PRAVASTATIN SODIUM- pravastatin sodium_tablet

Pravastatin is a reversible inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, the enzyme that catalyzes the conversion of HMG-CoA to mevalonate, an early and rate limiting step in the biosynthetic pathway for cholesterol. In addition, pravastatin reduces VLDL and TG and increases HDL-C. General Absorption Pravastatin sodium is administered orally in the active form. In studies in man, peak plasma pravastatin concentrations occurred 1 to 1. 5 hours upon oral administration. Based on urinary recovery of total radiolabeled drug, the average oral absorption of pravastatin is 34% and absolute bioavailability is 17%. While the presence of food in the gastrointestinal tract reduces systemic bioavailability, the lipid-lowering effects of the drug are similar whether taken with or 1 hour prior to meals. Pravastatin plasma concentrations, including area under the concentration-time curve (AUC), C max min The coefficient of variation (CV), based on between-subject variability, was 50% to 60% for AUC. The geometric means of pravastatin C max Steady-state AUCs, C max min Distribution Approximately 50% of the circulating drug is bound to plasma proteins. Metabolism The major biotransformation pathways for pravastatin are: (a) isomerization to 6-epi pravastatin and the 3alpha-hydroxyisomer of pravastatin (SQ 31,906) and (b) enzymatic ring hydroxylation to SQ 31,945. The 3alpha-hydroxyisomeric metabolite (SQ 31,906) has 1/10 to 1/40 the HMG-CoA reductase inhibitory activity of the parent compound. Pravastatin undergoes extensive first-pass extraction in the liver (extraction ratio 0. Excretion Approximately 20% of a radiolabeled oral dose is excreted in urine and 70% in the feces. After intravenous administration of radiolabeled pravastatin to normal volunteers, approximately 47% of total body clearance was via renal excretion and 53% by non-renal routes (i. , biliary excretion and biotransformation). Following single dose oral administration of 14 ½ Specific Populations Renal Impairment A single 20 mg oral dose of pravastatin was administered to 24 patients with varying degrees of renal impairment (as determined by creatinine clearance). No effect was observed on the pharmacokinetics of pravastatin or its 3alpha-hydroxy isomeric metabolite (SQ 31,906). Compared to healthy subjects with normal renal function, patients with severe renal impairment had 69% and 37% higher mean AUC and C max ½ Hepatic Impairment In a study comparing the kinetics of pravastatin in patients with biopsy confirmed cirrhosis (N=7) and normal subjects (N=7), the mean AUC varied 18-fold in cirrhotic patients and 5-fold in healthy subjects. Similarly, the peak pravastatin values varied 47-fold for cirrhotic patients compared to 6-fold for healthy subjects. [See Warnings and Precautions ( 5. 2 Geriatric In a single oral dose study using pravastatin 20 mg, the mean AUC for pravastatin was approximately 27% greater and the mean cumulative urinary excretion (CUE) approximately 19% lower in elderly men (65 to 75 years old) compared with younger men (19 to 31 years old). In a similar study conducted in women, the mean AUC for pravastatin was approximately 46% higher and the mean CUE approximately 18% lower in elderly women (65 to 78 years old) compared with younger women (18 to 38 years old). In both studies, C max max ½ Use in Specific Populations ( 8. 5 Pediatric After 2 weeks of once-daily 20 mg oral pravastatin administration, the geometric means of AUC were 80. 7 (CV 44%) and 44. 8 (CV 89%) ng*hr/mL for children (8 to 11 years, N=14) and adolescents (12 to 16 years, N=10), respectively. The corresponding values for C max Use in Specific Populations ( 8. 4 Drug-Drug Interactions Table 3Effect of Coadministered Drugs on the Pharmacokinetics of Pravastatin BID = twice daily; OD = once daily; QID = four times daily Coadministered Drug and Pravastatin Dosing Regimen Dose (mg) Change in AUC Change in C max Cyclosporine 5 mg/kg single dose 40 mg single dose up arrow 282% up arrow 327% Clarithromycin 500 mg BID for 9 days 40 mg OD for 8 days up arrow 110% up arrow 128% Boceprevir 800 mg TID for 6 days 40 mg single dose up arrow 63% up arrow 49% Darunavir 600 mg BID/Ritonavir 100 mg BID for 7 days 40 mg single dose up arrow 81% up arrow 63% Colestipol 10 g single dose 20 mg single dose down arrow 47% down arrow 53% Cholestyramine 4 g single dose 20 mg single dose down arrow 40% down arrow 39% Cholestyramine 24 g OD for 4 weeks 20 mg BID for 8 weeks down arrow 51% up arrow 4. 9% Fluconazole Verapamil IR 120 mg for 1 day and Verapamil ER 480 mg for 3 days 40 mg single dose up arrow 31% up arrow 42% Cimetidine 300 mg QID for 3 days 20 mg single dose up arrow 30% up arrow 9. 8% Antacids 15 mL QID for 3 days 20 mg single dose down arrow 28% down arrow 24% Digoxin 0. 2 mg OD for 9 days 20 mg OD for 9 days up arrow 23% up arrow 26% Probucol 500 mg single dose 20 mg single dose up arrow 14% up arrow 24% Warfarin 5 mg OD for 6 days 20 mg BID for 6 days down arrow 13% up arrow 6. 7% Itraconazole 200 mg OD for 30 days 40 mg OD for 30 days up arrow 11% (compared to Day 1) up arrow 17% (compared to Day 1) Gemfibrozil 600 mg single dose 20 mg single dose down arrow 7% down arrow 20% Aspirin 324 mg single dose 20 mg single dose up arrow 4. 7% up arrow 8. 9% Nicotinic Acid 1 g single dose 20 mg single dose down arrow 3. 6% down arrow 8. 2% Diltiazem 20 mg single dose up arrow 2. 7% up arrow 30% Grapefruit juice 40 mg single dose down arrow 1. 8% up arrow 3. 7% Table 4Effect of Pravastatin on the Pharmacokinetics of Coadministered Drugs Pravastatin Dosing Regimen Name and Dose Change in AUC Change in C max BID = twice daily; OD = once daily 20 mg BID for 6 days Warfarin 5 mg OD for 6 days up arrow 17% up arrow 15% 20 mg OD for 9 days Digoxin 0. 2 mg OD for 9 days up arrow 4. 6% up arrow 5. 3% 20 mg BID for 4 weeks Antipyrine 1. 2 g single dose up arrow 3% Not Reported 20 mg OD for 4 days Kaletra 400 mg/100 mg BID for 14 days No change No change.

