PSYCHOTROPIC DRUGS: SEDATIVES/HYPNOTICS, ANTIDEPRESSANTS, AND ANTIPSYCHOTICS INSTIs NNRTIs PIs RTI xBICTEGRAVIR xELVITEGRAVIR/ x DORAVIRINE x EFAVIRENZ xATAZANAVIR • TENOFOVIR • TENOFOVIR (Biktarvy) COBICISTAT (Pifeltro, (Sustiva, Atripla) (Reyataz/Norvir, ALAFENAMIDE, DISOPROXIL, TDF (Stribild, Genvoya) Delstrigo) Evotaz) TAF (Descovy, (Viread,Truvada, DOLUTEGRAVIR ETRAVIRINE x x Biktarvy, Genvoya, Atripla, Complera, (Tivicay, Triumeq, RILPIVIRINE (Intelence) DARUNAVIR x x Odefsey, Symtuza) Delstrigo, Stribild) Juluca) (Edurant, (Prezista/Norvir, x NEVIRAPINE Complera, Prezcobix, x RALTEGRAVIR (Viramune) •ABACAVIR (Kivexa, Odefsey, Juluca) Symtuza) (Isentress) Ziagen, Triumeq) xLOPINAVIR (Kaletra) SEDATIVES/HYPNOTICS xLorazepam, oxazepam, temazepam xAlprazolam, Potential for n Potential for p Potential for n bromazepam, benzodiazepine benzodiazepine benzodiazepine buspirone, clonazepam, estazolam, flurazepam, diazepam, nitrazepam, zolpidem, zopiclone xMidazolam, Potential for n Potential for p Potential for n triazolam benzodiazepine benzodiazepine benzodiazepine PSYCHOTROPICS INSTIs NNRTIs PIs RTI xBICTEGRAVIR xELVITEGRAVIR/ x DORAVIRINE x EFAVIRENZ xATAZANAVIR • TENOFOVIR • TENOFOVIR (Biktarvy) COBICISTAT (Pifeltro, (Sustiva, Atripla) (Reyataz/Norvir, ALAFENAMIDE, DISOPROXIL, TDF (Stribild, Genvoya) Delstrigo) Evotaz) TAF (Descovy, (Viread,Truvada, DOLUTEGRAVIR ETRAVIRINE x x Biktarvy, Genvoya, Atripla, Complera, (Tivicay, Triumeq, RILPIVIRINE (Intelence) DARUNAVIR x x Odefsey, Symtuza) Delstrigo, Stribild) Juluca) (Edurant, (Prezista/Norvir, x NEVIRAPINE Complera, Prezcobix, x RALTEGRAVIR (Viramune) •ABACAVIR (Kivexa, Odefsey, Juluca) Symtuza) (Isentress) Ziagen, Triumeq) xLOPINAVIR (Kaletra) ANTIDEPRESSANTS xMost TCAs, duloxetine xBupropion Etravirine may be Cobicistat-boosted used without dose PIs: may be used adjustment without dose adjustment Potential for p Ritonavir-boosted bupropion PIs: potential for p (efavirenz, bupropion nevirapine) xSt. John’s wort raltegravir WŽƚĞŶƚŝĂůĨŽƌљ WŽƚĞŶƚŝĂůĨŽƌљ WŽƚĞŶƚŝĂůĨŽƌљ WŽƚĞŶƚŝĂůĨŽƌљW/Ɛ WŽƚĞŶƚŝĂůĨŽƌљd& elvitegravir and TAF NNRTIs NNRTIs јĚŽůƵƚĞŐƌĂǀŝƌϱϬ *including Juluca mg BID bictegravir xMost SSRIs Potential for n WŽƚĞŶƚŝĂůĨŽƌљ Potential for n (citalopram, antidepressant antidepressant antidepressant escitalopram, PSYCHOTROPICS INSTIs NNRTIs PIs RTI xBICTEGRAVIR xELVITEGRAVIR/ x DORAVIRINE x EFAVIRENZ xATAZANAVIR • TENOFOVIR • TENOFOVIR (Biktarvy) COBICISTAT (Pifeltro, (Sustiva, Atripla) (Reyataz/Norvir, ALAFENAMIDE, DISOPROXIL, TDF (Stribild, Genvoya) Delstrigo) Evotaz) TAF (Descovy, (Viread,Truvada, DOLUTEGRAVIR ETRAVIRINE x x Biktarvy, Genvoya, Atripla, Complera, (Tivicay, Triumeq, RILPIVIRINE (Intelence) DARUNAVIR x x Odefsey, Symtuza) Delstrigo, Stribild) Juluca) (Edurant, (Prezista/Norvir, x NEVIRAPINE Complera, Prezcobix, x RALTEGRAVIR (Viramune) •ABACAVIR (Kivexa, Odefsey, Juluca) Symtuza) (Isentress) Ziagen, Triumeq) xLOPINAVIR (Kaletra) fluoxetine, sertraline), venlafaxine, desvenlafaxine, trazodone, reboxetine, mirtazapine ANTIP SYCHOTICS xAripiprazole, Potential for n WŽƚĞŶƚŝĂůĨŽƌљ Potential for n lurasidone, antipsychotic antipsychotic antipsychotic modafinil, quetiapine, pimozide, Lurasidone & Lurasidone & paliperidone, pimozide are pimozide are risperidone, contraindicated contraindicated ziprasidone xClozapine, Potential for n Potential for p Cobicistat-boosted olanzapine antipsychotic antipsychotic PIs: potential for n antipsychotic Ritonavir-boosted W/Ɛ͗ƉŽƚĞŶƚŝĂůĨŽƌљ PSYCHOTROPICS INSTIs NNRTIs PIs RTI xBICTEGRAVIR xELVITEGRAVIR/ x DORAVIRINE x EFAVIRENZ xATAZANAVIR • TENOFOVIR • TENOFOVIR (Biktarvy) COBICISTAT (Pifeltro, (Sustiva, Atripla) (Reyataz/Norvir, ALAFENAMIDE, DISOPROXIL, TDF (Stribild, Genvoya) Delstrigo) Evotaz) TAF (Descovy, (Viread,Truvada, DOLUTEGRAVIR ETRAVIRINE x x Biktarvy, Genvoya, Atripla, Complera, (Tivicay, Triumeq, RILPIVIRINE (Intelence) DARUNAVIR x x