-
HIV RNA <100,000 copies/mL
Table 1 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII], [CIII] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:11 DTG2/ABC3/3TC (Triumeq), EFV6/TDF/FTC (Atripla), EVG/c/TDF/FTC4 (Stribild), or RPV/TDF/FTC (Complera)
- Osteoporosis: consider avoiding TDF12
- Psychiatric illnesses: consider avoiding EFV13
- HIV-assoc dementia (HAD): use DRV5,9 or DTG;2 avoid EFV if possible14
- Methadone for NRT: consider avoiding EFV15
- High cardiac risk: consider avoiding ABC and LPV/r16
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV, EVG/c17
- HBV infxn: use TDF/(3TC/FTC)18 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)19
- TB infxn treated w/ rifampin: use EFV;6,20 if RAL or DTG2 used, adjust dose;21 if PI used, switch rifampin to rifabutin22 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
5 DRV not recommended in severe hepatic impairment.
6 Use EFV w/ caution in hepatic impairment.
7 ATV/c not recommended in hepatic impairment.
8 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
9 DRV/c not recommended in Child-Pugh Class C.
10 Use LPV/r with caution in hepatic impairment.
11 Available as fixed-dose combo tablets.
12 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
13 EFV can worsen psych sx, may be assoc w/ suicidality.
14 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
15 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
16 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
17 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV, EVG/c assoc w/ deleterious lipid effects.
18 TDF, FTC, 3TC are active vs HIV/HBV.
19 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
20 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
21 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid reduced in resistant pts.
22 Rifabutin is less potent inducer than rifampin and is good option for pts on non-EFV-based regimens.
Select antiretroviral regimen1 Table 2 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII], [CIII] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF10
- CrCl <50 mL/min: do not use coformulated ABC3/3TC11
- One-pill, once-daily regimen desired:12 DTG2/ABC3/3TC (Triumeq), EFV6/TDF/FTC (Atripla), or RPV/TDF/FTC (Complera)
- Osteoporosis: consider avoiding TDF13
- Psychiatric illnesses: consider avoiding EFV14
- HIV-assoc dementia (HAD): use DRV4,7 or DTG;2 avoid EFV if possible15
- Methadone for NRT: consider avoiding EFV16
- High cardiac risk: consider avoiding ABC and LPV/r17
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV18
- HBV infxn: use TDF/(3TC/FTC)19 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active agaiinst HBV [BII] w/ (3TC/FTC)20
- TB infxn treated w/ rifampin: use EFV;5,21 if RAL or DTG2 used, adjust dose;22 if PI used, switch rifampin to rifabutin23 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 ATV/c not recommended in hepatic impairment.
7 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
8 DRV/c not recommended in Child-Pugh Class C.
9 Use LPV/r with caution in hepatic impairment.
10 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7days.
11 3TC requires dose adj: if CrCl 30-49, use 150 mg q24h; if CrCl 15-29, use 150 mg x1, then 100 mg q24h; if CrCl 5-14, use 150 mg x1, then 50 mg q24h; if CrCl <5 or pt on HD, use 50 mg x1, then 25 mg q24h.
12 Available as fixed-dose combo tablets.
13 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
14 EFV can worsen psych sx, may be assoc w/ suicidality.
15 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
16 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
17 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
18 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV assoc w/ deleterious lipid effects.
19 TDF, FTC, 3TC are active vs HIV/HBV.
20 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
21 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
22 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
23 Rifabutin is less potent inducer than rifampin and is good option for pts receiving non-EFV-based regimens. HLA-B*5701 positive/unknown Select antiretroviral regimen1 Table 3 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [CI], [CII] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:10 EFV5/TDF/FTC (Atripla), EVG/c/TDF/FTC4 (Stribild), or RPV/TDF/FTC (Complera)
- Osteoporosis: consider avoiding TDF11
- Psychiatric illnesses: consider avoiding EFV12
- HIV-assoc dementia (HAD): use DRV4,8 or DTG;2 avoid EFV if possible13
- Methadone for NRT: consider avoiding EFV14
- High cardiac risk: consider avoiding LPV/r15
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV, EVG/c16
- HBV infxn: use TDF/(3TC/FTC)17 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)18
- TB infxn treated w/ rifampin: use EFV;5,19 if RAL or DTG2 used, adjust dose;20 if PI used, switch rifampin to rifabutin21 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 ATV/c not recommended in hepatic impairment.
