Drug Detail:Soliris (Eculizumab [ e-kue-liz-oo-mab ])
Drug Class: Selective immunosuppressants
Highlights of Prescribing Information
SOLIRIS® (eculizumab) injection, for intravenous use
Initial U.S. Approval: 2007
WARNING: SERIOUS MENINGOCOCCAL INFECTIONS
See full prescribing information for complete boxed warning
Life-threatening and fatal meningococcal infections have occurred in patients treated with Soliris and may become rapidly life-threatening or fatal if not recognized and treated early (5.1).
- Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for meningococcal vaccination in patients with complement deficiencies (5.1).
- Immunize patients with meningococcal vaccines at least 2 weeks prior to administering the first dose of Soliris, unless the risks of delaying Soliris therapy outweigh the risks of developing a meningococcal infection. (See Warnings and Precautions (5.1) for additional guidance on the management of the risk of meningococcal infection.)
- Vaccination reduces, but does not eliminate, the risk of meningococcal infections. Monitor patients for early signs of meningococcal infections, and evaluate immediately if infection is suspected.
Soliris is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS). Under the Soliris REMS, prescribers must enroll in the program (5.1).
Indications and Usage for Soliris
Soliris is a complement inhibitor indicated for:
- The treatment of patients with paroxysmal nocturnal hemoglobinuria (PNH) to reduce hemolysis (1.1).
- The treatment of patients with atypical hemolytic uremic syndrome (aHUS) to inhibit complement-mediated thrombotic microangiopathy (1.2).
Limitation of Use
Soliris is not indicated for the treatment of patients with Shiga toxin E. coli related hemolytic uremic syndrome (STEC-HUS). - The treatment of generalized myasthenia gravis (gMG) in adult patients who are anti-acetylcholine receptor (AchR) antibody positive (1.3).
- The treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive (1.4).
Soliris Dosage and Administration
For intravenous infusion only
PNH Dosage Regimen: (2.2)
aHUS Dosage Regimen: (2.3)
gMG and NMOSD Dosage Regimen: (2.4)
Dosage Forms and Strengths
Injection: 300 mg/30 mL (10 mg/mL) in a single-dose vial (3).
Contraindications
Soliris is contraindicated in:
- Patients with unresolved serious Neisseria meningitidis infection (4).
- Patients who are not currently vaccinated against Neisseria meningitidis, unless the risks of delaying Soliris treatment outweigh the risks of developing a meningococcal infection (5.1).
Warnings and Precautions
- Discontinue Soliris in patients who are being treated for serious meningococcal infections (5.1).
- Use caution when administering Soliris to patients with any other systemic infection (5.2).
- Infusion-Related Reactions: Monitor patients during infusion, interrupt for reactions, and institute appropriate supportive measures (5.5)
Adverse Reactions/Side Effects
The most frequently reported adverse reactions in the PNH randomized trial (≥10% overall and greater than placebo) are: headache, nasopharyngitis, back pain, and nausea (6.1).
The most frequently reported adverse reactions in aHUS single arm prospective trials (≥20%) are: headache, diarrhea, hypertension, upper respiratory infection, abdominal pain, vomiting, nasopharyngitis, anemia, cough, peripheral edema, nausea, urinary tract infections, pyrexia (6.1).
The most frequently reported adverse reaction in the gMG placebo-controlled clinical trial (≥10%) is: musculoskeletal pain (6.1).
The most frequently reported adverse reactions in the NMOSD placebo- controlled trial (≥10%) are: upper respiratory infection, nasopharyngitis, diarrhea, back pain, dizziness, influenza, arthralgia, pharyngitis, and contusion (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Alexion Pharmaceuticals, Inc. at 1-844-259-6783 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.
Revised: 11/2020
Full Prescribing Information
WARNING: SERIOUS MENINGOCOCCAL INFECTIONS
Life-threatening and fatal meningococcal infections have occurred in patients treated with Soliris. Meningococcal infection may become rapidly life-threatening or fatal if not recognized and treated early [see Warnings and Precautions (5.1)].
- Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for meningococcal vaccination in patients with complement deficiencies.
- Immunize patients with meningococcal vaccines at least 2 weeks prior to administering the first dose of Soliris, unless the risks of delaying Soliris therapy outweigh the risk of developing a meningococcal infection. [See Warnings and Precautions (5.1) for additional guidance on the management of the risk of meningococcal infection].
- Vaccination reduces, but does not eliminate, the risk of meningococcal infections. Monitor patients for early signs of meningococcal infections and evaluate immediately if infection is suspected.
