugs in its class, such as budeso- nide and mometasone, the inhalational steroid fluti- casone is a CYP3A substrate [29]. Under normal cir- cumstances, systemic exposure to fluticasone is limited by a very high presystemic and systemic CYP3A-mediated clearance.However, in the presence of ritonavir 100 mg twice daily, systemic exposure to nasally administeredfluticasone increasesmore than 350-fold, with concomitant suppression of endoge- nous cortisol synthesis [8]. Although similar effects might be expected from other drugs in this class, as mentioned previously, quantitative data are lacking concerning the interaction between ritonavir and other agents. It is notable that the great majority of published cases have involved fluticasone, and only recentlywasa case of adrenal suppressionandCush- ing’ssyndromepresumedbecauseofritonavirandbu- desonidereported [30]. Ithasbeenspeculatedthat the higher potency and lipophilicity, with consequent po- tential for accumulation, might make the interaction between fluticasone and ritonavir more significant than between budesonide and ritonavir [29]. Also, if the systemic bioavailability of fluticasone under nor- malcircumstances ismorerestrictedbyCYP3A-medi- ated metabolism, the quantitative effect of ritonavir maybehigheronfluticasone thanonbudesonide.Be- causeof thisuncertaintyconcerningtheDDIpotential of other inhalational steroids that are metabolized by CYP3A, beclometasone, which is not considered a substrate for this enzyme, is recommended when pa- tients treatedwitha ritonavir-boostedPIare inneedof therapywithaninhalationalsteroid[8,29]. Antiretrovirals and acid-reducing agents The bioavailability of some antiretrovirals is affected by gastric pH. Consequently, various classes of acid- reducing agents have been reported to affect the pharmacokinetics of several different antiretrovirals, with increased or decreased exposure as a conse- quence [6, 31, 32]. The bioavailability of atazanavir decreaseswith increasinggastricpH.A40-mgdoseof omeprazole reduces the AUC of ritonavir-boosted at- azanavir by 75% [33]. Even when the dose of ritona- vir-boostedatazanavir is increasedfromthestandard 300 mg once daily to 400 mg, a 20-mg dose of omep- razole reduces the AUC of atazanavir by about 30%, and a 40-mg dose by about 60%, relative to the stan- dard dose under normal conditions. Consequently, concomitant use of atazanavir and proton pump inhibitors is considered contraindicated, at least in treatment-experienced patients who might require higher exposure to atazanavir [6, 33]. Pharmacoki- netic interactions with other acid-reducing agents arealso significantandmayrequire temporal separa- tion of doses [6, 33]. By contrast, exposure to the in- tegrase inhibitor raltegravir is increased more than twofold by proton pump inhibitors [32]. However, at present, this isnot thought tobeclinically relevant. Antiretroviral therapy and opiate substitution As intravenous drug use is a major transmission route forHIV,many patients treatedwith antiretrovi- ral therapy receive concomitant opiate substitution with methadone or buprenorphine. Methadone is a long-acting l-opioid receptor agonist. On the basis of in vitro studies, the elimination of methadone was previously at least partly attributed to CYP3A. How- ever, as a recent study showed no relation between CYP3A activity when inhibited by ritonavir and the impact on methadone pharmacokinetic parameters, this has been questioned [34]. In addition tometabo- lism, presumably involving several different drug- metabolizing enzymes, methadone is also cleared by renal elimination [34]. Buprenorphine, which is administered sublingually because of extensive first- pass metabolism, is a partial agonist of the l-opioid receptor. It is converted to an active metabolite, nor- buprenorphine, via CYP3A and CYP2C8, and further metabolized through glucuronidation [35]. Thus, both of these drugshave thepotential to interactwith PIsandNNRTIs. Amongst the NNRTIs, efavirenz, which is an inducer of hepatic drug-metabolizing enzymes, approxi- mately halved exposure to methadone and precipi- tatedwithdrawal symptoms [1]. Clinically, the evalu- ation of such symptoms may be complicated by the fact that efavirenz, particularly during thefirstweeks of therapy,maycauseCNSsymptoms that canbedif- ficult to distinguish from symptoms of opiate with- drawal. Although the interaction between efavirenz andmethadonemaybemanagedbymethadonedose adjustments, many clinicians avoid the use of efavi- renz in such situations. The