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Aranesp 40 Mcg Solution For Injection Pre-Filled 4 Syringes

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FULL PRESCRIBING INFORMATION: CONTENTS*

WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE

1 INDICATIONS AND USAGE

1.1 Anemia Due to Chronic Kidney Disease

1.2 Anemia Due to Chemotherapy in Patients With Cancer

1.3 Limitations of Use

2 DOSAGE AND ADMINISTRATION

2.1 Evaluation of Iron Stores and Nutritional Factors

2.2 Patients with Chronic Kidney Disease

2.3 Patients on Cancer Chemotherapy

2.4 Preparation and Administration

3 DOSAGE FORMS AND STRENGTHS

4 CONTRAINDICATIONS

5 WARNINGS AND PRECAUTIONS

5.1 Increased Mortality, Myocardial Infarction, Stroke, and Thromboembolism

5.2 Prescribing and Distribution Program for Aranesp in Patients With Cancer

5.3 Increased Mortality and/or Increased Risk of Tumor Progression or Recurrence in Patients With Cancer

5.4 Hypertension

5.5 Seizures

5.6 Lack or Loss of Hemoglobin Response to Aranesp

5.7 Pure Red Cell Aplasia

5.8 Serious Allergic Reactions

5.9 Dialysis Management

5.10 Laboratory Monitoring

6 ADVERSE REACTIONS

6.1 Clinical Trial Experience

6.2 Postmarketing Experience

6.3 Immunogenicity

7 DRUG INTERACTIONS

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

8.3 Nursing Mothers

8.4 Pediatric Use

8.5 Geriatric Use

10 OVERDOSAGE

11 DESCRIPTION

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

12.2 Pharmacodynamics

12.3 Pharmacokinetics

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

13.3 Reproductive and Developmental Toxicology

14 CLINICAL STUDIES

14.1 Patients With Chronic Kidney Disease

14.2 Cancer Patients Receiving Chemotherapy

16 HOW SUPPLIED/STORAGE AND HANDLING

17 PATIENT COUNSELING INFORMATION

*Sections or subsections omitted from the full prescribing information are not listed.

FULL PRESCRIBING INFORMATION

WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE

  
Chronic Kidney Disease:

  • In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL.
  • No trial has identified a hemoglobin target level, Aranesp dose, or dosing strategy that does not increase these risks.
  • Use the lowest Aranesp dose sufficient to reduce the need for red blood cell (RBC) transfusions [see Warnings and Precautions (5.1)].

Cancer:

  • ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers [see Table 3, Warnings and Precautions (5.3)].
  • Because of these risks, prescribers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program to prescribe and/or dispense Aranesp to patients with cancer. To enroll in the ESA APPRISE Oncology Program, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance [see Warnings and Precautions (5.2)].
  • To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, use the lowest dose needed to avoid RBC transfusions [see Dosage and Administration (2.3)].
  • Use ESAs only for anemia from myelosuppressive chemotherapy [see Indications and Usage (1.2)].
  • ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure [see Indications and Usage (1.3)].
  • Discontinue following the completion of a chemotherapy course [see Dosage and Administration (2.3)].

1 INDICATIONS AND USAGE

1.1 Anemia Due to Chronic Kidney Disease

Aranesp is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and patients not on dialysis.

1.2 Anemia Due to Chemotherapy in Patients With Cancer

Aranesp is indicated for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy.

1.3 Limitations of Use

Aranesp has not been shown to improve quality of life, fatigue, or patient well-being.

Aranesp is not indicated for use:

  • In patients with cancer receiving hormonal agents, biologic products, or radiotherapy, unless also receiving concomitant myelosuppressive chemotherapy.
  • In patients with cancer receiving myelosuppressive chemotherapy when the anticipated outcome is cure.
  • As a substitute for RBC transfusions in patients who require immediate correction of anemia [see Clinical Pharmacology (12.2)].

