Statins and Viread (Tenofovir Disoproxil Fumarate) Can Be Used Together Safely
Yes, statins and Viread can be taken together, but specific statin selection and careful monitoring are essential. Pravastatin, atorvastatin (at low starting doses), and fluvastatin are the preferred statins in patients taking Viread, while simvastatin and lovastatin should be avoided when combined with certain HIV protease inhibitors 1.
Preferred Statin Choices with Viread
For patients on Viread, pravastatin (20-40 mg daily starting dose) is the first-line statin recommendation because it is metabolized by glucuronidation rather than CYP3A4, avoiding significant drug interactions with antiretroviral agents 1.
- Atorvastatin (10 mg daily starting dose) is an acceptable alternative but requires careful dose titration and monitoring for muscle toxicity 1.
- Fluvastatin (20-40 mg daily starting dose) is a reasonable third option as it is metabolized by CYP2C9 rather than CYP3A4 1.
- Pitavastatin and rosuvastatin can be used at low starting doses with careful monitoring, as they are not significantly metabolized by CYP3A4 1.
Critical Drug Interaction Concerns
The primary safety concern is not between Viread and statins directly, but rather when Viread is combined with ritonavir-boosted or cobicistat-boosted antiretroviral regimens (such as atazanavir/ritonavir, darunavir/ritonavir, lopinavir/ritonavir, or elvitegravir/cobicistat), which significantly increase tenofovir concentrations and require frequent renal monitoring 1.
- When pharmacokinetic enhancers (ritonavir or cobicistat) are present with Viread, these combinations should be used with caution and frequent renal monitoring 1.
- Efavirenz-containing regimens also increase tenofovir concentrations, requiring similar caution 1.
Statins to Avoid in HIV Patients
Simvastatin and lovastatin should NOT be used in patients taking protease inhibitors due to extensive CYP3A4 metabolism, which leads to dramatically increased statin levels and high risk of rhabdomyolysis 1.
- Protease inhibitors (especially ritonavir) are potent CYP3A4 inhibitors that can increase simvastatin and lovastatin levels by more than 10-fold 1.
- The risk of myopathy is further increased in HIV patients due to potential use of other myotoxic drugs like zidovudine 1.
Monitoring Requirements
All patients on statin-Viread combinations require regular monitoring for both muscle toxicity and renal function 1.
- Monitor for muscle symptoms (pain, weakness, tenderness) at every clinical visit 1.
- Check creatine kinase (CK) if muscle symptoms develop 1.
- Monitor renal function frequently, especially when Viread is combined with boosted antiretroviral regimens 1.
- Assess hepatic transaminases at baseline and periodically 1.
- Review all medications at each encounter to identify new drug interactions 1.
Special Considerations for Hepatitis C Treatment
When treating hepatitis C with sofosbuvir/ledipasvir in patients also taking Viread, rosuvastatin use is not recommended due to ledipasvir's inhibition of hepatic OATP transporters 1.
- Monitor carefully for statin adverse reactions when combining hepatitis C direct-acting antivirals with statins 1.
- Other statins may also interact through OATP inhibition, requiring careful monitoring 1.
Common Pitfalls to Avoid
- Never assume all statins are interchangeable in HIV patients—the metabolic pathway determines safety 1.
- Do not use standard statin doses without considering antiretroviral interactions—start low and titrate carefully 1.
- Avoid overlooking renal function monitoring when Viread is combined with boosted antiretroviral regimens 1.
- Do not ignore the cumulative myopathy risk from multiple potentially myotoxic medications in HIV patients 1.