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2–42 | Clinical Manual for Management of the HIV-Infected Adult/2006
Table 2. Combinations of Antiretroviral Medications with Rifampin or Rifabutin: Contraindicated Combinations and Dose
Adjustments
Rifampin Rifabutin*
Nonnucleoside Reverse Transcriptase Inhibitors
Efavirenz** Rifampin dose unchanged, efavirenz dose
600-800 mg daily
Nevirapine Generally not recommended; despite 25-
50% reduction in nevirapine levels, 2 small
studies claim standard doses are effective
Delavirdine Never combine Never combine
Protease Inhibitors (Nonboosted)
Ritonavir May be used at standard doses; limited
clinical experience
No change in efavirenz dose
Increase rifabutin to 450 mg/day or 600 mg 3 times weekly
Use standard dose of nevirapine
Rifabutin 300 mg daily or 3 times weekly
Ritonavir at standard dose
Rifabutin 150 mg alternate days or 3 times weekly
Amprenavir/fosamprenavir Never combine PIs at standard dose
Rifabutin 150 mg/day or 300 mg 3 times weekly
Atazanavir Never combine Atazanavir at standard dose
Rifabutin 150 mg alternate days or 3 times weekly
Indinavir Never combine Increase indinavir to 1,000 mg every 8 hours
Rifabutin 150 mg/day or 300 mg 3 times weekly
Nelfinavir Never combine Increase nelfinavir to 1,000 mg every 8 hours
Rifabutin 150 mg/day or 300 mg 3 times weekly
Saquinavir Never combine Never combine
Ritonavir-Boosted Protease Inhibitors
Lopinavir/ritonavir (Kaletra) Lopinavir/ritonavir (3 capsules twice daily)
must be supplemented with additional
ritonavir 300 mg twice daily; limited
experience, not well tolerated
Saquinavir/ritonavir Due to high rates of hepatotoxicity this
combination should not be used
All other ritonavir-boosted PIs Should not be used (adequate dosing
regimens not defined)
Standard dose of lopinavir/ritonavir
Decrease rifabutin to 150 mg alternate days or 3 times weekly
Standard dose of lopinavir/ritonavir;
Decrease rifabutin to 150 mg alternate days or 3 times weekly
Standard dose of PI/ritonavir;
Decrease rifabutin to 150 mg alternate days or 3 times weekly
Source: Updated Guidelines for the Use of Rifamycins for the Treatment of Tuberculosis Among HIV-Infected Patients Taking Protease Inhibitors or Nonnucleoside Reverse Transcriptase Inhibitors. Updated January 20,
2004. (Nucleoside and nucleotide analogues are given in standard doses with either rifampin or rifabutin.)
* If available, rifabutin may be substituted for rifampin when TB treatment and antiretroviral therapy is combined.
** Avoid efavirenz during pregnancy or in women who may become pregnant during therapy. Both rifampin and rifabutin significantly reduce estrogen and progestin levels for women on hormonal contraceptives;
efavirenz raises estrogen levels moderately. Two forms of birth control including one barrier method and either a mid- to high-dose hormonal contraceptive or intrauterine device are most often recommended. Barrier
methods are also recommended for reducing HIV transmission in women who are infertile.