Ezetimibe

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# Overview
Ezetimibe is a dietary cholesterol absorption inhibitor that is FDA approved for the treatment of primary hyperlipidemia, homozygous familial hypercholesterolemia (HoFH), homozygous sitosterolemia..   Common adverse reactions include diarrhea, arthralgia, myalgia, nasopharyngitis, sinusitis, upper respiratory infection..

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

### General Dosing Information
- Recommended dosage:  10 mg PO qd
- Ezetimibe can be administered with or without food.

### Concomitant Lipid-Lowering Therapy
- Dosing information
- Ezetimibe may be administered with a statin (in patients with primary hyperlipidemia) or with fenofibrate (in patients with mixed hyperlipidemia) for incremental effect. For convenience, the daily dose of Ezetimibe may be taken at the same time as the statin or fenofibrate, according to the dosing recommendations for the respective medications.

### Coadministration with Bile Acid Sequestrants
- Dosing information
- Dosing of Ezetimibe should occur either 2 hours before or 4 hours after administration of a bile acid sequestrant.

### Patients with Hepatic Impairment
- Dosing information
- No dosage adjustment is necessary in patients with mild hepatic impairment.

### Patients with Renal Impairment
- Dosing information
- No dosage adjustment is necessary in patients with renal impairment. When given with simvastatin in patients with moderate to severe renal impairment (estimated glomerular filtration rate <60 mL/min/1.73 m2), doses of simvastatin exceeding 20 mg should be used with caution and close monitoring.

### Geriatric Patients
- Dosing information
- No dosage adjustment is necessary in geriatric patients.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information about Off-Label Guideline-Supported Use of Ezetimibe  in adult patients.

### NonGuideline-Supported Use
There is limited information about Off-Label NonGuideline-Supported Use of Ezetimibe  in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
FDA Package Insert for Ezetimibe contains no information regarding Pediatric Indications and Dosage.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information about Off-Label Guideline-Supported Use of Ezetimibe  in pediatric patients.

### NonGuideline-Supported Use
There is limited information about Off-Label NonGuideline-Supported Use of Ezetimibe  in pediatric patients.

# Contraindications
Ezetimibe is contraindicated in the following conditions:
- The combination of Ezetimibe with a statin is contraindicated in patients with active liver disease or unexplained persistent elevations in hepatic transaminase levels.
- Women who are pregnant or may become pregnant because statins decrease cholesterol synthesis and possibly the synthesis of other biologically active substances derived from cholesterol, Ezetimibe in combination with a statin may cause fetal harm when administered to pregnant women.
- Additionally, there is no apparent benefit to therapy during pregnancy, and safety in pregnant women has not been established.
- If the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus and the lack of known clinical benefit with continued use during pregnancy.
- Nursing mothers-Because statins may pass into breast milk, and because statins have the potential to cause serious adverse reactions in nursing infants, women who require Ezetimibe treatment in combination with a statin should be advised not to nurse their infants.
- Patients with a known hypersensitivity to any component of this product. hypersensitivity reactions including anaphylaxis, angioedema, rash and urticaria have been reported with Ezetimibe.

# Warnings

### Use with statins or fenofibrate
Concurrent administration of Ezetimibe with a specific statin or fenofibrate should be in accordance with the product labeling for that medication.

### Liver Enzymes
- In controlled clinical monotherapy studies, the incidence of consecutive elevations (3  the upper limit of normal ) in hepatic transaminase levels was similar between Ezetimibe (0.5%) and placebo (0.3%).
- In controlled clinical combination studies of Ezetimibe initiated concurrently with a statin, the incidence of consecutive elevations (3  ULN) in hepatic transaminase levels was 1.3% for patients treated with Ezetimibe administered with statins and 0.4% for patients treated with statins alone.
- These elevations in transaminases were generally asymptomatic, not associated with cholestasis, and returned to baseline after discontinuation of therapy or with continued treatment.
- When Ezetimibe is coadministered with a statin, liver tests should be performed at initiation of therapy and according to the recommendations of the statin.
- Should an increase in ALT or AST 3  ULN persist, consider withdrawal of Ezetimibe and/or the statin.

