Qutavina - summary of medicine characteristics

1. NAME OF THE MEDICINAL PRODUCT

Qutavina 20 micrograms/80 microliters solution for injection in pre-filled pen

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each dose of 80 microliters contains 20 micrograms of teriparatide*.

Each pre-filled pen of 2.7 mL contains 675 micrograms of teriparatide (corresponding to 250 micrograms per mL).

*Teriparatide, rhPTH(1–34), produced in P. fluorescens , using recombinant DNA tech identical to the 34 N-terminal amino acid sequence of endogenous human parathyroid hormone.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Colourless, clear solution.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Qutavina is indicated in adults.

Treatment of osteoporosis in postmenopausal women and in men at increased risk of fracture (see section 5.1). In postmenopausal women, a significant reduction in the incidence of vertebral and nonvertebral fractures but not hip fractures have been demonstrated.

Treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in women and men at increased risk for fracture (see section 5.1).

4.2 Poso

Poso

nd method of administration

The recommended dose of Qutavina is 20 micrograms administered once daily.

The maximum total duration of treatment with Qutavina should be 24 months (see section 4.4).

The 24-month course of Qutavina should not be repeated over a patient’s lifetime.

Patients should receive supplemental calcium and vitamin D supplements if dietary intake is inadequate.

Following cessation of Qutavina therapy, patients may be continued on other osteoporosis therapies.

Special populations

Elderly patients

Dose adjustment based on age is not required (see section 5.2).

Renal impairment

Teriparatide must not be used in patients with severe renal impairment (see section 4.3). In patients with moderate renal impairment, teriparatide should be used with caution (see section 4.4). No special caution is required for patients with mild renal impairment.

Hepatic impairment

No data are available in patients with impaired hepatic function (see section 5.3). Therefore, teriparatide should be used with caution.

Paediatric population and young adults with open epiphyses

The safety and efficacy of teriparatide in children and adolescents less than 18 years established. Teriparatide should not be used in paediatric patients (less than 18 years with open epiphyses.

Method of administration

Qutavina should be administered once daily by subcutaneous injection in the thigh or abdomen.

Patients must be trained to use the proper injection techniques Please also refer to the user manual for instructions on the cor

Contraindications

Special warnings and precautions for useprove the traceability of biological medicinal products, the name and the batch number ministered product should be clearly recorded.

Serum and urine calcium

In normocalcaemic patients, slight and transient elevations of serum calcium concentrations have been observed following teriparatide injection. Serum calcium concentrations reach a maximum between 4 and 6 hours and return to baseline by 16 to 24 hours after each dose of teriparatide. Therefore, if blood samples for serum calcium measurements are taken, this should be done at least 16 hours after the most recent Qutavina injection. Routine calcium monitoring during therapy is not required.

Teriparatide may cause small increases in urinary calcium excretion, but the incidence of hypercalciuria did not differ from that in the placebo-treated patients in clinical trials.

Urolithiasis

Teriparatide has not been studied in patients with active urolithiasis. Qutavina should be used with caution in patients with active or recent urolithiasis because of the potential to exacerbate this condition.

Orthostatic hypotension

In short-term clinical studies with teriparatide, isolated episodes of transient orthostatic hypotension were observed. Typically, an event began within 4 hours of dosing and spontaneously resolved a few minutes to a few hours. When transient orthostatic hypotension occurred, it happened first several doses, was relieved by placing subjects in a reclining position, and did not pr continued treatment.

Renal impairment

Caution should be exercised in patients with moderate renal impairment (see s

Y ounger adult population

Experience in the younger adult population, including premeno Section 5.1). Treatment should only be initiated if the benefi population.

Women of childbearing potential should use effective methods of contraception during use of Qutavina. If pregnancy occurs, Qutavin             s­continued.

Studies in rats indicate an increased e of osteosarcoma with long-term administration of teriparatide (see section 5.3). Until r clinical data become available, the recommended treatment time of 24 months should not be exceeded.

Excipients

This medicinal product contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially ‘sodium-free’.

with other medicinal products and other forms of interaction

15 healthy subjects administered digoxin daily to steady state, a single teriparatide dose er the cardiac effect of digoxin. However, sporadic case reports have suggested that alcaemia may predispose patients to digitalis toxicity. Because teriparatide transiently increases serum calcium, Qutavina should be used with caution in patients taking digitalis.

Teriparatide has been evaluated in pharmacodynamic interaction studies with hydrochlorothi­azide. No clinically significant interactions were noted.

Co-administration of raloxifene or hormone replacement therapy with teriparatide did not alter the effects of teriparatide on serum or urine calcium or on clinical adverse events.

