Juxolu 50 mg/300 mg Film-Coated Tablets

JUXOLU is indicated for the treatment of HIV-1 infection in adults aged 18 years and older.

JUXOLU therapy should be initiated by a medical practitioner experienced in the management of human immunodeficiency virus (HIV) infection.

Posology

Adults: The dose of JUXOLU is one tablet taken orally, once daily.

Special populations

Dose adjustment for renal impairment

Significantly increased exposure occurred when tenofovir, as in JUXOLU, was administered to patients with moderate to severe renal impairment (see section 4.3). The pharmacokinetics of tenofovir, as in JUXOLU, have not been evaluated in non-haemodialysis patients with creatinine clearance < 50 m/min; therefore, no dosing recommendations is available for these patients. JUXOLU is not suitable for use in patients with renal impairment with creatinine clearance less than 50 ml/min. Rifampicin decreases the blood levels of dolutegravir. A supplementary dose of dolutegravir should be given to patients taking JUXOLU.

Paediatrics: JUXOLU is not recommended for use in patients younger than 18 years of age.

Method of administration

Oral use. It is recommended that JUXOLU be swallowed with water, with or without food.

• JUXOLU is contraindicated in patients with known hypersensitivity to dolutegravir, lamivudine, tenofovir disoproxil fumarate or to any of the excipients (see section 6.1).
• Uncontrolled renal failure (see section 4.4).
• Pregnancy and lactation (see section 4.6).
• Women of child-bearing age not using highly effective contraception.
• Concomitant use with adefovir dipivoxil.
• Co-administration with dofetilide and pilsicainide.
• Co-administration with didanosine.
• Co-administration with metformin.
• Patients younger than 18 years of age.
• Moderate and severe hepatic impairment.

Safety and efficacy of the individual active ingredients in various antiretroviral combination regimens with similar dosages as contained in JUXOLU have been established in clinical studies for the treatment of HIV patients. However, safety and efficacy of the fixed-drug combination as in JUXOLU for the treatment of HIV have not been established in clinical studies.

Metabolic abnormalities

Combination antiretroviral therapy, including JUXOLU has been associated with metabolic abnormalities such as hypertriglyceridaemia, hypercholesterolaemia, insulin resistance, hyperglycaemia and hyperlactataemia.

Lipodystrophy

Combination antiretroviral therapy, including JUXOLU, has also been associated with the redistribution/accumulation of body fat, including central obesity, dorso-cervical fat, enlargement (buffalo hump), peripheral wasting, facial wasting and breast enlargement in HIV patients. A higher risk of lipodystrophy has been associated with individual factors such as older age, and with medicine related factors such as longer duration of antiretroviral treatment and associated metabolic disturbances. Clinical examination should include evaluation for physical signs of fat redistribution. Fasting serum lipids and blood glucose levels should be monitored. Lipid disorders should be managed as clinically appropriate. Patients with evidence of lipodystrophy should also have a thorough cardiovascular risk assessment.

Immune reconstitution inflammatory syndrome

Immune reconstitution inflammatory syndrome (IRIS) is an immunopathological response resulting from the rapid restoration of pathogen-specific immune responses to pre-existing antigens combined with immune dysregulation, which occurs shortly after starting combination Anti-Retroviral Therapy (cART). Typically, such reaction presents by paradoxical deterioration of opportunistic infections being treated or with unmasking of an asymptomatic opportunistic disease, often with an atypical inflammatory presentation. IRIS usually develops within the first three months of initiation of ART and occurs more commonly in patients with low CD4 counts. Common examples of IRIS reactions to opportunistic diseases are tuberculosis, atypical mycobacterial infections, cytomegalovirus retinitis, pneumocystis jirovecii, and cryptococcal meningitis. Appropriate treatment of the opportunistic disease should be instituted or continued, and ART continued. Inflammatory manifestations generally subside after a few weeks. Severe cases may respond to glucocorticoids, but there is only limited evidence for this in patients with tuberculosis IRIS.

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), including components of JUXOLU. Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness, or difficulty in movement.

