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Definitions

• the invention relates to improved methods of administering pirfenidone therapy involving avoiding adverse drug interactions with fJuvoxamine, a strong inhibitor of CYP1A2.
• Pirfenidone is small molecule with a molecular weight of 185.23 daltons whose chemical name is 5-methyl-l -phenyl-2-(l H)-pyridone. Pirfenidone has anti-fibrotic properties and has been investigated for therapeutic benefits to patients suffering from various fibrotic conditions. It is approved in Japan for treatment of idiopathic pulmonary fibrosis (IPF) under the trade name Pirespa®.
• IPF idiopathic pulmonary fibrosis
• Pirfenidone has been shown to be metabolized by various isoforms of the cytochrome P450 (CYP) protein [See the Report on the Deliberation Results, Evaluation and Licensing Division, Phannaceuticai and Food Safety Bureau, Ministry of Health Labour and Welfare, September 16, 2008]. Specifically, several cytochrome P450 (CYP) isoforms (CYP1 A2, 2C9, 2C 19, 2D6 and 2E1 ) were involved in the earliest stages of oxidative metabolism of pirfenidone.
• CYP cytochrome P450
• Fluvoxamine belongs to a class of therapeutics known as selective serotonin reuptake inhibitors (SSRIs).
• SSRIs selective serotonin reuptake inhibitors
• the SSRIs are a group of antidepressants with similar pharmacologic effects, but with different chemical structures.
• Fluvoxamine has been approved for treatment of social anxiety disorder (social phobia), obsessive compulsive disorder (OCD), and has been prescribed to treat major depression, and other anxiety disorders such as panic disorder and post-traumatic stress disorder [McClellan et al., (Drugs October 2000). "Fluvoxamine An Updated Review of its Use in the Management of Adults with Anxiety Disorders".
• fluvoxamine other clinically available SSRIs are citalopram, fluoxetine, paroxetine and sertraline. The elimination of these lipophilic compounds proceeds predominantly via oxidation catalysed by CYP in the li ver. SSRIs have the potential for inhibition of CYP enzymes [Brosen, The pharmacogenetics of the selective serotonin reuptake inhibitors. Clin Invest 71 ( 12): 1002-1009, 1993]. Jeppesen et al. reported that fluvoxamine is a potent inhibitor of CYP1A2 in humans in vivo [Jeppesen et al.
• Fluvoxamine has also been shown to be a very potent inhibitor of CYP1A2 in vitro [Broscn et al , Fluvoxamine is a potent inhibitor of cytochrome P4501A2. Biochem Pharmacol 45: 121 1-1214, 1993; Rasmussen et al , Selective serotonin reuptake inhibitors and theophylline metabolism in human liver microsomes: potent inhibition by fluvoxamine. Br J Clin Pharmacol 39: 151 -159, 1995].
• the invention generally relates to improved uses and methods of administering pirfenidone to a patient in need of pirfenidone therapy, and to methods of preparing or packaging pirfenidone medicaments, containers, packages and kits.
• the patient may have idiopathic pulmonary fibrosis (IPF) and the medicament is for treatment of IPF.
• the therapeutically effective amount of pirfenidone being administered may be a daily dosage of 2400 mg or 2403 mg per day.
• the daily dosage may be administered in divided doses three times a day, or two times a day, or alternatively is administered in a single dose once a day.
• the pirfenidone may be administered with food.
• the daily dosage of 2400 mg or 2403 mg pirfenidone per day may be administered as follows: 801 mg taken three times a day, with food.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy (e.g. , a patient with IPF), involving administering to the patient a therapeutically effective amount of pirfenidone, and avoiding administration of fluvoxamine despite the patient being in need of fluvoxamine therapy.
• pirfenidone therapy e.g. , a patient with IPF
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy, comprising discontinuing administration of fluvoxamine to avoid an adverse drug interaction and administering a therapeutically effective amount of pirfenidone.
• the patient is in need of and thus is receiv ing fluvoxamine, and fluvoxamine is discontinued concurrent with starting
• fluvoxamine is discontinued within at least 3 days to 1 month prior to or after starting pirfenidone therapy. This time period, for example, permits adequate time for tapering and withdrawal without adverse effects.
• the invention in a method of administering a therapeutically effective amount o pirfenidone to a patient with 1PF, provides an improvement that comprises avoiding or discontinuing administration of fluvoxamine and administering a therapeutically effective amount of pirfenidone.
• an adverse drug interaction can include reduced clearance of pirfenidone, the potential for reduced clearance of pirfenidone, increased exposure to pirfenidone, or the potential for increased exposure to pirfenidone.
• an aspect of the invention provides pirfenidone for use in treating a patient in need of pirfenidone therapy, characterized in that the treating comprises avoiding, contraindicating or discontinuing concomitant use (or co-administration) of fluvoxamine.
• the concomitant use of fluvoxamine is avoided, contraindicated or discontinued, in order to avoid reduced clearance of pirfenidone, or the potential for reduced clearance of pirfenidone.
• the concomitant use of fluvoxamine is avoided, contraindicated or discontinued, in order to avoid increased exposure to pirfenidone, or the potential for increased exposure to pirfenidone.
• Administration of pirfenidone in patients that concomitantly use or are being administered fluvoxamine results in about a 6- fold increase in pirfenidone exposure. It is understood that any of the aspects or
• the patient may be a patient with IPF, and the therapeutically effective amount administered may be 2400 or 2403 tng per day.
• a further aspect of the invention provides the use of pirfenidone in the manufacture of a medicament for treating a patient in need of pirfenidone therapy, characterized in that the treating comprises avoiding, contraindicating or discontinuing concomitant use (or co-administration) o fluvoxamine.
• the treating comprises avoiding, contraindicating or discontinuing concomitant use (or co-administration) o fluvoxamine.
• any of the aspects or embodiments or examples described herein with respect to methods of treatment or "pirfenidone for use" in treating a patient apply to this aspect of the invention that provides for the use of pirfenidone in manufacture of a medicament.
• the patient may be a patient with IPF, and the therapeutical ly effective amount administered may be 2400 or 2403 mg per day.
• concomitant use is understood to be interchangeable with concurrent administration or co-administration.
