Esbriet (pirfenidone) dosing, indications, interactions, adverse effects, and more

Sections

Sections pirfenidone
Dosing & Uses
Interactions
Adverse Effects
Warnings
Pregnancy
Pharmacology
Administration
Images
Patient Handout
Formulary

Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

267mg (Esbreit, generic)

tablet

267 mg (Esbreit, generic)
801 mg (Esbreit, generic)

Idiopathic Pulmonary Fibrosis

Initial dose titration

Take with food
Days 1-7: 267 mg PO TID (801 mg/day)
Days 8-14: 534 mg PO TID (1602 mg/day)
Day 15 and thereafter (maintenance): 801 mg PO TID; not to exceed 2403 mg/day

Dosage Modifications

If patients experience significant adverse reactions (ie, gastrointestinal, photosensitivity reaction, rash, or severe cutaneous adverse reactions [SCAR]), consider temporary dosage reductions or therapy interruptions of pirfenidone to allow for resolution of symptoms; discontinue if symptoms persist despite these interventions

CYP1A2 inhibitors

Strong inhibitors (eg, fluvoxamine, enoxacin): Reduce maintenance dose to 267 mg (1 capsule) TID
Moderate inhibitors (eg, ciprofloxacin 750 mg BID): Reduce maintenance dose to 534 mg (2 capsules) TID

Elevated liver enzymes

AST/ALT >3 to ≤5 x ULN (without symptoms): Discontinue confounding medications, exclude other causes, repeat liver function tests as needed; the full daily dosage may be maintained, if clinically appropriate, or reduced or interrupted (eg, until liver chemistry tests are within normal limits), with subsequent retitration to the full dosage as tolerated
AST/ALT >5 x ULN or >3 times ULN with signs/symptoms of severe liver damage: Permanently discontinue; do not rechallenge

Hepatic impairment

Mild-to-moderate (Child Pugh A or B): Use caution; monitor and consider dosage modification or discontinuation as needed
Severe (Child Pugh C): Not recommended (not studied)

Renal impairment

Mild, moderate, or severe: Use caution; monitor and consider dosage modification or discontinuation as needed
ESRD requiring dialysis: Not recommended (not studied)

Dosing Considerations

Conduct liver function tests before initiating therapy (also see Dosage Modifications and Cautions)

Safety and efficacy not established

Interaction Checker

Enter a drug name and pirfenidone

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Serious - Use Alternative

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Contraindicated (4)

carbamazepine
carbamazepine will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
phenobarbital
phenobarbital will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
primidone
primidone will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
rifampin
rifampin will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment

Serious - Use Alternative (20)

aminolevulinic acid oral
aminolevulinic acid oral, pirfenidone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid administering other phototoxic drugs with aminolevulinic acid oral for 24 hr during perioperative period.
aminolevulinic acid topical
pirfenidone, aminolevulinic acid topical. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Each drug may increase the photosensitizing effect of the other.
cigarette smoking
cigarette smoking will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
cimetidine
cimetidine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
ciprofloxacin
ciprofloxacin will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
diclofenac
diclofenac will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
fluoxetine
fluoxetine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
fluvoxamine
fluvoxamine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating treatment and avoided during treatment; if strong CYP1A2 inhibitor is only option, dosage reduction recommended
gemfibrozil
gemfibrozil will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
givosiran
givosiran will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP1A2 substrates with givosiran. If unavoidable, decrease the CYP1A2 substrate dosage in accordance with approved product labeling.
leniolisib
leniolisib will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. If unable to avoid coadministration, decrease pirfenidone dose
methoxsalen
methoxsalen will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
methyl aminolevulinate
pirfenidone, methyl aminolevulinate. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Each drug may increase the photosensitizing effect of the other.
mexiletine
mexiletine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
nifedipine
nifedipine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
ofloxacin
ofloxacin will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
primaquine
primaquine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
propofol
propofol will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
tranylcypromine
tranylcypromine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
zileuton
zileuton will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended

Monitor Closely (13)

cannabidiol
cannabidiol, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Owing to the potential for both CYP1A2 induction and inhibition with the coadministration of CYP1A2 substrates and cannabidiol, consider reducing dosage adjustment of CYP1A2 substrates as clinically appropriate.
elranatamab
elranatamab will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Elranatamab causes cytokine release syndrome (CRS) that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. This is more likely to occur from initiation of elranatamab step-up dosing up to 14 days after the first treatment dose and during and after CRS.
epcoritamab
epcoritamab, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Epcoritamab causes release of cytokines that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. For certain CYP substrates, minimal changes in their concentration may lead to serious adverse reactions. If needed, modify therapy as recommended in the substrate's prescribing information. .
fexinidazole
fexinidazole will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor.
glofitamab
glofitamab, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Glofitamab causes release of cytokines that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. For certain CYP substrates, minimal changes in their concentration may lead to serious adverse reactions. If needed, modify therapy as recommended in the substrate's prescribing information. .
lonapegsomatropin
lonapegsomatropin will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
ritlecitinib
ritlecitinib will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Ritlecitinib inhibits CYP1A2 substrates; coadministration increases AUC and peak plasma concentration sensitive substrates, which may increase risk of adverse reactions. Additional monitoring and dosage adjustment may be needed in accordance with product labeling of CYP1A2 substrates.
rucaparib
rucaparib will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP1A2 substrates, if clinically indicated.
somapacitan
somapacitan will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
somatrogon
somatrogon will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
somatropin
somatropin will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
stiripentol
stiripentol, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP1A2 inhibitor and inducer. Monitor CYP1A2 substrates coadministered with stiripentol for increased or decreased effects. CYP1A2 substrates may require dosage adjustment.
talquetamab
talquetamab will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Talquetamab causes cytokine release syndrome (CRS) that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. This is more likely to occur from initiation of talquetamab step-up dosing up to 14 days after the first treatment dose and during and after CRS.

Minor (0)

