ISENTRESS
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raltegravir tablet, film coated
Merck & Co., Inc.
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ISENTRESS® (raltegravir) Tablets
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FULL PRESCRIBING INFORMATION
1. INDICATIONS AND USAGE
ISENTRESS1 in combination with other antiretroviral agents is indicated for the treatment of HIV-1 infection in treatment-experienced adult patients who have evidence of viral replication and HIV-1 strains resistant to multiple antiretroviral agents.
The use of other active agents with ISENTRESS is associated with a greater likelihood of treatment response [see Clinical Studies (14)].
The safety and efficacy of ISENTRESS have not been established in treatment-naïve adult patients or pediatric patients.
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Registered trademark of MERCK & CO., Inc.
COPYRIGHT © 2007, 2008 MERCK & CO., Inc.
All rights reserved
2. DOSAGE AND ADMINISTRATION
For the treatment of patients with HIV-1 infection, the dosage of ISENTRESS is 400 mg administered orally, twice daily with or without food. During coadministration with rifampin, the recommended dosage of ISENTRESS is 800 mg twice daily with or without food.
3. DOSAGE FORMS AND STRENGTHS
400 mg pink, oval shaped, film-coated tablets with "227" on one side.
4. CONTRAINDICATIONS
None
5. WARNINGS AND PRECAUTIONS
5.1 Immune Reconstitution Syndrome
During the initial phase of treatment, patients responding to antiretroviral therapy may develop an inflammatory response to indolent or residual opportunistic infections (such as Mycobacterium avium complex, cytomegalovirus, Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis, or reactivation of varicella zoster virus), which may necessitate further evaluation and treatment.
5.2 Drug Interactions
Due to rifampin’s potent induction of uridine diphosphate glucuronosyltransferase (UGT) 1A1, the recommended dosage of ISENTRESS is 800 mg twice daily during coadministration with rifampin. Caution should be used when coadministering ISENTRESS with other strong inducers of UGT1A1 due to reduced plasma concentrations of raltegravir [see Drug Interactions (7)].
6. ADVERSE REACTIONS
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Treatment-Experienced Studies
The safety assessment of ISENTRESS in treatment-experienced subjects is based on the pooled safety data from the randomized, double-blind, placebo-controlled trials, BENCHMRK 1 and BENCHMRK 2 (Protocols 018 and 019) in antiretroviral treatment-experienced HIV-1 infected adult subjects. A total of 462 subjects received the recommended dose of ISENTRESS 400 mg twice daily in combination with optimized background therapy (OBT) compared to 237 subjects taking placebo in combination with OBT. The median duration of therapy in these trials was 48 weeks for subjects receiving ISENTRESS and 38 weeks for subjects receiving placebo. The total exposure to ISENTRESS was 387 patient-years versus 156 patient-years on placebo. The rates of discontinuation due to adverse events were 2% in subjects receiving ISENTRESS and 3% in subjects receiving placebo.
Clinical adverse drug reactions (ADRs) were considered by investigators to be causally related to ISENTRESS + OBT or placebo + OBT. Clinical ADRs of moderate to severe intensity occurring in ≥2% of subjects treated with ISENTRESS and occurring at a higher exposure adjusted rate compared to placebo are presented in Table 1.
| System Organ Class, Adverse Reactions | Randomized Studies Protocol 018 and 019 | |
| ISENTRESS 400 mg Twice Daily + OBT (n = 462)‡ | Placebo + OBT (n = 237)‡ |
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Rate per 100 Patient-Years |
Rate per 100 Patient-Years |
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| Nervous System Disorders | ||
| Headache | 3 | 1 |
| Gastrointestinal Disorders | ||
| Nausea | 2 | 1 |
| General Disorders and Administration Site Conditions | ||
| Asthenia | 2 | 1 |
| Fatigue | 2 | 1 |
Less Common Adverse Reactions
The following ADRs occurred in <2% of subjects receiving ISENTRESS + OBT. These events have been included because of either their seriousness, increased frequency on ISENTRESS compared with placebo or investigator's assessment of potential causal relationship.
Gastrointestinal Disorders: abdominal pain, gastritis
Hepatobiliary Disorders: hepatitis
Immune System Disorders: hypersensitivity
Infections and Infestations: genital herpes, herpes zoster
Nervous System Disorders: dizziness
Renal and Urinary Disorders: renal failure
Adverse Events
Regardless of Drug Relationship
Cancers were reported in treatment-experienced subjects who initiated ISENTRESS with OBT; several were recurrent. The types and rates of specific cancers were those expected in a highly immunodeficient population (many had CD4+ cell counts below 50 cells/mm3 and most had prior AIDS diagnoses). The cancers included Kaposi’s sarcoma, lymphoma, squamous cell carcinoma, hepatocellular carcinoma and anal cancer. Most subjects had other risk factors for cancer including tobacco use, papillomavirus and active hepatitis B virus infection. It is unknown if these cancer diagnoses were related to ISENTRESS use.
Grade 2-4 creatine kinase laboratory abnormalities were observed in subjects treated with ISENTRESS (see Table 2). Myopathy and rhabdomyolysis have been reported; however, the relationship of ISENTRESS to these events is not known. Use with caution in patients at increased risk of myopathy or rhabdomyolysis, such as patients receiving concomitant medications known to cause these conditions.
