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Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection
Nucleoside and Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTIs)
(Last updated: March 5, 2015; last reviewed: March 5, 2015)
200 mg emtricitabine plus 600 mg efavirenz plus 300 mg TDF (Atripla)
With emtricitabine plus rilpivirine:
200 mg emtricitabine plus 25 mg rilpivirine plus 300 mg TDF (Complera)
With emtricitabine plus elvitegravir plus cobicistat:
200 mg emtricitabine plus 150 mg elvitegravir plus 150 mg cobicistat plus 300 mg TDF (Stribild)
Not Food and Drug Administration (FDA)-approved or recommended for use in neonates/infants aged <2 years.
Pediatric Dose (Aged ≥2 Years to <12 Years)*:
8 mg/kg/dose once daily
Once Daily Scoops of Powder
10 to <12
12 to <14
14 to <17
17 to <19
19 to <22
22 to <24
24 to <27
27 to <29
29 to <32
32 to <34
34 to <35
Tablet Once Daily
17 to <22
22 to <28
28 to <35
Adolescent (Aged ≥12 Years and Weight ≥35 kg)* and Adult Dose:
300 mg once daily
Fixed-Dose Combination Tablets Truvada (TDF plus emtricitabine):
Adolescent (aged ≥12 years and weight ≥35 kg) and adult dose: 1 tablet once daily.
Atripla (TDF plus emtricitabine plus efavirenz):
Adolescent (aged ≥12 years and weight ≥40 kg) and adult dose: 1 tablet once daily.
Complera (TDF plus emtricitabine plus rilpivirine):
Adult dose (aged ≥18 years): 1 tablet once daily in treatment-naive adults with baseline viral load <100,000 copies/mL. Administer with a meal.
Stribild (TDF plus emtricitabine plus elvitegravir plus cobicistat):
Adult dose (aged ≥18 years): 1 tablet once daily in treatment-naive adults. Administer with food.
Combinations with Other ARVs
TDF In combination With didanosine:
Co-administration increases didanosine concentrations, so the combination of TDF and didanosine should be avoided if possible. If used, requires didanosine dose reduction (see section on didanosine).
TDF in combination with atazanavir:
Co-administration reduces atazanavir concentrations, so when atazanavir is used in combination with TDF; atazanavir should always be boosted with ritonavir. Atazanavir co-administration increases TDF concentrations, so monitor for TDF toxicity.
TDF in combination with lopinavir/ritonavir:
Co-administration increases TDF concentrations. Monitor for TDF toxicity.
Renal insufficiency, proximal renal tubular dysfunction that may include Fanconi syndrome
Decreased bone mineral density (BMD)*
Do not crush tablets; oral powder formulation is available for patients unable to swallow tablets.
Oral powder should be measured only with the supplied dosing scoop: 1 level scoop = 1 g powder = 40 mg TDF.
Mix oral powder in 2 to 4 ounces of soft food that does not require chewing (e.g., applesauce, yogurt). Administer immediately after mixing to avoid the bitter taste.
Do not try to mix the oral powder with liquid: the powder may float on the top even after vigorous stirring.
TDF can be administered without regard to food, although absorption is enhanced when administered with a high-fat meal. Because Atripla also contains efavirenz, the combination tablet should be administered on an empty stomach.
Measure serum creatinine and urine dipstick for protein and glucose before starting a TDF-containing regimen and monitor serum creatinine and urine dipstick for protein and glucose at intervals (see Table 13i) during continued therapy. Measure serum phosphate if clinical suspicion of hypophosphatemia.
Screen patients for hepatitis B virus (HBV) infection before use of TDF. Severe acute exacerbation of HBV infection can occur when TDF is discontinued; therefore, monitor hepatic function for several months after therapy with TDF is stopped.
If using Stribild, please see the elvitegravir section of the drug appendix for additional information.
Dosing of TDF in patients with renal insufficiency: Decreased dosage should be used in patients with impaired renal function (creatinine clearance <50 mL/min). Consult manufacturer’s prescribing information for adjustment of dosage in accordance with creatinine clearance (CrCl).
Atripla and Complera (fixed-dose combinations) should not be used in patients with CrCl <50 mL/min or in patients requiring dialysis.
Truvada (fixed-dose combination) should not be used in patients with CrCl <30 mL/min or in patients requiring dialysis.
Stribild should not be initiated in patients with estimated CrCl <70 mL/min and should be discontinued in patients with estimated CrCl <50 mL/min.
Stribild should not be used in patients with severe hepatic impairment.
* See text for concerns about decreased BMD, especially in prepubertal patients and those in early puberty (Tanner Stages 1 and 2).