### Myopathy/Rhabdomyolysis
- In clinical trials, there was no excess of myopathy or rhabdomyolysis associated with Ezetimibe compared with the relevant control arm (placebo or statin alone).
- However, myopathy and rhabdomyolysis are known adverse reactions to statins and other lipid-lowering drugs.
- In clinical trials, the incidence of creatine phosphokinase (CPK) >10  ULN was 0.2% for Ezetimibe vs. 0.1% for placebo, and 0.1% for Ezetimibe coadministered with a statin vs. 0.4% for statins alone.
- Risk for skeletal muscle toxicity increases with higher doses of statin, advanced age (>65), hypothyroidism, renal impairment, and depending on the statin used, concomitant use of other drugs.
- In post-marketing experience with Ezetimibe, cases of myopathy and rhabdomyolysis have been reported.
- Most patients who developed rhabdomyolysis were taking a statin prior to initiating Ezetimibe.
- However, rhabdomyolysis has been reported with Ezetimibe monotherapy and with the addition of Ezetimibe to agents known to be associated with increased risk of rhabdomyolysis, such as fibrates.
- Ezetimibe and any statin or fibrate that the patient is taking concomitantly should be immediately discontinued if myopathy is diagnosed or suspected.
- The presence of muscle symptoms and a CPK level >10  the ULN indicates myopathy.

### Hepatic Impairment
Due to the unknown effects of the increased exposure to ezetimibe in patients with moderate to severe hepatic impairment, Ezetimibe is not recommended in these patients.

# Adverse Reactions

## Clinical Trials Experience
The following serious adverse reactions are discussed in greater detail in other sections of the label:
- Liver enzyme abnormalities
- Rhabdomyolysis and myopathy
Monotherapy Studies: In the Ezetimibe controlled clinical trials database (placebo-controlled) of 2396 patients with a median treatment duration of 12 weeks (range 0 to 39 weeks), 3.3% of patients on Ezetimibe and 2.9% of patients on placebo discontinued due to adverse reactions. The most common adverse reactions in the group of patients treated with Ezetimibe that led to treatment discontinuation and occurred at a rate greater than placebo were:
- Arthralgia (0.3%)
- Dizziness (0.2%)
- Gamma-glutamyltransferase increased (0.2%)
The most commonly reported adverse reactions (incidence 2% and greater than placebo) in the Ezetimibe monotherapy controlled clinical trial database of 2396 patients were: upper respiratory tract infection (4.3%), diarrhea (4.1%), arthralgia (3.0%), sinusitis (2.8%), and pain in extremity (2.7%).
Statin Coadministration Studies: In the Ezetimibe + statin controlled clinical trials database of 11,308 patients with a median treatment duration of 8 weeks (range 0 to 112 weeks), 4.0% of patients on Ezetimibe + statin and 3.3% of patients on statin alone discontinued due to adverse reactions. The most common adverse reactions in the group of patients treated with Ezetimibe + statin that led to treatment discontinuation and occurred at a rate greater than statin alone were:
- Alanine aminotransferase increased (0.6%)
- Myalgia (0.5%)
- Fatigue, aspartate aminotransferase increased, headache, and pain in extremity (each at 0.2%)
The most commonly reported adverse reactions (incidence 2% and greater than statin alone) in the Ezetimibe + statin controlled clinical trial database of 11,308 patients were: nasopharyngitis (3.7%), myalgia (3.2%), upper respiratory tract infection (2.9%), arthralgia (2.6%) and diarrhea (2.5%).

## Clinical Trials Experience
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice.

### Monotherapy
In 10 double-blind, placebo-controlled clinical trials, 2396 patients with primary hyperlipidemia (age range 986 years, 50% women, 90% Caucasians, 5% Blacks, 3% Hispanics, 2% Asians) and elevated LDL-C were treated with Ezetimibe 10 mg/day for a median treatment duration of 12 weeks (range 0 to 39 weeks).
Adverse reactions reported in 2% of patients treated with Ezetimibe and at an incidence greater than placebo in placebo-controlled studies of Ezetimibe, regardless of causality assessment, are shown in Table 1.

### Combination with a statin
In 28 double-blind, controlled (placebo or active-controlled) clinical trials, 11,308 patients with primary hyperlipidemia (age range 1093 years, 48% women, 85% Caucasians, 7% Blacks, 4% Hispanics, 3% Asians) and elevated LDL-C were treated with Ezetimibe 10 mg/day concurrently with or added to on-going statin therapy for a median treatment duration of 8 weeks (range 0 to 112 weeks).
The incidence of consecutive increased transaminases (3  ULN) was higher in patients receiving Ezetimibe administered with statins (1.3%) than in patients treated with statins alone (0.4%).
Clinical adverse reactions reported in 2% of patients treated with Ezetimibe + statin and at an incidence greater than statin, regardless of causality assessment, are shown in Table 2.

