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mecasermin injection, solution
FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
1.1 Severe Primary IGF-1 Deficiency (Primary IGFD)
INCRELEX® (mecasermin [rDNA origin] injection) is indicated for the treatment of:
Severe Primary IGF-1 deficiency (IGFD) is defined by:
Severe Primary IGFD includes classical and other forms of growth hormone insensitivity. Patients with Primary IGFD may have mutations in the GH receptor (GHR), post-GHR signaling pathway including the IGF-1 gene. They are not GH deficient, and therefore, they cannot be expected to respond adequately to exogenous GH treatment.
INCRELEX® is not intended for use in subjects with secondary forms of IGF-1 deficiency, such as GH deficiency, malnutrition, hypothyroidism, or chronic treatment with pharmacologic doses of anti-inflammatory steroids. Thyroid and nutritional deficiencies should be corrected before initiating INCRELEX® treatment.
Limitations of use: INCRELEX® is not a substitute to GH for approved GH indications.
2 DOSAGE AND ADMINISTRATION
Preprandial glucose monitoring is recommended at treatment initiation and until a well tolerated dose is established. If frequent symptoms of hypoglycemia or severe hypoglycemia occur, preprandial glucose monitoring should continue. The dosage of INCRELEX® should be individualized for each patient. The recommended starting dose of INCRELEX® is 0.04 to 0.08 mg/kg (40 to 80 micrograms/kg) twice daily by subcutaneous injection. If well-tolerated for at least one week, the dose may be increased by 0.04 mg/kg per dose, to the maximum dose of 0.12 mg/kg given twice daily. Doses greater than 0.12 mg/kg given twice daily have not been evaluated in children with Primary IGFD and, due to potential hypoglycemic effects, should not be used. If hypoglycemia occurs with recommended doses despite adequate food intake, the dose should be reduced. INCRELEX® should be administered shortly before or after (± 20 minutes) a meal or snack. If the patient is unable to eat shortly before or after a dose for any reason, that dose of INCRELEX® should be withheld. Subsequent doses of INCRELEX® should never be increased to make up for one or more omitted dose.
INCRELEX® is administered by subcutaneous injection.
INCRELEX® injection sites should be rotated to a different site (upper arm, thigh, buttock or abdomen) with each injection to avoid lipohypertrophy.
INCRELEX® should be administered using sterile disposable syringes and needles. The syringes should be of small enough volume so that the prescribed dose can be withdrawn from the vial with accuracy.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
3 DOSAGE FORMS AND STRENGTHS
INCRELEX® is a sterile solution available at a concentration of 10 mg per mL (40 mg per vial).
4.1 Active or Suspected Neoplasia
INCRELEX® is contraindicated in the presence of active or suspected malignancy, and therapy should be discontinued if evidence of malignancy develops.
4.2 Known Hypersensitivity
INCRELEX® should not be used by patients who are allergic to mecasermin (rhIGF-1) or any of the inactive ingredients in INCRELEX®, or who have experienced a severe hypersensitivity to INCRELEX® [see Warnings and Precautions (5.2) and Adverse Reactions (6.2)]
5 WARNINGS AND PRECAUTIONS
Because INCRELEX® has insulin-like hypoglycemic effects it should be administered shortly before or after (± 20 minutes) a meal or snack. Glucose monitoring and INCRELEX® dose titration are recommended until a well tolerated dose is established (see Dosage 2.1) and subsequently as medically indicated. Special attention should be paid to small children because their oral intake may not be consistent. Patients should avoid engaging in any high-risk activities (e.g., driving, etc.) within 2 to 3 hours after dosing, particularly during the initiation of INCRELEX® treatment until tolerability and a stable dose have been established [see Adverse Reactions (6.1)]. INCRELEX® should not be administered when the meal or snack is omitted. The dose of INCRELEX® should never be increased to make up for one or more omitted doses.
