Aranesp (Darbepoetin Alfa)
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Aranesp (Darbepoetin Alfa)

Aranesp®
(darbepoetin alfa)

WARNING

ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE

Chronic Kidney Disease:

  • In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL.
  • No trial has identified a hemoglobin target level, Aranesp dose, or dosing strategy that does not increase these risks.
  • Use the lowest Aranesp dose sufficient to reduce the need for red blood cell (RBC) transfusions [see WARNINGS AND PRECAUTIONS].

Cancer:

  • ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers [see Table 3, WARNINGS AND PRECAUTIONS].
  • Because of these risks, prescribers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program to prescribe and/or dispense Aranesp to patients with cancer. To enroll in the ESA APPRISE Oncology Program, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance [see WARNINGS AND PRECAUTIONS].
  • To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, use the lowest dose needed to avoid RBC transfusions [see DOSAGE AND ADMINISTRATION].
  • Use ESAs only for anemia from myelosuppressive chemotherapy [see INDICATIONS AND USAGE].
  • ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure [see INDICATIONS AND USAGE].
  • Discontinue following the completion of a chemotherapy course [see DOSAGE AND ADMINISTRATION].

DRUG DESCRIPTION

Aranesp (darbepoetin alfa) is an erythropoiesis-stimulating protein that is produced in Chinese hamster ovary (CHO) cells by recombinant DNA technology. Aranesp is a 165-amino acid protein that differs from recombinant human erythropoietin in containing 5 N-linked oligosaccharide chains, whereas recombinant human erythropoietin contains 3 chains. The 2 additional N-glycosylation sites result from amino acid substitutions in the erythropoietin peptide backbone. The approximate molecular weight of darbepoetin alfa is 37,000 daltons.

Aranesp is formulated as a sterile, colorless, preservative-free solution containing polysorbate for intravenous or subcutaneous administration. Each 1 mL contains polysorbate 80 (0.05 mg), sodium chloride (8.18 mg), sodium phosphate dibasic anhydrous (0.66 mg), and sodium phosphate monobasic monohydrate (2.12 mg) in Water for Injection, USP (pH 6.2 ± 0.2).

What are the possible side effects of darbepoetin alfa (Aranesp, Aranesp Albumin Free, Aranesp SureClick)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Contact your doctor if you feel light-headed or unusually weak or tired. These may be signs that your body has stopped responding to darbepoetin alfa.

Darbepoetin alfa can increase your risk of life-threatening heart or circulation problems, including heart attack or stroke. This risk will increase the longer you use darbepoetin alfa. Seek emergency medical help if you...

Read All Potential Side Effects and See Pictures of Aranesp »

What are the precautions when taking darbepoetin alfa (Aranesp)?

Before using darbepoetin alfa, tell your doctor or pharmacist if you are allergic to it; or to other drugs that cause more red blood cells to be made (e.g., epoetin alfa); or to products containing human albumin; or if you have any other allergies. This product may contain inactive ingredients (such as polysorbate, latex), which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

This medication should not be used if you have a certain medical condition. Before using this medicine, consult your doctor or pharmacist if you have: uncontrolled high blood pressure.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: high blood pressure (treated/controlled), blood disorders (e.g., sickle cell...

Read All Potential Precautions of Aranesp »

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

INDICATIONS

Anemia Due to Chronic Kidney Disease

Aranesp is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and patients not on dialysis.

Anemia Due to Chemotherapy in Patients With Cancer

Aranesp is indicated for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy.

Limitations of Use

Aranesp has not been shown to improve quality of life, fatigue, or patient well-being.

Aranesp is not indicated for use:

  • In patients with cancer receiving hormonal agents, biologic products, or radiotherapy, unless also receiving concomitant myelosuppressive chemotherapy.
  • In patients with cancer receiving myelosuppressive chemotherapy when the anticipated outcome is cure.
  • As a substitute for RBC transfusions in patients who require immediate correction of anemia [see CLINICAL PHARMACOLOGY].

DOSAGE AND ADMINISTRATION

Evaluation of Iron Stores and Nutritional Factors

Evaluate the iron status in all patients before and during treatment and maintain iron repletion. Correct or exclude other causes of anemia (e.g., vitamin deficiency, metabolic or chronic inflammatory conditions, bleeding, etc.) before initiating Aranesp [see WARNINGS AND PRECAUTIONS].

Patients with Chronic Kidney Disease

In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, Aranesp dose, or dosing strategy that does not increase these risks. Individualize dosing and use the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions [see WARNINGS AND PRECAUTIONS]. Physicians and patients should weigh the possible benefits of decreasing transfusions against the increased risks of death and other serious cardiovascular adverse events [see BOXED WARNING and Clinical Studies].

For all patients with CKD

  • When initiating or adjusting therapy, monitor hemoglobin levels at least weekly until stable, then monitor at least monthly. When adjusting therapy consider hemoglobin rate of rise, rate of decline, ESA responsiveness and hemoglobin variability. A single hemoglobin excursion may not require a dosing change.
  • Do not increase the dose more frequently than once every 4 weeks. Decreases in dose can occur more frequently. Avoid frequent dose adjustments.
  • If the hemoglobin rises rapidly (e.g., more than 1 g/dL in any 2-week period), reduce the dose of Aranesp by 25% or more as needed to reduce rapid responses.
  • For patients who do not respond adequately, if the hemoglobin has not increased by more than 1 g/dL after 4 weeks of therapy, increase the dose by 25%.
  • For patients who do not respond adequately over a 12-week escalation period, increasing the Aranesp dose further is unlikely to improve response and may increase risks. Use the lowest dose that will maintain a hemoglobin level sufficient to reduce the need for RBC transfusions. Evaluate other causes of anemia. Discontinue Aranesp if responsiveness does not improve.

For patients with CKD on dialysis:

  • Initiate Aranesp treatment when the hemoglobin level is less than 10 g/dL.
  • If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Aranesp.
  • The recommended starting dose is 0.45 mcg/kg intravenously or subcutaneously as a weekly injection or 0.75 mcg/kg once every 2 weeks as appropriate. The intravenous route is recommended for patients on hemodialysis.

For patients with CKD not on dialysis:

  • Consider initiating Aranesp treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:
    • The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion and,
    • Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.
  • If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Aranesp, and use the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions.
  • The recommended starting dose is 0.45 mcg/kg body weight intravenously or subcutaneously given once at four week intervals as appropriate.

When treating patients who have chronic kidney disease and cancer, physicians should refer to WARNINGS AND PRECAUTIONS.

Refer patients who self-administer Aranesp to the Instructions for Use [see PATIENT INFORMATION].

Conversion from Epoetin alfa to Aranesp in patients with CKD on dialysis

Aranesp is administered less frequently than epoetin alfa.

  • Administer Aranesp once weekly in patients who were receiving epoetin alfa 2 to 3 times weekly.
  • Administer Aranesp once every 2 weeks in patients who were receiving epoetin alfa once weekly.

Estimate the starting weekly dose of Aranesp for adults and pediatric patients on the basis of the weekly epoetin alfa dose at the time of substitution (see Table 1). Maintain the route of administration (intravenous or subcutaneous injection).

Table 1: Estimated Aranesp Starting Doses (mcg/week) for Patients With CKD on Dialysis Based on Previous Epoetin alfa Dose (Units/week)

Previous Weekly Epoetin alfa Dose (Units/week) Aranesp Dose (mcg/week)
Adult Pediatric
< 1,500 6.25 *
1,500 to 2,499 6.25 6.25
2,500 to 4,999 12.5 10
5,000 to 10,999 25 20
11,000 to 17,999 40 40
18,000 to 33,999 60 60
34,000 to 89,999 100 100
≥ 90,000 200 200
*For pediatric patients receiving a weekly epoetin alfa dose of < 1,500 Units/week, the available data are insufficient to determine an Aranesp conversion dose.

Conversion from Epoetin alfa to Aranesp in patients with CKD not on dialysis

The dose conversion depicted in Table 1 does not accurately estimate the once monthly dose of Aranesp.

Patients on Cancer Chemotherapy

Only prescribers enrolled in the ESA APPRISE Oncology Program may prescribe and/or dispense Aranesp [see WARNINGS AND PRECAUTIONS].

Initiate Aranesp in patients on cancer chemotherapy only if the hemoglobin is less than 10 g/dL, and if there is a minimum of two additional months of planned chemotherapy.

Use the lowest dose of Aranesp necessary to avoid RBC transfusions.

Recommended Starting Dose

The recommended starting dose and schedules are:

  • 2.25 mcg/kg every week subcutaneously until completion of a chemotherapy course
  • 500 mcg every 3 weeks subcutaneously until completion of a chemotherapy course

Dose Adjustment

Dose Adjustment Weekly Schedule Every 3 Week Schedule
  • If hemoglobin increases greater than 1 g/dL in any 2-week period or
  • If hemoglobin reaches a level needed to avoid RBC transfusion
Reduce dose by 40% Reduce dose by 40%
If hemoglobin exceeds a level needed to avoid RBC transfusion
  • Withhold dose until hemoglobin approaches a level where RBC transfusions may be required
  • Reinitiate at a dose 40% below the previous dose
  • Withhold dose until hemoglobin approaches a level where RBC transfusions may be required
  • Reinitiate at a dose 40% below the previous dose
If hemoglobin increases by less than 1 g/dL and remains below 10 g/dL after 6 weeks of therapy Increase dose to 4.5 mcg/kg/week No dose adjustment
  • If there is no response as measured by hemoglobin levels or if RBC transfusions are still required after 8 weeks of therapy
  • Following completion of a chemotherapy course
Discontinue Aranesp Discontinue Aranesp

Preparation and Administration

  • The needle cover of the prefilled syringe contains dry natural rubber (a derivative of latex), which may cause allergic reactions.
  • Do not shake. Do not use Aranesp that has been shaken or frozen.
  • Protect vials and prefilled syringes from light.
  • Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Do not use any vials or prefilled syringes exhibiting particulate matter or discoloration.
  • Discard unused portion of Aranesp in vials or prefilled syringes. Do not re-enter vial.
  • Do not dilute Aranesp and do not administer in conjunction with other drug solutions.

HOW SUPPLIED

Dosage Forms And Strengths

Aranesp is available as a polysorbate-containing solution.

  • Single-dose vials: 25, 40, 60, 100, 200, 300, and 500 mcg Aranesp/1 mL, and 150 mcg Aranesp/0.75 mL
  • Single-dose prefilled syringes: 25 mcg Aranesp/0.42 mL, 40 mcg Aranesp/0.4 mL,
    60 mcg Aranesp/0.3 mL, 100 mcg Aranesp/0.5 mL, and 150 mcg Aranesp/0.3 mL,
    200 mcg Aranesp/0.4 mL, 300 mcg Aranesp/0.6 mL, and 500 mcg Aranesp/1 mL

Storage And Handling

Store at 36°F to 46°F (2°C to 8°C). Do not freeze.

Do not shake. Protect from light; store Aranesp in the carton until use.

Do not use Aranesp that has been shaken or frozen.

