Glecaprevir And Pibrentasvir
Class: HCV Protease Inhibitors
Chemical Name: (3aR,7S,10S,12R,21E,24aR)-7-tert-butyl-N-((1R,2R)-2-(difluoromethyl)-1-((1-methylcyclopropane-1-sulfonyl)carbamoyl)cyclopropyl)-20,20-difluoro-5,8-dioxo-2,3,3a,5,6,7,8,11,12,20,23,24a-dodecahydro-1H,10H-9,12-methanocyclopenta(18,19)(1,10,17,3,6)trioxadiazacyclononadecino(11,12- b)quinoxaline-10-carboxamide
Molecular Formula: C38H46F4N6O9SC57H65F5N10O8
CAS Number: 1365970-03-1
Brands: Mavyret
Medically reviewed by Drugs.com. Last updated on April 6, 2020.
Warning
- Risk of HBV Reactivation in Patients Coinfected with HCV and HBV
-
HBV reactivation, including cases resulting in fulminant hepatitis, hepatic failure, and death, reported in patients coinfected with HCV and HBV who were receiving or had completed treatment with HCV direct-acting antivirals (DAAs) and were not receiving HBV antiviral therapy.1 25 (See Risk of HBV Reactivation in Patients Coinfected with HCV and HBV under Cautions.)
-
Test all patients for evidence of current or prior HBV infection before initiating fixed combination of glecaprevir and pibrentasvir (glecaprevir/pibrentasvir).1 25
-
Monitor patients coinfected with HCV and HBV for hepatitis flare or HBV reactivation during and after HCV treatment.1 25 Initiate appropriate management for HBV infection as clinically indicated.1
Introduction
HCV antiviral;1 fixed combination containing glecaprevir (HCV nonstructural 3/4A [NS3/4A] protease inhibitor) and pibrentasvir (HCV NS5A replication complex inhibitor [NS5A inhibitor]).1
Uses for Glecaprevir And Pibrentasvir
Chronic HCV Infection
Treatment of chronic HCV genotype 1, 2, 3, 4, 5, or 6 infection in treatment-naive (have not previously received HCV treatment) or previously treated adults and pediatric patients ≥12 years of age without cirrhosis or with compensated cirrhosis (Child-Pugh class A), including liver or kidney transplant recipients and those with HIV coinfection.1 3 4 5 6 7 10 11 12 16 17 24 119
Treatment of chronic HCV infection is complex and rapidly evolving; consult a specialist to obtain the most up-to-date information.119 Information from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) regarding diagnosis and management of HCV infection, including recommendations for initial treatment, is available at [Web].119
Glecaprevir And Pibrentasvir Dosage and Administration
General
-
Prior to initiating HCV treatment, test all patients for evidence of current or prior HBV infection by measuring hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc).1 25 119 (See Risk of HBV Reactivation in Patients Coinfected with HCV and HBV under Cautions.)
-
Prior to and during treatment, perform appropriate laboratory tests to evaluate liver function.119 (See Hepatic Impairment under Cautions.)
Administration
Oral Administration
Administer orally once daily with food.1
Dosage
Available as fixed-combination tablets containing 100 mg of glecaprevir and 40 mg of pibrentasvir (glecaprevir/pibrentasvir).1
Pediatric Patients
Treatment of Chronic HCV Infection
HCV Genotype 1, 2, 3, 4, 5, or 6 Infection
OralPediatric patients ≥12 years of age weighing ≥45 kg without cirrhosis or with compensated cirrhosis (Child-Pugh class A): 3 tablets (total of 300 mg of glecaprevir and 120 mg of pibrentasvir) once daily.1 Treatment duration depends on HCV genotype, previous HCV treatment experience, and presence of compensated cirrhosis.1 (See Tables 1 and 2.)
HCV Genotype |
Hepatic Impairment |
Duration of Glecaprevir/Pibrentasvir |
---|---|---|
HCV genotype 1, 2, 3, 4, 5, or 6 infection |
Noncirrhotic |
8 weeks |
Compensated cirrhosis (Child-Pugh class A) |
8 weeks |
Previously received HCV regimen containing interferon, peginterferon, ribavirin, and/or sofosbuvir; no previous treatment with HCV NS3/4A protease inhibitors or HCV NS5A inhibitors.1
In clinical trials, patients previously received HCV regimens containing the fixed combination of ledipasvir and sofosbuvir (ledipasvir/sofosbuvir) or daclatasvir (no longer commercially available) in conjunction with peginterferon and ribavirin.1
In clinical trials, patients previously received HCV regimens containing simeprevir (no longer commercially available) in conjunction with sofosbuvir or simeprevir, boceprevir, or telaprevir (drugs no longer commercially available) in conjunction with peginterferon and ribavirin.1
HCV Genotype |
Treatment Experience |
Hepatic Impairment |
Duration of Glecaprevir/Pibrentasvir |
---|---|---|---|
HCV genotype 1 infection |
Previously treated without HCV NS3/4A protease inhibitors or HCV NS5A inhibitors |
Noncirrhotic |
8 weeks |
Compensated cirrhosis (Child-Pugh class A) |
12 weeks |
||
Previously treated with an HCV NS5A inhibitor; no prior treatment with HCV NS3/4A protease inhibitors |
Noncirrhotic |
16 weeks |
|
Compensated cirrhosis |
16 weeks |
||
Previously treated with an HCV NS3/4A protease inhibitor; no prior treatment with HCV NS5A inhibitors |
Noncirrhotic |
12 weeks |
|
Compensated cirrhosis |
12 weeks |
||
HCV genotype 2, 4, 5, or 6 infection |
Previously treated without HCV NS3/4A protease inhibitors or HCV NS5A inhibitors |
Noncirrhotic |
8 weeks |
Compensated cirrhosis |
12 weeks |
||
HCV genotype 3 infection |
Previously treated without HCV NS3/4A protease inhibitors or HCV NS5A inhibitors |
Noncirrhotic |
16 weeks |
Compensated cirrhosis |
16 weeks |
HCV-infected Individuals with HIV Coinfection
OralPediatric patients ≥12 years of age weighing ≥45 kg without cirrhosis or with compensated cirrhosis (Child-Pugh class A): Dosage and duration of therapy generally same as those recommended for patients without HIV coinfection.1 (See Specific Drugs under Interactions.)
