CRITPOSA Injection (Posaconazole)

Table of Content

Hematologic malignancies represent the fifth most commonly occurring cancers and the second leading cause of cancer death.

The prevalence of IFI has steadily increased over the past few decades among patients with hematological malignancies and hence, antifungal prophylaxis is currently regarded as the gold standard in situations with a high risk of infection. Mostly azoles are the preferred antifungals for the same as they are available in both oral and intravenous (IV) formulations.

Posaconazole is a triazole antifungal with the broadest spectrum of antifungal activity and covers a wide array of IFIs such as aspergillosis, candidiasis, fusariosis, mucormycosis, cryptococcosis, chromoblastomycosis, mycetoma and coccidioidomycosis. It has a more favourable safety profile and is associated with fewer drug–drug interaction and low risk of cross-resistance as compared with the currently available other azoles.

The IV formulation of posaconazole results in higher trough concentrations of posaconazole; more consistent bioavailability; requires less therapeutic drug monitoring as compared to its oral suspension.

CRITPOSA (posaconazole IV) injection is indicated for the prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of developing these infections due to being severely immunocompromised, such as HSCT recipients with GVHD or those with hematologic malignancies with prolonged neutropenia from chemotherapy.

CRITPOSA injection is indicated in patients aged 18 years and older in the following dosage:

Indication

Dose and Duration of Therapy

Prophylaxis of invasive Aspergillus and Candida infections

Loading dose: 
300 mg Posaconazole injection intravenously twice a day on the first day. 
Maintenance dose: 
300 mg Posaconazole injection intravenously once a day, starting on the second day. Duration of therapy is based on recovery from neutropenia or immunosuppression.

July 2018

Composition

Each mL contains:

Posaconazole..........18 mg

Dosage Form

Concentrate for solution for infusion.

Pharmacology

Pharmacodynamics

Posaconazole is an azole antifungal agent available as concentrated solution to be diluted before intravenous administration.

Posaconazole is designated chemically as 4-methoxy]phenyl]-1-piperazinyl]phenyl]-2--2,4-dihydro-3H-1,2,4-triazol-3-one, with an empirical formula of C37H42F2N8O4 and a molecular weight of 700.8 g/mol.

Posaconazole is a white powder with a low aqueous solubility. Posaconazole injection is available as a clear, colourless-to-yellow sterile liquid essentially free of foreign matter. Each vial contains 300 mg of posaconazole and the following inactive ingredients: betadex sulphobutyl ether sodium (SBECD), edetate disodium, hydrochloric acid and sodium hydroxide and Water for Injections.

Mechanism of Action

Posaconazole blocks the synthesis of ergosterol, a key component of the fungal cell membrane, through the inhibition of cytochrome (CY) P450-dependent enzyme, lanosterol 14α-demethylase, which is responsible for the conversion of lanosterol to ergosterol in the fungal cell membrane. This results in an accumulation of methylated sterol precursors and a depletion of ergosterol within the cell membrane, thus weakening the structure and function of the fungal cell membrane. This may be responsible for the antifungal activity of posaconazole.

Microbiology

Resistance

Clinical isolates of Candida albicans and Candida glabrata with decreased susceptibility to

posaconazole were observed in oral swish samples taken during prophylaxis with posaconazole and fluconazole, suggesting a potential for development of resistance. These isolates also showed reduced susceptibility to other azoles, suggesting cross-resistance between azoles. The clinical significance of this finding is not known.

Antimicrobial Activity

Posaconazole has been shown in vitro to be active against the following microorganisms: Aspergillus species (Aspergillus fumigatus, A. flavus, A. terreus, A. nidulans, A. niger, A. ustus), Candida species (Candida albicans, C. glabrata, C. krusei, C. parapsilosis, C. tropicalis, C. dubliniensis, C. famata, C. inconspicua, C. lipolytica, C. norvegensis, C. pseudotropicalis), Coccidioides immitis, Fonsecaea pedrosoi, and species of Fusarium, Rhizomucor, Mucor, and Rhizopus. The microbiological data suggest that posaconazole is active against Rhizomucor, Mucor, and Rhizopus; however, the clinical data are currently too limited to assess the efficacy of posaconazole against these causative agents.

Susceptibility testing

Posaconazole interpretive criteria (breakpoints) have not been established.

Pharmacokinetics 

Absorption

Posaconazole injection exhibits dose-proportional pharmacokinetics after single doses between 200 and 300 mg in healthy volunteers and patients. The mean pharmacokinetic parameters after single doses with posaconazole injection in healthy volunteers and patients are shown in Table 1.

