英文药名：Olumiant（baricitinib Film-Coated Tablets）

中文药名：巴瑞克替尼薄膜衣片

生产厂家：礼来公司
药品介绍
【通用名】巴瑞克替尼baricitinib
【商品名】Olumiant
【开发商】Incyte公司原研
【药理机制】Baricitinib是一种选择性JAK1和JAK2抑制剂，无细胞试验中IC50分别为5.9 nM和5.7 nM，比作用于JAK3和Tyk2选择性高70和10倍左右，对c-Met和Chk2没有抑制作用。
【剂型/规格】片剂：2mg、4mg
【适 用 症】中度到重度的类风湿关节炎（RA）
【用法用量】口服，每日1次，日剂量为4mg，对于年龄大于75周岁且具有慢性复发性感染史的患者，推荐日剂量2mg，每日1次，对于采用日剂量4mg治疗的患者，如病情已取得持续控制，可将日剂量改为2mg。
【包装规格】（注：以下产品欧洲产品，采购者以在线咨询为准。不同规格和不同价格）
薄膜衣片
2毫克：14片，28片，28×1片剂（单位剂量）35片，56片，84片，84 X 1片剂（单位剂量），98片。
4毫克：14片，28片，28×1片剂（单位剂量）35片，56片，84片，84 X 1片剂（单位剂量），98片。
【上市情况】Incyte公司原研，礼来公司联合开发，2016年1月两家公司已经宣布向FDA提交了NDA申请。2017年2月14日已经获得EMA的批准在欧盟上市，商品名：Olumiant，用于治疗轻度至重度的类风湿关节炎。
Baricitinib是一种口服的JAK1和JAK2抑制剂，其对JAK1、2的抑制强度和选择性分别比JAK3高100倍和70倍。
Baricitinib的临床项目纳入了广泛的RA患者群体，包括疾病改善抗风湿药物（DMARD）初治群体，对甲氨蝶呤（MTX）治疗反应不足的群体，对抗肿瘤坏死因子（anti-TNF，包括全球最畅销抗炎药修美乐Humira和恩利Enbrel）治疗反应不足的群体。在关键III期研究RA-BEAM中，baricitinib在改善RA症状和体征方面显著优于Humira。该研究是首个证明一种每日一次口服药物疗效显著优于当前注射型标准护理药物（anti-TNF）的关键III期研究。此外，2014年10月，在至少一种抗肿瘤坏死因子（包括Humira和Enbrel）治疗失败的中重度RA群体中开展的关键III期RA-BEACON研究中，baricitinib也表现出显著疗效。
除了类风湿性关节炎（RA），原研公司也在研究baricitinib治疗银屑病、糖尿病肾病、特应性皮炎、系统性红斑狼疮等疾病的疗效，目前均处于II期临床阶段。

完整说明书附件：https://www.medicines.org.uk/emc/medicine/32997
Olumiant 2mg and 4mg Film-Coated Tablets
1. Name of the medicinal product
Olumiant❅2 mg film-coated tablets
Olumiant 4 mg film-coated tablets
2. Qualitative and quantitative composition
Olumiant 2 mg film-coated tablets
Each film-coated tablet contains 2 mg baricitinib.
Olumiant 4 mg film-coated tablets
Each film-coated tablet contains 4 mg baricitinib.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Film-coated tablet (tablet).
Olumiant 2 mg film-coated tablets
Light pink, 9.0 x 7.5 mm oblong tablets, debossed with “Lilly” on one side and “2” on the other.
Olumiant 4 mg film-coated tablets
Medium pink, 8.5 mm round tablets, debossed with “Lilly” on one side and “4” on the other.
The tablets contain a recessed area on each side.
4. Clinical particulars
4.1 Therapeutic indications
Olumiant is indicated for the treatment of moderate to severe active rheumatoid arthritis in adult patients who have responded inadequately to, or who are intolerant to one or more disease-modifying anti-rheumatic drugs. Olumiant may be used as monotherapy or in combination with methotrexate (see sections 4.4, 4.5 and 5.1 for available data on different combinations).
4.2 Posology and method of administration
Treatment should be initiated by physicians experienced in the diagnosis and treatment of rheumatoid arthritis.
Posology
The recommended dose of Olumiant is 4 mg once daily. A dose of 2 mg once daily is appropriate for patients such as those aged ≥ 75 years and may be appropriate for patients with a history of chronic or recurrent infections. A dose of 2 mg once daily may also be considered for patients who have achieved sustained control of disease activity with 4 mg once daily and are eligible for dose tapering (see section 5.1).
Treatment should not be initiated in patients with an absolute lymphocyte count (ALC) less than 0.5 x 109 cells/L, an absolute neutrophil count (ANC) less than 1 x 109 cells/L, or who have a haemoglobin value less than 8 g/dL. Treatment may be initiated once values have improved above these limits (see section 4.4).
Renal impairment
The recommended dose is 2 mg once daily in patients with creatinine clearance between 30 and 60 mL/min. Olumiant is not recommended for use in patients with creatinine clearance < 30 mL/min (see section 5.2).
