No specific information is available on the treatment of overdose with raltegravir.
In the event of an overdose, it is reasonable to employ the standard supportive measures, e.g., remove unabsorbed material from the gastrointestinal tract, employ clinical monitoring (including obtaining an electrocardiogram), and institute supportive therapy if required. It should be taken into account that raltegravir is presented for clinical use as the potassium salt. The extent to which raltegravir may be dialysable is unknown.
Not applicable.
Summary of the safety profile
In randomised clinical trials raltegravir 400 mg twice daily was administered in combination with fixed or optimised background treatment regimens to treatment-naïve (N=547) and treatment-experienced (N=462) adults for up to 96 weeks.
The most frequently reported adverse reactions during treatment were headache, nausea and abdominal pain. The most frequently reported serious adverse reaction was immune reconstitution syndrome and rash. The rates of discontinuation of raltegravir due to adverse reactions were 5% or less in clinical trials.
Rhabdomyolysis was an uncommonly reported serious adverse reaction in post-marketing use of raltegravir 400 mg twice daily.
Tabulated summary of adverse reactions
Adverse reactions considered by investigators to be causally related to raltegravir (alone or in combination with other ART), as well as adverse reactions established in post-marketing experience, are listed below by System Organ Class. Frequencies are defined as common (> 1/100 to < 1/10), uncommon (> 1/1,000 to < 1/100), and not known (cannot be estimated from the available data).
| System Organ Class | Frequency | Adverse reactions Raltegravir (alone or in combination with other ART) |
| Infections and infestations | Uncommon | genital herpes, folliculitis, gastroenteritis, herpes simplex, herpes virus infection, herpes zoster, influenza, lymph node abscess, molluscum contagiosum, nasopharyngitis, upper respiratory tract infection |
| Neoplasms benign, malignant and unspecified (including cysts and polyps) | Uncommon | skin papilloma |
| Blood and lymphatic system disorders | Uncommon | anaemia, iron deficiency anaemia, lymph node pain, lymphadenopathy, neutropenia, thrombocytopenia |
| Immune system disorders | Uncommon | immune reconstitution syndrome, drug hypersensitivity, hypersensitivity |
| Metabolism and nutrition disorders | Common | decreased appetite |
| Uncommon | cachexia, diabetes mellitus, dyslipidaemia, hypercholesterolaemia, hyperglycaemia, hyperlipidaemia, hyperphagia, increased appetite, polydipsia, body fat disorder | |
| Psychiatric disorders | Common | abnormal dreams, insomnia, nightmare, abnormal behaviour, depression |
| Uncommon | mental disorder, suicide attempt, anxiety, confusional state, depressed mood, major depression, middle insomnia, mood altered, panic attack, sleep disorder, suicidal ideation, suicidal behaviour (particularly in patients with a pre-existing history of psychiatric illness) | |
| Nervous system disorders | Common | dizziness, headache, psychomotor hyperactivity |
| Uncommon | amnesia, carpal tunnel syndrome, cognitive disorder, disturbance in attention, dizziness postural, dysgeusia, hypersomnia, hypoaesthesia, lethargy, memory impairment, migraine, neuropathy peripheral, paraesthesia, somnolence, tension headache, tremor, poor quality sleep | |
| Eye disorders | Uncommon | visual impairment |
| Ear and labyrinth disorders | Common | vertigo |
| Uncommon | tinnitus | |
| Cardiac disorders | Uncommon | palpitations, sinus bradycardia, ventricular extrasystoles |
| Vascular disorders | Uncommon | hot flush, hypertension |
| Respiratory, thoracic and mediastinal disorders | Uncommon | dysphonia, epistaxis, nasal congestion |
| Gastrointestinal disorders | Common | abdominal distention, abdominal pain, diarrhoea, flatulence, nausea, vomiting, dyspepsia |
| Uncommon | gastritis, abdominal discomfort, abdominal pain upper, abdominal tenderness, anorectal discomfort, constipation, dry mouth, epigastric discomfort, erosive duodenitis, eructation, gastroesophageal reflux disease, gingivitis, glossitis, odynophagia, pancreatitis acute, peptic ulcer, rectal haemorrhage | |
| Hepato-biliary disorders | Uncommon | hepatitis, hepatic steatosis, hepatitis alcoholic, hepatic failure |
| Skin and subcutaneous tissue disorders | Common | rash |
| Uncommon | acne, alopecia, dermatitis acneiforme, dry skin, erythema, facial wasting, hyperhidrosis, lipoatrophy, lipodystrophy acquired, lipohypertrophy, night sweats, prurigo, pruritus, pruritus generalised, rash macular, rash maculo-papular, rash pruritic, skin lesion, urticaria, xeroderma, Stevens Johnson syndrome, drug rash with eosinophilia and systemic symptoms (DRESS) | |
| Musculoskeletal and connective tissue disorders | Uncommon | arthralgia, arthritis, back pain, flank pain, musculoskeletal pain, myalgia, neck pain, osteopenia, pain in extremity, tendonitis, rhabdomyolysis |
| Renal and urinary disorders | Uncommon | renal failure, nephritis, nephrolithiasis, nocturia, renal cyst, renal impairment, tubulointerstitial nephritis |
| Reproductive system and breast disorders | Uncommon | erectile dysfunction, gynaecomastia, menopausal symptoms |
| General disorders and administration site conditions | Common | asthenia, fatigue, pyrexia |
| Uncommon | chest discomfort, chills, face oedema, fat tissue increased, feeling jittery, malaise, submandibular mass, oedema peripheral, pain | |
| Investigations | Common | alanine aminotransferase increased, atypical lymphocytes, aspartate aminotransferase increased, blood triglycerides increased, lipase increased, blood pancreatic amylase increased |
| Uncommon | absolute neutrophil count decreased, alkaline phosphatase increased, blood albumin decreased, blood amylase increased, blood bilirubin increased, blood cholesterol increased, blood creatinine increased, blood glucose increased, blood urea nitrogen increased, creatine phosphokinase increased, fasting blood glucose increased, glucose urine present, high density lipoprotein increased, international normalised ratio increased, low density lipoprotein increased, platelet count decreased, red blood cells urine positive, waist circumference increased, weight increased, white blood cell count decreased | |
| Injury, poisoning and procedural complications | Uncommon | accidental overdose |
Description of selected adverse reactions
Cancers were reported in treatment-experienced and treatment-naïve patients who initiated raltegravir in conjunction with other antiretroviral agents. The types and rates of specific cancers were those expected in a highly immunodeficient population. The risk of developing cancer in these studies was similar in the groups receiving raltegravir and in the groups receiving comparators.
