Does Kaletra (lopinavir and ritonavir) cause side effects?

Kaletra (lopinavir and ritonavir) contains antiviral medications called protease inhibitors used to treat infections with the human immunodeficiency virus (HIV). 

Although both lopinavir and ritonavir inhibit the HIV virus, they are combined in Kaletra because ritonavir increases the concentration of lopinavir in the body. The activity of Kaletra against HIV is due to the lopinavir because the amount of ritonavir in Kaletra is not enough to inhibit the HIV virus. 

During infection with HIV, the HIV virus multiplies within the body's cells. Viruses are released from the cells and spread throughout the body where they infect other cells. In this manner, HIV infection is perpetuated among new cells that the body produces continually. During the production of the viruses, new proteins for the viruses are made. 

Some of the proteins are structural proteins, that, is, proteins that form the body of the virus. Other proteins are enzymes which manufacture DNA and other components for the new viruses. 

Protease is the enzyme that forms the new structural proteins and enzymes. The lopinavir in Kaletra blocks the action of protease and results in the formation of defective viruses that are unable to infect the body's cells. 

As a result, the number of viruses in the body (the viral load) decreases. Nevertheless, Kaletra does not prevent the transmission of HIV among individuals, and it does not cure HIV infections or AIDS. The lopinavir and ritonavir combination is under investigation for treatment of the COVID-19 coronavirus disease, a deadly respiratory infection pandemic caused by the SARS-nCoV-2 virus.

Common side effects of Kaletra include

Serious side effects of Kaletra include liver failure and failure of the pancreas, redistribution or accumulation of body fat, increased cholesterol, worsening of diabetes, and abnormal heart rhythms.

Drug interactions of Kaletra include amiodarone, quinidine, triazolam, midazolam, pimozide, ergotamine derivatives, propafenone, and flecainide, because Kaletra increases the levels of these drugs in the body and as a result may lead to serious adverse effects of these drugs. 

Kaletra may also prevent the breakdown of lovastatin, simvastatin, rosuvastatin, and atorvastatin, causing their levels in the body to rise. This may increase the occurrence of muscle breakdown (rhabdomyolysis), which is a side effect of these drugs. 

Lovastatin and simvastatin should not be combined with Kaletra; the dose of rosuvastatin should not exceed 10 mg/day and the lowest dose of atorvastatin should be used. 

The blood concentration of rifabutin and sildenafil can be increased by Kaletra. Doses of rifabutin and sildenafil should be reduced. 

Kaletra can reduce the effectiveness of oral contraceptives

Rifampin, St. John's wort, efavirenz, and nevirapine decrease the blood levels of Kaletra and this can reduce the effectiveness of Kaletra. 

Use of Kaletra during pregnancy has not been adequately evaluated. It is unknown if Kaletra is excreted in breast milk

HIV-infected mothers should not breastfeed because of the potential risk of transmitting HIV to an infant that is not infected.

What are the important side effects of Kaletra (lopinavir and ritonavir)?

The most common side effects of Kaletra are:

Kaletra may cause liver failure and failure of the pancreas. Like other protease inhibitors use of Kaletra may be associated with:

  • redistribution or accumulation of body fat,
  • increased cholesterol,
  • worsening of diabetes, and
  • abnormal heart rhythms.

Kaletra should be used cautiously in patients with pre-existing heart conditions.

Kaletra (lopinavir and ritonavir) side effects list for healthcare professionals

The following adverse reactions are discussed in greater detail in other sections of the labeling.

  • QT Interval Prolongation, PR Interval Prolongation
  • Drug Interactions
  • Pancreatitis
  • Hepatotoxicity

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

Adverse Reactions In Adults

The safety of Kaletra has been investigated in about 2,600 patients in Phase II-IV clinical trials, of which about 700 have received a dose of 800/200 mg (6 capsules or 4 tablets) once daily. Along with nucleoside reverse transcriptase inhibitors (NRTIs), in some studies, Kaletra was used in combination with efavirenz or nevirapine.

In clinical studies the incidence of diarrhea in patients treated with either Kaletra capsules or tablets was greater in those patients treated once daily than in those patients treated twice daily.

Any grade of diarrhea was reported by at least half of patients taking once daily Kaletra capsules or tablets. At the time of treatment discontinuation, 4.2-6.3% of patients taking once daily Kaletra and 1.8-3.7% of those taking twice daily Kaletra reported ongoing diarrhea.

