Drug Interaction Report

CONTRAINDICATED: Coadministration with inhibitors of CYP450 3A4 may increase the plasma concentrations and duration of action of levomethadyl acetate, which is a substrate of the isoenzyme. High plasma levels of levomethadyl acetate may increase the risk of QT interval prolongation, which is thought to be associated with serious cardiac events such as ventricular arrhythmias (e.g., torsade de pointes, ventricular tachycardia), cardiac arrest, and sudden death. Cases of QT prolongation and torsade de pointes have been reported with levomethadyl acetate alone during postmarketing use.

MANAGEMENT: Concomitant use of levomethadyl acetate with CYP450 3A4 inhibitors is considered contraindicated.

CONTRAINDICATED: Coadministration with inhibitors of CYP450 3A4 may increase the plasma concentrations and duration of action of levomethadyl acetate, which is a substrate of the isoenzyme. High plasma levels of levomethadyl acetate may increase the risk of QT interval prolongation, which is thought to be associated with serious cardiac events such as ventricular arrhythmias (e.g., torsade de pointes, ventricular tachycardia), cardiac arrest, and sudden death. Cases of QT prolongation and torsade de pointes have been reported with levomethadyl acetate alone during postmarketing use.

MANAGEMENT: Concomitant use of levomethadyl acetate with CYP450 3A4 inhibitors is considered contraindicated.

GENERALLY AVOID: The concurrent use of levomethadyl acetate and alcohol may result in additive CNS and respiratory depression, hypotension, sedation, or coma. Grapefruit juice may increase the plasma concentrations of orally administered drugs which are substrates of the CYP450 3A4 isoenzyme, such as levomethadyl acetate. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruits. The extent and clinical significance are unknown. Moreover, pharmacokinetic alterations associated with interactions involving grapefruit juice are often subject to a high degree of interpatient variability.

MANAGEMENT: Patients who are known to abuse alcohol should be warned of the risk of potentially fatal overdose if these substances are taken concurrently. Patients who regularly consume grapefruits and grapefruit juice should be monitored for adverse effects and altered plasma concentrations of levomethadyl acetate. A 12-lead ECG should be performed before initiating therapy, 12 to 14 days after initiating therapy, and periodically thereafter. Patients should be advised to immediately seek medical attention if they experience palpitations, dizziness, lightheadedness, fainting, or seizures. Grapefruits and grapefruit juice should be avoided if an interaction is suspected. Orange juice is not expected to interact.

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.