Tegrad

Dolutegravir.

Dolutegravir tablets contains dolutegravir, as dolutegravir sodium, an HIV INSTI. The chemical name of dolutegravir sodium is sodium (4R,12as)-9-((2,4-difluorobenzyl)carbamoyl)-4-methyl-6,8-dioxo-3,4,6,8,12,12a- hexahydro-2H-pyrido[1', 2': 4,5] pyrazino [2,1-b][1,3]oxazin-7-olate. The molecular formula is C₂₀H₁₈F₂N₃NaO₅ and the molecular weight is 441.37.
Dolutegravir sodium is an off-white or white to light yellow colour powder and is very slightly soluble in methanol and practically insoluble in acetonitrile.
Each film-coated tablet of dolutegravir for oral administration contains 52.6 mg of dolutegravir sodium, which is equivalent to 50 mg dolutegravir free acid, and the following inactive ingredients: black iron oxide, mannitol, microcrystalline cellulose, polyethylene glycol, polyvinyl alcohol, povidone, red iron oxide, sodium starch glycolate, sodium stearyl fumarate, talc, titanium dioxide and yellow iron oxide.

Pharmacology: Mechanism of Action: Dolutegravir is an HIV-1 antiviral agent (see Microbiology as follows).
Pharmacodynamics: In a randomized, dose-ranging trial, HIV-1-infected subjects treated with dolutegravir monotherapy demonstrated rapid and dose-dependent antiviral activity with mean declines from baseline to Day 11 in HIV-1 RNA of 1.5, 2, and 2.5 log10 for dolutegravir 2 mg, 10 mg and 50 mg once daily, respectively. This antiviral response was maintained for 3 to 4 days after the last dose in the 50-mg group.
Effects on Electrocardiogram: In a randomized, placebo-controlled, cross-over trial, 42 healthy subjects received single-dose oral administrations of placebo, dolutegravir 250-mg suspension (exposures approximately 3- fold of the 50-mg once-daily dose at steady state), and moxifloxacin 400 mg (active control) in random sequence. After baseline and placebo adjustment, the maximum mean QTc change based on Fridericia correction method (QTcF) for dolutegravir was 2.4 msec (1-sided 95% upper CI: 4.9 msec). Dolutegravir did not prolong 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.
Clinical Studies: The efficacy of dolutegravir is based on analyses of data from 3 trials, SPRING-2 (ING113086), SINGLE (ING114467), and FLAMINGO (ING114915), in treatment-naïve, HIV-1-infected subjects (n = 2,125); one trial, SAILING (ING111762), in treatment-experienced, INSTI-naïve HIV-1-infected subjects (n = 715); and from VIKING-3 (ING112574) trial in INSTI-experienced HIV-1-infected subjects (n = 183). The use of dolutegravir in pediatric patients aged 12 years and older is based on evaluation of safety, pharmacokinetics, and efficacy through 24 weeks in a multicenter, open-label trial in subjects (n = 23) without INSTI resistance.
Adult Subjects: Treatment-Naïve Subjects In SPRING-2, 822 subjects were randomized and received at least 1 dose of either dolutegravir 50 mg once daily or raltegravir 400 mg twice daily, both in combination with fixed-dose dual NRTI treatment (either abacavir sulfate and lamivudine or emtricitabine/tenofovir. There were 808 subjects included in the efficacy and safety analyses. At baseline, the median age of subjects was 36 years, 13% female, 15% non-white, 11% had hepatitis B and/or C virus co-infection, 2% were CDC Class C (AIDS), 28% had HIV-1 RNA greater than 100,000 copies per mL, 48% had CD4+ cell count less than 350 cells per mm³, and 39% received Abacavir Sulfate and Lamivudine; these characteristics were similar between treatment groups.
In SINGLE, 833 subjects were randomized and received at least 1 dose of either dolutegravir 50 mg once daily with fixed-dose abacavir sulfate and lamivudine or fixed-dose Efavirenz, Emtricitabine and Tenofovir Disoproxil Fumarate. At baseline, the median age of subjects was 35 years, 16% female, 32% non-white, 7% had hepatitis C co-infection (hepatitis B virus co-infection was excluded), 4% were CDC Class C (AIDS), 32% had HIV-1 RNA greater than 100,000 copies per mL, and 53% had CD4+ cell count less than 350 cells per mm³; these characteristics were similar between treatment groups.
Outcomes for SPRING-2 (Week 96 analysis) and SINGLE (Week 144 open-label phase analysis which followed the Week 96 double-blind phase) are provided in Table 1. Side-by-side tabulation is to simplify presentation; direct comparisons across trials should not be made due to differing trial designs.

