Source: European Medicines Agency (EU) Revision Year: 2023 Publisher: Gedeon Richter Plc., Gyömrői út 19-21, 1103 Budapest, Hungary
Ryeqo must only be prescribed after careful diagnosis.
Prior to the initiation or reinstitution of Ryeqo, a complete medical history (including family history) must be taken. Blood pressure must be measured and a physical examination must be performed guided by the contraindications (see section 4.3) and warnings for use (see section 4.4). During treatment, periodic check-ups must be carried out according to standard clinical practice.
Any hormonal contraception needs to be stopped prior to initiation of Ryeqo (see section 4.3). Nonhormonal methods of contraception must be used for at least 1 month after initiation of treatment. Pregnancy must be ruled out prior to administering or re-initiation of Ryeqo.
The use of medicinal products containing an estrogen and a progestogen increases the risk of arterial or venous thromboembolism (ATE or VTE) compared with no use.
The risk of ATE/VTE with Ryeqo has not been established. Ryeqo contains doses of estrogen and progestogen lower than the doses used in combined hormonal contraceptives and are provided in combination with relugolix, a gonadotropin-releasing hormone (GnRH) receptor antagonist that suppresses ovarian production of estrogen and progesterone. Estradiol levels with Ryeqo are in the range observed in the early follicular phase of the menstrual cycle (see section 5.1).
If an ATE/VTE occurs, treatment must be discontinued immediately. Ryeqo is contraindicated in women with past or present venous or arterial thromboembolic disease (see section 4.3).
The risk for venous thromboembolic complications in women using a product with an estrogen and progestogen may increase substantially in a woman with additional risk factors, particularly if there are multiple risk factors (see Table 1 below).
Table 1. Risk factors for VTE:
| Risk factor | Comment |
|---|---|
| Obesity (body mass index [BMI] over 30 kg/m²) | Risk increases substantially as BMI rises. |
| Prolonged immobilisation, major surgery or major trauma | In these situations, it is advisable to discontinue use of the medicinal product (in the case of elective surgery at least four weeks in advance) and not resume until two weeks after complete remobilisation. |
| Positive family history (VTE) ever in a sibling or parent especially at a relatively early age e.g. before 50 years. | If a hereditary predisposition is suspected, the woman must be referred to a specialist for advice before using the medicinal product. |
| Other medical conditions associated with VTE | Cancer, systemic lupus erythematosus, haemolytic uraemic syndrome, chronic inflammatory bowel disease (Crohn’s disease or ulcerative colitis) and sickle cell disease. |
| Increasing age | Particularly above 35 years. |
The increased risk of thromboembolism in pregnancy, and particularly the 6-week period of the puerperium, must be considered (for information on “Pregnancy and lactation” see section 4.6).
In the event of symptoms, women must be advised to get urgent medical attention and to inform the physician that she is taking Ryeqo.
Symptoms of deep vein thrombosis (DVT) can include:
Symptoms of pulmonary embolism (PE) can include:
Some of these symptoms (e.g. “shortness of breath”, “coughing”) are non-specific and might be misinterpreted as more common or less severe events (e.g. respiratory tract infections).
Epidemiological studies have associated the use of estrogen/progestogen products with an increased risk for arterial thromboembolism (myocardial infarction) or for cerebrovascular accident (e.g. transient ischaemic attack, stroke). Arterial thromboembolic events may be fatal.
The risk for arterial thromboembolic complications in women using a product with an estrogen and progestogen may increase substantially in a woman with additional risk factors, particularly if there are multiple risk factors (see Table 2 below).
