Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Packet, Oral:
Kalydeco: 25 mg (56 ea); 50 mg (56 ea); 75 mg (56 ea)
Tablet, Oral:
Kalydeco: 150 mg [contains fd&c blue #2 (indigotine)]
Pharmacology
Mechanism of Action
Potentiates epithelial cell chloride ion transport of defective (G551D mutant) cell-surface CFTR protein thereby improving the regulation of salt and water absorption and secretion in various tissues (eg, lung, GI tract).
Pharmacokinetics/Pharmacodynamics
Absorption
Variable; increased (by 2.5- to 4-fold) with fatty foods
Distribution
Vd: 353 L ± 122 L (fed state)
Metabolism
Hepatic; extensive via CYP3A; forms 2 major metabolites (M1 [active; 1/6 potency] and M6 [inactive])
Excretion
Feces (87.8%, ~65% of administered dose as metabolites); urine (minimal, as unchanged drug)
Onset of Action
FEV1 increased, sweat chloride decreased within ~2 weeks (Ramsey 2011)
Time to Peak
Median: ~4 hours (range: 3 to 6 hours) (fed state)
Half-Life Elimination
~12 hours
Protein Binding
~99%; primarily to alpha1 acid glycoprotein, albumin
Use in Specific Populations
Special Populations: Hepatic Function Impairment
Adults with moderate hepatic impairment (Child-Pugh class B) had an ~2-fold increase in ivacaftor AUC0-∞; in adults with mild hepatic impairment (Child-Pugh class A), increase is expected to be <2-fold. The magnitude of increase in exposure in patients with severe hepatic impairment (Child-Pugh class C) is expected to be substantially higher than that observed in patients with moderate hepatic impairment.
Use: Labeled Indications
Cystic fibrosis: Treatment of cystic fibrosis (CF) in patients ≥6 months of age who have one mutation in the CF transmembrane conductance regulator (CFTR) gene that is responsive to ivacaftor potentiation based on clinical and/or in vitro assay data.
If the patient's genotype is unknown, an FDA-cleared CF mutation test should be used to detect the presence of a CFTR mutation followed by verification with bidirectional sequencing when recommended by the mutation test instructions for use.
Contraindications
There are no contraindications listed in the manufacturer's labeling.
Canadian labeling: Hypersensitivity to ivacaftor or any component of the formulation.
Dosage and Administration
Dosing: Adult
Cystic fibrosis: Oral: Tablet: 150 mg every 12 hours
Dosage adjustment for ivacaftor with concomitant medications:
CYP3A strong inhibitors (eg, ketoconazole, itraconazole, posaconazole, voriconazole, clarithromycin, telithromycin): 150 mg twice weekly
CYP3A moderate inhibitors (eg, erythromycin, fluconazole): 150 mg once daily
CYP3A strong inducers (eg, carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, St. John's wort): Use is not recommended.
Missed dose: If dose is missed within 6 hours of the usual time it is taken, take the dose as soon as possible; otherwise, skip the missed dose and resume the normal dosing schedule.
Dosing: Pediatric
Cystic fibrosis: Oral:
Infants ≥6 months and Children <6 years: Oral granules:
5 to <7 kg: 25 mg granule packet every 12 hours.
7 to <14 kg: 50 mg granule packet every 12 hours.
≥14 kg: 75 mg granule packet every 12 hours.
Children ≥6 years and Adolescents: Oral tablet: 150 mg every 12 hours.
Dosage adjustment for concomitant therapy:
Coadministration with CYP3A4 strong inhibitors (eg, ketoconazole, itraconazole, posaconazole, voriconazole, clarithromycin, telithromycin):
Infants ≥6 months and Children <6 years: Oral granules:
5 to <7 kg: 25 mg granule packet twice weekly.
7 to <14 kg: 50 mg granule packet twice weekly.
≥14 kg: 75 mg granule packet twice weekly.
Children ≥6 years and Adolescents: Oral tablet: 150 mg twice weekly.
