DailyMed Label: Trikafta

DailyMed Label: Trikafta

2024

DailyMed Prescription

Trikafta

Elexacaftor, Tezacaftor, and Ivacaftor

Vertex Pharmaceuticals Incorporated

NDC: 51167-331

NDC: 51167-331

NDC: 51167-106

NDC: 51167-106

NDC: 51167-445

NDC: 51167-445

NDC: 51167-446

NDC: 51167-446

TRIKAFTA is a co-package of elexacaftor, tezacaftor and ivacaftor fixed-dose combination tablets or granules and ivacaftor tablets or granules. Both tablets and granules are for oral administration. The elexacaftor, tezacaftor and ivacaftor fixed-dose combination tablets are available as: orange, capsule-shaped, film-coated tablet containing 100 mg of elexacaftor, 50 mg of tezacaftor, 75 mg of ivacaftor, or light-orange, capsule-shaped, film-coated tablet containing 50 mg of elexacaftor, 25 mg of tezacaftor, 37.5 mg of ivacaftor. The fixed-dose combination tablet contains the following inactive ingredients: croscarmellose sodium, hypromellose, hypromellose acetate succinate, magnesium stearate, microcrystalline cellulose, and sodium lauryl sulfate. The tablet film coat contains hydroxypropyl cellulose, hypromellose, iron oxide red, iron oxide yellow, talc, and titanium dioxide. The ivacaftor tablet is available as a light blue, capsule-shaped, film-coated tablet containing 150 mg or 75 mg of ivacaftor and the following inactive ingredients: colloidal silicon dioxide, croscarmellose sodium, hypromellose acetate succinate, lactose monohydrate, magnesium stearate, microcrystalline cellulose and sodium lauryl sulfate. The tablet film coat contains carnauba wax, FD&C Blue #2, PEG 3350, polyvinyl alcohol, talc, and titanium dioxide. The printing ink contains ammonium hydroxide, iron oxide black, propylene glycol, and shellac. The elexacaftor, tezacaftor and ivacaftor fixed-dose combination oral granules are white to off-white, sweetened, unflavored granules approximately 2 mm in diameter enclosed in unit-dose packets. Each unit-dose packet contains 100 mg of elexacaftor, 50 mg of tezacaftor, 75 mg of ivacaftor or 80 mg of elexacaftor, 40 mg of tezacaftor, 60 mg of ivacaftor and the following inactive ingredients: colloidal silicon dioxide, croscarmellose sodium, hypromellose, hypromellose acetate succinate, lactose monohydrate, magnesium stearate, mannitol, sodium lauryl sulfate, and sucralose. The ivacaftor oral granules are white to off-white, sweetened, unflavored granules approximately 2 mm in diameter enclosed in unit-dose packets. Each unit-dose packet contains 75 mg or 59.5 mg of ivacaftor and the following inactive ingredients: colloidal silicon dioxide, croscarmellose sodium, hypromellose acetate succinate, lactose monohydrate, magnesium stearate, mannitol, sodium lauryl sulfate, and sucralose. The active ingredients of TRIKAFTA are described below. Elexacaftor Elexacaftor is a white solid that is practically insoluble in water (<1 mg/mL). Its chemical name is N-(1,3-dimethyl-1H-pyrazole-4-sulfonyl)-6-[3-(3,3,3-trifluoro-2,2-dimethylpropoxy)-1H-pyrazol-1-yl]-2-[(4S)-2,2,4-trimethylpyrrolidin-1-yl]pyridine-3-carboxamide. Its molecular formula is C 26 H 34 N 7 O 4 SF 3 and its molecular weight is 597.66. Elexacaftor has the following structural formula: Chemical Structure Tezacaftor Tezacaftor is a white to off-white solid that is practically insoluble in water (<5 microgram/mL). Its chemical name is 1-(2,2-difluoro-2H-1,3-benzodioxol-5-yl)-N-{1-[(2R)-2,3-dihydroxypropyl]-6-fluoro-2-(1-hydroxy-2-methylpropan-2-yl)-1H-indol-5-yl}cyclopropane-1-carboxamide. Its molecular formula is C 26 H 27 N 2 F 3 O 6 and its molecular weight is 520.50. Tezacaftor has the following structural formula: Chemical Structure Ivacaftor Ivacaftor is a white to off-white crystalline solid that is practically insoluble in water (<0.05 microgram/mL). Pharmacologically it is a CFTR potentiator. Its chemical name is N -(2,4-di-tert-butyl-5-hydroxyphenyl)-1,4-dihydro-4-oxoquinoline-3-carboxamide. Its molecular formula is C 24 H 28 N 2 O 3 and its molecular weight is 392.49. Ivacaftor has the following structural formula: Chemical Structure

TRIKAFTA is indicated for the treatment of cystic fibrosis (CF) in patients aged 2 years and older who have at least one F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene or a mutation in the CFTR gene that is responsive based on in vitro data [see Clinical Pharmacology (12.1) ] . If the patient's genotype is unknown, an FDA-cleared CF mutation test should be used to confirm the presence of at least one F508del mutation or a mutation that is responsive based on in vitro data. TRIKAFTA is a combination of ivacaftor, a CFTR potentiator, tezacaftor, and elexacaftor indicated for the treatment of cystic fibrosis (CF) in patients aged 2 years and older who have at least one F508del mutation in the CFTR gene or a mutation in the CFTR gene that is responsive based on in vitro data. If the patient's genotype is unknown, an FDA-cleared CF mutation test should be used to confirm the presence of at least one F508del mutation or a mutation that is responsive based on in vitro data. ( 1 )

Recommended Dosage for Adult and Pediatric Patients Aged 2 Years and Older Age Weight Morning Dose Evening Dose 2 to less than 6 years Less than 14 kg One packet containing elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg oral granules One packet containing ivacaftor 59.5 mg oral granules 14 kg or more One packet containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg oral granules One packet containing ivacaftor 75 mg oral granules 6 to less than 12 years Less than 30 kg Two tablets, each containing elexacaftor 50 mg/tezacaftor 25 mg/ivacaftor 37.5 mg One tablet of ivacaftor 75 mg 30 kg or more Two tablets, each containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg One tablet of ivacaftor 150 mg 12 years and older - Two tablets, each containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg One tablet of ivacaftor 150 mg TRIKAFTA should be taken with fat-containing food. ( 2.5 , 12.3 ) Should not be used in patients with severe hepatic impairment. Use not recommended in patients with moderate hepatic impairment unless the benefit exceeds the risk. Reduce dose if used in patients with moderate hepatic impairment. Liver function tests should be closely monitored. ( 2.2 , 5.1 , 6 , 8.7 , 12.3 ) See full prescribing information for dosage modifications due to drug interactions with TRIKAFTA. ( 2.3 , 5.4 , 7.2 , 12.3 ) Recommended dosage for adult and pediatric patients aged 2 years and older is provided in Table 1. The morning and the evening dose should be taken approximately 12 hours apart. TRIKAFTA is for oral use. Table 1: Recommended Dosage of TRIKAFTA for Adult and Pediatric Patients Aged 2 Years and Older Age Weight Morning Dose Evening Dose 2 to less than 6 years Less than 14 kg One packet (containing elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg) oral granules One packet (containing ivacaftor 59.5 mg) oral granules 14 kg or more One packet (containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) oral granules One packet (containing ivacaftor 75 mg) oral granules 6 to less than 12 years Less than 30 kg Two tablets of elexacaftor 50 mg/tezacaftor 25 mg/ivacaftor 37.5 mg (total dose of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) One tablet of ivacaftor 75 mg 30 kg or more Two tablets of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) One tablet of ivacaftor 150 mg 12 years and older Two tablets of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) One tablet of ivacaftor 150 mg Mild Hepatic Impairment (Child-Pugh Class A): No dose adjustment is recommended [see Use in Specific Populations (8.7) and Clinical Pharmacology (12.3) ] . See Table 1 for recommended dosage of TRIKAFTA. Liver function tests should be closely monitored [see Warnings and Precautions (5.1) and Adverse Reactions (6) ]. Moderate Hepatic Impairment (Child-Pugh Class B): Treatment is not recommended. Use of TRIKAFTA in patients with moderate hepatic impairment should only be considered when there is a clear medical need, and the benefit exceeds the risk. If used, TRIKAFTA should be used with caution at a reduced dose (see Table 2 ) [see Use in Specific Populations (8.7) and Clinical Pharmacology (12.3) ] . Liver function tests should be closely monitored [see Warnings and Precautions (5.1) and Adverse Reactions (6) ]. Recommended dosage for patients with moderate hepatic impairment (Child-Pugh Class B) is provided in Table 2. Table 2: Recommended Dosage of TRIKAFTA, if used, in Patients with Moderate Hepatic Impairment (Child-Pugh Class B) Age Weight Morning Dose Evening Dose 2 to less than 6 years Less than 14 kg Weekly dosing schedule as follows: Days 1-3: One packet (containing elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg) oral granules each day Day 4: no dose Days 5-6: One packet (containing elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg) oral granules each day Day 7: no dose No evening dose of ivacaftor oral granules. 14 kg or more Weekly dosing schedule as follows: Days 1-3: One packet (containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) oral granules each day Day 4: no dose Days 5-6: One packet (containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) oral granules each day Day 7: no dose No evening dose of ivacaftor oral granules. 6 years to less than 12 years Less than 30 kg Alternating daily dosing schedule as follows: Day 1: Two tablets of elexacaftor 50 mg/tezacaftor 25 mg/ivacaftor 37.5 mg (total dose of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) Day 2: One tablet of elexacaftor 50 mg/tezacaftor 25 mg/ivacaftor 37.5 mg No evening ivacaftor tablet dose. 30 kg or more Alternating daily dosing schedule as follows: Day 1: Two tablets of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) Day 2: One tablet elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg No evening ivacaftor tablet dose. 12 years and older Alternating daily dosing schedule as follows: Day 1: Two tablets of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) Day 2: One tablet elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg No evening ivacaftor tablet dose. Severe Hepatic Impairment (Child-Pugh Class C): Should not be used. TRIKAFTA has not been studied in patients with severe hepatic impairment (Child-Pugh Class C), but the exposure is expected to be higher than in patients with moderate hepatic impairment. [see Warnings and Precautions (5.1) , Adverse Reactions (6) , Use in Specific Populations (8.7) and Clinical Pharmacology (12.3) ] . Table 3 describes the recommended dosage modification for TRIKAFTA when co-administered with strong (e.g., ketoconazole, itraconazole, posaconazole, voriconazole, telithromycin, and clarithromycin) or moderate (e.g., fluconazole, erythromycin) CYP3A inhibitors. Avoid food or drink containing grapefruit during TRIKAFTA treatment [see Warnings and Precautions (5.4) , Drug Interactions (7.2) and Clinical Pharmacology (12.3) ] . Table 3: Dosage Modification for Concomitant Use of TRIKAFTA with Moderate and Strong CYP3A Inhibitors Age Weight Moderate CYP3A Inhibitors Strong CYP3A Inhibitors 2 to less than 6 years Less than 14 kg Alternating daily dosing schedule is as follows: Day 1: One packet (containing elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg) in the morning Day 2: One packet (containing ivacaftor 59.5 mg) oral granules in the morning No evening packet of ivacaftor oral granules. One packet (containing elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg) in the morning twice a week, approximately 3 to 4 days apart. No evening packet of ivacaftor oral granules. 14 kg or more Alternating daily dosing schedule is as follows: Day 1: One packet (containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) in the morning Day 2: One packet (containing ivacaftor 75 mg) oral granules in the morning No evening packet of ivacaftor oral granules. One packet (containing elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) in the morning twice a week, approximately 3 to 4 days apart. No evening packet of ivacaftor oral granules. 6 years and older Less than 30 kg Alternating daily dosing schedule is as follows: Day 1: Two tablets of elexacaftor 50 mg/tezacaftor 25 mg/ivacaftor 37.5 mg (total dose of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) in the morning Day 2: One tablet of ivacaftor 75 mg in the morning No evening ivacaftor tablet dose. Two tablets of elexacaftor 50 mg/tezacaftor 25 mg/ivacaftor 37.5 mg (total dose of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg) in the morning twice a week, approximately 3 to 4 days apart. No evening ivacaftor tablet dose. 30 kg or more Alternating daily dosing schedule is as follows: Day 1: Two tablets elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) in the morning Day 2: One tablet of ivacaftor 150 mg in the morning No evening ivacaftor tablet dose. Two tablets elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) in the morning twice a week, approximately 3 to 4 days apart. No evening ivacaftor tablet dose. 12 years and older Alternating daily dosing schedule is as follows: Day 1: Two tablets elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) in the morning Day 2: One tablet of ivacaftor 150 mg in the morning No evening ivacaftor tablet dose. Two tablets elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg (total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg) in the morning twice a week, approximately 3 to 4 days apart. No evening ivacaftor tablet dose. If 6 hours or less have passed since the missed morning or evening dose, the patient should take the missed dose as soon as possible and continue on the original schedule. If more than 6 hours have passed since: the missed morning dose, the patient should take the missed dose as soon as possible and should not take the evening dose. The next scheduled morning dose should be taken at the usual time. the missed evening dose, the patient should not take the missed dose. The next scheduled morning dose should be taken at the usual time. Morning and evening doses should not be taken at the same time. Administer TRIKAFTA tablets or oral granules with fat-containing food. Examples of meals or snacks that contain fat are those prepared with butter or oils or those containing eggs, peanut butter, cheeses, nuts, whole milk, or meats [see Clinical Pharmacology (12.3) ] . Instructions for Administration of Tablets For oral use and swallow TRIKAFTA tablets whole. Instructions for Administration of Oral Granules Administer each dose of TRIKAFTA oral granules immediately before or after ingestion of fat containing food. Mix entire contents of each packet of oral granules with one teaspoon (5 mL) of age-appropriate soft food or liquid that is at or below room temperature. Some examples of soft food or liquids include pureed fruits or vegetables, yogurt, applesauce, water, milk, or juice. Once mixed, the product should be consumed completely within one hour.

