Disease-modifying treatment of grass pollen induced rhinitis and conjunctivitis in adults and children (5 years or older), with clinically relevant symptoms and diagnosed with a positive skin prick test and/or specific IgE test to grass pollen.

Posology

The recommended dose for adults and children (5 years or older) is one sublingual lyophilisate (75,000 SQ-T) daily.

Grazax treatment should only be initiated by physicians with experience in treatment of allergic diseases and the capability to treat allergic reactions.

Elderly population

Clinical experience on immunotherapy with Grazax in elderly (65 years or older) is lacking.

Paediatric population

For treatment of children, physicians should be experienced in treating allergic diseases in children. Clinical experience on immunotherapy with Grazax in children younger than 5 years is lacking.

Method of administration

In order to enable patient and physician to discuss any side effects and possible actions it is recommended that the first sublingual lyophilisate is taken under medical supervision (20-30 minutes).

Clinical effect on grass pollen allergic rhinitis and conjunctivitis in the grass pollen season is expected when treatment is initiated at least 4 months prior to the expected start of the grass pollen season and continued throughout the season. If treatment is initiated 2-3 months before the season some efficacy may also be obtained. If no relevant improvement of symptoms is observed during the first pollen season, there is no indication for continuing the treatment. For long term efficacy and disease modifying effect, it is recommended to continue daily treatment for 3 consecutive years.

Grazax is a sublingual lyophilisate. The sublingual lyophilisate should be taken from the blister unit with dry fingers, and placed under the tongue, where it will disperse.

Swallowing should be avoided for about 1 minute. Food and beverage should not be taken for the following 5 minutes.

The sublingual lyophilisate should be taken immediately after opening the blister.

Hypersensitivity to any of the excipients (for a full list of excipients, see section 6.1). Malignancy or systemic diseases affecting the immune system e.g. autoimmune diseases, immune complex diseases or immune deficiency diseases.

Inflammatory conditions in the oral cavity with severe symptoms such as oral lichen planus with ulcerations or severe oral mycosis.

Patients with uncontrolled or severe asthma (in adults: FEV₁ < 70% of predicted value after adequate pharmacologic treatment, in children: FEV₁ < 80% of predicted value after adequate pharmacologic treatment) should not be treated with Grazax.

Severe systemic allergic reactions

In post marketing experience, cases of serious anaphylactic reactions have been reported and therefore the medical supervision at start of treatment is an important precaution. In some cases, the serious anaphylactic reaction has occurred at doses subsequent to the initial dose.

The onset of systemic symptoms may include flushing, intensive itching in palms of hand and soles of the feet, and other areas of the body (like a nettle rash). Sense of heat, general discomfort and agitation/anxiety may also occur. In case of severe systemic reactions, angioedema, difficulty in swallowing, difficulty in breathing, changes in voice, hypotension or feeling of fullness in the throat a physician should be contacted immediately. In such cases treatment should be discontinued permanently or until otherwise advised by the physician. If patients with concomitant asthma experience symptoms and signs indicating asthma deterioration, treatment should be discontinued, and a physician consulted immediately in order to evaluate the continuation of treatment.

In patients who have previously had a systemic reaction to grass subcutaneous immunotherapy, the risk of experiencing a severe reaction with Grazax may be increased. Initiation of Grazax should be carefully considered and measures to treat reactions should be available.

Serious anaphylactic reactions may be treated with adrenaline. Consider whether your patient would be able to tolerate adrenaline (e.g. treatment with tricyclic antidrepressants, MAOIs, COMTIs and/or beta-blockers) in the rare case of a severe systemic allergic reaction.

Patients with cardiac disease may be at increased risk in case of severe systemic allergic reactions. Clinical experience with treatment with Grazax in patients with cardiac disease is limited.

Local allergic reactions

When treated with Grazax the patient is exposed to the allergen that causes the allergic symptoms. Therefore, primarily mild to moderate local allergic reactions are to be expected during the treatment period. If the patient experiences significant local adverse reactions from the treatment, anti-allergic medication (e.g. antihistamines) should be considered.

Oral conditions

In case of oral surgery, including dental extraction, and shedding of a deciduous tooth in children, treatment with Grazax should be stopped for 7 days to allow healing of oral cavity.

Asthma

Asthma is a known risk factor for severe systemic allergic reactions.

Grazax has not been studied in patients with severe and uncontrolled asthma.

Patients with asthma must be informed of the need to seek medical attention immediately if their asthma deteriorates suddenly.

In patients with asthma and experiencing an acute respiratory tract infection, initiation of Grazax treatment should be postponed until the infection has resolved.

Eosinophilic esophagitis

In post marketing experience, isolated cases of eosinophilic esophagitis have been reported in association with Grazax treatment. In patients with severe or persisting gastro-esophageal symptoms such as dysphagia or dyspepsia, discontinuation of Grazax treatment should be considered.

