A few cases of overdose with Copaxone (up to 300 mg glatiramer acetate) have been reported. These cases were not associated with any adverse reactions other than those mentioned in section “Undesirable effectsâ€.
In case of overdose, patients should be monitored and the appropriate symptomatic and supportive therapy instituted.
Copaxone is contraindicated under the following conditions:
-
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
Most Copaxone safety data were accumulated for Copaxone 20 mg/ml administered as a subcutaneous injection once daily. This section presents accumulated safety data from four placebo-controlled trials with Copaxone 20 mg/ml administered once daily, and from one placebo-controlled trial with Glatirate mg/ml administered three times a week.
A direct comparison of the safety between Copaxone 20 mg/ml (administered daily) and 40 mg/ml (administered three times per week) in the same study has not been performed.
Copaxone 20 mg/ml (administered once daily)
In all clinical trials with Copaxone 20 mg/ml, injection-site reactions were seen to be the most frequent adverse reactions and were reported by the majority of patients receiving Copaxone. In controlled studies, the proportion of patients reporting these reactions, at least once, was higher following treatment with Copaxone 20 mg/ml (70%) than placebo injections (37%). The most commonly reported injection-site reactions, which were more frequently reported in Copaxone 20 mg/ml vs. placebo-treated patients, were erythema, pain, mass, pruritus, oedema, inflammation and hypersensitivity.
A reaction, associated with at least one or more of the following symptoms, has been described as the immediate post-injection reaction: vasodilatation, chest pain, dyspnoea, palpitation or tachycardia. This reaction may occur within minutes of a Copaxone injection. At least one component of this immediate post-injection reaction was reported at least once by 31% of patients receiving Copaxone 20 mg/ml compared to 13% of patients receiving placebo.
All adverse reactions, which were more frequently reported in Copaxone 20 mg/ml vs. placebo-treated patients, are presented in the table below. This data was derived from four pivotal, double-blind, placebo-controlled clinical trials with a total of 512 patients treated with Copaxone 20 mg/day and 509 patients treated with placebo for up to 36 months. Three trials in relapsing-remitting MS (RRMS) included a total of 269 patients treated with Copaxone 20 mg/day and 271 patients treated with placebo for up to 35 months. The fourth trial in patients who have experienced a first clinical episode and were determined to be at high risk of developing clinically definite MS included 243 patients treated with Copaxone 20mg/day and 238 patients treated with placebo for up to 36 months.
| System Organ Class (SOC) | Very Common (>1/10) | Common (>1/100 to <1/10) | Uncommon (>1/1,000 to <1/100) |
| Infections and infestations | Infection, Influenza | Bronchitis, Gastroenteritis, Herpes Simplex, Otitis Media, Rhinitis, Tooth Abscess, Vaginal Candidiasis* | Abscess, Cellulitis, Furuncle, Herpes Zoster, Pyelonephritis |
| Neoplasms benign, malignant and unspecified (incl cysts and polyps) | Benign Neoplasm Of Skin, Neoplasm | Skin Cancer | |
| Blood and lymphatic system disorders | Lymphadenopathy* | Leukocytosis, Leukopenia, Splenomegaly Thrombocytopenia, Lymphocyte Morphology Abnormal | |
| Immune system disorders | Hypersensitivity | ||
| Endocrine disorders | Goitre, Hyperthyroidism | ||
| Metabolism and nutrition disorders | Anorexia, Weight Increased* | Alcohol Intolerance, Gout, Hyperlipidaemia, Blood Sodium Increased, Serum Ferritin Decreased | |
| Psychiatric disorders | Anxiety*, Depression | Nervousness | Abnormal Dreams, Confusional State, Euphoric Mood, Hallucination, Hostility, Mania, Personality Disorder, Suicide Attempt |
