NORVIR (ritonavir) is an inhibitor of HIV protease with activity against the Human Immunodeficiency Virus (HIV).
Ritonavir is chemically designated as 10-Hydroxy-2-methyl-5-(1-methylethyl)-1- [2-(1-methylethyl)-4-thiazolyl]-3,6-dioxo-8,11-bis(phenylmethyl)-2,4,7,12- tetraazatridecan-13-oic acid, 5-thiazolylmethyl ester, [5S-(5R*,8R*,10R*,11R*)]. Its molecular formula is C37H48N6O5S2, and its molecular weight is 720.95. Ritonavir has the following structural formula:
Ritonavir is a white-to-light-tan powder. Ritonavir has a bitter metallic taste. It is freely soluble in methanol and ethanol, soluble in isopropanol and practically insoluble in water.
NORVIR soft gelatin capsules are available for oral administration in a strength of 100 mg ritonavir with the following inactive ingredients: Butylated hydroxytoluene, ethanol, gelatin, iron oxide, oleic acid, polyoxyl 35 castor oil, and titanium dioxide.
NORVIR oral solution is available for oral administration as 80 mg/mL of ritonavir in a peppermint and caramel flavored vehicle. Each 8-ounce bottle contains 19.2 grams of ritonavir. NORVIR oral solution also contains ethanol, water, polyoxyl 35 castor oil, propylene glycol, anhydrous citric acid to adjust pH, saccharin sodium, peppermint oil, creamy caramel flavoring, and FD&C Yellow No. 6.
Mechanism of Action
Ritonavir is a peptidomimetic inhibitor of both the HIV-1 and HIV-2 proteases. Inhibition of HIV protease renders the enzyme incapable of processing the gag-pol polyprotein precursor which leads to production of non-infectious immature HIV particles.
Antiviral Activity In Vitro
The activity of ritonavir was assessed in vitro in acutely infected lymphoblastoid cell lines and in peripheral blood lymphocytes. The concentration of drug that inhibits 50% (EC50) of viral replication ranged from 3.8 to 153 nM depending upon the HIV-1 isolate and the cells employed. The average EC50 for low passage clinical isolates was 22 nM (n = 13). In MT4 cells, ritonavir demonstrated additive effects against HIV-1 in combination with either zidovudine (ZDV) or didanosine (ddI). Studies which measured cytotoxicity of ritonavir on several cell lines showed that > 20 µM was required to inhibit cellular growth by 50% resulting in an in vitro therapeutic index of at least 1000.
HIV-1 isolates with reduced susceptibility to ritonavir have been selected in vitro. Genotypic analysis of these isolates showed mutations in the HIV protease gene at amino acid positions 84 (Ile to Val), 82 (Val to Phe), 71 (Ala to Val), and 46 (Met to Ile). Phenotypic (n = 18) and genotypic (n = 44) changes in HIV isolates from selected patients treated with ritonavir were monitored in phase I/II trials over a period of 3 to 32 weeks. Mutations associated with the HIV viral protease in isolates obtained from 41 patients appeared to occur in a stepwise and ordered fashion; in sequence, these mutations were position 82 (Val to Ala/Phe), 54 (Ile to Val), 71 (Ala to Val/Thr), and 36 (Ile to Leu), followed by combinations of mutations at an additional 5 specific amino acid positions. Of 18 patients for whom both phenotypic and genotypic analysis were performed on free virus isolated from plasma, 12 showed reduced susceptibility to ritonavir in vitro. All 18 patients possessed one or more mutations in the viral protease gene. The 82 mutation appeared to be necessary but not sufficient to confer phenotypic resistance. Phenotypic resistance was defined as a ≥ 5-fold decrease in viral sensitivity in vitro from baseline. The clinical relevance of phenotypic and genotypic changes associated with ritonavir therapy has not been established.
Cross-Resistance to Other Antiretrovirals
Among protease inhibitors variable cross-resistance has been recognized. Serial HIV isolates obtained from six patients during ritonavir therapy showed a decrease in ritonavir susceptibility in vitro but did not demonstrate a concordant decrease in susceptibility to saquinavir in vitro when compared to matched baseline isolates. However, isolates from two of these patients demonstrated decreased susceptibility to indinavir in vitro (8-fold). Isolates from 5 patients were also tested for cross-resistance to amprenavir and nelfinavir; isolates from 2 patients had a decrease in susceptibility to nelfinavir (12- to 14-fold), and none to amprenavir. Cross-resistance between ritonavir and reverse transcriptase inhibitors is unlikely because of the different enzyme targets involved. One ZDV-resistant HIV isolate tested in vitro retained full susceptibility to ritonavir.
