Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Edurant: 25 mg
Pharmacology
Mechanism of Action
As a non-nucleoside reverse transcriptase inhibitor, rilpivirine has activity against HIV-1 by binding to reverse transcriptase. It consequently blocks the RNA-dependent and DNA-dependent DNA polymerase activities, including HIV-1 replication. It does not require intracellular phosphorylation for antiviral activity.
Pharmacokinetics/Pharmacodynamics
Absorption
Increased 40% with a meal (normal-to-high calorie)
Metabolism
Hepatic, primarily by CYP3A4
Excretion
Feces (85%, ~25% as unchanged drug); urine (~6%; <1% as unchanged drug)
Time to Peak
Plasma: 4 to 5 hours
Half-Life Elimination
~50 hours
Protein Binding
99.7% (primarily albumin)
Use in Specific Populations
Special Populations: Renal Function Impairment
Exposure was similar in HIV-1-infected subjects with mild renal impairment relative to HIV-1–infected subjects with healthy renal function; no dose adjustment is required. There is limited information regarding the pharmacokinetics in patients with moderate or severe renal impairment or in patients with ESRD. Concentrations may be increased because of alteration of drug absorption, distribution, and metabolism secondary to renal dysfunction. The potential impact is not expected to be of clinical relevance for subjects with moderate renal impairment; no dose adjustment is required.
Special Populations: Hepatic Function Impairment
The multiple-dose exposure was 47% higher in subjects with mild hepatic impairment and 5% higher in subjects with moderate hepatic impairment; no dose adjustment is required. Rilpivirine has not been studied in subjects with severe hepatic impairment.
Use: Labeled Indications
HIV-1 infection: Treatment of HIV-1 infections in antiretroviral treatment-naive patients ≥12 years of age and weighing ≥35 kg, with HIV-1 RNA ≤100,000 copies/mL at the start of therapy in combination with other antiretroviral agents
Contraindications
Coadministration with anticonvulsants (carbamazepine, oxcarbazepine, phenobarbital, phenytoin), antimycobacterials (rifampin, rifapentine), proton pump inhibitors (esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole), systemic dexamethasone (more than a single dose), or St John's wort.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to rilpivirine or any component of the formulation
Dosage and Administration
Dosing: Adult
HIV-1 infection, treatment: Patients ≥35 kg: Oral: 25 mg once daily.
Pregnancy: 25 mg once daily in patients on stable regimen prior to pregnancy and who are virologically suppressed
Dosage adjustment for concomitant therapy with rifabutin: Increase to 50 mg once daily in patients on concomitant rifabutin. Decrease to 25 mg once daily when rifabutin is stopped.
Dosing: Pediatric
HIV-1 infection, treatment: Use in combination with other antiretroviral agents.
Infants and Children <12 years or <35 kg: Not recommended for use; no dosing recommendations available
Children and Adolescents ≥12 years and ≥35 kg: Oral: 25 mg once daily
Dosage adjustment for concomitant therapy with rifabutin: Children ≥12 years and Adolescents: Increase to 50 mg once daily in patients on concomitant rifabutin. Decrease to 25 mg once daily when rifabutin is stopped.
Administration
Swallow tablet whole with water. Administer with a normal- to high-calorie meal. Taking with a protein supplement drink alone does not increase absorption.
Dietary Considerations
Take with a normal- to high-calorie meal. Taking with a protein supplement drink alone does not increase absorption.
Storage
Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Keep in original container; protect from light.
