vivo, dolutegravir did not alter the plasma concentrations of tenofovir or para-amino hippurate, substrates of oat1 and oat3. in vitro, dolutegravir did not inhibit (ic 50 >50 microm) the following: cytochrome p450 (cyp)1a2, cyp2a6, cyp2b6, cyp2c8, cyp2c9, cyp2c19, cyp2d6, cyp3a, uridine diphosphate (udp)-glucuronosyl transferase (ugt)1a1, ugt2b7, p-glycoprotein (p-gp), breast cancer resistance protein (bcrp), bile salt export pump (bsep), organic anion transporter polypeptide (oatp)1b1, oatp1b3, oct1, or multidrug resistance protein (mrp)2, or mrp4. in vitro, dolutegravir did not induce cyp1a2, cyp2b6, cyp3a4. based on these data and the results of drug interaction trials, dolutegravir is not expected to affect the pharmacokinetics of drugs that are substrates of these enzymes or transporters. in drug interaction trials, dolutegravir did not have a clinically relevant effect on the pharmacokinetics of the following drugs: daclatasvir, tenofovir, methadone, midazolam, rilpivirine, and oral contraceptives containing norgestimate and ethinyl estradiol. using cross-study comparisons to historical pharmacokinetic data for each interacting drug, dolutegravir did not appear to affect the pharmacokinetics of the following drugs: atazanavir, darunavir, efavirenz, etravirine, fosamprenavir, lopinavir, ritonavir, and boceprevir. 7.2 effect of other agents on the pharmacokinetics of dolutegravir dolutegravir is metabolized by ugt1a1 with some contribution from cyp3a. dolutegravir is also a substrate of ugt1a3, ugt1a9, bcrp, and p-gp in vitro. drugs that induce those enzymes and transporters may decrease dolutegravir plasma concentrations and reduce the therapeutic effect of dolutegravir. coadministration of dolutegravir and other drugs that inhibit these enzymes may increase dolutegravir plasma concentrations. etravirine significantly reduced plasma concentrations of dolutegravir, but the effect of etravirine was mitigated by coadministration of lopinavir/ritonavir or darunavir/ritonavir and is expected to be mitigated by atazanavir/ritonavir ( table 6 ) [see drug interactions ( 7.3 ), clinical pharmacology ( 12.3 )] . in vitro, dolutegravir was not a substrate of oatp1b1 or oatp1b3. darunavir/ritonavir, lopinavir/ritonavir, rilpivirine, tenofovir, boceprevir, daclatasvir, prednisone, rifabutin, and omeprazole had no clinically significant effect on the pharmacokinetics of dolutegravir. 7.3 established and other potentially significant drug interactions there were no drug-drug interaction trials conducted with the abacavir, dolutegravir, and lamivudine fixed-dose combination tablets. information regarding potential drug interactions with the individual components of triumeq and triumeq pd are provided below. these recommendations are based on either drug interaction trials or predicted interactions due to the expected magnitude of interaction and potential for serious adverse events or loss of efficacy. [see contraindications ( 4 ), clinical pharmacology ( 12.3 ).] table 6. established and other potentially significant drug interactions for dolutegravir: alterations in dose may be recommended based on drug interaction trials or predicted interactions a see clinical pharmacology ( 12.3 ) table 8 or table 9 for magnitude of interaction. concomitant drug class: drug name effect on concentration clinical comment hiv-1 antiviral agents non-nucleoside reverse transcriptase inhibitor: etravirine a ↓dolutegravir use of triumeq or triumeq pd with etravirine without coadministration of atazanavir/ritonavir, darunavir/ritonavir, or lopinavir/ritonavir is not recommended. non-nucleoside reverse transcriptase inhibitor: efavirenz a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional 50-mg dose of tivicay should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to <25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. non-nucleoside reverse transcriptase inhibitor: nevirapine ↓dolutegravir avoid coadministration with triumeq or triumeq pd because there are insufficient data to make dosing recommendations. protease inhibitor: fosamprenavir/ritonavir a tipranavir/ritonavir a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional tivicay 50-mg dose should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to <25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. other agents antiarrhythmic: dofetilide ↑dofetilide coadministration is contraindicated with triumeq and triumeq pd [see contraindications ( 4 )] . potassium channel blocker: dalfampridine ↑dalfampridine elevated levels of dalfampridine increase the risk of seizures. the potential benefits of taking dalfampridine concurrently with triumeq or triumeq pd should be considered against the risk of seizures in these patients. carbamazepine a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional tivicay 50-mg dose should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to < 25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. oxcarbazepine phenytoin phenobarbital st. john’s wort ( hypericum perforatum ) ↓dolutegravir avoid coadministration with triumeq or triumeq pd because there are insufficient data to make dosing recommendations. medications containing polyvalent cations (e.g., mg or al): cation-containing antacids a or laxatives sucralfate buffered medications ↓dolutegravir administer triumeq or triumeq pd 2 hours before or 6 hours after taking medications containing polyvalent cations. oral calcium and iron supplements, including multivitamins containing calcium or iron a ↓dolutegravir when taken with food, triumeq or triumeq pd and supplements or multivitamins containing calcium or iron can be taken at the same time. under fasting conditions, triumeq or triumeq pd should be taken 2 hours before or 6 hours after taking supplements containing calcium or iron. metformin a ↑metformin refer to the prescribing information for metformin for assessing the benefit and risk of concomitant use of triumeq or triumeq pd and metformin. rifampin a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional 50-mg dose of tivicay should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to < 25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. methadone abacavir: in a trial of 11 hiv-1–infected subjects receiving methadone-maintenance therapy with 600 mg of abacavir twice daily (twice the currently recommended dose), oral methadone clearance increased [see clinical pharmacology ( 12.3 )] . this alteration will not result in a methadone dose modification in the majority of patients; however, an increased methadone dose may be required in a small number of patients. sorbitol lamivudine: coadministration of single doses of lamivudine and sorbitol resulted in a sorbitol dose-dependent reduction in lamivudine exposures. when possible, avoid use of sorbitol-containing medicines with lamivudine-containing medicines [see clinical pharmacology ( 12.3 )] . riociguat abacavir: coadministration with triumeq resulted in increased riociguat exposure, which may increase the risk of riociguat adverse reactions [see clinical pharmacology ( 12.3 )] . the riociguat dose may need to be reduced. see full prescribing information for adempas (riociguat).

suspected insti resistance because the dose of dolutegravir in triumeq and triumeq pd is insufficient in these subpopulations. see the dolutegravir prescribing information. ( 1 )

meq tablets and triumeq pd tablets for oral suspension are not interchangeable. ( 2.3 , 5.8 ) 5.1 hypersensitivity reactions hypersensitivity reactions have been reported with the use of abacavir or dolutegravir, components of triumeq and triumeq pd. abacavir serious and sometimes fatal hypersensitivity reactions have occurred with abacavir-containing regimens. see full prescribing information for ziagen (abacavir). abacavir hypersensitivity reactions have included multi-organ failure and anaphylaxis and typically occurred within the first 6 weeks of treatment with abacavir (median time to onset was 9 days); although abacavir hypersensitivity reactions have occurred any time during treatment [see adverse reactions ( 6.1 )] . patients who carry the hla‑b*5701 allele are at a higher risk of abacavir hypersensitivity reactions; although, patients who do not carry the hla‑b*5701 allele have developed hypersensitivity reactions. hypersensitivity to abacavir was reported in approximately 206 (8%) of 2,670 patients in 9 clinical trials with abacavir-containing products where hla‑b*5701 screening was not performed. the incidence of suspected abacavir hypersensitivity reactions in clinical trials was 1% when subjects carrying the hla-b*5701 allele were excluded. in any patient treated with abacavir, the clinical diagnosis of hypersensitivity reaction must remain the basis of clinical decision making. due to the potential for severe, serious, and possibly fatal hypersensitivity reactions with abacavir: • all patients should be screened for the hla‑b*5701 allele prior to initiating therapy with triumeq or triumeq pd or reinitiation of therapy with triumeq or triumeq pd, unless patients have a previously documented hla‑b*5701 allele assessment. • triumeq and triumeq pd are contraindicated in patients with a prior hypersensitivity reaction to abacavir and in hla‑b*5701‑positive patients. • before starting triumeq or triumeq pd, review medical history for prior exposure to any abacavir-containing product. never restart triumeq or triumeq pd or any other abacavir-containing product following a hypersensitivity reaction to abacavir, regardless of hla‑b*5701 status. • to reduce the risk of a life‑threatening hypersensitivity reaction, regardless of hla‑b*5701 status, discontinue triumeq or triumeq pd immediately if a hypersensitivity reaction is suspected, even when other diagnoses are possible (e.g., acute onset respiratory diseases such as pneumonia, bronchitis, pharyngitis, or influenza; gastroenteritis; or reactions to other medications). clinical status, including liver chemistries, should be monitored and appropriate therapy initiated. • if a hypersensitivity reaction cannot be ruled out, do not restart triumeq or triumeq pd or any other abacavir-containing products because more severe symptoms, which may include life-threatening hypotension and death, can occur within hours. • clinically, it is not possible to determine whether a hypersensitivity reaction with triumeq or triumeq pd would be caused by abacavir or dolutegravir. therefore, never restart triumeq or triumeq pd or any other abacavir- or dolutegravir-containing product in patients who have stopped therapy with triumeq or triumeq pd due to a hypersensitivity reaction. • if a hypersensitivity reaction is ruled out, patients may restart triumeq or triumeq pd. rarely, patients who have stopped abacavir for reasons other than symptoms of hypersensitivity have also experienced life-threatening reactions within hours of reinitiating abacavir therapy. therefore, reintroduction of triumeq or triumeq pd, or any other abacavir-containing product, is recommended only if medical care can be readily accessed. • a medication guide and warning card that provide information about recognition of abacavir hypersensitivity reactions should be dispensed with each new prescription and refill. dolutegravir hypersensitivity reactions have been reported and were characterized by rash, constitutional findings, and sometimes organ dysfunction, including liver injury. the events were reported in <1% of subjects receiving tivicay in phase 3 clinical trials. discontinue triumeq or triumeq pd and other suspect agents immediately if signs or symptoms of hypersensitivity reactions develop (including, but not limited to, severe rash or rash accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters or peeling of the skin, oral blisters or lesions, conjunctivitis, facial edema, hepatitis, eosinophilia, angioedema, difficulty breathing). clinical status, including liver aminotransferases, should be monitored and appropriate therapy initiated. delay in stopping treatment with triumeq or triumeq pd or other suspect agents after the onset of hypersensitivity may result in a life-threatening reaction. clinically, it is not possible to determine whether a hypersensitivity reaction with triumeq or triumeq pd would be caused by abacavir or dolutegravir. therefore, never restart triumeq or triumeq pd or any other abacavir- or dolutegravir-containing product in patients who have stopped therapy with triumeq or triumeq pd due to a hypersensitivity reaction. 5.2 patients co-infected with hiv-1 and hbv: emergence of lamivudine-resistant hbv and the risk of posttreatment exacerbations of hbv all patients with hiv-1 should be tested for the presence of hbv prior to or when initiating triumeq or triumeq pd. emergence of lamivudine resistant hbv safety and efficacy of lamivudine have not been established for treatment of chronic hbv in subjects dually infected with hiv-1 and hbv. emergence of hbv variants associated with resistance to lamivudine has been reported in hiv‑1−infected subjects who have received lamivudine‑containing antiretroviral regimens in the presence of concurrent infection with hbv. if a decision is made to administer triumeq or triumeq pd to patients co-infected with hiv-1 and hbv, additional treatment should be considered for appropriate treatment of chronic hbv; otherwise, consider an alternative regimen. severe acute exacerbations of hbv in patients co-infected with hiv-1 and hbv severe acute exacerbations of hbv have been reported in patients who are co-infected with hiv-1 and hbv and have discontinued products containing lamivudine, and may occur with discontinuation of triumeq or triumeq pd. patients who are co-infected with hiv-1 and hbv who discontinue triumeq or triumeq pd should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping treatment with triumeq or triumeq pd. if appropriate, initiation of anti-hbv therapy may be warranted, especially in patients with advanced liver disease or cirrhosis, since posttreatment exacerbation of hepatitis may lead to hepatic decompensation and liver failure. 5.3 hepatotoxicity hepatic adverse events have been reported in patients receiving a dolutegravir-containing regimen [see adverse reactions ( 6.1 , 6.2 )] . patients with underlying hepatitis b or c may be at increased risk for worsening or development of transaminase elevations with use of triumeq or triumeq pd [see adverse reactions ( 6.1 )] . in some cases, the elevations in transaminases were consistent with immune reconstitution syndrome or hepatitis b reactivation particularly in the setting where anti-hepatitis therapy was withdrawn. cases of hepatic toxicity, including elevated serum liver biochemistries, hepatitis, and acute liver failure, have also been reported in patients, including pediatric patients receiving a dolutegravir-containing regimen who had no pre-existing hepatic disease or other identifiable risk factors. drug-induced liver injury leading to liver transplant has been reported with triumeq. monitoring for hepatotoxicity is recommended. 5.4 lactic acidosis and severe hepatomegaly with steatosis lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogues, including abacavir and lamivudine (components of triumeq and triumeq pd). a majority of these cases have been in women. female sex and obesity may be risk factors for the development of lactic acidosis and severe hepatomegaly with steatosis in patients treated with antiretroviral nucleoside analogues. see full prescribing information for ziagen (abacavir) and epivir (lamivudine). treatment with triumeq or triumeq pd should be suspended in any patient who develops clinical or laboratory findings suggestive of lactic acidosis or pronounced hepatotoxicity, which may include hepatomegaly and steatosis even in the absence of marked transaminase elevations. 5.5 embryo-fetal toxicity an ongoing observational study showed an association between dolutegravir and an increased risk of neural tube defects when dolutegravir was administered at the time of conception and in early pregnancy. as there is limited understanding of the association of reported types of neural tube defects with dolutegravir use, inform adolescents and adults of childbearing potential, including those actively trying to become pregnant, about the potential increased risk of neural tube defects with triumeq. assess the risks and benefits of triumeq and discuss with the patient to determine if an alternative treatment should be considered at the time of conception through the first trimester of pregnancy or if pregnancy is confirmed in the first trimester [see use in specific populations ( 8.1 , 8.3 )] . pregnancy testing is recommended before initiation of triumeq in adolescents and adults of childbearing potential [see dosage and administration ( 2.2 )] . adolescents and adults of childbearing potential should be counseled on the consistent use of effective contraception [see use in specific populations ( 8.1 , 8.3 )] . triumeq may be considered during the second and third trimesters of pregnancy if the expected benefit justifies the potential risk to the pregnant woman and the fetus. 5.6 risk of adverse reactions or loss of virologic response due to drug interactions the concomitant use of triumeq or triumeq pd and other drugs may result in known or potentially significant drug interactions, some of which may lead to [see contraindications ( 4 ), drug interactions ( 7.3 )] : • loss of therapeutic effect of triumeq or triumeq pd and possible development of resistance. • possible clinically significant adverse reactions from greater exposures of concomitant drugs. see table 6 for steps to prevent or manage these possible and known significant drug interactions, including dosing recommendations. consider the potential for drug interactions prior to and during therapy with triumeq or triumeq pd, review concomitant medications during therapy with triumeq or triumeq pd, and monitor for the adverse reactions associated with the concomitant drugs. 5.7 immune reconstitution syndrome immune reconstitution syndrome has been reported in patients treated with combination antiretroviral therapy, including triumeq or triumeq pd. during the initial phase of combination antiretroviral treatment, patients whose immune systems respond may develop an inflammatory response to indolent or residual opportunistic infections (such as mycobacterium avium infection, cytomegalovirus, pneumocystis jirovecii pneumonia [pcp], or tuberculosis), which may necessitate further evaluation and treatment. autoimmune disorders (such as graves’ disease, polymyositis, guillain-barré syndrome, autoimmune hepatitis) have also been reported to occur in the setting of immune reconstitution; however, the time to onset is more variable, and can occur many months after initiation of treatment. 5.8 different formulations are not interchangeable triumeq and triumeq pd are not bioequivalent and are not interchangeable on a milligram-per-milligram basis [see clinical pharmacology ( 12.3 )] . if a pediatric patient switches from the tablets for oral suspension to the tablets, the dosage must be adjusted [see dosage and administration ( 2.3 , 2.5 )] . incorrect dosing of a given formulation may result in underdosing and loss of therapeutic effect and possible development of resistance or possible clinically significant adverse reactions from greater exposure to the individual components. 5.9 myocardial infarction several prospective, observational, epidemiological studies have reported an association with the use of abacavir and the risk of myocardial infarction (mi). meta-analyses of randomized, controlled clinical trials have observed no excess risk of mi in abacavir‑treated subjects as compared with control subjects. to date, there is no established biological mechanism to explain a potential increase in risk. in totality, the available data from the observational studies and from controlled clinical trials show inconsistency; therefore, evidence for a causal relationship between abacavir and the risk of mi is inconclusive. as a precaution, the underlying risk of coronary heart disease should be considered when prescribing antiretroviral therapies, including abacavir, and action taken to minimize all modifiable risk factors (e.g., hypertension, hyperlipidemia, diabetes mellitus, smoking).

