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WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE See full prescribing information for complete boxed warning. Chronic Kidney Disease: In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL ( 5.1 ). No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks ( 2.2 ). Use the lowest PROCRIT dose sufficient to reduce the need for red blood cell (RBC) transfusions ( 5.1 ). Cancer: ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers ( 5.2 ). Use the lowest dose to avoid RBC transfusions ( 2.4 ). Use ESAs only for anemia from myelosuppressive chemotherapy ( 1.3 ). ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure ( 1.5 ). Discontinue following the completion of a chemotherapy course ( 2.4 ). Perisurgery: Due to increased risk of deep venous thrombosis (DVT), DVT prophylaxis is recommended ( 5.1 ). Chronic Kidney Disease: In controlled trials, patients with chronic kidney disease (CKD) experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL [see Warnings and Precautions (5.1) ] . No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks [see Dosage and Administration (2.2) ] . Use the lowest PROCRIT dose sufficient to reduce the need for red blood cell (RBC) transfusions [see Warnings and Precautions (5.1) ] . Cancer: ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers [see Warnings and Precautions (5.2) ] . To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, use the lowest dose needed to avoid RBC transfusions [see Dosage and Administration (2.4) ] . Use ESAs only for anemia from myelosuppressive chemotherapy [see Indications and Usage (1.3) ] . ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure [see Indications and Usage (1.5) ] . Discontinue following the completion of a chemotherapy course [see Dosage and Administration (2.4) ] . Perisurgery: Due to increased risk of Deep Venous Thrombosis (DVT), DVT prophylaxis is recommended [see Dosage and Administration (2.5) , Warnings and Precautions (5.1) ] .

Risk first

Contraindications

4 CONTRAINDICATIONS PROCRIT is contraindicated in patients with: Uncontrolled hypertension [see Warnings and Precautions (5.3) ] Pure red cell aplasia (PRCA) that begins after treatment with PROCRIT or other erythropoietin protein drugs [see Warnings and Precautions (5.6) ] Serious allergic reactions to PROCRIT [see Warnings and Precautions (5.7) ] PROCRIT from multiple-dose vials contains benzyl alcohol and is contraindicated in: Neonates, infants, pregnant women, and lactating women [see Warnings and Precautions (5.9) , Use in Specific Populations (8.1 , 8.2 , 8.4) ].
Uncontrolled hypertension ( 4 ) Pure red cell aplasia (PRCA) that begins after treatment with PROCRIT or other erythropoietin protein drugs ( 4 ) Serious allergic reactions to PROCRIT ( 4 ) Use of the multiple-dose vials containing benzyl alcohol in neonates, infants, pregnant women, and lactating women ( 4 )

Precautions

HB to be monitored every 2 wks until stabilized, then every 2-4wks
dose adjustments must not be made more frequently than once a month
the IV route of administration may reduce the risk for development of antibodies to the drug in comparison to SC.

Point of care

Dosing

Adult

Dose:SC: Initial dose: 3 x 20 IU/kg/wk increased every 4 wks by 3 x 20 IU/kg/ wk if the increase of Hb is < 0.25 g/dl/wk. IV: The initial dose: 3 x 40 IU/kg/wk increased after 4 wks to 80 IU/kg x 3 wkly up to 20 IU/kg x 3 per week, at monthly intervals [maximum dose < 720 IU/kg/wk. Main-tainance dose titrated to produce Hb of 10-12 g/dl

