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Ponesimod: Drug information

Ponesimod: Drug information
(For additional information see "Ponesimod: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Ponvory;
  • Ponvory Starter Pack
Brand Names: Canada
  • Ponvory;
  • Ponvory Initiation Pack
Pharmacologic Category
  • Sphingosine 1-Phosphate (S1P) Receptor Modulator
Dosing: Adult

Note: Cardiac monitoring: First-dose 4-hour monitoring is recommended for patients with certain preexisting cardiac conditions, including sinus bradycardia (heart rate <55 bpm), first- or second-degree (Mobitz type 1) atrioventricular block, or a history of myocardial infarction or heart failure ≥6 months prior to initiation. For these patients, administer the first dose and doses following therapy interruption (≥4 days) in a setting in which resources to appropriately manage symptomatic bradycardia and other conduction abnormalities are available. Infection: Delay initiation of therapy in patients with active infection. In high-risk populations or in countries with high tuberculosis (TB) burden, screen for latent infections (eg, hepatitis, TB) prior to initiating therapy. For patients who screen positive for latent infections, consult infectious disease or other appropriate specialists (eg, liver specialists) regarding treatment options before initiating therapy (AAN [Farez 2019]).

Multiple sclerosis, relapsing

Multiple sclerosis, relapsing: Oral:

Initial: Administer once daily according to the following 14-day dose titration:

Ponesimod Initial Dosage Titration

Day of therapy

Dose

1 and 2

2 mg

3 and 4

3 mg

5 and 6

4 mg

7

5 mg

8

6 mg

9

7 mg

10

8 mg

11

9 mg

12, 13, and 14

10 mg

15 and thereafter

20 mg

Maintenance: 20 mg once daily, beginning on day 15.

Missed dose:

≤3 consecutive doses missed: If during titration, resume with the first missed titration dose, and resume the titration schedule at that dose and titration day. If during maintenance, resume treatment with the maintenance dosage.

≥ 4 consecutive doses missed : Reinitiate treatment with day 1 of the initial titration regimen, including first-dose monitoring when appropriate.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

No dosage adjustment necessary.

Dosing: Hepatic Impairment: Adult

Mild impairment (Child-Pugh class A): No dosage adjustment necessary.

Moderate or severe impairment (Child-Pugh class B or C): Avoid use.

Dosing: Older Adult

Refer to adult dosing; use with caution.

Adverse Reactions (Significant): Considerations
Cardiovascular effects

Transient, dose dependent decreases in heart rate, bradycardia, and sinus bradycardia (HR <50 bpm) have been observed primarily following the first dose of ponesimod and with dose titration. Transient atrioventricular (AV) conduction delays, manifesting as first-degree AV block, have also been observed with initiation of therapy. Second- and third-degree AV blocks have occurred with other sphingosine 1-phosphate (S1P) receptor modulators. In addition, hypertension has commonly been reported with ponesimod.

Mechanism: Ponesimod is a selective S1P receptor modulator; S1P receptors play a role in regulating vascular tone, heart rate, and cardiac repolarization (Ref).

Bradycardia/decreased heart rate: Dose-related; S1P modulators have been associated with negative chronotropic effects; however, these effects may attenuate over time secondary to S1P desensitization on atrial myocytes (Ref).

Onset:

Bradycardia/decreased heart rate: Rapid; following the first dose, onset typically begins within 1 hour postdose, with maximal decrease usually occurring ~2 to 4 hours postdose. Following day 1, decreases in heart rate are typically less pronounced.

Hypertension: Delayed; increased BP occurred ~1 month after initiation of therapy and persisted with continued treatment.

Risk factors:

• Bradycardia/AV conduction delays: Preexisting conditions that may increase the risk for bradycardia or AV block; concurrent therapy with medications that decrease heart rate. Of note, contraindications related to these risk factors exist.

Cutaneous malignancies

Basal cell carcinoma and other skin malignancies (including malignant melanoma and squamous cell carcinoma of the skin) have occurred rarely with ponesimod.

