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Bosentan (Monograph)

Brand name: Tracleer
Drug class: Endothelin receptor antagonists

Medically reviewed by Drugs.com on Aug 10, 2024. Written by ASHP.

Warning

Risk Evaluation and Mitigation Strategy (REMS):

FDA approved a REMS for bosentan to ensure that the benefits outweigh the risks. The REMS may apply to one or more preparations of bosentan and consists of the following: elements to assure safe use and implementation system. See https://www.accessdata.fda.gov/scripts/cder/rems/.

Warning

    Hepatotoxicity
  • Risk of serious hepatic injury. Elevations in serum aminotransferase (AST/ALT) concentrations and liver failure reported.

  • Measure AST/ALT concentrations prior to initiation of therapy and monthly thereafter.

  • Discontinue therapy if AST/ALT elevations are accompanied by manifestations of liver injury (e.g., nausea, vomiting, fever, abdominal pain, jaundice, lethargy, fatigue) or bilirubin concentrations ≥2 times ULN.

  • Generally avoid in patients with elevated aminotransferases (>3 times ULN) at baseline (because monitoring for liver injury may be more difficult) and in those with preexisting moderate to severe hepatic impairment.

    Embryofetal Toxicity
  • May cause fetal harm; contraindicated in women who are or may become pregnant.

  • Must exclude pregnancy before start of treatment and prevent thereafter by using 2 reliable forms of contraception during and for 1 month following discontinuance of therapy.

  • Oral, injectable, transdermal, and implantable hormonal contraceptives may not be reliable when used concomitantly with bosentan and should not be the sole contraceptive method.

    Restricted Distribution
  • Distribution of bosentan is restricted because of risks of hepatotoxicity and major birth defects.

Introduction

Vasodilator; an endothelin receptor antagonist.

Uses for Bosentan

Pulmonary Arterial Hypertension (PAH)

Management of PAH (WHO group 1 pulmonary hypertension) in adults to improve exercise capacity and slow clinical worsening. Efficacy established principally in patients with NYHA/WHO functional class II–IV PAH (idiopathic, heritable, or associated with connective tissue diseases or congenital systemic-to-pulmonary shunts).

Management of PAH in pediatric patients ≥3 years of age with idiopathic or congenital PAH to improve pulmonary vascular resistance, which is expected to result in an improvement in exercise ability.

Expert consensus guidelines recommend that all adult patients with symptomatic PAH be treated with established PAH-specific medications. Endothelin-receptor antagonists such as bosentan are recommended among several options for treatment of WHO/NYHA class II or III PAH. Selection of drug therapy should be based on disease severity (WHO/NYHA class) in addition to comorbid conditions, concomitant medications, adverse effects, route of administration, costs, and patient preferences.

In pediatric patients, bosentan monotherapy is a recommended option in patients with lower-risk PAH and negative acute vasoreactivity testing.

Has been designated an orphan drug by FDA for treatment of PAH.

Bosentan Dosage and Administration

General

Pretreatment Screening

Patient Monitoring

Dispensing and Administration Precautions

REMS

Administration

Oral Administration

Administer orally twice daily (morning and evening) without regard to meals. Available as a film-coated tablet or dispersible tablet for oral suspension.

Disperse tablet for oral suspension, or half of the dispersible tablet, in a minimal amount of water immediately before administration.

Dosage

Pediatric Patients

PAH
Oral

Patients >12 years of age weighing >40 kg: Initially, 62.5 mg twice daily for 4 weeks, followed by 125 mg twice daily.

Patients >12 years of age weighing <40 kg: Initially, 62.5 mg twice daily for 4 weeks, followed by 62.5 mg twice daily.

Patients 3–12 years of age weighing ≥4–8 kg: 16 mg twice daily for initial and maintenance therapy.

Patients 3–12 years of age weighing >8–16 kg: 32 mg twice daily for initial and maintenance therapy.