Tablets: Fixed-dose combination containing elexacaftor 50 mg, tezacaftor 25 mg and ivacaftor 37.5 mg co-packaged with ivacaftor 75 mg; Fixed-dose combination containing elexacaftor 100 mg, tezacaftor 50 mg, and ivacaftor 75 mg co-packaged with ivacaftor 150 mg. ( 3 ) Oral granules: Unit-dose packets of elexacaftor 100 mg, tezacaftor 50 mg and ivacaftor 75 mg co-packaged with unit-dose packets of ivacaftor 75 mg; Unit-dose packets of elexacaftor 80 mg, tezacaftor 40 mg and ivacaftor 60 mg co-packaged with unit-dose packets of ivacaftor 59.5 mg. ( 3 ) Tablets: Fixed-dose combination containing elexacaftor 50 mg, tezacaftor 25 mg, and ivacaftor 37.5 mg co-packaged with ivacaftor 75 mg: Elexacaftor, tezacaftor and ivacaftor tablets are light orange, capsule-shaped and debossed with "T50" on one side and plain on the other Ivacaftor tablets are light blue, capsule-shaped, and printed with "V 75" in black ink on one side and plain on the other Fixed-dose combination containing elexacaftor 100 mg, tezacaftor 50 mg, and ivacaftor 75 mg co-packaged with ivacaftor 150 mg: Elexacaftor, tezacaftor and ivacaftor tablets are orange, capsule-shaped and debossed with "T100" on one side and plain on the other Ivacaftor tablets are light blue, capsule-shaped, and printed with "V 150" in black ink on one side and plain on the other Oral Granules: Fixed-dose combination oral granules containing elexacaftor 100 mg, tezacaftor 50 mg, and ivacaftor 75 mg co-packaged with ivacaftor 75 mg oral granules: Elexacaftor, tezacaftor, and ivacaftor oral granules are white to off-white, sweetened, unflavored granules approximately 2 mm in diameter contained in a white and orange unit-dose packet Ivacaftor oral granules are white to off-white, sweetened, unflavored granules approximately 2 mm in diameter contained in a white and pink unit-dose packet Fixed-dose combination oral granules containing elexacaftor 80 mg, tezacaftor 40 mg, ivacaftor 60 mg co-packaged with ivacaftor 59.5 mg oral granules: Elexacaftor, tezacaftor, and ivacaftor oral granules are white to off-white, sweetened, unflavored granules approximately 2 mm in diameter contained in a white and blue unit-dose packet Ivacaftor oral granules are white to off-white, sweetened, unflavored granules approximately 2 mm in diameter contained in a white and green unit-dose packet

None. None. ( 4 )

Elevated transaminases and hepatic injury: Liver failure leading to transplantation has been reported in a patient with cirrhosis and portal hypertension while receiving TRIKAFTA. Avoid use of TRIKAFTA in patients with pre-existing advanced liver disease, (e.g., as evidenced by cirrhosis, portal hypertension, ascites, hepatic encephalopathy) unless the benefits are expected to outweigh the risks. If used in these patients, they should be closely monitored after the initiation of treatment. Isolated elevations of transaminases or bilirubin have been observed in CF patients treated with TRIKAFTA. In some instances, transaminase elevations have been associated with concomitant elevations in total bilirubin and/or international normalized ratio (INR) and have resulted in patients being hospitalized for intervention, including patients without a history of pre-existing liver disease. Monitor liver function tests (ALT, AST, and bilirubin). Interrupt dosing in the event of significant elevations. In patients with a history of hepatobiliary disease or liver function test elevations, monitor more frequently. ( 2.2 , 5.1 , 8.7 ) Hypersensitivity reactions: Angioedema and anaphylaxis been reported with TRIKAFTA in the postmarketing setting. Initiate appropriate therapy in the event of a hypersensitivity reaction. ( 5.2 ) Use with CYP3A inducers: Concomitant use with strong CYP3A inducers (e.g., rifampin, St. John's wort) significantly decrease ivacaftor exposure and are expected to decrease elexacaftor and tezacaftor exposure, which may reduce TRIKAFTA efficacy. Therefore, co-administration is not recommended. ( 5.3 , 7.1 , 12.3 ) Cataracts: Non-congenital lens opacities/cataracts have been reported in pediatric patients treated with ivacaftor-containing regimens. Baseline and follow-up examinations are recommended in pediatric patients initiating TRIKAFTA treatment. ( 5.5 , 8.4 ) Liver failure leading to transplantation has been reported in a patient with cirrhosis and portal hypertension while receiving TRIKAFTA. Avoid use of TRIKAFTA in patients with pre-existing advanced liver disease (e.g., as evidenced by cirrhosis, portal hypertension, ascites, hepatic encephalopathy) unless the benefits are expected to outweigh the risks. If used in these patients, they should be closely monitored after the initiation of treatment [see Dosage and Administration (2.2) , Adverse Reactions (6) , Use in Specific Populations (8.7) and Clinical Pharmacology (12.3) ] . Isolated elevations of transaminases or bilirubin have been observed in patients with CF treated with TRIKAFTA. In some instances, transaminase elevations have been associated with concomitant elevations in total bilirubin and/or international normalized ratio (INR) and have resulted in patients being hospitalized for intervention, including in patients without a history of pre-existing liver disease. Assessments of liver function tests (ALT, AST, and bilirubin) are recommended for all patients prior to initiating TRIKAFTA, every 3 months during the first year of treatment, and annually thereafter. In the event of significant elevations in liver function tests, e.g., ALT or AST >5 × the upper limit of normal (ULN) or ALT or AST >3 × ULN with bilirubin >2 × ULN, dosing should be interrupted, and laboratory tests closely followed until the abnormalities resolve. Following the resolution of liver function test elevations, consider the benefits and risks of resuming treatment. For patients with a history of hepatobiliary disease or liver function test elevations, more frequent monitoring should be considered [see Dosage and Administration (2.2) , Adverse Reactions (6) , Use in Specific Populations (8.7) and Clinical Pharmacology (12.3) ] . Hypersensitivity reactions, including cases of angioedema and anaphylaxis, have been reported in the postmarketing setting [see Adverse Reactions (6.2) ] . If signs or symptoms of serious hypersensitivity reactions develop during treatment, discontinue TRIKAFTA and institute appropriate therapy. Consider the benefits and risks for the individual patient to determine whether to resume treatment with TRIKAFTA . Exposure to ivacaftor is significantly decreased and exposure to elexacaftor and tezacaftor are expected to decrease by the concomitant use of strong CYP3A inducers, which may reduce the therapeutic effectiveness of TRIKAFTA. Therefore, co-administration with strong CYP3A inducers is not recommended [see Drug Interactions (7.1) and Clinical Pharmacology (12.3) ] . Exposure to elexacaftor, tezacaftor and ivacaftor are increased when co-administered with strong or moderate CYP3A inhibitors. Therefore, the dose of TRIKAFTA should be reduced when used concomitantly with moderate or strong CYP3A inhibitors [see Dosage and Administration (2.3) , Drug Interactions (7.2) and Clinical Pharmacology (12.3) ] . Cases of non-congenital lens opacities have been reported in pediatric patients treated with ivacaftor-containing regimens. Although other risk factors were present in some cases (such as corticosteroid use, exposure to radiation), a possible risk attributable to treatment with ivacaftor cannot be excluded. Baseline and follow-up ophthalmological examinations are recommended in pediatric patients initiating treatment with TRIKAFTA [see Use in Specific Populations (8.4) ] .

