ODEFSEY Dailymed
Generic: emtricitabine, rilpivirine hydrochloride, and tenofovir alafenamide is used for the treatment of HIV Infections Hepatitis B, Chronic
Boxed Warning
Warning: Post Treatment Acute Exacerbation Of Hepatitis B
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Warning: Post Treatment Acute Exacerbation Of Hepatitis B
Severe acute exacerbations of hepatitis B have been reported in patients who are coinfected with HIV-1 and HBV and have discontinued products containing emtricitabine (FTC) and/or tenofovir disoproxil fumarate (TDF), and may occur with discontinuation of ODEFSEY.
Hepatic function should be monitored closely with both clinical and laboratory follow-up for at least several months in patients who are coinfected with HIV-1 and HBV and discontinue ODEFSEY. If appropriate, anti-hepatitis B therapy may be warranted [see Warnings and Precautions (5.1)].
WARNING: POST TREATMENT ACUTE EXACERBATION OF HEPATITIS B
See full prescribing information for complete boxed warning.
Severe acute exacerbations of hepatitis B have been reported in patients who are coinfected with HIV-1 and HBV and have discontinued products containing emtricitabine (FTC) and/or tenofovir disoproxil fumarate (TDF), and may occur with discontinuation of ODEFSEY. Hepatic function should be monitored closely in these patients. If appropriate, anti-hepatitis B therapy may be warranted. (5.1 )
Recent Major Changes Section
Warnings and Precautions, New Onset or Worsening Renal Impairment ( 5.5 )03/2021
1 Indications And Usage
ODEFSEY is indicated as a complete regimen for the treatment of HIV-1 infection in adult and pediatric patients weighing at least 35 kg:
- as initial therapy in those with no antiretroviral treatment history with HIV-1 RNA less than or equal to 100,000 copies per mL or
- to replace a stable antiretroviral regimen in those who are virologically-suppressed (HIV-1 RNA less than 50 copies per mL) for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of ODEFSEY [see Microbiology (12.4) and Clinical Studies (14)].
ODEFSEY is a three-drug combination of emtricitabine (FTC) and tenofovir alafenamide (TAF), both HIV nucleoside analog reverse transcriptase inhibitors (NRTIs), and rilpivirine (RPV), a non-nucleoside reverse transcriptase inhibitor (NNRTI), and is indicated as a complete regimen for the treatment of HIV-1 infection in patients weighing at least 35kg as initial therapy in those with no antiretroviral treatment history with HIV-1 RNA less than or equal to 100,000 copies per mL; or to replace a stable antiretroviral regimen in those who are virologically-suppressed (HIV-1 RNA less than 50 copies per mL) for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of ODEFSEY. (1 )
Limitations of Use:
- More rilpivirine-treated subjects with HIV-1 RNA greater than 100,000 copies/mL at the start of therapy experienced virologic failure (HIV-1 RNA ≥ 50 copies/mL) compared to rilpivirine-treated subjects with HIV-1 RNA less than or equal to 100,000 copies/mL. (
14.2 ,14.3 )
Limitations of Use:
- More rilpivirine-treated subjects with no antiretroviral treatment history with HIV-1 RNA greater than 100,000 copies/mL at the start of therapy experienced virologic failure (HIV-1 RNA ≥ 50 copies/mL) compared to rilpivirine-treated subjects with HIV-1 RNA less than or equal to 100,000 copies/mL [see Clinical Studies (14.2,14.3)].
2 Dosage And Administration
- Testing: Prior to or when initiating ODEFSEY, test for hepatitis B virus infection. Prior to or when initiating ODEFSEY, and during treatment on a clinically appropriate schedule, assess serum creatinine, estimated creatinine clearance, urine glucose, and urine protein in all patients. In patients with chronic kidney disease, also assess serum phosphorus (
2.1 )- Recommended dosage: one tablet taken orally once daily with a meal. (
2.2 )- For pregnant patients who are already on ODEFSEY prior to pregnancy and who are virologically suppressed (HIV-1 RNA less than 50 copies per mL), one tablet taken once daily may be continued. Lower exposures of rilpivirine were observed during pregnancy, therefore viral load should be monitored closely. (
2.3 )- Renal impairment: ODEFSEY is not recommended in patients with estimated creatinine clearance of 15 to below 30 mL per minute, or below 15 mL per minute who are not receiving chronic hemodialysis. (
2.4 )2.1Testing Prior to Initiation and During Treatment with ODEFSEY
Prior to or when initiating ODEFSEY, test patients for hepatitis B virus infection [see Warnings and Precautions (5.1)].
Prior to or when initiating ODEFSEY, and during treatment with ODEFSEY, on a clinically appropriate schedule, assess serum creatinine, estimated creatinine clearance, urine glucose, and urine protein in all patients. In patients with chronic kidney disease, also assess serum phosphorus [see Warnings and Precautions (5.5)].
2.2Recommended Dosage
ODEFSEY is a three-drug fixed dose combination product containing 200 mg of emtricitabine (FTC), 25 mg of rilpivirine (RPV), and 25 mg of tenofovir alafenamide (TAF). The recommended dosage of ODEFSEY is one tablet taken orally once daily with a meal in adults and pediatric patients with body weight at least 35 kg and creatinine clearance greater than or equal to 30 mL per minute [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].
2.3Recommended Dosage During Pregnancy
For pregnant patients who are already on ODEFSEY prior to pregnancy and are virologically suppressed (HIV-1 RNA less than 50 copies per mL), one tablet of ODEFSEY taken once daily may be continued. Lower exposures of rilpivirine, a component of ODEFSEY, were observed during pregnancy, therefore viral load should be monitored closely [see Use in Specific Populations (8.1) and Clinical Pharmacology (12.3)].
2.4Not Recommended in Patients with Severe Renal Impairment
ODEFSEY is not recommended in patients with:
- severe renal impairment (estimated creatinine clearance of 15 to below 30 mL per minute); or
- end stage renal disease (ESRD; estimated creatinine clearance below 15 mL per minute) who are not receiving chronic hemodialysis [see Dosage and Administration (2.2), Warnings and Precautions (5.5), and Use in Specific Populations (8.6)].
3 Dosage Forms And Strengths
Each ODEFSEY tablet contains 200 mg of emtricitabine (FTC), 25 mg of rilpivirine (RPV) (equivalent to 27.5 mg of rilpivirine hydrochloride), and 25 mg of tenofovir alafenamide (TAF) (equivalent to 28 mg of tenofovir alafenamide fumarate).
The tablets are gray, capsule-shaped, film-coated and debossed with "GSI" on one side and "255" on the other side.
Tablets: 200 mg of FTC, 25 mg of RPV and 25 mg of TAF. (3 )
4 Contraindications
ODEFSEY is contraindicated when coadministered with the following drugs; coadministration may result in loss of virologic response and possible resistance to ODEFSEY or to the class of NNRTIs [see Warnings and Precautions (5.6), Drug Interactions (7) and Clinical Pharmacology (12.3)]:
- Anticonvulsants: carbamazepine, oxcarbazepine, phenobarbital, phenytoin
- Antimycobacterials: rifampin, rifapentine
- Glucocorticoid (systemic): dexamethasone (more than a single-dose)
- Herbal Products: St. John's wort (Hypericum perforatum)
- Proton Pump Inhibitors: e.g., dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole
ODEFSEY is contraindicated when coadministered with drugs where significant decreases in RPV plasma concentrations may occur, which may result in loss of virologic response and possible resistance and cross-resistance. (4 )
5 Warnings And Precautions
- Skin and Hypersensitivity Reactions: Severe skin and hypersensitivity reactions have been reported during postmarketing experience with RPV-containing regimens, including cases of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Immediately discontinue treatment if hypersensitivity or rash with systemic symptoms or elevations in hepatic serum biochemistries develops and closely monitor clinical status, including hepatic serum biochemistries. (
5.2 )- Hepatotoxicity: Hepatic adverse events have been reported in patients receiving an RPV-containing regimen. Monitor liver-associated tests before and during treatment with ODEFSEY in patients with underlying hepatic disease or marked elevations in liver-associated tests. Also consider monitoring liver-associated tests in patients without risk factors. (
5.3 )- Depressive disorders: Severe depressive disorders have been reported. Immediate medical evaluation is recommended for severe depressive disorders. (
5.4 )- New onset or worsening renal impairment: Assessment of serum creatinine, estimated creatinine clearance, urine glucose, and urine protein when initiating ODEFSEY and during therapy on a clinically appropriate schedule in all patients. Also assess serum phosphorus in patients with chronic kidney disease. (
5.5 )- Concomitant use of ODEFSEY with drugs with a known risk to prolong the QTc interval of the electrocardiogram may increase the risk of Torsade de Pointes. (
5.6 )- Lactic acidosis/severe hepatomegaly with steatosis: Discontinue treatment in patients who develop symptoms or laboratory findings suggestive of lactic acidosis or pronounced hepatotoxicity. (
5.7 )- Immune reconstitution syndrome: May necessitate further evaluation and treatment. (
5.8 )5.1Severe Acute Exacerbation of Hepatitis B in Patients Coinfected with HIV-1 and HBV
Test patients with HIV-1 for the presence of hepatitis B virus (HBV) before or when initiating antiretroviral therapy [see Dosage and Administration (2.1)].
Severe acute exacerbations of hepatitis B (e.g., liver decompensation and liver failure) have been reported in patients who are coinfected with HIV-1 and HBV and have discontinued products containing FTC and/or TDF, and may occur with discontinuation of ODEFSEY. Patients coinfected with HIV-1 and HBV who discontinue ODEFSEY should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping treatment with ODEFSEY. If appropriate, anti-hepatitis B therapy may be warranted, especially in patients with advanced liver disease or cirrhosis, since post treatment exacerbation of hepatitis may lead to hepatic decompensation and liver failure.
5.2Skin and Hypersensitivity Reactions
Severe skin and hypersensitivity reactions, including cases of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), have been reported during postmarketing experience with RPV-containing regimens. While some skin reactions were accompanied by constitutional symptoms such as fever, other skin reactions were associated with organ dysfunction, including elevations in hepatic serum biochemistries. During Phase 3 clinical trials of RPV, treatment-related rashes with at least Grade 2 severity were reported in 1% of subjects. Overall, most rashes were Grade 1 or 2 and occurred in the first four to six weeks of therapy [see Adverse Reactions (6.2)].
Discontinue ODEFSEY immediately if signs or symptoms of severe skin or hypersensitivity reactions develop, including but not limited to, severe rash or rash accompanied by fever, bulers, mucosal involvement, conjunctivitis, facial edema, angioedema, hepatitis, or eosinophilia. Clinical status including laboratory parameters should be monitored and appropriate therapy should be initiated.
5.3Hepatotoxicity
Hepatic adverse events have been reported in patients receiving an RPV-containing regimen. Patients with underlying hepatitis B or C virus infection, or marked elevations in liver-associated tests prior to treatment, may be at increased risk for worsening or development of liver-associated test elevations with use of ODEFSEY. A few cases of hepatic toxicity have been reported in adult patients receiving an RPV-containing regimen who had no preexisting hepatic disease or other identifiable risk factors. Appropriate laboratory testing prior to initiating therapy and monitoring for hepatotoxicity during therapy with ODEFSEY is recommended in patients with underlying hepatic disease such as hepatitis B or C, or in patients with marked elevations in liver-associated tests prior to treatment initiation. Liver-associated test monitoring should also be considered for patients without preexisting hepatic dysfunction or other risk factors.
