7 DRUG INTERACTIONS 7.1 Polyvalent Cations ( Chelation ) Eltrombopag chelates polyvalent cations ( such as iron , calcium , aluminum , magnesium , selenium , and zinc ) in foods , mineral supplements , and antacids .
Take PROMACTA at least 2 hours before or 4 hours after any medications or products containing polyvalent cations , such as antacids , dairy products , and mineral supplements to avoid significant reduction in absorption of PROMACTA due to chelation [ see Dosage and Administration ( 2.4 ), Clinical Pharmacology ( 12.3 ) in the full prescribing information ].
7.2 Transporters Use caution when concomitantly administering PROMACTA and drugs that are substrates of OATP1B1 ( e . g ., atorvastatin , bosentan , ezetimibe , fluvastatin , glyburide , olmesartan , pitavastatin , pravastatin , rosuvastatin , repaglinide , rifampin , simvastatin acid , SN-38 [ active metabolite of irinotecan ], valsartan ) or breast cancer resistance protein ( BCRP ) ( e . g ., imatinib , irinotecan , lapatinib , methotrexate , mitoxantrone , rosuvastatin , sulfa salazine , topotecan ). Monitor patients closely for signs and symptoms of excessive exposure to the drugs that are substrates of OATP1B1 or BCRP and consider reduction of the dose of these drugs , if appropriate . In clinical trials with PROMACTA , a dose reduction of rosuvastatin by 50 % was recommended .
7.3 Protease Inhibitors HIV Protease Inhibitors : No dose adjustment is recommended when PROMACTA is coadministered with lopinavir / ritonavir ( LPV / RTV ). Drug interactions with other HIV protease inhibitors have not been evaluated .
Hepatitis C Virus Protease Inhibitors : No dose adjustments are recommended when PROMACTA is coadministered with boceprevir or telaprevir . Drug interactions with other hepatitis C virus ( HCV ) protease inhibitors have not been evaluated .
7.4 Peginterferon Alfa-2a / b Therapy No dose adjustments are recommended when PROMACTA is coadministered with peginterferon alfa-2a ( PEGASYS ® ) or -2b ( PEGINTRON ® ).
8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk Summary Available data from a small number of published case reports and postmarketing experience with PROMACTA use in pregnant women are insufficient to assess any drug-associated risks for major birth defects , miscarriage , or adverse maternal or fetal outcomes . In animal reproduction and developmental toxicity studies , oral administration of eltrombopag to pregnant rats during organogenesis resulted in embryolethality and reduced fetal weights at maternally toxic doses . These effects were observed at doses resulting in exposures that were six times the human clinical exposure based on area under the curve ( AUC ) in patients with persistent or chronic ITP at 75 mg / day , and three times the AUC in patients with chronic hepatitis C at 100 mg / day ( see Data ).
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown . All pregnancies have a background risk of birth defect , loss , or other adverse outcomes . In the U . S . general population , the estimated background risk of major birth defects and of miscarriage in clinically recognized pregnancies is 2 % -4% and 15 % -20%, respectively .
Data Animal Data In an early embryonic development study , female rats received oral eltrombopag at doses of 10 , 20 , or 60 mg / kg / day ( 0.8 , 2 , and 6 times , respectively , the human clinical exposure based on AUC in patients with ITP at 75 mg / day and 0.3 , 1 , and 3 times , respectively , the human clinical exposure based on AUC in patients with chronic hepa titis C at 100 mg / day ). Increased pre- and post-implantation loss and reduced fetal weight were observed at the highest dose which also caused maternal toxicity .
In an embryo-fetal development study eltrombopag was administered orally to pregnant rats during the period of organogenesis at doses of 10 , 20 , or 60 mg / kg / day ( 0.8 , 2 , and 6 times , respectively , the human clinical exposure based on AUC in patients with ITP at 75 mg / day and 0.3 , 1 , and 3 times , respectively , the human clinical exposure based on AUC in patients with chronic hepatitis C at 100 mg / day ). Decreased fetal weights ( 6 % to 7 %) and a slight increase in the presence of cervical ribs were observed at the highest dose which also caused maternal toxicity . However , no evidence of major structural malformations was observed .
