peginterferon alfa-2a
Dosage Form: injection, solution
FULL PRESCRIBING INFORMATION
Alpha interferons, including Pegasys (peginterferon alfa-2a), may cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders. Patients should be monitored closely with periodic clinical and laboratory evaluations. Therapy should be withdrawn in patients with persistently severe or worsening signs or symptoms of these conditions. In many, but not all cases, these disorders resolve after stopping Pegasys therapy [see Warnings and Precautions (5.2, 5.5, 5.8, 5.11, 5.14, 5.16), Adverse Reactions (6.1) and Nonclinical Toxicology (13.1)].
Use with Ribavirin
Ribavirin, including COPEGUS®, may cause birth defects and/or death of the fetus. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients. Ribavirin causes hemolytic anemia. The anemia associated with ribavirin therapy may result in a worsening of cardiac disease. [See COPEGUS Package Insert for additional information and other WARNINGS.]
Indications and Usage for Pegasys
Chronic Hepatitis C
Pegasys, peginterferon alfa-2a, alone or in combination with COPEGUS, is indicated for the treatment of patients 5 years of age and older with chronic hepatitis C (CHC) virus infection who have compensated liver disease and have not been previously treated with interferon alpha. Efficacy has been demonstrated in subjects with compensated liver disease and histological evidence of cirrhosis (Child-Pugh class A) and in adult subjects with clinically stable HIV disease and CD4 count greater than 100 cells/mm3.
The following points should be considered when initiating therapy with Pegasys and COPEGUS:
- Use of Pegasys monotherapy is not recommended for treatment of CHC unless a patient has a contraindication to or significant intolerance to ribavirin. Combination therapy provides substantially better response rates than monotherapy [see Clinical Studies (14)].
- Safety and efficacy have not been demonstrated for treatment longer than 48 weeks.
- The safety and efficacy have not been established in liver or other organ transplant recipients [see Use in Specific Populations (8.7)].
Chronic Hepatitis B
Pegasys is indicated for the treatment of adult patients with HBeAg positive and HBeAg negative chronic hepatitis B infection who have compensated liver disease and evidence of viral replication and liver inflammation.
Pegasys Dosage and Administration
Pegasys is administered by subcutaneous injection in the abdomen or thigh. See COPEGUS Package Insert for all instructions regarding COPEGUS dosing and administration.
Chronic Hepatitis C
Adult Patients
Pegasys Monotherapy:
The recommended dose of Pegasys monotherapy for chronic hepatitis C is 180 mcg (1 mL vial, 0.5 mL prefilled syringe or 0.5 mL disposable autoinjector) once weekly for 48 weeks.
Pegasys/COPEGUS Combination Therapy:
The recommended dose of Pegasys when used in combination with ribavirin for chronic hepatitis C is 180 mcg (1 mL vial, 0.5 mL prefilled syringe or 0.5 mL disposable autoinjector) once weekly. The recommended dose of COPEGUS and duration for Pegasys/COPEGUS therapy is based on viral genotype (see Table 1).
The daily dose of COPEGUS is 800 mg to 1200 mg administered orally in two divided doses.
COPEGUS should be taken with food.
| Hepatitis C virus Genotype | Pegasys Dose (once weekly) | COPEGUS Dose (daily) | Duration |
|---|---|---|---|
| Genotypes 2 and 3 showed no increased response to treatment beyond 24 weeks (see Table 13). | |||
| Data on genotypes 5 and 6 are insufficient for dosing recommendations. | |||
| Genotypes 1, 4 | 180 mcg | <75 kg = 1000 mg ≥75 kg = 1200 mg | 48 weeks 48 weeks |
| Genotypes 2, 3 | 180 mcg | 800 mg | 24 weeks |
Pediatric Patients
Pegasys/COPEGUS Combination Therapy:
Pegasys is administered as 180 mcg/1.73 m2 × BSA subcutaneously once weekly, to a maximum dose of 180 mcg, and should be given in combination with COPEGUS. The recommended treatment duration for patients with genotype 2 or 3 is 24 weeks and for other genotypes is 48 weeks.
