Consumer medicine information

Remicade

Infliximab

BRAND INFORMATION

Brand name

Remicade

Active ingredient

Infliximab

Schedule

What is in this leaflet

This leaflet answers some common questions about REMICADE. It does not contain all the available information. It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you using REMICADE against the benefits it is expected to have for you.

If you have any concerns about being given this medicine, ask your doctor or pharmacist.

Keep this leaflet. You may need to read it again.

What REMICADE is used for

REMICADE contains the active ingredient, infliximab. Infliximab is a monoclonal antibody that is produced from human and mouse proteins by recombinant technology. Monoclonal antibodies are proteins that recognise and bind to certain special proteins in the body.

Infliximab acts by binding to a special protein in the body called tumour necrosis factor alpha (TNFα). In people with diseases such as Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and psoriasis, the body produces too much TNFα, which can cause the body's immune system to attack normal healthy parts of the body. REMICADE can block the damage caused by too much TNFα.

Rheumatoid arthritis
Rheumatoid arthritis is an inflammatory disease of the joints. REMICADE is used to reduce the signs and symptoms of rheumatoid arthritis and to prevent damage to the joints. You will also be given a disease-modifying medicine called methotrexate.

Ankylosing Spondylitis
Ankylosing spondylitis is an inflammatory disease of the spine. REMICADE can reduce the signs and symptoms of ankylosing spondylitis, thereby improving physical function.

Psoriatic arthritis
Psoriatic arthritis is an inflammatory disease of the joints in which psoriasis usually occurs in association with arthritis. Often the fingers and toes are affected, although it may occur in other parts of the body. REMICADE is used to reduce the signs and symptoms of psoriatic arthritis and improve the physical function in adults who have not responded well enough to previous treatments with other disease-modifying anti-rheumatic drugs (DMARDS). REMICADE may be given alone or in combination with methotrexate.

Psoriasis
Psoriasis is an inflammatory disease of the skin. REMICADE is used to treat patients with moderate to severe psoriasis who have not responded well enough to treatments such as phototherapy or conventional systemic treatments, or when these treatments are not appropriate.

Crohn's disease
Crohn's disease is a chronic inflammatory disease of the bowel. It may also affect any part of the gut. REMICADE is used to treat moderate to severe Crohn's disease in adult patients and in children and adolescent patients (6 to 17 years old) who have not responded well enough to other treatments.

REMICADE can also reduce the number of abnormal openings from the bowel through the skin (called draining enterocutaneous fistula), a common complication of Crohn's disease.

Ulcerative Colitis
Ulcerative colitis is an inflammatory disease of the bowel. REMICADE is used to treat the signs and symptoms of ulcerative colitis in adult patients and in children and adolescent patients (6 to 17 years old) who have not responded well enough to other treatments.

Do not give REMICADE to children with Crohn's disease or ulcerative colitis who are younger than 6 years.

Do not give REMICADE to children and adolescents with any other disease.

Your doctor, however, may prescribe REMICADE for another purpose.

Ask your doctor if you have any questions about why REMICADE has been prescribed for you.

Before you are given REMICADE

When you must not be given it

Do not use REMICADE if you have an allergy to mouse proteins or any of the ingredients listed at the end of this leaflet.

Some of the symptoms of an allergic reaction to REMICADE may include skin rash, hives, fatigue, wheezing, difficulty in breathing, and/or low blood pressure.

Do not use REMICADE if you have severe infections such as tuberculosis and infected abscesses, a repeating infection or have had repeating infections.

Do not use REMICADE if you are already taking another medicine for arthritis, which contains the substance called anakinra.

If you have never been given REMICADE and have congestive heart failure, you should not use it.

Before you are given it

Tell your doctor if you:

currently have an infection, or if you are prone to infections, or if you have a history of infections
REMICADE may affect the normal immune response. You might get infections more easily. Some cases of serious infections, including tuberculosis (TB) and sepsis have been reported in patients treated with REMICADE.
have ever had or been in close contact with TB, even if you were treated for it.
have ever had or had been in close contact with hepatitis B
Reactivation of hepatitis B have been reported in people treated with TNFα blockers. However, these reports are very rare.
have lived in or travelled to an area where fungal infections called histoplasmosis, coccidioidomycosis, or blastomycosis are common. Ask your doctor if you don't know if these infections are common in the area in which you have lived in or travelled to.
These infections are caused by fungus that can affect the lungs or other parts of your body.
have had cancer
A type of blood cancer called lymphoma has been reported in patients receiving TNF blockers. The reports are rare but are more frequent than expected for people in general. Cancers, other than lymphoma, have also been reported.
have moderate to severe chronic obstructive pulmonary disease (COPD)
Lung, head, neck and other cancers have been reported in patients with a history of heavy smoking.
have a long history of Crohn's disease, rheumatoid arthritis, ankylosing spondilitis or psoriatic arthritis, especially if you have a highly active disease and/or have been taking medicine that reduces the activity of the body's natural defences.
You may be more likely to develop infections and lymphomas than people in general, even without receiving TNF blockers such as REMICADE.
are pregnant or plan to become pregnant
Like most medicines, REMICADE is not recommended in pregnancy.
You must use adequate contraception to avoid falling pregnant during REMICADE treatment and for at least 6 months after the last infusion.
are breast-feeding
REMICADE passes into breastmilk. Talk to your doctor about the best way to feed your baby.
have or have had a disease that affects the nervous system such as multiple sclerosis and seizures, or if you experience any numbness, weakness, tingling, or sight disturbances.
suffer from congestive heart failure.
Steps must be taken to monitor any changes to your condition during treatment with REMICADE.
have ongoing blood disorders or a history of blood disorders.
have recently received or are scheduled to receive any vaccines
Patients receiving REMICADE should not receive live vaccines. If possible, you should have all of your vaccines brought up to date before starting treatment with REMICADE.
have recently received or are scheduled to receive treatment with a therapeutic infectious agent (such as BCG instillation used for the treatment of cancer).

Your doctor will discuss with you the benefits of using REMICADE against the potential risks.

Taking or being given other medicines

Tell your doctor if you are taking any other medicines, including any that you buy without a prescription from your pharmacy, supermarket or health food shop. Some medicines may affect the way other medicines work.

Do not use REMICADE is you are already taking another medicine for arthritis, which contains the substance called anakinra.

Tell your doctor if you are already taking another medicine for arthritis, which contains the substance called abatacept.

Tell your doctor if you are receiving other treatments

for rheumatoid arthritis
for ankylosing spondylitis
for psoriatic arthritis
for psoriasis, such as phototherapy or other treatments
for Crohn's disease
for ulcerative colitis
to prevent rejection in organ transplantation.

Tell your doctor you are taking REMICADE before receiving any vaccinations. While using REMICADE you should not receive live vaccines. If possible, you should have all of your vaccines brought up to date before starting treatment with REMICADE. If you have a baby or if you are breast-feeding while you are using REMICADE, tell your baby’s doctor about your REMICADE use before the baby receives any vaccines, including live vaccines such as the BCG vaccine (used to prevent tuberculosis) and rotavirus vaccine. Live vaccines should not be given to your baby while you are breast-feeding unless your baby doctor recommends otherwise.

Your doctor or pharmacist will be able to tell you what to do when being given REMICADE with other medicines.

How REMICADE is given

REMICADE is only available on prescription. REMICADE is given in a drip into a vein (called an infusion) over at least 2 hours.

If you were able to tolerate the first 3 two-hour infusions, your doctor may decide to give your next REMICADE infusion over a period of not less than 1 hour.

For children and adolescents (6-17 years) the infusion is given over at least 2 hours.

A period of observation follows treatment.

Rheumatoid arthritis
The recommended starting dose is an infusion of 3 mg/kg. You will get additional doses of 3 mg/kg at 2 and 6 weeks after your first infusion and then every 8 weeks after that.

If, after 12 weeks of treatment, your arthritis does not respond well enough to the 3 mg/kg dose, your doctor may decide to gradually increase your dose to a maximum of 7.5 mg/kg every 8 weeks.

You will also be taking methotrexate as part of your treatment.

Ankylosing Spondylitis
The recommended starting dose is an infusion of 5 mg/kg. You will get additional doses of 5 mg/kg at 2 and 6 weeks after your first infusion and then every 6 weeks after that.

Psoriatic arthritis
The recommended starting dose is an infusion of 5 mg/kg. You will receive additional doses of 5 mg/kg at 2 and 6 weeks after your first infusion, then every 8 weeks after that.

REMICADE may be given alone or in combination with methotrexate.

Psoriasis
The recommended starting dose is an infusion of 5 mg/kg. You will get additional doses of 5 mg/kg at 2 and 6 weeks after your first infusion, and then every 8 weeks after that.

Crohn's disease
The recommended starting dose for Crohn's disease in adults and in children and adolescents (6 to 17 years); and for closure of fistula in adult patients is an initial infusion of 5 mg/kg followed by additional doses of 5 mg/kg at 2 and 6 weeks after your first infusion, and then every 8 weeks after that. In some cases, your doctor may decide to increase your dose up to 10 mg/kg.

Ulcerative colitis
The recommended starting dose for ulcerative colitis in adults and in children and adolescents (6 to 17 years) is an infusion of 5 mg/kg. You will get additional doses of 5 mg/kg at 2 and 6 weeks after your first infusion, and then every 8 weeks after that.

What do I do if I receive too much? (overdose):

As REMICADE is being given to you under the supervision of your doctor it is very unlikely you will receive too much.

If you think you or anybody else has been given too much REMICADE, contact your doctor, pharmacist or the Poisons Information Centre who will advise you what to do, or go to Accident and Emergency at your nearest hospital.

Poisons Information Centre telephone numbers:

Australia: 13 11 26

New Zealand: (03) 474 7000

Keep these telephone numbers handy.

While you are being given REMICADE

Things you must do

Tell your doctor, nurse or pharmacist if the medicine starts to upset you or your symptoms become worse.

Tell your doctor or dentist that you are being treated with REMICADE before you undergo any surgical procedures.

Tell your doctor:

if symptoms of TB (persistent cough, weight loss, listlessness, fever), or any other infection appear. Do this immediately.
if symptoms of hepatitis B (upset stomach, loss of appetite, vomiting, tiredness, dark yellow or brown urine, and yellow eyes or skin) appear. You must do this immediately.
that you are taking REMICADE before receiving any vaccinations.
Live vaccines should not be given while you are being treated with REMICADE.

You should continue to take adequate contraceptive measures to avoid pregnancy.

If you have a baby or if you are breast-feeding while you are using REMICADE, tell your baby’s doctor about your REMICADE use before the baby receives any vaccines, including live vaccines. Live vaccines should not be given to your baby while you are breast-feeding unless your baby doctor recommends otherwise.

Severely decreased numbers of white blood cells have also been reported in infants born to women treated with REMICADE during pregnancy. If your baby has continual fevers or infections, contact your baby’s doctor immediately.

Things to be careful of

Tell your doctor if you think you have an infection. REMICADE may affect the normal immune response. There is a possibility that you may be more prone to infections. You will be watched closely for signs of infection.

Tell your doctor immediately if you develop a skin rash or hives. Your doctor may discontinue REMICADE until the symptoms go away and then begin giving the medicine again. Symptoms will resolve with appropriate treatment.

If you suffer from congestive heart failure, tell your doctor immediately if your condition worsens.

REMICADE is unlikely to make you drowsy. If you are tired, do not drive a car or work with machinery.

Side effects

Tell your doctor, nurse, or pharmacist as soon as possible if you do not feel well while you are being given REMICADE.

All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Generally, patients with rheumatoid arthritis, Crohn's disease, ankylosing spondylitis, psoriatic arthritis, or psoriasis already take several medicines to treat their disease. These medicines may themselves cause side effects.

If you get additional side effects or any new symptoms, please tell your doctor.

Ask your doctor or pharmacist to answer any questions you may have.

Do not be alarmed by the following list of possible side effects. You may not experience any of them.

During the infusion of REMICADE the following reactions may occur:

fever or chills
itchiness or hives
chest pain
low blood pressure
high blood pressure
shortness of breath.

These reactions are more likely to occur during the first and second infusion but may also appear up to six months after the last infusion.

Tell your doctor immediately if you notice any of the following:

pain or tenderness in chest, muscles, joints or jaw
swelling of the hands, feet, ankles, face, lips, mouth or throat, which may cause difficulty in swallowing or breathing
fever
muscle pains
joint pains
tiredness
abnormal chest sounds
rash
itching
symptoms that may indicate heart failure, e.g. shortness of breath, especially with exercise or lying down, or swelling of your feet.

Tell your doctor or nurse as soon as possible if you notice any of the following:

headache
nausea or vomiting
dizziness and light-headedness
fatigue
fever
rash
hives
itching
sore throat
coughing
respiratory infections (such as bronchitis, sinus infections, cold)
hoarseness
shortness of breath
chest pain
back pain
muscle pain
abdominal pain
indigestion
diarrhoea
weight loss, muscle wasting
problems with urination
changes in the way your heart beats, for example, if you notice it beating faster
flushing
dry skin or increased sweating
fluid retention
new onset of psoriasis, mainly on the soles of the feet and on palms
worsening of rheumatoid arthritis.

There have been very rare cases where people taking REMICADE have developed liver problems. Signs that you could be having a problem include:

jaundice (skin and eyes turning yellow)
dark-brown coloured urine
right-sided abdominal pain
fever
severe fatigue (tiredness).

You should contact your doctor immediately if you develop any of these symptoms.

Tell your doctor if you notice any other effects.

Most of the side effects are mild to moderate in severity. Other side effects not listed above may also occur in some patients. Some side effects may appear up to six months after the last infusion.

Cancers
In clinical studies, more cancers were seen in patients who received TNF-blockers, including REMICADE, than patients who did not receive these treatments.

In children and adults being treated with TNF-blockers, the chances of getting lymphoma or other cancers may increase. It should be noted, however, that patients with longstanding and active rheumatoid arthritis or Crohn's disease may already have a higher risk for developing cancers even without TNF-blockers, making it difficult to estimate the risk of developing cancers in these patients. Nevertheless, the role of TNF-blockers in the development of cancers cannot be excluded.

A rare type of cancer called Hepatosplenic T-cell Lymphoma (HSTCL) has been reported rarely in adolescents and young adults with Crohn's disease or ulcerative colitis who have received REMICADE. All of these patients were also receiving drugs known as azathioprine or 6-mercaptopurine. No cases of HSTCL have been reported in patients receiving REMICADE only. HSTCL often results in death. The role of TNF blockers in the development of cancers in children and adolescents remain unclear.

