Switching from Atripla to Genvoya
Many long-time users of Atripla are plagued with the question of whether switching to newly approved HIV medications will provide better results. Many patients take a “if it is not broke, don’t fix it,” approach to this issue, especially if they think changing regimens would affect their already suppressed viral load. These patients can’t be blamed for their apprehension, especially if Atripla is working for them and they are not bothered by its side effects (if there are any). While no one can guarantee that Genvoya can provide life-changing results, novel drug formulations are always worth looking in to.
Atripla (efavirenz/emtricitabine/tenofovir disoproxil fumarate) used to be a first-line treatment for HIV-1 infection. After all, it was effective and relatively safe based on a number of clinical trials. It was part of the Department of Health and Human Services’ (DHHS) list of most preferred medications for treatment-naïve patients and suppressed patients that need to switch to a new regimen. Following the discovery of new antiretroviral agents and the availability of fixed-dose combination regimens with safer and more potent backbones, Atripla was removed from the list of recommended regimens in 2015. If your doctor is urging you to switch to Genvoya, it is because of the new HIV treatment guidelines. Newer medications, such as Complera, Stribild, Genvoya, and Triumeq, have displaced Atripla as an optimal treatment.
Recommended regimens for most people
- Dolutegravir/abacavir/lamivudine (Triumeq): This is only for patients who are HLA-B*5701-negative
- Dolutegravir plus tenofovir/emtricitabine (Tivicay + Truvada)
- Elvitegravir/cobicistat/tenofovir/emtricitabine (Stribild or Genvoya)
- Raltegravir plus tenofovir/emtricitabine (Isentress + Truvada)
The efavirenz component of Atripla is associated with a number of adverse effects, such as psychiatric symptoms and central nervous system toxicities. Psychiatric adverse experiences include the following:
- Severe depression (2.4%)
- Suicidal ideation (0.7%)
- Non-fatal suicide attempts (0.5%)
- Aggressive behavior (0.4%)
- Paranoid reactions (0.4%)
- Manic reactions (0.2%)
Efavirenz, though, is not the only problematic component in Atripla. If you are experiencing the side effects above, you should think about switching to Genvoya. This new fixed-dose combination drug from Gilead Sciences is the first single-tablet regimen (STR) to replace tenofovir with tenofovir alafenamide (TAF), a new prodrug. Stribild is a similar STR to the original tenofovir. Tenofovir disoproxil fumarate (TDF) was approved in 2001 for use in treating HIV and for chronic hepatitis B infection in 2008.
What’s wrong with the old tenofovir (Viread)?
There are many issues surrounding TDF. Despite being effective, it presents several health risks and safety concerns. All antiretroviral agents and regimens containing TDF have warnings in their prescribing information for new-onset or worsening kidney impairment risk. TDF is not recommended for patients who are taking medications that are known to be toxic to the kidneys, such as multiple NSAIDs and aminoglycosides. Another safety concern with the old tenofovir is its effects on bone mineral density. In clinical trials conducted on HIV-positive and HIV-negative individuals, TDF was associated with a slightly greater decrease in bone mineral density. Its long-term implications on bone health and fracture risk is not yet known.
Why you should consider switching to Genvoya?
Like Stribild, Genvoya contains a combination of emtricitabine, elvitegravir, cobicistat, and tenofovir, but its tenofovir component is replaced with the tenofovir alafenamide. TAF is a nucleoside reverse transcriptase inhibitor (NRTI) designed to circulate systemically, with most of its conversion to active metabolite occurring within HIV-infected cells instead of staying in the plasma, where it can trigger health risks. TDF has higher plasma tenofovir exposure than TAF. Because the dose of TAF in Genvoya is only a tenth of the dose of TDF in Stribild, there is 90% less circulating tenofovir in the plasma, resulting in less renal impairment and issues with bone mineral density. Most doctors prefer TAF-based regimens for patients who are at risk for impaired kidney function or whose doctors have concerns about their bone mineral density loss.
Several switching studies showed that Genvoya was safe and effective on patients who were initially on Atripla, Stribild, Truvada, Atazanavir, and cobicistat. Genvoya demonstrated statistically significant increases in maintained virologic suppression at week 48 in comparison to the TDF-based regimens. In a 96-week study, there was a 1% discontinuation rate for Genvoya. Reported side effects—which included nausea, fatigue, diarrhea, headache, and rashes— were similar to those seen with TDF. If there is one unique downside to Genvoya, it would be its less favorable effects on lipid levels. Another thing to consider is cost. Atripla is less expensive than Genvoya. If you are young and have healthy bones and kidneys and any psychiatric symptoms are under control, you may hold on to your Atripla for the time being.