英文药名：Lojuxta（lomitapide hard capsules） 中文药名：甲磺酸洛美他派硬胶囊 生产厂家：Aegerion制药 药品介绍 美国生物制药公司Aegerion制药今天宣布，欧洲药品管理局（EMA）已批准将Lojuxta（lomitapide）硬胶囊作为低脂肪饮食及其他降脂药用产品的一种辅助药物，用于纯合子家族性高胆固醇血症（HoFH）成人患者的治疗。 纯合子家族性高胆固醇血症(HoFH)是一种极罕见的常染色体显性遗传性疾病，发病机制为细胞膜表面的低密度脂蛋白（LDL）受体缺如或异常，导致体内LDL代谢异常，造成血浆总胆固醇(TC)水平和低密度脂蛋白-胆固醇(LDL-C)水平升高，往往导致极其严重的心血管问题。 Lojuxta hard capsules 1.Name of the medicinal product Lojuxta 5mg hard capsules Lojuxta 10mg hard capsules Lojuxta 20mg hard capsules 2.Qualitative and quantitative composition Each 5mg hard capsule contains lomitapide mesylate equivalent to 5 mg lomitapide. Each 10mg hard capsule contains lomitapide mesylate equivalent to 10 mg lomitapide. Each 20mg hard capsule contains lomitapide mesylate equivalent to 20 mg lomitapide Excipient with known effect: Each 5mg hard capsule contains 70.12 mg of lactose (as monohydrate) (see section 4.4). Each 10mg hard capsule contains 140.23 mg of lactose (as monohydrate) (see section 4.4). Each 20mg hard capsule contains 129.89 mg of lactose (as monohydrate) (see section 4.4). For the full list of excipients, see section 6.1. 3.Pharmaceutical form Capsule, hard. The 5 mg capsule is an orange cap/orange body hard capsule of 19.4 mm, printed with black ink imprinted with “5 mg” on body and “A733” on cap. The 10 mg capsule is an orange cap/white body hard capsule of 19.4 mm, printed with black ink imprinted with “10 mg” on body and “A733” on cap. The 20 mg capsule is a white cap/white body hard capsule of 19.4 mm, printed with black ink imprinted with “20 mg” on body and “A733” on cap. 4.Clinical particulars 4.1 Therapeutic indications Lojuxta is indicated as an adjunct to a low-fat diet and other lipid-lowering medicinal products with or without low density lipoprotein (LDL) apheresis in adult patients with homozygous familial hypercholesterolaemia (HoFH). Genetic confirmation of HoFH should be obtained whenever possible. Other forms of primary hyperlipoproteinemia and secondary causes of hypercholesterolaemia (e.g., nephrotic syndrome, hypothyroidism) must be excluded. 4.2 Posology and method of administration Treatment with Lojuxta should be initiated and monitored by a physician experienced in the treatment of lipid disorders. Posology The recommended starting dose is 5 mg once daily. After 2 weeks the dose may be increased, based on acceptable safety and tolerability, to 10 mg and then, at a minimum of 4-week intervals, to 20 mg, 40 mg, and to the maximum recommended dose of 60 mg (see section 4.8). The dose should be escalated gradually to minimise the incidence and severity of gastrointestinal side effects and aminotransferase elevations. Administration with food may increase exposure to Lojuxta. Lojuxta should be taken on an empty stomach, at least 2 hours after the evening meal because the fat content of a recent meal may adversely impact gastrointestinal tolerability. The occurrence and severity of gastrointestinal adverse reactions associated with the use of Lojuxta decreases in the presence of a low fat diet. Patients should follow a diet supplying less than 20% of energy from fat prior to initiating Lojuxta treatment, and should continue this diet during treatment. Dietary counselling should be provided. Patients should avoid consumption of grapefruit juice (see sections 4.4 and 4.5). Patients on a stable maintenance dose of Lojuxta who receive a weak CYP3A4 inhibitor should reduce the dose of Lojuxta as follows: • Patients on 40 mg or 60 mg should reduce to 10 mg • Patients on doses < 40 mg should reduce to 5 mg Careful up-titration may then be considered according to LDL-C response and safety/tolerability. Consider limiting the maximum dose of Lojuxta according to desired LDL-C response. Upon discontinuation of the weak CYP3A4 inhibitor, the dose of Lojuxta should be up-titrated according to LDL-C response and safety/tolerability. Exercise additional caution if administering more than 1 weak CYP3A4 inhibitor with Lojuxta. Based on observations of decreased essential fatty acid and vitamin E levels in clinical trials, patients should take daily dietary supplements that provide 400 IU vitamin E, and at least 200 mg linoleic acid, 110 mg eicosapentaenoic acid (EPA), 210 mg alpha linolenic acid (ALA) and 80 mg docosahexaenoic acid (DHA) per day, throughout treatment with Lojuxta. Elderly population There is limited experience with Lojuxta in patients aged 65 years or older. Therefore, particular caution should be exercised in these patients. Since the recommended dose regimen involves starting at the low end of the dosing range and escalating cautiously according to individual patient tolerability, no adjustment to the dosing regimen is recommended for the elderly. Hepatic impairment Lojuxta is contraindicated in patients with moderate or severe hepatic impairment including patients with unexplained persistent abnormal liver function tests (see section 5.2). Patients with mild hepatic impairment (Child-Pugh A) should not exceed 40 mg daily. Renal impairment Patients with end-stage renal disease receiving dialysis should not exceed 40 mg daily (see section 5.2). Paediatric population The safety and efficacy of Lojuxta in children < 18 years have not been established and the use of this medicinal product in children is therefore not recommended. No data are available. Method of administrationOral use. 4.3 Contraindications • Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. • Patients with moderate or severe hepatic impairment and those with unexplained persistent abnormal liver function tests. • Patients with a known significant or chronic bowel disease such as inflammatory bowel disease or malabsorption. • Concomitant administration of > 40 mg simvastatin (see section 4.5). • Concomitant use of Lojuxta with strong or moderate cytochrome P450 (CYP) 3A4 inhibitors (e.g., antifungal azoles such as itraconazole, fluconazole,ketoconazole, voriconazole, posaconazole; macrolide antibiotics such as erythromycin or clarithromycin; ketolide antibiotics such as telithromycin; HIV protease inhibitors; the calcium channel blockers diltiazem and verapamil, and the anti-arrhythmic dronedarone [see section 4.5]). • Pregnancy (see section 4.6). 