Consumer medicine information

Everocan

Everolimus

BRAND INFORMATION

Brand name

Everocan

Active ingredient

Everolimus

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Everocan.

EVEROCAN

EVEROCAN

 Consumer Medicine Information (CMI) summary

The full CMI on the next page has more details. If you are worried about using this medicine, speak to your doctor or pharmacist.

 1. Why am I using everolimus?

Everocan contains the active ingredient everolimus. Everolimus is used to used to treat adult patients who have had kidney, heart or liver transplants.

For more information, see Section 1. Why am I using everolimus? in the full CMI.

 2. What should I know before I use everolimus?

Do not use if you have ever had an allergic reaction to everolimus or any of the ingredients listed at the end of the CMI.

Talk to your doctor if you have any other medical conditions, take any other medicines, or are pregnant or plan to become pregnant or are breastfeeding.

For more information, see Section 2. What should I know before I use everolimus? in the full CMI.

 3. What if I am taking other medicines?

Some medicines may interfere with everolimus and affect how it works.

A list of these medicines is in Section 3. What if I am taking other medicines? in the full CMI.

 4. How do I use everolimus?

Kidney and heart transplantations:

  • The usual starting dose is 0.75 mg EVEROCAN twice daily, taken in the morning and in the evening together with cyclosporine.
  • The first dose of EVEROCAN will be given as soon as possible after transplantation.

Liver transplantation:

  • The general recommended daily dose is 1 mg EVEROCAN twice daily, taken in the morning and in the evening, together with tacrolimus.
  • The first dose of EVEROCAN will be given approximately four weeks after transplantation.

More instructions can be found in Section 4. How do I use everolimus? in the full CMI.

 5. What should I know while using everolimus?

Things you should do
  • Remind any doctor, dentist or pharmacist you visit that you are using everolimus.
  • Keep all of your doctor's appointments so that your progress can be checked.
  • Make sure you use a highly effective contraceptive to prevent pregnancy during treatment with EVEROCAN. If you become pregnant while taking this medicine, tell your doctor immediately.
Things you should not do
  • Do not take EVEROCAN to treat any other complaints unless your doctor tells you to.
  • Do not give your medicine to anyone else, even if they have the same condition as you.
Driving or using machines
  • Be careful driving or operating machinery until you know how EVEROCAN affects you.
Drinking alcohol
  • Tell your doctor if you drink alcohol.
Looking after your medicine
  • Keep the tablets in the original packet and foils until it is time to take them.
  • Follow the instructions in the carton on how to take care of your medicine properly.

For more information, see Section 5. What should I know while using everolimus? in the full CMI.

 6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention. See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

For more information, including what to do if you have any side effects, see Section 6. Are there any side effects? in the full CMI.

EVEROCAN

Active ingredient(s): EVEROLIMUS

 Consumer Medicine Information (CMI)

This leaflet provides important information about using everolimus. You should also speak to your doctor or pharmacist if you would like further information or if you have any concerns or questions about using everolimus.

Where to find information in this leaflet:

1. Why am I using everolimus?
2. What should I know before I use everolimus?
3. What if I am taking other medicines?
4. How do I use everolimus?
5. What should I know while using everolimus?
6. Are there any side effects?
7. Product details

 1. Why am I using everolimus?

Everocan contains the active ingredient everolimus. EVEROCAN is used to treat adult patients who have had kidney, heart or liver transplants. It helps to prevent your body from rejecting the transplanted organ. EVEROCAN contains the active ingredient everolimus. It belongs to a group of medicines called immunosuppressants. These medicines help to control your body's immune system.

Ask your doctor if you have any questions about why this medicine has been prescribed for you. Your doctor may have prescribed it for another reason. EVEROCAN is available only with a doctor's prescription and is not addictive. There is not enough information to recommend the use of this medicine in children and adolescents.

 2. What should I know before I use everolimus?

Warnings

  • Do not use everolimus if you are allergic to:
    - Everolimus, or any of the ingredients listed at the end of this leaflet.
    - A similar medicine called Rapamune which contains the active ingredient sirolimus.
  • Some of the symptoms of an allergic reaction may include shortness of breath, wheezing or difficulty breathing; sudden difficulty swallowing; swelling of the face, lips, tongue or other parts of the body; rash, itching or hives on the skin.
  • Always check the ingredients to make sure you can use this medicine.
  • Tell your doctor if you have allergies to any other medicines, foods, preservatives or dyes. Your doctor will want to know if you are prone to allergies.

Check with your doctor if you:

  • have any other medical conditions such as problems with your liver, high cholesterol.
  • take any medicines for any other condition.

During treatment, you may be at risk of developing certain side effects. It is important you understand these risks and how to monitor for them. See additional information under Section 6. Are there any side effects?

Pregnancy and breastfeeding

  • Check with your doctor if you are pregnant or intend to become pregnant.
  • Talk to your doctor if you are breastfeeding or intend to breastfeed.
  • EVEROCAN is not recommended for use during pregnancy. Your doctor can discuss with you the risks and benefits involved.
  • Tell your doctor if you are breastfeeding. Breastfeeding is not recommended while you are taking EVEROCAN. It is not known whether EVEROCAN passes into breast milk and could affect your baby.
  • Tell your doctor if you are male and you want to father children. EVEROCAN may reduce sperm production in men, thus reducing the ability to father children. The effect is generally reversible. Tell your doctor if you are male or female and you want children.
  • EVEROCAN may cause infertility in male or female patients.
  • Medicines that suppress the immune system like EVEROCAN reduce your body's ability to fight against infections. It is advisable to consult your doctor if you have a fever or generally feel unwell, or have local symptoms such as coughing or a burning sensation when urinating that are severe or persistent over several days.
  • Consult your doctor right away if you feel confused, have problems speaking, memory loss, a headache, impaired vision or seizures, as these may be symptoms of a rare but very serious condition called progressive multiple leukoencephalopathy (PML).
  • Tell your doctor if you have had recent major surgery, or if you still have an unhealed wound following surgery.
  • EVEROCAN may increase the risk of wound-healing problems.
  • If you have not told your doctor about any of the above, tell him/her before you start taking EVEROCAN.
 3. What if I am taking other medicines?

Tell your doctor or pharmacist if you are taking any other medicines, including any medicines, vitamins or supplements that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines and EVEROCAN may interfere with each other. These include:

  • Immunosuppressive medicines other than cyclosporine for microemulsion, tacrolimus or corticosteroids.
  • Antibiotics such as rifampicin, clarithromycin, erythromycin and rifabutin.
  • Antifungal medicines such as ketoconazole, fluconazole and itraconazole.
  • Medicines for high blood pressure or heart problems such as diltiazem and verapamil, dronedarone, a medicine used to help regulate your heartbeat.
  • Medicines used to treat HIV/ AIDS such as nelfinavir, indinavir, amprenavir, efavirenz and nevirapine
  • Medicines used to lower blood cholesterol, such as atorvastatin, pravastatin or fibrates
  • Midazolam, a medicine used to treat acute seizures, or used as a sedative before or during surgery or other medical procedure.
  • Epilepsy medicines such as carbamazepine, phenobarbitone and phenytoin.
  • Octreotide, a medicine used to treat acromegaly, a rare hormonal disorder that usually occurs in middle-aged adults.
  • Medicines for stomach ulcer or reflux such as cimetidine and cisapride.
  • Medicines to prevent nausea and vomiting such as metoclopramide.
  • Danazol, which is used to treat endometriosis.
  • Bromocriptine, which is used to treat Parkinson's disease.
  • Imatinib, a medicine used to inhibit the growth of abnormal cells.
  • St John's wort, an herbal product used to treat depression and other conditions.

Such medicines may be affected by EVEROCAN or may affect how well it works. You may need different amounts of your medicines, or you may need to take different medicines.

Some vaccines may be less effective if given when taking EVEROCAN.

Check with your doctor or pharmacist if you are not sure about what medicines, vitamins or supplements you are taking and if these affect everolimus.

 4. How do I use everolimus?

How much to take / use

Kidney and heart transplantations:

  • The usual starting dose is 0.75 mg EVEROCAN twice daily, taken in the morning and in the evening together with cyclosporine.
  • The first dose of EVEROCAN will be given as soon as possible after transplantation.

Liver transplantation:

  • The general recommended daily dose is 1 mg EVEROCAN twice daily, taken in the morning and in the evening, together with tacrolimus.
  • The first dose of EVEROCAN will be given approximately four weeks after transplantation.
  • Follow the instructions provided and use everolimus until your doctor tells you to stop.

