Yay.it's Alabam gal again...begin clapping K? l.ol (SUSTIVA/ ATRIPLA SIDE EFFECTS, 2009)


Well finally after nearly 8 yrs of being HIV positive I'm starting on HIV meds tonight. I am scared sh*tless. I have read conflicting info from my doc....Atripla is the best to for me to start with. Ok....so I ask THE questions.side effects? She says no nausea, and can take with food/a glass of milk even. After reading the pharmacy when I got my meds today........it says 'nausea is a very common complaint'..AND it says 'do not take with food because this drug can become more potent'..my doc said take it with food.

??????? Please help. You have become my friend-I would not ask anyone else..I trust you you compassionate sexy do you!! lol

Hope you are feeling as well as you can!



Atripla, approved in 2006, is a complete effective HIV regimen in a one-pill-once-a-day treatment that combines three drugs from two antiretroviral classes. It contains the "preferred" drugs (U.S. guidelines) from both classes: Truvada (Emtriva/Viread) and Sustiva. Atripla is the only dual-class, fixed-dose combination drug on the market so far. It is probably the most commonly prescribed medication for people taking HIV meds for the first time. Because of the Viread component, Atripla must be used with caution in folks with kidney problems. Because of the Sustiva component, Atripla must not be used during pregnancy. Sustiva can cause side effects that affect the central nervous system (CNS). It should not be used in folks who have a history of depression or mental health problems. It can cause "wooziness", enhanced vivid dreams and concentration problems. To reduce the CNS side effects, Sustiva (Atripla) can be taken at bedtime. High-fat food and alcohol can increase the risk of side effects. Consequently it is often recommended to take it on an empty stomach. If, however, you are not bothered by side effects, you can take your Atripla with or without foods and at any time during the day. (See below.) Hope that helps.

Dr. Bob

Atripla - Sustiva Side Effects Feb 8, 2009

Hello Doc,

I greatly enjoy your answers as they tend to be in depth. I wanted to run this one past you to get your reply.

I have been on Atripla now for about 6 months. I did not initially have the Sustiva related side effects of "vivid dreams" other than the first night UNTIL about a month or 2 ago. At one time the dreams were so intense that I could not rest because I felt as tho I was in an action movie all night long. Lately I have been using Lemon Balm as a relaxer and it appears that my dreams are getting lighter or perhaps im going thru a cycle but I also find myself being more tired during the day. I guess my question here doc is that as I read about the Sustiva side effects they seem to be intense at first and then taper off within 4 weeks or so after.. Have you had many patients like me who take Atripla and take MONTHS for these side effects to kick in and do you believe that if they take that long to start that they may perhaps take months to start to taper off? I have discussed this with my doctor and we are considering Truvada with a few other things however I love the idea of single dosing and when I look at the other side effects that I could experience such as diarrhea or stomach pains or vomiting etc which I have experienced NONE of.. I feel a little bad about complaining about "Dreams" which are not real when I might switch to something that bring me things that are very real. I always wait at least 2 hours after dinner so im fine there but im wondering if there is any chance these vivid dreams will taper off since they took so long to start in the first place. Any thoughts?

Thank you again

Response from Dr. Frascino

Hey there Vivid Dreamer,

I took Sustiva for about two weeks before having to discontinue it due to a severe allergic reaction. I didn't like the vivid dreams; rather I loved the vivid dreams! I remember waking my husband Steve (Dr. Steve, the expert in The Body's Tratamientos forum) in the middle of the night just to tell him what fun I was having in my frenetic but fabulous dream world. I was so disappointed when I had to discontinue that drug. (It reminded me of living in the early 70s!) Of course, I realize these "vivid dreams" are not always so pleasurable/desirable and in fact can be downright terrifying and exhausting. You are correct: Most Sustiva users experience these wild and wooly dreams when they first begin the drug and the dreams along with other Sustiva-related side effects ("brain fog," difficulty concentrating, etc.) tend to gradually subside over the first few weeks of therapy. If they don't subside after four weeks, chances are they never will. You also mention taking your Atripla two hours after dinner. We know from pharmacokinetic studies that when Sustiva is taken with food, especially fatty foods, there is an increase in the blood level of the drug. With increased blood levels there is a corresponding increase in Sustiva-related side effects. There is no danger in taking Sustiva with food and if someone is not bothered by side effects there is no reason for any food restrictions when taking the drug. Any chance you are taking Sustiva two hours after dinner but relatively close to a midnight snack consisting of, say, a dozen Krispy Kreme doughnuts and pint of Ben and Jerry's Chunky Monkey ice cream? OK, just checking.

