Orkambi 100mg/125mg film coated tablets
Orkambi 100mg/125mg film coated tablets
Vertex Pharmaceuticals (Europe) Limited
contact details
Active ingredient
ivacaftor
lumacaftor
Legal Category
POM: Prescription only medicine
Orkambi 100 mg/125 mg film-coated tablets
Orkambi 200 mg/125 mg film-coated tablets
Orkambi 100 mg/125 mg film-coated tablets
Each film-coated tablet contains 100 mg of lumacaftor and 125 mg of ivacaftor.
Orkambi 200 mg/125 mg film-coated tablets
Each film-coated tablet contains 200 mg of lumacaftor and 125 mg of ivacaftor.
For the full list of excipients, see section 6.1.
Film-coated tablet (tablet)
Orkambi 100 mg/125 mg film-coated tablets
Pink, oval-shaped tablets (dimensions 14 × 7.6 × 4.9 mm) printed with “1V125” in black ink on one side.
Orkambi 200 mg/125 mg film-coated tablets
Pink, oval-shaped tablets (dimensions 14 × 8.4 × 6.8 mm) printed with “2V125” in black ink on one side.
Orkambi is indicated for the treatment of cystic fibrosis (CF) in patients aged 6 years and older who are homozygous for the F508del mutation in the CFTR gene (see sections 4.2, 4.4 and 5.1).
Orkambi should only be prescribed by physicians with experience in the treatment of CF. If the patient's genotype is unknown, an accurate and validated genotyping method should be performed to confirm the presence of the F508del mutation on both alleles of the CFTR gene.
Posology
For standard dosing recommendations see Table 1.
Table 1: Recommended dose of Orkambi in patients aged 6 years and older
|
Age
|
Orkambi dose
|
Total daily dose
|
6 to 11 years
|
Two lumacaftor 100 mg/ivacaftor 125 mg tablets every 12 hours
|
lumacaftor 400 mg/ ivacaftor 500 mg
|
12 years and older
|
Two lumacaftor 200 mg/ivacaftor 125 mg tablets every 12 hours
|
lumacaftor 800 mg/ ivacaftor 500 mg
|
Orkambi should be taken with fat-containing food. A fat-containing meal or snack should be consumed just before or just after dosing (see section 5.2).
Missed dose
If less than 6 hours have passed since the missed dose, the scheduled dose of Orkambi should be taken with fat-containing food. If more than 6 hours have passed, the patient should be instructed to wait until the next scheduled dose. A double dose should not be taken to make up for the forgotten dose.
Concomitant use of CYP3A inhibitors
No dose adjustment is necessary when CYP3A inhibitors are initiated in patients currently taking Orkambi. However, when initiating Orkambi in patients taking strong CYP3A inhibitors, the dose should be reduced to one tablet daily (lumacaftor 100 mg/ivacaftor 125 mg total daily dose for patients aged 6 to 11 years; lumacaftor 200 mg/ivacaftor 125 mg total daily dose for patients aged 12 years and older) for the first week of treatment to allow for the steady state induction effect of lumacaftor. Following this period, the recommended daily dose should be continued.
If Orkambi is interrupted for more than one week and then re-initiated while taking strong CYP3A inhibitors, the Orkambi dose should be reduced to one tablet daily for the first week of treatment re-initiation. Following this period, the recommended daily dose should be continued (see section 4.5).
Special populations
Hepatic impairment
No dose adjustment is necessary for patients with mild hepatic impairment (Child-Pugh Class A). For patients with moderate hepatic impairment (Child-Pugh Class B), a dose reduction is recommended.
There is no experience of the use of Orkambi in patients with severe hepatic impairment (Child-Pugh Class C), but exposure is expected to be higher than in patients with moderate hepatic impairment. Therefore, after weighing the risks and benefits of treatment, Orkambi should be used with caution at a reduced dose (see sections 4.4, 4.8, and 5.2).
For dose adjustments for patients with hepatic impairment see Table 2.