Renal elimination: Drugs that decrease renal function or compete for active tubular secretion could reduce clearance of tenofovir.
Other nucleoside reverse transcriptase inhibitors (NRTIs): Didanosine serum concentrations are increased when the drug is co-administered with tenofovir and this combination should be avoided if possible because of increase in didanosine toxicity.
Protease inhibitors (PIs): TDF decreases atazanavir plasma concentrations. Atazanavir without ritonavir should not be co-administered with TDF. In addition, atazanavir and lopinavir/ritonavir increase tenofovir concentrations and could potentiate TDF-associated toxicity.
Use of Stribild: If using Stribild, please see the elvitegravir section of the drug appendix for additional information.
More common: Nausea, diarrhea, vomiting, and flatulence.
Less common (more severe): TDF caused bone toxicity (osteomalacia and reduced bone density) in animals when given in high doses. Decreases in bone mineral density (BMD) have been reported in both adults and children taking TDF; the clinical significance of these changes is not yet known. Renal toxicity, including increased serum creatinine, glycosuria, proteinuria, phosphaturia, and/or calciuria and decreases in serum phosphate, has been observed. Patients at increased risk of renal glomerular or tubular dysfunction should be closely monitored. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported.
TDF is Food and Drug Administration (FDA)-approved for use in children aged ≥2 years when used as a component of the two-NRTI backbone in combination antiretroviral therapy (cART).
TDF has antiviral activity and efficacy against hepatitis B virus (HBV). For a comprehensive review of this topic, and hepatitis C and tuberculosis during HIV coinfection, please see the Pediatric Opportunistic Infections guidelines. Testing for HBV should be performed prior to starting TDF treatment.
Efficacy in Clinical Trials in Adults Compared to Children and Adolescents
The standard adult dose of TDF approved by the FDA for adults and children aged ≥12 years and weight ≥35 kg is 300 mg once daily; for children ages 2 to 12 years, the FDA-approved dose is 8 mg/kg/dose administered once daily, which closely approximates the dose of 208 mg/m2/dose used in early studies in children.1
In adults, the recommended dose is highly effective.2,3
In children aged 12 to <18 years, no difference in viral load response was seen between two groups in a randomized, placebo-controlled trial of TDF 300 mg once daily or placebo, plus an optimized background regimen, in 87 treatment-experienced adolescents in Brazil and Panama4 Subgroup analyses suggest this lack of response was from imbalances in viral susceptibility to the optimized background regimens.
In children ages 2 to <12 years, TDF 8 mg/kg/dose once daily showed non-inferiority to twice daily zidovudine- or stavudine-containing cART over 48 weeks of randomized treatment using a snapshot analysis.5
Other pediatric studies also suggest that virologic success is related to prior treatment experience. In 115 pediatric patients treated with TDF, viral load decreased to <50 copies/mL at 12 months in 50%, 39%, and 13% of patients on first-, second-, and third-line therapy, respectively.6 This cohort used a target dose of 8 mg/kg, but 18% of patients were dosed at greater than 120% of the target dose and 37% were dosed at less than 80% of the target dose.
Relationship of Drug Exposure to Virologic Response and Toxicity
Virologic success is related to drug exposure. In a study using a median daily dose of 208 mg/m2,7 lower area under the curve (AUC) plasma tenofovir concentrations were associated with inferior virologic outcome.
Pharmacokinetic (PK) studies in children receiving an investigational 75-mg tablet formulation of TDF showed that a median dose of 208 mg/m2 of body surface area (range 161–256 mg/m2 body surface area) resulted in a median single dose AUC and maximum plasma concentration (Cmax) that were 34% and 27% lower, respectively, compared with values reported in adults administered a daily dose of 300 mg.1,8 Renal clearance of tenofovir was approximately 1.5-fold higher in children than previously reported in adults, possibly explaining the lower systemic exposure.1 This lower exposure occurred even though participants were concurrently treated with ritonavir, which boosts tenofovir exposure. Lower-than-anticipated tenofovir exposure was also found in young adults (median age 23 years) treated with ritonavir-boosted atazanavir plus TDF,9 although PK modeling suggested a higher intracellular tenofovir diphosphate concentration in younger patients.10
The taste-masked granules that make up the oral powder give the vehicle (e.g., applesauce, yogurt) a gritty consistency. Once mixed in the vehicle, TDF should be administered promptly because, if allowed to sit too long, its taste becomes bitter.
