Ocrevus Drug Information

OCREVUS is indicated for the treatment of: Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults Primary progressive MS, in adults Relapsing-remitting MS, in pediatric patients 10 years of age and older who weigh 25 kg or more.

Assessments Prior to First Dose of OCREVUS Hepatitis B Virus Screening Prior to initiating OCREVUS, perform Hepatitis B virus (HBV) screening. OCREVUS is contraindicated in patients with active HBV confirmed by positive results for HBsAg and anti-HBV tests. For patients who are negative for surface antigen and positive for HB core antibody or are carriers of HBV, consult liver disease experts before starting and during treatment.

Serum Immunoglobulins Prior to initiating OCREVUS, perform testing for quantitative serum immunoglobulins. For patients with low serum immunoglobulins, consult immunology experts before initiating treatment with OCREVUS. Vaccinations Because vaccination with live-attenuated or live vaccines is not recommended during treatment and after discontinuation until B-cell repletion, administer all age-appropriate immunizations according to immunization guidelines at least 4 weeks prior to initiation of OCREVUS for live or live-attenuated vaccines and, whenever possible, at least 2 weeks prior to initiation of OCREVUS for non-live vaccines.

Liver Function Tests Prior to initiating OCREVUS, obtain serum aminotransferases (alanine aminotransferase and aspartate aminotransferase ), alkaline phosphatase, and bilirubin levels.

Preparation Before Every Infusion Infection Assessment Prior to every infusion of OCREVUS, determine whether there is an active infection. In case of active infection, delay infusion of OCREVUS until the infection resolves. Recommended Premedication To reduce the frequency and severity of infusion reactions, administer the following premedications: Methylprednisolone (or an equivalent corticosteroid) by intravenous infusion to be completed approximately 30 minutes prior to each OCREVUS infusion, as follows: Adults and pediatric patients who weigh 40 kg or more: 100 mg Pediatric patients who weigh less than 40 kg: 2 mg/kg An antihistamine (e.g., diphenhydramine) 30 to 60 minutes prior to each OCREVUS infusion.

An antipyretic (e.g., acetaminophen) may also be considered.

Recommended Dosage and Dose Administration Administer

OCREVUS under the close supervision of an experienced healthcare professional with access to appropriate medical support to manage severe reactions such as serious infusion reactions. Observe the patient for at least one hour after the completion of the infusion. OCREVUS is administered as an intravenous infusion.

The initial dose is split into two equal infusions administered two weeks apart. Subsequent doses are administered every 6 months thereafter (see Table 1 ). Dosing for pediatric patients (10 years of age and older) is according to body weight (see Table 2 ).

Table 1 Recommended Dose, Infusion Rate, and Infusion Duration for Adult Patients with RMS and PPMS Amount and Volume Solutions of OCREVUS for intravenous infusion are prepared by dilution of the drug product into an infusion bag containing 0.9% Sodium Chloride Injection, to a final drug concentration of approximately 1.2 mg/mL. Infusion Rate and Duration Infusion time may take longer if the infusion is interrupted or slowed. Option 2 (If no prior serious infusion reaction with any previous OCREVUS infusion).

Duration for Pediatric Patients 10 Years of Age and Older Infusion Amount and Volume Solutions of OCREVUS for intravenous infusion are prepared by dilution of the drug product into an infusion bag containing 0.9% Sodium Chloride for Injection.

Delayed or Missed Doses If a planned infusion of OCREVUS is missed, administer OCREVUS as soon as possible; do not wait until the next scheduled dose. Reset the dose schedule to administer the next sequential dose 6 months after the missed dose is administered. Doses of OCREVUS must be separated by at least 5 months.

Dose Modifications Because of Infusion Reactions

Dose modifications in response to infusion reactions depends on the severity. Life-threatening Infusion Reactions Immediately stop and permanently discontinue OCREVUS if there are signs of a life-threatening or disabling infusion reaction. Provide appropriate supportive treatment.

Severe Infusion Reactions Immediately interrupt the infusion and administer appropriate supportive treatment, as necessary. Restart the infusion only after all symptoms have resolved. When restarting, begin at half of the infusion rate at the time of onset of the infusion reaction.

If this rate is tolerated, increase the rate as described in Table 1 and Table 2. This change in rate will increase the total duration of the infusion but not the total dose. Mild to Moderate Infusion Reactions Reduce the infusion rate to half the rate at the onset of the infusion reaction and maintain the reduced rate for at least 30 minutes.

