`
`
` HIGHLIGHTS OF PRESCRIBING INFORMATION
` These highlights do not include all the information needed to use
`
`
`PREZCOBIX® safely and effectively. See full prescribing information for
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`
`
`PREZCOBIX.
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`PREZCOBIX (darunavir and cobicistat) tablets, for oral use
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`Initial U.S. Approval: 2015
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`
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`
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`---------------------------RECENT MAJOR CHANGES--------------------------
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`
`06/2018
`Dosage and Administration (2.5)
`
`
`09/2018
`Contraindications (4)
`
`
`----------------------------INDICATIONS AND USAGE--------------------------
`
`
`PREZCOBIX is a two-drug combination of darunavir, a human
`
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`
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`immunodeficiency virus (HIV-1) protease inhibitor, and cobicistat, a CYP3A
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`inhibitor, and is indicated for the treatment of HIV-1 infection in treatment
`
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`
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`naïve and treatment-experienced adults with no darunavir resistance-
`
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`associated substitutions (V11I, V32I, L33F, I47V, I50V, I54L, I54M, T74P,
`
`
`
`
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`L76V, I84V, L89V). (1)
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`-----------------------DOSAGE AND ADMINISTRATION----------------------
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`Recommended dosage: One tablet taken once daily with food. (2.1)
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`Testing Prior to Initiation: HIV genotypic testing is recommended for
`
`
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`antiretroviral treatment experienced patients. Assess estimated creatinine
`
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`clearance in all patients prior to starting PREZCOBIX. When used with
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`tenofovir DF: Assess urine glucose and urine protein at baseline and monitor
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`creatinine clearance, urine glucose, and urine protein. Monitor serum
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`phosphorus in patients with or at risk for renal impairment. (2.2)
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`----------------------DOSAGE FORMS AND STRENGTHS--------------------
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`Tablets: 800 mg of darunavir and 150 mg of cobicistat. (3)
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`-------------------------------CONTRAINDICATIONS------------------------------
`PREZCOBIX is contraindicated in patients receiving certain co-administered
`
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`drugs for which altered plasma concentrations are associated with serious
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`and/or life-threatening events or loss of therapeutic effect. (4, 7.2)
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`------------------------WARNINGS AND PRECAUTIONS----------------------
`
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`Drug-induced hepatitis (e.g., acute hepatitis, cytolytic hepatitis), liver
`
`
`•
`injury, including some fatalities can occur with PREZCOBIX. Monitor
`
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`liver function before and during therapy, especially in patients with
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`
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`underlying chronic hepatitis, cirrhosis, or in patients who have pre
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`
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`treatment elevations of transaminases. (5.1)
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`FULL PRESCRIBING INFORMATION: CONTENTS*
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`
`INDICATIONS AND USAGE
`1
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`2 DOSAGE AND ADMINISTRATION
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`
`2.1 Recommended Dosage
`
`
`2.2
`Testing Prior to Initiation of PREZCOBIX
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`2.3 Not Recommended in Severe Renal Impairment
`
`2.4 Not Recommended in Severe Hepatic
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`
`Impairment
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`2.5 Not Recommended During Pregnancy
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`3 DOSAGE FORMS AND STRENGTHS
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`4 CONTRAINDICATIONS
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`5 WARNINGS AND PRECAUTIONS
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`
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`5.1 Hepatotoxicity
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`5.2 Severe Skin Reactions
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`
`5.3 Effects on Serum Creatinine
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`5.4 New Onset or Worsening Renal Impairment
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`
`
`When Used With Tenofovir Disoproxil Fumarate
`
`5.5 Risk of Serious Adverse Reactions or Loss of
`
`
`
`
`Virologic Response Due to Drug Interactions
`
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`5.6 Antiretrovirals Not Recommended
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`
`5.7 Sulfa Allergy
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`5.8 Diabetes Mellitus/Hyperglycemia
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`5.9
`Fat Redistribution
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`5.10
`Immune Reconstitution Syndrome
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`5.11 Hemophilia
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`6 ADVERSE REACTIONS
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`6.1 Clinical Trials Experience
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`6.2 Postmarketing Experience
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`7 DRUG INTERACTIONS
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`•
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`
`•
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`Skin reactions ranging from mild to severe, including Stevens-Johnson
`
`
`Syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and
`
`
`systemic symptoms and acute generalized exanthematous pustulosis, can
`
`
`
`
`occur with PREZCOBIX. Discontinue treatment if severe reaction
`
`
`develops. (5.2)
`
`• When PREZCOBIX is used in combination with a tenofovir disoproxil
`
`
`
`
`
`
`fumarate (tenofovir DF) containing regimen, cases of acute renal failure
`and Fanconi syndrome have been reported. (5.4)
`
`
`PREZCOBIX is not recommended in combination with other
`
`
`
`antiretroviral drugs that require pharmacokinetic boosting. (5.6)
`
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`• Monitor in patients with a known sulfonamide allergy. (5.7)
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`
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`Patients receiving PREZCOBIX may develop new onset or
`•
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`
`
`
`exacerbations of diabetes mellitus/hyperglycemia (5.8),
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`
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`redistribution/accumulation of body fat (5.9), and immune reconstitution
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`syndrome. (5.10)
`
`Patients with hemophilia may develop increased bleeding events. (5.11)
`•
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`
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`------------------------------ADVERSE REACTIONS------------------------------
`The most common adverse reactions to darunavir, a component of
`•
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`
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`PREZCOBIX (incidence greater than or equal to 5%) of at least
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`moderate severity (greater than or equal to Grade 2) were diarrhea,
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`
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`nausea, rash, headache, abdominal pain, and vomiting. (6.1)
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`To report SUSPECTED ADVERSE REACTIONS, contact Janssen
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`Products, LP at 1-800-JANSSEN (1-800-526-7736) or FDA at 1-800-FDA
`
`
`1088 or www.fda.gov/medwatch.
