My doctor warned me against Stribild, but I still want to take it...

[survivor703]

Hi gang,

So I went to the doctor yesterday to discuss starting the stribild regimen. He was slightly hesitant to prescribe the stribild for three reasons.

1. It contains an agent that amplifies other drugs. So lets say I take a nasal spray for congestion regularly, I might develop diabetes due to exposure to higher than normal concentrations of steroids. This goes for pretty much any other drug, antibiotic or whatever. I could be prone to overdosing much easier.

2. This is a new drug, and the long term effects simply aren't known yet. 

3. Due to me being at risk for other cardiac issues due to excess pounds, he thinks maybe I should look at a more friendly regimen when it comes to cardiac risks.

So he suggested Isentress/truvada, which is a twice a day regimen. *sigh* He did say that there are no restrictions as to when to take it though. I'm thinking I would take it at 10am and 10pm.

So what do you guys think? What would you choose?

Anyone who takes isentress & truvada, or stribild, please share your experience.

Thanks for your opinions.

[zach]

like you, i have recently changed meds. and am currently on a truvada based combo. initially i had wanted to discuss stiribild but was told the same thing you are. i am on a number of other medications, so for me, that answer was sufficient

is taking one pill, once a day, fundamentally more difficult than three days, once a day? its when i start having to schedule multiple med calls in a day that all the pills become an issue

[survivor703]

thanks for the input zach... how are you doing with the truvada based combo?

[zach]

little gas after dosage, nothing horrible... nothing else. total i'm taking 16 meds per day, 21 pills and a teaspoon of liquid. no prohibitive side effects. i know there are some serious ones, but i also think people get needlessly paranoid about side effects, and overreact to every little thing

[mikeyb39]

I dont know about the truvada, but Isentress i have no side effects. Im one if the few that does dual medications versus the normal three due to other issues

[Bizkits]

I just started meds last week. I as well wanted to start stribild and my doc said if I really insisted on it, she would give it to me. However she did mention the  long-term effects that weren't known and I also have a history of kidney stones so she said it'd be a possible increased risk for more kidney issues. So, we discussed all the other available options and she recommended truvada/tivicay. (Tivicay being a new drug, too). Its 2 pills once per day...no sweat. The first couple of days I had a very tiny bit of GI upset...more like a gas/bloating feeling for a couple hours after I took them...that's pretty much gone now...it was important to me to have a once daily regimen but the one-pill combos just didn't seem to be the best options for me. My partner is on truvada/issentress and its an annoyance to remember to take that second pill at night as we are usually active or out and about...it has worked extremely well for him as far as a treatment but he's going to talk to his doc next visit about switching to tivicay. I kinda look at it like this: I was diagnosed in 2014...20 or even 10 years ago, 2 pills wouldn't have even been an option, not to mention much worse side effects. So, I'd say stew it over, think about what your Dr. Said and what's really important to you.

[mecch]

survivor703 - take the isentress truvada. Especially since there are good reasons not to take the stribild in your case.
I take isentress truvada and don't notice it whatsoever but I've been on treatment now for several years so thats pretty standard. 
You might notice any combo when you first start treatment.

[survivor703]

Thanks for the advice everybody. I'm going to take the advice and go with the isentress / tivicay. It's not really a big deal taking two pills once a day versus one pill once a day. I'll just cross my fingers and pray that the tivicay doesn't have an hidden long term effects that aren't know just yet.

Thanks guys

[wolfter]

Thanks for the advice everybody. I'm going to take the advice and go with the isentress / tivicay. It's not really a big deal taking two pills once a day versus one pill once a day. I'll just cross my fingers and pray that the tivicay doesn't have an hidden long term effects that aren't know just yet.

Thanks guys

I'll quote one of my grandmother's hillbillyisms

Don't worry about what might go wrong; if nothing happens, you worried needlessly.  If it actually happens, you've experienced it twice.

best wishes

wolfie

[buginme2]

Thanks for the advice everybody. I'm going to take the advice and go with the isentress / tivicay. It's not really a big deal taking two pills once a day versus one pill once a day. I'll just cross my fingers and pray that the tivicay doesn't have an hidden long term effects that aren't know just yet.

