【药品名称】利妥昔单抗注射液

【通用名】利妥昔单抗注射液

【成分】本品主要活性成分为重组利妥昔单抗 辅料包括枸橼酸钠，聚山梨醇酯8，氯化钠和注射用水。

【适应症】本品适用于： 复发或耐药的滤泡性中央型淋巴瘤(国际工作分类B、C 和D 亚型的B 细胞非霍奇金淋巴瘤)的治疗。 先前未经治疗的CD2 阳性III-IV 期滤泡性非霍奇金淋巴瘤，患者应与标准CVP 化疗(环磷酰胺、长春新碱和强的松)8 个周期联合治疗。 CD2 阳性弥漫大B 细胞性非霍奇金淋巴瘤(DLBCL)应与标准CHOP 化疗(环磷酰胺、阿霉素、长春新碱、强的松)8 个周期联合治疗。

【用法用量】用法和使用说明 在无菌条件下抽取所需剂量的利妥昔单抗，置于无菌无致热源的含0.9%生理盐水或5%葡萄糖溶液的输液袋中，稀释到利妥昔单抗的浓度为1mg/ml。轻柔的颠倒注射袋使溶液混合并避免产生泡沫。由于本品不含抗微生物的防腐剂或抑菌制剂，必须检查无菌技术。静脉使用前应观察注射液有无微粒或变色。 利妥昔单抗稀释后通过独立的不与其他药物混用的输液管静脉滴注，适用于不卧床患者的治疗。 利妥昔单抗的治疗应在具有完备复苏设备的病区内进行，并在有经验的肿瘤医师或血液科医师的直接监督下进行。对出现呼吸系统症状或低血压的患者至少监护24 小时。每名患者均应被严密监护，监测是否发生细胞因子释放综合征(见【注意事项】)。对出现严重反应的患者，特别是有严重呼吸困难，支气管痉挛和低氧血症的患者应立即停止滴注。还应该评估患者是否出现肿瘤溶解综合征，例如可以进行适当的实验室检查。预先存在肺功能不全或肿瘤肺浸润的患者必须进行胸部X 线检查。所有的症状消失和实验室检查恢复正常后才能继续滴注，此时滴注速度不能超过原滴注速度的一半。如再次发生相同的严重不良反应，应考虑停药。 利妥昔单抗绝不能未稀释就静脉滴注，制备好的注射液也不能用于静脉推注。 滤泡性非霍奇金淋巴瘤 每次滴注利妥昔单抗前应预先使用解热镇痛药(例如扑热息痛)和抗组胺药(例如苯海拉明)。还应该预先使用糖皮质激素，尤其如果所使用的治疗方案不包括皮质激素。 初始治疗 作为成年病人的单一治疗药，推荐剂量为375 mg/m2 BSA(体表面积)，静脉给入，每周一次，22 天的疗程内共给药4 次。 结合CVP 方案化疗时，利妥昔单抗的推荐剂量是375 mg/m2 BSA，连续8 个周期(21 天/周期)。每次先口服皮质类固醇，然后在化疗周期的第1 天给药。 复发后的再治疗 首次治疗后复发的患者，再治疗的剂量是375 mg/m2 BSA，静脉滴注4 周，每周一次(参见【临床试验】，每周1次，连续4周)。 弥漫大B细胞性非霍奇金淋巴瘤 每次滴注利妥昔单抗前应预先使用解热镇痛药(例如扑热息痛)和抗组胺药(例如苯海拉明)。还应该预先使用糖皮质激素，尤其如果所使用的治疗方案不包括皮质激素。 利妥昔单抗应与CHOP 化疗联合使用。推荐剂量为37

