Simponi treatment is to be initiated and supervised by qualified physicians experienced in the diagnosis and treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis or ulcerative colitis. Patients treated with Simponi should be given the Patient Alert Card.
Posology
Rheumatoid arthritis
Simponi 50 mg given once a month, on the same date each month.
Simponi should be given concomitantly with MTX.
Psoriatic arthritis
Simponi 50 mg given once a month, on the same date each month.
Ankylosing spondylitis
Simponi 50 mg given once a month, on the same date each month.
For all of the above indications, available data suggest that clinical response is usually achieved within 12 to 14 weeks of treatment (after 3-4 doses). Continued therapy should be reconsidered in patients who show no evidence of therapeutic benefit within this time period.
Patients with bodyweight greater than 100 kg
For all of the above indications, in patients with RA, PsA or AS with a body weight of more than 100 kg who do not achieve an adequate clinical response after 3 or 4 doses, increasing the dose of golimumab to 100 mg once a month may be considered, taking into account the increased risk of certain serious adverse drug reactions with the 100 mg dose compared with the 50 mg dose (see section 4.8). Continued therapy should be reconsidered in patients who show no evidence of therapeutic benefit after receiving 3 to 4 additional doses of 100 mg.
Ulcerative colitis
Patients with body weight less than 80 kg
Simponi given as an initial dose of 200 mg, followed by 100 mg at week 2, then 50 mg every 4 weeks, thereafter (see section 5.1).
Patients with body weight greater than or equal to 80 kg
Simponi given as an initial dose of 200 mg, followed by 100 mg at week 2, then 100 mg every 4 weeks, thereafter (see section 5.1).
During maintenance treatment, corticosteroids may be tapered in accordance with clinical practice guidelines.
Available data suggest that clinical response is usually achieved within 12-14 weeks of treatment (after 4 doses). Continued therapy should be reconsidered in patients who show no evidence of therapeutic benefit within this time period.
Missed dose
If a patient forgets to inject Simponi on the planned date, the forgotten dose should be injected as soon as the patient remembers. Patients should be instructed not to inject a double dose to make up for the forgotten dose.
The next dose should be administered based on the following guidance:
• if the dose is less than 2 weeks late, the patient should inject his/her forgotten dose and stay on his/her original schedule.
• if the dose is more than 2 weeks late, the patient should inject his/her forgotten dose and a new schedule should be established from the date of this injection.
Special populations
Elderly (≥ 65 years)
No dose adjustment is required in the elderly.
Renal and hepatic impairment
Simponi has not been studied in these patient populations. No dose recommendations can be made.
Paediatric population
The safety and efficacy of Simponi in patients aged less than 18 have not yet been established. No data are available.
Method of administration
Simponi is for subcutaneous use. After proper training in subcutaneous injection technique, patients may self-inject with Simponi if their physician determines that this is appropriate, with medical follow-up as necessary. Patients should be instructed to inject the full amount of Simponi according to the comprehensive instructions for administration provided in the package leaflet. If multiple injections are required, the injections should be administered at different sites on the body.
For administration instructions, see section 6.6.
Infections
Patients must be monitored closely for infections including tuberculosis before, during and after treatment with Simponi. Because the elimination of golimumab may take up to 5 months, monitoring should be continued throughout this period. Further treatment with Simponi must not be given if a patient develops a serious infection or sepsis (see section 4.3).
Simponi should not be given to patients with a clinically important, active infection. Caution should be exercised when considering the use of Simponi in patients with a chronic infection or a history of recurrent infection. Patients should be advised of, and avoid exposure to, potential risk factors for infection as appropriate.
Patients taking TNF-blockers are more susceptible to serious infections.
Bacterial (including sepsis and pneumonia), mycobacterial (including TB), invasive fungal and opportunistic infections, including fatalities, have been reported in patients receiving Simponi. Some of these serious infections have occurred in patients on concomitant immunosuppressive therapy that, in addition to their underlying disease, could predispose them to infections. Patients who develop a new infection while undergoing treatment with Simponi should be monitored closely and undergo a complete diagnostic eva luation. Administration of Simponi should be discontinued if a patient develops a new serious infection or sepsis, and appropriate antimicrobial or antifungal therapy should be initiated until the infection is controlled. For patients who have resided in or travelled to regions where invasive fungal infections such as histoplasmosis, coccidioidomycosis, or blastomycosis are endemic, the benefits and risks of Simponi treatment should be carefully considered before initiation of Simponi therapy.
