Prior to First Infusion: Screen all patients for HBV infection by measuring HBsAg and anti-HBc before initiating treatment with RITUXAN [see Warnings and Precautions (5.3)]. Obtain complete blood counts (CBC) including platelets prior to the first dose.

During RITUXAN Therapy: In patients with lymphoid malignancies, during treatment with RITUXAN monotherapy, obtain complete blood counts (CBC) with differential and platelet counts prior to each RITUXAN course. During treatment with RITUXAN and chemotherapy, obtain CBC with differential and platelet counts at weekly to monthly intervals and more frequently in patients who develop cytopenias [see Adverse Reactions (6.1)]. In patients with RA, GPA or MPA, obtain CBC with differential and platelet counts at two to four month intervals during RITUXAN therapy. Continue to monitor for cytopenias after final dose and until resolution.

• First Infusion:
  Standard Infusion: Initiate infusion at a rate of 50 mg/hr. In the absence of infusion toxicity, increase infusion rate by 50 mg/hr increments every 30 minutes, to a maximum of 400 mg/hr.
  For Pediatric Patients with mature B-cell NHL/B-AL:
  Initiate infusion at a rate of 0.5 mg/kg/hr (maximum 50 mg/hr). In the absence of infusion toxicity, increase infusion rate by 0.5 mg/kg/hr every 30 minutes, to a maximum of 400 mg/hr.
• Subsequent Infusions: Standard Infusion: Initiate infusion at a rate of 100 mg/hr. In the absence of infusion toxicity, increase rate by 100 mg/hr increments at 30-minute intervals, to a maximum of 400 mg/hr.
  For Previously Untreated Follicular NHL and DLBCL adult patients:
  If patients did not experience a Grade 3 or 4 infusion-related adverse event during Cycle 1, a 90-minute infusion can be administered in Cycle 2 with a glucocorticoid-containing chemotherapy regimen.
  Initiate at a rate of 20% of the total dose given in the first 30 minutes and the remaining 80% of the total dose given over the next 60 minutes. If the 90-minute infusion is tolerated in Cycle 2, the same rate can be used when administering the remainder of the treatment regimen (through Cycle 6 or 8).
  Patients who have clinically significant cardiovascular disease or who have a circulating lymphocyte count greater than or equal to 5,000/mm3 before Cycle 2 should not be administered the 90-minute infusion [see Clinical Studies (14.4)].
  For Pediatric Patients with mature B-cell NHL/B-AL:
  Initiate infusion rate of 1 mg/kg/hr (maximum 50 mg/hr). In the absence of infusion toxicity, increase rate by 1 mg/kg/hr every 30 minutes, to a maximum of 400 mg/hr.
• Interrupt the infusion or slow the infusion rate for infusion-related reactions [see Boxed Warning, Warnings and Precautions (5.1)]. Continue the infusion at one-half the previous rate upon improvement of symptoms.

Induction Treatment of Adult Patients with Active GPA/MPA

• Administer RITUXAN as a 375 mg/m2 intravenous infusion once weekly for 4 weeks for patients with active GPA or MPA.
• Glucocorticoids administered as methylprednisolone 1,000 mg intravenously per day for 1 to 3 days followed by oral prednisone as per clinical practice. This regimen should begin within 14 days prior to or with the initiation of RITUXAN and may continue during and after the 4 week induction course of RITUXAN treatment.

Follow up Treatment of Adult Patients with GPA/MPA who have achieved disease control with induction treatment

• Administer RITUXAN as two 500 mg intravenous infusions separated by two weeks, followed by a 500 mg intravenous infusion every 6 months thereafter based on clinical evaluation.
• If induction treatment of active disease was with a rituximab product, initiate follow up treatment with RITUXAN within 24 weeks after the last induction infusion with a rituximab product or based on clinical evaluation, but no sooner than 16 weeks after the last induction infusion with a rituximab product.
• If induction treatment of active disease was with other standard of care immunosuppressants, initiate RITUXAN follow up treatment within the 4 week period that follows achievement of disease control.

Induction treatment of Pediatric Patients with Active GPA/MPA

• Administer RITUXAN as a 375 mg/m2 intravenous infusion once weekly for 4 weeks.
• Prior to the first RITUXAN infusion, administer intravenous methylprednisolone 30 mg/kg (not to exceed 1g/day) once daily for 3 days.
• Following intravenous methylprednisolone administration, oral steroids should be continued per clinical practice.

Follow up Treatment of Pediatric Patients with GPA/MPA who have achieved disease control with induction treatment

• Administer RITUXAN as two 250 mg/m2 intravenous infusions separated by two weeks, followed by a 250 mg/m2 intravenous infusion every 6 months thereafter based on clinical evaluation.
• If induction treatment of active disease was with a rituximab product, initiate follow up treatment with RITUXAN within 24 weeks after the last induction infusion with a rituximab product or based on clinical evaluation, but no sooner than 16 weeks after the last induction infusion with a rituximab product.
• If induction treatment of active disease was with other standard of care immunosuppressants, initiate RITUXAN follow up treatment within the 4 week period following achievement of disease control.

Administration

Use a sterile needle and syringe to prepare RITUXAN. Withdraw the necessary amount of RITUXAN and dilute to a final concentration of 1 mg/mL to 4 mg/mL in an infusion bag containing either 0.9% Sodium Chloride, USP, or 5% Dextrose Injection, USP. Gently invert the bag to mix the solution. Do not mix or dilute with other drugs. Discard any unused portion left in the vial.

Storage

Diluted RITUXAN solutions for infusion may be stored refrigerated at 2°C to 8°C (36°F to 46°F) for 24 hours. Diluted RITUXAN solutions for infusion have been shown to be stable for an additional 24 hours at room temperature. However, since RITUXAN solutions do not contain a preservative, diluted solutions should be stored refrigerated (2°C to 8°C). No incompatibilities between RITUXAN and polyvinylchloride or polyethylene bags have been observed.