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SPRING-2: Virologic outcomes were also comparable across baseline characteristics including CD4+ cell count, age, and use of Abacavir Sulfate and Lamivudine or Emtricitabine and Tenovir as NRTI background regimen. The median change in CD4+ cell counts from baseline were 276 cells per mm³ in the group receiving dolutegravir and 264 cells per mm³ for the raltegravir group at 96 weeks.
There was no treatment-emergent resistance to dolutegravir or to the NRTI background.
SINGLE: 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 mm³ in the group receiving dolutegravir + Abacavir Sulfate and Lamivudine and 332 cells per mm³ for the Efavirenz, Emtricitabine and Tenofovir Disoproxil Fumarate group at 144 weeks. The adjusted difference between treatment arms and 95% CI was 46.9 cells per mm³ (15.6 cells per mm³, 78.2 cells per mm³) (adjusted for pre-specified stratification factors: baseline HIV-1 RNA, and baseline CD4+ cell count).
There was no treatment-emergent resistance to dolutegravir, abacavir, or lamivudine.
FLAMINGO: In FLAMINGO, 485 subjects were randomized and received at least 1 dose of either dolutegravir tablets 50 mg once daily (n = 243) or darunavir + ritonavir 800 mg/100 mg once daily (n = 242), both in combination with investigator-selected NRTI background regimen (either fixed-dose abacavir and lamivudine or fixed-dose emtricitabine/tenofovir disoproxil fumarate. There were 484 subjects included in the efficacy and safety analyses. At baseline, the median age of subjects was 34 years, 15% female, 28% non-white, 10% had hepatitis B and/or C virus co-infection, 3% were CDC Class C (AIDS), 25% had HIV-1 RNA greater than 100,000 copies per mL, and 35% had CD4+ cell count less than 350 cells per mm3; these characteristics were similar between treatment groups. Overall response rates by Snapshot algorithm through Week 96 were 80% for dolutegravir and 68% for darunavir/ritonavir. The proportion of subjects who were non-responders (HIV-1 RNA greater than or equal to 50 copies per mL) at Week 96 was 8% and 12% in the arms receiving dolutegravir and darunavir + ritonavir, respectively; no virologic data were available for 12% and 21% for subjects treated with dolutegravir and darunavir + ritonavir, respectively. The adjusted overall response rate difference in proportion and 95% CI was 12.4% (4.7%, 20.2%). No treatment-emergent primary resistance substitutions were observed in either treatment group.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Naïve Subjects: In the international, multicenter, double-blind trial (SAILING), 719 HIV-1-infected, antiretroviral treatment- experienced adults were randomized and received either dolutegravir tablets 50 mg once daily or raltegravir 400 mg twice daily with investigator-selected background regimen consisting of up to 2 agents, including at least 1 fully active agent. There were 715 subjects included in the efficacy and safety analyses. At baseline, the median age was 43 years, 32% were female, 50% non-white, 16% had hepatitis B and/or C virus co- infection, 46% were CDC Class C (AIDS), 20% had HIV-1 RNA greater than 100,000 copies per mL, and 72% had CD4+ cell count less than 350 cells per mm3; these characteristics were similar between treatment groups. All subjects had at least 2-class antiretroviral treatment resistance, and 49% of subjects had at least 3-class antiretroviral treatment resistance at baseline. Week 48 outcomes for SAILING are shown in Table 2.

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Treatment differences were maintained across the baseline characteristics including CD4+ cell count and age.
The mean changes in CD4+ cell counts from baseline were 162 cells per mm³ in the group receiving dolutegravir and 153 cells per mm³ in the raltegravir group.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Experienced Subjects: VIKING-3 examined the effect of dolutegravir tablets 50 mg twice daily over 7 days of functional monotherapy, followed by optimized background therapy (OBT) with continued treatment of dolutegravir tablets 50 mg twice daily.
In the multicenter, open-label, single-arm VIKING-3 trial, 183 HIV-1-infected, antiretroviral treatment-experienced adults with virological failure and current or historical evidence of raltegravir and/or elvitegravir resistance received dolutegravir tablets 50 mg twice daily with the current failing background regimen for 7 days, then received dolutegravir tablets with OBT from Day 8. A total of 183 subjects enrolled: 133 subjects with INSTI resistance at screening and 50 subjects with only historical evidence of resistance (and not at screening). At baseline, median age of subjects was 48 years; 23% were female, 29% non-white, and 20% had hepatitis B and/or C virus co-infection. Median baseline CD4+ cell count was 140 cells per mm³, median duration of prior antiretroviral treatment was 13 years, and 56% were CDC Class C. Subjects showed multiple- class antiretroviral treatment resistance at baseline: 79% had greater than or equal to 2 NRTI, 75% greater than or equal to 1 NNRTI, and 71% greater than or equal to 2 PI major substitutions; 62% had non-R5 virus.
Mean reduction from baseline in HIV-1 RNA at Day 8 (primary endpoint) was 1.4 log10 (95% CI: 1.3 log10, 1.5 log10). Response at Week 48 was affected by baseline INSTI substitutions [see Microbiology as follows].
After the functional monotherapy phase, subjects had the opportunity to re-optimize their background regimen when possible. Week 48 virologic outcomes for VIKING-3 are shown in Table 3.

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Subjects harboring virus with Q148 and with additional Q148-associated secondary substitutions also had a reduced response at Week 48 in a stepwise fashion [see Microbiology as follows]. The median change in CD4+ cell count from baseline was 80 cells per mm³ at Week 48.
Pediatric Subjects: IMPAACT P1093 is a Phase 1/2, 48-week, multicenter, open-label trial to evaluate the pharmacokinetic parameters, safety, tolerability, and efficacy of dolutegravir in combination treatment regimens in HIV-1- infected infants, children, and adolescents. Subjects were stratified by age, enrolling adolescents first (Cohort 1: aged 12 to less than 18 years) and then younger children (Cohort 2A: aged 6 to less than 12 years). All subjects received a weight-based dose of dolutegravir [see Dosage & Administration].
These 46 subjects had a mean age of 12 years (range: 6 to 17), were 54% female and 52% black. At baseline, mean plasma HIV-1 RNA was 4.6 log10 copies per mL, median CD4+ cell count was 639 cells per mm³ (range: 9 to 1,700), and median CD4+% was 23% (range: 1% to 44%). Overall, 39% had baseline plasma HIV-1 RNA greater than 50,000 copies per mL and 33% had a CDC HIV clinical classification of category C. Most subjects had previously used at least 1 NNRTI (50%) or 1 PI (70%).
At Week 24, the proportion of subjects with HIV-1 RNA less than 50 copies per mL in Cohort 1 and Cohort 2A was 70% (16/23) and 61% (14/23), respectively. At Week 48, the proportion of subjects from Cohort 1 with HIV-1 RNA less than 50 copies per mL was 61% (14/23). Virologic outcomes were also evaluated based on body weight. Across both cohorts, virologic suppression (HIV-1 RNA less than 50 copies per mL) at Week 24 was achieved in 75% (18/24) of subjects weighing at least 40 kg and 55% (6/11) of subjects in the 30 to less than 40 kg weight-band. At Week 48, 63% (12/19) of the subjects in Cohort 1 weighing at least 40 kg were virologically suppressed.
The median CD4+ cell count increase from baseline to Week 48 was 84 cells per mm3 in Cohort 1. For Cohort 2A, the median CD4+ cell count increase from baseline to Week 24 was 209 cells per mm3.
Pharmacokinetics: 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. The non-linear exposure of dolutegravir following 50 mg twice daily compared with 50 mg once daily in HIV-1- infected subjects (Table 1) was attributed to the use of metabolic inducers in the background antiretroviral regimens of subjects receiving dolutegravir 50 mg twice daily in clinical trials. (See Table 4.)
Dolutegravir tablets were administered without regard to food in these trials.