4.6 Fertility, pregnancy and lactation

Women of childbearing potential/Con­traception in females

Women of childbearing potential should use effective methods of contraception during use of Qutavina. If pregnancy occurs, Qutavina should be discontinued.

Pregnancy

Qutavina is contraindicated for use during pregnancy (see section 4.3).

Breast-feeding

Qutavina is contraindicated for use during breast-feeding (see section 4.3). It is not known whether teriparatide is excreted in human milk.

Fertility

Studies in rabbits have shown reproductive toxicity (see section 5.3). The effect of teri human foetal development has not been studied. The potential risk for humans i

4.7 Effects on ability to drive and use machines

Qutavina has no or negligible influence on the ability to drive and use machines. Transient, orthostatic hypotension or dizziness was observed in some patients. These patients should refrain from driving or the use of machines until symptoms have subsided.

4.8 Undesirable effects

Summary of the safety profile

The most commonly reported adverse limb, headache and dizziness.

Tabulated list of adverse reactions

Of patients in the teriparatide trials, 82.8% of the teriparatide patients and 84.5% of the placebo patients reported at least 1 adverse event.

The adverse reactions associated with the use of teriparatide in osteoporosis clinical trials and postmarketing exposure are summarised in the table below.

The following convention has been used for the classification of the adverse reactions: very common (>1/10;        n (>1/100 to <1/10), uncommon (>1/1,000 to <1/100), rare (>1/10,000 to <1/1,000),

very ra ,000).

dverse reactions

T

MedDRA system organ class	Frequency	Adverse reactions
Blood and lymphatic system disorders	Common	Anaemia
Immune system disorder	Rare	Anaphylaxis
Metabolism and nutrition disorders	Common	Hypercholeste­rolaemia

	Uncommon	Hypercalcaemia greater than 2.76 mmol/L, hyperuricemia
	Rare	Hypercalcaemia greater than 3.25 mmol/L
Psychiatric disorders	Common	Depression
Nervous system disorders	Common	Dizziness, headache, sciatica, syncope
Ear and labyrinth disorders	Common	Vertigo
Cardiac disorders	Common	Palpitations X
	Uncommon	Tachycardia
Vascular disorders	Common	Hypotension
Respiratory, thoracic and mediastinal disorders	Common	Dyspnoea
	Uncommon	Emphysema^^
Gastrointestinal disorders	Common	Nausea, vomiting, hiatus hernia, gastroesophageal reflux disease
	Uncommon	¿Haemorrhoids
Skin and subcutaneous tissue disorders	Common	Sweating increased
Musculoskeletal and connective tissue disorders X xs>	Very common	Pain in limb
	Common II	Muscle cramps
	' Uncommon	Myalgia, arthralgia, back cramp/pain*
Renal and urinary disorders	Uncommon	Urinary incontinence, polyuria, micturition urgency, nephrolithiasis
	Rare	Renal failure/impairment
General disorders and administration site conditions^AX	Common	Fatigue, chest pain, asthenia, mild and transient injection site events, including pain, swelling, erythema, localised bruising, pruritis and minor bleeding at injection site.
	Uncommon	Injection site erythema, injection site reaction
	Rare	Possible allergic events soon after injection: acute dyspnoea, oro/facial oedema, generalised urticaria, chest pain, oedema (mainly peripheral).
Investigations	Uncommon	Weight increased, cardiac murmur, alkaline phosphatase increase

*Serious cases of back cramp or pain have been reported within minutes of the injection.

Description of selected adverse reactions

In clinical trials, the following reactions were reported at a >1% difference in frequency from placebo: vertigo, nausea, pain in limb, dizziness, depression, dyspnoea.

Teriparatide increases serum uric acid concentrations. In clinical trials, 2.8% of teriparatide patients had serum uric acid concentrations above the upper limit of normal compared with 0.7% of placebo patients. However, the hyperuricemia did not result in an increase in gout, arthralgia, or urolithiasis.

Anti-drug antibodies were observed in line with other teriparatide containing medicinal products.

There was no evidence of hypersensitivity reactions, allergic reactions, effects on serum calcium, or effects on Bone Mineral Density (BMD) response.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is i allows continued monitoring of the benefit/risk balance of the medicinal product. H professionals are asked to report any suspected adverse reactions via the nation listed in Appendix V.

4.9 Overdose

Signs and symptoms

Teriparatide has been administered in single doses of up to 1 up to 60 micrograms/day for 6 weeks.

The effects of overdose that might be expected include delayed hypercalcaemia and risk of orthostatic hypotension. Nausea, vomiting, dizziness, and headache can also occur.

