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Doravirine, Lamivudine, and Tenofovir Disoproxil

Class: HIV Nonnucleoside Reverse Transcriptase Inhibitors
Chemical Name: 3-chloro-5-[1-[(4-methyl-5-oxo-1H-1,2,4-triazol-3-yl)methyl]-2-oxo-4-(trifluoromethyl)pyridin-3-yl]oxybenzonitrile
Molecular Formula: C17H11ClF3N5O3C8H11N3O3SC9H14N5O4P • H2O
CAS Number: 1338225-97-0

Medically reviewed by Drugs.com on Mar 30, 2020. Written by ASHP.

Warning

    HBV Infection
  • Severe, acute exacerbations of HBV infection reported following discontinuance of lamivudine or tenofovir DF in patients coinfected with HIV and HBV. Monitor hepatic function closely with both clinical and laboratory follow-up for at least several months after doravirine/lamivudine/tenofovir DF is discontinued in patients coinfected with HIV and HBV. If appropriate, initiation of HBV treatment may be warranted. (See HIV-infected Individuals Coinfected with HBV under Cautions.)

Introduction

Antiretroviral; fixed combination of doravirine, lamivudine, and tenofovir disoproxil fumarate (doravirine/lamivudine/tenofovir DF). Doravirine is an HIV nonnucleoside reverse transcriptase inhibitor (NNRTI), lamivudine is an HIV nucleoside reverse transcriptase inhibitor (NRTI), and tenofovir DF is an HIV nucleotide reverse transcriptase inhibitor classified as an NRTI.

Uses for Doravirine, Lamivudine, and Tenofovir Disoproxil

Treatment of HIV Infection

Treatment of HIV-1 infection in antiretroviral-naive (have not previously received antiretroviral therapy) or antiretroviral-experienced (previously treated) adults.

Fixed combination of doravirine/lamivudine/tenofovir DF used alone as a complete regimen for treatment of HIV-1 infection; use with other antiretrovirals not recommended.

For initial treatment in antiretroviral-naive adults, experts state that doravirine/lamivudine/tenofovir DF is a recommended NNRTI-based regimen in certain clinical situations.

For antiretroviral-experienced adults, manufacturer states that doravirine/lamivudine/tenofovir DF can be used to replace the current antiretroviral regimen in those with plasma HIV-1 RNA levels <50 copies/mL on a stable antiretroviral regimen who have no history of treatment failure and are infected with HIV-1 with no known substitutions associated with resistance to doravirine, lamivudine, or tenofovir DF.

Most appropriate antiretroviral regimen cannot be defined for every clinical scenario; select regimen based on information regarding antiretroviral potency, potential rate of resistance development, known toxicities, potential for pharmacokinetic interactions, and patient's virologic, immunologic, and clinical characteristics. Guidelines for the management of HIV infection, including specific recommendations for initial treatment in antiretroviral-naive patients and recommendations for changing antiretroviral regimens, are available at [Web].

Doravirine, Lamivudine, and Tenofovir Disoproxil Dosage and Administration

General

  • Determine Scr, estimated Clcr, urine glucose, and urine protein prior to initiation of doravirine/lamivudine/tenofovir DF and routinely monitor during treatment in all patients as clinically appropriate. Also determine serum phosphorus in patients with chronic kidney disease. (See Renal Impairment under Cautions.)

  • Test for HBV infection prior to initiation. (See HIV-infected Individuals Coinfected with HBV under Cautions.)

Administration

Oral Administration

Administer orally once daily without regard to food.

Doravirine/lamivudine/tenofovir DF is used alone as a complete antiretroviral regimen.

Dosage

Each fixed-combination tablet of doravirine/lamivudine/tenofovir DF contains doravirine 100 mg, lamivudine 300 mg, and tenofovir DF 300 mg.

Adults

Treatment of HIV Infection
Antiretroviral-naive or Antiretroviral-experienced Adults
Oral

1 tablet of doravirine/lamivudine/tenofovir DF (doravirine 100 mg, lamivudine 300 mg, tenofovir DF 300 mg) once daily.

Antiretroviral-naive or Antiretroviral-experienced Adults Receiving Rifabutin
Oral

1 tablet of doravirine/lamivudine/tenofovir DF (doravirine 100 mg, lamivudine 300 mg, tenofovir DF 300 mg) once daily and one 100-mg tablet of single-entity doravirine once daily given approximately 12 hours after the fixed-combination tablet. (See Specific Drugs under Interactions.)

Special Populations

Hepatic Impairment

Mild or moderate hepatic impairment (Child-Pugh class A or B): Dosage adjustments not needed.

Severe hepatic impairment (Child-Pugh class C): Not studied. (See Hepatic Impairment under Cautions.)

Renal Impairment

Estimated Clcr <50 mL/minute: Not recommended. (See Renal Impairment under Cautions.)

Geriatric Patients

No specific dosage recommendations; use with caution because of possible age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant disease and drug therapy. (See Geriatric Use under Cautions.)