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Absorption: 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 plasma concentrations increased in a less than dose-proportional manner above 50 mg. Dolutegravir is a P-gp substrate in vitro. The absolute bioavailability of dolutegravir has not been established.
Effects of Food on Oral Absorption: Dolutegravir tablets may be taken with or without food. Food increased the extent of absorption and slowed the rate of absorption of dolutegravir. Low-, moderate-, and high-fat meals increased dolutegravir AUC_{(0 to w)} by 33%, 41%, and 66%; increased C_max by 46%, 52%, and 67%; and prolonged T_max to 3, 4, and 5 hours from 2 hours under fasted conditions, respectively.
Distribution: Dolutegravir is highly bound (greater than or equal to 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.
Cerebrospinal Fluid (CSF): In 12 treatment-naïve subjects on dolutegravir 50 mg daily plus abacavir/lamivudine, the median dolutegravir concentration in CSF was 13.2 ng per mL (range: 3.74 ng per mL to 18.3 ng per mL) 2 to 6 hours postdose after 16 weeks of treatment. The clinical relevance of this finding has not been established.
Metabolism and Elimination: Dolutegravir is primarily metabolized via UGT1A1 with some contribution from CYP3A. After a single oral dose of [¹⁴C] dolutegravir, 53% of the total oral dose was excreted unchanged in feces. Thirty-one percent of the total oral dose was excreted in urine, represented by an ether glucuronide of dolutegravir (18.9% of total dose), a metabolite formed by oxidation at the benzylic carbon (3% of total dose), and its hydrolytic N-dealkylation product (3.6% of total dose). Renal elimination of unchanged drug was low (less than 1% of the dose).
Dolutegravir has a terminal half-life of approximately 14 hours and an apparent clearance (CL/F) of 1 L per hour based on population pharmacokinetic analyses.
Polymorphisms in Drug-Metabolizing Enzymes: In a meta-analysis of healthy subject trials, subjects with UGT1A1 (n = 7) genotypes conferring poor dolutegravir metabolism had a 32% lower clearance of dolutegravir and 46% higher AUC compared with subjects with genotypes associated with normal metabolism via UGT1A1 (n = 41).
Specific Populations: Hepatic Impairment: Dolutegravir is primarily metabolized and eliminated by the liver. In a trial comparing 8 subjects with moderate hepatic impairment (Child-Pugh Score B) with 8 matched healthy controls, exposure of dolutegravir from a single 50-mg dose was similar between the 2 groups. No dosage adjustment is necessary for patients with mild to moderate hepatic impairment (Child-Pugh Score A or B). The effect of severe hepatic impairment (Child-Pugh Score C) on the pharmacokinetics of dolutegravir has not been studied. Therefore, dolutegravir is not recommended for use in patients with severe hepatic impairment.
HBV/HCV Co-infection: Population analyses using pooled pharmacokinetic data from adult trials indicated no clinically relevant effect of HCV co-infection on the pharmacokinetics of dolutegravir. There were limited data on HBV co-infection.
Renal Impairment: Renal clearance of unchanged drug is a minor pathway of elimination for dolutegravir. In a trial comparing 8 subjects with severe renal impairment (CrCl less than 30 mL per min) with 8 matched healthy controls, AUC, C_max, and C₂₄ of dolutegravir were decreased by 40%, 23%, and 43%, respectively, compared with those in matched healthy subjects. The cause of this decrease is unknown. Population pharmacokinetic analysis using data from SAILING and VIKING-3 trials indicated that mild and moderate renal impairment had no clinically relevant effect on the exposure of dolutegravir. No dosage adjustment is necessary for treatment-naïve or treatment-experienced and INSTI-naïve patients with mild, moderate, or severe renal impairment or for INSTI-experienced patients (with certain INSTI-associated resistance substitutions or clinically suspected INSTI resistance) with mild or moderate renal impairment. Caution is warranted for INSTI-experienced patients (with certain INSTI-associated resistance substitutions or clinically suspected INSTI resistance [see Microbiology as follows) with severe renal impairment, as the decrease in dolutegravir concentrations may result in loss of therapeutic effect and development of resistance to dolutegravir or other coadministered antiretroviral agents. Dolutegravir has not been studied in patients requiring dialysis.
Gender: Population analyses using pooled pharmacokinetic data from adult trials indicated gender had no clinically relevant effect on the exposure of dolutegravir.
Race: Population analyses using pooled pharmacokinetic data from adult trials indicated race had no clinically relevant effect on the pharmacokinetics of dolutegravir.
Geriatric Patients: Population analyses using pooled pharmacokinetic data from adult trials indicated age had no clinically relevant effect on the pharmacokinetics of dolutegravir.
Pediatric Patients: The pharmacokinetics of dolutegravir in HIV-1-infected children (n = 17) weighing at least 30 kg were similar to those observed in HIV-1-infected adults who received dolutegravir 50 mg once daily (Table 5) [see Clinical Studies previously].

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Population pharmacokinetic analyses demonstrate comparable exposures in children, at least 30 kg, dosed by weight-bands (35 mg or 50 mg of dolutegravir) to that observed in adults.
Drug Interactions: Drug interaction trials were performed with dolutegravir and other drugs likely to be coadministered or commonly used as probes for pharmacokinetic interactions. As dolutegravir is not expected to affect the pharmacokinetics of other drugs dependent on hepatic metabolism (Table 6) [see Interactions], the primary focus of these drug interaction trials was to evaluate the effect of coadministered drug on dolutegravir (Table 7). Dosing or regimen recommendations as a result of established and other potentially significant drug-drug interactions with dolutegravir are provided in Table 15 [see Dosage & Administration, Interactions].

