Side Effects of Cimzia (certolizumab)

Cimzia (certolizumab) is an injectable synthetic protein antibody that binds to tumor necrosis factor alpha (TNFα) in the body and blocks the effects of TNFα in patients with rheumatoid arthritis and Crohn's disease. 

Inflammation is the body's reaction to injury and is a necessary process for the repair of injury. TNF is a protein that the body produces when there is inflammation. TNF promotes inflammation and the signs of inflammation, which, in the case of arthritis, include fever as well as pain, tenderness, and swelling of joints. 

In the case of Crohn's disease, the signs of inflammation include fever, abdominal pain, and diarrhea. The unchecked inflammation of rheumatoid arthritis eventually leads to destruction of the joints. The inflammation in Crohn's disease can lead to strictures (narrowing) of the intestine or intestinal perforation. 

Cimzia binds to TNF in the body and thereby blocks the effects of TNF. As a result, inflammation and its consequences in the joints and intestine are reduced. In arthritis, the progressive destruction of the joints is slowed or prevented. 

Common side effects of Cimzia include

• respiratory tract infections,
• urinary tract infections (UTIs),
• joint pain,
• abdominal pain,
• diarrhea,
• intestinal obstruction, and
• injection site reactions (redness, pain and itching).

Serious side effects of Cimzia include

• serious infections (such as tuberculosis, sepsis, and fungal infections),
• worsening or new diseases of the nervous system,
• worsening congestive heart failure,
• possible cancer,
• hypersensitivity (allergic) reactions (including anaphylaxis),
• reduced levels in the blood of platelets and red blood cells (aplastic anemia), and
• increased risk of reactivating hepatitis B virus in chronic carriers of the virus.

Drug interactions of Cimzia include anakinra, abatacept, rituximab, or natalizumab because the combination may result in reduced white blood cells in the blood (neutropenia), serious infections and no additional benefit.

• Cimzia may interfere with the effectiveness of vaccines.
• Live vaccines, including attenuated vaccines, should not be used while patients are being treated with Cimzia.
• Cimzia may interfere with tests of coagulation in patients receiving blood thinners. 

There are no adequate studies of Cimzia in pregnant women. It is unknown if Cimzia is excreted in breast milk. Consult your doctor before breastfeeding.

The most common adverse effects in clinical studies were:

• respiratory tract infections,
• urinary tract infections, and
• arthralgia (pain in the joints),
• abdominal pain,
• diarrhea,
• intestinal obstruction,
• redness,
• pain and
• itching at the site of injection.

Like other drugs that block TNFα, use of certolizumab has been associated with serious infections such as tuberculosis, sepsis (bacteria in the blood) and fungal infections. Individuals with active infections should not be treated with certolizumab. Certolizumab may worsen or cause new diseases of the nervous system.

Certolizumab also may cause or worsen congestive heart failure. In studies, some patients who used certolizumab or other TNFα blocking drugs developed cancer. Since patients with Crohn's disease have a higher risk of cancers than the general population, the connection between cancer and use of certolizumab is unclear.

Other side effects of certolizumab include hypersensitivity (allergic) reactions (including anaphylaxis) and reduced levels in the blood of platelets and red blood cells (aplastic anemia). Certolizumab may increase the risk of reactivating hepatitis B virus in chronic carriers of the virus.

The most serious adverse reactions were:

• Serious Infections
• Malignancies
• Heart Failure

Clinical Trials Experience

Because clinical studies are conducted under widely varying and controlled conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug, and may not predict the rates observed in a broader patient population in clinical practice.

In premarketing controlled trials of all patient populations combined the most common adverse reactions (≥ 8%) were

• upper respiratory infections (18%),
• rash (9%) and
• urinary tract infections (8%).

Adverse Reactions Most Commonly Leading To Discontinuation Of Treatment In Premarketing Controlled Trials

The proportion of patients with Crohn’s disease who discontinued treatment due to adverse reactions in the controlled clinical studies was 8% for Cimzia and 7% for placebo. The most common adverse reactions leading to the discontinuation of Cimzia (for at least 2 patients and with a higher incidence than placebo) were

• abdominal pain (0.4% Cimzia, 0.2% placebo),
• diarrhea (0.4% Cimzia, 0% placebo), and
• intestinal obstruction (0.4% Cimzia, 0% placebo).