Grade 2-4 creatine kinase laboratory abnormalities were observed in patients treated with raltegravir. Myopathy and rhabdomyolysis have been reported. Use with caution in patients who have had myopathy or rhabdomyolysis in the past or have any predisposing issues including other medicinal products associated with these conditions.
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.
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.
For each of the following clinical adverse reactions there was at least one serious occurrence: genital herpes, anaemia, immune reconstitution syndrome, depression, mental disorder, suicide attempt, gastritis, hepatitis, renal failure, accidental overdose.
In clinical studies of treatment-experienced patients, rash, irrespective of causality, was more commonly observed with regimens containing raltegravir and darunavir compared to those containing raltegravir without darunavir or darunavir without raltegravir. 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.
Patients co-infected with hepatitis B and/or hepatitis C virus
In clinical trials, there were 79 patients co-infected with hepatitis B, 84 co-infected with hepatitis C, and 8 patients co-infected with hepatitis B and C who were treated with raltegravir in combination with other agents for HIV-1. In general the safety profile of raltegravir in patients with hepatitis B and/or hepatitis C virus co-infection was similar to that in patients without hepatitis B and/or hepatitis C virus co-infection, although the rates of AST and ALT abnormalities were somewhat higher in the subgroup co-infected with hepatitis B and/or hepatitis C virus
At 96-weeks, in treatment-experienced patients, Grade 2 or higher laboratory abnormalities that represent a worsening Grade from baseline of AST, ALT or total bilirubin occurred in 29 %, 34 % and 13 %, respectively, of co-infected patients treated with raltegravir as compared to 11 %, 10 % and 9 % of all other patients treated with raltegravir. At 240-weeks, in treatment-naïve patients, Grade 2 or higher laboratory abnormalities that represent a worsening Grade from baseline of AST, ALT or total bilirubin occurred in 22 %, 44 % and 17 %, respectively, of co-infected patients treated with raltegravir as compared to 13 %, 13 % and 5 % of all other patients treated with raltegravir.
Paediatric population
Children and adolescents 2 to 18 years of age
Raltegravir has been studied in 126 antiretroviral treatment-experienced HIV-1 infected children and adolescents 2 to 18 years of age, in combination with other antiretroviral agents in IMPAACT P1066. Of the 126 patients, 96 received the recommended dose of raltegravir.
In these 96 children and adolescents, frequency, type and severity of drug related adverse reactions through Week 48 were comparable to those observed in adults.
One patient experienced drug related clinical adverse reactions of Grade 3 psychomotor hyperactivity, abnormal behaviour and insomnia; one patient experienced a Grade 2 serious drug related allergic rash.
One patient experienced drug related laboratory abnormalities, Grade 4 AST and Grade 3 ALT, which were considered serious.
Infants and toddlers 4 weeks to less than 2 years of age
Raltegravir has also been studied in 26 HIV-1 infected infants and toddlers 4 weeks to less than 2 years of age, in combination with other antiretroviral agents in IMPAACT P1066.
In these 26 infants and toddlers, the frequency, type and severity of drug related adverse reactions through Week 48 were comparable to those observed in adults.
One patient experienced a Grade 3 serious drug related allergic rash that resulted in treatment discontinuation.
HIV-1 Exposed Neonates
In IMPAACT P1110 eligible infants were at least 37 weeks gestation and at least 2 kg in weight. Sixteen (16) neonates received 2 doses of Ралтегравир калия in first 2 weeks of life, and 26 neonates received 6 weeks of daily dosing; all were followed for 24 weeks. There were no drug related clinical adverse experiences and three drug-related laboratory adverse experiences (one a transient Grade 4 neutropenia in a subject receiving zidovudine containing prevention of mother to child transmission (PMTCT), and two bilirubin elevations (one each, Grade 1 and Grade 2) considered non-serious and not requiring specific therapy).
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 at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
Non-clinical toxicology studies, including conventional studies of safety pharmacology, repeated-dose toxicity, genotoxicity, developmental toxicity and juvenile toxicity, have been conducted with raltegravir in mice, rats, dogs and rabbits. Effects at exposure levels sufficiently in excess of clinical exposure levels indicate no special hazard for humans.
Mutagenicity
No evidence of mutagenicity or genotoxicity was observed in in vitro microbial mutagenesis (Ames) tests, in vitro alkaline elution assays for DNA breakage and in vitro and in vivo chromosomal aberration studies.