### Combination with Fenofibrate
- This clinical study involving 625 patients with mixed dyslipidemia (age range 2076 years, 44% women, 79% Caucasians, 0.1% Blacks, 11% Hispanics, 5% Asians) treated for up to 12 weeks and 576 patients treated for up to an additional 48 weeks evaluated coadministration of Ezetimibe and Fenofibrate.
- This study was not designed to compare treatment groups for infrequent events.
- Incidence rates (95% CI) for clinically important elevations (3  ULN, consecutive) in hepatic transaminase levels were 4.5% (1.9, 8.8) and 2.7% (1.2, 5.4) for Fenofibrate monotherapy (n=188) and Ezetimibe coadministered with Fenofibrate (n=183), respectively, adjusted for treatment exposure.
- Corresponding incidence rates for cholecystectomy were 0.6% (95% CI: 0.0%, 3.1%) and 1.7% (95% CI: 0.6%, 4.0%) for Fenofibrate monotherapy and Ezetimibe coadministered with Fenofibrate, respectively.
- The numbers of patients exposed to coadministration therapy as well as Fenofibrate and ezetimibe monotherapy were inadequate to assess gallbladder disease risk.
- There were no CPK elevations >10  ULN in any of the treatment groups.

## Postmarketing Experience
Because the reactions below are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
The following additional adverse reactions have been identified during post-approval use of Ezetimibe:
Hypersensitivity reactions, including anaphylaxis, angioedema, rash, and urticaria; erythema multiforme; arthralgia; myalgia; elevated creatine phosphokinase; myopathy/Rhabdomyolysis; elevations in liver transaminases; hepatitis; abdominal pain; thrombocytopenia; pancreatitis; nausea; dizziness; paresthesia; depression; headache; cholelithiasis; cholecystitis.

# Drug Interactions

### Cyclosporine
Caution should be exercised when using Ezetimibe and cyclosporine concomitantly due to increased exposure to both ezetimibe and cyclosporine. Cyclosporine concentrations should be monitored in patients receiving Ezetimibe and cyclosporine.
The degree of increase in ezetimibe exposure may be greater in patients with severe renal insufficiency. In patients treated with cyclosporine, the potential effects of the increased exposure to ezetimibe from concomitant use should be carefully weighed against the benefits of alterations in lipid levels provided by ezetimibe.

### Fibrates
The efficacy and safety of coadministration of ezetimibe with fibrates other than fenofibrate have not been studied.
Fibrates may increase cholesterol excretion into the bile, leading to cholelithiasis. In a preclinical study in dogs, ezetimibe increased cholesterol in the gallbladder bile. Coadministration of Ezetimibe with Fibrates other than fenofibrate is not recommended until use in patients is adequately studied.

### Fenofibrate
If cholelithiasis is suspected in a patient receiving Ezetimibe and fenofibrate, gallbladder studies are indicated and alternative lipid-lowering therapy should be considered and the product labeling for fenofibrate.

### Cholestyramine
Concomitant cholestyramine administration decreased the mean area under the curve (AUC) of total ezetimibe approximately 55%. The incremental LDL-C reduction due to adding ezetimibe to cholestyramine may be reduced by this interaction.

### Coumarin Anticoagulants
If ezetimibe is added to warfarin, a coumarin anticoagulant, the International Normalized Ratio (INR) should be appropriately monitored.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
There are no adequate and well-controlled studies of ezetimibe in pregnant women. Ezetimibe should be used during pregnancy only if the potential benefit justifies the risk to the fetus.
In oral (gavage) embryo-fetal development studies of ezetimibe conducted in rats and rabbits during organogenesis, there was no evidence of embryolethal effects at the doses tested (250, 500, 1000 mg/kg/day). In rats, increased incidences of common fetal skeletal findings (extra pair of thoracic ribs, unossified cervical vertebral centra, shortened ribs) were observed at 1000 mg/kg/day (~10  the human exposure at 10 mg daily based on AUC024hr for total ezetimibe). In rabbits treated with ezetimibe, an increased incidence of extra thoracic ribs was observed at 1000 mg/kg/day (150  the human exposure at 10 mg daily based on AUC024hr for total ezetimibe). Ezetimibe crossed the placenta when pregnant rats and rabbits were given multiple oral doses.
Multiple-dose studies of ezetimibe given in combination with statins in rats and rabbits during organogenesis result in higher ezetimibe and statin exposures. Reproductive findings occur at lower doses in combination therapy compared to monotherapy.
All statins are contraindicated in pregnant and nursing women. When Ezetimibe is administered with a statin in a woman of childbearing potential, refer to the pregnancy category and product labeling for the statin.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Ezetimibe in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Ezetimibe during labor and delivery.