�¢ do not interchange triumeq and triumeq pd on a milligram-per-milligram basis. ( 2.3 ) • if dosing with certain ugt1a or cyp3a inducers, then the recommended dolutegravir dosage regimen should be adjusted. see table 2 for complete dosing recommendations. ( 2.6 ) • because triumeq and triumeq pd are fixed-dose tablets and cannot be dose adjusted, triumeq and triumeq pd are not recommended in patients with creatinine clearance <30 ml/min, or patients with hepatic impairment. ( 2.7 , 4 ) 2.1 screening for hla-b*5701 allele prior to initiating triumeq screen for the hla ‑ b*5701 allele prior to initiating therapy with triumeq or triumeq pd [see boxed warning , warnings and precautions ( 5.1 )] . 2.2 testing prior to or when initiating treatment with triumeq prior to or when initiating triumeq or triumeq pd, test patients for hbv infection [see warnings and precautions ( 5.2 )] . pregnancy testing is recommended before initiation of triumeq in adolescents and adults of childbearing potential [see warnings and precautions ( 5.5 ), use in specific populations ( 8.1 , 8.3 )] . 2.3 overview of triumeq dosage forms triumeq is available in two dosage forms. do not interchange triumeq tablets and triumeq pd tablets for oral suspension on a milligram-per-milligram basis due to differing pharmacokinetic profiles for the dolutegravir component [see warnings and precautions ( 5.8 ), clinical pharmacology ( 12.3 )] . • triumeq tablets: 600 mg of abacavir, 50 mg of dolutegravir, and 300 mg of lamivudine. triumeq is recommended in adults and pediatric patients weighing at least 25 kg [see dosage and administration ( 2.4 , 2.5 )]. • triumeq pd tablets for oral suspension: 60 mg of abacavir, 5 mg of dolutegravir, and 30 mg of lamivudine. triumeq pd is recommended in pediatric patients weighing 10 kg to less than 25 kg. [see dosage and administration ( 2.5 )] . • because triumeq pd is a fixed-dose tablet and the dosage of individual components cannot be adjusted, it may lead to a suboptimal dosing for patients weighing ≥25 kg. triumeq pd is not recommended in patients weighing 25 kg or more [see dosage and administration ( 2.4 , 2.5 )] . 2.4 recommended dosage in adults triumeq is a fixed-dose combination product containing 600 mg of abacavir, 50 mg of dolutegravir, and 300 mg of lamivudine. the recommended dosage regimen of triumeq in adults is one tablet once daily orally with or without food. do not use triumeq pd in adults. 2.5 recommended dosage and administration instructions for pediatric patients weighing at least 10 kg the dosage and dosage form recommended for pediatric patients varies by weight as shown in table 1 below. table 1. recommended dosage of triumeq tablets and triumeq pd tablets for oral suspension in pediatric patients a triumeq is a fixed-dose combination product containing 600 mg of abacavir, 50 mg of dolutegravir, and 300 mg of lamivudine. a triumeq pd is a fixed-dose combination product containing 60 mg of abacavir, 5 mg of dolutegravir, and 30 mg of lamivudine. body weight triumeq tablets a triumeq pd b number of tablets total daily dose 10 kg to <14 kg not recommended 4 tablets once daily 240 mg abacavir, 20 mg dolutegravir, and 120 mg lamivudine once daily 14 kg to <20 kg not recommended 5 tablets once daily 300 mg abacavir, 25 mg dolutegravir, and 150 mg lamivudine once daily 20 kg to <25 kg not recommended 6 tablets once daily 360 mg abacavir, 30 mg dolutegravir, and 180 mg lamivudine once daily ≥25 kg 1 tablet once daily not recommended 600 mg of abacavir, 50 mg of dolutegravir, and 300 mg of lamivudine administer triumeq pd tablets for oral suspension with or without food. instruct patients (or instruct caregivers) to fully disperse the tablets for oral suspension in 20 ml of drinking water in the supplied cup; swirl the suspension so that no lumps remain. after full dispersion, administer the oral suspension within 30 minutes of mixing [see instructions for use] . do not chew, cut, or crush the tablets. administer triumeq tablet with or without food. do not chew, cut, or crush the tablet. 2.6 dosage recommendation with certain concomitant medications the dolutegravir dose in triumeq (50 mg) and triumeq pd (5 mg) is insufficient when coadministered with medications listed in table 2 that may decrease dolutegravir concentrations; the following dolutegravir dosage regimen is recommended. table 2. dosing recommendations for triumeq and triumeq pd with coadministered medications coadministered drug dosing recommendation efavirenz, fosamprenavir/ritonavir, tipranavir/ritonavir, carbamazepine, or rifampin in adults and in pediatric patients weighing at least 25 kg , the recommended dolutegravir dosage regimen is 50 mg twice daily. thus, an additional tivicay 50-mg tablet, separated by 12 hours from triumeq, should be taken. in pediatric patients weighing 10 kg to <25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. 2.7 not recommended due to lack of dosage adjustment because triumeq and triumeq pd are fixed-dose tablets and cannot be dose adjusted, triumeq and triumeq pd are not recommended in: • patients with creatinine clearance <30 ml/min [see use in specific populations ( 8.6 )] . • patients with mild hepatic impairment. triumeq and triumeq pd are contraindicated in patients with moderate or severe hepatic impairment [see contraindications ( 4 ), use in specific populations ( 8.7 )] .

cted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. clinical trials in adults serious and fatal abacavir-associated hypersensitivity reactions: in clinical trials, serious and sometimes fatal hypersensitivity reactions have occurred with abacavir, a component of triumeq and triumeq pd [see boxed warning , warnings and precautions ( 5.1 )]. these reactions have been characterized by 2 or more of the following signs or symptoms: (1) fever; (2) rash; (3) gastrointestinal symptoms (including nausea, vomiting, diarrhea, or abdominal pain); (4) constitutional symptoms (including generalized malaise, fatigue, or achiness); (5) respiratory symptoms (including dyspnea, cough, or pharyngitis). almost all abacavir hypersensitivity reactions include fever and/or rash as part of the syndrome. other signs and symptoms have included lethargy, headache, myalgia, edema, arthralgia, and paresthesia. anaphylaxis, liver failure, renal failure, hypotension, adult respiratory distress syndrome, respiratory failure, myolysis, and death have occurred in association with these hypersensitivity reactions. physical findings have included lymphadenopathy, mucous membrane lesions (conjunctivitis and mouth ulcerations), and maculopapular or urticarial rash (although some patients had other types of rashes and others did not have a rash). there were reports of erythema multiforme. laboratory abnormalities included elevated liver chemistries, elevated creatine phosphokinase, elevated creatinine, and lymphopenia and abnormal chest x‑ray findings (predominantly infiltrates, which were localized). serious dolutegravir hypersensitivity reactions: in clinical trials, hypersensitivity reactions have occurred with dolutegravir, a component of triumeq and triumeq pd [see warnings and precautions ( 5.1 )]. these hypersensitivity reactions have been characterized by rash, constitutional findings, and sometimes organ dysfunction, including liver injury. additional treatment-emergent adverse drug reactions (adrs) with use of triumeq: the safety assessment of triumeq is primarily based on the analyses of data from a randomized, international, multicenter, double-blind, active-controlled trial, single (ing114467) and supported by data in treatment-experienced, insti-naive subjects from sailing (ing111762) and by data from other treatment-naive trials. see full prescribing information for tivicay. treatment-naive subjects: in single, 833 adult subjects were randomized and received at least one dose of either dolutegravir (tivicay) 50 mg with fixed-dose abacavir and lamivudine (epzicom) once daily (n = 414) or fixed-dose efavirenz/emtricitabine/tenofovir (atripla) once daily (n = 419) (study treatment was blinded through week 96 and open-label from week 96 through week 144). through 144 weeks, the rate of adverse events leading to discontinuation was 4% in subjects receiving tivicay + epzicom and 14% in subjects receiving atripla once daily. treatment‑emergent adrs of moderate to severe intensity observed in at least 2% of subjects in either treatment arm of single are provided in table 3 . table 3. treatment-emergent adverse drug reactions of at least moderate intensity (grades 2 to 4) and at least 2% frequency in treatment-naive subjects in single (week 144 analysis) a includes pooled terms: rash, rash generalized, rash macular, rash maculo-papular, rash pruritic, and drug eruption. adverse reaction tivicay + epzicom once daily (n = 414) atripla once daily (n = 419) psychiatric insomnia 3% 3% depression 1% 2% abnormal dreams <1% 2% nervous system dizziness <1% 5% headache 2% 2% gastrointestinal nausea <1% 3% diarrhea <1% 2% general disorders fatigue 2% 2% skin and subcutaneous tissue rash a <1% 6% ear and labyrinth vertigo 0 2% treatment-experienced subjects: sailing is an international, double-blind trial in insti-naive, antiretroviral treatment-experienced adult subjects. subjects were randomized and received either tivicay 50 mg once daily or raltegravir 400 mg twice daily with investigator-selected background regimen consisting of up to 2 agents, including at least one fully active agent. at 48 weeks, the rate of adverse events leading to discontinuation was consistent with that seen in the overall treatment-naive patient population. see full prescribing information for tivicay. the adrs observed in the subset of subjects who received tivicay + epzicom were generally consistent with those seen in the overall treatment-naive patient population. less common adverse reactions observed in clinical trials: the following adverse reactions occurred in <2% of treatment-naive or treatment-experienced subjects in any one trial. these events have been included because of their seriousness and/or assessment of potential causal relationship. gastrointestinal disorders: abdominal pain, abdominal distention, abdominal discomfort, dyspepsia, flatulence, gastroesophageal reflux disease, upper abdominal pain, vomiting. general disorders: fever, lethargy. hepatobiliary disorders: hepatitis. metabolism and nutrition disorders: anorexia, hypertriglyceridemia. musculoskeletal disorders: arthralgia, myositis. nervous system disorders: somnolence. psychiatric disorders: suicidal ideation, attempt, behavior, or completion. these events were observed primarily in subjects with a pre-existing history of depression or other psychiatric illness. nightmare and sleep disorder. renal and urinary disorders: renal impairment. skin and subcutaneous tissue disorders: pruritus. laboratory abnormalities: treatment-naive subjects: selected laboratory abnormalities (grades 2 to 4) with a worsening grade from baseline and representing the worst-grade toxicity in at least 2% of subjects in single are presented in table 4 . the mean change from baseline observed for selected lipid values is presented in table 5 . table 4. selected laboratory abnormalities (grades 2 to 4) in treatment-naive subjects in single (week 144 analysis) alt = alanine aminotransferase, ast = aspartate aminotransferase, uln = upper limit of normal. laboratory abnormality tivicay + epzicom once daily (n = 414) atripla once daily (n = 419) alt grade 2 (>2.5-5.0 x uln) 3% 5% grade 3 to 4 (>5.0 x uln) 1% <1% ast grade 2 (>2.5-5.0 x uln) 3% 4% grade 3 to 4 (>5.0 x uln) 1% 3% creatine kinase grade 2 (6.0-9.9 x uln) 5% 3% grade 3 to 4 (≥10.0 x uln) 7% 8% hyperglycemia grade 2 (126-250 mg/dl) 9% 6% grade 3 (>250 mg/dl) 2% <1% lipase grade 2 (>1.5-3.0 x uln) 11% 11% grade 3 to 4 (>3.0 uln) 5% 4% total neutrophils grade 2 (0.75-0.99 x 10 9 ) 4% 5% grade 3 to 4 (<0.75 x 10 9 ) 3% 3% table 5. mean change from baseline in fasted lipid values in treatment-naive subjects in single (week 144 analysis a ) hdl = high-density lipoprotein, ldl = low-density lipoprotein. a subjects on lipid-lowering agents at baseline were excluded from these analyses (tivicay + epzicom: n = 30 and atripla: n = 27). seventy-two subjects initiated a lipid-lowering agent post-baseline; their last fasted on-treatment values (prior to starting the agent) were used regardless of whether they discontinued the agent (tivicay + epzicom: n = 36 and atripla: n = 36). lipid tivicay + epzicom once daily (n = 414) atripla once daily (n = 419) cholesterol (mg/dl) 24.0 26.7 hdl cholesterol (mg/dl) 5.4 7.2 ldl cholesterol (mg/dl) 16.0 14.6 triglycerides (mg/dl) 13.6 31.9 treatment-experienced subjects: laboratory abnormalities observed in sailing were generally similar compared with observations seen in the treatment-naive trials. hepatitis c virus co-infection: in single, the pivotal phase 3 trial, subjects with hepatitis c virus co-infection were permitted to enroll provided that baseline liver chemistry tests did not exceed 5 times the upper limit of normal; subjects with hepatitis b co-infection were excluded. overall, the safety profile in subjects with hepatitis c virus co-infection was similar to that observed in subjects without hepatitis c co-infection, although the rates of ast and alt abnormalities were higher in the subgroup with hepatitis c virus co-infection for both treatment groups. grades 2 to 4 alt abnormalities in hepatitis c co-infected compared with hiv mono-infected subjects receiving triumeq were observed in 15% and 2% (vs. 24% and 4% of subjects treated with atripla) (week 96 analysis), respectively [see warnings and precautions ( 5.2 )] . see also full prescribing information for tivicay. changes in serum creatinine: dolutegravir has been shown to increase serum creatinine due to inhibition of tubular secretion of creatinine without affecting renal glomerular function [see clinical pharmacology ( 12.2 )] . increases in serum creatinine occurred within the first 4 weeks of treatment and remained stable through 144 weeks. in single, a mean change from baseline of 0.14 mg per dl (range: -0.25 mg per dl to 0.81 mg per dl) was observed after 144 weeks of treatment. creatinine increases were similar in treatment-experienced subjects. abacavir and lamivudine: laboratory abnormalities observed in clinical trials of ziagen (in combination with other antiretroviral treatment) were anemia, neutropenia, liver function test abnormalities, and elevations of cpk, blood glucose, and triglycerides. additional laboratory abnormalities observed in clinical trials of epivir (in combination with other antiretroviral treatment) were thrombocytopenia and elevated levels of bilirubin, amylase, and lipase. clinical trials experience in pediatric subjects abacavir and lamivudine: the safety of once-daily compared with twice-daily dosing of abacavir and lamivudine, administered as either single products or as epzicom, was assessed in the arrow trial (n = 336). primary safety assessment in the arrow (col105677) trial was based on grade 3 and grade 4 adverse events. one event of grade 4 hepatitis in the once-daily cohort was considered as uncertain causality by the investigator and all other grade 3 or 4 adverse events were considered not related by the investigator. no additional safety issues were identified in pediatric subjects compared with historical data in adults. dolutegravir: the safety of dolutegravir in pediatric subjects with hiv-1 infection weighing at least 10 kg was evaluated in the impaact p1093 trial [see use in specific populations ( 8.4 ), clinical pharmacology ( 12.3 )] . overall, the safety data in this pediatric study was similar to that seen in adults. impaact p1093 is an ongoing multicenter, open-label, non-comparative trial of pediatric subjects with hiv-1 infection, aged <18 years. one hundred and five subjects weighing at least 10 kg were enrolled in this trial [see use in specific populations ( 8.4 ), clinical pharmacology ( 12.3 ), clinical studies ( 14.2 )] . the safety analysis through week 24 included 40 subjects from cohorts i (n = 19), iia (n = 5), iii-dt (n = 15), and iv-dt (n=1) weighing at least 10 kg at enrollment who received the recommended dose (determined by weight and age) and formulation. this analysis showed that 6 subjects (all from cohort i) experienced drug-related clinical adverse reactions. there were no grade 3 or 4 drug-related adverse reactions reported. no adverse reactions led to discontinuation. all laboratory abnormalities considered to be drug-related in subjects weighing at least 10 kg at enrollment were grade 1 or 2 in severity. only one grade 3 laboratory abnormality was reported in more than 1 subject (decreased blood bicarbonate, n = 2). changes in median serum creatinine were similar to those observed in adults. 6.2 postmarketing experience in addition to adverse reactions reported from clinical trials, the following adverse reactions have been identified during postmarketing use with one or more of the components of triumeq and triumeq pd. because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. blood and lymphatic systems aplastic anemia, anemia (including pure red cell aplasia and severe anemias progressing on therapy), lymphadenopathy, splenomegaly. digestive stomatitis. gastrointestinal pancreatitis. general weakness. hepatobiliary disorders acute liver failure, liver transplant [see warnings and precautions ( 5.3 )] . hypersensitivity sensitization reactions (including anaphylaxis), urticaria [see warnings and precautions ( 5.1 ), adverse reactions ( 6.1 )] . investigations weight increased. metabolism and nutrition disorders hyperlactemia. musculoskeletal cpk elevation, muscle weakness, myalgia, rhabdomyolysis. nervous paresthesia, peripheral neuropathy, seizures. psychiatric anxiety. respiratory abnormal breath sounds/wheezing. skin alopecia, erythema multiforme. suspected stevens‑johnson syndrome (sjs) and toxic epidermal necrolysis (ten) have been reported in patients receiving abacavir primarily in combination with medications known to be associated with sjs and ten, respectively. because of the overlap of clinical signs and symptoms between hypersensitivity to abacavir and sjs and ten, and the possibility of multiple drug sensitivities in some patients, abacavir should be discontinued and not restarted in such cases [see adverse reactions ( 6.1 )] .

