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Stribild

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Stribild

Side Effects
Interactions

SIDE EFFECTS

The following adverse drug reactions are discussed in other sections of the labeling:

Adverse Reactions From Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The safety assessment of STRIBILD is based on the Week 144 pooled data from 1408 subjects in two randomized, double-blind, active-controlled clinical trials, Study 102 and Study 103, in antiretroviral treatment-na´ve HIV-1 infected adult subjects [see Clinical Studies]. A total of 701 subjects received STRIBILD once daily in these two studies.

The proportion of subjects who discontinued treatment with STRIBILD (elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 200 mg/tenofovir DF 300 mg); ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir DF 300 mg); or atazanavir (ATV) + ritonavir (RTV) + TRUVADA (emtricitabine 200 mg/tenofovir DF 300 mg) due to adverse events, regardless of severity, was 6.0%, 7.4% and 8.5%, respectively. Table 2 displays the frequency of adverse drug reactions greater than or equal to 5% of subjects in any treatment arm.

Table 2 : Adverse Drug Reactionsa (all grades) Reported in ≥ 5% of Subjects in Any Treatment Arm in Studies 102 and 103 (Week 144 analysis).

  STRIBILD
N=701
ATRIPLA
N=352
ATV + RTV + TRUVADA
N=355
EYE DISORDERS
  Ocular icterus < 1% 0% 13%
GASTROINTESTINAL DISORDERS
  Diarrhea 12% 11% 17%
  Flatulence 2% < 1% 8%
  Nausea 16% 9% 14%
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
  Fatigue 4% 8% 6%
HEPATOBILIARY DISORDERS
  Jaundice 0% < 1% 9%
NERVOUS SYSTEM DISORDERS
  Somnolence 1% 7% 1%
  Headache 7% 4% 6%
  Dizziness 3% 21% 5%
PSYCHIATRIC DISORDERS
  Insomnia 3% 9% 1%
  Abnormal dreams 9% 27% 4%
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
  Rashb 4% 15% 6%
a Frequencies of adverse reactions are based on all treatment-emergent adverse events, attributed to study drugs.
b Rash event includes dermatitis, drug eruption, eczema, pruritus, pruritus generalized, rash, rash erythematous, rash generalized, rash macular, rash maculo-papular, rash morbilliform, rash papular, rash pruritic, and urticaria.

See WARNINGS AND PRECAUTIONS, for a discussion of renal adverse reactions from clinical trials experience with STRIBILD.

Additional adverse drug reactions observed with STRIBILD included suicidal ideation and suicide attempt (0.3%), all in subjects with a pre-existing history of depression or psychiatric illness.

Adverse Reactions from Clinical Trials of the Components of STRIBILD

Emtricitabine and Tenofovir Disoproxil Fumarate

In addition to the adverse reactions observed with STRIBILD, the following adverse reactions occurred in at least 5% of treatment-experienced or treatment-na´ve subjects receiving emtricitabine or tenofovir DF with other antiretroviral agents in other clinical trials: depression, abdominal pain, dyspepsia, vomiting, fever, pain, nasopharyngitis, pneumonia, sinusitis, upper respiratory tract infection, arthralgia, back pain, myalgia, paresthesia, peripheral neuropathy (including peripheral neuritis and neuropathy), anxiety, increased cough, and rhinitis.

Skin discoloration has been reported with higher frequency among emtricitabine-treated subjects; it was manifested by hyperpigmentation on the palms and/or soles and was generally mild and asymptomatic. The mechanism and clinical significance are unknown.

Laboratory Abnormalities

The frequency of laboratory abnormalities (Grades 3-4) occurring in at least 2% of subjects receiving STRIBILD in Studies 102 and 103 are presented in Table 3.

