Gonal F Rff Drug Information

    Generic name: FOLLITROPIN

    Gonadotropin [EPC]

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    Uses of Gonal F Rff

    Induction of Ovulation and Pregnancy in Oligo-Anovulatory Women in whom the Cause

    of Infertility is Functional and Not Due to Primary Ovarian Failure. Prior to initiation of treatment with GONAL-f ® RFF Redi-ject ® : Perform a complete gynecologic and endocrinologic evaluation Exclude primary ovarian failure Exclude the possibility of pregnancy Demonstrate tubal patency Evaluate the fertility status of the male partner

    Development of Multiple Follicles in Ovulatory Women as Part of an Assisted

    Reproductive Technology (ART) Cycle. Prior to initiation of treatment with GONAL-f ® RFF Redi-ject ® : Perform a complete gynecologic and endocrinologic evaluation, and diagnose the cause of infertility Exclude the possibility of pregnancy Evaluate the fertility status of the male partner

    Dosage & Administration of Gonal F Rff

    General Dosing Information Parenteral drug products should be inspected visually for particulate

    matter and discoloration prior to administration, whenever solution and container permit. GONAL-f ® RFF Redi-ject ® is a pre-filled disposable auto-injection device intended for multiple dose use. GONAL-f ® RFF Redi-ject ® can be set in

    International Units increments. Administer

    GONAL-f ® RFF Redi-ject ® subcutaneously in the abdomen as described in Instructions for Use Do not attempt to mix any other medications inside of the device with GONAL-f ® RFF Redi-ject ®. Instruct women to remove the GONAL-f ® RFF Redi-ject ® from the refrigerator at least 30 minutes prior to use in order to allow GONAL-f ® RFF Redi-ject ® to warm to room temperature and avoid the discomfort of a cold injection.

    Recommended Dosing for Ovulation

    Induction The dosing scheme is stepwise and is individualized for each woman . Starting doses less than

    International Units have not been studied in clinical trials and are not

    recommended. A starting daily dose of 75 International Units of GONAL-f ® RFF Redi-ject ® is administered subcutaneously daily for 14 days in the first cycle of use. In subsequent cycles of treatment, the starting dose (and dosage adjustments) of GONAL-f ® RFF Redi-ject ® should be determined based on the history of the ovarian response to GONAL-f ® RFF Redi-ject ®. The following should be considered when planning the woman's individualized dose: Appropriate GONAL-f ® RFF Redi-ject ® dose adjustment(s) should be used to prevent multiple follicular growth and cycle cancellation.

    The maximum, individualized, daily dose of GONAL-f ® RFF Redi-ject ® is 300 International Units per day. In general, do not exceed 35 days of treatment. If indicated by the ovarian response after the initial 14 days, make an incremental adjustment in dose, up to

    International Units.

    If indicated by the ovarian response, make additional adjustments in dose, up to

    International Units, every 7 days. Treatment should continue until follicular growth and/or

    serum estradiol levels indicate an adequate ovarian response. When pre-ovulatory conditions are reached, administer human chorionic gonadotropin (hCG) to induce final oocyte maturation and ovulation. Withhold hCG in cases where the ovarian monitoring suggests an increased risk of ovarian hyperstimulation syndrome (OHSS) on the last day of GONAL-f ® RFF Redi-ject ® therapy . Encourage the woman and her partner to have intercourse daily, beginning on the day prior to the administration of hCG and until ovulation becomes apparent.

    Discourage intercourse when the risk for OHSS is increased .

    Recommended Dosing for Assisted Reproductive Technology

    The dosing scheme follows a stepwise approach and is individualized for each woman. Beginning on cycle day 2 or 3, a starting dose of 150 International Units of GONAL-f ® RFF Redi-ject ® is administered subcutaneously daily until sufficient follicular development, as determined by ultrasound in combination with measurement of serum estradiol levels, is attained. In most cases, therapy should not exceed 10 days.

