VIREAD ACCESS- tenofovir disoproxil fumarate tablet, coated

Viread Access by

Drug Labeling and Warnings

Viread Access by is a Prescription medication manufactured, distributed, or labeled by Gilead Sciences, Inc.. Drug facts, warnings, and ingredients follow.

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  • BOXED WARNING (What is this?)

    WARNING: POSTTREATMENT EXACERBATION OF HEPATITIS

    Severe acute exacerbations of hepatitis have been reported in HBV-infected patients who have discontinued anti-hepatitis B therapy, including VIREAD. Hepatic function should be monitored closely with both clinical and laboratory follow-up for at least several months in patients who discontinue anti-hepatitis B therapy, including VIREAD. If appropriate, resumption of anti-hepatitis B therapy may be warranted [See Warnings and Precautions (5.1)].

  • 1 INDICATIONS AND USAGE

    1.1 HIV-1 Infection

    VIREAD™ is indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients 12 years of age and older.

    The following points should be considered when initiating therapy with VIREAD for the treatment of HIV-1 infection:

    • VIREAD should not be used in combination with ATRIPLA™, BIKTARVY™ COMPLERA™, DESCOVY™, GENVOYA™, ODEFSEY™, STRIBILD™, TRUVADA™ or VEMLIDY™ [See Warnings and Precautions (5.4)].

    1.2 Chronic Hepatitis B

    VIREAD is indicated for the treatment of chronic hepatitis B in adults and pediatric patients 12 years of age and older.

    The following points should be considered when initiating therapy with VIREAD for the treatment of chronic hepatitis B infection:

    • The indication in adults is based on safety and efficacy data from treatment of subjects who were nucleoside-treatment-naïve and subjects who were treatment-experienced with documented resistance to lamivudine. Subjects were adults with HBeAg-positive and HBeAg-negative chronic hepatitis B with compensated liver disease [See Clinical Studies (14.2)].
    • VIREAD was evaluated in a limited number of subjects with chronic hepatitis B and decompensated liver disease [See Adverse Reactions (6.1), Clinical Studies (14.2)].
    • The numbers of subjects in clinical trials who had adefovir resistance-associated substitutions at baseline were too small to reach conclusions of efficacy [See Microbiology (12.4), Clinical Studies (14.2)].
  • 2 DOSAGE AND ADMINISTRATION

    2.1 Recommended Dose in Adults and Pediatric Patients 12 Years of Age and Older (35 kg or more)

    For the treatment of HIV-1 or chronic hepatitis B: The dose is one 300 mg VIREAD tablet once daily taken orally, without regard to food.

    In the treatment of chronic hepatitis B, the optimal duration of treatment is unknown. Safety and efficacy in pediatric patients less than 12 years of age or weighing less than 35 kg have not been established.

    2.2 Dose Adjustment for Renal Impairment in Adults

    Significantly increased drug exposures occurred when VIREAD was administered to subjects with moderate to severe renal impairment [See Clinical Pharmacology (12.3)]. Therefore, the dosing interval of VIREAD should be adjusted in patients with baseline creatinine clearance below 50 mL/min using the recommendations in Table 1. These dosing interval recommendations are based on modeling of single-dose pharmacokinetic data in non-HIV and non-HBV infected subjects with varying degrees of renal impairment, including end-stage renal disease requiring hemodialysis. The safety and effectiveness of these dosing interval adjustment recommendations have not been clinically evaluated in patients with moderate or severe renal impairment; therefore, clinical response to treatment and renal function should be closely monitored in these patients [See Warnings and Precautions (5.2)].

    No dose adjustment is necessary for patients with mild renal impairment (creatinine clearance 50–80 mL/min). Routine monitoring of estimated creatinine clearance, serum phosphorus, urine glucose, and urine protein should be performed in patients with mild renal impairment [See Warnings and Precautions (5.2)].

    Table 1 Dosage Adjustment for Patients with Altered Creatinine Clearance
    Creatinine Clearance
    (mL/min)*    		Hemodialysis Patients
    50 or greater30–4910–29
  • * Calculated using ideal (lean) body weight.
  • † Generally once weekly assuming three hemodialysis sessions a week of approximately 4 hours duration. VIREAD should be administered following completion of dialysis.
    		•
    Recommended 300 mg Dosing IntervalEvery 24 hoursEvery 48 hoursEvery 72 to 96 hoursEvery 7 days or after a total of approximately 12 hours of dialysis†

    The pharmacokinetics of tenofovir have not been evaluated in non-hemodialysis patients with creatinine clearance below 10 mL/min; therefore, no dosing recommendation is available for these patients.

    No data are available to make dose recommendations in pediatric patients 12 years of age and older with renal impairment.

  • 3 DOSAGE FORMS AND STRENGTHS

    VIREAD is available as tablets. Each tablet contains 300 mg of tenofovir DF, which is equivalent to 245 mg of tenofovir disoproxil. The tablets are almond shaped, white, film coated, and debossed with "GILEAD" and "4331" on one side.

  • 4 CONTRAINDICATIONS

    None.

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Exacerbation of Hepatitis after Discontinuation of Treatment

    Discontinuation of anti-HBV therapy, including VIREAD, may be associated with severe acute exacerbations of hepatitis. Patients infected with HBV who discontinue VIREAD should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping treatment. If appropriate, resumption of anti-hepatitis B therapy may be warranted.

    5.2 New Onset or Worsening Renal Impairment

    Tenofovir is principally eliminated by the kidney. Renal impairment, including cases of acute renal failure and Fanconi syndrome (renal tubular injury with severe hypophosphatemia), has been reported with the use of VIREAD [See Adverse Reactions (6.2)].

    It is recommended that estimated creatinine clearance be assessed in all patients prior to initiating therapy and as clinically appropriate during therapy with VIREAD. In patients at risk of renal dysfunction, including patients who have previously experienced renal events while receiving HEPSERA™, it is recommended that estimated creatinine clearance, serum phosphorus, urine glucose, and urine protein be assessed prior to initiation of VIREAD, and periodically during VIREAD therapy.

    Dosing interval adjustment of VIREAD and close monitoring of renal function are recommended in all patients with creatinine clearance below 50 mL/min [See Dosage and Administration (2.2)]. No safety or efficacy data are available in patients with renal impairment who received VIREAD using these dosing guidelines, so the potential benefit of VIREAD therapy should be assessed against the potential risk of renal toxicity.

    VIREAD should be avoided with concurrent or recent use of a nephrotoxic agent (e.g., high-dose or multiple non-steroidal anti-inflammatory drugs (NSAIDs)) [See Drug Interactions (7.1)]. Cases of acute renal failure after initiation of high dose or multiple NSAIDs have been reported in HIV-infected patients with risk factors for renal dysfunction who appeared stable on tenofovir DF. Some patients required hospitalization and renal replacement therapy. Alternatives to NSAIDs should be considered, if needed, in patients at risk for renal dysfunction.

    Persistent or worsening bone pain, pain in extremities, fractures and/or muscular pain or weakness may be manifestations of proximal renal tubulopathy and should prompt an evaluation of renal function in at-risk patients.

    5.3 Lactic Acidosis/Severe Hepatomegaly with Steatosis

    Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogs, including tenofovir DF, alone or in combination with other antiretrovirals. Treatment with VIREAD should be suspended in any patient who develops clinical or laboratory findings suggestive of lactic acidosis or pronounced hepatotoxicity (which may include hepatomegaly and steatosis even in the absence of marked transaminase elevations).

    5.4 Coadministration with Other Products

    VIREAD should not be used in combination with other drugs containing tenofovir DF or tenofovir alafenamide, including ATRIPLA, BIKTARVY, COMPLERA, DESCOVY, GENVOYA, ODEFSEY, STRIBILD, TRUVADA or VEMLIDY.

    VIREAD should not be administered in combination with HEPSERA (adefovir dipivoxil) [See Drug Interactions (7.2)].

    5.5 Patients Coinfected with HIV-1 and HBV

    Due to the risk of development of HIV-1 resistance, VIREAD should only be used in HIV-1 and HBV coinfected patients as part of an appropriate antiretroviral combination regimen.

    HIV-1 antibody testing should be offered to all HBV-infected patients before initiating therapy with VIREAD. It is also recommended that all patients with HIV-1 be tested for the presence of chronic hepatitis B before initiating treatment with VIREAD.

    5.6 Bone Effects

    Bone Mineral Density:

    In clinical trials in HIV-1 infected adults, VIREAD was associated with slightly greater decreases in bone mineral density (BMD) and increases in biochemical markers of bone metabolism, suggesting increased bone turnover relative to comparators. Serum parathyroid hormone levels and 1,25 Vitamin D levels were also higher in subjects receiving VIREAD [See Adverse Reactions (6.1)].

    Clinical trials evaluating VIREAD in pediatric and adolescent subjects were conducted. Under normal circumstances, BMD increases rapidly in pediatric patients. In HIV-1 infected subjects aged 2 years to less than 18 years, bone effects were similar to those observed in adult subjects and suggest increased bone turnover. Total body BMD gain was less in the VIREAD-treated HIV-1 infected pediatric subjects as compared to the control groups. Similar trends were observed in chronic hepatitis B infected adolescent subjects aged 12 years to less than 18 years. In all pediatric trials, skeletal growth (height) appeared to be unaffected. [See Adverse Reactions (6.1)].

    The effects of VIREAD-associated changes in BMD and biochemical markers on long-term bone health and future fracture risk are unknown. Assessment of BMD should be considered for adults and pediatric patients 12 years of age and older who have a history of pathologic bone fracture or other risk factors for osteoporosis or bone loss. Although the effect of supplementation with calcium and vitamin D was not studied, such supplementation may be beneficial for all patients. If bone abnormalities are suspected then appropriate consultation should be obtained.

    Mineralization Defects:

    Cases of osteomalacia associated with proximal renal tubulopathy, manifested as bone pain or pain in extremities and which may contribute to fractures, have been reported in association with the use of VIREAD [See Adverse Reactions (6.2)]. Arthralgias and muscle pain or weakness have also been reported in cases of proximal renal tubulopathy. Hypophosphatemia and osteomalacia secondary to proximal renal tubulopathy should be considered in patients at risk of renal dysfunction who present with persistent or worsening bone or muscle symptoms while receiving products containing tenofovir DF [See Warnings and Precautions (5.2)].

    5.7 Immune Reconstitution Syndrome

    Immune reconstitution syndrome has been reported in HIV-infected patients treated with combination antiretroviral therapy, including VIREAD. 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 jirovecii pneumonia [PCP], or tuberculosis), which may necessitate further evaluation and treatment.

    Autoimmune disorders (such as Graves' disease, polymyositis, and Guillain-Barré syndrome) 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.

    5.8 Early Virologic Failure

    Clinical trials in HIV-infected subjects have demonstrated that certain regimens that only contain three nucleoside reverse transcriptase inhibitors (NRTI) are generally less effective than triple drug regimens containing two NRTIs in combination with either a non-nucleoside reverse transcriptase inhibitor or a HIV-1 protease inhibitor. In particular, early virological failure and high rates of resistance substitutions have been reported. Triple nucleoside regimens should therefore be used with caution. Patients on a therapy utilizing a triple nucleoside-only regimen should be carefully monitored and considered for treatment modification.

  • 6 ADVERSE REACTIONS

    The following adverse reactions are discussed in other sections of the labeling:

    6.1 Adverse Reactions from Clinical Trials Experience

    Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

    Clinical Trials in Adult Patients with HIV-1 Infection

    More than 12,000 subjects have been treated with VIREAD alone or in combination with other antiretroviral medicinal products for periods of 28 days to 215 weeks in clinical trials and expanded access programs. A total of 1544 subjects have received VIREAD 300 mg once daily in clinical trials; over 11,000 subjects have received VIREAD in expanded access programs.

    The most common adverse reactions (incidence greater than or equal to 10%, Grades 2–4) identified from any of the 3 large controlled clinical trials include rash, diarrhea, headache, pain, depression, asthenia, and nausea.

    Treatment-Naïve Patients

    Study 903 –Treatment-Emergent Adverse Reactions: The most common adverse reactions seen in a double-blind comparative controlled trial in which 600 treatment-naïve subjects received VIREAD (N=299) or stavudine (N=301) in combination with lamivudine and efavirenz for 144 weeks (Study 903) were mild to moderate gastrointestinal events and dizziness.

    Mild adverse reactions (Grade 1) were common with a similar incidence in both arms and included dizziness, diarrhea, and nausea. Selected treatment-emergent moderate to severe adverse reactions are summarized in Table 2.

