Elagolix, sold under the brand name Orilissa, is a gonadotropin-releasing hormone antagonist (GnRH antagonist) medication which is used in the treatment of pain associated with endometriosis in women. It is also under development for the treatment of uterine fibroids and heavy menstrual bleeding in women. The medication was under investigation for the treatment of prostate cancer and enlarged prostate in men as well, but development for these conditions was discontinued. Elagolix is taken by mouth once or twice per day. It can be taken for up to 6 to 24 months, depending on the dosage.
Side effects of elagolix include menopausal-like symptoms such as hot flashes, night sweats, insomnia, amenorrhea, mood changes, anxiety, and decreased bone density, among others. Elagolix is a GnRH antagonist, or an antagonist of the gonadotropin-releasing hormone receptor (GnRHR), the biological target of the hypothalamic hormone gonadotropin-releasing hormone (GnRH). By blocking the GnRHR, it dose-dependently suppresses the gonadal production and hence circulating levels of sex hormones such as estradiol, progesterone, and testosterone. Elagolix is a short-acting GnRH antagonist, and can be used to achieve either partial or more substantial suppression of sex hormone levels. Reduced estrogen levels in the endometrium are responsible for the efficacy of elagolix in the treatment of endometriosis.
Elagolix was first described in 2008 and was approved for medical use in July 2018. It has been described as a "second-generation" GnRH modulator due to its non-peptide and small-molecule nature and its oral activity. Unlike GnRH agonists and older GnRH antagonists, which are peptides and first-generation GnRH modulators, elagolix is not a GnRH analogue as it is not structurally related to GnRH. Elagolix was the first second-generation and orally active GnRH modulator to be introduced for medical use. The introduction of elagolix in the United States and Canada was followed by that of relugolix (brand name Relumina), the next second-generation GnRH antagonist, in Japan in January 2019. The U.S. Food and Drug Administration (FDA) considers it to be a first-in-class medication.
Medical uses Elagolix is used in the treatment of moderate to severe pain associated with endometriosis in premenopausal women. Endometriosis is a condition in which the endometrium, the inner lining of the uterus, grows outside of the uterus into surrounding tissues and causes symptoms such as pelvic pain and infertility. Around 10% of women may be affected by endometriosis. Elagolix significantly decreases symptoms of dysmenorrhea (menstrual pelvic pain), non-menstrual pelvic pain, and dyspareunia (pain during sexual intercourse) in women with endometriosis. The medication is used at a lower dosage of 150 mg once per day or at a higher dosage of 200 mg twice per day, depending on the severity of symptoms.
The effectiveness of elagolix in the treatment of symptoms of endometriosis was demonstrated in the 6-month Elaris Endometriosis I and II (EM-I and EM-II) phase III clinical trials. In Elaris EM-I, the percentage of women who had a clinical response with respect to dysmenorrhea was 46.4% in the lower-dose elagolix group and 75.8% in the higher-dose elagolix group, as compared with 19.6% in the placebo group; in Elaris EM-II, the corresponding percentages were 43.4% and 72.4%, as compared with 22.7% (P < 0.001 for all comparisons). In Elaris EM-I, the percentage of women who had a clinical response with respect to non-menstrual pelvic pain was 50.4% in the lower-dose elagolix group and 54.5% in the higher-dose elagolix group, as compared with 36.5% in the placebo group (P < 0.001 for all comparisons); in Elaris EM-II, the corresponding percentages were 49.8% and 57.8%, as compared with 36.5% (P = 0.003 and P < 0.001, respectively). The reductions in symptoms of endometriosis with elagolix resulted in an improved quality of life.
The duration of use of elagolix in the treatment of endometriosis should be limited due to a progressive risk of bone loss, and the lowest effective dosage should be used. Elagolix can be used for up to 24 months at the 150 mg once per day dosage and for up to 6 months at the 200 mg twice per day dosage.
Because of its relatively short duration, elagolix should be taken at approximately the same time each day. In the case of twice-daily administration, elagolix should be taken at approximate 12-hour intervals, for instance once in the morning and once at night. It can be taken with or without food.
Elagolix is approved only for the treatment of endometriosis. Other approved and off-label uses of GnRH antagonists in general are the same as those of GnRHR desensitization therapy with GnRH agonists such as leuprorelin, and include uterine fibroids and breast cancer in premenopausal women, prostate cancer in men, precocious puberty in children, and hormone therapy in transgender adolescents and adults, among others.
Available forms Elagolix is available in the form of Orilissa 150 and 200 mg oral tablets. The 150 mg tablets are light pink, oblong, and film-coated with "EL 150" debossed on one side, while the 200 mg tablets are light orange, oblong, and film-coated with "EL 200" debossed on one side. The inactive ingredients in the tablets include mannitol, sodium carbonate monohydrate, pregelatinized starch, povidone, magnesium stearate, polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, and a distinct color additive (carmine high tint in the 150 mg tablets and iron oxide red in the 200 mg tablets).
