Oprelvekin
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Oprelvekin is recombinant interleukin eleven (IL-11), a thrombopoietic growth factor that directly stimulates the proliferation of hematopoietic
stem cells In multicellular organisms, stem cells are undifferentiated or partially differentiated cells that can change into various types of cells and proliferate indefinitely to produce more of the same stem cell. They are the earliest type of cell ...
and megakaryocyte progenitor cells and induces megakaryocyte maturation resulting in increased platelet production. It is marketed under the trade name Neumega.


Chemical, pharmacological and marketing data

IL-11 is a member of a family of human growth factors and is being produced in the bone marrow of healthy adults. Synonyms are: * AGIF * Adipogenesis inhibitory factor * Interleukin-11 precursor. Oprelvekin is produced in Escherichia coli (E. coli) by recombinant DNA technology. The protein has a molecular mass of approximately 19,000 g/mol, and is non-glycosylated. The polypeptide is 177 amino acids in length (the natural IL-11 has 178). This alteration has not resulted in measurable differences in bioactivity either ''in vitro'' or ''in vivo''. The primary
hematopoietic Haematopoiesis (; ; also hematopoiesis in American English, sometimes h(a)emopoiesis) is the formation of blood cellular components. All cellular blood components are derived from haematopoietic stem cells. In a healthy adult human, roughly ten ...
activity of Neumega is stimulation of megakaryocytopoiesis and thrombopoiesis. In mice and nonhuman primate studies Neumega has shown potent thrombopoietic activity in compromised hematopoiesis, including moderately to severely myelosuppressed animals. In these studies, Neumega improved platelet
nadir The nadir is the direction pointing directly ''below'' a particular location; that is, it is one of two vertical directions at a specified location, orthogonal to a horizontal flat surface. The direction opposite of the nadir is the zenith. Et ...
s and accelerated platelet recoveries compared to controls. In animal studies oprelvekin also has non-hematopoietic activities. This includes the regulation of intestinal epithelium growth (enhanced healing of gastrointestinal lesions), the inhibition of adipogenesis, the induction of acute phase protein synthesis (e.g., fibrinogen), and inhibition of macrophageal released pro-inflammatory cytokines. However, pathologic changes, some also seen in humans, have been noticed: * papilledema * fibrosis of tendons and joint capsules * periosteal thickening and * embryotoxicity (see under pregnancy). In preclinical human trials mature megakaryocytes which develop during ''in vivo'' treatment with Neumega were ultrastructurally, morphologically, and functionally normal. They also showed a normal life span. In a study in which a single 50 μg/kg subcutaneous dose was administered to eighteen healthy men, the peak serum concentration (Cmax) of 17.4 ± 5.4 ng/mL was reached at 3.2 ± 2.4 h (Tmax) following dosing. The terminal half-life was 6.9 ± 1.7 hours. In a second study in which single 75 μg/kg subcutaneous and intravenous doses were administered to twenty-four healthy subjects, the pharmacokinetic profiles were similar between men and women. The absolute bioavailability of Neumega was >80%. In a study in which multiple, subcutaneous doses of both 25 and 50 μg/kg were administered to cancer patients receiving chemotherapy, Neumega did not accumulate and clearance of Neumega was not altered following multiple doses. Pediatric cancer patients treated with aggressive chemotherapy showed similar pharmakinetic characteristics. In humans treated with oprelvekin on a daily base a twofold increase in fibrinogen levels occurred. Healthy volunteers displayed an increase in von-Willebrand-factor (vWf) activity. Isolated molecules formed under oprelvekin were found to have exact the same multimere structure as the 'normal' factor and were therefore fully functioning. These increases in coagulation factors may contribute to the development of stroke (see under ), but a precise association cannot be made at this stage. In a variety of clinical studies upon which FDA approval is based, Neumega showed effectivity in reducing
thrombocytopenia In hematology, thrombocytopenia is a condition characterized by abnormally low levels of platelets (also known as thrombocytes) in the blood. Low levels of platelets in turn may lead to prolonged or excessive bleeding. It is the most common coag ...
in oncologic patients treated with myelosuppressant chemotherapeutic drugs as measured by significantly decreased need of platelet transfusions. Neumega is manufactured and sold by
Wyeth Wyeth Pharmaceuticals Inc. was a pharmaceutical company until it was purchased by Pfizer in 2009. The company was founded in Philadelphia, Pennsylvania, in 1860 as John Wyeth and Brother. Its headquarters moved to Collegeville, Pennsylvania, a ...
. The drug is formulated in single-use vials containing 5 mg of oprelvekin (specific activity approximately 8 million units/mg) as a sterile, lyophilized powder. The FDA approved the drug in 1997.


