INTELENCE, in combination with a boosted protease inhibitor and other antiretroviral medicinal products, is indicated for the treatment of human immunodeficiency virus type 1 (HIV‑1) infection in antiretroviral treatment‑experienced adult patients and in antiretroviral treatment‑experienced paediatric patients from 2 years of age (see sections 4.4, 4.5 and 5.1).

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

Posology

INTELENCE must always be given in combination with other antiretroviral medicinal products.

Adults

The recommended dose of etravirine for adults is 200 mg (one 200 mg tablet or two 100 mg tablets) taken orally twice daily following a meal (see section 5.2).

Paediatric population (2 years to less than 18 years of age)

The recommended dose of etravirine for paediatric patients (2 years to less than 18 years of age and weighing at least 10 kg) is based on body weight (see table below). INTELENCE tablet(s) should be taken orally, following a meal (see section 5.2).

Missed dose

If the patient misses a dose of INTELENCE within 6 hours of the time it is usually taken, the patient should take it following a meal as soon as possible and then take the next dose at the regularly scheduled time. If a patient misses a dose by more than 6 hours of the time it is usually taken, the patient should not take the missed dose and simply resume the usual dosing schedule.

If a patient vomits within 4 hours of taking the medicine, another dose of INTELENCE should be taken following a meal as soon as possible. If a patient vomits more than 4 hours after taking the medicine, the patient does not need to take another dose until the next regularly scheduled time.

Elderly

There is limited information regarding the use of INTELENCE in patients > 65 years of age (see section 5.2), therefore caution should be used in this population.

Hepatic impairment

No dose adjustment is suggested in patients with mild or moderate hepatic impairment (Child‑Pugh Class A or B); INTELENCE should be used with caution in patients with moderate hepatic impairment. The pharmacokinetics of etravirine have not been studied in patients with severe hepatic impairment (Child‑Pugh Class C). Therefore, INTELENCE is not recommended in patients with severe hepatic impairment (see sections 4.4 and 5.2).

Renal impairment

No dose adjustment is required in patients with renal impairment (see section 5.2).

Paediatric population (less than 2 years of age)

INTELENCE should not be used in children less than 2 years of age. Currently available data for children between 1 and 2 years old are described in sections 4.8, 5.1 and 5.2 and suggest that the benefits do not outweigh the risks in this age group. No data are available for children less than 1 year of age.

Method of administration

Oral use.

Patients should be instructed to swallow the tablet(s) whole with a liquid such as water. Patients who are unable to swallow the tablet(s) whole may disperse the tablet(s) in a glass of water (see section 4.4).

For instructions on dispersion of the medicinal product before administration, see section 6.6.

INTELENCE should optimally be combined with other antiretrovirals that exhibit activity against the patient’s virus (see section 5.1).

A decreased virologic response to etravirine was observed in patients with viral strains harbouring 3 or more among the following mutations V90I, A98G, L100I, K101E/P, V106I, V179D/F, Y181C/I/V, and G190A/S (see section 5.1).

Conclusions regarding the relevance of particular mutations or mutational patterns are subject to change with additional data, and it is recommended to always consult current interpretation systems for analysing resistance test results.

No data other than drug‑drug interaction data (see section 4.5) are available when etravirine is combined with raltegravir or maraviroc.

Severe cutaneous and hypersensitivity reactions

Severe cutaneous adverse reactions have been reported with etravirine. In clinical trials, Stevens‑Johnson Syndrome and erythema multiforme have been rarely (< 0.1%) reported. Treatment with INTELENCE should be discontinued if a severe cutaneous reaction develops.

The clinical data are limited and an increased risk of cutaneous reactions in patients with a history of NNRTI‑associated cutaneous reactions cannot be excluded. Caution should be observed in such patients, especially in case of history of a severe cutaneous drug reaction.

Cases of severe hypersensitivity syndromes, including DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) and TEN (toxic epidermal necrolysis), sometimes fatal, have been reported with the use of etravirine (see section 4.8). The DRESS syndrome is characterised by rash, fever, eosinophilia and systemic involvement (including, but not limited to, severe rash or rash accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and eosinophilia). Time to onset is usually around 3‑6 weeks and the outcome in most cases is favourable upon discontinuation and after initiation of corticosteroid therapy.

