STELARA- ustekinumab injection, solution
STELARA- ustekinumab solution
Janssen Biotech, Inc.
HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use STELARA ® safely and effectively. See full prescribing information for STELARA ®.
STELARA ® (ustekinumab) injection, for subcutaneous or intravenous use
Initial U.S. Approval: 2009
RECENT MAJOR CHANGES
INDICATIONS AND USAGE
STELARA® is a human interleukin-12 and -23 antagonist indicated for the treatment of adult patients with:
DOSAGE AND ADMINISTRATION
Psoriasis Recommended Adult Subcutaneous Dosage (2.1):
Psoriatic Arthritis Recommended Adult Subcutaneous Dosage (2.2):
Crohn's Disease Recommended Initial Adult Intravenous Dosage (2.3):
A single intravenous infusion using weight-based dosing:
Crohn's Disease Recommended Maintenance Adult Subcutaneous Dosage (2.3):
A subcutaneous 90 mg dose 8 weeks after the initial intravenous dose, then every 8 weeks thereafter.
DOSAGE FORMS AND STRENGTHS
Clinically significant hypersensitivity to ustekinumab or to any of the excipients. (4)
WARNINGS AND PRECAUTIONS
Most common adverse reactions are:
To report SUSPECTED ADVERSE REACTIONS, contact Janssen Biotech, Inc. at 1-800-JANSSEN (1-800-526-7736) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.
FULL PRESCRIBING INFORMATION: CONTENTS*
2.5 Instructions for Administration of STELARA® Prefilled Syringes Equipped with Needle Safety Guard
2.6 Preparation and Administration of STELARA® 130 mg/26 mL (5 mg/mL) Vial for Intravenous Infusion (Crohn's Disease)
STELARA® is indicated for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.
STELARA® is indicated for the treatment of adult patients with active psoriatic arthritis. STELARA® can be used alone or in combination with methotrexate (MTX).
Subcutaneous Adult Dosage Regimen
In subjects weighing more than 100 kg, 45 mg was also shown to be efficacious. However, 90 mg resulted in greater efficacy in these subjects [see Clinical Studies (14)].
Subcutaneous Adult Dosage Regimen
|Body Weight of Patient at the time of dosing||Dose||Number of 130 mg/26 mL (5 mg/mL) STELARA® vials|
|55 kg or less||260 mg||2|
|more than 55 kg to 85 kg||390 mg||3|
|more than 85 kg||520 mg||4|
Refer to the diagram below for the provided instructions.
To prevent premature activation of the needle safety guard, do not touch the NEEDLE GUARD ACTIVATION CLIPS at any time during use.
STELARA® (ustekinumab) is colorless to slightly yellow solution.
STELARA® is contraindicated in patients with clinically significant hypersensitivity to ustekinumab or to any of the excipients [see Warnings and Precautions (5.5)].
STELARA® may increase the risk of infections and reactivation of latent infections. Serious bacterial, fungal, and viral infections were observed in subjects receiving STELARA® [see Adverse Reactions (6.1)].
Serious infections requiring hospitalization occurred in patients with psoriasis, psoriatic arthritis and Crohn's disease in clinical studies. In patients with psoriasis, serious infections included diverticulitis, cellulitis, pneumonia, appendicitis, cholecystitis, sepsis, osteomyelitis, viral infections, gastroenteritis and urinary tract infections. In patients with psoriatic arthritis, serious infections included cholecystitis. In patients with Crohn's disease, serious or other clinically significant infections included anal abscess, gastroenteritis, ophthalmic herpes, pneumonia, and listeria meningitis.
Treatment with STELARA® should not be initiated in patients with any clinically important active infection until the infection resolves or is adequately treated. Consider the risks and benefits of treatment prior to initiating use of STELARA® in patients with a chronic infection or a history of recurrent infection.
Instruct patients to seek medical advice if signs or symptoms suggestive of an infection occur while on treatment with STELARA® and consider discontinuing STELARA® for serious or clinically significant infections until the infection resolves or is adequately treated.
Individuals genetically deficient in IL-12/IL-23 are particularly vulnerable to disseminated infections from mycobacteria (including nontuberculous, environmental mycobacteria), salmonella (including nontyphi strains), and Bacillus Calmette-Guerin (BCG) vaccinations. Serious infections and fatal outcomes have been reported in such patients.
It is not known whether patients with pharmacologic blockade of IL-12/IL-23 from treatment with STELARA® may be susceptible to these types of infections. Appropriate diagnostic testing should be considered, e.g., tissue culture, stool culture, as dictated by clinical circumstances.
Evaluate patients for tuberculosis infection prior to initiating treatment with STELARA®.
Do not administer STELARA® to patients with active tuberculosis infection. Initiate treatment of latent tuberculosis prior to administering STELARA®. Consider anti-tuberculosis therapy prior to initiation of STELARA® in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed. Closely monitor patients receiving STELARA® for signs and symptoms of active tuberculosis during and after treatment.
STELARA® is an immunosuppressant and may increase the risk of malignancy. Malignancies were reported among subjects who received STELARA® in clinical studies [see Adverse Reactions (6.1)]. In rodent models, inhibition of IL-12/IL-23p40 increased the risk of malignancy [see Nonclinical Toxicology (13)].
The safety of STELARA® has not been evaluated in patients who have a history of malignancy or who have a known malignancy.
There have been post marketing reports of the rapid appearance of multiple cutaneous squamous cell carcinomas in patients receiving STELARA® who had pre-existing risk factors for developing non-melanoma skin cancer. All patients receiving STELARA® should be monitored for the appearance of non-melanoma skin cancer. Patients greater than 60 years of age, those with a medical history of prolonged immunosuppressant therapy and those with a history of PUVA treatment should be followed closely [see Adverse Reactions (6.1)].
Hypersensitivity reactions, including anaphylaxis and angioedema, have been reported with STELARA® [see Adverse Reactions (6.1, 6.3)]. If an anaphylactic or other clinically significant hypersensitivity reaction occurs, institute appropriate therapy and discontinue STELARA®.