Simultaneous vaccination

Clinical experience in relation to simultaneous vaccination and treatment with Grazax is missing. Vaccination may be given without interrupting treatment with Grazax after medical evaluation of the general condition of the patient.

Food allergy

Grazax contains fish-derived gelatine. The available data have not indicated an increased risk of allergic reactions in severe fish allergic patients. However, awareness is suggested when initiating treatment with Grazax in these patients.

No studies investigating drug interactions have been conducted in humans.

Concomitant therapy with symptomatic anti-allergic agents (e.g. antihistamines, corticosteroids and/or mast cell stabilisers) may increase the tolerance level of the patient to immunotherapy.

There are limited data available on possible risks of simultaneous immunotherapy with other allergens during treatment with Grazax.

Pregnancy

There is no data on the clinical experience for the use of Grazax in pregnant women. Animal studies do not indicate increased risk to the foetus. Treatment with Grazax should not be initiated during pregnancy. If pregnancy occurs during treatment, the treatment may continue after evaluation of the general condition (including lung function) of the patient and reactions to previous administration of Grazax. In patients with pre-existing asthma close supervision during pregnancy is recommended.

Breastfeeding

No clinical data are available for the use of Grazax during lactation. No effects on the breastfed infants are anticipated.

Fertility

There is no clinical data with respect to fertility for the use of Grazax. In mice, there was no effect on mating or fertility with Grazax treatment (see section 5.3).

Treatment with Grazax has no or negligible influence on the ability to drive or use machines.

Summary of the safety profile

Subjects taking Grazax should primarily expect mild to moderate local allergic reactions to occur early in therapy that tend to subside spontaneously within 1 to 7 days. The most commonly reported adverse reactions are oral pruritus, throat irritation and oedema mouth. For the majority of events, the reaction should be expected to start within 5 minutes after intake of Grazax on each day of occurrence and abate after minutes to hours. More severe local or systemic allergic reactions may occur (see section 4.4).

Tabulated list of adverse reactions

Table 1, which shows the adverse reactions, is based on data from placebo-controlled clinical trials investigating Grazax in adult and paediatric patients with seasonal grass-pollen induced rhinoconjunctivitis including patients with mild to moderate co-existing grass-pollen induced asthma and from spontaneous reporting.

Adverse reactions are divided into groups according to the MedDRA convention frequencies: Very common (≥ 1/10), common (≥ 1/100 to <1/10), uncommon (≥ 1/1,000 to <1/100), rare (≥ 1/10,000 to <1/1,000), very rare (<1/10,000).

Table 1. Adverse reactions

Description of selected adverse reactions

If the patient experiences significant adverse events from the treatment, anti-allergic medication should be considered.

In post marketing experience, cases of serious anaphylactic reactions, including anaphylactic shock have been reported. Medical supervision at start of treatment is therefore an important precaution. In some cases the serious anaphylactic reaction has occurred at doses subsequent to the initial dose. Please refer to section 4.2 and 4.4.

In case of severe systemic reactions, angioedema, difficulty in swallowing, difficulty in breathing, changes in voice, hypotension or feeling of fullness in the throat a physician should be contacted immediately. In such cases treatment should be discontinued permanently or until otherwise advised by the physician.

Paediatric population

Overall, the adverse events profile in paediatric patients treated with Grazax was similar to that observed in adults. Most events were seen with a similar frequency category for paediatric patients compared to adults. In the paediatric population, eye irritation, ear pain, ear swelling, pharyngeal erythema and oral mucosal blistering are seen at a higher frequency than in table 1: eye irritation, ear pain, pharyngeal erythema and oral mucosal blistering were common and the ear swelling was uncommon. The events were primarily mild to moderate in severity.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the MHRA Yellow Card Scheme (www.mhra.gov.uk/yellowcard) or search for MHRA Yellow Card in the Google Play or Apple App Store.

In phase I studies adult patients with grass pollen allergy were exposed to doses up to 1,000,000 SQ-T. No data is available in children regarding exposure to doses above the recommended daily dose of 75,000 SQ-T.

If doses higher than the recommended daily dose are taken, the risk of side effects may increase, including the risk of systemic allergic reactions or severe local allergic reactions. In case of severe reactions such as angioedema, difficulty in swallowing, difficulty in breathing, changes in voice, or feeling of fullness in the throat, immediate medical evaluation is needed. These reactions should be treated with relevant symptomatic medication.

In such cases treatment should be discontinued permanently or until otherwise advised by the physician.

Pharmacotherapeutic group: Allergen extracts, Grass pollen.

ATC code: V01AA02.

Mechanism of action

Grazax is allergy immunotherapy. Allergy immunotherapy with allergen products is the repeated administration of allergens to allergic individuals with the purpose of modifying the immunological response to the allergen, providing sustained relief of symptoms, less need for medication, and improvement in quality of life during subsequent natural allergen exposure.

