HUMIRA®  (adalimumab)
HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use humira safely and effectively. See full prescribing information for humira.
humira (adalimumabinjection, solution for subcutaneous use
Initial U.S. Approval: 2002

WARNING: RISK OF SERIOUS INFECTIONS
See full prescribing information for complete boxed warning.

Tuberculosis (TB), invasive fungal, and other opportunistic infections, some fatal, have occurred. Perform test for latent TB; if positive, start treatment for TB prior to starting HUMIRA. Monitor all patients for active TB during treatment, even if initial latent TB test is negative.( 5.1)

RECENT MAJOR CHANGES

Indications and Usage, Psoriatic Arthritis ( 1.2)  11/2006
Indications and Usage, Crohn’s Disease ( 1.4)  2/2007
Dosage and Administration, Crohn’s Disease ( 2.2) 7/2007
Warnings and Precautions, Serious Infections ( 5.1)  2/2007
Warnings and Precautions, Malignancies ( 5.2)  2/2007
Warnings and Precautions, Immunizations ( 5.10)  2/2007

INDICATIONS AND USAGE

HUMIRA is a tumor necrosis factor (TNF) blocker indicated for treatment of:

Rheumatoid Arthritis (RA) ( 1.1)

  • Reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in adult patients with moderately to severely active disease.

Psoriatic Arthritis ( 1.2)

  • Reducing signs and symptoms of active arthritis, inhibiting the progression of structural damage, and improving physical function.

Ankylosing Spondylitis ( 1.3)

  • Reducing signs and symptoms in patients with active disease.

Crohn’s Disease ( 1.4)

  • Reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy. Reducing signs and symptoms and inducing clinical remission in these patients if they have also lost response to or are intolerant to infliximab.


DOSAGE AND ADMINISTRATION

Humira is administered by subcutaneous injection.

Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis (2.1)

  • 40 mg every other week. Some patients with RA not receiving methotrexate may benefit from increasing the frequency to 40 mg every week.

Crohn's Disease (2.2)

  • Initial dose (Day 1) is 160 mg (four 40 mg injections in one day or two 40 mg injections per day for two consecutive days), followed by 80 mg two weeks later (Day 15). Two weeks later (Day 29) begin a maintenance dose of 40 mg every other week.


DOSAGE FORMS AND STRENGTHS

  • 40 mg/0.8 mL in single use prefilled pen (HUMIRA Pen) ( 3)

  • 40 mg/0.8 mL in a single use prefilled glass syringe ( 3)


CONTRAINDICATIONS

  • None ( 4)

WARNINGS AND PRECAUTIONS

  • Serious infections – do not start HUMIRA during an active infection. If an infection develops, monitor carefully, and stop HUMIRA if infection becomes serious ( 5.1)
  • Malignancies – are seen more often than in controls, and lymphoma is seen more often than in the general population ( 5.2)
  • Anaphylaxis or serious allergic reactions may occur ( 5.3)
  • Hepatitis B virus reactivation – monitor HBV carriers during and several months after therapy. If reactivation occurs, stop HUMIRA and begin anti-viral therapy ( 5.4)
  • Demyelinating disease, exacerbation or new onset, may occur ( 5.5)
  • Cytopenias, pancytopenia – advise patients to seek immediate medical attention if symptoms develop, and consider stopping HUMIRA ( 5.6)
  • Heart failure, worsening or new onset, may occur ( 5.8)
  • Lupus-like syndrome – stop HUMIRA if syndrome develops ( 5.9)

ADVERSE REACTIONS

Most common adverse reactions (incidence >10%): infections (e.g. upper respiratory, sinusitis), injection site reactions, headache and rash ( 6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Abbott Laboratories, Inc. at 1-800-633-9110 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch


DRUG INTERACTIONS

  • Anakinra – increased risk of serious infection ( 5.7, 7.1)
  • Live vaccines – should not be given with HUMIRA (5.10, 7.2)

USE IN SPECIFIC POPULATIONS

  • Pregnancy: Physicians are encouraged to enroll pregnant patients in the HUMIRA pregnancy registry by calling 1-877-311-8972 ( 8.1)


See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling

Revised: 10/2007

FULL PRESCRIBING INFORMATION: CONTENTS*
* Sections or subsections omitted from the full prescribing information are not listed

WARNING: RISK OF SERIOUS INFECTIONS

RECENT MAJOR CHANGES

1 INDICATIONS AND USAGE

1.1 Rheumatoid Arthritis

1.2 Psoriatic Arthritis

1.3 Ankylosing Spondylitis

1.4 Crohn’s Disease

2 DOSAGE AND ADMINISTRATION

2.1 Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis

2.2 Crohn’s Disease

2.3 General Considerations for Administration

3 DOSAGE FORMS AND STRENGTHS

4 CONTRAINDICATIONS

5 WARNINGS AND PRECAUTIONS

5.1 Serious Infections

5.2 Malignancies

5.3 Hypersensitivity Reactions

5.4 Hepatitis B Virus Reactivation

5.5 Neurologic Reactions

5.6 Hematological Reactions

5.7 Use with Anakinra

5.8 Heart Failure

5.9 Autoimmunity

5.10 Immunizations

5.11 Immunosuppression

6 ADVERSE REACTIONS

6.1 Clinical Studies Experience

6.2 Postmarketing Experience

7 DRUG INTERACTIONS

7.1 Anakinra

7.2 Live Vaccines

7.3 Methotrexate

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

8.3 Nursing Mothers

8.4 Pediatric Use

8.5 Geriatric Use

10 OVERDOSAGE

11 DESCRIPTION

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

12.2 Pharmacodynamics

12.3 Pharmacokinetics

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

14 CLINICAL STUDIES

14.1 Rheumatoid Arthritis

14.2 Psoriatic Arthritis

14.3 Ankylosing Spondylitis

14.4 Crohn’s Disease

15 REFERENCES

16 HOW SUPPLIED/STORAGE AND HANDLING

17 PATIENT COUNSELING INFORMATION

17.1 Patient Counseling

17.2 Instruction on Injection Technique

17.3 FDA-Approved Patient Labeling


FULL PRESCRIBING INFORMATION

WARNING: RISK OF SERIOUS INFECTIONS

Tuberculosis (frequently disseminated or extrapulmonary at clinical presentation), invasive fungal infections, and other opportunistic infections, have been observed in patients receiving HUMIRA. Some of these infections have been fatal. Anti-tuberculosis treatment of patients with latent tuberculosis infection reduces the risk of reactivation in patients receiving treatment with HUMIRA. However, active tuberculosis has developed in patients receiving HUMIRA whose screening for latent tuberculosis infection was negative.

Patients should be evaluated for tuberculosis risk factors and be tested for latent tuberculosis infection prior to initiating HUMIRA and during therapy. Treatment of latent tuberculosis infection should be initiated prior to therapy with HUMIRA. Physicians should monitor patients receiving HUMIRA for signs and symptoms of active tuberculosis, including patients who tested negative for latent tuberculosis infection.[See Warnings and Precautions ( 5.1) and Adverse Reactions ( 6.1)]

1 INDICATIONS AND USAGE

1.1 Rheumatoid Arthritis

HUMIRA is indicated for reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in adult patients with moderately to severely active rheumatoid arthritis. HUMIRA can be used alone or in combination with methotrexate or other disease-modifying anti-rheumatic drugs (DMARDs).

1.2 Psoriatic Arthritis

HUMIRA is indicated for reducing signs and symptoms of active arthritis,  inhibiting the progression of structural damage, and improving physical function in patients with psoriatic arthritis. HUMIRA can be used alone or in combination with DMARDs.

1.3 Ankylosing Spondylitis

HUMIRA is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis.

1.4 Crohn’s Disease

 HUMIRA is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy. HUMIRA is indicated for reducing signs and symptoms and inducing clinical remission in these patients if they have also lost response to or are intolerant to infliximab.

2 DOSAGE AND ADMINISTRATION

HUMIRA is administered by subcutaneous injection.

2.1 Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis

The recommended dose of HUMIRA for adult patients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis is 40 mg administered every other week. Methotrexate, glucocorticoids, salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics or other DMARDs may be continued during treatment with HUMIRA. In rheumatoid arthritis, some patients not taking concomitant methotrexate may derive additional benefit from increasing the dosing frequency of HUMIRA to 40 mg every week.

2.2 Crohn’s Disease

 The recommended HUMIRA dose regimen for adult patients with Crohn’s disease is 160 mg initially at Day 1 (given as four 40 mg injections in one day or as two 40 mg injections per day for two consecutive days), followed by 80 mg two weeks later (Day 15). Two weeks later (Day 29) begin a maintenance dose of 40 mg every other week. Aminosalicylates, corticosteroids, and/or immunomodulatory agents (e.g., 6-mercaptopurine and azathioprine) may be continued during treatment with HUMIRA. The use of HUMIRA in Crohn’s disease beyond one year has not been evaluated in controlled clinical studies.

2.3 General Considerations for Administration

HUMIRA is intended for use under the guidance and supervision of a physician. A patient may self-inject HUMIRA if a physician determines that it is appropriate, and with medical follow-up, as necessary, after proper training in subcutaneous injection technique.