The following clinically significant adverse reactions are discussed in greater detail in other sections of the labeling:

Potential for other drugs to affect elexacaftor/tezacaftor/ivacaftor Strong CYP3A inducers: Avoid co-administration. ( 5.3 , 7.1 , 12.3 ) Strong or moderate CYP3A inhibitors: Reduce TRIKAFTA dosage when co-administered. Avoid food or drink containing grapefruit. ( 2.3 , 5.4 , 7.2 , 12.3 ) Elexacaftor, tezacaftor and ivacaftor are substrates of CYP3A (ivacaftor is a sensitive substrate of CYP3A). Concomitant use of CYP3A inducers may result in reduced exposures and thus reduced TRIKAFTA efficacy. Co-administration of ivacaftor with rifampin, a strong CYP3A inducer, significantly decreased ivacaftor area under the curve (AUC) by 89%. Elexacaftor and tezacaftor exposures are expected to decrease during co-administration with strong CYP3A inducers. Therefore, co-administration of TRIKAFTA with strong CYP3A inducers is not recommended [see Warnings and Precautions (5.3) and Clinical Pharmacology (12.3) ] . Examples of strong CYP3A inducers include: rifampin, rifabutin, phenobarbital, carbamazepine, phenytoin and St. John's wort ( Hypericum perforatum ) Co-administration with itraconazole, a strong CYP3A inhibitor, increased elexacaftor AUC by 2.8-fold and tezacaftor AUC by 4.0- to 4.5-fold. When co-administered with itraconazole and ketoconazole, ivacaftor AUC increased by 15.6-fold and 8.5-fold, respectively. The dosage of TRIKAFTA should be reduced when co-administered with strong CYP3A inhibitors [see Dosage and Administration (2.3) , Warnings and Precautions (5.4) and Clinical Pharmacology (12.3) ] . Examples of strong CYP3A inhibitors include: ketoconazole, itraconazole, posaconazole and voriconazole telithromycin and clarithromycin Simulations indicated that co-administration with moderate CYP3A inhibitors may increase elexacaftor and tezacaftor AUC by approximately 1.9- to 2.3-fold and 2.1-fold, respectively. Co-administration of fluconazole increased ivacaftor AUC by 2.9-fold. The dosage of TRIKAFTA should be reduced when co-administered with moderate CYP3A inhibitors [see Dosage and Administration (2.3) , Warnings and Precautions (5.4) and Clinical Pharmacology (12.3) ] . Examples of moderate CYP3A inhibitors include: fluconazole erythromycin Co-administration of TRIKAFTA with grapefruit juice, which contains one or more components that moderately inhibit CYP3A, may increase exposure of elexacaftor, tezacaftor and ivacaftor; therefore, food or drink containing grapefruit should be avoided during treatment with TRIKAFTA [see Dosage and Administration (2.3) ] . Ciprofloxacin had no clinically relevant effect on the exposure of tezacaftor or ivacaftor and is not expected to affect the exposure of elexacaftor. Therefore, no dose adjustment is necessary during concomitant administration of TRIKAFTA with ciprofloxacin [see Clinical Pharmacology (12.3) ] . Potential for elexacaftor/tezacaftor/ivacaftor to affect other drugs Ivacaftor may inhibit CYP2C9; therefore, monitoring of the international normalized ratio (INR) during co-administration of TRIKAFTA with warfarin is recommended. Other medicinal products for which exposure may be increased by TRIKAFTA include glimepiride and glipizide; these medicinal products should be used with caution [see Clinical Pharmacology (12.3) ] . Co-administration of ivacaftor or tezacaftor/ivacaftor with digoxin, a sensitive P-gp substrate, increased digoxin AUC by 1.3-fold, consistent with weak inhibition of P-gp by ivacaftor. Administration of TRIKAFTA may increase systemic exposure of medicinal products that are sensitive substrates of P-gp, which may increase or prolong their therapeutic effect and adverse reactions. When used concomitantly with digoxin or other substrates of P-gp with a narrow therapeutic index such as cyclosporine, everolimus, sirolimus and tacrolimus, caution and appropriate monitoring should be used [see Clinical Pharmacology (12.3) ] . Elexacaftor and M23-ELX inhibit uptake by OATP1B1 and OATP1B3 in vitro . Co-administration of TRIKAFTA may increase exposures of medicinal products that are substrates of these transporters, such as statins, glyburide, nateglinide and repaglinide. When used concomitantly with substrates of OATP1B1 or OATP1B3, caution and appropriate monitoring should be used [see Clinical Pharmacology (12.3) ] . Bilirubin is an OATP1B1 and OATP1B3 substrate. TRIKAFTA has been studied with ethinyl estradiol/levonorgestrel and was found to have no clinically relevant effect on the exposures of the oral contraceptive. TRIKAFTA is not expected to have an impact on the efficacy of oral contraceptives.