    Table 2 Selected Treatment-Emergent Adverse Reactions* (Grades 2–4) Reported in ≥5% in Any Treatment Group in Study 903 (0–144 Weeks)
    VIREAD+3TC+ EFVd4T+3TC+EFV
    N=299N=301
  • * Frequencies of adverse reactions are based on all treatment-emergent adverse events, regardless of relationship to study drug.
  • † Lipodystrophy represents a variety of investigator-described adverse events not a protocol-defined syndrome.
  • ‡ Peripheral neuropathy includes peripheral neuritis and neuropathy.
  • § Rash event includes rash, pruritus, maculopapular rash, urticaria, vesiculobullous rash, and pustular rash.
    		•
    Body as a Whole
      Headache14%17%
      Pain13%12%
      Fever8%7%
      Abdominal pain7%12%
      Back pain9%8%
      Asthenia6%7%
    Digestive System
      Diarrhea11%13%
      Nausea8%9%
      Dyspepsia4%5%
      Vomiting5%9%
    Metabolic Disorders
      Lipodystrophy†1%8%
    Musculoskeletal
      Arthralgia5%7%
      Myalgia3%5%
    Nervous System
      Depression11%10%
      Insomnia5%8%
      Dizziness3%6%
      Peripheral neuropathy‡1%5%
      Anxiety6%6%
    Respiratory
      Pneumonia5%5%
    Skin and Appendages
      Rash event§18%12%

    Laboratory Abnormalities: With the exception of fasting cholesterol and fasting triglyceride elevations that were more common in the stavudine group (40% and 9%) compared with VIREAD (19% and 1%), respectively, laboratory abnormalities observed in this trial occurred with similar frequency in the VIREAD and stavudine treatment arms. A summary of Grades 3–4 laboratory abnormalities is provided in Table 3.

    Table 3 Grades 3–4 Laboratory Abnormalities Reported in ≥1% of VIREAD-Treated Subjects in Study 903 (0–144 Weeks)
    VIREAD+3TC+EFVd4T+3TC+EFV
    N=299N=301
    Any ≥ Grade 3 Laboratory Abnormality36%42%
    Fasting Cholesterol (>240 mg/dL)19%40%
    Creatine Kinase (M: >990 U/L; F: >845 U/L)12%12%
    Serum Amylase (>175 U/L)9%8%
    AST (M: >180 U/L; F: >170 U/L)5%7%
    ALT (M: >215 U/L; F: >170 U/L)4%5%
    Hematuria (>100 RBC/HPF)7%7%
    Neutrophils (<750/mm3)3%1%
    Fasting Triglycerides (>750 mg/dL)1%9%

    Study 934 – Treatment -Emergent Adverse Reactions: In Study 934, 511 antiretroviral-naïve subjects received either VIREAD + EMTRIVA™ administered in combination with efavirenz (N=257) or zidovudine/lamivudine administered in combination with efavirenz (N=254). Adverse reactions observed in this trial were generally consistent with those seen in previous studies in treatment-experienced or treatment-naïve subjects (Table 4).

    Changes in Bone Mineral Density:

    In HIV-1 infected adult subjects in Study 903, there was a significantly greater mean percentage decrease from baseline in BMD at the lumbar spine in subjects receiving VIREAD + lamivudine + efavirenz (– 2.2% ± 3.9) compared with subjects receiving stavudine + lamivudine + efavirenz (– 1.0% ± 4.6) through 144 weeks. Changes in BMD at the hip were similar between the two treatment groups (– 2.8% ± 3.5 in the VIREAD group vs. –2.4% ± 4.5 in the stavudine group). In both groups, the majority of the reduction in BMD occurred in the first 24–48 weeks of the trial and this reduction was sustained through Week 144. Twenty-eight percent of VIREAD-treated subjects vs. 21% of the stavudine-treated subjects lost at least 5% of BMD at the spine or 7% of BMD at the hip. Clinically relevant fractures (excluding fingers and toes) were reported in 4 subjects in the VIREAD group and 6 subjects in the stavudine group. In addition, there were significant increases in biochemical markers of bone metabolism (serum bone-specific alkaline phosphatase, serum osteocalcin, serum C telopeptide, and urinary N telopeptide) and higher serum parathyroid hormone levels and 1,25 Vitamin D levels in the VIREAD group relative to the stavudine group; however, except for bone-specific alkaline phosphatase, these changes resulted in values that remained within the normal range [See Warnings and Precautions (5.6)].

    Table 4 Selected Treatment-Emergent Adverse Reactions* (Grades 2 – 4) Reported in ≥5% in Any Treatment Group in Study 934 (0– 144 Weeks)
    VIREAD†+FTC+EFVAZT/3TC+EFV
    N=257N=254
  • * Frequencies of adverse reactions are based on all treatment-emergent adverse events, regardless of relationship to study drug.
  • † From Weeks 96 to 144 of the trial, subjects received TRUVADA with efavirenz in place of VIREAD + EMTRIVA with efavirenz.
  • ‡ Rash event includes rash, exfoliative rash, rash generalized, rash macular, rash maculopapular, rash pruritic, and rash vesicular.
    		•
    Gastrointestinal Disorder
      Diarrhea9%5%
      Nausea9%7%
      Vomiting2%5%
    General Disorders and Administration Site Condition
      Fatigue9%8%
    Infections and Infestations
      Sinusitis8%4%
      Upper respiratory tract infections8%5%
      Nasopharyngitis5%3%
    Nervous System Disorders
      Headache6%5%
      Dizziness8%7%
    Psychiatric Disorders
      Depression9%7%
      Insomnia5%7%
    Skin and Subcutaneous Tissue Disorders
      Rash event‡7%9%

    Laboratory Abnormalities: Laboratory abnormalities observed in this trial were generally consistent with those seen in previous trials (Table 5).

    Table 5 Significant Laboratory Abnormalities Reported in ≥1% of Subjects in Any Treatment Group in Study 934 (0–144 Weeks)
    VIREAD*+FTC+EFVAZT/3TC+EFV
    N=257N=254
  • * From Weeks 96 to 144 of the trial, subjects received TRUVADA with efavirenz in place of VIREAD + EMTRIVA with efavirenz.
    		•
    Any ≥ Grade 3 Laboratory Abnormality30%26%
    Fasting Cholesterol (>240 mg/dL)22%24%
    Creatine Kinase (M: >990 U/L; F: >845 U/L)9%7%
    Serum Amylase (>175 U/L)8%4%
    Alkaline Phosphatase (>550 U/L)1%0%
    AST (M: >180 U/L; F: >170 U/L)3%3%
    ALT (M: >215 U/L; F: >170 U/L)2%3%
    Hemoglobin (<8.0 mg/dL)0%4%
    Hyperglycemia (>250 mg/dL)2%1%
    Hematuria (>75 RBC/HPF)3%2%
    Glycosuria (≥3+)<1%1%
    Neutrophils (<750/mm3)3%5%
    Fasting Triglycerides (>750 mg/dL)4%2%

    Treatment-Experienced Patients

    Treatment-Emergent Adverse Reactions: The adverse reactions seen in treatment -experienced subjects were generally consistent with those seen in treatment -naïve subjects including mild to moderate gastrointestinal events, such as nausea, diarrhea, vomiting, and flatulence. Less than 1% of subjects discontinued participation in the clinical trials due to gastrointestinal adverse reactions (Study 907).

    A summary of moderate to severe treatment-emergent adverse reactions that occurred during the first 48 weeks of Study 907 is provided in Table 6.

    Table 6 Selected Treatment-Emergent Adverse Reactions* (Grades 2 – 4) Reported in ≥3% in Any Treatment Group in Study 907 (0– 48 Weeks)
    VIREAD
    (N=368)
    (Week 0 – 24)    		Placebo
    (N=182)
    (Week 0–24)    		VIREAD
    (N=368)
    (Week 0– 48)    		Placebo Crossover to VIREAD
    (N=170)
    (Week 24 – 48)
  • * Frequencies of adverse reactions are based on all treatment-emergent adverse events, regardless of relationship to study drug.
  • † Peripheral neuropathy includes peripheral neuritis and neuropathy.
  • ‡ Rash event includes rash, pruritus, maculopapular rash, urticaria, vesiculobullous rash, and pustular rash.
    		•
    Body as a Whole
      Asthenia7%6%11%1%
      Pain7%7%12%4%
      Headache5%5%8%2%
      Abdominal pain4%3%7%6%
      Back pain3%3%4%2%
      Chest pain3%1%3%2%
      Fever2%2%4%2%
    Digestive System
      Diarrhea11%10%16%11%
      Nausea8%5%11%7%
      Vomiting4%1%7%5%
      Anorexia3%2%4%1%
      Dyspepsia3%2%4%2%
      Flatulence3%1%4%1%
    Respiratory
      Pneumonia2%0%3%2%
    Nervous System
      Depression4%3%8%4%
      Insomnia3%2%4%4%
      Peripheral neuropathy†3%3%5%2%
      Dizziness1%3%3%1%
    Skin and Appendage
      Rash event‡5%4%7%1%
      Sweating3%2%3%1%
    Musculoskeletal
      Myalgia3%3%4%1%
    Metabolic
      Weight loss2%1%4%2%

    Laboratory Abnormalities: Laboratory abnormalities observed in this trial occurred with similar frequency in the VIREAD and placebo-treated groups. A summary of Grades 3 – 4 laboratory abnormalities is provided in Table 7.

    Table 7 Grades 3 – 4 Laboratory Abnormalities Reported in ≥1% of VIREAD-Treated Subjects in Study 907 (0 – 48 Weeks)
    VIREAD
    (N=368)
    (Week 0 –24)    		Placebo
    (N=182)
    (Week 0 –24)    		VIREAD
    (N=368)
    (Week 0 –48)    		Placebo Crossover to VIREAD
    (N=170)
    (Week 24 –48)
    Any ≥ Grade 3 Laboratory Abnormality25%38%35%34%
    Triglycerides (>750 mg/dL)8%13%11%9%
    Creatine Kinase
    (M: >990 U/L; F: >845 U/L)    		7%14%12%12%
    Serum Amylase (>175 U/L)6%7%7%6%
    Glycosuria (≥3+)3%3%3%2%
    AST (M: >180 U/L; F: >170 U/L)3%3%4%5%
    ALT (M: >215 U/L; F: >170 U/L)2%2%4%5%
    Serum Glucose (>250 U/L)2%4%3%3%
    Neutrophils (<750/mm3)1%1%2%1%

    Clinical Trials in Pediatric Subjects 12 Years of Age and Older with HIV-1 Infection

    Assessment of adverse reactions is based on one randomized trial (Study 321) in 87 HIV-1 infected pediatric subjects (12 to less than 18 years of age) who received treatment with VIREAD (N=45) or placebo (N=42) in combination with other antiretroviral agents for 48 weeks. The adverse reactions observed in subjects who received treatment with VIREAD were consistent with those observed in clinical trials in adults.

    Changes in Bone Mineral Density:

    Clinical trials in HIV-1 infected children and adolescents evaluated BMD changes. In Study 321 (12 to less than 18 years), the mean rate of BMD gain at Week 48 was less in the VIREAD compared to the placebo treatment group. Six VIREAD-treated subjects and one placebo-treated subject had significant (greater than 4%) lumbar spine BMD loss at Week 48. Changes from baseline BMD Z-scores were – 0.341 for lumbar spine and – 0.458 for total body in the 28 subjects who were treated with VIREAD for 96 weeks, skeletal growth (height) appeared to be unaffected. [See Warnings and Precautions (5.6)].

    Clinical Trials in Adult Subjects with Chronic Hepatitis B and Compensated Liver Disease

    Treatment-Emergent Adverse Reactions: In controlled clinical trials in 641 subjects with chronic hepatitis B (0102 and 0103), more subjects treated with VIREAD during the 48-week double-blind period experienced nausea: 9% with VIREAD versus 2% with HEPSERA. Other treatment-emergent adverse reactions reported in more than 5% of subjects treated with VIREAD included: abdominal pain, diarrhea, headache, dizziness, fatigue, nasopharyngitis, back pain, and skin rash.

    During the open-label phase of treatment with VIREAD (weeks 48–384) in Studies 0102 and 0103, 2% of subjects (13/585) experienced a confirmed increase in serum creatinine of 0.5 mg/dL from baseline. No significant change in the tolerability profile was observed with continued treatment for up to 384 weeks.

    Laboratory Abnormalities: A summary of Grades 3–4 laboratory abnormalities through Week 48 is provided in Table 8. Grades 3–4 laboratory abnormalities were similar in subjects continuing VIREAD treatment for up to 384 weeks in these trials.

