cabotegravir/rilpivirine

Cabotegravir

Absorption: Increased with high-fat meals.

Distribution: Distributed to extravascular tissues.

Protein Binding: >99%.

Metabolism/Excretion: Primarily metabolized by the uridine diphosphate glucuronosyltransferase (UGT) 1A1 enzyme system, with some involvement of UGT1A9. Primarily excreted in feces as unchanged drug (47%), with 27% excreted in urine as metabolites.

Half-Life: 41 hr.

Rilpivirine

Absorption: Well absorbed following oral administration.

Distribution: Unknown.

Protein Binding: 99.7%.

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

Half-Life: 50 hr

Time/Action Profile ⬆ ⬇

(plasma concentrations)

ROUTE	ONSET	PEAK	DURATION
cabotegravir IM	unknown	7 days	unknown
rilpivirine IM	unknown	3–4 days	unknown

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity to cabotegravir or rilpivirine;
Concurrent use of carbamazepine, dexamethasone (more than a single dose), oxcarbazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine, or St. John's wort;
OB: Pregnancy;
Lactation: Breastfeeding not recommended in patients with HIV.

Use Cautiously in:

History of depression or suicide attempt;
Hepatic impairment;
Severe renal impairment or end-stage renal disease;
Pedi: Children <12 yr (safety and effectiveness not established);
Geri: Use with caution in older adults, considering concurrent disease states, drug therapy, and age-related ↓ in hepatic and renal function.

Adv. Reactions/Side Effects ⬆ ⬇

CV: QT interval prolongation

Derm: DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), rash, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS

GI: ↑lipase, HEPATOTOXICITY, nausea

Local: injection site reactions

Metab: weight gain

MS: ↑CK, pain

Neuro: depression, dizziness, fatigue, headache, insomnia, mood disturbances, somnolence, SUICIDAL THOUGHTS/BEHAVIORS

Misc: fever, HYPERSENSITIVITY REACTIONS (INCLUDING ANGIOEDEMA)

Interactions ⬆ ⬇

Drug-drug:

Strong UGT1A1 inducers or CYP3A inducers, including carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifabutin, rifampin, or rifapentine, may significantly ↓ cabotegravir and rilpivirine levels and effectiveness; concurrent use contraindicated.
Use of more than a single dose of dexamethasone may significantly ↓ rilpivirine levels and effectiveness; concurrent use contraindicated.
Macrolide antibiotics, including azithromycin, clarithromycin, and erythromycin, may ↑ rilpivirine levels and risk of toxicity, including QT interval prolongation; use alternative antibiotic therapy.
QT interval prolonging drugs may ↑ risk of QT interval prolongation and torsades de pointes.
May ↓ levels and effectiveness of methadone.

Drug-Natural Products:

St. John's wort may significantly ↓ rilpivirine levels and effectiveness; concurrent use contraindicated.

Route/Dosage ⬆ ⬇

Lead-in therapy with oral cabotegravir and oral rilpivirine must be used for ≥28 days to assess tolerability to both cabotegravir and rilpivirine prior to initiating cabotegravir/rilpivirine extended-release injection therapy.

Monthly Dosing

IM (Adults and Children ≥12 yr and ≥35 kg): Initiation injections: Cabotegravir 600 mg as a single injection and rilpivirine 900 mg as a single injection, both administered on the final day of lead-in therapy with oral cabotegravir and oral rilpivirine. Continuation injections: Cabotegravir 400-mg injection and rilpvirine 600-mg injection once monthly (administer both injections during same visit). Start continuation injections 1 mo following initiation injections. Monthly injections may be given within 7 days of originally scheduled date of injection. Switching to every-2-mo injection dosing: Administer cabotegravir 600-mg injection and rilpivirine 900-mg injection 1 mo after the last monthly continuation injection and then every 2 mo thereafter. Planned missed injections: If patient plans to miss a scheduled injection visit by >7 days, give oral cabotegravir 30 mg once daily and oral rilpivirine 25 mg once daily initiated at the same time as missed injection of cabotegravir/rilpivirine and then continue until day the cabotegravir/rilpivirine extended-release injection is restarted (oral replacement therapy can be continued for up to 2 mo). If time since last injection ≤2 mo, resume injection with cabotegravir 400-mg injection and rilpivirine 600-mg injection once monthly. If time since last injection >2 mo, resume injection with initiation of cabotegravir 600-mg single injection and rilpivirine 900-mg single injection followed in 1 mo by continuation injections of cabotegravir 400-mg injection and rilpivirine 600-mg injection once monthly (start continuation injections 1 mo following initiation injections). Unplanned missed injections: If monthly injections are missed or delayed by >7 days and oral cabotegravir and oral rilpivirine therapy have not been taken in the interim, reassess patient to determine if resumption of injection dosing remains appropriate.

