Pharmacokinetic interaction between rifampicin and the once-daily combination of saquinavir and low-dose ritonavir in HIV-infected patients with tuberculosis

• Published in: Journal of antimicrobial chemotherapy 2007-04, Vol.59 (4), p.690-697
• Main Authors: Ribera, Esteban, Azuaje, Carlos, Lopez, Rosa M., Domingo, Pere, Curran, Adria, Feijoo, Maria, Pou, Leonor, Sánchez, Paquita, Sambeat, Maria Antonia, Colomer, Joan, Lopez-Colomes, Josep Lluis, Crespo, Manuel, Falcó, Vicenç, Ocaña, Imma, Pahissa, Albert
• Format: Article
• Language: English
• Subjects: Adult; Anti-HIV Agents - adverse effects; Anti-HIV Agents - pharmacokinetics; Anti-HIV Agents - therapeutic use; Antibiotics. Antiinfectious agents. Antiparasitic agents; Antiretroviral drugs; antiretroviral therapy; Antitubercular Agents - adverse effects; Antitubercular Agents - pharmacokinetics; Antitubercular Agents - therapeutic use; Area Under Curve; Bacterial diseases; Biological and medical sciences; Chromatography, High Pressure Liquid; Drug Interactions; Female; HIV; HIV infection; HIV Infections - complications; HIV Infections - drug therapy; HIV Infections - metabolism; HIV Protease Inhibitors - adverse effects; HIV Protease Inhibitors - pharmacokinetics; HIV Protease Inhibitors - therapeutic use; Human bacterial diseases; Human immunodeficiency virus; Human viral diseases; Humans; Immunodeficiencies; Immunodeficiencies. Immunoglobulinopathies; Immunopathology; Infectious diseases; Male; Medical sciences; Models, Statistical; Pharmacology; Pharmacology. Drug treatments; Protease inhibitors; Rifampin - adverse effects; Rifampin - pharmacokinetics; Rifampin - therapeutic use; Ritonavir - adverse effects; Ritonavir - pharmacokinetics; Ritonavir - therapeutic use; Saquinavir - adverse effects; Saquinavir - pharmacokinetics; Saquinavir - therapeutic use; Spectrophotometry, Ultraviolet; Tuberculosis; Tuberculosis - complications; Tuberculosis - drug therapy; Tuberculosis - metabolism; Tuberculosis and atypical mycobacterial infections; tuberculosis therapy; Viral diseases; Viral diseases of the lymphoid tissue and the blood. Aids
• ISSN: 0305-7453; 1460-2091
• DOI: 10.1093/jac/dkl552

Objectives To assess plasma steady-state pharmacokinetics (PK) of rifampicin, isoniazid, saquinavir and ritonavir in HIV and tuberculosis (TB) co-infected patients, and investigate potential interactions between TB drugs and protease inhibitors (PIs). Methods Open-label, single-arm, sequential PK study including 22 patients with HIV infection and TB. During the first 2 months, patients received rifampicin, isoniazid and pyrazinamide, with or without ethambutol (first PK study, n = 22). Then patients stopped pyrazinamide and ethambutol and started once-daily antiretroviral therapy (ART) with didanosine, lamivudine, ritonavir (200 mg) and saquinavir (1600 mg) (second PK study, n = 18). Patients stopped all TB drugs after 9 months continuing the same ART (third PK study, n = 15). Differences between TB drug parameters in the first and second PK studies, and between PI parameters in the second and third PK studies were used to assess interactions. Results Rifampicin and isoniazid pharmacokinetics did not change substantially with saquinavir and ritonavir. A significant 39.5%, 34.9% and 48.7% reduction in median saquinavir AUC0–24, Cmax and Ctrough, respectively, was seen with rifampicin and isoniazid. Ritonavir AUC0–24, Cmax and Ctrough decreased 42.5%, 49.6% and 64.3%, respectively, with rifampicin and isoniazid. Conclusions There was a significant interaction between saquinavir, ritonavir and rifampicin, with reduction in median plasma concentrations of saquinavir and ritonavir. Saquinavir should be given with caution in patients receiving rifampicin. Twice-daily dosing or higher saquinavir doses in once-daily administration should be tested to obtain more appropriate plasma levels.