Paediatric

8.4 Pediatric Use The multiple-dose vials are formulated with benzyl alcohol and are contraindicated for use in neonates and infants [see Contraindications (4) , Warnings and Precautions (5.9) ] . When therapy with PROCRIT is needed in neonates and infants, use the single-dose vial, which is a benzyl alcohol-free formulation. Do not mix the single-dose vials with bacteriostatic saline when administering PROCRIT to neonates or infants because it contains benzyl alcohol [see Dosage and Administration (2.6) ] . Serious adverse reactions including fatal reactions and the "gasping syndrome" occurred in premature neonates and infants in the neonatal intensive care unit who received drugs containing benzyl alcohol as a preservative. In these cases, benzyl alcohol dosages of 99 to 234 mg/kg/day produced high levels of benzyl alcohol and its metabolites in the blood and urine (blood levels of benzyl alcohol were 0.61 to 1.378 mmol/L). Additional adverse reactions included gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic and renal failure, hypotension, bradycardia, and cardiovascular collapse. Preterm, low birth weight infants may be more likely to develop these reactions because they may be less able to metabolize benzyl alcohol. The minimum amount of benzyl alcohol at which serious adverse reactions may occur is not known [see Warnings and Precautions (5.9) ] . Pediatric Patients with CKD PROCRIT is indicated in pediatric patients, ages 1 month to 16 years of age, for the treatment of anemia associated with CKD requiring dialysis. Safety and effectiveness in pediatric patients less than 1 month old have not been established [see Clinical Studies (14.1) ] . Use of PROCRIT in pediatric patients with CKD not requiring dialysis is supported by efficacy in pediatric patients requiring dialysis. The mechanism of action of PROCRIT is the same for these two populations. Published literature also has reported the use of PROCRIT in pediatric patients with CKD not requiring dialysis. Dose-dependent increases in hemoglobin and hematocrit were observed with reductions in transfusion requirements. The safety data from the pediatric studies and postmarketing reports are similar to those obtained from the studies of PROCRIT in adult patients with CKD [see Warnings and Precautions (5) and Adverse Reactions (6.1) ] . Postmarketing reports do not indicate a difference in safety profiles in pediatric patients with CKD requiring dialysis and not requiring dialysis. Pediatric Patients with Cancer on Chemotherapy PROCRIT is indicated in patients 5 to 18 years old for the treatment of anemia due to concomitant myelosuppressive chemotherapy. Safety and effectiveness in pediatric patients less than 5 years of age have not been established [see Clinical Studies (14.3) ]. The safety data from these studies are similar to those obtained from the studies of PROCRIT in adult patients with cancer [see Warnings and Precautions (5.1 , 5.2) and Adverse Reactions (6.1) ]. Pediatric Patients with HIV Infection Receiving Zidovudine Published literature has reported the use of PROCRIT in 20 zidovudine-treated, anemic, pediatric patients with HIV Infection, ages 8 months to 17 years, treated with 50 to 400 Units/kg subcutaneously or intravenously 2 to 3 times per week. Increases in hemoglobin levels and in reticulocyte counts and decreases in or elimination of RBC transfusions were observed. Pharmacokinetics in Neonates Limited pharmacokinetic data from a study of 7 preterm, very low birth weight neonates and 10 healthy adults given intravenous erythropoietin suggested that distribution volume was approximately 1.5 to 2 times higher in the preterm neonates than in the healthy adults, and clearance was approximately 3 times higher in the preterm neonates than in the healthy adults.

Renal

Review renal impairment dosing; many agents need CrCl/eGFR adjustment.

CrCl 0–120: Confirm renal dosing in product SmPC / primary label.

Hepatic

Review hepatic impairment dosing; monitor LFTs if agent is hepatically cleared or hepatotoxic.

Safety

Drug interactions

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Professional use: confirm indication, dose, duration, monitoring and patient counselling points against current Kenya STG / EML and the product SmPC.
Document allergy status and key interactions.

Safety

Adverse effects

Hypertension
diarrhea
naso-pharyngitis
headache
coronary artery disease
septic shock
increased mortality
pure red cell aplasia
serious cardiovascular and thromboembolic events.

Use

Indications

Symptomatic anaemia associated with CRF in adults and paediatrics
prevention of anaemia of prematurity in infants with a birth weight of 0.75-1.5kg and a gestational age < 34 wks
symptomatic anaemia in adult patients with non-myeloid malignancies receiving chemotherapy
increasing the yield of autologous blood from patients in a pre-donation programme.

Pharmacology

Mode of action

12.