### Nursing Mothers
It is not known whether ezetimibe is excreted into human breast milk. In rat studies, exposure to total ezetimibe in nursing pups was up to half of that observed in maternal plasma. Because many drugs are excreted in human milk, caution should be exercised when Ezetimibe is administered to a nursing woman. Ezetimibe should not be used in nursing mothers unless the potential benefit justifies the potential risk to the infant.

### Pediatric Use
The effects of Ezetimibe coadministered with simvastatin (n=126) compared to simvastatin monotherapy (n=122) have been evaluated in adolescent boys and girls with heterozygous familial hypercholesterolemia (HeFH). In a multicenter, double-blind, controlled study followed by an open-label phase, 142 boys and 106 postmenarchal girls, 10 to 17 years of age (mean age 14.2 years, 43% females, 82% Caucasians, 4% Asian, 2% Blacks, 13% multi-racial) with HeFH were randomized to receive either Ezetimibe coadministered with simvastatin or simvastatin monotherapy. Inclusion in the study required 1) a baseline LDL-C level between 160 and 400 mg/dL and 2) a medical history and clinical presentation consistent with HeFH. The mean baseline LDL-C value was 225 mg/dL (range: 161351 mg/dL) in the Ezetimibe coadministered with simvastatin group compared to 219 mg/dL (range: 149336 mg/dL) in the simvastatin monotherapy group. The patients received coadministered Ezetimibe and simvastatin (10 mg, 20 mg, or 40 mg) or simvastatin monotherapy (10 mg, 20 mg, or 40 mg) for 6 weeks, coadministered Ezetimibe and 40-mg simvastatin or 40-mg simvastatin monotherapy for the next 27 weeks, and open-label coadministered Ezetimibe and simvastatin (10 mg, 20 mg, or 40 mg) for 20 weeks thereafter.
The results of the study at Week 6 are summarized in Table 3. Results at Week 33 were consistent with those at Week 6.
From the start of the trial to the end of Week 33, discontinuations due to an adverse reaction occurred in 7 (6%) patients in the Ezetimibe coadministered with simvastatin group and in 2 (2%) patients in the simvastatin monotherapy group.
During the trial, hepatic transaminase elevations (two consecutive measurements for ALT and/or AST 3  ULN) occurred in four (3%) individuals in the Ezetimibe coadministered with simvastatin group and in two (2%) individuals in the simvastatin monotherapy group. Elevations of CPK (10  ULN) occurred in two (2%) individuals in the Ezetimibe coadministered with simvastatin group and in zero individuals in the simvastatin monotherapy group.
In this limited controlled study, there was no significant effect on growth or sexual maturation in the adolescent boys or girls, or on menstrual cycle length in girls.
Coadministration of Ezetimibe with simvastatin at doses greater than 40 mg/day has not been studied in adolescents. Also, Ezetimibe has not been studied in patients younger than 10 years of age or in pre-menarchal girls.
Based on total ezetimibe (ezetimibe + ezetimibe-glucuronide), there are no pharmacokinetic differences between adolescents and adults. Pharmacokinetic data in the pediatric population less than 10 years of age are not available.

### Geriatic Use

### Monotherapy Studies
Of the 2396 patients who received Ezetimibe in clinical studies, 669 (28%) were 65 and older, and 111 (5%) were 75 and older.

### Statin Coadministration Studies
Of the 11,308 patients who received Ezetimibe + statin in clinical studies, 3587 (32%) were 65 and older, and 924 (8%) were 75 and older.
No overall differences in safety and effectiveness were observed between these patients and younger patients, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

### Gender
There is no FDA guidance on the use of Ezetimibe with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Ezetimibe with respect to specific racial populations.

### Renal Impairment
When used as monotherapy, no dosage adjustment of Ezetimibe is necessary.
In the Study of Heart and Renal Protection (SHARP) trial of 9270 patients with moderate to severe renal impairment (6247 non-dialysis patients with median serum creatinine 2.5 mg/dL and median estimated glomerular filtration rate 25.6 mL/min/1.73 m2, and 3023 dialysis patients), the incidence of serious adverse events, adverse events leading to discontinuation of study treatment, or adverse events of special interest (musculoskeletal adverse events, liver enzyme abnormalities, incident cancer) was similar between patients ever assigned to ezetimibe 10 mg plus simvastatin 20 mg (n=4650) or placebo (n=4620) during a median follow-up of 4.9 years. However, because renal impairment is a risk factor for statin-associated myopathy, doses of simvastatin exceeding 20 mg should be used with caution and close monitoring when administered concomitantly with Ezetimibe in patients with moderate to severe renal impairment.

