Sebelipase alfa

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# Overview
Sebelipase alfa is a hydrolytic lysosomal cholesteryl ester and triacylglycerol-specific enzyme that is FDA approved for the treatment of patients with Lysosomal Acid Lipase (LAL) deficiency.   Common adverse reactions include diarrhea, vomiting, fever, rhinitis,anemia, cough, nasopharyngitis, and urticaria (30%) in patients with rapidly progressive disease presenting within the first 6 months of life and for pediatric and adult patients the most common adverse reactions include headache,fever, oropharyngeal pain, nasopharyngitis, asthenia, constipation, and nausea (8%).

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
Sebelipase alfa is indicated for the treatment of patients with a diagnosis of Lysosomal Acid Lipase (LAL) deficiency
- Patients with Rapidly Progressive LAL Deficiency Presenting within the First 6 Months of Life:
- The recommended starting dosage is 1 mg/kg administered once weekly as an intravenous infusion. For patients who do not achieve an optimal clinical response, increase to 3 mg/kg once weekly.
- Pediatric and Adult Patients with LAL Deficiency:
- The recommended dosage is 1 mg/kg administered once every other week as an intravenous infusion.

## Off-Label Use and Dosage (Adult)

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

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

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
Safety and effectiveness of Sebelipase alfa have been established in pediatric patients aged 1 month and older (Same indications and dosage as adults). Clinical trials with Sebelipase alfa were conducted in 56 pediatric patients (range 1 month to <18 years old)

## Off-Label Use and Dosage (Pediatric)

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

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

# Contraindications
None

# Warnings
Hypersensitivity reactions, including anaphylaxis, have been reported in Sebelipase alfa-treated patients. In clinical trials, 3 of 106 (3%) patients treated with Sebelipase alfa experienced signs and symptoms consistent with anaphylaxis. These patients experienced reactions during infusion with signs and symptoms including chest discomfort, conjunctival injection, dyspnea, generalized and itchy rash, hyperemia, swelling of eyelids, rhinorrhea, severe respiratory distress, tachycardia, tachypnea, and urticaria. Anaphylaxis has occurred as early as the sixth infusion and as late as 1 year after treatment initiation.
In clinical trials, 21 of 106 (20%) Sebelipase alfa-treated patients, including 9 of 14 (64%) infants and 12 of 92 (13%) pediatric patients, 4 years and older, and adults, experienced signs and symptoms either consistent with or that may be related to a hypersensitivity reaction. Signs and symptoms of hypersensitivity reactions, occurring in two or more patients, included abdominal pain, agitation, fever, chills, diarrhea, eczema,edema, hypertension, irritability, laryngeal edema,nausea, pallor,pruritus,rash, and vomiting. The majority of reactions occurred during or within 4 hours of the completion of the infusion. Patients were not routinely pre-medicated prior to infusion of Sebelipase alfa in these clinical trials.
Due to the potential for anaphylaxis, appropriate medical support should be readily available when Sebelipase alfa is administered. If anaphylaxis occurs, immediately discontinue the infusion and initiate appropriate medical treatment. Observe patients closely during and after the infusion. Inform patients of the signs and symptoms of anaphylaxis, and instruct them to seek immediate medical care should signs and symptoms occur.
The management of hypersensitivity reactions should be based on the severity of the reaction and may include temporarily interrupting the infusion, lowering the infusion rate, and/or treatment with antihistamines, antipyretics, and/or corticosteroids. If interrupted, the infusion may be resumed at a slower rate with increases as tolerated. Pre-treatment with antipyretics and/or antihistamines may prevent subsequent reactions in those cases where symptomatic treatment was required. If a severe hypersensitivity reaction occurs, immediately discontinue the infusion and initiate appropriate medical treatment.
Consider the risks and benefits of re-administering Sebelipase alfa following a severe reaction. Monitor patients, with appropriate resuscitation measures available, if the decision is made to re-administer the product.
Sebelipase alfa is produced in the egg whites of genetically engineered chickens. Patients with a known history of egg allergies were excluded from the clinical trials. Consider the risks and benefits of treatment with Sebelipase alfa in patients with known systemic hypersensitivity reactions to eggs or egg products.

