英文药名: Simponi(Golimumab Injection)

中文药名: 戈利木单抗注射剂

生产厂家: 德国（MSD）
药品介绍
2013年9月23日，欧盟委员会批准SIMPONI(戈利木单抗)用于治疗对常规疗法(如激素、6-巯基嘌呤、咪唑硫嘌呤)没有足够响应，或对常规药物产生耐药性和禁忌征候的成人中度至重度溃疡性结肠炎。欧洲医管局下属机构人用医药产品委员会在2013年7月已经推荐SIMPONI的使用，欧盟委员会的批准延续了这种正面意见。
溃疡性结肠炎这种慢性的肠道疾病，会导致大肠内膜发炎和溃疡，进而引起便血、严重腹泻和腹部经常性疼痛。
Janssen 研发部门副总裁Jerome A. Boscia说：“对于患者和肠胃病相关组织来说，欧盟批准SIMPONI用于治疗中至重度溃疡性结肠炎是这一领域的里程碑式事件，并且SIMPONI在相关临床研究中表现优异。”
Simponi是目前首个也是唯一一个治疗溃疡性结肠炎的抗肿瘤坏死因子药物，每4周通过皮下注射给药1次。对于体重小于80kg的患者，初始剂量为200mg，第2周为100mg，以后每4周50mg。对于体重80kg及以上的患者，初始剂量为200mg，第2周为100mg，以后每4周100mg。
SIMPONI的临床试验遵循了欧盟委员会对溃疡性结肠炎所要求的标准(PURSUIT)，临床结果也显示对于中度至重度溃疡性结肠炎患者SIMPONI确实会减轻症状，提高患者生活质量。另外，经欧盟委员会批准的药品性质概要也显示Simpon在54周内可维持较好的临床应答，对Simponi有初始应答的患者被分为Simponi治疗组或者安慰剂对照组，在第30和54周时治疗组中有更多的患者显示并维持较长的临床缓解率和粘膜恢复率。

