II. Indications

  1. HIV Infection (part of combination therapy)

III. Mechanism

IV. Medications

  1. Lopinavir/Ritonavir (Kaletra) Tablets: 100/25 and 200/50 mg
    1. Do not crush, cut or chew
  2. Lopinavir/Ritonavir (Kaletra) Solution: 80/20 mg/ml
    1. Give buffered Didanosine either at least 1 hour before or 2 hours after Lopinavir/Ritonavir
    2. Ritonavir solution contains Alcohol
      1. With Feeding Tube administration, use only silicone or PVC
      2. Avoid polyurethane tubing due to Alcohols in solution

V. Dosing

  1. General
    1. Better tolerated when taken with food
    2. Typically used in its boosted form with Ritonavir (combined in Kaletra)
    3. Use in combination with other Antiretrovirals
  2. Adult
    1. Lopinavir/Ritonavir 800/200 mg orally once daily
    2. Lopinavir/Ritonavir 400/100 mg orally twice daily
      1. Dose twice daily if risk of resistance (>=3 resistance genes), pregnancy
      2. Dose twice daily if on Carbamazepine, Phenobarbital, Phenytoin
      3. Increase dose to 500/125 (tabs) or 533/133 (solution) twice daily if on Efavirenz, Nevirapine, Nelfinavir
  3. Child (off-label, but per guidelines)
    1. Doses are based on Lopinavir component (assumes use of Kaletra, combined Lopinavir with Ritonavir)
    2. Age 14 days to 12 months: Lopinavir 300 mg/m2
      1. Lopinavir 16 mg/kg orally twice daily
    3. Age 1 to 18 years
      1. Standard Dosing: All Lopinavir doses based on 300 mg/m2
        1. Weight: 13 to 15 kg: Lopinavir 13 mg/kg orally twice daily
        2. Weight: 15 to 45 kg: Lopinavir 11 mg/kg (up to 400 mg) orally twice daily
      2. Treatment-Naive Lower Dosing: All Lopinavir doses based on 230 mg/m2
        1. Weight: 13 to 15 kg: Lopinavir 12 mg/kg orally twice daily
        2. Weight: 15 to 45 kg: Lopinavir 10 mg/kg (up to 400 mg) orally twice daily
  4. Pregnancy
    1. Lopinavir/Ritonavir 400/100 mg orally twice daily
    2. Consider increasing to 600/150 mg orally twice daily in second and third trimesters
      1. Treatment experienced with prior Protease Inhibitor
      2. Viral load >50 copies/ml
      3. Higher dose directed by serum Lopinavir levels

VI. Adverse Effects

  1. See Protease Inhibitor for adverse effects attributed to the class
  2. Pancreatitis
    1. May be life threatening
  3. Cardiovascular
    1. Prolonged use increases risk of Myocardial Infarction
    2. PR Prolongation
    3. QT Prolongation

VII. Safety

  1. Avoid in Lactation
  2. Pregnancy
    1. Pregnancy registry exists
    2. Considered an alternative Protease Inhibitor for pregnant women, when other preferred agents are contraindicated

VIII. Drug Interactions

  1. See dosing above for interactions that lower Lopinavir/Ritonavir serum levels (and require twice daily and/or higher dose)
  2. Tenofovir
    1. Lopinavir/Ritonavir increases Tenofovir levels
  3. Oral Contraceptives (OCP)
    1. Decreased OCP effectiveness
  4. Statins
    1. Rosuvastatin dose limited to 10 mg
    2. Atorvastatin limited to lowest effective dose
  5. Voriconazole
    1. Ritonavir decreases Voriconazole levels and efficacy
    2. Avoid concurrent use if possible
  6. Opioids
    1. Methadone dose may need to be increased
    2. Fentanyl serum levels may be increased
  7. Clarithromycin
    1. Decrease Clarithromycin dose if Creatinine Clearance <60 ml/min
  8. Seizure medications
    1. Some antiepileptic agents lower Lopinavir levels (see dosing above)
    2. Monitor levels of Lamotrigine, Phenytoin and Valproic Acid

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