Velaglucerase alfa

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# Overview
Velaglucerase alfa is a hydrolytic lysosomal glucocerebroside-specific enzyme that is FDA approved for the treatment of type 1 Gaucher disease.   Common adverse reactions include hypersensitivity reactions, headache, dizziness, abdominal pain, nausea, back pain, joint pain, prolonged activated PTT, fatigue/asthenia, and pyrexia.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- VPRIV is indicated for long-term enzyme replacement therapy (ERT) for patients with type 1 Gaucher disease.
- VPRIV should be administered under the supervision of a healthcare professional. The recommended starting VPRIV dosage in naive adults is 60 Units/kg administered every other week as a 60-minute intravenous infusion. The dosage can be adjusted based on achievement and maintenance of each patient's therapeutic goals.
- Switching from Imiglucerase to VPRIV
- Adults currently being treated on a stable dosage of imiglucerase for type 1 Gaucher disease may be switched to VPRIV by starting treatment with VPRIV at the previous imiglucerase dosage two weeks after the last imiglucerase dose. VPRIV should be administered under the supervision of a healthcare professional as a 60-minute intravenous infusion. The dosage can be adjusted based on achievement and maintenance of each patient's therapeutic goals.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Velaglucerase alfa in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Velaglucerase alfa in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- VPRIV is indicated for long-term enzyme replacement therapy (ERT) for patients with type 1 Gaucher disease.
- VPRIV should be administered under the supervision of a healthcare professional. The recommended starting VPRIV dosage in naive pediatric patients 4 years of age and older is 60 Units/kg administered every other week as a 60-minute intravenous infusion. The dosage can be adjusted based on achievement and maintenance of each patient's therapeutic goals.
- Switching from Imiglucerase to VPRIV
- Pediatric patients 4 years of age and older currently being treated on a stable dosage of imiglucerase for type 1 Gaucher disease may be switched to VPRIV by starting treatment with VPRIV at the previous imiglucerase dosage two weeks after the last imiglucerase dose. VPRIV should be administered under the supervision of a healthcare professional as a 60-minute intravenous infusion. The dosage can be adjusted based on achievement and maintenance of each patient's therapeutic goals.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Velaglucerase alfa in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Velaglucerase alfa in pediatric patients.

# Contraindications
- None.

# Warnings

### Precautions
- Hypersensitivity Reactions Including Anaphylaxis
- Hypersensitivity reactions, including anaphylaxis, have occurred. Hypersensitivity reactions were the most commonly observed adverse reactions in patients treated with VPRIV in clinical studies. Patients were not routinely pre-medicated prior to infusion of VPRIV during clinical studies. The most commonly observed symptoms of hypersensitivity reactions were: headache, dizziness, hypotension, hypertension, nausea, fatigue/asthenia, and pyrexia. Generally the reactions were mild and, in treatment-naive patients, onset occurred mostly during the first 6 months of treatment and tended to occur less frequently with time.
- As with any intravenous protein product, hypersensitivity reactions are possible, therefore appropriate medical support including personnel adequately trained in cardiopulmonary resuscitative measures and access to emergency measures should be readily available when VPRIV is administered. If anaphylactic or other acute reactions occur, immediately discontinue the infusion of VPRIV and initiate appropriate medical treatment.
- The management of hypersensitivity reactions should be based on the severity of the reaction, e.g., slowing the infusion rate, treatment with medications such as antihistamines, antipyretics and/or corticosteroids, and/or stopping and resuming treatment with increased infusion time. In cases where patients have exhibited symptoms of hypersensitivity to the active ingredient or excipients in the drug product or to other enzyme replacement therapy, pre-treatment with antihistamines and/or corticosteroids may prevent subsequent reactions.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
- The data described below reflect exposure of 94 patients with type 1 Gaucher disease who received VPRIV at doses ranging from 15 Units/kg to 60 Units/kg every other week in 5 clinical studies. Fifty-four (54) patients were naive to enzyme replacement therapy (ERT) and received VPRIV for 9 months and 40 patients switched from imiglucerase to VPRIV treatment and received VPRIV for 12 months. Patients were between 4 and 71 years old at time of first treatment with VPRIV, and included 46 male and 48 female patients.
- The most serious adverse reactions in patients treated with VPRIV were hypersensitivity reactions.
- The most commonly reported adverse reactions (occurring in 10% of patients) that were considered related to VPRIV are shown in Table 1. The most common adverse reactions were hypersensitivity reactions.
- Less common adverse reactions affecting more than one patient (>3% in the treatment-naive group and >2% in patients switched from imiglucerase to VPRIV treatment) were bone pain, tachycardia, rash, urticaria, flushing, hypertension, and hypotension.
- Adverse Reactions in Pediatric Patients
- The safety profile of VPRIV was similar between pediatric patients (ages 4 to 17 years) and adult patients. Adverse reactions more commonly seen in pediatric patients compared to adult patients include (>10% difference): rash, aPTT prolonged, and pyrexia.
- Immunogenicity
- As with all therapeutic proteins, there is a potential for immunogenicity. In clinical studies, 1 of 54 enzyme treatment-naive patients treated with VPRIV developed IgG class antibodies to VPRIV. In this patient, the antibodies were determined to be neutralizing in an in vitro assay. No hypersensitivity reactions were reported for this patient. It is unknown if the presence of IgG antibodies to VPRIV is associated with a higher risk of infusion reactions. Patients with an immune response to other enzyme replacement therapies who are switching to VPRIV should continue to be monitored for antibodies to VPRIV.
- Immunogenicity assay results are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of 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 VPRIV with the incidence of antibodies to other products may be misleading.