B-Cell Malignancies

The data described below reflect exposure to RITUXAN in 3092 patients, with exposures ranging from a single infusion up to 2 years. RITUXAN was studied in both single-arm and controlled trials (n=356 and n=2427). The population included 1180 patients with low grade or follicular lymphoma, 927 patients with DLBCL, 676 patients with CLL, and 309 pediatric patients with mature B-cell NHL/B-AL. Most NHL patients received RITUXAN as an infusion of 375 mg/m2 per infusion, given as a single agent weekly for up to 8 doses, in combination with chemotherapy for up to 8 doses, or following chemotherapy for up to 16 doses. Pediatric patients received 6 total doses of RITUXAN or a non-U.S. licensed rituximab in combination with chemotherapy. CLL patients received RITUXAN 375 mg/m2 as an initial infusion followed by 500 mg/m2 for up to 5 doses, in combination with fludarabine and cyclophosphamide. Seventy-one percent of CLL patients received 6 cycles and 90% received at least 3 cycles of RITUXAN-based therapy.

The most common adverse reactions of RITUXAN (incidence greater than or equal to 25%) observed in clinical trials of patients with NHL were infusion-related reactions, fever, lymphopenia, chills, infection, and asthenia.

The most common adverse reactions of RITUXAN (incidence greater than or equal to 25%) observed in clinical trials of patients with CLL were: infusion-related reactions and neutropenia.

Rheumatoid Arthritis

The data presented below reflect the experience in 2578 RA patients treated with RITUXAN in controlled and long-term studies1 with a total exposure of 5014 patient-years.

Among all exposed patients, adverse reactions reported in greater than 10% of patients include infusion-related reactions, upper respiratory tract infection, nasopharyngitis, urinary tract infection, and bronchitis.

In placebo-controlled studies, patients received 2 × 500 mg or 2 × 1,000 mg intravenous infusions of RITUXAN or placebo, in combination with methotrexate, during a 24-week period. From these studies, 938 patients treated with RITUXAN (2 × 1,000 mg) or placebo have been pooled (see Table 4). Adverse reactions reported in greater than or equal to 5% of patients were hypertension, nausea, upper respiratory tract infection, arthralgia, pyrexia and pruritus (see Table 4). The rates and types of adverse reactions in patients who received RITUXAN 2 × 500 mg were similar to those observed in patients who received RITUXAN 2 × 1,000 mg.

1

Pooled studies: NCT00074438, NCT00422383, NCT00468546, NCT00299130, NCT00282308, NCT00266227, NCT02693210, NCT02093026 and NCT02097745.

Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA)

Pemphigus Vulgaris (PV)

Risk Summary

Based on human data, RITUXAN can cause adverse developmental outcomes including B-cell lymphocytopenia in infants exposed to RITUXAN in-utero (see Clinical Considerations). In animal reproduction studies, intravenous administration of rituximab to pregnant cynomolgus monkeys during the period of organogenesis caused lymphoid B-cell depletion in the newborn offspring at doses resulting in 80% of the exposure (based on AUC) of those achieved following a dose of 2 grams in humans. Advise pregnant women of the risk to a fetus.

Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The background risk of major birth defects and miscarriage for the indicated populations is unknown. The estimated background risk in the U.S. general population of major birth defects is 2%-4% and of miscarriage is 15%-20% of clinically recognized pregnancies.

Clinical Considerations

Data

Pregnancy Testing

Verify pregnancy status in females of reproductive potential prior to initiating RITUXAN.

Contraception

Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA)

RITUXAN is indicated for the treatment of GPA and MPA in pediatric patients 2 years of age and older with GPA and MPA. RITUXAN is not indicated in pediatric patients less than 2 years of age with GPA or MPA.

The use of RITUXAN for the treatment of pediatric patients with GPA and MPA 6 years of age and older is supported by evidence from adequate and well-controlled studies of RITUXAN in adults with GPA and MPA; a trial in pediatric patients 6 years of age and older with active GPA and MPA; and population pharmacokinetic (PK) analyses showing similar drug exposure levels in adults and pediatric patients 6 years to 17 years of age. The use of RITUXAN for the treatment of pediatric patients with GPA and MPA ages 2 to less than 6 years of age is supported by PK modeling in patients 2 years of age and older and safety data from pediatric patients less than 6 years of age treated with rituximab.

The pediatric trial was a multicenter, open-label, single arm study (GPA/MPA Study 4) to evaluate the safety, PK and exploratory efficacy of RITUXAN or non-U.S.-licensed rituximab in 25 pediatric patients (6 patients 6 years to less than 12 years of age and 19 patients 12 years to 17 years of age) with active GPA and MPA over a 6-month remission induction phase and minimum 12-month follow-up phase, up to 54 months [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14.7)].

Mature B-Cell NHL/B-AL

The safety and effectiveness of RITUXAN in combination with chemotherapy for the treatment of previously untreated, advanced stage, CD20-positive DLBCL/BL/BLL/B-AL have been established in pediatric patients aged 6 months and older. Use of RITUXAN for this indication is supported by evidence from an adequate and well-controlled study in pediatric patients aged 1 year and older on the basis that the course of advanced disease is expected to be similar between pediatric patients aged 6 months to less than 1 year to that of pediatric patients aged 1 year and older to allow extrapolation of data to younger pediatric patients and use pharmacokinetic modeling [see Clinical Pharmacology (12.3), Clinical Studies (14.2)]. Patients younger than 3 years had a higher incidence of infections compared to patients 3 years and older [see Adverse Reactions (6.1)].

The safety and effectiveness of RITUXAN in combination with chemotherapy for previously untreated, advanced stage, CD20-positive DLBCL/BL/BLL/B-AL have not been established in pediatric patients less than 6 months of age.

The safety and effectiveness of RITUXAN have not been established in pediatric patients with CLL.

Rheumatoid Arthritis and Pemphigus Vulgaris

The safety and effectiveness of RITUXAN have not been established in pediatric patients with PV or RA.

RITUXAN was not studied in pediatric patients with polyarticular juvenile idiopathic arthritis (PJIA) due to concerns regarding the potential for prolonged immunosuppression as a result of B-cell depletion in the developing juvenile immune system.

Diffuse Large B-Cell NHL

Among patients with DLBCL evaluated in three randomized, active-controlled trials, 927 patients received RITUXAN in combination with chemotherapy. Of these, 396 (43%) were age 65 or greater and 123 (13%) were age 75 or greater. No overall differences in effectiveness were observed between these patients and younger patients. Cardiac adverse reactions, mostly supraventricular arrhythmias, occurred more frequently among elderly patients. Serious pulmonary adverse reactions were also more common among the elderly, including pneumonia and pneumonitis.

