艾滋病新药Evotaz (atazanavir and cobicistat)获欧盟批准
近日，艾滋病复方新药Evotaz再获欧盟批准，联合其他抗逆转录病毒药物，用于HIV-1成人感染者的治疗，帮助患者实现长期病毒学抑制。
Evotaz（atazanavir/cobicistat，300mg/150mg）是一种每日口服一次的复方单片，其中atazanavir（阿扎那韦，商品名：Reyataz）是一种蛋白酶抑制剂。cobicistat（商品名Tybost）则是由吉利德（Gilead）开发的一种药物动力学增强剂，于2013年9月获欧盟批准，可提高特定HIV-1药物的血药浓度，使药物更加有效。Evotaz将为HIV-1感染者提供一种单一片剂选择，消除了服用Reyataz的同时需另服药效增强剂的必要性。
Reyataz（atazanavir，阿扎那韦）于2003年上市，联合低剂量药代动力学增强剂ritonavir（利托那韦）及其他抗逆转录病毒药物，用于HIV-1感染者的治疗。

EVOTAZ 300 mg/150 mg film-coated tablets
1. Name of the medicinal product
EVOTAZ 300 mg/150 mg film-coated tablets
2. Qualitative and quantitative composition
Each film-coated tablet contains atazanavir sulphate corresponding to 300 mg atazanavir and 150 mg of cobicistat.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Film-coated tablet
Pink, oval, biconvex, film-coated tablet of approximate dimensions of 19 mm x 10.4 mm, debossed with "3641" on one side and plain on the other side.
4. Clinical particulars
4.1 Therapeutic indications
EVOTAZ is indicated in combination with other antiretroviral medicinal products for the treatment of HIV-1 infected adults without known mutations associated with resistance to atazanavir (see sections 4.4 and 5.1).
4.2 Posology and method of administration
Therapy should be initiated by a physician experienced in the management of HIV infection.
Posology
Adults
The recommended dose of EVOTAZ is one tablet once daily taken orally with food (see section 5.2).
Advice on missed doses
If EVOTAZ is missed within 12 hours of the time it is usually taken, patients should be instructed to take the prescribed dose of EVOTAZ with food as soon as possible. If this is noticed later than 12 hours of the time it is usually taken, the missed dose should not be taken and the patient should resume the usual dosing schedule.
Special populations
Renal impairment
Based on the very limited renal elimination of cobicistat and atazanavir, no special precautions or dose adjustments of EVOTAZ are required for patients with renal impairment.
EVOTAZ is not recommended for patients undergoing haemodialysis (see sections 4.4 and 5.2).
Cobicistat has been shown to decrease estimated creatinine clearance due to inhibition of tubular secretion of creatinine without affecting actual renal glomerular function. EVOTAZ should not be initiated in patients with creatinine clearance less than 70 ml/min if any co-administered agent (e.g. emtricitabine, lamivudine, tenofovir disoproxil fumarate or adefovir) requires dose adjustment based on creatinine clearance (see sections 4.4, 4.8 and 5.2).
Hepatic impairment
There are no pharmacokinetic data regarding the use of EVOTAZ in patients with hepatic impairment.
Atazanavir and cobicistat are metabolised by the hepatic system. Atazanavir should be used with caution in patients with mild (Child-Pugh Class A) hepatic impairment. However, atazanavir must not be used in patients with moderate (Child-Pugh Class B) to severe (Child-Pugh Class C) hepatic impairment. No dose adjustment of cobicistat is required in patients with mild or moderate hepatic impairment. Cobicistat has not been studied in patients with severe hepatic impairment and is not recommended in these patients.
EVOTAZ should be used with caution in patients with mild hepatic impairment. EVOTAZ must not be used in patients with moderate to severe hepatic impairment (see section 4.3).
Paediatric population
EVOTAZ should not be used in children less than 3 months of age because of safety concerns especially taking into account the potential risk of kernicterus associated with the atazanavir component.
The safety and efficacy of EVOTAZ in children less than 18 years of age have not been established. Currently available data are described in sections 4.8, 5.1 and 5.2, but no recommendation on a posology can be made.
Method of administration
EVOTAZ is to be taken orally with food (see section 5.2). The film-coated tablet should be swallowed whole and must not be chewed, broken, cut or crushed.
4.3 Contraindications
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.
Co-administration with the following medicinal products that are strong inducers of the CYP3A4 isoform of cytochrome P450 due to the potential for loss of therapeutic effect (see section 4.5):
• carbamazepine, phenobarbital, phenytoin (antiepileptics)
• St John's wort (Hypericum perforatum) (herbal product)
• rifampicin (antimycobacterial)
Co-administration with the following medicinal products due to the potential for serious and/or life-threatening adverse reactions (see section 4.5):
• colchicine, when used in patients with renal and/or hepatic impairment (antigout) (see section 4.5)
• sildenafil - when used for the treatment of pulmonary arterial hypertension (see sections 4.4 and 4.5 for co-administration for the treatment of erectile dysfunction), avanafil (PDE5 inhibitors)
• simvastatin and lovastatin (HMG-CoA reductase inhibitors) (see section 4.5)
• substrates of CYP3A4 or the UGT1A1 isoform of UDP-glucuronyltransferase and have narrow therapeutic windows:
• alfuzosin (alpha-1-adrenoreceptor antagonist)
• amiodarone, bepridil, dronedarone, quinidine, systemic lidocaine (antiarrhythmics/antianginals)
• astemizole, terfenadine (antihistamines)
• cisapride (gastrointestinal motility agent)
• ergot derivatives (e.g. dihydroergotamine, ergometrine, ergotamine, methylergonovine)
• pimozide, quetiapine (antipsychotics/neuroleptics) (see section 4.5)
• ticagrelor (platelet aggregation inhibitor)
• triazolam, midazolam administered orally (sedatives/hypnotics) (for caution on parenterally administered midazolam, see section 4.5).
Moderate to severe hepatic impairment.
4.4 Special warnings and precautions for use
While effective viral suppression with antiretroviral therapy has been proven to substantially reduce the risk of sexual transmission, a residual risk cannot be excluded. Precautions to prevent transmission should be taken in accordance with national guidelines.
The choice of EVOTAZ in adult patients should be based on individual viral resistance testing and the patient's treatment history (see section 5.1).
Patients with co-existing conditions
Hepatic impairment
The use of EVOTAZ is contraindicated in patients with moderate to severe hepatic impairment. EVOTAZ should be used with caution in patients with mild hepatic impairment (see sections 4.2, 4.3 and 5.2).
Atazanavir
Atazanavir is primarily hepatically metabolised and increased plasma concentrations were observed in patients with hepatic impairment (see sections 4.2 and 5.2). The safety and efficacy of atazanavir have not been established in patients with significant underlying liver disorders. Patients with chronic hepatitis B or C and treated with combination antiretroviral therapy are at an increased risk for severe and potentially fatal hepatic adverse reactions (see section 4.8). In case of concomitant antiviral therapy for hepatitis B or C, please refer also to the relevant Summary of Product Characteristics for these medicinal products.
Patients with previous liver dysfunction or patients with chronic active hepatitis have an increased frequency of liver function abnormalities during combination antiretroviral therapy and should be monitored according to standard practice. If there is evidence of worsening liver disease in such patients, interruption or discontinuation of treatment must be considered.
Cobicistat
Cobicistat has not been studied in patients with severe hepatic impairment (Child-Pugh Class C).
Renal impairment
EVOTAZ is not recommended in patients undergoing haemodialysis (see sections 4.2 and 5.2).
Effects on estimated creatinine clearance
Cobicistat has been shown to decrease estimated creatinine clearance due to inhibition of tubular secretion of creatinine. This effect on serum creatinine, leading to a decrease in the estimated creatine clearance, should be taken into consideration when EVOTAZ is administered to patients in whom the estimated creatinine clearance is used to guide aspects of their clinical management, including adjusting doses of co-administered medicinal products. For more information consult the cobicistat Summary of Product Characteristics.
EVOTAZ should not be initiated in patients with creatinine clearance less than 70 ml/min if one or more co-administered agent requires dose adjustment based on creatinine clearance (e.g. emtricitabine, lamivudine, tenofovir disoproxil fumarate or adefovir; see sections 4.2, 4.8 and 5.2).
As atazanavir and cobicistat are highly bound to plasma proteins, it is unlikely that they will be significantly removed by haemodialysis or peritoneal dialysis (see sections 4.2 and 5.2).
There are currently inadequate data to determine whether co-administration of tenofovir disoproxil fumarate and cobicistat is associated with a greater risk of renal adverse reactions compared with regimens that include tenofovir disoproxil fumarate without cobicistat.
QT prolongation
Dose related asymptomatic prolongations in PR interval with atazanavir, a component of EVOTAZ have been observed in clinical studies. Caution should be used with medicinal products known to induce PR prolongations. In patients with pre-existing conduction problems (second degree or higher atrioventricular or complex bundle-branch block), EVOTAZ should be used with caution and only if the benefits exceed the risk (see section 5.1). Particular caution should be used when prescribing EVOTAZ in association with medicinal products which have the potential to increase the QT interval and/or in patients with pre-existing risk factors (bradycardia, long congenital QT, electrolyte imbalances (see sections 4.8 and 5.3)).
Haemophiliac patients
There have been reports of increased bleeding, including spontaneous skin haematomas and haemarthroses, in type A and B haemophiliac patients treated with protease inhibitors. In some patients additional factor VIII was given. In more than half of the reported cases, treatment with protease inhibitors was continued or reintroduced if treatment had been discontinued. A causal relationship has been suggested, although the mechanism of action has not been elucidated. Haemophiliac patients should, therefore, be made aware of the possibility of increased bleeding.
Weight and metabolic parameters
An increase in weight and in levels of blood lipids and glucose may occur during antiretroviral therapy. Such changes may in part be linked to the disease control and life style. For lipids, there is in some cases evidence for a treatment effect, while for weight gain there is no strong evidence relating this to any particular treatment. For monitoring of blood lipids and glucose, reference is made to established HIV treatment guidelines. Lipid disorders should be managed as clinically appropriate.
In clinical studies, atazanavir has been shown to induce dyslipidaemia to a lesser extent than comparators.
Hyperbilirubinaemia
Reversible elevations in indirect (unconjugated) bilirubin related to inhibition of UDP-glucuronosyl transferase (UGT) have occurred in patients receiving atazanavir (see section 4.8). Hepatic transaminase elevations that occur with elevated bilirubin in patients receiving EVOTAZ should be evaluated for alternative etiologies. Alternative antiretroviral therapy to EVOTAZ may be considered if jaundice or scleral icterus is unacceptable to a patient.
Indinavir is also associated with indirect (unconjugated) hyperbilirubinaemia due to inhibition of UGT. Combinations of EVOTAZ and indinavir have not been studied and co-administration of these medicinal products is not recommended (see section 4.5).
