Signs and symptoms
Movymia has been administered in single doses of up to 100 micrograms and in repeated doses of up to 60 micrograms/day for 6 weeks.
The effects of overdose that might be expected include delayed hypercalcaemia and risk of orthostatic hypotension. Nausea, vomiting, dizziness, and headache can also occur.
Overdose experience based on post-marketing spontaneous reports
In post-marketing spontaneous reports, there have been cases of medication error where the entire contents (up to 800 mcg) of the teriparatide pen have been administered as a single dose. Transient events reported have included nausea, weakness/lethargy and hypotension. In some cases, no adverse events occurred as a result of the overdose. No fatalities associated with overdose have been reported.
Overdose management
There is no specific antidote for Movymia. Treatment of suspected overdose should include transitory discontinuation of Movymia, monitoring of serum calcium, and implementation of appropriate supportive measures, such as hydration.
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
Summary of the safety profile
The most commonly reported adverse reactions in patients treated with Movymia are nausea, pain in limb, headache and dizziness.
Tabulated list of adverse reactions
Of patients in the teriparatide trials, 82.8 % of the Movymia patients and 84.5 % of the placebo patients reported at least 1 adverse event.
The adverse reactions associated with the use of teriparatide in osteoporosis clinical trials and post-marketing exposure are summarised in the table below. The following convention has been used for the classification of the adverse reactions: very common (> 1/10), common (> 1/100 to < 1/10), uncommon (> 1/1,000 to < 1/100), rare (> 1/10,000 to < 1/1,000), very rare (< 1/10,000).
| Blood and lymphatic system disorders Common: Anaemia |
| Immune System Disorder Rare: Anaphylaxis |
| Metabolism and nutrition disorders Common: Hypercholesterolaemia Uncommon: Hypercalcaemia greater than 2.76 mmol/L, hyperuricaemia Rare: Hypercalcaemia greater than 3.25 mmol/L |
| Psychiatric disorders Common: Depression |
| Nervous system disorders Common: Dizziness, headache, sciatica, syncope |
| Ear and labyrinth disorders Common: Vertigo |
| Cardiac disorders Common: Palpitations Uncommon: Tachycardia |
| Vascular disorders Common: Hypotension |
| Respiratory, thoracic and mediastinal disorders Common: Dyspnoea Uncommon: Emphysema |
| Gastrointestinal disorders Common: Nausea, vomiting, hiatus hernia, gastro-oesophageal reflux disease Uncommon: Haemorrhoids |
| Skin and subcutaneous tissue disorders Common: Sweating increased |
| Musculoskeletal and connective tissue disorders Very common: Pain in limb Common: Muscle cramps Uncommon: Myalgia, arthralgia, back cramp/pain* |
| Renal and urinary disorders Uncommon: Urinary incontinence, polyuria, micturition urgency, nephrolithiasis Rare: Renal failure/impairment |
| General disorders and administration site conditions Common: Fatigue, chest pain, asthenia, mild and transient injection site events, including pain, swelling, erythema, localised bruising, pruritus and minor bleeding at injection site Uncommon: Injection site erythema, injection site reaction Rare: Possible allergic events soon after injection: acute dyspnoea, oro/facial oedema, generalised urticaria, chest pain, oedema (mainly peripheral) |
| Investigations Uncommon: Weight increased, cardiac murmur, alkaline phosphatase increase |
* Serious cases of back cramp or pain have been reported within minutes of the injection.
Description of selected adverse reactions
In clinical trials the following reactions were reported at a > 1 % difference in frequency from placebo: vertigo, nausea, pain in limb, dizziness, depression, dyspnoea.
Movymia increases serum uric acid concentrations. In clinical trials, 2.8 % of Movymia patients had serum uric acid concentrations above the upper limit of normal compared with 0.7 % of placebo patients. However, the hyperuricaemia did not result in an increase in gout, arthralgia, or urolithiasis.