Thanks guys

You can't take Isentress and Tivicay

You can take Isentress OR Tivicay combined with either Truvada or Epzicom

[zach]

probably a minor mistake on the posters part bug

last couple of weeks i keep saying intellance instead of isentress... so many names, but a rose is a rose

but survivor, clarify that with your doctor, ensure you understand what is going on

[buginme2]

Ya probably.

To the OP.  I would take Isentress or Tivicay (with Truvada or Epzicom) before I would take Stribild. 

Stribild will get the job done but IMO they added unnecessary risks to get it all into one pill.

[survivor703]

yup, brain fart... 

I meant to say I'll ask my doctor for the truvada and tivicay.
In fact, I shot him an email, and he replied as follows:

----------------

Reply from my doctor:

Hi "survivor",

The only reason it's not my go-to yet is that it's still so new on the market. I've only got one guy on that regimen (tivicay/truvada), but he is doing well with it. Generally, many of the risks and side effects are consistent across medication classes, so hopefully it'll pan out to be as good from the cardiovascular risk perspective as isentress has been. I'd also recommend that you check with your insurance on the co-pay as it's usually one of the lower-tier medications (although isentress can be too depending on the plan...)

Let me know what you think. I'm glad to give it a shot if you're interested.

Will

**My initial message to my doc**

From: ME
Sent: Thursday, April 24, 2014 12:17 PM
To: MY DOCTOR (Will)
Subject: Re: Stribild / Truvada

Hi Dr. Will,

As discussed, I've been weighing my options with the stribild and the isentress/truvada regimen. The cobicistat has me concerned, so I'm leaning away from that.

During my research I stumbled across another truvada combo that is two pills, once daily -- truvada/tivicay. I see that this combo is well tolerated, although the tivicay is still quite new so we don't know what the long term effects will look like.

You mentioned that the isentress/truvada was a better fit given my size and my risk for possible cardiac issues. Can you say the same for the truvada/tivicay? If so, I'm thinking that this might be the regimen for me.

What is your opinion on this regimen?

Thanks,
Survivor

[eric48]

1. It contains an agent that amplifies other drugs.

It constains an hepatic metabolism inhibitor.

The metabolism (destruction) of other (unrelated) drugs will therefore be affected in an unknown fashion

This annoyance is expected to be similar to that of the other metabolism inhibitor: Norvir

If at one point you need to take statins, for example, due to your cholesterol or what ever, then you statin choice may be limited

Stribuild is a built around a great molecule (EVG) that has poor pharmacokinetics properties

Hope this helps you understand your doc's explanation

Eric 

[survivor703]

On second thought, I'll just suck it up and deal with the 2 a day regimen. The icentress and truvada. (10am & 10pm) Thanks again for all of the help with making the decision. Hopefully I can switch to tivicay later once we see how the side effect profile is looking.

Thanks eric for the explanation of the pharmacokinetics.

[vertigo]

I'm on Isentress/Truvada, and it's been easy to take.  No side effects.  The morning pills are a cinch to remember, but it can be a slight pain taking the evening Isentress dose, depending on what I'm up to.  Still, I haven't missed a dose yet in 10 months, so I can't say that adherence has been that hard.

The once-a-day convenience of Tivicay is very tempting, and I may switch to it later this year.  If I were starting today I think I would probably go for it.  But the fact that Isentress has been in use since 2007 gives it a proven track record that is quite reassuring.  I don't think you can go wrong either way.

[tednlou2]

I had finally settled on Stribild.  There had been other Stribild threads and I hadn't seen these negative reviews in those.  So, these responses gave me pause and feeling I needed to do more research.  It seems someone else here saw these comments and asked Dr. Gallant.  I went there to read any posts he may have made on Stribild or to ask him, if there weren't any.  I immediately ran into his response.  And, Trivicay is new and possible long-term issues are not yet known.  In fact, the longterm effects of all the regimens are not fully known. 