Opportunistic infections

Patients receiving JUXOLU may continue to develop opportunistic infections and other complications of HIV infection and therefore should remain under close clinical observation by doctors experienced in the treatment of patients with HIV associated diseases.

The risk of HIV transmission to others

Patients must be advised that treatment with JUXOLU, has not been proven to prevent the risk of transmission of HIV to others through sexual contact or blood contamination. Appropriate precautions must continue to be used.

Lactic acidosis/severe hepatomegaly with steatosis

Lactic acidosis, usually associated with hepatic steatosis, including fatal cases, has been reported with the use of nucleoside analogues, such as in JUXOLU. Early symptoms (symptomatic hyperlactataemia) include benign digestive symptoms (nausea, vomiting and abdominal pain), non-specific malaise, loss of appetite, weight loss, respiratory symptoms (rapid and/or deep breathing) or neurological symptoms (including motor weakness). Lactic acidosis has a high mortality and may be associated with pancreatitis, liver failure or renal failure. Lactic acidosis generally occurs after a few or several months of treatment. Treatment with nucleoside analogues should be discontinued in the setting of symptomatic hyperlactataemia and metabolic/lactic acidosis, progressive hepatomegaly, or rapidly elevating aminotransferase levels. Suspicious biochemical features include mild raised transaminases, raised lactate dehydrogenase (LDH) and/or creatine kinase. In patients with suspicious symptoms or biochemistry, measure the venous lactate level (normal < 2 mmol/L) and respond as follows:

• Lactate 2 - 5 mmol/L: monitor regularly and be alert for clinical signs.
• Lactate 5 - 10 mmol/L without symptoms: monitor closely.
• Lactate 5 - 10 mmol/L with symptoms: STOP all therapy. Exclude other causes (e.g. sepsis, uraemia, diabetic ketoacidosis, thyrotoxicosis, lymphoma).
• Lactate > 10 mmol/L: STOP all therapy (80 % mortality in case studies).

The above lactate values may not be applicable to paediatric patients. Diagnosis of lactic acidosis is confirmed by demonstrating metabolic acidosis with an increased anion gap and raised lactate level. Therapy should be stopped in any acidotic patient with a raised lactate level. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of JUXOLU alone or in combination, in the treatment of HIV infection. Most cases were women. Caution should be exercised when administering JUXOLU to patients with known risk factors for liver disease. Treatment with JUXOLU should be suspended in any patient who develops clinical or laboratory findings suggestive of lactic acidosis or hepatotoxicity. Caution should be exercised when administering nucleoside analogues as contained in JUXOLU to any patient (particularly obese women) with hepatomegaly, hepatitis or other known risk factors for liver disease and hepatic steatosis (including certain medicines and alcohol). Patients co-infected with hepatitis C and treated with alpha interferon and ribavirin may constitute a special risk. Patients at increased risk should be followed closely. However, cases have also been reported in patients with no known risk factors.

There are no study results demonstrating the effect of JUXOLU on clinical progression of HIV-1.

Mitochondrial dysfunction

Nucleoside and nucleotide analogues as contained in JUXOLU 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 events reported are haematological disorders (anaemia, neutropenia), metabolic disorders (hyperlactataemia, hyperlipidaemia). 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 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.

Pancreatitis

Pancreatitis has been observed in some patients receiving lamivudine, as in JUXOLU. It is unclear whether this is due to lamivudine or to underlying HIV disease. Pancreatitis must be considered whenever a patient develops abdominal pain, nausea, vomiting or elevated biochemical markers. Discontinue use of JUXOLU until diagnosis of pancreatitis is excluded.

Patients with moderate to severe renal impairment

In patients with moderate to severe renal impairment, the terminal half-life of JUXOLU is increased due to decreased clearance.

Liver disease

Use of JUXOLU can result in hepatomegaly due to non-alcoholic fatty liver disease (hepatic steatosis). The safety and efficacy of JUXOLU has not been established in patients with significant underlying liver disorders. Patients with pre-existing liver dysfunction, including chronic active hepatitis, have an increased frequency of liver function abnormalities during combination antiretroviral therapy and should be monitored according to standard practice. If there is evidence of worsening liver disease in such patients, interruption or discontinuation of treatment must be considered.

