ANNEX I

SUMMARY OF PRODUCT CHARACTERISTICS

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1. NAME OF THE MEDICINAL PRODUCT

Simulect 20 mg powder and solvent for solution for infusion.

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

One vial contains 20 mg basiliximab.

3. PHARMACEUTICAL FORM

Powder and solvent for solution for infusion.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Simulect is indicated for the prophylaxis of acute organ rejection in de novo allogeneic renal transplantation and is to be used concomitantly with ciclosporin for microemulsion- and corticosteroid-based immunosuppression, in patients with panel reactive antibodies less than 80%.

4.2 Posology and method of administration

Simulect should be prescribed only by physicians who are experienced in the use of immunosuppressive therapy following organ transplantation. Simulect should be administered under qualified medical supervision.

Recommended dose

The standard total dose is 40 mg, given in two doses of 20 mg each. The first 20 mg dose should be given within 2 hours prior to transplantation surgery. The second 20 mg dose should be given 4 days after transplantation. The second dose should be withheld if post-operative complications such as graft loss occur.

Mode of administration

Reconstituted Simulect should be administered as an intravenous infusion over 20–30 minutes.

For information on reconstituting Simulect, see section 6.6, “Instructions for use and handling”.

Use in children

The safety and efficacy of Simulect in paediatric patients has not been established. Very limited pharmacokinetic data are available (see section 5.2, “Pharmacokinetic properties”).

Use in the elderly

There are limited data available on the use of Simulect in the elderly, but there is no evidence that elderly patients require a different dosage from younger adult patients.

4.3 Contra-indications

Simulect is contraindicated in patients with known hypersensitivity to basiliximab or any other component of the formulation. See section 6.1, “List of excipients”.

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Simulect is contraindicated during pregnancy and lactation.

4.4 Special warnings and special precautions for use

Experience with the use of Simulect with immunosuppressive agents other than ciclosporin for microemulsion and corticosteroids is limited. Control studies using azathioprine or mycophenylate mofetil as part of a triple immunosuppressive regimen have not been performed.

Medications for the treatment of severe hypersensitivity reactions should be available for immediate use following administration of proteins.

Patients on immunosuppressive therapy following transplantation are at an increased risk of developing lymphoproliferative disorders (LPDs) and opportunistic infections. While Simulect is an immunosuppressive drug, to date no increase in LPDs or opportunistic infections has been observed in patients treated with Simulect.

4.5 Interaction with other medicinal products and other forms of interaction

Because Simulect is an immunoglobulin, no metabolic drug-drug interactions are to be expected.

In addition to ciclosporin for microemulsion and steroids other medications have been administered in clinical trials without any incremental adverse reactions in the Simulect group as compared to the placebo group, including systemic anti-viral medications (60% Simulect, 66% placebo), systemic anti- bacterial medications (99% both groups), systemic anti-mycotic medications (47% Simulect, 42% placebo), analgesics (91% Simulect, 92% placebo), anti-hypertensive medications such as beta- blocking agents (55% Simulect, 64% placebo) or calcium channel blockers (91% both groups), diuretics (86% Simulect, 89% placebo).

Other immunosuppressives given in the phase 3 studies included azathioprine, mycophenylate mofetil and antibody preparations. During the first 3 months post-transplantation, 10.5% of Simulect patients and 21.7% of placebo patients in the pooled phase 3 studies received triple therapy including azathioprine or mycophenylate mofetil for at least 1 month, with no increase in adverse events or infections in the Simulect group as compared to the placebo group. During the same period, 14% of patients in the Simulect group and 27% of patients in the placebo group had an acute rejection episode treated with antibody therapy (OKT 3 or ATG/ALG), with no increase in adverse events or infections in the Simulect group as compared to placebo.

Human antimurine antibody (HAMA) responses in Simulect-treated patients are rare (3.5%). The use of Simulect does not preclude subsequent treatment with murine antilymphocyte antibody preparations.

4.6 Use during pregnancy and lactation

Simulect is contraindicated during pregnancy and lactation. Basiliximab has potentially hazardous pharmacological effects with respect to the course of gestation and the suckling neonate exposed to basiliximab in breast milk. This concern is based on basiliximab’s immunosuppressive action. Women of child-bearing potential must use adequate contraception to prevent pregnancy and continue its use for an additional 8 weeks after the last dose of Simulect.

