4.1. Therapeutic indications

Xerava is indicated for the treatment of complicated intra-abdominal infections (cIAI) in adults (see sections 4.4 and 5.1).

Consideration should be given to official guidance on the appropriate use of antibacterial agents.

4.2. Posology and method of administration

Posology

The recommended dose regimen is 1 mg/kg eravacycline every 12 hours for 4 to 14 days.

Strong CYP3A4 inducers

In patients co-administered strong CYP3A4 inducers the recommended dose regimen is 1.5 mg/kg eravacycline every 12 hours for 4 to 14 days (see sections 4.4 and 4.5).

Elderly (≥ 65 years old)

No dose adjustment is required in elderly patients (see section 5.2).

Renal impairment

No dose adjustment is necessary in patients with renal impairment or in patients undergoing haemodialysis. Eravacycline may be administered without regard to the timing of haemodialysis (see section 5.2).

Hepatic impairment

No dose adjustment is necessary in patients with hepatic impairment (see sections 4.4, 4.5 and 5.2).

Paediatric population

The safety and efficacy of Xerava in children and adolescents less than 18 years of age have not been established. No data are available. Xerava should not be used in children aged under 8 years because of teeth discolouration (see sections 4.4 and 4.6).

Method of administration

Intravenous use.

Xerava is administered only by intravenous infusion over approximately 1 hour (see section 4.4).

For instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6.

4.3. Contraindications

Hypersensitivity to the active substance, or to any of the excipients listed in section 6.1.

Hypersensitivity to tetracycline class antibiotics.

4.4. Special warnings and precautions for use

Anaphylactic reactions

Serious and occasionally fatal hypersensitivity reactions are possible and have been reported with other tetracycline class antibiotics (see section 4.3). In case of hypersensitivity reactions, treatment with eravacycline must be discontinued immediately and appropriate emergency measures must be initiated.

Clostridioides difficile- associated diarrhoea

Antibiotic-associated colitis and pseudomembranous colitis have been reported with the use of nearly all antibiotics and may range in severity from mild to life-threatening. It is important to consider this diagnosis in patients who present with diarrhoea during or subsequent to treatment with eravacycline (see section 4.8). In such circumstances, the discontinuation of eravacycline and the use of supportive measures together with the administration of specific treatment for Clostridioides difficile should be considered. Medicinal products that inhibit peristalsis should not be given.

Infusion-site reactions

Eravacycline is administered via intravenous infusion, using an infusion time of approximately 1 hour to minimise the risk of infusion-site reactions. Infusion-site erythema, pain/tenderness, phlebitis and thrombophlebitis were observed with intravenous eravacycline in clinical trials (see section 4.8). In case of serious reactions, eravacycline should be discontinued until a new intravenous access site is established. Additional measures to reduce the occurrence and severity of infusion site reactions include decreasing the eravacycline infusion rate and/or concentration.

Non-susceptible micro-organisms

Prolonged use may result in the overgrowth of non-susceptible micro-organisms, including fungi. If superinfection occurs during therapy, it may require interruption of treatment. Other appropriate measures should be taken and alternative antimicrobial treatment should be considered in accordance with existing therapeutic guidelines.

Pancreatitis

Pancreatitis has been reported with eravacycline and has been severe in some cases (see section 4.8). If pancreatitis is suspected, eravacycline should be discontinued.

Paediatric population

Xerava should not be used during tooth development (during the 2nd and 3rd trimester of pregnancy, and in children under 8 years of age) as it may cause permanent discolouration of the teeth (yellow-grey-brown) (see sections 4.2 and 4.6).

Concomitant use of strong CYP3A4 inducers

Medicines that induce CYP3A4 are expected to increase the rate and extent of metabolism of eravacycline. CYP3A4 inducers exert their effect in a time-dependent manner, and may take at least 2 weeks to reach maximal effect after introduction. Conversely, on discontinuation, CYP3A4 induction may take at least 2 weeks to decline. Co-administration of a strong CYP3A4 inducer (such as phenobarbital, rifampicin, carbamazepine, phenytoin, St. John's Wort) is expected to reduce the effect of eravacycline (see sections 4.2 and 4.5).

Patients with severe hepatic impairment

Exposure may be increased in patients with severe hepatic impairment (Child-Pugh Class C). Therefore, such patients should be monitored for adverse reactions (see section 4.8), particularly if these patients are obese and/or are also being treated with strong CYP3A inhibitors where the exposure may be further increased (see sections 4.5 and 5.2). In these cases, no recommendation on a posology can be made.

Limitations of the clinical data

In clinical trials in cIAI, there were no immunocompromised patients, and the majority of patients (80%) had APACHE II scores <10 at baseline; 5.4% of the patients had concurrent bacteraemia at baseline; 34% of the patients had complicated appendicitis.

Coagulopathy

Eravacycline may prolong both prothrombin time (PT) and activated partial thromboplastin time (aPTT). Additionally, hypofibrinogenaemia has been reported with the use of eravacycline. Therefore, blood coagulation parameters such as PT or other suitable anticoagulation test, including blood fibrinogen, should be monitored prior to treatment initiation with eravacycline and regularly while on treatment.

4.5. Interaction with other medicinal products and other forms of interaction

Potential for other medicinal products to affect the pharmacokinetics of eravacycline

Concomitant administration of the strong CYP 3A4/3A5 inducer rifampicin altered the pharmacokinetics of eravacycline, decreasing exposure by approximately 32% and increasing clearance by approximately 54%. The eravacycline dose should be increased by approximately 50% (1.5 mg/kg intravenous q12h) when co-administered with rifampicin or other strong CYP3A inducers such as phenobarbital, carbamazepine, phenytoin and St. John's Wort (see sections 4.2 and 4.4).