Laboratory Abnormalities
The percentages of adult subjects treated with ISENTRESS 400 mg twice daily or placebo in Protocols 018 and 019 with selected Grade 2 to 4 laboratory abnormalities representing a worsening from baseline are presented in Table 2.
| Randomized Studies Protocol 018 and 019 |
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| Laboratory Parameter Preferred Term (Unit) | Limit | ISENTRESS 400 mg Twice Daily + OBT (N = 462) | Placebo + OBT (N = 237) |
| ULN = Upper limit of normal range | |||
| Hematology | |||
| Absolute neutrophil count (103/μL) | |||
| Grade 2 | 0.75 - 0.999 | 3% | 5% |
| Grade 3 | 0.50 - 0.749 | 3% | 3% |
| Grade 4 | <0.50 | 1% | <1% |
| Hemoglobin (gm/dL) | |||
| Grade 2 | 7.5 - 8.4 | 1% | 3% |
| Grade 3 | 6.5 - 7.4 | 1% | <1% |
| Grade 4 | <6.5 | <1% | 0% |
| Platelet count (103/μL) | |||
| Grade 2 | 50 - 99.999 | 3% | 5% |
| Grade 3 | 25 - 49.999 | 1% | <1% |
| Grade 4 | <25 | 1% | <1% |
| Blood chemistry | |||
| Fasting (non-random) serum glucose test (mg/dL) | |||
| Grade 2 | 126 – 250 | 8% | 5% |
| Grade 3 | 251 – 500 | 2% | 1% |
| Grade 4 | >500 | 0% | 0% |
| Total serum bilirubin | |||
| Grade 2 | 1.6 - 2.5 x ULN | 5% | 3% |
| Grade 3 | 2.6 - 5.0 x ULN | 2% | 2% |
| Grade 4 | >5.0 x ULN | 1% | 0% |
| Serum aspartate aminotransferase | |||
| Grade 2 | 2.6 - 5.0 x ULN | 8% | 6% |
| Grade 3 | 5.1 - 10.0 x ULN | 3% | 3% |
| Grade 4 | >10.0 x ULN | <1% | 1% |
| Serum alanine aminotransferase | |||
| Grade 2 | 2.6 - 5.0 x ULN | 7% | 8% |
| Grade 3 | 5.1 - 10.0 x ULN | 3% | 2% |
| Grade 4 | >10.0 x ULN | 1% | 2% |
| Serum alkaline phosphatase | |||
| Grade 2 | 2.6 - 5.0 x ULN | 2% | <1% |
| Grade 3 | 5.1 - 10.0 x ULN | <1% | 1% |
| Grade 4 | >10.0 x ULN | 1% | <1% |
| Serum pancreatic amylase test | |||
| Grade 2 | 1.6 - 2.0 x ULN | 2% | 1% |
| Grade 3 | 2.1 - 5.0 x ULN | 3% | 3% |
| Grade 4 | >5.0 x ULN | <1% | 0% |
| Serum lipase test | |||
| Grade 2 | 1.6 - 3.0 x ULN | 4% | 3% |
| Grade 3 | 3.1 - 5.0 x ULN | 1% | <1% |
| Grade 4 | >5.0 x ULN | 0% | 0% |
| Serum creatine kinase | |||
| Grade 2 | 6.0 - 9.9 x ULN | 2% | 2% |
| Grade 3 | 10.0 - 19.9 x ULN | 3% | 3% |
| Grade 4 | >10.0 x ULN | 2% | 1% |
Patients with Co-existing Conditions
Patients Co-infected with Hepatitis B and/or Hepatitis C Virus
In the clinical studies, P018 and P019, subjects with chronic (but not acute) active hepatitis B and/or hepatitis C virus co-infection (N = 114/699 or 16%) were permitted to enroll provided that baseline liver function tests did not exceed 5 times the upper limit of normal (ULN). The rates of AST and ALT abnormalities were higher in the subgroup of subjects with hepatitis B and/or hepatitis C virus co-infection for both treatment groups. In general the safety profile of ISENTRESS in subjects with hepatitis B and/or hepatitis C virus co-infection was similar to subjects without hepatitis B and/or hepatitis C virus co-infection. Grade 2 or higher laboratory abnormalities that represent a worsening Grade from baseline of AST, ALT or total bilirubin occurred in 25%, 31% and 12%, respectively, of co-infected subjects treated with ISENTRESS as compared to 8%, 7% and 8% of all other subjects treated with ISENTRESS.
6.2 Postmarketing Experience
The following adverse reactions have been identified during postapproval use of ISENTRESS. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Psychiatric Disorders: depression (particularly in patients with a pre-existing history of psychiatric illness), including suicidal ideation and behaviors
Skin and Subcutaneous Tissue Disorders: rash, Stevens-Johnson syndrome
7. DRUG INTERACTIONS
7.1 Effect of Raltegravir on the Pharmacokinetics of Other Agents
Raltegravir does not inhibit (IC50>100 µM) CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6 or CYP3A in vitro. Moreover, in vitro, raltegravir did not induce CYP3A4. A midazolam drug interaction study confirmed the low propensity of raltegravir to alter the pharmacokinetics of agents metabolized by CYP3A4 in vivo by demonstrating a lack of effect of raltegravir on the pharmacokinetics of midazolam, a sensitive CYP3A4 substrate. Similarly, raltegravir is not an inhibitor (IC50>50 µM) of the UDP-glucuronosyltransferases (UGT) tested (UGT1A1, UGT2B7), and raltegravir does not inhibit P-glycoprotein-mediated transport. Based on these data, ISENTRESS is not expected to affect the pharmacokinetics of drugs that are substrates of these enzymes or P-glycoprotein (e.g., protease inhibitors, NNRTIs, methadone, opioid analgesics, statins, azole antifungals, proton pump inhibitors and anti-erectile dysfunction agents).
In drug interaction studies, raltegravir did not have a clinically meaningful effect on the pharmacokinetics of the following: hormonal contraceptives, lamivudine, tenofovir, etravirine.