Hepatic impairment
No dose adjustment is required in patients with mild or moderate hepatic impairment. Olumiant is not recommended for use in patients with severe hepatic impairment (see section 5.2).
Co-administration with OAT3 inhibitors
The recommended dose is 2 mg once daily in patients taking Organic Anion Transporter 3 (OAT3) inhibitors with a strong inhibition potential, such as probenecid (see section 4.5).
Elderly
Clinical experience in patients ≥ 75 years is very limited and in these patients a starting dose of 2 mg is appropriate.
Paediatric population
The safety and efficacy of Olumiant in children and adolescents aged 0 to 18 years have not yet been established. No data are available.
Method of administration
Oral use.
Olumiant is to be taken once daily with or without food and may be taken at any time of the day.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Pregnancy (see section 4.6).
4.4 Special warnings and precautions for use
Infections
Baricitinib is associated with an increased rate of infections such as upper respiratory tract infections compared to placebo (see section 4.8). In treatment naïve patients, combination with methotrexate resulted in increased frequency of infections compared to baricitinib monotherapy. The risks and benefits of treatment with Olumiant should be carefully considered prior to initiating therapy in patients with active, chronic or recurrent infections (see section 4.2). If an infection develops, the patient should be monitored carefully and Olumiant therapy should be temporarily interrupted if the patient is not responding to standard therapy. Olumiant treatment should not be resumed until the infection resolves.
Tuberculosis
Patients should be screened for tuberculosis (TB) before starting Olumiant therapy. Olumiant should not be given to patients with active TB. Anti-TB therapy should be considered prior to initiation of Olumiant in patients with previously untreated latent TB.
Haematological abnormalities
Absolute Neutrophil Count (ANC) < 1 x 109 cells/L, Absolute Lymphocyte Count (ALC) < 0.5 x 109 cells/L and haemoglobin < 8 g/dL were reported in less than 1% of patients in clinical trials. Treatment should not be initiated, or should be temporarily interrupted, in patients with an ANC < 1 x 109 cells/L, ALC < 0.5 x 109 cells/L or haemoglobin < 8 g/dL observed during routine patient management (see section 4.2).
The risk of lymphocytosis is increased in elderly patients with rheumatoid arthritis. Rare cases of lymphoproliferative disorders have been reported.
Viral reactivation
Viral reactivation, including cases of herpes virus reactivation (e.g., herpes zoster, herpes simplex), were reported in clinical studies (see section 4.8). Herpes zoster was reported more commonly in patients ≥ 65 years of age who had previously been treated with both biologic and conventional DMARDs. If a patient develops herpes zoster, Olumiant treatment should be temporarily interrupted until the episode resolves.
Screening for viral hepatitis should be performed in accordance with clinical guidelines before starting therapy with Olumiant. Patients with evidence of active hepatitis B or C infection were excluded from clinical trials. Patients, who were positive for hepatitis C antibody but negative for hepatitis C virus RNA, were allowed to participate. Patients with hepatitis B surface antibody and hepatitis B core antibody, without hepatitis B surface antigen, were also allowed to participate; such patients should be monitored for expression of hepatitis B virus (HBV) DNA. If HBV DNA is detected, a liver specialist should be consulted to determine if treatment interruption is warranted.
Vaccination
No data are available on the response to vaccination with live or inactivated vaccines in patients receiving baricitinib. Use with live, attenuated vaccines during, or immediately prior to, Olumiant therapy is not recommended. International treatment guidelines on vaccination in rheumatoid arthritis patients should be followed when varicella zoster vaccination is considered prior to treatment with Olumiant.
Lipids
Dose dependent increases in blood lipid parameters were reported in patients treated with baricitinib compared to placebo (see section 4.8). Elevations in LDL cholesterol decreased to pre-treatment levels in response to statin therapy. Lipid parameters should be assessed approximately 12 weeks following initiation of Olumiant therapy and thereafter patients should be managed according to international clinical guidelines for hyperlipidaemia. The effect of these lipid parameter elevations on cardiovascular morbidity and mortality has not been determined.
Hepatic transaminase elevations
Increases in alanine transaminase (ALT) and aspartate transaminase (AST) to ≥ 5 and ≥ 10 x upper limit of normal (ULN) were reported in less than 1% of patients in clinical trials. In treatment-naïve patients, combination with methotrexate resulted in increased frequency of hepatic transaminase elevations compared with baricitinib monotherapy (see section 4.8). If increases in ALT or AST are observed during routine patient management and drug-induced liver injury is suspected, Olumiant should be temporarily interrupted until this diagnosis is excluded.
Malignancy
The risk of malignancies including lymphoma is increased in patients with rheumatoid arthritis. Immunomodulatory medicinal products may increase the risk of malignancies including lymphoma. The clinical data are insufficient to assess the potential incidence of malignancies following exposure to baricitinib. Long-term safety evaluations are ongoing.