5.2 Hypersensitivity and Allergic Reactions, including Anaphylaxis
Allergic reactions to INCRELEX® have been reported post-marketing. They range from localized (injection site) reactions to systemic reactions, including anaphylaxis requiring hospitalization. Parents and patients should be informed that such reactions are possible and that if a systemic allergic reaction occurs treatment should be interrupted and prompt medical attention should be sought. [see Contraindications (4.2) and Adverse Reactions (6.2, 6.3)]
5.3 Intracranial Hypertension
Intracranial hypertension (IH) with papilledema, visual changes, headache, nausea and/or vomiting have occurred in patients treated with INCRELEX®, similar to patients treated with therapeutic doses of growth hormone. IH-associated signs and symptoms resolved after interruption of dosing. Funduscopic examination is recommended at the initiation and periodically during the course of INCRELEX® therapy. [see Adverse Reactions (6.2)]
5.4 Lymphoid Tissue Hypertrophy
Lymphoid tissue (e.g., tonsillar and adenoidal) hypertrophy associated with complications, such as snoring, sleep apnea, and chronic middle-ear effusions have been reported with the use of INCRELEX®. Patients should have periodic examinations to rule out such potential complications and receive appropriate treatment if necessary. [see Adverse Reactions (6.2)]
5.5 Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis may occur in patients who experience rapid growth. Any pediatric patient with the onset of a limp or complaints of hip or knee pain during INCRELEX® therapy should be carefully evaluated.
5.6 Progression of Preexisting Scoliosis
Progression of scoliosis may occur in patients who experience rapid growth. Because INCRELEX® increases growth rate, patients with a history of scoliosis who are treated with INCRELEX® should be monitored for progression of scoliosis.
5.7 Benzyl Alcohol
Benzyl alcohol, a component of this product, has been associated with serious adverse events and death, particularly in pediatric patients. The "gasping syndrome," (characterized by central nervous system depression, metabolic acidosis, gasping respirations, and high levels of benzyl alcohol and its metabolites found in the blood and urine) has been associated with benzyl alcohol dosages >99 mg/kg/day in neonates and low-birth weight neonates. Additional symptoms may include gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic and renal failure, hypotension, bradycardia, and cardiovascular collapse. Practitioners administering this and other medications containing benzyl alcohol should consider the combined daily metabolic load of benzyl alcohol from all sources.
6 ADVERSE REACTIONS
6.1 Most Serious and/or Most Frequently Observed Adverse Reactions:
6.2 Clinical Trial Experience
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.
In clinical studies of 71 subjects with Primary IGFD treated for a mean duration of 3.9 years and representing 274 subject-years, no subjects withdrew from any clinical study because of adverse reactions. Adverse reactions to INCRELEX® treatment that occurred in 5% or more of these study participants are listed below by organ class.
Hypoglycemia was reported by 30 subjects (42%) at least once during their course of therapy. Most cases of hypoglycemia were mild or moderate in severity. Five subjects had severe hypoglycemia (requiring assistance and treatment) on one or more occasion and 4 subjects experienced hypoglycemic seizures/loss of consciousness on one or more occasion. Of the 30 subjects reporting hypoglycemia, 14 (47%) had a history of hypoglycemia prior to treatment. The frequency of hypoglycemia was highest in the first month of treatment, and episodes were more frequent in younger children. Symptomatic hypoglycemia was generally avoided when a meal or snack was consumed either shortly (i.e., 20 minutes) before or after the administration of INCRELEX®.
Tonsillar hypertrophy was noted in 11 (15%) subjects in the first 1 to 2 years of therapy with lesser tonsillar growth in subsequent years. Tonsillectomy or tonsillectomy/adenoidectomy was performed in 7 subjects; 3 of these had obstructive sleep apnea, which resolved after the procedure in all three cases.
Intracranial hypertension occurred in three subjects. In two subjects the events resolved without interruption of INCRELEX® treatment. INCRELEX® treatment was discontinued in the third subject and resumed later at a lower dose without recurrence.
Mild elevations in the serum AST and LDH were found in a significant proportion of patients before and during treatment. Rise in levels of these serum enzymes did not lead to treatment discontinuation. ALT elevations were occasionally noted during treatment.
Renal and splenic lengths (measured by ultrasound) increased rapidly on INCRELEX® treatment during the first years of therapy. This lengthening slowed down subsequently; though in some patients, renal and/or splenic length reached or surpassed the 95th percentile. Renal function (as defined by serum creatinine and calculated creatinine clearance) was normal in all patients, irrespective of renal growth.