Commonly reported adverse reactions to Kaletra included

  • diarrhea,
  • nausea,
  • vomiting,
  • hypertriglyceridemia and
  • hypercholesterolemia.

Diarrhea, nausea and vomiting may occur at the beginning of the treatment while hypertriglyceridemia and hypercholesterolemia may occur later. The following have been identified as adverse reactions of moderate or severe intensity (Table 2):

Table 2: Treatment-Emergent Adverse Reactions of Moderate or Severe Intensity Occurring in at Least 0.1% of Adult Patients Receiving Kaletra in Combined Phase II/IV Studies (N=2,612)

System Organ Class (SOC) and Adverse Reactionn%
BLOOD AND LYMPHATIC SYSTEM DISORDERS
  anemia*542.1
  leukopenia and neutropenia*441.7
  lymphadenop athy *351.3
CARDIAC DISORDERS
  atherosclerosis such as myocardial infarction*100.4
  atrioventricular block*30.1
  tricuspid valve incompetence*30.1
EAR AND LABYRINTH DISORDERS
  vertigo*70.3
  tinnitus60.2
ENDOCRINE DISORDERS
  hypogonadism*160.81
EYE DISORDERS
  visual impairment*80.3
GASTROINTESTINAL DISORDERS
  diarrhea*51019.5
  nausea26910.3
  vomiting*1776.8
  abdominal pain (upper and lower)*1606.1
  gastroenteritis and colitis*662.5
  dyspepsia532.0
  pancreatitis*451.7
  Gastroesophageal Reflux Disease (GERD)*401.5
  hemorrhoids391.5
  flatulence361.4
  abdominal distension341.3
  constipation*261.0
  stomatitis and oral ulcers*240.9
  duodenitis and gastritis*200.8
  gastrointestinal hemorrhage including rectal hemorrhage*130.5
  dry mouth90.3
  gastrointestinal ulcer*60.2
  fecal incontinence50.2
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
  fatigue including asthenia*1987.6
HEPATOBILIARY DISORDERS
  hepatitis including AST, ALT, and GGT increases*913.5
  hepatomegaly50.2
  cholangitis30.1
  hepatic steatosis30.1
IMMUNE SYSTEM DISORDERS
  hypersensitivity including urticaria and angioedema*702.7
  immune reconstitution syndrome30.1
INFECTIONS AND INFESTATIONS
  upper respiratory tract infection*36313.9
  lower respiratory tract infection*2027.7
  skin infections including cellulitis, folliculitis, and furuncle*863.3
METABOLISM AND NUTRITION DISORDERS
  hypercholesterol emia*1927.4
  hypertriglyceridemia*1616.2
  weight decreased*612.3
  decreased appetite522.0
  blood glucose disorders including diabetes mellitus*301.1
  weight increased*200.8
  lactic acidosis*110.4
  increased appetite50.2
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
  musculoskeletal pain including arthralgia and back pain*1666.4
  myalgia*461.8
  muscle disorders such as weakness and spasms*341.3
  rhabdomyolysis*180.7
  osteonecrosis30.1
NERVOUS SYSTEM DISORDERS
  headache including migraine*1656.3
  insomnia*993.8
  neuropathy and peripheral neuropathy*512.0
  dizziness*451.7
  ageusia*190.7
  convulsion*90.3
  tremor*90.3
  cerebral vascular event*60.2
PSYCHIATRIC DISORDERS
  anxiety*1013.9
  abnormal dreams*190.7
  libido decreased190.7
RENAL AND URINARY DISORDERS
  renal failure*311.2
  hematuria*200.8
  nephritis*30.1
REPRODUCTIVE SYSTEM AND BREAST DISORDERS
  erectile dysfunction*341.71
  menstrual disorders - amenorrhea, menorrhagia*101.72
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
  rash including maculopapular rash*993.8
  lipodystrophy acquired including facial wasting*582.2
  dermatitis/rash including eczema and seborrheic dermatitis*501.9
  night sweats*421.6
  pruritus*291.1
  alopecia100.4
  capillaritis and vasculitis*30.1
VASCULAR DISORDERS
  hypertension*471.8
  deep vein thrombosis*170.7
*Represents a medical concept including several similar MedDRA PTs
1. Percentage of male population (N=2,038)
2. Percentage of female population (N=574)

Laboratory Abnormalities In Adults

The percentages of adult patients treated with combination therapy with Grade 3-4 laboratory abnormalities are presented in Table 3 (treatment-naïve patients) and Table 4 (treatmentexperienced patients).

