Eravacycline

In vitro, eravacycline was shown to be a substrate for the transporters P-gp, OATP1B1 and OATP1B3. A drug-drug interaction in vivo cannot be excluded and co-administration of eravacycline and other medicinal products that inhibit these transporters (examples of OATP1B1/3 inhibitors; atazanavir, cyclosporine, lopinavir, and saquinavir) may increase the eravacycline plasma concentration.

Concomitant administration of the strong CYP3A inhibitor itraconazole altered the pharmacokinetics of eravacycline, increasing C_max by approximately 5% and AUC_0-24 by approximately 23%, and decreasing clearance. The increased exposure is not likely to be clinically significant; thus, no dose adjustment is required when eravacycline is co-administered with CYP3A inhibitors. However, patients receiving strong CYP3A inhibitors (for example ritonavir, itraconazole, clarithromycin) with a combination of factors that may increase the exposure, such as severe hepatic impairment and/or obesity should be monitored for adverse reactions.

Medicines that induce CYP3A4 are expected to increase the rate and extent of metabolism of eravacycline. CYP3A4 inducers exert their effect in a time-dependent manner, and may take at least 2 weeks to reach maximal effect after introduction. Conversely, on discontinuation, CYP3A4 induction may take at least 2 weeks to decline. Co-administration of a strong CYP3A4 inducer (such as phenobarbital, rifampicin, carbamazepine, phenytoin, St. John’s Wort) is expected to reduce the effect of eravacycline.

Concomitant administration of the strong CYP 3A4/3A5 inducer rifampicin altered the pharmacokinetics of eravacycline, decreasing exposure by approximately 32% and increasing clearance by approximately 54%. The eravacycline dose should be increased by approximately 50% (1.5 mg/kg intravenous q12h) when co-administered with rifampicin or other strong CYP3A inducers such as phenobarbital.

Exposure may be increased in patients with severe hepatic impairment (Child-Pugh Class C). Therefore, such patients should be monitored for adverse reactions, particularly if these patients are obese and/or are also being treated with strong CYP3A inhibitors where the exposure may be further increased. In these cases, no recommendation on a posology can be made.

There are limited data on the use of eravacycline in pregnant women. Studies in animals have shown reproductive toxicity. The potential risk for humans is unknown.

As for other tetracycline class antibiotics, eravacycline may induce permanent dental defects (discolouration and enamel defects) and a delay in ossification processes in foetuses exposed in utero during the 2^nd and 3^rd trimester, due to accumulation in tissues with a high calcium turnover and formation of calcium chelate complexes. Eravacycline should not be used during pregnancy unless the clinical condition of the woman requires treatment with eravacycline.

It is unknown whether eravacycline and its metabolites are excreted in human breast milk. Animal studies have shown excretion of eravacycline and its metabolites in breast milk.

Long term use of other tetracyclines during breast-feeding may result in significant absorption by the breast-fed infant and is not recommended because of the risk of dental discolouration and delay in ossification processes of the breast-fed infant.

A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with eravacycline should be made, taking into account the benefit of breast-feeding for the child, and the benefit of therapy for the woman.

Women of childbearing potential

Women of childbearing potential should avoid becoming pregnant while receiving eravacycline.

Fertility

There are no human data on the effect of eravacycline on fertility. Eravacycline did affect mating and fertility in male rats at clinically relevant exposures.

Eravacycline may have a minor influence on the ability to drive and use machines. Dizziness may occur following administration of eravacycline.

Summary of the safety profile

In clinical trials, the most common adverse reactions in patients with cIAI treated with eravacycline (n=576) were nausea (3.0%), vomiting, infusion site phlebitis (each 1.9%), phlebitis (1.4%), infusion site thrombosis (0.9%), diarrhoea (0.7%), vessel puncture site erythema (0.5%), hyperhidrosis, thrombophlebitis, infusion site hypoaesthesia, and headache (each 0.3%), which were generally mild or moderate in severity.

Tabulated list of adverse reactions

The adverse reactions identified with eravacycline are presented in the table below. Adverse reactions are classified according to MedDRA system organ classification and frequency. Frequency categories are derived according to the following conventions: 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). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Tabulated list of adverse reactions to eravacycline in clinical trials:

^a Thrombophlebitis includes the preferred terms thrombophlebitis and infusion site thrombosis
^b Phlebitis includes the preferred terms phlebitis, infusion site phlebitis, superficial phlebitis and injection site phlebitis
^c Infusion site reaction includes the preferred terms injection site erythema, infusion site hypoaesthesia, vessel puncture site erythema and vessel puncture site pain

Description of selected adverse reactions

Infusion site reactions

Mild to moderate infusion site reactions, including pain or discomfort, erythema and swelling or inflammation at the injection site as well as superficial thrombophlebitis and/or phlebitis have been reported in patients treated with eravacycline. Infusion site reactions can be mitigated by reducing the eravacycline infusion concentration or the infusion rate.

Tetracycline class effects

Tetracycline class adverse reactions include photosensitivity, pseudotumor cerebri, and anti-anabolic action which have led to increased blood urea nitrogen, azotaemia, acidosis, and hyperphosphataemia.

Diarrhoea

Antibiotic class adverse reactions include pseudomembranous colitis, and overgrowth of nonsusceptible organisms, including fungi. In clinical trials, treatment-related diarrhoea occurred in 0.7% of patients; all cases were mild in severity.