Ritocom

Lopinavir and Ritonavir is a co-formulation of lopinavir and ritonavir. Lopinavir is an inhibitor of the HIV-1 protease. As co-formulated in lopinavir and ritonavir, ritonavir inhibits the CYP3A-mediated metabolism of lopinavir, thereby providing increased plasma levels of lopinavir.
Lopinavir is chemically designated as [1S-[1R*,(R*),3R*,4R*]]-N-[4-[[(2,6-dimethylphenoxy)acetyl]amino]-3-hydroxy-5-phenyl-1-(phenylmethyl)pentyl]tetrahydro-alpha-(1-methylethyl)-2-oxo-1(2H)-pyrimidineacetamide. Its molecular formula is C₃₇H₄₈N₄O₅, and its molecular weight is 628.80. Lopinavir is a white to light tan powder. It is freely soluble in methanol and ethanol, soluble in isopropanol and practically insoluble in water.
Ritonavir is chemically designated as 10-hydroxy-2-methyl-5-(1-methylethyl)-1-[2-(1-methylethyl)-4-thiazolyl]-3,6-dioxo-8,11-bis(phenylmethyl)-2,4,7,12-tetraazatridecan-13-oic acid, 5-thiazolylmethyl ester, [5S-(5R*,8R*,10R*,11R*)]. Its molecular formula is C₃₇H₄₈N₆O₅S₂, and its molecular weight is 720.95. Ritonavir is a white to light tan powder. It is freely soluble in methanol and ethanol, soluble in isopropanol and practically insoluble in water.

Pharmacology: Mechanism of Action: Lopinavir is an antiviral drug (see Microbiology as follows).
Pharmacodynamics: Clinical Studies: Patients Without Prior Antiretroviral Therapy: Study 863: Lopinavir and Ritonavir Capsules twice daily + stavudine + lamivudine compared to nelfinavir three-times-daily + stavudine + lamivudine: Study 863 was a randomized, double-blind, multicenter trial comparing treatment with lopinavir and ritonavir capsules (400/100 mg twice daily) plus stavudine and lamivudine versus nelfinavir (750 mg three-times daily) plus stavudine and lamivudine in 653 antiretroviral treatment naïve patients. Patients had a mean age of 38 years (range: 19 to 84), 57% were Caucasian, and 80% were male. Mean baseline CD4⁺ cell count was 259 cells/mm³ (range: 2 to 949 cells/mm³) and mean baseline plasma HIV-1 RNA was 4.9 log₁₀ copies/mL (range: 2.6 to 6.8 log₁₀ copies/mL).
Treatment response and outcomes of randomized treatment are presented in Table 1. (See Table 1.)

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Overall discontinuation through Week 48, including patients who discontinued subsequent to virologic failure, was 17% in the lopinavir and ritonavir arm and 24% in the nelfinavir arm.
Through 48 weeks of therapy, there was a statistically significantly higher proportion of patients in the lopinavir and ritonavir arm compared to the nelfinavir arm with HIV-1 RNA < 400 copies/mL (75% vs. 62%, respectively) and HIV-1 RNA < 50 copies/mL (67% vs. 52%, respectively). Treatment response by baseline HIV-1 RNA level subgroups is presented in Table 2. (See Table 2.)

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Through 48 weeks of therapy, the mean increase from baseline in CD4⁺ cell count was 207 cells/mm³ for the lopinavir and ritonavir arm and 195 cells/mm³ for the nelfinavir arm.
Study 730: Lopinavir and Ritonavir Tablets once daily + tenofovir DF + emtricitabine compared to Lopinavir and Ritonavir Tablets twice daily + tenofovir DF + emtricitabine: Study 730 was a randomized, open-label, multicenter trial comparing treatment with lopinavir and ritonavir 800/200 mg once daily plus tenofovir DF and emtricitabine versus lopinavir and ritonavir 400/100 mg twice daily plus tenofovir DF and emtricitabine in 664 antiretroviral treatment-naïve patients. Patients were randomized in a 1:1 ratio to receive either lopinavir and ritonavir 800/200 mg once daily (n = 333) or lopinavir and ritonavir 400/100 mg twice daily (n = 331). Further stratification within each group was 1:1 (tablet vs. capsule). Patients administered the capsule were switched to the tablet formulation at Week 8 and maintained on their randomized dosing schedule. Patients were administered emtricitabine 200 mg once daily and tenofovir DF 300 mg once daily. Mean age of patients enrolled was 39 years (range: 19 to 71); 75% were Caucasian, and 78% were male. Mean baseline CD4⁺ cell count was 216 cells/mm³ (range: 20 to 775 cells/mm³) and mean baseline plasma HIV-1 RNA was 5.0 log₁₀ copies/mL (range: 1.7 to 7.0 log₁₀ copies/mL).
Treatment response and outcomes of randomized treatment through Week 48 are presented in Table 3. (See Table 3.)

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Through 48 weeks of therapy, 78% in the lopinavir and ritonavir once daily arm and 77% in the lopinavir and ritonavir twice daily arm achieved and maintained HIV-1 RNA < 50 copies/mL (95% confidence interval for the difference, -5.9% to 6.8%). Mean CD4⁺ cell count increases at Week 48 were 186 cells/mm³ for the lopinavir and ritonavir once daily arm and 198 cells/mm³ for the lopinavir and ritonavir twice daily arm.
Patients With Prior Antiretroviral Therapy: Study 888: Lopinavir and Ritonavir Capsules twice daily + nevirapine + NRTIs compared to investigator-selected protease inhibitor(s) + nevirapine + NRTIs: Study 888 was a randomized, open-label, multicenter trial comparing treatment with lopinavir and ritonavir capsules (400/100 mg twice daily) plus nevirapine and nucleoside reverse transcriptase inhibitors versus investigator-selected protease inhibitor(s) plus nevirapine and nucleoside reverse transcriptase inhibitors in 288 single protease inhibitor-experienced, non-nucleoside reverse transcriptase inhibitor (NNRTI)-naïve patients. Patients had a mean age of 40 years (range: 18 to 74), 68% were Caucasian, and 86% were male. Mean baseline CD4⁺cell count was 322 cells/mm³ (range: 10 to 1059 cells/mm³) and mean baseline plasma HIV-1 RNA was 4.1 log₁₀ copies/mL (range: 2.6 to 6.0 log₁₀ copies/mL).
Treatment response and outcomes of randomized treatment through Week 48 are presented in Table 4. (See Table 4.)