• the terms are understood to encompass administration simultaneously . or at different times, and by the same route or by di fferent routes, as long as the two agents are given in a manner that allows both agents to be affecting the body at the same time.
• concomitant use can refer to a medication concomitantly administered, whether prescribed by the same or a different practitioner, or for the same or a different indication.
• the patient is a patient in need of therapy with a CYP 1A2 inhibitor. In some embodiments, the patient is a patient in need of therapy with a strong CYP 1 A2 inhibitor, or a moderate to strong CYP 1 A2 inhibitor. In some embodiments, the patient is a patient in need of fluvoxamine therapy. In some embodiments, the patient is a patient who is avoiding concomitant use of fluvoxamine, e.g. because concomitant use of pirfenidone with fluvoxamine is contraindicated.
• the patient is a patient who was or is being administered a strong CYP 1A2 inhibitor, or a moderate to strong CYP 1 A2 inhibitor, e.g. fluvoxamine.
• the patient is a patient who has discontinued use of a strong CYP 1 A2 inhibitor, or a moderate to strong CYP 1 A2 inhibitor prior to the initiation of pirfenidone therapy in order to avoid reduced clearance (or increased exposure to) pirfenidone, or the potential for reduced clearance of (or increased exposure to) pirfenidone.
• the patient is a patient who has discontinued use of fluvoxamine prior to the initiation of pirfenidone therapy in order to avoid reduced clearance of pirfenidone, or the potential for reduced clearance of pirfenidone. In some embodiments, the patient is a patient who has discontinued use of fluvoxamine prior to the initiation of pirfenidone therapy in order to avoid increased exposure to pirfenidone. or the potential for increased exposure to pirfenidone.
• the patient is a patient who has discontinued administration of the strong CYP 1 A2 inhibitor, or moderate to strong CYP1 A2 inhibitor, e.g., fluvoxamine, within 1 month, or within 2 weeks, prior to starting pirfenidone therapy, or concurrent with starting pirfenidone therapy. It is understood that any of the aspects or embodiments or examples described herein with respect to methods of treatment apply to this aspect of the invention that provides for characterization o f the patients to be treated with pirfenidone.
• a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy and in need o f fluvoxamine therapy comprising administering a therapeutically effective amount of pirfenidone to the patient, and
• the alternative therapy that i s not fluvoxamine is a drug that is not a strong or moderate to strong inhibitor of cytochrome P450 1 A2 (CYP 1 A2).
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP 1 A2 cytochrome P450 1 A2
• CYP en/ymc selected from the group consisting of CYP3A4, CYP2C9, and/or CYP2C19.
• the alternative drug is selected from the group consisting of Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac, Prozac Weekly), Paroxetine (Paxil, Paxil CR, Pexeva), and/or Sertraline (Zoloft) .
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy (e.g. , a patient with IPF), involving administering to the patient a therapeutically effective amount of pirfenidone, and advising the patient in any one, two, three or more of the following ways:
• the method further includes advising the patient that coadministration of pirfenidone and fluvoxamine resulted in a 2-fold increase in average peak serum concentration of pirfenidone (Cmax ).
• the method also includes avoiding administering a strong CYPl A2 inhibitor, or discontinuing administration of a strong CYP 1 A2 inhibitor.
• a method of reducing toxicity of pirfenidone treatment in a patient comprising administering a therapeutically effective amount of pirfenidone to the patient and advising the patient of any of the foregoing advice.
• a method of improving safety of pirfenidone treatment in a patient comprising administering a therapeutically effective amount of pirfenidone to the patient and advising the patient of any of the foregoing advice.
• a method of reducing adverse drug interaction with pirfenidone treatment in a patient comprising administering a therapeutically effective amount of pirfenidone to the patient and advising the patient of any of the foregoing advice.
• the concomitant use of fluvoxamine is avoided, contraindicated or discontinued in order to:
• Figure 1 depicts a symmetrical dot plot of AUCo - ⁇ estimates by study day— circles indicate smokers, triangles indicate nonsmokers.
• Pirfenidone is an orally active, anti-fibrotic agent.
• Oral administration of pirfenidone results in the formation of four metabolites, 5 hydroxymeihyl-pirfenidone, 5 carboxy-pirfenidone, 4'- hydroxy-pirfeuidone, and the 5 O-acyl glucuronide metabolite of 5 carboxy-pirfenidone.
• 5 hydroxymeihyl-pirfenidone 5 carboxy-pirfenidone
• 4'- hydroxy-pirfeuidone 4'- hydroxy-pirfeuidone
• the 5 O-acyl glucuronide metabolite of 5 carboxy-pirfenidone In humans, only pirfenidone and 5-carboxy-pirfenidone are present in plasma in significant quantities; none of the other metabolites occur in sufficient quantities to allow for PK analysis. There are no unique human metabolites.
• Fluvoxamine is a potent CYP 1 A2 and CYP2C 19 inhibitor, and a moderate CYP2C9, CYP2D6, and CYP3A4 inhibitor [Hemeryck et al , Selective Serotonin Reuptake Inhibitors and Cytochrome P-450 Mediated Drug-Drug Interactions: An Update. Current Drug Metabolism 3(1): 1 3-37, 2002] .
• the invention disclosed herein is based on the discovery of an adverse drug interaction between pirfenidone and fluvoxamine. Adverse dmg interactions represent 3-5% of preventable in-hospital adverse drug reactions, and are an important contributor to the number of emergency room visits and hospital admissions [Leape LL et al , JAMA
• terapéuticaally effective amount refers to an amount of a compound sufficient to treat, ameliorate, or prevent the identified disease or condition, or to exhibit a detectable therapeutic, prophylactic, or inhibitory effect. The effect can be detected by, for example, an improvement in clinical condition, or reduction in symptoms.
• the precise effective amount for a subject will depend upon the subject's body weight, size, and health; the nature and extent of the condition; and the therapeutic or combination of therapeutics selected for administration.
• a "therapeutical ly effective amount” refers to the dosage approved by the FDA or its counterpart foreign agency for treatment of the identified disease or condition.
• a patient "in need of pirfenidone therapy” is a patient who would benefit from administration of pirfenidone.
