Human experience of acute overdose with Кемерувир co-administered with low dose ritonavir is limited. Single doses up to 3,200 mg of darunavir as oral solution alone and up to 1,600 mg of the tablet formulation of darunavir in combination with ritonavir have been administered to healthy volunteers without untoward symptomatic effects.
There is no specific antidote for overdose with Кемерувир. Treatment of overdose with Кемерувир consists of general supportive measures including monitoring of vital signs and observation of the clinical status of the patient. Since darunavir is highly protein bound, dialysis is unlikely to be beneficial in significant removal of the active substance.
Patients with severe (Child-Pugh Class C) hepatic impairment.
Combination of rifampicin with Кемерувир with concomitant low dose ritonavir.
Co-administration with the combination product lopinavir/ritonavir.
Co-administration with herbal preparations containing St John's wort (Hypericum perforatum).
Co-administration of Кемерувир with low dose ritonavir, with active substances that are highly dependent on CYP3A for clearance and for which elevated plasma concentrations are associated with serious and/or life-threatening events. These active substances include e.g.:
- alfuzosin
- amiodarone, bepridil, dronedarone, quinidine, ranolazine
- astemizole, terfenadine
- colchicine when used in patients with renal and/or hepatic impairment
- ergot derivatives (e.g. dihydroergotamine, ergometrine, ergotamine, methylergonovine)
- elbasvir/grazoprevir
- cisapride
- lurasidone, pimozide, quetiapine, sertindole
- triazolam, midazolam administered orally
- sildenafil - when used for the treatment of pulmonary arterial hypertension, avanafil
- simvastatin, lovastatin and lomitapide
- ticagrelor.
Not applicable.
Summary of the safety profile
During the clinical development program (N=2,613 treatment-experienced subjects who initiated therapy with Кемерувир/ritonavir 600/100 mg twice daily), 51.3% of subjects experienced at least one adverse reaction. The total mean treatment duration for subjects was 95.3 weeks. The most frequent adverse reactions reported in clinical trials and as spontaneous reports are diarrhoea, nausea, rash, headache and vomiting. The most frequent serious reactions are acute renal failure, myocardial infarction, immune reconstitution inflammatory syndrome, thrombocytopenia, osteonecrosis, diarrhoea, hepatitis and pyrexia.
In the 96 week analysis, the safety profile of Кемерувир/ritonavir 800/100 mg once daily in treatment-naïve subjects was similar to that seen with Кемерувир/ritonavir 600/100 mg twice daily in treatment-experienced subjects except for nausea which was observed more frequently in treatment-naïve subjects. This was driven by mild intensity nausea. No new safety findings were identified in the 192 week analysis of the treatment-naïve subjects in which the mean treatment duration of Кемерувир/ritonavir 800/100 mg once daily was 162.5 weeks.
Tabulated list of adverse reactions
Adverse reactions are listed by system organ class (SOC) and frequency category. Within each frequency category, adverse reactions are presented in order of decreasing seriousness. Frequency categories are 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) and not known (frequency cannot be estimated from the available data).
Adverse reactions observed with darunavir/ritonavir in clinical trials and post-marketing
| MedDRA system organ class Frequency category | Adverse reaction |
| Infections and infestations | |
| uncommon | herpes simplex |
| Blood and lymphatic system disorders | |
| uncommon | thrombocytopenia, neutropenia, anaemia, leukopenia |
| rare | increased eosinophil count |
| Immune system disorders | |
| uncommon | immune reconstitution inflammatory syndrome, (drug) hypersensitivity |
| Endocrine disorders | |
| uncommon | hypothyroidism, increased blood thyroid stimulating hormone |
| Metabolism and nutrition disorders | |
| common | diabetes mellitus, hypertriglyceridaemia, hypercholesterolaemia, hyperlipidaemia |
| uncommon | gout, anorexia, decreased appetite, decreased weight, increased weight, hyperglycaemia, insulin resistance, decreased high density lipoprotein, increased appetite, polydipsia, increased blood lactate dehydrogenase |
| Psychiatric disorders | |
| common | insomnia |
| uncommon | depression, disorientation, anxiety, sleep disorder, abnormal dreams, nightmare, decreased libido |
| rare | confusional state, altered mood, restlessness |
| Nervous system disorders | |
| common | headache, peripheral neuropathy, dizziness |
| uncommon | lethargy, paraesthesia, hypoaesthesia, dysgeusia, disturbance in attention, memory impairment, somnolence |
| rare | syncope, convulsion, ageusia, sleep phase rhythm disturbance |
| Eye disorders | |
| uncommon | conjunctival hyperaemia, dry eye |
| rare | visual disturbance |
| Ear and labyrinth disorders | |
| uncommon | vertigo |
| Cardiac disorders | |
| uncommon | myocardial infarction, angina pectoris, prolonged electrocardiogram QT, tachycardia |
| rare | acute myocardial infarction, sinus bradycardia, palpitations |
| Vascular disorders | |
| uncommon | hypertension, flushing |
| Respiratory, thoracic and mediastinal disorders | |
| uncommon | dyspnoea, cough, epistaxis, throat irritation |
| rare | rhinorrhoea |
| Gastrointestinal disorders | |
| very common | diarrhoea |
| common | vomiting, nausea, abdominal pain, increased blood amylase, dyspepsia, abdominal distension, flatulence |
| uncommon | pancreatitis, gastritis, gastrooesophageal reflux disease, aphthous stomatitis, retching, dry mouth, abdominal discomfort, constipation, increased lipase, eructation, oral dysaesthesia |
| rare | stomatitis, haematemesis, cheilitis, dry lip, coated tongue |
| Hepatobiliary disorders | |
| common | increased alanine aminotransferase |
| uncommon | hepatitis, cytolytic hepatitis, hepatic steatosis, hepatomegaly, increased transaminase, increased aspartate aminotransferase, increased blood bilirubin, increased blood alkaline phosphatase, increased gamma-glutamyltransferase |
| Skin and subcutaneous tissue disorders | |
| common | rash (including macular, maculopapular, papular, erythematous and pruritic rash), pruritus |
| uncommon | angioedema, generalised rash, allergic dermatitis, urticaria, eczema, erythema, hyperhidrosis, night sweats, alopecia, acne, dry skin, nail pigmentation |
| rare | DRESS, Stevens-Johnson syndrome, erythema multiforme, dermatitis, seborrhoeic dermatitis, skin lesion, xeroderma |
| not known | toxic epidermal necrolysis, acute generalised exanthematous pustulosis |
| Musculoskeletal and connective tissue disorders | |
| uncommon | myalgia, osteonecrosis, muscle spasms, muscular weakness, arthralgia, pain in extremity, osteoporosis, increased blood creatine phosphokinase |
| rare | musculoskeletal stiffness, arthritis, joint stiffness |
| Renal and urinary disorders | |
| uncommon | acute renal failure, renal failure, nephrolithiasis, increased blood creatinine, proteinuria, bilirubinuria, dysuria, nocturia, pollakiuria |
| rare | decreased creatinine renal clearance |
| Reproductive system and breast disorders | |
| uncommon | erectile dysfunction, gynaecomastia |
| General disorders and administration site conditions | |
| common | asthenia, fatigue |
| uncommon | pyrexia, chest pain, peripheral oedema, malaise, feeling hot, irritability, pain |
| rare | chills, abnormal feeling, xerosis |
Description of selected adverse reactions
Rash
In clinical trials, rash was mostly mild to moderate, often occurring within the first four weeks of treatment and resolving with continued dosing.
