Objective and Subjective Improvement of Cognition After Discontinuing Efavirenz in Asymptomatic Patients: A Randomized Controlled Trial

BACKGROUND: Efavirenz is well known for its clinical cognitive side-effects. Even asymptomatic patients who switch for other reasons than neurocognitive complaints have reported a subjective improvement in cognitive functioning after discontinuing Efavirenz. The aim of this study was to assess the effect on cognition of switching Atripla (TDF/FTC/EFV) to Eviplera (TDF/FTC/RPV), hypothesizing an improvement when discontinuing Efavirenz. SETTING: a randomized controlled design with a highly comparable comparator drug was used to minimize bias and to differentiate drug- versus learning effects. An extensive sensitive neuropsychological assessment (NPA) was used to detect subtle changes. METHODS: virologically suppressed, cognitively asymptomatic male HIV-infected patients on Atripla were included and randomized (2:1) to switch to Eviplera (switch group) or continue on Atripla (control group) for 12 weeks. At baseline and week 12, patients underwent an extensive NPA. RESULTS: 14 control and 34 switch subjects completed the study. There were no differences at baseline. Group-analysis demonstrated a significantly better improvement for the switch group on the domains attention (p=0.041) and speed of information processing (p=0.014). Normative comparison analyses showed that 5 out of the 34 patients who switched (15%) improved on NPA-score as compared to the control group. Interestingly, subjective improvement after discontinuing Efavirenz made 74% of the switch group chose for a regime without Efavirenz after study completion. CONCLUSION: switching from Atripla to Eviplera resulted in objective cognitive improvement on group level in cognitively asymptomatic patients. Discrepancies in objective and subjective cognitive complaints make it challenging to identify patients that would benefit from discontinuing Efavirenz