ORENCIA 250 mg powder for concentrate for solution for infusion.

Each vial contains 250 mg of abatacept.

Each ml contains 25 mg of abatacept, after reconstitution.

Abatacept is a fusion protein produced by recombinant DNA technology in Chinese hamster ovary cells.

Excipient: sodium: 0.375 mmol per vial

For a full list of excipients, see section 6.1.

Powder for concentrate for solution for infusion.

The powder is a white to offwhite whole or fragmented cake.

ORENCIA in combination with methotrexate is indicated for the treatment of moderate to severe active rheumatoid arthritis in adult patients who have had an insufficient response or intolerance to other diseasemodifying antirheumatic drugs including at least one tumour necrosis factor (TNF) inhibitor. A reduction in the progression of joint damage and improvement of physical function have been demonstrated during combination treatment with abatacept and methotrexate.

Treatment should be initiated and supervised by specialist physicians experienced in the diagnosis and treatment of rheumatoid arthritis.

Adults

To be administered as a 30minute intravenous infusion at the dose specified in Table 1. Following the initial administration, ORENCIA should be given 2 and 4 weeks after the first infusion, then every 4 weeks thereafter.

Table 1: Dose of ORENCIAa
Body Weight of Patient	Dose	Number of Vialsb
< 60 kg	500 mg	2
60 kg to 100 kg	750 mg	3
> 100 kg	1,000 mg	4

^a Approximating 10 mg/kg.

^b Each vial provides 250 mg of abatacept for administration.

Each vial of ORENCIA 250 mg must be reconstituted with 10 ml of water for injections, using the siliconefree syringe provided. The reconstituted solution must then be diluted to 100 ml with sodium chloride 9 mg/ml (0.9%) solution for injection, before administration by intravenous infusion (see section 6.6).

No dose adjustment is required when used in combination with other DMARDs, corticosteroids, salicylates, nonsteroidal antiinflammatory drugs (NSAIDs), or analgesics.

If a response to abatacept is not present within 6 months of treatment, the potential benefits of continuing treatment, known and potential risks, and therapeutic alternatives should be considered (see section 5.1).

Elderly patients

No dose adjustment is required.

Paediatric patients

There is no experience in children or adolescents. As a result, the use of ORENCIA in children or adolescents is not recommended until further data become available.

Renal and hepatic impairment

ORENCIA has not been studied in these patient populations. No dose recommendations can be made.

Hypersensitivity to the active substance or to any of the excipients.

Severe and uncontrolled infections such as sepsis and opportunistic infections (see section 4.4).

Combination with TNF blocking agents

There is limited experience with use of abatacept in combination with TNF blocking agents (see section 5.1). In placebocontrolled clinical trials, in comparison with patients treated with TNF blocking agents and placebo, patients who received combination TNF blocking agents with abatacept experienced an increase in overall infections and serious infections (see section 4.5). Abatacept is not recommended for use in combination with TNF blocking agents.

While transitioning from TNF blocking agent therapy to ORENCIA therapy, patients should be monitored for signs of infection.

Allergic reactions

Allergic reactions have been reported uncommonly with abatacept administration in clinical trials, where patients were not required to be pretreated to prevent allergic reactions (see section 4.8). Special caution should be exercised in patients with a history of allergic reactions to abatacept or to any of the excipients. If any serious allergic or anaphylactic reaction occurs, ORENCIA therapy should be discontinued immediately and appropriate therapy initiated.

Effects on the immune system

Medicinal products which affect the immune system, including ORENCIA, may affect host defences against infections and malignancies, and affect vaccination responses.

Coadministration of ORENCIA with biologic immunosuppressive or immunomodulatory agents could potentiate the effects of ORENCIA on the immune system. There is insufficient evidence to assess the safety and efficacy of ORENCIA in combination with anakinra or rituximab.

Infections

Serious infections, including sepsis and pneumonia, have been reported with abatacept (see section 4.8). Some of these infections have been fatal. Many of the serious infections have occurred in patients on concomitant immunosuppressive therapy which in addition to their underlying disease, could further predispose them to infections. Treatment with ORENCIA should not be initiated in patients with active infections until infections are controlled. Physicians should exercise caution when considering the use of ORENCIA in patients with a history of recurrent infections or underlying conditions which may predispose them to infections. Patients who develop a new infection while undergoing treatment with ORENCIA should be monitored closely. Administration of ORENCIA should be discontinued if a patient develops a serious infection.

No increase of tuberculosis was observed in the pivotal placebo-controlled studies. Nevertheless, patients should be screened for latent tuberculosis prior to initiating ORENCIA. The available medical guidelines should also be taken into account.

