"Analysis of three biomarkers in the urine of kidney transplant recipients can diagnose — and even predict — transplant rejection, according to results from a clinical trial sponsored by the National Institute of Allergy and Infect"...
Serious And Otherwise Important Adverse Reactions
The following adverse reactions are discussed in greater detail in other sections of the label:
- Hypersensitivity Reactions [see CONTRAINDICATIONS]
- Lymphomas and Other Malignancies [see BOXED WARNING, WARNINGS AND PRECAUTIONS]
- Serious Infections [see WARNINGS AND PRECAUTIONS]
- Kidney Graft Thrombosis [see WARNINGS AND PRECAUTIONS]
- Hepatic Artery Thrombosis [see WARNINGS AND PRECAUTIONS]
- Zortress and Calcineurin Inhibitor-Induced Nephrotoxicity [see WARNINGS AND PRECAUTIONS]
- Heart Transplantation [see WARNINGS AND PRECAUTIONS]
- Angioedema [see WARNINGS AND PRECAUTIONS]
- Wound Healing and Fluid Accumulation [see WARNINGS AND PRECAUTIONS]
- Interstitial Lung Disease/Non-Infectious Pneumonitis [see WARNINGS AND PRECAUTIONS]
- Hyperlipidemia [see WARNINGS AND PRECAUTIONS]
- Proteinuria [see WARNINGS AND PRECAUTIONS]
- Polyoma Virus Infections [see WARNINGS AND PRECAUTIONS]
- Thrombotic Microangiopathy/Thrombotic Thrombocytopenic Purpura/Hemolytic Uremic Syndrome (TMA/TTP/HUS) [see WARNINGS AND PRECAUTIONS]
- New Onset Diabetes After Transplant [see WARNINGS AND PRECAUTIONS]
- Male Infertility [see WARNINGS AND PRECAUTIONS]
Clinical Studies Experience
Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed cannot be directly compared to rates in other trials and may not reflect the rates observed in clinical practice.
The data described below reflect exposure to Zortress in an open-label, randomized trial of de novo kidney transplant patients of concentration-controlled everolimus at an initial Zortress starting dose of 1.5 mg per day [target trough concentrations 3 to 8 ng/mL with reduced exposure cyclosporine (N=274) compared to mycophenolic acid (N=273) with standard exposure cyclosporine]. All patients received basiliximab induction therapy and corticosteroids. The population was between 18 and 70 years, more than 43% were 50 years of age or older (mean age was 46 years in the Zortress group, 47 years control group); a majority of recipients were male (64% in the Zortress group, 69% control group); and a majority of patients were Caucasian (70% in the Zortress group, 69% control group). Demographic characteristics were comparable between treatment groups. The most frequent diseases leading to transplantation were balanced between groups and included hypertension/nephrosclerosis, glomerulonephritis/glomerular disease and diabetes mellitus. Significantly more patients discontinued Zortress 1.5 mg per day treatment (83/277, 30%) than discontinued the control regimen (60/277, 22%). Of those patients who prematurely discontinued treatment, most discontinuations were due to adverse reactions: 18% in the Zortress group compared to 9% in the control group (p-value = 0.004). This difference was more prominent between treatment groups among female patients. In those patients discontinuing study medication, adverse reactions were collected up to 7 days after study medication discontinuation and serious adverse reactions up to 30 days after study medication discontinuation.
Discontinuation of Zortress at a higher dose (3 mg per day) was 95/279, 34%, including 20% due to adverse reactions, and this regimen is not recommended (see below).
The overall incidences of serious adverse reactions were 57% (159/278) in the Zortress group and 52% (141/273) in the mycophenolic acid group. Infections and infestations reported as serious adverse reactions had the highest incidence in both groups [20% (54/274) in the Zortress group and 25% (69/273) in the control group]. The difference was mainly due to the higher incidence of viral infections in the mycophenolic acid group, mainly CMV and BK virus infections. Injury, poisoning and procedural complications reported as serious adverse reactions had the second highest incidence in both groups [14% (39/274) in the Zortress group and 12% (32/273) in the control group] followed by renal and urinary disorders [10% (28/274) in the Zortress group and 13% (36/273) in the control group] and vascular disorders [10% (26/274) in the Zortress group and 7% (20/273) in the control group].
