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Drug Details

Kaletra 100mg/25mg film-coated tablets

• Presentation
  Film-coated tablet Pale yellow debossed with [Abbott logo] and “KC”.
• Description
  Each film-coated tablet contains 100 mg of lopinavir co-formulated with 25 mg of ritonavir as a pharmacokinetic enhancer.
• Indications
  

  Kaletra is indicated for the treatment of HIV-1 infected children above the age of 2 years and adults, in combination with other antiretroviral agents.

  Most experience with Kaletra is derived from the use of the product in antiretroviral therapy naïve patients.

  The choice of Kaletra to treat protease inhibitor experienced HIV-1 infected patients should be based on individual viral resistance testing and treatment history of patients.

• Adult Dosage
  

  Kaletra should be prescribed by physicians who are experienced in the treatment of HIV infection.

  Kaletra tablets should be swallowed whole and not chewed, broken or crushed.

  Adult and adolescent use: the standard recommended dosage of Kaletra tablets is 400/100 mg (two 200/50 mg) tablets twice daily taken with or without food. In adult patients, in cases where once daily dosing is considered necessary for the management of the patient, Kaletra tablets may be administered as 800/200 mg (four 200/50 mg tablets) once daily with or without food. The use of a once daily dosing should be limited to those adult patients having only very few protease inhibitor (PI) associated mutations (i.e. less than 3 PI mutations in line with clinical trial results, and should take into account the risk of a lesser sustainability of the virologic suppression and higher risk of diarrhoea compared to the recommended standard twice daily dosing. An oral solution is available to patients who have difficulty swallowing. Refer to the Summary of Product Characteristics for Kaletra oral solution for dosing instructions.

  Paediatric use (2 years of age and above): the adult dose of Kaletra tablets (400/100 mg twice daily) may be used in children 40 kg or greater or with a Body Surface Area (BSA)* greater than 1.4 m². For children weighing less than 40 kg or with a BSA between 0.5 and 1.4 m² and able to swallow tablets, refer to the dosing guideline tables below. For children unable to swallow tablets, please refer to the Kaletra oral solution Summary of Product Characteristics. Kaletra dosed once daily has not been evaluated in paediatric patients.

  Before prescribing Kaletra 100/25 mg tablets, infants and young children should be assessed for the ability to swallow intact tablets. If a child is unable to reliably swallow a Kaletra tablet, Kaletra oral solution formulation should be prescribed.

  The following table contains dosing guidelines for Kaletra 100/25 mg tablets based on BSA. 

  Paediatric Dosing Guidelines
  Body Surface Area (m2)	Recommended number of 100/25 mg tablets twice-daily
  0.5 to < 0.9	2 tablets (200/50 mg)
  0.9 to < 1.4	3 tablets (300/75 mg)
  1.4	4 tablets (400/100 mg)

  If more convenient for patients, the Kaletra 200/50 mg tablets may also be considered alone or in combination with the Kaletra 100/25 mg tablet to achieve the recommended dose.

  * Body surface area can be calculated with the following equation:

  BSA (m²) = √ (Height (cm) X Weight (kg) / 3600)

  Children less than 2 years of age: Kaletra is not recommended for use in children below 2 years of age due to insufficient data on safety and efficacy.

  Concomitant Therapy: Efavirenz or nevirapine

  The following table contains dosing guidelines for Kaletra 100/25 mg tablets based on BSA when used in combination with efavirenz or nevirapine in children. 

  Paediatric Dosing Guidelines with concomitant efavirenz or nevirapine
  Body Surface Area (m2)	Recommended number of 100/25 mg tablets twice-daily
  0.5 to < 0.8	2 tablets (200/50 mg)
  0.8 to < 1.2	3 tablets (300/75 mg)
  1.2 to < 1.4	4 tablets (400/100 mg)
  1.4	5 tablets (500/125 mg)

  If more convenient for patients, the Kaletra 200/50 mg tablets may also be considered alone or in combination with the Kaletra 100/25 mg tablet to achieve the recommended dose.

  Hepatic impairment: In HIV-infected patients with mild to moderate hepatic impairment, an increase of approximately 30% in lopinavir exposure has been observed but is not expected to be of clinical relevance. No data are available in patients with severe hepatic impairment. Kaletra should not be given to these patients.