7 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
8 DRV/c not recommended in Child-Pugh Class C.
9 Use LPV/r with caution in hepatic impairment.
10 Available as fixed-dose combo tablets.
11 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
12 EFV can worsen psych sx, may be assoc w/ suicidality.
13 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
14 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
15 LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
16 TDF assoc w/ beneficial lipid effects. PI/r, EFV, EVG/c assoc w/ deleterious lipid effects.
17 TDF, FTC, 3TC are active vs HIV/HBV.
18 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
19 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
20 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
21 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 4 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [CI] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF7
- One-pill, once-daily regimen desired:8 EFV4/TDF/FTC (Atripla) or RPV/TDF/FTC (Complera)
- Osteoporosis: consider avoiding TDF9
- Psychiatric illnesses: consider avoiding EFV10
- HIV-assoc dementia (HAD): use DRV3 or DTG;2 avoid EFV if possible11
- Methadone for NRT: consider avoiding EFV12
- High cardiac risk: consider avoiding LPV/r13
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV14
- HBV infxn: use TDF/(3TC/FTC)15 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)16
- TB infxn treated w/ rifampin: use EFV;4,17 if RAL or DTG2 used, adjust dose;18 if PI used, switch rifampin to rifabutin19 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 DRV not recommended in severe hepatic impairment.
4 Use EFV w/ caution in hepatic impairment.
5 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
6 Use LPV/r with caution in hepatic impairment.
7 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
8 Available as fixed-dose combo tablets.
9 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
10 EFV can worsen psych sx, may be assoc w/ suicidality.
11 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
12 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
13 LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
14 TDF assoc w/ beneficial lipid effects. PI/r, EFV assoc w/ deleterious lipid effects.
15 TDF, FTC, 3TC are active vs HIV/HBV.
16 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
17 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
18 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
19 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 5 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII], [CIII] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:11 DTG2/ABC3/3TC (Triumeq), EFV6/TDF/FTC (Atripla), or EVG/c/TDF/FTC4 (Stribild)
- Osteoporosis: consider avoiding TDF12
- Psychiatric illnesses: consider avoiding EFV13
- HIV-assoc dementia (HAD): use DRV5,9 or DTG;2 avoid EFV if possible14
- Methadone for NRT: consider avoiding EFV15
- High cardiac risk: consider avoiding ABC and LPV/r16
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV, EVG/c17
- HBV infxn: use TDF/(3TC/FTC)18 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)19
- TB infxn treated w/ rifampin: use EFV;6,20 if RAL or DTG2 used, adjust dose;21 if PI used, switch rifampin to rifabutin22 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
5 DRV not recommended in severe hepatic impairment.
6 Use EFV w/ caution in hepatic impairment.
7 ATV/c not recommended in hepatic impairment.
8 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
9 DRV/c not recommended in Child-Pugh Class C.
10 Use LPV/r with caution in hepatic impairment.
11 Available as fixed-dose combo tablets.
12 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
13 EFV can worsen psych sx, may be assoc w/ suicidality.
14 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
15 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
16 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
17 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV, EVG/c assoc w/ deleterious lipid effects.
18 TDF, FTC, 3TC are active vs HIV/HBV.
19 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
20 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
21 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
22 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 6 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII], [CIII] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF10
- CrCl <50 mL/min: do not use coformulated ABC3/3TC11
- One-pill, once-daily regimen desired:12 DTG2/ABC3/3TC (Triumeq) or EFV5/TDF/FTC (Atripla)
- Osteoporosis: consider avoiding TDF13
- Psychiatric illnesses: consider avoiding EFV14
- HIV-assoc dementia (HAD): use DRV4,7 or DTG;2 avoid EFV if possible15
- Methadone for NRT: consider avoiding EFV16
- High cardiac risk: consider avoiding ABC and LPV/r17
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV18
- HBV infxn: use TDF/(3TC/FTC)19 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active vs HBV [BII] w/ (3TC/FTC)20
- TB infxn treated w/ rifampin: use EFV;5,21 if RAL or DTG2 used, adjust dose;22 if PI used, switch rifampin to rifabutin23 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 ATV/c not recommended in hepatic impairment.