Cholelithiasis
Cholelithiasis has been reported in patients receiving atazanavir (see section 4.8). Some patients required hospitalisation for additional management and some had complications. If signs or symptoms of cholelithiasis occurs, temporary interruption or discontinuation of treatment may be considered.
Nephrolithiasis
Nephrolithiasis has been reported in patients receiving atazanavir (see section 4.8). Some patients required hospitalisation for additional management and some had complications. In some cases, nephrolithiasis has been associated with acute renal failure or renal insufficiency. If signs or symptoms of nephrolithiasis occurs, temporary interruption or discontinuation of treatment may be considered.
Immune reactivation syndrome
In HIV-infected patients with severe immune deficiency at the time of institution of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic pathogens may arise and cause serious clinical conditions, or aggravation of symptoms. Typically, such reactions have been observed within the first few weeks or months of initiation of CART. Relevant examples are cytomegalovirus retinitis, generalised and/or focal mycobacterial infections, and Pneumocystis carinii pneumonia. Any inflammatory symptoms should be evaluated and treatment instituted when necessary. Autoimmune disorders (such as Graves' disease) have also been reported to occur in the setting of immune reactivation; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment.
Osteonecrosis
Although the aetiology is considered to be multifactorial (including corticosteroid use, alcohol consumption, severe immunosuppression, higher body mass index), cases of osteonecrosis have been reported particularly in patients with advanced HIV-disease and/or long-term exposure to combination antiretroviral therapy (CART). Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.
Rash and associated syndromes
Rashes are usually mild-to-moderate maculopapular skin eruptions that occur within the first 3 weeks of starting therapy with atazanavir, a component of EVOTAZ.
Stevens-Johnson syndrome (SJS), erythema multiforme, toxic skin eruptions and drug rash with eosinophilia and systemic symptoms (DRESS) syndrome have been reported in patients receiving atazanavir. Patients should be advised of the signs and symptoms and monitored closely for skin reactions. EVOTAZ or any other medicinal product containing atazanavir should be discontinued if severe rash develops.
The best results in managing these events come from early diagnosis and immediate interruption of any suspect medicines. If the patient has developed SJS or DRESS associated with the use of EVOTAZ, EVOTAZ may not be restarted.
Co-administration with antiretroviral medicinal products
EVOTAZ is indicated for use with other antiretrovirals for the treatment of HIV-1 infection. EVOTAZ should not be used in combination with products containing the same active components including atazanavir, cobicistat or with fixed-dose products that contain cobicistat. EVOTAZ should not be used in combination with another antiretroviral that requires pharmacokinetic enhancement (i.e., another protease inhibitor or elvitegravir) since dosing recommendations for such combinations have not been established and may result in decreased plasma concentrations of atazanavir and/or the other antiretroviral leading to loss of therapeutic effect and development of resistance. Co-administration of EVOTAZ with other protease inhibitors is not recommended. Because atazanavir is a component of EVOTAZ, co-administration of EVOTAZ with nevirapine or efavirenz is not recommended (see section 4.5).
EVOTAZ should not be used in combination with ritonavir or medicinal products containing ritonavir due to similar pharmacological effects of cobicistat and ritonavir on CYP3A (see section 4.5).
Interactions with other medicinal products
Atazanavir is metabolised principally by CYP3A4. Cobicistat is a strong mechanism-based CYP3A inhibitor and is a CYP3A substrate. Co-administration of EVOTAZ and medicinal products that induce CYP3A4 is contraindicated or not recommended (see sections 4.3 and 4.5) because, in addition to decreased plasma concentrations of atazanavir due to induction of CYP3A4, decreased plasma concentrations of cobicistat could result in cobicistat plasma levels that are insufficient to achieve adequate pharmacoenhancement of atazanavir.
Increased plasma concentrations of medicinal products that are metabolised by CYP3A (including atazanavir) are observed on co-administration with cobicistat. Higher plasma concentrations of co-administered medicinal products can result in increased or prolonged therapeutic effects or adverse reactions. For medicinal products metabolised by CYP3A these higher plasma concentrations may potentially lead to severe, life-threatening or fatal events (see sections 4.3 and 4.5).
Co-administration of EVOTAZ with medicinal products that inhibit CYP3A may decrease the clearance of atazanavir and cobicistat, resulting in increased atazanavir and cobicistat plasma concentrations (see section 4.5).
Unlike ritonavir, cobicistat is not an inducer of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19 or UGT1A1. If switching from atazanavir boosted with ritonavir to EVOTAZ, caution is required during the first two weeks of treatment with EVOTAZ, particularly if doses of any concomitantly administered medicinal products have been titrated or adjusted during use of ritonavir as a pharmacoenhancer (see section 4.5).
Cobicistat is a weak CYP2D6 inhibitor and is metabolised to a minor extent by CYP2D6. Co-administration with EVOTAZ can increase plasma concentrations of medicinal products that are metabolised by CYP2D6 (see sections 4.3 and 4.5).
Because atazanavir is a component of EVOTAZ, the combination of EVOTAZ with atorvastatin is not recommended (see section 4.5).
PDE5 inhibitors used for the treatment of erectile dysfunction
Particular caution should be used when prescribing PDE5-inhibitors (sildenafil, tadalafil, vardenafil, or avanafil) for the treatment of erectile dysfunction in patients receiving EVOTAZ. Co-administration of EVOTAZ with these medicinal products is expected to substantially increase their concentrations and may result in PDE5-associated adverse reactions such as hypotension, visual changes and priapism (see section 4.5).
Co-administration of voriconazole and EVOTAZ is not recommended unless an assessment of the benefit/risk justifies the use of voriconazole (see section 4.5).
Concomitant use of EVOTAZ and fluticasone or other glucocorticoids that are metabolized by CYP3A4 is not recommended unless the potential benefit of treatment outweighs the risk of systemic corticosteroid effects, including Cushing's syndrome and adrenal suppression (see section 4.5).
Co-administration of EVOTAZ with warfarin has the potential to produce serious and/or life-threatening bleeding due to increased warfarin plasma concentrations, and it is recommended that the INR (International Normalized Ratio) be monitored (see section 4.5).
Co-administration of EVOTAZ with proton pump inhibitors (PPIs) is not recommended due to the decreased solubility of atazanavir as intra-gastric pH increase with PPIs (see section 4.5).
Contraception requirements
No dosing recommendations can be made regarding the use of EVOTAZ with oral contraceptives (see section 4.5). Alternative forms of contraception (non-hormonal) should be considered (see section 4.6).
4.5 Interaction with other medicinal products and other forms of interaction
Drug interaction trials were not conducted for EVOTAZ. As EVOTAZ contains atazanavir and cobicistat, any interactions that have been identified with these active substances individually may occur with EVOTAZ.
Complex or unknown mechanisms of drug interaction preclude extrapolation of ritonavir drug interactions to certain cobicistat drug interactions. The recommendations given for concomitant use of atazanavir and other medicinal products may, therefore, differ depending on whether atazanavir is boosted with ritonavir or cobicistat. In particular, atazanavir boosted with cobicistat is more sensitive for CYP3A induction (see section 4.3 and the interaction table). Caution is also required during the first time of treatment if switching the pharmacoenhancer from ritonavir to cobicistat (see section 4.4).
Medicinal products that affect atazanavir/cobicistat exposure
Atazanavir is metabolised in the liver through CYP3A4.
Cobicistat is a CYP3A substrate and is metabolised to a minor extent by CYP2D6.
Concomitant use contraindicated
Co-administration of EVOTAZ with medicinal products that are strong inducers of CYP3A (such as carbamazepine, phenobarbital, phenytoin, rifampicin, and St. John's wort [Hypericum perforatum]) may result in decreased plasma concentrations of atazanavir and/or cobicistat, leading to loss of therapeutic effect and possible development of resistance to atazanavir (see section 4.3 and Table 1).
Concomitant use not recommended
Co-administration of EVOTAZ with medicinal products containing ritonavir or cobicistat, which are strong inhibitors of CYP3A, may result in additional boosting and increased plasma concentration of atazanavir.
Co-administration of EVOTAZ with medicinal products that inhibit CYP3A may result in increased plasma concentration of atazanavir and/or cobicistat. Some examples include, but are not limited to, itraconazole, ketoconazole and voriconazole (see Table 1).
Co-administration of EVOTAZ with medicinal products that are moderate to weak inducers of CYP3A may result in decreased plasma concentration of atazanavir and/or cobicistat, leading to loss of therapeutic effect and possible development of resistance to atazanavir. Some examples include, but are not limited to etravirine, nevirapine, efavirenz, boceprevir, fluticasone and bosentan (see Table 1).
Medicinal products that may be affected by atazanavir/cobicistat
Atazanavir is an inhibitor of CYP3A4 and UGT1A1. Atazanavir is a weak to moderate inhibitor of CYP2C8. Atazanavir has been shown in vivo not to induce its own metabolism, nor to increase the biotransformation of some medicinal products metabolised by CYP3A4.
Cobicistat is a strong mechanism-based CYP3A inhibitor and a weak CYP2D6 inhibitor. Cobicistat inhibits the transporters p-glycoprotein (P-gp), BCRP, MATE1, OATP1B1 and OATP1B3.
Cobicistat is not expected to inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9 or CYP2C19.
Cobicistat is not expected to induce CYP3A4 or P-gp. Unlike ritonavir, cobicistat is not an inducer of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19 or UGT1A1.
Concomitant use contraindicated
Co-administration of medicinal products that are substrates of CYP3A and have narrow therapeutic indeces and for which elevated plasma concentrations are associated with serious and/or life-threatening events are contraindicated with EVOTAZ. These medicinal products include alfuzosin, amiodarone, astemizole, bepridil, cisapride, colchicine, dronedarone, ergot deriviatives (e.g. dihydroergotamine, ergometrine, ergotamine, methylergonovine), lovastatin, orally administered midazolam, pimozide, quetiapine, quinidine, simvastatin, sildenafil (when used to treat pulmonary arterial hypertension), avanafil, systemic lidocaine, ticagrelor, terfenadine and triazolam (see section 4.3 and Table 1).
Increased plasma concentrations of medicinal products that are metabolised by CYP3A, CYP2C8, CYP2D6 and/or UGT1A1 are expected when co-administered with EVOTAZ. Co-administration of EVOTAZ in patients receiving medicinal products that are substrates of the transporters P-gp, BCRP, MATE1, OATP1B1 and OATP1B3 may result in increased plasma concentrations of the co-administered medicinal products (see section 4.4). Clinically significant interactions between EVOTAZ and substrates of CYP1A2, CYP2B6, CYP2C9 or CYP2C19 are not expected.
Interaction table
Interactions between EVOTAZ and other medicinal products are listed in Table 1 below (increase is indicated as “↑”, decrease as “↓”, no change as “↔”). The recommendations shown in Table 1 are based on either drug interaction trials of unboosted atazanavir, atazanavir boosted with ritonavir, cobicistat or predicted interactions due to the expected magnitude of the interaction and potential for serious adverse reactions or loss of therapeutic effect of EVOTAZ. If available, 90% confidence intervals (CI) are shown in parentheses. The studies presented in Table 1 were conducted in healthy subjects unless otherwise noted.