`
`
`-------------------------------DRUG INTERACTIONS------------------------------
`Co-administration of PREZCOBIX with other drugs can alter the
`•
`
`
`
`
`
`
`concentration of other drugs and other drugs may alter the
`
`concentrations of darunavir or cobicistat. Consult the full prescribing
`
`information prior to and during treatment for potential drug interactions.
`
`
`
`(4, 5.6, 7, 12.3)
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`-----------------------USE IN SPECIFIC POPULATIONS-----------------------
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`Pregnancy: PREZCOBIX is not recommended during pregnancy due to
`•
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`
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`substantially lower exposures of darunavir and cobicistat during
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`
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`pregnancy. (8.1, 12.3)
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`Lactation: Breastfeeding is not recomnmended. (8.2)
`•
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`See 17 for PATIENT COUNSELING INFORMATION and FDA-
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`approved patient labeling.
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`Revised: 09/2018
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`7.1 Potential for PREZCOBIX to Affect Other Drugs
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`7.2 Potential for Other Drugs to Affect PREZCOBIX
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`7.3 Established and Other Potentially Significant
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`Drug Interactions
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`7.4 Drugs without Clinically Significant Interactions
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`with PREZCOBIX
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`8 USE IN SPECIFIC POPULATIONS
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`8.1 Pregnancy
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`8.2
`Lactation
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`8.3
`Females and Males of Reproductive Potential
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`8.4 Pediatric Use
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`8.5 Geriatric Use
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`8.6 Hepatic Impairment
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`8.7 Renal Impairment
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`10 OVERDOSAGE
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`11 DESCRIPTION
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`12 CLINICAL PHARMACOLOGY
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`12.1 Mechanism of Action
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`12.2 Pharmacodynamics
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`12.3 Pharmacokinetics
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`12.4 Microbiology
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`13 NONCLINICAL TOXICOLOGY
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`13.1 Carcinogenesis, Mutagenesis, Impairment of
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`Fertility
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`14 CLINICAL STUDIES
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`16 HOW SUPPLIED/STORAGE AND HANDLING
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`17 PATIENT COUNSELING INFORMATION
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`*Sections or subsections omitted from the full prescribing information are not
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`listed.
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`Reference ID: 4317066
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`
`
` 1
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`
` FULL PRESCRIBING INFORMATION
`
` 1
` INDICATIONS AND USAGE
`
`
`
`PREZCOBIX® is indicated in combination with other antiretroviral agents for the treatment of
`
`
`
`
`
`human immunodeficiency virus (HIV-1) infection in treatment-naïve and treatment-experienced
`
`adults with no darunavir resistance-associated substitutions (V11I, V32I, L33F, I47V, I50V,
`
`I54L, I54M, T74P, L76V, I84V, L89V).
`
`
`2 DOSAGE AND ADMINISTRATION
`
`
`2.1 Recommended Dosage
`
`
`
`
`
`
`
`PREZCOBIX is a fixed-dose combination product containing 800 mg of darunavir and 150 mg
`
`of cobicistat. In treatment-naïve and treatment-experienced adults with no darunavir resistance-
`
`
`
`
`associated substitutions, the recommended dosage of PREZCOBIX is one tablet taken once daily
`
`
`
`orally with food. Administer PREZCOBIX in conjunction with other antiretroviral agents.
