Kalydeco granules

Overdose

No specific antidote is available for overdose with ivacaftor. Treatment of overdose consists of general supportive measures including monitoring of vital signs, liver function tests and observation of the clinical status of the patient.

Incompatibilities

Not applicable.

Undesirable effects

Summary of the safety profile

The most common adverse reactions experienced by patients aged 6 years and older who received ivacaftor in the pooled 48-week placebo-controlled Phase 3 studies that occurred with an incidence of at least 3% and up to 9% higher than in the placebo arm were headache (23.9%), oropharyngeal pain (22.0%), upper respiratory tract infection (22.0%), nasal congestion (20.2%), abdominal pain (15.6%), nasopharyngitis (14.7%), diarrhoea (12.8%), dizziness (9.2%), rash (12.8%) and bacteria in sputum (12.8%). Transaminase elevations occurred in 12.8% of ivacaftor-treated patients versus 11.5% of placebo-treated patients.

In patients aged 2 to less than 6 years the most common adverse reactions were nasal congestion (26.5%), upper respiratory tract infection (23.5%), transaminase elevations (14.7%), rash (11.8%), and bacteria in sputum (11.8%).

Serious adverse reactions in patients who received ivacaftor included abdominal pain and transaminase elevations.

Tabulated list of adverse reactions

Table 1 reflects the adverse reactions observed with ivacaftor in clinical trials (placebo-controlled and uncontrolled studies) in which the length of exposure to ivacaftor ranged from 16 weeks to 144 weeks. The frequency of adverse reactions is defined as follows: 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). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Description of selected adverse reactions

Hepatobiliary disorders

Transaminase elevations

During the 48-week placebo-controlled studies 1 and 2 in patients aged 6 years and older, the incidence of maximum transaminase (ALT or AST) >8, >5 or >3 x ULN was 3.7%, 3.7% and 8.3% in ivacaftor-treated patients and 1.0%, 1.9% and 8.7% in placebo-treated patients, respectively. Two patients, one on placebo and one on ivacaftor permanently discontinued treatment for elevated transaminases, each >8 x ULN. No ivacaftor-treated patients experienced a transaminase elevation >3 x ULN associated with elevated total bilirubin >1.5 x ULN. In ivacaftor-treated patients, most transaminase elevations up to 5 x ULN resolved without treatment interruption. Ivacaftor dosing was interrupted in most patients with transaminase elevations >5 x ULN. In all instances where dosing was interrupted for elevated transaminases and subsequently resumed, ivacaftor dosing was able to be resumed successfully.

Paediatric population

The safety data were evaluated in 34 patients between 2 to less than 6 years of age, 61 patients between 6 to less than 12 years of age and 94 patients between 12 to less than 18 years of age.

The safety profile is generally consistent among children and adolescents and is also consistent with adult patients.

During the 24-week open-label Phase 3 clinical study in 34 patients aged 2 to less than 6 years (study 7), the incidence of patients experiencing transaminase elevations (ALT or AST) >3 x ULN was 14.7% (5/34). All 5 patients had maximum ALT or AST levels >8 x ULN, which returned to baseline levels following interruption of dosing with ivacaftor granules. Ivacaftor was permanently discontinued in one patient. In children aged 6 to less than 12 years, the incidence of patients experiencing transaminase elevations (ALT or AST) >3 x ULN was 15.0% (6/40) in ivacaftor-treated patients and 14.6% (6/41) in patients who received placebo. A single ivacaftor-treated patient (2.5%) in this age range had an elevation of ALT and AST >8 x ULN. Peak LFT (ALT or AST) elevations were generally higher in paediatric patients than in older patients. In almost all instances where dosing was interrupted for elevated transaminases and subsequently resumed, ivacaftor dosing was able to be resumed successfully. Cases suggestive of positive rechallenge were observed.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard.

Preclinical safety data

Effects in non-clinical studies were observed only at exposures considered sufficiently in excess of the maximum human exposure indicating little relevance to clinical use.