Overdose experience based on post-marketing spontaneous reports

ave been cases of medicinal product error where the

entire contents (up to 800 mcg) of the teriparatide pen have been administered as a single dose.

d nausea, weakness/lethargy and hypotension. In some cases, of the overdose. No fatalities associated with overdose have

Overdose managemi

There is no specific antidote for teriparatide. Treatment of suspected overdose should include transitory d tinuation of Qutavina, monitoring of serum calcium, and implementation of appropriate ortive measures, such as hydration.

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Calcium homeostasis, parathyroid hormones and analogues, ATC code: H05AA02.

Qutavina is a biosimilar medicinal product. Detailed information is available on the website of the European Medicines Agency.

Mechanism of action

Endogenous 84-amino-acid parathyroid hormone (PTH) is the primary regulator of calcium and phosphate metabolism in bone and kidney. Teriparatide (rhPTH(1–34)) is the active fragment (1–34) of endogenous human parathyroid hormone. Physiological actions of PTH include stimulation of bone formation by direct effects on bone forming cells (osteoblasts) indirectly increasing the intestinal absorption of calcium and increasing the tubular re-absorption of calcium and excretion of phosphate by the kidney.

Pharmacodynamic effects

Teriparatide is a bone formation agent to treat osteoporosis. The skeletal effects of teriparatide depend upon the pattern of systemic exposure. Once-daily administration of teriparatide increases apposition of new bone on trabecular and cortical bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity.

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Clinical efficacy and safety

Risk factors

Independent risk factors, for example, low BMD, age, the existence of previous fracture, family history of hip fractures, high bone turnover and low body mass index should be considered in order to identify women and men at increased risk of osteoporotic fractures who could benefit from treatment.

Premenopausal women with glucocorticoid-induced osteoporosis should be considered at high risk for fracture if they have a prevalent fracture or a combination of risk factors that place them at high risk for fracture (e.g., low bone density [e.g., T score ← 2], sustained high dose glucocorticoid therapy [e.g., >7.5 mg/day for at least 6 months], high underlying disease activity, low sex steroid levels).

Postmenopausal osteoporosis

The pivotal study included 1,637 postmeno­pausal women (mean age 69.5 years). At baseline, ninety percent of the patients had one or more vertebral fractures, and on average, vertebral BMD was 0.82 g/cm2(equ­ivalent to a T score = – 2.6). All patients were offered 1,000 mg calcium per day and at least 400 IU vitamin D per day. Results from up to 24 months (median: 19 months) treatment with teriparatide demonstrate statistically significant fracture reduction (Table 1). To prevent one or more new vertebral fractures, 11 women had to be treated for a median of 19 months.

Table 2. Fracture incidence in postmenopausal women

	Placebo (N = 544) (%)	Teriparatide (N = 541) (%)	Relative risk (95% CI) vs. placebo
New vertebral fracture (>1)a	14.3	5.0b	0.35 (0.22, 0.55)
Multiple vertebral fractures (>2)a	4.9	1.1b	0.23 (0.09, 0.60)
Non-vertebral fragility fracturesc	5.5%	2.6%d	0.47 (0.25, 0.87)
Major non-vertebral fragility fracturesc (hip, radius, humerus, ribs and pelvis)	3.9%	1.5%d	0.38 (0.17, 0.86)

Abbreviations: N = number of patients randomly assigned to each treatment group; CI = Confidence Interval.

aThe incidence of vertebral fractures was assessed in 448 placebo and 444 teriparatide patients who had baseline and followup spine radiographs.

bp<0.001 compared with placebo

cA significant reduction in the incidence of hip fractures has not been demonstrated

dp<0.025 compared with placebo.

After 19 months (median) treatment, bone mineral density (BMD) had increased in the lumbar spine and total hip, respectively, by 9% and 4% compared with placebo (p<0.001).

Post-treatment management: Following treatment with teriparatide, 1,262 postmeno­pausal women from the pivotal trial enrolled in a post-treatment follow-up study. The primary objective of the study was to collect safety data of teriparatide. During this observational period, other osteoporosis treatments were allowed and additional assessment of vertebral fractures was performed.

During a median of 18 months following discontinuation of teriparatide, there was a 41% reduction (p=0.004) compared with placebo in the number of patients with a minimum of one new vertebral fracture.

In an open-label study, 503 postmenopausal women with severe osteoporosis and a fragility within the previous 3 years (83% had received previous osteoporosis therapy) were treated teriparatide for up to 24 months. At 24 months, the mean increase from baseline in lumbar spine, total hip and femoral neck BMD was 10.5%, 2.6% and 3.9% respectively. The mean increase in BMD from 18 to 24 months was 1.4%, 1.2%, and 1.6% at the lumbar spine, total hip and femoral neck, respectively.