During the clinical development program of raltegravir in treatment-experienced patients, rash, irrespective of causality, was more commonly observed with regimens containing Кемерувир/ritonavir + raltegravir compared to those containing Кемерувир/ritonavir without raltegravir or raltegravir without Кемерувир/ritonavir. Rash considered by the investigator to be drug-related occurred at similar rates. The exposure-adjusted rates of rash (all causality) were 10.9, 4.2, and 3.8 per 100 patient-years (PYR), respectively; and for drug-related rash were 2.4, 1.1, and 2.3 per 100 PYR, respectively. The rashes observed in clinical studies were mild to moderate in severity and did not result in discontinuation of therapy.
Metabolic parameters
Weight and levels of blood lipids and glucose may increase during antiretroviral therapy.
Musculoskeletal abnormalities
Increased CPK, myalgia, myositis and rarely, rhabdomyolysis have been reported with the use of protease inhibitors, particularly in combination with NRTIs.
Cases of osteonecrosis have been reported, particularly in patients with generally acknowledged risk factors, advanced HIV disease or long-term exposure to combination antiretroviral therapy (CART). The frequency of this is unknown.
Immune reconstitution inflammatory syndrome
In HIV infected patients with severe immune deficiency at the time of initiation of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic infections may arise. Autoimmune disorders (such as Graves' disease) have also been reported; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment.
Bleeding in haemophiliac patients
There have been reports of increased spontaneous bleeding in haemophiliac patients receiving antiretroviral protease inhibitors.
Paediatric population
The safety assessment in paediatric patients is based on the 48-week analysis of safety data from three Phase II trials. The following patient populations were evaluated :
- 80 ART-experienced HIV-1 infected paediatric patients aged from 6 to 17 years and weighing at least 20 kg who received Кемерувир tablets with low dose ritonavir twice daily in combination with other antiretroviral agents.
- 21 ART-experienced HIV-1 infected paediatric patients aged from 3 to < 6 years and weighing 10 kg to < 20 kg (16 participants from 15 kg to < 20 kg) who received Кемерувир oral suspension with low dose ritonavir twice daily in combination with other antiretroviral agents.
- 12 ART-naïve HIV-1 infected paediatric patients aged from 12 to 17 years and weighing at least 40 kg who received Кемерувир tablets with low dose ritonavir once daily in combination with other antiretroviral agents.
Overall, the safety profile in these paediatric patients was similar to that observed in the adult population.
Other special populations
Patients co-infected with hepatitis B and/or hepatitis C virus
Among 1,968 treatment-experienced patients receiving Кемерувир co-administered with ritonavir 600/100 mg twice daily, 236 patients were co-infected with hepatitis B or C. Co-infected patients were more likely to have baseline and treatment emergent hepatic transaminase elevations than those without chronic viral hepatitis.
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:
United Kingdom
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
Ireland
HPRA Pharmacovigilance
Earlsfort Terrace
IRL - Dublin 2
Tel: +353 1 6764971
Fax: +353 1 6762517
Website: www.hpra.ie
E-mail: [email protected]
Animal toxicology studies have been conducted at exposures up to clinical exposure levels with darunavir alone, in mice, rats and dogs and in combination with ritonavir in rats and dogs.
In repeated-dose toxicology studies in mice, rats and dogs, there were only limited effects of treatment with darunavir. In rodents the target organs identified were the haematopoietic system, the blood coagulation system, liver and thyroid. A variable but limited decrease in red blood cell-related parameters was observed, together with increases in activated partial thromboplastin time.
Changes were observed in liver (hepatocyte hypertrophy, vacuolation, increased liver enzymes) and thyroid (follicular hypertrophy). In the rat, the combination of darunavir with ritonavir lead to a small increase in effect on RBC parameters, liver and thyroid and increased incidence of islet fibrosis in the pancreas (in male rats only) compared to treatment with darunavir alone. In the dog, no major toxicity findings or target organs were identified up to exposures equivalent to clinical exposure at the recommended dose.
In a study conducted in rats, the number of corpora lutea and implantations were decreased in the presence of maternal toxicity. Otherwise, there were no effects on mating or fertility with darunavir treatment up to 1,000 mg/kg/day and exposure levels below (AUC-0.5 fold) of that in human at the clinically recommended dose. Up to same dose levels, there was no teratogenicity with darunavir in rats and rabbits when treated alone nor in mice when treated in combination with ritonavir. The exposure levels were lower than those with the recommended clinical dose in humans. In a pre- and postnatal development assessment in rats, darunavir with and without ritonavir, caused a transient reduction in body weight gain of the offspring pre-weaning and there was a slight delay in the opening of eyes and ears. Darunavir in combination with ritonavir caused a reduction in the number of pups that exhibited the startle response on day 15 of lactation and a reduced pup survival during lactation. These effects may be secondary to pup exposure to the active substance via the milk and/or maternal toxicity. No post weaning functions were affected with darunavir alone or in combination with ritonavir. In juvenile rats receiving darunavir up to days 23-26, increased mortality was observed with convulsions in some animals. Exposure in plasma, liver and brain was considerably higher than in adult rats after comparable doses in mg/kg between days 5 and 11 of age. After day 23 of life, the exposure was comparable to that in adult rats. The increased exposure was likely at least partly due to immaturity of the drug-metabolising enzymes in juvenile animals. No treatment related mortalities were noted in juvenile rats dosed at 1,000 mg/kg darunavir (single dose) on day 26 of age or at 500 mg/kg (repeated dose) from day 23 to 50 of age, and the exposures and toxicity profile were comparable to those observed in adult rats.
Due to uncertainties regarding the rate of development of the human blood brain barrier and liver enzymes, Кемерувир with low dose ritonavir should not be used in paediatric patients below 3 years of age.
Darunavir was evaluated for carcinogenic potential by oral gavage administration to mice and rats up to 104 weeks. Daily doses of 150, 450 and 1,000 mg/kg were administered to mice and doses of 50, 150 and 500 mg/kg were administered to rats. Dose-related increases in the incidences of hepatocellular adenomas and carcinomas were observed in males and females of both species. Thyroid follicular cell adenomas were noted in male rats. Administration of darunavir did not cause a statistically significant increase in the incidence of any other benign or malignant neoplasm in mice or rats. The observed hepatocellular and thyroid tumours in rodents are considered to be of limited relevance to humans. Repeated administration of darunavir to rats caused hepatic microsomal enzyme induction and increased thyroid hormone elimination, which predispose rats, but not humans, to thyroid neoplasms. At the highest tested doses, the systemic exposures (based on AUC) to darunavir were between 0.4- and 0.7-fold (mice) and 0.7- and 1-fold (rats), relative to those observed in humans at the recommended therapeutic doses.
