Cresemba

Capsule: Swedish Orange (reddish-brown) capsule body marked with "100" in black ink and a white cap marked with "C" in black ink. Capsules length: 24.2 mm.
Each capsule contains 186.3 mg isavuconazonium sulfate (equivalent to 100 mg isavuconazole).
Lyophilized powder for concentrate for solution for IV infusion: Each vial contains 372.6 mg isavuconazonium sulfate (equivalent to 200 mg isavuconazole).
Isavuconazonium Sulfate is a white to yellow powder chemically described as [2-[1-[1-[(2R,3R)-3-[4-(4-cyanophenyl)-1,3-thiazol-2-yl]-2-(2,5-difluorophenyl)-2-hydroxybutyl]-1,2,4-triazol-4-ium-4-yl]ethoxycarbonyl-methylamino]pyridin-3-yl]methyl 2-(methylamino)acetate; hydrogen sulfate.
Isavuconazonium Sulfate is the sulfate ester form of isavuconazonium, a prodrug of the triazole antifungal agent isavuconazole, with broad-spectrum antifungal activity. Upon administration, isavuconazonium sulfate is hydrolyzed by plasma esterases to yield the active moiety isavuconazole. Isavuconazole binds to and inhibits the fungal cytochrome P450 family enzyme lanosterol14-alpha-demethylase (CYP51), which catalyzes the demethylation of lanosterol to yield ergosterol, an important component of the fungal cell membrane. Inhibition of CYP51 leads to a decrease in fungal ergosterol production and disrupts synthesis of the fungal cell membrane, which decreases membrane integrity, increases cell membrane permeability and promotes the loss of essential intracellular elements. This results in fungal cell lysis and death.
Excipients/Inactive Ingredients: Capsule: Capsule contents: magnesium citrate (anhydrous), cellulose microcrystalline, talc, colloidal anhydrous silica and stearic acid.
Capsule shell: hypromellose, iron oxide red, titanium dioxide (E171), gellan gum, potassium acetate, disodium edetate, sodium lauril sulfate.
Printing ink: shellac, propylene glycol, ammonia solution (concentrated), iron oxide black.
Lyophilized powder for concentrate for solution for IV infusion: Mannitol, sulfuric acid (for pH-adjustment).

Pharmacotherapeutic group: Antimycotics for systemic use, triazole and tetrazole derivative. ATC code: J02AC05.
Pharmacology: Pharmacodynamics: Mechanism of action: Isavuconazole is the active moiety formed after oral or intravenous administration of isavuconazonium sulfate (see Pharmacokinetics as follows). Isavuconazole demonstrates a fungicidal effect by blocking the synthesis of ergosterol, a key component of the fungal cell membrane, through the inhibition of cytochrome P-450-dependent enzyme lanosterol 14-alpha-demethylase, responsible for the conversion of lanosterol to ergosterol. This results in an accumulation of methylated sterol precursors and a depletion of ergosterol within the cell membrane, thus weakening the structure and function of the fungal cell membrane.
Microbiology: In animal models of disseminated and pulmonary aspergillosis, the pharmacodynamic (PD) index important in efficacy is exposure divided by minimum inhibitory concentration (MIC) (AUC/MIC). No clear correlation between in vitro MIC and clinical response for the different species (Aspergillus and Mucorales) could be established.
Concentrations of isavuconazole required to inhibit Aspergillus species and genera/species of the order Mucorales in vitro have been very variable. Generally, concentrations of isavuconazole required to inhibit Mucorales are higher than those required to inhibit the majority of Aspergillus species.
Clinical efficacy has been demonstrated for the following Aspergillus species: Aspergillus fumigatus, A. flavus, A. niger, and A. terreus (see further as follows).
Mechanism(s) of resistance: Reduced susceptibility to triazole antifungal agents has been associated with mutations in the fungal cyp51A and cyp51B genes coding for the target protein lanosterol 14-alpha-demethylase involved in ergosterol biosynthesis. Fungal strains with reduced in vitro susceptibility to isavuconazole have been reported, and cross-resistance with voriconazole and other triazole antifungal agents cannot be excluded. (See Table 1.)

