Side Effects of Copaxone (glatiramer)

Copaxone (glatiramer) is a combination of four amino acids (proteins) used to treat relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

Copaxone's mechanism of action is not completely understood. Available data suggest that it may work by modifying immune processes by suppressing T-cells (white blood cells of the immune system) that cause inflammation and destruction of nerves in patients with MS. Copaxone does not cure MS. It decreases the number of MS flares and lesions in the brain.

Common side effects of Copaxone include

• injection site reactions (e.g., pain, redness, soreness, itching, swelling, or a hard lump),
• nausea,
• vomiting,
• chills,
• joint aches,
• body aches,
• neck pain,
• back pain,
• double vision,
• headache,
• increased urge to urinate,
• weakness,
• runny nose,
• swelling in hands or feet,
• vaginal itching or discharge,
• fever,
• chills,
• flu symptoms,
• sore throat, and
• white patches or sores inside the mouth or on the lips.

Immediately after injection with Copaxone, side effects may include flushing (warmth, redness, or tingly feeling), chest pain, fast heartbeat, anxiety, shortness of breath, and itching. These symptoms usually disappear quickly and usually do not require treatment. 

Serious side effects of Copaxone include

• dizziness,
• fainting,
• infection (such as fever, persistent sore throat),
• mental/mood changes (such as depression),
• severe pain at the injection site,
• shakiness (tremor), and
• vision problems.

Drug interactions between Copaxone and other drugs have not been fully evaluated. Results from existing clinical trials do not suggest any significant interactions of Copaxone with therapies commonly used in MS patients, including the concurrent use of corticosteroids for up to 28 days. Copaxone has not been formally evaluated in combination with interferon beta.

Before you use Copaxone, tell your doctor if you are pregnant or plan to become pregnant. It is unknown if Copaxone will harm a fetus. It is unknown if Copaxone passes into breast milk. Consult your doctor before breastfeeding. 

Common side effects include:

• Injection site pain
• Injection site redness
• Injection site inflammation
• Injection site itching
• Injection site lump
• Shortness of breath
• Itching
• Rash
• Diarrhea
• Lymphadenopathy
• Injection site welt
• Weakness
• Joint pain
• Anxiety
• Nausea
• Flu symptoms

Other side effects include:

• Infections
• Weight gain
• Facial swelling

Possible serious side effects include:

• Palpitations
• Chest pain
• Blood clots
• Skin necrosis (death)
• Increased heart rate
• Vaginal fungal infection
• Allergic reactions

The following serious adverse reactions are described elsewhere in the labeling:

• Immediate Post-Injection Reaction
• Chest Pain
• Lipoatrophy and Skin Necrosis
• Potential Effects on Immune Response

Clinical Trials 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.

Incidence In Controlled Clinical Trials

Copaxone 20 mg Per mL Per Day

Among 563 patients treated with Copaxone in blinded placebo-controlled trials, approximately 5% of the subjects discontinued treatment because of an adverse reaction.

The adverse reactions most commonly associated with discontinuation were:

• injection site reactions,
•  dyspnea,
• urticaria,
• vasodilatation, and
•  hypersensitivity.

The most common adverse reactions were:

• injection site reactions,
• vasodilatation,
• rash,
• dyspnea, and
• chest pain.

Table 1 lists signs and symptoms that occurred in at least 2% of patients treated with Copaxone 20 mg per mL in the placebo-controlled trials. These signs and symptoms were numerically more common in patients treated with Copaxone than in patients treated with placebo. Adverse reactions were usually mild in intensity.

Table 1: Adverse Reactions in Controlled Clinical Trials with an Incidence ≥2% of Patients and More Frequent with Copaxone (20 mg per mL Daily) than with Placebo

Adverse reactions which occurred only in 4 to 5 more subjects in the Copaxone group than in the placebo group (less than 1% difference), but for which a relationship to Copaxone could not be excluded, were arthralgia and herpes simplex.