5.4Depressive Disorders
Depressive disorders (including depressed mood, depression, dysphoria, major depression, mood altered, negative thoughts, suicide attempt, suicidal ideation) have been reported with RPV. Promptly evaluate patients with severe depressive symptoms to assess whether the symptoms are related to ODEFSEY, and to determine whether the risks of continued therapy outweigh the benefits.
In Phase 3 trials of RPV in adult subjects (N=1368) through 96 weeks, the incidence of depressive disorders (regardless of causality, severity) reported among RPV-treated subjects (n=686) was 9%. Most events were mild or moderate in severity. In RPV-treated subjects, the incidence of Grades 3 and 4 depressive disorders (regardless of causality) was 1%, the incidence of discontinuation due to depressive disorders was 1%, and suicidal ideation and suicide attempt was reported in 4 and 2 subjects, respectively.
During the Phase 2 trial in RPV-treated pediatric subjects 12 to less than 18 years of age (N=36), the incidence of depressive disorders (regardless of causality, severity) was 19% (7/36) through 48 weeks. Most events were mild or moderate in severity. The incidence of Grades 3 and 4 depressive disorders (regardless of causality) was 6% (2/36). None of the subjects discontinued due to depressive disorders. Suicidal ideation and suicide attempt were reported in 1 subject.
5.5New Onset or Worsening Renal Impairment
Postmarketing case of renal impairment, including acute renal failure, proximal renal tubulopathy (PRT), and Fanconi syndrome have been reported with TAF-containing products; while most of these cases were characterized by potential confounders that may have contributed to the reported renal events, it is also possible these factors may have predisposed patients to tenofovir-related adverse events [see Adverse Reactions (6.1, 6.2)]. ODEFSEY is not recommended in patients with estimated creatinine clearance of 15 to below 30 mL per minute, or in patients with estimated creatinine clearance below 15 mL per minute who are not receiving chronic hemodialysis.
Patients taking tenofovir prodrugs who have impaired renal function and those taking nephrotoxic agents, including nonsteroidal anti-inflammatory drugs are at increased risk of developing renal-related adverse reactions.
Prior to or when initiating ODEFSEY, and during treatment with ODEFSEY, on a clinically appropriate schedule, assess serum creatinine, estimated creatinine clearance, urine glucose and urine protein in all patients. In patients with chronic kidney disease, also assess serum phosphorus. Discontinue ODEFSEY in patients who develop clinically significant decreases in renal function or evidence of Fanconi syndrome.
5.6Risk of Adverse Reactions or Loss of Virologic Response Due to Drug Interactions
The concomitant use of ODEFSEY and other drugs may result in potentially significant drug interactions, some of which may lead to [ see Contraindications (4), and Drug Interactions (7)]:
- Loss of therapeutic effect of ODEFSEY and possible development of resistance due to reduced exposure of RPV.
In healthy subjects, higher than recommended doses of RPV (75 mg once daily and 300 mg once daily –3 and 12 times the recommended dosages in ODEFSEY, respectively) have been shown to prolong the QTc interval of the electrocardiogram. Consider alternatives to ODEFSEY when coadministered with a drug that is known to have a risk of Torsade de Pointes [see Drug Interactions (7.2) and Clinical Pharmacology (12.2)].
See Table 3 for steps to prevent or manage these possible and known significant drug interactions, including dosing recommendations [see Contraindications (4) and Drug Interactions (7)]. Consider the potential for drug interactions prior to and during ODEFSEY therapy and review concomitant medications during ODEFSEY therapy.
5.7Lactic Acidosis/Severe Hepatomegaly with Steatosis
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogs, including emtricitabine, a component of ODEFSEY, and tenofovir DF, another prodrug of tenofovir, alone or in combination with other antiretrovirals. Treatment with ODEFSEY should be suspended in any patient who develops clinical or laboratory findings suggestive of lactic acidosis or pronounced hepatotoxicity (which may include hepatomegaly and steatosis even in the absence of marked transaminase elevations).
5.8Immune Reconstitution Syndrome
Immune reconstitution syndrome has been reported in patients treated with combination antiretroviral therapy, including FTC and RPV, both components of ODEFSEY. During the initial phase of combination antiretroviral treatment, patients whose immune system responds may develop an inflammatory response to indolent or residual opportunistic infections [such as Mycobacterium avium infection, cytomegalovirus, Pneumocystis jirovecii pneumonia (PCP), or tuberculosis], which may necessitate further evaluation and treatment.
Autoimmune disorders (such as Graves' disease, polymyositis, Guillain-Barré syndrome, and autoimmune hepatitis) have also been reported to occur in the setting of immune reconstitution, however, the time to onset is more variable, and can occur many months after initiation of treatment.
6 Adverse Reactions
The following adverse reactions are discussed in other sections of the labeling:
- Severe Acute Exacerbations of Hepatitis B [see Warnings and Precautions (5.1)]
- Skin and Hypersensitivity Reactions [see Warnings and Precautions (5.2)]
- Hepatotoxicity [see Warnings and Precautions (5.3)]
- Depressive Disorders [see Warnings and Precautions (5.4)]
- New Onset or Worsening Renal Impairment [see Warnings and Precautions (5.5)]
- Lactic Acidosis/Severe Hepatomegaly with Steatosis [see Warnings and Precautions (5.7)]
- Immune Reconstitution Syndrome [see Warnings and Precautions (5.8)]
Most common adverse reactions (incidence greater than or equal to 2%, all grades) are headache and sleep disturbances. (6.1 )
To report SUSPECTED ADVERSE REACTIONS, contact Gilead Sciences, Inc. at 1-800-GILEAD-5 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
6.1Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug (or a drug given in various combinations with other concomitant therapy) cannot be directly compared to rates in the clinical trials of another drug (or drug given in the same or different combination therapy) and may not reflect the rates observed in practice.
Adverse Reactions in Clinical Trials of ODEFSEY in Virologically-Suppressed Adult Subjects with HIV-1 Infection
The safety of ODEFSEY in virologically-suppressed adults is based on Week 48 data from two randomized, double-blinded, active-controlled clinical trials, 1160 and 1216, that enrolled 1505 adult subjects who were virologically-suppressed for at least 6 months. Both trials were designed to compare switching to ODEFSEY to maintaining efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF) or emtricitabine/rilpivirine/tenofovir disoproxil fumarate (FTC/RPV/TDF) in Trials 1160 and 1216, respectively. A total of 754 subjects received one tablet of ODEFSEY daily [see Clinical Studies (14.1)].
The most common adverse reactions (all Grades) reported in at least 2% of subjects in the ODEFSEY group across Trials 1216 and 1160 were headache and sleep disturbances (Table 1). Over 98% of the adverse reactions in the ODEFSEY group were of mild to moderate intensity. The proportion of subjects who discontinued treatment with ODEFSEY due to adverse events, regardless of severity, was 2% compared to 1% for FTC/RPV/TDF and 2% for EFV/FTC/TDF.
Table 1 Adverse Reactions Frequencies of adverse reactions are based on all adverse events attributed to study drugs by the investigator. (All Grades) Reported in ≥1% of HIV-1 Infected Virologically-Suppressed Adults in Trial 1160 or Trial 1216 (Week 48 analysis)Adverse Reaction Trial 1160 Trial 1216 ODEFSEY(N=438) EFV/FTC/TDF (N=437) Data from Trials 1160 and 1216 do not provide an adequate basis for comparison of adverse reaction incidences between ODEFSEY and the FTC/RPV/TDF and EFV/FTC/TDF groups. ODEFSEY(N=316) FTC/RPV/TDF(N=313) Headache 2% 1% 0 1% Sleep Disturbances 2% 1% 0 <1% Flatulence 1% <1% <1% 1% Abnormal Dreams 1% 1% 0 2% Diarrhea 1% 3% 1% 2% Nausea 1% 1% 1% 1%
Renal Laboratory Tests
In Trial 1216, the median baseline eGFR was104 mL per minute for subjects who switched to ODEFSEY from FTC/RPV/TDF (N=316) and the mean serum creatinine decreased by 0.02 mg per dL from baseline to Week 48.
In Trial 1160, the median baseline eGFR was 110 mL per minute for subjects who switched to ODEFSEY from EFV/FTC/TDF (N=438), and the mean serum creatinine increased by 0.1 mg per dL from baseline to Week 48.
Bone Mineral Density Effects
Changes in BMD from baseline to Week 48 were assessed by dual-energy X-ray absorptiometry (DXA) in Trials 1216 and 1160.
In Trial 1216, mean bone mineral density (BMD) increased in subjects who switched to ODEFSEY (1.61% lumbar spine, 1.04% total hip) and remained stable or decreased in subjects who remained on FTC/RPV/TDF (0.08% lumbar spine, −0.25% total hip). BMD declines of 5% or greater at the lumbar spine were experienced by 1.7% of ODEFSEY subjects and 3.0% of FTC/RPV/TDF subjects. BMD declines of 7% or greater at the femoral neck were experienced by 0% of ODEFSEY subjects and 1.2% of FTC/RPV/TDF subjects.
In Trial 1160, mean BMD increased in subjects who switched to ODEFSEY (1.65% lumbar spine, 1.28% total hip) and decreased slightly in subjects who remained on EFV/FTC/TDF (−0.05% lumbar spine, −0.13% total hip). BMD declines of 5% or greater at the lumbar spine were experienced by 2.3% of ODEFSEY subjects and 4.9% of EFV/FTC/TDF subjects. BMD declines of 7% or greater at the femoral neck were experienced by 1.4% of ODEFSEY subjects and 3.3% of EFV/FTC/TDF subjects. The long-term clinical significance of these BMD changes is not known.
Serum Lipids
Changes from baseline in total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides, and total cholesterol to HDL ratio for Trials 1216 and 1160 are presented in Table 2.
Table 2 Lipid Values, Mean Change from Baseline Reported in Subjects Receiving ODEFSEY, FTC/RPV/TDF and EFV/FTC/TDF in Trials 1216 and 1160 at 48 Weeks Trial 1216 Trial 1160 ODEFSEY N=316[n=235] FTC/RPV/TDF N=314[n=245] ODEFSEY N=438[n=295] EFV/FTC/TDF N=437[n=308] Baseline Week 48 Baseline Week 48 Baseline Week 48 Baseline Week 48 mg/dL Change The change from baseline is the mean of within-subject changes from baseline for subjects with both baseline and Week 48 values. ,Subjects who received lipid-lowering agents during the treatment period were excluded. mg/dL Change , mg/dL Change , mg/dL Change , Total Cholesterol (fasted) 176 +17 171 0 193 -7 192 -3 HDL-Cholesterol (fasted) 50 +3 48 0 56 -4 55 -2 LDL-Cholesterol (fasted) 111 +13 108 +1 118 [n=296] for ODEFSEY group in Study 1160 for LDL-Cholesterol (fasted) -1 119 -1 Triglycerides (fasted) 116 +12 119 -9 139 -12 133 +3 Total Cholesterol to HDL Ratio 3.7 +0.2 3.8 +0.1 3.7 +0.2 3.8 0
Adverse Reactions in Clinical Trials of RPV-Containing Regimens in Treatment-Naïve Adult Subjects with HIV-1 Infection
In pooled 96-week trials of antiretroviral treatment-naïve HIV-1 infected adult subjects, the most common adverse reactions in subjects treated with RPV+FTC/TDF (N=550) (incidence greater than or equal to 2%, Grades 2–4) were headache, depressive disorders, and insomnia. The proportion of subjects who discontinued treatment with RPV+FTC/TDF due to adverse reactions, regardless of severity, was 2%. The most common adverse reactions that led to discontinuation in this treatment group were psychiatric disorders (1.6%) and rash (0.2%). Although the safety profile was similar in virologically-suppressed adults with HIV-1 infection who were switched to RPV and other antiretroviral drugs, the frequency of adverse events increased by 20% (N=317).