Odefsey, Symtuza) Delstrigo, Stribild) Juluca) (Edurant, (Prezista/Norvir, x NEVIRAPINE Complera, Prezcobix, x RALTEGRAVIR (Viramune) •ABACAVIR (Kivexa, Odefsey, Juluca) Symtuza) (Isentress) Ziagen, Triumeq) xLOPINAVIR (Kaletra) olanzapine and nͬљ clozapine xModafinil Dolutegravir, Potential for љ Potential for љ Potential for љ Potential for љ PIs Potential for љ raltegravir elvitegravir NNRTI NNRTI TAF Potential for љ bictegravir Legend: No dose adjustment required. Use combination with caution. Adjustment in drug dose or frequency or additional/more frequent monitoring may be required. May wish to consult with a pharmacist knowledgeable in HIV drug interactions. Contraindicated/avoid combination. PSYCHOTROPICS Mechanism of Drug Interactions, Management and Monitoring Class Mechanism of Interaction Main Interacting ARVs Management Monitoring Benzodiazepines Inhibition of CYP3A4 Ritonavir and cobicistat- Contraindicated. Use (midazolam, triazolam) boosted protease inhibitors alternate benzodiazepine. and elvitegravir Inhibition of mixed CYP Ritonavir and cobicistat- Adjust benzodiazepine dose Benzodiazepine toxicity: (Alprazolam, bromazepam, boosted protease inhibitors according to ataxia, dizziness, buspirone, clonazepam, and elvitegravir. response/toxicity. Other drowsiness, fatigue, muscle estazolam, eszopiclone, benzodiazepines may be weakness, slowed reaction flurazepam, diazepam, used without dose nitrazepam, zolpidem, adjustment. zopiclone) Lorazepam, oxazepam, May be used with all ARVs May use without dose temazepam adjustment Antidepressants Inhibition of mixed CYP Ritonavir and cobicistat- Adjust antidepressant dose Antidepressant toxicity: pathways (citalopram, boosted protease inhibitors according to anticholinergic effects, escitalopram, fluoxetine, and elvitegravir response/toxicity. Other orthostatic hypotension, sertraline, venlafaxine, antidepressants may be used tachycardia, agitation, desvenlafaxine, trazodone, without dose adjustment. headache, somnolence, mirtazapine) dizziness, diarrhea, excessive sweating, weight gain. Induction of mixed CYP Efavirenz, etravirine, Adjust antidepressant dose Antidepressant efficacy pathways pathways nevirapine according to response. (fluoxetine, sertraline, Other antidepressants may trazodone, reboxetine, be used without dose mirtazapine) adjustment. Induction of CYP2B6 Ritonavir-boosted protease Adjust antidepressant dose Antidepressant efficacy (Bupropion) inhibitors, efavirenz, according to response nevirapine (maximum 300 mg daily). Induction of CYP3A4 (St. Dolutegravir, Bictegravir, Contraindicated with most John’s wort) elvitegravir/cobicistat, all PIs antiretrovirals and NNRTIs and Tenofovir Alafenamide PSYCHOTROPICS Class Mechanism of Interaction Main Interacting ARVs Management Monitoring Antipsychotics Inhibition of mixed CYP Ritonavir and cobicistat- Adjust antipsychotic dose Antipsychotic toxicity: pathways (aripiprazole, boosted protease inhibitors according to somnolence, sweating, chest buspirone, lurasidone, and elvitegravir response/toxicity. pain, tachycardia, dizziness, modafinil, quetiapine, insomnia, headache, pimozide, paliperidone, nausea, diarrhea, dry risperidone, ziprasidone) mouth, numbness, weight gain Induction of mixed CYP Efavirenz, etravirine, Adjust antipsychotic dose Antipsychotic efficacy pathways (aripiprazole, nevirapine according to response buspirone, lurasidone, modafinil, quetiapine, pimozide, paliperidone, risperidone, ziprasidone) Induction of CYP1A2 Ritonavir-boosted protease Adjust antipsychotic dose Antipsychotic efficacy (Clozapine, olanzapine) inhibitors according to response. Modafinil Induction of CYP3A4 Most ARVS except for Consider non-interacting Antiretroviral efficacy dolutegravir, raltegravir, TDF ARV regimen if possible. and abacavir. PSYCHOTROPICS ô+,%#+#,2ô2--*ô$-0 '«5 "03%̞"03%ô',2#0!2'-,1 Printed with the assistance of an unrestricted educational grant from: ฀฀฀฀฀฀฀฀ ฀฀฀฀฀฀฀฀ ฀฀฀฀฀.