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Nonclinical Toxicology: Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenesis: Two-year carcinogenicity studies in mice and rats were conducted with dolutegravir. Mice were administered doses of up to 500 mg per kg, and rats were administered doses of up to 50 mg per kg. In mice, no significant increases in the incidence of drug-related neoplasms were observed at the highest doses tested, resulting in dolutegravir AUC exposures approximately 14-fold higher than those in humans at the recommended dose of 50 mg twice daily. In rats, no increases in the incidence of drug-related neoplasms were observed at the highest dose tested, resulting in dolutegravir AUC exposures 10-fold and 15-fold higher in males and females, respectively, than those in humans at the recommended dose of 50 mg twice daily.
Mutagenesis: Dolutegravir was not genotoxic in the bacterial reverse mutation assay, mouse lymphoma assay, or in the in vivo rodent micronucleus assay.
Impairment of Fertility: In a study conducted in rats, there were no effects on mating or fertility with dolutegravir up to 1,000 mg per kg per day. This dose is associated with an exposure that is approximately 24 times higher than the exposure in humans at the recommended dose of 50 mg twice daily.
Microbiology: Mechanism of Action: Dolutegravir inhibits HIV integrase by binding to the integrase active site and blocking the strand transfer step of retroviral deoxyribonucleic acid (DNA) integration which is essential for the HIV replication cycle. Strand transfer biochemical assays using purified HIV-1 integrase and pre-processed substrate DNA resulted in IC₅₀ values of 2.7 nM and 12.6 nM.
Antiviral Activity in Cell Culture: Dolutegravir exhibited antiviral activity against laboratory strains of wild-type HIV-1 with mean EC₅₀ values of 0.5 nM (0.21 ng per mL) to 2.1 nM (0.85 ng per mL) in peripheral blood mononuclear cells (PBMCs) and MT-4 cells. Dolutegravir exhibited antiviral activity against 13 clinically diverse clade B isolates with a mean EC₅₀ value of 0.52 nM in a viral integrase 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 (3 in each group of M clades A, B, C, D, E, F, and G, and 3 in group O) with EC₅₀ values ranging from 0.02 nM to 2.14 nM for HIV-1. Dolutegravir EC₅₀ values against 3 HIV-2 clinical isolates in PBMC assays ranged from 0.09 nM to 0.61 nM.
Antiviral Activity in Combination with Other Antiviral Agents: The antiviral activity of dolutegravir was not antagonistic when combined with the INSTI, raltegravir; non- nucleoside reverse transcriptase inhibitors (NNRTIs), efavirenz or nevirapine; the nucleoside reverse transcriptase inhibitors (NRTIs), abacavir or stavudine; the protease inhibitors (PIs), amprenavir or lopinavir; the CCR5 co-receptor antagonist, maraviroc; or the fusion inhibitor, enfuvirtide. Dolutegravir antiviral activity was not antagonistic when combined with the HBV reverse transcriptase inhibitor, adefovir, or inhibited by the antiviral, ribavirin.
Resistance: Cell Culture: 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. Passage of mutant viruses containing the Q148R or Q148H substitutions selected for additional substitutions in integrase that conferred decreased susceptibility to dolutegravir (fold-change increase of 13 to 46). The additional integrase substitutions included T97A, E138K, G140S, and M154I. Passage of mutant viruses containing both G140S and Q148H selected for L74M, E92Q, and N155H.
Treatment-Naïve Subjects: No subjects in the dolutegravir 50-mg once-daily treatment arms of treatment- naïve trials SPRING-2 (96 weeks) and SINGLE (144 weeks) had a detectable decrease in susceptibility to dolutegravir or background NRTIs in the resistance analysis subset (n = 12 with HIV-1 RNA greater than 400 copies per 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 per 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 the background regimen was observed in the dolutegravir arm in either the SPRING-2 or SINGLE trials. No treatment-emergent primary resistance substitutions were observed in either treatment group in the FLAMINGO trial through Week 96.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Naïve Subjects: In the dolutegravir arm of the SAILING trial for treatment-experienced and INSTI-naïve subjects (n = 354), treatment-emergent integrase substitutions were observed in 6 of 28 (21%) subjects who had virologic failure and resistance data. In 5 of the 6 subjects' isolates emergent INSTI substitutions included L74L/M/I, Q95Q/L, V151V/I (n = 1 each), and R263K (n = 2). The change in dolutegravir phenotypic susceptibility for these 5 subject isolates was less than 2-fold. One subject isolate had pre-existing raltegravir resistance substitutions E138A, G140S, and Q148H at baseline and had additional emergent INSTI-resistance substitutions T97A and E138A/T with a corresponding 148-fold reduction in dolutegravir susceptibility at failure. In the comparator raltegravir arm, 21 of 49 (43%) subjects with post-baseline resistance data had evidence of emergent INSTI-resistance substitutions (L74M, E92Q, T97A, E138Q, G140S/A, Y143R/C, Q148H/R, V151I, N155H, E157Q, and G163K/R) and raltegravir phenotypic resistance.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Experienced Subjects: VIKING-3 examined the efficacy of dolutegravir 50 mg twice daily plus optimized background therapy in subjects with prior or current virologic failure on an INSTI-(elvitegravir or raltegravir) containing regimen.
In VIKING-4 (ING116529), 30 subjects with current virological failure on an INSTI-containing regimen and genotypic evidence of INSTI-resistance substitutions at screening were randomized to receive either dolutegravir 50 mg twice daily or placebo with the current failing regimen for 7 days and then all subjects received open- label dolutegravir plus optimized background regimen from Day 8. Virologic responses at Week 48 by baseline genotypic and phenotypic INSTI-resistance categories and the INSTI resistance-associated substitutions that emerged on dolutegravir treatment in VIKING-4 were consistent with those seen in VIKING-3.
Response by Baseline Genotype: Of the 183 subjects with baseline data, 30% harbored virus with a substitution at Q148, and 33% had no primary INSTI-resistance substitutions (T66A/I/K, E92Q/V, Y143R/C/H, Q148H/R/K, and N155H) at baseline, but had historical genotypic evidence of INSTI-resistance substitutions, phenotypic evidence of elvitegravir or raltegravir resistance, or genotypic evidence of INSTI-resistance substitutions at screening. Response rates by baseline genotype were analyzed in an "as-treated" analysis at Week 48 (n = 175) (Table 8). The response rate at Week 48 to dolutegravir-containing regimens was 47% (24 of 51) when Q148 substitutions were present at baseline; Q148 was always present with additional INSTI-resistance substitutions (see Table 8). In addition, a diminished virologic response of 40% (6 of 15) was observed when the substitution E157Q or K was present at baseline with other INSTI-resistance substitutions but without a Q148H or R substitution.

