Source: European Medicines Agency (EU) Revision Year: 2025 Publisher: Insmed Netherlands B.V., Stadsplateau 7, 3521 AZ Utrecht, Netherlands
Pharmacotherapeutic group: Antibacterials for systemic use, other aminoglycosides
ATC code: J01GB06
Amikacin binds to a specific receptor protein on the 30S subunit of bacterial ribosomes and interferes with an initiation complex between mRNA (messenger RNA) and the 30S subunit resulting in inhibition of protein synthesis.
The mechanism of resistance to amikacin in mycobacteria has been linked to mutations in the rrs gene of the 16S rRNA.
The efficacy of inhaled liposomal amikacin was evaluated in study INS-212, a randomised, open-label study in adult patients with non-tuberculous mycobacterial lung infections caused by MAC.
Patients who had not achieved sputum culture conversion (SCC) while being treated with Multiple Drug Regimen(s) (MDR) for at least 6 months before study entry were randomised to receive ARIKAYCE in addition to their MDR treatment or to continue with MDR alone. Patients achieving SCC, defined as 3 consecutive negative MAC sputum cultures by month 6 on treatment continued therapy for up to 12 months after achieving SCC. Those not achieving SCC by month 6 were discontinued from the study at month 8.
A total of 335 patients were randomised and dosed (ARIKAYCE liposomal + MDR n=223; MDR alone n=112) (Safety population). Median duration of prior MDR treatment was 2.6 years and 2.4 years in the ARIKAYCE liposomal + MDR and MDR alone group, respectively. Patients were stratified per smoking status (current smoker or not) and MDR use at screening (on treatment or off treatment for at least 3 months prior to screening). The primary endpoint was durable SCC defined as the proportion of randomised patients that had achieved SCC by month 6 on treatment and had no positive solid media culture or no more than two broth media cultures by 3 months off treatment.
Sixty-five (29.0%) and 10 (8.9%) patients achieved SCC by month 6 on treatment in the ARIKAYCE liposomal + MDR and the MDR group, respectively (p<0.0001). Of these, based on the primary analysis durable SCC at 3 months off treatment was achieved by 16.1% [36/224] vs. 0% [0/112]; p-value<0.0001.
In a post-hoc analysis that eliminated patients with negative cultures (solid media or broth) at study baseline and which counted any post-treatment positive culture (solid media or broth) as positive, 30/224 (13.4%) in the ARIKAYCE liposomal + MDR group and 0/112 (0%) in the MDR group achieved durable SCC at 3 months off treatment. Respective rates at 12 months off treatment were 25/224 (11%) vs. 0/112 (0%).
The European Medicines Agency has deferred the obligation to submit the results of studies with inhaled liposomal amikacin in one or more subsets of the paediatric population in NTM lung infection (see section 4.2 for information on paediatric use).
Following once daily inhalation of 590 mg inhaled liposomal amikacin in MAC patients, sputum concentrations at 1 to 4 hours post-inhalation were 1720, 884, and 1300 μg/g at 1, 3, and 6 months, respectively. High variability in amikacin concentrations was observed (CV% >100%). After 48 to 72 hours post-inhalation, amikacin sputum concentrations decreased to approximately 5% of those at 1 to 4 hours post-inhalation.
Following daily inhalation of 590 mg ARIKAYCE in MAC patients, at steady state, the median serum AUC0-24 was 16.7 μg*hr/mL (range: 4.31 to 55.6 μg*hr/mL; n=53) and the median serum Cmax was 1.81 μg/mL (range: 0.482 to 6.87 μg/mL; n=53).
Amikacin is ≤10% bound to serum proteins. The mean total apparent volume of distribution has been estimated to be approximately 5.0 L/kg.
Amikacin is not metabolised.
Amikacin is excreted in the urine unchanged, primarily by glomerular filtration. The median apparent terminal serum half-life of amikacin after inhalation of ARIKAYCE liposomal ranged from approximately 3.29 to 14.0 hrs.
A population pharmacokinetic analysis for ARIKAYCE liposomal in 53 subjects with NTM lung disease aged 20 to 84 years indicated that amikacin clearance is 34 L/h. The only clinical covariate identified to be predictive of amikacin clearance was body weight.
In a 2-year inhalation carcinogenicity study with inhaled liposomal amikacin in rats at doses of 5, 15, and 45 mg/kg/day, squamous cell carcinoma was observed in the lungs of 2 of 120 rats (0/60 males and 2/60 females) administered the highest dose tested (45 mg/kg/day). This ARIKAYCE dose was 6-fold greater than the clinical dose when normalised on a lung weight basis. No squamous cell carcinoma was observed at the mid-dose of 15 mg/kg/day, which was 2-fold greater than the clinical dose when normalised on a lung weight basis. The squamous cell carcinomas may be the result of a high lung burden of particulates from inhaled liposomal amikacin in the rat lung. The relevance of the lung tumour findings with regards to humans receiving inhaled liposomal amikacin is unknown. In dogs administered inhaled liposomal amikacin daily by inhalation for 9 months at doses up to 30 mg/kg/day, no preneoplastic or neoplastic changes were observed in the lungs (approximately 3 to 11 times the recommended human dose based on lung weight).
No evidence of mutagenicity or genotoxicity was observed in a battery of in vitro and in vivo genotoxicity studies with liposomal amikacin formulations (in vitro microbial mutagenesis test, in vitro mouse lymphoma mutation assay, in vitro chromosomal aberration study, and an in vivo micronucleus study in rats).
Animal reproductive toxicology studies have not been conducted with inhaled amikacin. In non-GLP reproduction toxicology studies in mice and rats with parenterally administered amikacin, no effect of fertility or foetal toxicity was reported.
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