Triumeq

Triumeq is generally well tolerated. The most common side effects that occurred in 2–3% of study subjects are insomnia, headache, and fatigue. New data associate INSTIs with weight gain. See weight gain in “More information;” go to positivelyaware.com/articles/weighty-concerns and positivelyaware.com/articles/fatty-tissues. Dolutegravir 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, primarily in patients with a history of psychiatric illnesses, in people receiving INSTI-based regimens. DHHS guidelines recommend closely monitoring patients with pre-existing psychiatric conditions on an INSTI. Conflicting data suggest people who have a high risk for 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 for HLA-B*5701 (a genetic marker) to identify patients at risk for this reaction. This test is covered by most insurance and by LabCorp/ViiV (see company contact on co-pay chart).

Read more about HSR on the Ziagen page. Prior to initiation, people should be tested for hepatitis B virus (HBV) infection. Severe exacerbations of hepatitis B have been reported in people co-infected with hepatitis B who have discontinued Triumeq (due to elimination of the lamivudine component, which also treats HBV). Monitor liver enzymes closely in people co-infected with hepatitis B and, if appropriate, initiation of anti-hepatitis B therapy may be warranted upon Triumeq 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. See “More information” regarding pregnancy.

Do not take with the anti-arrhythmic dofetilide (a heart medication). Triumeq should be taken two hours before or six hours after taking antacids or laxatives, the ulcer medication 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). Not intended to be taken with other HIV medications, unless prescribed that way. When taking rifampin, take an additional dose of dolutegravir (in the form of one Tivicay tablet) 50 mg 12 hours after taking your 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 which are not listed here.

Weight gain is becoming more widely recognized as a side effect of INSTIs. In the community, enlargement of the stomach and waist area can be distressing. According to DHHS HIV treatment guidelines, “Weight gain has been associated with initiation of ART [antiretroviral therapy] and subsequent viral suppression. The increase appears to be greater with INSTIs than with other drug classes.” Other factors have been associated with weight gain in addition to medication used, including race, sex, and previous overweight status. There is no word yet on reversibility, but the race is on to find more answers. Dolutegravir is now a preferred medication at the time of conception as well as during pregnancy, per DHHS perinatal guidelines updated in December. See the onlline version of this page. Triumeq is the only single-tablet regimen (STR) that contains Epzicom as the NRTI backbone. Compared to other INSTIs, dolutegravir has a relatively high genetic barrier against the development of drug resistance, similar to the protease inhibitors (such as Prezista). 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.

Dr. Melanie Thompson:

Triumeq is recommended by DHHS and IAS-USA guidelines panels as a first-line initial therapy. It contains the INSTI dolutegravir and 2 NRTIs, abacavir and emtricitabine. Because of the risk of abacavir hypersensitivity (see Ziagen), a negative HLA B*5701 genetic test result must be obtained before starting an abacavir-containing regimen, so Triumeq cannot be used for rapid ART start. In addition, abacavir has been associated with cardiovascular disease in some, but not all, studies. It is generally not recommended for people with known heart disease or high risk for heart disease, when there are other options. Because Triumeq contains 3TC, which has activity against hepatitis B, stopping Triumeq can cause a flair of hepatitis B. Tenofovir (TAF or TDF) rather than lamivudine is recommended for persons with hepatitis B. Triumeq can be taken with or without food and is generally well tolerated, but some may experience insomnia or weight gain associated with dolutegravir. Calcium, magnesium, zinc, aluminum, and iron supplements can lower levels of all INSTIs and dosing recommendations should be observed.  Updated data from the Botswana Tsempano study showed a very small increased risk of neural tube defects (birth defects affecting the developing nervous system) among infants of people who were taking dolutegravir when they became pregnant. Persons capable of pregnancy should discuss these issues with their providers before starting dolutegravir. (See Tivicay.) There have been no concerns about using dolutegravir in the second or third trimesters of pregnancy.

This clears preliminary concerns over the potential for birth defects with dolutegravir raised in 2018 by a study in Botswana. In the latest study data reported in July 2020, it was found that 0.3% of infants exposed to dolutegravir were diagnosed with neural tube defects, compared to 0.1% of infants born to women with HIV on non-dolutegravir containing regimens, and 0.08% of infants born to women without HIV. These data show that the prevalence of the birth defect is not significantly different when taking dolutegravir around the time of conception or during pregnancy compared to other HIV drugs (see summary of data on page 19 of package insert).

Activist Bridgette Picou:

Triumeq can help you achieve your goal of viral suppression. A single tablet, it’s potent, if a bit big. Before starting Triumeq, you will need a blood test to check for a genetic disposition that makes you vulnerable to a hypersensitive reaction. This is one of the reasons people shouldn’t “borrow” a friend’s medication. This can also develop after starting the pill. If it does, stop taking it and notify your clinician. Do not take Triumeq again in this situation. You will want to be monitored for heart and kidney function while on Triumeq. Insomnia and fatigue have been reported on Triumeq. Discuss risks and benefits with a clinician.