Risk Summary There are limited and incomplete human data from clinical trials on the use of TRIKAFTA or its individual components, elexacaftor, tezacaftor and ivacaftor, in pregnant women to inform a drug-associated risk. Although there are no animal reproduction studies with the concomitant administration of elexacaftor, tezacaftor and ivacaftor, separate reproductive and developmental studies were conducted with each active component of TRIKAFTA in pregnant rats and rabbits. In animal embryo fetal development (EFD) studies oral administration of elexacaftor to pregnant rats and rabbits during organogenesis demonstrated no teratogenicity or adverse developmental effects at doses that produced maternal exposures up to approximately 2 times the exposure at the maximum recommended human dose (MRHD) in rats and 4 times the MRHD in rabbits [based on summed AUCs of elexacaftor and its metabolite (for rat) and AUC of elexacaftor (for rabbit)]. Oral administration of tezacaftor to pregnant rats and rabbits during organogenesis demonstrated no teratogenicity or adverse developmental effects at doses that produced maternal exposures up to approximately 3 times the exposure at the MRHD in rats and 0.2 times the MRHD in rabbits (based on summed AUCs of tezacaftor and M1-TEZ). Oral administration of ivacaftor to pregnant rats and rabbits during organogenesis demonstrated no teratogenicity or adverse developmental effects at doses that produced maternal exposures up to approximately 5 and 14 times the exposure at the MRHD, respectively [based on summed AUCs of ivacaftor and its metabolites (for rat) and AUC of ivacaftor (for rabbit)]. No adverse developmental effects were observed after oral administration of elexacaftor, tezacaftor or ivacaftor to pregnant rats from the period of organogenesis through lactation at doses that produced maternal exposures approximately 1 time, approximately 1 time and 3 times the exposures at the MRHD, respectively [based on summed AUCs of parent and metabolite(s)] ( see Data ). The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data Elexacaftor In an EFD study in pregnant rats dosed during the period of organogenesis from gestation Days 6-17, elexacaftor was not teratogenic and did not affect fetal survival at exposures up to 9 times the MRHD (based on summed AUC for elexacaftor and its metabolite at maternal doses up to 40 mg/kg/day). Lower mean fetal body weights were observed at doses ≥25 mg/kg/day that produced maternal exposures ≥4 times the MRHD. In an EFD study in pregnant rabbits dosed during the period of organogenesis from gestation Days 7-20, elexacaftor was not teratogenic at exposures up to 4 times the MRHD (based on AUC of elexacaftor at maternal doses up to 125 mg/kg/day). In a pre- and postnatal development (PPND) study in pregnant rats dosed from gestation Day 6 through lactation Day 18, elexacaftor did not cause developmental defects in pups at maternal doses up to 10 mg/kg/day (approximately 1 time the MRHD based on summed AUCs of elexacaftor and its metabolite). Placental transfer of elexacaftor was observed in pregnant rats. Tezacaftor In an EFD study in pregnant rats dosed during the period of organogenesis from gestation Days 6-17 and in pregnant rabbits dosed during the period of organogenesis from gestation Days 7-20, tezacaftor was not teratogenic and did not affect fetal development or survival at exposures up to 3 and 0.2 times, respectively the MRHD (based on summed AUCs of tezacaftor and M1-TEZ). Lower fetal body weights were observed in rabbits at a maternally toxic dose that produced exposures approximately 1 time the MRHD (based on summed AUCs of tezacaftor and M1-TEZ at a maternal dose of 50 mg/kg/day). In a PPND study in pregnant rats dosed from gestation Day 6 through lactation Day 18, tezacaftor had no adverse developmental effects on pups at an exposure of approximately 1 time the MRHD (based on summed AUCs for tezacaftor and M1-TEZ at a maternal dose of 25 mg/kg/day). Decreased fetal body weights and early developmental delays in pinna detachment, eye opening and righting reflex occurred at a maternally toxic dose (based on maternal weight loss) that produced exposures approximately 1 time the exposure at the MRHD (based on summed AUCs for tezacaftor and M1-TEZ at a maternal oral dose of 50 mg/kg/day). Placental transfer of tezacaftor was observed in pregnant rats. Ivacaftor In an EFD study in pregnant rats dosed during the period of organogenesis from gestation Days 7-17 and in pregnant rabbits dosed during the period of organogenesis from gestation Days 7-19, ivacaftor was not teratogenic and did not affect fetal survival at exposures up to 5 and 14 times, respectively, the MRHD [based on summed AUCs of ivacaftor and its metabolites (for rat) and AUC of ivacaftor (for rabbit)]. In a PPND study in pregnant rats dosed from gestation Day 7 through lactation Day 20, ivacaftor had no effects on delivery or growth and development of offspring at exposures up to 3 times the MRHD (based on summed AUCs for ivacaftor and its metabolites at maternal oral doses up to 100 mg/kg/day). Decreased fetal body weights were observed at a maternally toxic dose that produced exposures 5 times the MRHD (based on summed AUCs of ivacaftor and its metabolites). Placental transfer of ivacaftor was observed in pregnant rats and rabbits. Risk Summary There is no information regarding the presence of elexacaftor, tezacaftor, or ivacaftor in human milk, the effects on the breastfed infant, or the effects on milk production. Elexacaftor, tezacaftor, and ivacaftor are excreted into the milk of lactating rats (see Data ) . The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for TRIKAFTA and any potential adverse effects on the breastfed child from TRIKAFTA or from the underlying maternal condition. Data Elexacaftor Lacteal excretion of elexacaftor in rats was demonstrated following a single oral dose (10 mg/kg) of 14 C-elexacaftor administered 6 to 10 days postpartum to lactating dams. Exposure of 14 C-elexacaftor in milk was approximately 0.4 times the value observed in plasma (based on AUC 0-72h ). Tezacaftor Lacteal excretion of tezacaftor in rats was demonstrated following a single oral dose (30 mg/kg) of 14 C-tezacaftor administered 6 to 10 days postpartum to lactating dams. Exposure of 14 C-tezacaftor in milk was approximately 3 times higher than in plasma (based on AUC 0-72h ). Ivacaftor Lacteal excretion of ivacaftor in rats was demonstrated following a single oral dose (100 mg/kg) of 14 C-ivacaftor administered 9 to 10 days postpartum to lactating dams. Exposure of 14 C-ivacaftor in milk was approximately 1.5 times higher than in plasma (based on AUC 0-24h ). The safety and effectiveness of TRIKAFTA for the treatment of CF have been established in pediatric patients aged 2 to less than 18 years who have at least one F508del mutation in the CFTR gene or a mutation in the CFTR gene that is responsive based on in vitro data. Use of TRIKAFTA for this indication for pediatric patients 12 years of age and older was supported by evidence from two adequate and well-controlled studies (Trials 1 and 2) in CF patients aged 12 years and older [see Adverse Reactions (6.1) and Clinical Studies (14) ]. Use of TRIFAFTA for this indication in pediatric patients 2 to less than 12 years of age is based on the following: Trial 1, 56 pediatric patients aged 12 to less than 18 years who had an F508del mutation on one allele and a mutation on the second allele that results in either no CFTR protein or a CFTR protein that is not responsive to ivacaftor and tezacaftor/ivacaftor [see Adverse Reactions (6) and Clinical Studies (14) ] . Trial 2, 16 pediatric patients aged 12 to less than 18 years who were homozygous for the F508del mutation [see Adverse Reactions (6) and Clinical Studies (14) ] . Trial 3, 66 pediatric patients aged 6 to less than 12 years who were homozygous for the F508del mutation or heterozygous for the F508del mutation with a mutation on the second allele that results in either no CFTR protein or a CFTR protein that is not responsive to ivacaftor and tezacaftor/ivacaftor [see Adverse Reactions (6) and Clinical Pharmacology (12.3) ] . Trial 4, 75 pediatric patients aged 2 to less than 6 years who had at least one F508del mutation or a mutation known to be responsive to TRIKAFTA [see Adverse Reactions (6) and Clinical Pharmacology (12.3) ]. The effectiveness of TRIKAFTA in patients aged 2 to less than 12 years was extrapolated from patients aged 12 years and older with support from population pharmacokinetic analyses showing elexacaftor, tezacaftor, and ivacaftor exposure levels in patients aged 2 to less than 12 years within the range of exposures observed in patients aged 12 years and older [see Clinical Pharmacology (12.3) ] . Safety of TRIKAFTA in patients aged 6 to less than 12 years was derived from a 24-week, open-label, clinical trial in 66 patients aged 6 to less than 12 years (mean age at baseline 9.3 years) administered either a total dose of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg in the morning and ivacaftor 75 mg in the evening (for patients weighing less than 30 kg) or a total dose of elexacaftor 200 mg/tezacaftor 100 mg/ivacaftor 150 mg in the morning and ivacaftor 150 mg in the evening (for patients weighing 30 kg or more) (Trial 3). Safety of TRIKAFTA in patients aged 2 to less than 6 years was derived from a 24-week, open-label, clinical trial in 75 patients aged 2 to less than 6 years (mean age at baseline 4.1 years) administered either a total dose of elexacaftor 80 mg/tezacaftor 40 mg/ivacaftor 60 mg in the morning and ivacaftor 59.5 mg in the evening (for patients weighing 10 kg to less than 14 kg) or a total dose of elexacaftor 100 mg/tezacaftor 50 mg/ivacaftor 75 mg in the morning and ivacaftor 75 mg in the evening (for patients weighing 14 kg or more) (Trial 4). The safety profile of patients in these trials was similar to that observed in Trial 1 [see Adverse Reactions (6) ]. The safety and effectiveness of TRIKAFTA in patients with CF younger than 2 years of age have not been established. Juvenile Animal Toxicity Data Findings of cataracts were observed in juvenile rats dosed from postnatal Day 7 through 35 with ivacaftor dose levels of 10 mg/kg/day and higher (0.21 times the MRHD based on systemic exposure of ivacaftor and its metabolites). This finding has not been observed in older animals [see Warnings and Precautions (5.5) ] . Studies were conducted with tezacaftor in juvenile rats starting at postnatal day (PND) 21 and ranging up to PNDs 35 to 49. Findings of convulsions and death were observed in juvenile rats that received a tezacaftor dose level of 100 mg/kg/day (approximately equivalent to 1.9 times the MRHD based on summed AUCs of tezacaftor and its metabolite, M1-TEZ). A no effect dose level was identified at 30 mg/kg/day (approximately equivalent to 0.8 times the MRHD based on summed AUCs of tezacaftor and its metabolite, M1-TEZ). Findings were dose related and generally more severe when dosing with tezacaftor was initiated earlier in the postnatal period (PND 7, which would be approximately equivalent to a human neonate). Tezacaftor and its metabolite, M1-TEZ, are substrates for P-glycoprotein. Lower brain levels of P-glycoprotein activity in younger rats resulted in higher brain levels of tezacaftor and M1-TEZ. These findings are not relevant for the indicated pediatric population, 2 years of age and older, for whom levels of P-glycoprotein activity are equivalent to levels observed in adults. Clinical studies of TRIKAFTA did not include any patients aged 65 years and older. TRIKAFTA has not been studied in patients with severe renal impairment or end-stage renal disease. No dosage adjustment is recommended in patients with mild (eGFR 60 to <90 mL/min/1.73 m 2 ) or moderate (eGFR 30 to <60 mL/min/1.73 m 2 ) renal impairment. Use with caution in patients with severe (eGFR <30 mL/min/1.73 m 2 ) renal impairment or end-stage renal disease [see Clinical Pharmacology (12.3) ] . Mild Hepatic Impairment (Child-Pugh Class A): No dose modification is recommended. Liver function tests should be closely monitored. Moderate Hepatic Impairment (Child-Pugh Class B): Treatment is not recommended. Use of TRIKAFTA in patients with moderate hepatic impairment should only be considered when there is a clear medical need, and the benefit exceeds the risk. If used in patients with moderate hepatic impairment, TRIKAFTA should be used at a reduced dose [see Dosage and Administration (2.2) ] . Liver function tests should be closely monitored. In a clinical study of 11 subjects with moderate hepatic impairment, one subject developed total and direct bilirubin elevations >2 × ULN, and a second subject developed direct bilirubin elevation >4.5 × ULN [see Clinical Pharmacology (12.3) ] . Severe Hepatic Impairment (Child-Pugh Class C): Should not be used. TRIKAFTA has not been studied in patients with severe hepatic impairment (Child-Pugh Class C), but the exposure is expected to be higher than in patients with moderate hepatic impairment [see Dosage and Administration (2.2) , Warnings and Precautions (5.1) , Adverse Reactions (6) and Clinical Pharmacology (12.3) ] . Trial 1 included a total of 18 patients receiving TRIKAFTA with ppFEV 1 <40 at baseline. The safety and efficacy in this subgroup were comparable to those observed in the overall population.

TRIKAFTA tablets are supplied in a co-packaged blister pack sealed into a printed wallet, containing elexacaftor, tezacaftor and ivacaftor fixed-dose combination tablets and ivacaftor tablets. Four such wallets are placed in a printed outer carton. The elexacaftor 50 mg, tezacaftor 25 mg, and ivacaftor 37.5 mg tablets are supplied as light orange, capsule-shaped tablets; each containing 50 mg of elexacaftor, 25 mg of tezacaftor and 37.5 mg of ivacaftor. Each tablet is debossed with "T50" on one side and plain on the other. Ivacaftor 75 mg tablets are supplied as light blue, film-coated, capsule-shaped tablets; each containing 75 mg of ivacaftor. Each tablet is printed with the characters "V 75" in black ink on one side and plain on the other. TRIKAFTA is supplied as: 84-count tablet carton (4 wallets, each wallet containing 14 tablets of elexacaftor, tezacaftor and ivacaftor and 7 tablets of ivacaftor) NDC 51167-106-02 The elexacaftor 100 mg, tezacaftor 50 mg, and ivacaftor 75 mg tablets are supplied as orange, capsule-shaped tablets; each containing 100 mg of elexacaftor, 50 mg of tezacaftor and 75 mg of ivacaftor. Each tablet is debossed with "T100" on one side and plain on the other. Ivacaftor 150 mg tablets are supplied as light blue, film-coated, capsule-shaped tablets; each containing 150 mg of ivacaftor. Each tablet is printed with the characters "V 150" in black ink on one side and plain on the other. TRIKAFTA is supplied as: 84-count tablet carton (4 wallets, each wallet containing 14 tablets of elexacaftor, tezacaftor and ivacaftor and 7 tablets of ivacaftor) NDC 51167-331-01 TRIKAFTA oral granules are supplied in morning and evening unit-dose packets. The morning dose packets contain a fixed-dose combination of elexacaftor, tezacaftor, and ivacaftor oral granules. The evening dose packets contain ivacaftor oral granules. The packets are placed into a printed wallet. Four such wallets are placed in a printed outer carton. The elexacaftor 80 mg, tezacaftor 40 mg and ivacaftor 60 mg oral granules are supplied as white to off-white, sweetened, unflavored granules approximately 2 mm in diameter enclosed in unit-dose packets each containing 80 mg of elexacaftor, 40 mg of tezacaftor and 60 mg of ivacaftor. The packets are white and blue. The ivacaftor 59.5 mg oral granules are supplied as white to off-white, sweetened, unflavored granules approximately 2 mm in diameter enclosed in unit-dose packets each containing 59.5 mg of ivacaftor. The packets are white and green. TRIKAFTA is supplied as: 56-count packet carton (4 wallets, each containing 7 packets of elexacaftor, tezacaftor, and ivacaftor and 7 packets of ivacaftor) NDC 51167-445-01 The elexacaftor 100 mg, tezacaftor 50 mg and ivacaftor 75 mg oral granules are supplied as white to off-white, sweetened, unflavored granules approximately 2 mm in diameter enclosed in unit-dose packets each containing 100 mg of elexacaftor, 50 mg of tezacaftor and 75 mg of ivacaftor. The packets are white and orange. The ivacaftor 75 mg oral granules are supplied as white to off-white, sweetened, unflavored granules approximately 2 mm in diameter enclosed in unit-dose packets each containing 75 mg of ivacaftor. The packets are white and pink. TRIKAFTA is supplied as: 56-count packet carton (4 wallets, each containing 7 packets of elexacaftor, tezacaftor, and ivacaftor and 7 packets of ivacaftor) NDC 51167-446-01 Store at 20°C - 25°C (68°F - 77°F); excursions permitted to 15°C - 30°C (59°F - 86°F) [see USP Controlled Room Temperature].

