Elonva

Corifollitropin alfa.

Each pre-filled syringe contains 150 micrograms of corifollitropin alfa in a 0.5 mL solution for injection.
Corifollitropin alfa is a glycoprotein produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology, using a chemically defined cell culture medium without the addition of antibiotics, human- or animal-derived proteins (protein-free) or any other components of human or animal origin.
Excipients/Inactive Ingredients: Sodium citrate, Sucrose, Polysorbate 20, Methionine, Sodium hydroxide (for pH adjustment), Hydrochloric acid (for pH adjustment), Water for injections.

Pharmacotherapeutic group: sex hormones and modulators of the genital system, gonadotropins. ATC code: G03GA09.
Pharmacology: Pharmacodynamics: Corifollitropin alfa is designed as a sustained follicle stimulant with the same pharmacodynamic profile as (rec)FSH, but with a markedly prolonged duration of FSH activity. Due to its ability to initiate and sustain multiple follicular growth for an entire week, a single subcutaneous injection of the recommended dose of Elonva may replace the first seven injections of any daily (rec)FSH preparation in a COS treatment cycle. The long duration of FSH activity was achieved by adding the carboxy-terminal peptide of the β-subunit of human chorionic gonadotropin (hCG) to the β-chain of human FSH. Corifollitropin alfa does not display any intrinsic LH/hCG activity.
Clinical trial information: In three randomized, double-blind, clinical trials (ENSURE, ENGAGE, and PURSUE), treatment with a single subcutaneous injection of Elonva, 100 micrograms (ENSURE study) or 150 micrograms (ENGAGE and PURSUE study), for the first seven days of COS was compared to treatment with a daily dose of 150, 200, or 300 IU of recFSH, respectively. Pituitary suppression with a GnRH antagonist (ganirelix acetate injection at a daily dose of 0.25 mg) was used in each of the three clinical trials.
In the ENSURE study, 396 healthy normal ovulatory women, aged 18 to 36 years with a body weight less than or equal to 60 kg, were treated for one cycle with 100 micrograms of Elonva and pituitary suppression with a GnRH antagonist as part of an ART program. The primary efficacy endpoint was number of oocytes retrieved. The median total duration of stimulation was 9 days for both groups, indicating that two days of recFSH were required to complete ovarian stimulation from stimulation day 8 onwards (recFSH was given on the day of hCG for this study).
In the ENGAGE Study, 1,506 healthy normal ovulatory women, aged 18 to 36 years with a body weight greater than 60 kg and less than or equal to 90 kg, were treated for one cycle with 150 micrograms of Elonva and pituitary suppression with a GnRH antagonist as part of an ART program. The co-primary efficacy endpoints were ongoing pregnancy rate and number of oocytes retrieved. The median total duration of stimulation was 9 days for both groups, indicating that two days of recFSH were required to complete ovarian stimulation from stimulation day 8 onwards (recFSH was given on the day of hCG for this study).
In the PURSUE study, 1,390 healthy normal ovulatory women, aged 35 to 42 years with a body weight greater than or equal to 50 kg, were treated for one cycle with 150 micrograms of Elonva and pituitary suppression with a GnRH antagonist as part of an ART program. The primary efficacy endpoint was vital pregnancy rate. The number of oocytes retrieved was a key secondary efficacy endpoint. The median total duration of stimulation was 9 days for both groups, indicating that one day of recFSH was required to complete ovarian stimulation from stimulation day 8 onwards (no recFSH was given on the day of hCG for this study).
Number of oocytes retrieved: In all three studies, treatment with a single injection of Elonva, 100 or 150 micrograms, for the first seven days of COS, resulted in a higher number of oocytes retrieved compared with a daily dose of recFSH. However, the differences were within the predefined equivalence (ENGAGE and ENSURE) or non-inferiority (PURSUE) margins. See Table 1 as follows.

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Pregnancy from the fresh cycles of ENGAGE and PURSUE: In the ENGAGE study, non-inferiority was demonstrated in ongoing pregnancy rates between Elonva and recFSH, with ongoing pregnancy rate defined as presence of at least one foetus with heart activity assessed at least 10 weeks after embryo transfer.
In the PURSUE study, non-inferiority was demonstrated in vital pregnancy rate between Elonva and recFSH, with vital pregnancy rate defined as the percentage of subjects with at least one foetus with heart activity assessed 5 to 6 weeks after embryo transfer.
The pregnancy results from the fresh cycles of ENGAGE and PURSUE are summarized in Table 2 as follows.

