Atazanavir Sulfate and Oxymorphone Hydrochloride

• Generic Name: atazanavir
• Dosage Forms: n.a.
• Other Brand Names: Reyataz

Atazanavir with low-dose ritonavir (ritonavir-boosted atazanavir): Treatment of HIV-1 infection in adults, adolescents, and pediatric patients ≥3 months of age; used in conjunction with other antiretrovirals.

Atazanavir with cobicistat (cobicistat-boosted atazanavir): Treatment of HIV-1 infection in adults; used in conjunction with other antiretrovirals.

Unboosted atazanavir (i.e., without low-dose ritonavir or cobicistat): Treatment of HIV-1 infection in adults and adolescents ≥13 years of age; used in conjunction with other antiretrovirals.

Atazanavir usually used in conjunction with a pharmacokinetic enhancer (i.e., low-dose ritonavir or cobicistat). Pharmacokinetic enhancer (pharmacokinetic booster) used to improve atazanavir's pharmacokinetic profile. Low-dose ritonavir and cobicistat are not interchangeable in antiretroviral regimens; these pharmacokinetic enhancers have different dosage and administration requirements and are associated with different adverse effects, precautions, contraindications, and drug interactions.

When ritonavir-boosted atazanavir used, single-entity atazanavir is given with single-entity ritonavir.

When cobicistat-boosted atazanavir used, fixed combination containing both drugs (atazanavir/cobicistat) can be used; alternatively, single-entity atazanavir is given with single-entity cobicistat. Assess estimated Clcr in all patients prior to initiation of cobicistat-boosted atazanavir (see Renal Effects under Cautions).

For initial treatment in antiretroviral-naive adults and adolescents, experts state that ritonavir-boosted atazanavir in conjunction with tenofovir alafenamide fumarate (TAF) and emtricitabine or ritonavir-boosted atazanavir in conjunction with tenofovir disoproxil fumarate (tenofovir DF) and emtricitabine (or lamivudine) are alternative PI-based regimens. These experts state that cobicistat-boosted atazanavir in conjunction with TAF and emtricitabine or cobicistat-boosted atazanavir in conjunction with tenofovir DF and emtricitabine (or lamivudine) are alternative PI-based regimens for initial treatment in antiretroviral-naive adults and adolescents. Ritonavir-boosted or cobicistat-boosted atazanavir in conjunction with abacavir and lamivudine are other regimen options for initial treatment in antiretroviral-naive patients when recommended or alternative regimens cannot be used, but use only in those with baseline plasma HIV RNA levels <100,000 copies/mL who are human leukocyte antigen (HLA)-B*5701 negative.

For initial treatment in antiretroviral-naive pediatric patients, experts state that ritonavir-boosted atazanavir in conjunction with 2 nucleoside reverse transcriptase inhibitors (NRTIs) is a preferred regimen in those ≥3 years of age and an alternative regimen in those 3 months to <3 years of age weighing 5–25 kg.

Experts state that unboosted atazanavir is not recommended for initial treatment in antiretroviral-naive adults, adolescents, or children because it is less potent than boosted atazanavir.

Unboosted atazanavir should not be used in antiretroviral-experienced (previously treated) patients with prior virologic failure. If using ritonavir-boosted atazanavir or cobicistat-boosted atazanavir in antiretroviral-experienced patients, treatment should be guided by number of baseline primary PI resistance substitutions.

Postexposure prophylaxis of HIV infection following occupational exposure (PEP) in health-care personnel and others exposed via percutaneous injury (e.g., needlestick, cut with sharp object) or mucous membrane or nonintact skin (e.g., chapped, abraded, dermatitis) contact with blood, tissue, or other body fluids that might contain HIV.

USPHS recommends a 3-drug regimen of raltegravir and emtricitabine and tenofovir DF as preferred regimen for PEP following occupational exposures to HIV. Ritonavir-boosted atazanavir and 2 NRTIs is one of several alternative regimens. Preferred dual NRTI option for PEP regimens is emtricitabine and tenofovir DF; alternatives are tenofovir DF and lamivudine, zidovudine and lamivudine, or zidovudine and emtricitabine.

