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Drug Interactions between armodafinil and atazanavir / cobicistat

This report displays the potential drug interactions for the following 2 drugs:

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Interactions between your drugs

Moderate

atazanavir armodafinil

Applies to: atazanavir / cobicistat and armodafinil

MONITOR: Coadministration with modafinil (the racemate) or armodafinil (the R-enantiomer) may decrease the plasma concentrations of protease inhibitors (PIs). The mechanism involves induction of intestinal CYP450 3A4-mediated first-pass metabolism by modafinil and armodafinil, with possible secondary induction of hepatic 3A4 metabolism. Significant intestinal metabolism appears to occur with indinavir and saquinavir but has not been studied with other PIs. Conversely, PIs may increase the plasma concentrations of modafinil via inhibition of hepatic CYP450 3A4 metabolism. The clinical significance is unknown. However, the possibility of prolonged and/or increased pharmacologic effects of modafinil should be considered.

MANAGEMENT: Given the risk of reduced viral susceptibility and resistance development associated with decreased or subtherapeutic antiretroviral drug levels, caution is advised if modafinil or armodafinil must be used in patients treated with PIs, particularly if they are using only one PI in their antiretroviral regimen. Clinical monitoring for altered effects of both modafinil and the PI may be appropriate following addition or withdrawal of one or the other drug.

References (7)
  1. Barry M, Gibbons S, Back D, Mulcahy F (1997) "Protease inhibitors in patients with HIV disease. Clinically important pharmacokinetic considerations." Clin Pharmacokinet, 32, p. 194-209
  2. (2001) "Product Information. Provigil (modafinil)." Cephalon, Inc
  3. Sommadossi JP (1999) "HIV protease inhibitors: pharmacologic and metabolic distinctions." AIDS, 13, s29-40
  4. Durant J, Clevenbergh P, Garraffo R, Halfon P, Icard S, DelGiudice P, Montagne N, Schapiro JM, Dellamonica P (2000) "Importance of protease inhibitor plasma levels in HIV-infected patients treated with genotypic-guided therapy: pharmacological data from the Viradapt Study." Aids, 14, p. 1333-9
  5. Robertson P, Decory HH, Madan A, Parkinson A (2000) "In vitro inhibition and induction of human hepatic cytochrome P450 enzymes by modafinil." Drug Metab Dispos, 28, p. 664-71
  6. Doherty MM, Charman WN (2002) "The mucosa of the small intestine: how clinically relevant as an organ of drug metabolism?" Clin Pharmacokinet, 41, p. 235-53
  7. (2007) "Product Information. Nuvigil (armodafinil)." Cephalon Inc
Moderate

armodafinil cobicistat

Applies to: armodafinil and atazanavir / cobicistat

GENERALLY AVOID: Coadministration with moderate or weak inducers of CYP450 3A4 may reduce the plasma concentrations of cobicistat, which is primarily metabolized by the isoenzyme. The clinical significance is unknown.

MANAGEMENT: Given the risk of reduced viral susceptibility and resistance development associated with subtherapeutic antiretroviral drug levels, concomitant use of antiretroviral regimens containing cobicistat with these inducers should be avoided. Alternative treatment combinations that do not include metabolic inducers should be considered whenever possible. If concomitant use is required, close clinical and laboratory monitoring of antiretroviral response is recommended.

References (7)
  1. Smith DS, Fujimoto JM (1974) "Alterations produced by novobiocin during biliary excretion of morphine, morphine-3-glucuronide and other compounds." J Pharmacol Exp Ther, 188, p. 504-15
  2. Cerner Multum, Inc. "UK Summary of Product Characteristics."
  3. Canadian Pharmacists Association (2006) e-CPS. http://www.pharmacists.ca/function/Subscriptions/ecps.cfm?link=eCPS_quikLink
  4. EMEA. European Medicines Agency (2007) EPARs. European Union Public Assessment Reports. http://www.ema.europa.eu/ema/index.jsp?curl=pages/includes/medicines/medicines_landingpage.jsp&mid
  5. Cerner Multum, Inc. "Australian Product Information."
  6. (2014) "Product Information. Tybost (cobicistat)." Gilead Sciences
  7. (2015) "Product Information. Genvoya (cobicistat/elvitegravir/emtricitabine/tenofovir)." Gilead Sciences

Drug and food interactions

Moderate

atazanavir food

Applies to: atazanavir / cobicistat

ADJUST DOSING INTERVAL: Administration of atazanavir with food enhances oral bioavailability and reduces pharmacokinetic variability. According to the manufacturer, administration with a light meal increased the peak plasma concentration (Cmax) and area under the concentration-time curve (AUC) of a single 400 mg dose of atazanavir by 57% and 70%, respectively, relative to the fasting state. Administration with a high-fat meal resulted in a mean increase of 35% in atazanavir AUC and no change in Cmax compared to fasting. The coefficient of variation of AUC and Cmax decreased by approximately one-half when given with either a light or high-fat meal compared to the fasting state.

MANAGEMENT: To ensure maximal oral absorption, atazanavir should be administered with or immediately after a meal.

References (1)
  1. (2003) "Product Information. Reyataz (atazanavir)." Bristol-Myers Squibb
Minor

armodafinil food

Applies to: armodafinil

Administration with food may delay the absorption of modafinil (the racemate) and armodafinil (the R-enantiomer) without significantly affecting their overall bioavailability. According to the product labeling, modafinil's absorption may be delayed by approximately one hour if taken with food. Similarly, the time to reach peak plasma concentration (Tmax) of armodafinil may be delayed by approximately 2 to 4 hours in the fed state.

References (2)
  1. (2001) "Product Information. Provigil (modafinil)." Cephalon, Inc
  2. (2007) "Product Information. Nuvigil (armodafinil)." Cephalon Inc

Therapeutic duplication warnings

No warnings were found for your selected drugs.

Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum.

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Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

Further information

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