Con 015094

PL: 12375/0021
UKPAR Thymoglobuline

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THYMOGLOBULINE

(ANTI-THYMOCYTE GLOBULIN [RABBIT], rATG)

PL 12375/0021

UKPAR

TABLE OF CONTENTS

Lay summary P2

Scientific discussion P3

Steps taken for assessment P69

Steps taken after authorisation summary P70

Summary of product characteristics P71

Product information leaflet P83

Labelling P89
PL: 12375/0021
THYMOGLOBULINE


PL 12375/0021

LAY SUMMARY

The MHRA today granted Genzyme Europe BV a Marketing Authorisation (licence) for the
medicinal product Thymoglobuline (PL 12375/0021), which is an immunosuppressive agent.
This medicine is prescription only and indicated for immunosuppression in solid organ
transplantation. It is indicated for the prevention of graft rejection in renal transplantation,
treatment of steroid resistant graft rejection in renal transplantation, and prevention of graft
rejection in heart transplantation.

Organ transplantation has been an area of rapid development during more than four decades.
Transplantation of human organs and tissues saves many lives and restores essential functions
in circumstances when no medical alternative of comparable effectiveness exists. End-stage
organ failure is a public health concern with few treatment alternatives, transplantation often
being the best option for vital organs: kidney, liver, heart and lungs. The transplantation of
solid organs, such as kidney and heart, is increasingly a regular component of health care in
all countries and over 1 million people worldwide have undergone successful organ
transplantation. Of the 70 000 or so solid organs transplanted annually world-wide, 50 000 are
kidney replacements. In Europe, the annual transplantation rate is 15 000 kidneys and 2 000
hearts.

When an organ or tissue from one individual is transplanted into a genetically non-identical
other individual, a series of cellular and molecular events are initiated. If no action is taken,
this will result in rejection of the graft. The incidence of rejection depends on many internal
factors and type of transplantation. The aim of immunosuppression in clinical practice is to
control an undesirable immune response while avoiding, if possible, the complications of
immunodeficiency. Improvements in immunosuppressant agents also reduce the need for
living donors to be genetically related to the recipient. Immunosuppressant agents are used to
prevent acute rejection episodes without adversely affecting the organs and also without
overly immunosuppressing patients in the long term with the consequent increased risk of
infections and malignancies.

The data presented to the MHRA demonstrated that Thymoglobuline is effective in
immunosuppression in solid organ transplantation and there were no unexpected safety
concerns. It was therefore judged that the benefits of using this product outweigh the risks;
hence a Marketing Authorisation has been granted.


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THYMOGLOBULINE


PL 12375/0021

SCIENTIFIC DISCUSSION

TABLE OF CONTENTS

Introduction P4

Pharmaceutical assessment P5

Preclinical assessment P15

Clinical assessment P36

Overall conclusions and risk benefit assessment P68

Annex1 P91


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INTRODUCTION

Based on the review of clinical, pre-clinical and quality data, the UK granted a marketing
authorisation for the medicinal product Thymoglobuline on 19
th
March 2008. The product is
prescription only and indicated for immunosuppression in solid organ transplantation in the
following instances:

- Prevention of graft rejection in renal transplantation
- Treatment of steroid resistant graft rejection in renal transplantation
- Prevention of graft rejection in heart transplantation.

This was a national bibliographic application for Thymoglobuline submitted under article
10(a)(ii) of Directive 2001/83/EC as amended, a product with well established use in the
Community.

Thymoglobuline must always be used under strict medical supervision and prescribed by
physicians with experience in using immunosuppressive agents. The posology depends on the
indication, the administration regimen and the combination with other immunosuppressive
agents.

Current immunosuppressive pharmacological therapies can be classified according to
mechanism of action.

Glucocorticosteroids (e.g., prednisolone)
Immunophilin binding agents: calcineurin inhibitors (e.g., cyclosporine, tacrolimus) or
mTOR inhibitors (e.g., sirolimus, everolimus)
Inhibitors of de novo nucleotide synthesis: purine synthesis (e.g., mycophenolic acid,
mizoribine), pyrimidine synthesis (e.g., leflunomide)
Antimetabolites: (e.g., azathioprine)
Antibodies: antibodies against immune proteins (e.g., polyclonal ALG, ATG, IL-2R
targeted, anti-CD25 and anti-CD3 monoclonal), intravenous immunoglobulin (e.g., IVIG).

Thymoglobuline falls into the category of antibodies against immune proteins. The active
ingredient of Thymoglobuline is a stabilised solution of purified rabbit immune globulins
with immunosuppressive activity which recognises thymocytes and human peripheral blood
lymphocytes. Immune globulin type is IgG.


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QUALITY ASSESSMENT

INTRODUCTION
This is a National bibliographic application submitted under article 10(a)(ii) of Directive
2001/83/EC as amended, a product with well established use in the Community. The active
ingredient of Thymoglobuline is a stabilised solution of purified rabbit immune globulins
with immunosuppressive activity which recognises thymocytes and human peripheral blood
lymphocytes. Immune globulin type is IgG. The proposed indication is for prophylaxis and/or
treatment of rejection episodes in organ transplantation. Thymoglobuline is currently
prescribed on a compassionate use basis (named patient basis) in the UK. However, in light of
the continuing need for Thymoglobuline, the company has decided that they now wish to
apply for a marketing authorisation in the UK.

ATC classification: L04AA04 (Immunosuppressive agents). The pharmaceutical form is
Powder for solution for infusion and strength after reconstitution with water for injections is 5
mg/ml. The product is given by intravenous infusion.

BACKGROUND
Genzyme is seeking approval in accordance with 10a of 2001/83/EC, i.e. a "bibliographic
application", as this best reflects the well-established use of the product. Thymoglobuline was
first approved in 1984 in France. This product is currently authorised in 21 EU member states,
with Sweden (2002) being the most recent, and 29 non-EU member states. Most of the
clinical development was conducted in the late 1970s and early 1980s around the time of first
EU approvals. There are differences in medical practice within Member States and this is, to a
large extent reflected in different indications. Medical practice also varies in the selection of
the population of patients to be treated. As a result, it would not be feasible to harmonise
the use of the product in clinical practice. However, the proposed indications in this MAA
encompass those approved in current national authorisations. The European
Commission communicated the need for maintaining bibliographical national applications in
1998 at the end of the transition phase for the Mutual Recognition Procedure. This is reflected
in their Communication, (1998/C 229/03). "In the case of a medicinal product with a well
established use demonstrated in accordance with Article 4 (3) (8a) (ii) of
65/65/EEC, 'bibliographic application' (now Article 10a of 2001/83/EC), this well established
use being based on data referring to an existing group of products with different SPCs in the
Member States, national independent procedures could continue to be followed.". This
explanation justifies the application for this product by the National, instead of the Mutual
Recognition route.

The active ingredient is obtained by immunization of rabbits with human thymocytes and
subsequent isolation and purification. This immunosuppressive product contains cytotoxic
antibodies directed against a broad array of surface antigens expressed on T cells and
adhesion molecules including CD2, CD3, CD4, CD8, CD11a, CD28, CD45, Human
Leukocyte Antigen (HLA) Class I and HLA-DR subsets.

Possible mechanisms by which Thymoglobuline induces immunosuppression include:
lymphocyte depletion from the circulation and modulation of T-cell activation, homing.
Thymoglobuline is thought to induce T-cell depletion and modulation by a variety of
methods, including receptor-mediated complement-dependent lysis, opsonization and

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subsequent phagocytosis by macrophages, and immunomodulation leading to long-term
depletion via antibody dependent cell mediated cytotoxicity (ADCC), and activation-induced
and activation-associated apoptotic cell death.

COMPOSITION

Composition
Thymoglobuline is a freeze-dried powder consisting of rabbit anti-human thymocyte globulin
(5mg/ml reconstituted), glycine, mannitol and sodium chloride. It is reconstituted with 5 ml of
Water for Injections. The minimum and maximum lyophiliser load adequately cover the range
of DP detailed under Manufacturing Formula.

Container
Drug Product is presented in 10 ml type I glass tubing vials. A representative Certificate of
Analysis and list of specifications is provided for each component. Suppliers are audited.

Development Pharmaceutics

Drug Substance
As this application is based on the use of bibliographical data for efficacy and safety, the
applicant has used this section to demonstrate that the product proposed is similar from a
manufacturing perspective to the product described in the literature. The Drug Substance
manufacturing process described in this application is identical to the manufacturing process
approved by other EU countries with one exception: the number of cells used for the
immunization of the rabbits. It was planned to submit the variation for immunization of
rabbits with a decrease in the number of cells used for immunisation in all other EU customer
countries in 2006. As of J une 2007, this variation is approved in Austria, Estonia, Finland,
France, Germany, Latvia, The Netherlands, Norway, Romania, Sweden and Norway (and
USA). It is under review in 10 member states and 5 non-EU countries. It is not a reportable
change in the remaining countries in which a licence is granted.

The reason for the decrease in the number of cells used for immunisation is an increase in
demand for Thymoglobuline and the scarcity of thymocytes.

Data provided on DS remains valid for the bibliographic application.

Drug Product
The Thymoglobuline filling and lyophilization process has been transferred from the Sanofi-
Aventis facility in France to the Genzyme facility in Ireland. Several differences in
manufacturing equipment were noted. Critical parameters of protein concentration,
monomer/dimer content, aggregates and residual water content pre and post lyophilisation are
unaffected.

Vial Capping
A study report detailing the change in composition of the vial, and studies performed to
assure the adequacy of the new vial is provided and is acceptable.

Product Compatibility testing
The suitability of the closure system was demonstrated.

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The changes which have been introduced into the manufacture of drug product have been
adequately justified, the development has been adequately documented and it would appear to
be unlikely that they would adversely affect the quality or safety of the product. This is
confirmed by demonstrating that product meets current specifications. In particular, it has
been noted that no significant difference is noted in complement dependent activity,
molecular size distribution or residual water content. Solubility has not been affected.

Overall, the applicant has demonstrated that the quality of DS and DP has not changed
compared to product manufactured by the current process and facilities and the bibliographic
application remains valid

METHOD OF PREPARATION

Manufacturing Sites

GMP certificates from EU competent authorities (AFSSAPS, IMB,MHRA) are provided for
the following sites: manufacture and control of Thymoglobuline drug substance and final bulk
product, fill/finish, sterile filtration, labelling and packaging, finished product storage, QC
testing and batch release.

The Finished Product has been manufactured at Sanofi-Aventis, France. To increase
reliability it is proposed to manufacture the drug product at Genzyme Ireland Ltd, Ireland.
There are no changes made to the Finished Product components or formulation. Batch release
data from FP from Sanofi-Aventis, and several process validation lots from Genzyme Ireland
Ltd have been provided and pass all batch release specifications.

Manufacturing Formula
This has been provided and is acceptable.

Manufacturing Process
Process Flow Diagrams have been provided and are acceptable.

Active Ingredient

Preparation of Primary batches of Active Ingredient
This has been adequately described and demonstrates the suitability of the process.

Final Product

Shipping and Storage
Details have been provided and are satisfactory..

Component/Equipment Preparation
Details of line clearance, cleaning and sterilisation are provided for the major items of
equipment and are acceptable.

Sterile Filtration and Filling
Details of sterile filtration and filling have been provided and are satisfactory.


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Lyophilization
The process of lyophilisation has been adequately described and is acceptable.

Capping
Details of capping of lyophilized vials are capped have been provided and are satisfactory.
Incompletely sealed or uncapped vials are rejected. Capped vials are transported to a
refrigerated holding room within an inspection area of the Fill/Finish facility.

Inspection
Product inspection is performed by trained operators.

Labelling and Packaging
Automatic labelling and packaging are performed in two facilities in the UK and Ireland.
Descriptions of the processes have been given and are satisfactory. Checks are made to ensure
correct labelling with product name, batch code, expiry date etc.

Overall the manufacturing process is adequately described and controlled. Details have been
provided as requested.
Transport has been successfully validated in study 02-0161. Study date is in 1995.
A more recent study, W2-0436 (March 2007) successfully validated shipping in a refrigerated
van by SMS Temp Critical within the range 2-8C.

Process Validation
A number of process validation studies have been performed. These have been described for
the manufacture of drug substance and manufacture of drug product and are satisfactory.

Validation of DS and DP is comprehensive and has demonstrated the suitability of the
process.

CONTROL OF STARTING MATERIALS

ACTIVE SUBSTANCES

Immunogen
Thymoglobuline is prepared from rabbits which have been immunised with a thymocyte
suspension.

The preparation of immunogen is adequately described validated and controlled.

Rabbit Sera
Rabbits of New-Zealand or California or hybrid strains thereof are used. Generally,
procedures and controls are adequately described. Rabbit breeding and serum collection
facilities have been named and procedures to ensure SPF status are adequately described.

Formaldehyde-treated Red Blood Cells
The red blood cells (pre-formaldehyde treatment) are supplied and tested by the American
Red Cross. Certification covers testing for antibodies to HIV 1+2, antibodies to HTLV 1+2,
antibodies to HCV, antibodies to HBc, antigen to HBs, syphilis and HCV (RNA) and HIV
(RNA). Red Blood Cells are collected, stored and shipped in accordance with current US

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legislation 21 CFR 640 (Additional Standards for Human Blood and Blood Products), subpart
B (Red Blood Cells).

Use of RBC which are collected, stored and shipped according to the relevant US legislation
is acceptable. Since the USA is regarded as a low risk country for TSE infection, then RBC
sourced from the US are preferable to EU sourced cells. The collection centres used by the
ARC have been named and current certification from US and EU competent inspectors
provided for these sites.

OTHER INGREDIENTS

The following chemical ingredients are to current EP and USP specifications: glycine, sodium
chloride, D-mannitol, WFI.

The following chemical reagents are to current EP and USP specifications: hydrochloric acid,
sodium hydroxide, disodium phosphate dihydrate, anhydrous sodium sulphate, Tween 80,
formaldehyde, isopropyl alcohol, purified water. The applicant proposes including Contains
traces of Polysorbate 80 (Tween 80) in SPC 6.1, and the PIL.

DEAE Cellufine A-500 (Millipore) is tested to in house specifications which are provided.

The applicant states that Thymoglobuline does not contain any ingredients or reagents of
human or animal origin. Human RBC is considered separately.

The testing and specifications are acceptable.

PACKAGING MATERIAL (IMMEDIATE PACKAGING)

Details have been provided and are acceptable.

CONTROL TESTS ON INTERMEDIATE PRODUCTS

Specifications

Testing is performed on the Active Ingredient (AI) and on the Final Bulk Product (FBP). The
tests used in the specifications are selected based on past experience and on compendial
requirements.

The release specifications and the end of shelf life specifications for the Active Ingredient are
identical to each other.

Comment

The RBC supplied by ARC are not specifically tested for resistant non-enveloped viruses. A
specific assay for parvovirus B19 is included in batch release specifications, and the applicant
should also introduce testing for HAV to provide additional assurance.

Insufficient assurance is provided about the freedom of this product from HAV and specific
testing should be introduced as a batch release assay, as requested in the initial assessment.

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Batch Analysis

Active Ingredient
AI batch release results are supplied and all results are within current specification and no
trends are apparent.

Final Bulk Product
Data from consecutive FBP batches have been supplied. All results are within current
specifications and no trends are apparent.

Final Product
Data from commercial batches which were manufactured at the Waterford fill/finish facility is
provided. All results are within current specifications and no trends are apparent.

Data from consecutive batches of AI, FBP and FP has been provided and all data is within
current specifications and no trends are apparent.

Assays and Assay Validation
Test methods for haemolysins titre, haemagglutinins titre, determination of pH, bacterial and
fungal sterility and the test for pyrogens are performed according to European
Pharmacopoeial monographs and so the methods or validations are not required.

Appearance
The test consists of a visual examination of the product and validation data is not required for
this assay. Specification complies with PhEur <1928>.

Sufficient and satisfactory information is provided.

Determination of the lymphocytotoxic activity (LT 25%)
The validation as presented is adequate and demonstrates that the assay is under control.

Total Protein

Residual Formaldehyde Content
The limit of formaldehyde is based on historical data and is at a safe level.

Gammaglobulin Purity
Gammaglobulin purity is tested by agarose gel electrophoresis. Sufficient and satisfactory
information is provided.

Distribution of Molecular Size

Mannitol Content
Mannitol content is tested by ion exchange chromatography, with refractive index detection.


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Glycine Content
The specification is in compliance with the PhEur monograph <1928>and sufficient and
satisfactory information is provided.

Chloride Content
Sufficient and satisfactory information has been provided.

Parvovirus B19
A SOP has been provided regarding detection of parvovirus B19. Development, validation
and analysis are performed under GLP conditions. Sufficient and satisfactory information is
provided.

CONTROL TESTS ON THE FINISHED MEDICINAL PRODUCT

SPECIFICATIONS AND ROUTINE TESTS

The release specifications and test methods have been provided and generally the
requirements of the PhEur monograph 1928 are complied with.

Assay and Assay Validation
Test methods for identification A and B, determination of pH, osmolality, purity by SDS-
PAGE, haemolysins titre, haemagglutinins titre, bacterial and fungal sterility test, and the test
for pyrogens are performed according to the European Pharmacopoeia (EP) and so methods
and validation are not required.

The assays for; appearance after reconstitution, determination of lymphocytotoxic activity LT
25%, Identification C), total protein content, mannitol, glycine, chloride content, distribution
of molecular size and gammaglobulin purity (agarose gel electrophoresis) are identical to the
drug substance assays. FBP and FP have identical composition and therefore, validation with
FBP is relevant to FP. The remaining, FP specific assays are discussed below.