Elexacaftor and tezacaftor bind to different sites on the CFTR protein and have an additive effect in facilitating the cellular processing and trafficking of select mutant forms of CFTR (including F508del-CFTR) to increase the amount of CFTR protein delivered to the cell surface compared to either molecule alone. Ivacaftor potentiates the channel open probability (or gating) of the CFTR protein at the cell surface. The combined effect of elexacaftor, tezacaftor and ivacaftor is increased quantity and function of CFTR at the cell surface, resulting in increased CFTR activity as measured by CFTR mediated chloride transport. CFTR Chloride Transport Assay in Fischer Rat Thyroid (FRT) Cells Expressing Mutant CFTR The chloride transport response of mutant CFTR protein to elexacaftor/tezacaftor/ivacaftor was determined in Ussing chamber electrophysiology studies using a panel of FRT cell lines transfected with individual CFTR mutations. Elexacaftor/tezacaftor/ivacaftor increased chloride transport in FRT cells expressing CFTR mutations that result in CFTR protein being delivered to the cell surface. The in vitro CFTR chloride transport response threshold was designated as a net increase of at least 10% of normal over baseline because it is predictive or reasonably expected to predict clinical benefit. For individual mutations, the magnitude of the net change over baseline in CFTR-mediated chloride transport in vitro is not correlated with the magnitude of clinical response. Table 5 lists responsive CFTR mutations based on in vitro data in FRT cells indicating that elexacaftor/tezacaftor/ivacaftor increases chloride transport to at least 10% of normal over baseline. Table 5: List of CFTR Gene Mutations that are Responsive to TRIKAFTA 3141del9 E822K G1069R L967S R117L S912L 546insCTA F191V G1244E L997F R117P S945L A46D F311del G1249R L1077P R170H S977F A120T F311L G1349D L1324P R258G S1159F A234D F508C H139R L1335P R334L S1159P A349V F508C;S1251N Complex/compound mutations where a single allele of the CFTR gene has multiple mutations; these exist independent of the presence of mutations on the other allele. H199Y L1480P R334Q S1251N A455E F508del F508del is a responsive CFTR mutation based on both clinical and in vitro data [see Clinical Studies (14) ] . H939R M152V R347H S1255P A554E F575Y H1054D M265R R347L T338I A1006E F1016S H1085P M952I R347P T1036N A1067T F1052V H1085R M952T R352Q T1053I D110E F1074L H1375P M1101K R352W V201M D110H F1099L I148T P5L R553Q V232D D192G G27R I175V P67L R668C V456A D443Y G85E I336K P205S R751L V456F D443Y;G576A;R668C G126D I502T P574H R792G V562I D579G G178E I601F Q98R R933G V754M D614G G178R I618T Q237E R1066H V1153E D836Y G194R I807M Q237H R1070Q V1240G D924N G194V I980K Q359R R1070W V1293G D979V G314E I1027T Q1291R R1162L W361R D1152H G463V I1139V R31L R1283M W1098C D1270N G480C I1269N R74Q R1283S W1282R E56K G551D I1366N R74W S13F Y109N E60K G551S K1060T R74W;D1270N S341P Y161D E92K G576A L15P R74W;V201M S364P Y161S E116K G576A;R668C L165S R74W;V201M;D1270N S492F Y563N E193K G622D L206W R75Q S549N Y1014C E403D G628R L320V R117C S549R Y1032C E474K G970D L346P R117G S589N E588V G1061R L453S R117H S737F Sweat Chloride Evaluation In Trial 1 (patients with an F508del mutation on one allele and a mutation on the second allele that results in either no CFTR protein or a CFTR protein that is not responsive ivacaftor and tezacaftor/ivacaftor), a reduction in sweat chloride was observed from baseline at Week 4 and sustained through the 24-week treatment period [see Clinical Studies (14.1) ] . In Trial 2 (patients homozygous for the F508del mutation), a reduction in sweat chloride was observed from baseline at Week 4 [see Clinical Studies (14.2) ] . In Trial 3 (patients aged 6 to less than 12 years who are homozygous for the F508del mutation or heterozygous for the F508del mutation and a mutation on the second allele that results in either no CFTR protein or a CFTR protein that is not responsive to ivacaftor and tezacaftor/ivacaftor), the mean absolute change in sweat chloride from baseline through Week 24 was -60.9 mmol/L (95% CI: -63.7, -58.2). In Trial 4 (patients aged 2 to less than 6 years who had at least one F508del mutation or a mutation known to be responsive to TRIKAFTA, the mean absolute change in sweat chloride from baseline through Week 24 was -57.9 mmol/L (95% CI: -61.3, -54.6). Cardiac Electrophysiology At doses up to 2 times the maximum recommended dose of elexacaftor and 3 times the maximum recommended dose of tezacaftor and ivacaftor, the QT/QTc interval in healthy subjects was not prolonged to any clinically relevant extent. The pharmacokinetics of elexacaftor, tezacaftor and ivacaftor are similar between healthy adult subjects and patients with CF. The pharmacokinetic parameters for elexacaftor, tezacaftor and ivacaftor in patients with CF aged 12 years and older are shown in Table 6. Table 6: Pharmacokinetic Parameters of TRIKAFTA Components Elexacaftor Tezacaftor Ivacaftor AUC ss : area under the concentration versus time curve at steady state; SD: Standard Deviation; C max : maximum observed concentration; T max : time of maximum concentration; AUC: area under the concentration versus time curve. General Information   AUC ss (SD), mcg∙h/mL Based on elexacaftor 200 mg and tezacaftor 100 mg once daily/ivacaftor 150 mg every 12 hours at steady state in patients with CF aged 12 years and older. 162 (47.5) AUC 0-24h . 89.3 (23.2) 11.7 (4.01) AUC 0-12h .   C max (SD), mcg/mL 9.2 (2.1) 7.7 (1.7) 1.2 (0.3)   Time to Steady State, days Within 7 days Within 8 days Within 3-5 days   Accumulation Ratio 2.2 2.07 2.4 Absorption   Absolute Bioavailability 80% Not determined Not determined   Median T max (range), hours 6 (4 to 12) 3 (2 to 4) 4 (3 to 6)   Effect of Food AUC increases 1.9- to 2.5-fold (moderate-fat meal) No clinically significant effect Exposure increases 2.5- to 4-fold Distribution   Mean (SD) Apparent Volume of Distribution, L Elexacaftor, tezacaftor and ivacaftor do not partition preferentially into human red blood cells. 53.7 (17.7) 82.0 (22.3) 293 (89.8)   Protein Binding Elexacaftor and tezacaftor bind primarily to albumin. Ivacaftor primarily bind to albumin, alpha 1-acid glycoprotein and human gamma-globulin. >99% approximately 99% approximately 99% Elimination   Mean (SD) Effective Half-Life, hours Mean (SD) terminal half-lives of elexacaftor, tezacaftor and ivacaftor are approximately 24.7 (4.87) hours, 60.3 (15.7) hours and 13.1 (2.98) hours, respectively. 27.4 (9.31) 25.1 (4.93) 15.0 (3.92)   Mean (SD) Apparent Clearance, L/hours 1.18 (0.29) 0.79 (0.10) 10.2 (3.13) Metabolism   Primary Pathway CYP3A4/5 CYP3A4/5 CYP3A4/5   Active Metabolites M23-ELX M1-TEZ M1-IVA   Metabolite Potency Relative to Parent Similar Similar approximately 1/6 th of parent Excretion Following radiolabeled doses.   Primary Pathway Feces: 87.3% (primarily as metabolites) Urine: 0.23% Feces: 72% (unchanged or as M2-TEZ) Urine: 14% (0.79% unchanged) Feces: 87.8% Urine: 6.6% Specific Populations Pediatric Patients 2 to Less Than 12 Years of Age Elexacaftor, tezacaftor and ivacaftor exposures observed in patients aged 2 to less than 12 years as determined using population PK analysis are presented by age group and dose administered in Table 7. Elexacaftor, tezacaftor and ivacaftor exposures in this patient population are within the range observed in patients aged 12 years and older. Table 7: Mean (SD) Elexacaftor, Tezacaftor and Ivacaftor Exposures Observed at Steady State by Age Group and Dose Administered Age Group Dose ElexacaftorAUC 0-24h,ss (µg∙h/mL) Tezacaftor AUC 0-24h,ss (µg∙h/mL) Ivacaftor AUC 0-12h,ss (µg∙h/mL) SD: Standard Deviation; AUC ss : area under the concentration versus time curve at steady state. Patients aged 2 to less than 6 years weighing less than 14 kg (N = 16) elexacaftor 80 mg qd/tezacaftor 40 mg qd/ivacaftor 60 mg qAM and ivacaftor 59.5 mg qPM 128 (24.8) 87.3 (17.3) 11.9 (3.86) Patients aged 2 to less than 6 years weighing 14 kg or more (N = 59) elexacaftor 100 mg qd/tezacaftor 50 mg qd/ivacaftor 75 mg q12h 138 (47.0) 90.2 (27.9) 13.0 (6.11) Patients aged 6 to less than 12 years weighing less than 30 kg (N = 36) elexacaftor 100 mg qd/tezacaftor 50 mg qd/ivacaftor 75 mg q12h 116 (39.4) 67.0 (22.3) 9.78 (4.50) Patients aged 6 to less than 12 years weighing 30 kg or more (N = 30) elexacaftor 200 mg qd/ tezacaftor 100 mg qd/ ivacaftor 150 mg q12h 195 (59.4) 103 (23.7) 17.5 (4.97) Pediatric Patients 12 to Less Than 18 Years of Age The following conclusions about exposures between adults and the pediatric population are based on population pharmacokinetic (PK) analyses. Following oral administration of TRIKAFTA to patients 12 to less than 18 years of age (elexacaftor 200 mg qd/tezacaftor 100 mg qd/ivacaftor 150 mg q12h), the mean (±SD) AUC ss was 147 (36.8) mcg∙h/mL, 88.8 (21.8) mcg∙h/mL and 10.6 (3.35) mcg∙h/mL, respectively for elexacaftor, tezacaftor and ivacaftor, similar to the AUC ss in adult patients. Patients with Renal Impairment Renal excretion of elexacaftor, tezacaftor and ivacaftor is minimal. Elexacaftor alone or in combination with tezacaftor and ivacaftor has not been studied in subjects with severe (eGFR <30 mL/min/1.73 m 2 ) renal impairment or end-stage renal disease. Based on population PK analyses, the clearance of elexacaftor and tezacaftor was similar in subjects with mild (eGFR 60 to <90 mL/min/1.73 m 2 ) or moderate (eGFR 30 to <60 mL/min/1.73 m 2 ) renal impairment relative to patients with normal renal function [see Use in Specific Populations (8.6) ] . Patients with Hepatic Impairment Elexacaftor alone or in combination with tezacaftor and ivacaftor has not been studied in subjects with severe hepatic impairment (Child-Pugh Class C, score 10-15). In a clinical study, following multiple doses of elexacaftor, tezacaftor and ivacaftor for 10 days, subjects with moderately impaired hepatic function (Child-Pugh Class B, score 7-9) had 25% higher AUC and 12% higher C max for elexacaftor, 73% higher AUC and 70% higher C max for M23-ELX, 36% higher AUC and 24% higher C max for combined elexacaftor and M23-ELX, 20% higher AUC but similar C max for tezacaftor and 1.5-fold higher AUC and 10% higher C max for ivacaftor compared with healthy subjects matched for demographics [see Dosage and Administration (2.2) , Warnings and Precautions (5.1) , Adverse Reactions (6) and Use in Specific Populations (8.7) ] . Tezacaftor and Ivacaftor Following multiple doses of tezacaftor and ivacaftor for 10 days, subjects with moderately impaired hepatic function had an approximately 36% higher AUC and a 10% higher in C max for tezacaftor and a 1.5-fold higher AUC but similar C max for ivacaftor compared with healthy subjects matched for demographics. Ivacaftor In a study with ivacaftor alone, subjects with moderately impaired hepatic function had similar ivacaftor C max , but an approximately 2.0-fold higher ivacaftor AUC 0-∞ compared with healthy subjects matched for demographics. Male and Female Patients Based on population PK analysis, the exposures of elexacaftor, tezacaftor and ivacaftor are similar in males and females. Drug Interaction Studies Drug interaction studies were performed with elexacaftor, tezacaftor and/or ivacaftor and other drugs likely to be co-administered or drugs commonly used as probes for pharmacokinetic interaction studies [see Drug Interactions (7) ] . Potential for Elexacaftor, Tezacaftor and/or Ivacaftor to Affect Other Drugs Based on in vitro results, elexacaftor and tezacaftor have a low potential to inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6 and CYP3A4, whereas ivacaftor has the potential to inhibit CYP2C8, CYP2C9 and CYP3A. However, clinical studies showed that the combination regimen of tezacaftor/ivacaftor is not an inhibitor of CYP3A and ivacaftor is not an inhibitor of CYP2C8 or CYP2D6. Based on in vitro results, elexacaftor, tezacaftor and ivacaftor are not likely to induce CYP3A, CYP1A2 and CYP2B6. Based on in vitro results, elexacaftor and tezacaftor have a low potential to inhibit the transporter P-gp, while ivacaftor has the potential to inhibit P-gp. Co-administration of tezacaftor/ivacaftor with digoxin, a sensitive P-gp substrate, increased digoxin exposure by 1.3-fold in a clinical study. Based on in vitro results, elexacaftor and M23-ELX may inhibit OATP1B1 and OATP1B3 uptake. Tezacaftor has a low potential to inhibit BCRP, OCT2, OAT1, or OAT3. Ivacaftor is not an inhibitor of the transporters OCT1, OCT2, OAT1, or OAT3. The effects of elexacaftor, tezacaftor and/or ivacaftor on the exposure of co-administered drugs are shown in Table 8 [see Drug Interactions (7) ] . Table 8: Impact of Elexacaftor, Tezacaftor and/or Ivacaftor on Other Drugs Dose and Schedule Effect on Other Drug PK Geometric Mean Ratio (90% CI) of Other Drug No Effect=1.0 AUC C max ↑ = increase, ↓ = decrease, ↔ = no change. CI = Confidence Interval; ELX= elexacaftor; TEZ = tezacaftor; IVA = ivacaftor; PK = Pharmacokinetics Midazolam 2 mg single oral dose TEZ 100 mg qd/IVA 150 mg q12h ↔ Midazolam 1.12 (1.01, 1.25) 1.13 (1.01, 1.25) Digoxin 0.5 mg single dose TEZ 100 mg qd/IVA 150 mg q12h ↑ Digoxin 1.30 (1.17, 1.45) 1.32 (1.07, 1.64) Oral Contraceptive Ethinyl estradiol 30 µg/Levonorgestrel 150 µg qd ELX 200 mg qd/TEZ 100 mg qd/IVA 150 mg q12h ↑ Ethinyl estradiol Effect not clinically significant [ see Drug Interactions (7.6) ] . 1.33 (1.20, 1.49) 1.26 (1.14, 1.39) ↑ Levonorgestrel 1.23 (1.10, 1.37) 1.10 (0.985, 1.23) Rosiglitazone 4 mg single oral dose IVA 150 mg q12h ↔ Rosiglitazone 0.975 (0.897, 1.06) 0.928 (0.858, 1.00) Desipramine 50 mg single dose IVA 150 mg q12h ↔ Desipramine 1.04 (0.985, 1.10) 1.00 (0.939; 1.07) Potential for Other Drugs to Affect Elexacaftor, Tezacaftor and/or Ivacaftor In vitro studies showed that elexacaftor, tezacaftor and ivacaftor are all metabolized by CYP3A. Exposure to elexacaftor, tezacaftor and ivacaftor may be reduced by concomitant CYP3A inducers and increased by concomitant CYP3A inhibitors. In vitro studies showed that elexacaftor and tezacaftor are substrates for the efflux transporter P-gp, but ivacaftor is not. Elexacaftor and ivacaftor are not substrates for OATP1B1 or OATP1B3; tezacaftor is a substrate for OATP1B1, but not OATP1B3. Tezacaftor is a substrate for BCRP. The effects of co-administered drugs on the exposure of elexacaftor, tezacaftor and/or ivacaftor are shown in Table 9 [see Dosage and Administration (2.3) and Drug Interactions (7) ] . Table 9: Impact of Other Drugs on Elexacaftor, Tezacaftor and/or Ivacaftor Dose and Schedule Effect on ELX, TEZ and/or IVA PK Geometric Mean Ratio (90% CI) of Elexacaftor, Tezacaftor and Ivacaftor No Effect = 1.0 AUC C max ↑ = increase, ↓ = decrease, ↔ = no change. CI = Confidence Interval; ELX= elexacaftor; TEZ = tezacaftor; IVA = ivacaftor; PK = Pharmacokinetics Itraconazole 200 mg q12h on Day 1, followed by 200 mg qd TEZ 25 mg qd + IVA 50 mg qd ↑ Tezacaftor 4.02 (3.71, 4.63) 2.83 (2.62, 3.07) ↑ Ivacaftor 15.6 (13.4, 18.1) 8.60 (7.41, 9.98) Itraconazole 200 mg qd ELX 20 mg + TEZ 50 mg single dose ↑ Elexacaftor 2.83 (2.59, 3.10) 1.05 (0.977, 1.13) ↑ Tezacaftor 4.51 (3.85, 5.29) 1.48 (1.33, 1.65) Ketoconazole 400 mg qd IVA 150 mg single dose ↑ Ivacaftor 8.45 (7.14, 10.0) 2.65 (2.21, 3.18) Ciprofloxacin 750 mg q12h TEZ 50 mg q12h + IVA 150 mg q12h ↔ Tezacaftor 1.08 (1.03, 1.13) 1.05 (0.99, 1.11) ↑ Ivacaftor Effect is not clinically significant [ see Drug Interactions (7.3) ] . 1.17 (1.06, 1.30) 1.18 (1.06, 1.31) Rifampin 600 mg qd IVA 150 mg single dose ↓ Ivacaftor 0.114 (0.097, 0.136) 0.200 (0.168, 0.239) Fluconazole 400 mg single dose on Day 1, followed by 200 mg qd IVA 150 mg q12h ↑ Ivacaftor 2.95 (2.27, 3.82) 2.47 (1.93, 3.17)

