HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use EMEND safely and effectively. See full prescribing information for EMEND.
EMEND (aprepitant) capsules, for oral use
Initial U.S. Approval: 2003
INDICATIONS AND USAGE
EMEND® is a substance P/neurokinin 1 (NK1) receptor antagonist, indicated:
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in combination with other antiemetic agents for the:
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prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy (HEC) including high-dose cisplatin (1.1)
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prevention of nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (MEC) (1.1)
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for the prevention of postoperative nausea and vomiting (PONV) (1.2)
Limitations of Use (1.3)
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Not studied for the treatment of established nausea and vomiting.
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Chronic continuous administration is not recommended.
DOSAGE AND ADMINISTRATION
Prevention of Chemotherapy Induced Nausea and Vomiting (2.1)
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EMEND is given for 3 days as part of the chemotherapy induced nausea and vomiting (CINV) regimen that includes a corticosteroid and a 5-HT3 antagonist. (2.1)
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The recommended dose of EMEND is 125 mg orally 1 hour prior to chemotherapy treatment (Day 1) and 80 mg orally once daily in the morning on Days 2 and 3. (2.1)
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EMEND (fosaprepitant dimeglumine) for Injection may be substituted for oral EMEND (125 mg) on Day 1 only as part of the CINV regimen. (2.1)
Prevention of Postoperative Nausea and Vomiting (2.2)
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The recommended oral dosage of EMEND for the postoperative nausea and vomiting (PONV) indication is 40 mg within 3 hours prior to induction of anesthesia. (2.2)
DOSAGE FORMS AND STRENGTHS
Capsules: 40 mg; 80 mg; 125 mg (3)
CONTRAINDICATIONS
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Hypersensitivity to any component of this medication. (4, 6.2)
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EMEND should not be used concurrently with pimozide, terfenadine, astemizole, or cisapride, since inhibition of CYP3A4 by aprepitant could result in elevated plasma concentrations of these drugs, potentially causing serious or life-threatening reactions. (4)
WARNINGS AND PRECAUTIONS
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Coadministration of aprepitant with warfarin (a CYP2C9 substrate) may result in a clinically significant decrease in International Normalized Ratio (INR) of prothrombin time. (5.2)
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The efficacy of hormonal contraceptives during and for 28 days following the last dose of EMEND may be reduced. Alternative or back-up methods of contraception should be used. (5.3, 7.1)
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EMEND is a dose-dependent inhibitor of CYP3A4, and should be used with caution in patients receiving concomitant medications that are primarily metabolized through CYP3A4. (5.1)
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Caution should be exercised when administered in patients with severe hepatic impairment. (2.5, 5.4, 12.3)
ADVERSE REACTIONS
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Clinical adverse experiences for the CINV regimen in conjunction with highly and moderately emetogenic chemotherapy (incidence >10%) are: alopecia, anorexia, asthenia/fatigue, constipation, diarrhea, headache, hiccups, nausea. (6.1)
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Clinical adverse experiences for the PONV regimen (incidence >5%) are: constipation, hypotension, nausea, pruritus, pyrexia. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-877-888-4231 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
DRUG INTERACTIONS
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Aprepitant is a substrate for CYP3A4; therefore, coadministration of EMEND with drugs that inhibit or induce CYP3A4 activity may result in increased or reduced plasma concentrations of aprepitant, respectively. (5.1, 7.1, 7.2).
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Aprepitant is an inducer of CYP2C9; therefore, coadministration of EMEND with drugs that are metabolized by CYP2C9 (e.g., warfarin, tolbutamide), may result in lower plasma concentrations of these drugs. (5.2, 7.1)
See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling.
Revised: 8/2014
FULL PRESCRIBING INFORMATION: CONTENTS*
1 INDICATIONS AND USAGE
1.1 Prevention of Chemotherapy Induced Nausea and Vomiting (CINV)
EMEND®, in combination with other antiemetic agents, is indicated for the:
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prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy (HEC) including high-dose cisplatin
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prevention of nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (MEC) [see Dosage and Administration (2.1)].