### Hepatic Impairment
Ezetimibe is not recommended in patients with moderate to severe hepatic impairment.
Ezetimibe given concomitantly with a statin is contraindicated in patients with active liver disease or unexplained persistent elevations of hepatic transaminase levels.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Ezetimibe in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Ezetimibe in patients who are immunocompromised.

# Administration and Monitoring

### Administration
Oral

### Monitoring
FDA Package Insert for ezetimibe contains no information regarding drug monitoring.

# IV Compatibility
FDA Package Insert for ezetimibe contains no information regarding IV Compatibility.

# Overdosage
In clinical studies, administration of ezetimibe, 50 mg/day to 15 healthy subjects for up to 14 days, 40 mg/day to 18 patients with primary hyperlipidemia for up to 56 days, and 40 mg/day to 27 patients with homozygous sitosterolemia for 26 weeks was generally well tolerated. One female patient with homozygous sitosterolemia took an accidental overdose of ezetimibe 120 mg/day for 28 days with no reported clinical or laboratory adverse events.
In the event of an overdose, symptomatic and supportive measures should be employed.

# Pharmacology

## Mechanism of Action
Ezetimibe reduces blood cholesterol by inhibiting the absorption of cholesterol by the small intestine. In a 2-week clinical study in 18 hypercholesterolemic patients, Ezetimibe inhibited intestinal cholesterol absorption by 54%, compared with placebo. Ezetimibe had no clinically meaningful effect on the plasma concentrations of the fat-soluble vitamins A, D, and E (in a study of 113 patients), and did not impair adrenocortical steroid hormone production (in a study of 118 patients).
The cholesterol content of the liver is derived predominantly from three sources. The liver can synthesize cholesterol, take up cholesterol from the blood from circulating lipoproteins, or take up cholesterol absorbed by the small intestine. Intestinal cholesterol is derived primarily from cholesterol secreted in the bile and from dietary cholesterol.
Ezetimibe has a mechanism of action that differs from those of other classes of cholesterol-reducing compounds (statins, bile acid sequestrants , fibric acid derivatives, and plant stanols). The molecular target of ezetimibe has been shown to be the sterol transporter, Niemann-Pick C1-Like 1 (NPC1L1), which is involved in the intestinal uptake of cholesterol and phytosterols.
Ezetimibe does not inhibit cholesterol synthesis in the liver, or increase bile acid excretion. Instead, ezetimibe localizes at the brush border of the small intestine and inhibits the absorption of cholesterol, leading to a decrease in the delivery of intestinal cholesterol to the liver. This causes a reduction of hepatic cholesterol stores and an increase in clearance of cholesterol from the blood; this distinct mechanism is complementary to that of statins and of fenofibrate.

## Structure
Ezetimibe (ezetimibe) is in a class of lipid-lowering compounds that selectively inhibits the intestinal absorption of cholesterol and related phytosterols. The chemical name of ezetimibe is 1-(4-fluorophenyl)-3(R)--4(S)-(4-hydroxyphenyl)-2-azetidinone. The empirical formula is C24H21F2NO3. Its molecular weight is 409.4 and its structural formula is:
Ezetimibe is a white, crystalline powder that is freely to very soluble in ethanol, methanol, and acetone and practically insoluble in water. Ezetimibe has a melting point of about 163C and is stable at ambient temperature. Ezetimibe is available as a tablet for oral administration containing 10 mg of ezetimibe and the following inactive ingredients: croscarmellose sodium NF, lactose monohydrate NF, magnesium stearate NF, microcrystalline cellulose NF, povidone USP, and sodium lauryl sulfate NF.

## Pharmacodynamics
Clinical studies have demonstrated that elevated levels of total-C, LDL-C and Apo B, the major protein constituent of LDL, promote human atherosclerosis. In addition, decreased levels of HDL-C are associated with the development of atherosclerosis. Epidemiologic studies have established that cardiovascular morbidity and mortality vary directly with the level of total-C and LDL-C and inversely with the level of HDL-C. Like LDL, cholesterol-enriched triglyceride-rich lipoproteins, including very-low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), and remnants, can also promote atherosclerosis. The independent effect of raising HDL-C or lowering TG on the risk of coronary and cardiovascular morbidity and mortality has not been determined.
Ezetimibe reduces total-C, LDL-C, Apo B, non-HDL-C, and TG, and increases HDL-C in patients with hyperlipidemia. Administration of Ezetimibe with a statin is effective in improving serum total-C, LDL-C, Apo B, non-HDL-C, TG, and HDL-C beyond either treatment alone. Administration of Ezetimibe with fenofibrate is effective in improving serum total-C, LDL-C, Apo B, and non-HDL-C in patients with mixed hyperlipidemia as compared to either treatment alone. The effects of ezetimibe given either alone or in addition to a statin or fenofibrate on cardiovascular morbidity and mortality have not been established.