Every-2-Month Dosing

IM (Adults and Children ≥12 yr and ≥35 kg): Initiation injections: Cabotegravir 600-mg injection and rilpivirine 900-mg injection once monthly for 2 consecutive mo, with the 1st set of injections being administered on the final day of lead-in therapy with oral cabotegravir and oral rilpivirine. 2nd initiation injection may be given within 7 days of originally scheduled date of injection. Continuation injections: Cabotegravir 600-mg injection and rilpvirine 900-mg injection every 2 mo (administer both injections during same visit). Start continuation injections 2 mo following 2nd initiation injection. Every-2-mo injections may be given within 7 days of originally scheduled date of injection. Switching to monthly injection dosing: Administer cabotegravir 400-mg injection and rilpivirine 600-mg injection 2 mo after the last monthly continuation injection and then once monthly thereafter. Planned missed injections: If patient plans to miss a scheduled injection visit by >7 days, give oral cabotegravir 30 mg once daily and oral rilpivirine 25 mg once daily initiated at the same time as missed injection of cabotegravir/rilpivirine and then continue until day the cabotegravir/rilpivirine extended-release injection is restarted (oral replacement therapy can be continued for up to 2 mo). If time since 2nd initiation injection ≤2 mo, resume initiation injection with cabotegravir 600-mg injection and rilpivirine 900-mg injection, followed by continuation injections every 2 mo (starting 2 mo following 2nd initiation injection). If time since 2nd initiation injection >2 mo, restart the two initiation injections (see above) given once monthly for 2 consecutive mo, followed by the continuation injections (see above) given every 2 mo. If patient misses a continuation injection by ≤3 mo, resume injection with cabotegravir 600-mg injection and rilpivirine 900-mg injection every 2 mo. If time since last injection >3 mo, restart the two initiation injections (see above) given once monthly for 2 consecutive mo followed by the continuation injections (see above) given every 2 mo. Unplanned missed injections: If monthly injections are missed or delayed by >7 days and oral cabotegravir and oral rilpivirine therapy have not been taken in the interim, reassess patient to determine if resumption of injection dosing remains appropriate.

Availability ⬆ ⬇

Extended-release suspension for injection: 400-mg/600-mg kit (200 mg/mL vial of cabotegravir and 300 mg/mL vial of rilpivirine); 600-mg/900-mg kit (200 mg/mL vial of cabotegravir and 300 mg/mL vial of rilpivirine)

Assessment ⬆ ⬇

Assess patient for change in severity of HIV symptoms and for symptoms of opportunistic infections during therapy.
Observe patient for 10 min following injections for postinjection reactions (dyspnea, agitation, abdominal cramping, flushing, sweating, oral numbness, changes in BP).
Monitor mental status, mood changes, and affect. Monitor for anxiety, depression (especially in patients with a history of psychiatric illness), suicidal ideation, and paranoia during therapy.
Monitor for development of severe cutaneous adverse reactions, (DRESS, SJS, TEN), including signs and symptoms of prodrome of fever, malaise, mucosal lesions, progressive skin rash, blisters, lymphadenopathy, conjunctivitis, myalgias, hepatitis, and/or eosinophilia. If a severe cutaneous adverse reaction is suspected, interrupt therapy until etiology of reaction is determined. Consultation with a dermatologist is recommended. If a severe cutaneous adverse reaction is confirmed, permanently discontinue cabotegravir/rilpivirine.
Monitor for signs and symptoms of hypersensitivity reactions (rash, urticaria, pruritus, flushing, dizziness, vomiting, abdominal pain) and angioedema (swelling of throat, lips, tongue, or face; dyspnea; wheezing; hoarseness). If hypersensitivity reaction occurs, immediately discontinue cabotegravir/rilpivirine and provide supportive care.
Monitor for signs and symptoms of hepatotoxicity (fatigue, nausea, upper abdominal pain, jaundice, scleral icterus, dark urine, clay-colored stools). If hepatotoxicity suspected, discontinue cabotegravir/rilpivirine.