vivo, dolutegravir did not alter the plasma concentrations of tenofovir or para-amino hippurate, substrates of oat1 and oat3. in vitro, dolutegravir did not inhibit (ic 50 >50 microm) the following: cytochrome p450 (cyp)1a2, cyp2a6, cyp2b6, cyp2c8, cyp2c9, cyp2c19, cyp2d6, cyp3a, uridine diphosphate (udp)-glucuronosyl transferase (ugt)1a1, ugt2b7, p-glycoprotein (p-gp), breast cancer resistance protein (bcrp), bile salt export pump (bsep), organic anion transporter polypeptide (oatp)1b1, oatp1b3, oct1, or multidrug resistance protein (mrp)2, or mrp4. in vitro, dolutegravir did not induce cyp1a2, cyp2b6, cyp3a4. based on these data and the results of drug interaction trials, dolutegravir is not expected to affect the pharmacokinetics of drugs that are substrates of these enzymes or transporters. in drug interaction trials, dolutegravir did not have a clinically relevant effect on the pharmacokinetics of the following drugs: daclatasvir, tenofovir, methadone, midazolam, rilpivirine, and oral contraceptives containing norgestimate and ethinyl estradiol. using cross-study comparisons to historical pharmacokinetic data for each interacting drug, dolutegravir did not appear to affect the pharmacokinetics of the following drugs: atazanavir, darunavir, efavirenz, etravirine, fosamprenavir, lopinavir, ritonavir, and boceprevir. 7.2 effect of other agents on the pharmacokinetics of dolutegravir dolutegravir is metabolized by ugt1a1 with some contribution from cyp3a. dolutegravir is also a substrate of ugt1a3, ugt1a9, bcrp, and p-gp in vitro. drugs that induce those enzymes and transporters may decrease dolutegravir plasma concentrations and reduce the therapeutic effect of dolutegravir. coadministration of dolutegravir and other drugs that inhibit these enzymes may increase dolutegravir plasma concentrations. etravirine significantly reduced plasma concentrations of dolutegravir, but the effect of etravirine was mitigated by coadministration of lopinavir/ritonavir or darunavir/ritonavir and is expected to be mitigated by atazanavir/ritonavir ( table 6 ) [see drug interactions ( 7.3 ), clinical pharmacology ( 12.3 )] . in vitro, dolutegravir was not a substrate of oatp1b1 or oatp1b3. darunavir/ritonavir, lopinavir/ritonavir, rilpivirine, tenofovir, boceprevir, daclatasvir, prednisone, rifabutin, and omeprazole had no clinically significant effect on the pharmacokinetics of dolutegravir. 7.3 established and other potentially significant drug interactions there were no drug-drug interaction trials conducted with the abacavir, dolutegravir, and lamivudine fixed-dose combination tablets. information regarding potential drug interactions with the individual components of triumeq and triumeq pd are provided below. these recommendations are based on either drug interaction trials or predicted interactions due to the expected magnitude of interaction and potential for serious adverse events or loss of efficacy. [see contraindications ( 4 ), clinical pharmacology ( 12.3 ).] table 6. established and other potentially significant drug interactions for dolutegravir: alterations in dose may be recommended based on drug interaction trials or predicted interactions a see clinical pharmacology ( 12.3 ) table 8 or table 9 for magnitude of interaction. concomitant drug class: drug name effect on concentration clinical comment hiv-1 antiviral agents non-nucleoside reverse transcriptase inhibitor: etravirine a ↓dolutegravir use of triumeq or triumeq pd with etravirine without coadministration of atazanavir/ritonavir, darunavir/ritonavir, or lopinavir/ritonavir is not recommended. non-nucleoside reverse transcriptase inhibitor: efavirenz a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional 50-mg dose of tivicay should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to <25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. non-nucleoside reverse transcriptase inhibitor: nevirapine ↓dolutegravir avoid coadministration with triumeq or triumeq pd because there are insufficient data to make dosing recommendations. protease inhibitor: fosamprenavir/ritonavir a tipranavir/ritonavir a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional tivicay 50-mg dose should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to <25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. other agents antiarrhythmic: dofetilide ↑dofetilide coadministration is contraindicated with triumeq and triumeq pd [see contraindications ( 4 )] . potassium channel blocker: dalfampridine ↑dalfampridine elevated levels of dalfampridine increase the risk of seizures. the potential benefits of taking dalfampridine concurrently with triumeq or triumeq pd should be considered against the risk of seizures in these patients. carbamazepine a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional tivicay 50-mg dose should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to < 25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. oxcarbazepine phenytoin phenobarbital st. john’s wort ( hypericum perforatum ) ↓dolutegravir avoid coadministration with triumeq or triumeq pd because there are insufficient data to make dosing recommendations. medications containing polyvalent cations (e.g., mg or al): cation-containing antacids a or laxatives sucralfate buffered medications ↓dolutegravir administer triumeq or triumeq pd 2 hours before or 6 hours after taking medications containing polyvalent cations. oral calcium and iron supplements, including multivitamins containing calcium or iron a ↓dolutegravir when taken with food, triumeq or triumeq pd and supplements or multivitamins containing calcium or iron can be taken at the same time. under fasting conditions, triumeq or triumeq pd should be taken 2 hours before or 6 hours after taking supplements containing calcium or iron. metformin a ↑metformin refer to the prescribing information for metformin for assessing the benefit and risk of concomitant use of triumeq or triumeq pd and metformin. rifampin a ↓dolutegravir in adults and in pediatric patients weighing at least 25 kg , adjust dolutegravir dose to 50 mg twice daily. an additional 50-mg dose of tivicay should be taken, separated by 12 hours from triumeq. in pediatric patients weighing 10 to < 25 kg , an additional weight-based dose of dolutegravir should be given separated by 12 hours from triumeq pd. • 10 to <14 kg: administer an additional 20-mg dose of dolutegravir (4 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 14 to <20 kg: administer an additional 25-mg dose of dolutegravir (5 tivicay pd tablets for oral suspension), 12 hours after triumeq pd, • 20 to <25 kg: administer an additional 30-mg dose of dolutegravir (6 tivicay pd tablets for oral suspension), 12 hours after triumeq pd. methadone abacavir: in a trial of 11 hiv-1–infected subjects receiving methadone-maintenance therapy with 600 mg of abacavir twice daily (twice the currently recommended dose), oral methadone clearance increased [see clinical pharmacology ( 12.3 )] . this alteration will not result in a methadone dose modification in the majority of patients; however, an increased methadone dose may be required in a small number of patients. sorbitol lamivudine: coadministration of single doses of lamivudine and sorbitol resulted in a sorbitol dose-dependent reduction in lamivudine exposures. when possible, avoid use of sorbitol-containing medicines with lamivudine-containing medicines [see clinical pharmacology ( 12.3 )] . riociguat abacavir: coadministration with triumeq resulted in increased riociguat exposure, which may increase the risk of riociguat adverse reactions [see clinical pharmacology ( 12.3 )] . the riociguat dose may need to be reduced. see full prescribing information for adempas (riociguat).

ic impairment, then the individual components should be used. ( 8.7 ) 8.1 pregnancy pregnancy exposure registry there is a pregnancy exposure registry that monitors pregnancy outcomes in individuals exposed to triumeq during pregnancy. healthcare providers are encouraged to register patients by calling the antiretroviral pregnancy registry (apr) at 1‑800‑258‑4263. risk summary data from an ongoing birth outcome surveillance study has identified an increased risk of neural tube defects when dolutegravir, a component of triumeq, is administered at the time of conception. as defects related to closure of the neural tube occur from conception through the first 6 weeks of gestation, embryos exposed to dolutegravir from the time of conception through the first 6 weeks of gestation are at potential risk. advise adolescents and adults of childbearing potential, including those actively trying to become pregnant, of the potential risk of neural tube defects with use of triumeq. assess the risks and benefits of triumeq and discuss with the patient to determine if an alternative treatment should be considered at the time of conception through the first trimester of pregnancy or if pregnancy is confirmed in the first trimester. a benefit-risk assessment should consider factors such as feasibility of switching to another antiretroviral regimen, tolerability, ability to maintain viral suppression, and risk of hiv-1 transmission to the infant against the risk of neural tube defects associated with in utero dolutegravir exposure during critical periods of fetal development [see warnings and precautions ( 5.5 )] . there are insufficient human data on the use of triumeq during pregnancy to definitively assess a drug-associated risk for birth defects and miscarriage. the background risk for major birth defects for the indicated population is unknown. in the u.s. general population, the estimated background rate for major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. in animal reproduction studies, no evidence of adverse developmental outcomes was observed with dolutegravir at systemic exposures (auc) less than (rabbits) and approximately 50 times (rats) the exposure in humans at the recommended human dose (rhd) (see data) . oral administration of abacavir to pregnant rats during organogenesis resulted in fetal malformations and other embryonic and fetal toxicities at exposures 35 times the human exposure (auc) at the rhd. no adverse developmental effects were observed following oral administration of abacavir to pregnant rabbits during organogenesis at exposures approximately 9 times the human exposure (auc) at the rhd. oral administration of lamivudine to pregnant rabbits during organogenesis resulted in embryolethality at a human exposure (auc) similar to the rhd; however, no adverse development effects were observed with oral administration of lamivudine to pregnant rats during organogenesis at plasma concentrations (c max ) 35 times the rhd (see data). data human data: dolutegravir: in a birth outcome surveillance study in botswana, there were 7 cases of neural tube defects reported out of 3,591 deliveries (0.19%) to women who were exposed to dolutegravir-containing regimens at the time of conception. in comparison, the neural tube defect prevalence rates were 0.11% (21/19,361 deliveries) in the non-dolutegravir arm and 0.07% (87/119,630 deliveries) in the hiv-uninfected arm. seven cases reported with dolutegravir included 3 cases of myelomeningocele, 2 cases of encephalocele, and one case each of anencephaly and iniencephaly. in the same study, no increased risk of neural tube defects was identified in women who started dolutegravir during pregnancy. two infants out of 4,448 (0.04%) deliveries to women who started dolutegravir during pregnancy had a neural tube defect, compared with 5 infants out of 6,748 (0.07%) deliveries to women who started non-dolutegravir-containing regimens during pregnancy. the reported risks of neural tube defects by treatment groups were based on interim analyses from the ongoing surveillance study in botswana. it is unknown if baseline characteristics were balanced between the study treatment groups. the observed trends of association could change as data accumulate. data analyzed to date from other sources including the apr, clinical trials, and postmarketing data are insufficient to definitively address the risk of neural tube defects with dolutegravir. data from the birth outcome surveillance study described above and postmarketing sources with more than 1,000 pregnancy outcomes from second and third trimester exposure in pregnant women indicate no evidence of increased risk of adverse birth outcomes. based on prospective reports to the apr of over 1,000 exposures to dolutegravir during pregnancy resulting in live births (including 634 exposed in the first trimester), the prevalence of defects in live births was 3.3% (95% ci: 2.1% to 5.0%) following first-trimester exposure to dolutegravir-containing regimens and 5.1% (95% ci: 3.2% to 7.7%) following second-/third-trimester exposure to dolutegravir-containing regimens. in the u.s. reference population of the metropolitan atlanta congenital defects program (macdp), the background birth defect rate was 2.7%. dolutegravir has been shown to cross the placenta. in a clinical trial in uganda and south africa in women during the last trimester of pregnancy receiving dolutegravir 50 mg once daily, the ratio of median dolutegravir concentration in fetal umbilical cord to that in maternal peripheral plasma was 1.21 (range 0.51-2.11) (n = 15). abacavir: based on prospective reports to the apr of over 2,700 exposures to abacavir during pregnancy resulting in live births (including 1,391 exposed in the first trimester), there was no difference between the overall risk of birth defects for abacavir compared with the background birth defect rate of 2.7% in the u.s. reference population of the macdp. the prevalence of defects in live births was 3.2% (95% ci: 2.3% to 4.2%) following first trimester exposure to abacavir-containing regimens and 3.0% (95% ci: 2.1% to 4.0%) following second/third trimester exposure to abacavir-containing regimens. abacavir has been shown to cross the placenta and concentrations in neonatal plasma at birth were essentially equal to those in maternal plasma at delivery [see clinical pharmacology ( 12.3 )] . lamivudine: based on prospective reports to the apr of over 12,900 exposures to lamivudine during pregnancy resulting in live births (including 5,472 exposed in the first trimester), there was no difference between the overall risk of birth defects for lamivudine compared with the background birth defect rate of 2.7% in the u.s. reference population of the macdp. the prevalence of birth defects in live births was 3.1% (95% ci: 2.7% to 3.6%) following first trimester exposure to lamivudine-containing regimens and 2.9% (95% ci: 2.5%, 3.3%) following second/third trimester exposure to lamivudine-containing regimens. lamivudine pharmacokinetics were studied in pregnant women during 2 clinical trials conducted in south africa. the trials assessed pharmacokinetics in 16 women at 36 weeks’ gestation using 150 mg lamivudine twice daily with zidovudine, 10 women at 38 weeks’ gestation using 150 mg lamivudine twice daily with zidovudine, and 10 women at 38 weeks’ gestation using lamivudine 300 mg twice daily without other antiretrovirals. these trials were not designed or powered to provide efficacy information. lamivudine concentrations were generally similar in maternal, neonatal, and umbilical cord serum samples. in a subset of subjects, amniotic fluid specimens were collected following natural rupture of membranes and confirmed that lamivudine crosses the placenta in humans. based on limited data at delivery, median (range) amniotic fluid concentrations of lamivudine were 3.9-fold (1.2- to 12.8-fold) greater compared with paired maternal serum concentration (n = 8). animal data: dolutegravir: dolutegravir was administered orally to pregnant rats and rabbits (up to 1,000 mg/kg/day) on gestation days 6 to 17 and 6 to 18, respectively, and to rats on gestation day 6 to lactation/post-partum day 20. no adverse effects on embryo-fetal (rats and rabbits) or pre/post-natal (rats) development were observed up to the highest dose tested. during organogenesis, systemic exposures (auc) to dolutegravir in rabbits were less than the exposure in humans at the rhd and in rats were approximately 50 times the exposure in humans at the rhd. in the rat pre/post-natal development study, decreased body weight of the developing offspring was observed during lactation at a maternally toxic dose (approximately 50 times human exposure at the rhd). abacavir: abacavir was administered orally to pregnant rats (at 100, 300, and 1,000 mg/kg/day) and rabbits (at 125, 350, or 700 mg/kg/day) during organogenesis (on gestation days 6 through 17 and 6 through 20, respectively). fetal malformations (increased incidences of fetal anasarca and skeletal malformations) or developmental toxicity (decreased fetal body weight and crown‑rump length) were observed in rats at doses up to 1,000 mg/kg/day, resulting in exposures approximately 35 times the human exposure (auc) at the rhd. no developmental effects were observed in rats at 100 mg/kg/day, resulting in exposures (auc) 3.5 times the human exposure at the recommended daily dose. in a fertility and early embryo-fetal development study conducted in rats (at 60, 160, or 500 mg/kg/day), embryonic and fetal toxicities (increased resorptions, decreased fetal body weights) or toxicities to the offspring (increased incidence of stillbirth and lower body weights) occurred at doses up to 500 mg/kg/day. no developmental effects were observed in rats at 60 mg/kg/day, resulting in exposures (auc) approximately 4 times the human exposure at the rhd. studies in pregnant rats showed that abacavir is transferred to the fetus through the placenta. in pregnant rabbits, no developmental toxicities and no increases in fetal malformations occurred at up to the highest dose evaluated, resulting in exposures (auc) approximately 9 times the human exposure at the rhd. lamivudine: lamivudine was administered orally to pregnant rats (at 90, 600, and 4,000 mg/kg/day) and rabbits (at 90, 300 and 1,000 mg/kg/day and at 15, 40, and 90 mg/kg/day) during organogenesis (on gestation days 7 through 16 [rat] and 8 through 20 [rabbit]). no evidence of fetal malformations due to lamivudine was observed in rats and rabbits at doses producing plasma concentrations (c max ) approximately 35 times higher than human exposure at the recommended daily dose. evidence of early embryolethality was seen in the rabbit at systemic exposures (auc) similar to those observed in humans, but there was no indication of this effect in the rat at plasma concentrations (c max ) 35 times higher than human exposure at the recommended daily dose. studies in pregnant rats showed that lamivudine is transferred to the fetus through the placenta. in the fertility/pre- and postnatal development study in rats, lamivudine was administered orally at doses of 180, 900, and 4,000 mg/kg/day (from prior to mating through postnatal day 20). in the study, development of the offspring, including fertility and reproductive performance, were not affected by the maternal administration of lamivudine. 