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  5. Label Information: Posaconazole

FDA Label for Posaconazole

View Indications, Usage & Precautions

Table of Contents

    1. 1.1 PROPHYLAXIS OF INVASIVE ASPERGILLUS AND CANDIDA INFECTIONS
    2. 2.1 IMPORTANT ADMINISTRATION INSTRUCTIONS FOR POSACONAZOLE DELAYED-RELEASE TABLETS
    3. OTHER
    4. 2.5 NON-INTERCHANGEABILITY BETWEEN POSACONAZOLE DELAYED-RELEASE TABLETS AND POSACONAZOLE ORAL SUSPENSION
    5. 2.6 DOSAGE ADJUSTMENTS IN PATIENTS WITH RENAL IMPAIRMENT
    6. 3 DOSAGE FORMS AND STRENGTHS
    7. 4.1 HYPERSENSITIVITY
    8. 4.2 USE WITH SIROLIMUS
    9. 4.3 QT PROLONGATION WITH CONCOMITANT USE WITH CYP3A4 SUBSTRATES
    10. 4.4 HMG-COA REDUCTASE INHIBITORS PRIMARILY METABOLIZED THROUGH CYP3A4
    11. 4.5 USE WITH ERGOT ALKALOIDS
    12. 5.1 CALCINEURIN-INHIBITOR DRUG INTERACTIONS
    13. 5.2 ARRHYTHMIAS AND QT PROLONGATION
    14. 5.3 ELECTROLYTE DISTURBANCES
    15. 5.4 HEPATIC TOXICITY
    16. 5.5 RENAL IMPAIRMENT
    17. 5.6 USE WITH MIDAZOLAM
    18. 5.7 VINCRISTINE TOXICITY
    19. 6.1 CLINICAL TRIALS EXPERIENCE
    20. 6.2 POSTMARKETING EXPERIENCE
    21. 7 DRUG INTERACTIONS
    22. 7.2 CYP3A4 SUBSTRATES
    23. 7.3 HMG-COA REDUCTASE INHIBITORS (STATINS) PRIMARILY METABOLIZED THROUGH CYP3A4
    24. 7.4 ERGOT ALKALOIDS
    25. 7.5 BENZODIAZEPINES METABOLIZED BY CYP3A4
    26. 7.7 RIFABUTIN
    27. 7.8 PHENYTOIN
    28. 7.10 VINCA ALKALOIDS
    29. 7.11 CALCIUM CHANNEL BLOCKERS METABOLIZED BY CYP3A4
    30. 7.12 DIGOXIN
    31. 7.14 GLIPIZIDE
    32. 8.1 PREGNANCY
    33. 8.2 LACTATION
    34. 8.4 PEDIATRIC USE
    35. 8.5 GERIATRIC USE
    36. 8.6 RENAL IMPAIRMENT
    37. 8.7 HEPATIC IMPAIRMENT
    38. 8.8 GENDER
    39. 8.9 RACE
    40. 8.10 WEIGHT
    41. 10 OVERDOSAGE
    42. 11 DESCRIPTION
    43. 12.1 MECHANISM OF ACTION
    44. 13.1 CARCINOGENESIS, MUTAGENESIS, IMPAIRMENT OF FERTILITY
    45. 13.2 ANIMAL TOXICOLOGY AND/OR PHARMACOLOGY
    46. 14.1 PROPHYLAXIS OF ASPERGILLUS AND CANDIDA INFECTIONS WITH POSACONAZOLE ORAL SUSPENSION
    47. 17 PATIENT COUNSELING INFORMATION
    48. 17.2 DRUG INTERACTIONS
    49. 17.3 SERIOUS AND POTENTIALLY SERIOUS ADVERSE REACTIONS
    50. SPL PATIENT PACKAGE INSERT
    51. PRINCIPAL DISPLAY PANEL - 60 TABLET BOTTLE LABEL

Posaconazole Product Label

The following document was submitted to the FDA by the labeler of this product Northstar Rxllc. The document includes published materials associated whith this product with the essential scientific information about this product as well as other prescribing information. Product labels may durg indications and usage, generic names, contraindications, active ingredients, strength dosage, routes of administration, appearance, warnings, inactive ingredients, etc.

1.1 Prophylaxis Of Invasive Aspergillus And Candida Infections



Posaconazole delayed-release tablets are indicated for prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with graft-versus-host disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy.
Posaconazole delayed-release tablets 100 mg are indicated in patients 13 years of age and older.


2.1 Important Administration Instructions For Posaconazole Delayed-Release Tablets



Posaconazole delayed-release tablets and oral suspension are not to be used interchangeably due to the
differences in the dosing of each formulation [see Dosage and Administration (2.3), (2.5)].


Other



2.5 Non-Interchangeability Between Posaconazole Delayed-Release Tablets And Posaconazole Oral Suspension



Posaconazole delayed-release tablets and oral suspension are not to be used interchangeably due to the differences in the dosing of each formulation. Therefore, follow the specific dosage recommendations for each of the formulations [see Dosage and Administration (2.3)].


2.6 Dosage Adjustments In Patients With Renal Impairment



The pharmacokinetics of posaconazole delayed-release tablets is not significantly affected by renal impairment. Therefore, no adjustment is necessary for oral dosing in patients with mild to severe renal impairment.


