Atripla (NRTIs)

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Atripla (efavirenz + tenofovir + emtricitabine)

Pronunciation(s): uh-TRIP-luh; eh-FAH-vih-renz; te-NOE-fo-veer; em-tri-SIT-uh-bean



What is Atripla?
  • Atripla is an HIV medication. It contains two different types of HIV drugs: one non-nucleoside reverse transcriptase inhibitor (NNRTI) and two nucleoside reverse transcriptase inhibitors (NRTIs).
     
  • Atripla is marketed by two companies: Bristol-Myers Squibb and Gilead Sciences. It was approved by the U.S. Food and Drug Administration (FDA) in July 2006.
     
  • Atripla is a combination of three drugs: 600 mg of Sustiva (efavirenz), 300mg of Viread (tenofovir DF) and 200mg of Emtriva (emtricitabine). Atripla should be prescribed by a healthcare provider for patients who need all three of these drugs. All three drugs can still be purchased individually for use in combination with other HIV drugs.
     
  • Atripla is considered to be a complete one-pill, once-daily HIV treatment regimen. Atripla can be used alone or with other antiretrovirals if needed.
     
  • Both the Viread and the Emtriva in Atripla are active against the hepatitis B virus (HBV), the virus responsible for causing hepatitis B. See What about side effects? below for more important information regarding Viread, Emtriva, and hepatitis B.
     
  • Bristol-Myers Squibb and Gilead have established a patient assistance program (PAP) for people living with HIV who do not have private or public health insurance and are unable to afford Atripla. To learn more about the PAP for Atripla, call BMS (888-477-2669) or Gilead (800-226-2056). For those with private health insurance, BMS and Gilead have established a program to help cover up to $200 toward each monthly Atripla co-payment. To learn more about this co-pay program, call 866-784-3431.

What is known about Atripla?
  • Atripla is a tablet taken once a day. It should be taken without food, preferably at bedtime.
     
  • Atripla should not be any more or less effective than Sustiva, Viread, and Emtriva taken as separate pills together. However, it is considered to be a much more convenient way of taking these three HIV drugs.
     
  • For HIV-positive adults beginning HIV drug therapy for the first time, the three drugs in Atripla are listed as "preferred" options by the United States Department of Health and Human Services in its HIV treatment guidelines. To learn more about these recommendations, click here.
     
  • See the "What is known about..." sections of Sustiva, Viread and Emtriva for information about possible drug resistance.

What about drug interactions?
  • Atripla can lower or raise the levels of other medications in the body. Similarly, other medications can lower or raise the levels of Atripla in the body. While many interactions are not a problem, some can cause your medications to be less effective or increase the risk of side effects.
     
  • Tell your doctors and pharmacists about all medicines you take. This includes those you buy over-the-counter and herbal or natural remedies, such as St. John's Wort. Bring all your medicines when you see a doctor, or make a list of their names, how much you take, and how often you take them. Your doctor can then tell you if you need to change the dosages of any of your medications.
     
  • The following medications should not be taken while you are being treated with Atripla:
    Antifungals: Vfend (voriconazole)
    Antipsychotics: Orap (pimozide)
    Acid reflux/heartburn medications: Propulsid (cisapride)
    Heart medications: Vascor (bepridil)
    Sedatives: Versed (midazolam) and Halcion (triazolam)
    Antimigraine medications: Wigraine and Cafergot (ergot medications).
    Herbal products: St. John's wort (or products containing St. John's wort.
     
  • Atripla should not be taken at the same time as Sustiva, Emtriva, Viread, Hepsera, Truvada (tenofovir plus emtricitabine), Epivir (lamivudine) or other combination tablets that contain Epivir (for example, Epzicom, Combivir or Trizivir). This is because these medications contain the same or similar active ingredients as Atripla.
     
  • The Sustiva in Atripla can reduce the amount of various protease inhibitors in the bloodstream, including Reyataz (atazanavir), Invirase (saquinavir), Crixivan (indinavir), Kaletra (lopinavir/ritonavir), Agenerase and Lexiva (fosamprenavir). Atripla can increase the amount of Norvir (ritonavir) in the bloodstream. The Viread in Atripla can also decrease Reyataz levels in the bloodstream. Kaletra and Reyataz can also increase Viread levels in the bloodstream.