8.2 lactation risk summary the centers for disease control and prevention recommends that hiv‑1‑infected mothers in the united states not breastfeed their infants to avoid risking postnatal transmission of hiv‑1 infection. abacavir, dolutegravir and lamivudine are present in human milk. there is no information on the effects of triumeq or its components on the breastfed infant or the effects of the drug on milk production. because of the potential for (1) hiv‑1 transmission (in hiv-negative infants), (2) developing viral resistance (in hiv-positive infants), and (3) adverse reactions in a breastfed infant similar to those seen in adults, instruct mothers not to breastfeed if they are receiving triumeq. 8.3 females and males of reproductive potential in adolescents and adults of childbearing potential currently on triumeq who are actively trying to become pregnant or if pregnancy is confirmed in the first trimester, assess the risks and benefits of continuing triumeq and discuss with the patient if an alternative treatment should be considered [see warnings and precautions ( 5.5 ), use in specific populations ( 8.1 )] . pregnancy testing pregnancy testing is recommended in adolescents and adults of childbearing potential before initiation of triumeq [see dosage and administration ( 2.2 )] . contraception adolescents and adults of childbearing potential who are taking triumeq should be counseled on the consistent use of effective contraception. 8.4 pediatric use the clinical data supporting use of triumeq and triumeq pd in pediatric patients with hiv-1 infection weighing at least 10 kg is derived from the following previously conducted pediatric trials using the individual components of triumeq and triumeq pd: • the safety and efficacy of once-daily abacavir and lamivudine were established with a randomized, multicenter trial (arrow [col105677]) in hiv-1–infected, treatment-naive subjects aged 3 months to 17 years with a first-line regimen containing abacavir and lamivudine, using either the combination of epivir and ziagen or epzicom [see adverse reactions ( 6.1 ), clinical studies ( 14.2 )] . • the safety, pharmacokinetics, and antiviral activity (efficacy) of tivicay and tivicay pd were established through an ongoing, open-label, multicenter, dose-finding clinical trial (impaact p1093), in which hiv-1–infected, treatment-naive or treatment-experienced, insti-naive, pediatric and adolescent subjects aged 4 weeks to <18 years and weighing at least 3 kg were treated with tivicay or tivicay pd plus optimized background therapy [see adverse reactions ( 6.1 ), clinical pharmacology ( 12.3 ), clinical studies ( 14.2 )] . • additional pharmacokinetics data were evaluated in 2 pharmacokinetic substudies in odyssey, an ongoing open-label, randomized, non-inferiority trial to evaluate the safety, efficacy, and pharmacokinetic parameters of tivicay or tivicay pd plus two nrtis (mainly abacavir and lamivudine) compared with standard of care in hiv-1–infected pediatric subjects younger than 18 years [see clinical pharmacology ( 12.3 )] . overall, the safety, and efficacy profile of triumeq and triumeq pd in pediatric patients is comparable to that observed in adults. there are no data available on the use of lamivudine in pediatric patients with renal impairment [see warnings and precautions ( 5.4 ), adverse reactions ( 6.1 ), use in specific populations ( 8.6 ), clinical pharmacology ( 12.3 ), clinical studies ( 14.2 )] . safety and effectiveness of triumeq pd have not been established in pediatric patients weighing <10 kg. 8.5 geriatric use clinical trials of abacavir, dolutegravir, or lamivudine did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. in general, caution should be exercised in the administration of triumeq in elderly patients reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see clinical pharmacology ( 12.3 )]. 8.6 patients with impaired renal function triumeq and triumeq pd are not recommended for patients with creatinine clearance <30 ml/min because triumeq and triumeq pd are fixed-dose combinations and the dosage of the individual components cannot be adjusted. if a dose reduction of lamivudine, a component of triumeq and triumeq pd, is required for patients with creatinine clearance <30 ml/min, then the individual components should be used [see clinical pharmacology ( 12.3 )] . patients with a creatinine clearance between 30 and 49 ml/min receiving triumeq may experience a 1.6- to 3.3-fold higher lamivudine exposure (auc) than patients with a creatinine clearance ≥50 ml/min. there are no safety data from randomized, controlled trials comparing triumeq to the individual components in patients with a creatinine clearance between 30 and 49 ml/min who received dose-adjusted lamivudine. additionally, there are no data available on the use of lamivudine in pediatric patients with renal impairment. in the original lamivudine registrational trials in combination with zidovudine, higher lamivudine exposures were associated with higher rates of hematologic toxicities (neutropenia and anemia), although discontinuations due to neutropenia or anemia each occurred in <1% of subjects. patients with a sustained creatinine clearance between 30 and 49 ml/min who receive triumeq or triumeq pd should be monitored for hematologic toxicities. if new or worsening neutropenia or anemia develop, dose adjustment of lamivudine, per lamivudine prescribing information, is recommended. if lamivudine dose adjustment is indicated, triumeq or triumeq pd should be discontinued, and the individual components should be used to construct the treatment regimen. 8.7 patients with impaired hepatic function triumeq and triumeq pd are fixed-dose combinations, and the dosage of the individual components cannot be adjusted. if a dose reduction of abacavir, a component of triumeq and triumeq pd, is required for patients with mild hepatic impairment (child-pugh score a), then the individual components should be used [see clinical pharmacology ( 12.3 )] . the safety, efficacy, and pharmacokinetic properties of abacavir have not been established in patients with moderate (child-pugh score b) or severe (child-pugh score c) hepatic impairment; therefore, triumeq and triumeq pd are contraindicated in these patients [see contraindications ( 4 )].

o determine if an alternative treatment should be considered at the time of conception through the first trimester of pregnancy or if pregnancy is confirmed in the first trimester. a benefit-risk assessment should consider factors such as feasibility of switching to another antiretroviral regimen, tolerability, ability to maintain viral suppression, and risk of hiv-1 transmission to the infant against the risk of neural tube defects associated with in utero dolutegravir exposure during critical periods of fetal development [see warnings and precautions ( 5.5 )] . there are insufficient human data on the use of triumeq during pregnancy to definitively assess a drug-associated risk for birth defects and miscarriage. the background risk for major birth defects for the indicated population is unknown. in the u.s. general population, the estimated background rate for major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. in animal reproduction studies, no evidence of adverse developmental outcomes was observed with dolutegravir at systemic exposures (auc) less than (rabbits) and approximately 50 times (rats) the exposure in humans at the recommended human dose (rhd) (see data) . oral administration of abacavir to pregnant rats during organogenesis resulted in fetal malformations and other embryonic and fetal toxicities at exposures 35 times the human exposure (auc) at the rhd. no adverse developmental effects were observed following oral administration of abacavir to pregnant rabbits during organogenesis at exposures approximately 9 times the human exposure (auc) at the rhd. oral administration of lamivudine to pregnant rabbits during organogenesis resulted in embryolethality at a human exposure (auc) similar to the rhd; however, no adverse development effects were observed with oral administration of lamivudine to pregnant rats during organogenesis at plasma concentrations (c max ) 35 times the rhd (see data). data human data: dolutegravir: in a birth outcome surveillance study in botswana, there were 7 cases of neural tube defects reported out of 3,591 deliveries (0.19%) to women who were exposed to dolutegravir-containing regimens at the time of conception. in comparison, the neural tube defect prevalence rates were 0.11% (21/19,361 deliveries) in the non-dolutegravir arm and 0.07% (87/119,630 deliveries) in the hiv-uninfected arm. seven cases reported with dolutegravir included 3 cases of myelomeningocele, 2 cases of encephalocele, and one case each of anencephaly and iniencephaly. in the same study, no increased risk of neural tube defects was identified in women who started dolutegravir during pregnancy. two infants out of 4,448 (0.04%) deliveries to women who started dolutegravir during pregnancy had a neural tube defect, compared with 5 infants out of 6,748 (0.07%) deliveries to women who started non-dolutegravir-containing regimens during pregnancy. the reported risks of neural tube defects by treatment groups were based on interim analyses from the ongoing surveillance study in botswana. it is unknown if baseline characteristics were balanced between the study treatment groups. the observed trends of association could change as data accumulate. data analyzed to date from other sources including the apr, clinical trials, and postmarketing data are insufficient to definitively address the risk of neural tube defects with dolutegravir. data from the birth outcome surveillance study described above and postmarketing sources with more than 1,000 pregnancy outcomes from second and third trimester exposure in pregnant women indicate no evidence of increased risk of adverse birth outcomes. based on prospective reports to the apr of over 1,000 exposures to dolutegravir during pregnancy resulting in live births (including 634 exposed in the first trimester), the prevalence of defects in live births was 3.3% (95% ci: 2.1% to 5.0%) following first-trimester exposure to dolutegravir-containing regimens and 5.1% (95% ci: 3.2% to 7.7%) following second-/third-trimester exposure to dolutegravir-containing regimens. in the u.s. reference population of the metropolitan atlanta congenital defects program (macdp), the background birth defect rate was 2.7%. dolutegravir has been shown to cross the placenta. in a clinical trial in uganda and south africa in women during the last trimester of pregnancy receiving dolutegravir 50 mg once daily, the ratio of median dolutegravir concentration in fetal umbilical cord to that in maternal peripheral plasma was 1.21 (range 0.51-2.11) (n = 15). abacavir: based on prospective reports to the apr of over 2,700 exposures to abacavir during pregnancy resulting in live births (including 1,391 exposed in the first trimester), there was no difference between the overall risk of birth defects for abacavir compared with the background birth defect rate of 2.7% in the u.s. reference population of the macdp. the prevalence of defects in live births was 3.2% (95% ci: 2.3% to 4.2%) following first trimester exposure to abacavir-containing regimens and 3.0% (95% ci: 2.1% to 4.0%) following second/third trimester exposure to abacavir-containing regimens. abacavir has been shown to cross the placenta and concentrations in neonatal plasma at birth were essentially equal to those in maternal plasma at delivery [see clinical pharmacology ( 12.3 )] . lamivudine: based on prospective reports to the apr of over 12,900 exposures to lamivudine during pregnancy resulting in live births (including 5,472 exposed in the first trimester), there was no difference between the overall risk of birth defects for lamivudine compared with the background birth defect rate of 2.7% in the u.s. reference population of the macdp. the prevalence of birth defects in live births was 3.1% (95% ci: 2.7% to 3.6%) following first trimester exposure to lamivudine-containing regimens and 2.9% (95% ci: 2.5%, 3.3%) following second/third trimester exposure to lamivudine-containing regimens. lamivudine pharmacokinetics were studied in pregnant women during 2 clinical trials conducted in south africa. the trials assessed pharmacokinetics in 16 women at 36 weeks’ gestation using 150 mg lamivudine twice daily with zidovudine, 10 women at 38 weeks’ gestation using 150 mg lamivudine twice daily with zidovudine, and 10 women at 38 weeks’ gestation using lamivudine 300 mg twice daily without other antiretrovirals. these trials were not designed or powered to provide efficacy information. lamivudine concentrations were generally similar in maternal, neonatal, and umbilical cord serum samples. in a subset of subjects, amniotic fluid specimens were collected following natural rupture of membranes and confirmed that lamivudine crosses the placenta in humans. based on limited data at delivery, median (range) amniotic fluid concentrations of lamivudine were 3.9-fold (1.2- to 12.8-fold) greater compared with paired maternal serum concentration (n = 8). animal data: dolutegravir: dolutegravir was administered orally to pregnant rats and rabbits (up to 1,000 mg/kg/day) on gestation days 6 to 17 and 6 to 18, respectively, and to rats on gestation day 6 to lactation/post-partum day 20. no adverse effects on embryo-fetal (rats and rabbits) or pre/post-natal (rats) development were observed up to the highest dose tested. during organogenesis, systemic exposures (auc) to dolutegravir in rabbits were less than the exposure in humans at the rhd and in rats were approximately 50 times the exposure in humans at the rhd. in the rat pre/post-natal development study, decreased body weight of the developing offspring was observed during lactation at a maternally toxic dose (approximately 50 times human exposure at the rhd). abacavir: abacavir was administered orally to pregnant rats (at 100, 300, and 1,000 mg/kg/day) and rabbits (at 125, 350, or 700 mg/kg/day) during organogenesis (on gestation days 6 through 17 and 6 through 20, respectively). fetal malformations (increased incidences of fetal anasarca and skeletal malformations) or developmental toxicity (decreased fetal body weight and crown‑rump length) were observed in rats at doses up to 1,000 mg/kg/day, resulting in exposures approximately 35 times the human exposure (auc) at the rhd. no developmental effects were observed in rats at 100 mg/kg/day, resulting in exposures (auc) 3.5 times the human exposure at the recommended daily dose. in a fertility and early embryo-fetal development study conducted in rats (at 60, 160, or 500 mg/kg/day), embryonic and fetal toxicities (increased resorptions, decreased fetal body weights) or toxicities to the offspring (increased incidence of stillbirth and lower body weights) occurred at doses up to 500 mg/kg/day. no developmental effects were observed in rats at 60 mg/kg/day, resulting in exposures (auc) approximately 4 times the human exposure at the rhd. studies in pregnant rats showed that abacavir is transferred to the fetus through the placenta. in pregnant rabbits, no developmental toxicities and no increases in fetal malformations occurred at up to the highest dose evaluated, resulting in exposures (auc) approximately 9 times the human exposure at the rhd. lamivudine: lamivudine was administered orally to pregnant rats (at 90, 600, and 4,000 mg/kg/day) and rabbits (at 90, 300 and 1,000 mg/kg/day and at 15, 40, and 90 mg/kg/day) during organogenesis (on gestation days 7 through 16 [rat] and 8 through 20 [rabbit]). no evidence of fetal malformations due to lamivudine was observed in rats and rabbits at doses producing plasma concentrations (c max ) approximately 35 times higher than human exposure at the recommended daily dose. evidence of early embryolethality was seen in the rabbit at systemic exposures (auc) similar to those observed in humans, but there was no indication of this effect in the rat at plasma concentrations (c max ) 35 times higher than human exposure at the recommended daily dose. studies in pregnant rats showed that lamivudine is transferred to the fetus through the placenta. in the fertility/pre- and postnatal development study in rats, lamivudine was administered orally at doses of 180, 900, and 4,000 mg/kg/day (from prior to mating through postnatal day 20). in the study, development of the offspring, including fertility and reproductive performance, were not affected by the maternal administration of lamivudine.

