ADDITIONAL DOSING INFORMATION FOR WM
IMBRUVICA® Dose Modifications for CYP3A Inhibitors in B-cell Malignancies*
CYP Inhibitors
Coadministered Drug | Recommended IMBRUVICA® Dose |
---|---|
Moderate CYP3A inhibitor† | 280 mg once daily Modify dose as recommended per Section 2.2 of the full Prescribing Information |
Voriconazole 200 mg twice daily Posaconazole suspension 100 mg once daily, 100 mg twice daily, or 200 mg twice daily | 140 mg once daily Modify dose as recommended per Section 2.2 of the full Prescribing Information |
Posaconazole suspension 200 mg 3 times daily or 400 mg twice daily Posaconazole intravenously 300 mg once daily Posaconazole delayed-release tablets 300 mg once daily | 70 mg once daily Interrupt dose as recommended per Section 2.2 of the full Prescribing Information |
Other strong CYP3A inhibitors‡ | Avoid concomitant use. If these inhibitors will be used short-term (such as anti-infectives for 7 days or less), interrupt IMBRUVICA® |
After discontinuation of a CYP3A inhibitor, resume previous dose of IMBRUVICA® per Sections 2.1 and 7.1 of full Prescribing Information.
- Avoid grapefruit and Seville oranges during IMBRUVICA® treatment, as these contain strong or moderate inhibitors of CYP3A
CYP3A Inducers§
The coadministration of IMBRUVICA® with strong CYP3A inducers may decrease ibrutinib concentrations. Avoid coadministration with strong CYP3A inducers.
Please note that dose modifications for use with CYP3A inhibitors for patients with cGVHD differ from those with B-cell malignancies.
†Examples of moderate CYP3A inhibitors include: aprepitant, ciprofloxacin, conivaptan, crizotinib, cyclosporine, diltiazem, dronedarone, erythromycin, fluconazole, fluvoxamine, grapefruit juice, imatinib, isavuconazole, tofisopam, verapamil.
‡Examples of strong CYP3A inhibitors include: cobicistat, danoprevir and ritonavir, elvitegravir and ritonavir, grapefruit juice, indinavir and ritonavir, itraconazole, ketoconazole, lopinavir and ritonavir, paritaprevir and ritonavir and ombitasvir (and/or dasabuvir), posaconazole, ritonavir, saquinavir and ritonavir, tipranavir and ritonavir, telithromycin, troleandomycin, voriconazole.
§Examples of strong CYP3A inducers include: apalutamide, carbamazepine, enzalutamide, ivosidenib, lumacaftor, mitotane, phenytoin, rifampin, St. John’s wort. Please note that the induction potency of St. John’s wort may vary widely based on preparation.
These examples are a guide and not considered a comprehensive list of all possible drugs that may fit these categories.
CYP3A=cytochrome P450, family 3, subfamily A, WM=Waldenström's Macroglobulinemia.
- 140 mg daily for patients with mild hepatic impairment (Child-Pugh class A)
- 70 mg daily for patients with moderate hepatic impairment (Child-Pugh class B)
- For patients with mild or moderate hepatic impairment, monitor more frequently for adverse reactions of IMBRUVICA®
Avoid the use of IMBRUVICA® in patients with severe hepatic impairment (Child-Pugh class C).
CYP3A=cytochrome P450, family 3, subfamily A, WM=Waldenström's macroglobulinemia.
Use of either anticoagulant or antiplatelet agents concomitantly with IMBRUVICA® increases the risk of major hemorrhage. Across clinical trials, 3.1% of 2,838 patients who received IMBRUVICA® without antiplatelet or anticoagulant therapy experienced major hemorrhage. The addition of antiplatelet therapy with or without anticoagulant therapy increased this percentage to 4.4%, and the addition of anticoagulant therapy with or without antiplatelet therapy increased this percentage to 6.1%. Consider the risks and benefits of anticoagulant or antiplatelet therapy when co-administered with IMBRUVICA®. Monitor for signs and symptoms of bleeding.
Consider the benefit-risk of withholding IMBRUVICA® for at least 3 to 7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding.
CYP3A=cytochrome P450, family 3, subfamily A, WM=Waldenström's macroglobulinemia.