Carcinogenicity
A carcinogenicity study of raltegravir in mice did not show any carcinogenic potential. At the highest dose levels, 400 mg/kg/day in females and 250 mg/kg/day in males, systemic exposure was similar to that at the clinical dose of 400 mg twice daily. In rats, tumours (squamous cell carcinoma) of the nose/nasopharynx were identified at 300 and 600 mg/kg/day in females and at 300 mg/kg/day in males. This neoplasia could result from local deposition and/or aspiration of drug on the mucosa of the nose/nasopharynx during oral gavage dosing and subsequent chronic irritation and inflammation; it is likely that it is of limited relevance for the intended clinical use. At the NOAEL, systemic exposure was similar to that at the clinical dose of 400 mg twice daily. Standard genotoxicity studies to evaluate mutagenicity and clastogenicity were negative.
Developmental toxicity
Raltegravir was not teratogenic in developmental toxicity studies in rats and rabbits. A slight increase in incidence of supernumerary ribs was observed in rat pups of dams exposed to raltegravir at approximately 4.4-fold human exposure at 400 mg twice daily based on AUC0-24 hr. No development effects were seen at 3.4-fold human exposure at 400 mg twice daily based on AUC0-24 hr. Similar findings were not observed in rabbits.
Ралтегравир калия is indicated in combination with other anti-retroviral medicinal products for the treatment of human immunodeficiency virus (HIV-1) infection.
Pharmacotherapeutic group: antivirals for systemic use, other antivirals, ATC code: J05AX08.
Mechanism of action
Raltegravir is an integrase strand transfer inhibitor active against the Human Immunodeficiency Virus (HIV-1). Raltegravir inhibits the catalytic activity of integrase, an HIV-encoded enzyme that is required for viral replication. Inhibition of integrase prevents the covalent insertion, or integration, of the HIV genome into the host cell genome. HIV genomes that fail to integrate cannot direct the production of new infectious viral particles, so inhibiting integration prevents propagation of the viral infection.
Antiviral activity in vitro
Raltegravir at concentrations of 31 ± 20 nM resulted in 95 % inhibition (IC95) of HIV-1 replication (relative to an untreated virus-infected culture) in human T-lymphoid cell cultures infected with the cell-line adapted HIV-1 variant H9IIIB. In addition, raltegravir inhibited viral replication in cultures of mitogen-activated human peripheral blood mononuclear cells infected with diverse, primary clinical isolates of HIV-1, including isolates from 5 non-B subtypes, and isolates resistant to reverse transcriptase inhibitors and protease inhibitors. In a single-cycle infection assay, raltegravir inhibited infection of 23 HIV isolates representing 5 non-B subtypes and 5 circulating recombinant forms with IC50 values ranging from 5 to 12 nM.
Resistance
Most viruses isolated from patients failing raltegravir had high-level raltegravir resistance resulting from the appearance of two or more mutations in integrase. Most had a signature mutation at amino acid 155 (N155 changed to H), amino acid 148 (Q148 changed to H, K, or R), or amino acid 143 (Y143 changed to H, C, or R), along with one or more additional integrase mutations (e.g., L74M, E92Q, T97A, E138A/K, G140A/S, V151I, G163R, S230R). The signature mutations decrease viral susceptibility to raltegravir and addition of other mutations results in a further decrease in raltegravir susceptibility. Factors that reduced the likelihood of developing resistance included lower baseline viral load and use of other active anti-retroviral agents. Mutations conferring resistance to raltegravir generally also confer resistance to the integrase strand transfer inhibitor elvitegravir. Mutations at amino acid 143 confer greater resistance to raltegravir than to elvitegravir, and the E92Q mutation confers greater resistance to elvitegravir than to raltegravir. Viruses harbouring a mutation at amino acid 148, along with one or more other raltegravir resistance mutations, may also have clinically significant resistance to dolutegravir.
Clinical experience
The evidence of efficacy of raltegravir was based on the analyses of 96-week data from two randomised, double-blind, placebo-controlled trials (BENCHMRK 1 and BENCHMRK 2, Protocols 018 and 019) in antiretroviral treatment-experienced HIV-1 infected adult patients and the analysis of 240-week data from a randomised, double-blind, active-control trial (STARTMRK, Protocol 021) in antiretroviral treatment-naïve HIV-1 infected adult patients.
Efficacy
Treatment-experienced adult patients
BENCHMRK 1 and BENCHMRK 2 (multi-centre, randomised, double-blind, placebo-controlled trials) evaluated the safety and anti-retroviral activity of raltegravir 400 mg twice daily vs. placebo in a combination with optimised background therapy (OBT), in HIV-infected patients, 16 years or older, with documented resistance to at least 1 drug in each of 3 classes (NRTIs, NNRTIs, PIs) of anti-retroviral therapies. Prior to randomisation, OBT were selected by the investigator based on the patient's prior treatment history, as well as baseline genotypic and phenotypic viral resistance testing.
Patient demographics (gender, age and race) and baseline characteristics were comparable between the groups receiving raltegravir 400 mg twice daily and placebo. Patients had prior exposure to a median of 12 anti-retrovirals for a median of 10 years. A median of 4 ARTs was used in OBT.
Results 48 week and 96 week analyses
Durable outcomes (Week 48 and Week 96) for patients on the recommended dose raltegravir 400 mg twice daily from the pooled studies BENCHMRK 1 and BENCHMRK 2 are shown in Table 4.