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Through 48 weeks of therapy, there was a statistically significantly higher proportion of patients in the lopinavir and ritonavir arm compared to the investigator-selected protease inhibitor(s) arm with HIV-1 RNA < 400 copies/mL (57% vs. 33%, respectively).
Through 48 weeks of therapy, the mean increase from baseline in CD4⁺ cell count was 111 cells/mm³ for the lopinavir and ritonavir arm and 112 cells/mm³ for the investigator-selected protease inhibitor(s) arm.
Other Studies Supporting Approval: Study 720: Lopinavir and Ritonavir twice daily + stavudine + lamivudine.
Study 765: Lopinavir and Ritonavir twice daily + nevirapine + NRTIs.
Study 720 (patients without prior antiretroviral therapy) and study 765 (patients with prior protease inhibitor therapy) were randomized, blinded, multi-center trials evaluating treatment with lopinavir and ritonavir at up to three dose levels (200/100 mg twice daily [720 only], 400/100 mg twice daily, and 400/200 mg twice daily). In Study 720, all patients switched to 400/100 mg twice daily between Weeks 48 to 72. Patients in study 720 had a mean age of 35 years, 70% were Caucasian, and 96% were male, while patients in study 765 had a mean age of 40 years, 73% were Caucasian, and 90% were male. Mean (range) baseline CD4⁺ cell counts for patients in study 720 and study 765 were 338 (3 to 918) and 372 (72 to 807) cells/mm³, respectively. Mean (range) baseline plasma HIV-1 RNA levels for patients in study 720 and study 765 were 4.9 (3.3 to 6.3) and 4.0 (2.9 to 5.8) log₁₀ copies/mL, respectively.
Through 360 weeks of treatment in study 720, the proportion of patients with HIV-1 RNA < 400 (< 50) copies/mL was 61% (59%) [n = 100]. Among patients completing 360 weeks of treatment with CD4⁺ cell count measurements [n=60], the mean (median) increase in CD4⁺ cell count was 501 (457) cells/mm³. Thirty-nine patients (39%) discontinued the study, including 13 (13%) discontinuations due to adverse reactions and 1 (1%) death.
Through 144 weeks of treatment in study 765, the proportion of patients with HIV-1 RNA < 400 (< 50) copies/mL was 54% (50%) [n = 70], and the corresponding mean increase in CD4⁺ cell count was 212 cells/mm³. Twenty-seven patients (39%) discontinued the study, including 5 (7%) discontinuations secondary to adverse reactions and 2 (3%) deaths.
Pediatric Studies: Study 1030 was an open-label, multicenter, dose-finding trial evaluating the pharmacokinetic profile, tolerability, safety and efficacy of lopinavir and ritonavir oral solution containing lopinavir 80 mg/mL and ritonavir 20 mg/mL at a dose of 300/75 mg/m² twice daily plus 2 NRTIs in HIV-1 infected infants ≥14 days and <6 months of age.
Ten infants, ≥14 days and <6 wks of age, were enrolled at a median (range) age of 5.7 (3.6 to 6.0) weeks and all completed 24 weeks. At entry, median (range) HIV-1 RNA was 6.0 (4.7 to 7.2) log₁₀ copies/mL. Seven of 10 infants had HIV-1 RNA <400 copies/mL at Week 24. At entry, median (range) CD4⁺ percentage was 41 (16 to 59) with a median decrease of 1% (95% CI: -10, 18) from baseline to week 24 in 6 infants with available data.
Twenty-one infants, between 6 weeks and 6 months of age, were enrolled at a median (range) age of 14.7 (6.9 to 25.7) weeks and 19 of 21 infants completed 24 weeks. At entry, median (range) HIV RNA level was 5.8 (3.7 to 6.9) log₁₀ copies/mL. Ten of 21 infants had HIV RNA <400 copies/mL at Week 24. At entry, the median (range) CD4⁺ percentage was 32 (11 to 54) with a median increase of 4% (95% CI: - 1, 9) from baseline to week 24 in 19 infants with available data.
See Pharmacokinetics as follows for pharmacokinetic results.
Study 940 was an open-label, multicenter trial evaluating the pharmacokinetic profile, tolerability, safety and efficacy of lopinavir and ritonavir oral solution containing lopinavir 80 mg/mL and ritonavir 20 mg/mL in 100 antiretroviral naïve (44%) and experienced (56%) pediatric patients. All patients were non-nucleoside reverse transcriptase inhibitor naïve. Patients were randomized to either 230 mg lopinavir/57.5 mg ritonavir per m² or 300 mg lopinavir/75 mg ritonavir per m². Naïve patients also received lamivudine and stavudine. Experienced patients received nevirapine plus up to two nucleoside reverse transcriptase inhibitors.
Safety, efficacy and pharmacokinetic profiles of the two dose regimens were assessed after three weeks of therapy in each patient. After analysis of these data, all patients were continued on the 300 mg lopinavir/75 mg ritonavir per m² dose. Patients had a mean age of 5 years (range 6 months to 12 years) with 14% less than 2 years. Mean baseline CD4⁺ cell count was 838 cells/mm³ and mean baseline plasma HIV-1 RNA was 4.7 log₁₀ copies/mL.
Through 48 weeks of therapy, the proportion of patients who achieved and sustained an HIV-1 RNA < 400 copies/mL was 80% for antiretroviral naïve patients and 71% for antiretroviral experienced patients. The mean increase from baseline in CD4⁺ cell count was 404 cells/mm³ for antiretroviral naïve and 284 cells/mm³ for antiretroviral experienced patients treated through 48 weeks. At 48 weeks, two patients (2%) had prematurely discontinued the study. One antiretroviral naïve patient prematurely discontinued secondary to an adverse reaction, while one antiretroviral experienced patient prematurely discontinued secondary to an HIV-1 related event.
Dose selection in pediatric patients was based on the following: Among patients 14 days to 6 months of age receiving 300/75 mg/m² twice daily without nevirapine, plasma concentrations were lower than those observed in adults or in older children. This dose resulted in HIV-1 RNA < 400 copies/mL in 55% of patients (70% in those initiating treatment at <6 weeks of age).
Among patients 6 months to 12 years of age, the 230/57.5 mg/m² oral solution twice daily regimen without nevirapine and the 300/75 mg/m² oral solution twice daily regimen with nevirapine provided lopinavir plasma concentrations similar to those obtained in adult patients receiving the 400/100 mg twice daily regimen (without nevirapine). These doses resulted in treatment benefit (proportion of patients with HIV-1 RNA < 400 copies/mL) similar to that seen in the adult clinical trials.
Among patients 12 to 18 years of age receiving 400/100 mg/m² or 480/120 mg/m² (with efavirenz) twice daily, plasma concentrations were 60 to 100% higher than among 6 to 12 year old patients receiving 230/57.5 mg/m². Mean apparent clearance was similar to that observed in adult patients receiving standard dose and in patients 6 to 12 years of age. Although changes in HIV-1 RNA in patients with prior treatment failure were less than anticipated, the pharmacokinetic data supports use of similar dosing as in patients 6 to 12 years of age, not to exceed the recommended adult dose.
For all age groups, the body surface area dosing was converted to body weight dosing using the actual patient dose.
Pharmacokinetics: The pharmacokinetic properties of lopinavir co-administered with ritonavir have been evaluated in healthy adult volunteers and in HIV-1 infected patients; no substantial differences were observed between the two groups. Lopinavir is essentially completely metabolized by CYP3A. Ritonavir inhibits the metabolism of lopinavir, thereby increasing the plasma levels of lopinavir. Across studies, administration of lopinavir and ritonavir 400/100 mg twice daily yields mean steady-state lopinavir plasma concentrations 15- to 20-fold higher than those of ritonavir in HIV-1 infected patients. The plasma levels of ritonavir are less than 7% of those obtained after the ritonavir dose of 600 mg twice daily. The in vitro antiviral EC₅₀ of lopinavir is approximately 10-fold lower than that of ritonavir. Therefore, the antiviral activity of lopinavir and ritonavir is due to lopinavir.
Figure displays the mean steady-state plasma concentrations of lopinavir and ritonavir after lopinavir and ritonavir 400/100 mg twice daily with food for 3 weeks from a pharmacokinetic study in HIV-1 infected adult subjects (n = 19). (See figure.)