Tuberculosis
There have been reports of tuberculosis in patients receiving Simponi. It should be noted that in the majority of these reports, tuberculosis was extrapulmonary presenting as either local or disseminated disease.
Before starting treatment with Simponi, all patients must be eva luated for both active and inactive ('latent') tuberculosis. This eva luation should include a detailed medical history with personal history of tuberculosis or possible previous contact with tuberculosis and previous and/or current immunosuppressive therapy. Appropriate screening tests, i.e. tuberculin skin or blood test and chest X-ray, should be performed in all patients (local recommendations may apply). It is recommended that the conduct of these tests should be recorded in the patient's alert card. Prescribers are reminded of the risk of false negative tuberculin skin test results, especially in patients who are severely ill or immunocompromised.
If active tuberculosis is diagnosed, Simponi therapy must not be initiated (see section 4.3).
If latent tuberculosis is suspected, a physician with expertise in the treatment of tuberculosis should be consulted. In all situations described below, the benefit/risk balance of Simponi therapy should be very carefully considered.
If inactive ('latent') tuberculosis is diagnosed, treatment for latent tuberculosis must be started with anti-tuberculosis therapy before the initiation of Simponi, and in accordance with local recommendations.
In patients who have several or significant risk factors for tuberculosis and have a negative test for latent tuberculosis, anti-tuberculosis therapy should be considered before the initiation of Simponi. Use of anti-tuberculosis therapy should also be considered before the initiation of Simponi in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed.
Cases of active tuberculosis have occurred in patients treated with Simponi during and after treatment for latent tuberculosis. Patients receiving Simponi should be monitored closely for signs and symptoms of active tuberculosis, including patients who tested negative for latent tuberculosis, patients who are on treatment for latent tuberculosis, or patients who were previously treated for tuberculosis infection.
All patients should be informed to seek medical advice if signs/symptoms suggestive of tuberculosis (e.g. persistent cough, wasting/weight loss, low-grade fever) appear during or after Simponi treatment.
Hepatitis B virus reactivation
Reactivation of hepatitis B has occurred in patients receiving a TNF-antagonist including Simponi, who are chronic carriers of this virus (i.e. surface antigen positive). Some cases have had fatal outcome.
Patients should be tested for HBV infection before initiating treatment with Simponi. For patients who test positive for HBV infection, consultation with a physician with expertise in the treatment of hepatitis B is recommended.
Carriers of HBV who require treatment with Simponi should be closely monitored for signs and symptoms of active HBV infection throughout therapy and for several months following termination of therapy. Adequate data of treating patients who are carriers of HBV with anti-viral therapy in conjunction with TNF-antagonist therapy to prevent HBV reactivation are not available. In patients who develop HBV reactivation, Simponi should be stopped and effective anti-viral therapy with appropriate supportive treatment should be initiated.
Malignancies and lymphoproliferative disorders
The potential role of TNF-blocking therapy in the development of malignancies is not known. Based on the current knowledge, a possible risk for the development of lymphomas, leukaemia or other malignancies in patients treated with a TNF-antagonist cannot be excluded. Caution should be exercised when considering TNF-blocking therapy for patients with a history of malignancy or when considering continuing treatment in patients who develop malignancy.
Paediatric malignancy
Malignancies, some fatal, have been reported among children, adolescents and young adults (up to 22 years of age) treated with TNF-blocking agents (initiation of therapy ≤ 18 years of age) in the post marketing setting. Approximately half the cases were lymphomas. The other cases represented a variety of different malignancies and included rare malignancies usually associated with immunosuppression. A risk for the development of malignancies in children and adolescents treated with TNF-blockers cannot be excluded.
