EYE-va-KAF-tor

Therapeutic Classification: cystic fibrosis therapy adjuncts

Pharmacologic Classification: transmembrane conductance regulator potentiators

• Cystic fibrosis in patients with 1 mutation in the CFTR gene that is responsive to ivacaftor potentiation based on clinical and/or in vitro assay data.

• Acts as a potentiator of the CFTR protein (a chloride channel on the surface of endothelial cells) facilitating chloride transport by increasing the channel-open probability (gating).

• Improved lung function with increased weight, decreased exacerbations and CF symptoms.

Absorption: Some absorption follows oral administration; absorption in enhanced 4–8 fold by fat-containing foods.

Distribution: Unknown.

Protein Binding: >99%.

Metabolism/Excretion: Extensively metabolized by the liver, mostly by the CYP3A isoenzymes; one metabolite (M1) is pharmacologically active; 87.8% eliminated in feces, negligible urinary elimination.

Half-life: 12 hr.

(plasma concentrations)

†Improved lung function and symptoms.

Contraindicated in:

• Pedi: Children <6 mo with hepatic impairment or receiving moderate or strong CYP3A inhibitors.

Use Cautiously in:

• Moderate to severe hepatic impairment (↓ dose)
• Severe renal impairment or end stage renal disease
• OB: Safety not established in pregnancy
• Lactation: Safety not established in breastfeeding
• Pedi: Children <1 mo (safety and effectiveness not established).

Derm: rash.

EENT: nasal congestion, lens opacities/cataracts, oropharyngeal pain.

Endo: hyperglycemia, hypoglycemia.

GI: nausea, abdominal pain, diarrhea, ↑ liver enzymes.

MS: arthralgia, musculoskeletal chest pain, myalgia.

Neuro: headache, dizziness.
Misc: (INCLUDING ANAPHYLAXIS)HYPERSENSITIVITY REACTIONS .

Drug-Drug:

• Strong CYP3A inducers, including rifampin, rifabutin, phenobarbital, carbamazepine and phenytoin↓ levels and effectiveness; avoid concurrent use
• Strong CYP3A inhibitors, including ketoconazole, itraconazole, posaconazole, voriconazole, and clarithromycin may ↑ levels and risk of toxicity (↓ dose).
• Moderate CYP3A inhibitors, including fluconazole or erythromycin may ↑ levels and risk of toxicity (↓ dose).
• May ↑ levels and effects of CYP3A substrates, including alprazolam, diazepam, midazolam and triazolam.
• May ↑ levels and effects of P-glycoprotein substrates, including digoxin, cyclosporine and tacrolimus.
• May alter the effects of warfarin.

Drug-Natural Products:

• St. John's wort may ↓ levels and effectiveness; avoid concurrent use.

Drug-Food:

• Grapefruit or Seville oranges may ↑ levels and ↑ risk of toxicity; avoid concurrent use.

• PO (Adults and Children 6 yr): 150 mg every 12 hr with fat-containing food (use tablets); Concurrent use of strong CYP3A inhibitors: 150 mg twice weekly (use tablets); Concurrent use of moderate CYP3A inhibitors: 150 mg once daily (use tablets).
• PO (Children 6 mo–<6 yr and 14 kg): 75 mg every 12 hr with fat-containing food (use oral granules); Concurrent use of strong CYP3A inhibitors: 75 mg twice weekly (use oral granules); Concurrent use of moderate CYP3A inhibitors: 75 mg once daily (use oral granules).
• PO (Children 6 mo–<6 yr and 7–<14 kg): 50 mg every 12 hr with fat-containing food (use oral granules); Concurrent use of strong CYP3A inhibitors: 50 mg twice weekly (use oral granules); Concurrent use of moderate CYP3A inhibitors: 50 mg once daily (use oral granules).
• PO (Children 6 mo–<6 yr and 5–<7 kg): 25 mg every 12 hr with fat-containing food (use oral granules); Concurrent use of strong CYP3A inhibitors: 25 mg twice weekly (use oral granules); Concurrent use of moderate CYP3A inhibitors: 25 mg once daily (use oral granules).
• PO (Children 4 mo–<6 mo and 5 kg): 25 mg every 12 hr with fat-containing food (use oral granules); Concurrent use of moderate or strong CYP3A inhibitors: Not recommended.
• PO (Children 2 mo–<4 mo and 3 kg): 13.4 mg every 12 hr with fat-containing food (use oral granules). Concurrent use of moderate or strong CYP3A inhibitors: Not recommended.
• PO (Children 1 mo–<2 mo and 3 kg): 5.8 mg every 12 hr with fat-containing food (use oral granules). Concurrent use of moderate or strong CYP3A inhibitors: Not recommended.

• Tablets: 150 mg;
• Oral granules: 5.8 mg/pkt; 13.4 mg/pkt; 25 mg/pkt; 50 mg/pkt; 75 mg/pkt;
• In combination with: elexacaftor and tezacaftor (Trikafta); lumacaftor (Orkambi); and tezacaftor (Symdeko). See Appendix [not included in this PDA edition].

• Monitor lung function (FEV, lung sounds) before and periodically during therapy.
• Assess eyes for cataracts/opacities prior to and periodically during therapy.
• Monitor for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Notify health care professional immediately if these occur.

• Determine patient's genotype prior to starting therapy. If genotype is unknown, use an FDA-cleared CF mutation test to detect the presence of a CFTR mutation followed by verification with bidirectional sequencing when recommended by the mutation test instructions for use.
  • May cause ↑ serum transaminases. Monitor AST and ALT before, every 3 mo for the first year, and annually thereafter. If AST or ALT >5 times the upper limit of normal, interrupt therapy. Once AST or ALT have returned to normal, consider the benefits and risks before resuming therapy.

• PO: Administer tablet with fat-containing food.
  • For children 1 mo to <6 yr of age, administer one packet of granules in 1 tsp (5 mL) of soft food (pureed fruits or vegetables, yogurt, applesauce), breast milk, infant formula, or liquid (water, milk, or juice) that is at or below room temperature. Once mixed, the product should be consumed within 1 hr.

• Instruct patient to take as directed with a fat-containing meal to increase absorption. Fat-containing foods include eggs, butter, peanut butter, and cheese pizza. If a missed dose is remembered within 6 hr, take missed dose. If more than 6 hr, skip dose and take next dose at regular time; do not double doses.
• Advise patient to avoid eating grapefruit or Seville oranges or drinking grapefruit juice during therapy.
• Advise patient to notify health care professional if symptoms of liver problems (pain or discomfort in right abdominal area, yellowing of skin or whites of eyes, loss of appetite, nausea, vomiting, dark amber-colored urine) occur.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially St. John's wort.
• Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
• Emphasize the importance of blood tests to monitor liver function.

• Improved lung function with increased weight, decreased exacerbations and symptoms in patients with cystic fibrosis.

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