The solution in the HUMIRA Pen or prefilled syringe should be carefully inspected visually for particulate matter and discoloration prior to subcutaneous administration. If particulates and discolorations are noted, the product should not be used. HUMIRA does not contain preservatives; therefore, unused portions of drug remaining from the syringe should be discarded. NOTE: The needle cover of the syringe contains dry rubber (latex), which should not be handled by persons sensitive to this substance.

Patients using the HUMIRA Pen or prefilled syringe should be instructed to inject the full amount in the syringe (0.8 mL), which provides 40 mg of HUMIRA, according to the directions provided in the Patient Information Leaflet [see Patient Counseling Information ( 17.3)].

Injection sites should be rotated and injections should never be given into areas where the skin is tender, bruised, red or hard.

3 DOSAGE FORMS AND STRENGTHS

A single-use pen (HUMIRA Pen), containing a 1 mL prefilled glass syringe with a fixed 27 gauge ½ inch needle, providing 40 mg (0.8 mL) of HUMIRA.

A single-use, 1 mL prefilled glass syringe with a fixed 27 gauge ½ inch needle, providing 40 mg (0.8 mL) of HUMIRA.

4 CONTRAINDICATIONS

None.

5 WARNINGS AND PRECAUTIONS

5.1 Serious Infections

 Serious infections, sepsis, tuberculosis and cases of opportunistic infections, including fatalities, have been reported with the use of TNF blocking agents including HUMIRA. Many of the serious infections have occurred in patients on concomitant immunosuppressive therapy that, in addition to their rheumatoid arthritis could predispose them to infections. In postmarketing experience, infections have been observed with various pathogens including viral, bacterial, fungal and protozoal organisms. Infections have been noted in all organ systems and have been reported in patients receiving HUMIRA alone or in combination with immunosuppressive agents.

 Treatment with HUMIRA should not be initiated in patients with active infections including chronic or localized infections. Patients who develop a new infection while undergoing treatment with HUMIRA should be monitored closely. Administration of HUMIRA should be discontinued if a patient develops a serious infection. Physicians should exercise caution when considering the use of HUMIRA in patients with a history of recurrent infection or underlying conditions which may predispose them to infections, or patients who have resided in regions where tuberculosis and histoplasmosis are endemic. The benefits and risks of HUMIRA treatment should be carefully considered before initiation of HUMIRA therapy.

 As observed with other TNF blocking agents, tuberculosis associated with the administration of HUMIRA in clinical trials has been reported. While cases were observed at all doses, the incidence of tuberculosis reactivations was particularly increased at doses of HUMIRA that were higher than the recommended dose.

 Before initiation of therapy with HUMIRA, patients should be evaluated for tuberculosis risk factors and should be tested for latent tuberculosis infection. Treatment of latent tuberculosis infections should be initiated prior to therapy with HUMIRA. When tuberculin skin testing is performed for latent tuberculosis infection, an induration size of 5 mm or greater should be considered positive, even if vaccinated previously with Bacille Calmette-Guerin (BCG). If latent infection is diagnosed, appropriate prophylaxis should be instituted in accordance with the current guidelines from the Centers for Disease Control and Prevention.

 

 Patients receiving HUMIRA should be monitored for signs and symptoms of active tuberculosis, particularly because tests for latent tuberculosis infection may be falsely negative. Patients should be instructed to seek medical advice if signs or symptoms (e.g., persistent cough, wasting, weight loss, low grade fever) suggestive of a tuberculosis infection occur.

5.2 Malignancies

 In the controlled portions of clinical trials of some TNF-blocking agents, including HUMIRA, more cases of malignancies have been observed among patients receiving those TNF blockers compared to control patients. During the controlled portions of HUMIRA trials in patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and Crohn’s disease, malignancies, other than lymphoma and non-melanoma skin cancer, were observed at a rate (95% confidence interval) of 0.6 (0.3, 1.0)/100 patient-years among 2887 HUMIRA-treated patients versus a rate of 0.4 (0.2, 1.1)/100 patient-years among 1570 control patients (median duration of treatment of 5.7 months for HUMIRA-treated patients and 5.5 months for control-treated patients). The size of the control group and limited duration of the controlled portions of studies precludes the ability to draw firm conclusions. In the controlled and uncontrolled open-label portions of the clinical trials of HUMIRA, the more frequently observed malignancies, other than lymphoma and non-melanoma skin cancer, were breast, colon, prostate, lung, and melanoma. These malignancies in HUMIRA-treated and control-treated patients were similar in type and number to what would be expected in the general population.1 During the controlled portions of HUMIRA rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and Crohn’s disease trials, the rate (95% confidence interval) of non-melanoma skin cancers was 0.8 (0.47, 1.24)/100 patient-years among HUMIRA-treated patients and 0.2 (0.05, 0.82)/100 patient-years among control patients. The potential role of TNF blocking therapy in the development of malignancies is not known.

 In the controlled portions of clinical trials of all the TNF-blocking agents, more cases of lymphoma have been observed among patients receiving TNF blockers compared to control patients. In controlled trials in patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and Crohn’s disease, 2 lymphomas were observed among 2887 HUMIRA-treated patients versus 1 among 1570 control patients. In combining the controlled and uncontrolled open-label portions of these clinical trials with a median duration of approximately 2 years, including 4843 patients and over 13,000 patient-years of therapy, the observed rate of lymphomas is approximately 0.12/100 patient-years. This is approximately 3.5-fold higher than expected in the general population.1 Rates in clinical trials for HUMIRA cannot be compared to rates of clinical trials of other TNF blockers and may not predict the rates observed in a broader patient population. Patients with rheumatoid arthritis, particularly those with highly active disease, are at a higher risk for the development of lymphoma.

5.3 Hypersensitivity Reactions

In postmarketing experience, anaphylaxis and angioneurotic edema have been reported rarely following HUMIRA administration. If an anaphylactic or other serious allergic reaction occurs, administration of HUMIRA should be discontinued immediately and appropriate therapy instituted. In clinical trials of HUMIRA, allergic reactions overall (e.g., allergic rash, anaphylactoid reaction, fixed drug reaction, non-specified drug reaction, urticaria) have been observed in approximately 1% of patients.

5.4 Hepatitis B Virus Reactivation

Use of TNF blockers, including HUMIRA, may increase the risk of reactivation of hepatitis B virus (HBV) in patients who are chronic carriers of this virus. In some instances, HBV reactivation occurring in conjunction with TNF blocker therapy has been fatal. The majority of these reports have occurred in patients concomitantly receiving other medications that suppress the immune system, which may also contribute to HBV reactivation. Patients at risk for HBV infection should be evaluated for prior evidence of HBV infection before initiating TNF blocker therapy. Prescribers should exercise caution in prescribing TNF blockers for patients identified as carriers of HBV. Adequate data are not available on the safety or efficacy of treating patients who are carriers of HBV with anti-viral therapy in conjunction with TNF blocker therapy to prevent HBV reactivation. Patients who are carriers of HBV and require treatment with TNF blockers should be closely monitored for clinical and laboratory signs of active HBV infection throughout therapy and for several months following termination of therapy. In patients who develop HBV reactivation, HUMIRA should be stopped and effective anti-viral therapy with appropriate supportive treatment should be initiated. The safety of resuming TNF blocker therapy after HBV reactivation is controlled is not known. Therefore, prescribers should exercise caution when considering resumption of HUMIRA therapy in this situation and monitor patients closely.

5.5 Neurologic Reactions

Use of TNF blocking agents, including HUMIRA, has been associated with rare cases of new onset or exacerbation of clinical symptoms and/or radiographic evidence of demyelinating disease. Prescribers should exercise caution in considering the use of HUMIRA in patients with preexisting or recent-onset central nervous system demyelinating disorders.

5.6 Hematological Reactions

Rare reports of pancytopenia including aplastic anemia have been reported with TNF blocking agents. Adverse reactions of the hematologic system, including medically significant cytopenia (e.g., thrombocytopenia, leukopenia) have been infrequently reported with HUMIRA [see Adverse Reactions ( 6)]. The causal relationship of these reports to HUMIRA remains unclear. All patients should be advised to seek immediate medical attention if they develop signs and symptoms suggestive of blood dyscrasias or infection (e.g., persistent fever, bruising, bleeding, pallor) while on HUMIRA. Discontinuation of HUMIRA therapy should be considered in patients with confirmed significant hematologic abnormalities.

5.7 Use with Anakinra

Serious infections were seen in clinical studies with concurrent use of anakinra (an interleukin-1 antagonist) and another TNF-blocking agent, with no added benefit. Because of the nature of the adverse reactions seen with this combination therapy, similar toxicities may also result from combination of anakinra and other TNF blocking agents. Therefore, the combination of HUMIRA and anakinra is not recommended [see Drug Interactions ( 7.1)].

5.8 Heart Failure

Cases of worsening congestive heart failure (CHF) and new onset CHF have been reported with TNF blockers. Cases of worsening CHF have also been observed with HUMIRA. HUMIRA has not been formally studied in patients with CHF; however, in clinical trials of another TNF blocker, a higher rate of serious CHF-related adverse reactions was observed. Physicians should exercise caution when using HUMIRA in patients who have heart failure and monitor them carefully.

