VPRIV is a hydrolytic lysosomal glucocerebroside-specific enzyme indicated for long-term enzyme replacement therapy (ERT) for paediatric and adult patients with type 1 Gaucher disease.

VPRIV treatment should be supervised by a physician experienced in the management of patients with Gaucher disease.  
Posology
The recommended dose is 60 Units/kg administered every other week. 
Dose adjustments can be made on an individual basis based on achievement and maintenance of therapeutic goals. Clinical studies have evaluated doses ranging from 15 to 60 Units/kg every other week. Doses higher than 60 Units/kg have not been studied. 
Patients currently treated with imiglucerase enzyme replacement therapy for type 1 Gaucher disease may be switched to VPRIV, using the same dose and frequency. 

Special populations
Elderly (≥65 years old) 
Elderly patients may be treated within the same dose range (15 to 60 units/kg) as other adult patients (see section 5.1). 

Renal impairment 
No dosing adjustment is recommended in patients with renal impairment based on current knowledge of the pharmacokinetics and pharmacodynamics of velaglucerase alfa (see section 5.2). 
Hepatic impairment 
No dosing adjustment is recommended in patients with hepatic impairment based on current knowledge of the pharmacokinetics and pharmacodynamics of velaglucerase alfa (see section 5.2).

Paediatric population
Twenty of the 94 patients (21%) who received velaglucerase alfa during clinical studies were in the paediatric and adolescent age range (4 to 17 years). The safety and efficacy profiles were similar between paediatric and adult patients. See section 5.1 for further information.
The safety and efficacy of velaglucerase alfa in children below the age of 4 years have not yet been established. No data are available. 
 

Method of administration

For intravenous infusion use only.  
To be administered as a 60-minute intravenous infusion. 
Must be administered through a 0.2 or 0.22 µm filter. 
Home administration under the supervision of a healthcare professional may be considered only for those patients who have received at least three infusions and were tolerating their infusions well. Appropriate medical support, including adequately trained personnel in emergency measures, should be readily available when velaglucerase alfa is administered. If anaphylactic or other acute reactions occur, immediately discontinue the infusion and initiate appropriate medical treatment (see 
section 4.4). 
For instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6. 

Traceability

  In order to improve the traceability of biological medicinal products, the name and batch number of the administered medicinal product should be clearly recorded.

Hypersensitivity Reactions Including Anaphylaxis:

Hypersensitivity reactions, including symptoms consistent with anaphylaxis, have been reported in patients in clinical studies and in post-marketing experience. Patients were not routinely pre-medicated prior to infusion of VPRIV during clinical studies. The majority of hypersensitivity reactions usually occur up to 12 hours post infusion. The most frequently reported symptoms of hypersensitivity include nausea, dizziness, hypotension, hypertension, rash dyspnoea, back pain, chest discomfort (including chest tightness), urticaria, arthralgia, fatigue/asthenia, pyrexia/body temperature increased and headache. Generally the reactions were mild and, in treatment-naïve patients, onset occurred mostly during the first 6 months of treatment and tended to occur less frequently with time. Additional hypersensitivity reactions of chest discomfort, dyspnea, pruritus and vomiting have been reported in post-marketing experience. As with any intravenous protein product, hypersensitivity reactions are possible, therefore appropriate medical support including personnel adequately trained in cardiopulmonary resuscitative measures and access to emergency measures should be readily available when VPRIV is administered. If anaphylactic or other acute reactions occur, immediately discontinue the infusion of VPRIV and initiate appropriate medical treatment.

The management of hypersensitivity reactions should be based on the severity of the reaction, e.g., slowing the infusion rate, treatment with medications such as antihistamines, antipyretics and/or corticosteroids, and/or stopping and resuming treatment with increased infusion time. In cases where patients have exhibited symptoms of hypersensitivity to the active ingredient or excipients in the drug product or to other enzyme replacement therapy, pre-treatment with antihistamines and/or corticosteroids may prevent subsequent reactions.

