FORSTEO 20mg/80mcg 20mcg / 80mcl injectible solution medication leaflet

FORSTEO 20 micrograms/80 microliters solution for injection in pre-filled pen

Each dose of 80 microliters contains 20 micrograms of teriparatide*.

One pre-filled pen of 2.4 mL contains 600 micrograms of teriparatide (corresponding to250 micrograms per mL).

*Teriparatide, rhPTH(1-34), produced in E. coli, using recombinant DNA technology, is identical tothe 34 N-terminal amino acid sequence of endogenous human parathyroid hormone.

For the full list of excipients, see section 6.1

Solution for injection.

Colourless, clear solution.

FORSTEO is indicated in adults.

Treatment of osteoporosis in postmenopausal women and in men at increased risk of fracture (seesection 5.1). In postmenopausal women, a significant reduction in the incidence of vertebral and non-vertebral fractures but not hip fractures has been demonstrated.

Treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in women andmen at increased risk for fracture (see section 5.1).

The recommended dose of FORSTEO is 20 micrograms administered once daily.

The maximum total duration of treatment with FORSTEO should be 24 months (see section 4.4). The24-month course of FORSTEO should not be repeated over a patient’s lifetime.

Patients should receive supplemental calcium and vitamin D supplements if dietary intake isinadequate.

Following cessation of FORSTEO therapy, patients may be continued on other osteoporosis therapies.

FORSTEO must not be used in patients with severe renal impairment (see section 4.3.). In patientswith moderate renal impairment, FORSTEO should be used with caution. No special caution isrequired for patients with mild renal impairment.

No data are available in patients with impaired hepatic function (see section 5.3). Therefore,

FORSTEO should be used with caution.

Paediatric population and young adults with open epiphyses

The safety and efficacy of FORSTEO in children and adolescents less than 18 years has not beenestablished. FORSTEO should not be used in paediatric patients (less than 18 years), or young adultswith open epiphyses.

Dosage adjustment based on age is not required (see section 5.2).

FORSTEO should be administered once daily by subcutaneous injection in the thigh or abdomen.

Patients must be trained to use the proper injection techniques (see section 6.6). A user manual is alsoavailable to instruct patients on the correct use of the pen.

* Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

* Pregnancy and breast-feeding (see sections 4.4 and 4.6)

* Pre-existing hypercalcaemia

* Severe renal impairment

* Metabolic bone diseases (including hyperparathyroidism and Paget’s disease of the bone) otherthan primary osteoporosis or glucorticoid-induced osteoporosis.

* Unexplained elevations of alkaline phosphatase

* Prior external beam or implant radiation therapy to the skeleton

* Patients with skeletal malignancies or bone metastases should be excluded from treatment withteriparatide.

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

Serum and urine calcium

In normocalcaemic patients, slight and transient elevations of serum calcium concentrations have beenobserved following teriparatide injection. Serum calcium concentrations reach a maximum between 4and 6 hours and return to baseline by 16 to 24 hours after each dose of teriparatide. Therefore, if bloodsamples for serum calcium measurements are taken, this should be done at least 16 hours after themost recent FORSTEO injection. Routine calcium monitoring during therapy is not required.

FORSTEO may cause small increases in urinary calcium excretion, but the incidence of hypercalciuriadid not differ from that in the placebo-treated patients in clinical trials.

Urolithiasis

FORSTEO has not been studied in patients with active urolithiasis. FORSTEO should be used withcaution in patients with active or recent urolithiasis because of the potential to exacerbate thiscondition.

In short-term clinical studies with FORSTEO, isolated episodes of transient orthostatic hypotensionwere observed. Typically, an event began within 4 hours of dosing and spontaneously resolved withina few minutes to a few hours. When transient orthostatic hypotension occurred, it happened within thefirst several doses, was relieved by placing subjects in a reclining position, and did not precludecontinued treatment.

Caution should be exercised in patients with moderate renal impairment.

Younger adult population

Experience in the younger adult population, including premenopausal women, is limited (see section5.1). Treatment should only be initiated if the benefit clearly outweighs risks in this population.

Women of childbearing potential should use effective methods of contraception during use of

FORSTEO. If pregnancy occurs, FORSTEO should be discontinued.

Studies in rats indicate an increased incidence of osteosarcoma with long-term administration ofteriparatide (see section 5.3). Until further clinical data become available, the recommended treatmenttime of 24 months should not be exceeded.

This medicine contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially ‘sodium-free’.