Table 1: Interactions between EVOTAZ and other medicinal products

Medicinal products by therapeutic area	Interaction	Recommendations concerning co-administration
ANTI-RETROVIRALS
Protease inhibitors: EVOTAZ in combination with other protease inhibitors is not recommended because co-administration may not provide adequate protease inhibitor exposure.
Indinavir	Indinavir is associated with indirect unconjugated hyperbilirubinaemia due to inhibition of UGT.	Co-administration of EVOTAZ and indinavir is not recommended (see section 4.4).
Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
Lamivudine 150 mg twice daily + zidovudine 300 mg twice daily (atazanavir 400 mg once daily)	No significant effect on lamivudine and zidovudine concentrations was observed when co-administered with atazanavir.	Based on these data and because cobicistat is not expected to have a significant impact on the pharmacokinetics of NRTIs, the co-administration of EVOTAZ with these medicinal products is not expected to significantly alter the exposure of the co-administered medicinal products.
Didanosine (buffered tablets) 200 mg/stavudine 40 mg, both single dose (atazanavir 400 mg single dose)	Atazanavir, simultaneous administration with ddI+d4T (fasted) Atazanavir AUC ↓87% (↓92% ↓79%) Atazanavir Cmax ↓89% (↓94% ↓82%) Atazanavir Cmin ↓84% (↓90% ↓73%) Atazanavir, dosed 1 hr after ddI+d4T (fasted) Atazanavir AUC ↔3% (↓36% ↑67%) Atazanavir Cmax ↑12% (↓33% ↑18%) Atazanavir Cmin ↔3% (↓39% ↑73%) Atazanavir concentrations were greatly decreased when co-administered with didanosine (buffered tablets) and stavudine. The mechanism of interaction is a reduced solubility of atazanavir with increasing pH related to the presence of anti-acid agent in didanosine buffered tablets. No significant effect on didanosine and stavudine concentrations was observed.	Didanosine should be taken in the fasted state 2 hours after EVOTAZ taken with food. The co-administration of EVOTAZ with stavudine is not expected to significantly alter the exposure of stavudine.
Didanosine (enteric coated capsules) 400 mg single dose (atazanavir 400 mg once daily)	Didanosine (with food) Didanosine AUC ↓34% (↓40% ↓26%) Didanosine Cmax ↓36% (↓45% ↓26%) Didanosine Cmin ↑13% (↓9% ↑41%) No significant effect on atazanavir concentrations was observed when administered with enteric-coated didanosine, but administration with food decreased didanosine concentrations.
Tenofovir disoproxil fumarate 300 mg once daily (atazanavir 400 mg once daily)	Atazanavir AUC ↓25% (↓30% ↓19%) Atazanavir Cmax ↓21% (↓27% ↓14%) Atazanavir Cmin ↓40% (↓48% ↓32%) Tenofovir: AUC: ↑24% (↑21% ↑28%) Cmax: ↑14% (↑8% ↑20%) Cmin: ↑22% (↑15% ↑30%) Co-administration of tenofovir disoproxil fumarate with cobicistat is expected to increase tenofovir plasma concentrations. Tenofovir: AUC: ↑23% Cmin: ↑55% The mechanism of interaction between atazanavir and tenofovir is unknown.	Tenofovir may decrease the AUC and Cmin of atazanavir. When co-administered with tenofovir, it is recommended that EVOTAZ and tenofovir 300 mg be given together with food. Atazanavir increases tenofovir concentrations. Higher concentrations could potentiate tenofovir-associated adverse reactions, including renal disorders. Patients receiving tenofovir should be monitored for tenofovir-associated adverse reactions.
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz 600 mg once daily (atazanavir 400 mg once daily)	Atazanavir Atazanavir AUC ↓74% (↓78% ↓68%) Atazanavir Cmax ↓59% (↓77% ↓49%) Atazanavir Cmin ↓93% (↓95% ↓90%)	EVOTAZ is not recommended for co-administration with efavirenz. Efavirenz decreases atazanavir concentrations and is expected to decrease cobicistat plasma concentrations. This may result in loss of therapeutic effect of EVOTAZ and development of resistance to atazanavir (see section 4.4).
Efavirenz 600 mg single dose (cobicistat 150 mg once daily)	Efavirenz: AUC: ↔7% (↓11% ↓3%) Cmax: ↓13% (↓20% ↓6%) Cmin: Not determined The mechanism of interaction between efavirenz and atazanavir, or efavirenz and cobicistat is CYP3A4 induction by efavirenz.
Etravirine	Co-administration of etravirine and EVOTAZ is expected to decrease atazanavir and cobicistat plasma concentrations. The mechanism of interaction is CYP3A4 induction by etravirine.	EVOTAZ is not recommended for co-administration with etravirine because it may result in the loss of therapeutic effect and development of resistance to atazanavir.
Nevirapine 200 mg twice daily (atazanavir 300 mg once daily with ritonavir 100 mg once daily) Study conducted in HIV infected patients	Nevirapine AUC ↑25% (↑17% ↑34%) Nevirapine Cmax ↑17% (↑9% ↑25%) Nevirapine Cmin ↑32% (↑22% ↑43%) Atazanavir AUC ↓42% (↓52% ↓29%) Atazanavir Cmax ↓28% (↓40% ↓14%) Atazanavir Cmin ↓72% (↓80% ↓60%) Co-administration of nevirapine and cobicistat is expected to decrease cobicistat plasma concentrations while nevirapine plasma concentrations may be increased. The mechanism of interaction is CYP3A4 induction by nevirapine and CYP3A4 inhibition by atazanavir and cobicistat.	Co-administration of EVOTAZ and nevirapine is not recommended and may result in a loss of therapeutic effect of EVOTAZ and development of resistance to atazanavir. Co-administration of nevirapine and EVOTAZ is expected to increase nevirapine plasma concentrations which may increase the risk of nevirapine-associated toxicity (see section 4.4).
Rilpivirine	EVOTAZ is expected to increase rilpivirine plasma concentrations. The mechanism of interaction is CYP3A inhibition.	Co-administration of EVOTAZ and rilpivirine can be used without dose adjustments, as the expected increase in rilpivirine concentrations is not considered clinically relevant.
Integrase Inhibitors
Dolutegravir	Co-administration with EVOTAZ is expected to increase dolutegravir plasma concentrations. Dolutegravir is not expected to affect the pharmacokinetics of EVOTAZ. The mechanism of interaction is inhibition of UGT1A1 by atazanavir.	EVOTAZ and dolutegravir can be used without dose adjustments.
Raltegravir 400 mg twice daily (atazanavir 400 mg)	Raltegravir AUC ↑72% Raltegravir Cmax ↑53% Raltegravir C12hr ↑95% The mechanism is UGT1A1 inhibition by atazanavir.	No dose adjustment is required for raltegravir if co-administered with EVOTAZ.
CCR5 Antagonists
Maraviroc	Maraviroc is a substrate of CYP3A and its plasma concentration increases when co-administered with potent CYP3A inhibitors. Maraviroc is not expected to have an impact on concentrations of atazanavir and cobicistat. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	When co-administering maraviroc and EVOTAZ, patients should receive maraviroc 150 mg twice daily. For further details, consult the Summary of Product Characteristics for maraviroc.
HCV Protease Inhibitors
Boceprevir 800 mg three times daily (atazanavir 300 mg/ritonavir 100 mg once daily)	boceprevir AUC ↔5% boceprevir Cmax ↔7% boceprevir Cmin ↔18% atazanavir AUC ↓35% atazanavir Cmax ↓25% atazanavir Cmin ↓49% Concomitant administration of boceprevir and atazanavir/ritonavir resulted in reduced exposures to atazanavir and ritonavir. The mechanism of interaction is unknown.	Co-administration of boceprevir and EVOTAZ is not recommended.
Simeprevir	EVOTAZ is expected to increase simeprevir plasma concentrations. Simeprevir may increase atazanavir and/or cobicistat plasma concentrations. The mechanism of interaction is CYP3A inhibition.	It is not recommended to co-administer EVOTAZ with simeprevir.
Telaprevir 750 mg three times daily (atazanavir/ritonavir 300/100 mg once daily)	Telaprevir AUC ↓20% (↓24% ↓15%) Telaprevir Cmax ↓21% (↓26% ↓16%) Telaprevir Cmin ↓15% (↓25% ↓2%) Atazanavir AUC ↑17% (↓3% ↑43%) Atazanavir Cmax ↓15% (↓27% ↓2%) Atazanavir Cmin ↑85% (↑40% ↑144%)	No dose adjustment is required for telaprevir if co-administered with EVOTAZ. Clinical and laboratory monitoring for hyperbilirubinaemia is recommended.
Telaprevir 750 mg three times daily (cobicistat 150 mg once daily in combination with elvitegravir)	Telaprevir AUC ↔ Telaprevir Cmax ↔ Telaprevir Cmin ↔ Cobicistat AUC ↔ Cobicistat Cmax ↔ Cobicistat Cmin ↑232%
ANTIBIOTICS
Clarithromycin 500 mg twice daily (atazanavir 400 mg once daily)	Clarithromycin AUC ↑94% (↑75% ↑116%) Clarithromycin Cmax ↑50% (↑32% ↑71%) Clarithromycin Cmin ↑160% (↑135% ↑188%) 14-OH clarithromycin 14-OH clarithromycin AUC ↓70% (↓74% ↓66%) 14-OH clarithromycin Cmax ↓72% (↓76% ↓67%) 14-OH clarithromycin Cmin ↓62% (↓66% ↓58%) Atazanavir AUC ↑28% (↑16% ↑43%) Atazanavir Cmax ↔6% (↓7% ↑20%) Atazanavir Cmin ↑91% (↑66% ↑121%) Clarithromycin may increase concentrations of atazanavir and cobicistat. Exposure to clarithromycin is expected to increase if co-administered with EVOTAZ. The mechanism of interaction is CYP3A4 inhibition by atazanavir and/or cobicistat and clarithromycin.	Alternative antibiotics should be considered.
ANTIDIABETICS
Metformin	Cobicistat reversibly inhibits MATE1, and concentrations of metformin may be increased when co-administered with EVOTAZ.	Careful patient monitoring and dose adjustment of metformin is recommended in patients who are taking EVOTAZ.
ANTIFUNGALS
Ketoconazole 200 mg once daily (atazanavir 400 mg once daily)	No significant effect on atazanavir concentrations was observed.	Caution is warranted. Specific dosing recommendations are not available for co-administration of EVOTAZ with either ketoconazole or itraconazole. If co-administration is required, the daily dose of ketoconazole or itraconazole should not exceed 200 mg.