Risk factors:

• Preexisting skin cancer (potential risk factor)

Hepatotoxicity

Increased serum transaminases have been observed with ponesimod therapy, primarily as increased serum alanine aminotransferase (ALT), including increases up to 5 x ULN. Most ALT increases ≥3 x ULN were single transient asymptomatic events that resolved spontaneously or resulted in discontinuation of therapy (per trial protocol) (Ref). The majority of patients with ALT increases ≥3 x ULN continued treatment, with values decreasing to ALT <3 x ULN within ~2 to 4 weeks.

Onset: Delayed; median time to development of ALT ≥3 x ULN was 3 months.

Risk factors:

• History of significant liver disease (potential risk factor)

Lymphocytopenia/Infection

Reversible lymphocytopenia occurs during ponesimod therapy. Infection is commonly observed with use, typically upper respiratory tract infection and less commonly urinary tract infection; viral infections (eg, herpes virus infection) have also been observed. Infections may be serious, life-threatening, and potentially fatal. Fatal cryptococcal meningitis, disseminated cryptococcal infection, and progressive multifocal leukoencephalopathy have been reported with other sphingosine 1-phosphate (S1P) receptor modulators.

Mechanism: Dose-related; as an antagonist of the sphingosine 1-phosphate 1 receptor (S1P1R), ponesimod results in the blocking of S1P1R receptors on lymphocytes, a necessary signal for their release from peripheral lymphoid organs, causing a reduction in number of circulating lymphocytes. Sequestered lymphocytes remain in peripheral lymphoid organs preventing their movement to sites of inflammation where they would typically contribute to immune-mediated pathology (Ref).

Onset: Rapid; a single oral dose reduced circulating lymphocytes in a rapidly reversible manner; continued dosing results in a maximum effect within 7 to 14 days for each dose level (Ref).

Macular edema

Macular edema has occurred with ponesimod therapy. Though the incidence is rare, macular edema is also associated with other sphingosine 1-phosphate receptor modulators.

Risk factors:

• Diabetes

• Prior history of uveitis

Progressive multifocal leukoencephalopathy and sequelae

Cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients taking sphingosine 1-phosphate (S1P) receptor modulators. Symptoms may include progressive weakness on one side of the body or clumsiness of limbs, vision disturbances, and mental status changes. Immune reconstitution inflammatory syndrome (IRIS) has been reported in patients who discontinued S1P receptor modulator therapy due to developing PML and can result in a rapid decline in patient condition, including characteristic changes on MRI, neurological symptoms, and death.

Mechanism: An opportunistic viral infection of the brain caused by the John Cunningham (JC) virus.

Onset: PML: Symptoms progress over days to weeks. IRIS: Occurred within a few months after discontinuation in most cases.

Risk factors (general):

• Use in immunocompromised patients

• Polytherapy with immunosuppressants

Respiratory effects

Reduced forced expiratory volume over 1 second (FEV1) and reductions in diffusion lung capacity for carbon monoxide have occurred with ponesimod therapy. There is insufficient evidence to determine whether changes in FEV1 or decrease in forced vital capacity are reversible with drug discontinuation.

Mechanism: Dose-related; mechanism is unknown.

Onset: Varied; mostly occurred in the first month after therapy initiation.

Risk factors:

• Severe respiratory disease (eg, asthma, chronic obstructive pulmonary disease, pulmonary fibrosis)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Hepatic: Increased serum alanine aminotransferase (≥5 x ULN: 5%; ≥3 x ULN: 17%) (table 1), increased serum transaminases (23%) (table 2)

Ponesimod: Adverse Reaction: Increased Serum Alanine Aminotransferase

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

Comments

17%

8%

565

566

≥3 x ULN

5%

3%

565

566

≥5 x ULN

Ponesimod: Adverse Reaction: Increased Serum Transaminases

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

23%

12%

565

566

Infection: Infection (54%; serious or severe infection: 2%) (table 3)

Ponesimod: Adverse Reaction: Infection

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

Comments

54%

52%

565

566

N/A

2%

0.9%

565

566

Serious or severe infection

Respiratory: Upper respiratory tract infection (37%) (table 4)