Ivacaftor produced a concentration-dependent inhibitory effect on hERG (human ether-a-go-go related gene) tail currents, with an IC15 of 5.5 µM, which is comparable to the Cmax (5.0 µM) for ivacaftor at the therapeutic dosage. However, no ivacaftor-induced QT prolongation was observed in a dog telemetry study at single doses of up to 60 mg/kg or in ECG measurements from repeat-dose studies of up to 1 year's duration at the 60 mg/kg/day dose level in dogs (Cmax after 365 days = 36.2 to 47.6 μM). Ivacaftor produced a dose-related but transient increase in blood pressure parameters in dogs at single oral doses of up to 60 mg/kg.

Ivacaftor did not cause reproductive system toxicity in male and female rats at 200 and 100 mg/kg/day, respectively. In females, dosages above this were associated with reductions in the overall fertility index, number of pregnancies, number of corpora lutea and implantation sites, as well as changes in the oestrous cycle. In males, slight decreases of the seminal vesicle weights were observed.

Ivacaftor was not teratogenic when orally dosed to pregnant rats and rabbits during the organogenesis stage of foetal development at doses resulting in exposures approximately 5 times (based on the summed AUCs for ivacaftor and its major metabolites) and 11 times (based on the AUC for ivacaftor), respectively, the exposure in humans at the MRHD. At maternally toxic doses in rats, ivacaftor produced reductions in foetal body weight and an increase in the incidence of cervical ribs, hypoplastic ribs, wavy ribs and sternal irregularities, including fusions. The significance of these findings for humans is unknown.

Ivacaftor did not cause developmental defects in the offspring of pregnant rats dosed orally from pregnancy through parturition and weaning at 100 mg/kg/day. Dosages above this produced 92% and 98% reductions of survival and lactation indices, respectively, as well as reductions in pup body weights.

Findings of cataracts were observed in juvenile rats dosed from postnatal Day 7 through 35 with dose levels of 10 mg/kg/day and higher (resulting in exposures 0.22 times the human exposure at the MRHD based on systemic exposure of ivacaftor and its major metabolites). This finding has not been observed in foetuses derived from rat dams treated on gestation Day 7 to 17, in rat pups exposed to a certain extent through milk ingestion up to postnatal Day 20, in 7-week-old rats, or in 4- to 5-month-old dogs. The potential relevance of these findings in humans is unknown.

Two-year studies in mice and rats to assess the carcinogenic potential of ivacaftor demonstrated that ivacaftor was not carcinogenic in either species. Plasma exposures to ivacaftor in male and female mice at the non-carcinogenic dosage (200 mg/kg/day, the highest dosage tested) were approximately 4- and 7-fold higher, respectively, than the exposure measured in humans following ivacaftor therapy, and at least 1.2- and 2.4-fold higher, respectively, with regard to the summed AUCs for ivacaftor and its major metabolites. Plasma exposures to ivacaftor in male and female rats at the non-carcinogenic dosage (50 mg/kg/day, the highest dosage tested) were approximately 16- and 29-fold higher, respectively, than the exposure measured in humans following ivacaftor therapy, and 6- and 9-fold higher, respectively, with regard to the summed AUCs for ivacaftor and its major metabolites.

Ivacaftor was negative for genotoxicity in a standard battery of in vitro and in vivo tests.

Therapeutic indications

Kalydeco granules tablets are indicated for the treatment of patients with cystic fibrosis (CF) aged 6 years and older and weighing 25 kg or more who have one of the following gating (class III) mutations in the CFTR gene: G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N or S549R .

Kalydeco granules tablets are also indicated for the treatment of patients with cystic fibrosis (CF) aged 18 years and older who have an R117H mutation in the CFTR gene.

Pharmacodynamic properties

Pharmacotherapeutic group: Other respiratory system products, ATC code: R07AX02

Mechanism of action

Pharmacodynamic effects

In studies 1 and 2 in patients with the G551D mutation in one allele of the CFTR gene, ivacaftor led to rapid (15 days), substantial (the mean change in sweat chloride from baseline through Week 24 was -48 mmol/L [95% CI -51, -45] and -54 mmol/L [95% CI -62, -47], respectively) and sustained (through 48 weeks) reductions in sweat chloride concentration.

