Lemtrada

Alemtuzumab.

Each vial contains 12 mg alemtuzumab in 1.2 ml (10 mg/ml).
Alemtuzumab is a monoclonal antibody produced in mammalian cell (Chinese Hamster Ovary) suspension culture in a nutrient medium by recombinant DNA technology.
Excipients/Inactive Ingredients: Disodium phosphate dihydrate (E339), disodium edetate dihydrate, potassium chloride (E508), potassium dihydrogen phosphate (E340), polysorbate 80 (E433), sodium chloride, water for injections.

Pharmacotherapeutic Group: Selective immunosuppressants. ATC Code: L04AA34.
Pharmacology: Pharmacodynamics: Mechanism of Action: Alemtuzumab, is a recombinant DNA-derived humanised monoclonal antibody directed against the 21-28 kD cell surface glycoprotein CD52. Alemtuzumab is an IgG1 kappa antibody with human variable framework and constant regions, and complementary-determining regions from a murine (rat) monoclonal antibody. The antibody has an approximate molecular weight of 150 kD.
Alemtuzumab binds to CD52, a cell surface antigen present at high levels on T (CD3+) and B (CD19+) lymphocytes, and at lower levels on natural killer cells, monocytes, and macrophages. There is little or no CD52 detected on neutrophils, plasma cells, or bone marrow stem cells. Alemtuzumab acts through antibody-dependent cellular cytolysis and complement-mediated lysis following cell surface binding to T and B lymphocytes.
The mechanism by which LEMTRADA exerts its therapeutic effects in MS is not fully elucidated. However, research suggests immunomodulatory effects through the depletion and repopulation of lymphocytes, including: Alterations in the number, proportions, and properties of some lymphocyte subsets post-treatment;
Increased representation of regulatory T cell subsets;
Increased representation of memory T- and B-lymphocytes;
Transient effects on components of innate immunity (i.e., neutrophils, macrophages, NK cells).
The reduction in the level of circulating B and T cells by LEMTRADA and subsequent repopulation, may reduce the potential for relapse, which ultimately delays disease progression.
Pharmacodynamic Effects: LEMTRADA depletes circulating T and B lymphocytes after each treatment course with the lowest observed values occurring 1 month after a course of treatment (the earliest post-treatment time point in phase 3 studies). Lymphocytes repopulate over time with B-cell recovery usually completed within 6 months. CD3+ and CD4+ lymphocyte counts rise more slowly towards normal, but generally do not return to baseline by 12-months post-treatment. Approximately 40% of patients had total lymphocyte counts reaching the lower limit of normal (LLN) by 6 months after each treatment course, and approximately 80% of patients had total lymphocyte counts reaching the LLN by 12 months after each course.
Neutrophils, monocytes, eosinophils, basophils, and natural killer cells are only transiently affected by LEMTRADA.
Clinical Efficacy and Safety: The safety and efficacy of LEMTRADA were evaluated in 3 randomised, rater-blinded, active-comparator clinical trials and one uncontrolled, rater-blinded extension study in patients with RRMS.
For studies 1 and 2, Study design/demographics and results are shown in Tables 1 and 2 respectively. (See Tables 1 and 2.)

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See Figure.

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Relapse severity: In alignment with the effect on relapse rate, supportive analyses from Study 1 (CAMMS323) showed that LEMTRADA 12 mg/day led to significantly fewer LEMTRADA treated patients experiencing severe relapses (61% reduction, p=0.0056) and signficantly fewer relapses that led to steroid treatment (58% reduction, p<0.0001) compared to IFNB-1a.
Supportive analyses from Study 2 (CAMMS32400507) showed that LEMTRADA 12 mg/day led to significantly fewer LEMTRADA-treated patients experiencing severe relapses (48% reduction, p=0.0121), and significantly fewer relapses that led to steroid treatment (56% reduction, p<0.0001) or to hospitalization (55 % reduction, p=0.0045) compared to IFNB-1a.
Sustained reduction of disability (SRD): Time to onset of SRD was defined as a decrease of at least one point on the EDSS from a baseline EDSS score ≥ 2 that was sustained for at least 6 months. SRD is a measure for sustained disability improvement. 29% of patients treated with LEMTRADA reached SRD in study 2, while only 13% of subcutaneous IFNB- 1a treated patients reached this endpoint. The difference was statistically significant (p=0.0002).
Study 3 (phase 2 study CAMMS223) evaluated the safety and efficacy of LEMTRADA in patients with RRMS over the course of 5 years. Patients had an EDSS from 0-3.0, at least 2 clinical episodes of MS in the prior 2 years, and ≥1 gadolinium-enhancing lesion at study entry. Patients had not received prior therapy for MS. Patients were treated with LEMTRADA 12 mg/day (N=108) or 24 mg/day (N=108) administered once per day for 5 days at Month 0 and for 3 days at Month 12 or subcutaneous IFNB-1a 44 μg (N=107) administered 3 times per week for 3 years. Forty-six patients received a third course of LEMTRADA treatment at 12 mg/day or 24/mg day for 3 days at Month 24.
At 3 years, LEMTRADA reduced the risk of 6-month CDW by 76% (hazard ratio 0.24 [95% CI: 0.110, 0.545], p<0.0006) and reduced the ARR by 67% (rate ratio 0.33 [95% CI: 0.196, 0.552], p<0.0001) as compared to subcutaneous IFNB-1a. Alemtuzumab 12 mg/day led to significantly lower EDSS scores (improved compared to baseline) through 2 years of follow up, compared with IFNB-1a (p<0.0001).
Long-term efficacy data: Study 4, provides efficacy data for up to 6 years from entry into Studies 1 and 2. Of patients treated with LEMTRADA 12 mg in Studies 1 and 2, 91.8% entered Study 4.
Table 3 presents the key clinical and MRI outcomes in Study 4 for LEMTRADA 12 mg patients from Studies 1 and 2. (See Table 3.)

