SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Tenofovir Disoproxil Teva 245 mg Film-coated Tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each film-coated tablet contains tenofovir disoproxil phosphate equivalent to 245 mg of tenofovir disoproxil.

Excipient with known effect: Each tablet contains 100.0 mg lactose monohydrate.

For the full list of excipients, see section 6.1.

3    PHARMACEUTICAL FORM

Film-coated tablet.

Light blue to blue, film coated, oval shaped tablet, 16.6 mm long and 8.9 mm wide, debossed with “T” on one side of the tablet and plain on the other side.

4    CLINICAL PARTICULARS

4.1 Therapeutic indications

HIV-1 infection

Tenofovir Disoproxil Teva is indicated in combination with other antiretroviral medicinal products for the treatment of HIV-1 infected adults.

In adults, the demonstration of the benefit of tenofovir disoproxil in HIV-1 infection is based on results of one study in treatment-naive patients, including patients with a high viral load (> 100,000 copies/ml) and studies in which tenofovir disoproxil was added to stable background therapy (mainly tritherapy) in antiretroviral pre-treated patients experiencing early virological failure (< 10,000 copies/ml, with the majority of patients having < 5,000 copies/ml).

Tenofovir Disoproxil Teva is also indicated for the treatment of HIV-1 infected adolescents with NRTI resistance or toxicities precluding the use of first line agents, aged 12 to <18 years.

The choice of Tenofovir Disoproxil Teva to treat antiretroviral-experienced patients with HIV-1 infection should be based on individual viral resistance testing and/or treatment history of patients.

Hepatitis B infection

Tenofovir Disoproxil Teva is indicated for the treatment of chronic hepatitis B (see section 5.1) in adults with:

•    compensated liver disease, with evidence of active viral replication, persistently elevated serum alanine aminotransferase (ALT) levels and histological evidence of active inflammation and/or fibrosis (see section 5.1)

•    evidence of lamivudine-resistant hepatitis B virus (see sections 4.8 and 5.1).

•    decompensated liver disease (see sections 4.4, 4.8 and 5.1).

Tenofovir Disoproxil Teva is indicated for the treatment of chronic hepatitis B in adolescents 12 to < 18 years of age with:

•    compensated liver disease and evidence of immune active disease, i.e. active viral replication persistently elevated serum ALT levels and histological evidence of active inflammation and/or fibrosis (see section 4.4, 4.8 and 5.1).

4.2 Posology and method of administration

Therapy should be initiated by a physician experienced in the management of HIV infection and/or treatment of chronic hepatitis B.

Posology

Adults: The recommended dose of Tenofovir Disoproxil Teva for the treatment of HIV or for the treatment of chronic hepatitis B is 245 mg (one tablet) once daily taken orally with food.

Chronic hepatitis B: The optimal duration of treatment is unknown. Treatment discontinuation may be considered as follows:

-    In HBeAg positive patients without cirrhosis, treatment should be administered for at least 6-12 months after HBe seroconversion (HBeAg loss and HBV DNA loss with anti-HBe detection) is confirmed or until HBs seroconversion or there is loss of efficacy (see section 4.4). Serum ALT and HBV DNA levels should be followed regularly after treatment discontinuation to detect any late virological relapse.

-    In HBeAg negative patients without cirrhosis, treatment should be administered at least until HBs seroconversion or there is evidence of loss of efficacy. With prolonged treatment for more than 2 years, regular reassessment is recommended to confirm that continuing the selected therapy remains appropriate for the patient.

For treatment of HIV-1 infection and chronic hepatitis B in adults for whom a solid dosage form is not appropriate, other suitable formulations may be checked for their availability.

Paediatric population

HIV-1: In adolescents aged 12 to < 18 years and weighing > 35 kg, the recommended dose of Tenofovir Disoproxil Teva is 245 mg (one tablet) once daily taken orally with food (see sections 4.8 and 5.1).

Reduced doses of tenofovir disoproxil are used for treatment of HIV-1 infected paediatric patients aged 2 to < 12 years. As Tenofovir disoproxil Teva is available only as 245 mg film-coated tablets, it is not suitable for the use in paediatric patients aged 2 to < 12 years. Other suitable formulations may be checked for their availability.

The safety and efficacy of tenofovir disoproxil in HIV-1 infected children under 2 years of age have not been established. No data are available.

Chronic hepatitis B: In adolescents aged 12 to < 18 years and weighing > 35 kg, the recommended dose of Tenofovir Disoproxil Teva is 245 mg (one tablet) once daily, taken orally with food (see sections 4.8 and 5.1). The optimal duration of treatment is currently unknown.

The safety and efficacy of tenofovir disoproxil in children with chronic hepatitis B aged 2 to < 12 years or weighing < 35 kg have not been established. No data are available.

For treatment of HIV-1 infection and chronic hepatitis B in adolescents aged 12 to <18 years for whom a solid dosage form is not appropriate, other suitable formulations may be checked for their availability.

Missed dose

If a patient misses a dose of Tenofovir Disoproxil Teva within 12 hours of the time it is usually taken, the patient should take Tenofovir Disoproxil Teva with food as soon as possible and resume their normal dosing schedule. If a patient misses a dose of Tenofovir Disoproxil Teva by more than 12 hours and it is almost time for the next dose, the patient should not take the missed dose and simply resume the usual dosing schedule.

If the patient vomits within 1 hour of taking Tenofovir Disoproxil Teva another tablet should be taken. If vomiting occurs more than 1 hour after taking Tenofovir Disoproxil Teva the patient does not need to take another dose.

Special populations

Elderly: No data are available on which to make a dose recommendation for patients over the age of 65 years (see section 4.4).

Renal impairment: Tenofovir is eliminated by renal excretion and the exposure to tenofovir increases in patients with renal dysfunction.

Adults

There are limited data on the safety and efficacy of tenofovir disoproxil in patients with moderate and severe renal impairment (creatinine clearance < 50 ml/min) and long-term safety data has not been evaluated for mild renal impairment (creatinine clearance 50-80 ml/min). Therefore, in adult patients with renal impairment tenofovir disoproxil should only be used if the potential benefits of treatment are considered to outweigh the potential risks. Reduced daily dose is recommended for adult patients with creatinine clearance < 50 ml/min, including haemodialysis patients. Tenofovir disoproxil Teva is available only as 245 mg film-coated tablets. Other suitable formulations may be checked for their availability.

Mild renal impairment (creatinine clearance 50-80 ml/min): Limited data from clinical studies support once daily dosing of 245 mg tenofovir disoproxil in patients with mild renal impairment.

Moderate renal impairment (creatinine clearance 30-49 ml/min): If administration of a lower dose is not possible, prolonged dose intervals using the 245 mg film-coated tablets may be used. Administration of 245 mg tenofovir disoproxil every 48 hours is recommended based on modelling of single-dose pharmacokinetic data in HIV negative and non-HBV infected subjects with varying degrees of renal impairment, including end-stage renal disease requiring haemodialysis, but has not been confirmed in clinical studies. Therefore, clinical response to treatment and renal function should be closely monitored in these patients (see sections 4.4 and 5.2).

Severe renal impairment (creatinine clearance < 30 ml/min) and haemodialysis patients: Adequate dose adjustments cannot be applied due to lack of alternative tablet strengths, therefore use in this group of patients is not recommended. If no alternative treatment is available, prolonged dose intervals may be used as follows:

Severe renal impairment: 245 mg tenofovir disoproxil may be administered every 7296 hours (dosing twice a week).

Haemodialysis patients: 245 mg tenofovir disoproxil may be administered every 7 days following completion of a haemodialysis session*.

These dose interval adjustments have not been confirmed in clinical studies. Simulations suggest that the prolonged dose interval using Tenofovir Disoproxil Teva is not optimal and could result in increased toxicity and possibly inadequate response. Therefore, clinical response to treatment and renal function should be closely monitored (see sections 4.4 and 5.2).

*Generally, once weekly dosing assuming three haemodialysis sessions per week, each of approximately 4 hours duration or after 12 hours cumulative haemodialysis.

No dosing recommendations can be given for non-haemodialysis patients with creatinine clearance < 10 ml/min.

Paediatrics

The use of tenofovir disoproxil is not recommended in paediatric patients with renal impairment (see section 4.4).

Hepatic impairment: No dose adjustment is required in patients with hepatic impairment (see sections 4.4 and 5.2).

If tenofovir disoproxil is discontinued in patients with chronic hepatitis B with or without HIV co-infection, these patients should be closely monitored for evidence of exacerbation of hepatitis (see section 4.4).

Method of administration

Tenofovir Disoproxil Teva tablets should be taken once daily, orally with food.

In exceptional circumstances in patients having particular difficulty in swallowing, tenofovir disoproxil tablets can be crushed and then dispersed in at least 100 ml of water, orange juice or grape juice and drunk immediately.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

General

HIV antibody testing should be offered to all HBV infected patients before initiating tenofovir disoproxil therapy (see below Co-infection with HIV-1 and hepatitis B).

HIV-1

While effective viral suppression with antiretroviral therapy has been proven to substantially reduce the risk of sexual transmission, a residual risk cannot be excluded. Precautions to prevent transmission should be taken in accordance with national guidelines.

Chronic hepatitis B

Patients must be advised that tenofovir disoproxil has not been proven to prevent the risk of transmission of HBV to others through sexual contact or contamination with blood.

Appropriate precautions must continue to be used.

Co-administration of other medicinal products

-    Tenofovir Disoproxil Teva should not be administered concomitantly with other medicinal products containing tenofovir disoproxil.

-    Tenofovir Disoproxil Teva should not be administered concomitantly with adefovir dipivoxil.

-    Co-administration of tenofovir disoproxil and didanosine is not recommended. Co-administration of tenofovir disoproxil and didanosine results in a 40-60% increase in systemic exposure to didanosine that may increase the risk of didanosine-related adverse reactions (see section 4.5). Rarely, pancreatitis and lactic acidosis, sometimes fatal, have been reported. Co-administration of tenofovir disoproxil and didanosine at a dose of 400 mg daily has been associated with a significant decrease in CD4 cell count, possibly due to an intracellular interaction increasing phosphorylated (i.e. active) didanosine. A decreased dosage of 250 mg didanosine co-administered with tenofovir disoproxil therapy has been associated with reports of high rates of virological failure within several tested combinations for the treatment of HIV-1 infection.

Triple therapy with nucleosides/nucleotides

There have been reports of a high rate of virological failure and of emergence of resistance at an early stage in HIV patients when tenofovir disoproxil was combined with lamivudine and abacavir as well as with lamivudine and didanosine as a once daily regimen.

Renal and bone effects in adult population

Renal effects

Tenofovir is principally eliminated via the kidney. Renal failure, renal impairment, elevated creatinine, hypophosphataemia and proximal tubulopathy (including Fanconi syndrome) have been reported with the use of tenofovir disoproxil in clinical practice (see section 4.8).

Renal monitoring

It is recommended that creatinine clearance is calculated in all patients prior to initiating therapy with tenofovir disoproxil and renal function (creatinine clearance and serum phosphate) is also monitored after two to four weeks of treatment, after three months of treatment and every three to six months thereafter in patients without renal risk factors. In patients at risk for renal impairment, a more frequent monitoring of renal function is required.