Cautions for Doravirine, Lamivudine, and Tenofovir Disoproxil

Contraindications

  • Concomitant use with potent CYP3A inducers (e.g., carbamazepine, oxcarbazepine, phenobarbital, phenytoin, enzalutamide, rifampin, rifapentine, mitotane, St. John’s wort [Hypericum perforatum]). (See Specific Drugs under Interactions.)

  • History of hypersensitivity reaction to lamivudine.

Warnings/Precautions

Warnings

HIV-infected Individuals Coinfected with HBV

Test all HIV-infected patients for presence of HBV before initiating antiretroviral therapy.

In HIV-infected patients with HBV coinfection, severe acute exacerbations of HBV, including liver decompensation and liver failure, reported following discontinuance of lamivudine or tenofovir DF (components of doravirine/lamivudine/tenofovir DF). Such reactions could occur following discontinuance of doravirine/lamivudine/tenofovir DF.

Closely monitor hepatic function (using both clinical and laboratory follow-up) for at least several months after doravirine/lamivudine/tenofovir DF is discontinued in patients coinfected with HIV and HBV. If appropriate, initiation of HBV treatment may be warranted, especially in patients with advanced liver disease or cirrhosis.

Other Warnings and Precautions

Renal Toxicity

Renal impairment, including acute renal failure and Fanconi syndrome (renal tubular injury with hypophosphatemia), reported with tenofovir DF (a component of doravirine/lamivudine/tenofovir DF).

Determine Scr, estimated Clcr, urine glucose, and urine protein prior to initiation of doravirine/lamivudine/tenofovir DF and routinely monitor as clinically appropriate during treatment in all patients. Also determine serum phosphorus in those with chronic kidney disease. (See Renal Impairment under Cautions.)

Discontinue doravirine/lamivudine/tenofovir DF if clinically important decreases in renal function or evidence of Fanconi syndrome occurs or if estimated Clcr decreases to <50 mL/minute.

Because persistent or worsening bone pain, pain in extremities, fractures, and/or muscular pain or weakness may be manifestations of proximal renal tubulopathy, promptly evaluate renal function in patients at risk for renal dysfunction who present with such symptoms. (See Bone Effects under Cautions.)

Avoid doravirine/lamivudine/tenofovir DF in patients who are receiving or have recently received a nephrotoxic drug (e.g., high-dose or multiple NSAIAs). Acute renal failure reported after initiation of high-dose or multiple NSAIAs in HIV-infected patients at risk for renal dysfunction who appeared stable while receiving tenofovir DF; hospitalization and renal replacement therapy required in some patients. Consider alternatives to NSAIAs in patients at risk for renal dysfunction.

Bone Effects

Decreases in bone mineral density (BMD) from baseline at lumbar spine and hip, increases in several biochemical markers of bone metabolism, and increased serum parathyroid hormone and 1,25 vitamin D levels reported in patients receiving tenofovir DF (a component of doravirine/lamivudine/tenofovir DF). Effects of tenofovir-associated changes in BMD on long-term bone health and future fracture risk unknown.

Osteomalacia associated with proximal renal tubulopathy, which may contribute to fractures, reported in patients receiving tenofovir DF. Arthralgia and muscle pain or weakness also reported in cases of proximal renal tubulopathy. Consider hypophosphatemia and osteomalacia secondary to proximal renal tubulopathy in patients at risk of renal dysfunction who present with persistent or worsening bone or muscle symptoms while receiving preparations containing tenofovir DF.

Consider BMD monitoring in adults with history of pathologic bone fracture or other risk factors for osteoporosis or bone loss. Effect of calcium and vitamin D supplementation not studied, but may be beneficial for all patients. If bone abnormalities suspected, obtain appropriate consultation.

Interactions

Concomitant use with certain drugs may result in known or potentially clinically important drug interactions, some of which may lead to loss of therapeutic effect of the antiretrovirals and possible development of resistance or may increase plasma concentrations of the antiretroviral agents and/or concomitant drugs leading to clinically important adverse reactions.

Consider potential for drug interactions prior to and during doravirine/lamivudine/tenofovir DF therapy; review concomitant drugs during doravirine/lamivudine/tenofovir DF therapy and monitor for adverse effects. (See Interactions.)

Immune Reconstitution Syndrome

Immune reconstitution syndrome reported in HIV-infected patients receiving multiple-drug antiretroviral therapy. During the initial phase of treatment, HIV-infected patients whose immune systems respond to antiretroviral therapy may develop an inflammatory response to indolent or residual opportunistic infections (e.g., Mycobacterium avium, cytomegalovirus [CMV], Pneumocystis jirovecii [formerly P. carinii], tuberculosis); such responses may necessitate further evaluation and treatment.

Autoimmune disorders (e.g., Graves' disease, polymyositis, Guillain-Barré syndrome, autoimmune hepatitis) also reported in the setting of immune reconstitution; however, time to onset is more variable and can occur many months after initiation of antiretroviral therapy.

