Isturisa

• Correct hypokalemia and hypomagnesemia, and obtain baseline electrocardiogram prior to starting ISTURISA (
  2.1 Laboratory Testing Prior to ISTURISA Initiation

  • Correct hypokalemia and hypomagnesemia prior to starting ISTURISA
    [see Warnings and Precautions (5.2, 5.3)].
  • Obtain baseline electrocardiogram (ECG)
    .
    Repeat ECG within one week after treatment initiation, and as clinically indicated thereafter
    [see Warnings and Precautions (5.2)]
    .
  ,
  5.2 QTc Prolongation

  ISTURISA is associated with a dose-dependent QT interval prolongation (maximum mean estimated QTcF increase of up to 5.3 ms at 30 mg), which may cause cardiac arrhythmias

  [see Adverse Reactions (6)

  ,

  Clinical Pharmacology (12.2)

  ].

  Perform an ECG to obtain a baseline QTc interval measurement prior to initiating therapy with ISTURISA and monitor for an effect on the QTc interval thereafter. Correct hypokalemia and/or hypomagnesemia prior to ISTURISA initiation and monitor periodically during treatment with ISTURISA. Correct electrolyte abnormalities if indicated. Consider temporary discontinuation of ISTURISA in the case of an increase in QTc interval > 480 ms.

  Use caution in patients with risk factors for QT prolongation, (such as congenital long QT syndrome, congestive heart failure, bradyarrhythmias, uncorrected electrolyte abnormalities, and concomitant medications known to prolong the QT interval) and consider more frequent ECG monitoring.
  ,
  5.3 Elevations in Adrenal Hormone Precursors and Androgens

  ISTURISA blocks cortisol synthesis and may increase circulating levels of cortisol and aldosterone precursors (11-deoxy cortisol and 11-deoxycorticosterone) and androgens.

  Elevated 11-deoxycorticosterone levels may activate mineralocorticoid receptors and cause hypokalemia, edema and hypertension

  [see Adverse Reactions (6)]

  . Hypokalemia should be corrected prior to initiating ISTURISA. Monitor patients treated with ISTURISA for hypokalemia, worsening of hypertension and edema. ISTURISA-induced hypokalemia should be treated with intravenous or oral potassium supplementation based on event severity. If hypokalemia persists despite potassium supplementation, consider adding mineralocorticoid antagonists. ISTURISA dose reduction or discontinuation may be necessary.

  Accumulation of androgens may lead to hirsutism, hypertrichosis and acne (in females). Inform patients of the symptoms associated with hyperandrogenism and advise them to contact a healthcare provider if they occur.
  )
• Initiate dosage at 2 mg orally twice daily, with or without food (
  2.2 Recommended Dosage, Titration, and Monitoring

  • Initiate dosing at 2 mg orally twice daily, with or without food.
  • Initially, titrate the dosage by 1 mg to 2 mg twice daily, no more frequently than every 2 weeks based on the rate of cortisol changes, individual tolerability and improvement in signs and symptoms of Cushing's syndrome. If a patient tolerates ISTURISA dosage of 10 mg twice daily and continues to have elevated 24-hour urine free cortisol (UFC) levels above upper normal limit, the dosage can be titrated further by 5 mg twice daily every 2 weeks. Monitor cortisol levels from at least two 24-hour urine free cortisol collections every 1 to 2 weeks until adequate clinical response is maintained.
  • The maintenance dosage of ISTURISA is individualized and determined by titration based on cortisol levels and patient's signs and symptoms.
  • The maintenance dosage varied between 2 mg and 7 mg twice daily in clinical trials. The maximum recommended maintenance dosage of ISTURISA is 30 mg twice daily
    [see Clinical Studies (14)]
    .
  • Once the maintenance dosage is achieved, monitor cortisol levels at least every 1 to 2 months or as indicated.
  )
• Titrate dosage by 1 mg to 2 mg twice daily, no more frequently than every 2 weeks based on rate of cortisol changes, individual tolerability and improvement in signs and symptoms (
  2.2 Recommended Dosage, Titration, and Monitoring

  • Initiate dosing at 2 mg orally twice daily, with or without food.
  • Initially, titrate the dosage by 1 mg to 2 mg twice daily, no more frequently than every 2 weeks based on the rate of cortisol changes, individual tolerability and improvement in signs and symptoms of Cushing's syndrome. If a patient tolerates ISTURISA dosage of 10 mg twice daily and continues to have elevated 24-hour urine free cortisol (UFC) levels above upper normal limit, the dosage can be titrated further by 5 mg twice daily every 2 weeks. Monitor cortisol levels from at least two 24-hour urine free cortisol collections every 1 to 2 weeks until adequate clinical response is maintained.
  • The maintenance dosage of ISTURISA is individualized and determined by titration based on cortisol levels and patient's signs and symptoms.
  • The maintenance dosage varied between 2 mg and 7 mg twice daily in clinical trials. The maximum recommended maintenance dosage of ISTURISA is 30 mg twice daily
    [see Clinical Studies (14)]
    .
  • Once the maintenance dosage is achieved, monitor cortisol levels at least every 1 to 2 months or as indicated.
  )
• Maximum recommended dosage is 30 mg twice daily (
  2.2 Recommended Dosage, Titration, and Monitoring