Appearance of freeze-dried product
The appearance is determined by a visual examination of the lyophilizate. Aspect and colour
are recorded. SOP is supplied, validation is not required.


Solubility
The product is reconstituted with 5 ml of Water For Injection (WFI). Time for complete
dissolution is recorded. Validation is not required.


Water
The principle of the method is the one described in the European Pharmacopoeia Water:
Micro Determination. That is the Karl Fischer method. Specification is in compliance with
PhEur 1928. Sufficient and satisfactory information is provided.


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Thrombocyte antibodies
Specification is sufficient to satisfy the requirements of PhEur monograph 1928.


LTIP50 (Experimental Test for Additional Studies)

STABILITY

STABILITY TESTS ON ACTIVE SUBSTANCES
The stability test results for several batches of Active Ingredient (AI) remain within
specifications after storage at 2-8 C for up to 26 weeks.
The applicant has committed to adjusting the current stability protocol to comply with PhEur
monograph 1928. The protocol has been adjusted to comply with PhEur 1928. A copy of the
protocol is provided.

STABILITY TESTS ON THE FINISHED MEDICINAL PRODUCT

Accelerated stability data to 6 months supports the stability of the product.

In-Use Stability Tests
.A shelf-life of 36 months was accepted.

OTHER INFORMATION

Facilities and Equipment

Details of sub-contractors and external contract test laboratories have been provided.

The facilities and equipment have been adequately described, and appropriate and up to date
GMP licenses have been provided by EU competent authorities. The status (GLP, GMP) of
the contract facilities has been clarified and appropriate certification provided.

Pathogen Safety

Adventitious Bacteria and Fungi
The manufacturing process for the DS contains adequate steps to remove bacterial and fungal
bioburden. Bioburden is controlled throughout the DS process. The Final Product is
controlled for bacterial and fungal sterility and endotoxins (PhEur).


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TSE Risk
The risk assessment made for thymus is accepted.

This product has been available since the early 1980s and there appears to be no known
association of this product with nvCJ D. Therefore, the measures taken to ensure a positive
risk assessment of this product regarding TSE infectivity are regarded as sufficient.

Adventitious Viruses

Selection and testing of the Materials of Biological Origin

Rabbits: The animals are kept in Specific Pathogen Free groups. The conditions of an SPF
group including control of feedstuff and water, personnel, entry procedures, air quality,
containment from other animals, cleaning, and removal of potentially sick animals have been
described. A detailed discussion of pathogens of concern in rabbits has been provided.
Serology testing is carried out on rabbit blood sample.

Measures in case of positive serology result, or clinical sign of disease are outlined, and
include suspension of the use of the colony and quarantine or destruction of relevant sera.
The facility, maintenance procedures, testing and measures in case of disease are adequate

In addition, justifications are provided for the safety of the product from the appropriate
animal viruses.

Human Thymus Fragments: Thymus donors must be less than 14 years old and fit the
selection criteria. They must also be low risk for CJ D and other transmissible subacute
spongiform encephalopathies. Blood samples from the donor are screened for a number of
viruses using EU/US approved test kits.

Human Red Blood Cells: RBCs packs are supplied by American Red Cross (ARC) Blood
Services. They are controlled in accordance with US regulations in force for blood collection.
The contract specifications for supply of RBC have been provided in the application.
Specifications include suitability of donors, storage, collection of blood, testing of blood,
donor follow up, batch size, temperature, presentation, labelling, and shipment conditions.
Each bag is tested with FDA approved tests and found negative for a number of viruses. Prior
to use, the red blood cells are treated with formaldehyde to reduce risks of viral
contamination.

Rabbit Serum: The rabbit serum is also tested for contaminating viruses.

Viral Testing on the Active Ingredient and Final Bulk Product: Parvovirus B19 testing is
performed on Final Bulk Product (FBP) batches.

Inactivation and Removal Steps in the Downstream Process.

The viral clearance studies were performed in accordance with ICH guidance document Q5A
Viral Safety Evaluation of Biotechnology Products Derived from Cell Lines of Human or
Animal Origin and CPMP/BWP/268/95 Note for Guidance on Virus Validation Studies:

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The Design, Contribution and Interpretation of Studies Validating the Inactivation and
Removal of Viruses.

Virus Inactivation during Pasteurisation
The selected panel of viruses has been appropriately justified in terms of physicochemical
properties, resistance to inactivation and actual/model pathogens.

Viral Inactivation of Red Blood Cells before Use
Validation of virus inactivation was performed on a scaled down model of the commercial
process. Details are provided. The study was performed according to GLP and demonstrated
that formaldehyde treatment of RBC causes a significant amount of inactivation of the
enveloped and non-enveloped viruses tested. The viruses constitute a reasonable panel of
actual and model viruses with differing physicochemical properties.

Viral study of the regeneration of the DEAE resin
A virus inactivation study has been performed on the cleaning procedure of the DEAE A500
Cellufine resin to demonstrate the efficiency of this procedure to inactivate or to remove virus
bound onto the resin. This experiment indicates that the resin is effectively cleaned and
sanitised (for viruses) by the commercial conditions.

Reference Standards
Description and qualification of reference standards is generally acceptable.

DISCUSSION

As would be expected for a product which has already been licensed in approximately 50
countries, the standard of this application was high, and no major objections have been raised
on Quality issues.

Since this is a bibliographic application, it has been important for the applicant to establish
that the product which is proposed in this MAA is the same as the product with which the
non-clinical and clinical data has been generated. The drug substance manufacture is identical
to the licensed product, but with the introduction of a variation to the number of thymocyte
cells which are used during rabbit inoculation. A comparison of in-process control and batch
release data demonstrate that this does not appear to make any identifiable difference to the
potency or quality of the serum/product. The applicant wishes to use a different
manufacturing site for the drug product which uses equipment from different vendors, and
also a new step in the manufacturing process. Due to the nature of the operations it is unlikely
that the changes would impact on the product. Consequently, it is accepted that this product is
consistent with a bibliographic application.

CONCLUSION

Marketing authorisation for this product may be granted.

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PRECLINICAL ASSESSMENT

INTRODUCTION

TYPE OF APPLICATION AND ASPECTS ON DEVELOPMENT
This application is made in accordance with Article 10 (1)(a) of Directive 2001/83/EC, as
amended an application for a product with well-established use in the Community. The
product has been available in other European countries since it was first approved in 1984 in
France. The indications sought are virtually identical to those for which it is approved in other
EU countries and are the prevention and treatment of graft rejection in renal transplantation
and prevention of graft rejection in heart transplantation.

The product contains polyclonal rabbit anti-human thymocyte immunoglobulin and is
produced by immunisation of rabbits with human thymocytes and removal and separation of
immunoglobulin from rabbit sera, with pasteurisation, filtration, sterilization and freeze
drying to produce the finished dose form. Glycine, sodium chloride and mannitol are used as
excipients and the product is reconstituted for use in sterile water for injections, diluted to the
total infusion volume of 50 to 500 ml in 0.9% sodium chloride and infused intravenously with
use of an in-line filter. Premedication with steroids and antihistamines to facilitate tolerability
of the infusion is recommended in the SPC. Typically, the product will be administered every
day for several days post-transplant.

The application was discussed in a meeting between the Applicant and the MHRA in J uly
2004 in which the Applicant sought advice from the MHRA on quality, preclinical and
clinical data, as well as the route of submission. Concerning the standards of data in the
preclinical section of the dossier, because many of the studies were conducted many years ago
(in some cases, more than 25 years), study designs are not consistent with current practices,
with the consequence that the preclinical module in the dossier cannot be structured as it
would be for a new development programme. As examples, pharmacological effects are
explored in combined studies that also determine pharmacokinetic endpoints; combined
primary pharmacology and toxicology studies are reported and the quality of description of
studies is generally not at current standards (e.g. lack of GLP, limited detail in experimental
methods and results descriptions, no data for individual animals presented). The Applicant
has been straightforward about these deficiencies and the MHRA advised that presentation of
the preclinical and clinical experience with the product, with establishment of the
comparability of the products used in these studies with the current commercial product,
should constitute an acceptable data set. In the presentation of this Assessment Report, study
results are described under the most relevant heading.

The non-clinical expert is an employee in the Applicants group of companies. The
nonclinical overview is acceptable.

GLP ASPECTS
The status of many of the preclinical studies submitted is not described. Lack of compliance
is assumed except where specifically described in this report. As the application is determined
on the basis of well-established clinical use, the GLP status of the preclinical safety studies is
not an issue.


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PHARMACOLOGY

BRIEF SUMMARY
The primary pharmacological action of rabbit anti-human thymocyte immunoglobulin is
depletion of T lymphocytes in blood and in lymphoid organs. This impairs the capacity of the
immune system to mount responses to foreign tissues and is of value in the short term to
prevent organ rejection in transplantation.

PHYSICAL CHEMISTRY
The structure is that of a polyclonal gamma immune globulin, with two heavy chains of
approximately 450 amino acids and two light chains of 211 217 amino acids. The drug
substance is a colourless or pale yellow liquid, clear or slightly opalescent, and its protein
concentration is 2 7 g/l.

PRIMARY PHARMACODYNAMICS

Study to assess effect of heat treatment on pharmacodynamics of Thymoglobuline
A GLP-compliant study was reported in which effects of the pasteurisation step (heating at 56
- 60C for 10 hours) on in vitro activities of the product were assessed. In this study,
comparative binding to human peripheral blood mononuclear cells, and to B and T cell lines,
mitogenic activity on peripheral blood mononuclear cells, as measured by triated thymidine
incorporation, and competitive binding inhibition of monoclonal antibodies to CD2, CD3,
CD4, CD8, CD11a and CD18 was assessed. No significant differences were found between
pasteurised and non-pasteurised product and comparability between the two was concluded.

Toxico-pharmacology study with non-heat-treated Thymoglobuline
The Applicant submitted work conducted with non-heat-treated Thymoglobuline in 1981
1983 and which was reported in 1991. The report summarises pharmaceutical,
pharmacological and toxicological tests conducted. Pharmacological studies are described
immediately below and toxicological studies are presented under the heading of Safety
Pharmacology, in this Assessment Report. Details are extremely scant in some cases and the
text of the report has been reproduced to indicate this.


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In vitro test of cytotoxicity to human lymphocytes using blood from cynomolgus monkeys
Summary of method: Human peripheral blood lymphocytes were prepared in a suspension
and one drop is added to three drops of antilymphocyte serum and one drop of rabbit
complement. After incubation for 30 minutes at 37C, 1 drop of Trypan blue is added for a
further 10 minutes of incubation. Cell lysis is determined by counting 100 or 200 cells and
cytotoxicity is calculated from these data.

Results: The entire section of the report is presented below. There is no narrative.

In vivo test in monkeys rejection of skin grafts
Summary of method: Pharmacological proof of concept was sought by determining the effect
of treatment to prolong skin allografts in two cynomolgus monkeys, each of whom had three
skin grafts (2 from other monkeys and one allograft).

Results: The Applicant states that: It was noted that in grafter animals, the graft survived
longer than in controlled animals these are the only words describing the results. The table
below provides the data. Although not statistically robust, monkeys treated with three
different lots of Thymoglobuline survived longer than control monkeys.


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Thymoglobuline pharmacokinetics & potency in cynomolgus monkeys
This report describes multiple experiments conducted over a three-year period (1998 2000)
in cynomolgus monkeys into the mechanism of action of Thymoglobuline. The objective was
to determine the effects of Thymoglobuline on heterotopic heart transplant or skin grafts in
monkeys. For heart transplants, the duration of graft survival was recorded from the day of
implantation to the last day when the heart was beating, as determined by palpation. For skin
grafts, graft survival duration was assessed by the time elapsed between grafting to complete
graft rejection, based on the presence of a scabby aspect, or brown colouring with loss of
flexibility, or complete necrosis of the epidermis. It is not described as to whether blinded
assessments were done, but two assessments were performed with a further check by the
sponsoring companys appointed veterinarian at unspecified key points. Monkeys were
mismatched for major histocompatability complex by serology.

Effects on red blood cells, platelets, neutrophils and lymphocytes were determined by blood
cell counts. Immunohistochemical analysis of samples from lymph nodes, spleen and thymus
was undertaken. These measures were supported by kinetic measurements of rabbit
antilymphocyte globulin in monkey blood (quantified using an immunoenzymatic assay using
goat anti-rabbit IgG). This method was also applied for determining anti-rabbit antibodies,
except that peroxidase-conjugated goat anti-monkey IgG was used instead of anti-rabbit IgG.

Doses of Thymoglobuline of 1, 5 or 20 mg/kg were used, described as low dose (LOD), high
dose (HID) and very high dose (VHID) as shown in Figure 1. Doses were selected on the
basis of the human therapeutic dose of 1.5 mg/kg, with reference to a claim that binding of
Thymoglobuline to human lymphocytes is twice that to cynomolgus lymphocytes and to the
consideration that, on a body surface area comparison, the surface area is greater in the

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PL: 12375/0021
monkey than in humans, on a weight-corrected basis, by a factor of 3 to 6. The Assessors
calculations of these doses are:
dose of 1.5 mg/kg in humans =55 mg/m
2
1 mg/kg in cynomolgus monkey = 12 mg/m
2
(LOD)
5 mg/kg in cynomolgus monkey =60 mg/m
2
(HID)
20 mg/kg in cynolmolgus monkey =240 mg/m
2
(VHID)

Figure 1: Experimental schedule to study the effect of Thymoglobuline in skin grafts in
cynomolgus monkeys

Results: There were no unexpected deaths in the study. Behavioural changes indicative of a
first infusion syndrome linked to cytokine release (prostration, vomiting) were observed.
The graft survival data are presented below in Figure 2. Skin allografts had a median survival
time of 9.25 days in control monkeys (black circles, left hand trace, A, left panel) whereas for
LOD, HID and VHID groups, this figure was 13, 22 and 24 days respectively. Heart allograft
median survival times were 8.5 days in control, 12.5 in LOD, and 17 in HID groups. The
Applicant notes that the allograft survival was correlated with the magnitude of blood
lymphopenia during the first week of treatment.


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PL: 12375/0021
Figure 2: Graft survival and lymphocyte count data

Binding of rabbit anti-thymocyte globulin to human and monkey lymphocytes is shown in
Figure 3, where the upper line is human and the lower is monkey. This is the evidence for
comment above that binding of Thymoglobuline to human lymphocytes is twice that to
cynomolgus lymphocytes.

Peripheral blood counts are presented in Figure 4. Of note is that treatment produced a
transient dose-dependent lymphocytopenia (2d) with drops in each subset of lymphocyte
analysed (2e, f, g, h, i). Neutrophils were also depleted with the very high dose (VHID)
producing neutropenia (2c). Platelets were almost unaffected, except with VHID and red
blood cells were unaffected, except by a possible effect which is attributable to blood
withdrawal. The Applicant concluded that these results demonstrate that treatment resulted in
a significant decrease in peripheral blood lymphocytes on a dose-dependent basis, without
major depletion of other cell types, except for neutrophils and platelets in both VHID groups.

In lymphoid tissue, there was a dose-dependent T-cell depletion in lymph nodes and spleen
(Figure 5a). Depletion of B cells and natural killer cells occurred only at high dose (Figure 5e,
f). There was no effect on thymocytes (data not shown). There was a dose-dependent increase
in the proportion of apoptotic lymphocytes (Figure 6). Additional testing also indicated an
increase in double strand DNA breakages in lymph nodes and down-regulation of T cell
surface antigens (data not shown here).


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PL: 12375/0021
Figure 3: Binding of Thymoglobuline to human and monkey lymphocytes

Figure 4: Peripheral blood counts in monkeys dosed with Thymoglobuline


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PL: 12375/0021
Figure 5: Thymoglobuline-induced lymphocyte depletion in peripheral organs

Figure 6: Apoptotic lymphocytes in axillary lymph nodes 1 hour after Thymoglobuline

Kinetic results indicate that rabbit IgG concentration reached a maximum by day 6 then
returned to undetectable amounts by day 13 (Figure 7). The Applicant attributes clearance of
Thymoglobuline to the immunization of the animals, as demonstrated by the presence of
anti-rabbit IgG antibodies by day 8 in the sera of all treated animals and indicated by the (-)
and (+) identifiers in the left half of Figure 7 panel a.


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PL: 12375/0021
Figure 7: Kinetics of Thymoglobuline and anti-thymoglobuline antibodies in monkeys

Overall, from this study, the Applicant made the following conclusions:

(1) the mechanism of action of T cell depletion is apoptosis in peripheral lymphoid organs
(2) non-depleted T cells were coated by antithymocyte globulin and showed decreased T-cell
surface antigens
(3) statistically significant dose-dependent survival of graft was shown
(4) lymphocyte depletion and graft survival were correlated and the depletion of lymphocytes
seemed to be proportional to the dose of Thymoglobuline injected; however, the relative
contribution of T cell depletion and functional impairment cannot be delineated.

The Applicants conclusions are substantiated by the data presented.

SECONDARY PHARMACODYNAMICS
Separate secondary pharmacodynamic studies were not reported. The Applicant refers to
published literature on the effects of rabbit anti-human thymocyte immunoglobulin.

SAFETY PHARMACOLOGY

Pharmacotoxicological studies with non-heat-treated Thymoglobuline
The work described in this report was conducted with non-heat-treated Thymoglobuline in
1981 1983 and was reported in 1991. The report summarises pharmaceutical,
pharmacological and toxicological tests conducted. Pharmacological studies are described
immediately below and Toxicological studies summarised are then listed. The conclusion of
the Applicant is presented thereafter.