One case of reversible posterior leukoencephalopathy syndrome (RPLS) was observed in clinical studies of psoriasis and psoriatic arthritis. The subject, who had received 12 doses of STELARA® over approximately two years, presented with headache, seizures and confusion. No additional STELARA® injections were administered and the subject fully recovered with appropriate treatment. No cases of RPLS were observed in clinical studies of Crohn's disease.
RPLS is a neurological disorder, which is not caused by demyelination or a known infectious agent. RPLS can present with headache, seizures, confusion and visual disturbances. Conditions with which it has been associated include preeclampsia, eclampsia, acute hypertension, cytotoxic agents and immunosuppressive therapy. Fatal outcomes have been reported.
If RPLS is suspected, administer appropriate treatment and discontinue STELARA®.
Prior to initiating therapy with STELARA®, patients should receive all age-appropriate immunizations as recommended by current immunization guidelines. Patients being treated with STELARA® should not receive live vaccines. BCG vaccines should not be given during treatment with STELARA® or for one year prior to initiating treatment or one year following discontinuation of treatment. Caution is advised when administering live vaccines to household contacts of patients receiving STELARA® because of the potential risk for shedding from the household contact and transmission to patient.
Non-live vaccinations received during a course of STELARA® may not elicit an immune response sufficient to prevent disease.
In clinical studies of psoriasis the safety of STELARA® in combination with other immunosuppressive agents or phototherapy was not evaluated. Ultraviolet-induced skin cancers developed earlier and more frequently in mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone [see Nonclinical Toxicology (13.1)].
The following serious adverse reactions are discussed elsewhere in the label:
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The safety data reflect exposure to STELARA® in 3117 psoriasis subjects, including 2414 exposed for at least 6 months, 1855 exposed for at least one year, 1653 exposed for at least two years, 1569 exposed for at least three years, 1482 exposed for at least four years and 838 exposed for at least five years.
Table 2 summarizes the adverse reactions that occurred at a rate of at least 1% and at a higher rate in the STELARA® groups than the placebo group during the placebo-controlled period of Ps STUDY 1 and Ps STUDY 2 [see Clinical Studies (14)].
|Placebo||45 mg||90 mg|
|Nasopharyngitis||51 (8%)||56 (8%)||49 (7%)|
|Upper respiratory tract infection||30 (5%)||36 (5%)||28 (4%)|
|Headache||23 (3%)||33 (5%)||32 (5%)|
|Fatigue||14 (2%)||18 (3%)||17 (3%)|
|Diarrhea||12 (2%)||13 (2%)||13 (2%)|
|Back pain||8 (1%)||9 (1%)||14 (2%)|
|Dizziness||8 (1%)||8 (1%)||14 (2%)|
|Pharyngolaryngeal pain||7 (1%)||9 (1%)||12 (2%)|
|Pruritus||9 (1%)||10 (2%)||9 (1%)|
|Injection site erythema||3 (<1%)||6 (1%)||13 (2%)|
|Myalgia||4 (1%)||7 (1%)||8 (1%)|
|Depression||3 (<1%)||8 (1%)||4 (1%)|
Adverse reactions that occurred at rates less than 1% in the controlled period of Ps STUDIES 1 and 2 through week 12 included: cellulitis, herpes zoster, diverticulitis and certain injection site reactions (pain, swelling, pruritus, induration, hemorrhage, bruising, and irritation).
One case of RPLS occurred during clinical studies [see Warnings and Precautions (5.6)].
In the placebo-controlled period of clinical studies of psoriasis subjects (average follow-up of 12.6 weeks for placebo-treated subjects and 13.4 weeks for STELARA®-treated subjects), 27% of STELARA®-treated subjects reported infections (1.39 per subject-year of follow-up) compared with 24% of placebo-treated subjects (1.21 per subject-year of follow-up). Serious infections occurred in 0.3% of STELARA®-treated subjects (0.01 per subject-year of follow-up) and in 0.4% of placebo-treated subjects (0.02 per subject-year of follow-up) [see Warnings and Precautions (5.1)].
In the controlled and non-controlled portions of psoriasis clinical studies (median follow-up of 3.2 years), representing 8998 subject-years of exposure, 72.3% of STELARA®-treated subjects reported infections (0.87 per subject-years of follow-up). Serious infections were reported in 2.8% of subjects (0.01 per subject-years of follow-up).
In the controlled and non-controlled portions of psoriasis clinical studies (median follow-up of 3.2 years, representing 8998 subject-years of exposure), 1.7% of STELARA®-treated subjects reported malignancies excluding non-melanoma skin cancers (0.60 per hundred subject-years of follow-up). Non-melanoma skin cancer was reported in 1.5% of STELARA®-treated subjects (0.52 per hundred subject-years of follow-up) [see Warnings and Precautions (5.4)]. The most frequently observed malignancies other than non-melanoma skin cancer during the clinical studies were: prostate, melanoma, colorectal and breast. Malignancies other than non-melanoma skin cancer in STELARA®-treated patients during the controlled and uncontrolled portions of studies were similar in type and number to what would be expected in the general U.S. population according to the SEER database (adjusted for age, gender and race).1
The safety of STELARA® was assessed in 927 patients in two randomized, double-blind, placebo-controlled studies in adult patients with active psoriatic arthritis (PsA). The overall safety profile of STELARA® in patients with PsA was consistent with the safety profile seen in psoriasis clinical studies. A higher incidence of arthralgia, nausea, and dental infections was observed in STELARA®-treated patients when compared with placebo-treated patients (3% vs. 1% for arthralgia and 3% vs. 1% for nausea; 1% vs. 0.6% for dental infections) in the placebo-controlled portions of the PsA clinical studies.
The safety of STELARA® was assessed in 1407 patients with moderately to severely active Crohn's disease (Crohn's Disease Activity Index [CDAI] greater than or equal to 220 and less than or equal to 450) in three randomized, double-blind, placebo-controlled, parallel-group, multicenter studies. These 1407 patients included 40 patients who received a prior investigational intravenous ustekinumab formulation but were not included in the efficacy analyses. In Studies CD-1 and CD-2 there were 470 patients who received STELARA® 6 mg/kg as a weight-based single intravenous induction dose and 466 who received placebo [see Dosage and Administration (2.3)]. Patients who were responders in either Study CD-1 or CD-2 were randomized to receive a subcutaneous maintenance regimen of either 90 mg STELARA® every 8 weeks, or placebo for 44 weeks in Study CD-3. Patients in these 3 studies may have received other concomitant therapies including aminosalicylates, immunomodulatory agents [azathioprine (AZA), 6-mercaptopurine (6-MP), methotrexate (MTX)], oral corticosteroids (prednisone or budesonide), and/or antibiotics for their Crohn's Disease [see Clinical Studies (14.3)].