Laboratory monitoring
Table 1. Laboratory measures and monitoring guidance
Immunosuppressive medicinal products
Combination with biologic DMARDs or other Janus kinase (JAK) inhibitors is not recommended, as a risk of additive immunosuppression cannot be excluded. Data concerning use of baricitinib with potent immunosuppressive medicinal products (e.g., azathioprine, tacrolimus, ciclosporin) are limited and caution should be exercised when using such combinations (see section 4.5).
4.5 Interaction with other medicinal products and other forms of interaction
Pharmacodynamic interactions
Immunosuppressive medicinal products:
Combination with biologic DMARDs or other JAK inhibitors has not been studied. Use of baricitinib with potent immunosuppressive medicinal products such as azathioprine, tacrolimus, or ciclosporin was limited in clinical studies of baricitinib, and a risk of additive immunosuppression cannot be excluded (see section 4.4).
Potential for other medicinal products to affect the pharmacokinetics of baricitinib
Transporters
In vitro, baricitinib is a substrate for organic anionic transporter (OAT)3, P-glycoprotein (Pgp), breast cancer resistance protein (BCRP) and multidrug and toxic extrusion protein (MATE)2-K. In a clinical pharmacology study, dosing of probenecid (an OAT3 inhibitor with strong inhibition potential) resulted in approximately a 2-fold increase in AUC(0-∞) with no change in tmax or Cmax of baricitinib. Consequently, the recommended dose in patients taking OAT3 inhibitors with a strong inhibition potential, such as probenecid, is 2 mg once daily (see section 4.2). No clinical pharmacology study has been conducted with OAT3 inhibitors with less inhibition potential. The prodrug leflunomide rapidly converts to teriflunomide which is a weak OAT3 inhibitor and therefore may lead to an increase in baricitinib exposure. Since dedicated interaction studies have not been conducted, caution should be used when leflunomide or teriflunomide are given concomitantly with baricitinib. Concomitant use of the OAT3 inhibitors ibuprofen and diclofenac may lead to increased exposure of baricitinib, however their inhibition potential of OAT3 is less compared to probenecid and thus a clinically relevant interaction is not expected. Coadministration of baricitinib with ciclosporin (Pgp/BCRP inhibitor) or methotrexate (substrate of several transporters including OATP1B1, OAT1, OAT3, BCRP, MRP2, MRP3, and MRP4) resulted in no clinically meaningful effects on baricitinib exposure.
Cytochrome P450 enzymes
In vitro, baricitinib is a cytochrome P450 enzyme (CYP)3A4 substrate although less than 10% of the dose is metabolised via oxidation. In clinical pharmacology studies, coadministration of baricitinib with ketoconazole (strong CYP3A inhibitor) resulted in no clinically meaningful effect on the PK of baricitinib. Coadministration of baricitinib with fluconazole (moderate CYP3A/CYP2C19/CYP2C9 inhibitor) or rifampicin (strong CYP3A inducer) resulted in no clinically meaningful changes to baricitinib exposure.
Gastric pH modifying agents
Elevating gastric pH with omeprazole had no clinically significant effect on baricitinib exposure.
Potential for baricitinib to affect the pharmacokinetics of other medicinal products
Transporters
In vitro, baricitinib did inhibit OAT1, OAT3, organic cationic transporter (OCT) 1, OCT2, OATP1B3, BCRP and MATE1 and MATE2-K. Clinically meaningful changes in the PK of medicinal products that are substrates for these transporters are unlikely, with the exception of OCT1 substrates. It cannot be ruled out that baricitinib is a clinically relevant OCT1 inhibitor, however there are currently no known selective OCT1 substrates for which clinically significant interactions might be predicted. In clinical pharmacology studies there were no clinically meaningful effects on exposure when baricitinib was coadministered with digoxin (Pgp substrate) or methotrexate (substrate of several transporters).
Cytochrome P450 enzymes
In clinical pharmacology studies, coadministration of baricitinib with the CYP3A substrates simvastatin, ethinyl oestradiol, or levonorgestrel resulted in no clinically meaningful changes in the PK of these medicinal products.
4.6 Fertility, pregnancy and lactation
Pregnancy
The JAK/STAT pathway has been shown to be involved in cell adhesion and cell polarity which can affect early embryonic development. There are no adequate data from the use of baricitinib in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). Baricitinib was teratogenic in rats and rabbits. Animal studies indicate that baricitinib may have an adverse effect on bone development in utero at higher dosages.
Olumiant is contraindicated during pregnancy (see section 4.3). Women of childbearing potential have to use effective contraception during and for at least 1 week after treatment. If a patient becomes pregnant while taking Olumiant the parents should be informed of the potential risk to the foetus.
Breast-feeding
It is unknown whether baricitinib/metabolites are excreted in human milk. Available pharmacodynamic/toxicological data in animals have shown excretion of baricitinib in milk (see section 5.3).
A risk to newborns/infants cannot be excluded and Olumiant should not be used during breast-feeding. A decision must be made whether to discontinue breast-feeding or to discontinue Olumiant therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.
