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Take Atripla Every Other Day?
Jul 8, 2008

I spoke to two other friends of mine who have spoken to their doctor (same doctor) and are currently taking Atripla every other day for about 5 months now and are still undetectable. According to their doctor, the half life of the three medications in Atripla will allow this without becomming resistant to the medications and still maintain the virus. Is there new information about possibly taking Atripla safely every other day? If it is possible, it would make it cheaper for me (and others) and allow me (and others) to take a less toxic doses of medication and thus reduce the potential damange to my and other livers...

Response from Dr. Sherer

No, there are no controlled clinical trials to my knowledge that have studied every other day efavirenz + emtricitabine + tenofovir, which are the three drugs that are co-formulated into the once daily Atripla tablet. I would strongly discourage you or any other readers of this website from following this strategy. Based on our understanding of the development of drug resistance and the pharmacokinetics of these three drugs, this practice will increase the risk of drug resistance to one or more of the drugs in Atripla.

While it is true that the half life of the three drugs is more than 24 hours, it is also true that there is considerable variability between patients as to the amount of drug that is absorbed into the blood stream, the level of drug in the plasma, and the rate of excretion. While the strategy you describe might work for some people, it also might fail for others. Until there is compelling evidence that it DOES work with the same low rate of treatment failure and drug resistance that is KNOWN to be achieved by once daily Atripla, this strategy should be avoided.

There are many examples of intensive 'induction' ART therapy during the time when the viral load falls from its baseline value to a level of below detection, followed by a less intensive 'maintenance' phase. To date, most, but not all, of these strategies have failed in clinical trials. I will describe two that still have some promise, though are not ready for wide application in clinical practice.

The boosted PI lopinavir/r (Kaletra) used as a single drug therapy has been shown in clinical trials to come quite close to a three drug regimen when it is given AFTER (and only after) an individual has completely controlled their viral replication and achieved a viral load below detection for 3-6 months. In these studies, lopinavir monotherapy was not quite as good as three drug treatment, with more low level viremia and a little more drug resistance.

As another example of an alternate dosing schedule that IS in a clinical trial, a study in Boston is comparing standard daily therapy to ART taken on weekdays, i.e. 5 days in a row, followed by 2 days off treatment, but ONLY AFTER full virologic control has been achieved in all patients via standard daily dosing, i.e. a viral load below detection has been achieved for 3-6 months. Early results are promising, but the final outcome has yet to be released. Until that time, I don't recommend that people with HIV or their physicians adopt these strategies. To do so would be premature, when we have excellent outcomes with several standard ART regimens and dosing schedules.

There may be more to the strategy than you know, or than you described. It is possible that the two patients that you describe were initially controlled with full dose daily Atripla and, after they achieved a viral load below detection for a period of time, they and their doctor chose to undertake a risky experiment with every other day dosing. This would make more sense to me, though it would still be a risky venture, than starting a patient out with every other day Atripla from the first day of treatment.

I am sympathetic to the reasons for your interest in such a strategy, in particular cost reduction. The amount of liver damage with Atripla is quite small with regular dosing, though, so that is not as compelling a reason.

My advice is that you stick with standard dosing for now, as it is well established, convenient, and associated with excellent and durable clinical outcomes. And I advise you to talk to your doctor about your question, and take a copy of these this response with you.


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