5.9 Autoimmunity

Treatment with HUMIRA may result in the formation of autoantibodies and, rarely, in the development of a lupus-like syndrome. If a patient develops symptoms suggestive of a lupus-like syndrome following treatment with HUMIRA, treatment should be discontinued [see Adverse Reactions ( 6.1)].

5.10 Immunizations

 In a placebo-controlled clinical trial of patients with rheumatoid arthritis, no difference was detected in anti-pneumococcal antibody response between HUMIRA and placebo treatment groups when the pneumococcal polysaccharide vaccine and influenza vaccine were administered concurrently with HUMIRA. Similar proportions of patients developed protective levels of anti-influenza antibodies between HUMIRA and placebo treatment groups; however, titers in aggregate to influenza antigens were moderately lower in patients receiving HUMIRA. The clinical significance of this is unknown. Patients on HUMIRA may receive concurrent vaccinations, except for live vaccines. No data are available on the secondary transmission of infection by live vaccines in patients receiving HUMIRA.

5.11 Immunosuppression

The possibility exists for TNF blocking agents, including HUMIRA, to affect host defenses against infections and malignancies since TNF mediates inflammation and modulates cellular immune responses. In a study of 64 patients with rheumatoid arthritis treated with HUMIRA, there was no evidence of depression of delayed-type hypersensitivity, depression of immunoglobulin levels, or change in enumeration of effector T- and B-cells and NK-cells, monocyte/macrophages, and neutrophils. The impact of treatment with HUMIRA on the development and course of malignancies, as well as active and/or chronic infections, is not fully understood [see Warnings and Precautions ( 5.1, 5.2) and Adverse Reactions ( 6.1)]. The safety and efficacy of HUMIRA in patients with immunosuppression have not been evaluated.

6 ADVERSE REACTIONS

6.1 Clinical Studies Experience

The most serious adverse reactions were [see Warnings and Precautions ( 5)]:

The most common adverse reaction with HUMIRA was injection site reactions. In placebo-controlled trials, 20% of patients treated with HUMIRA developed injection site reactions (erythema and/or itching, hemorrhage, pain or swelling), compared to 14% of patients receiving placebo. Most injection site reactions were described as mild and generally did not necessitatedrug discontinuation.

The proportion of patients who discontinued treatment due to adverse reactions during the double-blind, placebo-controlled portion of Studies RA-I, RA-II, RA-III and RA-IV was 7% for patients taking HUMIRA and 4% for placebo-treated patients. The most common adverse reactions leading to discontinuation of HUMIRA were clinical flare reaction (0.7%), rash (0.3%) and pneumonia (0.3%).

Because clinical trials are conducted under widely varying and controlled conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not predict the rates observed in a broader patient population in clinical practice.

Infections

In placebo-controlled rheumatoid arthritis trials, the rate of infection was 1 per patient-year in the HUMIRA-treated patients and 0.9 per patient-year in the placebo-treated patients. The infections consisted primarily of upper respiratory tract infections, bronchitis and urinary tract infections. Most patients continued on HUMIRA after the infection resolved. The incidence of serious infections was 0.04 per patient-year in HUMIRA treated patients and 0.02 per patient-year in placebo-treated patients. Serious infections observed included pneumonia, septic arthritis, prosthetic and post-surgical infections, erysipelas, cellulitis, diverticulitis, and pyelonephritis [see Warnings and Precautions ( 5.1)].

Tuberculosis and Opportunistic Infections

In completed and ongoing global clinical studies that include over 13,000 patients, the overall rate of tuberculosis is approximately 0.26 per 100 patient-years. In over 4500 patients in the US and Canada, the rate is approximately 0.07 per 100 patient-years. These studies include reports of miliary, lymphatic, peritoneal, as well as pulmonary. Most of the cases of tuberculosis occurred within the first eight months after initiation of therapy and may reflect recrudescence of latent disease. Cases of opportunistic infections have also been reported in these clinical trials at an overall rate of approximately 0.075/100 patient-years. Some cases of opportunistic infections and tuberculosis have been fatal [see Warnings and Precautions ( 5.1)].

Malignancies

More cases of malignancy have been observed in HUMIRA-treated patients compared to control-treated patients in clinical trials [see Warnings and Precautions ( 5.2)].

Autoantibodies

In the rheumatoid arthritis controlled trials, 12% of patients treated with HUMIRA and 7% of placebo-treated patients that had negative baseline ANA titers developed positive titers at week 24. Two patients out of 3046 treated with HUMIRA developed clinical signs suggestive of new-onset lupus-like syndrome. The patients improved following discontinuation of therapy. No patients developed lupus nephritis or central nervous system symptoms. The impact of long-term treatment with HUMIRA on the development of autoimmune diseases is unknown.

Immunogenicity

Patients in Studies RA-I, RA-II, and RA-III were tested at multiple time points for antibodies to adalimumab during the 6- to 12-month period. Approximately 5% (58 of 1062) of adult rheumatoid arthritis patients receiving HUMIRA developed low-titer antibodies to adalimumab at least once during treatment, which were neutralizing in vitro. Patients treated with concomitant methotrexate had a lower rate of antibody development than patients on HUMIRA monotherapy (1% versus 12%). No apparent correlation of antibody development to adverse reactions was observed. With monotherapy, patients receiving every other week dosing may develop antibodies more frequently than those receiving weekly dosing. In patients receiving the recommended dosage of 40 mg every other week as monotherapy, the ACR 20 response was lower among antibody-positive patients than among antibody-negative patients. The long-term immunogenicity of HUMIRA is unknown.

In patients with ankylosing spondylitis, the rate of development of antibodies to adalimumab in HUMIRA-treated patients was comparable to patients with rheumatoid arthritis. In patients with psoriatic arthritis, the rate of antibody development in patients receiving HUMIRA monotherapy was comparable to patients with rheumatoid arthritis; however, in patients receiving concomitant methotrexate the rate was 7% compared to 1% in rheumatoid arthritis. In patients with Crohn's disease, the rate of antibody development was 2.6%.

The data reflect the percentage of patients whose test results were considered positive for antibodies to adalimumab in an ELISA assay, and 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 sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to adalimumab with the incidence of antibodies to other products may be misleading.

Other Adverse Reactions

The data described below reflect exposure to HUMIRA in 2468 patients, including 2073 exposed for 6 months, 1497 exposed for greater than one year and 1380 in adequate and well-controlled studies (Studies RA-I, RA-II, RA-III, and RA-IV). HUMIRA was studied primarily in placebo-controlled trials and in long-term follow up studies for up to 36 months duration. The population had a mean age of 54 years, 77% were female, 91% were Caucasian and had moderately to severely active rheumatoid arthritis. Most patients received 40 mg HUMIRA every other week.

Table 1 summarizes reactions reported at a rate of at least 5% in patients treated with HUMIRA 40 mg every other week compared to placebo and with an incidence higher than placebo. Adverse reaction rates in patients treated with HUMIRA 40 mg weekly were similar to rates in patients treated with HUMIRA 40 mg every other week. In Study RA-III, the types and frequencies of adverse reactions in the second year open-label extension were similar to those observed in the one-year double-blind portion.

Table 1: Adverse Reactions Reported by ≥5% of Patients Treated with HUMIRA During Placebo-Controlled Period of Rheumatoid Arthritis Studies
HUMIRA


40 mg subcutaneous


Every Other Week

Placebo
(N=705)(N=690)
Adverse Reaction (Preferred Term)PercentagePercentage
*  Laboratory test abnormalities were reported as adverse reactions in European trials

** Does not include erythema and/or itching, hemorrhage, pain or swelling

  Respiratory   
     Upper respiratory infection1713
     Sinusitis119
     Flu syndrome76
Gastrointestinal
     Nausea98
     Abdominal pain74
Laboratory Tests*
     Laboratory test abnormal87
     Hypercholesterolemia64
     Hyperlipidemia75
     Hematuria54
     Alkaline phosphatase increased53
Other
     Injection site pain1212
     Headache128
     Rash126
     Accidental injury108
     Injection site reaction **81
     Back pain64
     Urinary tract infection85
     Hypertension53

Other Adverse Reactions

Other infrequent serious adverse reactions occurring at an incidence of less than 5% in rheumatoid arthritis patients treated with HUMIRA were:

Body As A Whole: Fever, infection, pain in extremity, pelvic pain, sepsis, surgery, thorax pain, tuberculosis reactivated

Cardiovascular System: Arrhythmia, atrial fibrillation, cardiovascular disorder, chest pain, congestive heart failure, coronary artery disorder, heart arrest, hypertensive encephalopathy, myocardial infarct, palpitation, pericardial effusion, pericarditis, syncope, tachycardia, vascular disorder

Collagen Disorder: Lupus erythematosus syndrome

Digestive System: Cholecystitis, cholelithiasis, esophagitis, gastroenteritis, gastrointestinal disorder, gastrointestinal hemorrhage, hepatic necrosis, vomiting

Endocrine System: Parathyroid disorder

Hemic And Lymphatic System: Agranulocytosis, granulocytopenia, leukopenia, lymphoma like reaction, pancytopenia, polycythemia [see Warnings and Precautions ( 5.6)]

Metabolic And Nutritional Disorders: Dehydration, healing abnormal, ketosis, paraproteinemia, peripheral edema

Musculo-Skeletal System: Arthritis, bone disorder, bone fracture (not spontaneous), bone necrosis, joint disorder, muscle cramps, myasthenia, pyogenic arthritis, synovitis, tendon disorder

Neoplasia: Adenoma, carcinomas such as breast, gastrointestinal, skin, urogenital, and others; lymphoma and melanoma.

