Replagal is indicated for long-term enzyme replacement therapy in patients with a confirmed diagnosis of Fabry Disease (a-galactosidase A deficiency).

Replagal treatment should be supervised by a physician experienced in the management of patients with Fabry Disease or other inherited metabolic diseases. 2 Posology Replagal is administered at a dose of 0.2 mg/kg body weight every other week by intravenous infusion over 40 minutes. Special populations Elderly patients Studies in patients over the age of 65 years have not been performed and no dosage regimen can presently be recommended in these patients as safety and efficacy have not yet been established. Patients with hepatic impairment No studies have been performed in patients with hepatic impairment. Patients with renal impairment No dose adjustment is necessary in patients with renal impairment. The presence of extensive renal damage (eGFR <60ml/min) may limit the renal response to enzyme replacement therapy. Limited data are available in patients on dialysis or post- kidney transplantation, no dose adjustment is recommended. Paediatric Population The safety and efficacy of Replagal in children aged 0-6 years has not yet been established. Currently available data are described in section 5.1 but no recommendation on posology can be made. In clinical studies of children (7-18 years) who received Replagal 0.2 mg/kg every other week, no unexpected safety issues were encountered (see section 5.1). Method of administration For instructions on dilution of the medicinal product before administration, see section 6.6. Administer the infusion solution over a period of 40 minutes using an intravenous line with an integral filter. Do not infuse Replagal concomitantly in the same intravenous line with other agents. Replagal home infusion, and administration by the patient in presence of a responsible adult or administration by the patient’s caregiver (self-administration), may be considered for patients who are tolerating their infusions well. The decision to have a patient move to home infusion and/or self-administration should be made after evaluation and recommendation by the treating physician. Appropriate training should be given by the treating physician and/or nurse to the patient and/or caregiver prior to initiation of self-administration. Dose and infusion rate should remain constant while at home, and not be changed without supervision of a healthcare professional. Self-administration should be closely followed by the treating physician. 3 Any patients experiencing adverse events during the home infusion/self-administration need to immediately stop the infusion process and seek the attention of a healthcare professional. Subsequent infusions may need to occur in a clinical setting.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Traceability In order to improve the traceability of biological medicinal products, the name and batch number of the administered product should be clearly recorded. Idiosyncratic infusion related reactions 13.7% of adult patients treated with Replagal in clinical trials have experienced idiosyncratic infusion related reactions. Four of 17 (23.5%) paediatric patients =7 years of age enrolled in clinical trials experienced at least one infusion reaction over a period of 4.5 years of treatment (mean duration of approx. 4 years). Three of 8 (37.5%) paediatric patients <7 years of age experienced at least one infusion related reaction over a mean observation time of 4.2 years. The most common symptoms have been rigors, headache, nausea, pyrexia, flushing and fatigue. Serious infusion reactions have been reported uncommonly; symptoms reported include pyrexia, rigors, tachycardia, urticaria, nausea/vomiting, angioneurotic oedema with throat tightness, stridor and swollen tongue. Other infusion-related symptoms may include dizziness and hyperhidrosis. A review of cardiac events showed that infusion reactions may be associated with hemodynamic stress triggering cardiac events in patients with pre-existing cardiac manifestations of Fabry disease. The onset of infusion related reactions has generally occurred within the first 2-4 months after initiation of treatment with Replagal although later onset (after 1 year) has been reported as well. These effects have decreased with time. If mild or moderate acute infusion reactions occur, medical attention must be sought immediately, and appropriate actions instituted. The infusion can be temporarily interrupted (5 to 10 minutes) until symptoms subside and the infusion may then be restarted. Mild and transient effects may not require medical treatment or discontinuation of the infusion. In addition, oral or intravenous pre-treatment with antihistamines and/or corticosteroids, from 1 to 24 hours prior to infusion may prevent subsequent reactions in those cases where symptomatic treatment was required. Hypersensitivity reactions Hypersensitivity reactions have been reported. If severe hypersensitivity or anaphylactic reactions occur, the administration of Replagal should be discontinued immediately and appropriate treatment initiated. The current medical standards for emergency treatment are to be observed. Antibodies to the protein As with all protein pharmaceutical products, patients may develop antibodies to the protein. 4 A low titre IgG antibody response has been observed in approximately 24% of the male patients treated with Replagal. Based on limited data this percentage has been found to be lower (7%) in the male paediatric population. These IgG antibodies appeared to develop following approximately 3-12 months of treatment. After 12 to 54 months of therapy, 17% of Replagal treated patients were still antibody positive whereas 7% showed evidence for the development of immunologic tolerance, based on the disappearance of IgG antibodies over time. The remaining 76% were antibody negative throughout. In paediatric patients >7 years of age, 1/16 male patients tested positive for IgG anti-agalsidase alfa antibodies during the study. No increase in the incidence of adverse events was detected for this patient. In paediatric patients <7 years of age, 0/7 male patients tested positive for IgG anti-agalsidase alfa antibodies. IgE antibody positivity not associated with anaphylaxis has been reported in clinical trials in a very limited number of patients. Patients with renal impairment The presence of extensive renal damage may limit the renal response to enzyme replacement therapy, possibly due to underlying irreversible pathological changes. In such cases, the loss of renal function remains within the expected range of the natural progression of disease. Sodium This medicinal product contains 14.2 mg sodium per vial, equivalent to 0.7 % of the WHO recommended maximum daily intake of 2 g sodium for an adult. Polysorbate 20 This medicinal product contains 0.836 mg of polysorbate 20 in each vial which is equivalent to 0.22 mg/ml. Polysorbates may cause allergic reactions.