Table 3: Grade 3-4 Laboratory Abnormalities Reported in greater than or equal to 2% of Adult Antiretroviral-Naïve Patients

VariableLimit1Study 863 (48 Weeks)Study 720 (360 Weeks)Study 418 (48 weeks)Study 730 (48 Weeks)
Kaletra 400/100 mg Twice Daily + d4T +3TC
(N = 326)
Nelfinavir 750 mg Three Times Daily + d4T + 3TC
(N = 327)
Kaletra Twice Daily + d4T + 3TC
(N = 100)
Kaletra 800/200 mg Once Daily + TDF + FTC
(N=115)
Kaletra 400/100 mg Twice Daily + TDF + FTC
(N=75)
Kaletra Once Daily + TDF +FTC
(N=333)
Kaletra Twice Daily + TDF +FTC
(N=331)
ChemistryHigh
Glucose> 250 mg/dL2%2%4%3%1%0%< 1%
Uric Acid> 12 mg/dL2%2%5%0%3%< 1%1%
SGOT/ AST2> 180 U/L2%4%10%5%3%1%2%
SGPT/ ALT2> 215U/L4%4%11%4%3%1%1%
GGT> 300 U/LN/AN/A10%N/AN/AN/AN/A
Total Cholesterol> 300 mg/dL9%5%27%3%3%4%3%
Triglycerid es> 750 mg/dL9%1%29%5%4%3%6%
Amylase> 2 x ULN3%2%4%7%5%N/AN/A
Lipase> 2 x ULNN/AN/AN/AN/AN/A3%5%
ChemistryLow
Calculated Creatinine Clearance< 50 mL/minN/AN/AN/AN/AN/A2%2%
HematologyLow
Neutrophils< 0.75 x 109/L1%3%5%5%1%2%1%
1 ULN = upper limit of the normal range; N/A = Not Applicable.
2 Criterion for Study 730 was > 5x ULN (AST/ALT).

Table 4: Grade 3-4 Laboratory Abnormalities Reported in greater than or equal to 2% of Adult Protease Inhibitor-Experienced Patients

VariableLimit1Study 888 (48 Weeks)Study 9572 and Study 7653 (84-144 Weeks)Study 802 (48 Weeks)
Kaletra 400/100 mg Twice Daily + NVP + NRTIs
(N = 148)
Investigator-Selected Protease Inhibitor(s) + NVP + NRTIs
(N = 140)
Kaletra Twice Daily + NNRTI + NRTIs
(N = 127)
Kaletra 800/200 mg Once Daily +NRTIs
(N=300)
Kaletra 400/100 mg Twice Daily +NRTIs
(N=299)
ChemistryHigh
Glucose> 250 mg/dL1%2%5%2%2%
Total Bilirubin> 3.48 mg/dL1%3%1%1%1%
SGOT/AST4> 180 U/L5%11%8%3%2%
SGPT/ALT4> 215 U/L6%13%10%2%2%
GGT> 300 U/LN/AN/A29%N/AN/A
Total Cholesterol> 300 mg/dL20%21%39%6%7%
Triglycerides> 750 mg/dL25%21%36%5%6%
Amylase> 2 x ULN4%8%8%4%4%
Lipase> 2 x ULNN/AN/AN/A4%1%
Creatine Phosphokinase> 4 x ULNN/AN/AN/A4%5%
ChemistryLow
Calculated Creatinine Clearance< 50 mL/minN/AN/AN/A3%3%
Inorganic Phosphorus< 1.5 mg/dL1%0%2%1%< 1%
HematologyLow
Neutrophils< 0.75 x 109/L1%2%4%3%4%
Hemoglobin< 80 g/L1%1%1%1%2%
1 ULN = upper limit of the normal range; N/A = Not Applicable.
2 Includes clinical laboratory data from patients receiving 400/100 mg twice daily (n = 29) or 533/133 mg twice daily (n = 28) for 84 weeks. Patients received Kaletra in combination with NRTIs and efavirenz.
3 Includes clinical laboratory data from patients receiving 400/100 mg twice daily (n = 36) or 400/200 mg twice daily (n = 34) for 144 weeks. Patients received Kaletra in combination with NRTIs and nevirapine.
4 Criterion for Study 802 was > 5x ULN (AST/ALT).

Adverse Reactions In Pediatric Patients

Kaletra oral solution dosed up to 300/75 mg per m² has been studied in 100 pediatric patients 6 months to 12 years of age. The adverse reaction profile seen during Study 940 was similar to that for adult patients.