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The ARR of patients originally treated with LEMTRADA remained low throughout Study (Table 3), with a high percentage of patients relapse-free in each year of follow-up. Most patients never experienced confirmed disability worsening. Mean disability scores were stable or improved in most years. Through 6 years from first LEMTRADA treatment, 42.5% and 32.7% of patients from Studies 1 and 2, respectively, reached CDI. Patients also continued to show a low risk of forming new T2 lesions or gadolinium enhancing lesions in each year of follow-up. The T2 lesion volume remained lower throughout the follow-up period than prior to initial LEMTRADA treatment (median percent change at Year 6, -0.1 and -8.5 for Study 1 and 2 populations, respectively), with only small changes from year to year. The median annual percent change (reduction) in brain parenchymal fraction was lower during the extension period than in the prior studies. Approximately half (51.2%) of patients initially treated with LEMTRADA 12 mg/day in Study 1 or 2 who enrolled in Study 4 had received only the initial 2 courses of LEMTRADA and no other disease modifying treatment throughout 6 years of follow-up.
These results demonstrate durable efficacy of LEMTRADA on reducing the risk of MS relapse, suppressing the formation of new MS lesions, slowing brain volume loss (atrophy) and disability worsening in the absence of continuous treatment.
Additional as-needed treatment: In study 4, 40% of the patients initially treated with LEMTRADA 12 mg/day in Study 1 or 2 received additional courses upon documented evidence of MS disease activity (relapse and/or MRI) and the treating physician's decision to retreat. Additional course(s) of LEMTRADA were administered at 12 mg/day for 3 consecutive days (36 mg total dose) at least 12 months after the prior treatment course. Efficacy results in these patients, by treatment course, are presented in Table 4. (See Table 4.)

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Relapse rate, MRI activity and mean EDSS score all improved in the year both following a third or fourth LEMTRADA treatment course when compared with outcomes in the preceding year (Table 4).
These data demonstrate that patients with MS disease activity following a prior LEMTRADA treatment course can achieve clinical improvement on clinical and MRI measures (reduced ARR, decreased lesions and stabilization of disability) after additional LEMTRADA treatment courses.
The benefits and risks of 5 or more treatment courses have not been fully established, but results suggest that the safety profile does change with additional courses. If additional treatment courses are to be given they must be administered at least 12 months after the prior course.
Pharmacokinetics: The pharmacokinetics of LEMTRADA were evaluated in a total of 216 patients with RRMS who received intravenous infusions of either 12 mg/day or 24 mg/day for 5 consecutive days, followed by 3 consecutive days 12 months following the initial treatment course. Serum concentrations increased with each consecutive dose within a treatment course, with the highest observed concentrations occurring following the last infusion of a treatment course. Administration of 12 mg/day resulted in a mean C_max of 3014 ng/ml on Day 5 of the initial treatment course, and 2276 ng/ml on Day 3 of the second treatment course. The alpha half-life approximated 4-5 days and was comparable between courses leading to low or undetectable serum concentrations within approximately 30 days following each treatment course.
Alemtuzumab is a protein for which the expected metabolic pathway is degradation to small peptides and individual amino acids by widely distributed proteolytic enzymes. Classical biotransformation studies have not been conducted.
Conclusions cannot be made with available data on the effect of race and gender on the pharmacokinetics of LEMTRADA. The pharmacokinetics of LEMTRADA has not been studied in patients aged 55 years and older.
Toxicology: Preclinical Safety Data: Carcinogenesis and mutagenesis: There have been no studies to assess the carcinogenic or mutagenic potential of alemtuzumab.
Fertility and reproduction: Treatment with intravenous alemtuzumab at doses up to 10 mg/kg/day, administered for 5 consecutive days (AUC of 11.8 times the human exposure at the recommended daily dose) had no effect on fertility and reproductive performance in male huCD52 transgenic mice. The number of normal sperm was significantly reduced (<10%) relative to controls and the percent abnormal sperm (detached heads or no heads) were significantly increased (up to 3%). However, these changes did not affect fertility and were therefore considered to be non-adverse.
In female mice dosed with intravenous alemtuzumab up to 10 mg/kg/day (AUC of 7.9 times the human exposure at the recommended daily dose) for 5 consecutive days prior to cohabitation with wild-type male mice, the average number of corpora lutea and implantation sites per mouse were significantly reduced as compared to vehicle treated animals. Reduced gestational weight gain relative to the vehicle controls was observed in pregnant mice dosed with 10 mg/kg/day.
A reproductive toxicity study in pregnant mice exposed to intravenous doses of alemtuzumab up to 10 mg/kg/day (AUC 4.1 times the human exposure at the recommended dose of 12 mg/day) for 5 consecutive days during gestation resulted in significant increases in the number of dams with all conceptuses dead or resorbed, along with a concomitant reduction in the number of dams with viable foetuses. There were no external, soft tissue, or skeletal malformations or variations observed at doses up to 10 mg/kg/day.
Placental transfer and potential pharmacologic activity of alemtuzumab were observed during gestation and following delivery in mice. In studies in mice, alterations in lymphocyte counts were observed in pups exposed to alemtuzumab during gestation at doses of 3 mg/kg/day for 5 consecutive days (AUC 1.0 times the human exposure at the recommended dose of 12 mg/day). Cognitive, physical, and sexual development of pups exposed to alemtuzumab during lactation were not affected at doses up to 10 mg/kg/day alemtuzumab.