`
`2.2 Testing Prior to Initiation of PREZCOBIX
`
`
`
`HIV Genotypic Testing
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`HIV genotypic testing is recommended for antiretroviral treatment-experienced patients.
`
`
`However, when HIV genotypic testing is not feasible, PREZCOBIX can be used in protease
`
`
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`inhibitor-naïve patients, but is not recommended in protease inhibitor-experienced patients.
`
`
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`Creatinine Clearance
`
`Prior to starting PREZCOBIX, assess estimated creatinine clearance because cobicistat decreases
`
`
`
`estimated creatinine clearance due to inhibition of tubular secretion of creatinine without
`
`affecting actual renal glomerular function [see Warnings and Precautions (5.3)]. When co-
`
`
`
`
`administering PREZCOBIX with tenofovir disoproxil fumarate (tenofovir DF) assess estimated
`
`
`
`creatinine clearance, urine glucose, and urine protein at baseline [see Warnings and Precautions
`
`
`(5.4)].
`
`2.3 Not Recommended in Severe Renal Impairment
`
`
`
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`PREZCOBIX co-administered with tenofovir DF is not recommended in patients who have an
`
`
`estimated creatinine clearance below 70 mL per minute [see Warnings and Precautions (5.4) and
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`
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`Adverse Reactions (6.1)].
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`2.4 Not Recommended in Severe Hepatic Impairment
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`PREZCOBIX is not recommended for use in patients with severe hepatic impairment [see Use in
`
`
`
`Specific Populations (8.6) and Clinical Pharmacology (12.3)].
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`Reference ID: 4317066
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`
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` 2
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` 2.5 Not Recommended During Pregnancy
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` PREZCOBIX is not recommended during pregnancy because of substantially lower exposures of
`
` darunavir and cobicistat during pregnancy [see Use in Specific Populations (8.1) and Clinical
`
`
`
`
`Pharmacology (12.3)].
`
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`PREZCOBIX should not be initiated in pregnant individuals. An alternative regimen is
`
`
`recommended for those who become pregnant during therapy with PREZCOBIX.
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`3 DOSAGE FORMS AND STRENGTHS
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`PREZCOBIX is supplied as pink, oval-shaped, film-coated tablets containing darunavir
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`
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`ethanolate equivalent to 800 mg of darunavir and 150 mg cobicistat. Each tablet is debossed with
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`“800” on one side and “TG” on the other side.
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`4 CONTRAINDICATIONS
`
`
`PREZCOBIX is contraindicated in patients receiving the following co-administered drugs [see
`
`
`Drug Interactions (7.3) and Clinical Pharmacology (12.3)].
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`
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`• Alpha 1-adrenoreceptor antagonist: alfuzosin
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`• Antianginal: ranolazine
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`• Antiarrhythmic: dronedarone
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`• Anticonvulsants: carbamazepine, phenobarbital, phenytoin
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`• Anti-gout: colchicine, in patients with renal/and or hepatic impairment
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`• Antimycobacterial: rifampin
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`• Antipsychotics: lurasidone, pimozide
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`• Ergot derivatives, e.g. dihydroergotamine, ergotamine, methylergonovine
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`• GI motility agent: cisapride
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`• Herbal product: St. John’s wort (Hypericum perforatum)
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`• Hepatitis C direct acting antiviral: elbasvir/grazoprevir
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`• Lipid modifying agents: lomitapide, lovastatin, simvastatin
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`• PDE-5 inhibitor: sildenafil when used for treatment of pulmonary arterial hypertension
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`• Sedatives/hypnotics: orally administered midazolam, triazolam
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`
`5 WARNINGS AND PRECAUTIONS
`
`
`
`5.1 Hepatotoxicity
`
`
`During
`the darunavir clinical development program (N=3063), where darunavir was
`
`
`
`co-administered with ritonavir 100 mg once or twice daily, drug-induced hepatitis (e.g., acute
`
`
`
`hepatitis, cytolytic hepatitis) was reported in 0.5% of subjects. Patients with pre-existing liver
`
`
`
`
`
`
`
`
` 3
`
`Reference ID: 4317066
`
`
`
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`dysfunction, including chronic active hepatitis B or C, have an increased risk for liver function
`abnormalities including severe hepatic adverse reactions.
`
`Post-marketing cases of liver injury, including some fatalities, have also been reported with
`
`
`
`
`
`darunavir co-administered with ritonavir. These have generally occurred in patients with
`
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`advanced HIV-1 disease taking multiple concomitant medications, having co-morbidities
`
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`including hepatitis B or C co-infection, and/or developing immune reconstitution syndrome. A
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`causal relationship with darunavir co-administered with ritonavir has not been established.