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Response by Baseline Phenotype: Response rates by baseline phenotype were analyzed in an as-treated analysis using all subjects with available baseline phenotypes through Week 48 (n = 163) (see Table 9). These baseline phenotypic groups are based on subjects enrolled in VIKING-3 and are not meant to represent definitive clinical susceptibility cut points for dolutegravir. The data are provided to guide clinicians on the likelihood of virologic success based on pretreatment susceptibility to dolutegravir in INSTI-resistant patients.

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Integrase Strand Transfer Inhibitor Treatment-Emergent Resistance: There were 50 subjects with virologic failure on the dolutegravir twice-daily regimen in VIKING-3 with HIV-1 RNA greater than 400 copies per mL at the failure timepoint, Week 48 or beyond, or the last timepoint on trial. Thirty-nine subjects with virologic failure had resistance data that were used in the Week 48 analysis. In the Week 48 resistance analysis 85% (33 of 39) of the subjects with virologic failure had treatment- emergent INSTI-resistance substitutions in their isolates. The most common treatment-emergent INSTI-resistance substitution was T97A. Other frequently emergent INSTI-resistance substitutions included L74M, I or V, E138K or A, G140S, Q148H, R or K, M154I, or N155H. Substitutions E92Q, Y143R or C/H, S147G, V151A, and E157E/Q each emerged in 1 to 3 subjects' isolates. At failure, the median dolutegravir fold-change from reference was 61-fold (range: 0.75 to 209) for isolates with emergent INSTI-resistance substitutions (n = 33).
Resistance to one or more background drugs in the dolutegravir twice-daily regimen also emerged in 49% (19 of 39) subjects in the Week 48 resistance analysis.
Cross-Resistance: Site-Directed Integrase Strand Transfer Inhibitor-Resistant Mutant HIV-1 and HIV-2 Strains: The susceptibility of dolutegravir was tested against 60 INSTI-resistant site-directed mutant HIV-1 viruses (28 with single substitutions and 32 with 2 or more substitutions) and 6 INSTI-resistant site-directed mutant HIV-2 viruses. The single INSTI-resistance substitutions T66K, I151L, and S153Y conferred a greater than 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 greater than 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.
Reverse Transcriptase Inhibitor- and Protease Inhibitor-Resistant Strains: Dolutegravir demonstrated equivalent antiviral activity against 2 NNRTI-resistant, 3 NRTI-resistant, and 2 PI-resistant HIV-1 mutant clones compared with the wild-type strain.

Dolutegravir tablet is indicated in combination with other antiretroviral agents for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and children aged 12 years and older and weighing at least 40 kg.
Limitations of Use: Use of dolutegravir tablets in integrase strand transfer inhibitor (INSTI)-experienced patients should be guided by the number and type of baseline INSTI substitutions. The efficacy of dolutegravir tablets 50 mg twice daily is reduced in patients with an INSTI-resistance Q148 substitution plus 2 or more additional INSTI-resistance substitutions, including T66A, L74I/M, E138A/K/T, G140S/A/C, Y143R/C/H, E157Q, G163S/E/K/Q, or G193E/R [see Pharmacology: Microbiology under Actions].

Adults: Dolutegravir tablets may be taken with or without food. (See Table 10.)

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Pediatric Patients: Dolutegravir tablets may be taken with or without food.
Treatment-Naïve or Treatment-Experienced INSTI-Naïve: The recommended dose of dolutegravir tablets in pediatric patients weighing at least 30 kg is provided in Table 11. (See Table 11.)

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Safety and efficacy of dolutegravir tablets have not been established in pediatric patients who are INSTI-experienced with documented or clinically suspected resistance to other INSTIs (raltegravir, elvitegravir).

There is no known specific treatment for overdose with dolutegravir. If overdose occurs, the patient should be monitored and standard supportive treatment applied as required. As dolutegravir is highly bound to plasma proteins, it is unlikely that it will be significantly removed by dialysis.

Dolutegravir tablet is contraindicated in patients: with previous hypersensitivity reaction to dolutegravir [see Precautions]; receiving dofetilide due to the potential for increased dofetilide plasma concentrations and the risk for serious and/or life-threatening events [see Interactions].

