NOXAFIL (posaconazole) suspension
Merck Sharp & Dohme LLC

Merck Sharp & Dohme LLC
NOXAFIL
posaconazole
posaconazole
posaconazole
polysorbate 80
sodium benzoate
trisodium citrate dihydrate
citric acid monohydrate
glycerin
xanthan gum
anhydrous dextrose
titanium dioxide
water
NOXAFIL
posaconazole
posaconazole
posaconazole
HYPROMELLOSE ACETATE SUCCINATE 06081224 (3 MM2/S)
MICROCRYSTALLINE CELLULOSE
HYDROXYPROPYL CELLULOSE (1600000 WAMW)
SILICON DIOXIDE
CROSCARMELLOSE SODIUM
MAGNESIUM STEARATE
POLYVINYL ALCOHOL, UNSPECIFIED
POLYETHYLENE GLYCOL 3350
TITANIUM DIOXIDE
TALC
FERRIC OXIDE YELLOW
oblong
100
NOXAFIL
posaconazole
posaconazole
posaconazole
BETADEX SULFOBUTYL ETHER SODIUM
EDETATE DISODIUM
HYDROCHLORIC ACID
SODIUM HYDROXIDE
WATER
NOXAFIL
posaconazole
POSACONAZOLE
POSACONAZOLE
HYPROMELLOSE ACETATE SUCCINATE 06081224 (3 MM2/S)
ANHYDROUS CITRIC ACID
DIMETHICONE
CARBOXYMETHYLCELLULOSE SODIUM, UNSPECIFIED
CARRAGEENAN
GLYCERIN
METHYLPARABEN
MICROCRYSTALLINE CELLULOSE
POTASSIUM SORBATE
PROPYLPARABEN
WATER
SODIUM CITRATE, UNSPECIFIED FORM
SODIUM PHOSPHATE, MONOBASIC, MONOHYDRATE
SACCHARIN SODIUM
SORBITOL SOLUTION
XANTHAN GUM
CALCIUM SULFATE, UNSPECIFIED FORM
SODIUM PHOSPHATE, TRIBASIC, ANHYDROUS
berry citrus sweet flavor
Contraindications (4) 1/2022
Warnings and Precautions (5) 1/2022

1 INDICATIONS AND USAGE

Noxafil is an azole antifungal indicated as follows:

  • Noxafil injection and Noxafil delayed-release tablets are indicated for the treatment of invasive aspergillosis in adults and pediatric patients 13 years of age and older. (1.1)
  • Noxafil is indicated for the prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with graft-versus-host disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy as follows: (1.2) Noxafil injection: adults and pediatric patients 2 years of age and older Noxafil delayed-release tablets: adults and pediatric patients 2 years of age and older who weigh greater than 40 kg Noxafil oral suspension: adults and pediatric patients 13 years of age and older Noxafil PowderMix for delayed-release oral suspension: pediatric patients 2 years of age and older who weigh 40 kg or less
  • Noxafil oral suspension is indicated for the treatment of oropharyngeal candidiasis (OPC), including OPC refractory (rOPC) to itraconazole and/or fluconazole in adult and pediatric patients aged 13 years and older. (1.3)

1.1 Treatment of Invasive Aspergillosis

Noxafil® injection and Noxafil delayed-release tablets are indicated for the treatment of invasive aspergillosis in adults and pediatric patients 13 years of age and older.

1.2 Prophylaxis of Invasive Aspergillus and Candida Infections

Noxafil is indicated for the prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of developing these infections due to being severely immunocompromised, such as hematopoietic stem cell transplant (HSCT) recipients with graft-versus-host disease (GVHD) or those with hematologic malignancies with prolonged neutropenia from chemotherapy [see Clinical Studies (14.1)] as follows:

  • Noxafil injection: adults and pediatric patients 2 years of age and older
  • Noxafil delayed-release tablets: adults and pediatric patients 2 years of age and older who weigh greater than 40 kg
  • Noxafil oral suspension: adults and pediatric patients 13 years of age and older
  • Noxafil PowderMix for delayed-release oral suspension: pediatric patients 2 years of age and older who weigh 40 kg or less

1.3 Treatment of Oropharyngeal Candidiasis Including Oropharyngeal Candidiasis Refractory to Itraconazole and/or Fluconazole

Noxafil oral suspension is indicated for the treatment of oropharyngeal candidiasis, including oropharyngeal candidiasis refractory to itraconazole and/or fluconazole in adults and pediatric patients 13 years of age and older.

2 DOSAGE AND ADMINISTRATION

  • Noxafil oral suspension is not substitutable with Noxafil delayed-release tablets or Noxafil PowderMix for delayed-release oral suspension due to the differences in the dosing of each formulation. Therefore, follow the specific dosage recommendations for each of the formulations. (2.1, 2.2, 2.3, 2.8)
  • Noxafil injection must be administered through an in-line filter.
  • Administer Noxafil injection by intravenous infusion over approximately 90 minutes via a central venous line. (2.1)
  • Do NOT administer Noxafil injection as an intravenous bolus injection. (2.1)
  • Administer Noxafil delayed-release tablets with or without food. (2.1)
  • Administer Noxafil oral suspension with a full meal. (2.1)
  • Administer Noxafil PowderMix for delayed-release oral suspension with food. (2.1)
  • Administer Noxafil PowderMix for delayed-release oral suspension with the provided notched tip syringes only. (2.1)
Table 1: Recommended Dosage in Adult Patients
Indication Dosage Form, Dose, and Duration of Therapy
Treatment of invasive Aspergillosis Noxafil Injection:
Loading dose:
300 mg Noxafil injection intravenously twice a day on the first day.
Maintenance dose:
300 mg Noxafil injection intravenously once a day thereafter. Recommended total duration of therapy is 6 to 12 weeks. (2.2)
Noxafil Delayed-Release Tablets:
Loading dose: 300 mg (three 100 mg delayed-release tablets) twice a day on the first day.
Maintenance dose: 300 mg (three 100 mg delayed-release tablets) once a day thereafter. Recommended total duration of therapy is 6 to 12 weeks. (2.2)
Switching between the intravenous and delayed-release tablets is acceptable. A loading dose is not required when switching between formulations. (2.2)
Prophylaxis of invasive Aspergillus and Candida infections Noxafil Injection:
Loading dose: 300 mg Noxafil injection intravenously twice a day on the first day.
Maintenance dose: 300 mg Noxafil injection intravenously once a day thereafter. Duration of therapy is based on recovery from neutropenia or immunosuppression. (2.2, 2.3)
Noxafil Delayed-Release Tablets:
Loading dose: 300 mg (three 100 mg delayed-release tablets) twice a day on the first day.
Maintenance dose: 300 mg (three 100 mg delayed-release tablets) once a day, starting on the second day. Duration of therapy is based on recovery from neutropenia or immunosuppression. (2.2, 2.3)
Noxafil Oral Suspension: 200 mg (5 mL) three times a day. Duration of therapy is based on recovery from neutropenia or immunosuppression. (2.2, 2.3)
Oropharyngeal Candidiasis (OPC) Noxafil Oral Suspension:
Loading dose: 100 mg (2.5 mL) twice a day on the first day.
Maintenance dose: 100 mg (2.5 mL) once a day for 13 days. (2.2, 2.3)
OPC Refractory (rOPC) to Itraconazole and/or Fluconazole Noxafil Oral Suspension: 400 mg (10 mL) twice a day. Duration of therapy is based on the severity of the patient's underlying disease and clinical response. (2.2, 2.3)
  • For pediatric patients, see the Full Prescribing Information for dosing recommendations for Noxafil injection, Noxafil delayed-release tablets, Noxafil oral suspension, and Noxafil PowderMix for delayed-release oral suspension based on the age and indication associated with the dosage form. (1.1, 1.2, 1.3, 2.1, 2.3)

2.1 Important Administration Instructions

Non-substitutable

Noxafil oral suspension is not substitutable with Noxafil delayed-release tablets or Noxafil PowderMix for delayed-release oral suspension due to the differences in the dosing of each formulation. Therefore, follow the specific dosage recommendations for each of the formulations [see Dosage and Administration (2.2, 2.3, 2.8)].

Noxafil injection

  • Administer via a central venous line, including a central venous catheter or peripherally inserted central catheter (PICC), by slow intravenous infusion over approximately 90 minutes [see Dosage and Administration (2.4)].
  • If a central venous catheter is not available, Noxafil injection may be administered through a peripheral venous catheter by slow intravenous infusion over 30 minutes only as a single dose in advance of central venous line placement or to bridge the period during which a central venous line is replaced or is in use for other intravenous treatment.
  • When multiple dosing is required, the infusion should be done via a central venous line.
  • Do NOT administer Noxafil injection as an intravenous bolus injection.

Noxafil delayed-release tablets

  • Swallow tablets whole. Do not divide, crush, or chew.
  • Administer with or without food [see Dosage and Administration (2.5) and Clinical Pharmacology (12.3)].
  • For patients who cannot eat a full meal, Noxafil delayed-release tablets should be used instead of Noxafil oral suspension for the prophylaxis indication. Noxafil delayed-release tablets generally provide higher plasma drug exposures than Noxafil oral suspension under both fed and fasted conditions [see Dosage and Administration (2.6)].

Noxafil oral suspension

  • Administer with a full meal or with a liquid nutritional supplement or an acidic carbonated beverage (e.g., ginger ale) in patients who cannot eat a full meal [see Dosage and Administration (2.6)].
  • Co-administration of drugs that can decrease the plasma concentrations of posaconazole should generally be avoided unless the benefit outweighs the risk. If such drugs are necessary, patients should be monitored closely for breakthrough fungal infections [see Drug Interactions (7.6, 7.7, 7.8, 7.9, 7.13)].

Noxafil PowderMix for delayed-release oral suspension

  • Administer with food [see Clinical Pharmacology (12.3)].
  • Administration with alcohol is not recommended [see Drug Interactions (7.15)].
  • To ensure delivery of the correct dose, ONLY the provided notched tip syringes must be used for preparation and administration. The design of the notched tip syringe prevents aggregation of the suspension during preparation and administration [see Dosage and Administration (2.8)].

2.2 Dosing Regimen in Adult Patients

Table 1: Dosing Regimens in Adult Patients
Indication Dose and Frequency Duration of Therapy
Treatment of invasive Aspergillosis

Noxafil Injection:

Loading dose:
300 mg Noxafil injection intravenously twice a day on the first day.

Maintenance dose:
300 mg Noxafil injection intravenously once a day, starting on the second day.

Noxafil Delayed-Release Tablets:

Loading dose: 300 mg (three 100 mg delayed-release tablets) twice a day on the first day.

Maintenance dose: 300 mg (three 100 mg delayed-release tablets) once a day, starting on the second day.

Switching between the intravenous and delayed-release tablets is acceptable. A loading dose is not required when switching between formulations.

Loading dose:
1 day

Maintenance dose:
Recommended total duration of therapy is 6 to 12 weeks.

Prophylaxis of invasive Aspergillus and Candida infections Noxafil Injection:
Loading dose: 300 mg Noxafil injection intravenously twice a day on the first day.
Maintenance dose: 300 mg Noxafil injection intravenously once a day thereafter.
Noxafil Delayed-Release Tablets:
Loading dose: 300 mg (three 100 mg delayed-release tablets) twice a day on the first day.
Maintenance dose: 300 mg (three 100 mg delayed-release tablets) once a day, starting on the second day.
Noxafil Oral Suspension: 200 mg (5 mL) three times a day.
Loading dose:
1 day

Maintenance dose:
Duration of therapy is based on recovery from neutropenia or immunosuppression.
Oropharyngeal Candidiasis (OPC) Noxafil Oral Suspension:
Loading dose: 100 mg (2.5 mL) twice a day on the first day.
Maintenance dose: 100 mg (2.5 mL) once a day thereafter.
Loading dose:
1 day

Maintenance dose:
13 days
OPC Refractory (rOPC) to Itraconazole and/or Fluconazole Noxafil Oral Suspension: 400 mg (10 mL) twice a day. Duration of therapy is based on the severity of the patient’s underlying disease and clinical response.

2.3 Dosing Regimen in Pediatric Patients (ages 2 to less than 18 years of age)

The recommended dosing regimen of Noxafil for pediatric patients 2 to less than 18 years of age is shown in Tables 2, 3, and 4 [see Dosage and Administration (2.5, 2.6, 2.8) and Clinical Pharmacology (12.3)].

Noxafil PowderMix for delayed-release oral suspension is not recommended for use in patients who weigh greater than 40 kg because the recommended dosage cannot be achieved with this formulation.

Table 2: Noxafil Delayed-Release Tablet and Noxafil Injection Dosing Regimens for Pediatric Patients (ages 2 to less than 18 years of age)
Recommended Pediatric Dosage and Formulation
Indication Weight/Age Delayed-Release Tablet Injection Duration of therapy
Prophylaxis of invasive Aspergillus and Candida infections Less than or equal to 40 kg (2 to less than 18 years of age) Not Applicable Loading dose:
6 mg/kg up to a maximum of 300 mg twice daily on the first day
Duration of therapy is based on
recovery from neutropenia or
immunosuppression.
Greater than 40 kg (2 to less than 18 years of age) Loading dose:
300 mg twice daily on the first day

Maintenance dose:
300 mg once daily


Maintenance dose:

6 mg/kg up to a maximum of 300 mg once daily
Treatment of invasive Aspergillosis 13 to less than 18 years of age regardless of weight. Loading dose:
300 mg (three 100 mg delayed-release tablets) twice a day on the first day.
Loading dose:
300 mg Noxafil injection intravenously twice a day on the first day.
Loading dose:
1 day

Maintenance dose:
300 mg (three 100 mg delayed-release tablets) once a day, starting on the second day.

Maintenance dose:
300 mg Noxafil injection intravenously once a day, starting on the second day.
Maintenance dose:
Recommended total duration of therapy is 6 to 12 weeks.

Switching between the intravenous and delayed-release tablets is acceptable. A loading dose is not required when switching between formulations.

