Adempas (riociguat) | Managing Adempas

PHARMACODYNAMIC INTERACTIONS¹

NITRATES

Co-administration of Adempas with nitrates or nitric oxide donors
(such as amyl nitrite) in any form is contraindicated because of hypotension.

PDE INHIBITORS

Co-administration of Adempas with specific PDE-5 inhibitors (such as sildenafil, tadalafil, or vardenafil) and nonspecific PDE inhibitors (such as dipyridamole or theophylline) is contraindicated because of hypotension. Clinical experience with co-administration of Adempas and other phosphodiesterase inhibitors (such as milrinone, cilostazole, roflumilast) is limited.

To transition patients to and from a PDE-5 inhibitor to Adempas,
follow the timing information in the Dosing and Administration Guide.

PDE-5=phosphodiesterase type 5

Pharmacokinetic interactions considerations¹

If your patient is a smoker

Plasma concentrations in smokers are reduced by 50% to 60% compared to nonsmokers
Doses higher than 2.5 mg 3x a day may be considered to match exposure seen in nonsmoking patients
A dose reduction should be considered in patients who stop smoking

IF YOUR PATIENT TAKES STRONG CYP AND P-gp/BCRP INHIBITORS

Concomitant use of riociguat with strong cytochrome CYP inhibitors and P-gp/BCRP inhibitors such as azole antimycotics (for example, ketoconazole, itraconazole) or HIV protease inhibitors (such as ritonavir) increase riociguat exposure and may result in hypotension.

Consider a starting dose of 0.5 mg 3x a day when initiating Adempas in patients
Monitor for signs and symptoms of hypotension on initiation and on treatment with strong CYP and P-gp/BCRP inhibitors
A dose reduction should be considered in patients who may not tolerate the hypotensive effect of riociguat

CYP=cytochrome P450; P-gp/BCRP=P-glycoprotein/breast cancer resistance protein

IF YOUR PATIENT TAKES STRONG CYP3A INDUCERS

Strong inducers of CYP3A (such as rifampin, phenytoin, carbamazepine, phenobarbital, or St. John's Wort) may significantly reduce riociguat exposure. Data are not available to guide dosing of riociguat when strong CYP3A inducers are co-administered.

CYP3A=cytochrome P450, family 3, subfamily A

IF YOUR PATIENTS TAKE ANTACIDS

Antacids such as aluminum hydroxide/magnesium hydroxide decrease riociguat absorption and should not be taken within 1 hour of taking Adempas.

PHARMACODYNAMIC INTERACTIONS¹

NITRATES

Co-administration of Adempas with nitrates or nitric oxide donors
(such as amyl nitrite) in any form is contraindicated because of hypotension.

PDE INHIBITORS

To transition patients to and from a PDE-5 inhibitor to Adempas,
follow the timing information in the Dosing and Administration Guide.

PDE-5=phosphodiesterase type 5

Pharmacokinetic interactions considerations¹

If your patient is a smoker

Plasma concentrations in smokers are reduced by 50% to 60% compared to nonsmokers
Doses higher than 2.5 mg 3x a day may be considered to match exposure seen in nonsmoking patients
A dose reduction should be considered in patients who stop smoking

IF YOUR PATIENT TAKES STRONG CYP AND P-gp/BCRP INHIBITORS

Consider a starting dose of 0.5 mg 3x a day when initiating Adempas in patients
Monitor for signs and symptoms of hypotension on initiation and on treatment with strong CYP and P-gp/BCRP inhibitors
A dose reduction should be considered in patients who may not tolerate the hypotensive effect of riociguat

CYP=cytochrome P450; P-gp/BCRP=P-glycoprotein/breast cancer resistance protein

IF YOUR PATIENT TAKES STRONG CYP3A INDUCERS

CYP3A=cytochrome P450, family 3, subfamily A

IF YOUR PATIENTS TAKE ANTACIDS

Antacids such as aluminum hydroxide/magnesium hydroxide decrease riociguat absorption and should not be taken within 1 hour of taking Adempas.

MORE IMPORTANT SAFETY INFORMATION LESS IMPORTANT SAFETY INFORMATION

Important Safety Information and Indications

WARNING: EMBRYO-FETAL TOXICITY

Do not administer Adempas (riociguat) tablets to a pregnant female because it may cause fetal harm.

Females of reproductive potential: Exclude pregnancy before the start of treatment, monthly during treatment, and one month after stopping treatment. To prevent pregnancy, females of reproductive potential must use effective forms of contraception during treatment and for one month after stopping treatment.

For all female patients, Adempas is available only through a restricted program called the Adempas Risk Evaluation and Mitigation Strategy (REMS) Program.