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`Appropriate laboratory testing should be conducted prior to initiating therapy with PREZCOBIX
`
`
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`and patients should be monitored during treatment. Increased AST/ALT monitoring should be
`
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`considered in patients with underlying chronic hepatitis, cirrhosis, or in patients who have
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`pre-treatment elevations of transaminases, especially during the first several months of
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`PREZCOBIX treatment.
`
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`Evidence of new or worsening liver dysfunction (including clinically significant elevation of
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`liver enzymes and/or symptoms such as fatigue, anorexia, nausea, jaundice, dark urine, liver
`
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`tenderness, hepatomegaly) in patients on PREZCOBIX should prompt consideration of
`
`
`interruption or discontinuation of treatment.
`
`5.2 Severe Skin Reactions
`
`
`During
`the darunavir clinical development program (n=3063), where darunavir was
`
`co-administered with ritonavir 100 mg once or twice daily, severe skin reactions, accompanied
`
`
`
`
`
`by fever and/or elevations of transaminases in some cases, was reported in 0.4% of subjects.
`
`
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`Stevens-Johnson Syndrome was rarely (less than 0.1%) reported during the clinical development
`
`program. During post-marketing experience toxic epidermal necrolysis, drug rash with
`
`eosinophilia and systemic symptoms, and acute generalized exanthematous pustulosis have been
`
`
`
`reported. Discontinue PREZCOBIX immediately if signs or symptoms of severe skin reactions
`
`
`
`
`
`develop. These can include but are not limited to severe rash or rash accompanied with fever,
`
`
`
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`general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis
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`
`and/or eosinophilia.
`
`Mild-to-moderate rash was also reported and often occurred within the first four weeks of
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`
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`treatment and resolved with continued dosing.
`
`
`5.3 Effects on Serum Creatinine
`
`
`Cobicistat decreases estimated creatinine clearance due to inhibition of tubular secretion of
`
`creatinine without affecting actual renal glomerular function. This effect should be considered
`
`
`
`
`
`when interpreting changes in estimated creatinine clearance in patients initiating PREZCOBIX,
`
`particularly in patients with medical conditions or receiving drugs needing monitoring with
`estimated creatinine clearance.
`
`Prior to initiating therapy with PREZCOBIX, assess estimated creatinine clearance [see Dosage
`
`
`
`
`
`
`and Administration (2.2)]. Dosage recommendations are not available for drugs that require
`
`dosage adjustments in PREZCOBIX-treated patients with renal impairment [see Drug
`
`
`
`Interactions (7.3) and Clinical Pharmacology (12.2)]. Consider alternative medications that do
`
`
`
`
`not require dosage adjustments in patients with renal impairment.
`
`
`
`
` 4
`
`Reference ID: 4317066
`
`
`
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`Although cobicistat may cause modest increases in serum creatinine and modest declines in
`
`estimated creatinine clearance without affecting renal glomerular function, patients who
`
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`experience a confirmed increase in serum creatinine of greater than 0.4 mg/dL from baseline
`
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`
`
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`should be closely monitored for renal safety.
`
`
`
` 5.4 New Onset or Worsening Renal Impairment When Used With Tenofovir
`
`Disoproxil Fumarate
`
`Renal impairment, including cases of acute renal failure and Fanconi syndrome, has been
`
`
`
`
`reported when cobicistat, a component of PREZCOBIX, was used in an antiretroviral regimen
`that contained tenofovir DF. Co-administration of PREZCOBIX and tenofovir DF is not
`
`
`
`recommended in patients who have an estimated creatinine clearance below 70 mL/min [see
`
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`Dosage and Administration (2.3)].
`
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`•
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`•
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`Document urine glucose and urine protein at baseline [see Dosage and Administration
`
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`(2.2)] and perform routine monitoring of estimated creatinine clearance, urine glucose,
`
`
`and urine protein during treatment when PREZCOBIX is used with tenofovir DF.
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`
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`Measure serum phosphorus in patients with or at risk for renal impairment when used
`with tenofovir DF.
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`Co-administration of PREZCOBIX and tenofovir DF in combination with concomitant or
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`
`
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`recent use of a nephrotoxic agent is not recommended.
`
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`See cobicistat full prescribing information for additional information regarding cobicistat.
`
`5.5 Risk of Serious Adverse Reactions or Loss of Virologic Response Due to
`
`
`
`
`
`Drug Interactions
`
`Initiation of PREZCOBIX, which inhibits CYP3A, in patients receiving medications metabolized
`
`
`by CYP3A, or initiation of medications metabolized by CYP3A in patients already receiving
`
`PREZCOBIX may increase plasma concentrations of medications metabolized by CYP3A.
