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Prescribing Information US BL Amendment Rituximab asthenia
HIGHLIGHTS OF PRESCRIBING INFORMATION ---------------------DOSAGE FORMS AND STRENGTHS------------------ • 100 mg/10 mL and 500 mg/50 mL solution in a single-use vial (3). These highlights do not include all the information needed to use Rituxan safely and effectively. See full prescribing information ------------------------------CONTRAINDICATIONS-------------------------- for Rituxan. None. Rituxan (rituximab) -----------------------WARNINGS AND PRECAUTIONS-------------------- Injection for Intravenous Use • Tumor lysis syndrome - administer prophylaxis and monitor renal Initial U.S. Approval: 1997 function (5.2). WARNING: FATAL INFUSION REACTIONS, TUMOR LYSIS • PML - monitor neurologic function. Discontinue Rituxan (5.4). SYNDROME (TLS), SEVERE MUCOCUTANEOUS REACTIONS, • Hepatitis B reactivation with fulminant hepatitis, sometimes fatal - and PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY screen high risk patients and monitor HBV carriers during and several (PML) months after therapy. Discontinue Rituxan if reactivation occurs See full prescribing information for complete boxed warning. (5.5). • Fatal infusion reactions within 24 hours of Rituxan infusion occur; • Cardiac arrhythmias and angina can occur and can be life threatening. approximately 80% of fatal reactions occurred with first infusion. Monitor patients with these conditions closely (5.7). Monitor patients and discontinue Rituxan infusion for severe • Bowel obstruction and perforation - evaluate complaints of abdominal reactions (5.1). pain (5.9). • Tumor lysis syndrome (5.2). • Do not administer live virus vaccines prior to or during Rituxan • Severe mucocutaneous reactions, some with fatal outcomes (5.3). (5.10). • PML resulting in death (5.4). • Monitor CBC at regular intervals for severe cytopenias (5.11, 6.1). ------------------------------ADVERSE REACTIONS--------------------------- --------------------------RECENT MAJOR CHANGES------------------------ • Non−Hodgkin's Lymphoma (NHL) - Common adverse reactions Indications and Usage, RA (1.2) 10/2009 ( ≥ 25%) in clinical trials were: infusion reactions, fever, Dosage and Administration, RA (2.4) 10/2009 Dosage and Administration, Recommended Concomitant 10/2009 lymphopenia, chills, infection and asthenia (6.1). Medications (2.5) • Rheumatoid Arthritis (RA) - Common adverse reactions ( ≥ 10%) in Warnings and Precautions, Infusion Reactions (5.1) 10/2009 clinical trials: upper respiratory tract infection, nasopharyngitis, Warnings and Precautions, Infections (5.6) 09/2009 urinary tract infection, and bronchitis (6.2). Other important adverse Warnings and Precautions, Immunizations (5.10) 09/2009 reactions include infusion reactions, serious infections, and Warnings and Precautions, Use in RA Patients Who Have 10/2009 cardiovascular events (6.2). Not Had Prior IR to TNF antagonists (5.13) To report SUSPECTED ADVERSE REACTIONS, contact Genentech ---------------------------INDICATIONS AND USAGE------------------------ at 1-888-835-2555 or FDA at 1-800-FDA-1088 or Rituxan is a CD20-directed cytolytic antibody indicated for the www.fda.gov/medwatch. treatment of the following: • Non−Hodgkin's Lymphoma (NHL) (1.1) -------------------------------DRUG INTERACTIONS-------------------------- • Rheumatoid Arthritis (RA) in combination with methotrexate in adult • Renal toxicity when used in combination with cisplatin (5.8). patients with moderately-to severely-active RA who have inadequate response to one or more TNF antagonist therapies (1.2) -----------------------USE IN SPECIFIC POPULATIONS-------------------- • Pregnancy: Limited human data; B-cell lymphocytopenia occurred in ------------------------DOSAGE AND ADMINISTRATION------------------ infants exposed in utero (8.1). DO NOT ADMINISTER AS AN IV PUSH OR BOLUS. • Nursing Mothers: Caution should be exercised when administered to • The dose for NHL is 375 mg/m2 (2.2). a nursing woman (8.3). • The dose as a component of Zevalin (Ibritumomab tiuxetan) Therapeutic Regimen is 250 mg/m2 (2.3). See 17 for PATIENT COUNSELING INFORMATION and • The dose for RA in combination with methotrexate is two- 1000 mg Medication Guide. IV infusions separated by 2 weeks (one course) every 24 weeks or Revised: 10/2009 based on clinical evaluation, but not sooner than every 16 weeks. Methylprednisolone 100 mg IV or equivalent glucocorticoid is recommended 30 minutes prior to each infusion (2.4). U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 1 of 31/Regional (RA): Rituxan Final FULL PRESCRIBING INFORMATION: CONTENTS* 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience Non–Hodgkin's WARNING: FATAL INFUSION REACTIONS, TUMOR Lymphoma LYSIS SYNDROME (TLS), SEVERE MUCOCUTANEOUS REACTIONS, and 6.2 Clinical Trials Experience Rheumatoid Arthritis 6.3 Immunogenicity PROGRESSIVE MULTIFOCAL 6.4 Postmarketing Experience LEUKOENCEPHALOPATHY (PML) 1 INDICATIONS AND USAGE 7 DRUG INTERACTIONS 8 USE IN SPECIFIC POPULATIONS 1.1 Non–Hodgkin's Lymphoma (NHL) 8.1 Pregnancy 1.2 Rheumatoid Arthritis (RA) 2 DOSAGE AND ADMINISTRATION 8.3 Nursing Mothers 8.4 Pediatric Use 2.1 Administration 8.5 Geriatric Use 2.2 Recommended Dose for Non–Hodgkin's Lymphoma (NHL) 10 OVERDOSAGE 2.3 Recommended Dose as a Component of Zevalin 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 2.4 Recommended Dose for Rheumatoid Arthritis 12.1 Mechanism of Action 2.5 Recommended Concomitant Medications 2.6 Preparation for Administration 12.2 Pharmacodynamics 12.3 Pharmacokinetics 3 DOSAGE FORMS AND STRENGTHS 13 NONCLINICAL TOXICOLOGY 4 CONTRAINDICATIONS 5 WARNINGS AND PRECAUTIONS 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 13.2 Animal Toxicology and/or Pharmacology 5.1 Infusion Reactions 14 CLINICAL STUDIES 5.2 Tumor Lysis Syndrome (TLS) 5.3 Severe Mucocutaneous Reactions 14.1 Relapsed or Refractory, Low-Grade or Follicular, CD20 Positive, B-Cell NHL 5.4 Progressive Multifocal Leukoencephalopathy (PML) 14.2 Previously Untreated, Follicular, CD20-Positive, 5.5 Hepatitis B Virus (HBV) Reactivation 5.6 Infections B-Cell NHL 14.3 Non-Progressing, Low-Grade, CD20-Positive, B-Cell 5.7 Cardiovascular NHL Following First-Line CVP Chemotherapy 5.8 Renal 5.9 Bowel Obstruction and Perforation 14.4 Diffuse Large B-Cell NHL (DLBCL) 14.5 Rheumatoid Arthritis (RA) 5.10 Immunization 16 HOW SUPPLIED/STORAGE AND HANDLING 5.11 Laboratory Monitoring 5.12 Concomitant Use with Biologic Agents and Disease 17 PATIENT COUNSELING INFORMATION 17.1 General Counseling Information Modifying Anti-Rheumatic Drugs (DMARDs) other 17.2 Medication Guide than Methotrexate in RA * 5.13 Use in RA Patients Who Have Not Had Prior Sections or subsections omitted from the full prescribing information are not listed. Inadequate Response to Tumor Necrosis Factor (TNF) Antagonists U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 2 of 31/Regional (RA): Rituxan Final 1 FULL PRESCRIBING INFORMATION 2 WARNING: FATAL INFUSION REACTIONS, TUMOR LYSIS SYNDROME (TLS), 3 SEVERE MUCOCUTANEOUS REACTIONS, and 4 PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY (PML) 5 Infusion Reactions 6 Rituxan administration can result in serious, including fatal infusion reactions. Deaths within 7 24 hours of Rituxan infusion have occurred. Approximately 80% of fatal infusion reactions 8 occurred in association with the first infusion. Carefully monitor patients during infusions. 9 Discontinue Rituxan infusion and provide medical treatment for Grade 3 or 4 infusion 10 reactions [see Warnings and Precautions (5.1), Adverse Reactions (6.1)]. 11 Tumor Lysis Syndrome (TLS) 12 Acute renal failure requiring dialysis with instances of fatal outcome can occur in the setting of 13 TLS following treatment of non–Hodgkin's lymphoma (NHL) patients with Rituxan [see 14 Warnings and Precautions (5.2), Adverse Reactions (6)]. 15 Severe Mucocutaneous Reactions 16 Severe, including fatal, mucocutaneous reactions can occur in patients receiving Rituxan [see 17 Warnings and Precautions (5.3), Adverse Reactions (6)]. 18 Progressive Multifocal Leukoencephalopathy (PML) 19 JC virus infection resulting in PML and death can occur in patients receiving Rituxan [see 20 Warnings and Precautions (5.4), Adverse Reactions (6.4)]. 21 22 1 INDICATIONS AND USAGE 23 1.1 Non–Hodgkin's Lymphoma (NHL) 24 Rituxan (rituximab) is indicated for the treatment of patients with: 25 • Relapsed or refractory, low-grade or follicular, CD20-positive, B-cell NHL as a single agent 26 • Previously untreated follicular, CD20-positive, B-cell NHL in combination with CVP 27 chemotherapy 28 • Non−progressing (including stable disease), low-grade, CD20-positive, B-cell NHL, as a single 29 agent, after first-line CVP chemotherapy 30 • Previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or 31 other anthracycline-based chemotherapy regimens 32 1.2 Rheumatoid Arthritis 33 Rituxan® (rituximab) in combination with methotrexate is indicated for the treatment of adult 34 patients with moderately-to severely- active rheumatoid arthritis who have had an inadequate 35 response to one or more TNF antagonist therapies. 36 37 2 DOSAGE AND ADMINISTRATION 38 2.1 Administration 39 DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS. 40 Premedicate before each infusion [see Dosage and Administration (2.5)]. Administer only as an 41 intravenous (IV) infusion [see Dosage and Administration (2.5)]. 42 • First Infusion: Initiate infusion at a rate of 50 mg/hr. In the absence of infusion toxicity, 43 increase infusion rate by 50 mg/hr increments every 30 minutes, to a maximum of 400 mg/hr. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 3 of 31/Regional (RA): Rituxan Final 44 • Subsequent Infusions: Initiate infusion at a rate of 100 mg/hr. In the absence of infusion 45 toxicity, increase rate by 100 mg/hr increments at 30-minute intervals, to a maximum of 46 400 mg/hr. 47 • Interrupt the infusion or slow the infusion rate for infusion reactions [see Boxed Warning, 48 Warnings and Precautions (5.1)]. Continue the infusion at one-half the previous rate upon 49 improvement of symptoms. 50 2.2 Recommended Dose for Non–Hodgkin's Lymphoma (NHL) 51 The recommended dose is 375 mg/m2 as an IV infusion according to the following schedules: 52 • Relapsed or Refractory, Low-Grade or Follicular, CD20-Positive, B-Cell NHL 53 Administer once weekly for 4 or 8 doses. 54 • Retreatment for Relapsed or Refractory, Low-Grade or Follicular, CD20-Positive, B-Cell 55 NHL 56 Administer once weekly for 4 doses. 57 • Previously Untreated, Follicular, CD20-Positive, B-Cell NHL 58 Administer on Day 1 of each cycle of CVP chemotherapy, for up to 8 doses. 59 • Non-progressing, Low-Grade, CD20-Positive, B-cell NHL, after first-line CVP 60 chemotherapy 61 Following completion of 6−8 cycles of CVP chemotherapy, administer once weekly for 4 doses 62 at 6-month intervals to a maximum of 16 doses. 63 • Diffuse Large B-Cell NHL 64 Administer on Day 1 of each cycle of chemotherapy for up to 8 infusions. 65 2.3 Recommended Dose as a Component of Zevalin 66 • Infuse rituximab 250 mg/m2 within 4 hours prior to the administration of Indium-111- (In-111-) 67 Zevalin and within 4 hours prior to the administration of Yttrium-90- (Y-90-) Zevalin. 68 • Administer Rituxan and In-111-Zevalin 7−9 days prior to Rituxan and Y-90- Zevalin. 69 • Refer to the Zevalin package insert for full prescribing information regarding the Zevalin 70 therapeutic regimen. 71 2.4 Recommended Dose for Rheumatoid Arthritis 72 • Administer Rituxan as two 1000 mg intravenous infusions separated by 2 weeks. 73 • Glucocorticoids administered as methylprednisolone 100 mg IV or its equivalent 30 minutes 74 prior to each infusion are recommended to reduce the incidence and severity of infusion 75 reactions. 76 • Subsequent courses should be administered every 24 weeks or based on clinical evaluation, but 77 not sooner than every 16 weeks. 78 • Rituxan is given in combination with methotrexate. 79 2.5 Recommended Concomitant Medications 80 Premedicate before each infusion with acetaminophen and an antihistamine. For RA patients, 81 methylprednisolone 100 mg IV or its equivalent is recommended 30 minutes prior to each infusion. 