Replagal should not be co-administered with chloroquine, amiodarone, benoquin or gentamicin since these substances have the potential to inhibit intra-cellular a- galactosidase activity. As a-galactosidase A is itself an enzyme, it would be an unlikely candidate for cytochrome P450 mediated drug-drug

Pregnancy There is very limited data on pregnancies exposed to Replagal. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy or 5 embryonic/fetal development when exposed during organogenesis (see Section 5.3). Caution should be exercised when prescribing to pregnant women. Breast-feeding It is not known whether Replagal is excreted in human milk. Caution should be exercised when prescribing to breast-feeding women. Fertility No effects on male fertility were seen in reproductive studies in male rats.

Replagal has no or negligible influence on the ability to drive and use machines.

Summary of safety profile The most commonly reported adverse reactions were infusion associated reactions, which occurred in 13.7% of adult patients treated with Replagal in clinical trials. Most were mild to moderate in severity. Tabulated list of adverse reactions Table 1 lists adverse reactions reported for the 344 patients treated with Replagal in clinical trials, including 21 patients with history of end stage renal disease, 30 paediatric patients (=18 years of age) and 98 female patients, and from post-marketing spontaneous reports. Information is presented by system organ class and frequency (very common =1/10; common =1/100 to <1/10; uncommon =1/1 000 to <1/100). The adverse reactions categorized as incidence “not known (cannot be estimated from the available data)” are derived from post-marketing spontaneous reports. Within each frequency grouping, are presented in order of decreasing seriousness. The occurrence of an event in a single patient is defined as uncommon in view of the number of patients treated. A single patient could be affected by several adverse reactions. The following adverse reactions have been identified for agalsidase alfa: Table 1 System organ class Adverse reaction Very common Common Uncommon Not known 6 Metabolism and nutrition disorders peripheral oedema Nervous system disorders headache, dizziness, neuralgia, tremor, hypoesthesia, paraesthesia dysgeusia, hypersomnia parosmia Eye disorders lacrimation increased corneal reflex decreased Ear and labyrinth disorders tinnitus tinnitus aggravated Cardiac disorders palpitations tachycardia, atrial fibrillation tachyarrhythmia myocardial ischaemia, cardiac failure, ventricular extrasystoles Vascular disorders hypertension, hypotension, flushing Respiratory, thoracic and mediastinal disorders dyspnoea, cough, nasopharyng itis, pharyngitis dysphonia, throat tightness, rhinorrhoea oxygen saturation decreased, increased upper airway secretion 7 Table 1 System organ class Adverse reaction Very common Common Uncommon Not known Gastrointestinal disorders vomiting, nausea, abdominal pain, diarrhoea abdominal discomfort Skin and subcutaneous tissue disorders rash urticaria, erythema, pruritus, acne, hyperhidrosis angioedema, livedo reticularis Musculoskeletal, connective tissue and bone disorders arthralgia, pain in extremity, myalgia, back pain musculoskeletal discomfort, peripheral swelling, joint swelling sensation of heaviness Immune system disorders hypersensitivity anaphylactic reaction General disorders and administration site conditions chest pain, chills, pyrexia, pain, asthenia, fatigue chest discomfort, fatigue, feeling hot, feeling cold, influenza like illness, discomfort, malaise injection site rash See also section 4.4. Description of selected adverse reactions Infusion related reactions reported in the postmarketing setting (also see section 4.4) may include cardiac events such as cardiac arrhythmias (atrial fibrillation, ventricular extrasystoles, tachyarrhythmia), myocardial ischemia, and heart failure in patients with Fabry disease involving the heart structures. The most common infusion related reactions were mild and include rigors, pyrexia, flushing, headache, nausea, dyspnoea, tremor and pruritus. Infusion-related symptoms may also include dizziness, hyperhidrosis, hypotension, cough, vomiting and fatigue. Hypersensitivity, including anaphylaxis, has been reported. 8 Paediatric population Adverse drug reactions reported in the paediatric population (children and adolescents) were, in general, similar to those reported in adults. However, infusion related reactions (pyrexia, dyspnoea, chest pain) and pain exacerbation occurred more frequently. Other special populations Patients with renal disease Adverse drug reactions reported in patients with history of end stage renal disease were similar to those reported in the general patient population. 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 Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

In clinical trials doses up to 0.4 mg/kg weekly were used, and their safety profile was not different from the recommended dose of 0.2 mg/kg biweekly.