Drug Interactions
Antacids: May decrease the serum concentration of Rilpivirine. Management: Administer antacids at least 2 hours before or 4 hours after rilpivirine. Administer antacids at least 6 hours before or 4 hours after the rilpivirine/dolutegravir combination product. Consider therapy modification
Antihepaciviral Combination Products: May increase the serum concentration of Rilpivirine. Avoid combination
Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
CarBAMazepine: May decrease the serum concentration of Rilpivirine. Avoid combination
CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Rilpivirine. Monitor therapy
Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification
Darunavir: May increase the serum concentration of Rilpivirine. Monitor therapy
Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
DexAMETHasone (Systemic): May decrease the serum concentration of Rilpivirine. Avoid combination
Didanosine: Rilpivirine may decrease the absorption of Didanosine. More specifically, simultaneous coadministration of these drugs creates a conflict between recommendations to administer with (rilpivirine) and without (didanosine) food. Didanosine may decrease the absorption of Rilpivirine. More specifically, simultaneous coadministration of these drugs creates a conflict between recommendations to administer with (rilpivirine) and without (didanosine) food. Management: Administer didanosine on an empty stomach at least 2 hours before or 4 hours after rilpivirine, due to the requirement that rilpivirine be administered with food. Consider therapy modification
Efavirenz: Reverse Transcriptase Inhibitors (Non-Nucleoside) may increase the serum concentration of Efavirenz. Reverse Transcriptase Inhibitors (Non-Nucleoside) may decrease the serum concentration of Efavirenz. Avoid combination
Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification
Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Ergonovine: Reverse Transcriptase Inhibitors (Non-Nucleoside) may increase the serum concentration of Ergonovine. Specifically, this would be most likely with delavrdine, while other Non-Nucleoside Reverse Transcriptase Inhibitors may be more likely to decrease the concentration of Ergonovine. Avoid combination
Etravirine: Reverse Transcriptase Inhibitors (Non-Nucleoside) may decrease the serum concentration of Etravirine. This has been observed with the NNRTIs efavirenz and nevirapine. Reverse Transcriptase Inhibitors (Non-Nucleoside) may increase the serum concentration of Etravirine. This has been observed with delavirdine. Avoid combination
Fosphenytoin: May decrease the serum concentration of Rilpivirine. Avoid combination
Haloperidol: QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of Haloperidol. Monitor therapy
Histamine H2 Receptor Antagonists: May decrease the serum concentration of Rilpivirine. Management: Administer histamine H2 receptor antagonists at least 12 hours before or 4 hours after rilpivirine. Consider therapy modification
Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Ketoconazole (Systemic): May increase the serum concentration of Rilpivirine. Rilpivirine may decrease the serum concentration of Ketoconazole (Systemic). Monitor therapy
Levomethadone: Reverse Transcriptase Inhibitors (Non-Nucleoside) may decrease the serum concentration of Levomethadone. Management: Levomethadone dosage adjustments will likely be required with efavirenz and nevirapine, and may be necessary with rilpivirine as well. Monitor therapy
Lopinavir: May increase the serum concentration of Rilpivirine. Monitor therapy
Lorlatinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Avoid concurrent use of lorlatinib with any CYP3A4 substrates for which a minimal decrease in serum concentrations of the CYP3A4 substrate could lead to therapeutic failure and serious clinical consequences. Consider therapy modification
Macrolide Antibiotics: May increase the serum concentration of Rilpivirine. Management: Consider the use of azithromycin or another non-macrolide alternative when appropriate to avoid this potential interaction. Exceptions: Azithromycin (Systemic); Fidaxomicin; Roxithromycin; Spiramycin. Consider therapy modification
Methadone: Reverse Transcriptase Inhibitors (Non-Nucleoside) may increase the metabolism of Methadone. Management: Methadone dosage adjustments will likely be required with efavirenz and nevirapine, and may be necessary with rilpivirine as well. Monitor therapy
Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification
Orlistat: May decrease the serum concentration of Antiretroviral Agents. Monitor therapy
OXcarbazepine: May decrease the serum concentration of Rilpivirine. Avoid combination
PHENobarbital: May decrease the serum concentration of Rilpivirine. Avoid combination
Phenytoin: May decrease the serum concentration of Rilpivirine. Avoid combination
Primidone: May decrease the serum concentration of Rilpivirine. Avoid combination