Fertility
Studies in animals suggest that treatment with baricitinib has the potential to decrease female fertility while on treatment, but there was no effect on male spermatogenesis (see section 5.3).
4.7 Effects on ability to drive and use machines
Olumiant has no or negligible influence on the ability to drive and use machines.
4.8 Undesirable effects
Summary of safety profile
The most commonly reported adverse drug reactions (ADRs) occurring in ≥ 2% of patients treated with Olumiant monotherapy or in combination with conventional synthetic DMARDs were increased LDL cholesterol (33.6%), upper respiratory tract infections (14.7%) and nausea (2.8%). Infections reported with Olumiant treatment included Herpes zoster.
Tabulated list of adverse reactions
A total of 3,464 patients were treated with Olumiant in clinical studies in rheumatoid arthritis representing 4214 patient-years of exposure. Of these, 2166 rheumatoid arthritis patients were exposed to Olumiant for at least one year. Six placebo-controlled studies were integrated (997 patients on 4 mg once daily and 1070 patients on placebo) to evaluate the safety of Olumiant in comparison to placebo for up to 16 weeks after treatment initiation.
Table 2. Adverse Reactions
a Combined term (acute sinusitis, epiglottitis, laryngitis, nasopharyngitis, oropharyngeal pain, pharyngitis, pharyngotonsillitis, rhinitis, sinusitis, tonsillitis, tracheitis, upper respiratory tract infection).
b Combined term (eczema herpeticum, herpes simplex, ophthalmic herpes simplex, oral herpes).
c Includes changes detected during laboratory monitoring (see text below).
Description of selected adverse reactions
Nausea
In treatment-naïve patients, through 52 weeks, the frequency of nausea was greater for the combination treatment of methotrexate and Olumiant (9.3%) compared to methotrexate alone (6.2%) or Olumiant alone (4.4%). Nausea was most frequent during the first 2 weeks of treatment.
Infections
In controlled studies, for up to 16 weeks, the incidence rate of all infections (rate of patients with ≥ 1 event per 100 patient-years of exposure) was 101 with Olumiant compared to 83 in the placebo group. Most infections were mild to moderate in severity. In studies which included both doses, infections were reported in 31.9%, 28.8% and 24.1% of patients up to 16 weeks in the 4 mg, 2 mg and placebo groups, respectively. Reporting rates for Olumiant compared to placebo for the infection-related ADRs were: Upper respiratory tract infections (14.7% vs. 11.7%), urinary tract infections (3.4% vs. 2.7%), gastroenteritis (1.6% vs. 0.8%), herpes simplex (1.8% vs. 0.7%), and herpes zoster (1.4% vs. 0.4%). In treatment-naïve patients, for up to 52 weeks, the frequency of upper respiratory tract infections was greater for the combination treatment of methotrexate and Olumiant (26.0%) compared to methotrexate alone (22.9%) or Olumiant alone (22.0%). The rate of serious infections with Olumiant (1.1%) was similar to placebo (1.2%). For Olumiant, the most common serious infections were herpes zoster, and cellulitis. The rate of serious infections remained stable during long term exposure. The overall incidence rate of serious infections in the clinical trial programme was 3.2 per 100 patient-years.
Hepatic transaminase elevations
In controlled studies, for up to 16 weeks, alanine transaminase (ALT) and aspartate transaminase (AST) elevations ≥ 3 x upper limit of normal (ULN) were observed in 1.4% and 0.8% of patients treated with Olumiant, compared to 1.0% and 0.8% respectively of patients treated with placebo. Most cases of hepatic transaminase elevations were asymptomatic and transient.
In treatment-naïve patients, the combination of Olumiant with potentially hepatotoxic medicinal products, such as methotrexate, resulted in increased frequency of these elevations. For up to 52 weeks, the frequency of ALT and AST elevations ≥ 3 x ULN were greater for the combination treatment of methotrexate and Olumiant (7.5% and 3.8%) compared to methotrexate alone (2.9% and 0.5%) or Olumiant alone (1.9% and 1.3%).
The pattern and incidence of elevation in ALT/AST remained stable over time including in the long-term extension study.
Lipid elevations
Baricitinib treatment was associated with dose-dependent increases in lipid parameters including total cholesterol, triglycerides, LDL cholesterol, and HDL cholesterol. There was no change in the LDL/HDL ratio. Elevations were observed at 12 weeks and remained stable thereafter at a higher value than baseline including in the long-term extension study. In controlled studies, for up to 16 weeks, the following rates were observed for Olumiant vs. placebo:
• Increased total cholesterol ≥ 5.17 mmol/L: 49.1% vs.15.8%, respectively
• Increased LDL cholesterol ≥ 3.36 mmol/L: 33.6% vs. 10.3%, respectively
• Increased HDL cholesterol ≥ 1.55 mmol/L: 42.7% vs. 13.8%, respectively
• Increased triglycerides ≥ 5.65 mmol/L: 0.4% vs. 0.5%, respectively
In studies which included both doses, a dose-relationship was observed with increased total cholesterol ≥ 5.17 mmol/L reported in 48.8%, 34.7% and 17.8% of patients up to 16 weeks in the 4 mg, 2 mg and placebo groups, respectively.