    Invirase may need to be replaced with another HIV medication when taken with Atripla. Atripla should not be combined with Reyataz. If Atripla is taken with Kaletra, Crixivan, or Lexiva, their doses may need to be increased or they may need to be combined with a low dose of Norvir (e.g., 100 mg) to help maintain necessary drug levels in the bloodstream. If Kaletra and Atripla are used together, it is important to watch out for potential side effects of Viread (e.g., kidney problems).
     
  • Because of significant drug interactions between the Viread in Atripla and Videx EC (didanosine), many experts recommend avoiding the use of Videx EC in drug regimens that include Viread.
     
  • The Sustiva in Atripla can interact with some medications used to treat TB, MAC and other bacterial infections. Rifadin (rifampin) can decrease Sustiva levels. Atripla can decrease Mycobutin (rifabutin) levels. Your health care provider may change the dose of these medications. Atripla can also decrease Biaxin (clarithromycin) levels; an alternative to clarithromycin should be considered.
     
  • The Sustiva in Atripla can interact with some medications used to treat various fungal infections, including candidiasis and cryptococcal meningitis. If Vfend (voriconazole) must be used, the Sustiva dose must be reduced to 300 mg once daily. This requires stopping Atripla and starting the capsule formulation of Sustiva (one 200 mg and two 50 mg Sustiva capsules once a day) plus Truvada (tenofovir plus emtricitabine). The Vfend dose should also be increased to 400 mg every 12 hours.

    The Sustiva in Atripla can also decrease levels of Sporanox (itraconazole); it is recommended that a Sporanox alternative be used instead. Nizoral (ketoconazole) levels can decrease as well; no dosing recommendations have been made.
     
  • The Sustiva in Atripla can decrease blood levels of calcium channel blockers (used to control blood pressure, regulate heartbeats, and manage chest pain). Examples include Cardizem (diltiazem), Plendil (felodipine), Cardene (nicardipine), Procardia (nifedipine), Calan (verapamil). These medications may need to have their doses changed when taken with Atripla.
     
  • Other medications, such as Zoloft (sertraline) and cholesterol-lowering medicines such as Lipitor (atorvastatin), Pravachol (pravastatin) and Zocor (simvastatin), may need to have their doses changed when taken with Atripla.
     
  • Your health care provider may want to switch you to another medication or check drug levels in your blood from time to time if you are taking medications for seizures [for example, Dilantin (phenytoin), Tegretol (carbamazepine) or phenobarbital].
     
  • The Sustiva in Atripla can interact with oral contraceptives/birth control pills (ethinyl estradiol). Atripla increases the amount of ethinyl estradiol in the bloodstream. Women should use a reliable form of barrier contraception, such as a condom or diaphragm, even if they also use other methods of birth control.
     
  • If you take methadone, Atripla can decrease the amount of it in your blood. This might cause you to experience withdrawal symptoms and may require that your doctor or your rehabilitation program increase your dose of methadone.

What about side effects?
  • Many patients have dizziness, headache, trouble sleeping, drowsiness, trouble concentrating, and/or unusual dreams after starting treatment with Atripla. These feeling may be less noticeable if you take Atripla at bedtime on an empty stomach. They also tend to go away after you've taken the medicine for a few weeks. If you have these side effects, such as dizziness, it does not mean that you will also have severe depression, strange thoughts or angry behavior. Tell your doctor promptly if any of these side effects continue or if they bother you. There is the possibility that these symptoms may be more severe if Atripla is used with alcohol or mood-altering (street) drugs. You should also avoid driving or operating machinery if you are having these side effects. Check out our lesson on Tips & Tricks on Taking Sustiva to learn more.
     
  • A small number of patients have had severe depression, strange thoughts, or angry behavior while taking Sustiva, one of the drugs in Atripla. Some patients have had thoughts of suicide and a few patients have actually committed suicide. These problems tend to occur more often in patients with a history of mental illness. You should contact your doctor immediately if you think you are having these symptoms, so your doctor can decide whether you should continue to take Sustiva.
     
  • Lactic acidosis, which can be fatal, and severe liver problems have been reported in people taking nucleoside reverse transcriptase inhibitors (NRTIs). Contact your doctor immediately if you experience nausea, vomiting, or unusual or unexpected stomach discomfort; weakness and tiredness; shortness of breath; weakness in the arms and legs; yellowing of the skin or eyes; or pain in the upper stomach area.
     
