No pharmaceutical opinion available for this interaction.
Cobicistat can inhibit the metabolism (CYP 3A4) and increase the plasma concentration of Atorvastatin.
3A4 (major) and 2D6 (minor).
3A4 (strong) et 2D6 (moderate), P-gp, MATE 1, BCRP, OATP1B1 and OATP1B3.
3A4 (major), 2C8 (minor): metabolised in acid derivatives 2-hydroxy-atorvastatin and 4-hydroxy-atorvastatin. These active metabolites are responsable of about 70% of the inhibitory activity of HMG-CoA reductase circulating. OATP1B1 and P-gp.
3A4 (weak), OATP1B1 and P-gp.
Increased risk of adverse effects.
Start therapy with the lowest dose and titrate to desired response while monitoring for safety.
In patients already under treatment, a reduction in dosage may be necessary.
No more than 10 mg daily is recommended when co-administered with atazanavir/cobicistat.
We do not recommend more than 20 mg per day (U.S. guidelines) and 40 mg per day (European guidelines).
Or choose an alternative.
Pravastatin or ezetimibe.
Symptoms of toxicity associated with hypolipidemic agents : gastrointestinal effects, fatigue and muscular weaknesses, myalgias, muscular cramps, myopathies, rhabdomyolysis and myoglobinuria leading to renal insufficiency.
Ref #3360 : A study in two groups of 16 healthy patients studied co-administration of a single dose of 10 mg atorvastatin with darunavir/cobicistat 800/150 mg QD or atazanavir/cobicistat 300/150 mg QD. In the darunavir/cobicistat group, rosuvastatin AUC and Cmax increased by 3.9 and 4.2-fold, respectively, while in the atazanavir/cobicistat group atorvastatin AUC and Cmax increased by 9.2 and 18.9-fold, respectively. Therefore it is recommanded not to give more than 10 mg of atorvastatin daily when given with atazanavir/cobicistat. See atazanavir / cobicistat + atorvastatin and darunavir / cobicistat + atorvastatin.
We observe an increase in AUC of atorvastatin with lopinavir/ritonavir, saquinavir/ritonavir, tipranavir/ritonavir, fosamprenavir/ritonavir and nelfinavir.
Ref #1695: Case report of drug-induced rhabdomyolysis in a 34-year-old HIV-infected male with a history of liver disease and concomitant use of clarithromycin, atorvastatin, and lopinavir/ritonavir.