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1 Indications And Usage
ERAXIS is indicated for use in adults for the treatment of the following fungal infections listed below. Specimens for fungal culture and other relevant laboratory studies (including histopathology) should be obtained prior to therapy to isolate and identify causative organism(s). Therapy may be instituted before the results of the cultures and other laboratory studies known. However, once these results become available, antifungal therapy should be adjusted accordingly.
1.1 Candidemia And Other Forms Of Candida Infections (Intra-Abdominal Abscess And Peritonitis)
ERAXIS is indicated for the treatment of candidemia and the following Candida infections: intra-abdominal abscess and peritonitis [see Clinical Studies(14.1) and Clinical Pharmacology, Microbiology (12.4)].
1.2 Esophageal Candidiasis
ERAXIS is indicated for the treatment of esophageal candidiasis [see Clinical Studies (14.2), Table 12 for higher relapse rates off ERAXIS therapy].
1.3 Limitation Of Use
ERAXIS has not been studied in endocarditis, osteomyelitis, and meningitis due to Candida, and has not been studied in sufficient numbers of neutropenic patients to determine efficacy in this group.
Candidemia and other Candida infections (intra-abdominal abscess, and peritonitis)The recommended dose is a single 200 mg loading dose of ERAXIS on Day 1, followed by 100 mg daily dose thereafter. Duration of treatment should be based on the patient's clinical response. In general, antifungal therapy should continue for at least 14 days after the last positive culture.
Esophageal CandidiasisThe recommended dose is a single 100 mg loading dose of ERAXIS on Day 1, followed by 50 mg daily dose thereafter. Patients should be treated for a minimum of 14 days and for at least 7 days following resolution of symptoms. Duration of treatment should be based on the patient's clinical response. Because of the risk of relapse of esophageal candidiasis in patients with HIV infections, suppressive antifungal therapy may be considered after a course of treatment.
Reconstitution 50 mg/vialAseptically reconstitute each 50 mg vial with 15 mL of sterile Water for Injection to provide a concentration of 3.33 mg/mL. The reconstituted solution can be stored for up to 24 hours at temperatures up to 25°C (77°F) prior to dilution into the infusion solution.
Reconstitution 100 mg/vialAseptically reconstitute each 100 mg vial with 30 mL of sterile Water for Injection to provide a concentration of 3.33 mg/mL. The reconstituted solution can be stored for up to 24 hours at temperatures up to 25°C (77°F) prior to dilution into the infusion solution.
Risk SummaryBased on findings from animal studies, ERAXIS can cause fetal harm when administered to a pregnant woman. There are no available human data on the use of ERAXIS in pregnant women to inform a drug-associated risk of adverse developmental outcomes. In animal reproduction studies fetal toxicity was observed in the presence of maternal toxicity when anidulafungin was administered to pregnant rabbits during organogenesis at 4 times the proposed therapeutic maintenance dose of 100 mg/day on the basis of relative body surface area [see Data]. Inform pregnant woman of the risk to the fetus. The estimated background risk of major birth defects and miscarriage for the indicated populations are unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2–4% and 15–20% respectively.
Animal DataIn a combined fertility and embryo-fetal development study in rats dosed with anidulafungin for 4 weeks prior to cohabitation and through cohabitation for males or for 2 weeks prior to cohabitation and continuing through gestation day 19 for females, there was no maternal or embryo-fetal toxicity at intravenous doses up to 20 mg/kg/day (equivalent to 2 times the proposed therapeutic maintenance dose of 100 mg/day on the basis of relative body surface area).In a rabbit embryo-fetal development study, intravenous administration of anidulafungin (0, 5, 10, and 20 mg/kg/day) from gestation day 7 through 19, resulted in reduced fetal weights and incomplete ossification in the presence of maternal toxicity (decreased body weight gain) at 20 mg/kg/day (equivalent to 4 times the proposed therapeutic maintenance dose of 100 mg/day on the basis of relative body surface area).In a pre- and postnatal development study, pregnant rats were intravenously administered anidulafungin at doses of 2, 6, or 20 mg/kg/day from gestation day 7 through lactation day 20. Maternal toxicity was observed at ≥6 mg/kg/day (clinical signs at ≥6 mg/kg/day and reduced body weight gain and food consumption during gestation at 20 mg/kg/day group). There were no effects on the viability or growth and development of the offspring. In this study, anidulafungin was detected in fetal plasma, indicating that it crossed the placental barrier.
Risk SummaryThere are no data on the presence of anidulafungin in human milk, the effects on the breastfed infant or the effects on milk production. Anidulafungin was found in the milk of lactating rats [see Data]. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for ERAXIS and any potential adverse effects on the breastfed child from ERAXIS or from the underlying maternal condition.
Animal DataPregnant rats were intravenously administered anidulafungin at doses of 2, 6, or 20 mg/kg/day from gestation day 7 through lactation day 20. Milk samples were collected from 5 rats per group on lactation day 14 at approximately 1 hours post dose. Approximately dose-proportional anidulafungin concentrations were found in the milk of lactating rats.
General Pharmacokinetic CharacteristicsThe pharmacokinetics of anidulafungin following intravenous (IV) administration have been characterized in healthy subjects, special populations and patients. Systemic exposures of anidulafungin are dose-proportional and have low intersubject variability (coefficient of variation <25%) as shown in Table 4. The steady state was achieved on the first day after a loading dose (twice the daily maintenance dose) and the estimated plasma accumulation factor at steady state is approximately 2.Table 4: Mean (%CV) Steady State Pharmacokinetic Parameters of Anidulafungin Following IV Administration of Anidulafungin Once Daily for 10 Days in Healthy Adult SubjectsPK ParameterParameters were obtained from separate studiesAnidulafungin IV Dosing Regimen (LD/MD, mg)LD/MD: loading dose/maintenance dose once daily70/35Data were collected on Day 7,Safety and efficacy of these doses has not been established(N=6)200/100(N=10)260/130,See OVERDOSAGE(N=10)Cmax, ss = the steady state peak concentrationAUCss = the steady state area under concentration vs. time curveCL = clearancet1/2 = the terminal elimination half-lifeCmax, ss [mg/L]3.55 (13.2)8.6 (16.2)10.9 (11.7)AUCss [mg∙h/L]42.3 (14.5)111.8 (24.9)168.9 (10.8)CL [L/h]0.84 (13.5)0.94 (24.0)0.78 (11.3)t1/2 [h]43.2 (17.7)52.0 (11.7)50.3 (9.7)The clearance of anidulafungin is about 1 L/h and anidulafungin has a terminal elimination half-life of 40–50 hours.