Table 4
Efficacy Outcome at Weeks 48 and 96
| BENCHMRK 1 and 2 Pooled Parameter | 48 Weeks | 96 Weeks | ||
| Raltegravir 400 mg twice daily + OBT (N = 462) | Placebo + OBT (N = 237) | Raltegravir 400 mg twice daily + OBT (N = 462) | Placebo + OBT (N = 237) | |
| Percent HIV-RNA < 400 copies/mL (95 % CI) | ||||
| All patients†| 72 (68, 76) | 37 (31, 44) | 62 (57, 66) | 28 (23, 34) |
| Baseline Characteristic‡ |
|
|
|
|
| HIV-RNA > 100,000 copies/mL | 62 (53, 69) | 17 (9, 27) | 53 (45, 61) | 15 (8, 25) |
| ≤ 100,000 copies/mL | 82 (77, 86) | 49 (41, 58) | 74 (69, 79) | 39 (31, 47) |
| CD4-count ≤ 50 cells/mm3 | 61 (53, 69) | 21 (13, 32) | 51 (42, 60) | 14 (7, 24) |
| > 50 and ≤ 200 cells/mm3 | 80 (73, 85) | 44 (33, 55) | 70 (62, 77) | 36 (25, 48) |
| > 200 cells/mm3 | 83 (76, 89) | 51 (39, 63) | 78 (70, 85) | 42 (30, 55) |
| Sensitivity score (GSS) § |
|
|
|
|
| 0 | 52 (42, 61) | 8 (3, 17) | 46 (36, 56) | 5 (1, 13) |
| 1 | 81 (75, 87) | 40 (30, 51) | 76 (69, 83) | 31 (22, 42) |
| 2 and above | 84 (77, 89) | 65 (52, 76) | 71 (63, 78) | 56 (43, 69) |
| Percent HIV-RNA < 50 copies/mL (95 % CI) | ||||
| All patients†| 62 (57, 67) | 33 (27, 39) | 57 (52, 62) | 26 (21, 32) |
| Baseline Characteristic‡ |
|
|
|
|
| HIV-RNA > 100,000 copies/mL | 48 (40, 56) | 16 (8, 26) | 47 (39, 55) | 13 (7, 23) |
| ≤ 100,000 copies/mL | 73 (68, 78) | 43 (35, 52) | 70 (64, 75) | 36 (28, 45) |
| CD4-count ≤ 50 cells/mm3 | 50 (41, 58) | 20 (12, 31) | 50 (41, 58) | 13 (6, 22) |
| > 50 and ≤ 200 cells/mm3 | 67 (59, 74) | 39 (28, 50) | 65 (57, 72) | 32 (22, 44) |
| > 200 cells/mm3 | 76 (68, 83) | 44 (32, 56) | 71 (62, 78) | 41 (29, 53) |
| Sensitivity score (GSS) § |
|
|
|
|
| 0 | 45 (35, 54) | 3 (0, 11) | 41 (32, 51) | 5 (1, 13) |
| 1 | 67 (59, 74) | 37 (27, 48) | 72 (64, 79) | 28 (19, 39) |
| 2 and above | 75 (68, 82) | 59 (46, 71) | 65 (56, 72) | 53 (40, 66) |
| Mean CD4 Cell Change (95 % CI), cells/mm3 | ||||
| All patients‡ | 109 (98, 121) | 45 (32, 57) | 123 (110, 137) | 49 (35, 63) |
| Baseline Characteristic‡ |
|
|
|
|
| HIV-RNA > 100,000 copies/mL | 126 (107, 144) | 36 (17, 55) | 140 (115, 165) | 40 (16, 65) |
| ≤ 100,000 copies/mL | 100 (86, 115) | 49 (33, 65) | 114 (98, 131) | 53 (36, 70) |
| CD4-count ≤ 50 cells/mm3 | 121 (100, 142) | 33 (18, 48) | 130 (104, 156) | 42 (17, 67) |
| > 50 and ≤ 200 cells/mm3 | 104 (88, 119) | 47 (28, 66) | 123 (103, 144) | 56 (34, 79) |
| > 200 cells/mm3 | 104 (80, 129) | 54 (24, 84) | 117 (90, 143) | 48 (23, 73) |
| Sensitivity score (GSS) § |
|
|
|
|
| 0 | 81 (55, 106) | 11 (4, 26) | 97 (70, 124) | 15 (-0, 31) |
| 1 | 113 (96, 130) | 44 (24, 63) | 132 (111, 154) | 45 (24, 66) |
| 2 and above | 125 (105, 144) | 76 (48, 103) | 134 (108, 159) | 90 (57, 123) |
| †Non-completer is failure imputation: patients who discontinued prematurely are imputed as failure thereafter. Percent of patients with response and associated 95 % confidence interval (CI) are reported. ‡ For analysis by prognostic factors, virologic failures were carried forward for percent < 400 and 50 copies/mL. For mean CD4 changes, baseline-carry-forward was used for virologic failures. § The Genotypic Sensitivity Score (GSS) was defined as the total oral ARTs in the optimised background therapy (OBT) to which a patient's viral isolate showed genotypic sensitivity based upon genotypic resistance test. Enfuvirtide use in OBT in enfuvirtide-naïve patients was counted as one active drug in OBT. Similarly, darunavir use in OBT in darunavir-naïve patients was counted as one active drug in OBT. | ||||
Raltegravir achieved virologic responses (using Not Completer=Failure approach) of HIV RNA < 50 copies/mL in 61.7 % of patients at Week 16, in 62.1 % at Week 48 and in 57.0 % at Week 96. Some patients experienced viral rebound between Week 16 and Week 96. Factors associated with failure include high baseline viral load and OBT that did not include at least one potent active agent.
Switch to raltegravir
The SWITCHMRK 1 & 2 (Protocols 032 & 033) studies evaluated HIV-infected patients receiving suppressive (screening HIV RNA < 50 copies/mL; stable regimen > 3 months) therapy with lopinavir 200 mg (+) ritonavir 50 mg 2 tablets twice daily plus at least 2 nucleoside reverse transcriptase inhibitors and randomised them 1:1 to continue lopinavir (+) ritonavir 2 tablets twice daily (n=174 and n=178, respectively) or replace lopinavir (+) ritonavir with raltegravir 400 mg twice daily (n=174 and n=176, respectively). Patients with a prior history of virological failure were not excluded and the number of previous antiretroviral therapies was not limited.
