Viekira XR Tablets: Indications, Dosage, Precautions, Adverse Effects
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Viekira XR Tablets - Product Information

Manufacture: AbbVie
Country: United States
Condition: Hepatitis C
Class: Antiviral combinations
Form: Tablets
Ingredients: Dasabuvir, Ombitasvir, Paritaprevir, Ritonavir, Copovidone, K Value 28, Hypromellose 2208, 17,700 (mpa*s), Colloidal Silicon Dioxide/colloidal Anhydrous Silica, Magnesium Stearate, Vitamin E Polyethylene Glycol Succinate, Propylene Glycol Monolaurate, Sorbitan Monolaurate, Colloidal Silicon Dioxide/colloidal Anhydrous Silica, Hypromellose (6 Mpa*s), Hypromellose (15 Mpa*s), Polyethylene Glycol 400, Hydroxypropyl Cellulose, Polysorbate 80, Polyethylene Glycol 3350/macrogol 4000, Talc, Titanium Dioxide, Colloidal Silicon Dioxide/colloidal Anhydrous Silica, Iron Oxide Yellow

Indications and Usage

VIEKIRA XR is indicated for the treatment of adult patients with chronic hepatitis C virus (HCV) [see Dosage and Administration and Clinical Studies]:

  • genotype 1b infection without cirrhosis or with compensated cirrhosis
  • genotype 1a infection without cirrhosis or with compensated cirrhosis for use in combination with ribavirin.

Dosage and Administration

Testing Prior to Initiation of VIEKIRA XR

Prior to initiation of VIEKIRA XR, assess for laboratory and clinical evidence of hepatic decompensation [see Warnings and Precautions].

Recommended Dosage in Adults

VIEKIRA XR is a 4-drug fixed-dose combination, extended-release tablet containing 200 mg of dasabuvir, 8.33 mg of ombitasvir, 50 mg of paritaprevir, and 33.33 mg of ritonavir.

The recommended dosage of VIEKIRA XR is three tablets taken orally once daily.

  • VIEKIRA XR must be taken with a meal because administration under fasting conditions may result in reduced virologic response and possible development of resistance [see Clinical Pharmacology].
  • Swallow tablets whole. Splitting, crushing, or chewing tablets may compromise the extended-release performance, efficacy, and/or safety of VIEKIRA XR.
  • For optimal release of dasabuvir, alcohol should not be consumed within 4 hours of taking VIEKIRA XR.

VIEKIRA XR is used in combination with ribavirin (RBV) in certain patient populations (see Table 1). When administered with VIEKIRA XR, the recommended dosage of RBV is based on weight: 1000 mg/day for subjects <75 kg and 1200 mg/day for those ≥75 kg, divided and administered twice-daily with food. The starting dosage and on-treatment dosage of RBV can be decreased based on changes in hemoglobin levels and/or creatinine clearance. For ribavirin dosage modifications, refer to the ribavirin prescribing information.

For patients with HCV/HIV-1 co-infection, follow the dosage recommendations in Table 1. Refer to Drug Interactions for dosage recommendations for concomitant HIV-1 antiviral drugs.

Table 1 shows the recommended VIEKIRA XR treatment regimen and duration based on patient population.

Table 1. Treatment Regimen and Duration by Patient Population (Treatment-Naïve or Interferon-Experienced)
Patient Population Treatment* Duration
Genotype 1a, without cirrhosis VIEKIRA XR + ribavirin 12 weeks
Genotype 1a, with compensated cirrhosis (Child-Pugh A) VIEKIRA XR + ribavirin 24 weeks**
Genotype 1b, with or without compensated cirrhosis (Child-Pugh A) VIEKIRA XR 12 weeks

*Note: Follow the genotype 1a dosing recommendations in patients with an unknown genotype 1 subtype or with mixed genotype 1 infection.

**VIEKIRA XR administered with ribavirin for 12 weeks may be considered for some patients based on prior treatment history [see Clinical Studies].

Use in Liver Transplant Recipients

In liver transplant recipients with normal hepatic function and mild fibrosis (Metavir fibrosis score 2 or lower), the recommended duration of VIEKIRA XR with ribavirin is 24 weeks, irrespective of HCV genotype 1 subtype [see Clinical Studies]. When VIEKIRA XR is administered with calcineurin inhibitors in liver transplant recipients, dosage adjustment of calcineurin inhibitors is needed [see Drug Interactions].

Hepatic Impairment

VIEKIRA XR is contraindicated in patients with moderate to severe hepatic impairment (Child-Pugh B and C) [see Contraindications, Warnings and Precautions, Use in Specific Populations, and Clinical Pharmacology].

Dosage Forms and Strengths

Extended-release tablet: 200 mg of dasabuvir (equivalent to 216.2 mg of dasabuvir sodium monohydrate), 8.33 mg of ombitasvir, 50 mg of paritaprevir, and 33.33 mg of ritonavir. The tablets are pale yellow-colored, film-coated, oblong shaped, debossed with “3QD” on one side.

Contraindications

  • VIEKIRA XR is contraindicated in patients with moderate to severe hepatic impairment (Child-Pugh B and C) due to risk of potential toxicity [see Warnings and Precautions, Use in Specific Populations and Clinical Pharmacology].
  • If VIEKIRA XR is administered with ribavirin, the contraindications to ribavirin also apply to this combination regimen. Refer to the ribavirin prescribing information for a list of contraindications for ribavirin.
  • VIEKIRA XR is contraindicated:
    • With drugs that are highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life-threatening events.
    • With drugs that are moderate or strong inducers of CYP3A and strong inducers of CYP2C8 and may lead to reduced efficacy of VIEKIRA XR.
    • With drugs that are strong inhibitors of CYP2C8 and may increase dasabuvir plasma concentrations and the risk of QT prolongation.
    • In patients with known hypersensitivity to ritonavir (e.g. toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome).