Ponesimod: Adverse Reaction: Upper Respiratory Tract Infection

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

37%

34%

565

566

1% to 10%:

Cardiovascular: Bradycardia (≤6%) (table 5), chest discomfort (≥2%), first degree atrioventricular block (3%) (table 6), hypertension (10%) (table 7), peripheral edema (≥2%), sinus bradycardia (≤6%) (table 8)

Ponesimod: Adverse Reaction: Bradycardia

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

Comments

6%

2%

565

566

Bradycardia at treatment initiation

Ponesimod: Adverse Reaction: First Degree Atrioventricular Block

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

3%

1%

565

566

Ponesimod: Adverse Reaction: Hypertension

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

10%

9%

565

566

Ponesimod: Adverse Reaction: Sinus Bradycardia

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

Comments

6%

2%

565

566

Sinus bradycardia on ECG (defined as HR less than 50 bpm)

Endocrine & metabolic: Hypercholesterolemia (2%), hyperkalemia (<2%)

Gastrointestinal: Dyspepsia (≥2%), xerostomia (≥2%)

Genitourinary: Urinary tract infection (6%) (table 9)

Ponesimod: Adverse Reaction: Urinary Tract Infection

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

6%

5%

565

566

Hematologic & oncologic: C-reactive protein increased (2%), lymphocytopenia (≤3%, including severe lymphocytopenia)

Infection: Herpes virus infection (5%) (table 10), herpes zoster infection (<2%), viral infection (<2%)

Ponesimod: Adverse Reaction: Herpes Virus Infection

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

5%

5%

565

566

Nervous system: Depression (≥2%), dizziness (5%), drowsiness (3%), fatigue (≥2%), insomnia (≥2%), migraine (≥2%), seizure (1%), vertigo (2%)

Neuromuscular & skeletal: Back pain (≥2%), joint swelling (≥2%), limb pain (4%)

Ophthalmic: Macular edema (1%) (table 11)

Ponesimod: Adverse Reaction: Macular Edema

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

1%

0%

565

566

Respiratory: Cough (4%), dyspnea (5%), rhinitis (≥2%), sinusitis (≥2%)

Miscellaneous: Fever (2%)

<1%: Hematologic & oncologic: Basal cell carcinoma of skin (table 12), malignant melanoma

Ponesimod: Adverse Reaction: Basal Cell Carcinoma of Skin

Drug (Ponesimod)

Comparator (Teriflunomide)

Number of Patients (Ponesimod)

Number of Patients (Teriflunomide)

0.4%

0.2%

565

566

Frequency not defined: Respiratory: Reduced forced expiratory volume (dose dependent)

Postmarketing: Hematologic & oncologic: Squamous cell carcinoma of the skin

Contraindications

Myocardial infarction, unstable angina, stroke, transient ischemic attack, decompensated heart failure requiring hospitalization, or Class III or IV heart failure in the last 6 months; presence of Mobitz type II second-degree, third-degree atrioventricular block, or sick sinus syndrome, or sinoatrial block, unless patient has a functioning pacemaker.

Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to ponesimod or any component of the formulation; patients at risk for opportunistic infections, including those immunocompromised due to treatment (eg, antineoplastic, immunosuppressive, or immunomodulating therapies; total lymphoid irradiation; bone marrow transplantation) or disease (eg, immunodeficiency syndrome); patients with active bacterial, fungal, or viral (eg, hepatitis, tuberculosis) infections; patients with active malignancy (except basal cell carcinoma of the skin); moderate or severe hepatic impairment; pregnancy; patients of childbearing potential not using highly effective birth control.

Warnings/Precautions

Concerns related to adverse effects:

• Neurotoxicity: Posterior reversible encephalopathy syndrome (PRES) has occurred with S1P receptor modulators. Symptoms are usually reversible but may evolve into ischemic stroke or cerebral hemorrhage. Delayed diagnosis and treatment may result in permanent neurological sequelae. Discontinue use if PRES is suspected.

