HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use -----------------------WARNINGS AND PRECAUTIONS-----------------------­ ORKAMBI safely and effectively. See full prescribing information for • Use in patients with advanced liver disease: ORKAMBI should be used ORKAMBI. with caution in these patients and only if the benefits are expected to outweigh the risks. If ORKAMBI is used in these patients, they should ORKAMBI® (lumacaftor/ivacaftor) tablets, for oral use be closely monitored after the initiation of treatment and the dose should ORKAMBI® (lumacaftor/ivacaftor) oral granules be reduced. Liver function decompensation, including liver failure Initial U.S. Approval: 2015 leading to death, has been reported in CF patients with pre-existing cirrhosis with portal hypertension. (2.2, 5.1, 6.1) --------------------------- RECENT MAJOR CHANGES --------------------------­ • Liver-related events: Elevated transaminases (ALT/AST) have been Indications and Usage (1) 8/2018 observed in some cases associated with elevated bilirubin. Measure Dosage and Administration (2) 8/2018 serum transaminases and bilirubin before initiating ORKAMBI, every Warnings and Precautions (5) 1/2018 3 months during the first year of treatment, and annually thereafter. For patients with a history of ALT, AST, or bilirubin elevations, more ----------------------------INDICATIONS AND USAGE--------------------------­ frequent monitoring should be considered. Interrupt dosing in patients ORKAMBI is a combination of lumacaftor and ivacaftor, a cystic fibrosis with ALT or AST >5 x upper limit of normal (ULN), or ALT or AST transmembrane conductance regulator (CFTR) potentiator, indicated for the >3 x ULN with bilirubin >2 x ULN. Following resolution, consider the treatment of cystic fibrosis (CF) in patients age 2 years and older who are benefits and risks of resuming dosing. (5.2, 6.1) homozygous for the F508del mutation in the CFTR gene. If the patient’s • Respiratory events: Chest discomfort, dyspnea, and respiration abnormal genotype is unknown, an FDA-cleared CF mutation test should be used to detect were observed more commonly during initiation of ORKAMBI. Clinical the presence of the F508del mutation on both alleles of the CFTR gene. (1) experience in patients with percent predicted FEV1 (ppFEV1) <40 is limited, and additional monitoring of these patients is recommended Limitations of Use: during initiation of therapy. (5.3, 6.1) The efficacy and safety of ORKAMBI have not been established in patients • Blood pressure: Increased blood pressure has been observed in some with CF other than those homozygous for the F508del mutation. (1) patients. Periodically monitor blood pressure in all patients. (5.4, 6.1) ----------------------DOSAGE AND ADMINISTRATION----------------------­ • Drug interactions: Use with sensitive CYP3A substrates or CYP3A • Pediatric patients age 2 through 5 years and weighing less than 14 kg: one substrates with a narrow therapeutic index may decrease systemic packet of granules (each containing lumacaftor 100 mg/ivacaftor 125 mg) exposure of the medicinal products and co-administration is not mixed with 1 teaspoon (5 mL) of soft food or liquid and administered recommended. Hormonal contraceptives should not be relied upon as an orally every 12 hours with fat-containing food. (2.1, 12.3) effective method of contraception and their use is associated with • Pediatric patients age 2 through 5 years and weighing 14 kg or greater: increased menstruation-related adverse reactions. Use with strong one packet of granules (each containing lumacaftor 150 mg/ivacaftor CYP3A inducers may diminish exposure of ivacaftor, which may 188 mg) mixed with 1 teaspoon (5 mL) of soft food or liquid and diminish its effectiveness; therefore, co-administration is not administered orally every 12 hours with fat-containing food. (2.1, 12.3) recommended. (5.5, 6.1, 7, 12.3) • Pediatric patients age 6 through 11 years: two tablets (each containing • Cataracts: Non-congenital lens opacities/cataracts have been reported in lumacaftor 100 mg/ivacaftor 125 mg) taken orally every 12 hours with pediatric patients treated with ORKAMBI and ivacaftor, a component of fat-containing food. (2.1, 12.3) ORKAMBI. Baseline and follow-up examinations are recommended in • Adults and pediatric patients age 12 years and older: two tablets (each pediatric patients initiating ORKAMBI. (5.6) containing lumacaftor 200 mg/ivacaftor 125 mg) taken orally every ------------------------------ADVERSE REACTIONS------------------------------­ 12 hours with fat-containing food. (2.1, 12.3) The most common adverse reactions to ORKAMBI (occurring in ≥5% of • Reduce dose in patients with moderate or severe hepatic impairment. (2.2, patients with CF