Sporanox

Description for Sporanox

SPORANOX^® is the brand name for itraconazole, an azole antifungal agent. Itraconazole is a 1:1:1:1 racemic mixture of four diastereomers (two enantiomeric pairs), each possessing three chiral centers. It may be represented by the following structural formula and nomenclature:

(±)-1-[(R*)-sec-butyl]-4-[p-[4-[p-[[(2R*,4S*)-2-(2,4-dichlorophenyl)-2-(1H-1,2,4-triazol-1ylmethyl)- 1,3-dioxolan-4-yl]methoxy]phenyl]-1-piperazinyl]phenyl]-Δ²-1,2,4-triazolin-5-one mixture with (±)-1-[(R*)-sec-butyl]-4-[p-[4-[p-[[(2S*,4R*)-2-(2,4-dichlorophenyl)-2-(1H1,2,4- triazol-1-ylmethyl)-1,3-dioxolan-4-yl]methoxy]phenyl]-1-piperazinyl]phenyl]-Δ²-1,2,4triazolin- 5-one

or

(±)-1-[(RS)-sec-butyl]-4-[p-[4-[p-[[(2R,4S)-2-(2,4-dichlorophenyl)-2-(1H-1,2,4-triazol-1ylmethyl)- 1,3-dioxolan-4-yl]methoxy]phenyl]-1-piperazinyl]phenyl]-Δ²-1,2,4-triazolin-5-one

Itraconazole has a molecular formula of C₃₅H₃₈Cl₂N₈O₄ and a molecular weight of 705.64. It is a white to slightly yellowish powder. It is insoluble in water, very slightly soluble in alcohols, and freely soluble in dichloromethane. It has a pKa of 3.70 (based on extrapolation of values obtained from methanolic solutions) and a log (n-octanol/water) partition coefficient of 5.66 at pH 8.1.

SPORANOX^® Capsules contain 100 mg of itraconazole coated on sugar spheres (composed of sucrose, maize starch, and purified water). Inactive ingredients are hard gelatin capsule, hypromellose, polyethylene glycol (PEG) 20,000, titanium dioxide, FD&C Blue No. 1, FD&C Blue No. 2, D&C Red No. 22 and D&C Red No. 28.

Uses for Sporanox

SPORANOX^® (itraconazole) Oral Solution is indicated for the treatment of oropharyngeal and esophageal candidiasis.

(see CLINICAL PHARMACOLOGY: Special Populations, WARNINGS, and ADVERSE REACTIONS: Post-Marketing Experience for more information.)

Dosage for Sporanox

Treatment Of Oropharyngeal And Esophageal Candidiasis

The solution should be vigorously swished in the mouth (10 mL at a time) for several seconds and swallowed.

The recommended dosage of SPORANOX^® (itraconazole) Oral Solution for oropharyngeal candidiasis is 200 mg (20 mL) daily for 1 to 2 weeks. Clinical signs and symptoms of oropharyngeal candidiasis generally resolve within several days.

For patients with oropharyngeal candidiasis unresponsive/refractory to treatment with fluconazole tablets, the recommended dose is 100 mg (10 mL) b.i.d. For patients responding to therapy, clinical response will be seen in 2 to 4 weeks. Patients may be expected to relapse shortly after discontinuing therapy. Limited data on the safety of long-term use (>6 months) of SPORANOX^® Oral Solution are available at this time.

The recommended dosage of SPORANOX^® Oral Solution for esophageal candidiasis is 100 mg (10 mL) daily for a minimum treatment of three weeks. Treatment should continue for 2 weeks following resolution of symptoms. Doses up to 200 mg (20 mL) per day may be used based on medical judgment of the patient’s response to therapy.

SPORANOX^® Oral Solution and SPORANOX^® Capsules should not be used interchangeably. Patients should be instructed to take SPORANOX^® Oral Solution without food, if possible. Only SPORANOX^® Oral Solution has been demonstrated effective for oral and/or esophageal candidiasis.

Use In Patients With Renal Impairment

Limited data are available on the use of oral itraconazole in patients with renal impairment. Caution should be exercised when this drug is administered in this patient population. (see CLINICAL PHARMACOLOGY: Special Populations and PRECAUTIONS.)

Use In Patients With Hepatic Impairment

Limited data are available on the use of oral itraconazole in patients with hepatic impairment. Caution should be exercised when this drug is administered in this patient population. (see CLINICAL PHARMACOLOGY: Special Populations, WARNINGS, and PRECAUTIONS.)

HOW SUPPLIED

SPORANOX^® (itraconazole) Oral Solution is available in 150 mL amber glass bottles (NDC 50458-295-15) containing 10 mg of itraconazole per mL.

Store at or below 25°C (77°F). Do not freeze.

Manufactured for: Janssen Pharmaceuticals, Inc. Titusville, NJ 08560, USA. Revised: Mar 2024

Side Effects for Sporanox

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

SPORANOX^® has been associated with rare cases of serious hepatotoxicity, including liver failure and death. Some of these cases had neither pre-existing liver disease nor a serious underlying medical condition. If clinical signs or symptoms develop that are consistent with liver disease, treatment should be discontinued and liver function testing performed. The risks and benefits of SPORANOX^® use should be reassessed. (See WARNINGS: Hepatic Effects and PRECAUTIONS: Hepatotoxicity and PATIENT INFORMATION.)

Adverse Events Reported In Oropharyngeal Or Esophageal Candidiasis Trials

U.S. adverse experience data are derived from 350 immunocompromised patients (332 HIV seropositive/AIDS) treated for oropharyngeal or esophageal candidiasis. Table 3 below lists adverse events reported by at least 2% of patients treated with SPORANOX^® Oral Solution in U.S. clinical trials. Data on patients receiving comparator agents in these trials are included for comparison.

Table 3: Summary of Adverse Events Reported by ≥2% of SPORANOX^® Treated Patients in U.S. Clinical Trials (Total)

Body System/ Adverse Event	Itraconazole
	Total (n = 350*) %	All controlled studies (n = 272) %	Fluconazole (n = 125†) %	Clotrimazole (n = 81‡) %
Gastrointestinal disorders
Nausea	11	10	11	5
Diarrhea	11	10	10	4
Vomiting	7	6	8	1
Abdominal pain	6	4	7	7
Constipation	2	2	1	0
Body as a whole
Fever	7	6	8	5
Chest pain	3	3	2	0
Pain	2	2	4	0
Fatigue	2	1	2	0
Respiratory disorders
Coughing	4	4	10	0
Dyspnea	2	3	5	1
Pneumonia	2	2	0	0
Sinusitis	2	2	4	0
Sputum increased	2	3	3	1
Skin and appendages disorders
Rash	4	5	4	6
Increased sweating	3	4	6	1
Skin disorder unspecified	2	2	2	1
Central/peripheral nervous system
Headache	4	4	6	6
Dizziness	2	2	4	1
Resistance mechanism disorders
Pneumocystis carinii infection	2	2	2	0
Psychiatric disorders
Depression	2	1	0	1
* Of the 350 patients, 209 were treated for oropharyngeal candidiasis in controlled studies, 63 were treated for esophageal candidiasis in controlled studies and 78 were treated for oropharyngeal candidiasis in an open study. † Of the 125 patients, 62 were treated for oropharyngeal candidiasis and 63 were treated for esophageal candidiasis. ‡ All 81 patients were treated for oropharyngeal candidiasis

Adverse events reported by less than 2% of patients in U.S. clinical trials with SPORANOX^® included: adrenal insufficiency, asthenia, back pain, dehydration, dyspepsia, dysphagia, flatulence, gynecomastia, hematuria, hemorrhoids, hot flushes, implantation complication, infection unspecified, injury, insomnia, male breast pain, myalgia, pharyngitis, pruritus, rhinitis, rigors, stomatitis ulcerative, taste perversion, tinnitus, upper respiratory tract infection, vision abnormal, and weight decrease. Edema, hypokalemia and menstrual disorders have been reported in clinical trials with itraconazole capsules.