Simponi 50 mg solution for injection
1. Name of the medicinal product
Simponi® 50 mg solution for injection in pre-filled pen.
Simponi® 50 mg solution for injection in pre-filled syringe.
2. Qualitative and quantitative composition
One 0.5 mL pre-filled pen or pre-filled syringe contains 50 mg of golimumab*.
* Human IgG1κ monoclonal antibody produced by a murine hybridoma cell line with recombinant DNA technology.
Excipient with known effect:
Each pre-filled pen or pre-filled syringe contains 20.5 mg sorbitol per 50 mg dose.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Solution for injection in pre-filled pen (injection), SmartJect
Solution for injection in pre-filled syringe (injection)
The solution is clear to slightly opalescent, colourless to light yellow.
4. Clinical particulars
4.1 Therapeutic indications
Rheumatoid arthritis (RA)
Simponi, in combination with methotrexate (MTX), is indicated for:
• the treatment of moderate to severe, active rheumatoid arthritis in adults when the response to disease-modifying anti-rheumatic drug (DMARD) therapy including MTX has been inadequate.
• the treatment of severe, active and progressive rheumatoid arthritis in adults not previously treated with MTX.
Simponi, in combination with MTX, has been shown to reduce the rate of progression of joint damage as measured by X-ray and to improve physical function.
Psoriatic arthritis (PsA)
Simponi, alone or in combination with MTX, is indicated for the treatment of active and progressive psoriatic arthritis in adult patients when the response to previous DMARD therapy has been inadequate. Simponi has been shown to reduce the rate of progression of peripheral joint damage as measured by X-ray in patients with polyarticular symmetrical subtypes of the disease (see section 5.1) and to improve physical function.
Axial spondyloarthritis
Ankylosing spondylitis (AS)
Simponi is indicated for the treatment of severe, active ankylosing spondylitis in adults who have responded inadequately to conventional therapy.
Non-radiographic axial spondyloarthritis (nr-Axial SpA)
Simponi is indicated for the treatment of adults with severe, active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) evidence, who have had an inadequate response to, or are intolerant to nonsteroidal anti-inflammatory drugs (NSAIDs).
Ulcerative colitis (UC)
Simponi is indicated for treatment of moderately to severely active ulcerative colitis in adult patients who have had an inadequate response to conventional therapy including corticosteroids and 6-mercaptopurine (6-MP) or azathioprine (AZA), or who are intolerant to or have medical contraindications for such therapies.
4.2 Posology and method of administration
Simponi treatment is to be initiated and supervised by qualified physicians experienced in the diagnosis and treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, or ulcerative colitis. Patients treated with Simponi should be given the Patient Alert Card.
Posology
Rheumatoid arthritis
Simponi 50 mg given once a month, on the same date each month.
Simponi should be given concomitantly with MTX.
Psoriatic arthritis, ankylosing spondylitis, or non-radiographic axial spondyloarthritis
Simponi 50 mg given once a month, on the same date each month.
For all of the above indications, available data suggest that clinical response is usually achieved within 12 to 14 weeks of treatment (after 3-4 doses). Continued therapy should be reconsidered in patients who show no evidence of therapeutic benefit within this time period.
Patients with bodyweight greater than 100 kg
For all of the above indications, in patients with RA, PsA, AS, or nr-Axial SpA with a body weight of more than 100 kg who do not achieve an adequate clinical response after 3 or 4 doses, increasing the dose of golimumab to 100 mg once a month may be considered, taking into account the increased risk of certain serious adverse drug reactions with the 100 mg dose compared with the 50 mg dose (see section 4.8). Continued therapy should be reconsidered in patients who show no evidence of therapeutic benefit after receiving 3 to 4 additional doses of 100 mg.
Ulcerative colitis
Patients with body weight less than 80 kg
Simponi given as an initial dose of 200 mg, followed by 100 mg at week 2, then 50 mg every 4 weeks, thereafter (see section 5.1).
Patients with body weight greater than or equal to 80 kg
Simponi given as an initial dose of 200 mg, followed by 100 mg at week 2, then 100 mg every 4 weeks, thereafter (see section 5.1)
During maintenance treatment, corticosteroids may be tapered in accordance with clinical practice guidelines.
Available data suggest that clinical response is usually achieved within 12-14 weeks of treatment (after 4 doses). Continued therapy should be reconsidered in patients who show no evidence of therapeutic benefit within this time period.
Missed dose
If a patient forgets to inject Simponi on the planned date, the forgotten dose should be injected as soon as the patient remembers. Patients should be instructed not to inject a double dose to make up for the forgotten dose.
The next dose should be administered based on the following guidance:
• if the dose is less than 2 weeks late, the patient should inject his/her forgotten dose and stay on his/her original schedule.
• if the dose is more than 2 weeks late, the patient should inject his/her forgotten dose and a new schedule should be established from the date of this injection.
Special populations
Elderly (≥ 65 years)
No dose adjustment is required in the elderly.
Renal and hepatic impairment
Simponi has not been studied in these patient populations. No dose recommendations can be made.
Paediatric population
The safety and efficacy of Simponi in patients aged less than 18 have not yet been established. No data are available.
Method of administration
Simponi is for subcutaneous use. After proper training in subcutaneous injection technique, patients may self-inject with Simponi if their physician determines that this is appropriate, with medical follow-up as necessary. Patients should be instructed to inject the full amount of Simponi according to the comprehensive instructions for administration provided in the package leaflet. If multiple injections are required, the injections should be administered at different sites on the body.
For administration instructions, see section 6.6.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Active tuberculosis (TB) or other severe infections such as sepsis, and opportunistic infections (see section 4.4).
Moderate or severe heart failure (NYHA class III/IV) (see section 4.4).
4.4 Special warnings and precautions for use
Infections
Patients must be monitored closely for infections including tuberculosis before, during and after treatment with Simponi. Because the elimination of golimumab may take up to 5 months, monitoring should be continued throughout this period. Further treatment with Simponi must not be given if a patient develops a serious infection or sepsis (see section 4.3).
Simponi should not be given to patients with a clinically important, active infection. Caution should be exercised when considering the use of Simponi in patients with a chronic infection or a history of recurrent infection. Patients should be advised of, and avoid exposure to, potential risk factors for infection as appropriate.
Patients taking TNF-blockers are more susceptible to serious infections.
Bacterial (including sepsis and pneumonia), mycobacterial (including TB), invasive fungal and opportunistic infections, including fatalities, have been reported in patients receiving Simponi. Some of these serious infections have occurred in patients on concomitant immunosuppressive therapy that, in addition to their underlying disease, could predispose them to infections. Patients who develop a new infection while undergoing treatment with Simponi should be monitored closely and undergo a complete diagnostic evaluation. Administration of Simponi should be discontinued if a patient develops a new serious infection or sepsis, and appropriate antimicrobial or antifungal therapy should be initiated until the infection is controlled. For patients who have resided in or travelled to regions where invasive fungal infections such as histoplasmosis, coccidioidomycosis, or blastomycosis are endemic, the benefits and risks of Simponi treatment should be carefully considered before initiation of Simponi therapy.
Tuberculosis
There have been reports of tuberculosis in patients receiving Simponi. It should be noted that in the majority of these reports, tuberculosis was extrapulmonary presenting as either local or disseminated disease.
Before starting treatment with Simponi, all patients must be evaluated for both active and inactive ('latent') tuberculosis. This evaluation should include a detailed medical history with personal history of tuberculosis or possible previous contact with tuberculosis and previous and/or current immunosuppressive therapy. Appropriate screening tests, i.e. tuberculin skin or blood test and chest X-ray, should be performed in all patients (local recommendations may apply). It is recommended that the conduct of these tests should be recorded in the patient's alert card. Prescribers are reminded of the risk of false negative tuberculin skin test results, especially in patients who are severely ill or immunocompromised.
If active tuberculosis is diagnosed, Simponi therapy must not be initiated (see section 4.3).
If latent tuberculosis is suspected, a physician with expertise in the treatment of tuberculosis should be consulted. In all situations described below, the benefit/risk balance of Simponi therapy should be very carefully considered.
If inactive ('latent') tuberculosis is diagnosed, treatment for latent tuberculosis must be started with anti-tuberculosis therapy before the initiation of Simponi, and in accordance with local recommendations.
In patients who have several or significant risk factors for tuberculosis and have a negative test for latent tuberculosis, anti-tuberculosis therapy should be considered before the initiation of Simponi. Use of anti-tuberculosis therapy should also be considered before the initiation of Simponi in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed.
Cases of active tuberculosis have occurred in patients treated with Simponi during and after treatment for latent tuberculosis. Patients receiving Simponi should be monitored closely for signs and symptoms of active tuberculosis, including patients who tested negative for latent tuberculosis, patients who are on treatment for latent tuberculosis, or patients who were previously treated for tuberculosis infection.
All patients should be informed to seek medical advice if signs/symptoms suggestive of tuberculosis (e.g. persistent cough, wasting/weight loss, low-grade fever) appear during or after Simponi treatment.
Hepatitis B virus reactivation
Reactivation of hepatitis B has occurred in patients receiving a TNF-antagonist including Simponi, who are chronic carriers of this virus (i.e. surface antigen positive). Some cases have had fatal outcome.
Patients should be tested for HBV infection before initiating treatment with Simponi. For patients who test positive for HBV infection, consultation with a physician with expertise in the treatment of hepatitis B is recommended.
Carriers of HBV who require treatment with Simponi should be closely monitored for signs and symptoms of active HBV infection throughout therapy and for several months following termination of therapy. Adequate data of treating patients who are carriers of HBV with anti-viral therapy in conjunction with TNF-antagonist therapy to prevent HBV reactivation are not available. In patients who develop HBV reactivation, Simponi should be stopped and effective anti-viral therapy with appropriate supportive treatment should be initiated.
Malignancies and lymphoproliferative disorders
The potential role of TNF-blocking therapy in the development of malignancies is not known. Based on the current knowledge, a possible risk for the development of lymphomas, leukaemia or other malignancies in patients treated with a TNF-antagonist cannot be excluded. Caution should be exercised when considering TNF-blocking therapy for patients with a history of malignancy or when considering continuing treatment in patients who develop malignancy.
Paediatric malignancy
Malignancies, some fatal, have been reported among children, adolescents and young adults (up to 22 years of age) treated with TNF-blocking agents (initiation of therapy ≤ 18 years of age) in the post marketing setting. Approximately half the cases were lymphomas. The other cases represented a variety of different malignancies and included rare malignancies usually associated with immunosuppression. A risk for the development of malignancies in children and adolescents treated with TNF-blockers cannot be excluded.
Lymphoma and leukaemia
In the controlled portions of clinical trials of all the TNF-blocking agents including Simponi, more cases of lymphoma have been observed among patients receiving anti-TNF treatment compared with control patients. During the Simponi Phase IIb and Phase III clinical trials in RA, PsA and AS, the incidence of lymphoma in Simponi-treated patients was higher than expected in the general population. In the post-marketing setting, cases of leukaemia have been reported in patients treated with a TNF-antagonist. There is an increased background risk for lymphoma and leukaemia in rheumatoid arthritis patients with long-standing, highly active, inflammatory disease, which complicates risk estimation.
Rare post-marketing cases of hepatosplenic T-cell lymphoma (HSTCL) have been reported in patients treated with other TNF-blocking agents (see section 4.8). This rare type of T-cell lymphoma has a very aggressive disease course and is usually fatal. The majority of cases have occurred in adolescent and young adult males with nearly all on comcomitant treatment with azathioprine (AZA) or 6-mercaptopurine (6–MP) for inflammatory bowel disease. The potential risk with the combination of AZA or 6-MP and Simponi should be carefully considered. A risk for the development for hepatosplenic T-cell lymphoma in patients treated with TNF-blockers cannot be excluded.
Malignancies other than lymphoma
In the controlled portions of the Simponi Phase IIb and Phase III clinical trials in RA, PsA, AS, and UC, the incidence of non-lymphoma malignancies (excluding non-melanoma skin cancer) was similar between the Simponi and the control groups.
Colon dysplasia/carcinoma
It is not known if golimumab treatment influences the risk for developing dysplasia or colon cancer. All patients with ulcerative colitis who are at increased risk for dysplasia or colon carcinoma (for example, patients with long-standing ulcerative colitis or primary sclerosing cholangitis), or who had a prior history of dysplasia or colon carcinoma should be screened for dysplasia at regular intervals before therapy and throughout their disease course. This evaluation should include colonoscopy and biopsies per local recommendations. In patients with newly diagnosed dysplasia treated with Simponi, the risks and benefits to the individual patient must be carefully reviewed and consideration should be given to whether therapy should be continued.
In an exploratory clinical trial evaluating the use of Simponi in patients with severe persistent asthma, more malignancies were reported in patients treated with Simponi compared with control patients (see section 4.8). The significance of this finding is unknown.
In an exploratory clinical trial evaluating the use of another anti-TNF agent, infliximab, in patients with moderate to severe chronic obstructive pulmonary disease (COPD), more malignancies, mostly in the lung or head and neck, were reported in infliximab-treated patients compared with control patients. All patients had a history of heavy smoking. Therefore, caution should be exercised when using any TNF-antagonist in COPD patients, as well as in patients with an increased risk of malignancy due to heavy smoking.
Skin cancers
Melanoma has been reported in patients treated with TNF-blocking agents, including Simponi. Merkel cell carcinoma has been reported in patients treated with other TNF-blocking agents (see section 4.8). Periodic skin examination is recommended, particularly for patients with risk factors for skin cancer.
Congestive heart failure (CHF)
Cases of worsening congestive heart failure (CHF) and new onset CHF have been reported with TNF blockers, including Simponi. In a clinical trial with another TNF-antagonist worsening congestive heart failure and increased mortality due to CHF have been observed. Simponi has not been studied in patients with CHF. Simponi should be used with caution in patients with mild heart failure (NYHA class I/II). Patients should be closely monitored and Simponi must be discontinued in patients who develop new or worsening symptoms of heart failure (see section 4.3).
Neurological events
Use of TNF-blocking agents, including Simponi, has been associated with cases of new onset or exacerbation of clinical symptoms and/or radiographic evidence of central nervous system demyelinating disorders, including multiple sclerosis and peripheral demyelinating disorders. In patients with pre-existing or recent onset of demyelinating disorders, the benefits and risks of anti-TNF treatment should be carefully considered before initiation of Simponi therapy. Discontinuation of Simponi should be considered if these disorders develop (see section 4.8).
Surgery
There is limited safety experience of Simponi treatment in patients who have undergone surgical procedures, including arthroplasty. The long half-life should be taken into consideration if a surgical procedure is planned. A patient who requires surgery while on Simponi should be closely monitored for infections, and appropriate actions should be taken.
Immunosuppression
The possibility exists for TNF-blocking agents, including Simponi, to affect host defences against infections and malignancies since TNF mediates inflammation and modulates cellular immune responses.
Autoimmune processes
The relative deficiency of TNFα caused by anti-TNF therapy may result in the initiation of an autoimmune process. If a patient develops symptoms suggestive of a lupus-like syndrome following treatment with Simponi and is positive for antibodies against double-stranded DNA, treatment with Simponi should be discontinued (see section 4.8).
Haematologic reactions
There have been post-marketing reports of pancytopaenia, leucopaenia, neutropaenia, aplastic anaemia, and thrombocytopaenia in patients receiving TNF-blockers. Cytopaenias including pancytopaenia have been infrequently reported with Simponi in clinical trials. All patients should be advised to seek immediate medical attention if they develop signs and symptoms suggestive of blood dyscrasias (e.g. persistent fever, bruising, bleeding, pallor). Discontinuation of Simponi therapy should be considered in patients with confirmed significant haematologic abnormalities.
Concurrent administration of TNF-antagonists and anakinra
Serious infections and neutropenia were seen in clinical studies with concurrent use of anakinra and another TNF-blocking agent, etanercept, with no added clinical benefit. Because of the nature of the adverse events seen with this combination therapy, similar toxicities may also result from the combination of anakinra and other TNF-blocking agents. The combination of Simponi and anakinra is not recommended.
Concurrent administration of TNF-antagonists and abatacept
In clinical studies concurrent administration of TNF-antagonists and abatacept has been associated with an increased risk of infections including serious infections compared to TNF-antagonists alone, without increased clinical benefit. The combination of Simponi and abatacept is not recommended.
Concurrent administration with other biological therapeutics
There is insufficient information regarding the concomitant use of Simponi with other biological therapeutics used to treat the same conditions as Simponi. The concomitant use of Simponi with these biologics is not recommended because of the possibility of an increased risk of infection, and other potential pharmacological interactions.
Switching between biological DMARDs
Care should be taken and patients should continue to be monitored when switching from one biologic to another, since overlapping biological activity may further increase the risk for adverse events, including infection.
Vaccinations/therapeutic infectious agents
Patients treated with Simponi may receive concurrent vaccinations, except for live vaccines (see sections 4.5 and 4.6). In patients receiving anti-TNF therapy, limited data are available on the response to vaccination with live vaccines or on the secondary transmission of infection by live vaccines. Use of live vaccines could result in clinical infections, including disseminated infections.
Other uses of therapeutic infectious agents such as live attenuated bacteria (e.g. BCG bladder instillation for the treatment of cancer) could result in clinical infections, including disseminated infections. It is recommended that therapeutic infectious agents not be given concurrently with Simponi.
Allergic reactions
In post-marketing experience, serious systemic hypersensitivity reactions (including anaphylactic reaction) have been reported following Simponi administration. Some of these reactions occurred after the first administration of Simponi. If an anaphylactic reaction or other serious allergic reactions occur, administration of Simponi should be discontinued immediately and appropriate therapy initiated.
Latex sensitivity
The needle cover on the pre-filled pen or pre-filled syringe is manufactured from dry natural rubber containing latex, and may cause allergic reactions in individuals sensitive to latex.
Special populations
Elderly (≥ 65 years)
In the Phase III studies in RA, PsA, AS, and UC, no overall differences in adverse events (AEs), serious adverse events (SAEs), and serious infections in patients age 65 or older who received Simponi were observed compared with younger patients. However, caution should be exercised when treating the elderly and particular attention paid with respect to occurrence of infections. There were no patients age 45 and over in the nr-Axial SpA study.
Renal and hepatic impairment
Specific studies of Simponi have not been conducted in patients with renal or hepatic impairment. Simponi should be used with caution in subjects with impaired hepatic function (see section 4.2).
Excipients
Simponi contains sorbitol (E420). Patients with rare hereditary problems of fructose intolerance should not take Simponi.
Potential for medication errors
Simponi is registered in 50 mg and 100 mg strengths for subcutaneous administration. It is important that the right strength is used to administer the correct dose as indicated in the posology (see section 4.2). Care should be taken to provide the right strength to ensure that patients are not underdosed or overdosed.
4.5 Interaction with other medicinal products and other forms of interaction
No interaction studies have been performed.
Concurrent use with other biological therapeutics
The combination of Simponi with other biological therapeutics used to treat the same conditions as Simponi, including anakinra and abatacept is not recommended (see section 4.4).
Live vaccines/therapeutic infectious agents
Live vaccines should not be given concurrently with Simponi (see sections 4.4 and 4.6).
Therapeutic infectious agents should not be given concurrently with Simponi (see section 4.4).
Methotrexate
Although concomitant use of MTX results in higher steady-state trough concentrations of Simponi in patients with RA, PsA or AS, the data do not suggest the need for dose adjustment of either Simponi or MTX (see section 5.2).
4.6 Fertility, pregnancy and lactation
Women of childbearing potential
Women of childbearing potential must use adequate contraception to prevent pregnancy and continue its use for at least 6 months after the last golimumab treatment.
Pregnancy
There are no adequate data on the use of golimumab in pregnant women. Due to its inhibition of TNF, golimumab administered during pregnancy could affect normal immune responses in the newborn. Studies in animals do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see section 5.3). The use of golimumab in pregnant women is not recommended; golimumab should be given to a pregnant woman only if clearly needed.
Golimumab crosses the placenta. Following treatment with a TNF-blocking monoclonal antibody during pregnancy, the antibody has been detected for up to 6 months in the serum of the infant born by the treated woman. Consequently, these infants may be at increased risk of infection. Administration of live vaccines to infants exposed to golimumab in utero is not recommended for 6 months following the mother's last golimumab injection during pregnancy (see sections 4.4 and 4.5).
Breast-feeding
It is not known whether golimumab is excreted in human milk or absorbed systemically after ingestion. Golimumab was shown to pass over to breast milk in monkeys, and because human immunoglobulins are excreted in milk, women must not breast feed during and for at least 6 months after golimumab treatment.
Fertility
No animal fertility studies have been conducted with golimumab. A fertility study in mice, using an analogous antibody that selectively inhibits the functional activity of mouse TNFα, showed no relevant effects on fertility (see section 5.3).
4.7 Effects on ability to drive and use machines
Simponi may have a minor influence on the ability to drive and use machines. Dizziness may occur following administration of Simponi (see section 4.8).
4.8 Undesirable effects
Summary of the safety profile
In the controlled period of the pivotal trials in RA, PsA, AS, nr-Axial SpA, and UC, upper respiratory tract infection was the most common adverse drug reaction (ADR) reported in 12.6% of golimumab-treated patients compared with 11.0% of control patients. The most serious ADRs that have been reported for golimumab include serious infections (including sepsis, pneumonia, TB, invasive fungal and opportunistic infections), demyelinating disorders, lymphoma, HBV reactivation, CHF, autoimmune processes (lupus-like syndrome) and haematologic reactions (see section 4.4).
Tabulated list of adverse reactions
ADRs observed in clinical studies and reported from world-wide post-marketing use of golimumab are listed in Table 1. Within the designated system organ classes, the adverse drug reactions are listed under headings of frequency and using the following convention: 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); not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Table 1
Tabulated list of ADRs