Dysgeusia (22%), vomiting (21%), and diarrhea (12%) were the most common adverse reactions of any severity reported in pediatric patients treated with combination therapy for up to 48 weeks in Study 940. A total of 8 patients experienced adverse reactions of moderate to severe intensity. The adverse reactions meeting these criteria and reported for the 8 subjects include:

Rash was the only event of those listed that occurred in 2 or more subjects (N = 3).

Kaletra oral solution and soft gelatin capsules dosed at higher than recommended doses including 400/100 mg per m² (without concomitant NNRTI) and 480/120 mg per m² (with concomitant NNRTI) have been studied in 26 pediatric patients 7 to 18 years of age in Study 1038. Patients also had saquinavir mesylate added to their regimen at Week 4.

Rash (12%), blood cholesterol abnormal (12%) and blood triglycerides abnormal (12%) were the only adverse reactions reported in greater than 10% of subjects. Adverse drug reactions of moderate to severe intensity occurring in 2 or more subjects included

Both subjects with QT prolongation had additional predisposing conditions such as

  • electrolyte abnormalities,
  • concomitant medications, or
  • pre-existing cardiac abnormalities.
Laboratory Abnormalities In Pediatric Patients

The percentages of pediatric patients treated with combination therapy including Kaletra with Grade 3-4 laboratory abnormalities are presented in Table 5.

Table 5: Grade 3-4 Laboratory Abnormalities Reported in greater than or equal to 2% Pediatric Patients in Study 940

VariableLimit1Kaletra Twice Daily + RTIs
(N = 100)
ChemistryHigh
Sodium> 149 mEq/L3%
Total Bilirubin≥ 3.0 x ULN3%
SGOT/AST> 180U/L8%
SGPT/ALT> 215 U/L7%
Total Cholesterol> 300 mg/dL3%
Amylase> 2.5 x ULN7%2
ChemistryLow
Sodium< 130 mEq/L3%
HematologyLow
Platelet Count< 50 x 109/L4%
Neutrophils< 0.40 x 109/L2%
1 ULN = upper limit of the normal range.
2 Subjects with Grade 3-4 amylase confirmed by elevations in pancreatic amylase.

Postmarketing Experience

The following adverse reactions have been reported during postmarketing use of Kaletra. Because these reactions are reported voluntarily from a population of unknown size, it is not always possible to reliably estimate their frequency or establish a causal relationship to Kaletra exposure.

Body as a Whole

Redistribution/accumulation of body fat has been reported.

Cardiovascular

Bradyarrhythmias. First-degree AV block, second-degree AV block, third-degree AV block, QTc interval prolongation, torsades (torsade) de pointes.

Skin and Appendages

Toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome and erythema multiforme.

What drugs interact with Kaletra (lopinavir and ritonavir)?

See also prescribing information.

Potential For Kaletra To Affect Other Drugs

  • Lopinavir/ritonavir is an inhibitor of CYP3A and may increase plasma concentrations of agents that are primarily metabolized by CYP3A. Agents that are extensively metabolized by CYP3A and have high first pass metabolism appear to be the most susceptible to large increases in AUC ( > 3-fold) when co-administered with Kaletra.
  • Thus, co-administration of Kaletra with drugs highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life-threatening events is contraindicated. Co-administration with other CYP3A substrates may require a dose adjustment or additional monitoring as shown in Table 6.
  • Additionally, Kaletra induces glucuronidation.

Potential For Other Drugs To Affect Lopinavir

  • Lopinavir/ritonavir is a CYP3A substrate; therefore, drugs that induce CYP3A may decrease lopinavir plasma concentrations and reduce Kaletra's therapeutic effect.
  • Although not observed in the Kaletra/ketoconazole drug interaction study, co-administration of Kaletra and other drugs that inhibit CYP3A may increase lopinavir plasma concentrations.

Established And Other Potentially Significant Drug Interactions

  • Table 6 provides a listing of established or potentially clinically significant drug interactions. Alteration in dose or regimen may be recommended based on drug interaction studies or predicted interaction.