These studies were terminated after the primary efficacy analysis at Week 24 because they failed to demonstrate non-inferiority of raltegravir versus lopinavir (+) ritonavir.
Treatment-naïve adult patients
STARTMRK (multi-centre, randomised, double-blind, active-control trial) evaluated the safety and anti-retroviral activity of raltegravir 400 mg twice daily vs. efavirenz 600 mg at bedtime, in a combination with emtricitabine (+) tenofovir disoproxil fumarate, in treatment-naïve HIV-infected patients with HIV RNA > 5,000 copies/mL. Randomisation was stratified by screening HIV RNA level (≤ 50,000 copies/mL; and > 50,000 copies/mL) and by hepatitis B or C status (positive or negative).
Patient demographics (gender, age and race) and baseline characteristics were comparable between the group receiving raltegravir 400 mg twice daily and the group receiving efavirenz 600 mg at bedtime.
Results 48-week and 240-week analyses
With respect to the primary efficacy endpoint, the proportion of patients achieving HIV RNA < 50 copies/mL at Week 48 was 241/280 (86.1 %) in the group receiving raltegravir and 230/281 (81.9 %) in the group receiving efavirenz. The treatment difference (raltegravir - efavirenz) was 4.2 % with an associated 95 % CI of (-1.9, 10.3) establishing that raltegravir is non-inferior to efavirenz (p-value for non-inferiority < 0.001). At Week 240, the treatment difference (raltegravir - efavirenz) was 9.5 % with an associated 95 % CI of (1.7, 17.3). Week 48 and Week 240 outcomes for patients on the recommended dose of raltegravir 400 mg twice daily from STARTMRK are shown in Table 5.
Table 5
Efficacy Outcome at Weeks 48 and 240
| STARTMRK Study Parameter | 48 Weeks | 240 Weeks | ||
| Raltegravir 400 mg twice daily (N = 281) | Efavirenz 600 mg at bedtime (N = 282) | Raltegravir 400 mg twice daily (N = 281) | Efavirenz 600 mg at bedtime (N = 282) | |
| Percent HIV-RNA < 50 copies/mL (95 % CI) | ||||
| All patients†| 86 (81, 90) | 82 (77, 86) | 71 (65, 76) | 61 (55, 67) |
| Baseline Characteristic‡ | ||||
| HIV-RNA > 100,000 copies/mL | 91 (85, 95) | 89 (83, 94) | 70 (62, 77) | 65 (56, 72) |
| ≤ 100,000 copies/mL | 93 (86, 97) | 89 (82, 94) | 72 (64, 80) | 58 (49, 66) |
| CD4-count ≤ 50 cells/mm3 | 84 (64, 95) | 86 (67, 96) | 58 (37, 77) | 77 (58, 90) |
| > 50 and ≤ 200 cells/mm3 | 89 (81, 95) | 86 (77, 92) | 67 (57, 76) | 60 (50, 69) |
| > 200 cells/mm3 | 94 (89, 98) | 92 (87, 96) | 76 (68, 82) | 60 (51, 68) |
| Viral Subtype Clade B | 90 (85, 94) | 89 (83, 93) | 71 (65, 77) | 59 (52, 65) |
| Non-Clade B | 96 (87, 100) | 91 (78, 97) | 68 (54, 79) | 70 (54, 82) |
| Mean CD4 Cell Change (95 % CI), cells/mm3 | ||||
| All patients‡ | 189 (174, 204) | 163 (148, 178) | 374 (345, 403) | 312 (284, 339) |
| Baseline Characteristic‡ |
|
|
|
|
| HIV-RNA > 100,000 copies/mL | 196 (174, 219) | 192 (169, 214) | 392 (350, 435) | 329 (293, 364) |
| ≤ 100,000 copies/mL | 180 (160, 200) | 134 (115, 153) | 350 (312, 388) | 294 (251, 337) |
| CD4-count ≤ 50 cells/mm3 | 170 (122, 218) | 152 (123, 180) | 304 (209, 399) | 314 (242, 386) |
| > 50 and ≤ 200 cells/mm3 | 193 (169, 217) | 175 (151, 198) | 413 (360, 465) | 306 (264, 348) |
| > 200 cells/mm3 | 190 (168, 212) | 157 (134, 181) | 358 (321, 395) | 316 (272, 359) |
| Viral Subtype Clade B | 187 (170, 204) | 164 (147, 181) | 380 (346, 414) | 303 (272, 333) |
| Non-Clade B | 189 (153, 225) | 156 (121, 190) | 332 (275, 388)
| 329 (260, 398) |
| †Non-completer is failure imputation: patients who discontinued prematurely are imputed as failure thereafter. Percent of patients with response and associated 95 % confidence interval (CI) are reported. ‡ For analysis by prognostic factors, virologic failures were carried forward for percent < 50 and 400 copies/mL. For mean CD4 changes, baseline-carry-forward was used for virologic failures. Notes: The analysis is based on all available data. Raltegravir and efavirenz were administered with emtricitabine (+) tenofovir disoproxil fumarate. | ||||
Paediatric population
Children and adolescents 2 to 18 years of age
IMPAACT P1066 is a Phase I/II open label multicenter trial to evaluate the pharmacokinetic profile, safety, tolerability, and efficacy of raltegravir in HIV infected children. This study enrolled 126 treatment experienced children and adolescents 2 to 18 years of age. Patients were stratified by age, enrolling adolescents first and then successively younger children. Patients received either the 400 mg tablet formulation (6 to 18 years of age) or the chewable tablet formulation (2 to less than 12 years of age). Raltegravir was administered with an optimised background regimen.
