2013年9月3日,单抗药物Ilaris（canakinumab）已获欧盟委员会（EC）批准，用于2岁及以上活动性全身型幼年特发性关节炎（SJIA）患者的治疗。该药是首个获批用于SJIA的IL-1β抑制剂，同时也是唯一获批专门用于SJIA治疗且每月仅需一次的皮下注射药物。
Canakinumab是一种选择性、全人源化、抗-IL-1β单克隆抗体，靶向抑制白介素-1β（IL-1β）。IL-1β是人体免疫系统防御的重要组成部分。在某些炎症性疾病中，IL-1β的过度产生发挥了突出的作用。Ilaris能够中和IL-1β，从而抑制炎症反应。
SJIA是一种罕见致残性的幼年关节炎，其特点是反复性的发烧、皮疹及关节炎症，该病可影响仅2岁的儿童，并可持续至成年。
Ilaris的获批，是基于在2~19岁SJIA患者中开展的2项III期临床试验，结果表明Ilaris治疗组中大多数患者取得了显着性改善。
Study 1表明，经一个皮下剂量治疗后，Ilaris治疗组在第15天（Day-15）有84%的患者达到了ACR30的主要终点，而安慰剂组仅为10%。Study 2开放标签研究部分，128例患者中有92例尝试了皮质类固醇减少试验，这92例患者中有62%能够大大降低其糖皮质激素的使用，46%的患者能够完全停用糖皮质激素。Study 2对照研究部分中，Ilaris治疗组耀斑（flare）风险比安慰剂组低64%（风险比为0.36，95％CI：0.17-0.75）。
汇总的疗效分析数据表明，Ilaris治疗12周后，61%的患者实现儿科ACR70，28%的患者疾病实现非活动状态（inactive）。
今年5月，Ilaris获FDA批准用于2岁及以上活动性全身型幼年特发性关节炎（SJIA）患者的治疗。此外，Ilaris也已获欧盟批准用于难治性痛风性关节炎，并在超过60个国家和地区（包括欧盟、美国、瑞士、日本等）获批用于冷吡啉相关周期性综合征(Cryopyrin-Associated Periodic Syndromes，CAPS)，该病是一种罕见的致命性的自体发炎性疾病。
批准日期：2009年6月17美国FDA，2009年10月29日欧盟EMEA批准；2011年12月日本批准； 公司：Novartis AG
包装规格
美国：180mg

欧洲：150mg 

日本：150mg

Ilaris 150mg powder for solution for injection
1. Name of the medicinal product
Ilaris® 150 mg powder for solution for injection
2. Qualitative and quantitative composition
One vial contains 150 mg of canakinumab*.
After reconstitution, each ml of solution contains 150 mg canakinumab.
* fully human monoclonal antibody produced in mouse hybridoma Sp2/0 cells by recombinant DNA technology
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Powder for solution for injection.
The powder is white.
4. Clinical particulars
4.1 Therapeutic indications
Cryopyrin-Associated Periodic Syndromes
Ilaris is indicated for the treatment of Cryopyrin-Associated Periodic Syndromes (CAPS) in adults, adolescents and children aged 2 years and older with body weight of 7.5 kg or above, including:
− Muckle-Wells Syndrome (MWS),
− Neonatal-Onset Multisystem Inflammatory Disease (NOMID)/Chronic Infantile Neurological, Cutaneous, Articular Syndrome (CINCA),
− Severe forms of Familial Cold Autoinflammatory Syndrome (FCAS) / Familial Cold Urticaria (FCU) presenting with signs and symptoms beyond cold-induced urticarial skin rash.
Systemic Juvenile Idiopathic Arthritis (SJIA)
Ilaris is indicated for the treatment of active Systemic Juvenile Idiopathic Arthritis (SJIA) in patients aged 2 years and older who have responded inadequately to previous therapy with non-steroidal anti-inflammatory drugs (NSAIDs) and systemic corticosteroids. Ilaris can be given as monotherapy or in combination with methotrexate.
Gouty arthritis
Ilaris is indicated for the symptomatic treatment of adult patients with frequent gouty arthritis attacks (at least 3 attacks in the previous 12 months) in whom non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated, are not tolerated, or do not provide an adequate response, and in whom repeated courses of corticosteroids are not appropriate (see section 5.1).
4.2 Posology and method of administration
For CAPS and SJIA, the treatment should be initiated and supervised by a specialist physician experienced in the diagnosis and treatment of the relevant indication.
For gouty arthritis, the physician should be experienced in the use of biologics and Ilaris should be administered by a healthcare professional.
After proper training in the correct injection technique, patients or their caregivers may inject Ilaris if the physician determines that it is appropriate and with medical follow-up as necessary (see section 6.6).
Posology
CAPS: Adults, adolescents and children aged 2 years and older
The recommended starting dose of Ilaris for CAPS patients is:
Adults, adolescents and children ≥ 4 years of age:
− 150 mg for patients with body weight > 40 kg
− 2 mg/kg for patients with body weight ≥ 15 kg and ≤ 40 kg
− 4 mg/kg for patients with body weight ≥ 7.5 kg and < 15 kg
Children 2 to < 4 years of age:
− 4 mg/kg for patients with body weight ≥ 7.5 kg
This is administered every eight weeks as a single dose via subcutaneous injection.
For patients with a starting dose of 150 mg or 2 mg/kg, if a satisfactory clinical response (resolution of rash and other generalised inflammatory symptoms) has not been achieved 7 days after treatment start, a second dose of Ilaris at 150 mg or 2 mg/kg can be considered. If a full treatment response is subsequently achieved, the intensified dosing regimen of 300 mg or 4 mg/kg every 8 weeks should be maintained. If a satisfactory clinical response has not been achieved 7 days after this increased dose, a third dose of Ilaris at 300 mg or 4 mg/kg can be considered. If a full treatment response is subsequently achieved, maintaining the intensified dosing regimen of 600 mg or 8 mg/kg every 8 weeks should be considered, based on individual clinical judgement.
