Sofosbuvir
Medically reviewed on Sep 10, 2018
Pronunciation
See also: Mavyret
(soe FOS bue vir)
Index Terms
· Sovaldi
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Sovaldi: 400 mg
Brand Names: U.S.
· Sovaldi
Pharmacologic Category
· Antihepaciviral, Polymerase Inhibitor (Anti-HCV)
· NS5B RNA Polymerase Inhibitor
Pharmacology
Sofosbuvir, a direct-acting antiviral agent against the hepatitis C virus, is a prodrug converted to its pharmacologically active form (GS-461203) via intracellular metabolism. It inhibits HCV NS5B RNA-dependent RNA polymerase, essential for viral replication, and acts as a chain terminator.
Metabolism
Hepatic; forms pharmacologically active nucleoside (uridine) analog triphosphate GS-461203; dephosphorylation results in the formation of nucleoside inactive metabolite GS-331007
Excretion
Urine (80%; primarily as metabolite); feces (14%)
Time to Peak
~0.5 to 2 hours
Half-Life Elimination
0.4 hours
Protein Binding
~61% to 65%
Special Populations: Renal Function Impairment
AUC0-inf was higher in mild (eGFR ≥50 and <80 mL/minute/1.73 m2), moderate (eGFR ≥30 and <50 mL/minute/1.73 m2), and severe (eGFR <30 mL/minute/1.73 m2) renal impairment.
Special Populations: Hepatic Function Impairment
AUC0-24 was higher in moderate and severe hepatic impairment.
Use: Labeled Indications
Chronic hepatitis C: Treatment of genotype 1, 2, 3, or 4 chronic hepatitis C virus (HCV) infection in adults and genotype 2 or 3 chronic HCV infection in pediatric patients ≥12 years or weighing ≥35 kg, without cirrhosis or with compensated cirrhosis, as a component of a combination antiviral treatment regimen.
Off Label Uses
Chronic hepatitis C, genotype 1, 2, 3, or 4 (decompensated cirrhosis)
Based on the AASLD/IDSA Recommendations for Testing, Managing, and Treating Hepatitis C guidelines, sofosbuvir, in combination with daclatasvir with or without ribavirin, is effective and recommended for treatment of hepatitis C virus genotype 1, 2, 3, or 4 infection in patients with decompensated cirrhosis. Hepatitis C treatment guidelines are constantly changing with the advent of new treatment therapies and information; consult current clinical practice guidelines for the most recent treatment recommendations.
Chronic hepatitis C, genotype 1, 2, 3, 4, 5, or 6 (liver transplant recipients)
Based on the AASLD/IDSA Recommendations for Testing, Managing, and Treating Hepatitis C guidelines, sofosbuvir, in combination with daclatasvir and ribavirin, is an effective and recommended regimen for treatment of hepatitis C virus genotype 2, 3 infection in liver transplant recipients with or without cirrhosis (including decompensated cirrhosis) and recommended alternative regimen for treatment of genotype 5 or 6 in patients without cirrhosis or with compensated cirrhosis. Sofosbuvir, in combination with daclatasvir and ribavirin or simeprevir with or without ribavirin, is an effective and recommended alternative regimen for treatment of hepatitis C virus genotype 1 or 4 infection in liver transplant recipients without cirrhosis or with compensated cirrhosis. Hepatitis C treatment guidelines are constantly changing with the advent of new treatment therapies and information; consult current clinical practice guidelines for the most recent treatment recommendations.
Chronic hepatitis C, genotype 2, 3, 5, or 6 (renal transplant recipients)
Based on the AASLD/IDSA Recommendations for Testing, Managing, and Treating Hepatitis C guidelines, sofosbuvir, in combination with daclatasvir and ribavirin, is an effective and recommended alternative regimen for treatment of hepatitis C virus genotype 2, 3, 5, or 6 infection in renal transplant recipients without cirrhosis or with compensated cirrhosis. Hepatitis C treatment guidelines are constantly changing with the advent of new treatment therapies and information; consult current clinical practice guidelines for the most recent treatment recommendations.
Contraindications
There are no contraindications listed in the manufacturer's labeling. When administered with ribavirin and peginterferon alfa, the contraindications to ribavirin and peginterferon alfa also apply. See Ribavirin and Peginterferon Alfa monographs.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to sofosbuvir or any component of the formulation; males whose female partners may become pregnant
Dosing: Adult
Chronic hepatitis C (CHC) infection (monoinfection or coinfected with HIV-1): Oral: Note: Treatment-experienced refers to patients who have failed prior treatment with peginterferon and ribavirin. Combination therapy with ribavirin alone or ribavirin/peginterferon is not a recommended regimen in HCV treatment guidelines for patients with HCV (treatment-naive or treatment-experienced), regardless of genotype (AASLD/IDSA 2017).