DistributionThe pharmacokinetics of anidulafungin following IV administration are characterized by a short distribution half-life (0.5–1 hour) and a volume of distribution of 30–50 L that is similar to total body fluid volume. Anidulafungin is extensively bound (>99%) to human plasma proteins.
MetabolismHepatic metabolism of anidulafungin has not been observed. Anidulafungin is not a clinically relevant substrate, inducer, or inhibitor of cytochrome P450 (CYP450) isoenzymes. It is unlikely that anidulafungin will have clinically relevant effects on the metabolism of drugs metabolized by CYP450 isoenzymes.Anidulafungin undergoes slow chemical degradation at physiologic temperature and pH to a ring-opened peptide that lacks antifungal activity. The in vitro degradation half-life of anidulafungin under physiologic conditions is about 24 hours. In vivo, the ring-opened product is subsequently converted to peptidic degradants and eliminated.
ExcretionIn a single-dose clinical study, radiolabeled (14C) anidulafungin was administered to healthy subjects. Approximately 30% of the administered radioactive dose was eliminated in the feces over 9 days, of which less than 10% was intact drug. Less than 1% of the administered radioactive dose was excreted in the urine. Anidulafungin concentrations fell below the lower limits of quantitation 6 days post-dose. Negligible amounts of drug-derived radioactivity were recovered in blood, urine, and feces 8 weeks post-dose.
Patients with fungal infectionsPopulation pharmacokinetic analyses from four clinical trials including 107 male and 118 female patients with fungal infections showed that the pharmacokinetic parameters of anidulafungin are not affected by age, race, or the presence of concomitant medications which are known metabolic substrates, inhibitors or inducers.The pharmacokinetics of anidulafungin in patients with fungal infections are similar to those observed in healthy subjects. The pharmacokinetic parameters of anidulafungin estimated using population pharmacokinetic modeling following IV administration of a maintenance dose of 50 mg/day or 100 mg/day (following a loading dose) are presented in Table 5.Table 5: Mean (%CV) Steady State Pharmacokinetic Parameters of Anidulafungin Following IV Administration of Anidulafungin in Patients with Fungal Infections Estimated Using Population Pharmacokinetic ModelingPK ParameterAll the parameters were estimated by population modeling using a two-compartment model with first order elimination; AUCss, Cmax,ss and Cmin,ss (steady state trough plasma concentration) were estimated using individual PK parameters and infusion rate of 1 mg/min to administer recommended doses of 50 and 100 mg/day.Anidulafungin IV Dosing Regimen (LD/MD, mg)LD/MD: loading dose/daily maintenance dose100/50200/100Cmax, ss [mg/L]4.2 (22.4)7.2 (23.3)Cmin, ss [mg/L]1.6 (42.1)3.3 (41.8)AUCss [mg∙h/L]55.2 (32.5)110.3 (32.5)CL [L/h]1.0 (33.5)t1/2, β [h]t1/2, β is the predominant elimination half-life that characterizes the majority of the concentration-time profile.26.5 (28.5)
GenderDosage adjustments are not required based on gender. Plasma concentrations of anidulafungin in healthy men and women were similar. In multiple-dose patient studies, drug clearance was slightly faster (approximately 22%) in men.
GeriatricDosage adjustments are not required for geriatric patients. The population pharmacokinetic analysis showed that median clearance differed slightly between the elderly group (patients ≥65, median CL=1.07 L/h) and the non-elderly group (patients <65, median CL=1.22 L/h) and the range of clearance was similar.
RaceDosage adjustments are not required based on race. Anidulafungin pharmacokinetics were similar among Whites, Blacks, Asians, and Hispanics.
HIV StatusDosage adjustments are not required based on HIV status, irrespective of concomitant anti-retroviral therapy.
Hepatic Insufficiency Anidulafungin is not hepatically metabolized. Anidulafungin pharmacokinetics were examined in subjects with Child-Pugh class A, B or C hepatic insufficiency. Anidulafungin concentrations were not increased in subjects with any degree of hepatic insufficiency. Though a slight decrease in AUC was observed in patients with Child-Pugh C hepatic insufficiency, it was within the range of population estimates noted for healthy subjects [see Use in Specific Populations (8.6)].
Renal InsufficiencyAnidulafungin has negligible renal clearance. In a clinical study of subjects with mild, moderate, severe or end stage (dialysis-dependent) renal insufficiency, anidulafungin pharmacokinetics were similar to those observed in subjects with normal renal function. Anidulafungin is not dialyzable and may be administered without regard to the timing of hemodialysis [see Use in Specific Populations (8.7)].