For patients with a starting dose of 4 mg/kg, if a satisfactory clinical response has not been achieved 7 days after treatment start, a second dose of Ilaris 4 mg/kg can be considered. If a full treatment response is subsequently achieved, maintaining the intensified dosing regimen of 8 mg/kg every 8 weeks should be considered, based on individual clinical judgement.
Clinical experience with dosing at intervals of less than 4 weeks or at doses above 600 mg or 8 mg/kg is limited.
SJIA
The recommended dose of Ilaris for SJIA patients with body weight ≥ 7.5 kg is 4 mg/kg (up to a maximum of 300 mg) administered every four weeks via subcutaneous injection. Continued treatment with Ilaris in patients without clinical improvement should be reconsidered by the treating physician.
Gouty arthritis
Management of hyperuricaemia with appropriate urate lowering therapy (ULT) should be instituted or optimised. Ilaris should be used as an on-demand therapy to treat gouty arthritis attacks.
The recommended dose of Ilaris for adult patients with gouty arthritis is 150 mg administered subcutaneously as a single dose during an attack. For maximum effect, Ilaris should be administered as soon as possible after the onset of a gouty arthritis attack.
Patients who do not respond to initial treatment should not be re-treated with Ilaris. In patients who respond and require re-treatment, there should be an interval of at least 12 weeks before a new dose of Ilaris may be administered (see section 5.2).
Special populations
Paediatric population
The safety and efficacy of Ilaris in CAPS and SJIA patients under 2 years of age have not been established.
There is no relevant use of Ilaris in the paediatric population in the indication gouty arthritis.
Elderly
No dose adjustment is required.
Hepatic impairment
Ilaris has not been studied in patients with hepatic impairment.
Renal impairment
No dose adjustment is needed in patients with renal impairment. However, clinical experience in such patients is limited.
Method of Administration
Ilaris is to be administered via subcutaneous injection.
For instructions on use and handling of the reconstituted solution, see section 6.6.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Active, severe infections (see section 4.4).
4.4 Special warnings and precautions for use
Infections
Ilaris is associated with an increased incidence of serious infections. Therefore patients should be monitored carefully for signs and symptoms of infections during and after treatment with Ilaris. Physicians should exercise caution when administering Ilaris to patients with infections, a history of recurring infections, or underlying conditions which may predispose them to infections.
Treatment of CAPS and SJIA
Ilaris should not be initiated or continued in patients during an active infection requiring medical intervention.
Treatment of gouty arthritis
Ilaris should not be administered during an active infection.
Concomitant use of Ilaris with tumour necrosis factor (TNF) inhibitors is not recommended because this may increase the risk of serious infections (see section 4.5).
Isolated cases of unusual or opportunistic infections (including aspergillosis, atypical mycobacterial infections, herpes zoster) have been reported during Ilaris treatment. The causal relationship of Ilaris to these events cannot be excluded.
In approximately 12% of CAPS patients tested with a PPD (purified protein derivative) skin test in clinical trials, follow-up testing yielded a positive test result while treated with Ilaris without clinical evidence of a latent or active tuberculosis infection.
It is unknown whether the use of interleukin-1 (IL-1) inhibitors such as Ilaris increases the risk of reactivation of tuberculosis. Before initiation of therapy, all patients must be evaluated for both active and latent tuberculosis infection. Particularly in adult patients, this evaluation should include a detailed medical history. Appropriate screening tests (e.g. tuberculin skin test, interferon gamma release assay or chest X-ray) should be performed in all patients (local recommendations may apply). Patients must be monitored closely for signs and symptoms of tuberculosis during and after treatment with Ilaris. All patients should be instructed to seek medical advice if signs or symptoms suggestive of tuberculosis (e.g. persistent cough, weight loss, subfebrile temperature) appear during Ilaris therapy. In the event of conversion from a negative to a positive PPD test, especially in high-risk patients, alternative means of screening for a tuberculosis infection should be considered.
Neutropenia and leukopenia
Neutropenia (absolute neutrophil count [ANC] < 1.5 x 109/l) and leukopenia have been observed with medicinal products that inhibit IL-1, including Ilaris. Treatment with Ilaris should not be initiated in patients with neutropenia or leukopenia. It is recommended that white blood cell (WBC) counts including neutrophil counts be assessed prior to initiating treatment and again after 1 to 2 months. For chronic or repeated therapies, it is also recommended to assess WBC counts periodically during treatment. If a patient becomes neutropenic or leukopenic, the WBC counts should be monitored closely and treatment discontinuation should be considered.
Malignancies
Malignancy events have been reported in patients treated with Ilaris. The risk for the development of malignancies with anti-interleukin (IL)-1 therapy is unknown.
Hypersensitivity reactions
Hypersensitivity reactions with Ilaris therapy have been reported. The majority of these events were mild in severity. During clinical development of Ilaris in over 2,300 patients, no anaphylactoid or anaphylactic reactions were reported. However, the risk of severe hypersensitivity reactions, which is not uncommon for injectable proteins, cannot be excluded (see section 4.3).
Hepatic function
Transient and asymptomatic cases of elevations of serum transaminases or bilirubin have been reported in clinical trials (see section 4.8).
Vaccinations
No data are available on the risk of secondary transmission of infection by live (attenuated) vaccines in patients receiving Ilaris. Therefore, live vaccines should not be given concurrently with Ilaris unless the benefits clearly outweigh the risks (see section 4.5).
Prior to initiation of Ilaris therapy, adult and paediatric patients should receive all recommended vaccinations, as appropriate, including pneumococcal vaccine and inactivated influenza vaccine.
Mutation in NLRP3 gene in CAPS patients
Clinical experience in CAPS patients without a confirmed mutation in the NLRP3 gene is limited.