the qtc interval over 24 hours postdose. effects on renal function the effect of dolutegravir on renal function was evaluated in an open-label, randomized, 3-arm, parallel, placebo-controlled trial in healthy subjects (n = 37) who received dolutegravir 50 mg once daily (n = 12), dolutegravir 50 mg twice daily (n = 13), or placebo once daily (n = 12) for 14 days. a decrease in creatinine clearance, as determined by 24-hour urine collection, was observed with both doses of dolutegravir after 14 days of treatment in subjects who received 50 mg once daily (9% decrease) and 50 mg twice daily (13% decrease). neither dose of dolutegravir had a significant effect on the actual glomerular filtration rate (determined by the clearance of probe drug, iohexol) or effective renal plasma flow (determined by the clearance of probe drug, para-amino hippurate) compared with the placebo. 12.3 pharmacokinetics pharmacokinetics in adults one triumeq tablet was bioequivalent to one dolutegravir (tivicay) tablet (50 mg) plus one abacavir and lamivudine fixed-dose combination tablet (epzicom) under fasted conditions in healthy subjects (n = 62). triumeq tablets and triumeq pd tablets for oral suspension are bioequivalent for the abacavir and lamivudine components, but not for the dolutegravir component. the relative dolutegravir bioavailability of triumeq pd is approximately 1.7-fold higher than triumeq; therefore, the 2 dosage forms are not interchangeable on a milligram-per-milligram basis [see dosage and administration ( 2.3 ), warnings and precautions ( 5.8 )] . the relative dolutegravir bioavailability is expected to be similar between triumeq pd and tivicay pd. abacavir: following oral administration, abacavir is rapidly absorbed and extensively distributed. after oral administration of a single dose of 600 mg of abacavir in 20 subjects, c max was 4.26 ± 1.19 mcg/ml (mean ± sd) and auc ∞ was 11.95 ± 2.51 mcg•hour/ml. binding of abacavir to human plasma proteins is approximately 50% and was independent of concentration. total blood and plasma drug‑related radioactivity concentrations are identical, demonstrating that abacavir readily distributes into erythrocytes. the primary routes of elimination of abacavir are metabolism by alcohol dehydrogenase to form the 5′‑carboxylic acid and glucuronyl transferase to form the 5′‑glucuronide. in single-dose trials, the observed elimination half-life (t ½ ) was 1.54 ± 0.63 hours. after intravenous administration, total clearance was 0.80 ± 0.24 l/h/kg (mean ± sd). dolutegravir: following oral administration of dolutegravir, peak plasma concentrations were observed 2 to 3 hours postdose. with once-daily dosing, pharmacokinetic steady state is achieved within approximately 5 days with average accumulation ratios for auc, c max , and c 24 h ranging from 1.2 to 1.5. dolutegravir is a p-gp substrate in vitro. the absolute bioavailability of dolutegravir has not been established. dolutegravir is highly bound (≥98.9%) to human plasma proteins based on in vivo data and binding is independent of plasma concentration of dolutegravir. the apparent volume of distribution (vd/f) following 50-mg once-daily administration is estimated at 17.4 l based on a population pharmacokinetic analysis. dolutegravir is primarily metabolized via ugt1a1 with some contribution from cyp3a. after a single oral dose of [ 14 c] dolutegravir, 53% of the total oral dose is excreted unchanged in the feces. thirty-one percent of the total oral dose is excreted in the urine, represented by an ether glucuronide of dolutegravir (18.9% of total dose), a metabolite formed by oxidation at the benzylic carbon (3.0% of total dose), and its hydrolytic n-dealkylation product (3.6% of total dose). renal elimination of unchanged drug was <1% of the dose. dolutegravir has a terminal half-life of approximately 14 hours and an apparent clearance (cl/f) of 1.0 l/h based on population pharmacokinetic analyses. the pharmacokinetic properties of dolutegravir have been evaluated in healthy adult subjects and hiv‑1–infected adult subjects. exposure to dolutegravir was generally similar between healthy subjects and hiv‑1–infected subjects. table 7. dolutegravir steady-state pharmacokinetic parameter estimates in hiv-1–infected adults parameter 50 mg once daily geometric mean (%cv) auc (0-24) (mcg•h/ml) 53.6 (27) c max (mcg/ml) 3.67 (20) c min (mcg/ml) 1.11 (46) cerebrospinal fluid (csf): in 11 treatment-naive subjects on dolutegravir 50 mg daily plus abacavir/lamivudine, the median dolutegravir concentration in csf was 18 ng/ml (range: 4 ng/ml to 23.2 ng/ml) 2 to 6 hours postdose after 2 weeks of treatment. the clinical relevance of this finding has not been established. lamivudine: following oral administration, lamivudine is rapidly absorbed and extensively distributed. after multiple‑dose oral administration of lamivudine 300 mg once daily for 7 days to 60 healthy subjects, steady-state c max (c max,ss ) was 2.04 ± 0.54 mcg/ml (mean ± sd) and the 24‑hour steady‑state auc (auc 24,ss ) was 8.87 ± 1.83 mcg•hour/ml. binding to plasma protein is low. approximately 70% of an intravenous dose of lamivudine is recovered as unchanged drug in the urine. metabolism of lamivudine is a minor route of elimination. in humans, the only known metabolite is the trans‑sulfoxide metabolite (approximately 5% of an oral dose after 12 hours). in most single-dose trials with plasma sampling up to 48 or 72 hours after dosing, the observed mean elimination half-life (t ½ ) ranged from 13 to 19 hours. in hiv-1–infected subjects, total clearance was 398.5 ± 69.1 ml per min (mean ± sd). effect of food on oral absorption triumeq or triumeq pd may be taken with or without food. overall, when compared with fasted conditions, administration of triumeq to healthy adult subjects with a high-fat meal (53% fat, 869 calories) resulted in decreased c max for abacavir and increased c max and auc for dolutegravir. lamivudine exposures were not affected by food. with a high-fat meal, the c max of abacavir decreased 23% and the c max and auc of dolutegravir increased 37% and 48%, respectively. when compared with fasted conditions, administration of triumeq pd to healthy adult subjects with a high-fat meal (50% fat, 917 calories) resulted in decreased c max for abacavir (55%), dolutegravir (29%) and lamivudine (36%). aucs for all 3 components were not affected by food. specific populations patients with renal impairment: the pharmacokinetics for the individual components of triumeq and triumeq pd have been evaluated in patients with renal impairment (see the u.s. prescribing information for the individual abacavir, dolutegravir, and lamivudine components). patients with hepatic impairment: the pharmacokinetics for the individual components of triumeq and triumeq pd have been evaluated in patients with varying degrees of hepatic impairment (see the u.s. prescribing information for the individual abacavir, dolutegravir, and lamivudine components). pregnant women: abacavir: abacavir pharmacokinetics were studied in 25 pregnant women during the last trimester of pregnancy receiving abacavir 300 mg twice daily. abacavir exposure (auc) during pregnancy was similar to those in postpartum and in hiv-infected non-pregnant historical controls. consistent with passive diffusion of abacavir across the placenta, abacavir concentrations in neonatal plasma cord samples at birth were essentially equal to those in maternal plasma at delivery. lamivudine: lamivudine pharmacokinetics were studied in 36 pregnant women during 2 clinical trials conducted in south africa. lamivudine pharmacokinetics in pregnant women were similar to those seen in non-pregnant adults and in postpartum women. lamivudine concentrations were generally similar in maternal, neonatal and umbilical cord serum samples. pediatric patients: the pharmacokinetics for the individual components of triumeq and triumeq pd (abacavir, dolutegravir, and lamivudine) have been evaluated in pediatric subjects. dolutegravir: the pharmacokinetics of dolutegravir were evaluated in the impaact p1093 trial and in 2 weight-band–based pharmacokinetic substudies from the odyssey trial [see use in specific populations ( 8.4 ), clinical studies ( 14.2 )] . mean dolutegravir auc 0-24h and c 24h in hiv-1–infected pediatric subjects weighing at least 10 kg were comparable to those in adults after 50 mg once daily or 50 mg twice daily. mean c max is higher in pediatrics, but the increase is not considered clinically significant as the safety profiles were similar in pediatric and adult subjects [see adverse reactions (6.1)] . refer to the prescribing information for tivicay for pharmacokinetic information on dolutegravir in pediatric patients. abacavir and lamivudine: in pediatric patients weighing 25 kg and above, the dosing recommendations for triumeq in this population are based on the safety and efficacy established in a controlled trial conducted using either the combination of epivir and ziagen or epzicom. in pediatric patients weighing 10 to <25 kg, predicted exposures (auc 0-24h ) of abacavir and lamivudine at the recommended doses for triumeq pd are within the observed exposure ranges at the recommended doses of individual products in adults and pediatrics. refer to the prescribing information for epivir and ziagen for pharmacokinetic information on the individual products in pediatric patients [see dosage and administration ( 2.2 ), clinical studies ( 14.2 )] . geriatric patients: population analyses using pooled pharmacokinetic data from adult trials indicated age had no clinically relevant effect on the pharmacokinetics of dolutegravir. the pharmacokinetics of abacavir or lamivudine have not been studied in subjects older than 65 years. male and female patients: there are no significant or clinically relevant gender differences in the pharmacokinetics of the individual components (dolutegravir, abacavir, or lamivudine) based on the available information that was analyzed for each of the individual components. racial groups: there are no significant or clinically relevant racial differences in pharmacokinetics of the individual components (dolutegravir, abacavir, or lamivudine) based on the available information that was analyzed for each of the individual components. drug interaction studies the drug interaction trials described were conducted with dolutegravir, abacavir, and/or lamivudine as single entities; no drug interaction trials have been conducted using the combination of abacavir, dolutegravir, and lamivudine. no clinically significant drug interactions are expected between dolutegravir, abacavir, and lamivudine. dosing recommendations as a result of established and other potentially significant drug-drug interactions with the individual components of triumeq and triumeq pd are provided in section 7.3 [see drug interactions ( 7 )] . table 8. summary of effect of dolutegravir on the pharmacokinetics of coadministered drugs a the number of subjects represents the maximum number of subjects that were evaluated. coadministered drug(s) and dose(s) dose of dolutegravir n geometric mean ratio (90% ci) of pharmacokinetic parameters of coadministered drug with/without dolutegravir no effect = 1.00 c max auc c τ or c 24 daclatasvir 60 mg once daily 50 mg once daily 12 1.03 (0.84 to 1.25) 0.98 (0.83 to 1.15) 1.06 (0.88 to 1.29) ethinyl estradiol 0.035 mg 50 mg twice daily 15 0.99 (0.91 to 1.08) 1.03 (0.96 to 1.11) 1.02 (0.93 to 1.11) metformin 500 mg twice daily 50 mg once daily 15 a 1.66 (1.53 to 1.81) 1.79 (1.65 to 1.93) — metformin 500 mg twice daily 50 mg twice daily 15 a 2.11 (1.91 to 2.33) 2.45 (2.25 to 2.66) — methadone 16 to 150 mg 50 mg twice daily 11 1.00 (0.94 to 1.06) 0.98 (0.91 to 1.06) 0.99 (0.91 to 1.07) midazolam 3 mg 25 mg once daily 10 — 0.95 (0.79 to 1.15) — norelgestromin 0.25 mg 50 mg twice daily 15 0.89 (0.82 to 0.97) 0.98 (0.91 to 1.04) 0.93 (0.85 to 1.03) rilpivirine 25 mg once daily 50 mg once daily 16 1.10 (0.99 to 1.22) 1.06 (0.98 to 1.16) 1.21 (1.07 to 1.38) tenofovir disoproxil fumarate 300 mg once daily 50 mg once daily 15 1.09 (0.97 to 1.23) 1.12 (1.01 to 1.24) 1.19 (1.04 to 1.35) table 9. summary of effect of coadministered drugs on the pharmacokinetics of dolutegravir a comparison is rifampin taken with dolutegravir 50 mg twice daily compared with dolutegravir 50 mg twice daily. b comparison is rifampin taken with dolutegravir 50 mg twice daily compared with dolutegravir 50 mg once daily. c the number of subjects represents the maximum number of subjects that were evaluated. coadministered drug(s) and dose(s) dose of dolutegravir n geometric mean ratio (90% ci) of dolutegravir pharmacokinetic parameters with/without coadministered drugs no effect = 1.00 c max auc c τ or c 24 atazanavir 400 mg once daily 30 mg once daily 12 1.50 (1.40 to 1.59) 1.91 (1.80 to 2.03) 2.80 (2.52 to 3.11) atazanavir/ritonavir 300/100 mg once daily 30 mg once daily 12 1.34 (1.25 to 1.42) 1.62 (1.50 to 1.74) 2.21 (1.97 to 2.47) darunavir/ritonavir 600/100 mg twice daily 30 mg once daily 15 0.89 (0.83 to 0.97) 0.78 (0.72 to 0.85) 0.62 (0.56 to 0.69) efavirenz 600 mg once daily 50 mg once daily 12 0.61 (0.51 to 0.73) 0.43 (0.35 to 0.54) 0.25 (0.18 to 0.34) etravirine 200 mg twice daily 50 mg once daily 16 0.48 (0.43 to 0.54) 0.29 (0.26 to 0.34) 0.12 (0.09 to 0.16) etravirine + darunavir/ritonavir 200 mg + 600/100 mg twice daily 50 mg once daily 9 0.88 (0.78 to 1.00) 0.75 (0.69 to 0.81) 0.63 (0.52 to 0.76) etravirine + lopinavir/ritonavir 200 mg + 400/100 mg twice daily 50 mg once daily 8 1.07 (1.02 to 1.13) 1.11 (1.02 to 1.20) 1.28 (1.13 to 1.45) fosamprenavir/ritonavir 700 mg/100 mg twice daily 50 mg once daily 12 0.76 (0.63 to 0.92) 0.65 (0.54 to 0.78) 0.51 (0.41 to 0.63) lopinavir/ritonavir 400/100 mg twice daily 30 mg once daily 15 1.00 (0.94 to 1.07) 0.97 (0.91 to 1.04) 0.94 (0.85 to 1.05) rilpivirine 25 mg once daily 50 mg once daily 16 1.13 (1.06 to 1.21) 1.12 (1.05 to 1.19) 1.22 (1.15 to 1.30) tenofovir 300 mg once daily 50 mg once daily 15 0.97 (0.87 to 1.08) 1.01 (0.91 to 1.11) 0.92 (0.82 to 1.04) tipranavir/ritonavir 500/200 mg twice daily 50 mg once daily 14 0.54 (0.50 to 0.57) 0.41 (0.38 to 0.44) 0.24 (0.21 to 0.27) antacid (maalox) simultaneous administration 50 mg single dose 16 0.28 (0.23 to 0.33) 0.26 (0.22 to 0.32) 0.26 (0.21 to 0.31) antacid (maalox) 2 h after dolutegravir 50 mg single dose 16 0.82 (0.69 to 0.98) 0.74 (0.62 to 0.90) 0.70 (0.58 to 0.85) boceprevir 800 mg every 8 h 50 mg once daily 13 1.05 (0.96 to 1.15) 1.07 (0.95 to 1.20) 1.08 (0.91 to 1.28) calcium carbonate 1,200 mg simultaneous administration (fasted) 50 mg single dose 12 0.63 (0.50 to 0.81) 0.61 (0.47 to 0.80) 0.61 (0.47 to 0.80) calcium carbonate 1,200 mg simultaneous administration (fed) 50 mg single dose 11 1.07 (0.83 to 1.38) 1.09 (0.84 to 1.43) 1.08 (0.81 to 1.42) calcium carbonate 1,200 mg 2 h after dolutegravir 50 mg single dose 11 1.00 (0.78 to 1.29) 0.94 (0.72 to 1.23) 0.90 (0.68 to 1.19) carbamazepine 300 mg twice daily 50 mg once daily 16 c 0.67 (0.61 to 0.73) 0.51 (0.48 to 0.55) 0.27 (0.24 to 0.31) daclatasvir 60 mg once daily 50 mg once daily 12 1.29 (1.07 to 1.57) 1.33 (1.11 to 1.59) 1.45 (1.25 to 1.68) ferrous fumarate 324 mg simultaneous administration (fasted) 50 mg single dose 11 0.43 (0.35 to 0.52) 0.46 (0.38 to 0.56) 0.44 (0.36 to 0.54) ferrous fumarate 324 mg simultaneous administration (fed) 50 mg single dose 11 1.03 (0.84 to 1.26) 0.98 (0.81 to 1.20) 1.00 (0.81 to 1.23) ferrous fumarate 324 mg 2 h after dolutegravir 50 mg single dose 10 0.99 (0.81 to 1.21) 0.95 (0.77 to 1.15) 0.92 (0.74 to 1.13) multivitamin (one-a-day) simultaneous administration 50 mg single dose 16 0.65 (0.54 to 0.77) 0.67 (0.55 to 0.81) 0.68 (0.56 to 0.82) omeprazole 40 mg once daily 50 mg single dose 12 0.92 (0.75 to 1.11) 0.97 (0.78 to 1.20) 0.95 (0.75 to 1.21) prednisone 60 mg once daily with taper 50 mg once daily 12 1.06 (0.99 to 1.14) 1.11 (1.03 to 1.20) 1.17 (1.06 to 1.28) rifampin a 600 mg once daily 50 mg twice daily 11 0.57 (0.49 to 0.65) 0.46 (0.38 to 0.55) 0.28 (0.23 to 0.34) rifampin b 600 mg once daily 50 mg twice daily 11 1.18 (1.03 to 1.37) 1.33 (1.15 to 1.53) 1.22 (1.01 to 1.48) rifabutin 300 mg once daily 50 mg once daily 9 1.16 (0.98 to 1.37) 0.95 (0.82 to 1.10) 0.70 (0.57 to 0.87) abacavir or lamivudine: the drug interactions described are based on trials conducted with abacavir or lamivudine as single entities. effect of abacavir and lamivudine on the pharmacokinetics of other agents: in vitro studies have shown that abacavir has potential to inhibit cyp1a1 and limited potential to inhibit metabolism mediated by cyp3a4. lamivudine does not inhibit or induce cyp3a4. abacavir and lamivudine do not inhibit or induce other cyp enzymes (such as cyp2c9 or cyp2d6). based on in vitro study results, abacavir and lamivudine at therapeutic drug exposures are not expected to affect the pharmacokinetics of drugs that are substrates of the following transporters: oatp1b1/3, bcrp or p-gp, oct1, oct2, oct3 (lamivudine only), or mate1 and mate2‑k. abacavir, dolutegravir, and lamivudine: coadministration of a single dose of riociguat (0.5 mg) to hiv-1–infected subjects receiving triumeq is reported to increase riociguat auc (∞) compared with riociguat auc (∞) reported in healthy subjects due to cyp1a1 inhibition by abacavir. the exact magnitude of increase in riociguat exposure has not been fully characterized based on findings from two studies [see drug interactions ( 7.3 )] . effect of other agents on the pharmacokinetics of abacavir or lamivudine: in vitro, abacavir is not a substrate of oatp1b1, oatp1b3, oct1, oct2, oat1, mate1, mate2-k, mrp2 or mrp4; therefore, drugs that modulate these transporters are not expected to affect abacavir plasma concentrations. abacavir is a substrate of bcrp and p-gp in vitro; however, considering its absolute bioavailability (83%), modulators of these transporters are unlikely to result in a clinically relevant impact on abacavir concentrations. lamivudine is a substrate of mate1, mate2-k, and oct2 in vitro. trimethoprim (an inhibitor of these drug transporters) has been shown to increase lamivudine plasma concentrations. this interaction is not considered clinically significant as no dose adjustment of lamivudine is needed. lamivudine is a substrate of p-gp and bcrp; however, considering its absolute bioavailability (87%), it is unlikely that these transporters play a significant role in the absorption of lamivudine. therefore, coadministration of drugs that are inhibitors of these efflux transporters is unlikely to affect the disposition and elimination of lamivudine. ethanol: abacavir has no effect on the pharmacokinetic properties of ethanol. ethanol decreases the elimination of abacavir causing an increase in overall exposure. interferon alfa: there was no significant pharmacokinetic interaction between lamivudine and interferon alfa in a trial of 19 healthy male subjects. methadone: in a trial of 11 hiv‑1–infected subjects receiving methadone‑maintenance therapy (40 mg and 90 mg daily), with 600 mg of abacavir twice daily (twice the currently recommended dose), oral methadone clearance increased 22% (90% ci: 6% to 42%) [see drug interactions ( 7.3 )]. the addition of methadone has no clinically significant effect on the pharmacokinetic properties of abacavir . ribavirin: in vitro data indicate ribavirin reduces phosphorylation of lamivudine, stavudine, and zidovudine. however, no pharmacokinetic (e.g., plasma concentrations or intracellular triphosphorylated active metabolite concentrations) or pharmacodynamic (e.g., loss of hiv‑1/hcv virologic suppression) interaction was observed when ribavirin and lamivudine (n = 18), stavudine (n = 10), or zidovudine (n = 6) were coadministered as part of a multi‑drug regimen to hiv‑1/hcv co‑infected subjects. sorbitol (excipient): lamivudine and sorbitol solutions were coadministered to 16 healthy adult subjects in an open-label, randomized-sequence, 4-period, crossover trial. each subject received a single 300-mg dose of lamivudine oral solution alone or coadministered with a single dose of 3.2 g, 10.2 g, or 13.4 g of sorbitol in solution. coadministration of lamivudine with sorbitol resulted in dose-dependent decreases of 20%, 39%, and 44% in the auc (0-24) ; 14%, 32%, and 36% in the auc (∞) ; and 28%, 52%, and 55% in the c max ; of lamivudine, respectively. abacavir, lamivudine, zidovudine: fifteen hiv‑1–infected subjects were enrolled in a crossover-designed drug interaction trial evaluating single doses of abacavir (600 mg), lamivudine (150 mg), and zidovudine (300 mg) alone or in combination. analysis showed no clinically relevant changes in the pharmacokinetics of abacavir with the addition of lamivudine or zidovudine or the combination of lamivudine and zidovudine. lamivudine exposure (auc decreased 15%) and zidovudine exposure (auc increased 10%) did not show clinically relevant changes with concurrent abacavir. lamivudine and zidovudine: no clinically significant alterations in lamivudine or zidovudine pharmacokinetics were observed in 12 asymptomatic hiv‑1–infected adult patients given a single dose of zidovudine (200 mg) in combination with multiple doses of lamivudine (300 mg every 12 hours). the effects of other coadministered drugs on abacavir or lamivudine are provided in table 10 . table 10. effect of coadministered drugs on abacavir or lamivudine ↑ = increase; ↔ = no significant change. a the drug-drug interaction was only evaluated in males. coadministered drug and dose drug and dose n concentrations of abacavir or lamivudine concentration of coadministered drug auc variability ethanol 0.7 g/kg abacavir single 600 mg 24 ↑41% 90% ci: 35% to 48% ↔ a nelfinavir 750 mg every 8 h x 7 to 10 days lamivudine single 150 mg 11 ↑10% 95% ci: 1% to 20% ↔ trimethoprim 160 mg/ sulfamethoxazole 800 mg daily x 5 days lamivudine single 300 mg 14 ↑43% 90% ci: 32% to 55% ↔ 12.4 microbiology mechanism of action dolutegravir: dolutegravir inhibits hiv integrase by binding to the integrase active site and blocking the strand transfer step of retroviral dna integration which is essential for the hiv replication cycle. strand transfer biochemical assays using purified recombinant hiv‑1 integrase and pre-processed substrate dna resulted in ic 50 values of 2.7 nm and 12.6 nm. abacavir: abacavir is a carbocyclic synthetic nucleoside analogue. abacavir is converted by cellular enzymes to the active metabolite, carbovir triphosphate (cbv‑tp), an analogue of deoxyguanosine‑5′‑triphosphate (dgtp). cbv‑tp inhibits the activity of hiv‑1 reverse transcriptase (rt) both by competing with the natural substrate dgtp and by its incorporation into viral dna. lamivudine: lamivudine is a synthetic nucleoside analogue. intracellularly lamivudine is phosphorylated to its active 5′-triphosphate metabolite, lamivudine triphosphate (3tc‑tp). the principal mode of action of 3tc‑tp is inhibition of rt via dna chain termination after incorporation of the nucleotide analogue. antiviral activity in cell culture dolutegravir: dolutegravir exhibited antiviral activity against laboratory strains of wild-type hiv‑1 with mean concentration of drug necessary to affect viral replication by 50% (ec 50 ) values of 0.5 nm (0.21 ng/ml) to 2.1 nm (0.85 ng/ml) in peripheral blood mononuclear cells (pbmcs) and mt-4 cells. dolutegravir exhibited antiviral activity against 13 clinically diverse clade b isolates with a median ec 50 value of 0.54 nm (range: 0.41 to 0.60 nm) in a viral susceptibility assay using the integrase coding region from clinical isolates. dolutegravir demonstrated antiviral activity in cell culture against a panel of hiv‑1 clinical isolates with median ec 50 values of 0.18 nm (n = 3, range: 0.09 to 0.5 nm), 0.08 nm (n = 5, range: 0.05 to 2.14 nm), 0.12 nm (n = 4, range: 0.05 to 0.51 nm), 0.17 nm (n = 3, range: 0.16 to 0.35 nm), 0.24 nm (n = 3, range: 0.09 to 0.32 nm), 0.17 nm (n = 4, range: 0.07 to 0.44 nm), 0.2 nm (n = 3, range: 0.02 to 0.87 nm), and 0.42 nm (n = 3, range: 0.41 to 1.79 nm) for clades a, b, c, d, e, f, and g, and group o viruses, respectively. dolutegravir ec 50 values against three hiv-2 clinical isolates in pbmc assays ranged from 0.09 nm to 0.61 nm. abacavir: the antiviral activity of abacavir against hiv‑1 was assessed in a number of cell lines including in primary monocytes/macrophages and pbmcs. ec 50 values ranged from 3,700 to 5,800 nm (1 nm = 0.28 ng/ml) and 70 to 1,000 nm against hiv‑1 iiib and hiv‑1 bal , respectively, and the mean ec 50 value was 260 ± 180 nm against 8 clinical isolates. the median ec 50 values of abacavir were 344 nm (range: 14.8 to 676 nm), 16.9 nm (range: 5.9 to 27.9 nm), 8.1 nm (range: 1.5 to 16.7 nm), 356 nm (range: 35.7 to 396 nm), 105 nm (range: 28.1 to 168 nm), 47.6 nm (range: 5.2 to 200 nm), 51.4 nm (range: 7.1 to 177 nm), and 282 nm (range: 22.4 to 598 nm) against hiv‑1 clades a-g and group o viruses (n = 3 except n = 2 for clade b), respectively. the ec 50 values against hiv‑2 isolates (n = 4), ranged from 24 to 490 nm. lamivudine: the antiviral activity of lamivudine against hiv‑1 was assessed in a number of cell lines including monocytes and pbmcs using standard susceptibility assays. ec 50 values were in the range of 3 to 15,000 nm (1 nm = 0.23 ng/ml). the median ec 50 values of lamivudine were 60 nm (range: 20 to 70 nm), 35 nm (range: 30 to 40 nm), 30 nm (range: 20 to 90 nm), 20 nm (range: 3 to 40 nm), 30 nm (range: 1 to 60 nm), 30 nm (range: 20 to 70 nm), 30 nm (range: 3 to 70 nm), and 30 nm (range: 20 to 90 nm) against hiv‑1 clades a-g and group o viruses (n = 3 except n = 2 for clade b) respectively. the ec 50 values against hiv‑2 isolates (n = 4) from 3 to 120 nm in pbmcs. ribavirin (50,000 nm) used in the treatment of chronic hcv infection decreased the anti-hiv‑1 activity of lamivudine by 3.5‑fold in mt‑4 cells. antiviral activity in combination with other antiviral agents neither dolutegravir, abacavir, nor lamivudine were antagonistic to all tested anti-hiv agents. see full prescribing information for ziagen (abacavir), tivicay (dolutegravir), and epivir (lamivudine). resistance in cell culture dolutegravir: dolutegravir-resistant viruses were selected in cell culture starting from different wild-type hiv‑1 strains and clades. amino acid substitutions e92q, g118r, s153f or y, g193e or r263k emerged in different passages and conferred decreased susceptibility to dolutegravir of up to 4-fold. abacavir and lamivudine: hiv-1 isolates with reduced susceptibility to the combination of abacavir and lamivudine have been selected in cell culture with amino acid substitutions k65r, l74v, y115f, and m184v/i in hiv-1 rt. m184v or i substitutions resulted in high-level resistance to lamivudine and approximately 2-fold decrease in susceptibility to abacavir. substitutions k65r, l74v, or y115f with m184v or i conferred a 7- to 8-fold reduction in abacavir susceptibility, and combinations of three substitutions were required to confer more than an 8-fold reduction in susceptibility. resistance in clinical subjects no subjects in the treatment arm receiving dolutegravir + epzicom in single (treatment- naive trial) had a detectable decrease in susceptibility to dolutegravir or background nrtis in the resistance analysis subset (n = 11 with hiv-1 rna >400 copies/ml at failure or last visit and having resistance data). two virologic failure subjects in single had treatment-emergent g/d/e193d and g193g/e integrase substitutions at week 84 and week 108, respectively, and 1 subject with 275 copies/ml hiv-1 rna had a treatment-emergent q157q/p integrase substitution detected at week 24. none of these subjects had a corresponding decrease in dolutegravir susceptibility. no treatment-emergent genotypic resistance to abacavir and lamivudine, components of triumeq and triumeq pd, was observed in the arm receiving dolutegravir + epzicom in the single trial through week 144. cross-resistance dolutegravir: cross-resistance has been observed among instis. the single insti-resistance substitutions t66k, i151l, and s153y conferred a >2-fold decrease in dolutegravir susceptibility (range: 2.3-fold to 3.6-fold from reference). combinations of multiple substitutions t66k/l74m, e92q/n155h, g140c/q148r, g140s/q148h, r or k, q148r/n155h, t97a/g140s/q148, and substitutions at e138/g140/q148 showed a >2-fold decrease in dolutegravir susceptibility (range: 2.5-fold to 21-fold from reference). in hiv-2 mutants, combinations of substitutions a153g/n155h/s163g and e92q/t97a/n155h/s163d conferred 4-fold decreases in dolutegravir susceptibility, and e92q/n155h and g140s/q148r showed 8.5-fold and 17-fold decreases in dolutegravir susceptibility, respectively. abacavir and lamivudine: cross‑resistance has been observed among nrtis. the combination of abacavir/lamivudine has demonstrated decreased susceptibility to viruses with a k65r substitution with or without an m184v/i substitution, viruses with l74v plus the m184v/i substitution, and viruses with thymidine analog mutation (tam) substitutions (m41l, d67n, k70r, l210w, t215y/f, k219 e/r/h/q/n) plus m184v. an increasing number of tams is associated with a progressive reduction in abacavir susceptibility.