In study 5, part 1 in patients who had a non-G551D gating mutation in the CFTR gene, treatment with ivacaftor led to a rapid (15 days) and substantial mean change from baseline in sweat chloride of -49 mmol/L (95% CI -57, -41) through 8 weeks of treatment. However, in patients with the G970R-CFTR mutation, the mean (SD) absolute change in sweat chloride at Week 8 was -6.25 (6.55) mmol/L. Similar results to part 1 were seen in part 2 of the study. At the 4-week follow-up visit (4 weeks after dosing with ivacaftor ended), mean sweat chloride values for each group were trending to pre-treatment levels.

In study 6 in patients aged 6 years or older with CF who had an R117H mutation in the CFTR gene, the treatment difference in mean change in sweat chloride from baseline through 24 weeks of treatment was -24 mmol/L (95% CI -28, -20).

Clinical efficacy and safety

Study 1 and 2: studies in patients with CF with G551D gating mutations

The efficacy of Kalydeco granules has been evaluated in two Phase 3 randomised, double-blind, placebo-controlled, multi-centre studies of clinically stable patients with CF who had the G551D mutation in the CFTR gene on at least 1 allele and had FEV1 >40% predicted.

Patients in both studies were randomised 1:1 to receive either 150 mg of ivacaftor or placebo every 12 hours with food containing fat for 48 weeks in addition to their prescribed CF therapies (e.g., tobramycin, dornase alfa). The use of inhaled hypertonic sodium chloride was not permitted.

Study 1 evaluated 161 patients who were 12 years of age or older; 122 (75.8%) patients had the F508del mutation in the second allele. At the start of the study, patients in the placebo group used some medicinal products at a higher frequency than the ivacaftor group. These medications included dornase alfa (73.1% versus 65.1%), salbutamol (53.8% versus 42.2%), tobramycin (44.9% versus 33.7%) and salmeterol/fluticasone (41.0% versus 27.7%). At baseline, mean predicted FEV1 was 63.6% (range: 31.6% to 98.2%) and mean age was 26 years (range: 12 to 53 years).

Study 2 evaluated 52 patients who were 6 to 11 years of age at screening; mean (SD) body weight was 30.9 (8.63) kg; 42 (80.8%) patients had the F508del mutation in the second allele. At baseline, mean predicted FEV1 was 84.2% (range: 44.0% to 133.8%) and mean age was 9 years (range: 6 to 12 years); 8 (30.8%) patients in the placebo group and 4 (15.4%) patients in the ivacaftor group had an FEV1 less than 70% predicted at baseline.

The primary efficacy endpoint in both studies was the mean absolute change from baseline in percent predicted FEV1 through 24 weeks of treatment.

The treatment difference between ivacaftor and placebo for the mean absolute change (95% CI) in percent predicted FEV1 from baseline through Week 24 was 10.6 percentage points (8.6, 12.6) in study 1 and 12.5 percentage points (6.6, 18.3) in study 2. The treatment difference between ivacaftor and placebo for the mean relative change (95% CI) in percent predicted FEV1 from baseline through Week 24 was 17.1% (13.9, 20.2) in study 1 and 15.8% (8.4, 23.2) in study 2. The mean change from baseline through Week 24 in FEV1 (L) was 0.37 L in the ivacaftor group and 0.01 L in the placebo group in study 1 and 0.30 L in the ivacaftor group and 0.07 L in the placebo group in study 2. In both studies, improvements in FEV1 were rapid in onset (Day 15) and durable through 48 weeks.

The treatment difference between ivacaftor and placebo for the mean absolute change (95% CI) in percent predicted FEV1 from baseline through Week 24 in patients 12 to 17 years of age in study 1 was 11.9 percentage points (5.9, 17.9). The treatment difference between ivacaftor and placebo for the mean absolute change (95% CI) in percent predicted FEV1 from baseline through Week 24 in patients with baseline predicted FEV1 greater than 90% in study 2 was 6.9 percentage points (-3.8, 17.6).

The results for clinically relevant secondary endpoints are shown in Table 2.

