Interferon Beta
Drug class: Antineoplastic Agents
Usage of Interferon Beta
Multiple Sclerosis (MS)
Management of relapsing forms of MS, including clinically isolated syndrome (CIS), relapsing-remitting disease, and active secondary-progressive disease, in adults.
The American Academy of Neurology (AAN) recommends that disease-modifying therapy be offered to patients with relapsing-remitting MS who have had recent relapses and/or MRI activity. Clinicians should consider adverse effects, tolerability, method of administration, safety, efficacy, and cost of the drugs in addition to patient preferences when selecting an appropriate therapy.
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How to use Interferon Beta
General
Patient Monitoring
Premedication and Prophylaxis
Dispensing and Administration Precautions
Other General Considerations
Administration
Administer by IM or sub-Q injection depending on preparation.
Interferon beta-1a is commercially available as a once-weekly IM injection (Avonex) or a 3-times-weekly sub-Q injection (Rebif). Interferon beta-1b is commercially available as a sub-Q alternate-day injection (Betaseron, Extavia); the 2 currently available interferon beta-1b preparations are identical except for some packaging components (e.g., needle size).
Sub-Q administration associated with higher rates of injection site reactions than IM administration. Prefilled syringes and auto-injectors are for single use only; do not re-use.
IM Administration
Interferon Beta-1a (Avonex)Administer Avonex once weekly by IM injection into thigh or upper arm. Administer Avonex Pen once weekly into upper outer thigh. Rotate injection sites and avoid injecting into sites that appear irritated, reddened, bruised, infected, or scarred. Inspect injection site for any redness, swelling, or tenderness 2 hours after administration.
Commercially available as prefilled syringe or prefilled auto-injector (i.e., Avonex Pen).
The prefilled syringes are packaged with a 23-gauge, 1¼-inch needle supplied by the manufacturer; a 25-gauge, 1-inch needle for IM injection may be substituted by the clinician if appropriate. The prefilled auto-injector must be used with the supplied 25-gauge, (5/8)-inch needle; do not substitute with any other needle.
Remove prefilled syringes and auto-injectors from refrigerator about 30 minutes prior to use to allow solution to reach room temperature; do not use external heat sources (e.g., hot water) to warm solution.
Sub-Q Administration
Interferon Beta-1a (Rebif)Administer 3 times weekly by sub-Q injection into the abdomen (avoiding waistline or areas within 2 inches of navel), thigh, upper arm, or buttock. Administer on the same 3 days (e.g., Monday, Wednesday, and Friday) at least 48 hours apart each week and at the same time (preferably in the late afternoon or evening) each day.
Rotate injection sites and avoid injecting into sites that appear irritated, reddened, bruised, infected, or abnormal in any way.
Remove the drug from refrigerator 30 minutes prior to use.
Commercially available as a prefilled syringe or prefilled auto-injector (i.e., Rebidose).
Interferon Beta-1b (Betaseron, Extavia)Administer by sub-Q injection every other day into the abdomen (except areas near the waistline and navel), thigh, upper arm, or buttocks.
Rotate injection sites and avoid injecting into sites that appear reddened, bruised, infected, or abnormal in any way.
Available as a lyophilized powder that must be reconstituted prior to use. An optional auto-injector (Betaconnect) is commercially available and may be obtained through the manufacturer's patient support program by calling 1-800-788-1467.
Reconstitution of Betaseron and Extavia Lyophilized PowderReconstitute vial containing 0.3 mg of interferon-beta-1b (Betaseron, Extavia) lyophilized powder by attaching the manufacturer-supplied prefilled syringe containing 1.2 mL of 0.54% sodium chloride to the vial; slowly inject entire contents of syringe to provide a solution containing 0.25 mg of interferon beta-1b per 1 mL.
Gently swirl vial to ensure complete dissolution; do not shake.
Reconstituted solutions contain no preservatives; solutions preferably should be prepared immediately before use. Vials are for single use only; discard any residual solution.
Dosage
Available as interferon beta-1a or interferon beta-1b; dosage expressed in terms of mg.
Potency of interferon beta also has been expressed in terms of international units. Each mg of interferon beta-1a is equivalent to approximately 200 million units (for Avonex) and 270 million units (for Rebif); each mg of interferon beta-1b is equivalent to approximately 32 million units (for Betaseron and Extavia).
Adults
Multiple Sclerosis Interferon beta-1a (Avonex) IM30 mcg once weekly. To reduce incidence and severity of flu-like symptoms, initiate at a low dosage of 7.5 mcg once weekly, and then increase by 7.5 mcg each week for the next 3 weeks up to recommended dosage.
Interferon beta-1a (Rebif) Sub-QGradually titrate dosage over a 4-week period to 22 or 44 mcg 3 times weekly using the schedule in Table 1. When titrating to the 22-mcg dose, use only the prefilled syringes (not auto-injectors).