Coadministration with CYP3A4 moderate inhibitors (eg, erythromycin, fluconazole):
Infants ≥6 months and Children <6 years: Oral granules:
5 to <7 kg: 25 mg granule packet once daily.
7 to <14 kg: 50 mg granule packet once daily.
≥14 kg: 75 mg granule packet once daily.
Children ≥6 years and Adolescents: Oral tablet: 150 mg once daily.
Coadministration with CYP3A strong inducers (eg, carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, St. John's wort): Use is not recommended.
Dosing: Adjustment for Toxicity
ALT or AST >5 times ULN: Hold ivacaftor; may resume if elevated transaminases resolved and after assessing benefits vs risks of continued treatment.
Administration
Oral: Administer before or after high-fat-containing foods (eg, butter, cheese pizza, eggs, peanut butter, whole-milk dairy products [eg, whole milk, cheese, yogurt]).
Granules: Mix entire packet of granules with 5 mL of soft food (eg, pureed fruits [excluding grapefruit or Seville oranges] or vegetables, yogurt, applesauce) or liquid (eg, water, milk, juice [excluding grapefruit juice]); food or liquid should be at or below room temperature. Granule mixture should be completely consumed within 1 hour.
Dietary Considerations
Avoid grapefruit or Seville oranges.
Storage
Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F); after mixing the granules, the product is stable for 1 hour.
Drug Interactions
Afatinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Afatinib. Management: Reduce afatinib by 10 mg if not tolerated. Some non-US labeling recommends avoiding combination if possible. If used, administer the P-gp inhibitor simultaneously with or after the dose of afatinib. Consider therapy modification
ARIPiprazole: CYP3A4 Inhibitors (Weak) may increase the serum concentration of ARIPiprazole. Management: Monitor for increased aripiprazole pharmacologic effects. Aripiprazole dose adjustments may or may not be required based on concomitant therapy and/or indication. Consult full interaction monograph for specific recommendations. Monitor therapy
Betrixaban: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Betrixaban. Management: Decrease the adult betrixaban dose to an initial single dose of 80 mg followed by 40 mg once daily if combined with a P-glycoprotein inhibitor. Consider therapy modification
Bilastine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Bilastine. Management: Consider alternatives when possible; bilastine should be avoided in patients with moderate to severe renal insufficiency who are receiving p-glycoprotein inhibitors. Consider therapy modification
Bitter Orange: May increase the serum concentration of Ivacaftor. Avoid combination
Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Brentuximab Vedotin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Brentuximab Vedotin. Specifically, concentrations of the active monomethyl auristatin E (MMAE) component may be increased. Monitor therapy
Celiprolol: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Celiprolol. Monitor therapy
Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Colchicine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Colchicine. Colchicine distribution into certain tissues (e.g., brain) may also be increased. Management: Colchicine is contraindicated in patients with impaired renal or hepatic function who are also receiving a p-glycoprotein inhibitor. In those with normal renal and hepatic function, reduce colchicine dose as directed. See full monograph for details. Consider therapy modification
Conivaptan: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination
CycloSPORINE (Systemic): Ivacaftor may increase the serum concentration of CycloSPORINE (Systemic). Monitor therapy
CYP3A4 Inducers (Moderate): May decrease the serum concentration of Ivacaftor. Monitor therapy
CYP3A4 Inducers (Strong): May decrease the serum concentration of Ivacaftor. Avoid combination
CYP3A4 Inhibitors (Moderate): May increase the serum concentration of Ivacaftor. Management: Ivacaftor dose reductions may be required; consult full monograph content for age- and weight-specific dosage recommendations. Exceptions: Grapefruit Juice. Consider therapy modification
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Ivacaftor. Management: Ivacaftor dose reductions are required; consult full monograph content for age- and weight-specific recommendations. Consider therapy modification
Dabigatran Etexilate: P-glycoprotein/ABCB1 Inhibitors may increase serum concentrations of the active metabolite(s) of Dabigatran Etexilate. Monitor therapy
Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification
Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Digoxin: Ivacaftor may increase the serum concentration of Digoxin. Monitor therapy