Renal impairment

JUXOLU is a combination medicine and the dose of the individual components cannot be altered. Tenofovir and lamivudine are principally eliminated by the kidney. JUXOLU is not recommended for patients with creatinine clearance < 50 ml/min or patients who require haemodialysis. Renal impairment, including cases of acute renal failure and Fanconi syndrome (renal tubular injury with severe hypophosphataemia) has been reported with the use of tenofovir disoproxil fumarate in clinical practice. Careful monitoring of renal function (serum creatinine and serum phosphate) is therefore recommended before taking JUXOLU.

Renal function

Since JUXOLU is primarily eliminated by the kidneys, co-administration of JUXOLU with medicines that reduce renal function or compete for active tubular secretion may increase serum concentrations of JUXOLU and/or increase the concentrations of other renally eliminated medicines. Some examples include, but are not limited to adefovir dipivoxil, cidofovir, aciclovir, valaciclovir, ganciclovir and valganciclovir.

Renal safety with tenofovir

Renal safety with tenofovir has only been studied to a very limited degree in adult patients with impaired renal function (creatinine clearance < 80 ml/min).

Renal monitoring

It is recommended that renal function (creatinine clearance and serum phosphate) must be assessed in all patients prior to initiating therapy with tenofovir disoproxil fumarate and that it is also monitored every four weeks during the first year of tenofovir disoproxil fumarate therapy, and then every three months. In patients at risk for renal impairment, including patients who have previously experienced renal events while receiving adefovir dipivoxil, consideration should be given to more frequent monitoring of renal function.

Co-administration and risk of renal toxicity

Use of tenofovir disoproxil fumarate should be avoided with concurrent or recent use of a nephrotoxic medicine (e.g. aminoglycosides, amphotericin B, foscarnet, ganciclovir, pentamidine, vancomycin, cidofovir or interleukin-2). If concomitant use of tenofovir disoproxil fumarate and nephrotoxic medicines is unavoidable, renal function should be monitored weekly.

Tenofovir disoproxil fumarate has not been clinically evaluated in patients receiving medicines which are secreted by the same renal pathway, including the transport proteins human organic anion transporter (hOAT) 1 and 3 or MRP 4 (e.g. cidofovir, a known nephrotoxic medicine). These renal transport proteins may be responsible for tubular secretion and in part, renal elimination of tenofovir and cidofovir. Consequently, the pharmacokinetics of these medicines, which are secreted by the same renal pathway including transport proteins hOAT 1 and 3 or MRP 4, might be modified if they are co-administered. Unless clearly necessary, concomitant use of these medicines which are secreted by the same renal pathway is not recommended, but if such use is unavoidable, renal function should be monitored weekly.

JUXOLU should be avoided with concurrent or recent use of a nephrotoxic medicine. Patients at risk of, or with a history of, renal dysfunction and patients receiving concomitant nephrotoxic substances should be carefully monitored for changes in serum creatinine and phosphorus.

K65R mutation

JUXOLU should be avoided in antiretroviral experienced patients with HIV-1 harbouring the K65R mutation.

Bone mineral density

Decreases in bone mineral density of spine and changes in bone biomarkers from baseline are significantly greater with tenofovir disoproxil fumarate as contained in JUXOLU. Decreases in bone mineral density of the hip are significantly greater. Clinically relevant bone fractures are reported. If bone abnormalities are suspected, then appropriate consultation should be obtained. Bone monitoring should be considered for HIV infected patients who have a history of pathologic bone fracture or are at risk of osteopenia. JUXOLU may cause a reduction in bone mineral density. The effects of tenofovir disoproxil fumarate-associated changes in bone mineral density on long-term bone health and future fracture risk are currently unknown. Bone monitoring should be considered for HIV infected patients who have a history of pathologic bone fracture or are at risk for osteopenia. Although the effect of supplementation with calcium and vitamin D was not studied, such supplementation may be beneficial for all patients. If bone abnormalities are suspected, then appropriate consultation should be obtained. Bone abnormalities (infrequently contributing to fractures) may be associated with proximal renal tubulopathy.

