Switching from Apretude (Cabotegravir) to Descovy (Emtricitabine/Tenofovir Alafenamide)
When switching from injectable cabotegravir (Apretude) to Descovy, begin the oral Descovy-based regimen at least 1 month before the next scheduled cabotegravir injection would have been due to prevent periods of functional monotherapy and potential resistance development. 1
Protocol for Switching
- Begin Descovy (emtricitabine/tenofovir alafenamide) combined with an integrase strand transfer inhibitor (InSTI) like bictegravir or dolutegravir at least 1 month before the next scheduled cabotegravir injection would have been due 1
- This timing is critical because cabotegravir has a long half-life, and overlap with the new oral regimen prevents periods of inadequate viral suppression 1
- Never discontinue cabotegravir without immediately starting an effective alternative regimen due to the risk of developing resistance during the prolonged elimination phase 1
Recommended Regimens When Switching
- Descovy should be part of a complete regimen, not used as monotherapy 1
- Preferred combinations include:
- These regimens maintain a high barrier to resistance similar to cabotegravir 1, 5
Monitoring After Switching
- Check HIV viral load 1 month after switching regimens to ensure continued viral suppression 2, 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
Special Considerations
Hepatitis B Coinfection
- For patients with chronic hepatitis B virus (HBV) coinfection, Descovy is an appropriate choice as it contains tenofovir alafenamide, which is active against HBV 2, 1
- Never switch to a regimen without anti-HBV activity if the patient has chronic HBV 1
Prior Resistance
- If there is a history of NRTI resistance, do not switch to Descovy with agents having a low genetic barrier to resistance 1
- For patients with prior NRTI resistance, bictegravir/emtricitabine/tenofovir alafenamide has shown efficacy in maintaining viral suppression 5
Adherence Support
- For patients who had been using long-acting cabotegravir due to adherence challenges with daily oral therapy, provide additional adherence support when switching to daily Descovy 1
Common Pitfalls to Avoid
- Do not allow a gap between the effective period of cabotegravir and initiation of the new regimen 1
- Do not use Descovy as monotherapy, as this increases the risk of resistance development 1
- Do not switch to a regimen with a low genetic barrier to resistance (e.g., NNRTI) if there is a history of NRTI resistance 2, 1
- Review all potential drug interactions before switching, as tenofovir alafenamide dosing may need adjustment with certain medications 2, 1
By following this protocol, patients can safely transition from long-acting cabotegravir to an oral Descovy-based regimen while maintaining viral suppression and minimizing the risk of developing resistance.