Triumeq for HIV Treatment: Everything You Need to Know

Triumeq is a combination medication (ABC/DTG/3TC) that has been FDA-approved for the treatment of HIV since 2014. The lamivudine (3TC) component of Triumeq is one of the oldest HIV medications still in use, having been on the market for fighting HIV since 1995. Abacavir (ABC) is not far behind 3TC, having received FDA approval in 1998. The third medication in Triumeq is dolutegravir (DTG), which was FDA approved in 2013 and subsequently combined with 3TC and ABC as Triumeq a year later.

How Is Triumeq Different From Other Single-Tablet Regimens Used to Fight HIV?

Triumeq has been listed for several years as a recommended initial combination antiretroviral treatment (ARV) regimen for patients who have not taken ARVs before by the Department of Health and Human Services (HHS) Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. In order to examine its utility as an STR, we must look at the three medications contained within.

About the 3TC (a.k.a. Lamivudine, Epivir) in Triumeq

3TC is a medication that has been around a long time, incorporated into many different combination ARV regimens, including the older and largely obsolete combination tablets Combivir and Trizivir, as well the most recent STR, Dovato, approved by the FDA in 2019.

Overall, 3TC has always been well tolerated as a treatment option, with few side effects noted. Because of its consistent use as part of HIV treatment plans for the past few decades, however, issues have arisen with resistance that sometimes render it ineffective unless combined with other potent medications that work at different stages of the HIV life cycle.

Similarly, while 3TC is known for having activity against hepatitis B, there have also been issues with resistance developing with this virus as well, so you want to make sure it is combined with something like tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) that has more potent activity against hepatitis B. Since Triumeq does not have either TDF or TAF in it, Triumeq may not be recommended for individuals who also have chronic, active hepatitis B unless an additional medication that specifically treats hepatitis B is added on as well.

About the ABC (a.k.a. Abacavir, Ziagen) in Triumeq

ABC has also been around a long time, and it shares some of the same HIV mutations that cause resistance with 3TC. That being said, there are a couple of other unique qualities to consider when thinking about starting or switching to Triumeq as an ARV treatment option.

First, there is the issue of what we call an “abacavir hypersensitivity reaction.” This immune reaction, while relatively rare among patients who start a regimen that contains ABC, can be severe and include symptoms such as fever, rash, abdominal pain, nausea, vomiting, diarrhea, fatigue, joint pain, cough, and shortness of breath. If this reaction does happen, it is usually within the first six weeks after someone starts ABC.

If any allergy-type symptoms happen, it is recommended that ABC be immediately stopped, and clinicians should never prescribe it again, as reintroducing a patient to the medication a second time could provoke a much more serious anaphylactic response. Fortunately, studies have shown that the symptoms do reverse after the medication is stopped, so it is important for education to be given when starting ABC.

When ABC first came on the market, the percentage of patients taking it who developed this reaction was close to 3%. As we learned that there was a genetic link to this reaction in the form of a genetic variation called HLA-B*5701, guidelines were changed to require blood tests for patients who were planning to start an ARV regimen like Triumeq that contained ABC. In fact, many providers order the test regardless of which regimen is selected for initial use, to ensure a complete medical record.

The HLA-B*5701 test is obtained with routine bloodwork, and if it comes back negative, it is 100% predictive in that you do not have the genetics that would cause this reaction. Since we started screening more with this lab test before starting ARV regimens containing ABC, the percentage of patients developing a hypersensitivity reaction to ABC-containing regimens has dropped to 0.2%. In other words, you can feel confident if you have a negative HLA-B*5701 test that you can take Triumeq safely. If the test comes back positive, however, you should avoid Triumeq and seek other ARV treatment options that do not contain ABC.

About the DTG (a.k.a. Dolutegravir, Tivicay) in Triumeq

The third component of Triumeq, DTG, is a member of the class of HIV medications called integrase strand transfer inhibitors (INSTI) and has often been referred to as the “workhorse” of many HIV treatment combinations.