In a large clinical trial, antibodies that cross-reacted with teriparatide were detected in 2.8 % of women receiving Movymia. Generally, antibodies were first detected following 12 months of treatment and diminished after withdrawal of therapy. There was no evidence of hypersensitivity reactions, allergic reactions, effects on serum calcium, or effects on Bone Mineral Density (BMD) response.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Ireland: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517; website: www.hpra.ie; e-mail: [email protected], or United Kingdom: Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
Teriparatide was not genotoxic in a standard battery of tests. It produced no teratogenic effects in rats, mice or rabbits. There were no important effects observed in pregnant rats or mice administered teriparatide at daily doses of 30 to 1,000 µg/kg. However, foetal resorption and reduced litter size occurred in pregnant rabbits administered daily doses of 3 to 100 µg/kg. The embryotoxicity observed in rabbits may be related to their much greater sensitivity to the effects of PTH on blood-ionised calcium compared with rodents.
Rats treated with near-lifetime daily injections had dose-dependent exaggerated bone formation and increased incidence of osteosarcoma most probably due to an epigenetic mechanism. Teriparatide did not increase the incidence of any other type of neoplasia in rats. Due to the differences in bone physiology in rats and humans, the clinical relevance of these findings is probably minor. No bone tumours were observed in ovariectomised monkeys treated for 18 months or during a 3-year follow-up period after treatment cessation. In addition, no osteosarcomas have been observed in clinical trials or during the post-treatment follow-up study.
Animal studies have shown that severely reduced hepatic blood flow decreases exposure of PTH to the principal cleavage system (Kupffer cells) and consequently clearance of PTH(1-84).
Pharmaco-therapeutic group: Calcium homeostasis, parathyroid hormones and analogues, ATC code: H05 AA02.
Mechanism of action
Endogenous 84-amino-acid parathyroid hormone (PTH) is the primary regulator of calcium and phosphate metabolism in bone and kidney. Movymia (rhPTH[1-34]) is the active fragment (1-34) of endogenous human parathyroid hormone. Physiological actions of PTH include stimulation of bone formation by direct effects on bone-forming cells (osteoblasts) indirectly increasing the intestinal absorption of calcium and increasing the tubular re-absorption of calcium and excretion of phosphate by the kidney.
Pharmacodynamic effects
Movymia is a bone formation agent to treat osteoporosis. The skeletal effects of Movymia depend upon the pattern of systemic exposure. Once-daily administration of Movymia increases apposition of new bone on trabecular and cortical bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity.
Clinical efficacy
Risk Factors
Independent risk factors, for example, low BMD, age, the existence of previous fracture, family history of hip fractures, high bone turnover and low body mass index should be considered in order to identify women and men at increased risk of osteoporotic fractures who could benefit from treatment.
Premenopausal women with glucocorticoid-induced osteoporosis should be considered at high risk for fracture if they have a prevalent fracture or a combination of risk factors that place them at high risk for fracture (e.g., low bone density [e.g., T-score ≤−2], sustained high dose glucocorticoid therapy [e.g., >7.5 mg/day for at least 6 months], high underlying disease activity, low sex steroid levels).
Postmenopausal osteoporosis
The pivotal study included 1,637 postmenopausal women (mean age 69.5 years). At baseline, ninety percent of the patients had one or more vertebral fractures and on average, vertebral BMD was 0.82 g/cm2 (equivalent to a T-score = -2.6). All patients were offered 1,000 mg calcium per day and at least 400 IU vitamin D per day. Results from up to 24 months (median: 19 months) treatment with Movymia demonstrate statistically significant fracture reduction (Table 1). To prevent one or more new vertebral fractures, 11 women had to be treated for a median of 19 months.