In an embryo-fetal development study eltrombopag was administered orally to pregnant rabbits during the period of organogenesis at doses of 30 , 80 , or 150 mg / kg / day ( 0.04 , 0.3 , and 0.5 times , respectively , the human clinical exposure based on AUC in patients with ITP at 75 mg / day and 0.02 , 0.1 , and 0.3 times , respectively , the human clinical exposure based on AUC in patients with chronic hepatitis C at 100 mg / day ). No evidence of fetotoxicity , embryolethality , or teratogenicity was observed .
In a pre- and post-natal developmental toxicity study in pregnant rats ( F0 ), oral eltrombopag was administered from gestation Day 6 through lactation Day 20 . No adverse effects on maternal reproductive function or on the development of the offspring ( F1 ) were observed at doses up to 20 mg / kg / day ( 2 times the human clinical exposure based on AUC in patients with ITP at 75 mg / day and similar to the human clinical exposure based on AUC in patients with chronic hepatitis C at 100 mg / day ). Eltrombopag was detected in the plasma of offspring ( F1 ). The plasma concentrations in pups increased with dose following administration of drug to the F0 dams .
8.2 Lactation Risk Summary There are no data regarding the presence of eltrombopag or its metabolites in human milk , the effects on the breastfed child , or the effects on milk production . However , eltrombopag was detected in the pups of lactating rats 10 days postpartum suggesting the potential for transfer during lactation . Due to the potential for serious adverse reactions in a breastfed child from PROMACTA , breastfeeding is not recommended during treatment .
8.3 Females and Males of Reproductive Potential Contraception Based on animal reproduction studies , PROMACTA can cause fetal harm when administered to a pregnant woman . Sexually-active females of reproductive potential should use effective contraception ( methods that result in less than 1 % pregnancy rates ) when using PROMACTA during treatment and for at least 7 days after stopping treatment with PROMACTA .
8.4 Pediatric Use The safety and efficacy of PROMACTA have been established in pediatric patients 1 year and older with persistent or chronic ITP and in pediatric patients 2 years and older with IST-naïve severe aplastic anemia ( in combination with h-ATG and cyclosporine ). Safety and efficacy in pediatric patients below the age of 1 year with ITP have not been established . Safety and efficacy in pediatric patients with thrombocytopenia associated with chronic hepatitis C and refractory severe aplastic anemia have not been established .
The safety and efficacy of PROMACTA in pediatric patients 1 year and older with persistent or chronic ITP were evaluated in two double-blind , placebo-controlled trials [ see Adverse Reactions ( 6.1 ), Clinical Studies ( 14.1 ) in the full prescribing information ]. The pharmacokinetics of eltrombopag have been evaluated in 168 pediatric patients 1 year and older with ITP dosed once daily [ see Clinical Pharmacology ( 12.3 ) in the full prescribing information ]. See Dosage and Administration ( 2.1 ) in the full prescribing information for dosing recommendations for pediatric patients 1 year and older .
The safety and efficacy of PROMACTA in combination with h-ATG and cyclosporine for the first-line treatment of severe aplastic anemia in pediatric patients 2 years and older were evaluated in a single-arm , open-label trial [ see Adverse Reactions ( 6.1 ), Clinical Studies ( 14.3 ) in the full prescribing information ]. A total of 26 pediatric patients ( ages 2 to < 17 years ) were evaluated ; 12 children ( aged 2 to < 12 years ) and 14 adolescents ( aged 12 to < 17 ). See Dosage and Administration ( 2.3 ) in the full prescribing information for dosing recommendations for pediatric patients 2 years and older . The safety and efficacy of PROMACTA in combination with h-ATG and cyclosporine in pediatric patients younger than 2 years for the first-line treatment of severe aplastic anemia have not yet been established . In patients 2 to 16 years of age , 69 % of patients experienced serious adverse events compared to 42 % in patients 17 years and older . Among the 12 patients who were 2 to 11 years of age in the PROMACTA D1-M6 cohort and reached the 6-month assessment or withdrew earlier , the complete response rate at Month 6 was 8 % versus 46 % in patients age 12 to 16 years and 50 % in patients 17 years of age and older .