4.4 Special warnings and precautions for use Liver enzyme abnormalities and liver monitoring Lomitapide can cause elevations in alanine aminotransferase [ALT] and aspartate aminotransferase [AST] and hepatic steatosis. The extent to which lomitapide-associated hepatic steatosis promotes the elevations in aminotransferase is unknown. Although cases of hepatic dysfunction (elevated aminotransferase with increase in bilirubin or International Normalized Ratio [INR]) or hepatic failure have not been reported, there is concern that lomitapide could induce steatohepatitis, which can progress to cirrhosis over several years. The clinical studies supporting the safety and efficacy of lomitapide in HoFH would have been unlikely to detect this adverse outcome given their size and duration. Elevations in aminotransferases (ALT and/or AST) are associated with lomitapide (see section 5.1). There were no concomitant or subsequent clinically meaningful elevations in serum bilirubin, INR, or alkaline phosphatase. Liver enzyme changes occur most often during dose escalation, but may occur at any time during therapy. Monitoring of liver function tests Measure ALT, AST, alkaline phosphatase, total bilirubin, gamma-glutamyl transferase (gamma-GT) and serum albumin before initiation of treatment with Lojuxta. The medicinal product is contraindicated in patients with moderate or severe hepatic impairment and those with unexplained persistent abnormal liver function tests. If the baseline liver-related tests are abnormal, consider initiating the medicinal product after appropriate investigation by a hepatologist and the baseline abnormalities are explained or resolved. During the first year, measure liver-related tests (ALT and AST, at a minimum) prior to each increase in dose or monthly, whichever occurs first. After the first year, do these tests at least every 3 months and before any increase in dose. Decrease the dose of Lojuxta if elevations of aminotransferase are observed and discontinue treatment for persistent or clinically significant elevations (see Table 1 for specific recommendations). Dose modification based on elevated hepatic aminotransferases Table 1 summarizes recommendations for dose adjustment and monitoring for patients who develop elevated aminotransferase during therapy with Lojuxta. Table 1: Dose Adjustment and Monitoring for Patients with Elevated Aminotransferases ALT or AST Treatment and monitoring recommendations* ≥3x and <5x Upper Limit of Normal (ULN) • Confirm elevation with a repeat measurement within one week. • If confirmed, reduce the dose and obtain additional liver-related tests if not already measured (such as alkaline phosphatase, total bilirubin, and INR). • Repeat tests weekly and withhold dosing if there are signs of abnormal liver function (increase in bilirubin or INR), if aminotransferase levels rise above 5x ULN, or if aminotransferase levels do not fall below 3x ULN within approximately 4 weeks. Refer patients with persistent elevations in aminotransferase >3x ULN to a hepatologist for further investigation. • If resuming Lojuxta after aminotransferase levels resolve to <3x ULN, consider reducing the dose and monitor liver-related tests more frequently. ≥5x ULN • Withhold dosing and obtain additional liver-related tests if not already measured (such as alkaline phosphatase, total bilirubin, and INR). If aminotransferase levels do not fall below 3x ULN within approximately 4 weeks refer the patient to a hepatologist for further investigation. • If resuming Lojuxta after aminotransferase levels resolve to <3x ULN, reduce the dose and monitor liver-related tests more frequently. *Recommendations based on an ULN of approximately 30-40 international units/L. If aminotransferase elevations are accompanied by clinical symptoms of liver injury (such as nausea, vomiting, abdominal pain, fever, jaundice, lethargy, flu-like symptoms), increases in bilirubin ≥2x ULN, or active liver disease, discontinue treatment with Lojuxta and refer the patient to a hepatologist for further investigation. Reintroduction of treatment may be considered if the benefits are considered to outweigh the risks associated with potential liver disease. Hepatic steatosis and risk of progressive liver disease Consistent with the mechanism of action of lomitapide, most treated patients exhibited increases in hepatic fat content. In an open-label Phase 3 study, 18 of 23 patients with HoFH developed hepatic steatosis (hepatic fat >5.56%) as measured by nuclear magnetic resonance spectroscopy (MRS) (see section 5.1). The median absolute increase in hepatic fat was 6% after both 26 weeks and 78 weeks of treatment, from 1% at baseline, measured by MRS. Hepatic steatosis is a risk factor for progressive liver disease including steatohepatitis and cirrhosis. The long term consequences of hepatic steatosis associated with Lojuxta treatment are unknown. Clinical data suggest that hepatic fat accumulation is reversible after stopping treatment with Lojuxta, but whether histological sequelae remain is unknown, especially after long-term use. Monitoring for evidence of progressive liver disease. Regular screening for steatohepatitis/fibrosis should be performed at baseline and on an annual basis using the following imaging and biomarker evaluations: • Imaging for tissue elasticity, e.g. Fibroscan, acoustic radiation force impulse (ARFI), or magnetic resonance (MR) elastography • Gamma-GT and serum albumin to detect possible liver injury • At least