Adverse Events Reported From Other Clinical Trials

A comparative clinical trial in patients who received intravenous itraconazole followed by SPORANOX^® Oral Solution or received Amphotericin B reported the following adverse events in the itraconazole intravenous/SPORANOX^® Oral Solution treatment arm which are not listed above in the subsection “Adverse Events Reported in Oropharnyngeal or Esophageal Candidiasis Trials” or listed below as post-marketing reports of adverse drug reactions: serum creatinine increased, blood urea nitrogen increased, renal function abnormal, hypocalcemia, hypomagnesemia, hypophosphatemia, hypotension, tachycardia and pulmonary infiltration.

In addition, the following adverse drug reactions were reported in patients who participated in SPORANOX^® Oral Solution clinical trials:

Cardiac Disorders: cardiac failure;

General Disorders and Administration Site Conditions: edema;

Hepatobiliary Disorders: hepatic failure, hyperbilirubinemia;

Metabolism and Nutrition Disorders: hypokalemia;

Reproductive System and Breast Disorders: menstrual disorder

The following is a list of additional adverse drug reactions associated with itraconazole that have been reported in clinical trials of SPORANOX^® Capsules and itraconazole IV excluding the adverse reaction term “Injection site inflammation” which is specific to the injection route of administration:

Cardiac Disorders: left ventricular failure;

Gastrointestinal Disorders: gastrointestinal disorder;

General Disorders and Administration Site Conditions: face edema;

Hepatobiliary Disorders: jaundice, hepatic function abnormal;

Investigations: alanine aminotransferase increased, aspartate aminotransferase increased, blood alkaline phosphatase increased, blood lactate dehydrogenase increased, gammaglutamyltransferase increased, urine analysis abnormal;

Metabolism and Nutrition Disorders: hyperglycemia, hyperkalemia;

Nervous System Disorders: somnolence;

Psychiatric Disorders: confusional state;

Renal and Urinary Disorders: renal impairment;

Respiratory, Thoracic and Mediastinal Disorders: dysphonia;

Skin and Subcutaneous Tissue Disorders: rash erythematous;

Vascular Disorders: hypertension

In addition, the following adverse drug reaction was reported in children only who participated in SPORANOX^® Oral Solution clinical trials: mucosal inflammation.

Post-Marketing Experience

Adverse drug reactions that have been first identified during post-marketing experience with SPORANOX^® (all formulations) are listed in Table 4 below. Because these reactions are reported voluntarily from a population of uncertain size, reliably estimating their frequency or establishing a causal relationship to drug exposure is not always possible.

Table 4: Post-marketing Reports of Adverse Drug Reactions

Blood and Lymphatic System Disorders:	Leukopenia, neutropenia, thrombocytopenia
Immune System Disorders:	Anaphylaxis; anaphylactic, anaphylactoid and allergic reactions; serum sickness; angioneurotic edema
Metabolism and Nutrition Disorders:	Hypertriglyceridemia
Nervous System Disorders:	Peripheral neuropathy, paresthesia, hypoesthesia, tremor
Eye Disorders:	Visual disturbances, including vision blurred and diplopia
Ear and Labyrinth Disorders:	Transient or permanent hearing loss
Cardiac Disorders:	Congestive heart failure
Respiratory, Thoracic and Mediastinal Disorders:	Pulmonary edema
Gastrointestinal Disorders:	Pancreatitis
Hepatobiliary Disorders:	Serious hepatotoxicity (including some cases of fatal acute liver failure), hepatitis, reversible increases in hepatic enzymes
Skin and Subcutaneous Tissue Disorders:	Toxic epidermal necrolysis, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis, erythema multiforme, exfoliative dermatitis, leukocytoclastic vasculitis, alopecia, photosensitivity, urticaria
Musculoskeletal and Connective Tissue Disorders:	Arthralgia
Renal and Urinary Disorders:	Urinary incontinence, pollakiuria
Reproductive System and Breast Disorders:	Erectile dysfunction
General Disorders and Administration Site Conditions:	Peripheral edema
Investigations:	Blood creatine phosphokinase increased

There is limited information on the use of SPORANOX^® during pregnancy. Cases of congenital abnormalities including skeletal, genitourinary tract, cardiovascular and ophthalmic malformations as well as chromosomal and multiple malformations have been reported during post-marketing experience. A causal relationship with SPORANOX^® has not been established. (see CLINICAL PHARMACOLOGY: Special Populations, CONTRAINDICATIONS, WARNINGS, and DRUG INTERACTIONS for more information.)

Drug Interactions for Sporanox

Effect Of SPORANOX^® On Other Drugs

Itraconazole and its major metabolite, hydroxy-itraconazole, are potent CYP3A4 inhibitors. Itraconazole is an inhibitor of the drug transporters P-glycoprotein and breast cancer resistance protein (BCRP). Consequently, SPORANOX^® has the potential to interact with many concomitant drugs resulting in either increased or sometimes decreased concentrations of the concomitant drugs. Increased concentrations may increase the risk of adverse reactions associated with the concomitant drug which can be severe or life-threatening in some cases (e.g., QT prolongation, Torsade de Pointes, respiratory depression, hepatic adverse reactions, hypersensitivity reactions, myelosuppression, hypotension, seizures, angioedema, atrial fibrillation, bradycardia, priapism). Reduced concentrations of concomitant drugs may reduce their efficacy. The table below lists examples of drugs that may have their concentrations affected by itraconazole, but it is not a comprehensive list.

Refer to the approved product labeling to become familiar with the interaction pathways risk, potential and specific actions to be taken with regards to each concomitant drug prior to initiating therapy with SPORANOX^®.

Although many of the clinical drug interactions in Table 1 below are based on information with a similar azole antifungal, ketoconazole, these interactions are expected to occur with SPORANOX^®.

Table 1: Drug Interactions with SPORANOX^® that Affect Concomitant Drug Concentrations