Soliris is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS). Under the Soliris REMS, prescribers must enroll in the program [see Warnings and Precautions (5.1)]. Enrollment in the Soliris REMS program and additional information are available by telephone: 1-888-SOLIRIS (1-888-765-4747) or at www.solirisrems.com.
1. Indications and Usage for Soliris
1.1 Paroxysmal Nocturnal Hemoglobinuria (PNH)
Soliris is indicated for the treatment of patients with paroxysmal nocturnal hemoglobinuria (PNH) to reduce hemolysis.
1.2 Atypical Hemolytic Uremic Syndrome (aHUS)
Soliris is indicated for the treatment of patients with atypical hemolytic uremic syndrome (aHUS) to inhibit complement-mediated thrombotic microangiopathy.
2. Soliris Dosage and Administration
2.1 Recommended Vaccination and Prophylaxis
Vaccinate patients according to current ACIP guidelines to reduce the risk of serious infection [see Warnings and Precautions (5.1 and 5.2)].
Provide two weeks of antibacterial drug prophylaxis to patients if Soliris must be initiated immediately and vaccines are administered less than two weeks before starting Soliris therapy.
Healthcare professionals who prescribe Soliris must enroll in the Soliris REMS [see Warnings and Precautions (5.1)].
2.2 Recommended Dosage Regimen – PNH
For patients 18 years of age and older, Soliris therapy consists of:
- 600 mg weekly for the first 4 weeks, followed by
- 900 mg for the fifth dose 1 week later, then
- 900 mg every 2 weeks thereafter.
Administer Soliris at the recommended dosage regimen time points, or within two days of these time points [see Warnings and Precautions (5.4)].
2.3 Recommended Dosage Regimen – aHUS
For patients 18 years of age and older, Soliris therapy consists of:
- 900 mg weekly for the first 4 weeks, followed by
- 1200 mg for the fifth dose 1 week later, then
- 1200 mg every 2 weeks thereafter.
For patients less than 18 years of age, administer Soliris based upon body weight, according to the following schedule (Table 1):
| Patient Body Weight | Induction | Maintenance |
|---|---|---|
| 40 kg and over | 900 mg weekly × 4 doses | 1200 mg at week 5; then 1200 mg every 2 weeks |
| 30 kg to less than 40 kg | 600 mg weekly × 2 doses | 900 mg at week 3; then 900 mg every 2 weeks |
| 20 kg to less than 30 kg | 600 mg weekly × 2 doses | 600 mg at week 3; then 600 mg every 2 weeks |
| 10 kg to less than 20 kg | 600 mg weekly × 1 dose | 300 mg at week 2; then 300 mg every 2 weeks |
| 5 kg to less than 10 kg | 300 mg weekly × 1 dose | 300 mg at week 2; then 300 mg every 3 weeks |
Administer Soliris at the recommended dosage regimen time points, or within two days of these time points.
2.4 Recommended Dosage Regimen – gMG and NMOSD
For adult patients with generalized myasthenia gravis or neuromyelitis optica spectrum disorder, Soliris therapy consists of:
- 900 mg weekly for the first 4 weeks, followed by
- 1200 mg for the fifth dose 1 week later, then
- 1200 mg every 2 weeks thereafter.
Administer Soliris at the recommended dosage regimen time points, or within two days of these time points.
2.5 Dose Adjustment in Case of Plasmapheresis, Plasma Exchange, or Fresh Frozen Plasma Infusion
For adult and pediatric patients with aHUS, and adult patients with gMG or NMOSD, supplemental dosing of Soliris is required in the setting of concomitant plasmapheresis or plasma exchange, or fresh frozen plasma infusion (PE/PI) (Table 2).
| Type of Plasma Intervention | Most Recent Soliris Dose | Supplemental Soliris Dose with Each Plasma Intervention | Timing of Supplemental Soliris Dose |
|---|---|---|---|
| Plasmapheresis or plasma exchange | 300 mg | 300 mg per each plasmapheresis or plasma exchange session | Within 60 minutes after each plasmapheresis or plasma exchange |
| ≥600 mg | 600 mg per each plasmapheresis or plasma exchange session | ||
| Fresh frozen plasma infusion | ≥300 mg | 300 mg per infusion of fresh frozen plasma | 60 minutes prior to each infusion of fresh frozen plasma |
2.6 Preparation
Dilute Soliris to a final admixture concentration of 5 mg/mL using the following steps:
- Withdraw the required amount of Soliris from the vial into a sterile syringe.
