英文药名: Antara(Fenofibrate Capsules)

中文药名: 安塔拉（非诺贝特胶囊）

药品名称

通用名: 非诺贝特胶囊
英文名: FENOFIBRATE CAPSULES
药品类别: 调节血脂药
性状: 本品为胶囊剂，内容物为白色或类白色结晶性粉末。
药品简介

Reliant制药公司日前宣布，FDA已批准其非诺贝特胶囊（fenofibrate，Antara）的补充新药申请（sNDA）。此次批准了本品的43和130mg 2种新剂量规格，并修改了产品说明书，增加了新用法，即：130mg本品可伴（无）食物同服，这一改变使占美国成人15%的高甘油三酯血症患者更方便服药。
临床研究中，所有脂质参数均显示130mg本品有效，且疗效与本品是否在饭时或饭间服用无关。本品作为饮食疗法的辅助用药，用于原发性高脂血症或混合性血脂不良（Fredrickson IIa和IIb型）成人患者，以减少低密度脂蛋白（LDL-C）、总胆固醇、甘油三酯和载脂蛋白B（apo B）水平，并提升高密度脂蛋白（HDL-C）水平。
本品禁用于严重肝肾功能损伤的患者，包括原发性胆汁性肝硬变、原因不明的肝功能异常患者。同时，本品禁用于现有胆囊疾病的患者。
药理毒理

本品为氯贝丁酸衍生物类血脂调节药，通过抑制极低密度脂蛋白和甘油三酯的生成并同时使其分解代谢增多，降低血低密度脂蛋白、胆固醇和甘油三酯；还使载脂蛋白A1和A11生成增加，从而增高高密度脂蛋白。本品尚有降低正常人及高尿酸血症患者的血尿酸作用。动物实验表明，非诺贝特具有致畸性和致癌性。
药代动力学

本品口服后，胃肠道吸收良好，与食物同服可使非诺贝特的吸收增加。口服后4－7小时左右血药浓度达峰值。单剂量口服后吸收半衰期与消除半衰期分别为4.9小时与26.6小时，表观分布容积为0.9L/kg；持续治疗后半衰期β为21.7 小时。血浆蛋白结合率大约为99%，多剂量给药后未发现蓄积。吸收后在肝、肾、肠道中分布多，其次为肺、心和肾上腺，在睾丸、脾、皮肤内有少量。在肝内和肾组织内代谢，经羧基还原与葡糖醛酸化，代谢产物以葡糖醛酸化产物占大多数，经放射物标记，有大约60%的代谢产物经肾排泄，25%的代谢产物经大便排出。本品的消除半衰期为20小时，因此可以每天一次给药。有研究显示，严重肾功能不全的患者对本品的清除率显著下降，长期用药可造成蓄积。
适应症

本品用于治疗成人饮食控制疗法效果不理想的高脂血症，其降甘油三酯及混合型高脂血症作用较胆固醇明显。但本品不能完全代替饮食控制疗法，只能用作在控制饮食基础上的辅助治疗。
用法用量

成人常用量 口服，胶囊一次0.1g，每日3次，维持量每次0.1g，每日1 －2次。为减少胃部不适，可与饮食同服；肾功不全及老年患者用药应减量；治疗2 个月后无效应停药。
任何疑问, 请遵医嘱!
不良反应

发生率约有2%-15%。胃肠道反应包括腹部不适、腹泻、便秘最常见（约5%）；皮疹（2%）；神经系统不良反应包括乏力、头痛、性欲丧失、阳萎、眩晕、失眠（约3%-4%）；本品属氯贝丁酸衍生物，有可能引起肌炎、肌病和横纹肌溶解综合征，导致血肌酸磷酸激酶升高；发生横纹肌溶解，主要表现为肌痛合并血肌酸磷酸激酶升高、肌红蛋白尿、并可导致肾衰，但较罕见；在患有肾病综合征及其它肾损害而导致血白蛋白减少的患者或甲状腺机能亢进的患者，发生肌病的危险性增加。（约1%）；有使胆石增加的趋向，可引起胆囊疾病，乃至需要手术；在治疗初期可引起轻度至中度的血液学改变，如血红蛋白、血细胞比积和白细胞降低等偶有血氨基转移酶增高，包括丙氨酸及门冬氨酸氨基转移酶。
禁忌症

对非诺贝特过敏者禁用；有胆囊疾病史、患胆石症的患者禁用，本品可增加胆固醇向胆汁的排泌，从而引起胆结石。严重肾功能不全、肝功能不全、原发性胆汁性肝硬化或不明原因的肝功能持续异常的患者禁用。
注意事项

本品对诊断有干扰，服用本品时血小板计数、血尿素氮、氨基转移酶、血钙可能增高；血碱性磷酸酶、γ谷氨酰转肽酶及胆红素可能降低。用药期间应定期检查：
①全血象及血小板计数；
②肝功能试验；
③血胆固醇、甘油三酯或低密度脂蛋白；
④血肌酸磷酸激酶。如果临床有可疑的肌病的症状（如肌痛、触痛、乏力等）或血肌酸磷酸激酶显著升高，则应停药。在治疗高血脂的同时，还需关注和治疗可引起高血脂的各种原发病，如甲状腺机能减退、糖尿病等。某些药物也可引起高血脂，如雌激素、噻嗪类利尿药和β阻滞剂等，停药后，则不再需要相应的抗高血脂治疗。饮食疗法始终是治疗高血脂的首要方法，加上锻炼和减轻体重等方式，都将优于任何形式的药物治疗。
孕妇及哺乳期妇女用药

