Generic Name: nintedanib
Dosage Form: capsule
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
Testing Prior to Ofev Administration
Ofev capsules should be taken with food [see Clinical Pharmacology (12.3)] and swallowed whole with liquid. Ofev capsules should not be chewed or crushed because of a bitter taste. The effect of chewing or crushing of the capsule on the pharmacokinetics of nintedanib is not known.
If a dose of Ofev is missed, the next dose should be taken at the next scheduled time. Advise the patient to not make up for a missed dose. Do not exceed the recommended maximum daily dosage of 300 mg.
Dosage Modification due to Adverse Reactions
In addition to symptomatic treatment, if applicable, the management of adverse reactions of Ofev may require dose reduction or temporary interruption until the specific adverse reaction resolves to levels that allow continuation of therapy. Ofev treatment may be resumed at the full dosage (150 mg twice daily), or at the reduced dosage (100 mg twice daily), which subsequently may be increased to the full dosage. If a patient does not tolerate 100 mg twice daily, discontinue treatment with Ofev [see Warnings and Precautions (5.2, 5.3, 5.5, 5.7) and Adverse Reactions (6.1)].
Dose modifications or interruptions may be necessary for liver enzyme elevations. For aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >3 times to <5 times the upper limit of normal (ULN) without signs of severe liver damage, interrupt treatment or reduce Ofev to 100 mg twice daily. Once liver enzymes have returned to baseline values, treatment with Ofev may be reintroduced at a reduced dosage (100 mg twice daily), which subsequently may be increased to the full dosage (150 mg twice daily) [see Warnings and Precautions (5.2) and Adverse Reactions (6.1)]. Discontinue Ofev for AST or ALT elevations >5 times ULN or >3 times ULN with signs or symptoms of severe liver damage.
3 DOSAGE FORMS AND STRENGTHS
5 WARNINGS AND PRECAUTIONS
Treatment with Ofev is not recommended in patients with moderate (Child Pugh B) or severe (Child Pugh C) hepatic impairment [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)]. Patients with mild hepatic impairment (Child Pugh A) can be treated with a reduced dose of Ofev [see Dosage and Administration (2.2)].
Elevated Liver Enzymes
Cases of drug-induced liver injury have been observed with Ofev treatment [see Adverse Reactions (6.2)]. In clinical trials, administration of Ofev was associated with elevations of liver enzymes (ALT, AST, ALKP, GGT) and bilirubin. Liver enzyme and bilirubin increases were reversible with dose modification or interruption. The majority (94%) of patients with ALT and/or AST elevations had elevations <5 times ULN. The majority (95%) of patients with bilirubin elevations had elevations <2 times ULN [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)]. Patients with a low body weight (<65 kg), Asian, and female patients may have a higher risk of elevations in liver enzymes. Nintedanib exposure increased with patient age, which may also result in a higher risk of increased liver enzymes [see Clinical Pharmacology (12.3)]. Conduct liver function tests (ALT, AST, and bilirubin) prior to treatment with Ofev, then as clinically indicated. Dosage modifications or interruption may be necessary for liver enzyme elevations. If serious liver injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs during treatment with Ofev, promptly interrupt therapy [see Dosage and Administration (2.1, 2.3)].
Diarrhea was the most frequent gastrointestinal event reported in 62% versus 18% of patients treated with Ofev and placebo, respectively [see Adverse Reactions (6.1)]. In most patients, the event was of mild to moderate intensity and occurred within the first 3 months of treatment. Diarrhea led to permanent dose reduction in 11% of patients treated with Ofev compared to 0 placebo-treated patients. Diarrhea led to discontinuation of Ofev in 5% of the patients compared to <1% of placebo-treated patients.
Dosage modifications or treatment interruptions may be necessary in patients with adverse reactions of diarrhea. Treat diarrhea at first signs with adequate hydration and antidiarrheal medication (e.g., loperamide), and consider treatment interruption if diarrhea continues [see Dosage and Administration (2.3)]. Ofev treatment may be resumed at the full dosage (150 mg twice daily), or at the reduced dosage (100 mg twice daily), which subsequently may be increased to the full dosage. If severe diarrhea persists despite symptomatic treatment, discontinue treatment with Ofev.
Nausea and Vomiting
Nausea was reported in 24% versus 7% and vomiting was reported in 12% versus 3% of patients treated with Ofev and placebo, respectively [see Adverse Reactions (6.1)]. In most patients, these events were of mild to moderate intensity. Nausea led to discontinuation of Ofev in 2% of patients. Vomiting led to discontinuation of Ofev in 1% of the patients.