Low-Grade or Follicular Non-Hodgkin's Lymphoma

Patients with previously untreated follicular NHL evaluated in NHL Study 5 were randomized to RITUXAN as single-agent maintenance therapy (n=505) or observation (n=513) after achieving a response to RITUXAN in combination with chemotherapy. Of these, 123 (24%) patients in the RITUXAN arm were age 65 or older. No overall differences in safety or effectiveness were observed between these patients and younger patients. Other clinical studies of RITUXAN in low-grade or follicular, CD20-positive, B-cell NHL did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger subjects.

Chronic Lymphocytic Leukemia

Among patients with CLL evaluated in two randomized active-controlled trials, 243 of 676 RITUXAN-treated patients (36%) were 65 years of age or older; of these, 100 RITUXAN-treated patients (15%) were 70 years of age or older.

In exploratory analyses defined by age, there was no observed benefit from the addition of RITUXAN to fludarabine and cyclophosphamide among patients 70 years of age or older in CLL Study 1 or in CLL Study 2; there was also no observed benefit from the addition of RITUXAN to fludarabine and cyclophosphamide among patients 65 years of age or older in CLL Study 2 [see Clinical Studies (14.5)]. Patients 70 years or older received lower dose intensity of fludarabine and cyclophosphamide compared to younger patients, regardless of the addition of RITUXAN. In CLL Study 1, the dose intensity of RITUXAN was similar in older and younger patients, however in CLL Study 2 older patients received a lower dose intensity of RITUXAN.

The incidence of Grade 3 and 4 adverse reactions was higher among patients receiving R-FC who were 70 years or older compared to younger patients for neutropenia [44% vs. 31% (CLL Study 1); 56% vs. 39% (CLL Study 2)], febrile neutropenia [16% vs. 6% (NHL Study 10 (NCT00719472)], anemia [5% vs. 2% (CLL Study 1); 21% vs. 10% (CLL Study 2)], thrombocytopenia [19% vs. 8% (CLL Study 2)], pancytopenia [7% vs. 2% (CLL Study 1); 7% vs. 2% (CLL Study 2)] and infections [30% vs. 14% (CLL Study 2)].

Rheumatoid Arthritis

Among the 2578 patients in global RA studies completed to date, 12% were 65–75 years old and 2% were 75 years old and older. The incidences of adverse reactions were similar between older and younger patients. The rates of serious adverse reactions, including serious infections, malignancies, and cardiovascular events were higher in older patients.

Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis

Of the 99 RITUXAN-treated GPA and MPA patients in GPA/MPA Study 1, 36 (36%) were 65 years old and over, while 8 (8%) were 75 years and over. No overall differences in efficacy were observed between patients that were 65 years old and over and younger patients. The overall incidence and rate of all serious adverse events was higher in patients 65 years old and over. The clinical study did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger subjects.

In GPA/MPA Study 2, 30 (26%) of the enrolled patients were at least 65 years old, of which 12 patients were exposed to non-U.S.-licensed rituximab and 18 were exposed to azathioprine. The clinical study did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger subjects.

Pemphigus Vulgaris

Of the 46 patients treated with non-U.S.-licensed rituximab, 15 (33%) patients were 65 years of age and older. The clinical study did not include sufficient numbers of patients aged 65 and older to determine whether they respond differently from younger patients.

Non-Hodgkin's Lymphoma (NHL)

In NHL patients, administration of RITUXAN resulted in depletion of circulating and tissue-based B cells. Among 166 patients in NHL Study 1 (NCT000168740), circulating CD19-positive B cells were depleted within the first three weeks with sustained depletion for up to 6 to 9 months post treatment in 83% of patients. B-cell recovery began at approximately 6 months and median B-cell levels returned to normal by 12 months following completion of treatment.

There were sustained and statistically significant reductions in both IgM and IgG serum levels observed from 5 through 11 months following rituximab administration; 14% of patients had IgM and/or IgG serum levels below the normal range.

Rheumatoid Arthritis

In RA patients, treatment with RITUXAN induced depletion of peripheral B lymphocytes, with the majority of patients demonstrating near complete depletion (CD19 counts below the lower limit of quantification, 20 cells/µl) within 2 weeks after receiving the first dose of RITUXAN. The majority of patients showed peripheral B-cell depletion for at least 6 months. A small proportion of patients (~4%) had prolonged peripheral B-cell depletion lasting more than 3 years after a single course of treatment.

Total serum immunoglobulin levels, IgM, IgG, and IgA were reduced at 6 months with the greatest change observed in IgM. At Week 24 of the first course of RITUXAN treatment, small proportions of patients experienced decreases in IgM (10%), IgG (2.8%), and IgA (0.8%) levels below the lower limit of normal (LLN). In the experience with RITUXAN in RA patients during repeated RITUXAN treatment, 23.3%, 5.5%, and 0.5% of patients experienced decreases in IgM, IgG, and IgA concentrations below LLN at any time after receiving RITUXAN, respectively. The clinical consequences of decreases in immunoglobulin levels in RA patients treated with RITUXAN are unclear.

Treatment with rituximab in patients with RA was associated with reduction of certain biologic markers of inflammation such as interleukin-6 (IL-6), C-reactive protein (CRP), serum amyloid protein (SAA), S100 A8/S100 A9 heterodimer complex (S100 A8/9), anti-citrullinated peptide (anti-CCP), and RF.

Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis

In GPA and MPA patients in GPA/MPA Study 1, peripheral blood CD19 B-cells depleted to less than 10 cells/µl following the first two infusions of RITUXAN, and remained at that level in most (84%) patients through Month 6. By Month 12, the majority of patients (81%) showed signs of B-cell return with counts greater than 10 cells/µL. By Month 18, most patients (87%) had counts greater than 10 cells/µL.

