December 1, 2011
The release of co-formulated Atripla was a major milestone for the treatment of HIV infection. Not only was the combination of ART that is included in the tablet unsurpassed in efficacy, but the psychological impact of being able to treat this infection with one pill a day was substantially positive for patients.
Since then, other potent, once-a-day regimens have come on the scene. However, none are one pill, one bottle and one copay. Enter the fixed-dose combination of Complera (rilpivirine/tenofovir/FTC), released this year. Edurant (rilpivirine) is a new NNRTI that cut its teeth in the ECHO and THRIVE trials of treatment-naive patients. Originally available as a standalone ART, the co-formulation with Viread and Emtriva provides another one-pill-a-day option for patients.
Co-formulation improves adherence and reduces costs for those with insurance copays. The new, fixed-dose formulation was intended to be a new-and-improved version of the first one-pill-a-day, Sustiva-containing tablet. However, the ECHO trial comparing Edurant with Sustiva found higher rates of virologic failure among Edurant-assigned patients with a baseline viral load greater than 100,000 copies/mL. Further, among those failing Edurant, there was a significant risk for the development of resistance mutations that precluded the use of the second-generation non-nuke, Intelence (etravirine, TMC125).
Therefore, although better tolerated than Sustiva and able to be taken during the day, rather than before bed, Edurant will continue to play second fiddle to its older classmate. Still, for some patients, such as those with lower viral loads, who like to eat and are not on a proton pump inhibitor, this is a fine option.
Other one-pill-a-day ART regimens are in the offing and we should not take for granted how far we have come in providing HIV therapy that marries potency with convenience. If the advent of single-pill ART has not adjusted clinicians' thinking of HIV as a deadly foe, it certainly has helped many patients to accept that their infection is manageable and something they can live with.
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