Clinical Management
Clinical ManagementAIDS Survival Project
Risky Cocktails
Interactions Between Street Drugs and HIV Medications
April 2003
| Recreational/Street Drug/Abused Prescription | HIV/Prescription Medication | Interaction | Comments |
| Alcohol | ABC/Ziagen/Abacavir | Increases ABC levels in blood. One study observed a 41% increase in ABC.1 | ABC is metabolized by alcohol dehydrogenase, therefore increasing ABC levels. |
| Alcohol | APV/Agenerase/Amprenavir | Increases APV levels in blood. | Alcohol may decrease metabolism of propylene glycol in APV solution. |
| Alcohol | SQV-hgc/Invirase/Saquinavir-hard gel cap | Increases metabolism, Decreases SQV-hgc plasma levels. | |
| Alcohol | Protease Inhibitors (PI) and Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) | Acute ingestion of alcohol leads to enzyme (CYP2E1 and 3A4) inhibition. | Chronic ingestion leads to enzyme induction which may result in subtherapeutic levels of PIs and NNRTIs. |
| Amphetamines | Protease Inhibitors (PI) | 2x-3x amphedamine build-up in blood. | Inhibits CYP2D6 metabolism.2 Increased likelihood of overdose: hypertension, hyperthermia, seizures, arrhythmias, tachycardia, and tachypnea may be seen as a result. |
| Amphetamines and Cocaine | Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants | Combination may increase serotonin release, resulting in Serotonin Syndrome.3 | Both metabolize through CYP2D6. |
| Anabolic Steroids | RTV/Norvir/Ritonavir | 2x-3x build-up of anabolics in blood. | |
| Antidepressants (tricyclic) | RTV/Norvir/Ritonavir | Inhibits metabolism of antidepressants, increases plasma concentrations. | |
| Barbituates | Protease Inhibitors (PI) | Increases blood levels of barbituates. | |
| Ecstasy/X/E/MDMA | MAOI Antidepressants (Nardil, Marplan, or Parnate) | Increases levels of both MAOIs and MDMA. | Decreases CYP2D6 metabolism. |
| Ecstasy/X/E/MDMA | RTV/Norvir/Ritonavir | 3x-10x build-up of MDMA in blood. | Interferes with (decreases) CYP2D6 metabolism. Toxicities include hyponatremia, hyperthermia, arrhythmias, tremor, hyperreflexia, sweating, seizures, and tachycardia. At least one reported death from MDMA/RTV interaction.4 |
| Gamma Htdroxybutyrate/GHB/ Liquid X ("Date Rape Drug") | Protease Inhibitors (PI) | 5x-10x increase of GHB. | One case of GHB toxicity with RTV/SQV.5 Overdose symptoms include myoclonic or seizure activity, bradycardia, respiratory depression, or loss of consciousness. |
| Heroin | RTV/Norvir/Ritonavir | Decreases heroin levels by 50%. | Heroine rapidly converts to morphine by plasma and liver esterases. Expect interactions once converted to morphine. Watch for opiate withdrawal. |
| Ketamine/K/Special K | Protease Inhibitors (PI) | Build-up of K in blood with antiretrovirals, especially RTV, NFV, and EFV. | CYP2B6 is main metabolic enzyme. 3A and 2C9 are utilized to a lesser extent.6 |
| Ketamine/K/Special K | RTV/Norvir/Ritonavir | Build-up of Ketamine likely. | Overdose symptoms include respiratory depression, loss of consciousness, and hallucinations. |
| Lysergic Acid Diethylmide/LSD | Protease Inhibitors (PI) and Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) | PI and NNRTI CYP450 inhibitors may cause build-up of LSD. | Overdose symptoms include hallucinations, agitation, psychosis, and "flashbacks." |
| Marijuana | Protease Inhibitors (PI) | Increases THC (active compound in marijuana) levels. | Slowed metabolism of THC by Protease Inhibitors, therefore, smaller amounts required for medicinal purposes. |
| Marijuana | Protease Inhibitors (PI) and Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) | Smoked marijuana may lower PI and NNRTI levels. Smoked THC in one study decreased NFV by 17% and IDV by 21%.7 | THC interferes with CYP3A4, 2C9, and 2D6. Increases in THC if using medications that inhibit CYP450; decreases in THC if using medications that induce CYP450. |