`
`
`
`
`Initiation of medications that inhibit or induce CYP3A may respectively increase or decrease
`
`
`concentrations of PREZCOBIX.
`
`
`Increased concentrations may lead to:
`
`
`
`•
`
`clinically significant adverse reactions, potentially leading to severe, life threatening, or
`
`
`
`
`fatal events from higher exposures of concomitant medications.
`
`
`
`
`clinically significant adverse reactions from higher exposures of PREZCOBIX.
`
`
`
`
`•
`Decreased antiretroviral concentrations may lead to:
`
`
`
`
`loss of therapeutic effect of PREZCOBIX and possible development of resistance.
`
`
`
`
`
`•
`See Table 1 for steps to prevent or manage these possible and known significant drug
`
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`
`
`
`interactions, including dosing recommendations. Consider the potential for drug interactions
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`prior to and during PREZCOBIX therapy; review concomitant medications during PREZCOBIX
`
`
`
`Reference ID: 4317066
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`
`
` 5
`
`
`
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`therapy; and monitor for the adverse reactions associated with concomitant medications [see
`
`
`
`Contraindications (4) and Drug Interactions (7)].
`
`
`
`
`
`When used with concomitant medications, PREZCOBIX may result in different drug interactions
`
`
`than those observed or expected with darunavir co-administered with ritonavir. Complex or
`
`
`unknown mechanisms of drug interactions preclude extrapolation of drug interactions with
`
`
`darunavir co-administered with ritonavir to certain PREZCOBIX interactions [see Drug
`
`
`
`
`
`
`Interactions (7) and Clinical Pharmacology (12.3)].
`
`
`
`
`
`5.6 Antiretrovirals Not Recommended
`
`
`
`
`PREZCOBIX is not recommended in combination with other antiretroviral drugs that require
`
`
`pharmacokinetic boosting (i.e., another protease inhibitor or elvitegravir) because dosing
`
`
`recommendations for such combinations have not been established and co-administration may
`
`result in decreased plasma concentrations of the antiretroviral agents, leading to loss of
`
`
`
`therapeutic effect and development of resistance.
`
`PREZCOBIX is not recommended in combination with products containing the individual
`
`
`
`components of PREZCOBIX (darunavir and cobicistat) or with ritonavir. For additional
`
`
`
`
`
`
`recommendations on use of PREZCOBIX with other antiretroviral agents, [see Drug
`
`
`Interactions (7)].
`
`
`5.7 Sulfa Allergy
`
`
`Darunavir contains a sulfonamide moiety. Monitor patients with a known sulfonamide allergy
`
`
`
`after initiating PREZCOBIX. In clinical studies with darunavir co-administered with ritonavir,
`
`
`
`the incidence and severity of rash were similar in subjects with or without a history of
`
`
`
`sulfonamide allergy.
`
`5.8 Diabetes Mellitus/Hyperglycemia
`
`
`New onset diabetes mellitus, exacerbation of pre-existing diabetes mellitus, and hyperglycemia
`
`have been reported during postmarketing surveillance in HIV infected patients receiving HIV
`
`
`protease inhibitor (PI) therapy. Some patients required either initiation or dose adjustments of
`
`insulin or oral hypoglycemic agents for treatment of these events. In some cases, diabetic
`
`ketoacidosis has occurred. In those patients who discontinued PI therapy, hyperglycemia
`
`
`
`persisted in some cases. Because these events have been reported voluntarily during clinical
`
`
`practice, estimates of frequency cannot be made and causal relationships between HIV PI
`
`
`
`therapy and these events have not been established.
`
`5.9 Fat Redistribution
`
`
`Redistribution/accumulation of body fat, including central obesity, dorsocervical fat enlargement
`
`
`
`
`(buffalo hump), peripheral wasting, facial wasting, breast enlargement, and “cushingoid
`
`appearance” have been observed in patients receiving antiretroviral therapy. The mechanism and
`
`long-term consequences of these events are currently unknown. A causal relationship has not
`
`been established.
`
`
`Reference ID: 4317066
`
`
`
` 6
`
`
`
`
` 5.10 Immune Reconstitution Syndrome
`
`
`
` Immune reconstitution syndrome has been reported in patients treated with combination
` antiretroviral therapy, including PREZCOBIX. During the initial phase of combination
`
`
`
`
` antiretroviral treatment, patients whose immune systems respond may develop an inflammatory
` response to indolent or residual opportunistic infections (such as Mycobacterium avium
`
`
`
` infection, cytomegalovirus, Pneumocystis jirovecii pneumonia [PCP], or tuberculosis), which
`
`
`
` may necessitate further evaluation and treatment.