Pravastatin sodium tablet, USP is an HMG-CoA reductase inhibitor (statin) indicated as an adjunctive therapy to diet to: 1. 2 Limitations of use: Fredrickson 1. 3 Therapy with lipid-altering agents should be only one component of multiple risk factor intervention in individuals at significantly increased risk for atherosclerotic vascular disease due to hypercholesterolemia. Drug therapy is indicated as an adjunct to diet when the response to a diet restricted in saturated fat and cholesterol and other nonpharmacologic measures alone has been inadequate. In hypercholesterolemic patients without clinically evident coronary heart disease (CHD), pravastatin sodium tablets, USP are indicated to: In patients with clinically evident CHD, pravastatin sodium tablet is indicated to: reduce the risk of total mortality by reducing coronary death. Pravastatin sodium tablet is indicated: Fredrickson 1 Fredrickson Fredrickson a. LDL-C remains >= 190 mg/dL or b. LDL-C remains >= 160 mg/dL and: there is a positive family history of premature cardiovascular disease (CVD) or two or more other CVD risk factors are present in the patient. Pravastatin sodium has not been studied in conditions where the major lipoprotein abnormality is elevation of chylomicrons (Fredrickson.

3 The patient should be placed on a standard cholesterol-lowering diet before receiving pravastatin sodium tablets and should continue on this diet during treatment with pravastatin sodium tablets [see NCEP Treatment Guidelines for details on dietary therapy]. The recommended starting dose is 40 mg once daily. If a daily dose of 40 mg does not achieve desired cholesterol levels, 80 mg once daily is recommended. In patients with significant renal impairment, a starting dose of 10 mg daily is recommended. Pravastatin sodium tablets can be administered orally as a single dose at any time of the day, with or without food. Since the maximal effect of a given dose is seen within 4 weeks, periodic lipid determinations should be performed at this time and dosage adjusted according to the patient's response to therapy and established treatment guidelines. Children (Ages 8 to 13 Years, Inclusive) The recommended dose is 20 mg once daily in children 8 to 13 years of age. Doses greater than 20 mg have not been studied in this patient population. Adolescents (Ages 14 to 18 Years) The recommended starting dose is 40 mg once daily in adolescents 14 to 18 years of age. Doses greater than 40 mg have not been studied in this patient population. Children and adolescents treated with pravastatin should be reevaluated in adulthood and appropriate changes made to their cholesterol-lowering regimen to achieve adult goals for LDL-C [see Indications and Usage ( 1. 2 Pravastatin sodium tablets may be used with bile acid resins. When administering a bile-acid-binding resin (e. , cholestyramine, colestipol) and pravastatin, pravastatin sodium tablets should be given either 1 hour or more before or at least 4 hours following the resin. [See Clinical Pharmacology ( 12. 3 In patients taking immunosuppressive drugs such as cyclosporine concomitantly with pravastatin, therapy should begin with 10 mg of pravastatin sodium once-a-day at bedtime and titration to higher doses should be done with caution. Most patients treated with this combination received a maximum pravastatin sodium dose of 20 mg/day. In patients taking cyclosporine, therapy should be limited to 20 mg of pravastatin sodium once daily [see Warnings and Precautions ( 5. 1 Drug Interactions ( 7. 1 In patients taking clarithromycin, therapy should be limited to 40 mg of pravastatin sodium once daily [see Drug Interactions ( 7.