COPEGUS is available only as a 200 mg tablet and therefore the healthcare provider should determine if this sized tablet can be swallowed by the pediatric patient. COPEGUS should be administered with food. The recommended doses for COPEGUS are provided in Table 2. Patients who initiate treatment prior to their 18th birthday should maintain pediatric dosing through the completion of therapy.
| Body Weight in kilograms (kg) | COPEGUS Daily Dose* | COPEGUS Number of Tablets |
|---|---|---|
| ||
| 23 – 33 | 400 mg/day | 1 × 200 mg tablet A.M. 1 × 200 mg tablet P.M. |
| 34 – 46 | 600 mg/day | 1 × 200 mg tablet A.M. 2 × 200 mg tablets P.M. |
| 47 – 59 | 800 mg/day | 2 × 200 mg tablets A.M. 2 × 200 mg tablets P.M. |
| 60 – 74 | 1000 mg/day | 2 × 200 mg tablets A.M. 3 × 200 mg tablets P.M. |
| ≥75 | 1200 mg/day | 3 × 200 mg tablets A.M. 3 × 200 mg tablets P.M. |
Chronic Hepatitis C with HIV Coinfection
Adult Patients
Pegasys Monotherapy:
The recommended dose of Pegasys monotherapy for chronic hepatitis C in patients coinfected with HIV is 180 mcg (1 mL vial, 0.5 mL prefilled syringe or 0.5 mL disposable autoinjector) once weekly for 48 weeks.
Pegasys/COPEGUS Combination Therapy:
The recommended dose when used in combination with ribavirin is Pegasys 180 mcg once weekly and COPEGUS 800 mg orally daily given in two divided doses for a total of 48 weeks, regardless of genotype.
Since COPEGUS absorption increases when administered with a meal, patients are advised to take COPEGUS with food.
Chronic Hepatitis B
Adult Patients
Pegasys Monotherapy:
The recommended dose of Pegasys monotherapy for hepatitis B is 180 mcg (1 mL vial, 0.5 mL prefilled syringe or 0.5 mL disposable autoinjector) once weekly for 48 weeks.
Dose Modifications
If severe adverse reactions or laboratory abnormalities develop during combination Pegasys/COPEGUS therapy, the dose should be modified until the adverse reactions abate. If intolerance persists after dose adjustment, Pegasys/COPEGUS therapy should be discontinued. Table 3, Table 4, Table 5, and Table 6 provide guidelines for dose modifications and discontinuation of Pegasys/COPEGUS based on laboratory abnormalities, patient's depression status, and cardiac status.
Adult Patients
When dose modification of Pegasys is required for adverse reactions (clinical and/or laboratory), initial dose reduction to 135 mcg (which is 0.75 mL for the vials or adjustment to the corresponding graduation mark for the prefilled syringes) is recommended. Dose modification to 135 mcg per week can also be achieved by using a 135 mcg/0.5 mL strength disposable autoinjector. Dose reduction to 90 mcg (which is 0.5 mL for the vials or adjustment to the corresponding graduation mark for the prefilled syringes) may be needed if the adverse reaction persists or recurs. Following improvement of the adverse reaction, re-escalation of the dose may be considered [see Warnings and Precautions (5) and Adverse Reactions (6)].
| Laboratory Values | Recommended Dose |
|---|---|
| ANC <750 cells/mm3 | Reduce to 135 mcg |
| ANC <500 cells/mm3 | Discontinue treatment until ANC values return to more than 1000 cells/mm3. Reinstitute at 90 mcg and monitor ANC. |
| Platelet <50,000 cells/mm3 | Reduce to 90 mcg |
| Platelet <25,000 cells/mm3 | Discontinue treatment |
| Depression Severity | Initial Management (4-8 weeks) | Depression Status | |||
|---|---|---|---|---|---|
| Dose modification | Visit schedule | Remains stable | Improves | Worsens | |
| Mild | No change | Evaluate once weekly by visit and/or phone | Continue weekly visit schedule | Resume normal visit schedule | (See moderate or severe depression) |
| Moderate | Decrease Pegasys dose to 135 mcg (in some cases dose reduction to 90 mcg may be needed) | Evaluate once weekly (office visit at least every other week) | Consider psychiatric consultation. Continue reduced dosing | If symptoms improve and are stable for 4 weeks, may resume normal visit schedule. Continue reduced dosing or return to normal dose | (See severe depression) |
| Severe | Discontinue Pegasys permanently | Obtain immediate psychiatric consultation | Psychiatric therapy necessary | ||
Pediatric Patients
If toxicities occur which may be related to Pegasys or COPEGUS administration, the dose of one or both drugs can be modified. Additionally, COPEGUS or Pegasys plus COPEGUS combination therapy can be discontinued. COPEGUS should never be given as monotherapy. Recommendations for dose modifications in pediatric patients for toxicities associated with Pegasys administration are presented in Table 5.