    In women under 35 years of age whose endogenous gonadotropin levels are suppressed, initiate GONAL-f ® RFF Redi-ject ® administration at a dose of 150 International Units per day. In women 35 years of age and older whose endogenous gonadotropin levels are suppressed, initiate GONAL-f ® RFF Redi-ject ® administration at a dose of 225 International Units per day. Adjust the dose after 5 days based on the woman's ovarian response, as determined by ultrasound evaluation of follicular growth and serum estradiol levels.

    Do not make additional dosage adjustments more frequently than every 3-5 days or by more than 75-150 International Units at each adjustment. Continue treatment until adequate follicular development is evident, and then administer hCG. The administration of hCG should be withheld in cases where the ovarian monitoring suggests an increased risk of OHSS on the last day of GONAL-f ® RFF Redi-ject ® therapy. Doses greater than 450 International Units per day are not recommended.

    Side Effects of Gonal F Rff

    Clinical Study Experience

    Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trial of another drug and may not reflect the rates observed in practice. The safety of GONAL-f ® RFF was examined in two clinical studies (one ovulation induction study and one ART study). Ovulation Induction In a multiple cycle, assessor-blind, multinational, multicenter, active comparator study vs. a recombinant FSH comparator, a total of 83 oligo-anovulatory infertile women were randomized and underwent ovulation induction with GONAL-f ® RFF. Adverse reactions occurring in at least 2.0% of women receiving GONAL-f ® RFF are listed in Table 1. Table 1: Common Adverse Reactions Reported at a Frequency of ≥ 2% in an Ovulation Induction Study System Organ Class/Adverse Reactions GONAL-f ® RFF N=83 total number of women treated with GONAL-f ® RFF (176 treatment cycles up to 3 treatment cycles per woman ) n number of women with the adverse reaction (%) Central and Peripheral Nervous System Headache 22 (26.5%) Gastrointestinal System Abdominal Pain 10 (12.0%) Nausea 3 (3.6%) Flatulence 3 (3.6%) Diarrhea 3 (3.6%) Neoplasm Ovarian Cyst 3 (3.6%) Reproductive, Female Ovarian Hyperstimulation 6 (7.2%) Application Site Injection Site Pain 4 (4.8%) Injection Site Inflammation 2 (2.4%) Assisted Reproductive Technology In a single cycle, assessor-blind, multinational, multicenter, active comparator study vs. a recombinant FSH comparator, a total of 237 normal ovulatory infertile women were randomized and received GONAL-f ® RFF as part of an ART cycle. All women received pituitary down-regulation with gonadotropin releasing hormone (GnRH) agonist before stimulation.

    Adverse Reactions occurring in at least 2.0% of women are listed in Table 2. Table 2: Common Adverse Reactions Reported at a Frequency of ≥ 2% in an Assisted Reproductive Technologies Study System Organ Class/Adverse Reactions GONAL-f ® RFF N=237 total number of women treated with GONAL-f ® RFF n number of women with the adverse reaction (%) Gastrointestinal System Abdominal Pain 55 (23.2%) Nausea 19 (8.0%) Body as a Whole- General Abdomen Enlarged 33 (13.9%) Central and Peripheral Nervous System Headache 44 (18.6%) Application Site Disorders Injection Site Bruising 23 (9.7%) Injection Site Pain 13 (5.5%) Injection Site Inflammation 10 (4.2%) Injection Site Reaction 10 (4.2%) Application Site Edema 6 (2.5%) Reproductive, Female Ovarian Hyperstimulation 11 (4.6%)

    Postmarketing Experience

    The following adverse reactions have been reported during postmarketing use of GONAL-f ® RFF. Because these reactions were reported voluntarily from a population of uncertain size, the frequency or a causal relationship to GONAL - f ® RFF cannot be reliably determined. Body as a Whole - General: hypersensitivity reactions including anaphylactoid reactions Respiratory System: asthma Vascular disorders: thromboembolism

    Warnings & Cautions for Gonal F Rff

    Hypersensitivity Reactions and Anaphylaxis Serious systemic hypersensitivity reactions, including anaphylaxis, have been

    reported in the postmarketing experience with GONAL-f ® and GONAL-f ® RFF. Symptoms have included dyspnea, facial edema, pruritus, and urticaria. If an anaphylactic or other serious allergic reaction occurs, initiate appropriate therapy including supportive measures if cardiovascular instability and/or respiratory compromise occur, and discontinue further use.