aminolevulinic acid oral
Serious - Use Alternative (1)aminolevulinic acid oral, pirfenidone. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid administering other phototoxic drugs with aminolevulinic acid oral for 24 hr during perioperative period.
aminolevulinic acid topical
Serious - Use Alternative (1)pirfenidone, aminolevulinic acid topical. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Each drug may increase the photosensitizing effect of the other.
cannabidiol
Monitor Closely (1)cannabidiol, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Owing to the potential for both CYP1A2 induction and inhibition with the coadministration of CYP1A2 substrates and cannabidiol, consider reducing dosage adjustment of CYP1A2 substrates as clinically appropriate.
carbamazepine
Contraindicated (1)carbamazepine will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
cigarette smoking
Serious - Use Alternative (1)cigarette smoking will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
cimetidine
Serious - Use Alternative (1)cimetidine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
ciprofloxacin
Serious - Use Alternative (1)ciprofloxacin will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
diclofenac
Serious - Use Alternative (1)diclofenac will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
elranatamab
Monitor Closely (1)elranatamab will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Elranatamab causes cytokine release syndrome (CRS) that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. This is more likely to occur from initiation of elranatamab step-up dosing up to 14 days after the first treatment dose and during and after CRS.
epcoritamab
Monitor Closely (1)epcoritamab, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Epcoritamab causes release of cytokines that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. For certain CYP substrates, minimal changes in their concentration may lead to serious adverse reactions. If needed, modify therapy as recommended in the substrate's prescribing information. .
fexinidazole
Monitor Closely (1)fexinidazole will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor.
fluoxetine
Serious - Use Alternative (1)fluoxetine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
fluvoxamine
Serious - Use Alternative (1)fluvoxamine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating treatment and avoided during treatment; if strong CYP1A2 inhibitor is only option, dosage reduction recommended
gemfibrozil
Serious - Use Alternative (1)gemfibrozil will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
givosiran
Serious - Use Alternative (1)givosiran will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP1A2 substrates with givosiran. If unavoidable, decrease the CYP1A2 substrate dosage in accordance with approved product labeling.
glofitamab
Monitor Closely (1)glofitamab, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Glofitamab causes release of cytokines that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. For certain CYP substrates, minimal changes in their concentration may lead to serious adverse reactions. If needed, modify therapy as recommended in the substrate's prescribing information. .
leniolisib
Serious - Use Alternative (1)leniolisib will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. If unable to avoid coadministration, decrease pirfenidone dose
lonapegsomatropin
Monitor Closely (1)lonapegsomatropin will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
methoxsalen
Serious - Use Alternative (1)methoxsalen will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
methyl aminolevulinate
Serious - Use Alternative (1)pirfenidone, methyl aminolevulinate. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Each drug may increase the photosensitizing effect of the other.
mexiletine
Serious - Use Alternative (1)mexiletine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
nifedipine
Serious - Use Alternative (1)nifedipine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
ofloxacin
Serious - Use Alternative (1)ofloxacin will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
phenobarbital
Contraindicated (1)phenobarbital will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
primaquine
Serious - Use Alternative (1)primaquine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended
primidone
Contraindicated (1)primidone will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
propofol
Serious - Use Alternative (1)propofol will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
rifampin
Contraindicated (1)rifampin will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Use of strong CYP1A2 inducers should be discontinued before initiating pirfenidone and avoided during treatment
ritlecitinib
Monitor Closely (1)ritlecitinib will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Ritlecitinib inhibits CYP1A2 substrates; coadministration increases AUC and peak plasma concentration sensitive substrates, which may increase risk of adverse reactions. Additional monitoring and dosage adjustment may be needed in accordance with product labeling of CYP1A2 substrates.
rucaparib
Monitor Closely (1)rucaparib will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP1A2 substrates, if clinically indicated.
somapacitan
Monitor Closely (1)somapacitan will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
somatrogon
Monitor Closely (1)somatrogon will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
somatropin
Monitor Closely (1)somatropin will decrease the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substrates
stiripentol
Monitor Closely (1)stiripentol, pirfenidone. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP1A2 inhibitor and inducer. Monitor CYP1A2 substrates coadministered with stiripentol for increased or decreased effects. CYP1A2 substrates may require dosage adjustment.
talquetamab
Monitor Closely (1)talquetamab will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. Talquetamab causes cytokine release syndrome (CRS) that may suppress activity of CYP enzymes, resulting in increased exposure of CYP substrates. This is more likely to occur from initiation of talquetamab step-up dosing up to 14 days after the first treatment dose and during and after CRS.
tranylcypromine
Serious - Use Alternative (1)tranylcypromine will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid; coadministration of pirfenidone and moderate CYP1A2 inhibitors result in moderately increased exposure to pirfenidone; if unable to avoid, decrease dose of moderate CYP1A2 inhibitor
zileuton
Serious - Use Alternative (1)zileuton will increase the level or effect of pirfenidone by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Use of strong CYP1A2 inhibitors should be discontinued before initiating pirfenidone and avoided during treatment; if strong CYP1A2 inhibitors are the only drug of choice, dosage reductions are recommended

>10%

Nausea (36%)

Rash (30%)

Upper respiratory tract infection (27%)

Diarrhea (26%)

Fatigue (26%)

Abdominal pain (24%)

Headache (22%)

Decreased appetite (21%)

Dyspepsia (19%)

Dizziness (18%)

Vomiting (13%)

Gastroesophageal reflux disease (GERD) (11%)

Sinusitis (11%)

1-10%

Insomnia (10%)

Weight decreased (10%)

Arthralgia (10%)

Photosensitivity (9%)

Decreased appetite (8%)

Pruritus (8%)

Asthenia (6%)

Dysgeusia (6%)

Noncardiac chest pain (5%)