Lymphoma and leukaemia
In the controlled portions of clinical trials of all the TNF-blocking agents including Simponi, more cases of lymphoma have been observed among patients receiving anti-TNF treatment compared with control patients. During the Simponi Phase IIb and Phase III clinical trials in RA, PsA and AS, the incidence of lymphoma in Simponi-treated patients was higher than expected in the general population. In the post-marketing setting, cases of leukaemia have been reported in patients treated with a TNF-antagonist. There is an increased background risk for lymphoma and leukaemia in rheumatoid arthritis patients with long-standing, highly active, inflammatory disease, which complicates risk estimation.
Rare post-marketing cases of hepatosplenic T-cell lymphoma (HSTCL) have been reported in patients treated with other TNF-blocking agents (see section 4.8). This rare type of T-cell lymphoma has a very aggressive disease course and is usually fatal. The majority of cases have occurred in adolescent and young adult males with nearly all on comcomitant treatment with azathioprine (AZA) or 6-mercaptopurine (6–MP) for inflammatory bowel disease. The potential risk with the combination of AZA or 6-MP and Simponi should be carefully considered. A risk for the development for hepatosplenic T-cell lymphoma in patients treated with TNF-blockers cannot be excluded.
Malignancies other than lymphoma
In the controlled portions of the Simponi Phase IIb and Phase III clinical trials in RA, PsA, AS, and UC, the incidence of non-lymphoma malignancies (excluding non-melanoma skin cancer) was similar between the Simponi and the control groups.
Colon dysplasia/carcinoma
It is not known if golimumab treatment influences the risk for developing dysplasia or colon cancer. All patients with ulcerative colitis who are at increased risk for dysplasia or colon carcinoma (for example, patients with long-standing ulcerative colitis or primary sclerosing cholangitis), or who had a prior history of dysplasia or colon carcinoma should be screened for dysplasia at regular intervals before therapy and throughout their disease course. This eva luation should include colonoscopy and biopsies per local recommendations. In patients with newly diagnosed dysplasia treated with Simponi, the risks and benefits to the individual patient must be carefully reviewed and consideration should be given to whether therapy should be continued.
In an exploratory clinical trial eva luating the use of Simponi in patients with severe persistent asthma, more malignancies were reported in patients treated with Simponi compared with control patients (see section 4.8). The significance of this finding is unknown.
In an exploratory clinical trial eva luating the use of another anti-TNF agent, infliximab, in patients with moderate to severe chronic obstructive pulmonary disease (COPD), more malignancies, mostly in the lung or head and neck, were reported in infliximab-treated patients compared with control patients. All patients had a history of heavy smoking. Therefore, caution should be exercised when using any TNF-antagonist in COPD patients, as well as in patients with an increased risk of malignancy due to heavy smoking.
Skin cancers
Melanoma has been reported in patients treated with TNF-blocking agents, including Simponi. Merkel cell carcinoma has been reported in patients treated with other TNF-blocking agents (see section 4.8). Periodic skin examination is recommended, particularly for patients with risk factors for skin cancer.
Congestive heart failure (CHF)
Cases of worsening congestive heart failure (CHF) and new onset CHF have been reported with TNF blockers, including Simponi. In a clinical trial with another TNF-antagonist worsening congestive heart failure and increased mortality due to CHF have been observed. Simponi has not been studied in patients with CHF. Simponi should be used with caution in patients with mild heart failure (NYHA class I/II). Patients should be closely monitored and Simponi must be discontinued in patients who develop new or worsening symptoms of heart failure (see section 4.3).
Neurological events
Use of TNF-blocking agents, including Simponi, has been associated with cases of new onset or exacerbation of clinical symptoms and/or radiographic evidence of central nervous system demyelinating disorders, including multiple sclerosis and peripheral demyelinating disorders. In patients with pre-existing or recent onset of demyelinating disorders, the benefits and risks of anti-TNF treatment should be carefully considered before initiation of Simponi therapy. Discontinuation of Simponi should be considered if these disorders develop (see section 4.8).
Surgery
There is limited safety experience of Simponi treatment in patients who have undergone surgical procedures, including arthroplasty. The long half-life should be taken into consideration if a surgical procedure is planned. A patient who requires surgery while on Simponi should be closely monitored for infections, and appropriate actions should be taken.