Patients 3–12 years of age weighing >16–24 kg: 48 mg twice daily for initial and maintenance therapy.

Patients 3–12 years of age weighing >24–40 kg: 64 mg twice daily for initial and maintenance therapy.

Adults

PAH
Oral

Initially, 62.5 mg twice daily for 4 weeks, followed by 125 mg twice daily. If patient weighs <40 kg, recommended dosage for both initial and maintenance therapy is 62.5 mg twice daily.

Dosage Modification for Toxicity

Hepatotoxicity

If aminotransferase levels increase to >3 times ULN without clinical symptoms of hepatotoxicity, temporary interruption of therapy, dosage reduction, and/or discontinuance of bosentan may be necessary.

If aminotransferase levels increase to >3 but ≤5 times ULN without clinical symptoms of hepatotoxicity, retest aminotransferase levels to confirm the result. In adults and pediatric patients >12 years of age and >40 kg with confirmed aminotransferase elevation, reduce bosentan dosage to 62.5 mg twice daily or interrupt treatment. Monitor aminotransferase levels at least every 2 weeks. If aminotransferase levels return to pretreatment values, may continue treatment or reintroduce at 62.5 mg twice daily; re-assess aminotransferase levels within 3 days. In pediatric patients ≤12 years of age and/or ≤40 kg with confirmed aminotransferase elevation, interrupt treatment. If aminotransferase levels return to pretreatment levels, reintroduce bosentan at the dosage used prior to treatment interruption; reassess aminotransferase levels within 3 days.

If aminotransferase levels increase to >5 but ≤8 times ULN without clinical symptoms of hepatotoxicity, retest aminotransferase levels to confirm the result; if confirmed, interrupt bosentan treatment and monitor aminotransferase levels at least every 2 weeks. Once aminotransferase levels return to pretreatment levels, may resume bosentan therapy. In adults and pediatric patients >12 years of age and >40 kg, consider reintroduction of treatment at 62.5 mg twice daily, with reassessment of aminotransferase levels within 3 days. In pediatric patients ≤12 years of age and/or ≤40 kg, consider reintroduction at the dosage used prior to treatment interruption, with reassessment of aminotransferase levels within 3 days.

If aminotransferase levels increase to >8 times ULN without clinical symptoms of hepatotoxicity, discontinue bosentan; no experience with reintroduction of bosentan in these circumstances.

If aminotransferase elevations are accompanied by clinical symptoms of hepatotoxicity (e.g., nausea, vomiting, fever, abdominal pain, jaundice, unusual lethargy or fatigue), or if bilirubin elevations ≥2 times ULN, discontinue bosentan; no experience with reintroduction of bosentan in these circumstances.

Concomitant Use with Ritonavir

When bosentan therapy is initiated in patients who have been receiving ritonavir for ≥10 days, initiate bosentan at the recommended initial dosage once daily or every other day based on individual patient tolerance.

When therapy with ritonavir is initiated in patients receiving bosentan, discontinue bosentan ≥36 hours prior to initiating ritonavir; after ≥10 days of ritonavir therapy, may resume bosentan at the recommended initial dosage once daily or every other day based on patient tolerance.

Special Populations

Hepatic Impairment

Dosage adjustment not necessary in patients with preexisting mild hepatic impairment (Child-Pugh class A).

Avoid use in patients with aminotransferases >3 times ULN at baseline and/or preexisting moderate or severe hepatic impairment (Child-Pugh class B or C).

Renal Impairment

No dosage adjustments necessary.

Geriatric Patients

No specific dosage recommendations at this time.

Cautions for Bosentan

Contraindications

Warnings/Precautions

Warnings

Hepatotoxicity

Elevations in serum aminotransferase (AST/ALT) concentrations reported in both adults and pediatric patients, sometimes accompanied by elevated bilirubin. Combined elevation of aminotransferases and total bilirubin is a marker for potential serious hepatotoxicity. (See Boxed Warning.)