# 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 clinical practice.
In clinical trials, a total of 106 patients received treatment with Sebelipase alfa. The data described below reflect exposure to Sebelipase alfa in 75 patients who received Sebelipase alfa at dosages up to 3 mg/kg once weekly in clinical trials:
- Nine patients (5 males, 4 females) who had growth failure or other evidence of rapidly progressive LAL deficiency presenting within the first 6 months of life received Sebelipase alfa for up to 165 weeks (median 60 weeks) at escalating doses ranging between 0.35 mg/kg and 5 mg/kg once weekly. The recommended initial dosage for these patients is 1 mg/kg escalating to 3 mg/kg once weekly.
- 66 pediatric and adult patients with LAL deficiency aged 4 to 58 years (33 males, 33 females) received Sebelipase alfa 1 mg/kg every other week up to 36 weeks.
Table 2 summarizes the most common adverse reactions occurring in >30% of patients with rapidly progressive LAL deficiency presenting within the first 6 months of life receiving Sebelipase alfa.
- Table 2: Most Common Adverse Reactions- in Patients with Rapidly Progressive LAL Deficiency Presenting within the First 6 Months of Life
KANUMA: Sebelipase alfa's Brand name
Other less common adverse reactions reported in patients with rapidly progressive disease presenting within the first 6 months of life who received Sebelipase alfa included hypotonia, decreased oxygen saturation, retching, sneezing, and tachycardia.
Table 3 summarizes the most common adverse reactions that occurred in 8% of pediatric and adult patients with LAL deficiency receiving Sebelipase alfa at a dosage of 1 mg/kg once every other week during the 20-week double-blind treatment period.
- Table 3: Most Common Adverse Reactions- in Pediatric and Adult Patients with LAL Deficiency
KANUMA: Sebelipase alfa's Brand name
Other less common adverse reactions reported in pediatric and adult patients who received Sebelipase alfa included anxiety and chest discomfort.
- Hyperlipidemia
- Increases in circulating LDL-cholesterol (LDL-c) and triglycerides above pre-treatment values were observed in 29 of 36 (81%) and 21 of 36 (58%) patients, respectively, at 2 and 4 weeks following initiation of Sebelipase alfa. The maximum mean percentage increase was 18% for LDL-c at Week 2 and 5% for triglycerides at Week 4.
As with all therapeutic proteins, there is potential for immunogenicity. Patients have developed anti-drug antibodies (ADA) to Sebelipase alfa. Immunogenicity assay results are highly dependent on the sensitivity and specificity of the assay and may be influenced by several factors such as: assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to Sebelipase alfa with the incidence of antibodies to other products may be misleading.
- Patients with Rapidly Progressive LAL Deficiency Presenting within the First 6 Months of Life
- Seven of the 9 infants with rapidly progressive disease had at least one post-treatment ADA assessment, and 4 of these 7 (57%) patients developed ADA during treatment with Sebelipase alfa. Two of the 4 ADA-positive patients were determined to be positive for neutralizing antibodies that inhibit in vitro enzyme activity and cellular uptake of the enzyme. At the time of initial ADA positivity, 3 patients were receiving a dosage of 1 mg/kg once weekly and 1 patient was receiving a dosage of 3 mg/kg once weekly. Three of the 4 ADA-positive patients had ADA titers monitored from the initiation of treatment, and developed measureable ADA titers within the first 2 months of exposure. One of the 4 ADA-positive patients had persistent ADA titers. ADA titers decreased to undetectable levels in the remaining 3 patients while receiving continued treatment at a dosage of 3 mg/kg once weekly.
- Hypersensitivity reactions occurred in all 4 of the ADA-positive patients, whereas they occurred in only 1 of the 3 ADA-negative patients. None of the patients discontinued treatment. In 1 patient, decreased growth velocity in a setting of neutralizing antibodies to Sebelipase alfa was observed.
- Pediatric and Adult Patients with LAL Deficiency
- Five of 35 (14%) Sebelipase alfa-treated pediatric and adult patients who completed the 20-week double-blind period of study treatment developed ADA. All patients were receiving 1 mg/kg once every other week. All 5 ADA-positive patients first developed measurable ADA titers within the first 3 months of exposure. Two of the 5 ADA-positive patients had a measurable ADA titer at only one time point. In the 3 patients with measurable ADA titers at multiple time points, ADA titers decreased to undetectable levels during continued treatment. Two patients developed in vitro neutralizing antibodies during the open-label extension phase after 20 weeks and 52 weeks of treatment with Sebelipase alfa, respectively. There is no clear association between the development of ADA and decreased efficacy in pediatric and adult patients treated with Sebelipase alfa.

