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Sivextro

Generic Name: Tedizolid Phosphate
Class: Oxazolidinones
Chemical Name: (5R) - 3 - [3 - Fluoro - 4 - [6 - (2 - methyl - 2H - tetrazol - 5 - yl) - 3 - pyridinyl]phenyl] - 5 - (hydroxymethyl) - 2 - oxazolidinone
Molecular Formula: C17H15FN6O3C17H16FN6O6P
CAS Number: 856866-72-3

Introduction

Antibacterial; oxazolidinone.1 5 6 10

Uses for Sivextro

Skin and Skin Structure Infections

Treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA; also known as oxacillin-resistant S. aureus or ORSA] and methicillin-susceptible S. aureus), Streptococcus pyogenes (group A β-hemolytic streptococci, GAS), S. agalactiae (group B streptococci, GBS), S. anginosus group (includes S. anginosus, S. intermedius, and S. constellatus), or Enterococcus faecalis.1 2 3

Sivextro Dosage and Administration

Administration

Administer orally or by IV infusion.1

Oral Administration

Administer orally without regard to meals.1

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer only by IV infusion;1 do not administer by rapid or direct IV injection.1 Not intended for IM, intra-arterial, intrathecal, intraperitoneal, or sub-Q administration.1

Must be reconstituted and further diluted prior to IV infusion.1

Do not add or infuse simultaneously with other IV substances, additives, or drugs.1

If the same IV line is used for sequential infusion of several different drugs, flush IV line with 0.9% sodium chloride injection before and after infusion.1

Vials contain no preservatives; for single use only.1

Reconstitution

Reconstitute vial containing 200 mg of tedizolid phosphate by adding 4 mL of sterile water for injection.1 Gently swirl vial; leave standing until lyophilized powder or cake dissolves and foam disperses.1 Avoid vigorous agitation or shaking to minimize foaming.1

Inspect to ensure that no particulate matter, powder, or cake is attached to sides of vial.1 If needed, invert and gently swirl vial to dissolve any remaining powder.1 Reconstituted solution should appear clear and colorless to pale yellow.1

Dilution

Tilt reconstituted vial and withdraw 4 mL of reconstituted solution from bottom corner of vial using a syringe; avoid inverting vial while withdrawing solution.1 Slowly add the 4 mL of reconstituted solution to IV bag containing 250 mL of 0.9% sodium chloride injection.1 Gently invert bag to mix; do not shake.1

Reconstituted and diluted IV solution should appear clear and colorless to pale yellow.1 Inspect visually for particulate matter prior to administration; discard if particles are observed.1

Rate of Administration

Administer by IV infusion over 1 hour.1

Dosage

Available as tedizolid phosphate (inactive prodrug of tedizolid);1 dosage expressed in terms of tedizolid phosphate.1

Adults

Skin and Skin Structure Infections
Oral or IV

200 mg once daily for 6 days.1

Special Populations

Dosage adjustments not needed based on gender, race, body weight, or body mass index (BMI).1 19

Hepatic Impairment

Dosage adjustments not needed in patients with hepatic impairment.1 19 20

Renal Impairment

Dosage adjustments not needed in patients with renal impairment or undergoing hemodialysis.1 19 20

Geriatric Patients

Dosage adjustments not needed based on age.19

Cautions for Sivextro

Contraindications

  • Manufacturer states none.1

Warnings/Precautions

Patients with Neutropenia

Safety and efficacy in patients with neutropenia (i.e., neutrophil counts <1000 cells/mm3) not evaluated.1 In an animal model of infection, antibacterial activity of tedizolid was reduced in the absence of granulocytes.1

Consider alternative therapies when treating acute bacterial skin and skin structure infections in patients with neutropenia.1

Hematologic Effects

In phase 1 studies in healthy adults receiving tedizolid for 21 days, there was evidence of possible dose and duration effect on hematologic parameters after day 6.1 In phase 3 studies in patients with acute bacterial skin and skin structure infections, rate of clinically important hematologic changes generally were similar in those treated with tedizolid (6-day regimen) or linezolid (10-day regimen).1

