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The following adverse drug reactions are discussed in other sections of the labeling:
- Lactic Acidosis/Severe Hepatomegaly with Steatosis [See BOXED WARNING, WARNINGS AND PRECAUTIONS].
- Severe Acute Exacerbations of Hepatitis B [See BOXED WARNING, WARNINGS AND PRECAUTIONS].
- New Onset or Worsening Renal Impairment [See WARNINGS AND PRECAUTIONS].
- Decreases in Bone Mineral Density [See WARNINGS AND PRECAUTIONS].
- Immune Reconstitution Syndrome [See WARNINGS AND PRECAUTIONS].
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 pooled data from 1408 subjects in two comparative clinical trials, Study 102 and Study 103, in antiretroviral treatment-naive HIV-1 infected adult subjects. A total of 701 subjects received STRIBILD once daily for at least 48 weeks.
The proportion of subjects who discontinued treatment with STRIBILD, ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir DF 300 mg) or atazanavir + ritonavir + TRUVADA (emtricitabine 200 mg/tenofovir DF 300 mg) due to adverse events, regardless of severity, was 3.7%, 5.1% and 5.1%, respectively. Table 2 displays the frequency of adverse drug reactions greater than or equal to 5%.
Table 2 : Treatment-Emergent Adverse Drug Reactionsa
(all grades) Reported in ≥ 5% of Subjects in Any Treatment Arm in Studies
102 and 103 (Week 48 analysis)
|Atazanavir + ritonavir + TRUVADA
|Ocular icterus||< 1%||0%||13%|
|GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS|
|NERVOUS SYSTEM DISORDERS|
|SKIN AND SUBCUTANEOUS TISSUE DISORDERS|
|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 popular, rash pruritic, and urticaria.
See WARNINGS AND PRECAUTIONS, for a discussion of renal adverse events from clinical trials experience with STRIBILD.
Emtricitabine and Tenofovir Disoproxil Fumarate
In addition to the adverse drug reactions observed with STRIBILD, the following adverse drug reactions occurred in at least 5% of treatment-experienced or treatment-naive 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.
The frequency of treatment-emergent 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 48
|STRIBILD||ATRIPLA||Atazanavir + ritonavir + TRUVADA|
|Laboratory Parameter Abnormality||N=701||N=352||N=355|
|AST (>5.0 x ULN)||2%||3%||4%|
|Amylasea (>2.0 x ULN)||2%||2%||4%|
|Creatine Kinase ( ≥ 10.0 x ULN)||5%||11%||7%|
|Urine RBC (Hematuria) (> 75 RBC/HPF)||3%||1%||2%|
|a 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=58), ATRIPLA (N=33), and atazanavir + ritonavir + TRUVADA (N=33) was 12%, 15%, and 21%, respectively.|
Proteinuria (all grades) occurred in 39% of subjects receiving STRIBILD, 29% of subjects receiving ATRIPLA, and 24% of subjects receiving atazanavir + ritonavir + 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. The mean ± SD change in serum creatinine after 48 weeks of treatment was 0.14 mg per dL ± 0.13 mg per dL for STRIBILD, 0.01 mg per dL ± 0.12 mg per dL for ATRIPLA, and 0.09 mg per dL ± 0.13 mg per dL for atazanavir + ritonavir + TRUVADA. The mean ± SD change in estimated glomerular filtration rate (eGFR) by Cockcroft-Gault method after 48 weeks of treatment was -13.9 ± 14.9 mL per min for STRIBILD, -1.6 ± 16.5 mL per min for ATRIPLA, and 9.3 ± 15.8 mL per min for atazanavir + ritonavir + TRUVADA. Elevation in serum creatinine (all grades) occurred in 7% of subjects receiving STRIBILD, 1% of subjects receiving ATRIPLA, and 4% of subjects receiving atazanavir + ritonavir + TRUVADA.
Emtricitabine or Tenofovir Disoproxil Fumarate
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: Grades 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 mm³ ), fasting cholesterol (greater than 240 mg per dL), and fasting triglycerides (greater than 750 mg per dL).
