Drug information

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Efavirenz

Brand Name:

Sustiva

Other Names:

EFV

Drug Class:

Non-nucleoside Reverse Transcriptase Inhibitors

Registry Number:

154598-52-4 (CAS)

Drug Image(s): (Click to enlarge)

Chemical Image: (Click to enlarge)

efavirenz

Molecular Weight: 315.677

Several FDA-approved drug labels may be available for efavirenz. ClinicalInfo provides the following drug label solely as an example of the labels available for efavirenz. Inclusion or absence of a drug label on the ClinicalInfo site does not imply endorsement or lack thereof by ClinicalInfo. Search Drugs@FDA to access more information on efavirenz, including additional drug labels and any generic equivalents.

Highlights HIGHLIGHTS OF PRESCRIBING INFORMATION

These highlights do not include all the information needed to use SUSTIVA safely and effectively. See full prescribing information for SUSTIVA.

SUSTIVA® (efavirenz) capsules for oral use
SUSTIVA® (efavirenz) tablets for oral use
Initial U.S. Approval: 1998

RECENT MAJOR CHANGES

Warnings and Precautions, Nervous System Symptoms (5.6) 10/2019
Warnings and Precautions, Immune Reconstitution Syndrome (5.12) 10/2019

INDICATIONS AND USAGE

SUSTIVA is a non-nucleoside reverse transcriptase inhibitor indicated in combination with other antiretroviral agents for the treatment of human immunodeficiency virus type 1 infection in adults and in pediatric patients at least 3 months old and weighing at least 3.5 kg. (1)

DOSAGE AND ADMINISTRATION

SUSTIVA should be taken orally once daily on an empty stomach, preferably at bedtime. (2)
Recommended adult dose: 600 mg. (2.2)
With voriconazole, increase voriconazole maintenance dose to 400 mg every 12 hours and decrease SUSTIVA dose to 300 mg once daily using the capsule formulation. (2.2)
With rifampin, increase SUSTIVA dose to 800 mg once daily for patients weighing 50 kg or more. (2.2)
Pediatric dosing is based on weight. (2.3)

DOSAGE FORMS AND STRENGTHS

•: Capsules: 200 mg and 50 mg (3)
•: Tablets: 600 mg (3)

CONTRAINDICATIONS

• Patients with previously demonstrated hypersensitivity (eg, Stevens-Johnson syndrome, erythema multiforme, or toxic skin eruptions) to any of the components of this product. (4)
• Coadministration of efavirenz with elbasvir/grazoprevir.

WARNINGS AND PRECAUTIONS

QTc prolongation: Consider alternatives to SUSTIVA in patients taking other medications with a known risk of Torsade de Pointes or in patients at higher risk of Torsade de Pointes. (5.2)
Do not use as a single agent or add on as a sole agent to a failing regimen. Consider potential for cross-resistance when choosing other agents. (5.3)
Not recommended with ATRIPLA, which contains efavirenz, emtricitabine, and tenofovir disoproxil fumarate, unless needed for dose adjustment when coadministered with rifampin. (5.4)
Serious psychiatric symptoms: Immediate medical evaluation is recommended for serious psychiatric symptoms such as severe depression or suicidal ideation. (5.5, 17)
Nervous system symptoms (NSS): NSS are frequent and usually begin 1-2 days after initiating therapy and resolve in 2-4 weeks. Dosing at bedtime may improve tolerability. NSS are not predictive of onset of psychiatric symptoms. (5.6, 6.1, 17)
Embryo-Fetal Toxicity: Avoid administration in the first trimester of pregnancy as fetal harm may occur. (5.7, 8.1)
Hepatotoxicity: Monitor liver function tests before and during treatment in patients with underlying hepatic disease, including hepatitis B or C coinfection, marked transaminase elevations, or who are taking medications associated with liver toxicity. Among reported cases of hepatic failure, a few occurred in patients with no pre-existing hepatic disease. (5.9, 6.1, 8.6)
Rash: Rash usually begins within 1-2 weeks after initiating therapy and resolves within 4 weeks. Discontinue if severe rash develops. (5.8, 6.1, 17)
Convulsions: Use caution in patients with a history of seizures. (5.10)
Lipids: Total cholesterol and triglyceride elevations. Monitor before therapy and periodically thereafter. (5.11)
Immune reconstitution syndrome: May necessitate further evaluation and treatment. (5.12)
Redistribution/accumulation of body fat: Observed in patients receiving antiretroviral therapy. (5.13, 17)

ADVERSE REACTIONS

Most common adverse reactions (>5%, moderate-severe) are impaired concentration, abnormal dreams, rash, dizziness, nausea, headache, fatigue, insomnia, and vomiting. (6)

To report SUSPECTED ADVERSE REACTIONS, contact Bristol-Myers Squibb at 1-800-721-5072 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

DRUG INTERACTIONS

Coadministration of efavirenz can alter the concentrations of other drugs and other drugs may alter the concentrations of efavirenz. The potential for drug-drug interactions should be considered before and during therapy. (7 )

USE IN SPECIFIC POPULATIONS

Lactation: Breastfeeding not recommended. (8.2)
Females and Males of Reproductive Potential: Pregnancy testing and contraception are recommended. (8.3)
Hepatic impairment: SUSTIVA is not recommended for patients with moderate or severe hepatic impairment. Use caution in patients with mild hepatic impairment. (8.6)
Pediatric patients: The incidence of rash was higher than in adults. (5.8, 6.2, 8.4)

See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling

Revised: 10/2019

FULL PRESCRIBING INFORMATION

Indications & Usage 1 INDICATIONS AND USAGE

SUSTIVA® (efavirenz) in combination with other antiretroviral agents is indicated for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and in pediatric patients at least 3 months old and weighing at least 3.5 kg.

Dosage & Administration 2 DOSAGE AND ADMINISTRATION

Dosage & Administration 2.1 Hepatic Function

Monitor hepatic function prior to and during treatment with SUSTIVA [see Warnings and Precautions (5.9 )].
SUSTIVA is not recommended in patients with moderate or severe hepatic impairment (Child Pugh B or C) [see Warnings and Precautions (5.9) and Use in Specific Populations (8.6)].

2.2 Adults

The recommended dosage of SUSTIVA (efavirenz) is 600 mg orally, once daily, in combination with a protease inhibitor and/or nucleoside analogue reverse transcriptase inhibitors (NRTIs). It is recommended that SUSTIVA be taken on an empty stomach, preferably at bedtime. The increased efavirenz concentrations observed following administration of SUSTIVA with food may lead to an increase in frequency of adverse reactions [see Clinical Pharmacology (12.3)]. Dosing at bedtime may improve the tolerability of nervous system symptoms [see Warnings and Precautions (5.6), Adverse Reactions (6.1), and Patient Counseling Information (17)]. SUSTIVA capsules or tablets should be swallowed intact with liquid. For patients who cannot swallow capsules or tablets, the capsule sprinkle method of administration is recommended [see Dosage and Administration (2.4)].

Concomitant Antiretroviral Therapy

SUSTIVA must be given in combination with other antiretroviral medications [see Indications and Usage (1), Warnings and Precautions (5.3), Drug Interactions (7.1), andClinical Pharmacology (12.3)].

Dosage Adjustment

If SUSTIVA is coadministered with voriconazole, the voriconazole maintenance dose should be increased to 400 mg every 12 hours and the SUSTIVA dose should be decreased to 300 mg once daily using the capsule formulation (one 200 mg and two 50 mg capsules or six 50 mg capsules). SUSTIVA tablets must not be broken. [see Drug Interactions (7.1, Table 5) and Clinical Pharmacology (12.3, Tables 7 and 8).]
If SUSTIVA is coadministered with rifampin to patients weighing 50 kg or more, an increase in the dose of SUSTIVA to 800 mg once daily is recommended [see Drug Interactions (7.1, Table 5) and Clinical Pharmacology (12.3, Table 8)].

Dosage & Administration 2.3 Pediatric Patients

It is recommended that SUSTIVA be taken on an empty stomach, preferably at bedtime. Table 1 describes the recommended dose of SUSTIVA for pediatric patients 3 months of age or older and weighing between 3.5 kg and 40 kg [see Clinical Pharmacology (12.3)]. The recommended dosage of SUSTIVA for pediatric patients weighing 40 kg or greater is 600 mg once daily. For pediatric patients who cannot swallow capsules, the capsule contents can be administered with a small amount of food or infant formula using the capsule sprinkle method of administration [see Dosage and Administration (2.4)].

Table 1: SUSTIVA Dosing in Pediatric Patients
Patient Body Weight	SUSTIVA Daily Dose	Number of Capsulesa or Tabletsb and Strength to Administer
a Capsules can be administered intact or as sprinkles [see Dosage and Administration (2.4)]. b Tablets must not be crushed.
3.5 kg to less than 5 kg	100 mg	two 50 mg capsules
5 kg to less than 7.5 kg	150 mg	three 50 mg capsules
7.5 kg to less than 15 kg	200 mg	one 200 mg capsule
15 kg to less than 20 kg	250 mg	one 200 mg one 50 mg capsule
20 kg to less than 25 kg	300 mg	one 200 mg two 50 mg capsules
25 kg to less than 32.5 kg	350 mg	one 200 mg three 50 mg capsules
32.5 kg to less than 40 kg	400 mg	two 200 mg capsules
at least 40 kg	600 mg	one 600 mg tablet OR three 200 mg capsules

Dosage & Administration 2.4 Capsule Sprinkle Method of Administration

For pediatric patients at least 3 months old and weighing at least 3.5 kg and adults who cannot swallow capsules or tablets, the capsule contents may be administered with a small amount (1 to 2 teaspoons) of food. Use of infant formula for mixing should only be considered for those young infants who cannot reliably consume solid foods. Patients and caregivers should be instructed to open the capsule carefully to avoid spillage or dispersion of the capsule contents into the air. The capsule should be held horizontally over a small container and carefully twisted to open. For patients able to tolerate solid foods, the entire capsule contents should be gently mixed with an age-appropriate soft food, such as applesauce, grape jelly, or yogurt, in the small container. For young infants receiving the capsule sprinkle-infant formula mixture, the entire capsule contents should be gently mixed into 2 teaspoons of reconstituted room temperature infant formula in a small container by carefully stirring with a small spoon, and then drawing up the mixture into a 10 mL oral dosing syringe for administration. After administration of the SUSTIVA-food or -formula mixture, an additional small amount (approximately 2 teaspoons) of food or formula must be added to the empty mixing container, stirred to disperse any remaining SUSTIVA residue, and administered to the patient. The SUSTIVA-food or -formula mixture should be administered within 30 minutes of mixing. No additional food should be consumed for 2 hours after administration of SUSTIVA.

Further patient instructions on the capsule sprinkle method of administration are provided in the FDA-approved patient labeling (see Patient Information and Instructions for Use).

3 DOSAGE FORMS AND STRENGTHS

• Capsules

200 mg capsules are gold color, reverse printed with “SUSTIVA” on the body and imprinted “200 mg” on the cap.

50 mg capsules are gold color and white, printed with “SUSTIVA” on the gold color cap and reverse printed “50 mg” on the white body.

• Tablets

600 mg tablets are yellow, capsular-shaped, film-coated tablets, with “SUSTIVA” printed on both sides.

Contraindications 4 CONTRAINDICATIONS

Contraindications

SUSTIVA is contraindicated in patients with previously demonstrated clinically significant hypersensitivity (eg, Stevens-Johnson syndrome, erythema multiforme, or toxic skin eruptions) to any of the components of this product.
Coadministration of efavirenz with elbasvir and grazoprevir is contraindicated [see Warnings and Precautions (5.1) and Drug Interactions (7.1)].

5 WARNINGS AND PRECAUTIONS

5.1 Drug Interactions

Efavirenz plasma concentrations may be altered by substrates, inhibitors, or inducers of CYP3A. Likewise, efavirenz may alter plasma concentrations of drugs metabolized by CYP3A or CYP2B6. The most prominent effect of efavirenz at steady-state is induction of CYP3A and CYP2B6 [see Dosage and Administration (2.2) and Drug Interactions (7.1)].

5.2 QTc Prolongation

QTc prolongation has been observed with the use of efavirenz [see Drug Interactions (7.3, 7.4) and Clinical Pharmacology (12.2)]. Consider alternatives to SUSTIVA when coadministered with a drug with a known risk of Torsade de Pointes or when administered to patients at higher risk of Torsade de Pointes.

5.3 Resistance

SUSTIVA must not be used as a single agent to treat HIV-1 infection or added on as a sole agent to a failing regimen. Resistant virus emerges rapidly when efavirenz is administered as monotherapy. The choice of new antiretroviral agents to be used in combination with efavirenz should take into consideration the potential for viral cross-resistance.

5.4 Coadministration with Related Products

Coadministration of SUSTIVA with ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) is not recommended unless needed for dose adjustment (eg, with rifampin), since efavirenz is one of its active ingredients.

5.5 Psychiatric Symptoms

Serious psychiatric adverse experiences have been reported in patients treated with SUSTIVA. In controlled trials of 1008 patients treated with regimens containing SUSTIVA for a mean of 2.1 years and 635 patients treated with control regimens for a mean of 1.5 years, the frequency (regardless of causality) of specific serious psychiatric events among patients who received SUSTIVA or control regimens, respectively, were severe depression (2.4%, 0.9%), suicidal ideation (0.7%, 0.3%), nonfatal suicide attempts (0.5%, 0), aggressive behavior (0.4%, 0.5%), paranoid reactions (0.4%, 0.3%), and manic reactions (0.2%, 0.3%). When psychiatric symptoms similar to those noted above were combined and evaluated as a group in a multifactorial analysis of data from Study 006, treatment with efavirenz was associated with an increase in the occurrence of these selected psychiatric symptoms. Other factors associated with an increase in the occurrence of these psychiatric symptoms were history of injection drug use, psychiatric history, and receipt of psychiatric medication at study entry; similar associations were observed in both the SUSTIVA and control treatment groups. In Study 006, onset of new serious psychiatric symptoms occurred throughout the study for both SUSTIVA-treated and control-treated patients. One percent of SUSTIVA-treated patients discontinued or interrupted treatment because of one or more of these selected psychiatric symptoms. There have also been occasional postmarketing reports of death by suicide, delusions, and psychosis-like behavior although a causal relationship to the use of SUSTIVA cannot be determined from these reports. Postmarketing cases of catatonia have also been reported and may be associated with increased efavirenz exposure. Patients with serious psychiatric adverse experiences should seek immediate medical evaluation to assess the possibility that the symptoms may be related to the use of SUSTIVA, and if so, to determine whether the risks of continued therapy outweigh the benefits. [See Adverse Reactions (6.1).]

