dolutegravir, abacavir, lamivudine DTG, (INSTI); ABC, 3TC (two NRTIs)
Standard DoseOne tablet once daily, with or without food, for people with no evidence of INSTI resistance. An additional 50 mg dose of dolutegravir (brand name Tivicay) separated by 12 hours from Triumeq is required for people who have INSTI drug resistance or are taking certain other medications.
For adults and children. Triumeq PD, which are tablets that are dissolved in 20 ml of water and taken within 30 minutes of mixing, are for pediatric patients 22–55 pounds (10–25 kg). Triumeq PD is not interchangeable with the adult formulation. Therefore, adults should not take the pediatric formulation. 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. Dose cannot be adjusted for people with kidney or liver problems. According to the drug label, Triumeq is not recommended for people who have decreased kidney function (creatinine clearance less than 30 mL/min) due to lamivudine component, or those with mild, moderate, or severe liver impairment due to abacavir component. This medication combination, however, is often used in reduced renal function below 30 mL/min, due to relatively minimal risk of lamivudine accumulation and side effects. In addition, alternative doses may be obtained by using the individual components of this medication as needed.
- See the individual drugs contained in Triumeq: Tivicay, Ziagen, and Epivir.
- See package insert for more complete information on potential side effects and interactions.
Potential Side Effects and Toxicity
The most common side effects include insomnia, headache, and fatigue. Data associate INSTIs with weight gain. The pediatric ODYSSEY/PENTA-29 trial reported in 2021 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.
Potential Drug Interactions
Do not take with the antiarrhythmic dofetilide (a heart medication). 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, rifampin, Sustiva, or Rukobia or Aptivus + Norvir, take an additional dose of dolutegravir (Tivicay) 12 hours after taking Triumeq dose. The additional dose of dolutegravir is based on the individual’s weight. 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:
In 2022, the IAS-USA Antiretroviral Guidelines Panel removed Triumeq from the list of regimens recommended for initial HIV treatment due to longstanding concerns that abacavir increases the risk of cardiovascular disease, and to the risk of abacavir hypersensitivity—which can be a very serious side effect—requiring an HLA-B*5701 genetic test prior to prescribing. Now that there are other options, such as Dovato, the benefit of Triumeq appears to have waned. The federal HHS guidelines panel, however, retains Triumeq as an option, while cautioning to avoid abacavir in persons with or at high risk for cardiovascular disease. Both panels agree that Triumeq cannot be used for “rapid” or “same day” start of ART, before labs have returned.
Triumeq shares side effects common to all INSTIs, including 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, so keep track of your weight and pay attention to diet and exercise if you are starting Triumeq. Dolutegravir also slightly raises the level of creatinine in the blood by 0.1-0.15 mg/dL by blocking its secretion at the kidney, not by causing kidney damage.
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. Early concerns about an increased risk of birth defects (specifically neural tube defects) in infants exposed to dolutegravir at the time of conception have been largely put to rest by new data showing no significant difference in neural tube defects between persons on dolutegravir and those on non-dolutegravir-containing regimens. The very small and not statistically significant risk should be discussed with persons of childbearing potential who are starting Triumeq, and all pregnant people should take folate supplements to decrease the risk of neural tube birth defects. (See Tivicay.)
Activist Joey Wynn:
The size of the pill alone poses a big challenge, especially for someone not comfortable with taking pills in the first place. This option has a number of drug-to-drug interactions that make it a second line choice. Talk to your provider and figure out if this is the one for you. People with hepatitis B should definitely pass on this option.