Aranesp is available in the following packages:

Single-dose Vial
1 Vial/Pack, 4 Packs/Case 4 Vials/Pack, 10 Packs/Case
200 mcg/1 mL
(NDC 55513-006-01)
25 mcg/1 mL
(NDC 55513-002-04)
300 mcg/1 mL
(NDC 55513-110-01)
40 mcg/1 mL
(NDC 55513-003-04)
  60 mcg/1 mL
(NDC 55513-004-04)
  100 mcg/1 mL
(NDC 55513-005-04)
  150 mcg/0.75 mL
(NDC 55513-053-04)

Single-dose Prefilled Syringe (SingleJect®) with a 27-gauge, ½-inch needle with an UltraSafe® Needle Guard that is manually activated to cover the needle during disposal

1 Syringe/Pack, 4 Packs/Case 4 Syringes/Pack, 10 Packs/Case
200 mcg/0.4 mL
(NDC 55513-028-01)
25 mcg/0.42 mL
(NDC 55513-057-04)
300 mcg/0.6 mL
(NDC 55513-111-01)
40 mcg/0.4 mL
(NDC 55513-021-04)
500 mcg/1 mL
(NDC 55513-032-01)
60 mcg/0.3 mL
(NDC 55513-023-04)
  100 mcg/0.5 mL
(NDC 55513-025-04)
  150 mcg/0.3 mL
(NDC 55513-027-04)

Manufactured by: Amgen Manufacturing Limited, a subsidiary of Amgen Inc. One Amgen Center Drive, Thousand Oaks, CA 91320-1799. Revised: 06/2011

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

SIDE EFFECTS

The following serious adverse reactions are discussed in greater detail in other sections of the label:

Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of other drugs and may not reflect the rates observed in practice.

Patients with Chronic Kidney Disease

Adult Patients

Adverse reactions were determined based on pooled data from 5 randomized, active-controlled studies of Aranesp with a total of 1357 patients (Aranesp 766, epoetin alfa 591). The median duration of exposure for patients receiving Aranesp was 340 days, with 580 patients exposed for greater than 6 months and 360 patients exposed for greater than 1 year. The median (25th, 75th percentiles) weight-adjusted dose of Aranesp was 0.50 mcg/kg (0.32, 0.81). The median (range) age for patients administered Aranesp was 62 years (18 to 88). In the Aranesp group, 55% were male, 72% were white, 83% were receiving dialysis, and 17% were not receiving dialysis.

Table 4 lists adverse reactions occurring in ≥ 5% of patients treated with Aranesp.

Table 4: Adverse Reactions Occurring in ≥ 5% of Patients with CKD

Adverse Reaction Patients Treated With Aranesp
(n = 766)
Hypertension 31%
Dyspnea 17%
Peripheral edema 17%
Cough 12%
Procedural hypotension 10%
Angina pectoris 8%
Vascular access complications 8%
Fluid overload 7%
Rash/Erythema 5%
Arteriovenous graft thrombosis 5%

Rates of adverse reactions with Aranesp therapy were similar to those observed with other recombinant erythropoietins in these studies.

Pediatric Patients

Aranesp was administered to 81 pediatric patients with CKD who had stable hemoglobin concentrations while previously receiving epoetin alfa [see Clinical Studies]. In this study, the most frequently reported serious adverse reactions with Aranesp were hypertension and convulsions. The most commonly reported adverse reactions were hypertension, injection site pain, rash, and convulsions. Aranesp administration was discontinued because of injection site pain in 2 patients and moderate hypertension in a third patient.

Studies have not evaluated the effects of Aranesp when administered to pediatric patients as the initial treatment for the anemia associated with CKD.

Cancer Patients Receiving Chemotherapy

Adverse reactions were based on data from a randomized, double-blind, placebo-controlled study of Aranesp in 597 patients (Aranesp 301, placebo 296) with extensive stage small cell lung cancer (SCLC) receiving platinum-based chemotherapy. All patients were white, 64% were male, and the median age was 61 years (range: 28 to 82 years); 25% of the study population were from North America, Western Europe, and Australia. Patients received Aranesp at a dose of 300 mcg or placebo weekly for 4 weeks then every 3 weeks for a total of 24 weeks, and the median duration of exposure was 19 weeks (range: 1 to 26 weeks).

Adverse reactions were also based on data from 7 randomized, double-blind, placebo-controlled studies, including the SCLC study described above, that enrolled 2112 patients (Aranesp 1203, placebo 909) with non-myeloid malignancies. Most patients were white (95%), male (52%), and the median age was 63 years (range: 18 to 91 years); 73% of the study population were from North America, Western Europe, and Australia. Dosing and schedules varied by study from once weekly to once every 4 weeks, and the median duration of exposure was 12 weeks (range: 1 to 27 weeks).

Table 5: Thrombovascular Adverse Reactions in Patients Receiving Chemotherapy

Adverse Reaction SCLC Study All Placebo-controlled Studies
Aranesp
(n = 301)
Placebo
(n = 296)
Aranesp
(n = 1203)
Placebo
(n = 909)
Thromboembolic Adverse Reactions, n (%) 24 (8.0%) 13 (4.4%) 73 (6.1%) 37 (4.1%)
  Arterial 10 (3.3%) 3 (1.0%) 15 (1.2%) 5 (0.6%)
    Myocardial infarction 5 (1.7%) 0 7 (0.6%) 2 (0.2%)
  Venous 14 (4.7%) 10 (3.4%) 60 (5.0%) 32 (3.5%)
    Pulmonary embolism 5 (1.7%) 3 (1.0%) 16 (1.3%) 6 (0.7%)
  Cerebrovascular disorders* 14 (4.7%) 9(3.0%) 20 (1.7%) 17 (1.9%)
* “Cerebrovascular disorders” encompasses CNS hemorrhages and cerebrovascular accidents (ischemic and hemorrhagic). Events in this category may also be included under “thromboembolic adverse reactions.”

In addition to the thrombovascular adverse reactions, abdominal pain and edema occurred at a higher incidence in patients taking Aranesp compared to patients on placebo. Among all placebo-controlled studies, abdominal pain (13.2% vs. 9.4%) and edema (12.8% vs. 9.7%) were reported more frequently in patients receiving Aranesp compared to the placebo group. In the SCLC study the incidence of abdominal pain (10.3% vs. 3.4%) and edema (5.6% vs. 5.1%) in the Aranesp-treated patients compared to those receiving placebo.

Postmarketing Experience

Because postmarketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

The following adverse reactions have been identified during postmarketing use of Aranesp:

Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity. Neutralizing antibodies to darbepoetin alfa that cross-react with endogenous erythropoietin and other ESAs can result in PRCA or severe anemia (with or without other cytopenias) [see WARNINGS AND PRECAUTIONS].

In clinical studies, the percentage of patients with antibodies to Aranesp was examined using the Biacore® assay. Sera from 1501 patients with CKD and 1159 cancer patients were tested. At baseline, prior to Aranesp treatment, binding antibodies were detected in 59 patients (4%) with CKD and 36 cancer patients (3%). During Aranesp therapy (range: 22 to 177 weeks), a follow-up sample was taken. One additional patient with CKD and 8 additional cancer patients developed antibodies capable of binding Aranesp. None of the patients had antibodies capable of neutralizing the activity of Aranesp or endogenous erythropoietin at baseline or at end of study. No clinical sequelae consistent with PRCA were associated with the presence of these antibodies.

The incidence of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors, including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to Aranesp with the incidence of antibodies to other products may be misleading.

Read the Aranesp (darbepoetin alfa) Side Effects Center for a complete guide to possible side effects »

DRUG INTERACTIONS

No formal drug interaction studies have been conducted with Aranesp.

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Increased Mortality, Myocardial Infarction, Stroke, and Thromboembolism

  • In controlled clinical trials of patients with CKD comparing higher hemoglobin targets (13 - 14 g/dL) to lower targets (9 - 11.3 g/dL), Aranesp and other ESAs increased the risk of death, myocardial infarction, stroke, congestive heart failure, thrombosis of hemodialysis vascular access, and other thromboembolic events in the higher target groups.
  • Using Aranesp to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular reactions and has not been shown to provide additional benefit [see Clinical Studies]. Use caution in patients with coexistent cardiovascular disease and stroke [see DOSAGE AND ADMINISTRATION]. Patients with CKD and an insufficient hemoglobin response to ESA therapy may be at even greater risk for cardiovascular reactions and mortality than other patients. A rate of hemoglobin rise of greater than 1 g/dL over 2 weeks may contribute to these risks.
  • In controlled clinical trials of patients with cancer, Aranesp and other ESAs increased the risks for death and serious adverse cardiovascular reactions. These adverse reactions included myocardial infarction and stroke.
  • In controlled clinical trials, ESAs increased the risk of death in patients undergoing coronary artery bypass graft surgery (CABG) and the risk of deep venous thrombosis (DVT) in patients undergoing orthopedic procedures.

The design and overall results of the 3 large trials comparing higher and lower hemoglobin targets are shown in Table 2.

Table 2: Randomized Controlled Trials Showing Adverse Cardiovascular Outcomes in Patients With CKD

  Normal Hematocrit Study (NHS)
(N = 1265)
CHOIR
(N = 1432)
TREAT
(N = 4038)
Time Period of Trial 1993 to 1996 2003 to 2006 2004 to 2009
Population CKD patients on hemodialysis with coexisting CHF or CAD, hematocrit 30 ± 3% on epoetin alfa CKD patients not on dialysis with hemoglobin < 11 g/dL not previously administered epoetin alfa CKD patients not on dialysis with type II diabetes, hemoglobin . 11 g/dL
Hemoglobin Target; Higher vs. Lower (g/dL) 14.0 vs. 10.0 13.5 vs. 11.3 13.0 vs. . 9.0
Median (Q1, Q3) Achieved Hemoglobin level (g/dL) 12.6 (11.6, 13.3) vs. 10.3 (10.0, 10.7) 13.0 (12.2, 13.4) vs. 11.4 (11.1, 11.6) 12.5 (12.0, 12.8) vs. 10.6 (9.9, 11.3)
Primary Endpoint All-cause mortality or non-fatal MI All-cause mortality, MI, hospitalization for CHF, or stroke All-cause mortality, MI, myocardial ischemia, heart failure, and stroke
Hazard Ratio or Relative Risk (95% CI) 1.28 (1.06 - 1.56) 1.34 (1.03 - 1.74) 1.05 (0.94 - 1.17)
Adverse Outcome for Higher Target Group All-cause mortality All-cause mortality Stroke
Hazard Ratio or Relative Risk (95% CI) 1.27 (1.04 - 1.54) 1.48 (0.97 - 2.27) 1.92 (1.38 - 2.68)

Patients with Chronic Kidney Disease

Normal Hematocrit Study (NHS): A prospective, randomized, open-label study of 1265 patients with chronic kidney disease on dialysis with documented evidence of congestive heart failure or ischemic heart disease was designed to test the hypothesis that a higher target hematocrit (Hct) would result in improved outcomes compared with a lower target Hct. In this study, patients were randomized to epoetin alfa treatment targeted to a maintenance hemoglobin of either 14 ± 1 g/dL or 10 ± 1 g/dL. The trial was terminated early with adverse safety findings of higher mortality in the high hematocrit target group. Higher mortality (35% vs. 29%) was observed for the patients randomized to a target hemoglobin of 14 g/dL than for the patients randomized to a target hemoglobin of 10 g/dL. For all-cause mortality, the HR = 1.27; 95% CI (1.04, 1.54); p=0.018. The incidence of nonfatal myocardial infarction, vascular access thrombosis, and other thrombotic events was also higher in the group randomized to a target hemoglobin of 14 g/dL.