Nervous System: Confusion, multiple sclerosis, paresthesia, subdural hematoma, tremor

Respiratory System: Asthma, bronchospasm, dyspnea, lung disorder, lung function decreased, pleural effusion, pneumonia

Skin And Appendages: Cellulitis, erysipelas, herpes zoster

Special Senses: Cataract

Thrombosis: Thrombosis leg

Urogenital System: Cystitis, kidney calculus, menstrual disorder, pyelonephritis

Psoriatic Arthritis and Ankylosing Spondylitis Clinical Studies

HUMIRA has been studied in 395 patients with psoriatic arthritis in two placebo-controlled trials and in an open label study and in 393 patients with ankylosing spondylitis in two placebo-controlled studies. The safety profile for patients with psoriatic arthritis and ankylosing spondylitis treated with HUMIRA 40 mg every other week was similar to the safety profile seen in patients with rheumatoid arthritis, HUMIRA Studies RA-I through IV. In the clinical trials of patients with psoriatic arthritis and ankylosing spondylitis, elevations of aminotransferases were observed (ALT more common than AST) in a greater proportion of patients receiving HUMIRA than in controls, both when HUMIRA was given as monotherapy and when it was used in combination with other immunosuppressive agents. Most elevations of ALT and AST observed were in the range of 1.5 to 3 times the upper limit of normal. In general, patients who developed ALT and AST elevations were asymptomatic, and the abnormalities decreased or resolved with either continuation or discontinuation of HUMIRA, or modification of concomitant medications.

Crohn’s Disease Clinical Studies

HUMIRA has been studied in 1478 patients with Crohn’s disease in four placebo-controlled and two open-label extension studies. The safety profile for patients with Crohn’s disease treated with HUMIRA was similar to the safety profile seen in patients with rheumatoid arthritis.

6.2 Postmarketing Experience

Adverse reactions have been reported during post-approval use of HUMIRA. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to HUMIRA exposure.

Hematologic Reactions: Thrombocytopenia[see Warnings and Precautions ( 5.6)]

Hypersensitivity reactions: Anaphylaxis, angioneurotic edema [see Warnings and Precautions ( 5.3)]

Respiratory disorders: Interstitial lung disease, including pulmonary fibrosis.

Skin reactions: cutaneous vasculitis, erythema multiforme

7 DRUG INTERACTIONS

7.1 Anakinra

Concurrent administration of anakinra (an interleukin-1 antagonist) and another TNF-blocking agent has been associated with an increased risk of serious infections, an increased risk of neutropenia and no additional benefit compared to these medicinal products alone. Therefore, the combination of anakinra with other TNF-blocking agents, including HUMIRA, may also result in similar toxicities [see Warnings and Precautions ( 5.7)].

7.2 Live Vaccines

Live vaccines should not be given concurrently with HUMIRA [see Warnings and Precautions ( 5.10)].

7.3 Methotrexate

Humira has been studied in rheumatoid arthritis patients taking concomitant methotrexate. Although methotrexate reduced the apparent adalimumab clearance [see Clinical Pharmacology ( 12.3)], the data do not suggest the need for dose adjustment of either HUMIRA or methotrexate.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category B - An embryo-fetal perinatal developmental toxicity study has been performed in cynomolgus monkeys at dosages up to 100 mg/kg (266 times human AUC when given 40 mg subcutaneously with methotrexate every week or 373 times human AUC when given 40 mg subcutaneously without methotrexate) and has revealed no evidence of harm to the fetuses due to adalimumab. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction and developmental studies are not always predictive of human response, HUMIRA should be used during pregnancy only if clearly needed.

Pregnancy Registry: To monitor outcomes of pregnant women exposed to HUMIRA, a pregnancy registry has been established. Physicians are encouraged to register patients by calling 1-877-311-8972.

8.3 Nursing Mothers

It is not known whether adalimumab is excreted in human milk or absorbed systemically after ingestion. Because many drugs and immunoglobulins are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from HUMIRA, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

8.4 Pediatric Use

Safety and effectiveness of HUMIRA in pediatric patients have not been established.

8.5 Geriatric Use

A total of 519 rheumatoid arthritis patients 65 years of age and older, including 107 patients 75 years and older, received HUMIRA in clinical studies RA-I through IV. No overall difference in effectiveness was observed between these subjects and younger subjects. The frequency of serious infection and malignancy among HUMIRA treated subjects over age 65 was higher than for those under age 65. Because there is a higher incidence of infections and malignancies in the elderly population in general, caution should be used when treating the elderly.

10 OVERDOSAGE

Doses up to 10 mg/kg have been administered to patients in clinical trials without evidence of dose-limiting toxicities. In case of overdosage, it is recommended that the patient be monitored for any signs or symptoms of adverse reactions or effects and appropriate symptomatic treatment instituted immediately.

11 DESCRIPTION

HUMIRA (adalimumab) is a recombinant human IgG1 monoclonal antibody specific for human tumor necrosis factor (TNF). HUMIRA was created using phage display technology resulting in an antibody with human derived heavy and light chain variable regions and human IgG1:қ constant regions. Adalimumab is produced by recombinant DNA technology in a mammalian cell expression system and is purified by a process that includes specific viral inactivation and removal steps. It consists of 1330 amino acids and has a molecular weight of approximately 148 kilodaltons.

HUMIRA is supplied as a sterile, preservative-free solution of adalimumab for subcutaneous administration. The drug product is supplied as either a single-use, prefilled pen (HUMIRA Pen) or as a single-use, 1 mL prefilled glass syringe. Enclosed within the pen is a single-use, 1 mL prefilled glass syringe. The solution of HUMIRA is clear and colorless, with a pH of about 5.2. Each syringe delivers 0.8 mL (40 mg) of drug product. Each 0.8 mL of HUMIRA contains 40 mg adalimumab, 4.93 mg sodium chloride, 0.69 mg monobasic sodium phosphate dihydrate, 1.22 mg dibasic sodium phosphate dihydrate, 0.24 mg sodium citrate, 1.04 mg citric acid monohydrate, 9.6 mg mannitol, 0.8 mg polysorbate 80, and Water for Injection, USP. Sodium hydroxide added as necessary to adjust pH.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Adalimumab binds specifically to TNF-alpha and blocks its interaction with the p55 and p75 cell surface TNF receptors. Adalimumab also lyses surface TNF expressing cells in vitro in the presence of complement. Adalimumab does not bind or inactivate lymphotoxin (TNF-beta). TNF is a naturally occurring cytokine that is involved in normal inflammatory and immune responses. Elevated levels of TNF are found in the synovial fluid of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis patients and play an important role in both the pathologic inflammation and the joint destruction that are hallmarks of these diseases.

Adalimumab also modulates biological responses that are induced or regulated by TNF, including changes in the levels of adhesion molecules responsible for leukocyte migration (ELAM-1, VCAM-1, and ICAM-1 with an IC50 of 1-2 X 10-10M).

12.2 Pharmacodynamics

After treatment with HUMIRA, a decrease in levels of acute phase reactants of inflammation (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) and serum cytokines (IL-6) was observed compared to baseline in patients with rheumatoid arthritis. A decrease in CRP levels was also observed in patients with Crohn’s disease. Serum levels of matrix metalloproteinases (MMP-1 and MMP-3) that produce tissue remodeling responsible for cartilage destruction were also decreased after HUMIRA administration.

12.3 Pharmacokinetics

The maximum serum concentration (Cmax) and the time to reach the maximum concentration (Tmax) were 4.7 ± 1.6 µg/mL and 131 ± 56 hours respectively, following a single 40 mg subcutaneous administration of HUMIRA to healthy adult subjects. The average absolute bioavailability of adalimumab estimated from three studies following a single 40 mg subcutaneous dose was 64%. The pharmacokinetics of adalimumab were linear over the dose range of 0.5 to 10.0 mg/kg following a single intravenous dose.

The single dose pharmacokinetics of adalimumab in rheumatoid arthritis (RA) patients were determined in several studies with intravenous doses ranging from 0.25 to 10 mg/kg. The distribution volume (Vss) ranged from 4.7 to 6.0 L. The systemic clearance of adalimumab is approximately 12 mL/hr. The mean terminal half-life was approximately 2 weeks, ranging from 10 to 20 days across studies. Adalimumab concentrations in the synovial fluid from five rheumatoid arthritis patients ranged from 31 to 96% of those in serum.

In RA patients receiving 40 mg HUMIRA every other week, adalimumab mean steady-state trough concentrations of approximately 5 µg/mL and 8 to 9 µg/mL, were observed without and with methotrexate (MTX), respectively. MTX reduced adalimumab apparent clearance after single and multiple dosing by 29% and 44% respectively, in patients with RA. Mean serum adalimumab trough levels at steady state increased approximately proportionally with dose following 20, 40, and 80 mg every other week and every week subcutaneous dosing. In long-term studies with dosing more than two years, there was no evidence of changes in clearance over time.

