Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Allison Tu [2]
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Black Box Warning
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POST TREATMENT ACUTE EXACERBATION OF HEPATITIS B
See full prescribing information for complete Boxed Warning.
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Overview
Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide is a combination of an HIV-1 integrase strand transfer inhibitor, a CYP3A inhibitor, and two HIV-1 nucleoside analog reverse transcriptase inhibitors that is FDA approved for the treatment of HIV-1 infection in adults and pediatric patients 12 years of age and older weighing at least 35 kg who have no antiretroviral treatment history or to replace the current antiretroviral regimen in those who are virologically-suppressed (HIV-1 RNA less than 50 copies per mL) on a stable antiretroviral regimen for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of GENVOYA. There is a Black Box Warning for this drug as shown here. Common adverse reactions include nausea and decreased bone mineral density.
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
GENVOYA is indicated as a complete regimen for the treatment of HIV-1 infection in adults weighing at least 35 kg who have no antiretroviral treatment history or to replace the current antiretroviral regimen in those who are virologically-suppressed (HIV-1 RNA less than 50 copies per mL) on a stable antiretroviral regimen for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of GENVOYA.
Dosing Information
- GENVOYA is a four-drug fixed dose combination product containing 150 mg of elvitegravir, 150 mg of cobicistat, 200 mg of emtricitabine, and 10 mg of tenofovir alafenamide (TAF).
- The recommended dosage of GENVOYA is one tablet taken orally once daily with food in adults with body weight at least 35 kg and creatinine clearance greater than or equal to 30 mL per minute.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
GENVOYA is indicated as a complete regimen for the treatment of HIV-1 infection in pediatric patients 12 years of age and older weighing at least 35 kg who have no antiretroviral treatment history or to replace the current antiretroviral regimen in those who are virologically-suppressed (HIV-1 RNA less than 50 copies per mL) on a stable antiretroviral regimen for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of GENVOYA.
Dosing Information
- GENVOYA is a four-drug fixed dose combination product containing 150 mg of elvitegravir, 150 mg of cobicistat, 200 mg of emtricitabine, and 10 mg of tenofovir alafenamide (TAF).
- The recommended dosage of GENVOYA is one tablet taken orally once daily with food in pediatric patients 12 years of age and older with body weight at least 35 kg and creatinine clearance greater than or equal to 30 mL per minute.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in pediatric patients.
Contraindications
- Coadministration of GENVOYA is contraindicated with drugs that are highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life-threatening events.
- These drugs and other contraindicated drugs (which may lead to reduced efficacy of GENVOYA and possible resistance) are listed in Table 1.
Warnings
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POST TREATMENT ACUTE EXACERBATION OF HEPATITIS B
See full prescribing information for complete Boxed Warning.
|
- Severe Acute Exacerbation of Hepatitis B in Patients Coinfected with HIV-1 and HBV
- Patients with HIV-1 should be tested for the presence of hepatitis B virus (HBV) before initiating antiretroviral therapy.
- GENVOYA is not approved for the treatment of chronic HBV infection and the safety and efficacy of GENVOYA have not been established in patients coinfected with HIV-1 and HBV.
- Severe acute exacerbations of hepatitis B (e.g., liver decompensation and liver failure) have been reported in patients who are coinfected with HIV-1 and HBV and have discontinued products containing emtricitabine and/or tenofovir disoproxil fumarate (TDF), and may occur with discontinuation of GENVOYA.
- Patients coinfected with HIV-1 and HBV who discontinue GENVOYA should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping treatment.
- If appropriate, anti-hepatitis B therapy may be warranted, especially in patients with advanced liver disease or cirrhosis, since post-treatment exacerbation of hepatitis may lead to hepatic decompensation and liver failure.
- Risk of Adverse Reactions or Loss of Virologic Response Due to Drug Interactions
- The concomitant use of GENVOYA and other drugs may result in known or potentially significant drug interactions, some of which may lead to:
- Loss of therapeutic effect of GENVOYA and possible development of resistance.
- Possible clinically significant adverse reactions from greater exposures of concomitant drugs.
- See TABLE 5 for steps to prevent or manage these possible and known significant drug interactions, including dosing recommendations. Consider the potential for drug interactions prior to and during GENVOYA therapy; review concomitant medications during GENVOYA therapy; and monitor for the adverse reactions associated with the concomitant drugs.
