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尼替西农胶囊说明书

 

ORFADIN Capsules(nitisinone)尼替西农胶囊

 

简介： 英文药名：Orfadin（Nitisinone） 中文药名：尼替西农胶囊（别名：欧佛定） 给药说明研发与上市厂商：瑞典Swedish Orphan公司研制开发，2002年4月首次在美国上市。尼替西农胶囊又称Orfadin，

 

 

 

 

英文药名：ORFADIN Capsules(nitisinone)

中文药名：尼替西农胶囊（别名：欧佛定）

生产厂家：Swedish Orphan

药品介绍
美国食品及药品管理局(Food and Drug Administration)批准了一种称为“nitisinone胶囊”的新的药物。它能够治疗一种罕见的、可引起进展性肝衰和肝癌的儿科疾病——I型遗传性酪氨酸血症(HT-1)。

美国的I型遗传性酪氨酸血症(HT-1)患儿少于100例。如果不进行肝移植的话,HT-1患儿将因肝衰和肝癌在20岁前死亡。但是,如果患儿早期足量服用nitisinone,肝衰和肝癌的发病率明显降低。超过180例患儿参与研究,开始治疗的平均年龄为9个月。同时采用药物与限制饮食时,出生后2个月内确诊的患儿的4年存活率为88%。文献表明,仅采用限制饮食进行治疗的同期存活率为29%。应用nitisinone时,饮食必须限制酪氨酸和苯丙氨酸。高酪氨酸水平对眼、皮肤和神经系统具有毒性作用。该药的最常见副作用与患儿进食不当引起的酪氨酸水平升高有关。除此之外,还有少量病例出现血小板和白细胞计数的轻度降低。
FDA指出,nitisinone应由具有治疗I型遗传性酪氨酸血症经验的医师开具处方,每例患儿都应按照特异性生化检验调整到合适的剂量。他们补充说,治疗中非常重要的一部分就是,应由营养学医师为具有先天性代谢缺陷的患儿制订合适的低蛋白食物。

研发与上市厂商
瑞典Swedish Orphan公司研制开发，2002年4月首次在美国上市。

商品名 
Orfadin

适应证
本品适用于罕见儿科1型遗传性酪氨酸血症 (HT-1) 的治疗。作为酪氨酸和苯丙氨酸饮食限制的辅助用药。

药理
本品是羟苯丙酮酸二氧酶的竞争性抑制剂，该酶在酪氨酸分解代谢途径中可上调延胡索酰乙酰乙酸酶(FAH)。通过抑制HT-1患者酪氨酸的正常代谢，本品可预防代谢中间体马来酰乙酰乙酸盐和延胡索酰乙酰乙酸盐的累积。在HT-1患者中，这些代谢中间体被转换成毒性代谢物琥珀酰丙酮和琥珀酰乙酰乙酸盐，造成肝、肾毒性。琥珀酰丙酮还可抑制卟啉合成途径，导致5-氨基酮戊酸盐积累。作为羟苯丙酮酸二氧酶抑制剂，推测受本品影响的生化学参数包括尿琥珀酰丙酮、血浆琥珀酰丙酮和胆色素原 (PBG) 合酶的活性。

大鼠口服本品生物利用度在90%以上，且分布于各器官中，特别是在肝脏和肾脏，在这2个脏器中放射活性保持至给药后7天。在大鼠体内，本品经生物转换后经尿液排泄。
在19～39岁 (中位数32岁) 的健康男性志愿者中进行了本品单一剂量的药动学研究。以胶囊或液体制剂形式给予本品1mg/kg，血药浓度达峰时间分别为：胶囊制剂3小时，液体制剂15分钟。以药时曲线下面积和最大血药浓度分析，胶囊和液体制剂是生物等效的。平均终末半衰期为54小时。

临床评价
生化学作用
在25个国家的87家医院进行了一项开放性研究，为期6年以上，有207例HT-1患者参与，患者年龄中位数为9个月 (刚出生至21.7岁)。大多数患者 (87%) 的血浆琥珀酰丙酮水平减低到参照水平 (可检测水平) 以下，正常化时间的中位数为3.9个月；180例患者的PBG合酶活性增加到参照水平 (可检测水平) 内，正常化时间的中位数为0.3个月，这些参数的变化与治疗前相比具统计学意义 (P<0.001)。