LEMTRADA is indicated for adult patients with relapsing remitting multiple sclerosis (RRMS) with active disease defined by clinical or imaging features (see Precautions and Pharmacology under Actions).

LEMTRADA treatment should be initiated and supervised by a neurologist experienced in the treatment of patients with MS. Specialists and equipment required for the timely diagnosis and management of the most frequent adverse reactions, especially autoimmune conditions and infections, should be available.
Resources for the management of hypersensitivity and/or anaphylactic reactions should be available.
Patients treated with LEMTRADA must be given the Patient Alert Card and Patient Guide and be informed about the risks of LEMTRADA.
Posology: The recommended dose of LEMTRADA is 12 mg/day administered by intravenous infusion for 2 treatment courses: Initial treatment course: 12 mg/day on 5 consecutive days (60 mg total dose).
Second treatment course: 12 mg/day on 3 consecutive days (36 mg total dose) administered 12 months after the Initial treatment course.
Missed doses should not be given on the same day as scheduled dose.
Useful laboratory tests for monitoring patients: Laboratory tests should be conducted at periodic intervals for 48 months following the last treatment course of LEMTRADA in order to monitor the early signs of autoimmune disease: Complete blood count with differential (prior to treatment initiation and at monthly intervals thereafter).
Serum creatinine levels (prior to treatment initiation and at monthly intervals thereafter).
Urinalysis with microscopy (prior to treatment initiation and monthly intervals thereafter).
A test of thyroid function, such as thyroid stimulating hormone level (prior to treatment initiation and every 3 months thereafter);
After this period of time, any clinical findings suggestive of nephropathies or thyroid dysfunction will require further testing.
Follow-up patients: The therapy is recommended as 2 treatment courses (see previous text) with safety follow-up of patients from initiation of treatment and until 48 months after the last infusion (see Precautions).
Pre-treatment: Patients should be pre-treated with corticosteroids immediately prior to LEMTRADA administration on each of the first 3 days of any treatment course. In clinical trials, patients were pre-treated with 1,000 mg methylprednisolone for the first 3 days of each LEMTRADA treatment course.
Additionally, pretreatment with antihistamines and/or antipyretics prior to LEMTRADA administration may also be considered.
Oral prophylaxis for herpes infection should be administered to all patients starting on the first day of each treatment course and continuing for a minimum of 1 month following treatment with LEMTRADA (see Precautions). In clinical trials, patients were administered acyclovir 200 mg twice a day or equivalent.
Elderly: Clinical studies did not include any patients aged over 55 years old. It has not been determined whether they respond differently than younger patients.
Renal or hepatic impairment: LEMTRADA has not been studied in patients with renal or hepatic impairment.
Paediatric population: The safety and efficacy of LEMTRADA in children with MS aged 0 to 18 years have not yet been established. There is no relevant use of alemtuzumab in children aged from birth to less than 10 years for the treatment of multiple sclerosis. No data are available.
Method of administration: LEMTRADA must be diluted before infusion. The diluted solution should be administered by intravenous infusion over a period of approximately 4 hours.
For instructions on dilution of the medicinal product before administration, see Special precautions for disposal and other handling under Cautions for Usage.