孕妇及哺乳期妇女禁用。本品尚无用于人类的实验数据。
儿童用药

本品用于儿童的疗效和安全性，目前尚无实验研究加以证实，因此本品不能用于儿童。
老年患者用药

老年人单剂量口服本品的清除率与成年人相似，但如有肾功能不良时，须适当减少本品用药剂量。
药物相互作用

本品应慎与HMG-CoA还原酶抑制剂，如普伐他汀、氟伐他汀、辛伐他汀等合用，可引起肌痛、横纹肌溶解、血肌酸磷酸激酶增高等肌病，严重时应停药。本品与胆汁酸结合树脂，如考来烯胺等合用，则至少应在服用这些药物之前1小时或4－6小时之后再服用非诺贝特。因胆汁酸结合药物还可结合同时服用的其它药物，进而影响其它药的吸收。本品有增强香豆素类抗凝剂疗效的作用，同时使用可使凝血酶原时间延长，故合用时应减少口服抗凝药剂量，以后再按检查结果调整用量。本品主要经肾排泄，在与免疫抑制剂，如环孢素或其它具肾毒性的药物合用时，可能有导致肾功能恶化的危险，应减量或停药。本品与其它高蛋白结合率的药物合用时，可使它们的游离型增加，药效增强，如甲苯磺丁脲及其它磺脲类降糖药、苯妥英、呋塞米等，在降血脂治疗期间服用上述药物，则应调整降糖药及其它药的剂量。
药物过量

因非诺贝特与血浆蛋白高度结合，因此当药物过量时，不考虑血液透析，应采取系统性支持疗法。

DESCRIPTION
Antara (fenofibrate) Capsules, is a lipid regulating agent available as capsules for oral administration. Each capsule contains 43 mg, 87 mg, or 130 mg of micronized fenofibrate.The chemical name for fenofibrate is 2-[4-(4-chlorobenzoyl) phenoxy]-2-methyl-propanoic acid, 1-methylethyl ester with the following structural formula:

The empirical formula is C 20 H 21 O 4 Cl and the molecular weight is 360.83; fenofibrate is insoluble in water. The melting point is 79°-82°C. Fenofibrate is a white solid which is stable under ordinary conditions.

Inactive Ingredients:    Each gelatin capsule contains sugar spheres, hypromellose, sodium lauryl sulfate, dimethicone, simethicone, and talc. The gelatin capsules also contain sulfur dioxide, titanium dioxide, yellow iron oxide, Indigo carmine FD&C Blue #2, D&C Yellow #10 and black ink.

CLINICAL PHARMACOLOGY
A variety of clinical studies have demonstrated that elevated levels of total cholesterol (total-C), low density lipoprotein cholesterol (LDL-C), and apolipoprotein B (apo B), an LDL membrane complex, are associated with human atherosclerosis. Similarly, decreased levels of high density lipoprotein cholesterol (HDL-C) and its transport complex, apolipoprotein A (apo AI and apo AII) are associated with the development of atherosclerosis. Epidemiologic investigations have established that cardiovascular morbidity and mortality vary directly with the level of total-C, LDL-C, and triglycerides, and inversely with the level of HDL-C. The independent effect of raising HDL-C or lowering triglycerides (TG) on the risk of cardiovascular morbidity and mortality has not been determined.

Fenofibric acid, the active metabolite of fenofibrate, produces reductions in total cholesterol, LDL cholesterol, apolipoprotein B, total triglycerides, and triglyceride rich lipoprotein (VLDL) in treated patients. In addition, treatment with fenofibrate results in increases in high density lipoprotein (HDL) and apoproteins apo AI and apo AII.

The effects of fenofibric acid seen in clinical practice have been explained in vivo in transgenic mice and in vitro in human hepatocyte cultures by the activation of peroxisome proliferator activated receptor (alpha) (PPAR(alpha)).

Through this mechanism, fenofibrate increases lipolysis and elimination of triglyceride-rich particles from plasma by activating lipoprotein lipase and reducing production of apoprotein C-III (an inhibitor of lipoprotein lipase activity). The resulting fall in triglycerides produces an alteration in the size and composition of LDL from small, dense particles (which are thought to be atherogenic due to their susceptibility to oxidation), to large buoyant particles. These larger particles have a greater affinity for cholesterol receptors and are catabolized rapidly. Activation of PPAR(alpha) also induces an increase in the synthesis of apoproteins A-I, A-II and HDL-cholesterol.

Fenofibrate also reduces serum uric acid levels in hyperuricemic and normal individuals by increasing the urinary excretion of uric acid.

Pharmacokinetics/Metabolism
Plasma concentrations of fenofibric acid after multiple dose administration of Antara 130 mg capsules are equivalent, under low-fat fed conditions, to 200 mg fenofibrate capsules.

Absorption
The absolute bioavailability of fenofibrate cannot be determined as the compound is virtually insoluble in aqueous media suitable for injection. However, fenofibrate is well absorbed from the gastrointestinal tract. Following oral administration in healthy volunteers, approximately 60% of a single dose of radiolabelled fenofibrate appeared in urine, primarily as fenofibric acid and its glucuronate conjugate, and 25% was excreted in the feces. Peak plasma levels of fenofibric acid from Antara occur within 4 to 8 hours after administration.

