Date of report 29 May 2019
Reported case interaction between
Raltegravir and Dietary supplements
Raltegravir and Dietary supplements
Drugs suspected to be involved in the DDI
Complete list of drugs taken by the patient
Low calorie, [vitamin & mineral] fortified meal replacements (meals and shakes)
Clinical case description
The patient commenced meal replacement shakes and calorie restricted foods, fortified with vitamins and minerals to aid weight loss in early 2019. These replaced all meals and were taken throughout the day. Subsequently a detectable viral load was measured over three samples in April and May 2019, where the viral load had been previously undetectable for 2 years. On switching from Raltegravir to Dolutegravir and leaving appropriate time separation between Dolutegravir and the meal replacements the following viral load was undetectable.
Clinical Outcome
Drug Interaction Probability Scale (DIPS)
Editorial Comment
Co-administration of raltegravir (RAL) with antacids containing divalent metal cations may reduce RAL absorption by chelation, resulting in a decrease of RAL plasma levels. Co-administration of RAL 1200 mg once daily with aluminium/magnesium and calcium carbonate containing antacids are likely to result in clinically meaningful reductions in the plasma trough levels of raltegravir. Therefore, co-administration of aluminium/magnesium and calcium carbonate containing antacids with RAL 1200 mg once daily is not recommended. (Isentress Summary of Product Characteristics, Merck Sharp & Dohme Ltd, March 2019). If RAL 400 mg twice daily is used, antacids containing aluminium and magnesium are also contraindicated (even when separated 6h, RAL Cmin decreased about 50%), but NO dose adjustment is required with calcium (1000 mg x 3 tabs) as this interaction is not considered clinically meaningful (raltegravir Cmin decreased about 32%). This difference is mainly due to the lower Cmin with raltegravir 1,200 mg once daily compared to 400 mg twice daily (107 vs 142 nM, respectively) (https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=022145).