Itraconazole	Itraconazole, like ketoconazole, is a potent inhibitor as well as a substrate of CYP3A4. Concentrations of ketoconazole, itraconazole, and/or cobicistat may be increased with co-administration of ketoconazole or itraconazole with EVOTAZ. The mechanism of interaction is CYP3A4 inhibition by atazanavir, cobicistat and ketoconazole or itraconazole.
Voriconazole	Effects unknown	Voriconazole should not be co-administered with EVOTAZ unless the benefit/risk assessment justifies the use of voriconazole (see section 4.4). Clinical monitoring may be needed upon co-administration with EVOTAZ.
Fluconazole 200 mg once daily (atazanavir 300 mg and ritonavir 100 mg once daily)	Atazanavir and fluconazole concentrations were not significantly modified when atazanavir/ritonavir was co-administered with fluconazole. Concentration of fluconazole may be increased if co-administered with cobicistat.	Clinical monitoring is recommended upon co-administration with EVOTAZ.
ANTIGOUT
Colchicine	Colchicine plasma concentrations may be increased when co-administered with EVOTAZ. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	EVOTAZ must not be co-administered with colchicine to patients with renal or hepatic impairment. Recommended dosage of colchicine when administered with EVOTAZ in patients without renal or hepatic impairment: a dose reduction in colchicine dosage or an interruption of colchicine treatment is recommended in patients with normal renal or hepatic function if treatment with EVOTAZ is required.
ANTIMYCOBACTERIALS
Rifabutin 150 mg twice weekly (atazanavir 300 mg once daily with ritonavir 100 mg once daily)	Rifabutin AUC ↑48% (↑19% ↑84%)* Rifabutin Cmax ↑149% (↑103% ↑206%)* Rifabutin Cmin ↑40% (↑5% ↑87%)* 25-O-desacetyl-rifabutin AUC ↑990% (↑714% ↑1361%)* 25-O-desacetyl-rifabutin Cmax ↑677% (↑513% ↑883%)* 25-O-desacetyl-rifabutin Cmin ↑1045% (↑715% ↑1510%)* *When compared to rifabutin 150 mg once daily alone. Total rifabutin and 25-O-desacetyl-rifabutin AUC ↑119% (↑78% ↑169%).	Co-administration of EVOTAZ and rifabutin is not recommended. If the combination is needed, the recommended dose of rifabutin is 150 mg 3 times per week on set days (for example Monday-Wednesday-Friday). Increased monitoring for rifabutin-associated adverse reactions including neutropenia and uveitis is warranted due to an expected increase in exposure to rifabutin. Further dosage reduction of rifabutin to 150 mg twice weekly on set days is recommended for patients in whom the 150 mg dose 3 times per week is not tolerated. It should be kept in mind that the twice weekly dosage of 150 mg may not provide an optimal exposure to rifabutin thus leading to a risk of rifamycin resistance and a treatment failure. Consideration should be given to official guidance on the appropriate treatment of tuberculosis in HIV infected patients.
Rifabutin 150 mg every other day/elvitegravir 150 mg once daily/cobicistat 150 mg once daily	Cobicistat: AUC: ↔ Cmax: ↔ Cmin: ↓66% Rifabutin: AUC: ↔8% Cmax: ↔9% Cmin: ↔6% 25-O-desacetyl-rifabutin: AUC: ↑525% Cmax: ↑384% Cmin: ↑394% The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.
Rifampicin 600 mg once daily (atazanavir 300 mg once daily with ritonavir 100 mg once daily)	Rifampicin is a strong CYP3A4 inducer and has been shown to cause a 72% decrease in atazanavir AUC which can result in virological failure and resistance development. The mechanism of interaction is CYP3A4 induction by rifampicin.	Rifampicin substantially decreases plasma concentrations of atazanavir, which may result in loss of therapeutic effect of EVOTAZ and development of resistance to atazanavir. The combination of rifampicin and EVOTAZ is contraindicated (see section 4.3).
ACID REDUCING AGENTS
H2-Receptor antagonists
Without Tenofovir
Famotidine 20 mg twice daily (atazanavir 300 mg/ritonavir 100 mg once daily) in HIV-infected patients	Atazanavir AUC ↓18% (↓25% ↑1%) Atazanavir Cmax ↓20% (↓32% ↓7%) Atazanavir Cmin ↔1% (↓16% ↑18%)	For patients not taking tenofovir, EVOTAZ once daily with food should be administered simultaneously with, and/or at least 10 hours after, a dose of the H2-receptor antagonist. The dose of the H2-receptor antagonist should not exceed a dose comparable to famotidine 20 mg twice daily.
With Tenofovir 300 mg once daily
Famotidine 20 mg twice daily (atazanavir 300 mg/ritonavir 100 mg/tenofovir 300 mg once daily, simultaneous administration)	Atazanavir AUC ↓10% (↓18% ↓2%) Atazanavir Cmax ↓9% (↓16% ↓1%) Atazanavir Cmin ↓19% (↓31% ↓6%) The mechanism of interaction is decreased solubility of atazanavir as intra-gastric pH increases with H2 blockers.	For patients who are taking tenofovir, it is not recommended to co-administer EVOTAZ with an H2-receptor antagonist.
Proton pump inhibitors
Omeprazole 40 mg once daily (atazanavir 400 mg once daily, 2 hours after omeprazole)	Atazanavir AUC ↓94% (↓95% ↓93%) Atazanavir Cmax ↓96% (↓96% ↓95%) Atazanavir Cmin ↓95% (↓97% ↓93%)	Co-administration of EVOTAZ with proton pump inhibitors is not recommended.
Omeprazole 40 mg once daily (atazanavir 300 mg once daily with ritonavir 100 mg once daily, 2 hours after omeprazole)	Atazanavir AUC ↓76% (↓78% ↓73%) Atazanavir Cmax ↓72% (↓76% ↓68%) Atazanavir Cmin ↓78% (↓81% ↓74%)
Omeprazole 20 mg once daily am (atazanavir 300 mg once daily with ritonavir 100 mg once daily pm, 12 hours after omeprazole)	Atazanavir AUC ↓42% (↓66% ↓25%) Atazanavir Cmax ↓39% (↓64% ↓19%) Atazanavir Cmin ↓46% (↓59% ↓29%) The mechanism of interaction is decreased solubility of atazanavir as intra-gastric pH increases with proton pump inhibitors.
Antacids
Antacids and medicinal products containing buffers	Reduced plasma concentrations of atazanavir may be the consequence of increased gastric pH if antacids, including buffered medicinal products, are administered with EVOTAZ.	EVOTAZ should be administered 2 hours before or 1 hour after antacids or buffered medicinal products.
ALPHA 1-ADRENORECEPTOR ANTAGONIST
Alfuzosin	Potential for increased alfuzosin concentrations which can result in hypotension. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	Co-administration of EVOTAZ with alfuzosin is contraindicated (see section 4.3)
ANTICOAGULANTS
Warfarin	Co-administration with EVOTAZ has the potential to increase warfarin plasma concentrations. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	Co-administration with EVOTAZ has the potential to produce serious and/or life-threatening bleeding due to increased exposure to warfarin and has not been studied. It is recommended that the INR (International Normalized Ratio) be monitored.
Rivaroxaban	Co-administration of EVOTAZ and rivaroxaban may result in increased exposure to rivaroxaban and may lead to increased bleeding. The mechanism of interaction is CYP3A4 and P-gp inhibition by cobicistat.	Avoid concomitant use of EVOTAZ and rivaroxaban.
Dabigatran	Concentrations of dabigatran may be affected upon co-administration with EVOTAZ. The mechanism of interaction is P-gp inhibition by atazanavir and cobicistat.	Clinical monitoring is recommended when dabigatran is co-administered with P-gp inhibitors. A coagulation test helps to identify patients with an increased bleeding risk due to increased dabigatran exposure.
Ticagrelor	Co- administration of EVOTAZ and ticagrelor may increase concentrations of the anticoagulant. The mechanism of interaction is CYP3A and/or P-glycoprotein inhibition by atazanavir and cobicistat.	Concomitant administration of EVOTAZ with ticagrelor is contraindicated. Use of other antiplatelets not affected by CYP inhibition or induction (e.g. prasugrel) is recommended (see section 4.3).
ANTIEPILEPTICS
Carbamazepine Phenobarbital Phenytoin	These antiepileptics are expected to decrease atazanavir and/or cobicistat plasma concentrations. The mechanism of interaction is CYP3A induction by the antiepileptic.	Co-administration of EVOTAZ and these antiepileptics is contraindicated (see section 4.3).
ANTIHISTAMINE AGENTS
Astemizole Terfenadine	EVOTAZ must not be used in combination with medicinal products that are substrates of CYP3A4 and have a narrow therapeutic index.	Co-administration of EVOTAZ with astemizole and terfenadine is contraindicated (see section 4.3).
ANTINEOPLASTICS AND IMMUNOSUPRESSANTS
Antineoplastics
Irinotecan	Atazanavir inhibits UGT and may interfere with the metabolism of irinotecan, resulting in increased irinotecan toxicities.	If EVOTAZ is co-administered with irinotecan, patients should be closely monitored for adverse reactions related to irinotecan.
Dasatinib Nilotinib Vinblastine Vincristine	Concentrations of these medicinal products may be increased when co-administered with EVOTAZ. The mechanism of interaction is CYP3A4 inhibition by cobicistat.	Concentrations of these medicinal products may be increased when co-administered with EVOTAZ resulting in the potential for increased adverse events usually associated with these anticancer medicinal products.
Immunosuppressants
Ciclosporin Tacrolimus Sirolimus	Concentrations of these immunosuppressants may be increased when co-administered with EVOTAZ. The mechanism of interaction is inhibition of CYP3A4 by atazanavir and cobicistat.	More frequent therapeutic concentration monitoring is recommended for immunosuppressant agents when co-administered with EVOTAZ.
ANTIPSYCOTICS
Pimozide Quetiapine	Concentrations of these medicinal products may be increased when co-administered with EVOTAZ. The mechanism of interaction is CYP3A inhibition by atazanavir and cobicistat.	The combination of pimozide or quetiapine and EVOTAZ is contraindicated (see section 4.3).
CARDIOVASCULAR AGENTS
Antiarrhythmics
Disopyramide Flecainide Mexiletine Propafenone	Concentrations of these antiarrhythmics may be increased when co-administered with EVOTAZ. The mechanism of interaction is CYP3A inhibition by atazanavir and cobicistat.	Co-administration with EVOTAZ has the potential to produce serious and/or life-threatening adverse reactions. Caution is warranted and therapeutic concentration monitoring of these medicinal products is recommended if they are used concomitantly with EVOTAZ.
Amiodarone Dronedarone Quinidine Systemic lidocaine	Concentrations of these antiarrhythmics may be increased when co-administered with EVOTAZ. The mechanism of interaction is CYP3A inhibition by atazanavir and cobicistat.	Amiodarone, dronedarone, quinidine and systemic lidocaine have a narrow therapeutic window and are contraindicated due to potential inhibition of CYP3A by EVOTAZ (see section 4.3).
