for Health Care Providers

Psychoactive Medications: ARV Interactions

Class of Medication	Interactions	Comments
Antidepressants
SSRI	Citalopram, escitalopram: RTV causes no change in levels Fluoxetine: RTV: ↑ RTV AUC 19%, no change in Cmax Paroxetine: DRV/r: paroxetine AUC and Cmin ↓ 38% FPV/r: paroxetine AUC ↓ 58% Sertraline: DRV/r: sertraline AUC and Cmin ↓ 49%	Interactions with ARVs are incompletely studied. RTV may ↑ SSRI levels; this usually is not significant but there are case reports of SSRI toxicity. Start at low dosage, monitor for adverse effects. No dosage adjustment of citalopram or escitalopram required. Titrate paroxetine to effect. Titrate sertraline to effect.
SNRI	Venlafaxine, duloxetine: No data; PIs may ↑ SNRI levels	Start at low dosage, use lowest effective dosage; monitor for adverse effects.
Tricyclic (TCA)	Amitriptyline, nortriptyline, imipramine, desipramine, and others: NFV, RTV known to ↑ TCA levels; other PIs may ↑ TCA levels	Start at low dosage, use lowest effective dosage; monitor for adverse effects.
Other antidepressants	Bupropion: EFV: ↓ bupropion AUC 55% TPV: ↓ bupropion AUC 46% LPV: ↓ bupropion AUC 57%	Monitor for efficacy; may need increased dosage.
	Mirtazapine: No data; RTV may ↑ mirtazapine levels	Start at low dosage, use lowest effective dosage; monitor for adverse effects.
	Nefazodone: RTV may ↑ nefazodone levels Nefazodone may ↑ MVC levels	Start at low dosage, use lowest effective dosage; monitor for adverse effects. MVC dosage: 150 mg BID
	Trazodone: RTV: ↑ trazodone AUC >200% DRV, IDV, LPV/r: ↑ trazodone AUC SQV/r may ↑ trazodone and ↑ risk of arrhythmia	Start at low dosage, use lowest effective dosage; monitor for adverse effects. Avoid trazodone for patients taking SQV/r.
	St. John's wort: Substantial ↓ in levels of most PIs, NNRTIs, and MVC	Do not coadminister.
Sedatives, Hypnotics
Benzodiazepine	Midazolam: SQV/r: ↑ oral midazolam AUC 1,144% Other PIs: large ↑ in serum midazolam levels expected	Higher risk of benzodiazepine adverse effects in elderly patients; avoid if possible, Avoid midazolam and triazolam for patients taking PIs. For procedures, may consider single-dose IV midazolam with close monitoring.
	Triazolam: RTV: ↑ triazolam half-life 1,900%; ↑ AUC 20% Other PIs: large ↑ in serum triazolam levels expected
	Alprazolam: RTV: ↑ alprazolam half-life 200%	Avoid for patients taking PIs.
	Diazepam: All PIs: ↑ diazepam levels ETR: ↑ diazepam levels	Start at low dosage, use lowest effective dosage; monitor for adverse effects. Alternatives: Consider use of the following benzodiazepines: lorazepam, oxazepam, temazepam (these benzodiazepines are, in part, metabolized via non-CYP450 pathways; lower potential for interactions). Start at low dosage, use lowest effective dosage; monitor for adverse effects.
Other	Zolpidem: RTV: ↑ zolpidem AUC 27%	Start at low dosage, use lowest effective dosage; monitor for adverse effects.
Antipsychotics: Few data on interactions between ARVs and antipsychotics
	Olanzapine: RTV: ↓ olanzapine AUC 53%, half-life ↓ 50%	Start at low dosage, use lowest effective dosage; monitor for adverse effects.
	Pimozide: PIs and EFV may ↑ pimozide levels	Contraindicated with PIs and with EFV.

From Psychoactive Medications: ARV Interactions
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009