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PL: 12375/0021

Each of these studies is summarised below.

Bacterial and fungal sterility test
Summary of method: The presence of possible contaminant is tested by inoculation onto a
variety of media and assessing growth of various bacterial or fungal organisms.

Results: No organisms were shown up in the serum. Purity was thus concluded.

Research on cytotoxicity
Summary of method: The existence of cytotoxic antibodies in the product is assessed by
determining induction of fibroblast cell death by Thymoglobuline. The test uses MRC-5 or
WI-38 cells.

Results: The absence of toxicity was shown.

Summary of method: A second test assesses the potential effect of Thymoglobuline on the
granulomonocyte cell lineage, extracted from bone marrow and cultured. The source species
is not specified.

Results: These are presented below.

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PL: 12375/0021

Acute toxicity tests by intramuscular and intraperitoneal routes in mice, and by intramuscular
and intravenous routes in rabbits
Summary of method: 5 male and 5 female mice of the Swiss strain are injected by these
routes with a single injection of 0.5 ml of Thymoglobuline from Lot S 1136 (SL 81-1)
(equivalent to 10% of a human dose) and mortality, behaviour and body weight are assessed
over the subsequent 12 days with terminal autopsy examination. Twenty female albino rabbits
are injected by these routes with a single injection of 5 ml of Thymoglobuline from Lot 1136
(SL 81-1) (equivalent to a full human dose) and mortality, behaviour and body weight are
assessed over the subsequent 14 days with terminal autopsy examination.
Results: Treatment did not have any influence on the parameters under evaluation.

Administration every week for 12 weeks by intramuscular route in guinea pigs
Summary of method: 8 guinea pigs (sex described) are injected by the intramuscular route
with a single injection of 2 ml of Thymoglobuline from Lot S 1136 (SL 81-1) (equivalent to
40% of a human dose) every week for 12 weeks and mortality, behaviour and body weight are

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PL: 12375/0021
assessed over this period with terminal autopsy examination at an unspecified timepoint
thereafter.

Results: No animal died in the study and local tolerance was satisfactory. The examinations
made make it possible to conclude the absence of conclusive traces of any toxic action of the
sera tested.

Administration every day for 5 days, then 3 days a week until rejection of the graft in
monkeys, by the intramuscular route
Summary of method: 12 cynomolgus monkeys each undergo three skin grafts (2 from other
monkeys and one autograft) and are given 5 ml of Thymoglobuline (the full human dose) by
intramuscular injection every day for the first 5 days then 3 days a week until the graft is
rejected. Clinical, behavioural, haematological and anatomopathological examinations are
carried out.

Results: No animal died and no clinical or behavioural symptoms were observed throughout
the study, with local tolerance also described as satisfactory. Haematological examination
did not show any significant differences between controls and treated monkeys. On
macroscopic examination, no lesions were observed with the exception of pulmonary
emphysema which is not imputable to treatment. No differences in the structure of the
lymphoid structures or organs were noted. The overall conclusion was that ATG
administered by intramuscular route into monkeys did not lead to any clinical, behavioural,
haematological or biochemical modification, or any histological lesion the frequency of which
was significant or could be imputable to treatment.

Research for phenomena of hypersensitivity in guinea pigs
Statement of principle: 10 guinea pigs are injected with 0.2 ml of Thymoglobuline
intradermally with a further 30 given similar injections of equine anti-lymphocyte globulin or
physiological saline to act as controls. 21 days later, Thymoglobuline is given by intracardiac
injection of half the 10 guinea pigs with controls treated by a parallel test using either equine
anti-lymphocyte globulin or physiological saline. Immediate hypersensitivity is assessed over
the 8 hours following injection. The other 5 guinea pigs are injected by the intradermal route
and delayed hypersensitivity is assessed in the 72 hours after injection.

Results: Immediate hypersensitivity was confirmed in that in Thymoglobuline-primed guinea
pigs, all died following intracardiac injection of Thymoglobuline, as did those primed with
and given equine anti-lymphocyte globulin. There was specificity in this response as no
deaths occurred in Thymoglobuline-primed guinea pigs injected with equine anti-lymphocyte
globulin. No manifestation of delayed hypersensitivity was observed.

The Applicants comment on these data is copied below. This was written by an approved
expert toxicologist and pharmacologist.

GENERAL CONCLUSIONS

The toxico-pharmacological expertise of anti human thymocyte immunoglobulin, prepared in
rabbits, (ATG), by the Institute Merieux has demonstrated that the product presents:
absence of acute toxicity in mice and rabbits, and subactue toxicity in guinea pigs and
monkeys, but it is however capable of prevoking a phenomenum of immediate
hypersensitivity in guinea pigs, after a low dose priming injection and a high dose
triggering injection by intracardiac or intravenous route (it may be noted that the

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PL: 12375/0021
phenomemon dose not appear when the animals are given high repeated doses of the
product, if the subacute toxicity test on guinea pigs is considered);
distinct activity and efficacy;

That, in consequence, this product indeed seems to present the safety and efficacy required
(article 5-120-1 and article 601 of the Code de la Sant Publiqu) under the conditions of use,
the diverse experiments and different animal species described above.

And that, as it satisfies the requirements, its use may be authorised in human medicine.

The paucity of description present in this report is reflected in the above summaries. The
quality of the data and level of detail in description of methods and outcomes reflect standards
from over 25 years ago when GLP was not in place. This is sufficient to conclude that no
major hazard is identified. As current legislation requires, an expert summary of these data is
presented and this specifically endorses human use of the product.

PHARMACODYNAMIC DRUG INTERACTIONS
There is a cross-reference in the relevant section of dossier for pharmacodynamic drug
interactions to one report published in 2006
1
. This report describes the
immunopharmacological actions of Thymoglobuline administered at different doses to
cynomolgus monkeys receiving either skin allografts or heterotopic heart transplants. As such,
this study is not a study of pharmacodynamic interactions, although the drug is used in a
procedure resembling clinical use, and zolazepam and atropine are used. The studys
conclusion, however, that ATG monotherapy in cynomolgus monkeys resulted in a dose-
dependent T-cell depletion in peripheral blood and to a lesser extent in peripheral lymphoid
tissues but not in the thymus clearly indicates that the intent of this study is not to assess
pharmacodynamic interactions.

ASSESSORS OVERALL CONCLUSIONS ON PHARMACOLOGY
The mechanism for how depletion of lymphocytes is induced by Thymoglobuline is
suggested to be related to induction in peripheral tissues of apoptosis of cells coated with the
immunoglobulin. Similar cellular depletion occurs in immune tissues but the extent to which
this contributes to the observed therapeutic effect is difficult to judge. The target epitope is
unclear, but this may be because multiple epitopes may be involved in this polyclonal
preparation. Thymoglobuline binds to CD4+and CD8+peripheral T cells.

The data indicate correlation between peripheral T cell depletion and graft survival in vivo in
monkeys. No difference in immunological properties of Thymoglobuline was detected when a
heat-treatment step was introduced to the manufacture, which was done to improve
microbiological safety and consequently findings on non-heat-treated immunoglobulin may
apply to the heat-treated product which is the subject of this application.
Pharmacotoxicological tests in mice, guinea pigs, rabbits or monkeys did not identify
unexpected toxicity.

1
Prville X et al (2006) Transplantation 71(3) 460-8. mechanisms involved in antithymocyte globulin
immunosuppressive activity in a nonhuman primate model.

27
PL: 12375/0021
PHARMACOKINETICS

ANALYTICAL METHODS
The Applicant describes that in nonclinical studies Thymoglobuline was quantified using
immunological tests, including ELISA.

PHARMACOKINETIC STUDIES
Pharmacokinetics of Thymoglobuline, at one dose level of 20 mg/kg were described. Either
heat-treated or non-heat-treated Thymoglobuline was given to male and female cynomolgus
monkeys (n =1 or 2) daily by intravenous administration for two weeks, followed by a four-
week treatment free period. Blood samples were taken for toxicokinetic measures.

The results are depicted in Figure 8, where the filled-in black diamond represents data from
monkeys treated with heat-treated Thymoglobuline, the same product as is the subject of this
application. Kinetic parameters calculated from these data indicated that kinetics were not
different between heat-treated and non-heat-treated Thymoglobuline. Serum half life was
estimated at 30 days and mean maximal concentrations are reached by day 9 and peak at 988
200 g/ml. Antibodies to Thymoglobuline are detected and there is a clear correlation with
their development and the reduction in Thymoglobuline concentration in plasma (Figure 9).
From this study, the Applicant concluded that bioequivalence was shown between the heat-
treated and non-heat-treated products.

Figure 8: Kinetics of Thymoglobuline in cynomolgus monkeys given daily injections


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PL: 12375/0021
Figure 9: Development of antibody influences kinetics of Thymoglobuline in cynomolgus
monkeys given daily injections

No metabolism or excretion studies have been submitted. The Applicant states that in the light
of long term human experience, animal studies are not considered necessary and that
Thymoglobuline is expected to be cleared from the blood like other immunoglobulins. This is
accepted.

ASSESSORS OVERALL CONCLUSIONS ON PHARMACOKINETICS
Further animal studies are unnecessary due to extent of clinical experience with the product.

TOXICOLOGY

BRIEF SUMMARY
The following studies have been reported:
- cross-reactivity study in human tissues
- single dose toxicity by the intravenous route in the mouse
- single dose toxicity by the intravenous route in the rat
- 2 week repeated dose toxicity by the intravenous route in the cynomolgus monkey
- local tolerance in the rabbit.
CROSS-REACTIVITY
A GLP-compliant study was conducted to assess cross-reactivity with human tissues of
Thymoglobuline. The quality of the specimens used in the study was affirmed and its results
are judged to be reliable. Tissue samples were obtained within 24 hours of death from one
female and two male subjects, but cause of death was not reported. The study objective was to
determine binding of Thymoglobuline to related or unrelated epitopes on cells from various
human tissues (bone marrow, cerebrum, heart, ileum, jejunum, kidney, liver, lung, lymph
node, skin, spleen and thymus).

Lymphocytes were intensively stained with Thymoglobuline and were the only cells stained
in the tissue tested. Staining included the cytoplasm and the cell membrane, but not the cell
nucleus. Negative (on-immune IgG) and positive (anti-collagen IV antibody) controls
validated the findings of specificity of binding of Thymoglobuline to lymphocytes.


29
PL: 12375/0021
GENERAL TOXICITY

Single intravenous dose in the mouse
Thymoglobuline was administered by the intravenous route to 10 male and 10 female OF1
(Swiss) mice at one dose of 15 ml/kg and mice were monitored for a subsequent 14 day
period and necropsied on Day 15. No deaths or abnormal signs were noted, either on clinical
observations in the 14 days following injection or on macroscopic examination. This study
was reported in April 1992: no statement of GLP compliance is made. Data on individual
animals are not reported.

Single intravenous dose in the rat
Thymoglobuline was administered by the intravenous route to 10 male and 10 female Sprague
Dawley rats at one dose of 15 ml/kg and mice were monitored for a subsequent 14 day period
and necropsied on Day 15. No deaths or abnormal signs were noted, either on clinical
observations in the 14 days following injection or on macroscopic examination. This study
was reported in April 1992: no statement of GLP compliance is made. Data on individual
animals are not reported.

These two single dose tests, which are reported together in one report, are not of an acceptable
standard as no data on individual animals is presented. Although the Applicant has to submit
the data that are available, the data presented in this report are not considered sufficiently
reliable to be accepted for assessment.

REPEAT-DOSE TOXICITY
2-week repeated intravenous dose toxicity study in the cynomolgus monkey
Thymoglobuline, at one dose level of 20 mg/kg, was given to male and female cynomolgus
monkeys (n =1 or 2) daily by intravenous administration for two weeks, followed by a four-
week treatment free period. This study was conducted in compliance with GLP. These
monkeys were wild-caught, but healthy at the start of dosing.

This test was conducted to compare the toxicity associated with heat-treated thymoglobuline
with that associated with non-heat-treated thymoglobuline and was done to support a change
in the production process to introduce the viral inactivation step of a 10 hour treatment at
60C. As the product for which approval is sought is only the heat-treated product, this
comparison is not of direct relevance to the present application; rather, the absolute toxicity of
heat-treated Thymoglobuline is of interest. The dose was selected to be approximately three
times the anticipated maximum therapeutic dose.

With reference to the objective of the study, there was no detectable difference in toxicity
profile between heat-treated and non-heat-treated Thymoglobuline. These are called test
article in further descriptions of this study.

Mortality was significant in this study: in total, 5 monkeys dosed with test article died or were
killed due to moribund condition, of a total of 12 dosed with test article. These deaths
occurred in the following time sequence: one female was killed moribund on day 9 and one
male was found dead on day 13. Dosing stopped on day 14 and one male was killed moribund
on day 18 and two females were killed moribund on day 21. All monkeys alive at this
timepoint survived to the end of the four week treatment-free period.


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PL: 12375/0021
Clinical signs in the monkeys that died or were moribund were generally representative of
septicaemia, and reductions in food intake and body weight, with a short episode of
hyperthermia followed by hypothermia, subdued behaviour and the presence of sores or
abscesses. Haematological and histopathological changes were also indicative of septicaemia
and infection, although blood samples for bacterial examination were only taken from two
monkeys, in only one of whom only Staphylococcus aureus was isolated. There was a severe
but reversible (in surviving monkeys) decrease in absolute and relative lymphocyte counts in
all monkeys dosed with test article and in monkeys that died extremely low counts, as low as
2%, were noted (Table 1). Recovery to normal ranges took until day 43. Absolute neutrophil
counts generally decreased from starting treatment until about day 29, when recovery began.
Severe immune depression was expected as the pharmacological action of the test article and
the Applicant attributes the deaths to this, combined with the variable health status of the
wild-caught animals before start of treatment (although the Applicant also states that animals
were clinically in good health at the beginning of the treatment period). The pathologist
reported that Septicaemia secondary to this immune suppression was the cause of moribund
condition and unscheduled death.

Table 1: Individual white blood cell and lymphocyte count data in monkeys

Gp 1 =control; Gp 2 =non-heat-treated Thymoglobuline, 20 mg/kg; Gp 3 =neat-treated
Thymoglobuline.

Similar clinical signs, but of lesser intensity, were observed in surviving monkeys. In all
monkeys given test article, decreases in red cell parameters (haemoglobin, red blood cell
count, PCV) were observed, progressing throughout the treatment period, and tending to

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PL: 12375/0021
reverse from day 20. Platelet counts showed a similar pattern. Reticulocyte counts showed an
increase from day 3 in all groups, with monkeys given test article showing higher increases
than those in the control group, and a slower recovery in the treatment-free period. White
blood cell counts, which was described as the main severe but reversible treatment-related
observation are discussed above. Bone marrow smears showed a difference in the number of
lymphocytes from monkeys killed at day 14 (very poor) compared to smears from those
killed after the 4 week treatment free period (normally rich).

No noteworthy changes on ophthalmological examination, on blood pressure,
electrocardiographic parameters or on urinary parameters (with the possible exception of
some protein, glucose, blood, reducing substances, bacteria, yeasts and epithelial cells in
urine. at Day 13 which occurred in one male monkey) were observed. Changes in clinical
chemistry parameters were such as to be judged by the Applicant as being not directly related
to the treatment, considering the clinical behaviour of treated animals. Notable changes were
reversible increases in cholesterol and decreases in protein. No notable findings were evident
on organ weight. No macroscopic changes were identified in monkeys killed at the end of the
4 week treatment-free period: macroscopic changes indicative of septicaemia or infection in
multiple organs were observed in monkeys that died or were killed moribund on the study.
Microscopic changes were seen, but were attributed to either direct or secondary effects
consequent upon the pharmacological action (e.g. atrophy of lymph tissues) or were attributed
to study procedures (e.g. thrombosis in lungs, phlebitis or thrombophlebitis) or associated
stress. The Applicant made further comment on the instances of thromboemboli: the study
was conducted in 1992 at which time a historical database was not available. In a further 11
studies conducted in 1992 and 1993, spontaneous thromboemboli formation was noted in one
cynomolgus monkey, and the Applicant judges that the instances observed in this study is
random and are probably consequences of the method of administration and likely to have
been exacerbated by the concurrent condition of the monkeys.

The toxicity induced in this study, although perhaps unexpectedly severe, is in keeping with
the expected pharmacological action to deplete lymphocytes. In extrapolating to clinical use,
it is noted that the dose is three times higher than the expected maximal human dosage. 14
days is the maximum dosing period recommended in the SPC. Clinical monitoring of
lymphocyte counts will protect patients from drastic effects and reduced dosage or stopping
treatment are recommended in the presence of thrombocytopenia.

GENOTOXICITY
Genotoxicity studies have not been conducted with Thymoglobuline.

CARCINOGENICITY
Carcinogenicity studies have not been conducted with Thymoglobuline.

REPRODUCTIVE AND DEVELOPMENTAL TOXICITY
Studies to assess reproductive and developmental toxicity have not been conducted with
Thymoglobuline.

LOCAL TOLERANCE
This study was conducted in compliance with GLP. Local tolerance was assessed in male
New Zealand White rabbits after multiple intravenous and single perivenous injection with
the schedule as shown in Table 2. The test article is 25 mg Thymoglobuline per vial,
reconstituted in 5 ml of water for injection: excipients are mannitol (10 g/l), glycine (10 g/l),

32
PL: 12375/0021
sodium chloride (2 g/l) and Tween 80 (0.5 g/l) which is the same as the test article, but
without gamma globulin.