8.5 Geriatric Use Of the 106 patients in two randomized clinical trials of PROMACTA 50 mg in persistent or chronic ITP , 22 % were 65 years of age and over , while 9 % were 75 years of age and over . Of the 1439 patients in two randomized clinical trials of PROMACTA in patients with chronic hepatitis C and thrombocytopenia , 7 % were 65 years of age and over , while < 1 % were 75 years of age and over . Of the 196 patients who received PROMACTA for the treatment of severe aplastic anemia , 18 % were 65 years of age and over , while 3 % were 75 years of age and over . No overall differences in safety or effectiveness were observed between these patients and younger patients .
8.6 Hepatic Impairment Patients With Persistent or Chronic ITP and Severe Aplastic Anemia Reduce the initial dose of PROMACTA in patients with persistent or chronic ITP ( adult and pediatric patients 6 years and older only ) or refractory severe aplastic anemia who also have hepatic impairment ( Child-Pugh Class A , B , C ) [ see Dosage and Administration ( 2.1 , 2.3 ), Warnings and Precautions ( 5.2 ), Clinical Pharmacology ( 12.3 ) in the full prescribing information ].
In a clinical trial in patients with severe aplastic anemia who had not received prior definitive immunosuppressive therapy , patients with baseline ALT or AST > 5 x ULN were ineligible to participate . If a patient with hepatic impairment ( Child-Pugh Class A , B , C ) initiates therapy with PROMACTA for the first-line treatment of severe aplastic anemia , reduce the initial dose [ see Dosage and Administration ( 2.3 ), Warnings and Precautions ( 5.2 ), Clinical Pharmacology ( 12.3 ) in the full prescribing information ].
Patients With Chronic Hepatitis C No dosage adjustment is recommended in patients with chronic hepatitis C and hepatic impairment [ see Clinical Pharmacology ( 12.3 ) in the full prescribing information ].
8.7 Ethnicity Reduce the initial dose of PROMACTA for patients of Asian ancestry ( such as Chinese , Japanese , Taiwanese , Korean , or Thai ) with ITP ( adult and pediatric patients 6 years and older only ) or severe aplastic anemia [ see Dosage and Administration ( 2.1 , 2.3 ), Clinical Pharmacology ( 12.3 ) in the full prescribing information ]. No reduction in the initial dose of PROMACTA is recommended in patients of Asian ethnicity with chronic hepatitis C [ see Clinical Pharmacology ( 12.3 ) in the full prescribing information ].
10 OVERDOSAGE In the event of overdose , platelet counts may increase excessively and result in thrombotic / thromboembolic complications .
In one report , a subject who ingested 5000 mg of PROMACTA had a platelet count increase to a maximum of 929 x 10 9 / L at 13 days following the ingestion . The patient also experienced rash , bradycardia , ALT / AST elevations , and fatigue . The patient was treated with gastric lavage , oral lactulose , intravenous fluids , omeprazole , atropine , furosemide , calcium , dexamethasone , and plasmapheresis ; however , the abnormal platelet count and liver test abnormalities persisted for 3 weeks . After 2 months ’ follow-up , all events had resolved without sequelae .
In case of an overdose , consider oral administration of a metal cation-containing preparation , such as calcium , aluminum , or magnesium preparations to chelate eltrombopag and thus limit absorption . Closely monitor platelet counts . Reinitiate treatment with PROMACTA in accordance with dosing and administration recommendations [ see Dosage and Administration ( 2.1 , 2.2 ) in the full prescribing information ].
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