A total of 13 patients died during the first 12 months of study; 7 (3%) in the Zortress group and 6 (2%) in the control group. The most common causes of death across the study groups were related to cardiac conditions and infections.
There were 12 (4%) graft losses in the Zortress group and 8 (3%) in the control group over the 12 month study period. Of the graft losses, 4 were due to renal artery and two due to renal vein thrombosis in the Zortress group (2%) compared to two renal artery thromboses in the control group (1%) [see BOXED WARNING, WARNINGS AND PRECAUTIONS].
The most common (greater than or equal to 20%) adverse reactions observed in the Zortress group were: peripheral edema, constipation, hypertension, nausea, anemia, urinary tract infection, and hyperlipidemia.
The overall incidence of bacterial, fungal and viral infections reported as adverse reactions was higher in the control group (68%) compared to the Zortress group (64%) and was primarily due to an increased number of viral infections (21% in the control group and 10% in the Zortress group). The incidence of CMV infections reported as adverse reactions was 8% in the control group compared to 1% in the Zortress group; and 3% of the serious CMV infections in the control group versus 0% in the Zortress group were considered serious [see WARNINGS AND PRECAUTIONS].
BK virus infections were lower in incidence in the Zortress group (2 patients, 1%) compared to the control group (11 patients, 4%). One of the two BK virus infections in the Zortress group, and two of the 11 BK virus infections in the control group were also reported as serious adverse reactions. BK virus infections did not result in graft loss in any of the groups in the clinical trial.
Wound Healing And Fluid Collections
Wound healing-related reactions were identified through a retrospective search and request for additional data. The overall incidence of wound-related reactions, including lymphocele, seroma, hematoma, dehiscence, incisional hernia, and infections was 35% in the Zortress group compared to 26% in the control group. More patients required intraoperative repair debridement or drainage of incisional wound complications and more required drainage of lymphoceles and seromas in the Zortress group compared to control.
Adverse reactions due to major fluid collections such as edema and other types of fluid collections was 45% in the Zortress group and 40% in the control group [see WARNINGS AND PRECAUTIONS].
Adverse reactions due to malignant and benign neoplasms were reported in 3% of patients in the Zortress group and 6% in the control group. The most frequently reported neoplasms in the control group were basal cell carcinoma, squamous cell carcinoma, skin papilloma and seborrheic keratosis. One patient in the Zortress group who underwent a melanoma excision prior to transplantation died due to metastatic melanoma [see BOXED WARNING, WARNINGS AND PRECAUTIONS].
New Onset Diabetes Mellitus (NODM)
NODM reported based on adverse reactions and random serum glucose values, was 9% in the Zortress group compared to 7% in the control group.
Endocrine Effects In Males
In the Zortress group, serum testosterone levels significantly decreased while the FSH levels significantly increased without significant changes being observed in the control group. In both the Zortress and the control groups mean testosterone and FSH levels remained within the normal range with the mean FSH level in the Zortress group being at the upper limit of the normal range (11.1 U/L). More patients were reported with erectile dysfunction in the Zortress treatment group compared to the control group (5% compared to 2%, respectively).
Table 2 compares the incidence of treatment-emergent adverse reactions reported with an incidence of greater than or equal to 10% for patients receiving Zortress with reduced dose cyclosporine or mycophenolic acid with standard dose cyclosporine. Within each MedDRA system organ class, the adverse reactions are presented in order of decreasing frequency.
