Metreleptin

Metreleptin
Black Box Warning
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aparna Vuppala, M.B.B.S. [2]

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Black Box Warning

WARNING See full prescribing information for complete Boxed Warning. RISK OF ANTI-METRELEPTIN ANTIBODIES WITH NEUTRALIZING ACTIVITY AND RISK OF LYMPHOMA Anti-metreleptin antibodies with neutralizing activity have been identified in patients treated with Metreleptin. The consequences of these neutralizing antibodies are not well characterized but could include inhibition of endogenous leptin action and/or loss of Metreleptin efficacy. Severe infection and/or worsening metabolic control have been reported. Test for anti-metreleptin antibodies with neutralizing activity in patients who develop severe infections or show signs suspicious for loss of Metreleptin efficacy during treatment. Contact AstraZeneca at 1-866-216-1526 for neutralizing antibody testing of clinical samples. T-cell lymphoma has been reported in patients with acquired generalized lipodystrophy, both treated and not treated with Metreleptin. Carefully consider the benefits and risks of treatment with Metreleptin in patients with significant hematologic abnormalities and/or acquired generalized lipodystrophy. Because of these risks associated with the development of anti-metreleptin antibodies that neutralize endogenous leptin and/or Metreleptin and the risk for lymphoma, Metreleptin is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the Metreleptin REMS PROGRAM

Overview

Metreleptin is a endocrine agent that is FDA approved for the treatment of the complications of leptin deficiency in patients with congenital or acquired generalized lipodystrophy.. There is a Black Box Warning for this drug as shown here. Common adverse reactions include .

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Generalized Lipodystrophy

• Patients with Generalized Lipodystrophy

• Metreleptin for injection is indicated as an adjunct to diet as replacement therapy to treat the complications of leptin deficiency in patients with congenital or acquired generalized lipodystrophy.

Limitations of Use

• The safety and effectiveness of Metreleptin for the treatment of complications of partial lipodystrophy have not been established.
• The safety and effectiveness of Metreleptin for the treatment of liver disease, including nonalcoholic steatohepatitis (NASH), have not been established.
• Metreleptin is not indicated for use in patients with HIV-related lipodystrophy.
• Metreleptin is not indicated for use in patients with metabolic disease, including diabetes mellitus and hypertriglyceridemia, without concurrent evidence of congenital or acquired generalized lipodystrophy.

Recommended Dosing

• See Table 1 for the recommended daily dose and maximum recommended daily dose in adults and pediatric patients.

• Based on clinical response (e.g., inadequate metabolic control) or other considerations (e.g., tolerability issues, excessive weight loss [especially in pediatric patients]), Metreleptin dosage may be decreased or increased to the maximum dosage listed in Table 1.

File:Metreleptin02.png

This image is provided by the National Library of Medicine.

• Metreleptin should be administered once daily at the same time every day. Metreleptin can be administered any time of day without regard to the timing of meals.

• Instruct patients that if a dose is missed, administer the dose as soon as noticed, and resume the normal dosing schedule the next day.

Metreleptin Preparation and Storage

• Healthcare practitioners should provide proper training to patients and caregivers regarding how to prepare and administer the correct dose of Metreleptin prior to self-use. The patients and caregivers should prepare and administer the first dose of Metreleptin under the supervision of a qualified healthcare professional.

• Instruct patients to store the vials of lyophilized powder in their carton in the refrigerator as soon as received .

• Metreleptin can be reconstituted aseptically with 2.2 mL of sterile Bacteriostatic Water for Injection (BWFI), USP (0.9% benzyl alcohol), or with 2.2 mL of sterile Water for Injection (WFI).

• When reconstituted in BWFI, Metreleptin solution can be used within 3 days when stored in the refrigerator between 36°F and 46°F (2°C and 8°C) and protected from light . Discard unused reconstituted solution after 3 days. Attach the supplied sticker to the vial and enter the discard date.

• For use in neonates and infants, reconstitute with preservative-free sterile WFI . When reconstituted in sterile WFI, Metreleptin should be administered immediately. Unused reconstituted solution cannot be saved for later use and should be discarded.