【不良反应】国外不良反应 血液肿瘤临床试验经验 利妥昔单抗单药或与化疗联用的不良反应(ADRs)发生率见下表，数据来源于临床试验。包括单组研究的不良反应或至少一个主要随机临床试验中试验组与对照组相比发生率至少差2%的不良反应。根据任一主要临床试验中发生率最高的不良反应对其进行合理分类，详见下表。各组不良反应按照严重程度降序排列。发生率定义为：很常见，31/1;常见，31/1--1/1;不常见，31/1--1/1。 利妥昔单抗单药治疗/维持治疗 下表1的不良反应来自于多个利妥昔单抗单组研究，包括356例低度恶性或滤泡型淋巴瘤患者，接受每周一次利妥昔单抗单药治疗或再治疗(见【临床试验】)。表格还包括了671例滤泡性淋巴瘤患者接受利妥昔单抗维持治疗的数据，患者接受R-CHOP、R-CVP或R-FCM方案诱导治疗，缓解后继续为期2年的利妥昔单抗维持治疗(见【临床试验】)。单药治疗后12个月或利妥昔单抗维持治疗后1个月的不良反应都进行报告。利妥昔单抗联合化疗用于NHL和CLL 下表2所列不良反应来自于对照的临床试验中的利妥昔单抗治疗组，是在利妥昔单抗单药治疗/维持治疗所观察到的不良反应以外的和/或更高发生率的不良反应：22例接受R-CHOP方案治疗的DLBLC患者，234和162例分别接受R-CHOP方案和R-CVP方案治疗的滤泡型淋巴瘤患者，以及397例先前未经治疗的CLL患者和274例复发/难治性CLL患者，这些患者接受了利妥昔单抗联合氟达拉滨和环磷酰胺(R-FC)的治疗(见【临床试验】)。 包括原发性和复发性感染，发生率统计自采用R-FC方案治疗的复发/难治性CLL患者 仅统计严重不良反应(定义为≥3度NCI常见毒性标准) 仅报告在各临床试验中发生率最高的不良反应 利妥昔单抗组与对照组相比不良反应发生率相似(组间差异小于2%)或者更低的上报不良事件：血液学毒性、中性粒细胞减少所致的感染、泌尿道感染、感染性休克、肺部二次感染、移植物感染、葡萄球菌性败血病、肺部感染、鼻溢、肺水肿、心力衰竭、感觉障碍、静脉血栓形成、粘膜炎症、感冒样症状、下肢水肿、射血分数异常、发热、身体一般状况恶化、情绪低落、多器官衰竭、下肢深静脉血栓形成、血培养阳性、糖尿病控制不佳。 利妥昔单抗联合其他化疗方案(如：MC

【禁忌】非霍奇金淋巴瘤患者 已知对本药的任何组份和鼠蛋白过敏的患者禁用利妥昔单抗。 类风湿性关节炎患者 对处方中活性成分或任何辅料过敏者禁用。 严重活动性感染或免疫应答严重损害(如低g球蛋白血症，CD4 或CD8 细胞计数严重下降)的患者不应使用利妥昔单抗治疗(见【注意事项】)。 同样，严重心衰(NYHA 分类IV)患者不应使用利妥昔单抗治疗。 妊娠期间禁止利妥昔单抗与甲氨蝶呤联合用药。

【注意事项】非霍奇金淋巴瘤患者和慢性淋巴细胞性白血病患者 输注相关反应 利妥昔单抗可以引起输注反应，可能与细胞因子和/或其它化学介质的释放有关。在临床上，可能无法区别严重的输注反应与过敏反应或细胞因子释放综合征。在上市后的使用中，曾有报道致命的严重输注反应。严重输注反应通常出现在利妥昔单抗输注开始后的30分钟-2个小时之内，其特征为肺部事件的发生，在某些病例中除了出现发热、畏寒、寒战、低血压、风疹、血管精经性水肿以及其它症状以外，还可能发生肿瘤的快速溶解以及肿瘤溶解综合征症状(见【不良反应】)。具有高肿瘤负荷或者外周血恶性细胞数目较高(>25x109/L)的患者，例如CLL和套细胞淋巴瘤患者，发生严重的输注反应的风险可能更大。在中止输注以后，这些症状一般都是可以逆转的。建议采用苯海拉明和对乙酰氨基酚对输注症状进行治疗。此外，还可以采用支气管扩张剂或者静注生理盐水进行治疗。在大部分病例中，当症状完全缓解以后，可以减慢50%的速度重新开始输注治疗(例如从100mg/h降低到50mg/h)。大部分发生非致命性输注反应的患者都能完成整个疗程的利妥昔单抗治疗。症状和体征完全缓解后，患者继续接受治疗很少再次出现严重输注相关反应。已有报道静脉给予患者蛋白质后发生过敏反应和其他超敏反应。发生利妥昔单抗相关的超敏反应时，应当立即使用肾上腺素、抗组胺药和糖皮质激素。 外周血恶性肿瘤细胞数目高(>25x109/L)或肿瘤负荷较高的患者，如CLL和套细胞淋巴瘤患者，发生严重输注相关反应的风险相对较高，应特别谨慎处置。首次进行输注时应对患者进行密切观察。该类患者首次输注时应考虑是否需减慢输注速度，或者在第一个治疗周期中将一次给药剂量分为两份，在两天内完成给药。如果淋巴细胞数目仍然大于25x109/L，则在后续的治疗周期中仍应按此方式给药。 肺部事件 肺部事件包括组织缺氧、肺浸润和急性呼吸衰竭。其中有些事件可能继发于严重的支气管痉挛和呼吸困难。在某些病例中，症状可能随着时间的推移而加重，在另外一些病例中，初期有所改善以后，随之而来的是临床状况的恶化。因此，对于发生肺部事件或者其它严重输注症状的患者应该密切监视，直到其症状完全缓解为止。具有肺功能不全或者肺部肿瘤浸润病史的患者愈后不良的风险较大，医生在治疗中应该倍加小心。在胸部X-光片上可以观察到，发生急性呼吸衰竭时，可能伴发肺间质浸润性病变或者