Table 2: Incidence Rates of Frequent (Greater than or
Equal to 10% in Any Treatment Group) Adverse Reactions by Primary System Organ
Class and Preferred Term after Kidney Transplantation (Safety Population*)
|Primary System Organ Class
|Zortress (everolimus) 1.5 mg With reduced exposure cyclosporine
N=274 n (%)
|Mycophenolic acid 1.44 g With standard exposure cyclosporine
N=273 n (%)
|Any Adverse Reactions*||271 (99)||270 (99)|
|Blood lymphatic system disorders||93 (34)||111 (41)|
|Anemia||70 (26)||68 (25)|
|Leukopenia||8 (3)||33 (12)|
|Gastrointestinal disorders||196 (72)||207 (76)|
|Constipation||105 (38)||117 (43)|
|Nausea||79 (29)||85 (31)|
|Diarrhea||51 (19)||54 (20)|
|Vomiting||40 (15)||60 (22)|
|Abdominal pain||36 (13)||42 (15)|
|Dyspepsia||12 (4)||31 (11)|
|Abdominal pain upper||9 (3)||30 (11)|
|General disorders and administrative site conditions||181 (66)||160 (59)|
|Edema peripheral||123 (45)||108 (40)|
|Pyrexia||51 (19)||40 (15)|
|Fatigue||25 (9)||28 (10)|
|Infections and infestations||169 (62)||185 (68)|
|Urinary tract infection||60 (22)||63 (23)|
|Upper respiratory tract infection||44 (16)||49 (18)|
|Injury, poisoning and procedural complications||163 (60)||163 (60)|
|Incision site pain||45 (16)||47 (17)|
|Procedural pain||40 (15)||37 (14)|
|Investigations||137 (50)||133 (49)|
|Blood creatinine increased||48 (18)||59 (22)|
|Metabolism and nutrition disorders||222 (81)||199 (73)|
|Hyperlipidemia||57 (21)||43 (16)|
|Hyperkalemia||49 (18)||48 (18)|
|Hypercholesterolemia||47 (17)||34 (13)|
|Dyslipidemia||41 (15)||24 (9)|
|Hypomagnesemia||37 (14)||40 (15)|
|Hypophosphatemia||35 (13)||35 (13)|
|Hyperglycemia||34 (12)||38 (14)|
|Hypokalemia||32 (12)||32 (12)|
|Musculoskeletal and connective tissue disorders||112 (41)||105 (39)|
|Pain in extremity||32 (12)||29 (11)|
|Back pain||30 (11)||28 (10)|
|Nervous system disorders||92 (34)||109 (40)|
|Headache||49 (18)||40 (15)|
|Tremor||23 (8)||38 (14)|
|Psychiatric disorders||90 (33)||72 (26)|
|Insomnia||47 (17)||43 (16)|
|Renal and urinary disorders||112 (41)||124 (45)|
|Hematuria||33 (12)||33 (12)|
|Dysuria||29 (11)||28 (10)|
|Respiratory, thoracic and mediastinal disorders||86 (31)||93 (34)|
|Cough||20 (7)||30 (11)|
|Vascular disorders||122 (45)||124 (45)|
|Hypertension||81 (30)||82 (30)|
|*The safety analysis population defined as all randomized kidney transplant patients who received at least one dose of treatment and had at least one postbaseline safety assessment.|
Adverse reaction that occurred with at least a 5% higher frequency in the Zortress 1.5 mg group compared to the control group were: peripheral edema (45% compared to 40%), hyperlipidemia (21% compared to 16%), dyslipidemia (15% compared to 9%), and stomatitis/mouth ulceration (8% compared to 3%).
A third treatment group of Zortress 3.0 mg per day (1.5 mg twice daily; target trough concentrations 6 to 12 ng/mL) with reduced exposure cyclosporine was included in the study described above. Although as effective as the lower dose Zortress group, the overall safety was worse and consequently higher doses of Zortress cannot be recommended. Out of 279 patients, 95 (34%) discontinued the study medication with 57 (20%) doing so because of adverse reactions. The most frequent adverse reactions leading to discontinuation of Zortress when used at this higher dose were injury, poisoning and procedural complications (Zortress 1.5 mg: 5%, Zortress 3.0 mg: 7%, and control: 2%), infections (2%, 6%, and 3%, respectively), renal and urinary disorders (4%, 7%, and 4%, respectively) and gastrointestinal disorders (1%, 3%, and 2%).
The combination of fixed dose Zortress and standard doses of cyclosporine in previous kidney clinical trials resulted in frequent elevations of serum creatinine with higher mean and median serum creatinine values observed than in the current study with reduced exposure cyclosporine. These results indicate that Zortress increases the cyclosporine-induced nephrotoxicity; and therefore should only be used in a concentration-controlled regimen with reduced exposure cyclosporine [see BOXED WARNINGS, INDICATIONS AND USAGE, WARNINGS AND PRECAUTIONS].