  Renal impairment: since the renal clearance of lopinavir and ritonavir is negligible, increased plasma concentrations are not expected in patients with renal impairment. Because lopinavir and ritonavir are highly protein bound, it is unlikely that they will be significantly removed by haemodialysis or peritoneal dialysis.

• Contra Indications
  

  Hypersensitivity to the active substances or to any of the excipients.

  Patients with severe hepatic insufficiency.

  Kaletra contains lopinavir and ritonavir, both of which are inhibitors of the P450 isoform CYP3A. Kaletra should not be co-administered with medicinal products that are highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life threatening events. These medicinal products include astemizole, terfenadine, oral midazolam (for caution on parenterally administered midazolam, triazolam, cisapride, pimozide, amiodarone, ergot alkaloids (e.g. ergotamine, dihydroergotamine, ergonovine and methylergonovine) lovastatin, simvastatin, sildenafil used for the treatment of pulmonary arterial hypertension and vardenafil.

  Herbal preparations containing St John's wort (Hypericum perforatum) must not be used while taking lopinavir and ritonavir due to the risk of decreased plasma concentrations and reduced clinical effects of lopinavir and ritonavir.

• Special Precautions
  

  Patients with coexisting conditions

  Hepatic impairment: the safety and efficacy of Kaletra has not been established in patients with significant underlying liver disorders. Kaletra is contraindicated in patients with severe liver impairment. Patients with chronic hepatitis B or C and treated with combination antiretroviral therapy are at an increased risk for severe and potentially fatal hepatic adverse reactions. In case of concomitant antiviral therapy for hepatitis B or C, please refer to the relevant product information for these medicinal products.

  Patients with pre-existing liver dysfunction including chronic hepatitis have an increased frequency of liver function abnormalities during combination antiretroviral therapy and should be monitored according to standard practice. If there is evidence of worsening liver disease in such patients, interruption or discontinuation of treatment should be considered.

  Renal impairment: since the renal clearance of lopinavir and ritonavir is negligible, increased plasma concentrations are not expected in patients with renal impairment. Because lopinavir and ritonavir are highly protein bound, it is unlikely that they will be significantly removed by haemodialysis or peritoneal dialysis.

  Haemophilia: there have been reports of increased bleeding, including spontaneous skin haematomas and haemarthrosis in patients with haemophilia 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 if treatment had been discontinued. A causal relationship had been evoked, although the mechanism of action had not been elucidated. Haemophiliac patients should therefore be made aware of the possibility of increased bleeding.

  Lipid elevations

  Treatment with Kaletra has resulted in increases, sometimes marked, in the concentration of total cholesterol and triglycerides. Triglyceride and cholesterol testing is to be performed prior to initiating Kaletra therapy and at periodic intervals during therapy. Particular caution should be paid to patients with high values at baseline and with history of lipid disorders. Lipid disorders are to be managed as clinically appropriate.

  Pancreatitis

  Cases of pancreatitis have been reported in patients receiving Kaletra, including those who developed hypertriglyceridaemia. In most of these cases patients have had a prior history of pancreatitis and/or concurrent therapy with other medicinal products associated with pancreatitis. Marked triglyceride elevation is a risk factor for development of pancreatitis. Patients with advanced HIV disease may be at risk of elevated triglycerides and pancreatitis

  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 should occur. Patients who exhibit these signs or symptoms should be evaluated and Kaletra therapy should be suspended if a diagnosis of pancreatitis is made.

  Hyperglycaemia

  New onset diabetes mellitus, hyperglycaemia or exacerbation of existing diabetes mellitus has been reported in patients receiving protease inhibitors. In some of these the hyperglycaemia was severe and in some cases also associated with ketoacidosis. Many patients had confounding medical conditions some of which required therapy with agents that have been associated with the development of diabetes mellitus or hyperglycaemia.

  Fat redistribution and metabolic disorders

  Combination antiretroviral therapy has been associated with redistribution of body fat (lipodystrophy) in HIV patients. The long-term consequences of these events are currently unknown. Knowledge about the mechanism is incomplete. A connection between visceral lipomatosis and protease inhibitors (PIs) and lipoatrophy and nucleoside reverse transcriptase inhibitors (NRTIs) has been hypothesised. A higher risk of lipodystrophy has been associated with individual factors such as older age, and with drug related factors such as longer duration of antiretroviral treatment and associated metabolic disturbances. Clinical examination should include evaluation for physical signs of fat redistribution. Consideration should be given to measurement of fasting serum lipids and blood glucose. Lipid disorders should be managed as clinically appropriate.