Elevations in cholesterol and triglycerides to above the upper limit of normal were observed before and during treatment.
Echocardiographic evidence of cardiomegaly/valvulopathy was observed in a few individuals without associated clinical symptoms. The relation of these cardiac changes to drug treatment cannot be assessed due to underlying disease and the lack of a control group.
Thickening of the soft tissues of the face was observed in several patients and should be monitored during INCRELEX® treatment.
As with all therapeutic proteins, there is potential for immunogenicity. Anti-IGF-1 antibodies were present at one or more of the periodic assessments in 14 of 23 children with Primary IGFD treated for 2 years. However, no clinical consequences of these antibodies were observed (e.g., attenuation of growth). The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to INCRELEX® with the incidence of antibodies to other products may be misleading.
6.3 Post-Marketing Experience
The following adverse reactions have been identified during post approval use of INCRELEX®. Because these 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 drug exposure.
Systemic hypersensitivity; anaphylaxis, generalized urticaria, angioedema, dyspnea
In the post-marketing setting, the frequency of cases indicative of anaphylaxis was estimated to be 0.3%. Symptoms included hives, angioedema, and dyspnea, and some patients required hospitalization. Upon re-administration, symptoms did not re-occur in all patients.
Local allergic reactions at the injection site; pruritis, urticaria.
8 USE IN SPECIFIC POPULATIONS
Pregnancy Category C. Studies to assess embryo-fetal toxicity evaluated the effects of INCRELEX® during organogenesis in Sprague Dawley rats given 1, 4, and 16 mg/kg/day and in New Zealand White rabbits given 0.125, 0.5, and 2 mg/kg/day, administered intravenously. There were no observed embryo-fetal developmental abnormalities in rats given up to 16 mg/kg/day (20 times the maximum recommended human dose [MRHD] based on body surface area [BSA] comparison). In the rabbit study, the NOAEL for fetal toxicity was 0.5 mg/kg (2 times the MRHD based on BSA) due to an increase in fetal death at 2 mg/kg. INCRELEX® displayed no teratogenicity or maternal toxicity in rabbits given up to 2 mg/kg (8 times the MRHD based on BSA).
The effects of INCRELEX® on an unborn child have not been studied. Therefore, there is insufficient medical information to determine whether there are significant risks to a fetus.
8.3 Nursing Mothers
Excretion of INCRELEX® in human milk has not been studied. As many drugs are excreted in human milk, caution should be exercised when INCRELEX® is administered to a nursing woman.
8.4 Pediatric Use
Safety and effectiveness in pediatric patients below the age of 2 years of age have not been established.
8.5 Geriatric Use
The safety and effectiveness of INCRELEX® in patients aged 65 and over has not been established.
8.6 Renal Impairment
No Studies have been conducted in Primary IGFD children or adult subjects with renal impairment [see Clinical Pharmacology (12.3)].
8.7 Hepatic Impairment
No studies have been conducted in Primary IGFD children or adult subjects with hepatic impairment [see Clinical Pharmacology (12.3)].
There is no clinical experience with overdosage of INCRELEX®. Based on known pharmacological effects, acute overdosage may lead to hypoglycemia. Long-term overdosage may result in signs and symptoms of acromegaly. Treatment of acute overdose of INCRELEX® should be directed at reversing hypoglycemia. Oral glucose or food should be consumed. If the overdose results in loss of consciousness, intravenous glucose or parenteral glucagon may be required to reverse the hypoglycemic effects.
INCRELEX® (mecasermin [rDNA origin] injection) contains human insulin-like growth factor-1 (rhIGF-1) produced by recombinant DNA technology. IGF-1 consists of 70 amino acids in a single chain with three intramolecular disulfide bridges and a molecular weight of 7649 daltons. The amino acid sequence of the product is identical to that of endogenous human IGF-1. The rhIGF-1 protein is synthesized in bacteria (E. coli) that have been modified by the addition of the gene for human IGF-1.
