Pharmacokinetics

The pharmacokinetic parameters of single and multiple injections of ganirelix acetate injection in healthy adult females are summarized in Table I. Steady-state serum concentrations are reached after 3 days of treatment. The pharmacokinetics of ganirelix acetate are dose-proportional in the dose range of 125 mcg to 500 mcg.

Special Populations

The pharmacokinetics of ganirelix acetate injection have not been determined in special populations such as geriatric, pediatric, renally impaired and hepatically impaired patients (see PRECAUTIONS).

Clinical Studies

The efficacy of ganirelix acetate injection was established in two adequate and well-controlled clinical studies which included women with normal endocrine and pelvic ultrasound parameters. The studies intended to exclude subjects with polycystic ovary syndrome (PCOS) and subjects with low or no ovarian reserve. One cycle of study medication was administered to each randomized subject. For both studies, the administration of exogenous recombinant FSH [Follistim®1 (follitropin beta for injection)] 150 IU daily was initiated on the morning of Day 2 or 3 of a natural menstrual cycle. Ganirelix acetate injection was administered on the morning of Day 7 or 8 (Day 6 of recombinant FSH administration). The dose of recombinant FSH administered was adjusted according to individual responses starting on the day of initiation of ganirelix acetate. Both recombinant FSH and ganirelix acetate were continued daily until at least three follicles were 17 mm or greater in diameter at which time hCG [Pregnyl®1 (chorionic gonadotropin for injection, USP)] was administered. Following hCG administration, ganirelix acetate and recombinant FSH administration were discontinued. Oocyte retrieval, followed by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), was subsequently performed.

In a multicenter, double-blind, randomized, dose-finding study, the safety and efficacy of ganirelix acetate injection were evaluated for the prevention of LH surges in women undergoing COH with recombinant FSH. Ganirelix acetate injection doses ranging from 62.5 mcg to 2,000 mcg and recombinant FSH were administered to 332 patients undergoing COH for IVF (see TABLE II). Median serum LH on the day of hCG administration decreased with increasing doses of ganirelix acetate. Median serum E2 (17β-estradiol) on the day of hCG administration was 1,475; 1,110; and 1,160 pg/mL for the 62.5 mcg, 125 mcg, and 250 mcg doses, respectively. Lower peak serum E2 levels of 823, 703, and 441 pg/mL were seen at higher doses of ganirelix acetate 500 mcg, 1,000 mcg, and 2,000 mcg, respectively. The highest pregnancy and implantation rates were achieved with the 250 mcg dose of ganirelix acetate injection as summarized in Table II.

Transient LH rises alone were not deleterious to achieving pregnancy with ganirelix acetate at doses of 125 mcg (3/6 subjects) and 250 mcg (1/1 subjects). In addition, none of the subjects with LH rises ≥ 10 mIU/mL had premature luteinization indicated by a serum progesterone above 2 ng/mL.

A multicenter, open-label, randomized study was conducted to assess the efficacy and safety of ganirelix acetate injection in women undergoing COH. Follicular phase treatment with ganirelix acetate 250 mcg was studied using a luteal phase GnRH agonist as a reference treatment. A total of 463 subjects were treated with ganirelix acetate by subcutaneous injection once daily starting on Day 6 of recombinant FSH treatment. Recombinant FSH was maintained at 150 IU for the first 5 days of ovarian stimulation and was then adjusted by the investigator on the sixth day of gonadotropin use according to individual responses. The results for the ganirelix acetate arm are summarized in Table III.

Some centers were limited to the transfer of ≤ 2 embryos based on local practice standards The mean number of days of ganirelix acetate treatment was 5.4 (2 to 14).

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General

Special care should be taken in women with signs and symptoms of active allergic conditions.

Cases of hypersensitivity reactions, including anaphylactoid reactions, have been reported, as early as with the first dose, during postmarketing surveillance (see ADVERSE REACTIONS). In the absence of clinical experience, ganirelix acetate treatment is not advised in women with severe allergic conditions.

The packaging of this product contains natural rubber latex which may cause allergic reactions (see HOW SUPPLIED).

Information for Patients

Prior to therapy with ganirelix acetate injection, patients should be informed of the duration of treatment and monitoring procedures that will be required. The risk of possible adverse reactions should be discussed (see ADVERSE REACTIONS).

Ganirelix acetate should not be prescribed if the patient is pregnant.