Pharmacotherapeutic group: Other alimentary tract and metabolism products - Enzymes. ATC code: A16AB03. Mechanism of action Fabry Disease is a glycosphingolipid storage disorder that is caused by deficient activity of the lysosomal enzyme a-galactosidase A, resulting in accumulation of globotriaosylceramide (Gb3 or GL- 3, also known as ceramidetrihexoside (CTH)), the glycosphingolipid substrate for this enzyme. Agalsidase alfa catalyses the hydrolysis of Gb3, cleaving a terminal galactose residue from the molecule. Treatment with the enzyme has been shown to reduce accumulation of Gb3 in many cell types including endothelial and parenchymal cells. Agalsidase alfa has been produced in a human cell line to provide for a human glycosylation profile that can influence uptake by mannose-6-phosphate receptors on the surface of target cells. The selection of 0.2 mg/kg dose (infused over 40 minutes) for the registration clinical studies was intended to temporarily saturate the ability of the mannose-6- phosphate receptors to internalize the agalsidase alfa in the liver and allow distribution of enzyme to other relevant organ tissues. Data with patients indicates that at least 0.1mg/kg is required to 9 achieve a pharmacodynamics response. Clinical efficacy and safety The safety and efficacy of Replagal was assessed in two randomised, double blind, placebo controlled studies and open label extension studies, in a total of forty patients with a diagnosis of Fabry Disease based on clinical and biochemical evidence. Patients received the recommended dosage of 0.2 mg/kg of Replagal. Twenty-five patients completed the first study and entered an extension study. After 6 months of therapy there was a significant reduction in pain in the Replagal treated patients compared with placebo (p = 0.021), as measured by the Brief Pain Inventory (a validated pain measurement scale). This was associated with a significant reduction in chronic neuropathic pain medication use and number of days on pain medication. In subsequent studies, in male paediatric patients above the age of 7, a reduction in pain was observed after 9 and 12 months of Replagal therapy compared to pre- treatment baseline. This pain reduction persisted through 4 years of Replagal therapy in 9 patients (in patients 7-18 years of age). Twelve to 18 months of treatment with Replagal resulted in improvement in quality of life (QoL), as measured by validated instruments. After 6 months of therapy Replagal stabilised renal function compared with a decline in placebo treated patients. Kidney biopsy specimens revealed a significant increase in the fraction of normal glomeruli and a significant decrease in the fraction of glomeruli with mesangial widening in patients treated with Replagal in contrast to the patients treated with placebo. After 12 to 18 months of maintenance therapy, Replagal improved renal function as measured by inulin based glomerular filtration rate by 8.7 ± 3.7 ml/min. (p=0.030). Longer term therapy (48-54 months) resulted in stabilisation of GFR in male patients with normal baseline GFR (= 90 ml/min/1.73 m2) and with mild to moderate renal dysfunction (GFR 60 to < 90 ml/min/1.73 m2), and in slowing of the rate of decline in renal function and progression to end-stage renal disease in male Fabry patients with more severe renal dysfunction (GFR 30 to < 60 ml/min/1.73 m2). In a second study, fifteen patients with left ventricular hypertrophy completed a 6 month placebo- controlled study and entered an extension study. Treatment with Replagal resulted in an 11.5 g decrease in left ventricular mass as measured by magnetic resonance imaging (MRI) in the controlled study, while patients receiving placebo exhibited an increase in left ventricular mass of 21.8 g. In addition, in the first study involving 25 patients, Replagal effected a significant reduction in cardiac mass after 12 to 18 months of maintenance therapy (p < 0.001). Replagal was also associated with improved myocardial contractility, a decrease in mean QRS duration and a concomitant decrease in septal thickness on echocardiography. Two patients with right bundle branch block in the studies conducted reverted to normal following therapy with Replagal. Subsequent open label studies demonstrated significant reduction from baseline in left ventricular mass by echocardiography in both male and female Fabry patients