Table 6: Established and Other Potentially Significant Drug Interactions

Concomitant Drug Class: Drug Name Effect on Concentration of Lopinavir or Concomitant Drug Clinical Comment
HIV-1 Antiviral Agents
HIV-1 Protease Inhibitor: fosamprenavir/ritonavir ↓ amprenavir
↓lopinavir
An increased rate of adverse reactions has been observed with co-administration of these medications. Appropriate doses of the combinations with respect to safety and efficacy have not been established.
HIV-1 Protease Inhibitor: indinavir* ↑indinavir Decrease indinavir dose to 600 mg twice daily, when co-administered with Kaletra 400/100 mg twice daily. Kaletra once daily has not been studied in combination with indinavir.
HIV-1 Protease Inhibitor: nelfinavir* ↑ nelfinavir
↑ M8 metabolite of nelfinavir
↓ lopinavir
Increase Kaletra dose to 533/133 mg and decrease nelfinavir dose to 1000 mg twice daily, when co-administered. Kaletra should not be administered once-daily in combination with nelfinavir.
HIV-1 Protease Inhibitor: ritonavir* ↑ lopinavir Appropriate doses of additional ritonavir in combination with Kaletra with respect to safety and efficacy have not been established.
HIV-1 Protease Inhibitor: saquinavir* ↑ saquinavir The saquinavir dose is 1000 mg twice daily (with no additional ritonavir), when coadministered with Kaletra 400/100 mg twice daily. Kaletra once daily has not been studied in combination with saquinavir.
HIV-1 Protease Inhibitor: tipranavir ↓ lopinavir AUC and Cmin Kaletra should not be administered with tipranavir (500 mg twice daily) co-administered with ritonavir (200 mg twice daily).
HIV CCR5 - Antagonist: maraviroc ↑maraviroc Concurrent administration of maraviroc with Kaletra will increase plasma levels of maraviroc. When co-administered, patients should receive 150 mg twice daily of maraviroc. For further details see complete prescribing information for Selzentry® (maraviroc).
Non-nucleoside Reverse Transcriptase Inhibitor: etravirine ↓ etravirine Because the reduction in the mean systemic exposures of etravirine in the presence of lopinavir/ritonavir is similar to the reduction in mean systemic exposures of etravirine in the presence of darunavir/ritonavir, no dose adjustment is required.
Non-nucleoside Reverse Transcriptase Inhibitors: efavirenz*, nevirapine* ↓ lopinavir Kaletra dose increase is recommended in all patients. Increasing the dose of Kaletra capsules to 533/133 mg (given as four capsules) twice daily co-administered with efavirenz resulted in similar lopinavir concentrations compared to Kaletra tablets 400/100 mg (given as two 200/50 mg tablets) twice daily without efavirenz. Kaletra should not be administered once-daily in combination with efavirenz or nevirapine.
Non-nucleoside Reverse Transcriptase Inhibitor: delavirdine ↑lopinavir Appropriate doses of the combination with respect to safety and efficacy have not been established.
Non-nucleoside Reverse Transcriptase Inhibitor: rilpivirine ↑ rilpivirine No dose adjustment is required.
Nucleoside Reverse Transcriptase Inhibitor: didanosine   It is recommended that didanosine be administered on an empty stomach; therefore, didanosine should be given one hour before or two hours after Kaletra capsules (given with food).
Nucleoside Reverse Transcriptase Inhibitor: tenofovir ↑ tenofovir Kaletra increases tenofovir concentrations. The mechanism of this interaction is unknown. Patients receiving Kaletra and tenofovir should be monitored for adverse reactions associated with tenofovir.
Nucleoside Reverse Transcriptase Inhibitors: abacavir, zidovudine ↓ abacavir ↓ zidovudine Kaletra induces glucuronidation; therefore, Kaletra has the potential to reduce zidovudine and abacavir plasma concentrations. The clinical significance of this potential interaction is unknown.
Other Agents
Antiarrhythmics: e.g. amiodarone, bepridil, lidocaine (systemic), quinidine ↑antiarrhythmics Caution is warranted and therapeutic concentration monitoring (if available) is recommended for antiarrhythmics when coadministered with Kaletra.
Anticancer Agents: vincristine, vinblastine, dasatinib, nilotinib ↑ anticancer agents Concentrations of these drugs may be increased when co-administered with Kaletra resulting in the potential for increased adverse events usually associated with these anticancer agents.
For vincristine and vinblastine, consideration should be given to temporarily withholding the ritonavir-containing antiretroviral regimen in patients who develop significant hematologic or gastrointestinal side effects when Kaletra is administered concurrently with vincristine or vinblastine. If the antiretroviral regimen must be withheld for a prolonged period, consideration should be given to initiating a revised regimen that does not include a CYP3A or P-gp inhibitor.