对总体存活率的影响
数据显示，2个月以下单用饮食限制方法治疗的HT-1患者，2和4年的存活率均为29%。而本研究中，2个月以下接受饮食限制和本品治疗的患者，2和4年的存活率均为88%；6个月以下单用饮食限制方法治疗的HT-1患者，2和4年存活率分别为74%和60%，而本研究中，6个月以下接受饮食限制和本品治疗的HT-1患者的相应存活率均为94%。

不良反应
在用本品治疗的207例HT-1患者中，最常见的不良反应涉及肝胆系统 (肝肿瘤8%，肝功能衰竭7%)、视觉系统 (结膜炎2%，角膜混浊2%，畏光2%，眼睑炎1%，眼痛1%，白内障1%)、血液和淋巴系统(血小板减少3%，粒细胞减少3%，鼻衄1%)、皮肤系统(瘙痒1%，剥落性皮炎1%，斑丘疹1%，脱发1%)。

其他低于1%的不良反应包括死亡、癫痫、脑肿瘤、头痛、运动过度、紫绀、腹痛、腹泻、胃肠炎、消化道出血、牙齿变色、肝酶水平升高、肝功能障碍、肝肿大、脱水、低血糖、口渴、感染、败血症、支气管炎、呼吸衰竭、病理性骨折、停经、神经质和嗜睡。

注意事项
未适当限制酪氨酸和苯丙氨酸的摄入可导致血浆酪氨酸水平升高。血浆酪氨酸水平必须保持低于500mmol/L，以避免对眼 (角膜溃疡、角膜混浊、角膜炎、结膜炎、眼痛和畏光)、皮肤 (足底和手掌痛性过度角化) 和神经系统 (不同程度的智力低下和发育迟缓)的毒性作用。对于大多数患者，眼部症状是暂时的，持续不超过1周。有6例患者发病延续16～672天。本品治疗期间需进行眼科检查，如有不良反应症状出现，需立即检查血浆酪氨酸浓度。如果血浆酪氨酸水平超过500mmol/L，须采取更为严格的饮食限制。本品的剂量需进行调整以降低血浆酪氨酸浓度。

在用本品和饮食限制治疗的患者中观察到发生一过性血小板减少(3%)、粒细胞减少 (3%) 或两者同时发生 (1.5%)，其中1例发生这2种不良反应的患者在本品剂量从2mg/kg减少至1mg/kg后症状改善，另1例血小板减少的患者停药2周，血小板计数在其后的3个月里继续下降，5个月后逐渐恢复正常，其余患者的血小板和粒细胞计数在未改变本品剂量的情况下均逐渐正常化。此外，未见因这2种不良反应而发生感染或出血。本品治疗期间建议常规监测血小板和粒细胞计数。另外，还应常规监测肝功能。

用量与用法
本品的用量需个体化。推荐的起始剂量为一日1mg/kg，分早、晚2次在就餐前至少1小时给药。

先天性代谢缺陷儿童需由专业营养师设计低蛋白饮食。对于幼童，可在服药前将胶囊打开，将内含物混合于少量水、配方饮料或苹果酱中。
本品治疗必须使卟啉代谢正常化。如果治疗1个月内生化参数 (尿琥珀酰丙酮) 未正常化，剂量可增加至一日1.5mg/kg。而血浆琥珀酰丙酮要在治疗后3个月才会恢复正常。在治疗开始时和急性发作时，必须更为密切地监测各生化参数。特别是对于婴儿，一旦肝功能改善，剂量可增大至一日2mg/kg，这一剂量被认为是所有患者的最大剂量。

制剂
白色不透明的硬胶囊口服制剂，有2、5和10mg三种规格.. 

 

Nitisinone

Medically reviewed on Sep 10, 2018

 

 

Pronunciation

(ni TIS i known)

Index Terms

· NTBC

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral:

Orfadin: 2 mg, 5 mg, 10 mg, 20 mg

Suspension, Oral:

Orfadin: 4 mg/mL (90 mL) [contains polysorbate 80, sodium benzoate]

Tablet, Oral:

Nityr: 2 mg, 5 mg, 10 mg

Brand Names: U.S.

