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Dolutegravir

Classification: C

Drug products: DOVATO, Juluca, Tivicay, TIVICAY, Triumeq

ATC code: J05AR, J05AR13, J05AR21, J05AR25, J05AX12

Substances: dolutegravir, dolutegravir sodium

Summary

Controlled studies regarding differences in effect of dolutegravir have not been found. A population pharmacokinetic study based on data pooled from several studies did not find any clinically relevant differences between men and women regarding dolutegravir exposure. Observational studies have shown that more women than men discontinue dolutegravir treatment due to adverse effects.

Preilimnary results have shown an incresed risk of neural tube effects among children born to women who were treated with dolutegravir during pregnancy. Therefore, dolutegravir should not be used in girls/women who may become pregnant. More information can be found in Janusmed Drugs and Birth Defects (in Swedish, Janusmed fosterpåverkan).

Additional information

Pharmacokinetics and dosing

A population pharmacokinetic study based on data from 563 individuals (481 men, 82 women), identified factors that contribute to variability in dolutegravir pharmacokinetics. These factors were then used in a model to explore the pharmacokinetic/pharmacodynamic relationship [1]. In the final model, sex was a predictor of bioavailability. Oral bioavailability was 21% (95% CI 13-29%) higher in women than in men [1]. In a simulation based on the model, dolutegravir Cmax, AUC and Cmin were 32%, 26% and 15% higher in women, respectively, but these differences are not considered clinically significant and therefore no dose adjustment will be  necessary [1]. Population pharmacokinetic analyses using pooled data from Phase IIb and Phase III adult trials have not shown any clinically relevant sex difference in dolutegravir exposure [2].

Effects

Both men and women have been included in the pivotal studies, although the majority of subjects included have been men (70%-85%) [3, 4]. Data on effect of dolutegravir has not been presented by sex in these studies.

Adverse effects

In a study of adverse effects (AE) of integrase inhibitor-based therapies (in total 1704 patients, of whom 909 men and 70 women were treated with dolutegravir), discontinuation of dolutegravir due to an AE was seen in 6.3% and 15.7% of men and women, respectively [5]. Neuropsychiatric AE leading to discontinuation was reported in 4.6% in men and 10% in women. Relative hazards (RHs) for discontinuation of dolutegravir both due to any AE or neuropsychiatric AEs were higher in women, with a RH of 2.81 (p=0.002) for any AW and a RH of 2.64 (p=0.01) for neuropsychiatric AEs [5].

Another study assessed factors for discontinuing integrase inhibitor therapy in the Swiss HIV Cohort Study. The study population included 4,041 individuals, of whom 1455 men and 495 women were treated with dolutegravir. The only independent risk factor for modifying HIV treatment due to toxicity was female sex (HR 1.98, p<0.001) [6].

Reproductive health issues

Preliminary results from a study of almost 12,000 children born to women with HIV showed a higher risk of neural tube defects among children whose mothers who on dolutegravir-based ART when they became pregnant compared to mothers on other ART (0.9% vs. 0.1%). Until further information is available, EMA advices against dolutegravir treatment in women who are seeking to become pregnant and recommends that women of childbearing age on dolutegravir treatment should use effective contraception [7,8]. Regarding teratogenic aspects, please consult Janusmed Drugs and Birth Defects (in Swedish, Janusmed fosterpåverkan).

Other information

According to the product information, dolutegravir had no pharmacodynamic effect on luteinizing hormone, follicle stimulating hormone, or progesterone. No dose adjustment of oral contraceptives or dolutegravir is necessary in co-administration [2].

Updated: 2018-08-13

Date of litterature search: 2017-07-14

References

  1. Zhang J, Hayes S, Sadler BM, Minto I, Brandt J, Piscitelli S et al. Population pharmacokinetics of dolutegravir in HIV-infected treatment-naive patients. Br J Clin Pharmacol. 2015;80:502-14. PubMed
  2. Tivicay (dolutegravir). EPAR - Product information. European Medicines Agency (EMA); 2017.
  3. Raffi F, Rachlis A, Stellbrink HJ, Hardy WD, Torti C, Orkin C et al. Once-daily dolutegravir versus raltegravir in antiretroviral-naive adults with HIV-1 infection: 48 week results from the randomised, double-blind, non-inferiority SPRING-2 study. Lancet. 2013;381:735-43. PubMed
  4. Cahn P, Pozniak AL, Mingrone H, Shuldyakov A, Brites C, Andrade-Villanueva JF et al. Dolutegravir versus raltegravir in antiretroviral-experienced, integrase-inhibitor-naive adults with HIV: week 48 results from the randomised, double-blind, non-inferiority SAILING study. Lancet. 2013;382:700-8. PubMed
  5. Hoffmann C, Welz T, Sabranski M, Kolb M, Wolf E, Stellbrink HJ et al. Higher rates of neuropsychiatric adverse events leading to dolutegravir discontinuation in women and older patients. HIV Med. 2017;18:56-63. PubMed
  6. Elzi L, Erb S, Furrer H, Cavassini M, Calmy A, Vernazza P et al. Adverse events of raltegravir and dolutegravir. AIDS. 2017;31:1853-1858. PubMed
  7. New study suggests risk of birth defects in babies born to women on HIV medicine dolutegravir. European Medicines Agency (EMA) [www]. [cited 2018-08-13]. länk
  8. Dolutegravir ska inte användas av kvinnor som önskar bli gravida. Läkemedelsverket [www]. [cited 2018-08-13]. länk
  9. Läkemedelsstatistik. Stockholm: Socialstyrelsen. 2016 [cited 2017-05-20.] länk
  10. Hivinfektion 2016. Folkhälsomyndigheten (The Public Health Agency of Sweden): Stockholm, Sweden.

Authors: Jaran Eriksen

Reviewed by: Mia von Euler

Approved by: Karin Schenck-Gustafsson