XII. 参考資料
1. 主な外国での発売状況
エドキサバンは、
2011
年4
月22
日に「下肢整形外科手術施行患者における静脈血栓塞栓症の発症抑制」の適 応で、日本で初めて承認を取得し、その後、2014
年9
月26
日に「非弁膜症性心房細動患者における虚血性脳 卒中及び全身性塞栓症の発症抑制」及び「静脈血栓塞栓症（深部静脈血栓症及び肺血栓塞栓症）の治療及び再発 抑制」の適応で承認を取得した。エドキサバンは、現在、約40
の国又は地域で承認を取得し、20以上の国又は 地域で販売している。主な外国での承認（販売）状況は以下のとおりである。
国名 承認 販売
オーストリア ○ ○
ベルギー ○ ○
ブルガリア ○
カナダ ○ ○
チェコ共和国 ○
デンマーク ○ ○
フィンランド ○ ○
フランス ○
ドイツ ○ ○
ギリシャ ○
香港 ○ ○
ハンガリー ○ ○
アイルランド ○ ○
イタリア ○ ○
韓国 ○ ○
オランダ ○ ○
ノルウェー ○ ○
ポーランド ○
ポルトガル ○ ○
スペイン ○ ○
スウェーデン ○ ○
スイス ○ ○
台湾 ○ ○
タイ ○ ○
トルコ ○
英国 ○ ○
米国 ○ ○
OD
錠は海外で販売していない。（2017年
4
月現在）主な外国での効能・効果、用法・用量は以下のとおりである。
出 典 記載内容 米国の添付文書
（
SAVAYSA,
Daiichi Sankyo, Inc., 2016
年9
月）1 INDICATIONS AND USAGE
1.1 Reduction in the Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation
SAVAYSA is indicated to reduce the risk of stroke and systemic embolism (SE) in patients with nonvalvular atrial fibrillation (NVAF).
Limitation of Use for NVAF
SAVAYSA should not be used in patients with CrCL > 95 mL/min because of an increased risk of ischemic stroke compared to warfarin [see Dosage and Administration (2.1), Warnings and Precautions (5.1), Clinical Studies (14.1)].
1.2 Treatment of Deep Vein Thrombosis and Pulmonary Embolism
SAVAYSA is indicated for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) following 5 to 10 days of initial therapy with a parenteral anticoagulant.
2 DOSAGE AND ADMINISTRATION 2.1 Nonvalvular Atrial Fibrillation
The recommended dose of SAVAYSA is 60 mg taken orally once daily [see Warnings and Precautions (5.1), Clinical Studies (14.1)]. Assess creatinine clearance, as calculated using the Cockcroft-Gault equation
*, before initiating therapy with SAVAYSA. Do not use SAVAYSA in patients with CrCL > 95 mL/min.
Reduce SAVAYSA dose to 30 mg once daily in patients with CrCL 15 to 50 mL/min [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].
*
Cockcroft-Gault CrCL = (140-age) x (weight in kg) x (0.85 if female) / (72 x creatinine in mg/dL).
2.2 Treatment of Deep Vein Thrombosis and Pulmonary Embolism
The recommended dose of SAVAYSA is 60 mg taken orally once daily following 5 to 10 days of initial therapy with a parenteral anticoagulant [see Clinical Studies (14.2)].
The recommended dose of SAVAYSA is 30 mg once daily in patients with CrCL
15 to 50 mL/min, patients who weigh less than or equal to 60 kg, or patients
SAVAYSA can be taken without regard to food [see Clinical Pharmacology (12.3)].
2.4 Transition to or from SAVAYSA
Transition to SAVAYSA
From To Recommendation
Warfarin or other Vitamin K Antagonists
SAVAYSA Discontinue warfarin and start SAVAYSA when the INR is ≤ 2.5 Oral
anticoagulants other than warfarin or other Vitamin K Antagonists
SAVAYSA Discontinue current oral anticoagulant and start
SAVAYSA at the time of the next scheduled dose of the other oral anticoagulant
Low Molecular Weight
Heparin(LMWH)
SAVAYSA Discontinue LMWH and start SAVAYSA at the time of the next scheduled administration of LMWH Unfractionated
heparin
SAVAYSA Discontinue the infusion and start SAVAYSA 4 hours later
Transition from SAVAYSA
From To Recommendation
SAVAYSA Warfarin Oral option: For patients taking 60 mg of SAVAYSA, reduce the dose to 30 mg and begin warfarin
concomitantly. For patients receiving 30 mg of SAVAYSA, reduce the dose to 15 mg and begin warfarin
concomitantly. INR must be measured at least weekly and just prior to the daily dose of SAVAYSA to minimize the influence of
SAVAYSA on INR measurements.