82 2.6 Preparation for Administration 83 Use appropriate aseptic technique. Parenteral drug products should be inspected visually for 84 particulate matter and discoloration prior to administration. Do not use vial if particulates or 85 discoloration is present. Withdraw the necessary amount of Rituxan and dilute to a final 86 concentration of 1 to 4 mg/mL in an infusion bag containing either 0.9% Sodium Chloride, USP, or U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 4 of 31/Regional (RA): Rituxan Final 87 5% Dextrose in Water, USP. Gently invert the bag to mix the solution. Do not mix or dilute with 88 other drugs. Discard any unused portion left in the vial. 89 3 DOSAGE FORMS AND STRENGTHS 90 100 mg/10 mL single-use vial 91 500 mg/50 mL single-use vial 92 4 CONTRAINDICATIONS 93 None. 94 5 WARNINGS AND PRECAUTIONS 95 5.1 Infusion Reactions 96 Rituxan can cause severe, including fatal, infusion reactions. Severe reactions typically occurred 97 during the first infusion with time to onset of 30−120 minutes. Rituxan-induced infusion reactions 98 and sequelae include urticaria, hypotension, angioedema, hypoxia, bronchospasm, pulmonary 99 infiltrates, acute respiratory distress syndrome, myocardial infarction, ventricular fibrillation, 100 cardiogenic shock, anaphylactoid events, or death. 101 Premedicate patients with an antihistamine and acetaminophen prior to dosing. For RA patients, 102 methylprednisolone 100 mg IV or its equivalent is recommended 30 minutes prior to each infusion. 103 Institute medical management (e.g. glucocorticoids, epinephrine, bronchodilators, or oxygen) for 104 infusion reactions as needed. Depending on the severity of the infusion reaction and the required 105 interventions, consider resumption of the infusion at a minimum 50% reduction in rate after 106 symptoms have resolved. Closely monitor the following patients: those with pre-existing cardiac or 107 pulmonary conditions, those who experienced prior cardiopulmonary adverse reactions, and those 108 with high numbers of circulating malignant cells ( ≥ 25,000/mm3). [See Boxed Warning, Warnings 109 and Precautions (5.7), Adverse Reactions (6.1).] 110 5.2 Tumor Lysis Syndrome (TLS) 111 Rapid reduction in tumor volume followed by acute renal failure, hyperkalemia, hypocalcemia, 112 hyperuricemia, or hyperphosphatemia, can occur within 12−24 hours after the first infusion. Fatal 113 TLS cases have occurred after administration of Rituxan. A high number of circulating malignant 114 cells ( ≥ 25,000/mm3) or high tumor burden confers a greater risk of TLS after rituximab. Consider 115 prophylaxis for TLS in patients at high risk. Correct electrolyte abnormalities, monitor renal 116 function and fluid balance, and administer supportive care, including dialysis as indicated. [See 117 Boxed Warning.] 118 5.3 Severe Mucocutaneous Reactions 119 Mucocutaneous reactions, some with fatal outcome, can occur in patients treated with Rituxan. 120 These reactions include paraneoplastic pemphigus, Stevens-Johnson syndrome, lichenoid dermatitis, 121 vesiculobullous dermatitis, and toxic epidermal necrolysis. The onset of these reactions has varied 122 from 1−13 weeks following Rituxan exposure. Discontinue Rituxan in patients who experience a 123 severe mucocutaneous reaction. The safety of readministration of Rituxan to patients with severe 124 mucocutaneous reactions has not been determined. [See Boxed Warning, Adverse Reactions (6.1, 125 6.4).] 126 5.4 Progressive Multifocal Leukoencephalopathy (PML) 127 JC virus infection resulting in PML and death can occur in Rituxan-treated patients with 128 hematologic malignancies or with autoimmune diseases. The majority of patients with hematologic 129 malignancies diagnosed with PML received Rituxan in combination with chemotherapy or as part of 130 a hematopoietic stem cell transplant. The patients with autoimmune diseases had prior or concurrent 131 immunosuppressive therapy. Most cases of PML were diagnosed within 12 months of their last 132 infusion of Rituxan. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 5 of 31/Regional (RA): Rituxan Final 133 Consider the diagnosis of PML in any patient presenting with new-onset neurologic 134 manifestations. Evaluation of PML includes, but is not limited to, consultation with a neurologist, 135 brain MRI, and lumbar puncture. Discontinue Rituxan and consider discontinuation or reduction of 136 any concomitant chemotherapy or immunosuppressive therapy in patients who develop PML. [See 137 Boxed Warning, Adverse Reactions (6.4).] 138 5.5 Hepatitis B Virus (HBV) Reactivation 139 Hepatitis B virus (HBV) reactivation with fulminant hepatitis, hepatic failure, and death can occur 140 in patients with hematologic malignancies treated with Rituxan. The median time to the diagnosis of 141 hepatitis was approximately 4 months after the initiation of Rituxan and approximately one month 142 after the last dose. 143 Screen patients at high risk of HBV infection before initiation of Rituxan. Closely monitor 144 carriers of hepatitis B for clinical and laboratory signs of active HBV infection for several months 145 following Rituxan therapy. Discontinue Rituxan and any concomitant chemotherapy in patients who 146 develop viral hepatitis, and institute appropriate treatment including antiviral therapy. Insufficient 147 data exist regarding the safety of resuming Rituxan in patients who develop hepatitis subsequent to 148 HBV reactivation. [See Adverse Reactions (6.4).] 149 5.6 Infections 150 Rituxan is not recommended for treatment of patients with severe active infections. 151 The following additional serious viral infections, either new, reactivated, or exacerbated, have 152 been identified in clinical studies or postmarketing reports. The majority of patients received 153 Rituxan in combination with chemotherapy or as part of a hematopoietic stem cell transplant. These 154 viral infections included cytomegalovirus, herpes simplex virus, parvovirus B19, varicella zoster 155 virus, West Nile virus, and hepatitis C. In some cases, the viral infections occurred as late as one 156 year following discontinuation of Rituxan and have resulted in death. [See Adverse Reactions (6.1, 157 6.4).] 158 5.7 Cardiovascular 159 Discontinue infusions for serious or life-threatening cardiac arrhythmias. Perform cardiac 160 monitoring during and after all infusions of Rituxan for patients who develop clinically significant 161 arrhythmias, or who have a history of arrhythmia or angina. [See Adverse Reactions (6.4).] 162 5.8 Renal 163 Severe, including fatal, renal toxicity can occur after Rituxan administration in patients with 164 hematologic malignancies. Renal toxicity has occurred in patients with high numbers of circulating 165 malignant cells ( ≥ 25,000/mm3) or high tumor burden who experience tumor lysis syndrome and in 166 patients with NHL administered concomitant cisplatin therapy during clinical trials. The 167 combination of cisplatin and Rituxan is not an approved treatment regimen. Use extreme caution if 168 this non-approved combination is used in clinical trials and monitor closely for signs of renal failure. 169 Consider discontinuation of Rituxan for patients with a rising serum creatinine or oliguria. 170 5.9 Bowel Obstruction and Perforation 171 Abdominal pain, bowel obstruction and perforation, in some cases leading to death, can occur in 172 patients receiving Rituxan in combination with chemotherapy. In postmarketing reports, the mean 173 time to documented gastrointestinal perforation was 6 (range 1−77) days in patients with NHL. 174 Perform a thorough diagnostic evaluation and institute appropriate treatment for complaints of 175 abdominal pain, especially early in the course of Rituxan therapy. [See Adverse Reactions (6.4).] 176 5.10 Immunization 177 The safety of immunization with live viral vaccines following Rituxan therapy has not been 178 studied and vaccination with live virus vaccines is not recommended. 179 For RA patients, physicians should follow current immunization guidelines and administer non- U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 6 of 31/Regional (RA): Rituxan Final 180 live vaccines at least 4 weeks prior to a course of Rituxan. 181 The effect of Rituxan on immune responses was assessed in a randomized, controlled study in 182 patients with RA treated with Rituxan and methotrexate (MTX) compared to patients treated with 183 MTX alone. 184 A response to pneumococcal vaccination (a T-cell independent antigen) as measured by an 185 increase in antibody titers to at least 6 of 12 serotypes was lower in patients treated with Rituxan 186 plus MTX as compared to patients treated with MTX alone (19% vs. 61%). A lower proportion of 187 patients in the Rituxan plus MTX group developed detectable levels of anti-keyhole limpet 188 hemocyanin antibodies (a novel protein antigen) after vaccination compared to patients on MTX 189 alone (47% vs. 93%). 190 A positive response to tetanus toxoid vaccine (a T-cell dependent antigen with existing immunity) 191 was similar in patients treated with Rituxan plus MTX compared to patients on MTX alone (39% vs. 192 42%). The proportion of patients maintaining a positive Candida skin test (to evaluate delayed type 193 hypersensitivity) was also similar (77% of patients on Rituxan plus MTX vs. 70% of patients on 194 MTX alone). 195 Most patients in the Rituxan-treated group had B-cell counts below the lower limit of normal at 196 the time of immunization. The clinical implications of these findings are not known. 197 5.11 Laboratory Monitoring 198 Because Rituxan binds to all CD20-positive B lymphocytes (malignant and non-malignant), 199 obtain complete blood counts (CBC) and platelet counts at regular intervals during Rituxan therapy 200 and more frequently in patients who develop cytopenias [see Adverse Reactions (6.1)]. The duration 201 of cytopenias caused by Rituxan can extend months beyond the treatment period. 202 5.12 Concomitant Use with Biologic Agents and DMARDs other than Methotrexate in RA 203 Limited data are available on the safety of the use of biologic agents or DMARDs other than 204 methotrexate in patients exhibiting peripheral B-cell depletion following treatment with Rituxan. 205 Observe patients closely for signs of infection if biologic agents and/or DMARDs are used 206 concomitantly. 207 5.13 Use in RA Patients Who Have Not Had Prior Inadequate Response to Tumor Necrosis 208 Factor (TNF) Antagonists 209 While the efficacy of Rituxan was supported in four controlled trials in patients with RA with 210 prior inadequate responses to nonbiologic DMARDs, and in a controlled trial in MTX-naïve 211 patients, a favorable risk-benefit relationship has not been established in these populations. The use 212 of Rituxan in patients with RA who have not had prior inadequate response to one or more TNF 213 antagonists is not recommended [see Clinical Studies (14.5)]. 214 215 6 ADVERSE REACTIONS 216 The following adverse reactions are discussed in greater detail in other sections of the labeling: 217 • Infusion reactions [see Warnings and Precautions (5.1)] 218 • Tumor lysis syndrome [see Warnings and Precautions (5.2)] 219 • Mucocutaneous reactions [see Warnings and Precautions (5.3)] 220 • Progressive multifocal leukoencephalopathy [see Warnings and Precautions (5.4)] 221 • Hepatitis B reactivation with fulminant hepatitis [see Warnings and Precautions (5.5)] 222 • Other viral infections [see Warnings and Precautions (5.6)] 223 • Cardiac arrhythmias [see Warnings and Precautions (5.7)] 224 • Renal toxicity [see Warnings and Precautions (5.8)] 225 • Bowel obstruction and perforation [see Warnings and Precautions (5.9)] U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 7 of 31/Regional (RA): Rituxan Final 226 The most common adverse reactions of Rituxan (incidence ≥ 25%) observed in patients with 227 NHL are infusion reactions, fever, chills, infection, asthenia, and lymphopenia. 228 The most important serious adverse reactions of Rituxan are infusion reactions, tumor lysis 229 syndrome, mucocutaneous toxicities, hepatitis B reactivation with fulminant hepatitis, PML, other 230 viral infections, cardiac arrhythmias, renal toxicity, and bowel obstruction and perforation. 231 6.1 Clinical Trials Experience Non–Hodgkin's Lymphoma 232 Because clinical trials are conducted under widely varying conditions, adverse reaction rates 233 observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of 234 another drug and may not reflect the rates observed in practice. 