Table 3 : Laboratory Abnormalities (Grades 3-4) Reported in ≥ 2% of Subjects Receiving STRIBILD in Studies 102 and 103 (Week 144 analysis)

  STRIBILD ATRIPLA ATV + RTV + TRUVADA
Laboratory Parameter Abnormalitya,b N=701 N=352 N=355
AST ( > 5.0 x ULN) 3% 6% 6%
ALT ( > 3.0 x ULN) 2% 5% 4%
Amylasea ( > 2.0 x ULN) 3% 3% 5%
Creatine Kinase ( ≥ 10.0 x ULN) 8% 15% 11%
Urine RBC (Hematuria) ( > 75 RBC/HPF) 4% 2% 4%
a Frequencies are based on treatment-emergent laboratory abnormalities.
b For subjects with serum amylase > 1.5 x upper limit of normal, lipase test was also performed. The frequency of increased lipase (Grades 3-4) occurring in STRIBILD (N=69), ATRIPLA (N=40), and ATV +RTV + TRUVADA (N=38) was 17%, 15%, and 24%, respectively.

In Study 103, BMD was assessed by DEXA in a non-random subset of 120 subjects (STRIBILD group N = 54; ATV + RTV + TRUVADA group N = 66). Mean percentage decreases in BMD from baseline to Week 144 in the STRIBILD group were comparable to the ATV + RTV + TRUVADA group at the lumbar spine (-1.43% versus -3.68%, respectively) and at the hip (-2.83% versus -3.77%, respectively). In Studies 102 and 103, bone fractures occurred in 27 subjects (3.9%) in the STRIBILD group, 8 subjects (2.3%) in the ATRIPLA group, and 19 subjects (5.4%) in the ATV + RTV + TRUVADA group. These findings were consistent with data from an earlier 144-week trial of treatment-na´ve subjects receiving tenofovir DF + lamivudine + efavirenz.

Proteinuria (all grades) occurred in 52% of subjects receiving STRIBILD, 41% of subjects receiving ATRIPLA, and 42% of subjects receiving ATV + RTV + TRUVADA.

The cobicistat component of STRIBILD has been shown to increase serum creatinine and decrease estimated creatinine clearance due to inhibition of tubular secretion of creatinine without affecting renal glomerular function. In Studies 102 and 103, increases in serum creatinine and decreases in estimated creatinine clearance occurred early in treatment with STRIBILD, after which they stabilized. Table 4 displays the mean changes in serum creatinine and eGFR levels at Week 144 and the percentage of subjects with elevations in serum creatinine (All Grades).

Table 4 : Change from Baseline in Serum Creatinine and eGFR and Incidence of Elevated Serum Creatinine (All Grades) at Week 144

  STRIBILD
(N=701)
ATRIPLA
(N=352)
ATV + RTV + TRUVADA
(N=355)
Serum Creatinine (mg/dL)a 0.14 (±0.14) 0.01 (±0.12) 0.09 (±0.15)
eGFR by Cockcroft-Gault (mL/minute)a -14.0 (±16.6) -1.9 (±17.9) -9.8 (±19.4)
Subjects with Elevations in Serum Creatinine (All Grades) (%) 12 2 6
a Mean change ±SD

Emtricitabine or Tenofovir DF

In addition to the laboratory abnormalities observed with STRIBILD, the following laboratory abnormalities have been previously reported in subjects treated with emtricitabine or tenofovir DF with other antiretroviral agents in other clinical trials: Grade 3 or 4 laboratory abnormalities of ALT (M: greater than 215 U per L; F: greater than 170 U per L), alkaline phosphatase (greater than 550 U per L), bilirubin (greater than 2.5 x ULN), serum glucose (less than 40 or greater than 250 mg per dL), glycosuria (greater than or equal to 3+), neutrophils (less than 750 per m³), fasting cholesterol (greater than 240 mg per dL), and fasting triglycerides (greater than 750 mg per dL).

Serum Lipids

In the clinical trials of STRIBILD, a similar percentage of subjects receiving STRIBILD, ATRIPLA, and ATV + RTV + TRUVADA were on lipid lowering agents at baseline (12%, 12%, and 13%, respectively). While receiving study drug through Week 144, an additional 11% of STRIBILD subjects were started on lipid lowering agents, compared to 13% of ATRIPLA and 12% of ATV + RTV + TRUVADA subjects.

Changes from baseline in total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides are presented in Table 5.

