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Maralixibat

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Mar.23.2023

Maralixibat

Indications/Dosage

Labeled

  • Alagille syndrome-associated cholestatic pruritus

Off-Label

    † Off-label indication

    For the treatment of Alagille syndrome-associated cholestatic pruritus

    Maralixibat is designated as an orphan drug by the FDA for the treatment of cholestatic pruritus in patients with Alagille syndrome (ALGS).

    Oral dosage

    Adults

    190 mcg/kg/dose PO once daily 30 minutes before a meal in the morning; increase to 380 mcg/kg/dose once daily after 1 week, as tolerated (Max: 28.5 mg/day).[67014]

    Infants, Children, and Adolescents 3 months to 17 years

    190 mcg/kg/dose PO once daily 30 minutes before a meal in the morning; increase to 380 mcg/kg/dose once daily after 1 week, as tolerated (Max: 28.5 mg/day).[67014]

    Therapeutic Drug Monitoring

    Maximum Dosage Limits

    • Adults

      380 mcg/kg/day (Max: 28.5 mg/day) PO.

    • Geriatric

      Safety and efficacy have not been established.

    • Adolescents

      380 mcg/kg/day (Max: 28.5 mg/day) PO.

    • Children

      380 mcg/kg/day (Max: 28.5 mg/day) PO.

    • Infants

      3 to 11 months: 380 mcg/kg/day (Max: 28.5 mg/day) PO.

      1 to 2 months: Safety and efficacy have not been established.

    • Neonates

      Safety and efficacy have not been established.

    Patients with Hepatic Impairment Dosing

    Interrupt treatment if new onset hepatic function abnormalities occur. Once hepatic function returns to baseline or stabilizes at a new baseline, consider restarting maralixibat at 190 mcg/kg/day and increase to 380 mcg/kg/day as tolerated. Consider permanent discontinuation if abnormalities in liver tests recur or symptoms consistent with clinical hepatitis are observed. Permanently discontinue treatment if a patient experiences a hepatic decompensation event (e.g., variceal hemorrhage, ascites, hepatic encephalopathy).[67014]

    Patients with Renal Impairment Dosing

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    † Off-label indication
    Revision Date: 03/23/2023, 02:16:54 PM

    References

    67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

    How Supplied

    Maralixibat Oral solution

    Livmarli 9.5mg/mL Solution (79378-0110) (Mirum Pharmaceuticals, Inc.) nullLivmarli 9.5mg/mL Solution package photo

    Description/Classification

    Description

    Maralixibat is an ileal bile acid transporter (IBAT) inhibitor approved for the treatment of cholestatic pruritus in patients 3 months and older with Alagille syndrome (ALGS).[67014] ALGS is a rare, genetic disorder that can affect multiple organ systems, including the liver, heart, skeleton, eyes, and kidneys. ALGS causes abnormalities in the bile ducts that can progress to liver disease. Patients may present in the first 3 months of life with cholestasis, jaundice, poor weight gain and growth, and pruritus. The most prominent and problematic manifestation of ALGS is pruritus, which can lead to physical abrasions and scarring, as well as functional impacts (e.g., sleep and mood disorders) and deterioration in quality of life. Prior to maralixibat, treatment relied on supportive pharmacologic therapy for symptomatic relief (e.g., ursodeoxycholic acid, cholestyramine, antihistamines) or surgical intervention (e.g., liver transplantation).[67023][66823] Patients with ALGS treated with maralixibat during clinical trials (n = 31) demonstrated greater improvement in pruritus compared to placebo, based on caregiver-reported outcome. The most common adverse reactions are diarrhea, liver function test abnormalities, vomiting, abdominal pain, and fat-soluble vitamin deficiency. Monitor hepatic function and fat-soluble vitamin concentrations at baseline and periodically throughout treatment.[67014]

    Classifications

    • Alimentary Tract and Metabolism
      • Bile and Liver Therapy
        • Bile Therapy
          • Ileal Bile Acid Transporter (IBAT) Inhibitors
    Revision Date: 03/23/2023, 01:15:18 PM

    References

    66823 - Kamath BM, Stein P, Houwen RH, et al. Potential of ileal bile acid transporter inhibition as a therapeutic target in Alagille syndrome and progressive familial intrahepatic cholestasis. Liver Int 2020;40:1812-1822.67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.67023 - National Organization for Rare Disorders (NORD). Alagille Syndrome. Accessed October 1, 2021. Available on the World Wide Web at https://rarediseases.org/rare-diseases/alagille-syndrome/.

    Administration Information

    General Administration Information

    For storage information, see the specific product information within the How Supplied section.