7 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
8 DRV/c not recommended in Child-Pugh Class C.
9 Use LPV/r with caution in hepatic impairment.
10 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
11 3TC requires dose adj: if CrCl 30-49, use 150 mg q24h; if CrCl 15-29, use 150 mg x1, then 100 mg q24h; if CrCl 5-14, use 150 mg x1, then 50 mg q24h; if CrCl <5 or pt on HD, use 50 mg x1, then 25 mg q24h.
12 Available as fixed-dose combo tablets.
13 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
14 EFV can worsen psych sx, may be assoc w/ suicidality.
15 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
16 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
17 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
18 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV assoc w/ deleterious lipid effects.
19 TDF, FTC, 3TC are active vs HIV/HBV.
20 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
21 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
22 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
23 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. HLA-B*5701 positive/unknown Select antiretroviral regimen1 Table 7 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [CI] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:10 EFV5/TDF/FTC (Atripla) or EVG/c/TDF/FTC3 (Stribild)
- Osteoporosis: consider avoiding TDF11
- Psychiatric illnesses: consider avoiding EFV12
- HIV-assoc dementia (HAD): use DRV4,8 or DTG;2 avoid EFV if possible13
- Methadone for NRT: consider avoiding EFV14
- High cardiac risk: consider avoiding LPV/r15
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV, EVG/c16
- HBV infxn: use TDF/(3TC/FTC)17 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)18
- TB infxn treated w/ rifampin: use EFV;6,19 if RAL or DTG2 used, adjust dose;20 if PI used, switch rifampin to rifabutin21 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 ATV/c not recommended in hepatic impairment.
7 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
8 DRV/c not recommended in Child-Pugh Class C.
9 Use LPV/r with caution in hepatic impairment.
10 Available as fixed-dose combo tablets.
11 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
12 EFV can worsen psych sx, may be assoc w/ suicidality.
13 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
14 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
15 MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
16 TDF assoc w/ beneficial lipid effects. PI/r, EFV, EVG/c assoc w/ deleterious lipid effects.
17TDF, FTC, 3TC are active vs HIV/HBV.
18 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
19 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
20 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
21 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 8 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [CI] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF7
- One-pill, once-daily regimen desired:8 EFV4/TDF/FTC (Atripla)
- Osteoporosis: consider avoiding TDF9
- Psychiatric illnesses: consider avoiding EFV10
- HIV-assoc dementia (HAD): use DRV3 or DTG;2 avoid EFV if possible11
- Methadone for NRT: consider avoiding EFV12
- High cardiac risk: consider avoiding LPV/r13
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV14
- HBV infxn: use TDF/(3TC/FTC)15 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)16
- TB infxn treated w/ rifampin: use EFV;4,17 if RAL or DTG2 used, adjust dose;18 if PI used, switch rifampin to rifabutin19 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 DRV not recommended in severe hepatic impairment.
4 Use EFV w/ caution in hepatic impairment.
5 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
6 Use LPV/r with caution in hepatic impairment.
7 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
8 Available as fixed-dose combo tablets.
9 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
10 EFV can worsen psych sx, may be assoc w/ suicidality.
11 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
12 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
13 LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
14 TDF assoc w/ beneficial lipid effects. PI/r, EFV assoc w/ deleterious lipid effects.
15 TDF, FTC, 3TC are active vs HIV/HBV.
16 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
17 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
18 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
19 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. -
HIV RNA ≥100,000 copies/mL
Select antiretroviral regimen1 Table 9 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:11 DTG2/ABC3/3TC (Triumeq), EFV6/TDF/FTC (Atripla), or EVG/c/TDF/FTC4 (Stribild)
- Osteoporosis: consider avoiding TDF12
- Psychiatric illnesses: consider avoiding EFV13
- HIV-assoc dementia (HAD): use DRV5,9 or DTG;2 avoid EFV if possible14
- Methadone for NRT: consider avoiding EFV15
- High cardiac risk: consider avoiding ABC and LPV/r16
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV, EVG/c17
- HBV infxn: use TDF/(3TC/FTC)18 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)19
- TB infxn treated w/ rifampin: use EFV;6,20 if RAL or DTG2 used, adjust dose;21 if PI used, switch rifampin to rifabutin22 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
5 DRV not recommended in severe hepatic impairment.
6 Use EFV w/ caution in hepatic impairment.
7 ATV/c not recommended in hepatic impairment.
8 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
9 DRV/c not recommended in Child-Pugh Class C.
10 Use LPV/r with caution in hepatic impairment.
11 Available as fixed-dose combo tablets.
12 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
13 EFV can worsen psych sx, may be assoc w/ suicidality.
14 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
15 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
16 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
17 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV, EVG/c assoc w/ deleterious lipid effects.