`
` Autoimmune disorders (such as Graves’ disease, polymyositis, and Guillain-Barré syndrome)
`
`have also been reported to occur in the setting of immune reconstitution; however, the time to
`onset is more variable, and can occur many months after initiation of antiretroviral treatment.
`
`
`5.11 Hemophilia
`
`
`There have been reports of increased bleeding, including spontaneous skin hematomas and
`
`
`hemarthrosis in patients with hemophilia type A and B treated with HIV PIs. In some patients,
`
`
`
`
`
`
`additional factor VIII was given. In more than half of the reported cases, treatment with HIV PIs
`
`
`was continued or reintroduced if treatment had been discontinued. A causal relationship between
`
`PI therapy and these episodes has not been established.
`
`6 ADVERSE REACTIONS
`
`
`The following adverse reactions are discussed in other sections of the labeling:
`
`
`
`
`•
`
`
`•
`
`
`•
`
`Hepatotoxicity [see Warnings and Precautions (5.1)]
`
`
`
`
`Severe skin reactions [see Warnings and Precautions (5.2)]
`
`
`
`
`Effects on serum creatinine [see Warnings and Precautions (5.3)]
`
`
`
`
`
`•
`
`New onset or worsening renal impairment when used with tenofovir DF [see Warnings
`
`
`
`
`and Precautions (5.4)]
`
`
`6.1 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 clinical practice.
`
`
`
`During the darunavir clinical development program, where darunavir was co-administered with
`
`
`
`ritonavir 100 mg once or twice daily, the most common clinical adverse reactions (incidence
`
`
`
`
`greater than or equal to 5%) of at least moderate intensity (greater than or equal to Grade 2) were
`
`
`
`diarrhea, nausea, rash, headache, abdominal pain, and vomiting. See the darunavir full
`
`prescribing information for additional information on adverse reactions reported with darunavir
`
`co-administered with ritonavir. See cobicistat full prescribing information for clinical trial
`
`
`information on adverse reactions reported with cobicistat.
`
`One single arm clinical trial was conducted with darunavir and cobicistat administered as single
`
`
`
`entities in 313 HIV-infected subjects. Adverse reactions evaluated through Week 24 did not
`
`
`
`
`
` 7
`
`Reference ID: 4317066
`
`
`
`
`
`
` differ substantially from those reported in clinical trials with darunavir co-administered with
`
` ritonavir.
` 6.2 Postmarketing Experience
`
`
`
`
`
` The following events have been identified during post-approval use of darunavir. Because these
` events 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.
`
`
`
`
`
`
`
`
`
`
` Metabolism and Nutrition Disorders:
`
`Redistribution of body fat
`
`
`Musculoskeletal and Connective Tissue Disorders
`
`
`Rhabdomyolysis (associated with co-administration with HMG-CoA reductase inhibitors)
`
`
`Skin and Subcutaneous Tissue Disorders
`
`
`Toxic epidermal necrolysis, acute generalized exanthematous pustulosis, drug rash with
`
`
`eosinophilia and systemic symptoms [see Warnings and Precautions (5.2)].
`
`
`
`
`7 DRUG INTERACTIONS
`
`
`7.1 Potential for PREZCOBIX to Affect Other Drugs
`
`
`
`
`
`Darunavir co-administered with cobicistat is an inhibitor of CYP3A and CYP2D6. Cobicistat
`
`
`
`inhibits the following transporters: P-glycoprotein (P-gp), BCRP, MATE1, OATP1B1 and
`
`
`OATP1B3. Therefore, co-administration of PREZCOBIX with drugs that are primarily
`
`
`
`
`metabolized by CYP3A and/or CYP2D6 or are substrates of P-gp, BCRP, MATE1, OATP1B1 or
`
`
`
`
`OATP1B3 may result in increased plasma concentrations of such drugs, which could increase or
`
`
`
`prolong their therapeutic effect and can be associated with adverse events (see Table 1).
`
`
`7.2 Potential for Other Drugs to Affect PREZCOBIX
`
`
`
`
`Darunavir is metabolized by CYP3A. Cobicistat is metabolized by CYP3A, and to a minor
`
`
`
`
`extent, by CYP2D6. Co-administration of PREZCOBIX and drugs that induce CYP3A activity
`
`
`are expected to increase the clearance of darunavir and cobicistat, resulting in lowered plasma
`
`
`
`
`
`
`concentrations of darunavir and cobicistat which may lead to loss of therapeutic effect and
`
`
`development of resistance. Co-administration of PREZCOBIX and other drugs that inhibit
`
`
`
`
`CYP3A may result in increased plasma concentrations of darunavir and cobicistat (see Table 1).