• the patient may be suffering from any disease or condition f r w hich pirfenidone therapy may be useful in ameliorating symptoms.
• diseases or conditions include pulmonary fibrosis, idiopathic pulmonary fibrosis, idiopathic interstitial pneumonia, autoimmune lung diseases, benign prostate hypertrophy, coronary or myocardial infarction, atrial fibrillation, cerebral infarction, myocardiac fibrosis,
• musculoskeletal fibrosis post-surgical adhesions, liver cirrhosis, renal fibrotic disease, fibrotic vascular disease, scleroderma, Herman sky-Pudlak syndrome, neurofibromatosis, Alzheimer's disease, diabetic retinopathy, and/or skin lesions, lymph node fibrosis associated with HIV, chronic obstructive pulmonary disease (COPD), inflammatory pulmonary fibrosis, rheumatoid arthritis; rheumatoid spondylitis; osteoarthritis; gout, other arthritic conditions; sepsis; septic shock; endotoxic shock; gram-negative sepsis; toxic shock syndrome;
• COPD chronic obstructive pulmonary disease
• MRS myofacial pain syndrome
• Shigellosis asthma
• adult respiratory distress syndrome inflammatory bowel disease
• Crohn's disease psoriasis
• eczema ulcerative colitis
• glomerular nephritis glomerular nephritis; scleroderma; chronic thyroiditis; Grave's disease; Ormond's disease; autoimmune gastritis; myasthenia gravis; autoimmune hemolytic anemia; autoimmune neutropenia; thrombocytopenia; pancreatic fibrosis; chronic active hepatitis including hepatic fibrosis; acute and chronic renal disease; renal fibrosis; diabetic nephropathy; irritable bowel syndrome; pyresis; restenosis; cerebral malaria; stroke and ischemic injury; neural trauma; Alzheimer's disease; Huntington's disease; Parkinson's disease; acute and chronic pain;
• allergies including allergic rhinitis and allergic conjunctivitis; cardiac hypertrophy, chronic heart failure; acute coronary syndrome; cachexia; malaria; leprosy; leishmaniasis; Lyme disease; Reiter's syndrome; acute synoviitis; muscle degeneration, bursitis; tendonitis;
• tenosynoviitis herniated, ruptured, or prolapsed intervertebral disk syndrome; osteopetrosis; thrombosis; silicosis; pulmonary sarcosis; bone resorption diseases, such as osteoporosis or multiple myeloma-related bone disorders; cancer, including but not limited to metastatic breast carcinoma, colorectal carcinoma, malignant melanoma, gastric cancer, and non-small cell lung cancer; graft-versus-host reaction; and auto-immune diseases, such as multiple sclerosis, lupus and fibromyalgia; AIDS and other viral diseases such as Herpes Zoster, Heipes Simplex 1 or II, influenza virus, Severe Acute Respiratory Syndrome ( SARS) and cytomegalovirus: and diabetes mellitus.
• SARS Severe Acute Respiratory Syndrome
• the methods of the embodiments can be used to treat proli erative disorders (including both benign and malignant hyperplasias), including ac me myelogenous leukemia, chronic myelogenous leukemia, Kaposi's sarcoma, metastatic melanoma, multiple myeloma, breast cancer, including metastatic breast carcinoma; colorectal, carcinoma; malignant melanoma; gastric cancer; non-small cell lung cancer (NSCfC): bone metastases, and the l ike; pain disorders including neuromuscular pain, headache, cancer pain, dental pain, and arthritis pain; angiogenic disorders including solid tumor angiogenesis.
• proli erative disorders including both benign and malignant hyperplasias
• proli erative disorders including both benign and malignant hyperplasias
• proli erative disorders including both benign and malignant hyperplasias
• proli erative disorders including both benign and malignant hyperplasias
• ocular neovascularization and infantile hemangioma
• conditions associated with the cyclooxygenase and lipoxygenase signaling pathways including conditions associated with prostaglandin endoperoxide synthase- 2 (including edema, fever, analgesia, and pain); organ hypoxia; thrombin-induced platelet aggregation; protozoal diseases.
• a patient in need of “fiuvoxamine therapy” is understood to be a patient in need of “selective serotonin reuptake inhibitor (SSRI) therapy.”
• SSRI serotonin reuptake inhibitor
• Such patients include patients suffering from social anxiety disorder (social phobia), obsessive compulsive disorder (OCD), depression, anxiety disorders, panic disorder and post-traumatic stress disorder.
• the FDA generally defines a "strong inhibitor” as one that caused a > 5-fold increase in the plasma AUC values or more than 80% decrease in clearance of CYP substrates (not limited to sensitive CYP substrate) in clinical evaluations.
• the FDA generally defines a "moderate inhibitor” as one that caused a > 2- but ⁇ 5-fold increase in the AUC values or 50-80% decrease in clearance of sensitive CYP substrates when the inhibitor was given at the highest approved dose and the shortest dosing interval in clinical evaluations.
• the pirfenidone uses, methods, packages, kits, advice, warnings, discontinuation or dose titration may apply not only to fiuvoxamine but also to any other drug that is a moderate to strong inhibitor of both CYP1A2 and another CYP enzyme selected from the group consisting of CYP3A4, CYP2C9, and/or CYP2C19 (or a drug that is a strong inhibitor of CYP1A2 that also has inhibitory effects on other CYP isozymes [2C9, 2C 19, and/or
• the embodiments may also apply to any other drug that is a moderate to strong inhibitor of both CYP1A2 and another CYP enzyme selected from the group consisting of CYP3A4. CYP2C9, CYP2C1 9, CYP2B6, and/or CYP2D6.
• the embodiments may also apply to any other drug that is a moderate to strong inhibitor of both ( ⁇ 1 A2 and another CYP enzyme that metabolizes pirfenidone, e.g. selected from the group consisting of CYP 1 A l , CYP2A6, W
• the pirfenidone for use in treating a patient, the use of pirfenidone in the manufacture of a medicament for treating a patient in need of pirfenidone therapy, and treatment methods involving the advice, warnings, discontinuation or dose titration downwards, the packages and kits, and/or the methods of preparing or packaging pirfenidone
• the pirfenidone uses, methods, packages, kits, advice, warnings, discontinuation or dose titration may apply not only to fluvoxamine but also to any other drug that is a strong inhibitor of CYP1 A2 or a substrate for CYP1A2.