Adverse Reactions in Clinical Trials of FTC+TAF with EVG+COBI in Treatment-Naïve Adult Subjects with HIV-1 Infection
In pooled 48-week trials of antiretroviral treatment-naïve HIV-1 infected adult subjects, the most common adverse reaction in subjects treated with FTC+TAF with EVG+COBI (N=866) (incidence greater than or equal to 10%, all grades) was nausea (10%). In this treatment group, 0.9% of subjects discontinued FTC+TAF with EVG+COBI due to adverse event [see Clinical Studies (14)]. Antiretroviral treatment-naïve adult subjects treated with FTC+TAF with EVG+COBI experienced mean increases of 30 mg/dL of total cholesterol, 15 mg/dL of LDL cholesterol, 7 mg/dL of HDL cholesterol and 29 mg/dL of triglycerides after 48 weeks of use.
Renal Laboratory Tests
In two 48-week trials in antiretroviral treatment-naïve HIV-1 infected adults treated with FTC+TAF with elvitegravir (EVG) plus cobicistat (COBI) (N=866) with a median baseline eGFR of 115 mL per minute, mean serum creatinine increased by 0.1 mg per dL from baseline to Week 48.
In clinical trials of FTC+TAF with EVG+COBI in treatment-naïve subjects and in virologically-suppressed subjects switched to FTC+TAF with EVG+COBI with estimated creatinine clearance greater than 50 mL per minute, renal serious adverse events or discontinuations due to renal adverse reactions were encountered in less than 1% of participants treated with FTC+TAF with EVG+COBI.
In a 24-week trial in adults with renal impairment (baseline eGFR 30 to 69 mL per minute) who received FTC+TAF with EVG+COBI (N=248), mean serum creatinine was 1.5 mg per dL at both baseline and Week 24. FTC+TAF with EVG+COBI was permanently discontinued due to worsening renal function in two of 80 (3%) subjects.
Bone Mineral Density Effects
In the pooled analysis of two 48-week trials of antiretroviral treatment-naïve HIV-1 infected adult subjects, bone mineral density (BMD) from baseline to Week 48 was assessed by dual-energy X-ray absorptiometry (DXA). Mean BMD decreased from baseline to Week 48 by -1.30% with FTC+TAF with EVG+COBI at the lumbar spine and -0.66% at the total hip. BMD declines of 5% or greater at the lumbar spine were experienced by 10% of FTC+TAF with EVG+COBI subjects. BMD declines of 7% or greater at the femoral neck were experienced by 7% of FTC+TAF with EVG+COBI subjects. The long-term clinical significance of these BMD changes is not known.
Adverse Reactions in Clinical Trials in Pediatric Subjects with HIV-1 Infection
In an open-label 48-week trial of 36 antiretroviral treatment-naïve HIV-1 infected pediatric subjects 12 to less than 18 years old (weighing at least 32 kg) treated with 25 mg per day of RPV and other antiretrovirals, the most common adverse reactions were headache (19%), depression (19%), somnolence (14%), nausea (11%), dizziness (8%), abdominal pain (8%), vomiting (6%) and rash (6%).
In a 24-week, open-label trial of 23 antiretroviral treatment-naïve HIV-1 infected pediatric subjects aged 12 to less than 18 years old (weighing at least 35 kg) who received FTC+TAF with EVG+COBI, the safety of this combination was similar to that of adults. Among these pediatric subjects, mean BMD increased from baseline to Week 24, +1.7% at the lumbar spine and +0.8% for the total body less head. Mean changes from baseline BMD Z-scores were -0.10 for lumbar spine and -0.11 for total body less head at Week 24. Two subjects had significant (greater than 4%) lumbar spine BMD loss at Week 24.
6.2Postmarketing Experience
The following adverse reactions have been identified during postmarketing experience in patients receiving RPV or TAF-containing regimens. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Rilpivirine:
Metabolism and Nutrition Disorders
Weight increased
Skin and Subcutaneous Tissue Disorders
Severe skin and hypersensitivity reactions including DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms)
Renal and Urinary Disorders
Nephrotic syndrome
Tenofovir alafenamide:
Skin and Subcutaneous Tissue Disorders
Angioedema, urticaria, and rash
Renal and Urinary Disorders
Acute renal failure, acute tubular necrosis, proximal renal tubulopathy, and Fanconi syndrome
7 Drug Interactions
- ODEFSEY is a complete regimen for the treatment of HIV-1 infection; therefore, coadministration with other antiretroviral medications for the treatment of HIV-1 infection is not recommended. (
7.1 )- Consult the Full Prescribing Information prior to and during treatment for important drug interactions. (
4 ,5.6 ,7 )7.1Not Recommended with Other Antiretroviral Medications
Because ODEFSEY is a complete regimen, coadministration with other antiretroviral medications for the treatment of HIV-1 infection is not recommended.
7.2 Drugs Inducing or Inhibiting CYP3A Enzymes
RPV is primarily metabolized by CYP3A, and drugs that induce or inhibit CYP3A may affect the clearance of RPV [see Clinical Pharmacology (12.3)]. Coadministration of RPV and drugs that induce CYP3A may result in decreased plasma concentrations of RPV and loss of virologic response and possible resistance to RPV or to the class of NNRTIs [see Contraindications (4), Warnings and Precautions (5.6), and Table 3].
Coadministration of RPV and drugs that inhibit CYP3A may result in increased plasma concentrations of RPV and possible adverse events.
7.3 Drugs Inducing or Inhibiting P-glycoprotein
TAF, a component of ODEFSEY, is a substrate of P-gp, BCRP, OATP1B1, and OATP1B3. Drugs that strongly affect P-gp and BCRP activity may lead to changes in TAF absorption (see Table 3). Drugs that induce P-gp activity are expected to decrease the absorption of TAF, resulting in decreased plasma concentration of TAF, which may lead to loss of therapeutic effect of ODEFSEY and development of resistance. Coadministration of ODEFSEY with other drugs that inhibit P-gp and BCRP may increase the absorption and plasma concentration of TAF.
7.4 Drugs Increasing Gastric pH
Coadministration of RPV with drugs that increase gastric pH may decrease plasma concentrations of RPV and lead to loss of virologic response and possible resistance to RPV or to the class of NNRTIs. Use of RPV with proton pump inhibitors is contraindicated and use of RPV with H2-receptor antagonists requires staggered administration [see Contraindications (4) and Table 3].
7.5QT Prolonging Drugs
There is limited information available on the potential for a pharmacodynamic interaction between RPV and drugs that prolong the QTc interval. In a study of healthy subjects, higher than recommended doses of RPV, 75 mg once daily and 300 mg once daily (3 times and 12 times recommended daily dose in ODEFSEY) prolonged the QTc interval [see Warnings and Precautions (5.6) and Clinical Pharmacology (12.2)]. Consider alternative medications to ODEFSEY in patients taking a drug with a known risk of Torsade de Pointes.
7.6Drugs Affecting Renal Function
Because FTC and tenofovir are primarily excreted by the kidneys by a combination of glomerular filtration and active tubular secretion, coadministration of ODEFSEY with drugs that reduce renal function or compete for active tubular secretion may increase concentrations of FTC, tenofovir, and other renally eliminated drugs and this may increase the risk of adverse reactions. Some examples of drugs that are eliminated by active tubular secretion include, but are not limited to, acyclovir, cidofovir, ganciclovir, valacyclovir, valganciclovir, aminoglycosides (e.g., gentamicin), and high-dose or multiple NSAIDs [see Warnings and Precautions (5.5)].
7.7Significant Drug Interactions
Table 3 provides a uling of established or potentially clinically significant drug interactions with recommended steps to prevent or manage the drug interaction (the table is not all inclusive). The drug interactions described are based on studies conducted with either ODEFSEY, the components of ODEFSEY (FTC, RPV and TAF) as individual agents, or are predicted drug interactions that may occur with ODEFSEY [see Clinical Pharmacology (12.3), Tables 8–11]. For ul of contraindicated drugs, [see Contraindications (4)].
Table 3 Significant This table is not all inclusive. Drug InteractionsConcomitant Drug Class: Drug Name Effect on Concentration Increase=↑; Decrease=↓; No Effect=↔ Clinical Comment Antacids:   antacids(e.g., aluminum, magnesium hydroxide, or calcium carbonate) ↔ RPV(antacids taken at least 2 hours before or at least 4 hours after RPV)↓ RPV (concomitant intake) Administer antacids at least 2 hours before or at least 4 hours after ODEFSEY. Anticonvulsants:   carbamazepine   oxcarbazepine   phenobarbital   phenytoin ↓ RPV Coadministration is contraindicated due to potential for loss of virologic response and development of resistance. Antimycobacterials:   rifampin  rifapentine ↓ RPV Coadministration is contraindicated due to potential for loss of virologic response and development of resistance. Antimycobacterials:   rifabutin ↓ RPV The interaction was evaluated in a clinical study. All other drug interactions shown are predicted. ↓ TAFCoadministration of ODEFSEY with rifabutin is not recommended. Azole Antifungal Agents:   fluconazole  itraconazole  ketoconazole  posaconazole   voriconazole ↑ RPV , This interaction study has been performed with a dose higher than the recommended dose for RPV. The dosing recommendation is applicable to the recommended dose of RPV 25 mg once daily. ↑ TAF↓ ketoconazole, No dosage adjustment is required when ODEFSEY is coadministered with azole antifungal agents. Clinically monitor for breakthrough fungal infections when azole antifungals are coadministered with ODEFSEY. Glucocorticoid (systemic):   dexamethasone (more than a single dose) ↓ RPV Coadministration is contraindicated due to potential for loss of virologic response and development of resistance. H2-Receptor Antagonists:   cimetidine   famotidine  nizatidine  ranitidine ↔ RPV , (famotidine taken 12 hours before RPV or 4 hours after RPV)↓ RPV , (famotidine taken 2 hours before RPV) Administer H2-receptor antagonists at least 12 hours before or at least 4 hours after ODEFSEY. Herbal Products:   St. John's wort (Hypericum perforatum) ↓ RPV Coadministration is contraindicated due to potential for loss of virologic response and development of resistance. Macrolide or Ketolide Antibiotics:   clarithromycin   erythromycin   telithromycin ↑ RPV↔ clarithromycin↔ erythromycin↔ telithromycin Where possible, alternatives such as azithromycin should be considered. Narcotic Analgesics:   methadone ↓ R(–) methadone ↓ S(+) methadone ↔ RPV ↔ methadone (when used with tenofovir) No dosage adjustments are required when initiating coadministration of methadone with ODEFSEY. However, clinical monitoring is recommended, as methadone maintenance therapy may need to be adjusted in some patients. Proton Pump Inhibitors: e.g., dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole ↓ RPV Coadministration is contraindicated due to potential for loss of virologic response and development of resistance. 7.8Drugs Without Clinically Significant Interactions with ODEFSEY
Based on drug interaction studies conducted with the fixed dose combination or components of ODEFSEY, no clinically significant drug interactions have been observed when ODEFSEY is combined with the following drugs: acetaminophen, atorvastatin, chlorzoxazone, digoxin, ethinyl estradiol, ledipasvir, metformin, midazolam, norethindrone, norgestimate, sildenafil, simeprevir, sofosbuvir, velpatasvir, and voxilaprevir.
