"By Kathleen Doheny
WebMD Health News
Reviewed by Michael W. Smith, MD
Dec. 30, 2013 -- The FDA has rejected the new multiple sclerosis drug Lemtrada, saying the drugmaker didn't show the drug's benefits outweigh some s"...
Severe hepatic injury including cases of hepatic failure, some of which have been due to autoimmune hepatitis, has been rarely reported in patients taking EXTAVIA. In some cases, these events have occurred in the presence of other drugs or comorbid medical conditions that have been associated with hepatic injury. Consider the potential risk of EXTAVIA used in combination with known hepatotoxic drugs or other products (e.g., alcohol) prior to EXTAVIA administration, or when adding new agents to the regimen of patients already on EXTAVIA. Monitor patients for signs and symptoms of hepatic injury. Consider discontinuing EXTAVIA if serum transaminase levels significantly increase, or if they are associated with clinical symptoms such as jaundice.
Asymptomatic elevation of serum transaminases is common in patients treated with EXTAVIA. In controlled clinical trials, elevations of SGPT to greater than five times baseline value were reported in 12% of patients receiving interferon beta-1b (compared to 4% on placebo), and increases of SGOT to greater than five times baseline value were reported in 4% of patients receiving interferon beta-1b (compared to 1% on placebo), leading to dose-reduction or discontinuation of treatment in some patients [see ADVERSE REACTIONS]. Monitor liver function tests [see Monitoring for Laboratory Abnormalities].
Anaphylaxis And Other Allergic Reactions
Anaphylaxis has been reported as a rare complication of interferon beta-1b use. Other allergic reactions have included dyspnea, bronchospasm, tongue edema, skin rash, and urticaria [see ADVERSE REACTIONS]. Discontinue EXTAVIA if anaphylaxis occurs.
Depression And Suicide
Depression and suicide have been reported to occur with increased frequency in patients receiving interferon beta products, including interferon beta-1b. Advise patients to report any symptom of depression and/or suicidal ideation to their healthcare provider. If a patient develops depression, discontinuation of EXTAVIA therapy should be considered.
In randomized controlled clinical trials, there were three suicides and eight suicide attempts among the 1532 patients on interferon beta-1b compared to one suicide and four suicide attempts among 965 patients on placebo.
Congestive Heart Failure
Monitor patients with preexisting congestive heart failure (CHF) for worsening of their cardiac condition during initiation of and continued treatment with EXTAVIA. While beta interferons do not have any known direct-acting cardiac toxicity, cases of CHF, cardiomyopathy, and cardiomyopathy with CHF have been reported in patients without known predisposition to these events, and without other known etiologies being established. In some cases, these events have been temporally related to the administration of interferon beta-1b. Recurrence upon rechallenge was observed in some patients. Consider discontinuation of EXTAVIA if worsening of CHF occurs with no other etiology.
Injection Site Necrosis And Reactions
Injection site necrosis (ISN) was reported in 4% of interferon beta-1b-treated patients in controlled clinical trials (compared to 0% on placebo) [see ADVERSE REACTIONS]. Typically, ISN occurs within the first four months of therapy, although postmarketing reports have been received of ISN occurring over one year after initiation of therapy. The necrotic lesions are typically 3 cm or less in diameter, but larger areas have been reported. Generally the necrosis has extended only to subcutaneous fat, but has extended to the fascia overlying muscle. In some lesions where biopsy results are available, vasculitis has been reported. For some lesions, debridement, and/or skin grafting have been required. In most cases healing was associated with scarring.
Whether to discontinue therapy following a single site of necrosis is dependent on the extent of necrosis. For patients who continue therapy with EXTAVIA after injection site necrosis has occurred, avoid administration of EXTAVIA into the affected area until it is fully healed. If multiple lesions occur, discontinue therapy until healing occurs.
Periodically evaluate patient understanding and use of aseptic self-injection techniques and procedures, particularly if injection site necrosis has occurred.
In controlled clinical trials, injection site reactions occurred in 78% of patients receiving interferon beta-1b with injection site necrosis in 4%. Injection site inflammation (42%), injection site pain (16%), injection site hypersensitivity (4%), injection site necrosis (4%), injection site mass (2%), injection site edema (2%) and nonspecific reactions were significantly associated with interferon beta-1b treatment. The incidence of injection site reactions tended to decrease over time. Approximately 69% of patients experienced injection site reactions during the first three months of treatment, compared to approximately 40% at the end of the studies.
In controlled clinical trials, leukopenia was reported in 18% of patients receiving interferon beta-1b (compared to 6% on placebo), leading to a reduction of the dose of interferon beta-1b in some patients [see ADVERSE REACTIONS]. Monitoring of complete blood and differential white blood cell counts is recommended. Patients with myelosuppression may require more intensive monitoring of complete blood cell counts, with differential and platelet counts.
Cases of thrombotic microangiopathy (TMA), including thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, some fatal, have been reported with interferon beta products, including EXTAVIA. Cases have been reported several weeks to years after starting interferon beta products. Discontinue EXTAVIA if clinical symptoms and laboratory findings consistent with TMA occur, and manage as clinically indicated.
