London prescribing guidelines updated to include dolutegravir and Triumeq
Simon Collins, HIV i-Base
On 14 January 2015, London guidelines for first-line ARV therapy were updated to include dolutegravir and Triumeq and published as a PowerPoint slide set. 
This January 2015 update was to reflect new NHS England prescribing policy for dolutegravir. 
- In London, dolutegravir can now be prescribed as an option for first-line therapy when neither efavirenz nor raltegravir are appropriate. Because of its higher price, this requires referral to a multi-disciplinary team or virtual clinic. (Slide 14).
- The guidelines do not recognise a clinical advantage of fixed dose combinations for most patients in preference to prescribing recommendations. (Slide 15).
- Dolutegravir can also be considered as an option for people who are switching treatment due to side effects or intollerance as these people are not defined as being stable on therapy. (Slide 23).
- Dolutegravir should be prescribed in combination with Kivexa (abacavir and lamivudine) unless this is contraindicated. Dolutegravir plus Kivexa is recommended rather than the single pill fixed dose combination (Triumeq). (Slide 24).
- However, Triumeq can be prescribed for some patients if this is the outcome of the virtual clinic. (Slides 24 and 26).
A 6 month prospective audit is planned for all patients starting ART from December 2014. An audit of those switching within six months is also planned. Centres using higher proportions of non-efavirenz based regimens will have external audit of their virtual review and audit clinic. (Slide 16)
Since 2011, the London tender process have already saved more than £10 million which is equivalent to approximately 5.2% annual savings from the ARV drug budget. The contract from 2014 is expected to save a further £ 4.8 million. (Slide 2).
The trade name for dolutegravir is Tivicay and the trade name for the fixed dose combination is Triumeq. Both are manufactured and marketed by ViiV Healthcare.
This is an update to the current guidelines published in July 2014 (applied from April 2014). 
- London Therapeutic Tender Implementation: Guidance for Clinical Use.14 January 2015.
https://i-base.info/wp-content/uploads/2015/01/London-NHSE-guidance-14Jan2015.pdf (PDF download)
- NHS England. Clinical Commissioning Policy: Dolutegravir for treatment of HIV- 1 in adults and adolescents. Reference: NHS England B06/P/a. January 2015.
- Collins S. New ARV prescribing guidelines for London (2014). HIV Treatment Bulletin, July 2014.