Switching between the intravenous and delayed-release tablets is acceptable. A loading dose is not required when switching between formulations.
Table 3: Noxafil Oral Suspension Dosing Regimens for Pediatric Patients (ages 13 to less than 18 years of age)
Indication Loading Dose (volume) and
frequency
Maintenance Dose
(volume) and frequency
Duration of therapy
Prophylaxis of invasive Aspergillus and Candida infections 200 mg (5 mL) three times a day 200 mg (5 mL) three times a day Duration of therapy is based on recovery from neutropenia or immunosuppression.
Oropharyngeal Candidiasis (OPC) 100 mg (2.5 mL) twice daily on the first day 100 mg (2.5 mL) once daily 13 days
OPC Refractory (rOPC) to Itraconazole and/or Fluconazole 400 mg (10 mL) twice daily 400 mg (10 mL) twice daily Duration of therapy is based on the severity of the patient’s underlying disease and clinical response.
Table 4: Noxafil PowderMix for Delayed-Release Oral Suspension Dosing Regimen in Pediatric Patients (ages 2 to less than 18 years of age, weighing 10 to 40 kg)
Indication Weight (kg) Loading Dose (volume) Maintenance Dose (volume)
Prophylaxis of invasive Aspergillus and Candida infections 10 to less than 12 90 mg (3 mL) twice daily on the first day 90 mg (3 mL) once daily
12 to less than 17 120 mg (4 mL) twice daily on the first day 120 mg (4 mL) once daily
17 to less than 21 150 mg (5 mL) twice daily on the first day 150 mg (5 mL) once daily
21 to less than 26 180 mg (6 mL) twice daily on the first day 180 mg (6 mL) once daily
26 to less than 36 210 mg (7 mL) twice daily on the first day 210 mg (7 mL) once daily
36 to 40 240 mg (8 mL) twice daily on the first day 240 mg (8 mL) once daily

2.4 Preparation, Intravenous Line Compatibility, and Administration of Noxafil Injection

Preparation:

  • Equilibrate the refrigerated vial of Noxafil (posaconazole) injection to room temperature.
  • To prepare the required dose, aseptically transfer one vial (16.7 mL) of Noxafil injection (containing 300 mg of posaconazole in solution) to an intravenous bag (or bottle) of a compatible admixture diluent (as described in Table 5 ), to achieve a final concentration of posaconazole that is between 1 mg/mL and 2 mg/mL. Use of other diluents is not recommended because they may result in particulate formation.
  • Noxafil injection is a single-dose sterile solution without preservatives. Discard any unused portion from the vial.
  • Once admixed, the diluted solution of Noxafil in the intravenous bag (or bottle) should be used immediately. If not used immediately, the solution can be stored up to 24 hours refrigerated 2 to 8°C (36 to 46°F). Discard any unused portion.
  • Parenteral drug products should be inspected visually for particulate matter prior to administration, whenever solution and container permit. Once admixed, the solution of Noxafil ranges from colorless to yellow. Variations of color within this range do not affect the quality of the product.

Intravenous Line Compatibility:

A study was conducted to evaluate physical compatibility of Noxafil injection with injectable drug products and commonly used intravenous diluents during simulated Y-site infusion. Compatibility was determined through visual observations, measurement of particulate matter and turbidity. Compatible diluents and drug products are listed in Tables 5 and 6 below. Any diluents or drug products not listed in the tables below should not be co-administered through the same intravenous line (or cannula).

  • Noxafil injection can be infused at the same time through the same intravenous line (or cannula) with the following compatible diluents:
Table 5: Compatible Diluents
0.45% sodium chloride
0.9% sodium chloride
5% dextrose in water
5% dextrose and 0.45% sodium chloride
5% dextrose and 0.9% sodium chloride
5% dextrose and 20 mEq potassium chloride
  • Noxafil injection can be infused at the same time through the same intravenous line (or cannula) with the following drug products prepared in 5% dextrose in water or sodium chloride 0.9%. Co-administration of drug products prepared in other diluents may result in particulate formation.
Table 6: Compatible Drugs
Amikacin sulfate
Caspofungin
Ciprofloxacin
Daptomycin
Dobutamine hydrochloride
Famotidine
Filgrastim
Gentamicin sulfate
Hydromorphone hydrochloride
Levofloxacin
Lorazepam
Meropenem
Micafungin
Morphine sulfate
Norepinephrine bitartrate
Potassium chloride
Vancomycin hydrochloride

Incompatible Diluents:

Noxafil injection must not be diluted with the following diluents:

Lactated Ringer's solution
5% dextrose with Lactated Ringer's solution
4.2% sodium bicarbonate

Administration:

  • Noxafil injection must be administered through a 0.22-micron polyethersulfone (PES) or polyvinylidene difluoride (PVDF) filter.
  • Administer via a central venous line, including a central venous catheter or PICC by slow infusion over approximately 90 minutes. Noxafil injection is not for bolus administration.
  • If a central venous catheter is not available, Noxafil injection may be administered through a peripheral venous catheter only as a single dose in advance of central venous line placement or to bridge the period during which a central venous line is replaced or is in use for other treatment.
  • When multiple dosing is required, the infusion should be done via a central venous line. When administered through a peripheral venous catheter, the infusion should be administered over approximately 30 minutes. Note: In clinical trials, multiple peripheral infusions given through the same vein resulted in infusion site reactions [see Adverse Reactions (6.1)].

2.5 Administration Instructions for Noxafil Delayed-Release Tablets

  • Swallow tablets whole. Do not divide, crush, or chew.
  • Administer Noxafil delayed-release tablets with or without food [see Clinical Pharmacology (12.3)].

2.6 Administration Instructions for Noxafil Oral Suspension

  • Shake Noxafil oral suspension well before use. Administer with measured dosing spoon (see Figure 1) provided.
Figure 1
Figure 1: A measured dosing spoon is provided, marked for doses of 2.5 mL and 5 mL.
  • Rinse the spoon with water after each administration and before storage.
  • Administer each dose of Noxafil oral suspension during or immediately (i.e., within 20 minutes) following a full meal [see Clinical Pharmacology (12.3)].
  • For patients who cannot eat a full meal, Noxafil delayed-release tablets should be used instead of Noxafil oral suspension for the prophylaxis indication. Noxafil delayed-release tablets provide higher plasma drug exposures than Noxafil oral suspension under fasted conditions [see Dosage and Administration (2.1)].
  • In patients who cannot eat a full meal and for whom Noxafil delayed-release tablets or Noxafil injection are not options, administer each dose of Noxafil oral suspension with a liquid nutritional supplement or an acidic carbonated beverage (e.g., ginger ale).
  • For patients who cannot eat a full meal or tolerate an oral nutritional supplement or an acidic carbonated beverage and who do not have the option of taking Noxafil delayed-release tablets or Noxafil injection, an alternative antifungal therapy should be considered or patients should be monitored closely for breakthrough fungal infections.
Figure 1

2.7 Non-substitutability between Noxafil Oral Suspension and Other Formulations

Noxafil oral suspension is not substitutable with Noxafil delayed-release tablets or Noxafil PowderMix for delayed-release oral suspension due to the differences in the dosing of each formulation. Therefore, follow the specific dosage recommendations for each of the formulations [see Dosage and Administration (2.2, 2.3)].

2.8 Preparation and Administration Instructions for Noxafil PowderMix for Delayed-Release Oral Suspension (pediatric patients ages 2 to less than 18 years of age)

For details on preparation and administration of Noxafil PowderMix for delayed-release oral suspension, see Instructions for Use .

Preparation Instructions

  • Do not open packet in the Noxafil PowderMix kit until ready to prepare the medicine.
  • Remove cap from the mixing liquid and push the bottle adapter into the neck of the bottle. Once in place, the bottle adapter stays in the bottle. Remove 9 mL of mixing liquid using the provided BLUE syringe. Put the cap back on the bottle. ONLY the mixing liquid in the kit should be used to prepare Noxafil PowderMix for delayed-release oral suspension.
  • Using the provided mixing cup, combine 9 mL of mixing liquid and the entire contents of one packet in the Noxafil PowderMix kit and mix. Each single-use packet in the Noxafil PowderMix kit contains 300 mg of posaconazole to be suspended in 9 mL of mixing liquid giving a final concentration of approximately 30 mg per mL.
  • Shake the mixing cup vigorously for 45 seconds to mix the powder and mixing liquid from the Noxafil PowderMix kit. Check to make sure the powder is mixed. The mixture should look cloudy and free of clumps.
  • The reconstituted suspension must be used within 1 hour. Discard unused portion of the prepared drug product.

Administration Instructions

  • Administer Noxafil PowderMix for delayed-release oral suspension with food.
  • Choose the correct syringe based on the prescribed dose: Use 3 mL (GREEN) syringe if dose is 3 mL or less. Use 10 mL (BLUE) syringe if dose is more than 3 mL.
  • Measure the prescribed dose volume with the notched tip syringe provided with the kit and administer the dose orally. Administer the dose orally within 1 hour of mixing.
  • Not all of the Noxafil PowderMix in the mixing cup will be used. There will be some left over in the mixing cup.
  • The maximum dose that can be accurately withdrawn from the mixing cup after reconstitution is 240 mg (8 mL).
  • To ensure delivery of the correct dose, ONLY the provided notched tip syringes must be used for preparation and administration. The design of the notched tip syringe prevents aggregation of the suspension during preparation and administration.
  • Discard any remaining suspension. The mixing cup may be hand washed and reused. Alternatively, the mixing cup may be discarded, and a similar mixing cup with a lid may be used for subsequent doses.
  • The notched tip syringes may also be hand washed and reused. For additional supply, a separate box of notched tip syringes is provided with the Noxafil PowderMix kit.

2.9 Dosage Adjustments in Patients with Renal Impairment

The pharmacokinetics of Noxafil oral suspension and Noxafil delayed-release tablets are not significantly affected by renal impairment. Therefore, no adjustment is necessary for oral dosing in patients with mild to severe renal impairment.

  • Noxafil injection should be avoided in patients with moderate or severe renal impairment (eGFR <50 mL/min), unless an assessment of the benefit/risk to the patient justifies the use of Noxafil injection.
  • In patients with moderate or severe renal impairment (estimated glomerular filtration rate (eGFR) <50 mL/min), receiving the Noxafil injection, accumulation of the intravenous vehicle, Betadex Sulfobutyl Ether Sodium (SBECD), is expected to occur. Serum creatinine levels should be closely monitored in these patients, and, if increases occur, consideration should be given to changing to oral Noxafil therapy.

3 DOSAGE FORMS AND STRENGTHS

Noxafil injection

Noxafil injection (300 mg per vial) is available as a clear, colorless to yellow sterile liquid in a single-dose vial.

Noxafil Delayed-Release Tablets

Noxafil delayed-release tablets are available as yellow, coated, oblong tablets, debossed with "100" on one side containing 100 mg of posaconazole.

Noxafil Oral Suspension

Noxafil oral suspension is available as a white, cherry-flavored suspension in 4-ounce (123 mL) amber glass bottles with child-resistant closures containing 105 mL of suspension (40 mg of posaconazole per mL).

Noxafil PowderMix for Delayed-Release Oral Suspension

Each Noxafil PowderMix kit contains posaconazole, 300 mg, as an off-white to yellowish powder for delayed-release oral suspension and a mixing liquid.

  • Noxafil injection: 300 mg per vial (18 mg per mL) in a single dose vial (3)
  • Noxafil delayed-release tablet: 100 mg (3)
  • Noxafil oral suspension: 40 mg per mL (3)
  • Noxafil PowderMix for delayed-release oral suspension: 300 mg (3)

4 CONTRAINDICATIONS

  • Known hypersensitivity to posaconazole or other azole antifungal agents. (4.1)
  • Coadministration of Noxafil with the following drugs is contraindicated; Noxafil increases concentrations and toxicities of: Sirolimus (4.2, 5.1, 7.1) CYP3A4 substrates (pimozide, quinidine): can result in QTc interval prolongation and cases of torsades de pointes (TdP) (4.3, 5.2, 7.2) HMG-CoA Reductase Inhibitors Primarily Metabolized through CYP3A4 (4.4, 7.3) Ergot alkaloids (4.5, 7.4) Venetoclax: in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) at initiation and during the ramp up phase (4.6, 5.10, 7.16)
  • Noxafil PowderMix for delayed-release oral suspension is contraindicated in patients with known or suspected Hereditary Fructose Intolerance (HFI). (4.7, 5.8, 8.4)

4.1 Hypersensitivity

Noxafil is contraindicated in persons with known hypersensitivity to posaconazole or other azole antifungal agents.

4.2 Use with Sirolimus

Noxafil is contraindicated with sirolimus. Concomitant administration of Noxafil with sirolimus increases the sirolimus blood concentrations by approximately 9-fold and can result in sirolimus toxicity [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)].

4.3 QT Prolongation with Concomitant Use with CYP3A4 Substrates

Noxafil is contraindicated with CYP3A4 substrates that prolong the QT interval. Concomitant administration of Noxafil with the CYP3A4 substrates, pimozide and quinidine may result in increased plasma concentrations of these drugs, leading to QTc prolongation and cases of torsades de pointes [see Warnings and Precautions (5.2) and Drug Interactions (7.2)].

4.4 HMG-CoA Reductase Inhibitors Primarily Metabolized Through CYP3A4

Coadministration with the HMG-CoA reductase inhibitors that are primarily metabolized through CYP3A4 (e.g., atorvastatin, lovastatin, and simvastatin) is contraindicated since increased plasma concentration of these drugs can lead to rhabdomyolysis [see Drug Interactions (7.3) and Clinical Pharmacology (12.3)].

4.5 Use with Ergot Alkaloids

Noxafil may increase the plasma concentrations of ergot alkaloids (ergotamine and dihydroergotamine) which may lead to ergotism [see Drug Interactions (7.4)].

4.6 Use with Venetoclax

Coadministration of Noxafil with venetoclax at initiation and during the ramp-up phase is contraindicated in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) due to the potential for increased risk of tumor lysis syndrome [see Warnings and Precautions (5.10) and Drug Interactions (7.16)].

4.7 Use of Noxafil PowderMix for Delayed-Release Oral Suspension in Patients with Hereditary Fructose Intolerance

Noxafil PowderMix for delayed-release oral suspension is contraindicated in patients with known or suspected hereditary fructose intolerance (HFI) [see Warnings and Precautions (5.8) and Use in Specific Populations (8.4)].

