Date of report 03 Mar 2020

Reported case interaction between
Cobicistat and Atorvastatin

A 59-year-old man, smoker and with chronic alcohol use. He was diagnosed with HIV when he was hospitalized because a stroke in 2013. ART was initiated in 2013 and since 2015 he was receiving DRV/c (800/150 mg) + 3TC (300 mg), maintain undetectable plasma viral load. He was also on treatment with Atorvastatin/Ezetimibe (40/10mg) since 2013 because of dyslipidemia and Nebivolol+Ramipril because of hypertension. In addition, he presented chronic renal disease (estimated FGR 69 mL/min). In September 2019 the patient presented with rhabdomyolysis and impairment of renal function. Statin was suspended, ART was switched to DTG/3TC and corticosteroid treatment along immunoglobulins was initiated. Progressive improvement of clinical symptoms and laboratory abnormalities were observed. A muscle biopsy showed rhabdomyolysis and absence of histopathological signs suggestive of autoimmune myopathy, being the final diagnosis immune-mediated necrotizing myopathy associated with statins. Despite no adverse events during 4 years of treatment with atorvastatin 40 mg and darunavir/cobicistat, the patient finally presented statins associated myopathy probably related with the high atorvastatin plasma concentrations resulting of the CYP3A4 inhibition by cobicistat.