Infusion related-reactions
An infusion-related reaction is defined as any adverse drug reaction occurring within 24 hours after the initiation of velaglucerase alfa infusion. Infusion‑related reactions (IRR) were the most commonly observed adverse reactions in patients treated in clinical studies. An IRR often appears as a hypersensitivity reaction. The most frequently reported symptoms of hypersensitivity include nausea, rash, dyspnoea, back pain, chest discomfort (including chest tightness), urticaria, arthralgia, and headache. Symptoms consistent with anaphylaxis have been reported in patients in clinical studies and in post-marketing experience. Apart from symptoms associated with hypersensitivity reactions IRRs might show as fatigue, dizziness, pyrexia, blood pressure increase, pruritus, vision blurred, or vomiting. In treatment-naïve patients, the majority of infusion-related reactions occurred during the first 6 months of treatment.

Prevention and management of infusion related reactions including hypersensitivity reactions

The management of infusion‑related reactions should be based on the severity of the reaction, and include slowing the infusion rate, treatment with medicinal products such as antihistamines, antipyretics and/or corticosteroids, and/or stopping and resuming treatment with increased infusion time.

Due to the risk for hypersensitivity reactions including anaphylaxis, appropriate medical support, including adequately trained personnel in emergency measures, should be readily available when velaglucerase alfa is administered. If anaphylactic or other acute reactions occur, in the clinic or home setting, immediately discontinue the infusion and initiate appropriate medical treatment. For patients developing anaphylaxis in a home setting it should be considered to continue treatment in a clinical setting.

Treatment should be approached with caution in patients who have exhibited symptoms of hypersensitivity to velaglucerase alfa or other enzyme replacement therapy.

Pre-treatment with antihistamines and/or corticosteroids may prevent subsequent reactions in those cases where symptomatic treatment was required.

Immunogenicity
Antibodies may play a role in treatment-related reactions found with the use of velaglucerase alfa. To further evaluate the relationship, in cases of severe infusion-related reactions and in cases of lack or loss of effect patients should be tested for the presence of antibodies and the results reported to the company.

In the clinical studies for Marketing Authorisation one of 94 (1%) patients developed IgG-class antibodies to velaglucerase alfa. In this one event, the antibodies were determined to be neutralising in an in vitro assay.

- No patients developed IgE antibodies to velaglucerase alfa.

 - No infusion related reactions were reported.

Post-marketing phase

During a post marketing extension study, one patient developed IgG antibodies to VPRIV. In addition, a few events of positive neutralising antibodies and lack of effect were reported post marketing.

Sodium

This medicinal product contains 12.15 mg sodium per vial. This is equivalent to 0.6% of the WHO recommended maximum daily intake of 2 g sodium for an adult.

No interaction studies have been performed.

Women of child bearing potential
Patients who have Gaucher disease and become pregnant may experience a period of increased disease activity during pregnancy and the puerperium. A risk-benefit assessment is required for each pregnancy. Close monitoring of the pregnancy and clinical manifestations of Gaucher disease is necessary for the individualisation of therapy.
Pregnancy
Pregnancy Category C.
There are no data from the use of velaglucerase alfa in pregnant women.
Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development. Caution should be exercised when prescribing to pregnant women.
Breast-feeding
There are no data from studies in breast-feeding women. It is not known whether velaglucerase alfa is excreted in human milk. Because many active substances are excreted in human milk, caution should be exercised when prescribing to a breast-feeding woman.
Fertility
Animal studies show no evidence of impaired fertility.

VPRIV has no or negligible influence on the ability to drive or use machines. 

The data described below reflect exposure of 94 patients with type 1 Gaucher disease who received velaglucerase alfa at doses ranging from 15 to 60 Units/kg every other week in 5 clinical studies.
Fifty-four patients were naïve to ERT and 40 patients switched from imiglucerase to VPRIV. Patients were between 4 and 71 years old at the time of first treatment with VPRIV, and included 46 male and 48 female patients.

The most serious adverse reactions in patients in clinical trials were hypersensitivity reactions.

The most common adverse reactions were infusion-related reactions. The most commonly observed symptoms of infusion-related reactions were: headache, dizziness, hypotension, hypertension, nausea, fatigue/asthenia, and pyrexia/body temperature increased (see section 4.4 for further information). The only adverse reaction leading to discontinuation of treatment was an infusion-related reaction.