Examples of Concomitant Drugs Within Class	Prevention or Management
Drug Interactions with SPORANOX® that Increase Concomitant Drug Concentrations and May Increase Risk of Adverse Reactions Associated with the Concomitant Drug
Alpha Blockers
Alfuzosin Silodosin Tamsulosin	Not recommended during and 2 weeks after SPORANOX® treatment
Analgesics
Methadone	Contraindicated during and 2 weeks after SPORANOX® treatment
Fentanyl	Not recommended during and 2 weeks after SPORANOX® treatment
Alfentanil Buprenorphine (IV and sublingual) Oxycodonea Sufentanil	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Antiarrhythmics
Disopyramide Dofetilide Dronedarone Quinidinea	Contraindicated during and 2 weeks after SPORANOX® treatment.
Digoxina	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Antibacterials
Bedaquilineb	Concomitant SPORANOX® not recommended for more than 2 weeks at any time during bedaquiline treatment.
Rifabutin	Not recommended 2 weeks before, during, and 2 weeks after SPORANOX® treatment. See also Table 2.
Clarithromycin	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary. See also Table 2.
Trimetrexate	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Anticoagulants and Antiplatelets
Ticagrelor	Contraindicated during and 2 weeks after SPORANOX® treatment
Apixaban Rivaroxaban Vorapaxar	Not recommended during and 2 weeks after SPORANOX® treatment
Cilostazol Dabigatran Warfarin	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Anticonvulsants
Carbamazepine	Not recommended 2 weeks before, during, and 2 weeks after SPORANOX® treatment. See also Table 2.
Antidiabetic Drugs
Repaglinidea Saxagliptin	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Antihelminthics, Antifungals and Antiprotozoals
Isavuconazonium	Contraindicated during and 2 weeks after SPORANOX® treatment
Praziquantel	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Artemether-lumefantrine Quininea	Monitor for adverse reactions
Antimigraine Drugs
Ergot alkaloids (e.g., dihydroergotamine, ergotamine)	Contraindicated during and 2 weeks after SPORANOX® treatment
Eletriptan	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary.
Antineoplastics
Irinotecan	Contraindicated during and 2 weeks after SPORANOX® treatment.
Venetoclax	Contraindicated during the dose initiation and ramp-up phase in patients with CLL/SLL. Refer to the venetoclax prescribing information for dosing and safety monitoring instructions
Mobocertiniba	Avoid use during and 2 weeks after SPORANOX® treatment.
Axitinib Bosutinib Cabazitaxel Cabozantinib Ceritinib Cobimetiniba Crizotinib Dabrafenib Dasatinib Docetaxel Ibrutinib Lapatinib Nilotinib Olapariba Pazopanib Sunitinib Trabectedin Trastuzumabemtansine Vinca alkaloids	Avoid use during and 2 weeks after SPORANOX® treatment.
Entrectiniba Pemigatiniba Talazopariba	Refer to the entrectinib, pemigatinib and talazoparib prescribing information for dosing instructions if concomitant use cannot be avoided.
Glasdegib	Refer to the glasdegib prescribing information for safety monitoring if concomitant use cannot be avoided.
Bortezomib Brentuximabvedotin Busulfan Erlotinib Gefitiniba Idelalisib Imatinib Ixabepilone Nintedanib Panobinostat Ponatinib Ruxolitinib Sonidegib Tretinoin (oral) Vandetaniba	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary. For idelalisib: see also Table 2.
Antipsychotics, Anxiolytics and Hypnotics
Alprazolama Aripiprazolea Buspironea Cariprazine Diazepama Haloperidola Midazolam (IV)a Quetiapine Ramelteon Risperidonea Suvorexant	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary.
Zopiclonea	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Lurasidone Midazolam (oral)a Pimozide Triazolama	Contraindicated during and 2 weeks after SPORANOX® treatment
Antivirals
Daclatasvir Indinavira Maraviroc	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary. For indinavir: see also Table 2.
Cobicistat Elvitegravir (ritonavir-boosted) Ombitasvir/Paritaprevir/Ritonavir with or without Dasabuvir Ritonavir Saquinavir (unboosted)a	Monitor for adverse reactions.
Elbasvir/grazoprevir	Not recommended during and 2 weeks after SPORANOX® treatment
Glecaprevir/pibrentasvir	Monitor for adverse reactions.
Tenofovir disoproxil fumarate	Monitor for adverse reactions
Beta Blockers
Nadolola	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Calcium Channel Blockers
Felodipinea Nisoldipine	Contraindicated during and 2 weeks after SPORANOX® treatment.
Diltiazem Other dihydropyridines Verapamil	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary. For diltiazem: see also Table 2.
Cardiovascular Drugs, Miscellaneous
Ivabradine Ranolazine	Contraindicated during and 2 weeks after SPORANOX® treatment
Aliskirena Riociguat Sildenafil (for pulmonary hypertension) Tadalafil (for pulmonary hypertension)	Not recommended during and 2 weeks after SPORANOX® treatment. For sildenafil and tadalafil, see also Urologic Drugs below.
Bosentan Guanfacine	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Contraceptives*
Dienogest Ulipristal	Monitor for adverse reactions
Diuretics
Eplerenone Finerenone	Contraindicated during and 2 weeks after SPORANOX® treatment.
Gastrointestinal Drugs
Cisapride Naloxegol	Contraindicated during and 2 weeks after SPORANOX® treatment.
Aprepitant Loperamidea	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary.
Netupitant	Monitor for adverse reactions
Immunosuppressants
Voclosporin	Contraindicated during and for 2 weeks after SPORANOX® treatment
Everolimus Sirolimus Temsirolimus (IV)	Not recommended during and 2 weeks after SPORANOX® treatment.
Budesonide (inhalation)a Budesonide (noninhalation) Ciclesonide (inhalation) Cyclosporine (IV)a Cyclosporine (non- IV) Dexamethasonea Fluticasone (inhalation)a Fluticasone (nasal) Methylprednisolonea Tacrolimus (IV)a Tacrolimus (oral) Dexamethasonea	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary.
Lipid-Lowering Drugs
Lomitapide Lovastatina Simvastatina	Contraindicated during and 2 weeks after SPORANOX® treatment
Atorvastatina	Monitor for drug adverse reactions. Concomitant drug dose reduction may be necessary
Respiratory Drugs
Salmeterol	Not recommended during and 2 weeks after SPORANOX® treatment
SSRIs, Tricyclics and Related Antidepressants
Venlafaxine	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Urologic Drugs
Avanafil	Contraindicated during and 2 weeks after SPORANOX® treatment.
Fesoterodine	Patients with moderate to severe renal or hepatic impairment: Contraindicated during and 2 weeks after SPORANOX® treatment. Other patients: Monitor for adverse reactions. Concomitant drug dose reduction may be necessary.
Solifenacin	Patients with severe renal or moderate to severe hepatic impairment: Contraindicated during and 2 weeks after SPORANOX® treatment. Other patients: Monitor for adverse reactions. Concomitant drug dose reduction may be necessary.
Darifenacin Vardenafil	Not recommended during and 2 weeks after SPORANOX® treatment.
Dutasteride Oxybutynina Sildenafil (for erectile dysfunction) Tadalafil (for erectile dysfunction and benign prostatic hyperplasia) Tolterodine	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary. For sildenafil and tadalafil, see also Cardiovascular Drugs above.
Miscellaneous Drugs and Other Substances
Colchicine	Patients with renal or hepatic impairment: Contraindicated during and 2 weeks after SPORANOX® treatment. Other patients: Not recommended during and 2 weeks after SPORANOX® treatment.
Eliglustat	CYP2D6 EMsc taking a strong or moderate CYP2D6 inhibitor, CYP2D6 IMsc, or CYP2D6 PMsc: Contraindicated during and 2 weeks after SPORANOX® treatment. CYP2D6 EMscnot taking a strong or moderate CYP2D6 inhibitor: Monitor for adverse reactions. Eliglustat dose reduction may be necessary.
Lumacaftor/Ivacaftor	Not recommended 2 weeks before, during, and 2 weeks after SPORANOX® treatment.
Alitretinoin (oral) Cabergoline Cannabinoids Cinacalcet Galantamine Ivacaftor	Monitor for adverse reactions. Concomitant drug dose reduction may be necessary
Valbenazine	Concomitant drug dose reduction is necessary. Refer to the valbenazine prescribing information for dosing instructions
Vasopressin Receptor Antagonists
Conivaptan Tolvaptan	Not recommended during and 2 weeks after SPORANOX® treatment
Drug Interactions with SPORANOX® that Decrease Concomitant Drug Concentrations and May Reduce Efficacy of the Concomitant Drug
Antineoplastics
Regorafenib	Not recommended during and 2 weeks after SPORANOX® treatment.
Gastrointestinal Drugs
Saccharomyces boulardii	Not recommended during and 2 weeks after SPORANOX® treatment
Nonsteroidal Anti-Inflammatory Drugs
Meloxicama	Concomitant drug dose increase may be necessary
* CYP3A4 inhibitors (including itraconazole) may increase systemic contraceptive hormone concentrations. a Based on clinical drug interaction information with itraconazole. b Based on 400 mg bedaquiline once daily for 2 weeks. c EMs: extensive metabolizers; IMs: intermediate metabolizers, PMs: poor metabolizers

Effect Of Other Drugs On SPORANOX^®

Itraconazole is mainly metabolized through CYP3A4. Other substances that either share this metabolic pathway or modify CYP3A4 activity may influence the pharmacokinetics of itraconazole. Some concomitant drugs have the potential to interact with SPORANOX^® resulting in either increased or sometimes decreased concentrations of SPORANOX^®. Increased concentrations may increase the risk of adverse reactions associated with SPORANOX^®. Decreased concentrations may reduce SPORANOX^® efficacy.