Concomitant administration of the strong CYP3A inhibitor itraconazole altered the pharmacokinetics of eravacycline, increasing Cmax by approximately 5% and AUC0‑24 by approximately 23%, and decreasing clearance. The increased exposure is not likely to be clinically significant; thus, no dose adjustment is required when eravacycline is co-administered with CYP3A inhibitors. However, patients receiving strong CYP3A inhibitors (for example ritonavir, itraconazole, clarithromycin) with a combination of factors that may increase the exposure, such as severe hepatic impairment and/or obesity should be monitored for adverse reactions (see sections 4.4 and 4.8).

In vitro, eravacycline was shown to be a substrate for the transporters P-gp, OATP1B1 and OATP1B3. A drug-drug interaction in vivo cannot be excluded and co-administration of eravacycline and other medicinal products that inhibit these transporters (examples of OATP1B1/3 inhibitors; atazanavir, cyclosporine, lopinavir, and saquinavir) may increase the eravacycline plasma concentration.

Potential for eravacycline to affect the pharmacokinetics of other medicinal products

In vitro, eravacycline and its metabolites are not inhibitors or inducers of CYP enzymes or transport proteins (see section 5.2). Interactions with medicinal products that are substrates for these enzymes or transporters are therefore unlikely.

4.6. Fertility, pregnancy and lactation

Pregnancy

There are limited data on the use of eravacycline in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown.

As for other tetracycline class antibiotics, eravacycline may induce permanent dental defects (discolouration and enamel defects) and a delay in ossification processes in foetuses exposed in utero during the 2nd and 3rd trimester, due to accumulation in tissues with a high calcium turnover and formation of calcium chelate complexes (see sections 4.4 and 5.3). Xerava should not be used during pregnancy unless the clinical condition of the woman requires treatment with eravacycline.

Women of childbearing potential

Women of childbearing potential should avoid becoming pregnant while receiving eravacycline.

Breast-feeding

It is unknown whether eravacycline and its metabolites are excreted in human breast milk. Animal studies have shown excretion of eravacycline and its metabolites in breast milk (see section 5.3).

Long term use of other tetracyclines during breast-feeding may result in significant absorption by the breast-fed infant and is not recommended because of the risk of dental discolouration and delay in ossification processes of the breast-fed infant.

A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Xerava should be made, taking into account the benefit of breast-feeding for the child, and the benefit of therapy for the woman.

Fertility

There are no human data on the effect of eravacycline on fertility. Eravacycline did affect mating and fertility in male rats at clinically relevant exposures (see section 5.3).

4.7. Effects on ability to drive and use machines

Eravacycline may have a minor influence on the ability to drive and use machines. Dizziness may occur following administration of eravacycline (see section 4.8).

4.8. Undesirable effects

Summary of the safety profile

In clinical trials, the most common adverse reactions in patients with cIAI treated with eravacycline (n=576) were nausea (3.0%), vomiting, infusion site phlebitis (each 1.9%), phlebitis (1.4%), infusion site thrombosis (0.9%), diarrhoea (0.7%), vessel puncture site erythema (0.5%), hyperhidrosis, thrombophlebitis, infusion site hypoaesthesia, and headache (each 0.3%), which were generally mild or moderate in severity.

Tabulated list of adverse reactions

The adverse reactions identified with eravacycline are presented in Table 1. Adverse reactions are classified according to MedDRA system organ classification and frequency. Frequency categories are derived according to the following conventions: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Table 1 Tabulated list of adverse reactions to eravacycline in clinical trials

System Organ Class

Common

Uncommon

Blood and lymphatic system disorders

Hypofibrinogenaemia

Increased international normalised ratio (INR)

Prolonged activated partial thromboplastin time (aPTT)

Prolonged prothrombin time (PT)

Immune system disorders

Hypersensitivity

Nervous system disorders

Dizziness

Headache

Vascular disorders

Thrombophlebitisa

Phlebitisb

Gastrointestinal disorders

Nausea

Vomiting

Pancreatitis

Diarrhoea

Hepatobiliary disorders

Aspartate aminotransferase (AST) increased

Alanine aminotransferase (ALT) increased

Hyperbilirubinaemia

Skin and subcutaneous tissue disorders

Rash

Hyperhidrosis

General disorders and administration site conditions

Infusion site reactionc

a. Thrombophlebitis includes the preferred terms thrombophlebitis and infusion site thrombosis

b. Phlebitis includes the preferred terms phlebitis, infusion site phlebitis, superficial phlebitis and injection site phlebitis

c. Infusion site reactions includes the preferred terms injection site erythema, infusion site hypoaesthesia, vessel puncture site erythema and vessel puncture site pain

Description of selected adverse reactions

Infusion site reactions

Mild to moderate infusion site reactions, including pain or discomfort, erythema and swelling or inflammation at the injection site as well as superficial thrombophlebitis and/or phlebitis have been reported in patients treated with eravacycline. Infusion site reactions can be mitigated by reducing the eravacycline infusion concentration or the infusion rate.

Tetracycline class effects

Tetracycline class adverse reactions include photosensitivity, pseudotumor cerebri, and anti-anabolic action which have led to increased blood urea nitrogen, azotaemia, acidosis, and hyperphosphataemia.

Diarrhoea

Antibiotic class adverse reactions include pseudomembranous colitis, and overgrowth of non-susceptible organisms, including fungi (see section 4.4). In clinical trials, treatment-related diarrhoea occurred in 0.7% of patients; all cases were mild in severity.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme, website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

In trials administering up to 3 mg/kg eravacycline to healthy volunteers it has been observed that doses higher than the recommended dose lead to a higher rate of nausea and vomiting.

In the case of suspected overdose Xerava should be discontinued and the patient monitored for adverse reactions.