Antirheumatic therapies have been associated with hepatitis B reactivation. Therefore, screening for viral hepatitis should be performed in accordance with published guidelines before starting therapy with ORENCIA.

Malignancies

In the placebocontrolled clinical trials, the frequencies of malignancies in abatacept and placebotreated patients were 1.4% and 1.1%, respectively (see section 4.8). Patients with known malignancies were not included in these clinical trials. In carcinogenicity studies in mice, an increase in lymphomas and mammary tumours were noted. The clinical significance of this observation is unknown (see section 5.3). The potential role of ORENCIA in the development of malignancies, including lymphoma, in humans is unknown.

Vaccinations

Live vaccines should not be given concurrently with ORENCIA or within 3 months of its discontinuation. No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving ORENCIA. Insufficient data are available on the effects of vaccinations in patients receiving ORENCIA. Medicinal products that affect the immune system, including ORENCIA, may blunt the effectiveness of some immunisations.

Elderly patients

A total of 323 patients 65 years of age and older, including 53 patients 75 years and older, received abatacept in placebocontrolled clinical trials. Similar efficacy was observed in these patients and in younger patients. The frequencies of serious infection and malignancy relative to placebo among abatacepttreated patients over age 65 were higher than among those under age 65. Because there is a higher incidence of infections and malignancies in the elderly in general, caution should be used when treating the elderly (see section 4.8).

Autoimmune processes

There is a theoretical concern that treatment with ORENCIA might increase the risk for autoimmune processes, for example deterioration of multiple sclerosis. In the placebo-controlled clinical trials, abatacept treatment did not lead to increased autoantibody formation, such as antinuclear and anti-dsDNA antibodies, relative to placebo treatment (see section 4.8).

Blood glucose testing

Parenteral medicinal products containing maltose can interfere with the readings of blood glucose monitors that use test strips with glucose dehydrogenase pyrroloquinolinequinone (GDHPQQ). The GDHPQQ based glucose monitoring systems may react with the maltose present in ORENCIA, resulting in falsely elevated blood glucose readings on the day of infusion. When receiving ORENCIA, patients that require blood glucose monitoring should be advised to consider methods that do not react with maltose, such as those based on glucose dehydrogenase nicotine adenine dinucleotide (GDHNAD), glucose oxidase, or glucose hexokinase test methods.

Patients on controlled sodium diet

This medicinal product contains 1.5 mmol (or 34.5 mg) sodium per maximum dose of 4 vials (0.375 mmol or 8.625 mg sodium per vial). To be taken into consideration when treating patients on a controlled sodium diet.

Combination with TNF blocking agents

There is limited experience with the use of abatacept in combination with TNF blocking agents (see section 5.1). While TNF blocking agents did not influence abatacept clearance, in placebocontrolled clinical trials, patients receiving concomitant treatment with abatacept and TNF blocking agents experienced more infections and serious infections than patients treated with only TNF blocking agents. Therefore, concurrent therapy with ORENCIA and a TNF blocking agent is not recommended.

Combination with other medicinal products

Population pharmacokinetic analyses did not detect any effect of methotrexate, NSAIDs, and corticosteroids on abatacept clearance (see section 5.2).

No major safety issues were identified with use of abatacept in combination with sulfasalazine, hydroxychloroquine, or leflunomide.

See section 4.4 regarding combination with other medicinal products that affect the immune system and with vaccinations.

There are no adequate data from use of abatacept in pregnant women. In embryofoetal development studies no undesirable effects were observed at doses up to 29fold a human 10 mg/kg dose based on AUC. In a pre and postnatal development study limited changes in immune function were observed at 11fold a human 10 mg/kg dose based on AUC (see section 5.3). ORENCIA should not be used in pregnant women unless clearly necessary. Women of childbearing potential should use effective contraception during treatment with ORENCIA and up to 14 weeks after the last dose of abatacept treatment.

Use during lactation

Abatacept has been shown to be present in rat milk. It is not known whether abatacept is excreted in human milk. Women should not breastfeed while treated with ORENCIA and for up to 14 weeks after the last dose of abatacept treatment.

Fertility

Formal studies of the potential effect of ORENCIA on human fertility have not been conducted.

In rats, abatacept had no undesirable effects on male or female fertility (see section 5.3).

No studies on the effects on the ability to drive and use machines have been performed.