Table 2. Risk factors for ATE:
| Risk factor | Comment |
|---|---|
| Increasing age | Particularly above 35 years. |
| Smoking | Women are to be advised not to smoke if they wish to use the medicinal product. |
| Hypertension | |
| Obesity (body mass index [BMI] over 30 kg/m²) | Risk increases substantially as BMI increases. |
| Positive family history (ATE) ever in a sibling or parent especially at relatively early age e.g. before 50 years. | If a hereditary predisposition is suspected, the woman must be referred to a specialist for advice before using the medicinal product. |
| Migraine | An increase in frequency or severity of migraine during use of the medicinal product (which may be prodromal of a cerebrovascular event) may be a reason for immediate discontinuation. |
| Other medical conditions associated with adverse vascular events | Diabetes mellitus, hyperhomocysteinaemia, valvular heart disease and atrial fibrillation, dyslipoproteinaemia and systemic lupus erythematosus. |
In the event of symptoms, women must be advised to get urgent medical attention and to inform the physician that she is taking Ryeqo.
Symptoms of a cerebrovascular accident can include:
Temporary symptoms suggest the event is a transient ischaemic attack.
Symptoms of myocardial infarction can include:
Following an initial non-clinically relevant decrease in bone mineral density (BMD), it stabilized after 12-24 weeks of treatment and thereafter remained stable (as measured up to 2 years). The mean decrease in BMD during the first year of treatment with Ryeqo was 0.69%. However, decreases of >3% were seen in 21% of the patients. Therefore, a DXA scan is recommended after the first 52 weeks of treatment and as considered appropriate thereafter. Depending on the degree of change in BMD, the benefit and risks of Ryeqo may need to be reconsidered.
The benefits and risks of Ryeqo in patients with a history of a low trauma fracture or other risk factors for osteoporosis or bone loss, including those taking medications that may affect BMD, should be considered prior to initiating treatment. It is recommended to perform a DXA scan before commencing treatment with Ryeqo in these patients. Ryeqo should not be initiated if the risk associated with BMD loss exceeds the potential benefit of the treatment.
Ryeqo is contraindicated in women with liver tumours, benign or malignant; or liver disease as long as liver function values have not returned to normal (see section 4.3). Treatment must be discontinued if jaundice develops.
In clinical trials, asymptomatic transient elevations of serum alanine aminotransferase (ALT) at least 3 times the upper limit of the reference range occurred in < 1% of participants treated with Ryeqo. Acute liver test abnormalities may necessitate the discontinuation of Ryeqo use until the liver tests return to normal.
The exposure to relugolix is increased in patients with moderate or severe renal impairment (see section 5.2), although no dose adjustment is required (see section 4.2). The amount of relugolix removed by haemodialysis is unknown.
Patients must be informed that treatment with Ryeqo usually leads to a reduction in menstrual blood loss or amenorrhoea within the first 2 months of treatment.
Women receiving Ryeqo, for the treatment of uterine fibroids, were likely to have amenorrhoea (51.6%) or cyclic bleeding (15.4%), with the rest (31.9%) having an irregular bleeding pattern at the Week 24 assessment. Furthermore, at the Week 52 and Week 104 assessments 70.6%, and 58.3% of women respectively receiving Ryeqo were likely to have amenorrhoea. For those patients with endometriosis, the majority of patients (65.2%) were likely to have amenorrhoea at the Week 24 assessment, with a subsequent 76.6% at the Week 52 assessment and 82.3% at the Week 104 assessment.
In case of persistent excessive bleeding, patients must notify their physician.
Ryeqo provides adequate contraception when used for at least 1 month (see section 4.2). However, women of childbearing potential must be advised that ovulation will return rapidly after discontinuing treatment. Therefore, alternative contraception needs to be started immediately after discontinuation of treatment.
Women who take Ryeqo commonly experience amenorrhoea or a reduction in the amount, intensity, or duration of menstrual bleeding.
This change in menstrual bleeding pattern may reduce the ability to recognise the occurrence of a pregnancy in a timely manner. Perform pregnancy testing if pregnancy is suspected and discontinue treatment, if pregnancy is confirmed.
Submucosal uterine fibroids are common (15% to 20% of women with uterine fibroids) and some may prolapse through the cervix or be expelled, sometimes with transient worsening of uterine bleeding. Women known or suspected to have submucosal uterine fibroids must be advised regarding the possibility of uterine fibroid prolapse or expulsion when treated with Ryeqo, and should contact their physician if severe bleeding reoccurs after bleeding symptoms have improved while being treated with Ryeqo.