3 Dosage Forms And Strengths



Posaconazole delayed-release tablets are available as yellow, coated, oblong tablets, debossed with "100" on one side containing 100 mg of posaconazole.


4.1 Hypersensitivity



Posaconazole is contraindicated in persons with known hypersensitivity to posaconazole or other azole antifungal agents.


4.2 Use With Sirolimus



Posaconazole is contraindicated with sirolimus. Concomitant administration of posaconazole with sirolimus increases the sirolimus blood concentrations by approximately 9-fold and can result in sirolimus toxicity [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)].


4.3 Qt Prolongation With Concomitant Use With Cyp3a4 Substrates



Posaconazole is contraindicated with CYP3A4 substrates that prolong the QT interval. Concomitant administration of posaconazole with the CYP3A4 substrates, pimozide and quinidine may result in increased plasma concentrations of these drugs, leading to QTc prolongation and cases of torsades de pointes [see Warnings and Precautions (5.2) and Drug Interactions (7.2)].


4.4 Hmg-Coa Reductase Inhibitors Primarily Metabolized Through Cyp3a4



Coadministration with the HMG-CoA reductase inhibitors that are primarily metabolized through CYP3A4 (e.g., atorvastatin, lovastatin, and simvastatin) is contraindicated since increased plasma concentration of these drugs can lead to rhabdomyolysis [see Drug Interactions (7.3) and Clinical Pharmacology (12.3)].


4.5 Use With Ergot Alkaloids



Posaconazole may increase the plasma concentrations of ergot alkaloids (ergotamine and dihydroergotamine) which may lead to ergotism [see Drug Interactions (7.4)].


5.1 Calcineurin-Inhibitor Drug Interactions



Concomitant administration of posaconazole with cyclosporine or tacrolimus increases the whole blood trough concentrations of these calcineurin-inhibitors [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)]. Nephrotoxicity and leukoencephalopathy (including deaths) have been reported in clinical efficacy studies in patients with elevated cyclosporine or tacrolimus concentrations. Frequent monitoring of tacrolimus or cyclosporine whole blood trough concentrations should be performed during and at discontinuation of posaconazole treatment and the tacrolimus or cyclosporine dose adjusted accordingly.


5.2 Arrhythmias And Qt Prolongation



Some azoles, including posaconazole, have been associated with prolongation of the QT interval on the electrocardiogram. In addition, cases of torsades de pointes have been reported in patients taking posaconazole.
Results from a multiple time-matched ECG analysis in healthy volunteers did not show any increase in the mean of the QTc interval. Multiple, time-matched ECGs collected over a 12-hour period were recorded at baseline and steady-state from 173 healthy male and female volunteers (18 to 85 years of age) administered posaconazole oral suspension 400 mg BID with a high-fat meal. In this pooled analysis, the mean QTc (Fridericia) interval change from baseline was –5 msec following administration of the recommended clinical dose. A decrease in the QTc(F) interval (–3 msec) was also observed in a small number of subjects (n=16) administered placebo. The placebo-adjusted mean maximum QTc(F) interval change from baseline was <0 msec (–8 msec). No healthy subject administered posaconazole had a
QTc(F) interval ≥500 msec or an increase ≥60 msec in their QTc(F) interval from baseline.
Posaconazole should be administered with caution to patients with potentially proarrhythmic conditions. Do not administer with drugs that are known to prolong the QTc interval and are metabolized through CYP3A4 [see Contraindications (4.3) and Drug Interactions (7.2)]. 


5.3 Electrolyte Disturbances



Electrolyte disturbances, especially those involving potassium, magnesium or calcium levels, should be monitored and corrected as necessary before and during posaconazole therapy.


5.4 Hepatic Toxicity



Hepatic reactions (e.g., mild to moderate elevations in alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin, and/or clinical hepatitis) have been reported in clinical trials. The elevations in liver function tests were generally reversible on discontinuation of therapy, and in some instances these tests normalized without drug interruption. Cases of more severe hepatic reactions including cholestasis or hepatic failure including deaths have been reported in patients with serious underlying medical conditions (e.g., hematologic malignancy) during treatment with posaconazole. These severe hepatic reactions were seen primarily in subjects receiving the posaconazole oral suspension 800 mg daily (400 mg BID or 200 mg QID) in clinical trials.
Liver function tests should be evaluated at the start of and during the course of posaconazole therapy. Patients who develop abnormal liver function tests during posaconazole therapy should be monitored for the development of more severe hepatic injury. Patient management should include laboratory evaluation of hepatic function (particularly liver function tests and bilirubin). Discontinuation of posaconazole must be considered if clinical signs and symptoms consistent with liver disease develop that may be attributable to posaconazole.


5.5 Renal Impairment



Due to the variability in exposure with posaconazole delayed-release tablets, patients with severe renal impairment should be monitored closely for breakthrough fungal infections [see Dosage and Administration (2.6) and Use in Specific Populations (8.6)].


5.6 Use With Midazolam



Concomitant administration of posaconazole with midazolam increases the midazolam plasma concentrations by approximately 5-fold. Increased plasma midazolam concentrations could potentiate and prolong hypnotic and sedative effects. Patients must be monitored closely for adverse effects associated with high plasma concentrations of midazolam and benzodiazepine receptor antagonists must be available to reverse these effects [see Drug Interactions (7.5) and Clinical Pharmacology (12.3)].