Adverse reactions reported in patients with type 1 Gaucher disease are listed in Table 1. Information is presented by system organ class and frequency according to MedDRA convention. Frequency is defined as very common (1/10) and common (1/100 to <1/10). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Table 1: Adverse reactions reported with VPRIV observed in patients with type 1 Gaucher
disease

Paediatric population
The safety profile of VPRIV in clinical studies involving children and adolescents aged 4 to 17 years was similar to that observed in adult patients.

Elderly population (≥65yrs)
The safety profile of VPRIV in clinical studies involving patients aged 65 years and above was similar to that observed in other adult patients.

Reporting of suspected adverse reactions 
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed below: 

·Saudi Arabia: 

Please report adverse drug events to:

The National Pharmacovigilance Centre (NPC):

·    SFDA Call Centre: 19999

·    E-mail: npc.drug@sfda.gov.sa

Website: https://ade.sfda.gov.sa

·    Other GCC states:

·          Please contact the relevant competent authority.

There is limited information available regarding overdose with velaglucerase alfa. In the majority of the cases reporting overdose, no additional adverse events were observed. However, in the event of accidental or intentional overdose, patients should be carefully observed and treatment should be symptomatic and supportive. There is no antidote available. The maximum dose of velaglucerase alfa in clinical studies was 60 Units/kg (see section 4.4). 

Pharmacotherapeutic group: Other alimentary tract and metabolism products – enzymes, ATC code: A16A B10.

Gaucher disease is an autosomal recessive disorder caused by mutations in the GBA gene which results in a deficiency of the lysosomal enzyme beta-glucocerebrosidase. This enzymatic deficiency causes an accumulation of glucocerebroside primarily in macrophages, giving rise to foam cells or "Gaucher cells". In this lysosomal storage disorder (LSD), clinical features are reflective of the distribution of Gaucher cells in the liver, spleen, bone marrow, skeleton, and lungs. The accumulation of glucocerebroside in the liver and spleen leads to organomegaly. Bone involvement results in skeletal abnormalities and deformities as well as bone pain crises. Deposits in the bone marrow and splenic sequestration lead to clinically significant anaemia and thrombocytopenia.

The active substance of VPRIV is velaglucerase alfa, which is produced by gene activation technology in a human cell line. Velaglucerase alfa is a glycoprotein. The monomer is approximately 63 kDa, has 497 amino acids, and the same amino acid sequence as the naturally occurring human enzyme, glucocerebrosidase. There are 5 potential N-linked glycosylation sites, four of which are occupied. Velaglucerase alfa is manufactured to contain predominantly high-mannose-type glycans to facilitate internalisation of the enzyme by the phagocytic target cells via the mannose receptor.

Velaglucerase alfa supplements or replaces beta-glucocerebrosidase, the enzyme that catalyzes the hydrolysis of glucocerebroside to glucose and ceramide in the lysosome, reducing the amount of accumulated glucocerebroside and correcting the pathophysiology of Gaucher disease. Velaglucerase alfa increases haemoglobin concentration and platelet counts and reduces liver and spleen volumes in patients with type 1 Gaucher disease.

In Studies 025EXT and 034, patients were offered home therapy. In Study 025EXT, 7 of 10 patients received home therapy at least once during 60 months of treatment. In Study 034, 25 of 40 patients received home therapy at least once during the 12-month study.

Clinical efficacy and safety
Studies in treatment naïve patients
Study 025 was a 9 month, open-label study in 12 adults (≥18 years) patients who were naïve to ERT (defined as having not been treated with ERT for at least 12 months prior to study entry). VPRIV was initially administered in a dose-escalating fashion in the first 3 patients (15, 30, 60 Units/kg) and the 9 remaining patients began treatment with 60 Units/kg.

Clinically meaningful improvements from baseline were observed in haemoglobin concentration and platelet counts as early as 3 months and in liver and spleen volumes at both 6 months and 9 months following the initiation of treatment with VPRIV.