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

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

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): N
- Risk Summary
- There are no available data on Sebelipase alfa in pregnant women to inform any drug-associated risk. Animal reproductive studies conducted with sebelipase alfa showed no evidence of embryolethality, fetotoxicity, teratogenicity, or abnormal early embryonic development at dosages up to 164 and 526 times the human dosage of 1 mg/kg every other week (based on AUC) in rats and rabbits, respectively.
- The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.
- Animal Data
- Sebelipase alfa administered during the period of organogenesis to rats (on gestation days 6, 9, 12, 15 and 17) and rabbits (on gestation days 7, 10, 13, 16 and 19) at intravenous doses up to 60 and 50 mg/kg, respectively, (approximately 164 and 526 times the human AUC of 1387 ng.h/mL at 1 mg/kg dose administered once every other week, respectively) did not cause any adverse effects on embryofetal development. A pre- and postnatal development study in rats showed no evidence of adverse effects on pre- and postnatal development at intravenous doses (administered on gestation days 6, 9, 12, 15, 18, and 20 and days 4, 7, 10, 14, and 17 postpartum) of sebelipase alfa up to 60 mg/kg/day (approximately 164 times the human AUC of 1387 ng.h/mL at 1 mg/kg dose administered once every other week).
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Sebelipase alfa in women who are pregnant.

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

### Nursing Mothers
There are no data on the presence of sebelipase alfa in human milk, the effects on the breastfed infant, or the effects on milk production. It is not known if sebelipase alfa is present in animal milk. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Sebelipase alfa and any potential adverse effects on the breastfed infant from sebelipase alfa or from the underlying maternal condition.

### Pediatric Use
Safety and effectiveness of Sebelipase alfa have been established in pediatric patients aged 1 month and older. Clinical trials with Sebelipase alfa were conducted in 56 pediatric patients (range 1 month to <18 years old).

### Geriatic Use
Clinical trials of Sebelipase alfa did not include any patients aged 65 years old and older. It is not known whether they respond differently than younger patients.

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

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

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

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

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

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

# Administration and Monitoring

### Administration
- Preparation Instructions
Sebelipase alfa is for intravenous infusion only. Prepare Sebelipase alfa using the following steps.
- Table 1: Total Infusion Volumes*
KANUMA: Sebelipase alfa's Brand name
- Administration Instructions
- Administer the diluted solution as an intravenous infusion using a low-protein binding infusion set with an in-line, low-protein binding 0.2 micron filter.
- Infuse over at least 2 hours. Consider further prolonging the infusion time for patients receiving the 3 mg/kg dose or those who have experienced hypersensitivity reactions. A 1-hour infusion may be considered for those patients receiving the 1 mg/kg dose who tolerate the infusion.

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

# IV Compatibility
There is limited information regarding the compatibility of Sebelipase alfa and IV administrations.

# Overdosage
There is limited information regarding Sebelipase alfa overdosage.  If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

# Pharmacology

## Mechanism of Action
LAL deficiency is an autosomal recessive lysosomal storage disorder characterized by a genetic defect resulting in a marked decrease or loss in activity of the lysosomal acid lipase (LAL) enzyme. The primary site of action of the LAL enzyme is the lysosome, where the enzyme normally causes the breakdown of lipid particles including LDL-c. Deficient LAL enzyme activity results in progressive complications due to the lysosomal accumulation of cholesteryl esters and triglycerides in multiple organs, including the liver, spleen, intestine, and the walls of blood vessels. The resulting lipid accumulation in the liver may lead to increased liver fat content and progression of liver disease, including fibrosis and cirrhosis. Lipid accumulation in the intestinal wall leads to malabsorption and growth failure. In parallel, dyslipidemia due to impaired degradation of lysosomal lipid is common with elevated LDL-c and triglycerides and low HDL-cholesterol (HDL-c).
Sebelipase alfa binds to cell surface receptors via glycans expressed on the protein and is subsequently internalized into lysosomes. Sebelipase alfa catalyzes the lysosomal hydrolysis of cholesteryl esters and triglycerides to free cholesterol, glycerol and free fatty acids.