Infections and infestations
Very common:	Upper respiratory tract infection (nasopharyngitis, pharyngitis, laryngitis and rhinitis)
Common:	Bacterial infections (such as cellulitis), lower respiratory tract infection (such as pneumonia), viral infections (such as influenza and herpes), bronchitis, sinusitis, superficial fungal infections, abscess
Uncommon:	Sepsis including septic shock, pyelonephritis
Rare:	Tuberculosis, opportunistic infections (such as invasive fungal infections [histoplasmosis, coccidioidomycosis, pneumocytosis], bacterial, atypical mycobacterial infection and protozoal), hepatitis B reactivation, bacterial arthritis, infective bursitis
Neoplasms, benign, malignant and unspecified
Uncommon:	Neoplasms (such as skin cancer, squamous cell carcinoma and melanocytic naevus)
Rare:	Lymphoma, leukaemia, melanoma
Not known:	Merkel cell carcinoma*, hepatosplenic T-cell lymphoma*
Blood and lymphatic system disorders
Common:	Anaemia
Uncommon:	Leucopaenia, thrombocytopaenia, pancytopaenia
Rare:	Aplastic anaemia
Immune system disorders
Common:	Allergic reactions (bronchospasm, hypersensitivity, urticaria), autoantibody positive
Rare:	Serious systemic hypersensitivity reactions (including anaphylactic reaction), vasculitis (systemic), sarcoidosis
Endocrine disorders
Uncommon:	Thyroid disorder (such as hypothyroidism, hyperthyroidism and goitre)
Metabolism and nutrition disorders
Uncommon:	Blood glucose increased, lipids increased
Psychiatric disorders
Common:	Depression, insomnia
Nervous system disorders
Common:	Dizziness, headache, paraesthesia
Uncommon:	Balance disorders
Rare:	Demyelinating disorders (central and peripheral), dysguesia
Eye disorders
Uncommon:	Visual disorders (such as blurred vision and decreased visual acuity), conjunctivitis, eye allergy (such as pruritis and irritation)
Cardiac disorders
Uncommon:	Arrhythmia, ischemic coronary artery disorders
Rare:	Congestive heart failure (new onset or worsening)
Vascular disorders
Common:	Hypertension
Uncommon:	Thrombosis (such as deep venous and aortic), flushing
Rare:	Raynaud's phenomenon
Respiratory, thoracic and mediastinal disorders
Common:	Asthma and related symptoms (such as wheezing and bronchial hyperactivity)
Uncommon:	Interstitial lung disease
Gastrointestinal disorders
Common:	Dyspepsia, gastrointestinal and abdominal pain, nausea, gastrointestinal inflammatory disorders (such as gastritis and colitis), stomatitis
Uncommon:	Constipation, gastro-oesophageal reflux disease
Hepatobiliary disorders
Common:	Alanine aminotransferase increased, aspartate aminotransferase increased
Uncommon:	Cholelithiasis, hepatic disorders
Skin and subcutaneous tissue disorders
Common:	Pruritus, rash, alopecia, dermatitis
Uncommon:	Bullous skin reactions, psoriasis (new onset or worsening of pre-existing psoriasis, palmar/plantar and pustular), urticaria
Rare:	Skin exfoliation, vasculitis (cutaneous)
Musculoskeletal and connective tissue disorders
Rare:	Lupus-like syndrome
Renal and urinary disorders
Rare:	Bladder disorders, renal disorders
Reproductive system and breast disorders
Uncommon:	Breast disorders, menstrual disorders
General disorders and administration site conditions
Common:	Pyrexia, asthenia, injection site reaction (such as injection site erythema, urticaria, induration, pain, bruising, pruritus, irritation and paraesthesia), chest discomfort
Rare:	Impaired healing
Injury, poisoning and procedural complications
Common:	Bone fractures
*: Observed with other TNF-blocking agents, but not observed in clinical studies with golimumab.