Adalimumab mean steady-state trough concentrations were slightly higher in psoriatic arthritis patients treated with 40 mg HUMIRA every other week (6 to 10 µg/mL and 8.5 to 12 µg/mL, without and with MTX, respectively) compared to the concentrations in RA patients treated with the same dose.

The pharmacokinetics of adalimumab in patients with ankylosing spondylitis were similar to those in patients with RA.

In patients with Crohn’s disease, the loading dose of 160 mg HUMIRA on Week 0 followed by 80 mg HUMIRA on Week 2 achieves mean serum adalimumab trough levels of approximately 12 µg/mL at Week 2 and Week 4. Mean steady-state trough levels of approximately 7 µg/mL were observed at Week 24 and Week 56 in Crohn’s disease patients after receiving a maintenance dose of 40 mg HUMIRA every other week.

Population pharmacokinetic analyses in patients with RA revealed that there was a trend toward higher apparent clearance of adalimumab in the presence of anti-adalimumab antibodies, and lower clearance with increasing age in patients aged 40 to >75 years.

Minor increases in apparent clearance were also predicted in RA patients receiving doses lower than the recommended dose and in RA patients with high rheumatoid factor or CRP concentrations. These increases are not likely to be clinically important.

No gender-related pharmacokinetic differences were observed after correction for a patient’s body weight. Healthy volunteers and patients with rheumatoid arthritis displayed similar adalimumab pharmacokinetics.

No pharmacokinetic data are available in patients with hepatic or renal impairment.

HUMIRA has not been studied in children.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term animal studies of HUMIRA have not been conducted to evaluate the carcinogenic potential or its effect on fertility. No clastogenic or mutagenic effects of HUMIRA were observed in the in vivo mouse micronucleus test or the Salmonella-Escherichia coli (Ames) assay, respectively.

14 CLINICAL STUDIES

14.1 Rheumatoid Arthritis

The efficacy and safety of HUMIRA were assessed in five randomized, double-blind studies in patients ≥ age 18 with active rheumatoid arthritis diagnosed according to American College of Rheumatology (ACR) criteria. Patients had at least 6 swollen and 9 tender joints. HUMIRA was administered subcutaneously in combination with methotrexate (MTX) (12.5 to 25 mg, Studies RA-I, RA-III and RA-V) or as monotherapy (Studies RA-II and RA-V) or with other disease-modifying anti-rheumatic drugs (DMARDs) (Study RA-IV).

Study RA-I evaluated 271 patients who had failed therapy with at least one but no more than four DMARDs and had inadequate response to MTX. Doses of 20, 40 or 80 mg of HUMIRA or placebo were given every other week for 24 weeks.

Study RA-II evaluated 544 patients who had failed therapy with at least one DMARD. Doses of placebo, 20 or 40 mg of HUMIRA were given as monotherapy every other week or weekly for 26 weeks.

Study RA-III evaluated 619 patients who had an inadequate response to MTX. Patients received placebo, 40 mg of HUMIRA every other week with placebo injections on alternate weeks, or 20 mg of HUMIRA weekly for up to 52 weeks. Study RA-III had an additional primary endpoint at 52 weeks of inhibition of disease progression (as detected by X-ray results). Upon completion of the first 52 weeks, 457 patients enrolled in an open-label extension phase in which 40 mg of HUMIRA was administered every other week for up to 5 years.

Study RA-IV assessed safety in 636 patients who were either DMARD-naive or were permitted to remain on their pre-existing rheumatologic therapy provided that therapy was stable for a minimum of 28 days. Patients were randomized to 40 mg of HUMIRA or placebo every other week for 24 weeks.

Study RA-V evaluated 799 patients with moderately to severely active rheumatoid arthritis of less than 3 years duration who were ≥18 years old and MTX naïve. Patients were randomized to receive either MTX (optimized to 20 mg/week by week 8), HUMIRA 40 mg every other week or HUMIRA/MTX combination therapy for 104 weeks. Patients were evaluated for signs and symptoms, and for radiographic progression of joint damage. The median disease duration among patients enrolled in the study was 5 months. The median MTX dose achieved was 20 mg.

Clinical Response

The percent of HUMIRA treated patients achieving ACR 20, 50 and 70 responses in Studies RA-II and III are shown in Table 2.

Table 2: ACR Responses in Studies RA-II and RA-III (Percent of Patients)
Study RA-II
Monotherapy
(26 weeks)
Study RA-III
Methotrexate Combination
(24 and 52 weeks)
* p<0.01, HUMIRA vs. placebo
ResponsePlaceboHUMIRA 40 mgHUMIRAPlacebo/MTXHUMIRA/MTX
every other week40 mg weekly40 mg every
other week
N=110N=113N=103N=200N=207
ACR20
Month 619%46%*53%*30%63%*
Month 12NANANA24%59%*
ACR50
Month 68%22%*35%*10%39%*
Month 12NANANA10%42%*
ACR70
Month 62%12%*18%*3%21%*
Month 12NANANA5%23%*

The results of Study RA-I were similar to Study RA-III; patients receiving HUMIRA 40 mg every other week in Study RA-I also achieved ACR 20, 50 and 70 response rates of 65%, 52% and 24%, respectively, compared to placebo responses of 13%, 7% and 3% respectively, at 6 months (p<0.01).

The results of the components of the ACR response criteria for Studies RA-II and RA-III are shown in Table 3. ACR response rates and improvement in all components of ACR response were maintained to week 104. Over the 2 years in Study RA-III, 20% of HUMIRA patients receiving 40 mg every other week (every other week) achieved a major clinical response, defined as maintenance of an ACR 70 response over a 6-month period.

ACR responses were maintained in similar proportions of patients for up to 5 years with continuous HUMIRA treatment in the open-label portion of Study RA-III.

Table 3: Components of ACR Response in Studies RA-II and RA-III
Study RA-IIStudy RA-III
a
40 mg HUMIRA administered every other week
b
Visual analogue scale; 0 = best, 10 = worst
c
Disability Index of the Health Assessment Questionnaire; 0 = best, 3 = worst, measures the patient’s ability to perform the following: dress/groom, arise, eat, walk, reach, grip, maintain hygiene, and maintain daily activity
*
p<0.001, HUMIRA vs. placebo, based on mean change from baseline
Parameter (median)Placebo
N=110
HUMIRAa
N=113
Placebo/MTX
N=200
HUMIRAa/MTX N=207
BaselineWk 26BaselineWk 26BaselineWk 24BaselineWk 24
Number of tender joints (0-68)35263116*2615248*
Number of swollen joints (0-66)19161810*1711185*
Physician global assessmentb7.06.16.63.7*6.33.56.52.0*
Patient global assessmentb7.56.37.54.5*5.43.95.22.0*
Painb7.36.17.34.1*6.03.85.82.1*
Disability index (HAQ)c2.01.91.91.5*1.51.31.50.8*
CRP (mg/dL)3.94.34.61.8*1.00.91.00.4*

The time course of ACR 20 response for Study RA-III is shown in Figure 1.

In Study RA-III, 85% of patients with ACR 20 responses at week 24 maintained the response at 52 weeks. The time course of ACR 20 response for Study RA-I and Study RA-II were similar.

Figure 1: Study RA-III ACR 20 Responses over 52 Weeks

Image from Drug Label Content

In Study RA-IV, 53% of patients treated with HUMIRA 40 mg every other week plus standard of care had an ACR 20 response at week 24 compared to 35% on placebo plus standard of care (p<0.001). No unique adverse reactions related to the combination of HUMIRA (adalimumab) and other DMARDs were observed.

In Study RA-V with MTX naïve patients with recent onset rheumatoid arthritis, the combination treatment with HUMIRA plus MTX led to greater percentages of patients achieving ACR responses than either MTX monotherapy or HUMIRA monotherapy at Week 52 and responses were sustained at Week 104 (see Table 4).

Table 4: ACR Response in Study RA-V (Percent of Patients)
ResponseMTXb
N=257
HUMIRAc
N=274
HUMIRA/MTX
N=268
a
Major clinical response is defined as achieving an ACR70 response for a continuous six month period
b
p<0.05, HUMIRA/MTX vs. MTX for ACR 20
p<0.001, HUMIRA/MTX vs. MTX for ACR 50 and 70, and Major Clinical Response
c
p<0.001, HUMIRA/MTX vs. HUMIRA
ACR20
Week 52

Week 104

63%
56%

54%
49%

73%
69%
ACR50
Week 52

Week 104

46%
43%

41%
37%

62%
59%
ACR70
Week 52

Week 104

27%
28%

26%
28%

46%
47%
Major Clinical Response a28%25%49%

At Week 52, all individual components of the ACR response criteria for Study RA-V improved in the HUMIRA/MTX group and improvements were maintained to Week 104.