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In these clinical trials, the safety profile of a single injection with Elonva was comparable to daily injections with recFSH.
Pregnancy from the Frozen-Thawed Embryo Transfer (FTET) cycles of ENGAGE and PURSUE: The follow-up FTET trial for ENGAGE included women who had at least one embryo thawed for use up to at least one year after cryopreservation. The mean number of embryos transferred in the FTET cycles of ENGAGE was 1.7 in both treatment groups.
The follow-up FTET trial for PURSUE included women who had at least one embryo thawed for use within two years of the date of the last cryopreservation for this trial. The mean number of embryos transferred in the FTET cycles of PURSUE was 2.4 in both treatment groups. This trial also provided safety data on the infants born from cryopreserved embryos.
The pregnancy results from the FTET cycles of ENGAGE and PURSUE are summarized in Table 3 as follows.

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Pregnancy from the addition of FTET cycles to the fresh cycles of ENGAGE and PURSUE (Cumulative Vital Pregnancy Rates): The cumulative vital pregnancy rate (per subject and per cycle) was calculated based on the results of the fresh and subsequent FTET cycles of a single cohort of women who received Elonva or recFSH in ENGAGE or PURSUE.
The cumulative vital pregnancy rate from ENGAGE in subjects treated with a single injection of 150 μg Elonva was similar to that in subjects treated with daily 200 IU recFSH.
The cumulative vital pregnancy rate from PURSUE in subjects treated with a single injection of 150 μg Elonva was similar to that in subjects treated with daily 300 IU recFSH.
The pregnancy results are summarized in Table 4 as follows.

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Congenital malformations reported in infants born after a frozen-thawed embryo transfer (FTET) cycle: Following use of Elonva, 61 infants were born after an FTET cycle in the PURSUE study follow-up, and 607 infants were born after fresh ART cycles in the ENSURE, ENGAGE and PURSUE studies combined. The rates for congenital malformations (major and minor combined) reported for infants born after an FTET cycle in the PURSUE study follow-up (16.4%) were similar to those reported for infants born after fresh ART cycles in the ENSURE, ENGAGE and PURSUE studies combined (16.8%).
Immunogenicity: Of the 2,511 women treated with Elonva who were evaluated for the formation of post-treatment antibodies, four (0.16%) had evidence of antibody formation, including three who had been exposed once to Elonva and one who had been exposed twice to Elonva. In each case, these antibodies were non-neutralizing and did not interfere with the response to stimulation or the normal physiologic responses of the Hypothalamic-Pituitary-Ovarian (HPO) axis. Two of these four women became pregnant during the same treatment cycle in which antibodies were detected, suggesting that the presence of non-neutralizing antibodies after stimulation with Elonva is not clinically relevant.
Cardiac Electrophysiology: In a randomized, double-blind, placebo- and active-controlled, 4-period crossover study, 70 healthy postmenopausal women received a single therapeutic dose of 150 mcg of corifollitropin alfa subcutaneously, a single supratherapeutic dose of 240 mcg of corifollitropin alfa subcutaneously, 400 mg moxifloxacin orally, and placebo. Both doses of corifollitropin alfa did not appear to prolong the QTc interval for up to 216 hours postdose. After baseline and placebo adjustment, the maximum mean QTc interval change after administration of a therapeutic dose of 150 mcg of corifollitropin alfa was 1.4 msec (1-sided 95% upper CI: 3.4 msec). After administration of the supratherapeutic dose of 240 mcg of corifollitropin alfa, the maximum mean QTc interval change was 1.2 msec (1-sided 95% upper CI: 3.6 msec).
Pharmacokinetics: Pharmacokinetic parameters of corifollitropin alfa were evaluated after subcutaneous administration in women undergoing a COS treatment cycle.
Due to the long elimination half-life, after administration of the recommended dose, serum concentrations of corifollitropin alfa are sufficient to sustain multiple follicular growth for an entire week. Therefore, a single subcutaneous injection of Elonva may be used as an alternative to the first seven days of daily rec(FSH) in COS for the development of multiple follicles and pregnancy in an ART program (see Dosage & Administration).
Body weight is a determinant of exposure to corifollitropin alfa. The mean corifollitropin alfa exposure (AUC) after a single subcutaneous injection is 665 hours*ng/mL (426-1,037 hours*ng/mL¹) and is similar after administration of 100 micrograms corifollitropin alfa to women with a body weight less than or equal to 60 kilograms and of 150 micrograms corifollitropin alfa to women with a body weight greater than 60 kilograms.
Absorption: After a single subcutaneous injection of Elonva, the mean maximum serum concentration (C_max) of corifollitropin alfa is 4.24 ng/mL (2.49-7.21 ng/mL¹) and is reached at the mean T_max of 44 hours (35-57 hours¹) postdose. The absolute bioavailability is 58% (48-70%¹).
Distribution: Distribution, metabolism and elimination of corifollitropin alfa are very similar to other gonadotropins, such as FSH, hCG and LH. After absorption into the blood, corifollitropin alfa is distributed mainly to the ovaries and the kidneys. Elimination of corifollitropin alfa predominantly occurs via the kidneys. The steady state volume of distribution is 9.2 L (6.5-13.1 L¹). Exposure to corifollitropin alfa increases proportionally with dose within the range of 60 micrograms to 240 micrograms.
Elimination: Corifollitropin alfa has a mean elimination half-life (t_1/2) of 70 hours (59-82 hours¹) and a clearance of 0.13 L/h (0.10-0.18 L/h¹). Elimination of corifollitropin alfa predominantly occurs via the kidneys, and the rate of elimination may be reduced in patients with renal insufficiency (see Dosage & Administration and Precautions). Hepatic metabolism contributes to a minor extent to the elimination of corifollitropin alfa.
Other special populations: Hepatic impairment: Although data in hepatically impaired patients are not available, hepatic impairment is unlikely to affect the pharmacokinetic profile of corifollitropin alfa.
¹Predicted range for 90% of subjects
Toxicology: Preclinical safety data: Preclinical data revealed no special hazard for humans based on conventional studies of single and repeated dose toxicity and safety pharmacology.
Reproduction toxicology studies in rats and rabbits indicated that corifollitropin alfa does not affect adversely fertility. Administration of corifollitropin alfa to rats and rabbits, prior to and directly after mating, and during early pregnancy, resulted in embryotoxicity. In rabbits, when administered prior to mating, teratogenicity has been observed. Both embryotoxicity and teratogenicity are considered a consequence of the superovulatory state of the animal not able to support a number of embryos above a physiological ceiling. The relevance of these findings for the clinical use of Elonva is limited.