Lab Test Considerations:

Monitor liver function tests periodically during therapy.

Implementation ⬆ ⬇

Lead-in therapy with oral cabotegravir and oral rilpivirine must be used for ≥28 days to assess tolerability to both cabotegravir and rilpivirine prior to initiating cabotegravir/rilpivirine extended-release injection therapy. Start injections of cabotegravir/rilpivirine on last day of PO lead-in therapy.
Injection must be administered by health care provider.
IM: Administer cabotegravir and rilpivirine at separate gluteal (preferably ventrogluteal) injection sites (on opposite sides or 2 cm apart) during the same visit. Use needles long enough for IM injection. Allow suspensions to come to room temperature for 15 min before administration. Stable at room temperature for up to 6 hr. Shake suspensions vigorously to mix. Do not administer solutions that contain particulate matter. Administer within 2 hr of drawing into syringe; if >2 hr, discard injection. Do not refrigerate syringes. Start continuation injections 1 mo after the initiation injections. Injections may be given 7 days before or after the date to receive the injection.

Patient/Family Teaching ⬆ ⬇

Explain the purpose and side effects of cabotegravir/rilpivirine. Instruct patient in the importance of adhering to monthly schedule of injections. Planned Missed Injections: If a scheduled injection visit by >7 days, take daily PO therapy to replace up to 2 consecutive monthly injection visits. Take 1st dose of PO therapy approximately 1 mo after the last injection dose and continue until the day injection dosing is restarted. Unplanned Missed Injections: If monthly injections are missed or delayed by >7 days and PO therapy has not been taken in the interim, health care provider will reassess patient to determine if resumption of injection dosing remains appropriate. Instruct patient to read Patient Information before starting cabotegravir/rilpivirine therapy and with each injection in case of changes.
Counsel patients that adherence to scheduled dosing visits helps maintain viral suppression and ↓ risk of viral rebound and potential development of resistance with missed doses.
Advise patient to notify health care provider if signs and symptoms of allergic reaction (fever; generally ill feeling; tiredness; muscle or joint aches; trouble breathing; blisters or sores in mouth; blisters; redness or swelling of eyes; swelling of mouth, face, lips, or tongue), postinjection reactions (trouble breathing, stomach cramps, sweating, numbness of mouth, feeling anxious, feeling warm, feeling light-headed or faint, blood pressure changes), liver problems (yellow skin or white part of eyes; dark or tea-colored urine; light-colored stools; nausea or vomiting; loss of appetite; pain, aching, or tenderness on the right side of stomach area; itching), or depression (feeling sad or hopeless, feeling anxious or restless, have thoughts of hurting yourself [suicide], or have tried to hurt yourself) occur.
Encourage consistent and correct condom use; communication of HIV-1 status to partner(s); knowledge of partner(s)’ HIV-1 status, including viral suppression status; and regular testing for sexually transmitted infections that can facilitate HIV-1 transmission.
Instruct patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care provider before taking any new medications, especially St. John's wort.
Rep: May cause fetal harm. Advise women of reproductive potential to use effective contraception during therapy and to avoid breastfeeding. Cabotegravir is detected in systemic circulation for ≥12 mo after discontinuing cabotegravir/rilpivirine. Inform patient of pregnancy exposure registry that monitors pregnancy outcomes in women exposed to cabotegravir. Register patients by calling the Antiretroviral Pregnancy Registry at 1-800-258-4263.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