Table 2 lists drugs that are contraindicated with VIEKIRA XR [see Drug Interactions].

Table 2. Drugs that are Contraindicated with VIEKIRA XR
Drug Class Drug(s) within Class that are Contraindicated Clinical Comments
Alpha1-adrenoreceptor antagonist Alfuzosin HCL Potential for hypotension.
Anti-anginal Ranolazine Potential for serious and/or life-threatening reactions.
Antiarrhythmic Dronedarone Potential for serious and/or life-threatening reactions such as cardiac arrhythmias.
Anticonvulsants Carbamazepine, phenytoin, phenobarbital VIEKIRA XR exposures may decrease leading to a potential loss of therapeutic activity of VIEKIRA XR.
Anti-gout Colchicine Potential for serious and/or life-threatening reactions in patients with renal and/or hepatic impairment.
Antihyperlipidemic agent Gemfibrozil Increase in dasabuvir exposures by 10-fold which may increase the risk of QT prolongation.
Antimycobacterial Rifampin VIEKIRA XR exposures may decrease leading to a potential loss of therapeutic activity of VIEKIRA XR.
Antipsychotic Lurasidone

Pimozide
Potential for serious and/or life-threatening reactions.

Potential for serious and/or life-threatening reactions such as cardiac arrhythmias.
Ergot derivatives Ergotamine, dihydroergotamine, methylergonovine Acute ergot toxicity characterized by vasospasm and tissue ischemia has been associated with co-administration of ritonavir and ergonovine, ergotamine, dihydroergotamine, or methylergonovine.
Ethinyl estradiol-containing products Ethinyl estradiol-containing medications such as combined oral contraceptives Potential for ALT elevations [see Warnings and Precautions].
GI Motility Agent Cisapride Potential for serious and/or life threatening reactions such as cardiac arrhythmias.
Herbal Product St. John’s Wort (Hypericum perforatum) VIEKIRA XR exposures may decrease leading to a potential loss of therapeutic activity of VIEKIRA XR.
HMG-CoA Reductase Inhibitors Lovastatin, simvastatin Potential for myopathy including rhabdomyolysis.
Non-nucleoside reverse transcriptase inhibitor Efavirenz Co-administration of efavirenz based regimens with paritaprevir, ritonavir plus dasabuvir was poorly tolerated and resulted in liver enzyme elevations.
Phosphodiesterase-5 (PDE5) inhibitor Sildenafil when dosed as Revatio for the treatment of pulmonary arterial hypertension (PAH) There is increased potential for sildenafil-associated adverse events such as visual disturbances, hypotension, priapism, and syncope.
Sedatives/hypnotics Triazolam Orally administered midazolam Triazolam and orally administered midazolam are extensively metabolized by CYP3A4. Coadministration of triazolam or orally administered midazolam with VIEKIRA XR may cause large increases in the concentration of these benzodiazepines. The potential exists for serious and/or life threatening events such as prolonged or increased sedation or respiratory depression.

Warnings and Precautions

Risk of Hepatic Decompensation and Hepatic Failure in Patients with Cirrhosis

Hepatic decompensation and hepatic failure, including liver transplantation or fatal outcomes, have been reported postmarketing in patients treated with the components of VIEKIRA XR. Most patients with these severe outcomes had evidence of advanced cirrhosis prior to initiating therapy. Reported cases typically occurred within one to four weeks of initiating therapy and were characterized by the acute onset of rising direct serum bilirubin levels without ALT elevations in association with clinical signs and symptoms of hepatic decompensation. Because these events 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.

VIEKIRA XR is contraindicated in patients with moderate to severe hepatic impairment (Child-Pugh B and C) [see Contraindications, Adverse Reactions, Use in Specific Populations, and Clinical Pharmacology].

For patients with cirrhosis:

  • Monitor for clinical signs and symptoms of hepatic decompensation (such as ascites, hepatic encephalopathy, variceal hemorrhage).
  • Hepatic laboratory testing including direct bilirubin levels should be performed at baseline and during the first 4 weeks of starting treatment and as clinically indicated.
  • Discontinue VIEKIRA XR in patients who develop evidence of hepatic decompensation.

Increased Risk of ALT Elevations

During clinical trials with the combination of dasabuvir tablets and ombitasvir, paritaprevir, and ritonavir tablets (components of VIEKIRA XR) with or without ribavirin, elevations of ALT to greater than 5 times the upper limit of normal (ULN) occurred in approximately 1% of all subjects [see Adverse Reactions]. ALT elevations were typically asymptomatic, occurred during the first 4 weeks of treatment, and declined within two to eight weeks of onset with continued dosing.

These ALT elevations were significantly more frequent in female subjects who were using ethinyl estradiol-containing medications such as combined oral contraceptives, contraceptive patches or contraceptive vaginal rings. Ethinyl estradiol-containing medications must be discontinued prior to starting therapy with VIEKIRA XR [see Contraindications]. Alternative methods of contraception (e.g., progestin only contraception or non-hormonal methods) are recommended during VIEKIRA XR therapy. Ethinyl estradiol-containing medications can be restarted approximately 2 weeks following completion of treatment with VIEKIRA XR.

Women using estrogens other than ethinyl estradiol, such as estradiol and conjugated estrogens used in hormone replacement therapy had a rate of ALT elevation similar to those not receiving any estrogens; however, due to the limited number of subjects taking these other estrogens, caution is warranted for co-administration with VIEKIRA XR [see Adverse Reactions].