Table 5 : Lipid Values, Mean Change from Baseline at Week 144 in Subjects Receiving STRIBILD or Comparator in Studies 102 and 103

  STRIBILD
N=701
ATRIPLA
N=352
ATV + RTV + TRUVADA
N=355
Baseline Week 144 Baseline Week 144 Baseline Week 144
mg/dL Changea mg/dL Changea mg/dL Changea
Total Cholesterol (fasted) 166
[N=675]
+17
[N=535]
161
[N=343]
+22
[N=262]
168
[N=337]
+16
[N=243]
HDL- cholesterol (fasted) 43
[N=675]
+7
[N=535]
43
[N=343]
+9
[N=262]
42
[N=335]
+7
[N=242]
LDL- cholesterol (fasted) 100
[N=675]
+15
[N=535]
97
[N=343]
+19
[N=262]
101
[N=337]
+18
[N=242]
Triglycerides (fasted) 122
[N=675]
+12
[N=535]
121
[N=343]
+5
[N=262]
132
[N=337]
+22
[N=242]
a The change from baseline is the mean of within-patient changes from baseline for patients with both baseline and Week 144 values.

Postmarketing Experience

Because postmarketing reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The following adverse reactions have been identified during post approval use of tenofovir DF. No additional postmarketing adverse reactions specific for emtricitabine have been identified.

Immune System Disorders

allergic reaction, including angioedema

Metabolism and Nutrition Disorders

lactic acidosis, hypokalemia, hypophosphatemia

Respiratory, Thoracic, and Mediastinal Disorders

dyspnea

Gastrointestinal Disorders

pancreatitis, increased amylase, abdominal pain

Hepatobiliary Disorders

hepatic steatosis, hepatitis, increased liver enzymes (most commonly AST, ALT gamma GT)

Skin and Subcutaneous Tissue Disorders

rash

Musculoskeletal and Connective Tissue Disorders

rhabdomyolysis, osteomalacia (manifested as bone pain and which may contribute to fractures), muscular weakness, myopathy

Renal and Urinary Disorders

acute renal failure, renal failure, acute tubular necrosis, Fanconi syndrome, proximal renal tubulopathy, interstitial nephritis (including acute cases), nephrogenic diabetes insipidus, renal insufficiency, increased creatinine, proteinuria, polyuria

General Disorders and Administration Site Conditions

asthenia

The following adverse reactions, listed under the body system headings above, may occur as a consequence of proximal renal tubulopathy: rhabdomyolysis, osteomalacia, hypokalemia, muscular weakness, myopathy, hypophosphatemia.

Read the Stribild (elvitegravir, cobicistat, emtricitabine, tenofovir df) Side Effects Center for a complete guide to possible side effects

DRUG INTERACTIONS

See also CONTRAINDICATIONS and CLINICAL PHARMACOLOGY.

Other Antiretroviral Medications

STRIBILD is a complete regimen for the treatment of HIV-1 infection; therefore, STRIBILD should not be administered with other antiretroviral medications for treatment of HIV-1 infection. Complete information regarding potential drug-drug interactions with other antiretroviral medications is not provided.

Potential For STRIBILD To Affect Other Drugs

Cobicistat, a component of STRIBILD, is an inhibitor of CYP3A and CYP2D6 and an inhibitor of the following transporters: p-glycoprotein (P-gp), BCRP, OATP1B1 and OATP1B3. Thus, coadministration of STRIBILD with drugs that are primarily metabolized by CYP3A or CYP2D6, or are substrates of P-gp, BCRP, OATP1B1 or OATP1B3 may result in increased plasma concentrations of such drugs. Elvitegravir is a modest inducer of CYP2C9 and may decrease the plasma concentrations of CYP2C9 substrates.

Potential For Other Drugs To Affect One Or More Components Of STRIBILD

Elvitegravir and cobicistat, components of STRIBILD, are metabolized by CYP3A. Cobicistat is also metabolized, to a minor extent, by CYP2D6.

Drugs that induce CYP3A activity are expected to increase the clearance of elvitegravir and cobicistat, resulting in decreased plasma concentration of cobicistat and elvitegravir, which may lead to loss of therapeutic effect of STRIBILD and development of resistance (see Table 6).

Coadministration of STRIBILD with other drugs that inhibit CYP3A may decrease the clearance and increase the plasma concentration of cobicistat (see Table 6).