By repeated intravenous injection, the test article produced transient slight erythema in one
rabbit on day 6 and haemorrhagic infiltration in two rabbits for 1 or 2 days. The excipients
produced a similar effect in one rabbit on days 5 and 6 and haemorrhagic infiltration was seen
in two rabbits for either 3 or 6 days. By single perivenous injection, one rabbit dosed with test
article developed a haematoma, and transient haemorrhagic infiltration was noted in two out
of three rabbits. Administration of the excipient was associated with more severe irritation,
producing haemorrhagic infiltration in 7 out of 12 rabbits, slight erythema in 5 rabbits for 1 to
5 days and haematoma in three rabbits. On microscopic examination, it was concluded that all
injections were well tolerated and changes observed were at a low level and of the type
expected with the route of administration.

Table 2: Schedule for local tolerance study in the rabbit

The clinical route of administration is intravenous infusion. No concerns are raised.


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PL: 12375/0021
OTHER TOXICITY STUDIES
No other studies were reported.

ECOTOXICITY/ENVIRONMENTAL RISK ASSESSMENT
The Applicant affirms that no genetically modified organisms are present in the product and
that the excipients of the product (mannitol, sodium chloride and glycine) are not novel and
their use in this product does not significantly alter their concentration in the environment. As
a protein, the product does not need to be supported by an environmental risk assessment,
according to the relevant guideline (Guideline on the environmental risk assessment of
medicinal products for human use, EMEA/CHMP/SWP/4447/00). As a rabbit polyclonal
antibody mixture, Thymoglobuline is expected to break down into constituent amino acids in
vivo, with no attendant environmental hazard. The Applicants justification for the excipients
is accepted.

ASSESSORS OVERALL CONCLUSIONS ON TOXICOLOGY
The conclusion on the clinical safety data presented for the product should supersede the
findings from toxicity studies in animals. The toxicity detected in animals is consistent with
supra-pharmacological actions.

ASSESSORS OVERALL CONCLUSIONS
The well-established use criteria for seeking approval of a marketing authorization for a
medicinal product state that results of preclinical studies do not have to be submitted if the
Applicant can demonstrate that the active substances of the medicinal product have been
in well-established medicinal use within the Community for at least ten years, with recognised
efficacy and an acceptable level of safety. Consequently, consideration of efficacy and safety
of this product should rely on clinical experience. The preclinical studies presented are
supportive of the safety of the product, particularly the specificity shown in the cross-
reactivity study in human tissues. The pharmacodynamic actions of Thymoglobuline were
shown repeatedly in studies in cynomolgus monkeys and toxic effects seen can be attributed
to actions to deplete lymphocytes.

There are no objections, on preclinical grounds, to the granting of a marketing authorisation.


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PL: 12375/0021
CLINICAL ASSESSMENT

INTRODUCTION

This is a national marketing authorisation application (MAA) for Thymoglobuline according
to Article 10 (1) (a) (ii) of Directive 2001/83/EC as amended abridged applications (well
established use).

Thymoglobuline (anti-thymocyte globulin [rabbit], rATG) is a purified, pasteurized, gamma
immune globulin obtained by sensitization of rabbits with human thymocyte suspensions
derived from thymus fragments that are surgical waste during cardiac surgery in children. The
manufacture of Thymoglobuline involves a series of intricate processes and quality assurance
checks that are intended to reduce lot-to-lot variability. This consistency permits the
administration of drug from different lots during a clinical course of treatment with
Thymoglobuline.

It is classified as ATC class LO4AA04, anti-human thymocyte immunoglobulin.

Thymoglobuline is approved in Europe on a National Procedure basis. It is registered in a
total of 55 countries. In France and most international markets, Thymoglobuline is indicated
for prevention and treatment of solid organ transplant rejection, prevention of acute and
chronic graft-versus-host disease following haematopoietic stem cell transplantation (HCT),
treatment of steroid resistant, acute graft-versus-host disease and treatment of aplastic
anaemia (AA). Thymoglobuline was first approved in France in April 1984 for the indications
of prevention and treatment of rejection in kidney and heart transplantation, treatment of
severe aplastic anaemia, and treatment of acute graft versus host disease, obtained on the
basis of well established use of antithymocyte globulins (ATGs) in general. No traditional
pivotal trials were performed or presented as part of the original MAA dossier. The active
ingredient as well as the composition of the product has been used in the medical practice for
more than 10 years in the European Union. This meets the criteria established to justify well
established medicinal use.

Thymoglobuline was registered in the USA in 1998 for the indication of treatment of acute
rejection in renal transplantation in conjunction with concomitant immunosuppression.

There has been no worldwide modification(s) of the license status of Thymoglobuline, for
safety reasons, since it was first licensed.

This submission was supported by a single company sponsored prospective study for
Thymoglobuline (Study 00PTF01) which was conducted in compliance with the requirements
and principles of Good Clinical Practice (GCP). In 2003, the additional indication of
prophylaxis of graft versus host disease (GvHD) was approved in France.

The indications for which marketing approval is sought in the UK are the prevention of graft
rejection in renal and heart transplantation and the treatment of steroid resistant graft rejection
in renal transplantation.


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PL: 12375/0021
Proposed doses:
1. Prophylaxis of acute graft rejection renal transplantation 1 1.5 mg/kg/day for 3 to 9
days in transplantation of the kidney, corresponding to a cumulative dose of 3 13.5 mg/kg
2. Treatment of steroid resistant graft rejection renal transplantation 1.5 mg/kg/day for 7 to
14 days, corresponding to a cumulative dose of 10.5 21 mg/kg
3. Prophylaxis of acute graft rejection heart transplantation 1 2.5 mg/kg/day for 3 to 5
days in transplantation of the heart, corresponding to a cumulative dose of 3 12.5 mg/kg

GCP aspects
N/A

Orphan Medicinal Products
N/A

CLINICAL PHARMACOLOGY
Very few studies describing the pharmacokinetics and pharmacodynamics of Thymoglobuline
have been published in the literature. However, three studies with Thymoglobuline are
presented to provide an overview of the PK and PD effects characterised for Thymoglobuline.

PHARMACOKINETICS

Introduction
Pharmacokinetics of total Thymoglobuline was presented by Bunn et al. (Bunn, 1996, Clin
Nephrol) in eleven patients who had received renal transplants using an ELISA with a goat
anti-rabbit immunoglobulin. Eleven patients received 14 courses of rabbit ATG supplied
either by Fresenius (F-ATG) or Mrieux (M-ATG ie Thymoglobuline) as a daily infusion of
2-6 mg/kg body weight for a therapeutic course lasting 5-10 days. ATG was infused over 8
hours through a controlled-rate pump. In addition, patients received triple therapy
immunosuppression with cyclosporine, prednisolone and azathioprine. The dose of ATG was
adjusted according to the daily white cell count: ATG was not given if the count was less than
3.0 x 109/l and if stopped was restarted when the count was greater than 4.0 x 10
9
/l.

The study concluded the following:
Serum concentration of Thymoglobuline rises throughout the regime of daily
infusions with a clear maximum level on the final day.
Significant serum concentrations persist for at least 60 days.
Elimination half life T1/2 : 14.3 38.1 days
Estimated volume of distribution Vd: 0.07 0.13 l/kg this indicates that
Thymoglobuline remains within the plasma and extravascular fluid and does not enter
the lipophilic compartments of the body.
A second course of Thymoglobuline given to an individual patient appears to have a
slower rate of elimination than the first course.

Guttman et al. published pharmacokinetics data from 30 patients receiving renal and cardiac
transplantation in two different centres in France (Guttmann, 1997, Transplant Proc).
Elimination half life at the beginning of the administration, 0-24 hours was 44.2 hours and
after 10 days it was 13.8 days.


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PL: 12375/0021
It was recognised that these figures of elimination reflected a large variation depending on
individual patient fluctuations. Elimination of Thymoglobuline is proposed to be effected by
its binding to T cells, which consequently apoptose. The early and sharp drop in T cells
following Thymoglobuline administration explains the sharp drop in elimination and increase
in elimination half life.
There is a distinction between the measurement of total Thymoglobuline and the
concentrations of IgG with relevant anti-lymphocyte activity.

Regan et al. (Regan, 2001, Transplant Immunol) differentiate between active Thymoglobuline
(approximately 7% when measured in vitro) and total Thymoglobuline. Serum levels in renal
transplant patients undergoing acute rejection were measured. Total Thymoglobuline levels in
the serum were fairly close correlated to the number of doses (days of treatment).
Active Thymoglobuline levels revealed the same profiles as the total levels, although
the dose response was not as striking as that seen for total Thymoglobuline levels.
0.8% active Thymoglobuline was the highest value seen in serum during treatment.
By day 20 after treatment cessation, levels dropped to 0.1%, representing a drop in
90%. Thus residual total levels measured in the Regan and other studies are not
representative of activity.
By day 90, only 12% of patients had detectable active Thymoglobuline compared to
81% of patients with total Thymoglobuline. Thus, in the absence of further treatment,
active Thymoglobuline is rapidly depleted from the circulation.

About 7% of the protein content of Thymoglobuline is specific for human T cells (active
Thymoglobuline), the rest being rabbit IgG that is not directed against human epitopes
(Regan, 2001, Transplant Immunol). Initial pharmacokinetic (PK) studies looked only at the
kinetics of total Thymoglobuline. As this includes Thymoglobuline with no activity against
human cells, and no binding, the halflife is long, and not of relevance to the clinical situation
(Bunn, 1996, Clin Nephol).

Half-life
The half-life is dependent on whether total or active Thymoglobuline levels are measured.
Active Thymoglobuline, which binds to its target cells, lymphocytes, is more rapidly
eliminated. This binding (and elimination) depends on the number of available cells present.
As the non-active Thymoglobuline, the majority of the rabbit immunoglobulin, is not
bound, it stays in the circulation for a considerable time. This explains why the Bunn study
(Bunn, 1996, Clin Nephol) had an estimated half-life of elimination (of total Thymoglobuline)
of 30 days, as compared to Regan (Regan, 2001, Transplant Immunol; (in renal transplant
patients) where the elimination half-life (of active Thymoglobuline) was estimated to be one
to two weeks.

Regan further distinguished between the half-life immediately after the first administration
(44.2 hours) and the later measurements of half-life, again showing that the elimination half-
life will be a function of the numbers of lymphocytes present to which Thymoglobuline can
bind (which is related to infusion number in the case of solid organ transplantation). Total
Thymoglobuline remains detectable in 80% of patients at 2 months.

Sensitisation against Thymoglobuline
About 6% of patients have anti-rabbit antibodies prior to treatment (Regan, 2001, Transplant
Immunol; Regan, 1999, Transplant Immunol). Significant immunisation against rabbit IgG is
observed in about 40-70% of patients after treatment with Thymoglobuline. In most cases,

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immunisation develops within the first 15 days of treatment initiation. Sensitisation peak is
reached around day 30, and declines subsequently.

Patients with antibodies show a faster decline in total Thymoglobuline levels, but not in
active Thymoglobuline levels. There seems to be no relation between antibody levels and
efficacy.

Methods
In the Bunns study (Bunn, 1996, Clin Nephrol) eleven patients received 14 courses of ATG
supplied either by Fresenius (F-ATG) or Merieux (M-ATG) as a daily infusion of 2-6 mg/kg
body weight for a therapeutic course lasting 5-10 days.

Pharmacokinetic data analysis
Pharmacokinetics of total Thymoglobuline was presented by Bunn et al. (Bunn, 1996, Clin
Nephrol) in patients who had received renal transplants using an Enzyme-Linked
Immunosorbent Assay (ELISA) with a goat anti-rabbit immunoglobulin.

Statistical analysis
Bunn presented the half-life of ATG per ATG and patient. Data for the first four days of
treatment were analysed with linear regression to obtain mean value for the apparent volume
of distribution of ATG. The results of the study were compared with results obtained from
literature. In Reagans study multiple regression was used to examine the influence of dose
number and sensitization on both total and active Thymoglobuline levels.

Absorption
Since this product is administered intravenously, this is not applicable.

Bioavailability
Thymoglobuline is administered intravenously, and as per Applicant 100% bioavailability can
be assumed. Therefore no bioavailability studies have been performed. This is acceptable.

Distribution
Bunn estimated the volume of distribution to be around twice the plasma volume (Bunn,
1996, Clin Nephol).

Elimination
The Bunn study (Bunn, 1996, Clin Nephol) had an estimated half-life of elimination (of total
Thymoglobuline) of 30 days, as compared to Regan (Regan, 2001, Transplant Immunol; (in
renal transplant patients) where the elimination half-life (of active Thymoglobuline) was
estimated to be one to two weeks.

Children
The pharmacokinetics results in paediatric patients are not presented. However, a study on
long-term effects has identified that the age of the patient may affect CD4+ T cell
regeneration with adult patients exhibiting a persistent CD4+lymphopenia and paediatric
patients exhibiting normal reconstitution of the CD4+T cell population.
Conclusions on pharmacokinetics
Comprehensive data on Pharmacokinetics are presented by the Applicant. It is concluded that
the pharmacokinetic publications presented are adequate.

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PHARMACODYNAMICS

Introduction
Thymoglobuline is a pasteurised preparation of rabbit IgG from animals that have been
immunised with human thymocytes. Different techniques with different limitations have been
used to investigate the antibody specificities (Bonnefoy-Bernard, 1991, Transplantation). The
antibody specificities which have been characterised recognise key molecules involved in the
regulation of the immune system:
CD3 and the T cell receptor (TCR)
Co-receptors CD4 and CD8
Co-activation or adhesion molecules and their ligands, such as CD2, CD45, and CD28
(expressed on T lymphocytes); CD80 (B7-1) or CD86 (B7-2) (expressed on antigen
presenting cells); CD11a/CD18 (LFA-1) (expressed on all leukocytes); CD54 (ICAM-
1) (expressed on many cell types, notably leukocytes and endothelial cells).
Lymphocyte antigens, such as CD5, CD6 and CD7, the functions and importance of
which are poorly understood

Mechanism of action

Treatment of Solid Organ Transplant
The mechanism of action of Thymoglobuline in the treatment of solid organ transplants is not
fully understood. ATGs direct against human T-cells, cause human lymphocyte depletion
either by complement-dependent lysis, or by opsonisation and subsequent destruction via
reticulo-endothelial system. This anti-lymphocyte effect interrupts both the cell-mediated and
humoral components of the immune response cascade.

The Applicant presents a number of key effects that have been characterised and described in
the literature. Immediate, pronounced and prolonged T cell depletion, both in the peripheral
blood, but also of lymph nodes and spleen, demonstrated in both Cynomolgus monkeys and
in man (Camitta, 1976, Blood; Young, 1995, Lancet) is long-lasting, and some T cell subsets
are still below normal levels one year after treatment (Mueller, 2003, Front Biosci; Camitta,
1976, Blood). One study, where patients were pre-treated with Thymoglobuline several days
before receiving their transplant, showed similar T cell depletion of biopsies from lymph
nodes (Starzl, 2003, Lancet). Fiorinas study demonstrated apoptotic cells in renal biopsies
following Thymoglobuline induction treatment (Fiorina, 2004, Transplant Int). Initial brief
activation of T lymphocytes causing cytokine release, and, in vitro, proliferation of T cells has
also been demonstrated (Remberger, 1999, Bone Marrow Transplant; Bonnefoy- Bernard,
1992, Cell Immunol; Guttmann 1997, Transplant Proc).

The cell surface antigens against which Thymoglobuline has activity can be grouped into the
following categories:
Adhesion molecules, both on lymphocytes and endothelium, e.g. CD11a (LFA-1), or
CD50 (ICAM-3) required for migration of activated lymphocytes to the graft
Co-stimulatory molecules, e.g. CD28; CD152, required for initiation of the immune
response
T cell receptor (TCR) or CD3
Dendritic cell markers, e.g. CD1a, CD11a, CD86, CD32
Epitopes which have as yet unknown functions


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Brophy et al. report on the effect of Thymoglobuline on T cell populations using flow
cytometry (Brophy, 2001, Pediatr Transplantation) in patients receiving prophylaxis for renal
transplantation. Thymoglobuline effects a drop in CD3+, CD4+and CD8+T cells upon and
throughout administration- see next figure. The effect and degree is similar to that seen in
adults (Guttmann, 1997, Transplant Proc).

Figure 1: T Cell Distribution in Paediatric Patients Receiving Thymoglobuline Following Transplantation

In paediatric patients, a similar effect is seen, whereby Thymoglobuline administration effects
a rapid depletion in CD2, CD3, CD4 and CD8 positive cells (Piaggio, 1998, Eur J Haematol).
This drop is sustained for 2-3 weeks after completion.

Relationship between plasma concentration and effect
Following the first infusion of 1.25 mg/kg of Thymoglobuline (in kidney-transplant
recipients), serum total Thymoglobuline levels of between 10 and 40 Yg/mL were obtained.
The trough rabbit IgG levels increased progressively reaching 60 to 170 Yg/mL at the end of
an 11-day course treatment. An increase in total Thymoglobuline levels with increasing dose
was observed. In contrast, active Thymoglobuline levels did not show a dose response, with
peak levels around 0.8Yg/ml (Regan, 2001, Transplant Immunol). A gradual decline was
subsequently observed following discontinuation of the Thymoglobuline treatment.
Conclusions on pharmacodynamics
The applicant has discussed pharmacodynamics adequately.


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CLINICAL EFFICACY

Introduction
The studies presented in the dossier originate from a review of clinical studies reported in the
literature.