In GPA/MPA Study 2 where patients received non-U.S.-licensed rituximab as two 500 mg intravenous infusions separated by two weeks, followed by a 500 mg intravenous infusion at Month 6, 12, and 18, 70% (30 out of 43) of the rituximab-treated patients with CD19+ peripheral B cells evaluated post-baseline had undetectable CD19+ peripheral B cells at Month 24. At Month 24, all 37 patients with evaluable baseline CD19+ peripheral B cells and Month 24 measurements had lower CD19+ B cells relative to baseline.

Non-Hodgkin's Lymphoma (NHL)

Pharmacokinetics were characterized in 203 NHL patients receiving 375 mg/m2 RITUXAN weekly by intravenous infusion for 4 doses. Rituximab was detectable in the serum of patients 3 to 6 months after completion of treatment.

The pharmacokinetic profile of rituximab when administered as 6 infusions of 375 mg/m2 in combination with 6 cycles of CHOP chemotherapy was similar to that seen with rituximab alone.

Based on a population pharmacokinetic analysis of data from 298 NHL patients who received rituximab once weekly or once every three weeks, the estimated median terminal elimination half-life was 22 days (range, 6.1 to 52 days). Patients with higher CD19-positive cell counts or larger measurable tumor lesions at pretreatment had a higher clearance. However, dose adjustment for pretreatment CD19 count or size of tumor lesion is not necessary. Age and gender had no effect on the pharmacokinetics of rituximab.

Pharmacokinetics were characterized in 21 patients with CLL receiving rituximab according to the recommended dose and schedule. The estimated median terminal half-life of rituximab was 32 days (range, 14 to 62 days).

Rheumatoid Arthritis

Following administration of 2 doses of RITUXAN in patients with RA, the mean (± S.D.; % CV) concentrations after the first infusion (Cmax first) and second infusion (Cmax second) were 157 (± 46; 29%) and 183 (± 55; 30%) mcg/mL, and 318 (± 86; 27%) and 381 (± 98; 26%) mcg/mL for the 2 × 500 mg and 2 × 1,000 mg doses, respectively.

Based on a population pharmacokinetic analysis of data from 2005 RA patients who received RITUXAN, the estimated clearance of rituximab was 0.335 L/day; volume of distribution was 3.1 L and mean terminal elimination half-life was 18.0 days (range, 5.17 to 77.5 days). Age, weight and gender had no effect on the pharmacokinetics of rituximab in RA patients.

Granulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) and Microscopic Polyangiitis

The PK parameters in adult and pediatric patients 6 years to 17 years of age with GPA/MPA receiving 375 mg/m2 intravenous RITUXAN or non-U.S.-licensed rituximab once weekly for four doses are summarized in Table 8.

Based on a population PK analysis in pediatric patients with GPA and MPA, the PK parameters of rituximab were similar to those in adults with GPA and MPA, once taking into account the BSA effect on clearance and volume of distribution parameters. The population PK analysis in adults with GPA and MPA showed that male patients and patients with higher BSA or positive anti-rituximab antibody levels have higher clearance. However, further dose adjustment based on gender or anti-rituximab antibody status is not necessary.

Pemphigus Vulgaris

The PK parameters in adult PV patients receiving 1,000 mg IV infusion of RITUXAN at Days 1, 15, 168, and 182 are summarized in Table 9.

Following the first cycle of rituximab administration, the PK parameters of rituximab in patients with PV were similar to those in patients with RA and in patients with GPA/MPA. Following the 2nd cycle of rituximab administration, rituximab clearance decreased by 22% assuming Pemphigus Disease Area Index (PDAI) activity score of 0 at the start of both cycles, while the central volume of distribution remained unchanged. The presence of anti-rituximab antibodies was associated with a higher clearance resulting in lower rituximab concentrations.

Specific Populations

The clearance and volume of distribution of rituximab increased with increasing body surface area (BSA).

No formal studies were conducted to examine the effects of either renal or hepatic impairment on the pharmacokinetics of rituximab.

Drug Interaction Studies

Formal drug interaction studies have not been performed with RITUXAN.

NHL Study 1

A multicenter, open-label, single-arm study was conducted in 166 patients with relapsed or refractory, low-grade or follicular, B-cell NHL who received 375 mg/m2 of RITUXAN given as an intravenous infusion weekly for 4 doses. Patients with tumor masses > 10 cm or with > 5,000 lymphocytes/µL in the peripheral blood were excluded from the study.

Results are summarized in Table 11. The median time to onset of response was 50 days. Disease-related signs and symptoms (including B-symptoms) resolved in 64% (25/39) of those patients with such symptoms at study entry.

NHL Study 2

In a multicenter, single-arm study, 37 patients with relapsed or refractory, low-grade NHL received 375 mg/m2 of RITUXAN weekly for 8 doses. Results are summarized in Table 11.

NHL Study 3

In a multicenter, single-arm study, 60 patients received 375 mg/m2 of RITUXAN weekly for 4 doses. All patients had relapsed or refractory, low-grade or follicular, B-cell NHL and had achieved an objective clinical response to RITUXAN administered 3.8–35.6 months (median 14.5 months) prior to retreatment with RITUXAN. Of these 60 patients, 5 received more than one additional course of RITUXAN. Results are summarized in Table 11.

Bulky Disease

In pooled data from studies 1 and 3, 39 patients with bulky (single lesion > 10 cm in diameter) and relapsed or refractory, low-grade NHL received RITUXAN 375 mg/m2 weekly for 4 doses. Results are summarized in Table 11.

NHL Study 4

A total of 322 patients with previously untreated follicular NHL were randomized (1:1) to receive up to eight 3-week cycles of CVP chemotherapy alone (CVP) or in combination with RITUXAN 375 mg/m2 on Day 1 of each cycle (R-CVP) in an open-label, multicenter study. The main outcome measure of the study was progression-free survival (PFS) defined as the time from randomization to the first of progression, relapse, or death.

Twenty-six percent of the study population was >60 years of age, 99% had Stage III or IV disease, and 50% had an International Prognostic Index (IPI) score greater than or equal to 2. The results for PFS as determined by a blinded, independent assessment of progression are presented in Table 12. The point estimates may be influenced by the presence of informative censoring. The PFS results based on investigator assessment of progression were similar to those obtained by the independent review assessment.