For nausea or vomiting that persists despite appropriate supportive care including anti-emetic therapy, dose reduction or treatment interruption may be required [see Dosage and Administration (2.3)]. Ofev treatment may be resumed at the full dosage (150 mg twice daily), or at the reduced dosage (100 mg twice daily), which subsequently may be increased to the full dosage. If severe nausea or vomiting does not resolve, discontinue treatment with Ofev.
Based on findings from animal studies and its mechanism of action, Ofev can cause fetal harm when administered to a pregnant woman. Nintedanib caused embryo-fetal deaths and structural abnormalities in rats and rabbits when administered during organogenesis at less than (rats) and approximately 5 times (rabbits) the maximum recommended human dose (MRHD) in adults. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to avoid becoming pregnant while receiving treatment with Ofev and to use effective contraception during treatment and at least 3 months after the last dose of Ofev. Verify pregnancy status prior to treatment with Ofev [see Use in Specific Populations (8.1, 8.3) and Clinical Pharmacology (12.1)].
Arterial Thromboembolic Events
Arterial thromboembolic events have been reported in patients taking Ofev. In clinical trials, arterial thromboembolic events were reported in 2.5% of patients treated with Ofev and 0.8% of placebo-treated patients. Myocardial infarction was the most common adverse reaction under arterial thromboembolic events, occurring in 1.5% of Ofev-treated patients compared to 0.4% of placebo-treated patients.
Use caution when treating patients at higher cardiovascular risk including known coronary artery disease. Consider treatment interruption in patients who develop signs or symptoms of acute myocardial ischemia.
Risk of Bleeding
Based on the mechanism of action (VEGFR inhibition), Ofev may increase the risk of bleeding. In clinical trials, bleeding events were reported in 10% of patients treated with Ofev and in 7% of patients treated with placebo.
Based on the mechanism of action, Ofev may increase the risk of gastrointestinal perforation. In clinical trials, gastrointestinal perforation was reported in 0.3% of patients treated with Ofev, compared to 0 cases in the placebo-treated patients.
Use caution when treating patients who have had recent abdominal surgery. Discontinue therapy with Ofev in patients who develop gastrointestinal perforation. Only use Ofev in patients with known risk of gastrointestinal perforation if the anticipated benefit outweighs the potential risk.
6 ADVERSE REACTIONS
- Liver Enzyme and Bilirubin Elevations [see Warnings and Precautions (5.2)]
- Gastrointestinal Disorders [see Warnings and Precautions (5.3)]
- Embryo-Fetal Toxicity [see Warnings and Precautions (5.4)]
- Arterial Thromboembolic Events [see Warnings and Precautions (5.5)]
- Risk of Bleeding [see Warnings and Precautions (5.6)]
- Gastrointestinal Perforation [see Warnings and Precautions (5.7)]
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Ofev was studied in three randomized, double-blind, placebo-controlled, 52-week trials. In the phase 2 (Study 1) and phase 3 (Studies 2 and 3) trials, 723 patients with IPF received Ofev 150 mg twice daily and 508 patients received placebo. The median duration of exposure was 10 months for patients treated with Ofev and 11 months for patients treated with placebo. Subjects ranged in age from 42 to 89 years (median age of 67 years). Most patients were male (79%) and Caucasian (60%).
The most frequent serious adverse reactions reported in patients treated with Ofev, more than placebo, were bronchitis (1.2% vs. 0.8%) and myocardial infarction (1.5% vs. 0.4%). The most common adverse events leading to death in patients treated with Ofev, more than placebo, were pneumonia (0.7% vs. 0.6%), lung neoplasm malignant (0.3% vs. 0%), and myocardial infarction (0.3% vs. 0.2%). In the predefined category of major adverse cardiovascular events (MACE) including MI, fatal events were reported in 0.6% of Ofev-treated patients and 1.8% of placebo-treated patients.
Adverse reactions leading to permanent dose reductions were reported in 16% of Ofev-treated patients and 1% of placebo-treated patients. The most frequent adverse reaction that led to permanent dose reduction in the patients treated with Ofev was diarrhea (11%).