Renal management

If serum phosphate is < 1.5 mg/dl (0.48 mmol/l) or creatinine clearance is decreased to < 50 ml/min in any adult patient receiving tenofovir disoproxil, renal function should be re-evaluated within one week, including measurements of blood glucose, blood potassium and urine glucose concentrations (see section 4.8, proximal tubulopathy). Consideration should also be given to interrupting treatment with tenofovir disoproxil in adult patients with creatinine clearance decreased to < 50 ml/min or decreases in serum phosphate to < 1.0 mg/dl (0.32 mmol/l). Interrupting treatment with tenofovir disoproxil should also be considered in case of progressive decline of renal function when no other cause has been identified.

Co-administration and risk of renal toxicity

Use of tenofovir disoproxil should be avoided with concurrent or recent use of a nephrotoxic medicinal product (e.g. aminoglycosides, amphotericin B, foscarnet, ganciclovir, pentamidine, vancomycin, cidofovir or interleukin-2). If concomitant use of tenofovir disoproxil and nephrotoxic agents is unavoidable, renal function should be monitored weekly.

Cases of acute renal failure after initiation of high dose or multiple non-steroidal antiinflammatory drugs (NSAIDs) have been reported in patients treated with tenofovir disoproxil and with risk factors for renal dysfunction. If tenofovir disoproxil is coadministered with an NSAID, renal function should be monitored adequately.

A higher risk of renal impairment has been reported in patients receiving tenofovir disoproxil in combination with a ritonavir or cobicistat boosted protease inhibitor. A close monitoring of renal function is required in these patients (see section 4.5). In patients with renal risk factors, the co-administration of tenofovir disoproxil with a boosted protease inhibitor should be carefully evaluated.

Tenofovir disoproxil has not been clinically evaluated in patients receiving medicinal products which are secreted by the same renal pathway, including the transport proteins human organic anion transporter (hOAT) 1 and 3 or MRP 4 (e.g. cidofovir, a known nephrotoxic medicinal product). These renal transport proteins may be responsible for tubular secretion and in part, renal elimination of tenofovir and cidofovir. Consequently, the pharmacokinetics of these medicinal products which are secreted by the same renal pathway including transport proteins hOAT 1 and 3 or

MRP 4 might be modified if they are co-administered. Unless clearly necessary, concomitant use of these medicinal products which are secreted by the same renal pathway is not recommended, but if such use is unavoidable, renal function should be monitored weekly (see section 4.5).

Renal impairment

Renal safety with tenofovir disoproxil has only been studied to a very limited degree in adult patients with impaired renal function (creatinine clearance < 80 ml/min).

Adult patients with creatinine clearance < 50 ml/min, including haemodialysis patients:

There are limited data on the safety and efficacy of tenofovir disoproxil in patients with impaired renal function. Therefore, tenofovir disoproxil should only be used if the potential benefits of treatment are considered to outweigh the potential risks. In patients with severe renal impairment (creatinine clearance < 30 ml/min) and in patients who require haemodialysis use of tenofovir disoproxil is not recommended. If no alternative treatment is available, the dosing interval must be adjusted and renal function should be closely monitored (see sections 4.2 and 5.2).

Bone effects

In HIV infected patients, in a 144-week controlled clinical study that compared tenofovir disoproxil with stavudine in combination with lamivudine and efavirenz in antiretroviral-naive adult patients, small decreases in bone mineral density (BMD) of the hip and spine were observed in both treatment groups. Decreases in BMD of spine and changes in bone biomarkers from baseline were significantly greater in the tenofovir disoproxil treatment group at 144 weeks. Decreases in BMD of hip were significantly greater in this group until 96 weeks. However, there was no increased risk of fractures or evidence for clinically relevant bone abnormalities over 144 weeks.

Bone abnormalities (infrequently contributing to fractures) may be associated with proximal renal tubulopathy (see section 4.8).

If bone abnormalities are suspected or detected then appropriate consultation should be obtained.

Renal and bone effects in paediatric population

There are uncertainties associated with the long term effects of bone and renal toxicity. Moreover, the reversibility of renal toxicity cannot be fully ascertained. Therefore, a multidisciplinary approach is recommended to adequately weigh on a case by case basis the benefit/risk balance of treatment, decide the appropriate monitoring during treatment (including decision for treatment withdrawal) and consider the need for supplementation.

Renal effects

Renal adverse reactions consistent with proximal renal tubulopathy have been reported in HIV-1 infected paediatric patients aged 2 to < 12 years in clinical study GS-US-104-0352 (see sections 4.8 and 5.1).

Renal monitoring

Renal function (creatinine clearance and serum phosphate) should be evaluated prior to treatment, and monitored during treatment as in adults (see above).

Renal management

If serum phosphate is confirmed to be < 3.0 mg/dl (0.96 mmol/l) in any paediatric patient receiving tenofovir disoproxil, renal function should be reevaluated within one week, including measurements of blood glucose, blood potassium and urine glucose concentrations (see section 4.8, proximal tubulopathy). If renal abnormalities are suspected or detected then consultation with a nephrologist should be obtained to consider interruption of tenofovir disoproxil treatment. Interrupting treatment with tenofovir disoproxil should also be considered in case of progressive decline of renal function when no other cause has been identified.

Co-administration and risk of renal toxicity

The same recommendations apply as in adults (see above).

Renal impairment

The use of tenofovir disoproxil is not recommended in paediatric patients with renal impairment (see section 4.2). Tenofovir disoproxil should not be initiated in paediatric patients with renal impairment and should be discontinued in paediatric patients who develop renal impairment during tenofovir disoproxil therapy

Bone effects

Tenofovir disoproxil may cause a reduction in BMD. The effects of tenofovir disoproxil -associated changes in BMD on long-term bone health and future fracture risk are currently unknown (see section 5.1).

If bone abnormalities are detected or suspected in paediatric patients, consultation with an endocrinologist and/or nephrologist should be obtained.

Liver disease

Safety and efficacy data are very limited in liver transplant patients.

There are limited data on the safety and efficacy of tenofovir disoproxil in HBV infected patients with decompensated liver disease and who have a Child-Pugh-Turcotte (CPT) score > 9. These patients may be at higher risk of experiencing serious hepatic or renal adverse reactions. Therefore, hepatobiliary and renal parameters should be closely monitored in this patient population.

Exacerbations of hepatitis

Flares on treatment: Spontaneous exacerbations in chronic hepatitis B are relatively common and are characterised by transient increases in serum ALT. After initiating antiviral therapy, serum ALT may increase in some patients (see section 4.8). In patients with compensated liver disease, these increases in serum ALT are generally not accompanied by an increase in serum bilirubin concentrations or hepatic decompensation. Patients with cirrhosis may be at a higher risk for hepatic decompensation following hepatitis exacerbation, and therefore should be monitored closely during therapy.

Flares after treatment discontinuation: Acute exacerbation of hepatitis has also been reported in patients who have discontinued hepatitis B therapy. Post-treatment exacerbations are usually associated with rising HBV DNA, and the majority appears to be self-limited. However, severe exacerbations, including fatalities, have been reported. Hepatic function should be monitored at repeated intervals with both clinical and laboratory follow-up for at least 6 months after discontinuation of hepatitis B therapy. If appropriate, resumption of hepatitis B therapy may be warranted. In patients with advanced liver disease or cirrhosis, treatment discontinuation is not recommended since post-treatment exacerbation of hepatitis may lead to hepatic decompensation.

Liver flares are especially serious, and sometimes fatal in patients with decompensated liver disease.

Co-infection with hepatitis C or D: There are no data on the efficacy of tenofovir in patients co-infected with hepatitis C or D virus.

Co-infection with HIV-1 and hepatitis B: Due to the risk of development of HIV resistance, tenofovir disoproxil should only be used as part of an appropriate antiretroviral combination regimen in HIV/HBV co-infected patients. Patients with pre-existing liver dysfunction, including chronic active hepatitis, have an increased frequency of liver function abnormalities during combination antiretroviral therapy (CART) and should be monitored according to standard practice. If there is evidence of worsening liver disease in such patients, interruption or discontinuation of treatment must be considered. However, it should be noted that increases of ALT can be part of HBV clearance during therapy with tenofovir, see above Exacerbations of hepatitis.

Lipodystrophy

Combination antiretroviral therapy (CART) has been associated with the redistribution of body fat (lipodystrophy) in HIV patients. The long-term consequences of these events are currently unknown. Knowledge about the mechanism is incomplete. A connection between visceral lipomatosis and protease inhibitors and lipoatrophy and nucleoside reverse transcriptase inhibitors has been hypothesised. A higher risk of lipodystrophy has been associated with individual factors such as older age, and with drug related factors such as longer duration of antiretroviral treatment and associated metabolic disturbances. Clinical examination should include evaluation for physical signs of fat redistribution. Consideration should be given to the measurement of fasting serum lipids and blood glucose. Lipid disorders should be managed as clinically appropriate (see section 4.8).

Tenofovir is structurally related to nucleoside analogues hence the risk of lipodystrophy cannot be excluded. However, 144-week clinical data from antiretroviral-naive HIV infected adult patients indicate that the risk of lipodystrophy was lower with tenofovir disoproxil than with stavudine when administered with lamivudine and efavirenz.

Mitochondrial dysfunction

Nucleoside and nucleotide analogues have been demonstrated in vitro and in vivo to cause a variable degree of mitochondrial damage. There have been reports of mitochondrial dysfunction in HIV negative infants exposed in utero and/or postnatally to nucleoside analogues. The main adverse events reported are haematological disorders (anaemia, neutropenia), metabolic disorders (hyperlactataemia, hyperlipasaemia). These events are often transitory. Some late-onset neurological disorders have been reported (hypertonia, convulsion, abnormal behaviour). Whether the neurological disorders are transient or permanent is currently unknown. Any child exposed in utero to nucleoside and nucleotide analogues, even HIV negative children, should have clinical and laboratory follow-up and should be fully investigated for possible mitochondrial dysfunction in case of relevant signs or symptoms. These findings do not affect current national recommendations to use antiretroviral therapy in pregnant women to prevent vertical transmission of HIV.

Immune reactivation syndrome

In HIV infected patients with severe immune deficiency at the time of institution of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic pathogens may arise and cause serious clinical conditions, or aggravation of symptoms. Typically, such reactions have been observed within the first few weeks or months of initiation of CART. Relevant examples are cytomegalovirus retinitis, generalised and/or focal mycobacterial infections, and Pneumocystis jirovecii pneumonia. Any inflammatory symptoms should be evaluated and treatment instituted when necessary.

Autoimmune disorders (such as Graves’ disease) have also been reported to occur in the setting of immune reactivation; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment.

Osteonecrosis

Although the etiology is considered to be multifactorial (including corticosteroid use, alcohol consumption, severe immunosuppression, higher body mass index), cases of osteonecrosis have been reported particularly in patients with advanced HIV disease and/or long-term exposure to combination antiretroviral therapy (CART). Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.

Elderly

Tenofovir disoproxil has not been studied in patients over the age of 65. Elderly patients are more likely to have decreased renal function; therefore caution should be exercised when treating elderly patients with tenofovir disoproxil.