When dose modification is required for moderate to severe adverse reactions (clinical or laboratory), modification to 135 mcg/1.73 m2 × BSA is generally adequate. However, in some cases, dose modification to 90 mcg/1.73 m2 × BSA or 45 mcg/1.73 m2 × BSA may be needed. Up to 3 dose modifications for toxicity can be made before discontinuation is considered. These modifications apply to pediatric patients with depression, who can be managed similar to the algorithm for adult patients outlined in Table 4.
Guidelines for dose modification based on neutropenia, increased ALT levels, and decreased platelet counts for pediatric patients are provided in Table 5.
| Pegasys Dose Modification | |
|---|---|
| Neutropenia | 750-999 cells/mm3: Week 1-2 — immediate modification to 135 mcg/1.73 m2 × BSA; Week 3-48: no modification. |
| 500-749 cells/mm3: Week 1-2 — delay or hold dose until >750 cells/mm3 then resume dose with a modification to 135 mcg/1.73 m2 × BSA, assess weekly × 3 to verify WBC's >750 cells/mm3; Week 3-48 — immediate modification to 135 mcg/1.73 m2 × BSA. | |
| 250-499 cells/mm3: Week 1-2 — delay or hold dose until >750 cells/mm3 then resume dose with a modification to 90 mcg/1.73 m2 × BSA; Week 3-48 — delay or hold dose until >750 cells/mm3 then resume dose with a modification to 135 mcg/1.73 m2 × BSA. | |
| <250 cells/mm3 (or febrile neutropenia): discontinue treatment. | |
| Increased alanine transaminase (ALT) | For persistent or increasing elevations ≥5 but <10 × ULN, modify dose with a modification to 135 mcg/1.73 m2 × BSA. Monitor weekly, further modifying dose if necessary, until stable or ALT level decreases. |
| For persistent ALT values ≥10 × ULN discontinue treatment. | |
| Decreased platelet count | Platelet <50,000 cells/mm3: Modify dose to 90 mcg/1.73 m2 × BSA. |
COPEGUS Dose Modifications
See COPEGUS Package Insert for all instructions regarding COPEGUS dosing and administration.
Adult and Pediatric Patients
| Body weight in kilograms (kg) | Laboratory Values | |
|---|---|---|
| Hemoglobin <10 g/dL in patients with no cardiac disease, or Decrease in hemoglobin of ≥2 g/dL during any 4 week period in patients with history of stable cardiac disease | Hemoglobin <8.5 g/dL in patients with no cardiac disease, or Hemoglobin <12 g/dL despite 4 weeks at reduced dose in patients with history of stable cardiac disease | |
| Adult Patients older than 18 years of age | ||
| Any weight | 1 × 200 mg tablet A.M. 2 × 200 mg tablets P.M. | Discontinue COPEGUS |
| Pediatric Patients 5 to 18 years of age | ||
| 23 – 33 kg | 1 × 200 mg tablet A.M. | Discontinue COPEGUS |
| 34 – 46 kg | 1 × 200 mg tablet A.M. 1 × 200 mg tablet P.M. | |
| 47 – 59 kg | 1 × 200 mg tablet A.M. 1 × 200 mg tablet P.M. | |
| 60 – 74 kg | 1 × 200 mg tablet A.M. 2 × 200 mg tablets P.M. | |
| ≥75 kg | 1 × 200 mg tablet A.M. 2 × 200 mg tablets P.M. | |
The guidelines for COPEGUS dose modifications outlined in this table also apply to laboratory abnormalities or adverse reactions other than decreases in hemoglobin values.
Adult Patients
Once COPEGUS has been withheld due to a laboratory abnormality or clinical adverse reaction, an attempt may be made to restart COPEGUS at 600 mg daily and further increase the dose to 800 mg daily. However, it is not recommended that COPEGUS be increased to the original dose (1000 mg or 1200 mg).
Pediatric Patients
Upon resolution of a laboratory abnormality or clinical adverse reaction, an increase in COPEGUS dose to the original dose may be attempted depending upon the physician's judgment. If COPEGUS has been withheld due to a laboratory abnormality or clinical adverse reaction, an attempt may be made to restart COPEGUS at one-half the full dose.
Renal Impairment
In patients with CrCL less than 30 mL/min, including patients with end-stage renal disease requiring hemodialysis, dose reduction to 135 mcg Pegasys is recommended. Signs and symptoms of interferon toxicity should be closely monitored. If severe adverse reactions or laboratory abnormalities develop, the dose of Pegasys may be reduced to 90 mcg until the adverse reactions abate. If intolerance persists after dose adjustment, Pegasys/COPEGUS therapy should be discontinued.