Table 1: Summary of Mean Pharmacokinetic Parameters (%CV) in Healthy Volunteers (30-minute infusion via peripheral venous line) and Patients (90-minute infusion via central venous line) after Dosing with Posaconazole Injection on Day 1

 

Dose (mg)

n

AUC0–∞

(ng·hr/mL)

AUC0–12

(ng·hr/mL)

Cmax

(ng/mL)

t1/2

(hr)

CL

(L/hr)

Healthy

Volunteers

200

9

35,400 (50)

8,840 (20)

2,250 (29)

23.6 (23)

6.5 (32)

300

9

46,400 (26)

13,000 (13)

2,840 (30)

24.6 (20)

6.9 (27)

Patients

200

30

N/D

5,570 (32)

954 (44)

N/D

N/D

300

22

N/D

8,240 (26)

1,590 (62)

N/D

N/D

AUC0 - ∞ = Area under the plasma concentration-time curve from time zero to infinity; AUC0– 12 = Area under the plasma concentration-time curve from time zero to 12 hours after the first dose on Day 1; Cmax = maximum observed concentration; t½ = terminal phase half-life; CL = total body clearance; N/D = Not Determined

Table 2 displays the pharmacokinetic parameters of posaconazole in patients following administration of posaconazole injection 300 mg taken once a day for 10 or 14 days following b.i.d. dosing on Day 1.

Table 2: Arithmetic Mean (%CV) of Pharmacokinetic Parameters in Serial Pharmacokinetic-Evaluable Patients Following Dosing of Posaconazole Injection (300 mg)*

Day

N

Cmax

(ng/mL)

Tmax

(hr)

AUC0–24

(ng·hr/mL)

Cav

(ng/mL)

Cmin

(ng/mL)

10/14

49

3,280 (74)

1.5 (0.98–4.0)

36,100 (35)

1,500 (35)

1,090 (44)

AUC0–24 = area under the concentration-time curve over the dosing interval (i.e. 24 hours);

Cav = time-averaged concentrations (i.e., AUC0–24h/24 hours); Cmin = Posaconazole trough level immediately before a subject received the dose of posaconazole on the day specified in the protocol; C = observed maximum plasma concentration; CV = coefficient of variation, expressed as a percent (%); Day = study day on treatment; T = time of observed maximum plasma concentration.

* 300 mg dose administered over 90 minutes once a day following b.i.d. dosing on Day 1

Median (minimum-maximum)

Distribution

The mean volume of distribution of posaconazole after intravenous solution administration was 261 L and ranged from 226 to 295 L between studies and dose levels.

Posaconazole is highly bound to human plasma proteins (>98%), predominantly to albumin.

Metabolism

Posaconazole primarily circulates as the parent compound in plasma. Of the circulating metabolites, the majority are glucuronide conjugates formed via uridine diphosphate (UDP) glucuronidation (phase 2 enzymes). Posaconazole does not have any major circulating oxidative (CYP450-mediated) metabolites. The excreted metabolites in urine and faeces account for ~17% of the administered radiolabelled dose.

Posaconazole is primarily metabolised via UDP glucuronidation (phase 2 enzymes) and is a substrate for P-glycoprotein (P-gp) efflux. Therefore, inhibitors or inducers of these clearance pathways may affect posaconazole plasma concentrations.

Elimination

Posaconazole injection is eliminated with a mean terminal half-life (t½) of 27 hours and a total body clearance (CL) of 7.3 L/hr.

Special Populations

Renal Impairment

Following single-dose administration of posaconazole oral suspension, there was no effect of mild and moderate renal impairment on posaconazole pharmacokinetics; therefore, no dose adjustment is required. In subjects with severe renal impairment (n=6, CrCl <20 mL/min/1.73 m2), the area under the curve (AUC) of posaconazole was highly variable compared with other renal groups . However, as posaconazole is not significantly renally eliminated, an effect of severe renal impairment on the pharmacokinetics of posaconazole is not expected and no dose adjustment is recommended. Posaconazole is not removed by haemodialysis. Due to the variability in exposure, patients with severe renal impairment should be monitored closely for breakthrough fungal infections.

Similar recommendations apply to posaconazole concentrate for solution for infusion; however, a specific study has not been conducted with posaconazole concentrate for solution for infusion.