Tenofovir Disoproxil Teva contains lactose monohydrate. Consequently, patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption should not take this medicinal product.

4.5 Interaction with other medicinal products and other forms of interaction

Interaction studies have only been performed in adults.

Based on the results of in vitro experiments and the known elimination pathway of tenofovir, the potential for CYP450 mediated interactions involving tenofovir with other medicinal products is low.

Concomitant use not recommended

Tenofovir Disoproxil Teva should not be administered concomitantly with other medicinal products containing tenofovir disoproxil.

Tenofovir Disoproxil Teva should not be administered concomitantly with adefovir dipivoxil.

Didanosine: Co-administration of tenofovir disoproxil and didanosine is not recommended (see section 4.4 and Table 1).

Renally eliminated medicinal products: Since tenofovir is primarily eliminated by the kidneys, co-administration of tenofovir disoproxil with medicinal products that reduce renal function or compete for active tubular secretion via transport proteins hOAT 1, hOAT 3 or MRP 4 (e.g. cidofovir) may increase serum concentrations of tenofovir and/or the co-administered medicinal products.

Use of tenofovir disoproxil should be avoided with concurrent or recent use of a nephrotoxic medicinal product. Some examples include, but are not limited to, aminoglycosides, amphotericin B, foscarnet, ganciclovir, pentamidine, vancomycin, cidofovir or interleukin-2 (see section 4.4).

Given that tacrolimus can affect renal function, close monitoring is recommended when it is co-administered with tenofovir disoproxil.

Other interactions

Interactions between tenofovir disoproxil and protease inhibitors and antiretroviral agents other than protease inhibitors are listed in Table 1 below (increase is indicated as “t”, decrease as “ j”, no change as “^”, twice daily as “b.i.d.”, and once daily as “q.d”).

Table 1: Interactions between tenofovir disoproxil and other medicinal products

Medicinal product by therapeutic areas (dose in mg)	Effects on drug levels Mean percent change in AUC, Cmax, Cmin	Recommendation concerning coadministration with 245 mg tenofovir disoproxil
ANTI-INFECTIV1	2S
Antiretrovirals
Protease inhibitors
Atazanavir/Ritona vir (300 q.d./100 q.d./300 q.d.)	Atazanavir: AUC: | 25% Cmax: l 28% Cmin: l 26% Tenofovir: AUC: T 37% Cmax: T 34% Cmin: T 29%	No dose adjustment is recommended. The increased exposure of tenofovir could potentiate tenofovir associated adverse events, including renal disorders. Renal function should be closely monitored (see section 4.4).
Lopinavir/Ritona vir (400 b.i.d./100 b.i.d./300 q.d.)	Lopinavir/ritonavir: No significant effect on lopinavir/ritonavir PK parameters. Tenofovir: AUC: T 32% Cmax: ^ Cmin: T 51%	No dose adjustment is recommended. The increased exposure of tenofovir could potentiate tenofovir associated adverse events, including renal disorders. Renal function should be closely monitored (see section 4.4).
Darunavir/Ritona vir (300/100 b.i.d./300 q.d.)	Darunavir: No significant effect on darunavir/ritonavir PK parameters. Tenofovir: AUC: T 22% Cmin: T 37%	No dose adjustment is recommended. The increased exposure of tenofovir could potentiate tenofovir associated adverse events, including renal disorders. Renal function should be closely monitored (see section 4.4).
NRTIs

Didanosine	Co-administration of tenofovir disoproxil and didanosine results in a 40-60% increase in systemic exposure to didanosine that may increase the risk for didanosine-related adverse reactions. Rarely, pancreatitis and lactic acidosis, sometimes fatal, have been reported. Co-administration of tenofovir disoproxil and didanosine at a dose of 400 mg daily has been associated with a significant decrease in CD4 cell count, possibly due to an intracellular interaction increasing phosphorylated (i.e. active) didanosine. A decreased dosage of 250 mg didanosine co-administered with tenofovir disoproxil therapy has been associated with reports of high rates of virological failure within several tested combinations for the treatment of HIV-1 infection.	Co-administration of tenofovir disoproxil and didanosine is not recommended (see section 4.4).
Adefovir	AUC: ^	tenofovir disoproxil should
dipivoxil	Cmax: ^	not be administered concurrently with adefovir dipivoxil (see section 4.4).
Entecavir	AUC: ^	No clinically significant
	Cmax: ^	pharmacokinetic interactions when tenofovir disoproxil was co-administered with entecavir.

Studies conducted with other medicinal products There were no clinically significant pharmacokinetic interactions when tenofovir disoproxil was co-administered with emtricitabine, lamivudine, indinavir, efavirenz, nelfinavir, saquinavir (ritonavir boosted), methadone, ribavirin, rifampicin, tacrolimus, or the hormonal contraceptive norgestimate/ethinyl oestradiol.

Tenofovir disoproxil must be taken with food, as food enhances the bioavailability of tenofovir (see section 5.2).

4.6 Fertility, pregnancy and lactation

Pregnancy

A moderate amount of data on pregnant women (between 300-1,000 pregnancy outcomes) indicate no malformations or foetal/neonatal toxicity associated with tenofovir disoproxil. Animal studies do not indicate reproductive toxicity (see section

5.3). The use of tenofovir disoproxil may be considered during pregnancy, if necessary.

Breast-feeding

Tenofovir has been shown to be excreted in human milk. There is insufficient information on the effects of tenofovir in newborns/infants. Therefore Tenofovir Disoproxil Teva should not be used during breast-feeding.

As a general rule, it is recommended that HIV and HBV infected women do not breast-feed their infants in order to avoid transmission of HIV and HBV to the infant.

Fertility

There are limited clinical data with respect to the effect of tenofovir disoproxil on fertility. Animal studies do not indicate harmful effects of tenofovir disoproxil on fertility.

4.7 Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. However, patients should be informed that dizziness has been reported during treatment with tenofovir disoproxil.

4.8 Undesirable effects

Summary of the safety profile

HIV-1 and hepatitis B: In patients receiving tenofovir disoproxil, rare events of renal impairment, renal failure and proximal renal tubulopathy (including Fanconi syndrome) sometimes leading to bone abnormalities (infrequently contributing to fractures) have been reported. Monitoring of renal function is recommended for patients receiving Tenofovir disoproxil Teva (see section

4.4).

HIV-1: Approximately one third of patients can be expected to experience adverse reactions following treatment with tenofovir disoproxil in combination with other antiretroviral agents. These reactions are usually mild to moderate gastrointestinal events. Approximately 1% of tenofovir disoproxil-treated adult patients discontinued treatment due to the gastrointestinal events.

Lactic acidosis, severe hepatomegaly with steatosis and lipodystrophy are associated with tenofovir disoproxil (see sections 4.4 and 4.8 Description of selected adverse reactions).

Co-administration of Tenofovir Disoproxil Teva and didanosine is not recommended as this may result in an increased risk of adverse reactions (see section 4.5). Rarely, pancreatitis and lactic acidosis, sometimes fatal, have been reported (see section 4.4).

Hepatitis B: Approximately one quarter of patients can be expected to experience adverse reactions following treatment with tenofovir disoproxil, most of which are mild. In clinical trials of HBV infected patients, the most frequently occurring adverse reaction to tenofovir disoproxil was nausea (5.4%).

Acute exacerbation of hepatitis has been reported in patients on treatment as well as in patients who have discontinued hepatitis B therapy (see section 4.4).

Tabulated summary of adverse reactions

Assessment of adverse reactions for tenofovir disoproxil is based on safety data from clinical studies and post-marketing experience. All adverse reactions are presented in Table 2.

HIV-1 clinical studies: Assessment of adverse reactions from HIV-1 clinical study data is based on experience in two studies in 653 treatment-experienced patients receiving treatment with tenofovir disoproxil (n = 443) or placebo (n = 210) in combination with other antiretroviral medicinal products for 24 weeks and also in a double-blind comparative controlled study in which 600 treatment-naive patients received treatment with tenofovir disoproxil 245 mg (n = 299) or stavudine (n = 301) in combination with lamivudine and efavirenz for 144 weeks.

Hepatitis B clinical studies: Assessment of adverse reactions from HBV clinical study data is primarily based on experience in two double-blind comparative controlled studies in which 641 adult patients with chronic hepatitis B and compensated liver disease received treatment with tenofovir disoproxil 245 mg daily (n = 426) or adefovir dipivoxil 10 mg daily (n = 215) for 48 weeks. The adverse reactions observed with continued treatment for 384 weeks were consistent with the safety profile of tenofovir disoproxil.

After an initial decline of approximately -4.9 ml/min (using Cockcroft-Gault equation) or -3.9 ml/min/1.73 m (using modification of diet in renal disease [MDRD] equation) after the first 4 weeks of treatment, the rate of annual decline post baseline of renal function reported in tenofovir disoproxil treated patients was -1.41 ml/min per year (using Cockcroft-Gault equation) and -0.74 ml/min/1.73 m per year (using MDRD equation).

Patients with decompensated liver disease: The safety profile of tenofovir disoproxil in patients with decompensated liver disease was assessed in a double-blind active controlled study (GS-US-174-0108) in which patients received treatment with tenofovir disoproxil (n = 45) or emtricitabine plus tenofovir disoproxil (n = 45) or entecavir (n = 22) for 48 weeks.

In the tenofovir disoproxil treatment arm, 7% of patients discontinued treatment due to an adverse event; 9% of patients experienced a confirmed increase in serum creatinine of > 0.5 mg/dl or confirmed serum phosphate of < 2 mg/dl through week 48; there were no statistically significant differences between the combined tenofovir-containing arms and the entecavir arm. After 168 weeks, 16% (7/45) of the tenofovir disoproxil group, 4% (2/45) of the emtricitabine plus tenofovir disoproxil group, and 14% (3/22) of the entecavir

group experienced tolerability failure. Thirteen percent (6/45) of the tenofovir disoproxil group, 13% (6/45) of the emtricitabine plus tenofovir disoproxil group, and 9% (2/22) of the entecavir group had a confirmed increase in serum creatinine > 0.5 mg/dl or confirmed serum phosphate of < 2mg/dl.

At week 168, in this population of patients with decompensated liver disease, the rate of death was of 13% (6/45) in the tenofovir disoproxil group, 11% (5/45) in the emtricitabine plus tenofovir disoproxil group and 14% (3/22) in the entecavir group. The rate of hepatocellular carcinoma was 18% (8/45) in the tenofovir disoproxil group, 7% (3/45) in the emtricitabine plus tenofovir disoproxil group and 9% (2/22) in the entecavir group.

Subjects with a high baseline CPT score were at higher risk of developing serious adverse events (see section 4.4).

Patients with lamivudine-resistant chronic hepatitis B: No new adverse reactions to tenofovir disoproxil were identified from a randomised, doubleblind study (GS-US-174-0121) in which 280 lamivudine-resistant patients received treatment with tenofovir (n=141) or emtricitabine/tenofovir disoproxil (n=139) for 96 weeks.

The adverse reactions with suspected (at least possible) relationship to treatment are listed below by body system organ class and frequency. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. Frequencies are defined as very common (> 1/10), common (> 1/100 to < 1/10), uncommon (> 1/1,000 to < 1/100) or rare (> 1/10,000 to < 1/1,000).