Talk to your doctor if you are concerned about this.

Skin cancers (T cell lymphoma, mycosis fungoides, melanoma and Merkel cell carcinoma) have been reported rarely in patients treated with TNF-blockers, including REMICADE.

Tell your doctor if you notice any new skin lesions during or after therapy or if existing lesions change appearance.

Cervical cancer may occur more frequently in women treated with REMICADE. Periodic screening of women treated with REMICADE should continue.

Patients with a lung disease called Chronic Obstructive Pulmonary Disease and who have a history of heavy smoking may have an increased risk for getting cancer while being treated with REMICADE.

After REMICADE has been stopped

Tell your doctor immediately if:

you notice any of the following side effects, even if they occur several weeks after stopping treatment with REMICADE.
- skin rash or hives
- frequent infections
symptoms of TB (persistent cough, weight loss, listlessness, fever), or any other infection appear.
symptoms of hepatitis B (upset stomach, loss of appetite, vomiting, tiredness, dark yellow or brown urine, and yellow eyes or skin) appear.

These symptoms may appear several months after your last REMICADE treatment.

You should continue to take adequate contraceptive measures to avoid pregnancy for at least 6 months after the last infusion of REMICADE.

Tell your doctor if you notice any other effects.

Storage

REMICADE should be stored at 2°C to 8°C (Refrigerate.) Do not use beyond the expiry date.

REMICADE may be stored at temperatures up to a maximum of 30°C for a single period of up to 12 months; but not exceeding the original expiration date. The new expiration date should be written on the carton. Upon removal from refrigerated storage, REMICADE cannot be returned to refrigerated storage.

REMICADE vials are for single use only. Any unused portion should be discarded.

Product description

What it looks like

REMICADE comes as a white powder in a glass vial.

Ingredients

Active ingredient:

Infliximab (recombinant) 100 mg per vial

Inactive ingredients:

sodium phosphate monobasic monohydrate
sodium phosphate dibasic dihydrate
sucrose
polysorbate 80

Supplier

JANSSEN-CILAG Pty Ltd
1-5 Khartoum Road
Macquarie Park NSW 2113 Australia
Telephone: 1800 226 334

Australian Registration Number

AUST R 73827

Date of Preparation:

6 December 2022

Published by MIMS February 2023

BRAND INFORMATION

Brand name

Remicade

Active ingredient

Infliximab

Schedule

1 Name of Medicine

Infliximab.

2 Qualitative and Quantitative Composition

Remicade 100 mg powder for injection.
Each vial of Remicade contains 100 mg of infliximab, a chimeric human murine IgG1 monoclonal antibody produced in murine hybridoma cells by recombinant DNA technology.
Remicade Powder for Injection is to be reconstituted with sterile water for injections and further diluted in 0.9% sodium chloride solution for infusion. After reconstitution, each vial of Remicade contains infliximab 100 mg/10 mL.
For a full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Powder for injection.
The powder is a white solid, with no evidence of meltback; free of foreign particles.

4 Clinical Particulars

4.1 Therapeutic Indications

Rheumatoid arthritis in adults.

Remicade, in combination with methotrexate, is indicated for the reduction of signs and symptoms and prevention of structural joint damage (erosions and joint space narrowing) in:
patients with active disease despite treatment with methotrexate;
patients with active disease who have not previously received methotrexate.
Remicade should be given in combination with methotrexate. Efficacy and safety in rheumatoid arthritis have been demonstrated only in combination with methotrexate.

Ankylosing spondylitis.

Remicade is indicated for the reduction of signs and symptoms and improvement in physical function in patients with active disease.

Psoriatic arthritis.

Remicade is indicated for the treatment of the signs and symptoms, as well as for the improvement in physical function in adult patients with active and progressive psoriatic arthritis who have responded inadequately to disease modifying antirheumatic drug (DMARD) therapy. Remicade may be administered in combination with methotrexate.

Psoriasis.

Remicade is indicated for the treatment of adult patients with moderate to severe plaque psoriasis for whom phototherapy or conventional systemic treatments have been inadequate or are inappropriate. Safety and efficacy beyond 12 months have not been established.

Crohn's disease in adults and in children and adolescents (6 to 17 years).

Remicade is indicated for the treatment of moderate to severe Crohn's disease to reduce the signs and symptoms and to induce and maintain clinical remission in patients who have an inadequate response to conventional therapies.

Refractory fistulising Crohn's disease.

Remicade is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients.

Ulcerative colitis in adults and in children and adolescents (6 to 17 years).

Remicade is indicated for the treatment of moderately severe to severe active ulcerative colitis in patients who have had an inadequate response to conventional therapy.

4.2 Dose and Method of Administration

Remicade is administered by intravenous infusion.
Remicade is for intravenous use in adults across all indications. Remicade is approved for intravenous use in children and adolescents (6 to 17 years) for the indication of Crohn's disease and ulcerative colitis.
Remicade treatment is to be administered under the supervision of specialised physicians experienced in the diagnosis and treatment of rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel diseases, psoriasis or psoriatic arthritis.
For adult and paediatric patients, administer the infusion solution over a period of not less than 2 hours.
All patients administered Remicade are to be observed for at least one to two hours postinfusion for side effects. Medications, an artificial airway and other appropriate materials must be available for the treatment of these effects (see Section 4.4 Special Warnings and Precautions for Use).

Shortened infusions across adult indications.

In carefully selected adult patients who have tolerated at least 3 initial 2 hour infusions of Remicade (induction phase) and are receiving maintenance therapy, consideration may be given to administering subsequent infusions over a period of not less than 1 hour. If an infusion reaction occurs in association with a shortened infusion time, then a slower infusion rate should be considered for future infusions if treatment is to be continued. For doses greater than 6 mg/kg, data only support administering an infusion over a period of not less than two hours.

Rheumatoid arthritis in adults.

Patients not previously treated with Remicade: initially 3 mg/kg intravenous infusion is to be followed with additional 3 mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter.
Remicade should be given in combination with methotrexate.
To optimise clinical response, consideration may be given to adjusting the dose in increments of 1.5 mg/kg up to a maximum of 7.5 mg/kg.
Available data suggest that the clinical response is usually achieved within 12 weeks of treatment. If a patient has an inadequate response or loses response after this period, the dose may be adjusted as described above. If adequate response is achieved, patients should be continued on the selected dose or dose frequency. Continued therapy should be carefully reconsidered in patients who show no evidence of therapeutic benefit within the first 12 weeks of treatment or after dose adjustment.

Ankylosing spondylitis.

5 mg/kg given as an intravenous infusion followed by additional 5 mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 6 weeks thereafter.

Psoriatic arthritis.

5 mg/kg given as an intravenous infusion followed by additional 5 mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter. Efficacy and safety have been demonstrated alone or in combination with methotrexate.

Psoriasis.

5 mg/kg given as an intravenous infusion followed by additional 5 mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter.

Crohn's disease.

Moderate to severe Crohn's disease in adults and in children and adolescents (6 to 17 years).

For optimal long-term symptom control, 5 mg/kg given as a single intravenous infusion as an induction regimen at 0, 2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter. For patients who have an incomplete response during maintenance treatment, consideration may be given to adjusting the dose up to 10 mg/kg.
Paediatric Crohn's disease patients who have had their dose adjusted to greater than 5 mg/kg every 8 weeks, may be at greater risk for adverse reactions. Continued therapy with the adjusted dose should be carefully considered in patients who show no evidence of additional therapeutic benefit after dose adjustment.
Available data do not support further infliximab treatment in children and adolescent patients (6-17 years) not responding within 10 weeks to the initial infusion.

Refractory fistulising Crohn's disease.

5 mg/kg given as a single intravenous infusion as an induction regimen at 0, 2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks thereafter. If a patient does not respond after the initial 3 dose induction regimen, no additional treatment with infliximab should be given.
For patients who respond and then lose their response, consideration may be given to treatment with 10 mg/kg.
There are no efficacy and safety data on the use of infliximab for the treatment of refractory fistulising Crohn's disease beyond 54 weeks.

Ulcerative colitis in adults and in children and adolescents (6 to 17 years).

5 mg/kg given as an intravenous infusion followed by additional 5 mg/kg infusion dose at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter.
If patients have not responded to the initial three treatment infusion regimen at weeks 0, 2 and 6 weeks, then careful consideration should be given before persisting with further treatment.
Available data do not support further infliximab treatment in children and adolescent patients (6-17 years) not responding within 8 weeks to the initial infusion.

Readministration for Crohn's disease, refractory fistulising Crohn's disease and rheumatoid arthritis.

Readministration of a liquid formulation of infliximab, which is no longer in use, with a drug free interval of 2 to 4 years following a previous infusion has been associated with a delayed hypersensitivity reaction in 10 patients with Crohn's disease (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).
After a drug free interval of 16 weeks to 2 years, the risk of delayed hypersensitivity following readministration is not known. Therefore, after a drug free interval of 16 weeks, readministration is not recommended.

Readministration for ankylosing spondylitis.

Data supporting readministration, other than every 6 weeks, are not available at this time (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).

Readministration for psoriatic arthritis.

Data supporting readministration, other than every 8 weeks, are not available at this time (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).

Readministration for psoriasis.

Experience from intermittent treatment with Remicade in psoriasis after a period of no treatment suggests reduced efficacy and a higher incidence of infusion reactions when compared to the approved dosing guidance (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).

Readministration for ulcerative colitis.

Preparation and administration.

1. No physical biochemical compatibility studies have been conducted to evaluate the coadministration of Remicade with other agents. Remicade should not be infused concomitantly in the same intravenous line with other agents.
2. Calculate the dose and the required number of Remicade vials. Under aseptic conditions, reconstitute each vial with 10 mL of preservative free sterile water for injections using a syringe equipped with a 21 gauge or smaller needle. Upon reconstitution, each mL of reconstituted solution contains 10 mg of infliximab. Remove flip top from the vial and wipe the top with a 70% alcohol swab. Insert the syringe into the vial through the centre of the rubber stopper and direct the stream of sterile water for injections to the glass wall of the vial. Foaming during reconstitution is not unusual. Avoid prolonged or vigorous agitation. Do not shake the vial. Swirl gently until the lyophilised cake is completely dissolved. Allow the reconstituted solution to stand for 5 minutes. Because Remicade is a protein, the solution may develop a few fine translucent particles that do not affect its potency. The solution should be colourless to light yellow and opalescent. After reconstitution, the vials should be used immediately.
3. Further dilute the Remicade dose to a final volume of 250 mL with 0.9% sodium chloride solution for infusion in either a 250 mL glass infusion bottle or infusion bag. Do not dilute the reconstituted Remicade solution with any other diluent. Withdraw and discard a volume of 0.9% sodium chloride solution for infusion equal to the volume of the reconstituted Remicade dose; then, slowly add the Remicade to the bottle or bag of infusion solution. Gently mix. Depending on the number of Remicade vials used, the final concentration may range from 0.4 mg/mL to 4 mg/mL. For volumes greater than 250 mL, either use a larger infusion bag (e.g. 500 mL, 1000 mL) or use multiple 250 mL infusion bags to ensure that the concentration of the infusion solution does not exceed 4 mg/mL.
4. The solution for infusion must be administered over a period of not less than the infusion time recommended for the specific indication. Use only an infusion set with an in line, sterile, nonpyrogenic, low protein binding filter (pore size 1.2 micrometre or less).
5. Remicade infusion solution diluted in 0.9% sodium chloride is biochemically stable for 24 hours when stored between 2°C and 30°C. However, since no preservative is present, it is recommended the infusion begin within 3 hours after preparation and the solution not be stored for reuse. To reduce microbiological hazard, use as soon as practicable after reconstitution. If storage is necessary, hold at 2 to 8°C for no more than 24 hours. This product is for single use only and any unused portion of the solution should be discarded.
6. Parenteral drug products should be inspected visually for particulate matter or discolouration prior to administration. If opaque particles, discolouration or other foreign particulates are observed, the solution should not be used.

Traceability.

In order to improve the traceability of biological medicinal products, the trade name and the batch number of the administered product should be clearly recorded (or stated) in the patient file.

4.3 Contraindications

Remicade is contraindicated in patients with severe infections such as sepsis, abscesses, tuberculosis and opportunistic infections.
Remicade should not be given to patients with a history of hypersensitivity to infliximab (see Section 4.8 Adverse Effects (Undesirable Effects)), to other murine proteins or to any excipient of the product.
Concurrent administration of Remicade and anakinra (an interleukin-1 receptor antagonist) is contraindicated.
Do not initiate therapy in patients with congestive heart failure.

4.4 Special Warnings and Precautions for Use

Risk of infections.

Bacterial (including sepsis and pneumonia), mycobacterial [including tuberculosis (frequently disseminated or extrapulmonary at clinical presentation)], invasive fungal, viral, and other opportunistic infections have been observed in patients receiving Remicade. Some of these infections have been fatal.
Tumour necrosis factor alpha (TNFα) mediates inflammation and modulates cellular immune response. Experimental data show that TNFα is essential for the clearing of intracellular infections. Clinical experience shows that host defence against infection is compromised in some patients treated with infliximab.
In clinical studies in rheumatoid arthritis, starting Remicade therapy with doses higher than 3 mg/kg has been associated with an increased risk of infection compared to the risk of infection associated with the starting dose of 3 mg/kg. This increase in the risk of infection was not evident in patients receiving the starting regimen of 3 mg/kg at weeks 0, 2 and 6 and subsequently receiving higher or more frequent doses. However, caution should be exercised when continuing a rheumatoid arthritis patient on doses above 3 mg/kg or administering infliximab more frequently than every 8 weeks.
Remicade should not be given to patients with a clinically important, active infection. Caution should be exercised when considering the use of Remicade in patients with a chronic infection or a history of recurrent infection. Patients should be advised of and avoid exposure to potential risk factors for infection as appropriate.
Opportunistic infections including tuberculosis, viral infections, invasive fungal infections and other serious infections including sepsis and pneumonia have been reported in patients treated with infliximab (see Section 4.8 Adverse Effects (Undesirable Effects)).
Serious infections, including sepsis and fatal infections, have been reported in patients receiving TNF-blocking agents. Many of the serious infections in patients treated with Remicade have occurred in patients on concomitant immunosuppressive therapy that, in addition to their Crohn's disease or rheumatoid arthritis, could predispose them to infections.
Patients who have clinically manifested infections and/or abscesses must be treated for these conditions prior to treatment with Remicade as Remicade should not be given to patients with a clinically important, active infection.