Hepatic Impairment

After a single oral dose of 400 mg posaconazole oral suspension to patients with mild (Child-Pugh Class A), moderate (Child-Pugh Class B) or severe (Child-Pugh Class C) hepatic impairment (six per group), the mean AUC was 1.3- to 1.6-fold higher compared with that for matched control subjects with normal hepatic function. Unbound concentrations were not determined and it cannot be excluded that there is a larger increase in unbound posaconazole exposure than the observed 60% increase in total AUC. The elimination half-life (t1/2) was prolonged from approximately 27 hours up to ~43 hours in respective groups. No dose adjustment is recommended for patients with mild to severe hepatic impairment but caution is advised due to the potential for higher plasma exposure.

Similar recommendations apply to posaconazole concentrate for solution for infusion; however, a specific study has not been conducted with posaconazole concentrate for solution for infusion.

Paediatric

There is no paediatric experience with posaconazole concentrate for solution for infusion.

Geriatric

The pharmacokinetics of posaconazole concentrate for solution for infusion is comparable in young and elderly subjects. No overall differences in safety were observed between the geriatric patients and younger patients; therefore, no dosage adjustment is recommended for geriatric patients.

Weight

Pharmacokinetic modelling with an oral tablet formulation suggests that patients weighing greater than 120 kg may have lower posaconazole exposure. It is, therefore, suggested to closely monitor for breakthrough fungal infections in patients weighing more than 120 kg. Patients with a low body weight (<60 kg) are more likely to experience higher plasma concentrations of posaconazole and should be closely monitored for adverse events.

Gender

The pharmacokinetics of posaconazole concentration for solution for infusion is comparable in men and women.

Race

There is insufficient data among different races with posaconazole concentrate for solution for infusion.

There was a slight decrease (16%) in the AUC and peak plasma concentration (Cmax) of posaconazole oral suspension in Black subjects relative to Caucasian subjects. However, the safety profile of posaconazole between the Black and Caucasian subjects was similar.

Indications

CRITPOSA injection is indicated for the prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with graft-versus-host disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy.

CRITPOSA injection is indicated in patients aged 18 years and older.

Dosage and Administration

Dosage

Adults

Table 3: Dosage for Posaconazole Injection

Indication

Dose and Duration of Therapy

Prophylaxis of invasive

Aspergillus and Candida

infections

Loading dose

300 mg posaconazole injection intravenously twice a day on the first day.

Maintenance dose

300 mg posaconazole injection intravenously once a day, starting on the second day.

Duration of therapy is based on recovery from neutropenia or immunosuppression.

Method of Preparation and Administration

Preparation

  • Equilibrate the refrigerated vial of posaconazole injection to room temperature.
  • To prepare the required dose, aseptically transfer one vial (16.7 mL) of posaconazole injection (containing 300 mg of posaconazole in solution) to an intravenous bag (or bottle) of a compatible admixture diluent (as described in Table 4), to achieve a final concentration of posaconazole that is between 1 mg/mL and 2 mg/mL. Use of other diluents is not recommended because they may result in particulate formation.
  • Posaconazole injection is a single-dose sterile solution without preservatives. Once admixed, the product should be used immediately. If not used immediately, the solution can be stored up to 24 hours, refrigerated, at 2–8°C (36–46°F). Posaconazole injection is for single use only and any unused solution should be discarded.
  • Parenteral drug products should be inspected visually for particulate matter prior to administration, whenever solution and container permit. Once admixed, the solution of posaconazole ranges from colourless to yellow. Variations of colour within this range do not affect the quality of the product.

Intravenous Line Compatibility

A study was conducted to evaluate the physical compatibility of posaconazole injection with injectable drug products and commonly used intravenous diluents during simulated Y-site infusion. Compatibility was determined through visual observations, measurement of particulate matter and turbidity. Compatible diluents and drug products are listed in Tables 4 and 5 below. Any diluents or drug products not listed in the tables below should not be co-administered through the same intravenous line (or cannula).

Posaconazole injection can be infused at the same time through the same intravenous line (or cannula) with the following compatible diluents:

Table 4: Compatible Diluents

0.45% Sodium Chloride

0.9% Sodium Chloride

5% Dextrose in water

5% Dextrose and 0.45% Sodium Chloride

5% Dextrose and 0.9% Sodium Chloride

5% Dextrose and 20 mEq Potassium Chloride

Posaconazole injection can be infused at the same time through the same intravenous line (or cannula) with the following drug products prepared in 5% Dextrose in water or Sodium Chloride 0.9%. Co-administration of drug products prepared in other diluents may result in particulate formation.