5.6 Nervous System Symptoms

Fifty-three percent (531/1008) of patients receiving SUSTIVA in controlled trials reported central nervous system symptoms (any grade, regardless of causality) compared to 25% (156/635) of patients receiving control regimens [see Adverse Reactions (6.1, Table 3)]. These symptoms included, but were not limited to, dizziness (28.1% of the 1008 patients), insomnia (16.3%), impaired concentration (8.3%), somnolence (7.0%), abnormal dreams (6.2%), and hallucinations (1.2%). These symptoms were severe in 2.0% of patients; and 2.1% of patients discontinued therapy as a result. These symptoms usually begin during the first or second day of therapy and generally resolve after the first 2-4 weeks of therapy. After 4 weeks of therapy, the prevalence of nervous system symptoms of at least moderate severity ranged from 5% to 9% in patients treated with regimens containing SUSTIVA and from 3% to 5% in patients treated with a control regimen. Patients should be informed that these common symptoms were likely to improve with continued therapy and were not predictive of subsequent onset of the less frequent psychiatric symptoms [see Warnings and Precautions (5.5)]. Dosing at bedtime may improve the tolerability of these nervous system symptoms [see Dosage and Administration (2)].

Analysis of long-term data from Study 006 (median follow-up 180 weeks, 102 weeks, and 76 weeks for patients treated with SUSTIVA zidovudine lamivudine, SUSTIVA indinavir, and indinavir zidovudine lamivudine, respectively) showed that, beyond 24 weeks of therapy, the incidences of new-onset nervous system symptoms among SUSTIVA-treated patients were generally similar to those in the indinavir-containing control arm.

Late-onset neurotoxicity, including ataxia and encephalopathy (impaired consciousness, confusion, psychomotor slowing, psychosis, delirium), may occur months to years after beginning efavirenz therapy. Some events of late-onset neurotoxicity have occurred in patients with CYP2B6 genetic polymorphisms which are associated with increased efavirenz levels despite standard dosing of SUSTIVA. Patients presenting with signs and symptoms of serious neurologic adverse experiences should be evaluated promptly to assess the possibility that these events may be related to efavirenz use, and whether discontinuation of SUSTIVA is warranted.

Patients receiving SUSTIVA should be alerted to the potential for additive central nervous system effects when SUSTIVA is used concomitantly with alcohol or psychoactive drugs.

Patients who experience central nervous system symptoms such as dizziness, impaired concentration, and/or drowsiness should avoid potentially hazardous tasks such as driving or operating machinery.

5.7 Embryo-Fetal Toxicity

Efavirenz may cause fetal harm when administered during the first trimester to a pregnant woman. Advise females of reproductive potential who are receiving SUSTIVA to avoid pregnancy. [See Use in Specific Populations (8.1 and 8.3).]

5.8 Rash

In controlled clinical trials, 26% (266/1008) of adult patients treated with 600 mg SUSTIVA experienced new-onset skin rash compared with 17% (111/635) of those treated in control groups [see Adverse Reactions (6.1)]. Rash associated with blistering, moist desquamation, or ulceration occurred in 0.9% (9/1008) of patients treated with SUSTIVA. The incidence of Grade 4 rash (eg, erythema multiforme, Stevens-Johnson syndrome) in adult patients treated with SUSTIVA in all studies and expanded access was 0.1%. Rashes are usually mild-to-moderate maculopapular skin eruptions that occur within the first 2 weeks of initiating therapy with efavirenz (median time to onset of rash in adults was 11 days) and, in most patients continuing therapy with efavirenz, rash resolves within 1 month (median duration, 16 days). The discontinuation rate for rash in adult clinical trials was 1.7% (17/1008).

Rash was reported in 59 of 182 pediatric patients (32%) treated with SUSTIVA [see Adverse Reactions (6.2)]. Two pediatric patients experienced Grade 3 rash (confluent rash with fever, generalized rash), and four patients had Grade 4 rash (erythema multiforme). The median time to onset of rash in pediatric patients was 28 days (range 3-1642 days). Prophylaxis with appropriate antihistamines before initiating therapy with SUSTIVA in pediatric patients should be considered.

SUSTIVA can generally be reinitiated in patients interrupting therapy because of rash. SUSTIVA should be discontinued in patients developing severe rash associated with blistering, desquamation, mucosal involvement, or fever. Appropriate antihistamines and/or corticosteroids may improve the tolerability and hasten the resolution of rash. For patients who have had a life-threatening cutaneous reaction (eg, Stevens-Johnson syndrome), alternative therapy should be considered [see Contraindications (4)].

5.9 Hepatotoxicity

Postmarketing cases of hepatitis, including fulminant hepatitis progressing to liver failure requiring transplantation or resulting in death, have been reported in patients treated with SUSTIVA. Reports have included patients with underlying hepatic disease, including coinfection with hepatitis B or C, and patients without pre-existing hepatic disease or other identifiable risk factors.
SUSTIVA is not recommended for patients with moderate or severe hepatic impairment. Careful monitoring is recommended for patients with mild hepatic impairment receiving SUSTIVA. [see Adverse Reactions (6.1) and Use in Specific Populations (8.6)].
Monitoring of liver enzymes before and during treatment is recommended for all patients [see Dosage and Administration (2.1)]. Consider discontinuing SUSTIVA in patients with persistent elevations of serum transaminases to greater than five times the upper limit of the normal range.
Discontinue SUSTIVA if elevation of serum transaminases is accompanied by clinical signs or symptoms of hepatitis or hepatic decompensation.

5.10 Convulsions

Convulsions have been observed in adult and pediatric patients receiving efavirenz, generally in the presence of known medical history of seizures [see Nonclinical Toxicology (13.2)]. Caution should be taken in any patient with a history of seizures. Patients who are receiving concomitant anticonvulsant medications primarily metabolized by the liver, such as phenytoin and phenobarbital, may require periodic monitoring of plasma levels [see Drug Interactions (7.1)].

5.11 Lipid Elevations

Treatment with SUSTIVA has resulted in increases in the concentration of total cholesterol and triglycerides [see Adverse Reactions (6.1)]. Cholesterol and triglyceride testing should be performed before initiating SUSTIVA therapy and at periodic intervals during therapy.

5.12 Immune Reconstitution Syndrome

Immune reconstitution syndrome has been reported in patients treated with combination antiretroviral therapy, including SUSTIVA. During the initial phase of combination antiretroviral treatment, patients whose immune system responds may develop an inflammatory response to indolent or residual opportunistic infections (such as Mycobacterium avium infection, cytomegalovirus, Pneumocystis jiroveci pneumonia [PCP], or tuberculosis), which may necessitate further evaluation and treatment.

Autoimmune disorders (such as Graves’ disease, polymyositis, Guillain-Barré syndrome, and autoimmune hepatitis ) have also been reported to occur in the setting of immune reconstitution; however, the time to onset is more variable, and can occur many months after initiation of treatment.

5.13 Fat Redistribution

Redistribution/accumulation of body fat including central obesity, dorsocervical fat enlargement (buffalo hump), peripheral wasting, facial wasting, breast enlargement, and “cushingoid appearance” have been observed in patients receiving antiretroviral therapy. The mechanism and long-term consequences of these events are currently unknown. A causal relationship has not been established.

Adverse Reactions 6 ADVERSE REACTIONS

The most significant adverse reactions observed in patients treated with SUSTIVA are:

psychiatric symptoms [see Warnings and Precautions (5.5)],
nervous system symptoms [see Warnings and Precautions (5.6)],
rash [see Warnings and Precautions (5.8)].
hepatotoxicity [see Warnings and Precautions (5.9)]

Adverse Reactions 6.1 Clinical Trials Experience

Because clinical studies are conducted under widely varying conditions, the adverse reaction rates reported cannot be directly compared to rates in other clinical studies and may not reflect the rates observed in clinical practice.

Adverse Reactions Adverse Reactions in Adults

The most common (>5% in either efavirenz treatment group) adverse reactions of at least moderate severity among patients in Study 006 treated with SUSTIVA in combination with zidovudine/lamivudine or indinavir were rash, dizziness, nausea, headache, fatigue, insomnia, and vomiting.

Selected clinical adverse reactions of moderate or severe intensity observed in ≥2% of SUSTIVA-treated patients in two controlled clinical trials are presented in Table 2.

Table 2: Selected Treatment-Emergenta Adverse Reactions of Moderate or Severe Intensity Reported in ≥2% of SUSTIVA-Treated Patients in Studies 006 and ACTG 364
	Study 006 LAM-, NNRTI-, and Protease Inhibitor-Naive Patients			Study ACTG 364 NRTI-experienced, NNRTI-, and Protease Inhibitor-Naive Patients
	SUSTIVAb ZDV/LAM (n = 412)	SUSTIVAb Indinavir (n = 415)	Indinavir ZDV/LAM (n = 401)	SUSTIVAb Nelfinavir NRTIs (n = 64)	SUSTIVAb NRTIs (n = 65)	Nelfinavir NRTIs (n = 66)
Adverse Reactions	180 weeksc	102 weeksc	76 weeksc	71.1 weeksc	70.9 weeksc	62.7 weeksc
a Includes adverse events at least possibly related to study drug or of unknown relationship for Study 006. Includes all adverse events regardless of relationship to study drug for Study ACTG 364. b SUSTIVA provided as 600 mg once daily. c Median duration of treatment. d Includes erythema multiforme, rash, rash erythematous, rash follicular, rash maculopapular, rash petechial, rash pustular, and urticaria for Study 006 and macules, papules, rash, erythema, redness, inflammation, allergic rash, urticaria, welts, hives, itchy, and pruritus for ACTG 364. — = Not Specified. ZDV = zidovudine, LAM = lamivudine.
Body as a Whole
Fatigue	8%	5%	9%	0	2%	3%
Pain	1%	2%	8%	13%	6%	17%
Central and Peripheral Nervous System
Dizziness	9%	9%	2%	2%	6%	6%
Headache	8%	5%	3%	5%	2%	3%
Insomnia	7%	7%	2%	0	0	2%
Concentration impaired	5%	3%	<1%	0	0	0
Abnormal dreams	3%	1%	0	—	—	—
Somnolence	2%	2%	<1%	0	0	0
Anorexia	1%	<1%	<1%	0	2%	2%
Gastrointestinal
Nausea	10%	6%	24%	3%	2%	2%
Vomiting	6%	3%	14%	—	—	—
Diarrhea	3%	5%	6%	14%	3%	9%
Dyspepsia	4%	4%	6%	0	0	2%
Abdominal pain	2%	2%	5%	3%	3%	3%
Psychiatric
Anxiety	2%	4%	<1%	—	—	—
Depression	5%	4%	<1%	3%	0	5%
Nervousness	2%	2%	0	2%	0	2%
Skin & Appendages
Rashd	11%	16%	5%	9%	5%	9%
Pruritus	<1%	1%	1%	9%	5%	9%

Pancreatitis has been reported, although a causal relationship with efavirenz has not been established. Asymptomatic increases in serum amylase levels were observed in a significantly higher number of patients treated with efavirenz 600 mg than in control patients (see Laboratory Abnormalities).

Adverse Reactions Nervous System Symptoms

For 1008 patients treated with regimens containing SUSTIVA and 635 patients treated with a control regimen in controlled trials, Table 3 lists the frequency of symptoms of different degrees of severity and gives the discontinuation rates for one or more of the following nervous system symptoms: dizziness, insomnia, impaired concentration, somnolence, abnormal dreaming, euphoria, confusion, agitation, amnesia, hallucinations, stupor, abnormal thinking, and depersonalization [see Warnings and Precautions (5.6)]. The frequencies of specific central and peripheral nervous system symptoms are provided in Table 2.

Table 3: Percent of Patients with One or More Selected Nervous System Symptomsa,b
Percent of Patients with:	SUSTIVA 600 mg Once Daily (n = 1008)	Control Groups (n = 635)
Percent of Patients with:	%	%
a Includes events reported regardless of causality. b Data from Study 006 and three Phase 2/3 studies. c “Mild” = Symptoms which do not interfere with patient’s daily activities. d “Moderate” = Symptoms which may interfere with daily activities. e “Severe” = Events which interrupt patient’s usual daily activities.
Symptoms of any severity	52.7	24.6
Mild symptomsc	33.3	15.6
Moderate symptomsd	17.4	7.7
Severe symptomse	2.0	1.3
Treatment discontinuation as a result of symptoms	2.1	1.1

Adverse Reactions Psychiatric Symptoms

Serious psychiatric adverse experiences have been reported in patients treated with SUSTIVA. In controlled trials, psychiatric symptoms observed at a frequency greater than 2% among patients treated with SUSTIVA or control regimens, respectively, were depression (19%, 16%), anxiety (13%, 9%), and nervousness (7%, 2%).

Adverse Reactions Rash

In controlled clinical trials, the frequency of rash (all grades, regardless of causality) was 26% for 1008 adults treated with regimens containing SUSTIVA and 17% for 635 adults treated with a control regimen. Most reports of rash were mild or moderate in severity. The frequency of Grade 3 rash was 0.8% for SUSTIVA-treated patients and 0.3% for control groups, and the frequency of Grade 4 rash was 0.1% for SUSTIVA and 0 for control groups. The discontinuation rates as a result of rash were 1.7% for SUSTIVA-treated patients and 0.3% for control groups [see Warnings and Precautions (5.8)].

Experience with SUSTIVA in patients who discontinued other antiretroviral agents of the NNRTI class is limited. Nineteen patients who discontinued nevirapine because of rash have been treated with SUSTIVA. Nine of these patients developed mild-to-moderate rash while receiving therapy with SUSTIVA, and two of these patients discontinued because of rash.

Adverse Reactions Laboratory Abnormalities

Selected Grade 3-4 laboratory abnormalities reported in ≥2% of SUSTIVA-treated patients in two clinical trials are presented in Table 4.

Table 4: Selected Grade 3-4 Laboratory Abnormalities Reported in ≥2% of SUSTIVA-Treated Patients in Studies 006 and ACTG 364
		Study 006 LAM-, NNRTI-, and Protease Inhibitor-Naive Patients			Study ACTG 364 NRTI-experienced, NNRTI-, and Protease Inhibitor-Naive Patients
Variable	Limit	SUSTIVAa ZDV/LAM (n = 412)	SUSTIVAa Indinavir (n = 415)	Indinavir ZDV/LAM (n = 401)	SUSTIVAa Nelfinavir NRTIs (n = 64)	SUSTIVAa NRTIs (n = 65)	Nelfinavir NRTIs (n = 66)
Variable	Limit	180 weeksb	102 weeksb	76 weeksb	71.1 weeksb	70.9 weeksb	62.7 weeksb
a SUSTIVA provided as 600 mg once daily. b Median duration of treatment. c Isolated elevations of GGT in patients receiving SUSTIVA may reflect enzyme induction not associated with liver toxicity. d Nonfasting. ZDV = zidovudine, LAM = lamivudine, ULN = upper limit of normal, ALT = alanine aminotransferase, AST = aspartate aminotransferase, GGT = gamma-glutamyltransferase.
Chemistry
ALT	>5 × ULN	5%	8%	5%	2%	6%	3%
AST	>5 × ULN	5%	6%	5%	6%	8%	8%
GGTc	>5 × ULN	8%	7%	3%	5%	0	5%
Amylase	>2 × ULN	4%	4%	1%	0	6%	2%
Glucose	>250 mg/dL	3%	3%	3%	5%	2%	3%
Triglyceridesd	≥751 mg/dL	9%	6%	6%	11%	8%	17%
Hematology
Neutrophils	<750/mm3	10%	3%	5%	2%	3%	2%

Adverse Reactions Patients Coinfected with Hepatitis B or C

Liver function tests should be monitored in patients with a history of hepatitis B and/or C. In the long-term data set from Study 006, 137 patients treated with SUSTIVA-containing regimens (median duration of therapy, 68 weeks) and 84 treated with a control regimen (median duration, 56 weeks) were seropositive at screening for hepatitis B (surface antigen positive) and/or C (hepatitis C antibody positive). Among these coinfected patients, elevations in AST to greater than five times ULN developed in 13% of patients in the SUSTIVA arms and 7% of those in the control arm, and elevations in ALT to greater than five times ULN developed in 20% of patients in the SUSTIVA arms and 7% of patients in the control arm. Among coinfected patients, 3% of those treated with SUSTIVA-containing regimens and 2% in the control arm discontinued from the study because of liver or biliary system disorders [see Warnings and Precautions (5.9)].