Hypersensitivity Reactions: Hypersensitivity reactions have been reported and were characterized by rash, constitutional findings, and sometimes organ dysfunction, including liver injury. The events were reported in less than 1% of subjects receiving dolutegravir in Phase 3 clinical trials. Discontinue dolutegravir 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 dolutegravir or other suspect agents after the onset of hypersensitivity may result in a life-threatening reaction. Dolutegravir is contraindicated in patients who have experienced a previous hypersensitivity reaction to dolutegravir.
Effects on Serum Liver Biochemistries in Patients with Hepatitis B or C Co-infection: Patients with underlying hepatitis B or C may be at increased risk for worsening or development of transaminase elevations with use of dolutegravir [see Adverse Reactions]. 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. Appropriate laboratory testing prior to initiating therapy and monitoring for hepatotoxicity during therapy with dolutegravir are recommended in patients with underlying hepatic disease such as hepatitis B or C.
Fat Redistribution: Redistribution/accumulation of body fat, including central obesity, dorsocervical fat enlargement (buffalo hump), peripheral wasting, facial wasting, breast enlargement, and "cushingoid appearance" have been observed in patients receiving antiretroviral therapy. The mechanism and long-term consequences of these events are currently unknown. A causal relationship has not been established.
Immune Reconstitution Syndrome: Immune reconstitution syndrome has been reported in patients treated with combination antiretroviral therapy, including dolutegravir. 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, and Guillain-Barré syndrome) 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.
Hepatic Impairment: No clinically important pharmacokinetic differences between subjects with moderate hepatic impairment and matching healthy subjects were observed. No dosage adjustment is necessary for patients with mild to moderate hepatic impairment (Child-Pugh Score A or B). The effect of severe hepatic impairment (Child-Pugh Score C) on the pharmacokinetics of dolutegravir has not been studied. Therefore, dolutegravir is not recommended for use in patients with severe hepatic impairment [see Pharmacology under Actions].
Renal Impairment: Dolutegravir plasma concentrations were decreased in subjects with severe renal impairment compared with those in matched healthy controls. However, no dosage adjustment is necessary for treatment-naïve or treatment-experienced and INSTI-naïve patients with mild, moderate, or severe renal impairment or for INSTI- experienced patients (with certain INSTI-associated resistance substitutions or clinically suspected INSTI resistance) with mild or moderate renal impairment. Caution is warranted for INSTI-experienced patients (with certain INSTI-associated resistance substitutions or clinically suspected INSTI resistance [see Pharmacology: Microbiology under Actions]) with severe renal impairment, as the decrease in dolutegravir concentrations may result in loss of therapeutic effect and development of resistance to dolutegravir or other coadministered antiretroviral agents [see Pharmacology under Actions]. Dolutegravir has not been studied in patients on dialysis.
Use in Children: The safety, virologic, and immunologic responses in subjects who received dolutegravir were evaluated in 46 treatment-experienced, INSTI-naïve, HIV-1-infected subjects aged 6 to less than 18 years in an open-label, multicenter, dose-finding clinical trial, IMPAACT P1093 [see Pharmacology: Pharmacodynamics: Clinical Studies under Actions]. Frequency, type, and severity of adverse drug reactions among the 46 pediatric subjects were comparable to those observed in adults [see Adverse Reactions]. In 17 subjects weighing at least 30 kg, pharmacokinetic parameters of dolutegravir were comparable to adults receiving 50 mg once daily [see Pharmacology under Actions].
Safety and efficacy of dolutegravir have not been established in pediatric patients weighing less than 30 kg or in any pediatric patients who are INSTI-experienced.
Use in Elderly: Clinical trials of dolutegravir did not include sufficient numbers of subjects aged 65 and older to determine whether they respond differently from younger subjects. In general, caution should be exercised in the administration of dolutegravir in elderly patients reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see Pharmacology under Actions].

Pregnancy: Teratogenic Effects Risk: Summary: There are insufficient human data on the use of dolutegravir tablets during pregnancy to inform a drug- associated risk of birth defects and miscarriage. Given the limited number of pregnancies exposed to dolutegravir-based regimens reported to the APR, no definitive conclusions can be drawn on the safety of dolutegravir in pregnancy, and continued monitoring is ongoing through the APR. The background rate for major birth defects in a U.S. reference population of the Metropolitan Atlanta Congenital Defects Program (MACDP) is 2.7%. The estimated background rate of miscarriage in clinically recognized pregnancies in the U.S. general population is 15% to 20%. In animal reproduction studies, no evidence of adverse developmental outcomes was observed with dolutegravir [see Data as follows]. During organogenesis in the rat and rabbit, systemic exposures (AUC) to dolutegravir were less than (rabbits) and approximately 27 times (rats) the exposure in humans at the maximum recommended human dose (MRHD). In the rat pre/post- natal developmental study, maternal systemic exposure (AUC) to dolutegravir was approximately 27 times the exposure in humans at the MRHD.
Data: Animal Data: Dolutegravir was administered orally at up to 1,000 mg per kg daily to pregnant rats and rabbits on gestation Days 6 to 17 and 6 to 18, respectively, and also 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 at up to the highest dose tested. During organogenesis systemic exposures (AUC) to dolutegravir in rabbits were less than the exposure in humans at the maximum recommended human dose (MRHD) and in rats were approximately 27 times the exposure in humans at the MRHD. 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 27 times human exposure at the MRHD).
Lactation: Risk Summary: The Centers for Disease Control and Prevention recommend that HIV-1-infected mothers in the United States not breastfeed their infants to avoid risking postnatal transmission of HIV-1 infection. It is not known whether dolutegravir is present in human breast milk, affects human milk production, or has effects on the breastfed infant. When administered to lactating rats, dolutegravir was present in milk [see Data as follows]. Because of the potential for (1) HIV-1 transmission (in HIV-negative infants), and (2) developing viral resistance (in HIV-positive infants), instruct mothers not to breastfeed if they are receiving dolutegravir.
Data: Animal Data: Dolutegravir was the primary drug-related component excreted into the milk of lactating rats following a single oral dose of 50 mg per kg on lactation Day 10, with milk concentrations of up to approximately 1.3 times that of maternal plasma concentrations observed 8 hours post-dose.