Tuberculosis.

Tuberculosis (frequently disseminated or extrapulmonary at clinical presentation), has been observed in patients receiving Remicade. Patients must be evaluated for the risk of tuberculosis (including close contact with a person with active tuberculosis) and tested for latent tuberculosis, prior to initiation of Remicade. This evaluation should include a detailed medical history with personal history of tuberculosis or possible previous contact with tuberculosis and previous and/or current immunosuppressive therapy. Appropriate screening tests, i.e. tuberculin skin test and chest X-ray, should be performed in all patients. Prescribers are reminded of the risk of false negative tuberculin skin test results especially in patients who are severely ill or immunocompromised. If active tuberculosis is diagnosed, Remicade therapy must not be initiated (see Section 4.3 Contraindications). If latent tuberculosis is diagnosed, treatment must be initiated prior to treatment with Remicade, in accordance with local recommendations. Use of antituberculosis therapy should also be considered before the initiation of Remicade in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed. Patients must be monitored closely for infections, including miliary tuberculosis, while on and after treatment with Remicade.
Use of antituberculosis therapy should be considered before the initiation of Remicade in patients who have several or highly significant risk factors for tuberculosis infection and have a negative test for latent tuberculosis.
The decision to initiate antituberculosis therapy in these patients should only be made following consultation with a physician with expertise in the treatment of tuberculosis and taking into account both the risk for latent tuberculosis infection and the risks of antituberculosis therapy.
Cases of active tuberculosis have occurred in patients treated with Remicade during and after treatment for latent tuberculosis. Patients receiving Remicade should be monitored closely for signs and symptoms of active tuberculosis during and after treatment, including patients who tested negative for latent tuberculosis. All patients should be informed to seek medical advice if signs/symptoms suggestive of tuberculosis (e.g. persistent cough, wasting/weight loss, low grade fever) appear during or after Remicade treatment.

Invasive fungal infections.

For patients who have resided in or travelled to regions where invasive fungal infections such as histoplasmosis, coccidioidomycosis, or blastomycosis are endemic, the benefits and risks of Remicade treatment should be carefully considered before initiation or continuation of Remicade therapy.
In patients treated with Remicade, an invasive fungal infection such as aspergillosis, candidiasis, pneumocystosis, histoplasmosis, coccidioidomycosis or blastomycosis should be suspected if they develop a serious systemic illness. Invasive fungal infections may present as disseminated rather than localized disease, and antigen and antibody testing may be negative in some patients with active infection. Appropriate empiric antifungal therapy should be considered while a diagnostic workup is being performed. The decision to administer empiric antifungal therapy should be made, if feasible, in consultation with a physician with expertise in the diagnosis and treatment of invasive fungal infections and should take into account both the risk for severe fungal infection and the risks of antifungal therapy.

Other infections.

Invasive fungal infections and other opportunistic infections have been observed in patients receiving Remicade. Caution should be exercised when considering the use of Remicade in patients with a chronic infection or a history of recurrent infection. Patients must be monitored closely for infections while on and after treatment with Remicade. Suppression of TNFα may also mask symptoms of infection such as fever. Patients who develop a serious new infection while undergoing treatment with Remicade should be treated for the infection as quickly as possible and monitored closely. During treatment with infliximab patients should be carefully monitored for respiratory tract and urinary tract infections. Treatment with Remicade must be discontinued if a patient develops a serious infection or sepsis. As the elimination of Remicade may take up to six months, a close monitoring of the patients throughout this period is important.
The use of TNFα blocking agents in patients with chronic viral infections such as HIV, Hepatitis B or C has not been studied. Therefore, Remicade should not be given to these patients.
Patients with fistulising Crohn's disease with acute suppurative fistulas should not initiate Remicade therapy until a source for possible infection, specifically abscess, has been excluded (see Section 4.3 Contraindications).
There is limited safety experience of surgical procedures in Remicade treated patients. A patient who requires surgery while on Remicade should be closely monitored for infections, and appropriate actions should be taken.

Use in patients with congestive heart failure.

Do not initiate therapy in patients with congestive heart failure (see Section 4.3 Contraindications).
Treatment should be discontinued in patients whose congestive heart failure is worsening.
Treatment discontinuation should be considered in patients with stable congestive heart failure, especially in those who have not had a significant clinical response to Remicade therapy. If a decision is made to continue treatment, cardiac status should be closely monitored and only the lower doses of Remicade should be considered (see Section 4.2 Dose and Method of Administration; Section 4.8 Adverse Effects (Undesirable Effects), Heart failure).

Infusion reactions and hypersensitivity reactions.

Remicade has been associated with acute infusion effects and a delayed hypersensitivity reaction. These differ in their time of onset. Hypersensitivity reactions, which include urticaria, dyspnea, and/or bronchospasm, laryngeal edema, pharyngeal edema, and hypotension, have occurred during or within 2 hours of Remicade infusion. Therefore, all patients receiving Remicade should be observed for at least one to two hours post infusion for side effects.
To minimise the incidence of hypersensitivity reactions, including infusion reactions and serum sickness-like reactions, Remicade should be administered as regular maintenance therapy after an induction regimen at weeks 0, 2, 6 (see Section 4.2 Dose and Method of Administration).
Acute infusion reactions may develop immediately or within a few hours of infusion and are most likely to occur during the first and second infusion. These effects may be related to the rate of infusion of Remicade. If acute infusion reactions occur, the infusion must be interrupted immediately. Some of these effects have been described as anaphylaxis. Medications (e.g. antihistamines, corticosteroids, adrenaline and/or paracetamol), an artificial airway and other appropriate materials for the treatment of these effects must be available for immediate use. Patients may be pretreated with e.g. antihistamine, hydrocortisone and/or paracetamol to prevent mild and transient effects. The infusion rate may be slowed in order to decrease infusion reactions especially if infusion reactions have occurred previously.
Antibodies to infliximab may develop in some patients. These antibodies have been associated with an increased frequency of infusion reactions, and may be associated with an increased risk of serious infusion reactions. A low proportion of the infusion reactions were serious allergic reactions.
In Crohn's disease patients, an association between development of antibodies to infliximab and reduced duration of response has also been observed. Concomitant administration of immunomodulators has been associated with lower incidence of antibodies to infliximab and a reduction in the frequency of infusion reactions. The effect of concomitant immunomodulator therapy was more profound in episodically treated patients than in patients given maintenance therapy. Patients who are not receiving immunosuppressants during Remicade treatment are potentially at greater risk of developing these antibodies. These antibodies cannot always be detected in serum samples. If serious reactions occur, symptomatic treatment must be given and further Remicade infusions must not be administered.
Long-term efficacy of retreatments with Remicade has not yet been established. Reactions following readministration, including delayed hypersensitivity reactions have been observed in a significant number of patients (25% in one clinical trial) with Crohn's disease who were retreated with a liquid formulation of Remicade, which is no longer in use, following a 2 to 4 year period without Remicade treatment. Signs and symptoms included myalgia and/or arthralgia with fever and/or rash within 12 days following retreatment. Some patients also experienced pruritus, facial, hand or lip oedema, dysphagia, urticaria, sore throat and/or headache. These effects have sometimes been described as serum sickness-like reactions. In postmarketing studies, some patients required steroid therapy to treat the delayed hypersensitivity reaction rather than symptomatic treatment alone. Advise patients to seek immediate medical advice if they experience any delayed adverse event (see Section 4.8 Adverse Effects (Undesirable Effects), Delayed hypersensitivity). If patients are retreated after a prolonged period, they should be closely monitored for signs and symptoms of delayed hypersensitivity.

Infusion reactions following readministration of Remicade.

In a psoriasis clinical trial, a 3 dose reinduction of Remicade after a period of no treatment resulted in a higher incidence of serious infusion reactions during the reinduction regimen (see Section 4.8 Adverse Effects (Undesirable Effects)) than had been observed in rheumatoid arthritis, psoriasis, and Crohn's disease trials in which a period of no drug treatment was followed by regular maintenance therapy without reinduction.
In the case where Remicade maintenance therapy for psoriasis is interrupted, Remicade should be reinitiated as a single dose followed by maintenance therapy.
In general, the benefit/ risk of readministration of Remicade after a period of no treatment, especially as a reinduction regimen given at weeks 0, 2, and 6, should be carefully considered.

Auto-immune processes.

Treatment with Remicade may result in the formation of autoantibodies and in the development of a lupus-like syndrome.
The relative deficiency of TNFα caused by anti-TNF therapy may result in the initiation of an autoimmune process in a subgroup of genetically susceptible patients. If drug induced lupus is suspected, patients being treated with Remicade should have regular measurements of Antinuclear antibodies (ANA) and double stranded DNA (dsDNA) antibodies.
If a patient develops symptoms suggestive of a lupus-like syndrome following treatment with Remicade and is positive for antibodies against double stranded DNA, treatment should be discontinued (see Section 4.8 Adverse Effects (Undesirable Effects)).
Studies have not been performed to assess the effects of infliximab on the healing of the internal fistula canal, on closure of noncutaneously draining fistulas (e.g. entero-entero) or on cutaneously draining fistulas in locations other than perianal and periabdominal.

Neurological events.

Infliximab and other agents that inhibit TNFα have been associated with seizure and new onset or exacerbation of clinical symptoms and/or radiographic evidence of central nervous system demyelinating disorders including multiple sclerosis, and optic neuritis, and peripheral demyelinating disorders, including Guillain-Barre syndrome (see Section 4.8 Adverse Effects (Undesirable Effects), Table 1 and Table 2). Prescribers should exercise caution in considering the use of Remicade in patients with these neurological disorders and should consider discontinuation of Remicade if these disorders develop.

Hepatobiliary events.

Cases of jaundice and noninfectious hepatitis, some with features of autoimmune hepatitis, have been observed in the postmarketing experience of Remicade (see Section 4.8 Adverse Effects (Undesirable Effects), Table 2). Isolated cases of liver failure resulting in liver transplantation or death have occurred. A causal relationship between Remicade and these events has not been established. Patients with symptoms or signs of liver dysfunction should be evaluated for evidence of liver injury. If jaundice and/or ALT elevations ≥ 5 times the upper limit of normal develops, Remicade should be discontinued, and a thorough investigation of the abnormality should be undertaken. As also observed with the use of other immunosuppressive drugs, reactivation of hepatitis B has occurred in patients receiving Remicade who are chronic carriers of this virus (i.e. surface antigen positive). Patients should be tested for hepatitis B virus (HBV) infection before initiating treatment with immunosuppressants, including Remicade. For patients who test positive for hepatitis B surface antigen, consultation with a physician with expertise in the treatment of hepatitis B is recommended. Chronic carriers of hepatitis B should be appropriately evaluated and monitored prior to the initiation of, during treatment with, and for several months following the discontinuation of Remicade.

Malignancies and lymphoproliferative disorders.

In the controlled portions of clinical trials of TNF blocking agents, more cases of lymphoma have been observed among patients receiving a TNF blocker compared with control patients. During clinical trials of Remicade in patients with rheumatoid arthritis, Crohn's disease, psoriatic arthritis, ankylosing spondylitis, psoriasis, and ulcerative colitis, the incidence of lymphoma in Remicade treated patients was higher than expected in the general population, but the occurrence of lymphoma was rare. Furthermore, there is an increased background lymphoma risk even in the absence of TNF blocking therapy in rheumatoid arthritis and Crohn's disease patients with longstanding, highly active, inflammatory disease, and/or active chronic exposure to immunosuppressant therapies, which complicates the risk estimation.
In a clinical trial exploring the use of Remicade in patients with moderate to severe chronic obstructive pulmonary disease (COPD), more malignancies, the majority of lung or head and neck origin, were reported in Remicade treated patients compared with control patients. All patients had a history of heavy smoking (see Section 4.8 Adverse Effects (Undesirable Effects)). Prescribers should exercise caution when considering the use of Remicade in patients with moderate to severe COPD.
With the current knowledge, a possible risk for the development of lymphomas or other malignancies in patients treated with a TNF blocking agent cannot be excluded (see Section 4.8 Adverse Effects (Undesirable Effects)). Caution should be exercised when considering TNF blocking therapy for patients with a history of malignancy or when considering continuing treatment in patients who develop a malignancy.

Paediatric malignancy.

Postmarketing cases of malignancies, some fatal, have been reported among children, adolescents and young adults (up to 22 years of age) who received TNF-blocking agents (initiation of therapy ≤ 18 years of age), including Remicade, to treat juvenile idiopathic arthritis (JIA), Crohn's disease or other conditions. Approximately half the reports were lymphomas (Hodgkin's and non-Hodgkin's lymphoma). The other cases represented a variety of different malignancies and included malignancies that are not usually observed in children and adolescents. Most of the patients were receiving concomitant immunosuppressants, such as methotrexate, azathioprine or 6-mercaptopurine. The role of TNF blockers in the development of malignancies in children and adolescents remains unclear.

Hepatosplenic T-cell lymphomas.

Postmarketing cases of hepatosplenic T-cell lymphoma have been reported in patients treated with TNF blocking agents including Remicade (see Section 4.8 Adverse Effects (Undesirable Effects), Table 2). This rare type of T-cell lymphoma has a very aggressive disease course and is usually fatal. Almost all patients had received treatment with azathioprine or 6-mercaptopurine concomitantly with or immediately prior to a TNF-blocker. The vast majority of Remicade cases have occurred in patients with Crohn's disease or ulcerative colitis and most were reported in adolescent or young adult males.
It is uncertain whether the occurrence of the HSTCL is related to Remicade or Remicade in combination with these other immunosuppressants. When treating patients with inflammatory bowel disease, particularly in adolescents and young adults, consideration of whether to use Remicade alone or in combination with other immunosuppressants should take into account a possibility that there is a higher risk of HSTCL with combination therapy versus an observed increased risk of immunogenicity and hypersensitivity reactions with Remicade monotherapy from the clinical trial data.

Leukaemia.

Cases of acute and chronic leukaemia have been reported with postmarketing TNF blocker use in rheumatoid arthritis and other indications. Even in the absence of TNF blocker therapy, patients with rheumatoid arthritis may be at a higher risk (approximately 2-fold) than the general population for the development of leukaemia.

Colon carcinoma/ dysplasia.