After 2 years administration of darunavir at exposures at or below the human exposure, kidney changes were observed in mice (nephrosis) and rats (chronic progressive nephropathy).
Darunavir was not mutagenic or genotoxic in a battery of in vitro and in vivo assays including bacterial reverse mutation (Ames), chromosomal aberration in human lymphocytes and in vivo micronucleus test in mice.
Кемерувир, co-administered with low dose ritonavir is indicated in combination with other antiretroviral medicinal products for the treatment of patients with human immunodeficiency virus (HIV-1) infection.
Кемерувир 75 mg, 150 mg, 300 mg, and 600 mg tablets may be used to provide suitable dose regimens :
- For the treatment of HIV-1 infection in antiretroviral treatment (ART)-experienced adult patients, including those that have been highly pre-treated.
- For the treatment of HIV-1 infection in paediatric patients from the age of 3 years and at least 15 kg body weight.
In deciding to initiate treatment with Кемерувир co-administered with low dose ritonavir, careful consideration should be given to the treatment history of the individual patient and the patterns of mutations associated with different agents. Genotypic or phenotypic testing (when available) and treatment history should guide the use of Кемерувир.
Pharmacotherapeutic group: Antivirals for systemic use, protease inhibitors, ATC code: J05AE10.
Mechanism of action
Darunavir is an inhibitor of the dimerisation and of the catalytic activity of the HIV-1 protease (KD of 4.5 x 10-12M). It selectively inhibits the cleavage of HIV encoded Gag-Pol polyproteins in virus infected cells, thereby preventing the formation of mature infectious virus particles.
Antiviral activity in vitro
Darunavir exhibits activity against laboratory strains and clinical isolates of HIV-1 and laboratory strains of HIV-2 in acutely infected T-cell lines, human peripheral blood mononuclear cells and human monocytes/macrophages with median EC50 values ranging from 1.2 to 8.5 nM (0.7 to 5.0 ng/ml). Darunavir demonstrates antiviral activity in vitro against a broad panel of HIV-1 group M (A, B, C, D, E, F, G) and group O primary isolates with EC50 values ranging from < 0.1 to 4.3 nM.
These EC50 values are well below the 50% cellular toxicity concentration range of 87 µM to > 100 µM.
Resistance
In vitro selection of darunavir-resistant virus from wild type HIV-1 was lengthy (> 3 years). The selected viruses were unable to grow in the presence of darunavir concentrations above 400 nM. Viruses selected in these conditions and showing decreased susceptibility to darunavir (range: 23-50-fold) harboured 2 to 4 amino acid substitutions in the protease gene. The decreased susceptibility to darunavir of the emerging viruses in the selection experiment could not be explained by the emergence of these protease mutations.
The clinical trial data from ART-experienced patients (TITAN trial and the pooled analysis of the POWER 1, 2 and 3 and DUET 1 and 2 trials) showed that virologic response to Кемерувир co-administered with low dose ritonavir was decreased when 3 or more darunavir RAMs (V11I, V32I, L33F, I47V, I50V, I54L or M, T74P, L76V, I84V and L89V) were present at baseline or when these mutations developed during treatment.
Increasing baseline darunavir fold change in EC50 (FC) was associated with decreasing virologic response. A lower and upper clinical cut-off of 10 and 40 were identified. Isolates with baseline FC ≤ 10 are susceptible; isolates with FC > 10 to 40 have decreased susceptibility; isolates with FC > 40 are resistant (see Clinical results).
Viruses isolated from patients on Кемерувир/ritonavir 600/100 mg twice daily experiencing virologic failure by rebound that were susceptible to tipranavir at baseline remained susceptible to tipranavir after treatment in the vast majority of cases.
The lowest rates of developing resistant HIV virus are observed in ART-naïve patients who are treated for the first time with darunavir in combination with other ART.
The table below shows the development of HIV-1 protease mutations and loss of susceptibility to PIs in virologic failures at endpoint in the ARTEMIS, ODIN and TITAN trials.
|
| ARTEMIS Week 192 | ODIN Week 48 | TITAN Week 48 | |
| Кемерувир/ ritonavir 800/100 mg once daily N=343 | Кемерувир/ ritonavir 800/100 mg once daily N=294 | Кемерувир/ ritonavir 600/100 mg twice daily N=296 | Кемерувир/ ritonavir 600/100 mg twice daily N=298 | |
| Total number of virologic failuresa, n (%) | 55 (16.0%) | 65 (22.1%) | 54 (18.2%) | 31 (10.4%) |
| Rebounders | 39 (11.4%) | 11 (3.7%) | 11 (3.7%) | 16 (5.4%) |
| Never suppressed subjects | 16 (4.7%) | 54 (18.4%) | 43 (14.5%) | 15 (5.0%) |
| Number of subjects with virologic failure and paired baseline/endpoint genotypes, developing mutationsb at endpoint, n/N | ||||
| Primary (major) PI mutations | 0/43 | 1/60 | 0/42 | 6/28 |
| PI RAMs | 4/43 | 7/60 | 4/42 | 10/28 |
| Number of subjects with virologic failure and paired baseline/endpoint phenotypes, showing loss of susceptibility to PIs at endpoint compared to baseline, n/N | ||||
| PI |
|
|
|
|
| darunavir | 0/39 | 1/58 | 0/41 | 3/26 |
| amprenavir | 0/39 | 1/58 | 0/40 | 0/22 |
| atazanavir | 0/39 | 2/56 | 0/40 | 0/22 |
| indinavir | 0/39 | 2/57 | 0/40 | 1/24 |
| lopinavir | 0/39 | 1/58 | 0/40 | 0/23 |
| saquinavir | 0/39 | 0/56 | 0/40 | 0/22 |
| tipranavir | 0/39 | 0/58 | 0/41 | 1/25 |
| a TLOVR non-VF censored algorithm based on HIV-1 RNA < 50 copies/ml, except for TITAN (HIV-1 RNA < 400 copies/ml) b IAS-USA lists | ||||
Cross-resistance
Darunavir FC was less than 10 for 90% of 3,309 clinical isolates resistant to amprenavir, atazanavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir and/or tipranavir showing that viruses resistant to most PIs remain susceptible to darunavir.
In the virologic failures of the ARTEMIS trial no cross-resistance with other PIs was observed.
Clinical results
Adult patients
For clinical trial results in ART-naïve adult patients, refer to the Summary of Product Characteristics for Кемерувир 400 mg and 800 mg tablets or 100 mg/ml oral suspension.
Efficacy of Кемерувир 600 mg twice daily co administered with 100 mg ritonavir twice daily in ART experienced patients
The evidence of efficacy of Кемерувир co-administered with ritonavir (600/100 mg twice daily) in ART-experienced patients is based on the 96 weeks analysis of the Phase III trial TITAN in ART-experienced lopinavir naïve patients, on the 48 week analysis of the Phase III trial ODIN in ART-experienced patients with no DRV-RAMs, and on the analyses of 96 weeks data from the Phase IIb trials POWER 1 and 2 in ART-experienced patients with high level of PI resistance.