• Reconstitution of the Lyophilized Powder

• Instruct patients to follow the directions below for reconstitution of the lyophilized powder:

• Remove the vial containing the Metreleptin lyophilized powder from the refrigerator and allow the vial to warm to room temperature prior to use.
• Visually inspect the vial containing Metreleptin. The cake of lyophilized powder should be intact and white in color.
• Using a 3-mL syringe with a 22-gauge or smaller diameter needle withdraw 2.2 mL of sterile Bacteriostatic Water for Injection (BWFI) or preservative-free sterile Water for Injection (WFI). Do not reconstitute Metreleptin with other diluents.
• Inject the BWFI or WFI into the vial containing the lyophilized powder of Metreleptin, slowly injecting down the side of the vial. It is normal for some bubbles to form.
• Remove the needle and syringe from the vial and gently swirl the contents to reconstitute. Do not shake or vigorously agitate. When properly mixed, the Metreleptin reconstituted solution should be clear and free of clumps or dry powder, bubbles or foam. Do not use the solution if discolored or cloudy, or if particulate matter remains.
• Regarding the compatibility of Metreleptin reconstituted solution with other solutions:
• Do not mix with, or transfer into, the contents of another vial of Metreleptin.
• Do not add other medications, including insulin. Use a separate syringe for insulin injections.

Administration Instructions

• Healthcare practitioners should instruct patients and caregivers on the proper subcutaneous injection technique with care to avoid intramuscular injection in patients with minimal subcutaneous adipose tissue. Never administer Metreleptin intravenously or intramuscularly.

• Instruct patients to follow the recommended injection technique:

• Using a 1-mL syringe with a needle appropriate for subcutaneous injection, withdraw the prescribed dose of Metreleptin reconstituted solution.
• Remove any large air pockets or large bubbles from the filled syringe prior to administration. Some small bubbles may remain in the syringe.
• Administer Metreleptin into the subcutaneous tissue of the abdomen, thigh or upper arm. Advise patients to use a different injection site each day when injecting in the same region. After choosing an injection site, pinch the skin and at a 45-degree angle, inject the Metreleptin reconstituted solution subcutaneously. Avoid intramuscular injection, especially in patients with minimal subcutaneous adipose tissue.
• Doses exceeding 1 mL can be administered as two injections (the total daily dose divided equally) to minimize potential injection-site discomfort due to injection volume. When dividing doses due to volume, doses can be administered one after the other.

• Do not mix Metreleptin with insulin. Use a separate syringe for each medication. If Metreleptin and insulin are administered at the same time of day, they may be injected in the same body area using two different injection sites.

• See the Metreleptin Instructions for Use for complete administration instructions.

Dosage Adjustments of Medications Known to Cause Hypoglycemia

• Dosage adjustments, including possible large reductions, of insulin or insulin secretagogue (e.g., sulfonylurea) may be necessary in some patients to minimize the risk of hypoglycemia . Closely monitor blood glucose in patients on concomitant insulin therapy, especially those on high doses, or insulin secretagogue (e.g., sulfonylurea) when treating with Metreleptin.

Discontinuation in Patients at Risk for Pancreatitis

• When discontinuing Metreleptin therapy in patients with risk factors for pancreatitis (e.g., history of pancreatitis, severe hypertriglyceridemia), tapering of the dose over a one-week period is recommended. During tapering, monitor triglyceride levels and consider initiating or adjusting the dose of lipid-lowering medications as needed. Signs and/or symptoms consistent with pancreatitis should prompt an appropriate clinical evaluation.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Metreleptin in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Metreleptin in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

There is limited information regarding FDA-Labeled Use of Metreleptin in pediatric patients.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Metreleptin in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Metreleptin in pediatric patients.

Contraindications

General Obesity

• Metreleptin is contraindicated in patients with general obesity not associated with congenital leptin deficiency. Metreleptin has not been shown to be effective in treating general obesity, and the development of anti-metreleptin antibodies with neutralizing activity has been reported in obese patients treated with Metreleptin .