The table below lists examples of drugs that may affect itraconazole concentrations, but it is not a comprehensive list. Refer to the approved product labeling to become familiar with the interaction pathways, risk potential and specific actions to be taken with regards to each concomitant drug prior to initiating therapy with SPORANOX^®.

Although many of the clinical drug interactions in Table 2 below are based on information with a similar azole antifungal, ketoconazole, these interactions are expected to occur with SPORANOX^®.

Table 2: Drug Interactions with Other Drugs that Affect SPORANOX® Concentrations

Examples of Concomitant Drugs Within Class	Prevention or Management
Drug Interactions with Other Drugs that Increase SPORANOX® Concentrations and May Increase Risk of Adverse Reactions Associated with SPORANOX®
Antibacterials
Ciprofloxacina Erythromycina Clarithromycina	Monitor for adverse reactions. SPORANOX® dose reduction may be necessary
Antineoplastics
Idelalisib	Monitor for adverse reactions. SPORANOX® dose reduction may be necessary. See also Table 1.
Antivirals
Cobicistat Darunavir (ritonavir-boosted) Elvitegravir (ritonavir-boosted) Fosamprenavir (ritonavir-boosted) Indinavira Ombitasvir/ Paritaprevir/ Ritonavir with or without Dasabuvir Ritonavir Saquinavir	Monitor for adverse reactions. SPORANOX® dose reduction may be necessary. For Boceprevir, cobicistat, elvitegravir, indinavir, ombitasvir/ paritaprevir/ ritonavir with or without dasabuvir, ritonavir and saquinavir, see also Table 1.
Calcium Channel Blockers
Diltiazem	Monitor for adverse reactions. SPORANOX® dose reduction may be necessary. See also the table above.
Antibacterials
Isoniazid Rifampicina	Not recommended 2 weeks before and during SPORANOX® treatment
Rifabutina	Not recommended 2 weeks before, during, and 2 weeks after SPORANOX® treatment. See also Table 1.
Anticonvulsants
Phenobarbital Phenytoina	Not recommended 2 weeks before and during SPORANOX® treatment.
Carbamazepine	Not recommended 2 weeks before, during, and 2 weeks after SPORANOX® treatment. See also Table 1.
Antivirals
Efavirenza Nevirapinea	Not recommended 2 weeks before and during SPORANOX® treatment.
Miscellaneous Drugs and Other Substances
Lumacaftor/Ivacaftor	Not recommended 2 weeks before, during, and 2 weeks after SPORANOX® treatment.
a Based on clinical drug interaction information with itraconazole.

Pediatric Population

Interaction studies have only been performed in adults.

Warnings for Sporanox

Hepatic Effects

SPORANOX^® has been associated with rare cases of serious hepatotoxicity, including liver failure and death. Some of these cases had neither pre-existing liver disease nor a serious underlying medical condition, and some of these cases developed within the first week of treatment. If clinical signs or symptoms develop that are consistent with liver disease, treatment should be discontinued and liver function testing performed. Continued SPORANOX^® use or reinstitution of treatment with SPORANOX^® is strongly discouraged unless there is a serious or life-threatening situation where the expected benefit exceeds the risk. (see PATIENT INFORMATION and ADVERSE REACTIONS.)

Cardiac Dysrhythmias

Life-threatening cardiac dysrhythmias and/or sudden death have occurred in patients using drugs such as cisapride, pimozide, methadone, or quinidine concomitantly with SPORANOX^® and/or other CYP3A4 inhibitors. Concomitant administration of these drugs with SPORANOX^® is contraindicated. (see BOX WARNING, CONTRAINDICATIONS, and DRUG INTERACTIONS)

Cardiac Disease

SPORANOX^® Oral Solution should not be used in patients with evidence of ventricular dysfunction unless the benefit clearly outweighs the risk. For patients with risk factors for congestive heart failure, physicians should carefully review the risks and benefits of SPORANOX^® therapy. These risk factors include cardiac disease such as ischemic and valvular disease; significant pulmonary disease such as chronic obstructive pulmonary disease; and renal failure and other edematous disorders. Such patients should be informed of the signs and symptoms of CHF, should be treated with caution, and should be monitored for signs and symptoms of CHF during treatment. If signs or symptoms of CHF appear during administration of SPORANOX^® Oral Solution, monitor carefully and consider other treatment alternatives which may include discontinuation of SPORANOX^® Oral Solution administration.

Itraconazole has been shown to have a negative inotropic effect. When itraconazole was administered intravenously to anesthetized dogs, a dose-related negative inotropic effect was documented. In a healthy volunteer study of itraconazole intravenous infusion, transient, asymptomatic decreases in left ventricular ejection fraction were observed using gated SPECT imaging; these resolved before the next infusion, 12 hours later.

SPORANOX^® has been associated with reports of congestive heart failure. In post-marketing experience, heart failure was more frequently reported in patients receiving a total daily dose of 400 mg although there were also cases reported among those receiving lower total daily doses.

Calcium channel blockers can have negative inotropic effects which may be additive to those of itraconazole. In addition, itraconazole can inhibit the metabolism of calcium channel blockers. Therefore, caution should be used when co-administering itraconazole and calcium channel blockers due to an increased risk of CHF. Concomitant administration of SPORANOX^® and felodipine or nisoldipine is contraindicated.

Cases of CHF, peripheral edema, and pulmonary edema have been reported in the post-marketing period among patients being treated for onychomycosis and/or systemic fungal infections. (see CONTRAINDICATIONS, CLINICAL PHARMACOLOGY: Special Populations, DRUG INTERACTIONS, and ADVERSE REACTIONS: Post-Marketing Experience for more information.)

Interaction Potential

SPORANOX^® has a potential for clinically important drug interactions. Coadministration of specific drugs with itraconazole may result in changes in efficacy of itraconazole and/or the coadministered drug, life-threatening effects and/or sudden death. Drugs that are contraindicated, not recommended or recommended for use with caution in combination with itraconazole are listed in DRUG INTERACTIONS.

Interchangeability

SPORANOX^® (itraconazole) Oral Solution and SPORANOX^® Capsules should not be used interchangeably. This is because drug exposure is greater with the Oral Solution than with the Capsules when the same dose of drug is given. Only SPORANOX^® Oral Solution has been demonstrated effective for oral and/or esophageal candidiasis.

Hydroxypropyl-β-cyclodextrin

SPORANOX^® Oral Solution contains the excipient hydroxypropyl-β-cyclodextrin which produced adenocarcinomas in the large intestine and exocrine pancreatic adenocarcinomas in a rat carcinogenicity study. These findings were not observed in a similar mouse carcinogenicity study. The clinical relevance of these adenocarcinomas is unknown. (see PRECAUTIONS: Carcinogenesis, Mutagenesis, And Impairment Of Fertility.)