8 Use In Specific Populations
- Pregnancy: Total rilpivirine exposures were generally lower during pregnancy compared to the postpartum period. (
2.3 ,8.1 ,12.3 ).- Lactation: Breastfeeding not recommended due to the potential for HIV-1 transmission. (
8.2 )- Pediatrics: Not recommended for patients weighing less than 35 kg. (
8.4 )8.1 Pregnancy
Pregnancy Exposure Registry
There is a pregnancy exposure registry that monitors pregnancy outcomes in individuals exposed to ODEFSEY during pregnancy. Healthcare providers are encouraged to register patients by calling the Antiretroviral Pregnancy Registry (APR) at 1-800-258-4263.
Risk Summary
Available data from the APR show no statistically significant difference in the overall risk of major birth defects for emtricitabine (FTC), rilpivirine (RPV) or tenofovir alafenamide (TAF) compared with the background rate for major birth defects of 2.7% in a US reference population of the Metropolitan Atlanta Congenital Defects Program (MACDP) (see Data). The rate of miscarriage is not reported in the APR. The estimated background rate of miscarriage in the clinically recognized pregnancies in the U.S. general population is 15–20%.
Based on the experience of HIV-1-infected pregnant individuals who completed a clinical trial through the postpartum period with an RPV-based regimen, no dose adjustments are required for pregnant patients who are already on a stable RPV-containing regimen prior to pregnancy and who are virologically suppressed (HIV-1 RNA less than 50 copies per mL). Lower exposures of RPV were observed during pregnancy compared to the postpartum period. Therefore, viral load should be monitored closely [see Data and Clinical Pharmacology (12.3)].
In animal studies, no adverse developmental effects were observed when the components of ODEFSEY were administered separately during the period of organogenesis at exposures up to 60 and 108 times (mice and rabbits, respectively; FTC), 15 and 70 times (rats and rabbits, respectively; RPV) and equal to and 53 times (rats and rabbits, respectively; TAF) the exposure at the recommended daily dose of these components in ODEFSEY (see Data). Likewise, no adverse developmental effects were seen when FTC was administered to mice and RPV was administered to rats through lactation at exposures up to approximately 60 and 63 times, respectively, the exposure at the recommended daily dose of these components in ODEFSEY. No adverse effects were observed in the offspring when TDF was administered through lactation at tenofovir exposures of approximately 14 times the exposure at the recommended daily dosage of ODEFSEY.
Data
Human Data
Prospective reports from the APR of overall major birth defects in pregnancies exposed to drug components of ODEFSEY are compared with a U.S. background major birth defect rate. Methodological limitations of the APR include the use of MACDP as the external comparator group. The MACDP population is not disease-specific, evaluates women and infants from a limited geographic area, and does not include outcomes for births that occurred at less than 20 weeks gestation.
Animal Data
8.2 Lactation
Risk Summary
The Centers for Disease Control and Prevention recommend that HIV-infected mothers not breastfeed their infants, to avoid risking postnatal transmission of HIV.
Based on published data, emtricitabine has been shown to be present in human milk; it is unknown if rilpivirine (RPV) and tenofovir alafenamide (TAF) are present in human milk. RPV is present in rat milk and tenofovir has been shown to be present in the milk of lactating rats and rhesus monkeys after administration of TDF (see Data). It is unknown if TAF is present in animal milk.
It is not known if the components of ODEFSEY affect milk production or have effects on the breastfed infant. Because of the potential for (1) HIV transmission (in HIV-negative infants), (2) developing viral resistance (in HIV-positive infants), and (3) adverse reactions in a breastfed infant similar to those seen in adults, instruct mothers not to breastfeed if they are receiving ODEFSEY.
Data
Rilpivirine: In animals, no studies have been conducted to assess the excretion of RPV directly; however, RPV was measured in rat pups which were exposed through the milk of treated dams (dosed up to 400 mg/kg/day).
Tenofovir Alafenamide: Studies in rats and monkeys have demonstrated that tenofovir is excreted in milk. Tenofovir was excreted into the milk of lactating rats following oral administration of TDF (up to 600 mg/kg/day) at up to approximately 24% of the median plasma concentration in the highest dosed animals at lactation day 11 .Tenofovir was excreted into the milk of lactating monkeys, following a single subcutaneous (30 mg/kg) dose of tenofovir, at concentrations up to approximately 4% of plasma concentration resulting in exposure (AUC) of approximately 20% of plasma exposure.
8.4 Pediatric Use
The efficacy and safety of ODEFSEY as a complete regimen for the treatment of HIV-1 infection was established in pediatric patients 12 years of age and older with body weight greater than or equal to 35 kg [see Dosage and Administration (2.2)]. Use of ODEFSEY in this age group is supported by adequate and well-controlled studies of RPV+FTC+TDF in adults with HIV-1 infection, adequate and well-controlled studies of FTC+TAF with EVG+COBI in adults with HIV-1 infection, and by the following pediatric studies [see Clinical Studies (14)]:
- 48-week open-label trial of 36 antiretroviral treatment-naïve HIV-1 infected pediatric subjects 12 to less than 18 years old weighing at least 32 kg treated with 25 mg per day of RPV and other antiretrovirals. The safety and efficacy of RPV administered with other antiretrovirals were similar to that of antiretroviral treatment-naïve HIV-1 infected adults on this regimen [see Adverse Reactions (6.1) and Clinical Studies (14)].
- 24-week open-label trial of 23 antiretroviral treatment-naïve HIV-1 infected pediatric subjects 12 to less than 18 years old (weighing at least 35 kg) treated with FTC+TAF with EVG+COBI. The safety and efficacy of FTC+TAF with EVG+COBI were similar to that of antiretroviral treatment-naïve HIV-1 infected adults on this regimen [see Adverse Reactions (6.1) and Clinical Studies (14)].
Because it is a fixed-dose combination tablet, the dose of ODEFSEY cannot be adjusted for patients of lower age and weight. The safety and efficacy of ODEFSEY have not been established in pediatric patients weighing less than 35 kg [see Clinical Pharmacology (12.3)].
8.5 Geriatric Use
In clinical trials, 80 of the 97 subjects enrolled aged 65 years and over received FTC+TAF with EVG+COBI. No differences in safety or efficacy have been observed between elderly subjects and those between 12 and less than 65 years of age. Clinical trials of RPV did not include sufficient numbers of subjects aged 65 years and over to determine whether they respond differently from younger subjects [see Clinical Pharmacology (12.3)].
8.6Renal Impairment
No dosage adjustment of ODEFSEY is recommended in patients with estimated creatinine clearance greater than or equal to 30 mL per minute. ODEFSEY should be used with caution in adults patients with ESRD (estimated creatinine clearance below 15mL per minute) who are receiving chronic hemodialysis and increased monitoring is recommended for RPV-related adverse effects in patients with ESRD, as RPV concentrations may be increased due to alteration of drug absorption, distribution, and metabolism secondary to renal dysfunction. On days of hemodialysis, administer the daily dose of ODEFSEY after completion of hemodialysis treatment [see Dosage and Administration (2.4) and Clinical Pharmacology (12.3)].
ODEFSEY is not recommended in patients with severe renal impairment (estimated creatinine clearance of 15 to below 30 mL per minute), or in patients with ESRD who are not receiving chronic hemodialysis, as the safety of ODEFSEY has not been established in these populations [see Dosage and Administration (2.4) and Clinical Pharmacology (12.3)].
8.7Hepatic Impairment
No dosage adjustment of ODEFSEY is recommended in patients with mild (Child-Pugh Class A) or moderate (Child-Pugh Class B) hepatic impairment. ODEFSEY has not been studied in patients with severe hepatic impairment (Child-Pugh Class C) [see Clinical Pharmacology (12.3)].
10 Overdosage
Limited data are available on overdose of the components of ODEFSEY in patients. If overdose occurs, monitor the patient for evidence of toxicity. Treatment of overdose with ODEFSEY consists of general supportive measures including monitoring of vital signs and ECG (QT interval) as well as observation of the clinical status of the patient.
Emtricitabine (FTC): Hemodialysis treatment removes approximately 30% of the FTC dose over a 3-hour dialysis period starting within 1.5 hours of FTC dosing (blood flow rate of 400 mL per minute and a dialysate flow rate of 600 mL per minute). It is not known whether FTC can be removed by peritoneal dialysis.
Rilpivirine (RPV): Human experience of overdose with RPV is limited. There is no specific antidote for overdose with RPV. Since RPV is highly bound to plasma protein, dialysis is unlikely to result in significant removal of RPV.
Tenofovir Alafenamide (TAF): Tenofovir is efficiently removed by hemodialysis with an extraction coefficient of approximately 54%.
11 Description
ODEFSEY (emtricitabine, rilpivirine, and tenofovir alafenamide) is a fixed-dose combination tablet containing emtricitabine (FTC), rilpivirine (RPV), and tenofovir alafenamide (TAF) for oral administration.
- FTC, a synthetic nucleoside analog of cytidine, is an HIV-1 nucleoside analog reverse transcriptase inhibitor (HIV-1 NRTI).
- RPV is an HIV-1 non-nucleoside reverse transcriptase inhibitor (NNRTI).
- TAF, an HIV-1 NRTI, is converted in vivo to tenofovir, an acyclic nucleoside phosphonate (nucleotide) analog of adenosine 5′-monophosphate.
Each tablet contains 200 mg of FTC, 25 mg of RPV (equivalent to 27.5 of rilpivirine hydrochloride) and 25 mg of TAF (equivalent to 28 mg of tenofovir alafenamide fumarate) and the following inactive ingredients: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polysorbate 20, and povidone. The tablets are film-coated with a coating material containing iron oxide black, polyethylene glycol, polyvinyl alcohol, talc, and titanium dioxide.
Emtricitabine: The chemical name of FTC is 4-amino-5-fluoro-1-(2R-hydroxymethyl-1,3-oxathiolan-5S-yl)-(1H)-pyrimidin-2-one. FTC is the (-)enantiomer of a thio analog of cytidine, which differs from other cytidine analogs in that it has a fluorine in the 5 position.
FTC has a molecular formula of C8H10FN3O3S and a molecular weight of 247.24 and has the following structural formula:
FTC is a white to off-white powder with a solubility of approximately 112 mg per mL in water at 25 °C.
Rilpivirine: The chemical name of rilpivirine hydrochloride drug substance is 4-[[4-[[4-[(E)-2-cyanoethenyl]-2,6-dimethylphenyl]amino]-2-pyrimidinyl]amino]benzonitrile monohydrochloride. Its molecular formula is C22H18N6 ∙ HCl and its molecular weight is 402.88. Rilpivirine hydrochloride has the following structural formula:
Rilpivirine hydrochloride is a white to almost white powder. Rilpivirine hydrochloride is practically insoluble in water over a wide pH range.
Tenofovir Alafenamide: The chemical name of tenofovir alafenamide fumarate drug substance is L-alanine, N-[(S)-[[(1R)-2-(6-amino-9H-purin-9-yl)-1-methylethoxy]methyl]phenoxyphosphinyl]-, 1-methylethyl ester, (2E)-2-butenedioate (2:1).
Tenofovir alafenamide fumarate has an empirical formula of C21H29O5N6P∙½(C4H4O4) and a formula weight of 534.50 and has the following structural formula:
Tenofovir alafenamide fumarate is a white to off-white or tan powder with a solubility of 4.7 mg per mL in water at 20 °C.
12 Clinical Pharmacology
12.1 Mechanism of Action
ODEFSEY is a fixed dose combination of antiretroviral drugs emtricitabine, rilpivirine, and tenofovir alafenamide [see Microbiology (12.4)].