2 DOSAGE AND ADMINISTRATION

2.1 Evaluation of Iron Stores and Nutritional Factors

Evaluate the iron status in all patients before and during treatment and maintain iron repletion. Correct or exclude other causes of anemia (e.g., vitamin deficiency, metabolic or chronic inflammatory conditions, bleeding, etc.) before initiating Aranesp [see Warnings and Precautions (5.10)].

2.2 Patients with Chronic Kidney Disease

In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, Aranesp dose, or dosing strategy that does not increase these risks. Individualize dosing and use the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions [see Warnings and Precautions (5.1)]. Physicians and patients should weigh the possible benefits of decreasing transfusions against the increased risks of death and other serious cardiovascular adverse events [see Boxed Warning and Clinical Studies (14)].

For all patients with CKD

When initiating or adjusting therapy, monitor hemoglobin levels at least weekly until stable, then monitor at least monthly. When adjusting therapy consider hemoglobin rate of rise, rate of decline, ESA responsiveness and hemoglobin variability. A single hemoglobin excursion may not require a dosing change.

  • Do not increase the dose more frequently than once every 4 weeks. Decreases in dose can occur more frequently. Avoid frequent dose adjustments.
  • If the hemoglobin rises rapidly (e.g., more than 1 g/dL in any 2-week period), reduce the dose of Aranesp by 25% or more as needed to reduce rapid responses.
  • For patients who do not respond adequately, if the hemoglobin has not increased by more than 1 g/dL after 4 weeks of therapy, increase the dose by 25%.
  • For patients who do not respond adequately over a 12-week escalation period, increasing the Aranesp dose further is unlikely to improve response and may increase risks. Use the lowest dose that will maintain a hemoglobin level sufficient to reduce the need for RBC transfusions. Evaluate other causes of anemia. Discontinue Aranesp if responsiveness does not improve.


For patients with CKD on dialysis:

  • Initiate Aranesp treatment when the hemoglobin level is less than 10 g/dL.
  • If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Aranesp.
  • The recommended starting dose is 0.45 mcg/kg intravenously or subcutaneously as a weekly injection or 0.75 mcg/kg once every 2 weeks as appropriate. The intravenous route is recommended for patients on hemodialysis.


For patients with CKD not on dialysis:

  • Consider initiating Aranesp treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:
    • The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion and,
    • Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.
  • If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Aranesp, and use the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions.
  • The recommended starting dose is 0.45 mcg/kg body weight intravenously or subcutaneously given once at four week intervals as appropriate.

When treating patients who have chronic kidney disease and cancer, physicians should refer to Warnings and Precautions (5.1 and 5.3).

Refer patients who self-administer Aranesp to the Instructions for Use [see Patient Counseling Information (17)].

Conversion from Epoetin alfa to Aranesp in patients with CKD on dialysis

Aranesp is administered less frequently than epoetin alfa.

  • Administer Aranesp once weekly in patients who were receiving epoetin alfa 2 to 3 times weekly.
  • Administer Aranesp once every 2 weeks in patients who were receiving epoetin alfa once weekly.

Estimate the starting weekly dose of Aranesp for adults and pediatric patients on the basis of the weekly epoetin alfa dose at the time of substitution (see Table 1). Maintain the route of administration (intravenous or subcutaneous injection).

Table 1. Estimated Aranesp Starting Doses (mcg/week) for Patients With CKD on Dialysis Based on Previous Epoetin alfa Dose (Units/week)

*For pediatric patients receiving a weekly epoetin alfa dose of < 1,500 Units/week, the available data are insufficient to determine an Aranesp conversion dose.

