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Dosage regimen: General target population: Adults: Kidney and heart transplantation: An initial dose regimen of 0.75 mg b.i.d. which is recommended for the general kidney and heart transplant population, should be administered as soon as possible after transplantation.
Liver transplantation: The dose of 1.0 mg b.i.d is recommended for the hepatic transplant population with the initial dose approximately 4 weeks after transplantation.
Special populations: Black patients: The incidence of biopsy-proven acute rejection episodes was significantly higher in black renal transplant patients than in non-black patients. Limited information indicates that black patients, may require a higher Certican dose to achieve efficacy similar to that achieved in non-black patients at the recommended adult dose (see PHARMACOLOGY: PHARMACOKINETICS under Actions). Currently, the efficacy and safety data are too limited to allow specific recommendations for use of everolimus in Black patients.
Pediatric patients (below 18 years): There are no adequate data of the use of Certican in children and adolescents to support its use in patients in these age groups.
Limited information is, however, available in renal transplant pediatric patients (see PHARMACOLOGY: PHARMACOKINETICS under Actions).
Geriatric patients (65 years or above): Clinical experience is limited in patients ≥65 years of age.
Nevertheless, there are no apparent differences in the pharmacokinetics of everolimus in patients ≥65 to 70 years of age as compared with younger adults (see PHARMACOLOGY: PHARMACOKINETICS under Actions).
Renal impairment: No dosage adjustment is required (see PHARMACOLOGY: PHARMACOKINETICS under Actions).
Hepatic impairment: Whole blood trough levels (C0) of everolimus should be closely monitored in patients with impaired hepatic function. For patients with mild hepatic impairment (Child-Pugh Class A), the dose should be reduced to approximately two-thirds of the normal dose. For patients with moderate hepatic impairment (Child-Pugh B) the dose should be reduced to approximately one half of the normal dose. For patients with severe hepatic impairment (Child-Pugh C) the dose should be reduced to at least one half of the normal dose. Further dose titration should be based on therapeutic drug monitoring (see PHARMACOLOGY: PHARMACOKINETICS under Actions).
Method of administration: Certican is for oral use only.
The daily dose of Certican should always be given orally in two divided doses (b.i.d.). Certican should be consistently given either with or without food (see PHARMACOLOGY: PHARMACOKINETICS under Actions) and at the same time as ciclosporin for microemulsion or tacrolimus (see THERAPEUTIC DRUG MONITORING as follows).
Patients receiving Certican may require dose adjustments based on blood levels achieved, tolerability, individual response, change in co-medications and the clinical situation. Dose adjustments can be made at 4 to 5 days intervals (see THERAPEUTIC DRUG MONITORING as follows).
Certican tablets should be swallowed whole with a glass of water and not crushed before use.
Therapeutic drug monitoring: Certican has a narrow therapeutic index which may require adjustments in dosing to maintain therapeutic response. Routine whole blood therapeutic drug level monitoring of everolimus is recommended. Based on exposure-efficacy and exposure-safety analysis, patients achieving everolimus whole blood trough levels (C0) ≥3.0 ng/mL have been found to have a lower incidence of biopsy-proven acute rejection in renal, cardiac and hepatic transplantation than patients whose trough levels (C0) are below 3.0 ng/mL. The recommended upper limit of the therapeutic range is 8 ng/mL. Exposure above 12 ng/mL has not been studied. These recommended ranges for everolimus are based on chromatographic methods.
It is especially important to monitor everolimus blood concentrations, in patients with hepatic impairment, during concomitant administration of strong CYP3A4 inducers and inhibitors, when switching formulation and/or if ciclosporin dosing is markedly reduced (see INTERACTIONS). Everolimus concentrations might be slightly lower following the dispersible tablet administration.
Ideally, dose adjustments of Certican should be based on trough levels (C0) obtained >4 to 5 days after the previous dose change. Since ciclosporin interacts with everolimus, everolimus levels may decrease if ciclosporin exposure is markedly reduced (i.e. trough concentration (C0) <50 ng/mL).
Ciclosporin dose recommendation in renal transplantation: Certican should not be used long-term together with full doses of ciclosporin. Reduced exposure to ciclosporin in Certican-treated renal transplant patients improves renal function. Based on experience gained from study A2309, ciclosporin exposure reduction should be started immediately after transplantation with the following recommended whole blood trough level windows: See Table 14.
Click on icon to see table/diagram/image(Measured levels are shown in Pharmacology: PHARMACODYNAMICS under Actions).
Prior to dose reduction of ciclosporin it should be ascertained that steady state everolimus whole blood trough concentrations (C0) are equal to or above 3 ng/mL.
There are limited data regarding dosing Certican with ciclosporin trough concentrations (C0) below 50 ng/mL, or C2 levels below 350 ng/mL, in the maintenance phase. If the patient cannot tolerate reduction of ciclosporin exposure, the continued use of Certican should be reconsidered.
Ciclosporin dose recommendation in cardiac transplantation: Cardiac transplant patients in the maintenance phase should have ciclosporin dose reduced, beginning one month after transplantation as tolerated in order to improve kidney function. If impairment of renal function is progressive or if the calculated creatinine clearance is <60 mL/min, the treatment regimen should be adjusted. For cardiac transplant patients, the ciclosporin dose should be guided by the experience in study 2411 and confirmed in study 2310 in which Certican was administered with ciclosporin with recommended reduced target trough concentrations (C0) as follows: See Table 15.
Click on icon to see table/diagram/image(Measured levels are shown in Pharmacology: PHARMACODYNAMICS under Actions).
Prior to dose reduction of ciclosporin it should be ascertained that steady state everolimus whole blood trough concentrations (C0) are equal to or above 3 ng/mL.
In cardiac transplantation, there are limited data regarding dosing Certican with reduced ciclosporin trough concentrations (C0) of 50 to 100 ng/mL after 12 months. If the patient cannot tolerate reduction of ciclosporin exposure, the continued use of Certican should be reconsidered.
Tacrolimus dose recommendation in hepatic transplantation: Hepatic transplant patients should have the tacrolimus exposure reduced to minimize calcineurin related renal toxicity. The tacrolimus dose should be reduced starting approximately 3 weeks after initiation of dosing in combination with Certican based on tacrolimus blood trough levels (C0) targeting 3 to 5 ng/mL. Certican has not been evaluated with full dose tacrolimus in controlled clinical trials.