## Structure
Sebelipase alfa is a recombinant human lysosomal acid lipase (rhLAL). Lysosomal acid lipase (EC 3.1.1.13) is a lysosomal glycoprotein enzyme that catalyzes the hydrolysis of cholesteryl esters to free cholesterol and fatty acids and the hydrolysis of triglycerides to glycerol and free fatty acids.
Sebelipase alfa is produced by recombinant DNA technology in the egg white of eggs laid by genetically engineered chickens. Purified sebelipase alfa is a monomeric glycoprotein containing 6 N-linked glycosylation sites and has a molecular mass of approximately 55,000 daltons. The amino acid sequence for sebelipase alfa is the same as the amino acid sequence for human LAL. The specific activity of sebelipase alfa is 195 to 345 units/mg. One unit is the amount of enzyme activity that catalyzes the hydrolysis of 1 micromole of the synthetic substrate 4-methylumbelliferyl oleate per minute at 37C under specified assay conditions.
Sebelipase alfa is supplied as a sterile, preservative-free, non-pyrogenic aqueous solution in single-use vials for intravenous infusion. Each vial contains sebelipase alfa 20 mg/10 mL. Each mL of solution contains sebelipase alfa (2 mg), citric acid monohydrate (1.57 mg), Human Serum Albumin (10 mg), and trisodium citrate dihydrate (13.7 mg) at pH 5.9.

## Pharmacodynamics
In clinical trials, after initiation of dosing with Sebelipase alfa, breakdown of accumulated lysosomal lipid led to initial increases in LDL-c and triglycerides within the first 2 to 4 weeks of treatment. In general, following increases in LDL-c and triglycerides, these parameters decreased to below pre-treatment values within 8 weeks of treatment with Sebelipase alfa.
In all patients with elevated alanine aminotransferase (ALT) values at baseline (82 of 84 patients in clinical trials), reductions in ALT values were observed, generally within 2 weeks after initiation of treatment with Sebelipase alfa. Treatment interruption resulted in increases in LDL-c and ALT values and decreases in HDL-c.

## Pharmacokinetics
The pharmacokinetic profile of sebelipase alfa was nonlinear with a greater than dose-proportional increase in exposure between 1 and 3 mg/kg based on non-compartmental analysis of data from 26 adults. No accumulation was observed following once weekly or once every other week dosing.
Using a population pharmacokinetic model, sebelipase alfa pharmacokinetic parameters were estimated for 65 pediatric and adult patients who received intravenous infusions of Sebelipase alfa at 1 mg/kg at Week 22 (Table 4); 24 patients were 4 to 11 years old, 23 were 12 to 17 years old, and 18 were adults. The pharmacokinetic profiles of sebelipase alfa were similar between adolescents and adults. The Tmax and T1/2 were similar across all age groups.
- Table 4: Mean (SD) Pharmacokinetics Parameters at Week 22 in Pediatric and Adult Patients Receiving 1 mg/kg Once Every Other Week

## Nonclinical Toxicology
Long-term studies in animals to evaluate carcinogenic potential or studies to evaluate mutagenic potential have not been performed with sebelipase alfa. Sebelipase alfa at intravenous doses up to 60 mg/kg administered twice weekly (approximately 164 times the human AUC of 1387 ng.h/mL at 1 mg/kg dose administered once every other week) was found to have no adverse effect on fertility and reproductive performance of male and female rats.
In a rat disease model of LAL deficiency that exhibits several abnormalities analogous to the human disease, sebelipase alfa administered intravenously at dosages up to 3 mg/kg once weekly showed improvements in survival, body weight gain, organ weight reduction, reduction in serum transaminases (ALT and aspartate aminotransferase ), reduction in serum and hepatic lipids, and improvement in liver histopathology.