Study 5: study in patients with CF with non-G551D gating mutations

Study 5 was a Phase 3, two-part, randomised, double-blind, placebo-controlled, crossover study (part 1) followed by a 16-week open-label extension period (part 2) to evaluate the efficacy and safety of ivacaftor in patients with CF aged 6 years and older who have a non-G551D gating mutation in the CFTR gene (G178R, S549N, S549R, G551S, G970R, G1244E, S1251N, S1255P or G1349D).

In part 1, patients were randomised 1:1 to receive either 150 mg of ivacaftor or placebo every 12 hours with fat-containing food for 8 weeks in addition to their prescribed CF therapies and crossed over to the other treatment for the second 8 weeks after a 4- to 8-week washout period. The use of inhaled hypertonic saline was not permitted. In part 2, all patients received ivacaftor as indicated in part 1 for 16 additional weeks. The duration of continuous ivacaftor treatment was 24 weeks for patients randomised to part 1 placebo/ivacaftor treatment sequence and 16 weeks for patients randomised to part 1 ivacaftor/placebo treatment sequence.

Thirty-nine patients (mean age 23 years) with baseline FEV1 >40% predicted (mean FEV1 78% predicted [range: 43% to 119%]) were enrolled. Sixty-two percent (24/39) of them carried the F508del-CFTR mutation in the second allele. A total of 36 patients continued into part 2 (18 per treatment sequence).

In part 1 of study 5, the mean FEV1 percent predicted at baseline in placebo-treated patients was 79.3% while in ivacaftor-treated patients this value was 76.4%. The mean overall post-baseline value was 76.0% and 83.7%, respectively. The mean absolute change from baseline through Week 8 in percent predicted FEV1 (primary efficacy endpoint) was 7.5% in the ivacaftor period and -3.2% in the placebo period. The observed treatment difference (95% CI) between ivacaftor and placebo was 10.7% (7.3, 14.1) (P<0.0001).

The effect of ivacaftor in the overall population of study 5 (including the secondary endpoints absolute change in BMI at 8 weeks of treatment and absolute change in the respiratory domain score of the CFQ-R through 8 weeks of treatment) and by individual mutation (absolute change in sweat chloride and in percent predicted FEV1 at Week 8) is shown in Table 3. Based on clinical (percent predicted FEV1) and pharmacodynamic (sweat chloride) responses to ivacaftor, efficacy in patients with the G970R mutation could not be established.

In part 2 of study 5, the mean (SD) absolute change in percent predicted FEV1 following 16 weeks (patients randomised to the ivacaftor/placebo treatment sequence in part 1) of continuous ivacaftor treatment was 10.4% (13.2%). At the follow-up visit, 4 weeks after ivacaftor dosing had ended, the mean (SD) absolute change in percent predicted FEV1 from part 2 Week 16 was -5.9% (9.4%). For patients randomised to the placebo/ivacaftor treatment sequence in part 1 there was a further mean (SD) change of 3.3% (9.3%) in percent predicted FEV1 after the additional 16 weeks of treatment with ivacaftor. At the follow up visit, 4 weeks after ivacaftor dosing had ended, the mean (SD) absolute change in percent predicted FEV1 from part 2 Week 16 was -7.4% (5.5%).

Study 3: study in patients with CF with the F508del mutation in the CFTR gene

Study 3 (part A) was a 16-week, 4:1 randomised, double-blind, placebo-controlled, parallel-group Phase 2 study of ivacaftor (150 mg every 12 hours) in 140 patients with CF age 12 years and older who were homozygous for the F508del mutation in the CFTR gene and who had FEV1 >40% predicted.

The mean absolute change from baseline through Week 16 in percent predicted FEV1 (primary efficacy endpoint) was 1.5 percentage points in the ivacaftor group and -0.2 percentage points in the placebo group. The estimated treatment difference for ivacaftor versus placebo was 1.7 percentage points (95% CI -0.6, 4.1); this difference was not statistically significant (P = 0.15).

Study 4: open-label extension study

In study 4 patients who completed treatment in studies 1 and 2 with placebo were switched to ivacaftor while patients on ivacaftor continued to receive it for a minimum of 96 weeks, i.e., the length of treatment with ivacaftor was at least 96 weeks for patients in the placebo/ivacaftor group and at least 144 weeks for patients in the ivacaftor/ivacaftor group.

