ritonavir
Ritonavir (Norvir) is an oral medication that's used as part of an antiretroviral (ARV) regimen to treat human immunodeficiency virus (HIV) infections. It comes in three different formulations: tablets, powder, and solution. In particular, the tablets are available as brand name and generic. Some common side effects of this medication include diarrhea, nausea, vomiting, and belly pain. Finally, ritonavir (Norvir) has many serious interactions with other medications, so always let your provider know all the medications you take before starting ritonavir (Norvir).
What is Ritonavir (Norvir)?
What is Ritonavir (Norvir) used for?
Treatment of HIV infection (taken with other antiretroviral medications)
How Ritonavir (Norvir) works
Ritonavir (Norvir) is a protease inhibitor, which means it blocks a protein called protease. Normally, protease helps to process viral proteins so that the HIV virus can infect healthy cells. By blocking protease from working, ritonavir (Norvir) prevents the virus from making copies of itself and spreading.
In addition, ritonavir (Norvir) can slow the breakdown of other HIV ARVs. This "boosts" the levels of the other HIV ARVs, which helps them to work better to fight the infection. Ritonavir (Norvir) is most commonly used as a "booster" of other HIV medications.
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What are the side effects of Ritonavir (Norvir)?
Common Side Effects
- Diarrhea (68%)
- Nausea (57%)
- Pins and needles sensation (51%)
- Feeling weak or tired (46%)
- High cholesterol levels (up to 45%)
- Vomiting (32%)
- Rash (27%)
- Belly pain (26%)
- Coughing (22%)
- Back and joint pain (19%)
- Throat pain (16%)
- Feeling dizzy (16%)
- Changes in taste (16%)
- Flushing (13%)
- Indigestion (12%)
- Itching (12%)
- Nerve pain (10%)
Other Side Effects
- Excessive gas
- Blurry vision
- Heartburn
- Swelling
- Muscle pain
- Spinning sensation
- Changes in attention
- More urination
- Feeling cold in hands and feet
- Acne
Serious Side Effects
- Severe allergic reactions: facial swelling, hives, rash, itchy skin, blistering or peeling of skin, body aches, trouble breathing
- Serious liver problems: nausea, vomiting, not feeling hungry, pain in the right side of the stomach, yellowing of the whites of the eyes or skin, dark-colored urine, light-colored stool
- Abnormal heart rhythm: chest pounding, trouble breathing, chest pain, feeling faint or lightheaded
Source: DailyMed
The following side effects have also been reported
Side effects that you should report to your care team as soon as possible:
- Allergic reactions—skin rash, itching, hives, swelling of the face, lips, tongue, or throat
- Heart rhythm changes—fast or irregular heartbeat, dizziness, feeling faint or lightheaded, chest pain, trouble breathing
- High blood sugar (hyperglycemia)—increased thirst or amount of urine, unusual weakness or fatigue, blurry vision
- Liver injury—right upper belly pain, loss of appetite, nausea, light-colored stool, dark yellow or brown urine, yellowing skin or eyes, unusual weakness or fatigue
- Pancreatitis—severe stomach pain that spreads to your back or gets worse after eating or when touched, fever, nausea, vomiting
- Redness, blistering, peeling, or loosening of the skin, including inside the mouth
Side effects that usually do not require medical attention (report to your care team if they continue or are bothersome):
Pros and cons of Ritonavir (Norvir)
Pros
Available as a lower-cost generic medication
Available in a liquid or powder form for people who have difficulty swallowing pills
Can be used in young children 1 month or older
Can help other HIV ARVs to work better when taken together (e.g., darunavir (Prezista))
Cons
The oral solution and powder forms both have a bitter metallic taste
Interacts with a lot of medications
Requires regular blood work and lab tests
Available as 100-mg tablets, which means you might need to take up to 6 tablets for one dose
Pharmacist tips for Ritonavir (Norvir)
Ritonavir (Norvir) should always be taken along with other HIV ARVs and with food. This combination works better against HIV infection for you.
Get your routine blood tests done on time while you’re taking ritonavir (Norvir). Lab work is important to make sure that ritonavir (Norvir) works against the virus, and that the medication isn't causing unwanted effects.
Ritonavir (Norvir) can interact with many medications. Some medications might need to be stopped or the dose changed before you start HIV ARV regimen. Let your provider or pharmacist know what medications you're taking, including over-the-counter products and supplements.
Ritonavir (Norvir) might raise your blood sugars. This can lead to or worsen diabetes. If you have diabetes, it's important that you check your blood sugar while taking this medication. Talk to your provider to see if you need additional medications to help control your sugar levels during treatment with ritonavir (Norvir).
Ritonavir (Norvir) might also raise your cholesterol (fat) levels. This can raise your risk of a heart attack or stroke. If you have a history of high cholesterol, talk to your provider to see if you need additional medications to help control your cholesterol levels during treatment with ritonavir (Norvir).
Always follow the directions on your medications. This is extra important for HIV ARV medications. Don't stop or start any HIV medications, including ritonavir (Norvir), without speaking to your provider. Doing so can cause the virus to become harder to treat.
More tips for taking ritonavir (Norvir) oral solution or powder:
Ritonavir (Norvir) oral solution should be kept in its original container and at room temperature. Remember to shake it before each dose. And use the dosing cup provided to take your dose.
Ritonavir (Norvir) oral solution might have a bitter aftertaste. Mixing it with chocolate milk or nutritional shakes (e.g., Ensure) can improve the taste. Make sure to drink the whole mixture within an hour of it being mixed.
Ritonavir (Norvir) oral solution contains alcohol. It's not a good option for pregnant people, people receiving the medication through certain feeding tubes, and those who can't drink alcohol. Consider taking ritonavir (Norvir) oral powder as an alternative option.
Ritonavir (Norvir) oral powder can be mixed with soft food (applesauce, pudding) or liquid (water, infant formula, milk). The mixture should be given within 2 hours of mixing. Make sure you receive detailed instructions for mixing when you pick up the medication at the pharmacy.
Frequently asked questions about Ritonavir (Norvir)
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What are the risks and warnings for Ritonavir (Norvir)?
Ritonavir (Norvir) can cause some serious health issues. This risk may be even higher for certain groups. If this worries you, talk to your doctor or pharmacist about other options.
Interactions with other medications
Some medications can interfere with how well your body gets rid of ritonavir (Norvir) from your system. This can affect the amount of ritonavir (Norvir) in your body, how well it works, and the risk of side effects.
Taking certain supplements (e.g., St. John's Wort) or tuberculosis medication (e.g., rifampin (Rifadin)) can lower the amount of ritonavir (Norvir) in your body. This can make ritonavir (Norvir) not work as well to treat your HIV. So this combination must be avoided.
Ritonavir (Norvir) also interferes with how your body gets rid of other medications. For example, taking ritonavir (Norvir) with medications like alfuzosin (Uroxatral) can raise the amount of alfuzosin in your body. This can lead to dangerously low blood pressure. In addition, taking ritonavir (Norvir) with some statins (e.g., lovastatin (Altoprev), simvastatin (Zocor)) can cause your body to absorb more of these statins and raise your risk for serious muscle problems.
Because of the potential for serious interactions with ritonavir (Norvir) and various medications, tell your provider and pharmacist about all the medications you take or plan to take. They can make sure your medications are safe to take together.
Liver problems
Risk factors: Hepatitis B or C | History of liver problems
Ritonavir (Norvir) can cause life-threatening liver problems. These are more common in the first 3 months of treatment. Your provider will order blood tests for you before and during treatment so they can make sure this medication is safe for your liver. Let your provider know immediately if you experience signs and symptoms of liver damage, such as feeling sleepy, nausea, loss of appetite, light-colored stool, upper right stomach pain, yellowing of the skin or eyes, or dark urine.
Pancreas problems
Risk factors: Too much triglycerides (fats) in your blood | Advanced HIV
Though rare, few people who took ritonavir (Norvir) have reported having inflammation of the pancreas (pancreatitis). These people often have too much triglycerides (fats) in their blood as well. Stop taking ritonavir (Norvir) and let your provider know right away if you experience symptoms of an inflamed pancreas, such as pain in the upper stomach, fever, nausea, and vomiting.
Heart rhythm problems (PR prolongation)
Risk factors: History of heart problems | Taking medications that affect heart rhythm
Ritonavir (Norvir) can affect your heart rhythm, which can be serious and life-threatening. Your risk is higher if you've certain conditions, including electrolyte levels that's out of balance, heart rhythm problems, or are taking other medications that cause heart rhythm problems, such as digoxin (Lanoxin), among others. If you feel your chest pounding, have trouble breathing, have chest pain, or feel faint or lightheaded while taking ritonavir (Norvir), get medical attention right away.
Severe skin and allergic reactions
Ritonavir (Norvir) can sometimes cause rash and other severe skin reactions. If you have a mild or moderate rash, continue to take ritonavir (Norvir) and let your provider know. If you have a severe rash or your rash gets worse, talk with your provider right away. In rare cases, if you experience a severe rash with fever, general discomfort, muscle or joint pain, mouth sores, blisters, or facial swelling, stop taking ritonavir (Norvir) right away and get medical attention.
High blood sugar
Risk factor: Taking certain HIV ARVs (e.g., protease inhibitors)
Taking ritonavir (Norvir) and certain HIV ARVs can raise your blood sugar levels or worsen your diabetes. In some cases, your provider will need to adjust your dose of diabetic medications to make sure your blood sugar is under control. If you have a history of diabetes, let your provider know before starting ritonavir (Norvir). Your provider might ask you to check your blood sugar at home to make sure this medication is safe for you.
Higher cholesterol levels
Risk factor: Taking Invirase (saquinavir)
Ritonavir (Norvir) raises the amount of cholesterol and triglycerides (fats) in your blood, which can put you at higher risk for a heart attack or stroke. Your provider will monitor your blood works before and during treatment with this medication to make sure it's safe for you. If your cholesterol levels are too high, your might need to take medications to help keep them under control. Keep in mind that certain cholesterol medications, such as lovastatin (Altoprev) or simvastatin (Zocor), should be avoided with ritonavir (Norvir) to prevent serious side effects. Make sure to let your provider know all the medications you're taking before being prescribed new ones.
Changes in body fat
Rarely, people taking HIV medications, such as ritonavir (Norvir), have experienced changes in body fat. These changes include fat buildup in the back of the neck, breast, and around the middle of the body. Some people also lost fat from the legs, arms, and face. It's not clear whether ritonavir (Norvir) causes these changes to body fat, why this happens, and whether it will affect your health in the future. Let your provider know if these changes occur while you're taking ritonavir (Norvir).
Overactive immune system
Taking combination ARV therapy, such as ritonavir (Norvir) with other HIV medications, can cause changes to your immune system called immune reconstitution syndrome. This condition happens when your immune system becomes overly active after you start combination therapy. So your immune system begins to fight off different infections that it was too weak to fight off before you started treatment. In rare cases, your immune response might improve too much with treatment that it starts to attack normal cells in your body (autoimmune). You can develop these conditions as early as during the first few weeks of treatment or many months later. Tell your healthcare provider right away if you start having any new symptoms, such as fever, pain, hair loss, bulging eyes, or sweating, after starting ritonavir (Norvir).
Risk of bleeding
Risk factor: History of bleeding problems
Some people with a bleeding condition called hemophilia have had more bleeding after starting protease inhibitors, such as ritonavir (Norvir). About half the time, you can continue taking this medication after the bleeding stops. Let your provider know if you notice sudden bleeding or have bleeding that's difficult to stop.
Potential harm to newborns (oral solution only)
Risk factor: Babies who are born early
Ritonavir (Norvir) oral solution contains ethanol and propylene glycol, which are typically safe for children and adults. But in babies who are born early, this combination can raise the risk of propylene glycol side effects, which can sometimes be life-threatening. If you notice you or your child has trouble breathing, feels dizzy, has no appetite, nausea, or vomiting, get medical attention right away.
Ritonavir (Norvir) dosage forms
| Dosage | Quantity | Price as low as | Price per unit |
|---|---|---|---|
| 100mg | 30 tablets | $39.63 | $1.32 |
Typical dosing for Ritonavir (Norvir)
Adults: The typical starting dose is 300 mg by mouth twice daily with food. Your provider will raise your dose over time, typically to the recommended dose of 600 mg twice daily.
Children (older than 1 month of age): Your child's provider will determine their dose based on body surface area (BSA), which is your child's body size calculated based on weight and height. The typical dose ranges from 50 mg by mouth twice daily to 600 mg twice daily, depending on BSA.
Your dose might be different depending on what other HIV medications (e.g., darunavir (Prezista), atazanavir (Reyataz)) you take.
How much does Ritonavir (Norvir) cost?
Ritonavir (Norvir) contraindications
Taken with certain medications that are cleared by a specific liver protein (CYP3A4), including alfuzosin (Uroxatral), Multaq (dronedarone), lovastatin, and simvastatin (Zocor)
What are alternatives to Ritonavir (Norvir)?
Treatment of HIV infection (taken with other antiretroviral medications)
HIV treatment, in combination with Reyataz (atazanavir) or Prezista (darunavir) once daily
Treatment of HIV infection (used with other antiretroviral medications)
What is the latest news about Ritonavir (Norvir)?
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References
Best studies we foundAbbVie Inc. (2022). Norvir- ritonavir tablet, film coated; ritonavir solution; ritonavir powder [package insert]. DailyMed.
Centers for Disease Control and Prevention. (2021). What are condoms?
Centers for Disease Control and Prevention. (2023). What is hemophilia?
Cipla USA Inc. (2023). Ritonavir film coated- ritonavir 100 mg tablet [package insert]. DailyMed.
Clinical Info HIV.gov. (2023). Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States — What's new in the guidelines.
Clinical Info HIV.gov. (n.d.). Boosting.
Clinical Info HIV.gov. (n.d.). Immune reconstitution inflammatory syndrome (IRIS).
Clinical Info HIV.gov. (n.d.). Protease.
Hallare, J., et al. (2023). Half life. StatPearls.
HIVinfo.NIH.gov. (2021). HIV treatment — Drug resistance.
National Institute of Allergy and Infectious Diseases. (2017). Prevention of perinatal HIV transmission.
Talha, B., et al. (2023). Ritonavir. StatPearls.
Thapa, S., et al. (2023). Immune reconstitution inflammatory syndrome. StatPearls.
U.S. Food and Drug Administration. (2023). Drug development and drug interactions | Table of substrates, inhibitors and inducers.
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