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There are currently insufficient data to set clinical breakpoints for other Aspergillus species.
Clinical efficacy and safety: Treatment of invasive aspergillosis: The safety and efficacy of isavuconazole for the treatment of patients with invasive aspergillosis was evaluated in a double-blind, active-controlled clinical study in 516 patients with invasive fungal disease caused by Aspergillus species or other filamentous fungi. In the intent-to-treat (ITT) population, 258 patients received isavuconazole and 258 patients received voriconazole. Isavuconazole was administered intravenously (equivalent to 200 mg isavuconazole) every 8 hours for the first 48 hours, followed by once-daily intravenous or oral treatment (equivalent to 200 mg isavuconazole). The protocol-defined maximum treatment duration was 84 days. Median treatment duration was 45 days.
The overall response at end-of-treatment (EOT) in the myITT population (patients with proven and probable invasive aspergillosis based on cytology, histology, culture or galactomannan testing) was assessed by an independent blinded Data Review Committee. The myITT population comprised 123 patients receiving isavuconazole and 108 patients receiving voriconazole. The overall response in this population was n=43 (35%) for isavuconazole and n=42 (38.9%) for voriconazole. The adjusted treatment difference (voriconazole-isavuconazole) was 4.0 (95% confidence interval: -7.9; 15.9).
The all-cause mortality at Day 42 in this population was 18.7% for isavuconazole and 22.2% for voriconazole. The adjusted treatment difference (isavuconazole-voriconazole) was -2.7% (95% confidence interval: -12.9; 7.5).
Treatment of mucormycosis: In an open-label non-controlled study, 37 patients with proven or probable mucormycosis received isavuconazole at the same dose regimen as that used to treat invasive aspergillosis. Median treatment duration was 84 days for the overall mucormycosis patient population, and 102 days for the 21 patients not previously treated for mucormycosis. For patients with probable or proven mucormycosis as defined by the independent Data Review Committee (DRC), all-cause mortality at Day 84 was 43.2% (16/37) for the overall patient population, 42.9% (9/21) for mucormycosis patients receiving isavuconazole as primary treatment, and 43.8% (7/16) for mucormycosis patients receiving isavuconazole who were refractory to, or intolerant of, prior antifungal therapy (mainly amphotericin B-based treatments). The DRC-assessed overall success rate at EOT was 11/35 (31.4%), with 5 patients considered completely cured and 6 patients partially cured. A stable response was observed in an additional 10/35 patients (28.6%). In 9 patients with mucormycosis due to Rhizopus spp., 4 patients showed a favorable response to isavuconazole. In 5 patients with mucormycosis due to Rhizomucor spp., no favorable responses were observed. The clinical experience in other species is very limited (Lichtheimia spp. n=2, Cunninghamella spp. n=1, Actinomucor elegans n=1).
Pediatric population: The European Medicines Agency has deferred the obligation to submit the results of studies with isavuconazonium sulfate (Cresemba) in one or more subsets of the pediatric population in the treatment of invasive aspergillosis and the treatment of mucormycosis (see Dosage & Administration for information on pediatric use).
Pharmacokinetics: Isavuconazonium sulfate is a water-soluble prodrug that can be administered as an intravenous infusion or orally as hard capsules. Following administration, isavuconazonium sulfate is rapidly hydrolysed by plasma esterases to the active moiety isavuconazole; plasma concentrations of the prodrug are very low, and detectable only for a short time after intravenous dosing.
Absorption: Following oral administration of isavuconazonium sulfate (Cresemba) in healthy subjects, the active moiety isavuconazole is absorbed and reaches maximum plasma concentrations (C_max) approximately 2-3 hours after single and multiple dosing (see Table 2).

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As shown in table 3 as follows, the absolute bioavailability of isavuconazole following oral administration of a single dose of isavuconazonium sulfate (Cresemba) is 98%. Based on these findings, intravenous and oral dosing can be used interchangeably. (See Table 3.)