235 The data described below reflect exposure to Rituxan in 1606 patients, with exposures ranging 236 from a single infusion up to 6−8 months. Rituxan was studied in both single-agent and 237 active-controlled trials (n = 356 and n = 1250). These data were obtained in adults with low-grade, 238 follicular, or DLBCL NHL. Most patients received Rituxan as an infusion of 375 mg/m2 per 239 infusion, given as a single agent weekly for up to 8 doses, in combination with chemotherapy for up 240 to 8 doses, or following chemotherapy for up to 16 doses. 241 Infusion Reactions 242 In the majority of patients with NHL, infusion reactions consisting of fever, chills/rigors, nausea, 243 pruritus, angioedema, hypotension, headache, bronchospasm, urticaria, rash, vomiting, myalgia, 244 dizziness, or hypertension occurred during the first Rituxan infusion. Infusion reactions typically 245 occurred within 30 to 120 minutes of beginning the first infusion and resolved with slowing or 246 interruption of the Rituxan infusion and with supportive care (diphenhydramine, acetaminophen, and 247 intravenous saline). The incidence of infusion reactions was highest during the first infusion (77%) 248 and decreased with each subsequent infusion. [See Boxed Warning, Warnings and Precautions 249 (5.1).] 250 Infections 251 Serious infections (NCI CTCAE Grade 3 or 4), including sepsis, occurred in less than 5% of 252 patients with NHL in the single-arm studies. The overall incidence of infections was 31% (bacterial 253 19%, viral 10%, unknown 6%, and fungal 1%). [See Warnings and Precautions (5.4), (5.5), (5.6).] 254 In randomized, controlled studies where Rituxan was administered following chemotherapy for 255 the treatment of follicular or low-grade NHL, the rate of infection was higher among patients who 256 received Rituxan. In diffuse large B-cell lymphoma patients, viral infections occurred more 257 frequently in those who received Rituxan. 258 Cytopenias and hypogammaglobulinemia 259 In patients with NHL receiving rituximab monotherapy, NCI-CTC Grade 3 and 4 cytopenias were 260 reported in 48% of patients. These included lymphopenia (40%), neutropenia (6%), leukopenia 261 (4%), anemia (3%), and thrombocytopenia (2%). The median duration of lymphopenia was 14 days 262 (range, 1−588 days) and of neutropenia was 13 days (range, 2−116 days). A single occurrence of 263 transient aplastic anemia (pure red cell aplasia) and two occurrences of hemolytic anemia following 264 Rituxan therapy occurred during the single-arm studies. 265 In studies of monotherapy, Rituxan-induced B-cell depletion occurred in 70% to 80% of patients 266 with NHL. Decreased IgM and IgG serum levels occurred in 14% of these patients. 267 Single-Agent Rituxan 268 Adverse reactions in Table 1 occurred in 356 patients with relapsed or refractory, low-grade or 269 follicular, CD20-positive, B-cell NHL treated in single-arm studies of Rituxan administered as a 270 single agent [see Clinical Studies (14.1)]. Most patients received Rituxan 375 mg/m2 weekly for 271 4 doses. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 8 of 31/Regional (RA): Rituxan Final Table 1 Incidence of Adverse Reactions in ≥ 5% of Patients with Relapsed or Refractory, Low-Grade or Follicular NHL, Receiving Single-agent Rituxan (N = 356)a,b All Grades (%) Grade 3 and 4 (%) Any Adverse Reactions 99 57 Body as a Whole 86 10 Fever 53 1 Chills 33 3 Infection 31 4 Asthenia 26 1 Headache 19 1 Abdominal Pain 14 1 Pain 12 1 Back Pain 10 1 Throat Irritation 9 0 Flushing 5 0 Heme and Lymphatic System 67 48 Lymphopenia 48 40 Leukopenia 14 4 Neutropenia 14 6 Thrombocytopenia 12 2 Anemia 8 3 Skin and Appendages 44 2 Night Sweats 15 1 Rash 15 1 Pruritus 14 1 Urticaria 8 1 Respiratory System 38 4 Increased Cough 13 1 Rhinitis 12 1 Bronchospasm 8 1 Dyspnea 7 1 Sinusitis 6 0 Metabolic and Nutritional Disorders 38 3 Angioedema 11 1 Hyperglycemia 9 1 Peripheral Edema 8 0 LDH Increase 7 0 272 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 9 of 31/Regional (RA): Rituxan Final Table 1 (cont'd) Incidence of Adverse Reactions in ≥ 5% of Patients with Relapsed or Refractory, Low-Grade or Follicular NHL Receiving Single-agent Rituxan (N = 356)a,b All Grades (%) Grade 3 and 4 (%) Digestive System 37 2 Nausea 23 1 Diarrhea 10 1 Vomiting 10 1 Nervous System 32 1 Dizziness 10 1 Anxiety 5 1 Musculoskeletal System 26 3 Myalgia 10 1 Arthralgia 10 1 Cardiovascular System 25 3 Hypotension 10 1 Hypertension 6 1 a Adverse reactions observed up to 12 months following Rituxan. b Adverse reactions graded for severity by NCI-CTC criteria. 273 274 In these single-arm Rituxan studies, bronchiolitis obliterans occurred during and up to 6 months 275 after Rituxan infusion. 276 Rituxan in Combination with Chemotherapy 277 Adverse reactions information below is based on 1250 patients who received Rituxan in 278 combination with chemotherapy or following chemotherapy. 279 Rituxan in Combination with Chemotherapy for Low-Grade NHL 280 In Study 4, patients in the R-CVP arm experienced a higher incidence of infusional toxicity and 281 neutropenia compared to patients in the CVP arm. The following adverse reactions occurred more 282 frequently (≥ 5%) in patients receiving R-CVP compared to CVP alone: rash (17% vs. 5%), cough 283 (15% vs. 6%), flushing (14% vs. 3%), rigors (10% vs. 2%), pruritus (10% vs. 1%), neutropenia (8% 284 vs. 3%), and chest tightness (7% vs. 1%). [See Clinical Studies (14.2).] 285 In Study 5, the following adverse reactions were reported more frequently ( ≥ 5%) in patients 286 receiving Rituxan following CVP compared to patients who received no further therapy: fatigue 287 (39% vs. 14%), anemia (35% vs. 20%), peripheral sensory neuropathy (30% vs. 18%), infections 288 (19% vs. 9%), pulmonary toxicity (18% vs. 10%), hepato-biliary toxicity (17% vs. 7%), rash and/or 289 pruritus (17% vs. 5%), arthralgia (12% vs. 3%), and weight gain (11% vs. 4%). Neutropenia was the 290 only Grade 3 or 4 adverse reaction that occurred more frequently (≥ 2%) in the Rituxan arm 291 compared with those who received no further therapy (4% vs. 1%). [See Clinical Studies (14.3).] 292 Rituxan in Combination with Chemotherapy for DLBCL 293 In Studies 6 and 7 [see Clinical Studies (14.4)], the following adverse reactions, regardless of 294 severity, were reported more frequently ( ≥ 5%) in patients age ≥ 60 years receiving R-CHOP as 295 compared to CHOP alone: pyrexia (56% vs. 46%), lung disorder (31% vs. 24%), cardiac disorder U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 10 of 31/Regional (RA): Rituxan Final 296 (29% vs. 21%), and chills (13% vs. 4%). Detailed safety data collection in these studies was 297 primarily limited to Grade 3 and 4 adverse reactions and serious adverse reactions. 298 In Study 7, a review of cardiac toxicity determined that supraventricular arrhythmias or 299 tachycardia accounted for most of the difference in cardiac disorders (4.5% for R-CHOP vs. 1.0% 300 for CHOP). 301 The following Grade 3 or 4 adverse reactions occurred more frequently among patients in the 302 R-CHOP arm compared with those in the CHOP arm: thrombocytopenia (9% vs. 7%) and lung 303 disorder (6% vs. 3%). Other Grade 3 or 4 adverse reactions occurring more frequently among 304 patients receiving R-CHOP were viral infection (Study 7), neutropenia (Studies 7 and 8), and anemia 305 (Study 8). 306 6.2 Clinical Trials Experience Rheumatoid Arthritis 307 Because clinical trials are conducted under widely varying conditions, adverse reaction rates 308 observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of 309 another drug and may not reflect the rates observed in practice. 310 The data presented below reflect the experience in 2578 RA patients treated with Rituxan in 311 controlled and long-term studies with a total exposure of 5014 patient-years. 312 Among all exposed patients, adverse reactions reported in greater than 10% of patients include 313 infusion related reactions, upper respiratory tract infection, nasopharyngitis, urinary tract infection, 314 and bronchitis. 315 In placebo-controlled studies, patients received 2 x 500 mg or 2 x 1000 mg intravenous infusions 316 of Rituxan or placebo, in combination with methotrexate, during a 24-week period. From these 317 studies, 938 patients treated with Rituxan (2 x 1000 mg) or placebo have been pooled (see Table 2). 318 Adverse reactions reported in ≥ 5% of patients were hypertension, nausea, upper respiratory tract 319 infection, arthralgia, pyrexia and pruritus (see Table 2). The rates and types of adverse reactions in 320 patients who received Rituxan 2 x 500 mg were similar to those observed in patients who received 321 Rituxan 2 x 1000 mg. 322 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 11 of 31/Regional (RA): Rituxan Final Table 2* Incidence of All Adverse Reactions** Occurring in ≥ 2% and at Least 1% Greater Than Placebo Among Rheumatoid Arthritis Patients in Clinical Studies Up to Week 24 (Pooled) Placebo + MTX Rituxan + MTX Preferred Term N = 398 n (%) N = 540 n (%) Hypertension 21 (5) 43 (8) Nausea 19 (5) 41 (8) Upper Respiratory Tract 23 (6) 37 (7) Infection Arthralgia 14 (4) 31 (6) Pyrexia 8 (2) 27 (5) Pruritus 5 (1) 26 (5) Chills 9 (2) 16 (3) Dyspepsia 3 ( < 1) 16 (3) Rhinitis 6 (2) 14 (3) Paresthesia 3 ( < 1) 12 (2) Urticaria 3 ( < 1) 12 (2) Abdominal Pain Upper 4 (1) 11 (2) Throat Irritation 0 (0) 11 (2) Anxiety 5 (1) 9 (2) Migraine 2 ( < 1) 9 (2) Asthenia 1 ( < 1) 9 (2) *These data based on 938 patients treated in Phase 2 and 3 studies of Rituxan (2 × 1000 mg) or placebo administered in combination with methotrexate. **Coded using MedDRA. 323 324 Infusion Reactions 325 In the Rituxan RA pooled placebo-controlled studies, 32% of Rituxan-treated patients experienced 326 an adverse reaction during or within 24 hours following their first infusion, compared to 23% of 327 placebo-treated patients receiving their first infusion. The incidence of adverse reactions during the 328 24-hour period following the second infusion, Rituxan or placebo, decreased to 11% and 13%, 329 respectively. Acute infusion reactions (manifested by fever, chills, rigors, pruritus, urticaria/rash, 330 angioedema, sneezing, throat irritation, cough, and/or bronchospasm, with or without associated 331 hypotension or hypertension) were experienced by 27% of Rituxan-treated patients following their 332 first infusion, compared to 19% of placebo-treated patients receiving their first placebo infusion. 333 The incidence of these acute infusion reactions following the second infusion of Rituxan or placebo 334 decreased to 9% and 11%, respectively. Serious acute infusion reactions were experienced by < 1% 335 of patients in either treatment group. Acute infusion reactions required dose modification (stopping, 336 slowing, or interruption of the infusion) in 10% and 2% of patients receiving Rituxan or placebo, 337 respectively, after the first course. The proportion of patients experiencing acute infusion reactions 338 decreased with subsequent courses of Rituxan. The administration of intravenous glucocorticoids 339 prior to Rituxan infusions reduced the incidence and severity of such reactions, however, there was 340 no clear benefit from the administration of oral glucocorticoids for the prevention of acute infusion U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 12 of 31/Regional (RA): Rituxan Final 341 reactions. Patients in clinical studies also received antihistamines and acetaminophen prior to 342 Rituxan infusions. 343 Infections 344 In the pooled, placebo-controlled studies, 39% of patients in the Rituxan group experienced an 345 infection of any type compared to 34% of patients in the placebo group. The most common 346 infections were nasopharyngitis, upper respiratory tract infections, urinary tract infections, 347 bronchitis, and sinusitis. 348 The incidence of serious infections was 2% in the Rituxan-treated patients and 1% in the placebo 349 group. 350 In the experience with Rituxan in 2578 RA patients, the rate of serious infection was 4.31 per 100 351 patient years. The most common serious infections (≥0.5%) were pneumonia or lower respiratory 352 tract infections, cellulitis and urinary tract infections. Fatal serious infections included pneumonia, 353 sepsis and colitis. Rates of serious infection remain stable in patients receiving subsequent courses. 