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Patricia Pecora Fulco, Crushed bictegravir/emtricitabine/tenofovir alafenamide in a human immunodeficiency virus–positive patient with esophageal cancer, American Journal of Health-System Pharmacy, Volume 77, Issue 7, 1 April 2020, Pages 509–510, https://doi.org/10.1093/ajhp/zxaa017
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Enteral antiretroviral (ARV) administration is necessary in human immunodeficiency virus (HIV)–positive patients with dysphagia or oral cancer or during an acute hospitalization with altered mental status.1-3 Recommended ARV regimens for most patients with HIV infection include an integrase strand transfer inhibitor (INSTI) (bictegravir, dolutegravir, or raltegravir) in combination with 2 nucleoside/tide reverse transcriptase inhibitors (NRTIs).4 Both dolutegravir and raltegravir maintain virologic suppression when crushed and enterally administered via a feeding tube.3,5 Bictegravir is only available as a fixed-dose combination (FDC) tablet with emtricitabine and tenofovir alafenamide. FDC emtricitabine and tenofovir alafenamide with dolutegravir have resulted in viral suppression in a patient with a percutaneous endoscopic gastrostomy (PEG) tube.6 This author reports the first case of administration of crushed FDC bictegravir/emtricitabine/tenofovir alafenamide in a patient for 10 months via a PEG tube.
A 64-year-old white male with HIV (diagnosed in 1998 with virologic suppression for 15 years; CD4 count, 463 [CD4 cells, 42%]) on an ARV regimen including FDC dolutegravir/abacavir/lamivudine presented to the clinic with a new diagnosis of esophageal adenocarcinoma with liver metastasis, significant dysphagia, and an inability to consistently ingest oral medications. The patient reported being unable to successfully crush the dolutegravir FDC tablet. The ARV regimen was changed to FDC bictegravir/emtricitabine/tenofovir alafenamide for a smaller tablet size. The patient remained off medications for 6 weeks and had a virologic rebound (501 copies/mL) without immunologic decline (CD4 count, 440 [CD4 cells, 44%]). A PEG tube was placed for enteral nutrition, with chemotherapy initiated with 5-fluorouracil and oxilaplatin. The patient returned to the infectious diseases clinic 4 months later and reported crushing his FDC bictegravir regimen with a tablet pulverizer, diluting the powder with 30 to 60 mL of water (per patient report, it dissolved easily), and then administering the medication via his PEG tube. Immediately following this daily routine, 240 mL of an enteral formula (Jevity 1.2, Abbott) was administered for a total of 1,440 mL/24 hours for nutrition requirements. A repeat HIV viral load (VL) after 4 months of crushed FDC bictegravir was undetectable (CD4 count, 371 [CD4 cells, 53%]). The patient completed 3 cycles of chemotherapy with 5-fluorouracil and irinotecan, followed by Y90 chemoembolization to the liver. The oncologic treatment plan then included esophageal radiation and folfirinox, with continued cancer progression. Ramucirumab and paclitaxel were initiated, and the patient developed an infusion-related reaction attributed to the ramucirumab. Palliative radiation and doxetaxel were subsequently prescribed.
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