18 TDF, FTC, 3TC are active vs HIV/HBV.
19 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
20 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓ conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
21 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
22 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 10 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF9
- CrCl <50 mL/min: do not use coformulated ABC3/3TC10
- One-pill, once-daily regimen desired:11 DTG2/ABC3/3TC (Triumeq) or EFV5/TDF/FTC (Atripla)
- Osteoporosis: consider avoiding TDF12
- Psychiatric illnesses: consider avoiding EFV13
- HIV-assoc dementia (HAD): use DRV4,7 or DTG;2 avoid EFV if possible14
- Methadone for NRT: consider avoiding EFV15
- High cardiac risk: consider avoiding ABC- and LPV/r16
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV17
- HBV infxn: use TDF/(3TC/FTC)18 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)19
- TB infxn treated w/ rifampin: use EFV;5,20 if RAL or DTG2 used, adjust dose;21 if PI used, switch rifampin to rifabutin22 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
7 DRV/c not recommended in Child-Pugh Class C.
8 Use LPV/r with caution in hepatic impairment.
9 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
10 3TC requires dose adj: if CrCl 30-49, use 150 mg q24h; if CrCl 15-29, use 150 mg x1, then 100 mg q24h; if CrCl 5-14, use 150 mg x1, then 50 mg q24h; if CrCl <5 or pt on HD, use 50 mg x1, then 25 mg q24h.
11 Available as fixed-dose combo tablets.
12 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
13 EFV can worsen psych sx, may be assoc w/ suicidality.
14 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
15 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
16 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
17 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV assoc w/ deleterious lipid effects.
18 TDF, FTC, 3TC are active vs HIV/HBV.
19 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
20 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
21 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
22 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. HLA-B*5701 positive/unknown Select antiretroviral regimen1 Table 11 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [CI] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:10 EFV5/TDF/FTC (Atripla) or EVG/c/TDF/FTC3 (Stribild)
- Osteoporosis: consider avoiding TDF11
- Psychiatric illnesses: consider avoiding EFV12
- HIV-assoc dementia (HAD): use DRV4,8 or DTG;2 avoid EFV if possible13
- Methadone for NRT: consider avoiding EFV14
- High cardiac risk: consider avoiding LPV/r15
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV, EVG/c16
- HBV infxn: use TDF/(3TC/FTC)17 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)18
- TB infxn treated w/ rifampin: use EFV;5,19 if RAL or DTG2 used, adjust dose;20 if PI used, switch rifampin to rifabutin21 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 ATV/c not recommended in hepatic impairment.
7 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
8 DRV/c not recommended in Child-Pugh Class C.
9 Use LPV/r with caution in hepatic impairment.
10 Available as fixed-dose combo tablets.
11 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
12 EFV can worsen psych sx, may be assoc w/ suicidality.
13 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
14 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
15 MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
16 TDF assoc w/ beneficial lipid effects. PI/r, EFV, EVG/c assoc w/ deleterious lipid effects.
17 TDF, FTC, 3TC are active vs HIV/HBV.
18 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
19 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
20 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
21 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 12 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [CI] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF7
- One-pill, once-daily regimen desired:8 EFV4/TDF/FTC (Atripla)
- Osteoporosis: consider avoiding TDF9
- Psychiatric illnesses: consider avoiding EFV10
- HIV-assoc dementia (HAD): use DRV3- or DTG;2 avoid EFV if possible11
- Methadone for NRT: consider avoiding EFV12
- High cardiac risk: consider avoiding LPV/r13
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV14
- HBV infxn: use TDF/(3TC/FTC)15 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)16
- TB infxn treated w/ rifampin: use EFV;4,17 if RAL or DTG2 used, adjust dose;18 if PI used, switch rifampin to rifabutin19 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 DRV not recommended in severe hepatic impairment.