PediatricThe pharmacokinetics of anidulafungin after daily doses were investigated in immunocompromised pediatric (2 through 11 years) and adolescent (12 through 17 years) patients with neutropenia. The steady state was achieved on the first day after administration of the loading dose (twice the maintenance dose), and the Cmax and AUCss increased in a dose-proportional manner. Concentrations and exposures following administration of maintenance doses of 0.75 and 1.5 mg/kg/day in this population were similar to those observed in adults following maintenance doses of 50 and 100 mg/day, respectively (as shown in Table 6).Table 6: Mean (%CV) Steady State Pharmacokinetic Parameters of Anidulafungin Following IV Administration of Anidulafungin Once Daily in Pediatric SubjectsPK ParameterData were collected on Day 5Anidulafungin IV Dosing Regimen(LD/MD, mg/kg)LD/MD: loading dose/daily maintenance dose1.5/0.753.0/1.5Age Group Safety and effectiveness has not been established in pediatric patients ≤16 years of age2–11 years(N = 6)12–17 years(N = 6)2–11 years(N = 6)12–17 years(N = 6)Cmax, ss [mg/L]3.32 (50.0)4.35 (22.5)7.57 (34.2)6.88 (24.3)AUCss [mg∙h/L]41.1 (38.4)56.2 (27.8)96.1 (39.5)102.9 (28.2)
Cyclosporine (CYP3A4 substrate)In a study in which 12 healthy adult subjects received 100 mg/day maintenance dose of anidulafungin following a 200 mg loading dose (on Days 1 to 8) and in combination with 1.25 mg/kg oral cyclosporine twice daily (on Days 5 to 8), the steady state Cmax of anidulafungin was not significantly altered by cyclosporine; the steady state AUC of anidulafungin was increased by 22%. A separate in vitro study showed that anidulafungin has no effect on the metabolism of cyclosporine [see Drug Interactions (7.1)].
Voriconazole (CYP2C19, CYP2C9, CYP3A4 inhibitor and substrate)In a study in which 17 healthy subjects received 100 mg/day maintenance dose of anidulafungin following a 200 mg loading dose, 200 mg twice daily oral voriconazole (following two 400 mg loading doses) and both in combination, the steady state Cmax and AUC of anidulafungin and voriconazole were not significantly altered by co-administration [see Drug Interactions (7.2)].
Tacrolimus (CYP3A4 substrate)In a study in which 35 healthy subjects received a single oral dose of 5 mg tacrolimus (on Day 1), 100 mg/day maintenance dose of anidulafungin following a 200 mg loading dose (on Days 4 to 12) and both in combination (on Day 13), the steady state Cmax and AUC of anidulafungin and tacrolimus were not significantly altered by co-administration [see Drug Interactions (7.3)].
Rifampin (potent CYP450 inducer)The pharmacokinetics of anidulafungin were examined in 27 patients that were co-administered anidulafungin and rifampin. The population pharmacokinetic analysis showed that when compared to data from patients that did not receive rifampin, the pharmacokinetics of anidulafungin were not significantly altered by co-administration with rifampin [see Drug Interactions (7.4)].
Amphotericin B liposome for injectionThe pharmacokinetics of anidulafungin were examined in 27 patients that were co-administered liposomal amphotericin B. The population pharmacokinetic analysis showed that when compared to data from patients that did not receive amphotericin B, the pharmacokinetics of anidulafungin were not significantly altered by co-administration with amphotericin B [see Drug Interactions (7.5)].
ResistanceEchinocandin resistance is due to point mutations within the genes (FKS1 and FKS2) encoding for subunits in the glucan synthase enzyme complex. There have been reports of Candida isolates with reduced susceptibility to anidulafungin, suggesting a potential for development of drug resistance. The clinical significance of this observation is not fully understood.
Antimicrobial Activity Anidulafungin has been shown to be active against most isolates of the following microorganisms both in vitro and in clinical infections:Candida albicans Candida glabrata Candida parapsilosis Candida tropicalisThe following in vitro data are available, but their clinical significance is unknown. At least 90 percent of the following fungi exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for anidulafungin against isolates of the following Candida species. However, the effectiveness of anidulafungin in treating clinical infections due to these fungi has not been established in adequate and well-controlled clinical trials:Candida guilliermondii Candida krusei
Susceptibility Testing Methods
Candida species:The interpretive standards for anidulafungin against Candida species are applicable only to tests performed using Clinical Laboratory and Standards Institute (CLSI) broth dilution reference method M27 for MIC read at 24 hours.1,2
Dilution Techniques:Quantitative methods are used to determine MICs. These MICs provide estimates of the susceptibility of Candida spp. to antifungal compound. The MICs should be determined using a standardized test method at 24 hours1, 2 (broth microdilution). The MIC values should be interpreted according to the criteria provided in Table 7.Table 7: Susceptibility Interpretive CriteriaA report of Susceptible (S) indicates that the antimicrobial drug is likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentration usually achievable at the site of infection. A report of Intermediate (I) indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drugs are physiologically concentrated or when a high dosage of drug is used. This category also provides a buffer zone that prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of Resistant (R) indicates that the antimicrobial is not likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentrations usually achievable at the infection site; other therapy should be selected. for Anidulafungin against Candida speciesPathogenBroth Microdilution MIC (mcg/mL) at 24 hoursSusceptible (S)Intermediate (I)Resistant (R)C. albicans≤0.250.5>1C. glabrata≤0.120.25≥0.5C. guilliermondii≤24≥8C. krusei≤0.250.5≥1C. parapsilosis≤24≥8C. tropicalis≤0.250.5≥1
Quality ControlStandardized susceptibility test procedures require the use of laboratory controls to monitor and ensure the accuracy and precision of supplies and reagents used in the assay, and the techniques of the individuals performing the tests.1,2 Standardized anidulafungin powder should provide the following range of MIC values noted in Table 8.NOTE: Quality control microorganisms are specific strains of organisms with intrinsic biological properties relating to resistance mechanisms and their genetic expression within fungi; the specific strains used for microbiological control are not clinically significant.Table 8: Acceptable Quality Control Ranges for Anidulafungin to be Used in Validation of Susceptibility Test ResultsQC StrainMicrodilution (MIC in mcg/mL) @ 24 hoursCandida parapsilosis ATCC 220190.25–2.0Candida krusei ATCC 62580.03–0.12
Unreconstituted vialsERAXIS unreconstituted vials should be stored in a refrigerator at 2°C – 8°C (36°F – 46°F). Do not freeze.Excursions for 96 hours up to 25ºC (77ºF) are permitted, and the vial can be returned to storage at 2°C – 8°C (36°F – 46°F).