Abatacept has been studied in patients with active rheumatoid arthritis in placebocontrolled clinical trials (1,955 patients with abatacept, 989 with placebo). The trials had either a doubleblind, placebocontrolled period of 6 months (258 patients with abatacept, 133 with placebo) or 1 year (1,697 patients with abatacept, 856 with placebo). Most patients in these trials were taking methotrexate (81.9% with abatacept, 83.3% with placebo). Other concomitant medications included: NSAIDs (83.9% with abatacept, 85.1% with placebo); systemic corticosteroids (74.7% with abatacept, 75.8% with placebo); nonbiological DMARD therapy, most commonly chloroquine/hydroxychloroquine, leflunomide and/or sulfasalazine (26.9% with abatacept, 32.1% with placebo); TNF blocking agents, mainly etanercept (9.4% with abatacept, 12.3% with placebo); and anakinra (1.1% with abatacept, 1.6% with placebo).

In placebocontrolled clinical trials with abatacept, adverse drug reactions (ADRs) were reported in 52.2% of abatacepttreated patients and 46.1% of placebotreated patients. The most frequently reported adverse drug reactions ( 5%) among abatacepttreated patients were headache and nausea. The proportion of patients who discontinued treatment due to ADRs was 3.4% for abatacepttreated patients and 2.2% for placebotreated patients.

Listed in Table 2 are adverse drug reactions based on experience in controlled clinical trials in adults that occurred with greater frequency (difference> 0.2%) in abatacepttreated patients than in placebotreated patients. The list is presented by system organ class and frequency, using the following categories: very common ( 1/10); common ( 1/100 to < 1/10); uncommon ( 1/1,000 to < 1/100); rare ( 1/10,000 to < 1/1,000); very rare (< 1/10,000). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

Table 2: Undesirable Effects in PlaceboControlled Trials

Investigations	Common	Blood pressure increased, liver function test abnormal (including transaminases increased)
	Uncommon	Blood pressure decreased, weight increased
Cardiac disorders	Uncommon	Tachycardia, bradycardia, palpitations
Blood and lymphatic system disorders	Uncommon	Thrombocytopenia, leukopenia
Nervous system disorders	Very Common	Headache
	Common	Dizziness
	Uncommon	Paraesthesia
Eye disorders	Uncommon	Conjunctivitis, visual acuity reduced
Ear and labyrinth disorders	Uncommon	Vertigo
Respiratory, thoracic and mediastinal disorders	Common	Cough
Gastrointestinal disorders	Common	Abdominal pain, diarrhoea, nausea, dyspepsia
	Uncommon	Gastritis, mouth ulceration, aphthous stomatitis
Skin and subcutaneous tissue disorders	Common	Rash (including dermatitis)
	Uncommon	Increased tendency to bruise, alopecia, dry skin
Musculoskeletal and connective tissue disorders	Uncommon	Arthralgia, pain in extremity
Infections and infestations	Common	Lower respiratory tract infection (including bronchitis), urinary tract infection, herpes simplex, upper respiratory tract infection (including tracheitis, nasopharyngitis), rhinitis
	Uncommon	Tooth infection, infected skin ulcer, onychomycosis
Neoplasms benign, malignant and unspecified (incl. cysts and polyps)	Uncommon	Basal cell carcinoma
Vascular disorders	Common	Hypertension, flushing
	Uncommon	Hypotension, hot flush
General disorders and	Common	Fatigue, asthenia
administration site conditions	Uncommon	Influenza like illness
Reproductive system and breast disorders	Uncommon	Amenorrhea
Psychiatric disorders	Uncommon	Depression, anxiety

ADRs reported in abatacepttreated patients which did not occur with an excess incidence (i.e. the difference was not> 0.2%) over placebo but were considered to be medically relevant include the following events:

Common: herpes zoster;

Uncommon: pneumonia, hypersensitivity, pyelonephritis, bronchospasm, urticaria, psoriasis, cystitis, migraine, throat tightness, dry eye;

Rare: sepsis, bacteraemia.

Additional information

Infections

In the placebocontrolled clinical trials, infections at least possibly related to treatment were reported in 23.2% of abatacepttreated patients and 19.5% of placebotreated patients.

Serious infections at least possibly related to treatment were reported in 1.8% of abatacepttreated patients and 1.0% of placebotreated patients. Serious infections reported in at least one patient treated with abatacept (0.05% of patients) included the following: pneumonia; bronchitis; cellulitis; acute pyelonephritis; urinary tract infection; diverticulitis, intestinal abscess; localised infection; skin abscess; musculoskeletal infections; sepsis; empyema; hepatitis E; and tuberculosis (see section 4.4).