Macrophage activation syndrome in SJIA patients
Macrophage activation syndrome (MAS) is a known, life-threatening disorder that may develop in patients with rheumatic conditions, in particular SJIA. If MAS occurs, or is suspected, evaluation and treatment should be started as early as possible. Physicians should be attentive to symptoms of infection or worsening of SJIA, as these are known triggers for MAS. Based on clinical trial experience, Ilaris does not appear to increase the incidence of MAS in SJIA patients, but no definitive conclusion can be made.
4.5 Interaction with other medicinal products and other forms of interaction
Interactions between Ilaris and other medicinal products have not been investigated in formal studies.
An increased incidence of serious infections has been associated with administration of another IL-1 blocker in combination with TNF inhibitors. Use of Ilaris with TNF inhibitors is not recommended because this may increase the risk of serious infections.
The expression of hepatic CYP450 enzymes may be suppressed by the cytokines that stimulate chronic inflammation, such as interleukin-1 beta (IL-1 beta). Thus, CYP450 expression may be reversed when potent cytokine inhibitory therapy, such as canakinumab, is introduced. This is clinically relevant for CYP450 substrates with a narrow therapeutic index where the dose is individually adjusted. On initiation of canakinumab in patients being treated with this type of medicinal product, therapeutic monitoring of the effect or of the active substance concentration should be performed and the individual dose of the medicinal product adjusted as necessary.
No data are available on either the effects of live vaccination or the secondary transmission of infection by live vaccines in patients receiving Ilaris. Therefore, live vaccines should not be given concurrently with Ilaris unless the benefits clearly outweigh the risks. Should vaccination with live vaccines be indicated after initiation of Ilaris treatment, the recommendation is to wait for at least 3 months after the last Ilaris injection and before the next one (see section 4.4).
4.6 Fertility, pregnancy and lactation
Women of childbearing potential / Contraception in males and females
Women should use effective contraceptives during treatment with Ilaris and for up to 3 months after the last dose
Pregnancy
There is a limited amount of data from the use of canakinumab in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3). The risk for the foetus/mother is unknown. Women who are pregnant or who desire to become pregnant should therefore only be treated after a thorough benefit-risk evaluation.
Breast-feeding
It is unknown whether canakinumab is excreted in human milk. The decision whether to breast-feed during Ilaris therapy should therefore only be taken after a thorough benefit-risk evaluation.
Animal studies have shown that a murine anti-murine IL-1 beta antibody had no undesirable effects on development in nursing mouse pups and that the antibody was transferred to them (see section 5.3).
Fertility
Formal studies of the potential effect of Ilaris on human fertility have not been conducted.
Canakinumab had no effect on male fertility parameters in marmosets (C. jacchus). A murine anti-murine IL-1 beta antibody had no undesirable effects on fertility in male or female mice (see section 5.3).
4.7 Effects on ability to drive and use machines
Ilaris has minor influence on the ability to drive and use machines. Treatment with Ilaris may result in dizziness/vertigo or asthenia (see section 4.8). Patients who experience such symptoms during Ilaris treatment should wait for this to resolve completely before driving or operating machines.
4.8 Undesirable effects
Summary of the safety profile
Over 2,300 subjects including approximately 250 children (aged 2 to 17 years) have been treated with Ilaris in interventional studies in patients with CAPS, SJIA, gouty arthritis or other IL-1 beta mediated diseases, and healthy volunteers. Serious infections have been observed. The most frequent adverse drug reactions were infections predominantly of the upper respiratory tract. The majority of the events were mild to moderate. No impact on the type or frequency of adverse drug reactions was seen with longer-term treatment.
Hypersensitivity reactions have been reported in patients treated with Ilaris (see sections 4.3 and 4.4).
Opportunistic infections have been reported in patients treated with Ilaris (see section 4.4).
CAPS
A total of 194 adult and paediatric CAPS patients (including FCAS/FCU, MWS, and NOMID/CINCA) have received Ilaris in clinical trials. The safety of Ilaris compared with placebo was investigated in a pivotal phase III trial that consisted of an 8-week, open-label period (Part I), a 24-week, randomised, double-blind and placebo-controlled withdrawal period (Part II), and a 16-week open label period on Ilaris (Part III). All patients were treated with Ilaris 150 mg subcutaneous or 2 mg/kg if body weight was ≥ 15 kg and ≤ 40 kg.

SJIA
A total of 201 SJIA patients aged 2 to < 20 years have received Ilaris in clinical trials. The safety of Ilaris compared to placebo was investigated in two pivotal Phase III studies (see section 5.1).
Gouty arthritis
More than 700 patients with gouty arthritis have been treated with Ilaris at doses from 10 mg to 300 mg in randomised, double-blind and active-controlled clinical trials of up to 24 weeks' duration. More than 250 patients have been treated with the recommended dose of 150 mg in Phase II and III trials (see section 5.1).
Tabulated list of adverse reactions
Adverse reactions are listed according to MedDRA system organ class. Within each system organ class, the adverse reactions are ranked by frequency category with the most common first. Frequency categories are defined 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 adverse reactions in CAPS, SJIA and gouty arthritis

MedDRA System Organ Class	CAPS	SJIA	Gouty arthritis
Infections and infestations
Very Common	Nasopharyngitis	Pneumonia Gastroenteritis Urinary tract infection Viral infection Sinusitis Rhinitis Pharyngitis Tonsilitis Nasopharyngitis Upper respiratory tract infection	Pneumonia Bronchitis Gastroenteritis Urinary tract infection Influenza Cellulitis Sinusitis Ear infection Pharyngitis Nasopharyngitis Upper respiratory tract infection
Common	Urinary tract infection Upper respiratory tract infection Viral infection
Nervous system disorders
Common	Dizziness/vertigo		Dizziness/vertigo
Gastrointestinal disorders
Very common		Abdominal pain (upper)
Uncommon			Gastro-oesophageal reflux disease
Skin and subcutaneous tissue disorders
Very common	Injection site reaction	Injection site reaction
Common			Injection site reaction
Musculoskeletal and connective tissue disorders
Very common		Arthralgia
Common		Musculoskeletal pain	Back pain
General disorders and administration site conditions
Common			Fatigue/asthenia
Investigations
Very common		Creatinine renal clearance decreased * Proteinuria # Leukopenia
Common		Neutropenia
* based on estimated creatinine clearance, most were transient # most represented transient trace to 1+ positive urinary protein by dipstick

Description of selected adverse reactions
Long-term data and laboratory abnormalities in CAPS patients
During clinical trials with Ilaris in CAPS patients mean values for haemoglobin increased and those for white blood cell, neutrophils and platelets decreased.