TITAN is a randomised, controlled, open-label Phase III trial comparing Кемерувир co-administered with ritonavir (600/100 mg twice daily) versus lopinavir/ritonavir (400/100 mg twice daily) in ART-experienced, lopinavir naïve HIV-1 infected adult patients. Both arms used an Optimised Background Regimen (OBR) consisting of at least 2 antiretrovirals (NRTIs with or without NNRTIs).
The table below shows the efficacy data of the 48 week analysis from the TITAN trial.
| TITAN | |||
| Outcomes | Кемерувир/ritonavir 600/100 mg twice daily + OBR N=298 | Lopinavir/ritonavir 400/100 mg twice daily + OBR N=297 | Treatment difference (95% CI of difference)
|
| HIV-1 RNA < 50 copies/mla | 70.8% (211) | 60.3% (179) | 10.5% (2.9; 18.1)b |
| median CD4+ cell count change from baseline (x 106/l)c | 88 | 81 |
|
| a Imputations according to the TLOVR algorithm b Based on a normal approximation of the difference in % response c NC=F | |||
At 48 weeks non-inferiority in virologic response to the Кемерувир/ritonavir treatment, defined as the percentage of patients with plasma HIV-1 RNA level < 400 and < 50 copies/ml, was demonstrated (at the pre-defined 12% non-inferiority margin) for both ITT and OP populations. These results were confirmed in the analysis of data at 96 weeks of treatment in the TITAN trial, with 60.4% of patients in the Кемерувир/ritonavir arm having HIV-1 RNA < 50 copies/ml at week 96 compared to 55.2% in the lopinavir/ritonavir arm [difference: 5.2%, 95% CI (-2.8; 13.1)].
ODIN is a Phase III, randomised, open-label trial comparing Кемерувир/ritonavir 800/100 mg once daily versus Кемерувир/ritonavir 600/100 mg twice daily in ART-experienced HIV-1 infected patients with screening genotype resistance testing showing no darunavir RAMs (i.e. V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V, L89V) and a screening HIV-1 RNA > 1,000 copies/ml. Efficacy analysis is based on 48 weeks of treatment (see table below). Both arms used an optimised background regimen (OBR) of > 2 NRTIs.
| ODIN | |||
| Outcomes | Кемерувир/ritonavir 800/100 mg once daily + OBR N=294 | Кемерувир/ritonavir 600/100 mg twice daily + OBR N=296 | Treatment difference (95% CI of difference) |
| HIV-1 RNA < 50 copies/mla | 72.1% (212) | 70.9% (210) | 1.2% (-6.1; 8.5)b |
| With Baseline HIV-1 RNA (copies/ml) < 100,000 > 100,000 |
77.6% (198/255) 35.9% (14/39) |
73.2% (194/265) 51.6% (16/31) |
4.4% (-3.0; 11.9) -15.7% (-39.2; 7.7) |
| With Baseline CD4+ cell count (x 106/l) > 100 < 100 |
75.1% (184/245) 57.1% (28/49) |
72.5% (187/258) 60.5% (23/38) |
2.6% (-5.1; 10.3) -3.4% (-24.5; 17.8) |
| With HIV-1 clade Type B Type AE Type C Otherc |
70.4% (126/179) 90.5% (38/42) 72.7% (32/44) 55.2% (16/29) |
64.3% (128/199) 91.2% (31/34) 78.8% (26/33) 83.3% (25/30) |
6.1% (-3.4; 15.6) -0.7% (-14.0; 12.6) -6.1% (-2.6; 13.7) -28.2% (-51.0; -5.3) |
| mean CD4+ cell count change from baseline (x 106/l)e | 108 | 112 | -5d (-25; 16) |
| a Imputations according to the TLOVR algorithm b Based on a normal approximation of the difference in % response c Clades A1, D, F1, G, K, CRF02_AG, CRF12_BF, and CRF06_CPX d Difference in means e Last Observation Carried Forward imputation | |||
At 48 weeks, virologic response, defined as the percentage of patients with plasma HIV-1 RNA level < 50 copies/ml, with Кемерувир/ritonavir 800/100 mg once daily treatment was demonstrated to be non-inferior (at the pre-defined 12% non-inferiority margin) compared to Кемерувир/ritonavir 600/100 mg twice daily for both ITT and OP populations.
Кемерувир/ritonavir 800/100 mg once daily in ART-experienced patients should not be used in patients with one or more darunavir resistance associated mutations (DRV-RAMs) or HIV-1 RNA > 100,000 copies/ml or CD4+ cell count < 100 cells x 106/l. Limited data is available in patients with HIV-1 clades other than B.
POWER 1 and POWER 2 are randomised, controlled trials comparing Кемерувир co-administered with ritonavir (600/100 mg twice daily) with a control group receiving an investigator-selected PI(s) regimen in HIV-1 infected patients who had previously failed more than 1 PI containing regimen. An OBR consisting of at least 2 NRTIs with or without enfuvirtide (ENF) was used in both trials.
The table below shows the efficacy data of the 48-week and 96-week analyses from the pooled POWER 1 and POWER 2 trials.
| POWER 1 and POWER 2 pooled data | ||||||
| Week 48 | Week 96 | |||||
| Outcomes | Кемерувир/ ritonavir 600/100 mg twice daily n=131 | Control n=124 | Treatment difference | Кемерувир/ ritonavir 600/100 mg twice daily n=131 | Control n=124 | Treatment difference |
| HIV RNA < 50 copies/mla | 45.0% (59) | 11.3% (14) | 33.7% (23.4%; 44.1%)c | 38.9% (51) | 8.9% (11) | 30.1% (20.1; 40.0)c |
| CD4+ cell count mean change from baseline (x 106/l)b | 103 | 17 | 86 (57; 114)c | 133 | 15 | 118 (83.9; 153.4)c |
| a Imputations according to the TLOVR algorithm b Last Observation Carried Forward imputation c 95% confidence intervals. | ||||||
Analyses of data through 96 weeks of treatment in the POWER trials demonstrated sustained antiretroviral efficacy and immunologic benefit.
Out of the 59 patients who responded with complete viral suppression (< 50 copies/ml) at week 48, 47 patients (80% of the responders at week 48) remained responders at week 96.
Baseline genotype or phenotype and virologic outcome
Baseline genotype and darunavir FC (shift in susceptibility relative to reference) were shown to be a predictive factor of virologic outcome.