Adverse Reactions Lipids

Increases from baseline in total cholesterol of 10-20% have been observed in some uninfected volunteers receiving SUSTIVA. In patients treated with SUSTIVA zidovudine lamivudine, increases from baseline in nonfasting total cholesterol and HDL of approximately 20% and 25%, respectively, were observed. In patients treated with SUSTIVA indinavir, increases from baseline in nonfasting cholesterol and HDL of approximately 40% and 35%, respectively, were observed. Nonfasting total cholesterol levels ≥240 mg/dL and ≥300 mg/dL were reported in 34% and 9%, respectively, of patients treated with SUSTIVA zidovudine lamivudine; 54% and 20%, respectively, of patients treated with SUSTIVA indinavir; and 28% and 4%, respectively, of patients treated with indinavir zidovudine lamivudine. The effects of SUSTIVA on triglycerides and LDL in this study were not well characterized since samples were taken from nonfasting patients. The clinical significance of these findings is unknown [see Warnings and Precautions (5.11)].

Adverse Reactions Adverse Reactions in Pediatric Patients

Assessment of adverse reactions is based on three clinical trials in 182 HIV-1 infected pediatric patients (3 months to 21 years of age) who received SUSTIVA in combination with other antiretroviral agents for a median of 123 weeks. The adverse reactions observed in the three trials were similar to those observed in clinical trials in adults except that rash was more common in pediatric patients (32% for all grades regardless of causality) and more often of higher grade (ie, more severe). Two (1.1%) pediatric patients experienced Grade 3 rash (confluent rash with fever, generalized rash), and four (2.2%) pediatric patients had Grade 4 rash (all erythema multiforme). Five pediatric patients (2.7%) discontinued from the study because of rash [see Warnings and Precautions (5.8)].

Adverse Reactions 6.2 Postmarketing Experience

The following adverse reactions have been identified during postapproval use of SUSTIVA. Because these reactions are reported voluntarily from a population of unknown size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Body as a Whole: allergic reactions, asthenia, redistribution/accumulation of body fat [see Warnings and Precautions (5.13)]

Central and Peripheral Nervous System: abnormal coordination, ataxia, encephalopathy, cerebellar coordination and balance disturbances, convulsions, hypoesthesia, paresthesia, neuropathy, tremor, vertigo

Endocrine: gynecomastia

Gastrointestinal: constipation, malabsorption

Cardiovascular: flushing, palpitations

Liver and Biliary System: hepatic enzyme increase, hepatic failure, hepatitis.

Metabolic and Nutritional: hypercholesterolemia, hypertriglyceridemia

Musculoskeletal: arthralgia, myalgia, myopathy

Psychiatric: aggressive reactions, agitation, delusions, emotional lability, mania, neurosis, paranoia, psychosis, suicide, catatonia

Respiratory: dyspnea

Skin and Appendages: erythema multiforme, photoallergic dermatitis, Stevens-Johnson syndrome

Special Senses: abnormal vision, tinnitus

7 DRUG INTERACTIONS

7.1 Potential for SUSTIVA to Affect other Drugs

Efavirenz has been shown in vivo to induce CYP3A and CYP2B6. Other compounds that are substrates of CYP3A or CYP2B6 may have decreased plasma concentrations when coadministered with SUSTIVA.

7.2 Potential for Other Drugs to Affect SUSTIVA

Drugs that induce CYP3A activity (eg, phenobarbital, rifampin, rifabutin) would be expected to increase the clearance of efavirenz resulting in lowered plasma concentrations [see Dosage and Administration (2.2)].

7.3 QT Prolonging Drugs

There is limited information available on the potential for a pharmacodynamic interaction between SUSTIVA and drugs that prolong the QTc interval. QTc prolongation has been observed with the use of efavirenz [see Clinical Pharmacology (12.2)]. Consider alternatives to SUSTIVA when coadministered with a drug with a known risk of Torsade de Pointes.

7.4 Established and Other Potentially Significant Drug Interactions

Drug interactions with SUSTIVA are summarized in Table 5. For pharmacokinetics data, [see Clinical Pharmacology (12.3)] Tables 7 and 8. This table includes potentially significant interactions, but is not all inclusive.

Table 5: Established and Other Potentially Significant Drug Interactions: Alteration in Dose or Regimen May Be Recommended Based on Drug Interaction Studies or Predicted Interaction
Concomitant Drug Class: Drug Name	Effect	Clinical Comment
* The interaction between SUSTIVA and the drug was evaluated in a clinical study. All other drug interactions shown are predicted. This table is not all-inclusive.
HIV antiviral agents
Protease inhibitor: Fosamprenavir Calcium	↓ amprenavir	Fosamprenavir (unboosted): Appropriate doses of the combinations with respect to safety and efficacy have not been established. Fosamprenavir/ritonavir: An additional 100 mg/day (300 mg total) of ritonavir is recommended when SUSTIVA is administered with fosamprenavir/ritonavir once daily. No change in the ritonavir dose is required when SUSTIVA is administered with fosamprenavir plus ritonavir twice daily.
Protease inhibitor: Atazanavir	↓ atazanavir*	Treatment-naive patients: When coadministered with SUSTIVA, the recommended dose of atazanavir is 400 mg with ritonavir 100 mg (together once daily with food) and SUSTIVA 600 mg (once daily on an empty stomach, preferably at bedtime). Treatment-experienced patients: Coadministration of SUSTIVA and atazanavir is not recommended.
Protease inhibitor: Indinavir	↓ indinavir*	The optimal dose of indinavir, when given in combination with SUSTIVA, is not known. Increasing the indinavir dose to 1000 mg every 8 hours does not compensate for the increased indinavir metabolism due to SUSTIVA.
Protease inhibitor: Lopinavir/ritonavir	↓ lopinavir*	Lopinavir/ritonavir once daily dosing is not recommended when coadministered with SUSTIVA. The dose of lopinavir/ritonavir must be increased when coadministered with SUSTIVA. See the lopinavir/ritonavir prescribing information for dose adjustments of lopinavir/ritonavir when coadministered with efavirenz in adult and pediatric patients.
Protease inhibitor: Ritonavir	↑ ritonavir* ↑ efavirenz*	Monitor for elevation of liver enzymes and for adverse clinical experiences (e.g., dizziness, nausea, paresthesia) when SUSTIVA is coadministered with ritonavir.
Protease inhibitor: Saquinavir	↓ saquinavir*	Appropriate doses of the combination of SUSTIVA and saquinavir/ritonavir with respect to safety and efficacy have not been established.
NNRTI: Other NNRTIs	↑ or ↓ efavirenz and/or NNRTI	Combining two NNRTIs has not been shown to be beneficial. SUSTIVA should not be coadministered with other NNRTIs.
CCR5 co-receptor antagonist: Maraviroc	↓ maraviroc*	Refer to the full prescribing information for maraviroc for guidance on coadministration with efavirenz.
Hepatitis C antiviral agents
Boceprevir	↓ boceprevir*	Concomitant administration of boceprevir with SUSTIVA is not recommended because it may result in loss of therapeutic effect of boceprevir.
Elbasvir/Grazoprevir	↓ elbasvir ↓ grazoprevir	Coadministration of SUSTIVA with elbasvir/grazoprevir is contraindicated [see Contraindications (4)] because it may lead to loss of virologic response to elbasvir/grazoprevir.
Pibrentasvir/Glecaprevir	↓ pibrentasvir ↓ glecaprevir	Coadministration of SUSTIVA is not recommended because it may lead to reduced therapeutic effect of pibrentasvir/glecaprevir.
Simeprevir	↓ simeprevir* ↔ efavirenz*	Concomitant administration of simeprevir with SUSTIVA is not recommended because it may result in loss of therapeutic effect of simeprevir.
Velpatasvir/ Sofosbuvir	↓ velpatasvir	Coadministration of SUSTIVA and sofosbuvir/velpatasvir is not recommended because it may result in loss of therapeutic effect of sofosbuvir/velpatasvir.
Velpatasvir /Sofosbuvir/ /Voxilaprevir	↓ velpatasvir ↓ voxilaprevir	Coadministration of SUSTIVA and sofosbuvir/velpatasvir/voxilaprevir is not recommended because it may result in loss of therapeutic effect of sofosbuvir/velpatasvir/voxilaprevir.
Other agents
Anticoagulant: Warfarin	↑ or ↓ warfarin	Monitor INR and adjust warfarin dosage if necessary.
Anticonvulsants: Carbamazepine	↓ carbamazepine* ↓ efavirenz*	There are insufficient data to make a dose recommendation for efavirenz. Alternative anticonvulsant treatment should be used.
Phenytoin Phenobarbital	↓ anticonvulsant ↓ efavirenz	Potential for reduction in anticonvulsant and/or efavirenz plasma levels; periodic monitoring of anticonvulsant plasma levels should be conducted.
Antidepressants: Bupropion	↓ bupropion*	Increases in bupropion dosage should be guided by clinical response. Bupropion dose should not exceed the maximum recommended dose.
Sertraline	↓ sertraline*	Increases in sertraline dosage should be guided by clinical response.
Antifungals: Voriconazole	↓ voriconazole* ↑ efavirenz*	SUSTIVA and voriconazole should not be coadministered at standard doses. When voriconazole is coadministered with SUSTIVA, voriconazole maintenance dose should be increased to 400 mg every 12 hours and SUSTIVA dose should be decreased to 300 mg once daily using the capsule formulation. SUSTIVA tablets must not be broken. [See Dosage and Administration (2.2) and Clinical Pharmacology (12.3, Tables 7 and 8).]
Itraconazole	↓ itraconazole* ↓ hydroxyitraconazole*	Consider alternative antifungal treatment because no dose recommendation for itraconazole can be made.
Ketoconazole	↓ ketoconazole	Consider alternative antifungal treatment because no dose recommendation for ketoconazole can be made.
Posaconazole	↓ posaconazole*	Avoid concomitant use unless the benefit outweighs the risks.
Anti-infective: Clarithromycin	↓ clarithromycin* ↑ 14-OH metabolite*	Consider alternatives to macrolide antibiotics because of the risk of QT interval prolongation.
Antimycobacterials: Rifabutin	↓ rifabutin*	Increase daily dose of rifabutin by 50%. Consider doubling the rifabutin dose in regimens where rifabutin is given 2 or 3 times a week.
Rifampin	↓ efavirenz*	Increase SUSTIVA to 800 mg once daily when coadministered with rifampin to patients weighing 50 kg or more.
Antimalarials: Artemether/lumefantrine	↓ artemether* ↓ dihydroartemisinin* ↓ lumefantrine*	Consider alternatives to artemether/ lumefantrine because of the risk of QT interval prolongation.
Atovaquone/proguanil	↓ atovaquone ↓ proguanil	Concomitant administration is not recommended.
Calcium channel blockers: Diltiazem	↓ diltiazem* ↓ desacetyl diltiazem* ↓ N-monodesmethyl diltiazem*	Diltiazem dose adjustments should be guided by clinical response (refer to the full prescribing information for diltiazem). No dose adjustment of efavirenz is necessary when administered with diltiazem.
Others (eg, felodipine, nicardipine, nifedipine, verapamil)	↓ calcium channel blocker	When coadministered with SUSTIVA, dosage adjustment of calcium channels blocker may be needed and should be guided by clinical response (refer to the full prescribing information for the calcium channel blocker).
HMG-CoA reductase inhibitors: Atorvastatin Pravastatin Simvastatin	↓ atorvastatin* ↓ pravastatin* ↓ simvastatin*	Plasma concentrations of atorvastatin, pravastatin, and simvastatin decreased. Consult the full prescribing information for the HMG-CoA reductase inhibitor for guidance on individualizing the dose.
Hormonal contraceptives: Oral Ethinyl estradiol/ Norgestimate	↓ active metabolites of norgestimate*	A reliable method of barrier contraception should be used in addition to hormonal contraceptives.
Implant Etonogestrel	↓ etonogestrel	A reliable method of barrier contraception should be used in addition to hormonal contraceptives. Decreased exposure of etonogestrel may be expected. There have been postmarketing reports of contraceptive failure with etonogestrel in efavirenz-exposed patients.
Immunosuppressants: Cyclosporine, tacrolimus, sirolimus, and others metabolized by CYP3A	↓ immunosuppressant	Dose adjustments of the immunosuppressant may be required. Close monitoring of immunosuppressant concentrations for at least 2 weeks (until stable concentrations are reached) is recommended when starting or stopping treatment with efavirenz.
Narcotic analgesic: Methadone	↓ methadone*	Monitor for signs of methadone withdrawal and increase methadone dose if required to alleviate withdrawal symptoms.

7.5 Drugs Without Clinically Significant Interactions with SUSTIVA

No dosage adjustment is recommended when SUSTIVA is given with the following: aluminum/magnesium hydroxide antacids, azithromycin, cetirizine, famotidine, fluconazole, lorazepam, nelfinavir, nucleoside reverse transcriptase inhibitors (abacavir, emtricitabine, lamivudine, stavudine, tenofovir disoproxil fumarate, zidovudine), paroxetine, and raltegravir.

7.6 Cannabinoid Test Interaction

Efavirenz does not bind to cannabinoid receptors. False-positive urine cannabinoid test results have been reported with some screening assays in uninfected and HIV-infected subjects receiving efavirenz. Confirmation of positive screening tests for cannabinoids by a more specific method is recommended.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to SUSTIVA during pregnancy. Physicians are encouraged to register patients by calling the Antiretroviral Pregnancy Registry at 1-800-258-4263.

Risk Summary

There are retrospective case reports of neural tube defects in infants whose mothers were exposed to efavirenz-containing regimens in the first trimester of pregnancy. Prospective pregnancy data from the Antiretroviral Pregnancy Registry are not sufficient to adequately assess this risk. Available data from the Antiretroviral Pregnancy Registry show no difference in the risk of overall major birth defects compared to the background rate for major birth defects of 2.7% in the U.S. reference population of the Metropolitan Atlanta Congenital Defects Program (MACDP). Although a causal relationship has not been established between exposure to efavirenz in the first trimester and neural tube defects, similar malformations have been observed in studies conducted in monkeys at doses similar to the human dose. In addition, fetal and embryonic toxicities occurred in rats, at a dose ten times less than the human exposure at recommended clinical dose. Because of the potential risk of neural tube defects, efavirenz should not be used in the first trimester of pregnancy. Advise pregnant women of the potential risk to a fetus.