Neuropathy

Peripheral and optic neuropathies reported in patients who received >28 days of treatment with another oxazolidinone anti-infective (not tedizolid).1 In phase 3 studies of tedizolid in patients with acute bacterial skin and skin structure infections, peripheral neuropathy and optic nerve disorders reported in similar frequencies in those treated with tedizolid or linezolid.1 Data not available for patients exposed to >6 days of tedizolid.1

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Possible emergence and overgrowth of nonsusceptible bacteria or fungi.1 Monitor carefully; institute appropriate therapy if superinfection occurs.1

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.1 12 14 15 C. difficile infection (CDI) and C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) reported with nearly all anti-infectives, including tedizolid, and may range in severity from mild diarrhea to fatal colitis.1 12 14 15 C. difficile produces toxins A and B which contribute to development of CDAD;1 12 hypertoxin-producing strains of C. difficile are associated with increased morbidity and mortality since they may be refractory to anti-infectives and colectomy may be required.1

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.1 12 14 15 Obtain careful medical history since CDAD may occur as late as ≥2 months after anti-infective therapy is discontinued.1

If CDAD suspected or confirmed, discontinue anti-infectives not directed against C. difficile whenever possible.1 12 Initiate appropriate supportive therapy (e.g., fluid and electrolyte management, protein supplementation), anti-infective therapy directed against C. difficile (e.g., metronidazole, vancomycin), and surgical evaluation as clinically indicated.1 12 14 15

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of tedizolid and other antibacterials, use only for treatment of infections proven or strongly suspected to be caused by susceptible bacteria.1

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.1 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.1

Specific Populations

Pregnancy

Category C.1

Use during pregnancy only if potential benefits justify potential risks to fetus.1

No adequate and well-controlled studies in pregnant women;1 animal studies (mice, rats, rabbits) revealed reduced fetal weight, costal cartilage anomalies, increased skeletal variations, and/or reduced maternal weight at dosages at least 4 times estimated human exposure.1

Lactation

Distributed into milk in rats;1 not known whether distributed into human milk.1

Use with caution in nursing women.1

Pediatric Use

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

Geriatric Use

Insufficient numbers of patients ≥65 years of age in clinical studies to determine whether they respond differently than younger adults.1 Differences in pharmacokinetics not observed between elderly and younger patients;1 dosage adjustments not needed.1

Hepatic Impairment

Moderate or severe hepatic impairment (Child-Pugh class B or C): No clinically important pharmacokinetic changes.1

Renal Impairment

Severe renal impairment (Clcr <30 mL/minute per 1.73 m2): No clinically important pharmacokinetic changes;1 no clinically important removal during hemodialysis.1

Common Adverse Effects

Nausea,1 2 3 headache,1 2 3 diarrhea,1 2 3 vomiting,1 2 3 dizziness,1 2 fatigue.3

Interactions for Sivextro

Tedizolid phosphate and tedizolid not substrates for and do not inhibit or induce CYP isoenzymes (CYP1A2, 2B6, 2D6, 2C8, 2C9, 2C19, 3A4) in vitro.1 21 Drug interactions involving oxidative metabolism and CYP isoenzymes unlikely.1

No clinically important effect on drug uptake or drug efflux membrane transporters (e.g., organic anion transporter [OAT] 1, OAT3, organic anion transporting polypeptide [OATP] 1B1, OATP1B3, organic cation transporter [OCT] 1, OCT2, P-glycoprotein [P-gp], breast cancer resistance protein [BCRP]) in vitro.1

Specific Drugs and Foods

Drug

Interaction

Comments

Antibacterials (aztreonam, ceftazidime, ceftriaxone, ciprofloxacin, clindamycin, co-trimoxazole, daptomycin, gentamicin, imipenem, minocycline, rifampin, vancomycin)

No in vitro evidence of synergistic or antagonistic effects against gram-positive or gram-negative bacteria1 7

Antifungals (amphotericin B, ketoconazole, terbinafine)