Patients should be informed to seek medical advice if severe rash or hypersensitivity reactions occur. Patients who are diagnosed with a hypersensitivity reaction whilst on therapy must discontinue INTELENCE immediately.

Delay in stopping INTELENCE treatment after the onset of severe rash may result in a life‑threatening reaction.

Patients who have stopped treatment due to hypersensitivity reactions should not restart therapy with INTELENCE.

Rash

Rash has been reported with etravirine. Most frequently, rash was mild to moderate, occurred in the second week of therapy, and was infrequent after week 4. Rash was mostly self‑limiting and generally resolved within 1 to 2 weeks on continued therapy. When prescribing INTELENCE to females, prescribers should be aware that the incidence of rash was higher in females (see section 4.8).

Paediatric population

For children who cannot swallow the tablet(s) whole, the tablet(s) may be dispersed in liquid. This should only be considered if the child is likely to take the entire dose of the tablet(s) in liquid (see sections 4.2 and 6.6). The importance of consuming the entire dose needs to be highlighted to the child and his/her caregiver to avoid too low exposure and lack of virologic response. In case of any doubt that a child will take the entire dose of the tablet(s) dispersed in liquid, treatment with another antiretroviral product needs to be considered.

Elderly

Experience in geriatric patients is limited: in the Phase III trials, 6 patients aged 65 years or older and 53 patients aged 56‑64 years received etravirine. The type and incidence of adverse reactions in patients > 55 years of age were similar to the ones in younger patients (see sections 4.2 and 5.2).

Pregnancy

Given the increased etravirine exposure during pregnancy, caution should be applied for those pregnant patients that require concomitant medicinal products or have comorbidities that may further increase etravirine exposure.

Patients with coexisting conditions

Hepatic impairment

Etravirine is primarily metabolised and eliminated by the liver and highly bound to plasma proteins. Effects on unbound exposure could be expected (has not been studied) and therefore caution is advised in patients with moderate hepatic impairment. Etravirine has not been studied in patients with severe hepatic impairment (Child‑Pugh Class C) and its use is therefore not recommended in this group of patients (see sections 4.2 and 5.2).

Co‑infection with HBV (hepatitis B virus) or HCV (hepatitis C virus)

Caution should be exercised in patients co‑infected with hepatitis B or C virus due to the current limited data available. A potential increased risk of liver enzymes increase cannot be excluded.

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.

Immune reconstitution syndrome

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 are cytomegalovirus retinitis, generalised and/or focal mycobacterial infections and Pneumocystis jiroveci pneumonia. Any inflammatory symptoms should be evaluated and treatment instituted when necessary.

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

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 CART. Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.

Interactions with medicinal products

It is not recommended to combine etravirine with tipranavir/ritonavir, due to a marked pharmacokinetic interaction (76% decrease of etravirine AUC) that could significantly impair the virologic response to etravirine.

The combination of etravirine with daclatasvir, atazanavir/cobicistat or darunavir/cobicistat is not recommended (see section 4.5).

For further information on interactions with medicinal products see section 4.5.

Lactose intolerance and lactase deficiency

INTELENCE 100 mg tablets

Each tablet contains 160 mg of lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose‑galactose malabsorption should not take this medicine.

Medicinal products that affect etravirine exposure

Etravirine is metabolised by CYP3A4, CYP2C9 and CYP2C19 followed by glucuronidation of the metabolites by uridine diphosphate glucuronosyl transferase (UDPGT). Medicinal products that induce CYP3A4, CYP2C9 or CYP2C19 may increase the clearance of etravirine, resulting in lowered plasma concentrations of etravirine.

Co‑administration of etravirine and medicinal products that inhibit CYP3A4, CYP2C9 or CYP2C19 may decrease the clearance of etravirine and may result in increased plasma concentrations of etravirine.

Medicinal products that are affected by the use of etravirine

Etravirine is a weak inducer of CYP3A4. Co‑administration of etravirine with medicinal products primarily metabolised by CYP3A4 may result in decreased plasma concentrations of such medicinal products, which could decrease or shorten their therapeutic effects.