Ten patients who completed Study 025 enrolled in an open-label extension study (025EXT). After a minimum of 12 months of continuous treatment with VPRIV, all patients qualified to have the dose of VPRIV reduced in a step-wise fashion from 60 to 30 Units/kg after achieving at least 2 of the 4 “Year 1” therapeutic goals of ERT for type 1 Gaucher disease. Patients received doses ranging from 30 to 60 Units/kg (median dose 35 Units/kg) every other week for up to 60 months (5 years). Sustained clinical activity continued to be demonstrated during 5 years of treatment as observed by improvements in haemoglobin concentrations and platelet counts and reduced liver and spleen volumes.

Study 032 was a 12-month, randomized, double-blind, parallel-group efficacy study in 25 patients aged 2 years and older who were naïve to ERT (defined as having not been treated with ERT for at least 30 months prior to study entry). Patients were required to have Gaucher disease-related anaemia and either thrombocytopenia or organomegaly. Patients were randomized to receive VPRIV at a dose of either 45 Units/kg (N=13) or 60 Units/kg (N=12) every other week.

Velaglucerase alfa 60 Units/kg given IV every other week demonstrated clinically meaningful increases from baseline in mean haemoglobin concentration (+2.4 g/dl) and platelet count (+50.9 x 109/l), liver volume was reduced from 1.46 to 1.22 times normal (mean reduction of 17%) and spleen volume was reduced from 14.0 to 5.75 times normal (mean reduction of 50%). Meaningful increases from baseline were observed in the 45 Units/kg dose group in haemoglobin concentration (+2.4 g/dl) and platelet count (+40.9 x 109/l), liver volume was reduced from 1.40 to 1.24 times normal (mean reduction of 6%) and spleen volume was reduced from 14.5 to 9.50 times normal (mean reduction of 40%).

Study 039 was a 9-month, randomized, double-blind, non-inferiority, active-comparator (imiglucerase) controlled, parallel-group efficacy study in 34 patients aged 2 years and older who were naïve to ERT (defined as having not been treated with ERT for at least 12 months prior to study entry). Patients were required to have Gaucher disease-related anaemia and either thrombocytopenia or organomegaly. Patients received either 60 Units/kg of VPRIV (N=17) or 60 Units/kg of imiglucerase (N=17) every other week.

The mean absolute increase from baseline in haemoglobin concentrations was 1.624 g/dl (±0.223 SE) following 9 months of treatment with VPRIV. This increase in haemoglobin concentration was demonstrated to be clinically and statistically non-inferior to imiglucerase (mean treatment difference of change from baseline to 9 months [VPRIV – imiglucerase]: 0.135 g/dl). There were no statistically significant differences between VPRIV and imiglucerase in changes in platelet counts and liver and spleen volumes after 9 months of VPRIV treatment, and in the time to first haemoglobin response (defined as 1 g/dl increase from baseline).

Study in patients switching from imiglucerase treatment to VPRIV
Study 034 was a 12-month, open-label safety study in 40 patients aged 2 years and older who had been receiving treatment with imiglucerase at doses ranging from 15 to 60 Units/kg for a minimum of 30 consecutive months. Patients were required to have a stable dose of imiglucerase for at least 6 months prior to study enrolment. Treatment with VPRIV was administered as the same number of units and regimen as their imiglucerase dose. Haemoglobin concentration and platelet counts were evaluated as changes from baseline, which was defined as the end of the patient’s treatment with imiglucerase.

In patients who switched from imiglucerase to VPRIV, haemoglobin concentrations and platelet counts were sustained at therapeutic levels through 12 months of treatment.

Study 058 was an open-label clinical safety study in 211 patients including 205 patients previously treated with imiglucerase 6 treatment-naïve patients and 57 patients aged 65 years or older (56/57 had switched from imiglucerase to VPRIV). Patients transferring from imiglucerase were administered VPRIV infusions every other week at the same number of units as imiglucerase within the range of 15 to 60 U/kg. Patients transferring from a dose of <15 U/kg imiglucerase were administered 15 U/kg of
VPRIV.
Patients previously treated with imiglucerase received a median of 8 VPRIV infusions with median duration of treatment of 15.1 weeks. The safety profile in these patients was similar to that observed in other clinical trials. Only 1 out of 163 patients assessed developed anti-velaglucerase alfa antibodies during the study.