| Nervous system disorders | Headache, | Dysgeusia, Hypertonia, Migraine, Speech Disorder, Syncope, Tremor* | Carpal Tunnel Syndrome, Cognitive Disorder, Convulsion, Dysgraphia, Dyslexia, Dystonia, Motor Dysfunction, Myoclonus, Neuritis, Neuromuscular Blockade, Nystagmus, Paralysis, Peroneal Nerve Palsy, Stupor, Visual Field Defect |
| Eye disorders | Diplopia, Eye Disorder* | Cataract, Corneal Lesion, Dry Eye, Eye Haemorrhage, Eyelid Ptosis, Mydriasis, Optic Atrophy | |
| Ear and labyrinth disorders | Ear Disorder | ||
| Cardiac disorders | Palpitations*, Tachycardia* | Extrasystoles, Sinus Bradycardia, Tachycardia Paroxysmal | |
| Vascular disorders | Vasodilatation* | Varicose Vein | |
| Respiratory, thoracic and mediastinal disorders | Dyspnoea* | Cough, Rhinitis Seasonal | Apnoea, Epistaxis, Hyperventilation, Laryngospasm, Lung Disorder, Choking Sensation |
| Gastrointestinal disorders | Nausea* | Anorectal Disorder, Constipation, Dental Caries, Dyspepsia, Dysphagia, Faecal Incontinence, Vomiting* | Colitis, Colonic Polyp, Enterocolitis, Eructation, Oesophageal Ulcer, Periodontitis Rectal Haemorrhage, Salivary Gland Enlargement |
| Hepatobiliary disorders | Liver Function Test Abnormal | Cholelithiasis, Hepatomegaly | |
| Skin and subcutaneous tissue disorders | Rash* | Ecchymosis, Hyperhidrosis, Pruritus, Skin Disorder*, Urticaria | Angioedema, Dermatitis Contact, Erythema Nodosum, Skin Nodule |
| Musculoskeletal and connective tissue disorders | Arthralgia, Back Pain* | Neck Pain | Arthritis, Bursitis, Flank Pain, Muscle Atrophy, Osteoarthritis |
| Renal and urinary disorders | Micturition Urgency, Pollakiuria, Urinary Retention | Haematuria, Nephrolithiasis, Urinary Tract Disorder, Urine Abnormality | |
| Pregnancy, puerperium and perinatal Conditions | Abortion | ||
| Reproductive system and breast disorders | Breast Engorgement, Erectile Dysfunction, Pelvic Prolapse, Priapism, Prostatic Disorder, Smear Cervix Abnormal, Testicular Disorder, Vaginal Haemorrhage, Vulvovaginal Disorder | ||
| General disorders and administration site conditions | Asthenia, Chest Pain*, Injection Site Reactions*§, Pain* | Chills*, Face Oedema*, Injection Site Atrophy#, Local Reaction*, Oedema Peripheral, Oedema, Pyrexia | Cyst, Hangover, Hypothermia, Immediate Post-Injection Reaction, Inflammation, Injection Site Necrosis, Mucous Membrane Disorder |
| Injury, poisoning and procedural complications | Post Vaccination Syndrome |
* More than 2% (>2/100) higher incidence in the Copaxone treatment group than in the placebo group. Adverse reaction without the * symbol represents a difference of less than or equal to 2%.
§ The term 'injection site reactions' (various kinds) comprises all adverse events occurring at the injection site excluding injection site atrophy and injection site necrosis, which are presented separately within the table.
# Includes terms which relate to localized lipoatrophy at the injection sites.
In the fourth trial noted above, an open-label treatment phase followed the placebo-controlled period. No change in the known risk profile of Copaxone 20 mg/ml was observed during the open-label follow-up period of up to 5 years.
Rare (>1/10,000 to <1/1,000) reports of anaphylactoid reactions were collected from MS patients treated with Copaxone in uncontrolled clinical trials and from post-marketing experience with Copaxone.
Glatirate mg/ml (administered three times per week)
The safety of Glatirate mg/ml was assessed based on a double-blind, placebo-controlled clinical trial in RRMS patients with a total of 943 patients treated with Glatirate mg/ml three times per week, and 461 patients treated with placebo for 12 months.
In general, the kind of adverse drug reactions seen in patients treated with Glatirate mg/ml administered three times per week were those already known and labelled for Copaxone 20 mg/ml administered daily. In particular, adverse injection site reactions (ISR) and immediate post-injection reactions (IPIR) were reported at lower frequency for Glatirate mg/ml administered three times per week than for Copaxone 20 mg/ml administered daily (35.5 % vs. 70 % for ISRs and 7.8 % vs. 31 % for IPIRs, respectively).