Proportion (%) of patients with response (HIV-1 RNA < 50 copies/ml at week 24) to Кемерувир co-administered with ritonavir (600/100 mg twice daily) by baseline genotypea, and baseline darunavir FC and by use of enfuvirtide (ENF): As treated analysis of the POWER and DUET trials.
| Number of baseline mutationsa | Baseline DRV FCb | |||||||
| Response (HIV-1 RNA < 50 copies/ml at week 24) %, n/N | All ranges | 0-2 | 3 | > 4 | All ranges | ≤ 10 | 10-40 | > 40 |
| All patients | 45% 455/1,014 | 54% 359/660 | 39% 67/172 | 12% 20/171 | 45% 455/1,014 | 55% 364/659 | 29% 59/203 | 8% 9/118 |
| Patients with no/non-naïve use of ENFc | 39% 290/741 | 50% 238/477 | 29% 35/120 | 7% 10/135 | 39% 290/741 | 51% 244/477 | 17% 25/147 | 5% 5/94 |
| Patients with naïve use of ENFd | 60% 165/273 | 66% 121/183 | 62% 32/52 | 28% 10/36 | 60% 165/273 | 66% 120/182 | 61% 34/56 | 17% 4/24 |
| a Number of mutations from the list of mutations associated with a diminished response to Кемерувир/ritonavir (V11I, V32I, L33F, I47V, I50V, I54L or M, T74P, L76V, I84V or L89V) b fold change in EC50 c “Patients with no/non-naïve use of ENF†are patients who did not use ENF or who used ENF but not for the first time d “Patients with naïve use of ENF†are patients who used ENF for the first time | ||||||||
Paediatric patients
For clinical trial results in ART-naïve paediatric patients aged 12 to 17 years, refer to the Summary of Product Characteristics for Кемерувир 400 mg and 800 mg tablets or Кемерувир 100 mg/ml oral suspension.
ART-experienced paediatric patients from the age of 6 to < 18 years, and weighing at least 20 kg
DELPHI is an open-label, Phase II trial evaluating the pharmacokinetics, safety, tolerability, and efficacy of Кемерувир with low dose ritonavir in 80 ART-experienced HIV-1 infected paediatric patients aged 6 to 17 years and weighing at least 20 kg.). Virologic response was defined as a decrease in plasma HIV-1 RNA viral load of at least 1.0 log10 versus baseline.
In the study, patients who were at risk of discontinuing therapy due to intolerance of ritonavir oral solution (e.g. taste aversion) were allowed to switch to the capsule formulation. Of the 44 patients taking ritonavir oral solution, 27 switched to the 100 mg capsule formulation and exceeded the weight-based ritonavir dose without changes in observed safety.
| DELPHI | |
| Outcomes at week 48 | Кемерувир/ritonavir N=80 |
| HIV-1 RNA < 50 copies/mla | 47.5% (38) |
| CD4+ cell count mean change from baselineb | 147 |
| a Imputations according to the TLOVR algorithm. b Non-completer is failure imputation: patients who discontinued prematurely are imputed with a change equal to 0. | |
According to the TLOVR non-virologic failure censored algorithm 24 (30.0%) patients experienced virological failure, of which 17 (21.3%) patients were rebounders and 7 (8.8%) patients were non-responders.
ART-experienced paediatric patients from the age of 3 to < 6 years
The pharmacokinetics, safety, tolerability and efficacy of Кемерувир/ritonavir twice daily in combination with other antiretroviral agents in 21 ART-experienced HIV-1 infected paediatric patients aged 3 to < 6 years and weighing 10 kg to < 20 kg was evaluated in an open-label, Phase II trial, ARIEL.).
| ARIEL | ||
| Outcomes at week 48 | Кемерувир/ritonavir | |
| 10 kg to < 15 kg N=5 | 15 kg to < 20 kg N=16 | |
| HIV-1 RNA < 50 copies/mla | 80.0% (4) | 81.3% (13) |
| CD4+ percent change from baselineb | 4 | 4 |
| CD4+ cell count mean change from baselineb | 16 | 241 |
| a Imputations according to the TLOVR algorithm. b NC=F | ||
Limited efficacy data are available in paediatric patients below 15 kg and no recommendation on a posology can be made.
Pregnancy and postpartum
Darunavir/ritonavir (600/100 mg twice daily or 800/100 mg once daily) in combination with a background regimen was evaluated in a clinical trial of 34 pregnant women (17 in each arm) during the second and third trimesters, and postpartum. Virologic response was preserved throughout the study period in both arms. No mother to child transmission occurred in the infants born to the 29 subjects who stayed on the antiretroviral treatment through delivery. There were no new clinically relevant safety findings compared with the known safety profile of darunavir/ritonavir in HIV-1 infected adults.
The pharmacokinetic properties of darunavir, co-administered with ritonavir, have been evaluated in healthy adult volunteers and in HIV-1 infected patients. Exposure to darunavir was higher in HIV-1 infected patients than in healthy subjects. The increased exposure to darunavir in HIV-1 infected patients compared to healthy subjects may be explained by the higher concentrations of α1-acid glycoprotein (AAG) in HIV-1 infected patients, resulting in higher darunavir binding to plasma AAG and, therefore, higher plasma concentrations.
Darunavir is primarily metabolised by CYP3A. Ritonavir inhibits CYP3A, thereby increasing the plasma concentrations of darunavir considerably.
Absorption
Darunavir was rapidly absorbed following oral administration. Maximum plasma concentration of darunavir in the presence of low dose ritonavir is generally achieved within 2.5-4.0 hours.
The absolute oral bioavailability of a single 600 mg dose of darunavir alone was approximately 37% and increased to approximately 82% in the presence of 100 mg twice daily ritonavir. The overall pharmacokinetic enhancement effect by ritonavir was an approximate 14-fold increase in the systemic exposure of darunavir when a single dose of 600 mg darunavir was given orally in combination with ritonavir at 100 mg twice daily.
When administered without food, the relative bioavailability of darunavir in the presence of low dose ritonavir is 30% lower as compared to intake with food. Therefore, Кемерувир tablets should be taken with ritonavir and with food. The type of food does not affect exposure to darunavir.
Distribution
Darunavir is approximately 95% bound to plasma protein. Darunavir binds primarily to plasma α1-acid glycoprotein.
Following intravenous administration, the volume of distribution of darunavir alone was 88.1 ± 59.0 l (Mean ± SD) and increased to 131 ± 49.9 l (Mean ± SD) in the presence of 100 mg twice-daily ritonavir.
Biotransformation
In vitro experiments with human liver microsomes (HLMs) indicate that darunavir primarily undergoes oxidative metabolism. Darunavir is extensively metabolised by the hepatic CYP system and almost exclusively by isozyme CYP3A4. A 14C-darunavir trial in healthy volunteers showed that a majority of the radioactivity in plasma after a single 400/100 mg darunavir with ritonavir dose was due to the parent active substance. At least 3 oxidative metabolites of darunavir have been identified in humans; all showed activity that was at least 10-fold less than the activity of darunavir against wild type HIV.
Elimination
After a 400/100 mg 14C-darunavir with ritonavir dose, approximately 79.5% and 13.9% of the administered dose of 14C-darunavir could be retrieved in faeces and urine, respectively. Unchanged darunavir accounted for approximately 41.2% and 7.7% of the administered dose in faeces and urine, respectively. The terminal elimination half-life of darunavir was approximately 15 hours when combined with ritonavir.