In short-term clinical trials, the most commonly reported adverse reactions (>= 2% and > placebo) regardless of causality were: musculoskeletal pain, nausea/vomiting, upper respiratory infection, diarrhea, and headache. 1 To report SUSPECTED ADVERSE REACTIONS, contact Zydus Pharmaceuticals USA Inc. at 1-877-993-8779, or FDA at 1-800-FDA-1088 or www. gov/medwatch. Pravastatin is generally well tolerated; adverse reactions have usually been mild and transient. In 4 month-long placebo-controlled trials, 1. 7% of pravastatin-treated patients and 1. 2% of placebo-treated patients were discontinued from treatment because of adverse experiences attributed to study drug therapy; this difference was not statistically significant. Short-Term Controlled Trials In the pravastatin sodium placebo-controlled clinical trials database of 1313 patients (age range 20 to 76 years, 32. 4% women, 93. 5% Caucasians, 5% Blacks, 0. 9% Hispanics, 0. 4% Asians, 0. 2% Others) with a median treatment duration of 14 weeks, 3. 3% of patients on pravastatin sodium and 1. 2% patients on placebo discontinued due to adverse events regardless of causality. The most common adverse reactions that led to treatment discontinuation and occurred at an incidence greater than placebo were: liver function test increased, nausea, anxiety/depression, and dizziness. All adverse clinical events (regardless of causality) reported in >= 2% of pravastatin-treated patients in placebo-controlled trials of up to 8 months duration are identified in Table 1: Table 1Adverse Events in ( 2% of Patients Treated with Pravastatin 5 to 40 mg and at an Incidence Greater Than Placebo in Short-Term Placebo-Controlled Trials (% of patients) Body System/Event 5 mg N=100 10 mg N=153 20 mg N=478 40 mg N=171 Any Dose N=902 Placebo N=411 Cardiovascular 5 4. 4 Dermatologic 3 2. 4 Gastrointestinal 4 5. 1 General Fatigue 4 1. 9 Chest Pain 4 1. 9 Musculoskeletal Musculoskeletal Pain 13 3. 2 Myalgia 1 2. 2 Nervous System 5 6. 6 Respiratory 2 4. 7 Investigation 2 2 4 1. 2 The safety and tolerability of pravastatin sodium at a dose of 80 mg in 2 controlled trials with a mean exposure of 8. 6 months was similar to that of pravastatin sodium at lower doses except that 4 out of 464 patients taking 80 mg of pravastatin had a single elevation of CK > 10 times ULN compared to 0 out of 115 patients taking 40 mg of pravastatin. Long-Term Controlled Morbidity and Mortality Trials In the pravastatin sodium placebo-controlled clinical trials database of 21,483 patients (age range 24 to 75 years, 10. 3% women, 52. 3% Caucasians, 0. 8% Blacks, 0. 5% Hispanics, 0. 1% Asians, 0. 1% Others, 46. 1% Not Recorded) with a median treatment duration of 261 weeks, 8. 1% of patients on pravastatin sodium and 9. 3% patients on placebo discontinued due to adverse events regardless of causality. Adverse event data were pooled from 7 doubleblind, placebo-controlled trials (West of Scotland Coronary Prevention Study [WOS]; Cholesterol and Recurrent Events study [CARE]; Long-term Intervention with Pravastatin in Ischemic Disease study [LIPID]; Pravastatin Limitation of Atherosclerosis in the Coronary Arteries study [PLAC I]; Pravastatin, Lipids and Atherosclerosis in the Carotids study [PLAC II]; Regression Growth Evaluation Statin Study [REGRESS]; and Kuopio Atherosclerosis Prevention Study [KAPS]) involving a total of 10,764 patients treated with pravastatin 40 mg and 10,719 patients treated with placebo. The safety and tolerability profile in the pravastatin group was comparable to that of the placebo group. Patients were exposed to pravastatin for a mean of 4 to 5. 1 years in WOS, CARE, and LIPID and 1. 9 years in PLAC I, PLAC II, KAPS, and REGRESS. In these long-term trials, the most common reasons for discontinuation were mild, non-specific gastrointestinal complaints. Collectively, these 7 trials represent 47,613 patient-years of exposure to pravastatin. All clinical adverse events (regardless of causality) occurring in >= 2% of patients treated with pravastatin in these studies are identified in Table 2. Table 2Adverse Events in >= 2% of Patients Treated with Pravastatin 40 mg and at an Incidence Greater Than Placebo in Long-Term Placebo-Controlled Trials Body System/Event Pravastatin (N=10,764) % of patients Placebo (N=10,719) % of patients Dermatologic 7. 1 General Edema 3 2. 7 Fatigue 8. 8 Chest Pain 10 9. 9 Weight Gain 3. 3 Weight Loss 3. 8 Musculoskeletal Musculoskeletal Pain 24. 4 Muscle Cramp 5. 6 Musculoskeletal Traumatism 10. 6 Nervous System Dizziness 7. 6 Sleep Disturbance 3 2. 4 Anxiety/Nervousness 4. 7 Paresthesia 3. 