Carefully observe women with a history of depression and discontinue Ryeqo if depression recurs to a serious degree. Data are limited on the association of Ryeqo or other products containing estradiol and progestins with onset of depression or exacerbation of existing depression. Women must be advised to contact their physician in case of mood changes and depressive symptoms, including shortly after initiating the treatment.
Although small increases in blood pressure have been reported in women taking Ryeqo, clinically relevant increases are rare. However, if sustained clinically significant hypertension develops during the use of Ryeqo, hypertension should be treated, and the benefit of continued therapy should be assessed. If treatment with Ryeqo is discontinued, use may be resumed if normotensive values can be achieved with antihypertensive treatment.
Conditions such as gallbladder disease, cholelithiasis and cholecystitis have been reported to occur or worsen with estrogen and progestogen use, including Ryeqo, but the evidence of an association with Ryeqo is inconclusive.
The use of estrogens and progestogens may influence the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and renal function, plasma levels of (carrier) proteins, e.g. corticosteroid binding globulin and lipid/lipoprotein fractions, parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis. Changes generally remain within the normal laboratory range.
Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucosegalactose malabsorption should not take this medicinal product.
Recommendations regarding interactions with Ryeqo are based on evaluations of interactions for the individual components.
Concomitant use of Ryeqo with oral P-gp inhibitors is not recommended. Relugolix is a substrate of P-gp (see section 5.2) and in an interaction study with erythromycin, a P-gp and moderate cytochrome P450 (CYP) 3A4 inhibitor, the area under the curve (AUC) and maximum concentration (Cmax) of relugolix were increased by 4.1-fold and 3.8-fold, respectively. Concomitant use of P-gp inhibitors may increase the exposure of relugolix, including certain anti-infective medicinal products (e.g. erythromycin, clarithromycin, gentamicin, tetracycline), anti-fungal medicinal products (ketoconazole, itraconazole), antihypertensive medicinal products (e.g. carvedilol, verapamil), antiarrhythmic medicinal products (e.g. amiodarone, dronedarone, propafenone, quinidine), antianginal medicinal products (e.g. ranolazine), cyclosporine, human immunodeficiency virus (HIV) or hepatitis C virus (HCV) protease inhibitors (e.g. ritonavir, telaprevir). If concomitant use with once or twice daily oral P-gp inhibitors is unavoidable (e.g. azithromycin), take Ryeqo first, and separate dosing with the P-gp inhibitor by at least 6 hours and monitor patients more frequently for adverse reactions.
Co-administration of Ryeqo with strong CYP3A4 and/or P-gp inducers is not recommended. In a clinical interaction study with rifampicin, a strong CYP3A4 and P-gp inducer, the Cmax and AUC of relugolix were reduced by 23% and 55%, respectively. Medicinal products that cause strong CYP3A4 and/or P-gp induction, such as anticonvulsants (e.g. carbamazepine, topiramate, phenytoin, phenobarbital, primidone, oxcarbazepine, felbamate), anti-infective medicinal products (e.g. rifampicin, rifabutin, griseofulvin); St. John’s wort (Hypericum perforatum); bosentan and HIV or HCV protease inhibitors (e.g. ritonavir, boceprevir, telaprevir) and non-nucleoside reverse transcriptase inhibitors (e.g. efavirenz), may reduce the plasma concentrations of relugolix and may result in a decrease in therapeutic effects.
Concomitant use of relugolix with strong CYP3A4 inhibitors devoid of P-gp inhibition (voriconazole) did not increase the exposure of relugolix in a clinically-meaningful manner. Furthermore, in a clinical interaction study, concomitant administration with atorvastatin, a weak CYP3A4 enzyme inhibitor, did not change the exposure of relugolix in a clinically meaningful manner.
Effect of co-administered medicinal products on relugolix exposure from clinical trials and recommendations are summarised in Table 3.