homozygous for the F508del mutation in the CFTR gene) 8.6, 12.3) were dyspnea, nasopharyngitis, nausea, diarrhea, upper respiratory tract • When initiating ORKAMBI in patients taking strong CYP3A inhibitors, infection, fatigue, respiration abnormal, blood creatine phosphokinase reduce ORKAMBI dose for the first week of treatment. (2.3, 7.1, 12.3) increased, rash, flatulence, rhinorrhea, influenza. (6.1) ---------------------DOSAGE FORMS AND STRENGTHS---------------------­ • Tablets: lumacaftor 100 mg and ivacaftor 125 mg; lumacaftor 200 mg and To report SUSPECTED ADVERSE REACTIONS, contact Vertex ivacaftor 125 mg. (3) Pharmaceuticals Incorporated at 1-877-634-8789 or FDA at 1-800-FDA­ 1088 or www.fda.gov/medwatch. • Oral granules: Unit-dose packets of lumacaftor 100 mg and ivacaftor -----------------------------DRUG INTERACTIONS------------------------------­ 125 mg; lumacaftor 150 mg and ivacaftor 188 mg. (3) See Full Prescribing Information for a complete list. (2.3, 7, 12.3) -------------------------------CONTRAINDICATIONS-----------------------------­ • None. (4) See 17 for PATIENT COUNSELING INFORMATION and FDA- approved patient labeling. Revised: 08/2018 _____________________________________________________________________________________________________________________________________ FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE 7.3 CYP3A Substrates 2 DOSAGE AND ADMINISTRATION 7.4 CYP2B6 and CYP2C Substrates 2.1 Dosing Information in Adults and Children Age 2 Years and Older 7.5 Digoxin and Other P-gp Substrates 2.2 Dosage Adjustment for Patients with Hepatic Impairment 7.6 Anti-allergics and Systemic Corticosteroids 2.3 Dosage Adjustment for Patients Taking CYP3A Inhibitors 7.7 Antibiotics 3 DOSAGE FORMS AND STRENGTHS 7.8 Antifungals 4 CONTRAINDICATIONS 7.9 Anti-inflammatories 5 WARNINGS AND PRECAUTIONS 7.10 Antidepressants 5.1 Use in Patients with Advanced Liver Disease 7.11 Hormonal Contraceptives 5.2 Liver-related Events 7.12 Oral Hypoglycemics 5.3 Respiratory Events 7.13 Proton Pump Inhibitors, H2 Blockers, Antacids 5.4 Effect on Blood Pressure 7.14 Warfarin 5.5 Drug Interactions 7.15 Concomitant Drugs That Do Not Need Dose Adjustment 5.6 Cataracts 8 USE IN SPECIFIC POPULATIONS 6 ADVERSE REACTIONS 8.1 Pregnancy 6.1 Clinical Trials Experience 8.2 Lactation 6.2 Post-marketing Experience 8.3 Females and Males of Reproductive Potential 7 DRUG INTERACTIONS 8.4 Pediatric Use 7.1 Inhibitors of CYP3A 8.5 Geriatric Use 7.2 Inducers of CYP3A 8.6 Hepatic Impairment 1 of 18 Reference ID: 4303254 8.7 Renal Impairment 14 CLINICAL STUDIES 8.8 Patients with Severe Lung Dysfunction 16 HOW SUPPLIED/STORAGE AND HANDLING 8.9 Patients After Organ Transplantation 17 PATIENT COUNSELING INFORMATION 10 OVERDOSAGE Advanced Liver Disease 11 DESCRIPTION Abnormalities in Liver Function and Testing 12 CLINICAL PHARMACOLOGY Respiratory Events 12.1 Mechanism of Action Effect on Blood Pressure 12.2 Pharmacodynamics Drug Interactions with CYP3A Inhibitors and Inducers 12.3 Pharmacokinetics Use in Patients with Hepatic Impairment 13 NONCLINICAL TOXICOLOGY Administration 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Cataracts *Sections or subsections omitted from the full prescribing information are not listed. FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE ORKAMBI is a combination of lumacaftor and ivacaftor indicated for the treatment of cystic fibrosis (CF) in patients age 2 years and older who are homozygous for the F508del mutation in the CFTR gene. If the patient’s genotype is unknown, an FDA-cleared CF mutation test should be used to detect the presence of the F508del mutation on both alleles of the CFTR gene. Limitations of Use The efficacy and safety of ORKAMBI have not been established in patients with CF other than those homozygous for the F508del mutation. 2 DOSAGE AND ADMINISTRATION 2.1 Dosing Information in Adults and Children Age 2 Years and Older Table 1: Dosage of ORKAMBI in Patients Age 2 Years and Older Age ORKAMBI Dose Total Daily Dose 2 through 5 years One lumacaftor 100 mg/ lumacaftor 200 mg/ and weighing less ivacaftor 125 mg packet of ivacaftor 250 mg than 14 kg granules every 12 hours with fat-containing food. 2 through 5 years One lumacaftor 150 mg/ lumacaftor 300 mg/ and weighing 14 kg ivacaftor 188 mg packet of ivacaftor 376 mg or greater granules every 12 hours with fat-containing food. 6 through 11 years Take two lumacaftor lumacaftor 100 mg/ivacaftor 125 mg 400 mg/ivacaftor tablets every 12 hours with 500 mg fat-containing food. 12 years and older Take two lumacaftor lumacaftor 200 mg/ivacaftor 125 mg 800 mg/ivacaftor tablets every 12 hours with 500 mg fat-containing food. ORKAMBI oral granules The entire content of each packet of oral granules should