• CYP1 A2 metabolizes many commonly used drugs including theophylline, imipramine, propranolol, and clozapine. These drugs are commonly referred to as
• CYP1A2 substrates include but are not limited to acetaminophen, amitriptyline, caffeine, chlordiazepoxide, einacalcet, clomipramine, clopidogrel, cyclobenzaprine, desipramine, diazepam, duloxetine, erlotinib, estradiol, fiutamide, halopendol, levobupivacame, methadone, mirtazapine, naproxen, nortriptyline, olanzapine, ondansetron, ramelteon, riluzole, ropinirole, ropivacaine, tacrine, tizamdine, verapamil, and warfarin.
• Inhibitors of CYP1 A2 include fluvoxamine, cimetidine, amiodarone, echinacea, enoxacin, norfloxacin, oral contraceptives, tacrine, ticlopidine, and many fluoroquinolone antibiotics.
• Moderate inhibitors of CYP1A2 include ciprofloxacin, mexiletine, propafenone and zileuton. Additional inhibitors of CYP1 A2 include atazanavir, citalopram,
• CYP1A2 include acyclovir, caffeine, famotidine, fiutamide, grape ruit juice, lidocaine, lomeftoxacin, moclobemide, ofloxacin, perphenazine, phenacetin, propafenone, ropinirole, tocainide, and verapamil.
• Inhibitors of CYP3A4 include amiodarone, cimetidine, ciprofloxacin, delavirdine, fluvoxamine, miconazole, and voriconazole (VFFN'D). Strong inhibitors of CYP3A4 include atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir and telithromycin.
• Moderate inhibitors of CYP3A4 include amprenavir, aprepitant, diltiazem, erythromycin, fluconazole, fosamprenavir, grapefruit juice and verapamil. Additional inhibitors of CYP3A4 i nclude acitretin, cyclosporine, danazol, diethyldithiocarbamate, efavirenz, ethinyl estradiol, fl uoxetine, gestodene, imatinib, isoniazid, metronidazole, methylpredisolone, mifepristone, nicardipine, nifedipine, norethindrone, norfloxacin, norfhioxetine, oxiconazole, pomegranate, prednisone, quinine, ranolazine, roxithromycin, sertraline, Synercid, troleandomycin, zafirl
• Inhibitors of CYP2C9 include cimetidine, delavirdine, efavirenz, fenofibrate (Tricor), fluoxetine, fluvastatin, fluvoxamine, isoniazid, ketoconazole, leflunomide, modafmil, sertraline, voriconazole (VFEND), and zafirlukast (Accolate).
• Moderate inhibitors of CYP2C9 include amiodarone, fluconazole and oxandrolone.
• CYP2C9 metronidazole, omeprazole, paroxetine, sulfonamides, triclopidine, and tipranavir.
• Other inhibitors of CYP2C9 include anastrazole, phenylbutazone, sulfamethoxazole,
• Inhibitors of CYP2D6 include amiodarone, bupropion, celecoxib,
• Additional inhibitors of CYP2D6 include chloroquine, cocaine, darifenacin, escitalopram, fluphenazine, hydroxychloroquine, imatinib, levomepromazine, norfhioxetine, perphenazine, pomegranate, propoxyphene, propranolol, quinacrine, ranitidine, ranolazine, and tipranavir.
• Other inhibitors of CYP2D6 include amitriptyline, chlorpromazine, doxepm, fluvoxamine, goldenseal, hydroxyzine, imipramine, metoclopramide, pimozide, and ticlopidine (Ticlid).
• Inhibitors of CYP2C 19 include delavirdine, efavirenz, esomeprazole, felbamate, fluconazole, fluoxetine, fluvoxamine, indomethacin, isoniazid (INH), modafmi l ( Provigil), oxcarbazepine, ticlopidine, topiramate, and voriconazole (VFEND)
• a strong inh ibitor of CYP2C19 is omeprazole.
• Additional inhibitors of CYP2C 19 include citalopram, fluvastatin, ketoconazole, lansoprazole, letrozole, paroxetine, sertraline, telmisartan, and tipranavi r.
• inhibitors of CYP2C19 include artemisini n. chloramphenicol, and oral contraceptives.
• Inhibitors of CYP2B6 include clopidogrel (Plavix), efavirenz, fluoxetine, fluvoxamine, ketoconazole, memantine, nelfinavir, oral contraceptives, paroxetine, ritonavir, thiotepa, and ticlopidine (Ticlid).
• the term "avoid” and forms thereof are contemplated to have as alternatives the terms abstain, desist, forbear, and refrain, and forms thereof. In some cases, the alternative terms will be equivalent.
• "avoiding” means “refraining from.” Merriam- Webster Online Dictionary, 1 1 th ed., 24 November 2009.
• the term “discontinue” and forms thereof are contemplated to have as alternatives the terms cease, stop, suspend, and quit.
• the avoiding and/or discontinuing steps can be performed in anticipation of pirfenidone therapy.
• impending or imminent pirfenidone administration can be the proximate cause of the avoiding and/or discontinuing steps.
• concurrent pirfenidone administration can be the proximate cause of discontinuing and/or further avoiding steps.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy (e.g. , a patient with IPF), involving administering to the patient a therapeutically effective amount of pirfenidone, and avoiding or contraindicating administration of a CYP 1 A2 inhibitor.
• the CYP1A2 inhibitor is a strong CYP1A2 inhibitor.
• the CYP1A2 inhibitor is a moderate to strong CYP1 A2 inhibitor.
• the CYP1 A2 inhibitor is a drug that is a moderate-strong inhibitor of both CYP 1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 19 and/or CYP3A4 (or a drug that is a strong inhibitor of CYP1 A2 that also has inhibitory effects on other CYP isozymes [2C9, 2C 19, and/or 3A4]), or a drug that is a moderate to strong inhibitor of both CYP1 A2 and another CYP enzyme selected from the group consisting of CYP3A4, CYP2C9, CYP2C 19, CYP2B6, and/or CYP2D6.