The overall safety profile of STELARA® was consistent with the safety profile seen in the psoriasis and psoriatic arthritis clinical studies. Common adverse reactions in Studies CD-1 and CD-2 and in Study CD-3 are listed in Tables 3 and 4, respectively.
6 mg/kg single intravenous induction dose
Other less common adverse reactions reported in patients in Studies CD-1 and CD-2 included asthenia (1% vs 0.4%), acne (1% vs 0.4%), and pruritus (2% vs 0.4%).
90 mg subcutaneous maintenance dose every 8 weeks
|Injection site erythema||0||5%|
|Vulvovaginal candidiasis/mycotic infection||1%||5%|
|Urinary tract infection||2%||4%|
With up to one year of treatment in the Crohn's disease clinical studies, 0.2% of STELARA®-treated patients (0.36 events per hundred patient-years) and 0.2% of placebo-treated patients (0.58 events per hundred patient-years) developed non-melanoma skin cancer. Malignancies other than non-melanoma skin cancers occurred in 0.2% of STELARA®-treated patients (0.27 events per hundred patient-years) and in none of the placebo-treated patients.
Hypersensitivity Reactions Including Anaphylaxis
In CD studies, two patients reported hypersensitivity reactions following STELARA® administration. One patient experienced signs and symptoms consistent with anaphylaxis (tightness of the throat, shortness of breath, and flushing) after a single subcutaneous administration (0.1% of patients receiving subcutaneous STELARA®). In addition, one patient experienced signs and symptoms consistent with or related to a hypersensitivity reaction (chest discomfort, flushing, urticaria, and increased body temperature) after the initial intravenous STELARA® dose (0.08% of patients receiving intravenous STELARA®). These patients were treated with oral antihistamines or corticosteroids and in both cases symptoms resolved within an hour.
Approximately 6% of patients treated with STELARA® in psoriasis and psoriatic arthritis clinical studies developed antibodies to ustekinumab, which were generally low-titer. In Crohn's disease clinical studies, less than 3% of patients treated with STELARA® developed antibodies to ustekinumab. No apparent association between the development of antibodies to ustekinumab and the development of injection site reactions was seen. No ustekinumab-related serious hypersensitivity reactions were observed in psoriasis, psoriatic arthritis and Crohn's disease clinical studies. In psoriasis studies, the majority of patients who were positive for antibodies to ustekinumab had neutralizing antibodies.
The data above reflect the percentage of subjects whose test results were positive for antibodies to ustekinumab 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 ustekinumab with the incidence of antibodies to other products may be misleading.
The following adverse reactions have been reported during post-approval of STELARA®. 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 STELARA® exposure.
Immune system disorders: Serious hypersensitivity reactions (including anaphylaxis and angioedema), other hypersensitivity reactions (including rash and urticaria) [see Warnings and Precautions (5.5)].
Skin reactions: Pustular psoriasis, erythrodermic psoriasis.
Avoid use of live vaccines with STELARA® [see Warnings and Precautions (5.7)].
In psoriasis studies the safety of STELARA® in combination with immunosuppressive agents or phototherapy has not been evaluated [see Warnings and Precautions (5.8)]. In psoriatic arthritis studies, concomitant methotrexate use did not appear to influence the safety or efficacy of STELARA®. In Crohn's disease studies, immunomodulators (6-mercaptopurine, azathioprine, methotrexate) were used concomitantly in approximately 30% of patients and corticosteroids were used concomitantly in approximately 40% of patients. Use of these concomitant therapies did not appear to influence the overall safety or efficacy of STELARA®.
The formation of CYP450 enzymes can be altered by increased levels of certain cytokines (e.g., IL-1, IL-6, IL-10, TNFα, IFN) during chronic inflammation. Thus, STELARA®, an antagonist of IL-12 and IL-23, could normalize the formation of CYP450 enzymes. Upon initiation of STELARA® in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, monitoring for therapeutic effect (e.g., for warfarin) or drug concentration (e.g., for cyclosporine) should be considered and the individual dose of the drug adjusted as needed [see Clinical Pharmacology (12.3)].
STELARA® has not been evaluated in patients who have undergone allergy immunotherapy. STELARA® may decrease the protective effect of allergen immunotherapy (decrease tolerance) which may increase the risk of an allergic reaction to a dose of allergen immunotherapy. Therefore, caution should be exercised in patients receiving or who have received allergen immunotherapy, particularly for anaphylaxis.
Pregnancy Exposure Registry
There is a pregnancy registry that monitors pregnancy outcomes in women exposed to STELARA® during pregnancy. Patients should be encouraged to enroll by calling 1-877-311-8972.
Limited data on the use of STELARA® in pregnant women are insufficient to inform a drug associated risk [see Data]. In animal reproductive and developmental toxicity studies, no adverse developmental effects were observed after administration of ustekinumab to pregnant monkeys at exposures greater than 100 times the human exposure at the maximum recommended human subcutaneous dose (MRHD).
All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. The estimated background risk of major birth defects and miscarriage for the indicated population(s) are unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage of clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Limited data on use of STELARA® in pregnant women from observational studies, published case reports, and postmarketing surveillance are insufficient to inform a drug associated risk.
Ustekinumab was tested in two embryo-fetal development toxicity studies in cynomolgus monkeys. No teratogenic or other adverse developmental effects were observed in fetuses from pregnant monkeys that were administered ustekinumab subcutaneously twice weekly or intravenously weekly during the period of organogenesis. Serum concentrations of ustekinumab in pregnant monkeys were greater than 100 times the serum concentration in patients treated subcutaneously with 90 mg of ustekinumab weekly for 4 weeks.