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Effect of food on absorption: Oral administration of isavuconazonium sulfate (Cresemba) equivalent to 400 mg isavuconazole with a high-fat meal reduced isavuconazole C_max by 9% and increased AUC by 9%. Isavuconazonium sulfate (Cresemba) can be taken with or without food.
Distribution: Isavuconazole is extensively distributed, with a mean steady state volume of distribution (V_ss) of approximately 450 L. Isavuconazole is highly bound (>99%) to human plasma proteins, predominantly to albumin.
Biotransformation: In vitro/in vivo studies indicate that CYP3A4, CYP3A5, and subsequently uridine diphosphate-glucuronosyltransferases (UGT), are involved in the metabolism of isavuconazole.
Following single doses of [cyano-¹⁴C] isavuconazonium and [pyridinylmethyl-¹⁴C] isavuconazonium sulfate in humans, in addition to the active moiety (isavuconazole) and the inactive cleavage product, a number of minor metabolites were identified. Except for the active moiety isavuconazole, no individual metabolite was observed with an AUC >10% of total radio-labelled material.
Elimination: Following oral administration of radio-labelled isavuconazonium sulfate to healthy subjects, a mean of 46.1% of the radioactive dose was recovered in feces, and 45.5% was recovered in urine.
Renal excretion of intact isavuconazole was less than 1% of the dose administered.
The inactive cleavage product is primarily eliminated by metabolism and subsequent renal excretion of the metabolites.
Linearity/non-linearity: Studies in healthy subjects have demonstrated that the pharmacokinetics of isavuconazole are proportional up to 600 mg per day.
Pharmacokinetics in special populations: Pediatric patients: The pharmacokinetics in pediatric patients (<18 years) have not yet been evaluated. No data are available.
Renal impairment: No clinically relevant changes were observed in the total C_max and AUC of isavuconazole in subjects with mild, moderate or severe renal impairment compared to subjects with normal renal function. Of the 403 patients who received isavuconazole in the Phase 3 studies, 79 (20%) of patients had an estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m². No dose adjustment is required in patients with renal impairment, including those patients with end-stage renal disease. Isavuconazole is not readily dialyzable (see Dosage & Administration).
Hepatic impairment: After a single 100 mg dose of isavuconazole was administered to 32 patients with mild (Child-Pugh Class A) hepatic insufficiency and 32 patients with moderate (Child-Pugh Class B) hepatic insufficiency (16 intravenous and 16 oral patients per Child-Pugh class), the least square mean systemic exposure (AUC) increased 64% in the Child-Pugh Class A group, and 84% in the Child-Pugh Class B group, relative to 32 age- and weight-matched healthy subjects with normal hepatic function. Mean plasma concentrations (C_max) were 2% lower in the Child-Pugh Class A group and 30% lower in the Child-Pugh Class B group. The population pharmacokinetic evaluation of isavuconazole in healthy subjects and patients with mild or moderate hepatic dysfunction demonstrated that the mild and moderate hepatic impairment populations had 40% and 48% lower isavuconazole clearance (CL) values, respectively, than the healthy population.
No dose adjustment is required in patients with mild to moderate hepatic impairment.
Isavuconazole has not been studied in patients with severe hepatic impairment (Child-Pugh Class C). Use in these patients is not recommended unless the potential benefit is considered to outweigh the risks (see Dosage & Administration and Precautions).
Toxicology: Preclinical Safety Data: In rats and rabbits, isavuconazole at systemic exposures below the therapeutic level were associated with dose-related increases in the incidence of skeletal anomalies (rudimentary supernumerary ribs) in offspring. In rats, a dose-related increase in the incidence of zygomatic arch fusion was also noted in offspring (see Use in Pregnancy & Lactation).
Administration of isavuconazonium sulfate to rats at a dose of 90 mg/kg/day (approximately 1.0-fold the systemic exposure at the human clinical maintenance dose of 200 mg isavuconazole) during pregnancy through the weaning period showed an increased perinatal mortality of the pups. In utero exposure to the active moiety isavuconazole had no effect on the fertility of the surviving pups.
Intravenous administration of ¹⁴C-labelled isavuconazonium sulfate to lactating rats resulted in the recovery of radiolabel in the milk.
Isavuconazole did not affect the fertility of male or female rats treated with oral doses up to 90 mg/kg/day (approximately 1.0-fold the systemic exposure at the human clinical maintenance dose of 200 mg isavuconazole).
Isavuconazole has no discernible mutagenic or genotoxic potential. Isavuconazole was negative in a bacterial reverse mutation assay, was weakly clastogenic at cytotoxic concentrations in the L5178Y tk+/- mouse lymphoma chromosome aberration assay, and showed no biologically relevant or statistically significant increase in the frequency of micronuclei in an in vivo rat micronucleus test.
Isavuconazole has demonstrated carcinogenic potential in 2-year rodent carcinogenicity studies. Liver and thyroid tumors are likely caused by a rodent-specific mechanism that is not relevant for humans. Skin fibromas and fibrosarcomas were seen in male rats. The mechanism underlying this effect is unknown. Endometrial adenomas and carcinomas of the uterus were seen in female rats, which is likely due to a hormonal disturbance. There is no safety margin for these effects. The relevance for humans of the skin and uterine tumors cannot be excluded.
Isavuconazole inhibited the hERG potassium channel and the L-type calcium channel with an IC50 of 5.82 μM and 6.57 μM respectively (34- and 38-fold the human non-protein bound Cmax at maximum recommended human dose [MRHD], respectively). The in vivo 39-week repeated-dose toxicology studies in monkeys did not show QTcF prolongation at doses up to 40 mg/kg/day (approximately 1.0-fold the systemic exposure at the human clinical maintenance dose of 200 mg isavuconazole).
Environmental risk assessment has shown that Isavuconazonium sulfate (Cresemba) may pose a risk for the aquatic environment.

