TRIUMEQ
Clinical safety rating: caution
Comprehensive clinical and safety monograph for TRIUMEQ (TRIUMEQ).
TRIUMEQ is a fixed-dose combination of dolutegravir, an HIV integrase strand transfer inhibitor (INSTI) that blocks HIV replication by inhibiting integration of viral DNA into host cell DNA, and abacavir/lamivudine, nucleoside reverse transcriptase inhibitors (NRTIs) that inhibit HIV reverse transcriptase.
| Metabolism | Dolutegravir: Primarily metabolized by UGT1A1 with minor contribution from CYP3A. Abacavir: Metabolized by alcohol dehydrogenase and glucuronosyl transferases. Lamivudine: Eliminated unchanged renally and undergoes limited hepatic metabolism. |
| Excretion | Abacavir: 83% renal (unchanged and metabolites), 16% fecal. Dolutegravir: 64% fecal (unchanged), 31% renal (metabolites, <1% unchanged). Lamivudine: ~70% renal (unchanged). |
| Half-life | Abacavir: 1.5 h (intracellular carbovir-TP 20 h). Dolutegravir: 14 h (inhibits its own metabolism). Lamivudine: 13-19 h (intracellular lamivudine-TP 16-19 h). Clinical context: Once-daily dosing due to long intracellular half-lives. |
| Protein binding | Abacavir: ~50% (albumin). Dolutegravir: >99% (albumin and α-1-acid glycoprotein). Lamivudine: <36% (albumin). |
| Volume of Distribution | Abacavir: 0.86 L/kg (extensive extravascular distribution). Dolutegravir: 17.4 L (0.25 L/kg) (high tissue penetration). Lamivudine: 1.3 L/kg (wide distribution, including CSF). |
| Bioavailability | Abacavir: 83% (oral). Dolutegravir: ~72% (oral, fasted); 86% with moderate-fat meal. Lamivudine: 86% (oral). |
| Onset of Action | Oral: Antiviral activity begins within hours; maximal viral suppression observed by 8-12 weeks. |
| Duration of Action | Duration of antiviral effect persists 24 h with once-daily dosing; requires continuous daily dosing to maintain viral suppression. |
| Molecular Weight | Abacavir: 286.33 Da; Lamivudine: 229.26 Da; Dolutegravir: 419.38 Da |
One tablet (abacavir 600 mg, dolutegravir 50 mg, lamivudine 300 mg) orally once daily.
| Dosage form | TABLET |
| Renal impairment | Contraindicated if CrCl < 30 mL/min. No dose adjustment for CrCl ≥ 30 mL/min. |
| Liver impairment | Contraindicated in Child-Pugh Class B or C hepatic impairment. If Child-Pugh Class A, use only if benefit outweighs risk; monitor closely. No dose adjustment available. |
| Pediatric use | For children ≥40 kg: one tablet once daily. For children <40 kg or age <12 years: not recommended due to fixed-dose combination strength. |
| Geriatric use | No specific dose adjustment based on age alone; use with caution due to age-related renal and hepatic function decline. Monitor renal function. |
| 1st trimester | Avoid unless benefit outweighs risk. Dolutegravir has been associated with increased risk of neural tube defects when taken at conception and during first trimester. |
| 2nd trimester | Use if benefit outweighs risk. No increased risk of fetal toxicity reported. |
| 3rd trimester | Use if benefit outweighs risk. No increased risk of fetal toxicity reported. |
Clinical note
Comprehensive clinical and safety monograph for TRIUMEQ (TRIUMEQ).
| Placental transfer | All components cross the placenta. Abacavir and lamivudine are known to cross; dolutegravir crosses with measurable concentrations in cord blood. |
| Breastfeeding | Not recommended due to potential for HIV transmission via breast milk and drug excretion into breast milk. |
| Lactation Rating |
■ FDA Black Box Warning
WARNING: HYPERSENSITIVITY REACTIONS AND LACTIC ACIDOSIS/SEVERE HEPATOMEGALY WITH STEATOSIS. See full prescribing information for complete boxed warning. Abacavir: Serious and sometimes fatal hypersensitivity reactions have occurred, usually within the first 6 weeks of treatment. Discontinue immediately if hypersensitivity is suspected. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogues.
| Serious Effects |
Hypersensitivity to abacavir, lamivudine, or dolutegravirPatients with moderate to severe hepatic impairmentConcomitant use with dofetilideConcomitant use with drugs that interact with dolutegravir leading to reduced efficacy
| Precautions | Hypersensitivity reactions (abacavir): Screen for HLA-B*5701 allele prior to initiation. Lactic acidosis/hepatomegaly. Hepatotoxicity in patients with hepatitis B or C co-infection. Immune reconstitution syndrome. Fat redistribution. Myocardial infarction risk with abacavir (controversial). |
| Food/Dietary | No significant food interactions; can be taken with or without food. Avoid alcohol due to potential liver effects. No restrictions with grapefruit. |
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| L5 - Contraindicated |
| Teratogenic Risk | TRIUMEQ (abacavir/dolutegravir/lamivudine) is contraindicated in pregnancy. Dolutegravir has a known risk of neural tube defects when taken at conception and during first trimester. Risk: neural tube defects (0.9% vs 0.1% background), plus potential for mitochondrial toxicity from NRTIs. Second and third trimester risks include preterm delivery and low birth weight. |
| Fetal Monitoring | Pregnancy test before initiating; fetal ultrasound screening for neural tube defects at 18-20 weeks if exposed; HIV RNA viral load and CD4 count monitoring monthly; liver function tests; monitor for hypersensitivity reactions (abacavir). |
| Fertility Effects | No known adverse effects on fertility from TRIUMEQ. HIV infection itself may reduce fertility; effective viral suppression may improve fertility outcomes. |
| Clinical Pearls | Triumeq (abacavir/dolutegravir/lamivudine) is a complete once-daily regimen for HIV-1. Screen for HLA-B*5701 before use; if positive, abacavir is contraindicated due to risk of hypersensitivity. Dolutegravir has a high barrier to resistance; monitor for neural tube defects if used in women of childbearing potential. Take without regard to food. Avoid with dofetilide. |
| Patient Advice | Take one tablet once daily, with or without food. · If you miss a dose, take it as soon as you remember unless it's almost time for the next dose; do not double. · Seek immediate medical attention if you develop fever, rash, fatigue, nausea, or symptoms of hypersensitivity (especially within first 6 weeks). · Do not take with dofetilide (heart medication) or other abacavir- or dolutegravir-containing products. · Inform your healthcare provider if you are pregnant, planning to become pregnant, or breastfeeding. · Regular kidney function, liver function, and viral load monitoring is necessary. · Causes of hypersensitivity, including rash, require permanent discontinuation of abacavir. |