Symtuza 800 mg/150 mg/200 mg/10 mg film-coated tablets

Symtuza is indicated for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and adolescents (aged 12 years and older with body weight at least 40 kg).

Genotypic testing should guide the use of Symtuza (see sections 4.2, 4.4, and 5.1).

Therapy should be initiated by a physician experienced in the management of HIV-1 infection.

Posology

The recommended dose regimen in adults and adolescents aged 12 years and older, weighing at least 40 kg, is one tablet taken once daily with food.

Antiretroviral Therapy (ART) -naï ve patients

The recommended dose regimen is one film-coated tablet of Symtuza once daily taken with food.

ART-experienced patients

One film-coated tablet of Symtuza once daily taken with food may be used in patients with prior exposure to antiretroviral medicinal products but without darunavir resistance associated mutations (DRV-RAMs)* and who have plasma HIV-1 RNA < 100 000 copies/mL and CD4+ cell count ≥ 100 cells x 10⁶/L (see section 5.1).

* DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V, L89V.

Advice on missed doses

If a dose of Symtuza is missed within 12 hours of the time it is usually taken, patients should be instructed to take the prescribed dose of Symtuza with food as soon as possible. If a missed dose is noticed later than 12 hours of the time it is usually taken, it should not be taken and the patient should resume the usual dosing schedule.

In case a patient vomits within 1 hour of taking the medicinal product, another dose of Symtuza should be taken with food as soon as possible. If a patient vomits more than 1 hour after taking the medicinal product, the patient does not need to take another dose of Symtuza until the next regularly scheduled time.

Special populations

Elderly

Limited information is available in this population, and, therefore, Symtuza should be used with caution in patients above 65 years of age (see sections 4.4 and 5.2).

Hepatic impairment

No dose adjustment of Symtuza is required in patients with mild (Child-Pugh Class A) or moderate (Child-Pugh Class B) hepatic impairment, however, Symtuza should be used with caution in these patients, as the darunavir and cobicistat components of Symtuza are metabolised by the hepatic system.

Symtuza has not been studied in patients with severe hepatic impairment (Child-Pugh Class C), therefore, Symtuza must not be used in patients with severe hepatic impairment (see sections 4.3, 4.4 and 5.2).

Renal impairment

No dose adjustment of Symtuza is required in patients with estimated glomerular filtration rate (eGFR) according to the Cockcroft-Gault formula (eGFR_CG) ≥ 30 mL/min.

Symtuza should not be initiated in patients with eGFR_CG < 30 mL/min, as there are no data available regarding the use of Symtuza in this population (see sections 5.1 and 5.2).

Symtuza should be discontinued in patients with eGFR_CG that declines below 30 mL/min during treatment (see sections 5.1 and 5.2).

Paediatric population

The safety and efficacy of Symtuza in children aged 3-11 years, or weighing < 40 kg, have not yet been established. No data are available.

Symtuza should not be used in paediatric patients below 3 years of age because of safety concerns (see sections 4.4 and 5.3).

Pregnancy and postpartum

Treatment with darunavir/cobicistat (two of the components of Symtuza) during pregnancy results in low darunavir exposure (see sections 4.4 and 5.2). Therefore, therapy with Symtuza should not be initiated during pregnancy, and women who become pregnant during therapy with Symtuza should be switched to an alternative regimen (see sections 4.4 and 4.6).

Method of administration

Symtuza should be taken orally, once daily with food (see section 5.2). The tablet should not be crushed.

Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.

Patients with severe (Child-Pugh Class C) hepatic impairment.

Co-administration with strong CYP3A inducers such as the medicinal products listed below due to the potential for loss of therapeutic effect (see section 4.5):

- carbamazepine, phenobarbital, phenytoin

- rifampicin

- lopinavir/ritonavir

- St. John's wort (Hypericum perforatum)

Co-administration with medicinal products such as those products listed below due to the potential for serious and/or life-threatening adverse reactions (see section 4.5):

- alfuzosin

- amiodarone, dronedarone, ivabradine, quinidine, ranolazine

- colchicine when used in patients with renal and/or hepatic impairment (see section 4.5)

- rifampicin

- ergot derivatives (e.g. dihydroergotamine, ergometrine, ergotamine, methylergonovine)

- dapoxetine

- domperidone

- naloxegol

- pimozide, quetiapine, sertindole, lurasidone (see section 4.5)

- elbasvir/grazoprevir

- triazolam, midazolam administered orally (for caution on parenterally administered midazolam, see section 4.5)

- sildenafil when used for the treatment of pulmonary arterial hypertension, avanafil

- simvastatin, lovastatin and lomitapide (see section 4.5)

- ticagrelor

ART-experienced patients

Symtuza should not be used in treatment-experienced patients with one or more DRV-RAMs (see section 5.1) or with HIV-1 RNA ≥ 100 000 copies/mL or CD4+ cell count < 100 cells x 10⁶/L.

Pregnancy

Treatment with darunavir/cobicistat 800/150 mg during the second and third trimester has been shown to result in low darunavir exposure, with a reduction of around 90% in C_min levels (see section 5.2). Cobicistat levels decrease and may not provide sufficient boosting. The substantial reduction in darunavir exposure may result in virological failure and an increased risk of mother to child transmission of HIV infection. Therefore, therapy with Symtuza should not be initiated during pregnancy, and women who become pregnant during therapy with Symtuza should be switched to an alternative regimen (see sections 4.2 and 4.6).

Patients co-infected with HIV and hepatitis B or C virus

Patients with chronic hepatitis B or C treated with antiretroviral therapy are at an increased risk for severe and potentially fatal hepatic adverse reactions.

The safety and efficacy of Symtuza in patients co-infected with HIV-1 and hepatitis C virus (HCV) have not been established. Tenofovir alafenamide is active against hepatitis B virus (HBV).

In case of concomitant antiviral therapy for hepatitis C, please refer also to the relevant Summary of Product Characteristics for these medicinal products.

Discontinuation of Symtuza therapy in patients co-infected with HIV and HBV may be associated with severe acute exacerbations of hepatitis. Patients co-infected with HIV and HBV who discontinue Symtuza should be closely monitored with both clinical and laboratory follow-up for at least several months after stopping treatment. If appropriate, initiation of hepatitis B therapy may be warranted. In patients with advanced liver disease or cirrhosis, treatment discontinuation is not recommended since post-treatment exacerbation of hepatitis may lead to hepatic decompensation.

Symtuza should not be administered concomitantly with medicinal products containing tenofovir disoproxil (e.g. fumarate, phosphate, or succinate), lamivudine, or adefovir dipivoxil used for the treatment of HBV infection.

