Date of report 11 Jul 2019
Reported case interaction between
Ritonavir and Atorvastatin
Ritonavir and Atorvastatin
Drugs suspected to be involved in the DDI
Complete list of drugs taken by the patient
Atorvastatin, Fenofibrate, Insulin, Repaglinide, AAS, Gabapentin, Doluxetine, omperazole
Clinical case description
HIV infection known since 1995. Highly ART-experience with extensive resistance-associated mutations pattern. On ART with darunavir (600 mg bid), ritonavir (100 mg bid), etravirine (200 mg bid), raltegravir (400 mg bid) and maraviroc (300 mg bid). HIV-1 RNA <50 copies/mL. Diabetes mellitus, dyslipidemia and peripheral artery disease (intermittent claudication 100 m). On stable (>2 years) lipid lowering treatment with atorvastatin (20 mg qd) plus fenofibrate (150 mg qd). In December 20189 LDL-cholesterol levels 124 mg/dL (target <70 mg/dL). Atorvastatin dose was increased to 40 mg qd. In June 2019 the patient referred good tolerance. AST/ALT/CK levels remained with the normal range, and LDL-cholesterol levels had decreased to 88 mg/dL. Despite increase in atorvastatin exposure when combined with ritonavir. No adverse event was observed in this case. However, a daily dose of 40 mg atorvastatin should not be exceeded, and careful safety monitoring is recommended in this setting.
Clinical Outcome
Editorial Comment
Atorvastatin is metabolized by CYP3A4. Coadministration with ritonavir is expected to increase atorvastatin concentrations. If the use of atorvastatin is considered necessary, start with the lowest dose of atorvastatin and titrate carefully while monitoring for safety. A daily dose of 40 mg atorvastatin should not be exceeded with careful safety monitoring. Suboptimal cardiovascular risk management has been described in HIV patients. Intensification of lipid lowering therapy and control of other cardiovascular risk factors may be required (Rosan A van Zoest, et al. Eur J Prev Cardiol. 2017 Aug; 24(12): 1297–1307).
University of Liverpool Recommendation
Potential interaction - may require close monitoring, alteration of drug dosage or timing of administration