5.7 Vincristine Toxicity



Concomitant administration of azole antifungals, including posaconazole, with vincristine has been associated with neurotoxicity and other serious adverse reactions, including seizures, peripheral neuropathy, syndrome of inappropriate antidiuretic hormone secretion, and paralytic ileus. Reserve azole antifungals, including posaconazole, for patients receiving a vinca alkaloid, including vincristine, who have no alternative antifungal treatment options [see Drug Interactions (7.10)].


6.1 Clinical Trials Experience



Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of posaconazole cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In clinical trials, the type of adverse reactions reported for posaconazole injection and posaconazole delayed-release tablets were generally similar to that reported in trials of posaconazole oral suspension.


6.2 Postmarketing Experience



The following adverse reaction has been identified during the post-approval use of posaconazole. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency.

Endocrine Disorders: Pseudoaldosteronism 


7 Drug Interactions



Posaconazole is primarily metabolized via UDP glucuronosyltransferase and is a substrate of p­ glycoprotein (P-gp) efflux. Therefore, inhibitors or inducers of these clearance pathways may affect posaconazole plasma concentrations. Coadministration of drugs that can decrease the plasma concentrations of posaconazole should generally be avoided unless the benefit outweighs the risk. If such drugs are necessary, patients should be monitored closely for breakthrough fungal infections.
Posaconazole is also a strong inhibitor of CYP3A4. Therefore, plasma concentrations of drugs predominantly metabolized by CYP3A4 may be increased by posaconazole [see Clinical Pharmacology (12.3)].
The following information was derived from data with posaconazole oral suspension or early tablet formulation.


7.2 Cyp3a4 Substrates



Concomitant administration of posaconazole with CYP3A4 substrates such as pimozide and quinidine may result in increased plasma concentrations of these drugs, leading to QTc prolongation and cases of torsades de pointes. Therefore, posaconazole is contraindicated with these drugs [see Contraindications (4.3) and Warnings and Precautions (5.2)].


7.3 Hmg-Coa Reductase Inhibitors (Statins) Primarily Metabolized Through Cyp3a4



Concomitant administration of posaconazole with simvastatin increases the simvastatin plasma concentrations by approximately 10-fold. Therefore, posaconazole is contraindicated with HMG-CoA reductase inhibitors primarily metabolized through CYP3A4 [see Contraindications (4.4) and Clinical Pharmacology (12.3)].


7.4 Ergot Alkaloids



Most of the ergot alkaloids are substrates of CYP3A4. Posaconazole may increase the plasma concentrations of ergot alkaloids (ergotamine and dihydroergotamine) which may lead to ergotism. Therefore, posaconazole is contraindicated with ergot alkaloids [see Contraindications (4.5)].


7.5 Benzodiazepines Metabolized By Cyp3a4



Concomitant administration of posaconazole with midazolam increases the midazolam plasma concentrations by approximately 5-fold. Increased plasma midazolam concentrations could potentiate and prolong hypnotic and sedative effects. Concomitant use of posaconazole and other benzodiazepines metabolized by CYP3A4 (e.g., alprazolam, triazolam) could result in increased plasma concentrations of these benzodiazepines. Patients must be monitored closely for adverse effects associated with high plasma concentrations of benzodiazepines metabolized by CYP3A4 and benzodiazepine receptor antagonists must be available to reverse these effects [see Warnings and Precautions (5.6) and Clinical Pharmacology (12.3)].


7.7 Rifabutin



Rifabutin induces UDP-glucuronidase and decreases posaconazole plasma concentrations. Rifabutin is also metabolized by CYP3A4. Therefore, coadministration of rifabutin with posaconazole increases rifabutin plasma concentrations [see Clinical Pharmacology (12.3)]. Concomitant use of posaconazole and rifabutin should be avoided unless the benefit to the patient outweighs the risk. However, if concomitant administration is required, close monitoring for breakthrough fungal infections as well as frequent monitoring of full blood counts and adverse reactions due to increased rifabutin plasma concentrations (e.g., uveitis, leukopenia) are recommended.


7.8 Phenytoin



Phenytoin induces UDP-glucuronidase and decreases posaconazole plasma concentrations. Phenytoin is also metabolized by CYP3A4. Therefore, coadministration of phenytoin with posaconazole increases phenytoin plasma concentrations [see Clinical Pharmacology (12.3)]. Concomitant use of posaconazole and phenytoin should be avoided unless the benefit to the patient outweighs the risk. However, if concomitant administration is required, close monitoring for breakthrough fungal infections is recommended and frequent monitoring of phenytoin concentrations should be performed while coadministered with posaconazole and dose reduction of phenytoin should be considered.


7.10 Vinca Alkaloids



Most of the vinca alkaloids (e.g., vincristine and vinblastine) are substrates of CYP3A4. Concomitant administration of azole antifungals, including posaconazole, with vincristine has been associated with serious adverse reactions [see Warnings and Precautions (5.7)]. Posaconazole may increase the plasma concentrations of vinca alkaloids which may lead to neurotoxicity and other serious adverse reactions. Therefore, reserve azole antifungals, including posaconazole, for patients receiving a vinca alkaloid, including vincristine, who have no alternative antifungal treatment options.


7.11 Calcium Channel Blockers Metabolized By Cyp3a4



Posaconazole may increase the plasma concentrations of calcium channel blockers metabolized by CYP3A4 (e.g., verapamil, diltiazem, nifedipine, nicardipine, felodipine). Frequent monitoring for adverse reactions and toxicity related to calcium channel blockers is recommended during coadministration. Dose reduction of calcium channel blockers may be needed.


