RIL-pi-vir-een

Therapeutic Classification: antiretrovirals

Pharmacologic Classification: non nucleoside reverse transcriptase inhibitors

• Treatment-nave patients with HIV infection with HIV-1 RNA 100,000 copies/mL at start of therapy.
• Short-term treatment of HIV infection in patients with an HIV-1 RNA <50 copies/mL who are on a stable antiretroviral regimen with no history of treatment failure and with no known or suspected resistance to either cabotegravir or rilpivirine (in combination with cabotegravir) (to be used as either oral lead-in to assess the tolerability of rilpivirine prior to administration of cabotegravir/rilpivirine extended-release injection or oral therapy for patients who will miss planned injection dosing with cabotegravir/rilpivirine extended-release injection).

• Inhibits HIV-replication by non-competitively inhibiting HIV reverse transcriptase.

• Slowed progression of HIV infection and decreased occurrence of sequelae. Increases CD4 cell counts and decreases viral load.

Absorption: Well absorbed following oral administration.

Distribution: Unknown.

Protein Binding: 99.7%.

Metabolism/Excretion: Mostly metabolized by the liver by the CYP3A isoenzyme; 25% excreted in feces unchanged, <1% excreted unchanged in urine.

Half-life: 50 hr.

(plasma concentrations)

Contraindicated in:

• Concurrent use of CYP3A inducers or proton pump inhibitors
• Lactation: Breastfeeding not recommended in patients with HIV.

Use Cautiously in:

• Concurrent use of drugs that ↑ risk of torsades de pointes (may ↑ risk of arrhythmias)
• History of depression or suicide attempt
• Hepatitis B or C
• Pedi: Children <12 yr (safety and effectiveness not established).

Derm: DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), rash.

Endo: Grave's disease.

GI: autoimmune hepatitis, hepatotoxicity.

MS: polymyositis.

Neuro: depression (↑ in children), dizziness, Guillain-Barré syndrome, headache, insomnia.
Misc: immune reconstitution syndrome.

Drug-Drug:

• CYP3A inducers, including carbamazepine, dexamethasone (more than a single dose), oxcarbazepine, phenobarbital, phenytoin, rifampin, or rifapentine, ↓ levels and effectiveness and promote virologic resistance; concurrent use contraindicated.
• Proton pump inhibitors, including esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole, ↓ levels and effectiveness and may ↑ resistance; concurrent use contraindicated.
• Concurrent use with antacids may ↓ levels and effectiveness; use with caution, administer at least 2 hr before or 4 hr after rilpivirine.
• Concurrent use with H₂ antagonists may ↓ levels and effectiveness; use with caution, administer at least 12 hr before or 4 hr after rilpivirine.
• Rifabutin may ↓ levels; ↑ rilpivirine dose to 50 mg once daily during concurrent use
• Efavirenz, etravirine, and nevirapine may ↓ levels; avoid concurrent use
• Darunavir/ritonavir, lopinavir/ritonavir, atazanavir/ritonavir, fosamprenavir/ritonavir, tipranavir/ritonavir, atazanavir, fosamprenavir, and nelfinavir may ↑ levels
• Clarithromyin or erythromycin may ↑ levels; consider using azithromycin.
• Fluconazole, itraconazole, ketoconazole, posaconazole, and voriconazole may ↑ levels; rilpivirine may ↓ ketoconazole levels
• Concurrent use with QT interval-prolonging drugs may ↑ risk of serious arrhythmias.
• May ↓ levels of methadone; monitor clinical effects.

Drug-Natural Products:

• Concurrent use of St. John's wort↓ blood levels and effectiveness and promote virologic resistance; concurrent use contraindicated.

Treatment-Nave Patients With HIV Infection

• PO (Adults and Children 12 yr and 35 kg): 25 mg once daily; Pregnant patients on stable rilpivirine regimen prior to pregnancy and virologically suppressed (HIV RNA <50 copies/mL): 25 mg once daily; Concurrent rifabutin therapy: 50 mg once daily (↓ dose to 25 mg once daily when rifabutin discontinued).