Digoxin (0.5 mg single dose)/cobicistat (150 mg multiple doses)	Plasma concentrations of digoxin may be increased when co-administered with EVOTAZ. Digoxin: AUC: ↔ Cmax: ↑41% Cmin: not determined The mechanism of interaction is inhibition of P-gp by cobicistat.	The peak concentration of digoxin is increased when co-administered with cobicistat. When co-administering with EVOTAZ, titrate the digoxin dose and monitor digoxin concentrations. The lowest dose of digoxin should initially be prescribed.
Antihypertensives
Metoprolol Timolol	Concentrations of beta-blockers may be increased when co-administered with EVOTAZ. The mechanism of interaction is inhibition of CYP2D6 by cobicistat.	Clinical monitoring is recommended when co-administered with EVOTAZ and a dose reduction of the beta-blocker may be necessary.
Calcium channel blockers
Bepridil	EVOTAZ must not be used in combination with medicinal products that are substrates of CYP3A4 and have a narrow therapeutic index.	Co-administration with bepridil is contraindicated (see section 4.3).
Diltiazem 180 mg once daily (atazanavir 400 mg once daily)	Diltiazem AUC ↑125% (↑109% ↑141%) Diltiazem Cmax ↑98% (↑78% ↑119%) Diltiazem Cmin ↑142% (↑114% ↑173%) Desacetyl-diltiazem AUC ↑165% (↑145% ↑187%) Desacetyl-diltiazem Cmax ↑172% (↑144% ↑203%) Desacetyl-diltiazem Cmin ↑121% (↑102% ↑142%) No significant effect on atazanavir concentrations was observed. There was an increase in the maximum PR interval compared to atazanavir alone. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	Exposure to diltiazem and a metabolite, desacetyl-diltiazem, is increased when diltiazem is co-administered with atazanavir, a component of EVOTAZ. An initial dose reduction of diltiazem by 50% should be considered, and electrocardiogram monitoring is recommended.
Amlodipine Felodipine Nicardipine Nifedipine Verapamil	Concentrations of these calcium channel blockers may be increased when co-administered with EVOTAZ. The mechanism of interaction is inhibition of CYP3A4 by atazanavir and cobicistat.	Caution is warranted. Dose titration of the calcium channel blockers should be considered. Electrocardiogram monitoring is recommended. Clinical monitoring of therapeutic effect and adverse events is recommended when these medicinal products are co-administered with EVOTAZ.
Endothelin Receptor Antagonists
Bosentan	Co-administration of bosentan with cobicistat may lead to decreased cobicistat plasma concentrations. The mechanism of interaction is induction of CYP3A4 by bosentan.	Atazanavir plasma concentrations may decrease as a consequence of a reduction in cobicistat plasma concentrations, which may result in loss of therapeutic effect and development of resistance. Co-administration is not recommended (see section 4.4).
CORTICOSTEROIDS
Corticosteroids primarily metabolised by CYP3A (including betamethasone, budesonide, fluticasone, mometasone, prednisone, triamcinolone).	Interaction not studied with any of the components of EVOTAZ. Plasma concentrations of these medicinal products may be increased when co-administered with EVOTAZ, resulting in reduced serum cortisol concentrations	Concomitant use of EVOTAZ and corticosteroids that are metabolised by CYP3A (e.g. fluticasone propionate or other inhaled or nasal corticosteroids) may increase the risk of development of systemic corticosteroid effects, including Cushing's syndrome and adrenal suppression. Co-administration with CYP3A-metabolised corticosteroids is not recommended unless the potential benefit to the patient outweighs the risk, in which case patients should be monitored for systemic corticosteroid effects. Alternative corticosteroids which are less dependent on CYP3A metabolism, e.g. beclomethasone for intranasal or inhalational use, should be considered, particularly for long term use.
ANTIDEPRESSANTS
Other antidepressants:
Trazodone	Plasma concentrations of trazodone may be increased when co-administered with EVOTAZ. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	If trazodone is co-administered with EVOTAZ, the combination should be used with caution and a lower dose of trazodone should be considered.
ERECTILE DYSFUNCTION
PDE5 Inhibitors
Sildenafil Tadalafil Vardenafil Avanafil	Sildenafil, tadalafil, and vardenafil are metabolised by CYP3A4. Co-administration with EVOTAZ may result in increased concentrations of the PDE5 inhibitor and an increase in PDE5-associated adverse events, including hypotension, visual changes, and priapism. The mechanism of this interaction is CYP3A4 inhibition by atazanavir and cobicistat.	Patients should be warned about these possible side effects when using PDE5 inhibitors for erectile dysfunction with EVOTAZ (see section 4.4). For the treatment of erectile dysfunction, it is recommended that when co-administered with EVOTAZ, sildenafil should be used with caution at reduced doses of 25 mg every 48 hours; tadalafil should be used with caution at reduced doses of 10 mg every 72 hours; vardenafil should be used with caution at reduced doses of no more than 2.5 mg every 72 hours. Increase monitoring for adverse reactions. The combination of avanafil and EVOTAZ is contraindicated (see section 4.3). Also see PULMONARY ATERIAL HYPERTENSION in this table for further information regarding co-administration of EVOTAZ with sildenafil.
HERBAL PRODUCTS
St. John's wort (Hypericum perforatum)	Concomitant use of St. John's wort with EVOTAZ may be expected to result in significant reduction in plasma levels of cobicistat and atazanavir. This effect may be due to an induction of CYP3A4. There is a risk of loss of therapeutic effect and development of resistance to atazanavir (see section 4.3).	Co-administration of EVOTAZ with products containing St. John's wort is contraindicated (see section 4.3).
HORMONAL CONTRACEPTIVES
Progestin/estrogen	Concentrations of ethinyl estradiol and norethindrone are increased when a combined oral contraceptive containing those agents is co-administered with atazanavir. The mechanism of interaction is inhibition of metabolism by atazanavir. Effects of co-administration of EVOTAZ on progestin and estrogen are unknown.	Co-administration of EVOTAZ and hormonal contraceptives should be avoided. An alternate (non-hormonal) reliable method of contraception is recommended.
LIPID LOWERING AGENTS
HMG-CoA reductase inhibitors
Simvastatin Lovastatin	Simvastatin and lovastatin are highly dependent on CYP3A4 for their metabolism and co-administration with EVOTAZ may result in increased concentrations.	Co-administration of simvastatin or lovastatin with EVOTAZ is contraindicated due to an increased risk of myopathy including rhabdomyolysis (see section 4.3).
Atorvastatin	The risk of myopathy including rhabdomyolysis may also be increased with atorvastatin, which is also metabolised by CYP3A4.	Co-administration of atorvastatin with EVOTAZ is not recommended. If the use of atorvastatin is considered strictly necessary, the lowest possible dose of atorvastatin should be administered with careful safety monitoring (see section 4.4).
Pravastatin Fluvastatin Pitavastatin	Although not studied, there is a potential for an increase in pravastatin or fluvastatin exposure when co-administered with protease inhibitors. Pravastatin is not metabolised by CYP3A4. Fluvastatin is partially metabolised by CYP2C9. Plasma concentrations of pitavastatin may be increased if co-administered with EVOTAZ.	Caution should be exercised.
Rosuvastatin (10 mg single dose)/Elvitegravir (150 mg once daily)/Cobicistat (150 mg once daily)	Rosuvastatin: AUC: ↑38% Cmax: ↑89% Cmin: ↑43% Cobicistat: AUC: ↔ Cmax: ↔ Cmin: ↔ The mechanism of interaction is potential inhibition of the transporter OATP1B1 by cobicistat.	Rosuvastatin dose should not exceed 10 mg/day. The risk of myopathy, including rhabdomyolysis, may be increased.
INHALED BETA AGONISTS
Salmeterol	Co-administration with EVOTAZ may result in increased concentrations of salmeterol and an increase in salmeterol-associated adverse events. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	Co-administration of salmeterol with EVOTAZ is not recommended (see section 4.4).
ERGOT DERIVATES
Dihydroergotamine Ergometrine Ergotamine Methylergonovine	EVOTAZ must not be used in combination with medicinal products that are substrates of CYP3A4 and have a narrow therapeutic index.	Co-administration of EVOTAZ and these ergot derivates is contraindicated (see section 4.3).
NEUROLEPTICS
Perphenazine Risperidone Thioridazine	Co-administration of neuroleptics with EVOTAZ may result in increased plasma concentrations of neuroleptics. The mechanism of interaction is inhibition of CYP3A4 and/or CYP2D6 by atazanavir and/or cobicistat.	A decrease in the dose of neuroleptics metabolized by CYP3A or CYP2D6 may be required when co-administered with EVOTAZ.
OPIOIDS
Buprenorphine, once daily, stable maintenance dose (atazanavir 300 mg once daily with ritonavir 100 mg once daily)	Buprenorphine AUC ↑67% Buprenorphine Cmax ↑37% Buprenorphine Cmin ↑69% Norbuprenorphine AUC ↑105% Norbuprenorphine Cmax ↑61% Norbuprenorphine Cmin ↑101% The mechanism of interaction is CYP3A4 and UGT1A1 inhibition by atazanavir. Concentrations of atazanavir were not significantly affected.	Co-administration warrants clinical monitoring for sedation and cognitive effects. A dose reduction of buprenorphine may be considered.
Buprenorphine/naloxone in combination with cobicistat	Buprenorphine AUC: ↑35% Buprenorphine Cmax: ↑66% Buprenorphine Cmin: ↑12% Naloxone AUC: ↓28% Naloxone Cmax: ↓28% The mechanism of interaction is CYP3A4 inhibition by cobicistat.
Methadone, stable maintenance dose (atazanavir 400 mg once daily)	No significant effect on methadone concentrations was observed when co-administered with atazanavir. Given that cobicistat has been shown to have no significant effect on methadone concentrations, no interaction is expected if methadone is co-administered with EVOTAZ.	No dosage adjustment is necessary if methadone is co-administered with EVOTAZ.
PULMONARY ARTERIAL HYPERTENSION
PDE5 Inhibitors
Sildenafil	Co-administration with EVOTAZ may result in increased concentrations of the PDE5 inhibitor and an increase in PDE5 inhibitor-associated adverse events. The mechanism of interaction is CYP3A4 inhibition by atazanavir and cobicistat.	A safe and effective dose in combination with EVOTAZ has not been established for sildenafil when used to treat pulmonary arterial hypertension. Sildenafil, when used for the treatment of pulmonary arterial hypertension, is contraindicated (see section 4.3).
