Objective: Lipid lowering therapy is used increasingly in persons with HIV infection in the absence of safety data or information on drug interactions with antiretroviral agents. The primary objectives of this study were to examine the effects of ritonavir (RTV) plus saquinavir soft-gel (SQVsgc) capsules on the pharmacokinetics of pravastatin, simvastatin, and atorvastatin, and the effect of pravastatin on the pharmacokinetics of nelfinavir (NFV) in order to determine clinically important drug–drug interactions.
Design: Randomized, open-label study in healthy, HIV seronegative adults at AIDS Clinical Trials Units across the USA.
Methods: Three groups of subjects (arms 1, 2, and 3) received pravastatin, simvastatin or atorvastatin (40 mg daily each) from days 1–4 and 15–18. In these groups, RTV 400 mg and SQVsgc 400 mg twice daily were given from days 4–18. A fourth group (arm 4) received NFV 1250 mg twice daily from days 1–14 with pravastatin 40 mg daily added from days 15–18. Statin and NFV levels were measured by liquid chromatography/tandem mass spectrometry.
Results: Fifty-six subjects completed both pharmacokinetic study days. In arms 1–3, the median estimated area under the curves (AUC)0−−24 for the statins were: pravastatin (arm 1, n = 13), 151 and 75 nguu.h/ml on days 4 and 18 (decline of 50% in presence of RTV/SQVsgc), respectively (P = 0.005); simvastatin (arm 2, n = 14), 17 and 548 nguu.h/ml on days 4 and 18 (increase of 3059% in the presence of RTV/SQVsgc), respectively (P < 0.001); and total active atorvastatin (arm 3, n = 14), 167 and 289 nguu.h/ml on days 4 and 18 (increase of 79% in the presence of RTV/SQVsgc), respectively (P < 0.001). In arm 4, the median estimated AUC0−−8 for NFV (24 319 versus 26 760 nguu.h/ml;P = 0.58) and its active M8 metabolite (15 565 versus 14 571 nguu.h/m;P = 0.63) were not statistically different from day 14 to day 18 (without or with pravastatin).
Conclusions: Simvastatin should be avoided and atorvastatin may be used with caution in persons taking RTV and SQVsgc. Dose adjustment of pravastatin may be necessary with concomitant use of RTV and SQVsgc. Pravastatin does not alter the NFV pharmacokinetics, and thus appears to be safe for concomitant use.
From the aUniversity of Cincinnati College of Medicine, Cincinnati, Ohio, bWashington University, St. Louis, Missouri, the cUniversity of Colorado Health Sciences College, Denver, Colorado, dSDAC/Harvard School of Public Health, Boston, Massachusetts, the eUniversity of California at San Francisco, San Francisco, California, fStanford University, Stanford, California, the gDivision of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, and hPharmacia & Upjohn, Kalamazoo, Michigan, USA.
Requests for reprints to: C. J. Fichtenbaum, University of Cincinnati College of Medicine, Holmes Hospital, Mail Location 0405, Eden Avenue and Albert Sabin Way, Cincinnati, Ohio 45267-0405, USA.
Note: Presented in part at the Seventh Conference on Retroviruses and Opportunistic Infections. San Francisco, January–February 2000 [abstract LB6] and the XIII International Conference on AIDS. Durban, July 2000 [abstract WeOrB544].
Received: 22 June 2001;
revised: 16 October 2001; accepted: 24 October 2001.
Sponsorship: Supported by the National Institute of Allergy and Infectious Diseases, AI-38858 to the AIDS Clinical Trials Group, AI-25897 to the University of Cincinnati, AI-25903 to Washington University, AI-27666 to Stanford University, and AI-38855 to the SDAC/Harvard School of Public Health. Additional support provided by Stanford University GCRC grant 5-M01-RR00070-38, University of California at San Francisco GCRC grant 5-MO1-RR-00083-37 and the University of Colorado Health Sciences College GCRC grant 5-MO1-RR-00051-37. Funded in part by Bristol-Myers Squibb, Inc. and Abbott Laboratories, Inc.