Table 2: Tabulated summary of adverse reactions associated with tenofovir disoproxil based on clinical study and post-marketing experience_

Frequency	Tenofovir disoproxil
Metabolism and nutrition disorders:
Very common:	hypophosphataemia1
Uncommon:	hypokalaemia1
Rare:	lactic acidosis3
Nervous system disorders:
Very common:	dizziness
Common:	headache
Gastrointestinal disorders:
Very common:	diarrhoea, vomiting, nausea
Common:	abdominal pain, abdominal distension, flatulence
Uncommon:	pancreatitis3
Hepatobiliary disorders:
Common:	increased transaminases
Rare:	hepatic steatosis3, hepatitis
Skin and subcutaneous tissue disorders:
Very common:	rash

Rare:	angioedema
Musculoskeletal and connective tissue disorders:
Uncommon:	rhabdomyolysis1, muscular weakness1
Rare:	osteomalacia (manifested as bone pain and infrequently contributing to fractures)1, 2, myopathy1
Renal and urinary disorders:
Uncommon:	increased creatinine
Rare:	acute renal failure, renal failure, acute tubular necrosis, proximal renal tubulopathy (including Fanconi syndrome), nephritis (including acute interstitial nephritis)2, nephrogenic diabetes insipidus
General disorders and administration site conditions:
Very common:	asthenia
Common:	fatigue

¹    This adverse reaction may occur as a consequence of proximal renal tubulopathy. It is not considered to be causally associated with tenofovir disoproxil in the absence of this condition.

²    This adverse reaction was identified through post-marketing surveillance but not observed in randomised controlled clinical trials or the tenofovir disoproxil expanded access program. The frequency category was estimated from a statistical calculation based on the total number of patients exposed to tenofovir disoproxil in randomised controlled clinical trials and the expanded access program (n = 7,319).

³    See section 4.8 Description of selected adverse reactions for more details.

Description of selected adverse reactions HIV-1 and hepatitis B:

Renal impairment: As Tenofovir Disoproxil Teva may cause renal damage monitoring of renal function is recommended (see sections 4.4 and 4.8 Summary of the safety profile). Proximal renal tubulopathy generally resolved or improved after tenofovir disoproxil discontinuation. However, in some patients, declines in creatinine clearance did not completely resolve despite tenofovir disoproxil discontinuation. Patients at risk of renal impairment (such as patients with baseline renal risk factors, advanced HIV disease, or patients receiving concomitant nephrotoxic medications) are at increased risk of experiencing incomplete recovery of renal function despite tenofovir disoproxil discontinuation (see section 4.4).

HIV-1:

Interaction with didanosine: Co-administration of tenofovir disoproxil and didanosine is not recommended as it results in a 40-60% increase in systemic exposure to didanosine that may increase the risk of didanosine-related adverse reactions (see section 4.5). Rarely, pancreatitis and lactic acidosis, sometimes fatal, have been reported.

Lipids, lipodystrophy and metabolic abnormalities: CART has been associated with metabolic abnormalities such as hypertriglyceridaemia, hypercholesterolaemia, insulin resistance, hyperglycaemia and hyperlactataemia (see section 4.4).

CART has been associated with redistribution of body fat (lipodystrophy) in HIV patients including the loss of peripheral and facial subcutaneous fat, increased intra-abdominal and visceral fat, breast hypertrophy and dorsocervical fat accumulation (buffalo hump) (see section 4.4).

In a 144-week controlled clinical study in antiretroviral-naive adult patients that compared tenofovir disoproxil with stavudine in combination with lamivudine and efavirenz, patients who received tenofovir disoproxil had a significantly lower incidence of lipodystrophy compared with patients who received stavudine. The tenofovir disoproxil arm also had significantly smaller mean increases in fasting triglycerides and total cholesterol than the comparator arm.

Immune reactivation syndrome: In HIV infected patients with severe immune deficiency at the time of initiation of CART, an inflammatory reaction to asymptomatic or residual opportunistic infections may arise. Autoimmune disorders (such as Graves’ disease) have also been reported; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment (see section 4.4).

Osteonecrosis: Cases of osteonecrosis have been reported, particularly in patients with generally acknowledged risk factors, advanced HIV disease or long-term exposure to CART. The frequency of this is unknown (see section

4.4).

Lactic acidosis and severe hepatomegaly with steatosis: Lactic acidosis, usually associated with hepatic steatosis, has been reported with the use of nucleoside analogues. Treatment with nucleoside analogues should be discontinued in the setting of symptomatic hyperlactataemia and metabolic/lactic acidosis, progressive hepatomegaly, or rapidly elevating aminotransferase levels (see section 4.4).

Hepatitis B:

Exacerbations of hepatitis during treatment: In studies with nucleoside-naive patients, on-treatment ALT elevations > 10 times ULN (upper limit of normal) and > 2 times baseline occurred in 2.6% of tenofovir disoproxil-treated patients. ALT elevations had a median time to onset of 8 weeks, resolved with continued treatment, and, in a majority of cases, were associated with a > 2 log10 copies/ml reduction in viral load that preceded or coincided with the ALT elevation. Periodic monitoring of hepatic function is recommended during treatment (see section 4.4).

Exacerbations of hepatitis after discontinuation of treatment: In HBV infected patients, clinical and laboratory evidence of exacerbations of hepatitis have occurred after discontinuation of HBV therapy (see section 4.4).

Paediatric population

HIV-1

Assessment of adverse reactions is based on two randomised trials (studies GS-US-104-0321 and GS-US-104-0352) in 184 HIV-1 infected paediatric patients (aged 2 to < 18 years) who received treatment with tenofovir disoproxil (n = 93) or placebo/active comparator (n = 91) in combination with other antiretroviral agents for 48 weeks (see section 5.1). The adverse reactions observed in paediatric patients who received treatment with tenofovir disoproxil were consistent with those observed in clinical studies of tenofovir disoproxil in adults (see section 4.8 Tabulated summary of adverse reactions and 5.1).

Reductions in BMD have been reported in paediatric patients. In HIV-1 infected adolescents, the BMD Z-scores observed in subjects who received tenofovir disoproxil were lower than those observed in subjects who received placebo. In HIV-1 infected children, the BMD Z-scores observed in subjects who switched to tenofovir disoproxil were lower than those observed in subjects who remained on their stavudine- or zidovudine-containing regimen (see sections 4.4 and 5.1).

Of 89 patients (2 to < 12 years) who received tenofovir disoproxil in study GS-US-104-0352 (median exposure 104 weeks), 4 patients discontinued from the study due to adverse reactions consistent with proximal renal tubulopathy

Chronic hepatitis B

Assessment of adverse reactions is based on one randomised study (study GS-US-174-0115) in 106 adolescent patients (12 to < 18 years of age) with chronic hepatitis B receiving treatment with tenofovir disoproxil 245 mg (as fumarate) (n = 52) or placebo (n = 54) for 72 weeks. The adverse reactions observed in adolescent patients who received treatment with tenofovir disoproxil were consistent with those observed in clinical studies of tenofovir disoproxil in adults (see section 4.8 Tabulated summary of adverse reactions and 5.1).

Reductions in BMD have been observed in HBV infected adolescents. The BMD Z-scores observed in subjects who received tenofovir disoproxil were lower than those observed in subjects who received placebo (see sections 4.4 and 5.1).

Other special populations

Elderly: Tenofovir disoproxil has not been studied in patients over the age of 65. Elderly patients are more likely to have decreased renal function; therefore caution should be exercised when treating elderly patients with tenofovir disoproxil (see section 4.4).

Renal impairment: Since tenofovir disoproxil can cause renal toxicity, close monitoring of renal function is recommended in any patient with renal impairment treated with Tenofovir disoproxil Teva (see sections 4.2, 4.4 and 5.2). The use of tenofovir disoproxil is not recommended in paediatric patients with renal impairment (see sections 4.2 and 4.4).

Reporting of suspected adverse reactions

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. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

4.9 Overdose Symptoms

If overdose occurs the patient must be monitored for evidence of toxicity (see sections 4.8 and 5.3), and standard supportive treatment applied as necessary.

Management

Tenofovir can be removed by haemodialysis; the median haemodialysis clearance of tenofovir is 134 ml/min. It is not known whether tenofovir can be removed by peritoneal dialysis.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antiviral for systemic use; nucleoside and nucleotide reverse transcriptase inhibitors, ATC code: J05AF07

Mechanism of action and pharmacodynamic effects: Tenofovir disoproxil phosphate is the phosphate salt of the prodrug tenofovir disoproxil. Tenofovir disoproxil is absorbed and converted to the active substance tenofovir, which is a nucleoside monophosphate (nucleotide) analogue. Tenofovir is then converted to the active metabolite, tenofovir diphosphate, an obligate chain terminator, by constitutively expressed cellular enzymes. Tenofovir diphosphate has an intracellular half-life of 10 hours in activated and 50 hours in resting peripheral blood mononuclear cells (PBMCs). Tenofovir diphosphate inhibits HIV-1 reverse transcriptase and the HBV polymerase by direct binding competition with the natural deoxyribonucleotide substrate and, after incorporation into DNA, by DNA chain termination. Tenofovir diphosphate is a weak inhibitor of cellular polymerases a, P, and y. At concentrations of up to 300 pmol/l, tenofovir has also shown no effect on the synthesis of mitochondrial DNA or the production of lactic acid in in vitro assays.

Data pertaining to HIV:

HIV antiviral activity in vitro: The concentration of tenofovir required for 50% inhibition (EC₅₀) of the wild-type laboratory strain HIV-1 _IIIB is 1-6 pmol/l in lymphoid cell lines and 1.1 pmol/l against primary HIV-1 subtype B isolates in PBMCs. Tenofovir is also active against HIV-1 subtypes A, C, D, E, F, G, and O and against HIV_BaL in primary monocyte/macrophage cells. Tenofovir shows activity in vitro against HIV-2, with an EC50 of 4.9 ^mol/l in MT-4 cells.

Resistance: Strains of HIV-1 with reduced susceptibility to tenofovir and a K65R mutation in reverse transcriptase have been selected in vitro and in some patients (see Clinical efficacy and safety). Tenofovir disoproxil should be avoided in antiretroviral-experienced patients with strains harbouring the K65R mutation (see section 4.4). In addition, a K70E substitution in HIV-1 reverse transcriptase has been selected by tenofovir and results in low-level reduced susceptibility to tenofovir.

Clinical studies in treatment-experienced patients have assessed the anti-HIV activity of tenofovir disoproxil 245 mg against strains of HIV-1 with resistance to nucleoside inhibitors. The results indicate that patients whose HIV expressed 3 or more thymidine-analogue associated mutations (TAMs) that included either the M41L or L210W reverse transcriptase mutation showed reduced response to tenofovir disoproxil 245 mg therapy.

Clinical efficacy and safety: The effects of tenofovir disoproxil in treatment-experienced and treatment-naive HIV-1 infected adults have been demonstrated in trials of 48 weeks and 144 weeks duration, respectively.

