Inozi-Co 300 mg Tablets

INOZI-CO is indicated for the prevention of active tuberculosis in adults presenting with:

• (1) latent tuberculosis infection (LTBI) caused by Mycobacterium tuberculosis who are at high risk of progression to tuberculosis disease (including those in close contact with active tuberculosis patients, recent conversion to a positive tuberculin skin test),
• (2) HIV-infected patients not receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors (NNRTIs) as antiretroviral therapy (ART),
• (3) Patients with pulmonary fibrosis on radiograph with no signs and symptoms of TB regardless of HIV status.

Active tuberculosis disease should be ruled out before initiating treatment with INOZI-CO.

Posology

INOZI-CO should be administered once-weekly for 12 weeks as directly observed therapy (DOT).

Adults: The recommended dose of rifapentine should be determined based on weight of the patient up to a maximum of 900 mg once weekly (see Table 1). The recommended dose of isoniazid is 15 mg/kg (rounded to the nearest 50 mg or 100 mg) up to a maximum of 900 mg once weekly for 12 weeks.

Table 1: Weight Based Dose of INOZI-CO in the prophylactic treatment of latent Tuberculosis Infection in adults at high risk of progression to tuberculosis disease.

Special populations

Paediatric patients: Safety and efficacy in children has not been established.

Elderly patients (65 years of age and older): No dosage adjustment is required in the elderly, but caution should be exercised due to the possible decrease in renal and hepatic function.

Hepatic impairment: No dosage adjustment is required, however, the half-life of isoniazid may be prolonged in the presence of hepatic insufficiency. INOZI-CO should be used with caution in patients with mild to moderate hepatic impairment. (see sections 4.3 and 4.4).

Renal impairment: No dosage adjustment is required when given to patients with mild renal failure. However, INOZI-CO is contraindicated in patients with severe renal failure (glomerular filtration rate of less than 10 mL/minute (creatinine clearance < 30 mL/min) (See Section 4.3 and 4.4).

Method of administration

For oral use. Patients should be informed that adherence to the treatment regimen for INOZI-CO and other substances is essential for effective treatment, and the importance of not missing any doses must be stressed. INOZI-CO should be given with food. For patients who cannot swallow tablets, the tablets may be crushed and added to a small amount of semi-solid food, all of which should be consumed immediately (see section 5.2). Interactions with antacids have not been studied. However, in the clinical efficacy study, patients were advised to take INOZI-CO at least 1 hour before or 2 hours after the ingestion of antacids.

INOZI-CO is contraindicated:

• u2022 in patients with known hypersensitivity to isoniazid and rifapentine or any of the excipients listed in section 6.1.
• u2022 Hypersensitivity to ethionamide, pyrazinamide, niacin, or other chemically related compounds or to any of the excipients (see Section 6.1).
• u2022 In patients with porphyria.
• u2022 In patients with acute or chronic liver disease.
• u2022 Severe renal failure
• u2022 Alcoholism
• u2022 Seizure disorders
• u2022 Pregnancy and lactation
• u2022 HIV-infected patients on antiretroviral therapy with protease inhibitors and non-nucleoside reverse transcriptase inhibitors (NNRTIs) because of potential interactions leading to loss of efficacy (See Section 4.5).

Active tuberculosis should be ruled out before initiating treatment for latent tuberculosis infection.

Hepatotoxicity

INOZI-CO may cause serious hepatic disease/injury. Patients with abnormal liver tests and/or liver disease should only be given INOZI-CO if no safer alternative is available, and then with caution and under strict medical supervision (see section 4.3). In such patients, careful monitoring of liver function parameters (especially serum transaminases and bilirubin) should be carried out prior to therapy and then every 2 to 4 weeks during therapy. If there are indications of a liver reaction or of the hepatic condition worsening, INOZI-CO should be discontinued.

Hypersensitivity and related reactions

Hypersensitivity reactions may occur in patients receiving INOZI-CO. Signs and symptoms of these reactions may include hypotension, urticaria, angioedema, acute bronchospasm, conjunctivitis, thrombocytopenia, neutropenia or flu-like syndrome (weakness, fatigue, muscle pain, nausea, vomiting, headache, fever, chills, aches, rash, itching, sweats, dizziness, shortness of breath, chest pain, cough, syncope, palpitations) (see section 4.8). Monitor patients receiving INOZI-CO therapy for signs and/or symptoms of hypersensitivity reactions. If these symptoms occur, administer supportive measures and discontinue INOZI-CO.