Your doctor will take regular blood tests to measure the amount of EVEROCAN in your blood. If needed, your doctor will adjust your dose depending on the results from your blood tests.

When to take / use everolimus

  • Always take EVEROCAN twice a day. It is best to take the doses 12 hours apart if possible.
  • Taking your doses 12 hours apart and at the same time each day will have the best effect. It will also help you remember when to take them.
  • EVEROLIMUS can be taken with or without food but should always be taken the same way. (e.g. always with food or always without food).
  • If you are taking cyclosporine or tacrolimus, you should take it at the same time as EVEROCAN.

How to take it

  • Swallow the tablets whole with a full glass of water.
  • Do not crush or chew them.
  • Do not take EVEROCAN with grapefruit juice.

How long to take it

  • Keep taking this medicine for as long as your doctor tells you.
  • You will need to take EVEROCAN as long as you have your transplanted organ, or until your doctor changes your immunosuppressive medication.

If you forget to use everolimus

If it is almost time for your next dose skip the dose you missed and take your next dose when you are meant to.

Otherwise, take it as soon as you remember, and then go back to taking your medicine as you would normally.

Do not take a double dose to make up for the dose that you missed.

This may increase the chance of you getting an unwanted side effect.

If you miss more than one dose, ask your doctor for advice.

If you are not sure what to do, ask your doctor or pharmacist.

If you have trouble remembering to take your medicine, ask your pharmacist for some hints.

If you use too much everolimus

If you think that you have used too much everolimus, you may need urgent medical attention.

You should immediately:

  • phone the Poisons Information Centre
    (by calling 13 11 26), or
  • contact your doctor, or
  • go to the Emergency Department at your nearest hospital.

You should do this even if there are no signs of discomfort or poisoning.

 5. What should I know while using everolimus?

Things you should do

Keep all of your doctor's appointments so that your progress can be checked. Regular check-ups with blood and urine tests are essential for your doctor to assess the good function of your transplanted organ, to detect possible unwanted side effects and to adapt the dosages of your medicines to obtain the best treatment. Blood tests allow your doctor to measure levels of your medicines to check your kidney activity and the levels of sugar and cholesterol in your blood. Measurement of proteins in a urine sample also helps your doctor to assess kidney activity.

Make sure you use a highly effective contraceptive to prevent pregnancy during treatment with EVEROCAN. If you become pregnant while taking this medicine, tell your doctor immediately.

If you develop lumps anywhere in your body, or develop any moles, or you notice changes in existing moles, tell your doctor. This may be an early sign of a cancer. Immunosuppressant medicines, including EVEROCAN, may increase the risk of developing certain cancers, including skin cancer and lymphoma (cancer of the lymphatic system).

EVEROCAN may affect your response to vaccination. Some vaccines may not be suitable for you.

If you are experiencing respiratory symptoms (e.g. coughing, difficulty in breathing and wheezing), please inform your doctor.

Your doctor may decide whether and how you need to continue EVEROCAN, and/or whether you need to receive other medicines to resolve this condition.

Tell your doctor if you experience any swelling of the limbs or around your abdomen.

If you are about to be started on any new medicine, remind your doctor and pharmacist that you are taking EVEROCAN.

Tell any other doctors, dentists, and pharmacists who treat you that you are taking this medicine.

Things you must not do

Do not take EVEROCAN to treat any other complaints unless your doctor tells you to.

Do not give your medicine to anyone else, even if they have the same condition as you.

Things to be careful of

Be careful driving or operating machinery until you know how EVEROCAN affects you.

If you go out in the sun, wear a hat, protective clothing and sunscreen. Do not use a sun lamp.

Remind any doctor, dentist or pharmacist you visit that you are using everolimus.

Drinking alcohol

Tell your doctor if you drink alcohol.

Looking after your medicine

Keep the tablets in the original packet and foils until it is time to take them.

Follow the instructions in the carton on how to take care of your medicine properly.

Store it in a cool dry place away from moisture, heat or sunlight; for example, do not store it:

  • in the bathroom or near a sink, or
  • in the car or on window sills.

Keep it where young children cannot reach it.

Getting rid of any unwanted medicine

If you no longer need to use this medicine or it is out of date, take it to any pharmacy for safe disposal.

Do not use this medicine after the expiry date.

 6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

Less serious side effects

Less serious side effectsWhat to do
Nosebleeds, acne, abdominal pain, nausea, vomiting, diarrhea, impotence, menstrual disorders (including absent or heavy periods), cold sores, mouth sores, pain in the ear, nose or throat, jaundice (yellowing of the skin and eyes with darkened urine), general pain, muscle or joint pain or tenderness, weakness, bruising and frequent infections, upper and lower respiratory tract infections, urinary tract infections, slowed wound healing or wound infection, difficulty sleeping, anxiety, headache, fever, rash increased heart rate, breathlessness, ovarian cystSpeak to your doctor if you have any of these less serious side effects and they worry you.

Serious side effects

Serious side effectsWhat to do
  • swelling of hands, feet or limbs due to fluid retention
  • symptoms of an allergic reaction such as shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue, throat or other parts of the body; rash, itching or hives on the skin
  • burning sensation on urination or increased urgency to urinate
  • severe upper stomach pain, which may be accompanied by nausea and vomiting
  • constant "flu-like" symptoms such as fever (increased temperature), chills/shivering, sore throat, aching joints, swollen glands, cough, or any other signsof infection such as infection of a cut or scratch
  • new lumps or moles, or changes to existing moles, anywhere on the body
  • unusual bleeding or bruising without obvious cause
  • persistent or worsening lung/ breathing symptoms like coughing, difficulty breathing, wheezing
  • pain, hernia, unusual warmth, swelling or oozing from the site of surgery
  • tiredness, headaches, shortness of breath when exercising, dizziness and looking pale, which could be signs of anaemia
  • swelling of the face, lips, mouth, tongue, or throat which may cause difficulty in swallowing or breathing
  • sudden reduction in your urine output, especially if accompanied by pain where your transplanted kidney is located.
  • signs that blood clots may have formed, such as severe sudden headache, sudden loss of coordination, blurred vision, loss of vision, slurred speech, numbness in an arm or leg, pain in the calves, thighs or chest, shortness of breath, coughing blood.
Call your doctor straight away, or go straight to the Emergency Department at your nearest hospital if you notice any of these serious side effects.

Tell your doctor or pharmacist if you notice anything else that may be making you feel unwell.

Other side effects not listed here may occur in some people.

Reporting side effects

After you have received medical advice for any side effects you experience, you can report side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems. By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

 7. Product details

This medicine is only available with a doctor's prescription.

What everolimus contains

Active ingredient
(main ingredient)		Everolimus
Other ingredients
(inactive ingredients)		butylated hydroxytoluene
lactose Monohydrate
hypromellose
lactose anhydrous
crospovidone
magnesium stearate
Potential allergens 

Do not take this medicine if you are allergic to any of these ingredients.

What everolimus looks like

EVEROCAN 0.25 mg: White to off white, round shaped tablets debossed with "EVR" on one side and "25" on other side. (Aust R 335146).

EVEROCAN 0.5 mg: White to off white, round shaped tablets debossed with "EVR" on one side and "50" on other side. (Aust R 335141).

EVEROCAN 0.75 mg: White to off white, round shaped tablets debossed with "EVR" on one side and "75" on other side. (Aust R 335142).

EVEROCAN 1 mg: White to off white, round shaped tablets debossed with "EVR" on one side and "100" on other side.
(blister pack: Aust R 335144).
(bottle pack Aust R 335148 )

Who distributes everolimus

Pharmacor Pty Ltd.
Suite 803, Level 8, Tower A,
The Zenith, 821 Pacific Highway,
Chatswood, NSW, 2067,
Australia
www.pharmacor.com.au

This leaflet was prepared in 04/2021.

Published by MIMS July 2021

BRAND INFORMATION

Brand name

Everocan

Active ingredient

Everolimus

Schedule

S4

 

1 Name of Medicine

Everolimus.

2 Qualitative and Quantitative Composition

Everolimus is a white to faintly yellow powder practically insoluble in water but soluble in organic solvents such as ethanol and methanol.

Everocan 0.25 mg.

Each uncoated tablet contains 0.25 mg everolimus.

Everocan 0.5 mg.

