There are no adequate and well-controlled studies of SUSVIMO (ranibizumab injection) administration in pregnant women. Administration of ranibizumab to pregnant monkeys throughout the period of organogenesis resulted in a low incidence of skeletal abnormalities at intravitreal doses up to 41 times the human exposure (based on serum levels following the recommended clinical dose). No skeletal abnormalities were observed at serum trough levels similar to the human exposure after a single eye treatment at the recommended clinical dose [see Animal Data].
Animal reproduction studies are not always predictive of human response, and it is not known whether ranibizumab can cause fetal harm when administered to a pregnant woman. Based on the anti-VEGF mechanism of action for ranibizumab [see Clinical Pharmacology (12.1)] , treatment with SUSVIMO (ranibizumab injection) may pose a risk to human embryofetal development.
All pregnancies have a background risk of birth defects, loss, and other adverse outcomes. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects is 2% – 4% and of miscarriage is 15% – 20% of clinically recognized pregnancies.
An embryo-fetal developmental toxicity study was performed on pregnant cynomolgus monkeys. Pregnant animals received intravitreal injections of ranibizumab every 14 days starting on Day 20 of gestation, until Day 62 at doses of 0, 0.125, and 1 mg/eye. Skeletal abnormalities including incomplete and/or irregular ossification of bones in the skull, vertebral column, and hindlimbs and shortened supernumerary ribs were seen at a low incidence in fetuses from animals treated with 1 mg/eye of ranibizumab. The 1 mg/eye dose resulted in trough serum ranibizumab levels up to 41 times higher than observed human Cmax levels of SUSVIMO (ranibizumab injection) after treatment of a single eye.
No skeletal abnormalities were seen at the lower dose of 0.125 mg/eye, a dose which resulted in trough exposures similar to single eye treatment with SUSVIMO (ranibizumab injection) in humans. No effect on the weight or structure of the placenta, maternal toxicity, or embryotoxicity was observed.
There are no data available on the presence of ranibizumab in human milk, the effects of ranibizumab on the breastfed infant or the effects of ranibizumab on milk production/excretion. Because many drugs are excreted in human milk, and because the potential for absorption and harm to infant growth and development exists, caution should be exercised when SUSVIMO is administered to a nursing woman.
The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for SUSVIMO (ranibizumab injection) and any potential adverse effects on the breastfed child from ranibizumab.
Females of reproductive potential should use effective contraception during treatment with SUSVIMO (ranibizumab injection) and for at least 12 months after the last dose of SUSVIMO (ranibizumab injection).
No studies on the effects of ranibizumab on fertility have been conducted and it is not known whether ranibizumab can affect reproduction capacity. Based on the anti-VEGF mechanism of action for ranibizumab, treatment with SUSVIMO (ranibizumab injection) may pose a risk to reproductive capacity.
The safety and efficacy of SUSVIMO (ranibizumab injection) in pediatric patients have not been established.
In the Archway study, 90% (222 of 248) of the patients randomized to treatment with SUSVIMO were ≥ 65 years old and approximately 57% (141 of 248) were ≥ 75 years old. No notable difference in treatment effect or safety was seen with increasing age.
Ranibizumab is a recombinant humanized IgG1 kappa isotype monoclonal antibody fragment for intraocular use. Ranibizumab binds to and inhibits the biologic activity of human vascular endothelial growth factor-A (VEGF-A). Ranibizumab, which lacks an Fc region, has a molecular weight of approximately 48 kilodaltons and is produced by an E. coli expression system in a nutrient medium containing the antibiotic tetracycline. Tetracycline is not detectable in the final product.
SUSVIMO (ranibizumab injection) is supplied as a sterile, clear to slightly opalescent, colorless to pale brown solution for intravitreal use via the SUSVIMO implant. Each single-dose vial contains 10 mg of ranibizumab, histidine HCl (0.1 mg), polysorbate 20 (0.01 mg), sucrose (8.2 mg), and Water for Injection, in 0.1 mL of solution with a pH of 5.5. The SUSVIMO implant is designed to contain approximately 0.02 mL (2 mg) of ranibizumab solution when filled. SUSVIMO does not contain an antimicrobial preservative.
Ranibizumab binds to the receptor binding site of multiple biologically active forms of VEGF-A, including VEGF110 . VEGF-A has been shown to cause neovascularization and leakage in models of ocular angiogenesis and vascular occlusion and is thought to contribute to pathophysiology of neovascular AMD. The binding of ranibizumab to VEGF-A prevents the interaction of VEGF-A with its receptors (VEGFR1 and VEGFR2) on the surface of endothelial cells, reducing endothelial cell proliferation, vascular leakage, and new blood vessel formation.