Malignancies

In placebocontrolled clinical trials, malignancies were reported in 27 of 1,955 abatacepttreated patients observed during 1,687 patientyears, and in 11 of 989 placebotreated patients observed during 794 patientyears.

In double blind and open-label clinical trials in 4,149 patients treated with abatacept during 10,365 patient-years, the incidence rate of malignancy was 1.41 per 100 patient-years. The incidence rates per 100 patients-years were 0.74 for non-melanomatous skin cancer, 0.59 for solid malignancies and 0.12 for hematologic malignancies. The most frequently reported organ cancer was lung cancer (0.16 per 100 patient-years), and the most common hematologic malignancy was lymphoma (0.07 per 100 patient-years). The incidence rate did not increase for malignancies overall, by major type (non-melanomatous skin cancer, solid tumors, and hematologic malignancies), or for individual tumor types in the double blind and open label period compared to the double-blind experience. The type and pattern of malignancies reported during the openlabel period of the trials were similar to those reported for the doubleblind experience.

The incidence rate of observed malignancies was consistent with that expected in an age and gendermatched rheumatoid arthritis population (see section 4.4).

Infusionrelated reactions

Acute infusionrelated events (adverse reactions occurring within 1 hour of the start of the infusion) in Studies II, III, and IV (see section 5.1) were more common in the abatacepttreated patients than the placebotreated patients (9.8% for abatacept, 6.7% for placebo). The most frequently reported events with abatacept (12%) were dizziness, headache, and hypertension.

Acute infusionrelated events that were reported in> 0.1% and 1% of patients treated with abatacept included cardiopulmonary symptoms such as hypotension, increased blood pressure, decreased blood pressure, and dyspnea; other symptoms included nausea, flushing, urticaria, cough, hypersensitivity, pruritus, rash, and wheezing. Most of these reactions were mild to moderate.

Hypersensitivity, anaphylaxis, and drug hypersensitivity reactions were rarely reported in patients treated with abatacept during controlled and open-label clinical trials. Other reactions potentially associated with hypersensitivity to the medicinal product, such as hypotension, urticaria, and dyspnea, that occurred within 24 hours of ORENCIA infusion, were uncommon.

Discontinuation due to an acute infusionrelated reaction occurred in 0.4% of patients receiving abatacept and in 0.2% of placebotreated patients.

Adverse drug reactions in patients with chronic obstructive pulmonary disease (COPD)

In Study IV, there were 37 patients with COPD treated with abatacept and 17 treated with placebo. The COPD patients treated with abatacept developed adverse drug reactions more frequently than those treated with placebo (51.4% vs. 47.1%, respectively). Respiratory disorders occurred more frequently in abatacepttreated patients than in placebotreated patients (10.8% vs. 5.9%, respectively); these included COPD exacerbation, and dyspnea. A greater percentage of abatacept than placebotreated patients with COPD developed a serious adverse reaction (5.4% vs. 0%), including COPD exacerbation (1 of 37 patients [2.7%]) and bronchitis (1 of 37 patients [2.7%]).

Autoantibodies

Abatacept therapy did not lead to increased formation of autoantibodies, i.e., antinuclear and anti-dsDNA antibodies, compared with placebo.

Immunogenicity

Antibodies directed against the abatacept molecule were assessed by ELISA assays in rheumatoid arthritis patients treated for up to 3 years with abatacept. Sixtytwo of 2,237 (2.8%) patients developed binding antibodies. In patients assessed for antibodies at least 56 days after discontinuation of abatacept, 15 of 203 (7.4%) developed antibodies.

Samples with confirmed binding activity to CTLA4 were assessed for the presence of neutralizing antibodies. Eight of 13 evaluable patients were shown to possess neutralizing antibodies.

Overall, there was no apparent correlation of antibody development to clinical response or adverse events. However, the number of patients that developed antibodies was too limited to make a definitive assessment. The potential clinical relevance of neutralizing antibody formation is not known. Because immunogenicity analyses are product-specific, comparison of antibody rates with those from other products is not appropriate.

Safety information related to the pharmacological class

Abatacept is the first selective costimulation modulator. Information on the relative safety in a clinical trial versus infliximab is summarized in section 5.1.

Doses up to 50 mg/kg have been administered without apparent toxic effect. In case of overdose, it is recommended that the patient be monitored for any signs or symptoms of adverse reactions and appropriate symptomatic treatment instituted.