 Previous Weekly Epoetin alfa Dose (Units/week)

 Aranesp Dose (mcg/week)

 Adult

 Pediatric

 < 1,500

 6.25

 *

 1,500 to 2,499

 6.25

 6.25

 2,500 to 4,999

 12.5

 10

 5,000 to 10,999

 25

 20

 11,000 to 17,999

 40

 40

 18,000 to 33,999

 60

 60

 34,000 to 89,999

 100

 100

 ≥ 90,000

 200

 200

Conversion from Epoetin alfa to Aranesp in patients with CKD not on dialysis

The dose conversion depicted in Table 1 does not accurately estimate the once monthly dose of Aranesp.

2.3 Patients on Cancer Chemotherapy

Initiate Aranesp in patients on cancer chemotherapy only if the hemoglobin is less than 10 g/dL, and if there is a minimum of two additional months of planned chemotherapy.

Use the lowest dose of Aranesp necessary to avoid RBC transfusions.

Recommended Starting Dose

The recommended starting dose and schedules are:

  • 2.25 mcg/kg every week subcutaneously until completion of a chemotherapy course
  • 500 mcg every 3 weeks subcutaneously until completion of a chemotherapy course

Dose Adjustment

 Dose Adjustment

 Weekly Schedule

 Every 3 Week Schedule

 

  • If hemoglobin increases greater than 1 g/dL in any 2-week period or
  • If hemoglobin reaches a level needed to avoid RBC transfusion

 Reduce dose by 40%

 Reduce dose by 40%

 If hemoglobin exceeds a level needed to avoid RBC transfusion

 

  • Withhold dose until hemoglobin approaches a level where RBC transfusions may be required
  • Reinitiate at a dose 40% below the previous dose

 

  • Withhold dose until hemoglobin approaches a level where RBC transfusions may be required
  • Reinitiate at a dose 40% below the previous dose

 If hemoglobin increases by less than 1 g/dL and remains below 10 g/dL after 6 weeks of therapy

 Increase dose to 4.5 mcg/kg/week

 No dose adjustment

 

  • If there is no response as measured by hemoglobin levels or if RBC transfusions are still required after 8 weeks of therapy
  • Following completion of a chemotherapy course

 Discontinue Aranesp

 Discontinue Aranesp

2.4 Preparation and Administration

  • The needle cover of the prefilled syringe contains dry natural rubber (a derivative of latex), which may cause allergic reactions.
  • Do not shake. Do not use Aranesp that has been shaken or frozen.
  • Protect vials and prefilled syringes from light.
  • Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Do not use any vials or prefilled syringes exhibiting particulate matter or discoloration.
  • Discard unused portion of Aranesp in vials or prefilled syringes. Do not re-enter vial.
  • Do not dilute Aranesp and do not administer in conjunction with other drug solutions.

3 DOSAGE FORMS AND STRENGTHS

Aranesp is available as a polysorbate-containing solution.

  • Single-dose vials: 25, 40, 60, 100, 200, 300, and 500 mcg Aranesp/1 mL, and 150 mcg Aranesp/0.75 mL
  • Single-dose prefilled syringes: 25 mcg Aranesp/0.42 mL, 40 mcg Aranesp/0.4 mL, 60 mcg Aranesp/0.3 mL, 100 mcg Aranesp/0.5 mL, and 150 mcg Aranesp/0.3 mL, 200 mcg Aranesp/0.4 mL, 300 mcg Aranesp/0.6 mL, and 500 mcg Aranesp/1 mL

4 CONTRAINDICATIONS

Aranesp is contraindicated in patients with:

  • Uncontrolled hypertension [see Warnings and Precautions (5.4)].
  • Pure red cell aplasia (PRCA) that begins after treatment with Aranesp or other erythropoietin protein drugs [see Warnings and Precautions (5.7)].
  • Serious allergic reactions to Aranesp [see Warnings and Precautions (5.8)].