    Table 8 Grades 3–4 Laboratory Abnormalities Reported in ≥1% of VIREAD-Treated Subjects in Studies 0102 and 0103 (0–48 Weeks)
    VIREAD
    (N=426)    		HEPSERA
    (N=215)
    Any ≥ Grade 3 Laboratory Abnormality19%13%
    Creatine Kinase (M: >990 U/L; F: >845 U/L)2%3%
    Serum Amylase (>175 U/L)4%1%
    Glycosuria (≥3+)3%<1%
    AST (M: >180 U/L; F: >170 U/L)4%4%
    ALT (M: >215 U/L; F: >170 U/L)10%6%

    The overall incidence of on-treatment ALT flares (defined as serum ALT greater than 2 × baseline and greater than 10 × ULN, with or without associated symptoms) was similar between VIREAD (2.6%) and HEPSERA (2%). ALT flares generally occurred within the first 4–8 weeks of treatment and were accompanied by decreases in HBV DNA levels. No subject had evidence of decompensation. ALT flares typically resolved within 4 to 8 weeks without changes in study medication.

    The adverse reactions observed in subjects with chronic hepatitis B and lamivudine resistance who received treatment with VIREAD were consistent with those observed in other hepatitis B clinical trials in adults.

    Clinical Trials in Adult Subjects with Chronic Hepatitis B and Decompensated Liver Disease

    In a small randomized, double-blind, active-controlled trial (0108), subjects with CHB and decompensated liver disease received treatment with VIREAD or other antiviral drugs for up to 48 weeks [See Clinical Studies (14.2)]. Among the 45 subjects receiving VIREAD, the most frequently reported treatment-emergent adverse reactions of any severity were abdominal pain (22%), nausea (20%), insomnia (18%), pruritus (16%), vomiting (13%), dizziness (13%), and pyrexia (11%). Two of 45 (4%) subjects died through Week 48 of the trial due to progression of liver disease. Three of 45 (7%) subjects discontinued treatment due to an adverse event. Four of 45 (9%) subjects experienced a confirmed increase in serum creatinine of 0.5 mg/dL (1 subject also had a confirmed serum phosphorus less than 2 mg/dL through Week 48). Three of these subjects (each of whom had a Child-Pugh score greater than or equal to 10 and MELD score greater than or equal to 14 at entry) developed renal failure. Because both VIREAD and decompensated liver disease may have an impact on renal function, the contribution of VIREAD to renal impairment in this population is difficult to ascertain.

    One of 45 subjects experienced an on-treatment hepatic flare during the 48 week trial.

    Clinical Trials in Pediatric Subjects 12 Years of Age and Older with Chronic Hepatitis B

    Assessment of adverse reactions is based on one randomized study (Study GS-US-174-0115) in 106 pediatric subjects (12 to less than 18 years of age) infected with chronic hepatitis B receiving treatment with VIREAD (N = 52) or placebo (N = 54) for 72 weeks. The adverse reactions observed in pediatric subjects who received treatment with VIREAD were consistent with those observed in clinical trials of VIREAD in adults.

    In this study, both the VIREAD and placebo treatment arms experienced an overall increase in mean lumbar spine BMD over 72 weeks, as expected for an adolescent population. The BMD gains from baseline to Week 72 in lumbar spine and total body BMD in VIREAD-treated subjects (+5% and +3%, respectively) were less than the BMD gains observed in placebo-treated subjects (+8% and +5%, respectively). Three subjects in the VIREAD group and two subjects in the placebo group had significant (greater than 4%) lumbar spine BMD loss at Week 72. At baseline, mean BMD Z-scores in subjects randomized to VIREAD were −0.43 for lumbar spine and −0.20 for total body, and mean BMD Z-scores in subjects randomized to placebo were −0.28 for lumbar spine and −0.26 for total body. In subjects receiving VIREAD for 72 weeks, the mean change in BMD Z-score was −0.05 for lumbar spine and −0.15 for total body compared to +0.07 and +0.06, respectively, in subjects receiving placebo. As observed in pediatric studies of HIV-infected patients, skeletal growth (height) appeared to be unaffected [See Warnings and Precautions (5.6)].

    6.2 Postmarketing Experience

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

    Immune System Disorders
    allergic reaction, including angioedema

    Metabolism and Nutrition Disorders
    lactic acidosis, hypokalemia, hypophosphatemia

    Respiratory, Thoracic, and Mediastinal Disorders
    dyspnea

    Gastrointestinal Disorders
    pancreatitis, increased amylase, abdominal pain

    Hepatobiliary Disorders
    hepatic steatosis, hepatitis, increased liver enzymes (most commonly AST, ALT gamma GT)

    Skin and Subcutaneous Tissue Disorders
    rash

    Musculoskeletal and Connective Tissue Disorders
    rhabdomyolysis, osteomalacia (manifested as bone pain and which may contribute to fractures), muscular weakness, myopathy

    Renal and Urinary Disorders
    acute renal failure, renal failure, acute tubular necrosis, Fanconi syndrome, proximal renal tubulopathy, interstitial nephritis (including acute cases), nephrogenic diabetes insipidus, renal insufficiency, increased creatinine, proteinuria, polyuria

    General Disorders and Administration Site Conditions
    asthenia

    The following adverse reactions, listed under the body system headings above, may occur as a consequence of proximal renal tubulopathy: rhabdomyolysis, osteomalacia, hypokalemia, muscular weakness, myopathy, hypophosphatemia.

  • 7 DRUG INTERACTIONS

    7.1 Drugs Affecting Renal Function

    Tenofovir is primarily eliminated by the kidneys [see Clinical Pharmacology (12.3)]. Coadministration of VIREAD with drugs that are eliminated by active tubular secretion may increase concentrations of tenofovir and/or the coadministered drug. Some examples include, but are not limited to, acyclovir, cidofovir, ganciclovir, valacyclovir, valganciclovir, aminoglycosides (e.g., gentamicin), and high-dose or multiple NSAIDs [See Warnings and Precautions (5.2)]. Drugs that decrease renal function may increase concentrations of tenofovir.

    In the treatment of chronic hepatitis B, VIREAD should not be administered in combination with HEPSERA (adefovir dipivoxil).

    7.2 Established and Significant Interactions

    Table 9 provides a listing of established or clinically significant drug interactions. The drug interactions described are based on studies conducted with tenofovir DF [see Clinical Pharmacology (12.3)].

    Table 9 Established and Significant* Drug Interactions: Alteration in Dose or Regimen May Be Recommended Based on Drug Interaction Trials
    Concomitant Drug Class: Drug NameEffect on Concentration†Clinical Comment
  • * This table is not all inclusive.
  • † ↑=Increase, ↓=Decrease
    		•
    NRTI:
    didanosine    		↑ didanosinePatients receiving VIREAD and didanosine should be monitored closely for didanosine-associated adverse reactions. Discontinue didanosine in patients who develop didanosine-associated adverse reactions. Higher didanosine concentrations could potentiate didanosine-associated adverse reactions, including pancreatitis, and neuropathy. Suppression of CD4+ cell counts has been observed in patients receiving VIREAD with didanosine 400 mg daily.
    In patients weighing greater than 60 kg, reduce the didanosine dose to 250 mg when it is coadministered with VIREAD. In patients weighing less than 60 kg, reduce the didanosine dose to 200 mg when it is coadministered with VIREAD. When coadministered, VIREAD and Videx EC may be taken under fasted conditions or with a light meal (less than 400 kcal, 20% fat).
    HIV-1 Protease Inhibitors:
    atazanavir    		↓ atazanavirWhen coadministered with VIREAD, atazanavir 300 mg should be given with ritonavir 100 mg.
    lopinavir/ritonavir
    atazanavir/ritonavir
    darunavir/ritonavir    		↑ tenofovirMonitor patients receiving VIREAD concomitantly with lopinavir/ritonavir, ritonavir-boosted atazanavir, or ritonavir-boosted darunavir for tenofovir DF-associated adverse reactions. Discontinue VIREAD in patients who develop tenofovir DF-associated adverse reactions.
    Hepatitis C Antiviral Agents:
    sofosbuvir/velpatasvir
    sofosbuvir/velpatasvir/voxilaprevir    		↑ tenofovirMonitor patients receiving VIREAD concomitantly with EPCLUSA™ (sofosbuvir/velpatasvir) or VOSEVI™ (sofosbuvir/velpatasvir/voxilaprevir) for adverse reactions associated with tenofovir DF.
    ledipasvir/sofosbuvirMonitor patients receiving VIREAD concomitantly with HARVONI™ (ledipasvir/sofosbuvir) without an HIV-1 protease inhibitor/ritonavir or an HIV-1 protease inhibitor/cobicistat combination for adverse reactions associated with tenofovir DF. In patients receiving VIREAD concomitantly with HARVONI and an HIV-1 protease inhibitor/ritonavir or an HIV-1 protease inhibitor/cobicistat combination, consider an alternative HCV or antiretroviral therapy, as the safety of increased tenofovir concentrations in this setting has not been established. If coadministration is necessary, monitor for adverse reactions associated with tenofovir DF.
  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Pregnancy Category B

    There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, VIREAD should be used during pregnancy only if clearly needed.

    Antiretroviral Pregnancy Registry: To monitor fetal outcomes of pregnant women exposed to VIREAD, an Antiretroviral Pregnancy Registry has been established. Healthcare providers are encouraged to register patients on the worldwide web at www.apregistry.com/.

    Risk Summary

    Animal Data

    Reproduction studies have been performed in rats and rabbits at doses up to 14 and 19 times the human dose based on body surface area comparisons and revealed no evidence of impaired fertility or harm to the fetus due to tenofovir.

    8.3 Nursing Mothers

    Nursing Mothers: The Centers for Disease Control and Prevention recommend that HIV-1-infected mothers not breastfeed their infants to avoid risking postnatal transmission of HIV-1. Samples of breast milk obtained from five HIV-1 infected mothers in the first post-partum week show that tenofovir is secreted in human milk. The impact of this exposure in breastfed infants is unknown. Because of both the potential for HIV-1 transmission and the potential for serious adverse reactions in nursing infants, mothers should be instructed not to breastfeed if they are receiving VIREAD.

    8.4 Pediatric Use

    Pediatric Patients 12 Years of Age and Older with HIV-1 infection

    The safety of VIREAD in pediatric patients aged 12 to less than 18 years is supported by data from one randomized trial in which VIREAD was administered to HIV-1 infected treatment-experienced subjects. In this trial, the pharmacokinetic profile of VIREAD was similar to that found to be safe and effective in adult clinical trials [See Clinical Pharmacology (12.3)].

    In Study 321, 87 treatment-experienced subjects 12 to less than 18 years of age were treated with VIREAD (N=45) or placebo (N=42) in combination with an optimized background regimen (OBR) for 48 weeks. The mean baseline CD4 cell count was 374 cells/mm3 and the mean baseline plasma HIV-1 RNA was 4.6 log10 copies/mL. At baseline, 90% of subjects harbored NRTI resistance-associated substitutions in their HIV-1 isolates. Overall, the trial failed to show a difference in virologic response between the VIREAD and placebo treatment groups. Subgroup analyses suggest the lack of difference in virologic response may be attributable to imbalances between treatment arms in baseline viral susceptibility to VIREAD and OBR.

    Although changes in HIV-1 RNA in these highly treatment-experienced subjects were less than anticipated, the comparability of the pharmacokinetic and safety data to that observed in adults supports the use of VIREAD in pediatric patients 12 years of age and older who weigh greater than or equal to 35 kg and whose HIV-1 isolate is expected to be sensitive to VIREAD. [See Warnings and Precautions (5.6), Adverse Reactions (6.1), and Clinical Pharmacology (12.3)].

    Safety and effectiveness of VIREAD in pediatric patients younger than 12 years of age with HIV-1 infection have not been established.

    Pediatric Patients 12 Years of Age and Older with Chronic Hepatitis B

    In Study 115, 106 HBeAg negative (9%) and positive (91%) subjects aged 12 to less than 18 years with chronic HBV infection were randomized to receive blinded treatment with VIREAD 300 mg (N = 52) or placebo (N = 54) for 72 weeks. At study entry, the mean HBV DNA was 8.1 log10 copies/mL and mean ALT was 101 U/L. Of 52 subjects treated with VIREAD, 20 subjects were nucleos(t)ide-naïve and 32 subjects were nucleos(t)ide-experienced. Thirty-one of the 32 nucleos(t)ide-experienced subjects had prior lamivudine experience. At Week 72, 88% (46/52) of subjects in the VIREAD group and 0% (0/54) of subjects in the placebo group had HBV DNA <400 copies/mL (69 IU/mL). Among subjects with abnormal ALT at baseline, 74% (26/35) of subjects receiving VIREAD had normalized ALT at Week 72 compared to 31% (13/42) in the placebo group. One VIREAD-treated subject experienced sustained HBsAg-loss and seroconversion to anti-HBs during the first 72 weeks of study participation.

    Safety and effectiveness of VIREAD in pediatric patients younger than 12 years of age or less than 35 kg with chronic hepatitis B have not been established.