Table 3. Effect of co-administered medicinal products on relugolix exposure (AUC0-∞, Cmax; in order of decreasing magnitude) from clinical trials and recommendations:
| Interacting drug dose regimen | Relugolix dose regimen | Change in relugolix AUC0-∞ | Change in relugolix Cmax | Recommendation |
|---|---|---|---|---|
| erythromycin 500 mg QID, multiple doses | 40 mg single dose | 4.1-fold ↑ | 3.8-fold ↑ | Concomitant use of Ryeqo with erythromycin and other oral P-gp inhibitors is not recommended. If concomitant use with once or twice daily oral P-gp inhibitors is unavoidable (e.g. azithromycin), take Ryeqo first, followed by administration of the P-gp inhibitor at least 6 hours thereafter and monitor patients more frequently for adverse reactions. |
| azithromycin 500 mg single dose | 120 mg single dose** | 1.5-fold ↑ | 1.6-fold ↑ | |
| azithromycin 500 mg single dose 6 hours after administration of relugolix | 1.4-fold ↑ 1.3-fold ↑ | |||
| voriconazole 200 mg BID, multiple doses | 40 mg single dose | 51% ↑ | 21% ↑ | No dose modifications recommended for coadministration of relugolix and CYP3A4 inhibitors devoid of P-gp inhibition. |
| fluconazole 200 mg QD, multiple doses | 40 mg single dose | 19% ↑ | 44% ↑ | |
| atorvastatin 80 mg QD, multiple doses | 40 mg single dose | 5% ↓ | 22% ↓ | |
| rifampicin 600 mg QD, multiple doses | 40 mg single dose | 55% ↓ | 23% ↓ | Coadministration of Ryeqo with rifampicin and other combined P-gp and strong CYP3A4 inducers is not recommended as the efficacy of the relugolix component of Ryeqo could be reduced. |
* Data given as x-fold change represent a ratio between co-administration and relugolix alone. Data given as % change represent % difference relative to relugolix alone.
** For further details check Orgovyx SmPC, effect for the 40 mg dose not investigated, but expected to be larger.
Increase is indicated as “↑”, decrease as “↓”.
AUC = area under curve; Cmax= maximum concentration; QD = once daily; BID = twice daily; TID = three times daily; QID = four times daily
Medicinal products that inhibit the activity of hepatic drug-metabolising enzymes, e.g. ketoconazole, may increase circulating concentrations of the estrogen and norethisterone components in Ryeqo.
The metabolism of estrogens and progestogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants (e.g. phenobarbital, phenytoin, carbamazepine) and anti-infectives (e.g. rifampicin, rifabutin, nevirapine, efavirenz).
Ritonavir, telaprevir and nelfinavir, although known as strong inhibitors, are also inducers and may decrease the exposure of estrogens and progestogens.
Herbal preparations containing St John’s Wort (Hypericum perforatum) may induce the metabolism of estrogens and progestogens. Clinically, an increase in estrogen metabolism may lead to decreased effectiveness with regard to protection of bone loss. Therefore, long-term concomitant use of liver enzyme inducers with Ryeqo is not recommended.
Relugolix is a weak inducer of CYP3A4. After co-administration with daily 40 -mg doses of relugolix, the AUC and Cmax of midazolam, a sensitive CYP3A4 substrate, were decreased by 18% and 26%, respectively. However, based on the clinical study with midazolam, clinically meaningful effects of relugolix on other CYP3A4 substrates are not expected.
Relugolix is an inhibitor of breast cancer resistant protein (BCRP) in vitro, therefore, an interaction study was conducted with rosuvastatin, a BCRP and organic anion transporting polypeptide 1B1 (OATP1B1) substrate. After co-administration with daily 40-mg doses of relugolix, the AUC and Cmax of rosuvastatin were decreased by 13% and 23%, respectively. The effects are not considered clinically meaningful and therefore no dose-adjustments of rosuvastatin upon concomitant use are recommended. Clinical effects of Ryeqo on other BCRP substrates have not been evaluated and the relevance for other BCRP substrates is unknown.