Elevations of transaminases have been observed rarely in CAPS patients.
Asymptomatic and mild elevations of serum bilirubin have been observed in CAPS patients treated with Ilaris without concomitant elevations of transaminases.
In the long-term, open-label studies with dose escalation, events of infections (gastroenteritis, respiratory tract infection, upper respiratory tract infection), vomiting and dizziness were more frequently reported in the 600 mg or 8 mg/kg dose group than in other dose groups.
Laboratory abnormalities in SJIA patients
Haematology
In the overall SJIA program, transient decreased white blood cell (WBC) counts ≤ 0.8 x LLN were reported in 33 patients (16.5%).
In the overall SJIA program, transient decreases in absolute neutrophil count (ANC) to less than 1 x 109/l were reported in 12 patients (6.0%).
In the overall SJIA program, transient decreases in platelet counts (< LLN) were observed in 19 patients (9.5%).
ALT/AST
In the overall SJIA program, high ALT and/or AST > 3 x upper limit of normal (ULN) were reported in 19 patients (9.5%).
Laboratory abnormalities in gouty arthritis patients
Haematology
Decreased white blood cell counts (WBC) ≤ 0.8 x lower limit of normal (LLN) were reported in 6.7% of patients treated with Ilaris compared to 1.4% treated with triamcinolone acetonide. Decreases in absolute neutrophil counts (ANC) to less than 1 x 109/l were reported in 2% of patients in the comparative trials. Isolated cases of ANC counts < 0.5 x 109/l were also observed (see section 4.4).
Mild (< LLN and > 75 x 109/l) and transient decreases in platelet counts were observed at a higher incidence (12.7%) with Ilaris in the active-controlled clinical studies versus the comparator (7.7%) in gouty arthritis patients.
Uric acid
Increases in uric acid level (0.7 mg/dl at 12 weeks and 0.5 mg/dl at 24 weeks) were observed after Ilaris treatment in comparative trials in gouty arthritis. In another study, among patients who were starting on ULT, increases in uric acid were not observed. Uric acid increases were not observed in clinical trials in non-gouty arthritis populations (see section 5.1).
ALT/AST
Mean and median increases in alanine transaminase (ALT) of 3.0 U/l and 2.0 U/l, respectively, and in aspartate transaminase (AST) of 2.7 U/l and 2.0 U/l, respectively, from baseline to end of study were seen in the Ilaris-treated groups versus the triamcinolone acetonide-treated group(s), however the incidence of clinically significant changes (≥ 3 x the upper limit of normal) was greater for patients treated with triamcinolone acetonide (2.5% for both AST and ALT) compared with Ilaris-treated patients (1.6% for ALT and 0.8% for AST).
Triglycerides
In active-controlled gouty arthritis trials, there was a mean increase in triglycerides of 33.5 mg/dl in Ilaris-treated patients compared with a modest decrease of -3.1 mg/dl with triamcinolone acetonide. The incidence of patients with triglyceride elevations > 5 x upper limit of normal (ULN) was 2.4% with Ilaris and 0.7% with triamcinolone acetonide. The clinical significance of this observation is unknown.
Paediatric population
There were 69 paediatric CAPS patients (2-17 years of age) included in the studies. Overall, there were no clinically meaningful differences in the safety and tolerability profile of Ilaris in paediatric patients compared to the overall CAPS population (comprised of adult and pediatric patients, N=194), including the overall frequency and severity of infectious episodes. Infections of the upper respiratory tract were the most frequently reported infection events.
Elderly population
There is no significant difference in safety profile observed in patients ≥ 65 years of age.
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
Reported experience with overdose is limited. In early clinical trials, patients and healthy volunteers received doses as high as 10 mg/kg, administered intravenously or subcutaneously, without evidence of acute toxicity.
In case of overdose, it is recommended for the patient to be monitored for any signs or symptoms of adverse reactions, and appropriate symptomatic treatment instituted immediately.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Immunosuppressants, interleukin inhibitors, ATC code: L04AC08
Mechanism of action
Canakinumab is a fully human monoclonal anti-human interleukin-1 beta (IL-1 beta) antibody of the IgG1/κ isotype. Canakinumab binds with high affinity specifically to human IL-1 beta and neutralises the biological activity of human IL-1 beta by blocking its interaction with IL-1 receptors, thereby preventing IL-1 beta-induced gene activation and the production of inflammatory mediators.
Pharmacodynamic effects
CAPS
In clinical studies, CAPS patients who have uncontrolled over-production of IL-1 beta show a rapid response to therapy with canakinumab, i.e. laboratory parameters such as high C-reactive protein (CRP) and serum amyloid A (SAA), high neutrophil and platelet counts, and leukocytosis rapidly returned to normal.
SJIA
Systemic Juvenile Idiopathic Arthritis is a severe autoinflammatory disease, driven by innate immunity by means of pro-inflammatory cytokines, a key one being IL-1-beta.
Common features of SJIA include fever, rash, hepatosplenomegaly, lymphadenopathy, polyserositis and arthritis. Treatment with canakinumab resulted in a rapid and sustained improvement of both the articular and the systemic features of SJIA with significant reduction of the number of inflamed joints, prompt resolution of fever and reduction of acute phase reactants in the majority of patients (see Clinical efficacy and safety).