Hypersensitivity

• Metreleptin is contraindicated in patients with prior severe hypersensitivity reactions to metreleptin or to any of the product components. Known hypersensitivity reactions have included urticaria and generalized rash

Warnings

WARNING See full prescribing information for complete Boxed Warning. RISK OF ANTI-METRELEPTIN ANTIBODIES WITH NEUTRALIZING ACTIVITY AND RISK OF LYMPHOMA Anti-metreleptin antibodies with neutralizing activity have been identified in patients treated with Metreleptin. The consequences of these neutralizing antibodies are not well characterized but could include inhibition of endogenous leptin action and/or loss of Metreleptin efficacy. Severe infection and/or worsening metabolic control have been reported. Test for anti-metreleptin antibodies with neutralizing activity in patients who develop severe infections or show signs suspicious for loss of Metreleptin efficacy during treatment. Contact AstraZeneca at 1-866-216-1526 for neutralizing antibody testing of clinical samples. T-cell lymphoma has been reported in patients with acquired generalized lipodystrophy, both treated and not treated with Metreleptin. Carefully consider the benefits and risks of treatment with Metreleptin in patients with significant hematologic abnormalities and/or acquired generalized lipodystrophy. Because of these risks associated with the development of anti-metreleptin antibodies that neutralize endogenous leptin and/or Metreleptin and the risk for lymphoma, Metreleptin is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the Metreleptin REMS PROGRAM

Risk for Development of Antibodies that Neutralize Endogenous Leptin and/or Metreleptin

• Anti-metreleptin antibodies with in vitro neutralizing activity to leptin associated with adverse events consistent with loss of endogenous leptin activity and/or loss of efficacy have been identified in two patients with generalized lipodystrophy treated with Metreleptin (severe infections, increases in HbA1cand triglycerides), and in three patients without lipodystrophy who received Metreleptin in clinical studies (excessive weight gain, development of glucose intolerance or diabetes mellitus). The clinical implications associated with development of anti-metreleptin antibodies with neutralizing activity are not well characterized at this time due to the small number of reports. Test for anti-metreleptin antibodies with neutralizing activity in patients who develop severe infections or show signs suspicious for loss of Metreleptin efficacy during treatment.

Lymphoma

• Three cases of T-cell lymphoma have been reported in the Metreleptin lipodystrophy program; all three patients had acquired generalized lipodystrophy. Two of these patients were diagnosed with peripheral T-cell lymphoma while receiving Metreleptin. Both had immunodeficiency and significant hematologic abnormalities including severe bone marrow abnormalities before the start of Metreleptin treatment. A separate case of anaplastic large cell lymphoma was reported in a patient receiving Metreleptin who did not have hematological abnormalities before treatment.

• Lymphoproliferative disorders, including lymphomas, have been reported in patients with acquired generalized lipodystrophy not treated with Metreleptin. A causal relationship between Metreleptin treatment and the development and/or progression of lymphoma has not been established. Acquired lipodystrophies are associated with autoimmune disorders, and autoimmune disorders are associated with an increased risk of malignancies including lymphomas.

• The benefits and risks of Metreleptin treatment should be carefully considered in patients with acquired generalized lipodystrophy and/or those with significant hematologic abnormalities (including leukopenia, neutropenia, bone marrow abnormalities, lymphoma, and/or lymphadenopathy).

Metreleptin REMS Program

• Metreleptin is available only through a restricted distribution program under a REMS, called the Metreleptin REMS Program, because of the risks associated with the development of anti-metreleptin antibodies that neutralize endogenous leptin and/or Metreleptin and the risk for lymphoma .

• Notable requirements of the Metreleptin REMS Program include the following:

• Prescribers must be certified with the program by enrolling and completing training.
• Pharmacies must be certified with the program and only dispense Metreleptin after receipt of the Metreleptin REMS Prescription Authorization Form for each new prescription.

Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues

• Dosage adjustments, including possible large reductions, of insulin or insulin secretagogue (e.g., sulfonylurea) may be necessary in some patients to minimize the risk of hypoglycemia . Closely monitor blood glucose in patients on concomitant insulin therapy, especially those on high doses, or insulin secretagogue (e.g., sulfonylurea), when treating with Metreleptin.