The proportion of patients with rheumatoid arthritis who discontinued treatment due to adverse reactions in the controlled clinical studies was 5% for Cimzia and 2.5% for placebo. The most common adverse reactions leading to discontinuation of Cimzia were

• tuberculosis infections (0.5%); and
• pyrexia, urticaria, pneumonia, and rash (0.3%).

Controlled Studies With Crohn’s Disease

• The data described below reflect exposure to Cimzia at 400 mg subcutaneous dosing in studies of patients with Crohn’s disease.
• In the safety population in controlled studies, a total of 620 patients with Crohn’s disease received Cimzia at a dose of 400 mg, and 614 subjects received placebo (including subjects randomized to placebo in Study CD2 following open label dosing of Cimzia at Weeks 0, 2, 4).
• In controlled and uncontrolled studies, 1,564 patients received Cimzia at some dose level, of whom 1,350 patients received 400 mg Cimzia.
• Approximately 55% of subjects were female, 45% were male, and 94% were Caucasian. The majority of patients in the active group were between the ages of 18 and 64.
• During controlled clinical studies, the proportion of patients with serious adverse reactions was 10% for Cimzia and 9% for placebo.
• The most common adverse reactions (occurring in ≥ 5% of Cimzia-treated patients, and with a higher incidence compared to placebo) in controlled clinical studies with Cimzia were upper respiratory infections (e.g. nasopharyngitis, laryngitis, viral infection) in 20% of Cimzia-treated patients and 13% of placebo-treated patients, urinary tract infections (e.g. bladder infection, bacteriuria, cystitis) in 7% of Cimzia-treated patients and in 6% of placebo-treated patients, and arthralgia (6% Cimzia, 4% placebo).

Other Adverse Reactions

The most commonly occurring adverse reactions in controlled trials of Crohn’s disease were described above. Other serious or significant adverse reactions reported in controlled and uncontrolled studies in Crohn’s disease and other diseases, occurring in patients receiving Cimzia at doses of 400 mg or other doses include:

• Blood and lymphatic system disorders: Anemia, leukopenia, lymphadenopathy, pancytopenia, and thrombophilia.
• Cardiac disorders: Angina pectoris, arrhythmias, atrial fibrillation, cardiac failure, hypertensive heart disease, myocardial infarction, myocardial ischemia, pericardial effusion, pericarditis, stroke and transient ischemic attack.
• Eye disorders: Optic neuritis, retinal hemorrhage, and uveitis.
• General disorders and administration site conditions: Bleeding and injection site reactions.
• Hepatobiliary disorders: Elevated liver enzymes and hepatitis.
• Immune system disorders: Alopecia totalis.
• Psychiatric disorders: Anxiety, bipolar disorder, and suicide attempt.
• Renal and urinary disorders: Nephrotic syndrome and renal failure.
• Reproductive system and breast disorders: Menstrual disorder.
• Skin and subcutaneous tissue disorders: Dermatitis, erythema nodosum, and urticaria.
• Vascular disorders: Thrombophlebitis, vasculitis.

Controlled Studies with Rheumatoid Arthritis

• Cimzia was studied primarily in placebo-controlled trials and in long-term follow-up studies.
• The data described below reflect the exposure to Cimzia in 2,367 RA patients, including 2,030 exposed for at least 6 months, 1,663 exposed for at least one year and 282 for at least 2 years; and 1,774 in adequate and well-controlled studies.
• In placebo-controlled studies, the population had a median age of 53 years at entry; approximately 80% were females, 93% were Caucasian and all patients were suffering from active rheumatoid arthritis, with a median disease duration of 6.2 years.
• Most patients received the recommended dose of Cimzia or higher.
• Table 1 summarizes the reactions reported at a rate of at least 3% in patients treated with Cimzia 200 mg every other week compared to placebo (saline formulation), given concomitantly with methotrexate.

Table 1: Adverse Reactions Reported by ≥3% of Patients Treated with Cimzia Dosed Every Other Week during Placebo-Controlled Period of Rheumatoid Arthritis Studies, with Concomitant Methotrexate.

Hypertensive adverse reactions were observed more frequently in patients receiving Cimzia than in controls. These adverse reactions occurred more frequently among patients with a baseline history of hypertension and among patients receiving concomitant corticosteroids and non-steroidal anti-inflammatory drugs.