Renal function should be evaluated in all patients on COPEGUS. The dose of COPEGUS should be reduced for patients with creatinine clearance less than or equal to 50 mL/min [see Clinical Pharmacology (12.3) and COPEGUS Package Insert].
| Creatinine Clearance | Pegasys Dose (once weekly) | COPEGUS Dose (daily) |
|---|---|---|
| 30 to 50 mL/min | 180 mcg | Alternating doses, 200 mg and 400 mg every other day |
| < 30 mL/min | 135 mcg | 200 mg daily |
| Hemodialysis | 135 mcg | 200 mg daily |
No data are available for pediatric subjects with renal impairment.
Liver Function
Adult Patients
If ALT increases are progressive despite dose reduction or accompanied by increased bilirubin or evidence of hepatic decompensation, therapy should be immediately discontinued.
In chronic hepatitis C patients with progressive ALT increases above baseline values, the dose of Pegasys should be reduced to 135 mcg and more frequent monitoring of liver function should be performed. After Pegasys dose reduction or withholding, therapy can be resumed after ALT flares subside.
In chronic hepatitis B patients with elevations in ALT (greater than 5 × ULN), more frequent monitoring of liver function should be performed and consideration should be given to either reducing the dose of Pegasys to 135 mcg or temporarily discontinuing treatment. After Pegasys dose reduction or withholding, therapy can be resumed after ALT flares subside.
In adult patients with persistent, severe (ALT greater than 10 times above the upper limit of normal) hepatitis B flares, consideration should be given to discontinuation of treatment.
Discontinuation of Dosing
Discontinuation of therapy should be considered if the patient has failed to demonstrate at least a 2 log10 reduction from baseline in HCV RNA titer by 12 weeks of therapy or undetectable HCV RNA after 24 weeks of therapy [see Clinical Studies (14)].
During treatment, patients' clinical status and hepatic function should be closely monitored, and Pegasys treatment should be immediately discontinued if decompensation is observed [see Contraindications (4)].
Patients should be monitored for serious adverse reactions, some of which may become life threatening. Patients with persistently severe or worsening signs or symptoms should have their therapy withdrawn [see Boxed Warning].
Preparation and Administration
A patient should self-inject Pegasys only if the physician determines that it is appropriate and the patient agrees to medical follow-up as necessary and has been trained in proper injection technique [see illustrated FDA Approved Medication Guide for directions on injection site preparation and injection instructions].
Pegasys should be inspected visually for particulate matter and discoloration before administration, and not used if particulate matter is visible or product is discolored. Vials, prefilled syringes, and disposable autoinjectors with particulate matter or discoloration should be returned to the pharmacist.
Discard the unused portion of Pegasys in single-use vials or prefilled syringes in excess of the labeled volume. Use only one vial or prefilled syringe or disposable autoinjector per dose.
Dosage Forms and Strengths
- Vial for single use: 180 mcg/mL
- Prefilled Syringe for single use: 180 mcg/0.5 mL
- Autoinjector for single use: 180 mcg/0.5 mL
- Autoinjector for single use: 135 mcg/0.5 mL
Contraindications
Pegasys is contraindicated in patients with:
- Known hypersensitivity reactions such as urticaria, angioedema, bronchoconstriction, anaphylaxis, or Stevens-Johnson syndrome to alpha interferons, including Pegasys, or any of its components.
- Autoimmune hepatitis
- Hepatic decompensation (Child-Pugh score greater than 6 [class B and C]) in cirrhotic patients before treatment
- Hepatic decompensation with Child-Pugh score greater than or equal to 6 in cirrhotic CHC patients coinfected with HIV before treatment
Pegasys is contraindicated in neonates and infants because it contains benzyl alcohol. Benzyl alcohol is associated with an increased incidence of neurologic and other complications which are sometimes fatal in neonates and infants.
Pegasys/COPEGUS combination therapy is additionally contraindicated in:
- Women who are pregnant
- Men whose female partners are pregnant
- Patients with known hypersensitivity (urticaria, angioedema, bronchoconstriction, and anaphylaxis) to COPEGUS or to any component of the tablet
- Patients with hemoglobinopathies (e.g., thalassemia major, sickle-cell anemia)
- Combination with didanosine. Reports of fatal hepatic failure, as well as peripheral neuropathy, pancreatitis, and symptomatic hyperlactatemia/lactic acidosis have been reported in clinical trials [see Drug Interactions (7.4)].