In controlled clinical trials two MS patients accidentally received up to 60 mg LEMTRADA (i.e., total dose for initial treatment course) in a single infusion and experienced serious reactions (headache, rash, and either hypotension or sinus tachycardia). Doses of LEMTRADA greater than those tested in clinical studies may increase the intensity and/or duration of infusion-associated adverse reactions or its immune effects. There is no known antidote for alemtuzumab over dosage. Treatment consists of discontinuation of the medicinal product and supportive therapy.

Hypersensitivity to the active substance, or to any of the excipients listed in Description.
Human Immunodeficiency Virus (HIV) infection.

LEMTRADA is not recommended for patients with inactive disease or those stable on current therapy.
Patients treated with LEMTRADA must be given the Package Leaflet, the Patient Alert Card and the Patient Guide. Before treatment, patients must be informed about the risks and benefits, and the need to commit to follow up from treatment initiation until 48-months after the last infusion of the second LEMTRADA treatment course. If an additional course is administered, continue safety follow-up until 48 months after the last infusion.
Autoimmunity: Treatment may result in the formation of autoantibodies and increase the risk of autoimmune mediated conditions including immune thrombocytopenic purpura (ITP), thyroid disorders or, rarely, nephropathies (e.g. anti-glomerular basement membrane disease). Caution should be exercised in patients with previous autoimmune conditions other than MS, although available data suggests there is no worsening of pre-existing autoimmune conditions after alemtuzumab treatment.
Immune Thrombocytopenic Purpura (ITP): Serious events of ITP have been observed in 12 (1%) of patients treated in controlled clinical trials in MS (corresponding to an annualized rate 0.0047 events/patient/year). In a controlled clinical trial in patients with MS, one patient developed ITP that went unrecognized prior to implementation of monthly blood monitoring requirements and died from intracerebral haemorrhage. An additional 12 serious events of ITP have been observed through a median of 6.1 years (maximum 12 years) of follow-up (cumulative annualized rate 0.0028 events/patient/year).
ITP onset has generally occurred between 14 and 36 months after first exposure. Symptoms of ITP could include (but are not limited to) easy bruising, petechiae, spontaneous mucocutaneous bleeding (e.g., epistaxis, haemoptysis), heavier than normal or irregular menstrual bleeding. Haemoptysis may also be indicative of anti-GBM disease (see below), and an appropriate differential diagnosis has to be undertaken. Remind the patient to remain vigilant for symptoms they may experience and to seek immediate medical help if they have any concerns.
Complete blood counts with differential should be obtained prior to initiation of treatment and at monthly intervals thereafter until 48 months after the last infusion. After this period of time, testing should be performed based on clinical findings suggestive of ITP. If ITP is suspected a complete blood count should be obtained immediately.
If ITP onset is confirmed, appropriate medical intervention should be promptly initiated, including immediate referral to a specialist. Data from clinical trials in MS has shown that adherence to the blood monitoring requirements and education relative to signs and symptoms of ITP has led to early detection and treatment of ITP with most cases responding to first-line medical therapy.
The potential risk associated with retreatment with LEMTRADA following the occurrence of ITP is unknown.
Nephropathies: Nephropathies, including anti-glomerular basement membrane (anti-GBM) disease, have been observed in 6 (0.4%) patients in clinical trials in MS through a median of 6.1 years (maximum 12 years) of follow-up and generally occurred within 39 months following the last administration of LEMTRADA. In clinical trials, there were 2 cases of anti-GBM disease. Both cases were serious, were identified early through clinical and laboratory monitoring, and had a positive outcome after treatment.
Clinical manifestations of nephropathy may include elevation in serum creatinine, haematuria, and/or proteinuria. While not observed in clinical trials, alveolar haemorrhage manifested as haemoptysis may occur with anti-GBM disease. Haemoptysis may also be indicative of ITP (see above), and an appropriate differential diagnosis has to be undertaken. The patient should be reminded to remain vigilant for symptoms they may experience and to seek immediate medical help if they have any concerns. Anti-GBM disease may lead to renal failure requiring dialysis and/or transplantation if not treated rapidly and can be life-threatening if left untreated.
Serum creatinine levels should be obtained prior to initiation of treatment and at monthly intervals thereafter until 48 months after the last infusion. Urinalysis with microscopy should be obtained prior to initiation and at monthly intervals thereafter until 48 months after the last infusion. The observation of clinically significant changes from baseline in serum creatinine, unexplained haematuria, and/or proteinuria, should prompt further evaluation for nephropathies including immediate referral to a specialist. Early detection and treatment of nephropathies may decrease the risk of poor outcomes. After this period of time, testing should be performed based on clinical findings suggestive of nephropathies.
The potential risk associated with retreatment with LEMTRADA following the occurrence of nephropathies is unknown.
Thyroid disorders: Endocrine disorders including autoimmune thyroid disorders have been observed in 36.8% of patients treated with LEMTRADA 12 mg in clinical trials in MS through with a median of 6.1 years (maximum 12 years) of follow- up from the first LEMTRADA exposure. The incidence of thyroid events was higher in patients with a medical history of thyroid disorders both in the LEMTRADA and interferon beta 1a (IFNB-1a) treatment groups. In patients with ongoing thyroid disorder LEMTRADA should be administered if the potential benefit justifies the potential risks.
Observed autoimmune thyroid disorders included hyperthyroidism or hypothyroidism. Most events were mild to moderate in severity. Prior to authorisation, serious endocrine events occurred in 4.4% of patients, with only Basedow's disease (also known as Graves' disease), hyperthyroidism, hypothyroidism, autoimmune thyroiditis, and goitre occurring in more than 1 patient. Most thyroid events were managed with conventional medical therapy however some patients required surgical intervention. In clinical trials, patients who developed thyroid events were permitted to receive re-treatment with LEMTRADA. Approximately 5 % of patients from the total study population developed a thyroid adverse event during the year following the initial treatment course of alemtuzumab and were re-treated. The majority of those patients did not experience a worsening in severity of thyroid disorders. Further treatment with LEMTRADA should be considered on an individual basis taking into account the clinical condition of the respective patient.
Thyroid function tests, such as thyroid stimulating hormone levels, should be obtained prior to initiation of treatment and every 3 months thereafter until 48 months following the last infusion. After this period of time testing should be performed based on clinical findings suggestive of thyroid dysfunction.
Thyroid disease poses special risks in women who are pregnant (see Use in Pregnancy & Lactation).
In clinical trials, a patient's anti-thyroid peroxidase (anti-TPO) antibody status prior to treatment was not indicative for the development of a thyroid related adverse event. Half the patients who tested positive at baseline, and a quarter of patients who tested negative at baseline for anti-TPO antibodies developed a thyroid event. The vast majority (approximately 80%) of patients who presented with a thyroid event after treatment were anti-TPO antibody negative at baseline. Therefore, regardless of pretreatment anti-TPO antibody status patients may develop a thyroid adverse reaction and must have all tests periodically performed as described above.
Cytopenias: Suspected autoimmune cytopenias such as neutropenia, haemolytic anaemia and pancytopenia have been infrequently reported in clinical trials in MS. Complete blood count results (see above under ITP) should be used to monitor for cytopenias. If a cytopenia is confirmed, appropriate medical intervention should be promptly initiated, including referral to a specialist.