CHOIR: A randomized, prospective trial, 1432 patients with anemia due to CKD who were not undergoing dialysis and who had not previously received epoetin alfa therapy were randomized to epoetin alfa treatment targeting a maintenance hemoglobin concentration of either 13.5 g/dL or 11.3 g/dL. The trial was terminated early with adverse safety findings. A major cardiovascular event (death, myocardial infarction, stroke, or hospitalization for congestive heart failure) occurred in 125 of the 715 patients (18%) in the higher hemoglobin group compared to 97 of the 717 patients (14%) in the lower hemoglobin group [hazard ratio (HR) 1.34, 95% CI: 1.03, 1.74; p = 0.03].

TREAT: A randomized, double-blind, placebo-controlled, prospective trial of 4038 patients with CKD not on dialysis (eGFR of 20 – 60 mL/min), anemia (hemoglobin levels ≤ 11 g/dL), and type 2 diabetes mellitus, patients were randomized to receive either Aranesp treatment or a matching placebo. Placebo group patients also received Aranesp when their hemoglobin levels were below 9 g/dL. The trial objectives were to demonstrate the benefit of Aranesp treatment of the anemia to a target hemoglobin level of 13 g/dL, when compared to a “placebo” group, by reducing the occurrence of either of two primary endpoints: (1) a composite cardiovascular endpoint of all-cause mortality or a specified cardiovascular event (myocardial ischemia, CHF, MI, and CVA) or (2) a composite renal endpoint of all-cause mortality or progression to end stage renal disease. The overall risks for each of the two primary endpoints (the cardiovascular composite and the renal composite) were not reduced with Aranesp treatment (see Table 2), but the risk of stroke was increased nearly two-fold in the Aranesp-treated group versus the placebo group: annualized stroke rate 2.1% vs. 1.1%, respectively, HR 1.92; 95% CI: 1.38, 2.68; p < 0.001. The relative risk of stroke was particularly high in patients with a prior stroke: annualized stroke rate 5.2% in the Aranesp treated group and 1.9% in the placebo group, HR 3.07; 95% CI: 1.44, 6.54. Also, among Aranesp-treated subjects with a past history of cancer, there were more deaths due to all causes and more deaths adjudicated as due to cancer, in comparison with the control group.

Patients with Cancer

An increased incidence of thromboembolic reactions, some serious and life-threatening, occurred in patients with cancer treated with ESAs.

In a randomized, placebo-controlled study (Study 1 in Table 3) of 939 women with metastatic breast cancer receiving chemotherapy, patients received either weekly epoetin alfa or placebo for up to a year. This study was designed to show that survival was superior when epoetin alfa was administered to prevent anemia (maintain hemoglobin levels between 12 and 14 g/dL or hematocrit between 36% and 42%). This study was terminated prematurely when interim results demonstrated a higher mortality at 4 months (8.7% vs. 3.4%) and a higher rate of fatal thrombotic reactions (1.1% vs. 0.2%) in the first 4 months of the study among patients treated with epoetin alfa. Based on Kaplan-Meier estimates, at the time of study termination, the 12-month survival was lower in the epoetin alfa group than in the placebo group (70% vs. 76%; HR 1.37, 95% CI: 1.07, 1.75; p = 0.012).

Patients Having Surgery

Aranesp is not approved for reduction of RBC transfusions in patients scheduled for surgical procedures.

An increased incidence of DVT in patients receiving epoetin alfa undergoing surgical orthopedic procedures was demonstrated. In a randomized, controlled study, 680 adult patients, not receiving prophylactic anticoagulation and undergoing spinal surgery, received epoetin alfa and standard of care (SOC) treatment (n = 340) or SOC treatment alone (n = 340). A higher incidence of DVTs, determined by either color flow duplex imaging or by clinical symptoms, was observed in the epoetin alfa group (16 [4.7%] patients) compared with the SOC group (7 [2.1%] patients). In addition to the 23 patients with DVTs included in the primary analysis, 19 [2.8%] patients experienced 1 other thrombovascular event (TVE) each (12 [3.5%] in the epoetin alfa group and 7 [2.1%] in the SOC group).

Increased mortality was observed in a randomized, placebo-controlled study of epoetin alfa in adult patients who were undergoing CABG surgery (7 deaths in 126 patients randomized to epoetin alfa versus no deaths among 56 patients receiving placebo). Four of these deaths occurred during the period of study drug administration and all 4 deaths were associated with thrombotic events.

Prescribing and Distribution Program for Aranesp in Patients With Cancer

In order to prescribe and/or dispense Aranesp to patients with cancer and anemia due to myelosuppressive chemotherapy, prescribers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program requirements. To enroll, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance. Additionally, prior to each new course of Aranesp in patients with cancer, prescribers and patients must provide written acknowledgment of a discussion of the risks of Aranesp.

Increased Mortality and/or Increased Risk of Tumor Progression or Recurrence in Patients With Cancer

ESAs resulted in decreased locoregional control/progression-free survival and/or overall survival (see Table 3). These findings were observed in studies of patients with advanced head and neck cancer receiving radiation therapy (Studies 5 and 6), in patients receiving chemotherapy for metastatic breast cancer (Study 1) or lymphoid malignancy (Study 2), and in patients with non-small cell lung cancer or various malignancies who were not receiving chemotherapy or radiotherapy (Studies 7 and 8).

Table 3: Randomized, Controlled Studies With Decreased Survival and/or Decreased Locoregional Control

Study/Tumor/(n) Hemoglobin Target Hemoglobin (Median; Q1, Q3*) Primary Efficacy Outcome Adverse Outcome for ESA-containing Arm
Chemotherapy
Study 1
Metastatic breast cancer
(n = 939)
12-14 g/dL 12.9 g/dL; 12.2, 13.3 g/dL 12-month overall survival Decreased 12-month survival
Study 2
Lymphoid malignancy
(n = 344)
13-15 g/dL (M) 13-14 g/dL (F) 11 g/dL; 9.8, 12.1 g/dL Proportion of patients achieving a hemoglobin response Decreased overall survival
Study 3
Early breast cancer
(n = 733)
12.5-13 g/dL 13.1 g/dL; 12.5, 13.7 g/dL Relapse-free and overall survival Decreased 3-year relapse-free and overall survival
Study 4
Cervical cancer
(n = 114)
12-14 g/dL 12.7 g/dL; 12.1, 13.3 g/dL Progression-free and overall survival and locoregional control Decreased 3-year progression-free and overall survival and locoregional control
Radiotherapy Alone
Study 5
Head and neck cancer
(n = 351)
≥ 15 g/dL (M) ≥ 14 g/dL (F) Not available Locoregional progression-free survival Decreased 5-year locoregional progression-free and overall survival
Study 6
Head and neck cancer
(n = 522)
14-15.5 g/dL Not available Locoregional disease control Decreased locoregional disease control
No Chemotherapy or Radiotherapy
Study 7
Non-small cell lung cancer
(n = 70)
12-14 g/dL Not available Quality of life Decreased overall survival
Study 8
Non-myeloid malignancy
(n = 989)
12-13 g/dL 10.6 g/dL; 9.4, 11.8 g/dL RBC transfusions Decreased overall survival
*Q1= 25th percentile
Q3= 75th percentile

Decreased Overall Survival

Study 1 was described in the previous section. Mortality at 4 months (8.7% vs. 3.4%) was significantly higher in the epoetin alfa arm. The most common investigator-attributed cause of death within the first 4 months was disease progression; 28 of 41 deaths in the epoetin alfa arm and 13 of 16 deaths in the placebo arm were attributed to disease progression. Investigator-assessed time to tumor progression was not different between the 2 groups. Survival at 12 months was significantly lower in the epoetin alfa arm (70% vs. 76%; HR 1.37, 95% CI: 1.07, 1.75; p = 0.012).

Study 2 was a randomized, double-blind study (darbepoetin alfa vs. placebo) conducted in 344 anemic patients with lymphoid malignancy receiving chemotherapy. With a median follow-up of 29 months, overall mortality rates were significantly higher among patients randomized to darbepoetin alfa as compared to placebo (HR 1.36, 95% CI: 1.02, 1.82).

Study 7 was a multicenter, randomized, double-blind study (epoetin alfa vs. placebo) in which patients with advanced non-small cell lung cancer receiving only palliative radiotherapy or no active therapy were treated with epoetin alfa to achieve and maintain hemoglobin levels between 12 and 14 g/dL. Following an interim analysis of 70 patients (planned accrual 300 patients), a significant difference in survival in favor of the patients in the placebo arm of the study was observed (median survival 63 vs. 129 days; HR 1.84; p = 0.04).

Study 8 was a randomized, double-blind study (darbepoetin alfa vs. placebo) in 989 anemic patients with active malignant disease, neither receiving nor planning to receive chemotherapy or radiation therapy. There was no evidence of a statistically significant reduction in proportion of patients receiving RBC transfusions. The median survival was shorter in the darbepoetin alfa treatment group than in the placebo group (8 months vs. 10.8 months; HR 1.30, 95% CI: 1.07, 1.57).

Decreased Progression-free Survival and Overall Survival

Study 3 was a randomized, open-label, controlled, factorial design study in which darbepoetin alfa was administered to prevent anemia in 733 women receiving neo-adjuvant breast cancer treatment. A final analysis was performed after a median follow-up of approximately 3 years. The 3-year survival rate was lower (86% vs. 90%; HR 1.42, 95% CI: 0.93, 2.18) and the 3-year relapse-free survival rate was lower (72% vs. 78%; HR 1.33, 95% CI: 0.99, 1.79) in the darbepoetin alfa-treated arm compared to the control arm.

Study 4 was a randomized, open-label, controlled study that enrolled 114 of a planned 460 cervical cancer patients receiving chemotherapy and radiotherapy. Patients were randomized to receive epoetin alfa to maintain hemoglobin between 12 and 14 g/dL or to RBC transfusion support as needed. The study was terminated prematurely due to an increase in thromboembolic adverse reactions in epoetin alfa-treated patients compared to control (19% vs. 9%). Both local recurrence (21% vs. 20%) and distant recurrence (12% vs. 7%) were more frequent in epoetin alfa-treated patients compared to control. Progression-free survival at 3 years was lower in the epoetin alfa-treated group compared to control (59% vs. 62%; HR 1.06, 95% CI: 0.58, 1.91). Overall survival at 3 years was lower in the epoetin alfa-treated group compared to control (61% vs. 71%; HR 1.28, 95% CI: 0.68, 2.42).

Study 5 was a randomized, placebo-controlled study in 351 head and neck cancer patients where epoetin beta or placebo was administered to achieve target hemoglobins ≥ 14 and ≥ 15 g/dL for women and men, respectively. Locoregional progression-free survival was significantly shorter in patients receiving epoetin beta (HR 1.62, 95% CI: 1.22, 2.14; p = 0.0008) with medians of 406 days and 745 days in the epoetin beta and placebo arms respectively. Overall survival was significantly shorter in patients receiving epoetin beta (HR 1.39, 95% CI: 1.05, 1.84; p = 0.02).

Decreased Locoregional Control

Study 6 was a randomized, open-label, controlled study conducted in 522 patients with primary squamous cell carcinoma of the head and neck receiving radiation therapy alone (no chemotherapy) who were randomized to receive darbepoetin alfa to maintain hemoglobin levels of 14 to15.5 g/dL or no darbepoetin alfa. An interim analysis performed on 484 patients demonstrated that locoregional control at 5 years was significantly shorter in patients receiving darbepoetin alfa (RR 1.44, 95% CI: 1.06, 1.96; p = 0.02). Overall survival was shorter in patients receiving darbepoetin alfa (RR 1.28, 95% CI: 0.98, 1.68; p = 0.08).