Mitochondrial dysfunction

Nucleoside and nucleotide analogues have been demonstrated in vitro and in vivo to cause a variable degree of mitochondrial damage. There have been reports of mitochondrial dysfunction in HIV negative infants exposed in utero and/or postnatally to nucleoside analogues. The main adverse reactions reported are haematological disorders (anaemia, neutropenia) and metabolic disorders (hyperlactataemia, hyperlipasaemia). These events are often transitory. Some late-onset neurological disorders have been reported (hypertonia, convulsion, abnormal behaviour). Whether the neurological disorders are transient or permanent is currently unknown. Any child exposed in utero to nucleoside and nucleotide analogues, even HIV negative children, should have clinical and laboratory follow-up and should be fully investigated for possible mitochondrial dysfunction in case of relevant signs or symptoms. These findings do not affect current national recommendations to use antiretroviral therapy in pregnant women to prevent vertical transmission of HIV.

Elderly

As limited information is available on the use of Symtuza in patients aged 65 and over, caution should be exercised, reflecting the greater frequency of decreased hepatic function and of concomitant disease or other therapy (see sections 4.2 and 5.2).

Hepatotoxicity

Hepatitis (e.g. acute hepatitis, cytolytic hepatitis) has been reported with darunavir/ritonavir. During the darunavir/ritonavir clinical development program (N = 3 063), hepatitis was reported in 0.5% of patients receiving combination antiretroviral therapy with darunavir/ritonavir. Patients with pre existing liver dysfunction, including chronic hepatitis B or C, have an increased risk for liver function abnormalities including severe and potentially fatal hepatic adverse reactions. In case of concomitant antiviral therapy for hepatitis B or C, please refer to the relevant product information for these medicinal products.

Appropriate laboratory testing should be conducted prior to initiating therapy with Symtuza and patients should be monitored during treatment. Increased AST/ALT monitoring should be considered in patients with underlying chronic hepatitis, cirrhosis, or in patients who have pre-treatment elevations of transaminases, especially during the first several months of Symtuza treatment.

If there is evidence of new or worsening liver dysfunction (including clinically significant elevation of liver enzymes and/or symptoms such as fatigue, anorexia, nausea, jaundice, dark urine, liver tenderness, hepatomegaly) in patients using Symtuza, interruption or discontinuation of treatment should be considered promptly (see section 5.3).

Nephrotoxicity

Post-marketing cases of renal impairment, including acute renal failure and proximal renal tubulopathy have been reported with tenofovir alafenamide-containing products. A potential risk of nephrotoxicity resulting from chronic exposure to low levels of tenofovir due to dosing with tenofovir alafenamide cannot be excluded (see section 5.3). It is recommended that renal function is assessed in all patients prior to, or when, initiating therapy with Symtuza and that it is also monitored during therapy in all patients as clinically appropriate. In patients who develop clinically significant decreases in renal function or evidence of proximal renal tubulopathy, discontinuation of Symtuza should be considered.

Renal impairment

Cobicistat has been shown to decrease estimated creatinine clearance due to inhibition of tubular secretion of creatinine. This effect on serum creatinine, leading to a decrease in the estimated creatinine clearance, should be taken into consideration when Symtuza is administered to patients, in whom the estimated creatinine clearance is used to guide aspects of their clinical management,including adjusting doses of co-administered medicinal products. For more information consult the cobicistat Summary of Product Characteristics.

Patients with co-existing conditions

Hepatic impairment

The safety and efficacy of Symtuza or its components have not been established in patients with severe underlying liver disorders. Symtuza is, therefore, contraindicated in patients with severe hepatic impairment. Due to an increase in the unbound darunavir plasma concentrations, Symtuza should be used with caution in patients with mild or moderate hepatic impairment (see sections 4.2, 4.3 and 5.2).

Haemophiliac patients

There have been reports of increased bleeding, including spontaneous skin haematomas and haemarthrosis in patients with haemophilia type A and B treated with HIV PIs. In some patients additional factor VIII was given. In more than half of the reported cases, treatment with HIV PIs was continued or reintroduced if treatment had been discontinued. A causal relationship has been suggested, although the mechanism of action has not been elucidated. Haemophiliac patients should, therefore, be made aware of the possibility of increased bleeding.

Severe skin reactions

During the darunavir/ritonavir clinical development program (N = 3 063), severe skin reactions, which may be accompanied with fever and/or elevations of transaminases, have been reported in 0.4% of patients. DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) and Stevens Johnson syndrome has been rarely (< 0.1%) reported, and during post marketing experience toxic epidermal necrolysis and acute generalised exanthematous pustulosis have been reported. Symtuza should be discontinued immediately if signs or symptoms of severe skin reactions develop. These can include, but are not limited to, severe rash or rash accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.

Sulphonamide allergy

Darunavir contains a sulphonamide moiety. Symtuza should be used with caution in patients with a known sulphonamide allergy.

Weight and metabolic parameters

An increase in weight and in levels of blood lipids and glucose may occur during antiretroviral therapy. Such changes may in part be linked to disease control and life style. For lipids, there is in some cases evidence for a treatment effect, while for weight gain there is no strong evidence relating this to any particular treatment. For monitoring of blood lipids and glucose reference is made to established HIV treatment guidelines. Lipid disorders should be managed as clinically appropriate.

Osteonecrosis

Although the aetiology is considered to be multifactorial (including corticosteroid use, alcohol consumption, severe immunosuppression, higher body mass index), cases of osteonecrosis have been reported particularly in patients with advanced HIV disease and/or long-term exposure to combination antiretroviral therapy (CART). Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.

Immune reconstitution inflammatory syndrome (IRIS)

In HIV infected patients treated with CART, immune reactivation syndrome has been reported. In HIV infected patients with severe immune deficiency at the time of initiation of CART, an inflammatory reaction to asymptomatic or residual opportunistic pathogens may arise and cause serious clinical conditions, or aggravation of symptoms. Typically, such reactions have been observed within the first weeks or months of initiation of CART. Relevant examples include cytomegalovirus retinitis, generalised and/or focal mycobacterial infections and pneumonia caused by Pneumocystis jirovecii (formerly known as Pneumocystis carinii). Any inflammatory symptoms should be evaluated and treatment instituted when necessary. In addition, reactivation of herpes simplex and herpes zoster has been observed in clinical trials with darunavir co-administered with low dose ritonavir.

Autoimmune disorders (such as Graves' disease and autoimmune hepatitis) have also been reported to occur in the setting of IRIS; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment (see section 4.8).

Opportunistic infections

Patients receiving Symtuza or any other antiretroviral therapy may continue to develop opportunistic infections and other complications of HIV infection, and therefore should remain under close clinical observation by physicians experienced in the treatment of patients with HIV associated diseases.

Interactions with medicinal products

Co-administration of other medicinal products

Symtuza is indicated for use as a complete regimen for the treatment of HIV-1 infection and should not be administered with other antiretroviral products (see section 4.5). Symtuza should not be administered concomitantly with medicinal products requiring pharmacokinetic enhancement with ritonavir or cobicistat. Symtuza should not be administered concomitantly with medicinal products containing tenofovir disoproxil (as fumarate, phosphate or succinate), lamivudine, or adefovir dipivoxil used for the treatment of HBV infection.

Paediatric population

Symtuza should not be used in paediatric patients below 3 years of age (see sections 4.2 and 5.3).

Excipients

This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium free'.

