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RA SSc-ILD PJIA SJIA GCA COVID-19

Laboratory Monitoring for Patients With SJIA

  • Decreases in neutrophils and platelets, and elevations in hepatic transaminases and lipids, were seen with ACTEMRA in clinical trials
  • Dose interruptions of ACTEMRA are recommended for liver enzyme abnormalities, low neutrophil counts, and low platelet counts in patients with SJIA. In SJIA, the decision to discontinue ACTEMRA for a laboratory abnormality should be based upon the medical assessment of the individual patient
  • It is recommended that ACTEMRA not be initiated in patients with an absolute neutrophil count (ANC) below 2000 per mm3, platelet count below 100,000 per mm3, or who have ALT and AST above 1.5 times the upper limit of normal (ULN)

Hold ACTEMRA treatment if a patient develops a serious infection until the infection is controlled.

Laboratory Abnormalities Reported in the TENDER Clinical Study 1,3-5

Neutrophilsv Platelets Hepatic Transaminases; CTC Grades† Lipids
Neutrophilsv
Monitoring Guidance   12-Week Controlled Study Week 52* Week 260*
Neutrophils should be monitored at the time of the second infusion and every 2 to 4 weeks thereafter.   Placebo (n=37) ACTEMRA (n=75) ACTEMRA (N=112) ACTEMRA (N=112)
Neutrophils 
<1 x 109/L		 0% 7% 17% 33%

*Data from open-label extension.

  • There was no clear relationship between decreases in neutrophils <1 x 109/L and the occurrence of serious infections
Platelets
Monitoring Guidance   12-Week Controlled Study Week 52* Week 260*
Platelets should be monitored at the time of the second infusion and every 2 to 4 weeks thereafter.   Placebo (n=37) ACTEMRA (n=75) ACTEMRA (N=112) ACTEMRA (N=112)
Platelets
≤100 x 103/μL		 3% 1% 4% 4.5%

*Data from open-label extension.

Hepatic Transaminases; CTC Grades†
Monitoring Guidance   12-Week Double-blind Period All Exposure at Week 260
  Placebo (n=37) ACTEMRA (n=75) All ACTEMRA (N=112)
ALT and AST levels should be monitored at the time of the second infusion and every 2 to 4 weeks thereafter. ALT n (%)
Normal (<ULN) 32 (91%) 53 (71%) 30 (27%)
>1x ULN to 2.5x ULN 3 (9%) 16 (21%) 49 (44%)
>2.5x ULN to 5x ULN — 5 (7%) 19 (17%)
>5x ULN to 20x ULN — 1 (1%) 13 (12%)
>20x ULN — — 1 (1%)
AST n (%)
Normal (<ULN) 35 (100%) 61 (81%) 44 (39%)
>1x ULN to 2.5x ULN — 12 (16%) 49 (44%)
>2.5x ULN to 5x ULN — 2 (3%) 13 (12%)
>5x ULN to 20x ULN — — 5 (5%)
>20x ULN — — 1 (1%)

†Data presented are the highest ALT and AST elevations (by CTC grade) reported during study treatment for each patient.

ALT=alanine aminotransferase; AST=aspartate aminotransferase; ULN=upper limit of normal.

Concomitant MTX treatment did not affect elevations of ALT or AST ≥2.5x or ≥3x ULN.

Lipids
Monitoring Guidance   12-Week Controlled Study Week 104*
Assessment of lipid parameters should be performed approximately 4 to 8 weeks following initiation of ACTEMRA therapy. Subsequently, manage patients according to clinical guidelines for the management of hyperlipidemia.   Placebo (n=37) ACTEMRA (n=75) ACTEMRA (N=112)
Total cholesterol >1.5x to 2x ULN 0% 1.5% 1%
LDL-C >1.5x to 2x ULN 0% 1.9% 1%

*Data from open-label extension over an average duration of 104 weeks of treatment.
LDL-C=low-density lipoprotein cholesterol.

  • In the open-label extension study over an average duration of 73 weeks of treatment, the pattern and incidence of elevations in lipid parameters remained consistent with the 12-week controlled study data

Important Safety Information

INDICATIONS

ACTEMRA is indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs).

ACTEMRA is indicated for the treatment of giant cell arteritis (GCA) in adult patients.

ACTEMRA is indicated for the treatment of active polyarticular juvenile idiopathic arthritis (PJIA) in patients 2 years of age and older.

ACTEMRA is indicated for the treatment of active systemic juvenile idiopathic arthritis (SJIA) in patients 2 years of age and older.