5 WARNINGS AND PRECAUTIONS

  • Calcineurin-Inhibitor Toxicity: Noxafil increases concentrations of cyclosporine or tacrolimus; reduce dose of cyclosporine and tacrolimus and monitor concentrations frequently. (5.1)
  • Arrhythmias and QTc Prolongation: Noxafil has been shown to prolong the QTc interval and cause cases of TdP. Administer with caution to patients with potentially proarrhythmic conditions. Do not administer with drugs known to prolong QTc interval and metabolized through CYP3A4. (5.2)
  • Electrolyte Disturbances: Monitor and correct, especially those involving potassium (K+), magnesium (Mg++), and calcium (Ca++), before and during Noxafil therapy. (5.3)
  • Hepatic Toxicity: Elevations in liver tests may occur. Discontinuation should be considered in patients who develop abnormal liver tests or monitor liver tests during treatment. (5.4)
  • Renal Impairment: Noxafil injection should be avoided in patients with moderate or severe renal impairment (creatinine clearance <50 mL/min), unless an assessment of the benefit/risk to the patient justifies the use of Noxafil injection. (5.5, 8.6)
  • Concomitant Use with Midazolam: Noxafil can prolong hypnotic/sedative effects. Monitor patients and benzodiazepine receptor antagonists should be available. (5.6, 7.5)
  • Vincristine Toxicity: Concomitant administration of azole antifungals, including Noxafil, with vincristine has been associated with neurotoxicity and other serious adverse reactions; reserve azole antifungals, including Noxafil, for patients receiving a vinca alkaloid, including vincristine, who have no alternative antifungal treatment options. (5.7, 7.10)
  • Risk in Patients with Hereditary Fructose Intolerance (HFI): Noxafil PowderMix for delayed-release oral suspension contains sorbitol. Risk of metabolic crisis with life-threatening hypoglycemia, hypophosphatemia, lactic acidosis, and hepatic failure. Obtain history of HFI symptoms in pediatric patients before Noxafil PowderMix for delayed-release oral suspension administration. (5.8, 8.4)
  • Breakthrough Fungal Infections: Monitor patients with severe diarrhea or vomiting when receiving Noxafil delayed-release tablets, Noxafil oral suspension, and Noxafil PowderMix for delayed-release oral suspension. (5.9)
  • Venetoclax Toxicity: Concomitant administration of Noxafil with venetoclax may increase venetoclax toxicities, including the risk of tumor lysis syndrome, neutropenia, and serious infections; monitor for toxicity and reduce venetoclax dose. (4.6, 5.10, 7.16)

5.1 Calcineurin-Inhibitor Toxicity

Concomitant administration of Noxafil with cyclosporine or tacrolimus increases the whole blood trough concentrations of these calcineurin-inhibitors [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)]. Nephrotoxicity and leukoencephalopathy (including deaths) have been reported in clinical efficacy studies in patients with elevated cyclosporine or tacrolimus concentrations. Frequent monitoring of tacrolimus or cyclosporine whole blood trough concentrations should be performed during and at discontinuation of Noxafil treatment and the tacrolimus or cyclosporine dose adjusted accordingly.

5.2 Arrhythmias and QT Prolongation

Some azoles, including Noxafil, have been associated with prolongation of the QT interval on the electrocardiogram. In addition, cases of torsades de pointes have been reported in patients taking Noxafil.

Results from a multiple time-matched ECG analysis in healthy volunteers did not show any increase in the mean of the QTc interval. Multiple, time-matched ECGs collected over a 12-hour period were recorded at baseline and steady-state from 173 healthy male and female volunteers (18-85 years of age) administered Noxafil oral suspension 400 mg twice daily with a high-fat meal. In this pooled analysis, the mean QTc (Fridericia) interval change from baseline was –5 msec following administration of the recommended clinical dose. A decrease in the QTc(F) interval (–3 msec) was also observed in a small number of subjects (n=16) administered placebo. The placebo-adjusted mean maximum QTc(F) interval change from baseline was <0 msec (–8 msec). No healthy subject administered Noxafil had a QTc(F) interval ≥500 msec or an increase ≥60 msec in their QTc(F) interval from baseline.

Noxafil should be administered with caution to patients with potentially proarrhythmic conditions. Do not administer with drugs that are known to prolong the QTc interval and are metabolized through CYP3A4 [see Contraindications (4.3) and Drug Interactions (7.2)].

5.3 Electrolyte Disturbances

Electrolyte disturbances, especially those involving potassium, magnesium or calcium levels, should be monitored and corrected as necessary before and during Noxafil therapy.

5.4 Hepatic Toxicity

Hepatic reactions (e.g., mild to moderate elevations in alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin, and/or clinical hepatitis) have been reported in clinical trials. The elevations in liver tests were generally reversible on discontinuation of therapy, and in some instances these tests normalized without drug interruption. Cases of more severe hepatic reactions including cholestasis or hepatic failure including deaths have been reported in patients with serious underlying medical conditions (e.g., hematologic malignancy) during treatment with Noxafil. These severe hepatic reactions were seen primarily in subjects receiving the Noxafil oral suspension 800 mg daily (400 mg twice daily or 200 mg four times a day) in clinical trials.

Liver tests should be evaluated at the start of and during the course of Noxafil therapy. Patients who develop abnormal liver tests during Noxafil therapy should be monitored for the development of more severe hepatic injury. Patient management should include laboratory evaluation of hepatic function (particularly liver tests and bilirubin). Discontinuation of Noxafil must be considered if clinical signs and symptoms consistent with liver disease develop that may be attributable to Noxafil.

5.5 Renal Impairment

Due to the variability in exposure with Noxafil delayed-release tablets, Noxafil oral suspension, and Noxafil PowderMix for delayed-release oral suspension, patients with severe renal impairment should be monitored closely for breakthrough fungal infections [see Dosage and Administration (2.9) and Use in Specific Populations (8.6)].

Noxafil injection should be avoided in patients with moderate or severe renal impairment (eGFR <50 mL/min), unless an assessment of the benefit/risk to the patient justifies the use of Noxafil injection. In patients with moderate or severe renal impairment (eGFR <50 mL/min), receiving the Noxafil injection, accumulation of the intravenous vehicle, SBECD, is expected to occur. Serum creatinine levels should be closely monitored in these patients, and, if increases occur, consideration should be given to changing to oral Noxafil therapy [see Dosage and Administration (2.9) and Use in Specific Populations (8.6)].

5.6 Midazolam Toxicity

Concomitant administration of Noxafil with midazolam increases the midazolam plasma concentrations by approximately 5-fold. Increased plasma midazolam concentrations could potentiate and prolong hypnotic and sedative effects. Patients must be monitored closely for adverse effects associated with high plasma concentrations of midazolam and benzodiazepine receptor antagonists must be available to reverse these effects [see Drug Interactions (7.5) and Clinical Pharmacology (12.3)].

5.7 Vincristine Toxicity

Concomitant administration of azole antifungals, including Noxafil, with vincristine has been associated with neurotoxicity and other serious adverse reactions, including seizures, peripheral neuropathy, syndrome of inappropriate antidiuretic hormone secretion, and paralytic ileus. Reserve azole antifungals, including Noxafil, for patients receiving a vinca alkaloid, including vincristine, who have no alternative antifungal treatment options [see Drug Interactions (7.10)].

5.8 Risk in Patients with Hereditary Fructose Intolerance (HFI)

Noxafil PowderMix for delayed-release oral suspension contains sorbitol, an inactive ingredient, and may precipitate a metabolic crisis that may include, but is not limited to life-threatening hypoglycemia, hypophosphatemia, lactic acidosis, and hepatic failure in patients with HFI. Obtain careful history of HFI symptoms (nausea, vomiting, abdominal pain) with sorbitol/fructose/sucrose exposure prior to Noxafil PowderMix for delayed-release oral suspension administration because a diagnosis of HFI may not yet be established in pediatric patients [see Contraindications (4), Use in Specific Populations (8.4)].

5.9 Breakthrough Fungal Infections

Patients who have severe diarrhea or vomiting should be monitored closely for breakthrough fungal infections when receiving Noxafil delayed-release tablets, Noxafil oral suspension, or Noxafil PowderMix for delayed-release oral suspension.

5.10 Venetoclax Toxicity

Concomitant administration of Noxafil, a strong CYP3A4 inhibitor, with venetoclax may increase venetoclax toxicities, including the risk of tumor lysis syndrome (TLS), neutropenia, and serious infections. In patients with CLL/SLL, administration of Noxafil during initiation and the ramp-up phase of venetoclax is contraindicated [see Contraindications (4.6)]. Refer to the venetoclax labeling for safety monitoring and dose reduction in the steady daily dosing phase in CLL/SLL patients.

For patients with acute myeloid leukemia (AML), dose reduction and safety monitoring are recommended across all dosing phases when coadministering Noxafil with venetoclax [see Drug Interactions (7.16)]. Refer to the venetoclax prescribing information for dosing instructions.

6 ADVERSE REACTIONS

The following serious and otherwise important adverse reactions are discussed in detail in another section of the labeling:

  • Hypersensitivity [see Contraindications (4.1)]
  • Arrhythmias and QT Prolongation [see Warnings and Precautions (5.2)]
  • Hepatic Toxicity [see Warnings and Precautions (5.4)]
  • Adult Patients: Common adverse reactions in studies with Noxafil in adults are diarrhea, nausea, fever, vomiting, headache, coughing, and hypokalemia. (6.1)
  • Pediatric Patients: Common adverse reactions (incidence >20% receiving 6 mg/kg Noxafil injection and Noxafil PowderMix for delayed-release oral suspension) in a study in pediatric patients are pyrexia, febrile neutropenia, vomiting, mucosal inflammation, pruritus, hypertension, hypokalemia, and stomatitis. (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Merck Sharp & Dohme LLC at 1-877-888-4231 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of Noxafil cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Clinical Trial Experience in Adults

Clinical Trial Experience with Noxafil Injection and Noxafil Delayed-Release Tablets for the Treatment of Invasive Aspergillosis

The safety of Noxafil injection and Noxafil delayed-release tablet was assessed in a randomized, double-blind, active-controlled clinical study of Noxafil injection and Noxafil delayed-release tablets versus voriconazole for treatment of invasive aspergillosis (Aspergillosis Treatment Study). A total of 575 (288 in Noxafil arm, 287 in voriconazole arm) adult and pediatric patients 13 years of age and older with proven, probable or possible invasive aspergillosis were included. The median duration of treatment was 67 days for Noxafil injection or Noxafil delayed-release tablet and 64 days for voriconazole, with 55% to 60% of subjects starting treatment with the IV formulation of either drug. The median duration of the first instance of IV treatment (before switching to oral treatment or discontinuing or completing study treatment) was 9 days for both groups. Table 7 presents adverse reactions reported at an incidence of ≥10% in either one of the groups in Aspergillosis Treatment Study.

Adverse reactions leading to treatment discontinuation were reported for 33.9% of subjects. The most commonly reported adverse reactions (>2% of subjects) leading to treatment discontinuation were septic shock, respiratory failure, and bronchopulmonary aspergillosis in the Noxafil arm, and septic shock and acute myeloid leukemia in the voriconazole arm.

Table 7: Noxafil Invasive Aspergillosis Treatment Study: Adverse Reactions in at Least 10% of Subjects Treated with Noxafil Injection or Noxafil Delayed-Release Tablets
System Organ Class Noxafil injection or tablet
(N = 288), n (%)
Voriconazole injection or oral
(N = 287), n (%)
Blood and lymphatic system disorders
   Anemia 25 (8.7) 29 (10.1)
   Febrile neutropenia 42 (14.6) 38 (13.2)
Gastrointestinal disorders
   Abdominal pain 29 (10.1) 24 (8.4)
   Constipation 32 (11.1) 23 (8.0)
   Diarrhea 52 (18.1) 52 (18.1)
   Nausea 65 (22.6) 51 (17.8)
   Vomiting 52 (18.1) 39 (13.6)
General disorders and administration site conditions
   Edema peripheral 32 (11.1) 24 (8.4)
   Pyrexia 81 (28.1) 72 (25.1)
Infections and infestations
   Pneumonia 36 (12.5) 26 (9.1)
Investigations
   Alanine aminotransferase increased 42 (14.6) 37 (12.9)
   Aspartate aminotransferase increased 38 (13.2) 36 (12.5)
   Blood alkaline phosphatase increased 21 (7.3) 29 (10.1)
Metabolism and nutrition disorders
   Hypokalemia 82 (28.5) 49 (17.1)
   Hypomagnesemia 29 (10.1) 18 (6.3)
Nervous system disorders
   Headache 35 (12.2) 25 (8.7)
Respiratory, thoracic and mediastinal disorders
   Cough 30 (10.4) 24 (8.4)
   Epistaxis 32 (11.1) 17 (5.9)

The most frequently reported adverse reactions in the Noxafil-treated group were pyrexia (28%), hypokalemia (28%), and nausea (23%).

Clinical Trial Experience with Noxafil Injection for Prophylaxis

Multiple doses of Noxafil injection administered via a peripheral venous catheter were associated with thrombophlebitis (60% incidence). Therefore, in subsequent studies, Noxafil injection was administered via central venous catheter.

The safety of Noxafil injection has been assessed in 268 patients in a clinical trial. Patients were enrolled in a non-comparative pharmacokinetic and safety trial of Noxafil injection when given as antifungal prophylaxis (Noxafil Injection Study). Patients were immunocompromised with underlying conditions including hematological malignancy, neutropenia post-chemotherapy, GVHD, and post HSCT. This patient population was 55% male, had a mean age of 51 years (range 18-82 years, 19% of patients were ≥65 years of age), and were 95% white and 8% Hispanic. Ten patients received a single dose of 200 mg Noxafil injection, 21 patients received 200 mg daily dose for a median of 14 days, and 237 patients received 300 mg daily dose for a median of 9 days.

Table 8 presents adverse reactions observed in patients treated with Noxafil injection 300 mg daily dose in the Noxafil Injection Study. Each patient received a loading dose, 300 mg twice on Day 1. Following Noxafil intravenous therapy, patients received Noxafil oral suspension to complete 28 days of total Noxafil therapy.

