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NEWDRUGUPDATE2016LaurajoRyan,PharmD,MSc,BCPS
BrysonDuhon,PharmD,BCPSClinicalAssistantProfessor
AccreditaIon• NewDrugUpdate2016isaccreditedfor1.5contacthours– Pharmacists ACPE0154-0000-16-010-L01-P– Technicians ACPE0154-0000-16-010-L01-T– BrysonDuhon&LaurajoRyanhavenotdisclosedanyfinancialorconflictsofinterestinrelaIontothisprogram
PresentaIonObjecIves1. Discussthebasicpharmacologyofthenew
drugspresentedandhowthepharmacologicacIonsrelatetoboththerapeuIcandadverseeffects.
2. DiscussclinicallysignificantadverseeffectsanddruginteracIons,andtheappropriatedosingandmonitoringofthenewdrugspresented.
3. DiscussthetherapeuIcroleofthenewdrugspresentedascomparedtoagentsalreadymarketed.
NotableDrugPatentExpiraIonsin2016• Crestor–$6.4billionannualrevenue• Benicar–$2.6billionannualrevenue• ZeIa–$2.6billionannualrevenue• Cubicin–$1.5billionannualrevenue• SeroquelXR–$1.2billionannualrevenue• AciphexSprinkle–$1.1billionannualrevenue• Norvir–$1.0billionannualrevenue• Kaletra–$1.0billionannualrevenue• Epzicom–$1.0billionrevenue
hap://medcitynews.com/2016/01/drugs-off-patent/
FDADrugApprovalsin2015/2016• 2015– 45newdrugapprovals(mostsince1950)
– 16withnovelMOA(36%)– Almost½usedforrarediseases
– Expeditedreviewgrantedto60%ofnewdrugs
• 2016– 29drugsapprovedsofar
hap://www.forbes.com/sites/bernardmunos/2016/01/04/2015-new-drug-approvals-hit-66-year-high/#7b1b86721044hap://cen.acs.org/arIcles/94/i5/Year-New-Drugs.html
IDARUCIZUMAB(PRAXIBIND®-BOEHRINGER-INGELHEIM)
Idarucizumab• Dabigatranreversalagent– Life-threateningoruncontrolledbleeding– Emergent/urgentprocedure
Idarucizumab• HumanizedmonoclonalanIbodyfragment(Fab)– Bindsspecificallytodabigatran&dabigatranmetabolites• 350Xaffinityfordabigatranvs.thrombin
– ReversesanIcoagulanteffects• Onsetinminutes• HemostasIs~11½hours
– Doesnotinterferewithclorngproteinsdirectly
JACC2016;67:1654
Idarucizumab• Dosing– 5gIV• Pushorinfusion• 2X2.5g(50mL)
– ≤15minutesapart
– ConInuedorrepeatbleeding• Dataon2nddoselimited
Anesthes2015;123:A21
Idarucizumab• Adverseeffects– Headache– Hypokalemia– Delirium– PotenIalimmunereacIon
– ThromboIcrisk• Noincreaseoverbaseline
Anesthes2015;123:A21
Idarucizumab• SomesubjectsinRE-VERSEAD™trial– Re-elevaIonofbleedrisk
– RedistribuIonofdabigatranfromIssuestoplasma
IdarucizumabprescribinginformaIon
CEFTAZIDIME/AVIBACTAM(AVYCAZ®-ALLERGAN/ASTRAZENECA)
Cexazidime/Avibactam• 50,000FootView– AnIbioIcwithnovelbetalactamaseinhibitorusedfor“Armageddon”gram–negaIvepathogens
• DrugClass– CephalosporinclassanIbioIc
• FDAIndicaIons– Complicatedintra–abdominalinfecIons
• IncombinaIonw/metronidazole
– ComplicatedurinarytractinfecIons• IncombinaIonw/metronidazole
Cexazidime/Avibactam• MOA– Cexazidime
• 3rdgeneraIoncephalosporinonmarketsince1980s• Cellwallinhibitor(bindsPBPs)• AcIvityvs.Pseudomonasspp.