In a study of 15 healthy subjects administered digoxin daily to steady state, a single FORSTEO dosedid not alter the cardiac effect of digoxin. However, sporadic case reports have suggested thathypercalcaemia may predispose patients to digitalis toxicity. Because FORSTEO transiently increasesserum calcium, FORSTEO should be used with caution in patients taking digitalis.

FORSTEO has been evaluated in pharmacodynamic interaction studies with hydrochlorothiazide. Noclinically significant interactions were noted.

Co-administration of raloxifene or hormone replacement therapy with FORSTEO did not alter theeffects of FORSTEO on serum or urine calcium or on clinical adverse events.

Women of childbearing potential should use effective methods of contraception during use of

FORSTEO. If pregnancy occurs, FORSTEO should be discontinued.

FORSTEO is contraindicated for use during pregnancy (see section 4.3).

FORSTEO is contraindicated for use during breast-feeding. It is not known whether teriparatide isexcreted in human milk.

Studies in rabbits have shown reproductive toxicity (see section 5.3). The effect of teriparatide onhuman foetal development has not been studied. The potential risk for humans is unknown.

FORSTEO has no or negligible influence on the ability to drive and use machines. Transient,orthostatic hypotension or dizziness was observed in some patients. These patients should refrain fromdriving or the use of machines until symptoms have subsided.

The most commonly reported adverse reactions in patients treated with FORSTEO are nausea, pain inlimb, headache and dizziness.

Of patients in the teriparatide trials, 82.8 % of the FORSTEO patients and 84.5 % of the placebopatients reported at least 1 adverse event.

The adverse reactions associated with the use of teriparatide in osteoporosis clinical trials and post-marketing exposure are summarised in the table below. The following convention has been used forthe classification of the adverse reactions: very common (≥ 1/10), common (≥ 1/100 to <1/10),uncommon (≥ 1/1,000 to <1/100), rare (≥ 1/10,000 to <1/1,000) very rare (<1/10,000).

Common: Anaemia

Immune System Disorder

Rare: Anaphylaxis

Common: Hypercholesterolaemia

Uncommon: Hypercalcaemia greater than 2.76 mmol/L, hyperuricemia

Rare: Hypercalcaemia greater than 3.25 mmol/L

Common: Depression

Common: Dizziness, headache, sciatica, syncope

Ear and labyrinth disorders

Common: Vertigo

Common: Palpitations

Uncommon: Tachycardia

Common: Hypotension

Common: Dyspnoea

Uncommon: Emphysema

Common: Nausea, vomiting, hiatus hernia, gastroesophageal reflux disease

Uncommon: Haemorrhoids

Common: Sweating increased

Very common: Pain in limb

Common: Muscle cramps

Uncommon: Myalgia, arthralgia, back cramp/pain*

Uncommon: Urinary incontinence, polyuria, micturition urgency, nephrolithiasis

Rare: Renal failure/impairment

Common: Fatigue, chest pain, asthenia, mild and transient injection site events, including pain,swelling, erythema, localised bruising, pruritis and minor bleeding at injection site.

Uncommon: Injection site erythema, injection site reaction

Rare: Possible allergic events soon after injection: acute dyspnoea, oro/facial oedema, generalisedurticaria, chest pain, oedema (mainly peripheral).

Uncommon: Weight increased, cardiac murmur, alkaline phosphatase increase

*Serious cases of back cramp or pain have been reported within minutes of the injection.

In clinical trials the following reactions were reported at a ≥ 1 % difference in frequency from placebo:vertigo, nausea, pain in limb, dizziness, depression, dyspnoea.

FORSTEO increases serum uric acid concentrations. In clinical trials, 2.8 % of FORSTEO patientshad serum uric acid concentrations above the upper limit of normal compared with 0.7 % of placebopatients. However, the hyperuricemia did not result in an increase in gout, arthralgia, or urolithiasis.

In a large clinical trial, antibodies that cross-reacted with teriparatide were detected in 2.8 % of womenreceiving FORSTEO. Generally, antibodies were first detected following 12 months of treatment anddiminished after withdrawal of therapy. There was no evidence of hypersensitivity reactions, allergicreactions, effects on serum calcium, or effects on Bone Mineral Density (BMD) response.

Reporting suspected adverse reactions after authorisation of the medicinal product is important. Itallows continued monitoring of the benefit/risk balance of the medicinal product. Healthcareprofessionals are asked to report any suspected adverse reactions via the national reporting systemlisted in Appendix V.