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Absorption: In a pharmacokinetic study in HIV-1 positive subjects (n = 19), multiple dosing with 400/100 mg lopinavir and ritonavir twice daily with food for 3 weeks produced a mean ± SD lopinavir peak plasma concentration (C_max) of 9.8 ± 3.7 mcg/mL, occurring approximately 4 hours after administration. The mean steady-state trough concentration prior to the morning dose was 7.1 ± 2.9 mcg/mL and minimum concentration within a dosing interval was 5.5 ± 2.7 mcg/mL. Lopinavir AUC over a 12 hour dosing interval averaged 92.6 ± 36.7 mcg•h/mL. The absolute bioavailability of lopinavir co-formulated with ritonavir in humans has not been established. Under nonfasting conditions (500 kcal, 25% from fat), lopinavir concentrations were similar following administration of lopinavir and ritonavir co-formulated capsules and oral solution. When administered under fasting conditions, both the mean AUC and C_max of lopinavir were 22% lower for the lopinavir and ritonavir oral solution relative to the capsule formulation.
Plasma concentrations of lopinavir and ritonavir after administration of two 200/50 mg lopinavir and ritonavir tablets are similar to three 133.3/33.3 mg lopinavir and ritonavir capsules under fed conditions with less pharmacokinetic variability.
Effects of Food on Oral Absorption: Lopinavir and Ritonavir Tablets: No clinically significant changes in C_max and AUC were observed following administration of lopinavir and ritonavir tablets under fed conditions compared to fasted conditions. Relative to fasting, administration of lopinavir and ritonavir tablets with a moderate fat meal (500 to 682 Kcal, 23 to 25% calories from fat) increased lopinavir AUC and C_max by 26.9% and 17.6%, respectively. Relative to fasting, administration of lopinavir and ritonavir tablets with a high fat meal (872 Kcal, 56% from fat) increased lopinavir AUC by 18.9% but not C_max. Therefore, lopinavir and ritonavir tablets may be taken with or without food.
Distribution: At steady state, lopinavir is approximately 98 to 99% bound to plasma proteins. Lopinavir binds to both alpha-1-acid glycoprotein (AAG) and albumin; however, it has a higher affinity for AAG. At steady state, lopinavir protein binding remains constant over the range of observed concentrations after 400/100 mg lopinavir and ritonavir twice daily, and is similar between healthy volunteers and HIV-1 positive patients.
Metabolism: In vitro experiments with human hepatic microsomes indicate that lopinavir primarily undergoes oxidative metabolism. Lopinavir is extensively metabolized by the hepatic cytochrome P450 system, almost exclusively by the CYP3A isozyme. Ritonavir is a potent CYP3A inhibitor which inhibits the metabolism of lopinavir, and therefore increases plasma levels of lopinavir. A ¹⁴C-lopinavir study in humans showed that 89% of the plasma radioactivity after a single 400/100 mg lopinavir and ritonavir dose was due to parent drug. At least 13 lopinavir oxidative metabolites have been identified in man. Ritonavir has been shown to induce metabolic enzymes, resulting in the induction of its own metabolism. Pre-dose lopinavir concentrations decline with time during multiple dosing, stabilizing after approximately 10 to 16 days.
Elimination: Following a 400/100 mg ¹⁴C-lopinavir/ritonavir dose, approximately 10.4 ± 2.3% and 82.6 ± 2.5% of an administered dose of ¹⁴C-lopinavir can be accounted for in urine and feces, respectively, after 8 days. Unchanged lopinavir accounted for approximately 2.2 and 19.8% of the administered dose in urine and feces, respectively. After multiple dosing, less than 3% of the lopinavir dose is excreted unchanged in the urine. The apparent oral clearance (CL/F) of lopinavir is 5.98 ± 5.75 L/hr (mean ± SD, n = 19).
Once Daily Dosing: The pharmacokinetics of once daily lopinavir and ritonavir have been evaluated in HIV-1 infected subjects naïve to antiretroviral treatment. Lopinavir and Ritonavir 800/200 mg was administered in combination with emtricitabine 200 mg and tenofovir DF 300 mg as part of a once daily regimen. Multiple dosing of 800/200 mg lopinavir and ritonavir once daily for 4 weeks with food (n = 24) produced a mean ± SD lopinavir peak plasma concentration (C_max) of 11.8 ± 3.7 mcg/mL, occurring approximately 6 hours after administration. The mean steady-state lopinavir trough concentration prior to the morning dose was 3.2 ± 2.1 mcg/mL and minimum concentration within a dosing interval was 1.7 ± 1.6 mcg/mL. Lopinavir AUC over a 24 hour dosing interval averaged 154.1 ± 61.4 mcg·h/mL.
Effects on Electrocardiogram: QTcF interval was evaluated in a randomized, placebo and active (moxifloxacin 400 mg once daily) controlled crossover study in 39 healthy adults, with 10 measurements over 12 hours on Day 3. The maximum mean time-matched (95% upper confidence bound) differences in QTcF interval from placebo after baseline-correction were 5.3 (8.1) and 15.2 (18.0) mseconds (msec) for 400/100 mg twice daily and supratherapeutic 800/200 mg twice daily lopinavir and ritonavir, respectively. Lopinavir and Ritonavir 800/200 mg twice daily resulted in a Day 3 mean C_max approximately 2-fold higher than the mean C_max observed with the approved once daily and twice daily lopinavir and ritonavir doses at steady state.
PR interval prolongation was also noted in subjects receiving lopinavir and ritonavir in the same study on Day 3. The maximum mean (95% upper confidence bound) difference from placebo in the PR interval after baseline-correction were 24.9 (21.5, 28.3) and 31.9 (28.5, 35.3) msec for 400/100 mg twice daily and supratherapeutic 800/200 mg twice daily lopinavir and ritonavir, respectively. (See PR and QT Interval Prolongation under Precautions).
Special Populations: Gender, Race and Age: No gender related pharmacokinetic differences have been observed in adult patients. No clinically important pharmacokinetic differences due to race have been identified. Lopinavir pharmacokinetics have not been studied in elderly patients.
Pediatric Patients: The pharmacokinetics of lopinavir and ritonavir oral solution 300/75 mg/m² twice daily and 230/57.5 mg/m² twice daily have been studied in a total of 53 pediatric patients in Study 940, ranging in age from 6 months to 12 years [see Clinical Studies: Pediatric Studies as previously mentioned]. The 230/57.5 mg/m² twice daily regimen without nevirapine and the 300/75 mg/m² twice daily regimen with nevirapine provided lopinavir plasma concentrations similar to those obtained in adult patients receiving the 400/100 mg twice daily regimen (without nevirapine).
The mean steady-state lopinavir AUC, C_max, and C_min were 72.6 ± 31.1 mcg•h/mL, 8.2 ± 2.9 and 3.4 ± 2.1 mcg/mL, respectively after lopinavir and ritonavir oral solution 230/57.5 mg/m² twice daily without nevirapine (n = 12), and were 85.8 ± 36.9 mcg•h/mL, 10.0 ± 3.3 and 3.6 ± 3.5 mcg/mL, respectively, after 300/75 mg/m² twice daily with nevirapine (n = 12). The nevirapine regimen was 7 mg/kg twice daily (6 months to 8 years) or 4 mg/kg twice daily (> 8 years).
The pharmacokinetics of lopinavir and ritonavir oral solution at approximately 300/75 mg/m² twice daily have also been evaluated in infants at approximately 6 weeks of age (n = 9) and between 6 weeks and 6 months of age (n = 18) in Study 1030. The mean steady-state lopinavir AUC₁₂, C_max, and C₁₂ were 43.4 ± 14.8 mcg•h/mL, 5.2 ± 1.8 mcg/mL and 1.9 ± 1.1 mcg/mL, respectively, in infants at approximately 6 weeks of age, and 74.5 ± 37.9 mcg•h/mL, 9.4 ± 4.9 and 3.1 ± 1.8 mcg/mL, respectively, in infants between 6 weeks and 6 months of age after lopinavir and ritonavir oral solution was administered at approximately 300/75 mg/m² twice daily without concomitant NNRTI therapy.
The pharmacokinetics of lopinavir and ritonavir soft gelatin capsule and oral solution (Group 1: 400/100 mg/m² twice daily + 2 NRTIs; Group 2: 480/120 mg/m² twice daily + ≥ 1 NRTI + 1 NNRTI) have been evaluated in children and adolescents age ≥2 years to < 18 years of age who had failed prior therapy (n=26) in Study 1038. Lopinavir and Ritonavir doses of 400/100 and 480/120 mg/m² resulted in high lopinavir exposure, as almost all subjects had lopinavir AUC₁₂ above 100 mcg•h/mL. Both groups of subjects also achieved relatively high average minimum lopinavir concentrations.
Lopinavir and Ritonavir once daily has not been evaluated in pediatric patients.
Renal Impairment: Lopinavir pharmacokinetics have not been studied in patients with renal impairment; however, since the renal clearance of lopinavir is negligible, a decrease in total body clearance is not expected in patients with renal impairment.
Hepatic Impairment: Lopinavir is principally metabolized and eliminated by the liver. Multiple dosing of lopinavir and ritonavir 400/100 mg twice daily to HIV-1 and HCV co-infected patients with mild to moderate hepatic impairment (n = 12) resulted in a 30% increase in lopinavir AUC and 20% increase in C_max compared to HIV-1 infected subjects with normal hepatic function (n = 12). Additionally, the plasma protein binding of lopinavir was statistically significantly lower in both mild and moderate hepatic impairment compared to controls (99.09 vs. 99.31%, respectively). Caution should be exercised when administering lopinavir and ritonavir to subjects with hepatic impairment. Lopinavir and Ritonavir has not been studied in patients with severe hepatic impairment (see Hepatotoxicity and Hepatic Impairment under Precautions).
Drug Interactions: Lopinavir and Ritonavir is an inhibitor of the P450 isoform CYP3A in vitro. Co-administration of lopinavir and ritonavir and drugs primarily metabolized by CYP3A may result in increased plasma concentrations of the other drug, which could increase or prolong its therapeutic and adverse effects (see Contraindications and Interactions).
Lopinavir and Ritonavir does not inhibit CYP2D6, CYP2C9, CYP2C19, CYP2E1, CYP2B6 or CYP1A2 at clinically relevant concentrations.
Lopinavir and Ritonavir has been shown in vivo to induce its own metabolism and to increase the biotransformation of some drugs metabolized by cytochrome P450 enzymes and by glucuronidation.
Lopinavir and Ritonavir is metabolized by CYP3A. Drugs that induce CYP3A activity would be expected to increase the clearance of lopinavir, resulting in lowered plasma concentrations of lopinavir. Although not noted with concurrent ketoconazole, co-administration of lopinavir and ritonavir and other drugs that inhibit CYP3A may increase lopinavir plasma concentrations.
Drug interaction studies were performed with lopinavir and ritonavir and other drugs likely to be co-administered and some drugs commonly used as probes for pharmacokinetic interactions. The effects of co-administration of lopinavir and ritonavir on the AUC, C_max and C_min are summarized in Table 5 (effect of other drugs on lopinavir) and Table 6 (effect of lopinavir and ritonavir on other drugs). The effects of other drugs on ritonavir are not shown since they generally correlate with those observed with lopinavir (if lopinavir concentrations are decreased, ritonavir concentrations are decreased) unless otherwise indicated in the table footnotes. For information regarding clinical recommendations, see Table 17 in Interactions. (See Table 5 and Table 6.)