Hepatic laboratory testing should be performed during the first 4 weeks of starting treatment and as clinically indicated thereafter. If ALT is found to be elevated above baseline levels, it should be repeated and monitored closely:

  • Patients should be instructed to consult their health care professional without delay if they have onset of fatigue, weakness, lack of appetite, nausea and vomiting, jaundice or discolored feces.
  • Consider discontinuing VIEKIRA XR if ALT levels remain persistently greater than 10 times the ULN.
  • Discontinue VIEKIRA XR if ALT elevation is accompanied by signs or symptoms of liver inflammation or increasing direct bilirubin, alkaline phosphatase, or INR.

Risks Associated With Ribavirin Combination Treatment

If VIEKIRA XR is administered with ribavirin, the warnings and precautions for ribavirin, in particular the pregnancy avoidance warning, apply to this combination regimen. Refer to the ribavirin prescribing information for a full list of the warnings and precautions for ribavirin.

Risk of Adverse Reactions or Reduced Therapeutic Effect Due to Drug Interactions

The concomitant use of VIEKIRA XR and certain other drugs may result in known or potentially significant drug interactions, some of which may lead to:

  • Loss of therapeutic effect of VIEKIRA XR and possible development of resistance
  • Possible clinically significant adverse reactions from greater exposures of concomitant drugs or components of VIEKIRA XR.

See Table 5 for steps to prevent or manage these possible and known significant drug interactions, including dosing recommendations [see Drug Interactions]. Consider the potential for drug interactions prior to and during VIEKIRA XR therapy; review concomitant medications during VIEKIRA XR therapy; and monitor for the adverse reactions associated with the concomitant drugs [see Contraindications and Drug Interactions].

Risk of HIV-1 Protease Inhibitor Drug Resistance in HCV/HIV-1 Co-infected Patients

The ritonavir component of VIEKIRA XR is also an HIV-1 protease inhibitor and can select for HIV-1 protease inhibitor resistance-associated substitutions. Any HCV/HIV-1 co-infected patients treated with VIEKIRA XR should also be on a suppressive antiretroviral drug regimen to reduce the risk of HIV-1 protease inhibitor drug resistance.

Adverse Reactions

The following adverse reaction is described below and elsewhere in the labeling:

  • Risk of Hepatic Decompensation and Hepatic Failure in Patients with Cirrhosis [see Warnings and Precautions]
  • Increased Risk of ALT Elevations [see Warnings and Precautions]

Clinical Trials Experience

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

If VIEKIRA XR is administered with ribavirin (RBV), refer to the prescribing information for ribavirin for a list of ribavirin-associated adverse reactions.

The safety assessment was based on data from seven clinical trials in more than 2,000 subjects who received the components of VIEKIRA XR with or without ribavirin for 12 or 24 weeks.

Components of VIEKIRA XR with Ribavirin in GT 1-Infected Subjects without Cirrhosis

The safety of the components of VIEKIRA XR with ribavirin were assessed in 770 subjects with chronic HCV genotype 1 (GT1) infection without cirrhosis in two placebo-controlled trials (SAPPHIRE-I and -II) [see Clinical Studies]. Adverse reactions that occurred more often in subjects treated with the components of VIEKIRA XR with ribavirin compared to placebo were fatigue, nausea, pruritus, other skin reactions, insomnia, and asthenia (see Table 3). The majority of the adverse reactions were mild in severity. Two percent of subjects experienced a serious adverse event (SAE). The proportion of subjects who permanently discontinued treatment due to adverse reactions was less than 1%.

Table 3. Adverse Reactions with ≥5% Greater Frequency Reported in Subjects with Chronic HCV GT1 Infection without Cirrhosis Treated with the Components of VIEKIRA XR with Ribavirin Compared to Placebo for 12 Weeks
SAPPHIRE-I and -II
  Components of VIEKIRA XR + RBV
12 Weeks
N = 770
%
Placebo
12 Weeks
N = 255
%
Fatigue 34 26
Nausea 22 15
Pruritus* 18 7
Skin reactions$ 16 9
Insomnia 14 8
Asthenia 14 7

*Grouped term ‘pruritus’ included the preferred terms pruritus and pruritus generalized.

$ Grouped terms: rash, erythema, eczema, rash maculo-papular, rash macular, dermatitis, rash papular, skin exfoliation, rash pruritic, rash erythematous, rash generalized, dermatitis allergic, dermatitis contact, exfoliative rash, photosensitivity reaction, psoriasis, skin reaction, ulcer, urticaria.

Components of VIEKIRA XR with and without Ribavirin in GT1-Infected Subjects without Cirrhosis

The components of VIEKIRA XR with and without ribavirin were assessed in 401 and 509 subjects with chronic HCV infection GT1 infection without cirrhosis, respectively, in three clinical trials (PEARL-II, PEARL-III and PEARL-IV) [see Clinical Studies]. Pruritus, nausea, insomnia, and asthenia were identified as adverse events occurring more often in subjects treated with the components of VIEKIRA XR with ribavirin (see Table 4). The majority of adverse events were mild to moderate in severity. The proportion of subjects who permanently discontinued treatment due to adverse events was less than 1% for the components of VIEKIRA XR with or without ribavirin.

Table 4. Adverse Events with ≥5% Greater Frequency Reported in Subjects with Chronic HCV GT1 Infection without Cirrhosis Treated with the Components of VIEKIRA XR with or without Ribavirin for 12 Weeks
PEARL-II, -III and -IV
  Components of VIEKIRA XR + RBV
12 Weeks
N = 401
%
Components of VIEKIRA XR without RBV
12 Weeks
N = 509
%
Nausea 16 8
Pruritus* 13 7
Insomnia 12 5
Asthenia 9 4
*Grouped term ‘pruritus’ included the preferred terms pruritus and pruritus generalized.

