POSITIVELY AWARE MARCH/APRIL 2011
brand name: Crixivan
common name: indinavir sulfate
class: Protease inhibitor (PI)
manufacturer: Merck and Co. | www.merck.com, (800) 850–3430
Standard dose: Rarely used by itself (two 400 mg capsules every eight hours with no food or a low-fat snack). Almost always boosted with Norvir, both twice daily: 400 mg Crixivan + 400 mg Norvir; 800 mg + 100 mg; or 800 mg + 200 mg (all doses taken with food and with plenty of water to avoid kidney sludge or stones). Avoid grapefruit juice and vitamin C (more than one gram a day), which decrease Crixivan blood levels. Take missed dose as soon as possible, unless it is almost time for your next dose. Do not double up on your next dose. Also available in 100 mg, 200 mg, and 333 mg capsules.
AWP: $548.12 / month for 400 mg, 180 capsules
Potential side effects and toxicity
Headache, fatigue or weakness, malaise (general ill feeling), nausea, diarrhea, stomach pain, loss of appetite, yellowing of skin/eyes, changed skin color, dry mouth/sore throat, taste changes, painful urination, indigestion, joint pain, hives, and liver toxicity. Itchy/dry skin, ingrown toe nails, and hair loss are unique to Crixivan. Kidney stones, which may lead to more serious problems, can also occur—if pain develops in the middle to lower stomach or the back, or if there is blood in the urine, call your health care provider immediately. An increase in bilirubin (a test of liver function) has been reported, but it is not associated with liver problems. It may sometimes cause yellowing of the skin or eyes. As seen with other protease inhibitors (except unboosted Reyataz), there can be increased levels of cholesterol and triglycerides which may be associated with an increased risk of heart disease. Other possible side effects are lipodystrophy (body fat changes, including thinning of the face, arms, and legs, with or without fat accumulation in the stomach, breasts, and upper back), onset of new cases or worsening of diabetes (see your doctor promptly) and increased bleeding in hemophiliacs. Immune Reconstitution Inflammatory Syndrome (IRIS) may occur as the immune system regains strength; signs and symptoms of inflammation from previous infections may occur soon after anti-HIV treatment is initiated. Report symptoms of illness, such as shingles and TB, to a health care provider.
Potential drug interactions
Do not take with alfuzosin, Revatio, Tambocor (flecainide), Rythmol (propafenone), Cordarone (amiodarone), oral versed (midazolam), triazolam, rifampin, pimozide, ergot derivatives (such as Cafergot, Wigraine, Methergine, and D.H.E. 45), garlic supplements, or the herb St. John’s wort. Do not use Advicor, Altoprev, Livalo, Mevacor (lovastatin), Simcor, Vytorin, or Zocor (simvastatin) for the treatment of high lipids. Lipid-lowering alternatives are Crestor, Lescol, Lipitor, and Pravacol (pravastatin), but should be used with caution. Not recommended in combination with Reyataz. Reduce Crixivan to 600 mg every eight hours when taken with Rescriptor, itraconazole (200 mg twice a day), or ketoconazole (200 mg once a day). The dose of Mycobutin should be reduced to 150 mg daily or 300 mg three times a week and Crixivan dose increased to 1,000 mg every eight hours or use Norvir-boosted dose when taken together. Cialis, Levitra, and Viagra levels are increased; doses should not exceed 10 mg Cialis or 2.5 mg Levitra per 72 hours, or 25 mg Viagra per 48 hours. Effectiveness of birth control pills may be decreased; consider the use of alternative or additional contraception. Additional monitoring may be required when taking Coumadin (warfarin) or calcium channel blockers (such as Norvasc, Procardia, and others). Use caution with anti-convulsants: Tegretol (carbamazepine), phenobarbital, and Dilantin (phenytoin). Crixivan may decrease levels of methadone, but withdrawal rarely occurs. Methadone doses may need to be increased. Also, increased levels of trazodone can occur with Crixivan. Increased levels of the inhaled and nasal sprays with fluticasone, a steroid for asthma or allergies (found in Advair, Flonase, and Flovent) can occur with Crixivan and therefore should be used with caution. Use with caution with bosentan, salmeterol, immunosuppressants (including transplant drugs), and colchicine; use lower dose of colchicine.
More information
Drink at least 48 oz. of fluids daily, preferably water or clear liquids (soda pop doesn’t count!) to decrease the chances of kidney stones. Don’t forget to drink more water in summer or with increased sweating. Large amounts of coffee or alcohol can increase risk of stones due to increased dehydration. Stones may continue after stopping Crixivan. Store in original container and keep dry. See package insert for more complete information on potential side effects and interactions.
Doctor’s comments
Crixivan deserves our undying gratitude for having saved many lives in the late ’90s, but it’s now a drug of purely historical importance. Side effects included kidney stones or kidney failure, diabetes, lipid changes, dry skin, chapped lips, ingrown toenails, and possibly body-shape changes (the dreaded “Crix belly,” for example). When taken without Norvir boosting, its dosing schedule was unforgiving and complex; when boosted by Norvir, it just became more toxic. Avoid it. —Joel Gallant, MD, MPH
Activist’s comments
A drug that saved many lives when first introduced, its three-times-a-day on an empty stomach dosing schedule, and painful kidney stones if you didn’t drink enough water (and sometimes even if you did) made this a tough drug to tolerate. Norvir boosting has made it more convenient to take twice a day with or without food, but the kidney stones are still a danger—as is lipodystrophy (remember Crix belly?). Fortunately, there are better PI options these days. —Jeff Taylor