Radiographic Response

In Study RA-III, structural joint damage was assessed radiographically and expressed as change in Total Sharp Score (TSS) and its components, the erosion score and Joint Space Narrowing (JSN) score, at month 12 compared to baseline. At baseline, the median TSS was approximately 55 in the placebo and 40 mg every other week groups. The results are shown in Table 5. HUMIRA/MTX treated patients demonstrated less radiographic progression than patients receiving MTX alone at 52 weeks.

Table 5: Radiographic Mean Changes Over 12 Months in Study RA-III
Placebo/MTXHUMIRA/MTX
40 mg every other week
Placebo/MTX-HUMIRA/MTX
(95% Confidence Interval*)
P-value**
*95% confidence intervals for the differences in change scores between MTX and HUMIRA.
**Based on rank analysis
Total Sharp score2.70.12.6 (1.4, 3.8)<0.001
Erosion score1.60.01.6 (0.9, 2.2)<0.001
JSN score1.00.10.9 (0.3, 1.4)0.002

In the open-label extension of Study RA-III, 77% of the original patients treated with any dose of HUMIRA were evaluated radiographically at 2 years. Patients maintained inhibition of structural damage, as measured by the TSS. Fifty-four percent had no progression of structural damage as defined by a change in the TSS of zero or less.

Fifty-five percent (55%) of patients originally treated with 40 mg HUMIRA every other week have been evaluated radiographically at 5 years. Patients had continued inhibition of structural damage with 50% showing no progression of structural damage defined by a change in the TSS of zero or less.

In Study RA-V, structural joint damage was assessed as in Study RA-III. Greater inhibition of radiographic progression, as assessed by changes in TSS, erosion score and JSN was observed in the HUMIRA/MTX combination group as compared to either the MTX or HUMIRA monotherapy group at Week 52 as well as at Week 104 (see Table 6).

Table 6: Radiographic Mean Change* in Study RA-V
MTXa
N=257
HUMIRAa,b
N=274
HUMIRA/MTX
N=268
*
mean (95% confidence interval)
a
p<0.001, HUMIRA/MTX vs. MTX at 52 and 104 weeks and for HUMIRA/MTX vs. HUMIRA at 104 weeks
b
p<0.01, for HUMIRA/MTX vs. HUMIRA at 52 weeks
52 WeeksTotal Sharp score5.7 (4.2, 7.3)3.0 (1.7, 4.3)1.3 (0.5, 2.1)
Erosion score3.7 (2.7, 4.8)1.7 (1.0, 2.4)0.8 (0.4, 1.2)
JSN score2.0 (1.2, 2.8)1.3 (0.5, 2.1)0.5 (0.0, 1.0)
104 WeeksTotal Sharp score10.4 (7.7, 13.2)5.5 (3.6, 7.4)1.9 (0.9, 2.9)
Erosion score6.4 (4.6, 8.2)3.0 (2.0, 4.0)1.0 (0.4, 1.6)
JSN score4.1 (2.7, 5.4)2.6 (1.5, 3.7)0.9 (0.3, 1.5)

Physical Function Response

In studies RA-I through IV, HUMIRA showed significantly greater improvement than placebo in the disability index of Health Assessment Questionnaire (HAQ-DI) from baseline to the end of study, and significantly greater improvement than placebo in the health-outcomes as assessed by The Short Form Health Survey (SF 36). Improvement was seen in both the Physical Component Summary (PCS) and the Mental Component Summary (MCS).

In Study RA-III, the mean (95% CI) improvement in HAQ-DI from baseline at week 52 was 0.60 (0.55, 0.65) for the HUMIRA patients and 0.25 (0.17, 0.33) for placebo/MTX (p<0.001) patients. Sixty-three percent of HUMIRA-treated patients achieved a 0.5 or greater improvement in HAQ-DI at week 52 in the double-blind portion of the study. Eighty-two percent of these patients maintained that improvement through week 104 and a similar proportion of patients maintained this response through week 260 (5 years) of open label treatment. Mean improvement in the SF-36 was maintained through the end of measurement at week 156 (3 years).

In Study RA-V, the HAQ-DI and the physical component of the SF-36 showed greater improvement (p<0.001) for the HUMIRA/MTX combination therapy group versus either the MTX monotherapy or the HUMIRA monotherapy group at Week 52, which was maintained through Week 104.

14.2 Psoriatic Arthritis

The safety and efficacy of HUMIRA was assessed in two randomized, double-blind, placebo controlled studies in 413 patients with psoriatic arthritis. Upon completion of both studies, 383 patients enrolled in an open-label extension study, in which 40 mg HUMIRA was administered every other week.

Study PsA-I enrolled 313 adult patients with moderately to severely active psoriatic arthritis (>3 swollen and >3 tender joints) who had an inadequate response to NSAID therapy in one of the following forms: (1) distal interphalangeal (DIP) involvement (N=23); (2) polyarticular arthritis (absence of rheumatoid nodules and presence of psoriasis) (N=210); (3) arthritis mutilans (N=1); (4) asymmetric psoriatic arthritis (N=77); or (5) ankylosing spondylitis-like (N=2). Patients on MTX therapy (158 of 313 patients) at enrollment (stable dose of ≤30 mg/week for >1 month) could continue MTX at the same dose. Doses of HUMIRA 40 mg or placebo every other week were administered during the 24-week double-blind period of the study.

Compared to placebo, treatment with HUMIRA resulted in improvements in the measures of disease activity (see Tables 7 and 8). Among patients with psoriatic arthritis who received HUMIRA, the clinical responses were apparent in some patients at the time of the first visit (two weeks) and were maintained up to 88 weeks in the ongoing open-label study. Similar responses were seen in patients with each of the subtypes of psoriatic arthritis, although few patients were enrolled with the arthritis mutilans and ankylosing spondylitis-like subtypes. Responses were similar in patients who were or were not receiving concomitant MTX therapy at baseline.

Patients with psoriatic involvement of at least three percent body surface area (BSA) were evaluated for Psoriatic Area and Severity Index (PASI) responses. At 24 weeks, the proportions of patients achieving a 75% or 90% improvement in the PASI were 59% and 42% respectively, in the HUMIRA group (N=69), compared to 1% and 0% respectively, in the placebo group (N=69) (p<0.001). PASI responses were apparent in some patients at the time of the first visit (two weeks). Responses were similar in patients who were or were not receiving concomitant MTX therapy at baseline.

Table 7: ACR Response in Study PsA-I (Percent of Patients)
ResponsePlacebo
N=162
HUMIRA*
N=151
*
p<0.001 for all comparisons between HUMIRA and placebo
ACR20
Week 12

Week 24

14%
15%

58%
57%
ACR50
Week 12

Week 24

4%
6%

36%
39%
ACR70
Week 12

Week 24

1%
1%

20%
23%
Table 8: Components of Disease Activity in Study PsA-I
Placebo
N=162
HUMIRA*
N=151
*
p<0.001 for HUMIRA vs. placebo comparisons based on median changes
a
Scale 0-78
b
Scale 0-76
c
Visual analog scale; 0=best, 100=worst
d
Disability Index of the Health Assessment Questionnaire; 0=best, 3=worst; measures the patient’s ability to perform the following: dress/groom, arise, eat, walk, reach, grip, maintain hygiene, and maintain daily activity.
e
Normal range: 0-0.287 mg/dL
Parameter: medianBaseline24 weeksBaseline24 weeks
Number of tender jointsa23.017.020.05.0
Number of swollen jointsb11.09.011.03.0
Physician global assessmentc53.049.055.016.0
Patient global assessmentc49.549.048.020.0
Painc49.049.054.020.0
Disability index (HAQ) d1.00.91.00.4
CRP (mg/dL)e0.80.70.80.2

Similar results were seen in an additional, 12-week study in 100 patients with moderate to severe psoriatic arthritis who had suboptimal response to DMARD therapy as manifested by ≥3 tender joints and ≥3 swollen joints at enrollment.

Radiographic Response

Radiographic changes were assessed in the psoriatic arthritis studies. Radiographs of hands, wrists, and feet were obtained at baseline and Week 24 during the double-blind period when patients were on HUMIRA or placebo and at Week 48 when all patients were on open-label HUMIRA. A modified Total Sharp Score (mTSS), which included distal interphalangeal joints (i.e., not identical to the TSS used for rheumatoid arthritis), was used by readers blinded to treatment group to assess the radiographs.

HUMIRA-treated patients demonstrated greater inhibition of radiographic progression compared to placebo-treated patients and this effect was maintained at 48 weeks (see Table 9).

Table 9: Change in Modified Total Sharp Score in Psoriatic Arthritis
Placebo

N=141

HUMIRA

N=133

Week 24Week 24Week 48
* <0.001 for the difference between HUMIRA, Week 48 and Placebo, Week 24 (primary analysis)
Baseline mean22.123.423.4
Mean Change ± SD0.9 ± 3.1-0.1 ± 1.7-0.2 ± 4.9*

Physical Function Response

In Study PsA-I, physical function and disability were assessed using the HAQ Disability Index (HAQ-DI) and the SF-36 Health Survey. Patients treated with 40 mg of HUMIRA every other week showed greater improvement from baseline in the HAQ-DI score (mean decreases of 47% and 49% at Weeks 12 and 24 respectively) in comparison to placebo (mean decreases of 1% and 3% at Weeks 12 and 24 respectively). At Weeks 12 and 24, patients treated with HUMIRA showed greater improvement from baseline in the SF-36 Physical Component Summary score compared to patients treated with placebo, and no worsening in the SF-36 Mental Component Summary score. Improvement in physical function based on the HAQ-DI was maintained for up to 84 weeks through the open-label portion of the study.