Decreased bone mineral density (BMD) has been reported in both adult and pediatric studies. Younger children (i.e., Tanner Stages 1 and 2) may be at higher risk than children with more advanced development (i.e., Tanner Stage ≥3).1,11,12 In a Phase I/II study of an investigational 75-mg formulation of TDF in 18 heavily pretreated children and adolescents, a >6% decrease in BMD measured by dual-energy x-ray absorptiometry (DXA) scan was reported in 5 of 15 (33%) children evaluated at Week 48.1 Two of the 5 children who discontinued TDF at 48 weeks experienced partial or complete recovery of BMD by 96 weeks.13 Among children with BMD decreases, the median Tanner score was 1 (range 1–3) and mean age was 10.2 years; for children who had no BMD decreases, the median Tanner score was 2.5 (range 1–4) and median age was 13.2 years.7,13 In a second study of 6 patients who received the commercially available, 300 mg formulation of TDF, 2 prepubertal children experienced >6% BMD decreases. One of the 2 children experienced a 27% decrease in BMD, necessitating withdrawal of TDF from her cART regimen with subsequent recovery of BMD.14 Loss of BMD at 48 weeks was associated with higher drug exposure.7
In the industry-sponsored study that led to FDA approval of TDF in adolescents aged ≥12 years and weight ≥35 kg, 6 of 33 participants (18%) in the TDF arm experienced a >4% decline in absolute lumbar spine BMD in 48 weeks compared with 1 of 33 participants (3%) in the placebo arm.4
In the Gilead switch study in children ages 2 to 12 years over the 48 weeks of randomized treatment, total body BMD gain was less in the TDF group than in the zidovudine or stavudine group, but the mean rate of lumbar spine BMD gain was similar between groups. At 48 weeks, all participants were offered TDF, and for the participants who were treated with the drug for 96 weeks, total body BMD z score declined by -0.338 and lumbar spine BMD z score declined by -0.012.5
Not all studies of TDF in children have identified a decline in BMD.15,16 No effect of TDF on BMD was found in a study in pediatric patients on stable therapy with undetectable viral load who were switched from stavudine and PI-containing regimens to TDF/lamivudine/efavirenz.16 All patients in this study remained clinically stable and virologically suppressed after switching to the new regimen.17
Monitoring Potential Bone Toxicity
The Panel does not recommend routine DXA monitoring for children or adolescents treated with TDF. Given the potential for BMD loss in children treated with TDF, some experts obtain a DXA before initiation of TDF therapy and approximately 6 months after starting TDF, especially in pre-pubertal patients and those early in puberty (i.e., Tanner Stages 1 and 2). If DXA results are abnormal consider referral to a subspecialist. Despite the ease of use of a once-daily drug and the efficacy of TDF, the potential for BMD loss during the important period of rapid bone accrual in early adolescence is concerning and favors judicious use of TDF in this age group.
New onset or worsening of renal impairment has been reported in adults and children receiving TDF and may be more common in those with higher tenofovir trough plasma concentrations.18 The main target of TDF nephrotoxicity is the renal proximal tubule,19 and case reports highlight the infrequent but most severe manifestations of renal Fanconi syndrome, with hypophosphatemia-associated myalgias, hypocalcemia, bone pain and fractures, reduced creatinine clearance (CrCl), and diabetes insipidus,20,21 possibly from genetic polymorphisms related to renal tubular clearance of TDF.22 Irreversible renal failure is quite rare but has been reported.23
Renal toxicity leading to discontinuation of TDF was reported in 3.7% (6 of 159) of HIV-1-infected children treated with TDF in the United Kingdom and Ireland,6 but subclinical renal tubular damage is more frequent, and increased urinary beta-2 microglobulin was identified in 27% (12 of 44) of children treated with TDF compared with 4% (2 of 48) of children not treated with TDF.24 An observational cohort study of 2,102 children with HIV in the United States suggested a twofold increased risk of renal disease (increased creatinine or proteinuria) in children treated with TDF-containing cART compared to those treated with cART not containing TDF.25 Prospectively evaluated renal function reported for 40 pediatric patients on TDF-containing cART from 5 Spanish hospitals showed that 18 patients had CrCl declines after at least 6 months of therapy; 28 patients had decreases in tubular reabsorption of phosphate worsening with longer time on TDF; and 33 patients had proteinuria, including 10 patients with proteinuria in the nephrotic range.26 TDF-associated proteinuria or chronic kidney disease is more common with longer duration of treatment.27 Of 89 participants aged 2 to 12 years who received TDF in Gilead study 352 (median drug exposure 104 weeks), four were discontinued from the study for renal tubular dysfunction, three of whom had hypophosphatemia and decrease in total body or spine BMD z score.5
Monitoring Potential Renal Toxicity
Because of the potential for TDF to decrease creatinine clearance and to cause renal tubular dysfunction, measurement of serum creatinine and urine dipstick for protein and glucose prior to drug initiation is recommended. In asymptomatic individuals, the optimal frequency for routine monitoring of creatinine and renal tubular function (urine protein and glucose) is unclear. Many panel members monitor creatinine with other blood tests every 3 to 4 months, and urinalysis every 6 to 12 months. Serum phosphate should be measured if clinically indicated; renal phosphate loss can occur in the presence of normal creatinine and the absence of proteinuria. Because nephrotoxicity increases with the duration of TDF treatment, monitoring should be continued during therapy with the drug.