Controlled Ovarian Stimulation (COS) in combination with a GnRH antagonist for the development of multiple follicles in women participating in an Assisted Reproductive Technology (ART) program.

Treatment with Elonva should be initiated under the supervision of a physician experienced in the treatment of fertility problems.
Posology: In the treatment of women of reproductive age, the dose of Elonva is based on weight and age.
A single 100-microgram dose is recommended in women who weigh less than or equal to 60 kilograms and who are 36 years of age or younger.
A single 150-microgram dose is recommended in women: who weigh more than 60 kilograms, regardless of age; who weigh 50 kilograms or more and who are older than 36 years of age.
Women older than 36 years of age who weighed less than 50 kilograms were not studied. (See Table 5.)

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The recommended doses of Elonva have only been established in a treatment cycle with a GnRH antagonist that was administered from stimulation day 5 or day 6 onwards (see also Indications/Uses, Precautions and Pharmacology: Pharmacodynamics under Actions).
Stimulation day 1: Elonva should be administered as a single subcutaneous injection, preferably in the abdominal wall, during the early follicular phase of the menstrual cycle.
Stimulation day 5 or 6: Treatment with a Gonadotropin Releasing Hormone (GnRH) antagonist should be started on stimulation day 5 or day 6 depending on the ovarian response, i.e. the number and size of growing follicles. The concurrent determination of serum estradiol levels may also be useful. The GnRH antagonist is used to prevent premature Luteinizing Hormone (LH) surges.
Stimulation day 8: Seven days after the injection with Elonva on stimulation day 1, COS treatment may be continued with daily injections of (recombinant) Follicle Stimulating Hormone ((rec)FSH) until the criterion for triggering final oocyte maturation (3 follicles ≥ 17 mm) has been reached. The daily dose of (rec)FSH may depend on the ovarian response, which should be monitored by regular ultrasonographic assessments from stimulation day 5 or 6 onwards. In normal responders a daily dose of 150 IU (rec)FSH is advised. Administration of (rec)FSH on the day of human Chorionic Gonadotropin (hCG) administration can be omitted, depending on the ovarian response. In general, adequate follicular development is achieved on average by the ninth day of treatment (range 6 to 18 days).
As soon as three follicles ≥ 17 mm are observed, a single injection of 5,000 up to 10,000 IU urinary hCG is administered the same day or the day thereafter to induce final oocyte maturation. In case of an excessive ovarian response, see the recommendations given in Precautions in order to reduce the risk for developing ovarian hyperstimulation syndrome (OHSS).
Special populations: Renal impairment: No clinical studies have been performed in patients with renal insufficiency. Since the rate of elimination of corifollitropin alfa may be reduced in patients with renal insufficiency, the use of Elonva in these women is not recommended (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Hepatic impairment: Although data in hepatically impaired patients are not available, hepatic impairment is unlikely to affect the elimination of corifollitropin alfa (see Pharmacology: Pharmacokinetics under Actions).
Pediatric population: The use of Elonva in the pediatric population is not relevant within the approved indication.
Method of administration: Subcutaneous injection of Elonva may be carried out by the woman herself or her partner, provided that proper instructions are given by the physician. Self administration of Elonva should only be performed by women who are well-motivated, adequately trained and with access to expert advice.