Grazax is disease-modifying treatment of grass pollen induced rhinitis and conjunctivitis for patients with clinically relevant symptoms. Disease modification in adults and children is demonstrated by sustained post-treatment effect on rhinoconjunctivitis observed 2 years after 3 years of treatment with Grazax.

The immune system is the target for the pharmacodynamic effect. The aim is to induce an immune response against the allergen with which the patient is treated. The complete and exact mechanism of action regarding clinical effect of specific immunotherapy is not fully understood and documented. Treatment with Grazax has shown to induce a systemic competitive antibody response towards grass, and it induces an increase in specific IgG4 over 3 years of treatment. 2 years after completed Grazax treatment the increase in specific IgG4 was still present. The clinical significance of these findings has not been established.

Clinical efficacy and safety in adults

The efficacy of Grazax once-daily on rhinoconjunctivitis was evaluated in a randomised, double-blind, placebo controlled multi-national trial (GT-08), including 634 adult patients with grass pollen induced rhinoconjunctivitis. 72% of the patients had positive skin prick tests to one or more allergens other than grass pollen. The efficacy was based on the average daily rhinoconjunctivitis symptom and medication score during one grass pollen season. Treatment was initiated at least 16 weeks before the anticipated start of the first grass pollen season and was continued all year round.

Daily treatment with Grazax in adult patients for 3 years resulted in disease modification as demonstrated by a sustained effect after the completion of treatment (effect demonstrated after 1 and 2 years of follow-up). The magnitude of effect varied over the 5 seasons with a peak in season 2 and a possible trend towards a gradual decrease from season 3 to season 5 (1 additional treatment season +2 treatment free follow-up seasons). The variation in treatment effect followed the variation in grass pollen exposure. However, it cannot presently be established if the decrease in grass pollen exposure is the sole explanation for the possible trend towards a gradual decrease in treatment effect seen in seasons 3-5.

The efficacy and safety of Grazax has not been established in patients with significant allergic symptoms in the grass pollen season caused by other allergens than grass pollen.

Results after 3 years of daily Grazax treatment (Year 1-3) and 2 years of follow-up (Year 4-5) in adults are available in table 2 and table 3.

Table 2 Primary efficacy endpoints years 1-5 in adults

Table 3. Secondary efficacy endpoints years 1-5 in adults

Statistically significant effect was demonstrated for each of the scored rhinoconjunctivitis symptoms (runny nose, blocked nose, sneezing, itchy nose, gritty feeling/red/itchy eyes and watery eyes).

In a trial with shorter pre-treatment, less reductions in symptom and medication scores were found; Grazax treatment approximately 2 months prior to and during the grass pollen season resulted in a symptom score reduction of 16% (p=0.071) and a medication score reduction of 28% (p=0.047) (full analysis set).

Paediatric population

The short term efficacy of Grazax on rhinoconjunctivitis has been investigated in a randomised, double-blind, placebo controlled trial (GT-12) including 238 children (5– 16 years) with grass pollen induced rhinoconjunctivitis with/without asthma. Patients received treatment prior to the grass pollen season and continued throughout the entire season (table 4).

The long term efficacy of Grazax has been investigated in a randomised, double-blind, placebo-controlled, multinational trial (GT-21) including 812 children (5-12 years) with a clinically relevant history of grass pollen allergic rhinoconjunctivitis and no medical history of asthma. Daily treatment with Grazax for 3 years resulted in a sustained post-treatment effect on rhinoconjunctivitis symptoms. The effect on rhinoconjunctivitis symptoms was evident when assessed during the entire 5-year trial period, during the 2-year follow-up period after completion of treatment and at end of trial. Data on the clinical efficacy are shown in table 4.

Table 4. Efficacy of Grazax on rhinoconjunctivitis in children

The main part of the allergens in Grazax is polypeptides and proteins, which are expected to be broken down to amino acids and small polypeptides in the lumen of the gastrointestinal tract and in tissues. It is expected that allergens from Grazax are not absorbed into the vascular system to any significant extent. Thus, no pharmacokinetic studies in animals or clinical studies investigating the pharmacokinetic profile and metabolism of Grazax have been conducted.

Conventional studies in general toxicity in mice revealed no special hazard for humans. In toxicological studies in dogs, daily dosing for 52 weeks was associated with vasculitis/perivasculitis in males, but not in females. It is not expected that there is a risk of developing vasculitis/perivasculitis in humans. In a combined fertility and embryo-foetal development study in mice, mating performance and fertility were unaffected, and there were no adverse foetal findings. In a pre-/postnatal development study, mouse development was normal.

Gelatine (fish source)

Mannitol

Sodium hydroxide (for pH adjustment)

Not applicable.

5 years.

This medical product does not require any special storage conditions.

Aluminium blister cards with removable aluminium foil in an outer carton box. Each blister card contains 10 sublingual lyophilisates.

Pack sizes: 30 (3x10) sublingual lyophilisates, 90 (9x10) sublingual lyophilisates and 100 (10x10) sublingual lyophilisates.

Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.