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REGRANEX gel is indicated for the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply, when used as an adjunct to, and not a substitute for, good ulcer care practices including initial sharp debridement, pressure relief and infection control.
Limitations of Use:
The efficacy of REGRANEX gel has not been established for the treatment of pressure ulcers and venous stasis ulcers [see Clinical Studies (14.2) ] and has not been evaluated for the treatment of diabetic neuropathic ulcers that do not extend through the dermis into subcutaneous tissue [Stage I or II, International Association of Enterostomal Therapy (IAET) staging classification] or ischemic diabetic ulcers.
The effects of becaplermin on exposed joints, tendons, ligaments, and bone have not been established in humans [see Nonclinical Toxicology (13.2) ].
REGRANEX gel is a non-sterile, low bioburden preserved product. Therefore, it should not be used in wounds that close by primary intention.
Regranex gel is for topical use; it is not for oral, ophthalmic or intravaginal use.
The amount of REGRANEX gel to be applied depends upon the size of the ulcer area. To calculate the length of gel to apply to the ulcer, measure the greatest length of the ulcer by the greatest width of the ulcer in either inches or centimeters. To calculate the length of gel in inches, use the formula shown below in Table 1, and to calculate the length of gel in centimeters, use the formula shown below in Table 2.
Using the calculation, each square inch of ulcer surface will require approximately 2/3 inch length of gel squeezed from a 15g tube. For example, if the ulcer measures 1 inch by 2 inches, then a 1 1/4 inch length of gel should be used for 15g tubes (1 × 2 × 0.6 = 1 1/4).
Using the calculations for ulcer size in centimeters, each square centimeter of ulcer surface will require approximately a 0.25 centimeter length of gel squeezed from a 15g tube. For example, if the ulcer measures 4 cm by 2 cm, then a 2 centimeter length of gel should be used for a 15g tube [(4 × 2) ÷ 4 = 2].
The amount of REGRANEX gel to be applied should be recalculated by the physician or wound caregiver at weekly or biweekly intervals depending on the rate of change in ulcer area. The weight of REGRANEX gel from 15g tubes is 0.65g per inch length and 0.25g per centimeter length.
To apply REGRANEX gel, the calculated length of gel should be squeezed on to a clean measuring surface, e.g., wax paper. The measured REGRANEX gel is transferred from the clean measuring surface using an application aid and then spread over the entire ulcer area to yield a thin continuous layer of approximately 1/16 of an inch thickness. The site(s) of application should then be covered by a saline moistened dressing and left in place for approximately 12 hours. The dressing should then be removed and the ulcer rinsed with saline or water to remove residual gel and covered again with a second moist dressing (without REGRANEX gel) for the remainder of the day. REGRANEX gel should be applied once daily to the ulcer until complete healing has occurred. If the ulcer does not decrease in size by approximately 30% after 10 weeks of treatment or complete healing has not occurred in 20 weeks, continued treatment with REGRANEX gel should be reassessed. The step-by-step instructions for applying REGRANEX Gel for home administration are described under "Patient Counseling Information". [see Patient Counseling Information (17) ]
|15g tube||length × width × 0.6|
|15g tube||length × width ÷ 4|
Gel: 0.01%; clear, colorless to straw-colored gel
REGRANEX gel is contraindicated in patients with known neoplasm(s) at the site(s) of application.
Malignancies distant from the site of application have occurred in REGRANEX gel users in a clinical study and in postmarketing use [see Adverse Reactions ( 6.1) and Clinical Studies (14.3)]. REGRANEX gel contains becaplermin, a recombinant human platelet-derived growth factor, which promotes cellular proliferation and angiogenesis [see Clinical Pharmacology (12.1)].
The benefits and risks of REGRANEX gel treatment should be carefully evaluated before prescribing in patients with known malignancy.
If application site reactions occur, the possibility of sensitization or irritation caused by parabens or m-cresol should be considered. Consider interruption or discontinuation and further evaluation (e.g. patch testing) as dictated by clinical circumstances.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Because post-approval adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to the drug. The following adverse reactions have been identified during postapproval use of REGRANEX gel.
It is not known if REGRANEX gel interacts with other topical medications applied to the ulcer site. The use of REGRANEX gel with other topical drugs has not been studied.
There are no available data on REGRANEX gel use in pregnant women to inform a drug associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Animal reproduction studies have not been conducted with REGRANEX gel.