    8.5 Geriatric Use

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

    8.6 Patients with Impaired Renal Function

    It is recommended that the dosing interval for VIREAD be modified in patients with estimated creatinine clearance below 50 mL/min or in patients with ESRD who require dialysis [See Dosage and Administration (2.2), Clinical Pharmacology (12.3)].

  • 10 OVERDOSAGE

    Limited clinical experience at doses higher than the therapeutic dose of VIREAD 300 mg is available. In Study 901, 600 mg tenofovir DF was administered to 8 subjects orally for 28 days. No severe adverse reactions were reported. The effects of higher doses are not known.

    If overdose occurs the patient must be monitored for evidence of toxicity and standard supportive treatment applied as necessary.

    Tenofovir is efficiently removed by hemodialysis with an extraction coefficient of approximately 54%. Following a single 300 mg dose of VIREAD, a four-hour hemodialysis session removed approximately 10% of the administered tenofovir dose.

  • 11 DESCRIPTION

    VIREAD is the brand name for tenofovir DF (a prodrug of tenofovir) which is a fumaric acid salt of bis-isopropoxycarbonyloxymethyl ester derivative of tenofovir. In vivo tenofovir DF is converted to tenofovir, an acyclic nucleoside phosphonate (nucleotide) analog of adenosine 5'-monophosphate. Tenofovir exhibits activity against HIV-1 reverse transcriptase.

    The chemical name of tenofovir DF is 9-[(R)-2-[[bis[[(isopropoxycarbonyl)oxy]methoxy]phosphinyl]methoxy]propyl]adenine fumarate (1:1). It has a molecular formula of C19H30N5O10P ∙ C4H4O4 and a molecular weight of 635.52. It has the following structural formula:

    Chemical Structure

    Tenofovir DF is a white to off-white crystalline powder with a solubility of 13.4 mg/mL in distilled water at 25 °C. It has an octanol/phosphate buffer (pH 6.5) partition coefficient (log p) of 1.25 at 25 °C.

    VIREAD tablets are for oral administration. Each tablet contains 300 mg of tenofovir DF, which is equivalent to 245 mg of tenofovir disoproxil, and the following inactive ingredients: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and pregelatinized starch. The tablets are coated with Opadry II 32K18425, which contains hypromellose 2910, lactose monohydrate, titanium dioxide, and triacetin.

    In this insert, all dosages are expressed in terms of tenofovir DF except where otherwise noted.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Tenofovir DF is an antiviral drug [See Microbiology (12.4)].

    12.3 Pharmacokinetics

    The pharmacokinetics of tenofovir DF have been evaluated in healthy volunteers and HIV-1 infected individuals. Tenofovir pharmacokinetics are similar between these populations.

    Absorption

    VIREAD is a water soluble diester prodrug of the active ingredient tenofovir. The oral bioavailability of tenofovir from VIREAD in fasted subjects is approximately 25%. Following oral administration of a single dose of VIREAD 300 mg to HIV-1 infected subjects in the fasted state, maximum serum concentrations (Cmax) are achieved in 1.0 ± 0.4 hrs. Cmax and AUC values are 0.30 ± 0.09 µg/mL and 2.29 ± 0.69 µg∙hr/mL, respectively.

    The pharmacokinetics of tenofovir are dose proportional over a VIREAD dose range of 75 to 600 mg and are not affected by repeated dosing.

    Distribution

    In vitro binding of tenofovir to human plasma or serum proteins is less than 0.7 and 7.2%, respectively, over the tenofovir concentration range 0.01 to 25 µg/mL. The volume of distribution at steady-state is 1.3 ± 0.6 L/kg and 1.2 ± 0.4 L/kg, following intravenous administration of tenofovir 1.0 mg/kg and 3.0 mg/kg.

    Metabolism and Elimination

    In vitro studies indicate that neither tenofovir disoproxil nor tenofovir are substrates of CYP enzymes.

    Following IV administration of tenofovir, approximately 70–80% of the dose is recovered in the urine as unchanged tenofovir within 72 hours of dosing. Following single dose, oral administration of VIREAD, the terminal elimination half-life of tenofovir is approximately 17 hours. After multiple oral doses of VIREAD 300 mg once daily (under fed conditions), 32 ± 10% of the administered dose is recovered in urine over 24 hours.

    Tenofovir is eliminated by a combination of glomerular filtration and active tubular secretion. There may be competition for elimination with other compounds that are also renally eliminated.

    Effects of Food on Oral Absorption

    Administration of VIREAD 300 mg tablets following a high-fat meal (~700 to 1000 kcal containing 40 to 50% fat) increases the oral bioavailability, with an increase in tenofovir AUC0–∞ of approximately 40% and an increase in Cmax of approximately 14%. However, administration of VIREAD with a light meal did not have a significant effect on the pharmacokinetics of tenofovir when compared to fasted administration of the drug. Food delays the time to tenofovir Cmax by approximately 1 hour. Cmax and AUC of tenofovir are 0.33 ± 0.12 µg/mL and 3.32 ± 1.37 µg∙hr/mL following multiple doses of VIREAD 300 mg once daily in the fed state, when meal content was not controlled.

    Special Populations

    Race: There were insufficient numbers from racial and ethnic groups other than Caucasian to adequately determine potential pharmacokinetic differences among these populations.

    Gender: Tenofovir pharmacokinetics are similar in male and female subjects.

    Pediatric Patients 12 Years of Age and Older: Steady-state pharmacokinetics of tenofovir were evaluated in 8 HIV-1 infected pediatric subjects (12 to less than 18 years). Mean (± SD) Cmax and AUCtau are 0.38 ± 0.13 µg/mL and 3.39 ± 1.22 µg∙hr/mL, respectively. Tenofovir exposure achieved in these pediatric subjects receiving oral daily doses of VIREAD 300 mg was similar to exposures achieved in adults receiving once-daily doses of VIREAD 300 mg.

    Tenofovir exposures in 52 HBV-infected pediatric subjects (12 to less than 18 years of age) receiving oral once-daily doses of VIREAD 300 mg tablet were comparable to exposures achieved in HIV-1-infected adults and adolescents receiving once-daily doses of 300 mg.

    Pharmacokinetic trials have not been performed in pediatric subjects less than 12 years of age.

    Geriatric Patients: Pharmacokinetic trials have not been performed in the elderly (65 years and older).

    Patients with Impaired Renal Function: The pharmacokinetics of tenofovir are altered in subjects with renal impairment [See Warnings and Precautions (5.2)]. In subjects with creatinine clearance below 50 mL/min or with end-stage renal disease (ESRD) requiring dialysis, Cmax, and AUC0–∞ of tenofovir were increased (Table 10). It is recommended that the dosing interval for VIREAD be modified in patients with estimated creatinine clearance below 50 mL/min or in patients with ESRD who require dialysis [See Dosage and Administration (2.2)].

    Table 10 Pharmacokinetic Parameters (Mean ± SD) of Tenofovir* in Subjects with Varying Degrees of Renal Function
    Baseline Creatinine Clearance (mL/min)>80
    (N=3)    		50–80
    (N=10)    		30–49
    (N=8)    		12–29
    (N=11)
  • * 300 mg, single dose of VIREAD
    		•
    Cmax (µg/mL)0.34 ± 0.030.33 ± 0.060.37 ± 0.160.60 ± 0.19
    AUC0–∞ (µg∙hr/mL)2.18 ± 0.263.06 ± 0.936.01 ± 2.5015.98 ± 7.22
    CL/F (mL/min)1043.7 ± 115.4807.7 ± 279.2444.4 ± 209.8177.0 ± 97.1
    CLrenal (mL/min)243.5 ± 33.3168.6 ± 27.5100.6 ± 27.543.0 ± 31.2

    Tenofovir is efficiently removed by hemodialysis with an extraction coefficient of approximately 54%. Following a single 300 mg dose of VIREAD, a four-hour hemodialysis session removed approximately 10% of the administered tenofovir dose.

    Patients with Hepatic Impairment: The pharmacokinetics of tenofovir following a 300 mg single dose of VIREAD have been studied in non-HIV infected subjects with moderate to severe hepatic impairment. There were no substantial alterations in tenofovir pharmacokinetics in subjects with hepatic impairment compared with unimpaired subjects. No change in VIREAD dosing is required in patients with hepatic impairment.

    Assessment of Drug Interactions

    At concentrations substantially higher (~300-fold) than those observed in vivo, tenofovir did not inhibit in vitro drug metabolism mediated by any of the following human CYP isoforms: CYP3A4, CYP2D6, CYP2C9, or CYP2E1. However, a small (6%) but statistically significant reduction in metabolism of CYP1A substrate was observed. Based on the results of in vitro experiments and the known elimination pathway of tenofovir, the potential for CYP-mediated interactions involving tenofovir with other medicinal products is low.

    VIREAD has been evaluated in healthy volunteers in combination with other antiretroviral and potential concomitant drugs. Tables 11 and 12 summarize pharmacokinetic effects of coadministered drug on tenofovir pharmacokinetics and effects of VIREAD on the pharmacokinetics of coadministered drug.

    TDF is a substrate of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) transporters. When TDF is coadministered with an inhibitor of these transporters, an increase in absorption may be observed.

    No clinically significant drug interactions have been observed between VIREAD and efavirenz, methadone, nelfinavir, oral contraceptives, ribavirin or sofosbuvir.

    Table 11 Drug Interactions: Changes in Pharmacokinetic Parameters for Tenofovir* in the Presence of the Coadministered Drug
    Coadministered DrugDose of Coadministered Drug (mg)N% Change of Tenofovir Pharmacokinetic Parameters†
    (90% CI)
    CmaxAUCCmin
  • * Subjects received VIREAD 300 mg once daily.
  • † Increase = ↑; Decrease = ↓; No Effect = ⇔
  • ‡ Reyataz Prescribing Information
  • § Prezista Prescribing Information
  • Data generated from simultaneous dosing with HARVONI (ledipasvir/sofosbuvir). Staggered administration (12 hours apart) provided similar results.
  • # Comparison based on exposures when administered as atazanavir/ritonavir + emtricitabine/tenofovir DF.
  • Þ Comparison based on exposures when administered as darunavir/ritonavir + emtricitabine/tenofovir DF.
  • ß Study conducted with ATRIPLA (efavirenz/emtricitabine/tenofovir DF) coadministered with HARVONI; coadministration with HARVONI also results in comparable increases in tenofovir exposure when TDF is administered as COMPLERA, or TRUVADA + dolutegravir.
  • à Study conducted with ATRIPLA coadministered with SOVALDI™ (sofosbuvir).
  • è Study conducted with COMPLERA coadministered with EPCLUSA; coadministration with EPCLUSA also results in comparable increases in tenofovir exposures when TDF is administered as ATRIPLA, STRIBILD, TRUVADA + atazanavir/ritonavir, or TRUVADA + darunavir/ritonavir
  • ð Administered as raltegravir + emtricitabine/tenofovir DF.
  • ø Comparison based on exposures when administered as darunavir + ritonavir + emtricitabine/tenofovir DF.
  • ý Study conducted with additional voxilaprevir 100 mg to achieve voxilaprevir exposures expected in HCV-infected patients.
  • £ Aptivus Prescribing Information.
    		•
    Atazanavir‡400 once daily × 14 days33↑ 14
    (↑ 8 to ↑ 20)    		↑ 24
    (↑ 21 to ↑ 28)    		↑ 22
    (↑ 15 to ↑ 30)
    Atazanavir/ Ritonavir‡300/100 once daily12↑ 34
    (↑ 20 to ↑ 51)    		↑ 37
    (↑ 30 to ↑ 45)    		↑ 29
    (↑ 21 to ↑ 36)
    Darunavir/ Ritonavir§300/100 twice daily12↑ 24
    (↑ 8 to ↑ 42)    		↑ 22
    (↑ 10 to ↑ 35)    		↑ 37
    (↑ 19 to ↑ 57)
    Indinavir800 three times daily × 7 days13↑ 14
    (↓ 3 to ↑ 33)    		⇔⇔
    Ledipasvir/ Sofosbuvir,#90/400 once daily ×10 days24↑ 47
    (↑ 37 to ↑ 58)    		↑ 35
    (↑ 29 to ↑ 42 )    		↑ 47
    (↑ 38 to ↑ 57)
    Ledipasvir/ Sofosbuvir,Þ23↑ 64
    (↑ 54 to ↑ 74)    		↑ 50
    (↑ 42 to ↑ 59)    		↑ 59
    (↑ 49 to ↑ 70)
    Ledipasvir/ Sofosbuvirß90/400 once daily × 14 days15↑ 79
    (↑ 56 to ↑ 104)    		↑ 98
    (↑ 77 to ↑ 123)    		↑ 163
    (↑ 132 to↑197)
    Lopinavir/ Ritonavir400/100 twice daily × 14 days24⇔↑ 32
    (↑ 25 to ↑ 38)    		↑ 51
    (↑ 37 to ↑ 66)
    Saquinavir/ Ritonavir1000/100 twice daily × 14 days35⇔⇔↑ 23
    (↑ 16 to ↑ 30)
    Sofosbuvirà400 single dose16↑ 25
    (↑ 8 to ↑ 45)    		⇔⇔
    Sofosbuvir/ Velpatasvirè400/100 once daily24↑ 44
    (↑ 33 to ↑ 55)    		↑ 40
    (↑ 34 to ↑ 46)    		↑ 84
    (↑ 76 to ↑ 92)
    Sofosbuvir/ Velpatasvirð400/100 once daily30↑ 46
    (↑ 39 to ↑ 54)    		↑ 40
    (↑ 34 to ↑ 45)    		↑ 70
    (↑ 61 to ↑ 79)
    Sofosbuvir/ Velpatasvir/ Voxilaprevirø400/100/100 + Voxilaprevirý once daily29↑ 48
    (↑ 36 to ↑ 61)    		↑ 39
    (↑ 32 to ↑ 46)    		↑ 47
    (↑ 38 to ↑ 56)
    Tacrolimus0.05 mg/kg twice daily × 7 days21↑ 13
    (↑ 1 to ↑ 27)    		⇔⇔
    Tipranavir/ Ritonavir£500/100 twice daily22↓ 23
    (↓ 32 to ↓ 13)    		↓ 2
    (↓ 9 to ↑ 5)    		↑ 7
    (↓ 2 to ↑ 17)
    750/200 twice daily (23 doses)20↓ 38
    (↓ 46 to ↓ 29)    		↑ 2
    (↓ 6 to ↑ 10)    		↑ 14
    (↑ 1 to ↑ 27)