Isavuconazonium sulfate (Cresemba) is indicated in adults for the treatment of invasive aspergillosis; mucormycosis in patients for whom amphotericin B is inappropriate (see Precautions and Pharmacology: Pharmacodynamics under Actions).
Consideration should be given to official guidance on the appropriate use of antifungal agents.

Posology: Early targeted therapy (pre-emptive or diagnostic-driven therapy) may be instituted pending confirmation of the disease from specific diagnostic tests. However, once these results become available, antifungal therapy should be adjusted accordingly.
Loading dose: The recommended loading dose is two capsules (equivalent to 200 mg of isavuconazole) or one vial after reconstitution and dilution (equivalent to 200 mg of isavuconazole) every 8 hours for the first 48 hours (6 administrations in total).
Maintenance dose: The recommended maintenance dose is two capsules (equivalent to 200 mg of isavuconazole) or one vial after reconstitution and dilution (equivalent to 200 mg of isavuconazole) once daily, starting 12 to 24 hours after the last loading dose.
Duration of therapy should be determined by the clinical response (see Pharmacology: Pharmacodynamics under Actions). For long-term treatment beyond 6 months, the benefit-risk balance should be carefully considered (see Pharmacology: Pharmacodynamics and Toxicology: Preclinical Safety Data under Actions).
Switch to intravenous infusion: Isavuconazonium sulfate (Cresemba) is also available as powder for concentrate for solution for infusion containing 200 mg isavuconazole, equivalent to 372.6 mg isavuconazonium sulfate.
On the basis of the high oral bioavailability (98%, see Pharmacology: Pharmacokinetics under Actions), switching between intravenous and oral administration is appropriate when clinically indicated.
Switch to oral isavuconazole: Isavuconazonium sulfate (Cresemba) is also available as hard capsules containing 100 mg isavuconazole, equivalent to 186.3 mg isavuconazonium sulfate.
On the basis of the high oral bioavailability (98%, see Pharmacology: Pharmacokinetics under Actions), switching between intravenous and oral administration is appropriate when clinically indicated.
Elderly: No dose adjustment is necessary for elderly patients; however the clinical experience in elderly patients is limited.
Renal impairment: No dose adjustment is necessary in patients with renal impairment, including patients with end-stage renal disease (see Pharmacology: Pharmacokinetics under Actions).
Hepatic impairment: No dose adjustment is necessary in patients with mild or moderate hepatic impairment (Child-Pugh Classes A and B) (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Isavuconazole has not been studied in patients with severe hepatic impairment (Child-Pugh Class C). Use in these patients is not recommended unless the potential benefit is considered to outweigh the risks. See Precautions, Adverse Reactions and Pharmacology: Pharmacokinetics under Actions.
Pediatric population: The safety and efficacy of isavuconazonium sulfate (Cresemba) in children aged below 18 years has not yet been established. No data are available.
Method of administration: Capsule: Isavuconazonium sulfate (Cresemba) capsules can be taken with or without food.
Isavuconazonium sulfate (Cresemba) capsules should be swallowed whole. Do not chew, crush,dissolve or open the capsules.
Lyophilized powder for concentrate for solution for IV infusion: Intravenous use.
Precautions to be taken before handling or administering the medicinal product: Isavuconazonium sulfate (Cresemba) must be reconstituted and then further diluted to a concentration corresponding to approximately 0.8 mg/mL isavuconazole prior to administration by intravenous infusion over a minimum of 1 hour to reduce the risk of infusion-related reactions. The infusion must be administered via an infusion set with an in-line filter with a microporous membrane made of polyethersulfone (PES) and with a pore size of 0.2 μm to 1.2 μm. Isavuconazonium sulfate (Cresemba) must only be given as an intravenous infusion.
For detailed instructions on the reconstitution and dilution of isavuconazonium sulfate (Cresemba) before administration, see Instructions and Special Precautions for Handling and Disposal under Cautions for Use.