5 WARNINGS AND PRECAUTIONS

5.1 Increased Mortality, Myocardial Infarction, Stroke, and Thromboembolism

  • In controlled clinical trials of patients with CKD comparing higher hemoglobin targets (13 - 14 g/dL) to lower targets (9 - 11.3 g/dL), Aranesp and other ESAs increased the risk of death, myocardial infarction, stroke, congestive heart failure, thrombosis of hemodialysis vascular access, and other thromboembolic events in the higher target groups.
  • Using Aranesp to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular reactions and has not been shown to provide additional benefit [see Clinical Studies (14.1)].  Use caution in patients with coexistent cardiovascular disease and stroke [see Dosage and Administration (2.2)]. Patients with CKD and an insufficient hemoglobin response to ESA therapy may be at even greater risk for cardiovascular reactions and mortality than other patients. A rate of hemoglobin rise of greater than 1 g/dL over 2 weeks may contribute to these risks.
  • In controlled clinical trials of patients with cancer, Aranesp and other ESAs increased the risks for death and serious adverse cardiovascular reactions. These adverse reactions included myocardial infarction and stroke.
  • In controlled clinical trials, ESAs increased the risk of death in patients undergoing coronary artery bypass graft surgery (CABG) and the risk of deep venous thrombosis (DVT) in patients undergoing orthopedic procedures.


The design and overall results of the 3 large trials comparing higher and lower hemoglobin targets are shown in Table 2.

Table 2: Randomized Controlled Trials Showing Adverse Cardiovascular Outcomes in Patients With CKD

 

 Normal Hematocrit Study (NHS)
(N = 1265)

 
CHOIR
(N = 1432)

 
TREAT
(N = 4038)

 Time Period of Trial

 1993 to 1996

 2003 to 2006

 2004 to 2009

 Population

 CKD patients on hemodialysis with coexisting CHF or CAD, hematocrit 30 ± 3% on epoetin alfa

 CKD patients not on dialysis with hemoglobin < 11 g/dL not previously administered epoetin alfa

 CKD patients not on dialysis with type II diabetes, hemoglobin ≤ 11 g/dL

 Hemoglobin Target; Higher vs. Lower (g/dL)

 14.0 vs. 10.0

 13.5 vs. 11.3

 13.0 vs. ≥ 9.0

 Median (Q1, Q3) Achieved Hemoglobin level (g/dL)

 12.6 (11.6, 13.3) vs. 10.3 (10.0, 10.7)

 13.0 (12.2, 13.4) vs. 11.4 (11.1, 11.6)

 12.5 (12.0, 12.8) vs. 10.6 (9.9, 11.3)

 Primary Endpoint

 All-cause mortality or non-fatal MI

 All-cause mortality, MI, hospitalization for CHF, or stroke

 All-cause mortality, MI, myocardial ischemia, heart failure, and stroke

 Hazard Ratio or Relative Risk (95% CI)

 1.28 (1.06 - 1.56)

 1.34 (1.03 - 1.74)

 1.05 (0.94 - 1.17)

 Adverse Outcome for Higher Target Group

 All-cause mortality

 All-cause mortality

 Stroke

 Hazard Ratio or Relative Risk (95% CI)

 1.27 (1.04 - 1.54)

 1.48 (0.97 - 2.27)

 1.92 (1.38 - 2.68)

Patients with Chronic Kidney Disease

Normal Hematocrit Study (NHS): A prospective, randomized, open-label study of 1265 patients with chronic kidney disease on dialysis with documented evidence of congestive heart failure or ischemic heart disease was designed to test the hypothesis that a higher target hematocrit (Hct) would result in improved outcomes compared with a lower target Hct. In this study, patients were randomized to epoetin alfa treatment targeted to a maintenance hemoglobin of either 14 ± 1 g/dL or 10 ± 1 g/dL. The trial was terminated early with adverse safety findings of higher mortality in the high hematocrit target group. Higher mortality (35% vs. 29%) was observed for the patients randomized to a target hemoglobin of 14 g/dL than for the patients randomized to a target hemoglobin of 10 g/dL. For all-cause mortality, the HR = 1.27; 95% CI (1.04, 1.54); p=0.018. The incidence of nonfatal myocardial infarction, vascular access thrombosis, and other thrombotic events was also higher in the group randomized to a target hemoglobin of 14 g/dL.