Disease-related concerns:

• Cardiovascular disease: Use is not recommended in patients with a history of cardiac arrest, cerebrovascular disease (eg, transient ischemic attack, stroke occurring >6 months prior to treatment initiation), uncontrolled hypertension, or severe untreated sleep apnea, as bradycardia may be poorly tolerated; obtain cardiologist consultation prior to therapy initiation in these patients. Cardiologist consultation should also be obtained prior to initiation in patients with significant QT prolongation (≥500 msec), atrial flutter/fibrillation or arrhythmia treated with a class Ia or III antiarrhythmic, unstable ischemic heart disease, decompensated cardiac failure occurring ≥6 months prior to therapy initiation, history of Mobitz Type II second degree or higher AV block, sick sinus syndrome, sinoatrial heart block, recurrent syncope, or symptomatic bradycardia.

Concurrent drug therapy issues:

• Immunosuppressive or immune-modulating therapy: Initiating therapy following alemtuzumab treatment is not recommended. Treatment initiation following prior immunosuppressive or immune-modulating therapy may result in unintended additive immunosuppressive effects; half-life and mechanism of action of prior therapy should be taken into consideration.

Other warnings/precautions:

• Discontinuation of therapy: Severe exacerbation of disease and disease rebound has occurred following discontinuation of S1P receptor modulators. Monitor for development of immune reconstitution inflammatory syndrome in the setting of progressive multifocal leukoencephalopathy and severe increase in disability following discontinuation and begin appropriate treatment as needed.

• Immunizations: Vaccinations may be less effective if administered during treatment with ponesimod. Complete necessary live-attenuated vaccine immunization at least 1 month prior to initiation of therapy. Avoid live-attenuated vaccines in patients who currently receive or have discontinued ponesimod within the last 1 to 2 weeks; consider using live-attenuated vaccines only if risk of infection is high and killed vaccines are unavailable (AAN [Farez 2019]). Prior to initiation of therapy, test for VZV antibodies in patients without a health care professional–confirmed history of varicella (chickenpox) or without documentation of a full course of vaccination. Provide a full course of VZV vaccination prior to initiation of therapy in VZV antibody–negative patients; delay initiation of therapy for 4 weeks following VZV vaccination.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Ponvory: 20 mg

Tablet Therapy Pack, Oral:

Ponvory Starter Pack: 2 mg, 3 mg, 4 mg (two each); 5 mg, 6 mg, 7 mg, 8 mg, 9 mg (one each); 10 mg (three each) (14 ea)

Generic Equivalent Available: US

No

Pricing: US

Tablet Therapy Pack (Ponvory Starter Pack Oral)

2-3-4-5-6-7-8-9& 10 MG (per each): $364.66

Tablets (Ponvory Oral)

20 mg (per each): $364.66

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Ponvory: 20 mg

Tablet Therapy Pack, Oral:

Ponvory Initiation Pack: 2 mg, 3 mg, 4 mg (two each); 5 mg, 6 mg, 7 mg, 8 mg, 9 mg (one each); 10 mg (three each) (14 ea)

Administration: Adult

Oral: Administer with or without food. Swallow tablets whole.

Hazardous Drugs Handling Considerations

This medication is not on the NIOSH (2016) list; however, it may meet the criteria for a hazardous drug. Ponesimod may cause teratogenicity, reproductive toxicity, and has a structural or toxicity profile similar to an existing hazardous agent.

Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2016; USP-NF 2020).

Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (USP-NF 2020). Refer to institution-specific handling policies/procedures.

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:

Ponvory: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/213498s004lbl.pdf#page=30

Use: Labeled Indications

Multiple sclerosis, relapsing: Treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease in adults.