Use of Fixed Combinations

Consider cautions, precautions, contraindications, and interactions associated with each component of doravirine/lamivudine/tenofovir DF. Consider cautionary information applicable to specific populations (e.g., pregnant or nursing women, individuals with hepatic or renal impairment, geriatric patients) for each drug in the fixed combination.

Doravirine/lamivudine/tenofovir DF is used alone as a complete regimen; use in conjunction with other antiretrovirals not recommended.

Specific Populations

Pregnancy

Antiretroviral Pregnancy Registry at 800-258-4263 or [Web].

Doravirine/lamivudine/tenofovir DF: Insufficient data in pregnant women to assess the risk of birth defects and miscarriage.

Doravirine: Human data not available to establish whether or not doravirine poses a risk to pregnancy outcomes. In animal reproduction studies, no adverse developmental effects observed in rabbits or rats at exposures 8 or 9 times higher, respectively, than human exposures at recommended human dosage. In pregnant rabbits and rats, doravirine crossed the placenta resulting in fetal plasma concentrations up to 40 and 52%, respectively, of maternal concentrations observed on gestation day 20.

Lamivudine: Available human data show no difference in the overall risk of major birth defects. In pregnant rabbits, oral administration during organogenesis resulted in embryolethality at systemic exposures similar to the recommended clinical dose; no adverse development effects observed in rats and rabbits with oral administration during organogenesis at peak plasma concentrations approximately 35 times higher than human exposure at the recommended clinical dose.

Tenofovir DF: Available human data show no difference in the overall risk of major birth defects. No adverse developmental effects observed in pregnant rats and rabbits at doses up to 14 and 19 times higher, respectively, than recommended human dosage.

Lactation

Doravirine: Not known whether distributed into human milk. Distributed into milk of lactating rats (milk concentrations approximately 1.5 times higher than maternal plasma concentrations at 2 hours after a dose on lactation day 14).

Lamivudine and tenofovir DF: Distributed into human milk.

Doravirine/lamivudine/tenofovir DF: Not known whether the fixed combination or individual drug components affect human milk production or affect the breast-fed infant.

Instruct HIV-infected women not to breast-feed because of risk of HIV transmission and risk of adverse effects in the infant.

Pediatric Use

Safety and efficacy not established in pediatric patients <18 years of age.

Geriatric Use

Experience in patients ≥65 years of age insufficient to determine whether they respond differently than younger adults.

Use with caution in geriatric patients because of age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant disease and drug therapy.

Hepatic Impairment

Doravirine: No clinically important differences in doravirine pharmacokinetics in patients with moderate hepatic impairment (Child-Pugh class B). Not studied in those with severe hepatic impairment (Child-Pugh class C).

Lamivudine: Pharmacokinetics not substantially affected by diminishing hepatic function. Safety and efficacy not established in patients with decompensated liver disease.

Tenofovir: Pharmacokinetics not substantially affected by any degree of hepatic impairment.

Renal Impairment

Not recommended in patients with estimated Clcr <50 mL/minute because dosage of lamivudine and tenofovir DF (components of doravirine/lamivudine/tenofovir DF) cannot be adjusted for renal impairment.

Common Adverse Effects

Dizziness, nausea, abnormal dreams.

Interactions for Doravirine, Lamivudine, and Tenofovir Disoproxil

The following drug interactions are based on studies using the individual components of doravirine/lamivudine/tenofovir DF. Consider interactions associated with each drug in the fixed combination.

Drugs Affecting or Metabolized by Hepatic Microsomal Enzymes

Doravirine: Primarily metabolized by CYP3A. In vitro, does not inhibit CYP1A2, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4; not likely to induce CYP1A2, 2B6, or 3A4. Concomitant use of doravirine and CYP3A inducers may decrease doravirine plasma concentrations and may reduce efficacy of doravirine. Concomitant use of doravirine/lamivudine/tenofovir DF with CYP3A inhibitors may increase doravirine plasma concentrations. Not likely to have a clinically important effect on the exposure of drugs metabolized by CYP isoenzymes.

Lamivudine: Not substantially metabolized by CYP isoenzymes; does not inhibit or induce CYP isoenzymes. Clinically important CYP-mediated drug interactions unlikely.

Tenofovir DF: Not a substrate of CYP isoenzymes. In vitro, does not inhibit CYP isoenzymes 3A4, 2D6, 2C9, or 2E1; may have a slight inhibitory effect on CYP1A. Pharmacokinetic interactions with inhibitors or substrates of CYP isoenzymes unlikely.

Drugs Affecting or Metabolized by UGT

Doravirine: In vitro, does not inhibit UGT1A1.