7.2 Effect of Other Agents on the Pharmacokinetics of Raltegravir
Raltegravir is not a substrate of cytochrome P450 (CYP) enzymes. Based on in vivo and in vitro studies, raltegravir is eliminated mainly by metabolism via a UGT1A1-mediated glucuronidation pathway.
Rifampin, a strong inducer of UGT1A1, reduces plasma concentrations of ISENTRESS. Therefore, the dose of ISENTRESS should be increased during coadministration with rifampin [see Dosage and Administration (2)]. The impact of other inducers of drug metabolizing enzymes, such as phenytoin and phenobarbital, on UGT1A1 is unknown.
Coadministration of ISENTRESS with drugs that inhibit UGT1A1 may increase plasma levels of raltegravir.
Selected drug interactions are presented in Table 3 [see Clinical Pharmacology (12.3)].
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Concomitant Drug Class: Drug Name |
Effect on Concentration of Raltegravir | Clinical Comment |
| HIV-Antiviral Agents | ||
| atazanavir | ↑ | Atazanavir, a strong inhibitor of UGT1A1, increases plasma concentrations of raltegravir. However, since concomitant use of ISENTRESS with atazanavir/ritonavir did not result in a unique safety signal in Phase 3 studies, no dose adjustment is recommended. |
| atazanavir/ritonavir | ↑ | Atazanavir/ritonavir increases plasma concentrations of raltegravir. However, since concomitant use of ISENTRESS with atazanavir/ritonavir did not result in a unique safety signal in Phase 3 studies, no dose adjustment is recommended. |
| efavirenz | ↓ | Efavirenz reduces plasma concentrations of raltegravir. The clinical significance of this interaction has not been directly assessed. |
| etravirine | ↓ | Etravirine reduces plasma concentrations of raltegravir. The clinical significance of this interaction has not been directly assessed. |
| tipranavir/ritonavir | ↓ | Tipranavir/ritonavir reduces plasma concentrations of raltegravir. However, since comparable efficacy was observed for this combination relative to other ISENTRESS-containing regimens in Phase 3 studies 018 and 019, no dose adjustment is recommended. |
| Other Agents | ||
| omeprazole | ↑ | Coadministration of medicinal products that increase gastric pH (e.g., omeprazole) may increase raltegravir levels based on increased raltegravir solubility at higher pH. However, since concomitant use of ISENTRESS with proton pump inhibitors and H2 blockers did not result in a unique safety signal in Phase 3 studies, no dose adjustment is recommended. |
| rifampin | ↓ | Rifampin, a strong inducer of UGT1A1, reduces plasma concentrations of raltegravir. The recommended dosage of ISENTRESS is 800 mg twice daily during coadministration with rifampin. |
8. USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Pregnancy Category C
ISENTRESS should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. There are no adequate and well-controlled studies in pregnant women. In addition, there have been no pharmacokinetic studies conducted in pregnant patients.
Developmental toxicity studies were performed in rabbits (at oral doses up to 1000 mg/kg/day) and rats (at oral doses up to 600 mg/kg/day). The reproductive toxicity study in rats was performed with pre-, peri-, and postnatal evaluation. The highest doses in these studies produced systemic exposures in these species approximately 3- to 4-fold the exposure at the recommended human dose. In both rabbits and rats, no treatment-related effects on embryonic/fetal survival or fetal weights were observed. In addition, no treatment-related external, visceral, or skeletal changes were observed in rabbits. However, treatment-related increases over controls in the incidence of supernumerary ribs were seen in rats at 600 mg/kg/day (exposures 3-fold the exposure at the recommended human dose).
Placenta transfer of drug was demonstrated in both rats and rabbits. At a maternal dose of 600 mg/kg/day in rats, mean drug concentrations in fetal plasma were approximately 1.5- to 2.5-fold greater than in maternal plasma at 1 hour and 24 hours postdose, respectively. Mean drug concentrations in fetal plasma were approximately 2% of the mean maternal concentration at both 1 and 24 hours postdose at a maternal dose of 1000 mg/kg/day in rabbits.
Antiretroviral Pregnancy Registry
To monitor maternal-fetal outcomes of pregnant patients exposed to ISENTRESS, an Antiretroviral Pregnancy Registry has been established. Physicians are encouraged to register patients by calling 1-800-258-4263.
8.3 Nursing Mothers
Breast-feeding is not recommended while taking ISENTRESS. In addition, it is recommended that HIV-infected mothers not breast-feed their infants to avoid risking postnatal transmission of HIV.
It is not known whether raltegravir is secreted in human milk. However, raltegravir is secreted in the milk of lactating rats. Mean drug concentrations in milk were approximately 3-fold greater than those in maternal plasma at a maternal dose of 600 mg/kg/day in rats. There were no effects in rat offspring attributable to exposure of ISENTRESS through the milk.
8.4 Pediatric Use
Safety and effectiveness of ISENTRESS in pediatric patients less than 16 years of age have not been established.
8.5 Geriatric Use
Clinical studies of ISENTRESS did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger subjects. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
8.6 Use in Patients with Hepatic Impairment
No clinically important pharmacokinetic differences between subjects with moderate hepatic impairment and healthy subjects were observed. No dosage adjustment is necessary for patients with mild to moderate hepatic impairment. The effect of severe hepatic impairment on the pharmacokinetics of raltegravir has not been studied [see Clinical Pharmacology (12.3)].
8.7 Use in Patients with Renal Impairment
No clinically important pharmacokinetic differences between subjects with severe renal impairment and healthy subjects were observed. No dosage adjustment is necessary [see Clinical Pharmacology (12.3)].