1.2 Prevention of Postoperative Nausea and Vomiting (PONV)
EMEND is indicated for the prevention of postoperative nausea and vomiting [see Dosage and Administration (2.2)].
1.3 Limitations of Use
EMEND has not been studied for the treatment of established nausea and vomiting.
Chronic continuous administration is not recommended [see Warnings and Precautions (5.5)].
2 DOSAGE AND ADMINISTRATION
2.1 Prevention of Chemotherapy Induced Nausea and Vomiting (CINV)
Capsules of EMEND (aprepitant) are given for 3 days as part of a regimen that includes a corticosteroid and a 5-HT3 antagonist. The recommended dose of EMEND is 125 mg orally 1 hour prior to chemotherapy treatment (Day 1) and 80 mg orally once daily in the morning on Days 2 and 3.
The package insert for the co-administered 5-HT3 antagonist must be consulted prior to initiation of treatment with EMEND.
EMEND may be taken with or without food.
EMEND (fosaprepitant dimeglumine) for Injection (115 mg) is a prodrug of aprepitant and may be substituted for oral EMEND (125 mg), 30 minutes prior to chemotherapy, on Day 1 only of the CINV regimen as an intravenous infusion administered over 15 minutes.
The following regimen should be used for the prevention of nausea and vomiting associated with highly emetogenic cancer chemotherapy:
The following regimen should be used for the prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy:
2.2 Prevention of Postoperative Nausea and Vomiting (PONV)
The recommended oral dosage of EMEND is 40 mg within 3 hours prior to induction of anesthesia.
EMEND may be taken with or without food.
2.3 Geriatric Patients
No dosage adjustment is necessary for the elderly.
2.4 Patients with Renal Impairment
No dosage adjustment is necessary for patients with renal impairment or for patients with end stage renal disease (ESRD) undergoing hemodialysis.
2.5 Patients with Hepatic Impairment
No dosage adjustment is necessary for patients with mild to moderate hepatic impairment (Child-Pugh score 5 to 9). There are no clinical data in patients with severe hepatic impairment (Child-Pugh score >9).
2.6 Coadministration with Other Drugs
For additional information on dose adjustment for corticosteroids when coadministered with EMEND, see Drug Interactions (7.1).
Refer to the full prescribing information for coadministered antiemetic agents.
3 DOSAGE FORMS AND STRENGTHS
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Capsules EMEND 40 mg are opaque, hard, gelatin capsules, with white body and mustard yellow cap with "464" and "40 mg" printed radially in black ink on the body.
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Capsules EMEND 80 mg are white, opaque, hard, gelatin capsules, with "461" and "80 mg" printed radially in black ink on the body.
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Capsules EMEND 125 mg are opaque, hard, gelatin capsules, with white body and pink cap with "462" and "125 mg" printed radially in black ink on the body.
4 CONTRAINDICATIONS
EMEND is contraindicated in patients who are hypersensitive to any component of the product.
EMEND is a dose-dependent inhibitor of cytochrome P450 isoenzyme 3A4 (CYP3A4). EMEND should not be used concurrently with pimozide, terfenadine, astemizole, or cisapride. Inhibition of CYP3A4 by aprepitant could result in elevated plasma concentrations of these drugs, potentially causing serious or life-threatening reactions [see Drug Interactions (7.1)].
5 WARNINGS AND PRECAUTIONS
5.1 CYP3A4 Interactions
EMEND (aprepitant), a dose-dependent inhibitor of CYP3A4, should be used with caution in patients receiving concomitant medications that are primarily metabolized through CYP3A4.
Moderate inhibition of CYP3A4 by aprepitant, 125-mg/80-mg regimen, could result in elevated plasma concentrations of these concomitant medications.
Weak inhibition of CYP3A4 by a single 40-mg dose of aprepitant is not expected to alter the plasma concentrations of concomitant medications that are primarily metabolized through CYP3A4 to a clinically significant degree.
When aprepitant is used concomitantly with another CYP3A4 inhibitor, aprepitant plasma concentrations could be elevated. When EMEND is used concomitantly with medications that induce CYP3A4 activity, aprepitant plasma concentrations could be reduced and this may result in decreased efficacy of EMEND [see Drug Interactions (7.1)].