14.3 Ankylosing Spondylitis

The safety and efficacy of HUMIRA 40 mg every other week was assessed in 315 adult patients in a randomized, 24 week double-blind, placebo-controlled study in patients with active ankylosing spondylitis (AS) who had an inadequate response to glucocorticoids, NSAIDs, analgesics, methotrexate or sulfasalazine. Active AS was defined as patients who fulfilled at least two of the following three criteria: (1) a Bath AS disease activity index (BASDAI) score ≥4 cm, (2) a visual analog score (VAS) for total back pain ≥ 40 mm, and (3) morning stiffness ≥ 1 hour. The blinded period was followed by an open-label period during which patients received HUMIRA 40 mg every other week subcutaneously for up to an additional 28 weeks.

Improvement in measures of disease activity was first observed at Week 2 and maintained through 24 weeks as shown in Figure 2 and Table 10.

Responses of patients with total spinal ankylosis (n=11) were similar to those without total ankylosis.

Figure 2: ASAS 20 Response By Visit, Study AS-I

Image from Drug Label Content

At 12 weeks, the ASAS 20/50/70 responses were achieved by 58%, 38%, and 23%, respectively, of patients receiving HUMIRA, compared to 21%, 10%, and 5% respectively, of patients receiving placebo (p <0.001). Similar responses were seen at Week 24 and were sustained in patients receiving open-label HUMIRA for up to 52 weeks.

A greater proportion of patients treated with HUMIRA (22%) achieved a low level of disease activity at 24 weeks (defined as a value <20 [on a scale of 0 to 100 mm] in each of the four ASAS response parameters) compared to patients treated with placebo (6%).

Table 10:  Components of Ankylosing Spondylitis Disease Activity
Placebo
N=107
HUMIRA
N=208
a
Percent of subjects with at least a 20% and 10-unit improvement measured on a Visual Analog Scale (VAS) with 0 = “none” and 100 = “severe”
b
mean of questions 5 and 6 of BASDAI (defined in ‘d’)
c
Bath Ankylosing Spondylitis Functional Index
d
Bath Ankylosing Spondylitis Disease Activity Index
e
Bath Ankylosing Spondylitis Metrology Index
f
C-Reactive Protein (mg/dL)
*
statistically significant for comparisons between HUMIRA and placebo at Week 24
Baseline meanWeek 24 meanBaseline meanWeek 24 mean
ASAS 20 Response Criteria*
     Patient’s Global Assessment of Disease Activitya*65606338
     Total back pain*67586537
     Inflammationb*6.75.66.73.6
     BASFIc*56515234
BASDAIdscore*6.35.56.33.7
BASMIe score*4.24.13.83.3
     Tragus to wall (cm)15.915.815.815.4
     Lumbar flexion (cm)4.14.04.24.4
     Cervical rotation (degrees)42.242.148.451.6
     Lumbar side flexion (cm)8.99.09.711.7
     Intermalleolar distance (cm)92.994.093.5100.8
CRPf*2.22.01.80.6

A second randomized, multicenter, double-blind, placebo-controlled study of 82 patients with ankylosing spondylitis showed similar results.

Patients treated with HUMIRA achieved improvement from baseline in the Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) score (-3.6 vs. -1.1) and in the Short Form Health Survey (SF-36) Physical Component Summary (PCS) score (7.4 vs. 1.9) compared to placebo-treated patients at Week 24.

14.4 Crohn’s Disease

The safety and efficacy of multiple doses of HUMIRA were assessed in adult patients with moderately to severely active Crohn’s disease (Crohn’s Disease Activity Index (CDAI) ≥ 220 and ≤ 450) in randomized, double-blind, placebo-controlled studies. Concomitant stable doses of aminosalicylates, corticosteroids, and/or immunomodulatory agents were permitted, and 79% of patients continued to receive at least one of these medications.

Induction of clinical remission (defined as CDAI < 150) was evaluated in two studies. In Study CD-I, 299 TNF-blocker naïve patients were randomized to one of four treatment groups: the placebo group received placebo at Weeks 0 and 2, the 160/80 group received 160 mg HUMIRA at Week 0 and 80 mg at Week 2, the 80/40 group received 80 mg at Week 0 and 40 mg at Week 2, and the 40/20 group received 40 mg at Week 0 and 20 mg at Week 2. Clinical results were assessed at Week 4.

In the second induction study, Study CD-II, 325 patients who had lost response to, or were intolerant to, previous infliximab therapy were randomized to receive either 160 mg HUMIRA at Week 0 and 80 mg at Week 2, or placebo at Weeks 0 and 2. Clinical results were assessed at Week 4.

Maintenance of clinical remission was evaluated in Study CD-III. In this study, 854 patients with active disease received open-label HUMIRA, 80 mg at week 0 and 40 mg at Week 2. Patients were then randomized at Week 4 to 40 mg HUMIRA every other week, 40 mg HUMIRA every week, or placebo. The total study duration was 56 weeks. Patients in clinical response (decrease in CDAI ≥70) at Week 4 were stratified and analyzed separately from those not in clinical response at Week 4.

Induction of Clinical Remission

A greater percentage of the patients treated with 160/80 mg HUMIRA achieved induction of clinical remission versus placebo at Week 4 regardless of whether the patients were TNF blocker naïve (CD-I), or had lost response to or were intolerant to infliximab (CD-II) (see Table 11).

Table 11: Induction of Clinical Remission in Studies CD-I and CD-II (Percent of Patients)
CD-ICD-II

Clinical remission is CDAI score < 150; clinical response is decrease in CDAI of at least 70 points.

*
p<0.001 for HUMIRA vs. placebo pairwise comparison of proportions
**
p<0.01 for HUMIRA vs. placebo pairwise comparison of proportions
Placebo
N=74
HUMIRA 160/80 mg
N=76
Placebo
N=166
HUMIRA 160/80 mg
N=159
Week 4
Clinical remission12%36%*7%21%*
Clinical response34%58%**34%52%**

Maintenance of Clinical Remission

In Study CD-III at Week 4, 58% (499/854) of patients were in clinical response and were assessed in the primary analysis. At Weeks 26 and 56, greater proportions of patients who were in clinical response at Week 4 achieved clinical remission in the HUMIRA 40 mg every other week maintenance group compared to patients in the placebo maintenance group (see Table 12). The group that received HUMIRA therapy every week did not demonstrate significantly higher remission rates compared to the group that received HUMIRA every other week.

Table 12: Maintenance of Clinical Remission in CD-III (Percent of Patients)
Placebo40 mg HUMIRA
every other week
N=170N=172

Clinical remission is CDAI score < 150; clinical response is decrease in CDAI of at least 70 points.

*
p<0.001 for HUMIRA vs. placebo pairwise comparisons of proportions
Week 26
Clinical remission17%40%*
Clinical response28%54%*
Week 56
Clinical remission12%36%*
Clinical response18%43%*

Of those in response at Week 4 who attained remission during the study, patients in the HUMIRA every other week group maintained remission for a longer time than patients in the placebo maintenance group. Among patients who were not in response by Week 12, therapy continued beyond 12 weeks did not result in significantly more responses.

15 REFERENCES

  1. National Cancer Institute. Surveillance, Epidemiology, and End Results Database (SEER) Program. SEER Incidence Crude Rates, 11 Registries, 1993-2001.

16 HOW SUPPLIED/STORAGE AND HANDLING

HUMIRA® (adalimumab) is supplied in prefilled syringes as a preservative-free, sterile solution for subcutaneous administration. The following packaging configurations are available.

HUMIRA is dispensed in a carton containing two alcohol preps and two dose trays. Each dose tray consists of a single-use pen, containing a 1 mL prefilled glass syringe with a fixed 27 gauge½ inch needle, providing 40 mg (0.8 mL) of HUMIRA. The NDC number is 0074-4339-02.

HUMIRA is dispensed in a carton containing 6 alcohol preps and 6 dose trays (Crohn’s Disease Starter Package). Each dose tray consists of a single-use pen, containing a 1 mL prefilled glass syringe with a fixed 27 gauge½ inch needle, providing 40 mg (0.8 mL) of HUMIRA. The NDC number is 0074-4339-06.

HUMIRA is dispensed in a carton containing two alcohol preps and two dose trays. Each dose tray consists of a single-use, 1 mL prefilled glass syringe with a fixed 27 gauge ½ inch needle, providing 40 mg (0.8 mL) of HUMIRA. The NDC number is 0074-3799-02.

Do not use beyond the expiration date on the container. HUMIRA must be refrigerated at 2 to 8° C (36 to 46° F). DO NOT FREEZE. Protect the prefilled syringe from exposure to light. Store in original carton until time of administration.

17 PATIENT COUNSELING INFORMATION

See FDA-Approved Patient Labeling ( 17.3)

17.1 Patient Counseling

Patients should be advised of the potential benefits and risks of HUMIRA. Physicians should instruct their patients to read the Patient Package Insert before starting HUMIRA therapy and to reread each time the prescription is renewed.