Once a stable INR ≥ 2.0 is achieved, SAVAYSA should be discontinued and the warfarin continued SAVAYSA Warfarin Parenteral option: Discontinue
SAVAYSA and administer a parenteral anticoagulant and warfarin at the time of the next scheduled SAVAYSA dose.
Once a stable INR ≥ 2.0 is achieved
the parenteral anticoagulant should
be discontinued and the warfarin
SAVAYSA Parenteral anticoagulants
Discontinue SAVAYSA and start the parenteral anticoagulant at the time of the next dose of SAVAYSA
Abbreviations: INR=International Normalized Ratio 2.5 Discontinuation for Surgery and Other Interventions
Discontinue SAVAYSA at least 24 hours before invasive or surgical procedures because of the risk of bleeding [see Warnings and Precautions (5.3)].
If surgery cannot be delayed, there is an increased risk of bleeding. This risk of bleeding should be weighed against the urgency of intervention [see Warnings and Precautions (5.3)].
SAVAYSA can be restarted after the surgical or other procedure as soon as adequate hemostasis has been established noting that the time to onset of pharmacodynamic effect is 1-2 hours [see Warnings and Precautions (5.2)].
Administer a parenteral anticoagulant and then switch to oral SAVAYSA, if oral medication cannot be taken during or after surgical intervention.
英国の
SPC
（Lixiana 30 mg
film-coated tablets, Daiichi Sankyo UK Limited,
2016
年8
月）4. Clinical particulars 4.1 Therapeutic indications
Prevention of stroke and systemic embolism in adult patients with nonvalvular atrial fibrillation (NVAF) with one or more risk factors, such as congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).
Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE in adults (see section 4.4 for
haemodynamically unstable PE patients).
4.2 Posology and method of administration Posology
Prevention of stroke and systemic embolism
The recommended dose is 60 mg edoxaban once daily.
Therapy with edoxaban in NVAF patients should be continued long term.
Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTE)
The recommended dose is 60 mg edoxaban once daily following initial use of
parenteral anticoagulant for at least 5 days (see section 5.1). Edoxaban and
For NVAF and VTE the recommended dose is 30 mg edoxaban once daily in patients with one or more of the following clinical factors:
• Moderate or severe renal impairment (creatinine clearance (CrCL) 15 - 50 mL/min)
• Low body weight ≤ 60 kg
• Concomitant use of the following P-glycoprotein (P-gp) inhibitors: ciclosporin, dronedarone, erythromycin, or ketoconazole.
Table 1: Summary of posology in NVAF and VTE (DVT and PE)
Summary Guide for DosingRecommended dose 60 mg once daily
Dose recommendation for patients with one or more of the following clinical factors:
Renal Impairment Moderate or severe (CrCL 15 – 50 mL/min)
30 mg once daily Low Body Weight ≤ 60 kg
P-gp Inhibitors Ciclosporin, dronedarone, erythromycin, ketoconazole
Missed dose
If a dose of Lixiana is missed, the dose should be taken immediately and then be continued the following day with the once-daily intake as recommended.
The patient should not take double the prescribed dose on the same day to make up for a missed dose.
Switching to and from Lixiana
Continued anticoagulant therapy is important in patients with NVAF and VTE. There may be situations that warrant a change in anticoagulation therapy (Table 2).
Table 2: Switching
Switching to LixianaFrom To Recommendation
Vitamin K
Antagonist (VKA)
Lixiana Discontinue the VKA and start Lixiana when the international normalised ratio (INR) is ≤ 2.5.
Oral anticoagulants other than VKA
• dabigatran
• rivaroxaban
• apixaban
Lixiana Discontinue dabigatran, rivaroxaban or apixaban and start Lixiana at the time of the next dose of the oral
anticoagulant (see section 5.1).
Parenteral anticoagulants
Lixiana These medicinal products should not be administered simultaneously.
Discontinue subcutaneous
anticoagulant and start Lixiana at the time of the next scheduled
subcutaneous anticoagulant dose.
Intravenous unfractionated heparin (UFH):
Discontinue the infusion and start Lixiana 4 hours later.
Switching from Lixiana
From To Recommendation
Lixiana Vitamin K Antagonist (VKA)
There is a potential for inadequate anticoagulation during the transition from Lixiana to VKA. Continuous adequate anticoagulation should be ensured during any transition to an alternate anticoagulant.
