Lopinavir + Ritonavir


Concise Prescribing Info
Indications/Uses
HIV-1 infection. 
Dosage/Direction for Use
Adult : PO Each tab contains lopinavir (mg)/ritonavir (mg): 100/25 or 200/500; per mL of oral solution contains lopinavir 80 mg and ritonavir 20 mg: In combination with other antiretroviral agents (without efavirenz, nevirapine, or nelfinavir): 400 mg/100 mg bid; or 800 mg/200 mg once daily. In combination with other antiretroviral agents (with efavirenz, nevirapine or nelfinavir): As tab: 500 mg/125 mg bid. As oral solution: 520 mg/130 mg bid.
Dosage Details
Oral
HIV-1 infection
Adult: Available preparations:
Lopinavir 100 mg and ritonavir 25 mg tab
Lopinavir 200 mg and ritonavir 50 mg tab
Lopinavir 80 mg and ritonavir 20 mg per mL oral solution

In combination with other antiretroviral agents (without efavirenz, nevirapine, or nelfinavir): 400 mg/100 mg bid. Alternatively, 800 mg/200 mg may be given once daily (limited to patients having <3 mutations to protease inhibitor; not recommended in patients receiving carbamazepine, phenobarbital, or phenytoin). In combination with other antiretroviral agents, with efavirenz, nevirapine or nelfinavir): As tab: 500 mg/125 mg bid. As oral solution: 520 mg/130 mg (6.5 mL) bid; once-daily dosing is not recommended.
Child: Available preparations:
Lopinavir 80 mg and ritonavir 20 mg per mL oral solution
In combination with other antiretroviral agents (without efavirenz, nevirapine, or nelfinavir): 2 weeks to 6 months 16 mg/4 mg/kg (0.2 mL/kg) or 300 mg/75 mg/m2 bid. >6 months to 18 years 7-<15 kg: 12 mg/3 mg/kg or 230 mg/57.5 mg/m2 bid; 15-40 kg: 10 mg/5 mg/kg or 230 mg/57.5 mg/m2 bid; ≥40 kg: Same as adult dose. In combination with other antiretroviral agents (with efavirenz, nevirapine, or nelfinavir): 300 mg/75 mg/m2 bid (Max: 533 mg/133 mg or 6.5 mL bid).

Lopinavir 100 mg and ritonavir 25 mg tab
≥2 years In combination with other antiretroviral agents (without efavirenz, nevirapine, or nelfinavir): 15-25 kg or BSA ≥0.5-<0.9 m2: 200 mg/50 mg bid; >25-35 kg or BSA ≥0.9-<1.4 m2: 300 mg/75 mg bid; >35-40 mg or BSA ≥1.4 m2: 400 mg/100 mg bid; 40 kg or BSA >1.4 m2: Same as adult dose. In combination with other antiretroviral agents (with efavirenz, nevirapine, or nelfinavir): BSA ≥0.5-<0.8 m2: 200 mg/50 mg bid; ≥0.8-<1.2 m2: 300 mg/75 mg bid; ≥1.2-<1.4 m2: 400 mg/100 mg bid; ≥1.4 m2: 500 mg/125 mg bid.