Dose-response studies and main clinical studies

Dose response studies
Prophylaxis of Rejection in Renal Transplantation (PRRT)
As per applicant there has been a trend with time for lower doses of Thymoglobuline to be
used by clinicians. There might be two main factors the introduction of newer, more potent
maintenance immunosuppressive agents to the market requiring a lesser amount of induction
immunosuppression, and a better appreciation of longer term safety problems caused by the
global immunosuppressive load, as patients have survived longer.

The average prescribed mean daily dose in all these studies was 1.5 mg/kg, given for a mean
of 9.3 days, with a maximum cumulative dose ranging from 7.6 16.1 mg/kg. The
recommended dose range, based on the analysis here, is 1-1.5 mg/kg/day, for a duration of 3
to 9 days (which gives a cumulative dose of 3 13.5 mg/kg). The choice of total dose depends
on the risk the individual patient has of rejection, as well as the type and dose of concomitant
immunosuppression given.

The maximum cumulative dose of 13.5 mg/kg and the daily dose of 1-1.5 mg/kg/day are
supported by the data provided.

Treatment of Rejection in Renal Transplantation (TRRT)
The dose recommendation for Thymoglobuline when used in the treatment of acute renal
rejection was mainly derived from the US study carried out by Gaber (Gaber, 1998,
Transplantation), which studied biopsy proven acute rejection (i.e. not the more severe
steroid resistant acute rejections), and compared Thymoglobuline to Atgam. In this trial
(Gaber, 1998, Transplantation) the mean Thymoglobuline dose given to patients was 1.4
mg/kg/day, over a mean of 10 days (range 3-14 days). Nine patients (11%) were treated for
less than 7 days, in 4 cases because of successful reversal of rejection, in two cases because of
graft loss, in another two because no response was seen and rescue therapy was required, and
in one patient because of both response and adverse event requiring early discontinuation of
therapy.

The same dose was employed in the Alamartine study in fewer patients (32) than the Gaber
study (82). In this study (Alamartine, 1994, Transplant Proc) the prescribed duration of the
dose was 10 days, equivalent to the mean duration of dose in the Gaber study.

As the severity of renal rejection is usually determined by biopsy, and the length of the course
by response to treatment (which is usually rapid, sometimes within 48-72 hours); a range of
between 7 14 days is recommended, at a dose of 1.5 mg/kg.

The daily dose of 1-1.5 mg/kg/day seems appropriate.


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Prophylaxis of Rejection in Heart Transplantation (PRHT)
In the three controlled studies presented, the dose of Thymoglobuline was 2.5 mg/kg/day for
5 days (Zuckermann, 2000, Transplantation; De Santo, 2004, Transplant Proc; Schnetzler,
2002, Transplant Int) making a cumulative dose of 12.5 mg/kg.

Schnetzler et al. additionally monitored total lymphocyte count (TLC) in patients, but it was
not necessary to increase the Thymoglobuline dose in this study as the TLC did not exceed
300/ mm
3
. A dose of 2 mg/kg/day Thymoglobuline was administered over three days by
Azizs group (Aziz, 2001, J Heart Lung Transplant), or at 1.5 mg/kg/day over 5-7 days
(Cantarovich, 2004, Transplantation). Individual tailoring of the dose, either in terms of
amount or frequency, is possible. Such tailoring may be on the basis of, for example, the
results of blood cell counts, e.g. T cells (Koch, 2005, J Heart Lung Transplant) or the need to
delay calcineurin inhibitors because of renal dysfunction.

The symptoms of cytokine release syndrome increase with increasing dose of
Thymoglobuline, so it would be safer to divide the cumulative dose given in these studies
(12.5 mg/kg) into smaller daily doses, leading to a dose recommendation of: 1 2.5 mg/kg
over 3 to 5 days, giving a cumulative dose of 3 12.5 mg/kg.

The maximum cumulative dose of 12.5 mg/kg and the daily dose of 1-2.5 mg/kg/day are
supported by the data provided.

MAIN STUDIES

Prophylaxis of Rejection in Renal Transplantation (PRRT)
A total of seven randomised controlled studies for Prophylaxis of Rejection in Renal
Transplantation (PRRT) are presented, three of which compare Thymoglobuline plus triple
therapy to triple therapy alone (placebo-controlled), with the remaining four comparing
Thymoglobuline to other antibodies (ATG-Fresenius, Atgam, basiliximab and OKT3), all
with triple therapy.

Key studies in support of the indication are Mourad, 2001, Transplantation; and Charpentier,
2003, Transplantation; (both placebo controlled trials) and Hardinger, 2004, Transplantation;
Lebranchu, 2002, Am J Transplantation; and Mourad, 2004, Transplantation; (all comparator
controlled trials). Controlled studies in sensitised patients are provided with Fukuuchi, 1996,
Transplant Proc and Thibaudin, 1998, Nephrol Dial Transplant). Several uncontrolled
clinical studies are presented to provide a balanced review of the literature encompassing
different protocols, due to the evolving nature of this field (CHMP/EWP/83561/2005), and
importantly, studies in paediatric patients (Ault 2002, Pediatr Nephrol; Khwaja, 2003,
Pediatr Transplantation; Khositseth, 2005, Transplantation).

Randomised prospective studies comparing to triple therapy alone
The study of Mourad et al (Mourad, 2001, Transplantation) was carried out in 15 French and
Belgium centres with 309 patients randomised to receive either induction with
Thymoglobuline (n=151) followed by initiation of tacrolimus on day 9, or immediate
tacrolimus-based triple therapy (n=158). Results at 12 months showed less biopsy proven
acute rejection in induction group patients; 15.2% versus 30.4% (p=0.001). The mean
prescribed dose was 1.25 kg/mg/day for 10 days; the mean cumulative dose received was
10.25 mg/kg/patient. Patient and graft survival at 12 months were not significantly different
in the two groups, being 97.4% versus 95.8% and 92.1% versus 91.1%, respectively.

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Table 1: Histological grade of biopsy-proven acute rejection (Mourad, 2001)

Statistically significant differences between the treatment groups (induction vs. noninduction)
were observed for CMV infection (32.5% vs. 19.0%, P=0.009), leukopenia (37.7% vs.
9.5%, P=0.001), fever (25.2% vs. 10.1%, P=0.001), herpes simplex (17.9% vs. 5.7%,
P=0.001), and thrombocytopenia (11.3% vs. 3.2%, P=0.007).

Conclusion of the authors was that low incidences of acute rejection were found in both
treatment arms. Induction treatment with ATG has the advantage of a lower incidence of
acute rejection, but it significantly increases adverse events, particularly CMV infection.

The study reported by Charpentier et al., included three arms, the first comprising
Thymoglobuline induction with a ciclosporin-based triple therapy (n=190), the second
comprising Thymoglobuline induction with a tacrolimus-based triple therapy (n=190), with a
control arm comprising patients receiving a tacrolimus-based triple therapy alone (n=188).
Acute rejection rates after six months were significantly better in the
Thymoglobuline/tacrolimus arm than the other two arms (p=0.004 when compared to the
Thymoglobuline/ciclosporin arm, p=0.003 when compared to the triple therapy alone arm).
No significant difference in graft survival was found between the arms after six months.

In the ATG groups, the incidences of leukopenia, thrombocytopenia, serum sickness, fever,
and cytomegalovirus infection were significantly higher (P<0.05).

Table 2: Frequency of acute rejection (Charpentier et al, 2003)


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Table 3: Reasons for graft loss (Charpentier et al, 2003)

Table 4: Incidence of adverse events for which there were significant differences between groups
(Charpentier et al, 2003)

The authors conclude that acute rejection was significantly lower in the ATG-Tac group
compared with the ATG-CsA and Tac triple groups. Significantly more hematologic and
infectious adverse events were observed in both ATG induction groups.

Randomised prospective studies comparing to another antibody (polyclonal or
monoclonal)
Thymoglobuline was compared with Atgam in the Hardinger study (Hardinger, 2004,
Transplantation) in transplants conducted more recently during the period of 1996 to 1997.
The rate of rejection seen in the Thymoglobuline arm was significantly lower than the Atgam
arm, 8% compared with 34% after 5 years (p<0.01) and the number of steroid resistant
rejections was lower in the Thymoglobuline group. Graft survival at 5 years was significantly
higher in the Thymoglobuline arm (73%) than the Atgam arm (54%), p=0.046.


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Table 5: Five-year outcomes (Hardinger, 2004)

More recently, monoclonal antibodies have been developed to prevent rejection in solid organ
transplant, namely basiliximab and dacluzimab, which block the interleukin-2 receptor chain
on the surface of activate T lymphocytes. Older studies have compared Thymoglobuline to
OKT3, which binds to the T cell receptor.

Two studies are presented which compare Thymoglobuline with basiliximab, both using
ciclosporin as the calcineurin inhibition component of the triple therapy. Unsurprisingly, due
to the different mechanisms of action of the two drugs, Thymoglobuline caused a noticeably
greater degree of leucopenia. With regards to study endpoints, no significant differences in
acute rejection rates or graft survival were reported (Lebranchu, 2002, Am J Transplantation;
Mourad, 2004, Transplantation). In the Lebranchu study graft survival after 6 months was
100% and 94% in the Thymoglobuline and basiliximab arms of the study, respectively.

Table 6: Efficacy at month 12 (Mourad, 2004)


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Table 7: Safety parameters (Mourad, 2004)

Conclusions of the Mourad study were that both ATG and basiliximab, when used for IT in a
sequential protocol, are equally effective in terms of graft and patient survival as well as at
preventing acute rejection. However, basiliximab is associated with a lower incidence of
certain key adverse events, namely CMV infection, leukopenia, and thrombocytopenia.

It is noted that the administration of ciclosporin was not comparable between the two
treatment groups, which may account for differences in acute rejection, although these were
not significant. This was rectified in the protocol executed by Mourad et al. (Mourad, 2004,
Transplantation) whereby ciclosporin was not administered immediately to patients, but was
delayed in both arms of the trial until after serum creatinine levels in patients had dropped
below 200Ymol/L. Graft survival after one year for the Thymoglobuline arm was 96%
compared to 94% in the basiliximab arm of the study.

In the Norrby trial, transplants were conducted in an earlier period, whereby 48 patients
receiving Thymoglobuline were compared to 45 patients given ATG-Fresenius (Norrby,
1997, Transplant Proc). The mean prescribed dose of Thymoglobuline was 2.5 mg/kg/day
over 4-7 days; the mean cumulative dose was 14.49 mg/kg. However, in the Norrby trial the
rate of rejection was 67% and 58% (not significant) in Thymoglobuline and ATG Fresenius
groups respectively, a figure much higher than in the other studies. These major differences in
the rate of rejection were probably due to differences in the population inclusion criteria i.e.
patients had a high risk of delayed graft function in the Norrby trial. Additionally patients
were treated between 1989 and 1995, when rejection rates generally were higher than current
rates.

Two studies in sensitised patients (patients at higher risk of acute rejection because of
immunological sensitisation to alloantigens) have been published. Fukuuchi et al. published
the results of a study comparing Thymoglobuline with OKT3 in the treatment of highly
sensitised renal transplant recipients (Fukuuchi, 1996, Transplant Proc). In this study
Thymoglobuline delayed the onset time of first rejection, but graft and patient survival rates
between the two arms of the study were not significantly different. The authors noted that
Thymoglobuline seems to have a more beneficial effect in older patients than OKT3, as five
of the six patients who died in the OKT3 arm were over 50 years of age, despite the OKT3
population having a lower number of patients in this age range.

An older study in which patients received transplants from 1991 to 1995 was reported by
Thibaudin et al. Forty-seven (47) sensitised patients receiving Thymoglobuline induction
therapy with triple therapy were compared with 42 patients receiving triple therapy alone
(Thibaudin, 1998, Nephrol Dial Transplant). Although rejection rates in this study were
higher than those seen in the later studies, both because of the fact that patients were
sensitised, and because of the era in which the study was performed, Thymoglobuline

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administration yielded a significant reduction in the rate of acute rejection at 3 months (53%
Thymoglobuline compared to 71% without Thymoglobuline, p=0.008).

Table 8: Frequency of biopsy-proven acute rejection episodes in patients grouped on the basis of the
lowest PRA (Thibaudin, 1998)

Conclusion:
Thymoglobuline induction was beneficial in terms of preventing acute rejection, but it
significantly increases adverse events, particularly CMV infection.

Rejection is the main cause of graft failure, and if injury is sufficiently severe, the renal
function may not recover. It is therefore important to diagnose and treat rejection episodes as
soon as possible. Clinical features of acute rejection can be minimal, and may include features
such as moderate fever, increasing serum creatinine levels, and more rarely, decrease in urine
output and graft tenderness. Percutaneous biopsy of the transplanted kidney is therefore
routinely carried out to diagnose rejection, and to distinguish rejection from other causes of
allograft dysfunction. In many centres, episodes of acute rejection are treated with a short
term "pulses" of high dose methylprednisolone. When the rejection episode is sensitive to
high dose of corticosteroids, renal function improves within 48-96 hours. However, if there is
no early regression of the event because rejection is resistant to corticosteroids, other options
must be sought. The histological features may also influence the waiting period, for example
because vascular rejection has a poorer prognosis many centres will consider the early use of
anti-thymocyte antibodies in such cases. NICE has recently issued guidance (26 April 2006)
on the use of immunosuppressive therapy for renal transplantation in children and
adolescents. They comment If acute rejection does not resolve after treatment with
corticosteroids, it is defined as corticosteroid-resistant acute rejection. Corticosteroid-
resistant acute rejection may be treated with the polyclonal antibodies ALG or ATG or the
monoclonal antibody muromonab-CD3, or by switching the calcineurin inhibitor to high-dose
tacrolimus.

The proposed SmPC indication with the following dosage guide:1.5 mg/kg/day for 7 to 14
days, corresponding to a cumulative dose of 10.5 21 mg/kg

Four studies are presented to support the claim for treatment of rejection in renal
transplantation. All four studies were comparator trials. All the patients in three of the four
studies were diagnosed with steroid-resistant rejection; most of the patients in the Gaber study
(Gaber, 1998, Transplantation) also had steroid-resistant rejections (72 of 82 patients).
Otherwise, the patient population was predominantly male (where defined in the literature)
with a mean age between 39 and 51 years.

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monoclonal)
Gaber (Gaber, 1998, Transplantation) published the results of a company sponsored study
that was used for the registration of Thymoglobuline in the US and Canada. This study
compared the efficacy of two polyclonal antibodies (Atgam and Thymoglobuline) in a
randomised, prospective, comparative, multicentre trial conducted in the US, which included
163 renal transplant patients with steroid resistant or histologically severe rejections
(Gaber,1998, Transplantation; Woodle, 1999, Graft; Gaber,1999, Kidney International),
randomised to receive Thymoglobuline (1.5 mg/kg/day) or Atgam (15 mg/kg/day; the
manufacturers recommended dose) for 7 to 14 days and were followed-up for 12 months
post-therapy. Concurrent immunosuppression included steroids, azathioprine and ciclosporin.
Inclusion criteria were age 18 years, recipients of a first or second renal transplant and
biopsy proven rejection of Banff grade I-III (patients with Banff grade I were required to have
exhibited corticosteroid resistance, defined as an increase of 10% in serum creatinine level
despite 3 or more consecutive days treatment with intravenous methylprednisolone of at least
250 mg/day). The primary end point was return of the serum creatinine to, or below, baseline
on 2 consecutive measurements. The secondary end points were graft survival and serum
creatinine at day 30, and improvement in biopsy grade. The results showed that
Thymoglobuline was statistically significantly superior to Atgam for the primary end point; in
the Thymoglobuline group 88% of patients successfully responded to treatment compared
with 76% of Atgam treated patients (p=0.027).

Thymoglobuline and Atgam gave equivalent results for all secondary end-points. Allograft
survival rate at 30 days were 94% and 90% for Thymoglobuline and Atgam groups
respectively. Median serum creatinine levels at 30 days were 177 and 168 Ymol/L in the
Thymoglobuline and Atgam treatment groups respectively; recurrent rejection was
significantly less frequent 90 days after the end of treatment in the Thymoglobuline group;
17% versus 36% (p=0.001) respectively; and 8% versus 20% (p=0.039) for biopsy proven
rejection. Twelve months after completion of therapy there was no statistically significant
difference between two groups in terms of overall allograft survival, but there was a tendency
in favour of Thymoglobuline (83% versus 75%). In this trial the dose of Thymoglobuline
used for treatment of rejection as stated in the protocol was 1.5 mg/kg/day for 7 to 14 days;
thus with an imposed minimum duration of treatment of seven days. However, the number of
days of treatment actually received was less than that stated in the protocol being between 3-
14 days, 69.5% of patients receiving 10 infusions, and in 34% of patients the daily dose of
Thymoglobuline was reduced.

T-cell subset counts (CD2, CD3, CD4, CD8) were performed in a subgroup of 26 patients
(n=12 Thymoglobuline, n=14 Atgam). In Thymoglobuline patients a significantly greater
degree of T-depletion, as well as more prolonged depletion of T cells occurred, in comparison
with the Atgam group. In patients given Thymoglobuline, from day 6 until day 14, T cell
subset counts were as follows: CD2 cells <9 10 /ml; CD3 cells <23 36 /ml; CD4 cells<5
7 /ml and CD8 cells <7 6 /ml.

Similar results were reported by Alamartine in a prospective, randomised study of 59 renal
transplant recipients experiencing a first steroid-resistant acute rejection episode (Alamartine,
1994, Transplant Proc) showed similar efficacy. The doses used were 1.5 mg/kg/day of
Thymoglobuline or 5mg/kg/day of OKT3 for 10 days. The graft and patient survival were
similar in the two groups after one and two years of follow up. This study used

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Thymoglobuline that was manufactured prior to the introduction of the pasteurisation step for
viral clearance.