354 In 185 Rituxan-treated RA patients with active disease, subsequent treatment with a biologic 355 DMARD, the majority of which were TNF antagonists, did not appear to increase the rate of serious 356 infection. Thirteen serious infections were observed in 186.1 patient years (6.99 per 100 patient 357 years) prior to exposure and 10 were observed in 182.3 patient years (5.49 per 100 patient years) 358 after exposure. 359 Cardiac Adverse Reactions 360 In the pooled, placebo-controlled studies, the proportion of patients with serious cardiovascular 361 reactions was 1.7% and 1.3% in Rituxan and placebo treatment groups, respectively. 362 Three cardiovascular deaths occurred during the double-blind period of the RA studies including all 363 Rituxan regimens (3/769 = 0.4%) as compared to none in the placebo treatment group (0/389). 364 In the experience with Rituxan in 2578 RA patients, the rate of serious cardiac reactions was 1.93 365 per 100 patient years. The rate of myocardial infarction (MI) was 0.56 per 100 patient years 366 (28 events in 26 patients), which is consistent with MI rates in the general RA population. These 367 rates did not increase over three courses of Rituxan. 368 Since patients with RA are at increased risk for cardiovascular events compared with the general 369 population, patients with RA should be monitored throughout the infusion and Rituxan should be 370 discontinued in the event of a serious or life-threatening cardiac event. 371 Hypophosphatemia and hyperuricemia 372 In the pooled, placebo-controlled studies, newly occurring hypophosphatemia ( < 2.0 mg/dl) was 373 observed in 12% (67/540) of patients on Rituxan versus 10% (39/398) of patients on placebo. 374 Hypophosphatemia was more common in patients who received corticosteroids. Newly occurring 375 hyperuricemia ( > 10 mg/dl) was observed in 1.5% (8/540) of patients on Rituxan versus 0.3% 376 (1/398) of patients on placebo. 377 In the experience with Rituxan in RA patients, newly occurring hypophosphatemia was observed 378 in 21% (528/2570) of patients and newly occurring hyperuricemia was observed in 2% (56/2570) of 379 patients. The majority of the observed hypophosphatemia occurred at the time of the infusions and 380 was transient. 381 Retreatment in Patients with RA 382 In the experience with Rituxan in RA patients, 2578 patients have been exposed to Rituxan and 383 have received up to 10 courses of Rituxan in RA clinical trials, with 1890, 1043, and 425 patients 384 having received at least two, three, and four courses, respectively. Most of the patients who received 385 additional courses did so 24 weeks or more after the previous course and none were retreated sooner 386 than 16 weeks. The rates and types of adverse reactions reported for subsequent courses of Rituxan 387 were similar to rates and types seen for a single course of Rituxan. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 13 of 31/Regional (RA): Rituxan Final 388 In RA Study 2, where all patients initially received Rituxan, the safety profile of patients who 389 were retreated with Rituxan was similar to those who were retreated with placebo [see Clinical 390 Studies (14.5), and Dosage and Administration (2.2).] 391 6.3 Immunogenicity 392 As with all therapeutic proteins, there is a potential for immunogenicity. The observed incidence 393 of antibody (including neutralizing antibody) positivity in an assay is highly dependent on several 394 factors including assay sensitivity and specificity, assay methodology, sample handling, timing of 395 sample collection, concomitant medications, and underlying disease. For these reasons, comparison 396 of the incidence of antibodies to Rituxan with the incidence of antibodies to other products may be 397 misleading. 398 Using an ELISA assay, anti-human anti-chimeric antibody (HACA) was detected in 4 of 399 356 (1.1%) patients with low-grade or follicular NHL receiving single-agent Rituxan. Three of the 400 four patients had an objective clinical response. 401 A total of 273/2578 (11%) patients with RA tested positive for HACA at any time after receiving 402 Rituxan. HACA positivity was not associated with increased infusion reactions or other adverse 403 reactions. Upon further treatment, the proportions of patients with infusion reactions were similar 404 between HACA positive and negative patients, and most reactions were mild to moderate. Four 405 HACA positive patients had serious infusion reactions, and the temporal relationship between 406 HACA positivity and infusion reaction was variable. The clinical relevance of HACA formation in 407 Rituxan-treated patients is unclear. 408 6.4 Postmarketing Experience 409 The following adverse reactions have been identified during post-approval use of Rituxan in 410 hematologic malignancies. Because these reactions are reported voluntarily from a population of 411 uncertain size, it is not always possible to reliably estimate their frequency or establish a causal 412 relationship to drug exposure. 413 Decisions to include these reactions in labeling are typically based on one or more of the 414 following factors: (1) seriousness of the reaction, (2) frequency of reporting, or (3) strength of 415 causal connection to Rituxan. 416 • Hematologic: prolonged pancytopenia, marrow hypoplasia, and late-onset neutropenia, 417 hyperviscosity syndrome in Waldenstrom's macroglobulinemia. 418 • Cardiac: fatal cardiac failure. 419 • Immune/Autoimmune Events: uveitis, optic neuritis, systemic vasculitis, pleuritis, lupus-like 420 syndrome, serum sickness, polyarticular arthritis, and vasculitis with rash. 421 • Infection: viral infections, including progressive multifocal leukoencephalopathy (PML), 422 increase in fatal infections in HIV-associated lymphoma, and a reported increased incidence of 423 Grade 3 and 4 infections in patients with previously treated lymphoma without known HIV 424 infection. 425 • Neoplasia: disease progression of Kaposi's sarcoma. 426 • Skin: severe mucocutaneous reactions. 427 • Gastrointestinal: bowel obstruction and perforation. 428 • Pulmonary: fatal bronchiolitis obliterans and pneumonitis (including interstitial pneumonitis). 429 7 DRUG INTERACTIONS 430 Formal drug interaction studies have not been performed with Rituxan. In clinical trials of 431 patients with RA, concomitant administration of methotrexate or cyclophosphamide did not alter the 432 pharmacokinetics of rituximab. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 14 of 31/Regional (RA): Rituxan Final 433 8 USE IN SPECIFIC POPULATIONS 434 8.1 Pregnancy 435 Category C: There are no adequate and well-controlled studies of rituximab in pregnant women. 436 Postmarketing data indicate that B-cell lymphocytopenia generally lasting less than six months can 437 occur in infants exposed to rituximab in-utero. Rituximab was detected postnatally in the serum of 438 infants exposed in-utero. 439 Non−Hodgkin's lymphoma and moderate-severe rheumatoid arthritis are serious conditions that 440 require treatment. Rituximab should be used during pregnancy only if the potential benefit to the 441 mother justifies the potential risk to the fetus. 442 Reproduction studies in cynomolgus monkeys at maternal exposures similar to human therapeutic 443 exposures showed no evidence of teratogenic effects. However, B-cell lymphoid tissue was reduced 444 in the offspring of treated dams. The B-cell counts returned to normal levels, and immunologic 445 function was restored within 6 months of birth. 446 8.3 Nursing Mothers 447 It is not known whether Rituxan is secreted into human milk. However, Rituxan is secreted in the 448 milk of lactating cynomolgus monkeys, and IgG is excreted in human milk. Published data suggest 449 that antibodies in breast milk do not enter the neonatal and infant circulations in substantial amounts. 450 The unknown risks to the infant from oral ingestion of Rituxan should be weighed against the known 451 benefits of breastfeeding. 452 8.4 Pediatric Use 453 FDA has not required pediatric studies in polyarticular juvenile idiopathic arthritis (PJIA) patients 454 ages 0 to 16 due to concerns regarding the potential for prolonged immunosuppression as a result of 455 B cell depletion in the developing juvenile immune system. 456 The safety and effectiveness of Rituxan in pediatric patients have not been established. 457 8.5 Geriatric Use 458 Diffuse Large B-Cell NHL 459 Among patients with DLBCL evaluated in three randomized, active-controlled trials, 927 patients 460 received Rituxan in combination with chemotherapy. Of these, 396 (43%) were age 65 or greater 461 and 123 (13%) were age 75 or greater. No overall differences in effectiveness were observed 462 between these patients and younger patients. Cardiac adverse reactions, mostly supraventricular 463 arrhythmias, occurred more frequently among elderly patients. Serious pulmonary adverse reactions 464 were also more common among the elderly, including pneumonia and pneumonitis. 465 Low-Grade or Follicular Non−Hodgkin's Lymphoma 466 Clinical studies of Rituxan in low-grade or follicular, CD20-positive, B-cell NHL did not include 467 sufficient numbers of patients aged 65 and over to determine whether they respond differently from 468 younger subjects. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 15 of 31/Regional (RA): Rituxan Final 469 Rheumatoid Arthritis 470 Among the 2578 patients in global RA studies completed to date, 12% were 65−75 years old and 471 2% were 75 years old and older. The incidences of adverse reactions were similar between older and 472 younger patients. The rates of serious adverse reactions, including serious infections, malignancies, 473 and cardiovascular events were higher in older patients. 474 475 10 OVERDOSAGE 476 There has been no experience with overdosage in human clinical trials. Single doses of up to 477 500 mg/m2 have been given in dose-escalation clinical trials. 478 479 11 DESCRIPTION 480 Rituxan (rituximab) is a genetically engineered chimeric murine/human monoclonal IgG1 kappa 481 antibody directed against the CD20 antigen. Rituximab has an approximate molecular weight of 482 145 kD. Rituximab has a binding affinity for the CD20 antigen of approximately 8.0 nM. 483 Rituximab is produced by mammalian cell (Chinese Hamster Ovary) suspension culture in a 484 nutrient medium containing the antibiotic gentamicin. Gentamicin is not detectable in the final 485 product. Rituxan is a sterile, clear, colorless, preservative-free liquid concentrate for intravenous 486 administration. Rituxan is supplied at a concentration of 10 mg/mL in either 100 mg (10 mL) or 487 500 mg (50 mL) single-use vials. The product is formulated in 9 mg/mL sodium chloride, 488 7.35 mg/mL sodium citrate dihydrate, 0.7 mg/mL polysorbate 80, and Water for Injection. The pH 489 is 6.5. 490 491 12 CLINICAL PHARMACOLOGY 492 12.1 Mechanism of Action 493 Rituximab binds specifically to the antigen CD20 (human B-lymphocyte-restricted differentiation 494 antigen, Bp35), a hydrophobic transmembrane protein with a molecular weight of approximately 495 35 kD located on pre-B and mature B lymphocytes. The antigen is expressed on > 90% of B-cell 496 non−Hodgkin's lymphomas (NHL), but the antigen is not found on hematopoietic stem cells, 497 pro-B-cells, normal plasma cells or other normal tissues. CD20 regulates an early step(s) in the 498 activation process for cell cycle initiation and differentiation, and possibly functions as a calcium ion 499 channel. CD20 is not shed from the cell surface and does not internalize upon antibody binding. 500 Free CD20 antigen is not found in the circulation. 501 B cells are believed to play a role in the pathogenesis of rheumatoid arthritis (RA) and associated 502 chronic synovitis. In this setting, B cells may be acting at multiple sites in the 503 autoimmune/inflammatory process, including through production of rheumatoid factor (RF) and 504 other autoantibodies, antigen presentation, T-cell activation, and/or proinflammatory cytokine 505 production. 506 Mechanism of Action: The Fab domain of rituximab binds to the CD20 antigen on B 507 lymphocytes, and the Fc domain recruits immune effector functions to mediate B-cell lysis in vitro. 