Medicine interactions

Rifapentine, one of the components of INOZI-CO is an inducer of CYP3A4 and CYP2C8/9. Concomitant use of INOZI-CO with other medicines metabolised by any of these enzymes, such as protease inhibitors, non-nuclease-reverse transcriptase inhibitors (Efavirenz: CYP3A4 inducer and inhibitor), and hormonal contraceptives may cause a significant decrease in plasma concentrations and loss of therapeutic effect of these medicines (see sections 4.5 and 5.2). INOZI-CO has also been shown to inhibit and to induce P-gp which could modify plasma exposure of digoxin (a P-gp substrate with narrow therapeutic index). Appropriate monitoring and dose adjustment of digoxin may be necessary in case of co-administration with rifapentine as contained in INOZI-CO (see sections 4.5 and 5.2).

Severe cutaneous adverse reactions

Severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome (SJS) and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome have been reported in association with the use of INOZI-CO treatment regimen. Patients should be informed about the signs and symptoms of serious skin manifestations. Treatment should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.

Clostridium difficile -associated diarrhoea

Pseudomembranous colitis has been reported to occur with rifamycins such as in INOZI-CO. Diarrhoea, particularly if severe and/or persistent, occurring during treatment or in the initial weeks following treatment may be symptomatic of Clostridium difficile-associated disease, the most severe form of which is pseudomembranous colitis. If pseudomembranous colitis is suspected, INOZI-CO should be stopped immediately and the patient treated appropriately without delay. Medicines inhibiting the peristalsis are contraindicated in this clinical situation.

Discolouration of body fluids

INOZI-CO may produce a predominantly red-orange discolouration of body tissues and/or fluids (e.g. skin, teeth, tongue, urine, faeces, saliva, sputum, tears, sweat and cerebrospinal fluid). Contact lenses or dentures may become permanently stained. The administration of 10 mg pyridoxine daily is recommended to prevent or minimise symptoms of peripheral neuritis, as well as for those who are diabetic, alcoholic, malnourished or uraemic, infected with HIV (currently not on antiretroviral therapy). INOZI-CO should be given with caution in patients suffering from convulsive disorders and diabetes mellitus and patients with a history of psychosis. INOZI-CO should be used with caution in patients with mild to moderate hepatic or renal impairment (see section 4.2) or patients taking other potentially hepatotoxic medicines. If symptoms of hepatitis deteriorate in these patients, INOZI-CO should be discontinued immediately. Periodic eye examination during treatment is recommended.

Effect of INOZI-CO on other medicines

- Effect on medicines metabolised by CYP3A4 and CYP2C8/9

Rifapentine as contained in INOZI-CO is an inducer of CYP3A4 and CYP2C8/9. Therefore, INOZI-CO may increase the metabolism of other co-administered medicines that are metabolised by these enzymes. Appropriate monitoring and dosage adjustment may be necessary if medicines metabolised by CYP3A4 or CYP2C8/9 are co-administered with INOZI-CO. Induction of enzyme activities by INOZI-CO occurred after the first dose of INOZI-CO. Enzyme activities returned to baseline levels, in general, 14 days after discontinuing INOZI-CO. Examples of such substances include:

• - Antiretroviral medicines:
• u2022 Protease inhibitors: indinavir, darunavir, lopinavir, saquinavir, ritonavir, nelfinavir, amprenavir, fosamprenavir, atazanavir, tipranavir.
• u2022 Non-nucleoside reverse transcriptase inhibitors: rilpivirine, efavirenz
• u2022 Nucleoside reverse transcriptase inhibitor: zidovudine
• - Antifungals: itraconazole, ketoconazole, voriconazole
• - Narcotic analgesics: methadone, alfentanil, buprenorphine
• - Hypoglycaemic medicines: repaglinide
• - Calcium channel blockers: felodipine, diltiazem, verapamil, nifedipine
• - Alpha/Beta adrenergic antagonists: alfuzosin, propranolol
• - Ergot alkaloid derivatives: ergotamine
• - Oral anti-vitamin K anticoagulant: warfarin
• - Hormonal contraceptives: oral, transdermal and implant
• - Immunosuppressants: ciclosporin, tacrolimus, sirolimus
• - Benzodiazepines: midazolam.