Description of selected adverse drug reactions
Infections
In the controlled period of pivotal trials, upper respiratory tract infection was the most common adverse reaction reported in 12.6% of golimumab-treated patients (incidence per 100 subject-years: 60.8; 95% CI: 55.0, 67.1) compared with 11.0% of control patients (incidence per 100 subject-years: 54.5; 95% CI: 46.1, 64.0). In controlled and uncontrolled portions of the studies with a median follow-up of approximately 2 years, the incidence per 100 subject-years of upper respiratory tract infections was 36.0 events; 95% CI: 34.9, 37.2 for golimumab treated patients.
In the controlled period of pivotal trials, infections were observed in 23.0% of golimumab-treated patients (incidence per 100 subject-years: 132.0; 95% CI: 123.3, 141.1) compared with 20.2% of control patients (incidence per 100 subject-years: 122.3; 95% CI: 109.5, 136.2). In controlled and uncontrolled portions of the trials with a median follow-up of approximately 2 years, the incidence per 100 subject-years of infections was 83.5 events; 95% CI: 81.8, 85.3 for golimumab treated patients.
In the controlled period of RA, PsA, AS, and nr-Axial SpA trials, serious infections were observed in 1.2% of golimumab-treated patients and 1.2% of control-treated patients. The incidence of serious infections per 100 subject-years of follow-up in the controlled period of RA, PsA, AS, and nr-Axial SpA trials was 7.3; 95% CI: 4.6, 11.1 for the golimumab 100 mg group, 2.9; 95% CI: 1.2, 6.0 for the golimumab 50 mg group and 3.6; 95% CI: 1.5, 7.0 for the placebo group. In the controlled period of UC trials of golimumab induction, serious infections were observed in 0.8% of golimumab-treated patients compared with 1.5% of control-treated patients. Serious infections observed in golimumab-treated patients included tuberculosis, bacterial infections including sepsis and pneumonia, invasive fungal infections and other opportunistic infections. Some of these infections have been fatal. In the controlled and uncontrolled portions of the pivotal trials with a median follow-up of approximately 2 years, there was a greater incidence of serious infections, including opportunistic infections and TB in patients receiving golimumab 100 mg compared with patients receiving golimumab 50 mg. The incidence per 100 subject-years of all serious infections was 4.3; 95% CI: 3.8, 4.8, in patients receiving golimumab 100 mg and 2.6; 95% CI: 2.1, 3.2, in patients receiving golimumab 50 mg.
Malignancies
Lymphoma
The incidence of lymphoma in golimumab-treated patients during the pivotal trials was higher than expected in the general population. In the controlled and uncontrolled portions of these trials with a median follow-up of approximately 2 years, a greater incidence of lymphoma was observed in patients receiving golimumab 100 mg compared with patients receiving golimumab 50 mg. Lymphoma was diagnosed in 9 subjects (1 in the golimumab 50 mg treatment groups and 8 in the golimumab 100 mg treatment groups) with an incidence (95% CI) per 100 subject-years of follow-up of 0.03 (0.00, 0.16) and 0.12 (0.05, 0.24) events for golimumab 50 mg and 100 mg respectively and 0.00 (0.00, 0.59) events for the placebo. The majority of lymphomas occurred in study GO-AFTER, which enrolled patients previously exposed to anti-TNF agents who had longer disease duration and more refractory disease (see section 4.4).
Malignancies other than lymphoma
In the controlled periods of pivotal trials and through approximately 2 years of follow-up, the incidence of non-lymphoma malignancies (excluding non-melanoma skin cancer) was similar between the golimumab and the control groups. Through approximately 2 years of follow-up, the incidence of non-lymphoma malignancies (excluding non-melanoma skin cancer) was similar to the general population.
In the controlled and uncontrolled periods of pivotal trials with a median follow-up of approximately 2 years, non-melanoma skin cancer was diagnosed in 5 placebo-treated, 10 golimumab 50 mg-treated and 29 golimumab 100 mg-treated subjects with an incidence (95% CI) per 100 subject-years of follow-up of 0.38 (0.27, 0.52) for combined golimumab and 0.90 (0.29, 2.10) for placebo.
In the controlled and uncontrolled period of pivotal trials with a median follow-up of approximately 2 years, malignancies besides melanoma, non-melanoma skin cancer and lymphoma were diagnosed in 5 placebo-treated, 19 golimumab 50 mg-treated and 30 golimumab 100 mg-treated subjects with an incidence (95% CI) per 100 subject-years of follow-up of 0.47 (0.35, 0.63) for combined golimumab and 0.90 (0.29, 2.10) for placebo (see section 4.4).
Cases reported in clinical studies in asthma
In an exploratory clinical study, patients with severe persistent asthma received a golimumab loading dose (150% of the assigned treatment dose) subcutaneously at week 0 followed by golimumab 200 mg, golimumab 100 mg or golimumab 50 mg every 4 weeks subcutaneously through week 52. Eight malignancies in the combined golimumab treatment group (n = 230) and none in the placebo treatment group (n = 79) were reported. Lymphoma was reported in 1 patient, non-melanoma skin cancer in 2 patients, and other malignancies in 5 patients. There was no specific clustering of any type of malignancy.
During the placebo-controlled portion of the study, the incidence (95% CI) of all malignancies per 100 subject-years of follow-up was 3.19 (1.38, 6.28) in the golimumab group. In this study, the incidence (95% CI) per 100 subject-years of follow-up in golimumab-treated subjects was 0.40 (0.01, 2.20) for lymphoma, 0.79 (0.10, 2.86) for non-melanoma skin cancers, and 1.99 (0.64, 4.63) for other malignancies. For placebo subjects, the incidence (95% CI) per 100 subject-years of follow-up of these malignancies was 0.00 (0.00, 2.94). The significance of this finding is unknown.
Neurological events
In the controlled and uncontrolled periods of the pivotal trials with a median follow-up of approximately 2 years, a greater incidence of demyelination was observed in patients receiving golimumab 100 mg compared with patients receiving golimumab 50 mg (see section 4.4).
Liver enzyme elevations
In the controlled period of RA and PsA pivotal trials, mild ALT elevations (> 1 and < 3 x upper limit of normal (ULN)) occurred in similar proportions of golimumab and control patients in the RA and PsA studies (22.1% to 27.4% of patients); in the AS and nr-Axial SpA studies, more golimumab-treated patients (26.9%) than control patients (10.6%) had mild ALT elevations. In the controlled and uncontrolled periods of the RA and PsA pivotal trials, with a median follow-up of approximately 5 years, the incidence of mild ALT elevations was similar in golimumab-treated and control patients in RA and PsA studies. In the controlled period of the UC pivotal trials of golimumab induction, mild ALT elevations (> 1 and < 3 x ULN) occurred in similar proportions of golimumab-treated and control patients (8.0% to 6.9%, respectively). In controlled and uncontrolled periods of the UC pivotal trials with a mean follow-up of 1 year, the incidence of mild ALT elevations was 19.4% in patients receiving golimumab during the maintenance portion of the UC study.
In the controlled period of RA and AS pivotal trials, ALT elevations ≥ 5 x ULN were uncommon and seen in more golimumab-treated patients (0.4% to 0.9%) than control patients (0.0%). This trend was not observed in the PsA population. In the controlled and uncontrolled periods of RA, PsA and AS pivotal trials, with a median follow-up of 5 years, the incidence of ALT elevations ≥ 5 x ULN was similar in both golimumab-treated and control patients. In general these elevations were asymptomatic and the abnormalities decreased or resolved with either continuation or discontinuation of golimumab or modification of concomitant medicinal products. In the controlled periods of the pivotal UC trials, of golimumab induction, ALT elevations ≥ 5 x ULN occurred in similar proportions of golimumab-treated patients compared to placebo-treated patients (0.3% to 1.0%, respectively). In the controlled and uncontrolled periods of the pivotal UC trials with a mean follow-up of 1 year, the incidence of ALT elevations ≥ 5 x ULN was 0.7% in patients receiving golimumab during the maintenance portion of the UC study.
Within the RA, PsA, AS, and nr-Axial SpA pivotal trials, one patient in an RA trial with pre-existing liver abnormalities and confounding medicinal products treated with golimumab developed non-infectious fatal hepatitis with jaundice. The role of golimumab as a contributing or aggravation factor cannot be excluded.
Injection site reactions
In the controlled periods of pivotal trials, 5.4% of golimumab-treated patients had injection site reactions compared with 2.0% in control patients. The presence of antibodies to golimumab may increase the risk of injection site reactions. The majority of the injection site reactions were mild and moderate and the most frequent manifestation was injection site erythema. Injection site reactions generally did not necessitate discontinuation of the medicinal product.
In controlled Phase IIb and/or III trials in RA, PsA, AS, nr-Axial SpA, severe persistent asthma, and Phase II/III trials in UC, no patients treated with golimumab developed anaphylactic reactions.
Autoimmune antibodies
In the controlled and uncontrolled periods of pivotal trials through 1 year of follow-up, 3.5% of golimumab-treated patients and 2.3% of control patients were newly ANA-positive (at titres of 1:160 or greater). The frequency of anti-dsDNA antibodies at 1 year of follow-up in patients anti-dsDNA negative at baseline was uncommon.
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 Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
Single doses up to 10 mg/kg intravenously have been administered in a clinical study without dose-limiting toxicity. In case of an overdose, it is recommended that the patient be monitored for any signs or symptoms of adverse effects and appropriate symptomatic treatment be instituted immediately.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Immunosuppressants, tumour necrosis factor alpha (TNF-α) inhibitors, ATC code: L04AB06
Mechanism of action
Golimumab is a human monoclonal antibody that forms high affinity, stable complexes with both the soluble and transmembrane bioactive forms of human TNF-α, which prevents the binding of TNF-α to its receptors.
Pharmacodynamic effects
The binding of human TNF by golimumab was shown to neutralise TNF-α-induced cell-surface expression of the adhesion molecules E-selectin, vascular cell adhesion molecule (VCAM)-1 and intercellular adhesion molecule (ICAM)-1 by human endothelial cells. In vitro, TNF-induced secretion of interleukin (IL)-6, IL-8 and granulocyte-macrophage colony stimulating factor (GM-CSF) by human endothelial cells was also inhibited by golimumab.
Improvement in C-reactive protein (CRP) levels were observed relative to placebo groups and treatment with Simponi resulted in significant reductions from baseline in serum levels of IL-6, ICAM-1, matrix-metalloproteinase (MMP)-3 and vascular endothelial growth factor (VEGF) compared to control treatment. In addition, levels of TNF-α were reduced in RA and AS patients and levels of IL-8 were reduced in PsA patients. These changes were observed at the first assessment (week 4) after the initial Simponi administration and were generally maintained through week 24.
Clinical efficacy
Rheumatoid arthritis
The efficacy of Simponi was demonstrated in three multi-centre, randomised, double-blind, placebo-controlled studies in over 1500 patients ≥ 18 years of age with moderately to severely active RA diagnosed according to American College of Rheumatology (ACR) criteria for at least 3 months prior to screening. Patients had at least 4 swollen and 4 tender joints. Simponi or placebo were subcutaneously administered every 4 weeks.
GO-FORWARD evaluated 444 patients who had active RA despite a stable dose of at least 15 mg/week of MTX and who had not been previously treated with an anti-TNF agent. Patients were randomised to receive placebo + MTX, Simponi 50 mg + MTX, Simponi 100 mg + MTX or Simponi 100 mg + placebo. Patients receiving placebo + MTX were switched to Simponi 50 mg + MTX after week 24. At week 52, patients entered an open label long-term extension.
GO-AFTER evaluated 445 patients who were previously treated with one or more of the anti-TNF agents adalimumab, etanercept, or infliximab. Patients were randomised to receive placebo, Simponi 50 mg, or Simponi 100 mg. Patients were allowed to continue concomitant DMARD therapy with MTX, sulfasalazine (SSZ), and/or hydroxychloroquine (HCQ) during the study. The stated reasons for discontinuation of prior anti TNF therapies were lack of efficacy (58%), intolerance (13%), and/or reasons other than safety or efficacy (29%, mostly for financial reasons).
GO-BEFORE evaluated 637 patients with active RA who were MTX-naïve and had not previously been treated with an anti-TNF agent. Patients were randomised to receive placebo + MTX, Simponi 50 mg + MTX, Simponi 100 mg + MTX or Simponi 100 mg + placebo. At week 52, patients entered an open label long-term extension in which patients receiving placebo + MTX who had at least 1 tender or swollen joint were switched to Simponi 50 mg + MTX.
In GO-FORWARD, the (co-)primary endpoints were the percentage of patients achieving an ACR 20 response at week 14 and the improvement from baseline in Health Assessment Questionnaire (HAQ) at week 24. In GO-AFTER, the primary endpoint was the percentage of patients achieving an ACR 20 response at week 14. In GO-BEFORE, the co-primary endpoints were the percentage of patients achieving ACR 50 response at week 24 and the change from baseline in the van der Heijde-modified Sharp (vdH-S) score at week 52. In addition to the primary endpoint(s), additional assessments of the impact of Simponi treatment on the signs and symptoms of arthritis, radiographic response, physical function and health-related quality of life were performed.
In general, no clinically meaningful differences in measures of efficacy were observed between the Simponi 50 mg and 100 mg dosing regimens with concomitant MTX, through week 104 in GO-FORWARD and GO-BEFORE and through week 24 in GO-AFTER. In each of the RA studies by study design, patients in the long-term extension may have switched between the 50 mg and 100 mg Simponi doses at the discretion of the study physician.
Signs and symptoms
Key ACR results for the Simponi 50 mg dose at weeks 14, 24 and 52 for GO-FORWARD, GO-AFTER and GO-BEFORE are shown in Table 2 and are described below. Responses were observed at the first assessment (week 4) after the initial Simponi administration.
In GO-FORWARD, among 89 subjects randomised to Simponi 50 mg + MTX, 48 were still on this treatment at week 104. Among those, 40, 33 and 24 patients had ACR 20/50/70 response, respectively at week 104. Among patients remaining in the study and treated with Simponi, similar rates of ACR 20/50/70 response was observed from week 104 through week 256.
In GO-AFTER, the percentage of patients achieving an ACR 20 response was greater for patients receiving Simponi than for patients receiving placebo regardless of the reason reported for discontinuation of one or more prior anti-TNF therapies.
Table 2
Key efficacy outcomes from the controlled portions of GO-FORWARD, GO-AFTER and GO-BEFORE.