    Abnormal Ovarian Enlargement

    In order to minimize the hazards associated with abnormal ovarian enlargement that may occur with GONAL-f ® RFF Redi-ject ® therapy, treatment should be individualized and the lowest effective dose should be used. Use of ultrasound monitoring of ovarian response and/or measurement of serum estradiol levels is important to minimize the risk of ovarian stimulation . If the ovaries are abnormally enlarged on the last day of GONAL-f ® RFF Redi-ject ® therapy, hCG should not be administered in order to reduce the chance of developing Ovarian Hyperstimulation Syndrome (OHSS) . Intercourse should be prohibited in women with significant ovarian enlargement after ovulation because of the danger of hemoperitoneum resulting from rupture of ovarian cysts .

    Ovarian Hyperstimulation Syndrome (OHSS)

    OHSS is a medical entity distinct from uncomplicated ovarian enlargement and may progress rapidly to become a serious medical event. OHSS is characterized by a dramatic increase in vascular permeability, which can result in a rapid accumulation of fluid in the peritoneal cavity, thorax, and potentially, the pericardium. The early warning signs of development of OHSS are severe pelvic pain, nausea, vomiting, and weight gain.

    Abdominal pain, abdominal distension, gastrointestinal symptoms including nausea, vomiting and diarrhea, severe ovarian enlargement, weight gain, dyspnea, and oliguria have been reported with OHSS. Clinical evaluation may reveal hypovolemia, hemoconcentration, electrolyte imbalances, ascites, hemoperitoneum, pleural effusions, hydrothorax, acute pulmonary distress, and thromboembolic reactions . Transient liver function test abnormalities suggestive of hepatic dysfunction with or without morphologic changes on liver biopsy, have been reported in association with OHSS. OHSS occurs after gonadotropin treatment has been discontinued and it can develop rapidly, reaching its maximum about seven to ten days following treatment. Usually, OHSS resolves spontaneously with the onset of menses. If there is evidence that OHSS may be developing prior to hCG administration , the hCG must be withheld.

    Cases of OHSS are more common, more severe, and more protracted if pregnancy occurs; therefore, women should be assessed for the development of OHSS for at least two weeks after hCG administration. If serious OHSS occurs, gonadotropins, including hCG, should be stopped and consideration should be given as to whether the woman needs to be hospitalized. Treatment is primarily symptomatic and overall should consist of bed rest, fluid and electrolyte management, and analgesics (if needed). Because the use of diuretics can accentuate the diminished intravascular volume, diuretics should be avoided except in the late phase of resolution as described below.

    The management of OHSS may be divided into three phases as follows: Acute Phase : Management should be directed at preventing hemoconcentration due to loss of intravascular volume to the third space and minimizing the risk of thromboembolic phenomena and kidney damage. Fluid intake and output, weight, hematocrit, serum and urinary electrolytes, urine specific gravity, BUN and creatinine, total proteins with albumin: globulin ratio, coagulation studies, electrocardiogram to monitor for hyperkalemia, and abdominal girth should be thoroughly assessed daily or more often based on the clinical need. Treatment, consisting of limited intravenous fluids, electrolytes, human serum albumin, is intended to normalize electrolytes while maintaining an acceptable but somewhat reduced intravascular volume.

    Full correction of the intravascular volume deficit may lead to an unacceptable increase in the amount of third space fluid accumulation. Chronic Phase : After the acute phase is successfully managed as above, excessive fluid accumulation in the third space should be limited by instituting severe potassium, sodium, and fluid restriction. Resolution Phase : As third space fluid returns to the intravascular compartment, a fall in hematocrit and increasing urinary output are observed in the absence of any increase in intake.