For those saying they would choose Isentress and Truvada or Trivicay with Truvada or Epzicom over Stribild, I am curious why you'd go that route?  I mean specifically.  Do the aforementioned regimens not have the issues with drug interactions, that the Cobicicstat has?  When reading the Stribild pamphlet, it seems many of the meds are inhalers.  More common meds like the erectile drugs and Lipitor are listed.  Valium and Klonopin are on there, but I noticed Xanax is not.  Do the other regimens not have these drug interaction warnings?  Is the list much shorter?  Is the drug interaction issue the main issue with Stribild? 

Anyway, here's his response for anyone interested:

"I use Stribild a lot.  In fact, it’s probably my “go-to” starting regimen at the moment.  It has definite advantages over the other two single-tablet regimens: it’s better tolerated that Atripla, and probably more effective than Complera in people with high baseline viral loads. It can also be taken with proton pump inhibitors (medications that reduce stomach acid), which should be avoided with Complera.

There are no known cardiac issues with Stribild. In fact, it’s easier on lipids than other commonly used drugs, such as efavirenz (Sustiva, Atripla). Cobicistat, a component of Stribild, does have many drug interactions, but they’re essentially the same as those with ritonavir (Norvir), which we’re all quite familiar with.  If someone is taking drugs that have unfavorable drug interactions with cobicistat, then Complera or a Tivicay-containing regimen may be preferable.

Cobicistat inhibits excretion of creatinine by the kidneys, which raises the serum creatinine, giving the appearance of worsening kidney function. However, this is a modest effect, is not a true toxicity, and is also seen with Norvir and Tivicay, though to a lesser degree.  I avoid Stribild in people with significant kidney disease.

Tivicay is a great choice too. Its only real disadvantage is that it’s not coformulated in a single tablet…yet.  But if you don’t mind taking two pills instead of one, then the combination of Tivicay plus either Truvada or Epzicom is also a great way to start."

[vertigo]

Ted, yes the potential for drug interactions with Stribild is one of its main disadvantages.  Cobicstat is similar to Norvir in that respect.  It also has to be taken with food -- not a big deal, but something I didn't want to commit to.  But I think people are doing really well with the drug.  I know my doc has warmed up to it quite a bit since it first came out in late 2012.

The fact that we're able to debate such minor points is a testament to how far the science of HIV treatment has come.  So if you want to take Stribild, then go for it.

It seems as though you're quite anxious about meds in general.  Is that a fair statement?  Perhaps just starting a regime without any further ado is the best call.  Some of your worries will abate when you see how easy it is.

[eric48]

Anyway, here's his response for anyone interested:

"I use Stribild a lot.  In fact, it’s probably my “go-to” starting regimen at the moment.

are you referring to this:

http://www.positivelyaware.com/2014/14-03/antiretroviral-2014.shtml

here is what he says:

Stribild is a great choice for people who want an easy, single-tablet regimen, even if they have high viral loads or low CD4 counts. I avoid it in people with kidney disease or those who need drugs that can’t be taken with cobicistat, which is similar to Norvir in terms of drug interactions.

The choice tree is fairly simple for treatment naives:

95+ % of patients use 3TC or its analogue FTC (which may be the reason why no one complains about since there is no comparator)

Then you have to choose either ABC or TDF

Then choose a 'locking' molecule: the third molecule role's (which may not be so much needed after all ...)
serves mainly to 'lock' the virus so that it can not 'turn around' the backbone

Class choice: as much as possible I'd like to remain within the same class (whichever that is...) if I need to change for SE. I would prefer to spare class change for virologic