Pharmacotherapeutic group: selective immunosuppressants, ATC code: L04AA24

Abatacept is a fusion protein that consists of the extracellular domain of human cytotoxic Tlymphocyteassociated antigen 4 (CTLA4) linked to a modified Fc portion of human immunoglobulin G1 (IgG1). Abatacept is produced by recombinant DNA technology in Chinese hamster ovary cells.

Mechanism of action

Abatacept selectively modulates a key costimulatory signal required for full activation of T lymphocytes expressing CD28. Full activation of T lymphocytes requires two signals provided by antigen presenting cells: recognition of a specific antigen by a T cell receptor (signal 1) and a second, costimulatory signal. A major costimulatory pathway involves the binding of CD80 and CD86 molecules on the surface of antigen presenting cells to the CD28 receptor on T lymphocytes (signal 2). Abatacept selectively inhibits this costimulatory pathway by specifically binding to CD80 and CD86. Studies indicate that naive T lymphocyte responses are more affected by abatacept than memory T lymphocyte responses.

Studies in vitro and in animal models demonstrate that abatacept modulates T lymphocytedependent antibody responses and inflammation. In vitro, abatacept attenuates human T lymphocyte activation as measured by decreased proliferation and cytokine production. Abatacept decreases antigen specific TNFα, interferonγ, and interleukin2 production by T lymphocytes.

Pharmacodynamic effects

Dosedependent reductions were observed with abatacept in serum levels of soluble interleukin2 receptor, a marker of T lymphocyte activation; serum interleukin6, a product of activated synovial macrophages and fibroblastlike synoviocytes in rheumatoid arthritis; rheumatoid factor, an autoantibody produced by plasma cells; and Creactive protein, an acute phase reactant of inflammation. In addition, serum levels of matrix metalloproteinase3, which produces cartilage destruction and tissue remodelling, were decreased. Reductions in serum TNFα were also observed.

Clinical efficacy and safety

The efficacy and safety of abatacept were assessed in randomised, doubleblind, placebocontrolled clinical trials in adult patients with active rheumatoid arthritis diagnosed according to American College of Rheumatology (ACR) criteria. Studies I, II, III, and V required patients to have at least 12 tender and 10 swollen joints at randomization. Study IV did not require any specific number of tender or swollen joints.

In Studies I, II, and V the efficacy and safety of abatacept compared to placebo were assessed in patients with an inadequate response to methotrexate and who continued on their stable dose of methotrexate. In addition, Study V investigated the safety and efficacy of abatacept or infliximab relative to placebo. In Study III the efficacy and safety of abatacept were assessed in patients with an inadequate response to a TNF blocking agent, with the TNF blocking agent discontinued prior to randomization; other DMARDs were permitted. Study IV primarily assessed safety in patients with active rheumatoid arthritis requiring additional intervention in spite of current therapy with nonbiological and/or biological DMARDs; all DMARDs used at enrollment were continued.

Study I patients were randomized to receive abatacept 2 or 10 mg/kg or placebo for 12 months. Study II, III, and IV patients were randomized to receive a fixed dose approximating 10 mg/kg of abatacept or placebo for 12 (Studies II and IV) or 6 months (Study III). The dose of abatacept was 500 mg for patients weighing less than 60 kg, 750 mg for patients weighing 60 to 100 kg, and 1 gram for patients weighing greater than 100 kg. Study V patients were randomized to receive this same fixed dose of abatacept or 3 mg/kg infliximab or placebo for 6 months. Study V continued for an additional 6 months with the abatacept and infliximab groups only.

Studies I, II, III, IV, and V evaluated 339, 638, 389, 1,441, and 431 patients, respectively.

Clinical response

ACR response

The percent of abatacepttreated patients achieving ACR 20, 50, and 70 responses in Study II (patients with inadequate response to methotrexate) and Study III (patients with inadequate response to TNF blocking agent) are shown in Table 3.

In abatacepttreated patients in Studies II and III, statistically significant improvement in the ACR 20 response versus placebo was observed after administration of the first dose (day 15), and this improvement remained significant for the duration of the studies. In Study II, 43% of the patients who had not achieved an ACR 20 response at 6 months developed an ACR 20 response at 12 months.

Table 3: ACR Responses in PlaceboControlled Trials
	Percent of Patients
	Inadequate Response to Methotrexate (MTX)		Inadequate Response to TNF Blocking Agent
	Study II		Study III
Response Rate	Abatacepta +MTX n = 424	Placebo +MTX n = 214	Abatacepta + DMARDsb n = 256	Placebo + DMARDsb n = 133
ACR 20
Day 15	23%*	14%	18%**	5%
Month 6	68%***	40%	50%***	20%
Month 12	73%***	40%	NAd	NAd
ACR 50
Month 6	40%***	17%	20%***	4%
Month 12	48%***	18%	NAd	NAd
ACR 70
Month 6	20%***	7%	10%**	2%
Month 12	29%***	6%	NAd	NAd
Major Clinical Responsec	14%***	2%	NAd	NAd

* p < 0.05, abatacept vs. placebo.