– Avibactam• Betalactamaseinhibitor• AcIvevs.AmpC,ESBL,KPC• NotacIvevs.metallo–betalactamases
Cexazidime/Avibactam• Dosing(IVonly)– 2.5gevery8hoursincombinaIonwithmetronidazole– For5–14daysincIAI– For7–14daysincUTI
• Contains2gofcexazidimeand0.5gofavibactam• Dosingbasedonthesumofingredients(e.g.2.5g)• Requiresrenaldoseadjustmentw/CrCl<50mL/min
• Administeraxerdialysis• Administerovertwohours
Cexazidime/Avibactam• ClinicalEvidence– cIAI(LucasIJAC2013;MazuskiCID2016)
• Cexaz/avi+metrononinferiortomeropenem
– cUTI(VazquezCurrMedResOpin2012)• Cexaz/avi+metrononinferiortoimipenem/cilastaIn
• SafetyData– NonspecificGIsymptoms/headache– OnecaseofincreasedLFTs– Welltolerated
JAC2013;68:1183-92CID2016;62(11):1380-9
CurrMedResOpin2012;28(12):1921-31
Cexazidime/Avibactam• DrugInteracIons– MayincreaseeffectofVKAs– Levelsdecreasedbyprobenecid
• WarningsandPrecauIons– Neurotoxicityw/highdose(βlactam,duh)
• PregnancyCategoryB/excretedinbreastmilk• ContraindicaIons– HypersensiIvitytocephalosporins
Cexazidime/Avibactam• MarketNiche– SeriousgramnegaIveinfecIons– ContainingKPCbetalactamases– SparingtoxicalternaIves(i.e.colisIn)– IndicatedincIAIandcUTI,butlikelytobeusedofflabelindiresituaIons
• Pricing:$1,000/dayAWP
SUGAMMADEX(BRIDION®-MERCK)
Sugammadex• AnIdote– SelecIvereversalofaminosteroidalnon-depolarizingneuromuscularblockers• Rocuronium>vecuronium>>pancuronium
• MechanismofacIon– Bindsrocuronium1:1
• Decreasesfreerocuronium– Formsplasmagradient
• BoundrocuroniumdiffusesfromneuromuscularjuncIon– Newlyfreerocuroniumbindstosugammadex
• Water-solublecomplex– Excretedunchangedintheurine
Sugammadex• Dosing– RouInereversalofneuromuscularblockade
• IVassingledosebasedonactualbodyweight– Deepblockade=4mg/kg– Moderateblockade=2mg/kg
– Immediatereversalofneuromuscularblockade• IV16mg/kg
– Within3minutesof1.2mg/kgofrocuroniumdose
– WaitImesforre-administraIonvary• Ifimmediateneuromuscularblockaderequiredaxersugammadex– Canusenon-steroidalagent
Sugammadex• DruginteracIons– Displacementbysteroid-likestructures– Toremifene– Fusidicacid– Progesterones?
• Monitorforrecurrenceofneuromuscularblockade
PATIROMER(VELTASSA®-RELYPSA)
PaIromer• AnIdoteforhyperkalemia– ForchronicadministraIonispaIentswhorequireRAASinhibitors
– Notforemergentuse
• Mechanism– Non-absorbablecaIon-exchangepolymer• Calcium/sorbitol
PaIromer• Dosing– 8.4goraldaily
• Mixpowderwithwater;drinkimmediately• Takewithfood• Adjust≥weekly;maxdose25.2gperday
• DruginteracIons– Boxedwarning
• Bindsoraldrugs—separatedosesby6hoursbefore/axer• Adverseeffects– Hypomagnesemia– GI
• MaycauseconsIpaIonordiarrhea• IneffecIveinsevereconsIpaIon
ROLAPITANT(VARUBI®-TESARO)
Rolapitant• AnI-emeIc– IndicatedforprevenIonofdelayedchemotherapy-inducednausea&vomiIng(CINV)
• MechanismofacIon– SubstanceP/neurokinin1(NK1)receptorblocker• SubstancePsImulateschemoreceptortriggerzonecausingnausea/vomiIng
Rolapitant• Highlyemetogenictherapy
– 180mg1-2hourspriortotherapyonday1only• Givewithdexamethasone&5-HT3regimen
• DonotgivemorefrequentlythanQ2weeks
• Moderatelyemetogenictherapy– 180mg1-2hourspriortotherapyonday1only• DonotgivemorefrequentlythanQ2weeks
• t½~7days• MetabolizedviaCYP3A4to
acIvemetabolites
ISAVUCONAZOLECRESEMBA®-ASTELLAS
Isavuconazole• 50,000FootView– AnIfungalw/acIvityagainstAspergillusandMucormycosesspp.