7.12 Digoxin



Increased plasma concentrations of digoxin have been reported in patients receiving digoxin and posaconazole. Therefore, monitoring of digoxin plasma concentrations is recommended during coadministration.


7.14 Glipizide



Although no dosage adjustment of glipizide is required, it is recommended to monitor glucose concentrations when posaconazole and glipizide are concomitantly used.


8.1 Pregnancy



Risk Summary
Based on findings from animal data, posaconazole l may cause fetal harm when administered to pregnant women. Available data for use of posaconazole in pregnant women are insufficient to establish a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. In animal reproduction studies, skeletal malformations (cranial malformations and missing ribs) and maternal toxicity (reduced food consumption and reduced body weight gain) were observed when posaconazole was dosed orally to pregnant rats during organogenesis at doses ≥1.4 times the 400 mg twice daily oral suspension regimen based on steady-state plasma concentrations of posaconazole in healthy volunteers. In pregnant rabbits dosed orally during organogenesis, increased resorptions, reduced litter size, and reduced body weight gain of females were seen at doses 5 times the exposure achieved with the 400 mg twice daily oral suspension regimen. Doses of ≥ 3 times the clinical exposure caused an increase in resorptions in these rabbits (see Data). Based on animal data, advise pregnant women of the potential risk to a fetus.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.
Data
Animal Data
Posaconazole resulted in maternal toxicity (reduced food consumption and reduced body weight gain) and skeletal malformations (cranial malformations and missing ribs) when given orally to pregnant rats during organogenesis (Gestational Days 6 through 15) at doses ≥27 mg/kg (≥1.4 times the 400 mg twice daily oral suspension regimen based on steady-state plasma concentrations of drug in healthy volunteers). The no-effect dose for malformations and maternal toxicity in rats was 9 mg/kg, which is 0.7 times the exposure achieved with the 400 mg twice daily oral suspension regimen. No malformations were seen in rabbits dosed during organogenesis (Gestational Days 7 through 19) at doses up to 80 mg/kg (5 times the exposure achieved with the 400 mg twice daily oral suspension regimen). In the rabbit, the no-effect dose was 20 mg/kg, while high doses of 40 mg/kg and 80 mg/kg (3 or 5. times the clinical exposure) caused an increase in resorptions. In rabbits dosed at 80 mg/kg, a reduction in body weight gain of females and a reduction in litter size were seen.


8.2 Lactation



Risk Summary
There are no data on the presence of posaconazole in human milk, the effects on the breastfed infant, or the effects on milk production. Posaconazole is excreted in the milk of lactating rats. When a drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for posaconazole and any potential adverse effects on the breastfed child from posaconazole or from the underlying maternal condition.


8.4 Pediatric Use



The safety and effectiveness of posaconazole delayed-release tablets has been established in the age groups 13 to 17 years of age. Use of posaconazole in these age groups is supported by evidence from adequate and well-controlled studies of posaconazole in adults. The safety and effectiveness of posaconazole in pediatric patients below the age of 13 years (birth to 12 years) have not been established.
A total of 12 patients 13 to 17 years of age received 600 mg/day (200 mg three times a day) of posaconazole oral suspension for prophylaxis of invasive fungal infections. The safety profile in these patients <18 years of age appears similar to the safety profile observed in adults. Based on pharmacokinetic data in 10 of these pediatric patients, the mean steady-state average posaconazole concentration (Cavg) was similar between these patients and adults (≥18 years of age). In a study of 136 neutropenic pediatric patients 11 months to less than 18 years treated with posaconazole oral suspension, the exposure target of steady-state posaconazole Cavg between 500 ng/mL and less than 2,500 ng/mL was attained in approximately 50% of patients instead of the pre-specified 90% of patients.


8.5 Geriatric Use



Of the 230 patients treated with posaconazole delayed-release tablets, 38 (17%) were greater than 65 years of age. The pharmacokinetics of posaconazole delayed-release tablets are comparable in young and elderly subjects. No overall differences in safety were observed between the geriatric patients and younger patients; therefore, no dosage adjustment is recommended for geriatric patients.
No overall differences in the pharmacokinetics and safety were observed between elderly and young subjects during clinical trials, but greater sensitivity of some older individuals cannot be ruled out.


8.6 Renal Impairment



Following single-dose administration of 400 mg of the oral suspension, there was no significant effect of mild (eGFR: 50 to 80 mL/min/1.73 m2, n=6) or moderate (eGFR: 20 to 49 mL/min/1.73 m2, n=6) renal impairment on posaconazole pharmacokinetics; therefore, no dose adjustment is required in patients with mild to moderate renal impairment. In subjects with severe renal impairment (eGFR: <20 mL/min/1.73 m2), the mean plasma exposure (AUC) was similar to that in patients with normal renal function (eGFR: >80 mL/min/1.73 m2); however, the range of the AUC estimates was highly variable (CV=96%) in these subjects with severe renal impairment as compared to that in the other renal impairment groups (CV<40%). Due to the variability in exposure, patients with severe renal impairment should be monitored closely for breakthrough fungal infections [see Dosage and Administration (2)]. Similar recommendations apply to posaconazole delayed-release tablets; however, a specific study has not been conducted with the delayed-release tablets.