Table 2: Dose adjustment recommendations for patients with hepatic impairment
|
Hepatic impairment
|
Dose adjustment
|
Total daily dose
|
Mild hepatic impairment
(Child-Pugh Class A)
|
No dose adjustment
|
For patients aged 6 to 11 years
400 mg lumacaftor + 500 mg ivacaftor
For patients aged 12 years and older
800 mg lumacaftor + 500 mg ivacaftor
|
Moderate hepatic impairment
(Child-Pugh Class B)
|
2 tablets in the morning + 1 tablet in the evening (12 hours later)
|
For patients aged 6 to 11 years
300 mg lumacaftor + 375 mg ivacaftor
For patients aged 12 years and older
600 mg lumacaftor + 375 mg ivacaftor
|
Severe hepatic impairment
(Child-Pugh Class C)
|
1 tablet every 12 hours (or a lower dose)
|
For patients aged 6 to 11 years
200 mg lumacaftor + 250 mg ivacaftor (or a lower dose)
For patients aged 12 years and older
400 mg lumacaftor + 250 mg ivacaftor (or a lower dose)
|
Renal impairment
No dose adjustment is necessary for patients with mild to moderate renal impairment. Caution is recommended while using Orkambi in patients with severe renal impairment (creatinine clearance less than or equal to 30 mL/min) or end-stage renal disease (see sections 4.4 and 5.2).
Elderly people
The safety and efficacy of Orkambi in patients aged 65 years or older have not been eva luated.
Paediatric population
The safety and efficacy of Orkambi in children aged less than 6 years have not yet been established. No data are available (see section 5.1).
Method of administration
For oral use. Patients should be instructed to swallow the tablets whole. Patients should not chew, break, or dissolve the tablets. Patients may start taking Orkambi on any day of the week.
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.
Patients with CF who are heterozygous for the F508del mutation in the CFTR gene
Lumacaftor/ivacaftor is not effective in patients with CF who have the F508del mutation on one allele plus a second allele with a mutation predicted to result in a lack of CFTR production or that is not responsive to ivacaftor in vitro (see section 5.1).
Patients with CF who have a gating (Class III) mutation in the CFTR gene
Lumacaftor/ivacaftor has not been studied in patients with CF who have a gating (Class III) mutation in the CFTR gene on one allele, with or without the F508del mutation on the other allele. Since the exposure of ivacaftor is very significantly reduced when dosed in combination with lumacaftor, lumacaftor/ivacaftor should not be used in these patients.
Respiratory events
Respiratory events (e.g., chest discomfort, dyspnoea, and respiration abnormal) were more common during initiation of lumacaftor/ivacaftor therapy. Serious respiratory events were seen more frequently in patients with percent predicted FEV1 (ppFEV1) <40, and may lead to drug discontinuation. Clinical experience in patients with ppFEV1 <40 is limited and additional monitoring of these patients is recommended during initiation of therapy (see section 4.8). A transient decline in FEV1 has also been observed in some patients following initiation of lumacaftor/ivacaftor. There is no experience of initiating treatment with lumacaftor/ivacaftor in patients having a pulmonary exacerbation and initiating treatment in patients having a pulmonary exacerbation is not advisable.
Effect on Blood Pressure
Increased blood pressure has been observed in some patients treated with lumacaftor/ivacaftor. Blood pressure should be monitored periodically in all patients during treatment (see section 4.8).
Patients with advanced liver disease
Abnormalities in liver function, including advanced liver disease, can be present in patients with CF. Worsening of liver function in patients with advanced liver disease has been reported. Liver function decompensation, including liver failure leading to death, has been reported in CF patients with pre-existing cirrhosis with portal hypertension receiving lumacaftor/ivacaftor. Lumacaftor/ivacaftor should be used with caution in patients with advanced liver disease and only if the benefits are expected to outweigh the risks. If lumacaftor/ivacaftor is used in these patients, they should be closely monitored after the initiation of treatment and the dose should be reduced (see sections 4.2, 4.8, and 5.2).
Hepatobiliary events
Elevated transaminases have been reported in patients with CF receiving lumacaftor/ivacaftor. In some instances, these elevations have been associated with concomitant elevations in total serum bilirubin.
Because an association with liver injury cannot be excluded, assessments of liver function tests (ALT, AST and bilirubin) are recommended before initiating lumacaftor/ivacaftor, every 3 months during the first year of treatment, and annually thereafter. For patients with a history of ALT, AST, or bilirubin elevations, more frequent monitoring should be considered.