  Immune Reactivation Syndrome

  In HIV-infected patients with severe immune deficiency at the time of institution of combination antiretroviral therapy (CART), an inflammatory reaction to asymtomatic or residual opportunistic pathogens may arise and cause serious clinical conditions, or aggravation of symptoms. Typically, such reactions have been observed within the first few weeks or months of initiation of CART. Relevant examples are cytomegalovirus retinitis, generalised and/or focal mycobacterial infections, and Pneumocystis jiroveci pneumonia. Any inflammatory symptoms should be evaluated and treatment instituted when necessary.

  Osteonecrosis

  Although the etiology is considered to be multifactorial (including corticosteroid use, alcohol consumption, severe immunosuppression, higher body mass index), cases of osteonecrosis have been reported particularly in patients with advanced HIVdisease and/or longterm exposure to combination antiretroviral therapy (CART). Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.

  PR interval prolongation

  Lopinavir/ritonavir has been shown to cause modest asymptomatic prolongation of the PR interval in some healthy adult subjects. Rare reports of 2^nd or 3^rd degree atroventricular block in patients with underlying structural heart disease and pre-existing conduction system abnormalities or in patients receiving drugs known to prolong the PR interval (such as verapamil or atazanavir) have been reported in patients receiving lopinavir/ritonavir. Kaletra should be used with caution in such patients.

  Interactions with medicinal products

  Kaletra contains lopinavir and ritonavir, both of which are inhibitors of the P450 isoform CYP3A. Kaletra is likely to increase plasma concentrations of medicinal products that are primarily metabolised by CYP3A. These increases of plasma concentrations of co-administered medicinal products could increase or prolong their therapeutic effect and adverse events.

  The combination of Kaletra with atorvastatin is not recommended. If the use of atorvastatin is considered strictly necessary, the lowest possible dose of atorvastatin should be administered with careful safety monitoring. Caution must also be exercised and reduced doses should be considered if Kaletra is used concurrently with rosuvastatin. If treatment with a HMG-CoA reductase inhibitor is indicated, pravastatin or fluvastatin is recommended.

  PDE5 inhibitors: particular caution should be used when prescribing sildenafil or tadalafil for the treatment of erectile dysfunction in patients receiving Kaletra. Co-administration of Kaletra with these medicinal products is expected to substantially increase their concentrations and may result in associated adverse events such as hypotension, syncope, visual changes and prolonged erection. Concomitant use of vardenafil and lopinavir/ritonavir is contraindicated. Concomitant use of sildenafil prescribed for the treatment of pulmonary arterial hypertension with Kaletra is contraindicated.

  Particular caution must be used when prescribing Kaletra and medicinal products known to induce QT interval prolongation such as: chlorpheniramine, quinidine, erythromycin, clarithromycin. Indeed, Kaletra could increase concentrations of the co-administered medicinal products and this may result in an increase of their associated cardiac adverse events. Cardiac events have been reported with Kaletra in preclinical studies; therefore, the potential cardiac effects of Kaletra cannot be currently ruled out.

  Coadministration of Kaletra with rifampicin is not recommended. Rifampicin in combination with Kaletra causes large decreases in lopinavir concentrations which may in turn significantly decrease the lopinavir therapeutic effect. Adequate exposure to lopinavir/ritonavir may be achieved when a higher dose of Kaletra is used but this is associated with a higher risk of liver and gastrointestinal toxicity. Therefore, this coadministration should be avoided unless judged strictly necessary.

  Other

  Kaletra is not a cure for HIV infection or AIDS. It does not reduce the risk of passing HIV to others through sexual contact or blood contamination. Appropriate precautions should be taken. People taking Kaletra may still develop infections or other illnesses associated with HIV disease and AIDS.

  Concomitant use of Kaletra and fluticasone or other glucocorticoids that are metabolised by CYP3A4 is not recommended unless the potential benefit of treatment outweighs the risk of systemic corticosteroid effects, including Cushing's syndrome and adrenal suppression.