In a combined embryo-fetal development and pre- and post-natal development toxicity study, pregnant cynomolgus monkeys were administered subcutaneous doses of ustekinumab twice weekly at exposures greater than 100 times the human subcutaneous exposure from the beginning of organogenesis to Day 33 after delivery. Neonatal deaths occurred in the offspring of one monkey administered ustekinumab at 22.5 mg/kg and one monkey dosed at 45 mg/kg. No ustekinumab-related effects on functional, morphological, or immunological development were observed in the neonates from birth through six months of age.
There are no data on the presence of ustekinumab in human milk, the effects on the breastfed infant, or the effects on milk production. Ustekinumab was present in the milk of lactating monkeys administered ustekinumab. Due to species-specific differences in lactation physiology, animal data may not reliably predict drug levels in human milk. Maternal IgG is known to be present in human milk. Published data suggest that the systemic exposure to a breastfed infant is expected to be low because ustekinumab is a large molecule and is degraded in the gastrointestinal tract. However, if ustekinumab is transferred into human milk the effects of local exposure in the gastrointestinal tract are unknown.
The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for STELARA® and any potential adverse effects on the breastfed child from STELARA® or from the underlying maternal condition.
The safety and effectiveness of STELARA® in pediatric patients have not been established.
Of the 5884 subjects exposed to STELARA®, a total of 306 were 65 years or older (183 patients with psoriasis, 65 patients with psoriatic arthritis and 58 with Crohn's disease), and 34 subjects were 75 years or older. Although no differences in safety or efficacy were observed between older and younger subjects, the number of subjects aged 65 and over is not sufficient to determine whether they respond differently from younger subjects.
Single doses up to 6 mg/kg intravenously have been administered in clinical studies without dose-limiting toxicity. 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 be instituted immediately.
Ustekinumab is a human IgG1κ monoclonal antibody against the p40 subunit of the IL-12 and IL-23 cytokines. Using DNA recombinant technology, ustekinumab is produced in a well characterized recombinant cell line and is purified using standard bio-processing technology. The manufacturing process contains steps for the clearance of viruses. Ustekinumab is comprised of 1326 amino acids and has an estimated molecular mass that ranges from 148,079 to 149,690 Daltons.
STELARA® (ustekinumab) Injection is a sterile, preservative-free, colorless to slightly yellow solution that may contain a few small translucent or white particles with pH of 5.7– 6.3.
STELARA® for Subcutaneous Use
Available as 45 mg of ustekinumab in 0.5 mL and 90 mg of ustekinumab in 1 mL, supplied as a sterile solution in a single-dose prefilled syringe with a 27 gauge fixed ½ inch needle and as 45 mg of ustekinumab in 0.5 mL in a single-dose 2 mL Type I glass vial with a coated stopper. The syringe is fitted with a passive needle guard and a needle cover that contains dry natural rubber (a derivative of latex).
Each 0.5 mL prefilled syringe or vial delivers 45 mg ustekinumab, L-histidine and L-histidine monohydrochloride monohydrate (0.5 mg), Polysorbate 80 (0.02 mg), and sucrose (38 mg).
Each 1 mL prefilled syringe delivers 90 mg ustekinumab, L-histidine and L-histidine monohydrochloride monohydrate (1 mg), Polysorbate 80 (0.04 mg), and sucrose (76 mg).
STELARA® for Intravenous Infusion
Available as 130 mg of ustekinumab in 26 mL, supplied as a single-dose 30 mL Type I glass vial with a coated stopper.
Each 26 mL vial delivers 130 mg ustekinumab, EDTA disodium salt dihydrate (0.52 mg), L-histidine (20 mg), L-histidine hydrochloride monohydrate (27 mg), L-methionine (10.4 mg), Polysorbate 80 (10.4 mg) and sucrose (2210 mg).
Ustekinumab is a human IgG1қ monoclonal antibody that binds with specificity to the p40 protein subunit used by both the IL-12 and IL-23 cytokines. IL-12 and IL-23 are naturally occurring cytokines that are involved in inflammatory and immune responses, such as natural killer cell activation and CD4+ T-cell differentiation and activation. In in vitro models, ustekinumab was shown to disrupt IL-12 and IL-23 mediated signaling and cytokine cascades by disrupting the interaction of these cytokines with a shared cell-surface receptor chain, IL-12Rβ1. The cytokines IL-12 and IL-23 have been implicated as important contributors to the chronic inflammation that is a hallmark of Crohn's Disease. In animal models of colitis, genetic absence or antibody blockade of the p40 subunit of IL-12 and IL-23, the target of ustekinumab, was shown to be protective.
In a small exploratory study, a decrease was observed in the expression of mRNA of its molecular targets IL-12 and IL-23 in lesional skin biopsies measured at baseline and up to two weeks post-treatment in subjects with psoriasis.
In subjects with psoriasis, the median time to reach the maximum serum concentration (Tmax) was 13.5 days and 7 days, respectively, after a single subcutaneous administration of 45 mg (N=22) and 90 mg (N=24) of ustekinumab. In healthy subjects (N=30), the median Tmax value (8.5 days) following a single subcutaneous administration of 90 mg of ustekinumab was comparable to that observed in subjects with psoriasis.
Following multiple subcutaneous doses of STELARA® in patients with psoriasis, the steady-state serum concentrations of ustekinumab were achieved by Week 28. There was no apparent accumulation in serum ustekinumab concentration over time when given subcutaneously every 12 weeks.
In patients with Crohn's disease, following the recommended intravenous induction dose, mean peak serum ustekinumab concentration was 125.2 ± 33.6 mcg/mL. Starting at Week 8, the recommended subcutaneous maintenance dosing of 90 mg ustekinumab was administered every 8 weeks. Steady state ustekinumab concentration was achieved by the start of the second maintenance dose. There was no apparent accumulation in ustekinumab concentration over time when given subcutaneously every 8 weeks. Mean steady-state trough concentration was 2.51 ± 2.06 mcg/mL for 90 mg ustekinumab administered every 8 weeks.