effects of nevirapine on F. Josephson | Review-Symposium: Drug–drug interactions in the treatment of HIV infection 534 ª 2010 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 268; 530–539 methadone are similar to those of efavirenz, whereas the effects of etravirine are negligible [2, 3]. When ef- avirenz was co-administered with buprenorphine, themagnitude of the interaction in terms of pharma- cokinetic effect was similar to that with methadone; buprenorphine AUCwas decreased by 52% and nor- buprenorphine AUC even more so. However, no pa- tients displayed withdrawal symptoms [1]. Thus, the pharmacokinetic ⁄pharmacodynamic relationship of buprenorphine, a partial agonist, may be different from that of methadone in the clinically relevant concentration intervals. Data on the interactions between the other NNRTIs that are licensed in the European Union and buprenorphine appear to be lacking. Ritonavir at a boosting dose (100 mg twice daily) did not significantly affect methadone exposure [36], whereasritonavirata therapeuticdose (500 mgtwice daily) decreased methadone exposure by 36% [8], illustrating the dose dependence of an interaction presumably due to hepatic enzyme induction. In addition, the net effect of different boosted PI regi- mensmaydependonthepotencyof the individualPIs as enzyme inducers. Thus, lopinavir in combination with ritonavir at the boosting dose decreasedmetha- done AUC by an average of 28%, which was associ- atedwithsymptomsofopiatewithdrawal [36]. DDIs and the co-treatment of HIV and tuberculosis At leastone-thirdof thepeople livingwithHIVarealso infectedwithMycobacteriumtuberculosisandare20– 30 times more likely to develop clinical tuberculosis (TB) than peoplewithout HIV [37]. Inmany cases, TB and HIV are diagnosed at the same time. In such cases, initiating TB treatment is the first priority, but an increasing body of evidence indicates that delay- ing HIV treatment until after completion of TB ther- apy (usually 6 months) increasesmortality, and par- ticularly so in patients with substantial immune deficiency [38]. Standard TB regimens include rifam- picin, isoniazid and pyrazinamide with ⁄without eth- ambutol [39]. Theuse of rifampicin, a crucial agent in the TB regimen, may pose formidable problems with regard to DDIs when co-treating HIV and TB. Rifam- picinmaybe themost potent inducerofhepaticdrug- metabolizing enzymes of all therapeutic agents in current use [40]. As rifampicin induces CYP3A, it re- ducesexposure tobothPIsandNNRTIs.For example, theNNRTIs efavirenz andnevirapine are the first-line antiretroviral drugs predominantly used in the geo- graphical areas where HIV–TB co-infection is most prevalent; the AUC and trough concentration (lowest concentration during the dosinginterval, prior to the next scheduled dose, and assumed to be the most importantpharmacokinetic parameter for theseanti- retrovirals) are reduced by 26% and 32%, respec- tively, for efavirenz, and by 58% and 68%, respec- tively, for nevirapine [1, 2]. This has led to considerable controversy concerning the need for dose adjustments of these agents when co-treating with rifampicin. This issue has been complicated by the fact that efavirenz and to some extent nevirapine are substrates not only for CYP3A but also for the genetically polymorphic CYP2B6 enzyme [1, 41]. Thus, exposure to efavirenz varies greatly in a popu- lation, with patients who are homozygous for inacti- vating mutations in CYP2B6 exhibiting several-fold higher exposures at the recommended dose andhav- ing an increased risk of exposure-dependent central nervous system side effects [42]. The frequency of inactiveCYP2B6allelesmaybeashighas50%inAfri- can populations [43, 44], and increasing the dose in suchpatientsmay increase side effects [45].Whereas an increased dose of efavirenz when co-treating with rifampicin is suggested (though not actually recom- mended) according to European labelling [1], there is emergingevidence tosuggest that this isnotgenerally necessary tomaintain antiretroviral efficacy [46–48]. With nevirapine, evidence for maintained efficacy with labelled doses when co-treating with rifampicin is less strong [49, 50]; however, an increased dose of nevirapine may be associated with an increased risk ofhypersensitivity reactions, includingrashandhep- atitis [49]. Of note, rash is an important side effect of isoniazid, and both isoniazid and pyrazinamide may cause drug-induced hepatitis, complicating the dif- ferential diagnosis in case of such symptoms. There- fore, an efavirenz-based