JC is a 29-year-old female presenting with a new confirmed diagnosis of HIV (Human Immunodeficiency Virus). She has no known drug allergies and a past medical history of anxiety. She is also currently co-infected with Hepatitis B. Her current medications include Tri-Lo-Sprintec and Escitalopram. Her doctor would like your recommendation for the best initial treatment regimen for JC's HIV management.

Vitals: 

Heart Rate: 70bpm  Blood Pressure: 124/78mmHg  Weight: 58kg  Height: 5’5”  Temperature: 98.6F

Labs: 

Na 136 mEq/L  K 4.0 mEq/L  Cl 99 mEq/L  SCr 0.8 mg/dL  CD4 cell count 250 cells/mm³  HIV RNA viral load 650,000 copies/mL

Genetic Testing:

HLA-B*5701 positive 

Which of the following is the most appropriate choice for this patient?  

A. Triumeq

B. Dovato

C. Cabenuva 

D. Biktarvy

Brands/Generics:

Tri-Lo-Sprintec (Ethinyl Estradiol and Norgestimate); Lexapro (Escitalopram); Triumeq (Abacavir+Dolutegravir+Lamivudine); Dovato (Dolutegravir+Lamivudine); Cabenuva (Cabotegravir+Rilpivirine); Biktarvy (Bictegravir+Tenofovir Alafenamide+Emtricitabine) 

Rationale with answers:

HIV (Human Immunodeficiency Virus) is a zoonotic retrovirus that attacks CD4 cells causing immunodeficiency in the infected host. It is a chronic disease state and if left untreated can progress to Acquired Immunodeficiency Syndrome (AIDS). The mainstay of treatment for HIV is known as ART (Antiretroviral Therapy). ART is a combination therapy that requires multiple drugs from different classes given at the same time to attack the virus via multiple mechanisms of action. Let's go through important rationale for each answer!

Answer A is incorrect. Triumeq (Abacavir+Dolutegravir+Lamivudine) is a once daily, single-tablet regimen that is a recommended initial treatment option for ART naïve patients. However, this medication is not the best option for JC because she is HLA-B*5701 positive. When patients are positive for this specific genetic variation in HLA-B, they should not receive regimens containing abacavir, as they have a higher risk of experiencing severe hypersensitivity reactions that could be fatal. 

Answer B is incorrect. Dovato (Dolutegravir+Lamivudine) is a once daily, single-tablet regimen that is also a recommended initial treatment option for ART naïve patients. It is also not the best option for JC, as her HIV RNA viral load is 650,000 copies/mL. Patients that have an HIV RNA viral load of >500,000 copies/mL should not use Dovato, as it is a two drug regimen which may not be able to fully suppress the patient's viral load. 

Answer C is incorrect. Cabenuva (Cabotegravir+Rilpivirine) is a once or twice monthly injectable ART option for patients 12 years and older that weigh at least 35kg. This is not the best treatment option for JC because it is not indicated for initial treatment in ART naïve patients. This medication is for those that are virologically suppressed with no history of treatment failure or resistance to either cabotegravir or rilpivirine as a replacement for their current ART regimen. As this patient is not on an ART regimen currently and is not virologically suppressed, this would not be an appropriate initial choice for her. 

Answer D is correct. Biktarvy (Bictegravir+Tenofovir Alafenamide+Emtricitabine) is a once daily, single-tablet regimen that is recommended as an initial treatment option in ART naïve patients. This is the best option for JC to initiate treatment with, as she is ART naïve and there are no contraindications for her use of this drug. She is also Hepatitis B co-infected, meaning she needs at least two antiretroviral drugs that cover Hepatitis B. It is recommended to use tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) with emtricitabine or lamivudine in these patients. Biktarvy contains TAF and emtricitabine, which also covers her Hepatitis B. TAF is also an often recommended choice over TDF due to fewer side effects such as renal dysfunction and loss of bone mineral density.

NAPLEX Competencies Covered: 

Area 1: Obtain, Interpret, or Assess Data, Medical, or Patient Information

1.1 From instruments, screening tools, laboratory, genomic or genetic information, or diagnostic findings

1.3 From practitioners: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background

Area 2: Identify Drug Characteristics 

2.1 Pharmacology, mechanism of action, or therapeutic class

2.2 Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied

Area 3: Develop or Manage Treatment Plans 

3.3 Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions

3.5 Drug route of administration, dosage forms, or delivery systems

3.6 Drug contraindications, allergies, or precautions

3.7 Adverse drug effects, toxicology, or overdose

3.11 Evidence-based practice  

References: 

1. Clinical Guidelines for HIV at clinicalinfo.hiv.gov.