All patients with ulcerative colitis who are at increased risk for dysplasia or colon carcinoma (for example, patients with longstanding ulcerative colitis or primary sclerosing cholangitis), or who had a prior history of dysplasia or colon carcinoma should be screened for dysplasia at regular intervals before therapy and throughout their disease course. This evaluation should include colonoscopy and biopsies per local recommendations. With current data it is not known if Remicade treatment influences the risk for developing dysplasia or colon cancer (see Section 4.8 Adverse Effects (Undesirable Effects)).
Since the possibility of increased risk of cancer development in patients with newly diagnosed dysplasia treated with Remicade is not established, the risk and benefits to the individual patients must be carefully reviewed and consideration should be given to discontinuation of therapy.

Skin cancers.

Melanoma and Merkel cell carcinoma have been reported in patients treated with TNF blocker therapy, including Remicade (see Section 4.8 Adverse Effects (Undesirable Effects)). Periodic skin examination is recommended for all patients, particularly those with risk factors for skin cancer.
Psoriasis patients should be monitored for nonmelanoma skin cancers (NMSCs), particularly those patients who have had prior prolonged phototherapy treatment.

Cervical cancer.

A population-based retrospective cohort study using data from Swedish national health registries found an increased incidence of cervical cancer in women with rheumatoid arthritis treated with infliximab compared to biologics-naïve patients or the general population, including those over 60 years of age. A causal relationship between infliximab and cervical cancer cannot be excluded. Periodic screening should continue in women treated with Remicade, including those over 60 years of age.

Concurrent administration of TNF-alpha inhibitor and anakinra.

Concurrent administration of etanercept (another agent that inhibits TNFα) and anakinra (a recombinant, nonglycosylated form of the human interleukin-1 receptor antagonist) has been associated with an increased risk of serious infections, an increased risk of neutropaenia and no additional benefit compared to these medicinal products alone. The safety and efficacy of anakinra used in combination with infliximab has not been established. Therefore, combination of infliximab and anakinra is contraindicated.

Concurrent administration of TNF-alpha inhibitor and abatacept.

In clinical studies, concurrent administration of TNF blocking agents and abatacept have been associated with an increased risk of infections including serious infections compared with TNF blocking agents alone, without increased clinical benefit. Because of the nature of the adverse events seen with the combination of TNF blocking agents and abatacept therapy, the combination of infliximab and abatacept is not recommended.

Concurrent administration with other biological therapeutics.

There is insufficient information regarding the concomitant use of Remicade with other biological therapeutics used to treat the same conditions as Remicade. The concomitant use of Remicade with these biologics is not recommended because of the possibility of an increased risk of infection.

Switching between biological therapeutics.

When switching from one biologic to another, patients should continue to be monitored since overlapping biological activity may further increase the risk of infection.

Haematological events.

Cases of leukopaenia, neutropaenia, thrombocytopaenia, and pancytopaenia, some with a fatal outcome, have been reported in patients receiving TNF blockers, including Remicade. The causal relationship to Remicade therapy remains unclear. Although no high risk group(s) has been identified, caution should be exercised in patients being treated with Remicade who have ongoing or a history of significant haematological abnormalities. All patients should be advised to seek immediate medical attention if they develop signs and symptoms suggestive of blood dyscrasias or infection (e.g. persistent fever) while on Remicade. Discontinuation of Remicade therapy should be considered in patients who develop significant haematological abnormalities.

Vaccinations.

It is recommended that all patients, if possible, be brought up to date with all vaccinations in agreement with current vaccination guidelines prior to initiating Remicade therapy.
Live vaccines/ therapeutic infectious agents. In patients receiving anti-TNF therapy, limited data are available on the response to vaccination or on the secondary transmission of infection by live vaccines. Use of live vaccines can result in clinical infections, including disseminated infections. The concurrent administration of live vaccines with Remicade is not recommended.

Infant exposure in utero.

Fatal outcome due to disseminated Bacille Calmette-Guerin (BCG) infection has been reported in an infant who received BCG vaccine after in utero exposure to infliximab. A twelve month waiting period following birth is recommended before the administration of live vaccines to infants exposed in utero to infliximab, unless infliximab exposure was limited to the first trimester or if infant infliximab serum levels are undetectable. Administration of a live vaccine prior to 12 months of age might be considered if the benefit of the vaccination clearly outweighs the theoretical risk of administration of live vaccines to the infants (see Section 4.6 Fertility, Pregnancy and Lactation).

Infant exposure via breastmilk.

Administration of a live vaccine to a breastfed infant while the mother is receiving infliximab is not recommended unless infant infliximab serum levels are undetectable (see Section 4.6 Fertility, Pregnancy and Lactation).

Therapeutic infectious agents.

Other uses of therapeutic infectious agents such as live attenuated bacteria (e.g. BCG bladder instillation for the treatment of cancer) could result in clinical infections, including disseminated infections. It is recommended that therapeutic infectious agents not be given concurrently with Remicade.
Non-live vaccines. In a subset of patients from the ASPIRE study, a similar proportion of patients in each treatment group mounted an effective two-fold increase in titres to a polyvalent pneumococcal vaccine, indicating that Remicade did not interfere with T-cell independent humoral immune responses.

Use in psoriasis.

The safety and efficacy of infliximab in combination with other immunosuppressive agents used in psoriasis or with phototherapy have not been studied. Infliximab should not be used in combination with such agents because of the possibility of excessive immunosuppression.

Use in elderly.

No major differences were observed in the pharmacokinetics of Remicade in elderly (65-80 years) rheumatoid arthritis patients. The incidence of serious infections in Remicade treated patients 65 years and older was greater than in those under 65 years of age. In addition, there is a greater incidence of infections in the elderly population in general, therefore, caution should be used in treating the elderly. Clinical studies of Remicade did not include sufficient numbers of Crohn's disease patients aged 65 and over to determine whether they respond differently from patients aged 18 to 65. Studies have not been performed in patients with liver or renal disease.
Since elderly patients have a greater frequency of decreased hepatic, renal and/or cardiac function and a greater frequency of concomitant disease and/or other drug therapy, caution in the treatment of elderly patients is recommended.

Paediatric use.

Children and adolescents (6-17 years).

Treatment with Remicade has not been studied in children and adolescent patients ≤ 17 years with ankylosing spondylitis, psoriatic arthritis or plaque psoriasis. Treatment with Remicade has not been studied in paediatric patients with ulcerative colitis or Crohn's disease under the age of 6 years. Until safety and efficacy data in the above mentioned groups of paediatric patents are available, such treatment is to be avoided. It should be noted that all children and adolescent patients in the phase 3 trial in Crohn's disease (REACH) were required to be on a stable dose of either 6-mercaptopurine, azathioprine or methotrexate.
Remicade was studied in 120 patients (age range 4-17 years old) with active juvenile rheumatoid arthritis (JRA) despite methotrexate. This study did not provide conclusive evidence for the efficacy of Remicade in JRA.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

While specific studies on drug interactions with Remicade have not been conducted, the majority of patients in clinical trials received concomitant medications normally used in Crohn's disease. These medications included antibiotics (including antiviral agents), corticosteroids, 6-mercaptopurine/ azathioprine and aminosalicylates. No interactions were reported. Because corticosteroids alter electrolyte balance and fluid retention, the volume of distribution of infliximab was greater in patients taking corticosteroids. However, no significant clinical sequelae were apparent.
In rheumatoid arthritis, psoriatic arthritis and Crohn's disease patients, there are indications that concomitant use of methotrexate and other immunomodulators reduces the formation of antibodies against infliximab and increases the plasma concentrations of infliximab. However, the results are uncertain due to limitations in the methods used for serum analyses of infliximab and antibodies against infliximab. Corticosteroids do not appear to affect the pharmacokinetics of infliximab to a clinically relevant extent (see Section 4.8 Adverse Effects (Undesirable Effects), Immunogenicity).
In psoriasis, concomitant use of infliximab with other immunosuppressive agents has not been studied (see Section 4.4 Special Warnings and Precautions for Use).
No other information is available regarding possible effects of other immunosuppressive drugs or their effects on the pharmacokinetics of infliximab.

Concurrent use of Remicade with other biological therapeutics.

The combination of Remicade with other biological therapeutics used to treat the same conditions as Remicade, including anakinra and abatacept, is not recommended (see Section 4.4 Special Warnings and Precautions for Use).

Live vaccines/ therapeutic infectious agents.

It is recommended that live vaccines not be given concurrently with Remicade. It is also recommended that live vaccines not be given to infants after in utero exposure to infliximab for 12 months following birth, unless infliximab exposure was limited to the first trimester or if infant infliximab serum levels are undetectable. Administration of a live vaccine prior to 12 months of age might be considered if the benefit of the vaccination clearly outweighs the theoretical risk of administration of live vaccines to the infant (see Section 4.4 Special Warnings and Precautions for Use).
Administration of a live vaccine to a breastfed infant while the mother is receiving infliximab is not recommended unless infant infliximab serum levels are undetectable (see Section 4.6 Fertility, Pregnancy and Lactation).
It is recommended that therapeutic infectious agents not be given concurrently with Remicade (see Section 4.4 Special Warnings and Precautions for Use).

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

The effect of infliximab on fertility has not been investigated. No impairment of fertility was observed in a fertility and general reproduction study conducted in mice using an analogous antibody that selectively inhibits the functional activity of mouse TNFα.
(Category C)
Remicade is not recommended for use during pregnancy. It is not known whether Remicade can affect reproductive capacity or can cause foetal harm when administered to a pregnant woman. Women of childbearing potential must use adequate contraception to prevent pregnancy and continue its use for at least 6 months after the last Remicade treatment.
Since infliximab does not cross react with TNFα in species other than humans and chimpanzees, animal reproduction studies have not been conducted. In a developmental toxicity study conducted in mice using an analogous monoclonal antibody that selectively inhibits the functional activity of mouse TNFα, no evidence of maternal toxicity, embryotoxicity or teratogenicity was observed.
As with other IgG antibodies, infliximab crosses the placenta. Infliximab has been detected in the serum of infants up to twelve months following birth. The clinical significance of low serum levels of infliximab on the immune status in infants is unknown.
After in utero exposure to infliximab, infants may be at increased risk of infection, including disseminated infection that can become fatal (see Section 4.4 Special Warnings and Precautions for Use).
Remicade has been detected at low levels in human milk and in infant serum via breast milk. While systemic exposure in a breastfed infant is expected to be low because infliximab is largely degraded in the gastrointestinal tract, the administration of live vaccines to a breastfed infant when the mother is receiving infliximab is not recommended unless infant infliximab serum levels are undetectable. Limited data from published literature indicate infliximab has been detected at low levels in human milk at concentrations up to 5% of the maternal serum level.
Limited data from published literature also indicate that infants exposed to infliximab through breast milk had no increase in rates of infections and developed normally.
The consideration of Remicade use during breast-feeding should take into account the treatment benefit of the drug to the mother and health benefits of breast-feeding for the infant. Remicade should only be used if the treatment benefit to the mother outweighs the potential risks to the breastfed infant.

4.7 Effects on Ability to Drive and Use Machines

Remicade is unlikely to produce an effect on the ability to drive or operate machinery; however, patients who are fatigued should be cautioned to avoid driving or operating machinery.

4.8 Adverse Effects (Undesirable Effects)

In clinical trials with Remicade, adverse drug reactions (ADRs) reasonably attributable to treatment were observed in 36% of placebo treated patients and 57% of Remicade treated patients. Reasonably related ADRs are listed in Table 1 by system organ class and frequency. Frequency is based on the excess incidence of the ADR compared with placebo in pooled data from clinical trials involving 227 patients receiving placebo and 1,421 patients receiving Remicade (Crohn's disease and rheumatoid arthritis). Most ADRs were mild to moderate in severity. Infusion related reactions were the most common adverse reactions reported in clinical studies. The most common reason for discontinuation of treatment was infusion related reactions (dyspnoea, urticaria, hypotension, flushing and headache).
Vomiting and elevated hepatic transaminases were also reported.

Children and adolescent patients.

Paediatric Crohn's disease (children and adolescents (6-17 years)). In general, the adverse events in children and adolescent patients who received infliximab were similar in frequency and type to those seen in adult Crohn's disease patients. Differences from adults and other special considerations are discussed in the following paragraphs.
The following adverse events were reported more commonly in 103 children and adolescent Crohn's disease patients randomised at week 10 administered 5 mg/kg infliximab through 54 weeks (out of a total of 112 patients who entered the REACH trial, also see Section 5.1 Pharmacodynamic Properties, Clinical trials) than in adult Crohn's disease patients receiving a similar treatment regimen (ACCENT 1 trial, also see Section 5.1 Pharmacodynamic Properties, Clinical trials): anaemia (10.7%), blood in stool (9.7%), leukopaenia (8.7%), flushing (8.7%), viral infection (7.8%), neutropaenia (6.8%), bone fracture (6.8%), bacterial infection (5.8%), and respiratory tract allergic reaction (5.8%).

Infusion related reactions.

Overall, in REACH, 17.5% of randomised patients experienced 1 or more infusion reactions, with 17.0% and 18.0% of patients in the 8 weekly and 12 weekly maintenance treatment groups, respectively. There were no serious infusion reactions, and 2 subjects in REACH had nonserious anaphylactic reactions.

Immunogenicity.

Antibodies to infliximab developed in 3 (2.9%) children and adolescent patients.

Infections.

Infections were reported in 56.3% of randomised children and adolescent subjects treated with infliximab (REACH trial), and in 50.4% of subjects in adult's Crohn's (ACCENT 1 trial). In the REACH trial, infections were reported more frequently for subjects who received 8 weekly as opposed to 12 weekly infusions (73.6% and 38.0%, respectively), while serious infections were reported for 3 subjects in the q8 week and 4 subjects in the 12 weekly maintenance treatment group. The most commonly reported infections were upper respiratory tract infection and pharyngitis, and the most commonly reported serious infection was abscess. Pneumonia was reported in 3 patients, 2 in the 8 weekly and 1 in the 12 weekly maintenance treatment groups. Herpes zoster was reported in 2 patients in the 8 weekly maintenance treatment group.
Paediatric ulcerative colitis (children and adolescents (6-17 years)). Overall proportions of patients with adverse events and serious adverse events were generally consistent in the paediatric ulcerative colitis and adult ulcerative colitis (ACT 1 and ACT 2) studies. In the paediatric ulcerative colitis study (C0168T72), the most common adverse event was worsening of ulcerative colitis, the incidence of which was higher in patients on every 12 week vs. the every 8 week dosing regimen. In ACT 1 and ACT 2 studies, the most common adverse event was headache. The most common serious adverse event across these three studies was worsening of ulcerative colitis.

Infections.

