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英文药名：FYCOMPA(perampanel) 中文药名：吡仑帕奈片 生产厂家：卫材（Eisai）
Fycompa
Fycompa (perampanel) is indicated as adjunctive therapy for the treatment of partial-onset seizures with or without secondarily generalized seizures in patients with epilepsy aged 12 years and older. Table 1 shows absolute and relative risk by indication for all evaluated AEDs.
The relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications. Anyone considering prescribing Fycompa or any other AED must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated. Patients, their caregivers, and families should be informed that AEDs increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. Behaviors of concern should be reported immediately to healthcare providers. Neurologic Effects Dizziness and Gait Disturbance Fycompa caused dose-related increases in events related to dizziness and disturbance in gait or coordination [see Adverse Reactions (6.1)]. In the controlled Phase 3 epilepsy clinical trials, dizziness and vertigo were reported in 35% and 47% of patients randomized to receive Fycompa at doses of 8 mg and 12 mg/day, respectively, compared to 10% of placebo-treated patients. The gait disturbance related events (including ataxia, gait disturbance, balance disorder, and coordination abnormal) were reported in 12% and 16% of patients randomized to receive Fycompa at doses of 8 mg and 12 mg/day, respectively, compared to 2% of placebo-treated patients. These adverse reactions occurred mostly during the titration phase and led to discontinuation in 3% of perampanel-treated subjects compared to 1% of placebo-treated patients. Elderly patients had an increased risk of these adverse reactions compared to younger adults and adolescents. Somnolence and Fatigue Fycompa caused dose-dependent increases in somnolence and fatigue-related events (including fatigue, asthenia, and lethargy). In the controlled Phase 3 epilepsy clinical trials, 16% and 18% of patients randomized to receive Fycompa at doses of 8 mg and 12 mg/day, respectively, reported somnolence compared to 7% of placebo patients. In the controlled Phase 3 epilepsy clinical trials, 12% and 15% of patients randomized to receive Fycompa at doses of 8 mg and 12 mg/day, respectively, reported fatigue-related events compared to 5% of placebo patients. Somnolence or fatigue-related events led to discontinuation in 2% of perampanel-treated patients and 0.5% of placebo-treated patients. Elderly patients had an increased risk of these adverse reactions compared to younger adults and adolescents. Risk Amelioration Prescribers should advise patients against engaging in hazardous activities requiring mental alertness, such as operating motor vehicles or dangerous machinery, until the effect of Fycompa is known. In the controlled Phase 3 epilepsy clinical trials these adverse reactions occurred mostly during the titration phase. Falls An increased risk of falls, in some cases leading to serious injuries including head injuries and bone fracture, occurred in patients being treated with Fycompa (with and without concurrent seizures). In the controlled Phase 3 epilepsy clinical trials, falls were reported in 5% and 10% of patients randomized to receive Fycompa at doses of 8 mg and 12 mg/day, respectively, compared to 3% of placebo-treated patients. Falls were reported as serious and led to discontinuation more frequently in Fycompa-treated patients than placebo-treated patients. Elderly patients had an increased risk of falls compared to younger adults and adolescents. Withdrawal of Antiepileptic Drugs There is the potential of increased seizure frequency in patients with seizure disorders when anti-epileptic drugs are withdrawn abruptly. Fycompa has a half-life of approximately 105 hours so that even after abrupt cessation, blood levels fall gradually. In anti-epileptic clinical trials Fycompa was withdrawn without down-titration. Although a small number of patients exhibited seizures following discontinuation, the data were not sufficient to allow any recommendations regarding appropriate withdrawal regimens. A gradual withdrawal is generally recommended with anti-epileptic drugs, but if withdrawal is a response to adverse events, prompt withdrawal can be considered. Adverse Reactions The following adverse reactions are discussed in more detail in other sections of the prescribing information:
Clinical Trial Experience 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 clinical practice. A total of 1,038 patients on perampanel (2, 4, 8, or 12 mg once daily) constituted the safety population in the pooled analysis of Phase 3 placebo controlled studies (Studies 1, 2, and 3) in patients with partial onset seizures. Approximately 51% of patients were female and the mean age was 35 years. Adverse Reactions Leading to Discontinuation In controlled Phase 3 clinical trials (Studies 1, 2, and 3), the rate of discontinuation as a result of an adverse reaction was 3%, 8% and 19% in patients randomized to receive Fycompa at the recommended doses of 4 mg, 8 mg and 12 mg/day, respectively, and 5% in patients randomized to receive placebo [see Clinical Studies (14)]. The adverse events most commonly leading to discontinuation (≥1% in the 8 mg or 12 mg Fycompa group and greater than placebo) were dizziness, somnolence, vertigo, aggression, anger, ataxia, blurred vision, irritability, and dysarthria [see Warnings and Precautions (5.1 and 5.3)]. Most Common Adverse Reactions Table 2 gives the incidence in the Phase 3 controlled trials (Studies 1, 2, and 3) of the adverse reactions that occurred in ≥2% of patients with partial-onset seizures in any Fycompa dose group. Overall, the most frequently reported dose-related adverse reactions in patients receiving Fycompa at doses of 8 mg or 12 mg (≥4% and occurring at least 1% higher than the placebo group) included dizziness (36%), somnolence (16%), fatigue (10%), irritability (9%), falls (7%), nausea (7%), ataxia (5%), balance disorder (4%), gait disturbance (4%), vertigo (4%), and weight gain (4%). For almost every adverse reaction, rates were higher on 12 mg and more often led to dose reduction or discontinuation.
