ELELYSO- taliglucerase alfa injection, powder, lyophilized, for solution
Pfizer Laboratories Div Pfizer Inc
HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use ELELYSO safely and effectively. See full prescribing information for ELELYSO.
ELELYSO™ (taliglucerase alfa) for injection, for intravenous use
Initial U.S. Approval: 2012
RECENT MAJOR CHANGES
INDICATIONS AND USAGE
ELELYSO is a hydrolytic lysosomal glucocerebroside-specific enzyme indicated for long-term enzyme replacement therapy (ERT) for adult and pediatric patients with a confirmed diagnosis of Type 1 Gaucher disease (1).
DOSAGE AND ADMINISTRATION
DOSAGE FORMS AND STRENGTHS
For injection: lyophilized powder for reconstitution with diluent, 200 unit single-use vials (3)
WARNINGS AND PRECAUTIONS
The most commonly reported adverse reactions (≥5%) in clinical studies were pruritus, flushing, headache, arthralgia, pain in extremity, abdominal pain, vomiting, fatigue, back pain, dizziness, nausea and rash (6.1).
To report SUSPECTED ADVERSE REACTIONS, contact Pfizer Inc. at 1-800-438-1985 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
See 17 for PATIENT COUNSELING INFORMATION.
FULL PRESCRIBING INFORMATION: CONTENTS*
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the 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 practice.
In the clinical trials with ELELYSO, either as initial therapy or as therapy following a switch from imiglucerase (N=72), the most common (≥ 5%) adverse reactions included pruritus, flushing, headache, arthralgia, pain in extremity, abdominal pain, vomiting, fatigue, back pain, dizziness, nausea, and rash.
Clinical Trials of ELELYSO as Initial Therapy
The safety of ELELYSO at dosages of either 30 units/kg (n=16) or 60 units/kg (n=16) every other week was assessed in 32 adult treatment-naïve patients (aged 19 to 74 years) with Type 1 Gaucher disease in a 9-month randomized clinical trial.
|Preferred Term||Treatment-Naïve Adults (N=32)|
|Abdominal pain||2 (6%)|
Similar adverse reactions were observed in patients who continued ELELYSO treatment during the extension trial for up to 24 months. One patient experienced a mild and intermittent Type III immune-mediated fixed drug eruption and continued in the study.
The safety of ELELYSO at dosages of either 30 units/kg (n=4) or 60 units/kg (n=5) every other week was assessed in 9 pediatric treatment-naïve patients (aged 2 to 13 years) with Type 1 Gaucher disease in a 12-month randomized clinical trial.
The most common adverse reaction (≥10%) was vomiting, which occurred in 4 of 9 patients. Two patients developed hypersensitivity reactions; one patient experienced severe vomiting and gastrointestinal inflammation, and 1 experienced mild throat irritation and chest discomfort. Both patients responded to treatment with antihistamines and continued ELELYSO treatment.
Clinical Trial in Patients Switching from Imiglucerase Treatment to ELELYSO
The safety of ELELYSO was assessed in 31 patients (26 adult and 5 pediatric patients), ages 6 to 66 years old, with Type 1 Gaucher disease who had previously been receiving treatment with imiglucerase for a minimum of 2 years. ELELYSO was administered for 9 months at the same number of units as each patient's previous imiglucerase dose.
|Preferred Term||Patients Switched from Imiglucerase|
(N=31; 26 adults and 5 children)
|Pain in extremity||3 (10%)|
As with all therapeutic proteins, patients may develop anti-drug antibodies (ADA) to ELELYSO.
In clinical trials of treatment-naïve adults, 17 (53%) of 32 patients developed ADA during treatment with ELELYSO, and 2 (6%) of 32 patients tested positive for ADA at baseline prior to ELELYSO treatment. Of the 17 patients who developed ADA during ELELYSO treatment, 6 patients (35%) developed hypersensitivity reactions, 2 of whom met criteria for anaphylaxis. Two of the 17 patients who developed ADA during ELELYSO treatment discontinued treatment due to hypersensitivity reactions, one of whom had met criteria for anaphylaxis. Of the 2 patients who tested positive for ADA prior to initiation of ELELYSO treatment, one patient developed a hypersensitivity reaction during the first dose of ELELYSO and withdrew from the study. The second patient did not experience an adverse reaction.
In a clinical trial of treatment-naïve pediatric patients, 2 (22%) of 9 patients developed ADA during treatment with ELELYSO, and one of 9 patients was ADA-positive prior to initiation of ELELYSO. Two patients (1 who developed ADA during treatment and 1 who was ADA-positive at baseline) experienced hypersensitivity reactions. Both patients continued treatment with ELELYSO.