Drugs Affecting or Affected by Other Transporters

Doravirine: Based on in vitro studies, not likely to inhibit P-glycoprotein (P-gp) transport system, organic anion transport polypeptide (OATP) 1B1, OATP1B3, bile salt export pump (BSEP), organic anion transporter (OAT) 1, OAT3, organic cation transporter (OCT) 2, multidrug and toxin extrusion transporter (MATE) 1, or MATE2K. Not a substrate of breast cancer resistance protein (BCRP); unlikely to be a substrate of OATP1B1 or 1B3.

Lamivudine: Primarily eliminated in urine by active organic cationic secretion. Potential pharmacokinetic interactions with drugs that are primarily eliminated by active renal secretion via organic cationic transport.

Drugs Affecting Renal Function

Drugs that reduce renal function or compete for active tubular secretion: Potential increased concentrations of lamivudine, tenofovir, and/or concomitant drug.

Specific Drugs

Drug

Interaction

Comments

Adefovir dipivoxil

Tenofovir DF: Data not available

Tenofovir DF: Do not use concomitantly with adefovir dipivoxil

α1-Adrenergic blocking agents

Alfuzosin, doxazosin, silodosin, tamsulosin: No effect on α1-adrenergic blocking agent concentrations expected if used with doravirine

Dosage adjustments not needed if used with doravirine

Antacids

Antacid containing aluminum hydroxide, magnesium hydroxide, and simethicone: No clinically important effect on doravirine concentrations

Dosage adjustments not needed if used with doravirine

Anticoagulants

Apixaban, betrixaban, dabigatran, edoxaban, rivaroxaban: No effect on anticoagulant concentrations expected if used with doravirine

Warfarin: No effect on warfarin concentrations expected if used with doravirine

Apixaban, betrixaban, dabigatran, edoxaban, rivaroxaban: Experts state dosage adjustments not needed if used with doravirine

Warfarin: Dosage adjustments not needed if used with doravirine

Anticonvulsants

Carbamazepine, oxcarbazepine, phenobarbital, phenytoin: Decreased doravirine concentrations expected; possible decreased doravirine efficacy

Eslicarbazepine: Possible decreased doravirine concentrations

Ethosuximide, lacosamide, lamotrigine, tiagabine, zonisamide: No effect on anticonvulsant concentrations expected if used with doravirine

Carbamazepine, oxcarbazepine, phenobarbital, phenytoin: Concomitant use contraindicated; do not initiate doravirine/lamivudine/tenofovir DF until ≥4 weeks after anticonvulsant discontinued; experts state consider alternative anticonvulsant

Eslicarbazepine: If used concomitantly, experts state monitor virologic outcomes and consider doravirine plasma concentration monitoring; alternatively, consider different antiretroviral or anticonvulsant

Ethosuximide, lacosamide, lamotrigine, tiagabine, zonisamide: Dosage adjustments not needed if used with doravirine

Antidiabetic agents

Canagliflozin, dapagliflozin, empagliflozin: No effect on antidiabetic agent concentrations expected if used with doravirine

Linagliptin, saxagliptin, sitagliptin: No effect on antidiabetic agent concentrations expected if used with doravirine

Metformin: No clinically important effect on metformin concentrations when used with doravirine; possible decreased doravirine concentrations and AUC

Canagliflozin, dapagliflozin, empagliflozin: Dosage adjustments not needed if used with doravirine

Linagliptin, saxagliptin, sitagliptin: Dosage adjustments not needed if used with doravirine

Metformin: Dosage adjustments not needed if used with doravirine

Antifungals, azoles

Fluconazole, isavuconazonium sulfate [prodrug of isavuconazole], itraconazole, voriconazole: Possible increased doravirine concentrations

Ketoconazole: Increased doravirine exposures and peak plasma concentrations; not considered clinically important

Posaconazole: Possible increased doravirine concentrations

Fluconazole, isavuconazonium sulfate, itraconazole, voriconazole: Dosage adjustments not needed if used with doravirine

Posaconazole: Experts state monitor for doravirine-associated toxicities

Antimalarial and antiprotozoal agents

Atovaquone: Data not available regarding use with doravirine

Fixed combination of artemether and lumefantrine (artemether/lumefantrine): No effect on antimalarial agent concentrations expected if used with doravirine

Fixed combination of atovaquone and proguanil (atovaquone/proguanil): Data not available regarding use with doravirine

Atovaquone: Experts recommend monitoring for antiprotozoal efficacy if used with doravirine

Artemether/lumefantrine: Dosage adjustments not needed if used with doravirine

Atovaquone/proguanil: Experts recommend monitoring for antimalarial efficacy if used with doravirine

Antimycobacterials (bedaquiline, rifamycins)

Bedaquiline: No effect on bedaquiline concentrations expected if used with doravirine

Rifabutin: Decreased doravirine AUC and trough plasma concentrations; peak plasma concentrations not affected

Rifampin: Decreased doravirine AUC, peak plasma concentrations, and trough plasma concentrations; possible decreased doravirine efficacy

Rifapentine: Decreased doravirine concentrations expected; possible decreased efficacy of doravirine

