Dosage & Administration
Administration:
Dosage Recommendations:
Dosage Adjustments:
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Lupkynis Prescribing Information
Increased risk for developing malignancies and serious infections with LUPKYNIS or other immunosuppressants that may lead to hospitalization or death[see Warnings and Precautions( 5.1, 5.2)].
LUPKYNIS is indicated in combination with a background immunosuppressive therapy regimen [see Clinical Studies( 14)] for the treatment of adult patients with active lupus nephritis (LN).
Limitations of Use: Safety and efficacy of LUPKYNIS have not been established in combination with cyclophosphamide. Use of LUPKYNIS is not recommended in this situation.
Important Administration Instructions
- LUPKYNIS capsules must be swallowed whole and must not be opened, crushed, or divided.
- LUPKYNIS should be taken on an empty stomach consistently as close to a 12-hour schedule as possible, and with a minimum of 8 hours between doses.
- If a dose is missed, instruct the patient to take it as soon as possible within 4 hours after missing the dose. Beyond the 4-hour time frame, instruct the patient to wait until the usual scheduled time to take the next regular dose. Instruct the patient not to double the next dose.
- Instruct patients to avoid eating grapefruit or drinking grapefruit juice while taking LUPKYNIS [see Drug Interactions( 7.1)] .
Prior to Initiating LUPKYNIS Therapy
Establish an accurate baseline estimated glomerular filtration rate (eGFR). Use of LUPKYNIS is not recommended in patients with a baseline eGFR ≤45 mL/min/1.73 m 2 unless the benefit exceeds the risk; these patients may be at increased risk for acute and/or chronic nephrotoxicity [see Warnings and Precautions( 5.3)] .
Check blood pressure (BP) at baseline. Do not initiate LUPKYNIS in patients with BP >165/105 mmHg or with hypertensive emergency [see Warnings and Precautions( 5.4)] .
Dosage Recommendations
The recommended starting dose of LUPKYNIS is 23.7 mg twice a day.
Use LUPKYNIS in combination with mycophenolate mofetil (MMF) and corticosteroids [see Clinical Studies( 14)] .
Safety and efficacy of LUPKYNIS have not been established in combination with cyclophosphamide. Use of LUPKYNIS is not recommended in this situation.
- Assess eGFR every two weeks for the first month, every four weeks through the first year and quarterly thereafter.
Dosage of LUPKYNIS is based on the patient’s eGFR. Modify LUPKYNIS dosage based on eGFR [see Warnings and Precautions( 5.3)] :
- If eGFR <60 mL/min/1.73 m 2 and reduced from baseline by >20% and <30%, reduce the dose by 7.9 mg twice a day. Re-assess eGFR within two weeks; if eGFR is still reduced from baseline by >20%, reduce the dose again by 7.9 mg twice a day.
- If eGFR <60 mL/min/1.73 m 2 and reduced from baseline by ≥30%, discontinue LUPKYNIS. Re-assess eGFR within two weeks; consider re-initiating LUPKYNIS at a lower dose (7.9 mg twice a day) only if eGFR has returned to ≥80% of baseline.
- For patients that had a decrease in dose due to eGFR, consider increasing the dose by 7.9 mg twice a day for each eGFR measurement that is ≥80% of baseline; do not exceed the starting dose.
Monitor blood pressure every two weeks for the first month after initiating LUPKYNIS, and as clinically indicated thereafter [see Warnings and Precautions( 5.4)] . For patients with BP >165/105 mmHg or with hypertensive emergency, discontinue LUPKYNIS and initiate antihypertensive therapy.
If the patient does not experience therapeutic benefit by 24 weeks, consider discontinuation of LUPKYNIS.
Dosage Recommendations in Patients with Renal and Hepatic Impairment
Use of LUPKYNIS is not recommended in patients with a baseline eGFR ≤45 mL/min/1.73 m 2 unless the benefit exceeds the risk; LUPKYNIS has not been studied in patients with a baseline eGFR ≤45 mL/min/1.73 m 2. If used in patients with severe renal impairment at baseline, the recommended starting dose is 15.8 mg twice a day [see Use in Specific Populations( 8.6) and Clinical Pharmacology( 12.3)] .
In patients with mild and moderate hepatic impairment (Child-Pugh A and Child-Pugh B), the recommended dose is 15.8 mg twice daily. LUPKYNIS is not recommended to be used in patients with severe hepatic impairment (Child-Pugh C) [see Use in Specific Populations( 8.7) and Clinical Pharmacology( 12.3)] .
