Adverse reactions : תופעות לוואי

6          ADVERSE REACTIONS

The following adverse reactions are described, or described in greater detail, in other sections: • Anaphylaxis/Hypersensitivity Reactions [see Warnings and Precautions (5.1)] •   Myopathy and Rhabdomyolysis [see Warnings and Precautions (5.2)] •   Eosinophilic Pneumonia [see Warnings and Precautions (5.3)]
•   Drug Reaction with Eosinophilia and Systemic Symptoms [see Warnings and Precautions (5.4)] •   Tubulointerstitial Nephritis [see Warnings and Precautions (5.5)] •   Peripheral Neuropathy [see Warnings and Precautions (5.6)]
•   Increased International Normalized Ratio (INR)/Prolonged Prothrombin Time [see Warnings and Precautions (5.11) and Drug Interactions (7.2)]


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

Clinical trials enrolled 1,864 adult patients treated with daptomycin and 1,416 treated with comparator.

Complicated Skin and Skin Structure Infection Trials in Adults
In Phase 3 complicated skin and skin structure infection (cSSSI) trials in adult patients daptomycin was discontinued in 15/534 (2.8%) patients due to an adverse reaction, while comparator was discontinued in 17/558 (3.0%) patients.

The rates of the most common adverse reactions, organized by body system, observed in adult patients with cSSSI (receiving 4 mg/kg daptomycin ) are displayed in Table 4.

Table 4: Incidence of Adverse Reactions that Occurred in ≥2% of Adult Patients in the daptomycin Treatment Group and ≥ the Comparator Treatment Group in Phase 3 cSSSI Trials
Adult Patients (%)
Adverse Reaction               daptomycin 4         Comparator* mg/kg               (N=558)
(N=534)
Gastrointestinal disorders
Diarrhea                              5.2                4.3
Nervous system disorders
Headache                              5.4                5.4
Dizziness                             2.2                2.0
Skin/subcutaneous disorders
Rash                                  4.3                3.8
Diagnostic investigations
Abnormal liver function tests         3.0                1.6
Elevated CPK                          2.8                1.8
Infections
Urinary tract infections              2.4                0.5
Vascular disorders
Hypotension                           2.4                1.4
Respiratory disorders
Dyspnea                               2.1                1.6
*Comparator: vancomycin (1 g IV q12h) or an anti-staphylococcal semi-synthetic penicillin (i.e., nafcillin, oxacillin, cloxacillin, or flucloxacillin; 4 to 12 g/day IV in divided doses).Drug- related adverse reactions (possibly or probably drug-related) that occurred in <1% of adult patients receiving daptomycin in the cSSSI trials are as follows:

Body as a Whole: fatigue, weakness, rigors, flushing, hypersensitivity 
Blood/Lymphatic System: leukocytosis, thrombocytopenia, thrombocytosis, eosinophilia, increased International Normalized Ratio (INR)

Cardiovascular System: supraventricular arrhythmia

Dermatologic System: eczema
Digestive System: abdominal distension, stomatitis, jaundice, increased serum lactate dehydrogenase 
Metabolic/Nutritional System: hypomagnesemia, increased serum bicarbonate, electrolyte disturbance 
Musculoskeletal System: myalgia, muscle cramps, muscle weakness, arthralgia 
Nervous System: vertigo, mental status change, paresthesia

Special Senses: taste disturbance, eye irritation
S. aureus Bacteremia/Endocarditis Trial in Adults

In the S. aureus bacteremia/endocarditis trial involving adult patients, daptomycin was discontinued in 20/120 (16.7%) patients due to an adverse reaction, while comparator was discontinued in 21/116
(18.1%) patients.

Serious Gram-negative infections (including bloodstream infections) were reported in 10/120 (8.3%) daptomycin -treated patients and 0/115 comparator-treated patients. Comparator-treated patients received dual therapy that included initial gentamicin for 4 days. Infections were reported during treatment and during early and late follow-up. Gram-negative infections included cholangitis, alcoholic pancreatitis, sternal osteomyelitis/mediastinitis, bowel infarction, recurrent Crohn’s disease, recurrent line sepsis, and recurrent urosepsis caused by a number of different Gram-negative bacteria.

