Peginterferon Beta-1a

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# Overview
Peginterferon Beta-1a is an immunological agent that is FDA approved for the treatment of patients with relapsing forms of multiple sclerosis.   Common adverse reactions include injection site erythema, influenza-like illness, pyrexia, headache, myalgia, chills, injection site pain, asthenia, injection site pruritus, and arthralgia.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

# Indications
- PLEGRIDY (peginterferon beta-1a) is indicated for the treatment of patients with relapsing forms of multiple sclerosis.

# Dosage
- PLEGRIDY is administered subcutaneously.
- The recommended dosage of PLEGRIDY is 125 micrograms injected subcutaneously every 14 days.
Treatment initiation
- Patients should start treatment with 63 micrograms on day 1. On day 15 (14 days later), the dose is increased to 94 micrograms, reaching the full dose of 125 micrograms on day 29 (after another 14 days). Patients continue with the full dose (125 micrograms) every 14 days thereafter (see TABLE 1). A PLEGRIDY Starter Pack is available containing two prefilled pens or syringes: 63 micrograms (dose 1) and 94 micrograms (dose 2).
Important Administration Instructions (All Dosage Forms)
- Healthcare professionals should train patients in the proper technique for self-administering subcutaneous injections using the prefilled pen or syringe. Patients should be advised to rotate sites for subcutaneous injections. The usual sites for subcutaneous injections are abdomen, back of the upper arm, and thigh.
- Each PLEGRIDY pen and syringe is provided with the needle pre-attached. Prefilled pens and syringes are for a single dose only and should be discarded after use.
Premedication for Flu-like Symptoms
- Prophylactic and concurrent use of analgesics and/or antipyretics may prevent or ameliorate flu-like symptoms sometimes experienced during treatment with PLEGRIDY.

# DOSAGE FORMS AND STRENGTHS
Pen
- Injection: 125 micrograms of PLEGRIDY per 0.5 mL of solution in a single-dose prefilled pen
- Injection: Starter Pack containing 63 micrograms per 0.5 mL of solution in a single-dose prefilled pen and 94 micrograms per 0.5 mL solution in a single-dose prefilled pen
Prefilled Syringe
- Injection: 125 micrograms of PLEGRIDY per 0.5 mL of solution in a single-dose prefilled syringe
- Injection: Starter Pack containing 63 micrograms per 0.5 mL of solution in a single-dose prefilled syringe and 94 micrograms per 0.5 mL of solution in a single-dose prefilled syringe

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Peginterferon Beta-1a in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Peginterferon Beta-1a in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Peginterferon Beta-1a in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Peginterferon Beta-1a in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Peginterferon Beta-1a in pediatric patients.

# Contraindications
- PLEGRIDY is contraindicated in patients with a history of hypersensitivity to natural or recombinant interferon beta or peginterferon, or any other component of the formulation.