Dosage Adjustments due to Drug Interactions
When co-administering LUPKYNIS with moderate CYP3A4 inhibitors (e.g., verapamil, fluconazole, diltiazem), reduce LUPKYNIS daily dosage to 15.8 mg in the morning and 7.9 mg in the evening. No dose adjustment of LUPKYNIS is recommended when LUPKYNIS is co-administered with mild CYP3A4 inhibitors [see Drug Interactions( 7.1) and Clinical Pharmacology( 12.3)] .
Capsules: 7.9 mg (voclosporin) oval, pink/orange in color, imprinted on one side with VCS in white ink.
Pregnancy
Risk Summary
Avoid use of LUPKYNIS in pregnant women due to the alcohol content of the drug formulation. The available data on the use of LUPKYNIS in pregnant patients are insufficient to determine whether there is a drug-associated risk for major birth defects, miscarriage, or adverse maternal or fetal outcomes. There are risks to the mother and fetus associated with systemic lupus erythematosus (SLE) (see Clinical Considerations) .
LUPKYNIS may be used in combination with a background immunosuppressive therapy regimen that includes MMF. MMF used in pregnant women and men whose female partners are pregnant can cause fetal harm (major birth defects and miscarriage). Refer to the MMF prescribing information for more information on its use during pregnancy.
In animal reproductive studies, oral administration of either voclosporin or a 50:50 mixture of voclosporin and its cis-isomer was embryocidal and fetocidal in rats and rabbits at doses 15- and 1-times, respectively, the maximum recommended human dose (MRHD) of 23.7 mg twice a day, based on drug exposure AUC. There were no treatment-related fetal malformations or variations. Additional findings of reduced placental and fetal body weights occurred in rabbits at 0.1 to 0.3-times the MRHD and in rats at higher drug exposures. Voclosporin was transferred across the placenta in pregnant rats. For rats, but not all doses in rabbits, these effects were associated with maternal toxicity consisting of reductions in body weight gain. Dystocia was evident in a pre- and postnatal study in rats, but there were no effects of voclosporin on postnatal growth and development (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 background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Clinical Considerations
Disease-Associated Maternal and/or Embryo/Fetal Risk
Pregnant women with SLE are at increased risk of adverse pregnancy outcomes, including worsening of the underlying disease, premature birth, miscarriage, and intrauterine growth restriction. Maternal LN increases the risk of hypertension and preeclampsia/eclampsia. Passage of maternal autoantibodies across the placenta may result in adverse neonatal outcomes, including neonatal lupus and congenital heart block.
Fetal/Neonatal adverse reactions
The formulation of LUPKYNIS contains alcohol (21.6 mg of dehydrated ethanol per capsule for a total daily dose of 129.4 mg/day). Published studies have demonstrated that alcohol is associated with fetal harm including central nervous system abnormalities, behavioral disorders and impaired intellectual development. There is no safe level of alcohol exposure in pregnancy; therefore, avoid use of LUPKYNIS in pregnant women.
Data
Animal Data
Voclosporin (90 to 95% trans-isomer) is the active ingredient in LUPKYNIS. Animal reproductive studies were primarily conducted with an approximate 50:50 mixture of voclosporin and its cis-isomer. Similarity of the toxicity effects of the 50:50 mixture and voclosporin was demonstrated in comparative toxicity studies with adult rats. Interconversion between cis and trans isomers was not detected with in vitro or in vivo studies.
In an embryofetal developmental study, pregnant rats were dosed orally, during the period of organogenesis from gestation days 6-17, with the 50:50 mixture of voclosporin and its cis-isomer, litter size was reduced due to increased fetal resorptions and deaths at drug exposures approximately 15-times the MRHD (on an AUC basis with a maternal oral dose of 25 mg/kg/day). Surviving fetuses had reduced placental weights and slightly reduced fetal weights. There were no treatment-related fetal malformations or variations with doses up to 15-times the MRHD, although reductions in ossification sites were observed in the metatarsal bones. This dose was associated with maternal toxicity based on decreased body weight gain. The no effect dose for both fetal and maternal effects occurred at a drug exposure approximately 7-times the MRHD (on an AUC basis with a maternal oral dose of 10 mg/kg/day).