| Phencyclidine/PCP | Protease Inhibitors (PI) and Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) | Possible increased levels of PCP in blood. | Overdose symptoms include seizures, hypertension, rhabdonyolysis, and hyperthermia. Metabolism by CYP3A and CYP2C11; and inhibits CYP2B1.8 |
| Poppers/Amyl Nitrate | Viagra | Decreases blood pressure, can be fatal. | |
| Rohypnol ("Date Rape Drug") | RTV/Norvir/Ritonavir | 2x-3x build-up of Rohypnol in blood. | |
| Sedatives | Protease Inhibitors (PI) | Inhibits metabolism of sedatives, increases plasma concentrations. | |
| Speed/Crystal Meth/Tina | RTV/Norvir/Ritonavir | 2x-3x build-up of Crystal Meth in blood. | |
| Temazepam (Jellies) | RTV/Norvir/Ritonavir | Temazepam metabolized more quickly. | |
| Valium (Diazepam) | RTV/Norvir/Ritonavir | Huge increase in blood levels of Diazepam. | |
| Viagra | RTV/Norvir/Ritonavir | 4x build-up of Viagra in blood. | |
| Poppers/Amyl Nitrate | HIV (itself, not the medications) | Increases disease progression. | |
| Methadone | HIV (itself, not the medications) | Methadone can increase the infectivity of R5 strains of HIV -- those that use the CCR5 coreceptor. | Findings: (1) Methadone upregulates (increases) CCR5 expression on cell surfaces. (2) Methadone inhibits the production of beta chemokines that decrease infectivity. (3) Methadone increases Cortisol levels, temporarily driving CD4+ cells out of the blood and into lymph nodes and tissues. CD4+ cells return when cortisol levels decrease. (4) Methadone also enhances the activation and replication of latently infected cells. |
| Alcohol | HIV (itself, not the medications) | 4x less likely to achieve a low viral load. | This study compared heavy drinkers compared to non-heavy drinkers. |
| Cocaine | HIV (itself, not the medications) | Increases viral replication (200x).9 | May increase the number of CCR5 and CXCR4 receptors on CD4+ cells that HIV uses to infect the cells. |
| Ecstasy/X/E/MDMA | HIV (itself, not the medications) | One dose of MDMA (100 mg) decreased CD4+ cells by 30% within hours after a single dose. Two doses of MDMA, four hours apart, decreased CD4+ cells by 40%.10 | Additional finding: decreased ability of CD4+ cells to fight infection.10 |
| GHB/Liquid X | HIV (itself, not the medications) | Suppresses the immune system. | |
| Methadone | AZT/Retrovir/Zidovudine (NRTI) | Increases AZT levels by 50% in blood. | |
| Methadone | d4T/Zerit/Stavudine (NRTI) | Decreases d4T levels by 13% in blood. | |
| Methadone | ddI/Videx/Didanosine | Methadone may decrease ddI levels by about 50% below normal. | |
| Methadone | ddI/Videx/Didanosine (NRTI) | Decreases ddI levels by 52% in blood. | |
| Methadone | EFV/Sustiva/Efavirenz (NNRTI) | Decreases Methadone levels by 60% in blood. | Recommendation: Increase methadone dose by 5 mg to 50 mg (avg. 22 mg). |
| Methadone | IDV/Crixivan/Indinavir and SQV-sgc/Fortovase/Saquinavir-Soft Gel | Does not decrease Methadone levels in blood. | May increase Methadone levels slightly (studies pending). |
| Methadone | LPV-r/Kaletra/Lopinavir+Ritonavir | Decreases Methadone levels by 53% in blood. | |
| Methadone | NFV/Viracept/Nelfinavir | Decreases Methadone (-)enantiomer by 47% and (+)enantiomer by 39% in blood. | |
| Methadone | NVP/Viramune/Nevirapine | Decreases Methadone levels by 60% in blood. | Recommendation: Increase methadone dose by as much as 150 mg to avoid symptoms of withdrawal. |
| Methadone | RTV/Norvir/Ritonavir | Effect unpredictable; either increase or decrease methadone levels. | One study showed a decrease of Methadone levels by 40% in blood. |
| Methadone | RTV/Norvir/Ritonavir | Decreases Methadone levels by 40% in blood. | |
| Methadone | RTV/Norvir/Ritonavir and NFV/Viracept/Nelfinavir. | Decrease Methadone levels by 30%-40% in blood. |
This article was provided by AIDS Survival Project, and is a part of the publication Survival News.
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