In the event of significant elevation of ALT or AST, with or without elevated bilirubin (either ALT or AST >5 x the upper limit of normal [ULN], or ALT or AST >3 x ULN with bilirubin >2 x ULN), dosing with lumacaftor/ivacaftor should be discontinued and laboratory tests closely followed until the abnormalities resolve. Following resolution of transaminase elevations, the benefits and risks of resuming dosing should be considered (see sections 4.2, 4.8, and 5.2).
Interactions with medicinal products
Substrates of CYP3A
Lumacaftor is a strong inducer of CYP3A. Co-administration with sensitive CYP3A substrates or CYP3A substrates with a narrow therapeutic index is not recommended (see section 4.5).
Hormonal contraceptives, including oral, injectable, transdermal, and implantable, should not be relied upon as an effective method of contraception when co-administered with Orkambi (see section 4.5).
Strong CYP3A inducers
Ivacaftor is a substrate of CYP3A4 and CYP3A5. Therefore, co-administration with strong CYP3A inducers (e.g., rifampicin, St. John's wort [Hypericum perforatum]) is not recommended (see section 4.5).
Renal impairment
Caution is recommended while using lumacaftor/ivacaftor in patients with severe renal impairment or end-stage renal disease (see sections 4.2 and 5.2).
Cataracts
Cases of non-congenital lens opacities without impact on vision have been reported in paediatric patients treated with lumacaftor/ivacaftor and ivacaftor monotherapy. Although other risk factors were present in some cases (such as corticosteroid use and exposure to radiation), a possible risk attributable to ivacaftor cannot be excluded (see section 5.3). Baseline and follow-up ophthalmological examinations are recommended in paediatric patients initiating treatment with lumacaftor/ivacaftor.
Patients after organ transplantation
Lumacaftor/ivacaftor has not been studied in patients with CF who have undergone organ transplantation. Therefore, use in transplanted patients is not recommended. See section 4.5 for interactions with immunosuppressants.
The drug interaction profile for lumacaftor 200 mg/ivacaftor 250 mg every 12 hours is considered to be the same as that for lumacaftor 400 mg/ivacaftor 250 mg every 12 hours, based on exposure at the indicated doses.
Lumacaftor is a strong inducer of CYP3A and ivacaftor is a weak inhibitor of CYP3A when given as monotherapy. There is potential for other medicinal products to affect lumacaftor/ivacaftor when administered concomitantly, and also for lumacaftor/ivacaftor to affect other medicinal products.
Potential for other medicinal products to affect lumacaftor/ivacaftor
Inhibitors of CYP3A
Co-administration of lumacaftor/ivacaftor with itraconazole, a strong CYP3A inhibitor, did not impact the exposure of lumacaftor, but increased ivacaftor exposure by 4.3-fold. Due to the induction effect of lumacaftor on CYP3A, at steady-state, the net exposure of ivacaftor when co-administered with a CYP3A inhibitor is not expected to exceed that when given in the absence of lumacaftor at a dose of 150 mg every 12 hours, the approved dose of ivacaftor monotherapy.
No dose adjustment is necessary when CYP3A inhibitors are initiated in patients currently taking lumacaftor/ivacaftor. However, when initiating lumacaftor/ivacaftor in patients taking strong CYP3A inhibitors, the dose should be adjusted (see sections 4.2 and 4.4).
No dose adjustment is recommended when used with moderate or weak CYP3A inhibitors.
Inducers of CYP3A
Co-administration of lumacaftor/ivacaftor with rifampicin, a strong CYP3A inducer, had minimal effect on the exposure of lumacaftor, but decreased ivacaftor exposure (AUC) by 57%. Therefore, co-administration of lumacaftor/ivacaftor is not recommended with strong CYP3A inducers (see sections 4.2 and 4.4).
No dose adjustment is recommended when used with moderate or weak CYP3A inducers.
Potential for lumacaftor/ivacaftor to affect other medicinal products
CYP3A substrates
Lumacaftor is a strong inducer of CYP3A. Ivacaftor is a weak inhibitor of CYP3A when given as monotherapy. The net effect of lumacaftor/ivacaftor therapy is expected to be strong CYP3A induction. Therefore, concomitant use of lumacaftor/ivacaftor with CYP3A substrates may decrease the exposure of these substrates (see section 4.4).