Hypertension

Aranesp is contraindicated in patients with uncontrolled hypertension. In Aranesp clinical studies, approximately 40% of patients with CKD required initiation or intensification of antihypertensive therapy during the early phase of treatment. Hypertensive encephalopathy and seizures have been reported in patients with CKD receiving Aranesp.

Appropriately control hypertension prior to initiation of and during treatment with Aranesp. Reduce or withhold Aranesp if blood pressure becomes difficult to control. Advise patients of the importance of compliance with antihypertensive therapy and dietary restrictions [see PATIENT INFORMATION].

Seizures

Aranesp increases the risk of seizures in patients with CKD. During the first several months following initiation of Aranesp, monitor patients closely for premonitory neurologic symptoms. Advise patients to contact their healthcare practitioner for new-onset seizures, premonitory symptoms, or change in seizure frequency.

Lack or Loss of Hemoglobin Response to Aranesp

For lack or loss of hemoglobin response to Aranesp, initiate a search for causative factors (e.g., iron deficiency, infection, inflammation, bleeding). If typical causes of lack or loss of hemoglobin response are excluded, evaluate for PRCA. In the absence of PRCA, follow dosing recommendations for management of patients with an insufficient hemoglobin response to Aranesp therapy [see DOSAGE AND ADMINISTRATION].

Pure Red Cell Aplasia

Cases of PRCA and of severe anemia, with or without other cytopenias that arise following the development of neutralizing antibodies to erythropoietin have been reported in patients treated with Aranesp. This has been reported predominantly in patients with CKD receiving ESAs by subcutaneous administration. PRCA has also been reported in patients receiving ESAs for anemia related to hepatitis C treatment (an indication for which Aranesp is not approved).

If severe anemia and low reticulocyte count develop during treatment with Aranesp, withhold Aranesp and evaluate patients for neutralizing antibodies to erythropoietin. Contact Amgen (1-800-77-AMGEN) to perform assays for binding and neutralizing antibodies. Permanently discontinue Aranesp in patients who develop PRCA following treatment with Aranesp or other erythropoietin protein drugs. Do not switch patients to other ESAs.

Serious Allergic Reactions

Serious allergic reactions, including anaphylactic reactions, angioedema, bronchospasm, skin rash, and urticaria may occur with Aranesp. Immediately and permanently discontinue Aranesp and administer appropriate therapy if a serious allergic or anaphylactic reaction occurs.

Dialysis Management

Patients may require adjustments in their dialysis prescriptions after initiation of Aranesp. Patients receiving Aranesp may require increased anticoagulation with heparin to prevent clotting of the extracorporeal circuit during hemodialysis.

Laboratory Monitoring

Evaluate transferrin saturation and serum ferritin prior to and during Aranesp treatment. Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20% [see DOSAGE AND ADMINISTRATION]. The majority of patients with CKD will require supplemental iron during the course of ESA therapy. Following initiation of therapy and after each dose adjustment, monitor hemoglobin weekly until the hemoglobin is stable and sufficient to minimize the need for RBC transfusion. Thereafter, hemoglobin may be monitored less frequently provided hemoglobin levels remain stable.

Patient Counseling Information

See Medication Guide.

Prior to treatment, inform patients of the risks and benefits of Aranesp.

Inform patients with cancer that they must sign the patient-healthcare provider acknowledgment form before the start of each treatment course with Aranesp and that healthcare providers must enroll and comply with the ESA APPRISE Oncology Program in order to prescribe Aranesp.

Inform patients:

  • To read the Medication Guide and to review and discuss any questions or concerns with their healthcare provider before starting Aranesp and at regular intervals while receiving Aranesp.
  • Of the increased risks of mortality, serious cardiovascular reactions, thromboembolic reactions, stroke, and tumor progression [see WARNINGS AND PRECAUTIONS].
  • To undergo regular blood pressure monitoring, adhere to prescribed anti-hypertensive regimen and follow recommended dietary restrictions.
  • To contact their healthcare provider for new-onset neurologic symptoms or change in seizure frequency.
  • Of the need to have regular laboratory tests for hemoglobin.

Instruct patients who self-administer Aranesp of the:

  • Importance of following the Instructions for Use.
  • Dangers of reusing needles, syringes, or unused portions of single-dose vials.
  • Proper disposal of used syringes, needles, and unused vials, and of the full container.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity

The carcinogenic potential of Aranesp has not been evaluated in long-term animal studies. In toxicity studies of approximately 6 months duration in rats and dogs, no tumorigenic or unexpected mitogenic responses were observed in any tissue type.

Mutagenicity

Aranesp was not mutagenic or clastogenic under the conditions tested. Aranesp was negative in the in vitro bacterial reverse mutation assay, the in vitro mammalian cell gene mutation assay (using CHO cells), and in the in vivo mouse erythrocyte micronucleus assay.

Impairment of Fertility

Aranesp increased the incidence of post-implantation losses in rats. Male and female rats received intravenous doses prior to and during mating; then females were treated 3 times weekly during the first trimester of gestation (gestation days 1, 3, 5, and 7). No effect on reproductive performance, fertility, or sperm assessment parameters were detected at any of the doses evaluated (up to 10 mcg/kg, administered 3 times weekly). The dose of 10 mcg/kg is more than 10-fold higher than the clinical recommended starting dose. An increase in post-implantation fetal loss was seen at doses equal to or greater than 0.5 mcg/kg, administered 3 times weekly. The dose of 0.5 mcg/kg is approximately equivalent to the clinical recommended starting dose. Signs of exaggerated pharmacology were not observed in the mother receiving 0.5 mcg/kg or less, but were observed at 2.5 mcg/kg and higher.

Use In Specific Populations

Pregnancy

Pregnancy Category C

There are no adequate and well-controlled studies of Aranesp use in pregnant women. In animal reproduction and developmental toxicity studies, Aranesp increased early post-implantation loss. Use Aranesp during pregnancy only if the potential benefit justifies the potential risk to the fetus.

When Aranesp was administered intravenously to healthy pregnant rats and rabbits, there was no evidence of embryofetal toxicity or other adverse outcomes at the intravenous doses tested, up to 20 mcg/kg/day. This animal dose level of 20 mcg/kg/day is approximately 20-fold higher than the clinical recommended starting dose, depending on the patient's treatment indication. Slightly reduced fetal weights were observed when healthy rat and rabbit mothers received doses of 1 mcg/kg or more. This dose of 1 mcg/kg is near the clinical recommended starting dose. While no adverse effects on uterine implantation occurred in animals, there was an increase in early post-implantation loss in animal fertility studies. It is not clear whether the increased post-implantation loss reflects a drug effect on the uterine environment or on the conceptus. No significant placental transfer of Aranesp was detected.

In a peri/postnatal development study, pregnant female rats received Aranesp intravenously every other day from implantation throughout pregnancy and lactation. The lowest dose tested, 0.5 mcg/kg, did not cause fetal toxicity; this dose is approximately equivalent to the clinical recommended starting dose. At maternal doses of 2.5 mcg/kg and higher, pups had decreased fetal body weights, which correlated with a slight increase in the incidence of fetal deaths, as well as delayed eye opening and delayed preputial separation [see Nonclinical Toxicology].

Women who become pregnant during Aranesp treatment are encouraged to enroll in Amgen's Pregnancy Surveillance Program. Patients or their physicians should call 1-800-772-6436 (1-800-77-AMGEN) to enroll.

Nursing Mothers

It is not known whether Aranesp is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Aranesp is administeredr to a nursing woman.

Pediatric Use

Pediatric Patients with CKD

Aranesp safety and efficacy were similar between adults and pediatric patients with CKD who were over 1 year of age when patients were transitioned from treatment with epoetin alfa to Aranesp [see ADVERSE REACTIONS, CLINICAL PHARMACOLOGY, and Clinical Studies]. Aranesp safety and efficacy have not been established in the initial treatment of anemic pediatric patients with CKD or in the transition from another erythropoietin to Aranesp in pediatric CKD patients less than 1 year of age.

Pediatric Cancer Patients

The safety and efficacy of Aranesp in pediatric cancer patients have not been established.

Geriatric Use

Of the 1801 patients with CKD in clinical studies of Aranesp, 44% were age 65 and over, while 17% were age 75 and over. Of the 873 patients in clinical studies receiving Aranesp and concomitant cancer chemotherapy, 45% were age 65 and over, while 14% were age 75 and over. No differences in safety or efficacy were observed between older and younger patients.

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

OVERDOSE

Aranesp overdosage can cause hemoglobin levels above the desired level, which should be managed with discontinuation or reduction of Aranesp dosage and/or with phlebotomy, as clinically indicated [see Pharmacodynamics]. Cases of severe hypertension have been observed following overdose with ESAs [see WARNINGS AND PRECAUTIONS].

CONTRAINDICATIONS

Aranesp is contraindicated in patients with:

  • Uncontrolled hypertension [see WARNINGS AND PRECAUTIONS].
  • Pure red cell aplasia (PRCA) that begins after treatment with Aranesp or other erythropoietin protein drugs [see WARNINGS AND PRECAUTIONS].
  • Serious allergic reactions to Aranesp [see WARNINGS AND PRECAUTIONS].

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

CLINICAL PHARMACOLOGY

Mechanism of Action

Aranesp stimulates erythropoiesis by the same mechanism as endogenous erythropoietin.

Pharmacodynamics

Increased hemoglobin levels are not generally observed until 2 to 6 weeks after initiating treatment with Aranesp.

Pharmacokinetics

Adult Patients with CKD

The pharmacokinetics of Aranesp were studied in patients with CKD receiving or not receiving dialysis and cancer patients receiving chemotherapy.

Following intravenous administration of Aranesp to patients with CKD receiving dialysis, Aranesp serum concentration-time profiles were biphasic, with a distribution half-life of approximately 1.4 hours and a mean terminal half-life (t½) of 21 hours. The t½ of Aranesp was approximately 3-fold longer than that of epoetin alfa when administered intravenously.

Following subcutaneous administration of Aranesp to patients with CKD (receiving or not receiving dialysis), absorption was slow and Cmax occurred at 48 hours (range: 12 to 72 hours). In patients with CKD receiving dialysis, the average t½ was 46 hours (range: 12 to 89 hours), and in patients with CKD not receiving dialysis, the average t½ was 70 hours (range: 35 to 139 hours). Aranesp apparent clearance was approximately 1.4 times faster on average in patients receiving dialysis compared to patients not receiving dialysis. The bioavailability of Aranesp in patients with CKD receiving dialysis after subcutaneous administration was 37% (range: 30% to 50%).

Pediatric Patients with CKD

Aranesp pharmacokinetics was studied in 12 pediatric patients (age 3 to 16 years) with CKD receiving or not receiving dialysis. Following a single intravenous or subcutaneous Aranesp dose, Cmax and t½ were similar to those obtained in adult patients with CKD on dialysis. Following a single subcutaneous dose, the average bioavailability was 54% (range: 32% to 70%), which was higher than that obtained in adult patients with CKD on dialysis.

Adult Cancer Patients

Following the first subcutaneous dose of 6.75 mcg/kg (equivalent to 500 mcg for a 74-kg patient) in patients with cancer, the mean t½ was 74 hours (range: 24 to 144 hours) and Cmax was observed at 71 hours (range: 28 to 120 hours). When administered on a once every 3 week schedule, 48-hour postdose Aranesp levels after the fourth dose were similar to those after the first dose.