The Integrase Inhibitor class is very attractive. The binding efficiency seems very good (see Dolutegravir, almost perfect) and more specific but the Pharmacokinetics is not as good.
- dosage:
RAL has to be taken 2 x daily, EVG needs a booster and food (natural gastric booster), DTG may need to be taken on food (some limited patients only).
- Distribution:
Distribution in anatomic compartments (brain, Ilium, Semen) is much lower that NNRTis.
- Timing: EVG has a half life as low as 12h (compared to 50 for EFV): for very adherent, cautious patients it makes little difference. For patients with a hectic lifestyle, it may be less convenient as, say, Atripla
- the cost difference for the third molecule (alone), assuming the backbone is identical is ranging from $ X to 50 times more (if not more...)
- Interactions: more than 20% patients are currently using statins. The backbone remains a solid contributor to that requirement. So the patient (or doctor) might be locked
- FTC (one pill, co-formulated): in case the backbone has to be changed, you change it, but in case of Stribild you need to change the third molecule as well.
- Other medication : if you cannot take your once daily with other OTCs or Rx drugs, then the dosing is your current dosing (OTCs + others) + 1 and this is not 1 any longer

So for a younger patient with no much need for other medications or timing flexibility, S. may be a great choice

Once daily
I have had twice daily and once daily. For me this was a real improvement.
Two pills (even 3 when I use a generic) makes no difference

Choice
I read many times : my choice is ... Well... the patient is not writting the script and some doctors can have their own mind set, including being familiar with SE and interactions.

Modern combos: patient testimonies seem very much in favor of
Complera (Eviplera), Stribild or Tivicay. Unfortunately, only Complera is allowed where I live (officially Stribild is authorized, but Health Authorities are becoming nosy about it). We are waiting for Tivicay, still...

@survivor703: I have heard of a RAL (Issentress (tm)) 'hack' to allow for once daily. I'll ask my doctor about it (next visit is in a month)

Eric

[survivor703]

hi eric, thanks for this information. If there was some way to take it once a day, that would be great. Let me know.

Thanks

[absopozilutely]

Why not try complera or did I miss something that you can't take it? Once a day, super easy with a meal awesome half life you just take it at some point during the day at least 12 hours before your next dosage, I've had no side effects and honestly forget about hiv most the time, it's no different then taking an 800 mg ibuprofen, as far as size. Truly it's been a good powerful regimen and been on the market longer. Just my two cents.

[absopozilutely]

Sorry, final thought, but if you say you're going to suck it up and just do the two pills twice a day regimen, you might want to reconsider, remember this is something you have to do the rest of our lives, and we want to make it as easy with the least amount of complications as possible, including adherence, it's not something you suck up with for a month or two, while you CAN change later, people generally try and avoid that so they don't develop resistance, think it through, it doesn't seem you're at a point to rush into a decision yet, be as comfortable with this drug as you can be. Best of luck! Here if you want someone to talk to, and welcome!

[survivor703]

Hey absolutely poz.   Thanks for the input. I thought about complera but the taking every day at the same time with a meal deterred me from researching further. I usually get breakfast every morning before work... But not if I'm running behind. I suppose doing it at dinner everyday would be good... But I'm just not that consistent with eating times. Same time every day may be a challenge. You know?

[absopozilutely]

That was my biggest worry to, but you can guarantee that you eat at least once a day, and that's all the pill requires. Trust me research it a little more it's a very forgiving pill, you can take it with breakfast if you forget next day until dinner then take it then and you're still fine, it really is a good regimen, and from what I've read I think you'll like it. It doesn't have to be at the exact same time either, for instance I normally take it with breakfast at 845 every day yesterday I took it with lunch, no big deal.

[buginme2]

For those saying they would choose Isentress and Truvada or Trivicay with Truvada or Epzicom over Stribild, I am curious why you'd go that route?  I mean specifically.  Do the aforementioned regimens not have the issues with drug interactions, that the Cobicicstat has? 

 would take Isentress or Tivicay (with Truvada or Epzicom) before I would take Stribild. 

Ya, was me that said that and the reasons why are (personally speaking, im not telling you that you should do one thing or another, its just my opinion.)