508 Possible mechanisms of cell lysis include complement-dependent cytotoxicity (CDC) and 509 antibody-dependent cell-mediated cytotoxicity (ADCC). The antibody has been shown to induce 510 apoptosis in the DHL-4 human B-cell lymphoma line. 511 Normal Tissue Cross-reactivity: Rituximab binding was observed on lymphoid cells in the 512 thymus, the white pulp of the spleen, and a majority of B lymphocytes in peripheral blood and 513 lymph nodes. Little or no binding was observed in the non-lymphoid tissues examined. 514 12.2 Pharmacodynamics 515 In NHL patients, administration of Rituxan resulted in depletion of circulating and tissue-based B 516 cells. Among 166 patients in Study 1, circulating CD19-positive B cells were depleted within the U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 16 of 31/Regional (RA): Rituxan Final 517 first three weeks with sustained depletion for up to 6 to 9 months posttreatment in 83% of patients. 518 B-cell recovery began at approximately 6 months and median B-cell levels returned to normal by 519 12 months following completion of treatment. 520 There were sustained and statistically significant reductions in both IgM and IgG serum levels 521 observed from 5 through 11 months following rituximab administration; 14% of patients had IgM 522 and/or IgG serum levels below the normal range. 523 In RA patients, treatment with Rituxan induced depletion of peripheral B lymphocytes, with the 524 majority of patients demonstrating near complete depletion (CD19 counts below the lower limit of 525 quantification, 20 cells/µl) within 2 weeks after receiving the first dose of Rituxan. The majority of 526 patients showed peripheral B-cell depletion for at least 6 months. A small proportion of patients 527 (~4%) had prolonged peripheral B-cell depletion lasting more than 3 years after a single course of 528 treatment. 529 Total serum immunoglobulin levels, IgM, IgG, and IgA were reduced at 6 months with the 530 greatest change observed in IgM. At Week 24 of the first course of Rituxan treatment, small 531 proportions of patients experienced decreases in IgM (10%), IgG (2.8%), and IgA (0.8%) levels 532 below the lower limit of normal. In the experience with Rituxan in RA patients during repeated 533 rituximab treatment, 23.3%, 5.5%, and 0.5% of the patients experienced decreases in IgM, IgG, and 534 IgA concentrations below the LLN at any time after receiving rituximab, respectively. The clinical 535 consequences of decreases in immunoglobulin levels in RA patients treated with Rituxan are 536 unclear. 537 Treatment with Rituxan in patients with RA was associated with reduction of certain biologic 538 markers of inflammation such as interleukin-6 (IL-6), C-reactive protein (CRP), serum amyloid 539 protein (SAA), S100 A8/S100 A9 heterodimer complex (S100 A8/9), anti-citrullinated peptide 540 (anti-CCP), and RF. 541 12.3 Pharmacokinetics 542 Pharmacokinetics were characterized in 203 NHL patients receiving 375 mg/m2 rituximab weekly 543 by IV infusion for 4 doses. The mean Cmax increased with each successive infusion and was 544 486 mcg/mL (range, 78−997 mcg/mL) following the fourth infusion. Peak and trough serum levels 545 of rituximab were inversely correlated with pretreatment circulating CD19-positive B cells and 546 tumor burden. Rituximab was detectable in the serum of patients 3 to 6 months after completion of 547 treatment. 548 The pharmacokinetic profile of rituximab when administered as 6 infusions of 375 mg/m2 in 549 combination with 6 cycles of CHOP chemotherapy was similar to that seen with rituximab alone. 550 Based on a population pharmacokinetic analysis of data from 298 NHL patients who received 551 rituximab once weekly or once every three weeks, the estimated median terminal elimination 552 half-life was 22 days (range, 6.1 to 52 days). Patients with higher CD19-positive cell counts or 553 larger measurable tumor lesions at pretreatment had a higher clearance. However, dose adjustment 554 for pretreatment CD19 count or size of tumor lesion is not necessary. Age and gender had no effect 555 on the pharmacokinetics of rituximab. 556 Following administration of 2 doses of rituximab in patients with RA, the mean (± S.D.; % CV) 557 concentrations after the first infusion (Cmax first) and second infusion (Cmax second) were 157 (± 46; 558 29%) and 183 (± 55; 30%) mcg/mL, and 318 (± 86; 27%) and 381 (± 98; 26%) mcg/mL for the 559 2 × 500 mg and 2 × 1000 mg doses, respectively. 560 Based on a population pharmacokinetic analysis of data from 2005 RA patients who received 561 rituximab, the estimated clearance of Rituxan was 0.335 L/day; volume of distribution was 3.1 L and 562 mean terminal elimination half-life was 18.0 days (range, 5.17 to 77.5days). Age, weight and gender 563 had no effect on the pharmacokinetics of rituximab in RA patients. 564 The pharmacokinetics of rituximab have not been studied in children and adolescents. No formal 565 studies were conducted to examine the effects of either renal or hepatic impairment on the 566 pharmacokinetics of rituximab. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 17 of 31/Regional (RA): Rituxan Final 567 568 13 NONCLINICAL TOXICOLOGY 569 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 570 No long-term animal studies have been performed to establish the carcinogenic or mutagenic 571 potential of Rituxan, or to determine potential effects on fertility in males or females. 572 13.2 Animal Toxicology and/or Pharmacology 573 Reproductive Toxicology Studies 574 An embryo-fetal developmental toxicity study was performed on pregnant cynomolgus monkeys. 575 Pregnant animals received rituximab via the intravenous route during early gestation (organogenesis 576 period; post-coitum days 20 through 50). Rituximab was administered as loading doses on 577 postcoitum (PC) Days 20, 21 and 22, at 15, 37.5 or 75 mg/kg/day, and then weekly on PC Days 29, 578 36, 43 and 50, at 20, 50 or 100 mg/kg/week. The 100 mg/kg/week dose resulted in 80% of the 579 exposure (based on AUC) of those achieved following a dose of 2 grams in humans. Rituximab 580 crosses the monkey placenta. Exposed offspring did not exhibit any teratogenic effects but did have 581 decreased lymphoid tissue B cells. 582 A subsequent pre- and postnatal reproductive toxicity study in cynomolgus monkeys was 583 completed to assess developmental effects including the recovery of B cells and immune function in 584 infants exposed to rituximab in utero. Animals were treated with a loading dose of 0, 15, or 75 585 mg/kg every day for 3 days, followed by weekly dosing with 0, 20, or 100 mg/kg dose. Subsets of 586 pregnant females were treated from PC Day 20 through postpartum Day 78, PC Day 76 through PC 587 Day 134, and from PC Day 132 through delivery and postpartum Day 28. Regardless of the timing 588 of treatment, decreased B cells and immunosuppression were noted in the offspring of 589 rituximab-treated pregnant animals. The B-cell counts returned to normal levels, and immunologic 590 function was restored within 6 months postpartum. 591 592 14 CLINICAL STUDIES 593 14.1 Relapsed or Refractory, Low-Grade or Follicular, CD20-Positive, B-Cell NHL 594 The safety and effectiveness of Rituxan in relapsed, refractory CD20+ NHL were demonstrated in 595 3 single-arm studies enrolling 296 patients. 596 Study 1 597 A multicenter, open-label, single-arm study was conducted in 166 patients with relapsed or 598 refractory, low-grade or follicular, B-cell NHL who received 375 mg/m2 of Rituxan given as an 599 intravenous infusion weekly for 4 doses. Patients with tumor masses > 10 cm or with 600 > 5000 lymphocytes/µL in the peripheral blood were excluded from the study. 601 Results are summarized in Table 3. The median time to onset of response was 50 days. 602 Disease-related signs and symptoms (including B-symptoms) resolved in 64% (25/39) of those 603 patients with such symptoms at study entry. 604 Study 2 605 In a multicenter, single-arm study, 37 patients with relapsed or refractory, low-grade NHL 606 received 375 mg/m2 of Rituxan weekly for 8 doses. Results are summarized in Table 3. 607 Study 3 608 In a multicenter, single-arm study, 60 patients received 375 mg/m2 of Rituxan weekly for 4 doses. 609 All patients had relapsed or refractory, low-grade or follicular, B-cell NHL and had achieved an 610 objective clinical response to Rituxan administered 3.8−35.6 months (median 14.5 months) prior to 611 retreatment with Rituxan. Of these 60 patients, 5 received more than one additional course of 612 Rituxan. Results are summarized in Table 3. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 18 of 31/Regional (RA): Rituxan Final 613 Bulky Disease 614 In pooled data from Studies 1 and 3, 39 patients with bulky (single lesion > 10 cm in diameter) 615 and relapsed or refractory, low-grade NHL received Rituxan 375 mg/m2 weekly for 4 doses. Results 616 are summarized in Table 3. 617 Table 3 Summary of Rituxan Efficacy Data by Schedule and Clinical Setting Study 1 and Study 3 Study 3 Study 1 Study 2 Bulky disease, Retreatment, Weekly × 4 Weekly × 8 Weekly × 4 Weekly × 4 N = 166 N = 37 N = 39a N = 60 Overall Response Rate 48% 57% 36% 38% Complete Response Rate 6% 14% 3% 10% b, c, Median Duration of Response 11.2 13.4 6.9 15.0 d [1.9 to 42.1+] [2.5 to 36.5+] [2.8 to 25.0+] [3.0 to 25.1+] (Months) [Range] a Six of these patients are included in the first column. Thus, data from 296 intent-to-treat patients are provided in this table. b Kaplan-Meier projected with observed range. c "+" indicates an ongoing response. d Duration of response: interval from the onset of response to disease progression. 618 619 14.2 Previously Untreated, Follicular, CD20-Positive, B-Cell NHL 620 Study 4 621 A total of 322 patients with previously untreated follicular NHL were randomized (1:1) to receive 622 up to eight 3-week cycles of CVP chemotherapy alone (CVP) or in combination with Rituxan 623 375 mg/m2 on Day 1 of each cycle (R-CVP) in an open-label, multicenter study. The main outcome 624 measure of the study was progression-free survival (PFS) defined as the time from randomization to 625 the first of progression, relapse, or death. 626 Twenty-six percent of the study population was > 60 years of age, 99% had Stage III or IV 627 disease, and 50% had an International Prognostic Index (IPI) score ≥ 2. The results for PFS as 628 determined by a blinded, independent assessment of progression are presented in Table 4. The point 629 estimates may be influenced by the presence of informative censoring. The PFS results based on 630 investigator assessment of progression were similar to those obtained by the independent review 631 assessment. 632 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 19 of 31/Regional (RA): Rituxan Final Table 4 Efficacy Results in Study 4 Study Arm R-CVP CVP N=162 N=160 Median PFS (years)a 2.4 1.4 b Hazard ratio (95% CI) 0.44 (0.29, 0.65) a p < 0.0001, two-sided stratified log-rank test. b Estimates of Cox regression stratified by center. 633 634 14.3 Non-Progressing Low-Grade, CD20-Positive, B-Cell NHL Following First-Line CVP 635 Chemotherapy 636 Study 5 637 A total of 322 patients with previously untreated low-grade, B-cell NHL who did not progress 638 after 6 or 8 cycles of CVP chemotherapy were enrolled in an open-label, multicenter, randomized 639 trial. Patients were randomized (1:1) to receive Rituxan 375 mg/m2 intravenous infusion, once 640 weekly for 4 doses every 6 months for up to 16 doses or no further therapeutic intervention. The 641 main outcome measure of the study was progression-free survival defined as the time from 642 randomization to progression, relapse, or death. Thirty-seven percent of the study population was 643 > 60 years of age, 99% had Stage III or IV disease, and 63% had an IPI score ≥ 2. 644 There was a reduction in the risk of progression, relapse, or death (hazard ratio estimate in the 645 range of 0.36 to 0.49) for patients randomized to Rituxan as compared to those who received no 646 additional treatment. 647 14.4 Diffuse Large B-Cell NHL (DLBCL) 648 The safety and effectiveness of Rituxan were evaluated in three randomized, active-controlled, 649 open-label, multicenter studies with a collective enrollment of 1854 patients. Patients with 650 previously untreated diffuse large B-cell NHL received Rituxan in combination with 651 cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or other anthracycline-based 652 chemotherapy regimens. 