4.7 Effects on ability to drive and use machines

Simulect is not expected to affect the ability to drive or use machines.

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4.8 Undesirable effects

In two controlled trials, the pattern of adverse events in 363 patients treated with the recommended dose of Simulect was indistinguishable from that in 359 patients treated with placebo. Simulect did not appear to add to the background of adverse events seen in organ transplantation patients as a consequence of their underlying disease and the concurrent administration of immunosuppressants and other medications. Adverse events were reported by 99% of the patients in the placebo-treated group and 99% of the patients in the Simulect-treated group. Simulect did not increase the incidence of serious adverse events observed when compared to placebo. The most commonly reported (>20%) events in both treatment groups were constipation, urinary tract infection, pain, nausea, peripheral oedema, hypertension, anaemia, headache, and hyperkalaemia.

Incidence of Malignancies: The overall incidence of malignancies among all patients in the two 12- month controlled trials was not significantly different between the Simulect and the placebo-treatment groups. Overall, lymphoma/lymphoproliferative disease occurred in 1 patient (0.3%) in the Simulect group compared with 2 patients (0.6%) in the placebo group. Other malignancies were reported among 5 patients (1.4%) in the Simulect group compared with 7 patients (1.9%) in patients treated with placebo.

Incidence of Infectious Episodes: Cytomegalovirus infection was reported in 14% of Simulect-treated patients and 18% of placebo-treated patients. The rates of infections were 81% in both groups, for serious infections they were 28% in the Simulect and 27% in the placebo group, while for infectious organisms they were similar in both the Simulect and the placebo treatment groups.

The incidence and causes of deaths were similar in both groups, with the most common cause of deaths in both treatment groups being infections (13/26 or 50%).

4.9 Overdose

In clinical studies Simulect has been administered to humans in single doses of up to 60 mg and multiple doses of up to 150 mg over 24 days with no untoward acute effects.

In a 4-week study in rhesus monkeys, the no observable effect level was 5 mg/kg twice weekly, leading to a serum Cmax of 170 μg/ml. Levels in humans are generally <10 μg/ml with the recommended regimen.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: specific immunosuppressant; ATC code: L04AA09.

Simulect is a murine/human chimeric monoclonal antibody (IgG1κ) that is directed against the interleukin-2 receptor α-chain (CD25 antigen), which is expressed on the surface of T-lymphocytes in response to antigenic challenge. Simulect specifically binds to the CD25 antigen on activated T- lymphocytes expressing the high affinity interleukin-2 receptor and thereby prevents binding of interleukin-2, the signal for T-cell proliferation. Complete and consistent blocking of the interleukin-2 receptor is maintained as long as serum basiliximab levels exceed 0.2 μg/ml (which was 4–6 weeks). As concentrations fall below this level, expression of the CD25 antigen returns to pretherapy values within 1–2 weeks. Simulect does not cause cytokine release or myelosuppression.

Soluble IL-2R serum concentrations increase over the first 2–3 weeks following the administration of Simulect, reaching a plateau at levels of 80–120 ng/ml. These levels are maintained while IL-2R sites are saturated by basiliximab. When IL-2R sites are no longer saturated, soluble IL-2R levels fall to pretransplant levels over the following 1–2 weeks.

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Clinical studies

The efficacy of Simulect in prophylaxis of organ rejection in de novo renal transplantation has been demonstrated in placebo-controlled studies. Results from two pivotal 12-month multicentre studies comparing Simulect with placebo show that Simulect, used concomitantly with ciclosporin for microemulsion and corticosteroids, significantly reduces the incidence of acute rejection episodes both within 6 and 12 months after transplantation. There was no significant difference between Simulect and placebo treated patients in graft survival after 6 and 12 months (at 12 months 32 graft losses on Simulect (9%) and 37 graft losses on placebo (10%)).

Of 268 patients treated with Simulect and tested for anti-idiotype antibodies, only one developed an anti-idiotype antibody response. Of 172 patients receiving Simulect in a clinical trial, six (3.5%) developed a HAMA response.

