mepolizumab (Rx)

Brand and Other Names:Nucala
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injection, lyophilized powder for reconstitution

  • 100mg/vial

injection, solution

  • 100mg/mL
  • Available as single-dose prefilled autoinjector or syringe

Asthma

Indicated for add-on maintenance treatment of patients with severe asthma and with an eosinophilic phenotype

100 mg SC q4wk

Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome)

Indicated for adults with eosinophilic granulomatosis with polyangiitis (EGPA)

300 mg SC q4wk (ie, as 3 separate 100-mg SC injections)

Dosing Considerations

Renal impairment

  • No dosage adjustment provided in the manufacturer's labeling; dosage adjustment may not be necessary; drug is not renally eliminated

Hepatic impairment

  • No dosage adjustment provided in the manufacturer's labeling; dosage adjustment may not be necessary; drug is degraded by proteolytic enzymes, which are not restricted to hepatic tissue

Limitations of use

  • Not for relief of acute bronchospasm or status asthmaticus

Dosage Forms & Strengths

injection, lyophilized powder for reconstitution

  • 100mg/vial

injection, solution

  • 100mg/mL
  • Available as single-dose prefilled autoinjector or syringe

Asthma

Indicated for add-on maintenance treatment of patients with severe asthma aged ≥12 year, and with an eosinophilic phenotype

<12 years: Safety and efficacy not established

≥12 years: 100 mg SC q4wk

Dosing Considerations

Limitations of use

  • Not for relief of acute bronchospasm or status asthmaticus
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Adverse Effects

>10%

Headache (19%)

Injection site reactions (8-15%)

1-10%

Systemic allergic/nonallergic reactions (2-6%)

Back pain (5%)

Fatigue (5%)

Systemic allergic/hypersensitivity reactions (1-4%)

Influenza (3%)

Urinary tract infection (3%)

Upper abdominal pain (3%)

Pruritus (3%)

Eczema (3%)

Muscle spasms (3%)

Frequency Not Defined

Abdominal pain

Allergic rhinitis

Asthenia

Bronchitis

Cystitis

Dizziness

Dyspnea

Ear infection

Gastroenteritis

Lower respiratory tract infection

Musculoskeletal pain

Nasal congestion

Nasopharyngitis

Toothache

Viral infection

Viral respiratory tract infection

Postmarketing Reports

Hypersensitivity reactions, including anaphylaxis

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Warnings

Contraindications

Hypersensitivity

Cautions

Hypersensitivity reactions (eg, angioedema, bronchospasm, hypotension, urticaria, rash) reported; these reactions generally occur within hours of administration, but in some instances can have a delayed onset (ie, days); discontinue drug in the event of a hypersensitivity reaction

Not for treatment of acute asthma symptoms or acute exacerbations; do not use to treat acute bronchospasm or status asthmaticus; instruct patients to seek immediate medical advice if their asthma remains uncontrolled or worsens after initiating mepolizumab

In clinical trials, 2 serious adverse reactions of herpes zoster occurred during treatment compared with none in placebo; consider varicella vaccination if medically appropriate before initiating treatment

Do not discontinue systemic or inhaled corticosteroids abruptly upon initiation mepolizumab; reductions in corticosteroid dose, if appropriate, should be gradual and performed under the direct supervision of a physician; reduction in corticosteroid dose may be associated with systemic withdrawal symptoms and/or unmask conditions previously suppressed by systemic corticosteroid therapy

Eosinophils may be involved in the immunological response to some helminth infections; patients with known parasitic infections were excluded from participation in clinical trials; treat patients with preexisting helminth infection before initiating mepolizumab; if helminth infection occurs while receiving mepolizumab that does not respond to treatment, discontinue mepolizumab until the infection resolves

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Pregnancy

Pregnancy

Data on pregnancy exposure from the clinical trials are insufficient to inform on drug-associated risk

Monoclonal antibodies, such as mepolizumab, are transported across the placenta in a linear fashion as pregnancy progresses; therefore, potential effects on a fetus are likely to be greater during the second and third trimesters of pregnancy

Pregnancy exposure registry

  • Healthcare providers can enroll patients or encourage patients to enroll themselves by 1-877-311-8972 or www.mothertobaby.org/asthma

Clinical considerations

  • In women with poorly or moderately controlled asthma, evidence demonstrates that there is an increased risk of preeclampsia in the mother and prematurity, low birth weight, and small for gestational age in the neonate
  • Closely monitor the level of asthma control in pregnant women and treatment adjusted as necessary to maintain optimal control