In a clinical trial of 31 patients (26 adult and 5 pediatric patients) who switched from imiglucerase to ELELYSO treatment, 4 adults (13% of patients) developed ADA during treatment with ELELYSO. Four additional patients (13%, 2 adults and 2 children) tested positive for ADA at baseline but became ADA-negative after the switch to ELELYSO. Two adult patients (1 patient who developed ADA after the switch and 1 who was ADA positive at baseline) experienced hypersensitivity reactions. Both patients continued treatment with ELELYSO.
The relationship between ADA and hypersensitivity reactions is not fully understood. Monitoring for ADA to ELELYSO may be useful in ADA positive patients or in patients who have experienced hypersensitivity reactions to ELELYSO or other enzyme replacement therapies.
Twenty-nine of the 30 adult and pediatric patients who tested positive for ADA were tested for neutralizing antibodies capable of inhibiting the enzymatic activity of ELELYSO. Neutralizing antibodies were detected in 3 (10.3%) of 29 patients, 2 treatment-naïve adult patients and 1 adult patient who switched from imiglucerase. Due to limited available data, it is not possible to determine a relationship between the presence of neutralizing antibodies and therapeutic response with ELELYSO.
Immunogenicity assay results are highly dependent on the sensitivity and specificity of the assay and may be influenced by several factors such as: assay methodology, sample handling, timing of sample collection, concomitant medication, and underlying disease. For these reasons, comparison of the incidence of antibodies to ELELYSO with the incidence of antibodies to other products may be misleading.
The following adverse reactions have been identified during post approval use of ELELYSO in countries where it is marketed. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Immune system disorders: Anaphylaxis [see Warning and Precautions (5.1)].
There are no adequate and well-controlled studies of ELELYSO in pregnant women. In animal reproduction studies with taliglucerase alfa in pregnant rats at intravenous doses up to 5 times the recommended human dose (RHD) and in pregnant rabbits at intravenous doses up to 5 times the RHD, there was no evidence of harm to the fetus. Because animal reproduction studies are not always predictive of human response, ELELYSO should be used during pregnancy only if clearly needed.
Disease-associated maternal and embryo-fetal risk
Women with Type 1 Gaucher disease have an increased risk of spontaneous abortion if disease symptoms are not treated and controlled pre-conception and during a pregnancy. Pregnancy may exacerbate existing Type 1 Gaucher disease symptoms or result in new disease manifestations. Type 1 Gaucher disease manifestations may lead to adverse pregnancy outcomes, including hepatosplenomegaly which can interfere with the normal growth of a fetus and thrombocytopenia which can lead to increased bleeding and possible hemorrhage.
Reproduction studies have been performed with taliglucerase alfa administered during the period of organogenesis in rats and rabbits. In rats, intravenous doses up to 55 mg/kg/day (about 5 times the RHD of 60 units/kg based on the body surface area) did not cause any adverse effects on embryofetal development. In rabbits, intravenous doses up to 27.8 mg/kg/day (about 5 times the RHD of 60 units/kg based on the body surface area) did not show any embryofetal toxicity.
It is not known whether ELELYSO is present in human milk. Because many drugs are present in human milk, caution should be exercised when ELELYSO is administered to a nursing woman.
The use of ELELYSO for treatment of pediatric patients with Type 1 Gaucher disease is supported by evidence of effectiveness from adequate and well-controlled trials of ELELYSO in adults, with additional pharmacodynamic data from 5 pediatric patients and pharmacokinetic data from 9 pediatric patients who participated in clinical trials [see Clinical Studies (14.1, 14.2), Clinical Pharmacology (12.3)]. Data from 14 pediatric patients were included in the safety evaluation [Adverse Reactions (6.1)]. There are insufficient data to inform dosing in patients less than 4 years of age.
Pediatric patients experienced a higher frequency of vomiting during ELELYSO treatment (4 of 9 treatment-naïve patients) than adult patients, and this may be a symptom of hypersensitivity reaction. The frequencies of other adverse reactions were similar between pediatric and adult patients [see Adverse Reactions (6.1)].