Etravirine is a weak inhibitor of CYP2C9 and CYP2C19. Etravirine is also a weak inhibitor of P‑glycoprotein. Co‑administration with medicinal products primarily metabolised by CYP2C9 or CYP2C19, or transported by P‑glycoprotein, may result in increased plasma concentrations of such medicinal products, which could increase or prolong their therapeutic effect or alter their adverse events profile.

Known and theoretical interactions with selected antiretrovirals and non‑antiretroviral medicinal products are listed in table 2. The table is not all-inclusive.

Interaction table

Interactions between etravirine and co‑administered medicinal products are listed in table 2 (increase is indicated as “↑”, decrease as “↓”, no change as “↔”, not done as “ND”, confidence interval as “CI”).

Paediatric population

Interaction studies have only been performed in adults.

Pregnancy

As a general rule, when deciding to use antiretroviral agents for the treatment of HIV infection in pregnant women, and consequently for reducing the risk of HIV vertical transmission to the newborn, the animal data as well as the clinical experience in pregnant women should be taken into account in order to characterise the safety for the foetus.

Placental transfer has been seen in pregnant rats, but it is not known whether placental transfer of etravirine also occurs in pregnant women. Studies in animals do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see section 5.3). Based on animal data the malformative risk is unlikely in humans. The clinical data do not raise safety concern but are very limited.

Breast‑feeding

Etravirine is excreted in human milk.

Because of the potential for adverse events in nursing infants, women should be instructed not to breastfeed if they are receiving INTELENCE. It is recommended that women living with HIV do not breastfeed in order to avoid transmission of HIV.

Fertility

No human data on the effect of etravirine on fertility are available. In rats, there was no effect on mating or fertility with etravirine treatment (see section 5.3).

INTELENCE has minor influence on the ability to drive and use machines. No studies on the effects of INTELENCE on the ability to drive or operate machines have been performed. Adverse reactions such as somnolence and vertigo have been reported in etravirine‑treated patients and should be considered when assessing a patient’s ability to drive or operate machinery (see section 4.8).

Summary of the safety profile

The most frequent (incidence ≥ 10%) adverse reactions of all intensities reported for etravirine were rash, diarrhoea, nausea and headache. In the Phase III studies, the rates of discontinuation due to any adverse reaction were 7.2% in patients receiving etravirine. The most common adverse reaction leading to discontinuation was rash.

Tabulated list of adverse reactions

Adverse reactions reported in patients treated with etravirine are summarised in Table 3. The adverse reactions are listed by system organ class (SOC) and frequency. Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. Frequencies are defined as very common (≥ 1/10), common (≥ 1/100 to < 1/10) and uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000) and very rare (< 1/10,000).

Description of selected adverse reactions

Rash

Rash was most frequently mild to moderate, generally macular to maculopapular or erythematous, mostly occurred in the second week of therapy, and was infrequent after week 4. Rash was mostly self‑limiting, and generally resolved within 1‑2 weeks on continued therapy (see section 4.4). The incidence of rash was higher in women compared to men in the etravirine arm in the DUET trials (rash ≥ grade 2 was reported in 9/60 [15.0%] women versus 51/539 [9.5%] men; discontinuations due to rash were reported in 3/60 [5.0%] women versus 10/539 [1.9%] men) (see section 4.4). There was no gender difference in severity or treatment discontinuation due to rash. The clinical data are limited and an increased risk of cutaneous reactions in patients with a history of NNRTI‑associated cutaneous reaction cannot be excluded (see section 4.4).

Metabolic parameters

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

Immune reconstitution syndrome

In HIV infected patients with severe immune deficiency at the time of initiation of combination antiretroviral therapy (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).

Osteonecrosis

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

Paediatric population (1 year to less than 18 years of age)

The safety assessment in children and adolescents is based on two single-arm trials. PIANO (TMC125-C213) is a Phase II trial in which 101 antiretroviral treatment-experienced HIV-1 infected paediatric patients 6 years to less than 18 years of age received INTELENCE in combination with other antiretroviral agents. TMC125-C234/IMPAACT P1090 is a Phase I/II trial in which 26 antiretroviral treatment-experienced HIV-1 infected paediatric patients aged 1 years to less than 6 years received INTELENCE in combination with other antiretroviral agents (see section 5.1).

