What are the best blood pressure medications to use with Biktarvy (bictegravir)

Blood Pressure Medications with Biktarvy

Standard antihypertensive agents from all major classes can be safely used with Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide), as bictegravir has minimal drug-drug interaction potential and does not significantly affect blood pressure medication metabolism.

Key Drug Interaction Profile

Bictegravir demonstrates a low potential to perpetrate clinically meaningful drug-drug interactions via known drug metabolizing enzymes or transporters 1. While bictegravir is metabolized by CYP3A and UGT1A1, it does not significantly inhibit or induce these pathways in ways that would affect common antihypertensive medications 2, 1.

Recommended Antihypertensive Classes for Use with Biktarvy

First-Line Options (All Safe with Biktarvy)

ACE Inhibitors/ARBs:

• Losartan 25-100 mg once daily is explicitly recommended in HIV patients and has no interactions with bictegravir 3, 4
• Lisinopril can be safely combined with Biktarvy without dose adjustment 5
• These agents provide cardiovascular protection beyond blood pressure control 3, 4

Calcium Channel Blockers:

• Amlodipine 2.5-10 mg once daily is preferred and has no significant interactions with bictegravir 3, 5
• Dihydropyridine CCBs are explicitly endorsed in combination regimens 3
• No dose adjustment needed when combined with Biktarvy 3

Beta-Blockers:

• Metoprolol succinate 50-200 mg once daily can be safely used with Biktarvy 3, 4
• No metabolic interactions with bictegravir that would require dose modification 3
• Particularly useful in patients with heart failure or coronary disease 3

Thiazide/Thiazide-Like Diuretics:

• Can be safely added as part of combination therapy 5, 4
• No known interactions with bictegravir 1

Second-Line/Add-On Agents

Spironolactone:

• 25 mg daily for resistant hypertension (if potassium <4.5 mmol/L and eGFR >45 mL/min) 5, 4
• No interactions with bictegravir requiring dose adjustment 5
• Monitor potassium and renal function closely, especially when combined with ACE inhibitors or ARBs 5

Practical Implementation Algorithm

Step 1: Initial Monotherapy

• Start with ACE inhibitor/ARB or calcium channel blocker as first-line agent 3, 4
• Monitor blood pressure at each clinical visit as recommended for all HIV patients on integrase inhibitors 6

Step 2: Dual Therapy if BP Uncontrolled

• Add ACE inhibitor/ARB + calcium channel blocker combination (preferred two-drug combination) 3
• Alternative: ACE inhibitor/ARB + beta-blocker if compelling indication exists 3, 4

Step 3: Triple Therapy for Resistant Hypertension

• Combine ACE inhibitor/ARB + calcium channel blocker + beta-blocker or thiazide 3, 5
• Target systolic BP <130 mmHg 5, 4

Step 4: Quadruple Therapy if Still Uncontrolled

• Add spironolactone 25 mg daily after verifying adherence and ruling out white coat hypertension 5, 4
• Check potassium and renal function within 1-2 weeks 5

Important Monitoring Considerations

Blood Pressure Monitoring:

• Check BP at every clinical visit to diagnose and treat incident hypertension in patients on integrase inhibitors 6
• While data on bictegravir and hypertension are limited, monitoring remains essential 6

Laboratory Monitoring:

• Renal function and electrolytes should be monitored when using ACE inhibitors/ARBs, especially with spironolactone 5
• Check within 1-2 weeks after medication changes 5, 4

Critical Pitfalls to Avoid

Do NOT:

• Combine two RAS blockers (ACE inhibitor + ARB), as this increases adverse effects without benefit 5, 4
• Use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) with beta-blockers due to heart block risk 5
• Abruptly discontinue beta-blockers, which can cause rebound hypertension 3, 5
• Switch antiretroviral regimens due to hypertension; instead, treat the hypertension directly 6

Special Considerations for HIV Patients

Lifestyle Modifications:

• Exercise and diet intervention are recommended as first-line alongside medications 6
• Changing ART regimens due to hypertension is not recommended 6

Integrase Inhibitor Context:

• Data supporting an association between integrase inhibitors and hypertension are inconclusive 6
• Bictegravir-specific data on hypertension are lacking, but no unique concerns have emerged 6
• Weight gain associated with integrase inhibitors may contribute to hypertension incidence 6