In study GS-99-907, 550 treatment-experienced adult patients were treated with placebo or tenofovir disoproxil 245 mg for 24 weeks. The mean baseline CD4 cell count was 427 cells/mm³, the mean baseline plasma HIV-1 RNA was 3.4 log₁₀ copies/ml (78% of patients had a viral load of < 5,000 copies/ml) and the mean duration of prior HIV treatment was 5.4 years. Baseline genotypic analysis of HIV isolates from 253 patients revealed that 94% of patients had HIV-1 resistance mutations associated with nucleoside reverse transcriptase inhibitors, 58% had mutations associated with protease inhibitors and 48% had mutations associated with non-nucleoside reverse transcriptase inhibitors.

At week 24 the time-weighted average change from baseline in log10 plasma HIV-1 RNA levels (DAVG24) was -0.03 log₁₀ copies/ml and -0.61 log₁₀ copies/ml for the placebo and tenofovir disoproxil 245 mg recipients (p < 0.0001). A statistically significant difference in favour of tenofovir disoproxil 245 mg was seen in the time-weighted average change from baseline at week 24 (DAVG₂₄) for CD4 count (+13 cells/mm³ for tenofovir disoproxil 245 mg versus -11 cells/mm³ for placebo, p-value = 0.0008). The antiviral response to tenofovir disoproxil was durable through 48 weeks (DAVG₄₈ was -0.57 log₁₀ copies/ml, proportion of patients with HIV-1 RNA below 400 or 50 copies/ml was 41% and 18% respectively). Eight (2%) tenofovir disoproxil 245 mg treated patients developed the K65R mutation within the first 48 weeks.

The 144-week, double-blind, active controlled phase of study GS-99-903 evaluated the efficacy and safety of tenofovir disoproxil 245 mg versus stavudine when used in combination with lamivudine and efavirenz in HIV-1 infected patients naive to antiretroviral therapy. The mean baseline CD4 cell count was 279 cells/mm³, the mean baseline plasma HIV-1 RNA was 4.91 log₁₀ copies/ml, 19% of patients had symptomatic HIV-1 infection and 18% had AIDS. Patients were stratified by baseline HIV-1 RNA and CD4 count. Forty-three percent of patients had baseline viral loads > 100,000 copies/ml and 39% had CD4 cell counts < 200 cells/ml.

By intent to treat analysis (missing data and switch in antiretroviral therapy (ART) considered as failure), the proportion of patients with HIV-1 RNA below 400 copies/ml and 50 copies/ml at 48 weeks of treatment was 80% and 76% respectively in the tenofovir disoproxil 245 mg arm, compared to 84% and 80% in the stavudine arm. At 144 weeks, the proportion of patients with HIV-1 RNA below 400 copies/ml and 50 copies/ml was 71% and 68% respectively in the tenofovir disoproxil 245 mg arm, compared to 64% and 63% in the stavudine arm.

The average change from baseline for HIV-1 RNA and CD4 count at 48 weeks of treatment was similar in both treatment groups (-3.09 and -3.09 log₁₀

3

copies/ml; +169 and 167 cells/mm in the tenofovir disoproxil 245 mg and stavudine groups, respectively). At 144 weeks of treatment, the average change from baseline remained similar in both treatment groups (-3.07 and -3.03 log₁₀ copies/ml; +263 and +283 cells/mm³ in the tenofovir disoproxil 245 mg and stavudine groups, respectively). A consistent response to treatment with tenofovir disoproxil 245 mg was seen regardless of baseline HIV-1 RNA and CD4 count.

The K65R mutation occurred in a slightly higher percentage of patients in the tenofovir disoproxil group than the active control group (2.7% versus 0.7%). Efavirenz or lamivudine resistance either preceded or was coincident with the development of K65R in all cases. Eight patients had HIV that expressed K65R in the tenofovir disoproxil 245 mg arm, 7 of these occurred during the first 48 weeks of treatment and the last one at week 96. No further K65R development was observed up to week 144. One patient in the tenofovir disoproxil arm developed the K70E substitution in the virus. From both the genotypic and phenotypic analyses there was no evidence for other pathways of resistance to tenofovir.

Data pertaining to HBV:

HBVantiviral activity in vitro: The in vitro antiviral activity of tenofovir against HBV was assessed in the HepG2 2.2.15 cell line. The EC₅₀ values for tenofovir were in the range of 0.14 to 1.5 ^mol/l, with CC₅₀ (50% cytotoxicity concentration) values > 100 ^mol/l.

Resistance: No HBV mutations associated with tenofovir disoproxil resistance have been identified (see Clinical efficacy and safety). In cell based assays, HBV strains expressing the rtV173L, rtL180M, and rtM204I/V mutations associated with resistance to lamivudine and telbivudine showed a susceptibility to tenofovir ranging from 0.7- to 3.4-fold that of wild-type virus. HBV strains expressing the rtL180M, rtT184G, rtS202G/I, rtM204V and rtM250V mutations associated with resistance to entecavir showed a susceptibility to tenofovir ranging from 0.6- to 6.9-fold that of wild-type virus. HBV strains expressing the adefovir-associated resistance mutations rtA181V

and rtN236T showed a susceptibility to tenofovir ranging from 2.9- to 10-fold that of wild-type virus. Viruses containing the rtA181T mutation remained susceptible to tenofovir with EC₅₀ values 1.5-fold that of wild-type virus.

Clinical efficacy and safety: The demonstration of benefit of tenofovir disoproxil in compensated and decompensated disease is based on virological, biochemical and serological responses in adults with HBeAg positive and HBeAg negative chronic hepatitis B. Treated patients included those who were treatment-naive, lamivudine-experienced, adefovir dipivoxil-experienced and patients with lamivudine and/or adefovir dipivoxil resistance mutations at baseline. Benefit has also been demonstrated based on histological responses in compensated patients.

Experience in patients with compensated liver disease at 48 weeks (studies GS-US-174-0102 and GS-US-174-0103): Results through 48 weeks from two randomised, phase 3 double-blind studies comparing tenofovir disoproxil to adefovir dipivoxil in patients with compensated liver disease are presented in Table 3 below. Study GS-US-174-0103 was conducted in 266 (randomised and treated) HBeAg positive patients while study GS-US-174-0102 was conducted in 375 (randomised and treated) patients negative for HBeAg and positive for HBeAb.

In both of these studies tenofovir disoproxil was significantly superior to adefovir dipivoxil for the primary efficacy endpoint of complete response (defined as HBV DNA levels < 400 copies/ml and Knodell necroinflammatory score improvement of at least 2 points without worsening in Knodell fibrosis). Treatment with tenofovir disoproxil 245 mg was also associated with significantly greater proportions of patients with HBV DNA < 400 copies/ml, when compared to adefovir dipivoxil 10 mg treatment. Both treatments produced similar results with regard to histological response (defined as Knodell necroinflammatory score improvement of at least 2 points without worsening in Knodell fibrosis) at week 48 (see Table 3 below).

In study GS-US-174-0103 a significantly greater proportion of patients in the tenofovir disoproxil group than in the adefovir dipivoxil group had normalised ALT and achieved HBsAg loss at week 48 (see Table 3 below).

Table 3: Efficacy parameters in compensated HBeAg negative and HBeAg positive patients at week 48

	Study 174-0102 (HBeAg negative)		Study 174-0103 (HBeAg positive)
Parameter	Tenofovir disoproxil 245 mg n = 250	Adefovir dipivoxil 10 mg n = 125	Tenofovir disoproxil 245 mg n = 176	Adefovir dipivoxil 10 mg n = 90
Complete response (%)a	71*	49	67*	12
Histology Histological response (%)b	72	69	74	68

Median HBV DNA reduction from baselinec (log10 copies/ml)	-4.7*	-4.0	-6.4*	-3.7
HBV DNA (%) < 400 copies/ml (< 69 IU/ml)	93*	63	76*	13
ALT (%) Normalised ALTd	76	77	68*	54
Serology (%)
HBeAg loss/seroconve	n/a	n/a	22/21	18/18
rsion HBsAg loss/seroconve rsion	0/0	0/0	3*/1	0/0

* p-value versus adefovir dipivoxil < 0.05.

^a Complete response defined as HBV DNA levels < 400 copies/ml and Knodell necroinflammatory score improvement of at least 2 points without worsening in Knodell fibrosis. ^b Knodell necroinflammatory score improvement of at least 2 points without worsening in Knodell fibrosis.

^c Median change from baseline HBV DNA merely reflects the difference between baseline HBV DNA and the limit of detection (LOD) of the assay.

^d The population used for analysis of ALT normalisation included only patients with ALT above ULN

at baseline.

n/a = not applicable.

Tenofovir disoproxil was associated with significantly greater proportions of patients with undetectable HBV DNA (< 169 copies/ml [< 29 IU/ml]; the limit of quantification of the Roche Cobas Taqman HBV assay), when compared to adefovir dipivoxil (study GS-US-174-0102; 91%, 56% and study GS-US-174-0103; 69%, 9%), respectively.

Response to treatment with tenofovir disoproxil was comparable in nucleoside-experienced (n = 51) and nucleoside-naive (n = 375) patients and in patients with normal ALT (n = 21) and abnormal ALT (n = 405) at baseline when studies GS-US-174-0102 and GS-US-174-0103 were combined. Forty-nine of the 51 nucleoside-experienced patients were previously treated with lamivudine. Seventy-three percent of nucleoside-experienced and 69% of nucleoside-naive patients achieved complete response to treatment; 90% of nucleoside-experienced and 88% of nucleoside-naive patients achieved HBV DNA suppression < 400 copies/ml. All patients with normal ALT at baseline and 88% of patients with abnormal ALT at baseline achieved HBV DNA suppression < 400 copies/ml.

Experience beyond 48 weeks in studies GS-US-174-0102 and GS-US-174-0103: In studies GS-US-174-0102 and GS-US-174-0103, after receiving double-blind treatment for 48 weeks (either tenofovir disoproxil 245 mg or adefovir dipivoxil 10 mg), patients rolled over with no interruption in treatment to open-label tenofovir disoproxil. In studies GS-US-174-0102 and GS-US-174-0103, 77% and 61% of patients continued in the study through to 384 weeks, respectively. At weeks 96, 144, 192, 240,288 and 384 viral suppression, biochemical and serological responses were maintained with continued tenofovir disoproxil treatment (see Table 4 and 5 below).

Table 4: Efficacy parameters in compensated HBeAg negative patients at week 96, 144, 192, 240, 288 and 384 open-label treatment

Study 174-0102 (HBeAg negative)

Parametera

Tenofovir disoproxil 245 mg n = 250

Adefovir dipivoxil 10 mg roll over to tenofovir disoproxil 245 mg

n

= 125

Week

96 b

114

192

240 i

28

38

96

114 f

192

240

288m

38

e

g

8*

4o

c

h

j

4p

HBV DNA (%) <400 copies/ml (<69IU/ml )

90

87

84

83

80

74

89

88

87

84

84

76

ALT (%) Normalise d ALTd

72

73

67

70

68

64

68

70

77

76

74

69

Serology (%)

n/a

n/a

n/a

n/a

n/a

n/

n/

n/a

n/a

n/a

n/a

n/a

HBeAg loss/

a

a

0/0k

seroconver sion

0/0

0/0

0/0

0/0

0/0

1/

0/

0/0

0/0

1/1n

1/1n

1n

0

HBsAg loss/

seroconver

sion

^a Based upon Long Term Evaluation algorithm (LTE Analysis) - Patients who discontinued the study at any time prior to week 288 due to a protocol defined endpoint, as well as those completing week 288, are included in the denominator.