A decrease in the dosage or an adjustment of the dosing interval of nilotinib and dasatinib may be necessary for patients requiring coadministration with strong CYP3A inhibitors such as Kaletra. Please refer to the nilotinib and dasatinib prescribing information for dosing instructions.
Anticoagulants: warfarin, rivaroxaban ↑ rivaroxaban Concentrations of warfarin may be affected. It is recommended that INR (international normalized ratio) be monitored. Avoid concomitant use of rivaroxaban and Kaletra. Co-administration of Kaletra and rivaroxaban is expected to result in increased exposure of rivaroxaban which may lead to risk of increased bleeding.
Anticonvulsants: carbamazepine, phenobarbital, phenytoin ↓ lopinavir
↓phenytoin
Kaletra may be less effective due to decreased lopinavir plasma concentrations in patients taking these agents concomitantly and should be used with caution. Kaletra should not be administered once daily in combination with carbamazepine, phenobarbital, or phenytoin. In addition, co-administration of phenytoin and Kaletra may cause decreases in steady-state phenytoin concentrations. Phenytoin levels should be monitored when co-administering with Kaletra.
Anticonvulsants: lamotrigine, valproate ↓lamotrigine
↓ or ↔valproate
Co-administration of Kaletra and lamotrigine or valproate may decrease the exposure of lamotrigine or valproate. A dose increase of the lamotrigine or valproate may be needed when co-administered with Kaletra and therapeutic concentration monitoring for lamotrigine may be indicated; particularly during dosage adjustments.
Antidepressant: bupropion ↓ bupropion
↓ active metabolite, hydroxybupropion
Concurrent administration of bupropion with Kaletra may decrease plasma levels of both bupropion and its active metabolite (hydroxybupropion). Patients receiving Kaletra and bupropion concurrently should be monitored for an adequate clinical response to bupropion.
Antidepressant: trazodone ↑ trazodone Concomitant use of trazodone and Kaletra may increase concentrations of trazodone. Adverse reactions of nausea, dizziness, hypotension and syncope have been observed following co-administration of trazodone and ritonavir. If trazodone is used with a CYP3A4 inhibitor such as ritonavir, the combination should be used with caution and a lower dose of trazodone should be considered.
Anti-infective: clarithromycin ↑clarithromycin For patients with renal impairment, the following dosage adjustments should be considered:
  • For patients with CLcr 30 to 60 mL per min the dose of clarithromycin should be reduced by 50%.
  • For patients with CLcr less than 30 mL per min the dose of clarithromycin should be decreased by 75%.
No dose adjustment for patients with normal renal function is necessary.
Antifungals: ketoconazole*, itraconazole, voriconazole ↑ ketoconazole
↑itraconazole
↓voriconazole
High doses of ketoconazole (greater than 200 mg per day) or itraconazole (greater than 200 mg per day) are not recommended. Co-administration of voriconazole with Kaletra has not been studied. However, a study has been shown that administration of voriconazole with ritonavir 100 mg every 12 hours decreased voriconazole steady-state AUC by an average of 39%; therefore, co-administration of Kaletra and voriconazole may result in decreased voriconazole concentrations and the potential for decreased voriconazole effectiveness and should be avoided, unless an assessment of the benefit/risk to the patient justifies the use of voriconazole. Otherwise, alternative antifungal therapies should be considered in these patients.
Anti-gout: colchicine ↑colchicine Patients with renal or hepatic impairment should not be given colchicine with Kaletra.
Treatment of gout flares-co-administration of colchicine in patients on Kaletra:
0.6 mg (1 tablet) x 1 dose, followed by 0.3 mg (half tablet) 1 hour later. Dose to be repeated no earlier than 3 days.
Prophylaxis of gout flares-co-administration of colchicine in patients on Kaletra:
If the original colchicine regimen was 0.6 mg twice a day, the regimen should be adjusted to 0.3 mg once a day. If the original colchicine regimen was 0.6 mg once a day, the regimen should be adjusted to 0.3 mg once every other day.
Treatment of familial Mediterranean fever (FMF)-co-administration of colchicine in patients on Kaletra:
Maximum daily dose of 0.6 mg (may be given as 0.3 mg twice a day).
Antimycobacterial: bedaquiline ↑ bedaquiline Bedaquiline should only be used with Kaletra if the benefit of co-administration outweighs the risk.