AST/ALT ≥3 x ULN (3.7%)

<1%

AST/ALT ≥10 x ULN (0.3%)

Postmarketing Reports

Blood and lymphatic system disorders: Agranulocytosis

Immune system disorders: Angioedema

Hepatobiliary disorders: Drug-induced liver injury

Skin and Subcutaneous Tissue Disorders: Severe Cutaneous Adverse Reactions (SCAR)

Contraindications

None

Cautions

Photosensitivity and rash reported; avoid or minimize exposure to sunlight (including sunlamps), to use a sunblock (SPF 50 or higher), and to wear clothing that protects against sun exposure; additionally, instruct patients to avoid concomitant medications known to cause photosensitivity; dosage reduction or discontinuation may be necessary in some cases of photosensitivity reaction or rash

Nausea, vomiting, diarrhea, dyspepsia, gastroesophageal reflux disease, and abdominal pain reported; incidence of gastrointestinal events reported to be highest early in the course of treatment (with highest incidence occurring during initial 3 months); may decrease over time; temporary dosage reductions or discontinuations may be required

Drug-induced liver injury

Conduct liver function tests (ALT, AST, and bilirubin) before initiating, monthly for 6 months, and then q3months thereafter and, as clinically indicated
Patients treated with 2403 mg/day reported having higher incidence of elevated ALT/AST in clinical trials
Measure liver function tests promptly in patients who report symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice
Dosage modifications, interruption, or discontinuation may be necessary to reverse liver enzyme elevation

Cutaneous adverse reactions

Severe cutaneous adverse reactions (SCAR), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS), reported in association with therapy in the postmarketing setting
If signs or symptoms of SCAR occur, interrupt treatment until etiology of the reaction has been determined; consultation with a dermatologist recommended; if a SCAR is confirmed, permanently discontinue therapy

Drug interaction overview

Pirfenidone is a CYP1A2 substrate; discontinue moderate or strong CYP1A inhibitors before initiating pirfenidone and avoid use during therapy; if unable to avoid, pirfenidone dose reduction required
Discontinue strong CYP1A2 inducers before initiating pirfenidone and avoid use during therapy; likely to decrease exposure and lead to loss of pirfenidone efficacy
Smoking associated with decreased systemic exposure; encourage patient to quit smoking

Pregnancy & Lactation

Pregnancy: Data in pregnant women are insufficient to inform on drug associated risks for major birth defects and miscarriage

Lactation: No information is available on presence of pirfenidone in human milk, effects of drug on breastfed infant, or effects of drug on milk production; lack of clinical data during lactation precludes clear determination of risk of pirfenidone to infant during lactation; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and potential adverse effects on breastfed child from pirfenidone or from underlying maternal condition

Pregnancy Categories

A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA: Information not available.

Mechanism of Action

Precise mechanism by which pirfenidone may work in pulmonary fibrosis has not been established

Inhibits transforming growth factor (TGF)-beta, a chemical mediator that controls many cell functions including proliferation and differentiation

Also inhibits the synthesis of TNF-alpha, a cytokine that is known to have an active role in inflammation

Absorption

Peak plasma time: 0.5-4 hr

Food decreased the rate and extent of absorption; Cmax and AUC decreased by ~49% and 16% with food, respectively

A reduced incidence of adverse reactions was observed in the fed group when compared with the fasted group; administered with food in clinical trials

Distribution

Protein bound: 58%

Vd: 59-71 L

Metabolism

Metabolized in the liver by CYP1A2 to inactive metabolites

Elimination

Half-life: 3 hr

Majority of dose excreted as 5-carboxy-pirfenidone metabolite (99.6%)

Excretion: 80% urine

Oral Administration

Take with food

Take doses at same time each day

Missed doses

If ≥14 days: Reinitiate treatment by undergoing the initial 2-week titration regimen up to the full maintenance dosage
If <14 days: Resume the dosage prior to the interruption