No interaction trials have been performed using Symtuza. Interactions that have been identified in studies with individual components of Symtuza, i.e. with darunavir (in combination with low dose ritonavir), cobicistat, emtricitabine or tenofovir alafenamide, determine the interactions that may occur with Symtuza.

Darunavir and cobicistat

Darunavir is an inhibitor of CYP3A, a weak inhibitor of CYP2D6 and an inhibitor of P-gp. Cobicistat is a mechanism based inhibitor of CYP3A, and a weak CYP2D6 inhibitor. Cobicistat inhibits the transporters p-glycoprotein (P-gp), BCRP, MATE1, OATP1B1 and OATP1B3. Cobicistat is not expected to inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9 or CYP2C19. Cobicistat is not expected to induce CYP1A2, CYP3A4, CYP2C9, CYP2C19, UGT1A1, or P-gp (MDR1).

Co-administration of Symtuza and medicinal products primarily metabolised by CYP3A or transported by P-gp, BCRP, MATE1, OATP1B1 and OATP1B3 may result in increased systemic exposure to such medicinal products, which could increase or prolong their therapeutic effect and adverse reactions (see section 4.3 or table below).

Symtuza must not be combined with medicinal products that are highly dependent on CYP3A for clearance and for which increased systemic exposure is associated with serious and/or life-threatening events (narrow therapeutic index).

Co-administration of Symtuza and medicinal products that have active metabolite(s) formed by CYP3A may result in reduced plasma concentrations of these active metabolite(s) potentially leading to loss of their therapeutic effect. These interactions are described in the interaction table below.

Darunavir and cobicistat are metabolised by CYP3A. Medicinal products that induce CYP3A activity would be expected to increase the clearance of darunavir and cobicistat, resulting in lowered plasma concentrations of darunavir and cobicistat (e.g. efavirenz, carbamazepine, phenytoin, phenobarbital, rifampicin, rifapentine, rifabutin, St. John's Wort) (see section 4.3 and interaction table below).

Co-administration of Symtuza and other medicinal products that inhibit CYP3A may decrease the clearance of darunavir and cobicistat and may result in increased plasma concentrations of darunavir and cobicistat (e.g. azole antifungals like clotrimazole). These interactions are described in the interaction table below.

Unlike ritonavir, cobicistat is not an inducer of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19 or UGT1A1. If switching from ritonavir as a pharmacoenhancer to this regimen with cobicistat, caution is required during the first two weeks of treatment with Symtuza, particularly if doses of any concomitantly administered medicinal products have been titrated or adjusted during use of ritonavir.

Emtricitabine

In vitro and clinical pharmacokinetic interaction studies have shown that the potential for CYP-mediated interactions involving emtricitabine with other medicinal products is low.

Emtricitabine did not inhibit the glucuronidation reaction of a non-specific UGT substrate in vitro. Co-administration of emtricitabine with medicinal products that are eliminated by active tubular secretion may increase concentrations of emtricitabine, and/or the co-administered medicinal product. Medicinal products that decrease renal function may increase concentrations of emtricitabine.

Tenofovir alafenamide

Tenofovir alafenamide is transported by P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP). Medicinal products that strongly affect P-gp activity and BCRP may lead to changes in tenofovir alafenamide absorption. Medicinal products that induce P-gp activity (e.g., rifampicin, rifabutin, carbamazepine, phenobarbital) are expected to decrease the absorption of tenofovir alafenamide, resulting in decreased plasma concentration of tenofovir alafenamide, which may lead to loss of therapeutic effect of tenofovir alafenamide and development of resistance. Co-administration of tenofovir alafenamide with other medicinal products that inhibit P-gp (e.g., cobicistat, ritonavir, ciclosporin) are expected to increase the absorption and plasma concentration of tenofovir alafenamide. It is not known whether the co-administration of tenofovir alafenamide and xanthine oxidase inhibitors (e.g. febuxostat) would increase systemic exposure to tenofovir.

Tenofovir alafenamide is not an inhibitor of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, or CYP2D6 in vitro. It is not an inhibitor of CYP3A4 in vivo. Tenofovir alafenamide is a substrate of OATP1B1 and OATP1B3 in vitro. The distribution of tenofovir alafenamide in the body may be affected by the activity of OATP1B1 and OATP1B3.

Interaction table

Expected interactions between Symtuza with potential concomitant medicinal products are listed in Table 1 below and are based on the studies conducted with the components of Symtuza, as individual agents or combined, or are potential interactions that may occur.

Interaction trials with the components of Symtuza have only been performed in adults.

The interaction profile of darunavir depends on whether ritonavir or cobicistat is used as a pharmacokinetic enhancer; therefore, there may be different recommendations for the use of darunavir with concomitant medicines. Refer to the prescribing information for darunavir for further information.

The below list of examples of interactions is not comprehensive and therefore the label of each drug that is co-administered with Symtuza should be consulted for information related to the route of metabolism, interaction pathways, potential risks, and specific actions to be taken with regards to co-administration.

Pregnancy

There are no or limited amount of data (less than 300 pregnancy outcomes) from the use of Symtuza in pregnant women. A moderate amount of data on pregnant women (between 300-1 000 pregnancy outcomes) indicate no malformative or feto/neonatal toxicity of darunavir, cobicistat or tenofovir alafenamide. A large amount of data on pregnant women (more than 1 000 exposed outcomes) indicate no malformative nor foetal/neonatal toxicity associated with emtricitabine.

Animal studies do not indicate direct or indirect harmful effects of darunavir or emtricitabine with respect to reproductive toxicity (see section 5.3). Animal studies do not indicate direct harmful effects of cobicistat or tenofovir alafenamide with respect to reproductive toxicity (see section 5.3).

Treatment with darunavir/cobicistat (two of the components of Symtuza) during pregnancy results in low darunavir exposure (see section 5.2), which may be associated with an increased risk of treatment failure and an increased risk of HIV transmission to the child. Therefore, therapy with Symtuza should not be initiated during pregnancy, and women who become pregnant during therapy with Symtuza should be switched to an alternative regimen (see sections 4.2 and 4.4).

Breast-feeding

Emtricitabine is excreted in human milk. It is unknown whether darunavir, cobicistat, or tenofovir alafenamide are excreted in human milk. Studies in animals have demonstrated that darunavir, cobicistat and tenofovir are excreted in milk. Studies in rats have demonstrated that darunavir is excreted in milk and at high levels (1 000 mg/kg/day) resulted in toxicity of the offspring.

Because of the potential for adverse reactions in breast fed infants, women should be instructed not to breast feed if they are receiving Symtuza.

In order to avoid transmission of HIV to the infant it is recommended that women living with HIV do not breast feed.

Fertility

No human data on the effect of darunavir, cobicistat, emtricitabine, or tenofovir alafenamide on fertility are available. There was no effect on mating or fertility in animals (see section 5.3). Based on animal studies, no effect on reproduction or fertility is expected with Symtuza.

Symtuza has minor influence on the ability to drive and use machines. Patients should be informed that dizziness may occur when treated with Symtuza (see section 4.8).