Table 8: Noxafil Injection Study: Adverse Reactions in at Least 10% of Subjects Treated with Noxafil Injection 300 mg Daily Dose
Body System Noxafil Injection Treatment Phase
n=237 (%)Adverse reactions reported in patients with an onset during the Noxafil intravenous dosing phase of the study.
Noxafil Injection
Treatment Phase or Subsequent Noxafil Oral Suspension Treatment Phase
n=237 (%)Adverse reactions reported with an onset at any time during the study in patients who were treated for up to 28 days of Noxafil therapy.
Subjects Reporting any Adverse Reaction 220 (93) 235 (99)
Blood and Lymphatic System Disorder
   Anemia 16 (7) 23 (10)
   Thrombocytopenia 17 (7) 25 (11)
Gastrointestinal Disorders
   Abdominal Pain Upper 15 (6) 25 (11)
   Abdominal Pain 30 (13) 41 (17)
   Constipation 18 (8) 31 (13)
   Diarrhea 75 (32) 93 (39)
   Nausea 46 (19) 70 (30)
   Vomiting 29 (12) 45 (19)
General Disorders and Administration Site Conditions
   Fatigue 19 (8) 24 (10)
   Chills 28 (12) 38 (16)
   Edema Peripheral 28 (12) 35 (15)
   Pyrexia 49 (21) 73 (31)
Metabolism and Nutrition Disorders
   Decreased appetite 23 (10) 29 (12)
   Hypokalemia 51 (22) 67 (28)
   Hypomagnesemia 25 (11) 30 (13)
Nervous System Disorders
   Headache 33 (14) 49 (21)
Respiratory, Thoracic and Mediastinal Disorders
   Cough 21 (9) 31 (13)
   Dyspnea 16 (7) 24 (10)
   Epistaxis 34 (14) 40 (17)
Skin and Subcutaneous Tissue Disorders
   Petechiae 20 (8) 24 (10)
   Rash 35 (15) 56 (24)
Vascular Disorders
   Hypertension 20 (8) 26 (11)

The most frequently reported adverse reactions with an onset during the Noxafil intravenous phase of dosing with 300 mg once daily were diarrhea (32%), hypokalemia (22%), pyrexia (21%), and nausea (19%). These adverse reactions were consistent with those seen in studies with Noxafil oral suspension.

Clinical Trial Experience with Noxafil Delayed-Release Tablets for Prophylaxis

The safety of Noxafil delayed-release tablets has been assessed in 230 patients in clinical trials. Patients were enrolled in a non-comparative pharmacokinetic and safety trial of Noxafil delayed-release tablets when given as antifungal prophylaxis (Noxafil Delayed-Release Tablet Study). Patients were immunocompromised with underlying conditions including hematological malignancy, neutropenia post-chemotherapy, GVHD, and post HSCT. This patient population was 62% male, had a mean age of 51 years (range 19-78 years, 17% of patients were ≥65 years of age), and were 93% white and 16% Hispanic. Posaconazole therapy was given for a median duration of 28 days. Twenty patients received 200 mg daily dose and 210 patients received 300 mg daily dose (following twice daily dosing on Day 1 in each cohort). Table 9 presents adverse reactions observed in patients treated with 300 mg daily dose at an incidence of ≥10% in Noxafil Delayed-Release Tablet Study.

Table 9: Noxafil Delayed-Release Tablet Study: Adverse Reactions in at Least 10% of Subjects Treated with 300 mg Daily Dose
Body System Noxafil delayed-release tablet (300 mg)
n=210 (%)
Subjects Reporting any Adverse Reaction 207 (99)
Blood and Lymphatic System Disorder
   Anemia 22 (10)
   Thrombocytopenia 29 (14)
Gastrointestinal Disorders
   Abdominal Pain 23 (11)
   Constipation 20 (10)
   Diarrhea 61 (29)
   Nausea 56 (27)
   Vomiting 28 (13)
General Disorders and Administration Site Conditions
   Asthenia 20 (10)
   Chills 22 (10)
   Mucosal Inflammation 29 (14)
   Edema Peripheral 33 (16)
   Pyrexia 59 (28)
Metabolism and Nutrition Disorders
   Hypokalemia 46 (22)
   Hypomagnesemia 20 (10)
Nervous System Disorders
   Headache 30 (14)
Respiratory, Thoracic and Mediastinal Disorders
   Cough 35 (17)
   Epistaxis 30 (14)
Skin and Subcutaneous Tissue Disorders
   Rash 34 (16)
Vascular Disorders
   Hypertension 23 (11)

The most frequently reported adverse reactions (>25%) with Noxafil delayed-release tablets 300 mg once daily were diarrhea, pyrexia, and nausea.

The most common adverse reaction leading to discontinuation of Noxafil delayed-release tablets 300 mg once daily was nausea (2%).

Clinical Trial Safety Experience with Noxafil Oral Suspension

The safety of Noxafil oral suspension has been assessed in 1844 patients. This includes 605 patients in the active-controlled prophylaxis studies, 557 patients in the active-controlled OPC studies, 239 patients in refractory OPC studies, and 443 patients from other indications. This represents a heterogeneous population, including immunocompromised patients, e.g., patients with hematological malignancy, neutropenia post-chemotherapy, GVHD post HSCT, and HIV infection, as well as non-neutropenic patients. This patient population was 71% male, had a mean age of 42 years (range 8-84 years, 6% of patients were ≥65 years of age and 1% was <18 years of age), and were 64% white, 16% Hispanic, and 36% non-white (including 14% black). Noxafil therapy was given to 171 patients for ≥6 months, with 58 patients receiving Noxafil therapy for ≥12 months. Table 10 presents adverse reactions observed at an incidence of >10% in Noxafil prophylaxis studies. Table 11 presents adverse reactions observed at an incidence of at least 10% in the OPC/rOPC studies.

Prophylaxis of Aspergillus and Candida: In the 2 randomized, comparative prophylaxis studies (Noxafil Oral Suspension Study 1 and 2), the safety of Noxafil oral suspension 200 mg three times a day was compared to fluconazole 400 mg once daily or itraconazole 200 mg twice a day in severely immunocompromised patients.

The most frequently reported adverse reactions (>30%) in the prophylaxis clinical trials were fever, diarrhea, and nausea.

The most common adverse reactions leading to discontinuation of Noxafil in the prophylaxis studies were associated with GI disorders, specifically, nausea (2%), vomiting (2%), and hepatic enzymes increased (2%).

Table 10: Noxafil Oral Suspension Study 1 and Study 2. Adverse Reactions in at Least 10% of the Noxafil Oral Suspension or Fluconazole Treatment Groups (Pooled Prophylaxis Safety Analysis)
Body System Noxafil Oral Suspension
n=605 (%)
Fluconazole
n=539 (%)
Itraconazole
n=58 (%)
Subjects Reporting any Adverse Reaction 595 (98) 531 (99) 58 (100)
Body as a Whole - General Disorders
   Fever 274 (45) 254 (47) 32 (55)
   Headache 171 (28) 141 (26) 23 (40)
   Rigors 122 (20) 87 (16) 17 (29)
   Fatigue 101 (17) 98 (18) 5 (9)
   Edema Legs 93 (15) 67 (12) 11 (19)
   Anorexia 92 (15) 94 (17) 16 (28)
   Dizziness 64 (11) 56 (10) 5 (9)
   Edema 54 (9) 68 (13) 8 (14)
   Weakness 51 (8) 52 (10) 2 (3)
Cardiovascular Disorders, General
   Hypertension 106 (18) 88 (16) 3 (5)
   Hypotension 83 (14) 79 (15) 10 (17)
Disorders of Blood and Lymphatic System
   Anemia 149 (25) 124 (23) 16 (28)
   Neutropenia 141 (23) 122 (23) 23 (40)
Disorders of the Reproductive System and Breast
   Vaginal HemorrhagePercentages of sex-specific adverse reactions are based on the number of males/females. 24 (10) 20 (9) 3 (12)
Gastrointestinal System Disorders
   Diarrhea 256 (42) 212 (39) 35 (60)
   Nausea 232 (38) 198 (37) 30 (52)
   Vomiting 174 (29) 173 (32) 24 (41)
   Abdominal Pain 161 (27) 147 (27) 21 (36)
   Constipation 126 (21) 94 (17) 10 (17)
   Dyspepsia 61 (10) 50 (9) 6 (10)
Heart Rate and Rhythm Disorders
   Tachycardia 72 (12) 75 (14) 3 (5)
Infection and Infestations
   Pharyngitis 71 (12) 60 (11) 12 (21)
Liver and Biliary System Disorders
   Bilirubinemia 59 (10) 51 (9) 11 (19)
Metabolic and Nutritional Disorders
   Hypokalemia 181 (30) 142 (26) 30 (52)
   Hypomagnesemia 110 (18) 84 (16) 11 (19)
   Hyperglycemia 68 (11) 76 (14) 2 (3)
   Hypocalcemia 56 (9) 55 (10) 5 (9)
Musculoskeletal System Disorders
   Musculoskeletal Pain 95 (16) 82 (15) 9 (16)
   Arthralgia 69 (11) 67 (12) 5 (9)
   Back Pain 63 (10) 66 (12) 4 (7)
Platelet, Bleeding and Clotting Disorders
   Thrombocytopenia 175 (29) 146 (27) 20 (34)
   Petechiae 64 (11) 54 (10) 9 (16)
Psychiatric Disorders
   Insomnia 103 (17) 92 (17) 11 (19)
Respiratory System Disorders
   Coughing 146 (24) 130 (24) 14 (24)
   Dyspnea 121 (20) 116 (22) 15 (26)
   Epistaxis 82 (14) 73 (14) 12 (21)
Skin and Subcutaneous Tissue Disorders
   Rash 113 (19) 96 (18) 25 (43)
   Pruritus 69 (11) 62 (12) 11 (19)

HIV Infected Subjects with OPC : In 2 randomized comparative studies in OPC, the safety of Noxafil oral suspension at a dose of less than or equal to 400 mg once daily in 557 HIV-infected patients was compared to the safety of fluconazole in 262 HIV-infected patients at a dose of 100 mg once daily.

An additional 239 HIV-infected patients with refractory OPC received Noxafil oral suspension in 2 non-comparative trials for refractory OPC (rOPC). Of these subjects, 149 received the 800-mg/day dose and the remainder received the less than or equal to 400-mg once daily dose.

In the OPC/rOPC studies, the most common adverse reactions were fever, diarrhea, nausea, headache, vomiting, and coughing.

The most common adverse reactions that led to treatment discontinuation of Noxafil in the Controlled OPC Pool included respiratory impairment (1%) and pneumonia (1%). In the refractory OPC pool, the most common adverse reactions that led to treatment discontinuation of Noxafil were AIDS (7%) and respiratory impairment (3%).

Table 11: Adverse Reactions in at Least 10% of the Treated Population in OPC Studies with Noxafil Oral Suspension
Body System Number (%) of Subjects
Controlled OPC Pool Refractory OPC Pool
Noxafil Oral Suspension Fluconazole Noxafil Oral
Suspension
n=557 n=262 n=239
OPC=oropharyngeal candidiasis
Subjects Reporting any Adverse ReactionNumber of subjects reporting adverse reactions at least once during the study, without regard to relationship to treatment. Subjects may have reported more than 1 event. 356 (64) 175 (67) 221 (92)
Body as a Whole – General Disorders
  Fever 34 (6) 22 (8) 82 (34)
  Headache 44 (8) 23 (9) 47 (20)
  Anorexia 10 (2) 4 (2) 46 (19)
  Fatigue 18 (3) 12 (5) 31 (13)
  Asthenia 9 (2) 5 (2) 31 (13)
  Rigors 2 (<1) 4 (2) 29 (12)
  Pain 4 (1) 2 (1) 27 (11)
Disorders of Blood and Lymphatic System
  Neutropenia 21 (4) 8 (3) 39 (16)
  Anemia 11 (2) 5 (2) 34 (14)
Gastrointestinal System Disorders
  Diarrhea 58 (10) 34 (13) 70 (29)
  Nausea 48 (9) 30 (11) 70 (29)
  Vomiting 37 (7) 18 (7) 67 (28)
  Abdominal Pain 27 (5) 17 (6) 43 (18)
Infection and Infestations
  Candidiasis, Oral 3 (1) 1 (<1) 28 (12)
  Herpes Simplex 16 (3) 8 (3) 26 (11)
  Pneumonia 17 (3) 6 (2) 25 (10)
Metabolic and Nutritional Disorders
  Weight Decrease 4 (1) 2 (1) 33 (14)
  Dehydration 4 (1) 7 (3) 27 (11)
Psychiatric Disorders
  Insomnia 8 (1) 3 (1) 39 (16)
Respiratory System Disorders
  Coughing 18 (3) 11 (4) 60 (25)
  Dyspnea 8 (1) 8 (3) 28 (12)
Skin and Subcutaneous Tissue Disorders
  Rash 15 (3) 10 (4) 36 (15)
  Sweating Increased 13 (2) 5 (2) 23 (10)

Adverse reactions were reported more frequently in the pool of patients with refractory OPC. Among these highly immunocompromised patients with advanced HIV disease, serious adverse reactions (SARs) were reported in 55% (132/239). The most commonly reported SARs were fever (13%) and neutropenia (10%).

Other clinically significant adverse reactions reported in less than 5% of patients in clinical trials of Noxafil are listed below:

  • Blood and lymphatic system disorders: hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, neutropenia aggravated
  • Endocrine disorders: adrenal insufficiency
  • Nervous system disorders: paresthesia
  • Immune system disorders: allergic reaction [see Contraindications (4.1)]
  • Cardiac disorders: torsades de pointes [see Warnings and Precautions (5.2)]
  • Vascular disorders: pulmonary embolism
  • Gastrointestinal disorders: pancreatitis
  • Liver and Biliary System Disorders: hepatic enzymes increased, hepatic function abnormal, hepatitis, hepatomegaly, jaundice
  • Renal & Urinary System Disorders: renal failure acute

Clinical Laboratory Values: In healthy volunteers and patients, elevation of liver test values did not appear to be associated with higher plasma concentrations of posaconazole.

For the prophylaxis studies, the number of patients with changes in liver tests from Common Toxicity Criteria (CTC) Grade 0, 1, or 2 at baseline to Grade 3 or 4 during the study is presented in Table 12.