653 Study 6 654 A total of 632 patients age ≥ 60 years with DLBCL (including primary mediastinal B-cell 655 lymphoma) were randomized in a 1:1 ratio to treatment with CHOP or R-CHOP. Patients received 656 6 or 8 cycles of CHOP, each cycle lasting 21 days. All patients in the R-CHOP arm received 4 doses 657 of Rituxan 375 mg/m2 on Days 7 and 3 (prior to Cycle 1) and 48−72 hours prior to Cycles 3 and 5. 658 Patients who received 8 cycles of CHOP also received Rituxan prior to Cycle 7. The main outcome 659 measure of the study was progression-free survival, defined as the time from randomization to the 660 first of progression, relapse, or death. Responding patients underwent a second randomization to 661 receive Rituxan or no further therapy. 662 Among all enrolled patients, 62% had centrally confirmed DLBCL histology, 73% had 663 Stage III−IV disease, 56% had IPI scores ≥ 2, 86% had ECOG performance status of < 2, 57% had 664 elevated LDH levels, and 30% had two or more extranodal disease sites involved. Efficacy results 665 are presented in Table 5. These results reflect a statistical approach which allows for an evaluation 666 of Rituxan administered in the induction setting that excludes any potential impact of Rituxan given 667 after the second randomization. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 20 of 31/Regional (RA): Rituxan Final 668 Analysis of results after the second randomization in Study 6 demonstrates that for patients 669 randomized to R-CHOP, additional Rituxan exposure beyond induction was not associated with 670 further improvements in progression-free survival or overall survival. 671 Study 7 672 A total of 399 patients with DLBCL, age ≥ 60 years, were randomized in a 1:1 ratio to receive 673 CHOP or R-CHOP. All patients received up to eight 3-week cycles of CHOP induction; patients in 674 the R-CHOP arm received Rituxan 375 mg/m2 on Day 1 of each cycle. The main outcome measure 675 of the study was event-free survival, defined as the time from randomization to relapse, progression, 676 change in therapy, or death from any cause. Among all enrolled patients, 80% had Stage III or IV 677 disease, 60% of patients had an age-adjusted IPI ≥ 2, 80% had ECOG performance status scores 678 < 2, 66% had elevated LDH levels, and 52% had extranodal involvement in at least two sites. 679 Efficacy results are presented in Table 5. 680 Study 8 681 A total of 823 patients with DLBCL, aged 18−60 years, were randomized in a 1:1 ratio to receive 682 an anthracycline-containing chemotherapy regimen alone or in combination with Rituxan. The main 683 outcome measure of the study was time to treatment failure, defined as time from randomization to 684 the earliest of progressive disease, failure to achieve a complete response, relapse, or death. Among 685 all enrolled patients, 28% had Stage III−IV disease, 100% had IPI scores of ≤ 1, 99% had ECOG 686 performance status of < 2, 29% had elevated LDH levels, 49% had bulky disease, and 34% had 687 extranodal involvement. Efficacy results are presented in Table 5. 688 Table 5 Efficacy Results in Studies 6, 7, and 8 Study 6 Study 7 Study 8 (n = 632) (n = 399) (n = 823) R-CHOP CHOP R-CHOP CHOP R-Chemo Chemo Main outcome Progression-free Event-free survival Time to treatment failure survival (years) (years) (years) Median of main outcome 3.1 1.6 2.9 1.1 NEb NEb measure Hazard ratiod 0.69a 0.60a 0.45a Overall survival at 2 yearsc 74% 63% 69% 58% 95% 86% d a a a Hazard ratio 0.72 0.68 0.40 a Significant at p < 0.05, 2-sided. b NE = Not reliably estimable. c Kaplan-Meier estimates. d R-CHOP vs. CHOP. 689 690 In Study 7, overall survival estimates at 5 years were 58% vs. 46% for R-CHOP and CHOP, 691 respectively. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 21 of 31/Regional (RA): Rituxan Final 692 14.5 Rheumatoid Arthritis (RA) 693 Reducing Signs and Symptoms: Initial and Re-Treatment Courses 694 The efficacy and safety of Rituxan were evaluated in two randomized, double-blind, 695 placebo-controlled studies of adult patients with moderately to severely active RA who had a prior 696 inadequate response to at least one TNF inhibitor. Patients were 18 years of age or older, diagnosed 697 with active RA according to American College of Rheumatology (ACR) criteria, and had at least 8 698 swollen and 8 tender joints. 699 In RA Study 1, patients were randomized to receive either Rituxan 2 x 1000 mg + MTX or 700 placebo + MTX for 24 weeks. Further courses of Rituxan 2 x 1000 mg + MTX were administered in 701 an open label extension study at a frequency determined by clinical evaluation, but no sooner than 702 16 weeks after the preceding course of Rituxan. In addition to the IV premedication, glucocorticoids 703 were administered orally on a tapering schedule from baseline through Day 14. The proportions of 704 patients achieving ACR 20, 50, and 70 responses at Week 24 of the placebo-controlled period are 705 shown in Table 6. 706 In RA Study 2, all patients received the first course of Rituxan 2 x 1000 mg + MTX. Patients who 707 experienced ongoing disease activity were randomized to receive a second course of either 708 Rituxan 2 x 1000 mg + MTX or placebo + MTX, the majority between Weeks 24−28. The 709 proportions of patients achieving ACR 20, 50, and 70 responses at Week 24, before the re-treatment 710 course, and at Week 48, after retreatment, are shown in Table 6. 711 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 22 of 31/Regional (RA): Rituxan Final Table 6 ACR Responses in Study 1 and Study 2 (Percent of Patients) (Modified Intent-to-Treat Population) Inadequate Response to TNF Antagonists Study 1 Study 2 24 Week Placebo-Controlled Placebo-Controlled Retreatment (Week 24) (Week 24 and Week 48) Placebo + Rituxan + Treatment Difference Placebo + MTX Rituxan + MTX Treatment Difference MTX MTX (Rituxan – Placebo)c Retreatment Retreatment (Rituxan – Placebo) a , b, c Response n = 201 n = 298 (95% CI) Response n = 157 n = 318 (95% CI) ACR20 ACR20 Week 24 18% 51% 33% Week 24 48% 45% NA (26%, 41%) Week 48 45% 54% 11% (2%, 20%) ACR50 ACR50 Week 24 5% 27% 21% Week 24 27% 21% NA (15%, 27%) Week 48 26% 29% 4% (-4%, 13%) ACR70 ACR70 Week 24 1% 12% 11% Week 24 11% 8% NA (7%, 15%) Week 48 13% 14% 1% (-5%, 8%) a : In Study 2, all patients received a first course of Rituxan 2 x 1000 mg. Patients who experienced ongoing disease activity were randomized to receive a second course of either Rituxan 2 x 1000 mg + MTX or placebo + MTX at or after Week 24. b Since all patients received a first course of Rituxan, no comparison between Placebo + MTX and Rituxan + MTX is made at Week 24. c : For Study 1, weighted difference stratified by region (US, rest of the world) and Rheumatoid Factor (RF) status (positive >= 20 IU/mL, negative < 20 IU/mL) at baseline; For Study 2, weighted difference stratified by RF status at baseline and >=20% improvement from baseline in both SJC and TJC at Week 24 (Yes/No). 712 713 Improvement was also noted for all components of ACR response following treatment with 714 Rituxan, as shown in Table 7. 715 716 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 23 of 31/Regional (RA): Rituxan Final Table 7 Components of ACR Response at Week 24 in Study 1 (Modified Intent-to-Treat Population) Inadequate Response to TNF Antagonists Placebo + MTX Rituxan + MTX (n = 201) (n = 298) Parameter (median) Baseline Wk 24 Baseline Wk 24 Tender Joint Count 31.0 27.0 33.0 13.0 Swollen Joint Count 20.0 19.0 21.0 9.5 a Physician Global Assessment 71.0 69.0 71.0 36.0 a Patient Global Assessment 73.0 68.0 71.0 41.0 a Pain 68.0 68.0 67.0 38.5 b Disability Index (HAQ) 2.0 1.9 1.9 1.5 CRP (mg/dL) 2.4 2.5 2.6 0.9 a Visual Analogue Scale: 0 = best, 100 = worst. b Disability Index of the Health Assessment Questionnaire: 0 = best, 3 = worst. 717 718 The time course of ACR 20 response for Study 1 is shown in Figure 1. Although both treatment 719 groups received a brief course of intravenous and oral glucocorticoids, resulting in similar benefits at 720 Week 4, higher ACR 20 responses were observed for the Rituxan group by Week 8. A similar 721 proportion of patients achieved these responses through Week 24 after a single course of treatment 722 (2 infusions) with Rituxan. Similar patterns were demonstrated for ACR 50 and 70 responses. 723 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 24 of 31/Regional (RA): Rituxan Final 724 Figure 1 725 Percent of Patients Achieving ACR 20 Response by Visit* 726 Study 1 (Inadequate Response to TNF Antagonists) 727 728 *The same patients may not have responded at each time point. 729 Radiographic Response 730 In RA Study 1, structural joint damage was assessed radiographically and expressed as changes in 731 Genant-modified Total Sharp Score (TSS) and its components, the erosion score (ES) and the joint 732 space narrowing (JSN) score. Rituxan + MTX slowed the progression of structural damage 733 compared to placebo + MTX after 1 year as shown in Table 8. 734 Table 8 Mean Radiographic Change From Baseline to 104 Weeks Inadequate Response to TNF Antagonists Rituxan 2 x 1000 mg + Treatment Difference Parameter MTXb Placebo + MTXc (Placebo – Rituxan) 95% CI Change during First Year TSS 0.66 1.78 1.12 (0.48, 1.76) ES 0.44 1.19 0.75 (0.32, 1.18) JSN Score 0.22 0.59 0.37 (0.11, 0.63) Change during Second Yeara TSS 0.48 1.04 - - ES 0.28 0.62 - - JSN Score 0.20 0.42 - - a Based on radiographic scoring following 104 weeks of observation. b Patients received up to 2 years of treatment with Rituxan + MTX. c Patients receiving Placebo + MTX. Patients receiving Placebo+ MTX could have received retreatment with Rituxan + MTX from Week 16 onward. 735 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 25 of 31/Regional (RA): Rituxan Final 736 In RA Study 1 and its open-label extension, 70% of patients initially randomized to Rituxan + 737 MTX and 72% of patients initially randomized to placebo + MTX were evaluated radiographically at 738 Year 2. As shown in Table 8, progression of structural damage in Rituxan + MTX patients was 739 further reduced in the second year of treatment. 740 Following 2 years of treatment with Rituxan + MTX, 57% of patients had no progression of 741 structural damage. During the first year, 60% of Rituxan + MTX treated patients had no 742 progression, defined as a change in TSS of zero or less compared to baseline, compared to 46% of 743 placebo + MTX treated patients. In their second year of treatment with Rituxan + MTX, more 744 patients had no progression than in the first year (68% vs. 60%), and 87% of the Rituxan + MTX 745 treated patients who had no progression in the first year also had no progression in the second year. 746 Lesser Efficacy of 500 Vs. 1000 mg Treatment Courses for Radiographic Outcomes 747 RA Study 3 is a randomized, double-blind, placebo-controlled study which evaluated the effect of 748 placebo + MTX compared to Rituxan 2 x 500 mg + MTX and Rituxan 2 x 1000 mg + MTX 749 treatment courses in MTX-naïve RA patients with moderately to severely active disease. Patients 750 received a first course of two infusions of rituximab or placebo on Days 1 and 15. MTX was 751 initiated at 7.5 mg/week and escalated up to 20 mg/week by week 8 in all three treatment arms. 752 After a minimum of 24 weeks, patients with ongoing disease activity were eligible to receive re- 753 treatment with additional courses of their assigned treatment. After one year of treatment, the 754 proportion of patients achieving ACR 20/50/70 responses were similar in both Rituxan dose groups 755 and were higher than in the placebo group. However, with respect to radiographic scores, only the 756 Rituxan 1000 mg treatment group demonstrated a statistically significant reduction in TSS: a change 757 of 0.36 units compared to 1.08 units for the placebo group, a 67% reduction. 758 Physical Function Response 759 RA Study 4 is a randomized, double-blind, placebo-controlled study in adult RA patients with 760 moderately to severely active disease with inadequate response to MTX. Patients were randomized 761 to receive an initial course of Rituxan 500 mg, Rituxan 1000 mg, or placebo in addition to 762 background MTX. 763 Physical function was assessed at Weeks 24 and 48 using the Health Assessment Questionnaire 764 Disability Index (HAQ-DI). From baseline to Week 24, a greater proportion of Rituxan-treated 765 patients had an improvement in HAQ-DI of at least 0.22 (a minimal clinically important difference) 766 and a greater mean HAQ-DI improvement compared to placebo, as shown in Table 9. HAQ-DI 767 results for the Rituxan 500 mg treatment group were similar to the Rituxan 1000 mg treatment 768 group; however radiographic responses were not assessed (see Dosing Precaution in the 769 Radiographic Responses section above). These improvements were maintained at 48 weeks. 