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Mavyret

Generic Name: 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

Medically reviewed on Oct 1, 2018

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

See also: Harvoni

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 Mavyret

Chronic HCV Infection

Treatment of chronic HCV genotype 1, 2, 3, 4, 5, or 6 infection in treatment-naive (previously untreated) or previously treated adults without cirrhosis or with compensated cirrhosis, including those with HIV coinfection.1 3 4 5 6 7 119

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

Mavyret 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.1

Adults

Treatment of Chronic HCV Infection
HCV Genotype 1, 2, 3, 4, 5, or 6 Infection
Oral

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.)

Table 1. Recommended Treatment Duration of Glecaprevir/Pibrentasvir in Treatment-naive Adults with HCV Genotype 1, 2, 3, 4, 5, or 6 Infection.1119

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)

12 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 in conjunction with peginterferon and ribavirin.1

In clinical trials, patients previously received HCV regimens containing simeprevir in conjunction with sofosbuvir or simeprevir (or boceprevir or telaprevir [no longer commercially available]) in conjunction with peginterferon and ribavirin.1

Table 2. Recommended Treatment Duration of Glecaprevir/Pibrentasvir in Previously Treated Adults with HCV Genotype 1, 2, 3, 4, 5, or 6 Infection.1119

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 Coinfected with HIV
Oral

Dosage and duration of therapy generally same as those recommended for adults without HIV coinfection.1 119 (See Specific Drugs under Interactions.)

Special Populations

Hepatic Impairment

Mild hepatic impairment (Child-Pugh class A): Dosage adjustments not needed.1

Moderate hepatic impairment (Child-Pugh class B): Not recommended.1 (See Hepatic Impairment under Cautions.)

Severe hepatic impairment (Child-Pugh class C): Contraindicated.1

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 Mavyret

Contraindications

  • Severe hepatic impairment (Child-Pugh class C).1

  • 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 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

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 distributed 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 and efficacy not established in pediatric patients <18 years of age.1

Geriatric Use

No overall differences in safety and efficacy observed between patients ≥65 years of age and younger adults.1

Hepatic Impairment

Mild hepatic impairment (Child-Pugh class A): Dosage adjustments not needed.1

Moderate hepatic impairment (Child-Pugh class B): Safety and efficacy not established;1 not recommended.1

Severe hepatic impairment (Child-Pugh class C): Contraindicated;1 substantially increased glecaprevir and pibrentasvir AUCs.1

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 individuals 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 headache,1 3 5 6 7 fatigue,1 3 4 5 6 7 nausea,1 3 4 5 diarrhea,1 3 asthenia,1 urinary tract infection.3

Interactions for Mavyret

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 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 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 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

Abacavir

Fixed combination of abacavir, dolutegravir, and lamivudine (abacavir/dolutegravir/lamivudine): No clinically important pharmacokinetic interactions 1

Abacavir: Dosage adjustments not needed1

Angiotensin II receptor antagonists (losartan, valsartan)

Losartan, valsartan: No clinically important pharmacokinetic interactions1

Losartan, valsartan: Dosage adjustments not needed1

Anticonvulsants (carbamazepine, lamotrigine)

Carbamazepine: Clinically important decreases in glecaprevir and pibrentasvir concentrations and AUCs; may result in loss of therapeutic effect1

Lamotrigine: No clinically important pharmacokinetic interactions1

Carbamazepine: 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 effect1

Rifampin: Contraindicated1

Atazanavir

Ritonavir-boosted atazanavir: Increased glecaprevir and pibrentasvir concentrations and AUC;1 possible increased ALT concentrations1

Cobicistat-boosted, ritonavir-boosted, or unboosted atazanavir: Concomitant use with glecaprevir/pibrentasvir contraindicated1 200

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 plasma 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

Darunavir

Ritonavir-boosted darunavir: Increased glecaprevir concentrations and AUC and increased pibrentasvir concentrations1

Cobicistat-boosted or ritonavir-boosted darunavir: Concomitant use not recommended1 200

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

Dolutegravir

Abacavir/dolutegravir/lamivudine: No clinically important pharmacokinetic interactions1

Dolutegravir: Dosage adjustments not needed1 200

Efavirenz

Decreased glecaprevir and pibrentasvir concentrations expected;1 possible reduced therapeutic effect of glecaprevir/pibrentasvir1