Table 12: Noxafil Oral Suspension Study 1 and Study 2. Changes in Liver Test Results from CTC Grade 0, 1, or 2 at Baseline to Grade 3 or 4
Number (%) of Patients with ChangeChange from Grade 0 to 2 at baseline to Grade 3 or 4 during the study. These data are presented in the form X/Y, where X represents the number of patients who met the criterion as indicated, and Y represents the number of patients who had a baseline observation and at least one post-baseline observation.
Noxafil Oral Suspension Study 1
CTC = Common Toxicity Criteria; AST= Aspartate Aminotransferase;
ALT= Alanine Aminotransferase.
Laboratory Parameter Noxafil Oral Suspension
n=301
Fluconazole
n=299
  AST 11/266 (4) 13/266 (5)
  ALT 47/271 (17) 39/272 (14)
  Bilirubin 24/271 (9) 20/275 (7)
  Alkaline Phosphatase 9/271 (3) 8/271 (3)
Noxafil Oral Suspension Study 2
Laboratory Parameter Noxafil Oral Suspension
(n=304)
Fluconazole/Itraconazole
(n=298)
  AST 9/286 (3) 5/280 (2)
  ALT 18/289 (6) 13/284 (5)
  Bilirubin 20/290 (7) 25/285 (9)
  Alkaline Phosphatase 4/281 (1) 1/276 (<1)

The number of patients treated for OPC with clinically significant liver test abnormalities at any time during the studies is provided in Table 13 (liver test abnormalities were present in some of these patients prior to initiation of the study drug).

Table 13: Noxafil Oral Suspension Studies: Clinically Significant Laboratory Test Abnormalities without Regard to Baseline Value
Laboratory Test Controlled Refractory
Noxafil Oral Suspension Fluconazole Noxafil Oral Suspension
n=557 (%) n=262 (%) n=239 (%)
ALT= Alanine Aminotransferase; AST= Aspartate Aminotransferase.
ALT > 3.0 × ULN 16/537 (3) 13/254 (5)   25/226 (11)
AST > 3.0 × ULN 33/537 (6) 26/254 (10) 39/223 (17)
Total Bilirubin > 1.5 × ULN 15/536 (3) 5/254 (2) 9/197 (5)
Alkaline Phosphatase > 3.0 × ULN 17/535 (3) 15/253 (6)   24/190 (13)

The number of patients treated for invasive aspergillosis with clinically significant liver test abnormalities at any time during the Aspergillosis Treatment Study is provided in Table 14 . Liver test abnormalities present prior to the initiation of study drug included ALT (22%), AST (13%), and bilirubin (13%).

Table 14: Aspergillosis Treatment Study: Changes in Liver Test Results from CTC Grade 0, 1, or 2 at Baseline to Grade 3 or 4
Number (%) of Patients with ChangeChange from Grade 0 to 2 at baseline to Grade 3 or 4 during the study. These data are presented in the form n/N, where n represents the number of patients who met the criterion as indicated, and N represents the number of patients who had a baseline observation and at least one post-baseline observation.
Laboratory Parameter Noxafil
n/N (%)
Voriconazole
n/N (%)
N=Number of subjects for a given laboratory test with a baseline value of CTC Grade 0, 1, or 2 and at least one post-baseline value.
CTC = Common Toxicity Criteria; AST= Aspartate Aminotransferase;
ALT= Alanine Aminotransferase.
   AST 22/281 (8) 21/285 (7)
   ALT 29/281(10) 23/282 (8)
   Bilirubin 26/280 (9) 25/284 (9)
   Alkaline Phosphatase 12/282 (4) 20/284 (7)

Clinical Trial Experience in Pediatrics

Clinical Trial Experience in Pediatric Patients (2 to less than 18 Years of Age)

The safety of Noxafil injection and Noxafil PowderMix for delayed-release oral suspension for prophylaxis of invasive fungal infections has been assessed in an open label uncontrolled dose-ranging PK and safety study (Noxafil injection/ Noxafil PowderMix for delayed-release oral suspension Pediatric Study 1, NCT02452034); hereinafter referred to as Noxafil Pediatric Study) in 115 immunocompromised pediatric patients 2 to less than 18 years of age with known or expected neutropenia. Noxafil injection and Noxafil PowderMix for delayed-release oral suspension was administered at daily doses of up to 6 mg/kg (twice daily on day 1) in three dose cohorts. All 115 subjects initially received Noxafil injection for at least 7 days, and 63 subjects were transitioned to Noxafil PowderMix for delayed-release oral suspension. The mean overall treatment duration for all treated subjects was 20.6 days with 14.3 days (range: 1 to 28 days) on Noxafil injection and 11.6 days (range: 2 to 18 days) on Noxafil PowderMix for delayed-release oral suspension [see Clinical Pharmacology (12.3)].

Table 15 presents adverse reactions observed in greater than or equal to 10% of pediatric patients treated with Noxafil in the Noxafil Pediatric Study.

Reported adverse reaction profile of Noxafil in pediatric patients was consistent with the safety profile of Noxafil in adults. The most common adverse reactions (occurring in greater than 20% of pediatric patients receiving 6 mg/kg Noxafil injection and Noxafil PowderMix for delayed-release oral suspension daily dose) were pyrexia, febrile neutropenia, vomiting, mucosal inflammation, pruritus, hypertension, hypokalemia, and stomatitis.

Table 15: Adverse Reactions in at Least 10% of Pediatric Patients Treated with Noxafil Injection and Noxafil PowderMix for Delayed-Release Oral Suspension
Adverse Reaction Noxafil Injection
and
Noxafil PowderMix for
Delayed-Release Oral
Suspension
6 mg/kg Dose Cohort
n=49 (%)
Noxafil Injection
and
Noxafil PowderMix for
Delayed-Release Oral
Suspension
All Dose Cohorts
n=115 (%)
Pyrexia 16 (33) 50 (43)
Febrile neutropenia 15 (31) 25 (22)
Vomiting 12 (24) 30 (26)
Mucosal inflammation 11 (22) 32 (28)
Pruritus 11 (22) 18 (16)
Hypertension 10 (20) 20 (17)
Hypokalemia 10 (20) 16 (14)
Stomatitis 10 (20) 13 (11)
Diarrhea 9 (18) 25 (22)
Nausea 9 (18) 18 (16)
Abdominal pain 8 (16) 20 (17)
Decreased appetite 7 (14) 17 (15)
Rash 7 (14) 18 (16)
Alanine aminotransferase increased 6 (12) 8 (7)
Headache 6 (12) 16 (14)
Aspartate aminotransferase increased 5 (10) 8 (7)

The number of patients receiving Noxafil in the Noxafil Pediatric Study who had changes in liver tests from Grade 0, 1, or 2 at baseline to Grade 3 or 4 is presented in Table 16 .

Table 16: Noxafil Pediatric Study: Changes in Liver Tests from CTC Grade 0, 1, or 2 at Baseline to Grade 3 or 4
Number (%) of Patients with ChangeChange from Grade 0 to 2 at baseline to Grade 3 or 4 during the study. These data are presented in the form X/Y, where X represents the number of patients who met the criterion as indicated, and Y represents the number of patients who had a baseline observation and at least one post-baseline observation.
Pediatric Study 1
Laboratory Parameter Noxafil Injection and Noxafil PowderMix for Delayed-
Release Oral Suspension (6 mg/kg daily)
n=49 (%)
CTC = Common Toxicity Criteria; AST= Aspartate Aminotransferase;
ALT= Alanine Aminotransferase
           AST 2/49 (4)
           ALT 3/49 (6)
           Bilirubin 0/48 (0)
           Alkaline Phosphatase 0/48 (0)

6.2 Postmarketing Experience

The following adverse reaction has been identified during the post-approval use of Noxafil. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency.

Endocrine Disorders: Pseudoaldosteronism

7 DRUG INTERACTIONS

Posaconazole is primarily metabolized via UDP glucuronosyltransferase and is a substrate of p-glycoprotein (P-gp) efflux. Therefore, inhibitors or inducers of these clearance pathways may affect posaconazole plasma concentrations. Coadministration of drugs that can decrease the plasma concentrations of posaconazole should generally be avoided unless the benefit outweighs the risk. If such drugs are necessary, patients should be monitored closely for breakthrough fungal infections.

Posaconazole is also a strong inhibitor of CYP3A4. Therefore, plasma concentrations of drugs predominantly metabolized by CYP3A4 may be increased by posaconazole [see Clinical Pharmacology (12.3)].

The following information was derived from data with Noxafil oral suspension or early tablet formulation unless otherwise noted. All drug interactions with Noxafil oral suspension, except for those that affect the absorption of posaconazole (via gastric pH and motility), are considered relevant to Noxafil injection, Noxafil delayed-release tablet, and Noxafil PowderMix for delayed-release oral suspension as well [see Drug Interactions (7.9) and (7.13)].

Interaction Drug Interaction
Rifabutin, phenytoin, efavirenz, cimetidine, esomeprazoleThe drug interactions with esomeprazole and metoclopramide do not apply to Noxafil tablets. Avoid coadministration unless the benefit outweighs the risks (7.6, 7.7, 7.8, 7.9)
Other drugs metabolized by CYP3A4 Consider dosage adjustment and monitor for adverse effects and toxicity (7.1, 7.10, 7.11)
Digoxin Monitor digoxin plasma concentrations (7.12)
Fosamprenavir, metoclopramide
Monitor for breakthrough fungal infections (7.6, 7.13)

7.1 Immunosuppressants Metabolized by CYP3A4

Sirolimus: Concomitant administration of Noxafil with sirolimus increases the sirolimus blood concentrations by approximately 9-fold and can result in sirolimus toxicity. Therefore, posaconazole is contraindicated with sirolimus [see Contraindications (4.2) and Clinical Pharmacology (12.3)].

Tacrolimus: Noxafil has been shown to significantly increase the Cmax and AUC of tacrolimus. At initiation of posaconazole treatment, reduce the tacrolimus dose to approximately one-third of the original dose. Frequent monitoring of tacrolimus whole blood trough concentrations should be performed during and at discontinuation of Noxafil treatment and the tacrolimus dose adjusted accordingly [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].

Cyclosporine: Noxafil has been shown to increase cyclosporine whole blood concentrations in heart transplant patients upon initiation of Noxafil treatment. It is recommended to reduce cyclosporine dose to approximately three-fourths of the original dose upon initiation of Noxafil treatment. Frequent monitoring of cyclosporine whole blood trough concentrations should be performed during and at discontinuation of Noxafil treatment and the cyclosporine dose adjusted accordingly [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].

7.2 CYP3A4 Substrates

Concomitant administration of Noxafil with CYP3A4 substrates such as pimozide and quinidine may result in increased plasma concentrations of these drugs, leading to QTc prolongation and cases of torsades de pointes. Therefore, Noxafil is contraindicated with these drugs [see Contraindications (4.3) and Warnings and Precautions (5.2)].

7.3 HMG-CoA Reductase Inhibitors (Statins) Primarily Metabolized Through CYP3A4

Concomitant administration of Noxafil with simvastatin increases the simvastatin plasma concentrations by approximately 10-fold. Therefore, Noxafil is contraindicated with HMG-CoA reductase inhibitors primarily metabolized through CYP3A4 [see Contraindications (4.4) and Clinical Pharmacology (12.3)].

7.4 Ergot Alkaloids

Most of the ergot alkaloids are substrates of CYP3A4. Noxafil may increase the plasma concentrations of ergot alkaloids (ergotamine and dihydroergotamine) which may lead to ergotism. Therefore, Noxafil is contraindicated with ergot alkaloids [see Contraindications (4.5)].

7.5 Benzodiazepines Metabolized by CYP3A4

Concomitant administration of Noxafil with midazolam increases the midazolam plasma concentrations by approximately 5-fold. Increased plasma midazolam concentrations could potentiate and prolong hypnotic and sedative effects. Concomitant use of Noxafil and other benzodiazepines metabolized by CYP3A4 (e.g., alprazolam, triazolam) could result in increased plasma concentrations of these benzodiazepines. Patients must be monitored closely for adverse effects associated with high plasma concentrations of benzodiazepines metabolized by CYP3A4 and benzodiazepine receptor antagonists must be available to reverse these effects [see Warnings and Precautions (5.6) and Clinical Pharmacology (12.3)].

7.6 Anti-HIV Drugs

Efavirenz: Efavirenz induces UDP-glucuronidase and significantly decreases posaconazole plasma concentrations [see Clinical Pharmacology (12.3)]. It is recommended to avoid concomitant use of efavirenz with Noxafil unless the benefit outweighs the risks.

Ritonavir and Atazanavir: Ritonavir and atazanavir are metabolized by CYP3A4 and Noxafil increases plasma concentrations of these drugs [see Clinical Pharmacology (12.3)]. Frequent monitoring of adverse effects and toxicity of ritonavir and atazanavir should be performed during coadministration with Noxafil.

Fosamprenavir: Combining fosamprenavir with Noxafil may lead to decreased posaconazole plasma concentrations. If concomitant administration is required, close monitoring for breakthrough fungal infections is recommended [see Clinical Pharmacology (12.3)].

7.7 Rifabutin

Rifabutin induces UDP-glucuronidase and decreases posaconazole plasma concentrations. Rifabutin is also metabolized by CYP3A4. Therefore, coadministration of rifabutin with Noxafil increases rifabutin plasma concentrations [see Clinical Pharmacology (12.3)]. Concomitant use of Noxafil and rifabutin should be avoided unless the benefit to the patient outweighs the risk. However, if concomitant administration is required, close monitoring for breakthrough fungal infections as well as frequent monitoring of full blood counts and adverse reactions due to increased rifabutin plasma concentrations (e.g., uveitis, leukopenia) are recommended.

7.8 Phenytoin

Phenytoin induces UDP-glucuronidase and decreases posaconazole plasma concentrations. Phenytoin is also metabolized by CYP3A4. Therefore, coadministration of phenytoin with Noxafil increases phenytoin plasma concentrations [see Clinical Pharmacology (12.3)]. Concomitant use of Noxafil and phenytoin should be avoided unless the benefit to the patient outweighs the risk. However, if concomitant administration is required, close monitoring for breakthrough fungal infections is recommended and frequent monitoring of phenytoin concentrations should be performed while coadministered with Noxafil and dose reduction of phenytoin should be considered.