17.2 Instruction on Injection Technique

The first injection should be performed under the supervision of a qualified health care professional. If a patient or caregiver is to administer HUMIRA, he/she should be instructed in injection techniques and their ability to inject subcutaneously should be assessed to ensure the proper administration of HUMIRA [see Patient Counseling Information ( 17.3)].

A puncture-resistant container for disposal of needles and syringes should be used. Patients or caregivers should be instructed in the technique as well as proper syringe and needle disposal, and be cautioned against reuse of these items.

17.3 FDA-Approved Patient Labeling

HUMIRA®  (HU-MARE-AH)

(adalimumab)

Patient Information

Read the Patient Information that comes with HUMIRA before you start taking it and each time you get a refill. There may be new information. This leaflet does not take the place of talking with your doctor about your medical condition or treatment with HUMIRA.

What is the most important information I should know about HUMIRA?

HUMIRA is a medicine that affects your immune system. HUMIRA can lower the ability of your immune system to fight infections. Serious infections, including tuberculosis (TB) have happened in patients receiving HUMIRA. Some patients have died from these infections.

Before starting HUMIRA, tell your doctor if you:

After starting HUMIRA, if you get an infection, any sign of an infection including a fever, cough, flu-like symptoms, or have any open cuts or sores on your body, call your doctor right away.

HUMIRA can make you more likely to get infections or make any infection that you may have worse.

What is HUMIRA?

HUMIRA is a medicine called a Tumor Necrosis Factor (TNF) blocker. HUMIRA is used in adults to reduce the signs and symptoms of:

People with these diseases have too much protein called tumor necrosis factor (TNF), which is made by the body’s immune system. HUMIRA can reduce the amount of TNF in the body and block the damage that too much TNF can cause, but it can also lower the ability of the immune system to fight infections. See “What is the most important information I should know about HUMIRA?” and “What are the possible side effects of HUMIRA?”

HUMIRA has not been studied in children.

Who should not take HUMIRA?

Do not take HUMIRA if you have an allergy to HUMIRA or to any of its ingredients (including sodium phosphate, sodium citrate, citric acid, mannitol, and polysorbate 80). The needle cover on the prefilled syringe contains dry natural rubber. Tell your doctor if you have any allergies to rubber or latex.

What should I tell my doctor before starting HUMIRA?

To help your doctor decide if HUMIRA is right for you, before starting HUMIRA tell your doctor about all of your health conditions, including if you:

Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding.HUMIRA should only be used during a pregnancy if needed. Women who are breastfeeding should talk to their doctor about whether or not to use HUMIRA.

Pregnancy Registry: Abbott Laboratories has a registry for pregnant women exposed to HUMIRA. The purpose of this registry is to check the health of the pregnant mother and her child. Talk to your doctor to contact the registry for you at 1-877-311-8972.

Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. Your doctor will tell you if it is okay to take your other medicines while taking HUMIRA. Especially, tell your doctor if you take:

Know the medicines you take. Keep a list of your medicines with you to show your doctor and pharmacist each time you get a new medicine.

How should I take HUMIRA?

See the section, “How do I prepare and give an injection of HUMIRA?” at the end of this leaflet for complete instructions for use.

What are the possible side effects with HUMIRA?

Serious side effects have happened in people taking HUMIRA, including:

Call your doctor or get medical care right away if you develop any of the above symptoms. Your treatment with HUMIRA may be stopped.

Common side effects with HUMIRA include:

These are not all the side effects with HUMIRA. Ask your doctor or pharmacist for more information.

How do I store HUMIRA?

General information about HUMIRA

Medicines are sometimes prescribed for purposes not mentioned in a Patient Information Leaflet. Do not use HUMIRA for a condition for which it was not prescribed. Do not give HUMIRA to other people, even if they have the same condition. It may harm them.

This leaflet summarizes the most important information about HUMIRA. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about HUMIRA that was written for healthcare professionals.

For other information and ideas you can enroll in a patient support program by calling 1-800-4HUMIRA (448-6472).

What do I need to do to prepare and give an injection of HUMIRA?

HUMIRA comes as:

  1. a single-use pen (HUMIRA PEN) containing a prefilled syringe

  2. a single-use prefilled syringe (HUMIRA)

Follow the directions below for your dose form.

IF YOU ARE USING THE HUMIRA PEN

1) Setting up for an injection

Image from Drug Label Content

If you do not have all of the items you need to give yourself an injection, call your pharmacist. Use only the items provided in the box your HUMIRA comes in.

For your protection, it is important that you follow these instructions.

2) Choosing and preparing an injection site

Image from Drug Label Content

3) How to prepare your HUMIRA dose for injection with a HUMIRA Pen

Image from Drug Label Content

4) Injecting HUMIRA

Image from Drug Label Content

Image from Drug Label Content

IF YOU ARE USING THE PREFILLED SYRINGE

1) Setting up for an injection

Image from Drug Label Content

If you do not have all of the items you need to give yourself an injection, call your pharmacist. Use only the items provided in the box your HUMIRA comes in.

For your protection, it is important that you follow these instructions.

2) Choosing and preparing an injection site

Image from Drug Label Content

3) How to prepare your HUMIRA dose for injection with a Prefilled Syringe

Image from Drug Label Content

4) Injecting HUMIRA

How Do I Dispose of Syringes and Needles?

You should always check with your doctor's office for instructions on how to dispose of used needles and syringes. You should follow any special state or local laws regarding the disposal of needles and syringes. Do not throw the needle or syringe in the household trash or recycle trash.

Rev. July, 2007


U.S. Govt. Lic. No. 0043


Abbott Laboratories

North Chicago, IL 60064, U.S.A.


HUMIRA (adalimumab)
PRODUCT INFO
Product Code0074-3799Dosage FormINJECTION, SOLUTION
Route Of AdministrationSUBCUTANEOUSDEA Schedule
INGREDIENTS
Name (Active Moiety)TypeStrength
adalimumab (adalimumab) Active40 MILLIGRAM  In 0.8 MILLILITER
sodium chlorideInactive4.93 MILLIGRAM  In 0.8 MILLILITER
sodium phosphate, monobasic, dihydrateInactive0.69 MILLIGRAM  In 0.8 MILLILITER
sodium phosphate, dibasic, dihydrateInactive1.22 MILLIGRAM  In 0.8 MILLILITER
sodium citrateInactive0.24 MILLIGRAM  In 0.8 MILLILITER
citric acidInactive1.04 MILLIGRAM  In 0.8 MILLILITER
mannitolInactive9.6 MILLIGRAM  In 0.8 MILLILITER
polysorbate 80Inactive0.8 MILLIGRAM  In 0.8 MILLILITER
WaterInactive 
Sodium hydroxideInactive 
IMPRINT INFORMATION
CharacteristicAppearanceCharacteristicAppearance
ColorScore
ShapeSymbol
Imprint CodeCoating
Size
PACKAGING
#NDCPackage DescriptionMultilevel Packaging
10074-3799-011 SYRINGE In 1 CARTONcontains a SYRINGE
10.8 MILLILITER In 1 SYRINGEThis package is contained within the CARTON (0074-3799-01)
20074-3799-022 SYRINGE In 1 CARTONcontains a SYRINGE
20.8 MILLILITER In 1 SYRINGEThis package is contained within the CARTON (0074-3799-02)

HUMIRA (adalimumab)
PRODUCT INFO
Product Code0074-4339Dosage FormINJECTION, SOLUTION
Route Of AdministrationSUBCUTANEOUSDEA Schedule
INGREDIENTS
Name (Active Moiety)TypeStrength
adalimumab (adalimumab) Active40 MILLIGRAM  In 0.8 MILLILITER
sodium chlorideInactive4.93 MILLIGRAM  In 0.8 MILLILITER
sodium phosphate, monobasic, dihydrateInactive0.69 MILLIGRAM  In 0.8 MILLILITER
sodium phosphate, dibasic, dihydrateInactive1.22 MILLIGRAM  In 0.8 MILLILITER
sodium citrateInactive0.24 MILLIGRAM  In 0.8 MILLILITER
citric acidInactive1.04 MILLIGRAM  In 0.8 MILLILITER
mannitolInactive9.6 MILLIGRAM  In 0.8 MILLILITER
polysorbate 80Inactive0.8 MILLIGRAM  In 0.8 MILLILITER
WaterInactive 
Sodium hydroxideInactive 
IMPRINT INFORMATION
CharacteristicAppearanceCharacteristicAppearance
ColorScore
ShapeSymbol
Imprint CodeCoating
Size
PACKAGING
#NDCPackage DescriptionMultilevel Packaging
10074-4339-022 SYRINGE In 1 CARTONcontains a SYRINGE
10.8 MILLILITER In 1 SYRINGEThis package is contained within the CARTON (0074-4339-02)
20074-4339-066 SYRINGE In 1 CARTONcontains a SYRINGE
20.8 MILLILITER In 1 SYRINGEThis package is contained within the CARTON (0074-4339-06)

Revised: 10/2007Abbott Laboratories, Inc.