The correct answer is D. Elvitegravir is an integrase inhibitor metabolized by CYP3A4, and cobicistat is a novel cytochrome P450 3A4 (CYP3A4) inhibitor utilized as a pharmacoenhancer of antiretroviral drugs. Ketamine is metabolized by CYP3A4, so its levels could increase in the presence of cobicistat. Tenofovir is one of the newer, more tolerable, nucleotide reverse transcriptase inhibitors on the market and is a mainstay of many antiretroviral therapy combinations. In terms of cystitis, lower urinary tract symptoms nocturia, painful hematuria, dysuria, urinary urgency, and incontinence.in persons receiving ketamine affect approximately 20%–40% of individuals who use ketamine recreationally. A dose-response relationship is reported between ketamine exposure and probability of experiencing lower urinary tract symptoms, indicating that long-term exposure to ketamine, which is generally required for many individuals with major depression, may be cause for concern in some cases. It is reassuring that a long-term study with intranasal esketamine did not identify a significant percentage of individuals experiencing genitourinary symptoms. A is incorrect because, although tenofovir alafenamide (TAF) may have less risk of nephrotoxicity than Tenofovir disoproxil fumarate (TDF), the impact on cystitis is unclear and as noted, ketamine at therapeutic doses for depression has not been conclusively demonstrated to increase the risk of cystitis. B is incorrect because although bictegravir/emtricitabine/tenofovir does not inhibit CYP3A4, one should not reflexively rotate a regimen which has led to viral suppression. C is incorrect because although TAF may increase LDL, LDL elevation is in itself not considered a contraindication to proceeding with ketamine therapy.

Publication reference : Wassner C et al. A Review and Clinical Understanding of Tenofovir: Tenofovir Disoproxil Fumarate versus Tenofovir Alafenamide. J Int Assoc Provid AIDS Care . 2020 Jan-Dec:19:2325958220919231. doi: 10.1177/2325958220919231
Reference URL: https://pubmed.ncbi.nlm.nih.gov/32295453/
Publication reference : Greig S, Deeks E. Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Alafenamide: A Review in HIV-1 Infection. Drugs 2016;76:957-68.
Reference URL: https://pubmed.ncbi.nlm.nih.gov/27189707/
Publication reference : McIntyre R et al. Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation. AJP 2021; 178: 383–399
Reference URL: https://pmc.ncbi.nlm.nih.gov/articles/PMC9635017/