One hundred and forty-four (144) patients from study 1 were rolled over in study 4, 67 in the placebo/ivacaftor group and 77 in the ivacaftor/ivacaftor group. Forty-eight (48) patients from study 2 were rolled over in study 4, 22 in the placebo/ivacaftor group and 26 in the ivacaftor/ivacaftor group.

Table 4 shows the results of the mean (SD) absolute change in percent predicted FEV1 for both groups of patients. For patients in the placebo/ivacaftor group baseline percent predicted FEV1 is that of study 4 while for patients in the ivacaftor/ivacaftor group the baseline value is that of studies 1 and 2.

When the mean (SD) absolute change in percent predicted FEV1 is compared from study 4 baseline for patients in the ivacaftor/ivacaftor group (n=72) who rolled over from study 1, the mean (SD) absolute change in percent predicted FEV1 was 0.0% (9.05), while for patients in the ivacaftor/ivacaftor group (n=25) who rolled over from study 2 this figure was 0.6% (9.1). This shows that patients in the ivacaftor/ivacaftor group maintained the improvement seen at Week 48 of the initial study (Day 0 through Week 48) in percent predicted FEV1 through Week 144. There were no additional improvements in study 4 (Week 48 through Week 144).

For patients in the placebo/ivacaftor group from study 1, the annualised rate of pulmonary exacerbations was higher in the initial study when patients were on placebo (1.34 events/year) than during the subsequent study 4 when patients rolled over to ivacaftor (0.48 events/year across Day 1 to Week 48, and 0.67 events/year across Weeks 48 to 96). For patients in the ivacaftor/ivacaftor group from study 1, the annualised rate of pulmonary exacerbations was 0.57 events/year across Day 1 to Week 48 when patients were on ivacaftor. When they rolled over into study 4, the rate of annualised pulmonary exacerbations was 0.91 events/year across Day 1 to Week 48 and 0.77 events/year across Weeks 48 to 96.

For patients who rolled over from study 2 the number of events was, overall, low.

Study 6: study in patients with CF with an R117H mutation in the CFTR gene

Study 6 evaluated 69 patients who were 6 years of age or older; 53 (76.8%) of patients had the F508del mutation in the second allele. The confirmed R117H poly-T variant was 5T in 38 patients and 7T in 16 patients. At baseline, mean predicted FEV1 was 73% (range: 32.5% to 105.5%) and mean age was 31 years (range: 6 to 68 years). The mean absolute change from baseline through Week 24 in percent predicted FEV1 (primary efficacy endpoint) was 2.57 percentage points in the ivacaftor group and 0.46 percentage points in the placebo group. The estimated treatment difference for ivacaftor versus placebo was 2.1 percentage points (95% CI -1.1, 5.4).

A pre-planned subgroup analysis was conducted in patients 18 years and older (26 patients on placebo and 24 on ivacaftor). Treatment with ivacaftor resulted in a mean absolute change in percent predicted FEV1 through Week 24 of 4.5 percentage points in the ivacaftor group versus -0.46 percentage points in the placebo group. The estimated treatment difference for ivacaftor versus placebo was 5.0 percentage points (95% CI 1.1, 8.8).

In a subgroup analysis in patients 6 to 11 years of age (8 patients on placebo and 9 patients on ivacaftor), the placebo group showed an improvement in mean percent predicted FEV1 from 94.0% at baseline to 98.4% post-baseline; the ivacaftor group showed a slight decline in mean FEV1 from 97.5% at baseline to 96.2% overall post-baseline. The mean absolute change from baseline through Week 24 in percent predicted FEV1 was -2.8 percentage points in the ivacaftor group and 3.5 percentage points in the placebo group. The treatment difference for ivacaftor versus placebo was -6.3 percentage points (95% CI -12.0, -0.7). No statistical analysis was conducted for subjects 12 to 17 years of age because only 2 patients were enrolled in this study.

In a subgroup analysis in patients with a confirmed R117H-5T genetic variant, the difference in the mean absolute change from baseline through Week 24 in percent predicted FEV1 between ivacaftor and placebo was 5.3% (95% CI 1.3, 9.3). In patients with a confirmed R117H-7T genetic variant, the treatment difference between ivacaftor and placebo was 0.2% (95% CI -8.1, 8.5).