There was less than dose-proportional increase in the systemic exposure of fenofibric acid from three strengths (43 mg, 87 mg, and 130 mg) of Antara under fasting conditions.

Doses of two- or three-capsules of 43 mg Antara given concurrently were dose-equivalent to single-capsule doses of 87 mg and 130 mg, respectively.

The extent of absorption of acid was unaffected when Antara was taken either in fasted state or with a low-fat meal. However, the C max of Antara increased in the presence of a low-fat meal. T max was unaffected in the presence of a low-fat meal. In the presence of a high-fat meal, there was a 26% increase in AUC and 108% increase in C max of fenofibric acid from Antara relative to fasting state.

Distribution
In healthy volunteers, steady-state plasma levels of fenofibric acid were shown to be achieved within a week of dosing and did not demonstrate accumulation across time following multiple dose administration. Serum protein binding was approximately 99% in normal and hyperlipidemic subjects.

Metabolism
Following oral administration, fenofibrate is rapidly hydrolyzed by esterases to the active metabolite, fenofibric acid; no unchanged fenofibrate is detected in plasma.

Fenofibric acid is primarily conjugated with glucuronic acid and then excreted in urine. A small amount of fenofibric acid is reduced at the carbonyl moiety to a benzhydrol metabolite which is, in turn, conjugated with glucuronic acid and excreted in urine.

In vivo metabolism data indicate that neither fenofibrate nor fenofibric acid undergo oxidative metabolism (e.g., cytochrome P450) to a significant extent.

Excretion
After absorption, fenofibrate is mainly excreted in the urine in the form of metabolites, primarily fenofibric acid and fenofibric acid glucuronide. After administration of radiolabelled fenofibrate, approximately 60% of the dose appeared in the urine and 25% was excreted in the feces.

Fenofibrate acid from Antara is eliminated with a half-life of 23 hours, allowing once daily administration in a clinical setting.

Special Populations
Geriatrics
In elderly volunteers 77-87 years of age, the oral clearance of fenofibric acid following a single oral dose of fenofibrate was 1.2 L/h, which compares to 1.1 L/h in young adults. This indicates that a similar dosage regimen can be used in the elderly, without increasing accumulation of the drug or metabolites.

Pediatrics
Antara has not been investigated in adequate and well-controlled trials in pediatric patients.

Gender
No pharmacokinetic difference between males and females has been observed for fenofibrate.

Race
The influence of race on the pharmacokinetics of fenofibrate has not been studied; however, fenofibrate is not metabolized by enzymes known for exhibiting inter-ethnic variability. Therefore, inter-ethnic pharmacokinetic differences are very unlikely.

Renal insufficiency
In a study in patients with severe renal impairment (creatinine clearance <50 mL/min), the rate of clearance of fenofibric acid was greatly reduced, and the compound accumulated during chronic dosage. However, in patients having moderate renal impairment (creatinine clearance of 50 to 90 mL/min), the oral clearance and the oral volume of distribution of fenofibric acid are increased compared to healthy adults (2.1 L/h and 95 L versus 1.1 L/h and 30 L, respectively). Therefore, the dosage of Antara should be minimized in patients who have severe renal impairment, while no modification of dosage is required in patients having moderate renal impairment.

Hepatic insufficiency
No pharmacokinetic studies have been conducted in patients having hepatic insufficiency.

Drug-drug interactions
In vitro studies using human liver microsomes indicate that fenofibrate and fenofibric acid are not inhibitors of cytochrome (CYP) P450 isoforms CYP3A4, CYP2D6, CYP2E1, or CYP1A2. They are weak inhibitors of CYP2C19 and CYP2A6, and mild-to-moderate inhibitors of CYP2C9 at therapeutic concentrations.

Potentiation of coumarin-type anticoagulants has been observed with prolongation of the prothrombin time/INR.

Bile acid sequestrants have been shown to bind other drugs given concurrently. Therefore, fenofibrate should be taken at least 1 hour before or 4-6 hours after a bile acid binding resin to avoid impeding its absorption (see WARNINGS and PRECAUTIONS ).

Clinical Trials
Hypercholesterolemia (Heterozygous Familial and Nonfamilial) and Mixed Dyslipidemia
(Fredrickson Types IIa and IIb)
The effects of fenofibrate at a dose equivalent to 130 mg Antara per day were assessed from four randomized, placebo-controlled, double-blind, parallel-group studies including patients with the following mean baseline lipid values: total-C 306.9 mg/dL; LDL-C 213.8 mg/dL; HDL-C 52.3 mg/dL; and triglycerides 191.0 mg/dL. Fenofibrate therapy lowered LDL-C, Total-C, and the LDL-C/HDL-C ratio. Fenofibrate therapy also lowered triglycerides and raised HDL-C (see Table 1).