1 Mechanism of Action PROCRIT stimulates e… → Mechanism is agent-specific. → At receptor, enzyme, ion channel, transpor…

Full mechanism text

12.1 Mechanism of Action PROCRIT stimulates erythropoiesis by the same mechanism as endogenous erythropoietin. Mechanism is agent-specific. At receptor, enzyme, ion channel, transporter or microbial target level, the drug alters a physiological or pathological pathway to produce its therapeutic effect. Confirm precise molecular mechanism in current SmPC / pharmacology reference for this INN before high-stakes decisions.

ADME

Pharmacokinetics & PD

Onset	Product-specific
Duration	Product-specific
Route	INTRAVENOUS, SUBCUTANEOUS
Elimination	half-life (t 1/2 ) of plasma erythropoietin after intravenous administration of PROCRIT ranged from 4 to 13 hours. After subcutaneous administration, C max was achieved within 5 to 24 hours. The t 1/2 in adult patients with serum creatinine greater than 3 mg/dL was similar betwee...
Half-life	(t 1/2 ) of plasma erythropoietin after intravenous administration of PROCRIT ranged from 4 to 13 hours. After subcutaneous administration, C max was achieved within 5 to 24 hours. The t 1/2 in adult patients with serum creatinine greater than 3 mg/dL was similar between those no...

Full PK/PD text

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action PROCRIT stimulates erythropoiesis by the same mechanism as endogenous erythropoietin. 12.2 Pharmacodynamics PROCRIT increases the reticulocyte count within 10 days of initiation, followed by increases in the RBC count, hemoglobin, and hematocrit, usually within 2 to 6 weeks. The rate of hemoglobin increase varies among patients and is dependent upon the dose of PROCRIT administered. For correction of anemia in hemodialysis patients, a greater biologic response is not observed at doses exceeding 300 Units/kg 3 times weekly. 12.3 Pharmacokinetics In adult and pediatric patients with CKD, the elimination half-life (t 1/2 ) of plasma erythropoietin after intravenous administration of PROCRIT ranged from 4 to 13 hours. After subcutaneous administration, C max was achieved within 5 to 24 hours. The t 1/2 in adult patients with serum creatinine greater than 3 mg/dL was similar between those not on dialysis and those maintained on dialysis. The pharmacokinetic data indicate no apparent difference in PROCRIT t 1/2 among adult patients above or below 65 years of age. A pharmacokinetic study comparing 150 Units/kg subcutaneous 3 times weekly to 40,000 Units subcutaneous weekly dosing regimen was conducted for 4 weeks in healthy subjects (n=12) and for 6 weeks in anemic cancer patients (n=32) receiving cyclic chemotherapy. There was no accumulation of serum erythropoietin after the 2 dosing regimens during the study period. The 40,000 Units weekly regimen had a higher C max (3- to 7-fold), longer T max (2- to 3-fold), higher AUC 0–168 h (2- to 3-fold) of erythropoietin and lower clearance (CL) (50%) than the 150 Units/kg 3 times weekly regimen. In anemic cancer patients, the average t 1/2 was similar (40 hours with range of 16 to 67 hours) after both dosing regimens. After the 150 Units/kg 3 times weekly dosing, the values of T max and CL were similar (13.3 ± 12.4 vs. 14.2 ± 6.7 hours, and 20.2 ± 15.9 vs. 23.6 ± 9.5 mL/hr/kg) between week 1 when patients were receiving chemotherapy (n=14) and week 3 when patients were not receiving chemotherapy (n=4). Differences were observed after the 40,000 Units weekly dosing with longer T max (38 ± 18 hours) and lower CL (9.2 ± 4.7 mL/hr/kg) during week 1 when patients were receiving chemotherapy (n=18) compared with those (22 ± 4.5 hours, 13.9 ± 7.6 mL/hr/kg, respectively) during week 3 when patients were not receiving chemotherapy (n=7). The pharmacokinetic profile of PROCRIT in pediatric patients appeared similar to that of adults. The pharmacokinetics of PROCRIT has not been studied in patients with HIV Infection.