10. OVERDOSAGE
No specific information is available on the treatment of overdosage with ISENTRESS. Doses as high as 1600-mg single dose and 800-mg twice-daily multiple doses were studied in healthy volunteers without evidence of toxicity. Occasional doses of 1800 mg per day were taken in the clinical studies of HIV-1 infected subjects without evidence of toxicity.
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. The extent to which ISENTRESS may be dialyzable is unknown.
11. DESCRIPTION
ISENTRESS contains raltegravir potassium, a human immunodeficiency virus integrase strand transfer inhibitor. The chemical name for raltegravir potassium is N-[(4-Fluorophenyl)methyl]-1,6-dihydro-5-hydroxy-1-methyl-2-[1-methyl-1-[[(5-methyl-1,3,4-oxadiazol-2-yl)carbonyl]amino]ethyl]-6-oxo-4-pyrimidinecarboxamide monopotassium salt.
The empirical formula is C20H20FKN6O5 and the molecular weight is 482.51. The structural formula is:
Raltegravir potassium is a white to off-white powder. It is soluble in water, slightly soluble in methanol, very slightly soluble in ethanol and acetonitrile and insoluble in isopropanol.
Each film-coated tablet of ISENTRESS for oral administration contains 434.4 mg of raltegravir potassium (as salt), equivalent to 400 mg of raltegravir (free phenol) and the following inactive ingredients: microcrystalline cellulose, lactose monohydrate, calcium phosphate dibasic anhydrous, hypromellose 2208, poloxamer 407 (contains 0.01% butylated hydroxytoluene as antioxidant), sodium stearyl fumarate, magnesium stearate. In addition, the film coating contains the following inactive ingredients: polyvinyl alcohol, titanium dioxide, polyethylene glycol 3350, talc, red iron oxide and black iron oxide.
12. CLINICAL PHARMACOLOGY
12.1 Mechanism Of Action
Raltegravir is an HIV-1 antiviral drug [see Clinical Pharmacology (12.4)].
12.2 Pharmacodynamics
In a monotherapy study raltegravir (400 mg twice daily) demonstrated rapid antiviral activity with mean viral load reduction of 1.66 log10 copies/mL by Day 10.
In the randomized, double-blind, placebo-controlled, dose-ranged trial, Protocol 005, and Protocols 018 and 019, antiviral responses were similar among subjects regardless of dose.
Effects on Electrocardiogram
In a randomized, placebo-controlled, crossover study, 31 healthy subjects were administered a single oral supratherapeutic dose of raltegravir 1600 mg and placebo. Peak raltegravir plasma concentrations were approximately 4-fold higher than the peak concentrations following a 400 mg dose. ISENTRESS did not appear to prolong the QTc interval for 12 hours postdose. After baseline and placebo adjustment, the maximum mean QTc change was -0.4 msec (1-sided 95% upper Cl: 3.1 msec).
12.3 Pharmacokinetics
Absorption
Raltegravir is absorbed with a Tmax of approximately 3 hours postdose in the fasted state. Raltegravir AUC and Cmax increase dose proportionally over the dose range 100 mg to 1600 mg. Raltegravir C12hr 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 1600 mg. With twice-daily dosing, pharmacokinetic steady state is achieved within approximately the first 2 days of dosing. There is little to no accumulation in AUC and Cmax. The average accumulation ratio for C12hr ranged from approximately 1.2 to 1.6.
The absolute bioavailability of raltegravir has not been established.
In subjects who received 400 mg twice daily alone, raltegravir drug exposures were characterized by a geometric mean AUC0-12hr of 14.3 μM●hr and C12hr of 142 nM.
Considerable variability was observed in the pharmacokinetics of raltegravir. For observed C12hr in Protocols 018 and 019, the coefficient of variation (CV) for inter-subject variability = 212% and the CV for intra-subject variability = 122%.
Effect of Food on Oral Absorption
ISENTRESS 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. The effect of consumption of low-, moderate- and high-fat meals on steady-state raltegravir pharmacokinetics was assessed in healthy volunteers. Administration of multiple doses of raltegravir following a moderate-fat meal (600 Kcal, 21 g fat) did not affect raltegravir AUC to a clinically meaningful degree with an increase of 13% relative to fasting. Raltegravir C12hr was 66% higher and Cmax was 5% higher following a moderate-fat meal compared to fasting. Administration of raltegravir following a high-fat meal (825 Kcal, 52 g fat) increased AUC and Cmax by approximately 2-fold and increased C12hr by 4.1-fold. Administration of raltegravir following a low-fat meal (300 Kcal, 2.5 g fat) decreased AUC and Cmax by 46% and 52%, respectively; C12hr was essentially unchanged. Food appears to increase pharmacokinetic variability relative to fasting.
Distribution
Raltegravir is approximately 83% bound to human plasma protein over the concentration range of 2 to 10 µM.
Metabolism 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 feces and urine, respectively. In feces, only raltegravir was present, most of which is likely 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.
Special Populations
Pediatric
The pharmacokinetics of raltegravir in pediatric patients has not been established.
Age
The effect of age on the pharmacokinetics of raltegravir was evaluated in the composite analysis. No dosage adjustment is necessary.
Race
The effect of race on the pharmacokinetics of raltegravir was evaluated in the composite analysis. No dosage adjustment is necessary.
Gender
A study of the pharmacokinetics of raltegravir was performed in young healthy males and females. Additionally, the effect of gender was evaluated in a composite analysis of pharmacokinetic data from 103 healthy subjects and 28 HIV-1 infected subjects receiving raltegravir monotherapy with fasted administration. No dosage adjustment is necessary.