12.2 Pharmacodynamics
Cardiac Electrophysiology
When higher than recommended RPV doses of 75 mg (3 times the recommended dosage in ODEFSEY) once daily and 300 mg (12 times the recommended dosage in ODEFSEY) once daily were studied in healthy adults, the maximum mean time-matched (95% upper confidence bound) differences in QTcF interval from placebo after baseline correction were 10.7 (15.3) and 23.3 (28.4) milliseconds, respectively. Steady-state administration of RPV 75 mg once daily and 300 mg once daily resulted in a mean steady-state Cmax approximately 2.6 times and 6.7 times, respectively, higher than the mean Cmax observed with the recommended 25 mg once daily dose of RPV [see Warnings and Precautions (5.6)].
The effect of RPV at the recommended dose of 25 mg once daily on the QTcF interval was evaluated in a randomized, placebo-, and active- (moxifloxacin 400 mg once daily) controlled crossover study in 60 healthy adults, with 13 measurements over 24 hours at steady state. The maximum mean time-matched (95% upper confidence bound) differences in QTcF interval from placebo after baseline correction was 2 (5) milliseconds (i.e., below the threshold of clinical concern).
In a thorough QT/QTc study in 48 healthy subjects, TAF at the recommended dose and at a dose approximately 5 times the recommended dose, did not affect the QT/QTc interval and did not prolong the PR interval.
The effect of FTC on the QT interval is not known.
12.3 Pharmacokinetics
Absorption, Distribution, Metabolism, and Excretion
The pharmacokinetic properties of the components of ODEFSEY are provided in Table 4. The multiple dose pharmacokinetic parameters of FTC, RPV and TAF and its metabolite tenofovir are provided in Table 5.
Table 4 Pharmacokinetic Properties of the Components of ODEFSEY Rilpivirine Emtricitabine Tenofovir Alafenamide PBMCs = peripheral blood mononuclear cells; CES1 = carboxylesterase 1. Absorption Tmax (h) 4 3 1 Effect of moderate fat meal (relative to fasting) Values refer to geometric mean ratio [fed/ fasted] in PK parameters and (90% confidence interval). High-calorie/high-fat meal = ~800 kcal, 50% fat. Moderate-fat meal = ~600 kcal, 27% fat. AUC Ratio = 1.13 (1.03, 1.23) AUC Ratio = 0.91 (0.89, 0.93) AUC Ratio = 1.45(1.33, 1.58) Effect of high fat meal (relative to fasting) AUC Ratio = 1.72 (1.49, 1.99) AUC Ratio = 0.88 (0.85, 0.90) AUC Ratio = 1.53(1.39, 1.69) Distribution % Bound to human plasma proteins ~99 <4 ~80 Source of protein binding data In vitro In vitro Ex vivo Blood-to-plasma ratio 0.7 0.6 1.0 Metabolism Metabolism CYP3A Not significantly metabolized Cathepsin A In vivo, TAF is hydrolyzed within cells to form tenofovir (major metabolite), which is phosphorylated to the active metabolite, tenofovir diphosphate. In vitro studies have shown that TAF is metabolized to tenofovir by cathepsin A in PBMCs and macrophages; and by CES1 in hepatocytes. Upon coadministration with the moderate CYP3A inducer probe efavirenz, TAF exposure was unaffected. (PBMCs)CES1 (hepatocytes)CYP3A (minimal)Elimination Major route of elimination Metabolism Glomerular filtration and active tubular secretion Metabolism (>80% of oral dose) t1/2 (h) t1/2 values refer to median terminal plasma half-life. Note that the pharmacologically active metabolite, tenofovir diphosphate, has a half-life of 150–180 hours within PBMCs. 50 10 0.51 % Of dose excreted in urine Dosing in mass balance studies: FTC (single dose administration of [14C] emtricitabine after multiple dosing of emtricitabine for ten days); TAF (single dose administration of [14C] tenofovir alafenamide). 6 70 <1 % Of dose excreted in feces 85 13.7 31.7
Table 5 Multiple Dose Pharmacokinetic Parameters of Emtricitabine, Rilpivirine, Tenofovir Alafenamide and its Metabolite Tenofovir Following Oral Administration with a Meal in HIV-Infected Adults ParameterMean (CV%) Emtricitabine From Intensive PK analysis in a phase 2 trial in HIV infected adults treated with FTC+TAF with EVG+COBI (n=19). Rilpivirine From Population PK analysis in a trial of treatment-naïve adults with HIV-1 infection treated with RPV (n=679). Tenofovir Alafenamide From Population PK analysis in two trials of treatment-naïve adults with HIV-1 infection treated within EVG+COBI+FTC+TAF (n=539). Tenofovir From Population PK analysis in two trials of treatment-naïve adults with HIV-1 infection treated with EVG+COBI+FTC+TAF (n=841). CV = Coefficient of Variation; NA = Not Applicable Cmax (microgram per mL) 2.1 (20.2) NA 0.16 (51.1) 0.02 (26.1) AUCtau (microgram∙hour per mL) 11.7 (16.6) 2.2 (38.1) 0.21 (71.8) 0.29 (27.4) Ctrough (microgram per mL) 0.10 (46.7) 0.08 (44.3) NA 0.01 (28.5)
Specific Populations
Geriatric Patients
The pharmacokinetics of FTC and TAF have not been fully evaluated in the elderly (65 years of age and older). Population pharmacokinetics analysis of HIV-infected subjects in Phase 2 and Phase 3 trials of FTC+TAF with EVG+COBI showed that age did not have a clinically relevant effect on exposures of TAF up to 75 years of age.
The pharmacokinetics of RPV have not been fully evaluated in the elderly (65 years of age and older) [see Use in Specific Populations (8.5)].
Pediatric Patients
Exposures of TAF in 24 pediatric subjects with HIV-1 infection aged 12 to less than 18 years who received FTC+TAF with EVG+COBI were decreased (23% for TAF AUC) compared to exposures achieved in treatment-naïve adults following administration of FTC+TAF with EVG+COBI. These exposure differences are not thought to be clinically significant based on exposure-response relationships. FTC exposures were similar in adolescents compared to treatment-naïve adults. The PK of RPV in antiretroviral HIV-1-infected pediatric subjects 12 to less than 18 years of age who received RPV 25 mg once daily were comparable to those in HIV-1 infected adults. As in adults, there was no impact of body weight on RPV PK in pediatric subjects [see Use In Specific Populations (8.4)].
Race and Gender
No clinically significant changes in the pharmacokinetics of the components of ODEFSEY have been observed based on race or gender.
Patients with Renal Impairment
Patients with Hepatic Impairment
Hepatitis B and/or Hepatitis C Virus Coinfection
The pharmacokinetics of FTC and TAF have not been fully evaluated in subjects coinfected with hepatitis B and/or C virus. Population pharmacokinetic analysis indicated that hepatitis B and/or C virus coinfection had no clinically relevant effect on the exposure of RPV.
Pregnancy and Postpartum
Drug Interaction Studies
Rilpivirine: RPV is primarily metabolized by CYP3A, and drugs that induce or inhibit CYP3A may thus affect the clearance of RPV.
RPV at a dose of 25 mg once daily is not likely to have a clinically relevant effect on the exposure of medicinal products metabolized by CYP enzymes.
TAF is not an inhibitor of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, or UGT1A1. TAF is a weak inhibitor of CYP3A in vitro. TAF is not an inhibitor or inducer of CYP3A in vivo.
The drug interaction studies described in Tables 8–11 were conducted with ODEFSEY (FTC/RPV/TAF) or the components of ODEFSEY (FTC, RPV, or TAF) administered individually.
The effects of coadministered drugs on the exposures of RPV and TAF are shown in Tables 8 and 9, respectively. The effects of RPV and TAF on the exposure of coadministered drugs are shown in Tables 10 and 11, respectively. For information regarding clinical recommendations, see Drug Interactions (7).
Table 8 Changes in Pharmacokinetic Parameters for RPV in the Presence of Coadministered Drugs in Healthy Subjects Coadministered Drug Dose/Schedule Mean Ratio of RPVPharmacokinetic Parameters With/Without Coadministered Drug (90% CI);No Effect = 1.00 Coadministered Drug (mg) RPV (mg) N Cmax AUC Cmin CI=Confidence Interval; N=maximum number of subjects with data; NA=Not Available; ↔=no change Acetaminophen 500 single dose 150 once daily 25 mg, 75 mg, and 150 mg of RPV is 1, 3, and 6 times the recommended dose of RPV in ODEFSEY, respectively. 16 1.09(1.01, 1.18) 1.16(1.10, 1.22) 1.26(1.16, 1.38) Atorvastatin 40 once daily 150 once daily 16 0.91(0.79, 1.06) 0.90(0.81, 0.99) 0.90(0.84, 0.96) Chlorzoxazone 500 single dose taken 2 hours after RPV 150 once daily 16 1.17(1.08, 1.27) 1.25(1.16, 1.35) 1.18(1.09, 1.28) Ethinylestradiol/Norethindrone 0.035 once daily /1 mg once daily 25 once daily Study conducted with RPV. 15 ↔ Comparison based on historic controls. ↔ ↔ Famotidine 40 single dose taken 12 hours before RPV 150 single dose 24 0.99(0.84, 1.16) 0.91(0.78, 1.07) NA Famotidine 40 single dose taken 2 hours before RPV 150 single dose 23 0.15(0.12, 0.19) 0.24(0.20, 0.28) NA Famotidine 40 single dose taken 4 hours after RPV 150 single dose 24 1.21(1.06, 1.39) 1.13(1.01, 1.27) NA Ketoconazole 400 once daily 150 once daily 15 1.30(1.13, 1.48) 1.49(1.31, 1.70) 1.76(1.57, 1.97) Methadone 60–100 once daily, individualized dose 25 once daily 12 ↔ ↔ ↔ Ledipasvir/Sofosbuvir 90/400 once daily 25 once daily Study conducted with ODEFSEY (FTC/RPV/TAF). 42 0.97(0.92, 1.02) 0.95(0.91, 0.98) 0.93(0.89, 0.97) Omeprazole 20 once daily 25 single dose 15 0.30(0.24, 0.38) 0.35(0.28, 0.44) NA Rifabutin 300 once daily 25 once daily 18 0.69(0.62, 0.76) 0.58(0.52, 0.65) 0.52(0.46, 0.59) Rifampin 600 once daily 150 once daily 16 0.31(0.27, 0.36) 0.20(0.18, 0.23) 0.11(0.10, 0.13) Simeprevir 25 once daily 150 once daily 23 1.04(0.95, 1.30) 1.12(1.05, 1.19) 1.25(1.16, 1.35) Sildenafil 50 single dose 75 once daily 16 0.92(0.85, 0.99) 0.98(0.92, 1.05) 1.04(0.98, 1.09) Sofosbuvir/velpatasvir 400/100 once daily 10 once daily Study conducted with FTC/RPV/TDF. 24 0.93(0.88,0.98) 0.95(0.90, 1.00) 0.96(0.90,1.03) Sofosbuvir/velpatasvir/voxilaprevir 400/100/100 + 100 voxilaprevir Study conducted with additional voxilaprevir 100 mg to achieve voxilaprevir exposures expected in HCV-infected patients. once daily25 once daily 30 0.79(0.74, 0.84) 0.80(0.76, 0.85) 0.82(0.77, 0.87)