Summary of the safety profile

The overall safety profile of Symtuza is based on data from a randomised, double-blinded, comparative Phase 2 trial, GS-US-299-0102 (N = 103 on darunavir/cobicistat/emtricitabine/tenofovir alafenamide [D/C/F/TAF]), data from 2 Phase 3 trials TMC114FD2HTX3001 (AMBER, N = 362 on D/C/F/TAF) and TMC114IFD3013 (EMERALD, N = 763 on D/C/F/TAF), and on all available clinical trial and post-marketing data of its components. As Symtuza contains darunavir, cobicistat, emtricitabine, and tenofovir alafenamide, the adverse reactions associated with each of the individual compounds may be expected.

The most frequent (> 5%) adverse reactions reported in treatment-naï ve patients in the Phase 2 (GS-US-299-0102) and Phase 3 Study (AMBER, TMC114FD2HTX3001, Week 96 analysis) were diarrhoea (22.6%), headache (13.1%), rash (12.7%), nausea (9.7%), fatigue (8.0%), and abdominal pain (5.8%).

The most frequent (> 5%) adverse reactions reported in suppressed treatment-experienced patients (EMERALD Study TMC114IFD3013, Week 96 analysis) were diarrhoea (10.5%), headache (10.4%), arthralgia (7.7%), abdominal pain (7.5%), fatigue (5.9%), and rash (5.1%).

Tabulated list of adverse reactions

Adverse reactions are listed by system organ class (SOC) and frequency category in Table 2. Frequency categories are defined as follows: 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) and not known (frequency cannot be estimated from the available data)

Table 2

Description of selected adverse reactions

Rash

Rash is a common adverse reaction in patients treated with darunavir. Rash was mostly mild to moderate, often occurring within the first four weeks of treatment and resolving with continued dosing (see section 4.4). In the Phase 2/3 trials in treatment-naï ve patients, 12.7% (59/465) of patients receiving Symtuza experienced rash (most of which were grade 1), 1.5% (7/465) of patients discontinued treatment due to rash, of whom one for rash and hypersensitivity. In the Phase 3 trial in suppressed treatment-experienced patients (EMERALD Study TMC114IFD3013), 5.1% (39/763) of patients receiving Symtuza experienced rash (most of which were grade 1), none discontinued treatment due to rash.

Metabolic parameters

Weight and levels of blood lipids and glucose may increase during antiretroviral therapy (see section 4.4).

In the Phase 3 trial of Symtuza in treatment-naï ve patients, increases from baseline were observed in the fasting lipid parameters total cholesterol, direct low density lipoprotein (LDL) and high density lipoprotein (HDL) cholesterol, and triglycerides at Week 48 and 96 (see Table 3). The median increases from baseline were greater in the D/C/F/TAF group compared with the DRV/ cobicistat (COBI)+F/ tenofovir disoproxil fumarate (TDF) group at Week 48.

Table 3

p < 0.001 for all 4 lipid parameters when comparing D/C/F/TAF versus D/C + F/TDF at Week 48

^* No comparator data available beyond Week 48

Musculoskeletal abnormalities

Increased creatine phosphokinase (CPK), myalgia, myositis and rarely, rhabdomyolysis have been reported with the use of HIV protease inhibitors, particularly in combination with NRTIs.

Osteonecrosis

Cases of osteonecrosis have been reported, particularly in patients with generally acknowledged risk factors, advanced HIV disease or long-term exposure to CART. The frequency of this is unknown (see section 4.4).

Immune reconstitution inflammatory syndrome

In HIV infected patients with severe immune deficiency at the time of CART, an inflammatory reaction to asymptomatic or residual opportunistic infections may arise. Autoimmune disorders (such as Graves' disease and autoimmune hepatitis) have also been reported; however, the reported time to onset is more variable, and these events can occur many months after initiation of treatment (see section 4.4).

Bleeding in haemophiliac patients

There have been reports of increased spontaneous bleeding in haemophiliac patients receiving antiretroviral protease inhibitors (see section 4.4).

Decrease estimated creatinine clearance

Cobicistat increases serum creatinine due to inhibition of tubular secretion of creatinine without affecting renal glomerular function as assessed, for instance, by using Cystatin C (Cyst C) as filtration marker.

In the Phase 3 trial of Symtuza in treatment-naï ve patients, increases in serum creatinine and decreases in eGFR_CG occurred at the first on-treatment assessment (Week 2) and remained stable through 96 weeks. At Week 48 changes from baseline were smaller with D/C/F/TAF than D/C+F/TDF. The median change in eGFR_CG was -5.5 mL/min with D/C/F/TAF and -12.0 mL/min with D/C+F/TDF (p < 0.001). Using Cyst C as filtration marker, the median changes in estimated glomerular filtration rate calculated using the CKD-EPI (eGFR_{CKD-EPI CystC}) formula were respectively 4.0 mL/min/1.73 m² and 1.6 mL/min/1.73 m² (p<0.001). At Week 96, the median change in eGFR_CG was -5.2 mL/min with D/C/F/TAF. Using Cyst C as filtration marker, the median change in estimated glomerular filtration rate calculated using the CKD-EPI (eGFR_{CKD-EPI Cyst C}) formula (N=22) was +4.4 mL/min/1.73 m² with D/C/F/TAF.

Paediatric population

The safety of Symtuza in paediatric patients has not been investigated. However,the safety of components of Symtuza was evaluated through the clinical trial TMC114 C230 (N = 12) for darunavir with ritonavir and GS US 292 0106 (N = 50) for a fixed dose combination containing elvitegravir, cobicistat, emtricitabine and tenofovir alafenamide. The data from these studies showed that the overall safety profile of components of Symtuza in paediatric patients aged 12 to < 18 years and weighing at least 40 kg was similar to that observed in the adult population (see section 5.1).

Other special populations

Patients co-infected with hepatitis B and/or hepatitis C virus

Limited information is available on the use of Symtuza components in patients co-infected with hepatitis B and/or C virus.

Among 1 968 treatment experienced patients receiving darunavir co administered with ritonavir 600/100 mg twice daily, 236 patients were co infected with hepatitis B or C. Co infected patients were more likely to have baseline and treatment emergent hepatic transaminase elevations than those without chronic viral hepatitis. The safety of emtricitabine and tenofovir alafenamide in combination with elvitegravir and cobicistat as a fixed dose combination tablet was evaluated in approximately 70 HIV/HBV co infected patients currently receiving treatment for HIV in an open label clinical trial (GS US 292 1249). Based on this limited experience, the safety profile of emtricitabine/tenofovir alafenamide in patients with HIV/HBV co infection appears to be similar to that in patients with HIV 1 monoinfection (see section 4.4).

Reporting of suspected adverse reactions

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 Yellow Card Scheme Website: https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.

Human experience of acute overdose with Symtuza is limited.

If overdose occurs the patient must be monitored for evidence of toxicity (see section 4.8).

There is no specific antidote for overdose with Symtuza. Treatment of overdose with Symtuza consists of general supportive measures, including monitoring of vital signs as well as observation of the clinical status of the patient.