Components of VIEKIRA XR with Ribavirin in GT1-Infected Subjects with Compensated Cirrhosis

The components of VIEKIRA XR with ribavirin were assessed in 380 subjects with genotype 1 infection and compensated cirrhosis who were treated with the components of VIEKIRA XR plus ribavirin for 12 (n=208) or 24 (n=172) weeks duration (TURQUOISE-II) [see Clinical Studies]. The type and severity of adverse events in subjects with compensated cirrhosis was comparable to non-cirrhotic subjects in other phase 3 trials. Fatigue, skin reactions and dyspnea occurred at least 5% more often in subjects treated for 24 weeks. The majority of adverse events occurred during the first 12 weeks of dosing in both treatment arms. Most of the adverse events were mild to moderate in severity. The proportion of subjects treated with the components of VIEKIRA XR for 12 and 24 weeks who experienced SAEs were 6% and 5%, respectively and 2% of subjects permanently discontinued treatment due to adverse events in each treatment arm.

Components of VIEKIRA XR without Ribavirin in GT1b-Infected Subjects with Compensated Cirrhosis

The components of VIEKIRA XR without ribavirin for 12 weeks was assessed in 60 subjects with genotype 1b infection and compensated cirrhosis (TURQUOISE-III) [see Clinical Studies]. The type and severity of adverse events and laboratory abnormalities in genotype 1b-infected subjects with compensated cirrhosis were comparable to subjects in other trials without ribavirin.

Skin Reactions

In PEARL-II, -III and -IV, 7% of subjects receiving the components of VIEKIRA XR alone and 10% of subjects receiving the components of VIEKIRA XR with ribavirin reported rash-related events. In SAPPHIRE-I and -II 16% of subjects receiving the components of VIEKIRA XR with ribavirin and 9% of subjects receiving placebo reported skin reactions. In TURQUOISE-II, 18% and 24% of subjects receiving the components of VIEKIRA XR with ribavirin for 12 or 24 weeks reported skin reactions. The majority of events were graded as mild in severity. There were no serious events or severe cutaneous reactions, such as Stevens Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), erythema multiforme (EM) or drug rash with eosinophilia and systemic symptoms (DRESS).

Laboratory Abnormalities

Serum ALT Elevations

Approximately 1% of subjects treated with the components of VIEKIRA XR experienced post-baseline serum ALT levels greater than 5 times the upper limit of normal (ULN) after starting treatment. The incidence increased to 25% (4/16) among women taking a concomitant ethinyl estradiol containing medication [see Contraindications and Warnings and Precautions]. The incidence of clinically relevant ALT elevations among women using estrogens other than ethinyl estradiol, such as estradiol and conjugated estrogens used in hormone replacement therapy was 3% (2/59).

ALT elevations were typically asymptomatic, generally occurred during the first 4 weeks of treatment (mean time 20 days, range 8-57 days) and most resolved with ongoing therapy. The majority of these ALT elevations were assessed as drug-related liver injury. Elevations in ALT were generally not associated with bilirubin elevations. Cirrhosis was not a risk factor for elevated ALT [see Warnings and Precautions].

Serum Bilirubin Elevations

Post-baseline elevations in bilirubin at least 2 x ULN were observed in 15% of subjects receiving the components of VIEKIRA XR with ribavirin compared to 2% in those receiving the components of VIEKIRA XR without ribavirin. These bilirubin increases were predominately indirect and related to the inhibition of the bilirubin transporters OATP1B1/1B3 by paritaprevir and ribavirin-induced hemolysis. Bilirubin elevations occurred after initiation of treatment, peaked by study Week 1, and generally resolved with ongoing therapy. Bilirubin elevations were not associated with serum ALT elevations.

Anemia/Decreased Hemoglobin

Across all Phase 3 studies, the mean change from baseline in hemoglobin levels in subjects treated with the components of VIEKIRA XR with ribavirin was -2.4 g/dL and the mean change in subjects treated with the components of VIEKIRA XR without ribavirin was -0.5 g/dL. Decreases in hemoglobin levels occurred early in treatment (Week 1-2) with further reductions through Week 3. Hemoglobin values remained low during the remainder of treatment and returned towards baseline levels by post-treatment Week 4. Less than 1% of subjects treated with the components of VIEKIRA XR with ribavirin had hemoglobin levels decrease to less than 8.0 g/dL during treatment. Seven percent of subjects treated with the components of VIEKIRA XR with ribavirin underwent a ribavirin dose reduction due to a decrease in hemoglobin levels; three subjects received a blood transfusion and five required erythropoietin. One patient discontinued therapy due to anemia. No subjects treated with the components of VIEKIRA XR without ribavirin had a hemoglobin level less than 10 g/dL.

Components of VIEKIRA XR with Ribavirin in HCV/HIV-1 Co-infected Subjects

The components of VIEKIRA XR with ribavirin were assessed in 63 subjects with HCV/HIV-1 co-infection who were on stable antiretroviral therapy. The most common adverse events occurring in at least 10% of subjects were fatigue (48%), insomnia (19%), nausea (17%), headache (16%), pruritus (13%), cough (11%), irritability (10%), and ocular icterus (10%).

Elevations in total bilirubin greater than 2 x ULN (mostly indirect) occurred in 34 (54%) subjects. Fifteen of these subjects were also receiving atazanavir at the time of bilirubin elevation and nine also had adverse events of ocular icterus, jaundice or hyperbilirubinemia. None of the subjects with hyperbilirubinemia had concomitant elevations of aminotransferases [see Warnings and Precautions, Adverse Reactions and Clinical Studies]. No subject experienced a grade 3 ALT elevation.