The rates of the most common adverse reactions, organized by System Organ Class (SOC), observed in adult patients with S. aureus bacteremia/endocarditis (receiving 6 mg/kg daptomycin ) are displayed in Table 5.

Table 5: Incidence of Adverse Reactions that Occurred in ≥5% of Adult Patients in the daptomycin Treatment Group and ≥ the Comparator Treatment Group in the S.
aureus Bacteremia/Endocarditis Trial
Adult Patients n (%)
Adverse Reaction*                        daptomyci n6            Comparator† mg/kg             (N=116)
(N=120)
Infections and infestations
Sepsis NOS                                 6 (5%)             3 (3%)



Adult Patients n (%)
Adverse Reaction*                                             daptomyci n6           Comparator† mg/kg            (N=116)
(N=120)
Bacteremia                                                      6 (5%)            0 (0%) Gastrointestinal disorders
Abdominal pain NOS                                               7 (6%)                    4 (3%) General disorders and administration site conditions
Chest pain                                                       8 (7%)                    7 (6%) Edema NOS                                                        8 (7%)                    5 (4%) Respiratory, thoracic and mediastinal disorders
Pharyngolaryngeal pain                                          10 (8%)                    2 (2%) Skin and subcutaneous tissue disorders
Pruritus                                                         7 (6%)                    6 (5%) Sweating increased                                               6 (5%)                    0 (0%) Psychiatric disorders
Insomnia                                                        11 (9%)                    8 (7%) Investigations
Blood creatine phosphokinase increased                                                        8 (7%)                    1 (1%) Vascular disorders
Hypertension NOS                                                 7 (6%)                    3 (3%) *NOS, not otherwise specified.
†Comparator: vancomycin (1 g IV q12h) or an anti-staphylococcal semi-synthetic penicillin (i.e., nafcillin, oxacillin, cloxacillin, or flucloxacillin; 2 g IV q4h), each with initial low-dose gentamicin.


The following reactions, not included above, were reported as possibly or probably drug-related in the daptomycin -treated group:

Blood and Lymphatic System Disorders: eosinophilia, lymphadenopathy, thrombocythemia, thrombocytopenia

Cardiac Disorders: atrial fibrillation, atrial flutter, cardiac arrest 
Ear and Labyrinth Disorders: tinnitus

Eye Disorders: vision blurred
Gastrointestinal Disorders: dry mouth, epigastric discomfort, gingival pain, hypoesthesia oral 
Infections and Infestations: candidal infection NOS, vaginal candidiasis, fungemia, oral candidiasis, urinary tract infection fungal
Investigations: blood phosphorous increased, blood alkaline phosphatase increased, INR increased, liver function test abnormal, alanine aminotransferase increased, aspartate aminotransferase increased, prothrombin time prolonged

Metabolism and Nutrition Disorders: appetite decreased NOS

Musculoskeletal and Connective Tissue Disorders: myalgia
Nervous System Disorders: dyskinesia, paresthesia

Psychiatric Disorders: hallucination NOS

Renal and Urinary Disorders: proteinuria, renal impairment NOS
Skin and Subcutaneous Tissue Disorders: pruritus generalized, rash vesicular 
Other Trials in Adults

In Phase 3 trials of community-acquired pneumonia (CAP) in adult patients, the death rate and rates of serious cardiorespiratory adverse events were higher in daptomycin -treated patients than in comparator- treated patients. These differences were due to lack of therapeutic effectiveness of daptomycin in the treatment of CAP in patients experiencing these adverse events [see Indications and Usage (1.3)].

Laboratory Changes in Adults

Complicated Skin and Skin Structure Infection Trials in Adults
In Phase 3 cSSSI trials of adult patients receiving daptomycin at a dose of 4 mg/kg, elevations in CPK were reported as clinical adverse events in 15/534 (2.8%) daptomycin -treated patients, compared with 10/558 (1.8%) comparator-treated patients. Of the 534 patients treated with daptomycin , 1 (0.2%) had symptoms of muscle pain or weakness associated with CPK elevations to greater than 4 times the upper limit of normal (ULN). The symptoms resolved within 3 days and CPK returned to normal within 7 to 10 days after treatment was discontinued [see Warnings and Precautions (5.2)]. Table 6 summarizes the CPK shifts from Baseline through End of Therapy in the cSSSI adult trials.