Each uncoated tablet contains 0.5 mg everolimus.

Everocan 0.75 mg.

Each uncoated tablet contains 0.75 mg everolimus.

Everocan 1 mg.

Each uncoated tablet contains 1 mg everolimus.

Excipient with known effect.

Contain lactose.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Uncoated tablet.

Everocan 0.25 mg.

White to off white, round shaped tablets debossed with "EVR" on one side and "25" on other side.

Everocan 0.5 mg.

White to off white, round shaped tablets debossed with "EVR" on one side and "50" on other side.

Everocan 0.75 mg.

White to off white, round shaped tablets debossed with "EVR" on one side and "75" on other side.

Everocan 1 mg.

White to off white, round shaped tablets debossed with "EVR" on one side and "100" on other side.

4 Clinical Particulars

4.1 Therapeutic Indications

Everocan is indicated for the prophylaxis of organ rejection in adult patients at mild to moderate immunological risk receiving an allogeneic renal or cardiac transplant and in adult patients receiving an allogeneic hepatic transplant (see Section 4.4 Special Warnings and Precautions for Use).

4.2 Dose and Method of Administration

Dosage.

Treatment with Everocan should only be initiated and maintained by physicians who are experienced in immunosuppressive therapy following organ transplantation. Everolimus should be used in combination with cyclosporin microemulsion and corticosteroids with cyclosporin exposure reduced over time post-transplantation (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring).

Kidney and heart transplantation.

An initial dose regimen of 0.75 mg twice a day is recommended for the general kidney and heart transplant population, administered as soon as possible after transplantation.

Liver transplantation.

The dose of 1.0 mg twice a day is recommended for the hepatic transplant population with the initial dose approximately 4 weeks after transplantation. A higher everolimus dosage regimen (1.5 mg twice daily) was shown to be as effective as the recommended dosage regimen but the overall safety was worse. Therefore this higher-dosage regimen is not recommended.

Method of administration.

The daily dose of Everocan should always be given orally in two divided doses, consistently either with or without food and at the same time as cyclosporin microemulsion or tacrolimus.
Everocan tablets should be taken whole and not crushed before use.

Paediatric use.

There is insufficient experience to recommend the use of everolimus in children and adolescents. Limited information is available in renal transplant paediatric patients.

Use in the elderly.

Clinical experience is limited in patients ≥ 65 years of age.
Nevertheless, there are no apparent differences in the pharmacokinetics of everolimus in patients ≥ 65 to 70 years of age as compared with younger adults.

Use in renal impairment.

No dosage adjustment is required.

Use in hepatic impairment.

Everolimus whole blood trough levels should be closely monitored in patients with impaired hepatic function. For patients with mild hepatic impairment (Child-Pugh Class A), the dose should be reduced to two-thirds of the normal dose. For patients with moderate hepatic impairment (Child-Pugh Class B), the dose should be reduced to one half of the normal dose. For patients with severe hepatic impairment (Child-Pugh Class C), the dose should be reduced by at least one half the normal dose with strict attention to therapeutic drug monitoring. Further dose titration should be based on close therapeutic drug monitoring (see Section 5.2 Pharmacokinetic Properties).

Therapeutic drug monitoring.

Everolimus has a narrow therapeutic index which may require adjustments in dosing to maintain therapeutic response and safety. Routine everolimus whole blood therapeutic drug level monitoring is recommended. Based on exposure-efficacy and exposure-safety analysis, patients achieving everolimus whole blood trough levels 3.0 nanogram/mL have been found to have a lower incidence of biopsy-proven acute rejection in renal, cardiac and hepatic transplantation compared with the patients whose trough levels are below 3.0 nanogram/mL. The upper limit to the therapeutic range is recommended at 8 nanogram/mL. Exposure above 12 nanogram/mL has not been studied. These recommended ranges for everolimus are based on chromatographic methods.
It is especially important to monitor everolimus blood concentrations, in patients with hepatic impairment, during concomitant administration of strong CYP3A4 inducers and inhibitors, when switching formulation and/or if cyclosporin microemulsion dosing is markedly reduced.
Optimally, dose adjustments of everolimus should be based on trough levels obtained > 4-5 days after the previous dosing change. There is an interaction of cyclosporin on everolimus, and consequently, everolimus levels may decrease if cyclosporin exposure is markedly reduced (i.e. trough concentration < 50 nanogram/mL).

Cyclosporin dose recommendation in renal transplantation.

Everolimus should not be used long-term together with full doses of cyclosporin. Reduced exposure to cyclosporin in everolimus-treated renal transplant patients improves renal function. Based on experience gained from study A2309, cyclosporin exposure reduction should be started immediately after initiation of everolimus with the following whole blood trough level windows (see Table 1):
Prior to dose reduction of cyclosporin it should be ascertained that steady state everolimus whole blood trough concentrations (C0) are equal to or above 3 nanogram/mL there are limited data regarding the dosing of everolimus with cyclosporin trough concentrations below 50 nanogram/mL, or C2 levels below 350 nanogram/mL, in the maintenance phase. If the patient cannot tolerate reduction of cyclosporin exposure, the continued use of everolimus should be reconsidered.

Cyclosporin dose recommendation in cardiac transplantation.

Cardiac patients in the maintenance period could have their cyclosporin dose reduced beginning one month after transplantation, if everolimus is used de novo, as tolerated, in order to improve kidney function. If impairment of renal function is progressive or if the calculated creatinine clearance is < 60 mL/min, the treatment regimen should be adjusted. For cardiac transplant patients, the cyclosporin dose should be guided by the experience in Study 2411 and confirmed in study 2310 in which everolimus was administered with cyclosporin with recommended reduced target trough concentrations (C0) as follows (see Table 2):
Prior to dose reduction of cyclosporin it should be ascertained that steady state everolimus whole blood trough concentrations are equal to or above 3 nanogram/mL. In cardiac transplantation there are limited data regarding dosing everolimus with cyclosporin trough concentrations below 50-100 nanogram/mL after 12 months. If the patient cannot tolerate reduction of cyclosporin exposure, the continued use of everolimus should be reconsidered.

Tacrolimus dose recommendation in hepatic transplantation.

In liver transplantation, everolimus should be used in combination with tacrolimus and corticosteroids. Hepatic transplant patients should have the tacrolimus exposure reduced to minimize calcineurin related renal toxicity. The tacrolimus dose should be reduced starting approximately 3 weeks after initiation of dosing in combination with everolimus based on tacrolimus blood trough levels (C0) targeting 3-5 nanogram/mL. In a controlled clinical trial, complete withdrawal of tacrolimus has been associated with an increased risk of acute rejections, and is not recommended. Everolimus has not been evaluated with full dose tacrolimus in controlled clinical trials.

4.3 Contraindications

Everolimus is contraindicated in patients with a known hypersensitivity to everolimus, sirolimus or to any of the excipients.

4.4 Special Warnings and Precautions for Use

The clinical development of everolimus has involved use of specific combinations of medicines. In renal and cardiac transplantation, everolimus should be used in combination with cyclosporine microemulsion and corticosteroids. In hepatic transplantation, everolimus should be used in combination with tacrolimus and corticosteroids. Information about other combinations is lacking.

Management of immunosuppression.

There are limited data regarding the use of everolimus without calcineurin inhibitor (CNI) (cyclosporin or tacrolimus). An increased risk of acute rejection was observed in patients who discontinued the administration of CNI compared with those who continued the administration of CNI.
Everolimus has been administered in clinical trials concurrently with calcineurin inhibitors, basiliximab and corticosteroids. Everolimus in combination with immunosuppressive agents other than these has not been adequately investigated.
Everolimus has not been adequately studied in patients at high immunological risk.

Combination with thymoglobulin induction.

Caution is advised with the use of thymoglobulin (rabbit anti-thymocyte globulin) induction and the everolimus/cyclosporin/steroid regimen. In a clinical study in heart transplant recipients (Study A2310, see Section 5.1 Pharmacodynamic Properties), an increased incidence of serious infections was observed within the first three months after transplantation in the subgroup of patients who had received induction with rabbit anti-thymocyte globulin combined with everolimus, steroid and cyclosporin at the blood concentration recommended for heart transplantation (higher than in kidney transplantation). This was associated with greater mortality among patients who were both hospitalised and required ventricular assistance device prior to transplantation suggesting that they may have been particularly vulnerable to increased immunosuppression.

Serious and opportunistic infections.