GO-FORWARD Active RA despite MTX		GO-AFTER Active RA, previously treated with one or more anti-TNF agent(s)		GO-BEFORE Active RA, MTX Naïve
	Placebo + MTX	Simponi 50 mg + MTX	Placebo	Simponi 50 mg	Placebo + MTX	Simponi 50 mg + MTX
na	133	89	150	147	160	159
Responders, % of patients
ACR 20
Week 14	33%	55%*	18%	35%*	NA	NA
Week 24	28%	60%*	16%	31% p = 0.002	49%	62%
Week 52	NA	NA	NA	NA	52%	60%
ACR 50
Week 14	10%	35%*	7%	15% p = 0.021	NA	NA
Week 24	14%	37%*	4%	16%*	29%	40%
Week 52	NA	NA	NA	NA	36%	42%
ACR 70
Week 14	4%	14% p = 0.008	2%	10% p = 0.005	NA	NA
Week 24	5%	20%*	2%	9% p = 0.009	16%	24%
Week 52	NA	NA	NA	NA	22%	28%
a n reflects randomised patients; actual number of patients evaluable for each endpoint may vary by timepoint. * p ≤ 0.001 NA: Not Applicable

In GO-BEFORE the primary analysis in patients with moderate to severe rheumatoid arthritis (combined Simponi 50 and 100 mg + MTX groups vs MTX alone for ACR50) was not statistically significant at week 24 (p = 0.053). At week 52 in the overall population, the percentage of patients in the Simponi 50 mg + MTX group who achieved an ACR response was generally higher but not significantly different when compared with MTX alone (see Table 2). Additional analyses were performed in subsets representative of the indicated population of patients with severe, active and progressive RA. A generally greater effect of Simponi 50 mg + MTX versus MTX alone was demonstrated in the indicated population compared with the overall population.
In GO-FORWARD and GO-AFTER, clinically meaningful and statistically significant responses in Disease Activity Scale (DAS)28 were observed at each prespecified time point, at week 14 and at week 24 (p ≤ 0.001). Among patients who remained on the Simponi treatment to which they were randomised at study start, DAS28 responses were maintained through week 104. Among patients remaining in the study and treated with Simponi, DAS28 responses were similar from week 104 through week 256.
In GO-BEFORE, major clinical response, defined as the maintenance of an ACR 70 response over a continuous 6-month period, was measured. At week 52, 15% of patients in the Simponi 50 mg + MTX group achieved a major clinical response compared with 7% of patients in the placebo + MTX group (p = 0.018). Among 159 subjects randomised to Simponi 50 mg + MTX, 96 were still on this treatment at week 104. Among those, 85, 66 and 53 patients had ACR 20/50/70 response, respectively, at week 104. Among patients remaining in the study and treated with Simponi, similar rates of ACR 20/50/70 response were observed from week 104 through week 256.
Radiographic response:
In GO-BEFORE the change from baseline in the vdH-S score, a composite score of structural damage that radiographically measures the number and size of joint erosions and the degree of joint space narrowing in hands/wrists and feet, was used to assess the degree of structural damage. Key results for the Simponi 50 mg dose at week 52 are presented in Table 3.
The number of patients with no new erosions or a change from baseline in total vdH-S Score ≤ 0 was significantly higher in the Simponi treatment group than in the control group (p = 0.003). The radiographic effects observed at week 52 were maintained through week 104. Among patients remaining in the study and treated with Simponi, radiographic effects were similar from week 104 through week 256.
Table 3
Radiographic mean (SD) changes from baseline in total vdH-S score at week 52 in the overall population of GO-BEFORE

