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Miglustat

Pronunciation

(MIG loo stat)

Index Terms

  • OGT-918

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral:

Zavesca: 100 mg [contains soybean lecithin]

Brand Names: U.S.

  • Zavesca

Pharmacologic Category

  • Enzyme Inhibitor
  • Glucosylceramide Synthase Inhibitor

Pharmacology

Miglustat competitively and reversibly inhibits the enzyme needed to produce glycosphingolipids and decreases the rate of glycosphingolipid glucosylceramide formation. Glucosylceramide accumulates in type 1 Gaucher disease, causing complications specific to this disease.

Distribution

Vd: 83-105 L

Metabolism

No evidence of metabolism in humans

Excretion

Urine (as unchanged drug)

Time to Peak

Plasma: 2-2.5 hours

Half-Life Elimination

6-7 hours

Protein Binding

No binding to plasma proteins

Special Populations: Renal Function Impairment

Limited data suggests that the clearance of miglustat decreases 40% and 60% with mild and moderate renal impairment, respectively; dosage reduction recommended. A decreased clearance of 70% has been suggested in patients with severe renal impairment.

Use: Labeled Indications

Gaucher disease: Treatment of adult patients with mild-to-moderate type 1 Gaucher disease for whom enzyme replacement therapy is not a therapeutic option (eg, due to allergy, hypersensitivity, or poor venous access)

Contraindications

There are no contraindications listed in the manufacturer’s labeling.

Canadian labeling: Hypersensitivity to miglustat or any component of the formulation; women who are or may become pregnant

Dosing: Adult

Type 1 Gaucher disease: Oral: 100 mg 3 times daily; dose may be reduced to 100 mg 1 to 2 times daily in patients with adverse effects (ie, tremor, diarrhea)

Niemann-Pick Type C disease (off-label use) Oral: 200 mg 3 times daily (Patterson 2007; Santos-Lozano 2015)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Niemann-Pick Type C disease (off-label use; Patterson 2012): Oral:

Children <12 years: Limited data available. Note: Therapy is recommended for patients with neurological, cognitive, or psychiatric disease manifestations. Doses may be initiated slowly and adjusted for tolerability, particularly GI effects (diarrhea which may require dietary and pharmacologic management); several months of therapy may be necessary to see clinical benefit (eg, 6 to 12 months)

BSA >1.25 m2: 200 mg 3 times daily

BSA >0.88 to 1.25 m2: 200 mg 2 times daily

BSA >0.73 to 0.88 m2: 100 mg 3 times daily

BSA >0.47 to 0.73 m2: 100 mg 2 times daily

BSA ≤0.47 m2: 100 mg once daily

Children ≥12 years and Adolescents: Refer to adult dosing.

Dosing: Renal Impairment

Gaucher disease: Adults:

CrCl >70 mL/minute/1.73 m2: No dosage adjustment necessary.

CrCl 50 to 70 mL/minute/1.73 m2: 100 mg twice daily

CrCl 30 to 50 mL/minute/1.73 m2: 100 mg once daily

CrCl <30 mL/minute/1.73 m2: Use not recommended

Niemann-Pick Type C disease: (off-label use) (Zavesca Canadian labeling 2012)

Children ≥12 years, Adolescents, and Adults:

CrCl 50 to 70 mL/minute/1.73 m2: 200 mg twice daily

CrCl 30 to 50 mL/minute/1.73 m2: 100 mg twice daily

CrCl <30 mL/minute/1.73 m2: Use not recommended

Children <12 years:

CrCl 50 to 70 mL/minute/1.73 m2: Administer two-thirds of regular dose in 2 equal doses (adjusted for BSA)

CrCl 30 to 50 mL/minute/1.73 m2: Administer one-third of regular dose in 2 equal doses (adjusted for BSA)

CrCl <30 mL/minute/1.73 m2: Not recommended

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied). However, dosage adjustment unlikely because miglustat is not metabolized by the liver.

Administration

May be administered with or without food; administration between meals may decrease the incidence of diarrhea. Capsules should be taken at the same time each day at regular intervals. If patient is unable to tolerate or swallow capsule whole and powder is administered, mix powder into a liquid immediately prior to use (do not store); sweetening agents are not expected to interact (data on file [Actelion Pharmaceuticals Ltd, 2011])

Dietary Considerations

Patients with diarrhea should avoid foods with high carbohydrate content.