Table 6: Incidence of CPK Elevations from Baseline during Therapy in Either the daptomycin Treatment Group or the Comparator Treatment Group in Phase 3 cSSSI Adult Trials Adult Patients with
All Adult Patients                  Normal CPK at Baseline daptom                                  daptomycin
Change in CPK ycin 4          Comparator*          4 mg/kg             Comparator* mg/kg               (N=459)           (N=374)                 (N=392) (N=430)               %      n         %         n            %           n %            n
No Increase                           90.7       390           91.1   418       91.2     341           91.1        357 Maximum Valu >1× ULN          †       9.3           40         8.9     41       8.8        33          8.9           35 >2× ULN           4.9           21         4.8     22       3.7        14          3.1           12 >4× ULN           1.4            6         1.5      7       1.1         4          1.0             4 >5× ULN           1.4            6         0.4      2       1.1         4          0.0             0 >10× ULN          0.5            2         0.2      1       0.2         1          0.0             0 Note: Elevations in CPK observed in adult patients treated with daptomycin or comparator were not clinically or statistically significantly different.



*Comparator: vancomycin (1 g IV q12h) or an anti-staphylococcal semi-synthetic penicillin (i.e., nafcillin, oxacillin, cloxacillin, or flucloxacillin; 4 to 12 g/day IV in divided doses).
†ULN (Upper Limit of Normal) is defined as 200 U/L.


S. aureus Bacteremia/Endocarditis Trial in Adults

In the S. aureus bacteremia/endocarditis trial in adult patients, at a dose of 6 mg/kg, 11/120 (9.2%) daptomycin -treated patients, including two patients with baseline CPK levels >500 U/L, had CPK elevations to levels >500 U/L, compared with 1/116 (0.9%) comparator-treated patients. Of the 11 daptomycin -treated patients, 4 had prior or concomitant treatment with an HMG-CoA reductase inhibitor. Three of these 11 daptomycin -treated patients discontinued therapy due to CPK elevation, while the one comparator-treated patient did not discontinue therapy [see Warnings and Precautions (5.2)].

6.2      Post-Marketing Experience

The following adverse reactions have been identified during post-approval use of daptomycin . Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Blood and lymphatic system disorders: anemia, thrombocytopenia

General and administration site conditions: pyrexia
Immune System Disorders: anaphylaxis; hypersensitivity reactions, including angioedema, pruritus, hives, shortness of breath, difficulty swallowing, truncal erythema, and pulmonary eosinophilia [see Contraindications (4) and Warnings and Precautions (5.1)]

Infections and Infestations: Clostridioides difficile–associated diarrhea [see Warnings and Precautions (5.8)]

Laboratory Investigations: platelet count decreased

Musculoskeletal Disorders: myoglobin increased; rhabdomyolysis (some reports involved patients treated concurrently with daptomycin and HMG-CoA reductase inhibitors) [see Warnings and Precautions (5.2), Drug Interactions (7.1), and Clinical Pharmacology (12.3)] 
Respiratory, Thoracic, and Mediastinal Disorders: cough, eosinophilic pneumonia, organizing pneumonia [see Warnings and Precautions (5.3)]

Nervous System Disorders: peripheral neuropathy [see Warnings and Precautions (5.6)] 
Skin and Subcutaneous Tissue Disorders: serious skin reactions, including drug reaction with eosinophilia and systemic symptoms (DRESS), vesiculobullous rash (with or without mucous membrane involvement), including Stevens-Johnson syndrome [SJS] and toxic epidermal necrolysis [TEN], and acute generalized exanthematous pustulosis [see Warnings and Precautions (5.4)].

Gastrointestinal Disorders: nausea, vomiting



Renal and urinary disorders: acute kidney injury, renal insufficiency, renal failure, and tubulointerstitial nephritis (TIN) [see Warnings and Precautions (5.5)].

Special Senses: visual disturbances

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.
Any suspected adverse events should be reported to the Ministry of Health according to the National Regulation by using an online form: https://sideeffects.health.gov.il