HCV Genotype 1, 2, 3, 4, 5, or 6 Infection in Liver or Kidney Transplant Patients
OralPediatric patients ≥12 years of age weighing ≥45 kg without cirrhosis or with compensated cirrhosis (Child-Pugh class A): 3 tablets (total of 300 mg of glecaprevir and 120 mg of pibrentasvir) once daily.1
Manufacturer states usual treatment duration is 12 weeks.1
Manufacturer recommends treatment duration of 16 weeks in those with HCV genotype 1 infection previously treated with an HCV NS5A inhibitor, but not an HCV NS3/4A protease inhibitor, and in those with HCV genotype 3 infection previously treated with interferon, peginterferon, ribavirin, and/or sofosbuvir, but not an HCV NS3/4A protease inhibitor or HCV NS5A inhibitor.1
Adults
Treatment of Chronic HCV Infection
HCV Genotype 1, 2, 3, 4, 5, or 6 Infection
OralWithout cirrhosis or with compensated cirrhosis (Child-Pugh class A): 3 tablets (total of 300 mg of glecaprevir and 120 mg of pibrentasvir) once daily.1 Treatment duration depends on HCV genotype, previous HCV treatment experience, and presence of compensated cirrhosis.1 (See Tables 3 and 4.)
HCV Genotype |
Hepatic Impairment |
Duration of Glecaprevir/Pibrentasvir |
---|---|---|
HCV genotype 1, 2, 3, 4, 5, or 6 infection |
Noncirrhotic |
8 weeks |
Compensated cirrhosis (Child-Pugh class A) |
8 weeks |
Previously received HCV regimen containing interferon, peginterferon, ribavirin, and/or sofosbuvir; no previous treatment with HCV NS3/4A protease inhibitors or HCV NS5A inhibitors.1
In clinical trials, patients previously received HCV regimens containing the fixed combination of ledipasvir and sofosbuvir (ledipasvir/sofosbuvir) or daclatasvir (no longer commercially available) in conjunction with peginterferon and ribavirin.1
In clinical trials, patients previously received HCV regimens containing simeprevir (no longer commercially available) in conjunction with sofosbuvir or simeprevir, boceprevir, or telaprevir (drugs no longer commercially available) in conjunction with peginterferon and ribavirin.1
HCV Genotype |
Treatment Experience |
Hepatic Impairment |
Duration of Glecaprevir/Pibrentasvir |
---|---|---|---|
HCV genotype 1 infection |
Previously treated without HCV NS3/4A protease inhibitors or HCV NS5A inhibitors |
Noncirrhotic |
8 weeks |
Compensated cirrhosis (Child-Pugh class A) |
12 weeks |
||
Previously treated with an HCV NS5A inhibitor; no prior treatment with HCV NS3/4A protease inhibitors |
Noncirrhotic |
16 weeks |
|
Compensated cirrhosis |
16 weeks |
||
Previously treated with an HCV NS3/4A protease inhibitor; no prior treatment with HCV NS5A inhibitors |
Noncirrhotic |
12 weeks |
|
Compensated cirrhosis |
12 weeks |
||
HCV genotype 2, 4, 5, or 6 infection |
Previously treated without HCV NS3/4A protease inhibitors or HCV NS5A inhibitors |
Noncirrhotic |
8 weeks |
Compensated cirrhosis |
12 weeks |
||
HCV genotype 3 infection |
Previously treated without HCV NS3/4A protease inhibitors or HCV NS5A inhibitors |
Noncirrhotic |
16 weeks |
Compensated cirrhosis |
16 weeks |
HCV-infected Individuals with HIV Coinfection
OralWithout cirrhosis or with compensated cirrhosis (Child-Pugh class A): Dosage and duration of therapy generally same as those recommended for adults without HIV coinfection.1 119 (See Specific Drugs under Interactions.)
HCV Genotype 1, 2, 3, 4, 5, or 6 Infection in Liver or Kidney Transplant Recipients
OralWithout cirrhosis or with compensated cirrhosis (Child-Pugh class A): 3 tablets (total of 300 mg of glecaprevir and 120 mg of pibrentasvir) once daily.1 119
Manufacturer states usual treatment duration is 12 weeks.1
Manufacturer recommends treatment duration of 16 weeks in those with HCV genotype 1 infection previously treated with an HCV NS5A inhibitor, but not an HCV NS3/4A protease inhibitor, and in those with HCV genotype 3 infection previously treated with interferon, peginterferon, ribavirin, and/or sofosbuvir, but not an HCV NS3/4A protease inhibitor or HCV NS5A inhibitor.1
Some experts state that liver or kidney transplant recipients who are treatment-naive or previously treated (with or without compensated cirrhosis) can receive 3 tablets (total of 300 mg of glecaprevir and 120 mg of pibrentasvir) once daily for 12 weeks for treatment of HCV genotype 1, 2, 3, 4, 5, or 6 infection.119
Special Populations
Hepatic Impairment
Mild hepatic impairment (Child-Pugh class A): Dosage adjustments not needed.1 Monitor for signs and symptoms of hepatic decompensation.1 (See Hepatic Impairment under Cautions.)
Moderate or severe hepatic impairment (Child-Pugh class B or C) or any history of hepatic decompensation: Contraindicated.1 (See Hepatic Impairment under Cautions.)
Renal Impairment
Mild, moderate, or severe renal impairment (including hemodialysis patients): Dosage adjustments not needed.1 Not removed by hemodialysis to any clinically important extent.1
Geriatric Patients
Dosage adjustments not needed.1 (See Geriatric Use under Cautions.)
Cautions for Glecaprevir And Pibrentasvir
Contraindications
-
Moderate or severe hepatic impairment (Child-Pugh class B or C) or any history of hepatic decompensation.1 (See Hepatic Impairment under Cautions.)
-
Concomitant use with certain drugs (e.g., atazanavir, rifampin).1 (See Specific Drugs under Interactions.)