The pharmacokinetics of ritonavir have been studied in healthy volunteers and HIV-infected patients (CD4 ≥ 50 cells/µL). See Table 1 for ritonavir pharmacokinetic characteristics.
The absolute bioavailability of ritonavir has not been determined. After a 600 mg dose of oral solution, peak concentrations of ritonavir were achieved approximately 2 hours and 4 hours after dosing under fasting and non-fasting (514 KCal; 9% fat, 12% protein, and 79% carbohydrate) conditions, respectively.
Effect of Food on Oral Absorption
When the oral solution was given under non-fasting conditions, peak ritonavir concentrations decreased 23% and the extent of absorption decreased 7% relative to fasting conditions. Dilution of the oral solution, within one hour of administration, with 240 mL of chocolate milk, Advera® or Ensure® did not significantly affect the extent and rate of ritonavir absorption. After a single 600 mg dose under non-fasting conditions, in two separate studies, the soft gelatin capsule (n = 57) and oral solution (n = 18) formulations yielded mean ± SD areas under the plasma concentration-time curve (AUCs) of 121.7 ± 53.8 and 129.0 ± 39.3 µg • h/mL, respectively. Relative to fasting conditions, the extent of absorption of ritonavir from the soft gelatin capsule formulation was 13% higher when administered with a meal (615 KCal; 14.5% fat, 9% protein, and 76% carbohydrate).
Nearly all of the plasma radioactivity after a single oral 600 mg dose of 14C-ritonavir oral solution (n = 5) was attributed to unchanged ritonavir. Five ritonavir metabolites have been identified in human urine and feces. The isopropylthiazole oxidation metabolite (M-2) is the major metabolite and has antiviral activity similar to that of parent drug; however, the concentrations of this metabolite in plasma are low. In vitro studies utilizing human liver microsomes have demonstrated that cytochrome P450 3A (CYP3A) is the major isoform involved in ritonavir metabolism, although CYP2D6 also contributes to the formation of M-2.
In a study of five subjects receiving a 600 mg dose of 14C-ritonavir oral solution, 11.3 ± 2.8% of the dose was excreted into the urine, with 3.5 ± 1.8% of the dose excreted as unchanged parent drug. In that study, 86.4 ± 2.9% of the dose was excreted in the feces with 33.8 ± 10.8% of the dose excreted as unchanged parent drug. Upon multiple dosing, ritonavir accumulation is less than predicted from a single dose possibly due to a time and dose-related increase in clearance.
Table 1. Ritonavir Pharmacokinetic Characteristics
| Parameter || n || Values (Mean ± SD) |
† SS = steady state; patients taking ritonavir 600 mg q12h.
‡ Single ritonavir 600 mg dose.
* Primarily bound to human serum albumin and alpha-1 acid glycoprotein over the ritonavir concentration range of 0.01 to 30 µg/mL.
|Cmax SS†||10||11.2 ± 3.6 µg/mL|
|Ctrough SS†||10||3.7 ± 2.6 µg/mL|
|Vβ/F‡||91||0.41 ± 0.25 L/kg|
|t½||3 - 5 h|
|CL/F SS†||10||8.8 ± 3.2 L/h|
|CL/F‡||91||4.6 ± 1.6 L/h|
|CLR||62||< 0.1 L/h|
|Percent Bound*||98 to 99%|
Effects on Electrocardiogram
QTcF interval was evaluated in a randomized, placebo and active (moxifloxacin 400 mg once-daily) controlled crossover study in 45 healthy adults, with 10 measurements over 12 hours on Day 3. The maximum mean (95% upper confidence bound) time-matched difference in QTcF from placebo after baseline correction was 5.5 (7.6) milliseconds (msec) for 400 mg twice-daily ritonavir. Ritonavir 400 mg twice daily resulted in Day 3 ritonavir exposure that was approximately 1.5 fold higher than observed with ritonavir 600 mg twice-daily dose at steady state.
PR interval prolongation was also noted in subjects receiving ritonavir in the same study on Day 3. The maximum mean (95% confidence interval) difference from placebo in the PR interval after baseline correction was 22 (25) msec for 400 mg twice-daily ritonavir. See PRECAUTIONS– PR Interval Prolongation.
Gender, Race and Age
No age-related pharmacokinetic differences have been observed in adult patients (18 to 63 years). Ritonavir pharmacokinetics have not been studied in older patients.
A study of ritonavir pharmacokinetics in healthy males and females showed no statistically significant differences in the pharmacokinetics of ritonavir. Pharmacokinetic differences due to race have not been identified.