Symptoms: Symptoms reported more frequently at supratherapeutic doses of isavuconazole (equivalent to isavuconazole 600 mg/day) evaluated in a QT study than in the therapeutic dose group (equivalent to isavuconazole 200 mg/day dose) included: headache, dizziness, paresthesia, somnolence, disturbance in attention, dysgeusia, dry mouth, diarrhea, oral hypoesthesia, vomiting, hot flush, anxiety, restlessness, palpitations, tachycardia, photophobia and arthralgia.
Management of overdose: Isavuconazole is not removed by hemodialysis. There is no specific antidote for isavuconazole. In the event of an overdose, supportive treatment should be instituted.

Hypersensitivity to the active substance or to any of the excipients listed in Description.
Co-administration with ketoconazole (see Interactions).
Co-administration with high-dose ritonavir (>200 mg every 12 hours) (see Interactions).
Co-administration with strong CYP3A4/5 inducers such as rifampicin, rifabutin, carbamazepine, long-acting barbiturates (e.g. phenobarbital), phenytoin and St. John's wort or with moderate CYP3A4/5 inducers such as efavirenz, nafcillin and etravirine (see Interactions).
Patients with familial short QT syndrome (see Precautions).

Hypersensitivity: Hypersensitivity to isavuconazole may result in adverse reactions that include: anaphylactic reaction, hypotension, respiratory failure, dyspnea, drug eruption, pruritus, and rash (see Adverse Reactions). In case of anaphylactic reaction, isavuconazole should be discontinued immediately and appropriate medical treatment should be initiated.
Caution should be used in prescribing isavuconazole to patients with hypersensitivity to other azoleantifungal agents.
Severe cutaneous adverse reactions: Severe cutaneous adverse reactions, such as Stevens-Johnson syndrome, have been reported during treatment with azole antifungal agents. If a patient develops a severe cutaneous adverse reaction, isavuconazonium sulfate (Cresemba) should be discontinued.
Cardiovascular: QT shortening: Isavuconazole is contraindicated in patients with familial short QT syndrome (see Contraindications).
In a QT study in healthy human subjects, isavuconazole shortened the QTc interval in a concentration-related manner. For the 200 mg dosing regimen, the least squares mean (LSM) difference from placebo was 13.1 ms at 2 hours post dose [90% CI: 17.1, 9.1 ms]. Increasing the dose to 600 mg resulted in an LSM difference from placebo of 24.6 ms at 2 hours post dose [90% CI: 28.7, 20.4 ms].
Caution is warranted when prescribing isavuconazole to patients taking other medicinal products known to decrease the QT interval, such as rufinamide.
Elevated liver transaminases or hepatitis: Elevated liver transaminases have been reported in clinical studies (see Adverse Reactions). The elevations in liver transaminases rarely required discontinuation of isavuconazole.
Monitoring of hepatic enzymes should be considered, as clinically indicated. Hepatitis has been reported with azole antifungal agents including isavuconazole.
Concomitant use with other medicinal products: CYP3A4/5 inhibitors: Ketoconazole is contraindicated (see Contraindications). For the strong CYP3A4 inhibitor lopinavir/ritonavir, a two-fold increase in isavuconazole exposure was observed. For other strong CYP3A4/5 inhibitors, a less pronounced effect can be expected. No dose adjustment of isavuconazole is necessary when co-administered with strong CYP3A4/5 inhibitors, however caution is advised as adverse drug reactions may increase (see Interactions).
CYP3A4/5 inducers: Co-administration with mild CYP3A4/5 inducers such as aprepitant, prednisone, and pioglitazone, may result in mild to moderate decreases of isavuconazole plasma levels; co-administration with mild CYP3A4/5 inducers should be avoided unless the potential benefit is considered to outweigh the risk (see Interactions).
CYP3A4/5 substrates including immunosuppressants: Isavuconazole can be considered a moderate inhibitor of CYP3A4/5, and systemic exposure to medicinal products metabolized by CYP3A4 may be increased when co-administered with isavuconazole. Concomitant use of isavuconazole with CYP3A4 substrates such as the immunosuppressants tacrolimus, sirolimus or ciclosporin may increase the systemic exposure to these medicinal products. Appropriate therapeutic drug monitoring and dose adjustment may be necessary during co-administration (see Interactions).