Chemotherapy agents that are known to be metabolized by CYP3A4 include docetaxel, paclitaxel, etoposide, irinotecan, ifosfamide, imatinib, vinorelbine, vinblastine and vincristine. In clinical studies, EMEND (125-mg/80-mg regimen) was administered commonly with etoposide, vinorelbine, or paclitaxel. The doses of these agents were not adjusted to account for potential drug interactions.
In separate pharmacokinetic studies, no clinically significant change in docetaxel or vinorelbine pharmacokinetics was observed when EMEND (125-mg/80-mg regimen) was co-administered.
Due to the small number of patients in clinical studies who received the CYP3A4 substrates vinblastine, vincristine, or ifosfamide, particular caution and careful monitoring are advised in patients receiving these agents or other chemotherapy agents metabolized primarily by CYP3A4 that were not studied [see Drug Interactions (7.1)].
5.2 Coadministration with Warfarin (a CYP2C9 substrate)
Coadministration of EMEND with warfarin may result in a clinically significant decrease in International Normalized Ratio (INR) of prothrombin time. In patients on chronic warfarin therapy, the INR should be closely monitored in the 2-week period, particularly at 7 to 10 days, following initiation of the 3-day regimen of EMEND with each chemotherapy cycle, or following administration of a single 40-mg dose of EMEND for the prevention of postoperative nausea and vomiting [see Drug Interactions (7.1)].
5.3 Coadministration with Hormonal Contraceptives
Upon coadministration with EMEND, the efficacy of hormonal contraceptives during and for 28 days following the last dose of EMEND may be reduced. Alternative or back-up methods of contraception should be used during treatment with EMEND and for 1 month following the last dose of EMEND [see Drug Interactions (7.1)].
5.4 Patients with Severe Hepatic Impairment
There are no clinical or pharmacokinetic data in patients with severe hepatic impairment (Child-Pugh score >9). Therefore, caution should be exercised when EMEND is administered in these patients [see Clinical Pharmacology (12.3) and Dosage and Administration (2.5)].
5.5 Chronic Continuous Use
Chronic continuous use of EMEND for prevention of nausea and vomiting is not recommended because it has not been studied; and because the drug interaction profile may change during chronic continuous use.
6 ADVERSE REACTIONS
The overall safety of aprepitant was eva luated in approximately 5300 individuals.
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 clinical practice.
6.1 Clinical Trials Experience
Chemotherapy Induced Nausea and Vomiting
Highly Emetogenic Chemotherapy
In 2 well-controlled clinical trials in patients receiving highly emetogenic cancer chemotherapy, 544 patients were treated with aprepitant during Cycle 1 of chemotherapy and 413 of these patients continued into the Multiple-Cycle extension for up to 6 cycles of chemotherapy. EMEND was given in combination with ondansetron and dexamethasone.
In Cycle 1, clinical adverse experiences were reported in approximately 69% of patients treated with the aprepitant regimen compared with approximately 68% of patients treated with standard therapy. Table 1 shows the percent of patients with clinical adverse experiences reported at an incidence ≥3%.
In addition, isolated cases of serious adverse experiences, regardless of causality, of bradycardia, disorientation, and perforating duodenal ulcer were reported in highly emetogenic CINV clinical studies.
Moderately Emetogenic Chemotherapy
During Cycle 1 of 2 moderately emetogenic chemotherapy studies, 868 patients were treated with the aprepitant regimen and 686 of these patients continued into extensions for up to 4 cycles of chemotherapy. In the combined analysis of Cycle 1 data for these 2 studies, adverse experiences were reported in approximately 69% of patients treated with the aprepitant regimen compared with approximately 72% of patients treated with standard therapy.
In the combined analysis of Cycle 1 data for these 2 studies, the adverse experience profile in both moderately emetogenic chemotherapy studies was generally comparable to the highly emetogenic chemotherapy studies. Table 2 shows the percent of patients with clinical adverse experiences reported at an incidence ≥3%.
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