Patients on a regimen of immunosuppressive medicinal products, including everolimus, are at increased risk of developing infections especially with opportunistic pathogens (bacterial, fungal, viral, protozoal). Fatal infections and sepsis have been reported in patients treated with everolimus. Among opportunistic conditions to which immunosuppressed patients may be vulnerable are polyomavirus infections which include BK virus-associated nephropathy which can lead to kidney graft loss and potentially fatal JC virus-associated progressive multiple leukoencephalopathy (PML). These infections, often related to total immunosuppressive burden, should be considered in the differential diagnosis of immunosuppressed patients with deteriorating kidney graft function or neurological symptoms.
In clinical trials with everolimus, antimicrobial prophylaxis for Pneumocystis jirovecii (carinii) pneumonia was administered for the first 12 months following transplantation. Cytomegalovirus (CMV) prophylaxis was recommended for 3 months after transplantation, particularly for patients at increased risk for CMV disease.

Use in hepatic impairment.

Close monitoring of everolimus whole blood trough levels (C0) and everolimus dose adjustment is recommended in patients with impaired hepatic function (see Section 4.2 Dose and Method of Administration).

Interaction with strong inhibitors, inducers of CYP3A4.

Co-administration with strong 3A4-inhibitors (e.g. ketoconazole, itraconazole, voriconazole, clarithromycin, telithromycin, ritonavir) and inducers (e.g. rifampicin, rifabutin) is not recommended unless the benefit outweighs the risk. It is recommended that everolimus whole blood trough levels be monitored whenever inducers or inhibitors of CYP3A4 are concurrently administered and following their discontinuation (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Lymphomas and other malignancies.

Patients receiving a regimen of immunosuppressive drugs, including everolimus, are at increased risk of developing lymphomas or other malignancies, particularly of the skin. The absolute risk seems related to the duration and intensity of immunosuppression rather than to the use of a specific agent. Patients should be monitored regularly for skin neoplasms and advised to minimise exposure to UV light, sunlight and use appropriate sunscreen.

Hyperlipidemia.

In transplant patients, concomitant use of everolimus and cyclosporin microemulsion or tacrolimus has been associated with increased serum cholesterol and triglycerides that may require treatment. Patients receiving everolimus should be monitored for hyperlipidemia and, if necessary, treated with lipid-lowering agents and appropriate dietary adjustments made. The risk/benefit should be considered in patients with established hyperlipidemia before initiating an immunosuppressive regimen including everolimus. Similarly the risk/benefit of continued everolimus therapy should be re-evaluated in patients with severe refractory hyperlipidemia.
During everolimus therapy with cyclosporin microemulsion, patients administered everolimus in conjunction with an HMG-CoA reductase inhibitor and/or fibrates should be monitored for the development of rhabdomyolysis and other adverse effects associated with these agents.

Angioedema.

Everolimus has been associated with the development of angioedema. In the majority of cases reported patients were receiving ACE inhibitors as co-medication.

Everolimus and calcineurin inhibitor-induced renal dysfunction.

In renal and cardiac transplant everolimus may potentiate the renal toxicity of cyclosporin. Everolimus with full-dose cyclosporin increases the risk of renal dysfunction. Reduced doses of cyclosporin are required for use in combination with everolimus in order to avoid renal dysfunction. Appropriate adjustment of the immunosuppressive regimen, in particular reduction of the cyclosporin dose should be considered in patients with elevated serum creatinine levels.
In a liver transplant study everolimus with reduced tacrolimus exposure has not been found to worsen renal function in comparison to standard exposure tacrolimus.
Regular monitoring of renal function is recommended in all patients. Appropriate adjustment of the immunosuppressive regimen, in particular reduction of cyclosporin dose, should be considered in patients with elevated serum creatinine levels. In patients receiving renal transplants, everolimus should not be used long-term together with full doses of cyclosporin (see Section 4.2 Dose and Method of Administration). In patients receiving cardiac transplants, cyclosporin dose should be reduced as tolerated during the maintenance period, to prevent renal impairment. Caution should be exercised when co-administering other agents that are known to have a deleterious effect on renal function.

Proteinuria.

The use of everolimus with calcineurin inhibitors in transplant recipients has been associated with increased proteinuria. The risk increases with higher everolimus blood levels.
In renal transplant patients with mild proteinuria while on maintenance immunosuppressive therapy including a calcineurin inhibitor (CNI) there have been reports of worsening proteinuria when the CNI is replaced by everolimus. Reversibility has been observed with interruption of everolimus and reintroduction of the CNI. The safety and efficacy of conversion from CNI to everolimus in such patients have not been established.
Patients receiving everolimus should be monitored for proteinuria.

Renal graft thrombosis.

An increased risk of kidney arterial and venous thrombosis, resulting in graft loss, has been reported, mostly within the first 30 days post-transplantation.

Wound-healing complications.

Everolimus, like other mTOR inhibitors, can impair healing increasing the occurrence of post-transplant complications such as wound dehiscence, fluid collections and wound infection which may require further surgical attention. Lymphocele is the most frequently reported such event in renal transplant recipients and tends to be more frequent in patients with higher body mass index.

Fluid accumulation.

Generalized fluid accumulation, including peripheral edema (e.g. lymphoedema) and other types of localized fluid collection, such as pericardial and pleural effusions and ascites have also been reported. The frequency of pericardial and pleural effusion is increased in cardiac transplant recipients and the frequency of incisional hernias is increased in liver transplant recipients.

Thrombotic microangiopathic disorders.

The concomitant administration of everolimus with a calcineurin inhibitor (CNI) may increase the risk of CNI-induced haemolytic uraemic syndrome, thrombotic thrombocytopenic purpura and thrombotic microangiopathy.

Interstitial lung disease/non-infectious pneumonitis.

Cases of interstitial lung disease, implying lung intraparenchymal inflammation (pneumonitis) and/or fibrosis of non-infectious etiology, some fatal, have occurred in patients receiving rapamycins and their derivatives, including everolimus. A diagnosis of interstitial lung disease (ILD) should be considered in patients presenting with symptoms consistent with infectious pneumonia but not responding to antibiotic therapy and in whom infectious, neoplastic and other non-drug causes have been discounted through appropriate investigations. Mostly, the condition resolves after discontinuation of everolimus and/or addition of glucocorticoids. However, fatal cases have also occurred.

New onset diabetes mellitus.

Everolimus has been shown to increase the risk of new onset diabetes mellitus after transplant. Blood glucose concentrations should be monitored closely in patients treated with everolimus.

Risk of intolerance to excipients.

Patients with rare hereditary problems of galactose intolerance, severe lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Use in the elderly.

(See Section 4.2 Dose and Method of Administration, Use in the elderly.)

Paediatric use.

(See Section 4.2 Dose and Method of Administration, Paediatric use.)

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

CYP3A4 is the main P450 enzyme involved in the microsomal metabolism of everolimus, and everolimus is a substrate for the multidrug efflux pump, P-glycoprotein (PgP). Therefore, absorption and subsequent elimination of systemically absorbed everolimus may be influenced by drugs that affect CYP3A4 and/or P-glycoprotein. Concurrent treatment with strong 3A4-inhibitors and inducers is not recommended unless the benefits outweigh the risk. Inhibitors of PgP may decrease the efflux of everolimus from intestinal cells and increase everolimus blood concentrations. In vitro, everolimus was a competitive inhibitor of CYP3A4 and of CYP2D6, potentially increasing the concentrations of drugs eliminated by these enzymes. Thus, caution should be exercised when co-administering everolimus with 3A4- and 2D6 substrates with a narrow therapeutic index. All in vivo interaction studies were conducted without concomitant cyclosporin.

Cyclosporin (CYP3A4/PgP inhibitor).

The bioavailability of everolimus was significantly increased by co-administration of cyclosporin microemulsion. In a single-dose study in healthy subjects, cyclosporin increased everolimus AUC by 168% (range, 46% to 365%) and Cmax by 82% (range, 25% to 158%) compared with administration of everolimus alone. Dose adjustment of everolimus may be necessary if the cyclosporin dose is altered. Everolimus had a clinically minor influence on cyclosporin pharmacokinetics in renal and heart transplant patients receiving cyclosporin microemulsion. However, everolimus may potentiate the renal toxicity of cyclosporin. Patients should be monitored for decrease in creatinine clearance.

Rifampicin (CYP3A4 inducer).