Autoimmunity

• Leptin plays a role in immune system homeostasis. Acquired lipodystrophies are associated with autoimmune disorders including autoimmune hepatitis and membranoproliferative glomerulonephritis. Cases of progression of autoimmune hepatitis and membranoproliferative glomerulonephritis (associated with massive proteinuria and renal failure) were observed in some patients with acquired generalized lipodystrophy treated with Metreleptin. A causal relationship between Metreleptin treatment and the development and/or progression of autoimmune disease has not been established. The potential benefits and risks of Metreleptin treatment should be carefully considered in patients with autoimmune disease.

Hypersensitivity

• There have been reports of generalized hypersensitivity (e.g., urticaria or generalized rash) in patients taking Metreleptin. If a hypersensitivity reaction occurs, instruct the patient to promptly seek medical advice regarding discontinuation of Metreleptin.

Benzyl Alcohol Toxicity

• Metreleptin contains benzyl alcohol when reconstituted with BWFI. Metreleptin contains no preservative when reconstituted with sterile Water for Injection (WFI). Preservative-free WFI is recommended for use in neonates and infants. The preservative benzyl alcohol has been associated with serious adverse events and death in pediatric patients, particularly in neonates and premature infants

Adverse Reactions

Clinical Trials Experience

• 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.

Open-Label, Single-Arm Study

• The safety of Metreleptin was evaluated in 48 patients with generalized lipodystrophy in a single-arm, open-label study . The median duration of exposure in this trial was 2.7 years with a range of 3.6 months to 10.9 years. The most frequent adverse reactions are summarized in Table 2.

File:Metreleptin04.png

This image is provided by the National Library of Medicine.

• In patients with generalized lipodystrophy receiving Metreleptin in this study, less common adverse reactions included injection-site erythema and urticaria (N=2 [4%]).

• Six patients (13%) had 7 adverse reactions of hypoglycemia, 6 of which occurred in the setting of concomitant insulin use, with or without oral antihyperglycemic agents.

• Two patients (4%) had events of pancreatitis, both of whom had a medical history of pancreatitis.

Immunogenicity

• As with all therapeutic proteins, there is potential for immunogenicity. Anti-metreleptin antibodies were detected in 84% (36/43) of generalized lipodystrophy patients studied in the Metreleptin trials. Total anti-metreleptin antibody titers ranged between 1:5 and 1:1,953,125. The incompleteness of the current immunogenicity database precludes understanding of the magnitude and persistence of the observed anti-drug antibody responses. Anti-metreleptin antibodies with neutralizing activity associated with adverse events consistent with loss of endogenous leptin activity and/or loss of Metreleptin efficacy were observed in 6% (2/33) of the patients with generalized lipodystrophy tested. Adverse events reported in these two patients included severe infections and worsening of metabolic control (increases in HbA1c and/or triglycerides). Test for anti-metreleptin antibodies with neutralizing activity in patients who develop severe infections or show signs suspicious for loss of Metreleptin efficacy during treatment. Contact AstraZeneca at 1-866-216-1526 for testing of clinical samples.

• The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. The immunogenicity assays utilized in clinical trials lacked sensitivity, resulting in potential underestimation of the number of samples positive for anti-metreleptin antibodies with neutralizing activity. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to metreleptin with the incidence of antibodies to other products may be misleading.

Postmarketing Experience

There is limited information regarding Postmarketing Experience of Metreleptin in the drug label.

Drug Interactions

• No formal drug interaction studies were performed.

• Leptin is a cytokine and may have the potential to alter the formation of cytochrome P450 (CYP450) enzymes. This should be taken into account when prescribing concomitant drugs metabolized by CYP450 (e.g., oral contraceptives and drugs with a narrow therapeutic index). The effect of metreleptin on CYP450 enzymes may be clinically relevant for CYP450 substrates with narrow therapeutic index, where the dose is individually adjusted. Upon initiation or discontinuation of Metreleptin, in patients being treated with these types of agents, therapeutic monitoring of effect (e.g., warfarin) or drug concentration (e.g., cyclosporine or theophylline) should be performed and the individual dose of the agent adjusted as needed.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): C

• There is a program that monitors outcomes in women exposed to Metreleptin during pregnancy. Women who become pregnant during Metreleptin treatment are encouraged to enroll. Patients or their physicians should call 1-855-6Metreleptin to enroll.