Oral option: For patients currently on a 60 mg dose, administer a Lixiana dose of 30 mg once daily together with an appropriate VKA dose.
For patients currently on a 30 mg dose (for one or more of the following clinical factors: moderate to severe renal impairment (CrCL 15 – 50 mL/min), low body weight, or use with certain P-gp inhibitors), administer a Lixiana dose of 15 mg once daily together with an appropriate VKA dose.
Patients should not take a loading dose of VKA in order to promptly achieve a stable INR between 2 and 3. It is recommended to take into account the maintenance dose of VKA and if the patient was previously taking a VKA or to use valid INR driven VKA treatment algorithm, in accordance with local practice.
Once an INR ≥ 2.0 is achieved, Lixiana
It is recommended that during the first 14 days of concomitant therapy the INR is measured at least 3 times just prior to taking the daily dose of Lixiana to minimise the influence of Lixiana on INR measurements. Concomitant Lixiana and VKA can increase the INR post Lixiana dose by up to 46%.
Parenteral option: Discontinue Lixiana and administer a parenteral
anticoagulant and VKA at the time of the next scheduled Lixiana dose. Once a stable INR of ≥ 2.0 is achieved, the parenteral anticoagulant should be discontinued and the VKA continued.
Lixiana Oral
anticoagulants other than VKA
Discontinue Lixiana and start the non-VKA anticoagulant at the time of the next scheduled dose of Lixiana.
Lixiana Parenteral anticoagulants
These agents should not be administered simultaneously.
Discontinue Lixiana and start the parenteral anticoagulant at the time of the next scheduled dose of Lixiana.
Special populations
Assessment of renal function:
• Renal function should be assessed in all patients by calculating the creatinine clearance (CrCL) prior to initiation of treatment with Lixiana to exclude patients with end stage renal disease (i.e. CrCL < 15 mL/min), to use the correct Lixiana dose in patients with CrCL 15 – 50 mL/min (30 mg once daily), in patients with CrCL > 50 mL/min (60 mg once daily) and when deciding on the use of Lixiana in patients with increased creatinine clearance (see section 4.4).
• Renal function should also be assessed when a change in renal function is suspected during treatment (e.g. hypovolaemia, dehydration, and in case of concomitant use of certain medicinal products).
The method used to estimate renal function (CrCL in mL/min) during the clinical development of Lixiana was the Cockcroft-Gault method. The formula is as follows:
• For creatinine in µmol/L:
• For creatinine in mg/dL:
during Lixiana treatment.
Renal impairment
In patients with mild renal impairment (CrCL > 50 – 80 mL/min), the recommended dose is 60 mg Lixiana once daily.
In patients with moderate or severe renal impairment (CrCL 15 – 50 mL/min), the recommended dose is 30 mg Lixiana once daily (see section 5.2).
In patients with end stage renal disease (ESRD) (CrCL < 15 mL/min) or on dialysis, the use of Lixiana is not recommended (see sections 4.4 and 5.2).
Hepatic impairment
Lixiana is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk (see section 4.3).
In patients with severe hepatic impairment Lixiana is not recommended (see sections 4.4 and 5.2).
In patients with mild to moderate hepatic impairment the recommended dose is 60 mg Lixiana once daily (see section 5.2). Lixiana should be used with caution in patients with mild to moderate hepatic impairment (see section 4.4).
Patients with elevated liver enzymes (ALT/AST > 2 x ULN) or total bilirubin
≥ 1.5 x ULN were excluded in clinical trials. Therefore Lixiana should be used
with caution in this population (see sections 4.4 and 5.2). Prior to initiating Lixiana, liver function testing should be performed.
Body weight
For patients with body weight ≤ 60 kg, the recommended dose is 30 mg Lixiana once daily (see section 5.2).
Elderly patients
No dose reduction is required (see section 5.2).
Gender
No dose reduction is required (see section 5.2).
Concomitant use of Lixiana with P-glycoprotein (P-gp) inhibitors
In patients concomitantly taking Lixiana and the following P-gp inhibitors:
ciclosporin, dronedarone, erythromycin, or ketoconazole, the recommended
dose is 30 mg Lixiana once daily (see section 4.5).
years of age have not been established. No data are available.
Method of administration For oral use.
Lixiana can be taken with or without food (see section 5.2).