Pre-treatment of healthy subjects with multiple-dose rifampicin followed by a single dose of everolimus increased everolimus clearance nearly 3-fold, and decreased Cmax by 58% and AUC by 63%. Combination with rifampicin is not recommended (see Section 4.4 Special Warnings and Precautions for Use).

Atorvastatin (CYP3A4-substrate) and pravastatin (PgP-substrate).

Single-dose administration of everolimus with either atorvastatin or pravastatin to healthy subjects did not influence the pharmacokinetics of atorvastatin, pravastatin and everolimus, nor, to a clinically relevant extent, the total HMG-CoA reductase bioreactivity in plasma. These results cannot be extrapolated to other HMG-CoA reductase inhibitors. Patients should be monitored for the development of rhabdomyolysis and other adverse events as described in the Product Information of HMG-CoA reductase inhibitors.

Midazolam (CYP3A4A substrate).

In a two-period, fixed-sequence, crossover drug interaction study, 25 healthy subjects received a single oral 4 mg dose of midazolam in period 1. In period 2, they received everolimus 10 mg once-daily for 5 days and a single 4 mg dose of midazolam with the last dose of everolimus. The Cmax of midazolam increased 1.25-fold (90% CI, 1.14 - 1.37) and the AUCinf increased 1.30-fold (1.22 - 1.39). The half-life of midazolam was unaltered. This study indicated that everolimus is a weak inhibitor of CYP3A4.

Other possible interactions.

Inhibitors of CYP3A4 and PgP may increase everolimus blood levels (e.g. antifungal agents: fluconazole, ketoconazole, itraconazole; macrolide antibiotics: clarithromycin, erythromycin; calcium channel blockers: verapamil, nicardipine, diltiazem; protease inhibitors: nelfinavir, indinavir, amprenavir; other substances: cisapride, metoclopramide, bromocriptine, cimetidine, danazol). Inducers of CYP3A4 may increase the metabolism of everolimus and decrease everolimus blood levels (e.g. St. John's wort (Hypericum perforatum); anticonvulsants: carbamazepine, phenobarbitone, phenytoin; antibiotics: rifabutin), anti HIV drugs: efavirenz, nevirapine.
Grapefruit and grapefruit juice affect cytochrome P450 and PgP activity and should therefore be avoided.

Vaccination.

Immunosuppressants may affect response to vaccination and vaccination during treatment with everolimus may be less effective. The use of live vaccines should be avoided.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

There are literature reports of reversible azoospermia and oligospermia in patients treated with mTOR inhibitors. The potential for everolimus to cause infertility in male and female patients is unknown, however, male infertility and secondary amenorrhoea have been observed. Preclinical toxicology studies having shown that everolimus can reduce spermatogenesis, male infertility must be considered a potential risk of prolonged everolimus therapy.
Everolimus completely impaired male rat fertility at an everolimus dose that resulted in a drug exposure (blood AUC) that was slightly above the expected maximum human value, and sperm number and motility were reduced. Testicular atrophy was observed in all animal species tested (mouse, rat, minipigs and monkey) at drug exposures similar to or slightly above the expected clinical exposure (blood AUC). There was evidence for partial recovery of fertility over a period approximately equivalent to the treatment period. Female rat fertility could not be assessed at a dose resulting in an adequate drug exposure (blood AUC).

Females and males of reproductive potential.

Women of childbearing potential should be advised to use highly effective contraception methods while they are receiving everolimus and up to 8 weeks after ending treatment.
(Category C)

Risk summary.

There are no adequate data from the use of everolimus in pregnant women. Studies in animals have shown reproductive toxicity effects including embryo/foetotoxicity. The potential risk to humans is unknown. Everolimus should not be given to pregnant women unless the potential benefit outweighs the potential risk to the foetus.

Animal data.

In rats, everolimus crossed the placenta. Oral treatment started before mating and continued to the end of the period of organogenesis, treatment resulted in increased pre- and post-implantation losses. There was a low incidence of fetal cleft sternum, the significance of which is uncertain because it occurred at a dose giving a high fetal resorption rate. Systemic drug exposures (blood AUC) with the doses used in this study were below the expected maximum human value. Treatment of pregnant rabbits during the period of organogenesis slightly increased late fetal resorptions but did not otherwise affect fetal development. The highest dose used in this study gave a systemic drug exposure (blood AUC) that was slightly below the expected maximum human value.
 It is not known whether everolimus is excreted in human milk. In animal studies, everolimus and/or its metabolites were readily transferred into milk of lactating rats. Therefore, women who are taking everolimus should not breast feed.

4.7 Effects on Ability to Drive and Use Machines

No studies on the effects of everolimus on the ability to drive and operate machines have been performed.

4.8 Adverse Effects (Undesirable Effects)

Summary of the safety profile.

Everolimus combined with cyclosporin, was studied in five trials in renal transplant recipients totalling 2497 patients (including two studies without a non-everolimus control group) and three trials in heart transplant recipients totalling 1531 patients (ITT populations, see Section 5.1 Pharmacodynamic Properties, Clinical trials).
Everolimus, combined with tacrolimus, was studied in one trial which included 719 liver transplant recipients (ITT population, see Section 5.1 Pharmacodynamic Properties). The overall safety profile was not distinct from previous experiences with everolimus and expectations in a liver transplant population up to 36 months.
The occurrence of the adverse events may depend on the immunosuppressive regimen (i.e. degree and duration). In the studies, combining everolimus with full dose cyclosporine for microemulsion elevated serum creatinine was observed more frequently than in control patients. The overall incidence of adverse events was lower with reduced dose cyclosporin microemulsion (see Section 5.1 Pharmacodynamic Properties).
With the exception of elevation of serum creatinine, the safety profile of everolimus in the trials in which it was administered with reduced-dose cyclosporin was similar to that described in the 3 pivotal studies in which full dose of cyclosporin was administered, except that elevation of serum creatinine was less frequent, and mean and median serum creatinine values were lower, in the trials in which everolimus was administered with reduced-dose cyclosporin. A lower rate of viral infections, primarily due to CMV in renal and heart transplant recipients and BK virus in renal transplant recipients, has been shown with the currently-recommended everolimus-based immunosuppressive regimen in renal transplant recipients (see Section 5.1 Pharmacodynamic Properties).
In controlled clinical trials in which a total of 3256 patients receiving everolimus in combination with other immunosuppressants were monitored for at least 1 year, a total of 3.1% developed malignancies, with 1.0% developing skin malignancies and 0.6% developing lymphoma or lymphoproliferative disorder.

Tabulated summary of adverse drug reactions from clinical trials.

The frequency rates of the adverse drug reactions listed below are derived from analysis of the 12-month incidences of events reported in multicentre, randomised, controlled trials investigating everolimus in combination with calcineurin inhibitors (CNI) and corticosteroids in transplant recipients. All of the trials included non-everolimus, CNI-based standard-therapy arms.
The adverse reactions reported as possibly or probably related to everolimus seen in the Phase III clinical trials are presented in Tables 3 and 4. Unless noted otherwise, these disorders have been identified by an increased incidence in the phase III studies comparing patients on a everolimus-treated patients with patients on a non-everolimus standard-therapy regimen, or the same incidence in case the event is known as an ADR of the comparator (MPA in renal and heart transplant studies). Except where noted otherwise, the adverse reaction profile is relatively consistent across all transplant indications. Adverse drug reactions from clinical trials are listed by MedDRA system organ class. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. In addition, the corresponding frequency category for each adverse drug reaction is based on the following convention (CIOMS III): very common > 1/10, common > 1/100 and < 1/10, uncommon > 1/1,000 and < 1/100, rare > 1/10,000 and < 1/1,000, very rare < 1/10,000.

Adverse drug reactions from post-marketing spontaneous reports.

The following adverse drug reactions have been derived from post-marketing experience with everolimus via spontaneous case reports and literature cases. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorized as not known. Adverse drug reactions are listed according to system organ classes in MedDRA. Within each system organ class, ADRs are presented in order of decreasing seriousness. See Table 5.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at https://www.tga.gov.au/reporting-problems.

4.9 Overdose

In animal studies, everolimus showed a low acute toxic potential. No lethality or severe toxicity was observed after single oral doses of 2000 mg/kg (limit test) in either mice or rats. Reported experience with overdose in humans is very limited. There is a single case of an accidental ingestion of 1.5 mg everolimus in a 2-year old child where no adverse events were observed. Single doses up to 25 mg have been administered to transplant patients with acceptable acute tolerability.
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Pharmacotherapeutic group, ATC.