NHL Study 5

An open-label, multicenter, randomized (1:1) study was conducted in 1,018 patients with previously untreated follicular NHL who achieved a response (CR or PR) to RITUXAN in combination with chemotherapy. Patients were randomized to RITUXAN as single-agent maintenance therapy, 375 mg/m2 every 8 weeks for up to 12 doses or to observation. RITUXAN was initiated at 8 weeks following completion of chemotherapy. The main outcome measure of the study was progression-free survival (PFS), defined as the time from randomization in the maintenance/observation phase to progression, relapse, or death, as determined by independent review.

Of the randomized patients, 40% were greater than or equal to 60 years of age, 70% had Stage IV disease, 96% had ECOG performance status (PS) 0–1, and 42% had FLIPI scores of 3–5. Prior to randomization to maintenance therapy, patients had received R-CHOP (75%), R-CVP (22%), or R-FCM (3%); 71% had a complete or unconfirmed complete response and 28% had a partial response.

PFS was longer in patients randomized to RITUXAN as single agent maintenance therapy (HR: 0.54, 95% CI: 0.42, 0.70). The PFS results based on investigator assessment of progression were similar to those obtained by the independent review assessment.

Figure 1
Kaplan-Meier Plot of IRC Assessed PFS in NHL Study 5

NHL Study 6

A total of 322 patients with previously untreated low-grade, B-cell NHL who did not progress after 6 or 8 cycles of CVP chemotherapy were enrolled in an open-label, multicenter, randomized trial. Patients were randomized (1:1) to receive RITUXAN, 375 mg/m2 intravenous infusion, once weekly for 4 doses every 6 months for up to 16 doses or no further therapeutic intervention. The main outcome measure of the study was progression-free survival defined as the time from randomization to progression, relapse, or death. Thirty-seven percent of the study population was greater than 60 years of age, 99% had Stage III or IV disease, and 63% had an IPI score greater than or equal to 2.

There was a reduction in the risk of progression, relapse, or death (hazard ratio estimate in the range of 0.36 to 0.49) for patients randomized to RITUXAN as compared to those who received no additional treatment.

NHL Study 11

RITUXAN in combination with chemotherapy was evaluated in Inter-B-NHL Ritux 2010 (NCT01516580), a multicenter, open-label, randomized trial of patients with previously untreated, advanced stage, CD20-positive DLBCL/BL/BLL/B-AL aged 6 months and older. Advanced stage is defined as Stage III with elevated lactose dehydrogenase (LDH) level [LDH greater than twice the institutional upper limit of the adult normal values] or stage IV B-cell NHL or B-AL. LMB therapy was administered based on the clinical group classification of group B (stage III with high LDH and non-central nervous system (CNS) (Stage IV), group C1 (B-AL, CNS positive and cerebrospinal fluid (CSF) negative) and C3 (CSF positive).

Patients were randomized to Lymphome Malin B (LMB) chemotherapy (corticosteroids, vincristine, cyclophosphamide, high-dose methotrexate, cytarabine, doxorubicin, etoposide and triple drug [methotrexate/cytarabine/ corticosteroid] intrathecal therapy) alone or in combination with RITUXAN or non-U.S. licensed rituximab, administered as six infusions of RITUXAN IV at a dose of 375 mg/m2 BSA (two doses during each of the two induction courses and one during each of the two consolidation courses) as per the LMB scheme [see Dosage and Administration (2.2)].

The trial was planned to enroll 600 patients with 1:1 randomization. The randomization was stopped early for efficacy after 362 patients had been enrolled (181 in each arm) according to the first planned interim analysis result. A total of 328 randomized patients, aged 6 months and older, were included in the efficacy analyses, of which one patient under 3 years of age received intravenous RITUXAN or non-U.S.-licensed rituximab in combination with LMB chemotherapy. Demographic and disease characteristics of the randomized trial population are displayed in Table 13:

Efficacy was established based on event-free survival (EFS), where an event was defined as occurrence of progressive disease, relapse, second malignancy, death from any cause, or non-response as evidenced by detection of viable cells in residue after the second CYVE course, whichever occurs first.

Efficacy analyses were performed in 328 randomized patients with a median follow-up of 3.1 years. The results are described in Table 14.

As of data cutoff date of 31 December 2017, there were 20 and 8 deaths reported in LMB arm and R-LMB arm, respectively, with an estimated overall survival (OS) HR of 0.36 (95% CI, 0.16 - 0.81). No formal statistical test was conducted for overall survival and therefore the OS result is considered descriptive.

NHL Study 7

A total of 632 patients age greater than or equal to 60 years with DLBCL (including primary mediastinal B-cell lymphoma) were randomized in a 1:1 ratio to treatment with CHOP or R-CHOP. Patients received 6 or 8 cycles of CHOP, each cycle lasting 21 days. All patients in the R-CHOP arm received 4 doses of RITUXAN 375 mg/m2 on Days –7 and –3 (prior to Cycle 1) and 48–72 hours prior to Cycles 3 and 5. Patients who received 8 cycles of CHOP also received RITUXAN prior to Cycle 7. The main outcome measure of the study was progression-free survival, defined as the time from randomization to the first of progression, relapse, or death. Responding patients underwent a second randomization to receive RITUXAN or no further therapy.

Among all enrolled patients, 62% had centrally confirmed DLBCL histology, 73% had Stage III–IV disease, 56% had IPI scores greater than or equal to 2, 86% had ECOG performance status of < 2, 57% had elevated LDH levels, and 30% had two or more extranodal disease sites involved. Efficacy results are presented in Table 15. These results reflect a statistical approach which allows for an evaluation of RITUXAN administered in the induction setting that excludes any potential impact of RITUXAN given after the second randomization.

Analysis of results after the second randomization in NHL Study 7 demonstrates that for patients randomized to R-CHOP, additional RITUXAN exposure beyond induction was not associated with further improvements in progression-free survival or overall survival.

NHL Study 8

A total of 399 patients with DLBCL, age greater than or equal to 60 years, were randomized in a 1:1 ratio to receive CHOP or R-CHOP. All patients received up to eight 3-week cycles of CHOP induction; patients in the R-CHOP arm received RITUXAN 375 mg/m2 on Day 1 of each cycle. The main outcome measure of the study was event-free survival, defined as the time from randomization to relapse, progression, change in therapy, or death from any cause. Among all enrolled patients, 80% had Stage III or IV disease, 60% of patients had an age-adjusted IPI greater than or equal to 2, 80% had ECOG performance status scores less than 2, 66% had elevated LDH levels, and 52% had extranodal involvement in at least two sites. Efficacy results are presented in Table 15.