Seven subjects (11%) had at least one post-baseline hemoglobin value of less than 10 g/dL, and six of these subjects had a ribavirin dose modification; no subject in this small cohort required a blood transfusion or erythropoietin.

Median declines in CD4+ T-cell counts of 47 cells/mm3 and 62 cells/mm3 were observed at the end of 12 and 24 weeks of treatment, respectively, and most returned to baseline levels post-treatment. Two subjects had CD4+ T-cell counts decrease to less than 200 cells/mm3 during treatment without a decrease in CD4%. No subject experienced an AIDS-related opportunistic infection.

Components of VIEKIRA XR with Ribavirin in Selected Liver Transplant Recipients

The components of VIEKIRA XR with ribavirin were assessed in 34 post-liver transplant subjects with recurrent HCV infection. Adverse events occurring in more than 20% of subjects included fatigue 50%, headache 44%, cough 32%, diarrhea 26%, insomnia 26%, asthenia 24%, nausea 24%, muscle spasms 21% and rash 21%. Ten subjects (29%) had at least one post-baseline hemoglobin value of less than 10 g/dL. Ten subjects underwent a ribavirin dose modification due to decrease in hemoglobin and 3% (1/34) had an interruption of ribavirin. Five subjects received erythropoietin, all of whom initiated ribavirin at the starting dose of 1000 to 1200 mg daily. No subject received a blood transfusion [see Clinical Studies].

Postmarketing Experience

The following adverse reactions have been identified during post approval use of the components of VIEKIRA XR. Because these 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

Hypersensitivity reactions (including angioedema).

Hepatobiliary Disorders

Hepatic decompensation, hepatic failure [see Warnings and Precautions].

Drug Interactions

Potential for VIEKIRA XR to Affect Other Drugs

Dasabuvir, ombitasvir, and paritaprevir are inhibitors of UGT1A1, and ritonavir is an inhibitor of CYP3A4. Paritaprevir is an inhibitor of OATP1B1 and OATP1B3 and dasabuvir, paritaprevir, and ritonavir are inhibitors of BCRP. Co-administration of VIEKIRA XR with drugs that are substrates of CYP3A, UGT1A1, BCRP, OATP1B1 or OATP1B3 may result in increased plasma concentrations of such drugs [see also Contraindications, Warnings and Precautions, and Clinical Pharmacology].

Potential for Other Drugs to Affect One or More Components of VIEKIRA XR

Paritaprevir and ritonavir are primarily metabolized by CYP3A enzymes. Co-administration of VIEKIRA XR with strong inhibitors of CYP3A may increase paritaprevir and ritonavir concentrations. Dasabuvir is primarily metabolized by CYP2C8 enzymes. Co-administration of VIEKIRA XR with drugs that inhibit CYP2C8 may increase dasabuvir plasma concentrations. Ombitasvir is primarily metabolized via amide hydrolysis while CYP enzymes play a minor role in its metabolism. Ombitasvir, paritaprevir, dasabuvir and ritonavir are substrates of P-gp. Ombitasvir, paritaprevir and dasabuvir are substrates of BCRP. Paritaprevir is a substrate of OATP1B1 and OATP1B3. Inhibition of P-gp, BCRP, OATP1B1 or OATP1B3 may increase the plasma concentrations of the various components of VIEKIRA XR.

Established and Other Potential Drug Interactions

If dose adjustments of concomitant medications are made due to treatment with VIEKIRA XR, doses should be re-adjusted after administration of VIEKIRA XR is completed. Table 5 provides the effect of co-administration of VIEKIRA XR on concentrations of concomitant drugs and the effect of concomitant drugs on the various components of VIEKIRA XR. Refer to Contraindications for drugs that are contraindicated with VIEKIRA XR [see Contraindications]. Refer to the ritonavir prescribing information for other potentially significant drug interactions with ritonavir.

Table 5. Established Drug Interactions Based on Drug Interaction Trials
Concomitant Drug Class: Drug Name Effect on Concentration Clinical Comments
ANGIOTENSIN RECEPTOR BLOCKERS
valsartan*
losartan*
candesartan*
↑ angiotensin receptor blockers Decrease the dose of the angiotensin receptor blockers and monitor patients for signs and symptoms of hypotension and/or worsening renal function. If such events occur, consider further dose reduction of the angiotensin receptor blocker or switching to an alternative to the angiotensin receptor blocker.
ANTIARRHYTHMICS
amiodarone*,
bepridil*,
disopyramide*,
flecainide*,
lidocaine (systemic)*,
mexiletine*,
propafenone*,
quinidine*
↑ antiarrhythmics Contraindicated antiarrhythmics [see Contraindications].

Therapeutic concentration monitoring (if available) is recommended for antiarrhythmics when co-administered with VIEKIRA XR.
ANTIDIABETIC DRUGS
metformin ↔ metformin Monitor for signs of onset of lactic acidosis such as respiratory distress, somnolence, and non-specific abdominal distress or worsening renal function. Concomitant metformin use in patients with renal insufficiency or hepatic impairment is not recommended. Refer to the prescribing information of metformin for further guidance.
ANTIFUNGALS
ketoconazole ↑ ketoconazole When VIEKIRA XR is co-administered with ketoconazole, the maximum daily dose of ketoconazole should be limited to 200 mg per day.
voriconazole* ↓ voriconazole Co-administration of VIEKIRA XR with voriconazole is not recommended unless an assessment of the benefit-to-risk ratio justifies the use of voriconazole.
ANTIPSYCHOTIC
quetiapine* ↑ quetiapine Contraindicated antipsychotics [see Contraindications].