Relugolix may cause saturation of intestinal P-gp at the 40 mg dose, as relugolix exhibits more than dose proportional pharmacokinetics over the dose range of 10-120 mg, which could result in increased absorption of co-administered medicines that are sensitive substrates of P-gp. No clinically significant differences in the pharmacokinetics of dabigatran etexilate (P-gp substrate) were observed upon coadministration with relugolix, clinically meaningful effects of relugolix on other P-gp substrates are not expected.
Estrogen and progestogen medicinal products may affect the metabolism of certain other active substances. Accordingly, plasma concentrations may either increase (e.g. cyclosporin) or decrease (e.g. lamotrigine) with use of Ryeqo. Dose adjustment of these medicinal products may be necessary.
Ryeqo inhibits ovulation in women taking the recommended dose and provides adequate contraception. A nonhormonal contraceptive method is recommended for use for 1 month after initiation of treatment and for 7 days following 2 or more missed consecutive doses. Concomitant use of hormonal contraceptives is contraindicated (see section 4.3).
Women of childbearing potential must be advised that ovulation will return rapidly after discontinuing Ryeqo. A discussion with the patient, regarding appropriate contraceptive methods, must therefore take place prior to discontinuing treatment and alternative contraception needs to be started immediately after discontinuation of treatment (see section 4.4).
There is a limited amount of data from the use of relugolix in pregnant women. Studies in animals have shown that exposure to relugolix early in pregnancy may increase the risk of early pregnancy loss (see section 5.3). Based on the pharmacological effects, an adverse effect on pregnancy cannot be excluded.
Ryeqo is contraindicated during pregnancy (see section 4.3). Discontinue use of treatment if pregnancy occurs.
There appears to be little or no increased risk of harmful effects in children born to women who have used estrogens and progestogens as an oral contraceptive inadvertently during early pregnancy. The increased risk of VTE during the postpartum period must be considered when re-starting Ryeqo (see section 4.4).
Results from nonclinical studies indicate that relugolix is excreted into the milk of lactating rats (see section 5.3). No data are available regarding the presence of relugolix or its metabolites in human milk or its effect on the breastfed infant. Detectable amounts of estrogen and progestogens have been identified in the breast milk of women receiving estrogen plus progestogen therapy. An effect on breastfeeding newborns/infants cannot be excluded.
Breastfeeding is contraindicated during the use of Ryeqo (see section 4.3) and for 2 weeks following discontinuation of Ryeqo.
Ryeqo inhibits ovulation and often causes amenorrhoea. Ovulation and menstrual bleeding will return rapidly after discontinuing treatment (see section 5.1)
Ryeqo has no or negligible influence on the ability to drive and use machines.
The most frequent adverse drug reactions, in patients being treated for uterine fibroids or endometriosis, were headache (13.2%), hot flush (10.3%) and uterine bleeding (5.8%).
Adverse drug reactions listed in Table 4 are classified according to frequency and system organ class. Within each frequency grouping, adverse drug reactions are presented in order of decreasing seriousness. Frequencies are defined as very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), and not known (cannot be estimated from available data).
Table 4. Adverse drug reactions in patients with uterine fibroids and endometriosis:
| Psychiatric disorders | |
| Common | Irritability Libido decreased* |
| Nervous system disorders | |
| Very common | Headache |
| Common | Dizziness |
| Vascular disorders | |
| Very common | Hot flush |
| Gastrointestinal disorders | |
| Common | Nausea |
| Uncommon | Dyspepsia |
| Skin and subcutaneous tissue disorders | |
| Common | Alopecia Hyperhidrosis Night sweats |
| Uncommon | Angioedema Urticaria |
| Musculoskeletal and connective tissue disorders | |
| Common | Arthralgia |
| Reproductive system and breast disorders | |
| Common | Uterine bleeding** Vulvovaginal dryness |
| Uncommon | Breast cyst Uterine myoma expulsion |
* includes libido decreased, libido loss and libido disorder.
** includes menorrhagia (heavy menstrual bleeding), metrorrhagia (intermenstrual bleeding), vaginal haemorrhage, uterine haemorrhage, polymenorrhoea, and menstruation irregular
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.
Not applicable.
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