Elevations in aminotransferase concentrations are dose-dependent, may occur at any point during treatment, are typically asymptomatic, and generally progress slowly. In most cases reversible after treatment interruption or cessation; may also reverse spontaneously during continued treatment.

With close monitoring, unexplained hepatic cirrhosis and liver failure reported rarely after prolonged (i.e., >12 months) bosentan therapy.

Manufacturer reinforces importance of strict adherence to monthly monitoring schedule for the duration of bosentan therapy and to dosage adjustment and monitoring guidelines.

Measure serum aminotransferase concentrations prior to initiation of therapy and then monthly thereafter. Dosage reduction or discontinuance of the drug may be necessary depending on the degree of hepatic impairment. If liver aminotransferase elevations are accompanied by bilirubin levels ≥2 times ULN and/or clinical symptoms of hepatotoxicity (e.g., nausea, vomiting, fever, abdominal pain, jaundice, unusual lethargy or fatigue), discontinue bosentan.

Avoid initiation of bosentan in patients with elevated aminotransferases (>3 times ULN) at baseline, because monitoring hepatotoxicity may be more difficult in these patients.

In patients with WHO functional class II PAH, consider whether benefits of bosentan are sufficient to outweigh risks of hepatotoxicity.

Fetal/Neonatal Morbidity and Mortality

Based on data from animal studies, bosentan may cause fetal harm, including birth defects and fetal death.

Exclude pregnancy prior to initiating bosentan therapy in females of childbearing potential.

Women of childbearing potential must use 2 reliable contraceptive methods during and for 1 month following cessation of therapy.

Other Warnings and Precautions

Fluid Retention

Fluid retention, sometimes requiring intervention (e.g., diuretics, fluid management, hospitalization), reported. Peripheral edema is a known class effect of endothelin-receptor antagonists and also a consequence of PAH.

If clinically important fluid retention occurs, evaluate further to determine cause; initiate specific treatment or discontinue bosentan if necessary.

Pulmonary Veno-Occlusive Disease

If signs of pulmonary edema occur, consider possibility of associated pulmonary veno-occlusive disease and consider discontinuation of bosentan.

Decreased Sperm Counts

Reduced sperm counts observed in men with PAH receiving usual dosages of bosentan; cannot exclude possibility of adverse effects on spermatogenesis. May impair fertility in males of reproductive potential; unknown whether such effects would be reversible.

Decreases in Hemoglobin and Hematocrit

Possible dose-related decreases in hemoglobin and hematocrit. Anemia requiring transfusion reported in the postmarketing setting.

Monitor hemoglobin 1 and 3 months after initiation of therapy and every 3 months thereafter.

Specific Populations

Pregnancy

Based on data from animal reproduction studies, bosentan may cause fetal harm, including birth defects and fetal death.

Contraindicated during pregnancy; exclude pregnancy before treatment is initiated. Females of reproductive potential must use 2 acceptable methods of contraception during treatment and for 1 month after treatment discontinuation. Pregnancy testing should occur monthly during therapy with the drug and one month after stopping treatment.

If bosentan is used during pregnancy or if patient becomes pregnant during therapy, apprise patient of potential hazard to the fetus.

Lactation

Single case report describes bosentan presence in human milk; insufficient information on effects of bosentan on breastfeeding infant or milk production.

Because of the potential for serious adverse reactions to bosentan in breastfed infants (e.g., fluid retention, hepatotoxicity), advise patients not to breastfeed during treatment with bosentan.

Females and Males of Reproductive Potential

Exclude pregnancy before treatment is initiated in females of reproductive potential. Such females should use 2 reliable contraceptive methods during and for 1 month following treatment, unless patient has undergone tubal sterilization or chooses to use an IUD, in which case no additional contraceptive is needed. Hormonal contraceptives (including oral, injectable, transdermal, and implantable contraceptives) may be less effective for preventing pregnancy in patients receiving bosentan, and they should not be used as the only contraceptive method. If a partner’s vasectomy is the chosen method of contraception, a hormone or barrier method must also be used.

