Antiretroviral Combination Therapy Summary and Recommendations

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Antiretroviral Recommendations For Initiation of Therapy in Treatment-Naïve Patients

Antiretroviral Combination Therapy Putting It All Together
Recommended regimens for initial therapy of HIV (with rationale)
Author's Order of Preference	Regimen	Rationale					Other
Author's Order of Preference	Regimen	Dosing Frequency per day	Pill Burden per day	Potency	Tolerance	Barrier to Resistance	Other
1	efavirenz/tenofovir/emtricitabine (Atripla)	1	1	+++++	+++	++
	rilpivirine/tenofovir/emtricitabine (Complera)	1	1	++++	++++	++
	elvitegravir/cobicistat/tenofovir/emtricitabine (Stribild)	1	1	++++	++++	+
	atazanavir/ritonavir + emtricitabine/tenofovir (Truvada)	1	4	+++++	++++	+++
	atazanavir/ritonavir + abacavir/lamivudine (Epzicom)	1	4	+++++	+++	+++
	atazanavir/ritonavir + tenofovir + didanosine-EC	1	5	+++++	+++++	++++	L
	NNRTI-qd + zidovudine/lamivudine/abacavir (Trizivir)	2	3-4	+++++	++++	+++	H,C
	atazanavir + Trizivir	2	4	+++++	++++	+++
	fosamprenavir-qd + emtricitabine/tenofovir (Truvada)	1	5	+++++	++++	+++
	fosamprenavir-qd + abacavir/lamivudine (Epzicom)	1	5	+++++	++++	+++
	fosamprenavir-qd + didanosine-EC + tenofovir	1	6	+++++	++++	++++	L
	fosamprenavir-qd + Trizivir	2	6	+++++	++++	+++	L
2	atazanavir + zidovudine/lamivudine (Combivir)	2	4	++++	++++	+++
	NNRTI-qd + Combivir	2	3-4	++++	++++	+++	H,C
	lopinavir/ritonavir + Combivir	2	8	+++++	+++	+++++	L
	lopinavir/ritonavir + didanosine-EC + tenofovir¹	2	8	+++++	+++	+++++	L
	NNRTI-qd + didanosine-EC + lamivudine-qd or emtricitabine	1	3-5	+++++	++++	+++	H,C
	fosamprenavir-qd + Combivir	2	6	++++	++++	++++	L
3	PI-B + or (tenofovir + didanosine-EC)	2	8-12	+++++	+++	+++++	L
4	atazanavir or NNRTI-qd + stavudine-XR + emtricitabine	2	3-4	+++++	+++	+++/++++	M,H
5	PI-B + stavudine-XR + emtricitabine	2	8-12	+++++	++	++++	M,L
6	Trizivir and other triple NRTI regimens	2	2	+++	+++	+++	W

Key
NNRTI-qd	efavirenz or nevirapine using single daily dosing; pregnancy is a contraindication to the use of efavirenz
PI-B	single protease inhibitor at usual dosing or ritonavir-boosted PI dosing
lamivudine-qd	300 mg single daily dosing of lamivudine
didanosine-EC	Enteric-coated didanosine (Videx-EC)
fosamprenavir-qd	ritonavir-boosted single daily dosing of fosamprenavir
L	potential for fat redistribution, hyperlipidemia, Type 2 diabetes mellitus
M	moderate or greater probability of mitochondrial toxicity possible including lipoatrophy, peripheral neuropathy
H	if nevirapine single daily dosing is used, monitor closely for hepatotoxicity; avoid nevirapine when initiating therapy in women with CD4 > 250
C	CNS stimulation is likely with efavirenz-containing regimens
1	lopinavir may significantly increase tenofovir levels: monitor for possible toxicity especially renal especially in individuals with lower than average BMI
W(arning)	Warning: Trizivir therapy should not be used without a NNRTI or PI unless circumstances dictate that this is the only practical therapy for a particular client. In particular patients with advanced disease or higher viral loads should be treated with an alternative regimen until further information becomes available.

Antiretroviral Recommendations For Therapy in Treatment-Experienced Patients

Antiretroviral Salvage Therapy Considerations
Recommended components of regimens for salvage therapy of HIV (with rationale) Complete regimens will be determined by resistance profile of patient's HIV strain, patient's history of antiretroviral exposure, and tolerance to particular antiretroviral agents
Component(s)	Rationale					Other
Component(s)	mechanism of action	Pill Burden per day	Potency	Tolerance	Advantage	Other
enfuvirtide	FI	2 subcutaneous injections per day	+++++	++	Unique mechanism of action	injection site reactions; must be used with other active drugs or resistance develops rapidly
lopinavir / ritonavir or boosted lopinavir / ritonavir	boosted PI	6-8	+++++	+++	Active in setting of multiple resistance mutations	lipids, hepatitis, nausea, diarrhea
lopinavir / ritonavir + indinavir	double PI	10	+++++	++	Supported by small amounts of salvage trial data Active in setting of multiple resistance mutations	lipids, hepatitis, nausea, diarrhea nephrolithiasis
tipranavir / ritonavir	boosted PI	8	+++++	++/+	Investigational Active in setting of multiple resistance mutations	lipids, hepatitis, nausea, diarrhea
atazanavir + ritonavir	boosted PI	3	++++	++++	Possible activity in setting of multiple resistance mutations?	lipids, hepatitis, jaundice; less data on this option as salvage drug
tenofovir	NtRTI	1	+++++	+++++	Active in setting of multiple NRTI resistance mutations?
didanosine	NRTI	1	+++++	+++++	Active in setting of multiple NRTI resistance mutations?	pancreatitis, peripheral neuropathy
fosamprenavir + ritonavir	boosted PI	10	+++	+++	Active in setting of multiple resistance mutations?	nausea, lipids, hepatitis
saquinavir + ritonavir	boosted PI	12	++++	+++	classic salvage regimen but not active with L90M	nausea, lipids, hepatitis, diarrhea
capavirine	NNRTI	?	?	?	Investigational May overcome resistance mutations to other 1st generation NNRTIs

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Nucleoside & Nucleotide Reverse Transcriptase Inhibitors (NRTI)

AZT | ddI | d4T | 3TC | ABC | FTC | TDF ||| Coformulation NRTI: Combivir | Trizivir | Epzicom | Truvada

Nonnucleoside Reverse Transcriptase Inhibitors (NNRTI)

efavirenz | nevirapine | delavirdine | etravirine | rilpivirine

Protease Inhibitors (PI) | Boosted Protease Inhibitors

Co-receptor Inhibitors

maraviroc

Fusion Inhibitors

enfuvirtide

Integrase Inhibitors

raltegravir | elvitegravir

Antiretroviral Metabolic Inhibitors

cobicistat | ritonavir

Coformulations

Atripla (efavirenz/tenofovir/emtricitabine) | Complera (rilpivirine/tenofovir/emtricitabine) | Stribild (elvitegravir/cobicistat/tenofovir/emtricitabine)

Updated 1/17/2013