INCRELEX® is a sterile, aqueous, clear and colorless solution intended for subcutaneous injection. Each multi-dose vial of INCRELEX® contains 10 mg per mL mecasermin, 9 mg per mL benzyl alcohol, 5.84 mg per mL sodium chloride, 2 mg per mL polysorbate 20, and 0.05M acetate at a pH of approximately 5.4.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Insulin-like growth factor-1 (IGF-1) is a key hormonal mediator on statural growth. Under normal circumstances, growth hormone (GH) binds to its receptor in the liver, and other tissues, and stimulates the synthesis/secretion of IGF-1. In target tissues, the Type 1 IGF-1 receptor, which is homologous to the insulin receptor, is activated by IGF-1, leading to intracellular signaling which stimulates multiple processes resulting in statural growth. The metabolic actions of IGF-1 are in part directed at stimulating the uptake of glucose, fatty acids, and amino acids so that metabolism supports growing tissues.
The following actions have been demonstrated for endogenous human IGF-1:
Tissue Growth – 1) Skeletal growth occurs at the cartilage growth plates of the epiphyses of bones where stem cells divide to produce new cartilage cells or chondrocytes. The growth of chondrocytes is under the control of IGF-1 and GH. The chondrocytes become calcified so that new bone is formed allowing the length of the bones to increase. This results in skeletal growth until the cartilage growth plates fuse at the end of puberty. 2) Cell growth: IGF-1 receptors are present on most types of cells and tissues. IGF-1 has mitogenic activities that lead to an increased number of cells in the body. 3) Organ growth: Treatment of IGF-1 deficient rats with rhIGF-1 results in whole body and organ growth.
Carbohydrate Metabolism –IGF-1 suppresses hepatic glucose production and stimulates peripheral glucose utilization and therefore has a hypoglycemic potential. IGF-1 has inhibitory effects on insulin secretion.
Absorption – The absolute bioavailability of rhIGF-1 after subcutaneous administration in healthy subjects is estimated to be close to 100%. However, the absolute bioavailability of INCRELEX® given subcutaneously to subjects with primary insulin-like growth factor-1 deficiency (Primary IGFD) has not been determined.
Distribution – In blood, IGF-1 is bound to six IGF binding proteins, with > 80% bound as a complex with IGFBP-3 and an acid-labile subunit. IGFBP-3 is greatly reduced in subjects with severe Primary IGFD, resulting in increased clearance of IGF-1 in these subjects relative to healthy subjects. The total IGF-1 volume of distribution after subcutaneous administration in subjects with severe Primary IGFD is estimated to be 0.257 (± 0.073) L/kg at an INCRELEX® dose of 0.045 mg/kg, and is estimated to increase as the dose of INCRELEX® increases.
Elimination – IGF-1 is metabolized by both liver and kidney. The mean terminal t1/2 after single subcutaneous administration of 0.12 mg/kg INCRELEX® in pediatric subjects with severe Primary IGFD is estimated to be 5.8 hours. Clearance of INCRELEX® is inversely proportional to IGF binding protein-3 (IGFBP-3) levels. CL/F is estimated to be 0.04 L/hr/kg at 0.5 micrograms/mL of IGFBP-3, and 0.01 L/hr/kg at 3 micrograms/mL IGFBP-3; the latter is the median IGFBP-3 in subjects with normal IGF-1 serum levels.
Gender – In children with Primary IGFD there were no apparent differences between males and females in the pharmacokinetics of INCRELEX®.
Race –The effect of race on pharmacokinetics of INCRELEX® has not been studied.
Renal impairment– No studies have been conducted in Primary IGFD children with renal impairment.
Hepatic impairment– No studies have been conducted to determine the effect of hepatic impairment on the pharmacokinetics of rhIGF-1 in Primary IGFD children with hepatic impairment.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenesis: INCRELEX® was tumorigenic in rats in a study using doses of 0, 0.25, 1, 4, and 10 mg/kg/day by subcutaneous injection for up to 2 years. The incidence of adrenal medullary hyperplasia and pheochromocytoma increased in male rats given ≥1 mg/kg/day (≥ 1 times the clinical exposure with the maximum recommended human dose [MRHD] based on AUC) and in female rats at all dose levels (≥ 30% of the clinical exposure with the MRHD based on AUC). The incidence of keratoacanthoma in the skin increased in male rats given 4 and 10 mg/kg/day (≥ 4 times the MRHD). The incidence of mammary gland carcinoma in male rats increased in animals treated with 10 mg/kg/day (7 times the MRHD based on AUC). Only doses that exceeded the maximum tolerated dose (MTD) (based on excess mortality secondary to IGF-1 induced hypoglycemia) caused skin and mammary tumors.
