Date of report 19 May 2023

Reported case interaction between
Cobicistat and Atorvastatin

49 years old woman diagnosed with HIV-2. ART was initiated with TDF+3TC+LPV/r achieving plasma HIV RNA suppression and immune restoration. After some simplification ART switches, she is on TAF/FTC/DRV/cobi since 2018.

She receives treatment with amlodipine because of hypertension and she is also overweight (BMI 29.5)

In 2017 she received atorvastatin for some months because of dyslipidemia but this treatment was stopped because of myalgia. In 2020, atorvastatin was reinitiated because of high cholesterol levels. In 2022 she referred myalgia predominantly in the legs, initiated after the reintroduction of atorvastatin. During 2020 and 2021, face-to-face visits were replaced by phone calls because of the COVID-19 pandemic. Although she did not refer to symptoms in these phone calls, in the first face-to-face in April 2022, she referred initially to mild but progressive myalgia since the re-initiation of myalgia. AST was normal and CPK was not available. Atorvastatin was switched to ezetimibe. Myalgia was resolved and cholesterol levels remain within the normal range.

Cobicistat is a strong inhibitor of CYP3A4 as well as an inhibitor of BCRP and OATP1B1. Therefore, darunavir/cobicistat, might increase atorvastatin concentrations and favor the emergence of atorvastatin-related adverse effects. However, an intrinsic side effect of atorvastatin independently of the concomitant use of TAF/FTC/DRV/cobi cannot be ruled out.