A 24-month, randomised, double-blind, comparator-controlled Phase 4 s

postmenopausal women with established osteoporosis. 680 subjects and 680 subjects were randomised to oral risedronate 35 mg/week.

age of 72.1 years and a median of 2 prevalent vertebral fractures; 57

previous bisphosphonate therapy and 18.8% took concomita (74.5%) patients completed the 24-month follow-up. The me

glucocorticoid was 474.3 (66.2) mg in the teriparatide arm. The mean (median) vitamin D intake for the terip and for the risedronate arm was 1,191 IU/day (900 IU follow-up spine radiographs, the incidence of new ver

teriparatide- and 64/533 (12.0%) in risedronate-treated patients, relative risk (95% CI) = 0.44 (0.290.68), P<0.0001. The cumulative incidence of pooled clinical fractures (clinical vertebral and nonvertebral fractures) was 4.8% in teriparatide and 9.8% in risedronate-treated patients, hazard ratio (95% CI) = 0.48 (0.32–0.74), P=0.0009

437 patients (mean age 58.7 s) were enrolled in a clinical trial for men with hypogonadal (defined as low morning free testosterone or an elevated FSH or LH) or idiopathic osteoporosis. Baseline spinal and femoral neck bone mineral density mean T-scores were –2.2 and –2.1, respectively. At baseline, 35% of patients had a vertebral fracture and 59% had a non-vertebral fracture.

offered 1,000 mg calcium per day and at least 400 IU vitamin D per day. Lumbar

ignificantly increased by 3 months. After 12 months, BMD had increased in the lumbar total hip by 5% and 1%, respectively, compared with placebo. However, no significant n fracture rates was demonstrated.

Glucocorticoid-induced osteoporosis

The efficacy of teriparatide in men and women (N=428) receiving sustained systemic glucocorticoid therapy (equivalent to 5 mg or greater of prednisone for at least 3 months) was demonstrated in the 18-month primary phase of a 36 month, randomised, double-blind, comparator-controlled study (alendronate 10 mg/day). Twenty-eight percent of patients had one or more radiographic vertebral fractures at baseline. All patients were offered 1,000 mg calcium per day and 800 IU vitamin D per day.

5.2 Pharmacokinetic properties

El

No differences in teriparatide pharmacokinetics were detected with regard to age (range 31 to 85 years). Dosage adjustment based on age is not required.

5.3 Preclinical safety data

Teriparatide was not genotoxic in a standard battery of tests. It produced no teratogenic effects in rats, mice or rabbits. There were no important effects observed in pregnant rats or mice administered teriparatide at daily doses of 30 to 1,000 ^g/kg. However, fetal resorption and reduced litter size occurred in pregnant rabbits administered daily doses of 3 to 100 ^g/kg. The embryotoxicity observed in rabbits may be related to their much greater sensitivity to the effects of PTH on blood ionised calcium compared with rodents.

Rats treated with near-life time daily injections had dose-dependent exaggerated bone formation and increased incidence of osteosarcoma most probably due to an epigenetic mechanism. Teriparatide did not increase the incidence of any other type of neoplasia in rats. Due to the differences in bone physiology in rats and humans, the clinical relevance of these findings is probably minor. No bone tumours were observed in ovariectomised monkeys treated for 18 months or during a 3-year follow-up period after treatment cessation. In addition, no osteosarcomas have been observed in clinical trials or during the post treatment follow-up study.

Animal studies have shown that severely reduced hepatic blood flow decreases exposure of PTH to the principal cleavage system (Kupffer cells) and consequently clearance of PTH (1–84).

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6. PHARMACEUTICAL PARTICULARS6.1 List of excipients

Glacial acetic acid

Sodium acetate trihydrate

Mannitol

Metacresol

Water for injections

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

6.3 Shelf life 30 months

Chemical, physical and microbiological in-use stability has been demonstrated for 28 days at 2–8°C. Once opened, the medicinal product may be stored for a maximum of 28 days at 2°C to 8°C. Other inuse storage times and conditions are the responsibility of the user.

or storage

Store in a refrigerator (2°C – 8°C) at all times. The pen injector should be returned to the refrigerator

Do n

Do not store the pen injector with the needle attached.

Always store the pen injector with the white cap on after use, in order to protect from light.

6.5 Nature and contents of container

• 2.7 mL solution in cartridge (siliconised Type I glass) sealed at one end with a bromobutyl rubber plunger and at the other end crimp-sealed with a bi-layer combi-seal (polyisoprene/ bromobutyl rubber laminate with aluminium over cap). The cartridges are an integral and non-replaceable part of the pen injector.

The pen injector is composed of a clear cartridge holder, white protective cap to cover the cartridge holder and injector body with a black injection button.

Qutavina is available in pack sizes of 1 or 3 pens. Each pen contains 28 doses of 20 micrograms (per 80 microliters).

Not all pack sizes may be marketed.