`
`
`
`
`
`7.3 Established and Other Potentially Significant Drug Interactions
`
`
`
`
`
`Table 1 provides dosing recommendations for expected clinically relevant interactions with
`
`
`
`
`
`PREZCOBIX (this table is not all inclusive). These recommendations are based on either drug
`
`
`interaction trials or predicted interactions due to the expected magnitude of interaction and
`
`
`
`
`potential for serious adverse events or loss of therapeutic effect. For the list of contraindicated
`
`
`drugs, [see Contraindications (4)].
`
`
`Reference ID: 4317066
`
`
`
` 8
`
`
`
`
` Table 1:
`
`
`
`
`
`
`
` Established and Other Potentially Significant* Drug Interactions: Alterations in Dose or
`
` Regimen May Be Recommended
`
` Effect on Concentration of
` Darunavir, Cobicistat, or
`
` Concomitant Drug Class:
`
`
` Drug Name
` Concomitant Drug
` HIV-1 antiviral agents: Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
`
`
` didanosine
`
` Didanosine should be administered
`
`
` ↔ darunavir
`
`
`
` one hour before or two hours after
`
` ↔ cobicistat
`
` PREZCOBIX (administered with
`
`
`
` ↔ didanosine
`
` food).
` HIV-1 antiviral agents: Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
`
`
`
` Co-administration with efavirenz is
` efavirenz
`
`
` ↓ cobicistat
` not recommended because it may
`
`
`
` ↓ darunavir
`
` result in loss of therapeutic effect
`
`
` and development of resistance to
`
`
` darunavir.
`
` Co-administration with etravirine is
` not recommended because it may
`
`
` result in loss of therapeutic effect
`
`
` and development of resistance to
`
` darunavir.
`
` Co-administration with nevirapine
` is not recommended because it may
`
`
` result in loss of therapeutic effect
`
`
` and development of resistance to
`
` darunavir.
`
`
`
`
`
`
`
` Clinical Comment
`
`
`
` ↓ cobicistat
`
`
` darunavir: effect unknown
`
`
`
` ↓ cobicistat
`
`
` darunavir: effect unknown
`
`
`
`
`
` etravirine
`
`
`
` nevirapine
`
`
`
` HIV-1 antiviral agents: CCR5 co-receptor antagonists
`
` maraviroc
`
`
` ↑ maraviroc
`
`
` ↑ alfuzosin
`
`
`
`
`
`
`
` ↑ ranolazine
`
`
`
`
`
` ↑ dronedarone
`
`
`
`
`
` ↑ antiarrhythmics
`
`
`
`
`
` ↑ digoxin
`
`
`
` Other agents
`
`Alpha 1-adrenoreceptor
`
` antagonist:
`
` alfuzosin
`
`
` Antianginal:
`
` ranolazine
`
`
` Antiarrhythmics:
`
` dronedarone
`
`
` e.g. amiodarone, disopyramide,
`
` flecainide, lidocaine (systemic),
` mexiletine, propafenone, quinidine
`
`
`
`
`
`
`
` digoxin
`
`Reference ID: 4317066
`
`
`
`
`
`
`
` Maraviroc is a substrate of CYP3A.
`
` When co-administered with
` PREZCOBIX, patients should
`
`
` receive maraviroc 150 mg twice
`
` daily.
`
` Co-administration is
`
`
` contraindicated due to potential for
`
` serious and/or life-threatening
`
` reactions such as hypotension.
`
` Co-administration is
`
` contraindicated due to potential for
`
` serious and/or life-threatening
`
` reactions.
` Co-administration is
`
`
` contraindicated due to potential for
`
` serious and/or life-threatening
`reactions such as cardiac
`
` arrhythmias.
`
` Clinical monitoring is
`
`recommended upon co-
` administration with
`
`
` antiarrhythmics.
`
`When co-administering with
`
` digoxin, titrate the digoxin dose and
`
` monitor digoxin concentrations.