** p < 0.01, abatacept vs. placebo.

*** p < 0.001, abatacept vs. placebo.

^a Fixed dose approximating 10 mg/kg (see section 4.2).

^b Concurrent DMARDs included one or more of the following: methotrexate, chloroquine/hydroxychloroquine, sulfasalazine, leflunomide, azathioprine, gold, and anakinra.

^c Major clinical response is defined as achieving an ACR 70 response for a continuous 6month period.

^d After 6 months, patients were given the opportunity to enter an openlabel study.

In the openlabel extension of Studies I, II, and III durable and sustained ACR 20, 50, and 70 responses have been observed through 48, 24, and 18 months, respectively, of abatacept treatment. In study I, ACR 20 responses were observed in 71% (42/59) of patients, ACR 50 in 41% (24/59), and ACR 70 in 31% (18/58) at 48 months. In study II, ACR 20 responses were observed in 88% (291/332) of patients, ACR 50 in 62% (205/332), and ACR 70 in 38% (127/334) at 24 months. In study III, ACR 20 responses were observed in 70% (118/167) of patients, ACR 50 in 43% (73/168), and ACR 70 in 22% (37/169) at 18 months.

Greater improvements were seen with abatacept than with placebo in other measures of rheumatoid arthritis disease activity not included in the ACR response criteria, such as morning stiffness.

DAS28 response

Disease activity was also assessed using the Disease Activity Score 28 (DAS28 ESR). There was a significant improvement of DAS in Studies II, III, and V as compared to placebo.

Study V: abatacept or infliximab versus placebo

A randomized, doubleblind study was conducted to assess the safety and efficacy of abatacept or infliximab versus placebo in patients with an inadequate response to methotrexate (Study V). The primary outcome was the mean change in disease activity in abatacept treated patients compared to placebotreated patients at 6 months with a subsequent doubleblind assessment of safety and efficacy of abatacept and infliximab at 12 months. Greater improvement (p < 0.001) in DAS28 was observed with abatacept and with infliximab compared to placebo at six months in the placebocontrolled portion of the trial; the results between the abatacept and infliximab groups were similar. The ACR responses in Study V were consistent with the DAS28 score. Further improvement was observed at 12 months with abatacept. At 6 months, the incidence of AE of infections were 48.1% (75), 52.1% (86), and 51.8% (57) and the incidence of serious AE of infections were 1.3% (2), 4.2% (7), and 2.7% (3) for abatacept, infliximab and placebo groups, respectively. At 12 months, the incidence of AE of infections were 59.6% (93), 68.5% (113), and the incidence of serious AE of infections were 1.9% (3) and 8.5% (14) for abatacept and infliximab groups, respectively.

Radiographic response

Structural joint damage was assessed radiographically over a twoyear period in Study II. The results were measured using the Genantmodified total Sharp score (TSS) and its components, the erosion score and joint space narrowing (JSN) score. The baseline median TSS was 31.7 in abatacepttreated patients and 33.4 in placebotreated patients. Abatacept/methotrexate reduced the rate of progression of structural damage compared to placebo/methotrexate after 12 months of treatment as shown in Table 4. The rate of progression of structural damage in year 2 was significantly lower than that in year 1 for patients randomized to abatacept (p < 0.0001).

Table 4: Mean Radiographic Changes Over 12 Months in Study II
Parameter	Abatacept/MTX n = 391	Placebo/MTX n = 195	Pvaluea
Total Sharp score	1.21	2.32	0.012
Erosion score	0.63	1.14	0.029
JSN score	0.58	1.18	0.009

^a Based on nonparametric analysis.

Physical function response

Improvement in physical function was measured by the Health Assessment Questionnaire Disability Index (HAQDI) in Studies II, III, IV and V and the modified HAQDI in Study I. The results from Studies II and III are shown in Table 5.