Drugs Affecting Renal Function

Because emtricitabine and tenofovir, components of STRIBILD are primarily excreted by the kidneys by a combination of glomerular filtration and active tubular secretion, coadministration of STRIBILD with drugs that reduce renal function or compete for active tubular secretion may increase concentrations of emtricitabine, tenofovir, and other renally eliminated drugs and this may increase the risk of adverse reactions. Some examples of drugs that are eliminated by active tubular secretion include, but are not limited to acyclovir, cidofovir, ganciclovir, valacyclovir, valganciclovir, aminoglycosides (e.g. gentamicin), and high-dose or multiple NSAIDs [see WARNINGS AND PRECAUTIONS].

Established And Other Potentially Significant Interactions

Table 6 provides a listing of established or potentially clinically significant drug interactions. The drug interactions described are based on studies conducted with either STRIBILD, the components of STRIBILD, (elvitegravir, cobicistat, emtricitabine, and tenofovir DF) as individual agents and/or in combination, or are predicted drug interactions that may occur with STRIBILD [for magnitude of interaction, see CLINICAL PHARMACOLOGY]. The table includes potentially significant interactions but is not all inclusive.

Table 6 : Established and Other Potentially Significanta Drug Interactions: Alteration in Dose or Regimen May Be Recommended Based on Drug Interaction Studies or Predicted Interaction