Table 5: Compatible Drugs

Amikacin sulphate

Caspofungin

Ciprofloxacin

Daptomycin

Dobutamine hydrochloride

Famotidine

Filgrastim

Gentamicin sulphate

Hydromorphone hydrochloride

Levofloxacin

Lorazepam

Meropenem

Micafungin

Morphine sulphate

Norepinephrine bitartrate

Potassium chloride

Vancomycin hydrochloride

Administration

  • Posaconazole injection must be administered through a 0.22 micron polyethersulphone (PES) or polyvinylidene difluoride (PVDF) filter.
  • Administer via a central venous line, including a central venous catheter or a peripherally inserted central catheter (PICC), by slow infusion over approximately 90 minutes. Posaconazole injection is not for bolus administration.
  • If a central venous catheter is not available, posaconazole injection may be administered through a peripheral venous catheter only as a single dose in advance of central venous line placement or to bridge the period during which a central venous line is replaced or is in use for other treatment.
  • When multiple dosing is required, the infusion should be done via a central venous line. When administered through a peripheral venous catheter, the infusion should be administered over approximately 30 minutes. Note: In clinical trials, multiple peripheral infusions given through the same vein resulted in infusion-site reactions.

Special Populations

Renal Impairment

Posaconazole injection should be avoided in patients with moderate or severe renal impairment unless an assessment of the benefit/risk to the patient justifies the use of posaconazole injection.

In patients with moderate or severe renal impairment (CrCl <50 mL/min), accumulation of the intravenous vehicle SBECD, is expected to occur. Serum creatinine levels should be closely monitored in these patients and, if increases occur, consideration should be given to changing to oral posaconazole therapy.

Hepatic Impairment

Limited data on the effect of hepatic impairment (including Child-Pugh C classification of chronic liver disease) on the pharmacokinetics of posaconazole demonstrate an increase in plasma exposure compared to subjects with normal hepatic function, but do not suggest that dose adjustment is necessary. It is recommended to exercise caution due to the potential for higher plasma exposure.

Contraindications

Hypersensitivity

CRITPOSA injection is contraindicated in persons with known hypersensitivity to posaconazole or to any of its excipients or other azole antifungal agents.

Use with Sirolimus

Posaconazole is contraindicated with sirolimus. Concomitant administration of posaconazole with sirolimus increases the sirolimus blood concentrations by approximately 9-fold and can result in sirolimus toxicity.

QT Prolongation with Concomitant Use with CYP3A4 Substrates

Posaconazole is contraindicated with CYP3A4 substrates that prolong the QT interval. Concomitant administration of posaconazole with the CYP3A4 substrates, terfenadine, astemizole, cisapride, pimozide, halofantrine and quinidine may result in increased plasma concentrations of these drugs, leading to QTc prolongation and cases of torsades de pointes.

HMG-CoA Reductase Inhibitors Primarily Metabolized Through CYP3A4

Co-administration with the 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors that are primarily metabolised through CYP3A4 (e.g. atorvastatin, lovastatin, and simvastatin) is contraindicated since increased plasma concentration of these drugs can lead to rhabdomyolysis.

Use with Ergot Alkaloids

Posaconazole may increase the plasma concentrations of ergot alkaloids (ergotamine and dihydroergotamine) which may lead to ergotism.

Warnings and Precautions

General

Hypersensitivity

There is no information regarding cross-sensitivity between posaconazole and other azole antifungal agents. Caution should be used when prescribing posaconazole to patients with hypersensitivity to other azoles.

QTc Prolongation

Some azoles have been associated with prolongation of the QTc interval. Posaconazole must not be administered with medicinal products that are substrates for CYP3A4 and are known to prolong the QTc interval.

Posaconazole should be administered with caution to patients with pro-arrhythmic conditions such as the following:

  • Congenital or acquired QTc prolongation
  • Cardiomyopathy, especially in the presence of cardiac failure
  • Sinus bradycardia
  • Existing symptomatic arrhythmias
  • Concomitant use with medicinal products known to prolong the QTc interval (other than those mentioned in CONTRAINDICATIONS).

Electrolyte disturbances, especially those involving potassium, magnesium or calcium levels, should be monitored and corrected as necessary before and during posaconazole therapy.

In patients, mean maximum plasma concentrations (Cmax) after posaconazole concentrate for solution for infusion are 4-fold increased, compared with administration of oral suspension.

An increased effect on the QTc interval cannot be ruled out. Particular caution is advised in such cases where posaconazole is administered peripherally, as the recommended infusion time of 30 minutes may further increase Cmax.

Hepatic Toxicity

Hepatic reactions (e.g. elevations in alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin and/or clinical hepatitis) have been reported during treatment with posaconazole. Elevated liver function tests were generally reversible on discontinuation of therapy and, in some instances, these tests normalized without interruption of therapy. Rarely, more severe hepatic reactions with fatal outcomes have been reported.