1.  I don't like the extra med.  If you can take Tivicay/Truvada or Isentress/Truvada which is 3 drugs why would I choose to take 4 drugs just so I can take it as one pill.  For me, taking another drug isnt worth the convenience of one pill. 

We have all seen the phrase that every medication has side effects, including asprin.  So, why would I want to take a medication that isnt clinically necessary?  I would be taking an additional medication just so I could take it as one pill.  Well, there are one pill options (Complera) that dont include the additonal med.

2.  I do not like the drug interactions with Cobicistat.  Cobscistat boosts the amount of Elvitegravir so you can take it once per day, but it also boosts other non hiv drugs also.

From: http://hivinsite.ucsf.edu/InSite?page=ar-06-02

cobicistat may cause clinically significant alterations in serum levels of a variety of other drugs.....For example, cobicistat may increase levels of certain calcium channel blockers, beta-blockers, HMG-CoA reductase inhibitors (statins), antiarrhythmics, sedative-hypnotics, erectile dysfunction agents, inhaled corticosteroids, and norgestimate

3.  I do not like the increased Kidney issues.  Truvada already fucks with your kidneys (so does HIV).  Why do I want to take something else that also fucks with them.  They say that the increase in kidney labs while taking Stribild doesnt necessarily mean that its damaging your kidneys.  I'd rather not take that chance.

So, thats why.  I just dont think this formulation is right for me.  I'd rather take Isentress/Truvada or Tivicay/Truvada.  I dont mind 2 pills. 

[survivor703]

Ok, I'm looking more into complera now since there is some flexibility with the timing. Unfortunately, I'm seeing some psychological effects on a few people. Hopefully this isn't a trend. Thats one of the main reasons I avoided the dreaded atripla. 

But it seems that complera does use an NNRTI in it, which is the same class as the culprit in atripla (the Efavirenz).

Complera users, do you feel any CNS effects from this drug?

Thanks again,
S

[buginme2]

Complera users, do you feel any CNS effects from this drug?

No.

But that doesn't mean you won't.   If you suffer from depression, anxiety, or any other mental illness you may want to skip the nnrti class of drugs all together.  Your doctor should be evaluating this. 

Also, you have had a viral load > 100,000.  I would discuss with your doctor whether its appropriate even though its since gone below that. 

Most HIV drugs that people take nowadays have very little to no side effects.

[absopozilutely]

Nope no side effects, ok think do some homework, when you get a headache you take aspirin or ibuprofen, look up the side effects of those, now do you wait around for those side effects, or relief of the headache? Same concept. Don't stress yourself over possible side effects they're very rare now, and pass quickly if you get them, I've had none.

[tednlou2]

Bug,

Thanks for your response.

[WowThatWasLifeChanging]

After having read all of these comments i feel like i know absolutely less than i thought about the med choices. Some of you are experts and I wish i could take you with me to my doc appts! I started truvada plus reyataz and ritonavir about an hour ago. Funny comment about reading aspirin side effects. Touché!!! I asked my doc why i need two inhibitors and dont see anyone else taking truvada as a 3 pill regimen. Strange or not? Anyways, best of luck with the med choice you pick! I can say for me im scared of potential cognitive side effects, and more scared of picking wrong med choice and not being able to switch later. My doc wanted to give me stribild but i want to have a baby so that hasnt been out long enough for the safety studies.  Taking with food same time each day scares me too, but need to eat to be healthy so i thought well at least i will eat dinner now...

[SteveS]

So - I have read through this whole thread - and still being relatively new to all of this - I am wondering if anyone can help me understand why Atripla is not being commented on / considered?

My doc presented Stribild as an option, but - as several of you said - has concerns about the unknown long term effects and said that Atripla at least had a few years head start in demonstrating a safety record.

Why does there seem to be this move away from Atripla? Is it only because there are "new" things to try? Or is there some serious issue with Atripla other than the dreams, etc, which, it seems, each med has its own quirks.