No studies of carcinogenicity, mutagenicity, or impairment of fertility were conducted with the combination of elexacaftor, tezacaftor and ivacaftor; however, separate studies of elexacaftor, tezacaftor and ivacaftor are described below. Elexacaftor A 6-month study in Tg.rasH2 transgenic mice showed no evidence of tumorigenicity at 50 mg/kg/day dose, the highest dose tested. A two-year study was conducted in rats to assess the carcinogenic potential of elexacaftor. No evidence of tumorigenicity was observed in rats at elexacaftor oral doses up to 10 mg/kg/day (approximately 2 and 5 times the MRHD based on summed AUCs of elexacaftor and its metabolite in male and female rats, respectively). Elexacaftor was negative for genotoxicity in the following assays: Ames test for bacterial gene mutation, in vitro mammalian cell micronucleus assay in TK6 cells, and in vivo mouse micronucleus test. Elexacaftor did not cause reproductive system toxicity in male rats at 55 mg/kg/day and female rats at 25 mg/kg/day, equivalent to approximately 6 times and 4 times the MRHD, respectively (based on summed AUCs of elexacaftor and its metabolite). Elexacaftor did not cause embryonic toxicity at 35 mg/kg/day which was the highest dose tested, equivalent to approximately 7 times the MRHD (based on summed AUCs of elexacaftor and its metabolite). Lower male and female fertility, male copulation and female conception indices were observed in males at 75 mg/kg/day and females at 35 mg/kg/day, equivalent to approximately 6 times and 7 times, respectively, the MRHD (based on summed AUCs of elexacaftor and its metabolite). Tezacaftor A two-year study in Sprague-Dawley rats and a 6-month study in Tg.rasH2 transgenic mice were conducted to assess the carcinogenic potential of tezacaftor. No evidence of tumorigenicity from tezacaftor was observed in male and female rats at oral doses up to 50 and 75 mg/kg/day (approximately 1 and 2 times the MRHD based on summed AUCs of tezacaftor and its metabolites in males and females, respectively). No evidence of tumorigenicity was observed in male and female Tg.rasH2 transgenic mice at tezacaftor doses up to 500 mg/kg/day. Tezacaftor was negative for genotoxicity in the following assays: Ames test for bacterial gene mutation, in vitro chromosomal aberration assay in Chinese hamster ovary cells and in vivo mouse micronucleus test. There were no effects on male or female fertility and early embryonic development in rats at oral tezacaftor doses up to 100 mg/kg/day (approximately 3 times the MRHD based on summed AUC of tezacaftor and M1-TEZ). Ivacaftor Two-year studies were conducted in CD-1 mice and Sprague-Dawley rats to assess the carcinogenic potential of ivacaftor. No evidence of tumorigenicity from ivacaftor was observed in mice or rats at oral doses up to 200 mg/kg/day and 50 mg/kg/day, respectively (approximately equivalent to 2 and 7 times the MRHD, respectively, based on summed AUCs of ivacaftor and its metabolites). Ivacaftor was negative for genotoxicity in the following assays: Ames test for bacterial gene mutation, in vitro chromosomal aberration assay in Chinese hamster ovary cells and in vivo mouse micronucleus test. Ivacaftor impaired fertility and reproductive performance indices in male and female rats at 200 mg/kg/day (approximately 7 and 5 times, respectively, the MRHD based on summed AUCs of ivacaftor and its metabolites). Increases in prolonged diestrus were observed in females at 200 mg/kg/day. Ivacaftor also increased the number of females with all nonviable embryos and decreased corpora lutea, implantations and viable embryos in rats at 200 mg/kg/day (approximately 5 times the MRHD based on summed AUCs of ivacaftor and its metabolites) when dams were dosed prior to and during early pregnancy. These impairments of fertility and reproductive performance in male and female rats at 200 mg/kg/day were attributed to severe toxicity.

