Drug Interactions with SYMDEKO®
(tezacaftor/ivacaftor and ivacaftor)
Drug-Drug Interactions Tool
The Drug-Drug Interactions (DDI) tool provides the established or predicted effect of SYMDEKO on other medicinal products or effect of other medicinal products on SYMDEKO1-3
- Clinical considerations are based on drug interaction studies, modeling, other clinical factors, and/or predicted interactions due to elimination pathways
- Drugs shown within a therapeutic class do not represent all possible drugs within the class. Drugs within a class may have different metabolic profiles, and therefore, clinical recommendations apply only to the named drugs and not the class. The table does not represent all possible drugs or drug classes that a patient could be receiving. For further information, contact your clinical pharmacist
Choose or begin typing the brand or generic drug name or drug class to learn more about potential DDIs
Drug Class:
Drug Name | Potential Effect | Clinical Considerations |
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Alprazolam |
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Aripiprazole |
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Atorvastatin |
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Azithromycin |
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Carbamazepine |
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Ciprofloxacin* |
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Citalopram |
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Clarithromycin |
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Clozapine |
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Cyclosporine |
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Desipramine* |
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Dexamethasone2 |
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Diazepam |
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Digoxin* |
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Duloxetine |
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Erythromycin |
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Escitalopram |
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Esomeprazole |
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Ethinyl estradiol/Norethindrone, other oral contraceptives Ethinyl estradiol/ |
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Everolimus |
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Fluconazole* |
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Fluoxetine |
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Fluvastatin |
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Glimepiride |
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Glipizide |
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Ibuprofen |
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Itraconazole* |
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Ketoconazole |
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Lansoprazole |
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Lovastatin2 |
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Metformin |
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Methylprednisolone |
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Midazolam (oral)1* |
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Mirtazapine |
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Montelukast |
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Nateglinide2 |
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Omeprazole |
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Paroxetine |
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Phenobarbital1 |
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Phenytoin |
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Pitavastatin |
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Posaconazole |
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Pravastatin2 |
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Prednisolone2 |
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Prednisone2 |
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Quetiapine |
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Ranitidine |
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Repaglinide2 |
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Rifabutin |
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Rifampin* |
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Risperidone |
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Rosiglitazone* |
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Rosuvastatin |
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Sertraline |
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Simvastatin |
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Sirolimus |
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St. John’s wort |
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Tacrolimus |
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Telithromycin1 |
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Trazodone2 |
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Triazolam |
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Voriconazole |
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Warfarin |
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Drug names in the table that are bold are listed in the full Prescribing Information for SYMDEKO.
Potential drug interactions with SYMDEKO
STRONG CYP3A Inducers1
Examples
Effect
Clinical Considerations
- Rifampinᵃ
- Rifabutin
- Phenobarbital
- Carbamazepine
- Phenytoin
- St. John’s wort (Hypericum perforatum)
- Reduced blood levels of SYMDEKO are expected, potentially resulting in reduced efficacy
- Concomitant use is not recommended
STRONG CYP3A Inhibitors1
Examples
Effect
Clinical Considerations
- Ketoconazole
- Itraconazoleᵇ
- Posaconazole
- Voriconazole
- Telithromycin
- Clarithromycin
- Increased blood levels of SYMDEKO are expected
- SYMDEKO dosing adjustment is recommended
MODERATE CYP3A Inhibitors1
Examples
Effect
Clinical Considerations
- Fluconazolec
- Erythromycin
- Increased blood levels of SYMDEKO are expected
- SYMDEKO dosing adjustment is recommended
Food/Drink1
Food/Drink1
- Grapefruit
- Increased blood levels of SYMDEKO are expected
- Avoid during treatment with SYMDEKO
CYP2C9 Substrates1,2
Examples
Effect
Clinical Considerations
- Warfarin
- Ivacaftor may inhibit CYP2C9 and increase exposures of these drugs
- Monitor international normalized ratio
- Glimepiride
- Glipizide
- Ivacaftor may inhibit CYP2C9 and increase exposures of these drugs