Over the dose range of 0.45 to 4.5 mcg/kg Aranesp administered intravenously or subcutaneously on a once weekly schedule and 4.5 to 15 mcg/kg administered subcutaneously on a once every 3 week schedule, systemic exposure was approximately proportional to dose. No evidence of accumulation was observed beyond an expected less than 2-fold increase in blood levels when compared to the initial dose.

Reproductive and Developmental Toxicology

When Aranesp was administered intravenously during organogenesis to pregnant rats (gestational days 6 to 15) and rabbits (gestational days 6 to 18), no evidence of direct embryotoxic, fetotoxic, or teratogenic outcomes were observed at the doses tested, up to 20 mcg/kg/day. This animal dose level of 20 mcg/kg/day is approximately 20-fold higher than the clinical recommended starting dose, depending on the patient's treatment indication. The only adverse effect observed was a slight reduction in fetal weight, which occurred only at doses causing exaggerated pharmacological effects in both the rat and rabbit dams (1 mcg/kg/day and higher). No deleterious effects on uterine implantation were seen in either species.

No significant placental transfer of Aranesp was observed in rats; placental transfer was not evaluated in rabbits.

In a peri/postnatal development study, pregnant female rats were treated intravenously with Aranesp day 6 of gestation through day 23 of lactation at 2.5 mcg/kg and higher every other day. Pups of treated mothers had decreased fetal body weights, which correlated with slight increases in the incidences of fetal death, as well as delayed eye opening and delayed preputial separation. The offspring (F1 generation) of the treated rats were observed postnatally; rats from the F1 generation reached maturity and were mated; no Aranesp-related effects were apparent for their offspring (F2 generation fetuses).

Clinical Studies

Clinical studies in the nephrology and chemotherapy-induced anemia clinical programs are designated with the prefixes “N” and “C”, respectively.

Patients With Chronic Kidney Disease:

Patients with chronic kidney disease on dialysis: ESA effects on rates of transfusion

In early clinical studies conducted in CKD patients on dialysis, ESAs have been shown to reduce the use of RBC transfusions. These studies enrolled patients with mean baseline hemoglobin levels of approximately 7.5 g/dL and ESAs were generally titrated to achieve a hemoglobin level of approximately 12 g/dL. Fewer transfusions were given during the ESA treatment period when compared to a pre-treatment interval.

In the Normal Hematocrit Study, the yearly transfusion rate was 51.5% in the lower hemoglobin group (10 g/dL) and 32.4% in the higher hemoglobin group (14 g/dL).

Patients with chronic kidney disease not on dialysis: ESA effects on rates of transfusion

In TREAT, a randomized, double-blind trial of 4038 patients with CKD and type 2 diabetes not on dialysis, a post-hoc analysis showed that the proportion of patients receiving RBC transfusions was lower in patients administered Aranesp to target a hemoglobin of 13 g/dL compared to the control arm in which Aranesp was administered intermittently if hemoglobin concentration decreased to less than 9 g/dL (15% versus 25%, respectively). In CHOIR, a randomized open-label study of 1432 patients with CKD not on dialysis, use of an ESA to target a higher (13.5 g/dL) versus lower (11.3 g/dL) hemoglobin goal did not reduce the use of RBC transfusions. In each trial, no benefits occurred for the cardiovascular or end-stage renal disease outcomes. In each trial, the potential benefit of ESA therapy was offset by worse cardiovascular safety outcomes resulting in an unfavorable benefit-risk profile [see WARNINGS AND PRECAUTIONS].

ESA Effects on quality of life

Aranesp use has not been demonstrated in controlled clinical trials to improve quality of life, fatigue, or patient well-being.

ESA Effects on rates of death and other serious cardiac adverse events

Three randomized outcome trials (Normal Hematocrit Study [NHS], Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease [CHOIR], and Trial of Darbepoetin Alfa in Type 2 Diabetes and CKD [TREAT]) have been conducted in patients with CKD using Epogen/PROCRIT/Aranesp to target higher vs. lower hemoglobin levels. Though these trials were designed to establish a cardiovascular or renal benefit of targeting higher hemoglobin levels, in all 3 studies, patients randomized to the higher hemoglobin target experienced worse cardiovascular outcomes and showed no reduction in progression to ESRD. In each trial, the potential benefit of ESA therapy was offset by worse cardiovascular safety outcomes resulting in an unfavorable benefit-risk profile [see WARNINGS AND PRECAUTIONS].

Other ESA trials

Two studies evaluated the safety and efficacy of the de novo use of Aranesp for the correction of anemia in adult patients with CKD, and 3 studies (2 in adults and 1 in pediatric patients) assessed the ability of Aranesp to maintain hemoglobin concentrations in patients with CKD who had been receiving other recombinant erythropoietins.

De Novo Use of Aranesp

Once Weekly Aranesp Starting Dose

In 2 randomized, open-label studies, Aranesp or epoetin alfa was administered for the correction of anemia in patients with CKD who had not been receiving prior treatment with exogenous erythropoietin. Study N1 evaluated CKD patients receiving dialysis; Study N2 evaluated patients not requiring dialysis. In both studies, the starting dose of Aranesp was 0.45 mcg/kg administered once weekly. The starting dose of epoetin alfa was 50 Units/kg 3 times weekly in Study N1 and 50 Units/kg twice weekly in Study N2. When necessary, dosage adjustments were instituted to maintain hemoglobin in the study target range of 11 to 13 g/dL. (Note: The recommended hemoglobin target range is lower than the target range of these studies [see DOSAGE AND ADMINISTRATION].) The primary efficacy endpoint was the proportion of patients who experienced at least a 1 g/dL increase in hemoglobin concentration to a level of at least 11 g/dL by 20 weeks (Study N1) or 24 weeks (Study N2). The studies were designed to assess the safety and effectiveness of Aranesp but not to support conclusions regarding comparisons between the 2 products.

In Study N1, the primary efficacy endpoint was achieved by 72% (95% CI: 62%, 81%) of the 90 patients treated with Aranesp and 84% (95% CI: 66%, 95%) of the 31 patients treated with epoetin alfa. The mean increase in hemoglobin over the initial 4 weeks of Aranesp treatment was 1.1 g/dL (95% CI: 0.82 g/dL, 1.37 g/dL).

In Study N2, the primary efficacy endpoint was achieved by 93% (95% CI: 87%, 97%) of the 129 patients treated with Aranesp and 92% (95% CI: 78%, 98%) of the 37 patients treated with epoetin alfa. The mean increase in hemoglobin from baseline through the initial 4 weeks of Aranesp treatment was 1.38 g/dL (95% CI: 1.21 g/dL, 1.55 g/dL).

Once Every 2 Week Aranesp Starting Dose

In 2 single-arm studies (N3 and N4), Aranesp was administered for the correction of anemia in CKD patients not receiving dialysis. In both studies, the starting dose of Aranesp was 0.75 mcg/kg administered once every 2 weeks.

In Study N3 (study duration of 18 weeks), the hemoglobin goal (hemoglobin concentration ≥ 11 g/dL) was achieved by 92% (95% CI: 86%, 96%) of the 128 patients treated with Aranesp.

In Study N4 (study duration of 24 weeks), the hemoglobin goal (hemoglobin concentration of 11 to 13 g/dL) was achieved by 85% (95% CI: 77%, 93%) of the 75 patients treated with Aranesp.

Conversion from Other Recombinant Erythropoietins

Two studies of adults (N5 and N6) and 1 study in pediatric patients (N7) were conducted in patients who had been receiving other recombinant erythropoietins for treatment of the anemia due to CKD. The studies compared the abilities of Aranesp and other erythropoietins to maintain hemoglobin concentrations within a study target range of 9 to 13 g/dL in adults and 10 to 12.5 g/dL in pediatric patients. (Note: The recommended hemoglobin target is lower than the target range of these studies [see DOSAGE AND ADMINISTRATION].) Patients who had been receiving stable doses of other recombinant erythropoietins were randomized to Aranesp or continued with their prior erythropoietin at the previous dose and schedule. For patients randomized to Aranesp, the initial weekly dose was determined on the basis of the previous total weekly dose of recombinant erythropoietin.

Adult Patients

Study N5 was a double-blind study in which 169 hemodialysis patients were randomized to treatment with Aranesp and 338 patients continued on epoetin alfa. Study N6 was an open-label study in which 347 patients were randomized to treatment with Aranesp and 175 patients were randomized to continue on epoetin alfa or epoetin beta. Of the patients randomized to Aranesp, 92% were receiving hemodialysis and 8% were receiving peritoneal dialysis.

In Study N5, a median weekly dose of 0.53 mcg/kg Aranesp (25th, 75th percentiles: 0.30, 0.93 mcg/kg) was required to maintain hemoglobin in the study target range. In Study N6, a median weekly dose of 0.41 mcg/kg Aranesp (25th, 75th percentiles: 0.26, 0.65 mcg/kg) was required to maintain hemoglobin in the study target range.

Pediatric Patients

Study N7 was an open-label, randomized study conducted in the United States in pediatric patients from 1 to 18 years of age with CKD receiving or not receiving dialysis. Eighty-one patients with hemoglobin concentrations that were stable on epoetin alfa received darbepoetin alfa (subcutaneously or intravenously), and 42 patients continued to receive epoetin alfa at the current dose, schedule, and route of administration. Patients received darbepoetin alfa once weekly if previously receiving epoetin alfa 2 or 3 times weekly or once every other week if previously receiving epoetin alfa weekly. A median weekly dose of 0.41 mcg/kg darbepoetin alfa (25th, 75th percentiles: 0.25, 0.82 mcg/kg) was required to maintain hemoglobin in the study target range.

Cancer Patients Receiving Chemotherapy

The safety and efficacy of Aranesp was assessed in two multicenter, randomized studies in patients with anemia due to the effect of concomitantly administered cancer chemotherapy. Study C1 was a randomized (1:1), placebo-controlled, double-blind, multinational study conducted in 314 patients where Aranesp was administered weekly. Study C2 was a randomized (1:1), double-blind, double-dummy, active-controlled, multinational study conducted in 705 patients where Aranesp was administered either every week or every 3 weeks. Efficacy was demonstrated by a statistically significant reduction in the proportion of patients receiving RBC transfusions among patients who were on study therapy for more than 28 days.

Study C1

Study C1 was conducted in anemic patients (hemoglobin ≤ 11 g/dL) with non-small cell lung cancer or small cell lung cancer who were scheduled to receive at least 12 weeks of a platinum-containing chemotherapy regimen. Randomization was stratified by tumor type and region (Australia vs. Canada vs. Europe). Patients received Aranesp 2.25 mcg/kg or placebo as a weekly subcutaneous injection commencing on the first day of the chemotherapy cycle. Efficacy was determined by a reduction in the proportion of patients who received RBC transfusions between week 5 (day 29) and end of treatment period (12 weeks) in the subset of 297 randomized patients (148 Aranesp and 149 placebo) who were on-study at the beginning of study week 5. All 297 patients were white, 72% were male, 71% had non-small cell histology, and the median age was 62 years (range: 36 to 80). A significantly lower proportion of patients in the Aranesp arm received RBC transfusions during week 5 to the end of treatment compared to patients in the placebo arm (crude percentages: 26% vs. 50%; p < 0.001, based on a comparison of the difference in Kaplan-Meier proportions using the Cochran-Mantel-Haenszel strata-adjusted Chi-square test).