Steady-state pharmacokinetics were evaluated in 37 HIV-infected patients ages 2 to 14 years receiving doses ranging from 250 mg/m2 twice-daily to 400 mg/m2 twice-daily in PACTG Study 310, and in 41 HIV-infected patients ages 1 month to 2 years at doses of 350 and 450 mg/m2 twice-daily in PACTG Study 345. Across dose groups, ritonavir steady-state oral clearance (CL/F/m2) was approximately 1.5 to 1.7 times faster in pediatric patients than in adult subjects. Ritonavir concentrations obtained after 350 to 400 mg/m2 twice-daily in pediatric patients > 2 years were comparable to those obtained in adults receiving 600 mg (approximately 330 mg/m2) twice-daily. The following observations were seen regarding ritonavir concentrations after administration with 350 or 450 mg/m2 twice-daily in children < 2 years of age. Higher ritonavir exposures were not evident with 450 mg/m2 twice-daily compared to the 350 mg/m2 twice-daily. Ritonavir trough concentrations were somewhat lower than those obtained in adults receiving 600 mg twice-daily. The area under the ritonavir plasma concentration-time curve and trough concentrations obtained after administration with 350 or 450 mg/m2 twice-daily in children < 2 years were approximately 16% and 60% lower, respectively, than that obtained in adults receiving 600 mg twice-daily.
Ritonavir pharmacokinetics have not been studied in patients with renal insufficiency, however, since renal clearance is negligible, a decrease in total body clearance is not expected in patients with renal insufficiency.
Dose-normalized steady-state ritonavir concentrations in subjects with mild hepatic insufficiency (400 mg twice-daily, n = 6) were similar to those in control subjects dosed with 500 mg twice-daily. Dose-normalized steady-state ritonavir exposures in subjects with moderate hepatic impairment (400 mg twice-daily, n= 6) were about 40% lower than those in subjects with normal hepatic function (500 mg twice-daily, n = 6). Protein binding of ritonavir was not statistically significantly affected by mild or moderately impaired hepatic function. No dose adjustment is recommended in patients with mild or moderate hepatic impairment. However, health care providers should be aware of the potential for lower ritonavir concentrations in patients with moderate hepatic impairment and should monitor patient response carefully. Ritonavir has not been studied in patients with severe hepatic impairment.
See also CONTRAINDICATIONS, WARNINGS, and PRECAUTIONS - Drug Interactions.
Table 2 and Table 3 summarize the effects on AUC and Cmax, with 95% confidence intervals (95% CI), of co-administration of ritonavir with a variety of drugs. For information about clinical recommendations see PRECAUTIONS - Drug Interactions.
Table 2. Drug Interactions - Pharmacokinetic Parameters for Ritonavir in the Presence of the Co-administered Drug (See PRECAUTIONS - Table 6 for Recommended Alterations in Dose or Regimen)
| Co-administered Drug || Dose of Co-administered Drug (mg) || Dose of NORVIR (mg) || n || AUC % (95% CI) || Cmax (95% CI) || Cmin (95% CI) |
|Clarithromycin||500 q12h, 4 d||200 q8h, 4 d||22||↑ 12% (2, 23%)||↑ 15% (2, 28%)||↑ 14% (-3, 36%)|
|Didanosine||200 q12h, 4 d||600 q12h, 4 d||12||↔||↔||↔|
|Fluconazole||400 single dose, day 1; 200 daily, 4 d||200 q6h, 4 d||8||↑ 12% (5, 20%)||↑ 15% (7, 22%)||↑ 14% (0, 26%)|
|Fluoxetine||30 q12h, 8 d||600 single dose, 1 d||16||↑ 19% (7, 34%)||↔||ND|
|Ketoconazole||200 daily, 7 d||500 q12h, 10 d||12||↑ 18% (-3, 52%)||↑ 10% (-11, 36%)||ND|
|Rifampin||600 or 300 daily, 10 d||500 q12h, 20 d||7, 9*||↓ 35% (7, 55%)||↓ 25% (-5, 46%)||↓ 49% (-14, 91%)|
|Voriconazole||400 q12h, 1 d; then 200 q12h, 8 d||400 q12h, 9 d||↔||↔||ND|
|Zidovudine||200 q8h, 4 d||300 q6h, 4 d||10||↔||↔||↔|
Table 3. Drug Interactions - Pharmacokinetic Parameters for Co-administered Drug in the Presence of NORVIR (See PRECAUTIONS - Table 6 for Recommended Alterations in Dose or Regimen)
| Co-administered Drug || Dose of Co-administered Drug (mg) || Dose of NORVIR (mg) || n || AUC % (95% CI) || Cmax (95% CI) || Cmin (95% CI) |
1 Ritonavir and indinavir were co-administered for 15 days; Day 14 doses were administered after a 15%-fat breakfast (757 Kcal) and 9%-fat evening snack (236 Kcal), and Day 15 doses were administered after a 15%-fat breakfast (757 Kcal) and 32%-fat dinner (815 Kcal). Indinavir Cmin was also increased 4-fold. Effects were assessed relative to an indinavir 800 mg q8h regimen under fasting conditions.