Since darunavir and cobicistat are highly bound to plasma proteins, it is unlikely that they will be significantly removed by haemodialysis or peritoneal dialysis. Emtricitabine can be removed by haemodialysis, which removes approximately 30% of the emtricitabine dose over a 3 hour dialysis period starting within 1.5 hours of emtricitabine dosing. Tenofovir is efficiently removed by haemodialysis with an extraction coefficient of approximately 54%. It is not known whether emtricitabine or tenofovir can be removed by peritoneal dialysis.

Pharmacotherapeutic group: Antivirals for systemic use, antivirals for treatment of HIV infection, combinations, ATC code: J05AR22

Mechanism of action

Darunavir is an inhibitor of the dimerisation and of the catalytic activity of the HIV-1 protease (K_D of 4.5 x 10^-12M). It selectively inhibits the cleavage of HIV encoded Gag-Pol polyproteins in virus infected cells, thereby preventing the formation of mature infectious virus particles.

Cobicistat is a mechanism-based inhibitor of cytochrome P450 of the CYP3A subfamily. Inhibition of CYP3A-mediated metabolism by cobicistat enhances the systemic exposure of CYP3A substrates, such as darunavir, where bioavailability is limited and half-life is shortened due to CYP3A-dependent metabolism.

Emtricitabine is a nucleoside reverse transcriptase inhibitor (NRTI) and nucleoside analogue of 2'-deoxycytidine. Emtricitabine is phosphorylated by cellular enzymes to form emtricitabine triphosphate. Emtricitabine triphosphate inhibits HIV replication through incorporation into viral DNA by the HIV reverse transcriptase (RT), which results in DNA chain-termination.

Tenofovir alafenamide is a nucleotide reverse transcriptase inhibitor (NtRTI) and phosphonoamidate prodrug of tenofovir (2'-deoxyadenosine monophosphate analogue). Tenofovir alafenamide is permeable into cells and due to increased plasma stability and intracellular activation through hydrolysis by cathepsin A, tenofovir alafenamide is more efficient than tenofovir disoproxil in concentrating tenofovir in peripheral blood mononuclear cells (PBMC) (including lymphocytes and other HIV target cells) and macrophages. Intracellular tenofovir is subsequently phosphorylated to the pharmacologically active metabolite tenofovir diphosphate. Tenofovir diphosphate inhibits HIV replication through incorporation into viral DNA by the HIV RT, which results in DNA chain-termination.

Antiviral activity in vitro

Darunavir, emtricitabine and tenofovir alafenamide demonstrated additive to synergistic antiviral effects in two-drug combination studies in cell culture.

Darunavir exhibits activity against laboratory strains and clinical isolates of HIV-1 and laboratory strains of HIV-2 in acutely infected T-cell lines, human PBMCs and human monocytes/macrophages with median EC₅₀ values ranging from 1.2 to 8.5 nM (0.7 to 5.0 ng/mL). Darunavir demonstrates antiviral activity in vitro against a broad panel of HIV-1 group M (A, B, C, D, E, F, G) and group O primary isolates with EC₅₀ values ranging from < 0.1 to 4.3 nM. These EC₅₀ values are well below the 50% cellular toxicity concentration range of 87 µ M to > 100 µ M.

Cobicistat has no detectable antiviral activity against HIV-1 and does not antagonise the antiviral effect of darunavir, emtricitabine, or tenofovir.

The antiviral activity of emtricitabine against laboratory and clinical isolates of HIV-1 was assessed in lymphoblastoid cell lines, the MAGI CCR5 cell line, and PBMCs. The EC₅₀ values for emtricitabine were in the range of 0.0013 to 0.64 μ M. Emtricitabine displayed antiviral activity in cell culture against HIV-1 clades A, B, C, D, E, F, and G (EC₅₀ values ranged from 0.007 to 0.075 μ M) and showed strain specific activity against HIV-2 (EC₅₀ values ranged from 0.007 to 1.5 μ M).

The antiviral activity of tenofovir alafenamide against laboratory and clinical isolates of HIV-1 subtype B was assessed in lymphoblastoid cell lines, PBMCs, primary monocyte/macrophage cells and CD4+-T lymphocytes. The EC₅₀ values for tenofovir alafenamide were in the range of 2.0 to 14.7 nM. Tenofovir alafenamide displayed antiviral activity in cell culture against all HIV-1 groups (M, N, and O), including subtypes A, B, C, D, E, F, and G (EC₅₀ values ranged from 0.10 to 12.0 nM) and showed strain specific activity against HIV-2 (EC₅₀ values ranged from 0.91 to 2.63 nM).

Resistance

In vitro selection of darunavir-resistant virus from wild type HIV-1 was lengthy (> 3 years). The selected viruses were unable to grow in the presence of darunavir concentrations above 400 nM. Viruses selected in these conditions and showing decreased susceptibility to darunavir (range: 23-50-fold) harboured 2 to 4 amino acid substitutions in the protease gene. The decreased susceptibility to darunavir of the emerging viruses in the selection experiment could not be explained by the emergence of these protease mutations.

In vivo, darunavir resistance-associated mutations (V11I, V32I, L33F, I47V, I50V, I54L or M, T74P, L76V, I84V and L89V) in HIV-1 protease were derived from clinical trial data of ART-experienced patients, all of whom were protease inhibitor experienced.

Reduced susceptibility to emtricitabine is associated with M184V/I mutations in HIV-1 RT.

HIV-1 isolates with reduced susceptibility to tenofovir alafenamide express a K65R mutation in HIV-1 RT; in addition, a K70E mutation in HIV-1 RT has been transiently observed. HIV-1 isolates with the K65R mutation have low-level reduced susceptibility to abacavir, emtricitabine, tenofovir, and lamivudine.

Emerging resistance in HIV-1 infected, treatment-naï ve and virologically suppressed patients

Over 96 weeks of treatment in the Phase 3 studies TMC114FD2HTX3001 (AMBER) in treatment-naï ve patients and TMC114IFD3013 (EMERALD) in virologically suppressed treatment-experienced patients, resistance testing was performed on samples from patients experiencing protocol-defined virologic failure (PDVF) and who had HIV-1 RNA ≥ 400 copies/mL at failure or at later time points. Emerging resistance in the Symtuza groups is shown in Table 4. No DRV, primary PI, or TDF/TAF resistance-associated mutations were observed.

Cross-resistance in HIV-1 infected, treatment-naï ve and virologically suppressed patients

The emtricitabine-resistant virus with the M184M/I/V mutation was cross-resistant to lamivudine, but retained sensitivity to abacavir, stavudine, tenofovir, and zidovudine.

Clinical data

HIV-1 Treatment naï ve patients

In double-blind Phase 3 Trial TMC114FD2HTX3001 (AMBER), treatment-naï ve patients were randomised to receive either Symtuza (N = 362) or a combination of fixed-dose combination of darunavir and cobicistat and fixed-dose combination of emtricitabine and tenofovir disoproxil fumarate (F/TDF) (N = 363) once daily. Virologic response was defined as < 50 copies/mL using the snapshot approach (see Table 5).