Hepatic Impairment
Raltegravir is eliminated primarily by glucuronidation in the liver. A study of the pharmacokinetics of raltegravir was performed in subjects with moderate hepatic impairment. Additionally, hepatic impairment was evaluated in the composite pharmacokinetic analysis. There were no clinically important pharmacokinetic differences between subjects with moderate hepatic impairment and healthy subjects. No dosage adjustment is necessary for patients with mild to moderate hepatic impairment. The effect of severe hepatic impairment on the pharmacokinetics of raltegravir has not been studied.
Renal Impairment
Renal clearance of unchanged drug is a minor pathway of elimination. A study of the pharmacokinetics of raltegravir was performed in subjects with severe renal impairment. Additionally, renal impairment was evaluated in the composite pharmacokinetic analysis. There were no clinically important pharmacokinetic differences between subjects with severe renal impairment and healthy subjects. No dosage adjustment is necessary. Because the extent to which ISENTRESS may be dialyzable is unknown, dosing before a dialysis session should be avoided.
UGT1A1 Polymorphism
There is no evidence that common UGT1A1 polymorphisms alter raltegravir pharmacokinetics to a clinically meaningful extent. In a comparison of 30 subjects with *28/*28 genotype (associated with reduced activity of UGT1A1) to 27 subjects with wild-type genotype, the geometric mean ratio (90% CI) of AUC was 1.41 (0.96, 2.09).
Drug Interactions [see Drug Interactions (7).]
| Coadministered Drug | Coadministered Drug Dose/Schedule | Raltegravir
Dose/Schedule | Ratio (90% Confidence Interval) of Raltegravir Pharmacokinetic Parameters with/without Coadministered Drug; No Effect = 1.00 |
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| n | Cmax | AUC | Cmin | |||
| atazanavir | 400 mg daily | 100 mg single dose | 10 | 1.53 (1.11, 2.12) | 1.72 (1.47, 2.02) | 1.95 (1.30, 2.92) |
| atazanavir/ritonavir | 300 mg/100 mg daily | 400 mg twice daily | 10 | 1.24 (0.87, 1.77) | 1.41 (1.12, 1.78) | 1.77 (1.39, 2.25) |
| efavirenz | 600 mg daily | 400 mg single dose | 9 | 0.64 (0.41, 0.98) | 0.64 (0.52, 0.80) | 0.79 (0.49, 1.28) |
| etravirine | 200 mg twice daily | 400 mg twice daily | 19 | 0.89 (0.68, 1.15) | 0.90 (0.68, 1.18) | 0.66 (0.34, 1.26) |
| omeprazole | 20 mg daily | 400 mg single dose | 14 (10 for AUC) | 4.15 (2.82, 6.10) | 3.12 (2.13, 4.56) | 1.46 (1.10, 1.93) |
| rifampin | 600 mg daily | 400 mg single dose | 9 | 0.62 (0.37, 1.04) | 0.60 (0.39, 0.91) | 0.39 (0.30, 0.51) |
| rifampin | 600 mg daily | 400 mg twice daily when administered alone; 800 mg twice daily when administered with rifampin | 14 | 1.62 (1.12, 2.33) | 1.27 (0.94, 1.71) | 0.47 (0.36, 0.61) |
| ritonavir | 100 mg twice daily | 400 mg single dose | 10 | 0.76 (0.55, 1.04) | 0.84 (0.70, 1.01) | 0.99 (0.70 1.40) |
| tenofovir | 300 mg daily | 400 mg twice daily | 9 | 1.64 (1.16, 2.32) | 1.49 (1.15, 1.94) | 1.03 (0.73, 1.45) |
| tipranavir/ritonavir | 500 mg/200 mg twice daily | 400 mg twice daily | 15 (14 for Cmin) | 0.82 (0.46, 1.46) | 0.76 (0.49, 1.19) | 0.45 (0.31, 0.66) |
12.4 Microbiology
Mechanism of Action
Raltegravir inhibits the catalytic activity of HIV-1 integrase, an HIV-1 encoded enzyme that is required for viral replication. Inhibition of integrase prevents the covalent insertion, or integration, of unintegrated linear HIV-1 DNA into the host cell genome preventing the formation of the HIV-1 provirus. The provirus is required to direct the production of progeny virus, so inhibiting integration prevents propagation of the viral infection. Raltegravir did not significantly inhibit human phosphoryltransferases including DNA polymerases α, β, and γ.
Antiviral Activity in Cell Culture
Raltegravir at concentrations of 31 ± 20 nM resulted in 95% inhibition (EC95) of viral spread (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 at concentrations of 6 to 50 nM resulted in 95% inhibition of viral spread in cultures of mitogen-activated human peripheral blood mononuclear cells infected with diverse, primary clinical isolates of HIV-1, including isolates resistant to reverse transcriptase inhibitors and protease inhibitors. Raltegravir also inhibited replication of an HIV-2 isolate when tested in CEMx174 cells (EC95 value = 6 nM). Additive to synergistic antiretroviral activity was observed when human T-lymphoid cells infected with the H9IIIB variant of HIV-1 were incubated with raltegravir in combination with non-nucleoside reverse transcriptase inhibitors (delavirdine, efavirenz, or nevirapine); nucleoside analog reverse transcriptase inhibitors (abacavir, didanosine, lamivudine, stavudine, tenofovir, zalcitabine, or zidovudine); protease inhibitors (amprenavir, atazanavir, indinavir, lopinavir, nelfinavir, ritonavir, or saquinavir); or the entry inhibitor enfuvirtide.