Taliglucerase alfa, a hydrolytic lysosomal glucocerebroside-specific enzyme for intravenous infusion, is a recombinant active form of the lysosomal enzyme, β-glucocerebrosidase, which is expressed in genetically modified carrot plant root cells cultured in a disposable bioreactor system (ProCellEx®). β-Glucocerebrosidase (β-D-glucosyl-N-acylsphingosine glucohydrolase, E.C. 18.104.22.168) is a lysosomal glycoprotein enzyme that catalyzes the hydrolysis of the glycolipid glucocerebroside to glucose and ceramide.
ELELYSO is produced by recombinant DNA technology using plant cell culture (carrot). Purified taliglucerase alfa is a monomeric glycoprotein containing 4 N-linked glycosylation sites (Mr = 60,800). Taliglucerase alfa differs from native human glucocerebrosidase by two amino acids at the N terminal and up to 7 amino acids at the C terminal. Taliglucerase alfa is a glycosylated protein with oligosaccharide chains at the glycosylation sites having terminal mannose sugars. These mannose-terminated oligosaccharide chains of taliglucerase alfa are specifically recognized by endocytic carbohydrate receptors on macrophages, the cells that accumulate lipid in Gaucher disease.
ELELYSO is supplied as a sterile, non-pyrogenic, lyophilized product. The quantitative composition of each 200 Unit vial is D-mannitol (206.7 mg), polysorbate 80 (0.56 mg), sodium citrate (30.4 mg), and taliglucerase alfa (212 units). Citric acid may be added to adjust the pH at the time of manufacture.
A Unit is the amount of enzyme that catalyzes the hydrolysis of 1 micromole of the synthetic substrate para-nitrophenyl-β-D-glucopyranoside (pNP-Glc) per minute at 37°C. After reconstitution with Sterile Water for Injection, taliglucerase alfa concentration is 40 units/mL [see Dosage and Administration (2)]. Reconstituted solutions have a pH of approximately 6.0.
Gaucher disease is an autosomal recessive disorder caused by mutations in the human glucocerebrosidase gene, which results in a reduced activity of the lysosomal enzyme glucocerebrosidase. Glucocerebrosidase catalyzes the conversion of the sphingolipid glucocerebroside into glucose and ceramide. The enzymatic deficiency results in accumulation of substrate glucocerebroside primarily in the lysosomal compartment of macrophages, giving rise to foam cells or "Gaucher cells," which accumulate in the liver, spleen and bone marrow.
ELELYSO is a recombinant analog of human lysosomal glucocerebrosidase that catalyzes the hydrolysis of glucocerebroside to glucose and ceramide, reducing the amount of accumulated glucocerebroside. ELELYSO uptake into cellular lysosomes is mediated by binding of ELELYSO mannose oligosaccharide chains to specific mannose receptors on the cell surface leading to internalization and subsequent transport to the lysosomes.
Pharmacokinetics of taliglucerase alfa were evaluated in 38 patients (29 adult and 9 pediatric patients) who received intravenous infusions of ELELYSO 30 units/kg or 60 units/kg every other week. ELELYSO 30 units/kg is not a recommended dose in treatment-naïve Gaucher disease patients [see Dosage and Administration (2.1)]. The pharmacokinetic parameters in adult and pediatric patients are summarized in Table 3.
In adult Type 1 Gaucher disease patients treated with ELELYSO 30 units/kg or 60 units/kg (N=29) every other week as initial therapy, pharmacokinetics were determined with the first dose and at Week 38 of treatment. The pharmacokinetics of taliglucerase alfa appeared to be nonlinear with a greater than dose-proportional increase in exposure at the doses studied.
No significant accumulation or change in taliglucerase alfa pharmacokinetics over time from Weeks 1 to 38 was observed with repeated dosages of 30 units/kg or 60 units/kg every other week.Based on the limited data, there were no significant pharmacokinetic differences between male and female patients in this study.
Pharmacokinetics of taliglucerase alfa were evaluated in 9 pediatric patients 4 to 17 years of age with Type 1 Gaucher disease who were treated with ELELYSO for 10 to 27 months. Six of the 9 patients were treatment-naïve, and 3 patients were switched from imiglucerase. In both the 30 units/kg and 60 units/kg dose groups, clearance values in pediatric patients were similar to those in adult patients. AUC values in pediatric patients were lower than AUC values in adult patients, due to weight-based dosing of taliglucerase alfa and lower body weights in pediatric patients.