Hazra R, Balis FM, Tullio AN, et al. Single-dose and steady-state pharmacokinetics of tenofovir disoproxil fumarate in human immunodeficiency virus-infected children. Antimicrob Agents Chemother. 2004;48(1):124-129. Available at http://www.ncbi.nlm.nih.gov/pubmed/14693529.
Gallant JE, Staszewski S, Pozniak AL, et al. Efficacy and safety of tenofovir DF vs stavudine in combination therapy in antiretroviral-naive patients: a 3-year randomized trial. JAMA. 2004;292(2):191-201. Available at http://www.ncbi.nlm.nih.gov/pubmed/15249568.
Gallant JE, DeJesus E, Arribas JR, et al. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz for HIV. N Engl J Med. 2006;354(3):251-260. Available at http://www.ncbi.nlm.nih.gov/pubmed/16421366.
Della Negra M, de Carvalho AP, de Aquino MZ, et al. A randomized study of tenofovir disoproxil fumarate in treatment-experienced HIV-1 infected adolescents. Pediatr Infect Dis J. 2012;31(5):469-473. Available at http://www.ncbi.nlm.nih.gov/pubmed/22301477
Saez-Llorens X, Castaño E, Rathore M, et al. A randomized, open-label study of the safety and efficacy of switching stavudine or zidovudine to tenofovir disoproxil fumarate in human immunodeficiency virus-1 infected children with virologic suppression. Pediatr Infect Dis J. 2014. Available at: http://journals.lww.com/pidj/Abstract/publishahead/A_Randomized,_Open_Label_Study_of_the_Safety_and.98070.aspx.
Riordan A, Judd A, Boyd K, et al. Tenofovir use in human immunodeficiency virus-1-infected children in the United kingdom and Ireland. Pediatr Infect Dis J. 2009;28(3):204-209. Available at http://www.ncbi.nlm.nih.gov/pubmed/19209091.
Hazra R, Gafni RI, Maldarelli F, et al. Tenofovir disoproxil fumarate and an optimized background regimen of antiretroviral agents as salvage therapy for pediatric HIV infection. Pediatrics. 2005;116(6):e846-854. Available at http://www.ncbi.nlm.nih.gov/pubmed/16291735.
Barditch-Crovo P, Deeks SG, Collier A, et al. Phase i/ii trial of the pharmacokinetics, safety, and antiretroviral activity of tenofovir disoproxil fumarate in human immunodeficiency virus-infected adults. Antimicrob Agents Chemother. 2001;45(10):2733-2739. Available at http://www.ncbi.nlm.nih.gov/pubmed/11557462.
Kiser JJ, Fletcher CV, Flynn PM, et al. Pharmacokinetics of antiretroviral regimens containing tenofovir disoproxil fumarate and atazanavir-ritonavir in adolescents and young adults with human immunodeficiency virus infection. Antimicrob Agents Chemother. 2008;52(2):631-637. Available at http://www.ncbi.nlm.nih.gov/pubmed/18025112.
Baheti G, King JR, Acosta EP, Fletcher CV. Age-related differences in plasma and intracellular tenofovir concentrations in HIV-1-infected children, adolescents and adults. AIDS. 2013;27(2):221-225. Available at http://www.ncbi.nlm.nih.gov/pubmed/23032419.
Jacobson D, Dimeglio L, Hazra R, et al. Clinical determinants of bone mineral density in perinatally HIV-infected children. Presented at: 16th Conference on Retroviruses and Opportunistic Infections (CROI). 2009. Montreal, Canada.
Thomas V, Purdy J, Reynolds J, Hadigan C, Hazra R. Bone mineral density in adolescents infected with HIV perinatally or childhood: Data from the NIH intramural program. Paper presented at: 16th Conference on Retroviruses and Opportunistic Infections (CROI). 2009. Montreal, Canada.