Table 1.
Mean Percent Change in Lipid Parameters at End of Treatment

Treatment Group	Total-C	LDL-C	HDL-C	TG
Pooled Cohort
Mean baseline lipid values (n=646)	306.9 mg/dL	213.8 mg/dL	52.3 mg/dL	191.0 mg/dL
All FEN (n=361)	-18.7%	-20.6%	+11.0%	-28.9%
Placebo (n=285)	-0.4%	-2.2%	+0.7%	+7.7%
Baseline LDL-C >160 mg/dL and    TG <150 mg/dL (Type IIa)
Mean baseline lipid values (n=334)	307.7 mg/dL	227.7 mg/dL	58.1 mg/dL	101.7 mg/dL
All FEN (n=193)	-22.4%	-31.4%	+9.8%	-23.5%
Placebo (n=141)	+0.2%	-2.2%	+2.6%	+11.7%
Baseline LDL-C >160 mg/dL and    TG >/=150 mg/dL (Type IIb)
Mean baseline lipid values (n=242)	312.8 mg/dL	219.8 mg/dL	46.7 mg/dL	231.9 mg/dL
All FEN (n=126)	-16.8%	-20.1%	+14.6%	-35.9%
Placebo (n=116)	-3.0%	-6.6%	+2.3%	+0.9%
Duration of study treatment was 3 to 6 months.
p=<0.05 vs. placebo

In a subset of the subjects, measurements of apo B were conducted. Fenofibrate treatment significantly reduced apo B from baseline to endpoint as compared with placebo (-25.1% vs. 2.4%, p<0.0001, n=213 and 143 respectively).
Hypertriglyceridemia (Fredrickson Type IV and V)
The effects of fenofibrate on serum triglycerides were studied in two randomized, double-blind, placebo-controlled clinical trials 1 of 147 hypertriglyceridemic patients (Fredrickson Types IV and V). Patients were treated for eight weeks under protocols that differed only in that one entered patients with baseline triglyceride (TG) levels of 500 to 1500 mg/dL, and the other TG levels of 350 to 500 mg/dL. In patients with hypertriglyceridemia and normal cholesterolemia with or without hyperchylomicronemia (Type IV/V hyperlipidemia), treatment with fenofibrate at dosages equivalent to 130 mg Antara per day decreased primarily very low density lipoprotein (VLDL) triglycerides and VLDL cholesterol. Treatment of patients with Type IV hyperlipoproteinemia and elevated triglycerides often results in an increase of low density lipoprotein (LDL) cholesterol (see Table 2).

Table 2.
Effects of Fenofibrate in Patients With Fredrickson Type IV/V Hyperlipidemia

Study 1	Placebo				Fenofibrate
Baseline TG levels 350 to 499 mg/dL	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)
Triglycerides	28	449	450	-0.5	27	432	223	-46.2 *
VLDL Triglycerides	19	367	350	2.7	19	350	178	-44.1 *
Total Cholesterol	28	255	261	2.8	27	252	227	-9.1 *
HDL Cholesterol	28	35	36	4	27	34	40	19.6 *
LDL Cholesterol	28	120	129	12	27	128	137	14.5
VLDL Cholesterol	27	99	99	5.8	27	92	46	-44.7 *
Study 2	Placebo				Fenofibrate
Baseline TG levels 500 to 1500 mg/dL	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)
Triglycerides	44	710	750	7.2	48	726	308	-54.5 *
VLDL Triglycerides	29	537	571	18.7	33	543	205	-50.6 *
Total Cholesterol	44	272	271	0.4	48	261	223	-13.8 *
HDL Cholesterol	44	27	28	5.0	48	30	36	22.9 *
LDL Cholesterol	42	100	90	-4.2	45	103	131	45.0 *
VLDL Cholesterol	42	137	142	11.0	45	126	54	-49.4 *
*=p<0.05 vs. placebo

The effect of fenofibrate on cardiovascular morbidity and mortality has not been determined.

INDICATIONS AND USAGE
Treatment of Hypercholesterolemia
Antara is indicated as adjunctive therapy to diet to reduce elevated LDL-C, Total-C, Triglycerides, and Apo B, and to increase HDL-C in adult patients with primary hypercholesterolemia or mixed dyslipidemia (Fredrickson Types IIa and IIb). Lipid-altering agents should be used in addition to a diet restricted in saturated fat and cholesterol when response to diet and non-pharmacological interventions alone has been inadequate (see National Cholesterol Education Program [NCEP] Treatment Guidelines, below).

Treatment of Hypertriglyceridemia
Antara is also indicated as adjunctive therapy to diet for treatment of adult patients with hypertriglyceridemia (Fredrickson Types IV and V hyperlipidemia). Improving glycemic control in diabetic patients showing fasting chylomicronemia will usually reduce fasting triglycerides and eliminate chylomicronemia thereby obviating the need for pharmacologic intervention.

Markedly elevated levels of serum triglycerides (e.g. >2,000 mg/dL) may increase the risk of developing pancreatitis. The effect of Antara therapy on reducing this risk has not been adequately studied.

Drug therapy is not indicated for patients with Type I hyperlipoproteinemia, who have elevations of chylomicrons and plasma triglycerides, but who have normal levels of very low density lipoprotein (VLDL). Inspection of plasma refrigerated for 14 hours is helpful in distinguishing Types I, IV and V hyperlipoproteinemia. 2

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure. Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated. Estrogen therapy, like thiazide diuretics and beta-blockers, is sometimes associated with massive rises in plasma triglycerides, especially in subjects with familial hypertriglyceridemia. In such cases, discontinuation of the specific etiologic agent may obviate the need for specific drug therapy of hypertriglyceridemia.

The use of drugs should be considered only when reasonable attempts have been made to obtain satisfactory results with non-drug methods. If the decision is made to use drugs, the patient should be instructed that this does not reduce the importance of adhering to diet (see WARNINGS and PRECAUTIONS ).