The intravenous clearance of darunavir alone (150 mg) and in the presence of low dose ritonavir was 32.8 l/h and 5.9 l/h, respectively.
Special populations
Paediatric population
The pharmacokinetics of darunavir in combination with ritonavir taken twice daily in 74 treatment-experienced paediatric patients, aged 6 to 17 years and weighing at least 20 kg, showed that the administered weight-based doses of Кемерувир/ritonavir resulted in darunavir exposure comparable to that in adults receiving Кемерувир/ritonavir 600/100 mg twice daily.
The pharmacokinetics of darunavir in combination with ritonavir taken twice daily in 14 treatment-experienced paediatric patients, aged 3 to < 6 years and weighing at least 15 kg to < 20 kg, showed that weight-based dosages resulted in darunavir exposure that was comparable to that achieved in adults receiving Кемерувир/ritonavir 600/100 mg twice daily.
The pharmacokinetics of darunavir in combination with ritonavir taken once daily in 12 ART-naïve paediatric patients, aged 12 to < 18 years and weighing at least 40 kg, showed that Кемерувир/ritonavir 800/100 mg once daily results in darunavir exposure that was comparable to that achieved in adults receiving Кемерувир/ritonavir 800/100 mg once daily. Therefore the same once daily dosage may be used in treatment-experienced adolescents aged 12 to < 18 years and weighing at least 40 kg without darunavir resistance associated mutations (DRV-RAMs)* and who have plasma HIV-1 RNA < 100,000 copies/ml and CD4+ cell count > 100 cells x 106/l.
* DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V and L89V
The pharmacokinetics of darunavir in combination with ritonavir taken once daily in 10 treatment-experienced paediatric patients, aged 3 to < 6 years and weighing at least 14 kg to < 20 kg, showed that weight-based dosages resulted in darunavir exposure that was comparable to that achieved in adults receiving Кемерувир/ritonavir 800/100 mg once daily. In addition, pharmacokinetic modeling and simulation of darunavir exposures in paediatric patients across the ages of 3 to < 18 years confirmed the darunavir exposures as observed in the clinical studies and allowed the identification of weight-based Кемерувир/ritonavir once daily dosing regimens for paediatric patients weighing at least 15 kg that are either ART-naïve or treatment-experienced paediatric patients without DRV-RAMs* and who have plasma HIV-1 RNA < 100,000 copies/ml and CD4+ cell count > 100 cells x 106/l.
* DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V and L89V
Elderly
Population pharmacokinetic analysis in HIV infected patients showed that darunavir pharmacokinetics are not considerably different in the age range (18 to 75 years) evaluated in HIV infected patients (n=12, age > 65). However, only limited data were available in patients above the age of 65 year.
Gender
Population pharmacokinetic analysis showed a slightly higher darunavir exposure (16.8%) in HIV infected females compared to males. This difference is not clinically relevant.
Renal impairment
Results from a mass balance study with 14C-darunavir with ritonavir showed that approximately 7.7% of the administered dose of darunavir is excreted in the urine unchanged.
Although darunavir has not been studied in patients with renal impairment, population pharmacokinetic analysis showed that the pharmacokinetics of darunavir were not significantly affected in HIV infected patients with moderate renal impairment (CrCl between 30-60 ml/min, n=20).
Hepatic impairment
Darunavir is primarily metabolised and eliminated by the liver. In a multiple dose study with Кемерувир co-administered with ritonavir (600/100 mg) twice daily, it was demonstrated that the total plasma concentrations of darunavir in subjects with mild (Child-Pugh Class A, n=8) and moderate (Child-Pugh Class B, n=8) hepatic impairment were comparable with those in healthy subjects. However, unbound darunavir concentrations were approximately 55% (Child-Pugh Class A) and 100% (Child-Pugh Class B) higher, respectively. The clinical relevance of this increase is unknown therefore, Кемерувир should be used with caution. The effect of severe hepatic impairment on the pharmacokinetics of darunavir has not been studied.
Pregnancy and postpartum
The exposure to total darunavir and ritonavir after intake of darunavir/ritonavir 600/100 mg twice daily and darunavir/ritonavir 800/100 mg once daily as part of an antiretroviral regimen was generally lower during pregnancy compared with postpartum. However, for unbound (i.e. active) darunavir, the pharmacokinetic parameters were less reduced during pregnancy compared to postpartum, due to an increase in the unbound fraction of darunavir during pregnancy compared to postpartum.
| Pharmacokinetic results of total darunavir after administration of darunavir/ritonavir at 600/100 mg twice daily as part of an antiretroviral regimen, during the second trimester of pregnancy, the third trimester of pregnancy and postpartum | |||
| Pharmacokinetics of total darunavir (mean ± SD) | Second trimester of pregnancy (n=11)a | Third trimester of pregnancy (n=11) | Postpartum (6-12 weeks) (n=11) |
| Cmax, ng/ml | 4,601 ± 1,125 | 5,111 ± 1,517 | 6,499 ± 2,411 |
| AUC12h, ng.h/ml | 38,950 ± 10,010 | 43,700 ± 16,400 | 55,300 ± 27,020 |
| Cmin, ng/mlb | 1,980 ± 839.9 | 2,498 ± 1,193 | 2,711 ± 2,268 |
| a n=10 for AUC12h b excluding Cmin value below LLOQ, n=10 for postpartum | |||
| Pharmacokinetic results of total darunavir after administration of darunavir/ritonavir at 800/100 mg once daily as part of an antiretroviral regimen, during the second trimester of pregnancy, the third trimester of pregnancy and postpartum | |||
| Pharmacokinetics of total darunavir (mean ± SD) | Second trimester of pregnancy (n=16) | Third Trimester of pregnancy (n=14) | Postpartum (6-12 weeks) (n=15) |
| Cmax, ng/ml | 4,988 ± 1,551 | 5,138 ± 1,243 | 7,445 ± 1,674 |
| AUC24h, ng.h/ml | 61,303 ± 16,232 | 60,439 ± 14,052 | 94,529 ± 28,572 |
| Cmin, ng/mla | 1,193 ± 509 | 1,098 ± 609 | 1,572 ± 1,108 |
| a n=12 for postpartum, n=15 for second trimester and n=14 for third trimester | |||
In women receiving darunavir/ritonavir 600/100 mg twice daily during the second trimester of pregnancy, mean intra-individual values for total darunavir Cmax, AUC12h and Cmin were 28%, 24% and 17% lower, respectively, as compared with postpartum; during the third trimester of pregnancy, total darunavir Cmax, AUC12h and Cmin values were 19%, 17% lower and 2% higher, respectively, as compared with postpartum.
In women receiving darunavir/ritonavir 800/100 mg once daily during the second trimester of pregnancy, mean intra-individual values for total darunavir Cmax, AUC24h and Cmin were 34%, 34% and 32% lower, respectively, as compared with postpartum; during the third trimester of pregnancy, total darunavir Cmax, AUC24h and Cmin values were 31%, 35% and 50% lower, respectively, as compared with postpartum.