CYP2B6 substrates: Isavuconazole is an inducer of CYP2B6. Systemic exposure to medicinal products metabolized by CYP2B6 may be decreased when co-administered with isavuconazole. Therefore, caution is advised when CYP2B6 substrates, especially medicinal products with a narrow therapeutic index such as cyclophosphamide, are co-administered with isavuconazole. The use of the CYP2B6 substrate efavirenz with isavuconazole is contraindicated because efavirenz is a moderate inducer of CYP3A4/5 (see Contraindications).
P-gp substrates: Isavuconazole may increase the exposure of medicinal products that are P-gp substrates. Dose adjustment of medicinal products that are P-gp substrates, especially medicinal products with a narrow therapeutic index such as digoxin, colchicine and dabigatran etexilate, may be needed when concomitantly administered with isavuconazole (see Interactions).
Limitations of the clinical data: The clinical data for isavuconazole in the treatment of mucormycosis are limited to one prospective non-controlled clinical study in 37 patients with proven or probable mucormycosis who received isavuconazole for primary treatment, or because other antifungal treatments (predominantly amphotericin B) were inappropriate.
For individual Mucorales species, the clinical efficacy data are very limited, often to one or two patients (see Pharmacology: Pharmacodynamics under Actions). Susceptibility data were available in only a small subset of cases. These data indicate that concentrations of isavuconazole required for inhibition in vitro are very variable between genera/species within the order of Mucorales, and generally higher than concentrations required to inhibit Aspergillus species. It should be noted that there was no dose-finding study in mucormycosis, and patients were administered the same dose of isavuconazole as was used for the treatment of invasive aspergillosis.
Effects on Ability to Drive and Use Machines: Isavuconazole has a moderate potential to influence the ability to drive and use machines. Patients should avoid driving or operating machinery if symptoms of confusional state, somnolence, syncope, and/or dizziness are experienced.
Severe hepatic impairment: Isavuconazole has not been studied in patients with severe hepatic impairment (Child-Pugh Class C). Use in these patients is not recommended unless the potential benefit is considered to outweigh the risks. These patients should be carefully monitored for potential drug toxicity. See Dosage & Administration, Adverse Reactions and Pharmacology: Pharmacokinetics under Actions).
Lyophilized powder for concentrate for solution for IV infusion: Infusion-related reactions: During intravenous administration of isavuconazole, infusion-related reactions including hypotension, dyspnea, dizziness, paresthesia, nausea, and headache were reported (see Adverse Reactions). The infusion should be stopped if these reactions occur.

Pregnancy: There are no data from the use of isavuconazonium sulfate (Cresemba) in pregnant women. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical Safety Data under Actions). The potential risk for humans is unknown.
Isavuconazonium sulfate (Cresemba) must not be used during pregnancy except in patients with severe or potentially life-threatening fungal infections, in whom isavuconazole may be used if the anticipated benefits outweigh the possible risks to the fetus.
Women of child-bearing potential: Isavuconazonium sulfate (Cresemba) is not recommended for women of childbearing potential who are not using contraception.
Breast-feeding: Available pharmacodynamic/toxicological data in animals have shown excretion of isavuconazole/metabolites in milk (see Pharmacology: Toxicology: Preclinical Safety Data under Actions).
A risk to newborns and infants cannot be excluded.
Breast-feeding should be discontinued during treatment with isavuconazonium sulfate (Cresemba).
Fertility: There are no data on the effect of isavuconazole on human fertility. Studies in animals did not show impairment of fertility in male or female rats (see Pharmacology: Toxicology: Preclinical Safety Data under Actions).