Antimycobacterial: rifabutin* ↑rifabutin and rifabutin metabolite Dosage reduction of rifabutin by at least 75% of the usual dose of 300 mg per day is recommended (i.e., a maximum dose of 150 mg every other day or three times per week). Increased monitoring for adverse reactions is warranted in patients receiving the combination. Further dosage reduction of rifabutin may be necessary.
Antimycobacterial: rifampin ↓ lopinavir May lead to loss of virologic response and possible resistance to Kaletra or to the class of protease inhibitors or other co-administered antiretroviral agents. A study evaluated combination of rifampin 600 mg once daily, with Kaletra 800/200 mg twice daily or Kaletra 400/100 mg plus ritonavir 300 mg twice daily. Pharmacokinetic and safety results from this study do not allow for a dose recommendation. Nine subjects (28%) experienced a greater than or equal to grade 2 increase in ALT/AST, of which seven (21%) prematurely discontinued study per protocol. Based on the study design, it is not possible to determine whether the frequency or magnitude of the ALT/AST elevations observed is higher than what would be seen with rifampin alone.
Antiparasitic: atovaquone ↓atovaquone Clinical significance is unknown; however, increase in atovaquone doses may be needed.
Antipsychotics: quetiapine ↑quetiapine Initiation of Kaletra in patients taking quetiapine:
Consider alternative antiretroviral therapy to avoid increases in quetiapine exposures. If coadministration is necessary, reduce the quetiapine dose to 1/6 of the current dose and monitor for quetiapine-associated adverse reactions. Refer to the quetiapine prescribing information for recommendations on adverse reaction monitoring.
Initiation of quetiapine in patients taking Kaletra:
Refer to the quetiapine prescribing information for initial dosing and titration of quetiapine.
Benzodiazepines: parenterally administered midazolam ↑midazolam Midazolam is extensively metabolized by CYP3A4. Increases in the concentration of midazolam are expected to be significantly higher with oral than parenteral administration. Therefore, Kaletra should not be given with orally administered midazolam.
If Kaletra is co-administered with parenteral midazolam, close clinical monitoring for respiratory depression and/or prolonged sedation should be exercised and dosage adjustment should be considered.
Contraceptive: ethinyl estradiol* ↓ ethinyl estradiol Because contraceptive steroid concentrations may be altered when Kaletra is coadministered with oral contraceptives or with the contraceptive patch, alternative methods of nonhormonal contraception are recommended.
Corticosteroids (systemic): e.g. budesonide, dexamethasone, prednisone ↓ lopinavir
↑glucocorticoids
Use with caution. Kaletra may be less effective due to decreased lopinavir plasma concentrations in patients taking these agents concomitantly. Concomitant use may result in increased steroid concentrations and reduced serum cortisol concentrations. Concomitant use of glucocorticoids that are metabolized by CYP3A, particularly for long-term use, should consider the potential benefit of treatment versus the risk of systemic corticosteroid effects. Concomitant use may increase the risk for development of systemic corticosteroid effects including Cushing’s syndrome and adrenal suppression.
Dihydropyridine Calcium Channel Blockers: e.g. felodipine, nifedipine, nicardipine ↑dihydropyridine calcium channel blockers Caution is warranted and clinical monitoring of patients is recommended.
Endothelin Receptor Antagonists: bosentan t bosentan Co-administration of bosentan in patients on Kaletra:
In patients who have been receiving Kaletra for at least 10 days, start bosentan at 62.5 mg once daily or every other day based upon individual tolerability.
Co-administration of Kaletra in patients on bosentan:
Discontinue use of bosentan at least 36 hours prior to initiation of Kaletra.
After at least 10 days following the initiation of Kaletra, resume bosentan at 62.5 mg once daily or every other day based upon individual tolerability.
HCV-Protease Inhibitor: boceprevir ↓lopinavir
↓ boceprevir
↓ ritonavir
It is not recommended to co-administer Kaletra and boceprevir. Concomitant administration of Kaletra and boceprevir reduced boceprevir, lopinavir and ritonavir steady-state exposures.
HCV-Protease Inhibitor: simeprevir ↑ simeprevir It is not recommended to co-administer Kaletra and simeprevir.
HMG-CoA Reductase Inhibitors: atorvastatin, rosuvastatin ↑ atorvastatin
↑ rosuvastatin
Use atorvastatin with caution and at the lowest necessary dose. Titrate rosuvastatin dose carefully and use the lowest necessary dose; do not exceed rosuvastatin 10 mg per day. See Drugs with No Observed or Predicted Interactions with Kaletra and prescribing information for drug interaction data with other HMG-CoA reductase inhibitors.