- The concomitant use of GENVOYA and other drugs may result in known or potentially significant drug interactions, some of which may lead to:
- Immune Reconstitution Syndrome
- Immune reconstitution syndrome has been reported in patients treated with combination antiretroviral therapy, including emtricitabine, a component of GENVOYA. During the initial phase of combination antiretroviral treatment, patients whose immune system responds may develop an inflammatory response to indolent or residual opportunistic infections [such as Mycobacterium avium infection, cytomegalovirus, Pneumocystis jirovecii pneumonia (PCP), or tuberculosis], which may necessitate further evaluation and treatment.
- Autoimmune disorders (such as Graves' disease, polymyositis, and Guillain-Barré syndrome) have also been reported to occur in the setting of immune reconstitution, however, the time to onset is more variable, and can occur many months after initiation of treatment.
- New Onset or Worsening Renal Impairment
- Renal impairment, including cases of acute renal failure and Fanconi syndrome (renal tubular injury with severe hypophosphatemia), has been reported with the use of tenofovir prodrugs in both animal toxicology studies and human trials.
- In clinical trials of GENVOYA, there have been no cases of Fanconi syndrome or Proximal Renal Tubulopathy (PRT).
- In clinical trials of GENVOYA in treatment-naïve subjects and in virologically suppressed subjects switched to GENVOYA with eGFRs greater than 50 mL per minute, renal serious adverse events or discontinuations due to renal adverse reactions were encountered in less than 1% of participants treated with GENVOYA.
- In a study of virologically suppressed subjects with baseline eGFRs between 30 and 69 mL per minute treated with GENVOYA for a median duration of 108 weeks, GENVOYA was permanently discontinued due to worsening renal function in three of 80 (4%) subjects with a baseline eGFR between 30 and 50 mL per minute and two of 162 (1%) with a baseline eGFR greater than or equal to 50 mL per minute.
- GENVOYA is not recommended in patients with estimated creatinine clearance below 30 mL per minute.
- Patients taking tenofovir prodrugs who have impaired renal function and those taking nephrotoxic agents including non-steroidal anti-inflammatory drugs are at increased risk of developing renal-related adverse reactions.
- It is recommended that serum creatinine, serum phosphorus, estimated creatinine clearance, urine glucose and urine protein be assessed before initiating GENVOYA and during therapy in all patients as clinically appropriate. Discontinue GENVOYA in patients who develop clinically significant decreases in renal function or evidence of Fanconi syndrome.
- Cobicistat, a component of GENVOYA, produces elevations of serum creatinine due to inhibition of tubular secretion of creatinine without affecting glomerular filtration.
- The elevation is typically seen within 2 weeks of starting therapy and is reversible after discontinuation. Patients who experience a confirmed increase in serum creatinine of greater than 0.4 mg per dL from baseline should be closely monitored for renal safety.
- Lactic Acidosis/Severe Hepatomegaly with Steatosis
- Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogs, including emtricitabine, a component of GENVOYA, and tenofovir DF, another prodrug of tenofovir, alone or in combination with other antiretrovirals.
- Treatment with GENVOYA should be suspended in any patient who develops clinical or laboratory findings suggestive of lactic acidosis or pronounced hepatotoxicity (which may include hepatomegaly and steatosis even in the absence of marked transaminase elevations).
Adverse Reactions
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.
Clinical Trials in Treatment-Naïve Adults
The primary safety assessment of GENVOYA was based on Week 96 pooled data from 1,733 subjects in two randomized, double-blind, active-controlled trials, Study 104 and Study 111, in antiretroviral treatment-naïve HIV-1 infected adult subjects. A total of 866 subjects received one tablet of GENVOYA once daily. The most common adverse reaction (all Grades) reported in at least 10% of subjects in the GENVOYA group was nausea. The proportion of subjects who discontinued treatment with GENVOYA or STRIBILD® due to adverse events, regardless of severity, was 1% and 2%, respectively. Table 2 displays the frequency of adverse reactions (all Grades) greater than or equal to 5% in the GENVOYA group.
The majority of events presented in Table 2 occurred at severity Grade 1.
Clinical Trials in Virologically Suppressed Adults
The safety of GENVOYA in virologically-suppressed adults was based on Week 96 data from 959 subjects in a randomized, open-label, active-controlled trial (Study 109) in which virologically-suppressed subjects were switched from a TDF-containing combination regimen to GENVOYA. Overall, the safety profile of GENVOYA in subjects in this study was similar to that of treatment-naïve subjects. Additional adverse reactions observed with GENVOYA in Study 109 included suicidal ideation, suicidal behavior, and suicide attempt (<1% combined); all of these events were serious and all occurred in subjects with a preexisting history of depression or psychiatric illness.