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

JUXOLU is not indicated for the treatment of chronic HBV infection. The safety and efficacy of JUXOLU has not been established for the treatment of patients co-infected with HBV and HIV. Patients with chronic hepatitis B or C and treated with antiretroviral therapy are at an increased risk for severe and potentially fatal hepatic adverse reactions. Medical practitioners should refer to current HIV treatment guidelines for the optimal management of HIV infection in patients co-infected with hepatitis B virus (HBV). In case of concomitant antiviral therapy for hepatitis B or C, please refer also to the relevant professional information for these medicines. Patients with chronic hepatitis B or C treated with JUXOLU are at an increased risk for severe and potentially fatal hepatic adverse reactions. Doctors should refer to current HIV treatment guidelines for the optimal management of HIV infection in patients co-infected with hepatitis B virus (HBV).

Exacerbations of hepatitis

Flares on treatment

Spontaneous exacerbations in chronic hepatitis B are relatively common and are characterised by transient increases in serum ALT. After initiating antiviral therapy, serum ALT may increase in some patients. In patients with compensated liver disease, these increases in serum ALT are generally not accompanied by an increase in serum bilirubin concentrations or hepatic decompensation. Patients with cirrhosis may be at a higher risk for hepatic decompensation following hepatitis exacerbation, and therefore should be monitored closely during therapy.

Flares after treatment discontinuation

Acute exacerbations of hepatitis have been reported in patients after the discontinuation of hepatitis B therapy. Post-treatment exacerbations are usually associated with rising HBV DNA, and the majority appears to be self-limited. However, severe exacerbations, including fatalities, have been reported. Hepatic function should be monitored at repeated intervals with both clinical and laboratory follow-up for at least 6 months after discontinuation of hepatitis B therapy. If appropriate, resumption 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. Liver flares are especially serious, and sometimes fatal in patients with decompensated liver disease.

Hypersensitivity reactions

Hypersensitivity reactions have been reported with integrase inhibitors, including dolutegravir and were characterised by rash, constitutional findings and sometimes, organ dysfunction, including liver injury. Discontinue JUXOLU and other suspect medicines immediately if signs or symptoms of hypersensitivity reactions develop (including, but not limited to severe rash or rash accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, facial oedema, hepatitis, eosinophilia, angioedema). Clinical status including liver aminotransferases should be monitored and appropriate therapy initiated. Delay in stopping treatment with JUXOLU or other suspect medicines after the onset of hypersensitivity may result in a life-threatening reaction.

Paediatric population

Safety and effectiveness in paediatric patients and patients < 18 years of age have not been established.

Use in the elderly

Clinical studies did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

The likelihood of interactions is low due to the limited metabolism as plasma protein binding and almost complete renal clearance. Zidovudine plasma levels are not significantly altered when co-administered with lamivudine. Zidovudine has no effect on the pharmacokinetics of lamivudine. Lamivudine may inhibit the intracellular phosphorylation of zalcitabine when the two medicines are used concurrently. Lamivudine is therefore not recommended to be used in combination with zalcitabine.

Administration of trimethoprim, a constituent of co-trimoxazole causes an increase in lamivudine plasma levels. However, unless the patient has renal impairment, no dosage adjustment of lamivudine is necessary. Lamivudine has no effect on the pharmacokinetics of co-trimoxazole. The possibility of interactions with other medicines administered concurrently should be considered, particularly when the main route is renal. No medicine interaction studies have been conducted using JUXOLU. As JUXOLU contains tenofovir disoproxil fumarate and lamivudine, any interactions that have been identified with these individual medicines may occur with JUXOLU. Important medicine interaction information for JUXOLU is summarised Table 1, 2 and 3. The medicine interactions described are based on studies conducted with tenofovir disoproxil fumarate or lamivudine as individual medicines or are potential medicine interactions. While the tables include potentially significant interactions, they are not all inclusive. Based on the results of in vitro experiments and the known elimination pathway of tenofovir, the potential for CYP450-mediated interactions involving tenofovir with other medicines is low.

