Adult patients treated with etanercept and anakinra were observed to have a higher rate of serious infection when compared with patients treated with either etanercept or anakinra alone (historical data). In addition, in a double-blind, placebo-controlled trial in adult patients receiving background methotrexate, patients treated with etanercept and anakinra were observed to have a higher rate of serious infections (7%) and neutropenia than patients treated with etanercept (see sections 4.4 and 4.8). The combination etanercept and anakinra has not demonstrated increased clinical benefit, and is therefore not recommended.
Concurrent treatment with abatacept In clinical studies, concurrent administration of abatacept and etanercept resulted in increased incidences of serious adverse events. This combination has not demonstrated increased clinical benefit; such use is not recommended (see section 4.4). Concurrent treatment with sulfasalazine In a clinical study of adult patients who were receiving established doses of sulfasalazine, to which etanercept was added, patients in the combination group experienced a statistically significant decrease in mean white blood cell counts in comparison to groups treated with etanercept or sulfasalazine alone. The clinical significance of this interaction is unknown.
Physicians should use caution when considering combination therapy with sulfasalazine. Non-interactions In clinical trials, no interactions have been observed when etanercept was administered with glucocorticoids, salicylates (except sulfasalazine), non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, or methotrexate. See section 4.4 for vaccination advice. No clinically significant pharmacokinetic interactions were observed in studies with methotrexate, digoxin or warfarin.
4.6 Fertility, pregnancy and lactation Women of childbearing potential Women of childbearing potential should consider the use of appropriate contraception to avoid becoming pregnant during Erelzi therapy and for three weeks after discontinuation of therapy. Pregnancy Developmental toxicity studies performed in rats and rabbits have revealed no evidence of harm to the foetus or neonatal rat due to etanercept. The effects of etanercept on pregnancy outcomes have been investigated in two observational cohort studies.
A higher rate of major birth defects was observed in one observational study comparing pregnancies exposed to etanercept (n = 370) during the first trimester with pregnancies not exposed to etanercept or other TNF-antagonists (n = 164) (adjusted odds ratio 2.4, 95% CI: 1.0 - 5.5). The types of major birth defects were consistent with those most commonly reported in the general population and no particular pattern of abnormalities was identified. No change in the rate of spontaneous abortion, stillbirth, or minor malformations was observed.
In another observational multi-country registry study comparing the risk of adverse pregnancy outcomes in women exposed to etanercept during the first 90 days of pregnancy (n = 425) to those exposed to non- biologic drugs (n = 3497), there was no observed increased risk of major birth defects (crude odds ratio [OR] = 1.22, 95% CI: 0.79 - 1.90; adjusted OR = 0.96, 95% CI: 0.58 - 1.60 after adjusting for country, maternal disease, parity, maternal age and smoking in early pregnancy). This study also showed no increased risks of minor birth defects, preterm birth, stillbirth, or infections in the first year of life for 10