  • Rash is another common side effect of Atripla. These rashes usually go away without any change in treatment. In a small number of patients, rash may be serious. If you develop rash, call your doctor as soon as possible.
     
  • The Viread in Atripla may cause bone problems. In one clinical trial conducted by the manufacturer involving HIV-positive patients who were new to HIV therapy, Viread [combined with Sustiva and Epivir] caused decreases bone mineral density (osteopenia) at the hip and spine. Researchers are currently looking into the seriousness of this possible side effect. If you have a history of bone fracture or are at risk for osteopenia, your doctor may want to consider ordering bone scans on a regular basis while you are taking Atripla. While it's not clear if calcium and vitamin D supplementation can help this side effect, it might be beneficial if you are taking Atripla.
     
  • Atripla can be problematic for HIV-positive people who have a history of kidney problems (renal impairment). If you have a history of kidney problems, your doctor will need to order a simple laboratory test to calculate your "creatinine clearance," which is a measure of your kidney function. Depending on the results of this test, you may not be able to take Atripla. It is always important to be careful if using Atripla in combination with drugs that cause kidney problems or other drugs that are removed from the body by the kidneys.
     
  • HIV drug regimens containing Sustiva, Viread, and Emtriva can cause increased fat levels (cholesterol and triglycerides) in the blood, abnormal body-shape changes (lipodystrophy; including increased fat around the abdomen, breasts, and back of the neck, as well as decreased fat in the face, arms, and legs). These side effects of HIV drug therapy are reviewed in our lessons on Lipodystrophy, Facial Lipoatrophy, and Risks To Your Heart (Hyperlipidemia).
     
  • If you have hepatitis B and HIV and plan to stop taking Atripla, you need close medical follow-up and for several months your doctor might want to frequently check your liver enzymes after stopping treatment. This is because the Viread and Emtriva in Atripla are also active against the hepatitis B virus (HBV). If Atripla is stopped abruptly, it can cause liver disease to "flare" and damage the liver.
     
  • The Sustiva in Atripla can cause someone to test positive for marijuana as a result of testing for elicit drug use. If you are asked to submit urine for a drug test, you may want to tell the person collecting the sample that you take Atripla. This way, the laboratory conducting the test will know to use a more sensitive test to prevent false-positive results.
     
  • See the "What about side effects?" sections of Sustiva, Viread and Emtriva for additional possible side effects.

Can pregnant women take Atripla?
  • Because Atripla contains Sustiva, it is classified by the FDA as a pregnancy category D drug. Women should not become pregnant while taking Atripla and for 12 weeks after stopping it. Serious birth defects have been seen in babies or animal and women treated with Sustiva during pregnancy. It is not known whether Sustiva caused these defects. Tell your health care provider right away if you are pregnant. Also talk with your health care provider if you want to become pregnant.

    Women should not rely on hormone-based birth control, such as pills, injections, or implants, because Atripla may make these contraceptives ineffective. Women must use a reliable form of barrier contraception, such as condom or diaphragm, even if they also use other methods of birth control. Sustiva may remain in your blood for a time after treatment is stopped. Therefore, you should continue to use contraceptive measures for 12 weeks after you stop taking Atripla.
     
  • It is not known whether the three drugs in Atripla pass into breast milk and what effect they may have on a nursing baby. To prevent transmission of the virus to uninfected babies, it is recommended that HIV-positive mothers not breast-feed.

Who should not take Atripla?
  • Before taking this medication, tell your doctor if you have: kidney disease; liver disease (including hepatitis B); or bone problems. In addition, tell your doctor if you are pregnant or planning to become pregnant; if you are breast feeding, and all your medical conditions, including if you have ever had mental illness or are using drugs or alcohol, if you have ever had seizures or are taking medications for seizures.

Where can I learn more about clinical trials involving Atripla?
  • If you would like to find out if you are eligible for any clinical trials that include Atripla, visit ClinicalTrials.gov, a site run by the U.S. National Institutes of Health. The site has information about all HIV-related clinical studies in the United States. For more info, you can call their toll-free number at 1-800-HIV-0440 (1-800-448-0440) or email contactus@aidsinfo.nih.gov.

Last Revised: December 17, 2008

This content is written by the POZ and AIDSmeds editorial team. For more information, please visit our "About Us" page.


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