Reconstituted solutionERAXIS reconstituted solution can be stored at up to 25°C (77°F) for up to 24 hours.Chemical and physical in-use stability of the reconstituted solution has been demonstrated for 24 hours at 25ºC (77ºF).From a microbiological point of view, following good aseptic practices, the reconstituted solution can be utilized for up to 24 hours when stored at 25ºC.
Infusion SolutionERAXIS infusion solution can be stored at temperatures up to 25°C (77°F) for up to 48 hours or stored frozen for at least 72 hours.Chemical and physical in-use stability of the infusion solution has been demonstrated for 48 hours at 25ºC (77ºF) or 72 hours when stored frozen.From a microbiological point of view, following good aseptic practices, the infusion solution can be utilized for up to 48 hours from preparation when stored at 25ºC.
2.2 Preparation For Administration
ERAXIS for Injection must be reconstituted with sterile Water for Injection and subsequently diluted only with 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP (normal saline). The compatibility of reconstituted ERAXIS with intravenous substances, additives, or medications other than 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP (normal saline) has not been established.
2.3 Dilution And Infusion
Aseptically transfer the contents of the reconstituted vial(s) into the appropriately sized IV bag (or bottle) containing either 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP (normal saline). See Table 1 for the dilution and infusion instructions for each dose.Table 1: Dilution Requirements for ERAXIS AdministrationDoseNumber ofVials RequiredTotal Reconstituted Volume RequiredInfusion Volume Either 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP (normal saline)Total Infusion Volume Infusion solution concentration is 0.77 mg/mLRate of InfusionMinimum Duration of Infusion50 mg1–50 mg15 mL50 mL65 mL1.4 mL/min or84 mL/ hour)45 min100 mg2–50 mg or 1–100 mg30 mL100 mL130 mL1.4 mL/min or84 mL/ hour)90 min200 mg4–50 mg or 2–100 mg60 mL200 mL260 mL1.4 mL/min or84 mL/ hour)180 minCaution: The rate of infusion should not exceed 1.1 mg/minute (equivalent to 1.4 mL/minute or 84 mL/hour when reconstituted and diluted per instructions) [see Warnings and Precautions (5.2)].The infusion solution may be stored for up to 48 hours at temperatures up to 25°C (77°F), or stored frozen for at least 72 hours prior to administration.Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If particulate matter or discoloration is identified, discard the solution.
3 Dosage Forms And Strengths
Lyophilized powder for injection: 50 mg per vialLyophilized powder for injection: 100 mg per vial
ERAXIS is contraindicated in persons with known hypersensitivity to anidulafungin, any component of ERAXIS, or other echinocandins.
5.1 Hepatic Effects
Laboratory abnormalities in liver function tests have been seen in healthy volunteers and patients treated with ERAXIS. In some patients with serious underlying medical conditions who were receiving multiple concomitant medications along with ERAXIS, clinically significant hepatic abnormalities have occurred. Isolated cases of significant hepatic dysfunction, hepatitis, or hepatic failure have been reported in patients; a causal relationship to ERAXIS has not been established. Patients who develop abnormal liver function tests during ERAXIS therapy should be monitored for evidence of worsening hepatic function and evaluated for risk/benefit of continuing ERAXIS therapy.
Anaphylactic reactions, including shock were reported with the use of ERAXIS. If these reactions occur, ERAXIS should be discontinued and appropriate treatment administered [see Adverse Reactions (6.5)]. Infusion-related adverse reactions, possibly histamine-mediated, have been reported with ERAXIS, including rash, urticaria, flushing, pruritus, bronchospasm, dyspnea, and hypotension [see Adverse Reactions (6)]. To reduce occurrence of these reactions, do not exceed a rate of ERAXIS infusion of 1.1 mg/minute [see Dosage and Administration (2.3)].
6 Adverse Reactions
- The most serious adverse reactions reported with ERAXIS are:Hepatic effects [see Warnings and Precautions (5.1)]Hypersensitivity [see Warnings and Precautions (5.2)]
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.The safety of ERAXIS for Injection was assessed in 929 individuals, including 257 healthy subjects and 672 patients in clinical trials of candidemia, other forms of Candida infections, and esophageal candidiasis. A total of 633 patients received ERAXIS at daily doses of either 50 mg or 100 mg. A total of 481 patients received ERAXIS for ≥14 days.