CHOIR: A randomized, prospective trial, 1432 patients with anemia due to CKD who were not undergoing dialysis and who had not previously received epoetin alfa therapy were randomized to epoetin alfa treatment targeting a maintenance hemoglobin concentration of either 13.5 g/dL or 11.3 g/dL. The trial was terminated early with adverse safety findings. A major cardiovascular event (death, myocardial infarction, stroke, or hospitalization for congestive heart failure) occurred in 125 of the 715 patients (18%) in the higher hemoglobin group compared to 97 of the 717 patients (14%) in the lower hemoglobin group [hazard ratio (HR) 1.34, 95% CI: 1.03, 1.74; p = 0.03].


TREAT: A randomized, double-blind, placebo-controlled, prospective trial of 4038 patients with CKD not on dialysis (eGFR of 20 – 60 mL/min), anemia (hemoglobin levels ≤ 11 g/dL), and type 2 diabetes mellitus, patients were randomized to receive either Aranesp treatment or a matching placebo. Placebo group patients also received Aranesp when their hemoglobin levels were below 9 g/dL. The trial objectives were to demonstrate the benefit of Aranesp treatment of the anemia to a target hemoglobin level of 13 g/dL, when compared to a "placebo" group, by reducing the occurrence of either of two primary endpoints: (1) a composite cardiovascular endpoint of all-cause mortality or a specified cardiovascular event (myocardial ischemia, CHF, MI, and CVA) or (2) a composite renal endpoint of all-cause mortality or progression to end stage renal disease. The overall risks for each of the two primary endpoints (the cardiovascular composite and the renal composite) were not reduced with Aranesp treatment (see Table 2), but the risk of stroke was increased nearly two-fold in the Aranesp-treated group versus the placebo group: annualized stroke rate 2.1% vs. 1.1%, respectively, HR 1.92; 95% CI: 1.38, 2.68; p < 0.001. The relative risk of stroke was particularly high in patients with a prior stroke: annualized stroke rate 5.2% in the Aranesp treated group and 1.9% in the placebo group, HR 3.07; 95% CI: 1.44, 6.54. Also, among Aranesp-treated subjects with a past history of cancer, there were more deaths due to all causes and more deaths adjudicated as due to cancer, in comparison with the control group.


Patients with Cancer

An increased incidence of thromboembolic reactions, some serious and life-threatening, occurred in patients with cancer treated with ESAs.

In a randomized, placebo-controlled study (Study 1 in Table 3 [see Warnings and Precautions (5.3)]) of 939 women with metastatic breast cancer receiving chemotherapy, patients received either weekly epoetin alfa or placebo for up to a year. This study was designed to show that survival was superior when epoetin alfa was administered to prevent anemia (maintain hemoglobin levels between 12 and 14 g/dL or hematocrit between 36% and 42%). This study was terminated prematurely when interim results demonstrated a higher mortality at 4 months (8.7% vs. 3.4%) and a higher rate of fatal thrombotic reactions (1.1% vs. 0.2%) in the first 4 months of the study among patients treated with epoetin alfa. Based on Kaplan-Meier estimates, at the time of study termination, the 12-month survival was lower in the epoetin alfa group than in the placebo group (70% vs. 76%; HR 1.37, 95% CI: 1.07, 1.75; p = 0.012).

Patients Having Surgery

Aranesp is not approved for reduction of RBC transfusions in patients scheduled for surgical procedures.