Contraindications Contraindications of elagolix include pregnancy, known osteoporosis, severe hepatic impairment, and concomitant use with strong organic anion-transporting polypeptide (OATP) 1B1 inhibitors such as ciclosporin and gemfibrozil. Elagolix may increase the risk of miscarriage in early pregnancy. Women should avoid pregnancy while taking elagolix, for instance by using birth control, and should discontinue the medication if they become or wish to become pregnant. Elagolix should not be used in women with osteoporosis because it may increase the risk of further bone loss. Severe hepatic impairment is associated with 7-fold increased exposure to elagolix, which may increase the risk of bone loss. In women with moderate hepatic impairment, which is associated with 3-fold increased exposure to elagolix, the medication at 200 mg twice per day should not be used, while 150 mg once per day should be used for no more than 6 months. OATP1B1 inhibitors are likely to greatly increase exposure to elagolix similarly to moderate to severe hepatic impairment.
Combined birth control is not contraindicated with elagolix, but because of the estrogen component, is expected to decrease the effectiveness of elagolix in the treatment of endometriosis, and hence is not recommended. Other forms of birth control, such as non-hormonal birth control, can be used instead. Elagolix is not contraindicated in women who are breastfeeding, but it is unknown whether the medication is excreted in breast milk or if it has adverse effects on milk production or the breastfed child. The use of elagolix in women who are breastfeeding should be considered carefully, weighing both benefits and risks.
Side effects + Side effects of elagolix in clinical trials (mostly ≥5% incidence) Side effect 150 mg [n=475] (%) 200 mg [n=477] (%) Placebo[n=734] (%) Hot flashes/night sweats 23–24 45–46 9 Amenorrhea 4; 6–17 7; 13–57 <1 Headaches 17 20 12 Nausea 11 16 13 Mood changes/swings 6 5 3 Anxiety 3 5 3 Depressive symptoms 3 6 2 Insomnia 6 9 3 Upper respiratory tract infection 6 4 5 Nasopharyngitis 6 6 4 Sinusitis 5 6 4 Arthralgia 3 5 3 >8% decrease (6 months) <1–2 6–7 <1 >8% decrease (12 months) 2–8 21 <1 Elevated liver enzymesa 0.2 (n=1) 1.1 (n=5) 0.1 (n=1) Suicidal ideation 0.2 (n=1) 0.2 (n=1) 0 Suicide 0.2 (n=1) 0 0 Notes: Side effects reported in ≥3% but <5% included diarrhea, abdominal pain, constipation, weight gain, dizziness, irritability, and decreased libido. Footnotes: a = Asymptomatic; >3 times upper limit.
The side effects of elagolix are in general similar to menopausal symptoms. The most common side effects of elagolix (incidence ≥10%) are hot flashes, night sweats, headaches, nausea, and amenorrhea (cessation of menstruation). The next most frequent side effects of elagolix (incidence ≥5%) are insomnia, anxiety, arthralgia (joint pain), depression, and mood changes. Less common side effects of elagolix (incidence ≥3% and <5%) include decreased sex drive, diarrhea, abdominal pain, weight gain, dizziness, constipation, and irritability. Other common side effects of elagolix include decreased bone mineral density (BMD) and changes in the blood lipid profile. Rare but serious adverse effects that were observed during elagolix therapy in clinical trials included appendicitis (0.3%), abdominal pain (0.2%), and back pain (0.2%), though it is unknown if these were due to elagolix. Other serious adverse effects of elagolix may include bone loss, miscarriage, suicidality, and elevated liver enzymes. Elagolix was discontinued due to side effects by 5 to 10% of women in clinical trials, with the most common reasons being hot flashes or night sweats, nausea, and decreased BMD.
Elagolix dose- and duration-dependently decreases BMD in premenopausal women with long-term therapy. After 6 months of treatment with elagolix, lumbar spine BMD was decreased by 0.3 to 1.3% with 150 mg once per day and by 2.5 to 3.1% with 200 mg twice per day. The decrease in BMD during elagolix therapy may not be fully reversible with discontinuation, as only partial recovery was observed 12 months after discontinuation of therapy. The cause of the decrease in BMD with elagolix is estrogen deficiency, and is analogous to that associated with postmenopause. The consequences of the effects of elagolix on BMD are unknown, but may be an increase in the risk of bone loss and fractures. This is why the duration of use of elagolix should be limited. In women with risk factors for bone loss and osteoporosis, such as a history of low-trauma fracture, assessment of BMD may be considered. Elagolix should not be used in premenopausal women with known osteoporosis. Supplementation with calcium and/or vitamin D during treatment with elagolix has not been studied, but may be beneficial for helping to maintain bone health.
Elagolix decreases the amount, intensity, and duration of menstrual bleeding. Amenorrhea, the cessation of menstruation, was observed in 4 to 17% of women with 150 mg once per day and in 7 to 57% of women with 200 mg twice per day, compared to less than 1% of women given placebo. The decreased menstrual bleeding caused by elagolix may impede the ability to recognize pregnancy in a timely manner. Based on its mechanism of action, elagolix may increase the risk of miscarriage in early pregnancy, and so should be discontinued if pregnancy occurs. If pregnancy is suspected, pregnancy testing can be performed. Elagolix decreases the rate of ovulation and thereby decreases the likelihood of pregnancy, but has not been shown to be a fully effective contraceptive and should not be relied on to prevent pregnancy.