Pharmacokinetic drug interactions with nevirapine

Treatment of HIV infection is a multi-drug issue. Not only are there drugs for the treatment of HIV but also concomitant drugs for opportunistic infections, complications arising from the anti-retroviral therapy and other conditions related to a chronic disease. To have any understanding of drug-drug interactions in HIV treatment we need to appreciate the importance of key pharmacological areas including: 1) how each drug in a regimen is eliminated; 2) the potential for a drug to either induce or inhibit metabolic enzymes and/or transporters; 3) the therapeutic index of each drug. It is impossible to memorise all the possible drug-drug interactions in HIV, therefore understanding how drugs are metabolised/eliminated and the potential for a particular drug to modify the pharmacokinetics of another has predictive value even when substantive data are unavailable. NNRTIs interact with cytochrome P450 (CYP450) enzymes both as substrates and inducers. Because of the inductive effects caution must be exercised when using with protease inhibitors (either boosted or un-boosted with ritonavir). In this situation therapeutic drug monitoring may play a role in optimising response. There needs to be care when using many drugs with NNRTIs e.g. methadone, oral contraceptives, rifampicin, and there are some definite contraindications. By understanding pharmacological principles, it is possible to optimise use of multi-drug regimens.