Data

Human Data

There are retrospective postmarketing reports of findings consistent with neural tube defects, including meningomyelocele, all in infants of mothers exposed to efavirenz-containing regimens in the first trimester.

Based on prospective reports from the Antiretroviral Pregnancy Registry (APR) of approximately 1000 live births following exposure to efavirenz-containing regimens (including over 800 live births exposed in the first trimester), there was no difference between efavirenz and overall birth defects compared with the background birth defect rate of 2.7% in the U.S. reference population of the Metropolitan Atlanta Congenital Defects Program. As of the interim APR report issued December 2014, the prevalence of birth defects following first-trimester exposure was 2.3% (95% CI: 1.4%-3.6%). One of these prospectively reported defects with first-trimester exposure was a neural tube defect. A single case of anophthalmia with first-trimester exposure to efavirenz has also been prospectively reported. This case also included severe oblique facial clefts and amniotic banding, which have a known association with anophthalmia.

Animal Data

Effects of efavirenz on embryo-fetal development have been studied in three nonclinical species (cynomolgus monkeys, rats, and rabbits). In monkeys, efavirenz 60 mg/kg/day was administered to pregnant females throughout pregnancy (gestation days 20 through 150). The maternal systemic drug exposures (AUC) were 1.3 times the exposure in humans at the recommended clinical dose (600 mg/day), with fetal umbilical venous drug concentrations approximately 0.7 times the maternal values. Three of 20 fetuses/infants had one or more malformations; there were no malformed fetuses or infants from placebo-treated mothers. The malformations that occurred in these three monkey fetuses included anencephaly and unilateral anophthalmia in one fetus, microphthalmia in a second, and cleft palate in the third. There was no NOAEL (no observable adverse effect level) established for this study because only one dosage was evaluated. In rats, efavirenz was administered either during organogenesis (gestation days 7 to 18) or from gestation day 7 through lactation day 21 at 50, 100, or 200 mg/kg/day. Administration of 200 mg/kg/day in rats was associated with increase in the incidence of early resorptions; and doses 100 mg/kg/day and greater were associated with early neonatal mortality. The AUC at the NOAEL (50 mg/kg/day) in this rat study was 0.1 times that in humans at the recommended clinical dose. Drug concentrations in the milk on lactation day 10 were approximately 8 times higher than those in maternal plasma. In pregnant rabbits, efavirenz was neither embryo lethal nor teratogenic when administered at doses of 25, 50, and 75 mg/kg/day over the period of organogenesis (gestation days 6 through 18). The AUC at the NOAEL (75 mg/kg/day) in rabbits was 0.4 times that in humans at the recommended clinical dose.

8.2 Lactation

Risk Summary

The Centers for Disease Control and Prevention recommend that HIV-infected mothers not breastfeed their infants to avoid risking postnatal transmission of HIV. Because of the potential for HIV transmission in breastfed infants, advise women not to breastfeed.

8.3 Females and Males of Reproductive Potential

Because of potential teratogenic effects, pregnancy should be avoided in women receiving SUSTIVA. [See Use in Specific Populations (8.1).]

Pregnancy Testing

Females of reproductive potential should undergo pregnancy testing before initiation of SUSTIVA.

Contraception

Females of reproductive potential should use effective contraception during treatment with SUSTIVA and for 12 weeks after discontinuing SUSTIVA due to the long half-life of efavirenz. Barrier contraception should always be used in combination with other methods of contraception. Hormonal methods that contain progesterone may have decreased effectiveness [see Drug Interactions (7.1)].

8.4 Pediatric Use

The safety, pharmacokinetic profile, and virologic and immunologic responses of SUSTIVA were evaluated in antiretroviral-naive and -experienced HIV-1 infected pediatric patients 3 months to 21 years of age in three open-label clinical trials [see Adverse Reactions (6.2), Clinical Pharmacology (12.3), and Clinical Studies (14.2)]. The type and frequency of adverse reactions in these trials were generally similar to those of adult patients with the exception of a higher frequency of rash, including a higher frequency of Grade 3 or 4 rash, in pediatric patients compared to adults [see Warnings and Precautions (5.8) and Adverse Reactions (6.2)].

Use of SUSTIVA in patients younger than 3 months of age OR less than 3.5 kg body weight is not recommended because the safety, pharmacokinetics, and antiviral activity of SUSTIVA have not been evaluated in this age group and there is a risk of developing HIV resistance if SUSTIVA is underdosed. See Dosage and Administration (2.2) for dosing recommendations for pediatric patients.

8.5 Geriatric Use

Clinical studies of SUSTIVA did not include sufficient numbers of subjects aged 65 years and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other therapy.

8.6 Hepatic Impairment

SUSTIVA is not recommended for patients with moderate or severe hepatic impairment because there are insufficient data to determine whether dose adjustment is necessary. Patients with mild hepatic impairment may be treated with efavirenz without any adjustment in dose. Because of the extensive cytochrome P450-mediated metabolism of efavirenz and limited clinical experience in patients with hepatic impairment, caution should be exercised in administering SUSTIVA to these patients [see Warnings and Precautions (5.9) and Clinical Pharmacology (12.3)].

Overdosage 10 OVERDOSAGE

Some patients accidentally taking 600 mg twice daily have reported increased nervous system symptoms. One patient experienced involuntary muscle contractions.

Treatment of overdose with SUSTIVA should consist of general supportive measures, including monitoring of vital signs and observation of the patient’s clinical status. Administration of activated charcoal may be used to aid removal of unabsorbed drug. There is no specific antidote for overdose with SUSTIVA. Since efavirenz is highly protein bound, dialysis is unlikely to significantly remove the drug from blood.

Description 11 DESCRIPTION

SUSTIVA® (efavirenz) is an HIV-1 specific, non-nucleoside, reverse transcriptase inhibitor (NNRTI). Efavirenz is chemically described as (S)-6-chloro-4-(cyclopropylethynyl)-1,4-dihydro-4-(trifluoromethyl)-2H-3,1-benzoxazin-2-one. Its empirical formula is C14H9ClF3NO2 and its structural formula is:

Efavirenz is a white to slightly pink crystalline powder with a molecular mass of 315.68. It is practically insoluble in water (<10 microgram/mL).

Capsules: SUSTIVA is available as capsules for oral administration containing either 50 mg or 200 mg of efavirenz and the following inactive ingredients: lactose monohydrate, magnesium stearate, sodium lauryl sulfate, and sodium starch glycolate. The capsule shell contains the following inactive ingredients and dyes: gelatin, sodium lauryl sulfate, titanium dioxide, and/or yellow iron oxide. The capsule shells may also contain silicon dioxide. The capsules are printed with ink containing carmine 40 blue, FD&C Blue No. 2, and titanium dioxide.

Tablets: SUSTIVA is available as film-coated tablets for oral administration containing 600 mg of efavirenz and the following inactive ingredients: croscarmellose sodium, hydroxypropyl cellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and sodium lauryl sulfate. The film coating contains Opadry Yellow and Opadry Clear. The tablets are polished with carnauba wax and printed with purple ink, Opacode WB.

Clinical Pharmacology 12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Efavirenz is an antiviral drug [see Microbiology (12.4)].

12.2 Pharmacodynamics

Cardiac Electrophysiology

The effect of SUSTIVA on the QTc interval was evaluated in an open-label, positive and placebo controlled, fixed single sequence 3-period, 3-treatment crossover QT study in 58 healthy subjects enriched for CYP2B6 polymorphisms. The mean Cmax of efavirenz in subjects with CYP2B6 *6/*6 genotype following the administration of 600 mg daily dose for 14 days was 2.25-fold the mean Cmax observed in subjects with CYP2B6 *1/*1 genotype. A positive relationship between efavirenz concentration and QTc prolongation was observed. Based on the concentration-QTc relationship, the mean QTc prolongation and its upper bound 90% confidence interval are 8.7 ms and 11.3 ms in subjects with CYP2B6*6/*6 genotype following the administration of 600 mg daily dose for 14 days [see Warnings and Precautions (5.2 )].

12.3 Pharmacokinetics

Absorption

Peak efavirenz plasma concentrations of 1.6-9.1 μM were attained by 5 hours following single oral doses of 100 mg to 1600 mg administered to uninfected volunteers. Dose-related increases in Cmax and AUC were seen for doses up to 1600 mg; the increases were less than proportional suggesting diminished absorption at higher doses.

In HIV-1-infected patients at steady state, mean Cmax, mean Cmin, and mean AUC were dose proportional following 200 mg, 400 mg, and 600 mg daily doses. Time-to-peak plasma concentrations were approximately 3-5 hours and steady-state plasma concentrations were reached in 6-10 days. In 35 patients receiving SUSTIVA 600 mg once daily, steady-state Cmax was 12.9 ± 3.7 μM (mean ± SD), steady-state Cmin was 5.6 ± 3.2 μM, and AUC was 184 ± 73 μM•h.

Effect of Food on Oral Absorption:

Capsules: Administration of a single 600 mg dose of efavirenz capsules with a high-fat/high-caloric meal (894 kcal, 54 g fat, 54% calories from fat) or a reduced-fat/normal-caloric meal (440 kcal, 2 g fat, 4% calories from fat) was associated with a mean increase of 22% and 17% in efavirenz AUC∞ and a mean increase of 39% and 51% in efavirenz Cmax, respectively, relative to the exposures achieved when given under fasted conditions. [See Dosage and Administration (2) and Patient Counseling Information (17).]

Tablets: Administration of a single 600 mg efavirenz tablet with a high-fat/high-caloric meal (approximately 1000 kcal, 500-600 kcal from fat) was associated with a 28% increase in mean AUC∞ of efavirenz and a 79% increase in mean Cmax of efavirenz relative to the exposures achieved under fasted conditions. [See Dosage and Administration (2) and Patient Counseling Information (17).]

Bioavailability of capsule contents mixed with food vehicles: In healthy adult subjects, the efavirenz AUC when administered as the contents of three 200 mg capsules mixed with 2 teaspoons of certain food vehicles (applesauce, grape jelly or yogurt, or infant formula) met bioequivalency criteria for the AUC of the intact capsule formulation administered under fasted conditions.

Distribution

Efavirenz is highly bound (approximately 99.5-99.75%) to human plasma proteins, predominantly albumin. In HIV-1 infected patients (n = 9) who received SUSTIVA 200 to 600 mg once daily for at least one month, cerebrospinal fluid concentrations ranged from 0.26 to 1.19% (mean 0.69%) of the corresponding plasma concentration. This proportion is approximately 3-fold higher than the non-protein-bound (free) fraction of efavirenz in plasma.

Metabolism

Studies in humans and in vitro studies using human liver microsomes have demonstrated that efavirenz is principally metabolized by the cytochrome P450 system to hydroxylated metabolites with subsequent glucuronidation of these hydroxylated metabolites. These metabolites are essentially inactive against HIV-1. The in vitro studies suggest that CYP3A and CYP2B6 are the major isozymes responsible for efavirenz metabolism.

Efavirenz has been shown to induce CYP enzymes, resulting in the induction of its own metabolism. Multiple doses of 200-400 mg per day for 10 days resulted in a lower than predicted extent of accumulation (22-42% lower) and a shorter terminal half-life of 40-55 hours (single dose half-life 52-76 hours).

Elimination

Efavirenz has a terminal half-life of 52-76 hours after single doses and 40-55 hours after multiple doses. A one-month mass balance/excretion study was conducted using 400 mg per day with a 14C-labeled dose administered on Day 8. Approximately 14-34% of the radiolabel was recovered in the urine and 16-61% was recovered in the feces. Nearly all of the urinary excretion of the radiolabeled drug was in the form of metabolites. Efavirenz accounted for the majority of the total radioactivity measured in feces.

Special Populations

Pediatric: The pharmacokinetic parameters for efavirenz at steady state in pediatric patients were predicted by a population pharmacokinetic model and are summarized in Table 6 by weight ranges that correspond to the recommended doses.

Table 6: Predicted Steady-State Pharmacokinetics of Recommended Doses of Efavirenz (Capsules/Capsule Sprinkles) in HIV-Infected Pediatric Patients
Body Weight	Dose	Mean AUC(0-24) µM•h	Mean Cmax µg/mL	Mean Cmin µg/mL
3.5-5 kg	100 mg	220.52	5.81	2.43
5-7.5 kg	150 mg	262.62	7.07	2.71
7.5-10 kg	200 mg	284.28	7.75	2.87
10-15 kg	200 mg	238.14	6.54	2.32
15-20 kg	250 mg	233.98	6.47	2.3
20-25 kg	300 mg	257.56	7.04	2.55
25-32.5 kg	350 mg	262.37	7.12	2.68
32.5-40 kg	400 mg	259.79	6.96	2.69
>40 kg	600 mg	254.78	6.57	2.82

Gender and race: The pharmacokinetics of efavirenz in patients appear to be similar between men and women and among the racial groups studied.

Renal impairment: The pharmacokinetics of efavirenz have not been studied in patients with renal insufficiency; however, less than 1% of efavirenz is excreted unchanged in the urine, so the impact of renal impairment on efavirenz elimination should be minimal.

Hepatic impairment: A multiple-dose study showed no significant effect on efavirenz pharmacokinetics in patients with mild hepatic impairment (Child-Pugh Class A) compared with controls. There were insufficient data to determine whether moderate or severe hepatic impairment (Child-Pugh Class B or C) affects efavirenz pharmacokinetics.

Drug Interaction Studies

Efavirenz has been shown in vivo to cause hepatic enzyme induction, thus increasing the biotransformation of some drugs metabolized by CYP3A and CYP2B6. In vitro studies have shown that efavirenz inhibited CYP isozymes 2C9 and 2C19 with Ki values (8.5-17 μM) in the range of observed efavirenz plasma concentrations. In in vitro studies, efavirenz did not inhibit CYP2E1 and inhibited CYP2D6 and CYP1A2 (Ki values 82-160 μM) only at concentrations well above those achieved clinically. Coadministration of efavirenz with drugs primarily metabolized by CYP2C9, CYP2C19, CYP3A, or CYP2B6 isozymes may result in altered plasma concentrations of the coadministered drug. Drugs which induce CYP3A and CYP2B6 activity would be expected to increase the clearance of efavirenz resulting in lowered plasma concentrations.

Drug interaction studies were performed with efavirenz and other drugs likely to be coadministered or drugs commonly used as probes for pharmacokinetic interaction. The effects of coadministration of efavirenz on the Cmax, AUC, and Cmin are summarized in Table 7 (effect of efavirenz on other drugs) and Table 8 (effect of other drugs on efavirenz). For information regarding clinical recommendations see Drug Interactions (7.1).