6.2 Candidemia/Other Candida Infections
Three studies (one comparative vs. fluconazole, two non-comparative) assessed the efficacy and safety of ERAXIS (100 mg) in patients with candidemia and other Candida infections.The data described below reflect exposure to ERAXIS and fluconazole in 127 and 118 patients, respectively, with candidemia and other forms of invasive candidiasis, in the randomized, comparative trial of the efficacy and safety of ERAXIS to that of fluconazole. In ERAXIS-treated patients, the age range was 16–89 years, the gender distribution was 51% male and 49% female, and the race distribution was 72% White, 18% Black/African American, 9% other races. Patients were randomized to receive once daily IV ERAXIS (200 mg loading dose followed by 100 mg maintenance dose) or IV fluconazole (800 mg loading dose followed by 400 mg maintenance dose). Treatment was administered for at least 14 and not more than 42 days.The number of patients with adverse reactions leading to discontinuation of study medication was 11.5% in the ERAXIS arm and 21.6% in the fluconazole arm. The most common adverse reactions leading to study drug discontinuation were multi-organ failure and systemic Candida infection in the ERAXIS arm.Table 2 presents adverse reactions that were reported in ≥5% of subjects receiving ERAXIS or fluconazole therapy in this trial.Table 2: Adverse Reactions Reported in ≥5% of Subjects Receiving ERAXIS or Fluconazole Therapy for Candidemia/other Candida InfectionsA patient who experienced multiple reactions with a System Organ Class (SOC) or preferred term was counted one time for that class, one time for the preferred term and one time for "subjects with at least one adverse reaction", This trial was not designed to support comparative claims for ERAXIS for the adverse reactions reported in this table.ERAXIS100 mgN=131Fluconazole400 mgN=125N (%)N (%)Subjects with a least one adverse reaction130 (99)122 (98)Infections and infestations82 (63)80 (64) Bacteremia23 (18)23 (18) Urinary tract infection19 (15)22 (18) Sepsis9 (7)11 (9) Pneumonia8 (6)19 (15)Gastrointestinal disorders81 (62)72 (58) Nausea32 (24)15 (12) Diarrhea24 (18)23 (18) Vomiting23 (18)12 (10) Constipation11 (8)14 (11) Abdominal pain8 (6)16 (13)General disorders and administration site conditions70 (53)76 (61) Pyrexia23 (18)23 (18) Edema peripheral14 (11)16 (13) Chest pain7 (5)6 (5)Respiratory, thoracic, and mediastinal disorders67 (51)55 (44) Dyspnea15 (12)4 (3) Pleural effusion13 (10)11 (9) Cough9 (7)7 (6) Respiratory distress8 (6)2 (2)Investigations66 (50)46 (37) Blood alkaline phosphatase increased15 (12)14 (11) White blood cell increased11 (8)3 (2) Hepatic enzyme increased7 (5)14 (11) Blood creatinine increased7 (5)1 (1)Metabolism and nutrition disorders61 (47)61 (49) Hypokalemia33 (25)24 (19) Hypomagnesemia15 (12)14 (11) Hypoglycemia9 (7)10 (8) Hyperkalemia8 (6)14 (11) Hyperglycemia8 (6)8 (6) Dehydration8 (6)2 (2)Vascular disorders50 (38)41 (33) Hypotension19 (15)18 (14) Hypertension15 (12)5 (4) Deep vein thrombosis13 (10)9 (7)Psychiatric disorders48(37)45 (36) Insomnia20 (15)12 (10) Confusional state10 (8)10 (8) Depression8 (6)5 (4)Blood and lymphatic system disorders34 (26)36 (29) Anemia12 (9)20 (16) Thrombocythemia8 (6)1 (1) Leukocytosis7 (5)6 (5)Skin and subcutaneous tissue disorders30 (23)32 (26) Decubitus ulcer7 (5)10 (8)Nervous system disorders27 (21)31 (25) Headache11 (8)10 (8)Musculoskeletal and connective tissue disorders27 (21)25 (20) Back pain7 (5)13 (10)
6.3 Esophageal Candidiasis
The data described below reflect exposure to ERAXIS and fluconazole in 300 and 301 patients, respectively, with esophageal candidiasis in a randomized trial comparing the efficacy and safety of ERAXIS to that of oral fluconazole. In ERAXIS-treated patients, the age range was 18–68 years, the gender distribution was 42% male and 58% female and the race distribution was 15% White, 49% Black/African American, 15% Asian, 0.3 % Hispanic, 21% other races. Patients were randomized to receive IV ERAXIS (100 mg on day 1, followed by 50 mg per day) or oral fluconazole (200 mg on day 1, followed by 100 mg per day) for 7 days beyond resolution of symptoms (range, 14–21 days).Twenty eight (9%) patients in the ERAXIS arm and 36 (12%) patients in the fluconazole arm had adverse reactions leading to discontinuation of study medication. The most common adverse reactions leading to study drug discontinuation were maculopapular rash for the ERAXIS arm. The most common adverse reactions leading to discontinuation were rash and increased AST for the fluconazole arm.Table 3 presents adverse reactions that were reported in ≥5% of subjects receiving ERAXIS therapy.Table 3 Adverse Reactions Reported in ≥5% of Subjects Receiving ERAXIS or Fluconazole Therapy for Esophageal CandidiasisA patient who experienced multiple reactions with a System Organ Class (SOC) or preferred term was counted one time for that class, one time for the preferred term and one time for "subjects with at least one adverse reaction", This trial was not designed to support comparative claims for ERAXIS for the adverse reactions reported in this table.ERAXIS50 mgN=300Fluconazole100 mgN=301N (%)N (%)Subjects with a least one adverse reactions239 (80)227 (75)Infections and infestations115 (38)99 (33) Oral candidiasis15 (5)10 (3)Gastrointestinal disorders106 (35)113 (38) Diarrhea27(9)26(9) Vomiting27(7)30(10) Nausea20(7)23(8) Dyspepsia20(7)21(7)Blood and lymphatic system disorders55 (18)50 (17) Anemia25 (8)22 (7)Metabolism and nutrition disorders50 (17)46 (15) Hypokalemia14 (5)17 (6)General disorders and administration site condition49 (16)54 (18) Pyrexia27(9)28(9)Nervous system disorders39 (13)36 (12) Headache25 (8)20 (7)
6.4 Less Common Adverse Reactions
The following selected adverse reactions occurred in <2% of patients:Blood and Lymphatic: coagulopathy, thrombocytopeniaCardiac: atrial fibrillation, bundle branch block (right), sinus arrhythmia, ventricular extrasystolesEye: eye pain, vision blurred, visual disturbanceGeneral and Administration Site: infusion related reaction, peripheral edema, rigorsHepatobiliary: abnormal liver function tests, cholestasis, hepatic necrosisInfections: clostridial infectionInvestigations: amylase increased, bilirubin increased, CPK increased, electrocardiogram QT prolonged, gamma-glutamyl transferase increased, lipase increased, potassium decreased, prothrombin time prolonged, urea increasedNervous System: convulsion, dizzinessRespiratory, Thoracic and Mediastinal: coughSkin and Subcutaneous Tissue: angioneurotic edema, erythema, pruritus, sweating increased, urticariaVascular: flushing, hot flushes, thrombophlebitis superficial
6.5 Post-Marketing Experience
The following adverse reactions have been identified during post approval use of anidulafungin. 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.Immune: Anaphylactic shock, anaphylactic reaction, bronchospasm [see Warnings and Precautions (5.2)].