Posaconazole should be used with caution in patients with hepatic impairment due to limited clinical experience and the possibility that posaconazole plasma levels may be higher in these patients.

Monitoring of Hepatic Function

Liver function tests should be evaluated at the start of and during the course of posaconazole therapy. Patients who develop abnormal liver function tests during posaconazole therapy must be routinely monitored for the development of more severe hepatic injury. Patient management should include laboratory evaluation of hepatic function (particularly liver function tests and bilirubin). Discontinuation of posaconazole should be considered if clinical signs and symptoms are consistent with development of liver disease.

Plasma Exposure

Plasma concentrations following administration of posaconazole intravenous concentrate for solution for infusion are generally higher than those obtained with posaconazole oral suspension. Posaconazole plasma concentrations following administration of posaconazole may increase over time in some patients. Safety data at higher exposure levels achieved with posaconazole concentrate for solution for infusion are at present limited.

Thromboembolic Events

Thromboembolic events have been identified as a potential risk for posaconazole intravenous concentrate for solution for infusion but were not observed in the clinical studies. Thrombophlebitis was observed in clinical trials. Caution is warranted on any sign or symptom of thromboembolic events.

Sodium Content

Each vial of posaconazole contains 462 mg (20 mmol) of sodium. This should be taken into consideration for patients on a controlled sodium diet.

Drug Interactions

Posaconazole is primarily metabolised via UDP glucuronosyltransferase and is a substrate of P-gp efflux. Therefore, inhibitors or inducers of these clearance pathways may affect posaconazole plasma concentrations. Co-administration of drugs that can decrease the plasma concentrations of posaconazole should generally be avoided unless the benefit outweighs the risk. If such drugs are necessary, patients should be monitored closely for breakthrough fungal infections.

Posaconazole is also a strong inhibitor of CYP3A4. Therefore, plasma concentrations of drugs predominantly metabolised by CYP3A4 may be increased by posaconazole.

The following information was derived from data with posaconazole oral suspension or early tablet formulation. All drug interactions with posaconazole oral suspension, except for those that affect the absorption of posaconazole (via gastric pH and motility), are considered relevant to posaconazole injection as well.

Immunosuppressants Metabolised by CYP3A4

Sirolimus

Concomitant administration of posaconazole with sirolimus increases the sirolimus blood concentrations by approximately 9-fold and can result in sirolimus toxicity. Therefore, posaconazole is contraindicated with sirolimus.

Tacrolimus

Posaconazole has been shown to significantly increase the Cmax and AUC of tacrolimus. At initiation of posaconazole treatment, reduce the tacrolimus dose to approximately one-third of the original dose. Frequent monitoring of tacrolimus whole blood trough concentrations should be performed during and at discontinuation of posaconazole treatment and the tacrolimus dose adjusted accordingly.

Cyclosporine

Posaconazole has been shown to increase cyclosporine whole blood concentrations in heart transplant patients upon initiation of posaconazole treatment. It is recommended to reduce cyclosporine dose to approximately three-fourths of the original dose upon initiation of posaconazole treatment. Frequent monitoring of cyclosporine whole blood trough concentrations should be performed during and at discontinuation of posaconazole treatment and the cyclosporine dose adjusted accordingly.

CYP3A4 Substrates

Concomitant administration of posaconazole with CYP3A4 substrates such as pimozide and quinidine may result in increased plasma concentrations of these drugs, leading to QTc prolongation and cases of torsades de pointes. Therefore, posaconazole is contraindicated with these drugs.

HMG-CoA Reductase Inhibitors Metabolised through CYP3A4 (e.g. Simvastatin, Lovastatin and Atorvastatin)

Posaconazole may substantially increase plasma levels of HMG-CoA reductase inhibitors that are metabolised by CYP3A4. Treatment with these HMG-CoA reductase inhibitors should be discontinued during treatment with posaconazole as increased levels have been associated with rhabdomyolysis.

Ergot Alkaloids

Most of the ergot alkaloids are substrates of CYP3A4. Posaconazole may increase the plasma concentrations of ergot alkaloids (ergotamine and dihydroergotamine), which may lead to ergotism. Therefore, posaconazole is contraindicated with ergot alkaloids.