• Interactions
  

  Kaletra contains lopinavir and ritonavir, both of which are inhibitors of the P450 isoform CYP3A in vitro. Co-administration of Kaletra and medicinal products primarily metabolised by CYP3A may result in increased plasma concentrations of the other medicinal product, which could increase or prolong its therapeutic and adverse reactions. Kaletra does not inhibit CYP2D6, CYP2C9, CYP2C19, CYP2E1, CYP2B6 or CYP1A2 at clinically relevant concentrations.

  Kaletra has been shown in vivo to induce its own metabolism and to increase the biotransformation of some medicinal products metabolised by cytochrome P450 enzymes (including CYP2C9 and CYP2C19) and by glucuronidation. This may result in lowered plasma concentrations and potential decrease of efficacy of co-administered medicinal products.

  All interaction studies, when otherwise not stated, were performed using Kaletra capsules, which gives an approximately 20% lower exposure of lopinavir than the 200/50 mg tablets.

  Known and theoretical interactions with selected antiretrovirals and non-antiretroviral medicinal products are listed in the table below.

  Interaction table

  Interactions between Kaletra and co-administered medicinal products are listed in the table below (increase is indicated as “↑”, decrease as “”, no change as “↔”,once daily as “QD”, twice daily as “BID” and three times daily as "TID").

  Unless otherwise stated, studies detailed below have been performed with the recommended dosage of lopinavir/ritonavir (i.e. 400/100 mg twice daily). 