Warnings/Precautions
Warnings
Risk of HBV Reactivation in Patients Coinfected with HCV and HBV
Postmarketing reports of reactivation of HBV infection when HCV DAAs were used for treatment of HCV infection in patients with HBV coinfection;1 25 fulminant hepatitis, hepatic failure, and death reported in some cases.1 25
HBV reactivation (abrupt increase in HBV replication manifested as rapid increase in serum HBV DNA levels or detection of HBsAg in an individual who was previously HBsAg negative and anti-HBc positive) reported in patients with HCV and HBV coinfection receiving HCV treatment with a regimen that included HCV DAAs without HBV antiviral therapy.1 25 HBV reactivation usually occurred within 4–8 weeks after initiation of HCV treatment.25
Patients with HBV reactivation heterogeneous in terms of HCV genotype and baseline HBV disease.25 Some patients were HBsAg positive; others had serologic evidence of resolved HBV infection (i.e., HBsAg negative and anti-HBc positive).1 25
HBV reactivation also reported in patients receiving certain immunosuppressant or chemotherapeutic drugs;1 risk of reactivation associated with HCV DAAs may be increased in such patients.1
Mechanism for HBV reactivation in coinfected patients receiving HCV DAAs unknown.25 Although HCV DAAs not known to cause immunosuppression, HBV reactivation in coinfected patients may result from a complex interplay of host immunologic responses in the setting of infection with 2 hepatitis viruses.25
Prior to initiating treatment with an HCV DAA, including glecaprevir/pibrentasvir, screen all patients for evidence of current or prior HBV infection by measuring HBsAg, anti-HBs, and anti-HBc.1 25 119 If there is serologic evidence of HBV infection, measure baseline HBV DNA level.25 119
In all patients with evidence of current or prior HBV infection, monitor for clinical and laboratory signs (i.e., HBsAg, HBV DNA levels, serum aminotransferase and bilirubin concentrations) of hepatitis flare or HBV reactivation during and after treatment with HCV DAAs.1 25 119 Initiate appropriate management for HBV infection as clinically indicated 1 119
Advise coinfected patients to immediately contact a clinician if they develop any signs or symptoms of serious liver injury.25 (See Advice to Patients.)
When making decisions regarding HBV monitoring or HBV treatment in coinfected patients, consult a clinician with expertise in managing HBV infection.25 119
Other Warnings and Precautions
Risk of Hepatic Decompensation or Failure in Patients with Evidence of Advanced Liver Disease
Postmarketing reports of hepatic decompensation or failure, including some fatalities, in patients receiving HCV treatment regimens containing an HCV NS3/4A protease inhibitor, including glecaprevir/pibrentasvir.1 26 Data insufficient to estimate frequency of such events; causal relationship not established.1 Hepatic decompensation or failure usually occurred within first 4 weeks of HCV treatment.1
Majority of reported cases of hepatic decompensation or failure with severe outcomes in patients receiving glecaprevir/pibrentasvir occurred in those with evidence of advanced liver disease with moderate or severe hepatic impairment (Child-Pugh class B or C) prior to initiation of the drug.1 Some cases occurred in patients who had compensated cirrhosis with mild liver impairment (Child-Pugh class A) at baseline, but had a history of a decompensation event (i.e., history of ascites, variceal bleeding, encephalopathy).1 Rare cases of hepatic decompensation or failure reported in patients without cirrhosis or with compensated cirrhosis (Child-Pugh A); many of these patients had evidence of portal hypertension.1 Some cases also reported in patients receiving concomitant therapy with drugs not recommended for concomitant use with the HCV treatment regimen and in those with confounding factors (e.g., serious liver-related medical or surgical comorbidities).1
If glecaprevir/pibrentasvir used in patients who have compensated cirrhosis (Child-Pugh class A) or evidence of advanced liver disease (e.g., portal hypertension), perform hepatic function tests as clinically indicated and monitor for signs and symptoms of hepatic decompensation (e.g., jaundice, ascites, hepatic encephalopathy, variceal hemorrhage).1
Discontinue glecaprevir/pibrentasvir in patients who develop evidence of hepatic decompensation or failure.1 (See Contraindications under Cautions.)
Advise patients to contact a clinician if they develop any signs or symptoms of worsening liver disease.1 (See Advice to Patients.)
Interactions
Concomitant use with certain drugs (i.e., carbamazepine, efavirenz, St. John's wort) may result in clinically important decreases in glecaprevir and pibrentasvir plasma concentrations leading to reduced therapeutic effect of glecaprevir/pibrentasvir.1 Concomitant use with such drugs not recommended.1 (See Specific Drugs under Interactions.)
Precautions Related to Fixed Combinations
Consider cautions, precautions, contraindications, and drug interactions associated with both drugs in the fixed combination.1 Consider cautionary information applicable to specific populations (e.g., pregnant or nursing women, individuals with hepatic or renal impairment, geriatric patients) for both glecaprevir and pibrentasvir.1
Specific Populations
Pregnancy
Adequate data not available regarding use in pregnant women.1 In animal studies, no adverse effects on fetal development at glecaprevir or pibrentasvir exposures 53 or 51 times greater, respectively, than human exposures at recommended human dosage.1
Lactation
Not known whether glecaprevir or pibrentasvir distribute into human milk, affect human milk production, or affect the breast-fed infant.1
Glecaprevir and pibrentasvir distributed into milk in rodents;1 no apparent effects on growth and development observed in nursing pups.1
Consider benefits of breast-feeding and importance of glecaprevir/pibrentasvir to the woman; also consider potential adverse effects on breast-fed child from the drug or underlying maternal condition.1
Pediatric Use
Safety, efficacy, and pharmacokinetics not established in pediatric patients <12 years of age.1
Safety and efficacy for treatment of HCV genotype 1, 2, 3, or 4 infection in pediatric patients ≥12 years of age weighing ≥45 kg are based on safety, efficacy, and pharmacokinetic data from an open-label phase 2/3 trial in treatment-naive or previously treated noncirrhotic pediatric patients (DORA [Part 1]).1 Safety and efficacy in these noncirrhotic pediatric patients were consistent with those observed in adults.1 23
Safety and efficacy for treatment of HCV genotype 5 or 6 infection in pediatric patients ≥12 years of age weighing ≥45 kg and for treatment of HCV infection in pediatric patients ≥12 years of age weighing ≥45 kg who have compensated cirrhosis or have received a kidney and/or liver transplant are supported by data indicating that glecaprevir and pibrentasvir systemic exposures in pediatric patients ≥12 years of age are comparable to those reported in adults.1
Geriatric Use
No overall differences in safety and efficacy observed between patients ≥65 years of age and younger adults.1 13
In patients with severe renal impairment, higher incidence of adverse effects observed in patients ≥65 years of age compared with younger adults.13
Hepatic Impairment
Mild hepatic impairment or compensated cirrhosis (Child-Pugh class A): Monitor for signs and symptoms of hepatic decompensation (e.g., jaundice, ascites, hepatic encephalopathy, variceal hemorrhage).1
Moderate or severe hepatic impairment (Child-Pugh class B or C) or any history of hepatic decompensation: Contraindicated.1 Postmarketing reports of hepatic decompensation or failure in such patients.1 (See Risk of Hepatic Decompensation or Failure in Patients with Evidence of Advanced Liver Disease under Cautions.)