The initial dose finding stage included intensive pharmacokinetic evaluation. Dose selection was based upon achieving similar raltegravir plasma exposure and trough concentration as seen in adults, and acceptable short term safety. After dose selection, additional patients were enrolled for evaluation of long term safety, tolerability and efficacy. Of the 126 patients, 96 received the recommended dose of raltegravir.
Table 6
Baseline Characteristics and Efficacy Outcomes at Weeks 24 and 48 from IMPAACT P1066
(2 to 18 years of age)
| Parameter | Final dose population | |
| N=96 | ||
| Demographics | ||
| Age (years), median [range] | 13 [2 - 18] | |
| Male Gender | 49 % | |
| Race | ||
| Caucasian | 34 % | |
| Black | 59 % | |
| Baseline Characteristics | ||
| Plasma HIV-1 RNA (log10 copies/mL), mean [range] | 4.3 [2.7 - 6] | |
| CD4 cell count (cells/mm3 ), median [range] | 481 [0 - 2361] | |
| CD4 percent, median [range] | 23.3 % [0 - 44] | |
| HIV-1 RNA >100,000 copies/mL | 8 % | |
| CDC HIV category B or C | 59 % | |
| Prior ART Use by Class | ||
| NNRTI | 78 % | |
| PI | 83 % | |
| Response | Week 24 | Week 48 |
| Achieved >1 log10 HIV RNA drop from baseline or <400 copies/mL | 72 % | 79 % |
| Achieved HIV RNA <50 copies/mL | 54 % | 57 % |
| Mean CD4 cell count (%) increase from baseline | 119 cells/mm3 (3.8 %) | 156 cells/mm3 (4.6 %) |
Infants and toddlers 4 weeks to less than 2 years of age
IMPAACT P1066 also enrolled HIV-infected, infants and toddlers 4 weeks to less than 2 years of age who had received prior antiretroviral therapy either as prophylaxis for prevention of mother to child transmission (PMTCT) and/or as combination antiretroviral therapy for treatment of HIV infection. Raltegravir was administered as granules for oral suspension formulation without regard to food in combination with an optimised background regimen that included lopinavir plus ritonavir in two-thirds of patients.
Table 7
Baseline Characteristic
Absorption
As demonstrated in healthy volunteers administered single oral doses of raltegravir in the fasted state, raltegravir is rapidly absorbed with a tmax of approximately 3 hours postdose. Raltegravir AUC and Cmax increase dose proportionally over the dose range 100 mg to 1,600 mg. Raltegravir C12 hr increases dose proportionally over the dose range of 100 to 800 mg and increases slightly less than dose proportionally over the dose range 100 mg to 1,600 mg. Dose proportionality has not been established in patients.
With twice-daily dosing, pharmacokinetic steady state is achieved rapidly, within approximately the first 2 days of dosing. There is little to no accumulation in AUC and Cmax and evidence of slight accumulation in C12 hr. The absolute bioavailability of raltegravir has not been established.
Raltegravir may be administered with or without food. Raltegravir was administered without regard to food in the pivotal safety and efficacy studies in HIV-infected patients. Administration of multiple doses of raltegravir following a moderate-fat meal did not affect raltegravir AUC to a clinically meaningful degree with an increase of 13 % relative to fasting. Raltegravir C12 hr was 66 % higher and Cmax was 5 % higher following a moderate-fat meal compared to fasting. Administration of raltegravir following a high-fat meal increased AUC and Cmax by approximately 2-fold and increased C12 hr by 4.1-fold. Administration of raltegravir following a low-fat meal decreased AUC and Cmax by 46 % and 52 %, respectively; C12 hr was essentially unchanged. Food appears to increase pharmacokinetic variability relative to fasting.
Overall, considerable variability was observed in the pharmacokinetics of raltegravir. For observed C12 hr in BENCHMRK 1 and 2 the coefficient of variation (CV) for inter-subject variability = 212 % and the CV for intra-subject variability = 122 %. Sources of variability may include differences in co-administration with food and concomitant medicines.
Distribution
Raltegravir is approximately 83 % bound to human plasma protein over the concentration range of 2 to 10 µM.
Raltegravir readily crossed the placenta in rats, but did not penetrate the brain to any appreciable extent.
In two studies of HIV-1 infected patients who received raltegravir 400 mg twice daily, raltegravir was readily detected in the cerebrospinal fluid. In the first study (n=18), the median cerebrospinal fluid concentration was 5.8 % (range 1 to 53.5 %) of the corresponding plasma concentration. In the second study (n=16), the median cerebrospinal fluid concentration was 3 % (range 1 to 61 %) of the corresponding plasma concentration. These median proportions are approximately 3- to 6-fold lower than the free fraction of raltegravir in plasma.
Biotransformation and excretion
The apparent terminal half-life of raltegravir is approximately 9 hours, with a shorter α-phase half-life (~1 hour) accounting for much of the AUC. Following administration of an oral dose of radiolabeled raltegravir, approximately 51 and 32 % of the dose was excreted in faeces and urine, respectively. In faeces, only raltegravir was present, most of which is likely to be derived from hydrolysis of raltegravir-glucuronide secreted in bile as observed in preclinical species. Two components, namely raltegravir and raltegravir-glucuronide, were detected in urine and accounted for approximately 9 and 23 % of the dose, respectively. The major circulating entity was raltegravir and represented approximately 70 % of the total radioactivity; the remaining radioactivity in plasma was accounted for by raltegravir-glucuronide. Studies using isoform-selective chemical inhibitors and cDNA-expressed UDP-glucuronosyltransferases (UGT) show that UGT1A1 is the main enzyme responsible for the formation of raltegravir-glucuronide. Thus the data indicate that the major mechanism of clearance of raltegravir in humans is UGT1A1-mediated glucuronidation.