7.9 Gastric Acid Suppressors/Neutralizers

Noxafil Delayed-Release Tablet and Noxafil PowderMix for Delayed-Release Oral Suspension:

No clinically relevant effects on the pharmacokinetics of posaconazole were observed when Noxafil delayed-release tablets are concomitantly used with antacids, H2-receptor antagonists and proton pump inhibitors [see Clinical Pharmacology (12.3)]. No dosage adjustment of Noxafil delayed-release tablets or Noxafil PowderMix for delayed-release oral suspension is required when concomitantly used with antacids, H2-receptor antagonists and proton pump inhibitors.

Noxafil Oral Suspension:

Cimetidine (an H2-receptor antagonist) and esomeprazole (a proton pump inhibitor) when given with Noxafil oral suspension results in decreased posaconazole plasma concentrations [see Clinical Pharmacology (12.3)]. It is recommended to avoid concomitant use of cimetidine and esomeprazole with Noxafil oral suspension unless the benefit outweighs the risks. However, if concomitant administration is required, close monitoring for breakthrough fungal infections is recommended.

No clinically relevant effects were observed when Noxafil oral suspension is concomitantly used with antacids and H2-receptor antagonists other than cimetidine. No dosage adjustment of Noxafil oral suspension is required when Noxafil oral suspension is concomitantly used with antacids and H2-receptor antagonists other than cimetidine.

7.10 Vinca Alkaloids

Most of the vinca alkaloids (e.g., vincristine and vinblastine) are substrates of CYP3A4. Concomitant administration of azole antifungals, including Noxafil, with vincristine has been associated with serious adverse reactions [see Warnings and Precautions (5.7)]. Noxafil may increase the plasma concentrations of vinca alkaloids which may lead to neurotoxicity and other serious adverse reactions. Therefore, reserve azole antifungals, including Noxafil, for patients receiving a vinca alkaloid, including vincristine, who have no alternative antifungal treatment options.

7.11 Calcium Channel Blockers Metabolized by CYP3A4

Noxafil may increase the plasma concentrations of calcium channel blockers metabolized by CYP3A4 (e.g., verapamil, diltiazem, nifedipine, nicardipine, felodipine). Frequent monitoring for adverse reactions and toxicity related to calcium channel blockers is recommended during coadministration. Dose reduction of calcium channel blockers may be needed.

7.12 Digoxin

Increased plasma concentrations of digoxin have been reported in patients receiving digoxin and Noxafil. Therefore, monitoring of digoxin plasma concentrations is recommended during coadministration.

7.13 Gastrointestinal Motility Agents

Noxafil Delayed-Release Tablet and Noxafil PowderMix for Delayed-Release Oral Suspension:

Concomitant administration of metoclopramide with Noxafil delayed-release tablets did not affect the pharmacokinetics of posaconazole [see Clinical Pharmacology (12.3)]. No dosage adjustment of Noxafil delayed-release tablets or Noxafil PowderMix for delayed-release oral suspension is required when given concomitantly with metoclopramide.

Noxafil Oral Suspension:

Metoclopramide, when given with Noxafil oral suspension, decreases posaconazole plasma concentrations [see Clinical Pharmacology (12.3)]. If metoclopramide is concomitantly administered with Noxafil oral suspension, it is recommended to closely monitor for breakthrough fungal infections.

Loperamide does not affect posaconazole plasma concentrations after Noxafil oral suspension administration [see Clinical Pharmacology (12.3)]. No dosage adjustment of Noxafil oral suspension is required when loperamide and Noxafil oral suspension are used concomitantly.

7.14 Glipizide

Although no dosage adjustment of glipizide is required, it is recommended to monitor glucose concentrations when Noxafil and glipizide are concomitantly used.

7.15 Alcohol

Posaconazole was found to release faster from Noxafil PowderMix for delayed-release oral suspension in the presence of alcohol in vitro, which may interfere with its delayed release characteristics. Administration of Noxafil PowderMix for delayed-release oral suspension with alcohol is not recommended [see Clinical Pharmacology (12.3)].

7.16 Venetoclax

Concomitant use of venetoclax (a CYP3A4 substrate) with posaconazole increases venetoclax Cmax and AUC0-INF, which may increase venetoclax toxicities [see Contraindications (4.6), Warnings and Precautions (5.10)]. Refer to the venetoclax prescribing information for more information on the dosing instructions and the extent of increase in venetoclax exposure.

8 USE IN SPECIFIC POPULATIONS

  • Pregnancy: Based on animal data, may cause fetal harm. (8.1)
  • Pediatrics: Safety and effectiveness in patients younger than 2 years of age have not been established. (8.4)
  • Severe Renal Impairment: Monitor closely for breakthrough fungal infections. (8.6)

8.1 Pregnancy

Risk Summary

Based on findings from animal data, Noxafil may cause fetal harm when administered to pregnant women. Available data for use of Noxafil in pregnant women are insufficient to establish a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. In animal reproduction studies, skeletal malformations (cranial malformations and missing ribs) and maternal toxicity (reduced food consumption and reduced body weight gain) were observed when posaconazole was dosed orally to pregnant rats during organogenesis at doses ≥1.4 times the 400 mg twice daily oral suspension regimen based on steady-state plasma concentrations of Noxafil in healthy volunteers. In pregnant rabbits dosed orally during organogenesis, increased resorptions, reduced litter size, and reduced body weight gain of females were seen at doses 5 times the exposure achieved with the 400 mg twice daily oral suspension regimen. Doses of ≥ 3 times the clinical exposure caused an increase in resorptions in these rabbits (see Data). Based on animal data, advise pregnant women of the potential risk to a fetus.

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 miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Data

Animal Data

Posaconazole resulted in maternal toxicity (reduced food consumption and reduced body weight gain) and skeletal malformations (cranial malformations and missing ribs) when given orally to pregnant rats during organogenesis (Gestational Days 6 through 15) at doses ≥27 mg/kg (≥1.4 times the 400 mg twice daily oral suspension regimen based on steady-state plasma concentrations of drug in healthy volunteers). The no-effect dose for malformations and maternal toxicity in rats was 9 mg/kg, which is 0.7 times the exposure achieved with the 400 mg twice daily oral suspension regimen. No malformations were seen in rabbits dosed during organogenesis (Gestational Days 7 through 19) at doses up to 80 mg/kg (5 times the exposure achieved with the 400 mg twice daily oral suspension regimen). In the rabbit, the no-effect dose was 20 mg/kg, while high doses of 40 mg/kg and 80 mg/kg (3 or 5 times the clinical exposure) caused an increase in resorptions. In rabbits dosed at 80 mg/kg, a reduction in body weight gain of females and a reduction in litter size were seen.

8.2 Lactation

Risk Summary

There are no data on the presence of posaconazole in human milk, the effects on the breastfed infant, or the effects on milk production. Posaconazole is excreted in the milk of lactating rats. When a drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Noxafil and any potential adverse effects on the breastfed child from Noxafil or from the underlying maternal condition.

8.4 Pediatric Use

The safety and effectiveness of Noxafil injection, Noxafil delayed-release tablets, Noxafil PowderMix for delayed-release oral suspension, and Noxafil oral suspension for the prophylaxis of invasive Aspergillus and Candida infections have been established in pediatric patients aged 2 and older who are at high risk of developing these infections due to being severely immunocompromised, such as HSCT recipients with GVHD or those with hematologic malignancies with prolonged neutropenia from chemotherapy.

The safety and effectiveness of Noxafil injection and Noxafil delayed-release tablets for the treatment of invasive aspergillosis have been established in pediatric patients aged 13 years and older.

The safety and effectiveness of Noxafil oral suspension have been established for the treatment of oropharyngeal candidiasis (OPC), including OPC refractory (rOPC) to itraconazole and/or fluconazole in pediatric patients aged 13 years and older.

Use of Noxafil in these age groups is supported by evidence from adequate and well-controlled studies of Noxafil in adult and pediatric patients and additional pharmacokinetic and safety data in pediatric patients 2 years of age and older [see Adverse Reactions (6.1), Clinical Pharmacology (12.3) and Clinical Studies (14)].

The safety and effectiveness of Noxafil have not been established in pediatric patients younger than 2 years of age.

Noxafil PowderMix for delayed-release oral suspension is not recommended for use in patients who weigh greater than 40 kg because the recommended dosage cannot be achieved with this formulation.

Noxafil PowderMix for delayed-release oral suspension is contraindicated in patients with HFI. Because a diagnosis of HFI may not yet be established in pediatric patients, obtain a careful history of HFI symptoms with sorbitol/fructose/sucrose exposure prior to administration of Noxafil PowderMix for delayed-release oral suspension [see Warnings and Precautions (5.8)].

8.5 Geriatric Use

No overall differences in the safety of Noxafil injection, Noxafil delayed-release tablets, and Noxafil oral suspension were observed between geriatric patients and younger adult patients in the clinical trials; therefore, no dosage adjustment is recommended for any formulation of Noxafil in geriatric patients. No clinically meaningful differences in the pharmacokinetics of Noxafil were observed in geriatric patients compared to younger adult patients during clinical trials [see Clinical Pharmacology (12.3)].

Of the 279 patients treated with Noxafil injection in the Noxafil Injection Study, 52 (19%) were greater than 65 years of age. Of the 230 patients treated with Noxafil delayed-release tablets, 38 (17%) were greater than 65 years of age. Of the 605 patients randomized to Noxafil oral suspension in Noxafil Oral Suspension Study 1 and Study 2, 63 (10%) were ≥65 years of age. In addition, 48 patients treated with greater than or equal to 800-mg/day Noxafil oral suspension in another indication were ≥65 years of age. Of the 288 patients randomized to Noxafil injection/Noxafil delayed-release tablets in the Aspergillosis Treatment Study, 85 (29%) were ≥65 years of age.

No overall differences in the pharmacokinetics and safety were observed between elderly and young subjects during clinical trials, but greater sensitivity of some older individuals cannot be ruled out.

8.6 Renal Impairment

Following single-dose administration of 400 mg of the Noxafil oral suspension, there was no significant effect of mild (eGFR: 50-80 mL/min/1.73 m2, n=6) or moderate (eGFR: 20-49 mL/min/1.73 m2, n=6) renal impairment on posaconazole pharmacokinetics; therefore, no dose adjustment is required in patients with mild to moderate renal impairment. In subjects with severe renal impairment (eGFR: <20 mL/min/1.73 m2), the mean plasma exposure (AUC) was similar to that in patients with normal renal function (eGFR: >80 mL/min/1.73 m2); however, the range of the AUC estimates was highly variable (CV=96%) in these subjects with severe renal impairment as compared to that in the other renal impairment groups (CV<40%). Due to the variability in exposure, patients with severe renal impairment should be monitored closely for breakthrough fungal infections [see Dosage and Administration (2)]. Similar recommendations apply to Noxafil delayed-release tablets; however, a specific study has not been conducted with the Noxafil delayed-release tablets.

Noxafil injection should be avoided in patients with moderate or severe renal impairment (eGFR <50 mL/min), unless an assessment of the benefit/risk to the patient justifies the use of Noxafil injection. In patients with moderate or severe renal impairment (eGFR <50 mL/min), receiving the Noxafil injection, accumulation of the intravenous vehicle, SBECD, is expected to occur. Serum creatinine levels should be closely monitored in these patients, and, if increases occur, consideration should be given to changing to oral Noxafil therapy [see Dosage and Administration (2.9) and Warnings and Precautions (5.5)].

8.7 Hepatic Impairment

After a single oral dose of Noxafil oral suspension 400 mg, the mean AUC was 43%, 27%, and 21% higher in subjects with mild (Child-Pugh Class A, N=6), moderate (Child-Pugh Class B, N=6), or severe (Child-Pugh Class C, N=6) hepatic impairment, respectively, compared to subjects with normal hepatic function (N=18). Compared to subjects with normal hepatic function, the mean Cmax was 1% higher, 40% higher, and 34% lower in subjects with mild, moderate, or severe hepatic impairment, respectively. The mean apparent oral clearance (CL/F) was reduced by 18%, 36%, and 28% in subjects with mild, moderate, or severe hepatic impairment, respectively, compared to subjects with normal hepatic function. The elimination half-life (t½) was 27 hours, 39 hours, 27 hours, and 43 hours in subjects with normal hepatic function and mild, moderate, or severe hepatic impairment, respectively.

It is recommended that no dose adjustment of Noxafil oral suspension, Noxafil delayed-release tablets, Noxafil PowderMix for delayed-release oral suspension, and Noxafil injection is needed in patients with mild to severe hepatic impairment (Child-Pugh Class A, B, or C) [see Dosage and Administration (2) and Warnings and Precautions (5.4)]. However, a specific study has not been conducted with Noxafil delayed-release tablets, Noxafil PowderMix for delayed-release oral suspension, and Noxafil injection.

8.8 Gender

The pharmacokinetics of posaconazole are comparable in males and females. No adjustment in the dosage of Noxafil is necessary based on gender.

8.9 Race

The pharmacokinetic profile of posaconazole is not significantly affected by race. No adjustment in the dosage of Noxafil is necessary based on race.

8.10 Weight

Pharmacokinetic modeling suggests that patients weighing greater than 120 kg may have lower posaconazole plasma drug exposure. It is, therefore, suggested to closely monitor for breakthrough fungal infections particularly when using Noxafil oral suspension [see Clinical Pharmacology (12.3)].

10 OVERDOSAGE

There is no experience with overdosage of Noxafil injection and Noxafil delayed-release tablets.

During the clinical trials, some patients received Noxafil oral suspension up to 1600 mg/day with no adverse reactions noted that were different from the lower doses. In addition, accidental overdose was noted in one patient who took 1200 mg twice daily Noxafil oral suspension for 3 days. No related adverse reactions were noted by the investigator.

Posaconazole is not removed by hemodialysis.

11 DESCRIPTION

Noxafil (posaconazole) is an azole antifungal agent. Noxafil is available as an injection solution to be diluted before intravenous administration, delayed-release tablet, oral suspension, and for delayed-release oral suspension intended for oral administration. Noxafil PowderMix for delayed-release oral suspension must be reconstituted before oral administration.