^b 48 weeks double-blind tenofovir disoproxil followed by 48 weeks open-label. ^c 48 weeks double-blind adefovir dipivoxil followed by 48 weeks open-label tenofovir disoproxil. ^d The population used for analysis of ALT normalisation included only patients with ALT above ULN at baseline.

^e 48 weeks double-blind tenofovir disoproxil followed by 96 weeks open-label. ^f 48 weeks double-blind adefovir dipivoxil followed by 96 weeks open-label tenofovir disoproxil. ^g 48 weeks double-blind tenofovir disoproxil followed by 144 weeks open-label. ^h 48 weeks double-blind adefovir dipivoxil followed by 144 weeks open-label tenofovir disoproxil. ⁱ 48 weeks double-blind tenofovir disoproxil followed by 192 weeks open-label.

^J 48 weeks double-blind adefovir dipivoxil followed by 192 weeks open-label tenofovir disoproxil. ^k One patient in this group became HBsAg negative for the first time at the 240 week visit and was ongoing in the study at the time of the data cut-off. However, the subject’s HBsAg loss was ultimately confirmed at the subsequent visit.

^l 48 weeks double-blind tenofovir disoproxil followed by 240 weeks open-label. ^m 48 weeks double-blind adefovir dipivoxil followed by 240 weeks open-label tenofovir disoproxil. ⁿ Figures presented are cumulative percentages based upon a Kaplan Meier analysis excluding data collected after the addition of emtricitabine to open-label tenofovir disoproxil (KM-TDF). ^o 48 weeks of double-blind tenofovir disoproxil fumarate followed by 336 weeks open-label.

^p 48 weeks of double-blind adefovir dipivoxil followed by 336 weeks open-label tenofovir disoproxil fumarate.

n/a = not applicable.

Table 5: Efficacy parameters in compensated HBeAg positive patients at week 96, 144, 192, 240, 288 and 384 open-label treatment

	Study 174-0103 (HBeAg positive)
Parameter1	Tenofovir disoproxil 245 mg n = 176						Adefovir dipivoxil 10 mg roll over to tenofovir disoproxil 245 mg n = 90
Week	96 b	114 e	192 h	240 j	288m	384o	96 c	114 f	192 i	240 k	288n	384p
HBV DNA (%) <400 copies/ml (<69IU/ml)	76	72	68	64	61	56	74	71	72	66	65	61
ALT (%) Normalised ALTd	60	55	56	46	47	47	65	61	59	56	57	56
Serology (%) HBeAg loss/ seroconversion HBsAg loss/ seroconversion	26/ 23 5/4	29/ 23 8/ 6g	34/ 25 11/ 8g	38/ 30 11/ 8l	37/ 25 12/ 8l	30/ 20 15/ 12l	24/ 20 6/5	33/ 26 8/ 7g	36/ 30 8/ 7g	38/ 31 10/ 10l	40/ 31 11/ 10l	35/ 24 13/ 1f

^a Based upon Long Term Evaluation algorithm (LTE Analysis) - Patients who discontinued the study at any time prior to week 288 due to a protocol defined endpoint, as well as those completing week 288, are included in the denominator.

^b 48 weeks double-blind tenofovir disoproxil followed by 48 weeks open-label. ^c 48 weeks double-blind adefovir dipivoxil followed by 48 weeks open-label tenofovir disoproxil. ^d The population used for analysis of ALT normalisation included only patients with ALT above ULN at baseline.

^e 48 weeks double-blind tenofovir disoproxil followed by 96 weeks open-label. ^f 48 weeks double-blind adefovir dipivoxil followed by 96 weeks open-label tenofovir disoproxil. ^g Figures presented are cumulative percentages based upon a Kaplan Meier analysis including data collected after the addition of emtricitabine to open-label tenofovir disoproxil (KM-ITT). ^h 48 weeks double-blind tenofovir disoproxil followed by 144 weeks open-label.

¹ 48 weeks double-blind adefovir dipivoxil followed by 144 weeks open-label tenofovir disoproxil.

^J 48 weeks double-blind tenofovir disoproxil followed by 192 weeks open-label. ^k 48 weeks double-blind adefovir dipivoxil followed by 192 weeks open-label tenofovir disoproxil.

' Figures presented are cumulative percentages based upon a Kaplan Meier analysis excluding data collected after the addition of emtricitabine to open-label tenofovir disoproxil (KM-TDF). ^m 48 weeks double-blind tenofovir disoproxil followed by 240 weeks open-label. ⁿ 48 weeks double-blind adefovir dipivoxil followed by 240 weeks open-label tenofovir disoproxil. ^o 48 weeks of double-blind tenofovir disoproxil fumarate followed by 336 weeks open-label. ^p 48 weeks of double-blind adefovir dipivoxil followed by 336 weeks open-label tenofovir disoproxil fumarate.

Paired baseline and week 240 liver biopsy data were available for 331/489 patients who remained in studies GS-US-174-0102 and GS-US-174-0103 (see Table 6 below). Ninety-five percent (225/237) of patients without cirrhosis at baseline and 99% (93/94) of patients with cirrhosis at baseline had either no change or an improvement in fibrosis (Ishak fibrosis score). Of the 94 patients with cirrhosis at baseline (Ishak fibrosis score 5-6), 26% (24) experienced no change in Ishak fibrosis score and 72% (68) experienced regression of cirrhosis by week 240 with a reduction in Ishak fibrosis score of at least 2 points.

Table 6: Histological response (%) in compensated HBeAg negative and HBeAg positive subjects at week 240 compared to baseline

	Study 174-0102		Study 174-0103
	(HBeAg	negative)	(HBeAg positive)
	Tenofovir	Adefovir dipivoxil	Tenofovir	Adefovir
	disoproxil	10 mg roll over to	disoproxil 245 mg	dipivoxil
	245 mg n = 250c	tenofovir disoproxil 245 mg n = 125d	kO r-» II	10 mg roll over to tenofovir disoproxil 245 mg n = 90d
Histological	88	85	90	92
responsea’ b (%)	[130/148]	[63/74]	[63/70]	[36/39]

^a The population used for analysis of histology included only patients with available liver biopsy data (Missing = Excluded) by week 240. Response after addition of emtricitabine is excluded (total of 17 subjects across both studies).

^b Knodell necroinflammatory score improvement of at least 2 points without worsening in Knodell fibrosis score.

^c 48 weeks double-blind tenofovir disoproxil followed by up to 192 weeks open-label.

^d 48 weeks double-blind adefovir dipivoxil followed by up to 192 weeks open-label tenofovir

disoproxil.

Experience in patients with HIV co-infection and prior lamivudine experience: In a randomised, 48-week double-blind, controlled study of tenofovir disoproxil 245 mg in adult patients co-infected with HIV-1 and chronic hepatitis B with prior lamivudine experience (study ACTG 5127), the mean serum HBV DNA levels at baseline in patients randomised to the tenofovir arm were 9.45 log₁₀ copies/ml (n = 27). Treatment with tenofovir disoproxil 245 mg was associated with a mean change in serum HBV DNA from baseline, in the patients for whom there was 48-week data, of -5.74 log₁₀ copies/ml (n = 18). In addition, 61% of patients had normal ALT at week 48.

Experience in patients with persistent viral replication (study GS-US-174-0106):

The efficacy and safety of tenofovir disoproxil 245 mg or tenofovir disoproxil 245 mg plus 200 mg emtricitabine has been evaluated in a randomised, double-blind study (study GS-US-174-0106), in HBeAg positive and HBeAg negative adult patients who had persistent viraemia (HBV DNA > 1,000 copies/ml) while receiving adefovir dipivoxil 10 mg for more than 24 weeks. At baseline, 57% of patients randomised to tenofovir disoproxil versus 60% of patients randomised to emtricitabine plus tenofovir disoproxil treatment group had previously been treated with lamivudine. Overall at week 24, treatment with tenofovir disoproxil resulted in 66% (35/53) of patients with HBV DNA < 400 copies/ml (< 69 IU/ml) versus 69% (36/52) of patients treated with emtricitabine plus tenofovir disoproxil (p = 0.672). In addition 55% (29/53) of patients treated with tenofovir disoproxil had undetectable HBV DNA (< 169 copies/ml [< 29 IU/ml]; the limit of quantification of the Roche Cobas TaqMan HBV assay) versus 60% (31/52) of patients treated with emtricitabine plus tenofovir disoproxil (p = 0.504). Comparisons between treatment groups beyond week 24 are difficult to interpret since investigators had the option to intensify treatment to open-label emtricitabine plus tenofovir disoproxil. Longterm studies to evaluate the benefit/risk of bitherapy with emtricitabine plus tenofovir disoproxil in HBV monoinfected patients are ongoing.

Experience in patients with decompensated liver disease at 48 weeks GS-US-174-0108:

Study GS-US-174-0108 is a randomised, double-blind, active controlled study evaluating the safety and efficacy of tenofovir disoproxil (n = 45), emtricitabine plus tenofovir disoproxil (n = 45), and entecavir (n = 22), in patients with decompensated liver disease. In the tenofovir disoproxil treatment arm, patients had a mean CPT score of 7.2, mean HBV DNA of 5.8 logi₀ copies/ml and mean serum ALT of 61 U/l at baseline. Forty-two percent (19/45) of patients had at least 6 months of prior lamivudine experience, 20% (9/45) of patients had prior adefovir dipivoxil experience and 9 of 45 patients (20%) had lamivudine and/or adefovir dipivoxil resistance mutations at baseline. The co-primary safety endpoints were discontinuation due to an adverse event and confirmed increase in serum creatinine > 0.5 mg/dl or confirmed serum phosphate of < 2 mg/dl.

In patients with CPT scores < 9, 74% (29/39) of tenofovir disoproxil, and 94% (33/35) of emtricitabine plus tenofovir disoproxil treatment groups achieved HBV DNA < 400 copies/ml after 48 weeks of treatment.

Overall, the data derived from this study are too limited to draw any definitive conclusions on the comparison of emtricitabine plus tenofovir disoproxil versus tenofovir disoproxil, (see Table 7 below).

Table 7: Safety and efficacy parameters in decompensated patients at week 48

Study 174-0108
Parameter	Tenofovir disoproxil 245 mg (n = 45)	Emtricitabine 200 mg/ tenofovir disoproxil 245 mg (n = 45)	Entecavir (0.5 mg or 1 mg) n = 22
Tolerability failure (permanent discontinuation of study drug to a treatment emergent AE) n (%)a	3 (7%)	2 (4%)	2 (9%)
Confirmed increase in serum creatinine > 0.5 mg/dl from baseline or confirmed serum phosphate of < 2 mg/dl n (%)b	4 (9%)	3 (7%)	1 (5%)
HBV DNA n (%) < 400 copies/ml n (%)	31/44 (70%)	36/41 (88%)	16/22 (73%)
ALT n(%) Normal ALT	25/44 (57%)	31/41 (76%)	12/22 (55%)

> 2 point decrease in CPT from baseline n (%)	7/27 (26%)	12/25 (48%)	5/12 (42%)
Mean change from baseline in CPT score	-0.8	-0.9	-1.3
Mean change from baseline in MELD score	-1.8	-2.3	-2.6

^a p-value comparing the combined tenofovir -containing arms versus the entecavir arm = 0.622, ^b p-value comparing the combined tenofovir -containing arms versus the entecavir arm = 1.000.