In a population pharmacokinetic analysis of ustekinumab, the volume of distribution of the central compartment was 2.74 L (95% CI: 2.69, 2.78), and the total volume of distribution at steady-state was 4.62 L in patients with Crohn's disease.
The mean (±SD) half-life ranged from 14.9 ± 4.6 to 45.6 ± 80.2 days across all psoriasis studies following subcutaneous administration. In a population pharmacokinetic analysis of ustekinumab, the clearance was 0.19 L/day (95% CI: 0.185, 0.197) with an estimated median terminal half-life of approximately 19 days in patients with Crohn's disease.
The metabolic pathway of ustekinumab has not been characterized. As a human IgG1κ monoclonal antibody ustekinumab is expected to be degraded into small peptides and amino acids via catabolic pathways in the same manner as endogenous IgG.
When given the same dose, subjects with psoriasis or psoriatic arthritis weighing more than 100 kg had lower median serum ustekinumab concentrations compared with those subjects weighing 100 kg or less. The median trough serum concentrations of ustekinumab in subjects of higher weight (greater than 100 kg) in the 90 mg group were comparable to those in subjects of lower weight (100 kg or less) in the 45 mg group.
Age: Geriatric Population
A population pharmacokinetic analysis (N=106/1937 patients with psoriasis greater than or equal to 65 years old) was performed to evaluate the effect of age on the pharmacokinetics of ustekinumab. There were no apparent changes in pharmacokinetic parameters (clearance and volume of distribution) in subjects older than 65 years old.
Drug Interaction Studies
The effects of IL-12 or IL-23 on the regulation of CYP450 enzymes were evaluated in an in vitro study using human hepatocytes, which showed that IL-12 and/or IL-23 at levels of 10 ng/mL did not alter human CYP450 enzyme activities (CYP1A2, 2B6, 2C9, 2C19, 2D6, or 3A4). However, the clinical relevance of in vitro data has not been established [see Drug Interactions (7.3)].
No in vivo drug interaction studies have been conducted with STELARA®.
Population pharmacokinetic data analyses indicated that the clearance of ustekinumab was not impacted by concomitant MTX, NSAIDs, and oral corticosteroids, or prior exposure to a TNF blocker in patients with psoriatic arthritis.
Animal studies have not been conducted to evaluate the carcinogenic or mutagenic potential of STELARA®. Published literature showed that administration of murine IL-12 caused an anti-tumor effect in mice that contained transplanted tumors and IL-12/IL-23p40 knockout mice or mice treated with anti-IL-12/IL-23p40 antibody had decreased host defense to tumors. Mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone developed UV-induced skin cancers earlier and more frequently compared to wild-type mice. The relevance of these experimental findings in mouse models for malignancy risk in humans is unknown.
No effects on fertility were observed in male cynomolgus monkeys that were administered ustekinumab at subcutaneous doses up to 45 mg/kg twice weekly (45 times the MRHD on a mg/kg basis) prior to and during the mating period. However, fertility and pregnancy outcomes were not evaluated in mated females.
No effects on fertility were observed in female mice that were administered an analogous IL-12/IL-23p40 antibody by subcutaneous administration at doses up to 50 mg/kg, twice weekly, prior to and during early pregnancy.
Two multicenter, randomized, double-blind, placebo-controlled studies (Ps STUDY 1 and Ps STUDY 2) enrolled a total of 1996 subjects 18 years of age and older with plaque psoriasis who had a minimum body surface area involvement of 10%, and Psoriasis Area and Severity Index (PASI) score ≥12, and who were candidates for phototherapy or systemic therapy. Subjects with guttate, erythrodermic, or pustular psoriasis were excluded from the studies.
Ps STUDY 1 enrolled 766 subjects and Ps STUDY 2 enrolled 1230 subjects. The studies had the same design through Week 28. In both studies, subjects were randomized in equal proportion to placebo, 45 mg or 90 mg of STELARA®. Subjects randomized to STELARA® received 45 mg or 90 mg doses, regardless of weight, at Weeks 0, 4, and 16. Subjects randomized to receive placebo at Weeks 0 and 4 crossed over to receive STELARA® (either 45 mg or 90 mg) at Weeks 12 and 16.
In both studies, the endpoints were the proportion of subjects who achieved at least a 75% reduction in PASI score (PASI 75) from baseline to Week 12 and treatment success (cleared or minimal) on the Physician's Global Assessment (PGA). The PGA is a 6-category scale ranging from 0 (cleared) to 5 (severe) that indicates the physician's overall assessment of psoriasis focusing on plaque thickness/induration, erythema, and scaling.
In both studies, subjects in all treatment groups had a median baseline PASI score ranging from approximately 17 to 18. Baseline PGA score was marked or severe in 44% of subjects in Ps STUDY 1 and 40% of subjects in Ps STUDY 2. Approximately two-thirds of all subjects had received prior phototherapy, 69% had received either prior conventional systemic or biologic therapy for the treatment of psoriasis, with 56% receiving prior conventional systemic therapy and 43% receiving prior biologic therapy. A total of 28% of subjects had a history of psoriatic arthritis.
The results of Ps STUDY 1 and Ps STUDY 2 are presented in Table 5 below.
|Week 12||Ps STUDY 1||Ps STUDY 2|
|Placebo||45 mg||90 mg||Placebo||45 mg||90 mg|
|PASI 75 response||8 (3%)||171 (67%)||170 (66%)||15 (4%)||273 (67%)||311 (76%)|
|PGA of Cleared or Minimal||10 (4%)||151 (59%)||156 (61%)||18 (4%)||277 (68%)||300 (73%)|
Examination of age, gender, and race subgroups did not identify differences in response to STELARA® among these subgroups.
In subjects who weighed 100 kg or less, response rates were similar with both the 45 mg and 90 mg doses; however, in subjects who weighed greater than 100 kg, higher response rates were seen with 90 mg dosing compared with 45 mg dosing (Table 6 below).
|Ps STUDY 1||Ps STUDY 2|
|Placebo||45 mg||90 mg||Placebo||45 mg||90 mg|
|PASI 75 response at Week 12*|
|PGA of Cleared or Minimal at Week 12*|
Subjects in Ps STUDY 1 who were PASI 75 responders at both Weeks 28 and 40 were re-randomized at Week 40 to either continued dosing of STELARA® (STELARA® at Week 40) or to withdrawal of therapy (placebo at Week 40). At Week 52, 89% (144/162) of subjects re-randomized to STELARA® treatment were PASI 75 responders compared with 63% (100/159) of subjects re-randomized to placebo (treatment withdrawal after Week 28 dose). The median time to loss of PASI 75 response among the subjects randomized to treatment withdrawal was 16 weeks.