2 Effects were assessed on a dose-normalized comparison to a methadone 20 mg single dose.
3 Sulfamethoxazole and trimethoprim taken as single combination tablet.
4 90% CI presented for R- and S-warfarin AUC and Cmax ratios.
5 This significant increase in plasma fluticasone propionate exposure resulted in a significant decrease (86%) in plasma cortisol AUC.
↑ Indicates increase.
↓ Indicates decrease.
↔ Indicates no change.
* Parallel group design; entries are subjects receiving combination and control regimens, respectively.
|Alprazolam||1, single dose||500 q12h, 10 d||12||↓ 12% (-5,30%)||↓ 16% (5, 27%)||ND|
14-OH clarithromycin metabolite
|500 q12h, 4 d||200 q8h, 4 d||22||↑ 77% (56, 103%)|
|↑ 31% (15, 51%)|
|↑ 2.8-fold (2.4, 3.3X)|
2-OH desipramine metabolite
|100, single dose||500 q12h, 12 d||14||↑ 145% (103, 211%)|
↓ 15% (3, 26%)
|↑ 22% (12, 35%)|
↓ 67% (62, 72%)
|Didanosine||200 q12h, 4 d||600 q12h, 4 d||12||↓ 13% (0, 23%)||↓ 16% (5, 26%)||↔|
|Ethinyl estradiol||50 µg single dose||500 q12h, 16 d||23||↓ 40% (31, 49%)||↓ 32% (24, 39%)||ND|
|Fluticasone propionate aqueous nasal spray||200 mcg qd, 7 d||100 mg q12h, 7 d||18||↑ approximately 350-fold5||↑ approximately 25-fold5|
|400 q12h, 15 d||400 q12h, 15 d||10|
↑ 6% (-14, 29%)
↓ 7% (-22,28%)
↓ 51% (40, 61%)
↓ 62% (52, 70%)
|↑ 4-fold (2.8,6.8X)|
↑ 4-fold (2.5,6.5X)
|Ketoconazole||200 daily, 7 d||500 q12h, 10 d||12||↑ 3.4-fold (2.8, 4.3X)||↑ 55% (40, 72%)||ND|
|50 oral single dose||500 q12h, 10 d||8|
|↓ 62% (59, 65%)|
↑ 47% (-24, 345%)
|↓ 59% (42, 72%)|
↑ 87% (42, 147%)
|Methadone2||5, single dose||500 q12h, 15 d||11||↓ 36% (16, 52%)||↓ 38% (28, 46%)||ND|
25- O -desacetyl rifabutin metabolite
|150 daily, 16 d||500 q12h, 10 d||5,|
|↑ 4-fold (2.8, 6.1X)|
↑ 38-fold (28, 56X)
|↑ 2.5-fold (1.9, 3.4X)|
↑ 16-fold (13, 20X)
|↑ 6-fold (3.5, 18.3X)|
↑ 181-fold (ND)
|Sildenafil||100, single dose||500 BID, 8 d||28||↑ 11-fold||↑ 4-fold||ND|
|Sulfamethoxazole3||800, single dose||500 q12h, 12 d||15||↓ 20% (16, 23%)||↔||ND|
|Tadalafil||20 mg, single dose||200 mg q12h||↑ 124%||↔||ND|
|Theophylline||3 mg/kg q8h, 15 d||500 q12h, 10 d||13, 11*||↓ 43% (42, 45%)||↓ 32% (29, 34%)||↓ 57% (55,59%)|
|Trazodone||50 mg, single dose||200 mg q12h, 4 doses||10||↑ 2.4-fold||↑ 34%|
|Trimethoprim3||160, single dose||500 q12h, 12 d||15||↑ 20% (3, 43%)||↔||ND|
|Vardenafil||5 mg||600 q12h||↑ 49-fold||↑ 13-fold||ND|
|Voriconazole||400 q12h, 1 d; then 200 q12h, 8 d||400 q12h, 9 d||↓ 82%||↓ 66%|
|5, single dose||400 q12h, 12d||12|
↑ 9% (-17, 44%)4
↓ 33% (-38, -27%)4
↓ 9% (-16, -2%)4
|Zidovudine||200 q8h, 4 d||300 q6h, 4 d||9||↓ 25% (15, 34%)||↓ 27% (4, 45%)||ND|