Genotype 1:
Manufacturer’s labeling:
Treatment-naive patients without cirrhosis or with compensated cirrhosis (Child-Pugh class A): 400 mg once daily with concomitant peginterferon alfa and ribavirin for 12 weeks; for patients that cannot receive peginterferon alfa, administer with concomitant ribavirin for 24 weeks.
Alternate dosing (AASLD/IDSA 2017):
Treatment-naive or peginterferon + ribavirin treatment-experienced patients without cirrhosis (alternative regimen): 400 mg once daily in combination with simeprevir or daclatasvir for 12 weeks
Patients with decompensated cirrhosis (Child-Pugh class B or C) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks (if ribavirin-ineligible give in combination with daclatasvir only for 24 weeks)
Liver transplant recipients without cirrhosis or with compensated cirrhosis (Child-Pugh class A) (alternative regimen) (off-label use): 400 mg once daily, in combination with daclatasvir and ribavirin or simeprevir with or without ribavirin, for 12 weeks
Genotype 2:
Manufacturer’s labeling:
Treatment-naive and treatment-experienced patients without cirrhosis or with compensated cirrhosis (Child-Pugh class A): 400 mg once daily with concomitant ribavirin for 12 weeks.
Alternate dosing (AASLD/IDSA 2017):
Treatment-naive or peginterferon + ribavirin treatment-experienced patients (alternative regimen): 400 mg once daily in combination with daclatasvir for 12 weeks (without cirrhosis) or 16 to 24 weeks (with compensated cirrhosis [Child-Pugh class A]).
Patients with decompensated cirrhosis (Child-Pugh class B or C) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks (if ribavirin-ineligible give in combination with daclatasvir only for 24 weeks)
Liver transplant recipients with or without cirrhosis, including decompensated cirrhosis (Child-Pugh class B or C) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks
Renal transplant recipients without cirrhosis or with compensated cirrhosis (Child-Pugh class A) (alternative regimen) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks
Genotype 3:
Manufacturer’s labeling:
Treatment-naive or treatment-experienced patients without cirrhosis or with compensated cirrhosis (Child-Pugh class A): 400 mg once daily with concomitant ribavirin for 24 weeks.
Alternate dosing (AASLD/IDSA 2017):
Treatment-naive or peginterferon + ribavirin treatment-experienced patients without cirrhosis (alternative regimen): 400 mg once daily in combination with daclatasvir for 12 weeks
Treatment-naive patients with compensated cirrhosis (Child-Pugh class A) (alternative regimen): 400 mg once daily in combination with daclatasvir with or without ribavirin for 24 weeks
Patients with decompensated cirrhosis (Child-Pugh class B or C) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks (if ribavirin-ineligible give in combination with daclatasvir only for 24 weeks)
Liver transplant recipients with or without cirrhosis, including decompensated cirrhosis (Child-Pugh class B or C) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks
Renal transplant recipients without cirrhosis or with compensated cirrhosis (Child-Pugh class A) (alternative regimen) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks
Genotype 4:
Manufacturer’s labeling:
Treatment-naive patients without cirrhosis or with compensated cirrhosis (Child-Pugh class A): 400 mg once daily with concomitant peginterferon alfa and ribavirin for 12 weeks
Alternate dosing (AASLD/IDSA 2017):
Patients with decompensated cirrhosis (Child-Pugh class B or C) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks (if ribavirin-ineligible give in combination with daclatasvir only for 24 weeks)
Liver transplant recipients without cirrhosis or with compensated cirrhosis (Child-Pugh class A) (alternative regimen) (off-label use): 400 mg once daily, in combination with daclatasvir and ribavirin or simeprevir with or without ribavirin, for 12 weeks
Genotypes 5 and 6 (AASLD/IDSA 2017):
Liver transplant recipients without cirrhosis or with compensated cirrhosis (Child-Pugh class A) (alternative regimen) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks
Renal transplant recipients without cirrhosis or with compensated cirrhosis (Child-Pugh class A) (alternative regimen) (off-label use): 400 mg once daily in combination with daclatasvir and ribavirin for 12 weeks
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Chronic hepatitis C (CHC) infection (monoinfection or coinfected with HIV-1): Treatment-naïve or treatment-experienced patients without cirrhosis or with compensated cirrhosis (Child-Pugh class A):Children and Adolescents ≥12 years or ≥35 kg: Oral: Note: Treatment-experienced refers to patients who have failed prior treatment with interferon based regimen with or without ribavirin
Genotype 2: 400 mg once daily with concomitant ribavirin for 12 weeks
Genotype 3: 400 mg once daily with concomitant ribavirin for 24 weeks
Dosing: Renal Impairment
Estimated glomerular filtration rate (eGFR) ≥30 mL/minute: No dosage adjustment necessary.
eGFR <30 mL/minute: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied). Predominant metabolite accumulates in impaired renal function.