This is because it is a very potent medication that stops HIV from making copies of itself and has a higher genetic barrier to resistance than many other HIV medications, including many other INSTI medications, such as elvitegravir and raltegravir. This means that because Triumeq contains DTG, it is much more forgiving to the occasional missed dose than some other treatment regimens.

If you are living with HIV, you should strive to take your medication every day to give yourself the best chance of keeping the virus suppressed and at an undetectable level. We are all human, however, and some people may miss a dose from time to time. It is natural to worry about whether the meds will work effectively despite missed doses, and yes, if you start skipping doses and take your ARV every other day or every third day, it is more likely that you will become resistant to the medications, which will make treating HIV and becoming virally suppressed that much more difficult. You definitely do not want to do that.

However, what makes many confident about Triumeq is that if you do miss a rare dose and it’s been over 12 hours past when you usually take your medications, don’t panic, just skip that dose and wait for the next day’s dose. It is much less likely with Triumeq than with some other regimens that you will develop resistance and the meds will stop working from that single missed dose. Forgive yourself, and strive to do better in the future!

How to Take Triumeq

Triumeq is FDA-approved in the United States to be taken once daily, with or without food. Food does not impact absorption of the medication, but some may find that taking Triumeq with food is easier on the stomach.

How Much Does Triumeq Cost?

Triumeq contains 600 mg abacavir, 50 mg dolutegravir, and 300 mg lamivudine, with a cost approximated to be about $3,175 for a month’s supply. There is no generic version of Triumeq at this point, which can be a deterrent when considering it as an option for HIV treatment.

If you have health insurance, monthly copays for Triumeq can typically run between $50 and $100, depending on the plan, though you may qualify for cost-sharing assistance provided by the manufacturer. If you don’t have insurance or your insurance won’t cover the majority of Triumeq’s cost (you are “underinsured”), there is a patient assistance program that can help reduce or eliminate the cost, depending on your financial situation.

Side Effects of Triumeq

As with many ARV regimens, there is the potential for mild side effects, particularly when first starting out on meds or switching to Triumeq. Mild symptoms might include:

• upset stomach
• mild rash
• nausea
• diarrhea

These may be related to the coating on the outside of the pills rather than the medication itself.

A general rule of thumb is what we call “the two-week rule”: When starting your HIV treatment regimen, give your body about two weeks for it to get adjusted to the medication. Sometimes rashes, mild fever, joint pain, or other symptoms may happen, and this could be related to the medication working and your immune system getting stronger as a result—manifesting as these symptoms. Keep in touch with your medical team and let them know as you move forward.

If, however, after a couple of weeks, you are still having bothersome symptoms or they are progressing, let someone from your medical team know so that you can schedule a virtual or in-person meeting to discuss. In this day and age, we have varying options for HIV treatment, and it is possible that even if a medication worked well for one of your friends, that doesn’t necessarily mean that your body will respond to it in the same way. Speak up, let your provider know, and discuss whether they recommend labs or switching up your regimen altogether.

Specific Side Effects Tied to the Components of Triumeq

For Triumeq, we can consider all the components separately, as they have the potential for varied side effects, despite the majority of patients not having any issues with it.

3TC has been well tolerated by countless patients for decades, with few reports of serious side effects. Fears of lactic acidosis and other rare side effects were learned to be more associated with older HIV medications than with 3TC, hence why it has stayed around for so long. The main concern for many with 3TC is not necessarily the potential side effects, but the potential for resistance to it with both HIV and hepatitis B. This is often a non-issue as long as it is combined with other powerful HIV medications, as with Triumeq and other regimens.

For ABC, the noted hypersensitivity reaction mentioned earlier was a major issue in its early years of use, but with the development of screening guidelines and confirming a negative HLA-B*5701 test, this has become an extremely rare concern among people taking Triumeq. That said, while not considered a side effect, there has been an association of the risk for heart disease in patients who take an ARV regimen containing ABC. This was first reported in the late 2000s, but subsequent studies found no association between persons living with HIV being on an ABC-containing regimen and heart disease.