The 725 patients in total had a median age of 34 years (range 18-71), 88.3% were male, 83.2% White, 11.1% Black, 1.5% Asian. The mean baseline plasma HIV-1 RNA and the median baseline CD4+ cell count were 4.48 log₁₀ copies/mL (SD = 0.61) and 453 x 10⁶ cells/L (range 38 – 1,456 x 10⁶ cells/L), respectively.

Changes in measures of bone mineral density

In the Phase 3 study TMC114FD2HTX3001in treatment-naï ve patients, Symtuza was associated with no or smaller reductions in bone mineral density (BMD) compared DRV/COBI+F/TDF as measured by DXA analysis of hip (LS means percent change: 0.17% vs -2.69%, p < 0.001) and lumbar spine (LS means percent change: -0.68% vs -2.38%, p =0.004) after 48 weeks of treatment. After 96 weeks of treatment with Symtuza, the (95% CI) percent changes from baseline in BMD at the hip and spine region were respectively: -0.26 (-0.96; 0.45) % and -0.93 (-1.82; -0.05) %.

Changes in measures of renal function

In studies in treatment-naï ve patients, Symtuza was associated with a lower impact on the estimated glomerular filtration rate by Cockcroft-Gault method compared to control group (DRV/COBI+F/TDF).

HIV 1 Treatment experienced patients

Phase 3 trial TMC114IFD3013 (EMERALD) evaluated the efficacy of Symtuza in virologically-suppressed (HIV-1 RNA less than 50 copies/mL) HIV-1 infected patients. Patients were virologically suppressed for at least 2 months and no more than once had a viral load elevation above 50 HIV-1 RNA copies/mL during the year prior to enrollment. Patients were allowed in the study if they had previous failure on any non-darunavir ARV regimen. Patients had no history of virologic failure on darunavir-based regimens, and if historical genotypes were available, absence of darunavir RAMs. Patients were on a stable ARV regimen (for at least 6 months), consisting of a boosted protease inhibitor [either darunavir once daily or atazanavir (both boosted with ritonavir or cobicistat), or lopinavir with ritonavir] combined with emtricitabine and TDF. They either switched to Symtuza (N = 763) or continued their treatment regimen (N = 378) (randomised 2:1).

Patients had a median age of 46 years (range 19-78), 82% were male, 75.5% White, 20.9% Black, and 2.3% Asian. The median baseline CD4+ cell count was 628 x 10⁶ cells/mm³ (range 111-1 921 x 10⁶ cells/mm³). Week 48 and 96 virologic outcomes in the EMERALD trial are provided in Table 6.

Paediatric population

The use of Symtuza in ART-naï ve adolescent patients from the age of 12 years to < 18 years, and weighing at least 40 kg is supported by two trials in HIV-1 infected paediatric patients (TMC114-C230 and GS-US-292-0106). For more details, refer to the prescribing information of darunavir and emtricitabine/ tenofovir alafenamide.

An open-label, Phase 2 trial (TMC114-C230) was conducted for evaluating the pharmacokinetics, safety, tolerability, and efficacy of darunavir with low dose ritonavir in 12 ART-naï ve HIV-1 infected paediatric patients aged 12 to less than 18 years and weighing at least 40 kg. These patients received darunavir/ritonavir 800/100 mg once daily in combination with other antiretroviral agents. Virologic response was defined as a decrease in plasma HIV-1 RNA viral load of at least 1.0 log₁₀ versus baseline (see Table 7).

In the study GS-US-292-0106, the efficacy, safety, and pharmacokinetics of emtricitabine and tenofovir alafenamide were evaluated in an open-label study in which 50 HIV-1 infected, treatment-naï ve adolescents received emtricitabine and tenofovir alafenamide (10 mg) given with elvitegravir and cobicistat as a fixed-dose combination tablet. Patients had a median age of 15 years (range: 12-17), and 56% were female, 12% were Asian, and 88% were Black. At baseline, median plasma HIV-1 RNA was 4.7 log₁₀ copies/mL, median CD4+ cell count was 456 cells/mm³ (range: 95-1 110), and median CD4+ % was 23% (range: 7-45%). Overall, 22% had baseline plasma HIV-1 RNA > 100 000 copies/mL. At 48 weeks, 92% (46/50) achieved HIV-1 RNA < 50 copies/mL, similar to response rates in studies of treatment-naï ve HIV-1 infected adults. The mean increase from baseline in CD4+ cell count at Week 48 was 224 cells/mm³. No emergent resistance to E/C/F/TAF (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide) was detected through Week 48.

The European Medicines Agency has deferred the obligation to submit the results of studies with Symtuza in one or more subsets of the paediatric population in the treatment of HIV-1 infection (see section 4.2 for information on paediatric use).

The bioavailability of all components of Symtuza was comparable to that when darunavir 800 mg, cobicistat 150 mg, and emtricitabine/tenofovir alafenamide 200/10 mg were co-administered as separate formulations; bioequivalence was established following single-dose administration under fed conditions in healthy subjects (N = 96).

Absorption

The absolute bioavailability of a single 600 mg dose of darunavir alone was approximately 37% and increased to approximately 82% in the presence of 100 mg twice daily ritonavir. The absolute bioavailability of the emtricitabine 200 mg capsule was 93%.

All components were rapidly absorbed following oral administration of Symtuza in healthy subjects. Maximum plasma concentrations of darunavir, cobicistat, emtricitabine and tenofovir alafenamide were achieved at 4.00, 4.00, 2.00, and 1.50 hours after dosing, respectively. The bioavailability of the components of Symtuza was not affected when administered orally as a split tablet compared to administration as a tablet swallowed whole.

The exposure to darunavir and cobicistat administered as the Symtuza was 30-45% lower and 16-29% lower, respectively, in fasted compared to fed condition. For emtricitabine, the C_max was 1.26-fold higher in a fasted condition, while the AUC was comparable in fed and fasted condition. For tenofovir alafenamide, the C_max was 1.82-fold higher in fasted condition, while the area under the curve (AUC) was 20% lower to comparable in a fasted compared to fed condition. Symtuza tablets should be taken with food. The type of food does not affect exposure to Symtuza.

Distribution

Darunavir

Darunavir is approximately 95% bound to plasma protein. Darunavir binds primarily to plasma α ₁-acid glycoprotein.

Following intravenous administration, the volume of distribution of darunavir alone was 88.1 ± 59.0 L (mean ± SD) and increased to 131 ± 49.9 L (mean ± SD) in the presence of 100 mg twice-daily ritonavir.

Cobicistat

Cobicistat is 97% to 98% bound to human plasma proteins and the mean plasma to blood concentration ratio was approximately 2.

Emtricitabine

In vitro binding of emtricitabine to human plasma proteins was < 4% and independent of concentration over the range of 0.02-200 mcg/mL. At peak plasma concentration, the mean plasma to blood drug concentration ratio was approximately 1.0 and the mean semen to plasma drug concentration ratio was approximately 4.0.

Tenofovir alafenamide

In vitro binding of tenofovir to human plasma proteins is < 0.7% and is independent of concentration over the range of 0.01-25 mcg/mL. Ex vivo binding of tenofovir alafenamide to human plasma proteins in samples collected during clinical trials was approximately 80%.