## Postmarketing Experience
There is limited information regarding Postmarketing Experience of Velaglucerase alfa in the drug label.

# Drug Interactions
There is limited information regarding Velaglucerase alfa Drug Interactions in the drug label.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Pregnancy Category B
- Risk Summary
- There are no adequate and well controlled studies with VPRIV in pregnant women and there is limited experience in pregnant women. However, animal reproduction studies have been conducted for VPRIV. In these animal studies, no fetal harm was observed in rats or rabbits when velaglucerase alfa was administered intravenously during organogenesis at doses with exposures up to 1.8 times and 4.3 times greater than, respectively, the recommended human daily dose. Because animal reproduction studies are not always predictive of human response, VPRIV should be used during pregnancy only if clearly needed.
- Clinical Considerations
- Disease-Associated Maternal and Embryo/Fetal Risk
- Women with Type 1 Gaucher disease have an increased risk of spontaneous abortion, especially if disease symptoms are not treated and controlled pre-conception and during a pregnancy. Pregnancy may exacerbate existing Type 1 Gaucher disease symptoms or result in new disease manifestations. Type 1 Gaucher disease manifestations may lead to adverse pregnancy outcomes including hepatosplenomegaly which can interfere with the normal growth of a pregnancy, and thrombocytopenia which can lead to increased bleeding and possible hemorrhage.
- Data
- Animal Data
- Reproduction studies with velaglucerase alfa have been performed in pregnant rats at intravenous doses up to 17 mg/kg/day (102 mg/m2/day, about 1.8 times greater than the recommended human dose of 60 Units/kg/day or 1.5 mg/kg/day or 55.5 mg/m2/day based on the body surface area). Reproduction studies have been performed in pregnant rabbits at intravenous doses up to 20 mg/kg/day (240 mg/m2/day, about 4.3 times the recommended human dose of 60 Units/kg/day based on the body surface area). These studies did not reveal any evidence of impaired fertility or harm to the fetus due to velaglucerase alfa.
- A pre- and postnatal development study in rats showed no evidence of any adverse effect on pre-and postnatal development at doses up to 17 mg/kg/day (102 mg/m2/day, about 1.8 times greater than the recommended human dose of 60 Units/kg/day based on the body surface area).
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Velaglucerase alfa in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Velaglucerase alfa during labor and delivery.

### Nursing Mothers
- It is not known whether VPRIV is present in human milk. The developmental and health benefits of breastfeeding should be considered along with any potential adverse effects on the breastfed child from the drug or from the underlying maternal condition. Exercise caution when VPRIV is administered to a nursing woman.