Immunosuppression
The possibility exists for TNF-blocking agents, including Simponi, to affect host defences against infections and malignancies since TNF mediates inflammation and modulates cellular immune responses.
Autoimmune processes
The relative deficiency of TNFα caused by anti-TNF therapy may result in the initiation of an autoimmune process. If a patient develops symptoms suggestive of a lupus-like syndrome following treatment with Simponi and is positive for antibodies against double-stranded DNA, treatment with Simponi should be discontinued (see section 4.8).
Haematologic reactions
There have been post-marketing reports of pancytopaenia, leucopaenia, neutropaenia, aplastic anaemia, and thrombocytopaenia in patients receiving TNF-blockers. Cytopaenias including pancytopaenia have been infrequently reported with Simponi in clinical trials. All patients should be advised to seek immediate medical attention if they develop signs and symptoms suggestive of blood dyscrasias (e.g. persistent fever, bruising, bleeding, pallor). Discontinuation of Simponi therapy should be considered in patients with confirmed significant haematologic abnormalities.
Concurrent administration of TNF-antagonists and anakinra
Serious infections and neutropenia were seen in clinical studies with concurrent use of anakinra and another TNF-blocking agent, etanercept, with no added clinical benefit. Because of the nature of the adverse events seen with this combination therapy, similar toxicities may also result from the combination of anakinra and other TNF-blocking agents. The combination of Simponi and anakinra is not recommended.
Concurrent administration of TNF-antagonists and abatacept
In clinical studies concurrent administration of TNF-antagonists and abatacept has been associated with an increased risk of infections including serious infections compared to TNF-antagonists alone, without increased clinical benefit. The combination of Simponi and abatacept is not recommended.
Concurrent administration with other biological therapeutics
There is insufficient information regarding the concomitant use of Simponi with other biological therapeutics used to treat the same conditions as Simponi. The concomitant use of Simponi with these biologics is not recommended because of the possibility of an increased risk of infection, and other potential pharmacological interactions.
Switching between biological DMARDs
Care should be taken and patients should continue to be monitored when switching from one biologic to another, since overlapping biological activity may further increase the risk for adverse events, including infection.
Vaccinations/therapeutic infectious agents
Patients treated with Simponi may receive concurrent vaccinations, except for live vaccines (see sections 4.5 and 4.6). In patients receiving anti-TNF therapy, limited data are available on the response to vaccination with live vaccines or on the secondary transmission of infection by live vaccines. Use of live vaccines could result in clinical infections, including disseminated infections.
Other uses of therapeutic infectious agents such as live attenuated bacteria (e.g. BCG bladder instillation for the treatment of cancer) could result in clinical infections, including disseminated infections. It is recommended that therapeutic infectious agents not be given concurrently with Simponi.
Allergic reactions
In post-marketing experience, serious systemic hypersensitivity reactions (including anaphylactic reaction) have been reported following Simponi administration. Some of these reactions occurred after the first administration of Simponi. If an anaphylactic reaction or other serious allergic reactions occur, administration of Simponi should be discontinued immediately and appropriate therapy initiated.
Latex sensitivity
The needle cover on the pre-filled pen is manufactured from dry natural rubber containing latex, and may cause allergic reactions in individuals sensitive to latex.
Special populations
Elderly (≥ 65 years)
In the Phase III studies in RA, PsA, AS, and UC, no overall differences in adverse events (AEs), serious adverse events (SAEs), and serious infections in patients age 65 or older who received Simponi were observed compared with younger patients. However, caution should be exercised when treating the elderly and particular attention paid with respect to occurrence of infections.
Renal and hepatic impairment
Specific studies of Simponi have not been conducted in patients with renal or hepatic impairment. Simponi should be used with caution in subjects with impaired hepatic function (see section 4.2).
Excipients
Simponi contains sorbitol (E420). Patients with rare hereditary problems of fructose intolerance should not take Simponi.
Potential for medication errors
Simponi is registered in 50 mg and 100 mg strengths for subcutaneous administration. It is important that the right strength is used to administer the correct dose as indicated in the posology (see section 4.2). Care should be taken to provide the right strength to ensure that patients are not underdosed or overdosed.