770 U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 26 of 31/Regional (RA): Rituxan Final Table 9 Improvement from Baseline in Health Assessment Questionnaire Disability Index (HAQ-DI) at Week 24 in Study 4 Treatment Difference Placebo Rituxan (Rituxan – Placebo)b + MTX 2 x 1000 mg + MTX n = 172 n = 170 (95% CI) Mean Improvement from Baseline 0.19 0.42 0.23 (0.11, 0.34) Percent of patients with "Improved" score (Change 48% 58% 11% (0%, 21%) from Baseline ≥ MCID)a a Minimal Clinically Important Difference: MCID for HAQ = 0.22. b Adjusted difference stratified by region (US, rest of the world) and rheumatoid factor (RF) status (positive >= 20 IU/mL, negative < 20 IU/mL) at baseline 771 772 16 HOW SUPPLIED/STORAGE AND HANDLING 773 Rituxan vials [100 mg (NDC 50242-051-21) and 500 mg (NDC 50242-053-06)] are stable at 774 2°C−8°C (36°F−46°F). Do not use beyond expiration date stamped on carton. Rituxan vials should 775 be protected from direct sunlight. Do not freeze or shake. 776 Rituxan solutions for infusion may be stored at 2°C−8°C (36°F−46°F) for 24 hours. Rituxan 777 solutions for infusion have been shown to be stable for an additional 24 hours at room temperature. 778 However, since Rituxan solutions do not contain a preservative, diluted solutions should be stored 779 refrigerated (2°C−8°C). No incompatibilities between Rituxan and polyvinylchloride or 780 polyethylene bags have been observed. 781 782 17 PATIENT COUNSELING INFORMATION 783 See Medication Guide (17.2). 784 17.1 General Counseling Information 785 Patients should be provided the Rituxan Medication Guide and provided an opportunity to read 786 prior to each treatment session. Because caution should be exercised in administering Rituxan to 787 patients with active infections, it is important that the patient's overall health be assessed at each 788 visit and the risks of Rituxan therapy and any questions resulting from the patient's reading of the 789 Medication Guide be discussed. 790 Rituxan is detectable in serum for up to six months following completion of therapy. Individuals 791 of childbearing potential should use effective contraception during treatment and for 12 months after 792 Rituxan therapy. 793 Immunosuppression 794 Inform patients that Rituxan may lower the ability of the immune system to fight infections. 795 Instruct patients of the importance of contacting their doctor if they develop any symptoms of 796 infection, including new-onset neurologic symptoms that may be suggestive of PML including new 797 or worsening medical problems, such as a new or sudden change in thinking, walking, strength, 798 vision, or other problems that have lasted over several days. 799 Infusion Reactions 800 Advise patients of the potential for serious, including fatal infusion reactions and ask them to 801 report promptly any symptoms suggestive of infusion reactions including hives, swelling, dizziness, 802 blurred vision, drowsiness, headache, cough, wheezing, or trouble breathing while receiving or after 803 receiving Rituxan. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 27 of 31/Regional (RA): Rituxan Final 804 Other Medical Conditions 805 Counsel patients with NHL about the possible risk of tumor lysis syndrome while receiving 806 Rituxan. 807 Advise patients to report promptly any symptoms suggestive of severe mucocutaneous reactions 808 such as painful sores on skin or in mouth, ulcers, blisters, or peeling skin while receiving or after 809 receiving Rituxan. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 28 of 31/Regional (RA): Rituxan Final 810 17.2 Medication Guide 811 MEDICATION GUIDE 812 RITUXAN® (ri-tuk´-san) 813 (rituximab) 814 Read the Medication Guide given to you before you start Rituxan and before each Rituxan infusion. 815 The information may have changed. This Medication Guide does not take the place of talking to 816 your doctor about your medical condition or your treatment. Talk with your doctor if you have any 817 questions about your treatment with Rituxan. 818 What is the most important information I should know about Rituxan? 819 Rituxan can cause serious side effects including: 820 • Progressive Multifocal Leukoencephalopathy (PML) 821 • PML is a rare brain infection. PML usually causes death or severe disability. 822 • Call your doctor right away if you notice any new or worsening medical problems, such as a 823 new or sudden change in thinking, walking, strength, vision, or other problems that have 824 lasted over several days. 825 • PML usually happens in patients with weakened immune systems. 826 • PML can occur during treatment with Rituxan or after treatment has finished. 827 • There is no known treatment, prevention, or cure for PML. 828 • Infusion reactions. Tell your doctor or get medical treatment right away if you get hives, 829 swelling, dizziness, blurred vision, drowsiness, headache, cough, wheezing, or have trouble 830 breathing while receiving or after receiving Rituxan. 831 • Tumor Lysis Syndrome (TLS). TLS is caused by the fast breakdown of certain types of cancer 832 cells. TLS can cause kidney failure and the need for dialysis treatment. Patients receiving 833 Rituxan for non−Hodgkin's lymphoma (NHL) may get TLS. Your doctor will check you for 834 TLS. 835 • Severe skin reactions. Tell your doctor or get medical treatment right away if you get any of 836 these symptoms: painful sores on your skin or in your mouth, ulcers, blisters, or peeling skin 837 while receiving or after receiving Rituxan. 838 See "What are possible side effects with Rituxan?" for other serious side effects. 839 What is Rituxan? 840 Rituxan is a prescription medicine used in adults: 841 • alone or with other anti-cancer medicines to treat certain types of NHL. 842 • with another medicine called methotrexate to reduce the signs and symptoms of moderately to 843 severely active Rheumatoid Arthritis (RA) after at least one other medicine called a Tumor 844 Necrosis Factor (TNF) antagonist has been used and did not work well. 845 Rituxan has not been studied in children. 846 What should I tell my doctor before treatment with Rituxan? 847 Tell your doctor about all of your medical conditions, including if you: 848 • had a severe infusion reaction to Rituxan in the past. 849 • have an infection or have an infection that will not go away or that keeps coming back. 850 • have or had hepatitis (liver) infection. See "What are the possible side effects of Rituxan?" If 851 so, your doctor should check you closely for signs of hepatitis infection during treatment with 852 Rituxan and for several months after treatment ends. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 29 of 31/Regional (RA): Rituxan Final 853 • are scheduled to receive any vaccinations. You should not receive live vaccines after you 854 receive Rituxan. 855 • have heart or lung problems. 856 • are pregnant or planning to become pregnant. It is not known if Rituxan can harm your unborn 857 baby. 858 • are breastfeeding. It is not known if Rituxan passes into human breast milk. You should not 859 breastfeed while being treated with Rituxan and after finishing treatment, until blood tests show 860 that there is no Rituxan in your blood. 861 Tell your doctor about all the medicines you take, including prescription and nonprescription 862 medicines, vitamins, or herbal supplements. If you have RA, especially tell your doctor if you take 863 or have taken another medicine called a TNF antagonist or a DMARD (disease-modifying 864 anti-rheumatic drug). 865 How do I receive Rituxan? 866 • Rituxan is given through a needle placed in a vein (IV or intravenous infusion) in your arm. 867 Talk to your doctor about how you will receive Rituxan. 868 • Your doctor may prescribe medicines before each infusion of Rituxan to reduce side effects of 869 infusions (such as fever and chills). 870 • Your doctor should do regular blood tests to check for side effects to Rituxan. 871 Before each Rituxan treatment, your doctor or nurse will ask you questions about your general health 872 to make sure that Rituxan is still right for you. Tell your doctor or nurse about any new symptoms 873 and symptoms that get worse over a few days or that will not go away. 874 What are the possible side effects of Rituxan? 875 The "What is the most important information I should know about Rituxan?" section lists 876 certain serious and life-threatening side effects with Rituxan. Rituxan can cause other serious and 877 life-threatening side effects including: 878 • Hepatitis B virus reactivation. Tell your doctor if you had hepatitis B virus or are a carrier of 879 hepatitis B virus. Receiving Rituxan could cause the hepatitis B virus to become an active 880 infection again. This may cause serious liver problems and death. People with active liver 881 disease due to hepatitis B should stop receiving Rituxan. 882 • Heart problems. Tell your doctor about any heart problems you have including chest pain 883 (angina) and irregular heart beats. Rituxan can cause chest pain and irregular heart beats which 884 may require treatment. 885 • Infections. Rituxan can increase your chances for getting infections. Call your doctor right 886 away if you have a cough that will not go away, fever, chills, congestion, or any flu-like 887 symptoms while receiving Rituxan. These symptoms may be signs of a serious infection. 888 • Stomach and bowel problems. Serious stomach and bowel problems have been seen when 889 Rituxan has been used with anti-cancer medicines in some patients with non−Hodgkin's 890 lymphoma. Call your doctor right away if you have any stomach area pain during treatment with 891 Rituxan. 892 Common side effects during Rituxan infusions include: 893 • fever • headache 894 • chills and shakes • nausea 895 • itching • hives 896 • cough • sneezing 897 • throat irritation or tightness U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 30 of 31/Regional (RA): Rituxan Final 898 Other side effects with Rituxan include: 899 • aching joints 900 • upper respiratory tract infection 901 • decreased blood cell counts 902 • lung problems 903 Tell your doctor about any side effect that bothers you or that does not go away. These are not all of 904 the possible side effects with Rituxan. Ask your doctor for more information. 905 General Information about Rituxan 906 This Medication Guide provides a summary of the most important information about Rituxan. 907 Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. If 908 you would like more information or have any questions, talk with your doctor. You can ask your 909 doctor for information about Rituxan that is written for healthcare professionals. You can also visit 910 www.Rituxan.com or call 1-877-474-8892. 911 What are the ingredients in Rituxan? 912 Active ingredient: rituximab 913 Inactive ingredients: sodium chloride, sodium citrate dihydrate, polysorbate 80, and water for 914 injection. 915 916 Jointly Marketed by: Biogen Idec Inc. and Genentech USA, Inc. 917 918 Manufactured by: 919 Genentech, Inc. 920 1 DNA Way 921 South San Francisco, CA 94080-4990 922 2009 Biogen Idec Inc. and Genentech, Inc. 923 Revised 10/2009 (4851501) 924 This Medication Guide has been approved by the U.S. Food and Drug Administration. U.S. BL 103705/5297 Amendment: RituximabGenentech, Inc. 31 of 31/Regional (RA): Rituxan Final
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"Prescribing Information US BL Amendment Rituximab asthenia"Please download to view full document


text:
Sale of the Century Cast List
Sale of the Century cast list, including photos of the actors when available. This list includes all of the Sale of the Century main actors and actresses, so if they are an integral part of the show you'll find them below. You can various bits of trivia about these Sale of the Century stars, such as where the actor was born and what their year of birth is. This cast list of actors from Sale of the Century focuses primarily on the main characters, but there may be a few actors who played smaller roles on Sale of the Century that are on here as well.