The data described below reflect exposure to Zortress starting 30 days after transplantation in an open-label, randomized trial of liver transplant patients. Seven hundred and nineteen (719) patients who fulfilled the inclusion/exclusion criteria [see Clinical Studies] were randomized into one of the three treatment groups of the study. During the first 30 days prior to randomization patients received tacrolimus and corticosteroids, with or without mycophenolate mofetil (about 70 to 80% received MMF). No induction antibody was administered. At randomization, MMF was discontinued and patients were randomized to Zortress initial dose of 1.0 mg twice per day (2.0 mg daily) and adjusted to protocol specified target trough concentrations of 3 to 8 ng/mL with reduced exposure tacrolimus [protocol specified target troughs 3 to 5 ng/mL] (N=245) [see CLINICAL PHARMACOLOGY] or to a control group of standard exposure tacrolimus [protocol specified target troughs 8 to 12 ng/mL up to Month 4 posttransplant, then 6 to 10 ng/mL Month 4 through Month 12 posttransplant] (N=241). A third randomized group was discontinued prematurely [see Clinical Studies] and is not described in this section.
The population was between 18 and 70 years, more than 50% were 50 years of age (mean age was 54 years in the Zortress group, 55 years in the tacrolimus control group); 74% were male in both Zortress and control groups, respectively, and a majority were Caucasian (86% Zortress group, 80% control group). Demographic characteristics were comparable between treatment groups. The most frequent diseases leading to transplantation were balanced between groups. The most frequent causes of end-stage liver disease (ESLD) were alcoholic cirrhosis, hepatitis C, and hepatocellular carcinoma and were balanced between groups.
Twenty-seven percent discontinued study drug in the Zortress group compared with 22% for the tacrolimus control group during the first 12 months of study. The most common reason for discontinuation of study medication was due to adverse reactions (19% and 11%, respectively), including proteinuria, recurrent hepatitis C, and pancytopenia in the Zortress group. At 24 months, the rate of discontinuation of study medication in liver transplant patients was greater for the Zortress group (42%) compared to tacrolimus control group (33%).
The overall incidences of serious adverse reactions were 50% (122/245) in the Zortress group and 43% (104/241) in the control group at 12 months and similar at 24 months (56% and 54% respectively). Infections and infestations were reported as serious adverse reactions with the highest incidence followed by Gastrointestinal disorders and Hepatobiliary disorders.
During the first 12 months of study, 13 deaths were reported in the Zortress group (one patient never took Zortress). In the same 12 month period, 7 deaths were reported in the tacrolimus control group. Deaths occurred in both groups for a variety of reasons and were mostly associated with liver-related issues, infections and sepsis. In the following 12 months of study, four additional deaths were reported in each treatment group.
The most common adverse reactions (reported for greater than or equal to 10% patients in any group) in the Zortress group were: diarrhea, headache, peripheral edema, hypertension, nausea, pyrexia, abdominal pain, and leukopenia (see Table 3).
The overall incidence of infections reported as adverse reactions was 50% for Zortress and 44% in the control group and similar at 24 months (56% and 52% respectively). The types of infections were reported as follows: bacterial 16% vs 12%, viral 17% vs 13%; and fungal infections 2% vs 5% for Zortress and control, respectively [see WARNINGS AND PRECAUTIONS].
Wound Healing And Fluid Collections
Wound healing complications were reported as adverse reactions for 11% of patients in the Zortress group compared to 8% of patients in the control group up to 24 months. Pleural effusions were reported in 5% in both groups, and ascites in 4% of patients in the Zortress group and 3% in the control arm.
Malignant and benign neoplasms were reported as adverse reactions in 4% of patients in the Zortress group and 7% in the control group at 12 months. In the Zortress group 3 malignant tumors were reported compared to 9 cases in the control group. For the Zortress group this included lymphoma, lymphoproliferative disorder and a hepatocellular carcinoma, and for the control group included Kaposi's sarcoma (2), metastatic colorectal cancer, glioblastoma, malignant hepatic neoplasm, pancreatic neuroendocrine tumor, hemophagocytic histiocytosis, and squamous cell carcinomas. At 24 months, the rates of malignancies were similar (10% and 11% respectively) [see BOXED WARNING, WARNINGS AND PRECAUTIONS].
Hyperlipidemia adverse reactions (including the preferred terms: hyperlipidemia, hypercholesterolemia, blood cholesterol increased, blood triglycerides increased, hypertriglyceridemia lipids increased, total cholesterol/HDL ratio increased, and dyslipidemia) were reported for 24% Zortress patients, and 10% control patients at 12 months. Results were similar at 24 months (28% and 12%, respectively).