Increased glecaprevir and pibrentasvir exposures reported in patients with moderate or severe hepatic impairment.1 (See Special Populations under Pharmacokinetics.)
Renal Impairment
Mild, moderate, and severe renal impairment: Glecaprevir and pibrentasvir AUCs up to 56% higher compared with normal renal function;1 AUCs not affected by dialysis.1
HCV-infected with end-stage renal disease (ESRD): Glecaprevir and pibrentasvir AUCs 86 and 54% higher, respectively, compared with normal renal function.1
Common Adverse Effects
Pruritus,1 3 4 12 headache,1 3 5 6 7 10 11 12 16 17 fatigue,1 3 4 5 6 7 10 12 16 17 nausea,1 3 4 5 10 12 17 diarrhea,1 3 12 asthenia,1 nasopharyngitis,10 urinary tract infection.3
Interactions for Glecaprevir And Pibrentasvir
Glecaprevir and pibrentasvir are weak inhibitors of CYP3A and 1A2.1 Glecaprevir is a substrate of CYP3A.1 2
Glecaprevir and pibrentasvir inhibit P-glycoprotein (P-gp) transport system and are substrates of P-gp.1
Glecaprevir and pibrentasvir inhibit breast cancer resistance protein (BCRP) and are substrates of BCRP.1
Glecaprevir and pibrentasvir inhibit organic anion transporting polypeptide (OATP) 1B1 and 1B3.1 Glecaprevir is a substrate of OATP1B1 and 1B3.1
Glecaprevir and pibrentasvir are weak inhibitors of UGT1A1.1
Drugs Affecting or Metabolized by Hepatic Microsomal Enzymes
Substrates of CYP3A, 1A2, 2C9, 2C19, or 2D6: Clinically important pharmacokinetic interactions not expected.1
CYP3A4 inducers: Possible decreased glecaprevir and pibrentasvir plasma concentrations.1
Drugs Affecting or Affected by P-glycoprotein Transport System
P-gp substrates: Possible increased plasma concentrations of P-gp substrates.1
P-gp inducers: Possible decreased glecaprevir and pibrentasvir plasma concentrations.1
P-gp inhibitors: Possible increased glecaprevir and pibrentasvir plasma concentrations.1
Drugs Affecting or Affected by Breast Cancer Resistance Protein
BCRP substrates: Possible increased plasma concentrations of BCRP substrates.1
BCRP inducers: Possible decreased glecaprevir and pibrentasvir plasma concentrations.1
BCRP inhibitors: Possible increased glecaprevir and pibrentasvir plasma concentrations.1
Drugs Affecting or Affected by Organic Anion Transporting Polypeptides
OATP1B1 or 1B3 substrates: Possible increased plasma concentrations of these substrates.1
OATP1B1 or 1B3 inducers: Possible decreased glecaprevir plasma concentrations.1
OATP1B1 or 1B3 inhibitors: Possible increased glecaprevir plasma concentrations.1
Drugs Affecting or Affected by Other Membrane Transporters
UGT1A1 or 1A4 substrates: Clinically important pharmacokinetic interactions not expected.1
Specific Drugs
Drug |
Interaction |
Comments |
---|---|---|
Angiotensin II receptor antagonists (losartan, valsartan) |
Losartan, valsartan: No clinically important pharmacokinetic interactions1 |
Losartan, valsartan: Dosage adjustments not needed1 |
Anticonvulsants (carbamazepine, lamotrigine, phenytoin) |
Carbamazepine: Clinically important decreases in glecaprevir and pibrentasvir concentrations and AUCs;1 possible reduced therapeutic effect of 1 Lamotrigine: No clinically important pharmacokinetic interactions1 Phenytoin: May decrease glecaprevir and pibrentasvir concentrations;1 may result in loss of therapeutic effect1 |
Carbamazepine, phenytoin: Concomitant use not recommended1 Lamotrigine: Dosage adjustments not needed1 |
Antimycobacterial agents (rifampin) |
Rifampin: Clinically important decreases in glecaprevir and pibrentasvir concentrations and AUC;1 may result in loss of therapeutic effect of glecaprevir/pibrentasvir1 |
Rifampin: Contraindicated1 |
Antiretrovirals, HIV entry and fusion inhibitors |
Maraviroc: Effect on maraviroc concentrations not expected200 |
Maraviroc: Dosage adjustments not needed200 |
Antiretrovirals, HIV integrase inhibitors (INSTIs) |
Bictegravir: Effect on bictegravir concentrations not expected200 Dolutegravir: No clinically important pharmacokinetic interactions200 Cobicistat-boosted elvitegravir: Increased AUCs of elvitegravir, glecaprevir, and pibrentasvir200 Fixed combination of abacavir, dolutegravir, and lamivudine (abacavir/dolutegravir/lamivudine): No clinically important pharmacokinetic interactions1 Fixed combination of elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide fumarate (EVG/c/FTC/TAF): Increased concentrations and AUCs of glecaprevir and pibrentasvir1 Raltegravir: Increased raltegravir concentrations and AUC1 |
Bictegravir: Dosage adjustments not needed200 Dolutegravir: Dosage adjustments not needed1 200 Cobicistat-boosted elvitegravir: Dosage adjustments not needed1 200 |
Antiretrovirals, HIV nonnucleoside reverse transcriptase inhibitors (NNRTIs) |
Doravirine: Increased doravirine concentrations expected200 Efavirenz: Decreased glecaprevir and pibrentasvir concentrations expected;1 possible reduced therapeutic effect of glecaprevir/pibrentasvir1 Etravirine: Possible decreased glecaprevir and pibrentasvir concentrations200 Nevirapine: Possible decreased glecaprevir and pibrentasvir concentrations200 Rilpivirine: Increased rilpivirine concentrations and AUC;1 200 no effect on glecaprevir and pibrentasvir concentrations200 |
Doravirine: Dosage adjustments not needed200 Efavirenz: Concomitant use not recommended1 200 Etravirine: Concomitant use not recommended200 Nevirapine: Experts state consider alternative antiretroviral or alternative HCV antiviral;200 if concomitant use necessary, monitor for HCV antiviral efficacy200 |
Antiretrovirals, HIV nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs) |
Abacavir/dolutegravir/lamivudine: No clinically important pharmacokinetic interactions 1 Abacavir/dolutegravir/lamivudine: No clinically important pharmacokinetic interactions1 EVG/c/FTC/TAF: Increased glecaprevir and pibrentasvir concentrations and AUCs;1 no effect on tenofovir concentrations or AUC1 Fixed combination of efavirenz, emtricitabine, and tenofovir disoproxil fumarate (TDF): Increased tenofovir concentrations and AUC1 TAF or TDF: No clinically important pharmacokinetic interactions200 |