Concomitant use not recommended1 200

Elvitegravir

Fixed combination of elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (EVG/c/FTC/TAF): Increased concentrations and AUCs of glecaprevir and pibrentasvir;1 increased elvitegravir AUC200

Cobicistat-boosted elvitegravir: Dosage adjustments not needed1 200

EVG/c/FTC/TAF or fixed combination of elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate (EVG/c/FTC/TDF): Consider monitoring for hepatotoxicity200

Emtricitabine

EVG/c/FTC/TAF: Increased concentrations and AUCs of glecaprevir and pibrentasvir1

Emtricitabine: Dosage adjustments not needed1

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

Etravirine

Possible decreased glecaprevir and pibrentasvir concentrations200

Concomitant use not recommended200

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 AUC1

Tacrolimus: No clinically important pharmacokinetic interactions1

Cyclosporine: Concomitant use not recommended in patients receiving stable cyclosporine dosage >100 mg daily1

Tacrolimus: Dosage adjustments not needed1

Lamivudine

Abacavir/dolutegravir/lamivudine: No clinically important pharmacokinetic interactions1

Lamivudine: Dosage adjustments not needed1

Lopinavir

Fixed combination of lopinavir and ritonavir (lopinavir/ritonavir): Increased glecaprevir and pibrentasvir concentrations and AUCs1

Lopinavir/ritonavir: Concomitant use not recommended1 200

Maraviroc

No effect on maraviroc pharmacokinetics expected200

Dosage adjustments not needed200

Methadone

No clinically important pharmacokinetic interactions1 9

Dosage adjustments not needed1 9

Nevirapine

Possible decreased glecaprevir and pibrentasvir concentrations200

Concomitant use not recommended200

Proton-pump inhibitors (PPIs)

Omeprazole: No clinically important pharmacokinetic interactions1

Omeprazole: Dosage adjustments not needed1

Raltegravir

Increased raltegravir concentrations and AUC1

Dosage adjustments not needed1 200

Rilpivirine

Increased rilpivirine concentrations and AUC1

Dosage adjustments not needed1 200

Ritonavir

Increased glecaprevir and pibrentasvir concentrations expected1

Concomitant use not recommended1

Sofosbuvir

No clinically important pharmacokinetic interactions1

Dosage adjustments not needed1

St. John's Wort (Hypericum perforatum)

Possible substantially decreased glecaprevir and pibrentasvir concentrations;1 possible loss of therapeutic effect1

Concomitant use not recommended1

Tenofovir

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 (tenofovir DF): Increased tenofovir concentrations and AUC1

Tenofovir alafenamide or tenofovir DF: Dosage adjustments not needed1 200

EVG/c/FTC/TAF or EVG/c/FTC/TDF: Consider monitoring for hepatotoxicity200

Tipranavir

Ritonavir-boosted atazanavir: Concomitant use not recommended200

Tolbutamide

No clinically important pharmacokinetic interactions1

Dosage adjustments not needed1

Warfarin

Possible INR fluctuations1

Closely monitor INR during and after HCV treatment1

Mavyret 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 individuals with compensated cirrhosis (Child-Pugh class A): Glecaprevir exposures approximately twofold higher than those reported in individuals with normal hepatic function;1 pibrentasvir exposures similar to those in individuals with normal hepatic function.1

HCV-infected individuals with moderate hepatic impairment (Child-Pugh class B): Glecaprevir exposures twofold higher and pibrentasvir exposures 26% higher than those in individuals with normal hepatic function.1

HCV-infected individuals with severe hepatic impairment (Child-Pugh class C): Glecaprevir exposures 11-fold higher 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% higher than those in individuals with normal renal function.1 In dialysis-dependent individuals, pibrentasvir and glecaprevir exposures similar with or without dialysis (up to 18% difference).1

HCV-infected individuals with ESRD (with or without dialysis): Glecaprevir and pibrentasvir exposures 86 and 54% higher, respectively, than reported in individuals with normal renal function.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., M28G, 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 the fixed-combination preparation of glecaprevir and pibrentasvir (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 the 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 the 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 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.

Glecaprevir and Pibrentasvir

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

Glecaprevir 100 mg and Pibrentasvir 40 mg

Mavyret

AbbVie

AHFS DI Essentials™. © Copyright 2019, Selected Revisions October 1, 2018. 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; 2017 Dec.

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

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

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 2018 February 15. 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 living with HIV (October 17, 2017). Updates may be available at HHS AIDS Information (AIDSinfo) website. http://www.aidsinfo.nih.gov

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