`
`
`
` 9
`
`
`
`
`
` Antibacterials:
` clarithromycin, erythromycin,
`
`
` telithromycin
` Anticancer agents:
`
` dasatinib, nilotinib
`
`
`
`
`
`
`
` ↑ darunavir
`
`
` ↑ cobicistat
`
`
` ↑ antibacterial
`
` ↑ anticancer agent
`
`
`
`
`
` vinblastine, vincristine
`
`
`
`
`
` Anticoagulants:
`
` Direct Oral Anticoagulants
`
`(DOACs)
`
`apixaban
`
`
`
` ↑ apixaban
`
`
`
`
`
` rivaroxaban
`
`
`
` betrixaban
`
` dabigatran
`
` edoxaban
`
`
` Other Anticoagulants
`
` warfarin
`
`
`
`
` ↑ rivaroxaban
`
`
`
`
`
`
` ↔ betrixaban
`
`
` ↔ dabigatran
`
` ↔ edoxaban
`
`
`
`
`warfarin: effect unknown
`
`
`
`
`
`
`
`
`
`
`
`
` Consider alternative antibiotics
`
` with concomitant use of
`
` PREZCOBIX.
` A decrease in the dosage or an
`
` adjustment of the dosing interval of
`
` dasatinib or nilotinib may be
`
`
`
` necessary when co-administered
` with PREZCOBIX. Consult the
`
`
`
`
` dasatinib and nilotinib prescribing
` information for dosing instructions.
`
`
` For vincristine and vinblastine,
`
`
` consider temporarily withholding
`the cobicistat-containing
` antiretroviral regimen in patients
`
` who develop significant
` hematologic or gastrointestinal side
`
`effects when PREZCOBIX is
`
`
`administered concurrently with
`
`vincristine or vinblastine. If the
`
`
`antiretroviral regimen must be
`
`withheld for a prolonged period,
`
`consider initiating a revised
`
`regimen that does not include a
`
`CYP3A or P-gp inhibitor.
`
`
` Due to potentially increased
`
` bleeding risk, dosing
`
` recommendations for
`
`
` coadministration of apixaban with
`
` PREZCOBIX depends on the
` apixaban dose. Refer to apixaban
`
`
`
` dosing instructions for
`coadministration with strong
`
`CYP3A and P-gp inhibitors in
`
`apixaban prescribing information.
`
`Coadministration of rivaroxaban
`with PREZCOBIX is not
`recommended because it may lead
`
`
`
` to an increased bleeding risk.
`
`
` No dose adjustment is needed when
`
`
` betrixaban, dabigatran, or edoxaban
`
` is co-administered with
`
` PREZCOBIX.
`
`
`Monitor the international
`
` normalized ratio (INR) when co-
` administering with warfarin.
`
`
`Reference ID: 4317066
`
`
`
` 10
`
`
`
`
` Anticonvulsants:
`
` carbamazepine, phenobarbital,
`
` phenytoin
`
`
`
`
`
` ↓ darunavir
`
`
` ↓ cobicistat
`
`Anticonvulsants with CYP3A
` induction effects that are NOT
`
`
`contraindicated:
`
`e.g. eslicarbazepine, oxcarbazepine
`
` ↓ cobicistat
`
`
` darunavir: effect unknown
`
`
`
`
` Anticonvulsants that are
`
` metabolized by CYP3A:
`
` e.g. clonazepam
`
` Antidepressants:
`
` Selective Serotonin Reuptake
`
`
`Inhibitors (SSRIs):
`
`e.g. paroxetine, sertraline
`
`
`
` Tricyclic Antidepressants (TCAs):
`
`
` e.g. amitriptyline, desipramine,
`
` imipramine, nortriptyline
`
` Other antidepressants:
`
` trazodone
` Antifungals:
`
` itraconazole, ketoconazole,
`
` posaconazole
`
`
`
`
`
` voriconazole
`
`
` Anti-gout:
`
` colchicine
`
`
`
` ↑ clonazepam
`
`
`
`
`
` SSRIs: effects unknown
`
`
`
`
` ↑ TCAs
`
`
`
`
` ↑ trazodone
`
`
`
`
`
` ↑ darunavir
`
`
`↑ cobicistat
`
`
`
`↑ itraconazole
`
`
`↑ ketoconazole
`
`
`↔ posaconazole
`
`
`
` voriconazole: effects unknown
`
`
`
`
`
` ↑ colchicine
`
`
`
`
`
` Co-administration is
`
`
` contraindicated due to potential for
`
` reduced plasma concentrations of
` darunavir, which may result in loss
`
`
` of therapeutic effect and
` development of resistance.
`
`Consider alternative anticonvulsant
`
` or antiretroviral therapy to avoid
`
` potential changes in exposures. If
`
`
` co-administration is necessary,
` monitor for lack or loss of virologic
`
`
` response.
` Clinical monitoring of
`
` anticonvulsants is recommended.
`
`
`
` When co-administering with SSRIs,
`
`TCAs, or trazodone, careful dose
`
`titration of the antidepressant to the
`desired effect, including using the
`lowest feasible initi