Fredrickson Classification of Hyperlipoproteinemias

Type	Lipoprotein Elevated	Lipid Elevation
		Major	Minor
I (rare)	Chylomicrons	TG	up[harr ]C
IIa	LDL	C	-
IIb	LDL, VLDL	C	TG
III (rare)	IDL	C, TG	-
IV	VLDL	TG	up[harr ]C
V (rare)	Chylomicrons, VLDL	TG	up[harr ]
TG=triglycerides
LDL=low density lipoprotein
VLDL=very low density lipoprotein
IDL=intermediate density lipoprotein

After the LDL-C goal has been achieved, if the TG is still >200 mg/dL, non-HDL-C (total-C minus HDL-C) becomes secondary target of therapy. Non-HDL-C goals are set 30 mg/dL higher than LDL-C goals for each risk category.

CONTRAINDICATIONS
Antara is contraindicated in patients who exhibit hypersensitivity to fenofibrate.

Fenofibrate is contraindicated in patients with hepatic or severe renal dysfunction, including primary biliary cirrhosis, and patients with unexplained persistent liver function abnormality.

Fenofibrate is contraindicated in patients with preexisting gallbladder disease (see WARNINGS ).

WARNINGS
Liver Function:    Fenofibrate at doses equivalent to 87 mg to 130 mg Antara per day has been associated with increases in serum transaminases [AST (SGOT) or ALT (SGPT)]. In a pooled analysis of 10 placebo-controlled trials, increases to >3 times the upper limit of normal occurred in 5.3% of patients taking fenofibrate versus 1.1% of patients treated with placebo.

When transaminase determinations were followed either after discontinuation of treatment or during continued treatment, a return to normal limits was usually observed. The incidence of increases in transaminases related to fenofibrate therapy appear to be dose related. In an 8-week dose-ranging study, the incidence of ALT or AST elevations to at least three times the upper limit of normal was 13% in patients receiving dosages equivalent to 87 mg to 130 mg Antara per day and was 0% in those receiving dosages equivalent to 43 mg or less Antara per day, or placebo. Hepatocellular, chronic active and cholestatic hepatitis associated with fenofibrate therapy have been reported after exposures of weeks to several years. In extremely rare cases, cirrhosis has been reported in association with chronic active hepatitis.

Regular periodic monitoring of liver function, including serum ALT (SGPT) should be performed for the duration of therapy with Antara, and therapy discontinued if enzyme levels persist above three times the normal limit.

Cholelithiasis:  Fenofibrate, like clofibrate and gemfibrozil, may increase cholesterol excretion into the bile, leading to cholelithiasis. If cholelithiasis is suspected, gallbladder studies are indicated. Antara therapy should be discontinued if gallstones are found.

Concomitant Oral Anticoagulants:  Caution should be exercised when anticoagulants are given in conjunction with Antara because of the potentiation of coumarin-type anticoagulants in prolonging the prothrombin time/INR. The dosage of the anticoagulant should be reduced to maintain the prothrombin time/INR at the desired level to prevent bleeding complications. Frequent prothrombin time/INR determinations are advisable until it has been definitely determined that the prothrombin time/INR has stabilized.

Concomitant HMG-CoA Reductase Inhibitors:  The combined use of Antara and HMG-CoA reductase inhibitors should be avoided unless the benefit of further alterations in lipid levels is likely to outweigh the increased risk of this drug combination.

In a single-dose drug interaction study in 23 healthy adults the concomitant administration of fenofibrate and pravastatin resulted in no clinically important difference in the pharmacokinetics of fenofibric acid, pravastatin, or its active metabolite 3(alpha)-hydroxy iso-pravastatin when compared to either drug given alone.

The combined use of fibric acid derivatives and HMG-CoA reductase inhibitors has been associated, in the absence of a marked pharmacokinetic interaction, in numerous case reports, with rhabdomyolysis, markedly elevated creatine kinase (CK) levels and myoglobinuria, leading in a high proportion of cases to acute renal failure.

The use of fibrates alone, including Antara may occasionally be associated with myositis, myopathy, or rhabdomyolysis. Patients receiving Antara and complaining of muscle pain, tenderness, or weakness should have prompt medical evaluation for myopathy, including serum creatine kinase level determination. If myopathy/myositis is suspected or diagnosed, Antara therapy should be stopped.

Mortality:  The effect of Antara on coronary heart disease morbidity and mortality and non-cardiovascular mortality has not been established.

Other Considerations:  In the Coronary Drug Project, a large study of post myocardial infarction of patients treated for 5 years with clofibrate, there was no difference in mortality seen between the clofibrate group and the placebo group. There was however, a difference in the rate of cholelithiasis and cholecystitis requiring surgery between the two groups (3.0% vs. 1.8%).

Because of chemical, pharmacological, and clinical similarities between Atromid-S (clofibrate), and Lopid (gemfibrozil), the adverse findings in 4 large randomized, placebo-controlled clinical studies with these other fibrate drugs may also apply to Antara.

In a study conducted by the World Health Organization (WHO), 5000 subjects without known coronary artery disease were treated with placebo or clofibrate for 5 years and followed for an additional one year. There was a statistically significant, higher age-adjusted all-cause mortality in the clofibrate group compared with the placebo group (5.70% vs. 3.96%, p=<0.01). Excess mortality was due to a 33% increase in non-cardiovascular causes, including malignancy, post-cholecystectomy complications, and pancreatitis. This appeared to confirm the higher risk of gallbladder disease seen in clofibrate-treated patients studied in the Coronary Drug Project.

