Atripla / Symfi / Symfi Lo
Atripla is for adults and children 12 years of age and older weighing at least 88 pounds (40 kg). Symfi Lo is for adults and pediatric patients weighing at least 77 pounds (35 kg) and Symfi is for those who are at least 88 pounds (40 kg).
Take missed dose as soon as possible, unless it is closer to the time of your next dose. Do not double up on your next dose. Should not be used by people with moderate or severe kidney or liver impairment.
Atripla
600 mg efavirenz, 200 mg emtricitabine, 300 mg tenofovir DF
EFV (NNRTI), FTC and TDF (two NRTIs)
Symfi
600 mg efavirenz, 300 mg lamivudine, 300 mg tenofovir DF
EFV (NNRTI), 3TC and TDF (two NRTIs)
Symfi Lo
400 mg efavirenz, 300 mg lamivudine, 300 mg tenofovir DF
EFV (NNRTI), 3TC and TDF (two NRTIs)
- See the individual drugs contained in Atripla: Sustiva and Truvada.
- See the individual drugs contained in Symfi and Symfi Lo: Sustiva, Epivir, and Viread.
- See package insert for more complete information on potential side effects and interactions.
bms.com; atripla.com
(800) 321-1335
Gilead Sciences, Inc.
gilead.com; (800) GILEAD-5 (445–3235)
Mylan
symfi.com; symfi-lo.com
mylan.com
(877) 446-3679
Generic is available.
Symfi: $2,201.46/month
Symfi Lo: $2,201.46/month
JO-ANN JOSE, MD, MPH:
People can have very vivid dreams and balance issues that make it perhaps more likely for someone to experience a fall; other central nervous system issues include depression, sleepiness, headache and suicidality. Of the three drugs that comprise Atripla, efavirenz has a longer half-life than the other two components—it can stay in your system longer even after the other two drugs have washed out of your system, which creates the possibility for the virus to develop drug resistance. It’s also important to note that Atripla contains tenofovir disoproxil fumarate, or TDF, which is associated with some kidney and bone side effects that TAF, the newer formulation of tenofovir, is not associated with. As we think about aging and comorbidity development, I recommend a conversation with your care provider and may recommend a change from Atripla. Symfi Lo contains only 400 mg of efavirenz so it may have fewer side effects.
Avoid taking with drugs that negatively affect the kidneys, including chronic use or high doses of anti-inflammatory drugs for pain such as aspirin, ibuprofen and naproxen. Should not be taken with voriconazole, ergot derivatives, midazolam, pimozide, triazolam, bepridil or St. John’s wort, or medications that prolong QTc interval (these abnormal heart rhythms can make the heart stop) or with a risk for torsades de pointes. It is recommended to add 200 mg Sustiva (800 mg total) when taking rifampin for people weighing at least 110 pounds. May affect warfarin levels. Can decrease levels of buprenorphine and methadone—monitor for withdrawal. When taken with carbamazepine, phenobarbital or phenytoin, periodic monitoring of anticonvulsant and efavirenz levels should be done or alternative anti-seizure drugs considered. Effectiveness of birth control pills may be decreased. Closer monitoring and dose adjustments may be required with posaconazole (avoid unless benefit outweighs potential risk) and itraconazole. Monitor clarithromycin effectiveness or consider azithromycin. Monitor immunosuppressant level when starting or stopping. Cardizem, Lipitor, Pravachol and Zocor doses may need to be adjusted. Titrate dose of bupropion and sertraline based on clinical response. Use caution with Harvoni; monitor renal function closely. Should not be taken with Epclusa or Zepatier. Tell your provider or pharmacist about all medications, herbals and supplements you are taking or thinking of taking, prescribed or not, as there are other drug interactions not listed here.
Use with caution in individuals with depression or other psychiatric issues who are not receiving mental health care. People should be screened for depression and suicidality. Dizziness, drowsiness, abnormal or vivid dreams, difficulty concentrating, rash, diarrhea, nausea, fatigue, headache or insomnia may go away after a few weeks. TDF is associated with long-term decreases in bone mineral density. Prior to initiation, kidney function and hepatitis B status should be assessed (monitor liver enzymes closely in people with co-infection). Initiation of HBV therapy may be warranted upon discontinuation. Call your health care provider right away if you develop any of the following signs or symptoms of hepatitis: yellowing of the skin or whites of the eyes; dark or tea-colored urine; pale-colored bowel movements; nausea or vomiting; loss of appetite or pain, aching or tenderness on the right side below the ribs. Late-onset neurotoxicity—including ataxia and encephalopathy (impaired consciousness, confusion, psychomotor slowing, psychosis and delirium)—may occur months to years after beginning EFV. A link between efavirenz and birth defects in humans has not been supported in meta-analyses. The recommendation is that pregnant people in their first trimester continue taking efavirenz as long as their viral load remains undetectable; however, efavirenz should only be used if the potential benefit outweighs the potential risk (as when other treatment options are not available). It is recommended to screen for antenatal and postpartum depression in recently pregnant people. Efavirenz can cause a false positive result for marijuana on certain drug tests. A confirmatory test can be done.
Check with your provider or pharmacist first before stopping these drugs, so that you avoid the rapid development of HIV resistance to efavirenz. A genetic trait affecting efavirenz metabolism, causing a higher rate of side effects, occurs more in African Americans. NNRTIs are not recommended for HIV-2, primarily found in West Africa but also present in other countries, as it is resistant to NNRTIs. If you can’t sleep, ask your doctor about gradually adjusting the timing of your dose until it’s taken during the day. Pregnant individuals can voluntarily enroll in the Antiretroviral Pregnancy Registry through their provider; GO TO apregistry.com.
JUAN MICHAEL PORTER II:
Atripla was the first complete, one-pill-a-day HIV treatment option. It didn’t have some of the wilder physical side effects associated with other options, but it became clear that it could cause depression, sudden sleepiness, frightening dreams and other neurocognitive issues. One of my best friends is no longer the same person after a decade of its use—his memory is gone. So while it’s effective and forgiving (can be taken for five days with a two-day break), one of my doctor friends told me, “Tolerability can change over time,” and he saw no reason to prescribe it anymore. Despite their lower price, he felt the same way about Symfi and Symfi Lo.