Adverse reactions leading to discontinuation were reported in 21% of Ofev-treated patients and 15% of placebo-treated patients. The most frequent adverse reactions that led to discontinuation in Ofev-treated patients were diarrhea (5%), nausea (2%), and decreased appetite (2%).
|a Includes abdominal pain, abdominal pain upper, abdominal pain lower, gastrointestinal pain and abdominal tenderness.
b Includes gamma-glutamyltransferase increased, hepatic enzyme increased, alanine aminotransferase increased, aspartate aminotransferase increased, hepatic function abnormal, liver function test abnormal, transaminase increased, blood alkaline phosphatase-increased, alanine aminotransferase abnormal, aspartate aminotransferase abnormal, and gamma-glutamyltransferase abnormal.
c Includes hypertension, blood pressure increased, hypertensive crisis, and hypertensive cardiomyopathy.
|Adverse Reaction||Ofev, 150 mg
|Liver enzyme elevationb||14%||3%|
|Metabolism and nutrition disorders|
|Nervous systemic disorders|
The following adverse reactions have been identified during postapproval use of Ofev. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
- Drug-induced liver injury [see Warnings and Precautions (5.2)]
Non-serious and serious bleeding events have been observed in the postmarketing period in line with clinical trial experience [see Warnings and Precautions (5.6)].
7 DRUG INTERACTIONS
P-glycoprotein (P-gp) and CYP3A4 Inhibitors and Inducers
Nintedanib is a substrate of P-gp and, to a minor extent, CYP3A4 [see Clinical Pharmacology (12.3)]. Coadministration with oral doses of a P-gp and CYP3A4 inhibitor, ketoconazole, increased exposure to nintedanib by 60%. Concomitant use of P-gp and CYP3A4 inhibitors (e.g., erythromycin) with Ofev may increase exposure to nintedanib [see Clinical Pharmacology (12.3)]. In such cases, patients should be monitored closely for tolerability of Ofev. Management of adverse reactions may require interruption, dose reduction, or discontinuation of therapy with Ofev [see Dosage and Administration (2.3)].
Coadministration with oral doses of a P-gp and CYP3A4 inducer, rifampicin, decreased exposure to nintedanib by 50%. Concomitant use of P-gp and CYP3A4 inducers (e.g., carbamazepine, phenytoin, and St. John’s wort) with Ofev should be avoided as these drugs may decrease exposure to nintedanib [see Clinical Pharmacology (12.3)].
Nintedanib is a VEGFR inhibitor, and may increase the risk of bleeding. Monitor patients on full anticoagulation therapy closely for bleeding and adjust anticoagulation treatment as necessary [see Warnings and Precautions (5.6)].
8 USE IN SPECIFIC POPULATIONS
Based on findings from animal studies and its mechanism of action [see Clinical Pharmacology (12.1)], Ofev can cause fetal harm when administered to a pregnant woman. There are no data on the use of Ofev during pregnancy. In animal studies of pregnant rats and rabbits treated during organogenesis, nintedanib caused embryo-fetal deaths and structural abnormalities at less than (rats) and approximately 5 times (rabbits) the maximum recommended human dose [see Data]. Advise pregnant women of the potential risk to a fetus.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects is 2% to 4% and miscarriage in clinically recognized pregnancies is 15% to 20%.
In animal reproduction toxicity studies, nintedanib caused embryo-fetal deaths and structural abnormalities in rats and rabbits at less than and approximately 5 times the maximum recommended human dose (MRHD) in adults (on a plasma AUC basis at maternal oral doses of 2.5 and 15 mg/kg/day in rats and rabbits, respectively). Malformations included abnormalities in the vasculature, urogenital, and skeletal systems. Vasculature anomalies included missing or additional major blood vessels. Skeletal anomalies included abnormalities in the thoracic, lumbar, and caudal vertebrae (e.g., hemivertebra, missing, or asymmetrically ossified), ribs (bifid or fused), and sternebrae (fused, split, or unilaterally ossified). In some fetuses, organs in the urogenital system were missing. In rabbits, a significant change in sex ratio was observed in fetuses (female:male ratio of approximately 71%:29%) at approximately 15 times the MRHD in adults (on an AUC basis at a maternal oral dose of 60 mg/kg/day). Nintedanib decreased post-natal viability of rat pups during the first 4 post-natal days when dams were exposed to less than the MRHD (on an AUC basis at a maternal oral dose of 10 mg/kg/day).
There is no information on the presence of nintedanib in human milk, the effects on the breast-fed infant or the effects on milk production. Nintedanib and/or its metabolites are present in the milk of lactating rats [see Data]. Because of the potential for serious adverse reactions in nursing infants from Ofev, advise women that breastfeeding is not recommended during treatment with Ofev.
Females and Males of Reproductive Potential
Based on findings from animal studies and its mechanism of action, Ofev can cause fetal harm when administered to a pregnant woman and may reduce fertility in females of reproductive potential [see Use in Specific Populations (8.1), Clinical Pharmacology (12.1), and Nonclinical Toxicology (13.1)]. Counsel patients on pregnancy prevention and planning.