• the drug is fluvoxamine.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy (e.g. , a patient with IPF), involving administering to the patient a therapeutically effective amount of pirfenidone, and avoiding or contraindi eating administration of a strong CYP1 A2 inhibitor.
• pirfenidone therapy e.g. , a patient with IPF
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy (e.g. , a patient with IPF), involving administering to the patient a therapeutically effective amount of pirfenidone, and avoiding or contraindicating administration of a CYP l A2 substrate.
• pirfenidone therapy e.g. , a patient with IPF
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy, comprising discontinuing administration of a drug that is a moderate-strong inhibitor of both CYP 1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19 and/or CYP3A4 (or a drug that is a strong inhibitor of CYPl A2 that also has inhibitory effects on other CYP isozymes [2C9, 2C19, and/or 3A4]) to avoid an adverse drug interaction, and administering a therapeutically effective amount of pirfenidone.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy, comprising discontinuing administration of a drug that is a moderate-strong inhibitor of both CYP l A2 and another CYP enzyme selected from the group consisting of CYP 1 A1 , CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C 1 8, CYP2C 19, CYP2D6, CYP2E 1 , CYP2J2 CYP3A4, CYP3A5, CYP4A 1 I and/or CYP4F2 to avoid an adverse drug interaction, and adm i nostiring a therapeutically e ffective amount of pirfenidone.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy, comprising discontinuing administration of a drug that is a strong CYP1A2 inhibitor to avoid an adverse drug interaction, and administering a therapeutically effective amount o f pirf enidone.
• the invention provides a method of administering pri fenidone therapy to a patient in need of pirfenidone therapy, comprising discontinuing administration of a drug that is a CYP l A2 inhibitor, e.g. a moderate to strong CYP1A2 inhibitor.
• the invention in a method of administering a therapeutically effective amount of pirfenidone to a patient with IPF, provides an improvement that comprises avoiding, contraindicatmg or discontinuing administration of the drug that is a CYP inhibitor and administering a therapeutically effective amount of pirfenidone.
• the drug that is a CYP inhibitor is discontinued concurrent with starting administration of pirfenidone. In other embodiments, the drug that is a CYP inhibitor is discontinued within at least 3 days to 1 month prior to or after starting pirfemdone therapy. This time period, for example, permits adequate time for tapering and withdrawal without adverse effects.
• an aspect of the invention provides pirfenidone for use in treating a patient in need of pirfenidone therapy, characterized in that the treating comprises avoiding, contraindicating or discontinuing concomitant use (or co-administration) of a strong CYPl A2 inhibitor; or a moderate to strong CYPl A2 inhibitor; or a drug that is a moderate-strong inhibitor of both CYPl A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19 and/or CYP3A4; or a drug that is a strong inhibitor of C YPl A2 that also has inhibitory effects on other CYP isozymes [2C9, 2C 19, and/or 3A4]; or a drug that is a moderate-strong inhibitor of both CYPl A2 and another CYP enzyme selected from the group consisting of CYPl Al , CYP2A6, CYP2B6, CYP2C8, CY
• the concomitant use of the CYPl A2 inhibitor is avoided, contraindicated or discontinued, in order to avoid reduced clearance of pirfenidone, or the potential for reduced clearance of pirfenidone. In some embodiments, the concomitant use of the CYP l A2 inhibitor is avoided, contraindicated or discontinued, in order to avoid increased exposure to pirfenidone, or the potential for increased exposure to pirfenidone. Administration of pirfenidone in patients that
• the patient may be a patient with IPF, and the therapeutically effective amount administered may be 2400 or 2403 mg per day.
• a further aspect of the invention provides the use of pirfenidone in the manufacture of a medicament for treating a patient in need of pirfenidone therapy, characterized in that the treating comprises avoiding, contraindicating or discontinuing concomitant use (or co-administration) of a CYPl A2 inhibitor.
• the treating comprises avoiding, contraindicating or discontinuing concomitant use (or co-administration) of a CYPl A2 inhibitor.
• the patient is a patient in need of therapy with a CYPl A2 inhibitor. In some embodiments, the patient is a patient in need of therapy with a strong CYPl A2 inhibitor. In some embodiments, the patient is a patient in need of therapy with a moderate to strong CYP 1 A2 inhibitor.
• the patient is a patient in need of therapy with a drug that is a moderate-strong inhibitor of both CYP l A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19 and/or CYP3A4; or a drug that is a strong inhibitor of CYPl A2 that also has inhibitory effects on other CYP isozymes [2C9, 2C19, and/or 3A4].
• the patient is a patient in need of fluvoxamine therapy.
• the patient is a patient who is avoiding concomitant use of the CYPl A2 inhibitor, e.g.
• the patient is a patient who was or is being administered the CYPl A2 inhibitor. In some embodiments, the patient is a patient who is discontinuing use of the CYPl A2 inhibitor prior to the initiation of pirfenidone therapy in order to avoid reduced clearance (or increased exposure to) pirfenidone, or the potential for reduced c learance of (or increased exposure to) pirfenidone. In some embodiments, the patient is a patient who is discontinuing
• the drug being discontinued is a CYP inhibitor
• the drug is discontinued within at least 3 days prior to or after starting pirfenidone therapy.
• the drug that is a CYP inhibitor is discontinued within at least 4 days, or at least 5 days, or at least 6 days, or at least 7 days (or one week), or at least 8 days, or at least 9 days, or at least 1 0 days, or at least 1 1 days, or at least 12 days, or at least 1 3 days, or at least 14 days (or two weeks), or at least 15 days, or at least 16 days, or at least 1 7 days, or at least 18 days, or at least 19 days, or at least 20 days, or at least 21 days (or three weeks), or at least 22 days, or at least 23 days, or at least 24 days, or at least 25 days, or at least 26 clays, or at least 27 days, or at least 28 days (or four weeks), or at least 29 days, or at least 30 davs, or at least one month, prior
• the drug that is a CYP inhibitor is discontinued no earlier than one month, 3 weeks, 2 weeks or 1 week before starting pirfenidone therapy. Preferably, sufficient time is allowed for tapering and/or withdrawal of the drug upon discontinuation.