Treatment Of Severely Neutropenic Patients

SPORANOX^® Oral Solution as treatment for oropharyngeal and/or esophageal candidiasis was not investigated in severely neutropenic patients. Due to its pharmacokinetic properties, SPORANOX^® Oral Solution is not recommended for initiation of treatment in patients at immediate risk of systemic candidiasis.

Precautions for Sporanox

Hepatotoxicity

Rare cases of serious hepatotoxicity have been observed with SPORANOX^® treatment, including some cases within the first week. It is recommended that liver function monitoring be considered in all patients receiving SPORANOX^®. Treatment should be stopped immediately and liver function testing should be conducted in patients who develop signs and symptoms suggestive of liver dysfunction.

Neuropathy

If neuropathy occurs that may be attributable to SPORANOX^® Oral Solution, the treatment should be discontinued.

Cystic Fibrosis

If a patient with cystic fibrosis does not respond to SPORANOX^® Oral Solution, consideration should be given to switching to alternative therapy (see CLINICAL PHARMACOLOGY: Special Populations).

Hearing Loss

Transient or permanent hearing loss has been reported in patients receiving treatment with itraconazole. Several of these reports included concurrent administration of quinidine which is contraindicated (see BOXED WARNING: Drug Interactions, CONTRAINDICATIONS: Drug Interactions and DRUG INTERACTIONS). The hearing loss usually resolves when treatment is stopped, but can persist in some patients.

Carcinogenesis, Mutagenesis, And Impairment Of Fertility

Itraconazole

Itraconazole showed no evidence of carcinogenicity potential in mice treated orally for 23 months at dosage levels up to 80 mg/kg/day (approximately 1 time the maximum recommended human dose [MRHD] of 400 mg/day based on body surface area comparisons). Male rats treated with 25 mg/kg/day (0.6 times the MRHD based on body surface area comparisons) had a slightly increased incidence of soft tissue sarcoma. These sarcomas may have been a consequence of hypercholesterolemia, which is a response of rats, but not dogs or humans, to chronic itraconazole administration. Female rats treated with 50 mg/kg/day (1.2 times the MRHD based on body surface area comparisons) had an increased incidence of squamous cell carcinoma of the lung (2/50) as compared to the untreated group. Although the occurrence of squamous cell carcinoma in the lung is extremely uncommon in untreated rats, the increase in this study was not statistically significant.

Itraconazole produced no mutagenic effects when assayed in DNA repair test (unscheduled DNA synthesis) in primary rat hepatocytes, in Ames tests with Salmonella typhimurium (6 strains) and Escherichia coli, in the mouse lymphoma gene mutation tests, in a sex-linked recessive lethal mutation (Drosophila melanogaster) test, in chromosome aberration tests in human lymphocytes, in a cell transformation test with C3H/10T½ C18 mouse embryo fibroblasts cells, in a dominant lethal mutation test in male and female mice, and in micronucleus tests in mice and rats.

Itraconazole did not affect the fertility of male or female rats treated orally with dosage levels of up to 40 mg/kg/day (1 time the MRHD based on body surface area comparisons), even though parental toxicity was present at this dosage level. More severe signs of parental toxicity, including death, were present in the next higher dosage level, 160 mg/kg/day (4 times the MRHD based on body surface area comparisons).

Hydroxypropyl-β-Cyclodextrin (HP-β-CD)

Hydroxypropyl-β-cyclodextrin (HP-β-CD) is the solubilizing excipient used in SPORANOX^® Oral Solution.

Hydroxypropyl-β-cyclodextrin (HP-β-CD) was found to produce neoplasms in the large intestine at 5000 mg/kg/day in rat carcinogenicity study. This dose was about 3 times amount contained in the recommended clinical dose of SPORANOX^® Oral Solution (16 g) based on body surface area comparisons. The clinical relevance of this finding is unknown. The slightly higher incidence of adenocarcinomas in the large intestines was linked to the hypertrophic/hyperplastic and inflammatory changes in the colonic mucosa brought about by HP-β-CD-induced increased osmotic forces.

In addition, HP-β-CD was found to produce pancreatic exocrine hyperplasia and neoplasia when administered orally to rats at doses of 500, 2000 or 5000 mg/kg/day for 25 months. Adenocarcinomas of the exocrine pancreas produced in the treated animals were not seen in the untreated group and are not reported in the historical controls. The maximum recommended clinical dose of SPORANOX^® Oral Solution contains approximately 3.3 times the amount of HP-β-CD as was in the 500 mg/kg/day dose, based on body surface area comparisons. This finding was not observed in the mouse carcinogenicity study at doses of 500, 2000 or 5000 mg/kg/day for 22-23 months. This finding was also not observed in a 12-month toxicity study in dogs or in a 2-year toxicity study in female cynomolgus monkeys.

Since the development of the pancreatic tumors may be related to a mitogenic action of cholecystokinin and since there is no evidence that cholecystokinin has a mitogenic action in man, the clinical relevance of these findings is unknown.

HP-β-CD has no antifertile effect, and is not mutagenic.

Pregnancy

Teratogenic Effects

Itraconazole was found to cause a dose-related increase in maternal toxicity, embryotoxicity, and teratogenicity in rats at dosage levels of approximately 40-160 mg/kg/day (1-4 times the MRHD based on body surface area comparisons), and in mice at dosage levels of approximately 80 mg/kg/day (1 time the MRHD based on body surface area comparisons). Itraconazole has been shown to cross the placenta in a rat model. In rats, the teratogenicity consisted of major skeletal defects; in mice, it consisted of encephaloceles and/or macroglossia.

SPORANOX^® Oral Solution contains the excipient hydroxypropyl-β-cyclodextrin (HP-β-CD). HP-β-CD has no direct embryotoxic and no teratogenic effect.

There are no studies in pregnant women. SPORANOX^® should be used in pregnancy only if the benefit outweighs the potential risk. Highly effective contraception should be continued throughout SPORANOX^® therapy and for 2 months following the end of treatment.

During post-marketing experience, cases of congenital abnormalities have been reported. (See ADVERSE REACTIONS: Post-Marketing Experience.)

Nursing Mothers

Itraconazole is excreted in human milk; therefore, the expected benefits of SPORANOX^® therapy for the mother should be weighed against the potential risk from exposure of itraconazole to the infant. The U.S. Public Health Service Centers for Disease Control and Prevention advises HIV-infected women not to breast-feed to avoid potential transmission of HIV to uninfected infants.

Pediatric Use

The efficacy and safety of SPORANOX^® have not been established in pediatric patients.

The long-term effects of itraconazole on bone growth in children are unknown. In three toxicology studies using rats, itraconazole induced bone defects at dosage levels as low as 20 mg/kg/day (0.5 times the MRHD of 400 mg based on body surface area comparisons). The induced defects included reduced bone plate activity, thinning of the zona compacta of the large bones, and increased bone fragility. At a dosage level of 80 mg/kg/day (2 times the MRHD based on body surface area comparisons) over 1 year or 160 mg/kg/day (4 times the MRHD based on body surface area comparisons) for 6 months, itraconazole induced small tooth pulp with hypocellular appearance in some rats.