While effective viral suppression with antiretroviral therapy has been proven to substantially reduce the risk of sexual transmission, a residual risk cannot be excluded. Precautions to prevent transmission should be taken in accordance with national guidelines.
Regular assessment of virological response is advised. In the setting of lack or loss of virological response, resistance testing should be performed.
Кемерувир must always be given orally with low dose ritonavir as a pharmacokinetic enhancer and in combination with other antiretroviral medicinal products. The Summary of Product Characteristics of ritonavir as appropriate, must therefore be consulted prior to initiation of therapy with Кемерувир.
Darunavir binds predominantly to α1-acid glycoprotein. This protein binding is concentration-dependent indicative for saturation of binding. Therefore, protein displacement of medicinal products highly bound to α1-acid glycoprotein cannot be ruled out.
ART-experienced patients - once daily dosing
Кемерувир used in combination with cobicistat or low dose ritonavir once daily in ART-experienced patients should not be used in patients with one or more darunavir resistance associated mutations (DRV-RAMs) or HIV-1 RNA > 100,000 copies/ml or CD4+ cell count < 100 cells x 106/l. Combinations with optimised background regimen (OBRs) other than > 2 NRTIs have not been studied in this population. Limited data are available in patients with HIV-1 clades other than B.
Paediatric population
Кемерувир is not recommended for use in paediatric patients below 3 years of age or less than 15 kg body weight.
Pregnancy
Кемерувир should be used during pregnancy only if the potential benefit justifies the potential risk. Caution should be used in pregnant women with concomitant medications which may further decrease darunavir exposure.
Elderly
As limited information is available on the use of Кемерувир in patients aged 65 and over, caution should be exercised in the administration of Кемерувир in elderly patients, reflecting the greater frequency of decreased hepatic function and of concomitant disease or other therapy.
Severe skin reactions
During the darunavir/ritonavir clinical development program (N=3,063), severe skin reactions, which may be accompanied with fever and/or elevations of transaminases, have been reported in 0.4% of patients. DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) and Stevens-Johnson Syndrome has been rarely (< 0.1%) reported, and during post-marketing experience toxic epidermal necrolysis and acute generalised exanthematous pustulosis have been reported. Кемерувир should be discontinued immediately if signs or symptoms of severe skin reactions develop. These can include, but are not limited to, severe rash or rash accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
Rash occurred more commonly in treatment-experienced patients receiving regimens containing Кемерувир/ritonavir + raltegravir compared to patients receiving Кемерувир/ritonavir without raltegravir or raltegravir without Кемерувир.
Darunavir contains a sulphonamide moiety. Кемерувир should be used with caution in patients with a known sulphonamide allergy.
Hepatotoxicity
Drug-induced hepatitis (e.g. acute hepatitis, cytolytic hepatitis) has been reported with Кемерувир. During the darunavir/ritonavir clinical development program (N=3,063), hepatitis was reported in 0.5% of patients receiving combination antiretroviral therapy with Кемерувир/ritonavir. Patients with pre-existing liver dysfunction, including chronic active hepatitis B or C, have an increased risk for liver function abnormalities including severe and potentially fatal hepatic adverse reactions. In case of concomitant antiviral therapy for hepatitis B or C, please refer to the relevant product information for these medicinal products.
Appropriate laboratory testing should be conducted prior to initiating therapy with Кемерувир/ritonavir and patients should be monitored during treatment. Increased AST/ALT monitoring should be considered in patients with underlying chronic hepatitis, cirrhosis, or in patients who have pre-treatment elevations of transaminases, especially during the first several months of Кемерувир/ritonavir treatment.
If there is evidence of new or worsening liver dysfunction (including clinically significant elevation of liver enzymes and/or symptoms such as fatigue, anorexia, nausea, jaundice, dark urine, liver tenderness, hepatomegaly) in patients using Кемерувир/ritonavir, interruption or discontinuation of treatment should be considered promptly.
Patients with coexisting conditions
Hepatic impairment
The safety and efficacy of Кемерувир have not been established in patients with severe underlying liver disorders and Кемерувир is therefore contraindicated in patients with severe hepatic impairment. Due to an increase in the unbound darunavir plasma concentrations, Кемерувир should be used with caution in patients with mild or moderate hepatic impairment.
Renal impairment
No special precautions or dose adjustments for darunavir/ritonavir are required in patients with renal impairment. As darunavir and ritonavir are highly bound to plasma proteins, it is unlikely that they will be significantly removed by haemodialysis or peritoneal dialysis. Therefore, no special precautions or dose adjustments are required in these patients.
Haemophiliac patients
There have been reports of increased bleeding, including spontaneous skin haematomas and haemarthrosis in patients with haemophilia type A and B treated with PIs. In some patients additional factor VIII was given. In more than half of the reported cases, treatment with PIs was continued or reintroduced if treatment had been discontinued. A causal relationship has been suggested, although the mechanism of action has not been elucidated. Haemophiliac patients should, therefore, be made aware of the possibility of increased bleeding.
Weight and metabolic parameters
An increase in weight and in levels of blood lipids and glucose may occur during antiretroviral therapy. Such changes may in part be linked to disease control and life style. For lipids, there is in some cases evidence for a treatment effect, while for weight gain there is no strong evidence relating this to any particular treatment. For monitoring of blood lipids and glucose reference is made to established HIV treatment guidelines. Lipid disorders should be managed as clinically appropriate.
Osteonecrosis
Although the aetiology is considered to be multifactorial (including corticosteroid use, alcohol consumption, severe immunosuppression, higher body mass index), cases of osteonecrosis have been reported particularly in patients with advanced HIV disease and/or long-term exposure to combination antiretroviral therapy (CART). Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.
Immune reconstitution inflammatory syndrome
In HIV infected patients with severe immune deficiency at the time of initiation of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic pathogens may arise and cause serious clinical conditions, or aggravation of symptoms. Typically, such reactions have been observed within the first weeks or months of initiation of CART. Relevant examples are cytomegalovirus retinitis, generalised and/or focal mycobacterial infections and pneumonia caused by Pneumocystis jirovecii (formerly known as Pneumocystis carinii). Any inflammatory symptoms should be evaluated and treatment instituted when necessary. In addition, reactivation of herpes simplex and herpes zoster has been observed in clinical studies with Кемерувир co-administered with low dose ritonavir.
Autoimmune disorders (such as Graves' disease) have also been reported to occur in the setting of immune reactivation; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment.
Interactions with medicinal products
Several of the interaction studies have been performed with darunavir at lower than recommended doses.
Efavirenz in combination with boosted Кемерувир once daily may result in sub-optimal darunavir Cmin. If efavirenz is to be used in combination with Кемерувир, the Кемерувир/ritonavir 600/100 mg twice daily regimen should be used.
Life-threatening and fatal drug interactions have been reported in patients treated with colchicine and strong inhibitors of CYP3A and P-glycoprotein.
Кемерувир 300 mg tablets and 600 mg tablets contain sunset yellow FCF (E110) which may cause an allergic reaction.