· Nityr

· Orfadin

Pharmacologic Category

· 4-Hydroxyphenylpyruvate Dioxygenase Inhibitor

 

 

 

 

Pharmacology

In patients with HT-1, tyrosine metabolism is interrupted due to a lack of the enzyme (fumarylacetoacetate hydrolase) needed in the last step of tyrosine degradation. Toxic metabolites of tyrosine accumulate and cause liver and kidney toxicity. Nitisinone competitively inhibits 4-hydroxyphenyl-pyruvate dioxygenase, an enzyme present early in the tyrosine degradation pathway, thereby preventing the build-up of the toxic metabolites.

Distribution

Vd: Healthy volunteers: 8.2 L

Metabolism

Minor metabolism possibly via CYP3A4

Excretion

Healthy volunteers: Urine (Hall 2001)

Time to Peak

Healthy volunteers: Capsule: 3.5 hours (range: 0.8 to 8 hours); Suspension: 0.4 hours (range: 0.2 to 4 hours); Tablet: 3.5 hours (range: 1 to 4 hours)

Half-Life Elimination

Healthy volunteers: Terminal half-life: Capsule, suspension: 54 hours; Tablet: 59.3 hours

Protein Binding

>95%

Use: Labeled Indications

Hereditary tyrosinemia type 1: Treatment of hereditary tyrosinemia type 1 (HT-1) as an adjunct to dietary restriction of tyrosine and phenylalanine in adult and pediatric patients.

Contraindications

There are no contraindications listed in the manufacturer's labeling.

Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to nitisinone or any component of the formulation; breastfeeding

Dosing: Adult

Note: Must be used in conjunction with a diet restricted in tyrosine and phenylalanine. Titrate dose as needed based on biochemical and/or clinical response. If the biochemical response is satisfactory, the dosage should be adjusted only according to body weight gain. Do not adjust dose according to plasma tyrosine concentration.

Hereditary tyrosinemia type 1 (HT-1): Oral: Initial: 0.5 mg/kg twice daily. Increase to 0.75 mg/kg twice daily if succinylacetone is detectable 4 weeks after initiation. Further increase may be needed based on the evaluation of all biochemical parameters (maximum dose: 2 mg/kg/day); dose may be administered once daily (eg, 1 to 2 mg/kg once daily) if serum and urine succinylacetone is undetectable after ≥4 weeks of therapy.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: Must be used in conjunction with a diet restricted in tyrosine and phenylalanine. Titrate dose as needed based on biochemical and/or clinical response. If the biochemical response is satisfactory, the dosage should be adjusted only according to body weight gain. Do not adjust dose according to plasma tyrosine concentration.

Hereditary tyrosinemia type 1 (HT-1): Oral:

Infants and Children <5 years: Initial: 0.5 mg/kg twice daily. Increase to 0.75 mg/kg twice daily if succinylacetone is detectable 4 weeks after initiation. Further increase may be needed based on the evaluation of all biochemical parameters (maximum dose: 1 mg/kg twice daily).

Children ≥5 years and Adolescents: Refer to adult dosing.

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer's labeling.

Reconstitution

Suspension: Refer to manufacturer's product labeling for preparation instructions. Allow suspension to warm to room temperature (30 to 60 minutes). Shake vigorously for 5 seconds (bottles with adapter inserted) or 20 seconds (bottles without the adapter inserted); foam will form.

Administration

Capsules: Administer at least 1 hour prior to, or 2 hours after a meal. Capsules may be opened and contents suspended in a small quantity of water, formula, or apple sauce; administer immediately.

Suspension: Administer without regards to meals. Allow suspension to warm to room temperature (30 to 60 minutes) prior to preparation.

Tablets: Administer without regards to meals. Tablets may be disintegrated in water and administered using an oral syringe or crushed and mixed with applesauce (administration with other liquids or foods is not recommended [has not been studied]). Refer to manufacturer's labeling for detailed instructions.

Dietary Considerations

Nitisinone capsules should be taken at least 1 hour prior to, or 2 hours after a meal. Dietary restriction of tyrosine and phenylalanine is required.

Storage

Capsules: Store refrigerated at 2°C to 8°C (36°F to 46°F).