Table 5: Improvement in Physical Function in PlaceboControlled Trials
	Inadequate Response to Methotrexate		Inadequate Response to TNF Blocking Agent
	Study II		Study III
HAQc Disability Index	Abatacepta +MTX	Placebo +MTX	Abatacepta +DMARDsb	Placebo +DMARDsb
Baseline (Mean)	1.69 (n = 422)	1.69 (n = 212)	1.83 (n = 249)	1.82 (n = 130)
Mean Improvement from Baseline Month 6	0.59*** (n = 420)	0.40 (n = 211)	0.45*** (n = 249)	0.11 (n = 130)
Month 12	0.66*** (n = 422)	0.37 (n = 212)	NAe	NAe
Proportion of patients with a clinically meaningful improvementd   Month 6	61%***	45%	47%***	23%
Month 12	64%***	39%	NAe	NAe

*** p < 0.001, abatacept vs. placebo.

^a Fixed dose approximating 10 mg/kg (see section 4.2).

^b Concurrent DMARDs included one or more of the following: methotrexate, chloroquine/hydroxychloroquine, sulfasalazine, leflunomide, azathioprine, gold, and anakinra.

^c Health Assessment Questionnaire; 0 = best, 3 = worst; 20 questions; 8 categories: dressing and grooming, arising, eating, walking, hygiene, reach, grip, and activities.

^d Reduction in HAQDI of 0.3 units from baseline.

^e After 6 months, patients were given the opportunity to enter into an openlabel study.

In Study II, among patients with clinically meaningful improvement at month 12, 88% retained the response at month 18, and 85% retained the response at month 24. During the openlabel period of Studies I, II, and III, the improvement in physical function has been maintained through 48, 24, and 18 months, respectively.

Healthrelated outcomes and quality of life

Healthrelated quality of life was assessed by the SF36 questionnaire at 6 months in Studies I, II, and III and at 12 months in Studies I and II. In these studies, clinically and statistically significant improvement was observed in the abatacept group as compared with the placebo group in all 8 domains of the SF36 (4 physical domains: physical function, role physical, bodily pain, general health; and 4 mental domains: vitality, social function, role emotional, mental health), as well as the Physical Component Summary and the Mental Component Summary.

After multiple intravenous infusions (days 1, 15, 30, and every 4 weeks thereafter), the pharmacokinetics of abatacept in rheumatoid arthritis patients showed doseproportional increases of C_max and AUC over the dose range of 2 mg/kg to 10 mg/kg. At 10 mg/kg, the mean terminal halflife was 13.1 days, ranging from 8 to 25 days. The mean distribution volume (Vss) was 0.07 l/kg and ranged from 0.02 to 0.13 l/kg. The systemic clearance was approximately 0.22 ml/h/kg. Mean steadystate trough concentrations were approximately 25 μg/ml, and mean C_max concentrations were approximately 290 μg/ml. No systemic accumulation of abatacept occurred upon continued repeated treatment with 10 mg/kg at monthly intervals in rheumatoid arthritis patients.

Population pharmacokinetic analyses revealed that there was a trend toward higher clearance of abatacept with increasing body weight. Age and gender (when corrected for body weight) did not affect clearance. Methotrexate, NSAIDs, corticosteroids, and TNF blocking agents were not found to influence abatacept clearance.

The pharmacokinetics of abatacept have not been studied in children and adolescents. No studies were conducted to examine the effects of either renal or hepatic impairment on the pharmacokinetics of abatacept.

No mutagenicity or clastogenicity was observed with abatacept in a battery of in vitro studies. In a mouse carcinogenicity study, increases in the incidence of malignant lymphomas and mammary gland tumours (in females) occurred. The increased incidence of lymphomas and mammary tumours observed in mice treated with abatacept may have been associated with decreased control of murine leukaemia virus and mouse mammary tumour virus, respectively, in the presence of longterm immunomodulation. In a oneyear toxicity study in cynomolgus monkeys, abatacept was not associated with any significant toxicity. Reversible pharmacological effects consisted of minimal transient decreases in serum IgG and minimal to severe lymphoid depletion of germinal centres in the spleen and/or lymph nodes. No evidence of lymphomas or preneoplastic morphological changes was observed, despite the presence of a virus, lymphocryptovirus, which is known to cause such lesions in immunosuppressed monkeys within the time frame of this study. The relevance of these findings to the clinical use of ORENCIA is unknown.

In rats, abatacept had no undesirable effects on male or female fertility. Embryofoetal development studies were conducted with abatacept in mice, rats, and rabbits at doses up to 20 to 30 times a human 10 mg/kg dose and no undesirable effects were observed in the offspring. In rats and rabbits, abatacept exposure was up to 29fold a human 10 mg/kg exposure based on AUC. Abatacept was shown to cross the placenta in rats and rabbits. In a pre and postnatal development study with abatacept in rats, no undesirable effects were observed in pups of dams given abatacept at doses up to 45 mg/kg, representing 3fold a human 10 mg/kg exposure based on AUC. At a dose of 200 mg/kg, representing 11fold a human exposure at 10 mg/kg based on AUC, limited changes in immune function (a 9fold increase in the mean Tcelldependent antibody response in female pups and inflammation of the thyroid of 1 female pup out of 10 male and 10 female pups evaluated at this dose) were observed.