Placebo + MTX	Simponi 50 mg + MTX
n a	160	159
Total Score
Baseline	19.7 (35.4)	18.7 (32.4)
Change from baseline	1.4 (4.6)	0.7 (5.2)*
Erosion Score
Baseline	11.3 (18.6)	10.8 (17.4)
Change from baseline	0.7 (2.8)	0.5 (2.1)
JSN Score
Baseline	8.4 (17.8)	7.9 (16.1)
Change from baseline	0.6 (2.3)	0.2 (2.0)**
a n reflects randomised patients * p = 0.015 ** p = 0.044

Physical function and health-related quality of life
Physical function and disability were assessed as a separate endpoint in GO-FORWARD and GO-AFTER using the disability index of the HAQ DI. In these studies, Simponi demonstrated clinically meaningful and statistically significant improvement in HAQ DI from baseline versus control at week 24. Among patients who remained on the Simponi treatment to which they were randomised at study start, improvement in HAQ DI was maintained through week 104. Among patients remaining in the study and treated with Simponi, improvement in HAQ DI was similar from week 104 through week 256.
In GO-FORWARD clinically meaningful and statistically significant improvements were demonstrated in health-related quality of life as measured by the physical component score of the SF-36 in patients treated with Simponi versus placebo at week 24. Among patients who remained on the Simponi treatment to which they were randomised at study start, improvement of the SF-36 physical component was maintained through week 104. Among patients remaining in the study and treated with Simponi, improvement of the SF-36 physical component was similar from week 104 through week 256. In GO-FORWARD and GO-AFTER, statistically significant improvements were observed in fatigue as measured by functional assessment of chronic illness therapy-fatigue scale (FACIT-F).
Psoriatic arthritis
The safety and efficacy of Simponi were evaluated in a multi-centre, randomised, double-blind, placebo-controlled study (GO-REVEAL) in 405 adult patients with active PsA (≥ 3 swollen joints and ≥ 3 tender joints) despite non-steroidal anti-inflammatory (NSAID) or DMARD therapy. Patients in this study had a diagnosis of PsA for at least 6 months and had at least mild psoriatic disease. Patients with each sub-type of psoriatic arthritis were enrolled, including polyarticular arthritis with no rheumatoid nodules (43%), asymmetric peripheral arthritis (30%), distal interphalangeal (DIP) joint arthritis (15%), spondylitis with peripheral arthritis (11%), and arthritis mutilans (1%). Previous treatment with an anti-TNF agent was not allowed. Simponi or placebo were administered subcutaneously every 4 weeks. Patients were randomly assigned to placebo, Simponi 50 mg, or Simponi 100 mg. Patients receiving placebo were switched to Simponi 50 mg after week 24. Patients entered an open label long-term extension at week 52. Approximately forty-eight percent of patients continued on stable doses of methotrexate (≤ 25 mg/week). The co-primary endpoints were the percentage of patients achieving ACR 20 response at week 14 and change from baseline in total PsA modified vdH-S score at week 24.
In general, no clinically meaningful differences in measures of efficacy were observed between the Simponi 50 mg and 100 mg dosing regimens through week 104. By study design, patients in the long-term extension may have switched between the 50 mg and 100 mg Simponi doses at the discretion of the study physician.
Signs and symptoms
Key results for the 50 mg dose at weeks 14 and 24 are shown in Table 4 and described below.
Table 4
Key efficacy outcomes from GO-REVEAL

Placebo	Simponi 50 mg*
na	113	146
Responders, % of patients
ACR 20
Week 14	9%	51%
Week 24	12%	52%
ACR 50
Week 14	2%	30%
Week 24	4%	32%
ACR 70
Week 14	1%	12%
Week 24	1%	19%
PASIb 75c
Week 14	3%	40%
Week 24	1%	56%
* p < 0.05 for all comparisons; a n reflects randomised patients; actual number of patients evaluable for each endpoint may vary by timepoint b Psoriasis Area and Severity Index c Based on the subset of patients with ≥ 3% BSA involvement at baseline, 79 patients (69.9%) in the placebo group and 109 (74.3%) in the Simponi 50 mg group.

Responses were observed at the first assessment (week 4) after the initial Simponi administration. Similar ACR 20 responses at week 14 were observed in patients with polyarticular arthritis with no rheumatoid nodules and asymmetric peripheral arthritis PsA subtypes. The number of patients with other PsA subtypes was too small to allow meaningful assessment. Responses observed in the Simponi treated groups were similar in patients receiving and not receiving concomitant MTX. Among 146 patients randomised to Simponi 50 mg, 70 were still on this treatment at week 104. Of these 70 patients, 64, 46 and 31 patients had an ACR 20/50/70 response, respectively. Among patients remaining in the study and treated with Simponi, similar rates of ACR 20/50/70 response was observed from week 104 through week 256.
Statistically significant responses in DAS28 were also observed at weeks 14 and 24 (p < 0.05).
At week 24 improvements in parameters of peripheral activity characteristic of psoriatic arthritis (e.g. number of swollen joints, number of painful/tender joints, dactylitis and enthesitis) were seen in the Simponi-treated patients. Simponi treatment resulted in significant improvement in physical function as assessed by HAQ DI, as well as significant improvements in health-related quality of life as measured by the physical and mental component summary scores of the SF-36. Among patients who remained on the Simponi treatment to which they were randomised at study start, DAS28 and HAQ DI responses were maintained through week 104. Among patients remaining in the study and treated with Simponi, DAS28 and HAQ DI responses were similar from week 104 through week 256.
Radiographic response:
Structural damage in both hands and feet was assessed radiographically by the change from baseline in the vdH-S score, modified for PsA by addition of hand distal interphalangeal (DIP) joints.
Simponi 50 mg treatment reduced the rate of progression of peripheral joint damage compared with placebo treatment at week 24 as measured by change from baseline in total modified vdH-S Score (mean ± SD score was 0.27 ± 1.3 in the placebo group compared with -0.16 ± 1.3 in the Simponi group; p = 0.011). Out of 146 patients who were randomized to Simponi 50 mg, 52 week X-ray data were available for 126 patients, of whom 77% showed no progression compared to baseline. At week 104, X-ray data were available for 114 patients, and 77% showed no progression from baseline. Among patients remaining in the study and treated with Simponi, similar rates of patients showed no progression from baseline from week 104 through week 256.
Axial spondyloarthritis
Ankylosing spondylitis
The safety and efficacy of Simponi were evaluated in a multi-centre, randomised, double-blind, placebo-controlled study (GO-RAISE) in 356 adult patients with active ankylosing spondylitis (defined as a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4 and a VAS for total back pain of ≥ 4, on a scale of 0 to 10 cm). Patients enrolled in this study had active disease despite current or previous NSAID or DMARD therapy and had not previously been treated with anti-TNF therapy. Simponi or placebo were administered subcutaneously every 4 weeks. Patients were randomly assigned to placebo, Simponi 50 mg and Simponi 100 mg and were allowed to continue concomitant DMARD therapy (MTX, SSZ and/or HCQ). The primary endpoint was the percentage of patients achieving Ankylosing Spondylitis Assessment Study Group (ASAS) 20 response at week 14. Placebo-controlled efficacy data were collected and analysed through week 24.
Key results for the 50 mg dose are shown in Table 5 and described below. In general, no clinically meaningful differences in measures of efficacy were observed between the Simponi 50 mg and 100 mg dosing regimens through week 24. By study design, patients in the long-term extension may have switched bewtween the 50 mg and 100 mg Simponi doses at the discretion of the study physician.
Table 5
Key efficacy outcomes from GO-RAISE.