Infections were reported in 31 (51.7%) of 60 treated patients in C0168T72 and 22 (36.7%) required oral or parenteral antimicrobial treatment. The proportion of patients with infections in C0168T72 was similar to that in the paediatric Crohn's disease study (REACH) but higher than the proportion in the adults ulcerative colitis studies (ACT 1 and ACT 2). Unlike REACH, in which infections were reported more frequently for patients who received every 8 week as opposed to every 12 week infusions; in C0168T72, the overall incidence of infections was similar in the every 8 week (13/22 [59.1%]) and every 12 week (14/23 [60.9%]) maintenance treatment groups. In C0168T72, serious infections were reported for 3 of 22 (13.6%) patients in the every 8 week and 3 of 23 (13.0%) patients in the every 12 week maintenance treatment group. Upper respiratory tract infection (7/60 [11.7%]) and pharyngitis (5/60 [8.3%]) were the most frequently reported respiratory infections among all treated patients. The infections occurring in more than one patient in a treatment group that required antimicrobial treatment were pharyngitis (4/60 [6.7%]), urinary tract infection (4/60 [6.7%]), and bronchitis (2/60 [3.3%]).

Infusion related reactions.

Overall, 8 (13.3%) of 60 treated patients experienced one or more infusion reactions, with 4 of 22 (18.2%) in the every 8 week and 3 of 23 (13.0%) in the every 12 week treatment maintenance group. No serious infusion reactions were reported. All infusion reactions were mild or moderate in intensity.

Immunogenicity.

Antibodies to infliximab were detected in 4 (7.7%) patients through week 54.

Postmarketing experience.

During postmarketing experience, a rare type of hepatosplenic T-cell lymphoma has been reported in patients treated with Remicade with the vast majority of cases occurring in Crohn's disease or ulcerative colitis and most of whom were adolescent or young adult males (see Section 4.4 Special Warnings and Precautions for Use).
Juvenile rheumatoid arthritis. Remicade was studied in a trial in 120 patients (age range: 4-17 years old) with active JRA despite methotrexate. Patients received 3 mg/kg Remicade or placebo intravenously at weeks 0, 2 and 6. Subjects randomised to placebo crossed over to receive 6 mg/kg Remicade at weeks 14, 16 and 20 and then every 8 weeks through to week 44. Subjects randomised to 3 mg/kg Remicade continued to receive the same dose of Remicade at weeks 14, 20 and then every 8 weeks through to week 44. This study did not provide conclusive evidence for the efficacy of Remicade in JRA.

Infusion reactions.

Infusion reactions occurred in 35% of patients with JRA receiving 3 mg/kg compared with 17.5% of patients receiving 6 mg/kg. In the 3 mg/kg Remicade group, 4 out of 60 patients had a serious infusion reaction and 3 patients reported a possible anaphylactic reaction (2 of which were among the serious infusion reactions). In the 6 mg/kg group, 2 out of 57 patients had a serious infusion reaction, one of whom had a possible anaphylactic reaction.

Immunogenicity.

Antibodies to infliximab developed in 38% of patients receiving 3 mg/kg compared with 12% of patients receiving 6 mg/kg. The antibody titres were notably higher for the 3 mg/kg compared to the 6 mg/kg group.

Infections.

Infections occurred in 68% (41/60) of children receiving 3 mg/kg over 52 weeks, 65% (37/57) of children receiving infliximab 6 mg/kg over 38 weeks and 47% (28/60) of children receiving placebo over 14 weeks.

Postmarketing reports.

See Table 2.

In postmarketing spontaneous reporting, Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, paediatric malignancy, leukaemia and vasculitis have been reported. During or within 2 hours of Remicade infusion, transient visual loss, myocardial ischaemia/infarction, and arrhythmia have occurred. Fatal and non-fatal cases of cerebrovascular accidents and myocardial ischaemia/infarction have been reported within 24 hours of infusion. There have also been reports of arrhythmia occurring within 24 hours of infusion. In addition, interstitial lung disease (including pulmonary fibrosis/ interstitial pneumonitis) has been observed, which in some cases may be, rapidly aggressive.
Spontaneous serious adverse events in the postmarking experience with Remicade in the pediatric population have included malignancies, transient hepatic enzyme abnormalities, lupus-like syndromes, and positive autoantibodies.
Hemophagocytic lymphohistiocytosis (HLH) has been very rarely reported in patients treated with Remicade.

Psoriasis: new onset and exacerbations.

Cases of new onset psoriasis, including pustular psoriasis and palmoplantar psoriasis, have been reported with the use of TNF blockers, including Remicade. Cases of exacerbation of pre-existing psoriasis have also been reported with the use of TNF blockers. Many of these patients were taking concomitant immunosuppressants (e.g. MTX, corticosteroids). Some of these patients required hospitalisation. Most patients had improvement of their psoriasis following discontinuation of their TNF blocker. Some patients have had recurrences of the psoriasis when they were rechallenged with a different TNF blocker. Discontinuation of Remicade should be considered for severe cases and those that do not improve or that worsen despite topical treatments.

Infusion related reactions.

An infusion related reaction was defined in clinical studies as any adverse event occurring during an infusion or within 1 hour after an infusion. In phase 3 clinical studies, 18% of infliximab treated patients compared with 5% of placebo treated patients experienced an infusion related reaction. Among all Remicade infusions, approximately 3% of infusions were accompanied by nonspecific symptoms such as fever or chills, < 1% were accompanied by pruritus or urticaria, 1% were accompanied by cardiopulmonary reactions (primary chest pain, hypotension, hypertension or dyspnoea) and 0.1% were accompanied by combined symptoms of pruritus/ urticaria and cardiopulmonary reactions. Discontinuation of treatment resulted in 2% of patients and all patients recovered with or without medical therapy. Infusion related effects in patients were more likely to occur during the first (8%) and less likely, on subsequent infusions (second, 7%; third, 6%; and fourth, 5%; etc.). Patients who became positive for antibodies to infliximab were more likely (approximately 2-3 fold) to have an infusion reaction than were those who were negative. Use of concomitant immunosuppressant agents appeared to reduce the frequency of infusion related reactions.
Of infliximab treated patients who had an infusion reaction during the induction period, 27% experienced an infusion reaction during the maintenance period. Of patients who did not have an infusion reaction during the induction period, 9% experienced an infusion reaction during the maintenance period.
In the ASPIRE study, 66% of the patients (686 out of 1,040) received at least one shortened infusion of 90 minutes or less and 44% of the patients (454 out of 1,040) received at least one shortened infusion of 60 minutes or less. Of the infliximab treated patients who received at least one shortened infusion, infusion related reactions occurred in 15% of the patients and serious infusion reactions occurred in 0.4% of the patients.
In a post hoc analysis of ten phase 3 clinical studies, in patients receiving Remicade with or without concomitant immunomodulator therapy, 13-19% of patients receiving Remicade at a low infusion rate (≤ 6 mg/kg/2 hr) experienced an infusion related reaction, compared to 15-16% of patients receiving Remicade at a high infusion rate (> 6 mg/kg/2 hr). Of patients receiving Remicade at a low infusion rate, 0.4%-0.7% experienced a serious infusion related reaction, compared to 0.4%-0.5% of patients receiving Remicade at a high infusion rate.

Infusion reactions following readministration of Remicade.

In rheumatoid arthritis, Crohn's disease, and psoriasis clinical trials, readministration of Remicade after a period of no treatment resulted in a higher incidence of infusion reactions relative to regular maintenance treatment.
In a clinical trial of patients with moderate to severe psoriasis designed to assess the efficacy and safety of long-term maintenance therapy versus retreatment with an induction cycle of Remicade, 4% (8/219) of patients in the intermittent therapy arm experienced serious infusion reactions versus < 1% (1/222) in the maintenance therapy arm. Patients enrolled in this trial did not receive any concomitant immunosuppressant therapy. Intermittent therapy in this trial was defined as the readministration of an induction cycle (maximum of four infusions at 0, 2, 6, and 14 weeks) of Remicade upon disease flare after a period of no treatment. In this study, the majority of serious infusion reactions occurred during the second infusion at week 2. Symptoms included, but were not limited to, dyspnoea, urticaria, facial oedema, and hypotension. In all cases, Remicade treatment was discontinued and/or other treatment instituted with complete resolution of signs and symptoms.

Delayed hypersensitivity.

In a clinical study of 41 patients retreated with a liquid formulation of Remicade, which is no longer in use, following a 2 to 4 year period without Remicade treatment, 10 patients experienced undesirable effects manifesting 3 to 12 days following infusion. In 6 of these patients, the effects were considered serious. Signs and symptoms included myalgia and/or arthralgia with fever and/or rash. Some patients also experienced pruritus, facial, hand or lip oedema, dysphagia, urticaria, sore throat and/or headache. The clinical data are not adequate to determine if occurrence of these reactions is due to the different formulations administered to these patients in this study. Patients' signs and symptoms improved substantially or resolved with treatment in all cases. There are insufficient data on the incidence of these events after drug free intervals of 1 to 2 years. These events have been observed only infrequently in clinical studies and postmarketing surveillance with retreatment intervals up to 1 year. In the phase III psoriasis study, 1% (4/366) of patients experienced symptoms of arthralgia, myalgia, fever and rash early in the treatment course following infliximab infusions.

Immunogenicity.

Patients who developed antibodies to infliximab were more likely to develop infusion related reactions. In clinical studies using single and multiple infliximab doses ranging from 1 to 20 mg/kg, antibodies to infliximab were detected in approximately 24% of patients with any immunosuppressant therapy and in approximately 37% of patients without immunosuppressant therapy. In rheumatoid arthritis patients who received the recommended repeated treatment dose regimens with methotrexate, approximately 8% of patients developed antibodies to infliximab. In psoriatic arthritis patients who received 5 mg/kg with and without methotrexate, antibodies occurred overall in 15% of patients (antibodies occurred in 4% of patients receiving methotrexate and in 26% of patients not receiving methotrexate at baseline). Of Crohn's disease patients who received maintenance treatment, approximately 6-13% developed antibodies to infliximab. The antibody incidence was 2-3 fold higher for patients treated episodically. Due to methodological shortcomings, a negative assay did not exclude the presence of antibodies to infliximab. Some patients who developed high titres of antibodies to infliximab had evidence of reduced efficacy. In a phase III psoriasis study in which patients were treated with infliximab induction followed by every 8 week maintenance infusions without concomitant immunosuppressive therapy, antibodies were detected in approximately 20% of patients.

Infections.

In clinical studies, 35% of Remicade treated patients experienced infections compared with 22% of placebo treated patients. Serious infections, such as pneumonia, were reported in 5% of both Remicade treated patients and placebo treated patients (see Section 4.4 Special Warnings and Precautions for Use). In a phase III psoriasis study, after 24 weeks of follow-up, 1% (3/298) of infliximab treated psoriasis patients compared to 0% (0/76) of placebo treated patients developed serious infections.
In postmarketing surveillance, opportunistic infections such as tuberculosis, Pneumocystis carinii pneumonia (PCP), histoplasmosis, listeriosis, coccidioidomycosis, aspergillosis and oesophageal candidiasis have been reported.
In postmarketing spontaneous reporting, infections are the most common serious adverse event. Some of the cases have resulted in fatal outcome. Cases of tuberculosis, sometimes fatal, including miliary tuberculosis and tuberculosis with extrapulmonary location (see Section 4.4 Special Warnings and Precautions for Use), and protozoal infections have been reported.

Malignancies and lymphoproliferative disorders.

In clinical studies with infliximab, in which 5,780 patients were treated, representing 5,494 patient years, 5 cases of lymphomas and 26 nonlymphoma malignancies were detected as compared with no lymphomas and 1 nonlymphoma malignancy in 1,600 placebo treated patients observed during 941 patient years.
In long-term safety follow-up of clinical studies with infliximab of up to 5 years, representing 6,234 patient years, 5 cases of lymphoma and 38 cases of nonlymphoma malignancies were reported.
From August 1998 to August 2005, 1,909 cases of suspected malignancies have been reported from postmarketing, clinical trials and registries (321 in Crohn's disease patients, 1,302 in rheumatoid arthritis patients and 286 in patients with other or unknown indications). Among those there were 347 lymphoma cases. During this period, the estimated exposure is 1,909,941 patient years since first exposure (see Section 4.4 Special Warnings and Precautions for Use, Malignancies and lymphoproliferative disorders).
In the controlled portions of some clinical trials of the TNF blocking agents, more cases of nonlymphoma malignancy have been observed among patients receiving a TNF blocker compared with control patients. In an exploratory clinical trial evaluating the use of Remicade in patients with moderate to severe chronic obstructive pulmonary disease (COPD), more malignancies were reported in Remicade treated patients compared with control patients, 5.7% (95% CI 2.65%-10.6%) vs. 1% (95% CI 0.03%-7.0%). The malignancies were mainly lung and head and neck. All patients had a history of heavy smoking.
A population-based retrospective cohort study found an increased incidence of cervical cancer in women with rheumatoid arthritis treated with infliximab compared to biologics-naïve patients or the general population, including those over 60 years of age (see Section 4.4 Special Warnings and Precautions for Use).
During postmarketing experience, a rare type of hepatosplenic T-cell lymphoma has been reported in adolescent and young adult patients with Crohn's disease treated with Remicade (see Section 4.4 Special Warnings and Precautions for Use, Malignancies and lymphoproliferative disorders). There have also been cases of cutaneous T cell lymphoma, mycosis fungoides, reported in the postmarketing setting.

Heart failure.

In a phase II study aimed at evaluating Remicade in moderate to severe congestive heart failure (CHF), higher incidence of mortality due to worsening of heart failure was seen in patients treated with Remicade, especially those treated with the higher dose of 10 mg/kg. There have been postmarketing reports of worsening heart failure, with and without identifiable precipitating factors, in patients taking Remicade. There have also been postmarketing reports of new onset heart failure, including heart failure in patients without known pre-existing cardiovascular disease. Some of these patients have been under 50 years of age.

Autoantibodies/ lupus-like syndrome.

In clinical studies approximately 52% of (1,261) infliximab treated patients who were ANA negative at baseline developed a positive ANA during the trial (compared with approximately 19% of 129 placebo treated patients). Anti-dsDNA antibodies developed in approximately 17% (261) of patients treated with Remicade (compared with 0% of 162 placebo treated patients). At the last evaluation, 150 of these 261 infliximab treated patients (57%) remained anti-dsDNA positive. Clinical signs consistent with a lupus-like syndrome remain uncommon.

Hepatobiliary events.