Elevations in LDL cholesterol decreased to pre-treatment levels in response to statin therapy.
Creatine phosphokinase (CPK)
In controlled studies, for up to 16 weeks, increases in CPK values were common. Significant increases (> 5 x ULN) occurred in 0.8% of patients treated with Olumiant and 0.3% of patients treated with placebo. A dose relationship was observed with CPK elevations ≥ 5 x ULN of normal reported in 1.5%, 0.8% and 0.6% of patients at 16 weeks in the 4 mg, 2 mg and placebo groups, respectively. Most cases were transient and did not require treatment discontinuation. In clinical trials, there were no confirmed cases of rhabdomyolysis. Elevations of CPK were observed at 4 weeks and remained stable at a higher value than baseline thereafter including in the long-term extension study.
Neutropaenia
In controlled studies, for up to 16 weeks, decreases in neutrophil counts below 1 x 109 cells/L occurred in 0.3% of patients treated with Olumiant compared to 0% of patients treated with placebo. There was no clear relationship between decreases in neutrophil counts and the occurrence of serious infections. However, in clinical studies, treatment was interrupted in response to ANC < 1 x 109 cells/L. The pattern and incidence of decreases in neutrophil counts remained stable at a lower value than baseline over time including in the long-term extension study.
Thrombocytosis
In controlled studies, for up to 16 weeks, increases in platelet counts above 600 x 109 cells/L occurred in 2.0% of patients treated with Olumiant 4 mg and 1.1% of patients treated with placebo. No association was observed between increased platelet counts and adverse events of a thrombotic nature. The pattern and incidence of increases in platelet counts remained stable at a higher value than baseline over time including in the long term extension study.
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 Ireland: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517; website: www.hpra.ie; e-mail: medsafety@hpra.ie, or United Kingdom: Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard.
4.9 Overdose
Single doses up to 40 mg and multiple doses of up to 20 mg daily for 10 days have been administered in clinical trials without dose-limiting toxicity. Adverse events were comparable to those seen at lower doses and no specific toxicities were identified. Pharmacokinetic data of a single dose of 40 mg in healthy volunteers indicate that more than 90% of the administered dose is expected to be eliminated within 24 hours. In case of an overdose, it is recommended that the patient be monitored for signs and symptoms of adverse reactions. Patients who develop adverse reactions should receive appropriate treatment.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Selective immunosuppressants, ATC code: L04AA37
Mechanism of action
Baricitinib is a selective and reversible inhibitor of Janus kinase (JAK)1 and JAK2. In isolated enzyme assays, baricitinib inhibited the activities of JAK1, JAK2, Tyrosine Kinase 2 and JAK3 with IC50 values of 5.9, 5.7, 53 and > 400 nM, respectively.
Janus kinases (JAKs) are enzymes that transduce intracellular signals from cell surface receptors for a number of cytokines and growth factors involved in haematopoiesis, inflammation and immune function. Within the intracellular signalling pathway, JAKs phosphorylate and activate signal transducers and activators of transcription (STATs), which activate gene expression within the cell. Baricitinib modulates these signalling pathways by partially inhibiting JAK1 and JAK2 enzymatic activity, thereby reducing the phosphorylation and activation of STATs.
Pharmacodynamic effects
Inhibition of IL-6 induced STAT3 phosphorylation
Administration of baricitinib resulted in a dose dependent inhibition of IL-6 induced STAT3 phosphorylation in whole blood from healthy subjects with maximal inhibition observed 2 hours after dosing which returned to near baseline by 24 hours.
Immunoglobulins
Mean serum IgG, IgM, and IgA values decreased by 12 weeks after starting treatment with Olumiant, and remained stable at a lower value than baseline through at least 104 weeks. For most patients, changes in immunoglobulins occurred within the normal reference range.
Lymphocytes
Mean absolute lymphocyte count increased by 1 week after starting treatment with Olumiant, returned to baseline by week 24, and then remained stable through at least 104 weeks. For most patients, changes in lymphocyte count occurred within the normal reference range.
C-reactive protein
In patients with rheumatoid arthritis, decreases in serum C-reactive protein (CRP) were observed as early as 1 week after starting treatment with Olumiant and were maintained throughout dosing.
Creatinine
Baricitinib induced a mean increase in serum creatinine levels of 3.8 µmol/L after two weeks of treatment, as compared to placebo, which remained stable thereafter during up to 104 weeks of treatment. This may be due to inhibition of creatinine secretion by baricitinib in the renal tubules. Consequently, estimates of the glomerular filtration rate based on serum creatinine may be slightly reduced, without actual loss of renal function or the occurrence of renal adverse events.