- Transfer the recommended dose to an infusion bag.
- Dilute Soliris to a final concentration of 5 mg/mL by adding the appropriate amount (equal volume of diluent to drug volume) of 0.9% Sodium Chloride Injection, USP; 0.45% Sodium Chloride Injection, USP; 5% Dextrose in Water Injection, USP; or Ringer's Injection, USP to the infusion bag.
The final admixed Soliris 5 mg/mL infusion volume is 60 mL for 300 mg doses, 120 mL for 600 mg doses, 180 mL for 900 mg doses or 240 mL for 1200 mg doses (Table 3).
| Soliris Dose | Diluent Volume | Final Volume |
|---|---|---|
| 300 mg | 30 mL | 60 mL |
| 600 mg | 60 mL | 120 mL |
| 900 mg | 90 mL | 180 mL |
| 1200 mg | 120 mL | 240 mL |
Gently invert the infusion bag containing the diluted Soliris solution to ensure thorough mixing of the product and diluent. Discard any unused portion left in a vial, as the product contains no preservatives.
Prior to administration, the admixture should be allowed to adjust to room temperature [18°-25° C, 64°-77° F]. The admixture must not be heated in a microwave or with any heat source other than ambient air temperature.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
2.7 Administration
Only administer as an intravenous infusion.
Do not administer as an intravenous push or bolus injection.
Administer the Soliris admixture by intravenous infusion over 35 minutes in adults and 1 to 4 hours in pediatric patients via gravity feed, a syringe-type pump, or an infusion pump. Admixed solutions of Soliris are stable for 24 h at 2°-8° C (36°-46° F) and at room temperature.
If an adverse reaction occurs during the administration of Soliris, the infusion may be slowed or stopped at the discretion of the physician. If the infusion is slowed, the total infusion time should not exceed two hours in adults. Monitor the patient for at least one hour following completion of the infusion for signs or symptoms of an infusion-related reaction.
3. Dosage Forms and Strengths
Injection: 300 mg/30 mL (10 mg/mL) as a clear, colorless solution in a single-dose vial.
4. Contraindications
Soliris is contraindicated in:
- Patients with unresolved serious Neisseria meningitidis infection [see Warnings and Precautions (5.1)].
- Patients who are not currently vaccinated against Neisseria meningitidis, unless the risks of delaying Soliris treatment outweigh the risks of developing a meningococcal infection [see Warnings and Precautions (5.1)].
5. Warnings and Precautions
5.2 Other Infections
Serious infections with Neisseria species (other than N. meningitidis), including disseminated gonococcal infections, have been reported.
Soliris blocks terminal complement activation; therefore patients may have increased susceptibility to infections, especially with encapsulated bacteria. Additionally, Aspergillus infections have occurred in immunocompromised and neutropenic patients. Children treated with Soliris may be at increased risk of developing serious infections due to Streptococcus pneumoniae and Haemophilus influenzae type b (Hib). Administer vaccinations for the prevention of Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) infections according to ACIP guidelines. Use caution when administering Soliris to patients with any systemic infection [see Warnings and Precautions (5.1)].
5.4 Thrombosis Prevention and Management
The effect of withdrawal of anticoagulant therapy during Soliris treatment has not been established. Therefore, treatment with Soliris should not alter anticoagulant management.
5.5 Infusion-Related Reactions
Administration of Soliris may result in infusion-related reactions, including anaphylaxis or other hypersensitivity reactions. In clinical trials, no patients experienced an infusion-related reaction which required discontinuation of Soliris. Interrupt Soliris infusion and institute appropriate supportive measures if signs of cardiovascular instability or respiratory compromise occur.
6. Adverse Reactions/Side Effects
The following serious adverse reactions are discussed in greater detail in other sections of the labeling:
- Serious Meningococcal Infections [see Warnings and Precautions (5.1)]
- Other Infections [see Warnings and Precautions (5.2)]
- Monitoring Disease Manifestations after Soliris Discontinuation [see Warnings and Precautions (5.3)]
- Thrombosis Prevention and Management [see Warnings and Precautions (5.4)]
- Infusion-Related Reactions [see Warnings and Precautions (5.5)]
6.1 Clinical Trial 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 trials of another drug and may not reflect the rates observed in practice.
Meningococcal infections are the most important adverse reactions experienced by patients receiving Soliris. In PNH clinical studies, two patients experienced meningococcal sepsis. Both patients had previously received a meningococcal vaccine. In clinical studies among patients without PNH, meningococcal meningitis occurred in one unvaccinated patient. Meningococcal sepsis occurred in one previously vaccinated patient enrolled in the retrospective aHUS study during the post-study follow-up period [see Warnings and Precautions (5.1)].