ACTEMRA is indicated for slowing the rate of decline in pulmonary function in adult patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD).

ACTEMRA is indicated for the treatment of coronavirus disease 2019 (COVID-19) in hospitalized adults who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).

RISK OF SERIOUS INFECTIONS:

Patients treated with ACTEMRA are at increased risk for developing serious infections that may lead to hospitalization or death, including tuberculosis (TB), bacterial, invasive fungal, viral, or other opportunistic infections. If a serious infection develops, interrupt ACTEMRA until the infection is controlled.

Reported infections include:

  • Active tuberculosis, which may present with pulmonary or extrapulmonary disease. Patients should be tested for latent tuberculosis before ACTEMRA use and during therapy (except patients with COVID-19). Treatment for latent infection should be initiated prior to ACTEMRA use.
  • Invasive fungal infections, including candidiasis, aspergillosis, and pneumocystis. Patients with invasive fungal infections may present with disseminated, rather than localized, disease.
  • Bacterial, viral and other infections due to opportunistic pathogens.

The risks and benefits of treatment with ACTEMRA should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection.

Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with ACTEMRA, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy.

CONTRAINDICATION

ACTEMRA is contraindicated in patients with known hypersensitivity to ACTEMRA.

WARNINGS AND PRECAUTIONS

Gastrointestinal Perforations

Events of gastrointestinal (GI) perforation have been reported in clinical trials, primarily as complications of diverticulitis in RA patients. Use ACTEMRA with caution in patients who may be at increased risk for GI perforation. Promptly evaluate patients presenting with fever, new onset abdominal symptoms, and a change in bowel habits for early identification of GI perforation.

Hepatotoxicity

Serious cases of hepatic injury have been observed in patients taking intravenous or subcutaneous ACTEMRA. Some of these cases have resulted in liver transplant or death. Time to onset for cases ranged from months to years after treatment initiation. Most cases presented with marked elevations of transaminases (> 5 times ULN), and some cases presented with signs or symptoms of liver dysfunction and only mildly elevated transaminases.

Treatment with ACTEMRA was associated with a higher incidence of transaminase elevations; increased frequency and magnitude of these elevations were observed when ACTEMRA was used in combination with potentially hepatotoxic drugs (e.g., methotrexate).

It is not recommended to initiate ACTEMRA treatment in RA, GCA, PJIA, SJIA and SSc-ILD patients with elevated transaminases ALT or AST greater than 1.5x ULN. In patients who develop elevated ALT or AST greater than 5x ULN discontinue ACTEMRA.

It is not recommended to initiate ACTEMRA treatment in COVID-19 patients with elevated ALT or AST above 10 x ULN. ALT and AST should be monitored according to current standard clinical practice for COVID-19 patients.

Measure liver tests promptly in patients who report symptoms that may indicate liver injury. If the patient is found to have abnormal liver tests, ACTEMRA treatment should be interrupted. ACTEMRA should only be restarted in patients with another explanation for the liver test abnormalities after normalization of the liver tests.

Laboratory Parameters

Laboratory monitoring is recommended due to potential consequences of treatment-related laboratory abnormalities in neutrophils, platelets, lipids, and liver function tests. Dosage modifications may be required.

Neutropenia: Treatment with ACTEMRA was associated with a higher incidence of neutropenia. It is not recommended to initiate ACTEMRA treatment in RA, GCA, PJIA, SJIA and SSc-ILD patients with a low neutrophil count i.e., absolute neutrophil count (ANC) less than 2000 per mm3. In patients who develop an ANC less than 500 per mm3 treatment is not recommended.

It is not recommended to initiate ACTEMRA treatment in COVID-19 patients with an ANC less than 1000 per mm3. Neutrophils should be monitored according to current standard clinical practice.

Thrombocytopenia: Treatment with ACTEMRA was associated with a reduction in platelet counts. It is not recommended to initiate ACTEMRA in RA, GCA, PJIA, SJIA and SSc-ILD patients with a platelet count below 100,000 per mm3. In patients who develop a platelet count less than 50,000 per mm3, treatment is not recommended.

In COVID-19 patients who develop a platelet count less than 50,000 per mm3 treatment is not recommended. Platelets should be monitored according to current standard clinical practices.

Elevated Liver Enzymes: It is not recommended to initiate ACTEMRA treatment in patients with elevated transaminases ALT or AST >1.5x ULN. In patients who develop elevated ALT or AST >5x ULN, treatment is not recommended.