Clinical efficacy
The efficacy and safety of Olumiant once daily was assessed in 4 Phase III randomised, double-blind, multicentre studies in patients with moderate to severe active rheumatoid arthritis diagnosed according to the ACR/EULAR 2010 criteria (see Table 3). Patients over 18 years of age were eligible to participate. The presence of at least 6 tender and 6 swollen joints was required at baseline. All patients who completed these studies were eligible to enrol in a long term extension study for up to 4 years continued treatment.
The RA-BEGIN Study in MTX-naïve patients is supportive for the target population of patients with an inadequate response to, or intolerance to, other DMARDs (section 4.1).
Table 3. Clinical Trial Summary
Abbreviations: QD = Once daily; Q2W = Once every 2 weeks; SC = Subcutaneously; ACR = American College of Rheumatology; SDAI = Simplified Disease Activitity Index; HAQ-DI = Health Assessment Questionnaire-Disability Index; mTSS = modified Total Sharp Score
1 Patients who had received less than 3 doses of Methotrexate (MTX); naïve to other conventional or biologic DMARDs
2 Patients who had an inadequate response to MTX (+/- other cDMARDs); biologic-naïve
3 Patients who had an inadequate response or were intolerant to ≥ 1 cDMARDs; biologic- naïve
4 Patients who had an inadequate response or were intolerant to ≥ 1 bDMARDs; including at least one TNF inhibitor
5 Most common concomitant cDMARDs included MTX, hydroxychloroquine, leflunomide and sulfasalazine
Clinical Response:
In all studies, patients treated with Olumiant 4 mg once daily had statistically significantly higher ACR20, ACR50 and ACR70 response at 12 weeks compared to placebo, MTX or adalimumab (see Table 4).Time to onset of efficacy was rapid across measures with significantly greater responses seen as early as week 1. Continued, durable response rates were observed, with ACR20/50/70 responses maintained for at least 2 years including the long-term extension study.
Treatment with Olumiant 4 mg, alone or in combination with cDMARDs, resulted in significant improvements in all individual ACR components, including tender and swollen joint counts, patient and physician global assessments, HAQ-DI, pain assessment and CRP, compared to placebo or MTX monotherapy. In RA-BEAM, treatment with Olumiant resulted in significant improvement in patient and physician global assessments, HAQ-DI, pain assessment and CRP at Weeks 12, 24 and 52 compared to adalimumab.
In placebo-controlled trials in which MTX was not required, 501 subjects randomized to baricitinib 2 mg or 4 mg received MTX as background therapy, and 303 received conventional DMARDs other than MTX (approximately half with MTX and half without). The most common concomitant DMARDs in these subjects were MTX (79% of patients), hydroxychloroquine (19%), leflunomide (11%), and sulphasalazine (9%). No relevant differences regarding efficacy and safety were observed in subgroups defined by types of concomitant DMARDs used in combination with baricitinib.
Remission and low disease activity
A statistically significantly greater proportion of patients treated with Olumiant 4 mg compared to placebo or MTX achieved remission, as defined by SDAI ≤ 3.3 and CDAI ≤ 2.8, at weeks 12 and 24 (Table 4).
In all 4 studies, a significantly higher proportion of patients treated with Olumiant 4 mg compared to placebo or MTX achieved low disease activity or remission (DAS28-ESR or DAS28-hsCRP ≤ 3.2 and DAS28-ESR or DAS28-hsCRP < 2.6) at Weeks 12 and 24.
Greater rates of remission compared to placebo were observed as early as week 4. Including data from a long-term extension study, remission and low disease activity rates were maintained for at least 2 years.
Table 4: Response, Remission and Physical Function
Note: Proportions of responders at each time point based on those initially randomised to treatment (N). Patients who discontinued or received rescue therapy were considered as non-responders thereafter.
Abbreviations: ADA = adalimumab; MTX = methotrexate; OLU = Olumiant; PBO = Placebo
p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001 vs. placebo (vs. MTX for study RA-BEGIN)
p ≤ 0.05; †† p ≤ 0.01; ††† p ≤ 0.001 vs. adalimumab
Radiographic response
The effect of Olumiant on progression of structural joint damage was evaluated radiographically in studies RA-BEGIN, RA-BEAM and RA-BUILD and assessed using the modified Total Sharp Score (mTSS) and its components, the erosion score and joint space narrowing score.
Treatment with Olumiant 4 mg resulted in a statistically significant inhibition of progression of structural joint damage (Table 5). Analyses of erosion and joint space narrowing scores were consistent with the overall scores. The proportion of patients with no radiographic progression (mTSS change ≤ 0) was significantly higher with Olumiant 4 mg compared to placebo at weeks 24 and 52.