    No effect on the pharmacokinetic parameters of the following coadministered drugs was observed with VIREAD: abacavir, didanosine (buffered tablets), emtricitabine, entecavir, and lamivudine.

    Table 12 Drug Interactions: Changes in Pharmacokinetic Parameters for Coadministered Drug in the Presence of VIREAD
    Coadministered DrugDose of Coadministered Drug (mg)N% Change of Coadministered Drug Pharmacokinetic Parameters*
    (90% CI)
    CmaxAUCCmin
  • * Increase = ↑; Decrease = ↓; No Effect = ⇔; NA = Not Applicable
  • † Reyataz Prescribing Information
  • ‡ In HIV-infected subjects, addition of tenofovir DF to atazanavir 300 mg plus ritonavir 100 mg, resulted in AUC and Cmin values of atazanavir that were 2.3- and 4-fold higher than the respective values observed for atazanavir 400 mg when given alone.
  • § Prezista Prescribing Information
  • Videx EC Prescribing Information. Subjects received didanosine enteric-coated capsules.
  • # 373 kcal, 8.2 g fat
  • Þ Compared with didanosine (enteric-coated) 400 mg administered alone under fasting conditions.
  • ß Increases in AUC and Cmin are not expected to be clinically relevant; hence no dose adjustments are required when tenofovir DF and ritonavir-boosted saquinavir are coadministered.
  • à Aptivus Prescribing Information
    		•
    Abacavir300 once8↑ 12
    (↓ 1 to ↑ 26)    		⇔NA
    Atazanavir†400 once daily × 14 days34↓ 21
    (↓ 27 to ↓ 14)    		↓ 25
    (↓ 30 to ↓ 19)    		↓ 40
    (↓ 48 to ↓ 32)
    Atazanavir†Atazanavir/ Ritonavir 300/100 once daily × 42 days10↓ 28
    (↓ 50 to ↑ 5)    		↓ 25‡
    (↓ 42 to ↓ 3)    		↓ 23‡
    (↓ 46 to ↑ 10)
    Darunavir§Darunavir/Ritonavir 300/100 once daily12↑ 16
    (↓ 6 to ↑ 42)    		↑ 21
    (↓ 5 to ↑ 54)     		↑ 24
    (↓ 10 to ↑ 69)
    Didanosine250 once, simultaneously with VIREAD and a light meal#33↓ 20Þ
    (↓ 32 to ↓ 7)    		⇔ÞNA
    Emtricitabine200 once daily × 7 days17⇔⇔↑ 20
    (↑ 12 to ↑ 29)
    Entecavir1 mg once daily ×10 days28⇔↑ 13
    (↑ 11 to ↑ 15)    		⇔
    Indinavir800 three times daily × 7 days12 ↓ 11
    (↓ 30 to ↑ 12)    		⇔⇔
    Lamivudine150 twice daily × 7 days15↓ 24
    (↓ 34 to ↓ 12)    		⇔⇔
    LopinavirLopinavir/Ritonavir 400/100 twice daily × 14 days24⇔⇔⇔
    Ritonavir⇔⇔⇔
    SaquinavirSaquinavir/Ritonavir 1000/100 twice daily × 14 days32↑ 22
    (↑ 6 to ↑ 41)    		↑ 29ß
    (↑ 12 to ↑ 48)    		↑ 47ß
    (↑ 23 to ↑ 76)
    Ritonavir⇔⇔↑ 23
    (↑ 3 to ↑ 46)
    Tacrolimus0.05 mg/kg twice daily × 7 days21⇔⇔⇔
    TipranaviràTipranavir/Ritonavir 500/100 twice daily22↓ 17
    (↓ 26 to ↓ 6)    		↓ 18
    (↓ 25 to ↓ 9)    		↓ 21
    (↓ 30 to ↓ 10)
    Tipranavir/Ritonavir 750/200 twice daily (23 doses)20↓ 11
    (↓ 16 to ↓ 4)    		↓ 9
    (↓ 15 to ↓ 3)    		↓ 12
    (↓ 22 to 0)

    12.4 Microbiology

    Mechanism of Action

    Tenofovir DF is an acyclic nucleoside phosphonate diester analog of adenosine monophosphate. Tenofovir DF requires initial diester hydrolysis for conversion to tenofovir and subsequent phosphorylations by cellular enzymes to form tenofovir diphosphate, an obligate chain terminator. Tenofovir diphosphate inhibits the activity of HIV-1 reverse transcriptase and HBV reverse transcriptase by competing with the natural substrate deoxyadenosine 5'-triphosphate and, after incorporation into DNA, by DNA chain termination. Tenofovir diphosphate is a weak inhibitor of mammalian DNA polymerases α, β, and mitochondrial DNA polymerase γ.

    Activity against HIV

    Antiviral Activity

    The antiviral activity of tenofovir against laboratory and clinical isolates of HIV-1 was assessed in lymphoblastoid cell lines, primary monocyte/macrophage cells and peripheral blood lymphocytes. The EC50 (50% effective concentration) values for tenofovir were in the range of 0.04 µM to 8.5 µM. In drug combination studies, tenofovir was not antagonistic with nucleoside reverse transcriptase inhibitors (abacavir, didanosine, lamivudine, stavudine, zalcitabine, zidovudine), non-nucleoside reverse transcriptase inhibitors (delavirdine, efavirenz, nevirapine), and protease inhibitors (amprenavir, indinavir, nelfinavir, ritonavir, saquinavir). Tenofovir displayed antiviral activity in cell culture against HIV-1 clades A, B, C, D, E, F, G, and O (EC50 values ranged from 0.5 µM to 2.2 µM) and strain-specific activity against HIV-2 (EC50 values ranged from 1.6 µM to 5.5 µM).

    Resistance

    HIV-1 isolates with reduced susceptibility to tenofovir have been selected in cell culture. These viruses expressed a K65R substitution in reverse transcriptase and showed a 2- to 4- fold reduction in susceptibility to tenofovir. In addition, a K70E substitution in HIV-1 reverse transcriptase has been selected by tenofovir and results in low-level reduced susceptibility to tenofovir.

    In Study 903 of treatment-naïve subjects (VIREAD + lamivudine + efavirenz versus stavudine + lamivudine + efavirenz) [See Clinical Studies (14.1)], genotypic analyses of isolates from subjects with virologic failure through Week 144 showed development of efavirenz and lamivudine resistance-associated substitutions to occur most frequently and with no difference between the treatment arms. The K65R substitution occurred in 8/47 (17%) of analyzed patient isolates in the VIREAD arm and in 2/49 (4%) of analyzed patient isolates in the stavudine arm. Of the 8 subjects whose virus developed K65R in the VIREAD arm through 144 weeks, 7 occurred in the first 48 weeks of treatment and one at Week 96. One patient in the VIREAD arm developed the K70E substitution in the virus. Other substitutions resulting in resistance to VIREAD were not identified in this trial.

    In Study 934 of treatment-naïve subjects (VIREAD + EMTRIVA + efavirenz versus zidovudine (AZT)/lamivudine (3TC) + efavirenz) [See Clinical Studies (14.1)], genotypic analysis performed on HIV-1 isolates from all confirmed virologic failure subjects with greater than 400 copies/mL of HIV-1 RNA at Week 144 or early discontinuation showed development of efavirenz resistance-associated substitutions occurred most frequently and was similar between the two treatment arms. The M184V substitution, associated with resistance to EMTRIVA and lamivudine, was observed in 2/19 of analyzed subject isolates in the VIREAD + EMTRIVA group and in 10/29 of analyzed subject isolates in the zidovudine/lamivudine group. Through 144 weeks of Study 934, no subjects have developed a detectable K65R substitution in their HIV-1 as analyzed through standard genotypic analysis.

    Cross Resistance

    Cross resistance among certain reverse transcriptase inhibitors has been recognized. The K65R and K70E substitutions selected by tenofovir are also selected in some HIV-1 infected subjects treated with abacavir or didanosine. HIV-1 isolates with this substitution also show reduced susceptibility to emtricitabine and lamivudine. Therefore, cross resistance among these drugs may occur in patients whose virus harbors the K65R or K70E substitution. HIV-1 isolates from subjects (N=20) whose HIV-1 expressed a mean of three zidovudine-associated reverse transcriptase substitutions (M41L, D67N, K70R, L210W, T215Y/F, or K219Q/E/N) showed a 3.1-fold decrease in the susceptibility to tenofovir.

    In Studies 902 and 907 conducted in treatment-experienced subjects [VIREAD + Standard Background Therapy (SBT) compared to placebo + SBT] [See Clinical Studies (14.1)], 14/304 (5%) of the VIREAD-treated subjects with virologic failure through Week 96 had greater than 1.4-fold (median 2.7-fold) reduced susceptibility to tenofovir. Genotypic analysis of the baseline and failure isolates showed the development of the K65R substitution in the HIV-1 reverse transcriptase gene.

    The virologic response to VIREAD therapy has been evaluated with respect to baseline viral genotype (N=222) in treatment-experienced subjects participating in Studies 902 and 907. In these clinical trials, 94% of the participants evaluated had baseline HIV-1 isolates expressing at least one NRTI substitution. Virologic responses for subjects in the genotype substudy were similar to the overall trial results.

    Several exploratory analyses were conducted to evaluate the effect of specific substitutions and substitutional patterns on virologic outcome. Because of the large number of potential comparisons, statistical testing was not conducted. Varying degrees of cross resistance of VIREAD to pre-existing zidovudine resistance-associated substitutions (M41L, D67N, K70R, L210W, T215Y/F, or K219Q/E/N) were observed and appeared to depend on the type and number of specific substitutions. VIREAD-treated subjects whose HIV-1 expressed 3 or more zidovudine resistance-associated substitutions that included either the M41L or L210W reverse transcriptase substitution showed reduced responses to VIREAD therapy; however, these responses were still improved compared with placebo. The presence of the D67N, K70R, T215Y/F, or K219Q/E/N substitution did not appear to affect responses to VIREAD therapy. Subjects whose virus expressed an L74V substitution without zidovudine resistance associated substitutions (N=8) had reduced response to VIREAD. Limited data are available for subjects whose virus expressed a Y115F substitution (N=3), Q151M substitution (N=2), or T69 insertion (N=4), all of whom had a reduced response.

    In the protocol defined analyses, virologic response to VIREAD was not reduced in subjects with HIV-1 that expressed the abacavir/emtricitabine/lamivudine resistance-associated M184V substitution. HIV-1 RNA responses among these subjects were durable through Week 48.

    Studies 902 and 907 Phenotypic Analyses

    Phenotypic analysis of baseline HIV-1 from treatment-experienced subjects (N=100) demonstrated a correlation between baseline susceptibility to VIREAD and response to VIREAD therapy. Table 13 summarizes the HIV-1 RNA response by baseline VIREAD susceptibility.