4 Use EFV w/ caution in hepatic impairment.
5 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
6 Use LPV/r with caution in hepatic impairment.
7 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
8 Available as fixed-dose combo tablets.
9 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
10 EFV can worsen psych sx, may be assoc w/ suicidality.
11 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
12 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
13 LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
14 TDF assoc w/ beneficial lipid effects. PI/r, EFV assoc w/ deleterious lipid effects.
15 TDF, FTC, 3TC are active vs HIV/HBV.
16 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
17 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
18 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
19 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 13 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:11 DTG2/ABC3/3TC (Triumeq), EFV6/TDF/FTC (Atripla), or EVG/c/TDF/FTC4 (Stribild)
- Osteoporosis: consider avoiding TDF12
- Psychiatric illnesses: consider avoiding EFV13
- HIV-assoc dementia (HAD): use DRV5,9 or DTG;2 avoid EFV if possible14
- Methadone for NRT: consider avoiding EFV15
- High cardiac risk: consider avoiding ABC and LPV/r16
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV, EVG/c17
- HBV infxn: use TDF/(3TC/FTC)18 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)19
- TB infxn treated w/ rifampin: use EFV;6,20 if RAL or DTG2 used, adjust dose;21 if PI used, switch rifampin to rifabutin22 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
5 DRV not recommended in severe hepatic impairment.
6 Use EFV w/ caution in hepatic impairment.
7 ATV/c not recommended in hepatic impairment.
8 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
9 DRV/c not recommended in Child-Pugh Class C.
10 Use LPV/r with caution in hepatic impairment.
11 Available as fixed-dose combo tablets.
12 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
13 EFV can worsen psych sx, may be assoc w/ suicidality.
14 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
15 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
16 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
17 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV, EVG/c assoc w/ deleterious lipid effects.
18 TDF, FTC, 3TC are active vs HIV/HBV.
19 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
20 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
21 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
22 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 14 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [BIII], [CI], [CII] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF9
- CrCl <50 mL/min: do not use coformulated ABC3/3TC10
- One-pill, once-daily regimen desired:11 DTG2/ABC3/3TC (Triumeq) or EFV5/TDF/FTC (Atripla)
- Osteoporosis: consider avoiding TDF12
- Psychiatric illnesses: consider avoiding EFV13
- HIV-assoc dementia (HAD): use DRV4,7 - or DTG;2 avoid EFV if possible14
- Methadone for NRT: consider avoiding EFV15
- High cardiac risk: consider avoiding ABC and LPV/r16
- Hyperlipidemia: use TDF; consider avoiding PI/r, ABC, EFV17
- HBV infxn: use TDF/(3TC/FTC)18 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)19
- TB infxn treated w/ rifampin: use EFV;5,20 if RAL or DTG2 used, adjust dose;21 if PI used, switch rifampin to rifabutin22 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 If Child-Pugh Score 5-6, use ABC 200 mg bid; if Child-Pugh Score >6, ABC contraindicated.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
7 DRV/c not recommended in Child-Pugh Class C.
8 Use LPV/r with caution in hepatic impairment.
9 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
10 3TC requires dose adj: if CrCl 30-49, use 150 mg q24h; if CrCl 15-29, use 150 mg x1, then 100 mg q24h; if CrCl 5-14, use 150 mg x1, then 50 mg q24h; if CrCl <5 or pt on HD, use 50 mg x1, then 25 mg q24h.
11 Available as fixed-dose combo tablets.
12 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
13 EFV can worsen psych sx, may be assoc w/ suicidality.
14 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
15 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
16 Controversial association between ABC use and MI risk. LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
17 TDF assoc w/ beneficial lipid effects. PI/r, ABC, EFV assoc w/ deleterious lipid effects.
18 TDF, FTC, 3TC are active vs HIV/HBV.
19 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
20 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
21 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
22 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. HLA-B*5701 positive/unknown Select antiretroviral regimen1 Table 15 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [BII], [CI] Customize per specific clinical scenarios - One-pill, once-daily regimen desired:10 EFV5/TDF/FTC (Atripla) or EVG/c/TDF/FTC3 (Stribild)
- Osteoporosis: consider avoiding TDF11
- Psychiatric illnesses: consider avoiding EFV12
- HIV-assoc dementia (HAD): use DRV4,8 or DTG;2 avoid EFV if possible13
- Methadone for NRT: consider avoiding EFV14
- High cardiac risk: consider avoiding LPV/r15
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV, EVG/c16
- HBV infxn: use TDF/(3TC/FTC)17 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)18
- TB infxn treated w/ rifampin: use EFV;5,19 if RAL or DTG2 used, adjust dose;20 if PI used, switch rifampin to rifabutin21 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 EVG/c/TDF/FTC not recommended in severe hepatic impairment.