one marker from each of the following categories: • High sensitivity C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), CK-18 Fragment, NashTest (liver inflammation) • Enhanced Liver Fibrosis (ELF) panel, Fibrometer, AST/ALT ratio, Fib-4 score, Fibrotest (liver fibrosis) The performance of these tests and their interpretation should involve collaboration between the treating physician and the hepatologist. Patients with results suggesting the presence of steatohepatitis or fibrosis should be considered for liver biopsy. If a patient has biopsy-proven steatohepatitis or fibrosis, the benefit-risk should be reassessed and treatment stopped if necessary. Concomitant use of CYP3A4 inhibitors Lomitapide appears to be a sensitive substrate for CYP3A4 metabolism. CYP3A4 inhibitors increase the exposure of lomitapide, with strong inhibitors increasing exposure approximately 27-fold. Concomitant use of moderate or strong CYP3A4 inhibitors with Lojuxta is contraindicated (see section 4.3). In the lomitapide clinical trials, one patient with HoFH developed markedly elevated aminotransferase (ALT 24x ULN, AST 13x ULN) within days of initiating the strong CYP3A4 inhibitor clarithromycin. If treatment with moderate or strong CYP3A4 inhibitors is unavoidable, Lojuxta should be stopped during the course of treatment. Weak CYP3A4 inhibitors may substantially increase the exposure of lomitapide. The dose of Lojuxta should be reduced when administered with a weak CYP3A4 inhibitor and patients monitored carefully (see section 4.2). Concomitant use of CYP3A4 inducers Medicines that induce CYP3A4 would be expected to increase the rate and extent of metabolism of lomitapide. CYP3A4 inducers exert their effect in a time-dependent manner, and may take at least 2 weeks to reach maximal effect after introduction. Conversely, on discontinuation, CYP3A4 induction may take at least 2 weeks to decline. Co-administration of a CYP3A4 inducer is expected to reduce the effect of Lojuxta. Any impact on efficacy is likely to be variable. When co-administering CYP3A4 inducers (i.e. aminoglutethimide, nafcillin, non-nucleoside reverse transcriptase inhibitors, phenobarbital, rifampicin, carbamazepine, pioglitazone, glucocorticoids, modafinil and phenytoin) with Lojuxta, the possibility of a drug-drug interaction affecting efficacy should be considered. The use of St. John's Wort should be avoided with Lojuxta. It is recommended to increase the frequency of LDL-C assessment during such concomitant use and consider increasing the dose of Lojuxta to ensure maintenance of the desired level of efficacy if the CYP3A4 inducer is intended for chronic use. On withdrawal of a CYP3A4 inducer, the possibility of increased exposure should be considered and a reduction in the dose of Lojuxta may be necessary. Concomitant use of HMG-CoA reductase inhibitors ('statins') Lomitapide increases plasma concentrations of statins. Patients receiving Lojuxta as adjunctive therapy to a statin should be monitored for adverse events that are associated with the use of high doses of statins. Statins occasionally cause myopathy. In rare cases, myopathy may take the form of rhabdomyolysis with or without acute renal failure secondary to myoglobinuria, and can lead to fatality. All patients receiving Lojuxta in addition to a statin should be advised of the potential increased risk of myopathy and told to report promptly any unexplained muscle pain, tenderness, or weakness. Doses of simvastatin > 40 mg should not be used with Lojuxta (see section 4.3). Grapefruit juice Grapefruit juice must be omitted from the diet while patients are treated with Lojuxta. Risk of supratherapeutic or subtherapeutic anticoagulation with coumarin based anticoagulants Lomitapide increases the plasma concentrations of warfarin. Increases in the dose of Lojuxta may lead to supratherapeutic anticoagulation, and decreases in the dose may lead to subtherapeutic anticoagulation. Difficulty controlling INR contributed to early discontinuation from the Phase 3 trial for one of five patients taking concomitant warfarin. Patients taking warfarin should undergo regular monitoring of the INR, especially after any changes in Lojuxta dosage. The dose of warfarin should be adjusted as clinically indicated. Use of alcohol Alcohol may increase levels of hepatic fat and induce or exacerbate liver injury. In the Phase 3 trial, 3 of 4 patients with ALT elevations >5x ULN reported alcohol consumption beyond the limits recommended in the protocol. The use of alcohol during Lojuxta treatment is not recommended. Hepatotoxic agents Caution should be exercised when Lojuxta is used with other medicinal products known to have potential for hepatotoxicity, such as isotretinoin, amiodarone, acetaminophen (>4 g/day for ≥3 days/week), methotrexate, tetracyclines, and tamoxifen. The effect of concomitant administration of Lojuxta with other hepatotoxic medicine is unknown. More frequent monitoring of liver-related tests may be warranted. Reduced absorption of fat-soluble vitamins and serum fatty acids Given its mechanism of action in the small intestine, lomitapide may reduce the absorption of fat-soluble nutrients. In the Phase 3 trial, patients were provided daily dietary supplements of vitamin E, linoleic acid, ALA, EPA and DHA. In this trial, the median levels of serum vitamin E, ALA, linoleic acid, EPA, DHA, and arachidonic acid decreased from baseline to Week 26 but remained above the lower limit of the reference range. Adverse clinical consequences of these reductions were not observed with lomitapide treatment of up to 78 weeks. Patients treated with Lojuxta should take daily supplements that contain 400 international units vitamin E and at least 200 mg linoleic acid, 210 mg ALA, 110 mg EPA, and 80 mg DHA. Contraception measures in women of child-bearing potential Before initiating treatment in women of child-bearing potential, appropriate advice on effective methods of contraception should be provided, and effective contraception initiated. Patients taking oestrogen-based oral contraceptives should be advised about possible loss of effectiveness due to diarrhoea and/or vomiting (see section 4.5). Oestrogen-containing oral contraceptives are weak CYP3A4 inhibitors (see section 4.2). Patients should be advised to immediately contact their physician and stop taking Lojuxta if they become pregnant (see section 4.6). Lactose Lojuxta contains lactose and therefore should not be administered to patients with rare hereditary problems of galactose intolerance, the Lapp-lactase deficiency or glucose-galactose malabsorption. 