More than one injection of Elonva within one treatment cycle or too high a dose of Elonva and/or (rec)FSH may increase the risk of OHSS. After administration of Elonva, no additional FSH containing product should be administered prior to stimulation day 8, as this may also increase the risk of OHSS. (See OHSS in Precautions).

Hypersensitivity to the active substance or to any of the excipients.
Tumors of the ovary, breast, uterus, pituitary or hypothalamus.
Abnormal (not menstrual) vaginal bleeding without a known/diagnosed cause.
Primary ovarian failure.
Ovarian cysts or enlarged ovaries.
Fibroid Tumors of the uterus incompatible with pregnancy.
Malformations of the reproductive organs incompatible with pregnancy.
Pregnancy (see Use in Pregnancy & Lactation).
Risk factors of OHSS: A history of Ovarian Hyperstimulation Syndrome (OHSS); A previous COS cycle that resulted in more than 30 follicles ≥ 11 mm measured by ultrasound examination; A basal antral follicle count > 20; Polycystic ovarian syndrome (PCOS).

Infertility Evaluation Before Starting Treatment: Before starting treatment, the couple's infertility should be assessed as appropriate. In particular, the woman should be evaluated for hypothyroidism, adrenocortical insufficiency, hyperprolactinemia and pituitary or hypothalamic tumors, and appropriate specific treatment given. Medical conditions that contraindicate pregnancy should also be evaluated before starting treatment with Elonva.
Dosing During the Stimulation Cycle: Elonva is intended for single subcutaneous injection only. Additional injections of Elonva should not be given within the same treatment cycle. (See also Dosage & Administration).
After administration of Elonva, no additional FSH-containing product should be administered prior to stimulation day 8 (see also Dosage & Administration).
Renal Insufficiency: In patients with renal insufficiency the excretion of corifollitropin alfa may be reduced (see Dosage & Administration and Pharmacology: Pharmacokinetics under Actions). Therefore, the use of Elonva in these women is not recommended.
Not Recommended with a GnRH Agonist Protocol: There are limited data on the use of Elonva in combination with a GnRH agonist. Therefore, the use of Elonva is not recommended in combination with a GnRH agonist (see also Dosage & Administration).
Ovarian Hyperstimulation Syndrome (OHSS): OHSS is a medical event distinct from uncomplicated ovarian enlargement. Clinical signs and symptoms of mild and moderate OHSS are abdominal pain, nausea, diarrhea, mild to moderate enlargement of ovaries and ovarian cysts. Severe OHSS may be life-threatening. Clinical signs and symptoms of severe OHSS are large ovarian cysts, acute abdominal pain, ascites, pleural effusion, hydrothorax, dyspnea, oliguria, hematological abnormalities and weight gain. In rare instances, venous or arterial thromboembolism may occur in association with OHSS. Transient liver function test abnormalities suggestive of hepatic dysfunction with or without morphologic changes on liver biopsy have also been reported in association with OHSS.
OHSS may be caused by administration of human Chorionic Gonadotropin (hCG) and by pregnancy (endogenous hCG). Early OHSS usually occurs within 10 days after hCG administration and may be associated with an excessive ovarian response to gonadotropin stimulation. Late OHSS occurs more than 10 days after hCG administration, as a consequence of the hormonal changes with pregnancy. Because of the risk of developing OHSS, patients should be monitored for at least two weeks after hCG administration.
Women with known risk factors for a high ovarian response may be especially prone to the development of OHSS during or following treatment with Elonva. For women having their first cycle of ovarian stimulation, for whom risk factors are only partially known, close observation for early signs and symptoms of OHSS is recommended.
Follow current clinical practice for reducing the risk of OHSS during Assisted Reproductive Technology (ART). Adherence to the recommended Elonva dose and treatment regimen and careful monitoring of ovarian response is important to reduce the risk of OHSS. To monitor the risk of OHSS, ultrasonographic assesments of follicular development should be performed prior to treatment and at regular intervals during treatment; the concurrent determination of serum estradiol levels may also be useful. In ART there is an increased risk of OHSS with 18 or more follicles of 11 mm or more in diameter. If OHSS develops, standard and appropriate management of OHSS should be implemented and followed.
Ovarian Torsion: Ovarian torsion has been reported after treatment with gonadotropins, including Elonva. Ovarian Torsion may be related to other conditions, such as OHSS, pregnancy, previous abdominal surgery, past history of ovarian torsion, and previous or current ovarian cysts. Damage to the ovary due to reduced blood supply can be limited by early diagnosis and immediate detorsion.
Multi-fetal Gestation and Birth: Multiple pregnancies and births have been reported for all gonadotropin treatments, including Elonva. The woman and her partner should be advised of the potential risks for the mother (pregnancy and delivery complications) and the neonate (low birth weight) before starting treatment. In women undergoing ART procedures the risk of multiple pregnancy is mainly related to the number of embryos transferred.
Ectopic Pregnancy: Infertile women undergoing ART, have an increased incidence of ectopic pregnancies. It is important to have early ultrasound confirmation that a pregnancy is intrauterine, and to exclude the possibility of extrauterine pregnancy.
Congenital Malformations: The incidence of congenital malformations after ART may be slightly higher than after spontaneous conceptions. This is thought to be due to differences in parental characteristics (e.g., maternal age, sperm characteristics) and the higher incidence of multiple pregnancies.
Ovarian and Other Reproductive System Neoplasms: There have been reports of ovarian and other reproductive system neoplasms, both benign and malignant, in women who have undergone multiple treatment regimens for infertility treatment. It is not established whether or not treatment with gonadotropins increases the risk of these tumors in infertile women.
Vascular Complications: Thromboembolic events, both in association with and separate from OHSS, have been reported following treatment with gonadotropins, including Elonva. Intravascular thrombosis, which may originate in venous or arterial vessels, can result in reduced blood flow to vital organs or the extremities. In women with generally recognized risk factors for thromboembolic events, such as a personal or family history, severe obesity or thrombophilia, treatment with gonadotropins including Elonva, may further increase this risk. In these women the benefits of gonadotropin administration including Elonva, need to be weighed against the risks. It should be noted, however, that pregnancy itself also carries an increased risk of thrombosis.
Effects on ability to drive and use machines: No studies on the ability to drive and use machines have been performed.
Elonva may cause dizziness. Women should be advised that if they feel dizzy, they should not drive or use machines.