4 DRV not recommended in severe hepatic impairment.
5 Use EFV w/ caution in hepatic impairment.
6 ATV/c not recommended in hepatic impairment.
7 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
8 DRV/c not recommended in Child-Pugh Class C.
9 Use LPV/r with caution in hepatic impairment.
10 Available as fixed-dose combo tablets.
11 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
12 EFV can worsen psych sx, may be assoc w/ suicidality.
13 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
14 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
15 LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
16 TDF assoc w/ beneficial lipid effects. PI/r, EFV, EVG/c assoc w/ deleterious lipid effects.
17 TDF, FTC, 3TC are active vs HIV/HBV.
18 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
19 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
20 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
21 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens. Select antiretroviral regimen1 Table 16 __________________________________ __________________________________ View Table Evidence Grades: [AI], [BI], [CI] Customize per specific clinical scenarios - CrCl <60 mL/min: consider avoiding TDF7
- One-pill, once-daily regimen desired:8 EFV4/TDF/FTC (Atripla)
- Osteoporosis: consider avoiding TDF9
- Psychiatric illnesses: consider avoiding EFV10
- HIV-assoc dementia (HAD): use DRV3 or DTG;2 avoid EFV if possible11
- Methadone for NRT: consider avoiding EFV12
- High cardiac risk: consider avoiding LPV/r13
- Hyperlipidemia: use TDF; consider avoiding PI/r, EFV14
- HBV infxn: use TDF/(3TC/FTC)15 [AI]; if TDF contraindicated, use entecavir [BI] or another drug active against HBV [BII] w/ (3TC/FTC)16
- TB infxn treated w/ rifampin: use EFV;4,17 if RAL or DTG2 used, adjust dose;18 if PI used, switch rifampin to rifabutin19 [AII]
Footnotes 1 Drug order does not denote preference. Customize per pt factors.
2 DTG not recommended in Child-Pugh Class C.
3 DRV not recommended in severe hepatic impairment.
4 Use EFV w/ caution in hepatic impairment.
5 If Child-Pugh Class B, use ATV 300 mg qd; if Child-Pugh Class C, ATV not recommended; RTV boosting not recommended in pts w/ Child-Pugh Class B or C.
6 Use LPV/r with caution in hepatic impairment.
7 TDF assoc w/ renal tubulopathy. If TDF used and CrCl <50 mL/min, adjust TDF dose: if CrCl 30-49, use 300 mg q48h; if CrCl 10-29, use 300 mg twice weekly; if CrCl <10 and pt not on HD, no recommendation; if pt on HD, use 300 mg q7 days.
8 Available as fixed-dose combo tablets.
9 TDF assoc w/ ↓bone mineral density, renal tubulopathy, urine phosphate wasting, osteomalacia.
10 EFV can worsen psych sx, may be assoc w/ suicidality.
11 DRV and DTG offer theoretical CNS penetration advantage. EFV neuropsych sx may confound assessment of ART’s effect on HAD sx.
12 EFV ↓methadone conc and may lead to withdrawal sx. If EFV used, consider ↑methadone dose.
13 LPV/r assoc w/ slightly ↑MI risk. MI risk factors unlikely to be assoc w/ ART use: smoking status, FHx of CV dz, prior CV event, BMI. MI risk factors possibly assoc w/ ART use: ↑serum lipids, ↑BP, ↑glucose, presence of diabetes or physician-defined lipodystrophy.
14 TDF assoc w/ beneficial lipid effects. PI/r, EFV assoc w/ deleterious lipid effects.
15 TDF, FTC, 3TC are active vs HIV/HBV.
16 3TC- or FTC-assoc HBV mutations can emerge rapidly when used w/o another HBV-active agent.
17 Rifampin is strong inducer of CYP3A4 and UGT1A1 enzymes, which ↓conc of PI, INSTI, RPV. Rifampin has less significant effect on EFV conc than on other NNRTIs, PIs, INSTIs.
18 If RAL used, ↑dose to 800 mg bid since rifampin ↓RAL AUC and Cmin. If DTG used, ↑dose to 50 mg bid only in pts w/o INSTI-resistance Q148 substitution + <2 additional INSTI-resistance substitutions (T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R) since efficacy of DTG 50 mg bid is reduced in resistant pts.
19 Rifabutin is less potent inducer than rifampin and is a good option for pts receiving non-EFV-based regimens.
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