4.5 Interaction with other medicinal products and other forms of interaction Effects of other medicinal products on Lojuxta and other forms of interaction Table 2: Interactions between Lojuxta and other medicinal products and other forms of interaction Medicinal products Effects on lomitapide levels Recommendation concerning co-administration with Lojuxta Inhibitors of CYP3A4 When lomitapide 60 mg was co-administered with ketoconazole 200 mg twice daily, a strong inhibitor of CYP3A4, lomitapide AUC increased approximately 27-fold and Cmax increased approximately 15-fold. Interaction between moderate or weak CYP3A4 inhibitors and lomitapide has not been studied. Moderate and weak CYP3A4 inhibitors are predicted to have a substantial impact on lomitapide's pharmacokinetics. Concomitant use of moderate or weak CYP3A4 inhibitors are expected to increase lomitapide exposure by 4-10 fold and by 4 fold, respectively, based on the results of the study with the strong CYP3A4 inhibitor ketoconazole and on historical data for the model CYP3A4 probe midazolam. Use of strong or moderate inhibitors of CYP3A4 is contraindicated with Lojuxta. If treatment with antifungal azoles (e.g., itraconazole, ketoconazole, fluconazole, voriconazole, posaconazole); the antiarrhythmic dronedarone; macrolide antibiotics (e.g., erythromycin, clarithromycin); ketolide antibiotics (e.g., telithromycin); HIV protease inhibitors; the calcium channel blockers diltiazem and verapamil is unavoidable, therapy with Lojuxta should be suspended during the course of treatment (see sections 4.3 and 4.4). Grapefruit juice is a moderate inhibitor of CYP3A4 and is expected to substantially increase exposure to lomitapide. Patients taking Lojuxta should avoid consumption of grapefruit juice. The dose of Lojuxta should be reduced during concomitant administration with a weak CYP3A4 inhibitor (see section 4.2). Examples of weak CYP3A4 inhibitors include: alprazolam, amiodarone, amlodipine, atorvastatin, azithromycin, bicalutamide, cilostazol, cimetidine, ciclosporin, clotrimazole, fluoxetine, fluvoxamine, fosaprepitant, ginkgo, goldenseal, isoniazid, ivacaftor, lacidipine, lapatinib, linagliptin, nilotinib, oestrogen-containing oral contraceptives, pazopanib, peppermint oil, propiverine, ranitidine, ranolazine, ritonavir, roxithromycin, Seville oranges, tacrolimus, ticagrelor, tipranavir and tolvaptan. This list is not intended to be comprehensive and prescribers should check the prescribing information of drugs to be co-administered with Lojuxta for potential CYP3A4 mediated interactions. The effect of administration of more than one weak CYP3A4 inhibitor has not been tested, but the effect on the exposure of lomitapide is expected to be greater than for co-administration of the individual inhibitors with lomitapide. Inducers of CYP3A4 Medicines that induce CYP3A4 would be expected to increase the rate and extent of metabolism of lomitapide. Consequently, this would reduce the effect of lomitapide. Any impact on efficacy is likely to be variable. When co-administering CYP3A4 inducers (i.e., aminoglutethimide, nafcillin, non-nucleoside reverse transcriptase inhibitors, phenobarbital, rifampicin, carbamazepine, pioglitazone, St John's Wort, glucocorticoids, modafinil and phenytoin) with Lojuxta, the possibility of a drug-drug interaction affecting efficacy should be considered. It is recommended to increase the frequency of LDL-C assessment during such concomitant use and consider increasing the dose of Lojuxta to ensure maintenance of the desired level of efficacy if the CYP3A4 inducer is intended for chronic use. Bile acid sequestrants Lomitapide has not been tested for interaction with bile acid sequestrants (resins such as colesevelam and cholestyramine). Because bile acid sequestrants can interfere with the absorption of oral medicines, bile acid sequestrants should be taken at least 4 hours before or at least 4 hours after Lojuxta. Effects of lomitapide on other medicinal products HMG-CoA Reductase Inhibitors (“Statins”): Lomitapide increases plasma concentrations of statins. When lomitapide 60 mg was administered to steady state prior to simvastatin 40 mg, simvastatin acid AUC and Cmax increased 68% and 57%, respectively. When lomitapide 60 mg was administered to steady state prior to atorvastatin 20 mg, atorvastatin acid AUC and Cmax increased 52% and 63%, respectively. When lomitapide 60 mg was administered to steady state prior to rosuvastatin 20 mg, rosuvastatin Tmax increased from 1 to 4 hours, AUC was increased 32%, and its Cmax was unchanged. The risk of myopathy with simvastatin is dose related. Use of Lojuxta is contraindicated in patients treated with high doses of simvastatin (> 40 mg) (see sections 4.3 and 4.4). Coumarin anticoagulants: When lomitapide 60 mg was administered to steady state and 6 days following warfarin 10 mg, INR increased 1.26-fold. AUCs for R(+)-warfarin and S(-)-warfarin increased 25% and 30%, respectively. Cmax for R(+)-warfarin and S(-)-warfarin increased 14% and 15%, respectively. In patients taking coumarins (such as warfarin) and Lojuxta concomitantly, INR should be determined before starting Lojuxta and monitored regularly with dosage of coumarins adjusted as clinically indicated (see section 4.4). Fenofibrate, niacin and ezetimibe: When lomitapide was administered to steady state prior to micronised fenofibrate 145 mg, extended release niacin 1000 mg, or ezetimibe 10 mg, no clinically significant effects on the exposure of any of these medicinal products was observed. No dose adjustments are required when co-administered with Lojuxta. Oral contraceptives: When lomitapide 50 mg was administered to steady state along with an oestrogen-based oral contraceptive, no clinically meaningful nor statistically significant impact on the pharmacokinetics of the components of the oral contraceptive (ethinylestradiol and 17-deacetyl norgestimate, the metabolite of norgestimate) were observed. Lomitapide is not expected to directly influence the efficacy of oestrogen based oral contraceptives; however diarrhoea and/or vomiting may reduce hormone absorption. In cases of protracted or severe diarrhoea and/or vomiting lasting more than 2 days, additional contraceptive measures should be used for 7 days after resolution of symptoms. P-gp substrates: Lomitapide inhibits P-gp in vitro, and may increase the absorption of P-gp substrates. Coadministration of Lojuxta with P gp substrates (such as aliskiren, ambrisentan, colchicine, dabigatran etexilate, digoxin, everolimus, fexofenadine, imatinib, lapatinib, maraviroc, nilotinib, posaconazole, ranolazine, saxagliptin, sirolimus, sitagliptin, talinolol, tolvaptan, topotecan) may increase the absorption of P gp substrates. Dose reduction of the P gp substrate should be considered when used concomitantly with Lojuxta. In vitro assessment of drug interactions: Lomitapide inhibits CYP3A4. Lomitapide does not induce CYPs 1A2, 3A4, or 2B6, and does not inhibit CYPs 1A2, 2B6, 2C9, 2C19, 2D6, or 2E1. Lomitapide is not a P-gp substrate but does inhibit P-gp. Lomitapide does not inhibit breast cancer resistance protein (BCRP). 4.6 Fertility, pregnancy and lactation Pregnancy Lojuxta is contraindicated during pregnancy. There are no reliable data on its use in pregnant women. Animal studies have shown developmental toxicity (teratogenicity, embryotoxicity, see section 5.3). The potential risk for humans is unknown. Use in women of child-bearing potential Before initiating treatment in women of child-bearing potential, the absence of pregnancy should be confirmed, appropriate advice on effective methods of contraception provided, and effective contraception initiated. Patients taking oestrogen-based oral contraceptives should be advised about possible loss of effectiveness due to diarrhoea and/or vomiting. Additional contraceptive measures should be used until resolution of symptoms (see section 4.5). Breast-feeding It is not known whether lomitapide is excreted into human milk. Because of the potential for adverse effects based on findings in animal studies with lomitapide (see section 5.3), a decision should be made whether to discontinue breast-feeding or discontinue the medicinal product, taking into account the importance of the medicinal product to the mother. Fertility No adverse effects on fertility were observed in male and female rats administered lomitapide at systemic exposures (AUC) estimated to be 4 to 5 times higher than in humans at the maximum recommended human dose (see section 5.3). 4.7 Effects on ability to drive and use machines Lojuxta may have a minor influence on the ability to drive and use machines. 4.8 Undesirable effects Summary of the safety profile The most serious adverse reactions during treatment were liver aminotransferase abnormalities (see section 4.4). The most common adverse reactions were gastrointestinal effects. Gastrointestinal adverse reactions were reported by 27 (93%) of 29 patients in the Phase 3 clinical trial. Diarrhoea occurred in 79% of patients, nausea in 65%, dyspepsia in 38%, and vomiting in 34%. Other reactions reported by at least 20% of patients include abdominal pain, abdominal discomfort, abdominal distension, constipation, and flatulence. Gastrointestinal adverse reactions occurred more frequently during the dose escalation phase of the study and decreased once patients established the maximum tolerated dose of lomitapide. Gastrointestinal adverse reactions of severe intensity were reported by 6 (21%) of 29 patients in the Phase 3 clinical trial, with the most common being diarrhoea (4 patients, 14%); vomiting (3 patients, 10%); and abdominal pain, distension, and/or discomfort (2 patients, 7%). Gastrointestinal reactions contributed to the reasons for early discontinuation from the trial for 4 (14%) patients. The most commonly reported adverse reactions of severe intensity were diarrhoea (4 subjects, 14%), vomiting (3 patients, 10%), and abdominal distension and ALT increased (2 subjects each, 7%). Tabulated list of adverse reactions Frequency of the adverse reactions is defined as: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data). Table 3 lists all adverse reactions reported across the 35 patients treated in the Phase 2 Study UP1001 and in the Phase 3 Study UP1002/AEGR-733-005 or its extension study AEGR-733-012. Table 3: Frequency of Adverse Reactions in HoFH Patients System Organ Class Frequency Adverse Reaction Infections and infestations Common Gastroenteritis Metabolism and nutrition disorders Very common Decreased appetite Nervous system disorders Common Dizziness Headache Migraine Gastrointestinal disorders Very common Diarrhoea Nausea Vomiting Abdominal discomfort Dyspepsia Abdominal pain Abdominal pain upper Flatulence Abdominal distension Constipation Common Gastritis Rectal tenesmus Aerophagia Defaecation urgency Eructation Frequent bowel movements Gastric dilatation