# Warnings
Hepatic Injury
- Severe hepatic injury, including hepatitis, autoimmune hepatitis, and rare cases of severe hepatic failure, have been reported with interferon beta. Asymptomatic elevation of hepatic transaminases has also been reported, and in some patients has recurred upon rechallenge with interferon beta.
- Elevations in hepatic enzymes and hepatic injury have been observed with the use of PLEGRIDY in clinical studies. The incidence of increases in hepatic transaminases was greater in patients taking PLEGRIDY than in those taking placebo. The incidence of elevations of alanine aminotransferase above 5 times the upper limit of normal was 1% in placebo-treated patients and 2% in PLEGRIDY-treated patients. The incidence of elevations of aspartate aminotransferase above 5 times the upper limit of normal was less than 1% in placebo-treated patients and less than 1% in PLEGRIDY-treated patients. Elevations of serum hepatic transaminases combined with elevated bilirubin occurred in 2 patients. Both cases resolved following discontinuation of PLEGRIDY.
- Monitor patients for signs and symptoms of hepatic injury.
Depression and Suicide
- Depression, suicidal ideation, and suicide occur more frequently in patients receiving interferon beta than in patients receiving placebo.
- In clinical studies, the overall incidence of adverse events related to depression and suicidal ideation in multiple sclerosis patients was 8% in both the PLEGRIDY and placebo groups. The incidence of serious events related to depression and suicidal ideation was similar and less than 1% in both groups.
- Advise patients to report immediately any symptom of depression or suicidal ideation to their healthcare provider. If a patient develops depression or other severe psychiatric symptoms, consider stopping treatment with PLEGRIDY.
Seizures
- Seizures are associated with the use of interferon beta.
- The incidence of seizures in multiple sclerosis clinical studies was less than 1% in patients receiving PLEGRIDY and placebo.
- Exercise caution when administering PLEGRIDY to patients with a seizure disorder.
Anaphylaxis and Other Allergic Reactions
- Anaphylaxis and other serious allergic reactions are rare complications of treatment with interferon beta.
- Less than 1% of PLEGRIDY-treated patients experienced a serious allergic reaction such as angioedema or urticaria. Those who did have serious allergic reactions recovered promptly after treatment with antihistamines or corticosteroids.
- Discontinue PLEGRIDY if a serious allergic reaction occurs.
Injection Site Reactions
- Injection site reactions, including injection site necrosis, can occur with the use of subcutaneous interferon beta.
- In clinical studies, the incidence of injection site reactions (e.g., injection site erythema, pain, pruritus, or edema) was 66% in the PLEGRIDY group and 11% in the placebo group; the incidence of severe injection site reactions was 3% in the PLEGRIDY group and 0% in the placebo group. One patient out of 1468 patients who received PLEGRIDY in clinical studies experienced injection site necrosis. The injury resolved with standard medical treatment.
- Decisions to discontinue therapy following necrosis at a single injection site should be based on the extent of the necrosis. For patients who continue therapy with PLEGRIDY after injection site necrosis has occurred, avoid administration of PLEGRIDY near the affected area until it is fully healed. If multiple lesions occur, discontinue PLEGRIDY until healing occurs.
Congestive Heart Failure
- Congestive heart failure, cardiomyopathy, and cardiomyopathy with congestive heart failure occur in patients receiving interferon beta.
- In clinical studies, the incidence of cardiovascular events was 7% in both PLEGRIDY and placebo treatment groups. No serious cardiovascular events were reported in the PLEGRIDY group.
- Monitor patients with significant cardiac disease for worsening of their cardiac condition during initiation and continuation of treatment with PLEGRIDY.
Decreased Peripheral Blood Counts
- Interferon beta can cause decreased peripheral blood counts in all cell lines, including rare instances of pancytopenia and severe thrombocytopenia.
- In clinical studies, decreases in white blood cell counts below 3.0 x 109/L occurred in 7% of patients receiving PLEGRIDY and in 1% receiving placebo. There is no apparent association between decreases in white blood cell counts and an increased risk of infections or serious infections. The incidence of clinically significant decreases in lymphocyte counts (below 0.5 x 109/L), neutrophil counts (below 1.0 x 109/L), and platelet counts (below 100 x 109/L) were all less than 1% and similar in both placebo and PLEGRIDY groups. Two serious cases were reported in patients treated with PLEGRIDY: one patient (less than 1%) experienced severe thrombocytopenia (defined as a platelet count less than or equal to 10 x 109/L), and another patient (less than 1%) experienced severe neutropenia (defined as a neutrophil count less than or equal to 0.5 x 109/L). In both patients, cell counts recovered after discontinuation of PLEGRIDY. Compared to placebo, there were no significant differences in red blood cell counts in patients treated with PLEGRIDY.
- Monitor patients for infections, bleeding, and symptoms of anemia. Monitor complete blood cell counts, differential white blood cell counts, and platelet counts during treatment with PLEGRIDY. Patients with myelosuppression may require more intensive monitoring of blood cell counts.
Autoimmune Disorders
- Autoimmune disorders of multiple target organs including idiopathic thrombocytopenia, hyper- and hypothyroidism, and autoimmune hepatitis have been reported with interferon beta.
- In clinical studies, the incidence of autoimmune disorders was less than 1% in both PLEGRIDY and placebo treatment groups.
- If patients develop a new autoimmune disorder, consider stopping PLEGRIDY.