Efficacy : The efficacy of TRIKAFTA in patients with CF aged 12 years and older was evaluated in two double-blind, controlled trials (Trials 1 and 2). Trial 1 was a 24-week, randomized, double-blind, placebo-controlled study in patients who had an F508del mutation on one allele and a mutation on the second allele that results in either no CFTR protein or a CFTR protein that is not responsive to ivacaftor and tezacaftor/ivacaftor. An interim analysis was planned when at least 140 patients completed Week 4 and at least 100 patients completed Week 12. Trial 2 was a 4-week, randomized, double-blind, active-controlled study in patients who are homozygous for the F508del mutation. Patients received tezacaftor 100 mg qd/ivacaftor 150 mg q12h during a 4-week, open-label run-in period and were then randomized and dosed to receive TRIKAFTA or tezacaftor 100 mg qd/ivacaftor 150 mg q12h during a 4-week, double-blind treatment period. Patients in Trials 1 and 2 had a confirmed diagnosis of CF and at least one F508del mutation. Patients discontinued any previous CFTR modulator therapies, but continued on their other standard-of-care CF therapies (e.g., bronchodilators, inhaled antibiotics, dornase alfa and hypertonic saline). Patients had a ppFEV 1 at screening between 40-90%. Patients with a history of colonization with organisms associated with a more rapid decline in pulmonary status, including but not limited to Burkholderia cenocepacia , Burkholderia dolosa , or Mycobacterium abscessus , or who had an abnormal liver function test at screening (ALT, AST, ALP, or GGT ≥3 × ULN, or total bilirubin ≥2 × ULN), were excluded from the trials. Patients in Trials 1 and 2 were eligible to roll over into a 96-week, open-label extension study. Trial 1 evaluated 403 patients (200 TRIKAFTA, 203 placebo) with CF aged 12 years and older (mean age 26.2 years). The mean ppFEV 1 at baseline was 61.4% (range: 32.3%, 97.1%). The primary endpoint assessed at the time of interim analysis was mean absolute change in ppFEV 1 from baseline at Week 4. The final analysis tested all key secondary endpoints in the 403 patients who completed the 24-week study participation, including absolute change in ppFEV 1 from baseline through Week 24; absolute change in sweat chloride from baseline at Week 4 and through Week 24; number of pulmonary exacerbations through Week 24; absolute change in BMI from baseline at Week 24, and absolute change in CFQ-R Respiratory Domain Score (a measure of respiratory symptoms relevant to patients with CF, such as cough, sputum production and difficulty breathing) from baseline at Week 4 and through Week 24. Of the 403 patients included in the interim analysis, the treatment difference between TRIKAFTA and placebo for the mean absolute change from baseline in ppFEV 1 at Week 4 was 13.8 percentage points (95% CI: 12.1, 15.4; P <0.0001). The treatment difference between TRIKAFTA and placebo for mean absolute change in ppFEV 1 from baseline through Week 24 was 14.3 percentage points (95% CI: 12.7, 15.8; P <0.0001). Mean improvement in ppFEV 1 was observed at the first assessment on Day 15 and sustained through the 24-week treatment period (see Figure 1 ). Improvements in ppFEV 1 were observed regardless of age, baseline ppFEV 1 , sex and geographic region. See Table 10 for a summary of primary and key secondary outcomes in Trial 1. Table 10: Primary and Key Secondary Efficacy Analyses (Trial 1) Analysis Statistic Treatment Difference Treatment difference provided as the outcome measure for changes in ppFEV 1 , sweat chloride, CFQ-R and BMI; Rate ratio provided as the outcome measure for the number of pulmonary exacerbations. for TRIKAFTA (N=200) vs Placebo (N=203) ppFEV 1 : percent predicted Forced Expiratory Volume in 1 second; CI: Confidence Interval; CFQ-R: Cystic Fibrosis Questionnaire-Revised; BMI: Body Mass Index. Primary (Interim Full Analysis Set) Primary endpoint was based on interim analysis in 403 patients. Absolute change in ppFEV 1 from baseline at Week 4 (percentage points) Treatment difference (95% CI) P value 13.8 (12.1, 15.4) P <0.0001 Key Secondary (Full Analysis Set) Key secondary endpoints were tested at the final analysis in 403 patients. Absolute change in ppFEV 1 from baseline through Week 24 (percentage points) Treatment difference (95% CI) P value 14.3 (12.7, 15.8) P <0.0001 Number of pulmonary exacerbations from baseline through Week 24 A pulmonary exacerbation was defined as a change in antibiotic therapy (IV, inhaled, or oral) as a result of 4 or more of 12 pre-specified sino-pulmonary signs/symptoms. Number of pulmonary exacerbation events (event rate per year calculated based on 48 weeks per year) in the TRIKAFTA group were 41 (0.37) and 113 (0.98) in the placebo group. Rate ratio (95% CI) P value 0.37 (0.25, 0.55) P <0.0001 Absolute change in sweat chloride from baseline through Week 24 (mmol/L) Treatment difference (95% CI) P value -41.8 (-44.4, -39.3) P <0.0001 Absolute change in CFQ-R respiratory domain score from baseline through Week 24 (points) Treatment difference (95% CI) P value 20.2 (17.5, 23.0) P <0.0001 Absolute change in BMI from baseline at Week 24 (kg/m 2 ) Treatment difference (95% CI) P value 1.04 (0.85, 1.23) P <0.0001 Absolute change in sweat chloride from baseline at Week 4 (mmol/L) Treatment difference (95% CI) P value -41.2 (-44.0, -38.5) P <0.0001 Absolute change in CFQ-R respiratory domain score from baseline at Week 4 (points) Treatment difference (95% CI) P value 20.1 (16.9, 23.2) P <0.0001 Figure 1: Absolute Change from Baseline in Percent Predicted FEV 1 at Each Visit in Trial 1 Figure 1 Trial 2 evaluated 107 patients with CF aged 12 years and older (mean age 28.4 years). The mean ppFEV 1 at baseline, following the 4-week, open-label run-in period with tezacaftor/ivacaftor was 60.9% (range: 35.0%, 89.0%). The primary endpoint was mean absolute change in ppFEV 1 from baseline at Week 4 of the double-blind treatment period. The key secondary efficacy endpoints were absolute change in sweat chloride and CFQ-R Respiratory Domain Score from baseline at Week 4. Treatment with TRIKAFTA compared to tezacaftor/ivacaftor resulted in a statistically significant improvement in ppFEV 1 of 10.0 percentage points (95% CI: 7.4, 12.6; P <0.0001). Mean improvement in ppFEV 1 was observed at the first assessment on Day 15. Improvements in ppFEV 1 were observed regardless of age, sex, baseline ppFEV 1 and geographic region. See Table 11 for a summary of primary and key secondary outcomes. Table 11: Primary and Key Secondary Efficacy Analyses, Full Analysis Set (Trial 2) Analysis Baseline for primary and key secondary endpoints is defined as the end of the 4-week tezacaftor/ivacaftor run-in period. Statistic Treatment Difference for TRIKAFTA (N=55) vs Tezacaftor/Ivacaftor Regimen of tezacaftor 100 mg qd/ivacaftor 150 mg q12h. (N=52) ppFEV 1 : percent predicted Forced Expiratory Volume in 1 second; CI: Confidence Interval; CFQ-R: Cystic Fibrosis Questionnaire-Revised. Primary Absolute change in ppFEV 1 from baseline at Week 4 (percentage points) Treatment difference (95% CI) P value 10.0 (7.4, 12.6) P <0.0001 Key Secondary Absolute change in sweat chloride from baseline at Week 4 (mmol/L) Treatment difference (95% CI) P value -45.1 (-50.1, -40.1) P <0.0001 Absolute change in CFQ-R respiratory domain score from baseline at Week 4 (points) Treatment difference (95% CI) P value 17.4 (11.8, 23.0) P <0.0001