|Pediatric Patients (N=9)|
|Adult Patients at Week 38 (N=29)|
n = 5
n = 4
n = 14
n = 15
|Age (years)||15 (10, 17)||11 (4, 16)||35 (19, 74)||33 (19, 58)|
|Weight (kg)||44.3 (22.8, 71.0)||28.6 (16.5, 50.4)||72.5 (51.5, 99.5)||73.5 (58.5, 87.0)*|
|AUC0–∞ (ng*h/mL)†||1416 (535, 1969)||2984 (1606, 4273)||2007 (1007, 10092)||6459 (2548, 21020)*|
|T1/2 (min)||37.1 (22.5, 56.8)||32.5 (18.0, 42.9)||18.9 (9.20, 57.9)||28.7 (11.3, 104)*|
|CL (L/h)||30.5 (17.4, 37.8)||15.8 (11.7, 24.9)||30.5 (6.79, 68.0)||18.5 (6.20, 37.9)*|
|Vss (L)||14.9 (10.1, 35.6)||8.80 (3.75, 21.4)||11.7 (2.3, 22.7)||10.7 (1.4, 18.5)*|
Long-term studies in animals to evaluate carcinogenic potential or studies to evaluate mutagenic potential have not been performed with taliglucerase alfa. In a male and female fertility study in rats, taliglucerase alfa did not cause any significant adverse effect on male or female fertility parameters up to a maximum dose of 55 mg/kg/day (about 5 times the recommended human dose of 60 units/kg based on the body surface area).
Clinical Trial in Patients 19 Years and Older
The safety and efficacy of ELELYSO were assessed in 31 adult patients with Type 1 Gaucher disease. The trial was a 9-month, multi-center, double-blind, randomized trial in patients with Gaucher disease-related enlarged spleens (>8 times normal) and thrombocytopenia (<120,000 /mm3). Sixteen patients had enlarged livers and ten patients had anemia at baseline. All patients were naïve to ERT. Patients with severe neurological symptoms were excluded from the trial. Patients were 19 to 74 years of age (mean age 36 years), and 48% were male. Patients were randomized to receive ELELYSO at a dosage of either 30 units/kg (n=15) or 60 units/kg (n=16) every other week. The recommended dosage in treatment-naïve adult patients is 60 units/kg every other week. ELELYSO 30 units/kg every other week is not a recommended dosage [see Dosage and Administration (2.1)].
Table 4 shows the baseline values and mean (±SD) changes in clinical parameters (spleen volume, liver volume, platelet count, and hemoglobin) after 9 months of treatment with ELELYSO. For all clinical trials, liver and spleen volumes were measured by MRI and are reported as percentage of body weight (%BW) and multiples of normal (MN). The observed change from baseline in the primary endpoint, reduction in spleen volume, was considered to be clinically meaningful in light of the natural history of untreated Gaucher disease.
|Clinical Parameter||30 units/kg* (n=15)|
|60 units/kg (n=16)|
|Spleen Volume (%BW)||Baseline||3.1 (1.5)||3.3 (2.7)|
|Month 9||2.2 (1.3)||2.1 (1.9)|
|Change||-0.9 (0.4)||-1.3 (1.1)|
|Spleen Volume (MN)||Baseline||15.4 (7.7)||16.7 (13.4)|
|Month 9||11.1 (6.3)||10.4 (9.4)|
|Liver Volume (%BW)||Baseline||4.2 (0.9)||3.8 (1.0)|
|Month 9||3.6 (0.7)||3.1 (0.7)|
|Change||-0.6 (0.5)||-0.6 (0.4)|
|Liver Volume (MN)||Baseline||1.7 (0.4)||1.5 (0.4)|
|Month 9||1.4 (0.3)||1.2 (0.3)|
|Change||-0.2 (0.2)||-0.3 (0.2)|
|Platelet Count (mm3)||Baseline||75,320 (40,861)||65,038 (28,668)|
|Month 9||86,747 (50,989)||106,531 (53,212)|
|Change||11,427 (20,214)||41,494 (47,063)|
|Hemoglobin (g/dl)||Baseline||12.2 (1.7)||11.4 (2.6)|
|Month 9||14.0 (1.4)||13.6 (2.0)|
|Change||1.6 (1.4)||2.2 (1.4)|
Twenty-six of the 31 patients in this clinical trial continued blinded treatment with ELELYSO in an extension trial for a total treatment duration of 24 months. The following data are the changes in clinical parameters from baseline to Month 24 for the 30 units/kg (n=17) and 60 units/kg (n=14) dose groups, respectively: mean (SD) spleen volume (%BW) decreased -1.4 (0.6) and -2.0 (2.0); hemoglobin increased 1.3 (0.7) g/dL and 2.4 (2.3) g/dL; liver volume (%BW) decreased -1.1 (0.5) and -1.0 (0.7); and platelet count increased 28,433 (31,996) /mm3 and 72,029 (68,157) /mm3.