Warnings and Precautions
Patients should be monitored for the following serious conditions, some of which may become life threatening. Patients with persistently severe or worsening signs or symptoms should have their therapy withdrawn [see Boxed Warning].
Use with Ribavirin including COPEGUS
Pregnancy
COPEGUS may cause birth defects and/or death of the exposed fetus. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients taking Pegasys and COPEGUS combination therapy. COPEGUS therapy should not be started unless a report of a negative pregnancy test has been obtained immediately prior to initiation of therapy. Women of childbearing potential and men must use two forms of effective contraception during treatment and for at least 6 months after treatment has concluded. Routine monthly pregnancy tests must be performed during this time [see Boxed Warning, Contraindications (4), Patient Counseling Information (17) and COPEGUS Package Insert].
Anemia
The primary toxicity of COPEGUS is hemolytic anemia. Hemoglobin less than 10 g/dL was observed in approximately 13% of COPEGUS and Pegasys treated subjects in chronic hepatitis C clinical trials. The anemia associated with COPEGUS occurs within 1 to 2 weeks of initiation of therapy with maximum drop in hemoglobin observed during the first eight weeks. Because the initial drop in hemoglobin may be significant, it is advised that hemoglobin or hematocrit be obtained pre-treatment and at week 2 and week 4 of therapy or more frequently if clinically indicated. Caution should be exercised in initiating treatment in any patient with baseline risk of severe anemia (e.g., spherocytosis, history of GI bleeding).
Fatal and nonfatal myocardial infarctions have been reported in patients with anemia caused by COPEGUS. Patients should be assessed for underlying cardiac disease before initiation of COPEGUS therapy. Patients with pre-existing cardiac disease should have electrocardiograms administered before treatment, and should be appropriately monitored during therapy. If there is any deterioration of cardiovascular status, therapy should be suspended or discontinued [see Dosage and Administration (2.6)]. Because cardiac disease may be worsened by drug-induced anemia, patients with a history of significant or unstable cardiac disease should not use COPEGUS [see COPEGUS Package Insert].
Neuropsychiatric
Life-threatening or fatal neuropsychiatric reactions may manifest in all patients receiving therapy with Pegasys and include suicide, suicidal ideation, homicidal ideation, depression, relapse of drug addiction, and drug overdose. These reactions may occur in patients with and without previous psychiatric illness.
Pegasys should be used with extreme caution in all patients who report a history of depression. Neuropsychiatric adverse events observed with alpha interferon treatment include aggressive behavior, psychoses, hallucinations, bipolar disorders, and mania. Physicians should monitor all patients for evidence of depression and other psychiatric symptoms. Patients should be advised to report any sign or symptom of depression or suicidal ideation to their prescribing physicians. In severe cases, therapy should be stopped immediately and psychiatric intervention instituted [see Adverse Reactions (6.1) and Dosage and Administration (2.5)].
Cardiovascular Disorders
Hypertension, supraventricular arrhythmias, chest pain, and myocardial infarction have been observed in patients treated with Pegasys. Pegasys should be administered with caution to patients with pre-existing cardiac disease. Because cardiac disease may be worsened by ribavirin-induced anemia, patients with a history of significant or unstable cardiac disease should not receive Pegasys/COPEGUS [see Warnings and Precautions (5.1) and COPEGUS Package Insert].
Bone Marrow Suppression
Pegasys suppresses bone marrow function and may result in severe cytopenias. Ribavirin may potentiate the neutropenia and lymphopenia induced by alpha interferons including Pegasys. Very rarely, alpha interferons may be associated with aplastic anemia. It is advised that complete blood counts (CBC) be obtained pre-treatment and monitored routinely during therapy [see Warnings and Precautions (5.1)].
Pegasys/COPEGUS should be used with caution in patients with baseline neutrophil counts less than 1,500 cells/mm3, with baseline platelet counts less than 90,000 cells/mm3 or baseline hemoglobin less than 10 g/dL. Pegasys therapy should be discontinued, at least temporarily, in patients who develop severe decreases in neutrophil and/or platelet counts [see Dosage and Administration (2.6)].
Severe neutropenia and thrombocytopenia occur with a greater incidence in HIV coinfected patients than monoinfected patients and may result in serious infections or bleeding [see Adverse Reactions (6.1)].