  Co-administered Drug by Therapeutic Area	Effects on drug levels Geometric Mean Change (%) in AUC, Cmax, Cmin Mechanism of Interaction	Clinical Recommendation Concerning Co-Administration with Kaletra
  Antiretroviral Agents
  Nucleoside/Nucleotide reverse transcriptase inhibitors (NRTIs)
  Stavudine, Lamivudine	Lopinavir: ↔	No dose adjustment necessary.
  Abacavir, Zidovudine	Abacavir, Zidovudine: Concentrations may be reduced due to increased glucuronidation by Kaletra.	The clinical significance of reduced abacavir and zidovudine concentrations is unknown.
  Tenofovir, 300 mg QD	Tenofovir: AUC: ↑ 32% Cmax: ↔ Cmin: ↑ 51% Lopinavir: ↔	No dose adjustment necessary. Higher tenofovir concentrations could potentiate tenofovir associated adverse events, including renal disorders.
  Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  Efavirenz, 600 mg QD	Lopinavir: AUC: 20% Cmax: 13% Cmin: 42%	The Kaletra tablets dosage should be increased to 500/125 mg twice daily when co-administered with efavirenz. Kaletra must not be administered once daily in combination with efavirenz.
  Efavirenz, 600 mg QD (Lopinavir/ritonavir 500/125 mg BID)	Lopinavir: ↔ (Relative to 400/100 mg BID administered alone)
  Nevirapine, 200 mg BID	Lopinavir: AUC: 27% Cmax: 19% Cmin: 51%	The Kaletra tablets dosage should be increased to 500/125 mg twice daily when co-administered with nevirapine. Kaletra must not be administered once daily in combination with nevirapine.
  Co-administration with other HIV protease inhibitors (PIs) According to current treatment guidelines, dual therapy with protease inhibitors is generally not recommended.
  Fosamprenavir/ ritonavir (700/100 mg BID) (Lopinavir/ritonavir 400/100 mg BID) or Fosamprenavir (1400 mg BID) (Lopinavir/ritonavir 533/133 mg BID)	Fosamprenavir: Amprenavir concentrations are significantly reduced.	Co-administration of increased doses of fosamprenavir (1400 mg BID) with lopinavir/ritonavir (533/133 mg BID) to protease inhibitorexperienced patients resulted in a higher incidence of gastrointestinal adverse events and elevations in triglycerides with the combination regimen without increases in virological efficacy, when compared with standard doses of fosamprenavir/ritonavir. Concomitant administration of these medicinal products is not recommended. Kaletra must not be administered once daily in combination with amprenavir.
  Indinavir, 600 mg BID	Indinavir: AUC: ↔ Cmin: ↑ 3.5-fold Cmax: (relative to indinavir 800 mg TID alone) Lopinavir: ↔ (relative to historical comparison)	The appropriate doses for this combination, with respect to efficacy and safety, have not been established.
  Nelfinavir	Lopinavir: Concentrations	The appropriate doses for this combination, with respect to efficacy and safety, have not been established. Kaletra must not be administered once daily in combination with nelfinavir.
  Saquinavir 1000 mg BID	Saquinavir: ↔	No dose adjustment necessary.
  Tipranavir/ritonavir (500/100 mg BID)	Lopinavir: AUC: 55% Cmin: 47% Cmax: 70%	Concomitant administration of these medicinal products is not recommended.
  Acid reducing agents
  Omeprazole (40 mg QD)	Omeprazole: ↔ Lopinavir: ↔	No dose adjustment necessary
  Ranitidine (150 mg single dose)	Ranitidine: ↔	No dose adjustment necessary
  Analgesics
  Fentanyl	Fentanyl: Increased risk of side-effects (respiratory depression, sedation) due to higher plasma concentrations because of CYP3A4 inhibition by Kaletra	Careful monitoring of adverse effects (notably respiratory depression but also sedation) is recommended when fentanyl is concomitantly administered with Kaletra.
  Antiarrhythmics
  Digoxin	Digoxin: Plasma concentrations may be increased due to P-glycoprotein inhibition by Kaletra. The increased digoxin level may lessen over time as Pgp induction develops.	Caution is warranted and therapeutic drug monitoring of digoxin concentrations, if available, is recommended in case of coadministration of Kaletra and digoxin. Particular caution should be used when prescribing Kaletra in patients taking digoxin as the acute inhibitory effect of ritonavir on Pgp is expected to significantly increase digoxin levels. Initiation of digoxin in patients already taking Kaletra is likely to result in lower than expected increases of digoxin concentrations.
  Bepridil, Systemic Lidocaine, and Quinidine	Bepridil, Systemic Lidocaine, Quinidine: Concentrations may be increased when co-administered with Kaletra.	Caution is warranted and therapeutic drug concentration monitoring is recommended when available.
  Antibiotics
  Clarithromycin	Clarithromycin: Moderate increases in clarithromycin AUC are expected due to CYP3A inhibition by Kaletra.	For patients with renal impairment (CrCL <30 ml/min) dose reduction of clarithromycin should be considered (see section 4.4). Caution should be exercised in administering clarithromycin with Kaletra to patients with impaired hepatic or renal function.
  Anticancer agents
  Most tyrosine kinase inhibitors such as dasatinib and nilotinib, Vincristine, Vinblastine	Most tyrosine kinase inhibitors such as dasatinib and nilotinib, also vincristine and vinblastine: Risk of increased adverse events due to higher serum concentrations because of CYP3A4 inhibition by Kaletra.	Careful monitoring of the tolerance of these anticancer agents.