New Onset Of Diabetes After Transplant (NODAT)
Of the patients without diabetes mellitus at randomization, NODAT was reported in 32% in the Zortress group compared to 29% in the control group at 12 months and similar at 24 months.
Table 3 compares the incidence of treatment-emergent adverse reactions reported with an incidence of greater than or equal to 10% for patients receiving Zortress with reduced exposure tacrolimus or standard dose tacrolimus from randomization to 24 months. Within each MedDRA system organ class, the adverse reactions are presented in order of decreasing frequency.
Table 3: Incidence Rates of most Frequent (Greater
than or Equal to 10% in Any Treatment Group) Adverse Reactions by Primary
System Organ Class and Preferred Term and Treatment at 12 Months and 24 Months
after Liver Transplantation (Safety population*)
|Preferred System Organ Class
|12 month||24 month|
|Zortress with reduced exposure tacrolimus
N=245 n (%)
|Tacrolimus standard exposure
N=241 n (%)
|Zortress with reduced exposure tacrolimus
N=245 n (%)
|Tacrolimus standard exposure
N=242 n (%)
|Any Adverse Reaction/Infection||232 (95)||229 (95)||236 (96)||237 (98)|
|Blood & lymphatic system disorders||66 (27)||47 (20)||79 (32)||58 (24)|
|-Leucopenia||29 (12)||12 (5)||31 (13)||12 (5)|
|Gastrointestinal disorders||136 (56)||121 (50)||148 (60)||138 (57)|
|-Diarrhea||47 (19)||50 (21)||59 (24)||61 (25)|
|-Nausea||33 (14)||28 (12)||36 (15)||33 (14)|
|-Abdominal pain||32 (13)||22 (9)||37 (15)||31(13)|
|General disorders and administration site conditions||94 (38)||85 (35)||113 (46)||98 (41)|
|-Peripheral edema||43 (18)||26 (11)||49 (20)||31 (13)|
|-Pyrexia||32 (13)||25 (10)||43 (18)||28 (12)|
|-Fatigue||22 (9)||26 (11)||27 (11)||28 (12)|
|Infections and infestations||123 (50)||105 (44)||135 (56)||125 (52)|
|-Hepatitis C**||28 (11)||19 (8)||33 (14)||24 (10)|
|Investigations||81 (33)||78 (32)||92 (38)||98 (41)|
|-Liver function test abnormal||16 (7)||24 (10)||19 (8)||25 (10)|
|Metabolism and nutrition disorders||111(45)||92(38)||134(55)||106(44)|
|Nervous system disorders||89 (36)||85 (35)||99 (40)||101 (42)|
|-Headache||47 (19)||46 (19)||53 (22)||54 (22)|
|-Tremor||23 (9)||29 (12)||25 (10)||37(15)|
|-Insomnia||14 (6)||19 (8)||17 (7)||24 (10)|
|Renal and urinary disorder||49(20)||53(22)||67(27)||73(30)|
|Vascular disorders||56 (23)||57 (24)||72 (29)||68 (28)|
|-Hypertension||42 (17)||38 (16)||52 (21)||44 (18)|
|Primary system organ classes are presented alphabetically.
*The safety analysis population is defined as all randomized liver transplant patients who received at least one dose of treatment and had at least one postbaseline safety assessment.
**No de novo hepatitis C cases were reported
Less common adverse reactions, occurring overall in greater than or equal to 1% to less than 10% of either kidney or liver transplant patients treated with Zortress include:
Cardiac and Vascular Disorders: angina pectoris, atrial fibrillation, cardiac failure congestive, palpitations, tachycardia, hypertension including hypertensive crisis, hypotension, deep vein thrombosis
Gastrointestinal Disorders: abdominal distention, abdominal hernia, ascites, constipation, dyspepsia, dysphagia, epigastric discomfort, flatulence, gastritis, gastroesophageal reflux disease, gingival hypertrophy, hematemesis, hemorrhoids, ileus, mouth ulceration, peritonitis, stomatitis
Infections and Infestations: BK virus infection [see WARNINGS AND PRECAUTIONS], bacteremia, bronchitis, candidiasis, cellulitis, CMV, folliculitis, gastroenteritis, herpes infections, influenza, lower respiratory tract, nasopharyngitis, onychomycosis, oral candidiasis, oral herpes, osteomyelitis, pneumonia, pyelonephritis, sepsis, sinusitis, tinea pedis, upper respiratory tract infection, urethritis, urinary tract infection, wound infection [see BOXED WARNING, WARNINGS AND PRECAUTIONS].