Quetiapine:
  • Initiation of VIEKIRA XR in patients taking quetiapine: Consider alternative anti-HCV therapy to avoid increases in quetiapine exposures. If coadministration is necessary, reduce the quetiapine dose to 1/6th of the current dose and monitor for quetiapine-associated adverse reactions. Refer to the quetiapine prescribing information for the recommendations on adverse reaction monitoring.
  • Initiation of quetiapine in patients taking VIEKIRA XR: Refer to the quetiapine prescribing information for initial dosing and titration of quetiapine.
CALCIUM CHANNEL BLOCKERS
amlodipine
nifedipine*
diltiazem*
verapamil*
↑ calcium channel blockers Decrease the dose of the calcium channel blocker. The dose of amlodipine should be decreased by at least 50%. Clinical monitoring of patients is recommended for edema and/or signs and symptoms of hypotension. If such events occur, consider further dose reduction of the calcium channel blocker or switching to an alternative to the calcium channel blocker.
CORTICOSTEROIDS (INHALED/NASAL)
fluticasone* ↑ fluticasone Concomitant use of VIEKIRA XR with inhaled or nasal fluticasone may reduce serum cortisol concentrations. Alternative corticosteroids should be considered, particularly for long term use.
DIURETICS
furosemide ↑ furosemide (Cmax) Clinical monitoring of patients is recommended and therapy should be individualized based on patient’s response.
ANTIRETROVIRAL AGENTS: PROTEASE INHIBITORS
atazanavir/ritonavir once daily ↑ paritaprevir When coadministered with VIEKIRA XR, atazanavir 300 mg (without ritonavir) should only be given in the morning.
darunavir/ritonavir ↓ darunavir (Ctrough) Co-administration of VIEKIRA XR with darunavir/ritonavir is not recommended.
lopinavir/ritonavir ↑ paritaprevir Co-administration of VIEKIRA XR with lopinavir/ritonavir is not recommended.
ANTIRETROVIRAL AGENTS: NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
rilpivirine ↑ rilpivirine Contraindicated non-nucleoside reverse transcriptase inhibitors [see Contraindications].

Rilpivirine:
Co-administration of VIEKIRA XR with rilpivirine once daily is not recommended due to potential for QT interval prolongation with higher concentrations of rilpivirine.
HMG CoA REDUCTASE INHIBITORS:
pravastatin rosuvastatin ↑ pravastatin
↑ rosuvastatin
Contraindicated HMG CoA Reductase Inhibitors [see Contraindications].

Rosuvastatin:
Dose of rosuvastatin should not exceed 10 mg per day.

Pravastatin:
Dose of pravastatin should not exceed 40 mg per day.
IMMUNOSUPPRESSANTS
cyclosporine ↑ cyclosporine When initiating therapy with VIEKIRA XR, reduce cyclosporine dose to 1/5th of the patient’s current cyclosporine dose. Measure cyclosporine blood concentrations to determine subsequent dose modifications. Upon completion of VIEKIRA XR therapy, the appropriate time to resume pre-VIEKIRA  XR dose of cyclosporine should be guided by assessment of cyclosporine blood concentrations. Frequent assessment of renal function and cyclosporine-related side effects is recommended.
tacrolimus ↑ tacrolimus When initiating therapy with VIEKIRA XR, the dose of tacrolimus needs to be reduced. Do not administer tacrolimus on the day VIEKIRA XR is initiated. Beginning the day after VIEKIRA XR is initiated; reinitiate tacrolimus at a reduced dose based on tacrolimus blood concentrations. Typical tacrolimus dosing is 0.5 mg every 7 days. Measure tacrolimus blood concentrations and adjust dose or dosing frequency to determine subsequent dose modifications. Upon completion of VIEKIRA XR therapy, the appropriate time to resume pre-VIEKIRA XR dose of tacrolimus should be guided by assessment of tacrolimus blood concentrations. Frequent assessment of renal function and tacrolimus related side effects is recommended.
LONG ACTING BETA-ADRENOCEPTOR AGONIST
salmeterol* ↑ salmeterol Concurrent administration of VIEKIRA XR and salmeterol is not recommended. The combination may result in increased risk of cardiovascular adverse events associated with salmeterol, including QT prolongation, palpitations and sinus tachycardia.
MUSCLE RELAXANTS
carisoprodol ↓ carisoprodol
↔ mepobramate (metabolite of carisoprodol)
Increase dose if clinically indicated.
cyclobenzaprine ↓cyclobenzaprine
↓norcyclobenzaprine (metabolite of cyclobenzaprine)
Increase dose if clinically indicated.
NARCOTIC ANALGESICS
acetaminophen/hydrocodone ↑ hydrocodone
↔ acetaminophen
Reduce the dose of hydrocodone by 50% and monitor patients for respiratory depression and sedation at frequent intervals. Upon completion of VIEKIRA XR therapy, adjust the hydrocodone dose and monitor for signs of opioid withdrawal.
buprenorphine/naloxone ↑ buprenorphine
↑ norbuprenorphine (metabolite of buprenorphine)
Patients should be closely monitored for sedation and cognitive effects.
PROTON PUMP INHIBITORS
omeprazole ↓ omeprazole Monitor patients for decreased efficacy of omeprazole. Consider increasing the omeprazole dose in patients whose symptoms are not well controlled; avoid use of more than 40 mg per day of omeprazole.
SEDATIVES/HYPNOTICS
alprazolam ↑ alprazolam Contraindicated Sedatives/Hypnotics [see Contraindications].

Alprazolam:
Clinical monitoring of patients is recommended. A decrease in alprazolam dose can be considered based on clinical response.
diazepam ↓ diazepam
↓ nordiazepam (metabolite of diazepam)
Increase dose if clinically indicated.
The direction of the arrow indicates the direction of the change in exposures (Cmax and AUC) (↑ = increase of more than 20%, ↓ = decrease of more than 20%, ↔ = no change or change less than 20%). * not studied.