Signs and symptoms

FORSTEO has been administered in single doses of up to 100 micrograms and in repeated doses of upto 60 micrograms/day for 6 weeks.

The effects of overdose that might be expected include delayed hypercalcaemia and risk of orthostatichypotension. Nausea, vomiting, dizziness, and headache can also occur.

Overdose experience based on post-marketing spontaneous reports

In post-marketing spontaneous reports, there have been cases of medication error where the entirecontents (up to 800 mcg) of the teriparatide pen have been administered as a single dose. Transientevents reported have included nausea, weakness/lethargy and hypotension. In some cases, no adverseevents occurred as a result of the overdose. No fatalities associated with overdose have been reported.

Overdose management

There is no specific antidote for FORSTEO. Treatment of suspected overdose should includetransitory discontinuation of FORSTEO, monitoring of serum calcium, and implementation ofappropriate supportive measures, such as hydration.

Pharmaco-therapeutic group: Calcium homeostasis, parathyroid hormones and analogues, ATC code:

H05 AA02.

Endogenous 84-amino-acid parathyroid hormone (PTH) is the primary regulator of calcium andphosphate metabolism in bone and kidney. FORSTEO (rhPTH(1-34)) is the active fragment (1-34) ofendogenous human parathyroid hormone. Physiological actions of PTH include stimulation of boneformation by direct effects on bone forming cells (osteoblasts) indirectly increasing the intestinalabsorption of calcium and increasing the tubular re-absorption of calcium and excretion of phosphateby the kidney.

FORSTEO is a bone formation agent to treat osteoporosis. The skeletal effects of FORSTEO dependupon the pattern of systemic exposure. Once-daily administration of FORSTEO increases appositionof new bone on trabecular and cortical bone surfaces by preferential stimulation of osteoblasticactivity over osteoclastic activity.

Risk Factors

Independent risk factors, for example, low BMD, age, the existence of previous fracture, familyhistory of hip fractures, high bone turnover and low body mass index should be considered in order toidentify women and men at increased risk of osteoporotic fractures who could benefit from treatment.

Premenopausal women with glucocorticoid-induced osteoporosis should be considered at high risk forfracture if they have a prevalent fracture or a combination of risk factors that place them at high riskfor fracture (e.g., low bone density [e.g., T score ≤−2], sustained high dose glucocorticoid therapy[e.g., ≥7.5 mg/day for at least 6 months], high underlying disease activity, low sex steroid levels).

Postmenopausal osteoporosis

The pivotal study included 1637 postmenopausal women (mean age 69.5 years). At baseline, ninetypercent of the patients had one or more vertebral fractures, and on average, vertebral BMD was0.82 g/cm2 (equivalent to a T-score = - 2.6). All patients were offered 1000 mg calcium per day and atleast 400 IU vitamin D per day. Results from up to 24 months (median: 19 months) treatment with

FORSTEO demonstrate statistically significant fracture reduction (Table 1). To prevent one or morenew vertebral fractures, 11 women had to be treated for a median of 19 months.

Table 1

Fracture Incidence in Postmenopausal Women:

Placebo FORSTEO Relative risk(N = 544) (%) (N = 541) (%) (95% CI)vs. placebo

New vertebral 14.3 5.0 b 0.35fracture (≥1) a (0.22, 0.55)

Multiple vertebral 4.9 1.1 b 0.23fractures (≥2) a (0.09, 0.60)

Non-vertebral 5.5% 2.6% d 0.47fragility fractures c (0.25, 0.87)

Major non-vertebral 3.9% 1.5% d 0.38fragility fracturesc (0.17, 0.86)(hip, radius, humerus,ribs and pelvis)

Abbreviations: N = number of patients randomly assigned to each treatment group; CI = Confidence Interval.

a The incidence of vertebral fractures was assessed in 448 placebo and 444 Forsteo patients who had baseline and follow-upspine radiographs.b p≤0.001 compared with placeboc A significant reduction in the incidence of hip fractures has not been demonstratedd p≤0.025 compared with placebo.

After 19 months (median) treatment, bone mineral density (BMD) had increased in the lumbar spineand total hip, respectively, by 9 % and 4 % compared with placebo (p<0.001).

Post-treatment management: Following treatment with FORSTEO, 1262 postmenopausal women fromthe pivotal trial enrolled in a post-treatment follow-up study. The primary objective of the study was tocollect safety data of FORSTEO. During this observational period, other osteoporosis treatments wereallowed and additional assessment of vertebral fractures was performed.