Laboratory Tests

A neutrophil count ≥ 8.3 ( × 109/L) was noted in 11.9% (up to 16.8 × 109/L) of all subjects treated within the adequate and well-controlled clinical trials. In addition, downward shifts within the ganirelix acetate injection group were observed for hematocrit and total bilirubin. The clinical significance of these findings was not determined.

Drug Interactions

No formal drug-drug interaction studies have been performed.

Carcinogenesis and Mutagenesis, Impairment of Fertility

Long-term toxicity studies in animals have not been performed with ganirelix acetate injection to evaluate the carcinogenic potential of the drug. Ganirelix acetate did not induce a mutagenic response in the Ames test (S. typhimurium and E. coli) or produce chromosomal aberrations in in vitro assay using Chinese Hamster Ovary cells.

Pregnancy

Ganirelix acetate injection is contraindicated in pregnant women. When administered from Day 7 to near term to pregnant rats and rabbits at doses up to 10 and 30 mcg/day (approximately 0.4 to 3.2 times the human dose based on body surface area), ganirelix acetate increased the incidence of litter resorption. There was no increase in fetal abnormalities. No treatment-related changes in fertility, physical, or behavioral characteristics were observed in the offspring of female rats treated with ganirelix acetate during pregnancy and lactation.

The effects on fetal resorption are logical consequences of the alteration in hormonal levels brought about by the antigonadotropic properties of this drug and could result in fetal loss in humans. Therefore, this drug should not be used in pregnant women (see CONTRAINDICATIONS).

Nursing Mothers

Ganirelix acetate injection should not be used by lactating women. It is not known whether this drug is excreted in human milk.

Geriatric Use

Clinical studies with ganirelix acetate injection did not include a sufficient number of subjects aged 65 and over.

Congenital Anomalies

Ongoing clinical follow-up studies of 283 newborns of women administered ganirelix acetate injection were reviewed. There were three neonates with major congenital anomalies and 18 neonates with minor congenital anomalies. The major congenital anomalies were: hydrocephalus/meningocele, omphalocele, and Beckwith-Wiedemann Syndrome. The minor congenital anomalies were: nevus, skin tags, sacral sinus, hemangioma, torticollis/asymmetric skull, talipes, supernumerary digit finger, hip subluxation, torticollis/high palate, occiput/abnormal hand crease, hernia umbilicalis, hernia inguinalis, hydrocele, undescended testis, and hydronephrosis. The causal relationship between these congenital anomalies and ganirelix acetate is unknown. Multiple factors, genetic and others (including, but not limited to ICSI, IVF, gonadotropins, progesterone) may confound ART (Assisted Reproductive Technology) procedures.

Directions for Using Ganirelix Acetate Injection

1. Ganirelix acetate injection is supplied in a single-dose, sterile, prefilled syringe and is intended for SUBCUTANEOUS administration only.
2. Wash hands thoroughly with soap and water.
3. The most convenient sites for SUBCUTANEOUS injection are in the abdomen around the navel or upper thigh.
4. The injection site should be swabbed with a disinfectant to remove any surface bacteria. Clean about two inches around the point where the needle will be inserted and let the disinfectant dry for at least one minute before proceeding.
5. With syringe held upward, remove needle cover.
6. Pinch up a large area of skin between the finger and thumb. Vary the injection site a little with each injection.
7. The needle should be inserted at the base of the pinched-up skin at an angle of 45 to 90° to the skin surface.
8. When the needle is correctly positioned, it will be difficult to draw back on the plunger. If any blood is drawn into the syringe, the needle tip has penetrated a vein or artery. If this happens, withdraw the needle slightly and reposition the needle without removing it from the skin. Alternatively, remove the needle and use a new, sterile, prefilled syringe. Cover the injection site with a swab containing disinfectant and apply pressure; the site should stop bleeding within one or two minutes.
9. Once the needle is correctly placed, depress the plunger slowly and steadily, so the solution is correctly injected and the skin is not damaged.
10. Pull the syringe out quickly and apply pressure to the site with a swab containing disinfectant.
11. Use the sterile, prefilled syringe only once. Discard the unused portion and dispose of it properly.

Storage

Store at 20° to 25°C (68° to 77°F); excursions permitted between 15° and 30°C (59° and 86°F) [see USP Controlled Room Temperature]. Protect from light.