In postmarketing surveillance, cases of jaundice and hepatitis, some with features of autoimmune hepatitis, have been reported in patients receiving Remicade (see Table 2). A causal relationship between Remicade and these events has not been established.
In clinical trials, mild or moderate elevations of ALT and AST have been observed in patients receiving Remicade without progression to severe hepatic injury. Elevations of ALT ≥ 5 x ULN have been observed (see Table 3). Elevations of aminotransferases were observed (ALT more common than AST) in a greater proportion of patients receiving Remicade than in controls, both when Remicade was given as monotherapy and when it was used in combination with other immunosuppressive agents. Most aminotransferase abnormalities were transient; however, a small number of patients experienced more prolonged elevations. In general, patients who developed ALT and AST elevations were asymptomatic, and the abnormalities decreased or resolved with either continuation or discontinuation of Remicade, or modification of concomitant medications.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at https://www.tga.gov.au/reporting-problems.

4.9 Overdose

Single doses up to 20 mg/kg have been administered to patients without direct toxic effects. In case of overdose, it is recommended that patients be monitored for any signs and symptoms of adverse reactions or effects, and appropriate symptomatic treatment be instituted immediately.
For information on the management of overdose please contact the Poisons Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of actions.

Infliximab is a chimeric human murine monoclonal antibody that binds to human tumour necrosis factor alpha (TNFα). TNFα is a proinflammatory and immunoregulatory cytokine that, when overexpressed, mediates chronic inflammation in diseases such as Crohn's disease and rheumatoid arthritis. Cellular responses to TNFα include:
upregulation of other proinflammatory cytokines such as interleukin (IL) 1 and IL-12;
upregulation of chemokines such as IL-8;
priming and activation of neutrophils;
upregulation of adhesion molecules and tissue factor by endothelial cells;
induction of proliferation and increased synthesis of IL-6 and metalloproteinases by fibroblasts.
Infliximab neutralises the biological activity of TNFα by binding with high affinity to the soluble and transmembrane forms of TNFα and inhibits binding of TNFα with its receptors. Infliximab does not neutralise TNFβ (lymphotoxin α), a related cytokine that utilises the same receptors as TNFα. Biological activities attributed to TNFα include: induction of proinflammatory cytokines such as IL-1 and IL-6; enhancement of leukocyte migration by increasing endothelial layer permeability and expression of adhesion molecules by endothelial cells and leukocytes; activation of neutrophil and eosinophil functional activity; and induction of acute phase and other liver proteins. Cells expressing transmembrane TNFα bound by infliximab can be lysed in vitro by complement or effector cells. Infliximab inhibits the functional activity of TNFα in a wide variety of in vitro bioassays utilising human fibroblasts, endothelial cells, neutrophils, B and T lymphocytes and epithelial cells.
Elevated concentrations of TNFα have been found in the sera and stools of adult Crohn's disease patients and in the joints of rheumatoid arthritis patients and correlate with elevated disease activity. Increased concentrations of TNFα have also been found in joint fluid/ tissue and in psoriatic skin lesions in patients with psoriatic arthritis. In psoriatic arthritis, treatment with Remicade resulted in a reduction in the number of T-cells and blood vessels in the synovium and psoriatic skin as well as a reduction of macrophages in the synovium. In patients with Crohn's disease, treatment with Remicade reduced infiltration of inflammatory cells and TNFα production in inflamed areas of the intestine; it also reduced the proportion of mononuclear cells from the lamina propria able to express TNFα and interferon γ. In patients with rheumatoid arthritis, treatment with Remicade reduced infiltration of inflammatory cells into inflamed areas of the joint as well as expression of molecules mediating cellular adhesion, chemoattraction and tissue degradation. After treatment with Remicade, patients with rheumatoid arthritis or Crohn's disease exhibited decreased levels of serum IL-6 and C-reactive protein (CRP) compared to their baseline values. In patients with rheumatoid arthritis, peripheral blood lymphocytes further showed no significant decrease in number or in proliferative responses to in vitro mitogenic stimulation when compared to untreated patients' cells. In psoriasis patients, treatment with infliximab resulted in decreases in epidermal inflammation and normalization of keratinocyte differentiation in psoriatic plaques.

Clinical trials.

Adult rheumatoid arthritis. The safety and efficacy of Remicade were assessed in two multicentre, randomised, double blind pivotal trials: ATTRACT (anti-TNF trial in rheumatoid arthritis with concomitant therapy) and ASPIRE (active controlled study of patients receiving infliximab for the treatment of rheumatoid arthritis of early onset). Concurrent use of stable doses of folic acid, oral corticosteroids (≤ 10 mg/day) and/or nonsteroidal anti-inflammatory drugs was permitted.
The primary endpoints were the reduction of signs and symptoms as assessed by the American College of Rheumatology (ACR) criteria (ACR20 for ATTRACT, landmark ACR-N at week 54 for ASPIRE), the prevention of structural damage and the improvement in physical function. A reduction in signs and symptoms was defined to be at least a 20% improvement (ACR20) in both tender and swollen joint counts and in 3 of the following 5 criteria: evaluator's global assessment, patient's global assessment, functional/ disability measure, visual analogue pain scale and erythrocyte sedimentation rate or CRP. ACR-N uses the same criteria as the ACR20, calculated by taking the lowest percentage improvement in swollen joint count, tender joint count and the median of the remaining 5 components of the ACR response. Structural joint damage (erosions and joint space narrowing) in both hands and feet was measured by the change from baseline in the total van der Heijde modified Sharp score (0-440). The Health Assessment Questionnaire (HAQ; scale 0-3) was used to measure patients' average change from baseline scores over time, through week 54, in physical function.
The ATTRACT trial evaluated responses at 30 weeks (reduction in signs and symptoms), 54 weeks (the prevention of structural damage) and 102 weeks (the improvement in physical function) in a placebo controlled study of 428 adult patients with active rheumatoid arthritis despite treatment with methotrexate. Approximately 50% of patients were in functional class III. Patients received placebo, 3 mg/kg or 10 mg/kg Remicade at weeks 0, 2 and 6 and then every 4 or 8 weeks thereafter. All patients were on stable methotrexate doses (median 15 mg/week) for 6 months prior to enrolment and were to remain on stable doses throughout the study.
Results from week 54 (ACR20, total van der Heijde modified Sharp score and HAQ) are shown in Table 4. Higher degrees of clinical response (ACR20, ACR50 and ACR70) were observed with Remicade versus methotrexate alone at 30 and 54 weeks compared with methotrexate alone (see Table 4).
A reduction in the rate of the progression of structural joint damage (erosions and joint space narrowing) was observed in all infliximab groups at 54 weeks (see Table 4).
The effects observed at 54 weeks were maintained through 102 weeks. Due to a number of treatment withdrawals, the magnitude of the effect difference between infliximab and the methotrexate alone group cannot be defined.

The ASPIRE trial evaluated responses at 54 weeks in 1,004 methotrexate naive patients with early (≤ 3 years disease duration) active rheumatoid arthritis. Patients randomised had a median age of 51 years with a median disease duration of 0.6 years and median swollen and tender joint count of 19 and 31, respectively. All patients received methotrexate (optimised to 20 mg/week by week 8) and either placebo, 3 mg/kg or 6 mg/kg infliximab at weeks 0, 2 and 6 and every 8 weeks thereafter. Results from week 54 are shown in Table 5.
In this trial, infusions were to be administered over 2 hours for the first 3 infusions. The duration of subsequent infusions could be shortened to not less than 40 minutes in patients who did not experience serious infusion reactions. Sixty-six percent of the patients received at least one shortened infusion of 90 minutes or less and 44% received at least one shortened infusion of 60 minutes or less.
After 54 weeks of treatment, both doses of infliximab + methotrexate resulted in statistically significantly greater improvement in signs and symptoms compared to methotrexate alone as measured by the proportion of patients achieving ACR20, 50 and 70 responses.
In ASPIRE, more than 90% of patients had at least two evaluable X-rays. Reduction in the rate of progression of structural damage was observed at weeks 30 and 54 in the infliximab + methotrexate groups compared to methotrexate alone.

Data to support Remicade dose adjustment in rheumatoid arthritis comes from both ATTRACT and ASPIRE, as well as from the START study. START was a randomised, multicentre, double blind, 3 arm, parallel group safety study. In one of the arms the secondary objective was to assess the safety and efficacy of dose escalation above 3 mg/kg of infliximab in 1.5 mg/kg increments to a maximum of 9 mg/kg, given every 8 weeks in subjects with an inadequate response to 3 mg/kg at week 22 or if a flare occurred later. Results are shown in Table 6.

Rheumatoid arthritis associated anaemia.

Evidence suggests that TNFα plays a role in the inhibition of erythropoiesis in chronic inflammatory disease. In three clinical trials in patients with rheumatoid arthritis (ATTRACT, ASPIRE, START), 39.8% of patients with a baseline haemoglobin < 12 g/dL had an increase in haemoglobin ≥ 1 g/dL at week 22 when receiving infliximab plus methotrexate, versus 19.3% in those receiving methotrexate alone (p < 0.001). Additionally, 12.1% of patients treated with infliximab plus methotrexate had an increase ≥ 2 g/dL in haemoglobin vs. 4.5% of patients in the methotrexate arm alone (p < 0.001). Significant results were also found for patients with baseline haemoglobin < 10 g/dL.
Analyses of the data from ASPIRE showed that infliximab therapy improved rheumatoid arthritis associated anaemia in both ACR20 responders and nonresponders. See Table 7.

Furthermore, it showed that among ACR20 responders, infliximab 3 mg/kg plus methotrexate improved anaemia significantly (p = 0.034) better than methotrexate alone. Improvement in haemoglobin significantly correlated with improvement in physical function and quality of life at week 22.
Ankylosing spondylitis. Efficacy and safety of infliximab were assessed in two multicentre, double blind, placebo controlled studies in patients with active ankylosing spondylitis (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score ≥ 4 and spinal pain ≥ 4 on a scale of 1-10). Improvement in signs and symptoms was measured using the ASAS 20 response criteria and/or the BASDAI 50. Improvement in physical function was assessed using the Bath Ankylosing Spondylitis Functional Index (BASFI). Improvement in range of axial motion was evaluated using both the Bath Ankylosing Spondylitis Metrology Index (BASMI) and/or clinical measurements of chest expansion. Health related quality of life was assessed using the SF-36 (physical function, role physical, bodily pain, general health, vitality, social functioning, role emotional, mental health). The BASDAI measures disease activity on the basis of six questions relating to fatigue, spinal pain, peripheral arthritis, enthesitis (inflammation at the points where tendons/ ligaments/ joint capsule enter the bone), and morning stiffness.
In the first study (P01522), which had a 3 month double blind phase, patients received either 5 mg/kg infliximab or placebo at weeks 0, 2, 6 (35 patients in each group). Starting at week 12, placebo patients were switched to infliximab and all patients subsequently received 5 mg/kg infliximab every 6 weeks up to week 54. After the first year of the study, 53 patients continued into an open label extension to week 102.
At week 12, treatment with infliximab resulted in improvement in signs and symptoms, as assessed by the BASDAI, with 57% of infliximab treated patients achieving at least 50% reduction from baseline in BASDAI score (mean baseline score was 6.5 in the infliximab group and 6.3 in the placebo group), compared to 9% of placebo patients (p < 0.01). The absolute difference in the BASDAI score compared with placebo at week 12 was 2.4. At 54 and 102 weeks there were 54 and 49 subjects still on infliximab treatment and among those, 34 (63%) and 30 (61%) were BASDAI 50 responders. Improvement was observed as early as week 2 and was maintained through week 102. Physical function range of motion, and quality of life (SF-36) were improved similarly.
In the second trial (ASSERT), 279 patients (78 patients in the placebo group and 201 in the infliximab group) were randomised to receive either placebo (group 1) or 5 mg/kg infliximab (group 2) at 0, 2 and 6 weeks and every 6 weeks thereafter through to week 96. At week 24, patients receiving placebo (group 1) received 5 mg/kg infliximab every 6 weeks through to week 96. Starting with the week 36 infusion and continuing through the week 96 infusion, a patient in group 2 who had a BASDAI ≥ 3 at 2 consecutive visits received a 7.5 mg/kg infliximab infusion and continued to receive 7.5 mg/kg infliximab infusions every 6 weeks thereafter through week 96.
At 24 weeks, the primary efficacy timepoint, improvement in signs and symptoms, as measured by the proportion of patients achieving an ASAS 20 response, was 61% in the infliximab treated group vs. 19% in the placebo group (p < 0.001). The improvement was observed as early as week 2. Significant improvement in signs and symptoms was also assessed by the BASDAI, with 51% of infliximab treated subjects achieving at least 50% reduction from baseline in BASDAI score (mean baseline score was 6.5 in the infliximab group and 6.2 in the placebo group), compared with 10.7% of placebo patients (p < 0.001). The median improvement from baseline in range of axial motion, as assessed by the BASMI was 1.0 for the infliximab treated group vs. 0.0 for the placebo group (p = 0.019). The median percent improvement from baseline in chest expansion was 17% for the infliximab treated group and 0% for the placebo group (p = 0.037). Physical function and quality of life as measured by the BASFI and the SF-36 were also improved significantly at week 24.
All improvements were maintained through week 102 and patients who crossed over to infliximab from placebo at week 24 showed improvement in all scores that were similar to the infliximab treated group at week 102.
There is no evidence available to suggest that infliximab therapy is able to retard the progression of joint damage or deformity caused by ankylosing spondylitis.
Psoriatic arthritis. Efficacy and safety were assessed in two multicentre, double blind, placebo controlled studies in patients with active psoriatic arthritis.
In the first study (IMPACT), efficacy and safety of infliximab were studied in 104 patients with active polyarticular psoriatic arthritis. In total, 74 subjects were on at least one concomitant DMARD, and among those, 58 patients were treated with methotrexate. During the 16 week double blind phase, patients received either 5 mg/kg infliximab or placebo at weeks 0, 2, 6 and 14 (52 patients in each group). Starting at week 16, placebo patients were switched to infliximab and all patients subsequently received 5 mg/kg infliximab every 8 weeks up to week 46. After the first year of the study, 78 patients continued into an open label extension to week 98.
In the second trial (IMPACT 2), efficacy and safety of infliximab were studied in 200 patients with active psoriatic arthritis (≥ 5 swollen joints and ≥ 5 tender joints) with one or more of the following subtypes: arthritis involving DIP joints, arthritis mutilans, asymmetric peripheral arthritis, polyarticular arthritis and spondylitis with peripheral arthritis. Patients also had plaque psoriasis with a qualifying target lesion ≥ 2 cm in diameter. Forty-six percent of patients continued on stable doses of methotrexate (≤ 25 mg/week). Patients had previously been treated with NSAIDs (81.5%), DMARDs (79.5%) and corticosteroids (29.0%). During the 24 week double blind phase, patients received either 5 mg/kg infliximab or placebo at weeks 0, 2, 6, 14 and 22 (100 patients in each group). At week 16, placebo patients with < 10% improvement from baseline in both swollen and tender joint counts were switched to infliximab induction (early escape). At week 24, all placebo treated patients crossed over to infliximab induction. Dosing continued for all patients through week 46.
Key efficacy results for IMPACT and IMPACT 2 are shown in Table 8.

