MIRCERA 30 micrograms/0.3 ml solution for injection in pre-filled syringe

• Keep this leaflet. You may need to read it again.
• If you have any further questions, ask your doctor or pharmacist.
• This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
• If you get any side effects, talk to your doctor. This includes any possible side effects not listed in this leaflet. See section 4.

1. What MIRCERA is and what it is used for
2. What you need to know before you use MIRCERA
3. How to use MIRCERA
4. Possible side effects
5. How to store MIRCERA
6. Contents of the pack and other information

• if you are allergic to methoxy polyethylene glycol-epoetin beta or to any of the other ingredients of this medicine (listed in section 6)
• if you have high blood pressure that cannot be controlled

The safety and efficacy of MIRCERA therapy in other indications, including anaemia in patients with cancer, has not been established.

The safety and efficacy of MIRCERA therapy in paediatric patients have only been established in patients whose haemoglobin level has been previously stabilised by treatment with an ESA.

Before treatment with MIRCERA

• A condition called Pure Red Cell Aplasia (PRCA, stopped or reduced production of red blood cells) due to anti-erythropoietin antibodies was observed in some patients treated with erythropoiesis stimulating agents (ESAs), including MIRCERA.
• If your doctor suspects or confirms that you have these antibodies in your blood, you must not be treated with MIRCERA.
• If you are a patient with hepatitis C and you receive interferon and ribavirin you should discuss this with your doctor because a combination of ESAs with interferon and ribavirin has led to a loss of effect and development of PRCA, a severe form of anaemia, in rare cases. ESAs are not approved in the management of anaemia associated with hepatitis C.
• If you are a patient with chronic kidney disease and anaemia treated with an ESA and are also a cancer patient you should be aware that ESAs, might have a negative impact on your condition. You should discuss options for anaemia treatment with your doctor.
• It is not known if MIRCERA has a different effect in patients with haemoglobinopathies (disorders associated with abnormal haemoglobin), past or present bleeding, seizures or with a high blood platelet count. If you have any of these conditions, your doctor will discuss it with you and must treat you with caution.
• Healthy people should not use MIRCERA. Using it can lead to too high haemoglobin levels and cause problems with the heart or blood vessels that may be life-threatening.

During treatment with MIRCERA

• If you are a patient with chronic renal failure, and particularly if you do not respond properly to MIRCERA, your doctor will check your dose of MIRCERA because repeatedly increasing your dose of MIRCERA if you are not responding to treatment may increase the risk of having a problem of the heart or the blood vessels and could increase risk of myocardial infarction, stroke and death.
• Your doctor may initiate treatment with MIRCERA if your haemoglobin level is 10 g/dl (6.21 mmol/l) or less. After initiation of therapy, your doctor will seek to maintain your haemoglobin level between 10 and 12 g/dl (7.45 mmol/l).
• Your doctor will check the amount of iron in your blood before and during MIRCERA treatment. If the amount is too low your doctor may give you an additional iron supplement.
• Your doctor will check your blood pressure before and during your MIRCERA treatment. If your blood pressure is high and cannot be controlled, either by appropriate medicines or a special diet, your doctor will interrupt your MIRCERA treatment or reduce the dose.
• Your doctor will check that your haemoglobin does not exceed a certain level, as high haemoglobin could put you at risk of having a problem of the heart or the blood vessels and could increase risk of thrombosis, including pulmonary embolism, myocardial infarction, stroke and death.
• Contact your doctor if you feel tired, weak or have shortness of breath, because this could mean that your MIRCERA treatment is not effective. Your doctor will check that you do not have other causes of anaemia and may perform blood tests or examine your bone marrow. If you have developed PRCA, your MIRCERA treatment will be discontinued. You will not receive another ESA and your doctor will treat you for this condition.

MIRCERA can be used for the treatment of children and adolescents, 3 months of age to less than 18 years, with anaemia associated with chronic kidney disease. They should be stabilised on ESA maintenance treatment prior to switching to MIRCERA and may or may not be receiving dialysis. Talk to your doctor, pharmacist or nurse before you are given this medicine if you, or your child, are under 18 years of age.

Take special care with other products that stimulate red blood cell production: MIRCERA is one of a group of products that stimulate the production of red blood cells like the human protein erythropoietin does. Your healthcare professional will always record the exact product you are using.

Serious skin reactions including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported in association with epoetin treatment.

SJS/TEN can appear initially as reddish target-like spots or circular patches often with central blisters on the trunk. Also, ulcers of mouth, throat, nose, genitals and eyes (red and swollen eyes) can occur. These serious skin rashes are often preceded by fever and/or flu-like symptoms. The rashes may progress to widespread peeling of the skin and life-threatening complications.

If you develop a serious rash or another of these skin symptoms stop taking Mircera and contact your doctor or seek medical attention immediately.

Tell your doctor or pharmacist if you are using, have recently used or might use any other medicines. No interaction studies have been performed. There is no evidence that MIRCERA interacts with other medicines.

Food and drink do not affect MIRCERA.

Ask your doctor or pharmacist for advice before taking any medicine.

MIRCERA has not been studied in pregnant or breast-feeding women.