Management of occupational exposures to HIV is complex and evolving; consult infectious disease specialist, clinician with expertise in administration of antiretroviral agents, and/or National Clinicians’ Postexposure Prophylaxis Hotline (PEPline at 888-448-4911) whenever possible. Do not delay initiation of PEP while waiting for expert consultation.

Postexposure prophylaxis of HIV infection following nonoccupational exposure (nPEP) in individuals exposed to blood, genital secretions, or other potentially infectious body fluids that might contain HIV when the exposure represents a substantial risk for HIV transmission. Used in conjunction with other antiretrovirals.

When nPEP indicated in adults and adolescents ≥13 years of age with normal renal function, CDC states preferred regimen is either raltegravir or dolutegravir used in conjunction with emtricitabine and tenofovir DF (given as emtricitabine/tenofovir DF; Truvada); recommended alternative regimen in these patients is ritonavir-boosted darunavir used in conjunction with emtricitabine/tenofovir DF.

CDC states that ritonavir-boosted atazanavir is an alternative antiretroviral that can be used in nPEP regimens.

Consult infectious disease specialist, clinician with expertise in administration of antiretroviral agents, and/or the National Clinicians’ Postexposure Prophylaxis Hotline (PEPline at 888-448-4911) if nPEP indicated in certain exposed individuals (e.g., pregnant women, children, those with medical conditions such as renal impairment) or if considering a regimen not included in CDC guidelines, source virus is known or likely to be resistant to antiretrovirals, or healthcare provider is inexperienced in prescribing antiretrovirals. Do not delay initiation of nPEP while waiting for expert consultation.

• Generic Name: oxymorphone
• Dosage Forms: n.a.
• Other Brand Names: Opana, Opana ER, Numorphan HCl

Relief of moderate to severe pain.

Symptomatic relief of moderate to moderately severe pain such as that associated with acute and some chronic medical disorders including renal or biliary colic, acute trauma, postoperative pain, and cancer.

Extended-release tablets are used orally for management of moderate to severe pain when a continuous, around-the-clock analgesic is needed for an extended period of time. The extended-release tablets are not intended for use on an as-needed (“prn”) basis.

In symptomatic treatment of acute pain, reserve opiate analgesics for pain resulting from severe injuries, severe medical conditions, or surgical procedures, or when nonopiate alternatives for relieving pain and restoring function are expected to be ineffective or are contraindicated. Use smallest effective dosage for shortest possible duration since long-term opiate use often begins with treatment of acute pain. Optimize concomitant use of other appropriate therapies. (See Managing Opiate Therapy for Acute Pain under Dosage and Administration.)

In the management of chronic pain associated with a terminal illness such as cancer, the principal goal of analgesic therapy is to make the patient relatively pain-free while maintaining as good a quality of life as possible.

Generally use opiates for management of chronic pain (i.e., pain lasting >3 months or past the time of normal tissue healing ) that is not associated with active cancer treatment, palliative care, or end-of-life care only if other appropriate nonpharmacologic and nonopiate pharmacologic strategies have been ineffective and expected benefits for both pain relief and functional improvement are anticipated to outweigh risks.

If used for chronic pain, opiate analgesics should be part of an integrated approach that also includes appropriate nonpharmacologic modalities (e.g., cognitive-behavioral therapy, relaxation techniques, biofeedback, functional restoration, exercise therapy, certain interventional procedures) and other appropriate pharmacologic therapies (e.g., nonopiate analgesics, analgesic adjuncts such as selected anticonvulsants and antidepressants for certain neuropathic pain conditions).

Available evidence insufficient to determine whether long-term opiate therapy for chronic pain results in sustained pain relief or improvements in function and quality of life or is superior to other pharmacologic or nonpharmacologic treatments. Use is associated with serious risks (e.g., opiate use disorder, overdose). (See Managing Opiate Therapy for Chronic Noncancer Pain under Dosage and Administration.)

Used parenterally as a supplement to anesthesia.

Used parenterally for analgesia during labor.

Used in patients with acute pulmonary edema for its cardiovascular effects and to allay anxiety. Should not be used in the treatment of pulmonary edema resulting from a chemical respiratory irritant.