# Adverse Reactions

## Clinical Trials Experience
- The following serious adverse reactions are discussed in more detail in other sections of labeling:
- Hepatic Injury
- Depression and Suicide
- Seizures
- Anaphylaxis and Other Allergic Reactions
- Injection Site Reactions
- Congestive Heart Failure
- Decreased Peripheral Blood Counts
- Autoimmune Disorders
Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of PLEGRIDY cannot be directly compared to rates in clinical trials of other drugs and may not reflect the rates observed in practice.
- In clinical studies (Study 1 and Study 2), a total of 1468 patients with relapsing multiple sclerosis received PLEGRIDY for up to 177 weeks (41 months), with an overall exposure equivalent to 1932 person-years. A total of 1093 patients received at least 1 year, and 415 patients at least 2 years of treatment with PLEGRIDY. A total of 512 and 500 patients, respectively, received PLEGRIDY 125 micrograms every 14 days or every 28 days during the placebo-controlled phase of Study 1 (year 1). The experience in year 2 of Study 1 and in the 2-year safety extension study (Study 2) was consistent with the experience in the 1-year placebo-controlled phase of Study 1.
- In the placebo-controlled phase of Study 1, the most common adverse drug reactions for PLEGRIDY 125 micrograms subcutaneously every 14 days were erythema, influenza-like illness, pyrexia, headache, myalgia, chills, pain, asthenia, pruritus, and arthralgia (all had incidence more than 10% and at least 2% more than placebo). The most commonly reported adverse event leading to discontinuation in patients treated with PLEGRIDY 125 micrograms subcutaneously every 14 days was influenza-like illness (in less than 1% of patients).
- TABLE 2 summarizes adverse reactions reported over 48 weeks from patients treated in the placebo-controlled phase of Study 1 who received subcutaneous PLEGRIDY 125 micrograms (n=512), or placebo (n=500), every 14 days.
Immunogenicity
- For therapeutic proteins, there is a potential for immunogenicity. In Study 1, fewer than 1% of patients treated with PLEGRIDY every 14 days for 1 year developed neutralizing antibodies. Approximately 7% of PLEGRIDY-treated patients developed antibodies to PEG.
- The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to PLEGRIDY with the incidence of antibodies to other products may be misleading.
Flu-Like Symptoms
- Influenza-like illness was experienced by 47% of patients receiving PLEGRIDY 125 micrograms every 14 days and 13% of patients receiving placebo. Fewer than 1% of PLEGRIDY-treated patients in Study 1 discontinued treatment due to flu-like symptoms.

## Postmarketing Experience
There is limited information regarding Postmarketing Experience of Peginterferon Beta-1a in the drug label.

# Drug Interactions
There is limited information regarding Peginterferon Beta-1a Drug Interactions in the drug label.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): 
Pregnancy Category C
- There are no adequate and well-controlled studies in pregnant women. PLEGRIDY should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
- PLEGRIDY has not been tested for developmental toxicity in pregnant animals. In monkeys given interferon beta by subcutaneous injection every other day during early pregnancy, no teratogenic or other adverse effects on fetal development were observed. Abortifacient activity was evident following 3 to 5 doses.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Peginterferon Beta-1a in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Peginterferon Beta-1a during labor and delivery.

### Nursing Mothers
- It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when PLEGRIDY is administered to a nursing woman.

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

### Geriatic Use
- Safety and effectiveness in geriatric patients have not been established.

### Gender
There is no FDA guidance on the use of Peginterferon Beta-1a with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Peginterferon Beta-1a with respect to specific racial populations.

### Renal Impairment
- Monitor for adverse reactions due to increased drug exposure in patients with severe renal impairment

### Hepatic Impairment
There is no FDA guidance on the use of Peginterferon Beta-1a in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Peginterferon Beta-1a in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Peginterferon Beta-1a in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Subcutaneous

### Monitoring
There is limited information regarding Monitoring of Peginterferon Beta-1a in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Peginterferon Beta-1a in the drug label.

# Overdosage
There is limited information regarding Chronic Overdose of Peginterferon Beta-1a in the drug label.

# Pharmacology
There is limited information regarding Peginterferon Beta-1a Pharmacology in the drug label.

## Mechanism of Action
- The mechanism by which PLEGRIDY exerts its effects in patients with multiple sclerosis is unknown.