Verify the pregnancy status of females of reproductive potential prior to treatment with Ofev [see Dosage and Administration (2.1), Warnings and Precautions (5.4) and Use in Specific Populations (8.1)].
Advise females of reproductive potential to avoid becoming pregnant while receiving treatment with Ofev. Advise females of reproductive potential to use effective contraception during treatment, and for at least 3 months after taking the last dose of Ofev.
Based on animal data, Ofev may reduce fertility in females of reproductive potential [see Nonclinical Toxicology (13.1)].
Of the total number of subjects in phase 2 and 3 clinical studies of Ofev, 60.8% were 65 and over, while 16.3% were 75 and over. In phase 3 studies, no overall differences in effectiveness were observed between subjects who were 65 and over and younger subjects; no overall differences in safety were observed between subjects who were 65 and over or 75 and over and younger subjects, but greater sensitivity of some older individuals cannot be ruled out.
Nintedanib is predominantly eliminated via biliary/fecal excretion (>90%). In a PK study performed in patients with hepatic impairment (Child Pugh A, Child Pugh B), exposure to nintedanib was increased [see Clinical Pharmacology (12.3)]. In patients with mild hepatic impairment (Child Pugh A), the recommended dosage of Ofev is 100 mg twice daily [see Dosage and Administration (2.2)]. Monitor for adverse reactions and consider treatment interruption, or discontinuation for management of adverse reactions in these patients [see Dosage and Administration (2.3)]. Treatment of patients with moderate (Child Pugh B) and severe (Child Pugh C) hepatic impairment with Ofev is not recommended [see Warnings and Precautions (5.1)].
Based on a single-dose study, less than 1% of the total dose of nintedanib is excreted via the kidney [see Clinical Pharmacology (12.3)]. Adjustment of the starting dose in patients with mild to moderate renal impairment is not required. The safety, efficacy, and pharmacokinetics of nintedanib have not been studied in patients with severe renal impairment (<30 mL/min CrCl) and end-stage renal disease.
Smoking was associated with decreased exposure to Ofev [see Clinical Pharmacology (12.3)], which may alter the efficacy profile of Ofev. Encourage patients to stop smoking prior to treatment with Ofev and to avoid smoking when using Ofev.
In the trials, one patient was inadvertently exposed to a dose of 600 mg daily for a total of 21 days. A non-serious adverse event (nasopharyngitis) occurred and resolved during the period of incorrect dosing, with no onset of other reported events. Overdose was also reported in two patients in oncology studies who were exposed to a maximum of 600 mg twice daily for up to 8 days. Adverse events reported were consistent with the existing safety profile of Ofev. Both patients recovered. In case of overdose, interrupt treatment and initiate general supportive measures as appropriate.
Ofev capsules contain nintedanib, a kinase inhibitor [see Mechanism of Action (12.1)]. Nintedanib is presented as the ethanesulfonate salt (esylate), with the chemical name 1H-Indole-6-carboxylic acid, 2,3-dihydro-3-[[[4-[methyl[(4-methyl-1-piperazinyl)acetyl]amino]phenyl]amino]phenylmethylene]-2-oxo-,methyl ester, (3Z)-, ethanesulfonate (1:1).
Ofev capsules for oral administration are available in 2 dose strengths containing 100 mg or 150 mg of nintedanib (equivalent to 120.40 mg or 180.60 mg nintedanib ethanesulfonate, respectively). The inactive ingredients of Ofev are the following: Fill Material: triglycerides, hard fat, lecithin. Capsule Shell: gelatin, glycerol, titanium dioxide, red ferric oxide, yellow ferric oxide, black ink.
12 CLINICAL PHARMACOLOGY
Mechanism of Action
Nintedanib is a small molecule that inhibits multiple receptor tyrosine kinases (RTKs) and non-receptor tyrosine kinases (nRTKs). Nintedanib inhibits the following RTKs: platelet-derived growth factor receptor (PDGFR) α and β, fibroblast growth factor receptor (FGFR) 1-3, vascular endothelial growth factor receptor (VEGFR) 1-3, and Fms-like tyrosine kinase-3 (FLT3). Among them, FGFR, PDGFR, and VEGFR have been implicated in IPF pathogenesis. Nintedanib binds competitively to the adenosine triphosphate (ATP) binding pocket of these receptors and blocks the intracellular signaling which is crucial for the proliferation, migration, and transformation of fibroblasts representing essential mechanisms of the IPF pathology. In addition, nintedanib inhibits the following nRTKs: Lck, Lyn and Src kinases. The contribution of FLT3 and nRTK inhibition to IPF efficacy is unknown.