Posaconazole is designated chemically as 4-[4-[4-[4-[[ (3R,5R)-5- (2,4-difluorophenyl)tetrahydro-5- (1H-1,2,4-triazol-1-ylmethyl)-3-furanyl]methoxy]phenyl]-1-piperazinyl]phenyl]-2-[(1S,2S)-1-ethyl-2-hydroxypropyl]-2,4-dihydro-3H-1,2,4-triazol-3-one with an empirical formula of C37H42F2N8O4 and a molecular weight of 700.8. The chemical structure is:

Chemical Structure

Posaconazole is a white powder with a low aqueous solubility.

Noxafil Injection

Noxafil injection is available as a clear colorless to yellow, sterile liquid essentially free of foreign matter. Each vial contains 300 mg of posaconazole and the following inactive ingredients: 6.68 g Betadex Sulfobutyl Ether Sodium (SBECD), 0.0033 g edetate disodium, hydrochloric acid and sodium hydroxide to adjust the pH to 2.6, and water for injection.

Noxafil Delayed-Release Tablets

Noxafil delayed-release tablet is a yellow, coated, oblong tablet containing 100 mg of posaconazole. Each delayed-release tablet contains the inactive ingredients: croscarmellose sodium, hydroxypropylcellulose, hypromellose acetate succinate, iron oxide yellow, Macrogol/PEG 3350, magnesium stearate, microcrystalline cellulose, polyvinyl alcohol partially hydrolyzed, silicon dioxide, talc, and titanium dioxide.

Noxafil Oral Suspension

Noxafil oral suspension is a white, cherry-flavored immediate-release suspension containing 40 mg of posaconazole per mL and the following inactive ingredients: artificial cherry flavor, citric acid monohydrate, glycerin, liquid glucose, polysorbate 80, purified water, simethicone, sodium benzoate, sodium citrate dihydrate, titanium dioxide, and xanthan gum.

Noxafil PowderMix for Delayed-Release Oral Suspension

Noxafil PowderMix for delayed-release oral suspension is supplied as a component of a kit. Each kit contains Noxafil as an off-white to yellowish powder for delayed-release oral suspension, a bottle of mixing liquid, two 3 mL (green) notched tip syringes, two 10 mL (blue) notched tip syringes, two mixing cups, and one bottle adapter for the mixing liquid bottle. Noxafil PowderMix for delayed-release oral suspension contains 300 mg of posaconazole and the following inactive ingredient: hypromellose acetate succinate. The mixing liquid contains: anhydrous citric acid, antifoam Af emulsion, berry citrus sweet flavor, carboxymethylcellulose sodium, carrageenan calcium sulfate trisodium phosphate, glycerin, methylparaben, microcrystalline cellulose, potassium sorbate, propylparaben, purified water, sodium citrate, sodium phosphate monobasic monohydrate, sodium saccharin, sorbitol solution, and xanthan gum. Once reconstituted, the Noxafil PowderMix for delayed-release oral suspension will be cloudy and free of clumps.

Chemical Structure

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Posaconazole is an azole antifungal agent [see Clinical Pharmacology (12.4)].

12.2 Pharmacodynamics

Exposure Response Relationship Prophylaxis: In clinical studies of neutropenic patients who were receiving cytotoxic chemotherapy for acute myelogenous leukemia (AML) or myelodysplastic syndromes (MDS) or hematopoietic stem cell transplant (HSCT) recipients with Graft versus Host Disease (GVHD), a wide range of plasma exposures to posaconazole was noted following administration of Noxafil oral suspension. A pharmacokinetic-pharmacodynamic analysis of patient data revealed an apparent association between average posaconazole concentrations (Cavg) and prophylactic efficacy ( Table 17 ). A lower Cavg may be associated with an increased risk of treatment failure, defined as treatment discontinuation, use of empiric systemic antifungal therapy (SAF), or occurrence of breakthrough invasive fungal infections.

Table 17: Noxafil Oral Suspension Exposure Analysis (Cavg) in Prophylaxis Trials
Prophylaxis in AML/MDSNeutropenic patients who were receiving cytotoxic chemotherapy for AML or MDS Prophylaxis in GVHDHSCT recipients with GVHD
Cavg Range (ng/mL) Treatment FailureDefined as treatment discontinuation, use of empiric systemic antifungal therapy (SAF), or occurrence of breakthrough invasive fungal infections (%) Cavg Range (ng/mL) Treatment Failure
(%)
Cavg = the average posaconazole concentration when measured at steady state
Quartile 1 90-322 54.7 22-557 44.4
Quartile 2 322-490 37.0 557-915 20.6
Quartile 3 490-734 46.8 915-1563 17.5
Quartile 4 734-2200 27.8 1563-3650 17.5

Exposure Response Relationship Treatment of Invasive Aspergillosis :

Across a range of posaconazole plasma minimum concentrations (Cmin, range: 244 to 5663 ng/mL) following administration of Noxafil injection and Noxafil delayed-release tablets in patients treated for invasive aspergillosis in Aspergillosis Treatment Study, there was no association between posaconazole Cmin and treatment efficacy [see Clinical Pharmacology (12.3) and Clinical Studies (14.1)]. Similarly, across a range of population pharmacokinetic model-predicted steady-state plasma average concentrations (Cavg, range: 589 to 6315 ng/mL), there was no association between posaconazole Cavg and treatment efficacy.

12.3 Pharmacokinetics

General Pharmacokinetic Characteristics

Noxafil Injection

Noxafil injection exhibits dose proportional pharmacokinetics after single doses between 200 and 300 mg in healthy volunteers and patients. The mean pharmacokinetic parameters after single doses with Noxafil injection in healthy volunteers and patients are shown in Table 18 .

Table 18: Summary of Mean Pharmacokinetic Parameters (%CV) in Healthy Volunteers (30-minute infusion via peripheral venous line) and Patients (90 minute infusion via central venous line) after Dosing with Noxafil Injection on Day 1
Dose (mg) n AUC0-∞
(ng∙hr/mL)
AUC0-12
(ng∙hr/mL)
Cmax
(ng/mL)
t1/2
(hr)
CL
(L/hr)
AUC0-∞ = Area under the plasma concentration-time curve from time zero to infinity; AUC0-12 = Area under the plasma concentration-time curve from time zero to 12 hr after the first dose on Day 1; Cmax = maximum observed concentration; t½ = terminal phase half-life; CL = total body clearance; N/D = Not Determined
Healthy Volunteers 200 9 35400 (50) 8840 (20) 2250 (29) 23.6 (23) 6.5 (32)
300 9 46400 (26) 13000 (13) 2840 (30) 24.6 (20) 6.9 (27)
Patients 200 30 N/D 5570 (32) 954 (44) N/D N/D
300 22 N/D 8240 (26) 1590 (62) N/D N/D

Table 19 displays the pharmacokinetic parameters of posaconazole in patients following administration of Noxafil injection 300 mg taken once a day for 10 or 14 days following twice daily dosing on Day 1.

Table 19: Arithmetic Mean (%CV) of PK Parameters in Serial PK-Evaluable Patients Following Dosing of Noxafil Injection (300 mg)300 mg dose administered over 90 minutes once a day following twice daily dosing on Day 1
Day N Cmax
(ng/mL)
Tmax Median (minimum-maximum)
(hr)
AUC0-24
(ng*hr/mL)
Cav
(ng/mL)
Cmin
(ng/mL)
AUC0-24 = area under the concentration-time curve over the dosing interval (i.e. 24 hours); Cav= time-averaged concentrations (i.e., AUC0-24h/24hr);
Cmin = POS trough level immediately before a subject received the dose of POS on the day specified in the protocol; Cmax = observed maximum plasma concentration; CV = coefficient of variation, expressed as a percent (%); Day = study day on treatment; Tmax = time of observed maximum plasma concentration.
10/14 49 3280 (74) 1.5 (0.98-4.0) 36100 (35) 1500 (35) 1090 (44)

Noxafil Delayed-Release Tablets

Noxafil delayed-release tablets exhibit dose proportional pharmacokinetics after single and multiple dosing up to 300 mg. The mean pharmacokinetic parameters of posaconazole at steady state following administration of Noxafil delayed-release tablets 300 mg twice daily on Day 1, then 300 mg once daily thereafter in healthy volunteers and in neutropenic patients who are receiving cytotoxic chemotherapy for AML or MDS or HSCT recipients with GVHD are shown in Table 20 .

Table 20: Arithmetic Mean (%CV) of Steady State PK Parameters in Healthy Volunteers and Patients Following Administration of Noxafil Delayed-Release Tablets (300 mg)300 mg twice daily on Day 1, then 300 mg once daily thereafter
N AUC0-24 hr
(ng∙hr/mL)
CavCav = time-averaged concentrations (i.e., AUC0-24 hr/24hr)
(ng/mL)
Cmax
(ng/mL)
Cmin
(ng/mL)
Tmax Median (minimum-maximum)
(hr)
t1/2
(hr)
CL/F
(L/hr)
CV = coefficient of variation expressed as a percentage (%CV); AUC0-T = Area under the plasma concentration-time curve from time zero to 24 hr; Cmax = maximum observed concentration; Cmin = minimum observed plasma concentration; Tmax = time of maximum observed concentration; t½ = terminal phase half-life; CL/F = Apparent total body clearance
Healthy Volunteers 12 51618
(25)
2151
(25)
2764
(21)
1785
(29)
4
(3-6)
31
(40)
7.5
(26)
Patients 50 37900
(42)
1580
(42)
2090
(38)
1310
(50)
4 (1.3-8.3) - 9.39
(45)

Noxafil Oral Suspension

Dose-proportional increases in plasma exposure (AUC) to Noxafil oral suspension were observed following single oral doses from 50 mg to 800 mg and following multiple-dose administration from 50 mg twice daily to 400 mg twice daily in healthy volunteers. No further increases in exposure were observed when the dose of the oral suspension increased from 400 mg twice daily to 600 mg twice daily in febrile neutropenic patients or those with refractory invasive fungal infections.

The mean (%CV) [min-max] Noxafil oral suspension average steady-state plasma concentrations (Cavg) and steady-state pharmacokinetic parameters in patients following administration of 200 mg three times a day and 400 mg twice daily of the oral suspension are provided in Table 21.

Table 21: The Mean (%CV) [min-max] Posaconazole Steady-State Pharmacokinetic Parameters in Patients Following Oral Administration of Noxafil Oral Suspension 200 mg Three Times a Day and 400 mg Twice Daily
DoseOral suspension administration Cavg (ng/mL) AUCAUC (0-24 hr) for 200 mg three times a day and AUC (0-12 hr) for 400 mg twice daily (ng∙hr/mL) CL/F (L/hr) V/F (L) t½ (hr)
Cavg = the average posaconazole concentration when measured at steady state
The variability in average plasma posaconazole concentrations in patients was relatively higher than that in healthy subjects.
200 mg three times a dayHSCT recipients with GVHD (n=252) 1103 (67)
[21.5-3650]
NDNot done ND
ND
ND
200 mg three times a dayNeutropenic patients who were receiving cytotoxic chemotherapy for acute myelogenous leukemia or myelodysplastic syndromes (n=215) 583 (65)
[89.7-2200]
15,900 (62)
[4100-56,100]
51.2 (54)
[10.7-146]
2425 (39)
[828-5702]
37.2 (39)
[19.1-148]
400 mg twice dailyFebrile neutropenic patients or patients with refractory invasive fungal infections, Cavg n=24 (n=23) 723 (86)
[6.70-2256]
9093 (80)
[1564-26,794]
76.1 (78)
[14.9-256]
3088 (84)
[407-13,140]
31.7 (42)
[12.4-67.3]

Absorption:

Noxafil Delayed-Release Tablets

When given orally in healthy volunteers, Noxafil delayed-release tablets are absorbed with a median Tmax of 4 to 5 hours. Steady-state plasma concentrations are attained by Day 6 at the 300 mg dose (once daily after twice daily loading dose at Day 1). The absolute bioavailability of the oral delayed-release tablet is approximately 54% under fasted conditions. The Cmax and AUC of posaconazole following administration of Noxafil delayed-release tablets is increased 16% and 51%, respectively, when given with a high fat meal compared to a fasted state (see Table 22 ).

Table 22: Statistical Comparison of Plasma Pharmacokinetics of Posaconazole Following Single Oral Dose Administration of 300 mg Noxafil Delayed-Release Tablet to Healthy Subjects under Fasting and Fed Conditions
Fasting Conditions Fed Conditions (High Fat Meal)48.5 g fat Fed/Fasting
Pharmacokinetic Parameter N Mean (%CV) N Mean (%CV) GMR (90% CI)
GMR=Geometric least-squares mean ratio; CI=Confidence interval
Cmax (ng/mL) 14 935 (34) 16 1060 (25) 1.16 (0.96, 1.41)
AUC0-72hr (hr∙ng/mL) 14 26200 (28) 16 38400 (18) 1.51 (1.33, 1.72)
Tmax Median (Min, Max) reported for Tmax (hr) 14 5.00
(3.00, 8.00)
16 6.00
(5.00, 24.00)
N/A

Concomitant administration of Noxafil delayed-release tablets with drugs affecting gastric pH or gastric motility did not demonstrate any significant effects on posaconazole pharmacokinetic exposure (see Table 23 ).

Table 23: The Effect of Concomitant Medications that Affect the Gastric pH and Gastric Motility on the Pharmacokinetics of Noxafil Delayed-Release Tablets in Healthy Volunteers
Coadministered Drug Administration Arms Change in Cmax
(ratio estimateRatio Estimate is the ratio of coadministered drug plus Noxafil to Noxafil alone for Cmax or AUC0-last. ;
90% CI of the ratio estimate)
Change in AUC0-last
(ratio estimate
;
90% CI of the ratio estimate)
Mylanta® Ultimate strength liquid (Increase in gastric pH) 25.4 meq/5 mL, 20 mL ↑6%
(1.06; 0.90 -1.26)↑
↑4%
(1.04; 0.90 -1.20)
Ranitidine (Zantac®) (Alteration in gastric pH) 150 mg (morning dose of 150 mg Ranitidine twice daily) ↑4%
(1.04; 0.88 -1.23)↑
↓3%
(0.97; 0.84 -1.12)
Esomeprazole (Nexium®) (Increase in gastric pH) 40 mg (every morning for 5 days, Day -4 to 1) ↑2%
(1.02; 0.88-1.17)↑
↑5%
(1.05; 0.89 -1.24)
Metoclopramide (Reglan®) (Increase in gastric motility) 15 mg four times daily for 2 days (Day -1 and 1) ↓14%
(0.86, 0.73,1.02)
↓7%
(0.93, 0.803,1.07)

Noxafil PowderMix for Delayed-Release Oral Suspension

The absolute bioavailability of the Noxafil PowderMix for delayed-release oral suspension is approximately 70-80%. The effect of food on the pharmacokinetics of the Noxafil PowderMix for delayed-release oral suspension has not been determined.