The following serious adverse drug reactions are discussed in other sections of the labeling: Hypersensitivity reactions [see Precautions].
Effects on serum liver biochemistries in patients with hepatitis B or C co-infection [see Precautions]. Fat Redistribution [see Precautions].
Immune Reconstitution Syndrome [see Precautions].
Clinical Trials Experience: Because clinical trials are conducted 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 practice.
Clinical Trials Experience in Adult: Subjects Treatment-Naïve Subjects: The safety assessment of dolutegravir in HIV-1-infected treatment-naïve subjects is based on the analyses of data from 2 international, multicenter, double-blind trials, SPRING- 2 (ING113086) and SINGLE (ING114467) and data from the international, multicenter, open-label FLAMINGO (ING114915) trial.
In SPRING-2, 822 subjects were randomized and received at least 1 dose of either dolutegravir 50 mg once daily or raltegravir 400 mg twice daily, both in combination with fixed-dose dual nucleoside reverse transcriptase inhibitor (NRTI) treatment (either abacavir sulfate and lamivudine or emtricitabine/tenofovir. There were 808 subjects included in the efficacy and safety analyses. Through 96 weeks, the rate of adverse events leading to discontinuation was 2% in both treatment arms.
In SINGLE, 833 subjects were randomized and received at least 1 dose of either dolutegravir 50 mg with fixed-dose abacavir sulfate and lamivudine once daily or fixed-dose efavirenz/emtricitabine/tenofovir once daily (study treatment was blinded through Week 96 and open-label from Week 96 through Week 144). Through 144 weeks, the rates of adverse events leading to discontinuation were 4% in subjects receiving dolutegravir 50 mg once daily + Abacavir Sulfate and Lamivudine and 14% in subjects receiving Efavirenz, Emtricitabine and Tenofovir Disoproxil Fumarate once daily.
Treatment-emergent adverse drug reactions (ADRs) of moderate to severe intensity observed in at least 2% of subjects in either treatment arm in SPRING-2 and SINGLE trials are provided in Table 12. Side-by- side tabulation is to simplify presentation; direct comparisons across trials should not be made due to differing trial designs. (See Table 12.)

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In addition, Grade 1 insomnia was reported by 1% and less than 1% of subjects receiving dolutegravir and raltegravir, respectively, in SPRING-2; whereas in SINGLE the rates were 7% and 4% for dolutegravir and Efavirenz, Emtricitabine and Tenofovir Disoproxil Fumarate, respectively. These events were not treatment limiting.
In a multicenter, open-label trial (FLAMINGO), 243 subjects received dolutegravir 50 mg once daily versus 242 subjects who received darunavir 800 mg/ritonavir 100 mg once daily, both in combination with investigator-selected NRTI background regimen (either Abacavir Sulfate and Lamivudine or Emtricitabine and Tenovir). There were 484 subjects included in the efficacy and safety analyses. Through 96 weeks, the rates of adverse events leading to discontinuation were 3% in subjects receiving dolutegravir and 6% in subjects receiving darunavir/ritonavir. The ADRs observed in FLAMINGO were generally consistent with those seen in SPRING-2 and SINGLE.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Naïve Subjects: In an international, multicenter, double-blind trial (ING111762, SAILING), 719 HIV-1-infected, antiretroviral treatment-experienced adults were randomized and received either dolutegravir 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 rates of adverse events leading to discontinuation were 3% in subjects receiving dolutegravir 50 mg once daily + background regimen and 4% in subjects receiving raltegravir 400 mg twice daily + background regimen.
The only treatment-emergent ADR of moderate to severe intensity with at least 2% frequency in either treatment group was diarrhea, 2% (6 of 354) in subjects receiving dolutegravir 50 mg once daily + background regimen and 1% (5 of 361) in subjects receiving raltegravir 400 mg twice daily + background regimen.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Experienced Subjects: In a multicenter, open- label, single-arm trial (ING112574, VIKING-3), 183 HIV-1-infected, antiretroviral treatment-experienced adults with virological failure and current or historical evidence of raltegravir and/or elvitegravir resistance received dolutegravir 50 mg twice daily with the current failing background regimen for 7 days and with optimized background therapy from Day 8. The rate of adverse events leading to discontinuation was 4% of subjects at Week 48.
Treatment-emergent ADRs in VIKING-3 were generally similar compared with observations with the 50- mg once-daily dose in adult Phase 3 trials.
Less Common Adverse Reactions Observed in Treatment-Naïve and Treatment-Experienced Trials: The following ADRs occurred in less than 2% of treatment-naïve or treatment-experienced subjects receiving dolutegravir in a combination regimen in any one trial. These events have been included because of their seriousness and assessment of potential causal relationship.
Gastrointestinal Disorders: Abdominal pain, abdominal discomfort, flatulence, upper abdominal pain, vomiting.
Hepatobiliary Disorders: Hepatitis.
Musculoskeletal Disorders: Myositis.
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.
Renal and Urinary Disorders: Renal impairment.
Skin and Subcutaneous Tissue Disorders: Pruritus. Laboratory Abnormalities:
Treatment-Naïve 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 are presented in Table 13. The mean change from baseline observed for selected lipid values is presented in Table 14. Side-by-side tabulation is to simplify presentation; direct comparisons across trials should not be made due to differing trial designs. (See Tables 13 and 14.)

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Laboratory abnormalities observed in the FLAMINGO trial were generally consistent with observations in SPRING-2 and SINGLE.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Naïve Subjects: Laboratory abnormalities observed in SAILING were generally similar compared with observations seen in the treatment-naïve (SPRING-2 and SINGLE) trials.
Treatment-Experienced, Integrase Strand Transfer Inhibitor-Experienced Subjects: The most common treatment- emergent laboratory abnormalities (greater than 5% for Grades 2 to 4 combined) observed in VIKING-3 at Week 48 were elevated ALT (9%), AST (8%), cholesterol (10%), creatine kinase (6%), hyperglycemia (14%), and lipase (10%). Two percent (4 of 183) of subjects had a Grade 3 to 4 treatment-emergent hematology laboratory abnormality, with neutropenia (2% [3 of 183]) being the most frequently reported.
Hepatitis B and/or Hepatitis C Virus Co-infection: In Phase 3 trials, subjects with hepatitis B and/or C virus co-infection were permitted to enroll provided that baseline liver chemistry tests did not exceed 5 times the upper limit of normal. Overall, the safety profile in subjects with hepatitis B and/or C virus co-infection was similar to that observed in subjects without hepatitis B or C co-infection, although the rates of AST and ALT abnormalities were higher in the subgroup with hepatitis B and/or C virus co-infection for all treatment groups. Grades 2 to 4 ALT abnormalities in hepatitis B and/or C co-infected compared with HIV mono-infected subjects receiving dolutegravir were observed in 18% vs. 3% with the 50-mg once-daily dose and 13% vs. 8% with the 50-mg twice-daily dose. Liver chemistry elevations consistent with immune reconstitution syndrome were observed in some subjects with hepatitis B and/or C at the start of therapy with dolutegravir, particularly in the setting where anti-hepatitis therapy was withdrawn [see Precautions].
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 Pharmacology under Actions]. Increases in serum creatinine occurred within the first 4 weeks of treatment and remained stable through 96 weeks. In treatment-naïve subjects, a mean change from baseline of 0.15 mg per dL (range: - 0.32 mg per dL to 0.65 mg per dL) was observed after 96 weeks of treatment. Creatinine increases were comparable by background NRTIs and were similar in treatment-experienced subjects.
Clinical Trials Experience in Pediatric Subjects: IMPAACT P1093 is an ongoing multicenter, open-label, non-comparative trial of approximately 160 HIV-1- infected pediatric subjects aged 4 weeks to less than 18 years, of which 46 treatment-experienced, INSTI- naïve subjects aged 6 to less than 18 years have been enrolled [see Use in Children under Precautions, Pharmacology: Pharmacodynamics: Clinical Studies: Pediatric Subjects under Actions].
The adverse reaction profile was similar to that for adults. Grade 2 ADRs reported by more than one subject were decreased neutrophil count (n = 3) and diarrhea (n = 2).
There were no Grade 3 or 4 drug-related ADRs reported. No ADRs led to discontinuation. The Grade 3 or 4 laboratory abnormalities reported in more than one subject were elevated total bilirubin (n = 3) and decreased neutrophil count (n = 2). The changes in mean serum creatinine were similar to those observed in adults.