In a prospective, randomised study of 60 renal transplant recipients having a first steroid-
resistant acute rejection episode (Mariat, 1998, Transplant Int), the doses used in this study
comparing Thymoglobuline and OKT3 were approximately half of that recommended by the
manufacturers at 0.75 mg/kg/day and 0.05 mg/kg/day for Thymoglobuline and OKT3
respectively, both given for ten days. Successful reversion of rejection was similar in the two
groups. Three months after therapy, one allograft (3%) was lost in the Thymoglobuline group
and three (10%) in the OKT3 group. At 12 months actuarial allograft survival was 89% and
81% for the Thymoglobuline and OKT3 groups respectively. At the end of the three year
follow-up 87.5% and 79.3% of allografts were still functioning in the Thymoglobuline and
OKT3 groups respectively. Three patients died in the Thymoglobuline group and one in the
OKT3 group. The authors conclude that low doses of Thymoglobuline and low doses of
OKT3 are equally effective in reversing steroid resistant acute rejection. Tolerance was better
with Thymoglobuline, which also gave a potent and long-lasting immunodepression. The use
of reduced doses of Thymoglobuline and OKT3 did not appear to lessen their efficacy.

The most recent study is reported by Midtvedt (Midtvedt, 2003, Clin Transplant) where
patients were treated and followed up in the period of 1996 to 1999. As with the Mariat and
Alamartine studies, Thymoglobuline was compared with OKT3, but doses were administered
on the basis of daily T cell counts CD2+cells by an immunomagnetic method). An initial
dose of 2 mg/kg of Thymoglobuline was administered on day 1 and re-administered daily at 1
mg/kg only if and when the T cell count increased above 50 cells/ mm
3
. A mean of 2.3
administrations of Thymoglobuline was given i.e. 3.3mg/kg total dose. Five mg OKT3 was
administered on day 1, with a daily administration thereafter only if the T cell count increased
to more than 50 cells/ mm
3
.

Serum creatinine levels were comparable in the two groups at the control timepoints. After
treatment, serum creatinine levels in the Thymoglobuline group dropped from 308 125
Ymol/l to 254 122 Ymol/l, reaching 169 45 Ymol/l after 3 months. Similarly, levels in the
OKT3 group were 330 94 Ymol/l prior to treatment and dropped to 193 106 Ymol/l after
3 months. Re-rejection in this study (44% of Thymoglobuline patients and 50% of OKT3
patients) was higher than in the other studies, due to the patients being sensitized.

During the first three months following anti-lymphocyte antibody treatment, a total of 25
patients developed CMV infection (11 in the OKT3 group and 14 in the ATG group, p NS)

Table 9: Serum creatinine values
a


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Conclusion:
On the basis of the four studies presented, Thymoglobuline acts as an immunosuppression
therapy, producing a greater and more long-lasting drop in T cell count than OKT3. In terms
of efficacy, particularly the endpoints of serum creatinine levels and graft loss,
Thymoglobuline is considered comparable to OKT3 and superior to Atgam.

Prophylaxis of Rejection in Heart Transplantation (PRHT)
Induction prophylaxis by antibodies has been widely used in heart transplantation for more
than twenty years, initially with polyclonal antibodies, then with a switch to monoclonal
antibodies (OKT3), and for the last ten years with a return to the use of polyclonal antibodies
such as Thymoglobuline, following the report of Swinnen demonstrating the increased risk of
post-transplantation lymphoproliferative disorder (PTLD) with the use of OKT3 (Swinnen,
1990, N Engl J Med). Following the registration of new drugs including tacrolimus,
mycophenolate mofetil and microemulsion ciclosporin, Thymoglobuline still continued to be
widely used as induction immunosuppression.

In heart transplantation induction, doses of Thymoglobuline are usually higher than in renal
transplantation, but the courses are usually of a shorter duration (2 to 5 days in the SmPC in
countries where approved). Calcineurin inhibitors (being potentially nephrotoxic) are usually
introduced on the second or third post-operative day, when haemodynamic stability is attained
and the renal function returns to a satisfactory level.

The applicant proposed for this indication the following dosage: 1 2.5 mg/kg/day for 3 to 5
days giving a cumulative dose of 3 12.5mg/kg

There are fewer publications in the field of cardiac transplantation than in renal
transplantation. There are a number of difficulties in carrying out studies in the field of
cardiac transplantation, which include the small numbers of potential patients, the low event
rates leading to the need for unachievable patient numbers in order to have sufficiently
powered studies, and the lack of an appropriate endpoint (Hosenpud, 2005, N Engl J Med). In
general, in publications in cardiac transplantation, courses of Thymoglobuline tend to be
shorter than those in renal transplantation, being about 3-5 days long. Probably as a result of
the shorter course of therapy, less efficacy monitoring seems to be carried out by cardiac
transplantation units compared to renal transplantation units, as monitoring of T lymphocyte
subsets has no value until 48 72 hours after the first dose of Thymoglobuline.

Nine studies are presented. Key studies in support of the indication are the three comparator
controlled studies (placebo-controlled studies were not identified) (De Santo, 2004,
Transplant Pro; Schnetzler 2002, Transplant Int; Zuckermann, 2000, Transplantation). The
Zuckermann study was a retrospective study. These studies are supported by other
retrospective studies, which either have a historical control (Cantarovich, 2004,
Transplantation; Koch, 2005, J Heart Lung Transplant) or were uncontrolled. The
uncontrolled studies are included as a review of different immunosuppression protocols or
patient subpopulations, principally paediatric.

monoclonal)
Two prospective randomised trials (De Santo, 2004, Transplant Proc); Schnetzler, 2002,
Transplant Int) were performed which compared Thymoglobuline to ATG-Fresenius, another
rATG.

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These two studies demonstrated that Thymoglobuline remains efficacious in the recent heart
transplantation setting, and remains comparable (no statistically significant difference) to
ATG-Fresenius in the prophylaxis of rejection in heart transplantation.

In the De Santos study patients (n=40) received thymoglobulin at a daily dose of 2.5 mg/kg
for the first five postoperative days, while group B ATG-fresenius, at 2.5 mg/kg/d for seven
days. Conclusions of De Santo were that although thymoglobulin and ATG-fresenius showed
equivalent efficacy for rejection prevention, they have different immunological properties. In
particular, thymoglobulin seems to be associated with a significantly higher incidence of
cytomegalovirus disease/reactivation.

Patient survival in the Schnetzler study after one year was 85% (22/26) in the
Thymoglobuline arm and 88% (21/24) in the ATG-Fresenius arm, improving in the later De
Santo study to 95% in both arms (19/20 for both arms).

Randomised prospective studies no comparator
A controlled clinical study has been performed to compare ciclosporin and tacrolimus as part
of the triple therapy used in conjunction with Thymoglobuline (Wang, 2004, Transplant
Proc). This study involved 21 patients only, randomized into the two arms. All patients
received Thymoglobuline induction therapy (2.5 mg/kg on the first day post-operative and 1.5
mg/kg/day for a further four days) and follow-up was performed after six months. At this
time, patient survival was 100% in both groups, but differences were seen in the number of
acute rejections, with more rejections seen in the ciclosporin group, 40% at 60% at three and
six months, respectively, than in the tacrolimus group, 9% at both timepoints (p=0.15 and
p=0.14 at three and six months respectively).

Aziz et al. studied 220 patients who received Thymoglobuline in induction at a mean dose of
2 mg/kg/day, over three days, giving a mean cumulative dose of 6 mg/kg/patients (Aziz,
2001, J Heart Lung Transplant). Concomitant treatment was triple therapy by ciclosporin,
azathioprine and steroids. The median follow up was 87 months (over seven years), and the
aim of the study was to compare the outcomes of patients whose primary pathology was
ischaemic heart disease, with those with cardiomyopathy. The rate of rejection in the first six
months was not statistically significantly different in the two groups, 1.7 and 1.4 episodes of
rejection/patient occurring in each group respectively. Between month 6 and month 12 an
additional 0.64 and 0.46 acute rejections/patient occurred, and 0.42 and 0.38 acute
rejection/patient, between 12 and 24 months respectively in each group. Actuarial survival at
1, 5, and 10 years was 77%, 62%, and 39% for ischaemic heart disease patients compared
with 85%, 82%, and 80% for patients with cardiomyopathy.

It was concluded that after heart transplantation, medium- and long-term outcome is
significantly better for cardiomyopathy than for Ischemic heart disease recipients.

Retrospective studies comparator another antibody (polyclonal or monoclonal)
In the earliest publication (Zuckermann, 2000, Transplantation), a retrospective analysis
covering 1984 to 1996, Thymoglobuline was used at a mean dose of 2.5 mg/kg/day over
seven days, giving a theoretical cumulative dose of 17.5 mg/kg/course. The aim was to
compare Thymoglobuline (n=342) to ATG Fresenius (n=142). The freedom from rejection at
five years was significantly better in the Thymoglobuline group at 72% vs. 42% in the ATG
Fresenius group (p<0.01). One and five year survival was also significantly better in
Thymoglobuline group (87% vs. 78% and 76% vs. 60% respectively). Viral infections

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PL: 12375/0021
occurred more often in Thymoglobuline patients (53% vs 39%). Patients in the
Thymoglobuline group were older, with more HLA mismatches and received hearts which
had suffered longer cold ischaemia times, but were treated more recently than the ATG-
Fresenius patients.

It should be recognised that the Zuckermann results are limited by two factors, firstly the age
of the study, in a field where patient survival rates have noticeably improved, and secondly
the differences in study population between the two arms.

Conclusion:
The limitation of the review is the number of the published clinical trials with
Thymoglobuline in the prophylaxis of rejection in heart transplantation. It is acknowledged
that there are a number of difficulties in carrying out studies in the field of cardiac
transplantation. However, presented publications support the proposed indication.

CLINICAL STUDIES IN SPECIAL POPULATIONS

Sensitised allograft recipients
Two prospective studies have been carried out in immunologically sensitised patients (defined
as patients who have a high panel reactive antibody (PRA) or who are receiving a second or
higher transplant (Fukuuchi, 1996, Transplant Proc). In these patients the risk of acute
rejection is consistently higher and the benefit of induction by ATGs is well recognised. The
first study (Thibaudin, 1998, Nephrol Dial Transplant) compared outcomes with or without
Thymoglobuline induction in a total of 89 patients (47 received Thymoglobuline). The mean
prescribed dose of Thymoglobuline was 1.25 mg/kg/day over ten days, the mean dose
received was 0.79 mg/kg/day and so the mean cumulative dose received was 7.9 mg/kg (as a
result of adaptation of the initial dose following lymphocyte subset monitoring). The
incidence of acute rejection was less in Thymoglobuline group; 53% versus 71% (p=0.008),
for biopsy proven acute rejection the improvement in the Thymoglobuline group remained
statistically significant (38% vs. 64%; p =0.02). Graft survival at six and twelve months was
not significantly different in the two groups, 81% and 76%, 94% and 89% in control and
Thymoglobuline groups respectively. The authors concluded that Thymoglobuline induction
was beneficial for all sensitised patients regardless of their level of sensitisation, with regard
to acute rejection episodes, graft survival and graft function.

In the study of Fukuuchi et al. (Fukuuchi, 1996, Transplant Proc) 82 high risk patients
(sensitised, retransplant or both) were randomised to receive either OKT3 (n=45) or
Thymoglobuline (n=37). The prescribed Thymoglobuline dose was 75 mg/day over ten days,
the cumulative dose was 750 mg/patient (average cumulative dose was 10.7 mg/kg - for a
presumed mean patient weight of 70 kg). The mean time to first acute rejection was delayed
in the Thymoglobuline group, being 96 days vs. 21 days in the OKT3 group (p=0.002). No
significant difference in the incidence of rejection, or graft and patient survival was
demonstrated.

A retrospective study comparing Thymoglobuline with basiliximab in sensitised patients
(high responders) concluded that Thymoglobuline was the more effective treatment, although
limited by the small population size (Knight, 2004, Transplantation).


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Paediatric population
The immune response is very dependent upon age and the stage of maturation or involution of
the thymus. It is usually considered that the immune response will be strong in a paediatric
population and thus stronger immunosuppressive therapy is required (Bell, 1997,
Transplant Proc) - indeed immunosuppression is often given over a longer duration.

Prevention of Renal Transplant Rejection
Three studies in paediatric patients are presented in support of Thymoglobuline
administration in the prevention of renal transplant rejection. The only controlled study is
retrospective (Khositseth, 2005, Transplantation) based on the review of medical records at
the University of Minnesota. Patients (n=220) were categorised according to the
administration of Thymoglobuline (1.5 mg/kg/day over ten days) or Atgam (5 mg/kg/day
over 14 days). Authors concluded that Thymoglobuline induction was associated with a
decreased incidence of acute rejection and an increased incidence of EBV infection in
paediatric kidney transplant recipients. EBV monitoring should be performed in EBV-nave
recipients receiving Thymoglobuline.

A review of the demographics reveals that the patient populations did not differ significantly
other than the type of triple therapy (azathioprine vs. mycophenolate mofetil). As with the
adult study (Hardinger, 2004, Transplantation), the rate of acute rejection was lower in the
paediatric patients receiving Thymoglobuline (33% after three years compared with 50%,
p=0.02), but with higher incidences of EBV infection (8% vs. 3%, p=0.002). CMV infection
was comparable in the two arms, all patients having received viral prophylaxis (ganciclovir
5mg/kg ever 12 hours i.v. for 10 -14 days, followed by oral acyclovir 20 mg/kg/dose four
times a day for 12 weeks.

The remaining two studies (Ault, 2002, Pediatr Nephrol; Khwaja, 2003, Pediatr
Transplantation) are uncontrolled and retrospective, with small denominators, but there are
few reported studies on the use of Thymoglobuline in paediatric patients. Ault et al. presented
data from a prospective study in 17 paediatric patients, with ages ranging from 2 to 17 years
(Ault, 2002, Pediatr Nephrol).

Eleven of the patients were Caucasian and six were African-American. Thymoglobuline was
administered at 1.5 mg/kg/day intraoperatively and daily over the following 4-6 post-
operative days, which is comparable to the adult dosages used and the proposed SmPC.
According to the European Renal Association, the patient survival after one year is 98.3%
(97.0 99.1%) and 98.6% (98.0 99.2%), (ERA-EDTA Registry 2003 Annual Report - p67,
p71) for the cadaver donor and living donor first transplant patients, respectively, of the 1997-
2001 cohort. The attained patient survival of 100% is comparable to the database results,
bearing in mind the small number of patients.

A retrospective study in 46 infants is reported by Khwaja et al. (patients under one year of
age). In this study, patients received Thymoglobuline as induction therapy at a dose of 1.5
mg/kg/day for ten days, beginning post-operatively on day 1. Standard triple therapy was
additionally administered, with the exception of 13 patients who were treated in the pre-
ciclosporin era, who thus received azathioprine and steroids only. After introduction of
ciclosporin, patient survival was 100% (Khwaja, 2003, Pediatr Transplantation).

The ERA-EDTA does not report on incidence of rejection events. In the North American
Pediatric Renal Transplant Cooperative Study (NAPRTCS) (Seikaly, 2001, Pediatr

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Transplant), the authors report that the results of acute graft rejection with Thymoglobuline
(0% at six months and twelve months) are superior to results reported for the US population
(23% at six months for patients receiving living donor allografts and 25% at six months for
patients receiving cadaver allografts). These three studies presented (Khositseth, 2005,
Transplantation; Ault, 2002, Pediatr Nephrol; Khwaja, 2003, Pediatr Transplantation)
suggest that Thymoglobuline is effective in preventing rejection of renal transplants in
paediatric (and infant) patients.

The applicant has not presented studies for paediatrics in the TRRT. Mariat included also
patients less that 40kg in the study

Prevention of Heart Transplant Rejection
Two of the studies to support of using Thymoglobuline in paediatric patients in the prevention
of heart transplant rejection are retrospective and uncontrolled and not directly comparable as
they employed different dosing regimens for Thymoglobuline tailoring the dose according to
baseline platelet counts or absolute lymphocyte counts (Di Filippo, 2003, Transplantation;
Parisi, 2003, J Heart Lung Transplant). Patient survival rates were 80% (24/30) and 97%
(30/31) for the two studies, but over a varying duration of follow-up. In support of using
Thymoglobuline in the paediatric population, efficacy was achieved in these small patient
groups, but the studies are possibly more interesting as long-term safety studies in children.

Geriatric population
A retrospective analysis by the EBMT demonstrated that ATG treatment in older patients is
effective and maintains a positive benefit/risk balance, though greater care should be taken in
its administration and in the monitoring of the patients. The response rate was not
significantly different in 664 patients <60 and 127 patients >60 (Tichelli, 1999, Ann Int Med).

Renal dysfunction in the prophylaxis of Rejection in Heart Transplantation (PRHT)
The efficacy of Thymoglobuline-based prophylaxis in a subpopulation of heart
transplantation patients with renal dysfunction was confirmed by Cantarovich et al.
(Cantarovich, 2004, Transplantation). The study was designed to investigate the possibility of
delaying cyclosporins (nephrotoxic) administration during the first two weeks of
immunosuppression. Patient survival after one year in the control arm (historical control),
representing a standard Thymoglobuline plus triple therapy was 88% (15/17). The results
suggested that ATG-induction allows for a prolonged and safe delay in the initiation of
cyclosporin in heart transplant patients with postoperative renal dysfunction.