• the CYP1A2 substrate is discontinued within at least 3 days prior to or after starting pirfenidone therapy.
• the CYP1A2 substrate is discontinued within at least 4 days, or at least 5 days, or at least 6 days, or at least 7 days (or one week), or at least 8 days, or at least 9 days, or at least 10 days, or at least 1 1 days, or at least 12 days, or at least 13 days, or at least 14 days (or two weeks), or at least 15 days, or at least 16 days, or at least 1 7 days, or at least 1 8 days, or at least 19 days, or at least 20 days, or at least 21 days (or three weeks), or at least 22 days, or at least 23 days, or at least 24 days, or at least 25 days, or at least 26 days, or at least 27 days, or at least 28 days (or four weeks), or at least 29 days, or at least 30 days, or at least
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy and in need of therapy with a drug that is a moderate-strong inhibitor of both CYP1A2 and another CYP enzyme selected from the group consisting of CYP1 A 1 , CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C18, CYP2C 1 9.
• CYP2D6, CYP2E1 , CYP2J 2 CYP3A4, CYP3A5, CYP4A 1 1 and/or CYP4F2, comprising administering a therapeuiieally effective amount of pirfenidone to the patient, and
• CYP1A1 CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C 18, CYP2C 19, CYP2D6, CYP2E1 , CYP2J2 CYP3A4, CYP3A5, CYP4A 1 1 and/or CYP4F2.
• another CYP enzyme selected from the group consisting of CYP1A1 , CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C 18, CYP2C 19, CYP2D6, CYP2E1 , CYP2J2 CYP3A4, CYP3A5, CYP4A 1 1 and/or CYP4F2.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy and in need of therapy with a drug that is a moderate-strong inhibitor of both CYP 1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19, and/or CYP3A4, comprising administering a therapeutically effective amount of pirfenidone to the patient, and administering an alternative therapy that is not a moderate-strong inhibitor of both CYP1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 19, and/or CYP3A4.
• the invention provides a method of administering pirfenidone therapy to a patient in need of pirfenidone therapy and in need of therapy with a drug that is a strong CYP1 A2 inhibitor, comprising administering a therapeutically effective amount of pirfenidone to the patient, and administering an alternative therapy that is not a strong CYP1A2 inhibitor.
• the patient is advised that co-administration of pirfenidone with drugs that are a moderate-strong inhibitor of both CYPl A2 and another CYP enzyme selected from the group consisting of CYP l A l , CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C 18, CYP2C 19, CYP2D6, CYP2E1 , CYP2J2 CYP3A4, CYP3A5,
• the patient is advised that use of pirfenidone in patients being treated with a drug that is a moderate-strong inhibitor of both CYPl A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19 and/or CYP3A4 is contraindicated.
• the patient is advised that pirfenidone should be used with caution in patients taking a drug that is a moderate-strong inhibitor of both CYPl A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19 and/or CYP3A4.
• the patient is advised that use of pirfenidone in patients being treated with a drug that is a moderate-strong inhibitor of both CYP1A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 19, CYP3A4, CYP2B6 and/or CYP2D6 is contraindicated.
• a drug that is a moderate-strong inhibitor of both CYP1A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 19, CYP3A4, CYP2B6 and/or CYP2D6 is contraindicated.
• a method of administering pirfenidone and fiuvoxamine concurrently wherein the patient is administered a therapeutically effective amount of fiuvoxamine and a dosage of pirfenidone that is decreased relative to a patient not taking fiuvoxamine.
• a decreased dosage of pirfenidone is less than 2400 mg/day.
• the decreased dosage is about 2136 mg per day, 1869 mg per day, 1602 mg per day, 1335 mg per day, or 1068 mg per day (e.g., 8, 7, 6, 5, 4, or 3 capsules per day where each capsule is approximately 267 mg).
• the patient is already being administered fiuvoxamine.
• the patient is already being administered pirfenidone.
• the dosage of pirfenidone is decreased prior to administration of fiuvoxamine.
• such a decreased dosage of pirfenidone is less than 2400 mg/day.
• the decreased dosage is about 2136 mg per day, 1869 mg per day, 1602 mg per day, 1335 mg per day, or 1068 mg per day (e.g., 8, 7, 6, 5, 4, or 3 capsules per day where each capsule is approximately 267 mg).
• the patient is already being administered the drug that is a CYP inhibitor.
• the patient is already being administered pirfenidone.
• the dosage of pirfenidone is decreased prior to administration of the drug that is a CYP inhibitor.
• a method of administering pirfenidone and a drug that is a moderate-strong inhibitor of both CYP 1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 1 and/or CYP3A4 concurrently is provided, wherein the patient is administered a therapeutically effective amount of the drug that is a CYP inhibitor and a dosage of pirfenidone that is decreased relative to a patient not taking such drug that is a CYP inhibitor.
• a method of administeri ng pirfenidone and a drug that is a moderate-strong inhibitor of both CYP1A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C19, CYP3A4, CYP2BO and/or CYP2D6 concurrently is provided, wherein the patient is administered a therapeutical ! ⁇ e ffective amount of the drug that is a CYP inhibitor and a dosage of pirfenidone that is decreased relative to a patient not taking such drug that is a CYP inhibitor.
• such a decreased dosage of pirfenidone is less than 2400 mg/day.
• the patient is already being administered the strong CYPl A2 inhibitor. In other embodiments, the patient is already being administered pirfenidone. In related embodiments, the dosage of pirfenidone is decreased prior to administration of the strong CYP 1 A2 inhibitor.
• a method of administering pirfenidone and a CYPl A2 substrate concurrently wherein the patient is administered a therapeutically effective amount of the CYP l A2 substrate and a dosage of pirfenidone that is decreased relative to a patient not taking the CYP l A2 substrate.
• a decreased dosage of pirfenidone is less than 2400 mg/day.
• the decreased dosage is about 2136 mg per day, 1869 mg per day. 1602 mg per day, 1335 mg per day, or 1068 mg per day (e.g. , 8, 7, 6, 5, 4, or 3 capsules per day where each capsule is approximately 267 mg).