Concomitant administration of Noxafil PowderMix for delayed-release oral suspension with drugs affecting gastric pH or gastric motility would not be expected to demonstrate any significant effects on posaconazole pharmacokinetic exposure based on similarity to the delayed-release tablets.

An in vitro dissolution study was conducted to evaluate the impact of alcohol (5, 10, 20, and 40%) on the dissolution of Noxafil PowderMix delayed-release oral suspension. The study showed alcohol-induced dose-dumping potential with the Noxafil PowderMix delayed-release oral suspension [see Dosage and Administration (2.1) and Drug Interactions (7.15)].

Noxafil Oral Suspension

Noxafil oral suspension is absorbed with a median Tmax of ~3 to 5 hours. Steady-state plasma concentrations are attained at 7 to 10 days following multiple-dose administration.

Following single-dose administration of 200 mg, the mean AUC and Cmax of posaconazole are approximately 3-times higher when the oral suspension is administered with a nonfat meal and approximately 4-times higher when administered with a high-fat meal (~50 gm fat) relative to the fasted state. Following single-dose administration of Noxafil oral suspension 400 mg, the mean AUC and Cmax of posaconazole are approximately 3-times higher when administered with a liquid nutritional supplement (14 gm fat) relative to the fasted state (see Table 24 ). In addition, the effects of varying gastric administration conditions on the Cmax and AUC of Noxafil oral suspension in healthy volunteers have been investigated and are shown in Table 25 .

In order to assure attainment of adequate plasma concentrations, it is recommended to administer Noxafil oral suspension during or immediately following a full meal. In patients who cannot eat a full meal, Noxafil oral suspension should be taken with a liquid nutritional supplement or an acidic carbonated beverage (e.g., ginger ale).

Table 24: The Mean (%CV) [min-max] Posaconazole Pharmacokinetic Parameters Following Single-Dose Noxafil Oral Suspension Administration of 200 mg and 400 mg Under Fed and Fasted Conditions
Dose (mg) Cmax
(ng/mL)
Tmax Median [min-max].
(hr)
AUC (I)
(ng∙hr/mL)
CL/F
(L/hr)
t½
(hr)
200 mg fasted
(n=20)n=15 for AUC (I), CL/F, and t½
132 (50)
[45-267]
3.50
[1.5-36The subject with Tmax of 36 hrs had relatively constant plasma levels over 36 hrs (1.7 ng/mL difference between 4 hrs and 36 hrs).]
4179 (31)
[2705-7269]
51 (25)
[28-74]
23.5 (25)
[15.3-33.7]
200 mg nonfat
(n=20)
378 (43)
[131-834]
4 [3-5] 10,753 (35)
[4579-17,092]
21 (39)
[12-44]
22.2 (18)
[17.4-28.7]
200 mg high fat
(54 gm fat)
(n=20)
512 (34)
[241-1016]
5 [4-5] 15,059 (26)
[10,341-24,476]
14 (24)
[8.2-19]
23.0 (19)
[17.2-33.4]
400 mg fasted
(n=23)n=10 for AUC (I), CL/F, and t½
121 (75)
[27-366]
4 [2-12] 5258 (48)
[2834-9567]
91 (40)
[42-141]
27.3 (26)
[16.8-38.9]
400 mg with liquid nutritional supplement
(14 gm fat)
(n=23)
355 (43)
[145-720]
5 [4-8] 11,295 (40)
[3865-20,592]
43 (56)
[19-103]
26.0 (19)
[18.2-35.0]
Table 25: The Effect of Varying Gastric Administration Conditions on the Cmax and AUC of Noxafil Oral Suspension in Healthy VolunteersIn 5 subjects, the Cmax and AUC decreased substantially (range: -27% to -53% and -33% to -51%, respectively) when Noxafil was administered via an NG tube compared to when Noxafil was administered orally. It is recommended to closely monitor patients for breakthrough fungal infections when Noxafil is administered via an NG tube because a lower plasma exposure may be associated with an increased risk of treatment failure.
Study Description Administration Arms Change in Cmax
(ratio estimateRatio Estimate is the ratio of coadministered drug plus Noxafil to coadministered drug alone for Cmax or AUC.;
90% CI of the ratio estimate)
Change in AUC
(ratio estimate
;
90% CI of the ratio estimate)
400-mg single dose with a high-fat meal relative to fasted state (n=12)
5 minutes before high-fat meal ↑96%
(1.96; 1.48-2.59)
↑111%
(2.11; 1.60-2.78)
During high-fat meal ↑339%
(4.39; 3.32-5.80)
↑382%
(4.82; 3.66-6.35)
20 minutes after high-fat meal ↑333%
(4.33; 3.28-5.73)
↑387%
(4.87; 3.70-6.42)
400 mg twice daily and 200 mg four times daily for 7 days in fasted state and with liquid nutritional supplement (BOOST®) (n=12) 400 mg twice daily with BOOST ↑65%
(1.65; 1.29-2.11)
↑66%
(1.66; 1.30-2.13)
200 mg four times daily with BOOST No Effect No Effect
Divided daily dose from 400 mg twice daily to 200 mg four times daily for 7 days regardless of fasted conditions or with BOOST (n=12) Fasted state ↑136%
(2.36; 1.84-3.02)
↑161%
(2.61; 2.04-3.35)
With BOOST ↑137%
(2.37; 1.86-3.04)
↑157%
(2.57; 2.00-3.30)
400-mg single dose with carbonated acidic beverage (ginger ale) and/or proton pump inhibitor (esomeprazole) (n=12) Ginger ale ↑92%
(1.92; 1.51-2.44)
↑70%
(1.70; 1.43-2.03)
Esomeprazole ↓32%
(0.68; 0.53-0.86)
↓30%
(0.70; 0.59-0.83)
400-mg single dose with a prokinetic agent (metoclopramide 10 mg three times a day for 2 days) + BOOST or an antikinetic agent (loperamide 4-mg single dose) + BOOST (n=12) With metoclopramide + BOOST ↓21%
(0.79; 0.72-0.87)
↓19%
(0.81; 0.72-0.91)
With loperamide + BOOST ↓3%
(0.97; 0.88-1.07)
↑11%
(1.11; 0.99-1.25)
400-mg single dose either orally with BOOST or via an NG tube with BOOST (n=16) Via NG tubeNG = nasogastric ↓19%
(0.81; 0.71-0.91)
↓23%
(0.77; 0.69-0.86)

Concomitant administration of Noxafil oral suspension with drugs affecting gastric pH or gastric motility results in lower posaconazole exposure. (See Table 26 .)

Table 26: The Effect of Concomitant Medications that Affect the Gastric pH and Gastric Motility on the Pharmacokinetics of Noxafil Oral Suspension in Healthy Volunteers
Coadministered Drug (Postulated Mechanism of Interaction) Coadministered Drug Dose/Schedule Noxafil Dose/Schedule Effect on Bioavailability of Posaconazole
Change in Mean
Cmax
(ratio estimateRatio Estimate is the ratio of coadministered drug plus Noxafil to coadministered drug alone for Cmax or AUC.; 90% CI of the ratio estimate)
Change in Mean AUC
(ratio estimate
; 90% CI of the ratio estimate)
Cimetidine
(Alteration of gastric pH)
400 mg twice daily × 10 days 200 mg (tablets) once daily × 10 daysThe tablet refers to a non-commercial tablet formulation without polymer. ↓ 39%
(0.61; 0.53-0.70)
↓ 39%
(0.61; 0.54-0.69)
Esomeprazole (Increase in gastric pH)The drug interactions associated with the oral suspension are also relevant for the delayed-release tablet with the exception of Esomeprazole and Metoclopramide. 40 mg every morning × 3 days 400 mg (oral suspension) single dose ↓ 46%
(0.54; 0.43-0.69)
↓ 32%
(0.68; 0.57-0.81)
Metoclopramide (Increase in gastric motility)
10 mg three times a day × 2 days 400 mg (oral suspension) single dose ↓ 21%
(0.79; 0.72-0.87)
↓ 19%
(0.81; 0.72-0.91)

Distribution:

The mean volume of distribution of posaconazole after intravenous solution administration was 261 L and ranged from 226-295 L between studies and dose levels.

Posaconazole is highly bound to human plasma proteins (>98%), predominantly to albumin.

Metabolism:

Posaconazole primarily circulates as the parent compound in plasma. Of the circulating metabolites, the majority are glucuronide conjugates formed via UDP glucuronidation (phase 2 enzymes). Posaconazole does not have any major circulating oxidative (CYP450 mediated) metabolites. The excreted metabolites in urine and feces account for ~17% of the administered radiolabeled dose.

Posaconazole is primarily metabolized via UDP glucuronidation (phase 2 enzymes) and is a substrate for p-glycoprotein (P-gp) efflux. Therefore, inhibitors or inducers of these clearance pathways may affect posaconazole plasma concentrations. A summary of drugs studied clinically with the oral suspension or an early tablet formulation, which affect posaconazole concentrations, is provided in Table 27 .

Table 27: Summary of the Effect of Coadministered Drugs on Noxafil in Healthy Volunteers
Coadministered Drug (Postulated Mechanism of Interaction) Coadministered Drug Dose/Schedule Noxafil Dose/Schedule Effect on Bioavailability of Posaconazole
Change in Mean
Cmax
(ratio estimateRatio Estimate is the ratio of coadministered drug plus Noxafil to Noxafil alone for Cmax or AUC.; 90% CI of the ratio estimate)
Change in Mean AUC
(ratio estimate
; 90% CI of the ratio estimate)
Efavirenz
(UDP-G Induction)
400 mg once daily × 10 and 20 days 400 mg (oral suspension) twice daily × 10 and 20 days ↓45%
(0.55; 0.47-0.66)
↓ 50%
(0.50; 0.43-0.60)
Fosamprenavir (unknown mechanism) 700 mg twice daily × 10 days 200 mg once daily on the 1st day, 200 mg twice daily on the 2nd day, then 400 mg twice daily × 8 Days ↓21%
0.79 (0.71-0.89)
↓23%
0.77 (0.68-0.87)
Rifabutin
(UDP-G Induction)
300 mg once daily × 17 days 200 mg (tablets) once daily × 10 daysThe tablet refers to a non-commercial tablet formulation without polymer. ↓ 43%
(0.57; 0.43-0.75)
↓ 49%
(0.51; 0.37-0.71)
Phenytoin
(UDP-G Induction)
200 mg once daily × 10 days 200 mg (tablets) once daily × 10 days
↓ 41%
(0.59; 0.44-0.79)
↓ 50%
(0.50; 0.36-0.71)

In vitro studies with human hepatic microsomes and clinical studies indicate that posaconazole is an inhibitor primarily of CYP3A4. A clinical study in healthy volunteers also indicates that posaconazole is a strong CYP3A4 inhibitor as evidenced by a >5-fold increase in midazolam AUC. Therefore, plasma concentrations of drugs predominantly metabolized by CYP3A4 may be increased by posaconazole. A summary of the drugs studied clinically, for which plasma concentrations were affected by posaconazole, is provided in Table 28 [see Contraindications (4) and Drug Interactions (7.1) including recommendations].

Table 28: Summary of the Effect of Noxafil on Coadministered Drugs in Healthy Adult Volunteers and Patients
Coadministered Drug
(Postulated Mechanism of Interaction is Inhibition of CYP3A4 by posaconazole)
Coadministered Drug Dose/Schedule Noxafil Dose/Schedule Effect on Bioavailability of Coadministered Drugs
Change in Mean Cmax
(ratio estimateRatio Estimate is the ratio of coadministered drug plus Noxafil to coadministered drug alone for Cmax or AUC.; 90% CI of the ratio estimate)
Change in Mean AUC
(ratio estimate
; 90% CI of the ratio estimate)
Sirolimus 2-mg single oral dose 400 mg (oral suspension) twice daily × 16 days ↑ 572%
(6.72; 5.62-8.03)
↑ 788%
(8.88; 7.26-10.9)
Cyclosporine Stable maintenance dose in heart transplant recipients 200 mg (tablets) once daily × 10 daysThe tablet refers to a non-commercial tablet formulation without polymer. ↑ cyclosporine whole blood trough concentrations
Cyclosporine dose reductions of up to 29% were required
Tacrolimus 0.05-mg/kg single oral dose 400 mg (oral suspension) twice daily × 7 days ↑ 121%
(2.21; 2.01-2.42)
↑ 358%
(4.58; 4.03-5.19)
Simvastatin 40-mg single oral dose 100 mg (oral suspension) once daily × 13 days Simvastatin
↑ 841%
(9.41, 7.13-12.44)
Simvastatin Acid
↑ 817%
(9.17, 7.36-11.43)
Simvastatin
↑ 931%
(10.31, 8.40-12.67)
Simvastatin Acid
↑634%
(7.34, 5.82-9.25)
200 mg (oral suspension) once daily × 13 days Simvastatin
↑ 1041%
(11.41, 7.99-16.29)
Simvastatin Acid
↑851%
(9.51, 8.15-11.10)
Simvastatin
↑ 960%
(10.60, 8.63-13.02)
Simvastatin Acid
↑ 748%
(8.48, 7.04-10.23)
Midazolam 0.4-mg single intravenous doseThe mean terminal half-life of midazolam was increased from 3 hours to 7 to 11 hours during coadministration with Noxafil. 200 mg (oral suspension) twice daily × 7 days ↑ 30%
(1.3; 1.13-1.48)
↑ 362%
(4.62; 4.02-5.3)
0.4-mg single intravenous dose
400 mg (oral suspension) twice daily × 7 days ↑62%
(1.62; 1.41-1.86)