UGT1A1 Polymorphism
In a comparison of 30 subjects with *28/*28 genotype to 27 subjects with wild-type genotype, the geometric mean ratio (90 % CI) of AUC was 1.41 (0.96, 2.09) and the geometric mean ratio of C12 hr was 1.91 (1.43, 2.55). Dose adjustment is not considered necessary in subjects with reduced UGT1A1 activity due to genetic polymorphism.
Special populations
Paediatric population
Based on a formulation comparison study in healthy adult volunteers, the chewable tablet and granules for oral suspension have higher oral bioavailability compared to the 400 mg tablet. In this study, administration of the chewable tablet with a high fat meal led to an average 6 % decrease in AUC, 62 % decrease in Cmax, and 188 % increase in C12hr compared to administration in the fasted state. Administration of the chewable tablet with a high fat meal does not affect raltegravir pharmacokinetics to a clinically meaningful degree and the chewable tablet can be administered without regard to food. The effect of food on the granules for oral suspension formulation was not studied.
Table 8 displays pharmacokinetic parameters in the 400 mg tablet, the chewable tablet), and the granules for oral suspension, by body weight.
Table 8
(excluding neonates)
| Body weight | Formulation | Dose | N* | Geometric mean (%CV†) AUC0-12hr (μMâ—hr) | Geometric mean (%CV†) C12hr (nM) |
| > 25 kg | Film-coated tablet | 400 mg twice daily | 18 | 14.1 (121 %) | 233 (157 %) |
| > 25 kg | Chewable tablet | Weight based dosing, see dosing Table 1 | 9 | 22.1 (36 %) | 113 (80 %) |
| 11 to less than 25 kg | Chewable tablet | Weight based dosing, see dosing Table 2 | 13 | 18.6 (68 %) | 82 (123 %) |
| 3 to less than 20 kg | Oral suspension | Weight based dosing, see dosing table for granules for oral suspension | 19 | 24.5 (43 %) | 113 (69 %) |
| *Number of patients with intensive pharmacokinetic (PK) results at the final recommended dose. †Geometric coefficient of variation. | |||||
Elderly
There was no clinically meaningful effect of age on raltegravir pharmacokinetics in healthy subjects and patients with HIV-1 infection over the age range studied (19 to 84 years, with few individuals over the age of 65).
Gender, race and BMI
There were no clinically important pharmacokinetic differences due to gender, race or body mass index (BMI) in adults.
Renal impairment
Renal clearance of unchanged medicinal product is a minor pathway of elimination. In adults, there were no clinically important pharmacokinetic differences between patients with severe renal insufficiency and healthy subjects. Because the extent to which raltegravir may be dialysable is unknown, dosing before a dialysis session should be avoided.
Hepatic impairment
Raltegravir is eliminated primarily by glucuronidation in the liver. In adults, there were no clinically important pharmacokinetic differences between patients with moderate hepatic insufficiency and healthy subjects. The effect of severe hepatic insufficiency on the pharmacokinetics of raltegravir has not been studied.
General
Patients should be advised that current anti-retroviral therapy does not cure HIV and has not been proven to prevent the transmission of HIV to others through blood contact. 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.
Raltegravir has a relatively low genetic barrier to resistance. Therefore, whenever possible, raltegravir should be administered with two other active ARTs to minimise the potential for virological failure and the development of resistance.
In treatment-naïve patients, the clinical study data on use of raltegravir are limited to use in combination with two nucleotide reverse transcriptase inhibitors (NRTIs) (emtricitabine and tenofovir disoproxil fumarate).
Depression
Depression, including suicidal ideation and behaviours, has been reported, particularly in patients with a pre-existing history of depression or psychiatric illness. Caution should be used in patients with a pre-existing history of depression or psychiatric illness.
Hepatic impairment
The safety and efficacy of raltegravir have not been established in patients with severe underlying liver disorders. Therefore, raltegravir should be used with caution in patients with severe hepatic impairment.
Patients with pre-existing liver dysfunction including chronic hepatitis have an increased frequency of liver function abnormalities during combination anti-retroviral therapy and should be monitored according to standard practice. If there is evidence of worsening liver disease in such patients, interruption or discontinuation of treatment should be considered.
Patients with chronic hepatitis B or C and treated with combination anti-retroviral therapy are at an increased risk for severe and potentially fatal hepatic adverse reactions.
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 anti-retroviral therapy. Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.
Immune reactivation syndrome
In HIV-infected patients with severe immune deficiency at the time of institution of combination anti-retroviral 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 jiroveci (formerly known as Pneumocystis carinii). Any inflammatory symptoms should be evaluated and treatment instituted when necessary.
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.
Antacids
Co-administration of raltegravir with aluminium and magnesium antacids resulted in reduced raltegravir plasma levels. Co-administration of raltegravir with aluminium and/or magnesium antacids is not recommended.
Rifampicin
Caution should be used when co-administering raltegravir with strong inducers of uridine diphosphate glucuronosyltransferase (UGT) 1A1 (e.g., rifampicin). Rifampicin reduces plasma levels of raltegravir; the impact on the efficacy of raltegravir is unknown. However, if co-administration with rifampicin is unavoidable, a doubling of the dose of raltegravir can be considered in adults. There are no data to guide co-administration of raltegravir with rifampicin in patients below 18 years of age.
Myopathy and rhabdomyolysis
Myopathy and rhabdomyolysis have been reported. Use with caution in patients who have had myopathy or rhabdomyolysis in the past or have any predisposing issues including other medicinal products associated with these conditions.