The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
There are no data on the presence of becaplermin in human milk, the effects on the breastfed infant, or the effects on milk production after topical application of REGRANEX gel to lactating women. The developmental and health benefits of breastfeeding should be considered along with the lactating woman's clinical need for REGRANEX gel and any potential adverse effects on the breastfed child from becaplermin.
Safety and effectiveness of REGRANEX gel in pediatric patients below the age of 16 years have not been established.
Among patients receiving any dose of REGRANEX gel in clinical studies of diabetic lower extremity ulcers, 150 patients were 65 years of age and older. No overall differences in safety or effectiveness were observed between patients < 65 years of age and patients ≥ 65 years of age. The number of patients aged 75 and older were insufficient (n=34) to determine whether they respond differently from younger patients.
There are no data on the effects of REGRANEX gel overdose.
REGRANEX gel contains becaplermin, a recombinant human platelet-derived growth factor, for topical administration. Becaplermin is produced by recombinant DNA technology by insertion of the gene for the B chain of platelet-derived growth factor (PDGF) into the yeast, Saccharomyces cerevisiae.
Becaplermin has a molecular weight of approximately 25 KD and is a homodimer composed of two identical polypeptide chains that are bound together by disulfide bonds. REGRANEX gel is a non-sterile, low bioburden, preserved, sodium carboxymethylcellulose-based (CMC) topical gel, containing the active ingredient becaplermin and the following inactive ingredients: carboxymethylcellulose sodium, glacial acetic acid, l-lysine hydrochloride, m-cresol, methylparaben, propylparaben, sodium acetate trihydrate, sodium chloride, and water for injection. Each gram of REGRANEX gel contains 100 mcg of becaplermin.
REGRANEX gel has biological activity similar to that of endogenous platelet-derived growth factor, which includes promoting the chemotactic recruitment and proliferation of cells involved in wound repair and enhancing the formation of granulation tissue.
Clinical pharmacodynamic studies have not been conducted.
Ten patients with Stage III or IV [as defined in the International Association of Enterostomal Therapy (IAET) guide to chronic wound staging] lower extremity diabetic ulcers received topical applications of becaplermin gel 0.01% at a dose range of 0.32–2.95 µg/kg (7µg/cm) daily for 14 days. Six patients had non-quantifiable PDGF levels at baseline and throughout the study, two patients had PDGF levels at baseline which did not increase substantially, and two patients had PDGF levels that increased sporadically above their baseline values during the 14-day study period.
Becaplermin was not genotoxic in a battery of in vitro assays (including those for bacterial and mammalian cell point mutation, chromosomal aberration, and DNA damage/repair). Becaplermin was also not mutagenic in an in vivo assay for the induction of micronuclei in mouse bone marrow cells.
Carcinogenesis and reproductive toxicity studies have not been conducted with REGRANEX gel.
In nonclinical studies, rats injected at the metatarsals with 3 or 10 mcg/site (approximately 60 or 200 mcg/kg) of becaplermin every other day for 13 days displayed histological changes indicative of accelerated bone remodeling consisting of periosteal hyperplasia and subperiosteal bone resorption and exostosis. The soft tissue adjacent to the injection site had fibroplasia with accompanying mononuclear cell infiltration reflective of the ability of PDGF to stimulate connective tissue growth.
The effects of REGRANEX gel on the incidence of and time to complete healing in lower extremity diabetic neuropathic ulcers were assessed in four randomized controlled studies (Studies 1-4). Of 922 subjects studied, 478 received either REGRANEX gel 0.003% or 0.01%. All study participants had lower extremity diabetic neuropathic ulcers that extended into the subcutaneous tissue or beyond [Stages III and IV of the International Association of Enterostomal Therapy (IAET) guide to chronic wound staging]. Ninety-three percent of the subjects enrolled in these four trials had foot ulcers. The remaining 7% of the subjects had ankle or leg ulcers. The diabetic ulcers were of at least 8 weeks duration and had an adequate blood supply (defined as TpO > 30 mm Hg). In the four trials, 95% of the ulcers measured in area up to 10 cm, and the median ulcer size at baseline ranged from 1.4 cm to 3.5 cm.