Placebo	Simponi 50 mg*
na	78	138
Responders, % of patients
ASAS 20
Week 14	22%	59%
Week 24	23%	56%
ASAS 40
Week 14	15%	45%
Week 24	15%	44%
ASAS 5/6
Week 14	8%	50%
Week 24	13%	49%
* p ≤ 0.001 for all comparisons; a n reflects randomised patients; actual number of patients evaluable for each endpoint may vary by timepoint

Among patients remaining in the study and treated with Simponi, the proportion of patients with an ASAS 20 and ASAS 40 response were similar from week 24 through week 256.
Statistically significant responses in BASDAI 50, 70 and 90 (p ≤ 0.017) were also seen at weeks 14 and 24. Improvements in key measures of disease activity were observed at the first assessment (week 4) after the initial Simponi administration and were maintained through week 24. Among patients remaining in the study and treated with Simponi, similar rates of change from baseline in BASDAI were observed from week 24 through week 256. Consistent efficacy was seen in patients regardless of use of DMARDs (MTX, sulfasalazine and/or hydroxychloroquine), HLA-B27 antigen status or baseline CRP levels as assessed by ASAS 20 responses at week 14.
Simponi treatment resulted in significant improvements in physical function as assessed by changes from baseline in BASFI at weeks 14 and 24. Health-related quality of life as measured by the physical component score of the SF-36 was also improved significantly at weeks 14 and 24. Among patients remaining in the study and treated with Simponi, improvements in physical function and health-related quality of life were similar from week 24 through week 256.
Non-radiographic axial spondyloarthritis
The safety and efficacy of Simponi were evaluated in a multi-centre, randomised, double-blind, placebo-controlled study (GO-AHEAD) in 197 adult patients with severe active nr-Axial SpA (defined as those patients meeting the ASAS classification criteria of axial spondyloarthritis but did not meet the modified New York criteria for AS). Patients enrolled in this study had active disease (defined as a BASDAI ≥ 4 and a Visual Analogue Scale (VAS) for total back pain of ≥ 4, each on a scale of 0-10 cm) despite current or previous NSAID therapy and had not previously been treated with any biological agents including anti-TNF therapy. Patients were randomly assigned to placebo or Simponi 50 mg administered subcutaneously every 4 weeks. At week 16, patients entered an open label period in which all patients received Simponi 50 mg administered subcutaneously every 4 weeks through week 48. Analyses were performed on both the All Treated (AT, N = 197) and Objective Signs of Inflammation (OSI, N = 158, defined by elevated CRP and/or evidence of sacroiliitis on MRI at baseline) populations. Placebo-controlled efficacy data were collected and analysed through week 16. The primary endpoint was the proportion of patients achieving ASAS 20 response at week 16. Key results are shown in Table 6 and described below.
Table 6
Key efficacy outcomes from GO-AHEAD at week 16

Improvements in signs and symptoms
	All treated population (AT)		Objective signs of inflammation population (OSI)
	Placebo	Simponi 50 mg	Placebo	Simponi 50 mg
na	100	97	80	78
Responders, % of patients
ASAS 20	40%	71%**	38%	77%**
ASAS 40	23%	57%**	23%	60%**
ASAS 5/6	23%	54%**	23%	63%**
ASAS Partial Remission	18%	33%*	19%	35%*
ASDAS-C b < 1.3	13%	33%*	16%	35%*
BASDAI 50	30%	58%**	29%	59%**
Inhibition of inflammation in sacroiliac (SI) joints as measured by MRI
	Placebo	Simponi 50 mg	Placebo	Simponi 50 mg
n C	87	74	69	61
Mean change in SPARCCd MRI sacroiliac joint score	-0.9	-5.3**	-1.2	-6.4**
a n reflects randomized and treated patients b Ankylosing Spondylitis Disease Activity Score C-Reactive Protein (AT-Placebo, N = 90; AT-Simponi 50 mg, N = 88; OSI-Placebo, N = 71; OSI-Simponi 50 mg, N = 71) c n reflects number of patients with baseline and week 16 MRI data d SPARCC (Spondyloarthritis Research Consortium of Canada) ** p < 0.0001 for Simponi vs placebo comparisons * p < 0.05 for Simponi vs placebo comparisons

Statistically significant improvements in signs and symptoms of severe active nr-Axial SpA were demonstrated in patients treated with Simponi 50 mg compared to placebo at week 16 (Table 6). Improvements were observed at the first assessment (week 4) after the initial Simponi administration. SPARCC score as measured by MRI showed statistically significant reductions in SI joint inflammation at week 16 in patients treated with Simponi 50 mg compared to placebo (Table 6). Pain as assessed by the Total Back Pain and Nocturnal Back Pain VAS, and disease activity as measured by ASDAS-C also showed statistically significant improvement from baseline to week 16 in patients treated with Simponi 50 mg compared to placebo (p < 0.0001).
Statistically significant improvements in spinal mobility as assessed by BASMI (Bath Ankylosing Spondylitis Metrology Index) and in physical function as assessed by the BASFI were demonstrated in Simponi 50 mg-treated patients as compared to placebo-treated patients (p < 0.0001). Patients treated with Simponi experienced significantly more improvements in health-related quality of life as assessed by ASQoL, EQ-5D, and physical and mental components of SF-36, and experienced significantly more improvements in productivity as assessed by greater reductions in overall work impairment and in activity impairment as assessed by the WPAI questionnaire than patients receiving placebo.
For all of the endpoints described above, statistically significant results were also demonstrated in the OSI population. Similar improvements in signs and symptoms, spinal mobility, and physical function were observed at week 16 through week 24 among patients remaining in the study and treated with Simponi 50 mg.
Ulcerative colitis
The efficacy of Simponi was evaluated in two randomized, double-blind, placebo-controlled clinical studies in adult patients.
The induction study (PURSUIT-Induction) evaluated patients with moderately to severely active ulcerative colitis (Mayo score 6 to 12; Endoscopy subscore ≥ 2) who had an inadequate response to or failed to tolerate conventional therapies, or were corticosteroid dependent. In the dose confirming portion of the study, 761 patients were randomized to receive either 400 mg Simponi SC at week 0 and 200 mg at week 2, 200 mg Simponi SC at week 0 and 100 mg at week 2, or placebo SC at weeks 0 and 2. Concomitant stable doses of oral aminosalicylates, corticosteroids, and/or immunomodulatory agents were permitted. The efficacy of Simponi through week 6 was assessed in this study.
The results of the maintenance study (PURSUIT-Maintenance) were based on evaluation of 456 patients who achieved clinical response from previous induction with Simponi. Patients were randomized to receive Simponi 50 mg, Simponi 100 mg or placebo administered subcutaneously every 4 weeks. Concomitant stable doses of oral aminosalicylates, and/or immunomodulatory agents were permitted. Corticosteroids were to be tapered at the start of the maintenance study. The efficacy of Simponi through week 54 was assessed in this study.
Table 7
Key efficacy outcomes from PURSUIT - Induction and PURSUIT - Maintenance

PURSUIT-Induction
	Placebo N = 251	Simponi 200/100 mg N = 253
Percentage of patients
Patients in clinical response at week 6a	30%	51%**
Patients in clinical remission at week 6b	6%	18%**
Patients with mucosal healing at week 6c	29%	42%*
PURSUIT-Maintenance
	Placebod N = 154	Simponi 50 mg N = 151	Simponi 100 mg N = 151
Percentage of patients
Maintenance of response (Patients in clinical response through week 54)e	31%	47%*	50%**
Sustained remission (Patients in clinical remission at both week 30 and week 54)f	16%	23%g	28%*
N = number of patients ** p ≤ 0.001 * p ≤ 0.01 a defined as a decrease from baseline in the Mayo score by ≥ 30% and ≥ 3 points, accompanied by a decrease in the rectal bleeding subscore of ≥ 1 or a rectal bleeding subscore of 0 or 1. b Defined as a Mayo score ≤ 2 points, with no individual subscore > 1 c Defined as 0 or 1 on the endoscopy subscore of the Mayo score. d Simponi induction only. e Patients were assessed for UC disease activity by partial Mayo score every 4 weeks (loss of response was confirmed by endoscopy). Therefore, a patient who maintained response was in a state of continuous clinical response at each evaluation through week 54. f A patient had to be in remission at both weeks 30 and 54 (without demonstrating a loss of response at any time point through week 54) to achieve durable remission. g In patients weighing less than 80 kg, a greater proportion of patients who received 50 mg maintenance therapy showed sustained clinical remission compared with those who received placebo.