Abacavir: Dosage adjustments not needed1 Emtricitabine: Dosage adjustments not needed1 Lamivudine: Dosage adjustments not needed1 |
Antiretrovirals, HIV protease inhibitors (PIs) |
Ritonavir-boosted atazanavir: Increased glecaprevir and pibrentasvir concentrations and AUC;1 possible increased ALT concentrations1 Ritonavir-boosted darunavir: Increased glecaprevir concentrations and AUC and increased pibrentasvir concentrations1 Fixed combination of lopinavir and ritonavir (lopinavir/ritonavir): Increased glecaprevir and pibrentasvir concentrations and AUCs1 Ritonavir: Increased glecaprevir and pibrentasvir concentrations expected1 Ritonavir-boosted tipranavir: Increased glecaprevir and pibrentasvir concentrations expected200 |
Cobicistat-boosted, ritonavir-boosted, or unboosted atazanavir: Concomitant use with glecaprevir/pibrentasvir contraindicated1 200 Cobicistat-boosted or ritonavir-boosted darunavir: Concomitant use not recommended1 200 Lopinavir/ritonavir: Concomitant use not recommended1 200 Ritonavir: Concomitant use not recommended1 Ritonavir-boosted tipranavir: Concomitant use not recommended200 |
Benzodiazepines |
Midazolam: No clinically important pharmacokinetic interactions1 |
Midazolam: Dosage adjustments not needed1 |
Buprenorphine/naloxone |
Buprenorphine, naloxone, or fixed combination of buprenorphine and naloxone (buprenorphine/naloxone): No clinically important pharmacokinetic interactions1 9 |
Buprenorphine, naloxone, or buprenorphine/naloxone: Dosage adjustments not needed1 9 |
Caffeine |
No clinically important pharmacokinetic interactions1 |
Dosage adjustments not needed1 |
Calcium-channel blocking agents (amlodipine, felodipine) |
Amlodipine, felodipine: No clinically important pharmacokinetic interactions1 |
Amlodipine, felodipine: Dosage adjustments not needed1 |
Dabigatran |
Increased dabigatran concentrations and AUC1 |
If used concomitantly in patients with renal impairment, consult recommendations from manufacturer of dabigatran regarding dosage modifications for concomitant use with P-gp inhibitors1 |
Dextromethorphan |
No clinically important pharmacokinetic interactions1 |
Dosage adjustments not needed1 |
Digoxin |
Increased digoxin exposures1 |
Measure digoxin concentrations prior to and during glecaprevir/pibrentasvir therapy; decrease digoxin dosage by 50% or adjust frequency to reduce digoxin concentrations1 |
Estrogens and progestins |
Oral contraceptives containing ethinyl estradiol and norgestimate or levonorgestrel: Increased concentrations and AUC of ethinyl estradiol, norgestrel, and norgestromin and possible increased risk of ALT elevations;1 not expected to affect glecaprevir or pibrentasvir concentrations1 |
Ethinyl estradiol-containing preparations (e.g., combined oral contraceptives): Concomitant use not recommended1 Norethindrone or other progestin-only contraceptives: Dosage adjustments not needed1 |
HMG-CoA reductase inhibitors (statins) |
Atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin: Substantially increased statin concentrations and AUCs;1 possible increased risk of myopathy and rhabdomyolysis1 Fluvastatin, pitavastatin: Possible substantially increased statin concentrations and AUCs;1 possible increased risk of myopathy and rhabdomyolysis1 |
Atorvastatin, lovastatin, simvastatin: Concomitant use not recommended1 Fluvastatin, pitavastatin: Use lowest statin dosage;1 if higher dosages required, use lowest necessary dosage taking into account risks and benefits1 Pravastatin: Reduce pravastatin dosage by 50%1 Rosuvastatin: Do not exceed rosuvastatin dosage of 10 mg1 |
Immunosuppressive agents (cyclosporine, tacrolimus) |
Cyclosporine: Increased glecaprevir concentrations and AUC and increased pibrentasvir concentrations and AUC;1 19 no substantial effect on cyclosporine exposure19 Tacrolimus: No clinically important pharmacokinetic interactions1 19 |
Cyclosporine: Concomitant use not recommended in patients receiving stable cyclosporine dosage >100 mg daily1 19 |
Methadone |
||
Naltrexone |
Insufficient data regarding concomitant use1 |
|
Proton-pump inhibitors (PPIs) |
No clinically important pharmacokinetic interactions with omeprazole 20 mg once daily;1 20 21 decreased glecaprevir concentrations and AUC with omeprazole 40 mg once daily, but no effect on pibrentasvir concentrations or AUC 1 No evidence to date that PPIs affect efficacy of glecaprevir/pibrentasvir3 21 22 |
Omeprazole: Manufacturer states dosage adjustments not needed;1 some clinicians state avoid long-term concomitant use with omeprazole 40 mg once daily20 |
Sofosbuvir |
No clinically important pharmacokinetic interactions1 |
Dosage adjustments not needed1 |
St. John's Wort (Hypericum perforatum) |
Possible substantially decreased glecaprevir and pibrentasvir concentrations;1 may result in loss of therapeutic effect of glecaprevir/pibrentasvir1 |
Concomitant use not recommended1 |
Tolbutamide |
No clinically important pharmacokinetic interactions1 |
Dosage adjustments not needed1 |
Warfarin |
Possible INR fluctuations1 |
Glecaprevir And Pibrentasvir Pharmacokinetics
Absorption
Bioavailability
Following oral administration of glecaprevir/pibrentasvir in healthy individuals, peak plasma concentrations of glecaprevir and pibrentasvir occur 5 hours after the dose.1
Food
Administration of glecaprevir/pibrentasvir with a moderate- to high-fat meal increases glecaprevir exposures by 83–163% and increases pibrentasvir exposures by 40–53% relative to administration in the fasting state.1
Special Populations
HCV-infected with compensated cirrhosis (Child-Pugh class A): Glecaprevir exposures approximately twofold higher than those reported in HCV-infected individuals without cirrhosis;1 14 pibrentasvir exposures similar to those in HCV-infected individuals without cirrhosis.1 14
Moderate hepatic impairment (Child-Pugh class B): Glecaprevir exposures twofold higher1 18 and pibrentasvir exposures 26% higher than those in individuals with normal hepatic function.1