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Toxicology: Nonclinical Toxicology: Carcinogenesis, Mutagenesis, Impairment of Fertility: Lopinavir/ritonavir combination was evaluated for carcinogenic potential by oral gavage administration to mice and rats for up to 104 weeks. Results showed an increase in the incidence of benign hepatocellular adenomas and an increase in the combined incidence of hepatocellular adenomas plus carcinoma in both males and females in mice and males in rats at doses that produced approximately 1.6 to 2.2 times (mice) and 0.5 times (rats) the human exposure (based on AUC_0-24hr measurement) at the recommended dose of 400/100 mg lopinavir and ritonavir twice daily. Administration of lopinavir/ritonavir did not cause a statistically significant increase in the incidence of any other benign or malignant neoplasm in mice or rats.
Carcinogenicity studies in mice and rats have been carried out on ritonavir. In male mice, there was a dose dependent increase in the incidence of both adenomas and combined adenomas and carcinomas in the liver. Based on AUC measurements, the exposure at the high dose was approximately 4-fold for males that of the exposure in humans with the recommended therapeutic dose (400/100 mg lopinavir and ritonavir twice daily). There were no carcinogenic effects seen in females at the dosages tested. The exposure at the high dose was approximately 9-fold for the females that of the exposure in humans. There were no carcinogenic effects in rats. In this study, the exposure at the high dose was approximately 0.7-fold that of the exposure in humans with the 400/100 mg lopinavir and ritonavir twice daily regimen. Based on the exposures achieved in the animal studies, the significance of the observed effects is not known. However, neither lopinavir nor ritonavir was found to be mutagenic or clastogenic in a battery of in vitro and in vivo assays including the Ames bacterial reverse mutation assay using S. typhimurium and E. coli, the mouse lymphoma assay, the mouse micronucleus test and chromosomal aberration assays in human lymphocytes.
Lopinavir in combination with ritonavir at a 2:1 ratio produced no effects on fertility in male and female rats at levels of 10/5, 30/15 or 100/50 mg/kg/day. Based on AUC measurements, the exposures in rats at the high doses were approximately 0.7-fold for lopinavir and 1.8-fold for ritonavir of the exposures in humans at the recommended therapeutic dose (400/100 mg twice daily).
Microbiology: Mechanism of Action: Lopinavir, an inhibitor of the HIV-1 protease, prevents cleavage of the Gag-Pol polyprotein, resulting in the production of immature, non-infectious viral particles.
Antiviral Activity: The antiviral activity of lopinavir against laboratory HIV strains and clinical HIV-1 isolates was evaluated in acutely infected lymphoblastic cell lines and peripheral blood lymphocytes, respectively. In the absence of human serum, the mean 50% effective concentration (EC₅₀) values of lopinavir against five different HIV-1 subtype B laboratory strains ranged from 10 to 27 nM (0.006 to 0.017 mcg/mL, 1 mcg/mL = 1.6 µM) and ranged from 4 to 11 nM (0.003 to 0.007 mcg/mL) against several HIV-1 subtype B clinical isolates (n = 6). In the presence of 50% human serum, the mean EC₅₀ values of lopinavir against these five HIV-1 laboratory strains ranged from 65 to 289 nM (0.04 to 0.18 mcg/mL), representing a 7- to 11-fold attenuation. Combination antiviral drug activity studies with lopinavir in cell cultures demonstrated additive to antagonistic activity with nelfinavir and additive to synergistic activity with amprenavir, atazanavir, indinavir, saquinavir and tipranavir. The EC₅₀ values of lopinavir against three different HIV-2 strains ranged from 12 to 180 nM (0.008 to 113 mcg/mL).
Resistance: HIV-1 isolates with reduced susceptibility to lopinavir have been selected in cell culture. The presence of ritonavir does not appear to influence the selection of lopinavir-resistant viruses in cell culture.
The selection of resistance to lopinavir and ritonavir in antiretroviral treatment naïve patients has not yet been characterized. In a study of 653 antiretroviral treatment naïve patients (Study 863), plasma viral isolates from each patient on treatment with plasma HIV-1 RNA > 400 copies/mL at Week 24, 32, 40 and/or 48 were analyzed. No evidence of resistance to lopinavir and ritonavir was observed in 37 evaluable lopinavir and ritonavir-treated patients (0%). Evidence of genotypic resistance to nelfinavir, defined as the presence of the D30N and/or L90M substitution in HIV-1 protease, was observed in 25/76 (33%) of evaluable nelfinavir-treated patients. The selection of resistance to lopinavir and ritonavir in antiretroviral treatment naïve pediatric patients (Study 940) appears to be consistent with that seen in adult patients (Study 863).
Resistance to lopinavir and ritonavir has been noted to emerge in patients treated with other protease inhibitors prior to lopinavir and ritonavir therapy. In studies of 227 antiretroviral treatment naïve and protease inhibitor experienced patients, isolates from 4 of 23 patients with quantifiable (> 400 copies/mL) viral RNA following treatment with lopinavir and ritonavir for 12 to 100 weeks displayed significantly reduced susceptibility to lopinavir compared to the corresponding baseline viral isolates. Three of these patients had previously received treatment with a single protease inhibitor (indinavir, nelfinavir, or saquinavir) and one patient had received treatment with multiple protease inhibitors (indinavir, ritonavir, and saquinavir). All four of these patients had at least 4 substitutions associated with protease inhibitor resistance immediately prior to lopinavir and ritonavir therapy. Following viral rebound, isolates from these patients all contained additional substitutions, some of which are recognized to be associated with protease inhibitor resistance. However, there are insufficient data at this time to identify patterns of lopinavir-associated substitutions in isolates from patients on lopinavir and ritonavir therapy. The assessment of these patterns is under study.
Cross-resistance - Preclinical Studies: Varying degrees of cross-resistance have been observed among HIV-1 protease inhibitors. Little information is available on the cross-resistance of viruses that developed decreased susceptibility to lopinavir during lopinavir and ritonavir therapy.
The antiviral activity in cell culture of lopinavir against clinical isolates from patients previously treated with a single protease inhibitor was determined. Isolates that displayed > 4-fold reduced susceptibility to nelfinavir (n = 13) and saquinavir (n = 4), displayed < 4-fold reduced susceptibility to lopinavir. Isolates with > 4-fold reduced susceptibility to indinavir (n = 16) and ritonavir (n = 3) displayed a mean of 5.7- and 8.3-fold reduced susceptibility to lopinavir, respectively. Isolates from patients previously treated with two or more protease inhibitors showed greater reductions in susceptibility to lopinavir, as described in the following paragraph.
Clinical Studies - Antiviral Activity of lopinavir and ritonavir in Patients with Previous Protease Inhibitor Therapies: The clinical relevance of reduced susceptibility in cell culture to lopinavir has been examined by assessing the virologic response to lopinavir and ritonavir therapy in treatment-experienced patients, with respect to baseline viral genotype in three studies and baseline viral phenotype in one study.
Virologic response to lopinavir and ritonavir has been shown to be affected by the presence of three or more of the following amino acid substitutions in protease at baseline: L10F/I/R/V, K20M/N/R, L24I, L33F, M36I, I47V, G48V, I54L/T/V, V82A/C/F/S/T, and I84V. Table 7 shows the 48-week virologic response (HIV-1 RNA <400 copies/mL) according to the number of the above protease inhibitor resistance mutations at baseline in studies 888 and 765 (see Pharmacology: Pharmacodynamics: Clinical Studies: Patients with Prior Antiretroviral Therapy and Other Studies Supporting Approval as previously mentioned and study 957 (see as follows). (See Table 7.)