Lipid Abnormalities: Treatment with ACTEMRA was associated with increases in lipid parameters such as total cholesterol, triglycerides, LDL cholesterols, and/or HDL cholesterol.

Immunosuppression

The impact of treatment with ACTEMRA on the development of malignancies is not known, but malignancies were observed in clinical studies with ACTEMRA. ACTEMRA is an immunosuppressant, and treatment with immunosuppressants may result in an increased risk of malignancies.

Hypersensitivity Reactions

Hypersensitivity reactions, including anaphylaxis, have been reported in association with ACTEMRA and anaphylactic events with a fatal outcome have been reported with intravenous infusion of ACTEMRA. In addition, serious cutaneous reactions, including Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), have been reported in patients with autoinflammatory conditions treated with ACTEMRA. ACTEMRA for intravenous use should only be infused by a healthcare professional with appropriate medical support to manage anaphylaxis. For ACTEMRA subcutaneous injection, advise patients to seek immediate medical attention if they experience any symptoms of a hypersensitivity reaction. If a hypersensitivity reaction occurs, immediately discontinue ACTEMRA, treat promptly and monitor until signs and symptoms resolve.

Anaphylaxis and other hypersensitivity reactions that required treatment discontinuation were reported in 0.1% (3 out of 2644) of patients in the 6-month controlled trials of intravenous ACTEMRA, 0.2% (8 out of 4009) of patients in the intravenous all-exposure RA population, 0.7% (8 out of 1068) in the subcutaneous 6-month controlled RA trials, and in 0.7% (10 out of 1465) of patients in the subcutaneous all-exposure population. In the SJIA controlled trial with intravenous ACTEMRA, 1 out of 112 patients (0.9%) experienced hypersensitivity reactions that required treatment discontinuation. In the PJIA controlled trial with intravenous ACTEMRA, 0 out of 188 patients (0%) in the ACTEMRA all-exposure population experienced hypersensitivity reactions that required treatment discontinuation.

Demyelinating Disorders

The impact of treatment with ACTEMRA on demyelinating disorders is not known, but multiple sclerosis and chronic inflammatory demyelinating polyneuropathy were reported rarely in clinical studies. Monitor patients for signs and symptoms of demyelinating disorders. Prescribers should exercise caution in considering the use of ACTEMRA in patients with preexisting or recent-onset demyelinating disorders.

Active Hepatic Disease and Hepatic Impairment

Treatment with ACTEMRA is not recommended in patients with active hepatic disease or hepatic impairment.

Vaccinations

Avoid use of live vaccines concurrently with ACTEMRA. No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving ACTEMRA or on the effectiveness of vaccination in patients receiving ACTEMRA. Patients should be brought up to date on all recommended vaccinations prior to initiation of ACTEMRA therapy, if possible.

ADVERSE REACTIONS

RHEUMATOID ARTHRITIS (RA)

The most common serious adverse reactions were serious infections. The most common serious infections included pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis. In the ACTEMRA-IV monotherapy clinical study, the rate of serious infections was 3.6 per 100 patient-years in the ACTEMRA group and 1.5 per 100 patient-years in the methotrexate group. The rate of serious infections in the 4 mg/kg and 8 mg/kg ACTEMRA plus DMARD groups was 4.4 and 5.3 events per 100 patient-years, respectively, compared to 3.9 events per 100 patient-years in the placebo plus DMARD group.

In the 5 Phase III clinical trials, the most common adverse reactions (≥5% of patients treated with ACTEMRA-IV) through 6 months were:

  ACTEMRA-IV
8 mg/kg
Monotherapy (%)		 Methotrexate (%) ACTEMRA-IV
4 mg/kg
+ DMARDs (%)		 ACTEMRA-IV
8 mg/kg
+ DMARDs (%)		 Placebo
+ DMARDs (%)
URTI 7 5 6 8 6
Nasopharyngitis 7 6 4 6 4
Headache 7 2 6 5 3
Hypertension 6 2 4 4 3
Increased ALT 6 4 3 3 1

The safety observed for ACTEMRA administered subcutaneously was consistent with the known safety profile of intravenous ACTEMRA, with the exception of injection-site reactions, which were more common with ACTEMRA-SC compared with placebo-SC injections (IV-arm).

In the 6-month control period, in SC-I, the frequency of injection-site reactions was 10.1% (64/631) and 2.4% (15/631) for the weekly ACTEMRA-SC and placebo-SC (IV-arm) group, respectively. In SC-II, the frequency of injection-site reactions was 7.1% (31/437) and 4.1% (9/218) for the every other week ACTEMRA-SC and placebo-SC groups, respectively. These injection-site reactions were mild to moderate in severity. The majority resolved without any treatment and none necessitated drug discontinuation.

