Warnings for Vanrafia
Included as part of the PRECAUTIONS section.
Precautions for Vanrafia
Embryo-Fetal Toxicity
Based on data from animal reproduction studies, VANRAFIA
may cause fetal harm when administered to a pregnant patient and is
contraindicated during pregnancy. The available human data for endothelin
receptor antagonists do not establish the presence or absence of major birth
defects related to the use of VANRAFIA. Counsel patients who can become
pregnant of the potential risk to a fetus. Exclude pregnancy prior to
initiation of treatment with VANRAFIA. Advise patients to use effective
contraception prior to initiation of treatment, during treatment, and for two
weeks after discontinuation of treatment with VANRAFIA [see DOSAGE AND
ADMINISTRATION and Use In Specific Populations]. When pregnancy is
detected, discontinue VANRAFIA as soon as possible [see DOSAGE AND
ADMINISTRATION, CONTRAINDICATIONS, Use In Specific Populations].
Hepatotoxicity
Some endothelin receptor antagonists (ERAs) have caused
elevations of aminotransferases, hepatotoxicity, and liver failure.
Asymptomatic and transient transaminase elevations have been observed with
VANRAFIA [see ADVERSE REACTIONS]. Obtain liver enzyme testing before
initiating VANRAFIA and repeat during treatment as clinically indicated. In
patients with elevated aminotransferases at baseline (>3 Ã upper limit of
normal [ULN]), consider periodic liver test monitoring. Do not initiate
VANRAFIA in patients with severe hepatic impairment.
Advise patients to report symptoms suggesting hepatic
injury (nausea, vomiting, right upper quadrant pain, fatigue, anorexia,
jaundice, dark urine, fever, or itching). If clinically relevant
aminotransferase elevations occur, or if elevations are accompanied by an
increase in bilirubin >2 x ULN, or by clinical symptoms of hepatotoxicity,
discontinue VANRAFIA. Consider re-initiation of VANRAFIA when hepatic enzyme
levels normalize in patients who have not experienced clinical symptoms of
hepatotoxicity or jaundice.
Fluid Retention
Fluid retention may occur with ERAs and has been observed
in clinical studies with VANRAFIA [see ADVERSE REACTIONS]. VANRAFIA has
not been evaluated in IgAN patients with heart failure. If clinically
significant fluid retention develops, consider initiating or increasing
diuretic treatment and interrupting VANRAFIA treatment.
Decreased Sperm Counts
VANRAFIA, similar to other ERAs, may have an adverse
effect on spermatogenesis. Counsel men about potential effects on fertility
[see Use In Specific Populations and Nonclinical Toxicology].
Patient Counseling Information
Advise the patient to read the FDA-approved patient
labeling (Medication Guide)
Embryo-Fetal Toxicity
Educate and counsel female patients of reproductive
potential to use effective contraception prior to starting treatment with
VANRAFIA, during treatment and for two weeks after treatment discontinuation.
Patients who can become pregnant should have a negative pregnancy test prior to
treatment with VANRAFIA [see DOSAGE AND ADMINISTRATION, CONTRAINDICATIONS,
WARNINGS AND PRECAUTIONS, Use In Specific Populations].
Patients should be instructed to immediately contact
their physician if they suspect they may be pregnant. Patients should seek
additional contraceptive advice as needed.
Educate and counsel patients who can become pregnant on
the use of emergency contraception in the event of unprotected sex or
contraceptive failure.
Advise patients to contact their healthcare provider if
they want to change the form of birth control which is used to ensure that
another acceptable form of birth control is selected.
Hepatotoxicity
Some members of this pharmacological class are
hepatotoxic. Educate patients on signs of hepatotoxicity. Advise patients that
they should contact their doctor if they have unexplained nausea, vomiting,
right upper quadrant pain, fatigue, anorexia, jaundice, dark urine, fever, or
itching [see WARNINGS AND PRECAUTIONS].
Fluid Retention
Educate patients on signs of fluid retention. Advise
patients that they should contact their doctor if they have unusual weight
increase or swelling of the ankles or legs [see WARNINGS AND PRECAUTIONS].
Lactation
Advise patients not to breastfeed during treatment with
VANRAFIA [see Use In Specific Populations].
Other Risks Associated With VANRAFIA
Instruct patients that the risks associated with VANRAFIA
also include the following:
- Decreases in sperm count [see WARNINGS AND PRECAUTIONS]
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Carcinogenesis
In female rats orally administered atrasentan for 2
years, no atrasentan-related tumor findings were observed at exposures approximately
12 times the AUC at the MRHD. At a higher exposure (approximately 24 times the
AUC at the MRHD, or 2 mg/kg/day), an increased incidence of benign uterine
stromal polyps considered of low human relevance was observed. In male rats,
no carcinogenic effects were observed at exposures approximately 100 times the
AUC at the MRHD.
There were no atrasentan-related tumor findings observed
in male and female transgenic mice administered atrasentan for 6 months at
doses up to 60 mg/kg/day.
Mutagenesis
There was no evidence of mutagenicity or clastogenicity
for atrasentan in in vitro bacteria reverse mutation and chromosomal aberration
assays, or in an in vivo mouse micronucleus study.
Impairment Of Fertility
In a fertility study, male rats were treated with
atrasentan at doses of 5, 20, and 60 mg/kg/day and mated with untreated female
rats. No adverse effects on male fertility were observed at 5 mg/kg/day,
approximately 53 times the AUC at the MRHD. At higher doses, decreased numbers
of implantation sites, reduced viable fetuses, and increased pre-implantation loss
were observed in the untreated female rats mated with the treated male rats.
