What are considerations for antiretroviral medications used in the treatment of patients coinfected with HIV and hepatitis C virus (HCV)?

Updated: Oct 07, 2019
  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: BS Anand, MD  more...
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Answer

Several important points related to drug interactions with antiretroviral medications need to be emphasized, as follows [34] :

  • Daclatasvir in combination with other antiviral agents: Reduce daclatasvir to 30 mg/day with ritonavir-boosted atazanavir and with cobicistat-boosted atazanavir; increase daclatasvir to 90 mg/day with efavirenz and with etravirine.

  • Fixed-dose combination of elbasvir (50 mg)/grazoprevir (100 mg): This combination should be used with antiviral agents with which it doesn't have clinically significant interactions, such as abacavir, emtricitabine, enfuvirtide, lamivudine, raltegravir, dolutegravir, rilpivirine, and tenofovir.

  • Fixed-dose combination of glecaprevir (300 mg)/pibrentasvir (120 mg): As with combination elbasvir/grazoprevir, combination glecaprevir/pibrentasvir should be used with antiviral agents with which it doesn't have clinically significant interactions, such as abacavir, emtricitabine, enfuvirtide, lamivudine, raltegravir, dolutegravir, rilpivirine, and tenofovir. Monitor for hepatic toxicity.

  • Simeprevir in combination with other antiviral agents: Use simeprevir with antiviral agents with which it doesn't have clinically significant interactions, such as abacavir, emtricitabine, enfuvirtide, lamivudine, maraviroc, raltegravir, dolutegravir, rilpivirine, and tenofovir.

  • Fixed-dose combination of sofosbuvir (400 mg)/velpatasvir (100 mg): This combination should not be used with efavirenz, etravirine, or nevirapine. Because velpatasvir may increase tenofovir levels, concomitant use of these agents mandates consideration of the creatinine clearance (CrCl) rate; avoid their use in those with a CrCl level below 60 mL/min.

  • Fixed-dose combination of ledipasvir (90 mg)/sofosbuvir (400 mg): Because ledipasvir increases tenofovir levels, concomitant use of these agents mandates consideration of the CrCl rate; avoid their use in those with a CrCl level below 60 mL/min. Because potentiation of this effect is expected when tenofovir is used with ritonavir-boosted HIV protease inhibitors, avoid using ledipasvir with this combination unless the antiretroviral regimen cannot be changed and the urgency of treatment is high.

  • For combination agents expected to increase tenofovir levels, baseline and ongoing assessment for tenofovir nephrotoxicity is recommended.

  • Paritaprevir/ritonavir/ombitasvir plus dasabuvir should be used with antiretroviral drugs with which they do not have substantial interactions, such as atazanavir, dolutegravir, emtricitabine, enfuvirtide, lamivudine, raltegravir, and tenofovir.

  • The dose of ritonavir used for boosting atazanavir should be held when administered with paritaprevir/ritonavir/ombitasvir plus dasabuvir; restore the dose when the HCV treatment is completed. Atazanavir should be administered at the same time as the fixed-dose HCV combination.

  • Sofosbuvir/velpatasvir/voxilaprevir should be used with antiretroviral drugs with which they do not have substantial interactions, such as dolutegravir, emtricitabine, enfuvirtide, lamivudine, rilpivirine, and raltegravir. Monitor for hepatic toxicity. This drug combination may increase tenofovir levels. Thus, concomitant use of these agents mandates consideration of the CrCl rate; avoid their use in those with a CrCl level below 60 mL/min. Monitor renal function.


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