    Route-Specific Administration

    Oral Administration

    Oral Liquid Formulations

    • Administer 30 minutes before a meal in the morning using a calibrated measuring device (0.5 mL, 1 mL, or 3 mL oral dosing dispenser, depending on the dose) to allow for accurate delivery.
    • If a dose is missed, take it as soon as possible within 12 hours of the time it is usually taken, and resume original dosing schedule. If a dose is missed by more than 12 hours, omit the dose and resume original dosing schedule.
    • Storage: After opening, store below 30 degrees C (86 degrees F). Discard any remaining solution 100 days after first opening the bottle.[67014]

    Clinical Pharmaceutics Information

    From Trissel's 2‚Ñ¢ Clinical Pharmaceutics Database
      Revision Date: 03/15/2023, 01:11:09 PM

      References

      67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Adverse Reactions

      Mild

      • abdominal pain
      • diarrhea
      • nausea
      • vomiting

      Moderate

      • ascites
      • dehydration
      • elevated hepatic enzymes
      • hepatitis
      • vitamin A deficiency
      • vitamin D deficiency
      • vitamin K deficiency

      Severe

      • bone fractures
      • GI bleeding
      • hepatic decompensation
      • hepatic encephalopathy

      Treatment-emergent elevated hepatic enzymes were observed during maralixibat clinical trials. Elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were reported in 18.6% of maralixibat-treated patients. In a pooled analysis of patients with Alagille syndrome receiving maralixibat treatment (n = 86), ALT increases to more than 3 times baseline occurred in 24% of patients and increases to more than 5 times baseline occurred in 2% of patients. Increased ALT led to treatment discontinuation in 7 (8.1%) patients and dose reduction or treatment interruption in 3 (3.5%) patients. In most patients, the elevations resolved or improved after treatment discontinuation or dose modification. In some patients, the elevations resolved or improved without dosing modification. AST increases to more than 3 times baseline occurred in 14% of maralixibat-treated patients and an increase to more than 5 times baseline occurred in 1 patient. Elevations in transaminases were asymptomatic and not associated with bilirubin elevations or other laboratory abnormalities. Increases in bilirubin above baseline were reported in 4 patients (4.6%); maralixibat was discontinued in 2 of these patients, who had elevated bilirubin at baseline. Monitor hepatic enzymes and INR at baseline and during treatment. Interrupt treatment if new onset abnormalities occur. Once hepatic enzymes return to baseline or stabilize at a new baseline, consider restarting maralixibat at 190 mcg/kg/day and increase as tolerated. Consider treatment discontinuation for persistent or recurrent hepatic enzyme abnormalities or development of symptoms consistent with clinical hepatitis. Permanently discontinue treatment if a patient progresses to portal hypertension or experiences a hepatic decompensation event (e.g., variceal hemorrhage, ascites, hepatic encephalopathy).[67014]

      Diarrhea, abdominal pain, and vomiting are the most commonly reported adverse reactions in maralixibat-treated patients. Diarrhea was reported in 55.8% of maralixibat-treated patients during clinicals trials. Abdominal pain, defined as abdominal discomfort, abdominal distension, abdominal pain, lower abdominal pain, and upper abdominal pain, occurred in 53.5% of maralixibat-treated patients during clinicals trials. Vomiting (40.7%), nausea (8.1%), and GI bleeding (10.4%), defined as hematochezia, hematemesis, gastrointestinal hemorrhage, and melena, were also reported. Three patients (3%) experienced vomiting as a serious adverse reaction requiring hospitalization or intravenous fluid. Treatment interruptions or dose reductions occurred in 5 (6%) patients due to diarrhea, abdominal pain, or vomiting. If diarrhea or vomiting occurs, monitor for dehydration and treat promptly. If diarrhea, abdominal pain, and/or vomiting occurs, and no other etiologies are identified, consider reducing the maralixibat dose or interrupting treatment. Consider treatment interruption if patients experience persistent diarrhea or have diarrhea with accompanying signs and symptoms such as bloody stool, vomiting, dehydration requiring treatment, or fever. Once diarrhea, abdominal pain, and/or vomiting have resolved, restart maralixibat at 190 mcg/kg/day and increase the dose as tolerated. Consider discontinuing treatment if symptoms occur upon rechallenge.[67014]

      Maralixibat may affect the absorption of fat-soluble vitamins (A, D, E, and K) resulting in vitamin A deficiency, vitamin D deficiency, vitamin E deficiency, and vitamin K deficiency. In clinical trials, fat-soluble vitamin deficiency, defined as A, D, E, or K deficiency, or INR increase, was reported in 25.6% of maralixibat-treated patients. Obtain serum fat-soluble vitamin concentrations and INR (to monitor for vitamin K) at baseline and periodically during treatment. Supplement with fat-soluble vitamins if a deficiency is diagnosed. Discontinue maralixibat if the deficiency persists or worsens despite supplementation.[67014]

      Bone fractures, defined as tibia fracture, rib fracture, hand fracture, humerus fracture, pathological fracture, forearm fracture, and clavicle fracture, were reported in 9.3% of maralixibat-treated patients.[67014]

      Revision Date: 10/22/2021, 01:09:33 PM

      References

      67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Contraindications/Precautions

      Absolute contraindications are italicized.