Risk Summary

• There are no adequate and well-controlled studies of Metreleptin in pregnant women. All pregnancies, regardless of drug exposure, have a background rate of 2% to 4% for major malformations and 15% to 20% for pregnancy loss. In a pre- and postnatal development study in mice, administration of metreleptin caused prolonged gestation and dystocia resulting in maternal death during parturition and lower survival of offspring in the immediate postnatal period at doses starting approximately at the maximum recommended clinical dose. Because animal reproduction studies are not always predictive of human response, Metreleptin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Clinical Considerations

Disease-Associated Maternal and Fetal Risk

• The contribution of Metreleptin to obstetrical risks and complications is unknown compared with those already documented in the lipodystrophy patient population (e.g., gestational diabetes, macrosomia, eclampsia, intrauterine growth retardation, intrauterine death, and miscarriage).

Labor and Delivery

• The effects of Metreleptin on labor and delivery in pregnant women are unknown. In an in vitro study of human myometrial tissue exposed to a recombinant leptin, human uterine contractility was inhibited. Furthermore, prolonged gestation and dystocia were observed in animal studies with metreleptin (see below).

Animal Data

• Metreleptin administered to pregnant mice during the period of organogenesis was not teratogenic at doses ranging between 7- and 15-fold the maximum recommended clinical dose, based on body surface area of a 20- and 60-kg patient, respectively.

• In a pre- and postnatal development study in mice, metreleptin administered at doses of 3, 10, and 30 mg/kg (approximately 1-, 5-, and 15-fold the clinical dose for a 60-kg subject, based on body surface area) from gestation day 6 to lactation day 21 caused prolonged gestation and dystocia at all doses, starting at approximately the maximum recommended clinical dose. Prolonged gestation resulted in the death of some females during parturition and lower survival of offspring within the immediate postnatal period. Consistent with metreleptin pharmacology, decreased maternal body weight was observed from gestation throughout lactation at all doses and resulted in reduced weight of offspring at birth, which persisted into adulthood. However, no developmental abnormalities were observed and reproductive performance of the first or second generations was not affected at any dose.

• Placental transfer of metreleptin into the fetus was low (approximately 1%) following subcutaneous dosing.

Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Metreleptin in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Metreleptin during labor and delivery.

Nursing Mothers

There is no FDA guidance on the use of Metreleptin in women who are nursing.

Pediatric Use

There is no FDA guidance on the use of Metreleptin in pediatric settings.

Geriatic Use

There is no FDA guidance on the use of Metreleptin in geriatric settings.

Gender

There is no FDA guidance on the use of Metreleptin with respect to specific gender populations.

Race

There is no FDA guidance on the use of Metreleptin with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Metreleptin in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Metreleptin in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Metreleptin in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Metreleptin in patients who are immunocompromised.

Administration and Monitoring

Administration

There is limited information regarding Metreleptin Administration in the drug label.

Monitoring

There is limited information regarding Metreleptin Monitoring in the drug label.

IV Compatibility

There is limited information regarding the compatibility of Metreleptin and IV administrations.

Overdosage

There is limited information regarding Metreleptin overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

Pharmacology

There is limited information regarding Metreleptin Pharmacology in the drug label.

Mechanism of Action

There is limited information regarding Metreleptin Mechanism of Action in the drug label.

Structure

There is limited information regarding Metreleptin Structure in the drug label.

Pharmacodynamics

There is limited information regarding Metreleptin Pharmacodynamics in the drug label.

Pharmacokinetics

There is limited information regarding Metreleptin Pharmacokinetics in the drug label.

Nonclinical Toxicology

There is limited information regarding Metreleptin Nonclinical Toxicology in the drug label.

Clinical Studies

There is limited information regarding Metreleptin Clinical Studies in the drug label.

How Supplied

There is limited information regarding Metreleptin How Supplied in the drug label.

Storage

There is limited information regarding Metreleptin Storage in the drug label.

Images

Drug Images

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Package and Label Display Panel

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Patient Counseling Information

There is limited information regarding Metreleptin Patient Counseling Information in the drug label.

Precautions with Alcohol

Alcohol-Metreleptin interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Metreleptin Brand Names in the drug label.

Look-Alike Drug Names

There is limited information regarding Metreleptin Look-Alike Drug Names in the drug label.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.