## Structure
- PLEGRIDY (peginterferon beta-1a) is an interferon beta-1a to which a single, linear 20,000 dalton (Da) methoxy poly(ethyleneglycol)-O-2-methylpropionaldehyde molecule is covalently attached to the alpha amino group of the N-terminal amino acid residue.
- The interferon beta-1a portion of PLEGRIDY is produced as a glycosylated protein using genetically-engineered Chinese hamster ovary cells into which the human interferon beta gene has been introduced. The amino acid sequence of the recombinant interferon beta-1a is identical to that of the human interferon beta counterpart. The molecular mass of PLEGRIDY is approximately 44,000 Da, consistent with the mass of the protein (approximately 20,000 Da), the carbohydrate moieties (approximately 2,500 Da), and the attached poly(ethylene glycol). However, because of the extended and flexible nature of the attached poly(ethylene glycol) chain, the apparent mass of PLEGRIDY in solution is greater than 300,000 Da. The more than 10-fold increase in apparent mass of PLEGRIDY compared to interferon beta-1a has been shown to contribute to the reduced clearance in vivo.
- PLEGRIDY 125 micrograms contains 125 micrograms of interferon beta-1a plus 125 micrograms of poly(ethylene glycol). Using the World Health Organization International Standard for interferon beta, PLEGRIDY has a specific antiviral activity of approximately 100 million International Units (MIU) per mg of protein as determined using an in vitro cytopathic effect assay. PLEGRIDY 125 micrograms contains approximately 12 MIU of antiviral activity. PLEGRIDY contains no preservative.
PLEGRIDY PEN Single-Dose Prefilled Pen
- PLEGRIDY PEN is composed of an autoinjector that surrounds a prefilled glass syringe containing 0.5 mL of a sterile solution in water for injection of 63, 94, or 125 micrograms of peginterferon beta-1a, 15.8 mg of L-arginine HCl, 0.79 mg of sodium acetate trihydrate, 0.25 mg of glacial acetic acid, and 0.025 mg of polysorbate 20. The pH is approximately 4.8.
PLEGRIDY Single-Dose Prefilled Syringe
- A prefilled syringe of PLEGRIDY for subcutaneous injection contains 0.5 mL of a sterile solution in water for injection of 63, 94, or 125 micrograms of peginterferon beta-1a, 15.8 mg of L-arginine HCl, 0.79 mg of sodium acetate trihydrate, 0.25 mg of glacial acetic acid, and 0.025 mg of polysorbate 20. The pH is approximately 4.8.

## Pharmacodynamics
- There is no biochemical or physiologic effect known to relate directly to the clinical effect of PLEGRIDY.

## Pharmacokinetics
- After single-dose or multiple-dose subcutaneous administration of PLEGRIDY to healthy subjects, serum PLEGRIDY peak concentration (Cmax) and total exposure over time (area under the curve, or AUC) increased in proportion to doses from 63 to 188 micrograms. PLEGRIDY did not accumulate in the serum after multiple doses of 125 micrograms every 14 days. Pharmacokinetic parameters for PLEGRIDY, including Cmax and AUC, did not differ significantly between healthy volunteers and multiple sclerosis patients or between single-dose and multiple-dose administrations. However, the coefficient of variation between individual patients for AUC, Cmax, and half-life was high (41% to 68%, 74% to 89%, and 45% to 93%, respectively).
Absorption
- After 125 microgram subcutaneous doses of PLEGRIDY in multiple sclerosis patients, the maximum concentration occurred between 1 and 1.5 days, the mean Cmax was 280 pg/mL, and the AUC over the 14 day dosing interval was 34.8 ng.hr/mL.
Distribution
- In multiple sclerosis patients taking 125 microgram subcutaneous doses of PLEGRIDY every 14 days, the estimated volume of distribution was 481 liters.
Metabolism and Elimination
- Clearance mechanisms for PLEGRIDY include catabolism and excretion. The major pathway of elimination is renal. The half-life is approximately 78 hours in multiple sclerosis patients. The mean steady state clearance of PLEGRIDY is approximately 4.1 L/hr. PLEGRIDY is not extensively metabolized in the liver.
Specific Populations
- Body weight, gender, and age do not require dosage adjustment.
- Renal impairment can increase the Cmax and AUC for PLEGRIDY. Results of a pharmacokinetic study in patients with mild, moderate, and severe renal impairment (creatinine clearance 50 to 80, 30 to 50, and less than 30 mL/minute, respectively) showed increases above normal for Cmax of 27%, 26%, and 42%, and for AUC, increases of 30%, 40%, and 53%. The half-life was 53, 49, and 82 hours in patients with mild, moderate, and severe renal impairment, respectively, compared to 54 hours in normal subjects.
- In the same study, subjects with end stage renal disease requiring hemodialysis two or three times weekly had AUC and Cmax of PLEGRIDY values that were similar to those of normal controls. Each hemodialysis session removed approximately 24% of circulating PLEGRIDY from the systemic circulation

## Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenesis
- The carcinogenic potential of PLEGRIDY has not been tested in animals.
Mutagenesis
- PLEGRIDY was not mutagenic when tested in an in vitro bacterial reverse mutation (Ames) test and was not clastogenic in an in vitro assay in human lymphocytes.
Impairment of Fertility
- In monkeys administered interferon beta by subcutaneous injection over the course of one menstrual cycle, menstrual irregularities, anovulation, and decreased serum progesterone levels were observed. These effects were reversible after discontinuation of drug.