Administration of multiple doses of anidulafungin and cyclosporine to healthy subjects resulted in no significant alteration in the steady state pharmacokinetics of either drug. No dosage adjustment of cyclosporine or anidulafungin is needed when the two drugs are co-administered [see Clinical Pharmacology (12.3)].
Administration of multiple doses of anidulafungin and voriconazole to healthy subjects resulted in no significant alteration in the steady state pharmacokinetics of either drug. No dosage adjustment of voriconazole or anidulafungin is needed when the two drugs are co-administered [see Clinical Pharmacology (12.3)].
Administration of multiple doses of anidulafungin and a single dose of tacrolimus to healthy subjects resulted in no significant alteration in the steady state pharmacokinetics of either drug. No dosage adjustment of tacrolimus or anidulafungin is needed when the two drugs are co-administered [see Clinical Pharmacology (12.3)].
Administration of multiple doses of anidulafungin and rifampin to patients resulted in no significant alteration in the steady state pharmacokinetics of anidulafungin. No dosage adjustment of anidulafungin is needed when it is co-administered with rifampin [see Clinical Pharmacology (12.3)].
7.5 Amphotericin B Liposome For Injection
Administration of multiple doses of anidulafungin and liposomal amphotericin B to patients resulted in no significant alteration in the steady state pharmacokinetics of anidulafungin. No dosage adjustment of anidulafungin is needed when it is co-administered with liposomal amphotericin B [see Clinical Pharmacology (12.3)].
8.4 Pediatric Use
The safety and effectiveness of ERAXIS in patients ≤16 years old has not been established [see Clinical Pharmacology (12.4)].
8.5 Geriatric Use
Dosage adjustments are not required for geriatric patients [see Clinical Pharmacology (12.3)].Of the total number of subjects (N = 197) in the pivotal clinical studies of anidulafungin, 35% were 65 years and over, while 18% were 75 years and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.
8.6 Hepatic Insufficiency
No dosing adjustments are required for patients with any degree of hepatic insufficiency. Anidulafungin is not hepatically metabolized. Anidulafungin pharmacokinetics were examined in subjects with Child-Pugh class A, B or C hepatic insufficiency. Anidulafungin concentrations were not increased in subjects with any degree of hepatic insufficiency. Though a slight decrease in AUC was observed in patients with Child-Pugh C hepatic insufficiency, it was within the range of population estimates noted for healthy subjects [see Clinical Pharmacology (12.3)].
8.7 Renal Insufficiency
Dosage adjustments are not required for patients with any degree of renal insufficiency including those on hemodialysis. Anidulafungin has negligible (<1%) renal clearance. In a clinical study of subjects with mild, moderate, severe or end stage (dialysis-dependent) renal insufficiency, anidulafungin pharmacokinetics were similar to those observed in subjects with normal renal function. Anidulafungin is not dialyzable and may be administered without regard to the timing of hemodialysis [see Clinical Pharmacology (12.3)].
During clinical trials a single 400 mg dose of ERAXIS was inadvertently administered as a loading dose. No clinical adverse events were reported. In a study of 10 healthy subjects administered a loading dose of 260 mg followed by 130 mg daily, ERAXIS was generally well tolerated; 3 of the 10 subjects experienced transient, asymptomatic transaminase elevations (≤3 x ULN) [see Warnings and Precautions (5.1)].Anidulafungin is not dialyzable.The maximum non-lethal dose of anidulafungin in rats was 50 mg/kg, a dose which is equivalent to 10 times the recommended daily dose for esophageal candidiasis (50 mg/day) or equivalent to 5 times the recommended daily dose for candidemia and other Candida infections (100 mg/day), based on relative body surface area comparisons.
ERAXIS for Injection is a sterile, lyophilized product for intravenous (IV) infusion that contains anidulafungin. ERAXIS (anidulafungin) is a semi-synthetic lipopeptide synthesized from a fermentation product of Aspergillus nidulans. Anidulafungin is an echinocandin, a class of antifungal drugs that inhibits the synthesis of 1,3-β-D-glucan, an essential component of fungal cell walls.ERAXIS (anidulafungin) is 1-[(4R,5R)-4,5-dihydroxy-N2-[[4"-(pentyloxy)[1,1':4',1"-terphenyl]-4-yl]carbonyl]-L-ornithine]echinocandin B. Anidulafungin is a white to off-white powder that is practically insoluble in water and slightly soluble in ethanol. In addition to the active ingredient, anidulafungin, ERAXIS for Injection contains the following inactive ingredients:50 mg/vial - fructose (50 mg), mannitol (250 mg), polysorbate 80 (125 mg), tartaric acid (5.6 mg), and sodium hydroxide and/or hydrochloric acid for pH adjustment.100 mg/vial - fructose (100 mg), mannitol (500 mg), polysorbate 80 (250 mg), tartaric acid (11.2 mg), and sodium hydroxide and/or hydrochloric acid for pH adjustment.The empirical formula of anidulafungin is C58H73N7O17 and the formula weight is 1140.3.The structural formula is:Prior to administration, ERAXIS for Injection requires reconstitution with sterile Water for Injection and subsequent dilution with either 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP (normal saline).DO NOT dilute with other solutions or co-infuse with other medications or electrolytes [see Dosage and Administration (2)].
12.1 Mechanism Of Action
Anidulafungin is an anti-fungal drug [see Microbiology (12.4)].