    Table 13 HIV-1 RNA Response at Week 24 by Baseline VIREAD Susceptibility (Intent-To-Treat)*
    Baseline VIREAD Susceptibility†Change in HIV-1 RNA‡ (N)
  • * Tenofovir susceptibility was determined by recombinant phenotypic Antivirogram assay (Virco).
  • † Fold change in susceptibility from wild-type.
  • ‡ Average HIV-1 RNA change from baseline through Week 24 (DAVG24) in log10 copies/mL.
    		•
    <1−0.74 (35)
    >1 and ≤3−0.56 (49)
    >3 and ≤4−0.3 (7)
    >4−0.12 (9)

    Activity against HBV

    Antiviral Activity

    The antiviral activity of tenofovir against HBV was assessed in the HepG2 2.2.15 cell line. The EC50 values for tenofovir ranged from 0.14 to 1.5 µM, with CC50 (50% cytotoxicity concentration) values greater than 100 µM. In cell culture combination antiviral activity studies of tenofovir with the nucleoside HBV reverse transcriptase inhibitors entecavir, lamivudine, and telbivudine, and with the nucleoside HIV-1 reverse transcriptase inhibitor emtricitabine, no antagonistic activity was observed.

    Resistance

    Cumulative VIREAD genotypic resistance has been evaluated annually for up to 384 weeks in Studies 0102, 0103, 0106, 0108, and 0121 with the paired HBV reverse transcriptase amino acid sequences of the pre-treatment and on-treatment isolates from subjects who received at least 24 weeks of VIREAD monotherapy and remained viremic with HBV DNA greater than or equal to 400 copies/mL (69 IU/mL) at the end of each study year (or at discontinuation of VIREAD monotherapy) using an as-treated analysis. In the nucleotide-naïve population from Studies 0102 and 0103, HBeAg-positive subjects had a higher baseline viral load than HBeAg-negative subjects and a significantly higher proportion of the subjects remained viremic at their last time point on VIREAD monotherapy (15% versus 5%, respectively).

    HBV isolates from these subjects who remained viremic showed treatment-emergent substitutions (Table 14); however, no specific substitutions occurred at a sufficient frequency to be associated with resistance to VIREAD (genotypic and phenotypic analyses).

    Table 14 Amino Acid Substitutions in Viremic Subjects across HBV Trials of VIREAD
    Compensated Liver DiseaseDecompensated Liver Disease
    (N=39)*
    Nucleotide-Naïve
    (N=417)†    		HEPSERA-Experienced
    (N=247)‡    		Lamivudine- Resistant
    (N=136)§
  • * Subjects with decompensated liver disease from Study 0108 (N=39) receiving up to 48 weeks of treatment with VIREAD.
  • † Nucleotide-naïve subjects from Studies 0102 (N=246) and 0103 (N=171) receiving up to 384 weeks of treatment with VIREAD.
  • ‡ HEPSERA-experienced subjects from Studies 0102/0103 (N=195) and 0106 (N=52) receiving up to 336 weeks of treatment with VIREAD after switching to VIREAD from HEPSERA. Study 0106, a randomized, double-blind, 168-week Phase 2 trial, has been completed.
  • § Lamivudine-resistant subjects from Study 0121 (N=136) receiving up to 96 weeks of treatment with VIREAD after switching to VIREAD from lamivudine.
  • Denominator includes those subjects who were viremic at last time point on VIREAD monotherapy and had evaluable paired genotypic data.
  • # Of the 18 subjects with treatment-emergent amino acid substitutions during Studies 0102 and 0103, 5 subjects had substitutions at conserved sites and 13 subjects had substitutions only at polymorphic sites, and 8 subjects had only transient substitutions that were not detected at the last time point on VIREAD.
  • Þ Of the 11 HEPSERA-experienced subjects with treatment-emergent amino acid substitutions, 2 subjects had substitutions at conserved sites and 89 had substitutions only at polymorphic sites.
  • ß Of the 6 lamivudine-resistant subjects with treatment-emergent substitutions during Study 0121, 3 subjects had substitutions at conserved sites and 3 had substitutions only at polymorphic sites.
    		•
    Viremic at Last Time Point on VIREAD38/417 (9%)37/247 (15%)9/136 (7%)7/39 (18%)
    Treatment-Emergent Amino Acid Substitutions18#/32 (56%)11Þ/31 (35%)6ß/8 (75%)3/5 (60%)

    Cross Resistance

    Cross resistance has been observed between HBV nucleoside/nucleotide analogue reverse transcriptase inhibitors.

    In cell based assays, HBV strains expressing the rtV173L, rtL180M, and rtM204I/V substitutions associated with resistance to lamivudine and telbivudine showed a susceptibility to tenofovir ranging from 0.7- to 3.4-fold that of wild type virus. The rtL180M and rtM204I/V double substitutions conferred 3.4-fold reduced susceptibility to tenofovir.

    HBV strains expressing the rtL180M, rtT184G, rtS202G/I, rtM204V, and rtM250V substitutions associated with resistance to entecavir showed a susceptibility to tenofovir ranging from 0.6- to 6.9-fold that of wild type virus.

    HBV strains expressing the adefovir resistance-associated substitutions rtA181V and/or rtN236T showed reductions in susceptibility to tenofovir ranging from 2.9- to 10-fold that of wild type virus. Strains containing the rtA181T substitution showed changes in susceptibility to tenofovir ranging from 0.9- to 1.5-fold that of wild type virus.

    One hundred fifty-two subjects initiating VIREAD therapy in Studies 0102, 0103, 0106, 0108, and 0121 harbored HBV with known resistance substitutions to HBV nucleos(t)ide analogue reverse transcriptase inhibitors: 14 with adefovir resistance-associated substitutions (rtA181S/T/V and/or rtN236T), 135 with lamivudine resistance-associated substitutions (rtM204I/V), and 3 with both adefovir and lamivudine resistance-associated substitutions. Following up to 384 weeks of VIREAD treatment, 10 of the 14 subjects with adefovir-resistant HBV, 124 of the 135 subjects with lamivudine-resistant HBV, and 2 of the 3 subjects with both adefovir- and lamivudine-resistant HBV achieved and maintained virologic suppression (HBV DNA less than 400 copies/mL [69 IU/mL]). Three of the 5 subjects whose virus harbored both the rtA181T/V and rtN236T substitutions remained viremic.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Carcinogenesis

    Long-term oral carcinogenicity studies of tenofovir DF in mice and rats were carried out at exposures up to approximately 16 times (mice) and 5 times (rats) those observed in humans at the therapeutic dose for HIV-1 infection. At the high dose in female mice, liver adenomas were increased at exposures 16 times that in humans. In rats, the study was negative for carcinogenic findings at exposures up to 5 times that observed in humans at the therapeutic dose.

    Mutagenesis

    Tenofovir DF was mutagenic in the in vitro mouse lymphoma assay and negative in an in vitro bacterial mutagenicity test (Ames test). In an in vivo mouse micronucleus assay, tenofovir DF was negative when administered to male mice.

    Impairment of Fertility

    There were no effects on fertility, mating performance or early embryonic development when tenofovir DF was administered to male rats at a dose equivalent to 10 times the human dose based on body surface area comparisons for 28 days prior to mating and to female rats for 15 days prior to mating through day seven of gestation. There was, however, an alteration of the estrous cycle in female rats.

    13.2 Animal Toxicology and/or Pharmacology

    Tenofovir and tenofovir DF administered in toxicology studies to rats, dogs, and monkeys at exposures (based on AUCs) greater than or equal to 6 fold those observed in humans caused bone toxicity. In monkeys the bone toxicity was diagnosed as osteomalacia. Osteomalacia observed in monkeys appeared to be reversible upon dose reduction or discontinuation of tenofovir. In rats and dogs, the bone toxicity manifested as reduced bone mineral density. The mechanism(s) underlying bone toxicity is unknown.

    Evidence of renal toxicity was noted in 4 animal species. Increases in serum creatinine, BUN, glycosuria, proteinuria, phosphaturia, and/or calciuria and decreases in serum phosphate were observed to varying degrees in these animals. These toxicities were noted at exposures (based on AUCs) 2–20 times higher than those observed in humans. The relationship of the renal abnormalities, particularly the phosphaturia, to the bone toxicity is not known.

  • 14 CLINICAL STUDIES

    14.1 Clinical Efficacy in Adults with HIV-1 Infection

    Treatment-Naïve Adult Patients

    Study 903

    Data through 144 weeks are reported for Study 903, a double-blind, active-controlled multicenter trial comparing VIREAD (300 mg once daily) administered in combination with lamivudine and efavirenz versus stavudine (d4T), lamivudine, and efavirenz in 600 antiretroviral-naïve subjects. Subjects had a mean age of 36 years (range 18–64); 74% were male, 64% were Caucasian, and 20% were Black. The mean baseline CD4+ cell count was 279 cells/mm3 (range 3–956) and median baseline plasma HIV-1 RNA was 77,600 copies/mL (range 417–5,130,000). Subjects were stratified by baseline HIV-1 RNA and CD4+ cell count. Forty-three percent of subjects had baseline viral loads >100,000 copies/mL and 39% had CD4+ cell counts <200 cells/mm3. Treatment outcomes through 48 and 144 weeks are presented in Table 15.

    Table 15 Outcomes of Randomized Treatment at Week 48 and 144 (Study 903)
    At Week 48At Week 144
    OutcomesVIREAD+3TC+EFV
    (N=299)    		d4T+3TC+EFV
    (N=301)    		VIREAD+3TC+EFV
    (N=299)    		d4T+3TC+EFV
    (N=301)
  • * Subjects achieved and maintained confirmed HIV-1 RNA <400 copies/mL through Week 48 and 144.
  • † Includes confirmed viral rebound and failure to achieve confirmed <400 copies/mL through Week 48 and 144.
  • ‡ Includes lost to follow-up, subject's withdrawal, noncompliance, protocol violation and other reasons.
    		•
    Responder*79%82%68%62%
    Virologic failure†6%4%10%8%
      Rebound5%3%8%7%
      Never suppressed0%1%0%0%
      Added an antiretroviral agent1%1%2%1%
    Death<1%1%<1%2%
    Discontinued due to adverse event6%6%8%13%
    Discontinued for other reasons‡8%7%14%15%

    Achievement of plasma HIV-1 RNA concentrations of less than 400 copies/mL at Week 144 was similar between the two treatment groups for the population stratified at baseline on the basis of HIV-1 RNA concentration (> or ≤100,000 copies/mL) and CD4+ cell count (< or ≥200 cells/mm3). Through 144 weeks of therapy, 62% and 58% of subjects in the VIREAD and stavudine arms, respectively, achieved and maintained confirmed HIV-1 RNA <50 copies/mL. The mean increase from baseline in CD4+ cell count was 263 cells/mm3 for the VIREAD arm and 283 cells/mm3 for the stavudine arm.

    Through 144 weeks, 11 subjects in the VIREAD group and 9 subjects in the stavudine group experienced a new CDC Class C event.

    Study 934

    Data through 144 weeks are reported for Study 934, a randomized, open-label, active-controlled multicenter trial comparing emtricitabine + VIREAD administered in combination with efavirenz versus zidovudine/lamivudine fixed-dose combination administered in combination with efavirenz in 511 antiretroviral-naïve subjects. From Weeks 96 to 144 of the trial, subjects received a fixed-dose combination of emtricitabine and tenofovir DF with efavirenz in place of emtricitabine + VIREAD with efavirenz. Subjects had a mean age of 38 years (range 18–80); 86% were male, 59% were Caucasian, and 23% were Black. The mean baseline CD4+ cell count was 245 cells/mm3 (range 2–1191) and median baseline plasma HIV-1 RNA was 5.01 log10 copies/mL (range 3.56–6.54). Subjects were stratified by baseline CD4+ cell count (< or ≥200 cells/mm3); 41% had CD4+ cell counts <200 cells/mm3 and 51% of subjects had baseline viral loads >100,000 copies/mL. Treatment outcomes through 48 and 144 weeks for those subjects who did not have efavirenz resistance at baseline are presented in Table 16.