Table 5. Radiographic Changes
Abbreviations: ADA = adalimumab; MTX = methotrexate; OLU = Olumiant; PBO = Placebo
a Placebo data at week 52 derived using linear extrapolation
b No progression defined as mTSS change ≤ 0.
p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001 vs. placebo (vs. MTX for study RA-BEGIN)
Physical function response and health-related outcomes
Treatment with Olumiant 4 mg, alone or in combination with cDMARDs, resulted in a significant improvement in physical function compared to all comparators (placebo, MTX, adalimumab), as measured by HAQ-DI, at 12, 24 and 52 weeks. The proportion of patients achieving a clinically significant improvement (HAQ-DI ≥ 0.30) was also higher with Olumiant compared to placebo or MTX at week 12 (Table 4). Improvements were seen as early as Week 1 and, in studies RA-BEGIN and RA-BEAM, this was maintained for up to 52 weeks.
Treatment with Olumiant 4 mg, alone or in combination with cDMARDs, resulted in a significant improvement in pain compared to all comparators (placebo, MTX, adalimumab), as measured on a 0-100 visual analogue scale, at 12 weeks. Statistically significant pain reduction was seen as early as Week 1 and in studies RA-BEGIN and RA-BEAM this was maintained for up to 52 weeks.
In RA-BEAM and RA-BUILD, treatment with Olumiant 4 mg resulted in a significant improvement in the mean duration and severity of morning joint stiffness compared to placebo or adalimumab as assessed using daily electronic patient diaries for 12 weeks.
In all studies, Olumiant-treated patients reported improvements in patient-reported quality of life, as measured by the Short Form (36) Health Survey (SF-36) Physical Component Score and fatigue, as measured by the Functional Assessment of Chronic Illness Therapy-Fatigue score (FACIT-F).
Olumiant 4 mg vs. 2 mg
Differences in efficacy between the 4 mg and the 2 mg doses were most notable in the bDMARD-IR population (RA-BEACON), in which statistically significant improvements in the ACR components of swollen joint count, tender joint count and ESR were shown for Olumiant 4 mg compared to placebo at Week 24 but not for Olumiant 2 mg compared to placebo. In addition, for both study RA-BEACON and RA-BUILD, onset of efficacy was faster and the effect size was generally larger for the 4 mg dose groups compared to 2 mg.
In a long-term extension study, patients from Studies RA-BEAM, RA-BUILD and RA-BEACON who achieved sustained low disease activity or remission (CDAI ≤ 10) after at least 15 months of treatment with Olumiant 4 mg once daily were re-randomized 1:1 in a double-blind manner to continue 4 mg once daily or reduce dose to 2 mg once daily. The majority of patients maintained low disease activity or remission based on CDAI score:
• At week 12: 234/251 (93%) continuing 4 mg vs. 207/251 (82%) reduced to 2 mg (p ≤ 0.001)
• At week 24: 163/191 (85%) continuing 4 mg vs. 144/189 (76%) reduced to 2 mg (p ≤ 0.05)
• At week 48: 57/73 (78%) continuing 4 mg vs. 51/86 (59%) reduced to 2 mg (p ≤ 0.05)
The majority of patients who lost their low disease activity or remission status after dose reduction could regain disease control after the dose was returned to 4 mg.
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with Olumiant in one or more subsets of the paediatric population in chronic idiopathic arthritis (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
Following oral administration of baricitinib, a dose-proportional increase in systemic exposure was observed in the therapeutic dose range. The PK of baricitinib is linear with respect to time.
Absorption
Following oral administration, baricitinib is rapidly absorbed with a median tmax of approximately 1 hour (range 0.5 - 3.0 h) and an absolute bioavailability of approximately 79% (CV = 3.94%). Food intake led to a decreased exposure by up to 14%, a decrease in Cmax by up to 18% and delayed tmax by 0.5 hours. Administration with meals was not associated with a clinically relevant effect on exposure.
Distribution
Mean volume of distribution following intravenous infusion administration was 76 L, indicating distribution of baricitinib into tissues. Baricitinib is approximately 50% bound to plasma proteins.
Biotransformation
Baricitinib metabolism is mediated by CYP3A4, with less than 10% of the dose identified as undergoing biotransformation. No metabolites were quantifiable in plasma. In a clinical pharmacology study, baricitinib was excreted predominately as the unchanged active substance in urine (69%) and faeces (15%) and only 4 minor oxidative metabolites were identified (3 in urine; 1 in faeces) constituting approximately 5% and 1% of the dose, respectively. In vitro, baricitinib is a substrate for CYP3A4, OAT3, Pgp, BCRP and MATE2-K, and an inhibitor of the transporters OAT1, OAT3, OCT1, OCT2, OATP1B3, BCRP, MATE1 and MATE2-K, but clinically meaningful interactions with medicines that are substrates for these transporters are unlikely, with the exception of OCT1 substrates. (see section 4.5)
Elimination
Renal elimination is the principal mechanism for baricitinib's clearance through glomerular filtration and active secretion via OAT3, Pgp, BCRP and MATE2-K. In a clinical pharmacology study, approximately 75% of the administered dose was eliminated in the urine, while about 20% of the dose was eliminated in the faeces. Mean apparent clearance (CL/F) and half-life in patients with rheumatoid arthritis was 9.42 L/hr (CV = 34.3%) and 12.5 hrs (CV = 27.4%), respectively. Cmax and AUC at steady state are 1.4- and 2.0–fold higher, respectively, in subjects with rheumatoid arthritis compared to healthy subjects.