8.7 Hepatic Impairment



After a single oral dose of posaconazole oral suspension 400 mg, the mean AUC was 43%, 27%, and 21% higher in subjects with mild (Child-Pugh Class A, N=6), moderate (Child-Pugh Class B, N=6), or severe (Child-Pugh Class C, N=6) hepatic impairment, respectively, compared to subjects with normal hepatic function (N=18). Compared to subjects with normal hepatic function, the mean Cmax was 1% higher, 40% higher, and 34% lower in subjects with mild, moderate, or severe hepatic impairment, respectively. The mean apparent oral clearance (CL/F) was reduced by 18%, 36%, and 28% in subjects with mild, moderate, or severe hepatic impairment, respectively, compared to subjects with normal hepatic function. The elimination half-life (t½) was 27 hours, 39 hours, 27 hours, and 43 hours in subjects with normal hepatic function and mild, moderate, or severe hepatic impairment, respectively.

It is recommended that no dose adjustment of posaconazole is needed in patients with mild to severe hepatic impairment (Child-Pugh Class A, B, or C) [see Dosage and Administration (2) and Warnings and Precautions (5.4)]. Similar recommendations apply to posaconazole delayed-release tablets; however, a specific study has not been conducted with the delayed-release tablets.


8.8 Gender



The pharmacokinetics of posaconazole are comparable in men and women. No adjustment in the dosage of posaconazole is necessary based on gender.


8.9 Race



The pharmacokinetic profile of posaconazole is not significantly affected by race. No adjustment in the dosage of posaconazole is necessary based on race.


8.10 Weight



Pharmacokinetic modeling suggests that patients weighing greater than 120 kg may have lower posaconazole plasma drug exposure. It is, therefore, suggested to closely monitor for breakthrough fungal infections.


10 Overdosage



There is no experience with overdosage of posaconazole delayed-release tablets.
During the clinical trials, some patients received posaconazole oral suspension up to 1,600 mg/day with no adverse reactions noted that were different from the lower doses. In addition, accidental overdose was noted in one patient who took 1,200 mg BID posaconazole oral suspension for 3 days. No related adverse reactions were noted by the investigator.
Posaconazole is not removed by hemodialysis.


11 Description



Posaconazole is an azole antifungal agent available as delayed-release tablet for oral administration.

Posaconazole is designated chemically as 4-[4-[4-[4-[[ (3R,5R)-5- (2,4-difluorophenyl)tetrahydro-5- (1H-1,2,4-triazol-1-ylmethyl)-3-furanyl]methoxy]phenyl]-1-piperazinyl]phenyl]-2-[(1S,2S)-1-ethyl-2-hydroxypropyl]-2,4-dihydro-3H-1,2,4-triazol-3-one with an empirical formula of C37H42F2N8O4 and a molecular weight of 700.8. The chemical structure is:

1 - 6369970a 9b52 4fac 990f b470aa3057aa 1

1 - 6369970a 9b52 4fac 990f b470aa3057aa 1

Posaconazole is a white powder with a low aqueous solubility. Posaconazole delayed-release tablet is a yellow, coated, oblong tablet, debossed with “100” on one side containing 100 mg of posaconazole. Each delayed-release tablet contains the inactive ingredients: hypromellose acetate succinate, microcrystalline cellulose, hydroxypropylcellulose, croscarmellose sodium, colloidal silicon dioxide, magnesium stearate, polyvinyl alcohol partially hydrolyzed, titanium dioxide, macrogol/polyethylene glycol 3350, talc and iron oxide yellow.


12.1 Mechanism Of Action



Posaconazole is an azole antifungal agent [see Clinical Pharmacology (12.4)].


13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility



No drug-related neoplasms were recorded in rats or mice treated with posaconazole for 2 years at doses higher than the clinical dose. In a 2-year carcinogenicity study, rats were given posaconazole orally at doses up to 20 mg/kg (females), or 30 mg/kg (males). These doses are equivalent to 3.9- or 3.5-times the exposure achieved with a 400-mg BID oral suspension regimen, respectively, based on steady-state AUC in healthy volunteers administered a high-fat meal (400-mg BID oral suspension regimen). In the mouse study, mice were treated at oral doses up to 60 mg/kg/day or 4.8-times the exposure achieved with a 400-mg BID oral suspension regimen.

Posaconazole was not genotoxic or clastogenic when evaluated in bacterial mutagenicity (Ames), a chromosome aberration study in human peripheral blood lymphocytes, a Chinese hamster ovary cell mutagenicity study, and a mouse bone marrow micronucleus study.

Posaconazole had no effect on fertility of male rats at a dose up to 180 mg/kg (1.7 × the 400-mg BID oral suspension regimen based on steady-state plasma concentrations in healthy volunteers) or female rats at a dose up to 45 mg/kg (2.2 × the 400-mg BID oral suspension regimen).


13.2 Animal Toxicology And/Or Pharmacology



In a nonclinical study using intravenous administration of posaconazole in very young dogs (dosed from 2 to 8 weeks of age), an increase in the incidence of brain ventricle enlargement was observed in treated animals as compared with concurrent control animals. No difference in the incidence of brain ventricle enlargement between control and treated animals was observed following the subsequent 5-month treatment-free period. There were no neurologic, behavioral or developmental abnormalities in the dogs with this finding, and a similar brain finding was not seen with oral posaconazole administration to juvenile dogs (4 days to 9 months of age).

