Posology : מינונים

4.2   Posology and method of administration

Treatment should only be initiated and monitored by a physician experienced in the treatment of CTEPH or PAH.

Posology

Dose titration
The recommended starting dose is 1 mg three times daily for 2 weeks. Tablets should be taken three times daily approximately 6 to 8 hours apart (see section 5.2).

Dose should be increased by 0.5 mg three times daily every two weeks to a maximum of 2.5 mg three times daily, if systolic blood pressure is ≥95 mmHg and the patient has no signs or symptoms of hypotension. In some PAH patients, an adequate response on the 6-minute walk distance (6MWD) may be reached at a dose of 1.5 mg three times a day (see section 5.1). If systolic blood pressure falls below 95 mmHg, the dose should be maintained provided the patient does not show any signs or symptoms of hypotension. If at any time during the up-titration phase systolic blood pressure decreases below 95 mmHg and the patient shows signs or symptoms of hypotension the current dose should be decreased by 0.5 mg three times daily.

Maintenance dose
The established individual dose should be maintained unless signs and symptoms of hypotension occur. The maximum total daily dose is 7.5 mg i.e., 2.5 mg 3 times daily. If a dose is missed, treatment should be continued with the next dose as planned.
If not tolerated, dose reduction should be considered at any time.

Food
Tablets can generally be taken with or without food. For patients prone to hypotension, as a precautionary measure, switches between fed and fasted Adempas intake are not recommended because of increased peak plasma levels of riociguat in the fasting compared to the fed state (see section 5.2).

Treatment discontinuation
In case treatment has to be interrupted for 3 days or more, treatment should be restarted with 1 mg three times daily for 2 weeks, and continued with the dose titration regimen as described above.

Transitioning between phosphodiesterase-5 (PDE5) inhibitors and riociguat Sildenafil must be discontinued at least 24 hours prior to administration of riociguat.
Tadalafil must be discontinued at least 48 hours prior to administration of riociguat.
Riociguat must be discontinued at least 24 hours prior to administration of a PDE5 inhibitor.
It is recommended to monitor for signs and symptoms of hypotension after any transition (see sections 4.3, 4.5 and 5.1).


Special populations
Individual dose titration at treatment initiation allows adjustment of the dose to the patient´s needs.


Elderly
In elderly patients (65 years or older) there is a higher risk of hypotension and therefore particular care should be exercised during individual dose titration (see section 5.2).

Hepatic impairment
Patients with severe hepatic impairment (Child Pugh C) have not been studied and therefore use of Adempas is contraindicated in these patients (see section 4.3). Patients with moderate hepatic impairment 
(Child Pugh B) showed a higher exposure to this medicinal product (see section 5.2). Particular care should be exercised during individual dose titration.

Renal impairment
Data in patients with severe renal impairment (creatinine clearance <30 mL/min) are limited and there are no data for patients on dialysis. Therefore use of Adempas is not recommended in these patients (see section 4.4).
Patients with mild and moderate renal impairment (creatinine clearance < 80 - 30 mL/min) showed a higher exposure to this medicinal product (see section 5.2). There is a higher risk of hypotension in patients with renal impairment, therefore particular care should be exercised during individual dose titration.

Patients on stable doses of strong multi pathway CYP / P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) inhibitors
When initiating Adempas in patients on stable doses of strong multi pathway CYP and P-gp/BCRP inhibitors, such as azole antimycotics (e.g. ketoconazole, posaconazole, itraconazole) or HIV protease inhibitors (e.g.
ritonavir), consider a starting dose of 0.5 mg, three times a day to mitigate the risk of hypotension. Monitor for signs and symptoms of hypotension on initiation and on treatment. Consider a dose reduction for patients on Adempas doses higher than or equal to 1.0 mg if the patient develops signs or symptoms of hypotension (see sections 4.4 and 4.5).


Paediatric population
The safety and efficacy of riociguat in children and adolescents below 18 years have not been established. No clinical data are available. Non-clinical data show undesirable effects on growing bone (see section 5.3). Until more is known about the implications of these findings the use of riociguat in children and in growing adolescents should be avoided.


Smokers
Current smokers should be advised to stop smoking due to a risk of a lower response. Plasma concentrations of riociguat in smokers are reduced compared to non-smokers. A dose increase to the maximum daily dose of 2.5 mg three times daily may be required in patients who are smoking or start smoking during treatment (see sections 4.5 and 5.2).
A dose decrease may be required in patients who stop smoking.

Method of administration

For oral use.
Crushed tablets
For patients who are unable to swallow whole tablets, Adempas tablets may be crushed and mixed with water or soft foods, such as apple sauce, immediately prior to use and administered orally (see section 5.2).