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Virologic response to lopinavir and ritonavir therapy with respect to phenotypic susceptibility to lopinavir at baseline was examined in Study 957. In this study 56 NNRTI-naïve patients with HIV-1 RNA >1,000 copies/mL despite previous therapy with at least two protease inhibitors selected from indinavir, nelfinavir, ritonavir, and saquinavir were randomized to receive one of two doses of lopinavir and ritonavir in combination with efavirenz and nucleoside reverse transcriptase inhibitors (NRTIs). The EC₅₀ values of lopinavir against the 56 baseline viral isolates ranged from 0.5- to 96-fold the wild-type EC₅₀ value. Fifty-five percent (31/56) of these baseline isolates displayed >4-fold reduced susceptibility to lopinavir. These 31 isolates had a median reduction in lopinavir susceptibility of 18-fold. Response to therapy by baseline lopinavir susceptibility is shown in Table 8. (See Table 8.)

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Lopinavir and Ritonavir tablet is indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection.
The following points should be considered when initiating therapy with lopinavir and ritonavir tablet: The use of other active agents with lopinavir and ritonavir tablet is associated with a greater likelihood of treatment response (see Pharmacology: Microbiology under Actions and Pharmacology: Pharmacodynamics: Clinical Studies under Actions).
Genotypic or phenotypic testing and/or treatment history should guide the use of lopinavir and ritonavir tablet (see Pharmacology: Microbiology under Actions). The number of baseline primary protease inhibitor mutations affects the virologic response to lopinavir and ritonavir tablet (see Pharmacology: Microbiology under Actions).
Once daily administration of lopinavir and ritonavir tablet is not recommended for therapy-experienced adult patients or any pediatric patients.

Lopinavir and Ritonavir tablets may be taken with or without food. The tablets should be swallowed whole and not chewed, broken, or crushed.
Adult Patients: Therapy-Naïve Patients: Lopinavir and Ritonavir tablets 400/100 mg (given as two 200/50 mg tablets) twice daily taken with or without food.
Lopinavir and Ritonavir tablets 800/200 mg (given as four 200/50 mg tablets) once daily taken with or without food.
Therapy-Experienced Patients: Once daily administration of lopinavir and ritonavir tablet is not recommended in therapy-experienced patients.
Lopinavir and Ritonavir tablets 400/100 mg (given as two 200/50 mg tablets) twice daily taken with or without food.
Concomitant Therapy: Efavirenz, nevirapine, (fos)amprenavir or nelfinavir (see Pharmacology: Pharmacokinetics under Actions and Established and Other Potentially Significant Drug Interactions under Interactions): Lopinavir and Ritonavir tablets should not be administered as a once daily regimen in combination with efavirenz, nevirapine, (fos)amprenavir or nelfinavir.
A dose increase is recommended for all patients who use lopinavir and ritonavir tablets. The recommended dose of lopinavir and ritonavir tablets is 500/125 mg (such as two 200/50 tablets and one 100/25 mg tablet) twice daily in combination with efavirenz, nevirapine, (fos)amprenavir or nelfinavir.
Pediatric Patients: Lopinavir and Ritonavir tablets and oral solution should not be administered once daily in pediatric patients < 18 years of age.
Healthcare professionals should pay special attention to accurate calculation of the dose of lopinavir and ritonavir tablets, transcription of the medication order, dispensing information and dosing instructions to minimize the risk for medication errors, overdose, (see Overdosage) and underdose.
Prescribers should calculate the appropriate dose of lopinavir and ritonavir tablets for each individual child based on body weight (kg) or body surface area (BSA) and should not exceed the recommended adult dose.
Body surface area (BSA) can be calculated as follows: See Equation 1.

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The lopinavir and ritonavir dose can be calculated based on weight or BSA: Based on Weight: See Equation 2.

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Based on BSA: See Equation 3.

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Before prescribing lopinavir and ritonavir 100/25 mg tablets, children should be assessed for the ability to swallow intact tablets. If a child is unable to reliably swallow a lopinavir and ritonavir tablet, the lopinavir and ritonavir oral solution formulation should be prescribed.
14 Days to 6 Months: In pediatric patients 14 days to 6 months of age, the recommended dosage of lopinavir/ritonavir using lopinavir and ritonavir oral solution is 16/4 mg/kg or 300/75 mg/m² twice daily. Prescribers should calculate the appropriate dose based on body weight or body surface area.
Because no data exists for dosage when administered with efavirenz, nevirapine, (fos)amprenavir, or nelfinavir, it is recommended that lopinavir and ritonavir tablets not be administered in combination with these drugs in patients < 6 months of age.
6 Months to 18 Years: Without Concomitant Efavirenz, Nevirapine, (Fos) amprenavir or Nelfinavir: In children 6 months to 18 years of age, the recommended dosage of lopinavir/ritonavir using lopinavir and ritonavir oral solution without concomitant efavirenz, nevirapine, (fos)amprenavir, or nelfinavir is 230/57.5 mg/m² given twice daily, not to exceed the recommended adult dose. If weight-based dosing is preferred, the recommended dosage of lopinavir/ritonavir for patients < 15 kg is 12/3 mg/kg given twice daily and the dosage for patients ≥15 kg to 40 kg is 10/2.5 mg/kg given twice daily.
Table 9 provides the dosing recommendations for pediatric patients 6 months to 18 years of age based on body weight or body surface area for lopinavir and ritonavir tablets. (See Table 9.)

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Concomitant Therapy: Efavirenz, Nevirapine, (Fos) amprenavir, or Nelfinavir: A dose increase of lopinavir and ritonavir tablets to 300/75 mg/m² is needed when co-administered with efavirenz, nevirapine, (fos)amprenavir, or nelfinavir in children (both treatment-naïve and treatment-experienced) 6 months to 18 years of age, not to exceed the recommended adult dose. If weight-based dosing is preferred, the recommended dosage for patients <15 kg is 13/3.25 mg/kg given twice daily and the dosage for patients >15 kg to 45 kg is 11/2.75 mg/kg given twice daily.
Table 10 provides the dosing recommendations for pediatric patients 6 months to 18 years of age based on body weight or body surface area for lopinavir and ritonavir tablets when given in combination with efavirenz, nevirapine, (fos)amprenavir, or nelfinavir. (See Table 10.)

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Human experience of acute overdosage with lopinavir and ritonavir is limited. Treatment of overdose with lopinavir and ritonavir should consist of general supportive measures including monitoring of vital signs and observation of the clinical status of the patient. There is no specific antidote for overdose with lopinavir and ritonavir. If indicated, elimination of unabsorbed drug should be achieved by emesis or gastric lavage. Administration of activated charcoal may also be used to aid in removal of unabsorbed drug. Since lopinavir and ritonavir is highly protein bound, dialysis is unlikely to be beneficial in significant removal of the drug.

Lopinavir and Ritonavir tablet is contraindicated in patients with previously demonstrated clinically significant hypersensitivity (e.g., Stevens-Johnson syndrome, erythema multiforme) to any of its ingredients, including ritonavir.
Co-administration of lopinavir and ritonavir tablet is contraindicated with drugs that are highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life-threatening reactions.
Co-administration of lopinavir and ritonavir tablet is contraindicated with potent CYP3A inducers where significantly reduced lopinavir plasma concentrations may be associated with the potential for loss of virologic response and possible resistance and cross-resistance. These drugs are listed in Table 11. (See Table 11.)

