Considerations for Discontinuing Cabotegravir and Switching to Descovy
When discontinuing long-acting cabotegravir and switching to Descovy (emtricitabine/tenofovir alafenamide), careful planning is essential to prevent viral rebound and development of resistance, with monitoring of viral load at 1 month and every 3 months for the first year after switching. 1
Key Considerations Before Switching
A thorough review of the patient's ART history, prior resistance testing, comorbidities, potential drug interactions, and presence of hepatitis B coinfection is mandatory before making any treatment changes 1
For patients with virologic suppression on cabotegravir, switching to Descovy (emtricitabine/tenofovir alafenamide) should be part of a complete regimen, typically combined with an integrase strand transfer inhibitor (InSTI) like dolutegravir or bictegravir to maintain a high barrier to resistance 1
If switching from injectable cabotegravir plus rilpivirine, the long half-life of these medications requires overlap with the new oral regimen to prevent periods of functional monotherapy 1
Recommended Switching Protocol
Begin oral Descovy-based regimen (typically with bictegravir or dolutegravir) at least 1 month before the next scheduled cabotegravir injection would have been due 1
HIV viral load assessment is recommended 1 month after switching regimens and then every 3 months for the first year 1
For patients with chronic hepatitis B virus (HBV) coinfection, Descovy is an appropriate choice as it contains tenofovir alafenamide, which is active against HBV 1
Special Considerations
For patients who had been using long-acting cabotegravir due to adherence challenges with daily oral therapy, additional adherence support should be provided when switching to daily Descovy 1
Patients with previous NRTI resistance should be monitored more closely in the first year after switching to a Descovy-based regimen, especially if there are concerns about adherence 1
Weight gain may occur after switching to Descovy-containing regimens, particularly when combined with integrase inhibitors, and may be more pronounced in women 2
Potential Regimens When Switching to Descovy
Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) has demonstrated high efficacy (>99% viral suppression) when switching from dolutegravir-based regimens 3
Dolutegravir plus Descovy (emtricitabine/tenofovir alafenamide) is also highly effective and maintains a high barrier to resistance 4
For patients with concerns about weight gain, consider regimens with lower association with weight gain, though all modern ART regimens may contribute to some degree of weight gain 2
Monitoring After Switch
Check viral load at 1 month post-switch to ensure continued viral suppression 1
Continue monitoring viral load every 3 months for the first year after switching 1
Review for potential drug interactions with the new regimen, particularly if the patient is taking medications that may interact with tenofovir alafenamide 1
Monitor for any changes in renal function, bone density, and weight, as these parameters may change after switching to a Descovy-containing regimen 4, 2
Common Pitfalls to Avoid
Never discontinue cabotegravir without immediately starting an effective alternative regimen due to the risk of developing resistance during the prolonged elimination phase 1
Do not switch to Descovy monotherapy or with agents having a low genetic barrier to resistance if there is a history of NRTI resistance 1
For patients with chronic HBV, do not switch to a regimen without anti-HBV activity (Descovy contains tenofovir alafenamide which is active against HBV) 1
Be aware that the pharmacokinetic tail of long-acting cabotegravir can persist for months after the last injection, requiring continued monitoring even after switching to a new regimen 5