Metabolism/Transport Effects

Substrate of CYP2J2 (minor), CYP3A4 (minor), UGT1A1, UGT2B7; Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Alemtuzumab: Ponesimod may enhance the immunosuppressive effect of Alemtuzumab. Risk X: Avoid combination

Antithymocyte Globulin (Equine): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of immunosuppressive therapy is reduced. Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy

Baricitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination

BCG Products: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination

Bradycardia-Causing Agents: May enhance the bradycardic effect of Ponesimod. Management: Avoid coadministration of ponesimod with drugs that may cause bradycardia when possible. If combined, monitor heart rate closely and consider obtaining a cardiology consult. Do not initiate ponesimod in patients on beta-blockers if HR is less than 55 bpm. Risk D: Consider therapy modification

Brincidofovir: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy

Brivudine: May enhance the adverse/toxic effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Risk D: Consider therapy modification

Chikungunya Vaccine (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Chikungunya Vaccine (Live). Risk X: Avoid combination

Cladribine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination

Coccidioides immitis Skin Test: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the diagnostic effect of Coccidioides immitis Skin Test. Management: Consider discontinuing therapeutic immunosuppressants several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider therapy modification

Corticosteroids (Systemic): Sphingosine 1-Phosphate (S1P) Receptor Modulator may enhance the immunosuppressive effect of Corticosteroids (Systemic). Risk C: Monitor therapy

COVID-19 Vaccine (Adenovirus Vector): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy

COVID-19 Vaccine (mRNA): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider therapy modification

COVID-19 Vaccine (Subunit): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy

COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy

Dengue Tetravalent Vaccine (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination

Denosumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Denosumab. Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and immunosuppressants. If combined, monitor for signs/symptoms of serious infections. Risk D: Consider therapy modification

Deucravacitinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Etrasimod: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Fexinidazole: Bradycardia-Causing Agents may enhance the arrhythmogenic effect of Fexinidazole. Risk X: Avoid combination

Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk X: Avoid combination

Fingolimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Fingolimod. Management: Consult with the prescriber of any bradycardia-causing agent to see if the agent could be switched to an agent that does not cause bradycardia prior to initiating fingolimod. If combined, perform continuous ECG monitoring after the first fingolimod dose. Risk D: Consider therapy modification

Haloperidol: QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of Haloperidol. Risk C: Monitor therapy

Immunosuppressants (Cytotoxic Chemotherapy): Sphingosine 1-Phosphate (S1P) Receptor Modulator may enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor therapy

Immunosuppressants (Miscellaneous Oncologic Agents): Sphingosine 1-Phosphate (S1P) Receptor Modulator may enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk C: Monitor therapy

Immunosuppressants (Therapeutic Immunosuppressant Agents): Sphingosine 1-Phosphate (S1P) Receptor Modulator may enhance the immunosuppressive effect of Immunosuppressants (Therapeutic Immunosuppressant Agents). Risk C: Monitor therapy

Inebilizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy

Influenza Virus Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating immunosuppressants if possible. If vaccination occurs less than 2 weeks prior to or during therapy, revaccinate 2 to 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modification

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Risk C: Monitor therapy

Leflunomide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents. Risk D: Consider therapy modification

Methotrexate: May enhance the immunosuppressive effect of Sphingosine 1-Phosphate (S1P) Receptor Modulator. Risk C: Monitor therapy

Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Mitapivat: May decrease the serum concentration of UGT1A1 Substrates. Risk C: Monitor therapy

Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Nadofaragene Firadenovec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid combination

Natalizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination

Ocrelizumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy

Ofatumumab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy

Pidotimod: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy

Pimecrolimus: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Pimecrolimus. Risk X: Avoid combination

Pneumococcal Vaccines: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy

Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination

Polymethylmethacrylate: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the potential for allergic or hypersensitivity reactions to Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider therapy modification

QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Rabies Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider therapy modification

Ritlecitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ritlecitinib. Risk X: Avoid combination

Ruxolitinib (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination

Siponimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia. If combined, consider obtaining a cardiology consult regarding patient monitoring. Risk D: Consider therapy modification

Sipuleucel-T: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants prior to initiating sipuleucel-T therapy. Risk D: Consider therapy modification

Tacrolimus (Topical): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Talimogene Laherparepvec: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid combination

Tertomotide: Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination

Tofacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Tofacitinib. Management: Coadministration of tofacitinib with potent immunosuppressants is not recommended. Use with non-biologic disease-modifying antirheumatic drugs (DMARDs) was permitted in psoriatic arthritis clinical trials. Risk X: Avoid combination