Drug InteractionsIn vitro studies showed that anidulafungin is not metabolized by human cytochrome P450 or by isolated human hepatocytes, and does not significantly inhibit the activities of human CYP isoforms (1A2, 2B6, 2C8, 2C9, 2C19, 2D6 and 3A) in clinically relevant concentrations. No clinically relevant drug-drug interactions were observed with drugs likely to be co-administered with anidulafungin.
Mechanism Of Action
Mechanism of ActionAnidulafungin is a semi-synthetic echinocandin with antifungal activity. Anidulafungin inhibits glucan synthase, an enzyme present in fungal, but not mammalian cells. This results in inhibition of the formation of 1,3-β-D-glucan, an essential component of the fungal cell wall.
13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility
Long-term animal carcinogenicity studies of anidulafungin have not been conducted.Anidulafungin was not genotoxic in the following in vitro studies: bacterial reverse mutation assays, a chromosome aberration assay with Chinese hamster ovary cells, and a forward gene mutation assay with mouse lymphoma cells. Anidulafungin was not genotoxic in mice using the in vivo micronucleus assay.Anidulafungin produced no adverse effects on fertility in male or female rats at intravenous doses of 20 mg/kg/day (equivalent to 2 times the proposed therapeutic maintenance dose of 100 mg/day on the basis of relative body surface area).
13.2 Animal Toxicology And/Or Pharmacology
In 3 month studies, liver toxicity, including single cell hepatocellular necrosis, hepatocellular hypertrophy and increased liver weights were observed in monkeys and rats at doses equivalent to 5–6 times human exposure. For both species, hepatocellular hypertrophy was still noted one month after the end of dosing.
14.1 Candidemia And Other Candida Infections (Intra-Abdominal Abscess And Peritonitis)
The safety and efficacy of ERAXIS were evaluated in a Phase 3, randomized, double-blind study of patients with candidemia and/or other forms of invasive candidiasis. Patients were randomized to receive once daily IV ERAXIS (200 mg loading dose followed by 100 mg maintenance dose) or IV fluconazole (800 mg loading dose followed by 400 mg maintenance dose). Patients were stratified by APACHE II score (≤20 and >20) and the presence or absence of neutropenia. Patients with Candida endocarditis, osteomyelitis or meningitis, or those with infection due to C. krusei, were excluded from the study. Treatment was administered for at least 14 and not more than 42 days. Patients in both study arms were permitted to switch to oral fluconazole after at least 10 days of intravenous therapy, provided that they were able to tolerate oral medication, were afebrile for at least 24 hours, and the last blood cultures were negative for Candida species.Patients who received at least one dose of study medication and who had a positive culture for Candida species from a normally sterile site before entry into the study (modified intent-to-treat [MITT] population) were included in the analysis of global response at the end of IV therapy. A successful global response required clinical cure or improvement (significant, but incomplete resolution of signs and symptoms of the Candida infection and no additional antifungal treatment), and documented or presumed microbiological eradication. Patients with an indeterminate outcome were analyzed as failures in this population.Two hundred and fifty-six patients in the intent-to-treat (ITT) population were randomized and received at least one dose of study medication. In ERAXIS-treated patients, the age range was 16–89 years, the gender distribution was 50% male and 50% female, and the race distribution was 71% White, 20% Black/African American, 7% Hispanic, 2% other races. The median duration of IV therapy was 14 and 11 days in the ERAXIS and fluconazole arms, respectively. For those who received oral fluconazole, the median duration of oral therapy was 7 days for the ERAXIS arm and 5 days for the fluconazole arm.Patient disposition is presented in Table 9.Table 9: Patient Disposition and Reasons for Discontinuation in Candidemia and other Candida Infections StudyERAXISFluconazolen (%)n (%)Treated patients131125Patients completing study through 6 week follow-up94 (72)80 (64)DISCONTINUATIONS FROM STUDY MEDICATIONTotal discontinued from study medication34 (26)48 (38) Discontinued due to adverse events12 (9)21 (17) Discontinued due to lack of efficacy11 (8)16 (13)Two hundred and forty-five patients (127 ERAXIS, 118 fluconazole) met the criteria for inclusion in the MITT population. Of these, 219 patients (116 ERAXIS, 103 fluconazole) had candidemia only. Risk factors for candidemia among patients in both treatment arms in this study were: presence of a central venous catheter (78%), receipt of broad-spectrum antibiotics (69%), recent surgery (42%), recent hyperalimentation (25%), and underlying malignancy (22%). The most frequent species isolated at baseline was C. albicans (62%), followed by C. glabrata (20%), C. parapsilosis (12%) and C. tropicalis (11%). The majority (97%) of patients were non-neutropenic (ANC >500) and 81% had APACHE II scores less than or equal to 20.Global success rates in patients with candidemia and other Candida infections are summarized in Table 10.Table 10: Efficacy Analysis: Global Success in patients with Candidemia and other Candida Infections (MITT Population)Time-pointERAXIS(N=127)n (%)Fluconazole(N=118)n (%)Treatment DifferenceCalculated as ERAXIS minus fluconazole, % (95% C.I.)End of IV Therapy96 (75.6)71 (60.2)15.4(3.9, 27.0)End of All Therapy33 patients in each study arm (26% ERAXIS and 29% fluconazole-treated) switched to oral fluconazole after the end of IV therapy.94 (74.0)67 (56.8)17.2(2.9, 31.6)98.3% confidence intervals, adjusted post hoc for multiple comparisons of secondary time points2 Week Follow-up82 (64.6)58 (49.2)15.4(0.4, 30.4)6 Week Follow-up71 (55.9)52 (44.1)11.8(-3.4, 27.0)Table 11 presents global response by patients with candidemia or multiple sites of Candida infection and mortality data for the MITT population.Table 11: Global Response and Mortality in Candidemia and other Candida InfectionsERAXISFluconazoleBetween group difference Calculated as ERAXIS minus fluconazole(95% CI)No. of MITT patients127118Global Success (MITT) At End Of IV TherapyCandidemia88/116 (75.9%)63/103 (61.2%)14.7 (2.5, 26.9)Neutropenic1/22/4-Non neutropenic87/114 (76.3%)61/99 (61.6%)-Multiple sites Peritoneal fluid/ intra-abdominal abscess4/65/6-Blood/ peritoneum (intra-abdominal abscess)2/20/2-Blood /bile-1/1-Blood/renal-1/1-Pancreas-0/3-Pelvic abscess-1/2-Pleural fluid1/1--Blood/ pleural fluid0/1--Blood/left thigh lesion biopsy1/1--Total8/11 (72.7%)8/15 (53.3%)-MortalityOverall study mortality29/127 (22.8 %)37/118 (31.4%)-Mortality during study therapy10/127 (7.9%)17/118 (14.4%)-Mortality attributed to Candida2/127 (1.6%)5/118 (4.2%)-