Table 9 Changes in Pharmacokinetic Parameters for TAF in the Presence of the Coadministered Drug All interaction studies conducted in healthy volunteers. in Healthy SubjectsCoadministered Drug Dose of Coadministered Drug (mg) TAF (mg) N Mean Ratio of Tenofovir Alafenamide Pharmacokinetic Parameters (90% CI);No Effect = 1.00 Cmax AUC Cmin CI=Confidence Interval; N=maximum number of subjects with data; NA=Not Available Cobicistat Increases TAF exposure via inhibition of intestinal P-glycoprotein. 150 once daily 8 once daily 12 2.83(2.20, 3.65) 2.65(2.29, 3.07) NA Ledipasvir/Sofosbuvir 90/400 once daily 25 once daily Study conducted with ODEFSEY (FTC/RPV/TAF). 42 1.03(0.94, 1.14) 1.32(1.25, 1.40) NA Sofosbuvir/velpatasvir/voxilaprevir 400/100/100 + 100 voxilaprevir Study conducted with additional voxilaprevir 100 mg to achieve voxilaprevir exposures expected in HCV-infected patients. once daily25 once daily 30 1.32(1.17, 1.48) 1.52(1.43,1.61) NA
Table 10 Changes in Pharmacokinetic Parameters for Coadministered Drugs in the Presence of RPV in Healthy Subjects Coadministered Drug Dose/Schedule Mean Ratio of Coadministered Drug Pharmacokinetic Parameters With/Without RPV (90% CI); No Effect = 1.00 Coadministered Drug (mg) RPV (mg) N Cmax AUC Cmin CI=Confidence Interval; N=maximum number of subjects with data; NA=Not Available Acetaminophen 500 single dose 150 once daily 25 mg, 75 mg, and 150 mg of RPV is 1, 3, and 6 times the recommended dose of RPV in ODEFSEY, respectively. 16 0.97(0.86, 1.10) 0.92(0.85, 0.99) NA Atorvastatin 40 once daily 150 once daily 16 1.35(1.08, 1.68) 1.04(0.97, 1.12) 0.85(0.69, 1.03) 2-hydroxy-atorvastatin 1.58(1.33, 1.87) 1.39(1.29, 1.50) 1.32(1.10, 1.58) 4-hydroxy-atorvastatin 1.28(1.15, 1.43) 1.23(1.13, 1.33) NA Chlorzoxazone 500 single dose taken 2 hours after RPV 150 once daily 16 0.98(0.85, 1.13) 1.03(0.95, 1.13) NA Digoxin 0.5 single dose 25 once daily Study conducted with RPV. 22 1.06(0.97, 1.17) 0.98(0.93, 1.04) AUC(0–last). NA Ethinylestradiol 0.035 once daily 25 once daily 17 1.17(1.06, 1.30) 1.14(1.10, 1.19) 1.09(1.03, 1.16) Norethindrone 1 mg once daily 0.94(0.83, 1.06) 0.89(0.84, 0.94) 0.99(0.90, 1.08) Ketoconazole 400 once daily 150 once daily 14 0.85(0.80, 0.90) 0.76(0.70, 0.82) 0.34(0.25, 0.46) Ledipasvir 90 once daily 25 once daily Study conducted with ODEFSEY (FTC/RPV/TAF). 41 1.01(0.97, 1.05) 1.02(0.97, 1.06) 1.02(0.98, 1.07) Sofosbuvir 400 once daily 25 once daily 41 0.96(0.89, 1.04) 1.05(1.01, 1.09) NA GS-331007 The predominant circulating nucleoside metabolite of sofosbuvir. 1.08(1.05, 1.11) 1.08(1.06, 1.10) 1.10(1.07, 1.12) R(-) methadone 60–100 once daily, individualized dose 25 once daily 13 0.86(0.78, 0.95) 0.84(0.74, 0.95) 0.78(0.67, 0.91) S(+) methadone 0.87(0.78, 0.97) 0.84(0.74, 0.96) 0.79(0.67, 0.92) Metformin 850 single dose 25 once daily 20 1.02(0.95, 1.10) 0.97(0.90,1.06) N (maximum number of subjects with data for AUC(0–∞)=15) NA Rifampin 600 once daily 150 once daily 16 1.02(0.93, 1.12) 0.99(0.92, 1.07) NA 25-desacetylrifampin 1.00(0.87, 1.15) 0.91(0.77, 1.07) NA Simeprevir 150 once daily 25 once daily 21 1.10(0.97, 1.26) 1.06(0.94, 1.19) 0.96(0.83, 1.11) Sildenafil 50 single dose 75 once daily 16 0.93(0.80, 1.08) 0.97(0.87, 1.08) NA N-desmethyl-sildenafil 0.90(0.80, 1.02) 0.92(0.85, 0.99) NA Sofosbuvir GS-331007 400 once daily 25 once daily Study conducted with FTC/RPV/TDF. 24 1.09(0.95, 1.25)0.96(0.90, 1.01) 1.16(1.10, 1.24)1.04(1.00, 1.07) NA1.12(1.07, 1.17) Velpatasvir 100 once daily 25 once daily 24 0.96(0.85, 1.10) 0.99(0.88, 1.11) 1.02(0.91, 1.15) Sofosbuvir 400 once daily 25 once daily 30 0.95(0.86, 1.05) 1.01(0.97, 1.06) NA GS-331007 1.02(0.98, 1.06) 1.04(1.01, 1.06) NA Velpatasvir 100 once daily 25 once daily 30 1.05(0.96, 1.16) 1.01(0.94, 1.07) 1.01(0.95, 1.09) Voxilaprevir 100 + 100 once daily 25 once daily 30 0.96(0.84, 1.11) 0.94(0.84, 1.05) 1.02(0.92, 1.12)
Table 11 Changes in Pharmacokinetic Parameters for Coadministered Drug in the Presence of TAF in Healthy Subjects Coadministered Drug Dose of Coadministered Drug (mg) TAF (mg) N Mean Ratio of Coadministered Drug Pharmacokinetic Parameters (90% CI); No Effect = 1.00 Cmax AUC Cmin CI=Confidence Interval; N=maximum number of subjects with data; NA=Not Available Midazolam A sensitive CYP3A4 substrate. 2.5 single dose, orally 25 once daily Study conducted with TAF. 18 1.02(0.92, 1.13) 1.13(1.04, 1.23) NA 1 single dose, IV 0.99(0.89, 1.11) 1.08(1.04, 1.13) NA Ledipasvir Study conducted with ODEFSEY (FTC/RPV/TAF). 90/400 once daily 25 once daily 41 1.01(0.97, 1.05) 1.02(0.97, 1.06) 1.02(0.98,1.07) Sofosbuvir 0.96(0.89, 1.04) 1.05(1.01, 1.09) NA GS-331007 , The predominant circulating nucleoside metabolite of sofosbuvir. 1.08(1.05, 1.11) 1.08(1.06, 1.10) 1.10 (1.07, 1.12) Norelgestromin norgestimate 0.180/0.215/0.250 once daily/ethinyl estradiol 0.025 once daily 25 once daily Study conducted with FTC/TAF. 29 1.17(1.07,1.26) 1.12(1.07, 1.17) 1.16(1.08,1.24) Norgestrel 1.10(1.02, 1.18) 1.09(1.01, 1.18) 1.11(1.03,1.20) Ethinyl estradiol 1.22(1.15, 1.29) 1.11(1.07, 1.16) 1.02(0.93,1.12) Sofosbuvir 400 once daily 25 once daily 30 0.95(0.86, 1.05) 1.01(0.97, 1.06) NA GS-331007 1.02(0.98, 1.06) 1.04(1.01, 1.06) NA Velpatasvir 100 once daily 1.05(0.96, 1.16) 1.01(0.94, 1.07) 1.01(0.95,1.09) Voxilaprevir 100 + 100 once daily 0.96(0.84, 1.11) 0.94(0.84, 1.05) 1.02(0.92,1.12) 12.4 Microbiology
Mechanism of Action
Emtricitabine: FTC, a synthetic nucleoside analog of cytidine, is phosphorylated by cellular enzymes to form emtricitabine 5'-triphosphate. Emtricitabine 5'-triphosphate inhibits the activity of the HIV-1 reverse transcriptase (RT) by competing with the natural substrate deoxycytidine 5'-triphosphate and by being incorporated into nascent viral DNA which results in chain termination. Emtricitabine 5′-triphosphate is a weak inhibitor of mammalian DNA polymerases α, β, Æ, and mitochondrial DNA polymerase γ.
Rilpivirine: RPV is a diarylpyrimidine non-nucleoside reverse transcriptase inhibitor of HIV-1 and inhibits HIV-1 replication by non-competitive inhibition of HIV-1 RT. RPV does not inhibit the human cellular DNA polymerases α, β, and mitochondrial DNA polymerase γ.
Tenofovir Alafenamide: TAF is a phosphonamidate prodrug of tenofovir (2'-deoxyadenosine monophosphate analog). Plasma exposure to TAF allows for permeation into cells and then TAF is intracellularly converted to tenofovir through hydrolysis by cathepsin A. Tenofovir is subsequently phosphorylated by cellular kinases to the active metabolite tenofovir diphosphate. Tenofovir diphosphate inhibits HIV-1 replication through incorporation into viral DNA by the HIV reverse transcriptase, which results in DNA chain termination.
Tenofovir has activity against human immunodeficiency virus (HIV-1). Cell culture studies have shown that both tenofovir and FTC can be fully phosphorylated when combined in cells. Tenofovir diphosphate is a weak inhibitor of mammalian DNA polymerases that include mitochondrial DNA polymerase γ and there is no evidence of toxicity to mitochondria cell culture.
Antiviral Activity in Cell Culture
Emtricitabine, Rilpivirine, and Tenofovir Alafenamide: The combinations of FTC, RPV, and TAF were not antagonistic with each other in cell culture combination antiviral activity assays. In addition, FTC, RPV, and TAF were not antagonistic with a panel of representatives from the major classes of approved anti-HIV agents (NNRTIs, NRTIs, INSTIs, and PIs).
Resistance
In Cell Culture
In Clinical Trials
Cross-Resistance
Emtricitabine: FTC-resistant viruses with the M184V/I substitution were cross-resistant to lamivudine, but retained sensitivity to didanosine, stavudine, tenofovir, and zidovudine.
Viruses harboring substitutions conferring reduced susceptibility to stavudine and zidovudine—thymidine analog substitutions (M41L, D67N, K70R, L210W, T215Y/F, K219Q/E), or didanosine (L74V) remained sensitive to FTC. HIV-1 containing the K103N substitution or other substitutions associated with resistance to NNRTIs was susceptible to FTC.
Rilpivirine: Considering all of the available cell culture and clinical data, any of the following amino acid substitutions, when present at baseline, are likely to decrease the antiviral activity of RPV: K101E, K101P, E138A, E138G, E138K, E138R, E138Q, V179L, Y181C, Y181I, Y181V, Y188L, H221Y, F227C, M230I, M230L, and the combination of L100I+K103N.
Cross-resistance in site-directed mutant virus has been observed among NNRTIs. The single NNRTI substitutions K101P, Y181I, and Y181V conferred 52 times, 15 times, and 12 times decreased susceptibility to RPV, respectively. The combination of E138K and M184I showed 6.7 times reduced susceptibility to RPV compared to 2.8 times for E138K alone. The K103N substitution did not show reduced susceptibility to RPV by itself. However, the combination of K103N and L100I resulted in a 7 times reduced susceptibility to RPV. In another study, the Y188L substitution resulted in a reduced susceptibility to RPV of 9 times for clinical isolates and 6 times for site-directed mutants. Combinations of 2 or 3 NNRTI resistance-associated substitutions gave decreased susceptibility to RPV (fold change range of 3.7–554) in 38% and 66% of mutants, respectively.