This list features Jack Kelly Jay Stewart and more.
If you are wondering, "Who are the actors from Sale of the Century?" or "Who starred on Sale of the Century?" then this list will help you answer those questions.
In most cases you can click on the names of these popular
- 1
Alyce Platt DVD Region 4, Oceania, Australasia
- 2
Bill Wendell New York City, Area code 917, Contiguous United States
- 3
Delvene Delaney Australasia, Mackay, Australia
- 4
Jack Kelly Contiguous United States, New York, United States of America
- 5
Jay Stewart Madison County, Van Buren Township, Summitville
- 6
Jim Perry Camden County, Camden, Contiguous United States
- 7
Joe Garagiola, Sr. Area code 557, St. Louis, St. Louis County
- 8
Lee Menning
- 9
Nicholas Parsons Eurasia, Grantham, United Kingdom
- 10
Sally Julian
- 11
Summer Bartholomew California, Merced, Contiguous United States
- 12
Tony Barber Eurasia, Lancashire, United Kingdom
- 13
Glenn Ridge DVD Region 4, Oceania, South Australia
- 14
Charlie Tuna Nebraska, Kearney, Buffalo County
- 15
Jo Silvagni DVD Region 4, Oceania, Australasia

subset: commoncrawl


text:
Register with us or sign in
Here is my list - Front garden
primrose blue jean
Back garden
Violas (lots)
Snowflake took a pic just wont upload
Penstemon pink/red - great for this time of year first year it has flowered
yellow sugar rush wallflower
yellow primrose and primrose Emily
Hebe Lisa
Sweet William Vesuvio
Pansy fire
Fruitcake they first earlies are in the ground the shortest but the 2nd and main crop are all in the ground at the same time the main are just in there for longer - so best to have a separate bit of ground you can have them planted near to each other
Like if you planted them all the same day you lift the first crop shorted amount of time and then second and then main the longest it is just the length of time they are in the ground for
Sometimes people say if you don't have space for them all grow fist and second croppers as main crop are more likely to get problems e.g.. blight, you could grow them in a bag if not enough space
Is that for your head torch?
Sweet peas ok will take another pic and pit it on the SP thread
Gardening at this time a night Woody really
David K Woolmans with 10% off in the GW mag now new for next year
Keep going Woodgreen Wonderboy as we will be there
Gardenmaiden that is great lots of fruit for you
Zoomer44 oh no with the fruit trees but good luck - you are definitely a gardener moving plants around after planting them
Zoomer yes I mean the GW mag offer with the other bits as well looks a good one
The potato show I go to has seed swap, plants, trays gifts and lots of pea and bean seeds - I got my peach tree from there last year lots of stuff to look at and get
we just take some food with us as they do not have much to eat there apart from cups of hot drinks and biscuits for lunch - so we take sandwiches and doughnuts need extra sugar boost for looking at all the spud and picking which ones to go for
GWRS got my egg boxes ready as well
Got the handles on the coldframe today, few bits left and lots of pictures for you all to see
That was good Roy that you saw the lady that gave you the raspberry canes
GWRS that a lot that you managed to get done, was there newer bark chippings? enjoy your time tomorrow up the allotment
Roy if you have a whole plots it is probably equal to Fruitcakes 2 x half plots
I am going for the potato offer from T&M want the bags too also the spuds
Like this thread - My Challenge is to get the paving slabs out of the garage and put in the new turf area
To grow more plant from seeds, also to grow some cape gooseberries when I order the seeds
Lilylouise saw yours in my Garden News mag - nice garden pics
Yes Star gaze lily I was good still lots of things that need planting out yet for here and station so thought I need to keep away from them
Q for the new years day flower count do we count all flower heads on violas or is it counted as one?


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Another thread made me think of this question. Is it difficult to be a newb around here? Did you lurk before you posted? Did you just jump right in? Was it a mistake? Did you have to get used to it around here before you could ddebate effectively? Lastly, did your first thread go down in flames?
Is it hard to be a newb on DT?
I just jumped into the fray. I got smacked around a few times. I've been around long enough to see LOTS of my threads to down in flames.
How do you solve a problem like Maria?
I lurked a bit before I posted. I didn't post a lot at first because I would fart around on other boards. After awhile, I got really bored with the other boards and just hung out here mainly.
"Is it difficult to be a newb around here? Did you lurk before you posted? Did you just jump right in? Was it a mistake? Did you have to get used to it around here before you could ddebate effectively? Lastly, did your first thread go down in flames?"
I think it's hard if you aren't accustomed to a) "netiquette"; b) debating in general; and c) internet debating specifically.
I jumped right in after reading one or two threads and it went just fine. My first debate did not go down in flames.
"I choose to laugh but that's to hide my pain and incredulity." - Ms. Miyagi
I started on the BC Children with Autism Board. Wandered around the site and fell into the DT. I haven't been able to crawl out since.
I can't remember what my first thread was, probably a DML, and oddly enough, I wasn't eaten alive.
LMAO that they're gone and automatically, you think of illicit baptism, not 7-11 for toilet paper and coffee creamer.
Run! STAHP THEM -katoannie
It is not difficult to be a newb.
Yes, I lurked for awhile.
No, I would not just jump right in without being aware of some of the abbreviations, "rules," tone of the board, and what would probably/not fly here.
What, posting here, was it a mistake, you ask? Well, I spend a lot of time here and my son's just downstairs playing War with his left hand versus right hand, so yeah, probably. Then again, maybe not a mistake; I've learned a lot and there's some really nice people here and now I know what ombre is so there's that.
I cannot debate effectively so your second-to-last question is moot.
Can't remember my first thread at all.
Lurked for a looooong time, then posted some stuff, then a little more, then more and more. Now, I have a full blown addiction.
Are we on Cops again?
I jumped in, hmm, back when the DT was created on NBBC. I have a hard time not getting involved in things that interest me. Did I get it handed to me a time or two? Heck, I still do! It's pretty clear that it hasn't scared me away.
Dawn - BabyCenter Community Moderator
Finn 06/07
I will admit that I didn't read the rules here because my lurking on threads pretty much spelled out the rules for me. I've occasionally broken a rule here and there on accident. I think my first thread was actually really tame and kind of boring :-/
I lurked, then I made easy comments, then as I was getting comfy my name got thrown in for a GO nom. There was no turning back after that!
An apstrophe does not a plural make.


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Vivint Solar Electrician Apprentice. Vivint Solar is seeking an Electrician Apprentice in and around the Rosedale, MD area....
Jun 30 - Rosedale, MD
As a Journeyman Electrician you will be responsible for installing and repairing electrical systems, hydraulic, pneumatic and electronic components of...
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Electricians-Helper, Apprentice, & Journeyman
The Electrician's responsibility varies depending on whether you are a helper, apprentice, or journeyman. A wide variety of duties that include working with a team of technicians, ensuring safety and best practices, and conducting electrical duties. They will perform skilled technical work in the maintenance, repair, replacement, and installation of electrical equipment and ...
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Commercial Electrician
Outsource is currently hiring all levels of Electricians with commercial and industrial experience!
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Baltimore - Construction & trades
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May 18 -
Havre de Grace - Construction & trades
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text:
The Top 10 In Action Sports
01Brick By Brick: Camping Lego Style
02Booze and Bikes: 14 Tours That Let Combine Two of the Best Things in the World
03Who Needs Hollywood? These Incredible Videos Were All Filmed on the Simplest Cameras
04Sam Pilgrim vs. The World: The Champion Aiming To Reclaim His Crown In A New Era Of Biking
05Eccentric Adventures Episode 2: Britain's Most Brutal Illegal Event is All About Cheese
06A Journey Into Darkness: We Went Mountain Biking in the Abandoned Mines of Slovenia
07After the Apocalypse: Inside The World's Most Breathtaking Ghost Towns
08Debate: Let's Stop Hating On Parents Who Want To Raise Adventurous Kids
09Guns, Roses, And Eating Insects: Adventure Cycling in Vietnam
10From Intense Trails to Intensive Care: Dicing with Death In a Mountain Biking Paradise
The Main Idea: Prologue (Official)
PROLOGUE [proh-lawg] (noun): the preface or introduction to a work
The Main Idea presents to you "Prologue" - a recap of our winter and a taste of what is to come.
Over the course of the 2010-2011 season we traveled all over the east with a few adventures out west. Aiming to cover every aspect of the sport possible, our winter was filled with backcountry tours, sleepless nights in the city, and everything in between.
With zero funding and support, our only goal was to have an amazing time doing what we love with our friends. We had a great first year and we hope you enjoy what we put together from our endeavors!
This coming 2011-2012 season we'll be shifting our focus from a year long movie project to what we like to call Monthly Movies. Over the course of the year we'll be producing free, monthly releases that will cover a wide scope of the winter sports we all know and love. Each month's release will be a direct representation of everything we did, and everywhere we went during that time.
See you this winter! For now, enjoy Prologue...
Additional info can be seen at:
TheMainIdea.tv or
|Directed By|
Galin Foley
Joey Szela
|Filmed by|
Joey Szela
Galin Foley
Craig Stay
Alex Savarie
Dillon Calderone
Erme Catino
Colin Delaney
Jake Doan
Tyler Duncan
Caitlyn Foley
Galin Foley
Ian Foley
Andrew Holson
Sam Hurst
Sam Kimmerle
Eric Leone
Jeff Leone
Tanner Mccarty
Kieran McVeigh
Adam Newhard
Sam Parker
Justin Perry
Sam Putnam
Colin Sirois
Joey Szela
Jackson Tupper
Evan Williams
& Friends