Indinavir vs Other HIV Protease Inhibitors: Full Comparison & Alternatives

Choosing the right protease inhibitor for HIV can feel like navigating a maze of pills, doses, and side‑effects. If you’ve landed on this page, you probably want to know how Indinavir measures up against the other options on the market and whether an alternative might suit your lifestyle or health needs better.

What is Indinavir (Indinavir Sulphate)?

Indinavir is a synthetic protease inhibitor that blocks the HIV‑1 protease enzyme, preventing the virus from maturing into an infectious form. Sold under the brand name Crixivan, it was one of the first drugs in the class and remains a viable choice for many patients.

Key attributes:

• Typical dose: 800mg taken three times daily with plenty of water.
• Half‑life: roughly 1.5hours, which is why it requires multiple daily doses.
• Metabolism: primarily by CYP3A4 in the liver.
• Excretion: about 80% unchanged in urine, so kidney function matters.

Common side‑effects include kidney stones, high bilirubin, and a metallic taste. Because it’s cleared through the kidneys, patients with chronic kidney disease often need to switch to a drug that isn’t so renal‑heavy.

Why Look at Alternatives?

Even though Indinavir works well for many, several practical issues push clinicians and patients to consider other protease inhibitors:

• Kidney concerns: Stone formation can be painful and may require intervention.
• Convenience: Three‑times‑daily dosing can clash with work or school schedules.
• Drug interactions: Strong CYP3A4 metabolism means many meds can raise or lower Indinavir levels.
• Resistance patterns: Some viral strains have become less susceptible to older inhibitors.

Below is a side‑by‑side look at the most frequently prescribed alternatives.

When to Switch from Indinavir

If you’ve experienced any of the following, it’s worth a chat with your HIV specialist:

1. Recurrent kidney stones. Even with high fluid intake, some patients keep forming stones.
2. Difficulty adhering to three‑times‑daily dosing. Missing doses can let the virus rebound.
3. Significant drug‑drug interactions. For example, certain antifungals or antibiotics can cause toxic levels.
4. Elevated bilirubin or liver enzymes. Atazanavir also raises bilirubin, but it’s usually less painful than stones.

Switching early can keep your viral load suppressed and protect your kidneys.

Alternative #1 - Saquinavir

Saquinavir entered the market shortly after Indinavir. It’s available as a soft‑gel capsule that can be taken twice daily, simplifying the schedule. Because it’s not heavily excreted by the kidneys, it’s gentler on renal function.

Saquinavir’s biggest drawback is its reliance on a high‑fat meal for optimal absorption, which can be inconvenient for people watching their diet. It also has a higher propensity for drug‑interaction warnings, especially with statins.

Alternative #2 - Lopinavir/ritonavir (Kaletra)

Lopinavir/ritonavir combines two protease inhibitors in a single pill. Ritonavir acts as a “booster,” slowing the metabolism of lopinavir so the drug stays in the body longer. This lets patients stick to a twice‑daily regimen.

While the combo is potent, it often raises cholesterol and triglycerides, which can be a concern for patients with cardiovascular risk. It also has a distinctive taste that some find off‑putting.

Alternative #3 - Atazanavir (with or without ritonavir boost)

Atazanavir is known for its once‑daily dosing when paired with ritonavir. It’s praised for causing fewer metabolic disturbances compared with lopinavir/ritonavir.

The trade‑off is a higher chance of developing indirect hyperbilirubinemia, which can cause yellowing of the skin. Usually it’s harmless, but it can be cosmetically concerning for some patients.

Alternative #4 - Darunavir (with ritonavir boost)

Darunavir is a newer, high‑potency protease inhibitor that works well against many resistant HIV strains. Dosed once or twice daily depending on the boost, it gives flexibility.

Side‑effects are generally mild, but the drug does interact with a broad range of medications, so a thorough medication review is essential before starting.

Decision Checklist - Is Indinavir Right for You?

• Do you have normal kidney function? If yes, Indinavir remains a solid option.
• Can you commit to three daily doses with plenty of water? If you struggle, consider a once‑daily alternative.
• Are you on other meds that affect CYP3A4? If many, a drug with fewer interactions (like Atazanavir) might be safer.
• Do you experience frequent kidney stones or high bilirubin? Switch early to protect organ health.

Talk to your provider about your lifestyle, lab results, and any side‑effects you’ve noticed. A tailored regimen can keep your viral load undetectable and your quality of life high.