In PIANO and TMC125-C234/IMPAACT P1090, the frequency, type and severity of adverse reactions in paediatric patients were comparable to those observed in adults. In PIANO, rash was reported more frequently in female subjects than in male subjects (rash ≥ grade 2 was reported in 13/64 [20.3%] females versus 2/37 [5.4%] males; discontinuations due to rash were reported in 4/64 [6.3%] females versus 0/37 [0%] males) (see section 4.4). Most often, rash was mild to moderate, of macular/papular type, and occurred in the second week of therapy. Rash was mostly self‑limiting and generally resolved within 1 week on continued therapy.

In a postmarketing retrospective cohort study aiming at substantiating the long-term safety profile of etravirine in HIV‑1‑infected children and adolescents receiving etravirine with other HIV‑1 antiretrovirals (N = 182), Stevens-Johnson Syndrome was reported at a higher incidence (1%) than has been reported in adult clinical trials (< 0.1%).

Other special populations

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

In the pooled analysis for DUET‑1 and DUET‑2, the incidence of hepatic events tended to be higher in co‑infected subjects treated with etravirine compared to co‑infected subjects in the placebo group. INTELENCE should be used with caution in these patients (see also sections 4.4 and 5.2).

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 national reporting system listed in Appendix V.

To reports any side effect(s):

        Saudi Arabia:

·       The National Pharmacovigilance Centre (NPC):

-       SFDA Call Center: 19999

-       E-mail: npc.drug@sfda.gov.sa

-       Website: https://ade.sfda.gov.sa/

       Other GCC States:

-       Please contact the relevant competent authority.

There are no data with regard to symptomatic overdose with etravirine, but it is possible that the most frequent adverse reactions of etravirine, i.e. rash, diarrhoea, nausea, and headache would be the most common symptoms noted. There is no specific antidote for overdose with etravirine. Treatment of overdose with INTELENCE consists of general supportive measures including monitoring of vital signs and observation of the clinical status of the patient. Since etravirine is highly protein bound, dialysis is unlikely to result in significant removal of the active substance.

Pharmacotherapeutic group: Antivirals for systemic use, non‑nucleoside reverse transcriptase inhibitors, ATC code: J05AG04.

Mechanism of action

Etravirine is an NNRTI of human immunodeficiency virus type 1 (HIV‑1). Etravirine binds directly to reverse transcriptase (RT) and blocks the RNA‑dependent and DNA‑dependent DNA polymerase activities by causing a disruption of the enzyme’s catalytic site.

Antiviral activity in vitro

Etravirine exhibits activity against wild type HIV‑1 in T‑cell lines and primary cells with median EC₅₀ values ranging from 0.9 to 5.5 nM. Etravirine demonstrates activity against HIV‑1 group M (subtypes A, B, C, D, E, F, and G) and HIV‑1 group O primary isolates with EC₅₀ values ranging from 0.3 to 1.7 nM and from 11.5 to 21.7 nM, respectively. Although etravirine demonstrates in vitro activity against wild type HIV‑2 with median EC₅₀ values ranging from 5.7 to 7.2 µM, treatment of HIV‑2 infection with etravirine is not recommended in the absence of clinical data. Etravirine retains activity against HIV‑1 viral strains resistant to nucleoside reverse transcriptase and/or protease inhibitors. In addition, etravirine demonstrates a fold change (FC) in EC₅₀ ≤ 3 against 60% of 6,171 NNRTI‑resistant clinical isolates.

Resistance

Etravirine efficacy in relation to NNRTI resistance at baseline has mainly been analysed with etravirine given in combination with darunavir/ritonavir (DUET‑1 and DUET‑2). Boosted protease inhibitors, like darunavir/ritonavir, show a higher barrier to resistance compared to other classes of antiretrovirals. The breakpoints for reduced efficacy with etravirine (> 2 etravirine‑associated mutations at baseline, see clinical results section) applies when etravirine is given in combination with a boosted protease inhibitor. This breakpoint might be lower in antiretroviral combination therapy not including a boosted protease inhibitor.

In the Phase III trials DUET‑1 and DUET‑2, mutations that developed most commonly in patients with virologic failure to the etravirine containing regimen were V108I, V179F, V179I, Y181C and Y181I, which usually emerged in a background of multiple other NNRTI resistance‑associated mutations (RAMs). In all the other trials conducted with etravirine in HIV‑1 infected patients, the following mutations emerged most commonly: L100I, E138G, V179F, V179I, Y181C and H221Y.