Experience beyond 48 weeks in study GS-US-174-0108 Using a noncompleter/switch = failure analysis, 50% (21/42) of subjects receiving tenofovir disoproxil fumarate, 76% (28/37) of subjects receiving emtricitabine plus tenofovir disoproxil fumarate and 52% (11/21) of subjects receiving entecavir achieved HBV DNA < 400 copies/ml at week 168.

Experience in patients with lamivudine-resistant HBV at 96 weeks (study GS-US-174-0121)

The efficacy and safety of 245 mg tenofovir disoproxil was evaluated in a randomised, double-blind study (GS-US-174-0121) in HBeAg positive and HBeAg negative patients (n = 280) with compensated liver disease, viraemia (HBV DNA > 1,000 IU/ml), and genotypic evidence of lamivudine resistance (rtM204I/V +/- rtL180M). Only five had adefovir-associated resistance mutations at baseline. One hundred forty-one and 139 adult subjects were randomised to a tenofovir disoproxil and emtricitabine plus tenofovir disoproxil treatment arm, respectively.

Baseline demographics were similar between the two treatment arms: At baseline, 52.5% of subjects were HBeAg negative, 47.5% were HBeAg positive, mean HBV DNA level was 6.5 log10 copies/ml, and mean ALT was 79 U/l, respectively.

After 96 weeks of treatment, 126 of 141 subjects (89%) randomised to tenofovir disoproxil had HBV DNA < 400 copies/ml, and 49 of 79 subjects (62%) had ALT normalisation. After 96 weeks of treatment with emtricitabine plus tenofovir disoproxil, 120 of 139 subjects (86%) had HBV DNA < 400 copies/ml, and 52 of 83 subjects (63%) had ALT normalisation. Among the HBeAg positive subjects randomised to tenofovir disoproxil, 10 of 65 subjects (15%) experienced HBeAg loss, and 7 of 65 subjects (11%) experienced anti-HBe seroconversion through week 96. In the HBeAg positive subjects randomised to emtricitabine plus tenofovir disoproxil, 9 of 68 subjects (13%) experienced HBeAg loss, and 7 of 68 subjects (10%) experienced anti-HBe seroconversion through week 96. No subject randomised to tenofovir disoproxil experienced HBsAg loss or seroconversion to anti-HBs. One subject randomised to emtricitabine plus tenofovir disoproxil experienced HBsAg loss.

Clinical resistance:

Four hundred and twenty-six HBeAg negative (GS-US-174-0102, n = 250) and HBeAg positive (GS-US-174-0103, n = 176) patients initially randomised to double-blind tenofovir disoproxil treatment and the switched to open-label tenofovir disoproxil treatment were evaluated for genotypic changes in HBV polymerase from baseline. Genotypic evaluations performed on all patients with HBV DNA > 400 copies/ml at week 48 (n = 39), 96 (n = 24), 144 (n = 6), 192 (n = 5), 240 (n = 4), 288 (n=6) and 384 (n=2) on tenofovir disoproxil monotherapy, showed that no mutations associated with tenofovir disoproxil resistance have developed.

Two hundred and fifteen HBeAg negative (GS-US-174-0102, n = 125) and HBeAg positive (GS-US-174-0103, n = 90) patients initially randomised to double-blind adefovir dipivoxil treatment and then switched to open-label tenofovir disoproxil treatment were evaluated for genotypic changes in HBV polymerase from baseline. Genotypic evaluations performed on all patients with HBV DNA > 400 copies/ml at week 48 (n=16), 96 (n=5), 144 (n=1), 192 (n=2), 240 (n=1), 288 (n=1) and 384 (n=2) of tenofovir disoproxil monotherapy showed that no mutations associated with tenofovir disoproxil resistance have developed.

In study GS-US-174-0108, 45 patients (including 9 patients with lamivudine and/or adefovir dipivoxil resistance mutations at baseline) received tenofovir disoproxil for up to 168 weeks. Genotypic data from paired baseline and on treatment HBV isolates were available for 6/8 patients with HBV DNA > 400 copies/ml at week 48. No amino acid substitutions associated with resistance to tenofovir disoproxil were identified in these isolates. Genotypic analysis was conducted for 5 subjects in the tenofovir disoproxil arm post week 48. No amino acid substitutions associated with tenofovir disoproxil resistance were detected in any subject.

In study GS-US-174-0121, 141 patients with lamivudine resistance substitutions at baseline received tenofovir disoproxil for up to 96 weeks. Genotypic data from paired baseline and on treatment HBV isolates were available for 6 of 9 patients with HBV DNA > 400 copies/ml at their last time point on tenofovir disoproxil. No amino acid substitutions associated with resistance to tenofovir disoproxil were identified in these isolates.

In a paediatric study (GS-US-174-0115), 52 patients (including 6 patients with lamivudine resistance mutations at baseline) received tenofovir disoproxil for up to 72 weeks. Genotypic evaluations were performed on all patients with HBV DNA > 400 copies/ml at week 48 (n = 6) and week 72 (n = 5). No amino acid substitutions associated with resistance to tenofovir disoproxil fumarate were identified in these isolates.

Paediatric population:

HIV-1: In study GS-US-104-0321, 87 HIV-1 infected treatment-experienced patients 12 to < 18 years of age were treated with tenofovir disoproxil (n = 45) or placebo (n = 42) in combination with an optimised background regimen (OBR) for 48 weeks. Due to limitations of the study, a benefit of tenofovir disoproxil over placebo was not demonstrated based on plasma HIV-1 RNA levels at week 24. However, a benefit is expected for the adolescent population based on extrapolation of adult data and comparative pharmacokinetic data (see section 5.2).

In patients who received treatment with tenofovir disoproxil or placebo, mean lumbar spine BMD Z-score was -1.004 and -0.809, and mean total body BMD Z-score was -0.866 and -0.584, respectively, at baseline. Mean changes at week 48 (end of double-blind phase) were -0.215 and -0.165 in lumbar spine BMD Z-score, and -0.254 and -0.179 in total body BMD Z-score for the tenofovir disoproxil and placebo groups, respectively. The mean rate of BMD gain was less in the tenofovir disoproxil group compared to the placebo group. At week 48, six adolescents in the tenofovir disoproxil group and one adolescent in the placebo group had significant lumbar spine BMD loss (defined as > 4% loss). Among 28 patients receiving 96 weeks of treatment with tenofovir disoproxil, BMD Z-scores declined by -0.341 for lumbar spine and -0.458 for total body.

In study GS-US-104-0352, 97 treatment-experienced patients 2 to < 12 years of age with stable, virologic suppression on stavudine- or zidovudine-containing regimens were randomised to either replace stavudine or zidovudine with tenofovir disoproxil (n = 48) or continue on their original regimen (n = 49) for 48 weeks. At week 48, 83% of patients in the tenofovir disoproxil treatment group and 92% of patients in the stavudine or zidovudine treatment group had HIV-1 RNA concentrations < 400 copies/ml. The difference in the proportion of patients who maintained < 400 copies/ml at week 48 was mainly influenced by the higher number of discontinuations in the tenofovir disoproxil treatment group. When missing data were excluded, 91% of patients in the tenofovir disoproxil treatment group and 94% of patients in the stavudine or zidovudine treatment group had HIV-1 RNA concentrations < 400 copies/ml at week 48.

Reductions in BMD have been reported in paediatric patients. In patients who received treatment with tenofovir disoproxil , or stavudine or zidovudine, mean lumbar spine BMD Z-score was -1.034 and -0.498, and mean total body BMD Z-score was -0.471 and -0.386, respectively, at baseline.

Mean changes at week 48 (end of randomised phase) were 0.032 and 0.087 in lumbar spine BMD Z-score, and -0.184 and -0.027 in total body BMD Z-score for the tenofovir disoproxil and stavudine or zidovudine groups, respectively. The mean rate of lumbar spine bone gain at week 48 was similar between the tenofovir disoproxil treatment group and the stavudine or zidovudine treatment group. Total body bone gain was less in the tenofovir disoproxil treatment group compared to the stavudine or zidovudine treatment group. One tenofovir disoproxil treated subject and no stavudine or zidovudine treated subjects experienced significant (> 4%) lumbar spine BMD loss at week 48. BMD Z-scores declined by -0.012 for lumbar spine and by -0.338 for total body in the 64 subjects who were treated with tenofovir disoproxil for 96 weeks. BMD Z-scores were not adjusted for height and weight.

In study GS-US-104-0352, 4 out of 89 paediatric patients exposed to tenofovir disoproxil discontinued due to adverse reactions consistent with proximal renal tubulopathy (median tenofovir disoproxil exposure 104 weeks).

Chronic hepatitis B: In study GS-US-174-0115, 106 HBeAg negative and HBeAg positive patients aged 12 to < 18 years with chronic HBV infection [HBV DNA > 10 ⁵ copies/ml, elevated serum ALT (> 2 x ULN) or a history of elevated serum ALT levels in the past 24 months] were treated with tenofovir disoproxil 245 mg (n = 52) or placebo (n = 54) for 72 weeks. Subjects must have been naive to tenofovir disoproxil , but could have received interferon based regimens (> 6 months prior to screening) or any other non-tenofovir disoproxil containing oral anti-HBV nucleoside/nucleotide therapy (> 16 weeks prior to screening). At week 72, overall 88% (46/52) of patients in the tenofovir disoproxil treatment group and 0% (0/54) of patients in the placebo group had HBV DNA < 400 copies/ml. Seventy-four percent (26/35) of patients in the tenofovir disoproxil group had normalised ALT at week 72 compared to 31% (13/42) in the placebo group. Response to treatment with tenofovir disoproxil was comparable in nucleos(t)ide-naive (n = 20) and nucleos(t)ide-experienced (n = 32) patients, including lamivudineresistant patients (n = 6). Ninety-five percent of nucleos(t)ide-naive patients, 84% of nucleos(t)ide-experienced patients, and 83% of lamivudine-resistant patients achieved HBV DNA < 400 copies/ml at week 72. Thirty-one of the 32 nucleos(t)ide-experienced patients had prior lamivudine experience. At week 72, 96% (27/28) of immune-active patients (HBV DNA > 10⁵ copies/ml, serum ALT> 1.5 x ULN) in the tenofovir disoproxil treatment group and 0% (0/32) of patients in the placebo group had HBV DNA < 400 copies/ml. Seventy-five percent (21/28) of immune-active patients in the tenofovir disoproxil group had normal ALT at week 72 compared to 34% (11/32) in the placebo group.