  Anticoagulants
  Warfarin	Warfarin: Concentrations may be affected when co-administered with Kaletra due to CYP2C9 induction.	It is recommended that INR (international normalised ratio) be monitored.
  Anticonvulsants
  Phenytoin	Phenytoin: Steady-state concentrations was moderately decreased due to CYP2C9 and CYP2C19 induction by Kaletra. Lopinavir: Concentrations are decreased due to CYP3A induction by phenytoin.	Caution should be exercised in administering phenytoin with Kaletra. Phenytoin levels should be monitored when coadministering with lopinavir/ritonavir. When co-administered with phenytoin, an increase of Kaletra dosage may be envisaged. Dose adjustment has not been evaluated in clinical practice. Kaletra must not be administered once daily in combination with phenytoin.
  Carbamazepine and Phenobarbital	Carbamazepine: Serum concentrations may be increased due to CYP3A inhibition by Kaletra. Lopinavir: Concentrations may be decreased due to CYP3A induction by carbamazepine and phenobarbital.	Caution should be exercised in administering carbamazepine or phenobarbital with Kaletra. Carbamazepine and phenobarbital levels should be monitored when coadministering with lopinavir/ritonavir. When co-administered with carbamazepine or phenobarbital, an increase of Kaletra dosage may be envisaged. Dose adjustment has not been evaluated in clinical practice. Kaletra must not be administered once daily in combination with cabamazepine and phenobarbital.
  Antidepressants and Anxiolytics
  Trazodone single dose (Ritonavir, 200 mg BID)	Trazodone: AUC: ↑ 2.4-fold Adverse events of nausea, dizziness, hypotension and syncope were observed following co-administration of trazodone and ritonavir.	It is unknown whether the combination of lopinavir/ritonavir causes a similar increase in trazodone exposure. The combination should be used with caution and a lower dose of trazodone should be considered.
  Antifungals
  Ketoconazole and Itraconazole	Ketoconazole, Itraconazole: Serum concentrations may be increased due to CYP3A inhibition by Kaletra.	High doses of ketoconazole and itraconazole (> 200 mg/day) are not recommended.
  Voriconazole	Voriconazole: Concentrations may be decreased.	Coadministration of voriconazole and low dose ritonavir (100 mg BID) as contained in Kaletra should be avoided unless an assessment of the benefit/risk to patient justifies the use of voriconazole.
  Antimycobacterials
  Rifabutin, 150 mg QD	Rifabutin (parent drug and active 25-O-desacetyl metabolite): AUC: ↑ 5.7-fold Cmax: ↑ 3.5-fold	On the basis of these data, a rifabutin dose reduction of 75% (i.e. 150 mg every other day or 3 times per week) is recommended when administered with Kaletra. Further reduction may be necessary.
  Rifampicin	Lopinavir: Large decreases in lopinavir concentrations may be observed due to CYP3A induction by rifampicin.	Coadministration of Kaletra with rifampicin is not recommended as the decrease in lopinavir concentrations may in turn significantly decrease the lopinavir therapeutic effect A dose adjustment of Kaletra 400 mg/400 mg (i.e. Kaletra 400/100 mg + ritonavir 300 mg) twice daily has allowed compensating for the CYP 3A4 inducer effect of rifampicin. However, such a dose adjustment might be associated with ALT/AST elevations and with increase in gastrointestinal disorders. Therefore, this coadministration should be avoided unless judged strictly necessary. If this coadministration is judged unavoidable, increased dose of Kaletra at 400 mg/400 mg twice daily may be administered with rifampicin under close safety and therapeutic drug monitoring. The Kaletra dose should be titrated upward only after rifampicin has been initiated (see section 4.4).
  Benzodiazepines
  Midazolam	Oral Midazolam: AUC: ↑ 13-fold Parenteral Midazolam: AUC: ↑ 4-fold Due to CYP3A inhibition by Kaletra	Kaletra must not be coadministered with oral midazolam (see section 4.3), whereas caution should be used with coadministration of Kaletra and parenteral midazolam. If Kaletra is coadministered with parenteral midazolam, it should be done in an intensive care unit (ICU) or similar setting which ensures close clinical monitoring and appropriate medical management in case of respiratory depression and/or prolonged sedation. Dosage adjustment for midazolam should be considered especially if more than a single dose of midazolam is administered.
  Calcium channel blockers
  Felodipine, Nifedipine, and Nicardipine	Felodipine, Nifedipine, Nicardipine: Concentrations may be increased due to CYP3A inhibition by Kaletra.	Clinical monitoring of therapeutic and adverse effects is recommended when these medicines are concomitantly administered with Kaletra.
  Corticosteroids
  Dexamethasone	Lopinavir: Concentrations may be decreased due to CYP3A induction by dexamethasone.	Clinical monitoring of antiviral efficacy is recommended when these medicines are concomitantly administered with Kaletra.