SEDATIVES/HYPNOTICS
Midazolam Triazolam	Midazolam and triazolam are extensively metabolized by CYP3A4. Co-administration with EVOTAZ may cause a large increase in the concentration of these benzodiazepines. Based on data for other CYP3A4 inhibitors, plasma concentrations of midazolam are expected to be significantly higher when midazolam is given orally. Data from concomitant use of parenteral midazolam with other protease inhibitors suggest a possible 3-4 fold increase in midazolam plasma levels.	EVOTAZ should not be co-administered with triazolam or orally administered midazolam (see section 4.3), whereas caution should be used with co-administration of EVOTAZ and parenteral midazolam. If EVOTAZ is co-administered with parenteral midazolam, it should be done in an intensive care unit (ICU) or similar setting which ensures close clinical monitoring and appropriate medical management in case of respiratory depression and/or prolonged sedation. Dosage adjustment for midazolam should be considered, especially if more than a single dose of midazolam is administered.
Buspirone Clorazepate Diazepam Estazolam Flurazepam Zolpidem	Concentrations of these sedatives/hypnotics may be increased when co-administered with EVOTAZ. The mechanism of interaction is inhibition of CYP3A4 by cobicistat.	For these sedatives/hypnotics, dose reduction may be necessary and concentration monitoring is recommended.
GASTROINTESTINAL MOTILITY AGENTS
Cisapride	EVOTAZ must not be used in combination with medicinal products that are substrates of CYP3A4 and have a narrow therapeutic index.	Co-administration of EVOTAZ and cisapride is contraindicated (see section 4.3).

Paediatric population
Interaction studies have only been performed in adults.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no data from the use of EVOTAZ in pregnant women. Animal studies are insufficient with respect to reproductive toxicity (see section 5.3). The use of EVOTAZ may be considered during pregnancy only if the potential benefit justifies the potential risk.
Atazanavir
A moderate amount of data in pregnant women (between 300-1000 pregnancy outcomes) indicates no malformative toxicity of atazanavir. Animal studies do not indicate reproductive toxicity (see section 5.3).
It is not known whether atazanavir administered to the mother during pregnancy will exacerbate physiological hyperbilirubinaemia and lead to kernicterus in neonates and infants. In the prepartum period, additional monitoring should be considered.
Cobicistat
There are no or limited clinical data with cobicistat in pregnant women.
Animal studies do not indicate direct or indirect harmful effects of cobicistat with respect to reproductive toxicity (see section 5.3).
Breast-feeding
It is unknown whether EVOTAZ or its active components are excreted in human milk. Because of both the potential for HIV transmission and the potential for serious adverse reactions in breast-feeding infants, women should be instructed not to breast-feed if they are receiving EVOTAZ. Studies in rats have demonstrated that atazanavir is excreted in the milk. Similarly, studies in animals have shown excretion of cobicistat/metabolites in milk.
Fertility
The effect of EVOTAZ on fertility in humans has not been studied. In a nonclinical fertility and early embryonic development study in rats, atazanavir altered oestrus cycling with no effects on mating or fertility (see section 5.3). No human data on the effect of cobicistat on fertility are available. Animal studies do not indicate harmful effects of cobicistat on fertility.
4.7 Effects on ability to drive and use machines
EVOTAZ has no or negligible influence on the ability to drive or use machines. However, patients should be informed that dizziness has been reported during treatment with regimens containing atazanavir or cobicistat (see section 4.8).
4.8 Undesirable effects
Summary of the safety profile
The overall safety profile of EVOTAZ is based on available data from clinical trials conducted with atazanavir, atazanavir boosted with either cobicistat or ritonavir, and post-marketing data.
As EVOTAZ contains atazanavir and cobicistat, the adverse reactions associated with each of the individual components may be expected.
In clinical study GS-US-216-0114, a phase 3 randomised, active-controlled clinical study, in which 692 treatment-naïve patients received at least one dose of atazanavir boosted with cobicistat (n = 344) or atazanavir boosted with ritonavir (n = 348) administered with other antiretroviral medicinal products, the most frequently reported adverse reactions in the atazanavir boosted with cobicistat group during 144 weeks were associated with elevated bilirubin levels (see Table 2).
Of these 692 patients, 613 (300 atazanavir with cobicistat and 313 atazanavir with ritonavir) and 496 (250 atazanavir with cobicistat and 246 atazanavir with ritonavir) received at least 48 and 144 weeks of treatment, respectively.
In 2 controlled clinical studies for combination therapy with other antiretroviral medicinal products 1,806 adult patients receiving atazanavir 400 mg once daily (1,151 patients, 52 weeks median duration and 152 weeks maximum duration) or atazanavir 300 mg boosted with ritonavir 100 mg once daily (655 patients, 96 weeks median duration and 108 weeks maximum duration), the most frequently reported adverse reactions were nausea, diarrhoea and jaundice. In the majority of cases, jaundice was reported within a few days to a few months after the initiation of treatment (see section 4.4).
Tabulated list of adverse reactions
Adverse reactions are listed by system organ class and frequency: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100) and rare (≥1/10,000 to 1/1,000). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
Table 2: Tabulated summary of adverse reactions

System Organ Class Frequency	Adverse Reactions
Immune system disorders
uncommon	hypersensitivity
Metabolism and nutrition disorders
common	increased appetite
uncommon	weight decreased, weight gain, anorexia
Psychiatric disorders
common	insomnia, abnormal dreams
uncommon	depression, sleep disorder, disorientation, anxiety
Nervous system disorders
common	headache, dizziness, somnolence, dysgeusia
uncommon	peripheral neuropathy, syncope, amnesia
Eye disorders
very common	ocular icterus
Cardiac disorders
uncommon	torsades de pointesa
rare	QTc prolongationa, oedema, palpitation
Vascular disorders
uncommon	hypertension
Respiratory, thoracic and mediastinal disorders
uncommon	dyspnoea
Gastrointestinal disorders
very common	nausea
common	vomiting, diarrhoea, dyspepsia, abdominal pain, abdominal distension, flatulence, dry mouth
uncommon	pancreatitis, gastritis, stomatitis aphthous
Hepatobiliary disorders
very common	jaundice
common	hyperbilirubinaemia
uncommon	hepatitis, cholelithiasisa, cholestasisa
rare	hepatosplenomegaly, cholecystitisa
Skin and subcutaneous tissue disorders
common	rash
uncommon	pruritus, erythema multiformea,b, toxic skin eruptionsa,b, drug rash with eosinophilia and systemic symptoms (DRESS) syndromea,b, angioedemaa, urticaria, alopecia
rare	Stevens-Johnson syndromea,b, vesiculobullous rash, eczema, vasodilatation
Musculoskeletal and connective tissue disorders
uncommon	myalgia, muscle atrophy, arthralgia
rare	myopathy
Renal and urinary disorders
uncommon	nephrolithiasisa, haematuria, proteinuria, pollakiuria, interstitial nephritis
rare	kidney pain
Reproductive system and breast disorders
uncommon	gynaecomastia
General disorders and administration site conditions
common	fatigue
uncommon	pyrexia, asthenia, chest pain, malaise
rare	gait disturbance

a These adverse reactions were identified through post-marketing surveillance; however, the frequencies were estimated from a statistical calculation based on the total number of patients exposed to atazanavir (with and without ritonavir) in randomised controlled and other available clinical trials (n = 2321).
b See section Description of selected adverse reactions for more details.
Description of selected adverse reactions
Immune reactivation syndrome and autoimmune disorders
In HIV-infected patients with severe immune deficiency at the time of initiation of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic infections may arise. Autoimmune disorders (such as Graves' disease) have also been reported; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment (see section 4.4).
Osteonecrosis
Cases of osteonecrosis have been reported, particularly in patients with generally acknowledged risk factors, advanced HIV disease or long-term exposure to CART. The frequency of this is unknown (see section 4.4).
Metabolic parameters
Weight and levels of blood lipids and glucose may increase during antiretroviral therapy (see section 4.4).
Rash and associated syndromes
Rashes are usually mild-to-moderate maculopapular skin eruptions that occur within the first 3 weeks of starting therapy with atazanavir.
Stevens-Johnson syndrome (SJS), erythema multiforme, toxic skin eruptions and drug rash with eosinophilia and systemic symptoms (DRESS) syndrome have been reported with the use of atazanavir (see section 4.4).
Renal impairment
Cobicistat, a component of EVOTAZ, has been shown to decrease estimated creatinine clearance due to inhibition of tubular secretion of creatinine. An increase from baseline in serum creatinine solely due to cobicistat's inhibitory effect generally does not exceed 0.4 mg/dl.
In study GS-US-216-0114, decreases in estimated creatinine clearance occurred early in treatment with cobicistat, after which they stabilised. The mean (± SD) change in estimated glomerular filtration rate (eGFR) by Cockcroft-Gault method after 144 weeks of treatment was -15.1 ± 16.5 ml/min in the atazanavir boosted with cobicistat plus emtricitabine and tenofovir disoproxil fumarate fixed-dose combination group and -8.0 ± 16.8 ml/min in the atazanavir boosted with ritonavir plus emtricitabine and tenofovir disoproxil fumarate fixed-dose combination group.
Effects on the liver
In study GS-US-216-0114, through 144 weeks of treatment hyperbilirubinaemia (> 1 x ULN) was common: 97.7% in the atazanavir boosted with cobicistat plus emtricitabine and tenofovir disoproxil fumarate fixed-dose combination group, and 97.4% in the atazanavir boosted with ritonavir plus emtricitabine and tenofovir disoproxil fumarate fixed-dose combination group. However, a higher percentage of subjects in the atazanavir boosted with cobicistat group had increases in total bilirubin > 2 x ULN than those in the atazanavir boosted with ritonavir group (88.0% versus 80.9%). The rates of study drug discontinuation due to bilirubin-related adverse events were low and similar in both groups (4.9% in the cobicistat-boosted group and 4.0% in the ritonavir-boosted group). An increase of > 3 x ULN in alanine aminotransferase or aspartate aminotransferase was recorded in 12.8% of subjects in the cobicistat-boosted group and 9.0% in the ritonavir-boosted group.
Laboratory abnormalities
The most frequently reported laboratory abnormality in patients receiving regimens containing atazanavir and one or more NRTIs was elevated total bilirubin reported predominantly as elevated indirect [unconjugated] bilirubin (87% Grade 1, 2, 3, or 4). Grade 3 or 4 elevation of total bilirubin was noted in 37% (6% Grade 4). Among experienced patients treated with atazanavir 300 mg once daily with 100 mg ritonavir once daily for a median duration of 95 weeks, 53% had Grade 3-4 total bilirubin elevations. Among naïve patients treated with atazanavir 300 mg once daily with 100 mg ritonavir once daily for a median duration of 96 weeks, 48% had Grade 3-4 total bilirubin elevations (see section 4.4).
Other marked clinical laboratory abnormalities (Grade 3 or 4) reported in ≥ 2% of patients receiving regimens containing atazanavir and one or more NRTIs included: elevated creatine kinase (7%), elevated alanine aminotransferase/serum glutamic-pyruvic transaminase (ALT/SGPT) (5%), low neutrophils (5%), elevated aspartate aminotransferase/serum glutamic-oxaloacetic transaminase (AST/SGOT) (3%), and elevated lipase (3%).