Maltose

Sodium dihydrogen phosphate monohydrate

Sodium chloride

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products. ORENCIA should not be infused concomitantly in the same intravenous line with other medicinal products.

ORENCIA should NOT be used with siliconised syringes (see section 6.6).

Unopened vial: 3 years

After reconstitution: chemical and physical inuse stability has been demonstrated for 24 hours at 2°C 8°C. From a microbiological point of view, the reconstituted solution should be diluted immediately.

After dilution: when the reconstituted solution is diluted immediately, the chemical and physical inuse stability of the diluted infusion solution has been demonstrated for 24 hours at 2°C 8°C. From a microbiological point of view, the product should be used immediately.

Store in a refrigerator (2°C 8°C).

Store in the original package in order to protect from light.

For storage conditions of the reconstituted product see section 6.3.

250 mg powder in a vial (Type 1 glass) with a stopper (halobutylrubber) and flip off seal (aluminium) with a siliconefree syringe (polyethylene).

Packs of 1, 2, or 3 vials (each 15 ml) and 1, 2, or 3 silicone-free syringes, respectively.

Not all packsizes may be marketed.

Reconstitution and dilution should be performed in accordance with good practices rules, particularly with respect to asepsis.

Reconstitution

1. Determine the dose and the number of ORENCIA vials needed (see section 4.2).

2. Under aseptic conditions, reconstitute each vial with 10 ml of water for injections, using the silicone freedisposable syringe provided with each vial (see section 6.2) and an 1821 gauge needle.

- Remove the fliptop from the vial and wipe the top with an alcohol swab.

- Insert the syringe needle into the vial through the centre of the rubber stopper and direct the stream of water for injections to the glass wall of the vial.

- Do not use the vial if the vacuum is not present.

- Remove the syringe and needle after 10 ml of water for injections have been injected into the vial.

- To minimise foam formation in solutions of ORENCIA, the vial should be rotated with gentle swirling until the contents are completely dissolved. Do not shake. Avoid prolonged or vigorous agitation.

- Upon complete dissolution of the powder, the vial should be vented with a needle to dissipate any foam that may be present.

- After reconstitution the solution should be clear and colourless to pale yellow. Do not use if opaque particles, discolouration, or other foreign particles are present.

Dilution

3. Immediately after reconstitution, the product must be further diluted to 100 ml with sodium chloride 9 mg/ml (0.9%) solution for injection.

- From a 100 ml infusion bag or bottle, withdraw a volume of sodium chloride 9 mg/ml (0.9%) solution for injection equal to the volume of the reconstituted vials (for 2 vials remove 20 ml, for 3 vials remove 30 ml, for 4 vials remove 40 ml).

- Slowly add the reconstituted ORENCIA solution from each vial to the infusion bag or bottle using the same siliconefree disposable syringe provided with each vial.

- Gently mix. The concentration of the fully diluted ORENCIA solution in the infusion bag or bottle will be approximately 5, 7.5, or 10 mg of abatacept per ml of solution depending on whether 2, 3, or 4 vials of abatacept are used.

- Any unused portion in the vials must be immediately discarded in accordance with local requirements.

4. When reconstitution and dilution are performed under aseptic conditions ORENCIA infusion solution can be used immediately or within 24 hours if stored refrigerated at 2°C to 8°C. Prior to administration, the ORENCIA solution should be inspected visually for particulate matter and discolouration. Discard the solution if any particulate matter or discolouration is observed. The entire, fully diluted ORENCIA solution should be administered over a period of 30 minutes and must be administered with an infusion set and a sterile, nonpyrogenic, lowproteinbinding filter (pore size of 0.2 to 1.2 μm).

- Do not store any unused portion of the infusion solution for reuse.

Any unused product or waste material should be disposed of in accordance with local requirements.

BristolMyers Squibb Pharma EEIG

Uxbridge Business Park

Sanderson Road

Uxbridge UB8 1DH

United Kingdom

EU/1/07/389/001 (1 vial)

21/05/2007

05/2009

Detailed information on this product is available on the website of the European Medicines Agency (EMEA) http://www.emea.europa.eu/