Gouty arthritis
A gouty arthritis attack is caused by urate (monosodium urate monohydrate) crystals in the joint and surrounding tissue, which trigger resident macrophages to produce IL-1 beta via the “NALP3 inflammasome” complex. Activation of macrophages and concomitant over-production of IL-1 beta results in an acute painful inflammatory response. Other activators of the innate immune system, such as endogenous agonists of toll-like receptors, may contribute to the transcriptional activation of the IL-1 beta gene, initiating a gouty arthritis attack. Following canakinumab treatment, the inflammatory markers CRP or SAA and signs of acute inflammation (e.g. pain, swelling, redness) in the affected joint subside rapidly.
Clinical efficacy and safety
CAPS
The efficacy and safety of Ilaris have been demonstrated in patients with varying degrees of disease severity and different CAPS phenotypes (including FCAS/FCU, MWS, and NOMID/CINCA). Only patients with confirmed NLRP3 mutation were included in the pivotal study.
In the Phase I/II study, treatment with Ilaris had a rapid onset of action, with disappearance or clinically significant improvement of symptoms within one day after dosing. Laboratory parameters such as high CRP and SAA, high neutrophils and platelet counts normalised rapidly within days of Ilaris injection.
The pivotal study consisted of a 48-week three-part multicentre study, i.e. an 8-week open-label period (Part I), a 24-week randomised, double-blind, placebo-controlled withdrawal period (Part II), followed by a 16-week open-label period (Part III). The aim of the study was to assess efficacy, safety, and tolerability of Ilaris (150 mg or 2 mg/kg every 8 weeks) in patients with CAPS.
− Part I: A complete clinical and biomarker response to Ilaris (defined as composite of physician's global assessment on autoinflammatory and on skin disease ≤ minimal and CRP or SAA values < 10 mg/litre) was observed in 97% of patients and appeared within 7 days of initiation of treatment. Significant improvements were seen in physician's clinical assessment of autoinflammatory disease activity: global assessment of autoinflammatory disease activity, assessment of skin disease (urticarial skin rash), arthralgia, myalgia, headache/migraine, conjunctivitis, fatigue/malaise, assessment of other related symptoms, and patient's assessment of symptoms.
− Part II: In the withdrawal period of the pivotal study, the primary endpoint was defined as the proportion of patients with a disease relapse/flare: none (0%) of the patients randomised to Ilaris flared, compared with 81% of the patients randomised to placebo.
− Part III: Patients treated with placebo in Part II who flared regained and maintained clinical and serological response following entry into the open-label Ilaris extension.
Table 2 Tabulated summary of efficacy in Phase III trial, pivotal placebo-controlled withdrawal period (Part II)

Phase III trial, pivotal placebo-controlled withdrawal period (Part II)
	Ilaris N=15 n(%)	Placebo N=16 n(%)	p-value
Primary endpoint (flare)
Proportion of patients with disease flare in Part II	0 (0%)	13 (81%)	< 0.001
Inflammatory markers*
C-reactive protein, mg/l	1.10 (0.40)	19.93 (10.50)	< 0.001
Serum amyloid A, mg/l	2.27 (-0.20)	71.09 (14.35)	0.002
* mean (median) change from beginning of Part II

Two open-label, uncontrolled, long-term phase III studies were performed. One was a safety, tolerability, and efficacy study of canakinumab in patients with CAPS. The total treatment duration ranged from 6 months to 2 years. The other was an open-label study with canakinumab to evaluate the efficacy and safety in Japanese CAPS patients for 24 weeks, with an extension phase up to 48 weeks. The primary objective was to assess the proportion of patients who were free of relapse at week 24, including those patients whose dose was increased.
In the pooled efficacy analysis for these two studies, 65.6% of patients who had not previously been treated with canakinumab achieved complete response at 150 mg or 2 mg/kg, while 85.2% of patients achieved complete response at any dose. Of the patients treated with 600 mg or 8 mg/kg (or even higher), 43.8% achieved complete response. Fewer patients aged 2 to < 4 years achieved complete response (57.1%) than older paediatric and adult patients. Of the patients who had achieved a complete response, 89.3% maintained response without relapsing.
Experience from individual patients who achieved a complete response following dose escalation to 600 mg (8 mg/kg) every 8 weeks suggests that a higher dose may be beneficial in patients not achieving complete response or not maintaining complete response with the recommended doses (150 mg or 2 mg/kg for patients ≥ 15 kg and ≤ 40 kg). An increased dose was administered more frequently to patients aged 2 to < 4 years and to patients with NOMID/CINCA symptoms compared with FCAS or MWS.
Paediatric population
The CAPS trials with Ilaris included a total of 69 paediatric patients with an age range from 2 to 17 years (approximately half of them treated on an mg/kg basis). Overall, there were no clinically meaningful differences in the efficacy, safety and tolerability profile of Ilaris in paediatric patients compared to the overall CAPS population. The majority of paediatric patients achieved improvement in clinical symptoms and objective markers of inflammation (e.g. SAA and CRP).
SJIA
The efficacy of Ilaris for the treatment of active SJIA was assessed in two pivotal studies (G2305 and G2301). Patients enrolled were aged 2 to < 20 years (mean age of 8.5 years and mean disease duration of 3.5 years at baseline) and had active disease defined as ≥ 2 joints with active arthritis, fever and elevated CRP.