Severe hepatic impairment (Child-Pugh class C): Glecaprevir exposures 11-fold higher1 18 and pibrentasvir exposures 114% higher than those in individuals with normal hepatic function.1
Mild, moderate, severe, or ESRD without HCV infection: Glecaprevir and pibrentasvir exposures up to 56 and 46% higher, respectively, than those in individuals with normal renal function.1 15 In dialysis-dependent individuals, pibrentasvir and glecaprevir exposures similar with or without dialysis (up to 18% difference).1 15
HCV-infected with ESRD (with or without dialysis): Glecaprevir and pibrentasvir exposures 86 and 54% higher, respectively, than reported in individuals with normal renal function.1
Pediatric patients ≥12 years of age: Glecaprevir and pibrentasvir AUC and peak plasma concentrations comparable to those observed in adults.1
Pediatric patients <12 years of age: Pharmacokinetics not studied.1
Distribution
Plasma Protein Binding
Glecaprevir: 97.5%.1
Pibrentasvir: >99.9%.1
Elimination
Metabolism
Glecaprevir: Metabolized to some extent by CYP3A.1
Pibrentasvir: None.1
Elimination Route
Glecaprevir: Biliary and fecal excretion.1 Following a single dose, 92.1% excreted in feces and 0.7% eliminated in urine.1
Pibrentasvir: Biliary and fecal excretion.1 Following a single dose, 96.6% excreted in feces; no drug eliminated in urine.1
Half-life
Glecaprevir: 6 hours.1
Pibrentasvir: 13 hours.1
Stability
Storage
Oral
Tablets
≤30°C.1
Actions and Spectrum
-
Glecaprevir/pibrentasvir is a fixed combination containing 2 HCV antivirals.1 Glecaprevir is an HCV NS3/4A protease inhibitor and pibrentasvir is an HCV NS5A replication complex inhibitor (NS5A inhibitor).1
-
Glecaprevir and pibrentasvir are both direct-acting antivirals (DAAs) with activity against HCV.1 No in vitro evidence of antagonistic anti-HCV effects between the drugs in replicon studies.1
-
Glecaprevir binds to the active site of HCV NS3/4A protease, thereby blocking enzyme activity essential for viral replication (i.e., blocking cleavage of the HCV-encoded polyproteins into mature forms of NS3, NS4A, NS4B, NS5A, and NS5B).1 8 In vitro studies using biochemical assays indicate that glecaprevir has activity against clinical isolates of HCV genotypes 1a, 1b, 2a, 2b, 3a, 4a, 5a, and 6a.1
-
Pibrentasvir inhibits the HCV NS5A protein, which is required for viral replication and virion assembly.1 In HCV replicon assays, pibrentasvir has shown in vitro activity against laboratory and clinical isolates of HCV genotypes 1a, 1b, 2a, 2b, 3a, 4a, 4b, 4d, 5a, 6a, 6e, and 6p.1
-
Certain amino acid substitutions in NS3/4A protease inhibitor resistance-associated positions of HCV genotypes 1a (e.g., D168F/Y), 1b, 2a, 3a (e.g., Q168R), 4a, and 6a (e.g., D168A/G/H/V/Y) have been selected in cell culture and have been associated with reduced susceptibility to glecaprevir in vitro in replicon studies.1 Emergence of amino acid substitutions occurred most commonly at NS3 positions A156 or D/Q168.1 The combination of NS3 resistance-associated substitutions Y56H and D/Q168 resulted in greater reductions in glecaprevir susceptibility.1 Treatment-emergent NS3 resistance-associated substitutions were detected in clinical trials evaluating glecaprevir/pibrentasvir in patients with HCV genotype 1 (e.g., A156V, V36A/M, Y56H, R155K/T, A156G/T/V, D168A/T) or genotype 3 (e.g., Y56H/N, Q80K/R, A156G, Q168L/R) infection who experienced virologic failure.1
-
Certain amino acid substitutions in NS5A of HCV genotype 1a (e.g., Q30D/deletion, Y93D/H/N, H58D and Y93H, M28G), genotype 1b (e.g., P32-deletion), genotype 2a (e.g., F28S and M31I, P29S and K30G), and genotype 3a (e.g., Y93H) have been selected in cell culture and have been associated with reduced susceptibility to pibrentasvir in vitro in replicon studies.1 Combinations of these NS5A substitutions often resulted in greater reductions in susceptibility to pibrentasvir compared with a single NS5A substitution.1 Treatment-emergent NS5A resistance-associated substitutions were detected in clinical trials evaluating glecaprevir/pibrentasvir in patients with HCV genotype 1 (e.g., Q30R, L31M, M28A/G, L28M, P29Q/R, Q30K/R, H58D, Y93H/N) or genotype 3a (e.g., S24F, M28G/K, A30G/K, L31F, P58T, Y93H) infection who experienced virologic failure.1 Some of these patients also had baseline NS5A polymorphisms at resistance-associated amino acid positions.1
-
Cross-resistance is possible between glecaprevir and other HCV NS3/4A protease inhibitors and between pibrentasvir and other HCV NS5A inhibitors.1 Cross-resistance not expected between glecaprevir/pibrentasvir and sofosbuvir, peginterferon, or ribavirin.1
Advice to Patients
-
Importance of reading patient information provided by the manufacturer.1
-
Advise patients that glecaprevir/pibrentasvir should be taken once daily with food on a regular dosing schedule.1
-
Importance of taking the recommended dosage of glecaprevir/pibrentasvir for the recommended duration of treatment;1 importance of not missing doses.1
-
If a dose is missed and remembered <18 hours after scheduled administration time, take glecaprevir/pibrentasvir as soon as possible and then take the next dose at the usual time.1 If a dose is missed and remembered >18 hours after schedule administration time, skip the missed dose and take the next dose at the usual time.1
-
Inform patients that reactivation of HBV infection has occurred in patients being treated for HCV infection who were coinfected with HBV.1 25 Importance of informing clinician of any history of HBV infection or other liver problems (e.g., cirrhosis).1 25 Importance of immediately contacting a clinician if any signs or symptoms of serious liver injury (e.g., fatigue, weakness, loss of appetite, nausea and vomiting, yellowing of the eyes or skin, light-colored bowel movements) occur.25 (See Risk of HBV Reactivation in Patients Coinfected with HCV and HBV under Cautions.)