Infusion-associated Reactions (IARs): In controlled clinical trials, infusion associated reactions (IARs) were defined as any adverse event occurring during or within 24 hours of LEMTRADA infusion. The majority of these may be due to cytokine release during infusion. Most patients treated with LEMTRADA in clinical trials in MS experienced mild to moderate IARs during and/or up to 24 hours after LEMTRADA 12 mg administration. The incidence of IARs was higher in course 1 than in subsequent courses. Through all available follow-up, including patients who received additional treatment courses, the most common IARs included headache, rash, pyrexia, nausea, urticaria, pruritus, insomnia, chills, flushing, fatigue, dyspnoea, dysgeusia, chest discomfort, generalised rash, tachycardia, bradycardia, dyspepsia, dizziness, and pain. Serious reactions occurred in 3% of patients and included cases of headache, pyrexia, urticaria, tachycardia, atrial fibrillation, nausea, chest discomfort, and hypotension. Clinical manifestations of anaphylaxis may appear similar to clinical manifestations of infusion associated reactions, but would tend to be more severe or potentially life-threatening. Reactions attributed to anaphylaxis have been reported rarely in contrast to infusion associated reactions. It is recommended that patients be premedicated to ameliorate the effects of infusion reactions (see Dosage & Administration). Most patients in controlled clinical trials received antihistamines and/or antipyretics before at least one LEMTRADA infusion. IARs may occur in patients despite pretreatment. Observation for infusion reactions is recommended during and for 2 hours after LEMTRADA infusion. If an IAR occurs, provide the appropriate symptomatic treatment, as needed. If the infusion is not well tolerated, the infusion duration may be extended. If severe infusion reactions occur, immediate discontinuation of the intravenous infusion should be considered. Within the clinical trials, anaphylaxis or serious reactions that necessitated treatment discontinuation were very rare.
Physicians should be aware of the patient's cardiac history as infusion-associated reactions can include cardiac symptoms such as tachycardia.
Resources for the management of anaphylaxis or serious reactions should be available.
Infections: Infections occurred in 71% of patients treated with LEMTRADA 12 mg as compared to 53% of patients treated with subcutaneous interferon beta-1a [IFNB 1a](44mcg 3-times weekly) in controlled clinical trials in MS up to 2 years in duration and were predominantly mild to moderate in severity. Infections that occurred more often in LEMTRADA-treated patients than IFNB 1a patients included nasopharyngitis, urinary tract infection, upper respiratory tract infection, sinusitis, oral herpes, influenza, and bronchitis. Serious infections occurred in 2.7% of patients treated with LEMTRADA as compared to 1% of patients treated with IFNB-1a in controlled clinical trials in MS. Serious infections in the LEMTRADA group included: appendicitis, gastroenteritis, pneumonia, herpes zoster, and tooth infection. Infections were generally of typical duration and resolved following conventional medical treatment.
The cumulative annualized rate of infections was 0.99 through a median of 6.1 years (maximum 12 years) of follow-up from the first LEMTRADA exposure, as compared to 1.27 in controlled clinical trials.
Serious varicella zoster virus infections, including primary varicella and varicella zoster re-activation, have occurred more often in patients treated with LEMTRADA 12 mg (0.4%) in clinical trials as compared to IFNB-1a (0%). Cervical human papilloma virus (HPV) infection, including cervical dysplasia, has also been reported in patients treated with LEMTRADA 12 mg (2%). It is recommended that HPV screening be completed annually for female patients.
Tuberculosis has been reported for patients treated with LEMTRADA and IFNB-1a in controlled clinical trials. Active and latent tuberculosis have been reported in 0.3% of the patients treated with LEMTRADA, most often in endemic regions. Before initiation of therapy, all patients must be evaluated for both active or inactive ("latent") tuberculosis infection, according to local guidelines.
Superficial fungal infections, especially oral and vaginal candidiasis, occurred more commonly in LEMTRADA-treated patients (12%) than in patients treated with IFNB-1a (3%) in controlled clinical trials in MS.
Listeria meningitis has been reported in LEMTRADA-treated patients. The duration of increased risk for listeria meningitis is unclear, although cases of listeria meningitis generally occurred within 1 month of alemtuzumab dosing. Unless treated, listeria infection can lead to significant morbidity or mortality. Patients should avoid or adequately heat foods that are potential sources of Listeria monocytogenes.
Physicians should consider delaying initiation of LEMTRADA administration in patients with active infection until the infection is fully controlled.
Prophylaxis with an oral anti-herpes agent should be initiated starting on the first day of LEMTRADA treatment and continuing for a minimum of 1 month following each course of treatment. In clinical trials patients were administered aciclovir 200 mg twice a day or equivalent.
LEMTRADA has not been administered for treatment of MS concomitantly with or following antineoplastic or immunosuppressive therapies. As with other immunomodulating therapies, potential combined effects on the patient's immune system should be taken into account when considering administration of LEMTRADA. Concomitant use of LEMTRADA with any of these therapies could increase the risk of immunosuppression.
No data are available on the association of LEMTRADA with Hepatitis B virus (HBV) or Hepatitis C virus (HCV) reactivation as patients with evidence of active or chronic infections were excluded from clinical trials. Screening patients at high risk of HBV and/or HCV infection before initiation of LEMTRADA should be considered and caution should be exercised in prescribing LEMTRADA to patients identified as carriers of HBV and/or HCV as these patients may be at risk of irreversible liver damage relative to a potential virus reactivation as a consequence of their pre-existing status.
Malignancy: As with other immunomodulatory therapies, caution should be exercised in initiating LEMTRADA therapy in patients with pre-existing and/or an on-going malignancy. It is not currently known if alemtuzumab confers a higher risk for developing thyroid malignancies, since thyroid autoimmunity may itself be a risk factor for thyroid malignancies.
Pneumonitis: Pneumonitis has been reported in LEMTRADA treated patients. Most cases occurred within the first month after treatment with LEMTRADA. Patients should be advised to report symptoms of pneumonitis, which may include shortness of breath, cough, wheezing, chest pain or tightness and hemoptysis.
Contraception: Placental transfer and potential pharmacologic activity of LEMTRADA were observed in mice during gestation and following delivery. Women of childbearing potential should use effective contraceptive measures during treatment and for 4 months following a course of LEMTRADA treatment (see Use in Pregnancy & Lactation).
Vaccines: It is recommended that patients have completed local immunisation requirements at least 6 weeks prior to treatment with LEMTRADA. The ability to generate an immune response to any vaccine following LEMTRADA treatment has not been studied.
The safety of immunisation with live viral vaccines following a course of LEMTRADA treatment has not been formally studied in controlled clinical trials in MS and should not be administered to MS patients who have recently received a course of LEMTRADA.
Varicella zoster virus antibody testing/vaccination: As for any immune modulating medicinal product, before initiating a course of LEMTRADA treatment, patients without a history of chickenpox or without vaccination against varicella zoster virus (VZV) should be tested for antibodies to VZV. VZV vaccination of antibody-negative patients should be considered prior to treatment initiation with LEMTRADA. To allow for the full effect of the VZV vaccination to occur, treatment with LEMTRADA should be postponed for 6 weeks following vaccination.
Effects on ability to drive and use machines: No studies on the effects of LEMTRADA on the ability to drive and use machines have been performed. Most patients experience IARs which occur during or within 24 hours after treatment with LEMTRADA. Some of the IARs (e.g. dizziness) could temporarily impact the patient's ability to drive or use machines and caution should be exercised until these are resolved.
Women of childbearing potential: Serum concentrations were low or undetectable within approximately 30 days following each treatment course. Therefore, women of child bearing potential should use effective contraceptive measures when receiving a course of treatment with LEMTRADA and for 4 months following that course of treatment.
Fertility: There are no adequate clinical safety data on the effect of LEMTRADA on fertility. In a sub-study in 13 male alemtuzumab-treated patients (treated with either 12 mg or 24 mg), there was no evidence of aspermia, azoospermia, consistently depressed sperm count, motility disorders or an increase in sperm morphological abnormalities.
CD52 is known to be present in human and rodent reproductive tissues. Animal data have shown effects on fertility in humanised mice (see Pharmacology: Toxicology: Preclinical Safety Data under Actions), however a potential impact on human fertility during the period of exposure is unknown based on the available data.