Cross‑resistance

Following virologic failure of an etravirine‑containing regimen it is not recommended to treat patients with efavirenz and/or nevirapine.

Clinical efficacy and safety

Treatment‑experienced adult patients

Pivotal studies

The evidence of efficacy of etravirine is based on 48‑week data from 2 Phase III trials DUET‑1 and DUET‑2. These trials were identical in design and similar efficacy for etravirine was seen in each trial. The results below are pooled data from the two trials.

Trial characteristics

-              Design: randomised (1:1), double‑blinded, placebo‑controlled.

-              Treatment: Etravirine vs. placebo, in addition to a background regimen (BR) including darunavir/ritonavir (DRV/rtv), investigator‑selected N(t)RTIs and optional enfuvirtide (ENF).

-              Main inclusion criteria:

·              HIV‑1 plasma viral load > 5,000 HIV‑1 RNA copies/ml at screening

·              1 or more NNRTI resistance‑associated mutations (RAMs) at screening or from prior genotypic analysis (i.e., archived resistance)

·              3 or more primary PI mutations at screening

·              on a stable antiretroviral regimen for at least 8 weeks.

-              Stratification: Randomisation was stratified by the intended use of ENF in the BR, previous use of darunavir and screening viral load.

-              Virologic response was defined as achieving a confirmed undetectable viral load (< 50 HIV‑1 RNA copies/ml).

Summary of efficacy results

Since there was a significant interaction effect between treatment and ENF, the primary analysis was done for 2 ENF strata (patients reusing or not using ENF versus patients using ENF de novo). The week 48 results from the pooled analysis of DUET‑1 and DUET‑2 demonstrated that the etravirine arm was superior to the placebo arm irrespective of whether ENF was used de novo (p = 0.0199) or not (p < 0.0001). Results of this analysis (week 48 data) by ENF stratum are shown in table 4.

Significantly fewer patients in the etravirine arm reached a clinical endpoint (AIDS‑defining illness and/or death) as compared to the placebo arm (p = 0.0408).

A subgroup analysis of the virologic response (defined as a viral load < 50 HIV‑1 RNA copies/ml) at week 48 by baseline viral load and baseline CD4 count (pooled DUET data) is presented in table 5.

Baseline genotype or phenotype and virologic outcome analyses

In DUET‑1 and DUET‑2, the presence at baseline of 3 or more of the following mutations: V90I, A98G, L100I, K101E, K101P, V106I, V179D, V179F, Y181C, Y181I, Y181V, G190A and G190S, (etravirine RAMs) was associated with a decreased virologic response to etravirine (see table 6). These individual mutations occurred in the presence of other NNRTI RAMs. V179F was never present without Y181C.

Conclusions regarding the relevance of particular mutations or mutational patterns are subject to change with additional data, and it is recommended to always consult current interpretation systems for analysing resistance test results.

The presence of K103N alone, which was the most prevalent NNRTI mutation in DUET‑1 and DUET‑2 at baseline, was not identified as a mutation associated with resistance to etravirine. Furthermore, the presence of this mutation alone did not affect the response in the etravirine arm. Additional data is required to conclude on the influence of K103N when associated with other NNRTIs mutations.

Data from the DUET studies suggest that baseline fold change (FC) in EC₅₀ to etravirine was a predictive factor of virologic outcome, with gradually decreasing responses observed above FC 3 and FC 13.

FC subgroups are based on the select patient populations in DUET‑1 and DUET‑2 and are not meant to represent definitive clinical susceptibility breakpoints for etravirine.

Exploratory head to head comparison with protease inhibitor in protease inhibitor naïve patients (trial TMC125‑C227)

TMC125‑C227 was an exploratory, randomised, active‑controlled open‑label trial, which investigated the efficacy and safety of etravirine in a treatment regimen, which is not approved under the current indication. In the TMC125‑C227 study, etravirine (N = 59) was administered with 2 investigator‑selected NRTIs (i.e. without a ritonavir‑boosted PI) and compared to an investigator‑selected combination of a PI with 2 NRTIs (N = 57). The trial population included PI‑naïve, NNRTI‑experienced patients with evidence of NNRTI resistance.