Weight Gain Weight gain has been observed with Fycompa use in adults. In the controlled Phase 3 epilepsy clinical trials, Fycompa-treated adults gained an average of 1.1 kg (2.5 lbs) compared to an average of 0.3 kg (0.7 lbs) in placebo-treated adults with a median exposure of 19 weeks. The percentages of adults who gained at least 7% and 15% of their baseline body weight in Fycompa-treated patients were 9.1% and 0.9%, respectively, as compared to 4.5% and 0.2% of placebo-treated patients, respectively. Clinical monitoring of weight is recommended. Comparison of Sex and Race No significant sex differences were noted in the incidence of adverse reactions. Although there were few non-Caucasian patients, no differences in the incidences of adverse reactions compared to Caucasian patients were observed. Drug Interactions Contraceptives With concomitant use, Fycompa at a dose of 12 mg/day reduced levonorgestrel exposure by approximately 40% [see Clinical Pharmacology (12.3)]. Use of Fycompa with oral or implant contraceptives containing levonorgestrel may render them less effective. Additional non-hormonal forms of contraception are recommended. Cytochrome P450 (CYP) Inducers The concomitant use of known CYP enzyme inducers including carbamazepine, phenytoin, or oxcarbazepine with Fycompa decreased the plasma levels of perampanel by approximately 50~67% [see Clinical Pharmacology (12.3)]. The starting doses for Fycompa should be increased in the presence of enzyme-inducing AEDs [see Dosage and Administration (2.1)]. When these enzyme-inducing AEDs are introduced or withdrawn from a patient's treatment regimen, patient should be closely monitored for clinical response and tolerability. Dose adjustment of Fycompa may be necessary. As noted, however, the decrease in the therapeutic effect seen in patients on concomitant treatment, was not affected by use of higher doses (8 mg to 12 mg) [see Dosage and Administration (2.1)]. Concomitant use of Fycompa with other strong CYP3A inducers (e.g., rifampin, St. John's wort) should be avoided. Alcohol and Other CNS Depressants The concomitant use of Fycompa and CNS depressants including alcohol may increase CNS depression. A pharmacodynamic interaction study in healthy subjects found that the effects of Fycompa on complex tasks such as driving ability were additive or supra-additive to the impairment effects of alcohol [see Clinical Pharmacology (12.3)]. Multiple dosing of Fycompa 12 mg/day also enhanced the effects of alcohol to interfere with vigilance and alertness, and increased levels of anger, confusion, and depression. These effects may also be seen when Fycompa is used in combination with other CNS depressants. Care should be taken when administering Fycompa with these agents. Patients should limit activity until they have experience with concomitant use of CNS depressants (e.g. benzodiazepines, narcotics, barbiturates, sedating antihistamines). Advise patients not to drive or operate machinery until they have gained sufficient experience on Fycompa to gauge whether it adversely affects these activities. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C There are no adequate and well-controlled studies in pregnant women. In animal studies, perampanel induced developmental toxicity in pregnant rat and rabbit at clinically relevant doses. Fycompa should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Oral administration of perampanel (1, 3, or 10 mg/kg/day) to pregnant rats throughout organogenesis resulted in an increase in visceral abnormalities (diverticulum of the intestine) at all doses tested. In a dose-ranging study at higher oral doses (10, 30, or 60 mg/kg/day), embryo lethality and reduced fetal body weight were observed at the mid and high doses tested. The lowest dose tested (1 mg/kg/day) is similar to a human dose of 8 mg/day based on body surface area (mg/m2). Upon oral administration of perampanel (1, 3, or 10 mg/kg/day) to pregnant rabbits throughout organogenesis, embryo lethality was observed at the mid and high doses tested; the no effect dose for embryo-fetal developmental toxicity in rabbit (1 mg/kg/day) is approximately 2 times a human dose of 8 mg/day based on body surface area (mg/m2). Oral administration of perampanel (1, 3, or 10 mg/kg/day) to rats throughout gestation and lactation resulted in fetal and pup deaths at the mid and high doses and delayed