Use in Pregnancy: There is a limited amount of data from the use of LEMTRADA in pregnant women. LEMTRADA should be administered during pregnancy only if the potential benefit justifies the potential risk to the foetus.
Human IgG is known to cross the placental barrier; alemtuzumab may cross the placental barrier as well and thus potentially pose a risk to the foetus. Animal studies have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical Safety Data under Actions).
It is not known whether alemtuzumab can cause foetal harm when administered to pregnant women or whether it can affect reproductive capacity.
Thyroid disease (see Precautions) poses special risks in women who are pregnant. Without treatment of hypothyroidism during pregnancy, there is an increased risk for miscarriage and foetal effects such as mental retardation and dwarfism. In mothers with Graves' disease, maternal thyroid stimulating hormone receptor antibodies can be transferred to a developing foetus and can cause transient neonatal Graves' disease.
Use in Lactation: Alemtuzumab was detected in the milk and offspring of lactating female mice.
It is unknown whether alemtuzumab is excreted in human milk. A risk to the breastfed child cannot be excluded. Therefore, breast feeding should be discontinued during each course of treatment with LEMTRADA and for 4 months following the last infusion of each treatment course. However, benefits of conferred immunity through breast-milk may outweigh the risks of potential exposure to alemtuzumab for the breastfed child.