Pharmacotherapeutic group: selective immunosuppressive agents. ATC code: L04A A18.

Mechanism of action.

Everolimus, a proliferation signal inhibitor, prevents allograft rejection in rodent and non-human primate models of allotransplantation. It exerts its immunosuppressive effect by inhibiting the proliferation, and thus clonal expansion, of antigen-activated T cells which is driven by T cell-specific interleukins, e.g. interleukin-2 and interleukin-15. Everolimus inhibits an intracellular signalling pathway which is triggered upon binding of these T cell growth factors to their respective receptors, and which normally leads to cell proliferation. The blockage of this signal by everolimus leads to an arrest of the cells at the G1 stage of the cell cycle.
At the molecular level, everolimus forms a complex with the cytoplasmic protein FKBP12. In the presence of everolimus the growth factor-stimulated phosphorylation of the p70 S6 kinase is inhibited. Since p70 S6 kinase phosphorylation is under the control of FRAP (also called m-TOR), this finding suggests that the everolimus-FKBP-12 complex binds to and thus interferes with the function of FRAP. FRAP is a key regulatory protein which governs cell metabolism, growth and proliferation; disabling FRAP function thus explains the cell cycle arrest caused by everolimus.
Everolimus, has a different mode of action than cyclosporin. In preclinical models of allotransplantation, the combination of everolimus and cyclosporin was more effective than either drug alone.
The effect of everolimus is not restricted to T cells. It inhibits in general, growth factor-stimulated proliferation of haematopoietic as well as non-haematopoietic cells, like, for instance, that of vascular smooth muscle cells. Growth factor-stimulated vascular smooth muscle cell proliferation, triggered by injury to endothelial cells and leading to neointima formation, plays a key role in the pathogenesis of chronic rejection. Preclinical studies with everolimus have shown inhibition of neointima formation in a rat aorta allotransplantation model.

Clinical trials.

Renal transplantation.

Everolimus in fixed doses of 1.5 mg/day and 3 mg/day, in combination with standard doses of cyclosporin microemulsion and corticosteroids was investigated in two Phase III de novo renal transplant trials (Studies B201 and B251). Mycophenolate mofetil (MMF) 1 g twice a day was used as comparator. The co-primary composite endpoints were efficacy failure (biopsy-proven acute rejection, graft loss, death or loss to follow-up) at 6 months, and graft loss, death or loss to follow-up at 12 months. Everolimus was overall non-inferior to MMF in these trials. The incidence of biopsy-proven acute rejection at 6 months in the B201 study was 21.6%, 18.2%, and 23.5% for the everolimus 1.5 mg/day, everolimus 3 mg/day and MMF groups, respectively. In the B251 study, the incidences were 17.1%, 20.1%, and 23.5% for the everolimus 1.5 mg/day, everolimus 3 mg/day and MMF groups respectively.
Reduced allograft function with elevated serum creatinine was observed more frequently among subjects using everolimus in combination with full dose cyclosporin microemulsion than in MMF patients. This effect is believed to be due to increased cyclosporin nephrotoxicity. Drug concentration-pharmacodynamic analysis showed that renal function could be improved with reduced exposure to cyclosporin while conserving efficacy for as long as blood trough everolimus concentration was maintained above 3 nanogram/mL. This concept was subsequently confirmed in two further Phase IIIb studies (A2306 and A2307, including 237 and 256 patients respectively) which evaluated efficacy and safety of everolimus 1.5 and 3 mg per day (initial dosing, subsequent dosing based on target trough concentration ≥ 3 nanogram/mL) in combination with reduced exposure to cyclosporin. In both studies, renal function was improved without compromising efficacy. In these studies however there was no non-everolimus comparative arm. A phase III, multicentre, randomised, open-label, controlled trial A2309, has been completed in which 833 de-novo renal transplant recipients were randomised to either one of two everolimus regimens, differing by dosage, and combined with reduced-dose cyclosporin or a standard regimen of sodium mycophenolate (MPA) + cyclosporin and treated for 12 months. All patients received induction therapy with basiliximab pre-transplant and on Day 4 post-transplant. Steroids could be given as required post-transplant.
Starting dosages in the two everolimus groups were 1.5 mg/d and 3 mg/d, given twice a day, subsequently modified from Day 5 onwards to maintain target blood trough everolimus levels of 3 to 8 nanogram/mL and 6 to 12 nanogram/mL respectively. Sodium mycophenolate dosage was 1.44 g/d. Cyclosporin dosages were adapted to maintain target blood trough-level windows as shown in Table 6. The actual measured values for blood concentrations of everolimus and cyclosporin (C0 and C2) are shown in Table 7.
Although the higher dosage everolimus regimen was as effective as the lower-dosage regimen, the overall safety was worse and so the upper-dosage regimen is not recommended.
The lower dosage regimen for everolimus is that recommended (see Section 4.2 Dose and Method of Administration).
The primary efficacy endpoint was a composite failure variable (biopsy-proven acute rejection, graft loss, death or loss to follow-up). The outcome is shown in Table 8.
Changes in renal function, as shown by calculated glomerular filtration rate (GFR) using the MDRD formula are shown in Table 9.
Proteinuria was assessed at scheduled visits by spot analysis of urinary protein/creatinine and categorized by levels of clinical relevance as represented in Table 10. Few patients in any of the treatment groups reached the nephrotic threshold but a greater proportion of everolimus patients were consistently in the sub-nephrotic category than was the case in the MPA group. A concentration effect was shown relating proteinuria levels to everolimus trough levels particularly at values of C above 8 nanogram/mL.
Adverse events reported more frequently in the recommended (lower-dosage) everolimus regimen than in the MPA control group have been included in Table 3. A lower frequency for viral infection was reported for everolimus-treated patients resulting principally from lower reporting rates for CMV infection (0.7% versus 5.95%) and BK virus infection (1.5% versus 4.8%).

Cardiac transplantation.

