1009. Dolutegravir and Doravirine in Combination: When Standard Antiretroviral Regimens are Unacceptable

Abstract

Background. A drug-drug interaction study between dolutegravir and doravirine in healthy volunteers found no evidence of untoward interaction. Whilst we hypothesize that the combination would be safe and effective, there is no supportive clinical data. We aimed to assess the rationale for use of dolutegravir and doravirine in combination and clinical outcomes among persons with HIV infection (PWH) receiving care at the Washington DC VAMC. Methods. A quality improvement initiative utilized the clinical case registry to identify all PWH receiving both dolutegravir and doravirine. We conducted chart review to examine (a) the reasons for switch from other ART to dolutegravir and doravirine, and comorbidities, HIV resistance mutations or drug interactions precluding the use of standard ART, (b) adverse events or side effects and (c) achievement of virologic suppression. Results. A case registry search revealed 21 individuals receiving combination dolutegravir doravirine from 2018-2020 (Table 1 and Figure 1). Side effects were not noted except one patient developed mild diarrhea that improved with continuation of therapy. Four patients were hospitalized during the follow-up period for reasons unrelated to the medications. One patient who was admitted to the ICU with shock and multi-organ failure was switched on admission but died four days later and therefore was not included in the analysis of viral outcome (Table 2). One patient had cardiac arrest following missed dialysis, hyperkalemia and rectal hemorrhage from metastatic rectal cancer. Conclusion. In an era of abundant ART options, we identified a subset of older PWH whose treatment options are defined by extensive comorbidities, viral resistance, and medication interactions or toxicities. Doravirine is attractive for this population as it can be used in renal impairment, moderate hepatic impairment, is unaffected by timing of meals, and (unlike rilpivirine) has no interaction with proton pump inhibitors. Dolutegravir is included in NRTI-sparing regimens that HHS guidelines suggest should be considered in older PWH, especially with CKD. We found that dolutegravir with doravirine is well tolerated, and achieves virologic suppression in the majority of PWH, indicating this combination is useful when other ART options cannot be used.