I have seen several folks who reported no problems with Sustiva-induced dream-fantasies when they began treatment but noticed them a number of months later. Sometimes this was food related. Sometimes they had added a new drug or supplement to their regimen and there may have been a drug-drug or drug-supplement interaction. And sometimes we couldn't figure out any cause of the change. The good news is that most of these folks behaved just like those who developed symptoms when initially starting the drug. Their symptoms gradually subsided over a period of weeks. (One guy took eight weeks!) We have not had to switch anyone off the drug because of these late-onset vivid-dreams phenomena.

I realize being an action hero all night long can be exhausting. (We've all seen "The Dark Night" Batman movie.) However, things could be worse. You could be dreaming that you are the illegitimate love child of Dick Cheney and Ann Coulter. Now there's a nightmare that could land you in therapy for years. If you love the convenience of your one-pill-once-per-day regimen and the dreams are tolerable, I'd hold tight and see if they subside on their own. Alternatively you could consider using a mild sedative. That sometimes helps as well. Also check to see if anything else has changed in your routine. For instance, are you going to the gym in the evening after work rather than in the morning? Has your mother-in-law moved in with you? Things along those lines that might alter stress levels.

Hope that helps.

Dr. Bob

Sustiva and fatigue (SUSTIVA AND FATIGUE) Apr 8, 2008

After five years of being POZ I started Sustiva 2/7/08 (no previous combo or resistance issues present). CD4 was 246 and VL 255,000. I had my first blood work done about 4/5 weeks after starting and my CD4 went to 290 and VL dropped to 155. Unfortunately, I'm very tired, foggy, unmotivated, and kinda depressed. I'm pleased about the VL load reduction but my quality of life is very poor. Is it likely that things might improve at this point? I'm considering swapping out the Sustiva for either Viramune or Reyataz. Any preference for either of these drugs, and if so why? My virologic results have been so excellent I'm worried about switching and loosing the viral suppression that I have going on now - especially during the Viramune induction period (is an induction period even necessary?). Some friends have suggested even splitting up the Sustiva to twice a day to diminish the sides. I'm sort of perplexed as to where to go from here. Any light you can shed on this for me would be greatly appreciated. Long time reader and love the job you do here. Thanks

Response from Dr. Frascino


Sustiva side effects are legendary and extremely common. In general they do decrease in severity over six to eight weeks. If you're still having significant problems eight weeks after beginning therapy and haven't noted a significant reduction in the side effects, you could consider a switch. My personal preference would be to switch to Intellence, the new non-nucleoside reverse transcriptase inhibitor, if possible. It appears to be very well tolerated and highly effective so far; however, experience with this drug is still relatively limited. I'll reprint below several posts from the archives that discuss Sustiva's side effects.

Good luck.

Dr. Bob

Question about fatique and Sustiva Mar 1, 2008

Dr Bob,

I was wondering if you would give me some advice with some of my concerns about Sustiva? (hope this isn't too long)

I've been on this medication for seven months. In that time I've gone: From CD4=336/19% VL=1,080,000 To CD4=886/33.6% VL=undetectable

I've also been on a very very strict diet of <5g of saturated fats per day, which has taken me: FROM:: Weight:242 Trigs:307 Total-Choles:197 HDL:26 RATIO:7.58 LDL:109

TO:: Weight:195.5 Trigs:105 Total-Choles:155 HDL:33 RATIO:4.69 LDL:93

All my Hemo and Chem panels are in solid green territory.

Since Xmas I've been suffering the following "side-effects": 1) Memory "fuzziness", beyond just age 2) Diminished vision in my left eye 3) General malaise and loss of productivity in the mornings, that is starting to effect my work

In January, I wrote in to Dr Whol about the first two symptoms, and based on the information I provided he suggested that I speak with my HIV specialist about a possible adverse reaction to Sustiva being one possible root cause for these neurological issues.

After a lot of looking we figured out that the issue was being caused by the fact that I was eating, what equated to a full meal, each night when I took the Sustiva. Since I wasn't having any of the obvious GI related side-effects we assumed that I was tolerating the Sustiva very well, and the Dr said that my practice of an occasional bowl of sherbet before bed was probably fine. But during the holidays, with all the left overs, that occasional snack pretty much started to turn into a full meal.