Advise patients on pregnancy planning and prevention, including emergency contraception.

Perform pregnancy testing monthly during therapy and 1 month after stopping treatment. Advise females of reproductive potential to contact their physician immediately for pregnancy testing if onset of menses is delayed or pregnancy is suspected.

Decreased sperm counts observed. Bosentan may impair fertility in males of reproductive potential; unknown whether effects on fertility are reversible.

Pediatric Use

Efficacy in patients <18 years of age supported by an uncontrolled trial in 19 pediatric patients. In this study, hemodynamic improvements were similar to those seen in adults. Safety of bosentan in pediatric patients is supported by data from 100 pediatric patients treated with bosentan for a median of 17 months.

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.

Hepatic Impairment

Extensively metabolized by liver; hepatic impairment expected to increase exposure to bosentan. Use not recommended in patients with preexisting moderate to severe hepatic impairment or AST/ALT >3 times ULN.

Renal Impairment

Minimal effect of severe renal impairment Clcr 15–30 mL/minute) on bosentan pharmacokinetics.

Common Adverse Effects

Common adverse effects with conventional tablets (≥3%): respiratory tract infection, anemia.

Common adverse effects with dispersible tablets (≥15%): upper respiratory tract infection, pyrexia.

Drug Interactions

Induces and is metabolized by CYP2C9 and CYP3A4; may possibly induce CYP2C19.

Drugs Affecting Hepatic Microsomal Enzymes

CYP2C9 and CYP3A inhibitors: Potential pharmacokinetic interaction (increased plasma bosentan concentrations). Concomitant administration of both a CYP2C9 inhibitor and a potent or moderate CYP3A inhibitor with bosentan is not recommended.

Drugs Metabolized by Hepatic Microsomal Enzymes

Substrates of CYP2C9 and CYP3A, and possibly CYP2C19: Potential pharmacokinetic interaction (decreased plasma substrate concentrations).

Does not inhibit CYP isoenzymes 1A2, 2C9, 2C19, 2D6, or 3A in vitro; therefore, not expected to increase plasma concentrations of drugs metabolized by these enzymes.

Drugs Affecting the Organic Anion Transport Protein (OATP)

Potential pharmacokinetic interaction with drugs that inhibit OATP.

Specific Drugs

Drug

Interaction

Comments

Amiodarone

Potential for increased plasma bosentan concentrations

Concomitant use of both amiodarone and a potent/moderate CYP3A inhibitor with bosentan not recommended

Amprenavir (no longer commercially available in the US)

Potential for increased plasma bosentan concentrations

Concomitant use of both amprenavir and a CYP2C9 inhibitor with bosentan not recommended

Cyclosporine

Increased plasma bosentan and decreased plasma cyclosporine concentrations

Concomitant use contraindicated

Digoxin

Clinically important pharmacokinetic interaction unlikely

Diltiazem

Potential for increased plasma bosentan concentrations

Concomitant use of both diltiazem and a CYP2C9 inhibitor with bosentan not recommended

Erythromycin

Potential for increased plasma bosentan concentrations

Concomitant use of both erythromycin and a CYP2C9 inhibitor with bosentan not recommended

Fluconazole

Potential for increased plasma bosentan concentrations

Concomitant use of both fluconazole and a potent/moderate CYP3A inhibitor with bosentan not recommended

Glyburide

Increased risk of elevated serum aminotransferase concentrations; decreased plasma glyburide and bosentan concentrations

Concomitant use contraindicated

HIV protease inhibitors (PIs)

Increased peak plasma concentrations and systemic exposure to bosentan observed with concomitant lopinavir/ritonavir