l (mean ± sd) and auc ∞ was 11.95 ± 2.51 mcg•hour/ml. binding of abacavir to human plasma proteins is approximately 50% and was independent of concentration. total blood and plasma drug‑related radioactivity concentrations are identical, demonstrating that abacavir readily distributes into erythrocytes. the primary routes of elimination of abacavir are metabolism by alcohol dehydrogenase to form the 5′‑carboxylic acid and glucuronyl transferase to form the 5′‑glucuronide. in single-dose trials, the observed elimination half-life (t ½ ) was 1.54 ± 0.63 hours. after intravenous administration, total clearance was 0.80 ± 0.24 l/h/kg (mean ± sd). dolutegravir: following oral administration of dolutegravir, peak plasma concentrations were observed 2 to 3 hours postdose. with once-daily dosing, pharmacokinetic steady state is achieved within approximately 5 days with average accumulation ratios for auc, c max , and c 24 h ranging from 1.2 to 1.5. dolutegravir is a p-gp substrate in vitro. the absolute bioavailability of dolutegravir has not been established. dolutegravir is highly bound (≥98.9%) to human plasma proteins based on in vivo data and binding is independent of plasma concentration of dolutegravir. the apparent volume of distribution (vd/f) following 50-mg once-daily administration is estimated at 17.4 l based on a population pharmacokinetic analysis. dolutegravir is primarily metabolized via ugt1a1 with some contribution from cyp3a. after a single oral dose of [ 14 c] dolutegravir, 53% of the total oral dose is excreted unchanged in the feces. thirty-one percent of the total oral dose is excreted in the urine, represented by an ether glucuronide of dolutegravir (18.9% of total dose), a metabolite formed by oxidation at the benzylic carbon (3.0% of total dose), and its hydrolytic n-dealkylation product (3.6% of total dose). renal elimination of unchanged drug was <1% of the dose. dolutegravir has a terminal half-life of approximately 14 hours and an apparent clearance (cl/f) of 1.0 l/h based on population pharmacokinetic analyses. the pharmacokinetic properties of dolutegravir have been evaluated in healthy adult subjects and hiv‑1–infected adult subjects. exposure to dolutegravir was generally similar between healthy subjects and hiv‑1–infected subjects. table 7. dolutegravir steady-state pharmacokinetic parameter estimates in hiv-1–infected adults parameter 50 mg once daily geometric mean (%cv) auc (0-24) (mcg•h/ml) 53.6 (27) c max (mcg/ml) 3.67 (20) c min (mcg/ml) 1.11 (46) cerebrospinal fluid (csf): in 11 treatment-naive subjects on dolutegravir 50 mg daily plus abacavir/lamivudine, the median dolutegravir concentration in csf was 18 ng/ml (range: 4 ng/ml to 23.2 ng/ml) 2 to 6 hours postdose after 2 weeks of treatment. the clinical relevance of this finding has not been established. lamivudine: following oral administration, lamivudine is rapidly absorbed and extensively distributed. after multiple‑dose oral administration of lamivudine 300 mg once daily for 7 days to 60 healthy subjects, steady-state c max (c max,ss ) was 2.04 ± 0.54 mcg/ml (mean ± sd) and the 24‑hour steady‑state auc (auc 24,ss ) was 8.87 ± 1.83 mcg•hour/ml. binding to plasma protein is low. approximately 70% of an intravenous dose of lamivudine is recovered as unchanged drug in the urine. metabolism of lamivudine is a minor route of elimination. in humans, the only known metabolite is the trans‑sulfoxide metabolite (approximately 5% of an oral dose after 12 hours). in most single-dose trials with plasma sampling up to 48 or 72 hours after dosing, the observed mean elimination half-life (t ½ ) ranged from 13 to 19 hours. in hiv-1–infected subjects, total clearance was 398.5 ± 69.1 ml per min (mean ± sd). effect of food on oral absorption triumeq or triumeq pd may be taken with or without food. overall, when compared with fasted conditions, administration of triumeq to healthy adult subjects with a high-fat meal (53% fat, 869 calories) resulted in decreased c max for abacavir and increased c max and auc for dolutegravir. lamivudine exposures were not affected by food. with a high-fat meal, the c max of abacavir decreased 23% and the c max and auc of dolutegravir increased 37% and 48%, respectively. when compared with fasted conditions, administration of triumeq pd to healthy adult subjects with a high-fat meal (50% fat, 917 calories) resulted in decreased c max for abacavir (55%), dolutegravir (29%) and lamivudine (36%). aucs for all 3 components were not affected by food. specific populations patients with renal impairment: the pharmacokinetics for the individual components of triumeq and triumeq pd have been evaluated in patients with renal impairment (see the u.s. prescribing information for the individual abacavir, dolutegravir, and lamivudine components). patients with hepatic impairment: the pharmacokinetics for the individual components of triumeq and triumeq pd have been evaluated in patients with varying degrees of hepatic impairment (see the u.s. prescribing information for the individual abacavir, dolutegravir, and lamivudine components). pregnant women: abacavir: abacavir pharmacokinetics were studied in 25 pregnant women during the last trimester of pregnancy receiving abacavir 300 mg twice daily. abacavir exposure (auc) during pregnancy was similar to those in postpartum and in hiv-infected non-pregnant historical controls. consistent with passive diffusion of abacavir across the placenta, abacavir concentrations in neonatal plasma cord samples at birth were essentially equal to those in maternal plasma at delivery. lamivudine: lamivudine pharmacokinetics were studied in 36 pregnant women during 2 clinical trials conducted in south africa. lamivudine pharmacokinetics in pregnant women were similar to those seen in non-pregnant adults and in postpartum women. lamivudine concentrations were generally similar in maternal, neonatal and umbilical cord serum samples. pediatric patients: the pharmacokinetics for the individual components of triumeq and triumeq pd (abacavir, dolutegravir, and lamivudine) have been evaluated in pediatric subjects. dolutegravir: the pharmacokinetics of dolutegravir were evaluated in the impaact p1093 trial and in 2 weight-band–based pharmacokinetic substudies from the odyssey trial [see use in specific populations ( 8.4 ), clinical studies ( 14.2 )] . mean dolutegravir auc 0-24h and c 24h in hiv-1–infected pediatric subjects weighing at least 10 kg were comparable to those in adults after 50 mg once daily or 50 mg twice daily. mean c max is higher in pediatrics, but the increase is not considered clinically significant as the safety profiles were similar in pediatric and adult subjects [see adverse reactions (6.1)] . refer to the prescribing information for tivicay for pharmacokinetic information on dolutegravir in pediatric patients. abacavir and lamivudine: in pediatric patients weighing 25 kg and above, the dosing recommendations for triumeq in this population are based on the safety and efficacy established in a controlled trial conducted using either the combination of epivir and ziagen or epzicom. in pediatric patients weighing 10 to <25 kg, predicted exposures (auc 0-24h ) of abacavir and lamivudine at the recommended doses for triumeq pd are within the observed exposure ranges at the recommended doses of individual products in adults and pediatrics. refer to the prescribing information for epivir and ziagen for pharmacokinetic information on the individual products in pediatric patients [see dosage and administration ( 2.2 ), clinical studies ( 14.2 )] . geriatric patients: population analyses using pooled pharmacokinetic data from adult trials indicated age had no clinically relevant effect on the pharmacokinetics of dolutegravir. the pharmacokinetics of abacavir or lamivudine have not been studied in subjects older than 65 years. male and female patients: there are no significant or clinically relevant gender differences in the pharmacokinetics of the individual components (dolutegravir, abacavir, or lamivudine) based on the available information that was analyzed for each of the individual components. racial groups: there are no significant or clinically relevant racial differences in pharmacokinetics of the individual components (dolutegravir, abacavir, or lamivudine) based on the available information that was analyzed for each of the individual components. drug interaction studies the drug interaction trials described were conducted with dolutegravir, abacavir, and/or lamivudine as single entities; no drug interaction trials have been conducted using the combination of abacavir, dolutegravir, and lamivudine. no clinically significant drug interactions are expected between dolutegravir, abacavir, and lamivudine. dosing recommendations as a result of established and other potentially significant drug-drug interactions with the individual components of triumeq and triumeq pd are provided in section 7.3 [see drug interactions ( 7 )] . table 8. summary of effect of dolutegravir on the pharmacokinetics of coadministered drugs a the number of subjects represents the maximum number of subjects that were evaluated. coadministered drug(s) and dose(s) dose of dolutegravir n geometric mean ratio (90% ci) of pharmacokinetic parameters of coadministered drug with/without dolutegravir no effect = 1.00 c max auc c τ or c 24 daclatasvir 60 mg once daily 50 mg once daily 12 1.03 (0.84 to 1.25) 0.98 (0.83 to 1.15) 1.06 (0.88 to 1.29) ethinyl estradiol 0.035 mg 50 mg twice daily 15 0.99 (0.91 to 1.08) 1.03 (0.96 to 1.11) 1.02 (0.93 to 1.11) metformin 500 mg twice daily 50 mg once daily 15 a 1.66 (1.53 to 1.81) 1.79 (1.65 to 1.93) — metformin 500 mg twice daily 50 mg twice daily 15 a 2.11 (1.91 to 2.33) 2.45 (2.25 to 2.66) — methadone 16 to 150 mg 50 mg twice daily 11 1.00 (0.94 to 1.06) 0.98 (0.91 to 1.06) 0.99 (0.91 to 1.07) midazolam 3 mg 25 mg once daily 10 — 0.95 (0.79 to 1.15) — norelgestromin 0.25 mg 50 mg twice daily 15 0.89 (0.82 to 0.97) 0.98 (0.91 to 1.04) 0.93 (0.85 to 1.03) rilpivirine 25 mg once daily 50 mg once daily 16 1.10 (0.99 to 1.22) 1.06 (0.98 to 1.16) 1.21 (1.07 to 1.38) tenofovir disoproxil fumarate 300 mg once daily 50 mg once daily 15 1.09 (0.97 to 1.23) 1.12 (1.01 to 1.24) 1.19 (1.04 to 1.35) table 9. summary of effect of coadministered drugs on the pharmacokinetics of dolutegravir a comparison is rifampin taken with dolutegravir 50 mg twice daily compared with dolutegravir 50 mg twice daily. b comparison is rifampin taken with dolutegravir 50 mg twice daily compared with dolutegravir 50 mg once daily. c the number of subjects represents the maximum number of subjects that were evaluated. coadministered drug(s) and dose(s) dose of dolutegravir n geometric mean ratio (90% ci) of dolutegravir pharmacokinetic parameters with/without coadministered drugs no effect = 1.00 c max auc c τ or c 24 atazanavir 400 mg once daily 30 mg once daily 12 1.50 (1.40 to 1.59) 1.91 (1.80 to 2.03) 2.80 (2.52 to 3.11) atazanavir/ritonavir 300/100 mg once daily 30 mg once daily 12 1.34 (1.25 to 1.42) 1.62 (1.50 to 1.74) 2.21 (1.97 to 2.47) darunavir/ritonavir 600/100 mg twice daily 30 mg once daily 15 0.89 (0.83 to 0.97) 0.78 (0.72 to 0.85) 0.62 (0.56 to 0.69) efavirenz 600 mg once daily 50 mg once daily 12 0.61 (0.51 to 0.73) 0.43 (0.35 to 0.54) 0.25 (0.18 to 0.34) etravirine 200 mg twice daily 50 mg once daily 16 0.48 (0.43 to 0.54) 0.29 (0.26 to 0.34) 0.12 (0.09 to 0.16) etravirine + darunavir/ritonavir 200 mg + 600/100 mg twice daily 50 mg once daily 9 0.88 (0.78 to 1.00) 0.75 (0.69 to 0.81) 0.63 (0.52 to 0.76) etravirine + lopinavir/ritonavir 200 mg + 400/100 mg twice daily 50 mg once daily 8 1.07 (1.02 to 1.13) 1.11 (1.02 to 1.20) 1.28 (1.13 to 1.45) fosamprenavir/ritonavir 700 mg/100 mg twice daily 50 mg once daily 12 0.76 (0.63 to 0.92) 0.65 (0.54 to 0.78) 0.51 (0.41 to 0.63) lopinavir/ritonavir 400/100 mg twice daily 30 mg once daily 15 1.00 (0.94 to 1.07) 0.97 (0.91 to 1.04) 0.94 (0.85 to 1.05) rilpivirine 25 mg once daily 50 mg once daily 16 1.13 (1.06 to 1.21) 1.12 (1.05 to 1.19) 1.22 (1.15 to 1.30) tenofovir 300 mg once daily 50 mg once daily 15 0.97 (0.87 to 1.08) 1.01 (0.91 to 1.11) 0.92 (0.82 to 1.04) tipranavir/ritonavir 500/200 mg twice daily 50 mg once daily 14 0.54 (0.50 to 0.57) 0.41 (0.38 to 0.44) 0.24 (0.21 to 0.27) antacid (maalox) simultaneous administration 50 mg single dose 16 0.28 (0.23 to 0.33) 0.26 (0.22 to 0.32) 0.26 (0.21 to 0.31) antacid (maalox) 2 h after dolutegravir 50 mg single dose 16 0.82 (0.69 to 0.98) 0.74 (0.62 to 0.90) 0.70 (0.58 to 0.85) boceprevir 800 mg every 8 h 50 mg once daily 13 1.05 (0.96 to 1.15) 1.07 (0.95 to 1.20) 1.08 (0.91 to 1.28) calcium carbonate 1,200 mg simultaneous administration (fasted) 50 mg single dose 12 0.63 (0.50 to 0.81) 0.61 (0.47 to 0.80) 0.61 (0.47 to 0.80) calcium carbonate 1,200 mg simultaneous administration (fed) 50 mg single dose 11 1.07 (0.83 to 1.38) 1.09 (0.84 to 1.43) 1.08 (0.81 to 1.42) calcium carbonate 1,200 mg 2 h after dolutegravir 50 mg single dose 11 1.00 (0.78 to 1.29) 0.94 (0.72 to 1.23) 0.90 (0.68 to 1.19) carbamazepine 300 mg twice daily 50 mg once daily 16 c 0.67 (0.61 to 0.73) 0.51 (0.48 to 0.55) 0.27 (0.24 to 0.31) daclatasvir 60 mg once daily 50 mg once daily 12 1.29 (1.07 to 1.57) 1.33 (1.11 to 1.59) 1.45 (1.25 to 1.68) ferrous fumarate 324 mg simultaneous administration (fasted) 50 mg single dose 11 0.43 (0.35 to 0.52) 0.46 (0.38 to 0.56) 0.44 (0.36 to 0.54) ferrous fumarate 324 mg simultaneous administration (fed) 50 mg single dose 11 1.03 (0.84 to 1.26) 0.98 (0.81 to 1.20) 1.00 (0.81 to 1.23) ferrous fumarate 324 mg 2 h after dolutegravir 50 mg single dose 10 0.99 (0.81 to 1.21) 0.95 (0.77 to 1.15) 0.92 (0.74 to 1.13) multivitamin (one-a-day) simultaneous administration 50 mg single dose 16 0.65 (0.54 to 0.77) 0.67 (0.55 to 0.81) 0.68 (0.56 to 0.82) omeprazole 40 mg once daily 50 mg single dose 12 0.92 (0.75 to 1.11) 0.97 (0.78 to 1.20) 0.95 (0.75 to 1.21) prednisone 60 mg once daily with taper 50 mg once daily 12 1.06 (0.99 to 1.14) 1.11 (1.03 to 1.20) 1.17 (1.06 to 1.28) rifampin a 600 mg once daily 50 mg twice daily 11 0.57 (0.49 to 0.65) 0.46 (0.38 to 0.55) 0.28 (0.23 to 0.34) rifampin b 600 mg once daily 50 mg twice daily 11 1.18 (1.03 to 1.37) 1.33 (1.15 to 1.53) 1.22 (1.01 to 1.48) rifabutin 300 mg once daily 50 mg once daily 9 1.16 (0.98 to 1.37) 0.95 (0.82 to 1.10) 0.70 (0.57 to 0.87) abacavir or lamivudine: the drug interactions described are based on trials conducted with abacavir or lamivudine as single entities. effect of abacavir and lamivudine on the pharmacokinetics of other agents: in vitro studies have shown that abacavir has potential to inhibit cyp1a1 and limited potential to inhibit metabolism mediated by cyp3a4. lamivudine does not inhibit or induce cyp3a4. abacavir and lamivudine do not inhibit or induce other cyp enzymes (such as cyp2c9 or cyp2d6). based on in vitro study results, abacavir and lamivudine at therapeutic drug exposures are not expected to affect the pharmacokinetics of drugs that are substrates of the following transporters: oatp1b1/3, bcrp or p-gp, oct1, oct2, oct3 (lamivudine only), or mate1 and mate2‑k. abacavir, dolutegravir, and lamivudine: coadministration of a single dose of riociguat (0.5 mg) to hiv-1–infected subjects receiving triumeq is reported to increase riociguat auc (∞) compared with riociguat auc (∞) reported in healthy subjects due to cyp1a1 inhibition by abacavir. the exact magnitude of increase in riociguat exposure has not been fully characterized based on findings from two studies [see drug interactions ( 7.3 )] . effect of other agents on the pharmacokinetics of abacavir or lamivudine: in vitro, abacavir is not a substrate of oatp1b1, oatp1b3, oct1, oct2, oat1, mate1, mate2-k, mrp2 or mrp4; therefore, drugs that modulate these transporters are not expected to affect abacavir plasma concentrations. abacavir is a substrate of bcrp and p-gp in vitro; however, considering its absolute bioavailability (83%), modulators of these transporters are unlikely to result in a clinically relevant impact on abacavir concentrations. lamivudine is a substrate of mate1, mate2-k, and oct2 in vitro. trimethoprim (an inhibitor of these drug transporters) has been shown to increase lamivudine plasma concentrations. this interaction is not considered clinically significant as no dose adjustment of lamivudine is needed. lamivudine is a substrate of p-gp and bcrp; however, considering its absolute bioavailability (87%), it is unlikely that these transporters play a significant role in the absorption of lamivudine. therefore, coadministration of drugs that are inhibitors of these efflux transporters is unlikely to affect the disposition and elimination of lamivudine. ethanol: abacavir has no effect on the pharmacokinetic properties of ethanol. ethanol decreases the elimination of abacavir causing an increase in overall exposure. interferon alfa: there was no significant pharmacokinetic interaction between lamivudine and interferon alfa in a trial of 19 healthy male subjects. methadone: in a trial of 11 hiv‑1–infected subjects receiving methadone‑maintenance therapy (40 mg and 90 mg daily), with 600 mg of abacavir twice daily (twice the currently recommended dose), oral methadone clearance increased 22% (90% ci: 6% to 42%) [see drug interactions ( 7.3 )]. the addition of methadone has no clinically significant effect on the pharmacokinetic properties of abacavir . ribavirin: in vitro data indicate ribavirin reduces phosphorylation of lamivudine, stavudine, and zidovudine. however, no pharmacokinetic (e.g., plasma concentrations or intracellular triphosphorylated active metabolite concentrations) or pharmacodynamic (e.g., loss of hiv‑1/hcv virologic suppression) interaction was observed when ribavirin and lamivudine (n = 18), stavudine (n = 10), or zidovudine (n = 6) were coadministered as part of a multi‑drug regimen to hiv‑1/hcv co‑infected subjects. sorbitol (excipient): lamivudine and sorbitol solutions were coadministered to 16 healthy adult subjects in an open-label, randomized-sequence, 4-period, crossover trial. each subject received a single 300-mg dose of lamivudine oral solution alone or coadministered with a single dose of 3.2 g, 10.2 g, or 13.4 g of sorbitol in solution. coadministration of lamivudine with sorbitol resulted in dose-dependent decreases of 20%, 39%, and 44% in the auc (0-24) ; 14%, 32%, and 36% in the auc (∞) ; and 28%, 52%, and 55% in the c max ; of lamivudine, respectively. abacavir, lamivudine, zidovudine: fifteen hiv‑1–infected subjects were enrolled in a crossover-designed drug interaction trial evaluating single doses of abacavir (600 mg), lamivudine (150 mg), and zidovudine (300 mg) alone or in combination. analysis showed no clinically relevant changes in the pharmacokinetics of abacavir with the addition of lamivudine or zidovudine or the combination of lamivudine and zidovudine. lamivudine exposure (auc decreased 15%) and zidovudine exposure (auc increased 10%) did not show clinically relevant changes with concurrent abacavir. lamivudine and zidovudine: no clinically significant alterations in lamivudine or zidovudine pharmacokinetics were observed in 12 asymptomatic hiv‑1–infected adult patients given a single dose of zidovudine (200 mg) in combination with multiple doses of lamivudine (300 mg every 12 hours). the effects of other coadministered drugs on abacavir or lamivudine are provided in table 10 . table 10. effect of coadministered drugs on abacavir or lamivudine ↑ = increase; ↔ = no significant change. a the drug-drug interaction was only evaluated in males. coadministered drug and dose drug and dose n concentrations of abacavir or lamivudine concentration of coadministered drug auc variability ethanol 0.7 g/kg abacavir single 600 mg 24 ↑41% 90% ci: 35% to 48% ↔ a nelfinavir 750 mg every 8 h x 7 to 10 days lamivudine single 150 mg 11 ↑10% 95% ci: 1% to 20% ↔ trimethoprim 160 mg/ sulfamethoxazole 800 mg daily x 5 days lamivudine single 300 mg 14 ↑43% 90% ci: 32% to 55% ↔

e incidence of malignant and non‑malignant tumors. malignant tumors occurred in the preputial gland of males and the clitoral gland of females of both species, and in the liver of female rats. in addition, non‑malignant tumors also occurred in the liver and thyroid gland of female rats. these observations were made at systemic exposures in the range of 7 to 28 times the human exposure at the recommended dose of 600 mg. lamivudine: long‑term carcinogenicity studies with lamivudine in mice and rats showed no evidence of carcinogenic potential at exposures up to 12 times (mice) and 57 times (rats) the human exposures at the recommended dose of 300 mg. mutagenicity dolutegravir: dolutegravir was not genotoxic in the bacterial reverse mutation assay, mouse lymphoma assay, or in the in vivo rodent micronucleus assay. abacavir: abacavir induced chromosomal aberrations both in the presence and absence of metabolic activation in an in vitro cytogenetic study in human lymphocytes. abacavir was mutagenic in the absence of metabolic activation, although it was not mutagenic in the presence of metabolic activation in an l5178y mouse lymphoma assay. abacavir was clastogenic in males and not clastogenic in females in an in vivo mouse bone marrow micronucleus assay. abacavir was not mutagenic in bacterial mutagenicity assays in the presence and absence of metabolic activation. lamivudine: lamivudine was mutagenic in an l5178y mouse lymphoma assay and clastogenic in a cytogenetic assay using cultured human lymphocytes. lamivudine was not mutagenic in a microbial mutagenicity assay, in an in vitro cell transformation assay, in a rat micronucleus test, in a rat bone marrow cytogenetic assay, and in an assay for unscheduled dna synthesis in rat liver. impairment of fertility dolutegravir, abacavir, or lamivudine did not affect male or female fertility in rats at doses associated with exposures approximately 44, 9, or 112 times (respectively) higher than the exposures in humans at the doses of 50 mg, 600 mg, and 300 mg (respectively). 13.2 animal toxicology and/or pharmacology myocardial degeneration was found in mice and rats following administration of abacavir for 2 years. the systemic exposures were equivalent to 7 to 21 times the expected systemic exposure in humans at a dose of 600 mg. the clinical relevance of this finding has not been determined.