sexual maturation in males and females at the highest dose tested. No effects were observed on measures of neurobehavioral or reproductive function in the offspring. The no-effect dose for pre- and postnatal developmental toxicity in rat (1 mg/kg/day) is similar to a human dose of 8 mg/day based on body surface area (mg/m2). Pregnancy Registry To provide information regarding the effects of in utero exposure to Fycompa, physicians are advised to recommend that pregnant patients taking Fycompa enroll in the North American Antiepileptic Drug (NAAED) Pregnancy Registry. This can be done by calling the toll free number 1-888-233-2334, and must be done by patients themselves. Information on the registry can also be found at the website: Nursing Mothers Perampanel and/or its metabolites are excreted in rat milk, and are detected at concentrations higher than that in maternal plasma. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Fycompa is administered to a nursing woman. Pediatric Use The safety and efficacy of Fycompa for the adjunctive therapy of partial-onset seizures was established by three randomized double blind, placebo-controlled, multicenter studies which included 72 pediatric patients between 12 and 16 years old exposed to perampanel [see Clinical Studies (14.1), Clinical Pharmacology (12.3)]. The safety and effectiveness of Fycompa in pediatric patients <12 years old have not been established. Juvenile Animal Data Oral administration of perampanel (1, 3, 3/10/30 mg/kg/day; high dose increased on postnatal days [PND] 28 and 56) to young rats for 12 weeks starting on PND 7 resulted in reduced body weight, reduced growth, neurobehavioral impairment (water maze performance and auditory startle habituation) at the mid and high doses, and delayed sexual maturation at the high doses. CNS signs (reduced activity, incoordination, excessive grooming/scratching), pup death, decreased hindlimb splay, and decreased hindlimb grip strength were observed at all doses. Effects on pup body weight, pup growth, hindlimb splay, impairment in the water maze performance and auditory startle persisted after dosing was stopped. A no-effect dose for postnatal developmental toxicity was not identified in this study. Oral administration of perampanel (1, 5, 5/10 mg/kg/day; high dose increased on PND 56) to juvenile dogs for 33 weeks, starting on PND 42, resulted in CNS signs (incoordination, excessive grooming/licking/scratching, spatial disorientation, and/or ataxic gait) at all doses tested. Geriatric Use Clinical studies of Fycompa did not include sufficient numbers of patients aged 65 and over to determine the safety and efficacy of Fycompa in the elderly population. Because of increased likelihood for adverse reactions in the elderly dosing titration should proceed slowly in patients aged 65 years and older [see Dosage and Administration (2.1)]. Patients with Hepatic Impairment Use of Fycompa in patients with severe hepatic impairment is not recommended and dosage adjustments are recommended in patients with mild or moderate hepatic impairment [see Dosage and Administration (2.2), Clinical Pharmacology (12.3)]. Patients with Renal Impairment Dose adjustment is not required in patients with mild renal impairment. Fycompa should be used with caution in patients with moderate renal impairment and slower titration may be considered. Use in patients with severe renal impairment or patients undergoing hemodialysis is not recommended [see Dosage and Administration (2.3), Clinical Pharmacology (12.3)]. Drug Abuse and Dependence Controlled Substance Fycompa contains perampanel, (Schedule to be determined after DEA review). Abuse Prescription drug abuse is the intentional non-therapeutic use of a drug, even once, for its rewarding psychological or physiological effects. Drug addiction, which develops after repeated drug abuse, is characterized by a strong desire to take a drug despite harmful consequences, difficulty in controlling its use, giving a higher priority to drug use than to obligations, increased tolerance, and sometimes physical withdrawal. Drug abuse and drug addiction are separate and distinct from physical dependence (for example, abuse may not be accompanied by physical dependence) [see Drug Abuse and Dependence (9.3)]. Studies of human abuse potential were performed to evaluate the abuse potential of Fycompa (8 mg, 24 mg, and 36 