The Helsinki Heart Study was a large (n=4081) study of middle-aged men without a history of coronary artery disease. Subjects received either placebo or gemfibrozil for 5 years, with a 3.5 year open extension afterward. Total mortality was numerically higher in the gemfibrozil randomization group but did not achieve statistical significance (p=0.19, 95% confidence interval for relative risk G:P=.91-1.64). Although cancer deaths trended higher in the gemfibrozil group (p=0.11), cancers (excluding basal cell carcinoma) were diagnosed with equal frequency in both study groups. Due to the limited size of the study, the relative risk of death from any cause was not shown to be different than that seen in the 9 year follow-up data from World Health Organization study (RR=1.29). Similarly, the numerical excess of gallbladder surgeries in the gemfibrozil group did not differ statistically from that observed in the WHO study.

A secondary prevention component of the Helsinki Heart Study enrolled middle-aged men excluded from the primary prevention study because of known or suspected coronary heart disease. Subjects received gemfibrozil or placebo for 5 years. Although cardiac deaths trended higher in the gemfibrozil group, this was not statistically significant (hazard ratio 2.2, 95% confidence interval: 0.94-5.05). The rate of gallbladder surgery was not statistically significant between study groups, but did trend higher in the gemfibrozil group, (1.9% vs. 0.3%, p=0.07).There was a statistically significant difference in the number of appendectomies in the gemfibrozil group (6/311 vs. 0/317, p=0.029).

PRECAUTIONS
Initial Therapy:  Laboratory studies should be done to ascertain that the lipid levels are consistently abnormal before instituting Antara therapy. Every attempt should be made to control serum lipids with appropriate diet, exercise, weight loss in obese patients, and control of any medical problems such as diabetes mellitus and hypothyroidism that are contributing to the lipid abnormalities. Medications known to exacerbate hypertriglyceridemia (beta-blockers, thiazides, estrogens) should be discontinued or changed if possible prior to consideration of triglyceride-lowering drug therapy.

Continued Therapy:  Periodic determination of serum lipids should be obtained during initial therapy in order to establish the lowest effective dose of Antara. Therapy should be withdrawn in patients who do not have an adequate response after two months of treatment with the maximum recommended dose of 130 mg per day.

Pancreatitis:  Pancreatitis has been reported in patients taking fenofibrate, gemfibrozil, and clofibrate. This occurrence may represent a failure of efficacy in patients with severe hypertriglyceridemia, a direct drug effect, or a secondary phenomenon mediated through biliary tract stone or sludge formation with obstruction of the common bile duct.

Hypersensitivity Reactions:  Acute hypersensitivity reactions including severe skin rashes requiring patient hospitalization and treatment with steroids have occurred very rarely during treatment with fenofibrate, including rare spontaneous reports of Stevens-Johnson syndrome, and toxic epidermal necrolysis. Urticaria was seen in 1.1 vs 0%, and rash in 1.4 vs 0.8% of fenofibrate and placebo patients, respectively, in controlled trials.

Hematologic Changes:  Mild to moderate hemoglobin, hematocrit, and white blood cell decreases have been observed in patients following initiation of fenofibrate therapy. However, these levels stabilize during long-term administration. Extremely rare spontaneous reports of thrombocytopenia and agranulocytosis have been received during post-marketing surveillance outside of the U.S. Periodic blood counts are recommended during the first 12 months of Antara administration.

Skeletal Muscle:  The use of fibrates alone, including Antara, may occasionally be associated with myopathy. Treatment with drugs of the fibrate class has been associated on rare occasions with rhabdomyolysis, usually in patients with impaired renal function. Myopathy should be considered in any patient with diffuse myalgias, muscle tenderness or weakness, and/or marked elevations of creatine phosphokinase (CPK) levels.

Patients should be advised to report promptly unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever. CPK levels should be assessed in patients reporting these symptoms, and fenofibrate therapy should be discontinued if markedly elevated CPK levels occur or myopathy is diagnosed.

Drug Interactions:
Oral Anticoagulants:  CAUTION SHOULD BE EXERCISED WHEN COUMARIN ANTICOAGULANTS ARE GIVEN IN CONJUNCTION WITH ANTARA. THE DOSAGE OF THE ANTICOAGULANTS SHOULD BE REDUCED TO MAINTAIN THE PROTHROMBIN TIME/INR AT THE DESIRED LEVEL TO PREVENT BLEEDING COMPLICATIONS. FREQUENT PROTHROMBIN TIME/INR DETERMINATIONS ARE ADVISABLE UNTIL IT HAS BEEN DEFINITELY DETERMINED THAT THE PROTHROMBIN TIME/INR HAS STABILIZED.

HMG-CoA Reductase Inhibitors:  The combined use of Antara and HMG-CoA reductase inhibitors should be avoided unless the benefit of further alterations in lipid levels is likely to outweigh the increased risk of this drug combination (see WARNINGS ).

Resins:  Since bile acid sequestrants may bind other drugs given concurrently, patients should take Antara at least 1 hour before or 4-6 hours after a bile acid binding resin to avoid impeding its absorption.

Cyclosporine:  Because cyclosporine can produce nephrotoxicity with decreases in creatinine clearance and rises in serum creatinine, and because renal excretion is the primary elimination route of fibrate drugs including Antara, there is a risk that an interaction will lead to deterioration. The benefits and risks of using Antara with immunosuppressants and other potentially nephrotoxic agents should be carefully considered, and the lowest effective dose employed.