Study C2

Study C2 was conducted in anemic patients (hemoglobin < 11 g/dL) with non-myeloid malignancies receiving chemotherapy. Randomization was stratified by region (Western vs. Central/Eastern Europe), tumor type (lung and gynecological vs. others), and baseline hemoglobin ( < 10 vs. ≥ 10 g/dL); all patients received double-dummy placebo and either Aranesp 500 mcg every 3 weeks or Aranesp 2.25 mcg/kg weekly subcutaneous injections for 15 weeks. Only 1 patient was non-white, 55% were female, and the median age was 60 years (range: 20 to 86). One hundred seven patients (16%) had lung or gynecological cancer while 565 (84%) had other tumor types. In both treatment schedules, the dose was reduced by 40% of the previous dose if hemoglobin level increased by more than 1 g/dL in a 14-day period.

Efficacy was determined by a comparison of the proportion of patients who received at least 1 RBC transfusion between week 5 (day 29) and the end of treatment. Three hundred thirty-five patients in the every 3 week dosing arm and 337 patients in the weekly dosing arm remained on study through or beyond day 29 and were evaluable for efficacy. Two hundred thirty-eight patients (71%) in the every 3-week arm and 261 patients (77%) patients in the weekly arm required dose reductions. Twenty-three percent (95% CI: 18%, 28%) of patients in the every 3-week treatment schedule and 28% (95% CI: 24%, 34%) in the weekly schedule received at least 1 RBC transfusion. The observed difference in the RBC transfusion rates (every 3 week minus weekly) was -5.8% (95% CI: -12.4%, 0.8%).

Study C3

Lack of Efficacy in Improving Survival

Study C3 was conducted in patients required to have a hemoglobin concentration ≥ 9 g/dL and ≤ 13 g/dL with previously untreated extensive-stage small cell lung cancer (SCLC) receiving platinum and etoposide chemotherapy. Randomization was stratified by region (Western Europe, Australia/North America, and rest of world), Eastern Cooperative Oncology Group (ECOG) performance status (0 or 1 vs. 2), and lactate dehydrogenase (below vs. above the upper limit of normal). Patients were randomized to receive Aranesp (n = 298) at a dose of 300 mcg once weekly for the first 4 weeks, followed by 300 mcg once every 3 weeks for the remainder of the treatment period or placebo (n = 298).

This study was designed to detect a prolongation in overall survival (from a median of 9 months to a median of 12 months). For the final analysis, there was no evidence of improved survival (p = 0.43, log-rank test).

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

PATIENT INFORMATION

MEDICATION GUIDE

Aranesp®
(Air-uh-nesp)
(darbepoetin alfa)

Read this Medication Guide:

  • before you start Aranesp,
  • if you are told by your healthcare provider that there is new information about Aranesp,
  • if you are told by your healthcare provider that you may inject Aranesp at home, read this Medication Guide each time you receive a new supply of medicine.

This Medication Guide does not take the place of talking to your healthcare provider about your medical condition or your treatment. Talk with your healthcare provider regularly about the use of Aranesp and ask if there is new information about Aranesp.

What is the most important information I should know about Aranesp?

Using Aranesp can lead to death or other serious side effects.

For patients with cancer:

Your healthcare provider has received special training through the ESA APPRISE Oncology Program in order to prescribe Aranesp. Before you can begin to receive Aranesp, you must sign the patient-healthcare provider acknowledgment form. When you sign this form, you are stating that your healthcare provider talked with you about the risks of taking Aranesp.

These risks include that your tumor may grow faster and you may die sooner if you choose to take Aranesp.

You should talk with your healthcare provider about:

  • Why Aranesp treatment is being prescribed for you.
  • What are the chances you will get red blood cell transfusions if you do not take Aranesp.
  • What are the chances you will get red blood cell transfusions even if you take Aranesp.
  • How taking Aranesp may affect the success of your cancer treatment.

After you have finished your chemotherapy course, Aranesp treatment should be stopped.

For all patients who take Aranesp, including patients with cancer or chronic kidney disease:

  • If you decide to take Aranesp, your healthcare provider should prescribe the smallest dose of Aranesp that is needed to reduce your chance of getting red blood cell transfusions.
  • You may get serious heart problems such as heart attack, stroke, heart failure, and may die sooner if you are treated with Aranesp to reach a normal or near-normal hemoglobin level.
  • You may get blood clots at any time while taking Aranesp. If you are receiving Aranesp for any reason and you are going to have surgery, talk to your healthcare provider about whether or not you need to take a blood thinner to lessen the chance of blood clots during or following surgery. Clots can form in blood vessels (veins), especially in your leg (deep venous thrombosis or DVT). Pieces of a blood clot may travel to the lungs and block the blood circulation in the lungs (pulmonary embolus).

Call your healthcare provider or get medical help right away if you have any of these symptoms of blood clots:

  • Chest pain
  • Trouble breathing or shortness of breath
  • Pain in your legs, with or without swelling
  • A cool or pale arm or leg
  • Sudden confusion, trouble speaking, or trouble understanding others' speech
  • Sudden numbness or weakness in your face, arm, or leg, especially on one side of your body
  • Sudden trouble seeing
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Loss of consciousness (fainting)
  • Hemodialysis vascular access stops working

See “What are the possible side effects of Aranesp?” below.

What is Aranesp?

Aranesp is a man-made form of the protein human erythropoietin that is given to reduce or avoid the need for red blood cell transfusions. Aranesp stimulates your bone marrow to make more red blood cells. Having more red blood cells raises your hemoglobin level. If your hemoglobin level stays too high or if your hemoglobin goes up too quickly, this may lead to serious health problems which may result in death. These serious health problems may happen even if you take Aranesp and do not have an increase in your hemoglobin level.

Aranesp may be used to treat a lower than normal number of red blood cells (anemia) if it is caused by:

  • Chronic kidney disease (you may or may not be on dialysis).
  • Chemotherapy that will be used for at least two months after starting Aranesp.

Aranesp should not be used for the treatment of anemia:

  • If you have cancer and you will not be receiving chemotherapy that may cause anemia for at least 2 more months.
  • If you have a cancer that has a high chance of being cured.
  • In place of emergency treatment for anemia (red blood cell transfusions).

Aranesp has not been proven to improve the quality of life, fatigue, or well-being.

Who should not take Aranesp?

Do not take Aranesp if you:

  • Have cancer and have not been counseled by your healthcare provider regarding the risks of Aranesp or if you have not signed the patient-healthcare provider acknowledgment form before you start Aranesp treatment.
  • Have high blood pressure that is not controlled (uncontrolled hypertension).
  • Have been told by your healthcare provider that you have or have ever had a type of anemia called Pure Red Cell Aplasia (PRCA) that starts after treatment with Aranesp or other erythropoietin protein medicines.
  • Have had a serious allergic reaction to Aranesp.

What should I tell my healthcare provider before taking Aranesp?

Aranesp may not be right for you. Tell your healthcare provider about all your health conditions, including if you:

  • Have heart disease.
  • Have high blood pressure.
  • Have had a seizure (convulsion) or stroke.
  • Are allergic to latex.
  • Have any other medical conditions.
  • Are pregnant or planning to become pregnant. It is not known if Aranesp may harm your unborn baby. Talk to your healthcare provider about possible pregnancy and birth control choices that are right for you. If you are pregnant, discuss with your healthcare provider about enrolling in Amgen's Pregnancy Surveillance Program or call 1-800-772-6436 (l-800-77-AMGEN).
  • Are breast-feeding or planning to breast-feed. It is not known if Aranesp passes into breast milk.

Tell your healthcare provider about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements.

Know the medicines you take. Keep a list of your medicines with you and show it to your healthcare provider when you get a new medicine.

How should I take Aranesp?

See “What is the most important information I should know about Aranesp?

For patients with cancer:

Before you begin to receive Aranesp, your healthcare provider will:

  • Ask you to review this Aranesp Medication Guide.
  • Explain the risks of Aranesp and answer all your questions about Aranesp.
  • Have you sign the patient-healthcare provider acknowledgment form.

For all patients who take Aranesp:

  • Continue to follow your healthcare provider's instructions for diet, and medicines, including medicines for high blood pressure, while taking Aranesp.
  • Have your blood pressure checked as instructed by your healthcare provider.
  • If you or your caregiver has been trained to give Aranesp shots (injections) at home:
    • Be sure that you read, understand, and follow the “Instructions for Use” that come with Aranesp.
    • Take Aranesp exactly as your healthcare provider tells you to. Do not change the dose of Aranesp unless told to do so by your healthcare provider.
    • Your healthcare provider will show you how much Aranesp to use, how to inject it, how often it should be injected, and how to safely throw away the used vials, syringes, and needles.
    • If you miss a dose of Aranesp, call your healthcare provider right away and ask what to do.
    • If you take more than the prescribed amount of Aranesp, call your healthcare provider right away.

What are the possible side effects of Aranesp?

Aranesp may cause serious side effects.

  • See “What is the most important information I should know about Aranesp?
  • High blood pressure. High blood pressure is a common side effect of Aranesp in patients with chronic kidney disease. Your blood pressure may go up or be difficult to control with blood pressure medicine while taking Aranesp. This can happen even if you have never had high blood pressure before. Your healthcare provider should check your blood pressure often. If your blood pressure does go up, your healthcare provider may prescribe new or more blood pressure medicine.
  • Seizures. If you have any seizures while taking Aranesp, get medical help right away and tell your healthcare provider.
  • Antibodies to Aranesp. Your body may make antibodies to Aranesp. These antibodies can block or lessen your body's ability to make red blood cells and cause you to have severe anemia. Call your healthcare provider if you have unusual tiredness, lack of energy, dizziness, or fainting. You may need to stop taking Aranesp.
  • Serious allergic reactions. Serious allergic reactions can cause a rash over your whole body, shortness of breath, wheezing, dizziness and fainting because of a drop in blood pressure, swelling around your mouth or eyes, fast pulse, or sweating. If you have a serious allergic reaction, stop using Aranesp and call your healthcare provider or get medical help right away.

The needle cover on the prefilled syringe contains latex. If you know you are allergic to latex, talk to your healthcare provider before using Aranesp.

Common side effects of Aranesp include:

  • shortness of breath
  • cough
  • low blood pressure during dialysis
  • abdominal pain
  • edema (swelling) of the arms or legs

These are not all of the possible side effects of Aranesp. Your healthcare provider can give you a more complete list. Tell your healthcare provider about any side effects that bother you or that do not go away.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store Aranesp?

  • Do not shake Aranesp.
  • Protect Aranesp from light.
  • Store Aranesp in the refrigerator between 36°F to 46°F (2°C to 8°C).
  • Do not freeze Aranesp. Do not use Aranesp that has been frozen.
  • Throw away the Aranesp vial or prefilled syringe after one use. Do not re-use even if there is medicine left.

Keep Aranesp and all medicines out of the reach of children.

General information about Aranesp

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Use Aranesp only for the condition for which it has been prescribed. Do not give Aranesp to other patients even if they have the same symptoms that you have. It may harm them.

This Medication Guide summarizes the most important information about Aranesp. If you would like more information about Aranesp, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about Aranesp that is written for healthcare professionals. For more information, go to the following website: www.aranesp.com or call 1-800-77-AMGEN.

What are the ingredients in Aranesp?