GIANT CELL ARTERITIS (GCA)

The overall safety profile observed in the ACTEMRA treatment groups was generally consistent with the known safety profile of ACTEMRA. There was an overall higher incidence of infections in GCA patients relative to RA patients.

Infections

The rate of infections was 200.2 per 100 patient-years in the ACTEMRA SC weekly group and 160.2 per 100 patient-years in the ACTEMRA SC every other week group, as compared to 156.0 per 100 patient-years in the placebo + 26 week prednisone taper and 210.2 per 100 patient-years in the placebo + 52 week taper groups.

The rate of serious infections was 9.7 per 100 patient-years in the ACTEMRA SC weekly group and 4.4 per 100 patient-years in the ACTEMRA SC every other week group, as compared to 4.2 per 100 patient-years in the placebo + 26 week prednisone taper and 12.5 per 100 patient-years in the placebo + 52 week prednisone taper groups.

POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS (PJIA)

The most common adverse events seen in ACTEMRA-IV all-exposure population included: upper respiratory tract infections, headache, nasopharyngitis, and diarrhea.

Infections

The rate of infections in the ACTEMRA-IV all-exposure population was 163.7 per 100 patient-years. The most common events observed were nasopharyngitis and upper respiratory tract infections. The rate of serious infections was numerically higher in patients weighing less than 30 kg treated with 10 mg/kg ACTEMRA-IV (12.2 per 100 patient-years) compared to patients weighing at or above 30 kg, treated with 8 mg/kg ACTEMRA-IV (4.0 per 100 patient-years). The incidence of infections leading to dose interruptions was also numerically higher in patients weighing less than 30 kg treated with 10 mg/kg ACTEMRA-IV (21%) compared to patients weighing at or above 30 kg, treated with 8 mg/kg ACTEMRA-IV (8%).

Infusion Reactions

In PJIA patients, infusion-related reactions are defined as all events occurring during or within 24 hours of an infusion. In the ACTEMRA-IV all-exposure population, 11 patients (6%) experienced an event during the infusion, and 38 patients (20.2%) experienced an event within 24 hours of an infusion. The most common events occurring during infusion were headache, nausea and hypotension, and occurring within 24 hours of infusion were dizziness and hypotension.

In general, the safety observed for ACTEMRA administered subcutaneously was consistent with the known safety profile of intravenous ACTEMRA, with the exception of injection site reactions (ISRs), and neutropenia.

During the 1-year study, a frequency of 28.8% (15/52) ISRs was observed in ACTEMRA-SC treated PJIA patients. These ISRs occurred in a greater proportion of patients at or above 30 kg (44.0%) compared with patients below 30 kg (14.8%). All ISRs were mild in severity and none of the ISRs required patient withdrawal from treatment or dose interruption.

During routine laboratory monitoring in the ACTEMRA-SC all exposure population, a decrease in neutrophil counts below 1 × 109 per L occurred in 15.4% of patients, and was more frequently observed in the patients less than 30 kg (25.9%) compared to patients at or above 30 kg (4.0%). There was no clear relationship between decreases in neutrophils below 1 x 109 per L and the occurrence of serious infections.

SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (SJIA)

The most common adverse events (at least 5%) seen in ACTEMRA-IV treated patients in the 12-week controlled portion of the study were: upper respiratory tract infections, headache, nasopharyngitis, and diarrhea.

Infections

In the 12-week controlled phase, the rate of all infections in the ACTEMRA-IV group was 345 per 100 patient-years and 287 per 100 patient-years in the placebo group. In the open-label extension over an average duration of 73 weeks of treatment, the overall rate of infections was 304 per 100 patient-years.

In the 12-week controlled phase, the rate of serious infections in the ACTEMRA-IV group was 11.5 per 100 patient-years. In the open-label extension over an average duration of 73 weeks of treatment, the overall rate of serious infections was 11.4 per 100 patient-years. The most commonly reported serious infections included pneumonia, gastroenteritis, varicella, and otitis media.

Macrophage Activation Syndrome

In the 12-week controlled study, no patient in any treatment group experienced macrophage activation syndrome (MAS) while on assigned treatment; 3 per 112 (3%) developed MAS during open-label treatment with ACTEMRA-IV. One patient in the placebo group escaped to ACTEMRA-IV 12 mg per kg at Week 2 due to severe disease activity, and ultimately developed MAS at Day 70. Two additional patients developed MAS during the long-term extension. All 3 patients had ACTEMRA-IV dose interrupted (2 patients) or discontinued (1 patient) for the MAS event, received treatment, and the MAS resolved without sequelae. Based on a limited number of cases, the incidence of MAS does not appear to be elevated in the ACTEMRA-IV SJIA clinical development experience; however, no definitive conclusions can be made.