Concomitant Drug Class: Drug Name Effect on Concentrationb Clinical Comment
Acid Reducing Agents: Antacids* (for example aluminum and magnesium hydroxide) ↓elvitegravir Elvitegravir plasma concentrations are lower when STRIBILD is administered simultaneously with antacids. It is recommended to separate STRIBILD and antacid administration by at least 2 hours.
Antiarrhythmics: e.g. amiodarone
bepridil
digoxin*
disopyramide
flecainide
systemic lidocaine
mexiletine
propafenone
quinidine
↑ antiarrhythmics
↑digoxin
Concentrations of these antiarrhythmic drugs may be increased when coadministered with STRIBILD. Caution is warranted and therapeutic concentration monitoring, if available, is recommended for antiarrhythmics when coadministered with STRIBILD.
Antibacterials:
clarithromycin
telithromycin
↑clarithromycin
↑ telithromycin
↑cobicistat
Concentrations of clarithromycin and/or cobicistat may be altered when clarithromycin is coadministered with STRIBILD.
Patients with CLcr greater than or equal to 60 mL/minute:
No dose adjustment of clarithromycin is required.
Patients with CLcr between 50 mL/minute and 60 mL/minute:
The dose of clarithromycin should be reduced by 50%. Concentrations of telithromycin and/or cobicistat may be increased when telithromycin is coadministered with STRIBILD.
Anticoagulants:
warfarin
Effect on warfarin unknown Concentrations of warfarin may be affected upon coadministration with STRIBILD. It is recommended that the international normalized ratio (INR) be monitored upon coadministration with STRIBILD.
Anticonvulsants: carbamazepine
oxcarbazepine
phenobarbital
phenytoin
↑carbamazepine
↓ elvitegravir
↓ cobicistat
Coadministration of carbamazepine, oxcarbazepine, phenobarbital, or phenytoin with STRIBILD may significantly decrease cobicistat and elvitegravir plasma concentrations, which may result in loss of therapeutic effect and development of resistance. Alternative anticonvulsants should be considered
clonazepam ethosuximide ↑ clonazepam
↑ethosuximide
. Concentrations of clonazepam and ethosuximide may be increased when coadministered with STRIBILD. Clinical monitoring is recommended upon coadministration with STRIBILD.
Antidepressants:
Selective Serotonin Reuptake Inhibitors (SSRIs) e.g.
paroxetine
Tricyclic Antidepressants (TCAs) e.g. amitriptyline
desipramine
imipramine
nortriptyline
bupropion
trazodone
↑SSRIs
↑TCAs
↑trazodone
Concentrations of these antidepressant agents may be increased when coadministered with STRIBILD. Careful dose titration of the antidepressant and monitoring for antidepressant response are recommended.
Antifungals:
itraconazole
ketoconazole*
voriconazole
↑elvitegravir
↑cobicistat
↑ itraconazole
↑ketoconazole
↑voriconazole
Concentrations of ketoconazole, itraconazole and voriconazole may increase upon coadministration with STRIBILD. When administering with STRIBILD, the maximum daily dose of ketoconazole or itraconazole should not exceed 200 mg per day. An assessment of benefit/risk ratio is recommended to justify use of voriconazole with STRIBILD.
Anti-gout:
colchicine
↑colchicine STRIBILD is not recommended to be coadministered with colchicine to patients with renal or hepatic impairment.
Treatment of gout-flares - coadministration of colchicine in patients receiving STRIBILD:
0.6 mg (1 tablet) x 1 dose, followed by 0.3 mg (half tablet) 1 hour later. Treatment course to be repeated no earlier than 3 days.
Prophylaxis of gout-flares - coadministration of colchicine in patients receiving STRIBILD:
If the original regimen was 0.6 mg twice a day, the regimen should be adjusted to 0.3 mg once a day. If the original regimen was 0.6 mg once a day, the regimen should be adjusted to 0.3 mg once every other day.
Treatment of familial Mediterranean fever -coadministration of colchicine in patients receiving STRIBILD:
Maximum daily dose of 0.6 mg (may be given as 0.3 mg twice a day).
Antimycobacterial:
rifabutin*
rifapentine
↓elvitegravir
↓ cobicistat
Coadministration of rifabutin and rifapentine with STRIBILD may significantly decrease elvitegravir and cobicistat plasma concentrations, which may result in loss of therapeutic effect and development of resistance.
Coadministration of STRIBILD with rifabutin or rifapentine is not recommended.
Beta-Blockers:
e.g. metoprolol
timolol
↑beta-blockers Concentrations of beta-blockers may be increased when coadministered with STRIBILD. Clinical monitoring is recommended and a dose decrease of the beta blocker may be necessary when these agents are coadministered with STRIBILD.
Calcium Channel Blockers:
e.g. amlodipine
diltiazem
felodipine
nicardipine
nifedipine
verapamil
↑calcium channel blockers Concentrations of calcium channel blockers may be increased when coadministered with STRIBILD. Caution is warranted and clinical monitoring is recommended upon coadministration with STRIBILD.
Corticosteroid: Systemic:
dexamethasone
↓elvitegravir
↓ cobicistat
Systemic dexamethasone, a CYP3A inducer, may significantly decrease elvitegravir and cobicistat plasma concentrations, which may result in loss of therapeutic effect and development of resistance.
Corticosteroid: Inhaled/Nasal: fluticasone ↑fluticasone Concomitant use of inhaled or nasal fluticasone and STRIBILD may increase plasma concentrations of fluticasone, resulting in reduced serum cortisol concentrations. Alternative corticosteroids should be considered, particularly for long term use.
Endothelin Receptor Antagonists: bosentan ↑bosentan Coadministration of bosentan in patients on STRIBILD:
In patients who have been receiving STRIBILD for at least 10 days, start bosentan at 62.5 mg once daily or every other day based upon individual tolerability.
Coadministration of STRIBILD in patients on bosentan:
Discontinue use of bosentan at least 36 hours prior to initiation of STRIBILD. After at least 10 days following the initiation of STRIBILD, resume bosentan at 62.5 mg once daily or every other day based upon individual tolerability.
HMG-CoA Reductase Inhibitors: atorvastatin ↑atorvastatin Initiate with the lowest starting dose of atorvastatin and titrate carefully while monitoring for safety.
Hormonal Contraceptives: norgestimate/ethinyl estradiol* ↑ norgestimate
↓ ethinyl estradiol
The effects of increases in the concentration of the progestational component norgestimate are not fully known and can include increased risk of insulin resistance, dyslipidemia, acne, and venous thrombosis. The potential risks and benefits associated with coadministration of norgestimate/ethinyl estradiol with STRIBILD should be considered, particularly in women who have risk factors for these events.
Coadministration of STRIBILD with other hormonal contraceptives (e.g., contraceptive patch, contraceptive vaginal ring, or injectable contraceptives) or oral contraceptives containing progestogens other than norgestimate has not been studied; therefore, alternative (non-hormonal) methods of contraception can be considered.
Immuno- suppressants: e.g. cyclosporine
sirolimus
tacrolimus
↑immunosuppressants Concentrations of these immunosuppressant agents may be increased when coadministered with STRIBILD. Therapeutic monitoring of the immunosuppressive agents is recommended upon coadministration with STRIBILD.
Narcotic Analgesics: buprenorphine/ naloxone* ↑ buprenorphine ↑norbuprenorphine
↓naloxone
Concentrations of buprenorphine and norbuprenorphine are increased when coadministered with STRIBILD. No dose adjustment of buprenorphine/naloxone is required upon coadministration with STRIBILD. Patients should be closely monitored for sedation and cognitive effects.
Inhaled Beta Agonist: salmeterol ↑salmeterol Coadministration of salmeterol and STRIBILD is not recommended. Coadministration of salmeterol with STRIBILD may result in increased risk of cardiovascular adverse events associated with salmeterol, including QT prolongation, palpitations, and sinus tachycardia.
Neuroleptics: e.g. perphenazine
risperidone
thioridazine
↑neuroleptics A decrease in dose of the neuroleptic may be needed when coadministered with STRIBILD.
Phosphodiesterase- 5 (PDE5) Inhibitors:
sildenafil
tadalafil
vardenafil
↑ PDE5 inhibitors Coadministration with STRIBILD may result in an increase in PDE-5 inhibitor associated adverse reactions, including hypotension, syncope, visual disturbances, and priapism.
Use of PDE-5 inhibitors for pulmonary arterial hypertension (PAH):
  •   Use of sildenafil is contraindicated when used for the treatment of pulmonary arterial hypertension (PAH).
  • The following dose adjustments are recommended for the use of tadalafil with STRIBILD: Coadministration of tadalafil in patients on STRIBILD:
In patients receiving STRIBILD for at least 1 week, start tadalafil at 20 mg once daily. Increase tadalafil dose to 40 mg once daily based upon individual tolerability.
Coadministration of STRIBILD in patients on tadalafil:
Avoid use of tadalafil during the initiation of STRIBILD. Stop tadalafil at least 24 hours prior to starting STRIBILD. After at least one week following initiation of STRIBILD, resume tadalafil at 20 mg once daily. Increase tadalafil dose to 40 mg once daily based upon individual tolerability.
Use of PDE-5 inhibitors for erectile dysfunction:
Sildenafil at a single dose not exceeding 25 mg in 48 hours, vardenafil at a single dose not exceeding 2.5 mg in 72 hours, or tadalafil at a single dose not exceeding 10 mg in 72 hours can be used with increased monitoring for PDE-5 inhibitor associated with adverse events.
Sedative/hypnotics: Benzodiazepines: e.g. Parenterally administered midazolam
clorazepate
diazepam
estazolam
flurazepam
buspirone
zolpidem
↑ sedatives/hypnotics Concomitant use of parenteral midazolam with STRIBILD may increase plasma concentrations of midazolam. Coadministration should be done in a setting that ensures close clinical monitoring and appropriate medical management in case of respiratory depression and/or prolonged sedation. Dosage reduction for midazolam should be considered, especially if more than a single dose of midazolam is administered. Coadministration of oral midazolam with STRIBILD is contraindicated. With other sedative/hypnotics, dose reduction may be necessary and clinical monitoring is recommended.
*Indicates that a drug-drug interaction trial was conducted.
aThis table is not all inclusive.
b↑ = Increase, ↓ = Decrease, ↔ = No Effect

Drugs Without Clinically Significant Interactions With STRIBILD

Based on drug interaction studies conducted with the components of STRIBILD, no clinically significant drug interactions have been either observed or are expected when STRIBILD is combined with the following drugs: entecavir, famciclovir, H2 receptor antagonists, methadone, proton pump inhibitors, telaprevir and ribavirin.

Read the Stribild Drug Interactions Center for a complete guide to possible interactions

Last reviewed on RxList: 9/11/2014
This monograph has been modified to include the generic and brand name in many instances.

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Interactions
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