Benzodiazepines Metabolised by CYP3A4

Concomitant administration of posaconazole with midazolam increases the midazolam plasma concentrations by approximately 5-fold. Increased plasma midazolam concentrations could potentiate and prolong hypnotic and sedative effects. Concomitant use of posaconazole and other benzodiazepines metabolised by CYP3A4 (e.g. alprazolam, triazolam) could result in increased plasma concentrations of these benzodiazepines. Patients must be monitored closely for adverse effects associated with high plasma concentrations of benzodiazepines metabolised by CYP3A4 and benzodiazepine receptor antagonists must be available to reverse these effects.

Due to the risk of prolonged sedation it is recommended that dose adjustments should be considered when posaconazole is administered concomitantly with any benzodiazepine that is metabolised by CYP3A4 (e.g. midazolam, triazolam, alprazolam).

Anti-HIV Drugs

Efavirenz: Efavirenz induces UDP-glucuronidase and significantly decreases posaconazole plasma concentrations. It is recommended to avoid concomitant use of efavirenz with posaconazole unless the benefit outweighs the risks.

Ritonavir and Atazanavir: Ritonavir and atazanavir are metabolised by CYP3A4 and posaconazole increases plasma concentrations of these drugs. Frequent monitoring of adverse effects and toxicity of ritonavir and atazanavir should be performed during co-administration with posaconazole.

Fosamprenavir: Combining fosamprenavir with posaconazole may lead to decreased posaconazole plasma concentrations. If concomitant administration is required, close monitoring for breakthrough fungal infections is recommended.

Rifabutin

Rifabutin induces UDP-glucuronidase and decreases posaconazole plasma concentrations. Rifabutin is also metabolised by CYP3A4. Therefore, co-administration of rifabutin with posaconazole increases rifabutin plasma concentrations. Concomitant use of posaconazole

and rifabutin should be avoided unless the benefit to the patient outweighs the risk. However, if concomitant administration is required, close monitoring for breakthrough fungal infections as well as frequent monitoring of full blood counts and adverse reactions due to increased rifabutin plasma concentrations (e.g. uveitis, leukopenia) are recommended.

Phenytoin

Phenytoin induces UDP-glucuronidase and decreases posaconazole plasma concentrations. Phenytoin is also metabolised by CYP3A4. Therefore, co-administration of phenytoin with posaconazole increases phenytoin plasma concentrations. Concomitant use of posaconazole and phenytoin should be avoided unless the benefit to the patient outweighs the risk. However, if concomitant administration is required, close monitoring for breakthrough fungal infections is recommended and frequent monitoring of phenytoin concentrations should be performed while co-administered with posaconazole and dose reduction of phenytoin should be considered.

Vinca Alkaloids

Most of the vinca alkaloids (e.g. vincristine and vinblastine) are substrates of CYP3A4. Concomitant administration of azole antifungals, including posaconazole, with vincristine has been associated with serious adverse reactions. Posaconazole may increase the plasma concentrations of vinca alkaloids which may lead to neurotoxicity   and other serious adverse reactions. Therefore, reserve azole antifungals, including posaconazole, for patients receiving a vinca alkaloid, including vincristine, who have no alternative antifungal treatment options.

Calcium Channel Blockers Metabolised by CYP3A4

Posaconazole may increase the plasma concentrations of calcium channel blockers metabolised by CYP3A4 (e.g. verapamil, diltiazem, nifedipine, nicardipine, felodipine). Frequent monitoring for adverse reactions and toxicity related to calcium channel blockers is recommended during co-administration. Dose reduction of calcium channel blockers may be needed.

Digoxin

Increased plasma concentrations of digoxin have been reported in patients receiving digoxin and posaconazole. Therefore, monitoring of digoxin plasma concentrations is recommended during co-administration.

Glipizide

Although no dosage adjustment of glipizide is required, it is recommended to monitor glucose concentrations when posaconazole and glipizide are concomitantly used.

Calcineurin-Inhibitor Drug Interactions

Concomitant administration of posaconazole with cyclosporine or tacrolimus increases the whole blood trough concentrations of these calcineurin-inhibitors. Nephrotoxicity and leukoencephalopathy (including deaths) have been reported in clinical efficacy studies in patients with elevated cyclosporine or tacrolimus concentrations. Frequent monitoring of tacrolimus or cyclosporine whole blood trough concentrations should be performed during and at discontinuation of posaconazole treatment and the tacrolimus or cyclosporine dose adjusted accordingly.

Rifamycin Antibacterials (Rifampicin, Rifabutin), Certain Anticonvulsants (Phenytoin, Carbamazepine, Phenobarbital, Primidone), and Efavirenz

Posaconazole concentrations may be significantly lowered in combination; therefore, concomitant use with posaconazole should be avoided unless the benefit to the patient outweighs the risk.