Study G2305
Study G2305 was a randomised, double-blind, placebo-controlled, 4-week study assessing the short-term efficacy of Ilaris in 84 patients randomised to receive a single dose of 4 mg/kg (up to 300 mg) Ilaris or placebo. The primary objective was the proportion of patients at day 15 who achieved a minimum 30% improvement in the paediatric American College of Rheumatology (ACR) response criterion adapted to include absence of fever. Ilaris treatment improved all paediatric ACR response scores as compared to placebo at days 15 and 29 (Table 3)
Table 3 Paediatric ACR response and disease status at days 15 and 29

Day 15		Day 29
	Ilaris N=43	Placebo N=41	Ilaris N=43	Placebo N=41
ACR30	84%	10%	81%	10%
ACR50	67%	5%	79%	5%
ACR70	61%	2%	67%	2%
ACR90	42%	0%	47%	2%
ACR100	33%	0%	33%	2%
Inactive disease	33%	0%	30%	0%
Treatment difference for all ACR scores was significant (p ≤ 0.0001)

Results for the components of the adapted paediatric ACR which included systemic and arthritic components, were consistent with the overall ACR response results. At day 15, the median change from baseline in the number of joints with active arthritis and limited range of motion were -67% and -73% for Ilaris (N=43), respectively, compared to a median change of 0% and 0% for placebo (N=41). The mean change in patient pain score (0-100 mm visual analogue scale) at day 15 was -50.0 mm for Ilaris (N=43), as compared to +4.5 mm for placebo (N=25). The mean change in pain score among Ilaris treated patients was consistent at day 29.
Study G2301
Study G2301 was a randomised, double-blind, placebo-controlled withdrawal study of flare prevention by Ilaris. The study consisted of two parts with two independent primary endpoints (successful steroid taper and time to flare). In part I (open label) 177 patients were enrolled and received 4 mg/kg (up to 300 mg) Ilaris administered every 4 weeks for up to 32 weeks. Patients in part II (double-blind) received either Ilaris 4 mg/kg or placebo every 4 weeks until 37 flare events occurred.
Corticosteroid dose tapering:
Of the total 128 patients who entered part I taking corticosteroids, 92 attempted corticosteroid tapering. Fifty-seven (62%) of the 92 patients who attempted to taper were able to successfully taper their corticosteroid dose and 42 (46%) discontinued corticosteroids
Time to flare:
Patients taking Ilaris in part II had a 64% reduced risk of a flare event as compared to the placebo group (hazard ratio of 0.36; 95% CI: 0.17 to 0.75; p=0.0032). Sixty-three of the 100 patients entering part II, whether assigned to placebo or canakinumab, did not experience a flare over the observation period (up to a maximum of 80 weeks).
Health-related and quality of life outcomes in studies G2305 and G2301
Treatment with Ilaris resulted in clinically relevant improvements in patients' physical function and quality of life. In study G2305, the Childhood Health Assessment Questionnaire Least Squares means improvement was 0.69 for Ilaris vs placebo representing 3.6 times the minimal clinically important difference of 0.19 (p=0.0002). The median improvement from baseline to end of part I of study G2301 was 0.88 (79%). Statistically significant improvements in the Child Health Questionnaire-PF50 scores were reported for Ilaris vs placebo in study G2305 (physical p=0.0012; psychosocial well-being p=0.0017).
Pooled Efficacy Analysis
Data from the first 12 weeks of Ilaris treatment from studies G2305, G2301 and the extension study were pooled to assess maintenance of efficacy. These data showed similar improvements from baseline to week 12 in the adapted paediatric ACR responses and its components to those observed in the placebo controlled study (G2305). At week 12, the adapted paediatric ACR30, 50, 70, 90 and 100 responses were: 70%, 69%, 61%, 49% and 30%, respectively and 28% of patients had inactive disease (N=178).
The efficacy observed in the studies G2305 and G2301 was maintained in the ongoing, open-label long-term extension study (data available through median of 49 weeks of follow-up). In this study, 25 patients who had a strong ACR response for a minimum of 5 months reduced their Ilaris dose to 2 mg/kg every 4 weeks and maintained a paediatric ACR100 response throughout the time the reduced dose was given (median 32 weeks, 8-124 weeks).
Although limited, evidence from the clinical trials suggests that patients not responding to tocilizumab or anakinra, may respond to canakinumab.
Gouty arthritis
The efficacy of Ilaris for the treatment of acute gouty arthritis attacks was demonstrated in two multicentre, randomised, double-blind, active-controlled studies in patients with frequent gouty arthritis (≥ 3 attacks in the previous 12 months) unable to use NSAIDs or colchicine (due to contraindication, intolerance or lack of efficacy). The studies were 12 weeks followed by 12-week double-blind extension. A total of 225 patients were treated with subcutaneous Ilaris 150 mg and 229 patients were treated with intramuscular triamcinolone acetonide (TA) 40 mg at study entry, and when experiencing a new attack thereafter. The mean number of gouty arthritis attacks in the previous 12 months was 6.5. Over 85% of patients had comorbidity, including hypertension (60%), diabetes (15%), ischaemic heart disease (12%), and stage ≥ 3 chronic kidney disease (25%). Approximately one-third of the patients enrolled (76 [33.8%] in the Ilaris group and 84 [36.7%] in the triamcinolone acetonide group) had documented inability (intolerance, contraindication or lack of response) to use both NSAIDs and colchicine. Concomitant treatment with ULTs was reported by 42% of patients at entry.
The co-primary endpoints were: (i) gouty arthritis pain intensity (visual analogue scale, VAS) at 72 hours post-dose, and (ii) time to first new gouty arthritis attack.
For the overall study population, pain intensity was statistically significantly lower for Ilaris 150 mg compared with triamcinolone acetonide at 72 hours. Ilaris also reduced the risk of subsequent attacks (see Table 4).
Efficacy results in a subgroup of patients unable to use both NSAIDs and colchicine and who were on ULT, failed ULT or had a contraindication to ULT (N=101) were consistent with the overall study population with a statistically significant difference compared to triamcinolone acetonide in pain intensity at 72 hours (-10.2 mm, p=0.0208) and in reduction of risk of subsequent attacks (Hazard ratio 0.39, p=0.0047 at 24 weeks).
Efficacy results for a more stringent subgroup limited to current users of ULT (N=62) are presented in Table 4. Treatment with Ilaris induced a reduction of pain and reduced the risk of subsequent attacks in patients using ULT and unable to use both NSAIDs and colchicine, although the observed treatment difference compared to triamcinolone acetonide was less pronounced than with the overall study population.