NHL Study 9

A total of 823 patients with DLBCL, aged 18–60 years, were randomized in a 1:1 ratio to receive an anthracycline-containing chemotherapy regimen alone or in combination with RITUXAN. The main outcome measure of the study was time to treatment failure, defined as time from randomization to the earliest of progressive disease, failure to achieve a complete response, relapse, or death. Among all enrolled patients, 28% had Stage III–IV disease, 100% had IPI scores of less than or equal to 1, 99% had ECOG performance status of < 2, 29% had elevated LDH levels, 49% had bulky disease, and 34% had extranodal involvement. Efficacy results are presented in Table 15.

In NHL Study 8, overall survival estimates at 5 years were 58% vs. 46% for R-CHOP and CHOP, respectively.

Reducing the Signs and Symptoms: Initial and Re-Treatment Courses

The efficacy and safety of RITUXAN were evaluated in two randomized, double-blind, placebo-controlled studies of adult patients with moderately to severely active RA who had a prior inadequate response to at least one TNF inhibitor. Patients were 18 years of age or older, diagnosed with active RA according to American College of Rheumatology (ACR) criteria, and had at least 8 swollen and 8 tender joints.

In RA Study 1 (NCT00468546), patients were randomized to receive either RITUXAN 2 × 1,000 mg + MTX or placebo + MTX for 24 weeks. Further courses of RITUXAN 2 × 1,000 mg + MTX were administered in an open label extension study at a frequency determined by clinical evaluation, but no sooner than 16 weeks after the preceding course of RITUXAN. In addition to the intravenous premedication, glucocorticoids were administered orally on a tapering schedule from baseline through Day 14. The proportions of patients achieving ACR 20, 50, and 70 responses at Week 24 of the placebo-controlled period are shown in Table 18.

In RA Study 2 (NCT00266227), all patients received the first course of RITUXAN 2 × 1,000 mg + MTX. Patients who experienced ongoing disease activity were randomized to receive a second course of either RITUXAN 2 × 1,000 mg + MTX or placebo + MTX, the majority between Weeks 24–28. The proportions of patients achieving ACR 20, 50, and 70 responses at Week 24, before the re-treatment course, and at Week 48, after retreatment, are shown in Table 18.

Improvement was also noted for all components of ACR response following treatment with RITUXAN, as shown in Table 19.

The time course of ACR 20 response for RA Study 1 is shown in Figure 2. Although both treatment groups received a brief course of intravenous and oral glucocorticoids, resulting in similar benefits at Week 4, higher ACR 20 responses were observed for the RITUXAN group by Week 8. A similar proportion of patients achieved these responses through Week 24 after a single course of treatment (2 infusions) with RITUXAN. Similar patterns were demonstrated for ACR 50 and 70 responses.

Figure 2
* The same patients may not have responded at each time point.
Percent of Patients Achieving ACR 20 Response by Visit* RA Study 1 (Inadequate Response to TNF Antagonists)

Radiographic Response

In RA Study 1, structural joint damage was assessed radiographically and expressed as changes in Genant-modified Total Sharp Score (TSS) and its components, the erosion score (ES) and the joint space narrowing (JSN) score. RITUXAN + MTX slowed the progression of structural damage compared to placebo + MTX after 1 year as shown in Table 20.

In RA Study 1 and its open-label extension, 70% of patients initially randomized to RITUXAN + MTX and 72% of patients initially randomized to placebo + MTX were evaluated radiographically at Year 2. As shown in Table 20, progression of structural damage in RITUXAN + MTX patients was further reduced in the second year of treatment.

Following 2 years of treatment with RITUXAN + MTX, 57% of patients had no progression of structural damage. During the first year, 60% of RITUXAN + MTX treated patients had no progression, defined as a change in TSS of zero or less compared to baseline, compared to 46% of placebo + MTX treated patients. In their second year of treatment with RITUXAN + MTX, more patients had no progression than in the first year (68% vs. 60%), and 87% of the RITUXAN + MTX treated patients who had no progression in the first year also had no progression in the second year.

Lesser Efficacy of 500 Vs. 1,000 mg Treatment Courses for Radiographic Outcomes

RA Study 3 (NCT00299104) is a randomized, double-blind, placebo-controlled study which evaluated the effect of placebo + MTX compared to RITUXAN 2 × 500 mg + MTX and RITUXAN 2 × 1,000 mg + MTX treatment courses in MTX-naïve RA patients with moderately to severely active disease. Patients received a first course of two infusions of rituximab or placebo on Days 1 and 15. MTX was initiated at 7.5 mg/week and escalated up to 20 mg/week by Week 8 in all three treatment arms. After a minimum of 24 weeks, patients with ongoing disease activity were eligible to receive re-treatment with additional courses of their assigned treatment. After one year of treatment, the proportion of patients achieving ACR 20/50/70 responses were similar in both RITUXAN dose groups and were higher than in the placebo group. However, with respect to radiographic scores, only the RITUXAN 1,000 mg treatment group demonstrated a statistically significant reduction in TSS: a change of 0.36 units compared to 1.08 units for the placebo group, a 67% reduction.

Physical Function Response

RA Study 4 (NCT00299130) is a randomized, double-blind, placebo-controlled study in adult RA patients with moderately to severely active disease with inadequate response to MTX. Patients were randomized to receive an initial course of RITUXAN 500 mg, RITUXAN 1,000 mg, or placebo in addition to background MTX.

Physical function was assessed at Weeks 24 and 48 using the Health Assessment Questionnaire Disability Index (HAQ-DI). From baseline to Week 24, a greater proportion of RITUXAN-treated patients had an improvement in HAQ-DI of at least 0.22 (a minimal clinically important difference) and a greater mean HAQ-DI improvement compared to placebo, as shown in Table 21. HAQ-DI results for the RITUXAN 500 mg treatment group were similar to the RITUXAN 1,000 mg treatment group; however radiographic responses were not assessed (see Dosing Precaution in the Radiographic Responses section above). These improvements were maintained at 48 weeks.