All treatment groups received a program of good ulcer care consisting of initial complete sharp debridement, a non-weight-bearing regimen, systemic treatment for wound-related infection if present, moist saline dressings changed twice a day, and additional debridement as necessary. REGRANEX gel 0.003% or 0.01% or placebo gel was applied once a day and covered with a saline moistened dressing. After approximately 12 hours, the gel was gently rinsed off and a saline moistened dressing was then applied for the remainder of the day. Patients were treated until complete healing, or for a period of up to 20 weeks. Subjects were considered a treatment failure if their ulcer did not show an approximately 30% reduction in initial ulcer area after eight to ten weeks of therapy.
The results of the primary endpoint, incidence of complete ulcer closure within 20 weeks, for all treatment arms is shown in Figure 1. In each study, REGRANEX gel in conjunction with good ulcer care was compared to placebo gel plus good ulcer care or good ulcer care alone.
In Study 1, a multicenter, double-blind, placebo-controlled trial of 118 subjects, the incidence of complete ulcer closure for REGRANEX gel 0.003% (n=61) was 48% versus 25% for placebo gel (n=57; p=0.02, logistic regression analysis).
In Study 2, a multicenter, double-blind, placebo-controlled trial of 382 subjects, the incidence of complete ulcer closure for REGRANEX gel 0.01% (n=123) was 50% versus 36% for REGRANEX gel 0.003% (n=132) and 35% for placebo gel (n=127). Only REGRANEX gel 0.01% was significantly different from placebo gel (p=0.01, logistic regression analysis).
The primary goal of Study 3, a multicenter controlled trial of 172 subjects, was to assess the safety of vehicle gel (placebo; n=70) compared to good ulcer care alone (n=68). The study included a small (n=34) REGRANEX gel 0.01% arm. Incidences of complete ulcer closure were 44% for REGRANEX gel, 36% for placebo gel and 22% for good ulcer care alone.
In Study 4, a multicenter, evaluator-blind, controlled trial of 250 subjects, the incidences of complete ulcer closure in the REGRANEX gel 0.01% arm (n=128) (36%) and good ulcer care alone (n=122) (32%) were not statistically different.
In general, where REGRANEX gel was associated with higher incidences of complete ulcer closure, differences in the incidence first became apparent after approximately 10 weeks and increased with continued treatment (Table 3).
In a 3-month follow-up period where no standardized regimen of preventative care was utilized, the incidence of ulcer recurrence was approximately 30% in all treatment groups, demonstrating that the durability of ulcer closure was comparable in all treatment groups.
In a randomized, double-blind study of REGRANEX gel (100 mcg/g once daily for 16 weeks) in subjects with Stage III or IV pressure ulcers, the incidence of complete ulcer closure was 15% (28/189) in the REGRANEX gel group and 12% (22/190) in the vehicle control group. This difference was not statistically significant.
In two small, randomized, double-blinded studies of REGRANEX gel (100 mcg/g once daily for 16 weeks) in subjects with venous stasis ulcers, the combined incidence of complete ulcer closure was 46% (30/65) in the REGRANEX gel group and 39% (26/67) in the vehicle control group. This difference was not statistically significant.
The observational studies described below do not involve random allocation of treatments. They are susceptible to bias and confounding.
A retrospective study using medical claims database to assess cancer incidence with up to 6 years of follow-up observed development of 28 cancers and 8 cancer deaths in the REGRANEX gel-exposed cohort (n = 1,622) and 43 cancers and 8 cancer deaths in the matched comparator cohort not exposed to REGRANEX gel (n = 2,809). The rate ratio for incident cancer comparing the REGRANEX gel-exposed cohort to the unexposed comparator cohort was 1.2 (95% CI, 0.7 -1.9). The rate ratio for cancer mortality comparing the REGRANEX gel-exposed cohort to the unexposed comparator cohort was 1.8 (95% CI, 0.7 -4.9). The rate ratio comparing patients exposed to three or more tubes of REGRANEX gel to those not exposed was 5.2 (95% CI, 1.6 -17.6) [see Adverse Reactions (6.2) ].
A retrospective study using medical claims from the Veteran Affairs health care database with up to 11 years of follow-up among patients without prior cancer observed 197 cancer deaths in the REGRANEX gel-exposed cohort (n = 6,429) and 206 cancer deaths in the matched comparator cohort not exposed to REGRANEX gel (n = 6,429), resulting in a hazard ratio of 0.9 (95% CI, 0.8-1.2). The hazard ratio for cancer mortality comparing patients exposed to three or more tubes of REGRANEX gel to those not exposed was 1.0 (95% CI, 0.7 -1.5). The hazard ratio for incident cancer in a smaller cohort (1,507 REGRANEX gel-exposed and 1,507 unexposed patients) comparing patients exposed to REGRANEX gel to those not exposed was 1.1 (95% CI, 0.8-1.4).