BRAND	FORM.	UNIT PRICE	PILL IMAGE
pirfenidone oral -	267 mg capsule
pirfenidone oral -	801 mg tablet
pirfenidone oral -	267 mg tablet
pirfenidone oral -	267 mg tablet
pirfenidone oral -	267 mg capsule
pirfenidone oral -	267 mg tablet
pirfenidone oral -	267 mg capsule
pirfenidone oral -	801 mg tablet
pirfenidone oral -	801 mg tablet

Patient Handout

PIRFENIDONE - ORAL

(pir-FEN-i-done)

COMMON BRAND NAME(S): Esbriet

USES: Pirfenidone is used to treat a certain lung disease called idiopathic pulmonary fibrosis (IPF). This disease causes the lungs to get scarred and become stiff, making it hard to breathe. Pirfenidone may help slow down the worsening of your IPF.

HOW TO USE: Read the Patient Information Leaflet if available from your pharmacist before you start taking pirfenidone and each time you get a refill. If you have any questions, ask your doctor or pharmacist.Take this medication by mouth with food as directed by your doctor, usually 3 times a day. Taking pirfenidone with food may help decrease dizziness and nausea. To reduce your risk of side effects, your doctor may direct you to start this medication at a low dose and gradually increase your dose. Follow your doctor's instructions carefully.The dosage is based on your medical condition, response to treatment, and other medications you may be taking. Be sure to tell your doctor and pharmacist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Take this medication regularly to get the most benefit from it. To help you remember, take it at the same times each day.Tell your doctor if your condition worsens.

SIDE EFFECTS: Tiredness, lack of energy, loss of appetite, weight loss, or changes in taste may occur. Dizziness, nausea, upset stomach, vomiting, diarrhea, or heartburn may also occur but taking pirfenidone with food may lessen these side effects. If any of these effects last or get worse, tell your doctor or pharmacist promptly.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Pirfenidone may rarely cause serious liver disease. Get medical help right away if you have any symptoms of liver damage, including: nausea/vomiting that doesn't stop, loss of appetite, stomach/abdominal pain, yellowing eyes/skin, dark urine.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: fever, swollen lymph nodes, rash/blisters, mouth sores, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

PRECAUTIONS: Before taking pirfenidone tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: liver disease, kidney disease (such as dialysis).This drug may make you dizzy. Alcohol or marijuana (cannabis) can make you more dizzy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Limit alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).This medication may make you more sensitive to the sun. Limit your time in the sun. Avoid tanning booths and sunlamps. Use sunscreen and wear protective clothing when outdoors. Tell your doctor right away if you get sunburned or have skin blisters/redness.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.It is unknown if this medication passes into breast milk. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Other medications can affect the removal of pirfenidone from your body, which may affect how pirfenidone works. Examples include rifamycins (such as rifampin), drugs used to treat seizures (such as phenytoin), among others.Cigarette smoking decreases blood levels of this medication. Tell your doctor if you smoke or if you have recently stopped smoking.

OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

NOTES: Do not share this medication with others.Lab and/or medical tests (such as weight, liver function) should be done before you start taking this medication and while you are taking it. Keep all medical and lab appointments. Consult your doctor for more details.

MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.If you miss 14 days or more of treatment in a row, you may have to restart treatment with a lower dose. Ask your doctor for more details.

STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

Formulary

FormularyPatient Discounts

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Create Your List of Plans

Adding plans allows you to:

View the formulary and any restrictions for each plan.
Manage and view all your plans together – even plans in different states.
Compare formulary status to other drugs in the same class.
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The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

View explanations for tiers and restrictions

Tier	Description
1	This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
2	This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
3	This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
4	This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
5	This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
6	This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
NC	NOT COVERED – Drugs that are not covered by the plan.

Code	Definition
PA	Prior Authorization Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
QL	Quantity Limits Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
ST	Step Therapy Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
OR	Other Restrictions Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.

Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.

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Sections pirfenidone
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pirfenidone (Rx)