Bedaquiline: Dosage adjustments not needed if used with doravirine

Rifabutin: Increase doravirine dosage by using doravirine/lamivudine/tenofovir DF in conjunction with single-entity doravirine (see Antiretroviral-naive or Antiretroviral-experienced Adults Receiving Rifabutin under Dosage and Administration)

Rifampin, rifapentine: Concomitant use contraindicated; do not initiate doravirine/lamivudine/tenofovir DF until ≥4 weeks after rifampin or rifapentine discontinued

Antiplatelet agents

Ticagrelor, vorapaxar: No effect on antiplatelet agent concentrations expected if used with doravirine

Ticagrelor, vorapaxar: Dosage adjustments not needed if used with doravirine

Antipsychotic agents

Aripiprazole, brexpiprazole, cariprazine, lurasidone, pimavanserin, pimozide, quetiapine: No effect on antipsychotic agent concentrations expected

Aripiprazole, brexpiprazole, cariprazine, lurasidone, pimavanserin, pimozide, quetiapine: Dosage adjustments not needed if used with doravirine

Benzodiazepines

Alprazolam, diazepam, lorazepam, triazolam: No effect on benzodiazepine concentrations expected if used with doravirine

Midazolam: No clinically important pharmacokinetic interactions with doravirine

Alprazolam, diazepam, lorazepam, midazolam, triazolam: Dosage adjustments not needed if used with doravirine

Buprenorphine

Doravirine: No effect on buprenorphine concentrations expected if used with doravirine

Lamivudine or tenofovir DF: No clinically important pharmacokinetic interactions

Doravirine: Dosage adjustments not needed

Lamivudine or tenofovir DF: Dosage adjustments not needed

Bupropion

No effect on bupropion concentrations expected if used with doravirine

Dosage adjustments not needed if used with doravirine

Calcium-channel blocking agents

Dihydropyridine calcium-channel blocking agents: No effect on concentrations of these calcium-channel blocking agents expected if used with doravirine

Diltiazem, verapamil: Possible increased doravirine concentrations; no effect on diltiazem or verapamil concentrations expected if used with doravirine

Dihydropyridine calcium-channel blocking agents, diltiazem, verapamil: Dosage adjustments not needed if used with doravirine

Co-trimoxazole

Lamivudine: Increased lamivudine AUC and decreased lamivudine oral clearance; no effect on pharmacokinetics of trimethoprim or sulfamethoxazole

Dasabuvir

Dasabuvir used with the fixed combination of ombitasvir, paritaprevir, and ritonavir (ombitasvir/paritaprevir/ritonavir): Possible increased doravirine concentrations

Dasabuvir used with ombitasvir/paritaprevir/ritonavir: Dosage adjustments not needed if used with doravirine

Dexamethasone

Doravirine: Possible decreased doravirine concentrations

Doravirine: Experts state consider an alternative corticosteroid for long-term use; if used concomitantly, monitor virologic response

Dutasteride

Doravirine: Pharmacokinetic interactions not expected

Elbasvir and grazoprevir

Elbasvir and grazoprevir: No clinically important pharmacokinetic interactions with doravirine

Fixed combination of elbasvir and grazoprevir (elbasvir/grazoprevir): Dosage adjustments not needed if used with doravirine

Entecavir

Tenofovir DF: No clinically important pharmacokinetic interactions

Enzalutamide

Decreased doravirine concentrations expected; possible decreased doravirine efficacy

Concomitant use contraindicated; do not initiate doravirine/lamivudine/tenofovir DF until ≥4 weeks after enzalutamide discontinued

Estrogens and progestins

Contraceptives containing ethinyl estradiol or levonorgestrel (oral): No effect on ethinyl estradiol or levonorgestrel concentrations expected if used with doravirine or tenofovir DF

Contraceptives containing etonogestrel or levonorgestrel (transdermal systems) and contraceptives containing ethinyl estradiol and etonogestrel or segesterone (vaginal rings): No effect on concentrations of these hormones expected if used with doravirine

Medroxyprogesterone: No effect on concentrations of the hormone expected if used with doravirine

Contraceptives containing ethinyl estradiol and levonorgestrel (oral): Dosage adjustments not needed if used with doravirine

Contraceptives containing etonogestrel or levonorgestrel (transdermal systems) and contraceptives containing ethinyl estradiol and etonogestrel or segesterone (vaginal rings): Dosage adjustments not needed if used with doravirine

Medroxyprogesterone: Dosage adjustments not needed if used with doravirine

Ganciclovir and valganciclovir

Tenofovir DF: Concomitant use with ganciclovir or valganciclovir may result in increased tenofovir and/or ganciclovir concentrations

Tenofovir DF: Monitor for dose-related toxicities of tenofovir and/or ganciclovir

Glecaprevir and pibrentasvir

Fixed combination of glecaprevir and pibrentasvir (glecaprevir/pibrentasvir): Possible increased doravirine concentrations; no clinically important effect on tenofovir concentrations

