Transitioning from Biktarvy to Cabenuva for HIV Treatment

Considering the Switch from Biktarvy to the New Cabenuva for HIV Treatment

Biktarvy has become a widely used and trusted once-daily single tablet regimen for managing HIV. But newer long-acting injectable antiretroviral therapies like Cabenuva offer an alternative option that only require dosing once monthly or every two months.

What is Cabenuva?

Cabenuva was approved by the FDA in 2021 as an injectable form of two common antiretrovirals - cabotegravir and rilpivirine. These drugs have been used to effectively treat HIV, but Cabenuva packages them into nanosuspensions that slowly release over time from muscle tissue through a single injection.

This eliminates the need to take daily oral medication for maintaining viral suppression by two different mechanisms of action. It offers new freedom and convenience for HIV patients.

Cabenuva vs Oral Biktarvy Treatment

Both Bikarvy and Cabenuva achieve similar viral suppression, but have some differences in dosing/administration, side effects, and recommendations:

Dosing Frequency

Biktarvy: Once daily oral tablet
Cabenuva: Two monthly or every-other monthly intramuscular injections

Administration

Biktarvy: Self-administered pill
Cabenuva: Clinician administered injection into muscle (buttocks)

Side Effects

Biktarvy: Nausea, diarrhea, headache common
Cabenuva: Injection site reactions common

Appropriateness

Biktarvy: First line oral HIV treatment
Cabenuva: Those with stable viral suppression on other regimens

The unique advantages of Cabenuva center around dramatically less frequent dosing and not needing strict daily adherence. But oral Biktarvy remains the easiest to administer.

Who is a Candidate for Switching from Biktarvy to Cabenuva?

The key requirement for transitioning from Biktarvy to long-acting Cabenuva injections is having documented viral suppression already. Specific guidelines endorse Cabenuva for those who:

• Have had an undetectable viral load (<50 copies/mL) for at least 3-6 months prior on their current oral antiretroviral therapy
• Do not have known or suspected drug resistance that could reduce Cabenuva effectiveness
• Have adequate kidney and liver function to safely metabolize injectable drugs
• Are motivated by less frequent dosing over the strict daily pill regimen

Cabenuva has not been studied as a first line HIV treatment. But those stable on regimens like Biktarvy stand to benefit from this more intermittent injectable option.

The Benefits of Switching to Cabenuva

Transitioning from a daily oral HIV treatment to long-acting Cabenuva injections every 1-2 months provides possible advantages like:

• Avoiding daily dosing can improve quality of life, flexibility with schedules, and reduce feeling “chained” to HIV medication times
• Injectable nanosuspensions slowly release medication from tissue over weeks meaning missed or late doses are less urgent
• Intramuscular depot sites bypass the GI system, reducing side effects like diarrhea or nausea
• Stigma around visible daily HIV medication is diminished with private intermittent injectable treatment
• Clinics visits every 1-2 months to receive injections allow more provider interaction vs pharmacy refills alone

The switch to all-injectable HIV treatment allows for patient empowerment and convenience lacking from older regimens.

How the Transition Between Biktarvy and Cabenuva Occurs

When switching between these two HIV therapies, there is some overlap to ensure continual suppression and a smooth handoff. The transition process generally proceeds as follows in outpatient settings:

1. At least 3 months of proven viral suppression (undetectable viral load) first demonstrated on current oral therapy like Biktarvy
2. Establish tolerability of the cabotegravir and rilpivirine agents individually while still taking Biktarvy tablets
3. Monthly cabotegravir + rilpivirine injections are started while OVERLAPPING with Biktarvy tablets for at least 1 month until the injections reach steady therapeutic levels
4. Once the injections demonstrate adequate drug absorption, Biktarvy tablets are discontinued
5. Ongoing cabenuva injections every 4-8 weeks are now the sole HIV therapy

This careful crossover transition is well tolerated and ensures patients moving to Cabenuva maintain suppression through the change without complications.

Monitoring Effectiveness and Side Effects on Cabenuva

Following the transition from previous oral HIV treatment onto Cabenuva long-acting injections, patients require periodic monitoring to ensure effectiveness and watch for side effects. Guidelines endorse:

Viral Load Testing

Viral load blood tests should be conducted 1 month after starting Cabenuva, then every 3 months thereafter. Continued undetectable results indicate stable suppression sans Biktarvy.

Injection Site Checks

At monthly injection appointments, clinicians visually and physically examine the gluteal intramuscular injection sites for signs of irritation, swelling, nodules or infection.

Liver and Kidney Function Labs

Baseline metabolic panels are recommended prior to initiating Cabenuva. Follow up monitoring every 6-12 months allows evaluation of any organ toxicity over longer term use.

Patient Symptom Reports

While receiving Cabenuva injections, patients should relay any concerning symptoms like severe fatigue, fever, dark urine, abdominal pain or unexplained muscle aches that could indicate toxicity.

Staying vigilant through objective testing and subjective symptom reporting allows for prompt intervention if any complications were to emerge on the injectable regimen.

Maintaining Adherence with Cabenuva Injections

The long-acting depot formulations of cabotegravir + rilpivirine allow for viral suppression coverage lasting 1-2 months from each injection. But maintaining adherence to the injection schedule is still vital. Strategies like:

• Ongoing engagement with HIV specialty pharmacy services
• Phone/text reminders about upcoming injection appointments
• Combining injections with routine visits for other chronic conditions
• Travel planning around injection schedule dates if possible
• Financial assistance programs to aid procurement and administration

can help support reliability with the every 4-8 week Cabenuva injection regimen. While missing a single appointment is not catastrophic thanks to the sustained release, regularly skipping or delaying doses can still risk viral breakthrough and medication resistance.

The Potential Downsides of Transitioning to Cabenuva

Despite the benefits injectable Cabenuva offers over oral Biktarvy for HIV maintenance, there are some drawbacks to consider as well before switching:

• Injection site pain can persist for days/weeks
• Small risk of injection site reactions like nodules or infections
• Requires in-person clinical visits vs pharmacy refills alone
• Low risk of medication hypersensitivity with new agents
• Higher current costs and insurance restrictions
• Lingering oral medication aftertaste for 1 month after starting
• No data yet on long term use or complications after years

Weighing the pros and cons allows for shared decision making between patients, providers and payors on whether transitioning to Cabenuva is appropriate and worthwhile.

The Future Possibilities for Long-Acting HIV Therapy

The FDA approval of Cabenuva ushered in a new era in the HIV treatment landscape. As more investigational long-acting antiretrovirals complete ongoing trials, we inch closer to the ultimate goal of:

• Ultra-long-acting injectable therapy lasting 3-6 months between doses
• Combination single injections with multiple drugs
• Smaller gauge needles and less painful depot sites
• Implantable or in-dwelling pump delivery systems
• Further extend the interval between the end of oral lead-in drugs and sole reliance on injections

Future possibilities could revolutionize HIV disease management even beyond Cabenuva’s current every 1-2 month injection protocol. Such advances offer hope for reducing burden and barriers to effective treatment.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.