The following CIOMS frequency rating is used, when applicable: Very common ≥ 10%; Common ≥ 1 and < 10%; Uncommon ≥ 0.1 and < 1%; Rare ≥ 0.01 and < 0.1%; Very rare < 0.01%; Not known (cannot be estimated from available data).
A total of 1,486 patients treated with LEMTRADA (12 mg or 24 mg) constituted the safety population in a pooled analysis of MS clinical studies with a median follow-up of 6.1 years (maximum 12 years), resulting in 8,635 patient years of safety follow-up. Study 1 and Study 2 were 2-year active-controlled trials in RRMS patients treated with LEMTRADA 12 mg/day on 5 consecutive days at study entry and on 3 consecutive days at Study Month 12, or subcutaneous (SC) IFNB-1a 44 μg 3 times per week.
Study 3 (CAMMS223) evaluated the safety and efficacy of LEMTRADA in patients with RRMS over the course of 3 years. Study 4 (CAMMS03409) was an uncontrolled extension study to evaluate the long term safety and efficacy (4 additional years) of LEMTRADA in patients from Studies 1, 2, or 3.
Table 5 lists adverse reactions occurring in ≥5% of LEMTRADA-treated patients (12 mg/day) through complete follow-up by Medical Dictionary for Regulatory Activities (MedDRA) System Organ Class (SOC) and Preferred Term (PT). (See Table 5.)

