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INTERACTIONS BETWEEN ANTIDEPRESSANTS AND ANTIRETROVIRAL AGENTS
Interacting drug ARV Effect of interaction Recommendation
Sertraline EFV
DRV		 sertraline AUC decreased by 39%
sertraline AUC decreased by 49%

titrate to effect
Paroxetine FPV
DRV
RTV		 paroxetine AUC decreased by 50%
paroxetine AUC decreased by 40%
may increase level of paroxetine

titrate to effect
Venlafaxine RTV may increase level of venlafaxine

titrate to effect
Citalopram RTV may increase level of citalopram

titrate to effect
Mirtazapine PIs may increase level of mirtazapine

titrate to effect
Metabolism of the antidepressants (bold major pathway): Sertraline: CYP 2B6, 2C9, 2C19, 2D6, 3A4 (weak inhibitor of CYP 2D6, 3A4); Paroxetine: CYP 2D6 (inhibitor of CYP 2D6); Venlafaxine: CYP 2D6, 3A4 (weak inhibitor of CYP 2D6); Citalopram: CYP 2C19, 2D6, 3A4 (weak inhibitor of CYP 2D6); Mirtazapine: CYP 2D6, 3A4, 1A2.
Antidepressants do not modify PI and NNRTI concentrations. The antiretroviral agents may alter the antidepressants levels as summarized. Venlafaxine (and to a lesser extent mirtazapine) has been associated with prolonged QT. This may be relevant in patients on PI and/or methadone who require antidepressants.