In the Phase III cardiac study (B253), both everolimus 1.5 mg/day and 3 mg/day in combination with standard doses of cyclosporin microemulsion and corticosteroids, were investigated vs. azathioprine (AZA), 1-3 mg/kg/d. The primary endpoint was a composite of incidence of acute rejection ≥ ISHLT grade 3A, acute rejection associated with haemodynamic compromise, graft loss, patient death or loss to follow-up at 6, 12 and 24 months. Both doses of everolimus were superior to AZA at 6, 12 and 24 months. The incidence of biopsy proven acute rejection ≥ ISHLT grade 3A at month 6 was 27.8% for the 1.5 mg/d group, 19% for the 3 mg/d group and 41.6% for the AZA group respectively (p = 0.003 for 1.5 mg vs control, < 0.001 for 3 mg vs control).
Based on coronary artery intravascular ultrasound data obtained from a subset of the study population, both everolimus doses were statistically significantly more effective than AZA in preventing allograft vasculopathy (defined as an increase in maximum intimal thickness from baseline ≥ 0.5 mm in at least one matched slice of an automated pullback sequence), an important risk factor for long term graft loss.
In study (B253), cyclosporin doses were based on target trough levels of: weeks 1-4: 250-400 nanogram/mL, months 1-6: 200-350 nanogram/mL, months 7-24: 100-300 nanogram/mL.
Elevated serum creatinine was observed more frequently among subjects using everolimus in combination with full dose cyclosporin microemulsion than in AZA patients. This effect suggests that everolimus increases the cyclosporin-induced nephrotoxicity. However, further analysis suggested that renal function could be improved with cyclosporin dose-reduction without loss of efficacy as long as everolimus blood values are maintained above a given threshold. Studies A2411 and A2310 have subsequently been carried out to investigate this.
Study A2411 was a randomised, 12 month, open-label study comparing everolimus in combination with reduced doses of cyclosporin microemulsion and corticosteroids to mycophenolic mofetil (MMF) and standard doses of cyclosporin microemulsion and corticosteroids in de-novo adult cardiac transplant patients. The study included a total of 174 patients. Everolimus (N=92) was initiated at 1.5 mg/day and the dose was adjusted to maintain target blood everolimus trough levels between 3-8 nanogram/mL. MMF (N=84) was initiated at a dosage of 1500 mg twice daily. Cyclosporin microemulsion doses were adjusted to target the trough levels (nanogram/mL) listed in Table 11.
Renal function in study A2411 did not meet the non-inferiority criteria (-6 mL/min) vs MMF. Mean creatinine clearance (Cockcroft-Gault formula) at 6 months: everolimus: 65.4 v. MMF: 72.2 mL/min (difference: -6.85 mL/min, 95% CI: -14.9, 1.2) and at 12 months: everolimus: 68.7 v. MMF: 71.8 mL/min (Difference: -3.10 mL/min 95% CI (-12.26, 6.06). The change from baseline was: everolimus: -6.0 mL/min v. MMF: -4.2 mL/min; p=0.697. Efficacy, expressed as the rate of biopsy-proven acute rejection episodes (ISHLT grade ≥ 3A), was maintained as comparable in the two groups at 12 months (everolimus: 22.8% v. MMF: 29.8%).
Study A2310 is a phase III, multicentre, randomised, open-label study comparing the efficacy and safety of two everolimus/reduced-dose cyclosporin regimens against a standard mycophenolate mofetil (MMF)/cyclosporin regimen over 24 months. The use of induction therapy was centre-specific, the options being no-induction or induction with either basiliximab or thymoglobulin. All patients received corticosteroids.
Starting doses in the two everolimus groups were 1.5 mg/day and 3 mg/day, subsequently modified from Day 4 onwards to maintain target blood trough everolimus levels of 3 to 8 nanogram/mL and 6 to 12 nanogram/mL respectively. The MMF dose was 3 g/day. Cyclosporin dosages were adapted to maintain the same target blood trough level windows as in study A2411. Blood concentrations of everolimus and cyclosporin are shown in Table 12.
Recruitment to the experimental, upper-dosage everolimus treatment arm was prematurely discontinued because of an increased rate of fatalities within this treatment group, due to infection and cardiovascular disorders, occurring within the first 90 days post-randomisation. The nature and pattern of the fatalities in this dosage arm did not suggest the difference to be linked to the presence or type of induction therapy.
Statistical comparisons are limited to comparisons between the completed treatment arms. The drug blood concentration levels actually achieved are described in Table 12.
The primary efficacy endpoint was a composite failure variable, implying occurrence of any of the following: Biopsy Proven Acute Rejection (BPAR) episode of ISHLT grade >= 3A, acute rejection (AR) episode associated with hemodynamic compromise (HDC), graft loss/re-transplant, death, or loss to follow-up. Efficacy outcome at 12 and 24 months is shown in Table 13.
The higher fatality rate in the everolimus arm relative to the MMF arm was mainly the result of an increased rate of fatalities from infection in the first three months among everolimus patients in the study sub-group of patients receiving thymoglobulin induction therapy. A notably higher 3-month incidence in severe infections in everolimus than MMF patients in the thymoglobulin subgroup appears to reflect greater immunosuppressive potency. The imbalance in fatalities within the thymoglobulin subgroup being particularly evident among patients hospitalised prior to transplantation and with L-ventricular assistance devices, suggests greater vulnerability in such patients to the consequences of infectious complications.
The imbalance in mortality observed during the first 12 months was no longer apparent by Month 24.
Intravascular ultrasound (IVUS) studies were performed on a subset of patients to investigate changes post-transplantation (Month 12 value relative to a baseline value effected during the first three months post-transplant) in intimal thickness within a segment of the left anterior descending (LAD) coronary artery. The results of the measured change in maximum intimal thickness along with frequency of patients with cardiac allograft vasculopathy (defined as an increase in the maximal intimal thickness of 0.5 mm or more) are described in Table 14.
The reduced increase in intimal coronary thickness in everolimus relative to MMF patients was apparent regardless of age, gender, presence or absence of diabetes and maximum level of serum cholesterol observed by Month 12.
Renal function over the course of study A2310, assessed by estimated glomerular filtration rate (eGFR) using the MDRD formula, indicates a statistically significant difference of 5.5 mL/min/1.73 m2 (97.5% CI -10.9, -0.2; p=0.019) lower for the everolimus 1.5 mg group at Month 12. The decrease in mean GFR from baseline to Month 12 was: everolimus -7.1 mL/min vs MMF -2.9 mL/min, p=0.211.
Post-hoc data analyses suggest that the difference observed was mainly associated with the exposure to cyclosporin. This difference was reduced to -3.6 mL/min/1.73 m2 and not statistically significant (97.5% CI -8.9, 1.8) in centres where the mean cyclosporin levels were lower in patients receiving everolimus than in patients randomised to the control arm, as recommended.
Additionally, the difference was mainly driven by a difference developed during the first month post-transplantation when patients are still in an unstable hemodynamic situation possibly confounding the analysis of renal function. Thereafter, the decrease in mean GFR from Month 1 to Month 12 was significantly smaller in the everolimus group than in the control group (-6.4 vs -13.7 mL/min, p=0.002).
At Month 24, the calculated GFR was significantly lower for the everolimus 1.5 mg group (58.8 mL/min/1.73 m2) than for the MMF arm (65.3 mL/min/1.73 m2). The difference in mean GFR (MDRD) at Month 24 between the everolimus 1.5 mg group and MMF group was -6.47 mL/min/1.73 m2 (97.5% CI: -11.9, -1.0; p=0.008).
Proteinuria, expressed as urinary protein: urinary creatinine levels measured in spot urine samples tended to be more elevated in the everolimus-treated patients. Sub-nephrotic values were observed in 22% of the patients receiving everolimus compared to MMF patients (8.6%). Nephrotic levels were also reported (0.8%), representing 2 patients in each treatment group.
However, proteinuria was rarely reported as an AE by Month 24 (9 patients [3.2%] in everolimus 1.5 mg group and 5 patients [1.9%] in the MMF group), with no cases of severe intensity. The majority of patients were in the mild proteinuria range and an overall improvement observed between baseline and Month 12 and 24 in all groups. A total of 3 and 2 patients had proteinuria values reaching the nephrotic range at Month 24 in the everolimus 1.5 mg and MMF groups, respectively.
The adverse reactions for everolimus 1.5 mg group in Study A2310 are consistent with adverse drug reactions presented in Table 3. A lower rate of viral infections was reported for everolimus-treated patients resulting principally from a lower reporting rate for CMV infection compared to MMF (7.2% vs 19.4%).

Hepatic transplantation.

In the phase III adult hepatic transplant study (H2304), reduced exposure tacrolimus and everolimus was administered to HCV+ and HCV- patients with the initial everolimus dose (1.0 mg/day) starting approximately 4 weeks after transplantation and was investigated vs. standard exposure tacrolimus up to 24 months (core study) and for an additional 12 month extension period up to 36 months post-transplant. Everolimus was dose adjusted to maintain target blood everolimus trough levels between 3-8 nanogram/mL for the everolimus + Reduced tacrolimus arm. Mean everolimus trough levels were within the target ranges at all time points ranging from 3.4 to 6.3 nanogram/mL in the everolimus + Reduced tacrolimus arm. Tacrolimus doses were subsequently adjusted to achieve target trough levels between 3-5 nanogram/mL through 12 months in the everolimus + Reduced tacrolimus arm. A third arm in study H2304 with complete withdrawal of tacrolimus at 4 months post-transplantation has been associated with an increased risk of acute rejections and was terminated early.
The primary endpoint of the study was to compare the efficacy failure rate, defined as the composite endpoint of treated biopsy proven acute rejection, graft loss or death with early tacrolimus minimisation, facilitated by introduction of everolimus starting approximately 4 weeks after liver transplantation, to standard exposure tacrolimus, at 12 months.
Overall, in the 12 month analysis, the incidence of the composite endpoint (tBPAR, graft loss or death) was lower in everolimus + Reduced tacrolimus arm (6.7%) compared to the tacrolimus control arm (9.7%) (Table 15). The difference in estimates between everolimus + Reduced tacrolimus and tacrolimus control was -3.0% with 97.5% CI: (-8.7% to 2.6%). Regarding the rates of graft loss and fatal cases the everolimus + reduced tacrolimus arm was non-inferior compare to the tacrolimus control arm indicating no increased mortality risk in this population. A statistically significantly lower rate of biopsy proven acute rejection was seen in the everolimus + Reduced tacrolimus arm (4.1%) compared to tacrolimus control arm (10.7%) (Table 16). Results are similar between HCV+ and HCV- patients.

Extension - primary efficacy results at 36 months.