Effects on Ability to Drive and Use Machines

Since certain adverse reactions (e.g. dizziness, somnolence, etc.) have been reported with posaconazole use, which potentially may affect driving/operating machinery, caution needs to be used.

Renal Impairment

Posaconazole injection should be avoided in patients with moderate or severe renal impairment (CrCl <50 mL/min), unless an assessment of the benefit/risk to the patient justifies the use of posaconazole injection.

Patients with severe renal impairment should be monitored closely for breakthrough fungal infections due to the variability in exposure.

Hepatic Impairment

It is recommended to exercise caution due to the potential for higher plasma exposure.

Pregnancy

There is insufficient information on the use of posaconazole in pregnant women. Studies in animals have shown reproductive toxicity. The potential risk for humans is unknown.

Women of childbearing potential have to use effective contraception during treatment. Posaconazole must not be used during pregnancy unless the benefit to the mother clearly outweighs the potential risk to the foetus.

Lactation

Posaconazole is excreted into the milk of lactating rats. The excretion of posaconazole in human breast milk has not been investigated. Breastfeeding must be stopped on initiation of treatment with posaconazole.

Fertility

Posaconazole had no effect on fertility of male rats at doses up to 180 mg/kg (2.8 times the exposure achieved from a 300 mg intravenous dose in human) or female rats at a dose up to 45 mg/kg (3.4 times the exposure from a 300 mg intravenous dose in patients). There is no clinical experience assessing the impact of posaconazole on fertility in humans.

Paediatric Use

The safety and effectiveness of posaconazole injection in paediatric patients below the age of 18 years of age has not been established. Posaconazole injection should not be used in paediatric patients because of nonclinical safety concerns.

Geriatric Use

No dosage adjustment is recommended for geriatric patients.

Undesirable Effects

In initial studies of healthy volunteers, administration of a single dose of posaconazole infused over 30 minutes via a peripheral venous catheter was associated with a 12% incidence of infusion-site reactions (4% incidence of thrombophlebitis). Multiple doses of posaconazole administered via a peripheral venous catheter were associated with thrombophlebitis (60% incidence). Therefore, in subsequent studies posaconazole was administered via central venous catheter. If a central venous catheter was not readily available, patients could receive a single infusion over 30 minutes via a peripheral venous catheter. Peripheral infusion time longer than 30 minutes, leads to a higher incidence of infusion-site reactions and thrombophlebitis.

The safety of posaconazole concentrate for solution for infusion has been assessed in 268 patients in clinical trials. Patients were enrolled in a non-comparative pharmacokinetic and safety trial of posaconazole concentrate for solution for infusion when given as antifungal prophylaxis (Study 5520). While 11 patients received a single dose of 200 mg posaconazole concentrate for solution for infusion, 21 patients received 200 mg daily dose for a median of 14 days, and 237 patients received 300 mg daily dose for a median of 9 days. No safety data are available for administration >28 days. Safety data in the elderly are limited.

The most frequently reported adverse reaction (>25%) with an onset during the posaconazole intravenous phase of dosing with 300 mg once daily was diarrhoea (32%). The most common adverse reaction (>1%) leading to discontinuation of posaconazole concentrate for solution for infusion 300 mg once daily was acute myelogenous leukaemia (AML) (1%).

Tabulated List of Adverse Reactions

Within the organ system classes, adverse reactions are listed under headings of frequency using the following categories: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥ 1/10,000 to <1/1,000); very rare (<1/10,000); not known.

Table 6: Adverse Reactions by Body System and Frequency*

Blood and lymphatic system disorders

 

Common

neutropenia

Uncommon

thrombocytopenia, leukopenia, anaemia, eosinophilia, lymphadenopathy, splenic infarction

Rare

haemolytic uraemic syndrome, thrombotic thrombocytopenic purpura, pancytopenia, coagulopathy, haemorrhage

Immune system disorders

 

Uncommon

allergic reaction

Rare

hypersensitivity reaction

Endocrine disorders

 

Rare

adrenal insufficiency, blood gonadotropin decreased

Metabolism and nutrition disorders

 

Common

electrolyte imbalance, anorexia, decreased appetite, hypokalaemia, hypomagnesaemia

Uncommon

hyperglycaemia, hypoglycaemia

Psychiatric disorders

 

Uncommon

abnormal dreams, confusional state, sleep disorder

Rare

psychotic disorder, depression

Nervous system disorders

 

Common

paraesthesia, dizziness, somnolence, headache, dysgeusia

Uncommon

convulsions, neuropathy, hypoesthesia, tremor, aphasia, insomnia

Rare

cerebrovascular accident, encephalopathy, peripheral neuropathy, syncope

Eye disorders

 