Secondary efficacy variables included absolute change from baseline in sweat chloride through 24 weeks of treatment, absolute change from baseline in BMI at 24 weeks of treatment, absolute change in the CFQ-R respiratory domain score through 24 weeks of treatment and time to first pulmonary exacerbation. No treatment differences for ivacaftor versus placebo were observed except for the respiratory domain of the CFQ-R (the treatment difference through 24 weeks of ivacaftor versus placebo was 8.4 [2.2, 14.6] points) and for the mean change from baseline in sweat chloride (see Pharmacodynamic effects).

Paediatric population

Pharmacokinetic properties

The pharmacokinetics of ivacaftor are similar between healthy adult volunteers and patients with CF.

After oral administration of a single 150 mg dose to healthy volunteers in a fed state, the mean (±SD) for AUC and Cmax were 10600 (5260) ng*hr/mL and 768 (233) ng/mL, respectively. After every 12-hour dosing, steady-state plasma concentrations of ivacaftor were reached by Days 3 to 5, with an accumulation ratio ranging from 2.2 to 2.9.

Absorption

Following multiple oral dose administrations of ivacaftor, the exposure of ivacaftor generally increased with dose from 25 mg every 12 hours to 450 mg every 12 hours. The exposure of ivacaftor increased approximately 2.5- to 4-fold when given with food containing fat. Therefore, ivacaftor should be administered with fat-containing food. The median (range) tmax is approximately 4.0 (3.0; 6.0) hours in the fed state.

Ivacaftor granules (2 x 75 mg sachets) had similar bioavailability as the 150 mg tablet when given with fat-containing food to healthy adult subjects. The geometric least squares mean ratio (90% CI) for the granules relative to tablets was 0.951 (0.839, 1.08) for AUC0-∞ and 0.918 (0.750, 1.12) for Cmax.

The effect of food on ivacaftor absorption is similar for both formulations, i.e., tablets and granules.

Distribution

Ivacaftor is approximately 99% bound to plasma proteins, primarily to alpha 1-acid glycoprotein and albumin. Ivacaftor does not bind to human red blood cells.

After oral administration of 150 mg every 12 hours for 7 days in healthy volunteers in a fed state, the mean (±SD) apparent volume of distribution was 353 (122) L.

Biotransformation

Ivacaftor is extensively metabolised in humans. In vitro and in vivo data indicate that ivacaftor is primarily metabolised by CYP3A. M1 and M6 are the two major metabolites of ivacaftor in humans. M1 has approximately one-sixth the potency of ivacaftor and is considered pharmacologically active. M6 has less than one-fiftieth the potency of ivacaftor and is not considered pharmacologically active.

Elimination

Following oral administration, the majority of ivacaftor (87.8%) was eliminated in the faeces after metabolic conversion. The major metabolites M1 and M6 accounted for approximately 65% of the total dose eliminated with 22% as M1 and 43% as M6. There was negligible urinary excretion of ivacaftor as unchanged parent. The apparent terminal half-life was approximately 12 hours following a single dose in the fed state. The apparent clearance (CL/F) of ivacaftor was similar for healthy subjects and patients with CF. The mean (±SD) CL/F for a single 150 mg dose was 17.3 (8.4) L/hr in healthy subjects.

Linearity/non-linearity

The pharmacokinetics of ivacaftor are generally linear with respect to time or dose ranging from 25 mg to 250 mg.

Hepatic impairment

Following a single dose of 150 mg of ivacaftor, adult subjects with moderately impaired hepatic function (Child-Pugh Class B, score 7 to 9) had similar ivacaftor Cmax (mean [±SD] of 735 [331] ng/mL) but an approximately two-fold increase in ivacaftor AUC0-∞ (mean [±SD] of 16800 [6140] ng*hr/mL) compared with healthy subjects matched for demographics. Simulations for predicting the steady-state exposure of ivacaftor showed that by reducing the dosage from 150 mg q12h to 150 mg once daily, adults with moderate hepatic impairment would have comparable steady-state Cmin values as those obtained with a dose of 150 mg q12h in adults without hepatic impairment. Therefore in patients with moderate hepatic impairment, a reduced dose of 150 mg once daily is recommended. The impact of mild hepatic impairment (Child-Pugh Class A, score 5 to 6) on the pharmacokinetics of ivacaftor has not been studied, but the increase in ivacaftor AUC0-∞ is expected to be less than two-fold. Therefore, no dose adjustment is necessary for patients with mild hepatic impairment.