    Peripheral and/or pulmonary edema may result if the kidneys are unable to excrete third space fluid as rapidly as it is mobilized. Diuretics may be indicated during the resolution phase, if necessary, to combat pulmonary edema. Ascitic, pleural, and pericardial fluid should not be removed unless there is the necessity to relieve symptoms such as pulmonary distress or cardiac tamponade.

    OHSS increases the risk of injury to the ovary. Pelvic examination or intercourse may cause rupture of an ovarian cyst, which may result in hemoperitoneum, and should therefore be avoided. If bleeding occurs and requires surgical intervention, the clinical objective should be to control the bleeding and retain as much ovarian tissue as possible.

    A physician experienced in the management of this syndrome, or who is experienced in the management of fluid and electrolyte imbalances should be consulted. During clinical trials with GONAL-f ® RFF, OHSS occurred in 7.2% of 83 women and 4.6% of 237 women treated with GONAL-f ® RFF for ovulation induction and during Assisted Reproductive Technology, respectively.

    Pulmonary and Vascular Complications Serious pulmonary conditions (e.g., atelectasis, acute respiratory distress

    syndrome and exacerbation of asthma) have been reported in women treated with gonadotropins. In addition, thromboembolic events both in association with, and separate from OHSS have been reported in women treated with gonadotropins including GONAL-f ® RFF. Intravascular thrombosis and embolism, which may originate in venous or arterial vessels, can result in reduced blood flow to critical organs or the extremities. Women with generally recognized risk factors for thrombosis, such as personal or family history, severe obesity, or thrombophilia, may have an increased risk of venous or arterial thromboembolic events, during or following treatment with gonadotropins.

    Sequelae of such reactions have included venous thrombophlebitis, pulmonary embolism, pulmonary infarction, cerebral vascular occlusion (stroke), and arterial occlusion resulting in loss of limb and rarely in myocardial infarctions. In rare cases, pulmonary complications and/or thromboembolic reactions have resulted in death. In women with recognized risk factors, the benefits of ovulation induction and assisted reproductive technology need to be weighed against the risks.

    It should be noted that pregnancy also carries an increased risk of thrombosis.

    Ovarian Torsion Ovarian torsion has been reported after treatment with gonadotropins.

    This may be related to OHSS, pregnancy, previous abdominal surgery, past history of ovarian torsion, previous or current ovarian cyst and polycystic ovaries. Damage to the ovary due to reduced blood supply can be limited by early diagnosis and immediate detorsion.

    Multi-fetal Gestation and Birth Multi-fetal gestation and births have been reported with

    all gonadotropin therapy including therapy with GONAL-f ® RFF. During clinical trials with GONAL-f ® RFF, multiple births occurred in 20% of live births in women receiving therapy for ovulation induction and 35.1 % of live births in women undergoing ART. The woman and her partner should be advised of the potential risk of multi-fetal gestation and birth before beginning therapy with GONAL-f ® RFF Redi-ject ®.

    Congenital Malformations

    The incidence of congenital malformations after some ART may be slightly higher than after spontaneous conception. This slightly higher incidence is thought to be related to differences in parental characteristics (e.g., maternal age, maternal and paternal genetic background, sperm characteristics) and to the higher incidence of multi-fetal gestations after IVF or ICSI. There are no indications that the use of gonadotropins during IVF or ICSI is associated with an increased risk of congenital malformations.

    Ectopic Pregnancy

    Since infertile women undergoing ART often have tubal abnormalities, the incidence of ectopic pregnancy may be increased. Early confirmation of intrauterine pregnancy should be determined by β-hCG testing and transvaginal ultrasound.

    Spontaneous Abortion

    The risk of spontaneous abortion (miscarriage) is increased with gonadotropin products. However, causality has not been established. The increased risk may be a factor of the underlying infertility. 5.10 Ovarian Neoplasms There have been infrequent reports of ovarian neoplasms, both benign and malignant, in women who have had multiple drug therapy for controlled ovarian stimulation, however, a causal relationship has not been established. 5.11 Laboratory Tests In most instances, treatment of women with GONAL-f ® RFF Redi-ject ® will result only in follicular growth and maturation.