2 3 Renal/Genitourinary 2. 6 Respiratory Upper Respiratory Tract Infection 21. 4 Influenza 9. 2 9 Pulmonary Infection 3. 5 Sinus Abnormality 7 6. 7 Special Senses 3. 3 Infections 3. 9 In addition to the events listed above in the long-term trials table, events of probable, possible, or uncertain relationship to study drug that occurred in < 2 % of pravastatin-treated patients in the long-term trials included the following: Dermatologic scalp hair abnormality (including alopecia), urticaria. Endocrine/Metabolic sexual dysfunction, libido change. General flushing. Immunologic allergy, edema head/neck. Musculoskeletal muscle weakness. Nervous System vertigo, insomnia, memory impairment, neuropathy (including peripheral neuropathy). Special Senses taste disturbance. In addition to the events reported above, as with other drugs in this class, the following events have been reported rarely during postmarketing experience with pravastatin sodium, regardless of causality assessment: There have been rare reports of immune-mediated necrotizing myopathy associated with statin use [see Warnings and Precautions (5. 1) Musculoskeletal myopathy, rhabdomyolysis. Nervous System dysfunction of certain cranial nerves (including alteration of taste, impairment of extraocular movement, facial paresis), peripheral nerve palsy. There have been rare postmarketing reports of cognitive impairment (e. , memory loss, forgetfulness, amnesia, memory impairment, confusion) associated with statin use. These cognitive issues have been reported for all statins. The reports are generally nonserious, and reversible upon statin discontinuation, with variable times to symptom onset (1 day to years) and symptom resolution (median of 3 weeks). Hypersensitivity anaphylaxis, angioedema, lupus erythematosus-like syndrome, polymyalgia rheumatica, dermatomyositis, vasculitis, purpura, hemolytic anemia, positive ANA, ESR increase, arthritis, arthralgia, asthenia, photosensitivity, chills, malaise, toxic epidermal necrolysis, erythema multiforme (including Stevens-Johnson syndrome). Gastrointestinal abdominal pain, constipation, pancreatitis, hepatitis (including chronic active hepatitis), cholestatic jaundice, fatty change in liver, cirrhosis, fulminant hepatic necrosis, hepatoma, fatal and non-fatal hepatic failure. Dermatologic a variety of skin changes (e. , nodules, discoloration, dryness of mucous membranes, changes to hair/nails). Renal urinary abnormality (including dysuria, frequency, nocturia). Respiratory dyspnea. Reproductive gynecomastia. Laboratory Abnormalities liver function test abnormalities, thyroid function abnormalities. Increases in ALT, AST values and CPK have been observed [see Warnings and Precautions ( 5. 2 Transient, asymptomatic eosinophilia has been reported. Eosinophil counts usually returned to normal despite continued therapy. Anemia, thrombocytopenia, and leukopenia have been reported with statins. In a 2 year, doubleblind, placebo-controlled study involving 100 boys and 114 girls with HeFH (n=214; age range 8 to 18. 5 years, 53% female, 95% Caucasians, < 1% Blacks, 3% Asians, 1% Other), the safety and tolerability profile of pravastatin was generally similar to that of placebo. [See Warnings and Precautions ( 5. 3 Use in Specific Populations ( 8. 4 Clinical Pharmacology ( 12.

2 11 4. 3 Hypersensitivity to any component of this medication. Active liver disease or unexplained, persistent elevations of serum transaminases [see Warnings and Precautions ( 5. 2 Atherosclerosis is a chronic process and discontinuation of lipid-lowering drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hypercholesterolemia. Cholesterol and other products of cholesterol biosynthesis are essential components for fetal development (including synthesis of steroids and cell membranes). Since statins decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, they are contraindicated during pregnancy and in nursing mothers. PRAVASTATIN SHOULD BE ADMINISTERED TO WOMEN OF CHILDBEARING AGE ONLY WHEN SUCH PATIENTS ARE HIGHLY UNLIKELY TO CONCEIVE AND HAVE BEEN INFORMED OF THE POTENTIAL HAZARDS. If the patient becomes pregnant while taking this class of drug, therapy should be discontinued immediately and the patient apprised of the potential hazard to the fetus [see Use in Specific Populations ( 8. 1 A small amount of pravastatin is excreted in human breastmilk. Because statins have the potential for serious adverse reactions in nursing infants, women who require pravastatin sodium treatment should not breastfeed their infants [see Use in Specific Populations ( 8.