Proton Pump Inhibitors: May decrease the serum concentration of Rilpivirine. Avoid combination
QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Monitor therapy
Reverse Transcriptase Inhibitors (Non-Nucleoside): May increase the serum concentration of Rilpivirine. This mechanism applies to coadministration of delavirdine. Reverse Transcriptase Inhibitors (Non-Nucleoside) may decrease the serum concentration of Rilpivirine. This mechanism applies to coadministration of efavirenz, etravirine, and nevirapine. Avoid combination
Rifabutin: May decrease the serum concentration of Rilpivirine. Management: Increase the rilpivirine adult dose to 50 mg/day during rifabutin treatment. Decrease back to 25 mg/day following rifabutin discontinuation. Use of rifabutin with the emtricitabine/rilpivirine/tenofovir alafenamide combination product is not recommended. Consider therapy modification
Rifamycin Derivatives: May decrease the serum concentration of Rilpivirine. Exceptions: Rifabutin. Avoid combination
Saquinavir: May enhance the arrhythmogenic effect of Rilpivirine. Saquinavir may increase the serum concentration of Rilpivirine. Avoid combination
Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
St John's Wort: May decrease the serum concentration of Reverse Transcriptase Inhibitors (Non-Nucleoside). Specifically, St. Johns Wort may increase the metabolism of Reverse Transcriptase Inhibitors (Non-Nucleoside). Avoid combination
Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Adverse Reactions
>10%:
Central nervous system: Depression (5% to 9%; children and adolescents: 19%), headache (3%; children and adolescents: 19%), drowsiness (children and adolescents: 14%)
Endocrine & metabolic: Decreased plasma cortisol (7%; children and adolescents: 20%; decrease from baseline via ACTH stimulation test; clinical significance is unknown), increased serum cholesterol (7% to 17%), increased LDL cholesterol (5% to 14%)
Gastrointestinal: Nausea (1%; children and adolescents: 11%)
Hepatic: Increased serum ALT (1% to 18%), increased serum AST (1% to 16%)
1% to 10%:
Central nervous system: Dizziness (1%; children and adolescents: 8%), insomnia (3%), abnormal dreams (2%), fatigue (2%)
Dermatologic: Skin rash (3% to 6%)
Endocrine & metabolic: Increased serum triglycerides (2%)
Gastrointestinal: Abdominal pain (2%; children and adolescents: 8%), vomiting (1%; children and adolescents: 6%)
Hepatic: Increased serum bilirubin (1% to 5%)
Renal: Increased serum creatinine (1% to 6%)
<1%, postmarketing, and/or case reports (Limited to important or life-threatening): Angioedema, conjunctivitis, DRESS syndrome, facial edema, fever, hepatitis, hypersensitivity reaction, localized vesiculation, nephrotic syndrome, suicidal ideation
Warnings/Precautions
Concerns related to adverse effects:
- Depressive disorders: May cause depression, depressed mood, dysphoria, mood changes, negative thoughts, suicide attempts, or suicidal ideation; if changes are noted, seek professional intervention immediately; reevaluate risk versus benefit of continued rilpivirine therapy.
- Fat redistribution: May cause redistribution of fat (eg, buffalo hump, peripheral wasting with increased abdominal girth, cushingoid appearance).
- Hepatotoxicity: Has been reported during use. Patients with significant transaminase elevations or hepatitis B or C prior to treatment may be at greater risk for hepatic adverse events. Hepatotoxicity has occurred in a few adult patients with no prior hepatic disease or risk factors. Baseline and periodic laboratory LFT evaluation during therapy is recommended for patients with pre-existing risk factors; also consider LFT monitoring in patients without identifiable hepatic disease risk.
- Hypersensitivity: Hypersensitivity and severe skin reactions have been reported, including severe rash or rash accompanied by fever, blisters, mucosal involvement, conjunctivitis, facial edema, angioedema, hepatitis or eosinophilia, or drug reaction with eosinophilia and systemic symptoms (DRESS) with rilpivirine-containing regimens. Some skin reactions were accompanied by constitutional symptoms (eg, fever); other skin reactions were associated with organ dysfunction (eg, hepatic serum biochemistry elevations). In clinical trials, treatment-related rashes ≥ Grade 2 were reported in 3% of patients. Most rashes were Grade 1 or 2 and occurred within the first 4 to 6 weeks of therapy. No Grade 4 rashes were reported. Monitor laboratory parameters and clinical status; discontinue if any hypersensitivity or skin rash develop.
- Immune reconstitution syndrome: Patients may develop immune reconstitution syndrome resulting in the occurrence of an inflammatory response to an indolent or residual opportunistic infection during initial HIV treatment or activation of autoimmune disorders (eg, Graves’ disease, polymyositis, Guillain-Barré syndrome) later in therapy; further evaluation and treatment may be required.