Typhoid Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination

Ublituximab: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Ublituximab. Risk C: Monitor therapy

UGT1A1 Inducers: May decrease the serum concentration of Ponesimod. Risk X: Avoid combination

Upadacitinib: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination

Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of immunosuppressants when possible. Patients vaccinated less than 14 days before initiating or during therapy should be revaccinated at least 2 to 3 months after therapy is complete. Risk D: Consider therapy modification

Vaccines (Live): Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

Yellow Fever Vaccine: Immunosuppressants (Therapeutic Immunosuppressant Agents) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination

Reproductive Considerations

Patients who may become pregnant should use effective contraception during therapy and for 1 week after the last ponesimod dose.

In general, disease-modifying therapies for multiple sclerosis (MS) are stopped prior to a planned pregnancy, except in patients at high risk of MS activity (AAN [Rae-Grant 2018]).

Consider use other agents in patients at high risk of disease reactivation who are planning to become pregnant. Delaying pregnancy is recommended for patients with persistent high disease activity; when disease-modifying therapy is needed in these patients, other agents are preferred (ECTRIMS/EAN [Montalban 2018]).

Pregnancy Considerations

Based on data from animal reproduction studies, in utero exposure to ponesimod may cause fetal harm. Ponesimod acts on the sphingosine 1-phosphate receptor, a receptor involved in embryogenesis, including vascular and neural development.

In general, disease-modifying therapies for multiple sclerosis (MS) are not initiated during pregnancy, except in patients at high risk of MS activity (AAN [Rae-Grant 2018]). When disease-modifying therapy is needed in these patients, other agents are preferred (ECTRIMS/EAN [Montalban 2018]).

Breastfeeding Considerations

It is not known if ponesimod is present in breast milk.

According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother.

Monitoring Parameters

All patients:

CBC including lymphocyte count (baseline [within 6 months or after discontinuation of previous multiple sclerosis therapy]).

Hepatic monitoring: Bilirubin and transaminase levels (baseline [within 6 months]); transaminases in patients who develop symptoms of hepatic dysfunction (as clinically necessary).

ECG (baseline) and BP (as clinically indicated); ophthalmologic exam of fundus, including macula (at baseline and if vision changes; more frequent in patients with diabetes or a history of uveitis), respiratory function (FEV1) (as clinically indicated), latent infection screening (eg, hepatitis, tuberculosis [TB]) in high-risk populations or in countries with high TB burden (baseline); varicella-zoster virus (VZV) antibodies (prior to starting treatment in patients with no health care professional–confirmed history of chickenpox or without documented previous full series VZV vaccination), signs and symptoms of infection (during treatment and at least 1 to 2 weeks after discontinuation), signs/symptoms of progressive multifocal leukoencephalopathy, immune reconstitution inflammatory syndrome (IRIS), and/or posterior reversible encephalopathy syndrome; skin examination and monitoring for suspicious skin lesions (periodically); severe increase in disability following discontinuation of therapy.

Additional required monitoring for patients with sinus bradycardia (heart rate <55 bpm), first- or second-degree (Mobitz type 1) atrioventricular block, or a history of myocardial infarction or heart failure ≥ 6 months prior to treatment initiation and in stable condition:

First-dose 4-hour monitoring: Monitor patient for 4 hours following the first dose for signs and symptoms of bradycardia; assess heart rate and BP measurements every 1 hour. Obtain ECG prior to dosing and after initial 4-hour dose observation period. After the initial 4-hour monitoring, monitor until resolution (even if asymptomatic) if 4-hour postdose heart rate is <45 bpm, 4-hour postdose heart rate is lowest postbaseline measurement, or 4-hour postdose ECG shows new-onset second-degree or higher atrioventricular (AV) block. Start continuous ECG monitoring if postdose symptomatic bradycardia, bradyarrhythmia, or conduction-related symptoms occur or if 4-hour postdose ECG shows new-onset second-degree or higher AV block or QTc ≥500 msec. Monitor until symptom resolution if no pharmacologic treatment is necessary. Monitor overnight with continuous ECG in a medical facility and repeat observation period for second dose if pharmacologic intervention is necessary.