over 24 to 36 months of Replagal treatment. The reductions in LV mass observed by echocardiography in both male and female Fabry patients over 24 to 36 months of Replagal treatment were associated with meaningful symptom improvement as measured using the NYHA and CCS in Fabry patients with severe heart failure or anginal symptoms at baseline. Compared with placebo, treatment with Replagal also reduced accumulation of Gb3. After the first 6 months of therapy mean decreases of approximately 20-50% were observed in plasma, urine sediment, liver, kidney, and heart biopsy samples. After 12 to 18 months treatment a reduction of 50-80% was observed in plasma and urine sediment. The metabolic effects were also associated with clinically significant weight gain, increased 10 sweating and increased energy. Consistent with the clinical effects of Replagal, treatment with the enzyme reduced accumulation of Gb3 in many cell types, including renal glomerular and tubular epithelial cells, renal capillary endothelial cells (cardiac and dermal capillary endothelial cells were not examined) and cardiac myocytes. In male paediatric Fabry patients plasma Gb3 decreased 40-50% after 6 months of Replagal therapy 0.2 mg/kg and this reduction persisted after a total 4 years of treatment in 11 patients. Infusion of Replagal at home may be considered for patients who are tolerating their infusions well. Paediatric population In male paediatric Fabry patients = 7 years of age, hyperfiltration can be the earliest manifestation of renal involvement in the disease. Reduction in their hypernormal eGFRs was observed within 6 months of initiating Replagal therapy. After one year of treatment with agalsidase alfa 0.2 mg/kg every other week, the abnormally high eGFR decreased from 143.4 ± 6.8 to 121.3 ± 5.6 ml/min/1.73 m2 in this subgroup and these eGFRs stabilized in the normal range during 4 years of Replagal 0.2 mg/kg therapy, as did the eGFRs of the non-hyperfiltrators. In male paediatric patients = 7 years of age, heart rate variability was abnormal at baseline and improved after 6 months of Replagal therapy in 15 boys and the improvement was sustained through 6.5 years of Replagal 0.2 mg/kg therapy in an open-label long-term extension study in 9 boys. Among 9 boys with left ventricular mass (LVMI) indexed to height2.7 within the normal range for children (<39 g/m2.7 in boys) at baseline, LVMI remained stable at levels below the left ventricular hypertrophy (LVH) threshold throughout the 6.5 years of treatment. In a second study, in 14 patients = 7 years of age, the results regarding heart rate variability were consistent with previous findings. In this study, only one patient had LVH at baseline and remained stable over time. For patients between 0 and 7 years of age, limited data indicate no specific safety issues. Study in patients switching from agalsidase beta to Replagal (agalsidase alfa) 100 patients [(naïve (n = 29); or previously treated with agalsidase beta who switched to Replagal (n = 71)) were treated for up to 30 months in an open label, uncontrolled study. An analysis showed that serious adverse events were reported in 39.4% of those patients who switched from agalsidase beta compared to 31.0% in those who were naïve to therapy prior to study entry. Patients switched from agalsidase beta to Replagal had a safety profile consistent with that observed in other clinical experience. Infusion related reactions have been experienced by 9 patients of the naïve population (31.0%) compared to 27 patients of the switched population (38.0%). Study with various dosing regimen In an openlabel randomised study, there were no statistically significant differences between adult patients treated for 52 weeks with 0.2 mg/kg intravenously every other week (n = 20) and those treated with 0.2 mg/kg weekly (n = 19) in mean change from baseline LVMI or other endpoints (cardiac functional status, renal function, and pharmacodynamic activity). In each treatment group, LVMI remained stable over the treatment period of the study. The overall incidence of SAEs by treatment group did not show any obvious effect of treatment regimen on the SAE profile of the different treatment groups. Immunogenicity 11 Antibodies to agalsidase alfa have not been shown to be associated with any clinically significant effects on safety (e.g. infusion reactions) or efficacy.