Glecaprevir/pibrentasvir: Dosage adjustments not needed if used with doravirine or tenofovir DF

Histamine H2-receptor antagonists

No effect on doravirine concentrations expected

Dosage adjustments not needed if used with doravirine

HMG-CoA reductase inhibitors (statins)

Atorvastatin: No clinically important effect on atorvastatin concentrations when used with doravirine

Fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin: No effect on statin concentrations expected if used with doravirine

Atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin: Dosage adjustments not needed if used with doravirine

Immunosuppressive agents

Cyclosporine: Possible increased doravirine concentrations; no effect on cyclosporine concentrations expected if used with doravirine

Everolimus, sirolimus, tacrolimus: No effect on immunosuppressive agent concentrations expected if used with doravirine

Tenofovir DF: No clinically important pharmacokinetic interactions with tacrolimus

Cyclosporine, everolimus, sirolimus, tacrolimus: Dosage adjustments not needed if used with doravirine

Lamivudine

No clinically important pharmacokinetic interactions between doravirine, lamivudine, and tenofovir DF

No in vitro evidence of antagonistic antiretroviral effects between doravirine and lamivudine or tenofovir DF

Ledipasvir and sofosbuvir

Fixed combination of ledipasvir and sofosbuvir (ledipasvir/sofosbuvir): No clinically important pharmacokinetic interactions with doravirine; increased tenofovir exposures

Ledipasvir/sofosbuvir: Dosage adjustments not needed if used with doravirine/lamivudine/tenofovir DF; monitor for tenofovir-associated adverse effects

Lofexidine

No effect on lofexidine concentrations expected if used with doravirine

Dosage adjustments not needed if used with doravirine

Macrolides

Azithromycin: No effect on azithromycin concentrations expected if used with doravirine

Clarithromycin: Possible increased doravirine concentrations; no effect on clarithromycin concentrations expected if used with doravirine

Erythromycin: Possible increased doravirine concentrations

Azithromycin: Dosage adjustments not needed if used with doravirine

Clarithromycin: Experts state consider alternative (e.g., azithromycin) for prophylaxis or treatment of M. avium complex (MAC) infections in patients receiving doravirine

Erythromycin: Experts state monitor for doravirine tolerability

Methadone

Doravirine and tenofovir DF: No clinically important effects on pharmacokinetics of methadone or either antiretroviral

Dosage adjustments not needed if used with doravirine

Mitotane

Decreased doravirine concentrations expected; possible decreased doravirine efficacy

Concomitant use contraindicated; do not initiate doravirine/lamivudine/tenofovir DF until ≥4 weeks after mitotane discontinued

Nefazodone

Doravirine: Possible increased doravirine concentrations

Doravirine: Experts state monitor for doravirine-associated adverse effects

NSAIAs

High-dose or multiple NSAIAs: Possible increased concentrations of lamivudine, tenofovir, and/or the NSAIAs

Avoid doravirine/lamivudine/tenofovir DF in patients who are receiving or have recently received a nephrotoxic drug (e.g., high-dose or multiple NSAIAs)

Olanzapine

Doravirine: No clinically important effect on olanzapine concentrations expected

Doravirine: Experts state dosage adjustments not needed

Phosphodiesterase type 5 (PDE5) inhibitors

Avanafil, sildenafil, tadalafil, vardenafil: No effect on PDE5 inhibitor concentrations expected

Avanafil, sildenafil, tadalafil, vardenafil: Dosage adjustments not needed if used with doravirine

Platelet-aggregation inhibitors

Clopidogrel, prasugrel: No effect on platelet-aggregation inhibitor concentrations expected if used with doravirine

Clopidogrel, prasugrel: Dosage adjustments not needed if used with doravirine

Proton-pump inhibitors

Pantoprazole: No clinically important effect on doravirine concentrations

Other proton-pump inhibitors: No effect on doravirine concentrations expected

Pantoprazole and other proton-pump inhibitors: Dosage adjustments not needed if used with doravirine

Ribavirin

Tenofovir DF: No clinically important pharmacokinetic interactions

Tenofovir DF: Dosage adjustment not needed

St. John's wort (Hypericum perforatum)

Decreased doravirine concentrations expected; possible decreased doravirine efficacy

Concomitant use contraindicated; do not initiate doravirine/lamivudine/tenofovir DF until ≥4 weeks after St. John's wort discontinued

Sofosbuvir

Tenofovir DF: No clinically important pharmacokinetic interactions

Sofosbuvir and velpatasvir

Fixed combination of sofosbuvir and velpatasvir (sofosbuvir/velpatasvir): Possible increased tenofovir concentrations and AUC; no clinically important pharmacokinetic interactions with doravirine expected

Sofosbuvir/velpatasvir: Monitor for tenofovir-associated adverse effects

Sofosbuvir, velpatasvir, and voxilaprevir

Fixed combination of sofosbuvir, velpatasvir, and voxilaprevir (sofosbuvir/velpatasvir/voxilaprevir): Possible increased tenofovir concentrations and AUC; no clinically important pharmacokinetic interactions with doravirine expected