• DrugClass– AzoleanIfungal
• FDAIndicaIons– InvasiveAspergillosis– InvasiveMucormycosis
Isavuconazole• MOA– InhibitsCYP450–dependent14α–lanosterol– EssenIalforfungalcellmembraneformaIon– AcIveagainstyeasts,molds
• Administeredasprodrug– 186mgisavuconazoniumsulfate=100mgisavuconazole
• Dosing– LoadingDose:372mgq8hoursx6doses– MaintenanceDose:200mgoncedaily
Isavuconazole• AvailableIVandPO;98%bioavailability• Verylonghalf–life=>4days• MetabolizedviaCYP3A4– Notrecommendedinadvancedliverdisease
• Eliminatedviafeces– Noneedforrenaldoseadjustment– NotgoodforUTItreatment
Isavuconazole• ClinicalEvidence– SECURE:non–inferiortovoriconazoleforaspergillus– Preliminarydatavs.Mucormycosesindicatesimilarmortalitytohistoricaldata(35%)
– LimiteddataagainstFusarium/Endemicmolds• SafetyData– NonspecificGIsymptoms– Novisualdisturbanceslikevoriconazole– LiverenzymeelevaIons(it’sanazole)– ShortensQTc– InfusionreacIonsinafewpaIentsàusefilter
Isavuconazole• DrugInteracIons– CYP3A4àrifampin,CBZ,immunosuppressants
• WarningsandPrecauIons– HepaIceffects(10xLFTsin1.2%)– InfusionrelatedreacIons
• PregnancyCategoryC/excretedinbreastmilk– Higherperinatalmortalityinratsw/halfmaintenancedose
• ContraindicaIons– Useofstrong3A4inhibitors/inducers– FamilialshortQTcsyndrome
Isavuconazole• MarketNiche– AlternaIvetovoriconazoleforAspergillosis
• Beaerbioavailability• Beaersideeffectprofile
– AlternaIvetoposaconazole/anotheropIonagainstMucormycoses• Beaerbioavailability
• Pricing– IV:Onedose=$285– POOnedose=$168
INSULINDEGLUDECTRESIBA®–NOVONORDISK
InsulinDegludec• 50,000FootView– Ultra–longacIngbasalinsulinwithpromisestoreducehypoglycemia
• FDAIndicaIons– ImprovedglucosecontrolinType1andType2diabetesmellitus
InsulinDegludec• Dosing– T1DM
• Insulin–naïve:1/3to1/2oftotaldailyinsulindose(usually0.2–0.4units/kg)givenoncedaily• Insulin–experienced:Samedoseattotaldailybasaldose
– T2DM• Insulin–naïve:10unitsoncedaily• Insulin–experienced:Samedoseattotaldailybasaldose
– Ensure8hoursbetweenconsecuIvedoses
InsulinDegludec• Pharmacology– UsesphenolinformulaIontoformsolubledihexamers– Onceinjectedsubcutaneously,phenoldisperses,andself–associatesintolargermulIhexamers
– Individualinsulinmoleculesgraduallydissociateasmonomers
• KineIcs– SteadyabsorpIon– Zero–orderkineIcs– Onset=30–90minutes– Half–life=25hours– DuraIonofacIon>42hours