Кемерувир in combination with ritonavir has no or negligible influence on the ability to drive and use machines. However, dizziness has been reported in some patients during treatment with regimens containing Кемерувир co-administered with low dose ritonavir and should be borne in mind when considering a patient's ability to drive or operate machinery.
Therapy should be initiated by a health care provider experienced in the management of HIV infection. After therapy with Кемерувир has been initiated, patients should be advised not to alter the dosage, dose form or discontinue therapy without discussing with their health care provider.
Posology
Кемерувир must always be given orally with low dose ritonavir as a pharmacokinetic enhancer and in combination with other antiretroviral medicinal products. The Summary of Product Characteristics of ritonavir must, therefore, be consulted prior to initiation of therapy with Кемерувир.
Кемерувир is also available as an oral suspension for use in patients who are unable to swallow Кемерувир tablets (please refer to the Summary of Product Characteristics for Кемерувир oral suspension).
ART-experienced adult patients
The recommended dose regimen is 600 mg twice daily taken with ritonavir 100 mg twice daily taken with food. Кемерувир 75 mg, 150 mg, 300 mg, and 600 mg tablets can be used to construct the twice daily 600 mg regimen.
The use of 75 mg and 150 mg tablets to achieve the recommended dose is appropriate when there is a possibility of hypersensitivity to specific colouring agents, or difficulty in swallowing the 300 mg or 600 mg tablets.
A dose regimen of 800 mg once daily with cobicistat 150 mg once daily or ritonavir 100 mg once daily taken with food may be used in patients with prior exposure to antiretroviral medicinal products but without darunavir resistance associated mutations (DRV-RAMs)* and who have plasma HIV-1 RNA < 100,000 copies/ml and CD4+ cell count > 100 cells x 106/l (see the Summary of Product Characteristics for Кемерувир 400 mg and 800 mg tablets).
* DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V and L89V
ART-naïve adult patients
For dosage recommendations in ART-naïve patients see the Summary of Product Characteristics for Кемерувир 400 mg and 800 mg tablets.
ART-naïve paediatric patients (3 to 17 years of age and weighing at least 15 kg)
The weight-based dose of Кемерувир and ritonavir in paediatric patients is provided in the table below.
| Recommended dose for treatment-naïve paediatric patients (3 to 17 years) with Кемерувир tablets and ritonavira | |
| Body weight (kg) | Dose (once daily with food) |
| > 15 kg to < 30 kg | 600 mg Кемерувир/100 mg ritonavir once daily |
| > 30 kg to < 40 kg | 675 mg Кемерувир/100 mg ritonavir once daily |
| > 40 kg | 800 mg Кемерувир/100 mg ritonavir once daily |
| a ritonavir oral solution: 80 mg/ml | |
ART-experienced paediatric patients (3 to 17 years of age and weighing at least 15 kg)
Кемерувир twice daily taken with ritonavir taken with food is usually recommended.
A once daily dose regimen of Кемерувир taken with ritonavir taken with food may be used in patients with prior exposure to antiretroviral medicinal products but without darunavir resistance associated mutations (DRV-RAMs)* and who have plasma HIV-1 RNA < 100,000 copies/ml and CD4+ cell count > 100 cells x 106/l.
* DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V and L89V
The weight-based dose of Кемерувир and ritonavir in paediatric patients is provided in the table below. The recommended dose of Кемерувир with low dose ritonavir should not exceed the recommended adult dose (600/100 mg twice daily or 800/100 mg once daily).
| Recommended dose for treatment-experienced paediatric patients (3 to 17 years) with Кемерувир tablets and ritonavira | ||
| Body weight (kg) | Dose (once daily with food) | Dose (twice daily with food) |
| > 15 kg-< 30 kg | 600 mg Кемерувир/100 mg ritonavir once daily | 375 mg Кемерувир/50 mg ritonavir twice daily |
| > 30 kg-< 40 kg | 675 mg Кемерувир/100 mg ritonavir once daily | 450 mg Кемерувир/60 mg ritonavir twice daily |
| > 40 kg | 800 mg Кемерувир/100 mg ritonavir once daily | 600 mg Кемерувир/100 mg ritonavir twice daily |
| a ritonavir oral solution: 80 mg/ml | ||
For ART-experienced paediatric patients HIV genotypic testing is recommended. However, when HIV genotypic testing is not feasible, the Кемерувир/ritonavir once daily dosing regimen is recommended in HIV protease inhibitor-naïve paediatric patients and the twice daily dosing regimen is recommended in HIV protease inhibitor-experienced patients.
The use of only 75 mg and 150 mg tablets or the 100 mg/ml oral suspension to achieve the recommended dose of Кемерувир could be appropriate when there is a possibility of hypersensitivity to specific colouring agents.
Advice on missed doses
In case a dose of Кемерувир and/or ritonavir is missed within 6 hours of the time it is usually taken, patients should be instructed to take the prescribed dose of Кемерувир and ritonavir with food as soon as possible. If this is noticed later than 6 hours after the time it is usually taken, the missed dose should not be taken and the patient should resume the usual dosing schedule.
This guidance is based on the 15 hour half-life of darunavir in the presence of ritonavir and the recommended dosing interval of approximately 12 hours.
Special populations
Elderly
Limited information is available in this population, and therefore, Кемерувир should be used with caution in this age group.
Hepatic impairment
Darunavir is metabolised by the hepatic system. No dose adjustment is recommended in patients with mild (Child-Pugh Class A) or moderate (Child-Pugh Class B) hepatic impairment, however, Кемерувир should be used with caution in these patients. No pharmacokinetic data are available in patients with severe hepatic impairment. Severe hepatic impairment could result in an increase of darunavir exposure and a worsening of its safety profile. Therefore, Кемерувир must not be used in patients with severe hepatic impairment (Child-Pugh Class C).
Renal impairment
No dose adjustment is required in patients with renal impairment.
Paediatric population
Кемерувир/ritonavir should not be used in children with a body weight of less than 15 kg as the dose for this population has not been established in a sufficient number of patients. Кемерувир/ritonavir should not be used in children below 3 years of age because of safety concerns.
Darunavir exposures in treatment-naïve adolescents 12 to 17 years weighing at least 40 kg receiving Кемерувир 800 mg once daily have been determined and were found to be within the therapeutic range as has been established in adults receiving Кемерувир 800 mg once daily. As a consequence, since Кемерувир once daily has also been registered for use in treatment-experienced adults without darunavir resistance associated mutations (DRV-RAMs)* and who have plasma HIV-1 RNA < 100,000 copies/ml and CD4+ cell count > 100 cells x 106/l, the same indication of Кемерувир once daily applies to treatment-experienced children 3 to 17 years weighing at least 15 kg.
* DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V and L89V
Pregnancy and postpartum
No dose adjustment is required for darunavir/ritonavir during pregnancy and postpartum. Кемерувир should be used during pregnancy only if the potential benefit justifies the potential risk.
Method of administration
Patients should be instructed to take Кемерувир with low dose ritonavir within 30 minutes after completion of a meal. The type of food does not affect the exposure to darunavir.
No special requirements.