【孕妇用药】妊娠 已知免疫球蛋白IgG可通过胎盘屏障. 在猕猴中进行的发育毒性研究没有发现利妥昔单抗治疗具有子宫内胚胎毒性的证据。在研究中观察到母体动物暴露于利妥昔单抗时，其新生子代在出生后阶段出现B细胞群缺失现象。在人类临床试验中，还没有对母亲暴露于利妥昔单抗后对新生儿B细胞水平的影响进行研究。尚未无怀孕妇女有关的充分、良好对照研究数据，但是，怀孕期间使用过利妥昔单抗的母亲所产新生儿有报告一过性B细胞耗竭和淋巴细胞减少。鉴于此，孕妇应禁用利妥昔单抗，除非可能的获益高于风险。 育龄妇女在使用利妥昔单抗的过程中及治疗后的12个月，应采取有效的避孕措施。 哺乳 尚不清楚乳汁中是否有利妥昔单抗排出。已知母体的IgG可进入乳汁，因此利妥昔单抗不得用于哺乳的母亲。

【儿童用药】利妥昔单抗应用于儿童的有效性和安全性尚未确定。

【老年用药】国外和国内临床研究中均纳入了老年患者，结果提示本品可用于老年患者，无特殊禁忌，详见【药理毒理】项下内容。

【药物相互作用】目前，有关利妥昔单抗与其他药物可能发生的相互作用的资料十分有限。 慢性淋巴细胞性白血病患者合用利妥昔单抗和氟达拉滨或环磷酰胺时，利妥昔单抗未显示对氟达拉滨或环磷酰胺的药代动力产生影响;而且，氟达拉滨和环磷酰胺也不会对利妥昔单抗的药代动力学产生明显的影响。 类风湿性关节炎患者合用利妥昔单抗和甲氨蝶呤时，利妥昔单抗的药代动力学不会受到甲氨蝶呤的影响。 具有人抗鼠抗体(HAMA)或人抗嵌合抗体(HACA)效价的患者在使用其它诊断或治疗性单克隆抗体治疗时可能发生过敏或超敏反应。 在类风湿性关节炎临床试验中，有373例接受利妥昔单抗治疗的患者使用其他缓解疾病的抗风湿性药物(DMARD)进行了后续治疗，其中24人接受了生物类DMARD的治疗。患者在接受利妥昔单抗治疗时(在接受生物类DMARD的治疗前)，严重感染的发生率为6.1/1人年,而接受过生物类DMARD治疗后的严重感染的发生率为4.9/1人年。

【药理作用】利妥昔单抗是一种嵌合鼠/人的单克隆抗体，该抗体与纵贯细胞膜的CD20抗原特异性结合。此抗原位于前B和成熟B淋巴细胞，但在造血干细胞，后B细胞，正常血浆细胞，或其他正常组织中不存在。该抗原表达于95%以上的B淋巴细胞型的非何杰氏淋巴瘤。在与抗体结合后，CD20不被内在化或从细胞膜上脱落。CD20不以游离抗原形式在血浆中循环，因此，也就不会与抗体竞争性结合。利妥昔单抗与B淋巴细胞上的CD20结合，并引发B细胞溶解的免疫反应。细胞溶解的可能机制包括补体依赖性细胞毒性(CDC)和抗体依赖性细胞的细胞毒性(ADCC)。此外，体外研究证明，利妥昔单抗可使药物抵抗性的人体淋巴细胞对一些化疗药的细胞毒性敏感。 

Overview

This is a summary of the European public assessment report (EPAR) for Blitzima. It explains how the Agency assessed the medicine to recommend its authorisation in the EU and its conditions of use. It is not intended to provide practical advice on how to use Blitzima.

For practical information about using Blitzima, patients should read the package leaflet or contact their doctor or pharmacist.

What is Blitzima and what is it used for?

Blitzima is a medicine used in adults to treat the following blood cancers and inflammatory conditions:

· follicular lymphoma and diffuse large B cell non-Hodgkin’s lymphoma (two types of non-Hodgkin’s lymphoma, a blood cancer);

· chronic lymphocytic leukaemia (CLL, another blood cancer affecting white blood cells);

· granulomatosis with polyangiitis (GPA or Wegener’s granulomatosis) and microscopic polyangiitis (MPA), which are inflammatory conditions of the blood vessels.

Depending on the condition it is used to treat, Blitzima may be given with chemotherapy (other cancer medicines) or medicines used for inflammatory disorders (corticosteroids). Blitzima contains the active substance rituximab.