P-gp substrates
In vitro studies indicated that lumacaftor has the potential to both inhibit and induce P-gp. Additionally, a clinical study with ivacaftor monotherapy showed that ivacaftor is a weak inhibitor of P-gp. Therefore, concomitant use of lumacaftor/ivacaftor with P-gp substrates (e.g., digoxin) may alter the exposure of these substrates.
CYP2B6 and CYP2C substrates
Interaction with CYP2B6 and CYP2C substrates has not been investigated in vivo. In vitro studies suggest that lumacaftor has the potential to induce CYP2B6, CYP2C8, CYP2C9, and CYP2C19; however, inhibition of CYP2C8 and CYP2C9 has also been observed in vitro. Additionally, in vitro studies suggest that ivacaftor may inhibit CYP2C9. Therefore, concomitant use of lumacaftor/ivacaftor may alter (i.e., either increase or decrease) the exposure of CYP2C8 and CYP2C9 substrates, decrease the exposure of CYP2C19 substrates, and substantially decrease the exposure of CYP2B6 substrates.
Potential for lumacaftor/ivacaftor to interact with transporters
In vitro experiments show that lumacaftor is a substrate for Breast Cancer Resistance Protein (BCRP). Co-administration of Orkambi with medicinal products that inhibit BCRP may increase plasma lumacaftor concentration. Lumacaftor inhibits the organic anion transporter (OAT) 1 and 3. Lumacaftor and ivacaftor are inhibitors of BCRP. Co-administration of Orkambi with medicinal products that are substrates for OAT1/3 and BCRP transport may increase plasma concentrations of such medicinal products. Lumacaftor and ivacaftor are not inhibitors of OATP1B1, OATP1B3, and organic cation transporter (OCT) 1 and 2. Ivacaftor is not an inhibitor of OAT1 and OAT3.
Established and other potentially significant drug interactions
Table 3 provides the established or predicted effect of lumacaftor/ivacaftor on other medicinal products or the effect of other medicinal products on lumacaftor/ivacaftor. The information reported in the Table mostly derives from in vitro studies. The recommendations provided under “Clinical comment” in Table 3 are based on drug interaction studies, clinical relevance, or predicted interactions due to elimination pathways. Drug interactions that have the most clinical relevance are listed first.
Table 3: Established and other potentially significant drug interactions - dose recommendations for use of lumacaftor/ivacaftor with other medicinal products
|
Concomitant medicinal product class:
Active substance name
|
Effect
|
Clinical comment
|
Concomitant medicinal products of most clinical relevance
|
Anti-allergics:
montelukast
|
↔ LUM, IVA
↓ montelukast
Due to the induction of CYP3A/2C8/2C9 by LUM
|
No dose adjustment for montelukast is recommended. Appropriate clinical monitoring should be employed, as is reasonable, when co-administered with lumacaftor/ivacaftor. Lumacaftor/ivacaftor may decrease the exposure of montelukast, which may reduce its efficacy.
|
fexofenadine
|
↔ LUM, IVA
↑ or ↓ fexofenadine
Due to potential induction or inhibition of P-gp
|
Dose adjustment of fexofenadine may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may alter the exposure of fexofenadine.
|
Antibiotics:
clarithromycin, telithromycin
|
↔ LUM
↑ IVA
Due to inhibition of CYP3A by clarithromycin, telithromycin
↓ clarithromycin, telithromycin
Due to induction of CYP3A by LUM
|
No dose adjustment of lumacaftor/ivacaftor is recommended when clarithromycin or telithromycin are initiated in patients currently taking lumacaftor/ivacaftor.
The dose of lumacaftor/ivacaftor should be reduced to one tablet daily for the first week of treatment when initiating lumacaftor/ ivacaftor in patients currently taking clarithromycin or telithromycin.
An alternative to these antibiotics, such as azithromycin, should be considered. Lumacaftor/ivacaftor may decrease the exposures of clarithromycin and telithromycin, which may reduce their efficacy.
|
erythromycin
|
↔ LUM
↑ IVA
Due to inhibition of CYP3A by erythromycin
↓ erythromycin
Due to induction of CYP3A by LUM
|
No dose adjustment of lumacaftor/ivacaftor is recommended when co-administered with erythromycin.