Injection site reactions were reported by 36% of the patients on Glatirate mg/ml compared to 5% on placebo. Immediate post-injection reaction was reported by 8% of the patients on Glatirate mg/ml compared to 2% on placebo.
A few specific adverse reactions are noted:
- Anaphylactic response was seen rarely (>1/10,000, <1/1,000) in MS patients treated with Copaxone 20 mg/ml in uncontrolled clinical trials and from post-marketing experience. It was reported by 0.3% of the patients on Glatirate mg/ml (Uncommon: > 1/1,000 to < 1/100).
- No injection site necrosis was reported.
- Skin erythema and pain in extremity, not labelled for Copaxone 20 mg/ml, were reported each by 2.1% of the patients on Glatirate mg/ml (Common: > 1/100 to < 1/10).
- Drug-induced liver injury and toxic hepatitis, also seen rarely in MS patients treated with Copaxone 20 mg/ml in post marketing surveillance, were each reported by one patient (0.1%) on Glatirate mg/ml (Uncommon: > 1/1,000 to < 1/100).
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard
Preclinical data reveal no special hazard for humans based on studies of safety pharmacology, repeated dose toxicity, toxicity to reproduction, genotoxicity or carcinogenicity, beyond the information included in other sections of the SmPC. Due to the lack of pharmacokinetic data in humans, margins of exposure between humans and animals cannot be established.
Immune complex deposition in the glomeruli of the kidney was reported in a small number of rats and monkeys treated for at least 6 months. In a 2 years rat study, no indication of immune complex deposition in the glomeruli of the kidney was seen.
Anaphylaxis after administration to sensitised animals (guinea pigs or mice) was reported. The relevance of these data for humans is unknown.
Toxicity at the injection site was a common finding after repeated administration in animals.
). Copaxone is not indicated in primary or secondary progressive MS.
Pharmacotherapeutic group: Antineoplastic and immunomodulating agents, immunostimulantsATC code: L03AX13
The mechanism(s) by which glatiramer acetate exerts its effects in patients with MS is (are) not fully elucidated. However, it is thought to act by modifying immune processes that are currently believed to be responsible for the pathogenesis of MS. This hypothesis is supported by findings of studies that have been carried out to explore the pathogenesis of experimental allergic encephalomyelitis (EAE), a condition induced in several animal species through immunisation against central nervous system derived material containing myelin and often used as an experimental animal model of MS. Studies in animals and in MS patients suggest that upon its administration, glatiramer acetate-specific suppressor T cells are induced and activated in the periphery.
Relapsing-Remitting Multiple Sclerosis
Evidence supporting the effectiveness of Glatirate mg/ml injection administered subcutaneously three times a week in decreasing the frequency of relapses derives from one 12-month placebo-controlled study.
In the pivotal clinical trial Relapsing-Remitting Multiple Sclerosis was characterized by either at least one documented relapse in the last 12 months, or at least two documented relapses in the last 24 months, or one documented relapse between the last 12 and 24 months with at least one documented T1-gadolinium enhancing lesion on magnetic resonance imaging performed the last 12 months.
The primary outcome measure was the total number of confirmed relapses. Secondary MRI outcomes included the cumulative number of new/enlarging T2 lesions and the cumulative number of enhancing lesions on T1-weighted images, both measured at months 6 and 12.
A total of 1404 patients were randomized in a 2:1 ratio to receive either Glatirate mg/ml (n=943) or placebo (n=461). Both treatment groups were comparable with respect to baseline demographics, MS disease characteristics and MRI parameters. Patients had a median of 2.0 relapses in the 2 years prior to screening.
Compared to placebo, patients treated with Glatirate mg/ml three times per week had meaningful and statistically significant reductions in the primary and secondary outcome measures which are consistent with the treatment effect of Copaxone 20 mg/ml administered daily.