Tell your doctor if you are pregnant, think you are pregnant or intend to become pregnant. Your doctor will consider what is the best treatment for you during pregnancy.

Tell your doctor if you are breast-feeding or intend to breast-feed. Your doctor will advise if you should stop or continue breast-feeding and stop or continue your treatment.

MIRCERA has not shown evidence of impaired fertility in animals. The potential risk for humans is unknown.

MIRCERA does not affect your ability to drive and use machines.

This medicine contains less than 1 mmol sodium (23 mg) per ml, that is to say it is essentially ‘sodium-free’.

Please contact your doctor or pharmacist if you used too large a dose of MIRCERA as it may be necessary to perform some blood tests and interrupt your treatment.

If you miss a dose of MIRCERA administer the missed dose as soon as you remember and talk to your doctor about when to use the next doses.

Treatment with MIRCERA is normally long-term. It can, however, be stopped on the advice of your doctor at any time.

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. By reporting side effects you can help provide more information on the safety of this medicine.

• The active substance is methoxy polyethylene glycol-epoetin beta. One pre-filled syringe contains:
  30, 50, 75, 100, 120, 150, 200 or 250 micrograms in 0.3 ml and 360 micrograms in 0.6 ml.
• The other ingredients are sodium dihydrogen phosphate monohydrate, sodium sulphate, mannitol (E421), methionine, poloxamer 188 and water for injections.

MIRCERA is a solution for injection in pre-filled syringe.

The solution is clear, colourless to slightly yellowish and free of visible particles.

MIRCERA comes in pre-filled syringes with laminated plunger stopper and tip cap with one needle 27G1/2. Each pre-filled syringe contains 0.3 ml or 0.6 ml. Pre-filled syringes are not designed for administration of partial doses. MIRCERA is available, for all strengths, in pack sizes of 1 and also pack size of 3 for the strengths 30, 50, 75 micrograms/0.3ml. Not all pack sizes may be marketed.

• Only use MIRCERA pre-filled syringe if you have been prescribed this medication.
• Read the packaging and ensure you have the dose prescribed by your healthcare professional.
• Do not use MIRCERA if the syringe, the needle, the box or the plastic tray containing the syringe appears to be damaged.
• The needle is fragile, handle it with care.
• Do not touch the activation guards (see Figure A) as this may damage the syringe and make it unusable.
• Do not use the syringe if the contents are cloudy, hazy or contain particles.
• Never attempt to take the syringe apart.
• Never handle or pull on the syringe by its plunger.
• Do not remove the needle shield until you are ready to perform an injection.
• Do not swallow the medicine in the syringe.
• Do not inject through clothing.
• Do not reuse or resterilze the syringe or the needle.
• Pre-filled syringes are not designed for administration of partial doses.
• Keep syringe, needle and supplies out of the reach of children.

Keep the pre-filled syringe, the needle and the puncture-resistant/ sharps container out of the reach of children.

Store the syringe and the needle in its original box until ready to use.

Always store the syringe and the needle in a refrigerator at a temperature of 2 - 8°C (35.6 - 46.4°F).

Do not allow the medicine to freeze, and protect the medicine and the needle from light.

Keep the syringe and the needle dry.

• A pre-filled syringe containing MIRCERA
• A separate injection needle

Cleansing alcohol swabs

Sterile cotton ball or gauze

Puncture-resistant container or sharps container for safe disposal of needle and used syringe

Assemble all of the supplies you will need for an injection on a clean, well-lit flat surface such as a table.

Step 1: Allow the syringe to adjust to room temperature

Carefully remove the box containing the MIRCERA pre-filled syringe and the needle from the refrigerator. Keep the syringe in the box to protect it from light and allow it to reach room temperature for at least 30 minutes (Figure C).

• Not allowing the medicine to come to room temperature could result in an uncomfortable injection, and it may be difficult to depress the plunger.
• Do not warm up the syringe in any other way.

Open the box and Remove the plastic tray with the MIRCERA pre-filled syringe without peeling back the protective film (Figure D).

Step 2: Clean your hands

Disinfect your hands well with soap and warm water or hands sanitizer (Figure E).

Step 3: Unpack and visually inspect the pre-filled syringe

Peel back the protective film from the plastic tray and remove the packed needle and the syringe, holding the syringe by the middle of the body without touching the activation guards (Figure F).

Only handle the syringe by the body, because any contact with the activation guards could cause premature release of the safety device.

Examine the syringe for damage and check the expiration date on the syringe and box. This is important to ensure that the syringe and medicine are safe to use (Figure G).

Do not use the syringe if:

• You have accidentally dropped the syringe.
• Any part of the syringe appears to be damaged.
• The contents are cloudy, hazy or contain particles.
• If the colour is other than colourless to slightly yellowish.
• The expiration date has passed.

Step 4. Attach the needle to the syringe

Grasp the syringe in the middle of the body, hold the rubber tip cap firmly, and remove the rubber tip cap from the syringe (bend and pull) (Figure H).

• Once removed, immediately dispose of the rubber tip cap in the sharps/ puncture-resistant container.
• Do not touch the activation guards.
• Do not push the plunger.
• Do not pull on the plunger.