Pregnancy Category X [See Contraindications ( 4. 3 Safety in pregnant women has not been established. Available data in women inadvertently taking pravastatin while pregnant do not suggest any adverse clinical events. However, there are no adequate and well-controlled studies in pregnant women. Therefore, it is not known whether pravastatin can cause fetal harm when administered to a pregnant woman or can affect reproductive capacity. Pravastatin should be used during pregnancy only if the potential benefit outweighs the potential risk to the fetus and patients have been informed of the potential hazards. Rare reports of congenital anomalies have been received following intrauterine exposure to other statins. In a review 2 Contraindications ( 4. 3 Pravastatin was neither embryolethal nor teratogenic in rats at doses up to 1000 mg/kg daily or in rabbits at doses of up to 50 mg/kg daily. These doses resulted in 10 times (rabbit) or 120 times (rat) the human exposure at 80 mg/day maximum recommended human dose (MRHD) based on surface area (mg/m 2 In pregnant rats given oral gavage doses of 4, 20, 100, 500, and 1000 mg/kg/day from gestation days 7 through 17 (organogenesis) increased mortality of offspring and skeletal anomalies were observed at 100 mg/kg/day systemic exposure, 10 times the human exposure at 80 mg/day MRHD based on body surface area (mg/m 2 In pregnant rats given oral gavage doses of 10, 100, and 1000 mg/kg/day from gestation day 17 through lactation day 21 (weaning) increased mortality of offspring and developmental delays were observed at 100 mg/kg/day systemic exposure, 12 times the human exposure at 80 mg/day MRHD based on body surface area (mg/m 2 A small amount of pravastatin is excreted in human breastmilk. Because of the potential for serious adverse reactions in nursing infants, women taking pravastatin sodium should not nurse [see Contraindications ( 4. 4 Pravastatin crosses the placenta and is found in fetal tissue at 30% maternal plasma levels following a single 20 mg/kg dose given to pregnant rats on gestation day 18. Similar studies in lactating rats indicate secretion of pravastatin into breastmilk at 0. 5 times higher levels than maternal plasma at exposures equivalent to 2 times human exposure at the MRHD. The safety and effectiveness of pravastatin sodium in children and adolescents from 8 to 18 years of age have been evaluated in a placebo-controlled study of 2 years duration. Patients treated with pravastatin had an adverse experience profile generally similar to that of patients treated with placebo with influenza and headache commonly reported in both treatment groups. [See Adverse Reactions ( 6. 4 Doses greater than 40 mg have not been studied in this population. Contraindications ( 4. 3 Use in Specific Populations ( 8. 1 Dosage and Administration ( 2. 3 Doubleblind, placebo-controlled pravastatin studies in children less than 8 years of age have not been conducted. Two secondary prevention trials with pravastatin (CARE and LIPID) included a total of 6593 subjects treated with pravastatin 40 mg for periods ranging up to 6 years. Across these 2 studies, 36. 1% of pravastatin subjects were aged 65 and older and 0. 8% were aged 75 and older. The beneficial effect of pravastatin in elderly subjects in reducing cardiovascular events and in modifying lipid profiles was similar to that seen in younger subjects. The adverse event profile in the elderly was similar to that in the overall population. Other reported clinical experience has not identified differences in responses to pravastatin between elderly and younger patients. Mean pravastatin AUCs are slightly (25% to 50%) higher in elderly subjects than in healthy young subjects, but mean maximum plasma concentration (C max max ½ Clinical Pharmacology ( 12. 3 Since advanced age (>= 65 years) is a predisposing factor for myopathy, pravastatin sodium should be prescribed with caution in the elderly [see Warnings and Precautions ( 5. 1 Clinical Pharmacology ( 12. 3 Pravastatin has not been evaluated in patients with rare homozygous familial hypercholesterolemia. In this group of patients, it has been reported that statins are less effective because the patients lack functional LDL receptors.

7 2. 2 For the concurrent therapy of either cyclosporine, fibrates, niacin (nicotinic acid), or erythromycin, the risk of myopathy increases [see Warnings and Precautions ( Error! Hyperlink reference not valid. ) Clinical Pharmacology ( 12. 3 The risk of myopathy/rhabdomyolysis is increased with concomitant administration of cyclosporine. Limit pravastatin to 20 mg once daily for concomitant use with cyclosporine [see Dosage and Administration ( 2. 5 Warnings and Precautions ( 5. 1 Clinical Pharmacology ( 12. 3 The risk of myopathy/rhabdomyolysis is increased with concomitant administration of clarithromycin. Limit pravastatin to 40 mg once daily for concomitant use with clarithromycin [see Dosage and Administration ( 2. 6 Warnings and Precautions ( 5. 3 The risk of myopathy/rhabdomyolysis is increased with concomitant administration of colchicine [see Warnings and Precautions ( 5. 1 Due to an increased risk of myopathy/rhabdomyolysis when HMG-CoA reductase inhibitors are coadministered with gemfibrozil, concomitant administration of pravastatin sodium with gemfibrozil should be avoided [see Warnings and Precautions ( 5. 1 Because it is known that the risk of myopathy during treatment with HMG-CoA reductase inhibitors is increased with concurrent administration of other fibrates, pravastatin sodium should be administered with caution when used concomitantly with other fibrates [see Warnings and Precautions ( 5. 1 The risk of skeletal muscle effects may be enhanced when pravastatin is used in combination with niacin; a reduction in pravastatin sodium dosage should be considered in this setting [see Warnings and Precautions ( 5.

OVERDOSAGE
To date, there has been limited experience with overdosage of pravastatin. If an overdose occurs, it should be treated symptomatically with laboratory monitoring and supportive measures should be instituted as required.