During a median of 18 months following discontinuation of FORSTEO, there was a 41 % reduction(p=0.004) compared with placebo in the number of patients with a minimum of one new vertebralfracture.

In an open-label study, 503 postmenopausal women with severe osteoporosis and a fragility fracturewithin the previous 3 years (83 % had received previous osteoporosis therapy) were treated with

FORSTEO for up to 24 months. At 24 months, the mean increase from baseline in lumbar spine, totalhip and femoral neck BMD was 10.5 %, 2.6 % and 3.9 % respectively. The mean increase in BMDfrom 18 to 24 months was 1.4 %, 1.2 %, and 1.6 % at the lumbar spine, total hip and femoral neck,respectively.

A 24-month, randomized, double-blind, comparator-controlled Phase 4 study included 1,360postmenopausal women with established osteoporosis. 680 subjects were randomised to Forsteo and680 subjects were randomised to oral risedronate 35 mg/week. At baseline, the women had a mean ageof 72.1 years and a median of 2 prevalent vertebral fractures; 57.9% of patients had received previousbisphosphonate therapy and 18.8% took concomitant glucocorticoids during the study. 1,013 (74.5%)patients completed the 24-month follow-up. The mean (median) cumulative dose of glucocorticoidwas 474.3 (66.2) mg in the teriparatide arm and 898.0 (100.0) mg in the risedronate arm. The mean(median) vitamin D intake for the teriparatide arm was 1433 IU/day (1400 IU/day) and for therisedronate arm was 1191 IU/day (900 IU/day). For those subjects who had baseline and follow-upspine radiographs, the incidence of new vertebral fractures was 28/516 (5.4%) in Forsteo- and 64/533(12.0%) in risedronate-treated patients, relative risk (95% CI) = 0.44 (0.29-0.68), P<0.0001. Thecumulative incidence of pooled clinical fractures (clinical vertebral and non vertebral fractures) was4.8% in Forsteo and 9.8% in risedronate-treated patients, hazard ratio (95% CI) = 0.48 (0.32-0.74),

P=0.0009.

Male osteoporosis437 patients (mean age 58.7 years) were enrolled in a clinical trial for men with hypogonadal (definedas low morning free testosterone or an elevated FSH or LH) or idiopathic osteoporosis. Baseline spinaland femoral neck bone mineral density mean T-scores were -2.2 and -2.1, respectively. At baseline,35 % of patients had a vertebral fracture and 59 % had a non-vertebral fracture.

All patients were offered 1000 mg calcium per day and at least 400 IU vitamin D per day. Lumbarspine BMD significantly increased by 3 months. After 12 months, BMD had increased in the lumbarspine and total hip by 5 % and 1 %, respectively, compared with placebo. However, no significanteffect on fracture rates was demonstrated.

Glucocorticoid-induced osteoporosis

The efficacy of FORSTEO in men and women (N=428) receiving sustained systemic glucocorticoidtherapy (equivalent to 5 mg or greater of prednisone for at least 3 months) was demonstrated in the 18-month primary phase of a 36 month, randomised, double-blind, comparator-controlled study(alendronate 10 mg/day). Twenty-eight percent of patients had one or more radiographic vertebralfractures at baseline. All patients were offered 1000 mg calcium per day and 800 IU vitamin D perday.

This study included postmenopausal women (N=277), premenopausal women (N=67), and men(N=83). At baseline, the postmenopausal women had a mean age of 61 years, mean lumbar spine

BMD T score of −2.7, median prednisone equivalent dose of 7.5 mg/day, and 34 % had one or moreradiographic vertebral fractures; premenopausal women had a mean age of 37 years, mean lumbarspine BMD T score of −2.5, median prednisone equivalent dose of 10 mg/day, and 9 % had one ormore radiographic vertebral fractures; and men had a mean age of 57 years, mean lumbar spine BMD

T score of −2.2, median prednisone equivalent dose of 10 mg/day, and 24 % had one or moreradiographic vertebral fractures.

Sixty-nine percent of patients completed the 18-month primary phase. At the 18 month endpoint,

FORSTEO significantly increased lumbar spine BMD (7.2 %) compared with alendronate (3.4 %)(p<0.001). FORSTEO increased BMD at the total hip (3.6 %) compared with alendronate (2.2 %)(p<0.01), as well as at the femoral neck (3.7 %) compared with alendronate (2.1 %) (p<0.05). Inpatients treated with teriparatide, lumbar spine, total hip and femoral neck BMD increased between 18and 24 months by an additional 1.7 %, 0.9 %, and 0.4 %, respectively.