Table 7: Effect of Efavirenz on Coadministered Drug Plasma Cmax, AUC, and Cmin
↑ Indicates increase ↓ Indicates decrease ↔ Indicates no change or a mean increase or decrease of <10%. a Compared with atazanavir 400 mg qd alone. b Comparator dose of indinavir was 800 mg q8h × 10 days. c Parallel-group design; n for efavirenz lopinavir/ritonavir, n for lopinavir/ritonavir alone. d Values are for lopinavir; the pharmacokinetics of ritonavir in this study were unaffected by concurrent efavirenz. e 95% CI. f Soft Gelatin Capsule. g Tenofovir disoproxil fumarate. h 90% CI not available. i Relative to steady-state administration of voriconazole (400 mg for 1 day, then 200 mg po q12h for 2 days). j Not available because of insufficient data. NA = not available.
				Coadministered Drug (mean % change)
Coadministered Drug	Dose	Efavirenz Dose	Number of Subjects	Cmax (90% CI)	AUC (90% CI)	Cmin (90% CI)
Atazanavir	400 mg qd with a light meal d 1-20	600 mg qd with a light meal d 7-20	27	↓ 59% (49-67%)	↓ 74% (68-78%)	↓ 93% (90-95%)
	400 mg qd d 1-6, then 300 mg qd d 7-20 with ritonavir 100 mg qd and a light meal	600 mg qd 2 h after atazanavir and ritonavir d 7-20	13	↑ 14%a (↓ 17-↑ 58%)	↑ 39%a (2-88%)	↑ 48%a (24-76%)
	300 mg qd/ritonavir 100 mg qd d 1-10 (pm), then 400 mg qd/ritonavir 100 mg qd d 11-24 (pm) (simultaneous with efavirenz)	600 mg qd with a light snack d 11-24 (pm)	14	↑ 17% (8-27%)	↔	↓ 42% (31-51%)
Indinavir	1000 mg q8h × 10 days	600 mg qd × 10 days	20
	After morning dose			↔b	↓ 33%b (26-39%)	↓ 39%b (24-51%)
	After afternoon dose			↔b	↓ 37%b (26-46%)	↓ 52%b (47-57%)
	After evening dose			↓ 29%b (11-43%)	↓ 46%b (37-54%)	↓ 57%b (50-63%)
Lopinavir/ ritonavir	400/100 mg capsule q12h × 9 days	600 mg qd × 9 days	11,7c	↔d	↓ 19%d (↓ 36-↑ 3%)	↓ 39%d (3-62%)
	500/125 mg tablet q12h × 10 days with efavirenz compared to 400/100 mg q12h alone	600 mg qd × 9 days	19	↑ 12%d (2-23%)	↔d	↓ 10%d (↓ 22-↑ 4%)
	600/150 mg tablet q12h × 10 days with efavirenz compared to 400/100 mg q12h alone	600 mg qd × 9 days	23	↑ 36%d (28-44%)	↑ 36%d (28-44%)	↑ 32%d (21-44%)
Nelfinavir	750 mg q8h × 7 days	600 mg qd × 7 days	10	↑ 21% (10-33%)	↑ 20% (8-34%)	↔
Metabolite AG-1402				↓ 40% (30-48%)	↓ 37% (25-48%)	↓ 43% (21-59%)
Ritonavir	500 mg q12h × 8 days	600 mg qd × 10 days	11
	After AM dose			↑ 24% (12-38%)	↑ 18% (6-33%)	↑ 42% (9-86%)e
	After PM dose			↔	↔	↑ 24% (3-50%)e
Saquinavir SGCf	1200 mg q8h × 10 days	600 mg qd × 10 days	12	↓ 50% (28-66%)	↓ 62% (45-74%)	↓ 56% (16-77%)e
Lamivudine	150 mg q12h × 14 days	600 mg qd × 14 days	9	↔	↔	↑ 265% (37-873%)
Tenofovirg	300 mg qd	600 mg qd × 14 days	29	↔	↔	↔
Zidovudine	300 mg q12h × 14 days	600 mg qd × 14 days	9	↔	↔	↑ 225% (43-640%)
Maraviroc	100 mg bid	600 mg qd	12	↓ 51% (37-62%)	↓ 45% (38-51%)	↓ 45% (28-57%)
Raltegravir	400 mg single dose	600 mg qd	9	↓ 36% (2-59%)	↓ 36% (20-48%)	↓ 21% (↓ 51-↑ 28%)
Boceprevir	800 mg tid × 6 days	600 mg qd × 16 days	NA	↓ 8% (↓ 22-↑ 8%)	↓ 19% (11-25%)	↓ 44% (26-58%)
Simeprevir	150 mg qd × 14 days	600 mg qd × 14 days	23	↓ 51% (↓ 46-↓ 56%)	↓ 71% (↓ 67-↓ 74%)	↓ 91% (↓ 88-↓ 92%)
Azithromycin	600 mg single dose	400 mg qd × 7 days	14	↑ 22% (4-42%)	↔	NA
Clarithromycin	500 mg q12h × 7 days	400 mg qd × 7 days	11	↓ 26% (15-35%)	↓ 39% (30-46%)	↓ 53% (42-63%)
14-OH metabolite				↑ 49% (32-69%)	↑ 34% (18-53%)	↑ 26% (9-45%)
Fluconazole	200 mg × 7 days	400 mg qd × 7 days	10	↔	↔	↔
Itraconazole	200 mg q12h × 28 days	600 mg qd × 14 days	18	↓ 37% (20-51%)	↓ 39% (21-53%)	↓ 44% (27-58%)
Hydroxy-itraconazole				↓ 35% (12-52%)	↓ 37% (14-55%)	↓ 43% (18-60%)
Posaconazole	400 mg (oral suspension) bid × 10 and 20 days	400 mg qd × 10 and 20 days	11	↓ 45% (34-53%)	↓ 50% (40-57%)	NA
Rifabutin	300 mg qd × 14 days	600 mg qd × 14 days	9	↓ 32% (15-46%)	↓ 38% (28-47%)	↓ 45% (31-56%)
Voriconazole	400 mg po q12h × 1 day, then 200 mg po q12h × 8 days	400 mg qd × 9 days	NA	↓ 61%h	↓ 77%h	NA
	300 mg po q12h days 2-7	300 mg qd × 7 days	NA	↓ 36%i (21-49%)	↓ 55%i (45-62%)	NA
	400 mg po q12h days 2-7	300 mg qd × 7 days	NA	↑ 23%i (↓ 1-↑ 53%)	↓ 7%i (↓ 23-↑ 13%)	NA
Artemether/lumefantrine	Artemether 20 mg/lumefantrine 120 mg tablets (6 4-tablet doses over 3 days)	600 mg qd × 26 days	12
Artemether				↓ 21%	↓ 51%	NA
dihydroartemisinin				↓ 38%	↓ 46%	NA
Lumefantrine				↔	↓ 21%	NA
Atorvastatin	10 mg qd × 4 days	600 mg qd × 15 days	14	↓ 14% (1-26%)	↓ 43% (34-50%)	↓ 69% (49-81%)
Total active (including metabolites)				↓ 15% (2-26%)	↓ 32% (21-41%)	↓ 48% (23-64%)
Pravastatin	40 mg qd × 4 days	600 mg qd × 15 days	13	↓ 32% (↓ 59-↑ 12%)	↓ 44% (26-57%)	↓ 19% (0-35%)
Simvastatin	40 mg qd × 4 days	600 mg qd × 15 days	14	↓ 72% (63-79%)	↓ 68% (62-73%)	↓ 45% (20-62%)
Total active (including metabolites)				↓ 68% (55-78%)	↓ 60% (52-68%)	NAj
Carbamazepine	200 mg qd × 3 days, 200 mg bid × 3 days, then 400 mg qd × 29 days	600 mg qd × 14 days	12	↓ 20% (15-24%)	↓ 27% (20-33%)	↓ 35% (24-44%)
Epoxide metabolite				↔	↔	↓ 13% (↓ 30-↑ 7%)
Cetirizine	10 mg single dose	600 mg qd × 10 days	11	↓ 24% (18-30%)	↔	NA
Diltiazem	240 mg × 21 days	600 mg qd × 14 days	13	↓ 60% (50-68%)	↓ 69% (55-79%)	↓ 63% (44-75%)
Desacetyl diltiazem				↓ 64% (57-69%)	↓ 75% (59-84%)	↓ 62% (44-75%)
N- monodesmethyl diltiazem				↓ 28% (7-44%)	↓ 37% (17-52%)	↓ 37% (17-52%)
Ethinyl estradiol/ Norgestimate	0.035 mg/ 0.25 mg × 14 days	600 mg qd × 14 days
Ethinyl estradiol			21	↔	↔	↔
Norelgestromin			21	↓ 46% (39-52%)	↓ 64% (62-67%)	↓ 82% (79-85%)
Levonorgestrel			6	↓ 80% (77-83%)	↓ 83% (79-87%)	↓ 86% (80-90%)
Lorazepam	2 mg single dose	600 mg qd × 10 days	12	↑ 16% (2-32%)	↔	NA
Methadone	Stable maintenance 35- 100 mg daily	600 mg qd × 14-21 days	11	↓ 45% (25-59%)	↓ 52% (33-66%)	NA
Bupropion	150 mg single dose (sustained-release)	600 mg qd × 14 days	13	↓ 34% (21-47%)	↓ 55% (48-62%)	NA
Hydroxy- bupropion				↑ 50% (20-80%)	↔	NA
Paroxetine	20 mg qd × 14 days	600 mg qd × 14 days	16	↔	↔	↔
Sertraline	50 mg qd × 14 days	600 mg qd × 14 days	13	↓ 29% (15-40%)	↓ 39% (27-50%)	↓ 46% (31-58%)

Table 8: Effect of Coadministered Drug on Efavirenz Plasma Cmax, AUC, and Cmin
				Efavirenz (mean % change)
Coadministered Drug	Dose	Efavirenz Dose	Number of Subjects	Cmax (90% CI)	AUC (90% CI)	Cmin (90% CI)
↑ Indicates increase ↓ Indicates decrease ↔ Indicates no change or a mean increase or decrease of <10%. a Parallel-group design; n for efavirenz lopinavir/ritonavir, n for efavirenz alone. b 95% CI. c Soft Gelatin Capsule. d Tenofovir disoproxil fumarate. e 90% CI not available. f Relative to steady-state administration of efavirenz (600 mg once daily for 9 days). NA = not available.
Indinavir	800 mg q8h × 14 days	200 mg qd × 14 days	11	↔	↔	↔
Lopinavir/ritonavir	400/100 mg q12h × 9 days	600 mg qd × 9 days	11,12a	↔	↓ 16% (↓ 38-↑ 15%)	↓ 16% (↓ 42-↑ 20%)
Nelfinavir	750 mg q8h × 7 days	600 mg qd × 7 days	10	↓ 12% (↓ 32-↑ 13%)b	↓ 12% (↓ 35-↑ 18%)b	↓ 21% (↓ 53-↑ 33%)
Ritonavir	500 mg q12h × 8 days	600 mg qd × 10 days	9	↑ 14% (4-26%)	↑ 21% (10-34%)	↑ 25% (7-46%)b
Saquinavir SGCc	1200 mg q8h × 10 days	600 mg qd × 10 days	13	↓ 13% (5-20%)	↓ 12% (4-19%)	↓ 14% (2-24%)b
Tenofovird	300 mg qd	600 mg qd × 14 days	30	↔	↔	↔
Boceprevir	800 mg tid × 6 days	600 mg qd × 16 days	NA	↑ 11% (2-20%)	↑ 20% (15-26%)	NA
Simeprevir	150 mg qd × 14 days	600 mg qd × 14 days	23	↔	↓ 10% (5-15%)	↓ 13% (7-19%)
Azithromycin	600 mg single dose	400 mg qd × 7 days	14	↔	↔	↔
Clarithromycin	500 mg q12h × 7 days	400 mg qd × 7 days	12	↑ 11% (3-19%)	↔	↔
Fluconazole	200 mg × 7 days	400 mg qd × 7 days	10	↔	↑ 16% (6-26%)	↑ 22% (5-41%)
Itraconazole	200 mg q12h × 14 days	600 mg qd × 28 days	16	↔	↔	↔
Rifabutin	300 mg qd × 14 days	600 mg qd × 14 days	11	↔	↔	↓ 12% (↓ 24-↑ 1%)
Rifampin	600 mg × 7 days	600 mg qd × 7 days	12	↓ 20% (11-28%)	↓ 26% (15-36%)	↓ 32% (15-46%)
Voriconazole	400 mg po q12h × 1 day, then 200 mg po q12h × 8 days	400 mg qd × 9 days	NA	↑ 38%e	↑ 44%e	NA
	300 mg po q12h days 2-7	300 mg qd × 7 days	NA	↓ 14%f (7-21%)	↔f	NA
	400 mg po q12h days 2-7	300 mg qd × 7 days	NA	↔f	↑ 17%f (6-29%)	NA
Artemether/Lumefantrine	Artemether 20 mg/lumefantrine 120 mg tablets (6 4-tablet doses over 3 days)	600 mg qd × 26 days	12	↔	↓ 17%	NA
Atorvastatin	10 mg qd × 4 days	600 mg qd × 15 days	14	↔	↔	↔
Pravastatin	40 mg qd × 4 days	600 mg qd × 15 days	11	↔	↔	↔
Simvastatin	40 mg qd × 4 days	600 mg qd × 15 days	14	↓ 12% (↓ 28-↑ 8%)	↔	↓ 12% (↓ 25-↑ 3%)
Aluminum hydroxide 400 mg, magnesium hydroxide 400 mg, plus simethicone 40 mg	30 mL single dose	400 mg single dose	17	↔	↔	NA
Carbamazepine	200 mg qd × 3 days, 200 mg bid × 3 days, then 400 mg qd × 15 days	600 mg qd × 35 days	14	↓ 21% (15-26%)	↓ 36% (32-40%)	↓ 47% (41-53%)
Cetirizine	10 mg single dose	600 mg qd × 10 days	11	↔	↔	↔
Diltiazem	240 mg × 14 days	600 mg qd × 28 days	12	↑ 16% (6-26%)	↑ 11% (5-18%)	↑ 13% (1-26%)
Famotidine	40 mg single dose	400 mg single dose	17	↔	↔	NA
Paroxetine	20 mg qd × 14 days	600 mg qd × 14 days	12	↔	↔	↔
Sertraline	50 mg qd × 14 days	600 mg qd × 14 days	13	↑ 11% (6-16%)	↔	↔

12.4 Microbiology

Mechanism of Action

Efavirenz is an NNRTI of HIV-1. Efavirenz activity is mediated predominantly by noncompetitive inhibition of HIV-1 reverse transcriptase. HIV-2 reverse transcriptase and human cellular DNA polymerases α, β, γ, and δ are not inhibited by efavirenz.