    Table 16 Outcomes of Randomized Treatment at Week 48 and 144 (Study 934)
    OutcomesAt Week 48At Week 144
    FTC+VIREAD+EFV
    (N=244)    		AZT/3TC+EFV
    (N=243)    		FTC+VIREAD+EFV
    (N=227)*    		AZT/3TC+EFV
    (N=229)*
  • * Subjects who were responders at Week 48 or Week 96 (HIV-1 RNA <400 copies/mL) but did not consent to continue the trial after Week 48 or Week 96 were excluded from analysis.
  • † Subjects achieved and maintained confirmed HIV-1 RNA <400 copies/mL through Weeks 48 and 144.
  • ‡ Includes confirmed viral rebound and failure to achieve confirmed <400 copies/mL through Weeks 48 and 144.
  • § Includes lost to follow-up, subject withdrawal, noncompliance, protocol violation and other reasons.
    		•
    Responder†84%73%71%58%
    Virologic failure‡2%4%3%6%
      Rebound1%3%2%5%
      Never suppressed0%0%0%0%
      Change in antiretroviral regimen1%1%1%1%
    Death<1%1%1%1%
    Discontinued due to adverse event4%9%5%12%
    Discontinued for other reasons§10%14%20%22%

    Through Week 48, 84% and 73% of subjects in the emtricitabine + VIREAD group and the zidovudine/lamivudine group, respectively, achieved and maintained HIV-1 RNA <400 copies/mL (71% and 58% through Week 144). The difference in the proportion of subjects who achieved and maintained HIV-1 RNA <400 copies/mL through 48 weeks largely results from the higher number of discontinuations due to adverse events and other reasons in the zidovudine/lamivudine group in this open-label trial. In addition, 80% and 70% of subjects in the emtricitabine + VIREAD group and the zidovudine/lamivudine group, respectively, achieved and maintained HIV-1 RNA <50 copies/mL through Week 48 (64% and 56% through Week 144). The mean increase from baseline in CD4+ cell count was 190 cells/mm3 in the EMTRIVA + VIREAD group and 158 cells/mm3 in the zidovudine/lamivudine group at Week 48 (312 and 271 cells/mm3 at Week 144).

    Through 48 weeks, 7 subjects in the emtricitabine + VIREAD group and 5 subjects in the zidovudine/lamivudine group experienced a new CDC Class C event (10 and 6 subjects through 144 weeks).

    Treatment-Experienced Adult Patients

    Study 907

    Study 907 was a 24-week, double-blind, placebo-controlled multicenter trial of VIREAD added to a stable background regimen of antiretroviral agents in 550 treatment-experienced subjects. After 24 weeks of blinded trial treatment, all subjects continuing on trial were offered open-label VIREAD for an additional 24 weeks. Subjects had a mean baseline CD4+ cell count of 427 cells/mm3 (range 23–1385), median baseline plasma HIV-1 RNA of 2340 (range 50–75,000) copies/mL, and mean duration of prior HIV-1 treatment was 5.4 years. Mean age of the subjects was 42 years; 85% were male, 69% Caucasian, 17% Black, and 12% Hispanic.

    The percent of subjects with HIV-1 RNA <400 copies/mL and outcomes of subjects through 48 weeks are summarized in Table 17.

    Table 17 Outcomes of Randomized Treatment (Study 907)
    Outcomes0–24 weeks0–48 weeks24–48 weeks
    VIREAD
    (N=368)    		Placebo
    (N=182)    		VIREAD
    (N=368)    		Placebo Crossover to VIREAD
    (N=170)
  • * Subjects with HIV-1 RNA <400 copies/mL and no prior study drug discontinuation at Week 24 and 48 respectively.
  • † Subjects with HIV-1 RNA ≥400 copies/mL efficacy failure or missing HIV-1 RNA at Week 24 and 48 respectively.
  • ‡ Includes lost to follow-up, subject withdrawal, noncompliance, protocol violation and other reasons.
    		•
    HIV-1 RNA <400 copies/mL *40%11%28%30%
    Virologic failure†53%84%61%64%
    Discontinued due to adverse event3%3%5%5%
    Discontinued for other reasons‡3%3%5%1%

    At 24 weeks of therapy, there was a higher proportion of subjects in the VIREAD arm compared to the placebo arm with HIV-1 RNA <50 copies/mL (19% and 1%, respectively). Mean change in absolute CD4+ cell counts by Week 24 was +11 cells/mm3 for the VIREAD group and −5 cells/mm3 for the placebo group. Mean change in absolute CD4+ cell counts by Week 48 was +4 cells/mm3 for the VIREAD group.

    Through Week 24, one subject in the VIREAD group and no subjects in the placebo arm experienced a new CDC Class C event.

    14.2 Clinical Efficacy in Adults with Chronic Hepatitis B

    HBeAg-Negative Chronic Hepatitis B

    Study 0102 was a Phase 3, randomized, double-blind, active-controlled trial of VIREAD 300 mg compared to HEPSERA 10 mg in 375 HBeAg- (anti-HBe+) subjects with compensated liver function, the majority of whom were nucleoside-naïve. The mean age of subjects was 44 years; 77% were male, 25% were Asian, 65% were Caucasian, 17% had previously received alpha-interferon therapy, and 18% were nucleoside-experienced (16% had prior lamivudine experience). At baseline, subjects had a mean Knodell necroinflammatory score of 7.8; mean plasma HBV DNA was 6.9 log10 copies/mL; and mean serum ALT was 140 U/L.

    HBeAg-Positive Chronic Hepatitis B

    Study 0103 was a Phase 3, randomized, double-blind, active-controlled trial of VIREAD 300 mg compared to HEPSERA 10 mg in 266 HBeAg+ nucleoside-naïve subjects with compensated liver function. The mean age of subjects was 34 years; 69% were male, 36% were Asian, 52% were Caucasian, 16% had previously received alpha-interferon therapy, and <5% were nucleoside experienced. At baseline, subjects had a mean Knodell necroinflammatory score of 8.4; mean plasma HBV DNA was 8.7 log10 copies /mL; and mean serum ALT was 147 U/L.

    The primary data analysis was conducted after all subjects reached 48 weeks of treatment and results are summarized below.

    The primary efficacy endpoint in both trials was complete response to treatment defined as HBV DNA <400 copies/mL (69 IU/mL) and Knodell necroinflammatory score improvement of at least 2 points, without worsening in Knodell fibrosis at Week 48 (Table 18).

    Table 18 Histological, Virological, Biochemical, and Serological Response at Week 48
    0102 (HBeAg-)0103 (HBeAg+)
    VIREAD
    (N=250)    		HEPSERA
    (N=125)    		VIREAD
    (N=176)    		HEPSERA
    (N=90)
  • * Knodell necroinflammatory score improvement of at least 2 points without worsening in Knodell fibrosis.
  • † The population used for analysis of ALT normalization included only subjects with ALT above ULN at baseline.
  • ‡ NA = Not Applicable
    		•
    Complete Response71%49%67%12%
    Histology
    Histological Response*    		72%69%74%68%
    HBV DNA
    <400 copies/mL (<69 IU/mL)    		93%63%76%13%
    ALT
    Normalized ALT†    		76%77%68%54%
    Serology
    HBeAg Loss/ Seroconversion    		NA‡NA‡20%/19%16%/16%
    HBsAg Loss/ Seroconversion0/00/03%/1%0/0

    Treatment Beyond 48 Weeks

    In Studies 0102 (HBeAg-negative) and 0103 (HBeAg-positive), subjects who completed double-blind treatment (389 and 196 subjects who were originally randomized to VIREAD and HEPSERA, respectively) were eligible to roll over to open-label VIREAD with no interruption in treatment.

    In Study 0102, 266 of 347 subjects who entered the open-label period (77%) continued in the study through Week 384. Among subjects randomized to VIREAD followed by open-label treatment with VIREAD, 73% had HBV DNA < 400 copies/mL (69 IU/mL), and 63% had ALT normalization at Week 384. Among subjects randomized to HEPSERA followed by open-label treatment with VIREAD, 80% had HBV DNA < 400 copies/mL (69 IU/mL) and 70% had ALT normalization through Week 384. At Week 384, both HBsAg loss and seroconversion were approximately 1% in both treatment groups.

    In Study 0103, 146 of 238 subjects who entered the open-label period (61%) continued in the study through Week 384. Among subjects randomized to VIREAD, 49% had HBV DNA < 400 copies/mL (69 IU/mL), 42% had ALT normalization, and 20% had HBeAg loss (13% seroconversion to anti-HBe antibody) through Week 384. Among subjects randomized to HEPSERA followed by open-label treatment with VIREAD, 56% had HBV DNA < 400 copies/mL (69 IU/mL), 50% had ALT normalization, and 28% had HBeAg loss (19% seroconversion to anti-HBe antibody) through Week 384. At Week 384, HBsAg loss and seroconversion were 11% and 8%, respectively, in subjects initially randomized to VIREAD and 12% and 10%, respectively, in subjects initially randomized to HEPSERA.

    Of the originally randomized and treated 641 subjects in the two studies, liver biopsy data from 328 subjects who received continuing open-label treatment with VIREAD monotherapy were available for analysis at baseline, Week 48, and Week 240. There were no apparent differences between the subset of subjects who had liver biopsy data at Week 240 and those subjects remaining on open-label VIREAD without biopsy data that would be expected to affect histological outcomes at Week 240. Among the 328 subjects evaluated, the observed histological response rates were 80% and 88% at Week 48 and Week 240, respectively. In the subjects without cirrhosis at baseline (Ishak fibrosis score 0–4), 92% (216/235) and 95% (223/235) had either improvement or no change in Ishak fibrosis score at Week 48 and Week 240, respectively. In subjects with cirrhosis at baseline (Ishak fibrosis score 5–6), 97% (90/93) and 99% (92/93) had either improvement or no change in Ishak fibrosis score at Week 48 and Week 240, respectively. Twenty-nine percent (27/93) and 72% (67/93) of subjects with cirrhosis at baseline experienced regression of cirrhosis by Week 48 and Week 240, respectively, with a reduction in Ishak fibrosis score of at least 2 points. No definitive conclusions can be established about the remaining study population who were not part of this subset analysis.

    Patients with Lamivudine-Resistant Chronic Hepatitis B

    Study 121 was a randomized, double-blind, active-controlled trial evaluating the safety and efficacy of VIREAD compared to an unapproved antiviral regimen in subjects with chronic hepatitis B, persistent viremia (HBV DNA ≥ 1000 IU/mL), and genotypic evidence of lamivudine resistance (rtM204I/V +/- rtL180M). One hundred forty-one adult subjects were randomized to the VIREAD treatment arm. The mean age of subjects randomized to VIREAD was 47 years (range 18–73); 74% were male, 59% were Caucasian, and 37% were Asian. At baseline, 54% of subjects were HBeAg-negative, 46% were HBeAg-positive, and 56% had abnormal ALT. Subjects had a mean HBV DNA of 6.4 log10 copies/mL and mean serum ALT of 71 U/L at baseline.

    After 96 weeks of treatment, 126 of 141 subjects (89%) randomized to VIREAD had HBV DNA < 400 copies/mL (69 IU/mL), and 49 of 79 subjects (62%) with abnormal ALT at baseline had ALT normalization. Among the HBeAg-positive subjects randomized to VIREAD, 10 of 65 subjects (15%) experienced HBeAg loss and 7 of 65 subjects (11%) experienced anti-HBe seroconversion through Week 96. The proportion of subjects with HBV DNA concentrations below 400 copies/mL (69 IU/mL) at Week 96 was similar between the VIREAD monotherapy and the comparator arms.

    Across the combined chronic hepatitis B treatment trials, the number of subjects with adefovir-resistance associated substitutions at baseline was too small to establish efficacy in this subgroup.

    Patients with Chronic Hepatitis B and Decompensated Liver Disease

    VIREAD was studied in a small randomized, double-blind, active-controlled trial evaluating the safety of VIREAD compared to other antiviral drugs in subjects with chronic hepatitis B and decompensated liver disease through 48 weeks (Study 0108).

    Forty-five adult subjects (37 males and 8 females) were randomized to the VIREAD treatment arm. At baseline, 69% subjects were HBeAg-negative and 31% were HBeAg-positive. Subjects had a mean Child-Pugh score of 7, a mean MELD score of 12, mean HBV DNA of 5.8 log10 copies/Ml, and mean serum ALT of 61 U/L at baseline. Trial endpoints were discontinuation due to an adverse event and confirmed increase in serum creatinine ≥ 0.5 mg/dL or confirmed serum phosphorus of < 2 mg/dL [See Adverse Reactions (6.1)].

    At 48 weeks, 31/44 (70%) and 12/26 (46%) VIREAD-treated subjects achieved an HBV DNA < 400 copies/mL (69 IU/mL), and normalized ALT, respectively. The trial was not designed to evaluate treatment impact on clinical endpoints such as progression of liver disease, need for liver transplantation, or death.

  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    VIREAD tablets, 300 mg, are almond-shaped, white, film-coated tablets containing 300 mg of tenofovir DF, which is equivalent to 245 mg of tenofovir disoproxil, are debossed with "GILEAD" and "4331" on one side. VIREAD tablets are available in bottles of 30 tablets or 7 tablets. Each bottle also contains a desiccant (silica gel canister or sachet), and is closed with a child-resistant closure.

    Store below 30 °C (86 °F).

    Keep the bottle tightly closed. Dispense only in original container.

    Do not use if seal over bottle opening is broken or missing.

  • 17 PATIENT COUNSELING INFORMATION

    Advise the patient to read the approved patient labeling (Patient Information).