In the clinical trials of STRIBILD, a similar percentage of subjects receiving STRIBILD, ATRIPLA, and atazanavir + ritonavir + TRUVADA were on lipid lowering agents at baseline (11%, 11%, and 12%, respectively). While receiving study drug through Week 48, an additional 4% of STRIBILD subjects were started on lipid lowering agents, compared to 5% of ATRIPLA and 7% of atazanavir + ritonavir + TRUVADA subjects. During the first 48 weeks of study drug exposure, 1% or fewer subjects in any treatment arm experienced Grades 3 or 4 elevations in fasting cholesterol (greater than 300 mg per dL) or fasting triglycerides (greater than 750 mg per dL).
Changes from baseline in total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides are presented in Table 4.
Table 4: Lipid Values, Mean Change from Baseline,
Reported in Subjects Receiving STRIBILD or Comparator in Studies 102 and 103
|Atazanavir + ritonavir + TRUVADA
|Baseline mg/dL||Week 48 Changea||Baseline mg/dL||Week 48 Changea||Baseline mg/dL||Week 48 Changea|
|Total Cholesterol (fasted)||166 [N=675]||+11 [N=606]||161 [N=343]||+19 [N=298]||168 [N=337]||+9 [N=287]|
|HDL-cholesterol (fasted)||43 [N=675]||+6 [N=605]||43 [N=343]||+8 [N=298]||42 [N=335]||+5 [N=284]|
|LDL-cholesterol (fasted)||100 [N=675]||+10 [N=606]||97 [N=343]||+17 [N=298]||101 [N=337]||+11 [N=288]|
|Triglycerides (fasted)||122 [N=675]||+13 [N=606]||121 [N=343]||+13 [N=298]||132 [N=337]||+29 [N=287]|
|a The change from baseline is the mean of within-patient changes from baseline for patients with both baseline and Week 48 values.|
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
hepatic steatosis, hepatitis, increased liver enzymes (most commonly AST, ALT gamma GT)
Skin and Subcutaneous Tissue Disorders
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
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 »
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.
STRIBILD should not be used in conjunction with protease inhibitors or non-nucleoside reverse transcriptase inhibitors due to potential drug-drug interactions including altered and/or suboptimal pharmacokinetics of cobicistat, elvitegravir, and/or the coadministered antiretroviral products. STRIBILD should not be administered concurrently with products containing ritonavir or regimens containing ritonavir due to similar effects of cobicistat and ritonavir on CYP3A.
Potential for STRIBILD to Affect Other Drugs
Cobicistat, a component of STRIBILD, is an inhibitor of CYP3A and CYP2D6. The transporters that cobicistat inhibits include 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 5).
Coadministration of STRIBILD with other drugs that inhibit CYP3A may decrease the clearance and increase the plasma concentration of cobicistat (see Table 5).
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. Some examples of drugs that are eliminated by active tubular secretion include, but are not limited to acyclovir, cidofovir, ganciclovir, valacyclovir, and valganciclovir.
Established and Other Potentially Significant Interactions
Table 5 provides a listing of established or potentially clinically significant drug-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 5 : 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)
Proton Pump Inhibitors H2 Receptor Antagonists
|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.
No dose adjustment is needed when STRIBILD is combined with either H2 receptor antagonists or proton pump inhibitors.
|Antiarrhythmics: e.g. amiodarone bepridil digoxin* disopyramide flecainide systemic lidocaine mexiletine propafenone quinidine||↑ antiarrhythmics
|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
|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/min: No dose adjustment of clarithromycin is required.
Patients with CLcr between 50 mL/min and 60 mL/min: 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
|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.|
|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 nortriptylinebuproprion
|Concentrations of these antidepressant agents may be increased when coadministered with STRIBILD. Careful dose titration of the antidepressant and monitoring for antidepressant response is recommended.|
|Antifungals: itraconazole ketoconazole* voriconazole||↑ elvitegravir
|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 should not 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
|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 othe 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
|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||↑ immuno-suppressants||Concentrations of these immunosuppressant agents may be increased when coadministered with STRIBILD. Therapeutic monitoring of the immunosuppressive agents is recommended upon coadministration with STRIBILD.|
|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 events, including hypotension, syncope, visual disturbances, and priapism.
Coadministration of tadalafil in patients on STRIBILD:
|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.
a This 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, and ribavirin.
Last reviewed on RxList: 9/20/2012
This monograph has been modified to include the generic and brand name in many instances.
Additional Stribild Information
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