Patients receiving Cimzia 400 mg as monotherapy every 4 weeks in rheumatoid arthritis controlled clinical trials had similar adverse reactions to those patients receiving Cimzia 200 mg every other week.

Other Adverse Reactions

• Other infrequent adverse reactions (occurring in less than 3% of RA patients) were similar to those seen in Crohn’s disease patients.

Psoriatic Arthritis Clinical Study

• Cimzia has been studied in 409 patients with psoriatic arthritis (PsA) in a placebo-controlled trial.
• The safety profile for patients with PsA treated with Cimzia was similar to the safety profile seen in patients with RA and previous experience with Cimzia.

Ankylosing Spondylitis Clinical Study

• Cimzia has been studied in 325 patients with axial spondyloarthritis of whom the majority had ankylosing spondylitis (AS) in a placebo-controlled study (AS-1).
• The safety profile for patients in study AS-1 treated with Cimzia was similar to the safety profile seen in patients with RA.

Plaque Psoriasis Clinical Studies

• In clinical studies, a total of 1112 subjects with plaque psoriasis were treated with Cimzia.
• Of these, 779 subjects were exposed for at least 12 months, 551 for 18 months, and 66 for 24 months.
• Data from three placebo-controlled studies (Studies PS-1, PS-2, and PS-3) in 1020 subjects (mean age 46 years, 66% males, 94% white) were pooled to evaluate thesafety of Cimzia.

Placebo-Controlled Period (Week 0-16)

• In the placebo-controlled period of Studies PS-1, PS-2 and PS-3 in the 400 mg group, adverse events occurred in 63.5% of subjects in the Cimzia group compared to 61.8% of subjects in the placebo group.
• The rates of serious adverse events were 4.7% in the Cimzia group and 4.5% in the placebo group.
• Table 2 summarizes the adverse reactions that occurred at a rate of at least 1% and at a higher rate in the Cimzia group than in the placebo group.

Table 2: Adverse Reactions Occurring in ≥1% of Subjects in the Cimzia Group and More Frequently than in the Placebo Group in the Plaque Psoriasis Studies PS-1, PS-2, and PS-3.

Elevated Liver Enzymes

• Elevated liver enzymes were reported more frequently in the Cimzia-treated subjects (4.3% in the 200 mg group and 2.3% in the 400 mg group) than in the placebo-treated subjects (2.5%).
• Of Cimzia-treated subjects who had elevation of liver enzymes, two subjects were discontinued from the trial.
• In controlled Phase 3 studies of Cimzia in adults with PsO with a controlled period duration ranging from 0 to 16 weeks, AST and/or ALT elevations ≥5 x ULN occurred in 0.9% of Cimzia 200 mg or Cimzia 400 mg arms and none in placebo arm.

Psoriasis-Related Adverse Events

• In controlled clinical studies in psoriasis, change of plaque psoriasis into a different psoriasis sub-types (including erythrodermic, pustular and guttate), was observed in <1% of Cimzia treated subjects.

Adverse Reactions Of Special Interest Across Indications

Infections

• The incidence of infections in controlled studies in Crohn’s disease was 38% for Cimzia-treated patients and 30% for placebo-treated patients.
• The infections consisted primarily of upper respiratory infections (20% for Cimzia, 13% for placebo).
• The incidence of serious infections during the controlled clinical studies was 3% per patient-year for Cimzia-treated patients and 1% for placebo-treated patients.
• Serious infections observed included bacterial and viral infections, pneumonia, and pyelonephritis.
• The incidence of new cases of infections in controlled clinical studies in rheumatoid arthritis was 0.91 per patient-year for all Cimzia-treated patients and 0.72 per patient-year for placebo-treated patients.
• The infections consisted primarily of upper respiratory tract infections, herpes infections, urinary tract infections, and lower respiratory tract infections.
• In the controlled rheumatoid arthritis studies, there were more new cases of serious infection adverse reactions in the Cimzia treatment groups, compared to the placebo groups (0.06 per patient-year for all Cimzia doses vs. 0.02 per patient-year for placebo).
• Rates of serious infections in the 200 mg every other week dose group were 0.06 per patient-year and in the 400 mg every 4 weeks dose group were 0.04 per patient-year.
• Serious infections included tuberculosis, pneumonia, cellulitis, and pyelonephritis.
• In the placebo group, no serious infection occurred in more than one subject.
• There is no evidence of increased risk of infections with continued exposure over time.
• In controlled clinical studies in psoriasis, the incidence rates of infections were similar in the Cimzia and placebo groups.
• The infections consisted primarily of upper respiratory tract infections and viral infections (including herpes infections).
• Serious adverse events of infection occurred in Cimzia-treated patients during the placebo-controlled periods of the pivotal studies (pneumonia, abdominal abscess, and hematoma infection) and Phase 2 study (urinary tract infection, gastroenteritis, and disseminated tuberculosis).