Blitzima is a ‘biosimilar medicine’. This means that Blitzima is highly similar to a biological medicine(also known as the ‘reference medicine’) that is already authorised in the European Union (EU).

How is Blitzima used?

Blitzima can only be obtained with a prescription. It is available as a concentrate for making a solution that must be given by infusion (drip) into a vein. Before each infusion, the patient should be given an antihistamine (to prevent allergic reactions) and an anti-pyretic (a medicine to reduce fever). Blitzima should be given under the close supervision of an experienced healthcare professional and in a place where facilities for resuscitating patients are immediately available.

How does Blitzima work?

The active substance in Blitzima, rituximab, is a monoclonal antibody (a type of protein) designed to recognise and attach to a protein called CD20 present on the surface of B cells (types of white blood cells). When rituximab attaches to CD20, it causes the death of B cells, which helps in lymphoma and CLL, where B cells have become cancerous. In GPA and MPA, destroying the B cells lowers the production of antibodies thought to play an important role in attacking the blood vessels and causing inflammation.

What benefits of Blitzima have been shown in studies?

Laboratory studies comparing Blitzima with MabThera have shown that the active substance in Blitzima is highly similar to that in MabThera in terms of structure, purity and biological activity. Studies have also shown that giving Blitzima produces similar levels of the active substance in the body to giving MabThera.

In addition, Blitzima has been compared with MabThera given into a vein in a main study involving 372 patients with active rheumatoid arthritis (an inflammatory disease). The study showed that Blitzima and MabThera had comparable effects on arthritis symptoms: after 24 weeks, the proportion of patients with a 20% improvement in symptom score (called ACR20) was 74% (114 of 155 patients) with Blitzima and 73% (43 of 59 patients) with MabThera.

Further evidence came from supportive studies, including one involving 121 patients with advanced follicular lymphoma, where adding Blitzima to chemotherapy medicines was at least as effective as adding Rituxan, the US version of MabThera. In this study improvement was seen in 96% of cases (67 of 70 patients) with Blitzima and 90% (63 of 70 patients) with Rituxan.

Because Blitzima is a biosimilar medicine, the studies on effectiveness and safety of rituximab carried out with MabThera do not all need to be repeated for Blitzima.

What are the risks associated with Blitzima?

The most common side effects with rituximab are reactions related to the infusion (such as fever, chills and shivering) which occur in most cancer patients and in more than 1 in 10 GPA or MPA patients at the time of the first infusion. The risk of such reactions decreases in subsequent infusions. The most common serious side effects are infusion reactions, infections and, in cancer patients, heart-related problems. Other serious side effects include hepatitis B reactivation (return of previous active liver infection with hepatitis B virus) and a rare and severe brain infection known as progressive multifocal leukoencephalopathy (PML). For the full list of side effects reported with Blitzima, see the package leaflet.

Blitzima must not be used in people who are hypersensitive (allergic) to rituximab, mouse proteins or any of the other ingredients. It must also not be used in patients with a severe infection or a severely weakened immune system. Patients with GPA or MPA must also not receive Blitzima if they have severe heart problems.

Why is Blitzima approved?

The European Medicines Agency decided that, in accordance with EU requirements for biosimilar medicines, Blitzima has a highly similar structure, purity and biological activity to MabThera and is distributed in the body in the same way. In addition, a study comparing Blitzima to MabThera in patients with rheumatoid arthritis (which can support its use in other inflammatory disorders such as GPA and MPA) showed that both medicines are similarly effective, and a supportive study in follicular lymphoma showed effectiveness in cancer. Thus, all these data were considered sufficient to conclude that Blitzima will behave in the same way in terms of effectiveness as MabThera in its approved indications. Therefore, the Agency’s view was that, as for MabThera, the benefit outweighs the identified risk and it recommended that Blitzima be given marketing authorisation.

What measures are being taken to ensure the safe and effective use of Blitzima?

The company that markets Blitzima will provide doctors and patients using the medicine for non-cancer conditions with educational material including information on the need to give the medicine where facilities for resuscitation are available and on the risk of infection, including PML. Patients are also to receive an alert card to carry at all times, instructing them to contact their doctor immediately if they have any of the listed symptoms of infection.

Doctors prescribing Blitzima for cancer will be provided with educational material reminding them of the need to use the medicine only by infusion into a vein.

Recommendations and precautions to be followed by healthcare professionals and patients for the safe and effective use of Blitzima have also been included in the summary of product characteristics and the package leaflet.

Other information about Blitzima

The European Commission granted a marketing authorisation valid throughout the European Union for Blitzima on 13 July 2017.

For more information about treatment with Blitzima, read the package leaflet (also part of the EPAR) or contact your doctor or pharmacist.

Authorisation details