Patients may also require overnight monitoring during treatment initiation if they have prolonged QTc interval at baseline or during 4-hour monitoring, additional risks for QT prolongation, concurrent therapy with QT prolonging agents with a known risk of torsades de pointes, concurrent therapy with drugs that slow heart rate or AV conduction, or some preexisting heart and cerebrovascular conditions.

Initial monitoring procedures (ECG, heart rate, BP) must be repeated for treatment interruption of ≥4 consecutive doses during the titration or maintenance period.

Mechanism of Action

Ponesimod, a sphingosine 1-phosphate (S1P) receptor 1 modulator, binds with high affinity to S1P receptor 1. Ponesimod blocks lymphocytes’ ability to emerge from lymph nodes, reducing the number of lymphocytes available to the CNS, which reduces inflammation (Chaudhry 2017).

Pharmacokinetics (Adult Data Unless Noted)

Distribution: Vd: 160 L.

Protein binding: >99%.

Metabolism: Extensively metabolized via CYP450 (CYP2J2, CYP3A4, CYP3A5, CYP4F3A, and CYP4F12), non-CYP450 oxidation, and direct glucuronidation (primarily UGT1A1 and UGT2B7).

Bioavailability: 84%.

Half-life elimination: ~33 hours.

Time to peak: 2 to 4 hours.

Excretion: Feces: 57% to 80% (16% as unchanged drug); urine: 10% to 18% as metabolites.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Ponvory;
  • (AT) Austria: Ponvory;
  • (BE) Belgium: Ponvory;
  • (CH) Switzerland: Ponvory;
  • (CZ) Czech Republic: Ponvory;
  • (DE) Germany: Ponvory;
  • (EE) Estonia: Ponvory;
  • (ES) Spain: Ponvory;
  • (FI) Finland: Ponvory;
  • (FR) France: Ponvory;
  • (GB) United Kingdom: Ponvory;
  • (IE) Ireland: Ponvory;
  • (IT) Italy: Ponvory;
  • (LU) Luxembourg: Ponvory;
  • (LV) Latvia: Ponvory;
  • (NL) Netherlands: Ponvory;
  • (NO) Norway: Ponvory;
  • (PL) Poland: Ponvory;
  • (PR) Puerto Rico: Ponvory;
  • (QA) Qatar: Ponvory | Ponvory Starter Pack;
  • (SE) Sweden: Ponvory | Ponvory styrkeserie;
  • (SI) Slovenia: Ponvory;
  • (ZA) South Africa: Ponvory
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  2. Chaudhry BZ, Cohen JA, Conway DS. Sphingosine 1-phosphate receptor modulators for the treatment of multiple sclerosis. Neurotherapeutics. 2017;14(4):859-873. doi:10.1007/s13311-017-0565-4 [PubMed 28812220]
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  9. Ponvory (ponesimod) [prescribing information]. Titusville, NJ: Janssen Pharmaceuticals Inc; August 2023.
  10. Ponvory (ponesimod) [product monograph]. Toronto, Ontario, Canada: Janssen Inc; April 2021.
  11. Pouzol L, Piali L, Bernard CC, Martinic MM, Steiner B, Clozel M. Therapeutic potential of ponesimod alone and in combination with dimethyl fumarate in experimental models of multiple sclerosis. Innov Clin Neurosci. 2019;16(3-4):22-30. [PubMed 31214480]
  12. Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: disease-modifying therapies for adults with multiple sclerosis: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology. Neurology. 2018;90(17):777‐788. doi:10.1212/WNL.0000000000005347 [PubMed 29686116]
  13. Tan CS, Koralnik IJ. Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis. Lancet Neurol. 2010;9(4):425-437. doi:10.1016/S1474-4422(10)70040-5 [PubMed 20298966]
  14. US Department of Health and Human Services; Centers for Disease Control and Prevention; National Institute for Occupational Safety and Health. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings 2016. https://www.cdc.gov/niosh/docs/2016-161/default.html. Updated September 2016. Accessed May 7, 2021.
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