Table 4 Efficacy for the overall study population and in a subgroup of patients currently using ULT and unable to use both NSAIDs and colchicine

Efficacy endpoint	Overall study population; N=454	Unable to use both NSAIDs and colchicine; on ULT N=62
Treatment of gouty arthritis attacks as measured by pain intensity (VAS) at 72 h
Least Squares mean estimated difference to triamcinolone acetonide CI  p-value, 1-sided	-10.7 (-15.4, -6.0) p < 0.0001*	-3.8 (-16.7, 9.1) p=0.2798
Risk reduction of subsequent gouty arthritis attacks as measured by time to first new flare (24 weeks)
Hazard ratio to triamcinolone acetonide CI p-value, 1-sided	0.44 (0.32, 0.60) p < 0.0001*	0.71 (0.29, 1.77) p=0.2337
* Denotes significant p-value <0.025

Safety results showed an increased incidence of adverse events for canakinumab compared to triamcinolone acetonide, with 66% vs 53% of patients reporting any adverse event and 20% vs 10% of patients reporting an infection adverse event over 24 weeks.
Elderly population
Overall, the efficacy, safety and tolerability profile of Ilaris in elderly patients ≥ 65 years of age was comparable to patients < 65 years of age
Patients on urate lowering therapy (ULT)
In clinical studies, Ilaris has been safely administered with ULT. In the overall study population, patients on ULT had a less pronounced treatment difference in both pain reduction and reduction in the risk of subsequent gouty arthritis attacks compared to patients not on ULT.
Immunogenicity
Antibodies against Ilaris were observed in approximately 1.5%, 3% and 2% of the patients treated with Ilaris for CAPS, SJIA and gouty arthritis, respectively. No neutralising antibodies were detected. No apparent correlation of antibody development to clinical response or adverse events was observed.
This medicinal product has been authorised for CAPS under “Exceptional Circumstances”. This means that due to the rarity of the disease it has not been possible to obtain complete information on this medicinal product. The European Medicines Agency will review any new information which may become available every year and this SmPC will be updated as necessary.
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with Ilaris in one or more subsets of the paediatric population in Cryopyrin Associated Periodic Syndromes (CAPS) and Juvenile Idiopathic Arthritis (see section 4.2 for information on paediatric use).
The European Medicines Agency has waived the obligation to submit the results of studies with Ilaris in all subsets of the paediatric population in gouty arthritis (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
CAPS
Absorption
The peak serum canakinumab concentration (Cmax) occurred approximately 7 days following single subcutaneous administration of 150 mg in adult CAPS patients. The mean terminal half-life was 26 days. Mean values for Cmax und AUCinf after a single subcutaneous dose of 150 mg in a typical adult CAPS patient (70 kg) were 15.9 µg/ml and 708 µg*d/ml. The absolute bioavailability of subcutaneously administered canakinumab was estimated to be 66%. Exposure parameters (such as AUC and Cmax) increased in proportion to dose over the dose range of 0.30 to 10.0 mg/kg given as intravenous infusion or from 150 to 600 mg as subcutaneous injection. Predicted steady-state exposure values (Cmin,ss, Cmax,ss, AUC,ss,8w) after 150 mg subcutaneous administration (or 2 mg/kg, respectively) every 8 weeks were slightly higher in the weight category 40-70 kg (6.6 µg/ml, 24.3 µg/ml, 767 µg*d/ml) compared to the weight categories < 40 kg (4.0 µg/ml, 19.9 µg/ml, 566 µg*d/ml) and > 70 kg (4.6 µg/ml, 17.8 µg/ml, 545 µg*d/ml). The expected accumulation ratio was 1.3-fold following 6 months of subcutaneous administration of 150 mg canakinumab every 8 weeks.
Distribution
Canakinumab binds to serum IL-1 beta. The distribution volume (Vss) of canakinumab varied according to body weight. It was estimated to be 6.2 litres in a CAPS patient of body weight 70 kg.
Elimination
The apparent clearance (CL/F) of canakinumab increases with body weight. It was estimated to be 0.17 l/d in a CAPS patient of body weight 70 kg and 0.11 l/d in a SJIA patient of body weight 33 kg. After accounting for body weight differences, no clinically significant differences in the pharmacokinetic properties of canakinumab were observed between CAPS and SJIA patients.
There was no indication of accelerated clearance or time-dependent change in the pharmacokinetic properties of canakinumab following repeated administration. No gender or age-related pharmacokinetic differences were observed after correction for body weight.
SJIA
Bioavailability in SJIA patients has not been determined independently. Apparent clearance per kg body weight (CL/F per kg) was comparable between the SJIA and CAPS population (0.004 l/d per kg). The apparent volume of distribution per kg (V/F per kg) was 0.14 l/kg.
After repeated administration of 4 mg/kg every 4 weeks the accumulation ratio of canakinumab was 1.6 fold in SJIA patients. Steady state was reached after 110 days. The overall predicted mean (±SD) for Cmin,ss, Cmax,ss and AUC,ss4w were 14.7±8.8 μg/ml, 36.5 ± 14.9 μg/ml and 696.1 ± 326.5 μg*d/ml, respectively.
The AUCss4w in each age group was 692, 615, 707 and 742 µg*d/ml for 2-3, 4-5, 6-11, and 12-19 years old, respectively. When stratified by weight, a lower (30-40%) median of exposure for Cmin,ss (11.4 vs 19 µg/ml) and AUCss (594 vs 880 µg*d/ml) for the lower bodyweight category (≤ 40 kg) vs the higher bodyweight category (> 40 kg) was observed.