6.2 Immunogenicity
As with all proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to eculizumab in the studies described below with the incidence of antibodies in other studies or to other products may be misleading.
The immunogenicity of Soliris has been evaluated using two different immunoassays for the detection of anti-eculizumab antibodies: a direct enzyme-linked immunosorbent assay (ELISA) using the Fab fragment of eculizumab as target was used for the PNH indication; and an electro-chemiluminescence (ECL) bridging assay using the eculizumab whole molecule as target was used for the aHUS, gMG, and NMOSD indications, as well as for additional patients with PNH. In the PNH population, antibodies to Soliris were detected in 3/196 (2%) patients using the ELISA assay and in 5/161 (3%) patients using the ECL assay. In the aHUS population, antibodies to Soliris were detected in 3/100 (3%) patients using the ECL assay. None of the 62 patients with gMG had antibodies to Soliris detected following the 26-week active treatment. Two of the 96 (2%) Soliris-treated patients with NMOSD had antibodies to Soliris detected during the entire treatment period.
An ECL based neutralizing assay with a low sensitivity of 2 mcg/mL was performed to detect neutralizing antibodies for the 5 patients with PNH, the 3 patients with aHUS, and the 2 patients with NMOSD with anti-eculizumab antibody positive samples using the ECL assay. Two of 161 patients with PNH (1.2%) and 1 of 100 patients with aHUS (1%), and none of the 96 patients with NMOSD had low positive values for neutralizing antibodies.
No apparent correlation of antibody development to clinical response was observed.
6.3 Postmarketing Experience
The following adverse reactions have been identified during post-approval use of Soliris. 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 Soliris exposure.
Fatal or serious infections: Neisseria gonorrhoeae, Neisseria meningitidis, Neisseria sicca/subflava, Neisseria spp unspecified
8. Use In Specific Populations
8.4 Pediatric Use
Safety and effectiveness of Soliris for the treatment of PNH, gMG, or NMOSD in pediatric patients have not been established.
The safety and effectiveness of Soliris for the treatment of aHUS have been established in pediatric patients. Use of Soliris in pediatric patients for this indication is supported by evidence from four adequate and well-controlled clinical studies assessing the safety and effectiveness of Soliris for the treatment of aHUS. The studies included a total of 47 pediatric patients (ages 2 months to 17 years). The safety and effectiveness of Soliris for the treatment of aHUS appear similar in pediatric and adult patients [see Adverse Reactions (6.1), and Clinical Studies (14.2)].
Administer vaccinations for the prevention of infection due to Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) according to ACIP guidelines [see Warnings and Precautions (5.1, 5.2)].
8.5 Geriatric Use
Fifty-one patients 65 years of age or older (15 with PNH, 4 with aHUS, 26 with gMG, and 6 with NMOSD) were treated with Soliris in clinical trials in the approved indications. Although there were no apparent age-related differences observed in these studies, the number of patients aged 65 and over is not sufficient to determine whether they respond differently from younger patients.
11. Soliris Description
Eculizumab, a complement inhibitor, is a recombinant humanized monoclonal IgG2/4κ antibody produced by murine myeloma cell culture and purified by standard bioprocess technology. Eculizumab contains human constant regions from human IgG2 sequences and human IgG4 sequences and murine complementarity-determining regions grafted onto the human framework light- and heavy-chain variable regions. Eculizumab is composed of two 448 amino acid heavy chains and two 214 amino acid light chains and has a molecular weight of approximately 148 kDa.
Soliris (eculizumab) injection is a sterile, clear, colorless, preservative-free 10 mg/mL solution for intravenous infusion and is supplied in 30-mL single-dose vials. The product is formulated at pH 7 and each 30 mL vial contains 300 mg of eculizumab, polysorbate 80 (6.6 mg) (vegetable origin), sodium chloride (263.1 mg), sodium phosphate dibasic (53.4 mg), sodium phosphate monobasic (13.8 mg), and Water for Injection, USP.
12. Soliris - Clinical Pharmacology
12.1 Mechanism of Action
Eculizumab, the active ingredient in Soliris, is a monoclonal antibody that specifically binds to the complement protein C5 with high affinity, thereby inhibiting its cleavage to C5a and C5b and preventing the generation of the terminal complement complex C5b-9.