At week 12, virologic response was greater in the control‑PI arm (‑2.2 log₁₀ copies/ml from baseline; n = 53) compared to the etravirine arm (‑1.4 log₁₀ copies/ml from baseline; n = 40). This difference between treatment arms was statistically significant.

Based on these trial results, etravirine is not recommended for use in combination with N(t)RTIs only in patients who have experienced virological failure on an NNRTI‑ and N(t)RTI‑containing regimen.

Paediatric population

Treatment‑experienced paediatric patients (6 years to less than 18 years of age)

PIANO is a single‑arm, Phase II trial evaluating the pharmacokinetics, safety, tolerability, and efficacy of etravirine in 101 antiretroviral treatment‑experienced HIV‑1 infected paediatric patients 6 years to less than 18 years of age and weighing at least 16 kg. The study enrolled patients on a stable but virologically failing antiretroviral treatment regimen, with a confirmed HIV‑1 RNA plasma viral load ≥ 500 copies/ml. Sensitivity of the virus to etravirine at screening was required.

The median baseline plasma HIV‑1 RNA was 3.9 log₁₀ copies/ml, and the median baseline CD4 cell count was 385 x 10⁶ cells/l.

At week 48, 53.5% of all paediatric patients had a confirmed undetectable viral load < 50 HIV‑1 RNA copies/ml according to the TLOVR algorithm. The proportion of paediatric patients with < 400 HIV‑1 RNA copies/ml was 63.4%. The mean change in plasma HIV‑1 RNA from baseline to week 48 was ‑1.53 log₁₀ copies/ml, and the mean CD4 cell count increase from baseline was 156 x 10⁶ cells/l.

Treatment-experienced paediatric patients (1 year to less than 6 years of age)

TMC125‑C234/IMPAACT P1090 is a Phase I/II trial evaluating the pharmacokinetics, safety, tolerability, and efficacy of INTELENCE in 20 antiretroviral treatment-experienced HIV‑1 infected pediatric patients 2 years to less than 6 years of age (Cohort I) and 6 antiretroviral treatment-experienced HIV‑1 infected pediatric patients 1 year to less than 2 years of age (Cohort II). No patients have been enrolled in Cohort III (≥ 2 months to < 1 year). The study enrolled patients on a virologically failing antiretroviral treatment regimen for at least 8 weeks or on a treatment interruption of at least 4 weeks with a history of virologic failure while on an antiretroviral regimen, with a confirmed HIV‑1 RNA plasma viral load greater than 1,000 copies/ml and with no evidence of phenotypic resistance to etravirine at screening.

Table 8 summarizes the virologic response results for the TMC125‑C234/IMPAACT P1090 study.

Subgroup analyses showed that for subjects aged 2 to less than 6 years virologic response [HIV RNA < 400 copies/ml] was 100.0% [6/6] for subjects who swallowed the etravirine tablet whole, 100% [4/4] for subjects who took a combination of both etravirine dispersed in liquid and etravirine tablet whole and 60% [6/10] for subjects who took etravirine dispersed in liquid. Of the 4 subjects who did not show virologic response and took etravirine dispersed in liquid, 3 showed virologic failure and had adherence issues, and one discontinued prior to Week 48 for safety reasons.

The European Medicines Agency has deferred the obligation to submit the results of studies with INTELENCE in one or more subsets of the paediatric population in human immunodeficiency virus infection, as per Paediatric Investigation Plan (PIP) decision in the granted indication (see section 4.2 for information on paediatric use).

Pregnancy and postpartum

Etravirine (200 mg twice daily), evaluated in combination with other antiretroviral medicinal products in a study of 15 pregnant women during the second and third trimesters of pregnancy and postpartum, demonstrated that exposure to total etravirine was generally higher during pregnancy compared with postpartum, and less so for unbound etravirine exposure (see section 5.2). There were no new clinically relevant safety findings in the mothers or in the newborns in this trial.

The pharmacokinetic properties of etravirine have been evaluated in adult healthy subjects and in adult and paediatric treatment‑experienced HIV‑1 infected patients. Exposure to etravirine was lower (35‑50%) in HIV‑1 infected patients than in healthy subjects.