Gastric disorder Gastrooesophageal reflux disease Haemorrhoidal haemorrhage Regurgitation Hepatobiliary disorders Common Hepatic steatosis Hepatotoxicity Hepatomegaly Skin and subcutaneous tissue disorders Common Ecchymosis Papule Rash erythematous Xanthoma General disorders and administration site conditions Common Fatigue Investigations Very common Alanine aminotransferase increased Aspartate aminotransferase increased Weight decreased Common International normalised ratio increased Blood alkaline phosphatase increased Blood potassium decreased Carotene decreased International normalised ratio abnormal Liver function test abnormal Prothrombin time prolonged Transaminases increased Vitamin E decreased Vitamin K decreased Table 4 lists all adverse reactions for subjects who received lomitapide monotherapy (N=291) treated in Phase 2 studies in subjects with elevated LDL-C (N=462). Table 4: Frequency of Adverse Reactions in Elevated LDL-C Patients System Organ Class Frequency Adverse Reaction Infections and infestations Uncommon Gastroenteritis Gastrointestinal infection Influenza Nasopharyngitis Sinusitis Blood and lymphatic system disorders Uncommon Anaemia Metabolism and nutrition disorders Common Decreased appetite Uncommon Dehydration Increased appetite Nervous system disorders Uncommon Paraesthesia Somnolence Eye disorders Uncommon Eye swelling Ear and labyrinth disorders Uncommon Vertigo Respiratory, thoracic and mediastinal disorders Uncommon Pharyngeal lesion Upper-airway cough syndrome Gastrointestinal disorders Very common Diarrhoea Nausea Flatulence Common Abdominal pain upper Abdominal distension Abdominal pain Vomiting Abdominal discomfort Dyspepsia Eructation Abdominal pain lower Frequent bowel movements   Uncommon Dry mouth Faeces hard Gastrooeosophageal reflux disease Abdominal tenderness Epigastric discomfort Gastric dilatation Haematemesis Lower gastrointestinal haemorrhage Reflux oesophagitis Hepatobiliary disorders Uncommon Hepatomegaly Skin and subcutaneous tissue disorders Uncommon Blister Dry skin Hyperhidrosis Musculoskeletal and connective tissue disorders Common Muscle spasms Uncommon Arthralgia Myalgia Pain in extremity Joint swelling Muscle twitching Renal and urinary disorders Uncommon Haematuria General disorders and administrative site conditions Common Fatigue Asthenia Uncommon Chest pain Chills Early satiety Gait disturbance Malaise Pyrexia Investigations Common Alanine aminotransferase increased Aspartate aminotransferase increased Hepatic enzyme increased Liver function test abnormal Neutrophil count decreased White blood cell count decreased Uncommon Weight decreased Blood bilirubin increased Gamma-glutamyltransferase increased Neutrophil percentage increased Protein urine Prothrombin time prolonged Pulmonary function test abnormal White blood cell count increased Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard. 4.9 Overdose There is no specific treatment in the event of overdose. In rodents, single oral doses of lomitapide ≥600 times higher than the maximum recommended human dose (1 mg/kg) were well tolerated. The maximum dose administered to human subjects in clinical studies was 200 mg as a single dose; there were no adverse reactions. 5. Pharmacological properties 5.1 Pharmacodynamic properties Pharmacotherapeutic group: Other lipid modifying agents, plain. ATC code: C10AX12 Mechanism of action Lomitapide is a selective inhibitor of microsomal transfer protein (MTP), an intracellular lipid-transfer protein that is found in the lumen of the endoplasmic reticulum and is responsible for binding and shuttling individual lipid molecules between membranes. MTP plays a key role in the assembly of apo B containing lipoproteins in the liver and intestines. Inhibition of MTP reduces lipoprotein secretion and circulating concentrations of lipoprotein-borne lipids including cholesterol and triglycerides. Clinical efficacy and safety A single arm, open-label study (UP1002/AEGR-733-005) evaluated the efficacy and safety of lomitapide when co-administered with a low-fat diet and other lipid-lowering therapies in adult patients with HoFH. Patients were instructed to maintain a low-fat diet (<20% calories from fat) and their lipid-lowering therapies at study entry, including apheresis if applicable, from 6 weeks prior to baseline through at least Week 26. The dose of lomitapide was escalated from 5 mg to an individually determined maximum tolerated dose up to 60 mg. After Week 26, patients remained on lomitapide to determine the effects of longer-term treatment and were allowed to change background lipid-lowering therapies. The study provided for a total of 78 weeks of treatment. Twenty-nine patients were enrolled, of whom 23 completed through Week 78. Sixteen males (55%) and 13 females (45%) were included with a mean age of 30.7 years, ranging from 18 to 55 years. The mean dose of lomitapide was 45 mg at Week 26 and 40 mg at Week 78. At Week 26, the mean percent change in LDL-C from baseline of LDL-C was -40% (p<0.001) in the Intent to Treat (ITT) population. Mean percent change from baseline through Week 26 using last observation carried forward (LOCF) to each assessment is shown in Figure 1. Figure 1: Mean percent changes from baseline in LDL-C in the major effectiveness study UP1002/AEGR-733-005 through Week 26 (the Primary Endpoint) using LOCF to each assessment (N=29) Changes in lipids and lipoproteins through Week 26 and Week 78 of lomitapide treatment are presented in Table 5. Table 5: Absolute values and percent changes from baseline to Weeks 26 and 78 in lipids and lipoproteins (major effectiveness study UP1002/AEGR-733-005) Parameter (units) Baseline Week 26/LOCF (N=29) Week 78 (N=23) Mean (SD) Mean (SD) % Change p-valueb Mean(SD) % Change p-valueb LDL-C, direct (mg/dL) 336 (114) 190 (104) -40 <0.001 210 (132) -38 <0.001 Total Cholesterol (TC) (mg/dL) 430 (135) 258 (118) -36 <0.001 281 (149) -35 <0.001 Apolipoprotein B (apo B) (mg/dL) 259 (80) 148 (74) -39 <0.001 151 (89) -43 <0.001 Triglycerides (TG) (mg/dL)a 92 57 -45 0.009 59 -42 0.012 Non high-density lipoprotein cholesterol (Non-HDL-C) (mg/dL) 386 (132) 217 (113) -40 <0.001 239 (146) -39 <0.001 Very-low-density lipoprotein cholesterol (VLDL-C) (mg/dL) 21 (10) 13 (9) -29 0.012 16 (15) -31 0.013 Lipoprotein (a) (Lp(a)) (nmol/L)a 66 61 -13 0.094 72 -4 <0.842 High-density lipoprotein cholesterol (HDL-C) (mg/dL) 44 (11) 41 (13) -7 0.072 43 (12) -4.6 0.246 a Median presented for TG and Lp(a). p-value is based on the mean percent change b p-value on the mean percent change from baseline based on paired t-test At both Week 26 and Week 78, there were significant reductions in LDL-C, TC, apo B, TG, non-HDL-C, VLDL-C and changes in HDL-C trended lower at Week 26 and returned to baseline levels by Week 78. The effect of Lojuxta on cardiovascular morbidity and mortality has not been determined. At baseline, 93% were on a statin, 76% were on ezetimibe, 10% on niacin, 3% on a bile acid sequestrant and 62% were receiving apheresis. Fifteen of 23 (65%) patients had their lipid-lowering treatment reduced by Week 78, including planned and unplanned reductions/interruptions. Apheresis was discontinued in 3 out of 13 patients who were on it at Week 26, and frequency was reduced in 3 patients while maintaining low LDL-C levels through Week 78. The clinical benefit of reductions in background lipid-lowering therapy, including apheresis, is not certain. Of the 23 patients who completed through Week 26, 19 (83%) had LDL-C reductions ≥25% with 8 (35%) having LDL-C <100 mg/dL and 1 having LDL-C <70 mg/dL at that time point. In this study, 10 patients experienced elevations in AST and/or ALT >3 x ULN (see Table 6). Table 6: Highest liver function test results post first dose (major effectiveness study UP1002/AEGR-733-005) Parameter/Abnormality N (%) ALT   Number of Patients with Assessments 29 >3 to ≤5 x ULN 6 (20.7) >5 to ≤10 x ULN 3 (10.3) >10 to ≤20 x ULN 1 (3.4) >20 x ULN 0 AST   Number of Patients with Assessments 29 >3 to ≤5 x ULN 5 (17.2) >5 to ≤10 x ULN 1 (3.4) >10 to ≤20 x ULN 0 >20 x ULN 0 Elevations in ALT and/or AST >5 x ULN were managed with a dose reduction or temporary suspension of lomitapide dosing, and all patients were able to continue with study drug treatment. No clinically meaningful elevations in total bilirubin or alkaline phosphatase were observed. Hepatic fat was prospectively measured using MRS in all eligible patients during the clinical trial (Table 7). Data from individuals who had repeat measurements after stopping lomitapide show that hepatic fat accumulation is reversible, but whether histological sequelae remain is unknown. Table 7: Maximum categorical changes in % hepatic fat (major effectiveness study UP1002/AEGR-733-005) Maximum Absolute Increase in % Hepatic Fat Efficacy Phase Weeks 0-26 N (%) Safety Phase Weeks 26-78 N (%) Entire Trial Weeks 0-78 N (%) Number of evaluable patients 22 22 23 ≤5% 9 (41) 6 (27) 5 (22) >5% to ≤10% 6 (27) 8 (36) 8 (35) >10% to ≤15% 4 (18) 3 (14) 4 (17) >15% to ≤20% 1 (5) 4 (18) 3 (13) >20% to ≤25% 1 (5) 0 1 (4) >25% 1 (5) 1 (5) 2 (9) The European Medicines Agency has deferred the obligation to submit the results of studies with Lojuxta in one or more subsets of the paediatric population in HoFH (see section 4.2 for information on paediatric use). 5.2 Pharmacokinetic properties Absorption The absolute oral bioavailability of lomitapide is 7%. Absorption is not limited by penetration of the drug across the intestinal barrier but is predominantly influenced by an extensive first pass effect. Peak plasma concentrations of lomitapide were reached 4-8 hours following oral dosing. Lomitapide pharmacokinetics is approximately dose-proportional for oral single doses in the therapeutic range. Doses higher than 60 mg suggest a trend toward nonlinearity and are not recommended. Upon multiple dosing Cmax and AUC increased in approximate proportion to lomitapide dose. Cmax and AUC were increased following either a high-fat meal (77% and 58%, respectively) or low fat meal (70% and 28%, respectively). Accumulation of lomitapide in plasma was consistent with that predicted after a single dose following once daily oral dosing above 25 mg for up to 4 weeks. Inter-individual variability in lomitapide AUC was approximately 50%. At steady state the accumulation of lomitapide was 2.7 at 25 mg and 3.9 at 50 mg. Distribution Following intravenous administration, the volume of distribution of lomitapide was high (mean=1200 litres) despite a high degree (>99.8%) of binding to plasma protein. In animal studies lomitapide was highly concentrated (200-fold) in the liver. Biotransformation Lomitapide is extensively metabolised, predominantly by CYP3A4. CYP isoforms 2E1, 1A2, 2B6, 2C8, and 2C19 are involved to a lesser extent and isoforms 2D6 and 2C9 are not involved in the metabolism of lomitapide. Elimination Following administration of a radiolabeled oral solution dose to healthy subjects, 93% of the administered dose was recovered in urine and faeces. Approximately 33% of the radioactivity was excreted in urine as metabolites. The remainder was excreted in faeces, primarily as oxidised metabolites. The elimination half-life of lomitapide was approximately 29 hours. Special populations: Data in the pivotal clinical trial were analyzed with respect to the impact of potential covariates on lomitapide exposure. Of the parameters examined (race, body mass index (BMI), gender, weight, age), only BMI could be classified as a potential covariate. Age and gender There was no clinically relevant effect of age (18-64 years) or gender on the pharmacokinetics of lomitapide. Race No dose adjustment is required for