fingolimod
Pharmacologic class: Sphingosine 1-phosphate receptor modulator
Therapeutic class: Immunologic agent
Pregnancy risk category C
Action
Blocks capacity of lymphocytes to egress from lymph nodes, reducing number of lymphocytes in peripheral blood. Mechanism by which fingolimod exerts therapeutic effects in multiple sclerosis (MS) is unknown, but may involve reduction of lymphocyte migration into CNS.
Availability
Capsules: 0.5 mg
Indications and dosages
➣ Relapsing forms of MS
Adults: 0.5 mg P.O. daily
Contraindications
• Recent (within last 6 months) occurrence of myocardial infarction, unstable angina, stroke, transient ischemic attack, decompensated heart failure requiring hospitalization, Class III/IV heart failure
• History or presence of Mobitz Type II second- or third-degree AV block or sick sinus syndrome, unless patient has pacemaker
• Baseline QTc interval 500 ms or greater
• Treatment with Class Ia or Class III antiarrhythmics
Precautions
Use cautiously in:
• hepatic or severe renal impairment
• compromised respiratory function, AV conduction abnormalities, bradycardia, hypertension
• infections, macular edema
• patients without history of chickenpox or without vaccination against varicella zoster virus (VZV)
• concurrent use of drugs that slow heart rate or AV conduction
• concurrent use of vaccines (avoid use during treatment and for 2 months after treatment)
• concurrent use of antineoplastics, immunosuppressants, or immunomodulators
• elderly patients
• pregnant or breastfeeding patients
• children younger than age 18 (safety and efficacy not established).
Administration
• Administer with or without food.
• Be aware that patients with active acute or chronic infections shouldn't start treatment until infection is resolved.
• Before starting treatment, make sure recent CBC (within 6 months) is available.
• Before starting treatment, obtain liver enzyme values, particularly transaminase and bilirubin levels (within 6 months).
• Before starting treatment, test patient without history of chickenpox or without vaccination against VZV for antibodies to VZV. Consider VZV vaccination of antibody-negative patients before beginning treatment, after which initiation of fingolimod treatment should be postponed for 1 month to allow for full effect of vaccination.
• Be aware that decrease in heart rate and AV conduction may occur after first dose. To identify underlying risk factors for bradycardia and AV block before starting therapy: If a recent ECG (within 6 months) isn't available, obtain an ECG in patients using antiarrhythmics (including beta blockers and calcium channel blockers), in those with cardiac risk factors, and in those who on examination have a slow or irregular heartbeat.
• Obtain baseline ophthalmologic evaluation.
Adverse reactions
CNS: headache, dizziness, paresthesia, migraine, asthenia, depression, vascular events (including posterior reversible encephalopathy syndrome)
CV: hypertension, bradycardia, AV conduction abnormalities, vascular events (including ischemic and hemorrhagic strokes, peripheral arterial occlusive disease)
EENT: macular edema, blurred vision, eye pain, sinusitis
GI: gastroenteritis, diarrhea
Hematologic: lymphopenia, leukopenia, lymphomas
Hepatic: increased liver enzyme levels
Metabolic: increased triglyceride levels
Musculoskeletal: back pain
Respiratory: dyspnea, bronchitis, cough
Skin: alopecia, eczema, pruritus
Other: influenza-type viral infections, herpes viral infections, tinea infections
Interactions
Drug-drug. Antineoplastics, immunomodulators, immunosuppressants: increased risk of immunosuppression
Beta blockers (atenolol), Class Ia (such as procainamide, quinidine) or Class III (such as amiodarone, sotalol) antiarrhythmics: decreased heart rate
Ketoconazole: increased fingolimod and fingolimod-phosphate blood levels
Vaccines: reduced vaccine effectiveness
Live attenuated vaccines: increased risk of infection
Drug-diagnostic tests. Lymphocytes: reduced levels
Serum transaminases: elevated levels
Patient monitoring
• Continue to closely monitor CBC with differential; be aware that because drug reduces blood lymphocyte counts via redistribution in secondary lymphoid organs, peripheral blood lymphocyte counts can't be utilized to evaluate lymphocyte status during therapy.
☞ Be aware that patient with preexisting liver disease may be at increased risk for developing elevated liver enzyme levels. Closely monitor liver enzyme levels if hepatic injury is suspected. Discontinue drug if significant hepatic injury is confirmed.
• Monitor renal function tests in patients with renal impairment.
☞ At start of therapy, carefully watch for reduced heart rate in patients receiving concurrent beta blockers or heart rate-lowering calcium channel blockers, such as diltiazem, verapamil, or digoxin.
☞ Observe patient for 6 hours after first dose for bradycardia. Should post-dose bradyarrhythmia-related signs and symptoms occur, initiate appropriate management and continue observation until signs and symptoms have resolved.
☞ Closely monitor patients receiving Class Ia or Class III antiarrhythmics for bradycardia for development of torsades de pointes.
• Monitor patient for conduction abnormalities, which are usually transient and asymptomatic. Such abnormalities may resolve within first 24 hours of treatment, but occasionally may require treatment.
• Monitor blood pressure during treatment.
☞ Monitor patient for infection during treatment and for 2 months after discontinuation of drug. Consider suspending treatment if patient develops serious infection; reassess benefits and risks before restarting therapy.
• Be aware that patients who develop unexplained dyspnea during therapy should have spirometric evaluation of respiratory function and evaluation of diffusion lung capacity for carbon monoxide if clinically indicated.
• Monitor visual acuity 3 to 4 months after treatment initiation; be aware that patients with diabetes mellitus or history of uveitis are at increased risk and should have regular ophthalmologic evaluations.
• Closely monitor patients taking fingolimod and systemic ketoconazole concomitantly, because risk of adverse reactions is greater.
Patient teaching
• Tell patient to take drug with or without food.
• Inform patient that he will need to be observed for 6 hours after first dose.
• Advise patient who hasn't had chickenpox or VZV vaccination to consider vaccination before treatment begins.
• Advise patient to avoid live attenuated vaccines during treatment and for 2 months post treatment because of risk of infection.
• Tell patient not to discontinue drug without first discussing with prescriber.
☞ Advise patient to promptly report unexplained nausea, vomiting, abdominal pain, dizziness, fatigue, anorexia, dark urine, yellowing of skin or eyes, fever, infection, slow or irregular heartbeat, or unexplained shortness of breath.
☞ Advise patient to have eye examinations 3 to 4 months after beginning therapy and to contact prescriber if vision changes occur. Instruct patient to immediately report blurriness or shadows in center of vision, blind spot in center of vision, sensitivity to light, or unusually colored (tinted) vision.
• Instruct patient to tell prescriber about all drugs he's taking because some drugs have potential for serious drug interactions and shouldn't be taken with fingolimod.
• Advise female patient of childbearing age to use effective contraception to avoid pregnancy during therapy and for 2 months after treatment ends.
• Advise breastfeeding patient that she should decide whether to discontinue breastfeeding or discontinue drug, taking into account importance of the drug for her treatment.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.