Indications

Neumega is indicated for the prevention of severe thrombocytopenia and the reduction of the need for platelet transfusions following myelosuppressive
chemotherapy Chemotherapy (often abbreviated chemo, sometimes CTX and CTx) is the type of cancer treatment that uses one or more anti-cancer drugs (list of chemotherapeutic agents, chemotherapeutic agents or alkylating agents) in a standard chemotherapy re ...
in adult patients with nonmyeloid malignancies who are at high risk of severe thrombocytopenia. Efficacy was demonstrated in patients who had experienced severe thrombocytopenia following the previous chemotherapy cycle.


Contraindications and precautions

* Patients with known hypersensitivity to Oprelvekin itself or any other ingredient. * Patients with severe or decompensated
heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to Cardiac cycle, fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF ...
should not be treated, because Oprelvekin may cause excessive fluid retention with edema and cardiac decompensation. Patients with compensated heart disease should be treated with caution and under permanent
clinical supervision Supervision is used in counselling, psychotherapy, and other mental health disciplines as well as many other professions engaged in working with people. Supervision may be applied as well to practitioners in somatic disciplines for their preparatory ...
. * Neumega is not indicated following myeloablative chemotherapy (increased likelihood of severe side-effects) and in pediatric patients. *
Renal In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and right in the retrop ...
impairment: Neumega is excreted renally. No differences of pharmakinetic
parameter A parameter (), generally, is any characteristic that can help in defining or classifying a particular system (meaning an event, project, object, situation, etc.). That is, a parameter is an element of a system that is useful, or critical, when ...
s and clinical differences have been seen in mild to moderate impairment. Severe impairment has led to an increased number of patients with reduced
hemoglobin Hemoglobin (haemoglobin, Hb or Hgb) is a protein containing iron that facilitates the transportation of oxygen in red blood cells. Almost all vertebrates contain hemoglobin, with the sole exception of the fish family Channichthyidae. Hemoglobin ...
due to dilutional
anemia Anemia (also spelt anaemia in British English) is a blood disorder in which the blood has a reduced ability to carry oxygen. This can be due to a lower than normal number of red blood cells, a reduction in the amount of hemoglobin availabl ...
. Patients with severely disturbed renal function should be monitored very closely. * The efficacy of Oprelvekin has not been systematically studied in patients receiving chemotherapy regimes of more than 5 days duration/each cycle or in those regimes containing agents that induce delayed thrombocytopenia (e.g.
nitrosoureas Nitrosourea is both the name of a molecule, and a class of compounds that include a nitroso (R-NO) group and a urea. Examples Examples include: * Arabinopyranosyl-N-methyl-N-nitrosourea, Arabinopyranosyl-''N''-methyl-''N''-nitrosourea (Aranose) ...
,
mitomycin C Mitomycin C is a mitomycin that is used as a chemotherapy, chemotherapeutic agent by virtue of its antitumour activity. Medical uses It is given intravenously to treat upper gastro-intestinal cancers (e.g. esophageal carcinoma), anal cancer ...
. Neumega should not be given in these cases.


