Statin Interactions with HIV or Hepatitis C Drugs Can Cause Muscle and Kidney Damage, FDA Warns

alt

Statins, a class of drugs prescribed to lower cholesterol and reduce the risk of cardiovascular disease, can interact with certain medications used to treat HIV and hepatitis C virus (HCV) potentially leading to serious side effects, the U.S. Food and Drug Administration (FDA) warned yesterday.

Statins such as the widely prescribed atorvastatin (Lipitor) and rosuvastatin (Crestor) are metabolized by the same cytochrome P450 enzymes in the liver as HIV protease inhibitor and the recently approved HCV protease inhibitors boceprevir (Victrelis) and telaprevir (Incivek).

This drug-drug interaction can raise drug levels and increase the risk of adverse events; for statins these may include severe muscle toxicity known as rhabdomyolysis, which can lead to kidney damage. To avoid this, some statins should be dose adjusted and others are contraindicated with specific protease inhibitors.

In related news, the FDA this week also issued an announcement about new statin label changes cautioning that statin use may contribute to development of type 2 diabetes and transient memory problems. The agency no longer recommends regular liver function monitoring for statin users, however, and said the drugs' benefits for cardiovascular disease overall outweigh their risks.

Below is an edited excerpt from an FDA advisory describing product label changes to for statins and HIV and HCV protease inhibitors. More information is available online at http://www.fda.gov/Drugs/DrugSafety/ucm293877.htm.

Important Info about Interactions Between Certain HIV Drugs and Cholesterol-Lowering Statin Drugs

March 1, 2012 -- The U.S. Food and Drug Administration (FDA) is issuing updated recommendations concerning drug-drug interactions between drugs for human immunodeficiency virus (HIV) or hepatitis C virus (HCV) known as protease inhibitors and certain cholesterol-lowering drugs known as statins. Protease inhibitors and statins taken together may raise the blood levels of statins and increase the risk for muscle injury (myopathy). The most serious form of myopathy, called rhabdomyolysis, can damage the kidneys and lead to kidney failure, which can be fatal.

Facts about statins and protease inhibitors

  • Statins are a class of prescription drugs used together with diet and exercise to reduce blood levels of low-density lipoprotein (LDL) cholesterol (“bad cholesterol”).
  • HIV protease inhibitors are a class of prescription anti-viral drugs used to treat HIV.
  • HCV protease inhibitors are a class of prescription anti-viral drugs used to treat hepatitis C infection.
  • A side effect of taking HIV protease inhibitors is increased cholesterol and triglyceride (fat) levels. Therefore, some patients taking HIV protease inhibitors may need to take cholesterol-lowering medicines such as statins.
 

The labels for both the HIV protease inhibitors and the affected statins have been updated to contain consistent information about the drug-drug interactions. These labels also have been updated to include dosing recommendations for those statins that may safely be co-administered with HIV or HCV protease inhibitors (see Statin Dose Limitations below).

Healthcare professionals should refer to the current drug labels for protease inhibitors and statins for the latest recommendations on prescribing these drugs.

Patients should contact their healthcare professional if they have any questions or concerns about taking protease inhibitors and statins.

Additional Information for Patients

Additional Information for Healthcare Professionals 

Data Summary

Atorvastatin

The results from a drug-drug interaction study with atorvastatin and lopinavir/ritonavir that were previously in the atorvastatin label have not yet been validated. Therefore, these results have been removed from the label and the dose cap of atorvastatin 20 mg when co-administered with lopinavir/ritonavir has also been removed. Pending validation of the study, healthcare professionals should use caution when co-administering atorvastatin with lopinavir/ritonavir and use the lowest necessary dose of atorvastatin.

Lovastatin and simvastatin

Lovastatin and simvastatin are sensitive in vivo cytochrome P450 3A4 (CYP3A4) substrates. Therefore, strong CYP3A4 inhibitors are predicted to significantly increase lovastatin and simvastatin exposures. A literature review indicates that itraconazole, a strong CYP3A4 inhibitor, increases lovastatin exposure up to 20-fold, and the drug interaction appears to result in rhabdomyolysis.1 Itraconazole increases simvastatin exposure up to 13-fold. Hence, other CYP3A4 inhibitors, including ketoconazole, posaconazole, erythromycin, clarithromycin, telithromycin, nefazodone, human immunodeficiency virus (HIV) protease inhibitors, and the hepatitis C virus (HCV) protease inhibitors boceprevir and telaprevir, are also expected to significantly increase lovastatin and simvastatin exposures. Therefore, concomitant administration of lovastatin and simvastatin with HIV protease inhibitors or HCV protease inhibitors (boceprevir and telaprevir) is contraindicated.

Rosuvastatin

The HIV protease inhibitor combinations lopinavir/ritonavir and atazanavir/ritonavir increase rosuvastatin exposure up to 3-fold. For these combinations, the dose of rosuvastatin should be limited to 10 mg.

Statin Dose Limitations

Statin

Interacting protease inhibitor(s)

Prescribing recommendation

Atorvastatin

  • Tipranavir + ritonavir
  • Telaprevir

Avoid atorvastatin

  • Lopinavir + ritonavir

Use with caution and use with the lowest atorvastatin dose necessary

  • Darunavir + ritonavir
  • Fosamprenavir
  • Fosamprenavir + ritonavir
  • Saquinavir + ritonavir

Do not exceed 20 mg atorvastatin daily

  • Nelfinavir

Do not exceed 40 mg atorvastatin daily

Fluvastatin

 

No data available

Lovastatin

  • HIV protease inhibitors
  • Boceprevir
  • Telaprevir

Contraindicated

Pitavastatin

  • Atazanavir ± ritonavir
  • Darunavir + ritonavir
  • Lopinavir + ritonavir

No dose limitations

Pravastatin

  • Darunavir + ritonavir
  • Lopinavir + ritonavir

No dose limitations

Rosuvastatin

  • Atazanavir ± ritonavir
  • Lopinavir + ritonavir

Limit rosuvastatin dose to 10 mg once daily

Simvastatin

  • HIV protease inhibitors
  • Boceprevir
  • Telaprevir

Contraindicated

1. Lees RS, Lees AM. Rhabdomyolysis from the coadministration of lovastatin and the antifungal agent itraconazole. N Engl J Med. 1995;333:664-5.

3/2/12

Sources

U.S. Food and Drug Administration. Important info about interactions between certain HIV drugs and cholesterol-lowering statin drugs. Drug advisory. March 1, 2012.

U.S. Food and Drug Administration. FDA announces safety changes in labeling for some cholesterol-lowering drugs. News release. February 28, 2012.