Antiviral Activity in Cell Culture

The concentration of efavirenz inhibiting replication of wild-type laboratory adapted strains and clinical isolates in cell culture by 90-95% (EC90-95) ranged from 1.7 to 25 nM in lymphoblastoid cell lines, peripheral blood mononuclear cells (PBMCs), and macrophage/monocyte cultures. Efavirenz demonstrated antiviral activity against clade B and most non-clade B isolates (subtypes A, AE, AG, C, D, F, G, J, N), but had reduced antiviral activity against group O viruses. Efavirenz demonstrated additive antiviral activity without cytotoxicity against HIV-1 in cell culture when combined with the NNRTIs delavirdine and nevirapine, NRTIs (abacavir, didanosine, emtricitabine, lamivudine, stavudine, tenofovir, zalcitabine, zidovudine), PIs (amprenavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir), and the fusion inhibitor enfuvirtide. Efavirenz demonstrated additive to antagonistic antiviral activity in cell culture with atazanavir. Efavirenz was not antagonistic with adefovir, used for the treatment of hepatitis B virus infection, or ribavirin, used in combination with interferon for the treatment of hepatitis C virus infection.

Resistance

In cell culture

In cell culture, HIV-1 isolates with reduced susceptibility to efavirenz (>380-fold increase in EC90 value) emerged rapidly in the presence of drug. Genotypic characterization of these viruses identified single amino acid substitutions L100I or V179D, double substitutions L100I/V108I, and triple substitutions L100I/V179D/Y181C in reverse transcriptase.

Clinical studies

Clinical isolates with reduced susceptibility in cell culture to efavirenz have been obtained. One or more substitutions at amino acid positions 98, 100, 101, 103, 106, 108, 188, 190, 225, and 227 in reverse transcriptase were observed in patients failing treatment with efavirenz in combination with indinavir, or with zidovudine plus lamivudine. The K103N substitution was the most frequently observed. Long-term resistance surveillance (average 52 weeks, range 4-106 weeks) analyzed 28 matching baseline and virologic failure isolates. Sixty-one percent (17/28) of these failure isolates had decreased efavirenz susceptibility in cell culture with a median 88-fold change in efavirenz susceptibility (EC50 value) from reference. The most frequent NNRTI substitution to develop in these patient isolates was K103N (54%). Other NNRTI substitutions that developed included L100I (7%), K101E/Q/R (14%), V108I (11%), G190S/T/A (7%), P225H (18%), and M230I/L (11%).

Cross-Resistance

Cross-resistance among NNRTIs has been observed. Clinical isolates previously characterized as efavirenz-resistant were also phenotypically resistant in cell culture to delavirdine and nevirapine compared to baseline. Delavirdine- and/or nevirapine-resistant clinical viral isolates with NNRTI resistance-associated substitutions (A98G, L100I, K101E/P, K103N/S, V106A, Y181X, Y188X, G190X, P225H, F227L, or M230L) showed reduced susceptibility to efavirenz in cell culture. Greater than 90% of NRTI-resistant clinical isolates tested in cell culture retained susceptibility to efavirenz.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis

Long-term carcinogenicity studies in mice and rats were carried out with efavirenz. Mice were dosed with 0, 25, 75, 150, or 300 mg/kg/day for 2 years. Incidences of hepatocellular adenomas and carcinomas and pulmonary alveolar/bronchiolar adenomas were increased above background in females. No increases in tumor incidence above background were seen in males. There was no NOAEL in females established for this study because tumor findings occurred at all doses. AUC at the NOAEL (150 mg/kg) in the males was approximately 0.9 times that in humans at the recommended clinical dose. In the rat study, no increases in tumor incidence were observed at doses up to 100 mg/kg/day, for which AUCs were 0.1 (males) or 0.2 (females) times those in humans at the recommended clinical dose.

Mutagenesis

Efavirenz tested negative in a battery of in vitro and in vivo genotoxicity assays. These included bacterial mutation assays in S. typhimurium and E. coli, mammalian mutation assays in Chinese hamster ovary cells, chromosome aberration assays in human peripheral blood lymphocytes or Chinese hamster ovary cells, and an in vivo mouse bone marrow micronucleus assay.

Impairment of Fertility

Efavirenz did not impair mating or fertility of male or female rats, and did not affect sperm of treated male rats. The reproductive performance of offspring born to female rats given efavirenz was not affected. The AUCs at the NOAEL values in male (200 mg/kg) and female (100 mg/kg) rats were approximately ≤0.15 times that in humans at the recommended clinical dose.

13.2 Animal Toxicology

Nonsustained convulsions were observed in 6 of 20 monkeys receiving efavirenz at doses yielding plasma AUC values 4- to 13-fold greater than those in humans given the recommended dose [see Warnings and Precautions (5.10)].

14 CLINICAL STUDIES

14.1 Adults

Study 006, a randomized, open-label trial, compared SUSTIVA (600 mg once daily) zidovudine (ZDV, 300 mg q12h) lamivudine (LAM, 150 mg q12h) or SUSTIVA (600 mg once daily) indinavir (IDV, 1000 mg q8h) with indinavir (800 mg q8h) zidovudine (300 mg q12h) lamivudine (150 mg q12h). Twelve hundred sixty-six patients (mean age 36.5 years [range 18-81], 60% Caucasian, 83% male) were enrolled. All patients were efavirenz-, lamivudine-, NNRTI-, and PI-naive at study entry. The median baseline CD4 cell count was 320 cells/mm3 and the median baseline HIV-1 RNA level was 4.8 log10 copies/mL. Treatment outcomes with standard assay (assay limit 400 copies/mL) through 48 and 168 weeks are shown in Table 9. Plasma HIV RNA levels were quantified with standard (assay limit 400 copies/mL) and ultrasensitive (assay limit 50 copies/mL) versions of the AMPLICOR HIV-1 MONITOR assay. During the study, version 1.5 of the assay was introduced in Europe to enhance detection of non-clade B virus.

Table 9: Outcomes of Randomized Treatment Through 48 and 168 Weeks, Study 006
	SUSTIVA ZDV LAM (n = 422)		SUSTIVA IDV (n = 429)		IDV ZDV LAM (n = 415)
Outcome	Week 48	Week 168	Week 48	Week 168	Week 48	Week 168
a Patients achieved and maintained confirmed HIV-1 RNA <400 copies/mL through Week 48 or Week 168. b Includes patients who rebounded, patients who were on study at Week 48 and failed to achieve confirmed HIV-1 RNA <400 copies/mL at time of discontinuation, and patients who discontinued due to lack of efficacy. c Includes consent withdrawn, lost to follow-up, noncompliance, never treated, missing data, protocol violation, death, and other reasons. Patients with HIV-1 RNA levels <400 copies/mL who chose not to continue in the voluntary extension phases of the study were censored at date of last dose of study medication.
Respondera	69%	48%	57%	40%	50%	29%
Virologic failureb	6%	12%	15%	20%	13%	19%
Discontinued for adverse events	7%	8%	6%	8%	16%	20%
Discontinued for other reasonsc	17%	31%	22%	32%	21%	32%
CD4 cell count (cells/mm3)
Observed subjects (n)	(279)	(205)	(256)	(158)	(228)	(129)
Mean change from baseline	190	329	191	319	180	329

For patients treated with SUSTIVA zidovudine lamivudine, SUSTIVA indinavir, or indinavir zidovudine lamivudine, the percentage of responders with HIV-1 RNA <50 copies/mL was 65%, 50%, and 45%, respectively, through 48 weeks, and 43%, 31%, and 23%, respectively, through 168 weeks. A Kaplan-Meier analysis of time to loss of virologic response (HIV RNA <400 copies/mL) suggests that both the trends of virologic response and differences in response continue through 4 years.

ACTG 364 is a randomized, double-blind, placebo-controlled, 48-week study in NRTI-experienced patients who had completed two prior ACTG studies. One-hundred ninety-six patients (mean age 41 years [range 18-76], 74% Caucasian, 88% male) received NRTIs in combination with SUSTIVA (600 mg once daily), or nelfinavir (NFV, 750 mg three times daily), or SUSTIVA (600 mg once daily) nelfinavir in a randomized, double-blinded manner. The mean baseline CD4 cell count was 389 cells/mm3 and mean baseline HIV-1 RNA level was 8130 copies/mL. Upon entry into the study, all patients were assigned a new open-label NRTI regimen, which was dependent on their previous NRTI treatment experience. There was no significant difference in the mean CD4 cell count among treatment groups; the overall mean increase was approximately 100 cells at 48 weeks among patients who continued on study regimens. Treatment outcomes are shown in Table 10. Plasma HIV RNA levels were quantified with the AMPLICOR HIV-1 MONITOR assay using a lower limit of quantification of 500 copies/mL.

Table 10: Outcomes of Randomized Treatment Through 48 Weeks, Study ACTG 364*
Outcome	SUSTIVA NFV NRTIs (n = 65)	SUSTIVA NRTIs (n = 65)	NFV NRTIs (n = 66)
* For some patients, Week 56 data were used to confirm the status at Week 48. a Subjects achieved virologic response (two consecutive viral loads <500 copies/mL) and maintained it through Week 48. b Includes viral rebound and failure to achieve confirmed <500 copies/mL by Week 48. c See Adverse Reactions (6.1) for a safety profile of these regimens. d Includes loss to follow-up, consent withdrawn, noncompliance.
HIV-1 RNA <500 copies/mLa	71%	63%	41%
HIV-1 RNA ≥500 copies/mLb	17%	34%	54%
CDC Category C Event	2%	0%	0%
Discontinuations for adverse eventsc	3%	3%	5%
Discontinuations for other reasonsd	8%	0%	0%

A Kaplan-Meier analysis of time to treatment failure through 72 weeks demonstrates a longer duration of virologic suppression (HIV RNA <500 copies/mL) in the SUSTIVA-containing treatment arms.

14.2 Pediatric Patients

Study AI266922 is an open-label study to evaluate the pharmacokinetics, safety, tolerability, and antiviral activity of SUSTIVA in combination with didanosine and emtricitabine in antiretroviral-naive and -experienced pediatric patients. Thirty-seven patients 3 months to 6 years of age (median 0.7 years) were treated with SUSTIVA. At baseline, median plasma HIV-1 RNA was 5.88 log10 copies/mL, median CD4 cell count was 1144 cells/mm3, and median CD4 percentage was 25%. The median time on study therapy was 60 weeks; 27% of patients discontinued before Week 48. Using an ITT analysis, the overall proportions of patients with HIV RNA <400 copies/mL and <50 copies/mL at Week 48 were 57% (21/37) and 46% (17/37), respectively. The median increase from baseline in CD4 count at 48 weeks was 196 cells/mm3 and the median increase in CD4 percentage was 6%.

Study PACTG 1021 was an open-label study to evaluate the pharmacokinetics, safety, tolerability, and antiviral activity of SUSTIVA in combination with didanosine and emtricitabine in pediatric patients who were antiretroviral therapy naive. Forty-three patients 3 months to 21 years of age (median 9.6 years) were dosed with SUSTIVA. At baseline, median plasma HIV-1 RNA was 4.8 log10 copies/mL, median CD4 cell count was 367 cells/mm3, and median CD4 percentage was 18%. The median time on study therapy was 181 weeks; 16% of patients discontinued before Week 48. Using an ITT analysis, the overall proportions of patients with HIV RNA <400 copies/mL and <50 copies/mL at Week 48 were 77% (33/43) and 70% (30/43), respectively. The median increase from baseline in CD4 count at 48 weeks of therapy was 238 cells/mm3 and the median increase in CD4 percentage was 13%.

Study PACTG 382 was an open-label study to evaluate the pharmacokinetics, safety, tolerability, and antiviral activity of SUSTIVA in combination with nelfinavir and an NRTI in antiretroviral-naive and NRTI-experienced pediatric patients. One hundred two patients 3 months to 16 years of age (median 5.7 years) were treated with SUSTIVA. Eighty-seven percent of patients had received prior antiretroviral therapy. At baseline, median plasma HIV-1 RNA was 4.57 log10 copies/mL, median CD4 cell count was 755 cells/mm3, and median CD4 percentage was 30%. The median time on study therapy was 118 weeks; 25% of patients discontinued before Week 48. Using an ITT analysis, the overall proportion of patients with HIV RNA <400 copies/mL and <50 copies/mL at Week 48 were 57% (58/102) and 43% (44/102), respectively. The median increase from baseline in CD4 count at 48 weeks of therapy was 128 cells/mm3 and the median increase in CD4 percentage was 5%.

How Supplied 16 HOW SUPPLIED/STORAGE AND HANDLING

How Supplied 16.1 Capsules

SUSTIVA® (efavirenz) capsules are available as follows:

Capsules 200 mg are gold color, reverse printed with “SUSTIVA” on the body and imprinted “200 mg” on the cap.

Bottles of 90 NDC 0056-0474-92

Capsules 50 mg are gold color and white, printed with “SUSTIVA” on the gold color cap and reverse printed “50 mg” on the white body.

Bottles of 30 NDC 0056-0470-30

How Supplied 16.2 Tablets

SUSTIVA® (efavirenz) tablets are available as follows:

Tablets 600 mg are yellow, capsular-shaped, film-coated tablets, with “SUSTIVA” printed on both sides.

Bottles of 30 NDC 0056-0510-30

16.3 Storage

SUSTIVA capsules and SUSTIVA tablets should be stored at 25°C (77°F); excursions permitted to 15°C-30°C (59°F-86°F) [see USP Controlled Room Temperature].

Patient Counseling Information 17 PATIENT COUNSELING INFORMATION

Advise the patient to read the FDA-approved patient labeling (Patient Information and Instructions for Use).

Drug Interactions

A statement to patients and healthcare providers is included on the product’s bottle labels: ALERT: Find out about medicines that should NOT be taken with SUSTIVA.

SUSTIVA may interact with some drugs; therefore, advise patients to report to their doctor the use of any other prescription or nonprescription medication.

General Information for Patients

Inform patients that SUSTIVA is not a cure for HIV‑1 infection and patients may continue to experience illnesses associated with HIV‑1 infection, including opportunistic infections. Patients should remain under the care of a physician while taking SUSTIVA.

Advise patients to avoid doing things that can spread HIV-1 infection to others.

Do not share or reuse needles or other injection equipment.
Do not share personal items that can have blood or body fluids on them, like toothbrushes and razor blades.
Do not have any kind of sex without protection. Always practice safer sex by using a latex or polyurethane condom to lower the chance of sexual contact with semen, vaginal secretions, or blood.
Do not breastfeed. Mothers with HIV-1 should not breastfeed because HIV-1 can be passed to the baby in breast milk.

Dosing Instructions

Advise patients to take SUSTIVA every day as prescribed. If a patient forgets to take SUSTIVA, tell the patient to take the missed dose right away, unless it is almost time for the next dose. Advise the patient not to take 2 doses at one time and to take the next dose at the regularly scheduled time. Advise the patient to ask a healthcare provider if he/she needs help in planning the best times to take his/her medicine.

SUSTIVA must always be used in combination with other antiretroviral drugs. Advise patients to take SUSTIVA on an empty stomach, preferably at bedtime. Taking SUSTIVA with food increases efavirenz concentrations and may increase the frequency of adverse reactions. Dosing at bedtime may improve the tolerability of nervous system symptoms [see Dosage and Administration (2) and Adverse Reactions (6.1)]. Healthcare providers should assist parents or caregivers in determining the best SUSTIVA dosing schedule for infants and young children.