These effects were reversible at 20 mg/kg/day, approximately 422 times the AUC
at MRHD. In rats and dogs, testicular degeneration, dilatation of seminiferous
tubules, interstitial edema of the testes, and prostate inflammation were
observed at all doses tested, and a no adverse effect dose level could not be
determined.
In a female rat fertility study, no reproductive toxicity
was observed following oral administration during premating, mating, and early
gestation at doses up to 100 mg/kg/day.
In female rats, cystic endometrial hyperplasia was
observed at the lowest dose tested of 0.8 mg/kg/day.
Use In Specific Populations
Pregnancy
Risk Summary
Based on data from animal reproductive toxicity studies,
VANRAFIA may cause fetal harm, including birth defects and fetal death, when
administered to a pregnant patient and is contraindicated during pregnancy [see
CONTRAINDICATIONS]. There are no available data on VANRAFIA use in
pregnancy to evaluate for a drug-associated risk of major birth defects,
miscarriage, or other adverse maternal or fetal outcomes. Available data from
published literature and postmarketing surveillance over decades of use with
products in the same pharmacologic class (ERA) have not identified an increased
risk of major birth defects. However, these data are limited and do not
establish the presence or absence of a drug-associated risk of major birth
defects. Methodological limitations of these post marketing reports and
published literature include lack of a control group; limited information
regarding dose, duration, and timing of exposure; and missing data. These
limitations preclude establishing a reliable estimate of the risk of adverse
fetal and neonatal outcomes with maternal endothelin receptor antagonist use.
In animal reproduction studies, oral administration of
atrasentan to pregnant rats and rabbits throughout organogenesis at doses that
were below the maximum recommended human dose (MRHD) based on area under the
curve (AUC) caused teratogenic effects in rats and rabbits (see Data).
Advise pregnant patients of the potential risk to the fetus [see
CONTRAINDICATIONS].
The background risk of major birth defects and
miscarriage for the indicated population is unknown. All pregnancies have a
background risk of birth defects, 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
In embryo-fetal development studies in pregnant rats and
rabbits, teratogenicity and/or embryo-fetal toxicity were observed.
In pregnant rats, oral administration of atrasentan
throughout organogenesis at doses of 0.1, 0.3, 1.0, and 3.0 mg/kg/day resulted
in developmental abnormalities primarily including the ear, lower jaw, or skull
in all treated groups with detectable plasma exposures to atrasentan. The no
adverse effect level of atrasentan plasma exposure was not determined. In
pregnant rabbits, oral administration of atrasentan throughout organogenesis at
doses of 0.1, 0.3, 1.0 and 3.0 mg/kg/day resulted in visceral malformations
including deformities in the cardiovascular system in all atrasentan-treated
groups. The lowest detectable plasma exposures to atrasentan were approximately
0.2 times the AUC at the MRHD.
In the pre- and postnatal development study in rats,
atrasentan was orally administered to pregnant rats at doses of 1, 10, or 100
mg/kg/day during the period from gestation Day 15 through lactation Day 20. No
adverse effects on pre- and postnatal development were observed at doses up to
10 mg/kg/day which resulted in maternal exposure approximately 55 times the AUC
at the MRHD. Higher exposure to atrasentan (dose of 100 mg/kg/day) increased
pup mortality during the pre-weaning period, and increased heart weight which
correlated histologically with myocardial hypertrophy.
Lactation
Risk Summary
There are no data on the presence of atrasentan in human
milk, the effects on the breastfed infant, or the effect on milk production.
Because of the potential for adverse reactions, such as fluid retention in
breastfed infants, advise patients not to breastfeed during treatment with
VANRAFIA.
Females And Males Of Reproductive Potential
Based on data from animal reproductive toxicity studies,
VANRAFIA may cause fetal harm, including birth defects and fetal death, when
administered to a pregnant patient and is contraindicated during pregnancy [see
CONTRAINDICATIONS, Use In Specific Populations].
Pregnancy Testing
Exclude pregnancy before initiating VANRAFIA in females
of reproductive potential. The patient should contact their physician
immediately for pregnancy testing if onset of menses is delayed or pregnancy is
suspected. If pregnancy is confirmed, the physician should discuss with the
patient the risks to the pregnancy and the fetus.
Contraception
Patients who can become pregnant while using VANRAFIA
should use effective contraception prior to initiation of treatment, during
treatment, and for two weeks after discontinuation of treatment with VANRAFIA
to prevent pregnancy [see WARNINGS AND PRECAUTIONS].
Infertility
Decreased sperm counts have been observed in some
patients with diabetic kidney disease (DKD) receiving VANRAFIA 0.75 mg once
daily with return to normal levels within approximately 3 months after drug
discontinuation. This effect has not been studied in patients with IgAN [see Nonclinical
Toxicology].
Pediatric Use
The safety and efficacy of VANRAFIA in pediatric patients
have not been established.
Geriatric Use
There were 29 (7%) patients 65 years of age and older in
the ALIGN study of VANRAFIA. Of the total number of VANRAFIA-treated patients,
15 (7%) were 65 years to 75 years of age, and 3 (2%) were 75 years of age and
older. No overall differences in safety and effectiveness were observed between
these patients and younger patients.
Hepatic Impairment
No dose adjustment is required for patients with mild or
moderate hepatic impairment. Do not initiate VANRAFIA in patients with severe
hepatic impairment [see WARNINGS AND PRECAUTIONS].