Indications

Obeticholic Acid tablet is indicated for the treatment of adult patients with primary biliary cholangitis (PBC) without cirrhosis or with compensated cirrhosis who do not have evidence of portal hypertension Either in combination with ursodeoxycholic acid (UDCA) with an inadequate response to UDCA or as monotherapy in patients unable to tolerate UDCA.

Composition

Pharmacology

Mechanism of Action : Obeticholic acid is an agonist for Farnesoid X Receptor (FXR), a nuclear receptor expressed in the liver and intestine. FXR is a key regulator of bile acid, inflammatory, fibrotic and metabolic pathways. FXR activation decreases the intracellular hepatocyte concentrations of bile acids by suppressing de novo synthesis from cholesterol as well as by increased transport of bile acids out of the hepatocytes. These mechanisms limit the overall size of the circulating bile acid pool while promoting choleresis, thus reducing hepatic exposure to bile acids. Pharmacodynamics : Pharmacodynamic Markers: In the trial, administration of Obeticholic acid 10 mg once daily was associated with a 173% increase in concentrations of FGF-19 an FXR-inducible enterokine involved in bile acid homeostasis from baseline to Month 12. Concentrations of cholic acid and chenodeoxycholic acid were reduced 2.7 micromolar and 1.4 micromolar respectively from baseline to Month 12. The clinical relevance of these findings is unknown. Cardiac Electrophysiology : At a dose of 10 times the maximum recommended dose Obeticholic acid does not prolong the QT interval to any clinically relevant extent.

Dosage & Administration

Important Dosage and Administration Instructions : Prior to the initiation of Obeticholic acid, healthcare providers should determine whether the patient has decompensated cirrhosis (e.g., Child-Pugh Class B or C) has had a prior decompensation event or has compensated cirrhosis with evidence of portal hypertension (e.g., ascites, gastroesophageal varices, persistent thrombocytopenia) because Obeticholic acid is contraindicated in these patients. Recommended Dosage Regimen : The recommended dosage of Obeticholic acid for PBC patients without cirrhosis or with compensated cirrhosis who do not have evidence of portal hypertension, who have not achieved an adequate biochemical response to an appropriate dosage of UDCA for at least 1 year or are intolerant to UDCA follows below: Start with a dosage of 5 mg once daily for the first 3 months. After the first 3 months, for patients who have not achieved an adequate reduction in ALP and/or total bilirubin and who are tolerating Obeticholic acid increase to a maximum dosage of 10 mg once daily. Monitoring to Assess Safety, Need for Obeticholic acid Discontinuation : Routinely monitor patients during Obeticholic acid treatment for biochemical response, tolerability and progression of PBC. Closely monitor patients with compensated cirrhosis, concomitant hepatic disease (e.g., autoimmune hepatitis, alcoholic liver disease) and/or severe intercurrent illness for new evidence of portal hypertension (e.g., ascites, gastroesophageal varices, persistent thrombocytopenia) or increases above the upper limit of normal in total bilirubin, direct bilirubin or prothrombin time. Permanently discontinue Obeticholic acid in patients who develop laboratory or clinical evidence of hepatic decompensation, have compensated cirrhosis and develop evidence of portal hypertension, experience clinically significant hepatic adverse reactions, or develop complete biliary obstruction. Management of Patients with Intolerable Pruritus on Obeticholic acid : For patients with intolerable pruritus on Obeticholic acid consider one or more of the following management strategies. Add an antihistamine or bile acid-binding resin. Reduce the dosage of Obeticholic acid to: 5 mg every other day, for patients intolerant to 5 mg once daily. 5 mg once daily, for patients intolerant to 10 mg once daily. Temporarily interrupt Obeticholic acid dosing for up to 2 weeks. Restart at a reduced dosage. For patients whose dosage is reduced or interrupted, titrate the dosage based on biochemical response and tolerability. Consider discontinuing Obeticholic acid treatment in patients who continue to experience persistent, intolerable pruritus despite management strategies.

Contraindications

Obeticholic acid is contraindicated in patients with: Decompensated cirrhosis (e.g., Child-Pugh Class B or C) or a prior decompensation event Compensated cirrhosis who have evidence of portal hypertension (e.g., ascites, gastroesophageal varices, persistent thrombocytopenia) Complete biliary obstruction

Side Effects

The most common side effects of Obeticholic Acid include: Pruritus, Fatigue & Stomach pain and discomfort. Other common side effects include rash, arthralgia (joint pain), oropharyngeal pain (pain in the middle part of the throat), dizziness, constipation, abnormal thyroid function, and eczema (inflammation of the skin).

