TRIUMEQ SIDE EFFECTS
- Generic Name: abacavir, dolutegravir, and lamivudine film-coated tablets
- Brand Name: Triumeq
The following adverse reactions are discussed in other sections of the labeling:
- Serious and sometimes fatal hypersensitivity reaction
- Exacerbations of hepatitis B
- Lactic acidosis and severe hepatomegaly with steatosis
- Immune reconstitution syndrome
- Myocardial infarction
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 with rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
Clinical Trials In Adults
Serious And Fatal Abacavir-Associated Hypersensitivity Reactions
In clinical trials, serious and sometimes fatal hypersensitivity reactions have occurred with abacavir, a component of TRIUMEQ. These reactions have been characterized by 2 or more of the following signs or symptoms: (1) fever; (2) rash; (3) gastrointestinal symptoms (including nausea, vomiting, diarrhea, or abdominal pain); (4) constitutional symptoms (including generalized malaise, fatigue, or achiness); (5) respiratory symptoms (including dyspnea, cough, or pharyngitis). Almost all abacavir hypersensitivity reactions include fever and/or rash as part of the syndrome.
Other signs and symptoms have included lethargy, headache, myalgia, edema, arthralgia, and paresthesia. Anaphylaxis, liver failure, renal failure, hypotension, adult respiratory distress syndrome, respiratory failure, myolysis, and death have occurred in association with these hypersensitivity reactions. Physical findings have included lymphadenopathy, mucous membrane lesions (conjunctivitis and mouth ulcerations), and maculopapular or urticarial rash (although some patients had other types of rashes and others did not have a rash). There were reports of erythema multiforme. Laboratory abnormalities included elevated liver chemistries, elevated creatine phosphokinase, elevated creatinine, and lymphopenia and abnormal chest x-ray findings (predominantly infiltrates, which were localized).
Serious Dolutegravir Hypersensitivity Reactions
In clinical trials, hypersensitivity reactions have occurred with dolutegravir, a component of TRIUMEQ. These hypersensitivity reactions have been characterized by rash, constitutional findings, and sometimes organ dysfunction, including liver injury.
Additional Treatment-Emergent Adverse Drug Reactions (ADRs) With Use Of TRIUMEQ
The safety assessment of TRIUMEQ is primarily based on the analyses of data from a randomized, international, multicenter, double-blind, active-controlled trial, SINGLE (ING114467) and supported by data in treatment-experienced, INSTI-naive subjects from SAILING (ING111762) and by data from other treatment-naive trials. See full prescribing information for TIVICAY.
In SINGLE, 833 adult subjects were randomized and received at least one dose of either dolutegravir (TIVICAY) 50 mg with fixed-dose abacavir and lamivudine (EPZICOM) once daily (n = 414) or fixed-dose efavirenz/emtricitabine/tenofovir (ATRIPLA) once daily (n = 419) (study treatment was blinded through Week 96 and open-label from Week 96 through Week 144). Through 144 weeks, the rate of adverse events leading to discontinuation was 4% in subjects receiving TIVICAY + EPZICOM and 14% in subjects receiving ATRIPLA once daily.
Treatment-emergent ADRs of moderate to severe intensity observed in at least 2% of subjects in either treatment arm of SINGLE are provided in Table 1.
Table 1: Treatment-Emergent Adverse Drug Reactions of at Least Moderate Intensity (Grades 2 to 4) and at Least 2% Frequency in Treatment-Naive Subjects in SINGLE (Week 144 Analysis)
|Adverse Reaction||TIVICAY + EPZICOM Once Daily
(n = 414)
|ATRIPLA Once Daily
(n = 419)
|Skin and Subcutaneous Tissue|
|Ear and Labyrinth|
|a Includes pooled terms: rash, rash generalized, rash macular, rash maculo-papular, rash pruritic, and drug eruption.|
SAILING is an international, double-blind trial in INSTI-naive, antiretroviral treatment-experienced adult subjects. Subjects were randomized and received either TIVICAY 50 mg once daily or raltegravir 400 mg twice daily with investigator-selected background regimen consisting of up to 2 agents, including at least one fully active agent. At 48 weeks, the rate of adverse events leading to discontinuation was consistent with that seen in the overall treatment-naive patient population. See full prescribing information for TIVICAY.