Biotransformation

Darunavir

In vitro experiments with human liver microsomes (HLMs) indicate that darunavir primarily undergoes oxidative metabolism. Darunavir is extensively metabolised by the hepatic CYP system and almost exclusively by isozyme CYP3A4. A [¹⁴C]-darunavir trial in healthy volunteers showed that a majority of the radioactivity in plasma after a single 400/100 mg darunavir with ritonavir dose was due to the parent active substance. At least 3 oxidative metabolites of darunavir have been identified in humans; all showed activity that was at least 10-fold less than the activity of darunavir against wild type HIV.

Cobicistat

Cobicistat is metabolised via CYP3A (major)- and CYP2D6 (minor)-mediated oxidation and does not undergo glucuronidation. Following oral administration of [¹⁴C]-cobicistat, 99% of circulating radioactivity in plasma was unchanged cobicistat. Low levels of metabolites are observed in urine and faeces and do not contribute to the CYP3A inhibitory activity of cobicistat.

Emtricitabine

In vitro studies indicate that emtricitabine is not an inhibitor of human CYP enzymes. Following administration of [¹⁴C]-emtricitabine, complete recovery of the emtricitabine dose was achieved in urine (approximately 86%) and faeces (approximately 14%). Thirteen percent of the dose was recovered in the urine as three putative metabolites. The biotransformation of emtricitabine includes oxidation of the thiol moiety to form the 3'-sulfoxide diastereomers (approximately 9% of dose) and conjugation with glucuronic acid to form 2'-O-glucuronide (approximately 4% of dose). No other metabolites were identifiable.

Tenofovir alafenamide

Metabolism is a major elimination pathway for tenofovir alafenamide in humans, accounting for > 80% of an oral dose. In vitro studies have shown that tenofovir alafenamide is metabolised to tenofovir (major metabolite) by cathepsin A in PBMCs (including lymphocytes and other HIV target cells) and macrophages; and by carboxylesterase-1 in hepatocytes. In vivo, tenofovir alafenamide is hydrolysed within cells to form tenofovir (major metabolite), which is phosphorylated to the active metabolite tenofovir diphosphate.

In vitro, tenofovir alafenamide is not metabolised by CYP1A2, CYP2C8, CYP2C9, CYP2C19, or CYP2D6. Tenofovir alafenamide is minimally metabolised by CYP3A4. Upon co-administration with the moderate CYP3A inducer probe efavirenz, tenofovir alafenamide exposure was not significantly affected. Following administration of tenofovir alafenamide, plasma [¹⁴C]-radioactivity showed a time-dependent profile with tenofovir alafenamide as the most abundant species in the initial few hours and uric acid in the remaining period.

Elimination

Darunavir

After a 400/100 mg [¹⁴C]-darunavir with ritonavir dose, approximately 79.5% and 13.9% of the administered dose of [¹⁴C]-darunavir could be retrieved in faeces and urine, respectively. Unchanged darunavir accounted for approximately 41.2% and 7.7% of the administered dose in faeces and urine, respectively.

The intravenous clearance of darunavir alone (150 mg) and in the presence of low dose (100 mg) ritonavir was 32.8 l/h and 5.9 l/h, respectively. The median terminal plasma half-life of darunavir following administration of Symtuza is 5.5 hours.

Cobicistat

Following oral administration of [¹⁴C]-cobicistat, 86% and 8.2% of the dose were recovered in faeces and urine, respectively. The median terminal plasma half-life of cobicistat following administration of Symtuza is 3.6 hours.

Emtricitabine

Emtricitabine is primarily excreted by the kidneys with complete recovery of the dose achieved in urine (approximately 86%) and faeces (approximately 14%). Thirteen percent of the emtricitabine dose was recovered in urine as three metabolites. The systemic clearance of emtricitabine averaged 307 mL/min. Following oral administration of Symtuza, the median terminal elimination half-life of emtricitabine is 17.2 hours.

Tenofovir alafenamide

Tenofovir alafenamide is mainly eliminated following metabolism to tenofovir. The median terminal elimination half– life of tenofovir alafenamide was 0.3 hours when administered as Symtuza. Tenofovir is eliminated from the body by the kidneys by both glomerular filtration and active tubular secretion. Tenofovir has a median plasma half-life of approximately 32 hours. Renal excretion of intact tenofovir alafenamide is a minor pathway with less than 1% of the dose eliminated in urine. The pharmacologically active metabolite, tenofovir diphosphate, has a half-life of 150-180 hours within PBMCs.

Special populations

Paediatric population

The pharmacokinetics of Symtuza have not been investigated in paediatric patients. However, there are pharmacokinetic data for the different components of Symtuza, indicating that doses of 800 mg darunavir, 150 mg cobicistat, 200 mg emtricitabine and 10 mg tenofovir alafenamide result in similar exposures in adults and adolescents aged 12 years and older, weighing at least 40 kg.

Elderly

Limited PK information is available in the elderly (age ≥ 65 years of age) for Symtuza as well as its individual components.

Population pharmacokinetic analysis in HIV infected patients showed that darunavir pharmacokinetics are not considerably different in the age range (18 to 75 years) evaluated in HIV infected patients (N = 12, age ≥ 65 years) (see section 4.4).

No clinically relevant pharmacokinetic differences due to age have been identified for cobicistat, emtricitabine or tenofovir alafenamide in the age range ≤ 65 years.

Gender

Population pharmacokinetic analysis showed a slightly higher darunavir exposure (16.8%) in HIV-1 infected females compared to males. This difference is not clinically relevant.

No clinically relevant pharmacokinetic differences due to gender have been identified for cobicistat, emtricitabine or tenofovir alafenamide.

Renal impairment

Symtuza has not been investigated in patients with renal impairment. There are pharmacokinetic data for the (individual) components of Symtuza.

Darunavir

Results from a mass balance study with [¹⁴C]-darunavir with ritonavir showed that approximately 7.7% of the administered dose of darunavir is excreted in the urine unchanged.

Although darunavir has not been studied in patients with renal impairment, population pharmacokinetic analysis showed that the pharmacokinetics of darunavir were not significantly affected in HIV infected patients with moderate renal impairment (eGFR_CG between 30-60 mL/min, N = 20) (see sections 4.2 and 4.4).

Cobicistat

A trial of the pharmacokinetics of cobicistat was performed in non-HIV-1 infected subjects with severe renal impairment (eGFR_CG below 30 mL/min). No meaningful differences in cobicistat pharmacokinetics were observed between subjects with severe renal impairment and healthy subjects, consistent with low renal clearance of cobicistat.

Emtricitabine

Mean systemic emtricitabine exposure was higher in patients with severe renal impairment (eGFR_CG < 30 mL/min) (33.7 mcg• h/mL) than in subjects with normal renal function (11.8 mcg• h/mL).

