Drug Interactions between Symtuza and tadalafil

MONITOR: Coadministration of tenofovir and darunavir-ritonavir or darunavir-cobicistat may result in increased plasma concentrations of tenofovir and darunavir. Increased tenofovir plasma concentration may increase the risk for tenofovir-related renal adverse effects, including renal impairment, renal failure, elevated creatinine, and Fanconi syndrome. The mechanism of this interaction is unknown; however, increased tenofovir concentrations may be related to inhibition of P-glycoprotein by darunavir, cobicistat, or ritonavir in the renal tubules. Cobicistat may decrease estimated creatinine clearance via inhibition of tubular secretion of creatinine; however, renal glomerular function does not appear to be affected. In 12 study subjects, administration of darunavir-ritonavir (300 mg-100 mg twice daily) with tenofovir (300 mg once daily) increased the systemic exposure (AUC) and trough plasma concentration (Cmin) of darunavir by 21% and 24%, respectively, compared to administration without tenofovir. Tenofovir AUC and Cmin also increased by 22% and 37%, respectively, in the presence of darunavir-ritonavir. Data are lacking to determine whether concomitant use of tenofovir with cobicistat-containing regimens is associated with a greater risk of renal complications compared with regimens that do not include cobicistat.

MANAGEMENT: Caution and close monitoring of renal function is recommended if darunavir-ritonavir or darunavir-cobicistat is to be used in combination with tenofovir, particularly in patients with risk factors for renal impairment. No dose adjustments appear necessary during coadministration of darunavir-ritonavir with tenofovir. However, initiation of cobicistat or cobicistat-containing regimens is not recommended in patients with CrCl less than 70 mL/min if any coadministered medicine requires dose adjustment based on renal function (including tenofovir) or is nephrotoxic.

MONITOR: Concomitant use of tenofovir with cobicistat may increase the risk for tenofovir-related renal adverse effects, including renal impairment, renal failure, elevated creatinine, and Fanconi syndrome. The mechanism of this interaction has not been described. Cobicistat may decrease estimated creatinine clearance via inhibition of tubular secretion of creatinine; however, renal glomerular function does not appear to be affected. When given concomitantly with cobicistat, the systemic exposure (AUC) and trough plasma concentrations (Cmin) of tenofovir was also increased by 23% and 55%, respectively. However, data are lacking to determine whether concomitant use of tenofovir with cobicistat-containing regimens is associated with a greater risk of renal complications compared with regimens that do not include cobicistat.

MANAGEMENT: Initiation of cobicistat or cobicistat-containing regimens is not recommended in patients with CrCl less than 70 mL/min if any coadministered medicine requires dose adjustment based on renal function (including tenofovir), or is nephrotoxic. If concomitant therapy is necessary, monitoring of renal function is recommended, particularly in patients with risk factors for renal impairment.

GENERALLY AVOID: Cobicistat may increase the plasma concentrations of antiretroviral agents. The plasma concentrations of cobicistat may also be increased or reduced in the presence of antiretroviral agents. The proposed mechanism is cobicistat inhibition of the CYP450 3A4 isoenzyme, of which antiretroviral agents may be substrates, and the inhibition or induction of CYP450 3A4 by concomitant antiretroviral medications. Cobicistat is a mechanism-based inhibitor and substrate of CYP450 3A4 with no antiretroviral activity of its own. Rather, it is indicated in its capacity as a pharmacokinetic booster of CYP450 3A4 to increase the systemic exposure of some antiretroviral medications such as atazanavir, darunavir, and elvitegravir, which are substrates of this isoenzyme. Concomitant use of other antiretroviral agents with cobicistat may also increase the plasma levels and risk of side effects associated with these medicines. In contrast, concomitant use of cobicistat-boosted atazanavir or darunavir with CYP450 3A4 inducers nevirapine, etravirine, or efavirenz may reduce the plasma concentrations of cobicistat, darunavir, and atazanavir, leading to a potential loss of therapeutic effect and development of resistance to darunavir and atazanavir. Pharmacokinetic data are not available.

MANAGEMENT: Cobicistat is not intended for use with more than one antiretroviral medication that requires pharmacokinetic enhancement, such as two protease inhibitors or elvitegravir in combination with a protease inhibitor. In addition, cobicistat should not be used concomitantly with ritonavir due to their similar effects on CYP450 3A4. According to some authorities, use of the antiretroviral combinations of atazanavir-cobicistat or darunavir-cobicistat concomitantly with the CYP450 3A4 inducers efavirenz, etravirine, or nevirapine is also not recommended. Other authorities consider the administration of atazanavir-cobicistat with efavirenz or nevirapine to be contraindicated. Since dosing recommendations have only been established for a number of antiretroviral medications, product labeling and current antiretroviral treatment guidelines should be consulted.

