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sustiva drop from 600mg to 400mg

Oct 1, 2017

Hi dr benjamin, i would like to try sustiva 600mg to 400mg is this OK? I'm on atripla, 2 months and now having sleep problems are there any rules on being ud and cd4 count before trying etc?

Response from Dr. Young

Hello and thanks for posting.

Atripla (tenfovir DF, FTC and efavirenz) typically causes sleep disruption (insomnia, nightmares) in the first few weeks of treatment- these symptoms are made worse by taking the medication (it's really the efavirenz part) with food, and they resolve over time. If you've been taking your medication on an empty stomach and still have sleep problems after two months, it's worth asking about alternatives.

Here in the US, we've largely abandoned efavirenz-containing treatment in favor of better tolerated integrase inhibitors (raltegravir, elvitegravir/cobicistat and dolutegravir). Indeed, doltegravir is no longer a medication just for high income countries; following World Health Organization (WHO) listing on treatment guidelines, low-cost co-formulated tenofovir, lamivudine, dolutegravir is becoming available in many countries.

The WHO guidelines also list the use of lower dose 400 mg efavirenz (Sustiva) as an alternative to the standard 600 mg efavirenz found in Atripla- this was on the results of the ENCORE1 clinical trial. This study showed that for people starting treatment, there was no difference in the antiviral effectiveness of 400 vs 600 mg efavirenz (when combined with tenofovir and emtricitabine (a cousin of lamivudine), and the pesky side effect profile of efavirenz was lessened with the lower dose. Hence for individuals who are having persistent side effects of efavirenz (making sure that you and your care provider have addressed any other causes of sleep problems), the 400 mg dosing is both reasonable and evidence-based. As far as I'm aware, there isn't yet a coformulated tenofovir, emtricitabine, 400 mg efavirenz pill, so this switch would likely mean taking three pills (1 Truvada and 2, 200 mg Sustivas) instead of the single Atripla.

As noted above, in many countries, efavirenz has been replaced by one of the HIV integrase inhibitors for initial (and other) lines of HIV treatment. In several countries, including Brazil, switching to dolutegravir is now an option for people who started on, but are intolerant of efavirenz.

As long as you've been taking your medication with reasonable adherence (as proven by having an undetectable HIV viral load), then there's no particular CD4 count that limits switching- either to lower dose efavirenz or to dolutegravir.

I hope that's helpful, BY



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