# Clinical Studies
A multicenter, open-label, single-arm clinical study of Sebelipase alfa was conducted in 9 infants with LAL deficiency who had growth failure or other evidence of rapidly progressive disease prior to 6 months of age. The age range at entry was 1 to 6 months. Patients received Sebelipase alfa at 0.35 mg/kg once weekly for the first 2 weeks and then 1 mg/kg once weekly. Due to suboptimal clinical response, doses in all 6 surviving patients were escalated to 3 mg/kg once weekly, between 4 and 88 weeks (median 11 weeks) after starting treatment at 1 mg/kg. In one patient, the dose was escalated to 5 mg/kg once weekly at Week 88 due to decreased growth velocity in a setting of positive neutralizing anti-drug antibodies to Sebelipase alfa. The recommended dosage for these patients is 1 mg/kg to 3 mg/kg once weekly.
Efficacy of Sebelipase alfa was assessed by comparing the survival of 9 Sebelipase alfa-treated patients at 12 months of age with an untreated historical cohort of 21 patients with a similar age at disease presentation and clinical characteristics. Of the 9 Sebelipase alfa-treated infants, 6 patients survived beyond 12 months of age, compared to 0 of 21 patients in the historical cohort, all of whom died by 8 months of age. The median age of the 6 surviving Sebelipase alfa-treated patients was 18.1 months (range 12 to 42.2 months).
Following initiation of treatment with Sebelipase alfa 1 mg/kg once weekly, weight-for-age z-scores improved in 3 of 5 surviving patients with growth failure, and all 6 surviving patients demonstrated improvements in weight-for-age z-scores following dose escalation to 3 mg/kg once weekly.
The safety and efficacy of Sebelipase alfa were assessed in 66 pediatric and adult patients with LAL deficiency, aged 4 to 58 years (71% were less than 18 years old), in a multicenter, double-blind, placebo-controlled trial. Patients were randomized to receive Sebelipase alfa at a dosage of 1 mg/kg (n=36) or placebo (n=30) once every other week for 20 weeks in the double-blind period. Sixty-two of the 66 (94%) patients had LDL-c of 130 mg/dL or greater at study entry. The majority of patients (58%) had LDL-c above 190 mg/dL at study entry, and 24% of patients with LDL-c above 190 mg/dL remained on lipid lowering medications.
At the completion of the 20-week double-blind period of the trial, a statistically significant improvement in percent change from baseline in LDL-c was observed in the Sebelipase alfa-treated group as compared to the placebo group (mean difference and 95% C.I.: -22%, ; p<0.0001). LDL-c of less than 130 mg/dL was achieved in 13 of 32 (41%; 95% C.I.: ) Sebelipase alfa-treated patients and in only 2 of 30 (7%; 95% C.I.: ) placebo-treated patients with baseline LDL-c of 130 mg/dL or greater. A statistically significant improvement in percent change from baseline at 20 weeks was also observed in the Sebelipase alfa-treated group compared to the placebo group for other parameters related to LAL deficiency, including decreases in non-HDL-c (mean difference and 95% C.I.: -21%, ; p<0.0001) and triglycerides (mean difference and 95% C.I.: -14%, ; p=0.0375), and increases in HDL-c (mean difference and 95% C.I.: 20%, ; p<0.0001). The effect of Sebelipase alfa on cardiovascular morbidity and mortality has not been established.
Patients treated with Sebelipase alfa had larger reductions from baseline in ALT values and liver fat content (measured by MRI), compared to patients treated with placebo. The significance of these findings as they relate to progression of liver disease in LAL deficiency has not been established.
- Open-label Extension
- Pediatric and adult patients who participated in the randomized, placebo-controlled trial were eligible to continue treatment in an open-label extension. Sixty-five of 66 patients (98%) entered the open-label period in which all patients received Sebelipase alfa at a dosage of 1 mg/kg once every other week. During the open-label extension, patients treated with Sebelipase alfa for up to 36 weeks demonstrated improvements in lipid parameters, including LDL-c and HDL-c levels, and ALT.

# How Supplied
Sebelipase alfa 20 mg/10 mL vials are supplied as a sterile, preservative-free, nonpyrogenic solution in single-use, glass vials.
NDC 25682-007-01: 20 mg/10 mL vial

## Storage
Sebelipase alfa contains no preservatives; therefore, product should be used immediately after dilution. If immediate use is not possible, the diluted product may be stored up to 24 hours in the refrigerator at 2C to 8C (36F to 46F). Do not freeze or shake. Protect from light.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Hypersensitivity Reactions, including Anaphylaxis
- Advise patients and caregivers that reactions related to administration and infusion may occur during and after Sebelipase alfa treatment, including life-threatening anaphylaxis and severe hypersensitivity reactions. Inform patients of the signs and symptoms of anaphylaxis and hypersensitivity reactions, and have them seek immediate medical care should signs and symptoms occur.

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

# Brand Names
KANUMATM

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

# Drug Shortage Status

# Price