Resistance
The mutations observed in the HIV-1 integrase coding sequence that contributed to raltegravir resistance (evolved either in cell culture or in subjects treated with raltegravir) generally included an amino acid substitution at either Q148 (changed to H, K, or R) or N155 (changed to H) plus one or more additional substitutions (i.e., L74M, E92Q, T97A, E138A/K, G140A/S, V151I, G163R, H183P, Y226C/D/F/H, S230R and D232N). Amino acid substitution at Y143C/H/R is another pathway to raltegravir resistance. By Week 48 in the BENCHMRK trials, at least one of the 3 primary raltegravir resistance-associated substitutions, Y143C/H/R, Q148H/K/R, and N155H, was observed in 63 (64.3%) of the 98 virologic failure subjects with evaluable genotypic data from paired baseline and raltegravir treatment-failure isolates. Some (n=18) of those HIV isolates harboring one or more of the 3 primary raltegravir resistance-associated substitutions were evaluated for raltegravir susceptibility yielding a median decrease of 47.3-fold (mean 73.1 ± 60.8-fold decrease, ranging from 0.9- to 200-fold) compared to baseline isolates.
13. NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility
Carcinogenicity studies 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 1.8-fold (females) or 1.2-fold (males) greater than the AUC (54 µM●hr) at the 400-mg twice daily human dose. Treatment-related squamous cell carcinoma of nose/nasopharynx was observed in female rats dosed with 600 mg/kg/day raltegravir for 104 weeks. These tumors were possibly the result of local irritation and inflammation due to local deposition and/or aspiration of drug in the mucosa of the nose/nasopharynx during dosing. No tumors of the nose/nasopharynx were observed in rats dosed with 150 mg/kg/day (males) and 50 mg/kg/day (females) and the systemic exposure in rats was 1.7-fold (males) to 1.4-fold (females) greater than the AUC (54 μM●hr) at the 400-mg twice daily human dose.
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.
No effect on fertility was seen in male and female rats at doses up to 600 mg/kg/day which resulted in 3.0-fold exposure above the exposure at the recommended human dose.
14. CLINICAL STUDIES
Description of Clinical Studies
The evidence of durable efficacy of ISENTRESS is based on the analyses of 48-week data from 2 ongoing, randomized, double-blind, placebo-controlled studies, BENCHMRK 1 and BENCHMRK 2 (Protocols 018 and 019), in antiretroviral treatment-experienced HIV-1 infected adult subjects. These efficacy results were supported by the 48-week analysis of a randomized, double-blind, controlled, dose-ranging study, Protocol 005, in antiretroviral treatment-experienced HIV-1 infected adult subjects.
Treatment-Experienced Subjects
BENCHMRK 1 and BENCHMRK 2 are Phase 3 studies to evaluate the safety and antiretroviral activity of ISENTRESS 400 mg twice daily in combination with an optimized background therapy (OBT), versus OBT alone, in HIV-infected subjects, 16 years or older, with documented resistance to at least 1 drug in each of 3 classes (NNRTIs, NRTIs, PIs) of antiretroviral therapies. Randomization was stratified by degree of resistance to PI (1PI vs. >1PI) and the use of enfuvirtide in the OBT. Prior to randomization, OBT was selected by the investigator based on genotypic/phenotypic resistance testing and prior ART history.
Table 5 shows the demographic characteristics of subjects in the group receiving ISENTRESS 400 mg twice daily and subjects in the placebo group.
| Randomized Studies Protocol 018 and 019 | ISENTRESS 400 mg Twice Daily + OBT (N = 462) | Placebo + OBT (N = 237) |
|
||
| Gender | ||
| Male | 88% | 89% |
| Female | 12% | 11% |
| Race | ||
| White | 65% | 73% |
| Black | 14% | 11% |
| Asian | 3% | 3% |
| Hispanic | 11% | 8% |
| Others | 6% | 5% |
| Age (years) | ||
| Median (min, max) | 45 (16 to 74) | 45 (17 to 70) |
| CD4+ Cell Count | ||
| Median (min, max), cells/mm3 | 119 (1 to 792) | 123 (0 to 759) |
| ≤50 cells/mm3 | 32% | 33% |
| >50 and ≤200 cells/mm3 | 37% | 36% |
| Plasma HIV-1 RNA | ||
| Median (min, max), log10 copies/mL | 4.8 (2 to 6) | 4.7 (2 to 6) |
| >100,000 copies/mL | 35% | 33% |
| History of AIDS | ||
| Yes | 92% | 91% |
| Prior Use of ART, Median (1st Quartile, 3rd Quartile) | ||
| Years of ART Use | 10 (7 to 12) | 10 (8 to 12) |
| Number of ART | 12 (9 to 15) | 12 (9 to 14) |
| Hepatitis Co-infection* | ||
| No Hepatitis B or C virus | 83% | 85% |
| Hepatitis B virus only | 8% | 3% |
| Hepatitis C virus only | 8% | 11% |
| Co-infection of Hepatitis B and C virus | 1% | 1% |
| Stratum | ||
| Enfuvirtide in OBT | 38% | 38% |
| Resistant to ≥2 PI | 97% | 95% |
Table 6 compares the characteristics of optimized background therapy at baseline in the group receiving ISENTRESS 400 mg twice daily and subjects in the control group.
| Randomized Studies Protocol 018 and 019 | ISENTRESS 400 mg Twice Daily + OBT (N = 462) | Placebo + OBT (N = 237) |
|
||
| Number of ARTs in OBT | ||
| Median (min, max) | 4 (1 to 7) | 4 (2 to 7) |
| Number of Active PI in OBT by Phenotypic Resistance Test* |
||
| 0 | 36% | 41% |
| 1 or more | 60% | 58% |
| Phenotypic Sensitivity Score (PSS)† | ||
| 0 | 15% | 19% |
| 1 | 31% | 30% |
| 2 | 31% | 28% |
| 3 or more | 18% | 20% |
| Genotypic Sensitivity Score (GSS)† | ||
| 0 | 25% | 28% |
| 1 | 39% | 41% |
| 2 | 24% | 21% |
| 3 or more | 11% | 10% |
Week 48 outcomes for the 699 subjects randomized and treated with the recommended dose of ISENTRESS 400 mg twice daily or placebo in the pooled BENCHMRK 1 and 2 studies are shown in Table 7.