Soliris inhibits terminal complement-mediated intravascular hemolysis in PNH patients and complement-mediated thrombotic microangiopathy (TMA) in patients with aHUS.
The precise mechanism by which eculizumab exerts its therapeutic effect in gMG patients is unknown, but is presumed to involve reduction of terminal complement complex C5b-9 deposition at the neuromuscular junction.
The precise mechanism by which eculizumab exerts its therapeutic effect in NMOSD is unknown, but is presumed to involve inhibition of aquaporin-4-antibody induced terminal complement C5b-9 deposition.
12.2 Pharmacodynamics
In the placebo-controlled clinical study (PNH Study 1), Soliris when administered as recommended reduced serum LDH levels from 2200 ± 1034 U/L (mean ± SD) at baseline to 700 ± 388 U/L by week one and maintained the effect through the end of the study at week 26 (327 ± 433 U/L) in patients with PNH. In the single arm clinical study (PNH Study 2), the effect was maintained through week 52 [see Clinical Studies (14)].
In patients with PNH, aHUS, gMG, and NMOSD, free C5 concentrations of < 0.5 mcg/mL was correlated with complete blockade of terminal complement activity.
12.3 Pharmacokinetics
Following intravenous maintenance doses of 900 mg once every 2 weeks in patients with PNH, the week 26 observed mean ± SD serum eculizumab maximum concentration (Cmax) was 194 ± 76 mcg/mL and the trough concentration (Ctrough) was 97 ± 60 mcg/mL. Following intravenous maintenance doses of 1200 mg once every 2 weeks in patients with aHUS, the week 26 observed mean ± SD Ctrough was 242 ± 101 mcg/mL. Following intravenous maintenance doses of 1200 mg once every 2 weeks in patients with gMG, the week 26 observed mean ± SD Cmax was 783 ± 288 mcg/mL and the Ctrough was 341 ± 172 mcg/mL. Following intravenous maintenance doses of 1200 mg once every 2 weeks in patients with NMOSD, at week 24, the observed mean±SD Cmax was 877±331 and the Ctrough was 429±188 mcg/mL.
Steady state was achieved 4 weeks after starting eculizumab treatment, with accumulation ratio of approximately 2-fold in all studied indications. Population pharmacokinetic analyses showed that eculizumab pharmacokinetics were dose-linear and time-independent over the 600 mg to 1200 mg dose range, with inter-individual variability of 21% to 38%.
13. Nonclinical Toxicology
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term animal carcinogenicity studies of eculizumab have not been conducted.
Genotoxicity studies have not been conducted with eculizumab.
Effects of eculizumab upon fertility have not been studied in animals. Intravenous injections of male and female mice with a murine anti-C5 antibody at up to 4-8 times the equivalent of the clinical dose of Soliris had no adverse effects on mating or fertility.
14. Clinical Studies
14.1 Paroxysmal Nocturnal Hemoglobinuria (PNH)
The safety and efficacy of Soliris in PNH patients with hemolysis were assessed in a randomized, double-blind, placebo-controlled 26 week study (PNH Study 1, NCT00122330); PNH patients were also treated with Soliris in a single arm 52 week study (PNH Study 2, NCT00122304) and in a long-term extension study (E05-001, NCT00122317). Patients received meningococcal vaccination prior to receipt of Soliris. In all studies, the dose of Soliris was 600 mg study drug every 7 ± 2 days for 4 weeks, followed by 900 mg 7 ± 2 days later, then 900 mg every 14 ± 2 days for the study duration. Soliris was administered as an intravenous infusion over 25 - 45 minutes.
PNH Study 1:
PNH patients with at least four transfusions in the prior 12 months, flow cytometric confirmation of at least 10% PNH cells and platelet counts of at least 100,000/microliter were randomized to either Soliris (n = 43) or placebo (n = 44). Prior to randomization, all patients underwent an initial observation period to confirm the need for RBC transfusion and to identify the hemoglobin concentration (the "set-point") which would define each patient's hemoglobin stabilization and transfusion outcomes. The hemoglobin set-point was less than or equal to 9 g/dL in patients with symptoms and was less than or equal to 7 g/dL in patients without symptoms. Endpoints related to hemolysis included the numbers of patients achieving hemoglobin stabilization, the number of RBC units transfused, fatigue, and health-related quality of life. To achieve a designation of hemoglobin stabilization, a patient had to maintain a hemoglobin concentration above the hemoglobin set-point and avoid any RBC transfusion for the entire 26 week period. Hemolysis was monitored mainly by the measurement of serum LDH levels, and the proportion of PNH RBCs was monitored by flow cytometry. Patients receiving anticoagulants and systemic corticosteroids at baseline continued these medications.