antiretroviral regimen has emergedasa favouredoption incasesof concomitant TB. Incontrast to ritonavir-boostedPIs, efavirenz andne- virapine are both drugs with low barriers to resis- tance. Thismeans that following virological failure on a first-line regimen based on either of these agents, full resistancewilloftenhavedeveloped.Thus,partic- ularly in the geographical regions where HIV–TB co- infection is common, an effective second-line antiret- roviral regimenwill require a ritonavir-boosted PI. As mentioned earlier, PI exposure is decreasedby rifam- picin, and for pharmacokinetic reasons, unboosted PIs are not considered to be options for co-treatment [40]. Boosted PI regimens in combinationwith rifam- picin, however, are not well tolerated with a high fre- quency of hepatotoxicity [51, 52]. Thus, such combi- nations should be avoided. The recommended F. Josephson | Review-Symposium: Drug–drug interactions in the treatment of HIV infection ª 2010 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 268; 530–539 535 approach when treating TB in patients receiving a ri- tonavir-boosted PI regimen is to substitute rifabutin for rifampicin. Rifabutin induces CYP3A to a consid- erably lower extent than rifampicin, and it does not affect exposure to ritonavir-boosted PIs in a clinically relevant manner. Rifabutin is considered equipotent to rifampicin as an anti-TB agent [53]. It induces CYP3A considerably less than rifampicin and does not affect exposure to ritonavir-boosted PIs in a clini- cally meaningful way. Unfortunately, however, it is prohibitively expensive in most resource-poor set- tings. In addition, although there is no relevant effect of rifabutin on the pharmacokinetics of ritonavir- boosted PIs, the latter profoundly affect the disposi- tion of the former. Rifabutin is metabolized, mainly bynon-CYP450mechanisms, into the activemetabo- lite 25-O-desacetylrifabutin, which in turn is inacti- vated by CYP3A. Under normal circumstances, this comprisesaminorpart of the activemoiety.However, when co-treating with a ritonavir-boosted PI, expo- sure to rifabutin increases moderately, whereas exposure to the active metabolite increases more than 10-fold [5, 6]. Thus, the metabolite becomes a considerableportionof theactivemoiety.As rifabutin has exposure-dependent adverse effects, including leucopenia and uveitis, a dose reduction is man- dated. When used without significant interacting drugs, the usual dose of rifabutin is 150 or 300 mg oncedaily.When co-treatingwith a ritonavir-boosted PI, the commonly recommended dose regimen is 150 mg thriceweekly or every other day,whichyields anexposure to theactivemoiety that isstill somewhat greater than 300 mg once daily (and considerably higher thanwith150 mg once daily) in the absence of interactingdrugs [5,6]. Future perspectives on CYP3A inhibition in antiviral therapy As discussed previously, ritonavir was originally developedtobeusedasanantiretroviralagent,acting through inhibitionof theHIVprotease. In fact, the ini- tial studies of the combination of ritonavir and an- other PI were performed under the assumption that there would be additive pharmacodynamic effects, rather than to investigate the antiviral consequences ofpharmacokineticboosting [54,55]. It shouldbeevi- dent from the above that ritonavir is in fact not an ‘ideal’CYP3Ainhibitor, foranumberof reasons.First, even at boosting doses, ritonavir has gastrointestinal andmetabolic side effects. Secondly, the use of riton- avir asabooster iscomplicatedby its effects onmulti- ple other drug-metabolizing enzymes and transport proteins. Thirdly, the fact that ritonavir has intrinsic antiretroviral activity is not a problem when used to boost thepharmacokinetics of anotherPI, asdrugs in this class exhibit considerable similarity in terms of resistance profile and, when ritonavir-boosted, have a very high barrier to resistance. However, if ritonavir is used at boosting doses with an agent that is not a PI, resistance to PIs could be selected in cases of regi- men failure, because of the presence of sub-thera- peutic ritonavirconcentrations. Several CYP3A inhibitors without intrinsic antiretro- viral activity are under development; furthest along the path is cobicistat (GS-9350). According to preli- minary data, cobicistat is a weak inhibitor of CYP2D6, does not inhibit CYP1A2, CYP2C9 or CYP2C19 andhas a low tendency towards the induc- tion of hepatic drug-metabolizing enzymes [56]. With regard to CYP3A inhibition, cobicistat at a dose of 200 mg once daily in