The safety and efficacy of STELARA® was assessed in 927 patients (PsA STUDY 1, n=615; PsA STUDY 2, n=312), in two randomized, double-blind, placebo-controlled studies in adult patients 18 years of age and older with active PsA (≥5 swollen joints and ≥5 tender joints) despite non-steroidal anti-inflammatory (NSAID) or disease modifying antirheumatic (DMARD) therapy. Patients in these studies had a diagnosis of PsA for at least 6 months. Patients with each subtype of PsA were enrolled, including polyarticular arthritis with the absence of rheumatoid nodules (39%), spondylitis with peripheral arthritis (28%), asymmetric peripheral arthritis (21%), distal interphalangeal involvement (12%) and arthritis mutilans (0.5%). Over 70% and 40% of the patients, respectively, had enthesitis and dactylitis at baseline.
Patients were randomized to receive treatment with STELARA® 45 mg, 90 mg, or placebo subcutaneously at Weeks 0 and 4 followed by every 12 weeks (q12w) dosing. Approximately 50% of patients continued on stable doses of MTX (≤25 mg/week). The primary endpoint was the percentage of patients achieving ACR 20 response at Week 24.
In PsA STUDY 1 and PsA STUDY 2, 80% and 86% of the patients, respectively, had been previously treated with DMARDs. In PsA STUDY 1, previous treatment with anti-tumor necrosis factor (TNF)-α agent was not allowed. In PsA STUDY 2, 58% (n=180) of the patients had been previously treated with TNF blocker, of whom over 70% had discontinued their TNF blocker treatment for lack of efficacy or intolerance at any time.
In both studies, a greater proportion of patients achieved ACR 20, ACR 50 and PASI 75 response in the STELARA® 45 mg and 90 mg groups compared to placebo at Week 24 (see Table 7). ACR 70 responses were also higher in the STELARA® 45 mg and 90 mg groups, although the difference was only numerical (p=NS) in STUDY 2. Responses were similar in patients regardless of prior TNFα exposure.
|PsA STUDY 1||PsA STUDY 2|
|Placebo||45 mg||90 mg||Placebo||45 mg||90 mg|
|Number of patients randomized||206||205||204||104||103||105|
|ACR 20 response, N (%)||47 (23%)||87 (42%)||101 (50%)||21 (20%)||45 (44%)||46 (44%)|
|ACR 50 response, N (%)||18 (9%)||51 (25%)||57 (28%)||7 (7%)||18 (17%)||24 (23%)|
|ACR 70 response, N (%)||5 (2%)||25 (12%)||29 (14%)||3 (3%)||7 (7%)||9 (9%)|
|Number of patients with ≥ 3% BSA*||146||145||149||80||80||81|
|PASI 75 response, N (%)||16 (11%)||83 (57%)||93 (62%)||4 (5%)||41 (51%)||45 (56%)|
The percent of patients achieving ACR 20 responses by visit is shown in Figure 1.
Figure 1: Percent of patients achieving ACR 20 response through Week 24
|PsA STUDY 1|
The results of the components of the ACR response criteria are shown in Table 8.
|PsA STUDY 1|
|Number of swollen joints*|
|Mean Change at Week 24||-3||-5||-6|
|Number of tender joints †|
|Mean Change at Week 24||-4||-8||-9|
|Patient's assessment of pain‡|
|Mean Change at Week 24||-0.5||-2.0||-2.6|
|Patient global assessment‡|
|Mean Change at Week 24||-0.5||-2.0||-2.5|
|Physician global assessment‡|
|Mean Change at Week 24||-1.4||-2.6||-3.1|
|Disability index (HAQ)§|
|Mean Change at Week 24||-0.1||-0.3||-0.4|
|Mean Change at Week 24||0.01||-0.5||-0.8|
An improvement in enthesitis and dactylitis scores was observed in each STELARA® group compared with placebo at Week 24.
STELARA® treated patients showed improvement in physical function compared to patients treated with placebo as assessed by HAQ-DI at Week 24. In both studies, the proportion of HAQ-DI responders (≥0.3 improvement in HAQ-DI score) was greater in the STELARA® 45 mg and 90 mg groups compared to placebo at Week 24.
STELARA® was evaluated in three randomized, double-blind, placebo-controlled clinical studies in adult patients with moderately to severely active Crohn's disease (Crohn's Disease Activity Index [CDAI] score of 220 to 450). There were two 8-week intravenous induction studies (CD-1 and CD-2) followed by a 44-week subcutaneous randomized withdrawal maintenance study (CD-3) representing 52 weeks of therapy.
Studies CD-1 and CD-2
In studies CD-1 and CD-2, 1409 patients were randomized, of whom 1368 (CD-1, n=741; CD-2, n=627) were included in the final efficacy analysis. Induction of clinical response (defined as a reduction in CDAI score of greater than or equal to 100 points or CDAI score of less than 150) at Week 6 and clinical remission (defined as a CDAI score of less than 150) at Week 8 were evaluated. In both studies, patients were randomized to receive a single intravenous administration of STELARA® at either approximately 6 mg/kg, placebo (see Table 1), or 130 mg (a lower dose than recommended).
In Study CD-1, patients had failed or were intolerant to prior treatment with a TNF blocker: 29% patients had an inadequate initial response (primary non-responders), 69% responded but subsequently lost response (secondary non-responders) and 36% were intolerant to a TNF blocker. Of these patients, 48% failed or were intolerant to one TNF blocker and 52% had failed 2 or 3 prior TNF blockers. At baseline and throughout the study, approximately 46% of the patients were receiving corticosteroids and 31% of the patients were receiving immunomodulators (azathioprine, 6-mercaptopurine, methotrexate). The median baseline CDAI score was 319 in the STELARA® approximately 6 mg/kg group and 313 in the placebo group.