Mutagenesis: INCRELEX® was not clastogenic in the in vitro chromosome aberration assay and the in vivo mouse micronucleus assay.
14 CLINICAL STUDIES
14.1 Effects of INCRELEX® Treatment in Children with Severe Primary Insulin-like Growth Factor-1 Deficiency (Primary IGFD)
Five clinical studies (four open-label and one double-blind, placebo-controlled), with subcutaneous doses of INCRELEX® generally ranging from 0.06 to 0.12 mg/kg (60 to 120 micrograms/kg) administered twice daily, were conducted in 71 pediatric subjects with severe Primary IGFD. Patients were enrolled in the trials on the basis of extreme short stature, slow growth rates, low IGF-1 serum concentrations, and normal growth hormone secretion. Data from these 5 clinical studies were pooled for a global efficacy and safety analysis. Baseline characteristics for the patients evaluated in the primary and secondary efficacy analyses were (mean, SD): chronological age (years): 6.7 ± 3.8; height (cm): 84.8 ± 15.3 cm; height standard deviation score (SDS): -6.7 ± 1.8; height velocity (cm/yr): 2.8 ± 1.8; height velocity SDS: -3.3 ± 1.7; IGF-1 (ng/mL): 21.6 ± 20.6; IGF-1 SDS: -4.3 ± 1.6; and bone age (years): 4.2 ± 2.8. Sixty-one subjects had at least one year of treatment. Fifty-three (87%) had Laron Syndrome; 7 (11%) had GH gene deletion, and 1 (2%) had neutralizing antibodies to GH. Thirty-seven (61%) of the subjects were male; forty-eight (79%) were Caucasian. Fifty-six (92%) of the subjects were pre-pubertal at baseline.
Annual results for height velocity, height velocity SDS, and height SDS are shown in Table 1. Pre-treatment height velocity data were available for 58 subjects. The height velocities at a given year of treatment were compared by paired t-tests to the pre-treatment height velocities of the same subjects completing that treatment year.
Forty-nine subjects were included in an analysis of the effects of INCRELEX® on bone age advancement. The mean ± SD change in chronological age was 4.9 ± 3.4 years and the mean ± SD change in bone age was 5.3 ± 3.4 years.
16 HOW SUPPLIED/STORAGE AND HANDLING
Before Opening – Vials of INCRELEX® are stable when refrigerated [2° to 8°C (35° to 46°F)]. Avoid freezing the vials of INCRELEX®. Protect from direct light. Expiration dates are stated on the labels.
After Opening – Vials of INCRELEX® are stable for 30 days after initial vial entry when stored at 2° to 8°C (35° to 46°F). Avoid freezing the vials of INCRELEX®. Protect from direct light.
Vial contents should be clear without particulate matter. If the solution is cloudy or contains particulate matter, the contents must not be injected. INCRELEX® should not be used after its expiration date. Keep refrigerated and use within 30 days of initial vial entry. Remaining unused material should be discarded.
17 PATIENT COUNSELING INFORMATION
Patients and/or their parents should be instructed in the safe administration of INCRELEX®. INCRELEX® should be given shortly before or after (20 minutes on either side of) a meal or snack. INCRELEX® should not be administered when the meal or snack is omitted. The dose of INCRELEX® should never be increased to make up for one or more omitted doses. INCRELEX® therapy should be initiated at a low dose and the dose should be increased only if no hypoglycemia episodes have occurred after at least 7 days of dosing. If severe hypoglycemia or persistent hypoglycemia occurs on treatment despite adequate food intake, INCRELEX® dose reduction should be considered. Providers should educate patients and caregivers on how to recognize the signs and symptoms of hypoglycemia.