CYP3A inhibitors and inducers1,2
IMBRUVICA® Dose Modifications for CYP3A Inhibitors in B-cell Malignancies*
CYP Inhibitors
Coadministered Drug | Recommended IMBRUVICA® Dose |
---|---|
Moderate CYP3A inhibitor† | 280 mg once daily Modify dose as recommended per Section 2.2 of the full Prescribing Information |
Voriconazole 200 mg twice daily Posaconazole suspension 100 mg once daily, 100 mg twice daily, or 200 mg twice daily | 140 mg once daily Modify dose as recommended per Section 2.2 of the full Prescribing Information |
Posaconazole suspension 200 mg 3 times daily or 400 mg twice daily Posaconazole intravenously 300 mg once daily Posaconazole delayed-release tablets 300 mg once daily | 70 mg once daily Interrupt dose as recommended per Section 2.2 of the full Prescribing Information |
Other strong CYP3A inhibitors‡ | Avoid concomitant use. If these inhibitors will be used short-term (such as anti-infectives for 7 days or less), interrupt IMBRUVICA® |
After discontinuation of a CYP3A inhibitor, resume previous dose of IMBRUVICA® per Sections 2.1 and 7.1 of full Prescribing Information.
- Avoid grapefruit and Seville oranges during IMBRUVICA® treatment, as these contain strong or moderate inhibitors of CYP3A
CYP3A Inducers§
The coadministration of IMBRUVICA® with strong CYP3A inducers may decrease ibrutinib concentrations. Avoid coadministration with strong CYP3A inducers.
Please note that dose modifications for use with CYP3A inhibitors for patients with cGVHD differ from those with B-cell malignancies.
†Examples of moderate CYP3A inhibitors include: aprepitant, ciprofloxacin, conivaptan, crizotinib, cyclosporine, diltiazem, dronedarone, erythromycin, fluconazole, fluvoxamine, grapefruit juice, imatinib, isavuconazole, tofisopam, verapamil.
‡Examples of strong CYP3A inhibitors include: cobicistat, danoprevir and ritonavir, elvitegravir and ritonavir, grapefruit juice, indinavir and ritonavir, itraconazole, ketoconazole, lopinavir and ritonavir, paritaprevir and ritonavir and ombitasvir (and/or dasabuvir), posaconazole, ritonavir, saquinavir and ritonavir, tipranavir and ritonavir, telithromycin, troleandomycin, voriconazole.
§Examples of strong CYP3A inducers include: apalutamide, carbamazepine, enzalutamide, ivosidenib, lumacaftor, mitotane, phenytoin, rifampin, St. John’s wort. Please note that the induction potency of St. John’s wort may vary widely based on preparation.
These examples are a guide and not considered a comprehensive list of all possible drugs that may fit these categories.
CYP3A=cytochrome P450, family 3, subfamily A, WM=Waldenström's Macroglobulinemia.
Hepatic impairment1
- 140 mg daily for patients with mild hepatic impairment (Child-Pugh class A)
- 70 mg daily for patients with moderate hepatic impairment (Child-Pugh class B)
- For patients with mild or moderate hepatic impairment, monitor more frequently for adverse reactions of IMBRUVICA®
Avoid the use of IMBRUVICA® in patients with severe hepatic impairment (Child-Pugh class C).
CYP3A=cytochrome P450, family 3, subfamily A, WM=Waldenström's macroglobulinemia.
Hemorrhage1
Use of either anticoagulant or antiplatelet agents concomitantly with IMBRUVICA® increases the risk of major hemorrhage. Across clinical trials, 3.1% of 2,838 patients who received IMBRUVICA® without antiplatelet or anticoagulant therapy experienced major hemorrhage. The addition of antiplatelet therapy with or without anticoagulant therapy increased this percentage to 4.4%, and the addition of anticoagulant therapy with or without antiplatelet therapy increased this percentage to 6.1%. Consider the risks and benefits of anticoagulant or antiplatelet therapy when co-administered with IMBRUVICA®. Monitor for signs and symptoms of bleeding.
Consider the benefit-risk of withholding IMBRUVICA® for at least 3 to 7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding.
CYP3A=cytochrome P450, family 3, subfamily A, WM=Waldenström's macroglobulinemia.
References: 1. IMBRUVICA® (ibrutinib) Prescribing Information. 2. US Food & Drug Administration. Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers. https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers. Accessed January 23, 2023.