Cross-resistance to efavirenz, etravirine, and/or nevirapine is likely after virologic failure and development of RPV resistance.
Tenofovir Alafenamide: Tenofovir resistance substitutions K65R and K70E result in reduced susceptibility to abacavir, didanosine, emtricitabine, lamivudine, and tenofovir.
HIV-1 with multiple thymidine analog substitutions (M41L, D67N, K70R, L210W, T215F/Y, K219Q/E/N/R), or multinucleoside resistant HIV-1 with a T69S double insertion mutation or with a Q151M substitution complex including K65R showed reduced susceptibility to TAF in cell culture.
13 Nonclinical Toxicology
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Emtricitabine: In long-term carcinogenicity studies of FTC, no drug-related increases in tumor incidence were found in mice at doses up to 750 mg per kg per day (23 times the human systemic exposure at the recommended dose of 200 mg per day in ODEFSEY) or in rats at doses up to 600 mg per kg per day (28 times the human systemic exposure at the recommended dose in ODEFSEY).
FTC was not genotoxic in the reverse mutation bacterial test (Ames test), mouse lymphoma or mouse micronucleus assays.
FTC did not affect fertility in male rats at approximately 140 times or in male and female mice at approximately 60 times higher exposures (AUC) than in humans given the recommended 200 mg daily dose in ODEFSEY. Fertility was normal in the offspring of mice exposed daily from before birth (in utero) through sexual maturity at daily exposures (AUC) of approximately 60 times higher than human exposures at the recommended 200 mg daily dose in ODEFSEY.
Rilpivirine: RPV was evaluated for carcinogenic potential by oral gavage administration to mice and rats up to 104 weeks. Daily doses of 20, 60, and 160 mg per kg per day were administered to mice and doses of 40, 200, 500, and 1500 mg per kg per day were administered to rats. In rats, there were no drug-related neoplasms. In mice, RPV was positive for hepatocellular neoplasms in both males and females. The observed hepatocellular findings in mice may be rodent-specific. At the lowest tested doses in the carcinogenicity studies, the systemic exposures (based on AUC) to RPV were 21 times (mice) and 3 times (rats) relative to those observed in humans at the recommended dose (25 mg once daily) in ODEFSEY.
RPV has tested negative in the absence and presence of a metabolic activation system, in the in vitro Ames reverse mutation assay and in vitro clastogenicity mouse lymphoma assay. RPV did not induce chromosomal damage in the in vivo micronucleus test in mice.
In a study conducted in rats, there were no effects on mating or fertility with RPV up to 400 mg per kg per day, a dose of RPV that showed maternal toxicity. This dose is associated with an exposure that is approximately 40 times higher than the exposure in humans at the recommended dose of 25 mg once daily in ODEFSEY.
Tenofovir Alafenamide: Since TAF is rapidly converted to tenofovir and a lower tenofovir exposure in rats and mice was observed after TAF administration compared to TDF administration, carcinogenicity studies were conducted only with TDF. Long-term oral carcinogenicity studies of TDF in mice and rats were carried out at exposures up to approximately 10 times (mice) and 4 times (rats) those observed in humans at the recommended dose of TDF (300 mg) for HIV-1 infection. The tenofovir exposure in these studies was approximately 167 times (mice) and 55 times (rat) those observed in humans after administration of the daily recommended dose of ODEFSEY. At the high dose in female mice, liver adenomas were increased at tenofovir exposures approximately 10 times (300 mg TDF) and 167 times (ODEFSEY) the exposure observed in humans. In rats, the study was negative for carcinogenic findings.
TAF was not genotoxic in the reverse mutation bacterial test (Ames test), mouse lymphoma or rat micronucleus assays.
There were no effects on fertility, mating performance or early embryonic development when TAF was administered to male rats at a dose equivalent to 62 times the human dose based on body surface area comparisons for 28 days prior to mating and to female rats for 14 days prior to mating through Day 7 of gestation.
13.2 Animal Toxicology and/or Pharmacology
Minimal to slight infiltration of mononuclear cells in the posterior uvea was observed in dogs with similar severity after three- and nine-month administration of TAF; reversibility was seen after a three-month recovery period. No eye toxicity was observed in the dog at systemic exposures of 5 (TAF) and 15 (tenofovir) times the exposure seen in humans at the recommended daily TAF dose in ODEFSEY.
14 Clinical Studies
14.1 Clinical Trial Results in HIV-1 Virologically-Suppressed Subjects Who Switched to ODEFSEY
In Trial 1216, the efficacy and safety of switching from emtricitabine/rilpivirine/tenofovir disoproxil fumarate (FTC/RPV/TDF) to ODEFSEY were evaluated in a randomized, double-blind study of virologically-suppressed HIV-1 infected adults. Subjects were suppressed (HIV-1 RNA <50 copies/mL) on their baseline regimen of FTC/RPV/TDF for at least 6 months and have no documented resistance mutations to FTC, TAF, or RPV prior to study entry. Subjects were randomized in a 1:1 ratio to either switch to ODEFSEY (N=316) once daily or stay on FTC/RPV/TDF (N=314) once daily. Subjects had a mean age of 45 years (range: 23–72), 90% were male, 75% were White, and 19% were Black. The mean baseline CD4+ cell count was 709 cells/mm3 (range: 104–2527).
In Trial 1160, the efficacy and safety of switching from efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF) to ODEFSEY were evaluated in a randomized, double-blind study of virologically-suppressed HIV-1 infected adults. Subjects must have been stably suppressed (HIV-1 RNA <50 copies/mL) on their baseline regimen of EFV/FTC/TDF for at least 6 months and have no documented resistance mutations to FTC, TAF, or RPV prior to study entry. Subjects were randomized in a 1:1 ratio to either switch to ODEFSEY (N=438) once daily or stay on EFV/FTC/TDF (N=437) once daily. Subjects had a mean age of 48 years (range: 19−76), 87% were male, 67% were White, and 27% were Black. The mean baseline CD4+ cell count was 700 cells/mm3 (range: 140–1862).
Treatment outcomes of Trials 1216 and 1160 are presented in Table 12.
Table 12 Virologic Outcomes of Trials 1216 and 1160 at Week 48 Week 48 window was between Day 295 and 378 (inclusive). in Virologically-Suppressed Subjects who Switched to ODEFSEYStudy 1216 Study 1160 ODEFSEY(N=316) FTC/RPV/TDF(N=313) One subject who was not on FTC/RPV/TDF prior to screening was excluded from the efficacy analysis. ODEFSEY(N=438) EFV/FTC/TDF (N=437) HIV-1 RNA <50 copies/mL 94% 94% 90% 92% HIV-1 RNA ≥50 copies/mL Included subjects who had HIV-1 RNA ≥50 copies/mL in the Week 48 window; subjects who discontinued early due to lack or loss of efficacy; subjects who discontinued for reasons other than lack or loss of efficacy and at the time of discontinuation had a viral value of ≥50 copies/mL. 1% 0% 1% 1% No Virologic Data at Week 48 Window 6% 6% 9% 7% Discontinued Study Drug Due to AE or Death and Last Available HIV-1 RNA <50 copies/mL 2% 1% 3% 1% Discontinued Study Drug Due to Other Reasons and Last Available HIV-1 RNA <50 copies/mL Includes subjects who discontinued for reasons other than an AE, death, or lack or loss of efficacy; e.g., withdrew consent, loss to follow-up, etc. 4% 4% 5% 5% Missing Data During Window but on Study Drug <1% 1% 1% 1% 14.2Clinical Trial Results for Adult Subjects with no Antiretroviral Treatment History and Adults with Renal Impairment for Components of ODEFSEY
The efficacy of RPV, FTC, and TAF in the treatment of HIV-1 infection in adults as initial therapy in those with no antiretroviral treatment history [see Indications and Usage (1)] was established in trials of:
- RPV+FTC/TDF in HIV-1 infected adults as initial therapy in those with no antiretroviral treatment history (n=550). The virologic response rate (i.e., HIV-1 RNA less than 50 copies per mL) was 77% at Week 96. The virologic response rate at 96 weeks was 83% in subjects with baseline HIV-1 RNA less than or equal to 100,000 copies per mL and 71% in subjects with baseline HIV-1 RNA greater than 100,000 copies per mL. Further, the virologic response rate at 96 weeks among subjects with baseline CD4+ cell counts less than 200 and greater than or equal to 200 cells/mm3 were 68% and 82%, respectively.
- FTC+TAF with EVG+COBI in HIV-1 infected adults as initial therapy in those with no antiretroviral treatment history (n=866). The virologic response rate (i.e., HIV-1 RNA less than 50 copies per mL) was 92% at Week 48.
In the clinical trial of 248 HIV-1 infected adults with estimated creatinine clearance greater than 30 mL per minute but less than 70 mL per minute, 95% (235/248) of the combined populations of treatment-naïve (N=6) begun on FTC+TAF with EVG+COBI and those previously virologically-suppressed on other regimens (N=242) and switched to FTC+TAF with EVG +COBI had HIV-1 RNA levels less than 50 copies per mL at Week 24.
14.3Clinical Trial Results for Pediatric Subjects Aged 12 to Less than 18 Years Old with no Antiretroviral Treatment History for Components of ODEFSEY
The efficacy of RPV, FTC, and TAF in the treatment of HIV-1 infection in pediatric patients aged 12 to less than 18 years old and greater than 32–35 kg as initial therapy in those with no antiretroviral treatment history and to replace a stable antiretroviral regimen in those who are virologically-suppressed [see Indications and Usage (1)] was established in trials of antiretroviral treatment-naïve HIV-1 infected pediatric subjects 12 to less than 18 years old with:
- RPV in combination with other antiretroviral agents in 36 treatment-naïve HIV-1 infected adolescents weighing at least 32 kg. The majority of subjects (24/36) received RPV in combination with FTC and TDF. Of these 24 subjects, 20 had a baseline HIV-1 RNA less than or equal to 100,000 copies per mL. The virologic response rate in these 20 subjects (i.e., HIV-1 RNA less than 50 copies per mL) was 80% (16/20) at 48 weeks.
- FTC+TAF with EVG+COBI in 23 adolescents weighing at least 35 kg. The virologic response rate (i.e., HIV-1 RNA less than 50 copies per mL) was 91% at 24 weeks.
16 How Supplied/storage And Handling
ODEFSEY tablets are gray, capsule-shaped, and film coated with "GSI" debossed on one side and "255" on the other side. Each bottle contains 30 tablets (NDC 61958-2101-1), a silica gel desiccant, and a polyester coil, and is closed with a child-resistant closure.
STORAGE AND HANDLING SECTION
Store below 30°C (86°F).
- Keep container tightly closed.
- Dispense only in original container.
17 Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Patient Information).
Post-treatment Acute Exacerbation of Hepatitis B in Patients with HBV Coinfection
Severe acute exacerbations of hepatitis B have been reported in patients who are coinfected with HBV and HIV-1 and have discontinued products containing FTC and/or TDF, and may likewise occur with discontinuation of ODEFSEY [see Warnings and Precautions (5.1)]. Advise the patient to not discontinue ODEFSEY without first informing their healthcare provider.
Severe Skin Reactions and Hypersensitivity
Inform patients that skin reactions ranging from mild to severe, including Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), have been reported with RPV-containing products. Instruct patients to immediately stop taking ODEFSEY and seek medical attention if they develop a rash associated with any of the following symptoms: fever, bulers, mucosal involvement, eye inflammation (conjunctivitis), severe allergic reaction causing swelling of the face, eyes, lips, mouth, tongue or throat which may lead to difficulty swallowing or breathing, and any signs and symptoms of liver problems, as they may be a sign of a more serious reaction. Patients should understand that if severe rash occurs, they will be closely monitored, laboratory tests will be performed and appropriate therapy will be initiated [see Warnings and Precautions (5.2)].