nd non‑malignant tumors. malignant tumors occurred in the preputial gland of males and the clitoral gland of females of both species, and in the liver of female rats. in addition, non‑malignant tumors also occurred in the liver and thyroid gland of female rats. these observations were made at systemic exposures in the range of 7 to 28 times the human exposure at the recommended dose of 600 mg. lamivudine: long‑term carcinogenicity studies with lamivudine in mice and rats showed no evidence of carcinogenic potential at exposures up to 12 times (mice) and 57 times (rats) the human exposures at the recommended dose of 300 mg. mutagenicity dolutegravir: dolutegravir was not genotoxic in the bacterial reverse mutation assay, mouse lymphoma assay, or in the in vivo rodent micronucleus assay. abacavir: abacavir induced chromosomal aberrations both in the presence and absence of metabolic activation in an in vitro cytogenetic study in human lymphocytes. abacavir was mutagenic in the absence of metabolic activation, although it was not mutagenic in the presence of metabolic activation in an l5178y mouse lymphoma assay. abacavir was clastogenic in males and not clastogenic in females in an in vivo mouse bone marrow micronucleus assay. abacavir was not mutagenic in bacterial mutagenicity assays in the presence and absence of metabolic activation. lamivudine: lamivudine was mutagenic in an l5178y mouse lymphoma assay and clastogenic in a cytogenetic assay using cultured human lymphocytes. lamivudine was not mutagenic in a microbial mutagenicity assay, in an in vitro cell transformation assay, in a rat micronucleus test, in a rat bone marrow cytogenetic assay, and in an assay for unscheduled dna synthesis in rat liver. impairment of fertility dolutegravir, abacavir, or lamivudine did not affect male or female fertility in rats at doses associated with exposures approximately 44, 9, or 112 times (respectively) higher than the exposures in humans at the doses of 50 mg, 600 mg, and 300 mg (respectively).

s co-infection was excluded), 4% were cdc class c (aids), 32% had hiv‑1 rna >100,000 copies/ml, and 53% had cd4+ cell count <350 cells/mm 3 ; these characteristics were similar between treatment groups. week 144 (open-label-phase analysis which followed the week 96 double-blind phase) outcomes for single are provided in table 11 . table 11. virologic outcomes of randomized treatment in single at 144 weeks (snapshot algorithm) a adjusted for pre-specified stratification factors. b includes subjects who discontinued due to an adverse event or death at any time point if this resulted in no virologic data on treatment during the analysis window. c other includes reasons such as withdrew consent, loss to follow-up, moved, and protocol deviation. d the primary endpoint was assessed at week 48 and the virologic success rate was 88% in the group receiving tivicay and 81% in the atripla group, with a treatment difference of 7.4% and 95% ci of (2.5%, 12.3%). tivicay + epzicom once daily (n = 414) atripla once daily (n = 419) hiv ‑ 1 rna <50 copies/ml 71% 63% treatment difference a 8.3% (95% ci: 2.0%, 14.6%) d virologic nonresponse 10% 7% data in window not <50 copies/ml 4% <1% discontinued for lack of efficacy 3% 3% discontinued for other reasons while not suppressed 3% 4% no virologic data 18% 30% reasons discontinued study/study drug due to adverse event or death b 4% 14% discontinued study/study drug for other reasons c 12% 13% missing data during window but on study 2% 3% proportion (%) of subjects with hiv ‑ 1 rna <50 copies/ml by baseline category plasma viral load (copies/ml) ≤100,000 73% 64% ≥100,000 69% 61% gender male 72% 66% female 69% 48% race white 72% 71% african american/african heritage/other 71% 47% treatment differences were maintained across baseline characteristics including baseline viral load, cd4+ cell count, age, gender, and race. the adjusted mean changes in cd4+ cell counts from baseline were 378 cells per mm 3 in the group receiving tivicay + epzicom and 332 cells per mm 3 for the atripla group at 144 weeks. the adjusted difference between treatment arms and 95% ci was 46.9 cells per mm 3 (15.6 cells per mm 3 , 78.2 cells per mm 3 ) (adjusted for pre-specified stratification factors: baseline hiv‑1 rna, and baseline cd4+ cell count). treatment-experienced in sailing, there were 715 subjects included in the efficacy and safety analyses (see full prescribing information for tivicay). at week 48, 71% of subjects randomized to tivicay plus background regimen versus 64% of subjects randomized to raltegravir plus background regimen had hiv‑1 rna <50 copies/ml (treatment difference and 95% ci: 7.4% [0.7%, 14.2%]). 14.2 pediatric subjects the efficacy of the individual components of triumeq and triumeq pd for the treatment of hiv-1 infection was evaluated in pediatric patients enrolled in the arrow trial (nct02028676) and impaact p1093 trial (nct01302847), as summarized below. • abacavir and lamivudine once daily, in combination with a third antiretroviral drug, were evaluated in a randomized, multicenter trial (arrow) in treatment-naive pediatric subjects with hiv-1 infection. subjects randomized to once-daily dosing (n = 336) and who weighed at least 25 kg received abacavir 600 mg and lamivudine 300 mg, as either the single entities or as epzicom. at week 96, 67% of subjects receiving abacavir and lamivudine once-daily in combination with a third antiretroviral drug, had hiv-1 rna <80 copies/ml. • dolutegravir (tivicay or tivicay pd), in combination with other antiretroviral drugs was evaluated in treatment naive or treatment-experienced, insti- naive, hiv-1–infected subjects aged at least 4 weeks to 18 years in an ongoing open-label, multicenter, dose-finding clinical trial, impaact p1093. subjects were stratified by age cohort; subjects aged 12 to <18 years were enrolled in cohort i, subjects aged 6 to <12 years were enrolled in cohort iia, and subjects aged 2 to <6 years were enrolled in cohort iii-dt. subjects weighing at least 10 kg from cohorts i (n = 19), iia (n = 5), and iii-dt (n = 3) who received the recommended dose (determined by weight and age) and formulation contributed to the efficacy analysis at week 48. across all 3 cohorts, 67% (18/27) of subjects weighing at least 10 kg achieved hiv‑1 rna <50 copies/ml at week 48 (snapshot algorithm).

90 tablets (ndc 49702-272-59) with desiccant and child-resistant closure. each bottle is packaged as a kit (ndc 49702-258-37) with one 40-ml dosing cup. store at 20°c to 25°c (68°f to 77°f); excursions permitted between 15°c and 30°c (59°f to 86°f). [see usp controlled room temperature]. store and dispense in the original bottle, protect from moisture, and keep the bottle tightly closed. do not remove desiccant.

his document. • to carry the warning card with them. • how to identify a hypersensitivity reaction [see warnings and precautions ( 5.1 ), medication guide] . • that if they develop symptoms consistent with a hypersensitivity reaction they should call their healthcare provider right away to determine if they should stop taking triumeq or triumeq pd. • that a hypersensitivity reaction can worsen and lead to hospitalization or death if triumeq or triumeq pd is not immediately discontinued. • to not restart triumeq or triumeq pd or any other abacavir‑containing product following a hypersensitivity reaction because more severe symptoms can occur within hours and may include life‑threatening hypotension and death. • that if they have a hypersensitivity reaction, they should dispose of any unused triumeq or triumeq pd to avoid restarting abacavir. • that a hypersensitivity reaction is usually reversible if it is detected promptly and triumeq or triumeq pd is stopped right away. • that if they have interrupted triumeq or triumeq pd for reasons other than symptoms of hypersensitivity (for example, those who have an interruption in drug supply), a serious or fatal hypersensitivity reaction may occur with reintroduction of abacavir. • to not restart triumeq or triumeq pd or any other abacavir‑containing product without medical consultation and only if medical care can be readily accessed by the patient or others. • to not restart triumeq or triumeq pd or any other dolutegravir-containing product following a hypersensitivity reaction to triumeq or triumeq pd. hepatotoxicity inform patients that hepatotoxicity has been reported with dolutegravir, a component of triumeq and triumeq pd [see warnings and precautions ( 5.3 ), adverse reactions ( 6.1 )] . inform patients that monitoring for hepatotoxicity during therapy with triumeq or triumeq pd is recommended. severe acute exacerbations of hepatitis in patients with hbv co-infection advise all patients with hiv-1 to be tested for the presence of hbv prior to or when initiating triumeq or triumeq pd. advise patients co‑infected with hiv‑1 and hbv that worsening of liver disease has occurred in some cases when treatment with lamivudine was discontinued. advise patients to discuss any changes in regimen with their physician [see warnings and precautions ( 5.2 )]. lactic acidosis/hepatomegaly inform patients that some hiv medicines, including triumeq and triumeq pd, can cause a rare, but serious condition called lactic acidosis with liver enlargement (hepatomegaly) [see boxed warning , warnings and precautions ( 5.5 )]. embryo-fetal toxicity advise adolescents and adults of childbearing potential, including those actively trying to become pregnant, to discuss the risks and benefits of triumeq with their healthcare provider to determine if an alternative treatment should be considered at the time of conception through the first trimester of pregnancy. if pregnancy is confirmed in the first trimester, advise patients to contact their healthcare provider [see warnings and precautions ( 5.5 ), use in specific populations ( 8.1 , 8.3 )] . adolescents and adults of childbearing potential taking triumeq should be counseled on the consistent use of effective contraception [see warnings and precautions ( 5.5 ), use in specific populations ( 8.1 , 8.3 )] . immune reconstitution syndrome advise patients to inform their healthcare provider immediately of any signs and symptoms of infection as inflammation from previous infection may occur soon after combination antiretroviral therapy, including when triumeq or triumeq pd is started [see warnings and precautions ( 5.7 )]. triumeq tablets and triumeq pd tablets for oral suspension are not bioequivalent advise patients that triumeq and triumeq pd are not bioequivalent and are not interchangeable on a milligram-per-milligram basis. advise patients or their care provider that patients switching from the tablets for oral suspension to the tablets must adjust the dose [see dosage and administration ( 2.3 ) and warnings and precautions ( 5.8 )] . pregnancy registry inform patients that there is an antiretroviral pregnancy registry to monitor fetal outcomes in those exposed to triumeq during pregnancy [see use in specific populations ( 8.1 )] . lactation instruct mothers with hiv-1 infection not to breastfeed because hiv-1 can be passed to the baby in the breast milk [see use in specific populations ( 8.2 )] . administration instructions to avoid a dosing error from using the wrong formulation of triumeq, strongly advise patients and caregivers to visually inspect the tablets to verify the correct formulation each time the prescription is filled [see dosage and administration ( 2 ), warnings and precautions ( 5.8 ), how supplied/storage and handling ( 16 )] . inform patients and caregivers that triumeq pd tablets for oral suspension should be dispersed in drinking water and should not be chewed, cut or crushed [see dosage and administration ( 2.5 )] . instruct patients and caregivers that if a dose of triumeq or triumeq pd is missed, to take it as soon as they remember. advise patients and caregivers not to double the next dose or take more than the prescribed dose [see dosage and administration ( 2 )] . availability of medication guide instruct patients and caregivers to read the medication guide before starting triumeq or triumeq pd and to re-read it each time the prescription is renewed. instruct patients to inform their physician or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. storage instruct patients and caregivers to store triumeq and triumeq pd tablets for oral suspension in the original package, protect from moisture, and keep the bottle tightly closed. do not remove desiccant. epivir, epzicom, tivicay, tivicay pd, triumeq, triumeq pd, and ziagen are trademarks owned by or licensed to the viiv healthcare group of companies. epivir-hbv is a trademark owned by or licensed to the gsk group of companies. the other brands listed are trademarks owned by or licensed to their respective owners and are not owned by or licensed to the viiv healthcare group of companies. the makers of these brands are not affiliated with and do not endorse the viiv healthcare group of companies or its products. manufactured for: viiv healthcare durham, nc 27701 by: glaxosmithkline durham, nc 27701 ©2022 viiv healthcare group of companies or its licensor. trm:15pi