14.2 Esophageal Candidiasis
ERAXIS was evaluated in a double-blind, double-dummy, randomized Phase 3 study. Three hundred patients received ERAXIS (100 mg loading dose IV on Day 1 followed by 50 mg/day IV) and 301 received oral fluconazole (200 mg loading dose on Day 1 followed by 100 mg/day). Treatment duration was 7 days beyond resolution of symptoms for a minimum of 14 and a maximum of 21 days.Of the 442 patients with culture confirmed esophageal candidiasis, most patients (91%) had C. albicans isolated at the baseline.Treatment groups were similar in demographic and other baseline characteristics. In ERAXIS-treated patients, the age range was 16–69 years, the gender distribution was 42% male and 58% female, and the race distribution was 15% White, 49% Black/African American, 15% Asian, 0.3 % Hispanic, 21% other races.In this study, of 280 patients tested, 237 (84.6%) tested HIV positive. In both groups the median time to resolution of symptoms was 5 days and the median duration of therapy was 14 days.Efficacy was assessed by endoscopic outcome at end of therapy (EOT). Patients were considered clinically evaluable if they received at least 10 days of therapy, had an EOT assessment with a clinical outcome other than 'indeterminate', had an endoscopy at EOT, and did not have any protocol violations prior to the EOT visit that would affect an assessment of efficacy.An endoscopic success, defined as cure (endoscopic grade of 0 on a 4-point severity scale) or improvement (decrease of one or more grades from baseline), was seen in 225/231 (97.4%) ERAXIS-treated patients and 233/236 (98.7%) fluconazole-treated patients (Table 12). The majority of these patients were endoscopic cures (grade=0). Two weeks after completing therapy, the ERAXIS group had significantly more endoscopically-documented relapses than the fluconazole group, 120/225 (53.3%) vs. 45/233 (19.3%), respectively (Table 12).Table 12: Endoscopy Results in Patients with Esophageal Candidiasis (Clinically Evaluable Population)Endoscopic Response at End of TherapyResponseERAXISN=231FluconazoleN=236Treatment DifferenceCalculated as ERAXIS minus fluconazole95% CIEndoscopic Success, n (%)225 (97.4)233 (98.7)-1.3%-3.8%, 1.2%Cure 204 (88.3)221 (93.6)Improvement 21 (9.1)12 (5.1)Failure, n (%)6 (2.6)3 (1.3)Endoscopic Relapse Rates at Follow-Up, 2 Weeks Post-TreatmentERAXISFluconazoleTreatment Difference95% CI Endoscopic Relapse, n/N (%)120/225 (53.3%)45/233 (19.3%)34.0%25.8%, 42.3%Clinical success (cure or improvement in clinical symptoms including odynophagia/dysphagia and retrosternal pain) occurred in 229/231 (99.1%) of the ERAXIS-treated patients and 235/236 (99.6%) of the fluconazole-treated patients at the end of therapy. For patients with C. albicans, microbiological success occurred in 142/162 (87.7%) of the ERAXIS-treated group and 157/166 (94.6%) of the fluconazole-treated group at the end of therapy. For patients with Candida species other than C. albicans, success occurred in 10/12 (83.3%) of the ERAXIS-treated group and 14/16 (87.5%) of the fluconazole-treated group.
- Clinical and Laboratory Standards Institute (CLSI). Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved Standard – Third Edition. CLSI Document M27-A3 (2008). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087, USA.Clinical and Laboratory Standards Institute (CLSI). Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Fourth Informational Supplement. CLSI document M27-S4 (2012). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.
16.1 How Supplied
ERAXIS (anidulafungin) for Injection is supplied in a single-use vial of sterile, lyophilized, preservative-free, powder. ERAXIS (anidulafungin) is available in the following packaging configuration: Single-Use Vial of ERAXIS 50 mgNDC 0049-0114-28 One - 50 mg vialSingle-Use Vial of ERAXIS 100 mgNDC 0049-0116-28 One - 100 mg vial
17.1 Hepatic Effects
Inform patients about the risk of developing abnormal liver function tests and/or hepatic dysfunction. Advise the patient that liver function tests may be monitored during treatment.
Inform the patient that anaphylactic reactions, including shock were reported with ERAXIS. Inform the patient if these reactions occur, ERAXIS may be discontinued and appropriate treatment administered.Inform the patient that ERAXIS is also known to cause infusion-related adverse reactions, possibly histamine-mediated. Inform the patient to report symptoms including rash, urticaria, flushing, pruritus, dyspnea, and hypotension to their healthcare provider.
17.3 Pregnant Women And Breastfeeding Mothers
Inform patients that ERAXIS has not been studied in pregnant women or breastfeeding mothers so the effects of ERAXIS on pregnant women or breastfed infants are not known. Instruct patients to tell their healthcare provider if they are pregnant, become pregnant, or are thinking about becoming pregnant. Instruct patients to tell their healthcare provider if they plan to breastfeed their infant.This product's label may have been updated. For current full prescribing information, please visit www.pfizer.com.
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