# Clinical Studies
- The efficacy of PLEGRIDY was demonstrated in the randomized, double-blind, and placebo-controlled phase (year 1) of Study 1. The trial compared clinical and MRI outcomes at 48 weeks in patients who received PLEGRIDY 125 micrograms (n=512) or placebo (n=500) by the subcutaneous route, once every 14 days.
- Study 1 enrolled patients who had a baseline Expanded Disability Status Scale (EDSS) score from 0 to 5, who had experienced at least 2 relapses within the previous three years, and had experienced at least 1 relapse in the previous year. The trial excluded patients with progressive forms of multiple sclerosis. The mean age of the study population was 37 years, the mean disease duration was 3.6 years, and the mean EDSS score at baseline was 2.46. The majority of the patients were women (71%).
- The trial scheduled neurological evaluations at baseline, every 12 weeks, and at the time of a suspected relapse. Brain MRI evaluations were scheduled at baseline, week 24, and week 48.
- The primary outcome was the annualized relapse rate over 1 year. Secondary outcomes included the proportion of patients relapsing, number of new or newly enlarging T2 hyperintense lesions, and time to confirmed disability progression. Confirmed disability progression was defined as follows: if the baseline EDSS score was 0, a sustained 12-week increase in EDSS score of 1.5 points was required; if the baseline EDSS score was greater than 0, a sustained 12-week increase in EDSS score of 1 point was required. TABLE 3 and FIGURE 1 show the results of Study 1.

# How Supplied
- PLEGRIDY is supplied as a sterile, clear liquid for subcutaneous injection in two presentations, a prefilled pen and a prefilled syringe.
PLEGRIDY PEN Single-Dose Prefilled Pen
- Each dose of PLEGRIDY is stored in a 1 mL capacity glass syringe with a rubber stopper and rigid needle shield. A 29 gauge, 0.5 inch staked needle is pre-affixed to the syringe. A single prefilled syringe contains 0.5 mL of solution of PLEGRIDY containing 63 micrograms, 94 micrograms, or 125 micrograms of peginterferon beta-1a. The glass syringe is contained within a single-dose, disposable, injection device (prefilled pen). The following packaging configurations are available:
- A carton containing two single-dose prefilled pens, each providing 125 micrograms of PLEGRIDY. The NDC is 64406-011-01.
- A Starter Pack carton containing two single-dose prefilled pens; dose 1 provides 63 micrograms of PLEGRIDY, and dose 2 provides 94 micrograms of PLEGRIDY. The NDC is 64406-012-01.
PLEGRIDY Single-Dose Prefilled Syringe
- Each dose of PLEGRIDY is stored in a 1 mL capacity glass syringe with a rubber stopper and rigid needle shield. A 29 gauge, 0.5 inch staked needle is pre-affixed to the syringe. A single prefilled syringe contains 0.5 mL of solution of PLEGRIDY containing 63 micrograms, 94 micrograms, or 125 micrograms of peginterferon beta-1a. The following packaging configurations are available:
- A carton containing two single-dose prefilled syringes, each providing 125 micrograms of PLEGRIDY. The NDC is 64406-015-01.
- A Starter Pack carton containing two single-dose prefilled syringes; dose 1 provides 63 micrograms of PLEGRIDY, and dose 2 provides 94 micrograms of PLEGRIDY. The NDC is 64406-016-01.

## Storage
- Store in the closed original carton to protect from light until ready for injection.
- Store in a refrigerator between 2C to 8C (36F to 46F). Do not freeze. Discard if frozen. Once removed from the refrigerator, PLEGRIDY should be allowed to warm to room temperature (about 30 minutes) prior to injection. Do not use external heat sources such as hot water to warm PLEGRIDY.
- If refrigeration is unavailable, PLEGRIDY may be stored between 2C to 25C (36F to 77F) for a period up to 30 days, protected from light. PLEGRIDY can be removed from, and returned to, a refrigerator if necessary. The total combined time out of refrigeration, within a temperature range of 2C to 25C (36F to 77F), should not exceed 30 days.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
There is limited information regarding Patient Counseling Information of Peginterferon Beta-1a in the drug label.

# Precautions with Alcohol
- Alcohol-Peginterferon Beta-1a interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- PLEGRIDY

# Look-Alike Drug Names
- A  B

# Drug Shortage Status

# Price