## Pharmacokinetics

### Absorption
After oral administration, ezetimibe is absorbed and extensively conjugated to a pharmacologically active phenolic glucuronide (ezetimibe-glucuronide). After a single 10-mg dose of Ezetimibe to fasted adults, mean ezetimibe peak plasma concentrations (Cmax) of 3.4 to 5.5 ng/mL were attained within 4 to 12 hours (Tmax). Ezetimibe-glucuronide mean Cmax values of 45 to 71 ng/mL were achieved between 1 and 2 hours (Tmax). There was no substantial deviation from dose proportionality between 5 and 20 mg. The absolute bioavailability of ezetimibe cannot be determined, as the compound is virtually insoluble in aqueous media suitable for injection.

### Effect of Food on Oral Absorption
Concomitant food administration (high-fat or non-fat meals) had no effect on the extent of absorption of ezetimibe when administered as Ezetimibe 10-mg tablets. The Cmaxvalue of ezetimibe was increased by 38% with consumption of high-fat meals. Ezetimibe can be administered with or without food.

### Distribution
Ezetimibe and ezetimibe-glucuronide are highly bound (>90%) to human plasma proteins.

### Metabolism and Excretion
Ezetimibe is primarily metabolized in the small intestine and liver via glucuronide conjugation (a phase II reaction) with subsequent biliary and renal excretion. Minimal oxidative metabolism (a phase I reaction) has been observed in all species evaluated.
In humans, ezetimibe is rapidly metabolized to ezetimibe-glucuronide. Ezetimibe and ezetimibe-glucuronide are the major drug-derived compounds detected in plasma, constituting approximately 10 to 20% and 80 to 90% of the total drug in plasma, respectively. Both ezetimibe and ezetimibe-glucuronide are eliminated from plasma with a half-life of approximately 22 hours for both ezetimibe and ezetimibe-glucuronide. Plasma concentration-time profiles exhibit multiple peaks, suggesting enterohepatic recycling.
Following oral administration of 14C-ezetimibe (20 mg) to human subjects, total ezetimibe (ezetimibe + ezetimibe-glucuronide) accounted for approximately 93% of the total radioactivity in plasma. After 48 hours, there were no detectable levels of radioactivity in the plasma.
Approximately 78% and 11% of the administered radioactivity were recovered in the feces and urine, respectively, over a 10-day collection period. Ezetimibe was the major component in feces and accounted for 69% of the administered dose, while ezetimibe-glucuronide was the major component in urine and accounted for 9% of the administered dose.

### Specific Populations
Geriatric Patients: In a multiple-dose study with ezetimibe given 10 mg once daily for 10 days, plasma concentrations for total ezetimibe were about 2-fold higher in older (65 years) healthy subjects compared to younger subjects.
Pediatric Patients:
Gender: In a multiple-dose study with ezetimibe given 10 mg once daily for 10 days, plasma concentrations for total ezetimibe were slightly higher (less than 20%) in women than in men.
Race: Based on a meta-analysis of multiple-dose pharmacokinetic studies, there were no pharmacokinetic differences between Black and Caucasian subjects. Studies in Asian subjects indicated that the pharmacokinetics of ezetimibe were similar to those seen in Caucasian subjects.
Hepatic Impairment: After a single 10-mg dose of ezetimibe, the mean AUC for total ezetimibe was increased approximately 1.7-fold in patients with mild hepatic impairment (Child-Pugh score 5 to 6), compared to healthy subjects. The mean AUC values for total ezetimibe and ezetimibe were increased approximately 3- to 4-fold and 5- to 6-fold, respectively, in patients with moderate (Child-Pugh score 7 to 9) or severe hepatic impairment (Child-Pugh score 10 to 15). In a 14-day, multiple-dose study (10 mg daily) in patients with moderate hepatic impairment, the mean AUC values for total ezetimibe and ezetimibe were increased approximately 4-fold on Day 1 and Day 14 compared to healthy subjects. Due to the unknown effects of the increased exposure to ezetimibe in patients with moderate or severe hepatic impairment, Ezetimibe is not recommended in these patients.
Renal Impairment: After a single 10-mg dose of ezetimibe in patients with severe renal disease (n=8; mean CrCl 30 mL/min/1.73 m2), the mean AUC values for total ezetimibe, ezetimibe-glucuronide, and ezetimibe were increased approximately 1.5-fold, compared to healthy subjects (n=9).