NONCLINICAL TOXICOLOGY
In a 2 year study in rats fed pravastatin at doses of 10, 30, or 100 mg/kg body weight, there was an increased incidence of hepatocellular carcinomas in males at the highest dose (p < 0. These effects in rats were observed at approximately 12 times the human dose (HD) of 80 mg based on body surface area (mg/m 2 In a 2 year study in mice fed pravastatin at doses of 250 and 500 mg/kg/day, there was an increased incidence of hepatocellular carcinomas in males and females at both 250 and 500 mg/kg/day (p < 0. At these doses, lung adenomas in females were increased (p=0. These effects in mice were observed at approximately 15 times (250 mg/kg/day) and 23 times (500 mg/kg/day) the HD of 80 mg, based on AUC. In another 2 year study in mice with doses up to 100 mg/kg/day (producing drug exposures approximately 2 times the HD of 80 mg, based on AUC), there were no drug-induced tumors. No evidence of mutagenicity was observed in vitro Salmonella typhimurium Escherichia coli Saccharomyces cerevisiae In a fertility study in adult rats with daily doses up to 500 mg/kg, pravastatin did not produce any adverse effects on fertility or general reproductive performance. CNS Toxicity CNS vascular lesions, characterized by perivascular hemorrhage and edema and mononuclear cell infiltration of perivascular spaces, were seen in dogs treated with pravastatin at a dose of 25 mg/kg/day. These effects in dogs were observed at approximately 59 times the HD of 80 mg/day, based on AUC. Similar CNS vascular lesions have been observed with several other drugs in this class. A chemically similar drug in this class produced optic nerve degeneration (Wallerian degeneration of retinogeniculate fibers) in clinically normal dogs in a dose-dependent fashion starting at 60 mg/kg/day, a dose that produced mean plasma drug levels about 30 times higher than the mean drug level in humans taking the highest recommended dose (as measured by total enzyme inhibitory activity). This same drug also produced vestibulocochlear Wallerian-like degeneration and retinal ganglion cell chromatolysis in dogs treated for 14 weeks at 180 mg/kg/day, a dose which resulted in a mean plasma drug level similar to that seen with the 60 mg/kg/day dose. When administered to juvenile rats (postnatal days [PND] 4 through 80 at 5 to 45 mg/kg/day), no drug related changes were observed at 5 mg/kg/day. At 15 and 45 mg/kg/day, altered body-weight gain was observed during the dosing and 52 day recovery periods as well as slight thinning of the corpus callosum at the end of the recovery period. This finding was not evident in rats examined at the completion of the dosing period and was not associated with any inflammatory or degenerative changes in the brain. The biological relevance of the corpus callosum finding is uncertain due to the absence of any other microscopic changes in the brain or peripheral nervous tissue and because it occurred at the end of the recovery period. Neurobehavioral changes (enhanced acoustic startle responses and increased errors in water-maze learning) combined with evidence of generalized toxicity were noted at 45 mg/kg/day during the later part of the recovery period. Serum pravastatin levels at 15 mg/kg/day are approximately 1 times (AUC) the maximum pediatric dose of 40 mg. No thinning of the corpus callosum was observed in rats dosed with pravastatin ( 250 mg/kg/day) beginning PND 35 for 3 months suggesting increased sensitivity in younger rats. PND 35 in a rat is approximately equivalent to an 8 to 12 year-old human child. Juvenile male rats given 90 times (AUC) the 40 mg dose had decreased fertility (20%) with sperm abnormalities compared to controls.
CLINICAL STUDIES
In the Pravastatin Primary Prevention Study (WOS), 3 th th Pravastatin sodium significantly reduced the rate of first coronary events (either CHD death or nonfatal MI) by 31% (248 events in the placebo group [CHD death=44, nonfatal MI=204] versus 174 events in the pravastatin sodium group [CHD death=31, nonfatal MI=143], p=0. 0001 [see figure below]). The risk reduction with pravastatin sodium was similar and significant throughout the entire range of baseline LDL cholesterol levels. This reduction was also similar and significant across the age range studied with a 40% risk reduction for patients younger than 55 years and a 27% risk reduction for patients 55 years and older. The Pravastatin Primary Prevention Study included only men, and therefore it is not clear to what extent these data can be extrapolated to a similar population of female patients. Pravastatin sodium also significantly decreased the risk for undergoing myocardial revascularization procedures (coronary artery bypass graft [CABG] surgery or percutaneous transluminal coronary angioplasty [PTCA]) by 37% (80 vs 51 patients, p=0. 009) and coronary angiography by 31% (128 vs 90, p=0. Cardiovascular deaths were decreased by 32% (73 vs 50, p=0. 