Kenya

Brands & prices

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Special populations

Pregnancy & lactation

Pregnancy

8.1 Pregnancy Risk Summary PROCRIT from multiple-dose vials contains benzyl alcohol and is contraindicated in pregnant women [see Contraindications (4) ] . When therapy with PROCRIT is needed during pregnancy, use a benzyl alcohol-free formulation (i.e., single-dose vial). Do not mix PROCRIT with bacteriostatic saline when administering to pregnant women because it contains benzyl alcohol (see Clinical Considerations ) [see Dosage and Administration (2.1) ] . The limited available data on PROCRIT use in pregnant women are insufficient to determine a drug-associated risk of adverse developmental outcomes. In animal reproductive and developmental toxicity studies, adverse fetal effects including embryo-fetal death, skeletal anomalies, and growth defects occurred when pregnant rats received epoetin alfa at doses approximating the clinical recommended starting doses (see Data ) . Consider the benefits and risks of PROCRIT single-dose vials for the mother and possible risks to the fetus when prescribing PROCRIT to a pregnant woman. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. . All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies is 2–4% and 15–20%, respectively. Clinical Considerations Fetal/Neonatal Adverse Reactions The multiple-dose vials of PROCRIT contain benzyl alcohol. The preservative benzyl alcohol has been associated with serious adverse reactions and death when administered intravenously to neonates and infants [see Warnings and Precautions (5.9) , Use in Specific Populations (8.4) ]. There is a potential for similar risks to fetuses exposed to benzyl alcohol in utero . Data Human Data There are reports of pregnant women with anemia alone or anemia associated with severe renal disease and other hematologic disorders who received PROCRIT. Polyhydramnios and intrauterine growth restriction were reported in women with chronic renal disease, which is associated with an increased risk for these adverse pregnancy outcomes. Due to the limited number of exposed pregnancies and multiple confounding factors (such as underlying maternal conditions, other maternal medications, and gestational timing of exposure), these published case reports and studies do not reliably estimate the frequency, presence or absence of adverse outcomes. Animal Data When rats received PROCRIT at doses greater than or equal to 100 Units/kg/day during mating and through early pregnancy (dosing stopped prior to organogenesis), there were slight increases in the incidences of pre- and post-implantation loss, and a decrease in live fetuses in the presence of maternal toxicity (red limbs/pinna, focal splenic capsular toxicity, increased organ weights). This animal dose level of 100 Units/kg/day may approximate the clinical recommended starting dose, depending on the treatment indication. When pregnant rats and rabbits received intravenous doses of up to 500 mg/kg/day of PROCRIT only during organogenesis (gestational days 7 to 17 in rats and gestational days 6 to 18 in rabbits), no teratogenic effects were observed in the offspring. The offspring (F1 generation) of the treated rats were observed postnatally; rats from the F1 generation reached maturity and were mated; no PROCRIT-related effects were apparent for their offspring (F2 generation fetuses). When pregnant rats received PROCRIT at doses of 500 Units/kg/day late in pregnancy (after the period of organogenesis from day 17 of gestation through day 21 of lactation), pups exhibited decreased number of caudal vertebrae, decreased body weight gain, and delayed appearance of abdominal hair, eyelid opening, and ossification in the presence of maternal toxicity (red limbs/pinna, increased organ weights). This animal dose level of 500 U/kg/day is approximately five times the clinical recommended starting dose depending on the patient's treatment indication.

Lactation

Assess infant risk vs benefit of maternal therapy; prefer agents with lactation data.

Trust

Sources & disclaimer

Source: Local active-ingredient clinical extract; FDA drug label via OpenFDA/DailyMed; Professional class pharmacology (Therapeutic agent (verify pharmacological class))

Open source link

Clinical review date not recorded.

Decision support only — not a substitute for clinical judgment, product SmPC, or Kenya STG/EML.

Erythropoietin, Recombinant Human