Severe skin and hypersensitivity reactions
Severe, potentially life-threatening, and fatal skin reactions have been reported in patients taking raltegravir, in most cases concomitantly with other medicinal products associated with these reactions. These include cases of Stevens-Johnson syndrome and toxic epidermal necrolysis. Hypersensitivity reactions have also been reported and were characterised by rash, constitutional findings, and sometimes, organ dysfunction, including hepatic failure. Discontinue raltegravir and other suspect agents immediately if signs or symptoms of severe skin reactions or hypersensitivity reactions develop (including, but not limited to, severe rash or rash accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, facial oedema, hepatitis, eosinophilia, angioedema). Clinical status including liver aminotransferases should be monitored and appropriate therapy initiated. Delay in stopping raltegravir treatment or other suspect agents after the onset of severe rash may result in a life-threatening reaction.
Rash
Rash occurred more commonly in treatment-experienced patients receiving regimens containing raltegravir and darunavir compared to patients receiving raltegravir without darunavir or darunavir without raltegravir.
Fructose
Ралтегравир калия chewable tablets contain fructose and sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine.
Dizziness has been reported in some patients during treatment with regimens containing raltegravir. Dizziness may influence some patients' ability to drive and use machines.
Therapy should be initiated by a physician experienced in the management of HIV infection.
Posology
Ралтегравир калия should be used in combination with other active anti-retroviral therapies (ARTs).
The maximum dose of the chewable tablet is 300 mg twice daily.
Because the formulations have different pharmacokinetic profiles neither the chewable tablets nor the granules for oral suspension should be substituted for the 400 mg tablet or 600 mg tablet. The chewable tablets and the granules for oral suspension have not been studied in HIV-infected adolescents (12 to 18 years) or adults.
Paediatric Population
Children at least 11 kg: weight based dose of the chewable tablet to a maximum dose of 300 mg, twice daily as specified in Tables 1 and 2. The chewable tablets are available in 25 mg and scored 100 mg strengths.
Table 1
Recommended Dose* for Ралтегравир калия Chewable Tablets for Paediatric Patients Weighing at Least 25 kg
| Body weight (kg) | Dose | Number of chewable tablets |
| 25 to less than 28 | 150 mg twice daily | 1.5 x 100 mg†twice daily |
| 28 to less than 40 | 200 mg twice daily | 2 x 100 mg twice daily |
| At least 40 | 300 mg twice daily | 3 x 100 mg twice daily |
| *The weight-based dosing recommendation for the chewable tablet is based on approximately 6 mg/kg/dose twice daily. †The 100 mg chewable tablet can be divided into equal 50 mg doses. However, breaking the tablets should be avoided whenever possible. | ||
If at least 4 weeks of age and weighing at least 3 kg to less than 25 kg: Weight based dosing, as specified in Table 2.
For patients weighing between 11 and 20 kg, either the chewable tablet or oral suspension can be used, as specified in Table 2. Patients can remain on the oral suspension as long as their weight is below 20 kg. Refer to Table 2 for appropriate dosing.
Table 2
Recommended Dose* for Ралтегравир калия Granules For Oral Suspension and Chewable Tablets in Paediatric Patients at least 4 weeks of age and weighing 3 to 25 kg
| Body Weight (kg) | Volume (Dose) of Suspension to be Administered | Number of Chewable Tablets |
| 3 to less than 4 | 2.5 mL (25 mg) twice daily |
|
| 4 to less than 6 | 3 mL (30 mg) twice daily | |
| 6 to less than 8 | 4 mL (40 mg) twice daily | |
| 8 to less than 11 | 6 mL (60 mg) twice daily | |
| 11 to less than 14†| 8 mL (80 mg) twice daily | 3 x 25 mg twice daily |
| 14 to less than 20†| 10 mL (100 mg) twice daily | 1 x 100 mg twice daily |
| 20 to less than 25 |
| 1.5 x 100 mg‡ twice daily |
| *The weight-based dosing recommendation for the chewable tablet, and oral suspension in 10mL of water is based on approximately 6 mg/kg/dose twice daily . †For weight between 11 and 20 kg either formulation can be used. Note: The chewable tablets are available as 25 mg and 100 mg tablets. ‡The 100 mg chewable tablet can be divided into equal halves. | ||
No data are available in pre-term neonates. The use of Ралтегравир калия is not recommended in pre-term neonates.
Patients should be instructed to keep scheduled appointments because the Ралтегравир калия dosage should be adjusted as the child grows.
Additional formulations and strengths available
Ралтегравир калия is also available in a 400 mg tablet and as granules for oral suspension for use. Refer to the 400 mg tablet and granules for oral suspension SmPCs for additional dosing information.
The safety and efficacy of raltegravir in preterm (<37 weeks of gestation) and low birth weight (<2000 g) newborns have not been established. No data are available in this population and no dosing recommendations can be made.
Ралтегравир калия is also available for adults and paediatric patients (weighing at least 40 kg), as a 600 mg tablet to be administered as 1,200 mg once daily (two 600 mg tablets) for treatment-naïve patients or patients who are virologically suppressed on an initial regimen of Ралтегравир калия 400 mg twice daily. Refer to the 600 mg tablet SmPCs for additional dosing information.
Elderly
There is limited information regarding the use of raltegravir in the elderly. Therefore, Ралтегравир калия should be used with caution in this population.
Renal impairment
No dosage adjustment is required for patients with renal impairment.
Hepatic impairment
No dosage adjustment is required for patients with mild to moderate hepatic impairment. The safety and efficacy of raltegravir have not been established in patients with severe underlying liver disorders. Therefore, Ралтегравир калия should be used with caution in patients with severe hepatic impairment.
Method of administration
Oral use.
Ралтегравир калия chewable tablets can be administered with or without food.
No special requirements for disposal.