Tuberculosis And Opportunistic Infections

• In completed and ongoing global clinical studies in all indications including 5,118 Cimzia-treated patients, the overall rate of tuberculosis is approximately 0.61 per 100 patient-years across all indications.
• The majority of cases occurred in countries with high endemic rates of TB.
• Reports include cases of disseminated (miliary, lymphatic, and peritoneal) as well as pulmonary TB.
• The median time to onset of TB for all patients exposed to Cimzia across all indications was 345 days. In the studies with Cimzia in RA, there were 36 cases of TB among 2,367 exposed patients, including some fatal cases.
• Rare cases of opportunistic infections have also been reported in these clinical trials. In Phase 2 and Phase 3 studies with Cimzia in plaque psoriasis, there were 2 cases of TB among 1112 exposed patients.

Malignancies

• In clinical studies of Cimzia, the overall incidence rate of malignancies was similar for Cimzia-treated and control patients.
• For some TNF blockers, more cases of malignancies have been observed among patients receiving those TNF blockers compared to control patients.

Heart Failure

• In placebo-controlled and open-label studies, cases of new or worsening heart failure have been reported for Cimzia-treated patients.
• The majority of these cases were mild to moderate and occurred during the first year of exposure.

Hypersensitivity Reactions

• The following symptoms that could be compatible with hypersensitivity reactions have been reported rarely following Cimzia administration to patients:
  • angioedema,
  • allergic dermatitis,
  • dizziness (postural),
  • dyspnea,
  • hot flush,
  • hypotension,
  • injection site reactions,
  • malaise,
  • pyrexia,
  • rash,
  • serum sickness, and
  • (vasovagal) syncope.

Autoantibodies

• In clinical studies in Crohn’s disease, 4% of patients treated with Cimzia and 2% of patients treated with placebo that had negative baseline ANA titers developed positive titers during the studies.
• One of the 1,564 Crohn’s disease patients treated with Cimzia developed symptoms of a lupus-like syndrome.
• In clinical trials of TNF blockers, including Cimzia, in patients with RA, some patients have developed ANA.
• Four patients out of 2,367 patients treated with Cimzia in RA clinical studies developed clinical signs suggestive of a lupus-like syndrome.
• The impact of long-term treatment with Cimzia on the development of autoimmune diseases is unknown.