In Study CD-2, patients had failed or were intolerant to prior treatment with corticosteroids (81% of patients), at least one immunomodulator (6-mercaptopurine, azathioprine, methotrexate; 68% of patients), or both (49% of patients). Additionally, 69% never received a TNF blocker and 31% previously received but had not failed a TNF blocker. At baseline, and throughout the study, approximately 39% of the patients were receiving corticosteroids and 35% of the patients were receiving immunomodulators (azathioprine, 6-mercaptopurine, methotrexate). The median baseline CDAI score was 286 in the STELARA® and 290 in the placebo group.
In these induction studies, a greater proportion of patients treated with STELARA® achieved clinical response at Week 6 and clinical remission at Week 8 compared to placebo (see Table 9 for clinical response and remission rates). Clinical response and remission were significant as early as Week 3 in STELARA® treated patients and continued to improve through Week 8.
|Treatment difference and 95% CI||Placebo
|Treatment difference and 95% CI|
|Clinical remission is defined as CDAI score < 150; Clinical response is defined as reduction in CDAI score by at least 100 points or being in clinical remission:|
|70 point response is defined as reduction in CDAI score by at least 70 points|
|Clinical Response (100 point), Week 6||53 (21%)||84 (34%)§||12%
|60 (29%)||116 (56%)¶||27%
|Clinical Remission, Week 8||18 (7%)||52 (21%)¶||14%
|41 (20%)||84 (40%)¶||21%
|Clinical Response (100 point), Week 8||50 (20%)||94 (38%)¶||18%
|67 (32%)||121 (58%)¶||26%
|70 Point Response, Week 6||75 (30%)||109 (44%)§||13%
|81 (39%)||135 (65%)¶||26%
|70 Point Response, Week 3||67 (27%)||101 (41%)§||13%
|66 (32%)||106 (51%)¶||19%
The maintenance study (CD-3), evaluated 388 patients who achieved clinical response (≥100 point reduction in CDAI score) at Week 8 of induction with STELARA® in studies CD-1 or CD-2. Patients were randomized to receive a subcutaneous maintenance regimen of either 90 mg STELARA® every 8 weeks or placebo for 44 weeks (see Table 10).
|Placebo*||90 mg STELARA® every 8 weeks||Treatment difference and 95% CI|
|Clinical remission is defined as CDAI score < 150; Clinical response is defined as reduction in CDAI of at least 100 points or being in clinical remission|
|Clinical Remission||47 (36%)||68 (53%)‡||17%
|Clinical Response||58 (44%)||76 (59%)§||15%
|Clinical Remission in patients in remission at the start of maintenance therapy¶||36/79 (46%)||52/78 (67%)‡||21%
At Week 44, 47% of patients who received STELARA® were corticosteroid-free and in clinical remission, compared to 30% of patients in the placebo group.
At Week 0 of Study CD-3, 34/56 (61%) STELARA® treated patients who previously failed or were intolerant to TNF blocker therapies were in clinical remission and 23/56 (41%) of these patients were in clinical remission at Week 44. In the placebo arm, 27/61 (44%) patients were in clinical remission at Week 0 while 16/61 (26%) of these patients were in remission at Week 44.
At Week 0 of Study CD-3, 46/72 (64%) STELARA® treated patients who had previously failed immunomodulator therapy or corticosteroids (but not TNF blockers) were in clinical remission and 45/72 (63%) of these patients were in clinical remission at Week 44. In the placebo arm, 50/70 (71%) of these patients were in clinical remission at Week 0 while 31/70 (44%) were in remission at Week 44. In the subset of these patients who were also naïve to TNF blockers, 34/52 (65%) of STELARA® treated patients were in clinical remission at Week 44 as compared to 25/51 (49%) in the placebo arm.
Patients who were not in clinical response 8 weeks after STELARA® induction were not included in the primary efficacy analyses for Study CD-3; however, these patients were eligible to receive a 90 mg subcutaneous injection of STELARA® upon entry into Study CD-3. Of these patients, 102/219 (47%) achieved clinical response eight weeks later and were followed for the duration of the study.
STELARA® (ustekinumab) Injection is a sterile, preservative-free, colorless to slightly yellow solution. STELARA® is available in single-dose prefilled syringes containing 45 mg or 90 mg or single-dose vials containing 45 mg of ustekinumab for subcutaneous use. Each prefilled syringe is equipped with a 27 gauge fixed ½ inch needle, a needle safety guard, and a needle cover that contains dry natural rubber.
STELARA® is also available in single-dose vials containing 130 mg ustekinumab for intravenous use.
|45 mg/0.5 mL single-dose prefilled syringe||57894-060-03|
|90 mg/mL single-dose prefilled syringe||57894-061-03|
|45 mg/0.5 mL single-dose vial||57894-060-02|
|130 mg/26 mL (5 mg/mL) single-dose vial||57894-054-27|
Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use)
Inform patients that STELARA® may lower the ability of their immune system to fight infections and to contact their healthcare provider immediately if they develop any signs or symptoms of infection [see Warnings and Precautions (5.1)].
Inform patients of the risk of developing malignancies while receiving STELARA® [see Warnings and Precautions (5.4)].
Inform patients that STELARA® can interfere with the usual response to immunizations and that they should avoid live vaccines [see Warnings and Precautions (5.7)].
Inform patients that there is a pregnancy registry to monitor fetal outcomes of pregnant women exposed to STELARA® [see Use in Specific Populations (8.1)].
Prefilled Syringe Manufactured by: Janssen Biotech, Inc., Horsham, PA 19044, US License No. 1864 at Baxter Pharmaceutical Solutions, Bloomington, IN 47403 and at Cilag AG, Schaffhausen, Switzerland
Vial Manufactured by: Janssen Biotech, Inc., Horsham, PA 19044, US License No. 1864 at Cilag AG, Schaffhausen, Switzerland
© Janssen Biotech, Inc. 2012
|This Medication Guide has been approved by the U.S. Food and Drug Administration||Issued: 09 2016|
STELARA (stel ar' a)
injection, for subcutaneous or intravenous use
|What is the most important information I should know about STELARA?