## Nonclinical Toxicology
Clinical studies have demonstrated that elevated levels of total-C, LDL-C and Apo B, the major protein constituent of LDL, promote human atherosclerosis. In addition, decreased levels of HDL-C are associated with the development of atherosclerosis. Epidemiologic studies have established that cardiovascular morbidity and mortality vary directly with the level of total-C and LDL-C and inversely with the level of HDL-C. Like LDL, cholesterol-enriched triglyceride-rich lipoproteins, including very-low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), and remnants, can also promote atherosclerosis. The independent effect of raising HDL-C or lowering TG on the risk of coronary and cardiovascular morbidity and mortality has not been determined.
Ezetimibe reduces total-C, LDL-C, Apo B, non-HDL-C, and TG, and increases HDL-C in patients with hyperlipidemia. Administration of Ezetimibe with a statin is effective in improving serum total-C, LDL-C, Apo B, non-HDL-C, TG, and HDL-C beyond either treatment alone. Administration of Ezetimibe with fenofibrate is effective in improving serum total-C, LDL-C, Apo B, and non-HDL-C in patients with mixed hyperlipidemia as compared to either treatment alone. The effects of ezetimibe given either alone or in addition to a statin or fenofibrate on cardiovascular morbidity and mortality have not been established.

# Clinical Studies

## Primary hyperlipidemia
Ezetimibe reduces total-C, LDL-C, Apo B, non-HDL-C, and TG, and increases HDL-C in patients with hyperlipidemia. Maximal to near maximal response is generally achieved within 2 weeks and maintained during chronic therapy.

### Monotherapy
In two multicenter, double-blind, placebo-controlled, 12-week studies in 1719 patients with primary hyperlipidemia, Ezetimibe significantly lowered total-C, LDL-C, Apo B, non-HDL-C, and TG, and increased HDL-C compared to placebo (Table 6). Reduction in LDL-C was consistent across age, sex, and baseline LDL-C.

### Combination with statins
In a multicenter, double-blind, placebo-controlled, 8-week study, 769 patients with primary hyperlipidemia, known coronary heart disease or multiple cardiovascular risk factors who were already receiving statin monotherapy, but who had not met their NCEP ATP II target LDL-C goal were randomized to receive either Ezetimibe or placebo in addition to their on-going statin.
Ezetimibe, added to on-going statin therapy, significantly lowered total-C, LDL-C, Apo B, non-HDL-C, and TG, and increased HDL-C compared with a statin administered alone (see Table 7). LDL-C reductions induced by Ezetimibe were generally consistent across all statins.
In four multicenter, double-blind, placebo-controlled, 12-week trials, in 2382 hyperlipidemic patients, Ezetimibe or placebo was administered alone or with various doses of atorvastatin,simvastatin, pravastatin, or lovastatin.
When all patients receiving Ezetimibe with a statin were compared to all those receiving the corresponding statin alone, Ezetimibe significantly lowered total-C, LDL-C, Apo B, non-HDL-C, and TG, and, with the exception of pravastatin, increased HDL-C compared to the statin administered alone. LDL-C reductions induced by Ezetimibe were generally consistent across all statins.

### Combination with fenofibrate
In a multicenter, double-blind, placebo-controlled, clinical study in patients with mixed hyperlipidemia, 625 patients were treated for up to 12 weeks and 576 for up to an additional 48 weeks. Patients were randomized to receive placebo, Ezetimibe alone, 160-mg fenofibrate alone, or Ezetimibe and 160-mg fenofibrate in the 12-week study. After completing the 12-week study, eligible patients were assigned to Ezetimibe coadministered with fenofibrate or fenofibrate monotherapy for an additional 48 weeks.
Ezetimibe coadministered with fenofibrate significantly lowered total-C, LDL-C, Apo B, and non-HDL-C compared to fenofibrate administered alone. The percent decrease in TG and percent increase in HDL-C for Ezetimibe coadministered with fenofibrate were comparable to those for fenofibrate administered alone (see Table 12).
The changes in lipid endpoints after an additional 48 weeks of treatment with Ezetimibe coadministered with fenofibrate or with fenofibrate alone were consistent with the 12-week data displayed above.