|
Randomized Studies Protocol 018 and 019 | ISENTRESS 400 mg Twice Daily + OBT (N = 462) | Placebo + OBT (N = 237) |
|
||
| Outcome at Week 48 | ||
| Subjects with HIV-1 RNA less than 400 copies/mL Subjects with HIV-1 RNA less than 50 copies/mL | 72% 62% | 37% 33% |
| Virologic Failure (confirmed)*
Non-responder* Rebound* | 23% 3% 20% | 57% 30% 26% |
| Death†
Discontinuation due to adverse experiences Discontinuation due to other reasons‡ | 2% 2% 2% | 3% 3% 2% |
The mean changes in plasma HIV-1 RNA from baseline were -1.71 log10 copies/mL in the group receiving ISENTRESS 400 mg twice daily and -0.78 log10 copies/mL for the control group. The mean increase from baseline in CD4+ cell counts was higher in the arm receiving ISENTRESS 400 mg twice daily (109 cells/mm3) than in the control group (45 cells/mm3).
Treatment-emergent CDC Category C events occurred in 4% of the group receiving ISENTRESS 400 mg twice daily and 5% of the control group.
Virologic responses at Week 48 by baseline genotypic and phenotypic sensitivity score are shown in Table 8.
| Randomized Studies Protocol 018 and 019 (Noncompleters as failures approach) | Percent with HIV RNA <400 copies/mL at Week 48 | Percent with HIV RNA <50 copies/mL at Week 48 |
||||||
|
n | ISENTRESS 400 mg Twice Daily + OBT (N = 459)* |
n |
Placebo + OBT (N = 237) |
n | ISENTRESS 400 mg Twice Daily + OBT (N = 459) |
n |
Placebo + OBT (N = 237) |
|
|
||||||||
| Phenotypic Sensitivity Score (PSS)† | ||||||||
| 0 | 69 | 54 | 44 | 5 | 69 | 48 | 44 | 2 |
| 1 | 143 | 71 | 72 | 33 | 143 | 58 | 72 | 28 |
| 2 | 141 | 82 | 66 | 41 | 141 | 70 | 66 | 36 |
| 3 or more | 85 | 74 | 48 | 63 | 85 | 68 | 48 | 58 |
| Genotypic Sensitivity Score (GSS)† | ||||||||
| 0 | 115 | 50 | 66 | 8 | 115 | 43 | 66 | 3 |
| 1 | 175 | 77 | 96 | 39 | 175 | 63 | 96 | 35 |
| 2 | 111 | 86 | 49 | 65 | 111 | 76 | 49 | 59 |
| 3 or more | 51 | 73 | 23 | 52 | 51 | 69 | 23 | 48 |
16. HOW SUPPLIED/STORAGE AND HANDLING
ISENTRESS tablets 400 mg are pink, oval-shaped, film-coated tablets with “227” on one side. They are supplied as follows:
NDC 0006-0227-61 unit-of-use bottles of 60.
No. 3894
Storage and Handling
Store at 20-25°C (68-77°F); excursions permitted to 15-30°C (59-86°F). See USP Controlled Room Temperature.
17. PATIENT COUNSELING INFORMATION
[See FDA-Approved Patient Labeling.]
Patients should be informed that ISENTRESS is not a cure for HIV infection or AIDS. They should also be told that people taking ISENTRESS may still get infections or other conditions common in people with HIV (opportunistic infections). Patients should also be told that it is very important that they stay under a physician's care during treatment with ISENTRESS.
Patients should be informed that ISENTRESS does not reduce the chance of passing HIV to others through sexual contact, sharing needles, or being exposed to blood. Patients should be advised to continue to practice safer sex and to use latex or polyurethane condoms or other barrier methods to lower the chance of sexual contact with any body fluids such as semen, vaginal secretions or blood. Patients should also be advised to never re-use or share needles.
Physicians should instruct their patients that if they miss a dose, they should take it as soon as they remember. If they do not remember until it is time for the next dose, they should be instructed to skip the missed dose and go back to the regular schedule. Patients should not take two tablets of ISENTRESS at the same time.
Physicians should instruct their patients to read the Patient Package Insert before starting ISENTRESS therapy and to reread each time the prescription is renewed. Patients should be instructed to inform their physician or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens.
Manufactured and Distributed by:
MERCK & CO., INC., Whitehouse Station, NJ 08889, USA
Printed in USA
9795103
U.S. Patent Nos. US 7,169,780
FDA-Approved Patient Labeling
Patient Information
ISENTRESS® (eye sen tris)
(raltegravir)
Tablets
Read the patient information that comes with ISENTRESS1 before you start taking it and each time you get a refill. There may be new information. This leaflet is a summary of the information for patients. Your doctor or pharmacist can give you additional information. This leaflet does not take the place of talking with your doctor about your medical condition or your treatment.
What is ISENTRESS?
- ISENTRESS is an anti-HIV (antiretroviral) medicine that helps to control HIV infection. The term HIV stands for Human Immunodeficiency Virus. It is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). ISENTRESS is used along with other anti-HIV medicines in patients who are already taking or have taken anti-HIV medicines and the medicines are not controlling their HIV infection. ISENTRESS will NOT cure HIV infection.
- People taking ISENTRESS may still develop infections, including opportunistic infections or other conditions that happen with HIV infection.
- Stay under the care of your doctor during treatment with ISENTRESS.
- The safety and effectiveness of ISENTRESS in children less than 16 years of age has not been studied.