Conclusions on clinical efficacy
The studies presented in the dossier originate from a review of clinical studies reported in the
scientific literature.

A total of seven randomised controlled studies are presented in Prophylaxis of Rejection in
Renal Transplantation, three of which compare Thymoglobuline plus triple therapy to triple
therapy alone (placebo-controlled), with the remaining four comparing Thymoglobuline to
other antibodies (ATG-Fresenius, Atgam, basiliximab and OKT3), all with triple therapy.

Four comparator studies supported the claim for treatment of rejection in renal
transplantation. Three comparator controlled studies are presented to support the indication
for the Prophylaxis of Rejection in Heart Transplantation. The limitation of the review is the

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number of the published clinical trials with Thymoglobuline in the prophylaxis of rejection in
heart transplantation is acknowledged due to number of difficulties in carrying out studies in
the field of cardiac transplantation. However, presented publications support the proposed
indication.

Proposed indications and doses are discussed adequately and the presented data support the
indications.

CLINICAL SAFETY

Introduction
The Applicant has collected data from the following sources:
A prospective Pharmacovigilance (PV) survey, 00PTF01
Periodic Safety Update Reports (PSURs)
Safety data included in the efficacy publications discussed in this submission
Safety data from publications carried out to examine certain safety concerns of clinicians
in the field.

Adverse events
A mild to moderate first dose effect linked to the release of inflammatory cytokines. To
minimise first-dose effects, use of prophylactic agents, control of infusion rate and
concentration of the diluted product is specified in the SmPC.

As per applicant cytopenias (mostly thrombocytopenia) occur because of the cross reactivity
of Thymoglobuline with platelet antigens. Thrombocytopenia can be a particular management
problem in patients at risk of thrombocytopenia for other reasons such as the diagnosis of
aplastic anaemia, or the use of extra-corporeal circulation during heart transplantation.
Platelet transfusions may be required to be given during the course of the treatment period
with Thymoglobuline in these patients.

Immunisation of patients against rabbit antibodies which may theoretically result in three
separate problems: inefficacy of the product; anaphylaxis (type I immune reaction); serum
sickness (type III immune reaction) (Regan, 2001, Transplant Immunol).

Infections, in particular, CMV infection or reactivation, have been noted to be increased in
patients treated with Thymoglobuline, such that concomitant prophylaxis or close monitoring
with subsequent pre-emptive treatment with an antiviral medication is becoming more
common for renal transplant patients. Other malignancies occur commonly in solid organ
transplant patients being associated with the immunosuppression patients receive.
Thymoglobuline, as part of an immunosuppressive regimen may contribute to an increased
incidence of malignancy.

Patients in French Multi-centre Post-Marketing Surveillance observational study (00PTF01)
were solid organ transplant recipients. During the study period, the 240 patients each received
a total dose of approximately 138 grams of Thymoglobuline over a median duration of ten
days. All patients were evaluated for safety results.

In total, 32 serious adverse events were reported in 32 patients. Of these, 22 episodes in 22
patients occurred in the first month, the others occurring later.


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There were no cases of anaphylaxis during the period of administration of Thymoglobuline.
Infusion related reactions occurred in over half of patients, but were usually mild and
spontaneously recovered with no sequelae. There were no reports of local reactions such as
thrombophlebitis or pain at the site of the infusion in those patients who were infused
Thymoglobuline via peripheral vein (n=1) or arterio-venous fistula (n=67). There were no
reports of respiratory symptoms.

Temporary treatment discontinuations as a result of monitoring of efficacy, biological
abnormalities or clinical adverse events occurred in about one third of patients. Twelve
patients switched from Thymoglobuline to Lymphoglobuline. In six of these, the reason for
the switch was known, and was mostly rash and/or fever, and in two cases was due to serum
sickness. In most of the remaining six patients, there was either neutropenia (<1.5 x 10
9
/l) or
thrombocytopenia (<80 x 10
9
/l) noted on the switch day or preceding day, which was likely to
be the cause of the switch. Four deaths occurred during the study.

The table below lists the number of patients suffering from adverse events associated with
Thymoglobuline administration, and thought to be related to its use:

Table 10: Number of patients suffering from adverse events associated with Thymoglobuline
administration

All these adverse reactions were transient, resolved spontaneously and had no clinical
consequences. These infusion associated reactions were listed in the CRF and investigators
had to tick boxes if the event occurred. Any events which occurred which were not listed in
the CRF could be added in another section. Fever (>38.5C once) was the commonest

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adverse reaction, affecting 131 patients (55%); 39 patients (16%) having a fever which lasted
two or more consecutive days.

Twenty-one patients (9%) were reported as suffering from shivering/chills. Patients suffering
from fever secondary to infection or rejection for example are not included in these figures
unless they occurred within the first 15 days.

The definition used to identify possible cases of serum sickness was the occurrence after day
seven, of fever, with or without rash, together with one or more of the following: arthralgia,
myalgia, pruritus, dysphagia, trismus (i.e. temporo-mandibular joint pain and stiffness). This
definition of serum sickness was developed by a committee of investigators who discussed
each case or potential case of serum sickness. Using this definition, a total of 18 patients
(7.5%) were identified on median day 11 (range 10-14).

All patients identified as having serum sickness had fever and arthralgia, seven had a rash as
well, seven had myalgia, five dysphagia, five pruritus, and three trismus. Serum complement
was measured in 15/18 patients. Of these, 14 patients had lowered serum complement levels.
Four patients discontinued Thymoglobuline as a result of having serum sickness, two
switching to Lymphoglobuline.

For cutaneous events, twenty-eight patients (11%) suffered a rash while under treatment with
Thymoglobuline, and 12 patients (5%) pruritus. Of these patients, 11 (4%) suffered
simultaneous fever and rash.

Over half the patients (137 or 57%) were reported as having experienced no significant
infection in the year following transplantation; 102 patients had at least one episode of
infection. Only 10% of patients had more than one episode of significant infection.

Table 11: Overview of adverse events occurring over the year of follow-up (n=240)


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Serum sickness is also recognised in the literature with a frequency of approximately 4 16%
(Charpentier, 2003, Transplantation; Mourad 2001, Transplantation; Lebranchu, 2002, Am J
Transplantation; Mariat, 1998, Transplant Int). The common frequency in the PV trial, serum
sickness was spontaneously reported in only 53 patients over the six-year post-marketing
period. However, based on the results of the PV study, serum sickness should be considered
as common (>1/100, <1/10).

The table below examines the frequency of the broad categories of infection in the year of
follow up.

Table 12: Frequency of infection by type
Patients/episodes: Bacterial Viral (incl.
CMV)
Fungal Unknown
Patients affected 29 79 3 2
Episodes 38 95 3 2

On the basis of the PV trial, first dose effects consisting of fever and/or rash should be
considered as very common (>1/10), but are expected. Thus, there are few spontaneous
reports received.

Table 13: Comparison of other adverse events reported in the literature with the postmarketing study
(OOPTF01)


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Table 13 (cont): Comparison of infections and malignancies reported in the literature with the
postmarketing study (OOPTF01)

Table 13 (cont): Comparison of immune mediated adverse events reported in the literature with the
postmarketing study (OOPTF01)

The applicant has presented adverse events according to the MedDRA system organ class.
Adverse events from the French Multi-centre Post-marketing Surveillance Study are
presented in section 4.8 of the SmPC.

Serious adverse events and deaths
During the Short term no anaphylactic reactions or severe side effects were recorded. Two
non-responding patients died, both of sepsis, one month and one year after treatment,
respectively.


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Within the French post-marketing study (00PTF01), there were no deaths in the first month;
however two deaths from infection occurred during the second month. At one year, four
patients had died. A fifth patient died after the year of follow-up, but of an event which
occurred during the year of follow up. Causality assessment was not provided by
investigators.

In this study twenty serious adverse events occurred before day 30 and twelve serious adverse
events (in 11 patients) were reported by the investigators as occurring after day 30. Most of
these adverse events were infections.

In the post-marketing study 00PTF01 at one year, eight malignancies had been reported in
seven patients. Two malignancies (0.8%), a Kaposis sarcoma which has since partially
resolved and an Epstein-Barr virus-associated post-transplant lymphoproliferative disorder
from which a full recovery was made following reduction in immunosuppressive treatment,
could be considered related to immunosuppressive treatment; and additionally the two cases
of carcinoma of the cervix could possibly be related since they may be related to papilloma
virus infection. Of these seven patients who suffered from malignancies, one died, four were
in remission at one year and two patients had persistent disease at the end of the study period.

Most malignancies reported over the six year period of post-marketing under consideration
were lymphomas (PTLD):
1999 9 2000 12 2001 61
2002 29 2003 5 2004 27

Over the six year period of post-marketing under consideration a total of 143 cases were seen,
a frequency was lower than 1 %. Use of immunosuppressive agents, including
Thymoglobuline, may increase the incidence of malignancies, lymphoma or post-transplant
lymphoproliferative disease (PTLD).

The applicant should closely monitor the appearance of the malignancies in the next PSURs.

Anaphylaxis
Anaphylaxis was not recorded as an adverse event in the PV trial, nor in the literature articles
presented in support of efficacy.

Looking at the PSURs, during the period 1999 2003, 66 cases of anaphylactoid reactions or
allergic reactions were reported, although the number of anaphylactic events alone is not
specified. In 2004, seven reports of type 1 allergic reactions were made; two fatal (estimated
corresponding patient exposure was 15 534 patients). Fatal anaphylaxis is very rare. Thus
anaphylactic disorders should be considered as rare (>1/10 000 and <1/1000).

Laboratory findings
Leukopenia is commonly reported with Thymoglobuline use, and is expected as the primary
mechanism of action is lymphocyte depletion.

In the PV trial solid organ transplant recipients, 123 patients (44%) suffered from neutropenia
(<2.5x10
9
/L), 35 patients (14%) from thrombocytopenia (<80x10
9
/L), but only six patients
(2%) from severe neutropenia (< 0.8 x10
9
/L), and nine patients (3%) from severe
thrombocytopenia (<50x10
9
/L). Anaemia occurred in 50% of patients; a relation with

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Thymoglobuline use is possible but is more likely to be caused by other co-morbid conditions
of the graft recipient, i.e. renal failure and/or surgical procedures.

Both thrombocytopenia (approximately 7 11%) and anaemia (approximately 25 35%) are
reported in the literature, but without details of severity. Thrombocytopenia and neutropenia
are classically reported side-effects and are spontaneously reported. Thus haematological
events mainly thrombocytopenia, neutropenia and anaemia should be considered as very
common (>1/10) or common (>1/100, <1/10).

In the PSURs covering the six year period from 1999 to 2004, there were only nine
spontaneous reports of elevated hepatic enzymes associated with the use of Thymoglobuline.
Elevation of hepatic enzymes has been usually transitory.

Infections
Infections are often reported in detail in the literature references describing clinical trials with
Thymoglobuline. Bacterial infections are seen in all trials. Virus infections, especially CMV,
but also other herpes infections, are commonly reported. A significantly higher incidence of
CMV reactivations was recorded in patients treated with Thymoglobuline (75%) compared to
ATG-Fresenius (30%, p=0.028) and new infections due to CMV only occurred in the
Thymoglobuline arm (20%, p=0.05) (De Santo, 2004, Transplant Proc).

Ault et al. report on the prevalence of CMV infection in paediatric patients receiving renal
transplants and treated with Thymoglobuline. Seven of the 17 paediatric patients were CMV
nave and 4 of these patients received an allograft from a CMV-positive donor. At 12 months
post-transplant, all of these patients had a positive CMV IgM or IgG titre, but did not display
any symptoms of CMV infection. Thus as per applicant infectious events should be
considered as very common (>1/10).

Most organ transplant recipients will have had a primary CMV infection prior to
transplantation, and thus will be latently infected, and will be at significant risk of
reactivation. If they get a primary infection it is more severe than in a person with a normal
immune system. CMV infection is not transmitted to humans by animals and vice versa.
(Loh, 2006, virology). CMV reactivation is related to the overall level of immunosuppression,
and not to an immunosuppressive individual agent. Prophylaxis of CMV infection is
generally effective.

Analysis of all identified RCTs published since 1996 with Thymoglobuline in one arm and a
comparator arm with no polyclonal antibody or T cell depleting antibody shows no evidence
that CMV reactivation rates are higher in patients treated with Thymoglobuline

Based on the above, the Applicant states that there is no true increase in CMV infections
attributable to Thymoglobuline.

Post-transplantation lymphoproliferative disorder (PTLD)
EBV-associated PTLD is a well recognised complication of immunosuppressive therapy. The
incidence of PTLD reported in studies after Thymoglobuline therapy is comparable to that
reported with other immunosuppressive regimens, 1 2%.


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Table 14: Frequencies of PTLD and de novo tumours as reported in the safety studies

PTLD although rare by spontaneous reporting, the analyses by Bustami and Cherikh suggest
that it is common (>1/100, <1/10).

As PTLD is a common adverse event it is mentioned in the SmPC.

Immunological events
It is expected that the introduction of a xeno-protein, such as Thymoglobuline, will induce an
immune response, even in the immunosuppressed patient.

A study was conducted by Regan (Regan, 2001, Transplant Immunol) to quantify the degree
of sensitization following Thymoglobuline therapy. An analysis of anti-rabbit Ig antibodies
was as part of their study on pharmacokinetics. Serum samples were obtained from 80
Thymoglobuline- treated patients participating in a multicenter, double-blind randomized
phase III trial designed to compare Atgam. Anti-Thymoglobuline antibodies were
demonstrated to decrease both total and active Thymoglobuline concentrations. The percent
of patients with anti-Thymoglobuline antibodies on days O-5, days 6-14, day 21, day 30 and
day 90 were 6, 41, 68, 70 and 29%, respectively.


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Figure 2: Anti-Thymoglobuline antibody response. Percent of patients with anti-Thymoglobuline
antibodies as a function of days after initiation of Thymoglobulin treatment as determined by ELISA.
Number of patients tested for days 0-5, 6-14, 21, 30 and 90 were 62, 68, 38, 43 and 28 respectively.

Safety in special populations
No clinical safety study has been conducted in special groups and situations.

No data is available on intrinsic ethnic factors and differing responses to treatment, or need
for individualisation of treatment. The dose recommendations in infants, children, adolescents
and the elderly are the same as in adults, based on data from published studies where the same
doses as in adults were used.

No data is available on the influence of cultural habits and response to treatment. Given the
nature of the product it is unlikely that these would have any effect on response to the
product.

Pregnancy and lactation
Animal reproduction studies have not been conducted with Thymoglobuline. It is not known
whether Thymoglobuline can cause foetal harm or can affect reproductive capacity.
Thymoglobuline should be given to a pregnant woman only if clearly needed.

Thymoglobuline has not been studied in nursing women. It is not known whether this drug is
excreted in human milk. Because other immunoglobulins are excreted in human milk, breast-
feeding should be discontinued during Thymoglobuline therapy. Thymoglobuline has not
been studied in labour or delivery.

Effects on ability to drive and use machines
Given the possible adverse events which can occur during the period of Thymoglobuline
infusion, in particular cytokine release syndrome, it is recommended that patients should not
drive or operate machinery.

SmPC text regarding the Pregnancy and lactation and Effects on ability to drive and use
machines is acceptable.

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Safety related to drug-drug interactions and other interactions
No drug interaction studies have been carried out. Interactions with food and drink are
unlikely.

In the SPC the combinations to be taken into account are mentioned: Cyclosporin, tacrolimus,
mycophenolate mofetil: risk of over-immunosuppression with a risk of lymphoproliferation.
Live attenuated vaccines: risk of systemic infection which may potentially be fatal. This risk
is enhanced in subjects who are immunocompromised due to the underlying disease (aplastic
anaemia). Rabbit anti-human thymocyte globulin may induce formation of antibodies which
react with other rabbit immunoglobulins. Rabbit anti-human thymocyte globulin may
interfere with ELISA tests involving rabbit antibodies over a period of two months.

Discontinuation due to AES
No rebound or withdrawal effects have been described. As per Applicant there is no need for
gradual withdrawal or reduction of the product before discontinuation.

Contraindications
Thymoglobuline is contraindicated in patients with: 1) Hypersensitivity to rabbit proteins or
to any product excipients and 2) Acute infections, which would contraindicate any additional
immunosuppression.

The Applicant has not presented any data about contraindications, but contraindications in the
section 4.3 in the SmPC are acceptable.

Post marketing experience
Thymoglobuline currently has marketing authorisations or authorization for sales in over 50
countries worldwide, with varying indications. The current marketing authorisation in France
has the widest set of indications; whereas the USA has one indication, treatment of rejection
in renal transplantation. There is no ATG currently with marketing authorisation in the UK.

In 1984, Thymoglobuline was registered and marketed in France. In the 1992
pharmacovigilance study THP04492, 78% of patients had at least one symptom following use
of Thymoglobuline. Adverse events can be grouped into various types:
allergic: including anaphylaxis, serum sickness, rashes, fever
haematological
infections
other

Between 1st J anuary 2000 and 31st December 2004, 1.843.589 vials of Thymoglobuline,
corresponding to approximately 56.813 patients treated, were distributed worldwide. Between
1st J anuary 1999 and 31st December 2004, the PSURs contain a cumulative total of 642
adverse events reported worldwide and relating to Thymoglobuline use, 576 were serious
adverse events and 66 were non-serious adverse events. Up to the present day, adverse events
reported world-wide for Thymoglobuline are generally those expected for a polyclonal anti-
thymocyte globulin and confirm the good tolerability and safety of Thymoglobuline. The
types of adverse events reported are mostly explicable as a result of the known mechanisms of
action of Thymoglobuline: for example, virally induced lymphoma being a complication of
immunosuppression and infusion associated reactions being due to hypersensitivity or
cytokine release.