Grasp the packaged needle firmly in both hands and examine the packaged needle for damage. Break the seal of the needle, using a twisting motion, and remove the needle cap (Figure I).

Immediately throw away the needle cap in the sharps / puncture-resistant container or sharps container.

Do not remove the needle shield that protects the needle.

Do not use the needle if:

• You have accidently dropped the needle
• Any part of the needle appears to be damaged.

Attach the needle to the syringe by pushing it firmly straight onto the syringe and by twisting or turning it slightly (Figure J).

Step 5. Remove the needle shield and prepare for injection

Hold the syringe firmly with one hand in the middle of the body and pull the needle shield straight off with the other hand. Throw away the needle shield in the sharps/ puncture-resistant container or sharps container (Figure K).

• Once the needle shield is removed do not touch the needle or let it touch any surface, as the needle may become contaminated and may cause injury and pain if touched.
• You may see a drop of liquid at the end of the needle. This is normal.
• Never reattach the needle shield after removal.

To remove air bubbles from the pre-filled syringe, hold the syringe with the needle pointing up. Tap the syringe gently to bring any bubbles to the top (Figure L and M).

Push the plunger up slowly to remove all air, as shown to you by a healthcare professional. (Figure M).

Step 6. Perform the injection

There are two different ways (routes) to inject MIRCERA into your body. Follow the recommendations of your healthcare professional about how you should inject MIRCERA.

If you are advised to inject MIRCERA under your skin, please administer your dose as described below.

Choose one of the recommended injection sites as shown.

You may inject MIRCERA into the upper arm, thigh or abdomen, but not in the area around the navel (belly button) (Figure N).

The back of the upper arm is not a recommended site for self-injection. Use this injection site only if you inject someone else.

When selecting an injection site:

• You should use a different injection site each time you administer an injection, at least three centimeters from the area you used for the previous injection.
• Do not inject into areas that could be irritated by a belt or waistband.
• Do not inject into moles, scars, bruises, or areas where the skin is tender, red, hard or not intact.

Clean the chosen injection site area using an alcohol pad to reduce the risk of infection; carefully follow the instructions of the alcohol pad (Figure O).

• Let the skin dry for approximately 10 seconds.
• Be sure not to touch the cleaned area prior to the injection and do not fan or blow on the clean area.
• Immediately throw away the alcohol pad.

Adopt a comfortable posture before performing an injection of MIRCERA.

To be sure the needle can be inserted correctly under the skin, use your free hand to pinch a fold of loose skin at the clean injection site. Pinching the skin is important to ensure that you inject under the skin (into fatty tissue) but not any deeper (into muscle). Injection into muscle could result in an uncomfortable injection (Figure P).

Carefully fully insert the needle into the skin at an angle of 90° in a quick, “dart-like” motion. Then keep the syringe in position and let go of the pinch of skin.

Do not move the needle while it is inserted in the skin.

Once the needle is fully inserted into the skin, slowly push the plunger with your thumb while holding the syringe with the forefinger and the middle finger against the finger grips until all the medicine is injected. The plunger rod should be fully pushed down (depressed) and you should hear a click indicating the activation of the needle guard (Figure Q).

Do not release the plunger before the end of injection or before the plunger is completely depressed.

Take the needle out of the skin WITHOUT releasing the plunger (Figure R).

Release the plunger, allowing the needle guard to protect the needle (Figure S).

Now, the tear-off label can be removed, if necessary (Figure T).

• Place a sterile cotton ball or gauze over the injection site and press for several seconds.
• Immediately throw away the cotton ball or the gauze after use.
• Do not rub the injection site with a dirty hand or cloth.
• If needed, you may cover the injection site with a small bandage.

• Do not try to replace the needle shield on the needle.
• Do not reuse or resterilize the syringe and/or the needle.
• Do not throw away used syringes with the needle via the household waste.
• Throw away used syringes in a sharps/ puncture-resistant container and/or according to health institutions policies.
• Dispose of the full sharps/ puncture resistant container.

If your healthcare professional has recommended injection of MIRCERA into a vein, you should follow the procedure described below.

After preparation of the syringe as described in steps 1 to 5:

Clean the venous port of the hemodialysis tubing with an alcohol swab as instructed by the provider or manufacturer. Immediately throw away the alcohol swab after use.

Insert the needle of the pre-filled syringe into the cleaned venous port (Figure U).

Do not touch the injection site of the venous port

Push the plunger with the thumb while holding the syringe with the forefinger and the middle finger against the finger grips until all the medicine is injected (Figure V).

Remove the pre-filled syringe from the venous port WITHOUT releasing the plunger.

Once removed release the plunger, allowing the needle guard to protect the needle.

Now, the tear-off label can be removed, if necessary (See Figure T).

Step 7: Dispose of the used syringe with the needle

• Do not try to replace the needle shield on the needle.
• Do not reuse or resterilize the syringe and/or the needle.
• Do not throw away used syringes with the needle via household waste.
• Throw away used syringes in a sharps/ puncture-resistant container and/or according to health institutions policies.
• Dispose of the full sharps/ puncture resistant container.