Geriatric Use

Clinical studies of SPORANOX^® Oral Solution did not include sufficient numbers of subjects aged 65 years and over to determine whether they respond differently from younger subjects. It is advised to use SPORANOX^® Oral Solution in these patients only if it is determined that the potential benefit outweighs the potential risks. In general, it is recommended that the dose selection for an elderly patient should be taken into consideration, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

Transient or permanent hearing loss has been reported in elderly patients receiving treatment with itraconazole. Several of these reports included concurrent administration of quinidine which is contraindicated (see BOXED WARNING: Drug Interactions, CONTRAINDICATIONS: Drug Interactions and DRUG INTERACTIONS).

Renal Impairment

Limited data are available on the use of oral itraconazole in patients with renal impairment. The exposure of itraconazole may be lower in some patients with renal impairment. Caution should be exercised when itraconazole is administered in this patient population and dose adjustment may be needed. (see CLINICAL PHARMACOLOGY: Special Populations and DOSAGE AND ADMINISTRATION.)

Hepatic Impairment

Limited data are available on the use of oral itraconazole in patients with hepatic impairment. Caution should be exercised when this drug is administered in this patient population. It is recommended that patients with impaired hepatic function be carefully monitored when taking SPORANOX^®. It is recommended that the prolonged elimination half-life of itraconazole observed in the single oral dose clinical trial with itraconazole capsules in cirrhotic patients be considered when deciding to initiate therapy with other medications metabolized by CYP3A4.

In patients with elevated or abnormal liver enzymes or active liver disease, or who have experienced liver toxicity with other drugs, treatment with SPORANOX^® is strongly discouraged unless there is a serious or life-threatening situation where the expected benefit exceeds the risk. It is recommended that liver function monitoring be done in patients with pre-existing hepatic function abnormalities or those who have experienced liver toxicity with other medications. (see CLINICAL PHARMACOLOGY: Special Populations and DOSAGE AND ADMINISTRATION.)

Overdose Information for Sporanox

Itraconazole is not removed by dialysis. In the event of accidental overdosage, supportive measures should be employed. Contact a certified poison control center for the most up to date information on the management of SPORANOX^® (itraconazole) Oral Solution overdosage (1-800-222-1222 or www.poison.org). In general, adverse events reported with overdose have been consistent with adverse drug reactions already listed in this package insert for itraconazole. (See ADVERSE REACTIONS.)

Contraindications for Sporanox

Congestive Heart Failure

SPORANOX^® (itraconazole) Oral Solution should not be administered to patients with evidence of ventricular dysfunction such as congestive heart failure (CHF) or a history of CHF except for the treatment of life-threatening or other serious infections. (see BOX WARNING, WARNINGS, DRUG INTERACTIONS - Calcium Channel Blockers, ADVERSE REACTIONS: Post-Marketing Experience, and CLINICAL PHARMACOLOGY: Special Populations.)

Drug Interactions

Coadministration of a number of CYP3A4 substrates are contraindicated with SPORANOX^®. Some examples of drugs for which plasma concentrations increase are: methadone, disopyramide, dofetilide, dronedarone, quinidine, isavuconazole, ergot alkaloids (such as dihydroergotamine, ergometrine (ergonovine), ergotamine, methylergometrine (methylergonovine)), irinotecan, lurasidone, oral midazolam, pimozide, triazolam, felodipine, nisoldipine, ivabradine, ranolazine, eplerenone, cisapride, naloxegol, lomitapide, lovastatin, simvastatin, avanafil, ticagrelor, finerenone, voclosporin. In addition, coadministration with colchicine, fesoterodine, and solifenacin is contraindicated in subjects with varying degrees of renal or hepatic impairment, and coadministration with eliglustat is contraindicated in subjects that are poor or intermediate metabolizers of CYP2D6 and in subjects taking strong or moderate CYP2D6 inhibitors. (see DRUG INTERACTIONS Section for specific examples.) This increase in drug concentrations caused by coadministration with itraconazole may increase or prolong both the pharmacologic effects and/or adverse reactions to these drugs. For example, increased plasma concentrations of some of these drugs can lead to QT prolongation and ventricular tachyarrhythmias including occurrences of torsade de pointes, a potentially fatal arrhythmia. Some specific examples are listed in DRUG INTERACTIONS.

Coadministration with venetoclax is contraindicated in patients with CLL/SLL during the dose initiation and ramp-up phase of venetoclax due to the potential for an increased risk of tumor lysis syndrome.

SPORANOX^® is contraindicated for patients who have shown hypersensitivity to itraconazole. There is limited information regarding cross-hypersensitivity between itraconazole and other azole antifungal agents. Caution should be used when prescribing SPORANOX^® to patients with hypersensitivity to other azoles.

Clinical Pharmacology for Sporanox

Pharmacokinetics And Metabolism

General Pharmacokinetic Characteristics

Peak plasma concentrations of itraconazole are reached within 2 to 5 hours following oral administration. As a consequence of non-linear pharmacokinetics, itraconazole accumulates in plasma during multiple dosing. Steady-state concentrations are generally reached within about 15 days, with Cmax values of 0.5 μg/mL, 1.1 μg/mL and 2.0 μg/mL after oral administration of 100 mg once daily, 200 mg once daily and 200 mg b.i.d., respectively. The terminal half-life of itraconazole generally ranges from 16 to 28 hours after single dose and increases to 34 to 42 hours with repeated dosing. Once treatment is stopped, itraconazole plasma concentrations decrease to an almost undetectable concentration within 7 to 14 days, depending on the dose and duration of treatment. Itraconazole mean total plasma clearance following intravenous administration is 278 mL/min. Itraconazole clearance decreases at higher doses due to saturable hepatic metabolism.

Absorption

Itraconazole is rapidly absorbed after oral administration. Peak plasma concentrations of itraconazole are reached within 2 to 5 hours following an oral capsule dose. The observed absolute oral bioavailability of itraconazole is about 55%.

The oral bioavailability of itraconazole is maximal when SPORANOX® (itraconazole) Capsules are taken immediately after a full meal. Absorption of itraconazole capsules is reduced in subjects with reduced gastric acidity, such as subjects taking medications known as gastric acid secretion suppressors (e.g., H2-receptor antagonists, proton pump inhibitors) or subjects with achlorhydria caused by certain diseases. (See PRECAUTIONS: DRUG INTERACTIONS.) Absorption of itraconazole under fasted conditions in these subjects is increased when SPORANOX® Capsules are administered with an acidic beverage (such as a non-diet cola). When SPORANOX® Capsules were administered as a single 200-mg dose under fasted conditions with non-diet cola after ranitidine pretreatment, a H2-receptor antagonist, itraconazole absorption was comparable to that observed when SPORANOX® Capsules were administered alone. (See PRECAUTIONS: DRUG INTERACTIONS.)

Itraconazole exposure is lower with the Capsule formulation than with the Oral Solution when the same dose of drug is given. (See WARNINGS)

Distribution

Most of the itraconazole in plasma is bound to protein (99.8%), with albumin being the main binding component (99.6% for the hydroxy-metabolite). It has also a marked affinity for lipids. Only 0.2% of the itraconazole in plasma is present as free drug. Itraconazole is distributed in a large apparent volume in the body (>700 L), suggesting extensive distribution into tissues. Concentrations in lung, kidney, liver, bone, stomach, spleen and muscle were found to be two to three times higher than corresponding concentrations in plasma, and the uptake into keratinous tissues, skin in particular, up to four times higher. Concentrations in the cerebrospinal fluid are much lower than in plasma.

Metabolism

Itraconazole is extensively metabolized by the liver into a large number of metabolites. In vitro studies have shown that CYP3A4 is the major enzyme involved in the metabolism of itraconazole. The main metabolite is hydroxy-itraconazole, which has in vitro antifungal activity comparable to itraconazole; trough plasma concentrations of this metabolite are about twice those of itraconazole.