Two percent of patients treated with atazanavir experienced concurrent Grade 3-4 ALT/AST and Grade 3-4 total bilirubin elevations.
Paediatric population
In clinical studies, paediatric patients 3 months to less than 18 years of age had a mean duration of treatment with atazanavir of 115 weeks. The safety profile in these studies was overall comparable to that seen in adults. Both asymptomatic first-degree (23%) and second-degree (1%) atrioventricular block were reported in paediatric patients. The most frequently reported laboratory abnormality in paediatric patients receiving atazanavir was elevation of total bilirubin (≥ 2.6 times ULN, Grade 3-4) which occurred in 45% of patients.
Other special populations
Patients co-infected with hepatitis B and/or hepatitis C virus
Among 1,151 patients receiving atazanavir 400 mg once daily, 177 patients were co-infected with chronic hepatitis B or C, and among 655 patients receiving atazanavir 300 mg once daily with ritonavir 100 mg once daily, 97 patients were co-infected with chronic hepatitis B or C. Co-infected patients were more likely to have baseline hepatic transaminase elevations than those without chronic viral hepatitis. No differences in frequency of bilirubin elevations were observed between these patients and those without viral hepatitis. The frequency of treatment emergent hepatitis or transaminase elevations in co-infected patients was comparable between atazanavir and comparator regimens (see section 4.4).
Patients with chronic hepatitis B or hepatitis C virus co-infection:
In GS-US-216-0114, 3.6% of subjects were hepatitis B virus surface antigen positive and 5.3% were hepatitis C virus seropositive. Subjects with significant liver function test abnormalities generally had abnormal baseline transaminases (AST or ALT), underlying chronic or acute hepatitis B or C co-infection, concomitant hepatotoxic medications (e.g., isoniazid), or a medical history of alcoholism or alcohol abuse.
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 at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
Human experience of acute overdose with EVOTAZ is limited.
There is no specific antidote for overdose with EVOTAZ. If overdose occurs with EVOTAZ, the patient must be monitored for evidence of toxicity. Treatment should consist of general supportive measures including monitoring of vital signs and ECG as well as observation of the patient's clinical status. Since atazanavir and cobicistat are extensively metabolised by the liver and highly protein bound, dialysis is unlikely to be beneficial in significant removal of this medicinal product.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Antivirals for systemic use; antivirals for treatment of HIV infections, combinations. ATC code: J05AR15
Mechanism of action
EVOTAZ is a fixed-dose combination of the antiviral drug atazanavir boosted by the pharmacokinetic enhancer cobicistat.
Atazanavir
Atazanavir is an azapeptide HIV-1 protease inhibitor (PI). The compound selectively inhibits the virus-specific processing of viral Gag-Pol proteins in HIV-1 infected cells, thus preventing formation of mature virions and infection of other cells.
Cobicistat
Cobicistat is a selective, mechanism-based inhibitor of cytochromes P450 of the CYP3A subfamily. Inhibition of CYP3A-mediated metabolism by cobicistat enhances the systemic exposure of CYP3A substrates, such as atazanavir, where bioavailability is limited and half-life is shortened by CYP3A-dependent metabolism.
Antiviral activity in vitro
Atazanavir
Atazanavir exhibits anti-HIV-1 (including all clades tested) and anti-HIV-2 activity in cell culture.
Cobicistat
Cobicistat has no antiviral activity.
Pharmacodynamic effects
Effect of cobicistat on atazanavir pharmacokinetics
The antiretroviral effect of EVOTAZ is due to the atazanavir component. The activity of cobicistat as a pharmacokinetic enhancer to atazanavir has been demonstrated in pharmacokinetic trials. In these pharmacokinetic trials, the exposure of atazanavir 300 mg with cobicistat 150 mg was consistent with that observed when boosted with ritonavir 100 mg. EVOTAZ is bioequivalent to atazanavir 300 mg once daily in combination with cobicistat 150 mg once daily coadministered as single agents (see section 5.2).
Clinical efficacy and safety
In treatment-naïve HIV-1 infected patients
The safety and efficacy of atazanavir with cobicistat in HIV-1 infected patients were evaluated in the randomised, double-blind, active-controlled phase 3 study GS-US-216-0114 in HIV-1 infected patients with baseline estimated creatinine clearance above 70 ml/min who were treatment-naïve (n = 692).
Patients were randomised in a 1:1 ratio to receive either atazanavir 300 mg with cobicistat 150 mg once daily or atazanavir 300 mg with ritonavir 100 mg once daily, each administered with a fixed background regimen containing tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg administered as a fixed-dose combination tablet. Randomisation was stratified by screening HIV-1 RNA level (≤100,000 copies/ml or >100,000 copies/ml). Virologic response rate was evaluated in both treatment arms and virologic response was defined as achieving an undetectable viral load (<50 HIV-1 RNA copies/ml). Viruses were known to be susceptible to atazanavir, emtricitabine and tenofovir disoproxil fumarate at baseline.
The demographic and baseline characteristics were similar between the atazanavir with cobicistat and atazanavir with ritonavir groups. The median age of subjects was 36 years (range: 19-70). The median baseline plasma HIV-1 RNA was 4.81 log10 copies/ml (range: 3.21-6.44). The median baseline CD4+ cell count was 352 cells/mm3 (range: 1-1455) and 16.9% had CD4+ cell counts ≤200 cells/mm3. The percentage of subjects with baseline viral loads >100,000 copies/ml was 39.7%. Treatment outcomes at weeks 48 and 144 for study GS-US-216-0114 are presented in Table 3.
Table 3: Virologic outcome of randomised treatment of study GS-US-216-0114 at weeks 48a and 144b

Week 48		Week 144
Atazanavir with cobicistatf (n = 344)	Atazanavir with ritonavirf (n = 348)	Atazanavir with cobicistatf (n = 344)	Atazanavir with ritonavirf (n = 348)
Virologic success HIV-1 RNA <50 copies/ml	85%	87%	72%	74%
Treatment difference	-2.2% (95% CI = -7.4%, 3.0%)		-2.1% (95% CI = -8.7%, 4.5%)
Virologic failurec	6%	4%	8%	5%
No virologic data in week 48 window	9%	9%	20%	21%
Discontinued study drug due to AE or deathd	6%	7%	11%	11%
Discontinued study drug due to other reasons and last available HIV-1 RNA <50 copies/mle	3%	2%	8%	10%
Missing data during window but on study drug	0%	0%	< 1%	< 1%

a Week 48 window is between day 309 and 378 (inclusive)
b Week 144 window is between day 967 and 1,050 (inclusive)
c Includes subjects who had ≥50 copies/ml in the week 48 or 144 windows, subjects who discontinued early due to lack or loss of efficacy, subjects who discontinued for reasons other than an adverse event, death or lack or loss of efficacy and at the time of discontinuation had a viral value of ≥50 copies/ml.
d Includes patients who discontinued due to adverse event (AE) or death at any time point from day 1 through the time window if this resulted in no virologic data on treatment during the specified window.
e Includes subjects who discontinued for reasons other than an adverse event, death or lack or loss of efficacy, e.g., withdrew consent, loss to follow-up.
f Plus background regimen of emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg fixed-dose combination.
Atazanavir with cobicistat and emtricitabine and tenofovir disoproxil fumarate fixed-dose combination was non-inferior in achieving HIV-1 RNA <50 copies/ml when compared to atazanavir with ritonavir and emtricitabine and tenofovir disoproxil fumarate fixed-dose combination.
In study GS-US-216-0114, the mean increase from baseline in CD4+ cell count at weeks 48 and 144 were 213 and 310 cells/mm3 in patients receiving atazanavir boosted with cobicistat and 219 and 332 cells/mm3 in patients receiving atazanavir boosted with ritonavir, respectively.
Resistance
The resistance profile of EVOTAZ is driven by atazanavir. Cobicistat does not select any HIV resistance mutations, due to its lack of antiviral activity.
Atazanavir
In clinical trials of antiretroviral treatment naive patients treated with unboosted atazanavir, the I50L substitution, sometimes in combination with an A71V change, is the signature resistance substitution for atazanavir. Resistance levels to atazanavir ranged from 3.5- to 29-fold without evidence of phenotypic cross resistance to other PIs. For more information consult the REYATAZ Summary of Product Characteristics.
Atazanavir with cobicistat
Limited data are available on the development of resistance to atazanavir boosted with cobicistat.
In an analysis of treatment-failure subjects who received atazanavir 300 mg co-administered with cobicistat 150 mg in study GS-US-216-0114 through Week 48, evaluable genotypic data from paired baseline and treatment-failure isolates were available for 11 of the 12 virologic failures in this group (3%, 11/344). Among the 11 subjects, 2 developed the emtricitabine-associated resistance substitution M184V. No subject developed the tenofovir-associated resistance substitution K65R or any primary resistance substitution associated with protease inhibitors. In the group receiving atazanavir 300 mg co-administered with ritonavir 100 mg, evaluable genotypic data was available for all 12 virologic failures (3%, 12/348) and no subject had emergent resistance to any component of the regimen.
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with EVOTAZ in the treatment of HIV-1 infection (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
One EVOTAZ tablet is bioequivalent to one atazanavir capsule (300 mg) plus one cobicistat tablet (150 mg) following single oral dose administration with a light meal in healthy subjects (n=62).
The following statements reflect the pharmacokinetic properties of atazanavir in combination with cobicistat or the individual components of EVOTAZ.
Absorption
In a trial where HIV-infected subjects (n=22) were instructed to take atazanavir 300 mg with cobicistat 150 mg once daily with food, the steady-state atazanavir Cmax, AUCtau and Ctau (mean ± SD) values were 3.9 ± 1.9 μg/ml, 46.1 ± 26.2 μg•hr/ml and 0.80 ± 0.72 μg/ml, respectively. Steady-state cobicistat Cmax, AUCtau and Ctau (mean ± SD) values were 1.5 ± 0.5 μg/ml, 11.1 ± 4.5 μg•hr/ml and 0.05 ± 0.07 μg/ml, respectively (n=22).
Food effect
Administration of a single dose of EVOTAZ with a light meal (336 kcal, 5.1 g fat, 9.3 g protein) resulted in a 42% increase in atazanavir Cmax, a 28% increase in atazanavir AUC, a 31% increase in cobicistat Cmax, and a 24% increase in cobicistat AUC relative to the fasting state. Administration of a single dose of EVOTAZ with a high fat meal (1,038 kcal, 59 g fat, 37 g protein) resulted in a 14% reduction in atazanavir Cmax with no change in atazanavir AUC or cobicistat exposures (Cmax, AUC) relative to the fasting state. The 24-hour atazanavir concentration following a high-fat meal was increased approximately 23% due to delayed absorption; the median Tmax increased from 2.0 to 3.5 hours. Cmax and AUCs after a high fat meal decreased 36% and 25% in comparison to a light meal, respectively; however, the 24-hour atazanavir concentration was similar when EVOTAZ was given with a light meal and a high fat meal. To enhance bioavailability, EVOTAZ is to be taken with food.