An alternative to erythromycin, such as azithromycin, should be considered. Lumacaftor/ivacaftor may decrease the exposure of erythromycin, which may reduce its efficacy.
|
Anticonvulsants:
carbamazepine, phenobarbital, phenytoin
|
↔ LUM
↓ IVA
Due to induction of CYP3A by these anticonvulsants
↓ carbamazepine, phenobarbital, phenytoin
Due to induction of CYP3A by LUM
|
Concomitant use of lumacaftor/ivacaftor with these anticonvulsants is not recommended. The exposures of ivacaftor and the anticonvulsant may be significantly decreased, which may reduce the efficacy of both active substances.
|
Antifungals:
itraconazole*, ketoconazole, posaconazole, voriconazole
|
↔ LUM
↑ IVA
Due to inhibition of CYP3A by these antifungals
↓ itraconazole, ketoconazole, voriconazole
Due to induction of CYP3A by LUM
↓ posaconazole
Due to induction of UGT by LUM
|
No dose adjustment of lumacaftor/ivacaftor is recommended when these antifungals are initiated in patients currently taking lumacaftor/ivacaftor.
The dose of lumacaftor/ivacaftor should be reduced to one tablet daily for the first week of treatment when initiating lumacaftor/ ivacaftor in patients currently taking these antifungals.
Concomitant use of lumacaftor/ivacaftor with these antifungals is not recommended. Patients should be monitored closely for breakthrough fungal infections if such drugs are necessary. Lumacaftor/ivacaftor may decrease the exposures of these antifungals, which may reduce their efficacy.
|
fluconazole
|
↔ LUM
↑ IVA
Due to inhibition of CYP3A by fluconazole
↓ fluconazole
Due to induction by LUM; fluconazole is cleared primarily by renal excretion as unchanged drug; however, modest reduction in fluconazole exposure has been observed with strong inducers
|
No dose adjustment of lumacaftor/ivacaftor is recommended when co-administered with fluconazole.
A higher dose of fluconazole may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposure of fluconazole, which may reduce its efficacy.
|
Anti-inflammatories:
ibuprofen
|
↔ LUM, IVA
↓ ibuprofen
Due to induction of CYP3A/2C8/2C9 by LUM
|
A higher dose of ibuprofen may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposure of ibuprofen, which may reduce its efficacy.
|
Anti-mycobacterials:
rifabutin, rifampicin*, rifapentine
|
↔ LUM
↓ IVA
Due to induction of CYP3A by anti-mycobacterials
↓ rifabutin
Due to induction of CYP3A by LUM
↔ rifampicin, rifapentine
|
Concomitant use of lumacaftor/ivacaftor with these anti-mycobacterials is not recommended. The exposure of ivacaftor will be decreased, which may reduce the efficacy of lumacaftor/ivacaftor.
A higher dose of rifabutin may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposure of rifabutin, which may reduce its efficacy.
|
Benzodiazepines:
midazolam, triazolam
|
↔ LUM, IVA
↓ midazolam, triazolam
Due to induction of CYP3A by LUM
|
Concomitant use of lumacaftor/ivacaftor with these benzodiazepines is not recommended. Lumacaftor/ivacaftor will decrease the exposures of midazolam and triazolam, which will reduce their efficacy.
|
Hormonal contraceptives:
ethinyl estradiol, norethindrone, and other progestogens
|
↓ ethinyl estradiol, norethindrone, and other progestogens
Due to induction of CYP3A/UGT by LUM
|
Hormonal contraceptives, including oral, injectable, transdermal, and implantable, should not be relied upon as an effective method of contraception when co-administered with lumacaftor/ivacaftor. Lumacaftor/ivacaftor may decrease the exposure of hormonal contraceptives, which may reduce their efficacy.
|
Immunosuppressants:
ciclosporin, everolimus, sirolimus, tacrolimus (used after organ transplant)
|
↔ LUM, IVA
↓ ciclosporin, everolimus, sirolimus, tacrolimus
Due to induction of CYP3A by LUM
|
Concomitant use of lumacaftor/ivacaftor with these immunosuppressants is not recommended. Lumacaftor/ivacaftor will decrease the exposure of these immunosuppressants, which may reduce the efficacy of these immunosuppressants. The use of lumacaftor/ivacaftor in organ transplant patients has not been studied.
|
Proton pump inhibitors:
esomeprazole, lansoprazole, omeprazole
|
↔ LUM, IVA
↓ esomeprazole, lansoprazole, omeprazole
Due to induction of CYP3A/2C19 by LUM
|
A higher dose of these proton pump inhibitors may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposures of these proton pump inhibitors, which may reduce their efficacy.