- Use with caution
P-gp Substrates1,2
Examples
Effect
Clinical Considerations
- Digoxin
- Cyclosporine
- Everolimus
- Sirolimus
- Tacrolimus
- SYMDEKO increased digoxin exposure and may increase exposure of other sensitive P-gp substrates
- Caution and appropriate monitoring of these drugs should be used
STRONG CYP3A Inducers1
Examples
- Rifampinᵃ
- Rifabutin
- Phenobarbital
- Carbamazepine
- Phenytoin
- St. John’s wort (Hypericum perforatum)
Effect
- Reduced blood levels of SYMDEKO are expected, potentially resulting in reduced efficacy
Clinical Considerations
- Concomitant use is not recommended
STRONG CYP3A Inhibitors1
Examples
- Ketoconazole
- Itraconazoleᵇ
- Posaconazole
- Voriconazole
- Telithromycin
- Clarithromycin
Effect
- Increased blood levels of SYMDEKO are expected
Clinical Considerations
- SYMDEKO dosing adjustment is recommended
MODERATE CYP3A Inhibitors1
Examples
- Fluconazolec
- Erythromycin
Effect
- Increased blood levels of SYMDEKO are expected
Clinical Considerations
- SYMDEKO dosing adjustment is recommended
Examples
Food/Drink1
Food/Drink1
- Grapefruit
Effect
- Increased blood levels of SYMDEKO are expected
Clinical Considerations
- Avoid during treatment with SYMDEKO
CYP2C9 Substrates1,2
Examples
- Warfarin
Effect
- Ivacaftor may inhibit CYP2C9 and increase exposures of these drugs
Clinical Considerations
- Monitor international normalized ratio
Examples
- Glimepiride
- Glipizide
Effect
- Ivacaftor may inhibit CYP2C9 and increase exposures of these drugs
Clinical Considerations
- Use with caution
P-gp Substrates1,2
Examples
- Digoxin
- Cyclosporine
- Everolimus
- Sirolimus
- Tacrolimus
Effect
- SYMDEKO increased digoxin exposure and may increase exposure of other sensitive P-gp substrates
Clinical Considerations
- Caution and appropriate monitoring of these drugs should be used
aCo-administration of ivacaftor with rifampin, a strong CYP3A inducer, significantly decreased ivacaftor exposure (AUC) by 89%; tezacaftor exposures can also be expected to decrease significantly.1
bCo-administration with itraconazole, a strong CYP3A inhibitor, increased tezacaftor exposure (AUC) by 4.0-fold and ivacaftor by 15.6-fold.1
cCo-administration with fluconazole, a moderate CYP3A inhibitor, increased ivacaftor exposure (AUC) by approximately 3.0-fold, and may increase tezacaftor exposure by approximately 2.0-fold.1
Drugs not expected to have a clinically significant effect on SYMDEKO or vice versa
Drugs not requiring dose adjustments1,2
Examples (The list below is not intended to be exhaustive)
- Oral contraceptives (ethinyl estradiol/norethindrone)
- Specific antidepressants (desipramine, citalopram, escitalopram, sertraline, mirtazapine, paroxetine, trazodone)
- Azithromycin
- CYP3A substrates (e.g., midazolam [oral])
- Ciprofloxacin
- Pitavastatin (an OATP1B1 substrate)
AUC, area under the curve.
IMPORTANT SAFETY INFORMATION
WARNINGS AND PRECAUTIONS
Transaminase (ALT or AST) Elevations
- Elevated transaminases have been observed in patients with CF receiving SYMDEKO, as well as with ivacaftor monotherapy. Assessments of transaminases (ALT and AST) are recommended prior to initiating SYMDEKO, every 3 months during the first year of treatment, and annually thereafter. For patients with a history of transaminase elevations, more frequent monitoring should be considered
- Dosing should be interrupted in patients with significant elevations of transaminases (e.g., ALT or AST >5x upper limit of normal [ULN], or ALT or AST >3x ULN with bilirubin >2x ULN) and laboratory tests should be closely followed until abnormalities resolve. Following resolution of transaminase elevations, consider the benefits and risks of resuming treatment
INDICATIONS AND USAGE
SYMDEKO is indicated for the treatment of cystic fibrosis (CF) in patients age 6 years and older who are homozygous for the F508del mutation or who have at least one mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene that is responsive to tezacaftor/ivacaftor based on in vitro data and/or clinical evidence.
If the patient’s genotype is unknown, an FDA-cleared CF mutation test should be used to detect the presence of a CFTR mutation followed by verification with bi-directional sequencing when recommended by the mutation test instructions for use.
Hypersensitivity Reactions, Including Anaphylaxis
- Hypersensitivity reactions, including cases of anaphylaxis, have been reported in the postmarketing setting. If signs or symptoms of serious hypersensitivity reactions develop during treatment, discontinue SYMDEKO and institute appropriate therapy. Consider the benefits and risks for the individual patient to determine whether to resume treatment with SYMDEKO
Concomitant Use With CYP3A Inducers
- Exposure to ivacaftor is significantly decreased and exposure to tezacaftor may be reduced by concomitant use of CYP3A inducers, which may reduce the therapeutic effectiveness of SYMDEKO. Co-administration of SYMDEKO with strong CYP3A inducers, such as rifampin, rifabutin, phenobarbital, carbamazepine, phenytoin, and St. John’s wort, is not recommended
Cataracts
- Cases of non-congenital lens opacities have been reported in pediatric patients treated with SYMDEKO, as well as with ivacaftor monotherapy. Baseline and follow-up ophthalmological examinations are recommended in pediatric patients initiating treatment with SYMDEKO
ADVERSE REACTIONS
Serious Adverse Reactions
- Serious adverse reactions, whether considered drug-related or not by the investigators, that occurred more frequently in patients treated with SYMDEKO compared to placebo included distal intestinal obstruction syndrome, 3 (0.6%) patients treated with SYMDEKO vs. 0 placebo patients
Most Common Adverse Reactions
- The most common adverse reactions in Trials 1 and 3 occurring in ≥3% of patients treated with SYMDEKO (N=334) and at a higher rate than for placebo (N=343) were headache, nausea, sinus congestion, and dizziness
- The safety profile in patients age 6 to less than 12 years from an open-label Phase 3 trial (N=70) was similar to that observed in Trials 1 and 3
USE IN SPECIFIC POPULATIONS
Pediatric Use
- The safety and effectiveness of SYMDEKO in patients with CF younger than 6 years of age have not been studied
Click here to access full Prescribing Information for SYMDEKO.
References:
1. SYMDEKO [prescribing information]. Boston, MA: Vertex Pharmaceuticals Incorporated; August 2023. 2. Data on file. Vertex Pharmaceuticals Incorporated. Boston, MA. REF-10745 (v2.0); 2021. 3. FDA U.S. Food & Drug Administration. Drugs@FDA: FDA-Approved Drugs. https://www.accessdata.fda.gov/scripts/cder/daf/. Accessed May 1, 2024.