Table 1. Rebif Dosage Titration Schedule20Week
Rebif 22 mcg Target Dose
Rebif 44 mcg Target Dose
Weeks 1–2
4.4 mcg (use ½ of 8.8-mcg syringe)
8.8 mcg (use full 8.8-mcg syringe or auto-injector)
Weeks 3–4
11 mcg (use ½ of 22-mcg syringe)
22 mcg (use full 22-mcg syringe or auto-injector)
Weeks 5+
22 mcg (use full 22-mcg syringe or auto-injector)
44 mcg (use full 44-mcg syringe or auto-injector)
Interferon beta-1b (Betaseron, Extavia) Sub-QGradually titrate dosage over a 6-week period to 0.25 mg every other day using the schedule in Table 2.
Table 2. Betaseron and Extavia Dosage Titration Schedule16170Percentage of Target Dose
Betaseron and Extavia Dose
Volume
Weeks 1–2
25%
0.0625 mg
0.25 mL
Weeks 3–4
50%
0.125 mg
0.5 mL
Weeks 5–6
75%
0.1875 mg
0.75 mL
Weeks 7+
100%
0.25 mg
1 mL
If a dose is missed, administer as soon as possible; administer next scheduled dose approximately 48 hours later. Do not administer on 2 consecutive days.
Special Populations
Hepatic Impairment
Manufacturer of Rebif states to consider dosage reduction in patients whose serum ALT concentrations increase to >5 times ULN. May gradually re-escalate dosage when serum ALT concentrations have returned to normal.
Renal Impairment
No specific dosage recommendations.
Geriatric Patients
No specific dosage adjustments required; however, select dosage with caution, usually initiating therapy at the low end of the dosage range due to possible age-related decreases in hepatic, renal, and/or cardiac function and of concomitant disease and drug therapy.
Warnings
Contraindications
Warnings/Precautions
Hepatotoxicity
Serious hepatic injury including autoimmune hepatitis and possibly severe, fulminant hepatic failure requiring liver transplantation reported.
Use with caution in patients with active liver disease, alcohol abuse, increased serum ALT concentrations (>2.5 times ULN), or history of clinically important liver disease. Consider potential risks when interferon beta used concomitantly with other drugs associated with hepatic injury (including alcohol) or when other drugs are added to an existing interferon beta treatment regimen.
Monitor for manifestations of hepatic injury. Perform liver function tests at regular intervals (e.g., 1, 3, and 6 months) following initiation of therapy and then periodically thereafter in the absence of clinical symptoms.
Some manufacturers recommend discontinuance of therapy if substantial elevations in serum aminotransferase concentrations or clinical manifestations of liver dysfunction (e.g., jaundice) occur.
Asymptomatic elevations in serum aminotransferase concentrations (particularly ALT) reported commonly with interferon beta therapy.
Latex Sensitivity
Some packaging components of certain formulations (e.g., Avonex prefilled syringe pen cap, Extavia prefilled diluent syringe cap) contain natural rubber latex; individuals sensitive to latex should not handle these packaging components. Safety of Extavia reconstituted using the prefilled diluent syringe in latex-sensitive individuals not evaluated.
Hypersensitivity Reactions
Possible anaphylaxis or anaphylactoid reactions.
If acute, serious hypersensitivity reactions occur, discontinue immediately and initiate appropriate therapy.
Depression and Suicide
Possible depression, suicidal ideation, and suicide.
Some manufacturers state to use with caution in patients with depression or other mood disorders. Monitor patients closely for evidence of depression or other psyChiatric symptoms; consider discontinuance of therapy if any such symptoms occur.
Because of a high prevalence of mood disorders in patients with MS, a history of depression is not an absolute contraindication to use of interferon beta. It may be difficult to separate neuropsychiatric symptoms related to interferon beta therapy from those related to MS.
Congestive Heart Failure
Congestive heart failure (CHF), cardiomyopathy (with or without CHF), palpitations, and tachycardia, reported with some preparations of interferon beta during post marketing surveillance. In some cases, these events were temporally related to the administration of interferon beta-1b; recurrence upon rechallenge was observed in some patients.
Monitor patients with preexisting CHF for clinical worsening during therapy. Some manufacturers state to consider discontinuance of therapy if worsening CHF occurs without any other etiology.
Necrosis
Severe injection site necrosis reported following sub-Q and IM administration, sometimes requiring dermal debridement or skin grafting. Usually occurs within the first 3–4 months of therapy.
Factors that may be associated with development of skin necrosis include nonsterile injection techniques, administering cold interferon beta solutions, failure to rotate injection sites, and exposure of recent injection sites to UV light.
Injection-site Reactions
Mild to moderate injection site reactions (e.g., hemorrhage, hypersensitivity, inflammation, mass, pain, edema, atrophy, redness, induration) reported in some patients following sub-Q or IM administration.
Injection site abscess or cellulitis, possibly requiring surgical intervention, rarely reported during post marketing surveillance. Local reactions following IM or sub-Q injection generally are more severe with more frequent and higher doses of interferon beta.
Hematologic Effects
Decreased peripheral blood cell counts in all cell lines, including rare pancytopenia, leukopenia, thrombocytopenia, reported.