Infusion Reactions

In the 12-week controlled phase, 4% of ACTEMRA-IV and 0% of placebo-treated patients experienced events occurring during infusion.

Within 24 hours after infusion, 16% of patients in the ACTEMRA-IV treatment group and 5% of patients in the placebo group experienced an event. In the ACTEMRA-IV group the events included rash, urticaria, diarrhea, epigastric discomfort, arthralgia, and headache. One of these events, urticaria, was considered serious.

Anaphylaxis

Anaphylaxis was reported in 1 out of 112 patients (less than 1%) treated with ACTEMRA-IV during the controlled and open-label extension study.

In general, the safety observed for ACTEMRA administered subcutaneously was consistent with the known safety profile of intravenous ACTEMRA, with the exception of Injection Site Reactions (ISRs).

A total of 41.2% (21/51) SJIA patients experienced ISRs to ACTEMRA-SC. The most common ISRs were erythema, pruritus, pain, and swelling at the injection site. The majority of ISRs reported were Grade 1 events and all ISRs reported were non-serious and none required patient withdrawal from treatment or dose interruption.

CORONAVIRUS DISEASE 2019 (COVID-19)

The safety of ACTEMRA in hospitalized COVID-19 patients was evaluated in a pooled safety population that includes patients enrolled in EMPACTA, COVACTA, and REMDACTA. The analysis of adverse reactions included a total of 974 patients exposed to ACTEMRA:

Adverse Reaction ACTEMRA
8 mg per kg
N = 974
(%)		 Placebo
N = 483
(%)
Hepatic Transaminases increased 10% 8%
Constipation 9% 8%
Urinary tract infection 5% 4%
Hypertension 4% 1%
Hypokalaemia 4% 3%
Anxiety 4% 2%
Diarrhoea 4% 2%
Insomnia 4% 3%
Nausea 3% 2%

In the pooled safety population, the rates of infection/serious infection events were 40%/19% in patients receiving ACTEMRA versus 32%/23% receiving placebo.

Laboratory Abnormalities

In the pooled safety population of EMPACTA, COVACTA, and REMDACTA, neutrophil counts <1000 cells/mcl occurred in 3.4% of patients who received ACTEMRA and 0.5% of patients who received placebo. Platelet counts <50,000 cells/mcl occurred in 3.2% of patients who received ACTEMRA and 1.5% of patients who received placebo. ALT or AST at or above 5x ULN occurred in 11.7% of patients who received ACTEMRA and 9.9% of patients who received placebo.

DRUG INTERACTIONS

In GCA patients, no effect of concomitant corticosteroid on ACTEMRA exposure was observed.

Cytochrome P450s in the liver are down-regulated by infection and inflammation stimuli including cytokines such as IL-6. Inhibition of IL-6 signaling in RA patients treated with ACTEMRA may restore CYP450 activities to higher levels than those in the absence of ACTEMRA leading to increased metabolism of drugs that are CYP450 substrates.

Exercise caution when coadministering ACTEMRA with CYP3A4 substrate drugs where decrease in effectiveness is undesirable, e.g., oral contraceptives, lovastatin, atorvastatin, etc.

USE IN PREGNANCY

The available data with ACTEMRA in pregnant women are insufficient to draw conclusions about drug-associated risk of major birth defects, miscarriage or other adverse maternal or fetal outcomes.

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.

Please see additional Important Safety Information in full Prescribing Information, including BOXED WARNING.

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      De Benedetti F, Brunner H, Ruperto N, et al. Efficacy and safety of tocilizumab in patients with systemic juvenile idiopathic arthritis: 2-year data from TENDER, a Phase 3 clinical trial. Presented at the European League Against Rheumatism 2012 in Berlin, Germany; June 6-9, 2012. EULAR Poster #FRI0328. 

    • Data on file. Genentech, Inc.

      Data on file. Genentech, Inc.

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      ACTEMRA [package insert]. South San Francisco, CA: Genentech, Inc.

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      Brunner H, et al. Identification of optimal subcutaneous doses of tocilizumab in children with systemic juvenile idiopathic arthritis. Presented at the 2018 CARRA Annual Scientific Meeting in Denver, Colorado; April 12-15, 2018. Poster 007.