Caucasian or Latino patients. There is insufficient information to determine if Lojuxta requires dose adjustment in other races. However, since the medicinal product is dosed in an escalating fashion according to individual patient safety and tolerability, no adjustment to the dosing regimen is recommended based on race. Renal insufficiency In the renal impairment population, lomitapide was only studied in patients with end-stage renal disease (ESRD). A pharmacokinetic study in patients with ESRD undergoing hemodialysis demonstrated a 36% increase in mean lomitapide plasma concentration compared to matched healthy controls. The terminal half-life of lomitapide was not affected. Hepatic insufficiency A single-dose, open-label study was conducted to evaluate the pharmacokinetics of 60 mg lomitapide in healthy volunteers with normal hepatic function compared with patients with mild (Child-Pugh A) and moderate (Child-Pugh B) hepatic impairment. In patients with moderate hepatic impairment, lomitapide AUC and Cmax were 164% and 361% higher, respectively, compared with healthy volunteers. In patients with mild hepatic impairment, lomitapide AUC and Cmax were 47% and 4% higher, respectively, compared with healthy volunteers. Lojuxta has not been studied in patients with severe hepatic impairment (Child-Pugh score 10-15). Paediatric population Lojuxta has not been investigated in children less than 18 years of age. Elderly population Lojuxta has not been investigated in patients aged 65 years or older. 5.3 Preclinical safety data In repeat-dose oral toxicology studies in rodents and dogs, the principal drug-related findings were lipid accumulation in the small intestine and/or liver associated with decreases in serum cholesterol and/or triglyceride levels. These changes are secondary to the mechanism of action of lomitapide. Other liver-related changes in repeat-dose toxicity studies in rats and dogs included increased serum aminotransferases, subacute inflammation (rats only), and single-cell necrosis. In a 1 year repeat-dose study in dogs there were no microscopic changes in the liver although serum AST was minimally increased in females. Pulmonary histiocytosis was observed in rodents. Decreased red blood cell parameters as well as poikilocytosis and/or anisocytosis were observed in dogs. Testicular toxicity was observed in dogs at 205 times the human exposure (AUC) at 60 mg in a 6-month study. No adverse effects on the testes were observed in a 1-year study in dogs at 64 times the human exposure at 60mg. In a dietary carcinogenicity study in mice, lomitapide was administered up to 104 weeks at doses ranging from 0.3 to 45 mg/kg/day. There were statistically significant increases in the incidences of liver adenoma and carcinoma at doses ≥1.5 mg/kg/day in males (≥ 2 times the human exposure at 60 mg daily based on AUC) and ≥7.5 mg/kg/day in females (≥ 9 times the human exposure at 60 mg based on AUC). Incidences of small intestinal carcinoma and/or combined adenoma and carcinoma (rare tumours in mice) were significantly increased at doses ≥15 mg/kg/day in males (≥ 26 times the human exposure at 60 mg based on AUC) and at 15 mg/kg/day in females (22 times the human exposure at 60 mg based on AUC). In an oral carcinogenicity study in rats, lomitapide was administered up to 99 weeks at doses up to 7.5 mg/kg/day in males and 2.0 mg/kg/day in females. Focal hepatic fibrosis was observed in males and females and hepatic cystic degeneration was observed in males only. In high-dose males, an increased incidence of pancreatic acinar cell adenoma was observed at an exposure 6 times that in humans at 60 mg based on AUC. Lomitapide was not mutagenic or genotoxic in a battery of in vitro and in vivo studies. Lomitapide had no effect on reproductive function in female rats at doses up to 1 mg/kg or in male rats at doses up to 5 mg/kg. Systemic exposures to lomitapide at these doses were estimated to be 4 times (females) and 5 times (males) higher than the human exposure at 60 mg based on AUC. Lomitapide was teratogenic in rats in the absence of maternal toxicity at an exposure (AUC) estimated to be twice that in humans at 60 mg. There was no evidence of embryofoetal toxicity in rabbits at 3 times the maximum recommended human dose (MRHD) of 60 mg based on body surface area. Embryofoetal toxicity was observed in rabbits in the absence of maternal toxicity at ≥6.5 times the MRHD. In ferrets, lomitapide was both maternally toxic and teratogenic at <1 times the MRHD. 6. Pharmaceutical particulars 6.1 List of excipients Capsule content Pregelatinised starch (maize) Sodium starch glycolate Microcrystalline cellulose Lactose monohydrate Silica, colloidal anhydrous Magnesium stearate Capsule shell Gelatin Titanium dioxide (E171) Red iron oxide (E172) Printing ink Shellac Black iron oxide (E172) Propylene glycol 6.2 Incompatibilities Not applicable. 6.3 Shelf life 2 years. 6.4 Special precautions for storage Store below 30°C. Keep the bottle tightly closed in order to protect from moisture. 6.5 Nature and contents of container High density polyethylene (HDPE) bottle fitted with a polyester/aluminium foil/cardboard induction seal and polypropylene screw cap. Package sizes are: 28 capsules 6.6 Special precautions for disposal and other handling No special requirements. 7. Marketing authorisation holder Aegerion Pharmaceuticals Ltd Lakeside House 1 Furzeground Way Stockley Park East Uxbridge UB11 1BD United Kingdom 8. Marketing authorisation number(s) EU/1/13/851/001: Lojuxta 5 mg hard capsules EU/1/13/851/002: Lojuxta 10 mg hard capsules EU/1/13/851/003: Lojuxta 20 mg hard capsules 9. Date of first authorisation/renewal of the authorisation Date of first authorisation: 31 July 2013 10. Date of revision of the text 18 December 2013 Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.