Contraindications

Adempas is contraindicated in:

Pregnancy. Based on data from animal reproduction studies, Adempas may cause fetal harm when administered to a pregnant woman and is contraindicated in females who are pregnant. Adempas was consistently shown to have teratogenic effects when administered to animals. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.
Co-administration with nitrates or nitric oxide donors (such as amyl nitrite) in any form.
Concomitant administration with specific phosphodiesterase (PDE)-5 inhibitors (such as sildenafil, tadalafil, or vardenafil) or nonspecific PDE inhibitors (such as dipyridamole or theophylline) is contraindicated. Do not administer within 24 hours of sildenafil. Do not administer 24 hours before or within 48 hours after tadalafil.
Patients with concomitant use of other soluble guanylate cyclase (sGC) stimulators.
Patients with Pulmonary Hypertension associated with Idiopathic Interstitial Pneumonias (PH-IIP).

Warnings and Precautions

Embryo-Fetal Toxicity. Based on data from animal reproduction studies, Adempas may cause embryo-fetal toxicity when administered to a pregnant female and is contraindicated in females who are pregnant. Advise females of reproductive potential of the potential risk to a fetus. Obtain a pregnancy test before the start of treatment, monthly during treatment, and for one month after stopping treatment. Advise females of reproductive potential to use effective contraception during treatment with Adempas and for at least one month after the last dose.

For females, Adempas is only available through a restricted program under the Adempas REMS Program.

Adempas REMS Program. Females can only receive Adempas through the Adempas REMS Program, a restricted distribution program.

Important requirements of the Adempas REMS Program include the following:

Prescribers must be certified with the program by enrolling and completing training.
All females, regardless of reproductive potential, must enroll in the Adempas REMS Program prior to initiating Adempas. Male patients are not enrolled in the Adempas REMS Program.
Female patients of reproductive potential must comply with the pregnancy testing and contraception requirements.
Pharmacies must be certified with the program and must only dispense to patients who are authorized to receive Adempas.

Further information, including a list of certified pharmacies, is available at www.AdempasREMS.com or 1-855-4ADEMPAS.

Hypotension. Adempas reduces blood pressure. Consider the potential for symptomatic hypotension or ischemia in patients with hypovolemia, severe left ventricular outflow obstruction, resting hypotension, autonomic dysfunction, or concomitant treatment with antihypertensives or strong CYP and P-gp/BCRP inhibitors. Consider a dose reduction if patient develops signs or symptoms of hypotension.

Bleeding. In the placebo-controlled clinical trials, serious bleeding occurred in 2.4% of patients taking Adempas compared to 0% of placebo patients. Serious hemoptysis occurred in 5 (1%) patients taking Adempas compared to 0 placebo patients, including one event with fatal outcome. Serious hemorrhagic events also included 2 patients with vaginal hemorrhage, 2 with catheter-site hemorrhage, and 1 each with subdural hematoma, hematemesis, and intra-abdominal hemorrhage.

Pulmonary Veno-Occlusive Disease. Pulmonary vasodilators may significantly worsen the cardiovascular status of patients with pulmonary veno-occlusive disease (PVOD). Therefore, administration of Adempas to such patients is not recommended. Should signs of pulmonary edema occur, the possibility of associated PVOD should be considered and if confirmed, discontinue treatment with Adempas.

Most Common Adverse Reactions

The most common adverse reactions occurring more frequently (≥3%) on Adempas than placebo were headache (27% vs 18%), dyspepsia/gastritis (21% vs 8%), dizziness (20% vs 13%), nausea (14% vs 11%), diarrhea (12% vs 8%), hypotension (10% vs 4%), vomiting (10% vs 7%), anemia (7% vs 2%), gastroesophageal reflux disease (5% vs 2%), and constipation (5% vs 1%).

Other events that were seen more frequently in Adempas compared to placebo and potentially related to treatment were palpitations, nasal congestion, epistaxis, dysphagia, abdominal distension, and peripheral edema.

Indications

Adempas (riociguat) is indicated for the treatment of adults with persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH) (WHO Group 4) after surgical treatment or inoperable CTEPH to improve exercise capacity and WHO functional class.
Adempas is indicated for the treatment of adults with pulmonary arterial hypertension (PAH) (WHO Group 1) to improve exercise capacity, improve WHO functional class and to delay clinical worsening.*

Efficacy was shown in patients on Adempas monotherapy or in combination with endothelin receptor antagonists or prostanoids. Studies establishing effectiveness included predominantly patients with WHO functional class II–III and etiologies of idiopathic or heritable PAH (61%) or PAH associated with connective tissue diseases (25%).

^*Time to clinical worsening was a combined endpoint defined as death (all-cause mortality), heart/lung transplantation, atrial septostomy, hospitalization due to persistent worsening of pulmonary hypertension, start of new PAH-specific treatment, persistent decrease in 6MWD, and persistent worsening of WHO functional class.

For important risk and use information, please see the full Prescribing Information, including Boxed Warning.

References:

Adempas Prescribing Information. Whippany, NJ. Bayer Pharmaceuticals Inc., 2021.

DRUG INTERACTIONS¹

Potential drug interactions to consider when prescribing Adempas.

WARNING: EMBRYO-FETAL TOXICITY

DRUG INTERACTIONS1

Potential drug interactions to consider when prescribing Adempas.

WARNING: EMBRYO-FETAL TOXICITY

DRUG INTERACTIONS¹