POSITIVELY AWARE MARCH/APRIL 2011
brand name: Reyataz
common name: atazanavir sulfate
class: Protease inhibitor (PI)
manufacturer: Bristol-Myers Squibb | www.reyataz.com, (800) 321–1335
Standard dose: One 300 mg capsule plus 100 mg Norvir, once daily (this dose must be used if taking Viread or Truvada, or if pregnant), or two 200 mg capsules (without Norvir), once daily for treatment-naïve adults; take with food. Also available in 100 mg and 150 mg capsules. Take missed dose as soon as possible, unless it is almost time for your next dose. Do not double up on your next dose.
AWP: $1,120.31 / month for 300 mg capsules; $1,130.99 / month for 200 mg capsules
Potential side effects and toxicity
Dizziness and lightheadedness. Elevated levels of unconjugated bilirubin may cause jaundice (yellowing of the skin or eyes). Though this is not evidence of liver damage, some choose to change meds due to unsightliness. Report jaundice to your medical provider right away. Other side effects may include rash, kidney stones, and elevated liver function enzymes, a sign of liver damage; more common in people with hepatitis B or C. Reyataz should not be taken by treatment-experienced patients on hemodialysis due to end stage renal disease. Reyataz is the only PI not associated with increased lipid levels, which are associated with increased risk of heart disease, but higher lipid levels may be seen if Reyataz is boosted with Norvir. Other possible side effects are lipodystrophy, onset of new cases or worsening of diabetes (see your doctor promptly), and increased bleeding in hemophiliacs. Immune Reconstitution Inflammatory Syndrome (IRIS) may occur as the immune system regains strength; signs and symptoms of inflammation from previous infections may occur soon after anti-HIV treatment is initiated. Report symptoms of illness, such as shingles and TB, to a health care provider.
Potential drug interactions
Treatment-experienced people cannot take Reyataz with proton pump inhibitors (PPIs—medicine for acid reflux). Treatment-naïve people can take a PPI in a dose comparable to Prilosec OTC 12 hours before Reyataz/Norvir. H2-receptor antagonists like Pepcid may be taken (no more than 20 mg twice a day if treatment-experienced or 40 mg twice a day if treatment-naïve, or equivalent doses) at the same time as Reyataz/Norvir (before the antacid has started to work) or at least 10 hours later. If taking with Viread or Truvada and an H2-receptor antagonist, you must take the 400 mg Reyataz/100 mg Norvir dose. When taking Reyataz without Norvir, dose can be taken at least two hours before and at least 10 hours after Pepcid, Zantac, or Axid. Reyataz should be taken two hours before or one hour after antacids (Rolaids, Tums, etc.). Do not take with alfuzosin, Revatio, rifampin, Camptosar, oral Versed, Halcion, ergot derivatives, pimozide, Crixivan, or St. John’s wort. Do not use Advicor, Altoprev, Livalo, Mevacor, Simcor, Vytorin, or Zocor for the treatment of high lipids. Lipid-lowering alternatives are Crestor, Lescol, Lipitor, and Pravacol, but should be used with caution. Must be taken two hours apart from Videx, due to Videx’s buffer, and must be taken two hours before or one hour after Videx EC (unless taking Videx EC with Viread). Treatment-naïve people should take 400 mg Reyataz/Norvir (100 mg) when taking with Sustiva, but treatment-experienced people should not use Reyataz with Sustiva. Viread decreases the concentration levels of Reyataz and Reyataz increases Viread concentrations, which could increase adverse events, including kidney disorders. Those taking Reyataz and Viread should be monitored for Viread-associated adverse events. Use the heart medications bepridil, Cordarone, quinidine, and lidocaine cautiously. Monitoring may be required when used with Coumadin. Increased levels of the inhaled and nasal sprays with fluticasone (found in Advair, Flonase, and Flovent) can occur and should be used with caution. Effectiveness of birth control pills may be decreased; consider the use of alternative or additional contraception. Oral contraception should contain no more than 30 mcg of ethinyl estradiol if taking Reyataz without Norvir and at least 30 mcg if taken with Norvir. Use caution when using itraconazole or ketoconazole. Vfend is not recommended. Reducing dose and frequency of rifabutin to 150 mg every other day or three times a week is recommended. Use caution with Tegretol, phenobarbital, and Dilantin. Cialis, Levitra, and Viagra levels are increased; doses should not exceed 10 mg Cialis or 2.5 mg Levitra per 72 hours, or 25 mg Viagra per 48 hours. Calcium channel blockers should be monitored. A lower dose of trazodone is recommended. Use with caution with bosentan, salmeterol, immunosuppressants, and colchicine; use lower dose of colchicine. Boost Reyataz with Norvir when taking buprenorphine. Monitor before sedation. Reyataz can decrease the effects of Malarone; consider alternative drug for malaria prophylaxis.
More information
Norvir-boosted Reyataz is one of two protease inhibitors recommended by the U.S. HIV treatment guidelines for treatment naïve people. People who started out with unboosted Reyataz continued to do as well as those on boosted Reyataz, but many folks are still concerned about data showing that unboosted use is associated with a higher risk of treatment failure. Reyataz must be boosted if taken with Truvada, but can be unboosted with Epzicom. See package insert for more complete information on potential side effects and interactions.
Doctor’s comments
The first of the “kindler, gentler PIs,” Reyataz was first thought to be less potent than Kaletra, but for initial therapy, it was as effective as Kaletra with less diarrhea and lipid elevations in a large clinical trial. It also has the most convenient dosing of any PI (see Standard Dose section). Reyataz is also the only PI I would consider prescribing without boosting, because resistance to Reyataz doesn’t cause cross-resistance to other PIs. Because of an interaction with tenofovir, Reyataz must be boosted when combined with Viread or Truvada, and if combined with Sustiva or Atripla, an even higher dose of Reyataz should be used (400 mg plus 100 mg Norvir). Reyataz needs an acidic environment for absorption; it can’t be taken with most proton pump inhibitors, and strict dosing separation is required with other stomach acid reducers, such as H2 blockers and antacids. It’s probably better to just avoid Reyataz if you’re taking medications for reflux or ulcers. Reyataz also increases the indirect bilirubin, which for most is a harmless lab abnormality, but for others, can result in yellowing of the eyes and/or skin. These side effects are harmless but unattractive, and most people who develop them elect to change drugs. —Joel Gallant, MD, MPH
Activist’s comments
The first once-a-day PI, it can also be taken without a Norvir booster. It lacks the GI and increased cholesterol and triglycerides that plague most PIs. One downside to this heart-friendly drug is that it can raise levels of the liver enzyme bilirubin—which isn’t toxic but can cause unsightly yellowing of the eyes and even the skin. Another drawback is that it can’t be taken with proton pump inhibitors for acid reflux, and some other antacids can’t be taken at the same time. Despite this, the lack of usual PI side effects mean that,boosted with Norvir, it’s one of the most popular regimens when combined with Truvada. —Jeff Taylor