Drugs without Clinically Significant Interactions with VIEKIRA XR

No dosage adjustments are recommended when VIEKIRA XR is co-administered with the following medications: abacavir, dolutegravir, digoxin, duloxetine, emtricitabine/tenofovir disoproxil fumarate, escitalopram, lamivudine, methadone, progestin only contraceptives, raltegravir, sofosbuvir, sulfamethoxazole, trimethoprim, warfarin and zolpidem.

Use in Specific Populations

Pregnancy

Risk Summary

If VIEKIRA XR is administered with ribavirin, the combination regimen is contraindicated in pregnant women and in men whose female partners are pregnant. Refer to the ribavirin prescribing information for more information on use in pregnancy.

No adequate human data are available to establish whether or not VIEKIRA XR poses a risk to pregnancy outcomes. In animal reproduction studies, no adverse developmental effects were observed when the components of VIEKIRA XR were administered separately during organogenesis and lactation. During organogenesis, the exposures were up to 28 and 4 times (mice and rabbits, respectively; ombitasvir), 8 and 98 times (mice and rats, respectively; paritaprevir, ritonavir), and 24 and 6 times (rats and rabbits, respectively; dasabuvir) exposures at the recommended clinical dose of VIEKIRA XR. In rodent pre/postnatal developmental studies, maternal systemic exposures (AUC) to ombitasvir, paritaprevir and dasabuvir were approximately 25, 17 and 44 times, respectively, the exposure in humans at the recommended clinical dose [see Data].

The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Data

Animal data
Dasabuvir

Dasabuvir was administered orally to pregnant rats (0, 60, 300 and 800 mg/kg/day) and rabbits (0, 100, 200 or 400 mg/kg/day) during the period of organogenesis (on GD 6 to 17 and GD 7 to 20, respectively). There were no test article-related embryofetal effects (malformations or fetal toxicity) at any dose level in either species. The highest systemic exposure of dasabuvir was 24-times higher (rats) and 6-times higher (rabbits) than the exposures in humans at the recommended clinical dose.

In a pre- and postnatal developmental study in rats, dasabuvir was administered orally at 0, 50, 200, or 800 mg/kg/day from GD 7 to lactation day 21. There were no treatment-related effects at maternal exposures 44-times higher than exposures in humans at the recommended clinical dose.

Ombitasvir

Ombitasvir was administered orally to pregnant mice (0, 15, 50, or 150 mg/kg/day) and rabbits (0, 10 or 60 mg/kg/day) during the period of organogenesis (on gestation days (GD) 6 to 15, and GD 7 to 19, respectively). There were no ombitasvir-related embryofetal effects (malformations or fetal toxicity) at any dose level in either species. The systemic exposures at the highest doses were 28-times higher (mice) and 4-times higher (rabbits) than the exposures in humans at the recommended clinical dose.

In a pre- and postnatal developmental study in mice, ombitasvir was administered orally at 0, 10, 40, or 200 mg/kg/day from GD 6 to lactation day 20. There were no ombitasvir-related effects at maternal exposures 25-times higher than exposures in humans at the recommended clinical dose.

The major human metabolites of ombitasvir, M29 and M36, were tested in pregnant mice during the period of organogenesis from GD 6 to 15. M29 was administered orally at doses of 0, 1, 2.5 or 4.5 mg/kg/day. M36 was dosed orally at doses 1.5, 3, or 6 mg/kg/day. In both cases, there were no treatment related embryofetal effects (malformations or fetal toxicity) at any dose level. The highest doses produced exposures approximately 26-times higher than the exposures in humans at the recommended clinical dose.

Paritaprevir/ritonavir

Paritaprevir/ritonavir was administered orally to pregnant rats (0/0, 30/15, 100/15, 450/45 mg/kg/day) and mice (0/0, 30/30, 100/30, or 300/30 mg/kg/day) during the period of organogenesis (on GD 6 to 17, and GD 6 to 15, respectively). There were no test article-related embryofetal effects (malformations or fetal toxicity) at any dose level in either species. The highest systemic exposure of paritaprevir was 8-times higher (rats) and 98-times higher (mice) than the exposures in humans at the recommended clinical dose.

In a pre- and postnatal developmental study in rats, paritaprevir/ritonavir were administered orally at 0/0, 6/30, 30/30, or 300/30 mg/kg/day from GD 7 to lactation day 20. There were no treatment related effects at maternal exposures 17-times higher than exposures in humans at the recommended clinical dose.

Lactation

Risk Summary

It is not known whether VIEKIRA XR and its metabolites are present in human breast milk, affect human milk production or have effects on the breastfed infant. Unchanged ombitasvir, paritaprevir and its hydrolysis product M13, and dasabuvir were the predominant components observed in the milk of lactating rats, without effect on nursing pups [see Data].

The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for VIEKIRA XR and any potential adverse effects on the breastfed child from VIEKIRA XR or from the underlying maternal condition.

If VIEKIRA XR is administered with ribavirin, the nursing mother’s information for ribavirin also applies to this combination regimen. Refer to the ribavirin prescribing information for more information on use during lactation.

Data

Animal Data
Dasabuvir

No effects of dasabuvir on growth and postnatal development were observed in nursing pups at the highest dose tested (800 mg/kg/day) in rats. Maternal systemic exposure (AUC) to dasabuvir was approximately 44 times the exposure in humans at the recommended clinical dose. Although not measured directly, dasabuvir was likely present in the milk of lactating rats in this study, since systemic exposure was observed in nursing pups on post-natal day 14 (approximately 14% of maternal exposure).