本邦における効能・効果、用法・用量は以下のとおりである。
【効能・効果】
○非弁膜症性心房細動患者における虚血性脳卒中及び全身性塞栓症の発症抑制
○静脈血栓塞栓症（深部静脈血栓症及び肺血栓塞栓症）の治療及び再発抑制
○下記の下肢整形外科手術施行患者における静脈血栓塞栓症の発症抑制 膝関節全置換術、股関節全置換術、股関節骨折手術
＜効能・効果に関連する使用上の注意＞
＜静脈血栓塞栓症（深部静脈血栓症及び肺血栓塞栓症）の治療及び再発抑制＞
1.
ショックや低血圧が遷延するような血行動態が不安定な患者又は血栓溶解剤の使用や血栓摘除術が必要な患 者では、本剤は血行動態安定後に投与すること。［有効性及び安全性は確立していない。］2.
本剤は急性期への適切な初期治療（ヘパリン投与等）がなされた後に投与すること（「重要な基本的注意」及び「臨床成績」の項参照）。
＜参考＞
効能・効果 錠15mg 錠30mg 錠60mg 非弁膜症性心房細動患者における虚血性脳卒
中及び全身性塞栓症の発症抑制 ○注） ○ ○
静脈血栓塞栓症（深部静脈血栓症及び肺血栓
塞栓症）の治療及び再発抑制 ○注） ○ ○
下肢整形外科手術施行患者における静脈血栓
塞栓症の発症抑制 ○ ○ －
○：効能あり、－：効能なし 注）本剤からワルファリンへの切り替え時（「重要な基本的注意」の項参照）
【用法・用量】
○非弁膜症性心房細動患者における虚血性脳卒中及び全身性塞栓症の発症抑制
○静脈血栓塞栓症（深部静脈血栓症及び肺血栓塞栓症）の治療及び再発抑制 通常、成人には、エドキサバンとして以下の用量を
1
日1
回経口投与する。体重
60kg
以下 ：30mg体重
60kg
超 ：60mg なお、腎機能、併用薬に応じて1
日1
回30mg
に減量する。○下肢整形外科手術施行患者における静脈血栓塞栓症の発症抑制
通常、成人には、エドキサバンとして
30mg
を1
日1
回経口投与する。＜用法・用量に関連する使用上の注意＞
＜非弁膜症性心房細動患者における虚血性脳卒中及び全身性塞栓症の発症抑制、静脈血栓塞栓症（深部静脈血栓 症及び肺血栓塞栓症）の治療及び再発抑制＞
1.
体重60kg
を超える患者のうち、次のいずれかに該当する患者には、30mgを1
日1
回経口投与すること。(1) キニジン硫酸塩水和物、ベラパミル塩酸塩、エリスロマイシン、シクロスポリンの併用（「相互作用」、
「薬物動態」及び「臨床成績」の項参照）
(2) クレアチニンクリアランス 30mL/min
以上50mL/min
以下（「慎重投与」、「薬物動態」及び「臨床成績」の項参照）
2.
クレアチニンクリアランスが15mL/min
以上30mL/min
未満の患者では、本剤の血中濃度が上昇することが示 唆されており、これらの患者における有効性及び安全性は確立していないので、本剤投与の適否を慎重に判断 すること。投与する場合は、30mgを1
日1
回経口投与すること（「慎重投与」及び「薬物動態」の項参照）。3.
プロトロンビン時間－国際標準比（PT-INR
）や活性化部分トロンボプラスチン時間（APTT
）等の通常の凝 固能検査は、本剤の薬効をモニタリングする指標とはならないので、臨床症状を十分に観察すること。＜下肢整形外科手術施行患者における静脈血栓塞栓症の発症抑制＞
1.
原則として、術後の入院中に限って使用すること。2.
本剤の投与期間については、患者個々の静脈血栓塞栓症及び出血のリスクを考慮して決定すべきであり、静 脈血栓塞栓症のリスク低下後に漫然と継続投与しないこと。なお、国内臨床試験において、下肢整形外科手 術施行患者を対象として15
日間以上投与した場合の有効性及び安全性は検討されていない。3.
本剤の初回投与は、手術後12
時間を経過し、手術創等からの出血がないことを確認してから行うこと。4.
本剤の初回投与は、硬膜外カテーテル抜去あるいは腰椎穿刺から少なくとも2
時間を経過してから行うこと。また、初回投与以降にこれらの処置を行う場合には、前回投与から
12
時間以上の十分な時間をあけ、かつ、予定している次回の投与の少なくとも