Studies have not been conducted in patients with severe hepatic impairment (Child-Pugh Class C, score 10 to 15) but exposure is expected to be higher than in patients with moderate hepatic impairment. The use of ivacaftor in patients with severe hepatic impairment is therefore not recommended unless the benefits outweigh the risks. In such cases, the starting dose should be 150 mg every other day. Dosing intervals should be modified according to clinical response and tolerability.

Renal impairment

Pharmacokinetic studies have not been performed with ivacaftor in patients with renal impairment. In a human pharmacokinetic study, there was minimal elimination of ivacaftor and its metabolites in urine (only 6.6% of total radioactivity was recovered in the urine). There was negligible urinary excretion of ivacaftor as unchanged parent (less than 0.01% following a single oral dose of 500 mg). Therefore, no dose adjustments are recommended for mild and moderate renal impairment. However, caution is recommended when administering ivacaftor to patients with severe renal impairment (creatinine clearance less than or equal to 30 mL/min) or end-stage renal disease.

Paediatric population

Predicted ivacaftor exposure based on observed ivacaftor concentrations in Phase 2 and 3 studies as determined using population PK analysis is presented by age group in Table 5. Exposures in 6- to 11-year-olds are predictions based on simulations from the population PK model using data obtained for this age group.

Name of the medicinal product

Qualitative and quantitative composition

Special warnings and precautions for use

Only patients with CF who had a G551D, G1244E, G1349D, G178R, G551S, G970R, S1251N, S1255P, S549N, S549R gating (class III) or an R117H mutation in at least one allele of the CFTR gene were included in studies 1, 2, 5 and 6.

In study 5, four patients with the G970R mutation were included. In three of four patients the change in the sweat chloride test was <5 mmol/L and this group did not demonstrate a clinically relevant improvement in FEV1 after 8 weeks of treatment. Clinical efficacy in patients with the G970R mutation of the CFTR gene could not be established.

Efficacy results from a Phase 2 study in patients with CF who are homozygous for the F508del mutation in the CFTR gene showed no statistically significant difference in FEV1 over 16 weeks of ivacaftor treatment compared to placebo. Therefore, use of Kalydeco granules in these patients is not recommended.

Efficacy was not demonstrated in patients aged 6 to 11 years with CF who have an R117H mutation while only two adolescent patients were enrolled in study 6.

Less evidence of a positive effect of ivacaftor has been shown for patients with an R117H-7T mutation associated with less severe disease. Whenever possible the phase of the poly-T variant identified with the R117H mutation should be determined as this may be informative in considering treatment of patients with an R117H mutation.

Effect on liver function tests

Moderate transaminase (alanine transaminase [ALT] or aspartate transaminase [AST]) elevations are common in subjects with CF. In placebo-controlled studies (studies 1 and 2), the incidence of transaminase elevations (>3 x upper limit of normal [ULN]) were similar between subjects in the ivacaftor and placebo treatment groups. In the subset of patients with a medical history of elevated transaminases, increased ALT or AST has been reported more frequently in patients receiving ivacaftor compared to placebo. Therefore, liver function tests are recommended for all patients prior to initiating ivacaftor, every 3 months during the first year of treatment and annually thereafter. For all patients with a history of transaminase elevations, more frequent monitoring of liver function tests should be considered.

Patients who develop increased transaminase levels should be monitored closely until the abnormalities resolve. Dosing should be interrupted in patients with ALT or AST of greater than 5 times the ULN. Following resolution of transaminase elevations, the benefits and risks of resuming Kalydeco granules dosing should be considered.

Hepatic impairment

Use of ivacaftor is not recommended in patients with severe hepatic impairment unless the benefits are expected to outweigh the risks of overexposure. In such cases, the starting dose should be 150 mg every other day.