Pancytopenia (marked decreases in RBCs, neutrophils and platelets) and bone marrow suppression have been reported in the literature to occur within 3 to 7 weeks after the concomitant administration of pegylated interferon/ribavirin and azathioprine. In this limited number of patients (n=8), myelotoxicity was reversible within 4 to 6 weeks upon withdrawal of both HCV antiviral therapy and concomitant azathioprine and did not recur upon reintroduction of either treatment alone. Pegasys, COPEGUS, and azathioprine should be discontinued for pancytopenia, and pegylated interferon/ribavirin should not be re-introduced with concomitant azathioprine [see Drug Interactions (7)].
Autoimmune Disorders
Development or exacerbation of autoimmune disorders including myositis, hepatitis, thrombotic thrombocytopenic purpura, idiopathic thrombocytopenic purpura, psoriasis, rheumatoid arthritis, interstitial nephritis, thyroiditis, and systemic lupus erythematosus have been reported in patients receiving alpha interferon. Pegasys should be used with caution in patients with autoimmune disorders.
Endocrine Disorders
Pegasys causes or aggravates hypothyroidism and hyperthyroidism. Hyperglycemia, hypoglycemia, and diabetes mellitus have been observed to develop in patients treated with Pegasys. Patients with these conditions at baseline who cannot be effectively treated by medication should not begin Pegasys therapy. Patients who develop these conditions during treatment and cannot be controlled with medication may require discontinuation of Pegasys therapy.
Ophthalmologic Disorders
Decrease or loss of vision, retinopathy including macular edema, retinal artery or vein thrombosis, retinal hemorrhages and cotton wool spots, optic neuritis, papilledema and serous retinal detachment are induced or aggravated by treatment with Pegasys or other alpha interferons. All patients should receive an eye examination at baseline. Patients with pre-existing ophthalmologic disorders (e.g., diabetic or hypertensive retinopathy) should receive periodic ophthalmologic exams during interferon alpha treatment. Any patient who develops ocular symptoms should receive a prompt and complete eye examination. Pegasys treatment should be discontinued in patients who develop new or worsening ophthalmologic disorders.
Cerebrovascular Disorders
Ischemic and hemorrhagic cerebrovascular events have been observed in patients treated with interferon alfa-based therapies, including Pegasys. Events occurred in patients with few or no reported risk factors for stroke, including patients less than 45 years of age. Because these are spontaneous reports, estimates of frequency cannot be made and a causal relationship between interferon alfa-based therapies and these events is difficult to establish.
Hepatic Failure and Hepatitis Exacerbations
Chronic hepatitis C (CHC) patients with cirrhosis may be at risk of hepatic decompensation and death when treated with alpha interferons, including Pegasys. Cirrhotic CHC patients coinfected with HIV receiving highly active antiretroviral therapy (HAART) and interferon alfa-2a with or without ribavirin appear to be at increased risk for the development of hepatic decompensation compared to patients not receiving HAART. In Study 6 [see Clinical Studies (14.3)], among 129 CHC/HIV cirrhotic subjects receiving HAART, 14 (11%) of these subjects across all treatment arms developed hepatic decompensation resulting in 6 deaths. All 14 subjects were on NRTIs, including stavudine, didanosine, abacavir, zidovudine, and lamivudine. These small numbers of patients do not permit discrimination between specific NRTIs for the associated risk. During treatment, patients' clinical status and hepatic function should be closely monitored, and Pegasys/COPEGUS treatment should be immediately discontinued in patients with hepatic decompensation [see Contraindications (4)].
Exacerbations of hepatitis during hepatitis B therapy are not uncommon and are characterized by transient and potentially severe increases in serum ALT. Chronic hepatitis B subjects experienced transient acute exacerbations (flares) of hepatitis B (ALT elevation greater than 10-fold higher than the upper limit of normal) during Pegasys treatment (12% and 18%) and post-treatment (7% and 12%) in HBeAg negative and HBeAg positive subjects, respectively. Marked transaminase flares while on Pegasys therapy have been accompanied by other liver test abnormalities. Patients experiencing ALT flares should receive more frequent monitoring of liver function. Pegasys dose reduction should be considered in patients experiencing transaminase flares. If ALT increases are progressive despite reduction of Pegasys dose or are accompanied by increased bilirubin or evidence of hepatic decompensation, Pegasys should be immediately discontinued [see Adverse Reactions (6.1) and Dosage and Administration (2.5)].
Pulmonary Disorders
Dyspnea, pulmonary infiltrates, pneumonia, bronchiolitis obliterans, interstitial pneumonitis, pulmonary hypertension and sarcoidosis, some resulting in respiratory failure and/or patient deaths, may be induced or aggravated by Pegasys or alpha interferon therapy. Recurrence of respiratory failure has been observed with interferon rechallenge. Pegasys combination treatment should be suspended in patients who develop pulmonary infiltrates or pulmonary function impairment. Patients who resume interferon treatment should be closely monitored.