03) and there was no increase in death from non-cardiovascular causes. Pravastatin Sodium Tablets, USP In the LIPID4 study, the effect of pravastatin, 40 mg daily, was assessed in 9014 patients (7498 men; 1516 women; 3514 elderly patients [age >=65 years]; 782 diabetic patients) who had experienced either an MI `(5754 patients) or had been hospitalized for unstable angina pectoris (3260 patients) in the preceding 3 to 36 months. Patients in this multicenter, double-blind, placebo-controlled study participated for an average of 5. 6 years (median of 5. 9 years) and at randomization had Total-C between 114 and 563 mg/dL (mean 219 mg/dL), LDL-C between 46 and 274 mg/dL (mean 150 mg/dL), TG between 35 and 2710 mg/dL (mean 160 mg/dL), and HDL-C between 1 and 103 mg/dL (mean 37 mg/dL). At baseline, 82% of patients were receiving aspirin and 76% were receiving antihypertensive medication. Treatment with pravastatin significantly reduced the risk for total mortality by reducing coronary death (see Table 5). The risk reduction due to treatment with pravastatin on CHD mortality was consistent regardless of age. Pravastatin significantly reduced the risk for total mortality (by reducing CHD death) and CHD events (CHD mortality or nonfatal MI) in patients who qualified with a history of either MI or hospitalization for unstable angina pectoris. Table 5LIPID - Primary and Secondary Endpoints Number (%) of Subjects Event Pravastatin 40 mg (N=4512) Placebo (N=4502) Risk Reduction p Primary Endpoint CHD mortality 287 (6. 0004 Secondary Endpoints Total mortality 498 (11. 0001 CHD mortality or nonfatal MI 557 (12. 0001 Myocardial revascularization procedures (CABG or PTCA) 584 (12. 0001 Stroke All-cause 169 (3. 0477 Non-hemorrhagic 154 (3. 0154 Cardiovascular mortality 331 (7. 0001 In the CARE5 study, the effect of pravastatin, 40 mg daily, on CHD death and nonfatal MI was assessed in 4159 patients (3583 men and 576 women) who had experienced a MI in the preceding 3 to 20 months and who had normal (below the 75th percentile of the general population) plasma total cholesterol levels. Patients in this double-blind, placebo-controlled study participated for an average of 4. 9 years and had a mean baseline Total-C of 209 mg/dL. LDL-C levels in this patient population ranged from 101 to 180 mg/dL (mean 139 mg/dL). At baseline, 84% of patients were receiving aspirin and 82% were taking antihypertensive medications. Median (25th , 75th percentile) percent changes from baseline after 6 months of pravastatin treatment in Total-C, LDL-C, TG, and HDL-C were −22. 7), respectively. Treatment with pravastatin significantly reduced the rate of first recurrent coronary events (either CHD death or nonfatal MI), the risk of undergoing revascularization procedures (PTCA, CABG), and the risk for stroke or TIA (see Table 6). Table 6CARE - Primary and Secondary Endpoints Number (%) of Subjects Event Pravastatin 40 mg (N=2081) Placebo (N=2078) Risk Reduction p Primary Endpoint CHD mortality or nonfatal MI The risk reduction due to treatment with pravastatin was consistent in both sexes. 003 Secondary Endpoints Myocardial revascularization procedures (CABG or PTCA) 294 (14. 001 Stroke or TIA 93 (4. 029 In the PLAC I6 study, the effect of pravastatin therapy on coronary atherosclerosis was assessed by coronary angiography in patients with coronary disease and moderate hypercholesterolemia (baseline LDL-C range: 130-190 mg/dL). In this double-blind, multicenter, controlled clinical trial, angiograms were evaluated at baseline and at 3 years in 264 patients. Although the difference between pravastatin and placebo for the primary endpoint (per-patient change in mean coronary artery diameter) and 1 of 2 secondary endpoints (change in percent lumen diameter stenosis) did not reach statistical significance, for the secondary endpoint of change in minimum lumen diameter, statistically significant slowing of disease was seen in the pravastatin treatment group (p=0. In the REGRESS7 study, the effect of pravastatin on coronary atherosclerosis was assessed by coronary angiography in 885 patients with angina pectoris, angiographically documented coronary artery disease, and hypercholesterolemia (baseline total cholesterol range: 160-310 mg/dL). In this double-blind, multicenter, controlled clinical trial, angiograms were evaluated at baseline and at 2 years in 653 patients (323 treated with pravastatin). Progression of coronary atherosclerosis was significantly slowed in the pravastatin group as assessed by changes in mean segment diameter (p=0. 037) and minimum obstruction diameter (p=0. Analysis of pooled events from PLAC I, PLAC II,8 REGRESS, and KAPS9 studies (combined N=1891) showed that treatment with pravastatin was associated with a statistically significant reduction in the composite event rate of fatal and nonfatal MI (46 events or 6. 4% for placebo versus 21 events or 2. 