Uncommon

blurred vision, photophobia, visual acuity reduced

Rare

diplopia, scotoma

Ear and labyrinth disorder

 

Rare

hearing impairment

Cardiac disorders

 

Uncommon

long QT syndrome$, electrocardiogram abnormal$, palpitations, bradycardia, supraventricular extrasystoles, tachycardia

Rare

torsades de pointes, sudden death, ventricular tachycardia, cardiorespiratory arrest, cardiac failure, myocardial infarction

Vascular disorders

 

Common

hypertension

Uncommon

hypotension, thrombophlebitis, vasculitis

Rare

pulmonary embolism, deep vein thrombosis

Respiratory, thoracic and mediastinal disorders

 

Uncommon

cough, epistaxis, hiccups, nasal congestion, pleuritic pain, tachypnoea

Rare

pulmonary hypertension, interstitial pneumonia, pneumonitis

Gastrointestinal disorders

 

Very common

nausea

Common

vomiting, abdominal pain, diarrhoea, dyspepsia, dry mouth, flatulence, constipation, anorectal discomfort

Uncommon

pancreatitis, abdominal distension, enteritis, epigastric discomfort, eructation, gastro-oesophageal reflux disease, oedema mouth

Rare

gastrointestinal haemorrhage, ileus

Hepatobiliary disorders

 

Common

liver function tests raised

Uncommon

hepatocellular damage, hepatitis, jaundice, hepatomegaly, cholestasis, hepatic toxicity, hepatic function abnormal

Rare

hepatic failure, hepatitis cholestatic, hepatosplenomegaly, liver tenderness, asterixis

Skin and subcutaneous tissue disorders

 

Common

rash, pruritis

Uncommon

mouth ulceration, alopecia, dermatitis, erythema, petechiae

Rare

Stevens Johnson syndrome, vesicular rash

Musculoskeletal and connective tissue disorders

 

Uncommon

back pain, neck pain, musculoskeletal pain, pain in extremity

Renal and urinary disorders

 

Uncommon

acute renal failure, renal failure, blood creatinine increased

Rare

renal tubular acidosis, interstitial nephritis

Reproductive system and breast disorders

 

Uncommon

menstrual disorder

Rare

breast pain

General disorders and administration site conditions

 

Common

pyrexia (fever), asthenia, fatigue

Uncommon

oedema, pain, chills, malaise, chest discomfort, drug intolerance, feeling jittery, infusion-site pain, infusion-site phlebitis, infusion-site thrombosis, mucosal inflammation

Rare

tongue oedema, face oedema

Investigations

 

Uncommon

altered medicine levels, blood phosphorus decreased, chest X-ray abnormal

* Based on adverse reactions observed with the oral suspension, gastro-resistant tablets, and concentrate for solution for infusion.

$ See WARNINGS AND PRECAUTIONS.

Description of Selected Adverse Reactions

Hepatobiliary Disorders

During postmarketing surveillance, severe hepatic injury with fatal outcome has been reported (see WARNINGS AND PRECAUTIONS).

If you experience any side effects, talk to your doctor or pharmacist or write to drugsafety@Cipla.com. You can also report side effects directly via the National Pharmacovigilance Programme of India by calling on 1800 180 3024. By reporting side effects, you can help provide more information on the safety of this product.

Overdosage

There is no experience with overdose of posaconazole concentrate for solution for infusion.

During clinical trials, patients who received posaconazole oral suspension doses up to 1,600 mg/day experienced no different adverse reactions from those reported with patients at the lower doses. Accidental overdose was noted in one patient who took posaconazole oral suspension 1,200 mg twice a day for 3 days. No adverse reactions were noted by the investigator.

Posaconazole is not removed by haemodialysis. There is no special treatment available in the case of overdose with posaconazole. Supportive care may be considered.

Incompatibility

CRITPOSA injection must not be diluted with the following:

Lactated Ringer's solution

5% Dextrose with Lactated Ringer's solution

4.2% Sodium Bicarbonate

This medicinal product must not be mixed with other medicinal products except those mentioned under DOSAGE AND ADMINISTRATION.

Storage and Handling Instructions

Store refrigerated at 2–8°C (36–46°F).

Keep away from infants and small children.

Packaging Information

CRITPOSA injection is available in 20 mL tubular vials closed with a 20 mm bromobutyl rubber stopper and a 20 mm aluminium seal.

Last Reviewed: May 2018

Last Updated: May 2018