mg) as compared to alprazolam C-IV (1.5 mg and 3 mg), and oral ketamine C-III (100 mg) in recreational polydrug users. Supra-therapeutic doses of Fycompa 24 and 36 mg produced responses for "Euphoria" that were similar to ketamine 100 mg and alprazolam 3 mg. For "High," Fycompa 24 mg and 36 mg produced responses comparable to ketamine 100 mg and significantly higher than both doses of alprazolam on a visual analog scale (VAS). "Drug Liking", "Overall Drug Liking", and "Take Drug Again" for Fycompa were each statistically lower than ketamine 100mg. In addition, for "Bad Drug Effects", Fycompa 24 mg and 36 mg produced responses significantly higher than ketamine 100mg. For "Sedation," Fycompa 24 and 36 mg produced responses similar to alprazolam 3 mg and higher than ketamine 100 mg. Additionally, on VAS measures related to dissociative phenomena such as "Floating", "Spaced Out" and "Detached," Fycompa at supra-therapeutic doses produced responses similar to ketamine 100 mg and greater than both doses of alprazolam tested. Of note, due to somnolence a number of subjects had missing data around Tmax of Fycompa. The above described data might represent an underestimate of Fycompa's effects. The duration of effects of higher doses of Fycompa on the majority of measures was much greater than alprazolam 3 mg and ketamine 100 mg. In this study, the incidence of euphoria following Fycompa administration 8 mg, 24 mg and 36 mg was 37%, 46%, 46%, respectively, which was higher than alprazolam 3 mg (13%) but lower than ketamine 100 mg (89%). Dependence Physical dependence is characterized by withdrawal symptoms after abrupt discontinuation or a significant dose reduction of a drug. The potential for Fycompa to produce withdrawal symptoms has not been adequately evaluated. Overdosage Signs, Symptoms, and Laboratory Findings of Acute Overdose in Humans There is limited clinical experience with Fycompa overdose. The highest reported overdose (approximately 264 mg) was intentional. This patient experienced serious adverse reactions of altered mental status, agitation, and aggressive behavior and recovered without sequelae. In general, the adverse reactions associated with overdoses were similar to the reactions at therapeutic doses with dizziness reported most frequently. There were no reported sequelae. Treatment or Management of Overdose There is no available specific antidote to the overdose reactions of Fycompa. In the event of overdose, standard medical practice for the management of any overdose should be used. An adequate airway, oxygenation, and ventilation should be ensured; monitoring of cardiac rhythm and vital sign measurement is recommended. A certified poison control center should be contacted for updated information on the management of overdose with Fycompa. Due to its long half-life, the reactions caused by Fycompa could be prolonged. Fycompa Description Fycompa tablets contain perampanel, a non-competitive AMPA receptor antagonist. Perampanel is described chemically as 2-(2-oxo-1-phenyl-5-pyridin-2-yl-1,2-dihydropyridin-3-yl) benzonitrile hydrate (4:3). The molecular formula is C23H15N3O • 3/4H2O and the molecular weight is 362.90 (3/4 hydrate). The chemical structure of perampanel is: Perampanel is a white to yellowish white powder. It is freely soluble in N-methylpyrrolidone, sparingly soluble in acetonitrile and acetone, slightly soluble in methanol, ethanol and ethyl acetate, very slightly soluble in 1-octanol and diethyl ether and practically insoluble in heptane and water. Fycompa (perampanel) tablets are round, bi-convex, film coated tablets containing 2 mg, 4 mg, 6 mg, 8 mg, 10 mg or 12 mg of perampanel. Tablets contain the following inactive ingredients: lactose monohydrate, low substituted hydroxypropyl cellulose, povidone, microcrystalline cellulose, magnesium stearate, hypromellose, polyethylene glycol, talc and titanium dioxide. Tablets of different strengths also may contain yellow ferric oxide (10 mg and 2 mg), red ferric oxide (2 mg, 4 mg, 6 mg, 8 mg), black ferric oxide (8 mg) and FD&C blue # 2 indigo carmine aluminum lake (10 mg and 12 mg). Fycompa - Clinical Pharmacology Mechanism of Action Perampanel is a non-competitive antagonist of the ionotropic α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) glutamate receptor on post-synaptic neurons. Glutamate is the primary excitatory neurotransmitter in