• the amount of pirfenidone being administered is 2400 or 2403 mg day.
• Pirfenidone can be dosed at a total amount of about 50 to about 2400 mg per lay. The dosage can be divided into two or three doses over the day or given in a single dailv dose.
• Specific amounts of the total daily amount of the therapeutic contemplated for the disclosed methods include about 50 mg, about 100 mg, about 1 5 ⁇ > mg, about 200 mg, about 250 mg, about 267 mg, about 300 mg, about 350 mg, about 400 mg, about 450 mg, about 500 mg, about 534 mg, about 550 mg, about 600 mg, about 650 mg, about 700 mg, about 750 mg, about 800 mg, about 850 mg.
• Dosages of pirfenidone can alternately be administered as a dose measured in mg/kg.
• Contemplated mg/kg doses of the disclosed therapeutics include about 1 mg/kg to about 40 mg kg.
• Specific ranges of doses in mg/kg include about 1 mg/kg to about 20 mg/kg, about 5 mg/kg to about 20 mg/kg, about 10 mg/kg to about 20 mg/kg, about 10 mg/kg to about 30 mg/kg, and about 15 mg/kg to about 25 mg/kg.
• a dosage amount of pirfenidone is taken with food.
• the patient is instructed to administer the dosage of pirfenidone with food.
• a method of administering a SSR1 to a patient in need thereof comprising discontinuing administration of
• fluvoxamine for example, concurrent with starting administration of pirfenidone, and optionally administering an SSRI that is not a moderate to strong inhibitor of both CYP 1 A2, and a CYP enzyme selected from the group consisting of CYP2C9, CYP2C19 and/or
• a method of optimizing pirfenidone therapy comprising titrating the dosage of pirfenidone administered to a patient downward relative to a previously administered dosage in the patient, wherein co-administration of fluvoxamine to the patient does not result in an increased exposure to pirfenidone.
• the dose is reduced by about 100 mg/day. In other embodiments, the dose is reduced by about 1 0 mg/day, or about 200 mg/day. or about 250 mg/day, or about 267 mg/day, or about 300 mg/day, or about 350 mg/day, or about 400 mg/day, or about 450 mg day.
• the dose is reduced by about 100 mg/day. In other embodiments, the dose is reduced by about 150 mg/day, or about 200 mg/day, or about 250 mg/day, or about 267 mg/day, or about 300 mg/day, or about 350 mg/day, or about 400 mg/day, or about 450 mg/day, or about 500 mg/day, or about 550 mg/day, or about 600 mg/day, or about 650 mg/day, or about 700 mg/day, or about 750 mg/day, or about 800 mg/day (to a total daily dose of about 1600 mg/day or 1602 mg/day, or about 850 mg/day, or about 900 mg/day, or about 950 mg/day, or about 1000 mg/day, or about 1050 mg/day, or about 1 100 mg/day, or about 1 150 mg/day, or about 1200 mg/day, or about 1250 mg/day, or about 1300 mg/day, or about 1350 mg/day, or about 1400 mg/day, or about 1450 mg/
• a method of optimizing pirfenidone therapy comprising titrating the dosage of pirfenidone administered to a patient downward relative to a previously administered dosage in the patient, wherein co-administration of a drug that is a moderate-strong inhibitor of both CYP1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 19 and/or CYP3A4 to the patient does not result in an increased exposure to pirfenidone.
• a method of optimizing pirfenidone therapy comprising titrating the dosage o f pirfenidone administered to a patient downward relative to a previously administered dosage in the patient, wherein coadm inistration of a drug that is a moderate-strong inhibitor of both CYP 1 A2 and another CYP enzyme selected from the group consisting of CYP2C9, CYP2C 19, CYP3A4, CYP2B6 and. or CYP2D6 to the patient does not result in an increased exposure to pirfenidone.
• the dose is reduced by about 100 mg/day.
• the dose is reduced by about 150 mg, day, or about 200 mg/day, or about 250 mg/day, or about 267 mg/day, or about 300 mg/day. or about 350 mg/day, or aboul 400 mg/day, or about 450 mg/day, or about 500 mg/day, or about 550 mg day, or about 600 mg/day, or about 650 mg/day, or about 700 mg/day, or about 750 mg/day, or about 800 mg/day (to a total daily dose of about 1600 mg/day or 1602 mg/day), or about 850 mg/day, or about 900 mg/day, or about 950 mg/day, or about 1000 mg day, or about 1050 mg/day, or about 1 100 mg/day, or about 1 1 50 mg/day, or about 1200 mg/day, or about 1250 mg/day, or about 1300 mg/day, or about 1350 mg/day, or about 1400 mg/day, or about 1450 mg/day, or about 1500 mg/day, or about 1600 mg/day (
• a method of optimizing pirfenidone therapy comprising titrating the dosage of pirfenidone administered to a patient downward relative to a previously administered dosage in the patient, wherein co-administration of a strong CYP 1 A2 inhibitor to the patient does not result in an increased exposure to pirfenidone.
• the dose is reduced by about 100 mg/day.
• a method of optimizing pirfenidone therapy comprising titrating the dosage of pirfenidone administered to a patient downward relative to a previously administered dosage in the patient, wherein co-administration of a CYP 1A2 substrate to the patient does not result in an increased exposure to pirfenidone.
• the dose is reduced by about 100 mg/day.
• the dose is reduced by about 150 mg/day, or about 200 mg/day, or about 250 mg/day, or about 267 mg/day, or about 300 mg/day, or about 350 mg/day, or about 400 mg/day, or about 450 mg day, or about 500 mg/day, or about 550 mg/day, or about 600 mg/day, or about 650 mg/day, or about 700 mg/day, or about 750 mg/day, or about 800 mg/day (to a total daily dose of about 1600 mg/day or 1602 mg/day), or about 850 mg/day, or about 900 mg/day, or about 950 mg/day, or about 1000 mg. day, or about 1050 mg/day.
• a method of optimizing pirfenidone therapy comprising titrating the dosage of pirfenidone administered to a patient downward relative to a previously administered dosage in the patient, wherein co-administration of fluvoxamine to the patient does not result in an increased exposure to pirfenidone. It is understood that, in such embodiments comprising dose titration downwards, upon discontinuation of fluvoxamine, the dosage is titrated back up to a dose that is not less than 2400 or 2403 mg/day.