In IMPACT and IMPACT 2, clinical responses were observed as early as week 2 and were maintained through week 98 and week 54, respectively. The responses were similar regardless of concomitant use of methotrexate.
Treatment with infliximab also resulted in significant improvements in measures of disease activity, including swollen joints, tender joints, dactylitis and enthesopathy as compared to placebo in both trials.
In the IMPACT and IMPACT 2 studies, 31% and 12%, respectively, of patients randomised to infliximab at baseline achieved a major clinical response (defined as achieving an ACR70 response at all visits for a continuous 24 week period) at week 98 and week 54, respectively. In contrast, 0% of patients in the placebo group in IMPACT (p < 0.001) and 2% of patients in the placebo group in IMPACT 2 (p = 0.006) achieved an ACR70 response at the last visit before receiving infliximab therapy.
Radiographic changes were assessed in the IMPACT 2 study. Radiographs of both the hands and feet were collected at baseline, weeks 24 and 54 in all patients. Infliximab treatment inhibited the progression of structural damage compared with placebo treatment at the week 24 primary endpoint as measured by change from baseline in total modified vdH-S score. Differences between infliximab and placebo groups at week 24 were statistically significant for total modified vdH-S score, hands, feet, erosion and joint space narrowing (JSN) scores. Significantly more subjects in the placebo group had readily apparent radiographic progression at week 24 in total modified vdH-S, erosion, and JSN scores compared with the proportion of subjects in the infliximab group. The maintenance of radiographic benefit was observed through 1 year.
The change from baseline at weeks 24 and 54 in the total modified vdH-S score in IMPACT 2 is presented in Table 9.

Infliximab treated patients also demonstrated significant improvement in physical function as assessed by HAQ. Significant improvements in health related quality of life were also demonstrated as measured by the physical and mental component summary scores of the SF-36 in IMPACT 2.
Psoriasis. The efficacy of infliximab was assessed in two multicentre, randomised, double blind studies: SPIRIT and EXPRESS. Patients in both studies had plaque psoriasis (body surface area [BSA] ≥ 10% and Psoriasis Area and Severity Index [PASI] score ≥ 12). The primary endpoint in both studies was the percent of patients who achieved ≥ 75% improvement in PASI from baseline at week 10. Marked responders were identified as patients who achieved ≥ 90% improvement in PASI from baseline.
SPIRIT evaluated the efficacy of infliximab induction therapy in 249 patients with plaque psoriasis that had previously received PUVA or systemic therapy. Patients received either 3 mg/kg or 5 mg/kg infliximab or placebo infusions at weeks 0, 2 and 6. Patients with a physician's global assessment (PGA) score ≥ 3 were eligible to receive an additional infusion of the same treatment at week 26.
In SPIRIT, the median baseline BSA was 27.0%, the median baseline PASI score was 18.9; 62.2% of patients had a baseline PGA score of "moderate" and 24.9% of patients had a baseline PGA score of "marked" or "severe". Prior therapy with PUVA, methotrexate, cyclosporin or acitretin had been received by 81.5% of the patients. The proportion of patients with ≥ 75% improvement in PASI from baseline (PASI 75) at week 10 was 79.8% in the combined infliximab group, 71.7% in the 3 mg/kg infliximab group, 87.9% in the 5 mg/kg infliximab group, and 5.9% in the placebo group (p < 0.001 for each infliximab versus placebo comparison). At week 10, a significantly greater proportion of infliximab treated patients, both in the combined group (51.5%) and in the individual groups (3 mg/kg: 45.5%; 5 mg/kg: 57.6%), achieved a marked response (≥ 90% improvement in PASI from baseline) compared to the placebo treated patients (2.0%). In the 3 mg/kg group, 60.6% of patients maintained response through week 14 and 75.3% of patients in the 5 mg/kg group maintained response through week 18. By week 26, twenty weeks after the last induction dose, 30% of patients in the 5 mg/kg group and 13.8% of patients in the 3 mg/kg group were PASI 75 responders, suggesting the need for maintenance therapy.
Health related quality of life, was assessed with the Dermatology Life Quality Index (DLQI). The median baseline DLQI was 12. The median change from baseline in DLQI at week 10 was -8.0 and -10.0 for the infliximab 3 mg/kg and 5 mg/kg groups, respectively, compared with 0.0 in the placebo group (p < 0.001 for all infliximab versus placebo comparisons), demonstrating a substantial improvement in quality of life for patients on infliximab therapy.
EXPRESS evaluated the efficacy of infliximab induction and maintenance therapy in 378 patients with plaque psoriasis who were candidates for phototherapy or systemic therapy. Patients received 5 mg/kg infliximab or placebo infusions at weeks 0, 2 and 6 followed by maintenance therapy every 8 weeks through week 22 in the placebo group and through week 46 in the infliximab group. At week 24, the placebo group crossed over to infliximab induction therapy (5 mg/kg) followed by infliximab maintenance therapy (5 mg/kg).
In EXPRESS, the median baseline BSA was 29%, the median baseline PASI score was 21.1 and the majority of patients (89.9%) had a PGA score of moderate, marked or severe. Prior therapy with PUVA, methotrexate, cyclosporin or acitretin had been received by 71.4% of patients. At week 10, PASI 75 response was achieved by 80.4% in the infliximab group vs. a placebo group rate of 2.6% (p < 0.001). Median time to PASI 75 was between 2 and 6 weeks. Improvement in PASI was consistent across subgroups defined by baseline demographics, clinical disease characteristics and psoriasis medication history. Marked responses (PASI 90) at week 10 were achieved by 57.1% of the infliximab group compared to 1.3% in the placebo group (p < 0.001). The response was maintained through the 24 weeks, the placebo controlled period. PASI response rates through week 50 are presented in Table 10.

At week 10, 82.9% of infliximab patients achieved a PGA score of minimal or cleared compared to 3.9% of placebo patients (p < 0.001). PGA scores at weeks 6, 10, 24 and 50 are presented in Table 11.

The median baseline value for the DLQI was 12.5. The mean baseline values were 45.6 for the SF-36 physical component and 45.7 for the mental component. Quality of life improved significantly compared to placebo at weeks 10 and 24 when evaluated by both DLQI and SF-36.
The median baseline NAPSI score for nail psoriasis was 4 and the median number of nails involved with psoriasis was 10. Patients treated with infliximab showed a clear improvement in nail psoriasis from baseline compared to placebo treated patients, as measured by NAPSI score, and by the decrease in number of nails involved.
Moderate to severe active Crohn's disease in adult patients (≥ 18 years). The safety and efficacy of single and multiple doses of Remicade were assessed in two randomised, double blind, placebo controlled studies in patients with moderate to severe active Crohn's disease, with Crohn's Disease Activity Index (CDAI) of 220 to 400 with an inadequate response to prior conventional therapies. Concurrent use of stable dose regimens of corticosteroids, 5-aminosalicylic acid (5-ASA), 6-mercaptopurine (6-MP) and/or azathioprine (AZA) was permitted and 92% of patients continued to receive at least one of these medications.
In the single dose trial of 108 patients, 22 of 27 (81%) of the Remicade treated patients receiving a 5 mg/kg dose achieved a clinical response (decrease in CDAI by ≥ 70 points) vs. 4 of 25 (16%) of the placebo treated patients (p < 0.001). Also at week 4, 13 of 27 (48%) of Remicade treated patients achieved a clinical remission (CDAI < 150) vs. 1 of 25 (4%) of placebo treated patients. Results are shown in Figure 1.

In the multidose trial, 573 patients with a score of at least CDAI 220 received 5 mg/kg at week 0. After assessment of response, patients were randomly assigned to one of three treatment groups: placebo at weeks 2 and 6 and then every 8 weeks until week 46; 5 mg/kg at weeks 2 and 6, and then every 8 weeks; and the 10 mg/kg maintenance group which received 5 mg/kg at weeks 2 and 6, and then 10 mg/kg every 8 weeks. The prespecified coprimary endpoints were the proportion of patients who responded at week 2 and were in remission (CDAI < 150) at week 30 and the time to loss of response in patients who responded. Analyses of the endpoints were on the intent to treat patient population.
At week 2, 58% (335/573) of patients had responded to a single infusion of Remicade and were in clinical response (decrease in CDAI ≥ 25% and ≥ 70 points). At week 30, 23 of 110 (21%) of placebo patients were in remission, compared with 44 of 113 (39%) of 5 mg/kg maintenance group (p = 0.003) and 50 of 112 (45%) (p = 0.0002) of 10 mg/kg maintenance group. Patients in the infliximab maintenance groups had significantly longer time to loss of response than patients in the placebo maintenance group (p < 0.001) (see Figure 2). Median time to loss of response was 46 weeks in the combined infliximab maintenance treatment group versus 19 weeks in the placebo maintenance group. Patients who achieved a response and subsequently lost response were eligible to receive infliximab on an episodic basis at a dose that was 5 mg/kg higher than the dose to which they were randomised. Eighty-nine percent (50/56) of patients who lost clinical response on infliximab 5 mg/kg every eight week maintenance dosing responded to a 10 mg/kg infliximab infusion.