Excretion

Itraconazole is excreted mainly as inactive metabolites in urine (35%) and in feces (54%) within one week of an oral solution dose. Renal excretion of itraconazole and the active metabolite hydroxy-itraconazole account for less than 1% of an intravenous dose. Based on an oral radiolabeled dose, fecal excretion of unchanged drug ranges from 3% to 18% of the dose.

As re-distribution of itraconazole from keratinous tissues appears to be negligible, elimination of itraconazole from these tissues is related to epidermal regeneration. Contrary to plasma, the concentration in skin persists for 2 to 4 weeks after discontinuation of a 4-week treatment and in nail keratin – where itraconazole can be detected as early as 1 week after start of treatment – for at least six months after the end of a 3-month treatment period.

Special Populations

Renal Impairment

Limited data are available on the use of oral itraconazole in patients with renal impairment. A pharmacokinetic study using a single 200 mg oral dose of itraconazole was conducted in three groups of patients with renal impairment (uremia: n=7; hemodialysis: n=7; and continuous ambulatory peritoneal dialysis: n=5). In uremic subjects with a mean creatinine clearance of 13 mL/min. x 1.73 m², the exposure, based on AUC, was slightly reduced compared with normal population parameters. This study did not demonstrate any significant effect of hemodialysis or continuous ambulatory peritoneal dialysis on the pharmacokinetics of itraconazole (Tmax, Cmax, and AUC0-8h). Plasma concentration-versus-time profiles showed wide intersubject variation in all three groups. After a single intravenous dose, the mean terminal half-lives of itraconazole in patients with mild (defined in this study as CrCl 50-79 mL/min), moderate (defined in this study as CrCl 20-49 mL/min), and severe renal impairment (defined in this study as CrCl <20 mL/min) were similar to that in healthy subjects (range of means 42-49 hours vs 48 hours in renally impaired patients and healthy subjects, respectively). Overall exposure to itraconazole, based on AUC, was decreased in patients with moderate and severe renal impairment by approximately 30% and 40%, respectively, as compared with subjects with normal renal function. Data are not available in renally impaired patients during long-term use of itraconazole. Dialysis has no effect on the half-life or clearance of itraconazole or hydroxy-itraconazole. (See PRECAUTIONS and DOSAGE AND ADMINISTRATION.)

Hepatic Impairment

Itraconazole is predominantly metabolized in the liver. A pharmacokinetic study was conducted in 6 healthy and 12 cirrhotic subjects who were administered a single 100 mg dose of itraconazole as capsule. A statistically significant reduction in mean Cmax (47%) and a twofold increase in the elimination half-life (37±17 hours vs. 16±5 hours) of itraconazole were noted in cirrhotic subjects compared with healthy subjects. However, overall exposure to itraconazole, based on AUC, was similar in cirrhotic patients and in healthy subjects. Data are not available in cirrhotic patients during long-term use of itraconazole. (See CONTRAINDICATIONS, PRECAUTIONS: DRUG INTERACTIONS and DOSAGE AND ADMINISTRATION.)

Decreased Cardiac Contractility

When itraconazole was administered intravenously to anesthetized dogs, a dose-related negative inotropic effect was documented. In a healthy volunteer study of itraconazole intravenous infusion, transient, asymptomatic decreases in left ventricular ejection fraction were observed using gated SPECT imaging; these resolved before the next infusion, 12 hours later. If signs or symptoms of congestive heart failure appear during administration of SPORANOX® Capsules, SPORANOX® should be discontinued. (See BOXED WARNING, CONTRAINDICATIONS, WARNINGS, PRECAUTIONS: DRUG INTERACTIONS and ADVERSE REACTIONS: Post-marketing Experience for more information.)

Microbiology

Mechanism Of Action

In vitro studies have demonstrated that itraconazole inhibits the cytochrome P450-dependent synthesis of ergosterol, which is a vital component of fungal cell membranes.

Antimicrobial Activity

Itraconazole exhibits in vitro activity against Blastomyces dermatitidis, Histoplasma capsulatum, Histoplasma duboisii, Aspergillus flavus, Aspergillus fumigatus, and Trichophyton species (See INDICATIONS AND USAGE: Description of Clinical Studies).

Susceptibility Testing Methods

For specific information regarding susceptibility test interpretive criteria and associated test methods and quality control standards recognized by FDA for this drug, please see: https://www.fda.gov/STIC.

Resistance

Isolates from several fungal species with decreased susceptibility to itraconazole have been isolated in vitro and from patients receiving prolonged therapy.

Itraconazole is not active against Zygomycetes (e.g., Rhizopus spp., Rhizomucor spp., Mucor spp. and Absidia spp.), Fusarium spp., Scedosporium spp. and Scopulariopsis spp.

Cross-Resistance

Several in vitro studies have reported that some fungal clinical isolates with reduced susceptibility to one azole antifungal agent may also be less susceptible to other azole derivatives. The finding of cross-resistance is dependent on a number of factors, including the species evaluated, its clinical history, the particular azole compounds compared, and the type of susceptibility test that is performed.

Studies (both in vitro and in vivo) suggest that the activity of amphotericin B may be suppressed by prior azole antifungal therapy. As with other azoles, itraconazole inhibits the ¹⁴C-demethylation step in the synthesis of ergosterol, a cell wall component of fungi. Ergosterol is the active site for amphotericin B. In one study the antifungal activity of amphotericin B against Aspergillus fumigatus infections in mice was inhibited by ketoconazole therapy. The clinical significance of test results obtained in this study is unknown.

Description Of Clinical Studies

Blastomycosis

Analyses were conducted on data from two open-label, non-concurrently controlled studies (N=73 combined) in patients with normal or abnormal immune status. The median dose was 200 mg/day. A response for most signs and symptoms was observed within the first 2 weeks, and all signs and symptoms cleared between 3 and 6 months. Results of these two studies demonstrated substantial evidence of the effectiveness of itraconazole for the treatment of blastomycosis compared with the natural history of untreated cases.

Histoplasmosis

Analyses were conducted on data from two open-label, non-concurrently controlled studies (N=34 combined) in patients with normal or abnormal immune status (not including HIV-infected patients). The median dose was 200 mg/day. A response for most signs and symptoms was observed within the first 2 weeks, and all signs and symptoms cleared between 3 and 12 months. Results of these two studies demonstrated substantial evidence of the effectiveness of itraconazole for the treatment of histoplasmosis, compared with the natural history of untreated cases.

Histoplasmosis In HIV-Infected Patients

Data from a small number of HIV-infected patients suggested that the response rate of histoplasmosis in HIV-infected patients is similar to that of non-HIV-infected patients. The clinical course of histoplasmosis in HIV-infected patients is more severe and usually requires maintenance therapy to prevent relapse.

Aspergillosis

Analyses were conducted on data from an open-label, “single-patient-use” protocol designed to make itraconazole available in the U.S. for patients who either failed or were intolerant of amphotericin B therapy (N=190). The findings were corroborated by two smaller open-label studies (N=31 combined) in the same patient population. Most adult patients were treated with a daily dose of 200 to 400 mg, with a median duration of 3 months. Results of these studies demonstrated substantial evidence of effectiveness of itraconazole as a second-line therapy for the treatment of aspergillosis compared with the natural history of the disease in patients who either failed or were intolerant of amphotericin B therapy.