### Pediatric Use
- The safety and effectiveness of VPRIV have been established for enzyme replacement therapy (ERT) in patients between 4 and 17 years of age with type 1 Gaucher disease. Use of VPRIV in this age group is supported by evidence from adequate and well-controlled studies of VPRIV in 74 adult patients and 20 pediatric patients. The safety and efficacy profiles were similar between pediatric and adult patients. The efficacy and safety of VPRIV has not been established in pediatric patients younger than 4 years of age.

### Geriatic Use
- In clinical studies of VPRIV in Gaucher's disease, a total of 56 VPRIV-treated patients were 65 years of age or older including 10 patients who were 75 years of age or older. Among 205 patients who switched from imiglucerase to VPRIV, 52 patients were 65 years of age or older of which 10 were 75 years and older. The adverse reaction profile in elderly patients was consistent with that previously observed across pediatric and adult patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be approached cautiously, considering potential comorbid conditions.

### Gender
There is no FDA guidance on the use of Velaglucerase alfa with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Velaglucerase alfa with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Velaglucerase alfa in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Velaglucerase alfa in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Velaglucerase alfa in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Velaglucerase alfa in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intravenous

### Monitoring
There is limited information regarding Monitoring of Velaglucerase alfa in the drug label.

# IV Compatibility
- VPRIV is a lyophilized powder, which requires reconstitution and dilution, using sterile technique, prior to intravenous infusion. VPRIV should be prepared as follows:
- Determine the number of vials to be reconstituted based on the individual patient's weight and the prescribed dose.
- Inject 4.3 mL of Sterile Water for Injection, USP into a vial containing VPRIV lyophilized powder.
- Mix gently. DO NOT SHAKE. The reconstituted VPRIV solution will have a 100 Units/mL concentration (400 Units VPRIV in 4 mL of solution).
- If additional vials are needed, repeat steps (b) and (c)
- Visually inspect the reconstituted VPRIV solution in the vials. The solution should be clear to slightly opalescent and colorless. Do not use if the solution is discolored or if foreign particulate matter is present.
- With a single syringe, withdraw the calculated dose of drug from the appropriate number of vials. Using a separate syringe, withdraw air from a bag of 100 mL of 0.9% sodium chloride solution suitable for intravenous administration. Then dilute the calculated dose of VPRIV directly into the sodium chloride solution. Mix gently. DO NOT SHAKE. Slight flocculation (described as white irregular shaped particles) may occasionally occur. Diluted solution with slight flocculation is acceptable for administration.
- Because VPRIV contains no preservatives, use the reconstituted VPRIV solution and the diluted VPRIV solution immediately. If immediate use is not possible, the reconstituted VPRIV solution or the diluted VPRIV solution may be stored for up to 24 hours at 2 C to 8C (36 F to 46F). Do not freeze and protect from light. Complete the infusion within 24 hours of reconstitution of vials.
- Discard any unused solution.

# Overdosage

## Chronic Overdose
There is limited information regarding Chronic Overdose of Velaglucerase alfa in the drug label.

# Pharmacology

## Mechanism of Action
- Gaucher disease is an autosomal recessive disorder caused by mutations in the GBA gene, which results in a deficiency of the lysosomal enzyme beta-glucocerebrosidase. Glucocerebrosidase catalyzes the conversion of the sphingolipid glucocerebroside into glucose and ceramide. The enzymatic deficiency causes an accumulation of glucocerebroside primarily in the lysosomal compartment of macrophages, giving rise to foam cells or "Gaucher cells". Velaglucerase alfa catalyzes the hydrolysis of glucocerebroside, reducing the amount of accumulated glucocerebroside. In clinical trials VPRIV reduced spleen and liver size, and improved anemia and thrombocytopenia.
- In this lysosomal storage disorder (LSD), clinical features are reflective of the accumulation of Gaucher cells in the liver, spleen, bone marrow, and other organs. The accumulation of Gaucher cells in the liver and spleen leads to organomegaly. Presence of Gaucher cells in the bone marrow and spleen lead to clinically significant anemia and thrombocytopenia.