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Drug Interactions: See Tables 11 and 17 for listing of drugs that are contraindicated for use with lopinavir and ritonavir due to potentially life-threatening adverse events, significant drug interactions, or loss of virologic activity. (See Contraindications and Interactions.)
Pancreatitis: Pancreatitis has been observed in patients receiving lopinavir and ritonavir therapy, including those who developed marked triglyceride elevations. In some cases, fatalities have been observed. Although a causal relationship to lopinavir and ritonavir has not been established, marked triglyceride elevations are a risk factor for development of pancreatitis (see Immune Reconstitution Syndrome as follows). Patients with advanced HIV-1 disease may be at increased risk of elevated triglycerides and pancreatitis, and patients with a history of pancreatitis may be at increased risk for recurrence during lopinavir and ritonavir therapy.
Pancreatitis should be considered if clinical symptoms (nausea, vomiting, abdominal pain) or abnormalities in laboratory values (such as increased serum lipase or amylase values) suggestive of pancreatitis occur. Patients who exhibit these signs or symptoms should be evaluated and lopinavir and ritonavir and/or other antiretroviral therapy should be suspended as clinically appropriate.
Hepatotoxicity: Patients with underlying hepatitis B or C or marked elevations in transaminase prior to treatment may be at increased risk for developing or worsening of transaminase elevations or hepatic decompensation with use of lopinavir and ritonavir.
There have been postmarketing reports of hepatic dysfunction, including some fatalities. These have generally occurred in patients with advanced HIV-1 disease taking multiple concomitant medications in the setting of underlying chronic hepatitis or cirrhosis. A causal relationship with lopinavir and ritonavir therapy has not been established.
Appropriate laboratory testing should be conducted prior to initiating therapy with lopinavir and ritonavir and patients should be monitored closely during treatment. Increased AST/ALT monitoring should be considered in the patients with underlying chronic hepatitis or cirrhosis, especially during the first several months of lopinavir and ritonavir treatment (see Hepatic Impairment as follows).
Diabetes Mellitus/Hyperglycemia: New onset diabetes mellitus, exacerbation of pre-existing diabetes mellitus, and hyperglycemia have been reported during post-marketing surveillance in HIV-1 infected patients receiving protease inhibitor therapy. Some patients required either initiation or dose adjustments of insulin or oral hypoglycemic agents for treatment of these events. In some cases, diabetic ketoacidosis has occurred. In those patients who discontinued protease inhibitor therapy, hyperglycemia persisted in some cases. Because these events have been reported voluntarily during clinical practice, estimates of frequency cannot be made and a causal relationship between protease inhibitor therapy and these events has not been established.
PR Interval Prolongation: Lopinavir/ritonavir prolongs the PR interval in some patients. Cases of second or third degree atrioventricular block have been reported. Lopinavir and Ritonavir should be used with caution in patients with underlying structural heart disease, preexisting conduction system abnormalities, ischemic heart disease or cardiomyopathies, as these patients may be at increased risk for developing cardiac conduction abnormalities.
The impact on the PR interval of co-administration of lopinavir and ritonavir with other drugs that prolong the PR interval (including calcium channel blockers, beta-adrenergic blockers, digoxin and atazanavir) has not been evaluated. As a result, co-administration of lopinavir and ritonavir with these drugs should be undertaken with caution, particularly with those drugs metabolized by CYP3A. Clinical monitoring is recommended (see Pharmacology: Pharmacokinetics under Actions).
QT Interval Prolongation: Postmarketing cases of QT interval prolongation and torsade de pointes have been reported although causality of lopinavir and ritonavir could not be established. Avoid use in patients with congenital long QT syndrome, those with hypokalemia, and with other drugs that prolong the QT interval (see Pharmacology: Pharmacokinetics under Actions).
Immune Reconstitution Syndrome: Immune reconstitution syndrome has been reported in patients treated with combination antiretroviral therapy, including lopinavir and ritonavir. During the initial phase of combination antiretroviral treatment, patients whose immune system responds may develop an inflammatory response to indolent or residual opportunistic infections (such as Mycobacterium avium infection, cytomegalovirus, Pneumocystis jirovecii pneumonia [PCP], or tuberculosis) which may necessitate further evaluation and treatment.
Fat Redistribution: Redistribution/accumulation of body fat including central obesity, dorsocervical fat enlargement (buffalo hump), peripheral wasting, facial wasting, breast enlargement, and "cushingoid appearance" have been observed in patients receiving antiretroviral therapy. The mechanism and long-term consequences of these events are currently unknown. A causal relationship has not been established.
Lipid Elevations: Treatment with lopinavir and ritonavir has resulted in large increases in the concentration of total cholesterol and triglycerides (see Adults - Clinical Trials Experience under Adverse Reactions). Triglyceride and cholesterol testing should be performed prior to initiating lopinavir and ritonavir therapy and at periodic intervals during therapy. Lipid disorders should be managed as clinically appropriate, taking into account any potential drug-drug interactions with lopinavir and ritonavir and HMG-CoA reductase inhibitors. (See Contraindications and Established and Other Potentially Significant Drug Interactions under Interactions.)
Patients with Hemophilia: Increased bleeding, including spontaneous skin hematomas and hemarthrosis have been reported in patients with hemophilia type A and B treated with protease inhibitors. In some patients additional factor VIII was given. In more than half of the reported cases, treatment with protease inhibitors was continued or reintroduced. A causal relationship between protease inhibitor therapy and these events has not been established.
Resistance/Cross-resistance: Because the potential for HIV cross-resistance among protease inhibitors has not been fully explored in lopinavir and ritonavir-treated patients, it is unknown what effect therapy with lopinavir and ritonavir will have on the activity of subsequently administered protease inhibitors. (See Microbiology under Actions.)
Hepatic Impairment: Lopinavir and Ritonavir is principally metabolized by the liver; therefore, caution should be exercised when administering this drug to patients with hepatic impairment, because lopinavir concentrations may be increased (see Hepatotoxicity under Precautions and Pharmacology: Pharmacokinetics under Actions).
Use in Children: The safety, efficacy, and pharmacokinetic profiles of lopinavir and ritonavir in pediatric patients below the age of 14 days have not been established. Lopinavir and Ritonavir once daily has not been evaluated in pediatric patients.
An open-label, multi-center, dose-finding trial was performed to evaluate the pharmacokinetic profile, tolerability, safety and efficacy of lopinavir and ritonavir oral solution containing lopinavir 80 mg/mL and ritonavir 20 mg/mL at a dose of with 300/75 mg/m² twice daily plus two NRTIs in HIV-infected infants ≥14 days and < 6 months of age. Results revealed that infants younger than 6 months of age generally had lower lopinavir AUC₁₂ than older children (6 months to 12 years of age), however, despite the lower lopinavir drug exposure observed, antiviral activity was demonstrated as reflected in the proportion of subjects who achieved HIV-RNA <400 copies/mL at Week 24 (see Pediatric Patients - Clinical Trials Experience under Adverse Reactions, Pharmacology: Pharmacokinetics and Pharmacodynamics: Clinical Studies under Actions).
Safety and efficacy in pediatric patients > 6 months of age was demonstrated in a clinical trial in 100 patients. The clinical trial was an open-label, multicenter trial evaluating the pharmacokinetic profile, tolerability, safety, and efficacy of lopinavir and ritonavir oral solution containing lopinavir 80 mg/mL and ritonavir 20 mg/mL in 100 antiretroviral naïve and experienced pediatric patients ages 6 months to 12 years. Dose selection for patients 6 months to 12 years of age was based on the following results. The 230/57.5 mg/m² oral solution twice daily regimen without nevirapine and the 300/75 mg/m² oral solution twice daily regimen with nevirapine provided lopinavir plasma concentrations similar to those obtained in adult patients receiving the 400/100 mg twice daily regimen (without nevirapine) (see Pediatric Patients - Clinical Trials Experience under Adverse Reactions, Pharmacology: Pharmacokinetics and Pharmacodynamics: Clinical Studies under Actions).
A prospective multicenter, open-label trial evaluated the pharmacokinetic profile, tolerability, safety and efficacy of high-dose lopinavir and ritonavir with or without concurrent NNRTI therapy (Group 1: 400/100 mg/m² twice daily + ≥ 2 NRTIs; Group 2: 480/120 mg/m² twice daily + ≥ 1 NRTI + 1 NNRTI) in children and adolescents ≥ 2 years to < 18 years of age who had failed prior therapy. Patients also had saquinavir mesylate added to their regimen. This strategy was intended to assess whether higher than approved doses of lopinavir and ritonavir could overcome protease inhibitor cross-resistance. High doses of lopinavir and ritonavir exhibited a safety profile similar to those observed in previous trials; changes in HIV-1 RNA were less than anticipated; three patients had HIV-1 RNA <400 copies/mL at Week 48. CD4+ cell count increases were noted in the eight patients who remained on treatment for 48 weeks, (see Pediatric Patients - Clinical Trials Experience under Adverse Reactions and Pharmacology: Pharmacokinetics under Actions).
Use in the Elderly: Clinical studies of lopinavir and ritonavir did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, appropriate caution should be exercised in the administration and monitoring of lopinavir and ritonavir in elderly patients reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