Absorption

An intravenous formulation of etravirine is unavailable, thus, the absolute bioavailability of etravirine is unknown. After oral administration with food, the maximum plasma concentration of etravirine is generally achieved within 4 hours.

In healthy subjects, the absorption of etravirine is not affected by co‑administration of oral ranitidine or omeprazole, medicinal products that are known to increase gastric pH.

Effect of food on absorption

The systemic exposure (AUC) to etravirine was decreased by about 50% when etravirine was administered under fasting conditions, as compared to administration following a meal. Therefore, INTELENCE should be taken following a meal.

Distribution

Etravirine is approximately 99.9% bound to plasma proteins, primarily to albumin (99.6%) and α₁‑acid glycoprotein (97.66%‑99.02%) in vitro. The distribution of etravirine into compartments other than plasma (e.g., cerebrospinal fluid, genital tract secretions) has not been evaluated in humans.

Biotransformation

In vitro experiments with human liver microsomes (HLMs) indicate that etravirine primarily undergoes oxidative metabolism by the hepatic cytochrome CYP450 (CYP3A) system and, to a lesser extent, by the CYP2C family, followed by glucuronidation.

Elimination

After administration of a radiolabeled ¹⁴C‑etravirine dose, 93.7% and 1.2% of the administered dose of ¹⁴C‑etravirine could be retrieved in faeces and urine, respectively. Unchanged etravirine accounted for 81.2% to 86.4% of the administered dose in faeces. Unchanged etravirine in faeces is likely to be unabsorbed drug. Unchanged etravirine was not detected in urine. The terminal elimination half‑life of etravirine was approximately 30‑40 hours.

Special populations

Paediatric population (1 year to less than 18 years of age)

The pharmacokinetics of etravirine in 122 treatment‑experienced HIV‑1 infected paediatric patients, 1 year to less than 18 years of age, showed that the administered weight‑based dosages resulted in etravirine exposure comparable to that in adults receiving etravirine 200 mg twice daily (see sections 4.2 and 5.2). The population pharmacokinetic estimates for etravirine AUC_12h and C_0h are summarised in the table below.

Elderly

Population pharmacokinetic analysis in HIV infected patients showed that etravirine pharmacokinetics are not considerably different in the age range (18 to 77 years) evaluated, with 6 subjects aged 65 years or older (see sections 4.2 and 4.4).

Gender

No significant pharmacokinetic differences have been observed between males and females. A limited number of females were included in the studies.

Race

Population pharmacokinetic analysis of etravirine in HIV infected patients indicated no apparent difference in the exposure to etravirine between Caucasian, Hispanic and Black subjects. The pharmacokinetics in other races have not been sufficiently evaluated.

Hepatic impairment

Etravirine is primarily metabolised and eliminated by the liver. In a study comparing 8 patients with mild (Child‑Pugh Class A) hepatic impairment to 8 matched controls and 8 patients with moderate (Child‑Pugh Class B) hepatic impairment to 8 matched controls, the multiple dose pharmacokinetic disposition of etravirine was not altered in patients with mild to moderate hepatic impairment. However, unbound concentrations have not been assessed. Increased unbound exposure could be expected. No dose adjustment is suggested but caution is advised in patients with moderate hepatic impairment. INTELENCE has not been studied in patients with severe hepatic impairment (Child‑Pugh Class C) and is therefore not recommended (see sections 4.2 and 4.4).

Hepatitis B and/or hepatitis C virus co‑infection

Population pharmacokinetic analysis of the DUET‑1 and DUET‑2 trials showed reduced clearance (potentially leading to increased exposure and alteration of the safety profile) for etravirine in HIV‑1 infected patients with hepatitis B and/or hepatitis C virus co‑infection. In view of the limited data available in hepatitis B and/or C co‑infected patients, particular caution should be paid when INTELENCE is used in these patients (see sections 4.4 and 4.8).

Renal impairment

The pharmacokinetics of etravirine have not been studied in patients with renal insufficiency. Results from a mass balance study with radioactive ¹⁴C‑etravirine showed that < 1.2% of the administered dose of etravirine is excreted in the urine. No unchanged drug was detected in urine so the impact of renal impairment on etravirine elimination is expected to be minimal. As etravirine is highly bound to plasma proteins, it is unlikely that it will be significantly removed by haemodialysis or peritoneal dialysis (see section 4.2).