Dofetilide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Dofetilide. Monitor therapy
DOXOrubicin (Conventional): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of DOXOrubicin (Conventional). Management: Seek alternatives to P-glycoprotein inhibitors in patients treated with doxorubicin whenever possible. One U.S. manufacturer (Pfizer Inc.) recommends that these combinations be avoided. Consider therapy modification
Edoxaban: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Edoxaban. Management: See full monograph for details. Reduced doses are recommended for patients receiving edoxaban for venous thromboembolism in combination with certain P-gp inhibitors. Similar dose adjustment is not recommended for edoxaban use in atrial fibrillation. Consider therapy modification
Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Erdafitinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Everolimus: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Everolimus. Monitor therapy
Flibanserin: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Flibanserin. Monitor therapy
Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination
Grapefruit Juice: May increase the serum concentration of Ivacaftor. Avoid combination
Idelalisib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Avoid combination
Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Larotrectinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
Larotrectinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Larotrectinib. Monitor therapy
Lefamulin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Lefamulin. Management: Avoid concomitant use of lefamulin tablets with P-glycoprotein/ABCB1 inhibitors. If concomitant use is required, monitor for lefamulin adverse effects. Consider therapy modification
Lemborexant: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lemborexant. Management: The maximum recommended dosage of lemborexant is 5 mg, no more than once per night, when coadministered with weak CYP3A4 inhibitors. Consider therapy modification
Lomitapide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lomitapide. Management: Patients on lomitapide 5 mg/day may continue that dose. Patients taking lomitapide 10 mg/day or more should decrease the lomitapide dose by half. The lomitapide dose may then be titrated up to a max adult dose of 30 mg/day. Consider therapy modification
Lorlatinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Avoid concurrent use of lorlatinib with any CYP3A4 substrates for which a minimal decrease in serum concentrations of the CYP3A4 substrate could lead to therapeutic failure and serious clinical consequences. Consider therapy modification
MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Consider therapy modification
Naldemedine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Naldemedine. Monitor therapy
Naloxegol: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Naloxegol. Monitor therapy
NiMODipine: CYP3A4 Inhibitors (Weak) may increase the serum concentration of NiMODipine. Monitor therapy
Palbociclib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
PAZOPanib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of PAZOPanib. Avoid combination
P-glycoprotein/ABCB1 Substrates: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Exceptions: Loperamide. Monitor therapy
Pimozide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Pimozide. Avoid combination
Prucalopride: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Prucalopride. Monitor therapy
Ranolazine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Ranolazine. Monitor therapy
Rifabutin: May decrease the serum concentration of Ivacaftor. Monitor therapy
RifAXIMin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of RifAXIMin. Monitor therapy
Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Silodosin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Silodosin. Monitor therapy
Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Simeprevir: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Monitor therapy
St John's Wort: May decrease the serum concentration of Ivacaftor. Avoid combination
Stiripentol: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification
Tacrolimus (Systemic): Ivacaftor may increase the serum concentration of Tacrolimus (Systemic). Monitor therapy
Talazoparib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Talazoparib. Management: These listed exceptions are discussed in detail in separate interaction monographs. Monitor therapy
Tegaserod: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Tegaserod. Monitor therapy
Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Monitor therapy
Topotecan: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Topotecan. Avoid combination
Triazolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Triazolam. Management: Consider triazolam dose reduction in patients receiving concomitant weak CYP3A4 inhibitors. Consider therapy modification
Ubrogepant: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Ubrogepant. Management: In patients taking weak CYP3A4 inhibitors, the initial and second dose (if needed) of ubrogepant should be limited to 50 mg. Consider therapy modification
Ubrogepant: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Ubrogepant. Management: Use an initial ubrogepant dose of 50 mg and second dose (if needed) of 50 mg when used with a P-gp inhibitor. Consider therapy modification
Venetoclax: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Venetoclax. Management: Consider a venetoclax dose reduction by at least 50% in patients requiring concomitant treatment with P-glycoprotein (P-gp) inhibitors. Consider therapy modification
VinCRIStine (Liposomal): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of VinCRIStine (Liposomal). Avoid combination
Adverse Reactions
>10%:
Central nervous system: Headache (24%)
Dermatologic: Skin rash (13%)
Gastrointestinal: Abdominal pain (16%), diarrhea (13%), nausea (12%)
Respiratory: Oropharyngeal pain (22%), upper respiratory tract infection (22%), nasal congestion (20%), nasopharyngitis (15%)
1% to 10%:
Central nervous system: Dizziness (9%)
Dermatologic: Acne vulgaris (4% to 7%)
Endocrine & metabolic: Increased serum glucose (4% to 7%)
Hepatic: Increased liver enzymes (4% to 7%), increased serum aspartate aminotransferase (4% to 7%)
Infection: Bacterial infection (sputum: 4% to 7%)
Neuromuscular & skeletal: Arthralgia (4% to 7%), musculoskeletal chest pain (4% to 7%), myalgia (4% to 7%)
Respiratory: Paranasal sinus congestion (4% to 7%), pharyngeal erythema (4% to 7%), pleuritic chest pain (4% to 7%), rhinitis (4% to 7%), sinus headache (4% to 7%), wheezing (4% to 7%)
Frequency not defined: Endocrine & metabolic: Hypoglycemia
<1%, postmarketing, and/or case reports: Cataract (children)
Warnings/Precautions
Concerns related to adverse effects:
- Cataracts: Noncongenital lens opacities and cataracts have been reported in pediatric patients treated with ivacaftor; other risk factors were present in some cases (eg, corticosteroid use, exposure to radiation), but a possible risk related to ivacaftor cannot be excluded. Baseline and follow-up ophthalmological examinations are recommended in pediatric patients.
- CNS effects: May cause dizziness, which may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (eg, operating machinery or driving).
- Hepatic effects: May increase hepatic transaminases. Monitor liver function; increased monitoring may be necessary in patients with a history of elevated hepatic transaminases. Temporarily discontinue treatment if ALT or AST >5 times ULN. Following resolution of transaminase elevations, consider the benefits and risks of resuming therapy.
Disease-related concerns:
- Hepatic impairment: Use with caution in patients with hepatic impairment; dosage adjustment recommended in patients with moderate to severe (Child-Pugh class B or C) impairment.
- Renal impairment: Use with caution in patients with severe renal impairment (CrCl ≤30 mL/minute) or ESRD.
Concurrent drug therapy issues:
- Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Monitoring Parameters
CF mutation test (prior to therapy initiation if G551D mutation status unknown); ALT/AST at baseline, every 3 months for 1 year, then annually thereafter or as clinically indicated (consider more frequent monitoring in patients with a history of elevated hepatic transaminases); FEV1; baseline and follow-up ophthalmological exams in pediatric patients
Pregnancy
Pregnancy Considerations
Ivacaftor crosses the placenta (Trimble 2018).
In one case report, cord blood concentrations of ivacaftor at delivery were similar to maternal plasma concentrations following maternal use of ivacaftor/lumacaftor during pregnancy (Trimble 2018). Information related to ivacaftor use in pregnancy is limited (Heltshe 2017; Kaminski 2016; Ladores 2017; Marco 2015; Trimble 2018).
Patient Education
What is this drug used for?
- It is used to treat cystic fibrosis.
Frequently reported side effects of this drug
- Headache
- Common cold symptoms
- Dizziness
- Sore throat
- Stuffy nose
- Diarrhea
- Abdominal pain
- Nausea
- Acne
- Joint pain
- Muscle pain
Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:
- Liver problems like dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin
- High blood sugar like confusion, fatigue, increased thirst, increased hunger, passing a lot of urine, flushing, fast breathing, or breath that smells like fruit
- Chest pain
- Vision changes
- Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.