Pregnancy

In studies with rats and rabbits treated chronically, Oprelvekin showed embryo- and fetotoxicity (early death of
embryo An embryo ( ) is the initial stage of development for a multicellular organism. In organisms that reproduce sexually, embryonic development is the part of the life cycle that begins just after fertilization of the female egg cell by the male sp ...
s and reduction of number of
fetus A fetus or foetus (; : fetuses, foetuses, rarely feti or foeti) is the unborn offspring of a viviparous animal that develops from an embryo. Following the embryonic development, embryonic stage, the fetal stage of development takes place. Pren ...
, fetal malformations etc.). There is no sufficient human data available. Pregnant women should only be treated, if the benefit to the mother outweighs the potential risk to the unborn.


Lactation

No human data is available if the drug is distributed into human milk. Nursing women should either discontinue breast-feeding or Neumega, the decision should take into account the importance of the drug to the mother.


Side effects

Neumega has caused allergic reaction which at times have been very serious. Symptoms have been
edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...
of the face and tongue, or
larynx The larynx (), commonly called the voice box, is an organ (anatomy), organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal ...
; shortness of breath;
wheezing A wheeze is a clinical symptom of a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, part of the respiratory tree must be narrowed or obstructed (for example narrowing of the lower ...
; chest pain;
hypotension Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...
(including
shock Shock may refer to: Common uses Healthcare * Acute stress reaction, also known as psychological or mental shock ** Shell shock, soldiers' reaction to battle trauma * Circulatory shock, a medical emergency ** Cardiogenic shock, resulting from ...
);
dysarthria Dysarthria is a speech sound disorder resulting from neurological injury of the motor component of the motor–speech system and is characterized by poor articulation of phonemes. It is a condition in which problems effectively occur with the ...
; loss of consciousness,
rash A rash is a change of the skin that affects its color, appearance, or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cracke ...
,
urticaria Hives, also known as urticaria, is a kind of skin rash with red or flesh-colored, raised, itchy bumps. Hives may burn or sting. The patches of rash may appear on different body parts, with variable duration from minutes to days, and typically ...
,
flushing Flushing may refer to: Places Netherlands * Flushing, Netherlands, an English name for the city of Vlissingen, Netherlands United Kingdom * Flushing, Cornwall, a village in Cornwall, England * The Flushing, a building in Suffolk, England ...
, and
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
. These reaction can occur after the first dose or after any later application. Neumega should be permanently discontinued in patients with any sign of allergy. Treatment is largely symptomatic. Oprelvekin also has caused quite often fluid retention, ranging from peripheral
edema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue (biology), tissue. Most commonly, the legs or arms are affected. S ...
(approximately 40% of patients) to
dyspnea Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that ...
and full developed
lung edema Pulmonary edema (British English: oedema), also known as pulmonary congestion, is excessive fluid accumulation in the tissue or air spaces (usually alveoli) of the lungs. This leads to impaired gas exchange, most often leading to shortness ...
with or without cardiac decompensation (see contraindications and precautions). These symptoms have led to some deaths. Fluid retention may also lead to dilutional anemia (in 10 to 15% of patients). Hypokalemia may also result. Symptoms of fluid retention have been observed more often in patients following myeloablative chemotherapy (see contraindications). Severe arrhythmias (
atrial flutter Atrial flutter (AFL) is a common abnormal heart rhythm that starts in the atrial chambers of the heart. When it first occurs, it is usually associated with a fast heart rate and is classified as a type of supraventricular tachycardia (SVT). ...
and
atrial fibrillation Atrial fibrillation (AF, AFib or A-fib) is an Heart arrhythmia, abnormal heart rhythm (arrhythmia) characterized by fibrillation, rapid and irregular beating of the Atrium (heart), atrial chambers of the heart. It often begins as short periods ...
) as well as fatal
cardiac arrest Cardiac arrest (also known as sudden cardiac arrest CA is when the heart suddenly and unexpectedly stops beating. When the heart stops beating, blood cannot properly Circulatory system, circulate around the body and the blood flow to the ...
have also been seen which may or may be not attributed to fluid retention/increased volume. Isolated cases of
stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...
have been noted, those patients with previous transient ischemic attacks or partial/minor strokes may be at particular risk.
Papilledema Papilledema or papilloedema is optic disc swelling that is caused by increased intracranial pressure due to any cause. The swelling is usually bilateral and can occur over a period of hours to weeks. Unilateral presentation is extremely rare. In ...
of the eyes has been observed (2%) and may lead to disturbed
visual acuity Visual acuity (VA) commonly refers to the clarity of visual perception, vision, but technically rates an animal's ability to recognize small details with precision. Visual acuity depends on optical and neural factors. Optical factors of the eye ...
and even temporary or permanent
blindness Visual or vision impairment (VI or VIP) is the partial or total inability of visual perception. In the absence of treatment such as corrective eyewear, assistive devices, and medical treatment, visual impairment may cause the individual difficul ...
. Patients with preexisting papilledema or with involvement of the central nervous system may be at higher risk. In postmarketing studies isolated cases of severe
ventricular arrhythmias Arrhythmias, also known as cardiac arrhythmias, are irregularities in the cardiac cycle, heartbeat, including when it is too fast or too slow. Essentially, this is anything but normal sinus rhythm. A resting heart rate that is too fast – ab ...
and
renal failure Kidney failure, also known as renal failure or end-stage renal disease (ESRD), is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney fa ...
have been seen.
Injection site reaction Injection site reactions (ISRs) are reactions that occur at the site of injection of a drug. They may be mild or severe and may or may not require medical intervention. Some reactions may appear immediately after injection, and some may be delayed ...
s like have also been observed (dermatitis, pain, and discoloration), but are usually mild.