The ADRs observed in the subset of subjects who received TIVICAY + EPZICOM were generally consistent with those seen in the overall treatment-naive patient population.
Less Common Adverse Reactions Observed In Clinical Trials
The following adverse reactions occurred in less than 2% of treatment-naive or treatment-experienced subjects in any one trial. These events have been included because of their seriousness and/or assessment of potential causal relationship.
Gastrointestinal Disorders: Abdominal pain, abdominal distention, abdominal discomfort, dyspepsia, flatulence, gastroesophageal reflux disease, upper abdominal pain, vomiting.
General Disorders: Fever, lethargy.
Hepatobiliary Disorders: Hepatitis.
Metabolism and Nutrition Disorders: Anorexia, hypertriglyceridemia.
Musculoskeletal Disorders: Arthralgia, myositis.
Nervous System Disorders: Somnolence.
Psychiatric Disorders: Suicidal ideation, attempt, behavior, or completion. These events were observed primarily in subjects with a pre-existing history of depression or other psychiatric illness. Nightmare and sleep disorder.
Renal and Urinary Disorders: Renal impairment.
Skin and Subcutaneous Tissue Disorders: Pruritus.
Selected laboratory abnormalities (Grades 2 to 4) with a worsening grade from baseline and representing the worst-grade toxicity in at least 2% of subjects in SINGLE are presented in Table 3. The mean change from baseline observed for selected lipid values is presented in Table 2.
Table 2: Selected Laboratory Abnormalities (Grades 2 to 4) in Treatment-Naive Subjects in SINGLE (Week 144 Analysis)
|Laboratory Abnormality||TIVICAY + EPZICOM Once Daily
(n = 414)
|ATRIPLA Once Daily
(n = 419)
|Grade 2 (>2.5-5.0 x ULN)||3%||5%|
|Grade 3 to 4 (>5.0 x ULN)||1%||<1%|
|Grade 2 (>2.5-5.0 x ULN)||3%||4%|
|Grade 3 to 4 (>5.0 x ULN)||1%||3%|
|Grade 2 (6.0-9.9 x ULN)||5%||3%|
|Grade 3 to 4 (≥10.0 x ULN)||7%||8%|
|Grade 2 (126-250 mg/dL)||9%||6%|
|Grade 3 (>250 mg/dL)||2%||<1%|
|Grade 2 (>15-3.0 x ULN)||11%||11%|
|Grade 3 to 4 (>3.0 ULN)||5%||4%|
|Grade 2 (0.75-0.99 x 109)||4%||5%|
|Grade 3 to 4 (<0.75 x 109)||3%||3%|
|ULN = Upper limit of normal.|
Table 3: Mean Change from Baseline in Fasted Lipid Values in Treatment-Naive Subjects in SINGLE (Week 144 Analysisa)
|Lipid||TIVICAY + EPZICOM Once Daily
(n = 414)
|ATRIPLA Once Daily
(n = 419)
|HDL cholesterol (mg/dL)||5.4||7.2|
|LDL cholesterol (mg/dL)||16.0||14.6|
|a Subjects on lipid-lowering agents at baseline were excluded from these analyses (TIVICAY + EPZICOM: n = 30 and ATRIPLA: n = 27). Seventy-two subjects initiated a lipid-lowering agent post-baseline; their last fasted on-treatment values (prior to starting the agent) were used regardless if they discontinued the agent (TIVICAY + EPZICOM: n = 36 and ATRIPLA: n = 36).|
Laboratory abnormalities observed in SAILING were generally similar compared with observations seen in the treatment-naive trials.