Injury Poisoning and Procedural Complications: incision site complications including infections, perinephric collection, seroma, wound dehiscence, incisional hernia, perinephric hematoma, localized intraabdominal fluid collection, impaired healing, lymophocele, lymphorrhea
Metabolism and Nutrition Disorders: blood urea increased, acidosis, anorexia, dehydration, diabetes mellitus [see WARNINGS AND PRECAUTIONS], decreased appetite, fluid retention, gout, hypercalcemia, hypertriglyceridemia, hyperuricemia, hypocalcemia, hypokalemia, hypoglycemia, hypomagnesemia, hyponatremia, iron deficiency, new onset diabetes mellitus, vitamin B12 deficiency
Musculoskeletal and Connective Tissues Disorders: arthralgia, joint swelling, muscle spasms, muscular weakness, musculoskeletal pain, myalgia, osteoarthritis, osteonecrosis, osteopenia, osteoporosis, spondylitis
Psychiatric Disorders: agitation, anxiety, depression, hallucination
Renal and Urinary Disorders: bladder spasm, hydronephrosis, micturation urgency, nephritis interstitial, nocturia, pollakiuria, polyuria, proteinuria [see WARNINGS AND PRECAUTIONS], pyuria, renal artery thrombosis [see BOXED WARNING, WARNINGS AND PRECAUTIONS], acute renal failure, renal impairment [see WARNINGS AND PRECAUTIONS], renal tubular necrosis, urinary retention
Respiratory, Thoracic, Mediastinal Disorders: atelectasis, bronchitis, dyspnea, cough, epistaxis, lower respiratory tract infection, nasal congestion, oropharyngeal pain, pleural effusions, pulmonary edema, rhinorrhea, sinus congestion, wheezing
Less common, serious adverse reactions occurring overall in less than 1% of either kidney or liver transplant patients treated with Zortress include:
- Angioedema [see WARNINGS AND PRECAUTIONS]
- Interstitial Lung Disease/Non-Infectious Pneumonitis [see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS]
- Pericardial effusions [see WARNINGS AND PRECAUTIONS]
- PancreatitisThrombotic Microangiopathy (TMA), Thrombotic Thrombocytopenic Purpura (TTP), and Hemolytic Uremic Syndrome (HUS) [see WARNINGS AND PRECAUTIONS]
Adverse reactions identified from the postmarketing use of the combination regimen of Zortress and cyclosporine that are not specific to any one transplant indication include angioedema [see WARNINGS AND PRECAUTIONS], erythroderma, leukocytoclastic vasculitis, pancreatitis, pulmonary alveolar proteinosis, and pulmonary embolism. There have also been reports of male infertility with mTOR inhibitors including Zortress [see WARNINGS AND PRECAUTIONS].
Read the Zortress (everolimus) Side Effects Center for a complete guide to possible side effects
Interactions With Strong Inhibitors Or Inducers Of CYP3A4 And P-glycoprotein
Everolimus is mainly metabolized by CYP3A4 in the liver and to some extent in the intestinal wall and is a substrate for the multidrug efflux pump, P-glycoprotein (P-gp). Therefore, absorption and subsequent elimination of systemically absorbed everolimus may be influenced by medicinal products that affect CYP3A4 and/or P-gp. Concurrent treatment with strong inhibitors (e.g., ketoconazole, itraconazole, voriconazole, clarithromycin, telithromycin, ritonavir, boceprevir, telaprevir) and inducers (e.g., rifampin, rifabutin) of CYP3A4 is not recommended. Inhibitors of P-gp (e.g., digoxin, cyclosporine) may decrease the efflux of everolimus from intestinal cells and increase everolimus blood concentrations. In vitro, everolimus was a competitive inhibitor of CYP3A4 and of CYP2D6, potentially increasing the concentrations of medicinal products eliminated by these enzymes. Thus, caution should be exercised when co-administering Zortress with CYP3A4 and CYP2D6 substrates with a narrow therapeutic index [see DOSAGE AND ADMINISTRATION].