Carcinogenesis, Mutagenesis, Impairment of Fertility: In a 24-month study in rats (10, 45, and 200 mg/kg; 0.3, 1, and 6 times the maximum recommended human dose on the basis of mg/meter 2 of surface area), the incidence of liver carcinoma was significantly increased at 6 times the maximum recommended human dose in males and females. A statistically significant increase in pancreatic carcinomas occurred in males at 1 and 6 times the maximum recommended human dose; there were also increases in pancreatic adenomas and benign testicular interstitial cell tumors at 6 times the maximum recommended human dose in males. In a second 24-month study in a different strain of rats (doses of 10 and 60 mg/kg; 0.3 and 2 times the maximum recommended human dose based on mg/meter 2 surface area), there were significant increases in the incidence of pancreatic acinar adenomas in both sexes and increases in interstitial cell tumors of the testes at 2 times the maximum recommended human dose.

A comparative carcinogenicity study was done in rats comparing three drugs: fenofibrate (10 and 70 mg/kg; 0.3 and 1.6 times the maximum recommended human dose), clofibrate (400 mg/kg; 1.6 times the human dose), and gemfibrozil (250 mg/kg; 1.7 times the human dose) (multiples based on mg/meter 2 surface area). Pancreatic acinar adenomas were increased in males and females on fenofibrate; hepatocellular carcinoma and pancreatic acinar adenomas were increased in males and hepatic neoplastic nodules in females treated with clofibrate; hepatic neoplastic nodules were increased in males and females treated with gemfibrozil while testicular interstitial cell tumors were increased in males on all three drugs.

In a 21-month study in mice at doses of 10, 45, and 200 mg/kg (approximately 0.2, 0.7 and 3 times the maximum recommended human dose on the basis of mg/meter 2 surface area), there were statistically significant increases in liver carcinoma at 3 times the maximum recommended human dose in both males and females. In a second 18-month study at the same doses, there was a significant increase in liver carcinoma in male mice and liver adenoma in female mice at 3 times the maximum recommended human dose.

Electron microscopy studies have demonstrated peroxisomal proliferation following fenofibrate administration to the rat. An adequate study to test for peroxisome proliferation in humans has not been done, but changes in peroxisome morphology and numbers have been observed in humans after treatment with other members of the fibrate class when liver biopsies were compared before and after treatment in the same individual.

Fenofibrate has been demonstrated to be devoid of mutagenic potential in the following tests: Ames, mouse lymphoma, chromosomal aberration, and unscheduled DNA synthesis.

Pregnancy Category C: Fenofibrate has been shown to be embryocidal and teratogenic in rats when given in doses 7 to 10 times the maximum recommended human dose and embryocidal in rabbits when given at 9 times the maximum recommended human dose (on the basis of mg/meter 2 surface area). There are no adequate and well-controlled studies in pregnant women. Fenofibrate should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Administration of 9 times the maximum recommended human dose of fenofibrate to female rats before and throughout gestation caused 100% of dams to delay delivery and resulted in a 60% increase in post-implantation loss, a decrease in litter size, a decrease in birth weight, a 40% survival of pups at birth, a 4% survival of pups as neonates, and a 0% survival of pups to weaning, and an increase in spina bifida.

Administration of 10 times the maximum recommended human dose to female rats on days 6-15 of gestation caused an increase in gross, visceral and skeletal findings in fetuses (domed head/hunched shoulders/rounded body/abnormal chest, kyphosis, stunted fetuses, elongated sternal ribs, malformed sternebrae, extra foramen in palatine, misshapen vertebrae, supernumerary ribs).

Administration of 7 times the maximum recommended human dose to female rats from day 15 of gestation through weaning caused a delay in delivery, a 40% decrease in live births, a 75% decrease in neonatal survival, and decreases in pup weight, at birth as well as on days 4 and 21 post-partum.

Administration of 9 and 18 times the maximum recommended human dose to female rabbits caused abortions in 10% of dams at 9 times and 25% of dams at 18 times the maximum recommended human dose and death of 7% of fetuses at 18 times the maximum recommended human dose.

Nursing mothers:  Fenofibrate should not be used in nursing mothers. Because of the potential for tumorigenicity seen in animal studies, a decision should be made whether to discontinue nursing or to discontinue the drug.

Pediatric Use: Safety and efficacy in pediatric patients have not been established.

Geriatric Use: Fenofibric acid is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection.

ADVERSE REACTIONS
CLINICAL: Adverse events reported by 2% or more of patients treated with fenofibrate during the double-blind, placebo-controlled trials, regardless of causality, are listed in the table below. Adverse events led to discontinuation of treatment in 5.0% of patients treated with fenofibrate and in 3.0% treated with placebo. Increases in liver function tests were the most frequent events, causing discontinuation of fenofibrate treatment in 1.6% of patients in double-blind trials.

BODY SYSTEM Adverse Event	Fenofibrate * (N=439)	Placebo (N=365)
BODY AS A WHOLE
Abdominal Pain	4.6%	4.4%
Back Pain	3.4%	2.5%
Headache	3.2%	2.7%
Asthenia	2.1%	3.0%
Flu Syndrome	2.1%	2.7%
DIGESTIVE
Liver Function Tests     Abnormal	7.5% **	1.4%
Diarrhea	2.3%	4.1%
Nausea	2.3%	1.9%
Constipation	2.1%	1.4%
METABOLIC AND NUTRITIONAL DISORDERS
SGPT Increased	3.0%	1.6%
Creatine Phosphokinase     Increased	3.0%	1.4%
SGOT Increased	3.4% **	0.5%
RESPIRATORY
Respiratory Disorder	6.2%	5.5%
Rhinitis	2.3%	1.1%
*Dosage equivalent to 130 mg Antara
**Significantly different from placebo

Additional adverse events reported by three or more patients in placebo-controlled trials or reported in other controlled or open trials, regardless of causality are listed below.