The clinical significance of this finding is unknown; therefore, the use of posaconazole injection to patients under 18 years of age is not recommended.


14.1 Prophylaxis Of Aspergillus And Candida Infections With Posaconazole Oral Suspension



Two randomized, controlled studies were conducted using posaconazole as prophylaxis for the prevention of invasive fungal infections (IFIs) among patients at high risk due to severely compromised immune systems.

The first study (Oral Suspension Study 1) was a randomized, double-blind trial that compared posaconazole oral suspension (200 mg three times a day) with fluconazole capsules (400 mg once daily) as prophylaxis against invasive fungal infections in allogeneic hematopoietic stem cell transplant (HSCT) recipients with Graft versus Host Disease (GVHD). Efficacy of prophylaxis was evaluated using a composite endpoint of proven/probable IFIs, death, or treatment with systemic antifungal therapy (patients may have met more than one of these criteria). This assessed all patients while on study therapy plus 7 days and at 16 weeks post-randomization. The mean duration of therapy was comparable between the 2 treatment groups (80 days, posaconazole; 77 days, fluconazole). Table 24 contains the results from Oral Suspension Study 1.

Table 24: Results from Blinded Clinical Study in Prophylaxis of IFI in All Randomized Patients with Hematopoietic Stem Cell Transplant (HSCT) and Graft-vs.-Host Disease (GVHD): Oral Suspension Study 1
Posaconazole
n=301		Fluconazole
n=299
On therapy plus 7 days
Clinical Failure

Patients may have met more than one criterion defining failure.

50 (17%)55 (18%)
Failure due to:
  Proven/Probable IFI7 (2%)22 (7%)
(Aspergillus)3 (1%)17 (6%)
(Candida)1 (<1%)3 (1%)
(Other)3 (1%)2 (1%)
  All Deaths22 (7%)24 (8%)
Proven/probable fungal infection prior to death2 (<1%)6 (2%)
  SAF

Use of systemic antifungal therapy (SAF) criterion is based on protocol definitions (empiric/IFI usage >4 consecutive days).

27 (9%)25 (8%)
Through 16 weeks
Clinical Failure,

95% confidence interval (posaconazole-fluconazole) = (-11.5%, +3.7%).

99 (33%)110 (37%)
Failure due to:
  Proven/Probable IFI16 (5%)27 (9%)
(Aspergillus)7 (2%)21 (7%)
(Candida)4 (1%)4 (1%)
(Other)5 (2%)2 (1%)
  All Deaths58 (19%)59 (20%)
Proven/probable fungal infection prior to death10 (3%)16 (5%)
  SAF26 (9%)30 (10%)
  Event free lost to follow-up

Patients who are lost to follow-up (not observed for 112 days), and who did not meet another clinical failure endpoint. These patients were considered failures.

24 (8%)30 (10%)

The second study (Oral Suspension Study 2) was a randomized, open-label study that compared posaconazole oral suspension (200 mg 3 times a day) with fluconazole suspension (400 mg once daily) or itraconazole oral solution (200 mg twice a day) as prophylaxis against IFIs in neutropenic patients who were receiving cytotoxic chemotherapy for AML or MDS. As in Oral Suspension Study 1, efficacy of prophylaxis was evaluated using a composite endpoint of proven/probable IFIs, death, or treatment with systemic antifungal therapy (Patients might have met more than one of these criteria). This study assessed patients while on treatment plus 7 days and 100 days postrandomization. The mean duration of therapy was comparable between the 2 treatment groups (29 days, posaconazole; 25 days, fluconazole or itraconazole). Table 25 contains the results from Oral Suspension Study 2.

Table 25: Results from Open-Label Clinical Study 2 in Prophylaxis of IFI in All Randomized Patients with Hematologic Malignancy and Prolonged Neutropenia: Oral Suspension Study 2
Posaconazole
n=304		Fluconazole/Itraconazole
n=298
On therapy plus 7 days
Clinical Failure

95% confidence interval (posaconazole-fluconazole/itraconazole) = (-22.9%, -7.8%).

,

Patients may have met more than one criterion defining failure.

82 (27%)126 (42%)
  Failure due to:
    Proven/Probable IFI7 (2%)25 (8%)
(Aspergillus)2 (1%)20 (7%)
(Candida)3 (1%)2 (1%)
(Other)2 (1%)3 (1%)
    All Deaths17 (6%)25 (8%)
Proven/probable fungal infection prior to death1 (<1%)2 (1%)
    SAF

Use of systemic antifungal therapy (SAF) criterion is based on protocol definitions (empiric/IFI usage >3 consecutive days).

67 (22%)98 (33%)
Through 100 days postrandomization
Clinical Failure158 (52%)191 (64%)
  Failure due to:
    Proven/Probable IFI14 (5%)33 (11%)
(Aspergillus)2 (1%)26 (9%)
(Candida)10 (3%)4 (1%)
(Other)2 (1%)3 (1%)
    All Deaths44 (14%)64 (21%)
Proven/probable fungal infection prior to death2 (1%)16 (5%)
    SAF98 (32%)125 (42%)
    Event free lost to follow-up

Patients who are lost to follow-up (not observed for 100 days), and who did not meet another clinical failure endpoint. These patients were considered failures.