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The type of adverse events including seriousness and severity observed in LEMTRADA treatment groups through all available follow-up including patients who received additional treatment courses were similar to those in the active-controlled studies.
In patients continuing from controlled clinical studies and who did not receive any additional LEMTRADA after the initial 2 treatment courses, the rate (events per person-year) of most adverse reactions was comparable to or reduced in years 3-6 as compared to years 1 and 2. The rate of thyroid adverse reactions was highest in year three and declined thereafter.
Immunogenicity: As with all therapeutic proteins, there is potential for immunogenicity. Data reflect the percentage of patients whose test results were considered positive for antibodies to alemtuzumab using an enzyme-linked immunosorbent assay (ELISA) and confirmed by a competitive binding assay. Positive samples were further evaluated for evidence of in vitro inhibition using a flow cytometry assay. Patients in clinical trials in MS had serum samples collected 1, 3, and 12 months after each treatment course for determination of anti-alemtuzumab antibodies. Approximately 85% of patients receiving LEMTRADA tested positive for anti-alemtuzumab antibodies during the study, with 90% of these patients testing positive also for antibodies that inhibited LEMTRADA binding in vitro. Patients who developed anti-alemtuzumab antibodies did so by 15 months from initial exposure. Through 2 treatment courses, there was no association of the presence of anti-alemtuzumab or inhibitory anti-alemtuzumab antibodies with a reduction in efficacy, change in pharmacodynamics, or the occurrence of adverse reactions, including infusion associated reactions. High titer anti-alemtuzumab antibodies observed in some patients were associated with incomplete lymphocyte depletion following a third or fourth treatment course but there was no clear impact of anti-alemtuzumab antibodies on the clinical efficacy or safety profile of LEMTRADA.
The incidence of antibodies is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including inhibitory antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to LEMTRADA with the incidence of antibodies to other products may be misleading.
Post-Marketing Experience: The following adverse reactions were identified during post approval use of alemtuzumab for the treatment of B-cell chronic lymphocytic leukaemia (B-CLL), as well as for the treatment of other disorders, generally at higher and more frequent doses (e.g. 30 mg) than that recommended in the treatment of MS. 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 alemtuzumab exposure.
Autoimmune disease: Autoimmune events reported in alemtuzumab-treated patients include neutropenia, haemolytic anaemia (including a fatal case), acquired haemophilia, anti-GBM disease, and thyroid disease. Serious and sometimes fatal autoimmune phenomena including autoimmune haemolytic anaemia, autoimmune thrombocytopenia, aplastic anaemia, Guillain-Barré syndrome, and chronic inflammatory demyelinating polyradiculoneuropathy have been reported in alemtuzumab-treated non-MS patients. A positive Coombs test has been reported in an alemtuzumab-treated oncology patient. A fatal event of transfusion associated graft versus host disease has been reported in an alemtuzumab-treated oncology patient.
Infusion-associated reactions: Serious and sometimes fatal IARs including bronchospasm, hypoxia, syncope, pulmonary infiltrates, acute respiratory distress syndrome, respiratory arrest, myocardial infarction, arrhythmias, acute cardiac insufficiency, and cardiac arrest have been observed in non-MS patients treated with alemtuzumab at higher and more frequent doses than used in MS. Severe anaphylaxis and other hypersensitivity reactions, including anaphylactic shock and angioedema have also been reported.
Infections and infestations: Serious and sometimes fatal viral, bacterial, protozoan, and fungal infections, including those due to reactivation of latent infections, have been reported in non-MS patients treated with alemtuzumab at higher and more frequent doses than used in MS. Progressive multifocal leukoencephalopathy (PML) has been reported in patients with B-CLL with or without treatment with alemtuzumab. The frequency of PML in BCLL patients treated with alemtuzumab is no greater than the background frequency.
Blood and lymphatic system disorders: Severe bleeding reactions have been reported in non-MS patients.
Cardiac disorders:Congestive heart failure, cardiomyopathy, and decreased ejection fraction have been reported in alemtuzumab-treated non-MS patients previously treated with potentially cardiotoxic agents.
Epstein-Barr Virus-associated lymphoproliferative disorders: Epstein-Barr Virus-associated lymphoproliferative disorders have been observed outside company-sponsored studies.

No formal drug interaction studies have been conducted with LEMTRADA using the recommended dose in patients with MS. In a controlled clinical trial in MS patients recently treated with beta interferon and glatiramer acetate were required to discontinue treatment 28 days before initiating treatment with LEMTRADA.

Special precautions for disposal and other handling: The vial contents should be inspected for particulate matter and discoloration prior to administration.
Do not use if particulate matter is present or the concentrate is discoloured.
Do not shake the vials prior to use.
For intravenous administration, withdraw 1.2 ml of LEMTRADA from the vial into a syringe using aseptic technique. Inject into 100 ml of sodium chloride 9 mg/ml (0.9%) solution for infusion or glucose (5%) solution for infusion. This medicinal product must not be diluted with other solvents. The bag should be inverted gently to mix the solution.
LEMTRADA contains no antimicrobial preservatives and, therefore, care should be taken to ensure the sterility of the prepared solution. It is recommended that the diluted product be administered immediately. Each vial is intended for single use only.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Incompatibilities: In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products except those mentioned in the previous text.

Concentrate: Store in a refrigerator (2°C - 8°C).
Do not freeze.
Keep the vial in the outer carton in order to protect from light.
For storage conditions after dilution of the medicinal product, see section "Shelf Life".
Shelf-Life: Concentrate: 3 years.
Diluted solution: Chemical and physical in-use stability has been demonstrated for 8 hours at 2°C - 8°C.
From a microbiological point of view, it is recommended that the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and should not be longer than 8 hours at 2°C - 8°C, under protection from light.

Targeted Cancer Therapy

L04AA34 - alemtuzumab ; Belongs to the class of selective immunosuppressive agents. Used to induce immunosuppression.

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