Infections
While fever may be associated with the flu-like syndrome reported commonly during interferon therapy, other causes of high or persistent fever must be ruled out, particularly in patients with neutropenia. Serious and severe infections (bacterial, viral, or fungal), some fatal, have been reported during treatment with alpha interferons including Pegasys. Appropriate anti-infective therapy should be started immediately and discontinuation of therapy should be considered.
Colitis
Ulcerative and hemorrhagic/ischemic colitis, sometimes fatal, have been observed within 12 weeks of starting alpha interferon treatment. Abdominal pain, bloody diarrhea, and fever are the typical manifestations of colitis. Pegasys should be discontinued immediately if these symptoms develop. The colitis usually resolves within 1 to 3 weeks of discontinuation of alpha interferon.
Pancreatitis
Pancreatitis, sometimes fatal, has occurred during alpha interferon and ribavirin treatment. Pegasys/COPEGUS should be suspended if symptoms or signs suggestive of pancreatitis are observed. Pegasys/COPEGUS should be discontinued in patients diagnosed with pancreatitis.
Hypersensitivity
Severe acute hypersensitivity reactions (e.g., urticaria, angioedema, bronchoconstriction, and anaphylaxis) have been observed during alpha interferon and ribavirin therapy. If such reaction occurs, therapy with Pegasys/COPEGUS should be discontinued and appropriate medical therapy immediately instituted. Serious skin reactions including vesiculobullous eruptions, reactions in the spectrum of Stevens-Johnson Syndrome (erythema multiforme major) with varying degrees of skin and mucosal involvement and exfoliative dermatitis (erythroderma) have been reported in patients receiving Pegasys with and without ribavirin. Patients developing signs or symptoms of severe skin reactions must discontinue therapy [see Adverse Reactions (6.2)].
Impact on Growth in Pediatric Patients
Pediatric subjects treated with Pegasys plus COPEGUS combination therapy showed a delay in weight and height increases after 48 weeks of therapy compared with baseline. Both weight and height for age z-scores as well as the percentiles of the normative population for subject weight and height decreased during treatment. At the end of 2 years follow-up after treatment, most subjects had returned to baseline normative growth curve percentiles for weight and height (mean weight for age percentile was 64% at baseline and 60% at 2 years post-treatment; mean height percentile was 54% at baseline and 56% at 2 years post-treatment). At the end of treatment, 43% of subjects experienced a weight percentile decrease of 15 percentiles or more, and 25% experienced a height percentile decrease of 15 percentiles or more on the normative growth curves. At 2 years post-treatment, 16% of subjects remained 15 percentiles or more below their baseline weight curve and 11% remained 15 percentiles or more below their baseline height curve.
Peripheral Neuropathy
Peripheral neuropathy has been reported when alpha interferons were given in combination with telbivudine. In one clinical trial, an increased risk and severity of peripheral neuropathy was observed with the combination use of telbivudine and Pegasys as compared to telbivudine alone. The safety and efficacy of telbivudine in combination with interferons for the treatment of chronic hepatitis B have not been demonstrated.
Laboratory Tests
Before beginning Pegasys or Pegasys/COPEGUS combination therapy, standard hematological and biochemical laboratory tests are recommended for all patients. Pregnancy screening for women of childbearing potential must be performed. Patients who have pre-existing cardiac abnormalities should have electrocardiograms administered before treatment with Pegasys/COPEGUS.
After initiation of therapy, hematological tests should be performed at 2 weeks and 4 weeks and biochemical tests should be performed at 4 weeks. Additional testing should be performed periodically during therapy. In adult clinical studies, the CBC (including hemoglobin level and white blood cell and platelet counts) and chemistries (including liver function tests and uric acid) were measured at 1, 2, 4, 6, and 8 weeks, and then every 4 to 6 weeks or more frequently if abnormalities were found. In a pediatric clinical trial, hematological and chemistry assessments were at 1, 3, 5, and 8 weeks, then every 4 weeks. Thyroid stimulating hormone (TSH) was measured every 12 weeks. Monthly pregnancy testing should be performed during combination therapy and for 6 months after discontinuing therapy.