I ask because overall I am pleased with Atripla, but feel that perhaps I am missing out on something since many people - Docs included - seem to be moving away from it?

Thanks for your help -

[survivor703]

I asked my doc why i need two inhibitors and dont see anyone else taking truvada as a 3 pill regimen. Strange or not?

Hi wowthatwaslifechanging, I'm not too sure about why you're required to take 4 actives. Definitely follow up with your doctor and get an answer to that. If you're trying to get pregnant now, perhaps that has something to do with it, but I'm really not sure.

Why does there seem to be this move away from Atripla? Is it only because there are "new" things to try? Or is there some serious issue with Atripla other than the dreams, etc, which, it seems, each med has its own quirks.

Steve -- to answer your question, I'm staying away from the atripla because it contains the efavirenz. Efavierns (sustiva) is notorious for causing a few CNS related side effects which I would just rather not chance. I'm a chemist, and I do lots of complex calculations every day for work... I'd just rather not loose any of my cognitive ability, if possible. Fortunately, there are so many options these days in regards to treatment, so you can "pick your battles," if you will, more effectively. The regimen that I'm considering is two pills a day, but doesn't have many (if any) CNS side effects. Also it has a pretty good track record with minimal lipid changes, which is something important to me. My doctor was concerned about data showing increases in lipids in some people on Atripla long term.   

Hope this helps.

[Jeff G]

So - I have read through this whole thread - and still being relatively new to all of this - I am wondering if anyone can help me understand why Atripla is not being commented on / considered?

My doc presented Stribild as an option, but - as several of you said - has concerns about the unknown long term effects and said that Atripla at least had a few years head start in demonstrating a safety record.

Why does there seem to be this move away from Atripla? Is it only because there are "new" things to try? Or is there some serious issue with Atripla other than the dreams, etc, which, it seems, each med has its own quirks.

I ask because overall I am pleased with Atripla, but feel that perhaps I am missing out on something since many people - Docs included - seem to be moving away from it?

Thanks for your help -

I'm a critic of Atripla but if it works for you like it does for many then I would say if it aint broke don't fix it .

[leatherman]

I started truvada plus reyataz and ritonavir about an hour ago. Funny comment about reading aspirin side effects. Touché!!! I asked my doc why i need two inhibitors and dont see anyone else taking truvada as a 3 pill regimen.

I've been on truvada/reyataz/norvir for 8 or 9 years. It's actually quite a common regime and has been used for quite some time. Another similar regimen is Prezista/truvada/norvir

Taking with food same time each day scares me too, but need to eat to be healthy so i thought well at least i will eat dinner now...

surely you have got to eat at least one meal a day, right? I eat dinner every night (anytime from 4 to 9pm) and take my meds then

[buginme2]

So - I have read through this whole thread - and still being relatively new to all of this - I am wondering if anyone can help me understand why Atripla is not being commented on / considered?

The topic of the conversation wasnt about Atripla.  It was about Stribild and specifically the comparison of Strtibild versus the other Integrase inhibitor class of meds. 

There's nothing wrong with Atripla if you tolerate it well.  The problem is that many people dont tolerate it so there are some newer medications with less side effects. 

As far as efficacy goes it used to be considered the gold standard and nothing beat its efficacy until Epzicom/Tivicay.  But even that was because less people dropped out of the Tivicay arm than the Atripla arm....due to tolerability.

Truvada, Reyatazm, Norvir is also a very fine med combo.  Its considered the first choice if there may be adherence issues because it has a very low risk of causing resistance. 

[eric48]

The other day I was trying to count once daily regimen:

They are quite many:
- a few in the Pi class
- at least 3 widely used in the NNRTIs route : Viramune, Sustiva, Complera
- 2 in the Integrase class

That is a lot to choose from ...

So for most of us meds are once daily.

Patients on twice daily will have more options to move to once daily, should they want to to. It is just a matter of time. And with an one every 6 months visit to Doc, that means only a few Doc visits away

Eric