Clinical Trials in Adult Subjects with Renal Impairment
In an open-label trial (Study 112), 248 HIV-1 infected subjects with eGFR of 30 to 69 mL per minute (by Cockcroft-Gault method) were treated with GENVOYA for a median duration of 108 weeks. Of these subjects, 65% had previously been on a stable TDF-containing regimen. A total of 5 subjects permanently discontinued GENVOYA due to the development of renal adverse events. Three of these five were among the 80 subjects with baseline eGFRs of < 50mL/min and two subjects were among the 162 subjects with baseline eGFRs of ≥ 50mL/min. One additional subject with baseline eGFR of ≥ 50mL/min developed acute renal failure. Following a brief interruption, GENVOYA was resumed and this subject's renal function returned to baseline. Overall, renally impaired subjects receiving GENVOYA in this study had a mean serum creatinine of 1.5 mg/dL at baseline and 1.4 mg/dL at Week 96. Otherwise, the safety profile of GENVOYA in subjects in this study was similar to that of subjects with normal renal function.
Renal Laboratory Tests and Renal Safety
Treatment-Naïve Adults:
Cobicistat (a component of GENVOYA) has been shown to increase serum creatinine due to inhibition of tubular secretion of creatinine without affecting glomerular filtration. Increases in serum creatinine occurred by Week 2 of treatment and remained stable through 96 weeks. In two 96-week randomized, controlled trials in a total of 1,733 treatment-naïve adults with a median baseline eGFR of 115 mL per minute, mean serum creatinine increased by less than 0.1 mg per dL in the GENVOYA group and by 0.1 mg per dL in the STRIBILD group from baseline to Week 96.
Virologically Suppressed Adults:
In a study of 1,436 virologically-suppressed TDF-treated adults with a mean baseline eGFR of 112 mL per minute who were randomized to continue their treatment regimen or switch to GENVOYA, at Week 96 mean serum creatinine was similar to baseline for both those continuing baseline treatment and those switching to GENVOYA.
Bone Mineral Density Effects
Treatment-Naïve Adults:
In a pooled analysis of Studies 104 and 111, the effects of GENVOYA compared to STRIBILD on bone mineral density (BMD) change from baseline to Week 96 were assessed by dual-energy X-ray absorptiometry (DXA). Mean BMD decreased from baseline to Week 96 by −0.96% with GENVOYA compared to −2.79% with STRIBILD at the lumbar spine and −0.67% compared to −3.28% at the total hip. BMD declines of 5% or greater at the lumbar spine were experienced by 12% of GENVOYA subjects and 26% of STRIBILD subjects. BMD declines of 7% or greater at the femoral neck were experienced by 11% of GENVOYA subjects and 26% of STRIBILD subjects. The long-term clinical significance of these BMD changes is not known.
Virologically Suppressed Adults:
In Study 109, TDF-treated subjects were randomized to continue their TDF-based regimen or switch to GENVOYA; changes in BMD from baseline to Week 96 were assessed by DXA. Mean BMD increased in subjects who switched to GENVOYA (2.12% lumbar spine, 2.44% total hip) and decreased slightly in subjects who continued their baseline regimen (−0.09% lumbar spine, −0.46% total hip). BMD declines of 5% or greater at the lumbar spine were experienced by 2% of GENVOYA subjects and 6% of subjects who continued their TDF-based regimen. BMD declines of 7% or greater at the femoral neck were experienced by 2% of GENVOYA subjects and 7% of subjects who continued their TDF-based regimen. The long-term clinical significance of these BMD changes is not known.
Laboratory Abnormalities:
The frequency of laboratory abnormalities (Grades 3–4) occurring in at least 2% of subjects receiving GENVOYA in Studies 104 and 111 are presented in Table 3.
Serum Lipids:
Subjects receiving GENVOYA experienced greater increases in serum lipids compared to those receiving STRIBILD.
Changes from baseline in total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and total cholesterol to HDL ratio are presented in Table 4.
Clinical Trials in Pediatric Subjects:
The safety of GENVOYA in HIV-1 infected, treatment-naïve pediatric subjects aged 12 to less than 18 years and weighing at least 35 kg (77 lbs) was evaluated through Week 48 in an open-label clinical trial (Study 106). The safety profile in 50 adolescent subjects who received treatment with GENVOYA was similar to that in adults. One 13-year-old female subject developed unexplained uveitis while receiving GENVOYA that resolved and did not require discontinuation of GENVOYA.
Among the 50 pediatric subjects receiving GENVOYA, mean BMD increased from baseline to Week 48, + 4.2% at the lumbar spine and + 1.3% for the total body less head. Mean changes from baseline BMD Z-scores were −0.07 for lumbar spine and −0.20 for total body less head at Week 48. One GENVOYA subject had significant (greater than or equal to 4%) lumbar spine BMD loss at Week 48.