An interaction with trimethoprim, a constituent of co-trimoxazole, causes a 40 % increase in lamivudine exposure at therapeutic doses. This does not require dose adjustment unless the patient also has renal impairment. Administration of co-trimoxazole with the lamivudine/zidovudine combination in patients with renal impairment should be carefully assessed.

Tenofovir Renally eliminated medicines Tenofovir, as in JUXOLU, is primarily excreted by the kidneys by a combination of glomerular filtration and active tubular secretion. Co-administration of JUXOLU with medicines that are eliminated by active tubular secretion may increase serum concentrations of either tenofovir or the co-administered medicines due to competition for this elimination pathway. Medicines that decrease renal function may also increase serum concentrations of tenofovir, as in JUXOLU. Tenofovir has been evaluated in healthy volunteers in combination with abacavir, adefovir dipivoxil, atazanavir, didanosine, efavirenz, emtricitabine, indinavir, lamivudine, lopinavir/ritonavir, methadone, oral contraceptives and ribavirin. Tables 1 and 2 summarise pharmacokinetic effects of co-administered medicine on tenofovir pharmacokinetics and effects of tenofovir on the pharmacokinetics of co-administered medicine.

When administered with multiple doses of tenofovir, the C max and AUC of didanosine 400 mg increase significantly. The mechanism of this interaction is unknown. When didanosine 250 mg enteric-coated capsules are administered with tenofovir, systemic exposures to didanosine are similar to those seen with the 400 mg enteric-coated capsules alone under fasted conditions.

Women of childbearing potential

Women of childbearing potential should be counselled about the potential risk of neural tube defects with dolutegravir (see below), including consideration of using effective contraceptive measures. Perform pregnancy testing before initiation of JUXOLU in women of childbearing potential to exclude inadvertent (unintentional) use of JUXOLU during the first trimester of pregnancy. If a woman plans pregnancy, the benefits and risks of starting or continuing treatment with dolutegravir versus using another antiretroviral regimen should be discussed with her.

Pregnancy

Use of dolutegravir during pregnancy was associated with a small increase in the prevalence of neural tube defects (0,19 %) compared to non-dolutegravir regimens (0,11 %). Most neural tube defects occur within the first 4 weeks of embryonic development after conception (approximately 6 weeks after the last menstrual period). If pregnancy is confirmed in the first trimester while on dolutegravir, the benefits and risks of continuing dolutegravir versus switching to another antiretroviral regimen should be discussed with the patient, taking the gestational age and the critical time period of neural tube defect development into account. Dolutegravir may be used during the second and third trimester of pregnancy when the expected benefit outweighs the potential risk to the foetus. Dolutegravir was shown to cross the placenta in humans, leading to significant exposure to the foetus, but the implications of such exposure are not yet known. Tenofovir, dolutegravir and lamivudine were shown to cross the placenta in reproductive toxicity studies in animals. Late onset neurological disorders, including seizures, have been observed in children who have been exposed to nucleoside analogues such as tenofovir and lamivudine, (see Mitochondrial dysfunction under see section 4.4). JUXOLU should not be prescribed in women who plan to become pregnant. Women of childbearing age should not use JUXOLU unless they are reliably using highly effective contraception. Treatment with JUXOLU should not be initiated without a medically supervised negative pregnancy test. This test should be repeated at frequent intervals during treatment with JUXOLU; and especially in the event that pregnancy is suspected.

Breastfeeding

HIV infected mothers must not breastfeed their infants in order to avoid transmission of HIV or follow appropriate guidelines. Mothers breastfeeding their infants should not use JUXOLU. Lamivudine is excreted in human milk at similar concentrations to those found in serum; tenofovir is excreted in breast milk. Dolutegravir is excreted in human breast milk, and there is significant exposure to the neonate/infants due to slow elimination; the half-life of dolutegravir in the new born was 33 hr compared to 14 hr in the adults. There is insufficient information on the effects of dolutegravir in neonates/infants.