Sofosbuvir/velpatasvir/voxilaprevir: Monitor for tenofovir-associated adverse effects

Sorbitol

Lamivudine: Decreased lamivudine AUC and peak plasma concentrations

Avoid concomitant use of doravirine/lamivudine/tenofovir DF and sorbitol-containing drugs

SSRIs

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline: No effect on SSRI concentrations expected if used with doravirine

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline: Dosage adjustments not needed if used with doravirine

Tenofovir

No clinically important pharmacokinetic interactions between doravirine, lamivudine, and tenofovir DF

No in vitro evidence of antagonistic antiretroviral effects between doravirine and lamivudine or tenofovir DF

Trazodone

No effect on trazodone concentrations expected if used with doravirine

Dosage adjustments not needed if used with doravirine

Doravirine, Lamivudine, and Tenofovir Disoproxil Pharmacokinetics

Absorption

Bioavailability

Doravirine: 64%.

Lamivudine: 86%.

Tenofovir DF: 25%.

Food

Relative to fasting state, administration of doravirine, lamivudine, and tenofovir DF with high-fat meal increases AUC of doravirine and tenofovir by 10 and 25%, respectively, and decreases lamivudine AUC by 7%.

Effect of food not considered clinically important.

Plasma Concentrations

A fixed-combination tablet containing doravirine 100 mg, lamivudine 300 mg, and tenofovir DF 300 mg is bioequivalent to a 100-mg tablet of doravirine, 300-mg tablet of lamivudine, and 300-mg tablet of tenofovir DF given simultaneously.

Peak plasma concentrations of doravirine and tenofovir occur 2 hours and 1 hour, respectively, after oral administration.

Distribution

Extent

Doravirine: Distributed into milk in rats; not known whether distributed into human milk.

Lamivudine and tenofovir DF: Distributed into human milk.

Plasma Protein Binding

Doravirine: 76%.

Lamivudine: <35%.

Tenofovir: <0.7%.

Elimination

Metabolism

Doravirine: Primarily metabolized by CYP3A.

Lamivudine: Metabolized by CYP isoenzymes only to a minor extent.

Tenofovir DF: Does not undergo hepatic metabolism.

Elimination Route

Doravirine: Approximately 6% of oral dose eliminated in urine as unchanged doravirine; unchanged drug also eliminated to a minor extent by biliary and/or fecal routes.

Lamivudine: Eliminated by glomerular filtration and active tubular secretion; following an IV dose, approximately 71% eliminated in urine.

Tenofovir: Eliminated by glomerular filtration and active tubular secretion; following an IV dose, 70–80% eliminated in urine.

Half-life

Doravirine: 15 hours.

Lamivudine: 5–7 hours.

Tenofovir: 17 hours.

Special Populations

Hepatic impairment: Doravirine pharmacokinetics not substantially affected by moderate hepatic impairment (Child-Pugh class B). Lamivudine pharmacokinetics not substantially affected by diminishing hepatic function. Tenofovir pharmacokinetics not substantially affected by any degree of hepatic impairment.

Renal impairment: Doravirine exposures 43% higher in individuals with severe renal impairment compared with those without renal impairment. Based on population pharmacokinetic analysis, renal function does not have a clinically important effect on doravirine pharmacokinetics; insufficient data in patients with end-stage renal disease and not studied in patients receiving dialysis. Lamivudine exposures, peak plasma concentrations, and half-life increased and clearance decreased to a clinically important extent with diminishing renal function (Clcr 111 to < 10 mL/minute). Tenofovir exposures and peak plasma concentrations substantially increased in those with Clcr <50 mL/minute or with end-stage renal disease requiring dialysis.

No clinically important differences in pharmacokinetics based on age in adults (doravirine), race (doravirine, lamivudine), body mass index (BMI) (doravirine), or sex (doravirine, lamivudine, tenofovir DF).

Stability

Storage

Oral

Tablets

20–25°C (may be exposed to 15–30°C).

Store in original bottle. Protect from moisture; do not remove desiccant and keep bottle tightly closed.

Actions and Spectrum

  • Doravirine/lamivudine/tenofovir DF is a fixed-combination antiretroviral containing doravirine, lamivudine, and tenofovir DF.

  • Doravirine is a pyridinone HIV NNRTI antiretroviral. Inhibits replication of HIV-1 by interfering with viral polymerase activities of reverse transcriptase. Inhibits polymerization reaction by noncompetitive, non-active site binding to reverse transcriptase causing conformational changes within active site that result in an inactive conformation. Active against HIV-1, including certain strains resistant to some other NNRTIs.

  • Lamivudine is an HIV NRTI. Prodrug that is inactive until converted intracellularly to an active 5′-triphosphate metabolite (lamivudine triphosphate). After conversion, acts as a reverse transcriptase inhibitor via DNA chain termination after incorporation of the nucleotide analogue. Active against HIV-1; also active against HBV.

