Question
Should I switch to Dovato?
15 November 2023. Related: All topics, Changing treatment, Research.
I’ve been on Truvada and Raltegravir for 4 or 5 years and I’ve decided to switch to Dovato once daily. Two active drugs instead of 3 appeals to me and taking only 1 pill is much easier. However I’m now having second thoughts due to the emerging evidence of side effects associated with Douletegravir especially
those associated with the heart. Do you think this is a sensible switch or not? I have no real reason to switch other than the fact I’d like to explore the possibility of better long term health with less side effects through reducing the number of drugs in the combo. Any advice would be much appreciated thanks.
Answer
Hi, how are you doing?
Is Truvada and Raltegravir the first combination of ART you have used? and what is your current viral load and CD4 count?
In the last 5 years have you had any problems with your current regimen? Any side effects/long term health concerns? Is the sole reason of switching to move to a single tablet instead of 2?
Dovato: https://i-base.info/
It is a recommended switch to a 2 drug regimen when virologically suppressed. It is not a suitable switch in people who have any of the following:
- History of failure on an INSTI regimen or resistance to lamivudine/INSTI ART.
- Hepatitis B co-infection.
- At risk of Hep B infection with no known immunity.
The switch from a 3-drug regimen to a 2-drug regimen is supported by the TANGO study: https://i-base.info/
This study showed that after 48 weeks a drug regimen was non-inferior to the 3-drug. Small differences were noted in kidney and bone markers between 3-drug and 2-drug but this is unlikely to have clinical significance. Both groups had a similar amount of weight gain leading to similar cardiovascular health outcomes.
There was a meta-analaysis on dolutegravir and cardiovascular health. This is a type of study that looks at a number of studies with the same sort of data and compares them to check if they are right. This study showed that dolutegravir does not increase the risk of cardiovascular health problems in comparison to other anti-retrovirals.
The study can be found here: https://pubmed.ncbi.nlm.
For this reason, concerns about switching to a dolutegravir based regimen on the risk of cardiovascular problems should not be considered. How is your current cardiovascular health e.g., blood pressures, cholesterol/lipids and weight?
Where in the UK are you based? If you are seeking easier treatment options have you considered using the injectable ART? This is newly rolled out and is not avialable at every clinic in the UK but can be wroth enquiring about. It requires only an injection every other month with no daily treatment.
Injectable ART: https://i-base.info/qa/
Josh.
Hi Tom, thanks for the thorough reply.
Providing some further information. Dovato is considered an excellent switch combination. As you have stated you have no known resistance to the INSTI class of medication, it makes Dovato a more than suitable combination. This is compounded by the fact that UK guidelines now recommend dolutegravir based regimens over raltagravir, the combination you are already taking.
The two drug regimen has been shown to be non-inferior to a 3-drug regimen. This is explained here: https://www.aidsmap.com/news/may-2023/real-world-data-confirm-efficacy-dolutegravir-based-dual-therapy
Clearly using one tablet a day as opposed to two offers an improvement on quality of life. Being on a regimen that is easier to follow with less tablets will improve adherence and ongoing continuity of care. This does all need to be taken into the context of your baseline health. As you have mentioned a number of ongoing conditions this switch will need to be a decision between yourself and your doctor. From a standpoint of HIV, there is no reason to not do this switch, especially in the context of DTG having no cardiovascular risk.
Hi Josh.
Thank you for your detailed response.
Truvada + Raltegravir is my second combination. I was started on Truvada & Ritonovir but switched after 6 months due to side effects. I have been stable and undetectable on the current combination since switching and was also undetectable on the first combination. Unfortunately I did acquire a strain of HIV with some resistance to NNRIs which I think rules out the current class of drug used for the injectables. I have no known resistance to the INSTI class, I do not have Hep B, and am up to date with the vaccines.
That’s encouraging that the meta review found no increased cardiovascular risk.
My blood pressure and cholesterol is normal but I am overweight (80kg) and my BMI is not out of normal range. In addition I also have POTS, CFS & EDS which can affect cardiovascular heath. I have palpitations, PVCs, shortness of breath, exercise intolerance, disordered breathing and dysautonomia. However, all cardiovascular tests in the past have been normal.
I am based in the South West and receive my HIV care at Southmead Hospital.