Combination Therapy With Cabotegravir for HIV Infection

• PO (Adults and Children 12 yr and 35 kg): Oral lead-in therapy to assess tolerability of rilpivirine: 25 mg once daily (with oral cabotegravir 30 mg once daily) for 28 days, then switch to cabotegravir/rilpivirine extended-release injection. To replace planned missed cabotegravir/rilpivirine extended-release injections for patients on monthly dosing schedule (if patient plans to miss scheduled monthly injection by >7 days): 25 mg once daily (with oral cabotegravir 30 mg once daily) initiated at the same time as missed injection of cabotegravir/rilpivirine and then continued until day the cabotegravir/rilpivirine extended-release injection is restarted (oral replacement therapy can be continued for up to 2 mo). To replace planned missed cabotegravir/rilpivirine extended-release injections for patients on every 2-mo dosing schedule (if patient plans to miss scheduled every 2-mo injection by >7 days): 25 mg once daily (with oral cabotegravir 30 mg once daily) initiated the same time as missed injection of cabotegravir/rilpivirine and then continued until day the cabotegravir/rilpivirine extended-release injection is restarted (oral replacement therapy can be continued for up to 2 mo).

• Tablets: 25 mg;
• In combination with: cabotegravir (Cabenuva); dolutegravir (Juluca); emtricitabine and tenofovir alafenamide (Odefsey); emtricitabine and tenofovir disoproxil fumarate (Complera). See Appendix [not included in this PDA edition].

• Assess for change in severity of HIV symptoms and for symptoms of opportunistic infections during therapy.
• Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.
• Assess for rash periodically during therapy. May cause DRESS. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis, and/or eosinophilia.

• Monitor viral load and CD4 cell count regularly during therapy.
  • Monitor liver function tests before and periodically during therapy in patients with underlying liver disease, hepatitis B or C, or marked ↑ transaminase. May cause ↑ serum creatinine, AST, ALT, total bilirubin, total cholesterol, LDL, and triglycerides.

• PO: Administer once daily with a meal.
  • When administered with cabotegravir, administer rilpivirine with cabotegravir once daily at same time with a meal. Take last PO dose on same day as cabotegravir injection is started. If patient plans to miss a scheduled cabotegravir injection by >7 days, take daily PO therapy to replace up to 2 consecutive monthly injection visits. Take 1st PO dose 1 mo after last injection.

• Emphasize the importance of taking rilpivirine as directed, at the same time each day. It must always be used in combination with other antiretroviral drugs. Do not take more than prescribed amount and do not stop taking without consulting health care professional. Take missed doses with a meal if remembered <12 hr of the time it is usually taken, then return to regular schedule. If more than 12 hr from time dose is usually taken, omit dose and resume dosing schedule; do not double doses. Advise patient to read Patient Information prior to starting therapy and with each Rx refill in case of changes.
• Advise patient to take antacids 2 hr before or 4 hr after and H₂ antagonists 12 hr before or 4 hr after rilpivirine.
• Instruct patient that rilpivirine should not be shared with others.
• Inform patient that rilpivirine does not cure AIDS or prevent associated or opportunistic infections. Rilpivirine may reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom and to avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. Advise patient that the long-term effects of rilpivirine are unknown at this time.
• Inform patients and families of risk of suicidal thoughts and behavior and advise that behavioral changes, emergency or worsening signs and symptoms of depression, unusual changes in mood, or emergence of suicidal thoughts, behavior, or thoughts of self-harm should be reported to health care professional immediately.
• Immune reconstitution syndrome may trigger opportunistic infections or autoimmune disorders. Notify health care professional if symptoms or rash occur.
• May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
• Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially St. John's wort.
• Advise patient taking oral contraceptives to use a nonhormonal method of birth control during rilpivirine therapy. If pregnancy is suspected notify health care professional promptly. Encourage health care professionals to enroll pregnant women in the Antiretroviral Pregnancy Registry by calling 1-800-258-4263. Advise female patient to avoid breastfeeding.
• Emphasize the importance of regular follow-up exams and blood counts to determine progress and monitor for side effects.

• Delayed progression of AIDS and decreased opportunistic infections in patients with HIV.
• Decrease in viral load and increase in CD4 cell counts.

Edurant