European Medicines Agency (EMA) has concluded that Xeljanz (tofacitinib) could increase the risk of blood clots in the lungs and in deep veins in patients who are already at high risk.
As a result, EMA is recommending that Xeljanz should be used with caution in all patients at high risk of blood clots. In addition, the maintenance doses of 10 mg twice daily should not be used in patients with ulcerative colitis who are at high risk of blood clots unless there is no suitable alternative treatment. Further, EMA is recommending that, due to an increased risk of infections, patients older than 65 years of age should be treated with Xeljanz only when there is no alternative treatment.
These recommendations follow the EMA’s review of an ongoing study (study A3921133) in patients with rheumatoid arthritis and an increased risk of cardiovascular disease, plus data from earlier studies and consultation with experts in the field. All data combined showed that the risk of blood clots in deep veins and lungs was higher in patients taking Xeljanz, especially the 10 mg twice daily dose, and in those being treated for an extended period. Results also showed a further increased risk of serious and fatal infections in patients older than 65 years of age.
The recommendations were issued by the EMA’s safety committee (PRAC) and have now been endorsed by EMA’s human medicines committee (CHMP). They will replace the measures put in place at the start of the review in May 2019. The changes come into force when the European Commission issues its decision.
Information for patients
• Xeljanz could increase the risk of blood clots in patients who are already at high risk.
• If you are being treated with Xeljanz your doctor will review your risk of blood clots and modify your treatment if necessary.
• You may be at high risk of blood clots in the lungs and in deep veins if you have had a heart attack or have heart failure, cancer, inherited blood clotting disorder or a history of blood clots.
• You may also be at risk if you are taking combined hormonal contraceptives or hormone replacement therapy, will have or have recently had major surgery or are immobilised.
• To evaluate the risk your doctor will also consider your age, whether you are obese (your body mass index is above 30), have diabetes, have elevated blood pressure, or smoke.
• If you are at high risk or older than 65 years of age, your doctor may switch your treatment if there is an alternative treatment for you.
• If you are being treated with Xeljanz, you should not change the dose or stop taking the medicine without discussing it with your doctor.
• Ask for medical attention immediately if you develop sudden shortness of breath or difficulty in breathing, chest pain or pain in your upper back, swelling of the leg or arm, leg pain or tenderness, or redness or discoloration in the leg or arm. These may be symptoms of a blood clot in your lungs or veins.
• If you have any concerns about your medicine, you should discuss them with a healthcare professional.
Information for healthcare professionals
• An EMA review has found a dose-dependent increased risk of serious venous thromboembolism (VTE), including pulmonary embolism (PE) (some cases of which were fatal) and deep vein thrombosis in patients taking tofacitinib.
• The review considered data from study A3921133, an ongoing open-label clinical trial evaluating the safety of tofacitinib 5 mg twice daily and tofacitinib 10 mg twice daily compared with a tumour necrosis factor (TNF) inhibitor in patients with rheumatoid arthritis. Patients in the study are 50 years of age or older with at least one additional cardiovascular risk factor. After the interim results became available, treatment with tofacitinib 10 mg twice daily was stopped and patients were switched to 5 mg twice daily because of a signal of PE and all-cause mortality. The review also considered additional data from earlier studies.
• The review of study A3921133 showed that compared to treatment with a TNF inhibitor, tofacitinib 5 mg twice daily increased the risk of PE about 3-fold while tofacitinib 10 mg twice daily increased the risk roughly 6-fold.
• In total there were 17 cases of PE out of 3,123 patient-years with the tofacitinib 10 mg twice daily dose and 9 cases of PE out of 3,317 patient-years with the tofacitinib 5 mg twice daily dose compared with 3 cases out of 3,319 patient-years with a TNF inhibitor. Additionally, there were 28 deaths from all causes out of 3140 patient-years in the tofacitinib 10 mg twice daily arm and 19 deaths from all causes out of 3,324 patient-years in the tofacitinib 5 mg twice daily arm compared with 9 cases out of 3323 patient-years in the TNF inhibitor arm.
• As a result, tofacitinib should be used with caution in patients with known risk factors for VTE, regardless of indication and dosage. This includes patients who have had a heart attack or have heart failure, cancer, inherited blood clotting disorders or a history of blood clots, as well as patients taking combined hormonal contraceptives or hormone replacement therapy, are undergoing major surgery or are immobile.
• Other risk factors to be considered when prescribing tofacitinib include age, diabetes, obesity (BMI>30), smoking status and hypertension.
• The use of tofacitinib 10 mg twice daily for maintenance treatment in patients with ulcerative colitis who have known VTE risk factors is not recommended, unless there is no suitable alternative treatment available.
• For treatment of rheumatoid arthritis and psoriatic arthritis, the recommended dose of 5 mg twice daily should not be exceeded.
• Patients should be informed about the signs and symptoms of VTE before receiving tofacitinib and be advised to seek prompt medical help if they develop these symptoms during treatment.
• Available data also showed that the risk of serious infections and fatal infections was further increased in elderly patients above 65 years of age, as compared to younger patients. Therefore, tofacitinib should only be considered in these patients if no suitable alternative treatment is available.
• A letter will be sent to all healthcare professionals expected to prescribe the medicine to inform them of the updated treatment recommendations. The physician’s guide and the patient alert card will be updated with advice to minimise the risk of blood clots.
Please refer to the following website in EMA for details:http://www.ema.europa.eu/en/documents/../ema-confirms-xeljanz-be-used-caution-patients-high-risk-blood-clots_en.pdf
Local Situation in Hong Kong: In Hong Kong, Xeljanz Tablets 5mg (HK-63303) and Xeljanz XR Extended Release Tablets 11mg (HK-66141) are registered pharmaceutical products containing tofacitinib. Both products are registered by Pfizer Corporation Hong Kong Limited, and are prescription-only medicines. So far, the Department of Health (DH) has received 5 cases of adverse drug reaction related to tofacitinib, of which one case is related to deep vein thrombosis.
Related news was previously issued by various overseas drug regulatory authorities, and was posted on the Drug Office website since 26 Feb 2019, with the latest update posted on 1 Nov 2019. Letters to inform local healthcare professionals were issued by DH on 29 Jul 2019. As previously reported, the matter will be discussed by the Registration Committee of the Pharmacy and Poisons Board.
Ends/ Saturday, November 16, 2019
Issued at HKT 12:00
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