5.2 Pharmacokinetic properties

Single-dose and multiple-dose pharmacokinetic studies have been conducted in patients undergoing kidney transplantation. Cumulative doses ranged from 20 mg up to 60 mg. Peak serum concentration following intravenous infusion of 20 mg over 30 minutes is 7.1±5.1 mg/l. There is a proportional increase in Cmax and AUC from 20 mg to 60 mg, the range of single-dose administrations tested. The volume of distribution at steady state is 8.6±4.1 l. The extent and degree of distribution to various body compartments have not been fully studied. In vitro studies using human tissues indicate that Simulect binds only to activated lymphocytes and macrophages/monocytes. The terminal half-life is 7.2±3.2 days. Total body clearance is 41±19 ml/h.

No clinically relevant influence of body weight or gender on distribution volume or clearance has been observed in adult patients. Elimination half-life was not influenced by age (20–69 years), gender, or race.

No data exist on the use of Simulect in neonates or infants aged less than 2 years. The pharmacokinetics of Simulect were assessed in 12 paediatric de novo renal transplantation patients. In children (age 2–11 years, n=8), the steady-state distribution volume was 5.2±2.8 l, half-life was 11.5±6.3 days and clearance was 17±6 ml/h. Distribution volume and clearance are reduced by about 50% compared to adult renal transplantation patients. Disposition parameters were not influenced to a clinically relevant extent by age (2–11 years), body weight (9–37 kg) or body surface area (0.44– 1.20 m2) in this age group. In adolescents (age 12–15 years, n=4), the steady-state distribution volume was 10.1±7.6 l, half-life was 7.2±3.6 days and clearance was 45±25 ml/h. Disposition in adolescents was similar to that in adult renal transplantation patients. The relationship between serum concentration and receptor saturation was assessed in two patients (2 and 12 years) and was similar to that characterised in adult renal transplantation patients.

5.3 Preclinical safety data

No toxicity was observed when rhesus monkeys received intravenous doses of up to 5 mg/kg basiliximab twice weekly for 4 weeks, resulting in approximately 20 times the systemic exposure (Cmax) observed in patients given the recommended clinical dose together with concomitant immunosuppressive therapy.

No maternal toxicity, embryotoxicity, or teratogenicity was observed in cynomolgous monkeys following injections of up to 5 mg/kg basiliximab administered twice weekly during the organogenesis period.

No mutagenic potential was observed in vitro.

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6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Potassium dihydrogen phosphate, disodium hydrogen phosphate, sodium chloride, sucrose, mannitol glycine, and water for injections.

6.2 Incompatibilities

No known incompatibilities.

6.3 Shelf-life

2 years

6.4 Special precautions for storage

Shipping and storage should be under refrigerated conditions (2–8°C).

6.5 Nature and content of container

Simulect powder

Colourless glass vial, hydrolytic glass type I, grey fluor-resin coated butyl rubber stopper, held in place by a flanged aluminium band, blue polypropylene flip-off cap.

Water for injections

Colourless glass ampoule, hydrolytic glass type I.

6.6 Instructions for use and handling

To prepare the infusion solution, add 5 ml of water for injection from the accompanying ampoule aseptically to the vial containing the Simulect powder. Shake the vial gently to dissolve the powder. It is recommended that after reconstitution the solution should be used immediately. After reconstitution it may be stored at 2–8°C for 24 hours or at room temperature for 4 hours.

Discard the reconstituted solution if not used within 24 hours.

The reconstituted solution is isotonic and is given diluted to a volume of 50 ml or greater with normal saline or dextrose 5% for infusion.

Since no data are available on the compatibility of Simulect with other intravenous substances, Simulect should not be mixed with other medications/substances and should always be given through a separate infusion line.

Compatibility with a number of infusion sets has been verified.

7. MARKETING AUTHORISATION HOLDER

Novartis Europharm Limited Wimblehurst Road Horsham West Sussex, RH12 5AB UNITED KINGDOM

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8. NUMBER IN THE COMMUNITY REGISTER OF MEDICINAL PRODUCTS

EU/1/98/084/001

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

09.10.1998

10. DATE OF REVISION OF THE TEXT

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