Drug Interactions between amoxicillin / clarithromycin / vonoprazan and dolutegravir

Although some in vitro data indicate synergism between macrolide antibiotics and penicillins, other in vitro data indicate antagonism. When these drugs are given together, neither has predictable therapeutic efficacy. Data are available for erythromycin, although theoretically this interaction could occur with any macrolide. Except for monitoring of the effectiveness of antibiotic therapy, no special precautions appear to be necessary.

Theoretically, coadministration with inhibitors of UGT1A or CYP450 3A4 isoenzymes may increase the plasma concentrations of dolutegravir, which is primarily metabolized by UGT1A1 with some contribution from CYP450 3A4. Dolutegravir is also a substrate of UGT1A3, UGT1A9, and P-glycoprotein in vitro. Potent CYP450 3A4 inhibitors such as boceprevir (800 mg every 8 hours) and telaprevir (750 mg every 8 hours) had no significant effects on the pharmacokinetics of dolutegravir given at 50 mg once daily. The interaction has not been studied or reported with UGT1A1 inhibitors such as nilotinib, regorafenib, and sorafenib. However, it is possible that simultaneous inhibition of UGT1A1 and CYP450 3A4 may lead to a clinically significant interaction with dolutegravir. In 12 study subjects, administration of dolutegravir (30 mg once daily) with the dual UGT1A1 and CYP450 3A4 inhibitor, atazanavir (400 mg once daily), increased dolutegravir peak plasma concentration (Cmax), systemic exposure (AUC) and trough plasma concentration (Cmin; 24 hours postdose) by 50%, 91% and 180%, respectively, compared to administration without atazanavir. When the same dosage of dolutegravir was given with atazanavir/ritonavir 300 mg/100 mg once daily, the Cmax, AUC and Cmin of dolutegravir increased by 34%, 62% an 121%, respectively. Because safety data regarding increased dolutegravir exposures are limited, caution may be advisable if dolutegravir is used in combination with both a UGT1A1 inhibitor and a CYP450 3A4 inhibitor.