the central nervous system and is implicated in a number of neurological disorders caused by neuronal over excitation. The precise mechanism by which Fycompa exerts its antiepileptic effects in humans has not been fully elucidated. Pharmacodynamics Psychomotor Performance. In a healthy volunteer study to assess the effects of Fycompa on psychomotor performance using a standard battery of assessments including simulated driving, single and multiple daily doses of Fycompa 4 mg did not impair simple psychomotor tasks, driving performance or sensori-motor coordination. Single and multiple doses of 8 mg and 12 mg impaired psychomotor performance in a dose-related manner. Car handling ability was impaired after dosing of Fycompa 12 mg, but postural stability was not significantly impaired. Performance testing returned to baseline within 2 weeks of cessation of Fycompa dosing. Interactions with Alcohol. In the above study (See Psychomotor Performance), when administered to healthy subjects receiving alcohol to achieve a blood concentration of 80-100mg/100mL, Fycompa consistently impaired simple psychomotor performance after single doses of 4 to 12 mg, and after 21 days of multiple 12 mg/day doses. The effects of Fycompa on complex tasks such as driving ability were additive or supra-additive to the impairment effects of alcohol. Fycompa enhanced the effects of alcohol on vigilance and alertness, and increased levels of anger, confusion, and depression. Potential to Prolong QT Interval. In a placebo-controlled thorough QT study perampanel in healthy subjects, there was no evidence that perampanel caused QT interval prolongation of clinical significance at doses of 6 or 12 mg (i.e., the upper bound of the 95% confidence interval for the largest placebo-adjusted baseline-corrected QTc was below 10 msec). The exposures observed with the 12 mg dose in this study will not cover the exposures expected in patients with hepatic impairment taking doses over 6 mg/day. At the maximum recommended dose (12 mg), perampanel did not prolong the QTc interval to any clinically relevant extent. Pharmacokinetics Pharmacokinetics of perampanel are similar in healthy subjects and patients with partial-onset seizures. The half-life of perampanel is about 105 hours, so that steady state is reached in about 2-3 weeks. AUC of perampanel increased in a dose-proportional manner after single-dose administration of 0.2-12 mg and after multiple-dose administration of 1-12 mg once daily. Absorption Perampanel is rapidly and completely absorbed after oral administration with negligible first-pass metabolism. Median Tmax ranged from 0.5 to 2.5 hours under fasted condition. Food does not affect the extent of absorption (AUC), but slows the rate of absorption. Under fed conditions, Cmax of perampanel was decreased by 28-40% and Tmax was delayed by 2-3 hours compared to that under fasted conditions. Distribution Data from in vitro studies indicate that, in the concentration range of 20 to 2000 ng/mL, perampanel is approximately 95-96% bound to plasma proteins, mainly bound to albumin and α1-acid glycoprotein. Blood to plasma ratio of perampanel is 0.55-0.59. Metabolism Perampanel is extensively metabolized via primary oxidation and sequential glucuronidation. Oxidative metabolism is mediated by CYP3A4 and/or CYP3A5 based on results of in vitro studies using recombinant human CYPs and human liver microsomes. Other CYP enzymes may also be involved. Following administration of radiolabeled perampanel, unchanged perampanel accounted for 74-80% of total radioactivity in systemic circulation, whereas only trace amounts of individual perampanel metabolites were detected in plasma. Elimination Following administration of a radiolabeled perampanel dose to 8 healthy elderly subjects, 22% of administered radioactivity was recovered in the urine and 48% in the feces. In urine and feces, recovered radioactivity was primarily composed of a mixture of oxidative and conjugated metabolites. Population pharmacokinetic analysis of pooled data from 19 Phase 1 studies reported that t1/2 of perampanel was 105 hours on average. Apparent clearance of perampanel in healthy subjects and patients was approximately 12 mL/min. Specific Populations Hepatic Impairment The pharmacokinetics of perampanel following a single 1 mg dose were evaluated in 12 subjects with mild and moderate hepatic impairment (Child-Pugh A and B, respectively) compared with 12 demographically matched healthy subjects. The total (free and protein bound) exposure (AUC0-inf) of perampanel was 50% greater in subjects with mild hepatic impairment and more than doubled (2.55-fold) in subjects with moderate hepatic impairment compared to their healthy controls. The AUC0-inf of free perampanel in subjects with mild and moderate hepatic impairment was 1.8-fold and 3.3-fold, respectively, of those in matched healthy controls. The t1/2 was prolonged in subjects with mild impairment (306 vs. 125 hours) and moderate impairment (295 vs. 139 hours). Perampanel has not been studied in subjects with severe hepatic impairment [see Dosage and Administration (2.2), Use in Specific Populations (8.6)]. Renal Impairment A dedicated study has not been conducted to evaluate the pharmacokinetics of perampanel in patients with renal impairment. Population pharmacokinetic analysis was performed on pooled data from patients with partial-onset seizures and receiving Fycompa up to 12 mg/day in placebo-controlled clinical trials. Results showed that perampanel apparent clearance was decreased by 27% in patients with mild renal impairment (creatinine clearance 50-80 mL/min) compared to patients with normal renal function (creatinine clearance > 80 mL/min), with a corresponding 37% increase in AUC. Considering the substantial overlap in the exposure between normal and mildly impaired patients, no dosage adjustment is necessary for patients with mild renal impairment. Perampanel has not been studied in patients with severe renal impairment and patients undergoing hemodialysis [see Dosage and Administration (2.3), Use in Specific Populations (8.7)]. Sex In a population pharmacokinetic analysis of patients with partial-onset seizures receiving Fycompa in placebo-controlled clinical trials, perampanel apparent clearance in females (0.605 L/hr) was 17% lower than in males (0.730 L/hr). No dosage adjustment is necessary based on sex. Pediatric Patients Fycompa has not been studied in patients <12 years old. In a population pharmacokinetic analysis of patients with partial-onset seizures ranging in age from 12 to 74 years receiving Fycompa in placebo-controlled trials, apparent clearance of perampanel in adolescents (0.787 L/hr) was slightly, but not significantly, higher than that in adults. Pediatric patients above 12 years old can be dosed similarly to adults. Geriatrics In a population pharmacokinetic analysis of patients with partial-onset seizures ranging in age from 12 to 74 years receiving Fycompa in placebo-controlled trials, no significant effect of age on perampanel apparent clearance was found [see Dosage and Administration (2.1), Use in Specific Populations (8.5)]. Race In a population pharmacokinetic analysis of patients with partial-onset seizures which included 576 Caucasians, 14 Blacks, 97 non-Chinese Asians, and 62 Chinese receiving Fycompa in placebo-controlled trials, no significant effect of race on perampanel apparent clearance was found. No dosage adjustment is necessary. Drug Interaction Studies In Vitro Assessment of Drug Interactions Drug Metabolizing Enzymes In human liver microsomes, perampanel at a concentration of 30 μmol/L, about 10 fold the steady state Cmax at a 12 mg dose, had a weak inhibitory effect on CYP2C8, CYP3A4, UGT1A9 and UGT2B7. Perampanel did not inhibit CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E1, UGT1A1, UGT1A4 and UGT1A6 at a concentration of 30 μmol/L. Compared with positive controls (including phenobarbital and rifampin), perampanel was found to weakly induce CYP2B6 (30μmol/L) and CYP3A4/5 (≥ 3μmol/L) in cultured human hepatocytes. Perampanel also induced UGT1A1 (≥ 3μmol/L) and UGT1A4 (30μmol/L). Perampanel did not induce CYP1A2 at concentrations up to 30 μmol/L. Transporters In vitro studies showed that perampanel is not a substrate or significant inhibitor of the following: organic anion transporting polypeptides 1B1 and 1B3; organic anion transporters 1, 2, 3, and 4; organic cation transporters 1, 2, and 3; efflux transporters P-glycoprotein and Breast Cancer Resistance Protein. In Vivo Assessment of Drug Interactions Drug Interactions with AEDs Effect of concomitant AEDs on Fycompa: Carbamazepine. As an inducer of CYP enzymes, carbamazepine increases perampanel clearance. Steady state administration of carbamazepine