An increased incidence of DVT in patients receiving epoetin alfa undergoing surgical orthopedic procedures was demonstrated. In a randomized, controlled study, 680 adult patients, not receiving prophylactic anticoagulation and undergoing spinal surgery, received epoetin alfa and standard of care (SOC) treatment (n = 340) or SOC treatment alone (n = 340). A higher incidence of DVTs, determined by either color flow duplex imaging or by clinical symptoms, was observed in the epoetin alfa group (16 [4.7%] patients) compared with the SOC group (7 [2.1%] patients). In addition to the 23 patients with DVTs included in the primary analysis, 19 [2.8%] patients experienced 1 other thrombovascular event (TVE) each (12 [3.5%] in the epoetin alfa group and 7 [2.1%] in the SOC group).

Increased mortality was observed in a randomized, placebo-controlled study of epoetin alfa in adult patients who were undergoing CABG surgery (7 deaths in 126 patients randomized to epoetin alfa versus no deaths among 56 patients receiving placebo). Four of these deaths occurred during the period of study drug administration and all 4 deaths were associated with thrombotic events.

5.2 Prescribing and Distribution Program for Aranesp in Patients With Cancer

In order to prescribe and/or dispense Aranesp to patients with cancer and anemia due to myelosuppressive chemotherapy, prescribers and hospitals must enroll in and comply with the ESA APPRISE Oncology Program requirements. To enroll, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance. Additionally, prior to each new course of Aranesp in patients with cancer, prescribers and patients must provide written acknowledgment of a discussion of the risks of Aranesp.

5.3 Increased Mortality and/or Increased Risk of Tumor Progression or Recurrence in Patients With Cancer

ESAs resulted in decreased locoregional control/progression-free survival and/or overall survival (see Table 3). These findings were observed in studies of patients with advanced head and neck cancer receiving radiation therapy (Studies 5 and 6), in patients receiving chemotherapy for metastatic breast cancer (Study 1) or lymphoid malignancy (Study 2), and in patients with non-small cell lung cancer or various malignancies who were not receiving chemotherapy or radiotherapy (Studies 7 and 8).

Table 3. Randomized, Controlled Studies With Decreased Survival and/or Decreased Locoregional Control

*Q1= 25th percentile
Q3= 75th percentile

 Study/Tumor/(n)

 Hemoglobin Target

 Hemoglobin(Median; 
Q1, Q3*)

 Primary Efficacy Outcome

 Adverse Outcome for 
ESA- containing Arm

 Chemotherapy

Study 1
Metastatic breast 
cancer
(n = 939)

 12-14 g/dL

 12.9 g/dL;12.2, 13.3 g/dL

 12-month overall survival

 Decreased 12-month survival

Study 2
Lymphoid malignancy
(n = 344)

13-15 g/dL (M)

13-14 g/dL (F)

 11 g/dL;9.8, 12.1 g/dL

 Proportion of patients achieving a hemoglobin response

 Decreased overall survival

Study 3
Early breast 
cancer
(n = 733)

 12.5-13 g/dL

13.1 g/dL;

12.5, 13.7 g/dL

 Relapse-free and overall survival

Decreased 3-year relapse-free and overall survival

Study 4
Cervical cancer
(n = 114)

 12-14 g/dL

 12.7 g/dL;
12.1, 13.3 g/dL

 Progression-free and overall survival and locoregional control

 Decreased 3-year progression-free and overall survival and locoregional control

 Radiotherapy Alone

Study 5
Head and neck 
cancer
(n = 351)

≥15 g/dL (M)

≥14 g/dL (F)

 Not available

 Locoregional progression-free survival

  Decreased 5-year locoregional progression-free and overall survival

Study 6
Head and neck 
cancer
(n = 522)

 14-15.5 g/dL

 Not available

 Locoregional disease control

 Decreased locoregional disease control

 No Chemotherapy or Radiotherapy

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Aranesp 40 Mcg Solution For Injection Pre-Filled 4 Syringes

  • Brand: Amgen
  • Product Code: 8699862950039
  • Availability: In Stock
  • $475.00

Tags: Aranesp 40 Mcg Solution For Injection Pre-Filled 4 Syringes, Amgen, All Products