11 - Interactions between antiretroviral drugs and

Interactions between antiretroviral drugs and psychotropics

Drug treatment of psychiatric symptoms in the context of other conditions CHAPTER 10 Interactions between antiretroviral drugs and psychotropics Pharmacokinetic interactions between antiretroviral drugs and psychotropics occur frequently and can be clinically significant. Potential interactions should be investigated for all patients receiving antiretrovirals and psychotropics concomitantly and include current prescribed medication, alternative/herbal treatments, recreational drugs and other non-­prescribed medicines. Interactions are numerous and complex. Readers are directed to regularly updated online resources for information about individual ­pharmacokinetic interactions such as www.hiv-­druginteractions.org (also available as an app). Pharmacodynamic interactions may also occur, usually through overlapping adverse effects. Potential pharmacodynamic interactions are shown in Table 10.1. Table 10.1  Potential pharmacodynamic interactions with antiretrovirals.40,41 Potential adverse effect Implicated antiretroviral drug(s)21,42,43 Implications for psychotropic prescribing Bone marrow suppression Zidovudine (anaemia, neutropenia) Concurrent use with certain psychotropics (e.g. clozapine) may increase the risk of myelosuppression/neutropenia Bone mineral density (BMD) reduction Tenofovir disoproxil fumarate (TDF) (tenofovir alafenamide has smaller decline of BMD) NNRTIs, PIs, INSTIs: decreases in BMD following any regimen May compound the reductions in BMD possible with prolactin elevating antipsychotics Creatine kinase (CK) elevations Dolutegravir, emtricitabine, raltegravir May be important to acknowledge associated link if diagnosis of NMS is being considered ECG changes Efavirenz, rilpivirine, saquinavir/ ritonavir: QT prolongation Atazanavir, lopinavir saquinavir: PR prolongation May increase risk of arrhythmias associated with certain psychotropic drugs Cardiovascular effects Abacavir, darunavir/ritonavir, lopinavir/ritonavir Cardiovascular events (e.g. myocardial infarction) occurred in some cohorts Renal effects TDF (risk increased if used with ritonavir) Tenofovir alafenamide: less impact on renal function versus TDF Atazanavir (kidney stones, tubo-­interstitial nephritis) Proteinuria, hypophosphataemia, glycosuria, hypokalaemia, renal tubular Gastrointestinal disturbances Atazanavir, darunavir, dolutegravir, didanosine, elvitegravir/cobicistat, fosamprenavir, indinavir, lopinavir, nelfinavir, raltegravir, saquinavir, tipranavir, zidovudine May compound gastrointestinal disturbances associated with certain psychotropics (e.g. SSRIs) (Continued )