Renal Impairment
Renal function was found to significantly affect baricitinib exposure. The mean ratios of AUC in patients with mild and moderate renal impairment to patients with normal renal function are 1.41 (90% CI: 1.15-1.74) and 2.22 (90% CI: 1.81-2.73), respectively. The mean ratios of Cmax in patients with mild and moderate renal impairment to patients with normal renal function are 1.16 (90%CI: 0.92-1.45) and 1.46 (90%CI: 1.17-1.83), respectively. See section 4.2 for dose recommendations.
Hepatic Impairment
There was no clinically relevant effect on the PK of baricitinib in patients with mild or moderate hepatic impairment. The use of baricitinib has not been studied in patients with severe hepatic impairment.
Elderly
Age ≥ 65 years or ≥ 75 years has no effect on baricitinib exposure (Cmax and AUC).
Paediatric population
The safety, efficacy and pharmacokinetics of baricitinib have not yet been established in a paediatric population (see section 4.2).
Other intrinsic Factors
Body weight, sex, race, and ethnicity did not have a clinically relevant effect on the PK of baricitinib. The mean effects of intrinsic factors on PK parameters (AUC and Cmax) were generally within the inter-subject PK variability of baricitinib. Therefore, no dose adjustment is needed based on these patient factors.
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, genotoxicity and carcinogenic potential.
Decreases in lymphocytes, eosinophils and basophils as well as lymphoid depletion in organs/tissues of the immune system were observed in mice, rats and dogs. Opportunistic infections related to demodicosis (mange) were observed in dogs at exposures approximately 7 times the human exposure. Decreases in red blood cell parameters were observed in mice, rats and dogs at exposures approximately 6 to 36 times the human exposure. Degeneration of the sternal growth plate was observed in some dogs, at low incidence and also in control animals, but with a dose-effect relationship regarding severity. At present it is not known whether this is clinically relevant.
In rat and rabbit reproductive toxicology studies, baricitinib was shown to reduce foetal growth/weight and produce skeletal malformations (at exposures of approximately 10 and 39 times the human exposure, respectively). No adverse foetal effects were observed at exposures 2 times the human exposure based on AUC.
In a combined male/female rat fertility study, baricitinib decreased overall mating performance (decreased fertility and conception indices). In female rats there were decreased numbers of corpora lutea and implantation sites, increased pre-implantation loss, and/or adverse effects on intrauterine survival of the embryos. Since there were no effects on spermatogenesis (as assessed by histopathology) or semen/sperm endpoints in male rats, the decreased overall mating performance was likely the result of these female effects.
Baricitinib was detected in the milk of lactating rats. In a pre- and postnatal development study, decreased pup weights and decreased postnatal survival were observed at exposures 4 and 21 times, respectively, the human exposure.
6. Pharmaceutical particulars
6.1 List of excipients
Tablet cores
• cellulose, microcrystalline
• croscarmellose sodium
• magnesium stearate
• mannitol
Film coating
• iron oxide red (E172)
• lecithin (soya) (E322)
• macrogol
• poly (vinyl alcohol)
• talc
• titanium dioxide (E171)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
2 years.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
Polyvinylchloride/polyethylene/polychlorotrifluoroethylene - aluminium blisters in cartons of 14, 28, 35, 56, 84 or 98 film-coated tablets.
Polyvinylchloride/aluminium/oriented polyamide - aluminium perforated unit dose blisters in cartons of 28 x 1 or 84 x 1 film-coated tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
No special requirements for disposal.
7. Marketing authorisation holder
Eli Lilly Nederland B.V., Papendorpseweg 83, 3528BJ Utrecht, The Netherlands.
8. Marketing authorisation number(s)
Olumiant 2 mg film-coated tablets
EU/1/16/1170/001
 14 tablets
EU/1/16/1170/002
 28 tablets
EU/1/16/1170/003
 28 x 1 tablets (unit dose)
EU/1/16/1170/004
 35 tablets
EU/1/16/1170/005
 56 tablets
EU/1/16/1170/006
 84 tablets
EU/1/16/1170/007
 84 x 1 tablets (unit dose)
EU/1/16/1170/008
 98 tablets
Olumiant 4 mg film-coated tablets
EU/1/16/1170/009
 14 tablets
EU/1/16/1170/010
 28 tablets
EU/1/16/1170/011
 28 x 1 tablets (unit dose)
EU/1/16/1170/012
 35 tablets
EU/1/16/1170/013
 56 tablets
EU/1/16/1170/014
 84 tablets
EU/1/16/1170/015
 84 x 1 tablets (unit dose)
EU/1/16/1170/016
 98 tablets
9. Date of first authorisation/renewal of the authorisation
Date of first Authorisation: 13 February 2017
10. Date of revision of the text
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.
https://www.medicines.org.uk/emc/medicine/32997