The mean haemoglobin concentration and platelet count of patients previously treated with imiglucerase were maintained throughout the study and remained within the reference intervals.
Paediatric population
Use in the age group 4 to 17 is supported by evidence from controlled studies in adults and paediatric [20 of 94 (21%)] patients. The safety and efficacy profiles were similar between paediatric and adult patients. The studies allowed the inclusion of patients 2 years and older and the safety and efficacy profiles are expected to be similar down to the age of 2 years. However, no data are available for children under the age of 4 years.

The European Medicines Agency has waived the obligation to submit the results of studies with VPRIV in all subsets of the paediatric population with type 2 Gaucher disease and has deferred the obligation to submit the results of studies with VPRIV in one or more subsets of the paediatric population in Gaucher disease type 1 and 3, as per the PIP decision.

There were no apparent pharmacokinetic differences between male and female patients with type 1 Gaucher disease. None of the subjects in the pharmacokinetic studies were positive for anti-velaglucerase alfa antibodies on the days of pharmacokinetic evaluation. Therefore, it was not possible to evaluate the effect of antibody response on the pharmacokinetic profile of velaglucerase alfa.

Absorption
Velaglucerase alfa serum concentrations rose rapidly for the first 20 minutes of the 60-minute infusion before leveling off, and Cmax was typically attained between 40 and 60 minutes after the start of the infusion. After the end of the infusion, velaglucerase alfa serum concentrations fell rapidly in a monophasic or biphasic fashion with a mean t1/2 ranging from 5 to 12 minutes at doses of 15, 30, 45, and 60 Units/kg.

Distribution
Velaglucerase alfa exhibited an approximately linear (i.e. first-order) pharmacokinetic profile, and Cmax and AUC increased approximately proportional to the dose over the dose range 15 to 60 Units/kg. The steady state volume of distribution was approximately 10% of the body weight. The high clearance of velaglucerase alfa from serum (mean 6.7 to 7.6 ml/min/kg) is consistent with the rapid uptake of velaglucerase alfa into macrophages via mannose receptors.
 

Elimination
The range of velaglucerase alfa clearance in paediatric patients (N=7, age range 4 to 17 years) was contained within the range of clearance values in adult patients (N=15, age range 19 to 62 years).

Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, and toxicity to reproduction and development.

Sucrose
Sodium citrate dihydrate (E331)
Citric acid monohydrate (E330)
Polysorbate 20

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

Store in a refrigerator ( 2^oC to 8^oC).
Do not freeze.
Keep the vial in the outer carton in order to protect from light.

From a microbiological point of view, the medicinal product should be used immediately. If not used
immediately, in-use storage times and conditions prior to use are the responsibility of the user and
must not exceed 24 hours at 2^oC to 8^oC.

Reconstituted and diluted solution for infusion:
Chemical and physical in-use stability has been demonstrated for 24 hours at 2^oC to 8^oC under protection from light.

20 ml vial (type I glass) with a stopper (fluoro-resin coated butyl rubber), one piece seal, and flip-off cap, containing 400 Units of velaglucerase alfa in powder. Pack sizes of 1, 5 and 25 vials.

Not all pack sizes may be marketed.

VPRIV requires reconstitution and dilution, and is intended for intravenous infusion only. VPRIV is
for single-use only and is administered through a 0.22 μm filter.
Use aseptic technique.
Prepare VPRIV as follows:
1. The number of vials to be reconstituted is determined based on the individual patient’s weight and the prescribed dose.
2. The required vials are removed from the refrigerator. Each 400 Units vial is reconstituted with
4.3 ml of sterile water for injections.
3. Upon reconstitution, mix vials gently. Do not shake. Each vial will contain an extractable volume of 4.0 ml (100 Units/ml).
4. Prior to further dilution, visually inspect the solution in the vials; the solution should be clear to slightly opalescent and colourless; do not use if the solution is discoloured or if foreign particulate matter is present.
5. The calculated volume of medicinal product is withdrawn from the appropriate number of vials
and the total volume required is diluted in 100 ml of sodium chloride 9 mg/ml (0.9%) solution for infusion. Mix gently. Do not shake. The infusion should be initiated within 24 hours from the time of reconstitution.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.