Triumeq

The most common side effects include insomnia, headache, and fatigue. Data associate INSTIs with weight gain. The pediatric ODYSSEY/PENTA-29 trial reported this year did not observe the weight gain seen in adults. DTG can cause a small, reversible increase in serum creatinine within the first few weeks of treatment, but does not affect actual kidney function. There have been rare reports of depression and suicidal ideation with INSTIs, primarily in people with a history of psychiatric illnesses. DHHS guidelines recommend closely monitoring people with pre-existing psychiatric conditions. Conflicting data suggest people who have a high risk of cardiovascular problems have a potential for heart problems when using abacavir-containing regimens. Monitor for signs of hypersensitivity reaction (HSR) to abacavir. Prior to starting Triumeq, all individuals should be given a simple blood test to identify people at risk for this reaction. This test is covered by most insurance and by LabCorp/ViiV. Prior to initiation, test for hepatitis B virus (HBV). Severe exacerbations of HBV have been reported in people with co-infection who have discontinued Triumeq (due to elimination of the lamivudine component, which also treats HBV). Monitor liver enzymes closely. Initiation of HBV therapy may be warranted upon discontinuation of Triumeq. Call your health care provider right away if you develop any of the following signs 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.

Do not take with dofetilide. Triumeq should be taken two hours before or six hours after taking antacids or laxatives, sucralfate, iron or calcium supplements, or buffered medications. Triumeq can be taken together with iron- or calcium-containing supplements if taken with food. Other acid reducers/heartburn medications (e.g., Aciphex, Dexilant, Nexium, Pepcid, Prevacid, Prilosec, and Zantac) are okay to use. Avoid co-administration with oxcarbazepine, phenobarbital, phenytoin, or St. John’s wort. Start metformin at lowest dose and titrate based on tolerability and clinical effect. Monitor for metformin adverse effects. Avoid use of sorbitol-containing medicines with lamivudine; there are many, such as acetaminophen liquid (Tylenol liquid and others). May increase levels of dalfampridine, which may increase the risk of seizures. When taking carbamazepine or rifampin, take an additional dose of DTG (in the form of one Tivicay tablet) 50 mg 12 hours after taking Triumeq dose. 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 that are not listed here.

Triumeq has relatively few drug interactions and is well tolerated. Triumeq does not cover hepatitis B as well as other STRs and therefore requires another anti-HBV medication in addition to its lamivudine component. Triumeq is a relatively large STR tablet, which can potentially be an issue for individuals who have difficulty swallowing. Other STRs containing dolutegravir are Juluca and Dovato. Pregnant individuals can voluntarily enroll in the Antiretroviral Pregnancy Registry through their provider; go to apregistry.com.

Dr. Melanie Thompson:

Triumeq is the only 3-drug INSTI-based STR not using a tenofovir base. This is helpful for people with renal or bone density abnormalities who can’t take TDF or even TAF. The risk of abacavir hypersensitivity must be addressed with an HLA-B*5701 test prior to prescribing, therefore Triumeq cannot be used for rapid HIV treatment initiation.

Side effects common to all INSTIs may include insomnia or, rarely, worsening of depression or suicidal ideation, particularly if there are pre-existing mental health issues.  Dolutegravir can be associated with weight gain, especially for women and African Americans. Keep track of your weight and pay attention to diet and exercise if you are starting Triumeq. There are concerns about using abacavir in persons with or with high risk for cardiovascular disease (see Ziagen).

The DHHS panel recommends avoiding abacavir in persons with, or at high risk for, cardiovascular disease.

Drug interactions with dolutegravir are few but some are important. Do not take dofetilide or St. John’s wort, and talk with your HIV care provider if you are taking metformin or medications for seizures or tuberculosis. For more info on drug interactions, see the comments about Tivicay.

Concerns have decreased regarding serious birth defects (specifically neural tube defects) in infants when dolutegravir is taken at the time of conception. The very small and not statistically significant risk should be discussed with persons of childbearing potential who are starting Triumeq. (See Tivicay.)

Activist Michael Broder:

Triumeq (approved in 2014) cannot be taken by people who have a certain gene that makes them more likely to have a life-threatening allergic reaction to abacavir (your doctor will test you for the gene before prescribing Triumeq). Triumeq should not be taken by people with HBV. Concerns have emerged about weight gain on INSTI-containing regimens. As always, your provider should help you weigh the benefits against the risks.