## Structure
- The active ingredient of VPRIV is velaglucerase alfa, which is produced by gene activation technology in a human fibroblast cell line. Velaglucerase alfa is a glycoprotein of 497 amino acids; with a molecular weight of approximately 63 kDa. Velaglucerase alfa has the same amino acid sequence as the naturally occurring human enzyme, glucocerebrosidase. Velaglucerase alfa contains 5 potential N-linked glycosylation sites; four of these sites are occupied by glycan chains. Velaglucerase alfa contains predominantly high mannose-type N-linked glycan chains. The high mannose type N-linked glycan chains are specifically recognized and internalized via the mannose receptor present on the surface on macrophages, the cells that accumulate glucocerebroside in Gaucher disease. Velaglucerase alfa catalyzes the hydrolysis of the glycolipid glucocerebroside to glucose and ceramide in the lysosome.
- VPRIV is a hydrolytic lysosomal glucocerebroside-specific enzyme. VPRIV is dosed by Units/kg, where one Unit of enzyme activity is defined as the quantity of enzyme required to convert one micromole of p-nitrophenyl -D-glucopyranoside to p-nitrophenol per minute at 37C.
- VPRIV is supplied as a sterile, preservative free, lyophilized powder in single-use vials, each containing 400 Units, for intravenous use. Following reconstitution with Sterile Water for Injection, USP, the solution contains the components listed in Table 2.

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of Velaglucerase alfa in the drug label.

## Pharmacokinetics
- In a multicenter study conducted in pediatric (N=7, 4 to 17 years old) and adult (N=15, 19 to 62 years old) patients with type 1 Gaucher disease, pharmacokinetic evaluations were performed at Weeks 1 and 37 following 60-minute intravenous infusions of VPRIV 60 Units/kg every other week. Serum velaglucerase alfa concentrations declined rapidly with a mean half life of 11 to 12 minutes. The mean velaglucerase alfa clearance ranged from 6.72 to 7.56 mL/min/kg. The mean volume of distribution at steady state ranged from 82 to 108 mL/kg (8.2% to 10.8% of body weight).
- No accumulation or change in velaglucerase alfa pharmacokinetics over time from Weeks 1 to 37 was observed upon multiple-dosing 60 Units/kg every other week.
- Based on the limited data, there were no notable pharmacokinetic differences between male and female patients in this study. The effect of age on pharmacokinetics of velaglucerase alfa was inconclusive.
- The effect of anti-drug antibody formation on the pharmacokinetic parameters of velaglucerase alfa is unknown.

## Nonclinical Toxicology
- Carcinogenesis, Mutagenesis, Impairment of Fertility
- Long-term studies in animals to evaluate carcinogenic potential or studies to evaluate mutagenic potential have not been performed with velaglucerase alfa.
- In a male and female fertility study in rats, velaglucerase alfa did not cause any significant adverse effect on male or female fertility parameters up to a maximum dose of 17 mg/kg/day (102 mg/m2/day, about 1.8 times the recommended human dose of 60 Units/kg/day based on the body surface area).