Immunogenicity

• As with all therapeutic proteins, there is potential for immunogenicity.
• The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay.
• Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease.
• For these reasons, comparison of the incidence of antibodies to certolizumab pegol in the studies described below with the incidence of antibodies in other studies or to other products may be misleading.
• Patients with Crohn’s disease were tested at multiple time points for antibodies to certolizumab pegol during Studies CD1 and CD2.
• In patients continuously exposed to Cimzia, the overall percentage of patients who were antibody positive to Cimzia on at least one occasion was 8%; approximately 6% were neutralizing in vitro.
• No apparent correlation of antibody development to adverse events or efficacy was observed.
• Patients treated with concomitant immunosuppressants had a lower rate of antibody development than patients not taking immunosuppressants at baseline (3% and 11%, respectively).
• The following adverse events were reported in Crohn’s disease patients who were antibody-positive (N = 100) at an incidence at least 3% higher compared to antibody-negative patients (N = 1,242):
  • abdominal pain,
  • arthralgia,
  • edema peripheral,
  • erythema nodosum,
  • injection site erythema,
  • injection site pain,
  • pain in extremity, and
  • upper respiratory tract infection.
• In two long-term (up to 7 years of exposure), open-label Crohn’s disease studies, overall 23% (207/903) of patients developed antibodies against certolizumab pegol on at least one occasion.
• Of the 207 patients who were antibody positive, 152 (73%) had a persistent reduction of drug plasma concentration, which represents 17% (152/903) of the study population.
• The data from these two studies do not suggest an association between the development of antibodies and adverse events.
• The overall percentage of patients with antibodies to certolizumab pegol detectable on at least one occasion was 7% (105 of 1,509) in the rheumatoid arthritis placebo-controlled trials.
• Approximately one third (3%, 39 of 1,509) of these patients had antibodies with neutralizing activity in vitro.
• Patients treated with concomitant immunosuppressants (MTX) had a lower rate of antibody development than patients not taking immunosuppressants at baseline.
• Patients treated with concomitant immunosuppressant therapy (MTX) in RA-I, RA-II, RA-III had a lower rate of neutralizing antibody formation overall than patients treated with Cimzia monotherapy in RA-IV (2% vs. 8%).
• Both the loading dose of 400 mg every other week at Weeks 0, 2 and 4 and concomitant use of MTX were associated with reduced immunogenicity.
• Antibody formation was associated with lowered drug plasma concentration and reduced efficacy.
• In patients receiving the recommended Cimzia dosage of 200 mg every other week with concomitant MTX, the ACR20 response was lower among antibody positive patients than among antibody-negative patients (Study RA-I, 48% versus 60%; Study RA-II 35% versus 59%, respectively).
• In Study RA-III, too few patients developed antibodies to allow for meaningful analysis of ACR20 response by antibody status.
• In Study RA-IV (monotherapy), the ACR20 response was 33% versus 56%, antibody-positive versus antibody-negative status, respectively.
• No association was seen between antibody development and the development of adverse events.
• Approximately 8 % (22/265) and 19% (54/281) of subjects with psoriasis who received Cimzia 400 mg every 2 weeks and Cimzia 200 mg every 2 weeks for 48 weeks, respectively, developed antibodies to certolizumab pegol.
• Of the subjects who developed antibodies to certolizumab pegol, 45% (27/60) had antibodies that were classified as neutralizing.
• Antibody formation was associated with lowered drug plasma concentration and reduced efficacy.
• The data reflect the percentage of patients whose test results were considered positive for antibodies to certolizumab pegol in an ELISA, and are highly dependent on the sensitivity and specificity of the assay.

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of Cimzia. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate reliably their frequency or establish a causal relationship to drug exposure.

• Vascular disorder: systemic vasculitis has been identified during post-approval use of TNF blockers.
• Skin: case of severe skin reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, and new or worsening psoriasis (all sub-types including pustular and palmoplantar) have been identified during post-approval use of TNF blockers.
• Immune System Disorders: sarcoidosis
• Neoplasms benign, malignant and unspecified (including cysts and polyps): Melanoma, Merkel cell carcinoma (neuroendocrine carcinoma of the skin).

Use With Anakinra, Abatacept, Rituximab, And Natalizumab

• An increased risk of serious infections has been seen in clinical studies of other TNF-blocking agents used in combination with anakinra or abatacept, with no added benefit.
• Formal drug interaction studies have not been performed with rituximab or natalizumab.
• Because of the nature of the adverse events seen with these combinations with TNF blocker therapy, similar toxicities may also result from the use of Cimzia in these combinations.
• There is not enough information to assess the safety and efficacy of such combination therapy.
• Therefore, the use of Cimzia in combination with anakinra, abatacept, rituximab, or natalizumab is not recommended.

Live Vaccines

• Avoid use of live (including attenuated) vaccines concurrently with Cimzia.

Laboratory Tests

• Interference with certain coagulation assays has been detected in patients treated with Cimzia.
• Certolizumab pegol may cause erroneously elevated activated partial thromboplastin time (aPTT) assay results in patients without coagulation abnormalities.This effect has been observed with the PTT-Lupus Anticoagulant (LA) test and Standard Target Activated Partial Thromboplastin time (STA-PTT) Automate tests from Diagnostica Stago, and the HemosIL APTT-SP liquid and HemosIL lyophilized silica tests from Instrumentation Laboratories.
• Other aPTT assays may be affected as well. Interference with thrombin time (TT) and prothrombin time (PT) assays has not been observed.
• There is no evidence that Cimzia therapy has an effect on in vivo coagulation.