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Brief Summary

GUIDELINE TITLE

Drug-drug interactions between HAART, medications used in substance use treatment, and recreational drugs.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Drug-drug interactions between HAART, medications used in substance use treatment, and recreational drugs. New York (NY): New York State Department of Health; 2008 Jan. 18 p. [69 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Drug-drug interactions between HAART, medications used in substance use treatment, and recreational drugs. New York (NY): New York State Department of Health; 2005 Jul. 22 p.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory information has been released:

  • March 12, 2008, Prezista (darunavir): The U.S. Food and Drug Administration (FDA) and Tibotec Therapeutics notified healthcare professionals of changes to the WARNINGS section of the prescribing information for Prezista (darunavir) tablets regarding the risk of hepatotoxicity, specifically, drug induced hepatitis in patients receiving combination therapy with Prezista/ritonavir.
  • September 10, 2007, Viracept (nelfinavir mesylate): Pfizer issued a Dear Healthcare Professional Letter to inform healthcare professionals of the presence of ethyl methanesulfonate (EMS), a process-related impurity in Viracept and to provide guidance on the use of Viracept in pregnant women and pediatric patients.

BRIEF SUMMARY CONTENT

 ** REGULATORY ALERT **
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

General Recommendation

The clinician should conduct a thorough medication history at each visit that includes prescription medications, including those prescribed by other providers, over-the-counter medications, recreational drugs, and herbal/alternative therapies.

Drug Interactions Related to the Metabolism of Highly Active Antiretroviral Therapy (HAART)

Table 2 in the original guideline document shows the potential interactions among antiretroviral (ARV) agents and the most common medications used to treat substance use disorders according to how they are metabolized.

Drug Interactions with Methadone

Clinicians should discuss potential drug interactions with patients receiving methadone before initiating ARV therapy.

Clinicians should report all prescribed HAART-related drug changes for patients receiving methadone to the patient's methadone maintenance program.

Clinicians should monitor human immunodeficiency virus (HIV)-infected substance users receiving concurrent methadone and ARV therapy for symptoms of withdrawal and/or excess sedation when ARV therapy is initiated or changed.

Key Point:

Interactions between HAART and methadone may precipitate symptoms of oversedation or withdrawal.

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)

When using didanosine in patients receiving methadone, clinicians should consider using the enteric-coated capsule formulation because it does not lead to a clinically significant interaction when given concurrently with methadone.

Clinicians should monitor patients for symptoms of zidovudine toxicity, such as anemia, nausea, and headaches, when zidovudine and methadone are used concurrently.

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Clinicians initiating a HAART regimen consisting of efavirenz or nevirapine in patients receiving methadone should contact the methadone maintenance program clinicians to ensure that the onset of withdrawal symptoms, if they occur, is promptly addressed by increasing the patient's methadone dose.

Clinicians prescribing methadone maintenance therapy should closely monitor patients when adding efavirenz or nevirapine to their ARV regimens.

Recreational Drugs and HAART

Clinicians should assess adherence and be alert for signs of hepatotoxicity in HIV-infected patients receiving HAART who are concurrently using recreational drugs.

See Appendix XI in the original guideline document for a list of known drug interactions with HAART and recreational drugs.

Amphetamines

Clinicians should not prescribe ritonavir, even in low doses for boosting, if patients report using amphetamines.

Barbiturates

Clinicians treating HIV-infected patients misusing barbiturates should:

  • Avoid co-administration of NNRTIs and phenobarbital
  • Use caution if maraviroc and phenobarbital are used concomitantly
  • Consider doubling the raltegravir dose when co-administered with phenobarbital

Benzodiazepines

Clinicians should avoid concurrent use of alprazolam, midazolam, and triazolam with all protease inhibitors (PIs), delavirdine, and efavirenz.

Ecstasy (Methylenedioxy-methamphetamine [MDMA])

Clinicians should not prescribe protease inhibitors (PIs), even in low doses for boosting, if patients report using ecstasy or gamma hydroxybutyrate (GHB).

Psychotropics

Clinicians should consider medication interactions as a potential cause of mental status changes in persons receiving psychotropic medications and HAART.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each recommendation.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Drug-drug interactions between HAART, medications used in substance use treatment, and recreational drugs. New York (NY): New York State Department of Health; 2008 Jan. 18 p. [69 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2005 Jul (revised 2008 Jan)

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Substance Use Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Chair: Marc N Gourevitch, MD, MPH, New York University School of Medicine , New York, New York

Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Julia H Arnsten, MD, MPH, Montefiore Medical Center, Bronx, New York; Lawrence S Brown, Jr, MD, MPH, FASAM, Addiction Research and Treatment Corporation, Brooklyn, New York; Brenda Chabon, PhD, Montefiore Medical Center, Bronx, New York; Barbara H Chaffee, MD, MPH, Binghamton Family Care Center, Binghamton, New York; Michael L Christie, MD, AIDS Community Health Center, Rochester, New York; Chinazo O Cunningham, MD; Montefiore Medical Center, Bronx, New York; Nereida L Ferran-Hansard, MD, Jacobi Medical Center, Bronx, New York; Steven S Kipnis, MD, FACP, FASAM, New York State Office of Alcoholism and Substance Abuse Services, Orangeburg, New York; Joseph P Merlino, MD, MPA, Mount Sinai School of Medicine, New York, New York; Nancy Murphy, NP, St. Luke's Roosevelt Hospital Center, New York, New York; Edward Nunes, MD, New York State Psychiatric Institute, New York, New York; David C Perlman, MD, Beth Israel Medical Center, New York, New York; Sharon L Stancliff, MD, Harm Reduction Coalition, New York, New York; Robert Whitney, MD, Erie County Medical Center, Buffalo, New York

Liaisons: Daliah I Heller, MPH, Liaison to the New York City Department of Health and Mental Hygiene, New York, New York

AIDS Institute Staff Liaisons: Diane M Rudnick, MEd, Liaison to the New York State Department of Health AIDS Institute, New York, New York

AIDS Institute Staff Physician: Eunmee H Chun, MD, New York State Department of Health AIDS Institute, New York, New York

Principal Contributors: John J Faragon, PharmD, Albany Medical Center, Albany; Paul Pham, PharmD, The Johns Hopkins University, Baltimore

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Drug-drug interactions between HAART, medications used in substance use treatment, and recreational drugs. New York (NY): New York State Department of Health; 2005 Jul. 22 p.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

This guideline is also available as a Personal Digital Assistant (PDA) download from the New York State Department of Health AIDS Institute Web site.

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on August 18, 2005. This NGC summary was updated by ECRI Institute on June 11, 2008.

COPYRIGHT STATEMENT

DISCLAIMER

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