The entrance criteria used for the clinical studies of Pegasys may be considered as a guideline to acceptable baseline values for initiation of treatment:
- Platelet count greater than or equal to 90,000 cells/mm3 (as low as 75,000 cells/mm3 in HCV subjects with cirrhosis or 70,000 cells/mm3 in subjects with CHC and HIV)
- Absolute neutrophil count (ANC) greater than or equal to 1,500 cells/mm3
- Serum creatinine concentration less than 1.5 × upper limit of normal
- TSH and T4 within normal limits or adequately controlled thyroid function
- CD4+ cell count greater than or equal to 200 cells/mm3 or CD4+ cell count greater than or equal to 100 cells/mm3 but less than 200 cells/mm3 and HIV-1 RNA less than 5,000 copies/mL in subjects coinfected with HIV
- Hemoglobin greater than or equal to 12 g/dL for women and greater than or equal to 13 g/dL for men in CHC monoinfected subjects
- Hemoglobin greater than or equal to 11 g/dL for women and greater than or equal to 12 g/dL for men in subjects with CHC and HIV
Adverse Reactions
In clinical trials, a broad variety of serious adverse reactions were observed in 1,010 subjects who received Pegasys at doses of 180 mcg for 48 weeks, alone or in combination with COPEGUS [see Boxed Warning and Warnings and Precautions (5)]. The most common life-threatening or fatal events induced or aggravated by Pegasys and COPEGUS include depression, suicide, relapse of drug abuse/overdose, and bacterial infections, each occurring at a frequency of less than 1%. Hepatic decompensation occurred in 2% (10/574) of CHC/HIV subjects [see Warnings and Precautions (5.9)].
Clinical Trials Experience
Because clinical trials are conducted under widely varying and controlled conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug, and may not reflect the rates observed in clinical practice.
Adult Subjects
In all hepatitis C studies, one or more serious adverse reactions occurred in 10% of CHC monoinfected subjects and in 19% of CHC/HIV subjects receiving Pegasys alone or in combination with COPEGUS. The most common serious adverse reactions (3% in CHC and 5% in CHC/HIV) was bacterial infection (e.g., sepsis, osteomyelitis, endocarditis, pyelonephritis, pneumonia). Other SAEs occurred at a frequency of less than 1% and included: suicide, suicidal ideation, aggression, anxiety, drug abuse and drug overdose, angina, hepatic dysfunction, fatty liver, cholangitis, arrhythmia, diabetes mellitus, autoimmune phenomena (e.g., hyperthyroidism, hypothyroidism, sarcoidosis, systemic lupus erythematosus, rheumatoid arthritis), peripheral neuropathy, aplastic anemia, peptic ulcer, gastrointestinal bleeding, pancreatitis, colitis, corneal ulcer, pulmonary embolism, coma, myositis, cerebral hemorrhage, thrombotic thrombocytopenic purpura, psychotic disorder, and hallucination.
In clinical trials, 98 to 99 percent of subjects experienced one or more adverse reactions. For hepatitis C subjects, the most commonly reported adverse reactions were psychiatric reactions, including depression, insomnia, irritability, anxiety, and flu-like symptoms such as fatigue, pyrexia, myalgia, headache, and rigors. Other common reactions were anorexia, nausea and vomiting, diarrhea, arthralgias, injection site reactions, alopecia, and pruritus. Table 8 displays pooled rates of adverse reactions occurring in greater than 5% of subjects in the Pegasys monotherapy and Pegasys/COPEGUS combination therapy clinical trials.
Overall 11% of CHC monoinfected subjects receiving 48 weeks of therapy with Pegasys either alone or in combination with COPEGUS discontinued therapy; 16% of CHC/HIV coinfected subjects discontinued therapy. The most common reasons for discontinuation of therapy were psychiatric, flu-like syndrome (e.g., lethargy, fatigue, headache), dermatologic and gastrointestinal disorders, and laboratory abnormalities (thrombocytopenia, neutropenia, and anemia).
Overall 39% of subjects with CHC or CHC/HIV required modification of Pegasys and/or COPEGUS therapy. The most common reasons for dose modification of Pegasys in CHC and CHC/HIV subjects was for neutropenia (20% and 27%, respectively) and thrombocytopenia (4% and 6%, respectively). The most common reason for dose modification of COPEGUS in CHC and CHC/HIV subjects was anemia (22% and 16%, respectively). Pegasys dose was reduced in 12% of subjects receiving 1000 mg to 1200 mg COPEGUS for 48 weeks and in 7% of subjects receiving 800 mg COPEGUS for 24 weeks. COPEGUS dose was reduced in 21% of subjects
No comments:
Post a Comment