Pregnancy & Lactation

Pregnancy : The limited available human data on the use of obeticholic acid during pregnancy are not sufficient to inform a drug-associated risk. In animal reproduction studies, no developmental abnormalities or fetal harm was observed when pregnant rats or rabbits were administered obeticholic acid during the period of organogenesis at exposures approximately 13-times and 6-times human exposures, respectively, at the  maximum recommended human dose (MRHD) of 10 mg. Lactation : There is no information on the presence of obeticholic acid in human milk, the effects on the breastfed infant or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Obeticholic acid and any potential adverse effects on the breastfed infant from Obeticholic acid or from the underlying maternal condition.

Precautions & Warnings

Hepatic Decompensation and Failure in PBC Patients with Cirrhosis : Hepatic decompensation and failure, sometimes fatal or resulting in liver transplant have been reported with Obeticholic acid treatment in PBC patients with cirrhosis either compensated or decompensated. Among postmarketing cases reporting it, median time to hepatic decompensation (e.g., new onset ascites) was 4 months for patients with compensated cirrhosis; median time to a new decompensation event (e.g., hepatic encephalopathy) was 2.5 months for patients with decom- pensated cirrhosis. Some of these cases occurred in patients with decompensated cirrhosis when they were treated with higher than the recommended dosage for that patient population; however, case of hepatic decompensation and failure have continued to be reported in patients with decompensated cirrhosis even when they received the recommended dosage. Hepatotoxicity was observed in the Obeticholic acid clinical trials. A dose-response relationship was observed for the occurrence of hepatic adverse reactions including jaundice, worsening ascites and primary biliary cholangitis flare with dosages of Obeticholic acid of 10mg once daily to 50mg once daily (up to 5-times the highest recommended dosage) as early as one month after starting treatment with Obeticholic acid in two 3-month, placebo-controlled clinical trials in patients with primarily early stage PBC. In a pooled analysis of three placebo-controlled clinical trials in patients with primarily early-stage PBC the exposure-adjusted incidence rates for all serious and otherwise clinically significant hepatic adverse reactions and isolated elevations in liver biochemical tests per 100 patient exposure years (PEY) were: 5.2 in the Obeticholic acid 10mg group (highest recommended dosage) 19.8 in the Obeticholic acid 25mg group (2.5-times the highest recommended dosage) and 54.5 in the Obeticholic acid 50mg group (5-times the highest recommended dosage) compared to 2.4 in the placebo group. Severe Pruritus : Severe pruritus was reported in 23% of patients in the Obeticholic acid 10mg arm, 19% of patients in the Obeticholic acid titration arm and 7% of patients in the placebo arm in Trial 1, a 12-month double-blind randomized controlled clinical trial of 216 patients. Severe pruritus was defined as intense or widespread itching, interfering with activities of daily living or causing severe sleep disturbance or intolerable discomfort and typically requiring medical interventions. In the subgroup of patients in the Obeticholic acid titration arm who increased their dosage from 5mg once daily to 10mg once daily after 6 months of treatment (n=33), the incidence of severe pruritus was 0% from months 0 to 6 and 15% from months 6 to 12. The median time to onset of severe pruritus was 11, 158 and 75 days for patients in the Obeticholic acid 10 mg, Obeticholic acid titration and placebo arms respectively. Consider clinical evaluation of patients with new onset or worsening severe pruritus. Management strategies include the addition of bile acid binding resins or antihistamines, Obeticholic acid dosage reduction and/or temporary interruption of Obeticholic acid dosing. Reduction in HDL-C : Patients with PBC generally exhibit hyperlipidemia characterized by a significant elevation in total cholesterol primarily due to increased levels of high-density lipoprotein-cholesterol (HDL-C). In Trial, dose-dependent reductions from baseline in mean HDL-C levels were observed at 2 weeks in Obeticholic acid-treated patients, 20% and 9% in the 10 mg and titration arms respectively, compared to 2% in the placebo arm. At Month 12, the reduction from baseline in mean HDL-C level was 19% in the Obeticholic acid 10 mg arm, 12% in the Obeticholic acid titration arm and 2% in the placebo arm. Nine patients in the Obeticholic acid 10mg arm, 6 patients in the Obeticholic acid titration arm versus 3 patients in the placebo arm had reductions in HDL-C to less than 40 mg/dL. Monitor patients for changes in serum lipid levels during treatment. For patients who do not respond to Obeticholic acid after 1 year at the highest recommended dosage that can be tolerated (maximum of 10 mg once daily) and who experience a reduction in HDL-C, weigh the potential risks against the benefits of continuing treatment.

Therapeutic Class

Farnesoid X Receptor Agonists

Storage Conditions

Store below 30°C in a dry place, and protect from light. Keep out of children’s reach.