    In the absence of an endogenous LH surge, hCG is given when monitoring of the woman indicates that sufficient follicular development has occurred. This may be estimated by ultrasound alone or in combination with measurement of serum estradiol levels. The combination of both ultrasound and serum estradiol measurement are useful for monitoring follicular growth and maturation, timing of the ovulatory trigger, detecting ovarian enlargement and minimizing the risk of the OHSS and multiple gestation.

    The clinical confirmation of ovulation is obtained by direct or indirect indices of progesterone production as well as sonographic evidence of ovulation. Direct or indirect indices of progesterone production: Urinary or serum luteinizing hormone (LH) rise A rise in basal body temperature Increase in serum progesterone Menstruation following a shift in basal body temperature Sonographic evidence of ovulation: Collapsed follicle Fluid in the cul-de-sac Features consistent with corpus luteum formation Secretory endometrium

    Drug Interactions with Gonal F Rff

    No drug-drug interaction studies have been performed.

    Pregnancy Safety for Gonal F Rff

    Pregnancy Risk Summary GONAL-f ® RFF Redi-ject ® is not indicated in pregnant women. The incidence of congenital malformations after some Assisted Reproductive Technology (ART), procedures, specifically in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI)], may be slightly higher than after spontaneous conception. This slightly higher incidence is thought to be related to differences in parental characteristics (e.g., maternal age, maternal and paternal genetic background, sperm characteristics) and to a higher incidence of multi-fetal gestations after IVF or ICSI. There is no human data that the use of gonadotropins (including GONAL-f ® RFF Redi-ject ® ), alone or as part of IVF or ICSI cycles, increases the risk of congenital malformations.

    The risk of spontaneous abortion (miscarriage) is increased in women who have used gonadotropins products (including GONAL-f ® RFF Redi-ject ® ) to achieve pregnancy. In animal studies, the continuous administration of recombinant human FSH during pregnancy resulted in a decrease in the number of viable fetuses and difficult and prolonged delivery. No teratogenic effect has been observed.

    In the US general population, the estimated background risk of major birth defects and miscarriage after spontaneous clinically recognized pregnancies, is 2% to 4% and 15% to 20%, respectively. Data Human Data Data on a limited number of exposed pregnancies indicate no adverse reactions of gonadotropins on pregnancy, embryonal or fetal development, parturition or postnatal development following controlled ovarian stimulation. Animal Data Embryofetal development studies with recombinant human FSH in rats, where dosing occurred during organogenesis, showed a dose dependent increase in difficult and prolonged parturition in dams, and dose dependent increases in resorptions, pre- and post-implantation losses, and stillborn pups at doses representing 5 and 41 times the lowest clinical dose of 75 IU based on body surface area.

    Pre-/post-natal development studies with recombinant human FSH in rats, where dosing occurred from mid-gestation through lactation, showed difficult and prolonged parturition in all dams dosed at 41 times the lowest clinical dose of 75 IU based on body surface area, along with maternal death and stillborn pups associated with the difficult and prolonged parturition. This toxicity was not observed in dams and offspring dosed at a level 5 times the lowest clinical dose of 75 IU based on body surface area.

    Pediatric Use of Gonal F Rff

    Pediatric Use Safety and effectiveness in pediatric patients have not been established.