Postmarketing Experience
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Postmarketing Experience in the drug label.
Drug Interactions
- Not Recommended with Other Antiretroviral Medications
- GENVOYA is a complete regimen for the treatment of HIV-1 infection; therefore, coadministration of GENVOYA with other antiretroviral medications for treatment of HIV-1 infection should be avoided. Complete information regarding potential drug-drug interactions with other antiretroviral medications is not provided
- Potential for GENVOYA to Affect Other Drugs
- Cobicistat, a component of GENVOYA, 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 GENVOYA 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 (see TABLE 5).
- Elvitegravir is a modest inducer of CYP2C9 and may decrease the plasma concentrations of CYP2C9 substrates. TAF is not an inhibitor of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, or UGT1A1. TAF is a weak inhibitor of CYP3A in vitro. TAF is not an inhibitor or inducer of CYP3A in vivo.
- Potential for Other Drugs to Affect One or More Components of GENVOYA
- Elvitegravir and cobicistat, components of GENVOYA, 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, elvitegravir, and TAF, which may lead to loss of therapeutic effect of GENVOYA and development of resistance (see TABLE 5).
- Coadministration of GENVOYA with other drugs that inhibit CYP3A may decrease the clearance and increase the plasma concentration of cobicistat (see TABLE 5).
- TAF, a component of GENVOYA, is a substrate of P-gp, BCRP, OATP1B1 and OATP1B3. Drugs that inhibit P-gp and/or BCRP, such as cobicistat, may increase the absorption of TAF (see TABLE 10). However, when TAF is administered as a component of GENVOYA, its availability is increased by cobicistat and a further increase of TAF concentrations is not expected upon coadministration of an additional P-gp and/or BCRP inhibitor.
- Drugs that induce P-gp activity are expected to decrease the absorption of TAF, resulting in decreased plasma concentration of TAF.
- Drugs Affecting Renal Function
- Because emtricitabine and tenofovir are primarily excreted by the kidneys by a combination of glomerular filtration and active tubular secretion, coadministration of GENVOYA 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.
- Established and Other Potentially Significant Interactions
- Table 5 provides a listing of established or potentially clinically significant drug interactions. The drug interactions described are based on studies conducted with either GENVOYA, the components of GENVOYA (elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide) as individual agents and/or in combination, or are predicted drug interactions that may occur with GENVOYA.
- The table includes potentially significant interactions but is not all inclusive.
These images are provided by the National Library of Medicine
- Drugs without Clinically Significant Interactions with GENVOYA
- Based on drug interaction studies conducted with the components of GENVOYA, no clinically significant drug interactions have been either observed or are expected when GENVOYA is combined with the following drugs: entecavir, famciclovir, H2 receptor antagonists, ledipasvir, lorazepam, methadone, proton pump inhibitors, ribavirin, sertraline, sofosbuvir, and velpatasvir.
Use in Specific Populations
Pregnancy
Pregnancy Category (FDA):
There is no FDA guidance on usage of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in women who are pregnant.
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in women who are pregnant.
Labor and Delivery
There is no FDA guidance on use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide during labor and delivery.
Nursing Mothers
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in women who are nursing.
Pediatric Use
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in pediatric settings.
Geriatic Use
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in geriatric settings.
Gender
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide with respect to specific gender populations.
Race
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in patients with hepatic impairment.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide in patients who are immunocompromised.
Administration and Monitoring
Administration
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Administration in the drug label.
Monitoring
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Monitoring in the drug label.
IV Compatibility
There is limited information regarding the compatibility of Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide and IV administrations.
Overdosage
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.
Pharmacology
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Pharmacology in the drug label.
Mechanism of Action
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Mechanism of Action in the drug label.
Structure
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Structure in the drug label.
Pharmacodynamics
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Pharmacodynamics in the drug label.
Pharmacokinetics
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Pharmacokinetics in the drug label.
Nonclinical Toxicology
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Nonclinical Toxicology in the drug label.
Clinical Studies
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Clinical Studies in the drug label.
How Supplied
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide How Supplied in the drug label.
Storage
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Storage in the drug label.
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Patient Counseling Information
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Patient Counseling Information in the drug label.
Precautions with Alcohol
Alcohol-Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
Brand Names
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Brand Names in the drug label.
Look-Alike Drug Names
There is limited information regarding Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide Look-Alike Drug Names in the drug label.
Drug Shortage Status
Price
References
The contents of this FDA label are provided by the National Library of Medicine.