In a study in renal cell cancer patients, QT/QTc measurements were recorded and showed that a single oral dose of 200 mg nintedanib as well as multiple oral doses of 200 mg nintedanib administered twice daily for 15 days did not prolong the QTcF interval.
The PK properties of nintedanib were similar in healthy volunteers, patients with IPF, and cancer patients. The PK of nintedanib is linear. Dose proportionality was shown by an increase of nintedanib exposure with increasing doses (dose range 50 to 450 mg once daily and 150 to 300 mg twice daily). Accumulation upon multiple administrations in patients with IPF was 1.76-fold for AUC. Steady-state plasma concentrations were achieved within one week of dosing. Nintedanib trough concentrations remained stable for more than one year. The inter-individual variability in the PK of nintedanib was moderate to high (coefficient of variation of standard PK parameters in the range of 30% to 70%), intra-individual variability low to moderate (coefficients of variation below 40%).
Nintedanib reached maximum plasma concentrations approximately 2 to 4 hours after oral administration as a soft gelatin capsule under fed conditions. The absolute bioavailability of a 100 mg dose was 4.7% (90% CI: 3.62 to 6.08) in healthy volunteers. Absorption and bioavailability are decreased by transporter effects and substantial first-pass metabolism.
After food intake, nintedanib exposure increased by approximately 20% compared to administration under fasted conditions (90% CI: 95.3% to 152.5%) and absorption was delayed (median tmax fasted: 2.00 hours; fed: 3.98 hours), irrespective of the food type.
The in vitro protein binding of nintedanib in human plasma was high, with a bound fraction of 97.8%. Serum albumin is considered to be the major binding protein. Nintedanib is preferentially distributed in plasma with a blood to plasma ratio of 0.87.
The effective half-life of nintedanib in patients with IPF was 9.5 hours (gCV 31.9%). Total plasma clearance after intravenous infusion was high (CL: 1390 mL/min; gCV 28.8%). Urinary excretion of unchanged drug within 48 hours was about 0.05% of the dose after oral and about 1.4% of the dose after intravenous administration; the renal clearance was 20 mL/min.
The prevalent metabolic reaction for nintedanib is hydrolytic cleavage by esterases resulting in the free acid moiety BIBF 1202. BIBF 1202 is subsequently glucuronidated by UGT enzymes, namely UGT 1A1, UGT 1A7, UGT 1A8, and UGT 1A10 to BIBF 1202 glucuronide. Only a minor extent of the biotransformation of nintedanib consisted of CYP pathways, with CYP 3A4 being the predominant enzyme involved. The major CYP-dependent metabolite could not be detected in plasma in the human absorption, distribution, metabolism, and elimination study. In vitro, CYP-dependent metabolism accounted for about 5% compared to about 25% ester cleavage.
The major route of elimination of drug-related radioactivity after oral administration of [14C] nintedanib was via fecal/biliary excretion (93.4% of dose), and the majority of Ofev was excreted as BIBF 1202. The contribution of renal excretion to the total clearance was low (0.65% of dose). The overall recovery was considered complete (above 90%) within 4 days after dosing.
Age, Body Weight, and Sex
Based on population PK analysis, age and body weight were correlated with nintedanib exposure. However, the effects on exposure are not sufficient to warrant a dose adjustment. There was no influence of sex on the exposure of nintedanib.
Based on a population PK analysis of data from 933 patients with IPF, exposure to nintedanib was not influenced by mild (CrCl: 60 to 90 mL/min; n=399) or moderate (CrCl: 30 to 60 mL/min; n=116) renal impairment. Data in severe renal impairment (CrCl below 30 mL/min) was limited.
A dedicated single-dose phase I pharmacokinetics study of Ofev compared 8 subjects with mild hepatic impairment (Child Pugh A) and 8 subjects with moderate hepatic impairment (Child Pugh B) to 17 subjects with normal hepatic function. In subjects with mild hepatic impairment, the mean exposure to nintedanib was 2.4-fold higher based on Cmax (90% CI 1.6 to 3.6) and 2.2-fold higher based on AUC0-inf (90% CI 1.4 to 3.5). In subjects with moderate hepatic impairment, exposure was 6.9-fold higher based on Cmax (90% CI 4.4 to 11.0) and 7.6-fold higher based on AUC0-inf (90% CI 5.1 to 11.3). Subjects with severe hepatic impairment (Child Pugh C) have not been studied.