34 (11%)24 (8%)

In summary, 2 clinical studies of prophylaxis were conducted with the posaconazole oral suspension. As seen in the accompanying tables (Tables 24 and 25), clinical failure represented a composite endpoint of breakthrough IFI, mortality and use of systemic antifungal therapy. In Oral Suspension Study 1 (Table 24), the clinical failure rate of posaconazole (33%) was similar to fluconazole (37%), (95% CI for the difference posaconazole–comparator -11.5% to 3.7%) while in Oral Suspension Study 2 (Table 25) clinical failure was lower for patients treated with posaconazole (27%) when compared to patients treated with fluconazole or itraconazole (42%), (95% CI for the difference posaconazole–comparator -22.9% to -7.8%).

All-cause mortality was similar at 16 weeks for both treatment arms in Oral Suspension Study 1 [POS 58/301 (19%) vs. FLU 59/299 (20%)]; all-cause mortality was lower at 100 days for posaconazole-treated patients in Oral Suspension Study 2 [POS 44/304 (14%) vs. FLU/ITZ 64/298 (21%)]. Both studies demonstrated substantially fewer breakthrough infections caused by Aspergillus species in patients receiving posaconazole prophylaxis when compared to patients receiving fluconazole or itraconazole.


17 Patient Counseling Information



Advise the patient to read the FDA-approved patient labeling (Patient Information).


17.2 Drug Interactions



Advise patients to inform their physician immediately if they:

  • develop severe diarrhea or vomiting.
  • are currently taking drugs that are known to prolong the QTc interval and are metabolized through CYP3A4.
  • are currently taking a cyclosporine or tacrolimus, or they notice swelling in an arm or leg or shortness of breath.
  • are taking other drugs or before they begin taking other drugs as certain drugs can decrease or increase the plasma concentrations of posaconazole.

17.3 Serious And Potentially Serious Adverse Reactions



Advise patients to inform their physician immediately if they:

  • notice a change in heart rate or heart rhythm, or have a heart condition or circulatory disease. Posaconazole can be administered with caution to patients with potentially proarrhythmic conditions.
  • are pregnant, plan to become pregnant, or are nursing.
  • have liver disease or develop itching, nausea or vomiting, their eyes or skin turn yellow, they feel more tired than usual or feel like they have the flu.
  • have ever had an allergic reaction to other antifungal medicines such as ketoconazole, fluconazole, itraconazole, or voriconazole.

Spl Patient Package Insert



This Patient Information has been approved by the U.S. Food and Drug Administration.

NH01001   Iss. 02/2021

Patient Information

Posaconazole (po-sa-kon-a-zole)
Delayed-Release Tablets

What is posaconazole delayed-release tablets?
Posaconazole delayed-release tablets are prescription medicines used to help prevent fungal infections that can spread throughout your body (invasive fungal infections). These infections are caused by fungi called Aspergillus or Candida. Posaconazole is used in people who have an increased chance of getting these infections due to a weak immune system. These include people who have:
  • had a hematopoietic stem cell transplantation (bone marrow transplant) with graft versus host disease
  • a low white blood cell count due to chemotherapy for blood cancers (hematologic malignancy)
    • Posaconazole delayed-release tablets are for adults and children over 13 years of age.
    It is not known if posaconazole delayed-release tablets are safe and effective in children under 13 years of age.
Who should not take posaconazole delayed-release tablets?
Do not take posaconazole delayed-release tablets if you:
  • are allergic to posaconazole, any of the ingredients in posaconazole delayed-release tablets, or other azole antifungal medicines. See the end of this leaflet for a complete list of ingredients in posaconazole delayed-release tablets..
  • are taking any of the following medicines:
    • sirolimus
    • pimozide
    • quinidine
    • certain statin medicines that lower cholesterol (atorvastatin, lovastatin, simvastatin)
    • ergot alkaloids (ergotamine, dihydroergotamine)
      • Ask your healthcare provider or pharmacist if you are not sure if you are taking any of these medicines. Do not start taking a new medicine without talking to your healthcare provider or pharmacist.
What should I tell my healthcare provider before taking posaconazole delayed-release tablets?
Before you take posaconazole delayed-release tablets, tell your healthcare provider if you:
  • are taking certain medicines that lower your immune system like cyclosporine or tacrolimus.
  • are taking certain drugs for HIV infection, such as ritonavir, atazanavir, efavirenz, or fosamprenavir. Efavirenz and fosamprenavir can cause a decrease in the posaconazole levels in your body. Efavirenz and fosamprenavir should not be taken with posaconazole delayed-release tablets.
  • are taking midazolam, a hypnotic and sedative medicine.
  • are taking vincristine, vinblastine and other "vinca alkaloids" (medicines used to treat cancer).
  • have or had liver problems.
  • have or had kidney problems.
  • have or had an abnormal heart rate or rhythm, heart problems, or blood circulation problems.
  • are pregnant or plan to become pregnant. It is not known if posaconazole delayed-release tablets will harm your unborn baby.
  • are breastfeeding or plan to breastfeed. It is not known if posaconazole passes into your breast milk. You and your healthcare provider should decide if you will take posaconazole delayed-release tablets or breastfeed. You should not do both.

    • Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Posaconazole can affect the way other medicines work, and other medicines can affect the way posaconazole works, and can cause serious side effects.
    Especially tell your healthcare provider if you take:

    • rifabutin or phenytoin. If you are taking these medicines, you should not take posaconazole delayed-release tablets.