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Study 00PTF01 was a prospective study with Thymoglobuline for prophylaxis of rejection
after kidney transplantation between 1997 and 1998. At one year, 65 out of 236 patients still
alive (28%) have suffered at least one acute rejection. In the first 30 days there were 35
episodes of clinically diagnosed rejections in 34 patients, of which 21 episodes were biopsy
confirmed.

There were 15 cases of histologically confirmed chronic rejection in the first 12 months.
During the first year four patients died, giving the survival rate of 98% at one year. At one
year 228 patients were alive and with a functional graft (four deaths and eight graft losses). At
one year in those with functional graft (n=228) the median creatinine was 124 mmol/l and the
median creatinine clearance at one year was 63 mls/min.

There were no deaths in the first month. The median day of death was day 71. None of the
deaths were considered to be causally related to Thymoglobuline use.

During the PSUR period between 01 J anuary 2005 and 31 December 2005 forty-five (45)
cases with fatal outcomes were reported to Genzyme during. Of the forty-five (45) reported
fatal cases, thirty-four were considered related.

The results of the study 00PTF01 show a similar profile and incidence of adverse events as
documented by previous studies. Fever remains the commonest reported adverse event, with
55% of patients suffering from it. As the Applicant noted it is difficult to ascertain the
relationship of Thymoglobuline to the reported adverse events, because Thymoglobuline is
always given in combination with other immunosuppressant drugs, drugs used for
prophylaxis of infection and other drugs.

Proposals for post authorisation follow up (post marketing surveillance)
The product is well-established and documented in the literature. So there are no proposals for
post authorisation follow up.

Overall conclusions on clinical safety
Data from clinical trials, spontaneous adverse event reporting, active post-marketing surveys,
and literature reports demonstrate a consistent safety profile of Thymoglobuline therapy,
which has not changed in the 20 years or more that it has been marketed.

Most of the adverse effects are explained by the immunological properties of
Thymoglobuline. A mild to moderate first dose effect linked to the release of inflammatory
cytokines. To minimise first-dose effects, use of prophylactic agents, control of infusion rate
and concentration of the diluted product is specified in the SmPC. Cytopenias (mostly
thrombocytopenia) occurs because of the cross reactivity of Thymoglobuline with platelet
antigens. Thrombocytopenia can be a particular management problem in aplastic anaemia, or
in the use of extra-corporeal circulation during heart transplantation. Platelet transfusions may
be required to be given during the course of the treatment period with Thymoglobuline in
these patients.

Immunisation of patients against rabbit antibodies may theoretically result in three separate
problems: inefficacy of the product; anaphylaxis (type I immune reaction); serum sickness
(type III immune reaction) (Regan, 2001, Transplant Immunol).


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Induction therapy may be the most significant risk factor for developing infection and
especially CMV infection or disease in patients treated with Thymoglobuline. Concomitant
prophylaxis or close monitoring with subsequent pre-emptive treatment with an antiviral
medication is becoming more common for renal transplant patients.

Another concern regarding the use of prophylactic antibody therapy is that it may be
associated with an increased risk of malignancy or lymphoproliferative disease. Malignancies
occur commonly in solid organ transplant patients being associated with the
immunosuppression patients receive. Thymoglobuline, as part of an immunosuppressive
regimen may contribute to an increased incidence of malignancy.

Estimates of frequencies of adverse events are usually derived from company sponsored
randomised controlled studies (RCTs), where there is adequate identification and recording of
adverse events and their relationship to the study drug. Spontaneous reporting usually
underreports adverse events, and causality may be inadequately assessed. For
Thymoglobuline adequate company sponsored RCTs across the range of indications and
populations are lacking.

The efficacy and safety results presented in this overview are adequately reflected in the
proposed SmPC.

The application for granting of a marketing authorisation is approvable.

Risk benefit conclusions
Thymoglobuline has been demonstrated to be effective both in the treatment of steroid-
resistant renal rejections and as first-line treatment of acute rejection.

The studies presented in the application support the indication for the prevention of rejection
in heart transplantation. Independent of the duration of treatment, the cumulative dose is the
key, when considering the efficacy and safety of Thymoglobuline induction therapy, because
of the long pharmacokinetic and even longer pharmacodynamic duration of action.

Clinical data gathered prospectively by the multicentre group (Di Bona, 1999, Br J Haematol)
showed that Thymoglobuline was safe, in the short and the long term, and effective in 30
patients who failed to respond to a first course of Lymphoglobuline, in combination with
ciclosporin and G-CSF.

The difficulty with Thymoglobuline is in finding a dose which is still effective, but which
does not cause adverse events due to this immune suppression, such as infections and
malignancies induced by viral agents (in particular PTLD). The risk of these adverse events
can be reduced, not only by reducing the dose of Thymoglobuline, but also by the use of anti-
viral prophylaxis.

The efficacy and safety of Thymoglobuline is demonstrated in the immunosuppression in
solid organ transplantation, prevention and treatment of graft rejection in renal transplantation
and prevention of graft rejection in heart transplantation.

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OVERALL CONCLUSION AND RISK BENEFIT ASSESSMENT

QUALITY

The important quality characteristics of Thymoglobuline are well defined and controlled.
There are no outstanding quality issues that would have a negative impact on the benefit/risk
balance.

PRECLINICAL

The preclinical studies presented are supportive of the safety of the product, particularly the
specificity shown in the cross-reactivity study in human tissues. The pharmacodynamic
actions of Thymoglobuline were shown repeatedly in studies in cynomolgus monkeys and
toxic effects seen can be attributed to actions to deplete lymphocytes.

There are no objections, on preclinical grounds, to the granting of a marketing authorisation.

CLINICAL

No new or unexpected safety concerns arose from this application. The efficacy and safety of
Thymoglobuline for the indications sought is demonstrated.

The SPC, PIL and labelling are satisfactory.

RISK-BENEFIT ASSESSMENT

The quality of the product is acceptable and no new pre-clinical, quality or clinical safety
concerns have been identified. The risk-benefit assessment is therefore considered to be
favourable.


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THYMOGLOBULINE


PL 12375/0021

STEPS TAKEN FOR ASSESSMENT

1 The MHRA received the marketing authorisation application on 13th August 2006.
2 The MHRAs quality assessment of the submitted data was completed on 21st
March 2007.
3 The MHRAs clinical and pre-clinical assessment of the submitted data was
completed on 22nd March 2007.
5 Following assessment, a series of requests for supplementary information were sent
to the applicant to which they provided further information to complete assessment
of the product.
6 The MHRA completed its assessment of the application on 28
th
February 2008.
7 The application was determined on 19
th
March 2008.


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THYMOGLOBULINE


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STEPS TAKEN AFTER AUTHORISATION SUMMARY

Date submitted Application type Scope Outcome
27/01/2012 Type IB mutual
recognition variation
To update sections 4.4
(Special warnings) and
4.8 (Undesirable effects)
of the SPC and PIL in line
with the agreed CSP
following the finalisation
of the EU PSUR work-
sharing procedure
EE/H/PSUR/0008/001 on
14th September 2011.
Granted
28.04.12

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SUMMARY OF PRODUCT CHARACTERISTICS


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Patient Information Leaflet


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Labelling


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Annex 1

Our Reference: PL 12375/00210022
Product: PL 12375/0021 Thymoglobuline
Marketing Authorisation Holder: GENZYME EUROPE BV

Reason:
To update sections 4.4 (Special warnings) and 4.8 (Undesirable effects) of the Summary of Product
Characteristics (SmPC) and Patient Information Leaflet (PIL) in line with the agreed Core Safety
Profile (CSP) following the finalisation of the European Union Periodic Safety Update Reports (EU
PSUR) work-sharing procedure EE/H/PSUR/0008/001 on 14th September 2011.

Linked / Related Variation(s) or Case(s):
NA

Supporting Evidence
The P-RMS (Member State responsible for the PSUR assessment report) final assessment report
from procedure EE/H/PSUR/0008/001.

Evaluation
Updates were made to sections 4.4, 4.8, and 10 of the SmPC for Thymoglobuline 25 mg powder for
solution for infusion.

Conclusion
The following text was accepted for sections 4.4, 4.8, and 10.

The PIL is acceptable.

4.4 Special warnings and precautions for use

Thymoglobuline should be used under strict medical supervision in a hospital setting.
Thymoglobuline must only be administered according to the instructions of a physician with
experience of immunosuppressive therapy in the transplant setting. Patients should be
carefully monitored during the infusion. Particular attention must be paid to monitoring the
patient for any symptoms of anaphylactic shock. Close monitoring of the patient must
continue during the infusion and for a period of time following the end of the infusion until
the patient is stable.

Prior to administration of Thymoglobuline it is advisable to determine whether the patient is
allergic to rabbit proteins. Medical personnel and equipment, etc. must be readily at hand
during the first days of therapy to provide emergency treatment if necessary.

Warnings
Immune-mediated reactions
In rare instances, serious immune-mediated reactions have been reported with the use of
Thymoglobuline and consist of anaphylaxis or severe cytokine release syndrome (CRS).

Very rarely, fatal anaphylaxis has been reported (See section 4.8 Adverse Events). If an
anaphylactic reaction occurs, the infusion should be terminated immediately and appropriate
emergency treatment should be initiated. Equipment for emergency therapy for anaphylactic
shock must be readily available.
Thymoglobuline 25 mg powder for solution for infusion
Any further administration of Thymoglobuline to a patient who has a history of anaphylaxis
to Thymoglobuline should only be undertaken after serious consideration.

Severe, acute infusion-associated reactions (IARs) are consistent with CRS which is attributed
to the release of cytokines by activated monocytes and lymphocytes. In rare instances, these
reported reactions are associated with serious cardiorespiratory events and/or death (See under
Precautions and section 4.8 Adverse Events).

Infection
Thymoglobuline is routinely used in combination with other immunosuppressive agents.
Infections (bacterial, fungal, viral and protozoal), reactivation of infection (particularly CMV)
and sepsis have been reported after Thymoglobuline administration in combination with
multiple immunosuppressive agents. In rare cases, these infections have been fatal.

Precautions
General
Appropriate dosing for Thymoglobuline is different from dosing for other anti-thymocyte
globulin (ATG) products, as protein composition and concentrations vary depending on the
source of ATG used. Physicians should therefore exercise care to ensure that the dose
prescribed is appropriate for the ATG product being administered.

Thymoglobuline should be used under strict medical supervision in a hospital setting. Patients
should be carefully monitored during the infusion and for a period of time following the end
of the infusion until the patient is stable. Close compliance with the recommended dosage and
infusion time may reduce the incidence and severity of IARs. Additionally, reducing the
infusion rate may minimize many of these adverse reactions. Premedication with antipyretics,
corticosteroids, and/or antihistamines may decrease both the incidence and severity of these
adverse reactions.

Rapid infusion rates have been associated with case reports consistent with cytokine release
syndrome (CRS). In rare instances, severe CRS can be fatal.

Haematological Effects
Thrombocytopenia and/or leukopenia (including lymphopenia and neutropenia) have been
identified and are reversible following dose adjustments. When thrombocytopenia and/or
leukopenia are not part of the underlying disease or associated with the condition for which
Thymoglobuline is being administered, the following dose reductions are suggested:
A reduction in dosage must be considered if the platelet count is between 50,000 and
75,000 cells/mm
3
or if the white cell count is between 2,000 and 3,000 cells/mm
3
;
Stopping Thymoglobuline treatment should be considered if persistent and severe
thrombocytopenia (<50,000 cells/mm
3
) occurs or leukopenia (<2,000 cells/mm
3
)
develops.

White blood cell and platelet counts should be monitored during and after Thymoglobuline
therapy. Patients with severe neutropenic aplastic anaemia require very careful monitoring,
appropriate prophylaxis and treatment of fevers and infections as well as adequate platelet
transfusion support.

Infection
Infections, reactivation of infection (particularly CMV) , and sepsis have been reported after
Thymoglobuline administration in combination with multiple immunosuppressive agents.
Careful patient monitoring and appropriate anti-infective prophylaxis are recommended.

Malignancy
Use of immunosuppressive agents, including Thymoglobuline, may increase the incidence of
malignancies, lymphoma or lymphoproliferative disorders (which may be virally mediated).
These events have sometimes been associated with fatal outcomes (See section 4.8 Adverse
Events).

Risk of Transmission of Infectious Agents
Human blood components (formaldehyde treated red blood cells), as well as thymus cells are
used in the manufacturing process for Thymoglobuline.Standard measures to prevent
infections resulting from the use of medicinal products prepared using human components
include selection of donors, screening of individual donations for specific markers of infection
and the inclusion of effective manufacturing steps for inactivation/removal of viruses.
Despite this, when medicinal products prepared using human components are administered,
the possibility of transmitting infective agents cannot be totally excluded. This also applies to
unknown or emerging viruses and other pathogens.

The measures taken for Thymoglobuline are considered effective for enveloped viruses such
as HIV, HBV and HCV, and for the non-enveloped viruses such as HAV and parvovirus B19

It is strongly recommended that every time that Thymoglobuline is administered to a patient,
the name and batch number of the product are recorded in order to maintain a link between
the patient and the batch of the product.

Special Considerations for Thymoglobuline Infusion
As with any infusion, reactions at the injection site can occur and may include pain, swelling,
and erythema.

The recommended route of administration for Thymoglobulin is intravenous infusion using a
high-flow vein; however, it may be administered through a peripheral vein. When
Thymoglobuline is administered through a peripheral vein, concomitant use of heparin and
hydrocortisone in an infusion solution of 0.9% sodium chloride may minimize the potential
for superficial thrombophlebitis and deep vein thrombosis.

The combination of Thymoglobuline, heparin and hydrocortisone in a dextrose infusion
solution has been noted to precipitate and is not recommended (See section 6.2
Incompatabilities).

Immunisations
The safety of immunisation with attenuated live vaccines following Thymoglobuline therapy
has not been studied; therefore, immunisation with attenuated live vaccines is not
recommended for patients who have recently received Thymoglobuline.

4.8 Undesirable effects

Adverse events from French Multi-centre Post-marketing Surveillance Study
From J une 1997 to March 1998, 18 French transplantation centres participated in the French
Multicentre Post-marketing Surveillance Study-00PTF0.
A total of 240 patients participated in this prospective, single arm, observational cohort study.
All patients received Thymoglobuline as prophylaxis of acute rejection for renal transplant.
The safety data in the table represent all adverse events reported in the study regardless of
relationship to Thymoglobuline.

Blood and lymphatic system disorders
Very common
**
: lymphopenia, neutropenia, thrombocytopenia
Gastrointestinal disorders
Common
*
: Diarrhoea, dysphagia, nausea, vomiting
General disorders and administrative site conditions
Very common: Fever
Common: Shivering
Immune system disorders
Common: Serum sickness
Infections and infestations
Very common: Infection
Musculoskeletal and connective tissue disorders
Common: Myalgia
Neoplasms benign, malignant and unspecified (including cysts and polyps)
Common: Malignancy
Respiratory, thoracic and mediastinal disorders
Common: Dyspnoea
Skin and subcutaneous tissue disorder
Common: Pruritus, rash
Vascular disorder
Common: Hypotension
* Common : (1/100 to <1/10)
** Very common (1/10)

Undesirable effects which have been discussed in other sections of this document are listed
per clinical disorder below. Because these events are from post marketing surveillance, their
true frequencies are not known.

Infusion-Associated Reactions and Immune System Disorders
Infusion-associated reactions (IAR) may occur following the administration of
Thymoglobuline and may occur as soon as the first or second dose. Clinical manifestations of
IARs have included some of the following signs and symptoms: fever, chills/rigors, dyspnoea,
nausea/vomiting, diarrhoea, hypotension or hypertension, malaise, rash, urticaria, and/or
headache. IARs with Thymoglobuline are usually mild and transient and are managed with
reduced infusion rates and/or medications. Transient reversible elevations in transaminases
without any clinical signs or symptoms have also been reported during Thymoglobuline
administration. Serious and in very rare instances, fatal anaphylactic reactions have been
reported (See section 4.4 Warnings). These fatal reactions occurred in patients who did not
receive adrenaline during the event.

IARs consistent with Cytokine Release Syndrome (CRS) have been reported. Severe and
potentially life-threatening CRS is rarely reported. Post-marketing reports of severe Cytokine
Release Syndrome have been associated with cardiorespiratory dysfunction (including
hypotension, ARDS, pulmonary oedema, myocardial infarction, tachycardia, and/or death).

Serum Sickness
During post-marketing surveillance, reactions such as fever, rash, urticaria, arthralgia, and/or
myalgia, indicating possible serum sickness, have been reported. Serum sickness tends to
occur 5 to 15 days after onset of Thymoglobuline therapy. Symptoms are usually self-limited
or resolve rapidly with corticosteroid treatment.

Adverse events due to immunosuppression
Infections, reactivation of infection, febrile neutropenia, and sepsis have been reported after
Thymoglobuline administration in combination with multiple immunosuppressive agents. In
rare cases, these infections have been fatal. Malignancies including, but not limited to
lymphoproliferative disorders (LPD) and other lymphomas (which may be virally mediated)
as well as solid tumours have been reported. These events have sometimes been associated
with fatal outcome.(See section 4.4 Precautions). These adverse events were always
associated with a combination of multiple immunosuppressive agents.

For safety relating to transmissible agents, see section 4.4 Precautions

10 DATE OF REVISION OF THE TEXT

28/04/2012




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