|
Herbals:
St. John's wort (Hypericum perforatum)
|
↔ LUM
↓ IVA
Due to induction of CYP3A by St. John's wort
|
Concomitant use of lumacaftor/ivacaftor with St. John's wort is not recommended. The exposure of ivacaftor will be decreased, which may reduce the efficacy of lumacaftor/ivacaftor.
|
Other concomitant medicinal products of clinical relevance
|
Antiarrhythmics:
digoxin
|
↔ LUM, IVA
↑ or ↓ digoxin
Due to potential induction or inhibition of P-gp
|
The serum concentration of digoxin should be monitored and the dose should be titrated to obtain the desired clinical effect. Lumacaftor/ivacaftor may alter the exposure of digoxin.
|
Anticoagulants:
dabigatran
|
↔ LUM, IVA
↑ or ↓ dabigatran
Due to potential induction or inhibition of P-gp
|
Appropriate clinical monitoring should be employed when co-administered with lumacaftor/ivacaftor. Dose adjustment of dabigatran may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may alter the exposure of dabigatran.
|
warfarin
|
↔ LUM, IVA
↑ or ↓ warfarin
Due to potential induction or inhibition of CYP2C9 by LUM
|
The international normalised ratio (INR) should be monitored when warfarin co-administration with lumacaftor/ivacaftor is required. Lumacaftor/ivacaftor may alter the exposure of warfarin.
|
Antidepressants:
citalopram, escitalopram, sertraline
|
↔ LUM, IVA
↓ citalopram, escitalopram, sertraline
Due to induction of CYP3A/2C19 by LUM
|
A higher dose of these antidepressants may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposures of these antidepressants, which may reduce their efficacy.
|
bupropion
|
↔ LUM, IVA
↓ bupropion
Due to induction of CYP2B6 by LUM
|
A higher dose of bupropion may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposure of bupropion, which may reduce its efficacy.
|
Corticosteroids, systemic:
methylprednisolone, prednisone
|
↔ LUM, IVA
↓ methylprednisolone, prednisone
Due to induction of CYP3A by LUM
|
A higher dose of these systemic corticosteroids may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposures of methylprednisolone and prednisone, which may reduce their efficacy.
|
H2 blockers:
ranitidine
|
↔ LUM, IVA
↑ or ↓ ranitidine
Due to potential induction or inhibition of P-gp
|
Dose adjustment of ranitidine may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may alter the exposure of ranitidine.
|
Oral hypoglycemics:
repaglinide
|
↔ LUM, IVA
↓ repaglinide
Due to induction of CYP3A/2C8 by LUM
|
A higher dose of repaglinide may be required to obtain the desired clinical effect. Lumacaftor/ivacaftor may decrease the exposure of repaglinide, which may reduce its efficacy.
|
Note: ↑ = increase, ↓ = decrease, ↔ = no change; LUM = lumacaftor; IVA = ivacaftor.
* Based on clinical drug-drug interaction studies. All other drug interactions shown are predicted.
|
Paediatric population
Interaction studies have only been performed in adults.
Pregnancy
There are no or limited amount of data (less than 300 pregnancy outcomes) from the use of lumacaftor/ivacaftor in pregnant women. Animal studies with lumacaftor and ivacaftor do not indicate direct or indirect harmful effects with respect to developmental and reproductive toxicity, whereas effects were noted with ivacaftor only at maternally toxic doses (see section 5.3). As a precautionary measure, it is preferable to avoid the use of lumacaftor/ivacaftor during pregnancy unless the clinical condition of the mother requires treatment with lumacaftor/ivacaftor.
Breast-feeding
It is unknown whether lumacaftor and/or ivacaftor and metabolites are excreted in human milk. Available pharmacokinetic data in animals have shown excretion of both lumacaftor and ivacaftor into the milk of lactating female rats. As such, risks to the suckling child cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from lumacaftor/ ivacaftor therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the mother.
Fertility
Lumacaftor had no effects on fertility and reproductive performance indices in male and female rats. Ivacaftor impaired fertility and reproductive performance indices in male and female rats. No effects on male or female fertility and reproductive performance indices were observed at ≤100 mg/kg/day (see section 5.3).