Drug Interaction Studies
Potential for Nintedanib to Affect Other Drugs
Effect of nintedanib coadministration on pirfenidone AUC and Cmax was evaluated in a multiple-dose study. Nintedanib did not have an effect on the exposure of pirfenidone.
In in vitro studies, nintedanib was shown not to be an inhibitor of OATP-1B1, OATP-1B3, OATP-2B1, OCT-2, or MRP-2. In vitro studies also showed that nintedanib has weak inhibitory potential on OCT-1, BCRP, and P-gp; these findings are considered to be of low clinical relevance. Nintedanib and its metabolites, BIBF 1202 and BIBF 1202 glucuronide, did not inhibit or induce CYP enzymes in vitro.
Potential for Other Drugs to Affect Nintedanib
Nintedanib is a substrate of P-gp and, to a minor extent, CYP3A4. Coadministration with the P-gp and CYP3A4 inhibitor, ketoconazole, increased exposure to nintedanib 1.61-fold based on AUC and 1.83-fold based on Cmax in a dedicated drug-drug interaction study. In a drug-drug interaction study with the P-gp and CYP3A4 inducer, rifampicin, exposure to nintedanib decreased to 50.3% based on AUC and to 60.3% based on Cmax upon coadministration with rifampicin compared to administration of nintedanib alone.
Based on a multiple-dose study in Japanese IPF patients, exposure to nintedanib decreased to 68.3% based on AUC and to 59.2% based on Cmax upon coadministration with pirfenidone compared to administration of nintedanib alone.
Nintedanib displays a pH-dependent solubility profile with increased solubility at acidic pH<3. However, in the clinical trials, coadministration with proton pump inhibitors or histamine H2 antagonists did not influence the exposure (trough concentrations) of nintedanib.
In in vitro studies, nintedanib was shown not to be a substrate of OATP-1B1, OATP-1B3, OATP-2B1, OCT-2, MRP-2, or BCRP. In vitro studies also showed that nintedanib was a substrate of OCT-1; these findings are considered to be of low clinical relevance.
13 NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Two-year oral carcinogenicity studies of nintedanib in rats and mice have not revealed any evidence of carcinogenic potential. Nintedanib was dosed up to 10 and 30 mg/kg/day in rats and mice, respectively. These doses were less than and approximately 4 times the MRHD on a plasma drug AUC basis.
In rats, nintedanib reduced female fertility at exposure levels approximately 3 times the MRHD (on an AUC basis at an oral dose of 100 mg/kg/day). Effects included increases in resorption and post-implantation loss, and a decrease in gestation index. Changes in the number and size of corpora lutea in the ovaries were observed in chronic toxicity studies in rats and mice. An increase in the number of females with resorptions only was observed at exposures approximately equal to the MRHD (on an AUC basis at an oral dose of 20 mg/kg/day). Nintedanib had no effects on male fertility in rats at exposure levels approximately 3 times the MRHD (on an AUC basis at an oral dose of 100 mg/kg/day).
14 CLINICAL STUDIES
The clinical efficacy of Ofev has been studied in 1231 patients with IPF in one phase 2 (Study 1) and two phase 3 (Studies 2 and 3). These were randomized, double-blind, placebo-controlled studies comparing treatment with Ofev 150 mg twice daily to placebo for 52 weeks.
Studies 2 and 3 were identical in design. Study 1 was very similar in design. Patients were randomized in a 3:2 ratio (1:1 for Study 1) to either Ofev 150 mg or placebo twice daily for 52 weeks. Study 1 also included other treatment arms (50 mg daily, 50 mg twice daily, and 100 mg twice daily) that are not further discussed. The primary endpoint was the annual rate of decline in Forced Vital Capacity (FVC). Time to first acute IPF exacerbation was a key secondary endpoint in Studies 2 and 3 and a secondary endpoint in Study 1. Change from baseline in FVC percent predicted and survival were additional secondary endpoints in all studies.