Inhibition of CYP450

Isoniazid, as in INOZI-CO can inhibit the hepatic metabolism of a number of medicines, in some cases leading to increased toxicity. These include the antiepileptics carbamazepine, primidone, and phenytoin, the benzodiazepines diazepam and triazolam, and others such as warfarin and theophylline. Concomitant administration of benzodiazepines (diazepam/carbamazepine) and isoniazid, as in INOZI-CO therapy, has been reported to result in benzodiazepine toxicity (sedation, respiratory depression, etc.). Concurrent administration of INOZI-CO and rifampicin may lead to a higher risk of hepatotoxicity, while increased central nervous system adverse effects have occurred when INOZI-CO is given with potentially neurotoxic medicines such as cycloserine or disulfiram. Hepatotoxic reactions have been reported when paracetamol is given concurrently with INOZI-CO, while chronic alcoholism increases the risk of isoniazid induced hepatitis. When isoniazid, as in INOZI-CO is given to patients receiving paraminosalicyclic acid concurrently, the plasma concentrations of isoniazid may be increased, and adverse effects are more likely to occur. Prednisolone may increase hepatic metabolism and/or excretion of INOZI-CO. Aluminium-containing antacids may delay and decrease absorption and serum concentrations of isoniazid. It is therefore recommended that INOZI-CO be administered at least 1 hour before taking antacids (see section 4.2). Isoniazid, as in INOZI-CO may reduce the therapeutic effects of levodopa. Concomitant administration of isoniazid, as in INOZI-CO with itraconazole or ketoconazole may result in significant decreases in either medicineu2019s serum concentrations, and thus therapeutic failure. Concurrent use should be well monitored, and dosage increases made if necessary. Because the clearance of isoniazid, as in INOZI-CO was found to be doubled when zalcitabine was given in HIV-positive patients, concurrent use of isoniazid and zalcitabine should be monitored to ensure isoniazid effectiveness.

- Effect of INOZI-CO on transporter substrates

In vitro, INOZI-CO has been shown to inhibit and to induce P-gp which could modify plasma exposure of digoxin (P-gp substrate) (see section 5.2). Because of the narrow therapeutic index of digoxin, appropriate monitoring and dose adjustment of digoxin may be necessary in case of co-administration with INOZI-CO.

- Effect of INOZI-CO on antiretroviral medicines

- Protease inhibitors and non-nucleoside reverse transcriptase inhibitors

Concomitant use of rifapentine with protease inhibitors and non-nucleoside reverse transcriptase inhibitors, metabolised by CYP3A4 or CYP2C8/9, may cause a significant decrease in plasma concentrations and loss of therapeutic effect of these medicines. Concomitant use of INOZI-CO with protease inhibitors and non-nucleoside reverse transcriptase inhibitors is contraindicated.

- Hormonal contraceptives

INOZI-CO may reduce the effectiveness of hormonal contraceptives. Women taking oral contraception, using a transdermal patch, or other systemic hormonal contraceptives who need INOZI-CO therapy should discuss the use of an additional non-hormonal means of contraception or the change of their contraceptive pill with their medical practitioner.

Effect of other medicines on INOZI-CO

Potential interaction with CYP450 inducer/inhibitor medicines, as well as with transporters inhibitor/inducer medicines are not expected (see section 5.2). Since INOZI-CO is highly bound to albumin, medicine displacement interactions with non-steroidal anti-inflammatory drugs (NSAIDs), sulfonylureas and oral anticoagulants may also occur. Adverse reactions have occurred when INOZI-CO has been given with anti-epileptics such as phenytoin, primidone, carbamazepine, and ethosuximide, with benzodiazepines, such as diazepam or triazolam, and with warfarin. Interferences with laboratory and diagnostic tests Therapeutic concentrations of rifampin have been shown to inhibit standard microbiological assays for serum folate and vitamin B12. Similar interferences should be considered for INOZI-CO. Therefore, alternative assay methods should be considered. Food interactions: Palpitations, headache, conjunctival irritation, severe flushing, tachycardia, tachypnoea, sweating and itching on the skin have been reported following ingestion of cheese, red wine, and some fish.