• Laboratory analyses were performed on all patients participating in the clinical program for Copaxone.
• Clinically-significant laboratory values for hematology, chemistry, and urinalysis were similar for both Copaxone and placebo groups in blinded clinical trials.
• In controlled trials one patient discontinued treatment due to thrombocytopenia (16 x10⁹/L), which resolved after discontinuation of treatment.
• Data on adverse reactions occurring in the controlled clinical trials of Copaxone 20 mg per mL were analyzed to evaluate differences based on sex.
• No clinically-significant differences were identified.
• Ninety-six percent of patients in these clinical trials were Caucasian.
• The majority of patients treated with Copaxone were between the ages of 18 and 45.
• Consequently, data are inadequate to perform an analysis of the adverse reaction incidence related to clinically-relevant age subgroups.

Other Adverse Reactions

In the paragraphs that follow, the frequencies of less commonly reported adverse clinical reactions are presented. Because the reports include reactions observed in open and uncontrolled premarketing studies (n= 979), the role of Copaxone in their causation cannot be reliably determined.

Furthermore, variability associated with adverse reaction reporting, the terminology used to describe adverse reactions, etc., limit the value of the quantitative frequency estimates provided. Reaction frequencies are calculated as the number of patients who used Copaxone and reported a reaction divided by the total number of patients exposed to Copaxone.

All reported reactions are included except those already listed in the previous table, those too general to be informative, and those not reasonably associated with the use of the drug.

Reactions are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: Frequent adverse reactions are defined as those occurring in at least 1/100 patients and infrequent adverse reactions are those occurring in 1/100 to 1/1,000 patients.

Body as a Whole

• Frequent: Abscess
• Infrequent: Injection site hematoma, moon face, cellulitis, hernia, injection site abscess, serum sickness, suicide attempt, injection site hypertrophy, injection site melanosis, lipoma, and photosensitivity reaction.

Cardiovascular

• Frequent: Hypertension.
• Infrequent: Hypotension, midsystolic click, systolic murmur, atrial fibrillation, bradycardia, fourth heart sound, postural hypotension, and varicose veins.

Digestive

• Infrequent: Dry mouth, stomatitis, burning sensation on tongue, cholecystitis, colitis, esophageal ulcer, esophagitis, gastrointestinal carcinoma, gum hemorrhage, hepatomegaly, increased appetite, melena, mouth ulceration, pancreas disorder, pancreatitis, rectal hemorrhage, tenesmus, tongue discoloration, and duodenal ulcer.

Endocrine

• Infrequent: Goiter, hyperthyroidism, and hypothyroidism.

Gastrointestinal

• Frequent: Bowel urgency, oral moniliasis, salivary gland enlargement, tooth caries, and ulcerative stomatitis.

Hemic and Lymphatic

• Infrequent: Leukopenia, anemia, cyanosis, eosinophilia, hematemesis, lymphedema, pancytopenia, and splenomegaly.

Metabolic and Nutritional

• Infrequent: Weight loss, alcohol intolerance, Cushing’s syndrome, gout, abnormal healing, and xanthoma.

Musculoskeletal

• Infrequent: Arthritis, muscle atrophy, bone pain, bursitis, kidney pain, muscle disorder, myopathy, osteomyelitis, tendon pain, and tenosynovitis.

Nervous

• Frequent: Abnormal dreams, emotional lability, and stupor.
• Infrequent: Aphasia, ataxia, convulsion, circumoral paresthesia, depersonalization, hallucinations, hostility, hypokinesia, coma, concentration disorder, facial paralysis, decreased libido, manic reaction, memory impairment, myoclonus, neuralgia, paranoid reaction, paraplegia, psychotic depression, and transient stupor.

Respiratory

• Frequent: Hyperventilation and hay fever. Infrequent: Asthma, pneumonia, epistaxis, hypoventilation, and voice alteration.