Hepatitis C Virus Co-infection
In SINGLE, the pivotal Phase 3 trial, subjects with hepatitis C virus co-infection were permitted to enroll provided that baseline liver chemistry tests did not exceed 5 times the upper limit of normal; subjects with hepatitis B co-infection were excluded. Overall, the safety profile in subjects with hepatitis C virus co-infection was similar to that observed in subjects without hepatitis C co-infection, although the rates of AST and ALT abnormalities were higher in the subgroup with hepatitis C virus co-infection for both treatment groups. Grades 2 to 4 ALT abnormalities in hepatitis C co-infected compared with HIV mono-infected subjects receiving TRIUMEQ were observed in 15% and 2% (vs. 24% and 4% of subjects treated with ATRIPLA) (Week 96 analysis), respectively. See also full prescribing information for TIVICAY.
Changes In Serum Creatinine
Dolutegravir has been shown to increase serum creatinine due to inhibition of tubular secretion of creatinine without affecting renal glomerular function. Increases in serum creatinine occurred within the first 4 weeks of treatment and remained stable through 144 weeks. In SINGLE, a mean change from baseline of 0.14 mg per dL (range: -0.25 mg per dL to 0.81 mg per dL) was observed after 144 weeks of treatment. Creatinine increases were similar in treatment-experienced subjects.
Abacavir And Lamivudine
Laboratory abnormalities observed in clinical trials of ZIAGEN (in combination with other antiretroviral treatment) were anemia, neutropenia, liver function test abnormalities, and elevations of CPK, blood glucose, and triglycerides. Additional laboratory abnormalities observed in clinical trials of EPIVIR (in combination with other antiretroviral treatment) were thrombocytopenia and elevated levels of bilirubin, amylase, and lipase.
Clinical Trials Experience In Pediatric Subjects
Abacavir And Lamivudine
The safety of once-daily compared with twice-daily dosing of abacavir and lamivudine, administered as either single products or as EPZICOM, was assessed in the ARROW trial (n = 336). Primary safety assessment in the ARROW (COL105677) trial was based on Grade 3 and Grade 4 adverse events. One event of Grade 4 hepatitis in the once-daily cohort was considered as uncertain causality by the investigator and all other Grade 3 or 4 adverse events were considered not related by the investigator. No additional safety issues were identified in pediatric subjects compared with historical data in adults.
IMPAACT P1093 is a 48-week multicenter, open-label, non-comparative trial of approximately 160 HIV-1-infected pediatric subjects aged 4 weeks to less than 18 years, of which, 23 treatment-experienced, INSTI-naive subjects aged 12 to less than 18 years were enrolled.
The ADR profile was similar to that for adults. Grade 2 ADRs reported by more than one subject were decreased neutrophil count (n = 2). No Grade 3 or 4 ADRs were reported. No ADRs led to discontinuation. The Grade 3 laboratory abnormalities reported in 1 subject each were elevated total bilirubin, elevated lipase, and decreased white blood cell count. There was one Grade 4 decreased neutrophil count. The changes in mean serum creatinine were similar to those observed in adults.
In addition to adverse reactions reported from clinical trials, the following adverse reactions have been identified during postmarketing use with one or more of the components of TRIUMEQ. Because these 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.
Blood And Lymphatic Systems
Aplastic anemia, anemia (including pure red cell aplasia and severe anemias progressing on therapy), lymphadenopathy, splenomegaly.
Acute liver failure, liver transplant.
Sensitization reactions (including anaphylaxis), urticaria
Metabolism And Nutrition Disorders
CPK elevation, muscle weakness, myalgia, rhabdomyolysis.
Paresthesia, peripheral neuropathy, seizures.
Abnormal breath sounds/wheezing.
Alopecia, erythema multiforme. Suspected Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported in patients receiving abacavir primarily in combination with medications known to be associated with SJS and TEN, respectively. Because of the overlap of clinical signs and symptoms between hypersensitivity to abacavir and SJS and TEN, and the possibility of multiple drug sensitivities in some patients, abacavir should be discontinued and not restarted in such cases.
SRC: NLM .