VANRAFIA Film-coated tablet Ref.[115500] Active ingredients: Atrasentan

5.1 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 (2.1) and Use in Specific Populations (8.1, 8.3)]. When pregnancy is detected, discontinue VANRAFIA as soon as possible [see Dosage and Administration (2.1), Contraindications (4.1), Use in Specific Populations (8.1, 8.3)].

5.2 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 (6.1)]. Obtain liver enzyme testing before initiating VANRAFIA and repeat during treatment as clinically indicated. In patients with elevated aminotransferases at baseline (>3 × 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.

5.3 Fluid Retention

Fluid retention may occur with ERAs and has been observed in clinical studies with VANRAFIA [see Adverse Reactions (6.1)]. 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.

5.4 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 (8.3) and Nonclinical Toxicology (13.1)].

The following clinically significant adverse reactions are described elsewhere in the labeling:

• Embryo-fetal Toxicity [see Warnings and Precautions (5.1)]
• Hepatotoxicity [see Warnings and Precautions (5.2)]
• Fluid Retention [see Warnings and Precautions (5.3)]
• Decreased Sperm Counts [see Warnings and Precautions (5.4)]

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

The safety of VANRAFIA was evaluated in ALIGN (NCT04573478), a randomized, double-blind, placebo controlled clinical study in 403 adults with IgAN [see Clinical Studies (14.1)]. The median duration of treatment was 47 weeks (range: 0 to 128 weeks). The most common adverse reactions (≥5%) with VANRAFIA were peripheral edema and anemia. Table 1 describes the adverse reactions that occurred in ≥2% of patients treated with VANRAFIA and higher than placebo in the ALIGN study.

Table 1. Adverse Reactions Reported in ≥2% of Adult Patients with IgAN Treated with VANRAFIA and Higher than Placebo in ALIGN:

^* Includes related terms
^** Elevations in ALT or AST >3-fold upper limit of normal (ULN)

Laboratory Tests and Vital Signs

Hemoglobin Decrease

At Week 36, the mean change in hemoglobin from baseline for those patients receiving VANRAFIA in the ALIGN study was -0.7 g/dL compared to -0.2 g/dL for those receiving placebo. The incidence of a hemoglobin decrease >2 g/dL compared to baseline and below the lower limit of normal was greater for the VANRAFIA arm (12%) compared to the placebo arm (4%). These decreases are thought to be in part due to hemodilution. There were no treatment discontinuations due to anemia or hemoglobin decrease in the ALIGN study.

Blood Pressure Decrease

At Week 36, the mean change from baseline in systolic and diastolic blood pressure (BP) for patients receiving VANRAFIA in the ALIGN study was -4 mmHg and -4 mmHg, respectively, compared to +3 mmHg and +2 mmHg, respectively, in patients receiving placebo. Hypotension observed in VANRAFIA treated patients was mild or moderate in severity, rarely symptomatic, and did not necessitate treatment discontinuation.

7.1 Effect of Other Drugs on VANRAFIA

Strong or Moderate CYP3A Inducers

Avoid concomitant use with a strong or moderate CYP3A inducer.

Atrasentan is a CYP3A substrate [see Clinical Pharmacology (12.3)]. Concomitant use with a strong and moderate CYP3A inducer is expected to decrease atrasentan exposure [see Clinical Pharmacology (12.3)], which may reduce VANRAFIA efficacy.

OATP1B1/1B3 Inhibitors

Avoid concomitant use with organic anion transporting polypeptides 1B1/1B3 (OATP1B1/1B3) inhibitors.

Atrasentan is a OATP1B1/1B3 substrate [see Clinical Pharmacology (12.3)]. Concomitant use with a OATP1B1/1B3 inhibitor increases atrasentan exposure [see Clinical Pharmacology (12.3)], which may increase the risk of VANRAFIA adverse reactions.

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 (4.1)]. 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 post-marketing 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 (4.1)].

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.

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.

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 (4.1), Use in Specific Populations (8.1)].

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 (5.1)].

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 (13.1)].

The safety and efficacy of VANRAFIA in pediatric patients have not been established.

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.

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 (5.2)].