  • Initiate dosing at 2 mg orally twice daily, with or without food.
  • Initially, titrate the dosage by 1 mg to 2 mg twice daily, no more frequently than every 2 weeks based on the rate of cortisol changes, individual tolerability and improvement in signs and symptoms of Cushing's syndrome. If a patient tolerates ISTURISA dosage of 10 mg twice daily and continues to have elevated 24-hour urine free cortisol (UFC) levels above upper normal limit, the dosage can be titrated further by 5 mg twice daily every 2 weeks. Monitor cortisol levels from at least two 24-hour urine free cortisol collections every 1 to 2 weeks until adequate clinical response is maintained.
  • The maintenance dosage of ISTURISA is individualized and determined by titration based on cortisol levels and patient's signs and symptoms.
  • The maintenance dosage varied between 2 mg and 7 mg twice daily in clinical trials. The maximum recommended maintenance dosage of ISTURISA is 30 mg twice daily
    [see Clinical Studies (14)]
    .
  • Once the maintenance dosage is achieved, monitor cortisol levels at least every 1 to 2 months or as indicated.
  )
• See Full Prescribing Information for complete titration, laboratory, and dosage modification recommendations (
  2.1 Laboratory Testing Prior to ISTURISA Initiation

  • Correct hypokalemia and hypomagnesemia prior to starting ISTURISA
    [see Warnings and Precautions (5.2, 5.3)].
  • Obtain baseline electrocardiogram (ECG)
    .
    Repeat ECG within one week after treatment initiation, and as clinically indicated thereafter
    [see Warnings and Precautions (5.2)]
    .
  ,
  2.2 Recommended Dosage, Titration, and Monitoring

  • Initiate dosing at 2 mg orally twice daily, with or without food.
  • Initially, titrate the dosage by 1 mg to 2 mg twice daily, no more frequently than every 2 weeks based on the rate of cortisol changes, individual tolerability and improvement in signs and symptoms of Cushing's syndrome. If a patient tolerates ISTURISA dosage of 10 mg twice daily and continues to have elevated 24-hour urine free cortisol (UFC) levels above upper normal limit, the dosage can be titrated further by 5 mg twice daily every 2 weeks. Monitor cortisol levels from at least two 24-hour urine free cortisol collections every 1 to 2 weeks until adequate clinical response is maintained.
  • The maintenance dosage of ISTURISA is individualized and determined by titration based on cortisol levels and patient's signs and symptoms.
  • The maintenance dosage varied between 2 mg and 7 mg twice daily in clinical trials. The maximum recommended maintenance dosage of ISTURISA is 30 mg twice daily
    [see Clinical Studies (14)]
    .
  • Once the maintenance dosage is achieved, monitor cortisol levels at least every 1 to 2 months or as indicated.
  ,
  2.3 Dosage Interruptions and Modifications

  • Decrease or temporarily discontinue ISTURISA if urine free cortisol levels fall below the target range, there is a rapid decrease in cortisol levels, and/or patients report symptoms of hypocortisolism. If necessary, glucocorticoid replacement therapy should be initiated.
  • Stop ISTURISA and administer exogenous glucocorticoid replacement therapy if serum or plasma cortisol levels are below target range and patients have symptoms of adrenal insufficiency
    [see Warnings and Precautions (5.1)].
  • If treatment is interrupted, re-initiate ISTURISA at a lower dose when cortisol levels are within target ranges and patient symptoms have been resolved.
  )
• Patients with Hepatic Impairment:
  • Child-Pugh B:
    Recommended starting dose is 1 mg twice daily (
    2.5 Recommended Dosage and Monitoring in Patients with Hepatic Impairment

    • For patients with moderate hepatic impairment (Child-Pugh B), the recommended starting dose is 1 mg twice daily. For patients with severe hepatic impairment (Child-Pugh C), the recommended starting dose is 1 mg once daily in the evening.
    • No dose adjustment is required for patients with mild hepatic impairment (Child-Pugh A).
    • More frequent monitoring of adrenal function may be required during dose titration in all patients with hepatic impairment
      [see Clinical Pharmacology (12.3)].
    ,
    8.7 Hepatic Impairment

    Dosage adjustment is not required in patients with mild hepatic impairment (Child-Pugh A) but is required for patients with moderately impaired hepatic function (Child-Pugh B) and for patients with severe hepatic impairment (Child-Pugh C)

    [see Dosage and Administration (2.3), Clinical Pharmacology (12.3)]

    . More frequent monitoring of adrenal function may be required during dose titration in all patients with hepatic impairment.
    )
  • Child-Pugh C
    : Recommended starting dose is 1 mg once daily in the evening (
    2.5 Recommended Dosage and Monitoring in Patients with Hepatic Impairment

    • For patients with moderate hepatic impairment (Child-Pugh B), the recommended starting dose is 1 mg twice daily. For patients with severe hepatic impairment (Child-Pugh C), the recommended starting dose is 1 mg once daily in the evening.
    • No dose adjustment is required for patients with mild hepatic impairment (Child-Pugh A).
    • More frequent monitoring of adrenal function may be required during dose titration in all patients with hepatic impairment
      [see Clinical Pharmacology (12.3)].
    ,
    8.7 Hepatic Impairment

    Dosage adjustment is not required in patients with mild hepatic impairment (Child-Pugh A) but is required for patients with moderately impaired hepatic function (Child-Pugh B) and for patients with severe hepatic impairment (Child-Pugh C)

    [see Dosage and Administration (2.3), Clinical Pharmacology (12.3)]

    . More frequent monitoring of adrenal function may be required during dose titration in all patients with hepatic impairment.
    )

ISTURISA is available as:

• 1 mg tablets: Pale yellow, unscored, round, biconvex with beveled edge tablet, debossed "1" on one side.
• 5 mg tablets: Yellow, unscored, round, biconvex with beveled edge tablet, debossed "5" on one side.

• Lactation
  : Breastfeeding is not recommended during treatment with ISTURISA and for at least one week after treatment (
  8.2 Lactation

  Risk Summary

  There are no available data on the presence of osilodrostat in human or animal milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions (such as adrenal insufficiency) in the breastfed infant, advise patients that breastfeeding is not recommended during treatment with ISTURISA and for one week after the final dose.
  )