So we figured out that with eating as much as I was when taking the Sustiva, that my absorption was very high, which may have caused some of the problems I was seeing. So I stopped eating two hours before and after my dosage of Sustiva and issues #1 and #2 disappeared in about three days. Honestly I was a little surprised that the issues resolved so quickly, and that really gives me some new insight on how active these drugs are.

The issue now is that I'm still having problems with my third issue: "General malaise and loss of productivity in the mornings, that is starting to effect my work."

Just to confirm that my diet wasn't having an adverse effect on my hormone levels (to reach such low saturated fat levels, a goodly part of my diet is now Soy), we even ordered a test of hormones, which all came back normal.

So, finally, my question: How likely is it that Sustiva is the culprit for this remaining issue? I'm going to engage my "Employee Assistance Program [EAP]" at work to get some focused psychological counseling, to help me try to wrap my hands around my problems of procrastinating, but I'm also wondering if I should seriously consider going off the Sustiva? Since my results have been so dramatically good, I really don't want to mess with a good thing, but if I can't get my arms around this loss of productivity then I'm going to be in serious trouble, and soon.

Another BIG OL BEAR HUG, -Zac

Response from Dr. Frascino

Hey Zac,

General malaise, loss of productivity in the mornings and procrastination are all rather general complaints. Psychological evaluation is a good idea. There are a variety of psychological conditions, ranging from depression to anxiety, which can be associated with symptoms like these. As for Sustiva, one possible way it could be related would be its tendency to cause vivid dreams and disrupt sleep. If you are not getting adequate sleep/rest at night, that could account for some of your sluggishness in the morning. Some folks also complain that Sustiva just makes them feel like a "wool-headed zombie." You could try taking the Sustiva a bit earlier in the evening (if convenient) to see if there is any difference the next morning. I certainly agree your results on Sustiva have been excellent both virologically (viral load plummeting form 1,080,000 to undetectable) and immunologically (CD4 count skyrocketing form 336 to 886). Consequently we wouldn't want to switch off this regimen unless you were fairly certain the symptoms you are experiencing are indeed related to the drug. If indeed a switch is necessary, a new drug in the same class as Sustiva (non-nucleoside reverse transcriptase inhibitor) has recently been FDA approved. It's called Intelence. And from the limited experience we have to date it does not have a Sustiva-like side effect profile.

Thanks again for the hugs. Consider yourself cyber-hugged back.

Dr. Bob

Sustiva and possible Fatigue Jan 25, 2005

Dr. Bob,

I read one of your responses regarding Sustiva and its possible side effects. I have been on Sustiva since September 2003 and continue to have wild dreams. Unfortunately, not the sexual ones as many have claimed, but intense, action, drama (as if I'm in a movie), etc. I wake up so exhausted every morning because I appears that I have been living the dream. Are there ways that I can suppress the side effects with diet or other methods? Ambien seems to work, but I don't want this to be a constant remedy. I try not to eat late since I have read that fatty/heavy foods can cause intense side effects. Not sure of what else to do. The Sustiva/Combivir combo is working in regards to labs so I don't want to switch - No VL and T-cell of 600. Any suggestions or just live with it.

Response from Dr. Frascino


Over 50% of folks who start Sustiva report undesirable side effects. Of these, the vast majority note the undesirable effects decrease to a very tolerable level within four to six weeks. Approximately 5% of folks ultimately need to discontinue Sustiva due to ongoing problems.

As for ways to suppress the "vivid dreams" side effects with diet and other methods, here's what's been tried with some success:

  1. Sustiva taken with food increases blood levels and possibly may increase side effects, so taking it on an empty stomach might help.

  2. Using a sedative, such as ativan, trazadone or haldol, for several weeks might help; although the vivid dreams may return when the sedative is discontinued.

  1. Splitting the dose by taking 200 mg in the morning and 400 mg in the evening might help.

  2. Switch off Sustiva to another medication in the same class that doesn't have this particular side effect, i.e. Viramune.

  3. Try to change your intense action drama dreams into the more desirable sexual ones by watching your favorite porno tapes before going to sleep. At least you'll wake up exhausted and satisfied, rather than just exhausted. (OK, OK, I just made that last one up, but hey . . . . )

Good luck. You do have options if this is becoming a quality of life issue. Talk to your HIV specialist and pleasant dreams!

Dr. Bob