InsulinDegludec• Differencesfromdetemirandglargine– LessvariabilityinbloodglucoseloweringfrominjecIontoinjecIon
– Abilitytoco-formulatewithbolusinsulins• Glargineformsprecipitate• Detemirlowerseffectofbolusinsulin• Degludecincombow/aspartindevelopment
– Increasedflexibilityindosing• ChangesininjecIonImew/degludecdonotadverselyeffectglucosecontrol
– StabilityinhepaIc/renaldisease
InsulinDegludec
BEGINBasal–BolusType1Degludec Glargine
A1cReducIon 0.4% 0.39%Nocturnal
Hypoglycemia 3.9% 5.2%
Lancet2012;379(9825):1489-97Lancet2012;379(9825):1498-1507
BEGINBasal–BolusType2Degludec Glargine
A1cReducIon 1.1% 1.18%Overall
Hypoglycemia 11% 13.6%
InsulinDegludec• WarningsandPrecauIons– Hypoglycemia/hypokalemia– NotforuseinDKA
• PregnancyCategoryC– Notstudiedinpregnantwoman/animalstudiesrevealedadverseeventsduetomaternalhypoglycemia
• Excretedinbreastmilk• OpImaltransiIondosingfromotherlong–acInginsulinsyettobeelucidated
• Storage:Stablefor8weeksatroomtemperature
InsulinDegludec• MarketNiche– Alreadyco–formulatedwithinsulinaspart
• IDegAspàRyzodeg70/30®
– TheFuture• IDegLiraàliragluIde/degludecco–formulaIon
• Pricing– 100units/mL(3mL)=$100– 200units/mL(3mL)=$213
SELEXIPAG(UPTRAVI®–ACTELION)
Selexipag• 50,000FootView– NewPAHdrugforearlystagedisease(WHOII/III)
• MOA– ProstacyclinIPreceptoragonistàrelaxedsmoothmuscle
– LessGIeffectsthanotherPAHdrugs• Dosing– Startedat200mcgtwicedaily– Titratedweeklyupto1600mcgtwicedaily– Ifdosemissedfor>3days,restartatlowerdose
• AvoidgemfibrozilincombinaIon• Onetablet=$155
PIMAVANSERIN(NUPLAZID®–ACADIA)
Pimavanserin• 50,000FootView– NondopamineatypicalanI-psychoIcforParkinson’spsychosis
• MOA– Inverseagonistofserotonin5-HT2A– ExciIngtargetforpsychosisofdifferentdiseases
• Dosing– 34mgQDay(1/2dosew/Strong3A4inhibitors)
• CanprolongQTcinterval
AnIpsychoIcReceptorAcIvity
NeurochemRes2014;39:2008-17
SECUKINUMAB(COSENTYX®–NOVARTIS)
NeurochemRes2014
Secukinumab• 50,000FootView– AnIbodyinjectableformoderate–severeplaquepsoriasis,ankylosingspondyliIs,andpsoriaIcarthriIs
• MOA– IL-17AmonocolonalanIbody
• Dosing– Psoriasis:300mgSCQWkx5doses,thenQmonth– AS/PA:150mgSCQWkx5doses,thenQmonth
• IncreasesriskofinfecIon/RequiresTBtestNeurochemRes2014
CANGRELOR(KENGREAL®-THEMEDICINECO.)
