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FOTO regimen with Genvoya

Jan 28, 2017

I was recently switched from Atripla to Genvoya. I took the Atripla on the five on, two off regimen, with no change in my (undetectable) status. I wish to try this with Genvoya, as I understand that one of the medications can cause bone toxicity with extended use. Will this work with Genvoya? Thank you.

Response from Dr. Young

Hello and thanks for posting your question.

It's reasonable to switch from Atripla (TDF/FTC/efavirenz) to Genvoya (TAF/FTC/cobicistat/elvitegravir). While Atripla was a global standard of care for over 10 years, efavirenz has largely been replaced with better tolerated medications, such as the integrase inhibitors (like the elvitegravir in Genvoya), and more recently, tenofovir has been updated with the better absorbed and less risky (for bone and kidney) TAF version. In this light, Atripla is no longer a recommended initial therapy in the US, whereas Genvoya and other integrase inhibitor regimens are recommended in current US DHHS treatment guidelines.

The FOTO study was a small intriguing clinical trial done over a decade ago that treated individuals with Atripla (compared with other drugs) five days on, two days off. The results showed that viral suppression was excellent in the efavirenz treated individuals, but not as good in people treated with protease inhibitors or a different non-nuke, nevirapine. This result was attributed to the very long half-life (the time the drug stays in your body) of efavirenz. While FOTO dosing should reduce toxicity and costs, he strategy never really took off because of concerns of adherence.

So while FOTO might apply to especially adherent people on efavirenz, it might not apply to other treatments, like the cobicistat-boosted elvitegravir in Genvoya. Moreover, since the new TAF already has lower risk of bone and kidney toxicity than the TDF in Atripla, it's not entirely clear if FOTO dosing would add any additional benefit to people taking TAF (as in Genvoya).

Overall, it's my strong belief that current HIV medications are extremely safe and well tolerated if selected and monitored appropriately. Because they work so well, I'd be hesitant to recommend a dosing scheme that's unproven for a particular set of drugs (ie., Genvoya and others).

I hope that's helpful, BY



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