The following table presents the values for the primary and secondary outcome measures for the intent-to-treat population:
| Outcome Measure | Adjusted Mean Estimates | P-Value | |
| Copaxone (40 mg/ml) (N=943) | Placebo (N=461) | ||
| Annualized relapse rate (ARR) | 0.331 | 0.505 | p<0.0001 |
| Absolute Risk Difference* (95% confidence intervals) | -0.174 [-0.2841 to -0.0639] | ||
| Cumulative number of new/enlarging T2 lesions at months 6 and 12 | 3.650 | 5.592 | p<0.0001 |
| Rate ratio** (95% confidence intervals) | 0.653 [0.546 to 0.780] | ||
| Cumulative number of enhancing lesions on T1-weighted images at months 6 and 12 | 0.905 | 1.639 | p<0.0001 |
| Rate ratio** (95% confidence intervals) | 0.552 [0.436 to 0.699] | ||
*Absolute risk difference is defined as the difference between the adjusted mean ARR of GA 40 mg TIW and adjusted mean ARR of Placebo.
** Rate ratio is defined as the ratio between GA 40 mg TIW and Placebo adjusted mean rates.
A direct comparison of the efficacy and safety between Copaxone 20 mg/ml (administered daily) and 40 mg/ml (administered three times per week) in the same study has not been performed.
There is no evidence that Copaxone treatment had an effect on progression of disability or relapse duration in this 12-month study.
There is currently no evidence for the use of Copaxone in patients with primary or secondary progressive disease.
Pharmacokinetic studies in patients have not been performed. In vitro data and limited data from healthy volunteers indicate that with subcutaneous administration of glatiramer acetate, the active substance is readily absorbed and that a large part of the dose is rapidly degraded to smaller fragments already in subcutaneous tissue.
Copaxone should only be administered subcutaneously. Copaxone should not be administered by intravenous or intramuscular routes.
The initiation of Copaxone treatment should be supervised by a neurologist or a physician experienced in the treatment of MS.
The treating physician should explain to the patient that a reaction associated with at least one of the following symptoms may occur within minutes of a Copaxone injection: vasodilatation (flushing), chest pain, dyspnoea, palpitations or tachycardia. The majority of these symptoms is short-lived and resolves spontaneously without any sequelae. Should a severe adverse event occur, the patient must immediately stop Copaxone treatment and contact his/her physician or any emergency doctor. Symptomatic treatment may be instituted at the discretion of the physician.
There is no evidence to suggest that any particular patient groups are at special risk for these reactions. Nevertheless, caution should be exercised when administering Copaxone to patients with pre-existing cardiac disorders. These patients should be followed up regularly during treatment.
Convulsions and/or anaphylactoid or allergic reactions have been reported rarely. Serious hypersensitivity reactions (e.g. bronchospasm, anaphylaxis or urticaria) may rarely occur. If reactions are severe, appropriate treatment should be instituted and Copaxone should be discontinued.
Glatiramer acetate-reactive antibodies were detected in patients' sera during daily chronic treatment with Copaxone. Maximal levels were attained after an average treatment duration of 3-4 months and, thereafter, declined and stabilised at a level slightly higher than baseline.
There is no evidence to suggest that these glatiramer acetate-reactive antibodies are neutralising or that their formation is likely to affect the clinical efficacy of Copaxone.
In patients with renal impairment, renal function should be monitored while they are treated with Copaxone. Whilst there is no evidence of glomerular deposition of immune complexes in patients, the possibility cannot be excluded.
No studies on the effects on the ability to drive and use machines have been performed.
Posology
The recommended dosage in adults is 40 mg of Copaxone (one pre-filled syringe), administered as a subcutaneous injection three times a week with at least 48 hours apart.
At the present time, it is not known for how long the patient should be treated.
A decision concerning long term treatment should be made on an individual basis by the treating physician.
Paediatric population
Children and adolescents: No clinical trials or pharmacokinetic studies have been conducted in children or adolescents for Copaxone. There is not enough information available on the use of Glatirate mg/ml TIW in children and adolescents below 18 years of age to make any recommendation for its use. Therefore, Glatirate mg/ml TIW should not be used in this population.
Elderly patients
Copaxone has not been specifically studied in the elderly.
Patients with renal impairment
Copaxone has not been specifically studied in patients with renal impairment.
Method of administration
Patients should be instructed in self-injection techniques and should be supervised by a health-care professional the first time they self-inject and for 30 minutes after.
A different site should be chosen for every injection, so this will reduce the chances of any irritation or pain at the site of the injection. Sites for self-injection include the abdomen, arms, hips and thighs.
For single use only. Any unused product or waste material should be disposed of in accordance with local requirements.
