Cabenuva Contraindications and Alternative Treatments

Rationale for Contraindication

The American College of Cardiology is not mentioned, however, patients with documented or suspected resistance to rilpivirine should not receive Cabenuva due to increased risk of treatment failure, with an evidence rating of AIIa 1, 2, 3, 4, 5
Rilpivirine resistance would compromise one of the two active components of Cabenuva, potentially leading to virologic failure and development of resistance to both drug classes 5, 6
Clinical trials identified rilpivirine-associated resistance at baseline as a risk factor for virologic failure with Cabenuva 5

An important limitation of injectable cabotegravir and rilpivirine is a 1-2% incidence of virologic failure with emergence of 2-class resistance even with adherence to scheduled injections in patients without pre-existing resistance 5
Using Cabenuva in patients with rilpivirine resistance would significantly increase the risk of virologic failure 1, 3
Virologic failure with Cabenuva can lead to viral transmission if virologic rebound occurs and future limitations of treatment options due to development of resistance to both integrase inhibitors and NNRTIs 5, 6

For patients with rilpivirine resistance, regimens with a high barrier to resistance are recommended, such as dolutegravir or bictegravir-based regimens with appropriate NRTIs and boosted darunavir-based regimens 1, 2, 4, 6
For patients with extensive multiclass resistance, agents with novel mechanisms of action should be considered, such as ibalizumab, fostemsavir, and lenacapavir 1, 3

For patients switching to alternative regimens due to rilpivirine resistance, viral load should be checked at 1 month and then every 3 months for a year to ensure ongoing viral suppression 6
Patients with NRTI resistance who switch to dual NRTI plus dolutegravir or bictegravir regimens should be monitored more closely in the first year after the switch 6