STELARA is a medicine that affects your immune system. STELARA can increase your risk of having serious side effects, including:
Serious infections: STELARA may lower the ability of your immune system to fight infections and may increase your risk of infections. Some people have serious infections while taking STELARA, including tuberculosis (TB), and infections caused by bacteria, fungi, or viruses. Some people have to be hospitalized for treatment of their infection.
You should not start taking STELARA if you have any kind of infection unless your doctor says it is okay.
Before starting STELARA, tell your doctor if you:
After starting STELARA, call your doctor right away if you have any symptoms of an infection (see above). STELARA can make you more likely to get infections or make an infection that you have worse. People who have a genetic problem where the body does not make any of the proteins interleukin 12 (IL-12) and interleukin 23 (IL-23) are at a higher risk for certain serious infections. These infections can spread throughout the body and cause death. People who take STELARA may also be more likely to get these infections.
STELARA may decrease the activity of your immune system and increase your risk for certain types of cancers. Tell your doctor if you have ever had any type of cancer. Some people who are receiving STELARA and have risk factors for skin cancer have developed certain types of skin cancers. During your treatment with STELARA, tell your doctor if you develop any new skin growths.
Reversible Posterior Leukoencephalopathy Syndrome (RPLS):
RPLS is a rare condition that affects the brain and can cause death. The cause of RPLS is not known. If RPLS is found early and treated, most people recover. Tell your doctor right away if you have any new or worsening medical problems including:
|What is STELARA?
STELARA is a prescription medicine used to treat adults 18 years and older with:
STELARA may improve your psoriasis, psoriatic arthritis or Crohn's disease, but may also lower the ability of your immune system to fight infections. Taking STELARA may also increase your risk for certain types of cancer.
It is not known if STELARA is safe and effective in children.
|Do not take STELARA if you are allergic to ustekinumab or any of the ingredients in STELARA. See the end of this Medication Guide for a complete list of ingredients in STELARA.|
Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
Know the medicines you take. Keep a list of them to show your doctor and pharmacist when you get a new medicine.
|How should I use STELARA?
What should I avoid while using STELARA?
You should not receive a live vaccine while taking STELARA. See "What should I tell my doctor before receiving STELARA?"
|What are the possible side effects of STELARA?
STELARA may cause serious side effects, including:
|Common side effects of STELARA include:|
|These are not all of the possible side effects of STELARA. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
You may also report side effects to Janssen Biotech, Inc. at 1-800 JANSSEN (1-800-526-7736).
|How should I store STELARA?
Keep STELARA and all medicines out of the reach of children.
|General information about the safe and effective use of STELARA.
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use STELARA for a condition for which it was not prescribed. Do not give STELARA to other people, even if they have the same symptoms that you have. It may harm them.
You can ask your doctor or pharmacist for information about STELARA that was written for health professionals.
|What are the ingredients in STELARA?
Active ingredient: ustekinumab
Inactive ingredients: single-dose prefilled syringe contains L-histidine, L-histidine monohydrochloride monohydrate, polysorbate 80, and sucrose. Single-dose vial contains L-histidine, L-histidine hydrochloride monohydrate, polysorbate 80 and sucrose.
Manufactured by: Janssen Biotech , Inc., Horsham, PA 19044, US License No. 1864
© 2016 Janssen Biotech, Inc.
For more information, go to www.stelarainfo.com or call 1-800-JANSSEN (1-800-526-7736).
INSTRUCTIONS FOR USE
STELARA (stel ar' a)
injection, for subcutaneous use
Instructions for injecting STELARA using a prefilled syringe.
Read this Instructions for Use before you start using STELARA. Your doctor or nurse should show you how to prepare and give your injection of STELARA the right way.
If you cannot give yourself the injection:
Do not try to inject STELARA yourself until you have been shown how to inject STELARA by your doctor, nurse or health professional.
Gather the supplies you will need to prepare and to give your injection. (See Figure A)
You will need:
Step 1: Prepare the injection.
Step 2: Prepare your injection site
*Areas in gray are recommended injection sites.
Step 3: Inject STELARA
Keep STELARA and all medicines out of the reach of children.
Prefilled Syringe Manufactured by:
Janssen Biotech, Inc., Horsham, PA 19044, US License No. 1864 at Baxter Pharmaceutical Solutions, Bloomington, IN 47403 and at Cilag AG, Schaffhausen, Switzerland
This Instructions for Use has been approved by the U.S. Food and Drug Administration.
© Janssen Biotech, Inc. 2012
PRINCIPAL DISPLAY PANEL - 45 mg/0.5 mL Vial Carton
Single use vial–
Discard unused portion
45 mg/0.5 mL
For subcutaneous use
Each vial contains 0.5 mL
Information for use and dosage–
See package insert
ATTENTION: Dispense the enclosed
Medication Guide to each patient.
PRINCIPAL DISPLAY PANEL - 90 mg/mL Syringe Carton
For subcutaneous use
Contains one 90 mg/mL syringe
Single dose prefilled syringe –
Discard unused portion
See package insert for dosing information
ATTENTION: Dispense the enclosed Medication Guide
to each patient.
ustekinumab injection, solution
ustekinumab injection, solution
|Labeler - Janssen Biotech, Inc. (099091753)|
|Patheon Biologics LLC||965750420||API MANUFACTURE(57894-060, 57894-061) , ANALYSIS(57894-060, 57894-061)|
|Cilag AG||483237103||MANUFACTURE(57894-060, 57894-061, 57894-054) , ANALYSIS(57894-060, 57894-061, 57894-054)|
|Janssen Biologics B.V.||409612918||ANALYSIS(57894-060, 57894-061, 57894-054) , API MANUFACTURE(57894-054)|
|Baxter Pharmaceutical Solutions||604719430||MANUFACTURE(57894-060, 57894-061)|
|Janssen Biologics (Ireland)||987061921||API MANUFACTURE(57894-060, 57894-061, 57894-054) , ANALYSIS(57894-060, 57894-061, 57894-054)|
|PPD Development Ireland Ltd.||985036175||ANALYSIS(57894-054)|