-
Advise patients to immediately contact a clinician if they have symptoms of worsening liver problems (e.g., nausea, tiredness, yellowing of skin or white part of the eyes, bleeding or bruising more easily than normal, confusion, loss of appetite, diarrhea, dark or brown urine, dark or bloody stool, abdominal swelling, pain in upper right side of stomach area, sleepiness, vomiting of blood).1 (See Risk of Hepatic Decompensation or Failure in Patients with Evidence of Advanced Liver Disease under Cautions.)
-
Advise patients that glecaprevir/pibrentasvir may interact with some drugs.1 Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as any concomitant illnesses.1
-
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1
-
Importance of informing patients of other important precautionary information.1 (See Cautions.)
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.
Routes |
Dosage Forms |
Strengths |
Brand Names |
Manufacturer |
---|---|---|---|---|
Oral |
Tablets, film-coated |
Glecaprevir 100 mg and Pibrentasvir 40 mg |
Mavyret |
AbbVie |
AHFS DI Essentials™. © Copyright 2021, Selected Revisions April 6, 2020. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
References
1. AbbVie. Mavyret (glecaprevir and pibrentasvir) tablets prescribing information. North Chicago, IL; 2019 Sep.
2. US Food and Drug Administration. Center for Drug Evaluation and Research. Application number 209394Orig1s000: Clinical review. From FDA website. https://www.accessdata.fda.gov/drugsatfda_docs/nda/2017/209394Orig1s000MedR.pdf
3. Forns X, Lee SS, Valdes J et al. Glecaprevir plus pibrentasvir for chronic hepatitis C virus genotype 1, 2, 4, 5, or 6 infection in adults with compensated cirrhosis (EXPEDITION-1): a single-arm, open-label, multicentre phase 3 trial. Lancet Infect Dis. 2017; 17:1062-1068. http://www.ncbi.nlm.nih.gov/pubmed/28818546?dopt=AbstractPlus
4. Gane E, Lawitz E, Pugatch D et al. Glecaprevir and Pibrentasvir in Patients with HCV and Severe Renal Impairment. N Engl J Med. 2017; 377:1448-1455. http://www.ncbi.nlm.nih.gov/pubmed/29020583?dopt=AbstractPlus
5. Poordad F, Felizarta F, Asatryan A et al. Glecaprevir and pibrentasvir for 12 weeks for hepatitis C virus genotype 1 infection and prior direct-acting antiviral treatment. Hepatology. 2017; 66:389-397. http://www.ncbi.nlm.nih.gov/pubmed/28128852?dopt=AbstractPlus
6. Wyles D, Poordad F, Wang S et al. Glecaprevir/Pibrentasvir for HCV Genotype 3 Patients with Cirrhosis and/or Prior Treatment Experience: A Partially Randomized Phase III Clinical Trial. Hepatology. 2018; 67:514-23. http://www.ncbi.nlm.nih.gov/pubmed/28926120?dopt=AbstractPlus
7. Asselah T, Kowdley KV, Zadeikis N et al. Efficacy of Glecaprevir/Pibrentasvir for 8 or 12 Weeks in Patients With Hepatitis C Virus Genotype 2, 4, 5, or 6 Infection Without Cirrhosis. Clin Gastroenterol Hepatol. 2017; http://www.ncbi.nlm.nih.gov/pubmed/28951228?dopt=AbstractPlus
8. Hubbard H, Lawitz E. Glecaprevir + pibrentasvir (ABT493 + ABT-530) for the treatment of Hepatitis C. Expert Rev Gastroenterol Hepatol. 2017; :1-9. http://www.ncbi.nlm.nih.gov/pubmed/29187007?dopt=AbstractPlus
9. Kosloski MP, Zhao W, Asatryan A et al. No Clinically Relevant Drug-Drug Interactions between Methadone or Buprenorphine-Naloxone and Antiviral Combination Glecaprevir and Pibrentasvir. Antimicrob Agents Chemother. 2017; 61 http://www.ncbi.nlm.nih.gov/pubmed/28807904?dopt=AbstractPlus
10. Rockstroh JK, Lacombe K, Viani RM et al. Efficacy and Safety of Glecaprevir/Pibrentasvir in Patients Coinfected With Hepatitis C Virus and Human Immunodeficiency Virus Type 1: The EXPEDITION-2 Study. Clin Infect Dis. 2018; 67:1010-1017. http://www.ncbi.nlm.nih.gov/pubmed/29566246?dopt=AbstractPlus
11. Poordad F, Pol S, Asatryan A et al. Glecaprevir/Pibrentasvir in patients with hepatitis C virus genotype 1 or 4 and past direct-acting antiviral treatment failure. Hepatology. 2018; 67:1253-1260. http://www.ncbi.nlm.nih.gov/pubmed/29152781?dopt=AbstractPlus
12. Reau N, Kwo PY, Rhee S et al. Glecaprevir/Pibrentasvir Treatment in Liver or Kidney Transplant Patients With Hepatitis C Virus Infection. Hepatology. 2018; 68:1298-1307. http://www.ncbi.nlm.nih.gov/pubmed/29672891?dopt=AbstractPlus
13. Foster GR, Asselah T, Kopecky-Bromberg S et al. Safety and efficacy of glecaprevir/pibrentasvir for the treatment of chronic hepatitis C in patients aged 65 years or older. PLoS One. 2019; 14:e0208506. http://www.ncbi.nlm.nih.gov/pubmed/30601818?dopt=AbstractPlus