at 300 mg BID in healthy subjects reduced the Cmax and AUC0-inf of a single 2 mg dose of perampanel by 26% and 67% respectively. The t1/2 of perampanel was shortened from 56.8 hours to 25 hours. In clinical studies examining partial-onset seizures, a population pharmacokinetic analysis showed that perampanel AUC was reduced by 67% in patients on carbamazepine compared to the AUC in patients not on enzyme-inducing AEDs [see Dosage and Administration (2.1), Drug Interactions (7.2)]. Oxcarbazepine. In clinical studies examining partial-onset seizures, a population pharmacokinetic analysis showed that perampanel AUC was reduced by half in patients on oxcarbazepine compared to patients not on enzyme-inducing AEDs [see Dosage and Administration (2.1), Drug Interactions (7.2)]. Phenytoin. In clinical studies examining partial-onset seizures, a population pharmacokinetic analysis showed that perampanel AUC was reduced by half in patients on phenytoin compared to patients not on enzyme-inducing AEDs [see Dosage and Administration (2.1), Drug Interactions (7.2)]. Phenobarbital and Primidone: In a population pharmacokinetic analysis of patients with partial-onset seizures in clinical trials (37 patients co-administered phenobarbital and 9 patients co-administered primidone) no significant effect on perampanel AUC was found. A modest effect of phenobarbital and primidone on perampanel concentrations cannot be excluded. Topiramate: Population pharmacokinetic analysis of patients with partial-onset seizures in clinical trials showed that perampanel AUC was reduced by approximately 20% in patients on topiramate compared to patients not on enzyme-inducing AEDs. Other AEDs: Population pharmacokinetic analysis of patients with partial-onset seizures in clinical trials showed that clobazam, clonazepam, lamotrigine, levetiracetam, valproate, and zonisamide did not have an effect on perampanel clearance. Other strong CYP3A inducers (e.g., rifampin, St. John's wort) may also greatly increase clearance of perampanel and reduce perampanel plasma concentrations [see Drug Interactions (7.2)]. Effect of Fycompa on concomitant AEDs: Fycompa up to 12 mg/day did not significantly affect the clearance of clonazepam, levetiracetam, phenobarbital, phenytoin, topiramate, or zonisamide based on a population pharmacokinetic analysis of patients with partial-onset seizures in clinical trials. Fycompa had a statistically significant effect on the clearance of carbamazepine, clobazam, lamotrigine, and valproic acid, but the increases in clearance of these drugs were each less than 10% at the highest perampanel dose evaluated (12 mg/day). Fycompa co-administration resulted in a 26% decrease in oxcarbazepine clearance and increased its concentrations. The concentrations of 10-monohydroxy metabolite (MHD), the active metabolite of oxcarbazepine, were not measured. Drug-drug interaction studies with other drugs Effect of other drugs on Fycompa Ketoconazole. Co-administration of single 1-mg dose of perampanel with 400 mg once daily doses of ketoconazole, a strong CYP3A4 inhibitor, for 8 days in healthy subjects prolonged perampanel t1/2 by 15% (67.8 vs. 58.4 hours) and increased AUC0-inf by 20%. Oral contraceptives. Perampanel Cmax and AUC0-72h were not altered when a single 6-mg dose of perampanel was administered to healthy female subjects following a 21-day course of oral contraceptives containing ethinylestradiol 30 μg and levonorgestrel 150 μg. Effect of Fycompa on other drugs Midazolam. Perampanel administered as 6 mg once daily doses for 20 days decreased AUC0-inf and Cmax of midazolam (a CYP3A4 substrate) by 13% and 15%, respectively, in healthy subjects. Oral Contraceptives. Co-administration of perampanel 4 mg once daily with an oral contraceptive containing ethinylestradiol 30 μg and levonorgestrel 150 μg for 21 days did not alter Cmax or AUC0-24h of either ethinylestradiol or levonorgestrel in healthy female subjects. In another study, a single dose of the oral contraceptive was administered following 21-day once daily dosing of Fycompa 12 mg or 8 mg in healthy females. Fycompa at 12 mg did not alter AUC0-24h of ethinylestradiol but decreased its Cmax by 18%, and also decreased Cmax and AUC0-24h of levonorgestrel by 42% and 40%, respectively. Fycompa at 8 mg did not have significant effect on Cmax or AUC0-24h of either ethinylestradiol or levonorgestrel, with