Hepatotoxicity
Inform patients that hepatotoxicity has been reported with RPV, therefore, it is important to inform the healthcare professional if patients have underlying hepatitis B or C or elevations in liver-associated tests prior to treatment [see Dosage and Administration (2.1) and Warnings and Precautions (5.3)].
Depressive Disorders
Inform patients that depressive disorders (depressed mood, depression, dysphoria, major depression, mood altered, negative thoughts, suicide attempt, suicidal ideation) have been reported with RPV. Inform patients to seek immediate medical evaluation if they experience depressive symptoms [see Warnings and Precautions (5.4)].
New Onset or Worsening Renal Impairment
Advise patients to avoid taking ODEFSEY with concurrent or recent use of nephrotoxic agents. Postmarketing cases of renal impairment, including acute renal failure, have been reported [see Warnings and Precautions (5.5)].
Drug Interactions
ODEFSEY may interact with many drugs and is not recommended to be coadministered with numerous drugs. Advise patients to report to their healthcare provider the use of any other prescription or nonprescription medication or herbal products, including St. John's wort [see Contraindications (4), Warnings and Precautions (5.6) and Drug Interactions (7)].
Lactic Acidosis and Severe Hepatomegaly
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with use of drugs similar to ODEFSEY. Advise patients to stop taking ODEFSEY if they develop clinical symptoms suggestive of lactic acidosis or pronounced hepatotoxicity [see Warnings and Precautions (5.7)].
Immune Reconstitution Syndrome
Advise patients to inform their healthcare provider immediately of any symptoms of infection, as in some patients with advanced HIV infection (AIDS), signs and symptoms of inflammation from previous infections may occur soon after anti-HIV treatment is started [see Warnings and Precautions (5.8)].
Missed Dosage
Inform patients that it is important to take ODEFSEY on a regular dosing schedule with a meal and to avoid missing doses, as it can result in development of resistance [see Dosage and Administration (2.2)].
Pregnancy Registry
Inform patients that there is an antiretroviral pregnancy registry to monitor fetal outcomes in those exposed to ODEFSEY during pregnancy [see Use in Specific Populations (8.1)].
Lactation
Instruct patients with HIV-1 infection not to breastfeed because HIV-1 can be passed to the baby in breast milk [see Use in Specific Populations (8.2)].
ODEFSEY is a trademark of Gilead Sciences, Inc., or its related companies. All other trademarks referenced herein are the property of their respective owners.
Spl Patient Package Insert Section
Patient Information ODEFSEY® (oh-DEF-see) (emtricitabine, rilpivirine and tenofovir alafenamide) tablets This Patient Information has been approved by the U.S. Food and Drug Administration Revised: 03/2021 Important: Ask your healthcare provider or pharmacist about medicines that should not be taken with ODEFSEY. For more information, see "What should I tell my healthcare provider before taking ODEFSEY?" What is the most important information I should know about ODEFSEY?ODEFSEY can cause serious side effects, including: For more information about side effects, see "What are the possible side effects of ODEFSEY?"
- Worsening of hepatitis B virus (HBV) infection. Your healthcare provider will test you for HBV infection before or when you start treatment with ODEFSEY. If you have HBV infection and take ODEFSEY, your HBV may get worse (flare-up) if you stop taking ODEFSEY. A "flare-up" is when your HBV infection suddenly returns in a worse way than before.
- Do not run out of ODEFSEY. Refill your prescription or talk to your healthcare provider before your ODEFSEY is all gone.
- Do not stop taking ODEFSEY without first talking to your healthcare provider.
- If you stop taking ODEFSEY, your healthcare provider will need to check your health often and do blood tests regularly for several months to check your liver, and may give you a medicine to treat hepatitis B. Tell your healthcare provider about any new or unusual symptoms you may have after you stop taking ODEFSEY.
What is ODEFSEY? ODEFSEY is a prescription medicine that is used to treat human immunodeficiency virus-1 (HIV-1) infection in adults and children who weigh at least 77 pounds (35 kg): HIV-1 is the virus that causes Acquired Immune Deficiency Syndrome (AIDS). ODEFSEY contains the prescription medicines emtricitabine, rilpivirine and tenofovir alafenamide.It is not known if ODEFSEY is safe and effective in children under 12 years of age or who weigh less than 77 lb (35 kg).
- who have not received HIV-1 medicines in the past and who have an amount of HIV-1 in their blood (this is called "viral load") that is no more than 100,000 copies/mL, or
- to replace their current HIV-1 medicines for people whose healthcare provider determines that they meet certain requirements.
Who should not take ODEFSEY?Do not take ODEFSEY if you also take a medicine that contains:
- carbamazepine
- dexamethasone
- dexlansoprazole
- esomeprazole
- lansoprazole
- omeprazole
- oxcarbazepine
- pantoprazole sodium
- phenobarbital
- phenytoin
- rabeprazole
- rifampin
- rifapentine
- St. John's wort (Hypericum perforatum) or a product that contains St. John's wort
What should I tell my healthcare provider before taking ODEFSEY?Before taking ODEFSEY, tell your healthcare provider about all your medical conditions, including if you: Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some medicines may interact with ODEFSEY. Keep a ul of your medicines and show it to your healthcare provider and pharmacist when you get a new medicine.
- have liver problems, including HBV or hepatitis C virus infection
- have kidney problems
- have a history of depression or suicidal thoughts
- are pregnant or plan to become pregnant. It is not known if ODEFSEY can harm your unborn baby. Tell your healthcare provider if you become pregnant during treatment with ODEFSEY. Pregnancy Registry: There is a pregnancy registry for those who take ODEFSEY during pregnancy. The purpose of this registry is to collect information about the health of you and your baby. Talk with your healthcare provider about how you can take part in this registry.
- are breastfeeding or plan to breastfeed. Do not breastfeed if you take ODEFSEY.
Talk with your healthcare provider about the best way to feed your baby during treatment with ODEFSEY.
- You should not breastfeed if you have HIV-1 because of the risk of passing HIV-1 to your baby.
- At least one of the medicines in ODEFSEY can pass to your baby in your breast milk. It is not known if the other medicines in ODEFSEY can pass into your breast milk.
- You can ask your healthcare provider or pharmacist for a ul of medicines that interact with ODEFSEY.
- Do not start a new medicine without telling your healthcare provider. Your healthcare provider can tell you if it is safe to take ODEFSEY with other medicines.
How should I take ODEFSEY?
- Take ODEFSEY exactly as your healthcare provider tells you to take it. ODEFSEY is taken by itself (not with other HIV-1 medicines) to treat HIV-1 infection.
- Take ODEFSEY 1 time each day with a meal.
- If you are on dialysis, take your daily dose of ODEFSEY following dialysis.
- Do not change your dose or stop taking ODEFSEY without first talking with your healthcare provider. Stay under a healthcare provider's care during treatment with ODEFSEY.
- Do not miss a dose of ODEFSEY.
- When your ODEFSEY supply starts to run low, get more from your healthcare provider or pharmacy. This is very important because the amount of virus in your blood may increase if the medicine is stopped for even a short time. The virus may develop resistance to ODEFSEY and become harder to treat.
- If you take too much ODEFSEY, call your healthcare provider or go to the nearest hospital emergency room right away.
What are the possible side effects of ODEFSEY?ODEFSEY may cause serious side effects, including:
- See "What is the most important information I should know about ODEFSEY?"
- Severe skin rash and allergic reactions. Skin rash is a common side effect of ODEFSEY. Rash can be serious. Call your healthcare provider right away if you get a rash. In some cases, rash and allergic reaction may need to be treated in a hospital. If you get a rash with any of the following symptoms, stop taking ODEFSEY and call your healthcare provider or get medical help right away:
- fever
- skin bulers
- mouth sores
- redness or swelling of the eyes (conjunctivitis)
- swelling of the face, lips, mouth, or throat
- trouble breathing or swallowing
- pain on the right side of the stomach (abdominal) area
- dark "tea colored" urine
The most common side effects of ODEFSEY are headache and problems sleeping. These are not all the possible side effects of ODEFSEY. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
- Change in liver enzymes. People with a history of hepatitis B or C virus infection or who have certain liver enzyme changes may have an increased risk of developing new or worsening liver problems during treatment with ODEFSEY. Liver problems can also happen during treatment with ODEFSEY in people without a history of liver disease. Your healthcare provider may need to do tests to check your liver enzymes before and during treatment with ODEFSEY.
- Depression or mood changes. Tell your healthcare provider right away if you have any of the following symptoms:
- feel sad or hopeless
- feel anxious or restless
- have thoughts of hurting yourself (suicide) or have tried to hurt yourself
- New or worse kidney problems, including kidney failure. Your healthcare provider should do blood and urine tests to check your kidneys before you start and during treatment with ODEFSEY. Your healthcare provider may tell you to stop taking ODEFSEY if you develop new or worse kidney problems.
- Too much lactic acid in your blood (lactic acidosis). Too much lactic acid is a serious but rare medical emergency that can lead to death. Tell your healthcare provider right away if you get these symptoms: weakness or being more tired than usual, unusual muscle pain, being short of breath or fast breathing, stomach pain with nausea and vomiting, cold or blue hands and feet, feel dizzy or lightheaded, or a fast or abnormal heartbeat.
- Severe liver problems. In rare cases, severe liver problems can happen that can lead to death. Tell your healthcare provider right away if you get these symptoms: skin or the white part of your eyes turns yellow, dark "tea-colored" urine, light-colored stools, loss of appetite for several days or longer, nausea, or stomach-area pain.
- Changes in your immune system (Immune Reconstitution Syndrome) can happen when you start taking HIV-1 medicines. Your immune system may get stronger and begin to fight infections that have been hidden in your body for a long time. Tell your healthcare provider right away if you start having any new symptoms after starting your HIV-1 medicine.
How should I store ODEFSEY? Keep ODEFSEY and all medicines out of reach of children.
- Store ODEFSEY below 86°F (30°C).
- Keep ODEFSEY in its original container.
- Keep the container tightly closed.
General information about the safe and effective use of ODEFSEY. Medicines are sometimes prescribed for purposes other than those uled in a Patient Information leaflet. Do not use ODEFSEY for a condition for which it was not prescribed. Do not give ODEFSEY to other people, even if they have the same symptoms you have. It may harm them. You can ask your healthcare provider or pharmacist for information about ODEFSEY that is written for health professionals. What are the ingredients in ODEFSEY? Active ingredients: emtricitabine, rilpivirine, and tenofovir alafenamide. Inactive ingredients: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polysorbate 20, and povidone. The tablet film coating contains iron oxide black, polyethylene glycol, polyvinyl alcohol, talc, and titanium dioxide.Manufactured and distributed by: Gilead Sciences, Inc. Foster City, CA 94404ODEFSEY is a trademark of Gilead Sciences, Inc., or its related companies.© 2021 Gilead Sciences, Inc. All rights reserved. 208351-GS-006 For more information, call 1-800-445-3235 or go to www.ODEFSEY.com.
Principal Display Panel - 30 Tablet Bottle Label
NDC 61958- 2101-1 30 tablets
Odefsey ® (emtricitabine, rilpivirine, and tenofovir alafenamide) Tablets 200 mg/25 mg/25 mg
Note to pharmacist: Do not cover ALERT box with pharmacy label.
ALERT: Find out about medicines that should NOT be taken with Odefsey ®
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