This Patient Information has been approved by the U.S. Food and Drug Administration. Revised: 08/2023     Patient Information TRIKAFTA ® (tri-KAF-tuh) (elexacaftor, tezacaftor, and ivacaftor tablets; ivacaftor tablets), co-packaged for oral use (elexacaftor, tezacaftor, and ivacaftor oral granules; ivacaftor oral granules), co-packaged What is TRIKAFTA? TRIKAFTA is a prescription medicine used for the treatment of cystic fibrosis (CF) in people aged 2 years and older who have at least one copy of the F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene or another mutation that is responsive to treatment with TRIKAFTA. Talk to your doctor to learn if you have an indicated CF gene mutation. It is not known if TRIKAFTA is safe and effective in children under 2 years of age. Before taking TRIKAFTA, tell your doctor about all of your medical conditions, including if you: are allergic to TRIKAFTA or any ingredients in TRIKAFTA. See the end of this patient information leaflet for a complete list of ingredients in TRIKAFTA. have kidney problems. have or have had liver problems. are pregnant or plan to become pregnant. It is not known if TRIKAFTA will harm your unborn baby. You and your doctor should decide if you will take TRIKAFTA while you are pregnant. are breastfeeding or planning to breastfeed. It is not known if TRIKAFTA passes into your breast milk. You and your doctor should decide if you will take TRIKAFTA while you are breastfeeding. Tell your doctor about all the medicines you take , including prescription and over-the-counter medicines, vitamins, and herbal supplements. TRIKAFTA may affect the way other medicines work and other medicines may affect how TRIKAFTA works. The dose of TRIKAFTA may need to be adjusted when taken with certain medicines. Ask your doctor or pharmacist for a list of these medicines if you are not sure. Especially tell your doctor if you take: antibiotics such as rifampin (RIFAMATE ® , RIFATER ® ) or rifabutin (MYCOBUTIN ® ) seizure medicines such as phenobarbital, carbamazepine (TEGRETOL ® , CARBATROL ® , EQUETRO ® ), or phenytoin (DILANTIN ® , PHENYTEK ® ) St. John's wort antifungal medicines including ketoconazole, itraconazole (such as SPORANOX ® ), posaconazole (such as NOXAFIL ® ), voriconazole (such as VFEND ® ), or fluconazole (such as DIFLUCAN ® ). antibiotics including telithromycin, clarithromycin (such as BIAXIN ® ), or erythromycin (such as ERY-TAB ® ). Know the medicines you take. Keep a list of them to show your doctor and pharmacist when you get a new medicine. How should I take TRIKAFTA? Take TRIKAFTA exactly as your doctor tells you to take it. Take TRIKAFTA by mouth only. TRIKAFTA consists of 2 different doses (a morning dose and an evening dose). Each dose has different ingredients. Always take TRIKAFTA oral granules or tablets with food that contains fat . Examples of fat-containing foods include butter, oil, eggs, peanut butter, nuts, meat, and whole-milk dairy products such as whole milk, cheese, and yogurt. TRIKAFTA oral granules (age 2 to less than 6 years weighing less than 14 kg): The white and blue packets each contain the medicines elexacaftor, tezacaftor, and ivacaftor. Take one morning dose packet in the morning. The white and green color packets each contain the medicine ivacaftor. Take one evening dose packet in the evening. TRIKAFTA oral granules (age 2 to less than 6 years weighing 14 kg or more): The white and orange packets each contain the medicines elexacaftor, tezacaftor, and ivacaftor. Take one morning dose packet in the morning. The white and pink color packets each contain the medicine ivacaftor. Take one evening dose packet in the evening. To prepare TRIKAFTA oral granules: Hold the packet with the cut line on top. Shake the packet gently to settle the TRIKAFTA oral granules. Tear or cut the packet open along the cut line. Carefully pour all the TRIKAFTA oral granules in the packet into 1 teaspoon (5 mL) of soft food or liquid in a small container (like an empty bowl). The food or liquid should be at or below room temperature. Some examples of soft foods or liquids include pureed fruits or vegetables, yogurt, applesauce, water, milk, or juice. Mix the TRIKAFTA granules with food or liquid. After mixing, give TRIKAFTA within 1 hour. Make sure all the medicine is taken. TRIKAFTA tablets (age 6 to less than 12 years weighing less than 30 kg): The light orange tablet is marked with 'T50' and each tablet contains the medicines elexacaftor, tezacaftor and ivacaftor. Take 2 light orange tablets in the morning. The light blue tablet is marked with 'V 75' and contains the medicine ivacaftor. Take 1 light blue tablet in the evening. TRIKAFTA tablets (age 6 to less than 12 years weighing 30 kg or more, and age 12 years and older): The orange tablet is marked with 'T100' and each tablet contains the medicines elexacaftor, tezacaftor and ivacaftor. Take 2 orange tablets in the morning. The light blue tablet is marked with 'V 150' and contains the medicine ivacaftor. Take 1 light blue tablet in the evening. Take TRIKAFTA tablets whole. Take the morning and the evening doses about 12 hours apart. If you miss a dose of TRIKAFTA and: it is 6 hours or less from the time you usually take the morning dose or the evening dose, take the missed dose with food that contains fat as soon as you can. Then take your next dose at your usual time. it is more than 6 hours from the time you usually take the morning dose, take the missed dose with food that contains fat as soon as you can. Do not take the evening dose . it is more than 6 hours from the time you usually take the evening dose, do not take the missed dose . Take your next morning dose at the usual time with food that contains fat. Do not take more than your usual dose of TRIKAFTA to make up for a missed dose. Do not take the morning and evening doses at the same time. If you are not sure about your dosing, call your doctor. What should I avoid while taking TRIKAFTA? Avoid food or drink that contains grapefruit while you are taking TRIKAFTA. What are the possible side effects of TRIKAFTA? TRIKAFTA can cause serious side effects, including: Liver damage and worsening liver function in people with severe liver disease that can be serious and may require transplantation. Liver damage has also happened in people without liver disease. High liver enzymes in the blood is a common side effect in people treated with TRIKAFTA. These can be serious and may be a sign of liver injury. Your doctor will do blood tests to check your liver: before you start TRIKAFTA every 3 months during your first year of taking TRIKAFTA then every year while you are taking TRIKAFTA Your doctor may do blood tests to check the liver more often if you have had high liver enzymes in your blood in the past. Call your doctor right away if you have any of the following symptoms of liver problems: pain or discomfort in the upper right stomach (abdominal) area yellowing of your skin or the white part of your eyes loss of appetite nausea or vomiting dark, amber-colored urine Serious Allergic Reactions can happen to people who are treated with TRIKAFTA. Call your healthcare provider or go to the emergency room right away if you have any symptoms of an allergic reaction. Symptoms of an allergic reaction may include: rash or hives tightness of the chest or throat or difficulty breathing swelling of the face, lips and/or tongue, difficulty swallowing light-headedness or dizziness Abnormality of the eye lens (cataract) has happened in some children and adolescents treated with TRIKAFTA. If you are a child or adolescent, your doctor should perform eye examinations before and during treatment with TRIKAFTA to look for cataracts. The most common side effects of TRIKAFTA include: headache upper respiratory tract infection (common cold) including stuffy and runny nose stomach (abdominal) pain diarrhea rash increase in liver enzymes increase in a certain blood enzyme called creatine phosphokinase flu (influenza) inflamed sinuses increase in blood bilirubin Tell your doctor if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of TRIKAFTA. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store TRIKAFTA? Store TRIKAFTA at room temperature between 68ºF to 77ºF (20ºC to 25ºC). Keep TRIKAFTA and all medicines out of the reach of children. General information about the safe and effective use of TRIKAFTA. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use TRIKAFTA for a condition for which it was not prescribed. Do not give TRIKAFTA to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or doctor for information about TRIKAFTA that is written for health professionals. What are the ingredients in TRIKAFTA? Elexacaftor/tezacaftor/ivacaftor tablets: Active ingredients: elexacaftor, tezacaftor and ivacaftor. Inactive ingredients: croscarmellose sodium, hypromellose, hypromellose acetate succinate, magnesium stearate, microcrystalline cellulose, sodium lauryl sulfate. The tablet film coat contains hydroxypropyl cellulose, hypromellose, iron oxide red, iron oxide yellow, talc, and titanium dioxide. Ivacaftor tablets: Active ingredients: ivacaftor. Inactive ingredients: colloidal silicon dioxide, croscarmellose sodium, hypromellose acetate succinate, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and sodium lauryl sulfate. The tablet film coat contains carnauba wax, FD&C Blue #2, PEG 3350, polyvinyl alcohol, talc, and titanium oxide. The printing ink contains ammonium hydroxide, iron oxide black, propylene glycol, and shellac. Elexacaftor/tezacaftor/ivacaftor oral granules: Active ingredients: elexacaftor, tezacaftor, and ivacaftor. Inactive ingredients : colloidal silicon dioxide, croscarmellose sodium, hypromellose, hypromellose acetate succinate, lactose monohydrate, magnesium stearate, mannitol, sodium lauryl sulfate, and sucralose. Ivacaftor oral granules: Active ingredients : ivacaftor. Inactive ingredients: colloidal silicon dioxide, croscarmellose sodium, hypromellose acetate succinate, lactose monohydrate, magnesium stearate, mannitol, sodium lauryl sulfate, and sucralose. Manufactured for: Vertex Pharmaceuticals Incorporated; 50 Northern Avenue, Boston, MA 02210 TRIKAFTA, VERTEX and associated logos are registered trademarks of Vertex Pharmaceuticals Incorporated. All other trademarks referenced herein are the property of their respective owners. ©2023 Vertex Pharmaceuticals Incorporated For more information, go to www.trikafta.com or call 1-877-752-5933.

NDC 51167-331-01 Rx Only trikafta ® (elexacaftor, tezacaftor and ivacaftor) 100 mg, 50 mg and 75 mg; (ivacaftor) 150 mg tablets 84 Tablets 4-wallets (each containing 14 tablets of elexacaftor, tezacaftor, and ivacaftor and 7 tablets of ivacaftor) LIFT HERE TO OPEN ► PRINCIPAL DISPLAY PANEL - Kit Carton