In patients currently receiving bosentan, discontinue bosentan for ≥36 hours prior to ritonavir initiation; after ≥10 days of ritonavir therapy, resume bosentan at the recommended initial daily dose once daily or every other day based on individual patient tolerance

Hormonal contraceptives

Decreased plasma norethindrone and ethinyl estradiol concentrations and systemic exposure; possible contraceptive failure

Use concomitant nonhormonal contraceptive method; do not use hormonal contraceptive as sole contraceptive method

Itraconazole

Potential for increased plasma bosentan concentrations

Concomitant use of both itraconazole and a CYP2C9 inhibitor with bosentan not recommended

Ketoconazole

Increased plasma bosentan concentrations

Bosentan dosage adjustment not necessary, but consider potential for increased effects

Concomitant use of both ketoconazole and a CYP2C9 inhibitor with bosentan not recommended

Losartan

No significant effect on bosentan plasma levels

No dosage adjustment needed

Nimodipine

No significant interaction

No dosage adjustment needed

PDE type 5 inhibitors

Sildenafil: Decreased plasma sildenafil and increased plasma bosentan concentrations

Tadalafil: Decreased exposure to tadalafil, but no substantial alteration in bosentan exposure

Sildenafil: Manufacturer states dosage adjustments not necessary

Rifampin

Healthy individuals: Plasma bosentan concentrations increased by about sixfold after first concurrent dose, then decreased with continued coadministration

If concomitant use necessary, monitor liver function tests weekly

Simvastatin

Decreased plasma concentrations of simvastatin and active metabolite

Monitor serum cholesterol

Warfarin

Decreased plasma warfarin concentrations and anticoagulant effects

Monitor INR closely when bosentan is initiated or discontinued

Bosentan Pharmacokinetics

Absorption

Bioavailability

Healthy individuals: Following oral administration, peak plasma concentrations attained within approximately 3–5 hours. Absolute bioavailability about 50%.

Food

Food does not affect bioavailability.

Special Populations

Increased (twofold) exposure to bosentan following oral or IV administration in adult patients with PAH compared with healthy adults.

Exposure to bosentan reaches a plateau at lower doses in pediatric patients than in adults, and doses higher than 2 mg/kg twice daily do not increase exposure to bosentan in pediatric patients.

Distribution

Extent

Does not penetrate into erythrocytes.

Plasma Protein Binding

>98% (mainly albumin).

Elimination

Metabolism

Metabolized by CYP2C9 and CYP3A4; appears to induce its own metabolism following multiple-dose administration.

Elimination Route

Biliary excretion following metabolism in the liver. Less than 3% of dose excreted in urine.

Half-life

Healthy adults: Terminal elimination half-life about 5 hours.

Special Populations

Because of extensive hepatic metabolism, hepatic impairment may increase exposure to the drug.

Pharmacokinetics not affected in patients with mild hepatic impairment (Child-Pugh class A). Increased exposure to bosentan and its active metabolite observed in patients with moderate hepatic impairment (Child-Pugh class B) and PAH associated with portal hypertension; not evaluated in those with severe hepatic impairment (Class-Pugh class C).

Stability

Storage

Oral

Film-coated Tablets

20–25°C (may be exposed to 15–30°C).

Dispersible Tablets for Oral Suspension

Intact tablets: 20–25°C (excursions permitted to 15–30°C).

Divided tablets: 20–25°C in the opened blister for up to 7 days.

Actions

Advice to Patients

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Distribution of bosentan is restricted.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Bosentan

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

62.5 mg (of anhydrous bosentan)*

Bosentan Tablets

Tracleer

Actelion

125 mg (of anhydrous bosentan)

Bosentan Tablets

Tracleer

Actelion

Dispersible tablets, for oral suspension

32 mg (of anhydrous bosentan)

Tracleer

Actelion

AHFS DI Essentials™. © Copyright 2024, Selected Revisions August 10, 2024. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

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