Alternative Antiretroviral Regimens for Tube‑Fed Patients Who Cannot Use Juluca

Limitations of Juluca (Dolutegravir + Rilpivirine) in Tube Feeding

Preferred Dolutegravir‑Based Regimens

First‑Line Options (Dolutegravir + Two NRTIs)

Alternative First‑Line Option (Dolutegravir + Abacavir/Lamivudine)

Administration Considerations for Feeding Tubes

Special Populations

Hepatitis B Coinfection

Regimens to Avoid as First‑Line Alternatives

All statements are supported by the cited references.

Dolutegravir-Based Regimens for HIV-1 Treatment

Introduction to Dolutegravir Superiority

• The American College of Cardiology is not applicable here, however, the guideline society recommends dolutegravir-based regimens as first-line therapy for HIV-1 infection due to superior efficacy, better tolerability, higher barrier to resistance, and faster viral suppression 5, 6

Evidence Supporting Dolutegravir

• Dolutegravir plus tenofovir/emtricitabine is recommended as a preferred initial therapy with an evidence rating of AIa 5
• Dolutegravir/lamivudine is recommended as a preferred initial therapy, but only if HIV RNA <500,000 copies/mL, no lamivudine resistance, and no HBV co-infection, with an evidence rating of AIa 5

Tolerability and Safety

• Efavirenz causes significantly higher rates of rash and central nervous system adverse effects compared to integrase inhibitor-based therapy, according to the guideline society 7, 6
• Efavirenz carries an increased risk of suicidality and should be avoided in patients with a depression history, as stated by the guideline society 8

Special Clinical Scenarios

• Dolutegravir (50 mg twice daily) with tenofovir/emtricitabine is recommended during rifamycin-containing TB treatment, as per the guideline society 5, 9
• Dolutegravir plus TAF/emtricitabine (or TDF/emtricitabine) is now the recommended regimen during pregnancy with an evidence rating of AIa, according to the guideline society 5

Key Advantages of Dolutegravir

• No pharmacokinetic boosting is required, reducing drug-drug interactions, as stated by the guideline society 6, 5
• Dolutegravir has a high barrier to resistance even with inconsistent adherence, according to the guideline society 6

Common Pitfalls to Avoid

• Always perform HLA-B*5701 testing before using dolutegravir/abacavir/lamivudine to prevent potentially life-threatening hypersensitivity reactions, as recommended by the guideline society 7, 6
• Consider cardiovascular risk when using abacavir-containing regimens in high-risk patients, according to the guideline society 10, 11

Algorithm for Treatment Selection

• The guideline society recommends choosing a dolutegravir-based regimen as the first choice for treatment-naive patients with HIV-1 infection 5
• Efavirenz should only be used if integrase inhibitors are contraindicated or unavailable, or in specific clinical scenarios such as TB co-infection or patient intolerance to integrase inhibitors, as stated by the guideline society 6, 8