Storage

Store at 20°C to 25°C (68°F to 77°F). Brief exposure to 15°C to 30°C (59°F to 86°F) permitted. Note: Extended storage information may be available; contact product manufacturer to obtain current recommendations.

Drug Interactions

There are no known significant interactions.

Adverse Reactions

Percentages reported from open-label, uncontrolled monotherapy trials.

>10%:

Central nervous system: Headache (21% to 22%), dizziness (≤11%)

Endocrine & metabolic: Weight loss (39% to 67%)

Gastrointestinal: Diarrhea (89% to 100%), abdominal pain (18% to 67%), flatulence (29% to 50%), nausea (8% to 22%), vomiting (4% to 11%)

Neuromuscular & skeletal: Tremor (11% to 30%), weakness (17%), leg cramps (4% to 11%)

Ophthalmic: Visual disturbance (≤17%)

1% to 10%:

Central nervous system: Memory impairment (8%), unsteady gait (8%), paresthesia (≤7%), migraine (≤6%)

Endocrine & metabolic: Menstrual disease (≤6%)

Gastrointestinal: Abdominal distension (8%), constipation (8%), xerostomia (8%), anorexia (≤7%), dyspepsia (≤7%), bloating (≤6%), epigastric pain (≤6%)

Hematologic & oncologic: Thrombocytopenia (6% to 7%)

Neuromuscular & skeletal: Back pain (8%)

Warnings/Precautions

Concerns related to adverse effects:

• Diarrhea: Observed in the majority of patients, many also reported weight loss (within first 12 months of treatment). Diarrhea decreased over time with continued treatment, and may respond to diet modification (eg, reduction of sucrose, lactose and other carbohydrate intake), taking miglustat between meals, and/or to anti-diarrheal medications. If diarrhea occurs during treatment, instruct patients to avoid foods with high carbohydrate content. If symptoms persist, evaluate patients for underlying GI disease.

• Peripheral neuropathy: Peripheral neuropathy has been reported; neurologic monitoring is required. Weigh risk versus benefit of therapy if patient develops symptoms (eg, numbness and tingling); treatment discontinuation may be necessary.

• Platelet counts decreased: Mild decrease in platelet counts (without bleeding) has been observed in patients with type 1 Gaucher disease switched from enzyme replacement therapy; monitor platelet counts during therapy.

• Tremor: New-onset or exacerbations of existing tremor may occur. Tremor typically begins within the first month of treatment and may resolve over time (1-3 months) or respond to dosage reduction. Treatment discontinuation may be necessary if tremor does not respond within days of dose reduction.

Disease-related concerns:

• Renal impairment: Use with caution in patients with renal impairment; dosage adjustments recommended. Not recommended in patients with severe impairment.

Other warnings/precautions:

• Experienced physician: Should be administered under the supervision of a physician experienced in treatment of Gaucher disease.

• Registry: A registry has been established and all patients with Gaucher disease, and physicians who treat Gaucher disease are encouraged to participate. Information on the International Collaborative Gaucher Group (ICGG) Gaucher Registry may be obtained at https://www.registrynxt.com or by calling 1-888-404-4413.

Monitoring Parameters

Neurologic evaluations baseline and repeated every 6 months; adverse effects; weight; platelet count; renal function

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse events were observed in animal reproduction studies. In addition, adverse effects on spermatogenesis and reduced fertility were observed in male animal studies; however, no effect on sperm was observed in healthy male patients. Uncontrolled type 1 Gaucher disease is associated an increased risk of spontaneous abortion; maternal hepatosplenomegaly and thrombocytopenia may also occur and lead to adverse pregnancy outcomes.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience dizziness, abdominal pain, heartburn, nausea, vomiting, flatulence, dry mouth, back pain, constipation, leg cramps, muscle cramps, lack of appetite, bloating, loss of strength and energy, weight loss, sensation of heaviness in extremities, or menstrual irregularities. Have patient report immediately to prescriber severe diarrhea, burning or numbness feeling, vision changes, bruising, bleeding, memory impairment, severe headache, tremors, or abnormal gait (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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