Beneficial pharmacokinetic interaction between atazanavir and lopinavir/ritonavir

BACKGROUND: The combination of lopinavir/ritonavir (LPV/r) and atazanavir (ATV) with nucleoside reverse transcriptase inhibitors has been used as a salvage regimen in HIV-infected patients. Because these agents, to various degrees, are substrates, inducers, and inhibitors of CYP450 3A4, there is concern for alterations in the pharmacokinetics (PK) of these combined agents. OBJECTIVE: To determine the steady-state PK interactions between ATV, ritonavir (RTV), and LPV when coadministered at various doses. METHODS: HIV-negative subjects (n = 15) received a combination of ATV, RTV, and LPV in the following sequence: period I (days 1-10), ATV/r at a dose of 300/100 mg once daily; period II (days 11-24), ATV at a dose of 300 mg once daily plus LPV/r at a dose of 400/100 mg twice daily; and period III (days 25-34), ATV/r at a dose of 300/100 mg once daily plus LPV/r at a dose of 400/100 mg twice daily. Intensive PK analysis was performed on days 10, 24, and 34. A paired t test was used for pairwise comparison of log-transformed PK parameters of ATV and LPV. RESULTS: In period II, the ATV minimum concentration (Cmin) geometric mean (GM) was higher compared with period I (GM: 0.75 vs. 0.51 μg/mL, geometric mean ratio (GMR) = 1.45, 90% confidence interval [CI]: 1.19 to 1.77; P = 0.006). The ATV area under the concentration-time curve from dosing to 24 hours after the dose (AUC0-24; GM: 36.40 vs. 39.62 μg•h/mL, GMR = 0.92, 90% CI: 0.80 to 1.05; P = 0.28) did not differ, however. The addition of 100 mg of RTV in period III did not significantly increase the ATV Cmin (GM: 0.84 vs. 0.75 μg/mL, GMR = 1.13, 90% CI: 0.91 to 1.40; P = 0.34) or ATV AUC0-24 (GM: 39.59 vs. 36.40 μg•h/mL, GMR = 1.09, 90% CI: 0.99 to 1.20; P = 0.14) compared with period II. The additional RTV in period III resulted in a higher LPV Cmin (GM: 5.12 vs. 3.99 μg/mL, GMR = 1.28, 90% CI: 1.15 to 1.43; P = 0.001), but the LPV areas under the concentration-time curve from dosing to 12 hours after the dose and maximum concentration were not significantly different. LPV PK parameters in period II were comparable to those of historical control subjects receiving LPV/r at a dose of 400/100 mg twice daily. All studied regimens were well tolerated. Indirect hyperbilirubinemia was the only grade 3 and 4 abnormality reported, which was expected given that ATV competitively inhibits UGTIA1 and has not been shown to result in other hepatic abnormalities. CONCLUSIONS: The combination of ATV at a dose of 300 mg once daily plus LPV/r at a dose of 400/100 mg twice daily resulted in an appropriate PK profile for ATV and LPV and could be further evaluated in treatment-experienced patients requiring a dual-boosted protease inhibitor-containing regimen.