      • ascites
      • breast-feeding
      • hepatic decompensation
      • hepatic encephalopathy
      • hepatitis
      • pregnancy
      • vitamin A deficiency
      • vitamin D deficiency
      • vitamin K deficiency

      Patients with Alagille syndrome may have hepatic impairment at baseline. Establish a baseline pattern of hepatic function variability prior to maralixibat initiation so that potential signs of liver injury can be identified. Monitor alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, direct bilirubin, and INR during treatment. Interrupt treatment if new onset hepatic function abnormalities occur. Once hepatic function returns to baseline or stabilizes at a new baseline, consider restarting maralixibat at 190 mcg/kg/day and increase as tolerated. Consider treatment discontinuation for persistent or recurrent hepatic function abnormalities or development of symptoms consistent with clinical hepatitis. Permanently discontinue treatment if a patient progresses to portal hypertension or experiences a hepatic decompensation event (e.g., variceal hemorrhage, ascites, hepatic encephalopathy). Safety and efficacy of maralixibat have not been established in patients with clinically significant portal hypertension or decompensated cirrhosis.[67014]

      Maralixibat may affect the absorption of fat-soluble vitamins (A, D, E, and K). Obtain serum fat-soluble vitamin concentrations and INR (to monitor for vitamin K) at baseline and periodically during treatment. Supplement with fat-soluble vitamins if vitamin A deficiency, vitamin D deficiency, vitamin E deficiency, or vitamin K deficiency is diagnosed. Discontinue maralixibat if the deficiency persists or worsens despite supplementation.[67014]

      Maralixibat use during pregnancy is not expected to result in measurable fetal exposure due to low systemic absorption after oral administration. Maralixibat may inhibit the absorption of fat-soluble vitamins; increased fat-soluble vitamin supplementation may be needed during pregnancy. Monitor for fat-soluble vitamin deficiency and supplement as needed. In animal reproduction studies, no developmental effects were observed.[67014]

      Breast-feeding is not expected to result in exposure of the infant to maralixibat at recommended doses; maralixibat has low absorption after oral administration. However, there are no data on the presence of maralixibat in human milk, the effects on the breast-fed infant, or the effects on milk production. Maralixibat may reduce the absorption of fat-soluble vitamins. Monitor fat-soluble vitamin concentrations and increase intake if deficiency is observed during lactation. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.[67014]

      Revision Date: 10/01/2021, 04:49:19 PM

      References

      67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Mechanism of Action

      Maralixibat is a reversible inhibitor of the ileal bile acid transporter (IBAT). The mechanism by which maralixibat improves pruritus in patients with Alagille syndrome (ALGS) is not completely understood; however, it may involve inhibition of the IBAT. Inhibition of the IBAT blocks the reabsorption of bile acids (primarily in the salt form) from the terminal ileum, interrupting enterohepatic circulation by shunting the bile acids away from the liver and towards fecal excretion which reduces the bile acid pool. Intrahepatic accumulation of bile acids can damage hepatic tissue and spill over into the systemic circulation.[66823][67014]

      Revision Date: 10/06/2021, 10:01:43 AM

      References

      66823 - Kamath BM, Stein P, Houwen RH, et al. Potential of ileal bile acid transporter inhibition as a therapeutic target in Alagille syndrome and progressive familial intrahepatic cholestasis. Liver Int 2020;40:1812-1822.67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Pharmacokinetics

      Maralixibat is administered orally. It is 91% protein bound; no maralixibat metabolites have been detected in plasma. After a single dose, maralixibat is primarily eliminated in the feces (73%, with 94% unchanged) with a mean half-life of 1.6 hours. Three minor metabolites have been detected in the feces, which account for less than 3% of maralixibat-associated fecal radioactivity.[67014]

       

      Serum bile acid concentrations decrease as early week 12 of treatment and, in a clinical trial, the reduction was generally maintained until the end of the 18-week treatment period.[67014]

       

      Affected cytochrome P450 isoenzymes and drug transporters: CYP3A4, OATP2B1

      Maralixibat inhibits CYP3A4 in vitro; however, clinically significant drug interactions are not expected. Maralixibat inhibits the drug transporter OATP2B1 in vitro, which may result in reduced absorption of medications that rely on OATP2B1-mediated uptake in the GI tract. Maralixibat is not a substrate of the drug transporters MDR1 (P-gp), BCRP, OATP1B1, OATP1B3, or OATP2B2. In vitro, maralixibat does not induce CYP1A2, 2B6, or 3A4, nor inhibit CYP1A2, 2B6, 2C8, 2C9, 2C19, or 2D6 at clinically relevant concentrations. In vitro, maralixibat does not inhibit the transporters MDR1 (P-gp), BCRP, OAT1, OAT3, OATP1B1, OATP1B3, PEPT1, OCT1, OCT2, OCT3, OCTN1, OCTN2, MRP2, MATE1, or MATE2-K at clinically relevant concentrations.[67014]

      Route-Specific Pharmacokinetics

      Oral Route

      Maralixibat is minimally absorbed after oral administration. Under fasted conditions, AUC and Cmax increased in a dose-dependent manner with increases of 4.6- and 2.4-fold, respectively, after a 3.3-fold dose increase from 30 to 100 mg. Maralixibat accumulation was not observed after repeated oral administration in healthy adults at doses up to 100 mg once daily. The highest measurable maralixibat concentration in a pediatric patient was 5.93 ng/mL after a 380 mcg/kg once daily dose; in the majority of plasma samples, concentrations were below the limit of quantification (0.25 ng/mL). The effect of food on the systemic exposure of maralixibat is not clinically significant. Concomitant administration with a high-fat meal decreased AUC and Cmax 64.8% and 85.8%, respectively.[67014]

      Special Populations

      Renal Impairment

      The pharmacokinetics of maralixibat were not studied in patients with impaired renal function, including those with end-stage renal disease or those on hemodialysis.[67014]

      Revision Date: 10/06/2021, 11:11:33 AM

      References

      67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Pregnancy/Breast-feeding

      pregnancy

      Maralixibat use during pregnancy is not expected to result in measurable fetal exposure due to low systemic absorption after oral administration. Maralixibat may inhibit the absorption of fat-soluble vitamins; increased fat-soluble vitamin supplementation may be needed during pregnancy. Monitor for fat-soluble vitamin deficiency and supplement as needed. In animal reproduction studies, no developmental effects were observed.[67014]

      breast-feeding

      Breast-feeding is not expected to result in exposure of the infant to maralixibat at recommended doses; maralixibat has low absorption after oral administration. However, there are no data on the presence of maralixibat in human milk, the effects on the breast-fed infant, or the effects on milk production. Maralixibat may reduce the absorption of fat-soluble vitamins. Monitor fat-soluble vitamin concentrations and increase intake if deficiency is observed during lactation. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.[67014]

      Revision Date: 10/01/2021, 04:49:19 PM

      References

      67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Interactions

      Level 3 (Moderate)

      • Bile acid sequestrants
      • Cholestyramine
      • Colesevelam
      • Colestipol

      Level 4 (Minor)

      • Amlodipine; Atorvastatin
      • Atorvastatin
      • Ezetimibe; Simvastatin
      • Fluvastatin
      • HMG-CoA reductase inhibitors
      • Lovastatin
      • Pitavastatin
      • Pravastatin
      • Rosuvastatin
      • Rosuvastatin; Ezetimibe
      • Simvastatin
      Amlodipine; Atorvastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Atorvastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Bile acid sequestrants: (Moderate) Take maralixibat at least 4 hours before or 4 hours after taking a bile acid sequestrant. Bile acid sequestrants may bind maralixibat in the gut, which may reduce its efficacy. [67014] Cholestyramine: (Moderate) Take maralixibat at least 4 hours before or 4 hours after taking a bile acid sequestrant. Bile acid sequestrants may bind maralixibat in the gut, which may reduce its efficacy. [67014] Colesevelam: (Moderate) Take maralixibat at least 4 hours before or 4 hours after taking a bile acid sequestrant. Bile acid sequestrants may bind maralixibat in the gut, which may reduce its efficacy. [67014] Colestipol: (Moderate) Take maralixibat at least 4 hours before or 4 hours after taking a bile acid sequestrant. Bile acid sequestrants may bind maralixibat in the gut, which may reduce its efficacy. [67014] Ezetimibe; Simvastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Fluvastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] HMG-CoA reductase inhibitors: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Lovastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Pitavastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Pravastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Rosuvastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Rosuvastatin; Ezetimibe: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014] Simvastatin: (Minor) Maralixibat may reduce the oral absorption of HMG-CoA reductase inhibitors, also known as statins, which may reduce their efficacy. This risk is greatest with maralixibat doses greater than 4.75 mg. Monitor statin therapy and adjust the dose as needed based on clinical response. Maralixibat is a OATP2B1 inhibitor and statins are OATP2B1 substrates. [67014]
      Revision Date: 09/29/2023, 01:50:00 AM

      References

      67014 - Livmarli (maralixibat) oral solution package insert. Foster City, CA. Mirum Pharmaceuticals, Inc. 2023 March.

      Monitoring Parameters

      • INR
      • LFTs
      • serum bilirubin

      US Drug Names

      • Livmarli
      ;