Pregnancy: Teratogenic Effects: Pregnancy Category C: No treatment-related malformations were observed when lopinavir in combination with ritonavir was administered to pregnant rats or rabbits. Embryonic and fetal developmental toxicities (early resorption, decreased fetal viability, decreased fetal body weight, increased incidence of skeletal variations and skeletal ossification delays) occurred in rats at a maternally toxic dosage. Based on AUC measurements, the drug exposures in rats at the toxic doses were approximately 0.7-fold for lopinavir and 1.8-fold for ritonavir for males and females that of the exposures in humans at the recommended therapeutic dose (400/100 mg twice daily). In a peri- and postnatal study in rats, a developmental toxicity (a decrease in survival in pups between birth and postnatal Day 21) occurred.
No embryonic and fetal developmental toxicities were observed in rabbits at a maternally toxic dosage. Based on AUC measurements, the drug exposures in rabbits at the toxic doses were approximately 0.6-fold for lopinavir and 1.0-fold for ritonavir that of the exposures in humans at the recommended therapeutic dose (400/100 mg twice daily). There are, however, no adequate and well-controlled studies in pregnant women. Lopinavir and Ritonavir should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Nursing Mothers: The Centers for Disease Control and Prevention recommend that HIV-1 infected mothers not breast-feed their infants to avoid risking postnatal transmission of HIV-1. Studies in rats have demonstrated that lopinavir is secreted in milk. It is not known whether lopinavir is secreted in human milk. Because of both the potential for HIV-1 transmission and the potential for serious adverse reactions in nursing infants, mothers should be instructed not to breast-feed if they are receiving lopinavir and ritonavir.

The following adverse reactions are discussed in greater detail in other sections of the labeling.
PR Interval Prolongation, QT Interval Prolongation (see Precautions); Drug Interactions (see Precautions); Pancreatitis (see Precautions); Hepatotoxicity (see Precautions).
Because clinical trials are conducted under widely varying conditions, adverse reactions 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 practice.
Adults - Clinical Trials Experience: The safety profile of lopinavir and ritonavir in adults is primarily based on 1555 HIV-1 infected patients in clinical trials.
The most common adverse reaction was diarrhea, which was generally of mild to moderate severity. In study 730, the incidence of diarrhea of any severity during 48 weeks of therapy was 60% in patients receiving lopinavir and ritonavir tablets once daily compared to 57% in patients receiving lopinavir and ritonavir tablets twice daily. More patients receiving lopinavir and ritonavir tablets once daily (14, 4.2%) had ongoing diarrhea at the time of discontinuation as compared to patients receiving lopinavir and ritonavir tablets twice daily (6, 1.8%). In study 730, discontinuations due to any adverse reaction were 4.8% in patients receiving lopinavir and ritonavir tablets once daily as compared to 3% in patients receiving lopinavir and ritonavir tablets twice daily. In study 863, discontinuations of randomized therapy due to adverse reactions were 3.4% in lopinavir and ritonavir-treated and 3.7% in nelfinavir-treated patients.
Treatment-emergent clinical adverse reactions of moderate or severe intensity in ≥2% of patients treated with combination therapy for up to 48 weeks (Study 863 and 730) and for up to 360 weeks (Study 720) are presented in Table 12 (treatment-naïve patients); and for up to 48 weeks (Study 888), 84 weeks (Study 957) and 144 weeks (Study 765) in Table 13 (protease inhibitor experienced patients). (See Table 12 and Table 13.)

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Less Common Adverse Reactions: Treatment-emergent adverse reactions occurring in less than 2% of adult patients receiving lopinavir and ritonavir in the clinical trials supporting approval and of at least moderate intensity are listed as follows by system organ class.
Blood and Lymphatic System Disorders: Anemia, leukopenia, lymphadenopathy, and splenomegaly.
Cardiac Disorders: Atrial fibrillation, atrioventricular block, myocardial infarction, palpitation.
Ear and Labyrinth Disorders: Hyperacusis, tinnitus, and vertigo.
Endocrine Disorders: Cushing's syndrome and hypothyroidism.
Eye Disorders: Eye disorder and visual disturbance.
Gastrointestinal Disorders: Abdominal distension, abdominal pain upper, constipation, dry mouth, enteritis, enterocolitis, enterocolitis hemorrhagic, eructation, esophagitis, fecal incontinence, gastric disorder, gastritis, gastroesophageal reflux disease, hemorrhoids, mouth ulceration, pancreatitis, periodontitis, stomach discomfort, and stomatitis.
General Disorders and Administration Site Conditions: Chest pain, cyst, drug interaction, edema, edema peripheral, face edema, fatigue, hypertrophy, and malaise.
Hepatobiliary Disorders: Cholangitis, cholecystitis, cytolytic hepatitis, hepatic steatosis, hepatitis, hepatomegaly, jaundice, and liver tenderness.
Immune System Disorders: Drug hypersensitivity, hypersensitivity, and immune reconstitution syndrome.
Infections and Infestations: Bacterial infection, cellulitis, folliculitis, furuncle, gastroenteritis, influenza, otitis media, perineal abscess, pharyngitis, rhinitis, sialoadenitis, sinusitis, and viral infection.
Investigations: Drug level increased, glucose tolerance decreased, and weight increased.
Metabolism and Nutrition Disorders: Decreased appetite, dehydration, diabetes mellitus, hypovitaminosis, increased appetite, lactic acidosis, lipomatosis, and obesity.
Musculoskeletal and Connective Tissue Disorders: Arthralgia, arthropathy, back pain, muscular weakness, osteoarthritis, osteonecrosis, and pain in extremity.
Neoplasms Benign, Malignant and Unspecified (incl Cysts and Polyps): Benign neoplasm of skin, lipoma, and neoplasm.
Nervous System Disorders: Ageusia, amnesia, ataxia, cerebral infarction, convulsion, dizziness, dysgeusia, dyskinesia, encephalopathy, extrapyramidal disorder, facial palsy, hypertonia, migraine, neuropathy, neuropathy peripheral, somnolence, and tremor.
Psychiatric Disorders: Abnormal dreams, affect lability, agitation, anxiety, apathy, confusional state, nervousness, and thinking abnormal.
Renal and Urinary Disorders: Nephritis, nephrolithiasis, renal disorder, and urine abnormality.
Reproductive System and Breast Disorders: Breast enlargement, ejaculation disorder, erectile dysfunction, and gynecomastia.
Respiratory, Thoracic and Mediastinal Disorders: Asthma, cough, dyspnea, and pulmonary edema.
Skin and Subcutaneous Tissue Disorders: Acne, alopecia, dermatitis acneiform, dermatitis allergic, dermatitis exfoliative, dry skin, eczema, hyperhidrosis, idiopathic capillaritis, nail disorder, pruritis, rash generalized, rash maculo-papular, seborrhea, skin discoloration, skin hypertrophy, skin striae, skin ulcer, and swelling face.
Vascular Disorders: Deep vein thrombosis, orthostatic hypotension, thrombophlebitis, varicose vein, and vasculitis.
Laboratory Abnormalities: The percentages of adult patients treated with combination therapy with Grade 3 to 4 laboratory abnormalities are presented in Table 14 (treatment-naïve patients) and Table 15 (treatment-experienced patients). (See Table 14 and Table 15.)