Summary of the safety profile: The most common treatment-related adverse reactions were elevated liver chemistry tests (7.9%), nausea (7.4%), vomiting (5.5%), dyspnea (3.2%), abdominal pain (2.7%), diarrhea (2.7%), injection site reaction (for lyophilized powder for concentrate for solution for IV infusion only) (2.2%), headache (2.0%), hypokalemia (1.7%) and rash (1.7%).
The adverse reactions which most often led to permanent discontinuation of isavuconazole treatment were confusional state (0.7%), acute renal failure (0.7%), increased blood bilirubin (0.5%), convulsion (0.5%), dyspnea (0.5%), epilepsy (0.5%), respiratory failure (0.5%) and vomiting (0.5%).
Tabulated list of adverse reactions: Table 4 presents adverse reactions with isavuconazole in the treatment of invasive fungal infections, by System Organ Class and frequency.
The frequency of adverse reactions is defined as follows: very common (≥1/10); common (≥1/100 to <1/10); and uncommon (≥1/1,000 to <1/100); not known (frequency cannot be estimated from available data).
Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. (See Table 4.)

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Description of selected adverse reactions: Delirium includes reactions of confusional state.
Elevated liver chemistry tests includes events of alanine aminotransferase increased, aspartate aminotransferase increased, blood alkaline phosphatase increased, blood bilirubin increased, blood lactate dehydrogenase increased, gamma-glutamyltransferase increased, hepatic enzyme increased, hepatic function abnormal, hyperbilirubinemia, liver function test abnormal, and transaminases increased.
Laboratory effects: In a double-blind, randomized, active-controlled clinical study of 516 patients with invasive fungal disease caused by Aspergillus species or other filamentous fungi, elevated liver transaminases (alanine aminotransferase or aspartate aminotransferase) >3 × Upper Limit of Normal (ULN) were reported at the end of study treatment in 4.4% of patients who received isavuconazole. Marked elevations of liver transaminases >10 × ULN developed in 1.2% of patients on isavuconazole.

Potential of medicinal products to affect the pharmacokinetics of isavuconazole: Isavuconazole is a substrate of CYP3A4 and CYP3A5 (see Pharmacology: Pharmacokinetics under Actions). Co-administration of medicinal products which are inhibitors of CYP3A4 and/or CYP3A5 may increase the plasma concentrations of isavuconazole. Co-administration of medicinal products which are inducers of CYP3A4 and/or CYP3A5 may decrease the plasma concentrations of isavuconazole.
Medicinal products that inhibit CYP3A4/5: Co-administration of isavuconazole with the strong CYP3A4/5 inhibitor ketoconazole is contraindicated, since this medicinal product can significantly increase plasma concentrations of isavuconazole (see Contraindications and Interactions).
For the strong CYP3A4 inhibitor lopinavir/ritonavir, a two-fold increase in isavuconazole exposure was observed. For other strong CYP3A4 inhibitors, such as clarithromycin, indinavir and saquinavir, a less pronounced effect can be expected, based on their relative potency. No dose adjustment of isavuconazole is necessary when co-administered with strong CYP3A4/5 inhibitors, however caution is advised as adverse drug reactions may increase (see Precautions).
No dose adjustment is warranted for moderate to mild CYP3A4/5 inhibitors.
Medicinal products that induce CYP3A4/5: Co-administration of isavuconazole with potent CYP3A4/5 inducers such as rifampicin, rifabutin, carbamazepine, long-acting barbiturates (e.g., phenobarbital), phenytoin and St. John's wort, or with moderate CYP3A4/5 inducers such as efavirenz, nafcillin and etravirine, is contraindicated, since these medicinal products can significantly decrease plasma concentrations of isavuconazole (see Contraindications).
Co-administration with mild CYP3A4/5 inducers such as aprepitant, prednisone and pioglitazone, may result in mild to moderate decreases of isavuconazole plasma levels; co-administration with mild CYP3A4/5 inducers should be avoided unless the potential benefit is considered to outweigh the risk (see Precautions).
Co-administration with high-dose ritonavir (>200 mg twice daily) is contraindicated, as at high doses ritonavir may induce CYP3A4/5 and decrease isavuconazole plasma concentrations (see Contraindications).
Potential for isavuconazole to affect exposures of other medicines: Medicinal products metabolized by CYP3A4/5: Isavuconazole is a moderate inhibitor of CYP3A4/5; co-administration of isavuconazole with medicinal products which are substrates of CYP3A4/5 may result in increased plasma concentrations of these medicinal products.
Medicinal products metabolized by CYP2B6: Isavuconazole is a mild CYP2B6 inducer; co-administration of isavuconazole may result in decreased plasma concentrations of CYP2B6 substrates.
Medicinal products transported by P-gp in the intestine: Isavuconazole is a mild inhibitor of P-glycoprotein (P-gp); co-administration with isavuconazole may result in increased plasma concentrations of P-gp substrates.
Medicinal products transported by BCRP: Isavuconazole is an inhibitor in vitro of BCRP, and plasma concentrations of substrates of BCRP may therefore be increased. Caution is advised when isavuconazole is given concomitantly with substrates of BCRP.
Medicinal products renally excreted via transport proteins: Isavuconazole is a mild inhibitor of the organic cation transporter 2 (OCT2). Co-administration of isavuconazole with medicinal products which are substrates of OCT2 may result in increased plasma concentrations of these medicinal products.
Uridine diphosphate-glucuronosyltransferases (UGT) substrates: Isavuconazole is a mild inhibitor of UGT. Co-administration of isavuconazole with medicinal products which are substrates of UGT may result in mildly increased plasma concentrations of these medicinal products.
Interaction table: Interactions between isavuconazole and co-administered medicinal products are listed in Tables 5a, 5b and 5c (increase is indicated as "↑", decrease as "↓"), ordered by therapeutic class. Unless otherwise stated, studies detailed in Tables 5a, 5b and 5c have been performed with the recommended dose of isavuconazole. (See Tables 5a, 5b and 5c.)