## Homozygous Familial Hypercholesterolemia (HoFH)
A study was conducted to assess the efficacy of Ezetimibe in the treatment of HoFH. This double-blind, randomized, 12-week study enrolled 50 patients with a clinical and/or genotypic diagnosis of HoFH, with or without concomitant LDL apheresis, already receiving atorvastatin or simvastatin (40 mg). Patients were randomized to one of three treatment groups, atorvastatin or simvastatin (80 mg), Ezetimibe administered with atorvastatin or simvastatin (40 mg), or Ezetimibe administered with atorvastatin or simvastatin (80 mg). Due to decreased bioavailability of ezetimibe in patients concomitantly receiving cholestyramine, ezetimibe was dosed at least 4 hours before or after administration of resins. Mean baseline LDL-C was 341 mg/dL in those patients randomized to atorvastatin 80 mg or simvastatin 80 mg alone and 316 mg/dL in the group randomized to Ezetimibe plus atorvastatin 40 or 80 mg or simvastatin 40 or 80 mg. Ezetimibe, administered with atorvastatin or simvastatin (40- and 80-mg statin groups, pooled), significantly reduced LDL-C (21%) compared with increasing the dose of simvastatin or atorvastatin monotherapy from 40 to 80 mg (7%). In those treated with Ezetimibe plus 80-mg atorvastatin or with Ezetimibe plus 80-mg simvastatin, LDL-C was reduced by 27%.

## Homozygous Sitosterolemia (Phytosterolemia)
A study was conducted to assess the efficacy of Ezetimibe in the treatment of homozygous sitosterolemia. In this multicenter, double-blind, placebo-controlled, 8-week trial, 37 patients with homozygous sitosterolemia with elevated plasma sitosterol levels (more than 5 mg/dL) on their current therapeutic regimen (diet, bile-acid-binding resins, statins, ileal bypass surgery and/or LDL apheresis), were randomized to receive Ezetimibe (n=30) or placebo (n=7). Due to decreased bioavailability of ezetimibe in patients concomitantly receiving cholestyramine, ezetimibe was dosed at least 2 hours before or 4 hours after resins were administered. Excluding the one subject receiving LDL apheresis, Ezetimibe significantly lowered plasma sitosterol and campesterol, by 21% and 24% from baseline, respectively. In contrast, patients who received placebo had increases in sitosterol and campesterol of 4% and 3% from baseline, respectively. For patients treated with Ezetimibe, mean plasma levels of plant sterols were reduced progressively over the course of the study. The effects of reducing plasma sitosterol and campesterol on reducing the risks of cardiovascular morbidity and mortality have not been established.
Reductions in sitosterol and campesterolwere consistent between patients taking Ezetimibe concomitantly with bile acid sequestrants (n=8) and patients not on concomitant bile acid sequestrant therapy (n=21).

### Limitations of Use
The effect of Ezetimibe on cardiovascular morbidity and mortality has not been determined.

# How Supplied
No. 3861  Tablets Ezetimibe, 10 mg, are white to off-white, capsule-shaped tablets debossed with "414" on one side. They are supplied as follows:
NDC 66582-414-31 bottles of 30 NDC 66582-414-54 bottles of 90 NDC 66582-414-74 bottles of 500 NDC 66582-414-76 bottles of 5000 NDC 66582-414-28 unit dose packages of 100.

## Storage
Store at 25C (77F); excursions permitted to 1530C (5986F).  Protect from moisture.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
See FDA-Approved Patient Labeling (Patient Information).
Patients should be advised to adhere to their National Cholesterol Education Program (NCEP)-recommended diet, a regular exercise program, and periodic testing of a fasting lipid panel.

## Muscle Pain
All patients starting therapy with ezetimibe should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness or weakness. The risk of this occurring is increased when taking certain types of medication. Patients should discuss all medication, both prescription and over-the-counter, with their physician.

## Liver Enzymes
Liver tests should be performed when Ezetimibe is added to statin therapy and according to statin recommendations.

## Pregnancy
Women of childbearing age should be advised to use an effective method of birth control to prevent pregnancy while using Ezetimibe added to statin therapy. Discuss future pregnancy plans with your patients, and discuss when to stop combination Ezetimibe and statin therapy if they are trying to conceive. Patients should be advised that if they become pregnant they should stop taking combination Ezetimibe and statin therapy and call their healthcare professional.

## Breastfeeding
Women who are breastfeeding should be advised to not use Ezetimibe added to statin therapy. Patients who have a lipid disorder and are breastfeeding should be advised to discuss the options with their healthcare professionals.

# Precautions with Alcohol
Alcohol-Ezetimibe  interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
There is limited information regarding Ezetimibe Brand Names in the drug label.

# Look-Alike Drug Names
Ezetimibe - Zebeta
Ezetimibe - Zestril

# Drug Shortage Status

# Price