INCRELEX® treatment may need to be discontinued if allergic reactions occur. Providers should educate patients and caregivers on the identification of signs and symptoms of serious allergic reactions to INCRELEX® and the need to seek prompt medical contact should such a reaction occur.
Patients and/or parents should be thoroughly instructed in the importance of proper needle disposal. A puncture-resistant container should be used for the disposal of used needles and/or syringes (consistent with applicable state requirements). Needles and syringes must not be reused.
Read the Patient Information that comes with INCRELEX® before your child starts taking INCRELEX® and each time you get a refill. There may be new information. This leaflet does not take the place of talking with your child's doctor about your child's condition or treatment.
What is INCRELEX®?
INCRELEX® is a liquid that contains man-made insulin-like growth factor-1 (IGF-1), which is the same as the IGF-1 made by your body. INCRELEX® is used to treat children who are very short for their age because their bodies do not make enough IGF-1. This condition is called primary IGF-1 deficiency. IGF-1 should not be used instead of growth hormone.
INCRELEX® has not been studied in children under 2 years of age.
Who Should Not Use INCRELEX®?
Your child should not take INCRELEX® if your child:
What should I tell my child's doctor before my child starts INCRELEX®?
Tell your child's doctor about all of your child's health conditions, including if your child:
Tell your child's doctor about all the medicines your child takes, including prescription and nonprescription medicines, vitamins, and herbal supplements. Especially tell your child's doctor if your child takes insulin or other anti-diabetes medicines. A dose adjustment may be needed for these medicines.
How Should My Child Use INCRELEX®?
What are the Possible Side Effects of INCRELEX®?
INCRELEX® may cause the following side effects, which can be serious:
Severe hypoglycemia may cause unconsciousness, seizures, or death. If you take INCRELEX®, you should avoid participating in high risk activities (such as driving) within 2 to 3 hours after INCRELEX® injection, especially at the beginning of INCRELEX® treatment.
Before beginning treatment with INCRELEX® your doctor or nurse will explain to you how to treat hypoglycemia. You/your child should always have a source of sugar such as orange juice, glucose gel, candy, or milk available in case symptoms of hypoglycemia occur. For severe hypoglycemia, if your child is not responsive and cannot drink sugar-containing fluids, you should give an injection of glucagon. Your doctor or nurse will instruct you how to give the injection.
Glucagon raises the blood sugar when it is injected. It is important that your child have a well-balanced diet including protein and fat such as meat and cheese in addition to sugar-containing foods.
INCRELEX® can cause reactions at the injection site including:
Injection site reactions can be avoided by changing the injection site at each injection ("injection site rotation").
Call your child's doctor if your child has side effects that are bothersome or that do not go away.
These are not all the side effects of INCRELEX®. Ask your child's doctor or pharmacist for more information.
How Should I Store INCRELEX®?
Keep INCRELEX® and all medicines out of reach of children.
General Information About INCRELEX®
Medicines are sometimes prescribed for conditions other than those described in patient information leaflets. Do not give INCRELEX® to your child for a condition for which it was not prescribed. Do not give INCRELEX® to a person other than your child. It may be harmful.
This leaflet summarizes the most important information about INCRELEX®. If you would like more information, talk to your child's doctor. You can also ask your child's doctor or pharmacist for information that is written for health professionals.
More information is available at 1-866-TERCICA (1-866-837-2422).
What are the Ingredients in INCRELEX®?
Active ingredient: mecasermin
Inactive ingredients: sodium chloride, polysorbate 20, benzyl alcohol, and acetate.
INCRELEX® should be administered using sterile disposable syringes and needles. The syringes should be of small enough volume that the prescribed dose can be withdrawn from the vial with reasonable accuracy.
Preparing the Dose:
Injecting the Dose:
Inject INCRELEX® as instructed by your child's doctor.
For additional information, call 1-866-TERCICA (1-866-837-2422).
Issued: August 2005
PRINCIPAL DISPLAY PANEL - 40 mg Carton
40 mg/4 mL
For subcutaneous use only
Net wt. 40 mg
Revised: 02/2011 Tercica, Inc.
Reproduced with permission of U.S. National Library of Medicine
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