For adult and pediatric patients who cannot swallow capsules or tablets, patients or their caregivers should be advised to read and carefully follow the instructions for administering the capsule contents in a small amount of food or infant formula [see Dosage and Administration (2.3) and FDA-approved patient labeling (Patient Information and Instructions for Use)]. Patients should call their healthcare provider or pharmacist if they have any questions.

Nervous System Symptoms

Inform patients that central nervous system symptoms (NSS) including dizziness, insomnia, impaired concentration, drowsiness, and abnormal dreams are commonly reported during the first weeks of therapy with SUSTIVA [see Warnings and Precautions (5.6)]. Dosing at bedtime may improve the tolerability of these symptoms, which are likely to improve with continued therapy. Alert patients to the potential for additive effects when SUSTIVA is used concomitantly with alcohol or psychoactive drugs. Instruct patients that if they experience NSS they should avoid potentially hazardous tasks such as driving or operating machinery.

Inform patients that there is a risk of developing late-onset neurotoxicity, including ataxia and encephalopathy which may occur months to years after beginning SUSTIVA therapy [see Warnings and Precautions (5.6)].

Psychiatric Symptoms

Inform patients that serious psychiatric symptoms including severe depression, suicide attempts, aggressive behavior, delusions, paranoia, psychosis-like symptoms and catatonia have been reported in patients receiving SUSTIVA [see Warnings and Precautions (5.5)]. If they experience severe psychiatric adverse experiences they should seek immediate medical evaluation. Advise patients to inform their physician of any history of mental illness or substance abuse.

Rash

Inform patients that a common side effect is rash [see Warnings and Precautions (5.8)]. Rashes usually go away without any change in treatment. However, since rash may be serious, advise patients to contact their physician promptly if rash occurs.

Hepatotoxicity

Inform patients to watch for early warning signs of liver inflammation or failure, such as fatigue, weakness, lack of appetite, nausea and vomiting, as well as later signs such as jaundice, confusion, abdominal swelling, and discolored feces, and to consult their health care professional without delay if such symptoms occur [see Warnings and Precautions (5.9) and Adverse Reactions (6.1)].

Females of Reproductive Potential

Advise females of reproductive potential to use effective contraception as well as a barrier method during treatment with SUSTIVA and for 12 weeks after discontinuing SUSTIVA. Advise patients to contact their healthcare provider if they plan to become pregnant, become pregnant, or if pregnancy is suspected during treatment with SUSTIVA [see Warnings and Precautions (5.7) and Use in Specific Populations (8.1, 8.3)].

Pregnancy Exposure Registry

Advise patients that there is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to SUSTIVA during pregnancy [see Use in Specific Populations (8.1)].

Fat Redistribution

Inform patients that redistribution or accumulation of body fat may occur in patients receiving antiretroviral therapy and that the cause and long-term health effects of these conditions are not known [see Warnings and Precautions (5.13)].

SUSTIVA is a registered trademark of Bristol-Myers Squibb Pharma Company. ATRIPLA is a trademark of Bristol-Myers Squibb & Gilead Sciences, LLC.

Distributed by:
Bristol-Myers Squibb Company
Princeton, NJ 08543 USA

[print code]

Patient Package Insert Patient Information

SUSTIVA® (sus-TEE-vah)
(efavirenz)
capsules

SUSTIVA® (sus-TEE-vah)
(efavirenz)
tablets

Important: Ask your doctor or pharmacist about medicines that should not be taken with SUSTIVA. For more information, see the section "What should I tell my doctor before taking SUSTIVA?"

Read this Patient Information before you start taking SUSTIVA and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or treatment.

What is SUSTIVA?

SUSTIVA is a prescription HIV-1 (Human Immunodeficiency Virus type 1) medicine used with other antiretroviral medicines to treat HIV-1 infection in adults and in children who are at least 3 months old and who weigh at least 7 pounds 12 ounces (3.5 kg). HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome).

It is not known if SUSTIVA is safe and effective in children younger than 3 months of age or who weigh less than 7 pounds 12 ounces (3.5 kg).

When used with other antiretroviral medicines to treat HIV-1 infection, SUSTIVA may help:

reduce the amount of HIV-1 in your blood. This is called viral load.
increase the number of CD4 (T) cells in your blood that help fight off other infections.

Reducing the amount of HIV-1 and increasing the CD4 (T) cells in your blood may help improve your immune system. This may reduce your risk of death or getting infections that can happen when your immune system is weak (opportunistic infections).

SUSTIVA does not cure HIV-1 infection or AIDS. You should keep taking HIV-1 medicines to control HIV-1 infection and decrease HIV-related illnesses.

Avoid doing things that can spread HIV-1 infection to others:

Do not share or reuse needles or other injection equipment.
Do not share personal items that can have blood or body fluids on them, like toothbrushes and razor blades.
Do not have any kind of sex without protection. Always practice safer sex by using a latex or polyurethane condom to lower the chance of sexual contact with any body fluids such as semen, vaginal secretions, or blood.

Ask your doctor if you have any questions about how to prevent passing HIV to other people.

Who should not take SUSTIVA?

Do not take SUSTIVA if you are allergic to efavirenz or any of the ingredients in SUSTIVA. See the end of this leaflet for a complete list of ingredients in SUSTIVA.

Do not take SUSTIVA if you are currently taking elbasvir and grazoprevir (ZEPATIER ®).

What should I tell my doctor before taking SUSTIVA?

Before taking SUSTIVA, tell your doctor if you have any medical conditions and in particular, if you:

have a heart condition
have ever had a mental health problem
have ever used street drugs or large amounts of alcohol
have liver problems, including hepatitis B or C virus infection
have a history of seizures
are pregnant or plan to become pregnant. SUSTIVA may harm your unborn baby. If you are able to become pregnant your healthcare provider should do a pregnancy test before you start SUSTIVA. You should not become pregnant while taking SUSTIVA and for 12 weeks after stopping treatment with SUSTIVA. Females who are able to become pregnant should use 2 effective forms of birth control during treatment and for 12 weeks after stopping treatment with SUSTIVA. A barrier form of birth control should always be used along with another type of birth control.
Barrier forms of birth control may include latex or polyurethane condom, contraceptive sponge, diaphragm with spermicide, and cervical cap.
Hormonal forms of birth control, such as birth control pills, injections, vaginal rings, or implants may not work during treatment with SUSTIVA.
Talk to your doctor about forms of birth control that may be used during treatment with SUSTIVA.
Pregnancy Registry. There is a pregnancy registry for women who take antiretroviral medicines during pregnancy. The purpose of this registry is to collect information about the health of you and your baby. Talk to your doctor about how you can take part in this registry.
Do not breastfeed if you take SUSTIVA.
You should not breastfeed if you have HIV because of the risk of passing HIV to your baby.

Tell your doctor and pharmacist about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

SUSTIVA may affect the way other medicines work, and other medicines may affect how SUSTIVA works, and may cause serious side effects. If you take certain medicines with SUSTIVA, the amount of SUSTIVA in your body may be too low and it may not work to help control your HIV infection. The HIV virus in your body may become resistant to SUSTIVA or other HIV medicines that are like it.

You should not take SUSTIVA if you take ATRIPLA (efavirenz, emtricitabine, tenofovir disoproxil fumarate) unless your doctor tells you to.

Tell your doctor and pharmacist about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some medicines interact with SUSTIVA.

Keep a list of your medicines to show your doctor and pharmacist.

You can ask your doctor or pharmacist for a list of medicines that interact with SUSTIVA.
Do not start taking a new medicine without telling your doctor. Your doctor can tell you if it is safe to take SUSTIVA with other medicines.

How should I take SUSTIVA?

Take SUSTIVA exactly as your doctor tells you to.
Do not change your dose or stop taking SUSTIVA unless your doctor tells you to.
Stay under the care of your doctor during treatment with SUSTIVA.
SUSTIVA must be used with other antiretroviral medicines.
Take SUSTIVA 1 time each day.
SUSTIVA comes as tablets or capsules.
SUSTIVA tablets must not be broken.
Swallow SUSTIVA tablets or capsules whole with liquid.

How and when to take SUSTIVA.

You should take SUSTIVA on an empty stomach at bedtime. Taking SUSTIVA with food increases the amount of medicine in your body. Some side effects may bother you less if you take SUSTIVA on an empty stomach and at bedtime.
Your child's doctor will prescribe the right dose of SUSTIVA based on your child's weight.
If you have difficulty swallowing tablets or capsules, tell your doctor. Your doctor may recommend opening the SUSTIVA capsule and mixing the contents with food or infant formula. See the detailed "Instructions for Use" at the end of this Patient Information to learn the right way to take SUSTIVA using the capsule sprinkle method.
Adults and children who take SUSTIVA using the capsule sprinkle method should not eat for 2 hours after taking a dose of SUSTIVA.
Babies should not be given infant formula for 2 hours after taking a dose of SUSTIVA using the capsule sprinkle method.
Do not miss a dose of SUSTIVA. If you forget to take SUSTIVA, take the missed dose right away, unless it is almost time for your next dose. Do not take 2 doses at one time. Just take your next dose at your regularly scheduled time. If you need help in planning the best times to take your medicine, ask your doctor or pharmacist.
If you take too much SUSTIVA, call your doctor or go to the nearest hospital emergency room right away.
When your SUSTIVA supply starts to run low, get more from your doctor or pharmacy. It is important not to run out of SUSTIVA. The amount of HIV-1 in your blood may increase if the medicine is stopped for even a short time. The virus may become resistant to SUSTIVA and harder to treat.

What are the possible side effects of SUSTIVA?

SUSTIVA may cause serious side effects, including:

Serious mental health problems can happen in people who take SUSTIVA. Tell your doctor right away if you have any of the following symptoms:


feel sad or hopeless	do not trust other people
feel anxious or restless	hear or see things that are not real
have thoughts of hurting yourself (suicide) or have tried to hurt yourself or others	are not able to move or speak normally
are not able to tell the difference between what is true or real and what is false or unreal

Nervous system symptoms are common in people who take SUSTIVA and can be severe. These symptoms usually begin during the first or second day of treatment with SUSTIVA and usually go away after 2 to 4 weeks of treatment. Some symptoms may occur months to years after beginning SUSTIVA therapy. These symptoms may become worse if you drink alcohol, take a medicine for mental health problems, or use certain street drugs during treatment with SUSTIVA. Symptoms may include:

dizziness	trouble concentrating
trouble sleeping	drowsiness
unusual dreams	lack of coordination or difficulty with balance

If you have dizziness, trouble concentrating or drowsiness, do not drive a car, use machinery, or do anything that needs you to be alert.

Some nervous system symptoms (e.g. confusion, slow thoughts and physical movement, and delusions [false beliefs] or hallucinations [seeing or hearing things that others do not see or hear]) may occur months to years after beginning SUSTIVA therapy. Promptly contact your health care provider should any of these symptoms occur.

Skin rash is common with SUSTIVA but can sometimes be severe. Skin rash usually goes away without any change in treatment. If you develop a rash with any of the following symptoms, tell your doctor right away:

skin rash, with or without itching	peeling skin
fever	mouth sores
swelling of your face	red or inflamed eyes, like "pink eye" (conjunctivitis)
blisters or skin lesions

Liver problems, including liver failure and death can happen in people who take SUSTIVA. Liver problems can happen in people without a history of liver problems. Your doctor will do blood tests to check your liver before you start SUSTIVA and during treatment. Tell your doctor right away if you get any of the following symptoms:

your skin or the white part of your eyes turns yellow (jaundice)	you don't feel like eating food for several days or longer
your urine turns dark	you feel sick to your stomach (nausea)
your bowel movements (stools) turn light in color	you have lower stomach area (abdominal) pain

Seizures can happen in people who take SUSTIVA. Seizures are more likely to happen if you have had seizures in the past. Tell your doctor if you have had a seizure or if you take a medicine to help prevent seizures.
Changes in your immune system (Immune Reconstitution Syndrome) can happen when you start taking HIV-1 medicines. Your immune system may get stronger and begin to fight infections that have been hidden in your body for a long time. Tell your doctor if you start having new symptoms after starting your HIV-1 medicine.
Changes in body fat can happen in people who take HIV-1 medicine. These changes may include increased amount of fat in the upper back and neck ("buffalo hump"), breast, and around the main part of your body (trunk). Loss of fat from the legs, arms, and face may also happen. The cause and long-term health effects of these conditions are not known.

The most common side effects of SUSTIVA include:

rash	abnormal dreams
dizziness	tiredness
nausea	trouble sleeping
headache	vomiting
difficulty concentrating

Some patients taking SUSTIVA have experienced increased levels of lipids (cholesterol and triglycerides) in the blood. Tell your doctor if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of SUSTIVA. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store SUSTIVA?

Store SUSTIVA capsules and tablets at room temperature between 68°F to 77°F (20°C to 25°C).

Keep SUSTIVA and all medicines out of the reach of children.

General information about SUSTIVA

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use SUSTIVA for a condition for which it was not prescribed. Do not give SUSTIVA to other people, even if they have the same symptoms that you have. It may harm them.

If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about SUSTIVA that is written for health professionals. For more information, go to www.sustiva.com or call 1-800-321-1335.

What are the ingredients in SUSTIVA?

Active ingredient: efavirenz

Inactive ingredients:

SUSTIVA capsules: lactose monohydrate, magnesium stearate, sodium lauryl sulfate, and sodium starch glycolate. The capsule shell contains gelatin, sodium lauryl sulfate, titanium dioxide, and/or yellow iron oxide. The capsule shell may also contain silicon dioxide. The capsules are printed with ink containing carmine 40 blue, FD&C Blue No. 2, and titanium dioxide.

SUSTIVA tablets: croscarmellose sodium, hydroxypropyl cellulose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and sodium lauryl sulfate. The tablet film coating contains Opadry Yellow and Opadry Clear. The tablets are polished with carnauba wax and printed with purple ink, Opacode WB.

This Patient Information has been approved by the U.S. Food and Drug Administration.

Distributed by:
Bristol-Myers Squibb Company
Princeton, NJ 08543 USA

[print code] Revised: October 2019

SUSTIVA is a registered trademark of Bristol-Myers Squibb Pharma Company. ATRIPLA is a registered trademark of Bristol-Myers Squibb & Gilead Sciences, LLC.

ZEPATIER is a registered trademark of Merck Sharp & Dohme Corp.

Instructions for Use

SUSTIVA® (sus-TEE-vah)
(efavirenz)
capsules

Preparing a dose of SUSTIVA using the capsule sprinkle method

Read this Instructions for Use before you prepare your first dose of SUSTIVA mixed with food or infant formula using the capsule sprinkle method, each time you get a refill, and as needed. There may be new information. This information does not take the place of talking to your doctor about your medical condition or treatment. Ask your doctor or pharmacist if you have any questions about how to mix or give a dose of SUSTIVA using the capsule sprinkle method.