Active Ingredient: darbepoetin alfa

Inactive Ingredients: polysorbate 80, sodium phosphate monobasic monohydrate, sodium phosphate dibasic anhydrous, and sodium chloride in Water for Injection, USP.

This Medication Guide has been approved by the U.S. Food and Drug Administration.

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

>

PATIENT INFORMATION

MEDICATION GUIDE

Aranesp®
(Air-uh-nesp)
(darbepoetin alfa)

Read this Medication Guide:

  • before you start Aranesp,
  • if you are told by your healthcare provider that there is new information about Aranesp,
  • if you are told by your healthcare provider that you may inject Aranesp at home, read this Medication Guide each time you receive a new supply of medicine.

This Medication Guide does not take the place of talking to your healthcare provider about your medical condition or your treatment. Talk with your healthcare provider regularly about the use of Aranesp and ask if there is new information about Aranesp.

What is the most important information I should know about Aranesp?

Using Aranesp can lead to death or other serious side effects.

For patients with cancer:

Your healthcare provider has received special training through the ESA APPRISE Oncology Program in order to prescribe Aranesp. Before you can begin to receive Aranesp, you must sign the patient-healthcare provider acknowledgment form. When you sign this form, you are stating that your healthcare provider talked with you about the risks of taking Aranesp.

These risks include that your tumor may grow faster and you may die sooner if you choose to take Aranesp.

You should talk with your healthcare provider about:

  • Why Aranesp treatment is being prescribed for you.
  • What are the chances you will get red blood cell transfusions if you do not take Aranesp.
  • What are the chances you will get red blood cell transfusions even if you take Aranesp.
  • How taking Aranesp may affect the success of your cancer treatment.

After you have finished your chemotherapy course, Aranesp treatment should be stopped.

For all patients who take Aranesp, including patients with cancer or chronic kidney disease:

  • If you decide to take Aranesp, your healthcare provider should prescribe the smallest dose of Aranesp that is needed to reduce your chance of getting red blood cell transfusions.
  • You may get serious heart problems such as heart attack, stroke, heart failure, and may die sooner if you are treated with Aranesp to reach a normal or near-normal hemoglobin level.
  • You may get blood clots at any time while taking Aranesp. If you are receiving Aranesp for any reason and you are going to have surgery, talk to your healthcare provider about whether or not you need to take a blood thinner to lessen the chance of blood clots during or following surgery. Clots can form in blood vessels (veins), especially in your leg (deep venous thrombosis or DVT). Pieces of a blood clot may travel to the lungs and block the blood circulation in the lungs (pulmonary embolus).

Call your healthcare provider or get medical help right away if you have any of these symptoms of blood clots:

  • Chest pain
  • Trouble breathing or shortness of breath
  • Pain in your legs, with or without swelling
  • A cool or pale arm or leg
  • Sudden confusion, trouble speaking, or trouble understanding others' speech
  • Sudden numbness or weakness in your face, arm, or leg, especially on one side of your body
  • Sudden trouble seeing
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Loss of consciousness (fainting)
  • Hemodialysis vascular access stops working

See “What are the possible side effects of Aranesp?” below.

What is Aranesp?

Aranesp is a man-made form of the protein human erythropoietin that is given to reduce or avoid the need for red blood cell transfusions. Aranesp stimulates your bone marrow to make more red blood cells. Having more red blood cells raises your hemoglobin level. If your hemoglobin level stays too high or if your hemoglobin goes up too quickly, this may lead to serious health problems which may result in death. These serious health problems may happen even if you take Aranesp and do not have an increase in your hemoglobin level.

Aranesp may be used to treat a lower than normal number of red blood cells (anemia) if it is caused by:

  • Chronic kidney disease (you may or may not be on dialysis).
  • Chemotherapy that will be used for at least two months after starting Aranesp.

Aranesp should not be used for the treatment of anemia:

  • If you have cancer and you will not be receiving chemotherapy that may cause anemia for at least 2 more months.
  • If you have a cancer that has a high chance of being cured.
  • In place of emergency treatment for anemia (red blood cell transfusions).

Aranesp has not been proven to improve the quality of life, fatigue, or well-being.

Who should not take Aranesp?

Do not take Aranesp if you:

  • Have cancer and have not been counseled by your healthcare provider regarding the risks of Aranesp or if you have not signed the patient-healthcare provider acknowledgment form before you start Aranesp treatment.
  • Have high blood pressure that is not controlled (uncontrolled hypertension).
  • Have been told by your healthcare provider that you have or have ever had a type of anemia called Pure Red Cell Aplasia (PRCA) that starts after treatment with Aranesp or other erythropoietin protein medicines.
  • Have had a serious allergic reaction to Aranesp.

What should I tell my healthcare provider before taking Aranesp?

Aranesp may not be right for you. Tell your healthcare provider about all your health conditions, including if you:

  • Have heart disease.
  • Have high blood pressure.
  • Have had a seizure (convulsion) or stroke.
  • Are allergic to latex.
  • Have any other medical conditions.
  • Are pregnant or planning to become pregnant. It is not known if Aranesp may harm your unborn baby. Talk to your healthcare provider about possible pregnancy and birth control choices that are right for you. If you are pregnant, discuss with your healthcare provider about enrolling in Amgen's Pregnancy Surveillance Program or call 1-800-772-6436 (l-800-77-AMGEN).
  • Are breast-feeding or planning to breast-feed. It is not known if Aranesp passes into breast milk.

Tell your healthcare provider about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements.

Know the medicines you take. Keep a list of your medicines with you and show it to your healthcare provider when you get a new medicine.

How should I take Aranesp?

See “What is the most important information I should know about Aranesp?

For patients with cancer:

Before you begin to receive Aranesp, your healthcare provider will:

  • Ask you to review this Aranesp Medication Guide.
  • Explain the risks of Aranesp and answer all your questions about Aranesp.
  • Have you sign the patient-healthcare provider acknowledgment form.

For all patients who take Aranesp:

  • Continue to follow your healthcare provider's instructions for diet, and medicines, including medicines for high blood pressure, while taking Aranesp.
  • Have your blood pressure checked as instructed by your healthcare provider.
  • If you or your caregiver has been trained to give Aranesp shots (injections) at home:
    • Be sure that you read, understand, and follow the “Instructions for Use” that come with Aranesp.
    • Take Aranesp exactly as your healthcare provider tells you to. Do not change the dose of Aranesp unless told to do so by your healthcare provider.
    • Your healthcare provider will show you how much Aranesp to use, how to inject it, how often it should be injected, and how to safely throw away the used vials, syringes, and needles.
    • If you miss a dose of Aranesp, call your healthcare provider right away and ask what to do.
    • If you take more than the prescribed amount of Aranesp, call your healthcare provider right away.

What are the possible side effects of Aranesp?

Aranesp may cause serious side effects.

  • See “What is the most important information I should know about Aranesp?
  • High blood pressure. High blood pressure is a common side effect of Aranesp in patients with chronic kidney disease. Your blood pressure may go up or be difficult to control with blood pressure medicine while taking Aranesp. This can happen even if you have never had high blood pressure before. Your healthcare provider should check your blood pressure often. If your blood pressure does go up, your healthcare provider may prescribe new or more blood pressure medicine.
  • Seizures. If you have any seizures while taking Aranesp, get medical help right away and tell your healthcare provider.
  • Antibodies to Aranesp. Your body may make antibodies to Aranesp. These antibodies can block or lessen your body's ability to make red blood cells and cause you to have severe anemia. Call your healthcare provider if you have unusual tiredness, lack of energy, dizziness, or fainting. You may need to stop taking Aranesp.
  • Serious allergic reactions. Serious allergic reactions can cause a rash over your whole body, shortness of breath, wheezing, dizziness and fainting because of a drop in blood pressure, swelling around your mouth or eyes, fast pulse, or sweating. If you have a serious allergic reaction, stop using Aranesp and call your healthcare provider or get medical help right away.

The needle cover on the prefilled syringe contains latex. If you know you are allergic to latex, talk to your healthcare provider before using Aranesp.

Common side effects of Aranesp include:

  • shortness of breath
  • cough
  • low blood pressure during dialysis
  • abdominal pain
  • edema (swelling) of the arms or legs

These are not all of the possible side effects of Aranesp. Your healthcare provider can give you a more complete list. Tell your healthcare provider about any side effects that bother you or that do not go away.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store Aranesp?

  • Do not shake Aranesp.
  • Protect Aranesp from light.
  • Store Aranesp in the refrigerator between 36°F to 46°F (2°C to 8°C).
  • Do not freeze Aranesp. Do not use Aranesp that has been frozen.
  • Throw away the Aranesp vial or prefilled syringe after one use. Do not re-use even if there is medicine left.

Keep Aranesp and all medicines out of the reach of children.

General information about Aranesp

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Use Aranesp only for the condition for which it has been prescribed. Do not give Aranesp to other patients even if they have the same symptoms that you have. It may harm them.

This Medication Guide summarizes the most important information about Aranesp. If you would like more information about Aranesp, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about Aranesp that is written for healthcare professionals. For more information, go to the following website: www.aranesp.com or call 1-800-77-AMGEN.

What are the ingredients in Aranesp?

Active Ingredient: darbepoetin alfa

Inactive Ingredients: polysorbate 80, sodium phosphate monobasic monohydrate, sodium phosphate dibasic anhydrous, and sodium chloride in Water for Injection, USP.

This Medication Guide has been approved by the U.S. Food and Drug Administration.

Last reviewed on RxList: 6/20/2012
This monograph has been modified to include the generic and brand name in many instances.

Disclaimer

Aranesp Consumer

IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

DARBEPOETIN ALFA - INJECTION

(DAR-boh-poh-EE-tin AL-fuh)

COMMON BRAND NAME(S): Aranesp

WARNING: Discuss the risks and benefits of use for darbepoetin alfa with your doctor, as this medication may rarely cause very serious (possibly fatal) side effects, including blood clots. It will be very important to keep all laboratory test appointments, as your doctor will need to carefully check your red blood cell tests (hemoglobin). The lowest effective dose of this medication should be used. When used to treat anemia related to cancer, this medication should be stopped after completing a treatment course of chemotherapy as directed by your doctor.

USES: This medication is used to treat anemia (low red blood cell count) in people with long-term serious kidney disease (chronic renal failure) and people receiving chemotherapy for some types of cancer (non-myeloid cancers). Darbepoetin alfa helps to reverse anemia. It also helps to reduce the need for blood transfusions. It works by signaling the bone marrow to make more red blood cells. This medication is very similar to the natural substance in your body (erythropoietin) that prevents anemia.

HOW TO USE: Read the Medication Guide and Patient Information Leaflet provided by your pharmacist before you start using this medication and each time you get a refill. Learn all preparation and usage instructions in the product package. If you have any questions, ask your doctor or pharmacist.

This medication is given as an injection under the skin or into a vein, usually once a week or as directed by your doctor. Hemodialysis patients should receive this medication by injection into a vein.

Do not shake this medication and do not mix it with other drugs or IV solutions. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. If you are injecting this medication under the skin, change the location of the injection site every time to avoid problem areas under the skin.

Learn how to store and discard needles and medical supplies safely. Consult your pharmacist.

The dosage is based on your medical condition, weight, and response to treatment. Blood tests should be performed frequently to check how well this medication is working and to determine the correct dose for you. Consult your doctor for more details.

Do not increase your dose or use this medication more often than directed. Use this medication regularly to get the most benefit from it. To help you remember, use it on the same day each week as directed.