The SUSVIMO implant provides a continuous release of ranibizumab where the release of ranibizumab into the vitreous decreases over time as the concentration in the implant decreases with a half-life of approximately 25 weeks. The ranibizumab serum concentrations with a SUSVIMO 24-week treatment interval are maintained below the maximum and above the minimum concentrations experienced with monthly 0.5 mg intravitreal ranibizumab.
Following implant insertion of SUSVIMO, the mean (±SD) maximum ranibizumab serum concentration (Cmax ) was 0.48 (±0.17) ng/mL and median (range) time to maximum serum concentration (Tmax ) was 26 (1 – 89) days. Following the initial fill and refill of SUSVIMO in patients with AMD, maximum serum concentrations of ranibizumab were below the ranibizumab concentration necessary to inhibit the biological activity of VEGF by 50%. Ranibizumab did not accumulate in serum when administered with refills every 24 weeks.
The metabolism of SUSVIMO (ranibizumab injection) has not been studied. SUSVIMO (ranibizumab injection) is a monoclonal antibody fragment and antibodies are cleared principally by catabolism.
The full excretion profile for ranibizumab following administration of SUSVIMO is unknown.
In a population pharmacokinetic analysis of AMD patients with SUSVIMO, 75% (220 of 295) had renal impairment (42% mild [CrCL 60 to 89 mL/min], 30% moderate [CrCL 30 to 59 mL/min] and 2% severe [CrCL < 30mL/min]). Systemic clearance of ranibizumab was slightly lower in renally impaired patients, but was not clinically significant. No clinically significant differences in the pharmacokinetics of ranibizumab were observed based on age.
No studies have been conducted to determine the carcinogenic or mutagenic potential of SUSVIMO (ranibizumab injection). Based on the anti-VEGF mechanism of action for ranibizumab, treatment with SUSVIMO (ranibizumab injection) may pose a risk to reproductive capacity [see Females and Males of Reproductive Potential (8.3)].
The clinical efficacy and safety of SUSVIMO (ranibizumab injection) was assessed in a randomized, visual assessor-masked, active treatment-controlled study (Archway-NCT03677934) in patients with AMD. A total of 415 patients (248 in the SUSVIMO arm and 167 in the intravitreal ranibizumab arm) were enrolled and treated in this study. Patients were diagnosed with nAMD within the 9 months prior to screening and received ≥ 3 doses of anti-VEGF intravitreal agents in the study eye within the last 6 months prior to screening. Each patient was required to have demonstrated a response to an anti-VEGF intravitreal agent prior to randomization. Patients were randomized in a 3:2 ratio to receive continuous delivery of SUSVIMO (ranibizumab injection) via the SUSVIMO implant every 24 weeks or 0.5 mg intravitreal ranibizumab injections every 4 weeks. For patients randomized to the SUSVIMO arm, supplemental treatment with 0.5 mg intravitreal ranibizumab injections was available at Weeks 16, 20, 40, 44, 64, 68, 88, and 92, if needed. In the first 24 weeks, 1.6% of patients assessed for supplemental treatment received 1 or more supplemental treatment(s) and in the following 24 weeks, 5.4% of patients assessed for supplemental treatment received 1 or more supplemental treatment(s).
The primary efficacy endpoint of change from baseline in distance Best Corrected Visual Acuity (BCVA) score averaged over Week 36 and Week 40 demonstrated that SUSVIMO was equivalent to intravitreal ranibizumab injections administered every 4 weeks. Detailed efficacy results are shown in Table 3 and Figure 29 below.
|Outcome Measure *||SUSVIMO (100 mg/mL)n=248||Intravitreal ranibizumab 0.5 mg (10 mg/mL)n=167||Difference(95% CI)†|
|BCVA = Best corrected visual acuity|
|Adjusted Mean change from baseline in BCVA score averaged over Weeks 36 and 40||0.2||0.5||-0.3(-1.7, 1.1)‡|
|Q24W = every 24 weeks; Q4W = every 4 weeks|
|Figure 29 Adjusted Mean change from Baseline in Best Corrected Visual Acuity in study eye through Week 48 in the Archway (GR40548) study *, †|
Consistent results were observed across patient subgroup analyses for mean change from baseline in BCVA score (age, gender, number of prior anti-VEGF intravitreal injections, and baseline BCVA score).
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