What are the considerations for using Descovy (emtricitabine and tenofovir alafenamide) in patients with a history of psychosis?

Descovy (Emtricitabine/Tenofovir Alafenamide) in Patients with History of Psychosis

Descovy can be safely used in patients with a history of psychosis as it has not been associated with significant neuropsychiatric adverse effects that would exacerbate psychotic symptoms.

Neuropsychiatric Profile of Descovy

Descovy, a fixed-dose combination of emtricitabine and tenofovir alafenamide (F/TAF), has a favorable neuropsychiatric profile compared to some other antiretroviral medications:

• Unlike efavirenz-containing regimens which are known to cause significant CNS side effects including psychosis, Descovy has not been associated with severe neuropsychiatric adverse events 1
• Studies evaluating tenofovir alafenamide-containing regimens show minimal neuropsychiatric adverse effects compared to older antiretrovirals 2
• In clinical practice, neuropsychiatric adverse events leading to discontinuation of TAF-containing regimens are uncommon 3

Monitoring Recommendations

When prescribing Descovy to patients with a history of psychosis:

1. Baseline Assessment:

   • Document current psychiatric status and stability
   • Review current psychotropic medications for potential interactions
   • Consider consultation with psychiatry for patients with recent or unstable psychosis

2. Follow-up Monitoring:

   • Regular follow-up at intervals of no longer than every 3 months is recommended for all patients on PrEP or HIV treatment 4
   • Monitor for any changes in mental status or emergence of psychiatric symptoms
   • Pay particular attention to sleep disturbances, mood changes, or thought disturbances

3. Medication Management:

   • Avoid polypharmacy when possible, as multiple medications increase the risk of adverse effects and drug interactions 5
   • If the patient is on antipsychotic medications, continue these as prescribed while monitoring for any interactions

Advantages of Descovy in Patients with Psychosis

• Tenofovir alafenamide (TAF) has better bone and renal safety than tenofovir disoproxil fumarate (TDF), which may be beneficial for patients on long-term antipsychotic medications that can affect bone density 1
• Once-daily dosing simplifies medication regimens, which is particularly important for patients with psychiatric conditions who may have challenges with medication adherence
• Can be used in individuals with a creatinine clearance >30 mL/min, providing flexibility for patients who may have compromised renal function due to other medications 1

Potential Concerns and Management

While Descovy itself has minimal neuropsychiatric effects, there are several considerations for patients with psychosis:

1. Adherence Challenges:

   • Patients with psychosis may have difficulty with medication adherence
   • Personal telephone and interactive text reminders for scheduled appointments are recommended to enhance adherence 4
   • Consider opioid substitution therapy for patients with comorbid substance use disorders to improve adherence 4

2. Medication Interactions:

   • Review potential interactions between Descovy and antipsychotic medications
   • Monitor for any changes in efficacy or side effects of either medication

3. Distinguishing Symptoms:

   • Any new mental status changes should be carefully evaluated to distinguish between medication side effects, progression of psychiatric illness, or other medical causes 4
   • For acute mental status changes, appropriate neuroimaging may be indicated to rule out intracranial processes 4

Clinical Pearls

• Patients with a pre-existing history of depression may be at higher risk for neuropsychiatric adverse events with antiretroviral therapy in general 3
• Cross-intolerance between different antiretrovirals regarding neuropsychiatric effects appears to be low, so patients who experienced neuropsychiatric effects with other regimens may still tolerate Descovy well 3
• Regular reassessment of psychiatric symptoms using validated tools is important for early detection of any changes in mental status 5

In summary, Descovy represents a safe option for HIV treatment or prevention in patients with a history of psychosis, with minimal neuropsychiatric concerns compared to older antiretroviral regimens. Close monitoring and coordination with mental health providers remain important aspects of comprehensive care for these patients.