Concurrent drug therapy issues:
- Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
- QTc prolongation: Doses >25 mg daily (ie, 75 mg daily, 300 mg daily) have been associated with QTc prolongation; use caution when coadministering with a drug with a known risk of torsades de pointes (HHS [adult] 2015).
Other warnings/precautions:
- Appropriate use: Do not use in adolescent and adult HIV-1 patients with a pre-ART of CD4 count <200 cells/mm3 and/or HIV RNA >100,000 copies/mL (HHS [adult] 2015).
Monitoring Parameters
Cholesterol, triglycerides, hepatic transaminases; signs of skin rash, fever, and/or hypersensitivity reactions, signs and symptoms of infection
Pregnancy
Pregnancy Considerations
Rilpivirine has moderate to high placental transfer.
No increased risk of overall birth defects has been observed following first trimester exposure according to data collected by the antiretroviral pregnancy registry. Maternal antiretroviral therapy (ART) may be associated with adverse pregnancy outcomes including preterm delivery, stillbirth, low birth weight, and small for gestational age infants. Actual risks may be influenced by maternal factors, such as disease severity, gestational age at initiation of therapy, and specific ART regimen; therefore, close fetal monitoring is recommended. Because there is clear benefit to appropriate treatment, maternal ART should not be withheld due to concerns for adverse neonatal outcomes. Long-term follow-up is recommended for all infants exposed to antiretroviral medications; children without HIV but who were exposed to ART in utero and develop significant organ system abnormalities of unknown etiology (particularly of the CNS or heart) should be evaluated for potential mitochondrial dysfunction. Hypersensitivity reactions (including hepatic toxicity and rash) are more common in women on nonneucleoside reverse transcriptase inhibitor therapy; it is not known if pregnancy increases this risk.
The Health and Human Services (HHS) perinatal HIV guidelines consider rilpivirine an alternative ART for pregnant females living with HIV who are antiretroviral naive, who have had ART therapy in the past but are restarting, who require a new ART regimen (due to poor tolerance or poor virologic response of current regimen), and who are not yet pregnant but are trying to conceive. Females who become pregnant while taking rilpivirine may continue if viral suppression is effective and the regimen is well tolerated. The pharmacokinetics are highly variable in pregnancy; data are insufficient to recommend pregnancy-specific dosing; however, viral loads should be monitored more frequently when standard doses are used in pregnant females.
The HHS perinatal HIV guidelines recommend rilpivirine as a component in alternative regimens for initial use in antiretroviral-naive pregnant females with a pretreatment HIV RNA ≤100,000 copies/mL and CD4 cell count ≥200 cells/mm3.
In general, ART is recommended for all pregnant females living with HIV to keep the viral load below the limit of detection and reduce the risk of perinatal transmission. Therapy should be individualized following a discussion of the potential risks and benefits of treatment during pregnancy. Monitoring of pregnant females is more frequent than in nonpregnant adults. ART should be continued postpartum for all females living with HIV and can be modified after delivery.
Health care providers are encouraged to enroll pregnant females exposed to antiretroviral medications as early in pregnancy as possible in the Antiretroviral Pregnancy Registry (1-800-258-4263 or http://www.APRegistry.com). Health care providers caring for pregnant females living with HIV and their infants may contact the National Perinatal HIV Hotline (1-888-448-8765) for clinical consultation (HHS [perinatal] 2019).
Patient Education
What is this drug used for?
- It is used to treat HIV infection.
Frequently reported side effects of this drug
- Nausea
- Vomiting
- Dizziness
- Abdominal pain
- Fatigue
- Headache
- Trouble sleeping
Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:
- Behavioral changes
- Mood changes
- Infection
- Depression like thoughts of suicide, anxiety, emotional instability, or confusion
- Liver problems like dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin.
- Abnormal heartbeat
- Change in body fat
- Severe skin problems like red, blistered, or swollen skin; peeling skin; itchy or painful skin
- Eye irritation
- Eye redness
- Difficulty swallowing
- Severe abdominal pain
- Sores in mouth, throat, nose, or eyes
- Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.