Induction Treatment of Adult Patients with Active Disease (GPA/MPA Study 1)

A total of 197 patients with active, severe GPA and MPA (two forms of ANCA Associated Vasculitides) were treated in a randomized, double-blind, active-controlled, multicenter, non-inferiority study, conducted in two phases – a 6 month remission induction phase and a 12 month remission maintenance phase. Patients were 15 years of age or older, diagnosed with GPA (75% of patients) or MPA (24% of patients) according to the Chapel Hill Consensus conference criteria (1% of the patients had unknown vasculitis type). All patients had active disease, with a Birmingham Vasculitis Activity Score for Granulomatosis with Polyangiitis (BVAS/GPA) greater than or equal to 3, and their disease was severe, with at least one major item on the BVAS/GPA. Ninety-six (49%) of patients had new disease and 101 (51%) of patients had relapsing disease.

Patients in both arms received 1,000 mg of pulse intravenous methylprednisolone per day for 1 to 3 days within 14 days prior to initial infusion. Patients were randomized in a 1:1 ratio to receive either RITUXAN 375 mg/m2 once weekly for 4 weeks or oral cyclophosphamide 2 mg/kg daily for 3 to 6 months in the remission induction phase. Patients were pre-medicated with antihistamine and acetaminophen prior to RITUXAN infusion. Following intravenous corticosteroid administration, all patients received oral prednisone (1 mg/kg/day, not exceeding 80 mg/day) with pre-specified tapering. Once remission was achieved or at the end of the 6 month remission induction period, the cyclophosphamide group received azathioprine to maintain remission. The RITUXAN group did not receive additional therapy to maintain remission. The main outcome measure for both GPA and MPA patients was achievement of complete remission at 6 months defined as a BVAS/GPA of 0, and off glucocorticoid therapy. The pre-specified non-inferiority margin was a treatment difference of 20%. As shown in Table 22, the study demonstrated non-inferiority of RITUXAN to cyclophosphamide for complete remission at 6 months.

Complete Remission (CR) at 12 and 18 months

In the RITUXAN group, 44% of patients achieved CR at 6 and 12 months, and 38% of patients achieved CR at 6, 12, and 18 months. In patients treated with cyclophosphamide (followed by azathioprine for maintenance of CR), 38% of patients achieved CR at 6 and 12 months, and 31% of patients achieved CR at 6, 12, and 18 months.

Retreatment of Flares with RITUXAN

Based upon investigator judgment, 15 patients received a second course of RITUXAN therapy for treatment of relapse of disease activity which occurred between 8 and 17 months after the induction treatment course of RITUXAN.

Follow up Treatment of Adult Patients with GPA/MPA who have achieved disease control with other Immunosuppressant (GPA/MPA Study 2)

A total of 115 patients (86 with GPA, 24 with MPA, and 5 with renal-limited ANCA-associated vasculitis) in disease remission were randomized to receive azathioprine (58 patients) or non-U.S.-licensed rituximab (57 patients) in this open-label, prospective, multi-center, randomized, active-controlled study. Eligible patients were 21 years and older and had either newly diagnosed (80%) or relapsing disease (20%). A majority of the patients were ANCA-positive. Remission of active disease was achieved using a combination of glucocorticoids and cyclophosphamide. Within a maximum of 1 month after the last cyclophosphamide dose, eligible patients (based on BVAS of 0), were randomized in a 1:1 ratio to receive either non-U.S.-licensed rituximab or azathioprine.

The non-U.S.-licensed rituximab was administered as two 500 mg intravenous infusions separated by two weeks (on Day 1 and Day 15) followed by a 500 mg intravenous infusion every 6 months for 18 months. Azathioprine was administered orally at a dose of 2 mg/kg/day for 12 months, then 1.5 mg/kg/day for 6 months, and finally 1 mg/kg/day for 4 months; treatment was discontinued after 22 months. Prednisone treatment was tapered and then kept at a low dose (approximately 5 mg per day) for at least 18 months after randomization. Prednisone dose tapering and the decision to stop prednisone treatment after month 18 were left at the investigator's discretion.

Planned follow-up was until month 28 (10 or 6 months, respectively, after the last non-U.S.-licensed rituximab infusion or azathioprine dose). The primary endpoint was the occurrence of major relapse (defined by the reappearance of clinical and/or laboratory signs of vasculitis activity that could lead to organ failure or damage, or could be life threatening) through month 28.

By month 28, major relapse occurred in 3 patients (5%) in the non-U.S.-licensed rituximab group and 17 patients (29%) in the azathioprine group.

The observed cumulative incidence rate of first major relapse during the 28 months was lower in patients on non-U.S.-licensed rituximab relative to azathioprine (Figure 3).

Treatment of Pediatric Patients (GPA/MPA Study 4)

The study design consisted of an initial 6-month remission induction phase, and a minimum 12-month follow-up phase up to a maximum of 54 months (4.5 years) in pediatric patients 2 years to 17 years of age with GPA and MPA. Patients were to receive a minimum of 3 doses of intravenous methylprednisolone (30 mg/kg/day, not exceeding 1g/day) prior to the first RITUXAN or non-U.S.-licensed rituximab intravenous infusion. If clinically indicated, additional daily doses (up to three), of intravenous methylprednisolone could be given. The remission induction regimen consisted of four once weekly intravenous infusions of RITUXAN or non-U.S.-licensed rituximab at a dose of 375 mg/m2 BSA, on study days 1, 8, 15 and 22 in combination with oral prednisolone or prednisone at 1 mg/kg/day (max 60 mg/day) tapered to 0.2 mg/kg/day minimum (max 10 mg/day) by Month 6. After the remission induction phase, patients could receive subsequent RITUXAN or non-U.S.-licensed rituximab intravenous infusions on or after Month 6 to maintain remission and control disease activity.

The primary objectives of this study were to evaluate safety and PK parameters in pediatric GPA and MPA patients (2 years to 17 years of age). The efficacy objectives of the study were exploratory and principally assessed using the Pediatric Vasculitis Activity Score (PVAS).