No in vitro evidence of synergistic or antagonistic effects against gram-positive bacteria1 7

Food, tyramine-containing

Recommended dosage (200 mg of tedizolid phosphate daily) not expected to exert clinically important pressor response in patients receiving a tyramine-rich meal;4 21 palpitations reported in 72% of patient receiving tedizolid with tyramine compared with 46% of patients receiving tyramine with placebo1

Restrictions of foods high in tyramine not needed21

MAO inhibitors

Tedizolid is a weak4 reversible inhibitor of MAO in vitro;1 4 interactions with MAO inhibitors not evaluated in clinical studies1

Pseudoephedrine

No substantial increase in maximum BP or heart rate when recommended dosage (200 mg of tedizolid phosphate daily) used with pseudoephedrine (60 mg);1 4 no effect on pharmacokinetics of either drug4

Serotonergic drugs (SSRIs, tricyclic antidepressants, serotonin type 1 [5-hydroxytryptamine; 5-HT1] receptor agonists [“triptans”], meperidine, buspirone)

No evidence of serotonergic activity in mouse model using tedizolid dosages up to 30-fold higher than equivalent human dosages;1 interactions with serotonergic agents not evaluated in clinical studies1

Sivextro Pharmacokinetics

Absorption

Bioavailability

Tedizolid phosphate rapidly converted in vivo by phosphatases to the active moiety, tedizolid.1 10 11 Well absorbed following oral administration; absolute bioavailability approximately 91%.1 8 11 19

Peak plasma concentrations of tedizolid achieved approximately 3 hours after oral administration in the fasted state or at end of a 1-hour IV infusion.1

Food

Systemic exposure similar whether given orally in the fasted state or with high-fat, high-calorie meal.1 13

Plasma Concentrations

Steady-state concentrations achieved within approximately 3 days with oral or IV administration; accumulation is about 30% after ≥7 days of once-daily dosing.1 11 13

Distribution

Extent

Distributed into interstitial space fluid of adipose and skeletal muscle tissue at concentrations similar to plasma concentrations.1 8

Distributed into epithelial lining fluid of pulmonary tissue in concentrations higher than plasma concentrations.16

Distributed into milk in rats;1 not known whether distributed into human milk.1

Plasma Protein Binding

70–90% bound to plasma proteins.1

Elimination

Metabolism

Tedizolid phosphate and tedizolid do not appear to be substrates of CYP enzymes.1 21

A major metabolite (tedizolid sulfate) and several minor metabolites identified in feces and urine.10

Elimination Route

Following single oral dose of tedizolid phosphate, excreted in feces (82%) and urine (18%), principally as the noncirculating sulfate conjugate;1 10 20 <3% eliminated in feces and urine as unchanged tedizolid.1 10

Approximately 10% of a dose removed by hemodialysis.20

Half-life

12 hours.1

Special Populations

No clinically important changes in peak plasma concentrations or AUC observed in adults with moderate or severe hepatic impairment (Child-Pugh class B or C), adults with severe renal impairment (Clcr <30 mL/minute per 1.73 m2), or geriatric adults ≥65 years of age.1 20

Stability

Storage

Oral

Tablets

20–25°C (may be exposed to 15–30°C).1

Parenteral

Powder for IV Infusion

20–25°C (may be exposed to 15–30°C).1

Store reconstituted or diluted solutions under refrigeration (i.e., 2–8°C) or at room temperature.1

Total time from reconstitution to administration should not exceed 24 hours whether stored at 2–8°C or room temperature.1

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility1

Compatible

Sodium chloride 0.9%

Incompatible

Dextrose 5% in Ringer's injection

Dextrose 5% in Ringer's injection, lactated

Hartmann's solution

Ringer's injection

Ringer's injection, lactated

Actions and Spectrum

  • Oxazolidinone anti-infective agent.1 5 6 10 Tedizolid phosphate is a prodrug and is inactive until hydrolyzed in vivo to tedizolid.1 5