ADJUST DOSE: Coadministration with protease inhibitors (PIs) may increase the plasma concentrations of tadalafil. The mechanism is PI inhibition of tadalafil metabolism via CYP450 3A4. In study subjects, administration of a single 20 mg dose of tadalafil during treatment with ritonavir 500 mg or 600 mg twice daily at steady state resulted in a 30% reduction in tadalafil peak plasma concentration (Cmax) and 32% increase in systemic exposure (AUC) compared to tadalafil administered alone. Administration of the same dose of tadalafil in combination with ritonavir 200 mg twice a day was associated with a 124% increase in tadalafil AUC and no change in Cmax. The pharmacokinetics of tadalafil in the treatment of pulmonary arterial hypertension (PAH) have been studied in the presence of tipranavir/ritonavir. Tadalafil concentrations increased when coadministered with the first dose of tipranavir/ritonavir, but not with tipranavir/ritonavir at steady-state. This would suggest that the initial inhibitory effect of ritonavir on CYP450 3A4 may be mitigated by a more slowly evolving induction effect so that after about one week of ritonavir administered twice daily, the exposure to tadalafil is similar in the presence and absence of ritonavir. Although not specifically studied, other HIV protease inhibitors are expected to increase tadalafil exposure.

MANAGEMENT: Caution is advised if tadalafil is administered in combination with protease inhibitors. For the treatment of erectile dysfunction, the dosage of tadalafil should not exceed 10 mg once every 72 hours when used on an as-needed basis in patients receiving PI therapy. When given for once-daily use in the treatment of erectile dysfunction or benign prostatic hyperplasia, the maximum recommended dose is 2.5 mg. For the treatment of pulmonary arterial hypertension, tadalafil should be started at 20 mg once daily in patients who have been receiving ritonavir-boosted PI therapy for at least one week. The dosage may be increased to 40 mg once daily based upon individual tolerability. The use of tadalafil for PAH should be avoided during the initiation of ritonavir-boosted PI therapy. The manufacturers recommend that tadalafil be discontinued at least 24 hours prior to initiating the PIs. After at least one week, tadalafil may be resumed at 20 mg once daily, and the dosage increased to 40 mg once daily based upon individual tolerability. There is no need to discontinue tadalafil when initiating PI therapy that does not contain ritonavir as a pharmacokinetic booster, nor wait at least one week after PI therapy to start tadalafil. The tadalafil dosage should be initiated at or adjusted to 20 mg once daily when coadministered with nonritonavir-boosted PI regimens, then increased to 40 mg as tolerated. All patients treated with tadalafil should be advised to promptly notify their physician if they experience pain or tightness in the chest or jaw, irregular heartbeat, nausea, shortness of breath, visual disturbances, syncope, or prolonged erection (greater than 4 hours).

ADJUST DOSE: Coadministration with the pharmacokinetic booster cobicistat may increase the plasma concentrations of tadalafil. The mechanism is cobicistat inhibition of tadalafil metabolism via CYP450 3A4. The interaction has not been studied with cobicistat, but has been reported with ritonavir, a pharmacokinetic booster with a similar metabolic profile to cobicistat. In study subjects, administration of a single 20 mg dose of tadalafil during treatment with ritonavir 500 mg or 600 mg twice daily at steady state resulted in a 30% reduction in tadalafil peak plasma concentration (Cmax) and 32% increase in systemic exposure (AUC) compared to tadalafil administered alone. Administration of the same dose of tadalafil in combination with ritonavir 200 mg twice a day was associated with a 124% increase in tadalafil AUC and no change in Cmax. The pharmacokinetics of tadalafil in the treatment of pulmonary arterial hypertension (PAH) have been studied in the presence of tipranavir/ritonavir. Tadalafil concentrations increased when coadministered with the first dose of tipranavir/ritonavir, but not with tipranavir/ritonavir at steady-state. This would suggest that the initial inhibitory effect of ritonavir on CYP450 3A4 may be mitigated by a more slowly evolving induction effect so that after about one week of ritonavir administered twice daily, the exposure to tadalafil is similar in the presence and absence of ritonavir.

MANAGEMENT: Caution is advised if tadalafil is administered in combination with cobicistat. For the treatment of erectile dysfunction, the dosage of tadalafil should not exceed 10 mg once every 72 hours when used on an as-needed basis. When given for once-daily use in the treatment of erectile dysfunction or benign prostatic hyperplasia, the maximum recommended dose is 2.5 mg. According to some authorities, concomitant use of tadalafil and cobicistat for the treatment of pulmonary arterial hypertension (PAH) is not recommended. If coadministration is required, for the treatment of PAH, tadalafil should be started at 20 mg once daily in patients who have been receiving cobicistat for at least one week. The dosage may be increased to 40 mg once daily based upon individual tolerability. The use of tadalafil for PAH should be avoided during the initiation of cobicistat-containing antiretroviral therapy. The manufacturers recommend that tadalafil be discontinued at least 24 hours prior to initiating the cobicistat regimen. After at least one week, tadalafil may be resumed at 20 mg once daily, and the dosage increased to 40 mg once daily based upon individual tolerability. All patients treated with tadalafil should be advised to promptly notify their physician if they experience pain or tightness in the chest or jaw, irregular heartbeat, nausea, shortness of breath, visual disturbances, syncope, or prolonged erection (greater than 4 hours).