A total of 25 pediatric patients 6 years to 17 years of age with active GPA and MPA were treated with RITUXAN or non-U.S.-licensed rituximab in a multicenter, open-label, single-arm, uncontrolled study (NCT01750697). The median age of patients in the study was 14 years and the majority of patients (20/25 [80%]) were female. A total of 19 patients (76%) had GPA and 6 patients (24%) had MPA at baseline. Eighteen patients (72%) had newly diagnosed disease upon study entry (13 patients with GPA and 5 patients with MPA) and 7 patients had relapsing disease (6 patients with GPA and 1 patient with MPA).

All 25 patients completed all four once weekly intravenous infusions for the 6-month remission induction phase. A total of 24 out of 25 patients completed at least 18 months from Day 1 (baseline).

The exploratory efficacy using the PVAS is described in Table 23.

Follow-Up Treatment

After the 6-month remission induction phase, patients who had not achieved remission or who had progressive disease or flare that could not be controlled by glucocorticoids alone received additional treatment for GPA and MPA, that could include RITUXAN or non-U.S.-licensed rituximab and/or other therapies, at the discretion of the investigator. Planned follow-up was until Month 18 (from Day 1).

Fourteen out of 25 patients (56%) received additional RITUXAN or non-U.S.-licensed rituximab treatment at or post Month 6, up to Month 18. Five of these patients received four once weekly doses (375 mg/m2) of intravenous RITUXAN or non-U.S.-licensed rituximab approximately every 6 months; 5 of these patients received a single dose (375 mg/m2) of RITUXAN or non-U.S.-licensed rituximab every 6 months, and 4 of these patients received various other RITUXAN or non-U.S.-licensed rituximab doses/regimens according to investigator. Of the 14 patients who received follow-up treatment between Month 6 and Month 18, 4 patients first achieved remission between Months 6 and 12 and 1 patient first achieved remission between Months 12 and 18. Nine of these 14 patients achieved PVAS remission by Month 6 but required additional follow-up treatment after Month 6.

PV Study 1 (NCT00784589)

Non-U.S.-licensed rituximab in combination with short-term prednisone was compared to prednisone monotherapy as first-line treatment in 90 newly diagnosed adult patients with moderate to severe pemphigus (74 Pemphigus Vulgaris [PV] and 16 Pemphigus Foliaceus [PF]) in this randomized, open-label, controlled, multicenter study (PV Study 1). Patients were between 19 and 79 years of age and had not received prior therapies for pemphigus. In the PV population, 5 (13%) patients in the group treated with non-U.S.-licensed rituximab and 3 (8%) patients in the prednisone group had moderate disease and 33 (87%) patients in the group treated with non-U.S.-licensed rituximab and 33 (92%) patients in the prednisone group had severe disease according to disease severity defined by Harman's criteria.

Patients were stratified by baseline disease severity (moderate or severe) and randomized 1:1 to receive either the non-U.S.-licensed rituximab and short-term prednisone or long-term prednisone monotherapy. Patients were pre-medicated with antihistamine, acetaminophen and methylprednisolone prior to infusion of the non-U.S.-licensed rituximab. Patients randomized to the group treated with non-U.S.-licensed rituximab received an initial intravenous infusion of 1,000 mg non-U.S.-licensed rituximab on Study Day 1 in combination with a short-term regimen of 0.5 mg/kg/day oral prednisone tapered off over 3 months if they had moderate disease or 1 mg/kg/day oral prednisone tapered off over 6 months if they had severe disease. All patients received a second intravenous infusion of 1,000 mg non-U.S.-licensed rituximab on Study Day 15. Maintenance infusions of 500 mg non-U.S.-licensed rituximab were administered at Months 12 and 18. Patients randomized to the prednisone monotherapy group received an initial 1 mg/kg/day oral prednisone tapered off over 12 months if they had moderate disease or 1.5 mg/kg/day oral prednisone tapered off over 18 months if they had severe disease. Patients in the group treated with non-U.S.-licensed rituximab who relapsed could receive an additional infusion of 1,000 mg non-U.S.-licensed rituximab in combination with reintroduced or escalated prednisone dose. Maintenance and relapse infusions were administered no sooner than 16 weeks following the previous infusion.

The primary endpoint for the study was complete remission (complete epithelialization and absence of new and/or established lesions) at Month 24 without the use of prednisone therapy for 2 months or more (CRoff for greater than or equal to 2 months).

The results of the trial are presented in Table 24.

PV Study 2 (NCT02383589)

In a randomized, double-blind, double-dummy, active-comparator, multicenter study, the efficacy and safety of RITUXAN compared to mycophenolate mofetil (MMF) were evaluated in patients with moderate-to-severe PV receiving 60-120 mg/day oral prednisone or equivalent (1.0-1.5 mg/kg/day) at study entry and tapered to reach a dose of 60 or 80 mg/day by Day 1. Patients had a confirmed diagnosis of PV within the previous 24 months and evidence of moderate-to-severe disease defined as a total Pemphigus Disease Area Index (PDAI) activity score of greater than or equal to 15. The study consisted of a screening period of up to 28 days, a 52-week double-blind treatment period, and a 48-week safety follow up period.

One hundred and thirty-five patients were randomized to treatment with RITUXAN 1,000 mg administered on Day 1, Day 15, Week 24 and Week 26 or oral MMF 2 g/day (starting at 1 g/day on Day 1 and titrated to achieve a goal of 2 g/day by Week 2) for 52 weeks in combination with an initial dose of 60 or 80 mg oral prednisone with the aim of tapering to 0 mg/day by Week 24. Randomization was stratified by duration of PV (within the 1 year prior to screening or greater than 1 year) and geographical region. A dual-assessor approach was used during the study for efficacy and safety evaluations to prevent potential unblinding.

One hundred and twenty-five patients (excluding exploratory data from ten telemedicine patients) were analyzed for efficacy (Modified Intent-to-Treat Population). The primary efficacy endpoint for this study was the proportion of subjects achieving sustained complete remission defined as achieving healing of lesions with no new active lesions (i.e., PDAI activity score of 0) while on 0 mg/day prednisone or equivalent, and maintaining this response for at least 16 consecutive weeks, during the 52-week treatment period.

Secondary endpoints included cumulative oral corticosteroid dose and the total number of disease flares.

The results of the trial are presented in Table 25.