Preparation and Storage of the Dilute Solution for Infusion Preparation OCREVUS must be prepared by a healthcare professional using aseptic technique. A sterile needle and syringe should be used to prepare the diluted infusion solution. Visually inspect for particulate matter and discoloration prior to administration.

Do not use the solution if discolored or if the solution contains discrete foreign particulate matter. Do not shake. Withdraw the required dose of OCREVUS and further dilute into an infusion bag containing 0.9% Sodium Chloride Injection, as described in Table 3.

Table 3: Dilution of OCREVUS Do not use other diluents to dilute OCREVUS because their use has not been tested. The product contains no preservative and is intended for single use only. Discard any unused portion left in the vial.

Storage of Infusion Solution Prior to the start of the intravenous infusion, the content of the infusion bag should be at room temperature. Use the prepared infusion solution immediately. If not used immediately, store up to 24 hours in the refrigerator at 2°C to 8°C (36°F to 46°F) and 8 hours at room temperature up to 25°C (77°F), which includes infusion time.

In the event an intravenous infusion cannot be completed the same day, discard the remaining solution. No incompatibilities between OCREVUS and polyvinyl chloride (PVC) or polyolefin (PO) bags and intravenous (IV) administration sets have been observed. Administration Administer the diluted infusion solution through a dedicated line using an infusion set with a 0.2 or 0.22 micron in-line filter.

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reactions rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. Adults The safety of OCREVUS has been evaluated in 1311 adult patients across MS clinical studies, which included 825 patients in active-controlled clinical trials in patients with relapsing forms of MS (RMS) and 486 patients in a placebo-controlled study in patients with primary progressive MS (PPMS). The overall exposure in the 96-week controlled treatment periods was 1448 patient-years.

The most common adverse reactions in RMS trials (incidence ≥ 10%) were upper respiratory tract infections and infusion reactions. Table 4 summarizes the adverse reactions that occurred in RMS trials (Study 1 and Study 2). Table 4 Adverse Reactions in Adult Patients with RMS with an Incidence of at least 5% for OCREVUS and Higher than REBIF in Adult Patients with Primary Progressive MS In a placebo-controlled clinical trial (Study 3), a total of 486 patients with PPMS received one course of OCREVUS (600 mg of OCREVUS administered as two 300 mg infusions two weeks apart) given intravenously every 24 weeks and 239 patients received placebo intravenously.

The overall exposure in the controlled treatment period was 1416 patient-years, with median treatment duration of 3 years. The most common adverse reactions in the PPMS trial (incidence ≥ 10%) were upper respiratory tract infections, infusion reactions, skin infections, and lower respiratory tract infections. Table 5 summarizes the adverse reactions that occurred in the PPMS trial (Study 3).

Table 5 Adverse Reactions in Adult Patients with PPMS with an Incidence of at least 5% for OCREVUS and Higher than in Adult Patients who Received 2-hour Infusions Study 4 was designed to characterize the safety profile of OCREVUS infusions administered over 2 hours in patients with Relapsing-Remitting Multiple Sclerosis who did not experience a serious infusion reaction with any previous OCREVUS infusion. In this study, the incidence, intensity, and types of symptoms of infusion reactions were consistent with those of infusions administered over 3.5 hours. Laboratory Abnormalities in Adults Decreased Immunoglobulins OCREVUS decreased total immunoglobulins with the greatest decline seen in IgM levels; however, a decrease in IgG levels was associated with an increased rate of serious infections.

The pooled data of OCREVUS clinical studies (RMS and PPMS) and their open-label extensions (up to approximately 7 years of exposure) have shown an association between decreased levels of IgG and increased rates of serious infections. The type, severity, latency, duration, and outcome of serious infections observed during episodes of immunoglobulins below LLN were consistent with the overall serious infections observed in patients treated with OCREVUS. Decreased Neutrophil Levels In the PPMS clinical trial (Study 3), decreased neutrophil counts occurred in 13% of OCREVUS-treated patients compared to 10% in placebo patients.

Pediatric Patients Adverse Reactions in Patients 10 to Less Than 18 Years of Age with Relapsing-Remitting MS The safety of OCREVUS in pediatric patients with relapsing-remitting MS was evaluated in one randomized, double-blind clinical study in 185 patients, 93 of whom received OCREVUS and 92 of whom received fingolimod. In the controlled pediatric trial (Study 5), the safety profile in pediatric patients was consistent with that observed in adult patients. Infusion Reactions Infusion reactions were the most common adverse reactions in patients treated with OCREVUS with an incidence of 48%, compared to an incidence of 24% in fingolimod-treated patients (placebo infusion).