• the pirfenidone uses, methods, packages, kits, advice, warnings, discontinuation or dose titration may apply not only to fluvoxamine but also to (a) any other drug that is a moderate to strong inhibitor of both CYP1 A2 and another CYP enzyme selected from the group consisting of CYP3A4.
• CYPl Al selected from the group consisting of CYPl Al , CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C 18, CYP2C19, CYP2D6, CYP2E 1 , CYP2J2 CYP3A4, CYP3A5, CYP4A1 1 and/or ( ⁇ 4 ⁇ ⁇ or (e) any other drug that is a strong inhibitor of CYP l A2 or (i) any other drug that is a substrate for CYP 1A2.
• a package or kit comprising pirfenidone, optionally in a container, and a package insert, package label, instructions or other labeling including any one, two, three or more of the following information or recommendations:
• the information or recommendation may include that coadministration of pirfenidone and resulted in a 2-fold increase in average peak serum concentration of pirfenidone (Cmax).
• the in formation or recommendation may include that coadministration of pirfenidone with drugs that are moderate to strong inhibitors of both CYP 1 A2 and another CYP enzyme selected from the group consisting of CYP3A4, CYP2C9, CYP2C 1 , CYP2B6, and/or CYP2D6 can alter the therapeutic effect or adverse reaction profi le of pirfenidone.
• the information or recommendation may include that co-administration of pirfenidone with drugs that are moderate to strong inhibitors of both ( ⁇ 1 A2 and another CYP enzyme selected from the group consisting of CYP 1A1 , CY P2A6.
• CYP3A5, CYP4A1 1 and/or CY P4F2 can alter the therapeutic effect or adverse reaction profile of pirfenidone.
• the information or recommendation may incl ude that co-administration of pirfenidone with drugs that are strong CYP1A2 inhibitors can alter the therapeutic effect or adverse reaction profi le of pirfenidone.
• the information or recom mendation may include that co-administration of W 201 pirfenidone with drugs that are CYP 1 A2 substrates can alter the therapeutic effect or adverse reaction profile of pirfenidone.
• the information or recommendation may include that drugs that are moderate to strong inhibitors of both CYP1 A2 and another CYP enzyme selected from the group consisting of CYP3A4, CYP2C9, and/or CYP2C19 should be avoided or discontinued, or are contraindicated, or should be used with caution.
• the information or recommendation may include that administering a strong CYP 1 A2 inhibitor should be avoided or discontinued, or are contraindicated, or should be used with caution.
• the information or recommendation may include that drugs that are CY 1 A2 substrates should be avoided or discontinued, or are
• the package insert, package label, instructions or other labeling may further comprise directions for treating IPF by administering pirfenidone, e.g. , at a dosage of 2400 mg or 2403 mg per day.
• the invention provides a method of preparing or packaging a pirfenidone medicament comprising packaging pirfenidone, optionally in a container, together with a package insert or package label or instructions including any one, two, three or more of the foregoing information or recommendations.
• a method of treating IPF comprising providing, selling or delivering any of the kits of disclosed herein to a hospital, physician or patient.
• a method of treating a patient in need of fluvoxamine comprising providing or delivering any of the kits disclosed herein comprising fluvoxamine to a hospital, physician or patient.
• the invention provides a method of administering a SSRI to a patient in need thereof, the improvement comprising discontinuing administration of fluvoxamine, for example, concurrent with starting administration of pirfenidone, and optionally administering an SSRI that is not a moderate to strong inhibitor of both CYP 1A2 and another CYP enzyme selected from the group consisting of CYP3A4, CYP2C9, and/or CYP2C19.
• Study Design The study was a Phase 1 , open-label, parallel-group study in healthy subjects. Fifty-four subjects were to be enrolled in two groups, consisting of 27 subjects who were smokers (Group 1 ) and 27 subjects who were nonsmokers (Group 2). Smoking induces CYP 1A2 activity. Each group (smokers and nonsmokers) was to include a minimum of nine females and nine males, and attempts were to be made to enroll equal numbers of each sex in each group. Each subject was to receive a single 801 -mg dose of pirfenidone on Days 1 and 1 1 . Fluvoxamine dosing was started on Day 2 and titrated to the final dose according to the following schedule:
• AUCO- ⁇ estimates were generated by simulating plasma PK profiles and compared for statistically significant differences between days (to test the effect of fl uvox amine co-administration) and between groups (to test the effect of smoking status).
• Ph armacokinetic Results Fi fty-one of the 54 subjects enrolled in the study were included in the PK analyses. Three subjects were removed from the PK analyses as they did not meet the protocol-specified requirement for adequate compliance with the fluvoxamine dosing regimen. Two subjects discontinued the study early due to adverse events, and one subject only took 73% of the protocol-requi red fluvoxamine dose. All 5 1 subjects had the full complement of PK samples available for analysis. Each subject had two profiles on each day: one for pirfenidone and one for 5-carboxy pirfenidone. There were a total of 1224 samples ( 1 2 per subject per day); each sample was assayed for pirfenidone and 5-carboxy- pirfenidone for a total of 2448 concentrations.
• smoking status was the only signi ficant predictor of the ratio of the pirfenidone AUCo--r. on Day 1 1 to the AUCo- / on Day 1 ; body size, sex, and age were not significant.
• Pirfenidone for use in treating a patient in need of pirfenidone therapy, characterized in that the treating comprises avoiding, contraindicating or discontinuing concomitant use of fluvoxamine.
• pirfenidone in the manufacture of a medicament for treating a patient in need of pirfenidone therapy, characterized in that the treating comprises avoiding, contraindicating or discontinuing concomitant use of fluvoxamine.
• IPF Idiopathic Pulmonary Fibrosis
• a method of administering pirfenidone therapy to a patient in need thereof comprising discontinuing administration of fluvoxamine to avoid an adverse drug interaction, and administering to the patient a therapeutically effective amount of pirfenidone.
• CYP2C 19 and CYP3A4 can alter the therapeutic effect or adverse reaction profile of pirfenidone.

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