BODY AS A WHOLE: Chest pain, pain (unspecified), infection, malaise, allergic reaction, cyst, hernia, fever, photosensitivity reaction, and accidental injury.

CARDIOVASCULAR SYSTEM: Angina pectoris, hypertension, vasodilatation, coronary artery disorder, electrocardiogram abnormal, ventricular extrasystoles, myocardial infarct, peripheral vascular disorder, migraine, varicose vein, cardiovascular disorder, hypotension, palpitation, vascular disorder, arrhythmia, phlebitis, tachycardia, extrasystoles, and atrial fibrillation.

DIGESTIVE SYSTEM: Dyspepsia, flatulence, nausea, increased appetite, gastroenteritis, cholelithiasis, rectal disorder, esophagitis, gastritis, colitis, tooth disorder, vomiting, anorexia, gastrointestinal disorder, duodenal ulcer, nausea and vomiting, peptic ulcer, rectal hemorrhage, liver fatty deposit, cholecystitis, eructation, gamma glutamyl transpeptidase, and diarrhea.

ENDOCRINE SYSTEM: Diabetes mellitus.

HEMIC AND LYMPHATIC SYSTEM: Anemia, leukopenia, ecchymosis, eosinophilia, lymphadenopathy, and thrombocytopenia.

METABOLIC AND NUTRITIONAL DISORDERS: Creatinine increased, weight gain, hypoglycemia, gout, weight loss, edema, hyperuricemia, and peripheral edema.

MUSCULOSKELETAL SYSTEM: Myositis, myalgia, arthralgia, arthritis, tenosynovitis, joint disorder, arthrosis, leg cramps, bursitis, and myasthenia.

NERVOUS SYSTEM: Dizziness, insomnia, depression, vertigo, libido decreased, anxiety, paresthesia, dry mouth, hypertonia, nervousness, neuralgia, and somnolence.

RESPIRATORY SYSTEM: Pharyngitis, bronchitis, cough increased, dyspnea, asthma, pneumonia, laryngitis, and sinusitis.

SKIN AND APPENDAGES: Rash, pruritus, eczema, herpes zoster, urticaria, acne, sweating, fungal dermatitis, skin disorder, alopecia, contact dermatitis, herpes simplex, maculopapular rash, nail disorder, and skin ulcer.

SPECIAL SENSES: Conjunctivitis, eye disorder, amblyopia, ear pain, otitis media, abnormal vision, cataract specified, and refraction disorder.

UROGENITAL SYSTEM: Urinary frequency, prostatic disorder, dysuria, kidney function abnormal, urolithiasis, gynecomastia, unintended pregnancy, vaginal moniliasis, and cystitis.

OVERDOSAGE
There is no specific treatment for overdose with Antara. General supportive care of the patient is indicated, including monitoring of vital signs and observation of clinical status, should an overdose occur. If indicated, elimination of unabsorbed drug should be achieved by emesis or gastric lavage; usual precautions should be observed to maintain the airway. Because fenofibrate is highly bound to plasma proteins, hemodialysis should not be considered.

DOSAGE AND ADMINISTRATION
Patients should be placed on an appropriate lipid-lowering diet before receiving Antara, and should continue this diet during treatment with Antara. Antara capsules should be taken with meals, thereby optimizing the bioavailability of the medication.

For the treatment of adult patients with primary hypercholesterolemia or mixed hyperlipidemia, the initial dose of Antara is 130 mg per day.

For adult patients with hypertriglyceridemia, the initial dose is 43 to 130 mg per day. Dosage should be individualized according to patient response, and should be adjusted if necessary following repeat lipid determinations at 4 to 8 week intervals. The maximum dose is 130 mg per day.

Treatment with Antara should be initiated at a dose of 43 mg/day in patients having impaired renal function, and increased only after evaluation of the effects on renal function and lipid levels at this dose. In the elderly, the initial dose should likewise be limited to 43 mg/day.

Lipid levels should be monitored periodically and consideration should be given to reducing the dosage of Antara if lipid levels fall significantly below the targeted range.

HOW SUPPLIED
Antara (fenofibrate) Capsules, is available in three strengths:

43 mg capsules, imprinted with "43" and a segmented band, on the light green cap and "RH405" with the Reliant logo on the white to off-white body, available in bottles of 30 (NDC # 65726-401-10) and 100 (NDC # 65726-401-25).

87 mg capsules, imprinted with "87" and a segmented band, on the dark green cap and "RH405" with the Reliant logo on the light green body, available in bottles of 30 (NDC # 65726-402-10) and 100 (NDC # 65726-402-25).

130 mg capsules, imprinted with "130" and a segmented band, on the dark green cap and "RH405" with the Reliant logo on the white body, available in bottles of 30 (NDC # 65726-403-10) and 100 (NDC # 65726-403-25).

Storage

Store at 25°C (77°F); excursions permitted to 15°-30°C (59°-86°F) [see USP Controlled Room Temperature] in a tightly closed container.