At the first subsequent dose (at 6 months), 16% of patients had an infusion reaction. The incidence and severity of infusion reactions decreased with additional subsequent infusions. The majority of infusion reactions were mild to moderate.

One infusion reaction with infusion 1 of the initial dose was reported as serious because it required hospitalization. Laboratory Abnormalities Decreased Immunoglobulins OCREVUS decreased total immunoglobulins over the controlled period of Study 5, with the greatest decline seen in IgM levels. Similar to the pattern observed in the adult population, reduction in IgM occurred earlier and in a higher proportion of patients compared to IgG and IgA.

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of OCREVUS. 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 drug exposure. Gastrointestinal Disorders: Immune-mediated colitis Hepatobiliary Disorders: Liver injury Infections and Infestations: Serious herpes infections, progressive multifocal leukoencephalopathy, and babesiosis Skin: Pyoderma gangrenosum

Immunosuppressive or Immune-Modulating Therapies

The concomitant use of OCREVUS and other immune-modulating or immunosuppressive therapies, including immunosuppressant doses of corticosteroids, is expected to increase the risk of immunosuppression. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with OCREVUS. When switching from drugs with prolonged immune effects, such as daclizumab, fingolimod, natalizumab, teriflunomide, or mitoxantrone, consider the duration and mode of action of these drugs because of additive immunosuppressive effects when initiating OCREVUS.

Vaccinations A Phase 3b randomized, open-label study examined the concomitant use of OCREVUS and several non-live vaccines in adults 18-55 years of age with relapsing forms of MS (68 subjects undergoing treatment with OCREVUS at the time of vaccination and 34 subjects not undergoing treatment with OCREVUS at the time of vaccination). Concomitant exposure to OCREVUS attenuated antibody responses to tetanus toxoid-containing vaccine, pneumococcal polysaccharide, pneumococcal conjugate vaccines, and seasonal inactivated influenza vaccines. The impact of the observed attenuation on vaccine effectiveness in this patient population is unknown.

The safety and effectiveness of live or live-attenuated vaccines administered concomitantly with OCREVUS have not been assessed.

Pregnancy Risk Summary OCREVUS is a humanized monoclonal antibody of an immunoglobulin G1 subtype and immunoglobulins are known to cross the placental barrier. There are no adequate data on the developmental risk associated with use of OCREVUS in pregnant women. However, transient peripheral B-cell depletion and lymphocytopenia have been reported in infants born to mothers exposed to other anti-CD20 antibodies during pregnancy.

B-cell levels in infants following maternal exposure to OCREVUS have not been studied in clinical trials. The potential duration of B-cell depletion in such infants, and the impact of B-cell depletion on vaccine safety and effectiveness, is unknown. Following administration of ocrelizumab to pregnant monkeys at doses similar to or greater than those used clinically, increased perinatal mortality, depletion of B-cell populations, renal, bone marrow, and testicular toxicity were observed in the offspring in the absence of maternal toxicity.

In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is respectively. The background risk of major birth defects and miscarriage for the indicated population is unknown. Intravenous administration of OCREVUS (three daily loading doses of 15 or 75 mg/kg, followed by weekly doses of 20 or 100 mg/kg) to pregnant monkeys throughout the period of organogenesis and continuing through the neonatal period resulted in perinatal deaths (some associated with bacterial infections), renal toxicity (glomerulopathy and inflammation), lymphoid follicle formation in the bone marrow, and severe decreases in circulating B-lymphocytes in neonates.

The cause of the neonatal deaths is uncertain; however, both affected neonates were found to have bacterial infections. Reduced testicular weight was observed in neonates at the high dose. A no-effect dose for adverse developmental effects was not identified; the doses tested in monkey are 2 and 10 times the recommended human dose of 600 mg, on a mg/kg basis.

Pediatric Use The safety and effectiveness of OCREVUS for the treatment of relapsing-remitting MS have been established in pediatric patients 10 years of age and older who weigh 25 kg or more. Use of OCREVUS for this indication is supported by evidence from one randomized, double-blind clinical study in 187 pediatric patients (93 of whom received OCREVUS) and additional pharmacokinetic data in pediatric patients. The overall safety profile in pediatric patients 10 years of age and older receiving OCREVUS was generally consistent with that observed in adult patients.

Safety and effectiveness of OCREVUS have not been established in pediatric patients less than 10 years of age or who weigh less than 25 kg.

OCREVUS is contraindicated in patients with: Active HBV infection A history of life-threatening infusion reaction to OCREVUS Active hepatitis B virus infection History of life-threatening infusion reaction to OCREVUS