# Clinical Studies
- The efficacy of VPRIV was assessed in three clinical trials in a total of 99 patients with type 1 Gaucher disease: 82 patients age 4 years and older received VPRIV and 17 patients age 3 years and older received imiglucerase. Studies I and II were conducted in patients who were not currently receiving Gaucher disease-specific therapy. Study III was conducted in patients who were receiving imiglucerase treatment immediately before starting VPRIV. The long-term safety of VPRIV was assessed in Study IV, an open-label extension trial in a total of 93 patients with type 1 Gaucher disease ages 3 years and older. Patients who had completed Studies I to III were eligible to participate in Study IV. In Studies I through IV, VPRIV was administered intravenously over 60 minutes at a maximum dose of 60 Units/kg every other week. Doses above 60 Units/kg were not studied in these trials.
- Study I was a 12-month, randomized, double-blind, parallel-dose-group, multinational trial in 25 patients age 4 years and older with Gaucher disease-related anemia and either thrombocytopenia or organomegaly. Patients were not allowed to have had disease-specific therapy for at least the previous 30 months; all but one had no prior therapy. The mean age was 26 years and 60% were male. Patients were randomized to receive VPRIV at a dose of either 45 Units/kg (N=13) or 60 Units/kg (N=12) every other week. The recommended starting dose in naive patients is 60 Units/kg. The 45 Units/kg dosage is not recommended as a starting dose in naive patients.
- At baseline, mean hemoglobin concentration was 10.6 g/dL, mean platelet count was 97  109/L, mean liver volume was 3.6 % of body weight (% BW), and mean spleen volume was 2.9 % BW.
- For all studies, liver and spleen volumes were measured by MRI. The changes in clinical parameters after 12 months of treatment are shown in Table 3. The observed change from baseline in the primary endpoint, hemoglobin concentration, was considered to be clinically meaningful in the 60 Units/kg dose, in light of the natural history of untreated Gaucher disease.
- Study II was a 9-month, randomized, double-blind, active-controlled (imiglucerase), parallel-group, multinational study in 34 patients age 4 years and older. Patients were required to have Gaucher disease-related anemia and either thrombocytopenia or organomegaly. Patients were not allowed to have had disease-specific therapy for at least the previous 12 months. The mean age was 30 years and 53% were female; the youngest patient who received VPRIV was age 4 years. Patients were randomized to receive either 60 Units/kg of VPRIV (N=17) or 60 Units/kg of imiglucerase (N=17) every other week.
- At baseline, the mean hemoglobin concentration was 11.0 g/dL, mean platelet count was 171  109/L, and mean liver volume was 4.3 % BW. For the patients who had not had splenectomy (7 in each group) the mean spleen volume was 3.4 % BW. After 9 months of treatment, the mean absolute increase from baseline in hemoglobin concentration was 1.6 g/dL  0.2 (SE) for patients treated with VPRIV. The mean treatment difference in change from baseline to 9 months  was 0.1 g/dL  0.4 (SE).
- In both studies, examination of age and gender subgroups did not identify differences in response to VPRIV among these subgroups. The number of non-Caucasian patients in these studies was too small to adequately assess any difference in effects by race.
- In Study IV, treatment naive patients were administered VPRIV. Treatment-naive patients continued to show improvements in clinical parameters (hemoglobin concentration, platelet count, liver volume, and spleen volume) compared with baseline for up to 60 months of treatment with ERT.
- Study III was a 12-month, open-label, single-arm, multinational study in 40 patients age 9 years and older who had been receiving treatment with imiglucerase at doses ranging between 15 Units/kg to 60 Units/kg for a minimum of 30 consecutive months. Patients also were required to have a stable biweekly dose of imiglucerase for at least 6 months prior to enrollment. The mean age was 36 years and 55% were female. Imiglucerase therapy was stopped, and treatment with VPRIV was administered every other week at the same number of units as the patient's previous imiglucerase dose. Adjustment of dosage was allowed by study criteria if needed in order to maintain clinical parameters.
- Hemoglobin concentrations and platelet counts remained stable on average through 12 months of VPRIV treatment. After 12 months of treatment with VPRIV the median hemoglobin concentration was 13.5 g/dL (range: 10.8, 16.1) vs. the baseline value of 13.8 g/dL (range: 10.4, 16.5), and the median platelet count after 12 months was 174  109/L (range: 24, 408) vs. the baseline value of 162  109/L (range: 29, 399). No patient required dosage adjustment during the 12-month treatment period.
- In Study IV, patients who had previously been receiving imiglucerase treatment were administered VPRIV. Patients previously treated with imiglucerase maintained stability in clinical parameters (hemoglobin concentration, platelet count, liver volume, and spleen volume) compared with baseline for up to 60 months of treatment with ERT.

# How Supplied
- VPRIV is a sterile, preservative free, lyophilized powder requiring reconstitution and further dilution prior to use. It is supplied in individually packaged glass vials, which are closed with a butyl rubber stopper with a fluoro-resin coating and are sealed with an aluminum overseal with a flip-off plastic cap. The vials are intended for single use only. VPRIV is available as: 400 Units/vial NDC 54092-701-04.
- Storage
- Store VPRIV at 2 C to 8C (36F to 46F). Do not use VPRIV after the expiration date on the vial. Do not freeze.
- Protect vial from light.

## Storage
There is limited information regarding Velaglucerase alfa Storage in the drug label.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Advise patients that VPRIV is a treatment that is given intravenously every other week. The infusion typically takes up to 60 minutes.
- Advise patients that VPRIV may cause hypersensitivity reactions.

# Precautions with Alcohol
- Alcohol-Velaglucerase alfa interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- VPRIV

# Look-Alike Drug Names
There is limited information regarding Velaglucerase alfa Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price