What antiretroviral regimen can replace Juluca (dolutegravir/rilpivirine) for a patient receiving enteral tube feeding who cannot crush rilpivirine tablets?

Alternative Antiretroviral Regimens for Patients on Tube Feeding Who Cannot Use Juluca

Switch to a dolutegravir-based regimen with two NRTIs (such as dolutegravir plus tenofovir/emtricitabine or dolutegravir plus abacavir/lamivudine) as the preferred alternative, since rilpivirine in Juluca cannot be crushed and requires food for adequate absorption, making it unsuitable for tube feeding administration. 1, 2

Why Juluca Is Problematic for Tube Feeding

• Rilpivirine requires administration with a meal to optimize absorption and cannot be reliably administered through feeding tubes, particularly when patients are NPO or receiving intermittent tube feeds 1
• While one case report demonstrated crushed rilpivirine administration via orogastric tube with a bolus feed achieved subtherapeutic drug levels (slightly below therapeutic range), this is not a reliable or recommended approach 3
• Rilpivirine should not be crushed per standard pharmaceutical guidance, unlike some other antiretrovirals that have established crushing protocols 1

Recommended Alternative Regimens

First-Line Option: Dolutegravir Plus Two NRTIs

• Dolutegravir plus tenofovir alafenamide (TAF)/emtricitabine or dolutegravir plus tenofovir disoproxil fumarate (TDF)/emtricitabine represents the optimal replacement regimen 1, 2
• Dolutegravir has superior efficacy compared to efavirenz and ritonavir-boosted darunavir in clinical trials, with the lowest risk of resistance development 1
• Dolutegravir can be taken with or without food, making it ideal for tube feeding scenarios 1
• The regimen has minimal drug interactions and can be administered once daily 1, 2

Alternative Option: Dolutegravir Plus Abacavir/Lamivudine

• Dolutegravir coformulated with abacavir/lamivudine is another preferred initial therapy option 1, 2
• Critical caveat: Must perform HLA-B*5701 testing before initiating to prevent potentially life-threatening hypersensitivity reactions 4
• Consider cardiovascular risk assessment when using abacavir-containing regimens in high-risk patients 4

Tube Feeding Administration Considerations

Dolutegravir Administration via Feeding Tube

• Dolutegravir tablets can be crushed and administered enterally, as demonstrated in the case report where crushed twice-daily dolutegravir (separated from enteral nutrition by 2 hours) achieved therapeutic absorption 3
• The small pill size of dolutegravir facilitates crushing and administration 1

NRTI Backbone Administration

• Tenofovir and emtricitabine formulations can typically be crushed or are available in alternative formulations suitable for tube administration
• Ensure adequate separation from tube feeds if using medications that require specific timing relative to nutrition

Special Populations and Considerations

Hepatitis B Coinfection

• If the patient has HBV coinfection, tenofovir (TAF or TDF) plus lamivudine or emtricitabine is mandatory as part of the regimen for dual HIV/HBV activity 1, 4
• Never use lamivudine or emtricitabine alone for HBV due to high resistance risk 1, 4

Pregnancy

• Dolutegravir plus TAF/emtricitabine (or TDF/emtricitabine) is the recommended regimen during pregnancy with evidence rating AIa 4

Tuberculosis Coinfection

• Dolutegravir 50 mg twice daily (not once daily) with tenofovir/emtricitabine is recommended during rifamycin-containing TB treatment 4

Common Pitfalls to Avoid

• Do not attempt to continue Juluca with crushed rilpivirine through feeding tubes, as this results in subtherapeutic levels and risks virological failure 3
• Do not use protease inhibitor-based regimens as first-line alternatives unless integrase inhibitors are contraindicated, as they have more drug interactions, require boosting, and must be taken with food 1
• Avoid efavirenz-based regimens unless absolutely necessary, as they cause significantly higher rates of rash and CNS adverse effects, and carry increased suicidality risk 2, 4
• Never add dolutegravir alone to a failing regimen—always switch to a complete new regimen 5

Monitoring After Switch

• Check HIV viral load at 1 month post-switch to confirm virologic response 5
• Continue viral load monitoring every 3 months for the first year, then at least every 6 months if suppression is maintained 5
• Monitor renal function (serum creatinine and eGFR) at baseline and periodically, particularly with tenofovir-based regimens 5