Pregnancy: The use of Elonva during pregnancy is contraindicated. In case of inadvertent exposure to Elonva during pregnancy, clinical data are not sufficient to exclude an adverse outcome of pregnancy. In animal studies reproductive toxicity has been observed (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Breast-feeding: The use of Elonva during breast-feeding is not indicated.

The most frequently reported adverse drug reactions during treatment with Elonva in clinical trials (N=2,397) are pelvic discomfort (6.0%), OHSS (4.3%, see also Precautions), headache (4.0%), pelvic pain (2.9%), nausea (2.3%), fatigue (1.5%) and breast tenderness (1.3%).
The table as follows displays the main adverse drug reactions in women treated with Elonva in clinical trials according to system organ class and frequency; common (≥ 1%, < 10%), uncommon (≥ 0.1%, < 1%). (See Table 6.)

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There have been post-marketing reports of hypersensitivity reactions, both local and generalized, including rash.
In addition, ectopic pregnancy and multiple gestations have been reported. These are considered to be related to ART or subsequent pregnancy.

No interaction studies with Elonva and other medicines have been performed. Since corifollitropin alfa is not a substrate of cytochrome P450 enzymes, no metabolic interactions with other medicinal products are anticipated.
Elonva may cause a false positive hCG pregnancy test if the test is administered during the ovarian stimulation portion of the ART cycle. This may be due to cross-reactivity of some hCG pregnancy tests with the carboxy-terminal peptide of the beta subunit of Elonva.

Incompatibilities: In the absence of compatibility studies, the medicinal product must not be mixed with other medicinal products.
Special precautions for disposal and other handling: Do not use Elonva if the solution is not clear.
Any unused product or waste material should be disposed of in accordance with local requirements.

Store in a refrigerator (2°C-8°C). For convenience, the patient is allowed to store the product at or below 25°C for a period of not more than 1 month.
Do not freeze.
Keep the syringe in the outer carton in order to protect from light.
Shelf life: 3 years.

Trophic Hormones & Related Synthetic Drugs

G03GA09 - corifollitropin alfa ; Belongs to the class of gonadotropins. Used as ovulation stimulants.

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