Fertility

There are no data on the effects of dolutegravir on human male or female fertility. Animal studies indicate no effects of dolutegravir on male or female fertility.

JUXOLU causes dizziness, impaired concentration and/or drowsiness and may affect the ability to drive and use machines. Patients should ensure that they do not engage in driving or using machines until they know how JUXOLU affects them.

a. Summary of the safety profile

The most severe adverse reactions linked to dolutegravir are hypersensitivity reactions that include rash and severe liver effects. The most frequent adverse reactions of dolutegravir are nausea, diarrhoea and headache.

b. Tabulated summary of adverse reactions

Dolutegravir

MedDRA system organ class Frequency Adverse reactions

Immune system disorders Less frequent Hypersensitivity, immune reconstitution syndrome.

Psychiatric disorders Frequent Insomnia.

Nervous system disorders Frequent Headache, dizziness, abnormal dreams.

Gastrointestinal disorders Frequent Nausea, diarrhoea. Less frequent Flatulence, upper abdominal pain, vomiting. Frequency unknown Abdominal pain, abdominal discomfort.

Hepato-biliary disorders Frequency unknown Hepatitis.

Skin and subcutaneous tissue disorders Frequent Rash, pruritus.

Lamivudine

MedDRA system organ class Frequency Adverse reactions

Blood and lymphatic system disorders Less frequent Neutropenia, anaemia, thrombocytopenia. Frequency unknown Pure red cell aplasia.

Metabolism and nutrition disorders Frequent Hyperlactataemia. Less frequent Lactic acidosis, lipodystrophy (redistribution/ accumulation of body fat) (see section 4.4).

Nervous system disorders Frequent Headache, insomnia. Frequency unknown Peripheral neuropathy (or paraesthesia), late onset neurological disorders in children exposed in utero.

Gastrointestinal disorders Frequent Nausea, vomiting, upper abdominal pain or cramps, diarrhoea. Less frequent Pancreatitis, elevations in serum amylase.

Hepato-biliary disorders Less frequent Transient elevations in liver enzymes (AST ALT).

Skin and subcutaneous tissue disorders Frequent Rash, alopecia.

Musculoskeletal and connective tissue disorders Frequent Arthralgia, muscle disorders. Less frequent Rhabdomyolysis, decrease in bone mineral density, osteopenia, fractures.

General disorders and administration site conditions Frequent Malaise, fever, fatigue.

Tenofovir

MedDRA system organ class Frequency Immune system disorders Less frequent Allergic reactions.

Metabolism and nutrition disorders Frequent Hypophosphataemia, lactic acidosis.

Respiratory, thoracic and mediastinal disorders Frequency unknown Dyspnoea.

Gastrointestinal disorders Frequent Anorexia, dyspepsia, flatulence, abdominal pain. Less frequent Increased amylase, pancreatitis.

Hepato-biliary disorders Frequent Increased liver enzymes, hepatitis.

Renal and urinary disorders Frequent Renal insufficiency, increased creatinine, proximal renal tubulopathy (including Fanconi syndrome), renal failure, acute tubular necrosis, nephrogenic diabetes insipidus, proteinuria.

If overdose occurs the patients must be monitored for evidence of toxicity, and standard supportive treatment applied, as necessary.

Dolutegravir

Management should be as clinically indicated or as recommended by the national poisons centre, where available. There is no specific treatment for an overdose of JUXOLU. If overdose occurs, the patient should be treated supportively with appropriate monitoring as necessary. As JUXOLU is highly bound to plasma proteins, it is unlikely that it will be significantly removed by dialysis.

Lamivudine

Limited data are available on the consequences of ingestion of acute overdose in humans. If overdosage occurs the patient should be monitored, and palliative supportive treatment applied as required.

Tenofovir disoproxil fumarate

If overdose occurs the patient must be monitored for evidence of toxicity and palliative supportive treatment be applied, as necessary. Tenofovir can be removed by haemodialysis; the median haemodialysis clearance of tenofovir is 134 ml/min. The elimination of tenofovir by peritoneal dialysis has not been studied.