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Pediatric Patients - Clinical Trials Experience: Lopinavir and Ritonavir oral solution dosed up to 300/75 mg/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: hypersensitivity (characterized by fever, rash and jaundice), pyrexia, viral infection, constipation, hepatomegaly, pancreatitis, vomiting, alanine aminotransferase increased, dry skin, rash, and dysgeusia. Rash was the only event of those listed that occurred in 2 or more subjects (N = 3).
Lopinavir and Ritonavir oral solution dosed at 300/75 mg/m² has been studied in 31 pediatric patients 14 days to 6 months of age. The adverse reaction profile in Study 1030 was similar to that observed in older children and adults. No adverse reaction was reported in greater than 10% of subjects. Adverse drug reactions of moderate to severe intensity occurring in 2 or more subjects included decreased neutrophil count (N=3), anemia (N=2), high potassium (N=2), and low sodium (N=2).
Lopinavir and Ritonavir oral solution and soft gelatin capsules dosed at higher than recommended doses including 400/100 mg/m² (without concomitant NNRTI) and 480/120 mg/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 rash (N=3), blood triglycerides abnormal (N=3), and electrocardiogram QT prolonged (N=2). Both subjects with QT prolongation had additional predisposing conditions such as electrolyte abnormalities, concomitant medications, or pre-existing cardiac abnormalities.
Laboratory Abnormalities: The percentages of pediatric patients treated with combination therapy including lopinavir and ritonavir with Grade 3 to 4 laboratory abnormalities are presented in Table 16. (See Table 16.)

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Postmarketing Experience: The following adverse reactions have been reported during postmarketing use of lopinavir and ritonavir. Because these reactions are reported voluntarily from a population of unknown size, it is not possible to reliably estimate their frequency or establish a causal relationship to lopinavir and ritonavir exposure.
Body as a Whole: Redistribution/accumulation of body fat has been reported (see Fat Redistribution under Precautions).
Cardiovascular: Bradyarrhythmias. First-degree AV block, second-degree AV block, third-degree AV block, QTc interval prolongation, torsades (torsade) de pointes (see PR and QT Interval Prolongation under Precautions).
Skin and Appendages: Stevens Johnson Syndrome and erythema multiforme.

See also Contraindications and Pharmacology: Pharmacokinetics under Actions.
Potential for Lopinavir and Ritonavir 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 lopinavir and ritonavir. Thus, co-administration of lopinavir and ritonavir 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 17.
Additionally, lopinavir and ritonavir 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 lopinavir and ritonavir's therapeutic effect. Although not observed in the lopinavir and ritonavir/ketoconazole drug interaction study, co-administration of lopinavir and ritonavir and other drugs that inhibit CYP3A may increase lopinavir plasma concentrations.
Established and Other Potentially Significant Drug Interactions: Table 17 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. (See Pharmacology: Pharmacokinetics under Actions for magnitude of interaction). (See Table 17a, Table 17b and Table 17c.)

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Drugs with No Observed or Predicted Interactions with Lopinavir and Ritonavir: Drug interaction studies reveal no clinically significant interaction between lopinavir and ritonavir and desipramine (CYP2D6 probe), pravastatin, stavudine, lamivudine, omeprazole or ranitidine.
Based on known metabolic profiles, clinically significant drug interactions are not expected between lopinavir and ritonavir and fluvastatin, dapsone, trimethoprim/sulfamethoxazole, azithromycin, erythromycin, or fluconazole.

Store below 30°C and protect from light and moisture.

Information For Patients: Patients or parents of patients should be informed that: General Information: They should pay special attention to accurate administration of their dose to minimize the risk of accidental overdose or underdose of lopinavir and ritonavir.
They should inform their healthcare provider if their children's weight changes in order to make sure that the child's lopinavir and ritonavir dose is the correct one.
They should take the prescribed dose of lopinavir and ritonavir as directed and to set up a daily routine in order to do so.
Lopinavir and Ritonavir tablets may be taken with or without food.
Sustained decreases in plasma HIV-1 RNA have been associated with a reduced risk of progression to AIDS and death. Patients should remain under the care of a physician while using lopinavir and ritonavir. Patients should be advised to take lopinavir and ritonavir and other concomitant antiretroviral therapy every day as prescribed. Lopinavir and Ritonavir must always be used in combination with other antiretroviral drugs. Patients should not alter the dose or discontinue therapy without consulting with their doctor. If a dose of lopinavir and ritonavir is missed patients should take the dose as soon as possible and then return to their normal schedule. However, if a dose is skipped the patient should not double the next dose.
Lopinavir and Ritonavir is not a cure for HIV-1 infection and that they may continue to develop opportunistic infections and other complications associated with HIV-1 disease. The long-term effects of lopinavir and ritonavir are unknown at this time. Patients should be told that there are currently no data demonstrating that therapy with lopinavir and ritonavir can reduce the risk of transmitting HIV-1 to others through sexual contact, sharing needles, or being exposed to their blood. For their health and the health of others, it is important that they always practice safer sex by using a latex or polyurethane condom or other barrier method to lower the chance of sexual contact with any body fluids such as semen, vaginal secretions, or blood. They should also be advised to never re-use or share needles.
Drug Interactions: Lopinavir and Ritonavir may interact with some drugs; therefore, patients should be advised to report to their doctor the use of any other prescription, non-prescription medication or herbal products, particularly St. John's Wort.
Lopinavir and Ritonavir tablets can be taken at the same time as didanosine without food.
If they are receiving sildenafil, tadalafil, or vardenafil, there may be at an increased risk of associated adverse reactions including hypotension, visual changes, and sustained erection, and should promptly report any symptoms to their doctor.
If they are receiving estrogen-based hormonal contraceptives, additional or alternate contraceptive measures should be used during therapy with lopinavir and ritonavir.
Potential Adverse Effects: Skin rashes ranging in severity from mild to Stevens Johnson syndrome and Erythema multiforme have been reported in patients receiving lopinavir and ritonavir or its components lopinavir and/or ritonavir. Patients should be advised to contact their healthcare provider if they develop a rash while taking lopinavir and ritonavir. The healthcare provider will determine if treatment should be continued or an alternative antiretroviral regimen used.
Pre-existing liver disease including Hepatitis B or C can worsen with use of lopinavir and ritonavir. This can be seen as worsening of transaminase elevations or hepatic decompensation. Patients should be advised that their liver function tests will need to be monitored closely especially during the first several months of lopinavir and ritonavir treatment and that they should notify their healthcare provider if they develop the signs and symptoms of worsening liver disease including loss of appetite, abdominal pain, jaundice, and itchy skin.
New onset of diabetes or exacerbation of pre-existing diabetes mellitus, and hyperglycemia have been reported during lopinavir and ritonavir use. Patients should be advised to notify their healthcare provider if they develop the signs and symptoms of diabetes mellitus including frequent urination, excessive thirst, extreme hunger or unusual weight loss and/or an increased blood sugar while on lopinavir and ritonavir as they may require a change in their diabetes treatment or new treatment.
Lopinavir and Ritonavir might produce changes in the electrocardiogram (e.g., PR and/or QT prolongation). Patients should consult their physician if they experience symptoms such as dizziness, lightheadedness, abnormal heart rhythm or loss of consciousness.
They should seek medical assistance immediately if they develop a sustained penile erection lasting more than 4 hours while taking lopinavir and ritonavir and a PDE 5 Inhibitor such as Sildenafil, Tadalafil, Vardenafil.
Redistribution or accumulation of body fat may occur in patients receiving antiretroviral therapy and that the cause and long term health effects of these conditions are not known at this time.
Patients should be informed that there may be a greater chance of developing diarrhea with the once daily regimen as compared with the twice daily regimen.

Antivirals

J05AR10 - lopinavir and ritonavir ; Belongs to the class of antivirals for treatment of HIV infections, combinations.

Rx