Tenofovir alafenamide

No clinically relevant differences in tenofovir alafenamide, or tenofovir pharmacokinetics were observed between healthy subjects and patients with severe renal impairment (eGFR_CG > 15 but < 30 mL/min) in studies of tenofovir alafenamide. There are no pharmacokinetic data on tenofovir alafenamide in patients with eGFR_CG < 15 mL/min.

Hepatic impairment

Symtuza has not been investigated in patients with hepatic impairment. There are pharmacokinetic data for the (individual) components of Symtuza.

Darunavir

Darunavir is primarily metabolised and eliminated by the liver. In a multiple dose trial with darunavir/ritonavir (600/100 mg) twice daily, it was demonstrated that the total plasma concentrations of darunavir in subjects with mild (Child-Pugh Class A, N = 8) and moderate (Child-Pugh Class B, N = 8) hepatic impairment were comparable with those in healthy subjects. However, unbound darunavir concentrations were approximately 55% (Child-Pugh Class A) and 100% (Child-Pugh Class B) higher, respectively. The clinical relevance of this increase is unknown. The effect of severe hepatic impairment on the pharmacokinetics of darunavir has not been studied (see sections 4.2, 4.3 and 4.4).

Cobicistat

Cobicistat is primarily metabolised and eliminated by the liver. A trial of the pharmacokinetics of cobicistat was performed in non-HIV-1 infected subjects with moderate hepatic impairment (Child-Pugh Class B). No clinically relevant differences in cobicistat pharmacokinetics were observed between subjects with moderate impairment and healthy subjects. The effect of severe hepatic impairment (Child-Pugh Class C) on the pharmacokinetics of cobicistat has not been studied.

Emtricitabine

The pharmacokinetics of emtricitabine have not been studied in patients with hepatic impairment; however, emtricitabine is not significantly metabolised by liver enzymes, so the impact of liver impairment should be limited.

Tenofovir alafenamide

Clinically relevant changes in tenofovir pharmacokinetics in patients with hepatic impairment were not observed in patients with mild to moderate hepatic impairment. The effect of severe hepatic impairment (Child-Pugh Class C) on the pharmacokinetics of tenofovir alafenamide has not been studied.

Hepatitis B and/or hepatitis C virus co-infection

There were insufficient pharmacokinetic data in the clinical trials to determine the effect of hepatitis B and/or C virus infection on the pharmacokinetics of darunavir,cobicistat, emtricitabine, or tenofovir alafenamide (refer to sections 4.4 and 4.8).

Pregnancy and postpartum

Treatment with darunavir/cobicistat 800/150 mg once daily during pregnancy results in low darunavir exposure (see Table 8). In women receiving darunavir/cobicistat during the second trimester of pregnancy, mean intra-individual values for total darunavir C_max, AUC_24h and C_min were 49%, 56% and 92% lower, respectively, as compared with postpartum; during the third trimester of pregnancy, total darunavir C_max, AUC_24h and C_min values were 37%, 50% and 89% lower, respectively, as compared with postpartum. The unbound fraction was also substantially reduced, including around 90% reductions of C_min levels. The main cause of these low exposures is a marked reduction in cobicistat exposure as a consequence of pregnancy-associated enzyme induction (see below).

Table 8

The exposure to cobicistat was lower during pregnancy, potentially leading to suboptimal boosting of darunavir. During the second trimester of pregnancy, cobicistat C_max, AUC_24h, and C_min were 50%, 63%, and 83% lower, respectively, as compared with postpartum. During the third trimester of pregnancy, cobicistat C_max, AUC_24h, and C_min, were 27%, 49%, and 83% lower, respectively, as compared with postpartum.

No pharmacokinetic data are available for emtricitabine and tenofovir alafenamide during pregnancy.

Darunavir

Non-clinical data on darunavir reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential. Darunavir has no effect on fertility or early embryonic development and DRV shows no teratogenic potential, at exposure levels below those at the recommended clinical dose in humans.

In juvenile rats receiving darunavir up to days 23-26 (equivalent to less than 2 years of age in humans), increased mortality was observed with convulsions in some animals. These findings were attributed to the immaturity of the liver enzymes and of the blood brain barrier. Due to uncertainties regarding the rate of development of the human blood brain barrier and liver enzymes Symtuza should not be used in paediatric patients below 3 years of age.

Cobicistat

Non-clinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity, genotoxicity, and toxicity to reproduction and development. No teratogenic effects were observed in rats and rabbit developmental toxicity studies. In rats, ossification changes in the spinal column and sternebrae of foetuses occurred at a dose that produced significant maternal toxicity.

Ex vivo rabbit studies and in vivo dog studies suggest that cobicistat has a low potential for QT prolongation, and may slightly prolong the PR interval and decrease left ventricular function at mean concentrations at least 10-fold higher than the human exposure at the recommended 150 mg daily dose.

A long-term carcinogenicity study of cobicistat in rats revealed tumourigenic potential specific for this species, that is regarded as of no relevance for humans. A long-term carcinogenicity study in mice did not show any carcinogenic potential.

Emtricitabine

Non-clinical data on emtricitabine reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, toxicity to reproduction and development.

Emtricitabine had demonstrated low carcinogenic potential in mice and rats.

Tenofovir alafenamide

Non-clinical studies of tenofovir alafenamide in rats and dogs revealed bone and kidney as the primary target organs of toxicity. Bone toxicity was observed as reduced bone mineral density in rats and dogs at tenofovir exposures at least four times greater than those expected after administration of Symtuza. A minimal infiltration of histiocytes was present in the eye in dogs at tenofovir alafenamide and tenofovir exposures of approximately 15 and 40 times greater, respectively, than those expected after administration of Symtuza.

Tenofovir alafenamide was not mutagenic or clastogenic in conventional genotoxicity assays.

Because there is a lower tenofovir exposure in rats and mice after the administration of tenofovir alafenamide compared to tenofovir disoproxil, carcinogenicity studies and a rat peri-postnatal study were conducted only with tenofovir disoproxil. No special hazard for humans was revealed in conventional studies of carcinogenic potential and toxicity to reproduction and development. Reproductive toxicity studies in rats and rabbits showed no effects on mating, fertility, pregnancy or foetal parameters. However, tenofovir disoproxil reduced the viability index and weight of pups in a peri-postnatal toxicity study at maternally toxic doses.

Tablet core

Croscarmellose sodium

Magnesium stearate

Cellulose, microcrystalline

Silica, colloidal anhydrous

Tablet coating

Macrogol 4 000

Poly (vinyl alcohol)– partially hydrolysed

Talc

Titanium dioxide (E171)

Iron oxide yellow (E172)

Not applicable.

3 years

After first opening: 6 weeks

Store in the original package with desiccant inside the bottle in order to protect the tablets from moisture. Keep the bottle tightly closed. Tablets may be stored outside of the original container for up to 7 days and should be discarded after that time if not taken. Tablets stored outside of the original container should not be placed back into the container.

White, high density polyethylene (HDPE) bottle with a silica gel desiccant (contained in a separate sachet or canister) fitted with polypropylene (PP) child resistant closure with induction seal.

Each bottle contains 30 tablets.

Pack size of one bottle or three bottles per carton.

Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.