a multiple dose regimen pro- duced a similar inhibition of oral midazolam clear- anceas ritonavir100 mgoncedaily [56].Cobicistat is entering phase III trials, and it remains to be seen whether advantagesover ritonavir asaboosterwill be demonstrated in terms of side effect profile. Also of interest is the putative effect of cobicistat on trans- membrane drug transporters; however, no data ap- pear tohavebeenpublished todate. Another development in the field of pharmacoki- netic enhancement of antiviral therapy through CYP3A inhibition is the boosting of inhibitors of the hepatitis C virus (HCV) NS3 ⁄4A protease. Applica- tions for marketing approval of the first-generation, directly acting antivirals against HCV, boceprevir and telaprevir are expected by the end of 2010. In phase III studies, both of these drugs have been administered thrice daily; though, twice daily administration of telaprevir is under investigation. Of interest, several second-generation HCV protease inhibitors are being investigated in ritonavir- boosted dosing regimens [57, 58]. Whilst it remains to be seen whether this will increase therapeutic efficacy, it does provide the pharmacokinetic prere- quisite for once-daily dosing. Conclusions The aim of this review has not been to provide a com- plete overview of pharmacokinetic DDIs in antiretro- viral therapy,but rather to giveanoutlineof thescope of theproblemand thecomplexity of themechanisms involved.WhereasknowledgeofDDIs relating toanti- retroviral agents is substantial amongst physicians who regularly treat patients with HIV, awareness of the problems because of pharmacoenhancement by F. Josephson| Review-Symposium: Drug–drug interactions in the treatment of HIV infection 536 ª 2010 The Association for the Publication of the Journal of Internal Medicine Journal of Internal Medicine 268; 530–539 CYP3A inhibition, as well as of DDIs because of other mechanisms, is lower outside the infectious disease speciality, where physicians may only rarely see pa- tients treated with antiretroviral therapy. Yet, as dis- cussed, several commonly used medications, and some drugs used to treat co-morbidities that are highly prevalent, may need to be avoided in patients with certain antiretroviral drug regimens or should prompt dose adjustment of either of the co-treating agents. Several valuable internet-based DDI data- bases are available (e.g. http://www.hiv-druginter- actions.org, http://www.janusinfo.se/In-English/), some of which are available free of charge. Also, the European summaries of product characteristics for many of the antiretroviral drugs, available at the European Medicines Agency home page (http:// www.ema.europa.eu),providevaluableguidance. In addition to a general awareness of the risk ofDDIs, some very simple general principles may be of use when facing theproblemofapotentially clinically sig- nificant interaction in patients receiving antiretrovi- ral therapy. One is to consider the fact that quite of- ten drugs within the same pharmacodynamic class may have different pharmacokinetics and metabolic DDI potential (e.g. statins, rifamycins and corticos- teroids, as discussed earlier). In such cases, it may be more rational to look for an equivalent drug that might not interact, rather than to make a – perhaps empirical – dose adjustment, or risk toxicities or lack of efficacyby ignoring thepossibility of aDDI.Whena co-treatment is crucial and there are no equally good, noninteracting alternatives, consideration may also be given to altering the antiretroviral regimen, unless there is a well-established dose adjustment de- scribed for use in the particular situation. With an increasing number of antiretroviral agents, there may be alternatives for many patients; for instance, using regimens based on raltegravir, which has a considerably lower tendency to cause DDIs than PIs and NNRTIs, may sometimes be a way of avoiding potentially significant interactions. Furthermore, when considering co-medications in patients treated with antiretroviral therapy or when facing symptoms and signs that may be because of DDIs, it should be remembered that several over-the-counter medi- cines, and some natural remedies, may interact with antiretroviral drugs, resulting in toxicities or lack of efficacy. Finally, it appears that the concept of pharmacoki- neticboostingbyCYP3Ablockade ishere tostay,with new agents being developed and its use in fields out- side antiretroviral therapy under investigation. 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