At 36 months, analysis of spinal X-rays from 169 alendronate patients and 173 FORSTEO patientsshowed that 13 patients in the alendronate group (7.7 %) had experienced a new vertebral fracturecompared with 3 patients in the FORSTEO group (1.7 %) (p=0.01). In addition, 15 of 214 patients inthe alendronate group (7.0 %) had experienced a non-vertebral fracture compared with 16 of 214patients in the FORSTEO group (7.5 %) (p=0.84).

In premenopausal women, the increase in BMD from baseline to 18 month endpoint was significantlygreater in the FORSTEO group compared with the alendronate group at the lumbar spine (4.2 %versus −1.9 %; p<0.001) and total hip (3.8 % versus 0.9 %; p=0.005). However, no significant effecton fracture rates was demonstrated.

The volume of distribution is approximately 1.7 L/kg. The half-life of FORSTEO is approximately 1hour when administered subcutaneously, which reflects the time required for absorption from theinjection site.

Biostransformation

No metabolism or excretion studies have been performed with FORSTEO but the peripheralmetabolism of parathyroid hormone is believed to occur predominantly in liver and kidney.

FORSTEO is eliminated through hepatic and extra-hepatic clearance (approximately 62 L/hr in womenand 94 L/hr in men).

No differences in FORSTEO pharmacokinetics were detected with regard to age (range 31 to 85years). Dosage adjustment based on age is not required.

Teriparatide was not genotoxic in a standard battery of tests. It produced no teratogenic effects in rats,mice or rabbits. There were no important effects observed in pregnant rats or mice administeredteriparatide at daily doses of 30 to 1000 µg/kg. However, fetal resorption and reduced litter sizeoccurred in pregnant rabbits administered daily doses of 3 to 100 µg/kg. The embryotoxicity observedin rabbits may be related to their much greater sensitivity to the effects of PTH on blood ionisedcalcium compared with rodents.

Rats treated with near-life time daily injections had dose-dependent exaggerated bone formation andincreased incidence of osteosarcoma most probably due to an epigenetic mechanism. Teriparatide didnot increase the incidence of any other type of neoplasia in rats. Due to the differences in bonephysiology in rats and humans, the clinical relevance of these findings is probably minor. No bonetumours were observed in ovariectomised monkeys treated for 18 months or during a 3-year follow-upperiod after treatment cessation. In addition, no osteosarcomas have been observed in clinical trials orduring the post treatment follow-up study.

Animal studies have shown that severely reduced hepatic blood flow decreases exposure of PTH to theprincipal cleavage system (Kupffer cells) and consequently clearance of PTH(1-84).

Glacial acetic acid

Sodium acetate (anhydrous)

Mannitol

Metacresol

Hydrochloric acid (for pH adjustment)

Sodium hydroxide (for pH adjustment)

Water for injections

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

2 years

Chemical, physical and microbiological in-use stability has been demonstrated for 28 days at 2-8°C.

Once opened, the product may be stored for a maximum of 28 days at 2°C to 8°C. Other in-use storagetimes and conditions are the responsibility of the user.

Store in a refrigerator (2°C - 8°C) at all times. The pen should be returned to the refrigeratorimmediately after use. Do not freeze.

Do not store the injection device with the needle attached.

2.4 mL solution in cartridge (siliconised Type I glass) with a plunger (halobutyl rubber), disc seal(polyisoprene/bromobutyl rubber laminate)/aluminium assembled into a disposable pen.

FORSTEO is available in pack sizes of 1 or 3 pens. Each pen contains 28 doses of 20 micrograms (per80 microliters).

Not all pack sizes may be marketed.

FORSTEO is supplied in a pre-filled pen. Each pen should be used by only one patient. A new, sterileneedle must be used for every injection. Each FORSTEO pack is provided with a user manual thatfully describes the use of the pen. No needles are supplied with the product. The device can be usedwith insulin pen injection needles. After each injection, the FORSTEO pen should be returned to therefrigerator.

FORSTEO should not be used if the solution is cloudy, coloured or contains particles.

Please also refer to the user manual for instructions on how to use the pen.

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

Eli Lilly Nederland B.V., Papendorpseweg 83, 3528 BJ Utrecht, The Netherlands

EU/1/03/247/001-002

Date of first authorisation: 10 June 2003

Date of the latest renewal: 13 February 2013

Detailed information on this medicinal product is available on the website of the European Medicines

Agency http://www.ema.europa.eu