Patients were required to have a diagnosis of IPF (ATS/ERS/JRS/ALAT criteria) for <5 years. Diagnoses were centrally adjudicated based on radiologic and, if applicable, histopathologic confirmation. Patients were required to be ≥40 years of age with an FVC ≥50% of predicted and a carbon monoxide diffusing capacity (DLCO, corrected for hemoglobin) 30% to 79% of predicted. Patients with relevant airways obstruction (i.e., pre-bronchodilator FEV1/FVC <0.7) or, in the opinion of the investigator, likely to receive a lung transplant during the studies were excluded (being listed for lung transplant was acceptable for inclusion). Patients with >1.5 times ULN of ALT, AST, or bilirubin, patients with a known risk or predisposition to bleeding, patients receiving a full dose of anticoagulation treatment, and patients with a recent history of myocardial infarction or stroke were excluded from the studies. Patients were also excluded if they received other investigational therapy, azathioprine, cyclophosphamide, or cyclosporine A within 8 weeks of entry into this trial, or n-acetyl cysteine and prednisone (>15 mg/day or equivalent) within 2 weeks. The majority of patients were Caucasian (60%) or Asian (30%) and male (79%). Patients had a mean age of 67 years and a mean FVC percent predicted of 80%.
Annual Rate of Decline in FVC
A statistically significant reduction in the annual rate of decline of FVC (in mL) was demonstrated in patients receiving Ofev compared to patients receiving placebo based on the random coefficient regression model, adjusted for gender, height, and age. The treatment effect on FVC was consistent in all 3 studies. See Table 2 for individual study results.
|aRandomized set in Study 1; treated set in Studies 2 and 3
bEstimated based on a random coefficient regression model
|Study 1||Study 2||Study 3|
|Number of analyzed patients||84||83||309||204||329||219|
|Ratea of decline over 52 weeks||-60||-191||-115||-240||-114||-207|
|Comparison vs placebo|
|95% CI||(27, 235)||(78, 173)||(45, 143)|
Figure 1 displays the change from baseline over time in both treatment groups for Study 2. When the mean observed FVC change from baseline was plotted over time, the curves diverged at all timepoints through Week 52. Similar plots were seen for Studies 1 and 3.
Change from Baseline in Percent Predicted Forced Vital Capacity
Figure 2 presents the cumulative distribution for all cut-offs for the change from baseline in FVC percent predicted at Week 52 for Study 2. For all categorical declines in lung function, the proportion of patients declining was lower on Ofev than on placebo. Study 3 showed similar results.
*Missing data for change from baseline at Week 52 in percent predicted FVC (due to death, lost to follow-up or censoring before 52 weeks) was imputed using the worst decline from baseline at Week 52 observed among all patients with available data, regardless of treatment.
bid = twice daily
Time to First Acute IPF Exacerbation
Acute IPF exacerbation was defined as unexplained worsening or development of dyspnea within 30 days, new diffuse pulmonary infiltrates on chest x-ray, and/or new high-resolution CT parenchymal abnormalities with no pneumothorax or pleural effusion, and exclusion of alternative causes. Acute IPF exacerbation was adjudicated in Studies 2 and 3. In Studies 1 (investigator-reported) and 3 (adjudicated), the risk of first acute IPF exacerbation over 52 weeks was significantly reduced in patients receiving Ofev compared to placebo (hazard ratio [HR]: 0.16, 95% CI: 0.04, 0.71) and (HR: 0.20, 95% CI: 0.07, 0.56), respectively. In Study 2 (adjudicated), there was no difference between the treatment groups (HR: 0.55, 95% CI: 0.20, 1.54).
Survival was evaluated for Ofev compared to placebo in Studies 2 and 3 as an exploratory analysis to support the primary endpoint (FVC). All-cause mortality was assessed over the study duration and available follow-up period, irrespective of cause of death and whether patients continued treatment. All-cause mortality did not show a statistically significant difference (See Figure 3).
16 HOW SUPPLIED/STORAGE AND HANDLING
150 mg: brown, opaque, oblong, soft capsules imprinted in black with the Boehringer Ingelheim company symbol and "150". They are packaged in HDPE bottles with a child-resistant closure, available as follows:
Bottles of 60 NDC: 0597-0145-60
100 mg: peach, opaque, oblong, soft capsules imprinted in black with the Boehringer Ingelheim company symbol and "100". They are packaged in HDPE bottles with a child-resistant closure, available as follows:
Bottles of 60 NDC: 0597-0143-60
Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Protect from exposure to high humidity and avoid excessive heat. If repackaged, use USP tight container. Keep out of reach of children.
17 PATIENT COUNSELING INFORMATION
Liver Enzyme and Bilirubin Elevations
Advise patients that they will need to undergo liver function testing periodically. Advise patients to immediately report any symptoms of a liver problem (e.g., skin or the whites of eyes turn yellow, urine turns dark or brown (tea colored), pain on the right side of stomach, bleed or bruise more easily than normal, lethargy) [see Warnings and Precautions (5.2)].