| Table 1 Fracture Incidence in Postmenopausal Women | |||
|
| Placebo (N = 544) (%) | Movymia (N = 541) (%) | Relative Risk (95% CI) vs placebo |
| New vertebral fracture (>1)a | 14.3 | 5.0 b | 0.35 (0.22, 0.55) |
| Multiple vertebral fractures (>2)a | 4.9 | 1.1 b | 0.23 (0.09, 0.60) |
| Non-vertebral fragility fractures c | 5.5 | 2.6 d | 0.47 (0.25, 0.87) |
| Major non-vertebral fragility fracturesc (hip, radius, humerus, ribs and pelvis) | 3.9 | 1.5 d | 0.38 (0.17, 0.86) |
| Abbreviations: N = number of patients randomly assigned to each treatment group; CI = Confidence Interval. a The incidence of vertebral fractures was assessed in 448 placebo and 444 Movymia patients who had baseline and follow-up spine radiographs b p≤0.001 compared with placebo c A significant reduction in the incidence of hip fractures has not been demonstrated d p≤0.025 compared with placebo | |||
After 19 months (median) treatment, bone mineral density (BMD) had increased in the lumbar spine and total hip, respectively, by 9 % and 4 % compared with placebo (p < 0.001).
Post-treatment management: Following treatment with Movymia, 1,262 postmenopausal women from the pivotal trial enrolled in a post-treatment follow-up study. The primary objective of the study was to collect safety data of Movymia. During this observational period, other osteoporosis treatments were allowed and additional assessment of vertebral fractures was performed.
During a median of 18 months following discontinuation of Movymia, there was a 41 % reduction (p = 0.004) compared with placebo in the number of patients with a minimum of one new vertebral fracture.
In an open-label study, 503 postmenopausal women with severe osteoporosis and a fragility fracture within the previous 3 years (83 % had received previous osteoporosis therapy) were treated with Movymia for up to 24 months. At 24 months, the mean increase from baseline in lumbar spine, total hip and femoral neck BMD was 10.5 %, 2.6 %, and 3.9 % respectively. The mean increase in BMD from 18 to 24 months was 1.4 %, 1.2 %, and 1.6 % at the lumbar spine, total hip and femoral neck, respectively.
A 24-month, randomized, double-blind, comparator-controlled Phase 4 study included 1,360 postmenopausal women with established osteoporosis. 680 subjects were randomised to Movymia and 680 subjects were randomised to oral risedronate 35 mg/week. At baseline, the women had a mean age of 72.1 years and a median of 2 prevalent vertebral fractures; 57.9 % of patients had received previous bisphosphonate therapy and 18.8 % took concomitant glucocorticoids during the study. 1,013 (74.5 %) patients completed the 24-month follow-up. The mean (median) cumulative dose of glucocorticoid was 474.3 (66.2) mg in the teriparatide arm and 898.0 (100.0) mg in the risedronate arm. The mean (median) vitamin D intake for the teriparatide arm was 1433 IU/day (1400 IU/day) and for the risedronate arm was 1191 IU/day (900 IU/day). For those subjects who had baseline and follow-up spine radiographs, the incidence of new vertebral fractures was 28/516 (5.4 %) in Movymia- and 64/533 (12.0 %) in risedronate-treated patients, relative risk (95 % CI) = 0.44 (0.29-0.68), P < 0.0001. The cumulative incidence of pooled clinical fractures (clinical vertebral and non vertebral fractures) was 4.8 % in Movymia and 9.8 % in risedronate-treated patients, hazard ratio (95 % CI) = 0.48 (0.32-0.74), P=0.0009.
Male osteoporosis
437 patients (mean age 58.7 years) were enrolled in a clinical trial for men with hypogonadal (defined as low-morning free testosterone or an elevated FSH or LH) or idiopathic osteoporosis. Baseline spinal and femoral neck bone mineral density mean T-scores were -2.2 and -2.1, respectively. At baseline, 35 % of patients had a vertebral fracture and 59 % had a non-vertebral fracture.