Pregnancy

Safety during pregnancy has not been established. INOZI-CO is not recommended during pregnancy. Human data: Rifampicin is known to cause postnatal haemorrhages in the mother and infant when taken during the last few weeks of pregnancy. Since INOZI-CO might have a similar effect, appropriate coagulation testing should be performed when pregnant women are inadvertently exposed to INOZI-CO during late pregnancy. Treatment with vitamin K may be indicated.

Breastfeeding

Mothers on treatment with INOZI-CO should not breastfeed their babies. It is not known whether INOZI-CO is excreted in human milk. INOZI-CO may produce a red-orange discolouration of body fluids, including breast milk.

Fertility

No data on the effect of INOZI-CO on fertility is available.

INOZI-CO may cause dizziness, impaired concentration, and/or drowsiness. Patients should be instructed that if they experience these symptoms they should avoid potentially hazardous tasks such as driving or operating machinery.

Tabulated summary of adverse reactions

Rifapentine:

System organ class

Frequent

Less frequent

Frequency unknown

Infections and infestations

- Influenza pneumonia

Immune system disorders

Hypersensitivity

-

-

Nervous system disorders

- Headache

-

Gastrointestinal disorders

- Nausea, Upper abdominal pain

Pancreatitis, oesophageal irritation

Hepatobiliary disorders

- Hepatitis

-

Skin and subcutaneous tissue disorders

- Skin reaction

Severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome (SJS) and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome (see section 4.4)

Musculoskeletal and connective tissue disorders

- Myalgia

-

General disorders and administration site conditions

- Influenza-like illness, fatigue, chills, pyrexia, asthenia

-

Isoniazid:

Blood and lymphatic system disorders:

- Haematological effects (various anaemias, agranulocytosis, thrombocytopenia and eosinophilia).

- Immune system disorders:

- Hypersensitivity reactions (fever, skin rashes, joint pain).

- Metabolism and nutrition disorders:

- Hyperglycaemia, metabolic acidosis.

- Psychiatric disorders:

- Neurotoxicity (psychotic reactions)

- Nervous system disorders:

Peripheral neuritis.

Convulsions, hyperreflexia

- Eye disorders:

- Optic neuritis

- Ear and labyrinth disorders:

- Vertigo

-

Gastrointestinal disorders:

Nausea, vomiting, constipation, dry mouth, gastrointestinal irritation.

-

Hepato-biliary disorders:

Hepatitis, hepatitis prodromal symptoms (loss of appetite, nausea or vomiting, unusual tiredness or weakness), transient increases in liver enzymes.

-

Skin and subcutaneous tissue disorders:

Skin reactions such as purpura, acneform syndrome, lupus erythematosus-like syndrome, exfoliative dermatitis, pellagra, alopecia, urticaria.

-

Musculoskeletal and connective tissue disorders:

- - Rheumatoid syndrome

Renal and urinary disorders:

- Urinary retention.

-

Reproductive system and breast disorders:

- Gynaecomastia.

-

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicine is important. It allows continued monitoring of the benefit/risk balance of the medicine. Health care providers are asked to report any suspected adverse reactions to SAHPRA via the u201c6.04 Adverse Drug Reactions Reporting Formu201d, found online under SAHPRAu2019s publications: https://www.sahpra.org.za/Publications/Index/8

An overdose may precipitate side effects and increase the severity thereof. Symptoms of overdose u2013 include slurred speech, metabolic acidosis, hyperglycaemia, hallucinations, respiratory and CNS depression, convulsions and coma. Treatment consists of gastric lavage following intubation (if the patient is in a coma and seen within one hour after overdose) symptomatic and supportive therapy. This includes use of large doses of pyridoxine (1:1) and anti-convulsants given intravenously u2013 to prevent and/or control convulsions, and sodium bicarbonate for metabolic acidosis.

Instillation of activated charcoal slurry via naso-gastric tube into the stomach, may help adsorb any remaining medicine from the gastrointestinal tract. Forced diuresis and haemodialysis or peritoneal dialysis has been used in case isoniazid (as contained) in INOZI-CO have been used.