    Contraindications for Gonal F Rff

    • GONAL-f ® RFF Redi-ject ® is contraindicated in women who exhibit: Prior hypersensitivity to recombinant FSH products High levels of FSH indicating primary gonadal failure Presence of uncontrolled non-gonadal endocrinopathies (e.g., thyroid, adrenal, or pituitary disorders) Sex hormone dependent tumors of the reproductive tract and accessory organs Tumors of pituitary gland or hypothalamus Abnormal uterine bleeding of undetermined origin Ovarian cyst or enlargement of undetermined origin, not due to polycystic ovary syndrome GONAL-f ® RFF Redi-ject ® is contraindicated in women who exhibit : Hypersensitivity to recombinant FSH preparations or one of their excipients High levels of FSH indicating primary gonadal failure Uncontrolled non-gonadal endocrinopathies Sex hormone dependent tumors of the reproductive tract and accessory organ. Tumors of pituitary gland or hypothalamus Abnormal uterine bleeding of undetermined origin Ovarian cyst or enlargement of undetermined origin, not due to polycystic ovary syndrome

    Overdosage Information for Gonal F Rff

    Aside from possible OHSS and multiple gestations, there is no additional information on the consequences of acute overdosage with GONAL-f ® RFF Redi-ject ®.

    Clinical Studies of Gonal F Rff

    Ovulation

    Induction (OI) Ovulation induction was evaluated in a randomized, assessor-blind, multinational, multicenter, active-controlled, study in oligo-anovulatory infertile women. Women were randomized to either GONAL-f ® RFF (n=83), administered subcutaneously, or a comparator recombinant human FSH. The use of insulin-sensitizing agents was allowed during the study. The study was designed to evaluate and compare mean ovulation rates in the first cycle of treatment.

    Results for GONAL-f ® RFF are presented in Table 4. Also presented in this table are secondary outcome results from cycle 1 through cycle 3. The study was not powered to demonstrate differences in any of the secondary outcomes. Table 4: Cumulative Ovulation and Clinical Pregnancy Rates in Ovulation Induction Cycle GONAL-f ® RFF (n=83) Cumulative Cumulative rates were determined per woman over cycles 1, 2, and 3. Percent Ovulation Cumulative Clinical Pregnancy Clinical pregnancy was defined as a pregnancy for which a fetal sac (with or without heart activity) was visualized by ultrasound on day 34-36 after hCG administration. Rate Cycle 1 72% Non-inferior to comparator recombinant human FSH based on a two-sided 95% confidence interval, intent-to-treat analysis. 28% Secondary efficacy outcomes.

    The study was not powered to demonstrate differences in these outcomes. Cycle 2 89% 41% Cycle 3 92% 45%

    Assisted Reproductive Technology (ART)

    The efficacy of GONAL-f ® RFF was evaluated in a randomized, assessor-blind, multinational, multicenter, active controlled study in healthy normal ovulatory, infertile women treated for one cycle with controlled ovarian stimulation, as part of an ART cycle. Women were randomized to either GONAL-f ® RFF (n=237), administered subcutaneously, or a comparator recombinant human FSH. Randomization was stratified by insemination technique, (IVF vs. ICSI). All women received pituitary down-regulation with a GnRH agonist before stimulation with recombinant FSH. Efficacy was assessed using the mean number of fertilized oocytes the day after insemination.

    The initial doses of GONAL-f ® RFF were 150 International Units per day for women less than 35 years of age and 225 International Units per day for women 35 years of age and older. The maximum dose given for both age groups was 450 International Units per day. Treatment outcomes for GONAL-f ® RFF are summarized in Table 5. Table 5: Treatment Outcomes in ART Study Outcome value (n) Mean number of 2PN oocytes per woman

    Non-inferior to comparator recombinant human

    FSH based on a two-sided 95% confidence interval, intent-to-treat analysis. Mean number of 2PN oocytes per subject receiving IVF

    Subgroup analyses.

    The study was not powered to demonstrate differences in subgroups. Mean number of 2PN oocytes per subject receiving ICSI

    Clinical pregnancy

    A clinical pregnancy was defined as a pregnancy during which a fetal sac (with or without heart activity) was visualized by ultrasound on day 35-42 after hCG administration. rate per attempt 33.5% Secondary efficacy outcomes. The study was not powered to demonstrate differences in these outcomes. Clinical pregnancy rate per embryo transfer 35.8% Mean treatment duration in days (range) 9.7

    Drug information sourced from the FDA. This content is for informational purposes only and does not constitute medical advice. Consult a healthcare professional before making any medication decisions.

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