What is the interaction between ayahuasca (iowaska) and Biktarvy (bictegravir, emtricitabine, and tenofovir alafenamide)?

Ayahuasca (Iowaska) and Biktarvy Interaction: Potentially Dangerous Combination

Ayahuasca should not be used with Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) due to potentially dangerous drug interactions that could lead to increased toxicity and treatment failure.

Understanding the Components

Biktarvy Components

• Bictegravir: An integrase strand transfer inhibitor (InSTI)
• Emtricitabine and Tenofovir Alafenamide: Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)

Ayahuasca Components

• Contains monoamine oxidase inhibitors (MAOIs) from the plant Banisteriopsis caapi
• Contains N,N-dimethyltryptamine (DMT) from Psychotria viridis

Mechanism of Interaction

1. Metabolic Pathway Conflicts:

   • Bictegravir is transported by P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) 1
   • Ayahuasca's MAOIs can interfere with multiple metabolic pathways

2. Potential Consequences:

   • Altered drug levels of Biktarvy components
   • Risk of serotonin syndrome due to MAOI activity
   • Possible reduced efficacy of HIV treatment
   • Increased risk of adverse effects

Clinical Recommendations

For Patients on Biktarvy:

• Avoid ayahuasca completely
• The International Antiviral Society-USA guidelines recommend using antiretroviral drugs with minimal drug interactions 2
• Bictegravir-based regimens are generally favored for their lower drug interaction potential, but this does not extend to powerful psychoactive substances like ayahuasca 1

For Healthcare Providers:

• Counsel patients about the risks of combining these substances
• Emphasize that maintaining HIV viral suppression requires consistent, uninterrupted antiretroviral therapy
• Consider that drug interactions could lead to:
  • Treatment failure
  • Development of viral resistance
  • Increased toxicity

Evidence-Based Rationale

While there are no specific studies on ayahuasca-Biktarvy interactions, we can draw conclusions based on:

1. Drug Metabolism Knowledge:

   • Biktarvy has fewer drug interactions than protease inhibitor-based regimens but still has interaction potential 2
   • The 2024 International Antiviral Society-USA guidelines highlight the importance of avoiding drug interactions with antiretroviral therapy 2

2. Similar Documented Interactions:

   • MAOIs are known to have numerous serious drug interactions
   • Biktarvy's metabolism through P-gp and BCRP transporters creates potential for interaction 1

Important Monitoring If Exposure Occurs

If a patient on Biktarvy reports ayahuasca use:

1. Immediate Assessment:

   • Monitor for signs of serotonin syndrome (agitation, hyperthermia, neuromuscular abnormalities)
   • Check vital signs and mental status
   • Consider more frequent HIV viral load testing

2. Long-term Follow-up:

   • Assess HIV viral load 4-6 weeks after exposure
   • Monitor for any signs of treatment failure
   • Reinforce adherence to antiretroviral therapy

Alternative Considerations

For patients interested in psychedelic experiences for spiritual or therapeutic purposes:

• Discuss legal alternatives with fewer drug interaction concerns
• Consider consultation with both HIV specialist and addiction/psychiatry specialist
• Emphasize that maintaining HIV viral suppression must remain the priority

Remember that maintaining consistent antiretroviral therapy is crucial for long-term health outcomes in people living with HIV, and any substances that might compromise treatment efficacy should be avoided.