Skin and Appendages

• Frequent: Eczema, herpes zoster, pustular rash, skin atrophy, and warts. Infrequent: Dry skin, skin hypertrophy, dermatitis, furunculosis, psoriasis, angioedema, contact dermatitis, erythema nodosum, fungal dermatitis, maculopapular rash, pigmentation, benign skin neoplasm, skin carcinoma, skin striae, and vesiculobullous rash.

Special Senses

• Frequent: Visual field defect.
• Infrequent: Dry eyes, otitis externa, ptosis, cataract, corneal ulcer, mydriasis, optic neuritis, photophobia, and taste loss.

Urogenital

• Frequent: Amenorrhea, hematuria, impotence, menorrhagia, suspicious papanicolaou smear, urinary frequency, and vaginal hemorrhage.
• Infrequent: Vaginitis, flank pain (kidney), abortion, breast engorgement, breast enlargement, carcinoma in situ cervix, fibrocystic breast, kidney calculus, nocturia, ovarian cyst, priapism, pyelonephritis, abnormal sexual function, and urethritis.

Copaxone 40 mg per mL Three Times Per Week

Among 943 patients treated with Copaxone 40 mg per mL three times per week in a blinded, placebo-controlled trial, approximately 3% of the subjects discontinued treatment because of an adverse reaction. The most common adverse reactions were injection site reactions, which were also the most common cause of discontinuation.

Table 2 lists signs and symptoms that occurred in at least 2% of patients treated with Copaxone 40 mg per mL in the blinded, placebo-controlled trial. These signs and symptoms were numerically more common in patients treated with Copaxone 40 mg per mL than in patients treated with placebo. Adverse reactions were usually mild in intensity.

Table 2: Adverse Reactions in a Controlled Clinical Trial with an Incidence ≥2% of Patients and More Frequent with Copaxone (40 mg per mL Three Times per Week) than with Placebo

No new adverse reactions appeared in subjects treated with Copaxone 40 mg per mL three times per week as compared to subjects treated with Copaxone 20 mg per mL per day in clinical trials and during postmarketing experience. Data on adverse reactions occurring in the controlled clinical trial of Copaxone 40 mg per mL were analyzed to evaluate differences based on sex.

No clinically significant differences were identified. Ninety-eight percent of patients in this clinical trial were Caucasian and the majority were between the ages of 18 and 50. Consequently, data are inadequate to perform an analysis of the adverse reaction incidence related to clinically-relevant age groups.

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of Copaxone. 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.

• Body as a Whole: sepsis; SLE syndrome; hydrocephalus; enlarged abdomen; allergic reaction; anaphylactoid reaction
• Cardiovascular System: thrombosis; peripheral vascular disease; pericardial effusion; myocardial infarct; deep thrombophlebitis; coronary occlusion; congestive heart failure; cardiomyopathy; cardiomegaly; arrhythmia; angina pectoris
• Digestive System: tongue edema; stomach ulcer; hemorrhage; liver function abnormality; liver damage; hepatitis; eructation; cirrhosis of the liver; cholelithiasis
• Hemic and Lymphatic System: thrombocytopenia; lymphoma-like reaction; acute leukemia
• Metabolic and Nutritional Disorders: hypercholesterolemia
• Musculoskeletal System: rheumatoid arthritis; generalized spasm
• Nervous System: myelitis; meningitis; CNS neoplasm; cerebrovascular accident; brain edema; abnormal dreams; aphasia; convulsion; neuralgia
• Respiratory System: pulmonary embolus; pleural effusion; carcinoma of lung
• Special Senses: glaucoma; blindness
• Urogenital System: urogenital neoplasm; urine abnormality; ovarian carcinoma; nephrosis; kidney failure; breast carcinoma; bladder carcinoma; urinary frequency

• Interactions between Copaxone and other drugs have not been fully evaluated.
• Results from existing clinical trials do not suggest any significant interactions of Copaxone with therapies commonly used in MS patients, including the concurrent use of corticosteroids for up to 28 days.
• Copaxone has not been formally evaluated in combination with interferon beta.