Renal impairment

Caution is recommended while using ivacaftor in patients with severe renal impairment or end-stage renal disease.

Patients after organ transplantation

Ivacaftor has not been studied in patients with CF who have undergone organ transplantation.

Interactions with medicinal products

CYP3A inducers

Exposure to ivacaftor may be reduced by the concomitant use of CYP3A inducers, potentially resulting in the loss of ivacaftor efficacy. Therefore, co-administration with strong CYP3A inducers is not recommended.

CYP3A inhibitors

The dose of Kalydeco granules must be adjusted when concomitantly used with strong or moderate CYP3A inhibitors.

Cataracts

Cases of non-congenital lens opacities without impact on vision have been reported in paediatric patients treated with ivacaftor. 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. Baseline and follow-up ophthalmological examinations are recommended in paediatric patients initiating ivacaftor treatment.

Lactose

Kalydeco granules contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.

Effects on ability to drive and use machines

Kalydeco granules has minor influence on the ability to drive or use machines. Ivacaftor may cause dizziness and, therefore, patients experiencing dizziness should be advised not to drive or use machines until symptoms abate.

Dosage (Posology) and method of administration

Kalydeco granules should only be prescribed by physicians with experience in the treatment of cystic fibrosis. If the patient's genotype is unknown, an accurate and validated genotyping method should be performed before starting treatment to confirm the presence of one of the above-listed gating (class III) mutations or an R117H mutation in at least one allele of the CFTR gene. The phase of the poly-T variant identified with the R117H mutation should be determined in accordance with local clinical recommendations.

Posology

Adults, adolescents and children aged 6 years and older and weighing 25 kg or more

The recommended dose of Kalydeco granules tablets is 150 mg taken orally every 12 hours (300 mg total daily dose) with fat-containing food.

Missed dose

If a dose is missed within 6 hours of the time it is usually taken, the patient should be told to take it as soon as possible and then take the next dose at the regularly scheduled time. If more than 6 hours have passed since the time the dose is usually taken, the patient should be told to wait until the next scheduled dose.

Concomitant use of CYP3A inhibitors

When co-administered with strong inhibitors of CYP3A (e.g., ketoconazole, itraconazole, posaconazole, voriconazole, telithromycin and clarithromycin), the Kalydeco granules dose should be reduced to 150 mg twice a week.

When co-administered with moderate inhibitors of CYP3A (e.g., fluconazole, erythromycin), the Kalydeco granules dose should be reduced to 150 mg once daily.

Special populations

Elderly

Although very limited data are available for elderly patients with an R117H-CFTR mutation treated with ivacaftor in study 6, no dose adjustment is considered necessary unless moderate hepatic impairment exists. Caution is recommended for patients with severe renal impairment or end-stage renal disease.

Renal impairment

No dose adjustment is necessary for patients with mild to moderate renal impairment. Caution is recommended while using Kalydeco granules in patients with severe renal impairment (creatinine clearance less than or equal to 30 mL/min) or end-stage renal disease.

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 reduced dose of 150 mg once daily is recommended. There is no experience of the use of Kalydeco granules in patients with severe hepatic impairment and therefore its use is not recommended unless the benefits outweigh the risks. In such cases, the starting dose should be 150 mg every other day. Dosing intervals should be modified according to clinical response and tolerability.

Paediatric population

The safety and efficacy of Kalydeco granules in children aged less than 2 years with a gating (class III) mutation have not been established. No data are available.

An appropriate dose for children under 6 years of age and weighing less than 25 kg cannot be achieved with Kalydeco granules tablets.

The efficacy of Kalydeco granules in patients less than 18 years of age with an R117H mutation in the CFTR gene has not been established.8 and 5.1, but no recommendation on a posology can be made.

Method of administration

For oral use.

Kalydeco granules should be taken with fat-containing food.

Food containing grapefruit or Seville oranges should be avoided during treatment with Kalydeco granules.

Patients should be instructed to swallow the tablets whole (i.e., patients should not chew, break or dissolve the tablets).

Special precautions for disposal and other handling

No special requirements for disposal.