14. Gane E, Poordad F, Zadeikis N et al. Safety and Pharmacokinetics of Glecaprevir/Pibrentasvir in Adults With Chronic Genotype 1-6 Hepatitis C Virus Infections and Compensated Liver Disease. Clin Infect Dis. 2019; http://www.ncbi.nlm.nih.gov/pubmed/30923816?dopt=AbstractPlus
15. Kosloski MP, Zhao W, Marbury TC et al. Effects of Renal Impairment and Hemodialysis on the Pharmacokinetics and Safety of the Glecaprevir and Pibrentasvir Combination in Hepatitis C Virus-Negative Subjects. Antimicrob Agents Chemother. 2018; 62 http://www.ncbi.nlm.nih.gov/pubmed/29263061?dopt=AbstractPlus
16. Asselah T, Lee SS, Yao BB et al. Efficacy and safety of glecaprevir/pibrentasvir in patients with chronic hepatitis C virus genotype 5 or 6 infection (ENDURANCE-5,6): an open-label, multicentre, phase 3b trial. Lancet Gastroenterol Hepatol. 2019; 4:45-51. http://www.ncbi.nlm.nih.gov/pubmed/30393106?dopt=AbstractPlus
17. Zeuzem S, Foster GR, Wang S et al. Glecaprevir-Pibrentasvir for 8 or 12 Weeks in HCV Genotype 1 or 3 Infection. N Engl J Med. 2018; 378:354-369. http://www.ncbi.nlm.nih.gov/pubmed/29365309?dopt=AbstractPlus
18. Kosloski MP, Wang H, Pugatch D et al. Pharmacokinetics and safety of glecaprevir and pibrentasvir in HCV-negative subjects with hepatic impairment. Eur J Clin Pharmacol. 2019; 75:217-226. http://www.ncbi.nlm.nih.gov/pubmed/30341499?dopt=AbstractPlus
19. Kosloski MP, Zhao W, Li H et al. Drug-Drug Interactions of Tacrolimus or Cyclosporine With Glecaprevir and Pibrentasvir in Healthy Subjects. Clin Pharmacol Drug Dev. 2019; http://www.ncbi.nlm.nih.gov/pubmed/30861340?dopt=AbstractPlus
20. Yu G, Li GF, Zhou HH. Proton-pump inhibitors and glecaprevir plus pibrentasvir in HCV infection. Lancet Infect Dis. 2017; 17:1239-1240. http://www.ncbi.nlm.nih.gov/pubmed/29173883?dopt=AbstractPlus
21. Forns X, Mensa FJ. Proton-pump inhibitors and glecaprevir plus pibrentasvir in HCV infection - Authors' reply. Lancet Infect Dis. 2017; 17:1240. http://www.ncbi.nlm.nih.gov/pubmed/29173884?dopt=AbstractPlus
22. Flamm S, Reddy KR, Zadeikis N et al. Efficacy and Pharmacokinetics of Glecaprevir and Pibrentasvir With Concurrent Use of Acid-Reducing Agents in Patients With Chronic HCV Infection. Clin Gastroenterol Hepatol. 2019; 17:527-535.e6. http://www.ncbi.nlm.nih.gov/pubmed/30012435?dopt=AbstractPlus
23. Jonas MM, Squires RH, Rhee SM et al. Pharmacokinetics, Safety, and Efficacy of Glecaprevir/Pibrentasvir in Adolescents with Chronic HCV: Part 1 of the DORA Study. Hepatology. 2019; http://www.ncbi.nlm.nih.gov/pubmed/31254392?dopt=AbstractPlus
24. Brown RS, Buti M, Rodrigues L et al. Glecaprevir/pibrentasvir for 8 weeks in treatment-naïve patients with chronic HCV genotypes 1-6 and compensated cirrhosis: the EXPEDITION-8 trial. J Hepatol. 2019; http://www.ncbi.nlm.nih.gov/pubmed/31682879?dopt=AbstractPlus
25. US Food and Drug Administration. FDA drug safety communication: FDA warns about the risk of hepatitis B reactivating in some patients treated with direct-acting antivirals for hepatitis C. 2016 Oct 4. From FDA website. http://www.fda.gov/Drugs/DrugSafety/ucm522932.htm
26. US Food and Drug Administration. FDA drug safety communication: FDA warns about rare occurrence of serious liver injury with use of hepatitis C medicines Mavyret, Zepatier, and Vosevi in some patients with advanced liver disease. 2019 Aug 28. From FDA website. https://www.fda.gov/media/130351/download
119. American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America. HCV guidance: Recommendations for testing, managing, and treating hepatitis C. From the AASLD website. Accessed 2019 November 5. http://www.hcvguidelines.org
200. Panel on Antiretroviral Guidelines for Adults and Adolescents, US Department of Health and Human Services (HHS). Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Accessed January 2, 2020. Updates may be available at HHS AIDS Information (AIDSinfo) website. http://www.aidsinfo.nih.gov
Frequently asked questions
- Does Mavyret cure hep C (HCV)? What is the success rate?
- Can you take antibiotics with Mavyret?
- Does Mavyret cause itching?
- What are the new drugs for the treatment of hepatitis C?
- What types of Hepatitis C does Mavyret treat?
More about glecaprevir / pibrentasvir
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