Significant improvement in quality of life measures were seen in both the IBDQ and SF-36 (p < 0.001) scores in Remicade treated patients at week 30.
For patients receiving corticosteroids at baseline, the proportion of these patients in clinical remission and not receiving corticosteroids at week 30 was 31% (18 patients) for the 5 mg/kg maintenance group and 37% (21 patients) for the 10 mg/kg maintenance group, compared with 11% (6 patients) in the placebo maintenance group (p = 0.001 for both the 5 mg/kg and 10 mg/kg maintenance groups). The median corticosteroid dose at baseline (20 mg/day) was reduced to 10 mg/day in the placebo maintenance group and 0 mg/day in the combined infliximab maintenance groups by week 30, indicating that at least 50% of the infliximab maintenance patients were able to discontinue steroid use.
In a subset of patients who participated in an endoscopic substudy, a significantly greater proportion of patients in the infliximab maintenance groups combined (10/32 patients, 31%) had healing of the mucosa compared to patients in the placebo group (0/17 patients, 0%) at week 10 (p = 0.010). Results were similar at week 54.
Fistulising Crohn's disease. The safety and efficacy of Remicade were assessed in a randomised, double blind, placebo controlled study of 94 patients with fistulising Crohn's disease with fistulas that were of at least 3 months duration. Thirty-one of these patients were treated with infliximab 5 mg/kg. Approximately 93% of the patients had previously received antibiotic or immunosuppressive therapy.
Concurrent use of stable doses of conventional therapies was permitted and 83% of patients continued to receive at least one of these medications. Fifty-two (55%) had multiple cutaneously draining fistulas, 90% of patients had fistulas in the perianal area and 10% had abdominal fistulas.
Patients received 3 doses of Remicade 5 or 10 mg/kg or placebo at weeks 0, 2 and 6 and were followed up to 26 weeks. The primary endpoint was the proportion of patients who experienced a clinical response, defined as ≥ 50% reduction from baseline in the number of fistulas draining upon gentle compression, on at least two consecutive visits, without an increase in medication or surgery for Crohn's disease.
Sixty-eight percent (21/31) of infliximab treated patients receiving a 5 mg/kg dose regimen achieved a clinical response vs 26% (8/31) placebo treated patients (p = 0.002). The median time to onset of response in the Remicade treated group was 2 weeks. The median duration of response was 12 weeks. Additionally, closure of all fistulas was achieved in 55% of infliximab treated patients compared with 13% of placebo treated patients (p = 0.001).
The safety and efficacy of repeated infliximab infusions in patients with fistulising Crohn's disease were studied in a 1 year trial. A total of 306 patients received 3 doses of Remicade 5 mg/kg at weeks 0, 2 and 6. Among the randomised patients at baseline, 87% of the patients had perianal fistulas, 14% had abdominal fistulas, 9% had rectovaginal fistulas. The median CDAI score was 180. One hundred and ninety five patients responding to the 3 doses (for definition of response see description of primary endpoint for the trial above) were randomised at week 14 to receive either placebo or 5 mg/kg infliximab every 8 weeks through week 46. At week 14, 65% (177/273) of randomised patients were in fistula response. Patients randomised to infliximab maintenance had a significantly longer time to loss of fistula response compared to the placebo maintenance group (p < 0.001). Median time to loss of response was > 40 weeks in the infliximab group compared with 14 weeks in the placebo group. At week 54, 38% (33/87) of Remicade treated patients had no draining fistulas compared with 22% (20/90) of placebo treated patients (p = 0.02). The infliximab group showed greater improvement in CDAI score from baseline compared with placebo (p = 0.04). Patients who achieved a fistula response and subsequently lost response were eligible to receive Remicade maintenance therapy at a dose that was 5 mg/kg higher than the dose to which they were randomised. Of the placebo maintenance patients, 66% (25/38) responded to 5 mg/kg Remicade and 57% (12/21) of Remicade maintenance patients responded to 10 mg/kg. Compared to placebo maintenance, patients on Remicade maintenance had a trend toward fewer hospitalisations. At week 30, greater improvement from baseline in IBDQ scores was seen in the Remicade maintenance group compared to placebo maintenance. Improvement in both scores was maintained through week 54.
Active Crohn's disease in children and adolescent patients (6 to 17 years). The safety and efficacy of single and multiple doses of Remicade were assessed in a randomised, single dose, multicentre phase II study in 21 children and adolescent patients with active Crohn's disease and in a randomised, multiple dose, open label, multicentre phase III study in 112 children and adolescent Crohn's disease patients (the REACH trial). In REACH, all subjects were required to be on a stable dose of 6-mercaptopurine (6-MP), azathioprine (AZA) or methotrexate (MTX) (35% were also receiving corticosteroids at baseline).
In the phase II single dose trial of 21 patients (11 to 17 years old, median age 15.0 years), all patients achieved a clinical response (decrease in CDAI ≥ 70 points or decrease in PCDAI ≥ 10) at some point in the 20 weeks following the single dose of infliximab, and clinical remission (defined as a reduction in the modified CDAI score to below 150 points or a reduction in the PCDAI to below 10) was achieved by 10 (47.6%) patients. Of the 3 doses administered (1, 5 or 10 mg/kg), the 5 mg/kg and 10 mg/kg treatment groups had a larger proportion of patients achieving clinical remission (16.7% in the 1 mg/kg infliximab treatment group as compared with 57.1% and 62.5% in the 5 mg/kg and 10 mg/kg infliximab treatment groups, respectively). All 7 patients who had fistulising disease had their fistulas closed for at least 1 evaluation visit (8 weeks).
In the multiple dose phase III trial (REACH), 112 patients (6 to 17 years, median age 13.0 years) received 5 mg/kg infliximab at weeks 0, 2 and 6. Patients assessed by the investigator to be in clinical response at week 10 were randomised and received either 5 mg/kg infliximab 8 weekly or 12 weekly as a maintenance treatment regimen. If response was lost during maintenance treatment, crossing over to a higher dose or shorter dosing interval was allowed.
In REACH, clinical response at week 10 was 88.4% (99/112) as compared with 66.7% (128/192) in adults (ACCENT 1). Similarly, the proportion of subjects achieving clinical remission at week 10 was 58.9% (66/112) as compared with 39.1% (75/192) in adults (ACCENT 1).
At week 30, the proportion of subjects in clinical response was significantly higher in the 8 weekly (73.1%, 38/52) than in the 12 weekly maintenance treatment group (47.1%, 24/51; p = 0.007). At week 54, the proportion of subjects in clinical response was also significantly higher for subjects in the 8 weekly (63.5%, 33/52) than in the 12 weekly maintenance treatment group (33.3%, 17/51; p = 0.002).
At week 30, the proportion of patients in clinical remission was significantly higher in the 8 weekly maintenance treatment group (59.6%, 31/52) than in the 12 weekly maintenance treatment group (35.3%, 18/51; p = 0.013). At week 54, the proportion of patients in clinical remission was also significantly higher for patients in the 8 weekly (55.8%, 29/52) than in the 12 weekly (23.5%, 12/51; p < 0.001) maintenance treatment groups.
In REACH, the change from baseline in average daily corticosteroid use was significant at weeks 10, 30 and 54 (p < 0.001). For patients receiving corticosteroids at baseline in REACH, clinical remission achieved with no corticosteroids at week 30 was 45.8% for the 8 weekly and 33.3% for the 12 weekly maintenance treatment group. At week 54, 45.8% of patients in the 8 weekly and 16.7% of subjects in the 12 weekly maintenance treatment group were in clinical remission and not receiving corticosteroids.
Quality of life was assessed using the IMPACT III score (a QOL questionnaire specifically developed and validated for paediatric patients with inflammatory bowel disease). It was administered only to subjects in North America. The mean changes (negative change indicates improvement) from baseline of the IMPACT III score at weeks 10, 30 and 54 (-22.9, -21.1 and -24.3, respectively) were all significant (p < 0.001).
The height z-score is a measure of the deviation of the paediatric patient's height from the expected height for a population of the same age and gender. In the population studied, the median z-score at baseline was -1.6. The median changes from baseline in the z-scores were 0.3 and 0.4 for week 30 and week 54, respectively. The z-scores were significantly improved from baseline at both week 30 (p < 0.001) and week 54 (p < 0.001).
Ulcerative colitis. The safety and efficacy of infliximab were assessed in two (ACT 1 and ACT 2) randomised, double blind, placebo controlled clinical studies in adult patients with moderately to severely active ulcerative colitis (Mayo score 6 to 12; endoscopy subscore ≥ 2) with an inadequate response to conventional therapies [oral corticosteroids, aminosalicylates and/or immunomodulators (6-mercaptopurine (6-MP), azathioprine (AZA)]. Concomitant stable doses of oral aminosalicylates, corticosteroids and/or immunomodulatory agents were permitted. In both studies, patients were randomised to receive either placebo, 5 mg/kg infliximab, or 10 mg/kg infliximab at weeks 0, 2, 6, 14 and 22, and in ACT 1 at weeks 30, 38 and 46. Corticosteroid taper was permitted after week 8.
In both studies, clinical response and clinical remission were defined based on the Mayo score, which consists of four subscores: stool frequency, rectal bleeding, findings of endoscopy and physician's global assessment. Each subscore is rated on a scale from 0 to 3, indicating normal (0) to severe (3) activity. The Mayo score is the sum of the 4 subscores. Clinical response was defined as a decrease from baseline in the Mayo score of ≥ 30% and ≥ 3 points, accompanied by a decrease in the rectal bleeding subscore of ≥ 1 or a rectal bleeding subscore of 0 or 1. Clinical remission was defined as a Mayo score ≤ 2 points, with no individual subscore > 1.
In both ACT 1 and ACT 2 the primary endpoint was clinical response at week 8. The major secondary endpoints were clinical response at week 30, clinical remission at week 8 and clinical remission at week 30. The other major secondary endpoint was mucosal healing, which is defined as a Mayo endoscopy subscore of 0 or 1. Other efficacy endpoints include corticosteroid endpoint (decrease in median daily corticosteroid dose from baseline to week 30), sustained response (subjects in clinical response at both week 8 and week 30), sustained remission (subjects in clinical remission at both week 8 and week 30) and quality of life, as measured by the IBDQ, SF 36, and EQ-5D.

In both studies, a significantly greater percentage of patients in the infliximab groups were in clinical response and clinical remission at week 8 when compared to placebo. Furthermore, in both ACT 1 and ACT 2, a significantly greater proportion of patients treated with 5 mg/kg or 10 mg/kg infliximab experienced clinical response and clinical remission at week 30 compared to placebo treatment. In addition, the proportion of patients in sustained response (i.e. were in clinical response at both week 8 and week 30) in the infliximab groups was at least twice as large as in the placebo group. Results from weeks 8 and 30 are shown in Table 12.
Of patients treated with corticosteroids at baseline, a significantly greater proportion of patients in the infliximab treated groups were in clinical remission at week 30 and able to discontinue corticosteroids compared to the placebo treated patients (22.3% versus 7.2%, respectively, see Table 12).
Additionally, at weeks 8 and 30, a significantly greater proportion of patients in the 5 mg/kg and 10 mg/kg dose groups in ACT 1 and ACT 2 achieved mucosal healing compared to patients in the placebo group. The proportion of subjects with mucosal healing was similar between the 2 infliximab dose groups in the two studies (see Table 12).
The efficacy of Remicade through week 54 was assessed in the ACT 1 trial.
At 54 weeks, 44.9% of patients in the combined infliximab treatment group were in clinical response compared to 19.8% in the placebo treatment group (p < 0.001). Clinical remission and mucosal healing occurred in a greater proportion of patients in the combined infliximab treatment group compared to the placebo treatment group at week 54 (34.6% vs. 16.5%, p < 0.001 and 46.1% vs. 18.2%, p < 0.001, respectively). The proportions of patients in sustained response and sustained remission at week 54 were greater in the combined infliximab treatment group than in the placebo treatment group (37.9% vs. 14.0%, p < 0.001; and 20.2% vs. 6.6%, p < 0.001, respectively).
A greater proportion of patients in the combined infliximab treatment group were able to discontinue corticosteroids while remaining in clinical remission compared to the placebo treatment group at both week 30 (22.3% vs. 7.2%, p ≤ 0.001, see Table 12) and week 54 (21.0% vs. 8.9%, p = 0.022).
Infliximab improved quality of life, confirmed by statistically and clinically significant improvement in both disease specific measure, IBDQ, and by improvement in the generic 36 item short form survey SF-36.
From baseline through week 30 in the pooled data from ACT 1 and ACT 2, the mean number of hospitalisations was 50% lower in the combined infliximab treatment group than in the placebo treatment group (9 versus 18 hospitalisations per 100 subjects, p = 0.005). No notable differences were observed between the 5 mg/kg and 10 mg/kg infliximab treatment groups.
Paediatric ulcerative colitis (6 through 17 years). The efficacy and safety of induction and maintenance infliximab were assessed in a multicentre, randomised, open label, parallel group clinical study (C0168T72) in 60 paediatric patients aged 6 through 17 years (median age 14.5 years) with moderately to severe active ulcerative colitis (Mayo score of 6 to 12; endoscopic subscore > 2) with an inadequate response to conventional therapies. At baseline, 53% of patients were receiving aminosalicylates, 53% were receiving immunomodulator therapy (6-mercaptopurine (6-MP), azathioprine (AZA) and/or methotrexate (MTX)) and 62% of patients were receiving corticosteroids. Discontinuation of immunomodulators and corticosteroid taper were permitted after week 0.77% of patients had extensive disease as indicated by endoscopy.
All patients received an induction regimen of 5 mg/kg infliximab at weeks 0, 2, and 6. Patients who did not respond to infliximab at week 8 (n = 15) received no further drug and returned for safety follow-up. At week 8, 45 patients were randomised and received 5 mg/kg infliximab at either every 8 weeks or every 12 weeks as a maintenance treatment regimen.
The primary endpoint was clinical response at week 8, defined as a decrease from baseline in the Mayo score by ≥ 30% and ≥ 3 points, including a decrease in the rectal bleeding subscore by ≥ 1 points or achievement of a rectal bleeding subscore of 0 or 1. The proportion of patients in clinical response at week 8 was 73.3% (44/60). Clinical response at week 8 was similar between those with or without concomitant immunomodulator use at baseline.
Clinical remission at week 8 was measured by the Mayo score, defined as a Mayo score of ≤ 2 points with no individual subscore > 1. Clinical remission was also assessed at week 8 and week 54 using the Paediatric Ulcerative Colitis Activity Index (PUCAI) score and was defined by a PUCAI score of < 10 points. Clinical remission at week 8 was 40% (24/60) as measured by the Mayo score and 33.3% (17/51) as measured by the PUCAI score.
At week 54, the proportion of patients in clinical remission as measured by the PUCAI score was 38% (8/21) in the every 8 weeks maintenance group and 18% (4/22) in the every 12 weeks maintenance treatment group. For patients receiving corticosteroids at baseline, the proportion of patients in remission and not receiving corticosteroids at week 54 was 38.5% (5/13) for the every 8 weeks and 0% (0/13) for the every 12 weeks maintenance treatment group.
Mucosal healing was defined as an endoscopy subscore (from the Mayo score) of 0 or 1. The proportion of patients with mucosal healing at week 8 was 68.3% (41/60) of which 33% (20/60) of patients achieved complete mucosal healing defined as having an endoscopy subscore of 0.
Although endoscopy was optional at week 54, 9 patients who had mucosal healing at week 8 had endoscopies at week 54. 89% (8/9) of these patients were still in mucosal healing.

5.2 Pharmacokinetic Properties

In clinical trials in rheumatoid arthritis and Crohn's disease patients, single dose intravenous infusions of 1, 3, 5, 10 or 20 mg/kg of infliximab yielded dose proportional increases in the maximum serum concentration (C_max) and area under the concentration time curve (AUC). The volume of distribution at steady-state (median V_ss of 3.0 to 4.1 L) was not dependent on the administered dose and indicated that infliximab is predominantly distributed within the vascular compartment. The elimination pathways for infliximab have not been characterised. No major differences in clearance or volume of distribution were observed in patient subgroups defined by age, weight or hepatic or renal function. Paediatric Crohn's patients in the 5 mg/kg and 10 mg/kg treatment groups had slightly higher serum concentrations after the initial infusion and slightly lower serum concentrations at later time periods (4 to 12 weeks) compared to adult Crohn's patients. No notable differences in single dose pharmacokinetic parameters and terminal half-life were observed between paediatric and adult Crohn's disease patients. The relatively small number of patients evaluated makes further detailed comparison difficult.
Infliximab pharmacokinetic characteristics (including peak and trough concentrations and terminal half-life) were similar in paediatric (aged 6 to 17 years old) and adult patients with Crohn's disease or ulcerative colitis following the administration of 5 mg/kg infliximab.
At single doses of 3 and 10 mg/kg in rheumatoid arthritis patients and 5 mg/kg in Crohn's disease patients, the median C_max values were 77 and 277 microgram/mL and 118 microgram/mL, respectively. The median terminal half-life at these doses ranged from 8 to 9.5 days. In most patients, infliximab could be detected in the serum for at least 8 weeks after a single infusion. Following the 3 dose regimen a slight accumulation of infliximab was observed in the serum after the second dose and no further clinically relevant accumulation thereafter. The proportion of patients who had undetectable infliximab concentrations at 8 weeks, after a maintenance infusion, was approximately 20%.
Limited pharmacokinetic studies of infliximab in psoriasis appear to show no significant differences to the pharmacokinetics in other indications.

5.3 Preclinical Safety Data

Genotoxicity.

No genotoxic effects of infliximab were observed in assays for chromosomal damage (an assay performed using human lymphocytes and the in vivo mouse micronucleus test) or gene mutations (Salmonella-Escherichia coli, Ames, assay).

Carcinogenicity.

Long-term studies in animals have not been performed to evaluate the carcinogenic potential.

6 Pharmaceutical Particulars

6.1 List of Excipients

Monobasic sodium phosphate monohydrate, dibasic sodium phosphate dihydrate, sucrose, polysorbate 80.

6.2 Incompatibilities

No physical biochemical compatibility studies have been conducted to evaluate the coadministration of Remicade with other agents. Remicade should not be infused concomitantly in the same intravenous line with other agents.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store at 2° to 8° Celsius. Refrigerate.
Remicade may be stored at temperatures up to a maximum of 30°C for a single period of up to 12 months; but not exceeding the original expiration date. The new expiration date should be written on the carton. Upon removal from refrigerated storage, Remicade cannot be returned to refrigerated storage.

6.5 Nature and Contents of Container

Remicade 100 mg is supplied as a lyophilised powder in individually boxed single use glass vials with rubber stoppers and aluminium crimps protected by plastic caps.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Infliximab is a chimeric IgG1 monoclonal antibody composed of human constant and murine variable regions, having an approximate molecular weight of 149,100 daltons. Infliximab is produced by recombinant cell line cultured by continuous perfusion and it is purified by a series of steps that includes measures to inactivate and remove viruses.

7 Medicine Schedule (Poisons Standard)

S4 - Prescription Only Medicine.

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