Cangrelor• Plateletinhibitor– Decreasesriskofperi-proceduralmyocardialinfarcIonduringpercutaneouscoronaryintervenIon(PCI)
• Mechanism– Direct-acIngP2Y12inhibitor• IrreversiblyinhibitsADPreceptor
NatRevCardol2011;8:547
Cangrelor• IVadministraIon– 30mcg/kgbolus30minutepriortoPCI
– 4mcg/kg/minuteinfusionduringprocudure• ConInueatleast2hours
NatRevCardol2011;8:547
Cangrelor• TransiIontooralagent– 600mgclopidogrelor60mgprasugrel• Immediatelyatendofinfusion;doNOTgivepriortodisconInuaIonofinfusion
– 180mgIcagrelor• Immediatelyatendof,orduringinfusion
• Rapidonset/offset– DonotusewithgpIIB/IIIaP2Y12inhibitor
NatRevCardol2011;8:547
SACUBATRIL/VALSARTAN(ENTRESTO®-NOVARTIS)
• DegradesvasoacIvepepIdes– NatriureIcpepIdes– Bradykinin– Others
Neprilysin
• IncreasesnaIureIcpepIdes&opposesneurohormonalacIvity
NeprilysinInhibiIon
PARADIGM-HF• HFrEF– LCZ696(valsartan&neprilysininhibitor)vs.enalapril
• Methods– Double-blindRCT• N=8442classII-IVHF• EF≤40%
– Primaryoutcome• CompositeofCVdeathorhospitalizaIonforHF
NEnglJMed2014;371;11
PARADIGM-HF• Results
– Trialstopped@meanf/u27months
– Primaryoutcome• LCZ696=914(21.8%)vs.enalapril=1117(26.5%)– HazardraIo0.80;95%CI0.73
to0.87;P<0.001
– LCZ696group• >hypotension,non-seriousangioedema
• <renalimpairment,hyperkalemia,cough
• Conclusions– LCZ696superiortoenalaprilinreducingriskofdeath&hospitalizaIonforHF
NEnglJMed2014;371;11
Sacubatril&Valsartan(Entresto®)• PotenIaltoreplaceACEinhibitor– ContraindicatedwithACEI,pregnancy– HFrEFNYHAclassII-IV
• LVEF≤40%• Stable
– SymptomaIcdespiteopImaltherapy
• Dosing– Sacubatril/valsartan
• 24mg/26mg=50mg(~40mgvalsartan)• 49mg/51mg=100mg(~80mgvalsartan)• 97mg/103mg=200mg(~160mgvalsartan)
IVABRADINE(CORLANOR®-AMGEN)
HeartRateControl• HFrEFpaIents– ElevatedHR
• Increaseinmorbidity&mortality
• PlacebogroupinSHIFTtrial– RiskofCVdeathorHFhospitalizaIon• 2.9%per1BPMincrease• 15.6%per5BPMincrease
• HR<60bpmvs.>75bpm– 32.4%decreasemortality&HFhospitalizaIon
HRRegulaIon• SAnodeproduces“pacemaker”impulses– SpreadstoAVnodetriggeringventricularcontracIon
• Ifcurrent– IniIatesdiastolicdepolarizaIonofSAnode
Ivabradine• Ifinhibitor– BindstoHCNchannels
• “usedependent”
• SAnode(fchannels)– CarriesIfcurrent
• prolongsdiastolicIme• InhibiIonreducesheartrate
• ReIna(hchannels)– CarriesIhcurrent
• InhibiIoncausesvisualdisturbances
Ivabradine• ProlongsdiastolicIme– InhibitsIfcurrent,reducingheartrate
• Increasesstrokevolume– PreservesmyocardialcontracIlity
– BP
NatRevDrugDisc2006;5:1034
Ivabradine• HFrEFpaIents
– ElevatedHR• Increaseinmorbidity&mortality
• HR≥87BPM– >2XriskforCVdeathorhospitalizaIonforHFvs.HR70-72BPM• HazardraIo2.34,95%CI1.84–2.98,p<0.0001
• ElderlyHFpEFpaIentshadsymptomaIcimprovement&HRreducIon
EurHeartJ2013;34:suppl1CirculaIon2001;103:1428
Lancet2010;376:886
Ivabradine(Corlanor®)• ApprovedtoreducehospitalizaIonfromHF– ConsiderinHFrEF
• LVEF≤35%• ResIngheartrate
– ≥70BPM
• OnmaxdoseofBB– Orintolerant
• TitratetoresIngHR