Clinical Trial in patients 16 years and younger
The safety and efficacy of ELELYSO were assessed in 9 pediatric patients with Type 1 Gaucher disease. The trial was a 12-month, multi-center, double-blind, randomized study in treatment-naïve patients. Patients were 2 to 13 years of age (mean age 8.1 years), and 67% were male. Patients were randomized to receive ELELYSO at a dosage of either 30 units/kg (n=4) or 60 units/kg (n=5) every other week. The recommended ELELYSO dosage in treatment-naïve pediatric patients is 60 units/kg every other week. ELELYSO 30 units/kg every other week is not a recommended dosage [see Dosage and Administration (2.1)].
Mean (±SD) baseline spleen volume for the 60 units/kg dose group was 29.4 (±24.3) MN, and decreased to 12.9 (±7.2) MN at 12 months. Baseline liver volume for the 60 units/kg dose group was 2.2 (±0.5) MN, and decreased to 1.7 (±0.3) MN at 12 months. Mean (±SD) platelet count for the 60 units/kg dose group was 99,600 (±42,899)/mm3 at baseline, and increased to 172,200 (±89,290)/mm3 at 12 months.
The safety and efficacy of ELELYSO were assessed in 31 patients (26 adult and 5 pediatric patients) with Type 1 Gaucher disease who were switched from imiglucerase to ELELYSO. The trial was a 9-month, multi-center, open-label, single arm study in patients who had been receiving treatment with imiglucerase at dosages ranging from 9.5 units/kg to 60 units/kg every other week for a minimum of 2 years. Patients were required to be clinically stable and have a stable biweekly dose of imiglucerase for at least 6 months prior to enrollment. Patients were 6 to 66 years of age (mean age 42 years, including pediatric patients), and 55% were male. Imiglucerase therapy was stopped, and treatment with ELELYSO was administered every other week at the same number of units as each patient's previous imiglucerase dose. If needed, adjustment of dosage was allowed during the study in order to maintain stability of clinical parameters (i.e., spleen volume, liver volume, platelet count, and hemoglobin).
Mean (±SD) organ volumes and hematologic values remained stable through 9 months of ELELYSO treatment. At baseline, spleen volume was 5.2 (±0.9) MN, liver volume was 1.0 (±0.1) MN, platelet count was 161,137 (±73,387)/mm3, and hemoglobin was 13.5 (±1.4) g/dL. After 9 months of ELELYSO treatment, spleen volume was 4.8 (±0.9) MN, liver volume was 1.0 (±0.0) MN, platelet count was 161,167 (±80,820)/mm3, and hemoglobin was 13.4 (±1.5) g/dL. ELELYSO dose remained unchanged in 30 of 31 patients. One patient required a dose increase at Week 24 (from 9.5 units/kg to 19 units/kg) for a platelet count of 92,000/mm3 at Week 22, which subsequently increased to 170,000/mm3 at Month 9.
ELELYSO is supplied as a lyophilized powder in single use vials. Each vial contains 200 units of ELELYSO.
NDC 0069-0106-01, 200 units per vial
Store ELELYSO under refrigeration at 2° C to 8° C (36° F to 46° F). Do not freeze. Protect vials from light.
As ELELYSO contains no preservative, the product should be used immediately once reconstituted. If immediate use is not possible, the reconstituted product may be stored for up to 24 hours at 2 to 8 °C (36 to 46 °F) under protection from light or up to 4 hours at 20 to 25 °C (68 to 77 °F) without protection from light. The diluted product may be stored for up to 24 hours at 2 to 8 °C (36 to 46 °F) under protection from light. Storage of the reconstituted product and the diluted product should not exceed a total of 24 hours. Do not freeze. Discard any unused product.
Hypersensitivity Reactions Including Anaphylaxis
Advise patients and caregivers that reactions related to administration and infusion may occur during and after ELELYSO treatment, including life-threatening anaphylaxis and severe hypersensitivity reactions. Inform patients of the signs and symptoms of anaphylaxis and hypersensitivity reactions, and have them seek medical care should signs and symptoms occur. Inform patients that they should be carefully re-evaluated for treatment with ELELYSO if serious hypersensitivity reactions, including anaphylaxis, occur. Reduction of the infusion rate and/or pre-treatment with antihistamines, antipyretics and/or corticosteroids may prevent subsequent reactions [see Warnings and Precautions (5.1)].