All in vivo interaction studies were conducted without concomitant cyclosporine. Pharmacokinetic interactions between Zortress and concomitantly administered drugs are discussed below. Drug interaction studies have not been conducted with drugs other than those described below.
Cyclosporine (CYP3A4/P-gp Inhibitor and CYP3A4 Substrate)
The steady-state Cmax and area under curve (AUC) estimates of everolimus were significantly increased by coadministration of single dose cyclosporine [see CLINICAL PHARMACOLOGY]. Dose adjustment of Zortress might be needed if the cyclosporine dose is altered [see DOSAGE AND ADMINISTRATION]. Zortress had a clinically minor influence on cyclosporine pharmacokinetics in transplant patients receiving cyclosporine (Neoral).
Ketoconazole And Other Strong CYP3A4 Inhibitors
Multiple-dose ketoconazole administration to healthy volunteers significantly increased single dose estimates of everolimus Cmax, AUC, and half-life. It is recommended that strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, voriconazole, clarithromycin, telithromycin, ritonavir, boceprevir, telaprevir) should not be coadministered with Zortress [see WARNINGS AND PRECAUTIONS, CLINICAL PHARMACOLOGY].
Erythromycin (Moderate CYP3A4 Inhibitor)
Multiple-dose erythromycin administration to healthy volunteers significantly increased single dose estimates of everolimus Cmax, AUC, and half-life. If erythromycin is co-administered, everolimus blood concentrations should be monitored and a dose adjustment made as necessary [see CLINICAL PHARMACOLOGY].
Verapamil (CYP3A4 and P-gp Substrate)
Multiple-dose verapamil administration to healthy volunteers significantly increased single dose estimates of everolimus Cmax and AUC. Everolimus half-life was not changed. If verapamil is coadministered, everolimus blood concentrations should be monitored and a dose adjustment made as necessary [see CLINICAL PHARMACOLOGY].
Atorvastatin (CYP3A4 substrate) And Pravastatin (P-gp substrate)
Single-dose administration of Zortress with either atorvastatin or pravastatin to healthy subjects did not influence the pharmacokinetics of atorvastatin, pravastatin and everolimus, as well as total HMG-CoA reductase bioreactivity in plasma to a clinically relevant extent. However, these results cannot be extrapolated to other HMG-CoA reductase inhibitors. Patients should be monitored for the development of rhabdomyolysis and other adverse reactions as described in the respective labeling for these products.
Simvastatin And Lovastatin
Due to an interaction with cyclosporine, clinical studies of Zortress with cyclosporine conducted in kidney transplant patients strongly discouraged patients with receiving HMG-CoA reductase inhibitors such as simvastatin and lovastatin [see WARNINGS AND PRECAUTIONS].
Rifampin (Strong CYP3A4/P-gp Inducers)
Pretreatment of healthy subjects with multiple-dose rifampin followed by a single dose of Zortress increased everolimus clearance and decreased the everolimus Cmax and AUC estimates. Combination with rifampin is not recommended [see WARNINGS AND PRECAUTIONS, CLINICAL PHARMACOLOGY].
Midazolam (CYP3A4/5 substrate)
Single-dose administration of midazolam to healthy volunteers following administration of multiple-dose Zortress indicated that everolimus is a weak inhibitor of CYP3A4/5. Dose adjustment of midazolam or other CYP3A4/5 substrates is not necessary when Zortress is coadministered with midazolam or other CYP3A4/5 substrates [see CLINICAL PHARMACOLOGY].
Other Possible Interactions
Moderate inhibitors of CYP3A4 and P-gp may increase everolimus blood concentrations (e.g., fluconazole; macrolide antibiotics; nicardipine, diltiazem; nelfinavir, indinavir, amprenavir). Inducers of CYP3A4 may increase the metabolism of everolimus and decrease everolimus blood concentrations (e.g., St. John's Wort [Hypericum perforatum]; anticonvulsants: carbamazepine, phenobarbital, phenytoin; efavirenz, nevirapine).
Coadministration of everolimus and depot octreotide increased octreotide Cmin by approximately 50%.
There is little to no pharmacokinetic interaction of tacrolimus on everolimus, and consequently, dose adjustment of Zortress is not necessary when Zortress is coadministered with tacrolimus.
Read the Zortress Drug Interactions Center for a complete guide to possible interactions
Last reviewed on RxList: 1/9/2017
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