Gouty arthritis population
Bioavailability in gouty arthritis patients has not been determined independently. Apparent clearance per kg body weight (CL/F per kg) was comparable between the gouty arthritis and CAPS population (0.004 l/d/kg). Mean exposure in a typical gouty arthritis patient (93 kg) after a single subcutaneous 150 mg dose (Cmax: 10.8 µg/ml and AUCinf: 495 µg*d/ml) was lower than in a typical 70 kg CAPS patient (15.9 µg/ml and 708 µg*d/ml). This is consistent with the observed increase in CL/F with body weight.
The expected accumulation ratio was 1.1-fold following subcutaneous administration of 150 mg canakinumab every 12 weeks.
Paediatric population
Peak concentrations of canakinumab occurred between 2 to 7 days (Tmax) following single subcutaneous administration of canakinumab 150 mg or 2 mg/kg in paediatric patients. The terminal half-life ranged from 22.9 to 25.7 days, similar to the pharmacokinetic properties observed in adults. Based on the population pharmacokinetic modelling analysis, the pharmacokinetics of canakinumab in children aged 2 to < 4 years were similar to those in patients 4 years of age and older. Subcutaneous absorption rate was estimated to decrease with age and appeared to be fastest in the youngest patients. Accordingly, Tmax was shorter (3.6 days) in younger SJIA patients (2-3 years) compared to older SJIA patients (12-19 years; Tmax 6 days). Bioavailability (AUCss) was not affected.
Pharmacokinetic properties are similar in CAPS and SJIA paediatric populations.
Elderly population
No change in pharmacokinetic parameters based on clearance or volume of distribution were observed between elderly patients and adult patients < 65 years of age.
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on cross-reactivity, repeated dose, immunotoxicity, reproductive and juvenile toxicity studies performed with canakinumab or a murine anti-murine IL-1 beta antibody.
Since canakinumab binds to marmoset (C. jacchus) and human IL-1 beta with a similar affinity, the safety of canakinumab has been studied in the marmoset. No undesirable effects of canakinumab were seen following twice weekly administration to marmosets for up to 26 weeks or in an embryofoetal developmental toxicity study in pregnant marmosets. Plasma concentrations that are well tolerated in animals are in excess of at least 42-fold (Cmax) and 78-fold (Cavg) the plasma concentrations in paediatric CAPS patients (body weight 10 kg) treated with clinical doses of canakinumab up to 8 mg/kg subcutaneously every 8 weeks. Plasma concentrations that are well tolerated in animals exceed at least 62-fold (Cmax) and 104-fold (Cavg) the plasma concentrations in paediatric SJIA patients, treated with up to 4 mg/kg via the subcutaneous route every 4 weeks. In addition, no antibodies to canakinumab were detected in these studies. No non-specific tissue cross-reactivity was demonstrated when canakinumab was applied to normal human tissues.
Formal carcinogenicity studies have not been conducted with canakinumab.
In an embryofoetal development study in marmosets canakinumab showed no maternal toxicity, embryotoxicity or teratogenicity when administered throughout organogenesis.
No undesirable effects of a murine anti-murine IL-1 beta antibody were seen in a complete set of reproductive and juvenile studies in mice. Anti-murine IL-1 beta did not elicit adverse events on foetal or neonatal growth when administered throughout late gestation, delivery and nursing (see section 4.6). The high dose used in these studies was in excess of the maximally effective dose in terms of IL-1 beta suppression and activity.
An immunotoxicology study in mice with a murine anti-murine IL-1 beta antibody showed that neutralising IL-1 beta has no effects on immune parameters and caused no impairment of immune function in mice.
6. Pharmaceutical particulars
6.1 List of excipients
Sucrose
Histidine
Histidine hydrochloride monohydrate
Polysorbate 80
6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3 Shelf life
3 years.
After reconstitution, from a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C - 8°C.
6.4 Special precautions for storage
Store in a refrigerator (2°C - 8°C).
Do not freeze.
Store in the original package in order to protect from light.
For storage conditions after reconstitution of the medicinal product, see section 6.3.
6.5 Nature and contents of container
150 mg of powder for solution for injection in a vial (type I glass) with a stopper (coated chlorobutyl rubber) and flip-off cap (aluminium).
Packs containing 1 vial or multipacks containing 4 (4x1) vials.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Ilaris 150 mg powder for solution for injection is supplied in a single-use vial for individual use. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Instructions for reconstitution
Using aseptic technique, reconstitute each vial of Ilaris at room temperature (typically 15°C to 25°C) by slowly injecting 1.0 ml water for injections with a 1 ml syringe and an 18 G x 2 inch (50 mm) needle. Swirl the vial slowly at an angle of about 45° for approximately 1 minute and allow to stand for about 5 minutes. Then gently turn the vial upside down and back again ten times. If possible, avoid touching the rubber stopper with your fingers. Allow to stand for about 15 minutes at room temperature to obtain a clear to opalescent solution. Do not shake. Do not use if particles are present in the solution.
Tap the side of the vial to remove any residual liquid from the stopper. The solution should be free of visible particles and clear to opalescent. The solution should be colourless or may have a slight brownish-yellow tint. If the solution has a distinctly brown discolouration it should not be used. If not used immediately after reconstitution, the solution should be kept at 2°C to 8°C and used within 24 hours.
Instructions for administration
Carefully withdraw the required volume depending on the dose to be administered (0.2 ml to 1.0 ml) and subcutaneously inject using a 27 G x 0.5 inch (13 mm) needle.
The following are suitable injection sites: upper thigh, abdomen, upper arm or buttocks. Broken skin and areas which are bruised or covered by a rash should be avoided. Injection into scar-tissue should be avoided as this may result in insufficient exposure to Ilaris.
Disposal
Patients or their caregivers should be instructed on the appropriate procedure for disposal of the vials, syringes and needles in accordance with local requirements.
7. Marketing authorisation holder
Novartis Europharm Limited
Frimley Business Park
Camberley
GU16 7SR
United Kingdom
8. Marketing authorisation number(s)
EU/1/09/564/001-002
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation:
 23 October 2009
Date of latest renewal:
 26 October 2014
10. Date of revision of the text
10 October 2014
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu