HIV Protease Inhibitor Selection Tool
Choose your patient factors
Select the key characteristics that influence protease inhibitor selection.
Recommended Options
Indinavir
$28-30/month (generic)
Key Benefit: Lowest cost option for budget-sensitive patients
Key Limitation: Requires twice-daily dosing and may cause kidney stones
Darunavir
$150/month (generic)
Key Benefit: High genetic barrier to resistance, once-daily dosing
Key Limitation: Higher cost, requires ritonavir boost
Atazanavir
$120/month (generic)
Key Benefit: Once-daily dosing with minimal lipid impact
Key Limitation: Requires empty stomach for absorption
When you or a loved one needs a protease inhibitor for HIV, you’ll see a long list of brand and generic names. Indinavir is a sulfonated protease inhibitor that was one of the first drugs approved for HIV treatment back in 1996. It still shows up in many treatment plans, but clinicians often wonder whether newer options are a better fit.
Key Takeaways
- Indinavir offers a twice‑daily dosing schedule but can cause kidney stones and lipodystrophy.
- Newer protease inhibitors such as darunavir and atazanavir provide once‑daily dosing and fewer metabolic issues.
- Drug-food interactions differ: atazanavir needs an empty stomach, while darunavir requires a boost with low‑dose ritonavir.
- Cost and insurance coverage vary widely; generic indinavir is often cheaper but may not be covered under modern formularies.
- Choosing the right inhibitor depends on kidney function, pill burden tolerance, and co‑medications.
What Is Indinavir (Indinavir Sulphate)?
Indinavir belongs to the class of protease inhibitors that block the HIV‑1 protease enzyme, preventing the virus from maturing into infectious particles. It is taken as a 800mg capsule twice daily, usually with a full glass of water to reduce the risk of crystalluria. The drug is metabolized mainly by CYP3A4 and excreted unchanged in the urine, making kidney health a crucial factor.
How Does Indinavir Compare to the Most Common Alternatives?
The market now offers several protease inhibitors that differ in dosing frequency, side‑effect profile, and drug‑interaction potential. Below is a side‑by‑side look at the most frequently prescribed alternatives.
| Drug | Typical Dose | Key Advantage | Major Side Effect | Food Interaction |
|---|---|---|---|---|
| Indinavir | 800mg twice daily | Generic, low acquisition cost | Kidney stones, lipodystrophy | Take with a full glass of water; avoid dehydration |
| Ritonavir | 100mg once daily (boosting dose) | Strong CYP3A4 inhibitor, boosts other PIs | Gastro‑intestinal upset, drug‑drug interactions | Can be taken with food |
| Lopinavir/ritonavir (Kaletra) | 400/100mg twice daily | Fixed‑dose combination, widely studied | Hypertriglyceridemia, diarrhea | Take with food to increase absorption |
| Atazanavir | 300mg once daily (with low‑dose ritonavir) | Once‑daily dosing, low lipid impact | Hyperbilirubinemia, potential for rash | Empty stomach; food reduces absorption |
| Darunavir | 800mg once daily (with low‑dose ritonavir) | High genetic barrier to resistance | Moderate lipid changes, nausea | Take with food to improve bioavailability |
| Fosamprenavir | 700mg twice daily (with ritonavir) | Pro‑drug that improves solubility | Diarrhea, abdominal pain | Take with food |
When to Choose Indinavir Over the Others
Even with newer agents on the shelf, indinavir can still be the right pick in specific scenarios:
- Cost‑sensitivity: Generic indinavir often costs less than $30 per month, making it attractive for patients on tight budgets or in countries where newer PIs are not on the national formulary.
- Renal function: If a patient has stable kidney function and can stay well‑hydrated, the risk of crystalluria can be managed.
- Resistance profile: Some HIV‑1 strains that have developed resistance to newer PIs remain susceptible to indinavir, especially in treatment‑experienced patients.
When Alternatives Are a Better Fit
Most clinicians now prefer once‑daily agents when possible, because they improve adherence. Here’s when you’d likely skip indinavir:
- Kidney disease or a history of stones: Atazanavir and darunavir have minimal renal excretion.
- Metabolic concerns: Indinavir is notorious for causing lipodystrophy and raising triglycerides, while atazanavir has a neutral lipid profile.
- Complex drug regimens: Boosted darunavir works well with many other antiretrovirals because its high barrier to resistance reduces the need for frequent resistance testing.
Practical Tips for Switching or Starting Therapy
- Check baseline labs: serum creatinine, hepatic enzymes, fasting lipids, and CD4 count.
- If moving from indinavir to a once‑daily PI, overlap for at least two weeks to avoid a viral rebound.
- Hydration matters: advise patients to drink at least 2L of water daily while on indinavir.
- Review co‑medications for CYP3A4 interactions-especially statins, anticoagulants, and certain antibiotics.
- Schedule a follow‑up viral load test at 4weeks after any change.
Cost & Accessibility Overview (2025)
Pricing data from major pharmacies in the U.S., U.K., and Australia (average retail):
- Indinavir (generic): US$28/month, UK£22/month, AustraliaA$30/month.
- Atazanavir (generic): US$120/month, UK£95/month, AustraliaA$130/month.
- Darunavir (generic): US$150/month, UK£130/month, AustraliaA$160/month.
Insurance plans in 2025 often place indinavir on Tier1, while the newer agents sit in Tier2 or3, affecting copays.
Frequently Asked Questions
Can indinavir cause kidney stones?
Yes. About 1-2% of patients develop crystalluria that can turn into stones, especially if they are dehydrated. Drinking plenty of water and taking the medication with a full glass can lower the risk.
Is it safe to take indinavir with a boosted regimen?
Mixing two protease inhibitors is generally avoided because of overlapping toxicities and heightened CYP3A4 inhibition. If a boost is needed, clinicians normally add low‑dose ritonavir to a newer PI, not indinavir.
How does indinavir’s resistance profile compare to darunavir?
Darunavir has a higher genetic barrier, meaning the virus needs multiple mutations to become resistant. Indinavir’s barrier is lower, so resistance can emerge after a few missed doses.
Do food restrictions differ between indinavir and atazanavir?
Indinavir should be taken with plenty of water, but food does not significantly affect absorption. Atazanavir, on the other hand, loses efficacy if taken with a high‑fat meal; it’s best taken on an empty stomach.
Is indinavir still recommended in 2025 guidelines?
The 2025 WHO and DHHS guidelines list indinavir as an alternative option for patients who cannot access newer agents or who need a low‑cost regimen, provided they have good renal function.
Bottom Line
Indinavir remains a viable, budget‑friendly choice for certain patients, but its twice‑daily schedule and kidney‑related side effects often make newer, once‑daily protease inhibitors a better overall fit. Weighing factors like cost, kidney health, resistance risk, and pill burden will guide the right decision for each individual.
Comments
Julien Martin
October 13, 2025 AT 17:42 PMIndinavir’s pharmacokinetic profile is characterized by high renal excretion, which mandates careful assessment of glomerular filtration rate before initiation. In patients with normal to mildly impaired kidneys, the drug can be dosed twice daily without significant accumulation, but vigilant monitoring of serum creatinine is prudent. Its CYP3A4 metabolism also introduces potential drug–drug interactions, especially with statins and certain antibiotics, so a thorough medication reconciliation is essential. From a cost-effectiveness perspective, the generic formulation remains attractive, especially in resource‑constrained settings where budgetary constraints dominate formulary decisions. However, the twice‑daily schedule may compromise adherence relative to once‑daily agents such as darunavir or atazanavir. Ultimately, the choice hinges on a composite of renal function, pill burden tolerance, and economic considerations.