  Fluticasone propionate, 50 μg intranasal 4 times daily (100 mg ritonavir BID)	Fluticasone propionate: Plasma concentrations ↑ Cortisol levels 86%	Greater effects may be expected when fluticasone propionate is inhaled. Systemic corticosteroid effects including Cushing's syndrome and adrenal suppression have been reported in patients receiving ritonavir and inhaled or intranasally administered fluticasone propionate; this could also occur with other corticosteroids metabolised via the P450 3A pathway eg budesonide. Consequently, concomitant administration of Kaletra and these glucocorticoids is not recommended unless the potential benefit of treatment outweighs the risk of systemic corticosteroid effects. A dose reduction of the glucocorticoid should be considered with close monitoring of local and systemic effects or a switch to a glucocorticoid, which is not a substrate for CYP3A4 (eg beclomethasone). Moreover, in case of withdrawal of glucocorticoids progressive dose reduction may have to be performed over a longer period.
  Erectile Dysfunction, Phosphodiesterase(PDE5) inhibitors
  Tadalafil	Tadalafil: AUC: ↑ 2-fold Due to CYP3A inhibition by Kaletra.	Particular caution must be used when prescribing sildenafil or tadalafil in patients receiving Kaletra with increased monitoring for adverse events including hypotension, syncope, visual changes and prolonged erection. When coadministered with Kaletra, sildenafil doses must not exceed 25 mg in 48 hours and tadalafil doses must not exceed 10 mg every 72 hours. Coadministration of Kaletra with sildenafil used for the treatment of pulmonary arterial hypertension is contraindicated.
  Sildenafil	Sildenafil: AUC: ↑ 11-fold Due to CYP3A inhibition by Kaletra.
  Vardenafil	Vardenafil: AUC: ↑ 49-fold Due to CYP3A inhibition by Kaletra.	The use of vardenafil with Kaletra is contraindicated.
  Herbal products
  St John's wort (Hypericum perforatum)	Lopinavir: Concentrations may be reduced due to induction of CYP3A by the herbal preparation St John's wort.	Herbal preparations containing St John's wort must not be combined with lopinavir and ritonavir. If a patient is already taking St John's wort, stop St John's wort and if possible check viral levels. Lopinavir and ritonavir levels may increase on stopping St John's wort. The dose of Kaletra may need adjusting. The inducing effect may persist for at least 2 weeks after cessation of treatment with St John's wort. Therefore, Kaletra can be started safely 2 weeks after cessation of St. John's wort.
  Immunosuppressants
  Cyclosporin, Sirolimus (rapamycin), and Tacrolimus	Cyclosporin, Sirolimus (rapamycin), Tacrolimus: Concentrations may be increased due to CYP3A inhibition by Kaletra.	More frequent therapeutic concentration monitoring is recommended until plasma levels of these products have been stabilised.
  Lipid lowering agents
  Lovastatin and Simvastatin	Lovastatin, Simvastatin: Markedly increased plasma concentrations due to CYP3A inhibition by Kaletra.	Since increased concentrations of HMG-CoA reductase inhibitors may cause myopathy, including rhabdomyolysis, the combination of these agents with Kaletra is contraindicated.
  Atorvastatin	Atorvastatin: AUC: ↑ 5.9-fold Cmax: ↑ 4.7-fold Due to CYP3A inhibition by Kaletra.	The combination of Kaletra with atorvastatin is not recommended. If the use of atorvastatin is considered strictly necessary, the lowest possible dose of atorvastatin should be administered with careful safety monitoring.
  Rosuvastatin, 20 mg QD	Rosuvastatin: AUC: ↑ 2-fold Cmax: ↑ 5-fold While rosuvastatin is poorly metabolised by CYP3A4, an increase of its plasma concentrations was observed. The mechanism of this interaction may result from inhibition of transport proteins.	Caution should be exercised and reduced doses should be considered when Kaletra is coadministered with rosuvastatin.
  Fluvastatin or Pravastatin	Fluvastatin, Pravastatin: No clinical relevant interaction expected. Pravastatin is not metabolised by CYP450. Fluvastatin is partially metabolised by CYP2C9.	If treatment with an HMG-CoA reductase inhibitor is indicated, fluvastatin or pravastatin is recommended.
  Opioids
  Buprenorphine, 16 mg QD	Buprenorphine: ↔	No dose adjustment necessary.
  Methadone	Methadone:	Monitoring plasma concentrations of methadone is recommended.
  Oral Contraceptives
  Ethinyl Oestradiol	Ethinyl Oestradiol:	In case of coadministration of Kaletra with contraceptives containing ethinyl oestradiol (whatever the contraceptive formulation e.g. oral or patch), additional methods of contraception must be used.
  Smoking cessation aids
  Bupropion	Buproprion and its active metabolite, hydroxybupropion: AUC and Cmax ~50% This effect may be due to induction of bupropion metabolism.	If the coadministration of lopinavir/ritonavir with bupropion is judged unavoidable, this should be done under close clinical monitoring for bupropion efficacy, without exceeding the recommended dosage, despite the observed induction.
  Other medicinal products
  Based on known metabolic profiles, clinically significant interactions are not expected between Kaletra and dapsone, trimethoprim/sulfamethoxazole, azithromycin or fluconazole.