No subjects met the primary safety endpoint of a 6% decrease in lumbar spine BMD. In subjects receiving tenofovir disoproxil or placebo, mean (SD) lumbar spine BMD Z-score was -0.43 (0.764) and -0.28 (0.813), and mean total body BMD Z-score was -0.20 (1.126) and -0.26 (0.878), respectively, at baseline. The mean (SD) change in lumbar spine BMD Z-score from baseline to week 72 in subjects receiving tenofovir disoproxil was -0.05 (0.310) and 0.07 (0.377) in those receiving placebo. The mean change in whole body BMD Z-score in subjects receiving tenofovir disoproxil was -0.15 (0.379) and 0.06 (0.361) in those receiving placebo. BMD Z-scores were not adjusted for height and weight. The mean percentage increase in whole body and lumbar spine BMD from baseline to week 72 was 2.84% and 4.95%, respectively, in subjects receiving tenofovir disoproxil. These mean percentage increases in whole body and lumbar spine BMD were 2.53% and 3.19% less, respectively, when compared to subjects receiving placebo. Three subjects in the tenofovir disoproxil group and 2 subjects in the placebo group had a decrease of > 4% in spine BMD.

The European Medicines Agency has deferred the obligation to submit the results of studies with Tenofovir disoproxil in one or more subsets of the paediatric population in HIV chronic hepatitis B (see section 4.2 for information on paediatric use).

5.2 Pharmacokinetic properties

Tenofovir disoproxil phosphate is a water soluble ester prodrug which is rapidly converted in vivo to tenofovir.

Tenofovir is converted intracellularly to tenofovir monophosphate and to the active component, tenofovir diphosphate.

Absorption: Following oral administration of tenofovir disoproxil to HIV infected patients, tenofovir disoproxil is rapidly absorbed and converted to tenofovir. Administration of multiple doses of tenofovir disoproxil with a meal to HIV infected patients resulted in mean (%CV) tenofovir C_max, AUC_0-QO, and C_min values of 326 (36.6%) ng/ml, 3,324 (41.2%) ngh/ml and 64.4 (39.4%) ng/ml, respectively. Maximum tenofovir concentrations are observed in serum within one hour of dosing in the fasted state and within two hours when taken with food. The oral bioavailability of tenofovir from tenofovir disoproxil in fasted patients was approximately 25%. Administration of tenofovir disoproxil with a high fat meal enhanced the oral bioavailability, with an increase in tenofovir AUC by approximately 40% and C_max by approximately 14%. Following the first dose of tenofovir disoproxil in fed patients, the median Cmax in serum ranged from 213 to 375 ng/ml. However, administration of tenofovir disoproxil with a light meal did not have a significant effect on the pharmacokinetics of tenofovir.

Distribution: Following intravenous administration the steady-state volume of distribution of tenofovir was estimated to be approximately 800 ml/kg. After oral administration of tenofovir disoproxil, tenofovir is distributed to most tissues with the highest concentrations occurring in the kidney, liver and the intestinal contents (preclinical studies). In vitro protein binding of tenofovir to plasma or serum protein was less than 0.7 and 7.2%, respectively, over the tenofovir concentration range 0.01 to 25 pg/ml.

Biotransformation: In vitro studies have determined that neither tenofovir disoproxil nor tenofovir are substrates for the CYP450 enzymes. Moreover, at concentrations substantially higher (approximately 300-fold) than those observed in vivo, tenofovir did not inhibit in vitro drug metabolism mediated by any of the major human CYP450 isoforms involved in drug biotransformation (CYP3A4, CYP2D6, CYP2C9, CYP2E1, or CYP1A1/2). Tenofovir disoproxil at a concentration of 100 pmol/l had no effect on any of the CYP450 isoforms, except CYP1A1/2, where a small (6%) but statistically significant reduction in metabolism of CYP1A1/2 substrate was observed. Based on these data, it is unlikely that clinically significant interactions involving tenofovir disoproxil and medicinal products metabolised by CYP450 would occur.

Elimination: Tenofovir is primarily excreted by the kidney by both filtration and an active tubular transport system with approximately 70-80% of the dose excreted unchanged in urine following intravenous administration. Total clearance has been estimated to be approximately 230 ml/h/kg (approximately 300 ml/min). Renal clearance has been estimated to be approximately 160 ml/h/kg (approximately 210 ml/min), which is in excess of the glomerular filtration rate. This indicates that active tubular secretion is an important part of the elimination of tenofovir. Following oral administration the terminal half-life of tenofovir is approximately 12 to 18 hours.

Studies have established the pathway of active tubular secretion of tenofovir to be influx into proximal tubule cell by the human organic anion transporters (hOAT) 1 and 3 and efflux into the urine by the multidrug resistant protein 4 (MRP 4).

Linearity/non-linearity: The pharmacokinetics of tenofovir were independent of tenofovir disoproxil dose over the dose range 75 to 600 mg and were not affected by repeated dosing at any dose level.

Age: Pharmacokinetic studies have not been performed in the elderly (over 65 years of age).

Gender: Limited data on the pharmacokinetics of tenofovir in women indicate no major gender effect.

Ethnicity: Pharmacokinetics has not been specifically studied in different ethnic groups.

Paediatric population: HIV-1: Steady-state pharmacokinetics of tenofovir were evaluated in 8 HIV-1 infected adolescent patients (aged 12 to < 18 years) with body weight > 35 kg. Mean (± SD) C_max and AUC_tau are 0.38 ± 0.13 pg/ml and 3.39 ± 1.22 pgh/ml, respectively. Tenofovir exposure achieved in adolescent patients receiving oral daily doses of tenofovir disoproxil 245 mg was similar to exposures achieved in adults receiving once-daily doses of tenofovir disoproxil 245 mg.

Chronic hepatitis B: Steady-state tenofovir exposure in HBV infected adolescent patients (12 to < 18 years of age) receiving an oral daily dose of tenofovir disoproxil 245 mg was similar to exposures achieved in adults receiving once-daily doses of tenofovir disoproxil 245 mg.

Pharmacokinetic studies have not been performed with tenofovir disoproxil 245 mg tablets in children under 12 years or with renal impairment

Renal impairment: Pharmacokinetic parameters of tenofovir were determined following administration of a single dose of tenofovir disoproxil 245 mg to 40 non-HIV, non-HBV infected adult patients with varying degrees of renal impairment defined according to baseline creatinine clearance (CrCl) (normal renal function when CrCl > 80 ml/min; mild with CrCl = 50-79 ml/min; moderate with CrCl = 30-49 ml/min and severe with CrCl = 10-29 ml/min). Compared with patients with normal renal function, the mean (%CV) tenofovir exposure increased from 2,185 (12%) ngh/ml in subjects with CrCl > 80 ml/min to respectively 3,064 (30%) ngh/ml, 6,009 (42%) ngh/ml and 15,985 (45%) ngh/ml in patients with mild, moderate and severe renal impairment. The dosing recommendations in patients with renal impairment, with increased dosing interval, are expected to result in higher peak plasma concentrations and lower C_min levels in patients with renal impairment compared with patients with normal renal function. The clinical implications of this are unknown.

In patients with end-stage renal disease (ESRD) (CrCl < 10 ml/min) requiring haemodialysis, between dialysis tenofovir concentrations substantially increased over 48 hours achieving a mean C_max of 1,032 ng/ml and a mean AUCo-48h of 42,857 ngh/ml.

It is recommended that the dosing interval for tenofovir disoproxil 245 mg is modified in adult patients with creatinine clearance < 50 ml/min or in patients who already have ESRD and require dialysis (see section 4.2).

The pharmacokinetics of tenofovir in non-haemodialysis patients with creatinine clearance < 10 ml/min and in patients with ESRD managed by peritoneal or other forms of dialysis have not been studied.

The pharmacokinetics of tenofovir in paediatric patients with renal impairment have not been studied.

No data are available to make dose recommendations (see sections 4.2 and 4.4).

Hepatic impairment: A single 245 mg dose of tenofovir disoproxil was administered to non-HIV, non-HBV infected adult patients with varying degrees of hepatic impairment defined according to Child-Pugh-Turcotte (CPT) classification. Tenofovir pharmacokinetics were not substantially altered in subjects with hepatic impairment suggesting that no dose adjustment is required in these subjects. The mean (%CV) tenofovir C_max and AUC_0-QO values were 223 (34.8%) ng/ml and 2,050 (50.8%) ngh/ml, respectively, in normal subjects compared with 289 (46.0%) ng/ml and 2,310 (43.5%) ngh/ml in subjects with moderate hepatic impairment, and 305 (24.8%) ng/ml and 2,740 (44.0%) ngh/ml in subjects with severe hepatic impairment.

Intracellular pharmacokinetics: In non-proliferating human peripheral blood mononuclear cells (PBMCs) the half-life of tenofovir diphosphate was found to be approximately 50 hours, whereas the half-life in phytohaemagglutinin-stimulated PBMCs was found to be approximately 10 hours.

5.3 Preclinical safety data

Non-clinical safety pharmacology studies reveal no special hazard for humans. Findings in repeated dose toxicity studies in rats, dogs and monkeys at exposure levels greater than or equal to clinical exposure levels and with possible relevance to clinical use include renal and bone toxicity and a decrease in serum phosphate concentration. Bone toxicity was diagnosed as osteomalacia (monkeys) and reduced bone mineral density (BMD) (rats and dogs). The bone toxicity in young adult rats and dogs occurred at exposures > 5-fold the exposure in paediatric or adult patients; bone toxicity occurred in juvenile infected monkeys at very high exposures following subcutaneous dosing (> 40-fold the exposure in patients). Findings in the rat and monkey studies indicated that there was a substance-related decrease in intestinal absorption of phosphate with potential secondary reduction in BMD.

Genotoxicity studies revealed positive results in the in vitro mouse lymphoma assay, equivocal results in one of the strains used in the Ames test, and weakly positive results in an UDS test in primary rat hepatocytes. However, it was negative in an in vivo mouse bone marrow micronucleus assay.

Oral carcinogenicity studies in rats and mice only revealed a low incidence of duodenal tumours at an extremely high dose in mice. These tumours are unlikely to be of relevance to humans.

Reproductive studies in rats and rabbits showed no effects on mating, fertility, pregnancy or foetal parameters. However, tenofovir disoproxil reduced the viability index and weight of pups in peri-postnatal toxicity studies at maternally toxic doses.

The active substance tenofovir disoproxil and its main transformation products are persistent in the environment.

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Tablet core

Cellulose, microcrystalline Lactose monohydrate Starch, pregelatinised Hydrogenated vegetable oil Sodium laurilsulfate

Film-coating

Polyvinyl alcohol, partially hydrolysed (E1203) Titanium dioxide (E171)

Macrogol (E1521)

Talc (E553b)

Indigo carmine aluminium lake (E132) Carminic acid (E120)

6.2 Incompatibilities

Not applicable.

Shelf life

6.4    Special precautions for storage

This medicinal product does not require any special storage conditions.

6.5    Nature and contents of container

Aluminium-aluminium blisters: 30, 30x1, 90 and 90x1 tablets

White HDPE bottle with a polypropylene child resistant induction closure and

one or two desiccant canisters containing 30 tablets and 90 tablets (3 x 30).

Not all pack sizes may be marketed.

6.6    Special precautions for disposal

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

7 MARKETING AUTHORISATION HOLDER

TEVA UK Limited,

Brampton Road,

Hampden Park,

Eastbourne,

East Sussex, BN22 9AG UNITED KINGDOM

8    MARKETING AUTHORISATION NUMBER(S)

PL 00289/1897

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

17/07/2015

10 DATE OF REVISION OF THE TEXT

17/07/2015