      • Ask yourhealthcare provider or pharmacist for a list of these medicines if you are not sure. Know the medicines you take. Keep a list of them with you to show your healthcare provider or pharmacist when you get a new medicine.

How will I take posaconazole delayed-release tablets?

  • Do not switch between taking posaconazole delayed-release tablets and posaconazole oral suspension without talking to your healthcare provider.
  • Take posaconazole delayed-release tablets exactly as your healthcare provider tells you to take it.
  • Your healthcare provider will tell you how much posaconazole delayed-release tablets to take and when to take it.
  • Take posaconazole delayed-release tablets for as long as your healthcare provider tells you to take it.
  • If you take too much posaconazole delayed-release tablets, call your healthcare provider or go to the nearest hospital emergency room right away.
  • Take posaconazole delayed-release tablets with food.
  • Take posaconazole delayed-release tablets whole. Do not break, crush, or chew posaconazole delayed-release tablets before swallowing. If you cannot swallow posaconazole delayed-release tablets whole, tell your healthcare provider. You may need a different medicine.
  • If you miss a dose, take it as soon as you remember and then take your next scheduled dose at its regular time. If it is within 12 hours of your next dose, do not take the missed dose. Skip the missed dose and go back to your regular schedule. Do not double your next dose or take more than your prescribed dose.

    • Follow the instructions from your healthcare provider on how much posaconazole delayed-release tablets you should take and when to take it.

What are the possible side effects of posaconazole delayed-release tablets?

Posaconazole delayed-release tablets may cause serious side effects, including:

  • drug interactions with cyclosporine or tacrolimus. If you take posaconazole delayed-release tablets with cyclosporine or tacrolimus, your blood levels of cyclosporine or tacrolimus may increase. Serious side effects can happen in your kidney or brain if you have high levels of cyclosporine or tacrolimus in your blood. Your healthcare provider should do blood tests to check your levels of cyclosporine or tacrolimus if you are taking these medicines while taking posaconazole delayed-release tablets. Tell your healthcare provider right away if you have swelling in your arm or leg or shortness of breath.
  • problems with the electrical system of your heart (arrhythmias and QTc prolongation). Certain medicines used to treat fungus called azoles, including posaconazole, the active ingredient in posaconazole delayed-release tablets, may cause heart rhythm problems. People who have certain heart problems or who take certain medicines have a higher chance for this problem. Tell your healthcare provider right away if your heartbeat becomes fast or irregular.
  • liver problems. Some people who also have other serious medical problems may have severe liver problems that may lead to death, especially if you take certain doses of posaconazole. Your healthcare provider should do blood tests to check your liver while you are taking posaconazole delayed-release tablets. Call your healthcare provider right away if you have any of the following symptoms of liver problems:
    • itchy skin
    • nausea or vomiting
    • yellowing of your eyes
    • feeling very tired
    • flu-like symptoms
  • increased amounts of midazolam in your blood. If you take posaconazole delayed-release tablets with midazolam, posaconazole increases the amount of midazolam in your blood. This can make your sleepiness last longer. Your healthcare provider should check you closely for side effects if you take midazolam with posaconazole delayed-release tablets.

    • The most common side effects of posaconazole delayed-release tablets include:

  • diarrhea
  • nausea
  • fever
  • vomiting
  • headache
  • coughing
  • low potassium levels in the blood

If you take posaconazole delayed-release tablets, tell your healthcare provider right away if you have diarrhea or vomiting.
Tell your healthcare provider if you have any side effect that bothers you or that does not go away.
These are not all the possible side effects of posaconazole delayed-release tablets. For more information, ask your healthcare provider or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store posaconazole delayed-release tablets?

  • Store posaconazole delayed-release tablets at room temperature between 68°F to 77°F (20°C to 25°C).
  • Safely throw away medicine that is out of date or no longer needed.

    • Keep posaconazole delayed-release tablets and all medicines out of the reach of children.

General information about the safe and effective use of posaconazole delayed-release tablets.

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use posaconazole delayed-release tablets for a condition for which it was not prescribed. Do not give posaconazole delayed-release tablets to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about posaconazole delayed-release tablets that is written for health professionals.

What are the ingredients in posaconazole delayed-release tablets?
Active ingredient: posaconazole
Inactive ingredients:
hypromellose acetate succinate, microcrystalline cellulose, hydroxypropylcellulose, croscarmellose sodium, colloidal silicon dioxide, magnesium stearate, polyvinyl alcohol partially hydrolyzed, titanium dioxide, macrogol/polyethylene glycol 3350, talc and iron oxide yellow

Manufactured for:


Northstar Rx LLC
Memphis, TN 38141

Manufactured by:
Haimen Pharma Inc.,
No. 163, Zhuhai Rd., Binjiang Street,
Haimen, Jiangsu 226100,
China

The trademarks depicted in this piece are owned by their respective companies.

For more information, call 1-800-206-7821.


Principal Display Panel - 60 Tablet Bottle Label



NDC 16714-156-01

Posaconazole Delayed-Release Tablets

100 mg

Attention: Posaconazole Oral Suspension and Delayed-
Release Tablets are NOT interchangeable due to
differences in the dosing of each formulation.

Rx only     60 Tablets

60 tablets - 60s

60 tablets - 60s


* Please review the disclaimer below.