a small decrease in AUC0-24h of levonorgestrel (9%) [see Drug Interactions (7.1)]. Levodopa. Perampanel administered as 4 mg once daily doses for 19 days had no effect on Cmax and AUC0-inf of levodopa in healthy subjects. Nonclinical Toxicology Carcinogenesis, Mutagenesis, and Impairment of Fertility Carcinogenesis Perampanel was administered orally to mice (1, 3, 10, or 30 mg/kg/day) and rats (10, 30, or 100 mg/kg/day in males; 3, 10, or 30 mg/kg/day in females) for up to 104 weeks. There was no evidence of drug-related tumors in either species. Plasma perampanel exposures (AUC) at the highest doses tested were less than that in humans dosed at 8 mg/day. Mutagenesis Perampanel was negative in the in vitro Ames and mouse lymphoma tk assays, and in the in vivo rat micronucleus assay. Impairment of Fertility In male and female rats administered perampanel (oral doses of 1, 10, or 30 mg/kg/day) prior to and throughout mating and continuing in females to gestation day 6, there were no clear effects on fertility. Prolonged and/or irregular estrus cycles were observed at all doses but particularly at the highest dose tested. Plasma perampanel exposures (AUC) at all doses were lower than that in humans dosed at 8 mg/day. Clinical Studies The efficacy of Fycompa in partial-onset seizures, with or without secondary generalization, was studied in patients who were not adequately controlled with 1 to 3 concomitant AEDs in 3 randomized, double-blind, placebo-controlled, multicenter trials (Studies 1, 2, and 3) in adult and adolescent patients (aged 12 years and older). All trials had an initial 6-week Baseline Period, during which patients were required to have more than five seizures in order to be randomized. The Baseline Period was followed by a 19 week Treatment Period consisting of a 6 week Titration Phase and a 13 week Maintenance Phase. Patients in these 3 trials had a mean duration of epilepsy of approximately 21 years and a median baseline seizure frequency ranging from 9.3 to 14.3 seizures per 28 days. During the trials, more than 85% of patients were taking 2 to 3 concomitant AEDs with or without concurrent vagal nerve stimulation, and approximately 50% were on at least one AED known to induce CYP3A4, an enzyme critical to the metabolism of Fycompa (i.e. carbamazepine, oxcarbazepine, or phenytoin), resulting in a significant reduction in Fycompa's serum concentration [see Drug Interactions (7.2), Clinical Pharmacology (12.3)]. Each study evaluated placebo and multiple Fycompa dosages (see Figure 1). During the Titration period in all 3 trials, patients on Fycompa received an initial 2 mg once daily dose, which was subsequently increased in weekly increments of 2 mg per day to the final target dose. Patients experiencing intolerable adverse reactions were permitted to have their dose reduced to the previously tolerated dose. The primary endpoint in Studies 1, 2, and 3 was the percent change in seizure frequency per 28 days during the Treatment Period as compared to the Baseline Period. The criterion for statistical significance was p<0.05. Table 3 shows the results of these studies. A statistically significant decrease in seizure rate was observed at doses of 4 to 12 mg per day. Dose response was apparent at 4 to 8 mg with little additional reduction in frequency at 12 mg per day.
Table 4 presents an analysis combining data from all 3 studies, grouping patients based upon whether or not concomitant AED inducers (carbamazepine, oxcarbazepine, or phenytoin) were used. The analysis revealed a substantially reduced effect in the presence of inducers.
Figure 1 shows the proportion of patients with different percent reductions during the maintenance phase over baseline across all three trials. Patients in whom the seizure frequency increased are shown at left as "worse." Patients in whom the seizure frequency decreased are shown in the remaining five categories. Thus, the percentages of patients with a 40 to <60% reduction in seizure frequency were 13.2%, 17.4%, 19.0%, and 15.8% for placebo, 4, 8, and 12 mg, respectively. The percentages of patients with a 50% or greater reduction in seizure frequency were 19.3%, 28.5%, 35.3%, 35.0% for placebo, 4, 8, and 12 mg, respectively. Storage Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F). [See USP Controlled Room Temperature] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