  • Binds to 50S subunit of bacterial ribosomes resulting in inhibition of bacterial translation and inhibition of protein synthesis.1 5 Ribosomal binding site is similar to that of other oxazolidinones (e.g., linezolid),5 but tedizolid may engage additional sites compared with linezolid.5 6

  • Bacteriostatic in vitro against certain gram-positive bacteria, including staphylococci, streptococci, and enterococci.1 5

  • Active in vitro and in clinical infections against S. aureus (including methicillin-resistant S. aureus [MRSA; also known as oxacillin-resistant S. aureus]), S. pyogenes (group A β-hemolytic streptococci, GAS), S. agalactiae (group B streptococci, GBS), S. anginosus group (includes S. anginosus, S. intermedius, and S. constellatus), and E. faecalis.1 5 9 Some in vitro evidence that tedizolid may be more potent than linezolid against susceptible bacteria;5 6 9 tedizolid has been active against some strains of S. aureus resistant to linezolid.5 18

  • Active in vitro against E. faecium,1 S. epidermidis (including methicillin-resistant strains [oxacillin-resistant strains]),1 S. haemolyticus,1 and S. lugdunensis;1 safety and efficacy in treating clinical infections caused by these bacteria not established.1 Some in vitro evidence of activity against Mycobacterium tuberculosis.17

  • S. aureus and E. faecium with reduced susceptibility or resistance to tedizolid produced in vitro by serial passage in the presence of increasing concentrations of the drug;5 7 spontaneous mutations conferring reduced susceptibility reported in vitro.1

  • Cross-resistance between tedizolid and linezolid reported.5 7 Bacteria resistant to oxazolidinones via mutations in chromosomal genes encoding 23S rRNA or ribosomal proteins (L3 and L4) generally cross-resistant to tedizolid.1 In vitro data indicate presence of chloramphenicol-florfenicol resistance (cfr) gene in S. aureus that results in resistance to linezolid may not result in resistance to tedizolid in the absence of chromosomal mutations.1 5 6 7

  • Cross-resistance between tedizolid and non-oxazolidinone anti-infectives unlikely.1

Advice to Patients

  • Advise patients that antibacterials (including tedizolid) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).1

  • Importance of completing full course of therapy, even if feeling better after a few days.1

  • Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with tedizolid or other antibacterials in the future.1

  • Advise patients that tedizolid may be taken orally without regard to meals and without any dietary restriction.1

  • Importance of informing patients that if they miss a dose and it is remembered within 8 hours after the scheduled time, to take the dose as soon as possible and then take next scheduled dose at the usual time.1 If <8 hours remain before the next dose, skip the dose and wait until the next scheduled dose.1

  • Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.1 Importance of contacting a clinician if watery and bloody stools (with or without stomach cramps and fever) occur during or as late as 2 months or longer after the last dose.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.

Tedizolid Phosphate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, film-coated

200 mg

Sivextro

Cubist

Parenteral

For injection, for IV infusion only

200 mg

Sivextro

Cubist

AHFS DI Essentials. © Copyright 2016, Selected Revisions April 8, 2015. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

1. Sivextro. Cubist Pharmaceuticals (tedizolid) for injection prescribing information. Lexington, MA; 2014 June.

2. Prokocimer P, De Anda C, Fang E et al. Tedizolid phosphate vs linezolid for treatment of acute bacterial skin and skin structure infections: the ESTABLISH-1 randomized trial. JAMA. 2013; 309:559-69. [PubMed 23403680]

3. Moran GJ, Fang E, Corey GR et al. Tedizolid for 6 days versus linezolid for 10 days for acute bacterial skin and skin-structure infections (ESTABLISH-2): a randomised, double-blind, phase 3, non-inferiority trial. Lancet Infect Dis. 2014; :. [PubMed 24909499]

4. Flanagan S, Bartizal K, Minassian SL et al. In vitro, in vivo, and clinical studies of tedizolid to assess the potential for peripheral or central monoamine oxidase interactions. Antimicrob Agents Chemother. 2013; 57:3060-6. [PubMed 23612197]