Gafni RI, Hazra R, Reynolds JC, et al. Tenofovir disoproxil fumarate and an optimized background regimen of antiretroviral agents as salvage therapy: impact on bone mineral density in HIV-infected children. Pediatrics. 2006;118(3):e711-718. Available at http://www.ncbi.nlm.nih.gov/pubmed/16923923.
Purdy JB, Gafni RI, Reynolds JC, Zeichner S, Hazra R. Decreased bone mineral density with off-label use of tenofovir in children and adolescents infected with human immunodeficiency virus. J Pediatr. 2008;152(4):582-584. Available at http://www.ncbi.nlm.nih.gov/pubmed/18346519.
Vigano A, Zuccotti GV, Puzzovio M, et al. Tenofovir disoproxil fumarate and bone mineral density: a 60-month longitudinal study in a cohort of HIV-infected youths. Antivir Ther. 2010;15(7):1053-1058. Available at http://www.ncbi.nlm.nih.gov/pubmed/21041922.
Giacomet V, Mora S, Martelli L, Merlo M, Sciannamblo M, Vigano A. A 12-month treatment with tenofovir does not impair bone mineral accrual in HIV-infected children. J Acquir Immune Defic Syndr. 2005;40(4):448-450. Available at http://www.ncbi.nlm.nih.gov/pubmed/16280700.
Vigano A, Aldrovandi GM, Giacomet V, et al. Improvement in dyslipidaemia after switching stavudine to tenofovir and replacing protease inhibitors with efavirenz in HIV-infected children. Antivir Ther. 2005;10(8):917-924. Available at http://www.ncbi.nlm.nih.gov/pubmed/16430197.
Rodriguez-Novoa S, Labarga P, D'Avolio A, et al. Impairment in kidney tubular function in patients receiving tenofovir is associated with higher tenofovir plasma concentrations. AIDS. 2010;24(7):1064-1066. Available at http://www.ncbi.nlm.nih.gov/pubmed/20299966.
Hall AM. Update on tenofovir toxicity in the kidney. Pediatr Nephrol. 2013;28(7):1011-1023. Available at http://www.ncbi.nlm.nih.gov/pubmed/22878694.
Hussain S, Khayat A, Tolaymat A, Rathore MH. Nephrotoxicity in a child with perinatal HIV on tenofovir, didanosine and lopinavir/ritonavir. Pediatr Nephrol. 2006;21(7):1034-1036. Available at http://www.ncbi.nlm.nih.gov/pubmed/16773419.
Lucey JM, Hsu P, Ziegler JB. Tenofovir-related Fanconi's syndrome and osteomalacia in a teenager with HIV. BMJ case reports. 2013;2013. Available at http://www.ncbi.nlm.nih.gov/pubmed/23843401.
Giacomet V, Cattaneo D, Vigano A, et al. Tenofovir-induced renal tubular dysfunction in vertically HIV-infected patients associated with polymorphisms in ABCC2, ABCC4 and ABCC10 genes. Pediatr Infect Dis J. 2013;32(10):e403-405. Available at http://www.ncbi.nlm.nih.gov/pubmed/24067562.
Wood SM, Shah SS, Steenhoff AP, Meyers KE, Kaplan BS, Rutstein RM. Tenofovir-associated nephrotoxicity in two HIV-infected adolescent males. AIDS Patient Care STDS. 2009;23(1):1-4. Available at http://www.ncbi.nlm.nih.gov/pubmed/19183077.
Papaleo A, Warszawski J, Salomon R, et al. Increased beta-2 microglobulinuria in human immunodeficiency virus-1-infected children and adolescents treated with tenofovir. Pediatr Infect Dis J. 2007;26(10):949-951. Available at http://www.ncbi.nlm.nih.gov/pubmed/17901802.
Andiman WA, Chernoff MC, Mitchell C, et al. Incidence of persistent renal dysfunction in human immunodeficiency virus-infected children: associations with the use of antiretrovirals, and other nephrotoxic medications and risk factors. Pediatr Infect Dis J. 2009;28(7):619-625. Available at http://www.ncbi.nlm.nih.gov/pubmed/19561425.
Soler-Palacin P, Melendo S, Noguera-Julian A, et al. Prospective study of renal function in HIV-infected pediatric patients receiving tenofovir-containing HAART regimens. AIDS. 2011;25(2):171-176. Available at http://www.ncbi.nlm.nih.gov/pubmed/21076275.
Purswani M, Patel K, Kopp JB, et al. Tenofovir treatment duration predicts proteinuria in a multiethnic United States Cohort of children and adolescents with perinatal HIV-1 infection. Pediatr Infect Dis J. 2013;32(5):495-500. Available at http://www.ncbi.nlm.nih.gov/pubmed/23249917.