Inform patients that gastrointestinal disorders such as diarrhea, nausea, and vomiting were the most commonly reported gastrointestinal events occurring in patients who received Ofev. Advise patients that their healthcare provider may recommend hydration, antidiarrheal medications (e.g., loperamide), or anti-emetic medications to treat these side effects. Temporary dosage reductions or discontinuations may be required. Instruct patients to contact their healthcare provider at the first signs of diarrhea or for any severe or persistent diarrhea, nausea, or vomiting [see Warnings and Precautions (5.3) and Adverse Reactions (6.1)].
Counsel patients on pregnancy prevention and planning. Advise females of reproductive potential of the potential risk to a fetus and to avoid becoming pregnant while receiving treatment with Ofev. Advise females of reproductive potential to use effective contraception during treatment, and for at least 3 months after taking the last dose of Ofev. Advise female patients to notify their doctor if they become pregnant during therapy with Ofev [see Warnings and Precautions (5.4) and Use in Specific Populations (8.1, 8.3)].
Arterial Thromboembolic Events
Advise patients about the signs and symptoms of acute myocardial ischemia and other arterial thromboembolic events and the urgency to seek immediate medical care for these conditions [see Warnings and Precautions (5.5)].
Risk of Bleeding
Bleeding events have been reported. Advise patients to report unusual bleeding [see Warnings and Precautions (5.6)].
Serious gastrointestinal perforation events have been reported. Advise patients to report signs and symptoms of gastrointestinal perforation [see Warnings and Precautions (5.7)].
Advise patients that breastfeeding is not recommended while taking Ofev [see Use in Specific Populations (8.2)].
Encourage patients to stop smoking prior to treatment with Ofev and to avoid smoking when using with Ofev [see Clinical Pharmacology (12.3)].
Instruct patients to swallow Ofev capsules whole with liquid and not to chew or crush the capsules due to the bitter taste. Advise patients to not make up for a missed dose [see Dosage and Administration (2)].
|What is the most important information I should know about Ofev?|
|Ofev can cause birth defects or death to an unborn baby. Women should not become pregnant while taking Ofev. Women who are able to become pregnant should have a pregnancy test before starting treatment with Ofev. Women who are able to become pregnant should use birth control during treatment and for at least 3 months after treatment. If you become pregnant while taking Ofev, tell your doctor right away.|
|What is Ofev?|
|What should I tell my doctor before taking Ofev?|
|Before you take Ofev, tell your doctor if you:|
|Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements such as St. John’s wort. Keep a list of the medicines you take and show it to your doctor and pharmacist when you get a new medicine.|
|How should I take Ofev?|
|What are the possible side effects of Ofev?|
|Ofev may cause serious side effects, including:|
|The most common side effects of Ofev are diarrhea, nausea, stomach pain, vomiting, liver problems, decreased appetite, headache, and weight loss.
These are not all the possible side effects of Ofev. For more information, ask your doctor or pharmacist.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
|How should I store Ofev?|
|Keep Ofev and all medicines out of reach of children.|
|General information about the safe and effective use of Ofev.|
|What are the ingredients in Ofev?
Active ingredient: nintedanib.
Inactive ingredients: Fill Material: triglycerides, hard fat, lecithin. Capsule Shell: gelatin, glycerol, titanium dioxide, red ferric oxide, yellow ferric oxide, black ink.
|Distributed by: Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT 06877 USA
Ofev is a registered trademark of and used under license from Boehringer Ingelheim International GmbH.
Copyright © 2017 Boehringer Ingelheim International GmbH, ALL RIGHTS RESERVED
|Labeler - Boehringer Ingelheim Pharmaceuticals, Inc. (603175944)|
|Registrant - Boehringer Ingelheim Pharmaceuticals, Inc. (603175944)|
|Boehringer Ingelheim Pharma GmbH and Co. KG||551147440||ANALYSIS(0597-0143, 0597-0145), API MANUFACTURE(0597-0143, 0597-0145), PACK(0597-0143, 0597-0145), LABEL(0597-0145, 0597-0143)|
|West-Ward Columbus Inc.||058839929||ANALYSIS(0597-0143, 0597-0145), LABEL(0597-0145, 0597-0143), PACK(0597-0143, 0597-0145)|
|Catalent Germany Eberbach GmbH||318612223||ANALYSIS(0597-0143, 0597-0145), MANUFACTURE(0597-0143, 0597-0145)|
|Sixarp, LLC||016329513||LABEL(0597-0145, 0597-0143), PACK(0597-0143, 0597-0145)|
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- Drug class: multikinase inhibitors