5. Locke JB, Zurenko GE, Shaw KJ et al. Tedizolid for the management of human infections: in vitro characteristics. Clin Infect Dis. 2014; 58 Suppl 1:S35-42. [PubMed 24343830]

6. Locke JB, Finn J, Hilgers M et al. Structure-activity relationships of diverse oxazolidinones for linezolid-resistant Staphylococcus aureus strains possessing the cfr methyltransferase gene or ribosomal mutations. Antimicrob Agents Chemother. 2010; 54:5337-43. [PubMed 20837751]

7. US Food and Drug Administration. Center for Drug Evaluation and Research: Application number 205435Orig1s000: Microbiology/virology review. 2014 Feb 24. From FDA website.

8. Sahre M, Sabarinath S, Grant M et al. Skin and soft tissue concentrations of tedizolid (formerly torezolid), a novel oxazolidinone, following a single oral dose in healthy volunteers. Int J Antimicrob Agents. 2012; 40:51-4. [PubMed 22584101]

9. Prokocimer P, Bien P, Deanda C et al. In vitro activity and microbiological efficacy of tedizolid (TR-700) against Gram-positive clinical isolates from a phase 2 study of oral tedizolid phosphate (TR-701) in patients with complicated skin and skin structure infections. Antimicrob Agents Chemother. 2012; 56:4608-13. [PubMed 22687509]

10. Ong V, Flanagan S, Fang E et al. Absorption, distribution, metabolism, and excretion of the novel antibacterial prodrug tedizolid phosphate. Drug Metab Dispos. 2014; 42:1275-84. [PubMed 24875463]

11. Flanagan S, Fang E, Muñoz KA et al. Single- and multiple-dose pharmacokinetics and absolute bioavailability of tedizolid. Pharmacotherapy. 2014; :. [PubMed 24989138]

12. Cohen SH, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010; 31:431-55. [PubMed 20307191]

13. Flanagan SD, Bien PA, Muñoz KA et al. Pharmacokinetics of tedizolid following oral administration: single and multiple dose, effect of food, and comparison of two solid forms of the prodrug. Pharmacotherapy. 2014; 34:240-50. [PubMed 23926058]

14. Fekety R for the American College of Gastroenterology Practice Parameters Committee. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. Am J Gastroenterol. 1997; 92:739-50. [IDIS 386628] [PubMed 9149180]

15. American Society of Health-System Pharmacists Commission on Therapeutics. ASHP therapeutic position statement on the preferential use of metronidazole for the treatment of Clostridium difficile-associated disease. Am J Health-Syst Pharm. 1998; 55:1407-11. [IDIS 407213] [PubMed 9659970]

16. Housman ST, Pope JS, Russomanno J et al. Pulmonary disposition of tedizolid following administration of once-daily oral 200-milligram tedizolid phosphate in healthy adult volunteers. Antimicrob Agents Chemother. 2012; 56:2627-34. [PubMed 22330925]

17. Molina-Torres CA, Barba-Marines A, Valles-Guerra O et al. Intracellular activity of tedizolid phosphate and ACH-702 versus Mycobacterium tuberculosis infected macrophages. Ann Clin Microbiol Antimicrob. 2014; 13:13. [PubMed 24708819]

18. Rodríguez-Avial I, Culebras E, Betriu C et al. In vitro activity of tedizolid (TR-700) against linezolid-resistant staphylococci. J Antimicrob Chemother. 2012; 67:167-9. [PubMed 21954458]

19. Flanagan S, Passarell J, Lu Q et al. Tedizolid population pharmacokinetics, exposure-response, and target attainment. Antimicrob Agents Chemother. 2014; :. [PubMed 25136028]

20. Flanagan S, Minassian SL, Morris D et al. Pharmacokinetics of tedizolid in subjects with renal or hepatic impairment. Antimicrob Agents Chemother. 2014; 58:6471-6. [PubMed 25136024]

21. US Food and Drug Administration. Center for Drug Evaluation and Research: Application number 205435Orig1s000: Clinicaal pharmacology and biopharmaceutics review(s). From FDA website.

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