When dasabuvir was administered to lactating rats (5 mg/kg on post-partum day 10 to 11), milk exposure (AUC) was 2 times higher than that in plasma, with unchanged parent drug (78%) accounting for the majority of drug-related material in milk.

Ombitasvir

No effects of ombitasvir on growth and postnatal development were observed in nursing pups at the highest dose tested (200 mg/kg/day) in mice. Maternal systemic exposure (AUC) to ombitasvir was approximately 25 times the exposure in humans at the recommended clinical dose. Although not measured directly, ombitasvir was likely present in the milk of lactating mice in this study, since systemic exposure was observed in nursing pups on post-natal day 21 (approximately 16% of maternal exposure).

When ombitasvir was administered to lactating rats (5 mg/kg on post-partum day 10 to 11), milk exposure (AUC) was 4 times higher than that in plasma, with unchanged parent drug (91%) accounting for the majority of drug-related material in milk.

Paritaprevir/ritonavir

No effects of paritaprevir/ritonavir on growth and postnatal development were observed in nursing pups at the highest dose tested (300/30 mg/kg/day) in rats. Maternal systemic exposure (AUC) to paritaprevir was approximately 17 times the exposure in humans at the recommended clinical dose. Although not measured directly, paritaprevir was likely present in the milk of lactating rats at the high dose in this study, since systemic exposure was observed in nursing pups on post-natal day 15 (approximately 0.3 % of maternal exposure).

When paritaprevir/ritonavir was administered to lactating rats (30/15 mg/kg on post-partum day 10 to 11), milk exposure (AUC) was half that in plasma, with the hydrolysis product M13 (84%) and unchanged parent drug (16%) accounting for all paritaprevir-related material in milk.

Females and Males of Reproductive Potential

If VIEKIRA XR is administered with ribavirin, the information for ribavirin with regard to pregnancy testing, contraception, and infertility also applies to this combination regimen. Refer to ribavirin prescribing information for additional information.

Pediatric Use

Safety and effectiveness of VIEKIRA XR in pediatric patients less than 18 years of age have not been established.

Geriatric Use

No dosage adjustment of VIEKIRA XR is warranted in geriatric patients. Of the total number of subjects in clinical studies of the components of VIEKIRA XR, 8.5% (174/2053) were 65 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger subjects, but greater sensitivity of some older individuals cannot be ruled out.

Hepatic Impairment

No dosage adjustment of VIEKIRA XR is required in patients with mild hepatic impairment (Child-Pugh A). VIEKIRA XR is contraindicated in patients with moderate to severe (Child-Pugh B and C) hepatic impairment [see Contraindications, Warnings and Precautions and Clinical Pharmacology].

Renal Impairment

No dosage adjustment of VIEKIRA XR is required in patients with mild, moderate or severe renal impairment, including those on dialysis. For patients that require ribavirin, refer to the ribavirin prescribing information for information regarding use in patients with renal impairment [see Clinical Pharmacology].

Overdosage

In case of overdose, it is recommended that the patient be monitored for any signs or symptoms of adverse reactions and appropriate symptomatic treatment instituted immediately.

How Supplied/Storage and Handling

VIEKIRA XR is dispensed in a monthly carton for a total of 28 days of therapy. Each monthly carton contains four weekly cartons. Each weekly carton contains seven daily dose packs.

Each child-resistant daily dose pack contains three tablets. The NDC number is 0074-0063-28.

Dasabuvir, ombitasvir, paritaprevir, and ritonavir 200 mg/8.33 mg/50 mg/33.33 mg tablets are pale yellow-colored, film-coated, oblong shaped, debossed with “3QD” on one side.

Store at or below 30°C (86°F).

Patient Counseling Information

Advise the patient to read the FDA-approved patient labeling (Consumer Medicine Information).

Inform patients to review the Consumer Medicine Information for ribavirin [see Warnings and Precautions].

Risk of ALT Elevations or Hepatic Decompensation and Failure

Inform patients to watch for early warning signs of liver inflammation or failure, such as fatigue, weakness, lack of appetite, nausea and vomiting, as well as later signs such as jaundice, onset of confusion, abdominal swelling, and discolored feces, and to consult their health care professional without delay if such symptoms occur [see Warnings and Precautions and Adverse Reactions].

Pregnancy

Advise patients taking VIEKIRA XR with ribavirin to avoid pregnancy during treatment and within 6 months of stopping ribavirin. Inform patients to notify their health care provider immediately in the event of a pregnancy [see Use in Specific Populations].

Drug Interactions

Inform patients that VIEKIRA XR may interact with some drugs; therefore, patients should be advised to report to their healthcare provider the use of any prescription, non-prescription medication or herbal products [see Contraindications, Warnings and Precautions and Drug Interactions].

Inform patients that contraceptives containing ethinyl estradiol are contraindicated with VIEKIRA XR [see Contraindications and Warnings and Precautions].

Administration

Advise patients to take VIEKIRA XR every day at the regularly scheduled time and that VIEKIRA XR must be taken with a meal because taking it under fasting conditions may result in reduced virologic response and possible development of resistance. Inform patients to swallow tablets whole and not to consume alcohol within 4 hours of taking VIEKIRA XR [see Dosage and Administration].

Inform patients that it is important not to miss or skip doses and to take VIEKIRA XR for the duration that is recommended by the healthcare provider.

Manufactured by AbbVie Inc., North Chicago, IL 60064.

VIEKIRA XR and NORVIR are trademarks of AbbVie Inc. All other brands listed are trademarks of their respective owners and are not trademarks of AbbVie Inc. The makers of these brands are not affiliated with and do not endorse AbbVie Inc. or its products.

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