    • Inform patients that VIREAD 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 when using VIREAD.
    • Advise patients to avoid doing things that can spread HIV or HBV to others.
      • Do not share 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. Tenofovir is excreted in breast milk and it is not known whether it can harm the baby. Mothers with HIV-1 should not breastfeed because HIV-1 can be passed to the baby in the breast milk.

    Inform patients that:

    • The long term effects of VIREAD are unknown.
    • VIREAD Tablets are for oral ingestion only.
    • VIREAD should not be discontinued without first informing their physician.
    • If you have HIV-1 infection, with or without HBV coinfection, it is important to take VIREAD with combination therapy.
    • It is important to take VIREAD on a regular dosing schedule and to avoid missing doses.
    • Severe acute exacerbations of hepatitis have been reported in patients who are infected with HBV or coinfected with HBV and HIV-1 and have discontinued VIREAD [See Warnings and Precautions (5.1)].
    • Renal impairment, including cases of acute renal failure and Fanconi syndrome, has been reported. VIREAD should be avoided with concurrent or recent use of a nephrotoxic agent (e.g., high-dose or multiple NSAIDs) [See Warnings and Precautions (5.2)].
    • Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported. Treatment with VIREAD should be suspended in any patient who develops clinical symptoms suggestive of lactic acidosis or pronounced hepatotoxicity [See Warnings and Precautions (5.3)].
    • VIREAD should not be coadministered with ATRIPLA, BIKTARVY, COMPLERA, DESCOVY, GENVOYA, ODEFSEY, STRIBILD, TRUVADA, or VEMLIDY [See Warnings and Precautions (5.4)].
    • VIREAD should not be administered in combination with HEPSERA [See Warnings and Precautions (5.4)].
    • Decreases in bone mineral density have been observed with the use of VIREAD. Bone mineral density monitoring should be considered in patients who have a history of pathologic bone fracture or at risk for osteopenia [See Warnings and Precautions (5.6)].
    • In some patients treated with combination antiretroviral therapy, including VIREAD, signs and symptoms of inflammation from previous infections may occur soon after anti-HIV treatment is started. It is believed that these symptoms are due to an improvement in the body's immune response, enabling the body to fight infections that may have been present with no obvious symptoms. Advise patients to inform their healthcare provider immediately of any symptoms of infection [See Warnings and Precautions (5.7)].
    • In the treatment of chronic hepatitis B, the optimal duration of treatment is unknown. The relationship between response and long-term prevention of outcomes such as hepatocellular carcinoma is not known.
  • SPL UNCLASSIFIED SECTION

    Manufactured for and distributed by:
    Gilead Sciences, Inc.
    Foster City, CA 94404
    Revised: July 2018

    VIREAD, ATRIPLA, BIKTARVY, COMPLERA, DESCOVY, EMTRIVA, EPCLUSA, GENVOYA, HARVONI, HEPSERA, ODEFSEY, SOVALDI, STRIBILD, TRUVADA, VEMLIDY, and VOSEVI are trademarks of Gilead Sciences, Inc., or its related companies. All other trademarks referenced herein are the property of their respective owners.
    © 2018 Gilead Sciences, Inc. All rights reserved.

    21-356-GS-039A

  • PATIENT PACKAGE INSERT

    PATIENT INFORMATION
    VIREAD™ (VEER-ee-ad)
    (tenofovir disoproxil fumarate)
    Tablets

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

    What is the most important information I should know about VIREAD?

    VIREAD can cause serious side effects, including:

    • Worsening of your Hepatitis B infection. Your hepatitis B Virus (HBV) infection may become worse (flare-up) if you take VIREAD and then stop it. A "flare-up" is when your HBV infection suddenly returns in a worse way than before.
      • Do not let your VIREAD run out. Refill your prescription or talk to your healthcare provider before your VIREAD is all gone.
      • Do not stop taking VIREAD without first talking to your healthcare provider.
      • If you stop taking VIREAD, your healthcare provider will need to check your health often and do blood tests regularly to check your HBV infection. Tell your healthcare provider about any new or unusual symptoms you may have after you stop taking VIREAD.

    Talk to your doctor about taking an HIV test before starting treatment with VIREAD for chronic hepatitis B. You should also get a test for HBV if you are taking VIREAD for treatment of HIV.

    What is VIREAD?

    VIREAD is a prescription medicine used:

    • with other antiviral medicines to treat Human Immunodeficiency Virus-1 (HIV-1) in adults and pediatric patients 12 years of age and older. HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome).
      • When used with other HIV medicines, VIREAD may reduce the amount of HIV in your blood (called "viral load"). VIREAD may also help to increase the number of CD4 (T) cells in your blood which help fight off other infections. Reducing the amount of HIV and increasing the CD4 (T) cell count may improve your immune system. This may reduce your risk of death or infections that can happen when your immune system is weak (opportunistic infections).
      • VIREAD does not cure HIV infection or AIDS. People taking VIREAD may still develop infections or other conditions associated with HIV infection.
      • You must stay on continuous HIV therapy to control infection and decrease HIV-related illnesses.
      • It is very important that you stay under the care of your healthcare provider.
      • HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome).
      • It is not known if VIREAD 300mg is safe and effective for the treatment of HIV-1 infection in children under the age of 12 years.
    • to treat chronic (long-lasting) hepatitis B virus (HBV) in people 12 years of age and older.
      • VIREAD will not cure HBV.
      • VIREAD may lower the amount of HBV in your body.
      • VIREAD may improve the condition of your liver.
      • It is not known if VIREAD is safe and effective for treatment of chronic hepatitis B in children under the age of 12 years.

    What should I tell my healthcare provider before taking VIREAD?

    Before you take VIREAD, tell your healthcare provider if you:

    • have liver problems, including hepatitis B (HBV) infection.
    • have kidney problems.
    • have bone problems.
    • have any other medical conditions, including HIV infection.
    • are pregnant or plan to become pregnant. It is not known if VIREAD will harm your unborn baby.
      Pregnancy Registry. There is a pregnancy registry for women who take antiviral medicines during pregnancy. Its purpose is to collect information about the health of you and your baby. Talk to your healthcare provider about how you can take part in this registry.
    • are breastfeeding or plan to breast-feed. Do not breastfeed if you are taking VIREAD. Tenofovir passes into your breast milk. You should not breastfeed because of the risk of passing HIV to your baby. Talk to your healthcare provider about the best way to feed your baby.

    Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins and herbal supplements.

    Some medicines may affect how VIREAD works.

    • Keep a list of your medicines and show it to your healthcare provider and pharmacist when you get a new medicine. You can ask your healthcare provider or pharmacist for a list of medicines that interact with VIREAD.
    • Do not start a new medicine without telling your healthcare provider. Your healthcare provider can tell you if it is safe to take VIREAD with other medicines.

    How should I take VIREAD?

    • See "What is the most important information I should know about VIREAD?"
    • Take VIREAD exactly as your healthcare provider tells you to take it.
    • Take VIREAD at the same time every day.
    • For adults and children 12 years of age and older, the usual dose of VIREAD is one 300 mg tablet each day.
    • If you are an adult with kidney problems, your healthcare provider may tell you to take VIREAD less often.
    • Take VIREAD tablets by mouth, with or without food.
    • Do not miss a dose of VIREAD. If you miss a dose of VIREAD, take the missed dose as soon as you remember. If it is almost time for your next dose of VIREAD, do not take the missed dose. Take the next dose of VIREAD at your regular time.
    • If you take too much VIREAD, call your local poison control center or go right away to the nearest hospital emergency room.

    What are the possible side effects of VIREAD?

    VIREAD may cause serious side effects, including:

    • See "What is the most important information I should know about VIREAD?"
    • New or worse kidney problems, including kidney failure, can happen in some people who take VIREAD. Your healthcare provider should do blood tests to check your kidneys before you start treatment with VIREAD. If you have had kidney problems in the past or need to take another medicine that can cause kidney problems, your healthcare provider may need to do blood tests to check your kidneys during your treatment with VIREAD.
    • Too much lactic acid in your blood (lactic acidosis). Too much lactic acid is a serious but rare medical emergency that can lead to death. Tell your healthcare provider right away if you get these symptoms: weakness or being more tired than usual, unusual muscle pain, being short of breath or fast breathing, stomach pain with nausea and vomiting, cold or blue hands and feet, feel dizzy or lightheaded, or a fast or abnormal heartbeat.
    • Severe liver problems. In rare cases, severe liver problems can happen that can lead to death. Tell your healthcare provider right away if you get these symptoms: skin or the white part of your eyes turns yellow, dark "tea-colored" urine, light-colored stools, loss of appetite for several days or longer, nausea, or stomach-area pain.
    • Bone problems can happen in some people who take VIREAD. Bone problems include bone pain, softening or thinning (which may lead to fractures). Your healthcare provider may need to do additional tests to check your bones.
    • Changes in your immune system (Immune Reconstitution Syndrome) can happen when you start taking HIV 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 healthcare provider if you start having new symptoms after starting your HIV medicine.

    The most common side effects in all people who take VIREAD are:

    • nausea
    • rash
    • diarrhea
    • headache
    • pain
    • depression
    • weakness

    In some people with advanced HBV-infection, other common side effects may include:

    • sleeping problems
    • itching
    • vomiting
    • dizziness
    • fever

    Tell your healthcare provider if you have any side effect that bothers you or that does not go away.

    These are not all the possible side effects of VIREAD. For more information, ask your healthcare provider or pharmacist.

    Call your doctor for medical advice about side effects.

    To report SUSPECTED ADVERSE REACTIONS, contact Gilead Sciences, Inc. at safety_fc@gilead.com or the US FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.

    How should I store VIREAD?

    • Store VIREAD below 30°C (86°F).
    • Keep VIREAD in the original container.
    • Do not use VIREAD if the seal over the bottle opening is broken or missing.
    • Keep the bottle tightly closed.

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

    General information about VIREAD:

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

    Avoid doing things that can spread HIV-1 or HBV infection to others.

    • Do not share or re-use 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 safe sex by using a latex or polyurethane condom to lower the chance of sexual contact with semen, vaginal secretions, or blood.

    A vaccine is available to protect people at risk for becoming infected with HBV. You can ask your healthcare provider for information about this vaccine.

    This leaflet summarizes the most important information about VIREAD. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information about VIREAD that is written for health professionals.

    For more information, go to www.viread.com

    What are the ingredients in VIREAD?

    Active Ingredient: tenofovir disoproxil fumarate

    Inactive Ingredients: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and pregelatinized starch.

    Tablet Coating: Opadry II 32K18425, which contains hypromellose 2910, lactose monohydrate, titanium dioxide, and triacetin.

    Manufactured for and distributed by:

    Gilead Sciences, Inc.

    Foster City, CA 94404

    Revised: July 2018

    VIREAD is a trademark of Gilead Sciences, Inc., or its related companies, in the United States and other countries.

    21-356-GS-039A
  • PRINCIPAL DISPLAY PANEL - 300 mg Tablet Bottle Label

    61958-0402-6
    30 tablets

    Viread™
    (tenofovir disoproxil
    fumarate) tablets, 300 mg

    GILEAD ACCESS PROGRAM

    Note to pharmacist:
    Do not cover ALERT box with pharmacy label.

    ALERT: Find out about medicines that
    should NOT be taken with Viread

    Rx only
    POM

    PRINCIPAL DISPLAY PANEL - 300 mg Tablet Bottle Label
  • INGREDIENTS AND APPEARANCE
    VIREAD ACCESS 
    tenofovir disoproxil fumarate tablet, coated
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 61958-0402
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    TENOFOVIR DISOPROXIL FUMARATE (UNII: OTT9J7900I) (TENOFOVIR ANHYDROUS - UNII:W4HFE001U5) TENOFOVIR DISOPROXIL FUMARATE300 mg
    Inactive Ingredients
    Ingredient NameStrength
    STARCH, CORN (UNII: O8232NY3SJ)  
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    LACTOSE MONOHYDRATE (UNII: EWQ57Q8I5X)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    HYPROMELLOSE, UNSPECIFIED (UNII: 3NXW29V3WO)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    TRIACETIN (UNII: XHX3C3X673)  
    WATER (UNII: 059QF0KO0R)  
    Product Characteristics
    ColorwhiteScoreno score
    ShapeFREEFORM (Almond-shaped) Size17mm
    FlavorImprint Code GILEAD;4331
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 61958-0402-330 in 1 BOTTLE, PLASTIC; Type 0: Not a Combination Product10/26/2001
    2NDC: 61958-0402-630 in 1 BOTTLE, PLASTIC; Type 0: Not a Combination Product10/26/2001
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    Export only10/26/2001
    Labeler - Gilead Sciences, Inc. (185049848)
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