Flu-like Symptom Complex
In controlled clinical trials, the rate of flu-like symptom complex for patients on interferon beta-1b was 57% [see ADVERSE REACTIONS]. The incidence decreased over time, with 10% of patients reporting flu-like symptom complex at the end of the studies. The median duration of flu-like symptom complex in Study 1 was 7.5 days [see Clinical Studies]. Analgesics and/or antipyretics on treatment days may help ameliorate flu-like symptoms associated with EXTAVIA use.
Seizures have been temporally associated with the use of beta interferons in clinical trials and postmarketing safety surveillance. It is not known whether these events were related to a primary seizure disorder, the effects of multiple sclerosis alone, the use of beta interferons, other potential precipitants of seizures (e.g., fever), or to some combination of these.
Monitoring For Laboratory Abnormalities
In addition to those laboratory tests normally required for monitoring patients with multiple sclerosis, complete blood and differential white blood cell counts, platelet counts and blood chemistries, including liver function tests, are recommended at regular intervals (one, three, and six months) following introduction of EXTAVIA therapy, and then periodically thereafter in the absence of clinical symptoms.
Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use).
Instruction on Self-Injection Technique and Procedures
Provide appropriate instruction for reconstitution of EXTAVIA and methods of self-injection, including careful review of the EXTAVIA Medication Guide. Instruct patients in the use of aseptic technique when administering EXTAVIA.
Tell patients not to re-use needles or syringes and instruct patients on safe disposal procedures. Advise patients of the importance of rotating areas of injection with each dose, to minimize the likelihood of severe injection site reactions, including necrosis or localized infection [see Medication Guide].
Advise patients that severe hepatic injury, including hepatic failure, has been reported during the use of EXTAVIA.
Inform patients of symptoms of hepatic dysfunction, and instruct patients to report them immediately to their healthcare provider [see WARNINGS AND PRECAUTIONS].
Anaphylaxis and Other Allergic Reactions
Advise patients of the symptoms of allergic reactions and anaphylaxis, and instruct patients to seek immediate medical attention if these symptoms occur [see WARNINGS AND PRECAUTIONS].
Depression and Suicide
Advise patients that depression and suicidal ideation have been reported during the use of EXTAVIA. Inform patients of the symptoms of depression or suicidal ideation, and instruct patients to report them immediately to their healthcare provider [see WARNINGS AND PRECAUTIONS].
Congestive Heart Failure
Advise patients that worsening of preexisting congestive heart failure have been reported in patients using EXTAVIA.
Advise patients of symptoms of worsening cardiac condition, and instruct patients to report them immediately to their healthcare provider [see WARNINGS AND PRECAUTIONS].
Injection Site Necrosis and Reactions
Advise patients that injection site reactions occur in most patients treated with EXTAVIA, and that injection site necrosis may occur at one or multiple sites. Instruct patients to promptly report any break in the skin, which may be associated with blue-black discoloration, swelling, or drainage of fluid from the injection site, prior to continuing their EXTAVIA therapy [see WARNINGS AND PRECAUTIONS].
Flu-like Symptom Complex
Inform patients that flu-like symptoms are common following initiation of therapy with EXTAVIA, and that concurrent use of analgesics and/or antipyretics on treatment days may help ameliorate flu-like symptoms associated with EXTAVIA use [see WARNINGS AND PRECAUTIONS and DOSAGE AND ADMINISTRATION].
Instruct patients to report seizures immediately to their healthcare provider [see WARNINGS AND PRECAUTIONS].
Advise patients that EXTAVIA should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus [see Use in Special Population]. Therefore, inform patients that if a pregnancy is considered, or does occur, the risks and benefits of continuing EXTAVIA should be discussed with their healthcare provider.
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Interferon beta-1b has not been tested for its carcinogenic potential in animals.
Interferon beta-1b was not genotoxic in the in vitro Ames bacterial test or the in vitro chromosomal aberration assay in human peripheral blood lymphocytes. Interferon beta-1b treatment of mouse BALBc-3T3 cells did not result in increased transformation frequency in an in vitro model of tumor transformation.
Impairment of Fertility
Administration of interferon beta-1b (doses of up to 0.33 mg/kg/day) to normally cycling female rhesus monkeys had no apparent adverse effects on either menstrual cycle duration or associated hormonal profiles (progesterone and estradiol) when administered over three consecutive menstrual cycles. The highest dose tested is approximately 30 times the recommended human dose of 0.25 mg on a body surface area (mg/m²) basis. The potential for other effects on fertility or reproductive performance was not evaluated.
Use In Specific Populations
Pregnancy Category C
There are no adequate and well-controlled studies in pregnant women; however, spontaneous abortions while on treatment were reported in four patients participating in the interferon beta-1b RRMS clinical trial. EXTAVIA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
When interferon beta-1b (doses ranging from 0.028 to 0.42 mg/kg/day) was administered to pregnant rhesus monkeys throughout the period of organogenesis (gestation days 20 to 70), a dose-related abortifacient effect was observed. The low-effect dose is approximately 3 times the recommended human dose of 0.25 mg on a body surface area (mg/m²) basis. A no-effect dose for embryo-fetal developmental toxicity in rhesus monkeys was not established.
It is not known whether interferon beta-1b is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from interferon beta-1b, a decision should be made to either discontinue nursing or discontinue the drug, taking into account the importance of drug to the mother.
Safety and efficacy in pediatric patients have not been established.
Clinical studies of interferon beta-1b did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently than younger patients.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 1/3/2016
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