All patients were offered 1,000 mg calcium per day and at least 400 IU vitamin D per day. Lumbar spine BMD significantly increased by 3 months. After 12 months, BMD had increased in the lumbar spine and total hip by 5 % and 1 %, respectively, compared with placebo. However, no significant effect on fracture rates was demonstrated.
Glucocorticoid-induced osteoporosis
The efficacy of Movymia in men and women (N =428) receiving sustained systemic glucocorticoid therapy (equivalent to 5 mg or greater of prednisone for at least 3 months) was demonstrated in the 18-month primary phase of a 36-month, randomised, double-blind, comparator-controlled study (alendronate 10 mg/day). Twenty-eight percent of patients had one or more radiographic vertebral fractures at baseline. All patients were offered 1,000 mg calcium per day and 800 IU vitamin D per day.
This study included postmenopausal women (N =277), premenopausal women (N =67), and men (N =83). At baseline, the postmenopausal women had a mean age of 61 years, mean lumbar spine BMD T-score of −2.7, median prednisone equivalent dose of 7.5 mg/day, and 34 % had one or more radiographic vertebral fractures; premenopausal women had a mean age of 37 years, mean lumbar spine BMD T-score of −2.5, median prednisone equivalent dose of 10 mg/day, and 9 % had one or more radiographic vertebral fractures; and men had a mean age of 57 years, mean lumbar spine BMD T-score of −2.2, median prednisone equivalent dose of 10 mg/day, and 24 % had one or more radiographic vertebral fractures.
Sixty-nine percent of patients completed the 18-month primary phase. At the 18-month endpoint, Movymia significantly increased lumbar spine BMD (7.2 %) compared with alendronate (3.4 %) (p<0.001). Movymia increased BMD at the total hip (3.6 %) compared with alendronate (2.2 %) (p<0.01), as well as at the femoral neck (3.7 %) compared with alendronate (2.1 %) (p<0.05). In patients treated with teriparatide, lumbar spine, total hip and femoral neck BMD increased between 18 and 24 months by an additional 1.7 %, 0.9 %, and 0.4 %, respectively.
At 36 months, analysis of spinal X-rays from 169 alendronate patients and 173 Movymia patients showed that 13 patients in the alendronate group (7.7 %) had experienced a new vertebral fracture compared with 3 patients in the Movymia group (1.7 %) (p=0.01). In addition, 15 of 214 patients in the alendronate group (7.0 %) had experienced a non-vertebral fracture compared with 16 of 214 patients in the Movymia group (7.5 %) (p=0.84).
In premenopausal women, the increase in BMD from baseline to 18-month endpoint was significantly greater in the Movymia group compared with the alendronate group at the lumbar spine (4.2 % versus −1.9 %; p<0.001) and total hip (3.8 % versus 0.9 %; p =0.005). However, no significant effect on fracture rates was demonstrated.
Distribution
The volume of distribution is approximately 1.7 L/kg. The half-life of Movymia is approximately 1 hour when administered subcutaneously, which reflects the time required for absorption from the injection site.
Biotransformation
No metabolism or excretion studies have been performed with Movymia, but the peripheral metabolism of parathyroid hormone is believed to occur predominantly in liver and kidney.
Elimination
Movymia is eliminated through hepatic and extra-hepatic clearance (approximately 62 L/hr in women and 94 L/hr in men).
Elderly
No differences in Movymia pharmacokinetics were detected with regard to age (range 31 to 85 years). Dosage adjustment based on age is not required.
Movymia is supplied in a pre-filled pen. Each pen should be used by only one patient. A new, sterile needle must be used for every injection. Each Movymia pack is provided with a User Manual that fully describes the use of the pen. No needles are supplied with the product. The device can be used with insulin pen injection needles. After each injection, the Movymia pen should be returned to the refrigerator.
Movymia should not be used if the solution is cloudy, coloured or contains particles.
Please also refer to the user manual for instructions on how to use the pen.
Any unused product or waste material should be disposed of in accordance with local requirements.