A recent review published in 2018 took a look at all the data and concluded that the associated risk of heart disease with ABC is real, particularly for those just starting ARVs or with recent exposure to ABC, though more work needs to be done to determine what cumulative exposure to ABC does to heart disease risk, and exactly what is the mechanism of this elevated risk.

With the DTG component of Triumeq, a few potential side effects should be noted. First, there have been reports of an increased likelihood of neuropsychiatric side effects, such as sleep disturbances or mood issues. Most of these have been case reports and smaller studies with very specific populations. A review of double-blind, randomized controlled trials with these side effects of DTG noted they did exist, but with a low frequency, and they rarely caused people to stop taking the medication.

There were also early reports of neural tube defects among pregnant women on DTG, but these early reports have been refuted in subsequent studies that did not confirm an association.

Finally, an emerging side-effect concern that has come up with Triumeq has been weight gain. Although data is still emerging, early reports suggest that patients are experiencing some weight gain when on DTG-inclusive regimens, including Triumeq, though not in excess of what folks are seeing while on other HIV regimens that include an INSTI-class medication. In the future, medical and general communities will learn more about the patterns and locations of this weight gain and its clinical significance in patients’ everyday lives. For now, however, it’s something that patients, clinicians, and our medical teams should be paying attention to as we have more people taking INSTI-containing regimens like Triumeq. While the side effect of weight gain may not seem challenging compared to the more drastic side effects of older HIV medications, there is much we still don’t know. Discussions of both the medical concerns of weight gain as well as cosmetic concerns should be part of our review of side effects when patients are on Triumeq.

Interactions Between Triumeq and Other Drugs

Triumeq is an STR that does not have a boosting medication in it (e.g., cobicistat or ritonavir) that makes the other medications work more effectively; thus, it doesn’t have too much in the way of drug interactions with which to be concerned.

Moreover, one of the benefits that many see in choosing Triumeq as the STR to treat HIV is that it doesn’t contain either of the tenofovir products on the market, TDF or TAF, which have the potential for kidney and bone-loss issues. Thus, kidney monitoring while on Triumeq, still a part of routine check-ups while on ARVs, does not hold the same concern of potential kidney toxicity as with other regimens that contain TDF in particular.

How Do I Weigh the Pros and Cons of Triumeq?

Triumeq has become a primary option for HIV treatment since its approval in 2014 and has been shown to be a very durable option for HIV treatment. But there are both pluses and minuses to taking it.

Pros:

1. Powerful treatment for managing HIV.
2. High genetic barrier for resistance.
3. More forgiving with missed doses.
4. Doesn’t have tenofovir, so fewer kidney concerns.

Cons:

1. Pill is large compared to other STR options.
2. Possible sleep and mood side effects.
3. Need for HLA-B*5701 blood testing to ensure no hypersensitivity reaction.
4. Associated elevated risk of heart disease.

What’s the Verdict on Triumeq?

Triumeq has been around for a few years and has conclusively shown its effectiveness as an HIV treatment option. It is a potent ARV regimen, is relatively safer on the kidneys than previous treatment regimens, is much more forgiving to the occasional missed dose, and is less likely to have HIV develop resistance against it.

The main considerations before starting Triumeq are mostly around getting HLA-B*5701 testing to ensure that if you are starting it you do not develop an allergic reaction, and that if you have chronic, active hepatitis B, this combination may not be enough to treat it effectively due to resistance concerns—so speak with your medical provider, as you may need a separate medication to treat hepatitis B.

Triumeq is an option both for starting HIV medication for the first time or when making a switch due to convenience or side effects from another regimen, even when there may be some background resistance to ABC or 3TC.

While the concerns over the association with weight gain and heart disease appear to be supported by the scientific literature, the associations with psychiatric side effects and neural tube defects may not be as clinically significant as first thought. HIV treatment today has varying options, and the ultimate decision is up to patients and their comfort level with the potential for different side effects that may or may not happen.

Triumeq is a wonderfully potent and durable option, with a much more forgiving temperament for missed doses than some other regimens. It is up to the patient and their medical team working together to determine, given other history of the patient (mental health, likelihood for developing heart disease, plans for pregnancy), whether Triumeq will truly be the best option for them moving forward.