Suspension: Store refrigerated at 2°C to 8°C (36°F to 46°F) prior to first use. After opening, store at room temperature (up to 25°C [77°F]) for up to 60 days. Do not freeze.

Tablets: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C and 30°C (59°F and 86°F).

Drug Interactions

There are no known significant interactions.

Adverse Reactions

>10%:

Endocrine & metabolic: Increased plasma tyrosine

1% to 10%:

Dermatologic: Alopecia (1%), exfoliative dermatitis (1%), maculopapular rash (1%), pruritus (1%), xeroderma (1%)

Endocrine & metabolic: Porphyria (1%)

Hematologic & oncologic: Leukopenia (3%), thrombocytopenia (3%), granulocytopenia (1%)

Hepatic: Hepatic failure (7%), hepatic neoplasm (malignant: 5%; benign: 3%)

Ophthalmic: Conjunctivitis (2%), corneal opacity (2%), keratitis (2%), photophobia (2%), blepharitis (1%), cataract (1%), eye pain (1%)

Respiratory: Epistaxis (1%)

<1%, postmarketing, and/or case reports: Abdominal pain, brain disease, brain neoplasm, bronchitis, corneal ulcer, cyanosis, diarrhea, enanthema, gastric distress, gastrointestinal hemorrhage, headache, hepatomegaly, hyperkinesia, hypoglycemia, increased liver enzymes, melena, seizure, septicemia

Warnings/Precautions

Concerns related to adverse effects:

• Dermatologic effects: Failure to adequately restrict dietary tyrosine and phenylalanine may lead to hyperkeratotic plaques on the soles and palms.

• Hematologic effects: Leukopenia and/or thrombocytopenia have been reported; may improve with dose reduction. May be due to underlying liver disease rather than drug-related (McKiernan 2006). Monitor platelets and WBC regularly during therapy.

• Neurological effects: Failure to adequately restrict dietary tyrosine and phenylalanine may lead to variable degrees of intellectual disability and developmental delay; clinical laboratory assessment including tyrosine levels is recommended for any patient exhibiting abrupt changes in neurological status while on therapy.

• Ocular effects: Failure to adequately restrict dietary tyrosine and phenylalanine may lead to ocular toxicities (eg, conjunctivitis, corneal ulcers, corneal opacities, eye pain, keratitis, photophobia). Slit-lamp examination of the eyes is recommended prior to initiation of therapy and in patients who develop photophobia, eye pain, or signs of inflammation (eg, redness, swelling, burning of the eyes). Immediate measurement of plasma tyrosine concentration is also recommended in patients who develop ocular symptoms.

Dosage form specific issues:

• Glycerol: Oral suspension contains 500 mg/mL of glycerol; oral doses of glycerol ≥10 g may cause headache, upset stomach, and diarrhea. Patients receiving single doses >20 mL are at increased risk for these adverse reactions; consider switching patients unable to tolerate the oral suspension to nitisinone capsules.

Other warnings/precautions:

• Dietary restrictions: Must be used with dietary restriction of tyrosine and phenylalanine; inadequate restriction can result in toxic effects to the eyes, skin, and nervous system. Evaluate plasma tyrosine concentrations in patients who develop signs and symptoms of toxicity. Nutritional consultation is recommended.

Monitoring Parameters

Dietary tyrosine and phenylalanine (assess dietary intake with tyrosine concentrations >500 micromole/L); urine and/or plasma succinylacetone, liver function parameters, and alpha-fetoprotein levels (in addition, at initiation or if there is a deterioration of the patient's clinical condition, may also monitor urine 5-aminolevulinate and erythrocyte porphobilinogen-synthase activity); body weight; slit-lamp examination (prior to initiation of therapy and in patients who develop symptoms of ocular toxicity); plasma tyrosine (as clinically indicated with side effects; concentrations should be kept <500 micromole/L to avoid toxicity); platelet and white blood cell counts (regularly during therapy).

Note: Plasma succinylacetone may take up to 3 months to normalize after start of therapy.

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies.

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?)

• Have patient report immediately to prescriber signs of liver problems (dark urine, feeling tired, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin or eyes), skin changes on extremities, vision changes, eye pain, severe eye irritation, confusion, chills, pharyngitis, bleeding, or bruising (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 healthcare 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.