Effect of Dolutegravir on the Pharmacokinetics of Other Agents: In vitro, dolutegravir inhibited the renal organic cation transporters, OCT2 (IC₅₀ = 1.93 μM) and multidrug and toxin extrusion transporter (MATE) 1 (IC₅₀ = 6.34 μM). In vivo, dolutegravir inhibits tubular secretion of creatinine by inhibiting OCT2 and potentially MATE1. Dolutegravir may increase plasma concentrations of drugs eliminated via OCT2 or MATE1 (dofetilide and metformin, Table 15) [see Contraindications, Established and Other Potentially Significant Drug Interactions as follows].
In vitro, dolutegravir inhibited the basolateral renal transporters, organic anion transporter (OAT) 1 (IC₅₀ = 2.12 μM) and OAT3 (IC₅₀ = 1.97 μM). However, in 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 (IC₅₀ greater than 50 μM) the following: cytochrome P450 (CYP)1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP3A, uridine diphosphate (UDP)-glucuronosyl transferase 1A1 (UGT1A1), UGT2B7, P-glycoprotein (P-gp), breast cancer resistance protein (BCRP), bile salt export pump (BSEP), organic anion transporter polypeptide (OATP)1B1, OATP1B3, OCT1, multidrug resistance protein (MRP)2, or MRP4. In vitro, dolutegravir did not induce CYP1A2, CYP2B6, or 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.
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 concentration and reduce the therapeutic effect of dolutegravir.
Coadministration of dolutegravir and other drugs that inhibit these enzymes may increase dolutegravir plasma concentration. 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 15) [see Established and Other Potentially Significant Drug Interactions as follows, Pharmacology under Actions].
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.
Established and Other Potentially Significant Drug Interactions: Table 15 provides clinical recommendations as a result of drug interactions with dolutegravir. 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 Dosage & Administration, Pharmacology under Actions.] (See Table 15.)

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Store below 30°C and protect from moisture.

Advise the patient to read the patient labeling (Patient Information).
Drug Interactions: Dolutegravir tablet is contraindicated with dofetilide because interactions between these drugs can result in potentially life-threatening adverse events [see Contraindications].
Hypersensitivity Reactions: Advise patients to immediately contact their healthcare provider if they develop rash. Instruct patients to immediately stop taking dolutegravir tablets and other suspect agents, and seek medical attention if they develop a rash associated with any of the following symptoms, as it may be a sign of a more serious reaction such as severe hypersensitivity: fever; generally ill feeling; extreme tiredness; muscle or joint aches; blisters or peeling of the skin; oral blisters or lesions; eye inflammation; facial swelling; swelling of the eyes, lips, tongue, or mouth; breathing difficulty; and/or signs and symptoms of liver problems (e.g., yellowing of the skin or whites of the eyes, dark or tea-colored urine, pale-colored stools or bowel movements, nausea, vomiting, loss of appetite, or pain, aching, or sensitivity on the right side below the ribs) [see Precautions].
Effects on Serum Liver Biochemistries in Patients with Hepatitis B or C Co-infection: Advise patients that it is recommended to have laboratory testing before and during therapy as patients with underlying hepatitis B or C may be at increased risk for worsening or development of transaminase elevations with use of dolutegravir tablets [see Precautions].
Fat Redistribution: Inform patients that redistribution or accumulation of body fat may occur in patients receiving antiretroviral therapy and that the cause and long-term health effects of these conditions are not known at this time [see Precautions].
Immune Reconstitution Syndrome: Advise patients to inform their healthcare provider immediately of any signs or symptoms of infection as inflammation from previous infection may occur soon after combination antiretroviral therapy, including when dolutegravir tablet is started [see Precautions].
Pregnancy Registry: Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to dolutegravir tablets during pregnancy [see Use in Pregnancy and Lactation]. Lactation: Instruct women with HIV-1 infection not to breastfeed because HIV-1 can be passed to the baby in the breast milk [see Use in Pregnancy and Lactation].
Missed Dosage: Instruct patients that if they miss a dose of dolutegravir tablets, to take it as soon as they remember. Advise patients not to double their next dose or take more than the prescribed dose [see Dosage & Administration].
Storage Condition: Store below 30°C and protect from moisture.

Antivirals

J05AJ03 - dolutegravir ; Belongs to the class of integrase inhibitors. Used as direct acting antiviral in the systemic treatment of viral infections.

Rx

FC tab 50 mg (pink, round, biconvex, debossed with 'H' on one side and 'D13' on the other side) x 30's.