It may take 2 to 6 weeks before your red blood cell count increases. Tell your doctor if your symptoms do not improve or if they worsen.

Disclaimer

Aranesp Consumer (continued)

SIDE EFFECTS: Headache, body aches, diarrhea, and irritation at the injection site may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Darbepoetin alfa may sometimes cause or worsen high blood pressure, especially in patients with long-term kidney failure. This effect may be caused by the number of red blood cells increasing too quickly, usually within the first 3 months of starting treatment. If you have high blood pressure, it should be adequately controlled before beginning treatment with this medication. Your blood pressure should be checked frequently. Ask your doctor if you should learn how to monitor your own blood pressure. If high blood pressure develops or worsens, follow your doctor's instructions about diet changes and starting or adjusting your high blood pressure medication. Lowering high blood pressure helps prevent strokes, heart attacks, and further kidney problems. Keep all laboratory appointments to have your blood count tested regularly to reduce the chance of this side effect.

Tell your doctor immediately if any of these unlikely but serious side effects occur: seizures, confusion, loss of consciousness.

This medication may rarely cause blood clots. Seek immediate medical attention if you notice any of the following rare but very serious side effects: pain/redness/swelling/weakness of the arms or legs, calf pain/swelling that is warm to the touch, new/worsening shortness of breath, coughing up blood, sudden vision changes, slurred speech, weakness on one side of the body, sudden severe headache, chest/jaw/left arm pain, irregular heartbeat, fainting, blood clots in your hemodialysis vascular access site.

Rarely, this medication may suddenly stop working well after a period of time because your body may make antibodies that reduce the effectiveness of darbepoetin alfa, and a very serious anemia can result. Tell your doctor immediately if symptoms of anemia return (e.g., increased tiredness, low energy, pale skin color, shortness of breath).

Though very unlikely to occur, this product may contain substances such as viruses that could cause infections because it may contain albumin from human blood. Careful screening of blood donors, special manufacturing methods, and tests are all used to reduce this risk. Discuss the benefits and risks of treatment with your doctor. Tell your doctor immediately if you develop any signs of an infection (e.g., persistent fever/sore throat, increased tiredness, yellowing eyes/skin, dark urine).

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US -

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Read the Aranesp (darbepoetin alfa) Side Effects Center for a complete guide to possible side effects »

PRECAUTIONS: Before using darbepoetin alfa, tell your doctor or pharmacist if you are allergic to it; or to other drugs that cause more red blood cells to be made (e.g., epoetin alfa); or to products containing human albumin; or if you have any other allergies. This product may contain inactive ingredients (such as polysorbate, latex), which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

This medication should not be used if you have a certain medical condition. Before using this medicine, consult your doctor or pharmacist if you have: uncontrolled high blood pressure.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: high blood pressure (treated/controlled), blood disorders (e.g., sickle cell anemia, white blood cell or platelet problems, bone marrow problems), bleeding/clotting problems, blood vessel problems (e.g., stroke), heart problems (e.g., angina, heart failure), seizure disorder, a certain metabolic disorder (porphyria), certain vitamin deficiencies (folic acid, vitamin B12).

Infrequently, patients with long-term kidney failure on dialysis may be at increased risk of seizures during the first 3 months of treatment with this medication, possibly caused by the number of red blood cells increasing too quickly. Therefore, these patients should use caution and avoid activities such as driving or using machinery during this period. Limit alcoholic beverages because alcohol may also increase the risk of seizures.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor. In some women of child-bearing age, menstrual periods have resumed during treatment with a similar drug (epoetin alfa). If this occurs with darbepoetin alfa treatment, it may be possible to get pregnant while using this medication. Discuss the need for birth control with your doctor.

It is not known whether this drug passes into breast milk. Consult your doctor before breast-feeding.

Disclaimer

Aranesp Consumer (continued)

DRUG INTERACTIONS: Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: desmopressin.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center.

NOTES: Do not share this medication with others.

Laboratory and/or medical tests (e.g., complete blood count that includes hemoglobin and hematocrit, reticulocyte count) must be performed regularly to monitor your progress or check for side effects. Consult your doctor for more details.

Blood tests for your iron levels will also be performed and you may be prescribed iron supplements to take. Your doctor may recommend that you eat a well-balanced diet rich in iron (e.g., raisins, figs, meat, eggs, vegetables, iron-fortified cereals). Follow your doctor's instructions and dietary recommendations.

MISSED DOSE: If you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

STORAGE: Store the medication in the refrigerator between 36-46 degrees F (2-8 degrees C). Do not freeze. Protect it from light. Store the medication in the original carton until ready for use. Let the medication come to room temperature before using. After each dose, discard any unused medication immediately. Keep all medicines away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-800-854-1166 (USA) or 1-800-668-1507 (Canada).

Information last revised June 2011. Copyright(c) 2011 First Databank, Inc.

Aranesp Patient Information Including Side Effects

Brand Names: Aranesp, Aranesp Albumin Free, Aranesp SureClick

Generic Name: darbepoetin alfa (Pronunciation: DAR be POE e tin AL fa)

What is darbepoetin alfa (Aranesp)?

Darbepoetin alfa is a man-made form of a protein that helps your body produce red blood cells. The amount of this protein in your body may be reduced when you have kidney failure or use certain medications. When fewer red blood cells are produced, you can develop a condition called anemia.

Darbepoetin alfa is used to treat anemia (a lack of red blood cells in the body).

Darbepoetin alfa may also be used for purposes not listed in this medication guide.

What are the possible side effects of darbepoetin alfa (Aranesp)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Contact your doctor if you feel light-headed or unusually weak or tired. These may be signs that your body has stopped responding to darbepoetin alfa.

Darbepoetin alfa can increase your risk of life-threatening heart or circulation problems, including heart attack or stroke. This risk will increase the longer you use darbepoetin alfa. Seek emergency medical help if you have symptoms of heart or circulation problems, such as:

  • chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;
  • feeling short of breath, even with mild exertion;
  • swelling, rapid weight gain;
  • sudden numbness or weakness, especially on one side of the body;
  • sudden severe headache, confusion, problems with vision, speech, or balance; or
  • pain, swelling, warmth, or redness in one or both legs.

Stop using darbepoetin alfa and call your doctor at once if you have other serious side effects such as:

  • fever, chills, body aches, flu symptoms;
  • feeling like you might pass out;
  • easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin;
  • seizure (black-out or convulsions); or
  • dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).

Less serious side effects may include:

  • stomach pain;
  • mild cough;
  • mild skin rash or redness; or
  • pain, bruising, swelling, warmth, redness, oozing, or bleeding where the IV needle is placed.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Read the Aranesp (darbepoetin alfa) Side Effects Center for a complete guide to possible side effects »

What is the most important information I should know about darbepoetin alfa (Aranesp)?

You should not use this medication if you have untreated or uncontrolled high blood pressure, if you are allergic to darbepoetin alfa or epoetin alfa (Epogen or Procrit), or if you have ever had pure red cell aplasia (PRCA, a type of anemia) caused by using either of these two drugs.

Before using darbepoetin alfa, tell your doctor if you have heart disease, congestive heart failure, high blood pressure, kidney disease, a blood cell or clotting disorder, cancer, a seizure disorder, a latex allergy, or a history of stroke, heart attack, or blood clots.

This medicine can increase your risk of life-threatening heart or circulation problems, including heart attack or stroke. This risk will increase the longer you use epoetin alfa. Darbepoetin alfa may also shorten remission time or survival time in some people with certain types of cancer. Talk with your doctor about the risks and benefits of using darbepoetin alfa.

Seek emergency medical help if you have symptoms of heart or circulation problems, such as chest pain or heavy feeling, pain spreading to the arm or shoulder, shortness of breath, slurred speech, or problems with vision or balance.

To be sure this medication is helping your condition, your blood may need to be tested often. Your blood pressure will also need to be checked. Visit your doctor regularly.

Contact your doctor if you feel light-headed or unusually weak or tired. These may be signs that your body has stopped responding to darbepoetin alfa.

Some women using darbepoetin alfa have started having menstrual periods, even after not having a period for a long time due to a medical condition. You may be able to get pregnant if your periods restart. Talk with your doctor about the need for birth control.

Side Effects Centers

Aranesp Patient Information including How Should I Take

What should I discuss with my healthcare provider before using darbepoetin alfa (Aranesp)?

You should not use this medication if you are allergic to darbepoetin alfa or epoetin alfa (Epogen or Procrit), or if you have:

  • untreated or uncontrolled high blood pressure; or
  • if you have ever had pure red cell aplasia (PRCA, a type of anemia) caused by using darbepoetin alfa or epoetin alfa.

To make sure you can safely take darbepoetin alfa, tell your doctor if you have any of these other conditions:

  • heart disease, congestive heart failure, high blood pressure;
  • kidney disease (or if you are on dialysis);
  • a history of stroke, heart attack, or blood clots;
  • a blood cell or clotting disorder, such as sickle cell anemia or hemophilia;
  • cancer;
  • a seizure disorder; or
  • if you are allergic to latex.

FDA pregnancy category C. It is not known whether darbepoetin alfa will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medication.

It is not known whether darbepoetin alfa passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

Some women using darbepoetin alfa have started having menstrual periods, even after not having a period for a long time due to a medical condition. You may be able to get pregnant if your periods restart. Talk with your doctor about the need to use birth control while you are using darbepoetin alfa.

Darbepoetin alfa may shorten remission time in some people with head and neck cancer who are also being treated with radiation. Darbepoetin alfa may also shorten survival time in certain people with breast cancer, non-small cell lung cancer, head and neck cancer, cervical cancer, or lymphoid cancer. Talk with your doctor about your individual risk.

How should I use darbepoetin alfa (Aranesp)?

Use exactly as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results.

Darbepoetin alfa is injected under the skin or into a vein. You may be shown how to use an IV at home. Do not self-inject this medicine if you do not fully understand how to give the injection and properly dispose of used needles, IV tubing, and other items used to inject the medicine.

Do not shake the medication bottle or you may ruin the medicine. Prepare your dose in a syringe only when you are ready to give yourself an injection. Do not use the medication if it has changed colors or has particles in it. Call your doctor for a new prescription.

Use a disposable needle only once. Throw away used needles in a puncture-proof container (ask your pharmacist where you can get one and how to dispose of it). Keep this container out of the reach of children and pets.

To be sure this medication is helping your condition, your blood may need to be tested often. Your blood pressure will also need to be checked. Visit your doctor regularly.

If you need surgery, tell the surgeon ahead of time that you are using darbepoetin alfa.

Store in the refrigerator and protect from light. Do not freeze darbepoetin alfa, and throw away the medication if it has become frozen.

Side Effects Centers

Aranesp Patient Information including If I Miss a Dose

What happens if I miss a dose (Aranesp)?

Call your doctor for instructions if you miss a dose of darbepoetin alfa.

What happens if I overdose (Aranesp)?

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

Overdose symptoms may include some of the serious side effects listed in this medication guide.

What should I avoid while using darbepoetin alfa (Aranesp)?

Follow your doctor's instructions about any restrictions on food, beverages, or activity.

What other drugs will affect darbepoetin alfa (Aranesp)?

There may be other drugs that can interact with darbepoetin alfa. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

Where can I get more information?

Your pharmacist can provide more information about darbepoetin alfa.


Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

Copyright 1996-2012 Cerner Multum, Inc. Version: 7.01. Revision date: 8/12/2011.

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Side Effects Centers

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