End stage renal disease (ESRD), including hemodialysis patients: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied). Predominant metabolite accumulates in impaired renal function.
Dosing: Hepatic Impairment
Mild, moderate, or severe impairment (Child-Pugh class A, B, or C): No dosage adjustment necessary.
Administration
Administer with or without food.
Storage
Store below 30°C (86°F). Dispense only in original container.
Drug Interactions
Amiodarone: Sofosbuvir may enhance the bradycardic effect of Amiodarone. Avoid combination
CarBAMazepine: May decrease the serum concentration of Sofosbuvir. Avoid combination
Lumacaftor: May decrease the serum concentration of P-glycoprotein/ABCB1 Substrates. Lumacaftor may increase the serum concentration of P-glycoprotein/ABCB1 Substrates. Monitor therapy
Modafinil: May decrease the serum concentration of Sofosbuvir. Avoid combination
OXcarbazepine: May decrease the serum concentration of Sofosbuvir. Avoid combination
P-glycoprotein/ABCB1 Inducers: May decrease the serum concentration of Sofosbuvir. Avoid combination
P-glycoprotein/ABCB1 Inhibitors: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Monitor therapy
PHENobarbital: May decrease the serum concentration of Sofosbuvir. Avoid combination
Primidone: May decrease the serum concentration of Sofosbuvir. Avoid combination
Ranolazine: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates. Monitor therapy
Rifabutin: May decrease the serum concentration of Sofosbuvir. Avoid combination
Rifapentine: May decrease the serum concentration of Sofosbuvir. Avoid combination
Tenofovir Alafenamide: Sofosbuvir may increase the serum concentration of Tenofovir Alafenamide.Monitor therapy
Tipranavir: May decrease the serum concentration of Sofosbuvir. Avoid combination
Vitamin K Antagonists (eg, warfarin): Antihepaciviral NS5B RNA Polymerase Inhibitors may diminish the anticoagulant effect of Vitamin K Antagonists. Monitor therapy
Adverse Reactions
Adverse reactions reported with combination therapy.
>10%:
Central nervous system: Fatigue (30% to 59%), headache (24% to 36%), insomnia (15% to 25%), chills (2% to 17%), irritability (10% to 13%)
Dermatologic: Pruritus (11% to 27%), skin rash (8% to 18%)
Gastrointestinal: Nausea (22% to 34%), decreased appetite (18%), diarrhea (9% to 12%)
Hematologic & oncologic: Decreased hemoglobin (<10 g/dL: 6% to 23%; <8.5 g/dL: ≤2%), anemia (6% to 21%), neutropenia (<1% [interferon-free regimen] to 17% [interferon-containing regimen]), decreased neutrophils (≥0.5 to <0.75 times 109/L: <1% [interferon-free regimen] to 15%; <0.5 times 109/L: ≤5%)
Neuromuscular & skeletal: Weakness (5% to 21%), myalgia (6% to 14%)
Respiratory: Flu-like symptoms (6% to 16%)
Miscellaneous: Fever (4% to 18%)
1% to 10%:
Gastrointestinal: Increased serum lipase (>3 times ULN: ≤2%)
Hematologic & oncologic: Thrombocytopenia (≤1%)
Hepatic: Increased serum bilirubin (>2.5 times ULN: 3%)
Renal: Increased creatine kinase (≥10 times ULN: 1% to 2%)
<1%, postmarketing, and/or case reports: Bradycardia, pancytopenia, reactivation of HBV, severe depression, suicidal ideation
ALERT: U.S. Boxed Warning
Hepatitis B virus reactivation:
Test all patients for evidence of current or prior hepatitis B virus (HBV) infection before initiating treatment with sofosbuvir. HBV reactivation has been reported in hepatitis C virus (HCV)/HBV co-infected patients who were undergoing or had completed treatment with HCV direct acting antivirals and were not receiving HBV antiviral therapy. Some cases have resulted in fulminant hepatitis, hepatic failure, and death. Monitor HCV/HBV co-infected patients for hepatitis flare or HBV reactivation during HCV treatment and post-treatment follow-up. Initiate appropriate patient management for HBV infection as clinically indicated.
