Standard dose: Almost never used at its approved dose (a lead-in dosing, then six 100 mg soft gelatin capsules twice-a-day, preferably with food—dose escalation is important to avoid side effects). Norvir is primarily used as a boosting agent for other PIs, at smaller doses of 100 to 400 mg, either once or twice a day. Take a missed dose as soon as possible, but do not double up on your next dose. Approved for children ages one month and older. Liquid formula available, but tastes unbelievably horrific.

AWP: $321.46 / month for 30 capsules

Manufacturer contact: Abbott Laboratories, www.norvir.com, 1 (800) 222–6885

AIDS Treatment Information Service: 1 (800) HIV–0440 (448–0440)

As seen with all other protease inhibitors are increased levels of cholesterol and triglycerides, except possibly unboosted Reyataz (atazanavir) and these increased levels may be associated with heart disease. Other possible side effects are lipodystrophy (body fat changes, including thinning of the face, arms and legs, with or without fat accumulation in the stomach, breasts and sometimes the upper back), onset of new cases or worsening of diabetes (see your doctor promptly) and increased bleeding in hemophiliacs.

Other potential side effects are liver problems, such as increase in liver enzymes (AST, ALT and GGT), hepatitis, or jaundice (yellowing of skin); and increased muscle enzyme (CPK) and uric acid. People with hepatitis B or C may be at increased risk.

Potential drug interactions: Ritonavir interacts with many other drugs. See the manufacturer package insert for the most complete list. Do not take with Tambocor (flecainide), Rythmol (propafenone), Versed, Halcion, Hismanol, Seldane, rifampin, ergot derivatives (such as Cafergot, Wigraine and Methergine, D.H.E. 45, in any form—serious interactions seen with dilation during gynecological exams), Antabuse or Flagyl, garlic supplements, or the herb St. John’s wort. Do not use Zocor (simvastatin) or Mevacor (lovastatin); lipid-lowering alternatives are Lipitor (atorvastatin), Lescol, and Pravachol (pravastatin), but they should be used with caution due to potential for liver toxicity.

Protease inhibitors increase blood levels of Viagra (sidenafil citrate), Cialis (tadalafil) and Levitra (vardenafil). Use with caution. Initially the Viagra dose should be 12.5 mg (1/2 of 25 mg tablet) and increased as needed and tolerated. It’s recommended that people on PIs do not exceed 25 mg of Viagra in a 48-hour period because of potential for serious reaction. Use Cialis at reduced doses of 10 mg every 72 hours and Levitra at reduced doses of no more than 2.5 mg every 72 hours, with increased monitoring for adverse events.

The effectiveness of birth control pills may be decreased when taking Norvir; women and their male partners should consider the use of alternative contraception methods with barrier.

Levels of the street drug Ecstasy are greatly increased by Norvir, and at least one death has been attributed to the combination. GHB is also dangerous with Norvir. Tobacco and alcohol may lower blood levels of Norvir. Increases seen in clarithromycin (Biaxin) levels by 80 percent. Rifampin decreases Norvir levels by 35 percent. Contains alcohol (but should not be enough to trigger relapse), so be cautious with Antabuse or Flagyl, and greatly hastens intoxication.

Tips: The real strength of Norvir is in combination with other PIs (used as a boosting agent), allowing for a lower dose of both. Stomach side effects are reduced by taking Norvir with high fat foods (such as peanut butter or avocado)—however, be careful because some other HIV medicines should not be taken with high fat foods. You can mix liquid solution in ice cream, milk or pudding to hide the bitter taste. Capsules do not need refrigeration if stored below 77º F and used within 30 days, but keep them tightly sealed in original container. The capsules contain castor oil and have bitter taste. Chocolate masks the bitter taste. Plasma concentration increases in people with hepatic (liver) impairment.

Doctor

Ritonavir (RTV) is not used as a single agent protease inhibitor anymore because of intolerable side effects at prescribed doses (600 mg twice a day). However, due to this drug’s effect on an important metabolic pathway in the liver, it is now commonly used in smaller doses to boost the levels of other protease inhibitors. This not only improves the pharmacokinetic profiles of many other PIs, but allows for much smaller overall pill burdens. It should be used with caution in patients on other drugs, as this metabolic effect may also impact other medicines, such as antihypertensives, antidepressants, pain medicines, and many others. It has been implicated in elevated triglyceride levels in the blood.—Chad J. Zawitz, MD

Activist

This protease came out in the mid-90s and helped us out a lot, but we suffered from severe diarrhea and triglycerides. Then there was a problem with the manufacture of the capsules and people had to take a foul-tasting Norvir liquid. Luckily, we do not take this PI as an HIV drug but as a booster of other protease inhibitors (and soon, entry inhibitors). Norvir seems to be here to stay as a booster even after Abbott increased its price by 400%, although Abbott has frozen the old price for ADAPs and says that they are providing the drug for free to anyone who cannot access it through other means. Its standard dose is 100 mg once or twice a day, except for Aptivus, which requires 200 mg twice a day. Companies are actively looking for booster compounds that can replace Norvir, with no success so far. We are waiting for a new formulation in the future that will not require refrigeration.—Nelson Vergel