Lopinavir 200 mg and ritonavir 50 mg tab
≥2 years In combination with other antiretroviral agents (with efavirez, nevirapine, or nelfinavir): BSA ≥0.5-<0.8 m2: 200 mg/50 mg bid; ≥0.8-<1.2 m2: 300 mg/75 mg bid; ≥1.2-<1.4 m2: 400 mg/100 mg bid; ≥1.4 m2: 500 mg/125 mg bid; ≥40 kg or BSA >1.4 m2: Same as adult dose.
Hepatic Impairment
Severe: Contraindicated.
Administration
Cap & Oral Soln: Should be taken with food.
Tab: May be taken with or without food. Swallow whole, do not chew/crush/break.
Contraindications
Hypersensitivity. Congenital long QT syndrome. Severe hepatic impairment. Lactation. Concomitant use with drugs which are highly dependent on CYP3A for clearance and for which increased plasma concentrations are associated with serious or life-threatening reactions (e.g. alfuzosin, ergot alkaloids), or with potent inducers of CYP3A4 where significantly reduced lopinavir concentration may be associated with potential loss of virologic response. (e.g. rifampicin, St John’s wort).
Special Precautions
Patient with diabetes, haemophilia A or B, current or history of pancreatitis, underlying structural heart disease, ischaemic heart disease, cardiomyopathies, hepatitis B, C or cirrhosis. Mild to moderate hepatic impairment. Children. Pregnancy (once-daily dosing not recommended; avoid use of oral solution).
Adverse Reactions
Significant: Altered cardiac conduction, fat redistribution, increased cholesterol, elevated AST/ALT, haemophilia, hepatitis or exacerbation of existing hepatic dysfunction, hypertriglyceridaemia, immune reconstitution inflammatory syndrome, osteonecrosis.
Blood and lymphatic system disorders: Anaemia, leucopenia, neutropenia, lymphadenopathy.
Gastrointestinal disorders: Diarrhoea, nausea, vomiting, GERD, gastroenteritis, colitis, abdominal pain or distention, dyspepsia, haemorrhoids, flatulence.
General disorders and administration site conditions: Fatigue, asthenia.
Metabolism and nutrition disorders: Blood glucose disorder, decreased weight.
Musculoskeletal and connective tissue disorders: Myalgia, musculoskeletal pain (e.g. weakness, spasms).
Nervous system disorders: Headache, neuropathy, dizziness.
Psychiatric disorders: Anxiety, insomnia.
Reproductive system and breast disorders: Decreased libido, erectile dysfunction, menstrual disorders.
Respiratory, thoracic and mediastinal disorders: Respiratory tract infection.
Skin and subcutaneous tissue disorders: Rash, dermatitis.
Vascular disorders: Hypertension.
Potentially Fatal: Hypersensitivity (e.g. angioedema, bronchospasm, erythema multiforme; rarely, anaphylaxis, Stevens-Johnson syndrome). Hepatotoxicity, pancreatitis, QT interval prolongation, torsade de pointes. cardiogenic shock.
MonitoringParameters
Monitor LFT, electrolytes, viral load, CD4 count, and glucose levels. Obtain triglyceride and cholesterol level prior to initiation, then periodically thereafter.
Drug Interactions
Co-administration with other drugs that are primarily metabolised by CYP3A (e.g. dihydropyridine Ca channel blockers, rosuvastatin, immunosuppressants) may result in increased plasma concentrations of the other drugs that could increase or prolong their therapeutic and adverse effects.
Potentially Fatal: Increases the plasma concentration of ranolazine, amiodarone, dronedarone, alfuzosin, colchicine (when used in patients with renal and/or hepatic impairment), astemizole, terfenadine, lurasidone, pimozide, quetiapine, ergot alkaloids, cisapride, lovastatin, simvastatin, sildenafil or tadalafil (when used for the treatment of pulmonary arterial hypertension), oral midazolam, triazolam, fusidic acid, elbasvir grazoprevir, resulting to serious or life-threatening events. Concomitant use with potent CYP3A inhibitors (e.g. rifampicin) may result in suboptimal antiretroviral concentrations leading to loss of virologic response and development of resistance.
Food Interaction
Increased bioavailability with high fat meal (oral solution). Decreased plasma concentration and reduced clinical effects with St John’s wort, avoid combination.
Action
Description: Lopinavir and ritonavir are both inhibitors of HIV protease. Viral resistance develops rapidly when HIV protease inhibitors are given alone and therefore they are used with other antiretrovirals. Lopinavir mainly provides the antiviral activity by preventing the cleavage of the Gag-Pol polyprotein precursors into individual functional proteins. This leads to the formation of immature, non-infectious viral particles.
Ritonavir enhances lopinavir activity by inhibiting its CYP3A-mediated metabolism, thus increasing plasma levels of lopinavir.
Ritonavir dosage in the fixed combination is only sufficient to inhibit CYP3A, hence lopinavir is the active ingredient for antiretroviral activity.
Pharmacokinetics:
Absorption: Lopinavir: Rapidly absorbed from the gastrointestinal tract. Increased bioavailability with high fat meals (oral solution). Time to peak plasma concentration: 4 hours.
Ritonavir: Increased absorption with food. Time to peak plasma concentration: Oral solution: 2 hours (fasted); 4 hours (nonfasted).
Distribution: Lopinavir: Plasma protein binding: 98-99%, binds to both α1 glycoprotein and albumin.
Ritonavir: High concentrations in serum and lymph nodes. Enters breast milk. Volume of distribution: 0.41 ± 0.25 L/kg. Plasma protein binding: 98-99%.
Metabolism: Lopinavir: Extensively metabolised in the liver mainly via oxidation by CYP3A4 enzyme to 13 metabolites.
Ritonavir: Metabolised in the liver by CYP3A4 and CYP2D6 into 5 metabolites.
Excretion: Lopinavir: Mainly via faeces (83%, 20% as unchanged drug); urine (10%, <3% as unchanged drug). Elimination half-life: 5-6 hours.
Ritonavir: Mainly via faeces (approx 86%, with approx 34% as unchanged drug); via urine (approx 11%, with approx 4% as unchanged drug). Elimination half-life: 3-5 hours.
Chemical Structure

Chemical Structure Image
Lopinavir

Source: National Center for Biotechnology Information. PubChem Database. Lopinavir, CID=92727, https://pubchem.ncbi.nlm.nih.gov/compound/Lopinavir (accessed on Jan. 22, 2020)


Chemical Structure Image
Ritonavir

Source: National Center for Biotechnology Information. PubChem Database. Ritonavir, CID=392622, https://pubchem.ncbi.nlm.nih.gov/compound/Ritonavir (accessed on Jan. 22, 2020)

Storage
Tab: Store between 20-25°C. Oral solution: Store between 2-8°C. Protect from excessive heat.
MIMS Class
ATC Classification
J05AR - Antivirals for treatment of HIV infections, combinations ; Used in the systemic treatment of HIV infections.
References
Anon. Lopinavir and Ritonavir. AHFS Clinical Drug Information [online]. Bethesda, MD. American Society of Health-System Pharmacists, Inc. https://www.ahfscdi.com. Accessed 11/10/2018.

Anon. Lopinavir and Ritonavir. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 11/10/2018.

Anon. Ritonavir. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 11/10/2018.

Buckingham R (ed). Lopinavir. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 11/10/2018.

Joint Formulary Committee. Lopinavir with Ritonavir. British National Formulary [online]. London. BMJ Group and Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 11/10/2018.

Kaletra Tablet, Film Coated (AbbVie Inc.). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed 11/10/2018.

Disclaimer: This information is independently developed by MIMS based on Lopinavir + Ritonavir from various references and is provided for your reference only. Therapeutic uses, prescribing information and product availability may vary between countries. Please refer to MIMS Product Monographs for specific and locally approved prescribing information. Although great effort has been made to ensure content accuracy, MIMS shall not be held responsible or liable for any claims or damages arising from the use or misuse of the information contained herein, its contents or omissions, or otherwise. Copyright © 2020 MIMS. All rights reserved. Powered by MIMS.com
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