Of the total 231 patients who entered the extension for everolimus + Reduced tacrolimus (n=106) and tacrolimus control (n=125), 84% and 86% of patients completed study medication, 91% and 94% of patients completed study phase with 16% and 14% of patients discontinuing study medication, respectively.
The incidence of patients with composite efficacy failure events (tBPAR, graft loss or death) at Month 36 since extension baseline (Month 24) was low and similar across the treatment arms at 1.9% (n=2), and 2.4% (n=3) in the everolimus + Reduced tacrolimus and tacrolimus control arms respectively.
For the ITT population (all patients randomized in the core study), the Kaplan-Meier estimates of the primary composite efficacy endpoint (tBPAR, graft loss or death) to 36 months was lower in the everolimus + Reduced tacrolimus arm (11.5%) than in the tacrolimus control arm (14.6%). The difference between everolimus + Reduced tacrolimus and tacrolimus control was -3.2% (97.5% CI: -10.5%, 4.2%; p-value 0.3337).

Renal function.

Comparison between treatment groups for change in eGFR (MDRD4) [mL/min/1.73 m2] from time of randomisation (day 30) to Month 12, 24 and 36 for the ITT population is presented in Table 17. The eGFR at 12 months was higher for everolimus + Reduced tacrolimus (80.6 mL/min/1.73 m2) in comparison to the tacrolimus control (70.3 mL/min/1.73 m2) and a higher eGFR was also observed throughout the entire study.
Statistically significant between-treatment group difference (everolimus + Reduced tacrolimus vs. tacrolimus control arm) was observed in favor of everolimus + Reduced tacrolimus arm for the mean eGFR from Week 6 up to Month 36 (including at study endpoint and treatment endpoint). At randomization, mean eGFR was 85.0 and 78.0 mL/min/1.73 m2 for the everolimus + Reduced tacrolimus and tacrolimus control arms respectively. At the Month 36 time point, the difference in mean eGFR between everolimus + Reduced tacrolimus and tacrolimus control was 15.2 mL/min/1.73 m2. The mean eGFR at Month 36 was 78.7 and 63.5 mL/min/1.73 m2 for the everolimus + Reduced tacrolimus and tacrolimus control arms respectively.

5.2 Pharmacokinetic Properties

Absorption.

After oral dosing, peak everolimus concentrations occur 1 to 2 h post dose. Everolimus blood concentrations are dose proportional over the dose range 0.25 to 15 mg in transplant patients.

Effects of food.

The Cmax and AUC of everolimus are reduced by 60% and 16% when the tablet formulation is given with a high fat meal. To minimise variability, everolimus should be taken consistently with or without food.

Distribution.

The blood-to-plasma ratio of everolimus is concentration-dependent ranging from 17% to 73% over the range of 5 to 5000 nanogram/mL. Plasma protein binding is approximately 74% in healthy subjects and patients with moderate hepatic impairment. The distribution volume associated with the terminal phase (Vz/F) in maintenance renal transplant patients is 342 ± 107 L.

Metabolism.

Everolimus is a substrate of CYP3A4 and P-glycoprotein. The main metabolic pathways identified in man were mono-hydroxylations and O-dealkylations. Two main metabolites were formed by hydrolysis of the cyclic lactone. Everolimus was the main circulating component in blood. None of the main metabolites are likely to contribute significantly to the immunosuppressive activity of everolimus.

Excretion.

After a single dose of radiolabeled everolimus to transplant patients receiving cyclosporin the majority (80%) of radioactivity was recovered from the faeces, and only a minor amount (5%) was excreted in urine. Parent drug was not detected in urine nor faeces.

Steady-state pharmacokinetics.

Pharmacokinetics were comparable for kidney and heart transplant patients receiving everolimus twice daily simultaneously with cyclosporin. Steady-state is reached by day 4 with an accumulation in blood levels of 2 to 3-fold compared with the exposure after the first dose. Tmax occurs at 1 to 2 h post dose. Cmax averages 11.1 ± 4.6 and 20.3 ± 8.0 nanogram/mL and AUC averages 75 ± 31 and 131 ± 59 nanogram.h/mL at 0.75 and 1.5 mg bid, respectively. Predose trough blood levels (Cmin) average 4.1 ± 2.1 and 7.1 ± 4.6 nanogram/mL at 0.75 and 1.5 mg bid, respectively. Everolimus exposure remains stable over time in the first post-transplant year. Cmin is significantly correlated with AUC yielding a correlation coefficient between 0.86 and 0.94. Based on a population pharmacokinetic analysis, oral clearance (CL/F) is 8.8 L/h (27% interpatient variation) and the central distribution volume (Vc/F) is 110 L (36% interpatient variation). Residual variability in blood concentrations is 31%. The elimination half-life is 28 ± 7 h.

Hepatic impairment.

Relative to the AUC of everolimus in subjects with normal hepatic function, the average AUC in 6 patients with mild hepatic impairment (Child-Pugh Class A) was 1.6-fold higher; in two independently studied groups of 8 and 9 patients with moderate hepatic impairment (Child-Pugh Class B) the average AUC was 2.1-fold and 3.3-fold higher respectively; and in 6 patients with severe hepatic impairment (Child-Pugh Class C) the average AUC was 3.6-fold higher. For patients with mild hepatic impairment (Child-Pugh Class A), the dose should be reduced to two-thirds of the normal dose. For patients with moderate hepatic impairment (Child-Pugh Class B), the dose should be reduced to one half of the normal dose. For patients with severe hepatic impairment (Child-Pugh Class C) the dose should be reduced by at least one half the normal dose with strict attention to therapeutic drug monitoring. Further dose titration should be based on close therapeutic drug monitoring (see Section 4.4 Special Warnings and Precautions for Use; Section 4.2 Dose and Method of Administration).

Renal impairment.

Post-transplant renal impairment (Clcrea range, 11-107 mL/min) did not affect the pharmacokinetics of everolimus.

Paediatrics.

Everolimus CL/F increased in a linear manner with patient age (1 to 16 years), body surface area (0.49-1.92 m2), and weight (11-77 kg). Steady-state CL/F was 10.2 ± 3.0 L/h/m2 and elimination half-life was 30 ± 11 h. Nineteen paediatric de novo renal transplant patients (1 to 16 years) received everolimus dispersible tablets (available in other brands) at a dose of 0.8 mg/m2 (maximum 1.5 mg) twice-daily with cyclosporin microemulsion. They achieved an everolimus AUC of 87 ± 27 nanogram.h/mL which is similar to adults receiving 0.75 mg twice daily. Steady-state trough levels were 4.4 ± 1.7 nanogram/mL.

Elderly.

A limited reduction in everolimus oral CL of 0.33% per year was estimated in adults (age range studied was 16-70 years). No dose adjustment is considered necessary.

Exposure-response relationships.

The average everolimus trough concentration over the first 6 months post-transplant was related to the incidence of biopsy-confirmed acute rejection and with thrombocytopenia in renal and cardiac transplant patients (see Table 18). In hepatic transplant patients the relationship of everolimus trough concentrations and clinical events is less well defined, however, higher exposures do not correlate with an increase in adverse effects.

5.3 Preclinical Safety Data

Genotoxicity.

Everolimus did not show genotoxicity in in vitro tests for gene mutation (bacteria and mammalian cells), and in an in vitro test and in vivo mouse micronucleus assay for clastogenic activity.

Carcinogenicity.

Long-term carcinogenicity studies have been carried out in mice and rats and no oncogenic responses were observed. Drug exposures (blood AUC) were up to 8-times the expected maximum human value in mice, but were less than the expected maximum human value in rats.

6 Pharmaceutical Particulars

6.1 List of Excipients

Each Everocan tablet contains: butylated hydroxytoluene, lactose monohydrate, hypromellose, lactose anhydrous, crospovidone, magnesium stearate.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C. Protect from moisture and light.

6.5 Nature and Contents of Container

0.25 mg, 0.5 mg and 0.75 mg.

Al/Al desiccant blister pack of 60's and 120's tablets.

1 mg.

Al/Al desiccant blister pack of 60's and 120's tablets.
Al/Al blister Pack of 60's and 120's tablets.
HDPE Bottle Pack of 60's tablets.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

The chemical name is 40-O-(2-hydroxyethyl)-rapamycin or 40-O-(2-hydroxyethyl) sirolimus. Its molecular formula is C53H83NO14 and its molecular weight is 958.2.

Chemical structure.


CAS number.

159351-69-6.

7 Medicine Schedule (Poisons Standard)

Prescription only medicine (S4).

Summary Table of Changes