Warnings/Precautions
Disease-related concerns:
• Hepatitis B virus reactivation: [US Boxed Warning]: Hepatitis B virus (HBV) reactivation has been reported in hepatitis C virus (HCV)/HBV co-infected patients who were receiving or had completed treatment with HCV direct-acting antivirals and were not receiving HBV antiviral therapy; some cases have resulted in fulminant hepatitis, hepatic failure, and death. Test all patients for evidence of current or prior HBV infection prior to initiation of sofosbuvir; monitor HCV/HBV co-infected patients for hepatitis flare or HBV reactivation during treatment and post-treatment follow-up. Initiate treatment for HBV infection as clinically indicated. HBV reactivation has been reported in HBsAg positive patients and in patients with serologic evidence of resolved HBV infection (ie, HBsAg negative and anti-HBc positive) and is characterized by an abrupt increase in HBV replication manifested as a rapid increase in serum HBV DNA level; reappearance of HBsAg may occur in patients with resolved HBV infection. Risk of HBV reactivation may be increased in patients receiving certain immunosuppressants or chemotherapeutic agents.
Concurrent drug therapy issues:
• Amiodarone: Symptomatic bradycardia (some requiring pacemaker intervention) has occurred in patients receiving amiodarone and a sofosbuvir-containing regimen. Fatal cardiac arrest occurred in a patient taking amiodarone and the ledipasvir/sofosbuvir combination product. Bradycardia generally occurred within hours to days following coadministration, however some cases have occurred 2 weeks following the initiation of sofosbuvir. The risk of bradycardia may be increased in patients taking beta blockers or patients with underlying cardiac comorbidities and/or advanced liver disease. Bradycardia generally resolves following discontinuation of HCV treatment. Coadministration of amiodarone and sofosbuvir in combination with another direct acting antiviral (DAA) is not recommended. However, if patients have no treatment alternatives, patients should have inpatient cardiac monitoring for the first 48 hours, followed by daily outpatient or self-monitoring of heart rate for at least the first 2 weeks of treatment. Due to the long half-life of amiodarone, cardiac monitoring (as described) is also recommended if amiodarone was discontinued just prior to beginning treatment with sofosbuvir. Patients should seek medical attention immediately if they experience fainting or near-fainting, dizziness, lightheadedness, malaise, weakness, excessive tiredness, shortness of breath, chest pains, confusion or memory problems.
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Special populations:
• Hepatic impairment: Safety and efficacy have not been established in patients with decompensated cirrhosis.
Other warnings/precautions:
• Appropriate use: Do not use as monotherapy; use only as part of a multiple drug regimen for treatment of HCV; consult current HCV treatment guidelines for guidance (AASLD/IDSA 2017).
Monitoring Parameters
Manufacturer’s labeling:
Bilirubin, liver enzymes, and serum creatinine at baseline and periodically when clinically indicated. If used in combination with amiodarone and another direct acting antiviral (DAA) (or in patients who discontinued amiodarone just prior to initiating sofosbuvir in combination with a DAA), inpatient cardiac monitoring for the first 48 hours of coadministration, then daily outpatient or self monitoring of heart rate through at least the first 2 weeks of treatment.
Serum HCV-RNA at baseline, during treatment, at the end of treatment, during treatment follow-up, and when clinically indicated.
Hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) prior to initiation; in patients with serologic evidence of hepatitis B virus (HBV) infection, monitor for clinical and laboratory signs of hepatitis flare or HBV reactivation during treatment and during post-treatment follow-up.
Alternate recommendations (AASLD/IDSA 2017):
Baseline (within 12 weeks prior to starting antiviral therapy): CBC, INR, hepatic function panel (albumin, total and direct bilirubin, ALT, AST, and alkaline phosphatase), calculated GFR
Baseline (at any time prior to starting antiviral therapy): HCV genotype and subtype, quantitative HCV viral load
During therapy: CBC, serum creatinine, calculated GFR, hepatic function panel (after 4 weeks of therapy and as clinically indicated); quantitative HCV viral load testing (after 4 weeks of therapy and at 12 weeks after completion of therapy). If quantitative HCV viral load is detectable at treatment week 4, repeat testing is recommended after 2 additional weeks of treatment (treatment week 6).
Pregnancy Considerations
Sofosbuvir is not used as monotherapy; combination therapy with ribavirin is contraindicated in pregnant females and males whose female partners are pregnant. If used in combination with ribavirin, all warnings related to the use of ribavirin and pregnancy and/or contraception should be followed. Refer to the ribavirin monograph for additional information.
Treatment of hepatitis C is not currently recommended to treat maternal infection or to decrease the risk of mother-to-child transmission during pregnancy (Tran 2016). HCV-infected females of childbearing potential should consider postponing pregnancy until therapy is complete to reduce the risk of HCV transmission (AASLD/IDSA 2017). When HCV infection is detected during pregnancy, treatment should be deferred until after delivery. Direct-acting antiviral medications should not be used in pregnant females outside of clinical trials until safety and efficacy information is available (SMFM [Hughes 2017]).
Patient Education
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience headache, nausea, or insomnia. Have patient report immediately to prescriber signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice) and severe loss of strength and energy (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