Non-clinical data reveal no special hazard for humans based on studies of repeated dose toxicity. Genotoxic and carcinogenic potential are not expected. Reproduction toxicity studies in female rats and rabbits have shown no effect on pregnancy or the developing foetus. No studies have been conducted with respect to parturition or peri/post-natal development. It is not known whether Replagal crosses the placenta.

Sodium phosphate monobasic, monohydrate (E339) Polysorbate 20 (E432) Sodium chloride Sodium hydroxide (E524) Water for injections

In the absence of compatibility studies this medicinal product must not be mixed with other medicinal products.

3 years. Chemical and physical in use stability has been demonstrated for 24 hours at 25°C. From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8°C, unless dilution has taken place in controlled and validated aseptic conditions. 12

Store in a refrigerator (2°C – 8°C).

3.5 ml of concentrate for solution for infusion in a 5 ml vial (Type I glass) with a stopper (fluoro-resin coated butyl rubber), a one piece seal (aluminium) and flip-off cap. Pack sizes of 1, 4 or 10 vials. Not all pack sizes may be marketed.

• Calculate the dose and number of Replagal vials needed. • Any dose change should occur only at the direction of the treating physician. • Dilute the total volume of Replagal concentrate required in 100 ml of 9 mg/ml (0.9%) sodium chloride solution for infusion. Care must be taken to ensure the sterility of the prepared solutions since Replagal does not contain any preservative or bacteriostatic agent; aseptic technique must be observed. Once diluted, the solution should be mixed gently but not shaken. • Since no preservative is present, it is recommended that administration is started as soon as possible after dilution. (see section 6.3). • The solution should be inspected visually for particulate matter and discolouration prior to administration. • For single use only. Any unused product or waste material should be disposed of in accordance with local requirements.

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