Ivacaftor, which is one of the active components of Orkambi, has a minor influence on the ability to drive or use machines. Ivacaftor may cause dizziness (see section 4.8).
Patients experiencing dizziness while taking Orkambi should be advised not to drive or use machines until symptoms abate.
Summary of the safety profile
The most common adverse reactions experienced by patients aged 12 years and older who received lumacaftor/ivacaftor in the pooled, placebo-controlled, Phase 3 studies were dyspnoea (14.0% versus 7.8% on placebo), diarrhoea (11.0% versus 8.4% on placebo), and nausea (10.2% versus 7.6% on placebo).
Serious adverse reactions occurring in at least 0.5% of patients included hepatobiliary events, e.g., transaminase elevations, cholestatic hepatitis and hepatic encephalopathy.
Tabulated list of adverse reactions
Adverse reactions identified from the 24-week, placebo-controlled, Phase 3 studies (Trials 1 and 2) in patients aged 12 years and older and from a 24-week, placebo-controlled study in patients aged 6 to 11 years (Trial 7), who are homozygous for the F508del mutation in the CFTR gene are presented in Table 4 and are listed by system organ class, frequency, and adverse reactions. Adverse reactions observed with ivacaftor alone are also provided in Table 4. Adverse reactions are ranked under the MedDRA frequency classification: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); and not known (frequency cannot be estimated using the available data).
Table 4: Adverse reactions in lumacaftor/ivacaftor-treated patients and in patients treated with ivacaftor alone
|
System organ class
|
Frequency
|
Adverse reactions
|
Infections and infestations
|
very common
|
Nasopharyngitis*
|
common
|
Upper respiratory tract infection, rhinitis
|
Vascular disorders
|
uncommon
|
Hypertension
|
Nervous system disorders
|
very common
|
Headache*, dizziness*
|
uncommon
|
Hepatic encephalopathy†
|
Ear and labyrinth disorders
|
common
|
Ear pain*, ear discomfort*, tinnitus*, tympanic membrane hyperaemia*, vestibular disorder*
|
uncommon
|
Ear congestion*
|
Respiratory, thoracic and mediastinal disorders
|
very common
|
Nasal congestion*, dyspnoea, productive cough, sputum increased
|
common
|
Respiration abnormal, oropharyngeal pain, sinus congestion*, rhinorrhoea, pharyngeal erythema*
|
Gastrointestinal disorders
|
very common
|
Abdominal pain*, abdominal pain upper, diarrhoea, nausea
|
common
|
Flatulence, vomiting
|
Hepatobiliary disorders
|
common
|
Transaminase elevations
|
uncommon
|
Cholestatic hepatitis‡
|
Skin and subcutaneous tissue disorders
|
common
|
Rash
|
Reproductive system and breast disorders
|
common
|
Menstruation irregular, dysmenorrhoea, metrorrhagia, breast mass*
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uncommon
|
Menorrhagia, amenorrhoea, polymenorrhoea, breast inflammation*, gynaecomastia*, nipple disorder*, nipple pain*, oligomenorrhoea
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Investigations
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very common
|
Bacteria in sputum*
|
common
|
Blood creatine phosphokinase increased
|
uncommon
|
Blood pressure increased
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*Adverse reactions and frequencies observed in patients in clinical studies with ivacaftor monotherapy (a component of Orkambi).
† 1 patient out of 738
‡ 2 patients out of 738
The safety data from 1029 patients aged 12 years and older who were homozygous for the F508del mutation in the CFTR gene treated with lumacaftor/ivacaftor for up to an additional 96 weeks in the long-term safety and efficacy rollover study (Trial 3) were similar to the 24-week, placebo-controlled studies (see section 5.1).
Description of selected adverse reactions
Hepatobiliary events
During Trials 1 and 2, the incidence of maximum transaminase (ALT or AST) levels >8, >5, and >3 x ULN was 0.8%, 2.0%, and 5.2%; and 0.5%, 1.9%, and 5.1% in lumacaftor/ivacaftor- and placebo-treated patients, respectively. The incidence of transaminase-related adverse reactions was 5.1% and 4.6% in lumacaftor/ivacaftor-treated patients and those who received placebo, respectively. Seven patients who received lumacaftor/ivacaftor had liver-related serious adverse events with elevated transaminases, including 3 with concurrent e |
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