More Simponi-treated patients demonstrated sustained mucosal healing (patients with mucosal healing at both week 30 and week 54) in the 50 mg group (42%, nominal p < 0.05) and 100 mg group (42%, p < 0.005) compared with patients in the placebo group (27%).
Among the 54% of patients (247/456) who were receiving concomitant corticosteroids at the start of PURSUIT-Maintenance, the proportion of patients who maintained clinical response through week 54 and were not receiving concomitant corticosteroids at week 54 was greater in the 50 mg group (38%, 30/78) and 100 mg group (30%, 25/82) compared with the placebo group (21%, 18/87). The proportion of patients who eliminated corticosteroids by week 54 was greater in the 50 mg group (41%, 32/78) and 100 mg group (33%, 27/82) compared with the placebo group (22%, 19/87).
At week 6, Simponi significantly improved quality of life as measured by change from baseline in a disease specific measure, IBDQ (inflammatory bowel disease questionnaire). Among patients who received Simponi maintenance treatment, the improvement in quality of life as measured by IBDQ was maintained through week 54.
Immunogenicity
Across the Phase III RA, PsA and AS studies through week 52, antibodies to golimumab were detected in 5% (105/2115) of golimumab treated patients and, where tested, nearly all antibodies were neutralising in vitro. Similar rates were shown across rheumatologic indications. Treatment with concomitant MTX resulted in a lower proportion of patients with antibodies to golimumab than patients receiving golimumab without MTX (approximately 3% [41/1262] versus 8% [64/853], respectively).
In nr-Axial SpA, antibodies to golimumab were detected in 4% (4/93) of golimumab treated patients through week 16.
In the Phase II and III UC studies through week 54, antibodies to golimumab were detected in 3% (26/946) of golimumab treated patients. Sixty-eight percent (21/31) of antibody-positive patients had neutralizing antibodies in vitro. Treatment with concomitant immunomodulators (azathioprine, 6-mercaptopurine and MTX) resulted in a lower proportion of patients with antibodies to golimumab than patients receiving golimumab without immunomodulators (1% (4/308) versus 3% (22/638), respectively).
The presence of antibodies to golimumab may increase the risk of injection site reactions (see section 4.4). The small number of patients positive for antibodies to golimumab limits the ability to draw definitive conclusions regarding the relationship between antibodies to golimumab and clinical efficacy or safety measures.
Because immunogenicity analyses are product- and assay-specific, comparison of antibody rates with those from other products is not appropriate.
Paediatric population
The European Medicines Agency has waived the obligation to conduct studies with Simponi in all subsets of the paediatric population in ankylosing spondylitis and rheumatoid arthritis (see section 4.2 for information on paediatric use).
The European Medicines Agency has deferred the obligation to submit the results of studies with Simponi in one or more subsets of the paediatric population in juvenile idiopathic arthritis, psoriatic arthritis, and ulcerative colitis (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
Absorption
Following a single subcutaneous administration of golimumab to healthy subjects or patients with RA, the median time to reach maximum serum concentrations (Tmax) ranged from 2 to 6 days. A subcutaneous injection of 50 mg golimumab to healthy subjects produced a mean ± standard deviation maximum serum concentration (Cmax) of 3.1 ± 1.4 μg/mL.
Following a single subcutaneous injection of 100 mg, the absorption of golimumab was similar in the upper arm, abdomen, and thigh, with a mean absolute bioavailability of 51%. Since golimumab exhibited approximately dose proportional PK following a subcutaneous administration, the absolute bioavailability of a golimumab 50 mg or 200 mg dose is expected to be similar.
Distribution
Following a single IV administration, the mean volume of distribution was 115 ± 19 mL/kg.
Elimination
The systemic clearance of golimumab was estimated to be 6.9 ± 2.0 mL/day/kg. Terminal half-life value was estimated to be approximately 12 ± 3 days in healthy subjects and similar values were observed in patients with RA, PsA, AS, or UC.
When 50 mg golimumab was administered subcutaneously to patients with RA, PsA or AS every 4 weeks, serum concentrations reached steady state by week 12. With concomitant use of MTX, treatment with 50 mg golimumab subcutaneously every 4 weeks resulted in a mean (± standard deviation) steady-state trough serum concentration of approximately 0.6 ± 0.4 μg/mL in RA patients with active RA despite MTX therapy, and approximately 0.5 ± 0.4 μg/mL in patients with active PsA and approximately 0.8 ± 0.4 μg/mL in patients with AS. Steady-state trough mean serum golimumab concentrations in patients with nr-Axial SpA were similar to those observed in patients with AS following subcutaneous administration of 50 mg golimumab every 4 weeks.
Patients with RA, PsA or AS who did not receive concomitant MTX had approximately 30% lower steady-state trough concentrations of golimumab than those who received golimumab with MTX. In a limited number of RA patients treated with subcutaneous golimumab over a 6-month period, concomitant use of MTX reduced the apparent clearance of golimumab by approximately 36%. However, population pharmacokinetic analysis indicated that concomitant use of NSAIDs, oral corticosteroids or sulfasalazine did not influence the apparent clearance of golimumab.
Following induction doses of 200 mg and 100 mg golimumab at week 0 and 2, respectively, and maintenance doses of 50 mg or 100 mg golimumab subcutaneously every 4 weeks thereafter to patients with UC, serum golimumab concentrations reached steady state approximately 14 weeks after the start of therapy. Treatment with 50 mg or 100 mg golimumab subcutaneous every 4 weeks during maintenance resulted in a mean steady-state trough serum concentration of approximately 0.9 ± 0.5 μg/mL and 1.8 ± 1.1 μg/mL, respectively.
In UC patients treated with 50 mg or 100 mg golimumab subcutaneously every 4 weeks, concomitant use of immunomodulators did not have a substantial effect on steady-state trough levels of golimumab.
Patients who developed anti-golimumab antibodies generally had low trough steady-state serum concentrations of golimumab (see section 5.1).
Linearity
Golimumab exhibited approximately dose-proportional pharmacokinetics in patients with RA over the dose range of 0.1 to 10.0 mg/kg following a single intravenous dose. Following a single SC dose in healthy subjects, approximately dose-proportional pharmacokinetics were also observed over a dose range of 50 mg to 400 mg.
Effect of weight on pharmacokinetics
There was a trend toward higher apparent clearance of golimumab with increasing weight (see section 4.2).
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, toxicity to reproduction and development.
No mutagenicity studies, animal fertility studies nor long-term carcinogenic studies have been conducted with golimumab.
In a fertility and general reproductive function study in mouse, using an analogous antibody that selectively inhibits the functional activity of mouse TNFα, the number of pregnant mice was reduced. It is not known whether this finding was due to effects on the males and/or the females. In a developmental toxicity study conducted in mice following administration of the same analogous antibody, and in cynomolgus monkeys using golimumab, there was no indication of maternal toxicity, embryotoxicity or teratogenicity.
6. Pharmaceutical particulars
6.1 List of excipients
Sorbitol(E420)
L-histidine
L-histidine monohydrochloride monohydrate
Polysorbate 80
Water for injection.
6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3 Shelf life
18 months
6.4 Special precautions for storage
Store in a refrigerator (2°C – 8°C).
Do not freeze.
Keep the pre-filled pen or pre-filled syringe in the outer carton in order to protect it from light.
6.5 Nature and contents of container
0.5 mL solution in a pre-filled syringe (Type 1 glass) with a fixed needle (stainless steel) and a needle cover (rubber containing latex) in a pre-filled pen or pre-filled syringe. Simponi is available in packs containing 1 pre-filled pen or pre-filled syringe and multipacks containing 3 (3 packs of 1) pre-filled pens or pre-filled syringes.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Simponi is supplied in a single use pre-filled pen called SmartJect or pre-filled syringe. Each Simponi pack is provided with instructions for use that fully describe the use of the pen or syringe. After removing the pre-filled pen or syringe from the refrigerator this should be allowed to reach room temperature by waiting for 30 minutes, before injecting Simponi. The pen or syringe should not be shaken.
The solution is clear to slightly opalescent, colourless to light yellow and may contain a few small translucent or white particles of protein. This appearance is not unusual for solutions containing protein. Simponi should not be used if the solution is discoloured, cloudy or containing visible foreign particles.
Comprehensive instructions for the preparation and administration of Simponi in a pre-filled pen or pre-filled syringe are given in the package leaflet.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. Marketing authorisation holder
Janssen Biologics B.V.
Einsteinweg 101
2333 CB Leiden
The Netherlands
8. Marketing authorisation number(s)
EU/1/09/546/001 1 pre-filled pen
EU/1/09/546/002 3 pre-filled pens
EU/1/09/546/003 1 pre-filled syringe
EU/1/09/546/004 3 pre-filled syringes
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation: 1 October 2009
Date of latest renewal: 19 June 2014
10. Date of revision of the text
22 June 2015
11. Legal category
Prescription Only Medicine
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.
附：Simponi 100 mg solution for injection（http://www.medicines.org.uk/emc/medicine/28316）

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产地国家: 德国
原产地英文商品名:
Simponi 50 MG/0.5ML 1Pen Injector
原产地英文药品名:
GOLIMUMAB
中文参考商品译名:
Simponi 50毫克/0.5毫升 1支筆式注射器
中文参考药品译名:
戈利木单抗注射剂
生产厂家中文参考译名:
MSD
生产厂家英文名:
MSD
-------------------------------------------------
产地国家: 德国
原产地英文商品名:
Simponi 50 MG/0.5ML 3Pen Injector
原产地英文药品名:
GOLIMUMAB
中文参考商品译名:
Simponi 50毫克/0.5毫升 3支筆式注射器
中文参考药品译名:
戈利木单抗注射剂
生产厂家中文参考译名:
MSD
生产厂家英文名:
MSD