Pregnancy and postpartum

Study TMC114HIV3015 evaluated etravirine 200 mg twice daily in combination with other antiretroviral medicinal products in 15 pregnant women during the second and third trimesters of pregnancy and postpartum. The total etravirine exposure after intake of etravirine 200 mg twice daily as part of an antiretroviral regimen was generally higher during pregnancy compared with postpartum (see Table 11). The differences were less pronounced for unbound etravirine exposure.

In women receiving etravirine 200 mg twice daily, higher mean values for C_max, AUC_12h and C_min were observed during pregnancy compared to postpartum. During the 2^nd and 3^rd trimester of pregnancy mean values of these parameters were comparable.

Each subject served as her own control, and with an intra-individual comparison, the total etravirine C_min, C_max and AUC_12h values were 1.2-, 1.4- and 1.4-fold higher, respectively, during the 2^nd trimester of pregnancy as compared to postpartum, and 1.1-, 1.4- and 1.2-fold higher, respectively, based during the 3^rd trimester of pregnancy as compared to postpartum.

Animal toxicology studies have been conducted with etravirine in mice, rats, rabbits and dogs. In mice, the key target organs identified were the liver and the coagulation system. Haemorrhagic cardiomyopathy was only observed in male mice and was considered to be secondary to severe coagulopathy mediated via the vitamin K pathway. In the rat, the key target organs identified were the liver, the thyroid and the coagulation system. Exposure in mice was equivalent to human exposure while in rats it was below the clinical exposure at the recommended dose. In the dog, changes were observed in the liver and gall bladder at exposures approximately 8‑fold higher than human exposure observed at the recommended dose (200 mg twice daily).

In a study conducted in rats, there were no effects on mating or fertility at exposure levels equivalent to those in humans at the clinically recommended dose. There was no teratogenicity with etravirine in rats and rabbits at exposures equivalent to those observed in humans at the recommended clinical dose. Etravirine had no effect on offspring development during lactation or post weaning at maternal exposures equivalent to those observed at the recommended clinical dose.

Etravirine was not carcinogenic in rats and in male mice. An increase in the incidences of hepatocellular adenomas and carcinomas were observed in female mice. The observed hepatocellular findings in female mice are generally considered to be rodent specific, associated with liver enzyme induction, and of limited relevance to humans. At the highest tested doses, the systemic exposures (based on AUC) to etravirine were 0.6‑fold (mice) and between 0.2‑ and 0.7‑fold (rats), relative to those observed in humans at the recommended therapeutic dose (200 mg twice daily).

In vitro and in vivo studies with etravirine revealed no evidence of a mutagenic potential.

INTELENCE 100 mg tablets

Hypromellose

Microcrystalline cellulose

Colloidal anhydrous silica

Croscarmellose sodium

Magnesium stearate

Lactose monohydrate

Not applicable.

Store below 30^○C

Store in the original bottle and keep the bottle tightly closed in order to protect from moisture. Do not remove the desiccant pouches.

INTELENCE 100 mg tablets

The bottle is a high‑density polyethylene (HDPE) plastic bottle containing 120 

 tablets and 3 desiccant pouches, fitted with a polypropylene (PP) child resistant closure.

Each carton contains one bottle.

Patients who are unable to swallow the tablet(s) whole may disperse the tablet(s) in a glass of water. The patient should be instructed to do the following:

-              place the tablet(s) in 5 ml (1 teaspoon) of water, or at least enough liquid to cover the medicine,

-              stir well until the water looks milky,

-              if desired, add more water or alternatively orange juice or milk (patients should not place the tablets in orange juice or milk without first adding water),

-              drink it immediately,

-              rinse the glass several times with water, orange juice, or milk and completely swallow the rinse each time to make sure the patient takes the entire dose.

INTELENCE tablet(s) dispersed in liquid should be taken before other antiretroviral liquids that may need to be taken concomitantly.

The patient and his/her caregiver should be instructed to contact the prescribing physician if unable to swallow the entire dose when dispersed in liquid (see section 4.4).

The use of warm (> 40°C) or carbonated beverages should be avoided.

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