Immunosuppressants: e.g. cyclosporine, tacrolimus, sirolimus ↑immunosuppressants Therapeutic concentration monitoring is recommended for immunosuppressant agents when co-administered with Kaletra.
Inhaled or Intranasal Steroids: e.g. fluticasone, budesonide ↑ glucocorticoids Concomitant use of Kaletra and fluticasone or other glucocorticoids that are metabolized by CYP3A is not recommended unless the potential benefit of treatment outweighs the risk of systemic corticosteroid effects. Concomitant use may result in increased steroid concentrations and reduce serum cortisol concentrations.
Systemic corticosteroid effects including Cushing's syndrome and adrenal suppression have been reported during postmarketing use in patients when certain ritonavir-containing products have been co-administered with fluticasone propionate or budesonide.
Long-acting Beta-Adrenoceptor Agonist: salmeterol ↑salmeterol Concurrent administration of salmeterol and Kaletra is not recommended. The combination may result in increased risk of cardiovascular adverse events associated with salmeterol, including QT prolongation, palpitations and sinus tachycardia.
Narcotic Analgesics: methadone*, fentanyl ↓ methadone
↑ fentanyl
Dosage of methadone may need to be increased when co-administered with Kaletra. Concentrations of fentanyl are expected to increase. Careful monitoring of therapeutic and adverse effects (including potentially fatal respiratory depression) is recommended when fentanyl is concomitantly administered with Kaletra.
PDE5 Inhibitors: avanafil, sildenafil, tadalafil, vardenafil ↑ avanafil
↑ sildenafil
↑tadalafil
↑ vardenafil
Do not use Kaletra with avanafil because a safe and effective avanafil dosage regimen has not been established.
Particular caution should be used when prescribing sildenafil, tadalafil, or vardenafil in patients receiving Kaletra. Coadministration of Kaletra with these drugs is expected to substantially increase their concentrations and may result in an increase in PDE5 inhibitor associated adverse reactions including hypotension, syncope, visual changes and prolonged erection.
Use of PDE5 inhibitors for pulmonary arterial hypertension (PAH):
Sildenafil (Revatio®) is contraindicated when used for the treatment of pulmonary arterial hypertension (PAH) because a safe and effective dose has not been established when used with Kaletra.
The following dose adjustments are recommended for use of tadalafil (Adcirca) with Kaletra:
Co-administration of ADCIRCA in patients on Kaletra:
In patients receiving Kaletra for at least one week, start ADCIRCA at 20 mg once daily. Increase to 40 mg once daily based upon individual tolerability.
Co-administration of Kaletra in patients on ADCIRCA:
Avoid use of ADCIRCA during the initiation of Kaletra. Stop ADCIRCA at least 24 hours prior to starting Kaletra. After at least one week following the initiation of Kaletra, resume ADCIRCA at 20 mg once daily. Increase to 40 mg once daily based upon individual tolerability.
Use of PDE5 inhibitors for erectile dysfunction:
It is recommended not to exceed the following doses:
  • Sildenafil: 25 mg every 48 hours
  • Tadalafil: 10 mg every 72 hours
  • Vardenafil: 2.5 mg every 72 hours
Use with increased monitoring for adverse events.
* see prescribing information for magnitude of interaction.

Drugs With No Observed Or Predicted Interactions With Kaletra

Summary

Kaletra (lopinavir and ritonavir) contains antiviral medications called protease inhibitors used to treat infections with the human immunodeficiency virus (HIV). The lopinavir and ritonavir combination is under investigation for treatment of the COVID-19 coronavirus disease, a deadly respiratory infection pandemic caused by the SARS-nCoV-2 virus. Common side effects of Kaletra include abdominal pain, weakness, nausea, diarrhea, vomiting, headache and insomnia. Use of Kaletra during pregnancy has not been adequately evaluated. It is unknown if Kaletra is excreted in breast milk. HIV-infected mothers should not breastfeed because of the potential risk of transmitting HIV to an infant that is not infected.

Treatment & Diagnosis

Medications & Supplements

FDA Logo

Report Problems to the Food and Drug Administration

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.

Medically Reviewed on 9/25/2020
References
FDA Prescribing Information

Professional side effects and drug interactions sections courtesy of the U.S. Food and Drug Administration.

COVID-19 section data provided by Dominic Chan, Pharm. D. and infectious disease specialist at Legacy Health System
CONTINUE SCROLLING FOR RELATED SLIDESHOW