  • Tenofovir DF is a nucleotide reverse transcriptase inhibitor antiretroviral classified as an HIV NRTI. Prodrug that is inactive until it undergoes diester hydrolysis in vivo to tenofovir and is subsequently metabolized to the active metabolite (tenofovir diphosphate). Active against HIV-1 and has some in vitro activity against HIV-2; also active against HBV.

  • HIV-1 strains resistant to doravirine, lamivudine, or tenofovir produced in vitro and have emerged during doravirine/lamivudine/tenofovir DF therapy. One or more primary mutations associated with resistance to doravirine identified in HIV-1 isolates from patients who received doravirine/lamivudine/tenofovir DF and were included in the resistance analysis subset (i.e., those with plasma HIV-1 RNA levels exceeding 400 copies/mL at virologic failure or early study discontinuation with resistance data); genotypic resistance against lamivudine and tenofovir DF also identified.

  • Cross-resistance occurs among HIV NNRTIs (e.g., efavirenz, etravirine, nevirapine, rilpivirine). Treatment-emergent doravirine resistance-associated substitutions can confer cross-resistance to other NNRTIs; however, treatment-emergent doravirine resistance-associated substitution Y318F does not appear to confer reduced susceptibility to efavirenz, etravirine, or rilpivirine. Cross-resistance also occurs among HIV NRTIs.

Advice to Patients

  • Critical nature of compliance with HIV therapy and importance of remaining under the care of a clinician. Importance of taking as prescribed; do not alter or discontinue antiretroviral regimen without consulting clinician.

  • Antiretroviral therapy is not a cure for HIV infection; opportunistic infections and other complications associated with HIV disease may still occur.

  • Advise patients that early initiation of antiretroviral therapy and sustained decreases in plasma HIV RNA have been associated with reduced risk of progression to acquired immunodeficiency syndrome (AIDS) and death.

  • Advise patients that effective antiretroviral regimens can decrease HIV levels in blood and genital secretions and strict adherence to such regimens in conjunction with risk-reduction measures may decrease, but cannot absolutely eliminate, the risk of secondary transmission of HIV to others. Importance of continuing to practice safer sex (e.g., using latex or polyurethane condoms to minimize sexual contact with body fluids) and reducing high-risk behaviors (e.g., reusing or sharing needles).

  • Importance of reading patient information provided by the manufacturer.

  • Advise patients to take doravirine/lamivudine/tenofovir DF once every day at a regularly scheduled time with or without food.

  • Advise patients not to miss or skip doses since this can result in development of resistance. If a patient forgets to take doravirine/lamivudine/tenofovir DF, tell the patient to take the missed dose right away, unless it is almost time for the next dose. Advise the patient not to take 2 doses at one time and to take the next dose at the regularly scheduled time.

  • Inform patients that testing for HBV infection is recommended before antiretroviral therapy is initiated. Also advise patients that severe acute exacerbations of HBV infection have been reported following discontinuance of lamivudine or tenofovir DF (components of doravirine/lamivudine/tenofovir DF) in HIV-infected patients coinfected with HBV. Importance of not discontinuing doravirine/lamivudine/tenofovir DF without consulting a clinician.

  • Inform patients that renal impairment, including cases of acute renal failure or Fanconi syndrome, has occurred in association with use of tenofovir DF (a component of doravirine/lamivudine/tenofovir DF). Importance of not using doravirine/lamivudine/tenofovir DF concomitantly with or shortly after nephrotoxic agents (e.g., high-dose or multiple NSAIAs).

  • Inform patients that decreased BMD has occurred with the use of tenofovir DF (a component of doravirine/lamivudine/tenofovir DF) and that assessment of BMD should be considered in those with a history of pathologic bone fracture or other risk factors for osteoporosis or bone loss.

  • Advise patients that doravirine/lamivudine/tenofovir DF may interact with certain other drugs. For patients receiving rifabutin, importance of taking one 100-mg tablet of single-entity doravirine once daily approximately 12 hours after taking doravirine/lamivudine/tenofovir DF.

  • Inform patients that signs and symptoms of inflammation from other previous infections may occur soon after initiation of antiretroviral therapy in some patients with advanced HIV infection (AIDS). These symptoms may be due to an improvement in immune response, enabling the body to fight infections that may have been present with no obvious symptoms. Importance of immediately informing a clinician if any symptoms of infection occur.

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and herbal supplements (e.g., St. John’s wort), as well as any concomitant illnesses.

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed. Advise HIV-infected women not to breast-feed.

  • Importance of advising patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Doravirine, Lamivudine, and Tenofovir Disoproxil Fumarate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

Doravirine 100 mg, Lamivudine 300 mg, and Tenofovir Disoproxil Fumarate 300 mg

Delstrigo

Merck

AHFS DI Essentials™. © Copyright 2022, Selected Revisions March 30, 2020. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

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