Important Information:

For more information about SUSTIVA capsules, see the Patient Information leaflet.
The capsule sprinkle method for mixing the contents of SUSTIVA capsules with soft food or infant formula may be used for adults or children who cannot swallow capsules or tablets.
You should take SUSTIVA on an empty stomach at bedtime.
You should not eat for 2 hours after taking SUSTIVA mixed with food.
Babies who are old enough to swallow food should be given SUSTIVA using the capsule sprinkle method mixed with food instead of with infant formula.
Talk with your doctor to help decide the best schedule for giving your baby SUSTIVA mixed with infant formula using the capsule sprinkle method.

Preparing a dose of SUSTIVA mixed with food using the capsule sprinkle method.

Before you prepare a dose of SUSTIVA mixed with food using the capsule sprinkle method, gather the following supplies:

paper towels
teaspoon for measuring
small spoon for stirring and feeding
small clean container (such as a small cup or bowl)
soft food such as applesauce, grape jelly, or yogurt

Step 1. Choose a clean, flat work surface. Place a clean paper towel on the work surface. Then place the other supplies on the paper towel.

Step 2. Wash and dry your hands well.

Step 3. Place 1 to 2 teaspoons of soft food such as applesauce, grape jelly, or yogurt in the small container (see Figure A). The color and thickness of the food may change when mixed with the medicine.	Figure A

Step 4. There are 2 parts of the SUSTIVA capsule. Look at the SUSTIVA capsule to see which part of the capsule overlaps the other part (see Figure B).	Figure B

Step 5. Hold the SUSTIVA capsule in a sideways (horizontal) position directly over the container of food. Hold each end of the SUSTIVA capsule between your thumbs and index (pointer) fingers (see Figure C).	Figure C

Step 6. Use your thumb and index finger to pinch near the end of the overlapping part of the SUSTIVA capsule (see Figure D).	Figure D

Then, carefully twist both ends of the SUSTIVA capsule in opposite directions to open it (see Figure E). Be careful not to spill the capsule contents or spread it in the air.	Figure E

Step 7. Sprinkle the contents of the SUSTIVA capsule onto the food (see Figure F). Check the capsule shells to make sure they are empty. Throw away the empty capsule shells.	Figure F

If the total prescribed dose is more than 1 capsule, follow Steps 4 through 7 for each capsule. Do not add more food.

Steps 8 through 11 should be completed within 30 minutes of mixing the medicine (see Figure G).	Figure G

Step 8. Use the small spoon to gently mix the capsule contents and food together (see Figure H). Sprinkles will not dissolve. Mixture will look grainy but should not be lumpy.	Figure H

Step 9. Use the small spoon to give or take the food and capsule contents mixture. Make sure that all of the mixture is swallowed.

Step 10. Add about 2 teaspoons more of the food to the empty container and gently stir with the small spoon to mix with any capsule contents that may still be in the container.

Step 11. Use the small spoon to give or take the food and capsule contents mixture. Make sure all of the mixture is swallowed.

Step 12. Wash the container and spoons. Throw away the paper towel and clean the work surface. Wash your hands.

Preparing a dose of SUSTIVA mixed with infant formula using the capsule sprinkle method

To make sure that your baby gets all of the medicine, do not give SUSTIVA capsule contents to your baby in a bottle.

Before you prepare a dose of SUSTIVA mixed with infant formula using the capsule sprinkle method, gather the following supplies:
paper towels teaspoon for stirring and measuring small clean container (such as a small cup or bowl) (see Figure I). 10 mL oral dosing syringe (ask your pharmacist for this) (see Figure I). infant formula at room temperature.	Figure I

Step 1. Prepare the infant formula according to the directions on the infant formula package. You will use about 1 ounce of the formula to give the medicine. Any remaining formula should not be given to the child for 2 hours.

Step 2. Choose a clean, flat work surface. Place a clean paper towel on the work surface. Place the supplies you will need on the paper towel.

Step 3. Wash and dry your hands well.

Step 4. Pour 2 teaspoons of room temperature infant formula into the container (see Figure J).	Figure J

Step 5. There are 2 parts of the SUSTIVA capsule. Look at the SUSTIVA capsule to see which part of the capsule overlaps the other part (see Figure K).	Figure K

Step 6. Hold the SUSTIVA capsule in a sideways (horizontal) position directly over the container with the infant formula. Hold each end of the SUSTIVA capsule between your thumbs and index (pointer) fingers (see Figure L).	Figure L

Step 7. Use your thumb and index finger to pinch near the end of the overlapping part of the SUSTIVA capsule (see Figure M).	Figure M

Then, carefully twist both ends of the SUSTIVA capsule in opposite directions to open it (see Figure N). Be careful not to spill the capsule contents or spread it in the air.	Figure N

Step 8. Sprinkle the contents of the SUSTIVA capsule onto the infant formula (see Figure O). Check the capsule shells to make sure they are empty. Throw away the empty capsule shells.	Figure O

If the total prescribed dose is more than 1 capsule, follow Steps 5 through 8 for each capsule. Do not add more infant formula.

Steps 9 through 12 should be completed within 30 minutes of mixing the medicine (see Figure P).	Figure P

Step 9. Hold the container with one hand. With your other hand, use the teaspoon to gently mix the capsule contents and the infant formula (see Figure Q). Sprinkles will not dissolve. Mixture will look grainy but should not be lumpy.	Figure Q

Step 10. To draw up all of the mixture into the oral dosing syringe: •Check that the plunger is completely pushed into barrel of the syringe (see Figure R).	Figure R

•Place the tip of the syringe into the mixture in the container (see Figure S).	Figure S

•Slowly pull back on the plunger and draw up all of the mixture (see Figure T).	Figure T

Step 11. Place the tip of the syringe in your baby’s mouth along the inner cheek (see Figure U). Slowly push on the plunger to give your baby all of the mixture.	Figure U

Step 12. To make sure all of the medicine is given to your baby: Repeat Step 4 above. Stir with a teaspoon. Then, repeat Steps 10 and 11 above (see Figure V).	Figure V
Step 13. Remove the plunger from the oral dosing syringe. Wash the container, teaspoon, and oral dosing syringe. Allow the plunger and the syringe barrel to dry before putting them back together.

Step 14. Throw away the paper towel and clean the work surface. Wash your hands.

How should I store SUSTIVA capsules?

•Store SUSTIVA capsules at room temperature between 68°F to 77°F (20°C to 25°C).

Keep SUSTIVA capsules and all medicines out of the reach of children.

This Instructions for Use has been approved by the U.S. Food and Drug Administration.

Distributed by:

Bristol-Myers Squibb Company
Princeton, NJ 08543 USA

[print code]

Revised: October 2017

SUSTIVA 50 mg capsules Representative Packaging

See How Supplied section for a complete list of available packages of SUSTIVA.

NDC 0056-0470-30 30 Capsules
SUSTIVA® Rx only
(efavirenz) capsules50 mg
Each capsule contains 50 mg of efavirenz.
DOSAGE: For dosage and full prescribing
information, read accompanying package
insert.
Note to pharmacist: Do not cover
ALERT box with pharmacy label.
ALERT: Find out about medicines that
should NOT be taken with SUSTIVA®

SUSTIVA 200 mg capsules Representative Packaging

NDC 0056-0474-92 90 Capsules
SUSTIVA® Rx only
(efavirenz) capsules200 mg
Each capsule contains 200 mg of efavirenz.
DOSAGE: For dosage and full prescribing information,
read accompanying package insert.
Note to pharmacist: Do not cover ALERT box with
pharmacy label.
ALERT: Find out about medicines that
should NOT be taken with SUSTIVA®

SUSTIVA 600 mg tablets Representative Packaging

NDC 0056-0510-30 30 Tablets
SUSTIVA® Rx only
(efavirenz) tablets600 mg
Each tablet contains 600 mg of efavirenz.
DOSAGE: For dosage and full prescribing
information, read accompanying package
insert.
Note to pharmacist: Do not cover
ALERT box with pharmacy label.
ALERT: Find out about medicines that
should NOT be taken with SUSTIVA®

SUSTIVA
efavirenz capsule, gelatin coated

Product Information
Product Type		Item Code (Source)	0056-0470
Route of Administration	ORAL	DEA Schedule

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
efavirenz (efavirenz)	efavirenz	50 mg

Inactive Ingredients
Ingredient Name	Strength
lactose monohydrate
magnesium stearate
sodium lauryl sulfate
sodium starch glycolate type A potato
GELATIN, UNSPECIFIED
titanium dioxide
ferric oxide yellow
silicon dioxide
FD&C Blue No. 2

Product Characteristics
Color	white (white) , yellow (gold)	Score	no score
Shape	CAPSULE (capsule)	Size	14mm
Flavor		Imprint Code	SUSTIVA;50mg
Contains

Packaging
#	Item Code	Package Description	Multilevel Packaging
1	0056-0470-30	30 CAPSULE, GELATIN COATED in 1 BOTTLE	None

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
NDA	NDA020972	09/17/1998

SUSTIVA
efavirenz capsule, gelatin coated

Product Information
Product Type		Item Code (Source)	0056-0474
Route of Administration	ORAL	DEA Schedule

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
efavirenz (efavirenz)	efavirenz	200 mg

Inactive Ingredients
Ingredient Name	Strength
lactose monohydrate
magnesium stearate
sodium lauryl sulfate
sodium starch glycolate type A potato
GELATIN, UNSPECIFIED
titanium dioxide
ferric oxide yellow
silicon dioxide
FD&C Blue No. 2

Product Characteristics
Color	yellow (gold)	Score	no score
Shape	CAPSULE (capsule)	Size	22mm
Flavor		Imprint Code	SUSTIVA;200mg
Contains

Packaging
#	Item Code	Package Description	Multilevel Packaging
1	0056-0474-92	90 CAPSULE, GELATIN COATED in 1 BOTTLE	None

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
NDA	NDA020972	09/17/1998

SUSTIVA
efavirenz tablet, film coated

Product Information
Product Type		Item Code (Source)	0056-0510
Route of Administration	ORAL	DEA Schedule

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
efavirenz (efavirenz)	efavirenz	600 mg

Inactive Ingredients
Ingredient Name	Strength
croscarmellose sodium
HYDROXYPROPYL CELLULOSE (1600000 WAMW)
lactose monohydrate
magnesium stearate
MICROCRYSTALLINE CELLULOSE
sodium lauryl sulfate
carnauba wax

Product Characteristics
Color	yellow (yellow)	Score	no score
Shape	OVAL (capsule-shaped)	Size	19mm
Flavor		Imprint Code	SUSTIVA;SUSTIVA
Contains

Packaging
#	Item Code	Package Description	Multilevel Packaging
1	0056-0510-30	30 TABLET, FILM COATED in 1 BOTTLE	None

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
NDA	NDA021360	01/02/2002

Labeler - Bristol-Myers Squibb Pharma Company (830615030)

Revised: 10/2019 Bristol-Myers Squibb Pharma Company

Drug Database: Efavirenz

Drug information

HighlightsHIGHLIGHTS OF PRESCRIBING INFORMATION

RECENT MAJOR CHANGES

INDICATIONS AND USAGE

DOSAGE AND ADMINISTRATION

DOSAGE FORMS AND STRENGTHS

CONTRAINDICATIONS

WARNINGS AND PRECAUTIONS

ADVERSE REACTIONS

DRUG INTERACTIONS

USE IN SPECIFIC POPULATIONS

FULL PRESCRIBING INFORMATION

Indications & Usage1 INDICATIONS AND USAGE

Dosage & Administration2 DOSAGE AND ADMINISTRATION

Dosage & Administration2.1 Hepatic Function

2.2 Adults

Dosage & Administration2.3 Pediatric Patients

Dosage & Administration2.4 Capsule Sprinkle Method of Administration

3 DOSAGE FORMS AND STRENGTHS

Contraindications4 CONTRAINDICATIONS

Contraindications

5 WARNINGS AND PRECAUTIONS

5.1 Drug Interactions

5.2 QTc Prolongation

5.3 Resistance

5.4 Coadministration with Related Products

5.5 Psychiatric Symptoms

5.6 Nervous System Symptoms

5.7 Embryo-Fetal Toxicity

5.8 Rash

5.9 Hepatotoxicity

5.10 Convulsions

5.11 Lipid Elevations

5.12 Immune Reconstitution Syndrome

5.13 Fat Redistribution

Adverse Reactions6 ADVERSE REACTIONS

Adverse Reactions6.1 Clinical Trials Experience

Adverse ReactionsAdverse Reactions in Adults

Adverse ReactionsNervous System Symptoms

Adverse ReactionsPsychiatric Symptoms

Adverse ReactionsRash

Adverse ReactionsLaboratory Abnormalities

Adverse ReactionsPatients Coinfected with Hepatitis B or C

Adverse ReactionsLipids

Adverse ReactionsAdverse Reactions in Pediatric Patients

Adverse Reactions6.2 Postmarketing Experience

7 DRUG INTERACTIONS

7.1 Potential for SUSTIVA to Affect other Drugs

7.2 Potential for Other Drugs to Affect SUSTIVA

7.3 QT Prolonging Drugs

7.4 Established and Other Potentially Significant Drug Interactions

7.5 Drugs Without Clinically Significant Interactions with SUSTIVA

7.6 Cannabinoid Test Interaction

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

Data

Human Data

Animal Data

8.2 Lactation

Risk Summary

8.3 Females and Males of Reproductive Potential

Pregnancy Testing

Contraception

8.4 Pediatric Use

8.5 Geriatric Use

8.6 Hepatic Impairment

Overdosage10 OVERDOSAGE

Description11 DESCRIPTION

Clinical Pharmacology12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

12.2 Pharmacodynamics

Cardiac Electrophysiology

12.3 Pharmacokinetics

Absorption

Effect of Food on Oral Absorption:

Distribution

Metabolism

Elimination

Highlights HIGHLIGHTS OF PRESCRIBING INFORMATION

Indications & Usage 1 INDICATIONS AND USAGE

Dosage & Administration 2 DOSAGE AND ADMINISTRATION

Dosage & Administration 2.1 Hepatic Function

Dosage & Administration 2.3 Pediatric Patients

Dosage & Administration 2.4 Capsule Sprinkle Method of Administration

Contraindications 4 CONTRAINDICATIONS

Adverse Reactions 6 ADVERSE REACTIONS

Adverse Reactions 6.1 Clinical Trials Experience

Adverse Reactions Adverse Reactions in Adults

Adverse Reactions Nervous System Symptoms

Adverse Reactions Psychiatric Symptoms

Adverse Reactions Rash

Adverse Reactions Laboratory Abnormalities

Adverse Reactions Patients Coinfected with Hepatitis B or C

Adverse Reactions Lipids

Adverse Reactions Adverse Reactions in Pediatric Patients

Adverse Reactions 6.2 Postmarketing Experience

Overdosage 10 OVERDOSAGE

Description 11 DESCRIPTION

Clinical Pharmacology 12 CLINICAL PHARMACOLOGY

How Supplied 16 HOW SUPPLIED/STORAGE AND HANDLING

How Supplied 16.1 Capsules

How Supplied 16.2 Tablets

Patient Counseling Information 17 PATIENT COUNSELING INFORMATION

Patient Package Insert Patient Information