ISENTRESS must be used with other anti-HIV medicines.
How does ISENTRESS work?
- ISENTRESS blocks an enzyme which the virus (HIV) needs in order to make more virus. The enzyme that ISENTRESS blocks is called HIV integrase.
- When used with other anti-HIV medicines, ISENTRESS may do two things:
- It may reduce the amount of HIV in your blood. This is called your "viral load".
- It may also increase the number of white blood cells called CD4 (T) cells that help fight off other infections.
- ISENTRESS may not have these effects in all patients.
Does ISENTRESS lower the chance of passing HIV to other people?
No. ISENTRESS does not reduce the chance of passing HIV to others through sexual contact, sharing needles, or being exposed to your blood.
- Continue to practice safer sex.
- Use latex or polyurethane condoms or other barrier methods to lower the chance of sexual contact with any body fluids. This includes semen from a man, vaginal secretions from a woman, or blood.
- Never re-use or share needles.
Ask your doctor if you have any questions about safer sex or how to prevent passing HIV to other people.
What should I tell my doctor before and during treatment with ISENTRESS?
Tell your doctor about all of your medical conditions. Include any of the following that applies to you:
- You have any allergies.
- You are pregnant or plan to become pregnant.
- ISENTRESS is not recommended for use during pregnancy. ISENTRESS has not been studied in pregnant women. If you take ISENTRESS while you are pregnant, talk to your doctor about how you can be included in the Antiretroviral Pregnancy Registry.
- You are breast-feeding or plan to breast-feed.
- It is recommended that HIV-infected women should not breast-feed their infants. This is because their babies could be infected with HIV through their breast milk.
- Talk with your doctor about the best way to feed your baby.
Tell your doctor about all the medicines you take. Include the following:
- prescription medicines, including rifampin (a medicine used to treat some infections such as tuberculosis)
- non-prescription medicines
- vitamins
- herbal supplements
Know the medicines you take.
- Keep a list of your medicines. Show the list to your doctor and pharmacist when you get a new medicine.
How should I take ISENTRESS?
Take ISENTRESS exactly as your doctor has prescribed. The recommended dose is as follows:
- Take only one 400 mg tablet at a time.
- Take it twice a day.
- Take it by mouth.
- Take it with or without food.
Do not change your dose or stop taking ISENTRESS or your other anti-HIV medicines without first talking with your doctor.
IMPORTANT: Take ISENTRESS exactly as your doctor prescribed and at the right times of day because if you don't:
- The amount of virus (HIV) in your blood may increase if the medicine is stopped for even a short period of time.
- The virus may develop resistance to ISENTRESS and become harder to treat.
- Your medicines may stop working to fight HIV.
- The activity of ISENTRESS may be reduced (due to resistance).
If you fail to take ISENTRESS the way you should, here's what to do:
- If you miss a dose, take it as soon as you remember. If you do not remember until it is time for your next dose, skip the missed dose and go back to your regular schedule. Do NOT take two tablets of ISENTRESS at the same time. In other words, do NOT take a double dose.
- If you take too much ISENTRESS, call your doctor or local Poison Control Center.
Be sure to keep a supply of your anti-HIV medicines.
- When your ISENTRESS supply starts to run low, get more from your doctor or pharmacy.
- Do not wait until your medicine runs out to get more.
What are the possible side effects of ISENTRESS?
When ISENTRESS has been given with other anti-HIV drugs, the most common side effects included:
- nausea
- headache
- tiredness
- weakness
Other side effects include rash, severe skin reactions, depression, suicidal thoughts and actions.
A condition called Immune Reconstitution Syndrome can happen in some patients with advanced HIV infection (AIDS) when combination antiretroviral treatment is started. Signs and symptoms of inflammation from opportunistic infections that a person has or had may occur as the medicines work to control the HIV infection and strengthen the immune system. Call your doctor right away if you notice any signs or symptoms of an infection after starting ISENTRESS with other anti-HIV medicines.
Contact your doctor promptly if you experience unexplained muscle pain, tenderness, or weakness while taking ISENTRESS.
Tell your doctor if you have any side effect that bothers you or that does not go away.
These are not all the side effects of ISENTRESS. For more information, ask your doctor or pharmacist.
How should I store ISENTRESS?
- Store ISENTRESS at room temperature (68 to 77°F).
- Keep ISENTRESS and all medicines out of the reach of children.
General information about the use of ISENTRESS
Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets.
- Do not use ISENTRESS for a condition for which it was not prescribed.
- Do not give ISENTRESS to other people, even if they have the same symptoms you have. It may harm them.
This leaflet gives you the most important information about ISENTRESS.
- If you would like to know more, talk with your doctor.
- You can ask your doctor or pharmacist for additional information about ISENTRESS that is written for health professionals.
- For more information go to www.ISENTRESS.com or call 1-800-622-4477.
What are the ingredients in ISENTRESS?
Active ingredient: Each film-coated tablet contains 400 mg of raltegravir.
Inactive ingredients: Microcrystalline cellulose, lactose monohydrate, calcium phosphate dibasic anhydrous, hypromellose 2208, poloxamer 407 (contains 0.01% butylated hydroxytoluene as antioxidant), sodium stearyl fumarate, magnesium stearate. In addition, the film coating contains the following inactive ingredients: polyvinyl alcohol, titanium dioxide, polyethylene glycol 3350, talc, red iron oxide and black iron oxide.
Manufactured and Distributed by:
MERCK & CO., Inc.
Whitehouse Station, NJ 08889, USA
Revised January 2009
9795103
U.S. Patent Nos. US 7,169,780
| ISENTRESS
raltegravir tablet, film coated |
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Revised: 02/2009Merck & Co., Inc.