4% for pravastatin, p=0. The predominant effect of pravastatin was to reduce the rate of nonfatal MI. Pravastatin sodium is highly effective in reducing Total-C, LDL-C, and TG in patients with heterozygous familial, presumed familial combined, and non-familial (non-FH) forms of primary hypercholesterolemia, and mixed dyslipidemia. A therapeutic response is seen within 1 week, and the maximum response usually is achieved within 4 weeks. This response is maintained during extended periods of therapy. In addition, pravastatin sodium is effective in reducing the risk of acute coronary events in hypercholesterolemic patients with and without previous MI. A single daily dose is as effective as the same total daily dose given twice a day. In multicenter, doubleblind, placebo-controlled studies of patients with primary hypercholesterolemia, treatment with pravastatin in daily doses ranging from 10 to 40 mg consistently and significantly decreased Total-C, LDL-C, TG, and Total-C/HDL-C and LDL-C/HDL-C ratios (see Table 7). In a pooled analysis of 2 multicenter, doubleblind, placebo-controlled studies of patients with primary hypercholesterolemia, treatment with pravastatin at a daily dose of 80 mg (N=277) significantly decreased Total-C, LDL-C, and TG. The 25 th th Treatment with pravastatin sodium modestly decreased VLDL-C and pravastatin sodium across all doses produced variable increases in HDL-C (see Table 7). Table 7Primary Hypercholesterolemia Studies: Dose Response of Pravastatin Sodium Once Daily Administration Dose Total-C LDL-C HDL-C TG Mean Percent Changes From Baseline After 8 Weeks A multicenter, doubleblind, placebo-controlled study. Placebo (N=36) −3% −4% +1% −4% 10 mg (N=18) −16% −22% +7% −15% 20 mg (N=19) −24% −32% +2% −11% 40 mg (N=18) −25% −34% +12% −24% Mean Percent Changes From Baseline After 6 Weeks Pooled analysis of 2 multicenter, doubleblind, placebo-controlled studies. Placebo (N=162) 0% −1% −1% +1% 80 mg (N=277) −27% −37% +3% −19% In another clinical trial, patients treated with pravastatin in combination with cholestyramine (70% of patients were taking cholestyramine 20 or 24 g per day) had reductions equal to or greater than 50% in LDL-C. Furthermore, pravastatin attenuated cholestyramine-induced increases in TG levels (which are themselves of uncertain clinical significance). The response to pravastatin in patients with Type IV hyperlipidemia (baseline TG > 200 mg/dL and LDL-C < 160 mg/dL) was evaluated in a subset of 429 patients from the CARE study. For pravastatin-treated subjects, the median (min, max) baseline TG level was 246 (200. 5) mg/dL (see Table 8. ) Table 8Patients with Fredrickson Type IV Hyperlipidemia Median (25 th th Pravastatin 40 mg (N=429) Placebo (N=430) TG −21. 3) Total-C −22. 8) LDL-C −31. 7 (−9, 10) HDL-C 7. 7) Non-HDL-C −27. 2 (−34, −18. 2, 7) The response to pravastatin in two doubleblind crossover studies of 46 patients with genotype E2/E2 and Fredrickson Table 9Patients with Fredrickson Type III Dysbetalipoproteinemia Median (min, max) % Change from Baseline Median (min, max) at Baseline (mg/dL) Median % Change (min, max) Pravastatin 40 mg (N=20) Study 1 Total-C 386. 5 (245, 672) −32. 6) TG 443 (275, 1299) −23. 7) VLDL-C a 206. 5 (110, 379) −43. 3) LDL-C 117. 5 (80, 170) −40. 6) HDL-C 30 (18, 88) 6. 4 (−45, 105. 6) Non-HDL-C 344. 5 (215, 646) −36. 8) a Median (min, max) at Baseline (mg/dL) Median % Change (min, max) Pravastatin 40 mg (N=26) Study 2 Total-C 340. 5, −13) TG 343. 8) VLDL-C 145 (71. 1) LDL-C 128. 5) HDL-C 38. 1, 58) 5 (−17. 7) Non-HDL-C 295. 5 (−81, −13. 5) A doubleblind, placebo-controlled study in 214 patients (100 boys and 114 girls) with heterozygous familial hypercholesterolemia (HeFH), aged 8 to 18 years was conducted for 2 years. The children (aged 8 to 13 years) were randomized to placebo (N=63) or 20 mg of pravastatin daily (N=65) and the adolescents (aged 14 to 18 years) were randomized to placebo (N=45) or 40 mg of pravastatin daily (N=41). Inclusion in the study required an LDL-C level > 95 th Pravastatin significantly decreased plasma levels of LDL-C, Total-C, and ApoB in both children and adolescents (see Table 10). The effect of pravastatin treatment in the 2 age groups was similar. Table 10Lipid-Lowering Effects of Pravastatin in Pediatric Patients with Heterozygous Familial Hypercholesterolemia: Least-Squares Mean % Change from Baseline at Month 24 (Last Observation Carried Forward: Intent-to-Treat) a Pravastatin 20 mg (Aged 8 to 13 years) N=65 Pravastatin 40 mg (Aged 14 to 18 years) N=41 Combined Pravastatin (Aged 8 to 18 years) N=106 Combined Placebo (Aged 8 to 18 years) N=108 95% CI of the Difference Between Combined Pravastatin and Placebo a b LDL-C −26. 83) HDL-C 1. 01) ApoB −23. 18) The mean achieved LDL-C was 186 mg/dL (range: 67 to 363 mg/dL) in the pravastatin group compared to 236 mg/dL (range: 105 to 438 mg/dL) in the placebo group. The safety and efficacy of pravastatin doses above 40 mg daily have not been studied in children. The long-term efficacy of pravastatin therapy in childhood to reduce morbidity and mortality in adulthood has not been established.
REFERENCES
N Engl J Med Reprod Toxicol N Engl J Med N Engl J Med N Engl J Med J Am Coll Cardiol Circ Control Clin Trials Circ

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