A second retrospective study using medical claims from the Veteran Affairs health care database with up to 11 years of follow-up among patients with prior cancer observed 87 cancer deaths in the REGRANEX gel-exposed cohort (n = 477) and 340 cancer deaths in the matched comparator cohort not exposed to REGRANEX gel (n = 1,756), resulting in a hazard ratio of 0.9 (95% CI, 0.7-1.2). The hazard ratio for cancer mortality comparing patients exposed to three or more tubes of REGRANEX gel to those not exposed was 0.9 (95% CI, 0.6 -1.2).
REGRANEX gel (0.01%) is clear, colorless to straw-colored and is available in multi-use tubes in the following size:
15 g tube NDC 50484-810-15
Store refrigerated at 2° – 8° C (36° – 46°F). Do not freeze.
Advise the patient or caregiver to read the FDA-approved patient labeling (Medication Guide).
Counsel patients to review and discuss any questions or concerns with their healthcare provider before starting REGRANEX and at regular intervals while receiving REGRANEX.
Advise patients that:
Step-by-step instructions for application of REGRANEX gel are as follows:
Manufactured by: Smith & Nephew, Inc., Fort Worth, TX 76109
U.S. Gov’t License # 2004
Marketed by: Smith & Nephew, Inc., Fort Worth, TX 76109
REGRANEX is a registered trademark of Smith & Nephew, Inc.
Part No. 141054-1118
REGRANEX (RE–GRAN ' –IX )
Read this Medication Guide before you start using REGRANEX and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment.
What is the most important information I should know about REGRANEX?
If you already have cancer, you and your healthcare provider should carefully consider whether you will use REGRANEX.
If you decide to use REGRANEX, your healthcare provider will tell you how to use REGRANEX. See the section "How should I use REGRANEX?" below.
What is REGRANEX?
REGRANEX is a protein medicine made in yeast that is used with other ulcer care practices (such as good wound care) to treat diabetic sores (ulcers) of your legs or feet that are deeper than just your skin, in people who have good blood supply to the legs.
It is not known if REGRANEX is effective for the treatment of pressure ulcers or ulcers that are due to poor blood flow (circulation).
It is not known if REGRANEX is safe and effective in children under 16 years of age.
Who should not use REGRANEX?
Do not use REGRANEX if you have a skin tumor at the area where you apply REGRANEX.
What should I tell my healthcare provider before using REGRANEX?
Before you use REGRANEX tell your healthcare provider if you:
Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Especially tell your healthcare provider if you apply other medicines to diabetic ulcers of your legs or feet.
Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist when you get a new medicine.
How should I use REGRANEX?
Apply REGRANEX as follows:
What are the possible side effects of REGRANEX?
REGRANEX may cause serious side effects.
Tell your doctor if you have any side effect that bothers you or that does not go away.
These are not all the possible side effects of REGRANEX gel. For more information, ask your doctor or pharmacist.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
You may also report side effects to Smith & Nephew, Inc. at 1-800-441-8227.
How should I store REGRANEX?
Keep REGRANEX and all medicines out of the reach of children.
General information about REGRANEX
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use REGRANEX for a condition for which it was not prescribed. Do not give REGRANEX to other people, even if they have the same symptoms that you have. It may harm them.
This Medication Guide summarizes the most important information about REGRANEX. If you would like more information about REGRANEX, talk to your healthcare provider. You can ask your healthcare provider or pharmacist for information about REGRANEX that is written for health professionals.
What are the ingredients in REGRANEX?
Active ingredient: becaplermin
Inactive ingredients: carboxymethylcellulose sodium, glacial acetic acid, l-lysine hydrochloride, m-cresol, methylparaben, propylparaben, sodium acetate trihydrate, sodium chloride, and water for injection.
Manufactured by: Smith & Nephew, Inc., Fort Worth, TX 76109
U.S. Gov’t License # 2004
Smith & Nephew, Inc., Fort Worth, TX 76109
Trademark of Smith & Nephew. Registered in the US Patent & TM Office.
Part No. 141054-1118
Revised: November 2018
This Medication Guide has been approved by the U.S. Food and Drug Administration.
PACKAGE LABEL.PRINCIPAL DISPLAY PANEL
Tube LABEL.PRINCIPAL DISPLAY PANEL
Smith & Nephew, Inc.
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