Distribution
Atazanavir
Atazanavir was approximately 86% bound to human serum proteins over a concentration range of 100 to 10,000 ng/ml. Atazanavir binds to both alpha-1-acid glycoprotein (AAG) and albumin to a similar extent (89% and 86%, respectively, at 1,000 ng/ml). In a multiple-dose study in HIV-infected patients dosed with 400 mg of atazanavir once daily with a light meal for 12 weeks, atazanavir was detected in the cerebrospinal fluid and semen.
Cobicistat
Cobicistat is 97-98% bound to human plasma proteins and the mean plasma to blood drug concentration ratio was 2.
Biotransformation
Atazanavir
Studies in humans and in vitro studies using human liver microsomes have demonstrated that atazanavir is principally metabolised by CYP3A4 isozyme to oxygenated metabolites. Metabolites are then excreted in the bile as either free or glucuronidated metabolites. Additional minor metabolic pathways consist of N-dealkylation and hydrolysis. Two minor metabolites of atazanavir in plasma have been characterised. Neither metabolite demonstrated in vitro antiviral activity.
Cobicistat
Cobicistat is metabolised via CYP3A (major)- and CYP2D6 (minor)-mediated oxidation and does not undergo glucuronidation. Following oral administration of [14C]cobicistat, 99% of circulating radioactivity in plasma was unchanged cobicistat. Low levels of metabolites are observed in urine and faeces and do not contribute to the CYP3A inhibitory activity of cobicistat.
Elimination
Atazanavir
Following a single 400 mg dose of [14C]atazanavir, 79% and 13% of the total radioactivity was recovered in the faeces and urine, respectively. Unchanged drug accounted for approximately 20% and 7% of the administered dose in the faeces and urine, respectively. Mean urinary excretion of unchanged drug was 7% following 2 weeks of dosing at 800 mg once daily. In HIV-infected adult patients (n=33, combined studies), the mean half-life within a dosing interval for atazanavir was 12 hours at steady state following a dose of 300 mg daily with ritonavir 100 mg once daily with a light meal.
Cobicistat
Following oral administration of [14C]cobicistat, 86% and 8.2% of the dose were recovered in faeces and urine, respectively. The median terminal plasma half-life of cobicistat following administration of cobicistat is approximately 3-4 hours.
Linearity/non-linearity
Atazanavir
Atazanavir demonstrates nonlinear pharmacokinetics with greater than dose-proportional increases in AUC and Cmax values over the dose range of 200 mg to 800 mg once daily.
Cobicistat
Cobicistat exposures are non-linear and greater than dose-proportional over the range of 50 mg to 400 mg, consistent with a mechanism-based CYP3A inhibitor.
Special populations
Renal impairment
Atazanavir
In healthy subjects, the renal elimination of unchanged atazanavir was approximately 7% of the administered dose. There are no pharmacokinetic data available for atazanavir in combination with cobicistat in patients with renal insufficiency. Atazanavir has been studied in adult patients with severe renal impairment (n=20), including those on haemodialysis, at multiple doses of 400 mg once daily. Although this study presented some limitations (i.e., unbound drug concentrations not studied), results suggested that the atazanavir pharmacokinetic parameters were decreased by 30% to 50% in patients undergoing haemodialysis compared to patients with normal renal function. The mechanism of this decrease is unknown (see sections 4.2 and 4.4.)
Cobicistat
A study of the pharmacokinetics of cobicistat was performed in non-HIV-1 infected subjects with severe renal impairment (estimated creatinine clearance below 30 ml/min). No meaningful differences in cobicistat pharmacokinetics were observed between subjects with severe renal impairment and healthy subjects, consistent with low renal clearance of cobicistat.
Hepatic impairment
Atazanavir
Atazanavir is metabolised and eliminated primarily by the liver. The effects of hepatic impairment on the pharmacokinetics of atazanavir given with cobicistat have not been studied. Concentrations of atazanavir given with cobicistat are expected to be increased in patients with impaired hepatic function (see sections 4.2 and 4.4).
Cobicistat
Cobicistat is primarily metabolised and eliminated by the liver. A study of the pharmacokinetics of cobicistat was performed in non-HIV-1 infected subjects with moderate hepatic impairment (Child-Pugh Class B). No clinically relevant differences in cobicistat pharmacokinetics were observed between subjects with moderate impairment and healthy subjects. The effect of severe hepatic impairment (Child-Pugh Class C) on the pharmacokinetics of cobicistat has not been studied.
Elderly
The pharmacokinetics of atazanavir and cobicistat, alone or in combination, have not been evaluated in an elderly population (65 years of age and older).
Paediatric population
No data are available on the pharmacokinetics of atazanavir and cobicistat in combination in paediatric patients.
Gender
No clinically relevant pharmacokinetic differences due to gender have been identified for atazanavir or cobicistat.
Race
No clinically relevant pharmacokinetic differences due to ethnicity have been identified for atazanavir or cobicistat.
5.3 Preclinical safety data
In a 3-month combination oral toxicity study of atazanavir and cobicistat in rats, there were no toxicologic interactions apparent as no additive or synergistic toxicities were observed. When compared to their single-agent profiles all findings could be attributed to either atazanavir or cobicistat.
In an ex vivo rabbit pharmacology study, isolated hearts were exposed to atazanavir, cobicistat, or atazanavir and cobicistat in combination. Each single agent produced effects on left ventricular contractility and PR prolongation at concentrations at least 35-fold higher than the free atazanavir and cobicistat concentrations at the recommended human dose (RHD) Cmax. When administered in combination, no clear additive or synergistic cardiovascular effects were observed at atazanavir and cobicistat concentrations at least 2-fold higher than the free atazanavir and cobicistat concentrations at the RHD Cmax.
The following statements reflect the preclinical safety results of the individual active substances of EVOTAZ.
Atazanavir
In repeat-dose toxicity studies, conducted in mice, rats, and dogs, atazanavir-related findings were generally confined to the liver and included generally minimal to mild increases in serum bilirubin and liver enzymes, hepatocellular vacuolation and hypertrophy, and, in female mice only, hepatic single-cell necrosis. Systemic exposures of atazanavir in mice (males), rats, and dogs at doses associated with hepatic changes were at least equal to that observed in humans given 400 mg once daily. In female mice, atazanavir exposure at a dose that produced single-cell necrosis was 12 times the exposure in humans given 400 mg once daily. Serum cholesterol and glucose were minimally to mildly increased in rats but not in mice or dogs.
During in vitro studies, cloned human cardiac potassium channel (hERG), was inhibited by 15% at a concentration (30 μM) of atazanavir corresponding to 30 fold the free drug concentration at Cmax in humans. Similar concentrations of atazanavir increased by 13% the action potential duration (APD90) in rabbit Purkinje fibres study. Electrocardiographic changes (sinus bradycardia, prolongation of PR interval, prolongation of QT interval, and prolongation of QRS complex) were observed only in an initial 2 week oral toxicity study performed in dogs. Subsequent 9 month oral toxicity studies in dogs showed no drug-related electrocardiographic changes. The clinical relevance of these non-clinical data is unknown. Potential cardiac effects of this product in humans cannot be ruled out (see sections 4.4 and 4.8). The potential for PR prolongation should be considered in cases of overdose (see section 4.9).
In a fertility and early embryonic development study in rats, atazanavir altered oestrus cycling with no effects on mating or fertility. No teratogenic effects were observed in rats or rabbits at maternally toxic doses. In pregnant rabbits, gross lesions of the stomach and intestines were observed in dead or moribund does at maternal doses 2 and 4 times the highest dose administered in the definitive embryo-development study. In the pre- and postnatal development assessment in rats, atazanavir produced a transient reduction in body weight in the offspring at a maternally toxic dose. Systemic exposure to atazanavir at doses that resulted in maternal toxicity was at least equal to or slightly greater than that observed in humans given 400 mg once daily.
Atazanavir was negative in an Ames reverse-mutation assay but did induce chromosomal aberrations in vitro in both the absence and presence of metabolic activation. In in vivo studies in rats, atazanavir did not induce micronuclei in bone marrow, DNA damage in duodenum (comet assay), or unscheduled DNA repair in liver at plasma and tissue concentrations exceeding those that were clastogenic in vitro.
In long-term carcinogenicity studies of atazanavir in mice and rats, an increased incidence of benign hepatic adenomas was seen in female mice only. The increased incidence of benign hepatic adenomas in female mice was likely secondary to cytotoxic liver changes manifested by single-cell necrosis and is considered to have no relevance for humans at intended therapeutic exposures. There were no tumorigenic findings in male mice or in rats.
Atazanavir increased opacity of bovine corneas in an in vitro ocular irritation study, indicating it may be an ocular irritant upon direct contact with the eye.
Cobicistat
Non-clinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity, genotoxicity, and toxicity to reproduction and development. No teratogenic effects were observed in rats and rabbit developmental toxicity studies. In rats, ossification changes in the spinal column and sternebra of foetuses occurred at a dose that produced significant maternal toxicity.
Ex vivo rabbit studies and in vivo dog studies suggest that cobicistat has a low potential for QT prolongation, and may slightly prolong the PR interval and decrease left ventricular function at mean concentrations at least 10-fold higher than the human exposure at the recommended 150 mg daily dose.
A long-term carcinogenicity study of cobicistat in rats revealed tumourigenic potential specific for this species that is regarded as of no relevance for humans. A long-term carcinogenicity study in mice did not show any carcinogenic potential.
6. Pharmaceutical particulars
6.1 List of excipients
Tablet core
microcrystalline cellulose (E460(i))
croscarmellose sodium (E468)
sodium starch glycolate
crospovidone (E1202)
stearic acid (E570)
magnesium stearate (E470b)
hydroxypropyl cellulose (E463)
silicon dioxide (E551)
Film-coating
hypromellose (hydroxypropyl methyl cellulose, E464)
titanium dioxide (E171)
talc (E553b)
triacetin (E1518)
red iron oxide (E172)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
2 years
6.4 Special precautions for storage
Do not store above 30°C.
6.5 Nature and contents of container
High density polyethylene (HDPE) bottle with a child-resistant polypropylene closure. Each bottle contains 30 film-coated tablets and a silica gel dessicant.
The following pack sizes are available: outer cartons containing 1 bottle of 30 film-coated tablets and outer cartons containing 90 (3 bottles of 30) film-coated tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. Marketing authorisation holder
Bristol-Myers Squibb Pharma EEIG
Uxbridge Business Park
Sanderson Road
Uxbridge UB8 1DH
United Kingdom
8. Marketing authorisation number(s)
EU/1/15/1025/001-002
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation: 13 July 2015
10. Date of revision of the text
20 January 2017
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.