Major baseline characteristics were balanced (see Table 10).
| Study 1 | ||
|---|---|---|
| Parameter | Placebo (N=44) | Soliris (N=43) |
| Mean age (SD) | 38 (13) | 42 (16) |
| Gender - female (%) | 29 (66) | 23 (54) |
| History of aplastic anemia or myelodysplastic syndrome (%) | 12 (27) | 8 (19) |
| Patients with history of thrombosis (events) | 8 (11) | 9 (16) |
| Concomitant anticoagulants (%) | 20 (46) | 24 (56) |
| Concomitant steroids/immunosuppressant treatments (%) | 16 (36) | 14 (33) |
| Packed RBC units transfused per patient in previous 12 months (median (Q1,Q3)) | 17 (14, 25) | 18 (12, 24) |
| Mean Hgb level (g/dL) at setpoint (SD) | 8 (1) | 8 (1) |
| Pre-treatment LDH levels (median, U/L) | 2,234 | 2,032 |
| Free hemoglobin at baseline (median, mg/dL) | 46 | 41 |
Patients treated with Soliris had significantly reduced (p< 0.001) hemolysis resulting in improvements in anemia as indicated by increased hemoglobin stabilization and reduced need for RBC transfusions compared to placebo treated patients (see Table 11). These effects were seen among patients within each of the three pre-study RBC transfusion strata (4 - 14 units; 15 - 25 units; > 25 units). After 3 weeks of Soliris treatment, patients reported less fatigue and improved health-related quality of life. Because of the study sample size and duration, the effects of Soliris on thrombotic events could not be determined.
| Placebo (N=44) | Soliris (N=43) |
|
|---|---|---|
| Percentage of patients with stabilized hemoglobin levels | 0 | 49 |
| Packed RBC units transfused per patient (median) | 10 | 0 |
| (range) | (2 - 21) | (0 - 16) |
| Transfusion avoidance (%) | 0 | 51 |
| LDH levels at end of study (median, U/L) | 2,167 | 239 |
| Free hemoglobin at end of study (median, mg/dL) | 62 | 5 |
14.2 Atypical Hemolytic Uremic Syndrome (aHUS)
Five single-arm studies [four prospective: C08-002A/B (NCT00844545 and NCT00844844), C08-003A/B (NCT00838513 and NCT00844428), C10-003 (NCT01193348), and C10-004 (NCT01194973); and one retrospective: C09-001r (NCT01770951)] evaluated the safety and efficacy of Soliris for the treatment of aHUS. Patients with aHUS received meningococcal vaccination prior to receipt of Soliris or received prophylactic treatment with antibiotics until 2 weeks after vaccination. In all studies, the dose of Soliris in adult and adolescent patients was 900 mg every 7 ± 2 days for 4 weeks, followed by 1200 mg 7 ± 2 days later, then 1200 mg every 14 ± 2 days thereafter. The dosage regimen for pediatric patients weighing less than 40 kg enrolled in Study C09-001r and Study C10-003 was based on body weight [see Dosage and Administration (2.3)]. Efficacy evaluations were based on thrombotic microangiopathy (TMA) endpoints.
Endpoints related to TMA included the following:
- platelet count change from baseline
- hematologic normalization (maintenance of normal platelet counts and LDH levels for at least four weeks)
- complete TMA response (hematologic normalization plus at least a 25% reduction in serum creatinine for a minimum of four weeks)
- TMA-event free status (absence for at least 12 weeks of a decrease in platelet count of >25% from baseline, plasma exchange or plasma infusion, and new dialysis requirement)
- Daily TMA intervention rate (defined as the number of plasma exchange or plasma infusion interventions and the number of new dialyses required per patient per day).
14.3 Generalized Myasthenia Gravis (gMG)
The efficacy of Soliris for the treatment of gMG was established in gMG Study 1 (NCT01997229), a 26-week randomized, double-blind, parallel-group, placebo-controlled, multi-center trial that enrolled patients who met the following criteria at screening:
- Positive serologic test for anti-AChR antibodies,
- Myasthenia Gravis Foundation of America (MGFA) Clinical Classification Class II to IV,
- MG-Activities of Daily Living (MG-ADL) total score ≥6,
- Failed treatment over 1 year or more with 2 or more immunosuppressive therapies (ISTs) either in combination or as monotherapy, or failed at least 1 IST and required chronic plasmapheresis or plasma exchange (PE) or intravenous immunoglobulin (IVIg).
A total of 62 patients were randomized to receive Soliris treatment and 63 were randomized to receive placebo. Baseline characteristics were similar between treatment groups, including age at diagnosis (38 years in each group), gender [66% female (eculizumab) versus 65% female (placebo)], and duration of gMG [9.9 (eculizumab) versus 9.2 (placebo) years]. Over 95% of patients in each group were receiving acetylcholinesterase (AchE) inhibitors, and 98% were receiving immunosuppressant therapies (ISTs). Approximately 50% of each group had been previously treated with at least 3 ISTs.
Soliris was administered according to the recommended dosage regimen [see Dosage and Administration (2.4)].
The primary efficacy endpoint for gMG Study 1 was a comparison of the change from baseline between treatment groups in the Myasthenia Gravis-Specific Activities of Daily Living scale (MG-ADL) total score at Week 26. The MG-ADL is a categorical scale that assesses the impact on daily function of 8 signs or symptoms that are typically affected in gMG. Each item is assessed on a 4-point scale where a score of 0 represents normal function and a score of 3 represents loss of ability to perform that function (total score 0-24). A statistically significant difference favoring Soliris was observed in the mean change from baseline to Week 26 in MG-ADL total scores [-4.2 points in the Soliris-treated group compared with -2.3 points in the placebo-treated group (p=0.006)].
A key secondary endpoint in gMG Study 1 was the change from baseline in the Quantitative Myasthenia Gravis (QMG) total score at Week 26. The QMG is a 13-item categorical scale assessing muscle weakness. Each item is assessed on a 4-point scale where a score of 0 represents no weakness and a score of 3 represents severe weakness (total score 0-39). A statistically significant difference favoring Soliris was observed in the mean change from baseline to Week 26 in QMG total scores [-4.6 points in the Soliris-treated group compared with -1.6 points in the placebo-treated group (p=0.001)].
The results of the analysis of the MG-ADL and QMG from gMG Study 1 are shown in Table 21.
| Efficacy Endpoints | Soliris-LS Mean (N=62) (SEM) | Placebo-LS Mean (N=63) (SEM) | Soliris change relative to placebo – LS Mean Difference (95% CI) | p-values |
|---|---|---|---|---|
| SEM= Standard Error of the Mean; Soliris-LSMean = least square mean for the treatment group; Placebo-LSMean = least square mean for the placebo group; LSMean-Difference (95% CI) = Difference in least square mean with 95% confidence interval; p-values (testing the null hypothesis that there is no difference between the two treatment arms |
||||
|
||||
| MG-ADL | -4.2 (0.49) | -2.3 (0.48) | -1.9 (-3.3, -0.6) | (0.006*; 0.014†) |
| QMG | -4.6 (0.60) | -1.6 (0.59) | -3.0 (-4.6, -1.3) | (0.001 *; 0.005 †) |
In gMG Study 1, a clinical response was defined in the MG-ADL total score as at least a 3-point improvement and in QMG total score as at least a 5-point improvement. The proportion of clinical responders at Week 26 with no rescue therapy was statistically significantly higher for Soliris compared to placebo for both measures. For both endpoints, and also at higher response thresholds (≥4-, 5-, 6-, 7-, or 8-point improvement on MG-ADL, and ≥6-, 7-, 8-, 9-, or 10-point improvement on QMG), the proportion of clinical responders was consistently greater for Soliris compared to placebo. Available data suggest that clinical response is usually achieved by 12 weeks of Soliris treatment.
14.4 Neuromyelitis Optica Spectrum Disorder (NMOSD)
The efficacy of Soliris for the treatment of NMOSD was established in NMOSD Study 1 (NCT01892345), a randomized, double-blind, placebo-controlled trial that enrolled 143 patients with NMOSD who were anti-AQP4 antibody positive and met the following criteria at screening:
- History of at least 2 relapses in last 12 months or 3 relapses in the last 24 months, with at least 1 relapse in the 12 months prior to screening,
- Expanded Disability Status Scale (EDSS) score ≤ 7 (consistent with the presence of at least limited ambulation with aid),
- If on immunosuppressive therapy (IST), on a stable dose regimen,
- The use of concurrent corticosteroids was limited to 20 mg per day or less,
- Patients were excluded if they had been treated with rituximab or mitoxantrone within 3 months or with IVIg within 3 weeks prior to screening.
A total of 96 patients were randomized to receive Soliris treatment and 47 were randomized to receive placebo.
The baseline demographic and disease characteristics were balanced between treatment groups. During the treatment phase of the trial, 76% percent of patients received concomitant IST, including chronic corticosteroids; 24% of patients did not receive concomitant IST or chronic corticosteroids during the treatment phase of the trial.
Soliris was administered according to the recommended dosage regimen [see Dosage and Administration (2.4)].
The primary endpoint for NMOSD Study 1 was the time to the first adjudicated on-trial relapse. The time to the first adjudicated on-trial relapse was significantly longer in Soliris-treated patients compared to placebo-treated patients (relative risk reduction 94%; hazard ratio 0.058; p < 0.0001) (Figure 1).
Figure 1: Kaplan-Meier Survival Estimates for Time to First Adjudicated On-Trial Relapse – Full Analysis Set
Note: Patients who did not experience an adjudicated on-trial relapse were censored at the end of the study period. Abbreviations: CI = confidence interval
Soliris-treated patients experienced similar improvement in time to first adjudicated on-trial relapse with or without concomitant treatment. Soliris-treated patients had a 96% relative reduction in the adjudicated on-trial annualized relapse rate (ARR) compared to patients on placebo, as shown in Table 22.
| Variable | Statistic | Placebo (N=47) | Soliris (N=96) |
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| ARR = annualized relapse rate | |||
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| Total number of relapses | Sum | 21 | 3 |
| Adjusted adjudicated ARR* | Rate | 0.350 | 0.016 |
| Treatment effect* | Rate ratio (eculizumab/placebo) | … | 0.045 |
| p-value | … | <0.0001 | |
Compared to placebo-treated patients, Soliris-treated patients had reduced annualized rates of hospitalizations (0.04 for Soliris versus 0.31 for placebo), of corticosteroid administrations to treat acute relapses (0.07 for Soliris versus 0.42 for placebo), and of plasma exchange treatments (0.02 for Soliris versus 0.19 for placebo).
16. How is Soliris supplied
Soliris (eculizumab) injection is a sterile, preservative-free, clear, colorless solution supplied as one 300 mg/30 mL (10 mg/mL) single-dose vial per carton (NDC 25682-001-01).
17. Patient Counseling Information
Advise the patient to read FDA-approved patient labeling (Medication Guide).
| This Medication Guide has been approved by the U.S. Food and Drug Administration | Revised 11/2020 | |||
| MEDICATION GUIDE
SOLIRIS® (so-leer-is) (eculizumab) injection, for intravenous use |
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| Your doctor will give you a Patient Safety Card about the risk of meningococcal infection. Carry it with you at all times during treatment and for 3 months after your last SOLIRIS dose. Your risk of meningococcal infection may continue for several weeks after your last dose of SOLIRIS. It is important to show this card to any doctor or nurse who treats you. This will help them diagnose and treat you quickly. SOLIRIS is only available through a program called the SOLIRIS REMS. Before you can receive SOLIRIS, your doctor must:
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| What is SOLIRIS?
SOLIRIS is a prescription medicine called a monoclonal antibody. SOLIRIS is used to treat:
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| Who should not receive SOLIRIS?
Do not receive SOLIRIS if you:
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Before you receive SOLIRIS, tell your doctor about all of your medical conditions, including if you:
It is important that you:
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How should I receive SOLIRIS?
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What are the possible side effects of SOLIRIS?
The most common side effects in people with PNH treated with SOLIRIS include: |
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| The most common side effects in people with aHUS treated with SOLIRIS include: | ||||
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The most common side effects in people with gMG treated with SOLIRIS include:
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| The most common side effects in people with NMOSD treated with SOLIRIS include: | ||||
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| Tell your doctor about any side effect that bothers you or that does not go away. These are not all the possible side effects of SOLIRIS. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. |
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| General information about the safe and effective use of SOLIRIS.
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use SOLIRIS for a condition for which it was not prescribed. Do not give SOLIRIS to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or doctor for information about SOLIRIS that is written for health professionals. |
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| What are the ingredients in SOLIRIS?
Active ingredient: eculizumab Inactive ingredients: polysorbate 80 (vegetable origin), sodium chloride, sodium phosphate dibasic, sodium phosphate monobasic, and Water for Injection Manufactured by Alexion Pharmaceuticals, Inc., 121 Seaport Boulevard, Boston, MA 02210 USA. US License Number 1743 |
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| SOLIRIS
eculizumab injection, solution, concentrate |
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| Labeler - Alexion Pharmaceuticals Inc. (789359510) |