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Capsule: Incompatibilities: Not applicable.
Instructions and Special Precautions for Handling and Disposal: This medicinal product may pose a risk to the environment (see Pharmacology: Toxicology: Preclinical Safety Data under Actions).
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Lyophilized powder for concentrate for solution for IV infusion: Incompatibilities: In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products except those mentioned in Instructions and Special Precautions for Handling and Disposal.
Instructions and Special Precautions for Handling and Disposal: Reconstitution: One vial of the powder for concentrate for solution for infusion should be reconstituted by addition of 5 mL water for injections to the vial. The vial should be shaken to dissolve the powder completely. The reconstituted solution should be inspected visually for particulate matter and discoloration. Reconstituted concentrate should be clear and free of visible particulate. It must be further diluted prior to administration.
Dilution and administration: After reconstitution, the entire content of the reconstituted concentrate should be removed from the vial and added to an infusion bag containing at least 250 mL of either sodium chloride 9 mg/mL (0.9%) solution for injection or 50 mg/mL (5%) dextrose solution. The infusion solution contains approximately 0.8 mg isavuconazole per mL). After the reconstituted concentrate is further diluted, the diluted solution may show fine white-to-translucent particulates of isavuconazole, that do not sediment (but will be removed by in-line filtration). The diluted solution should be mixed gently, or the bag should be rolled to minimize the formation of particulates. Unnecessary vibration or vigorous shaking of the solution should be avoided. The solution for infusion must be administered via an infusion set with an in-line filter (pore size 0.2 μm to 1.2 μm) made of polyether sulfone (PES).
Isavuconazole should not be infused into the same line or cannula concomitantly with other intravenous products.
Storage conditions after reconstitution and dilution are provided in Shelf-Life under Storage.
If possible, the intravenous administration of isavuconazole should be completed within 6 hours after reconstitution and dilution at room temperature. If this is not possible, the infusion solution should be immediately refrigerated after dilution, and infusion should be completed within 24 hours. Further information regarding the storage conditions after reconstitution and dilution of the medicinal product is provided in Shelf-Life under Storage.
An existing intravenous line should be flushed with sodium chloride 9 mg/mL (0.9%) solution for injection or 50 mg/mL (5%) dextrose solution.
This medicinal product is for single use only. Discard partially-used vials.
This medicinal product may pose a risk to the environment (see Toxicology: Preclinical Safety Data under Actions).
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Capsule: Store at temperatures not exceeding 30°C. Store in the original packaging in order to protect from moisture.
Lyophilized powder for concentrate for solution for IV infusion: Store in a refrigerator (2°C to 8°C).
For storage conditions after reconstitution and dilution of the medicinal product, (see Shelf-Life as follows).
Shelf-Life: Chemical and physical in-use stability after reconstitution and dilution has been demonstrated for 24 hours at 2°C to 8°C, or 6 hours at room temperature.
From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C, unless reconstitution and dilution has taken place in controlled and validated aseptic conditions.

Antifungals

J02AC - Triazole and tetrazole derivatives ; Used in the systemic treatment of mycotic infections.

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