Two embryofetal developmental studies were conducted in pregnant rabbits that received either the 50:50 mixture of voclosporin and its cis-isomer or voclosporin during the period of organogenesis from gestation days 6-18. Litter size was reduced due to increased fetal resorptions and deaths with 50:50 mixture at drug exposures approximately the MRHD (on an AUC basis with a maternal oral dose of 20 mg/kg/day). Increased resorptions were observed with voclosporin at 0.1-times the MRHD (on an AUC basis with a maternal dose of 20 mg/kg/day); however, litter size was not significantly affected. Decreased placental weights and fetal body weights were observed with the 50:50 mixture at doses 0.3-times the MRHD and higher (on an AUC basis with maternal oral doses of 10 mg/kg/day and higher). Decreased fetal body weights were observed with voclosporin at doses 0.1-times the MRHD and higher (on an AUC basis with maternal oral doses of 5 mg/kg/day and higher). There were no treatment-related malformations or variations. Both studies had reductions of ossification sites in the metacarpal bones with the 50:50 mixture at doses 2-times the MRHD, and the sternabrae and hyoid body and/or arches with voclosporin at doses 0.1-times the MRHD and higher. The high dose of 20 mg/kg/day 50:50 mixture or voclosporin was associated with maternal toxicity based on decreased body weight gains. These rabbit studies indicated that the toxicity of 50:50 mixture of voclosporin and its cis-isomer and voclosporin were qualitatively similar; however, voclosporin was more potent than the 50:50 mixture, consistent with its pharmacological potency. The no effect dose for the fetal effects of voclosporin occurred at a drug exposure approximately 0.01-times the MRHD (on an AUC basis with a maternal oral dose of 1 mg/kg/day).
In a pre-and post-natal developmental study, rats were dosed from gestation day 7 through lactation day 20 with a 50:50 mixture of voclosporin and its cis-isomer. Dystocia (delayed parturition) occurred at a dose 12-times the MRHD (on an AUC basis with a maternal oral dose of 25 mg/kg/day) that resulted in reductions of the mean number of total pups delivered and surviving pups per litter. This dose was associated with maternal toxicity based on decreased body weight gain. No adverse effects on dams or their pups were observed at doses 3-times the MRHD and lower (on an AUC basis with a maternal oral dose of 10 mg/kg/day). There were no effects on behavioral and physical development, or the reproductive performance of male or female pups. The no effect dose for delivery and pup survival was 10 mg/kg/day.
Lactation
Risk Summary
The available human data from a clinical lactation study detected small amounts of voclosporin in human milk. Following a single dose to lactating subjects, a fully breastfed infant was estimated to receive a daily infant dose of 0.00675 mg/kg, and relative infant dose of 1.4% the maternal weight-adjusted dose. No change is expected for infant exposure at steady state with maternal twice daily dosing (see Data). Available data from the clinical study and published scientific literature are insufficient to determine the effects of LUPKYNIS on the breastfed infant or on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for LUPKYNIS and any potential adverse effects on the breastfed infant from LUPKYNIS or from the medical condition of the mother.
Data
Following a single 23.7 mg dose of voclosporin in healthy lactating subjects, an average of 0.00472 mg voclosporin was excreted in breast milk. Data showed that the voclosporin milk to maternal blood exposure ratio was in the range of 0.42 to 0.95. Based on the infant milk intake of 200 mL/kg/day, the highest estimated voclosporin dose ingested by fully breastfed infant was 1.4% of maternal weight-adjusted dose, which equals estimated daily infant dose of 0.00675 mg/kg/day. At steady state following maternal twice daily dosing regimen, the percent of voclosporin dose present in breast milk is expected to be similar to that following maternal single dose.
Females and Males of Reproductive Potential
LUPKYNIS may be used in combination with a background immunosuppressive therapy regimen that includes MMF. If LUPKYNIS is administered with MMF, the information for MMF regarding pregnancy testing, contraception, and infertility also applies to this combination regimen. Refer to MMF prescribing information for additional information.
Pediatric Use
The safety and efficacy of LUPKYNIS in pediatric patients has not been established.
Geriatric Use
Clinical studies of LUPKYNIS did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Renal Impairment
Use of LUPKYNIS is not recommended in patients with a baseline eGFR ≤45 mL/min/1.73 m 2 unless the benefit exceeds the risk. If used in patients with severe renal impairment at baseline, LUPKYNIS should be used at a reduced dose [see Dosage and Administration( 2.4)] . No dosage adjustment is recommended in patients with mild or moderate renal impairment at baseline [see Clinical Pharmacology( 12.3)] . Monitor eGFR closely.
After initiating therapy, dosing adjustments should be made based on eGFR [see Dosage and Administration( 2.3)] .
Hepatic Impairment
In patients with mild and moderate hepatic impairment (Child-Pugh A and Child-Pugh B), reduce the LUPKYNIS dosage [see Dosage and Administration( 2.4)] . Avoid LUPKYNIS in patients with severe hepatic impairment (Child-Pugh C) [see Clinical Pharmacology( 12.3)] .
LUPKYNIS is contraindicated in:
- Patients concomitantly using strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin) because these medications can significantly increase exposure to LUPKYNIS which may increase the risk of acute and/or chronic nephrotoxicity [see Warnings and Precautions( 5.3), Drug Interactions( 7.1), and Pharmacokinetics( 12.3)] .
- Patients who have had a known serious or severe hypersensitivity reaction to LUPKYNIS or any of its excipients.