Monitor patients for signs and symptoms of decreased blood counts. Perform CBCs, platelet counts, and appropriate blood chemistry tests prior to initiation of therapy and periodically thereafter. Patients with myelosuppression may require more intensive monitoring.
Thrombotic Microangiopathy
Thrombotic microangiopathy (TMA), including sometimes fatal thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, reported. Onset ranged from several weeks to years after the drug was initiated. If TMA occurs, discontinue treatment and manage as clinically indicated.
Flu-like syndrome
Flu-like syndrome occurs commonly. Although there is considerable interindividual variation, symptoms occur most frequently during initiation of therapy (e.g., within hours or days after injection) and usually subside within a few months.
Consider premedication with analgesic and/or antipyretic agents.
Seizures
Possible seizures, including in patients with no history of seizure; not known whether related to preexisting seizure disorder, effects of MS alone, use of interferon beta, or other potential risk factors (e.g., fever). Use with caution in patients with preexisting seizure disorders.
If patients with no seizure history develop seizures during therapy, establish an etiologic basis and institute appropriate anticonvulsant therapy prior to considering resumption of therapy.
Drug-Induced Lupus Erythematosus
Autoimmune disorders of multiple target organs, including idiopathic thrombocytopenia, hyperthyroidism, hypothyroidism, and autoimmune hepatitis, reported.
Discontinue interferon beta therapy if a new autoimmune disorder develops, or if patients develop any manifestations of lupus (e.g., rash, serositis, polyarthritis, nephritis, Raynaud phenomenon).
Pulmonary Arterial Hypertension
Pulmonary arterial hypertension (PAH) reported even in the absence of other contributory factors. Many cases required hospitalization; one patient underwent lung transplant. May occur at varying time points during therapy including several years after treatment initiation.
Assess patients who develop new onset dyspnea or increasing fatigue for PAH. If alternative causes have been ruled out and a PAH diagnosis confirmed, discontinue interferon beta therapy and manage as clinically indicated.
Immunogenicity
Potential for immunogenicity. Possible development of binding or neutralizing antibodies to interferon beta following long-term therapy.
The presence of neutralizing antibodies, particularly in persistently high titers, associated with reductions in radiographic and clinical efficacy of interferon beta therapy. Neutralizing antibodies generally develop 6–24 months after initiation of therapy.
Risk of antibody development may vary based on preparation, dosing frequency, total dose, and route of administration.
Specific Populations
PregnancyNo well-controlled studies in pregnant women; however, available data have generally not identified drug-associated risk of major birth defects. Findings regarding a potential risk for low birth weight or miscarriage with the use of interferon beta in pregnancy inconsistent. In animal studies, administration during pregnancy resulted in increased rate of abortion at doses greater than those used clinically; however, unclear whether, as a class of products, administration to pregnant animals at doses greater than those used clinically results in an increased rate of abortion. Use during pregnancy only if the potential benefits justify the possible risks to the fetus.
LactationLimited data suggest that interferon beta-1a distributes into human milk. No data on the presence of interferon beta-1b in human milk. Not known whether interferon beta has any effects on the breastfed infant or on milk production.
Consider developmental and health benefits of breastfeeding along with the mother's clinical need for interferon beta and any potential adverse effects on the breastfed child from the drug or underlying maternal condition.
Females and Males of Reproductive PotentialStudies not conducted to determine whether interferon beta affects fertility in humans. Menstrual irregularities, anovulation, and decreased serum progesterone concentrations observed in some animal studies at dosages higher than recommended in humans.
Pediatric UseAlthough the safety and efficacy of interferon beta in children <18 years of age have not been established, the drug has been used with variable results for the management of childhood onset MS.
Geriatric UseInsufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults; select dosage with caution.
Hepatic ImpairmentSafety and efficacy not evaluated in hepatic impairment. Discontinue if serum ALT levels significantly increase.
Renal ImpairmentSafety and efficacy not evaluated in renal impairment.
Common Adverse Effects
Interferon beta-1a (Avonex): The most common adverse reactions (≥5%) in clinical studies were flu-like symptoms including chills, fever, myalgia, and asthenia.
Interferon beta-1a (Rebif): The most common adverse reactions in controlled clinical trials were injection site disorders, influenza-like symptoms, abdominal pain, depression, elevation of liver enzymes, and hematologic abnormalities.
Interferon beta-1b (Betaseron): The most common adverse reactions (≥5%) in clinical studies were injection site reaction, lymphopenia, flu-like symptoms, myalgia, leukopenia, neutropenia, increased liver enzymes, headache, hypertonia, pain, rash, insomnia, abdominal pain, and asthenia.
Interferon beta-1b (Extavia): The most common adverse reactions (≥5%) in clinical studies were injection site reaction, lymphopenia, flu-like symptoms, myalgia, leukopenia, neutropenia, increased liver enzymes, headache, hypertonia, pain, rash, insomnia, abdominal pain, and asthenia.
What other drugs will affect Interferon Beta
No formal drug interaction studies to date.
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