Onychomycosis Of The Toenail

Analyses were conducted on data from three double-blind, placebo-controlled studies (N=214 total; 110 given SPORANOX® Capsules) in which patients with onychomycosis of the toenails received 200 mg of SPORANOX® Capsules once daily for 12 consecutive weeks. Results of these studies demonstrated mycologic cure, defined as simultaneous occurrence of negative KOH plus negative culture, in 54% of patients. Thirty-five percent (35%) of patients were considered an overall success (mycologic cure plus clear or minimal nail involvement with significantly decreased signs) and 14% of patients demonstrated mycologic cure plus clinical cure (clearance of all signs, with or without residual nail deformity). The mean time to overall success was approximately 10 months. Twenty-one percent (21%) of the overall success group had a relapse (worsening of the global score or conversion of KOH or culture from negative to positive).

Onychomycosis Of The Fingernail

Analyses were conducted on data from a double-blind, placebo-controlled study (N=73 total; 37 given SPORANOX® Capsules) in which patients with onychomycosis of the fingernails received a 1-week course (pulse) of 200 mg of SPORANOX® Capsules b.i.d., followed by a 3-week period without SPORANOX®, which was followed by a second 1-week pulse of 200 mg of SPORANOX® Capsules b.i.d. Results demonstrated mycologic cure in 61% of patients. Fifty-six percent (56%) of patients were considered an overall success and 47% of patients demonstrated mycologic cure plus clinical cure. The mean time to overall success was approximately 5 months. None of the patients who achieved overall success relapsed.

Patient Information for Sporanox

SPORANOX®
(SPOR-ah-nox)
(itraconazole) Capsules

Read this Patient Information that comes with SPORANOX before you start taking it and each time you get a refill. There may be new information. This information does not take the place of talking with your healthcare provider about your medical condition or your treatment.

What is the most important information I should know about SPORANOX?

SPORANOX can cause serious side effects, including:

1. Heart failure. Do not take SPORANOX if you have had heart failure, including congestive heart failure. Stop taking SPORANOX and call your healthcare provider right away if you have any of these symptoms of congestive heart failure:

• shortness of breath
• coughing up white or pink mucus (phlegm)
• swelling of your feet, ankles or legs
• fast heartbeat
• sudden weight gain
• waking up at night more than normal for you
• increased tiredness

2. Heart problems and other serious medical problems. Serious medical problems that affect the heart and other parts of your body can happen if you take SPORANOX with certain other medicines. Do not take SPORANOX if you also take the following medicines:

• methadone
• irinotecan
• naloxegol
• disopyramide
• lurasidone
• lomitapide
• dofetilide
• oral midazolam
• lovastatin
• dronedarone
• pimozide
• simvastatin
• quinidine
• triazolam
• avanafil
• isavuconazole
• felodipine
• ticagrelor
• ergot alkaloids (such as dihydroergotamine, ergometrine ergonovine)
• nisoldipine
• venetoclax (see below)
• ivabradine
• finerenone
• ranolazine
• voclosporin
• ergotamine
• eplerenone
• methylergometrine (methylergonovine)
• cisapride

Do not take SPORANOX with venetoclax for chronic lymphocytic leukemia/small lymphocytic lymphoma when you first start treatment with venetoclax or with increasing doses of venetoclax.

This is not a complete list of medicines that can interact with SPORANOX. SPORANOX may affect the way other medicines work, and other medicines may affect how SPORANOX works. You can ask your pharmacist for a list of medicines that interact with SPORANOX.

Before you start taking SPORANOX, tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

Before you start any new medicine, ask your healthcare provider or pharmacist if it is safe to take it with SPORANOX.

3. Liver problems. SPORANOX can cause serious liver problems which may be severe and lead to death. Stop taking SPORANOX and call your healthcare provider right away if you have any of these symptoms of liver problems:

• tiredness
• your skin or the white part of your eyes turn yellow
• loss of appetite for several days or longer (jaundice)
• nausea or vomiting
• light-colored stools (bowel movement)
• dark or “tea-colored” urine

For more information about side effects, see “What are the possible side effects of SPORANOX?”

What is SPORANOX?

• SPORANOX is a prescription medicine used to treat the following fungal infections of the toenails, fingernails and other parts of the body: blastomycosis, histoplasmosis, aspergillosis, and onychomycosis.
• It is not known if SPORANOX is safe and effective in children.

Do not take SPORANOX if you:

• have or have had heart failure, including congestive heart failure.
• take certain medicines. See “What is the most important information I should know about SPORANOX?”
• are pregnant or plan to become pregnant. SPORANOX can harm your unborn baby. Tell your healthcare provider right away if you become pregnant while taking SPORANOX. Females who are able to become pregnant must use effective forms of birth control during treatment and for 2 months after stopping treatment with SPORANOX.
• are allergic to itraconazole or any of the ingredients in SPORANOX. See the end of this Patient Information leaflet for a complete list of ingredients in SPORANOX.

Before taking SPORANOX, tell your healthcare provider about all of your medical conditions, including if you:

• have heart problems.
• have liver problems.
• have kidney problems.
• have a weakened immune system (immunocompromised).
• have lung problems including cystic fibrosis.
• are breastfeeding or plan to breastfeed. SPORANOX can pass into your breast milk. You and your healthcare provider should decide if you will take SPORANOX or breastfeed.

Taking SPORANOX with certain medicines may affect each other. Taking SPORANOX with other medicines can cause serious side effects.

How should I take SPORANOX?

• Take SPORANOX exactly as prescribed by your healthcare provider. Your healthcare provider will tell you how much SPORANOX to take and when to take it.
• You will receive SPORANOX capsules in a blister pack or bottle. Your healthcare provider will decide the type of SPORANOX that is right for you.
• Take SPORANOX with a full meal.
• Swallow SPORANOX capsules whole.
• You should not take SPORANOX oral solution instead of SPORANOX capsules, because they will not work the same way.
• If you take too much SPORANOX, call your healthcare provider or go to the nearest hospital emergency room right away.

What should I avoid while taking SPORANOX?

SPORANOX can cause dizziness and vision problems. Do not drive or operate machinery until you know how SPORANOX affects you.

What are the possible side effects of SPORANOX?

SPORANOX may cause serious side effects, including:

• See “What is the most important information I should know about SPORANOX?”
• Nerve problems (neuropathy). Call your healthcare provider right away if you have tingling or numbness in your hands or feet. Your healthcare provider may stop your treatment with SPORANOX if you have nerve problems.
• Hearing loss. Hearing loss can happen for a short time or permanently in some people who take SPORANOX. Stop taking SPORANOX and call your healthcare provider right away if you have any changes in your hearing.

The most common side effects of SPORANOX include: headache, rash, digestive system problems (such as nausea and vomiting), and edema.

Additional possible side effects include upset stomach, constipation, fever, inflammation of the pancreas, menstrual disorder, erectile dysfunction, dizziness, muscle pain, painful joints, unpleasant taste, or hair loss.

These are not all the possible side effects of SPORANOX.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store SPORANOX?

• Store SPORANOX at room temperature between 59°F to 77°F (15°C to 25°C).
• Keep SPORANOX dry and away from light.

Keep SPORANOX and all medicines out of the reach of children.

General information about the safe and effective use of SPORANOX.

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use SPORANOX for a condition for which it was not prescribed. Do not give SPORANOX to other people, even if they have the same symptoms that you have. It may harm them. You can ask your doctor or pharmacist for information about SPORANOX that is written for health professionals.

What are the ingredients in SPORANOX?

Active ingredients: itraconazole

Inactive ingredients: hard gelatin capsule, hypromellose, polyethylene glycol (PEG) 20,000, titanium dioxide, FD&C Blue No. 1, FD&C Blue No. 2, D&C Red No. 22 and D&C Red No. 28.

This Patient Information has been approved by the U.S. Food and Drug Administration