Animal data

  • In a prenatal and postnatal development study, pregnant cynomolgus monkeys received mepolizumab from gestation days 20 to 140 at doses that produced exposures up to ~9 times that achieved with the MRHD (on an AUC basis with maternal IV doses up to 100 mg/kg once every 4 weeks)
  • Mepolizumab did not elicit adverse effects on fetal or neonatal growth (including immune function) up to 9 months after birth
  • Examinations for internal or skeletal malformations were not performed
  • Mepolizumab crossed the placenta in cynomolgus monkeys
  • Concentrations of mepolizumab were ~2.4 times higher in infants than in mothers up to day 178 postpartum

Lactation

Unknown if distributed in human breast milk

However, mepolizumab is a humanized monoclonal antibody (IgG1 kappa), and immunoglobulin G (IgG) is present in human milk in small amounts

Present in the milk of cynomolgus monkeys postpartum following dosing during pregnancy; levels in milk were ≤0.5% of maternal serum concentration

Consider developmental and health benefits of breastfeeding along with the mother’s clinical need for the drug, and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal condition

Pregnancy Categories

A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA:Information not available.

more...
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Pharmacology

Mechanism of Action

Humanized IgG1 kappa monoclonal antibody specific for IL-5; binds IL-5, and therefore stops IL-5 from binding to its receptor on the surface of eosinophils

Inhibiting IL-5 binding to eosinophils reduces blood, tissue, and sputum eosinophil levels

Absorption

Bioavailability: 80%

Following repeat SC administration once every 4 weeks, there was ~2-fold accumulation at steady-state

Distribution

Vd: 3.6 L

Metabolism

Degraded by proteolytic enzymes widely distributed in the body and not restricted to hepatic tissue

Elimination

Half-life: 16-22 days

Systemic clearance: 0.28 L/day

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Administration

SC Preparation

Lyophilized powder for reconstitution

  • Reconstitute each vial with 1.2 mL sterile water for injection (SWI), preferably using a 2- or 3-mL syringe and a 21-G needle
  • Use a 1-mL polypropylene syringe fitted with a disposable 21- to 27-G x 0.5-inch (13- mm) needle
  • Reconstituted solution yields a concentration of 100 mg/mL
  • Preparation of the 300-mg dose for treatment of EGPA requires the reconstitution of 3 separate 100-mg vials
  • Do not mix with other medications
  • Direct the stream of SWI vertically onto the center of the lyophilized cake
  • Gently swirl the vial for 10 seconds with a circular motion at 15-second intervals until the powder is dissolved
  • Do NOT shake the reconstituted solution during the procedure as this may lead to product foaming or precipitation
  • Reconstitution is typically complete within 5 minutes after the SWI has been added, but it may take additional time
  • If a mechanical reconstitution device (swirler) is used, swirl at 450 rpm for no longer than 10 minutes; alternatively, may swirl at 1000 rpm for no longer than 5 minutes
  • Visually inspect the reconstituted solution for particulate matter and clarity before use
  • Solution should be clear to opalescent and colorless to pale yellow or pale brown, essentially particle free; small air bubbles, however, are expected and acceptable
  • Discard solution if particulate matter remains in the solution or if solution appears cloudy or milky

Prefilled autoinjector or syringe

  • Remove from the refrigerator and allow to sit at room temperature for ~30 minutes before administration; do not warm in any other way
  • Visually inspect the window of autoinjector or syringe for particulate matter or discoloration
  • Solution should be clear-to-opalescent, colorless-to-pale yellow or pale brown in color
  • Do not use if solution appears discolored, cloudy, or has particulate matte
  • Do not use if dropped on a hard surface

SC Administration

Do NOT shake solution; gently swirl

For SC use only

Administer SC into the upper arm, thigh, or abdomen

EGPA 300-mg dose: Administer as 3 separate 100-mg injections; individual 100-mg injections should be administered at least 5-cm (~2-inches) apart if administered at the same site

Missed dose: Administer as soon as possible; thereafter, resume dosing on usual day of administration; if next dose is due, then administer as scheduled

Storage

Lyophilized powder

  • Store below 25°C (77°F)
  • Do not freeze
  • Store in the original package to protect from light

Reconstituted solution

  • Store below 30°C (86°F)
  • Do not freeze
  • Discard if not used within 8 hr of reconstitution

Autoinjector or prefilled syringe

  • Before or after dispensing
    • Refrigerate at 36-46°F (2-8°C)
    • Keep in the original carton to protect from light
    • Do not freeze
    • Do not shake
    • Avoid exposure to heat
    • If necessary, unopened carton can be stored outside refrigerator at up to 86°F (30°C) for up to 7 days
    • Discard if left out of refrigerator >7 days
    • Must be administered within 8 hr after removal from carton; discard if not administered within 8 hr
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Formulary

FormularyPatient Discounts

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The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

Tier Description
1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
NC NOT COVERED – Drugs that are not covered by the plan.
Code Definition
PA Prior Authorization
Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
QL Quantity Limits
Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
ST Step Therapy
Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
OR Other Restrictions
Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.