Interactions

The concomitant application of GM-CSFs such as
filgrastim Filgrastim, sold under the brand name Neupogen among others, is a medication used to treat low neutrophil count. Low neutrophil counts may occur with HIV/AIDS, following chemotherapy or radiation poisoning, or be of an unknown cause. It may ...
or
Sargramostim Sargramostim (tradename Leukine) is a recombinant granulocyte macrophage colony-stimulating factor (GM-CSF) that functions as an immunostimulator. Medical uses Sargramostim is primarily used for myeloid reconstitution after autologous or allo ...
showed no potential interactions. Additionally, no other interactions are known. Interactions with drugs undergoing P450 enzyme metabolism are not likely to occur.


Necessary examinations during treatment

Complete blood counts should be obtained before starting chemotherapy and in short intervals afterwards. Platelet counts should be done at the time of expected nadir (lowest number of platelets) and at least until remission starts (platelet counts greater than 50,000). The patients should be watched for signs of allergy, fluid retention and anemia during and after therapy with Neumega. Preexisting
ascites Ascites (; , meaning "bag" or "sac") is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdo ...
and pericardial effusions should be monitored closely for signs of worsening.


Dosage regimen

The dosage in patients without severe renal impairment is 50 μg/kg subcutaneously once a day either
abdominal The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...
, in
thigh In anatomy, the thigh is the area between the hip (pelvis) and the knee. Anatomically, it is part of the lower limb. The single bone in the thigh is called the femur. This bone is very thick and strong (due to the high proportion of bone tissu ...
, or
hip In vertebrate anatomy, the hip, or coxaLatin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) (: ''coxae'') in medical terminology, refers to either an anatomical region or a joint on t ...
. Most patients will be able to self-administer the drug after appropriate training. Patients with severe renal impairment should receive only 25 μg/kg daily. The first dose should be given 6 to 24 hours after completion of chemotherapy. Dosing should be continued until platelet counts reach at least 50,000 cells. Usually, one course of Neumega encompasses 10 to 21 days. The drug should be discontinued at least 2 days before starting the next chemotherapy cycle.


Additional information

Neumega vials must be stored in a refrigerator at . Protect from light. Do not freeze.


References

* http://www.rxlist.com/cgi/generic3/oprelvek.htm * http://www.wyeth.com/products_hcp?product=/wyeth_html/home/products/prescription/Neumega®%20(oprelvekin)/Neumega®%20(oprelvekin)_overview.html (Drug Information provided by Wyeth) {{Interleukin receptor modulators Cytokines Immunostimulants Embryotoxicants Drugs developed by Pfizer Fetotoxicants