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Antineoplastic Monoclonal Antibodies
Ipilimumab administration can result in severe and fatal immune-mediated reactions. Reactions usually manifest during treatment although a minority have been reported weeks to months after treatment discontinuation. While any organ system can be affected, the most common severe reactions are enterocolitis, hepatitis, dermatitis (including toxic epidermal necrolysis), neuropathy, and endocrinopathy. Prior to treatment initiation and before each dose is administered, asses for signs and symptoms of enterocolitis, dermatitis, neuropathy, and endocrinopathy; also, evaluate clinical blood chemistries including liver function tests, adrenocorticotropic hormone (ACTH) concentrations, and thyroid function tests. Permanently discontinue ipilimumab and initiate systemic high-dose corticosteroid therapy for severe immune-mediated reactions.
Monoclonal antibody that binds to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and blocks its interaction with its ligands CD80/CD86Indicated for malignant melanomaMay cause fatal immune-mediated adverse reactions such as enterocolitis, hepatitis, dermatitis, neuropathy, and endocrinopathy
YERVOY Intravenous Inj Sol: 1mL, 5mg
3 mg/kg IV over 90 minutes repeated every 3 weeks for a total of 4 doses. Doses may be delayed for toxicity; however, all treatment must be administered within 16 weeks of the first dose. In a multinational, randomized, double-blind, placebo-controlled, phase III study (the MDX010-20 study), treatment with ipilimumab (n = 137), a melanoma vaccine consisting of HLA-A*0201-restricted peptides derived from the melanosomal glycoprotein 100 (gp100) (n = 136), or ipilimumab plus gp100 (combination therapy arm; n = 403) was evaluated in adult patients with HLA-A*0201-positive, unresectable stage III or stage IV melanoma who had previously received at least 1 of the following therapies: carboplatin, dacarbazine, fotemustine, interleukin-2, or temozolomide. In this study, 31 evaluable patients with disease progression who had stable disease for 3 months at week 12 or a confirmed partial or complete response received additional courses (reinduction) of ipilimumab-containing therapy. For the primary end point comparison, the median overall survival (OS) time was significantly improved with combination therapy compared with gp100 alone (10 months vs. 6.4 months; hazard ratio (HR) = 0.68; 95% CI, 0.55 to 0.85; p < 0.001). In a pre-specified comparison, the OS time was significantly improved with ipilimumab alone compared with gp100 alone (10.1 months vs. 6.4 months; HR = 0.66; 95% CI, 0.51 to 0.87; p = 0.003) and there was no significant OS difference between the 2 ipilimumab-containing arms. The 12-, 18-, and 24-month OS rates for the single-agent ipilimumab arm were 45.6%, 33.2%, and 23.5%, respectively. The median progression-free survival (PFS) time for single-agent ipilimumab was 2.86 months and the 12-week PFS rate was 57.7%. In an analysis of all patients who survived at least 2 years (n = 94 of 474; 20%) or 3 years (n = 42 of 259; 16%), the 2- and 3-year OS rates were 25% (n = 24 of 95) and 25% (n = 13 of 53), respectively, for patients who received ipilimumab alone. Additionally, disease control (defined as a best response of stable disease or better) was 28.5% at week 24 and 83.3% in patients who received single-agent ipilimumab and survived at least 2 years.
10 mg/kg IV plus dacarbazine 850 mg/m2 IV repeated every 3 weeks (at weeks 1, 4, 7, and 10) for 4 doses followed by dacarbazine 850 mg/m2 IV every 3 weeks through week 22 (if no progressive disease) as induction therapy resulted in favorable overall survival in a randomized, double-blind, placebo-controlled, phase III trial. At week 24, patients with stable disease or an objective response received maintenance therapy with ipilimumab 10 mg/kg IV every 12 weeks until progressive disease.
10 mg/kg (actual body weight) IV on day 1 repeated every 3 weeks for 4 cycles in combination with sargramostim 250 micrograms (mcg) subcutaneously on days 1 to 14 repeated every 3 weeks for 4 cycles as induction therapy was evaluated in a randomized, phase IIb study. In patients with stable disease or better, maintenance therapy consisted of ipilimumab 10 mg/kg (actual body weight) IV on day 1 repeated every 12 weeks (starting on cycle 8) in combination with sargramostim 250 mcg subcutaneously on days 1 to 14 repeated every 3 weeks (starting on cycle 5). At a median follow-up of 13.3 months, median OS was significantly improved with combination therapy of ipilimumab plus GM-CSF compared to single-agent ipilimumab (17.5 months vs. 12.7 months; p = 0.01).
3 mg/kg IV over 90 minutes plus nivolumab 1 mg/kg IV over 60 minutes repeated every 3 weeks for 4 doses followed by nivolumab 240 mg IV over 60 minutes repeated every 2 weeks until disease progression or unacceptable toxicity. Administer ipilumumab after nivolumab. Both agents may need to be temporarily withheld or permanently discontinued in patients who develop immune-related reactions. Interrupt or slow the rate of the nivolumab infusion in patients who develop mild or moderate infusion reactions; discontinue therapy for severe or life-threatening infusion-related reactions.
10 mg/kg IV over 90 minutes every 3 weeks for 4 doses, followed by 10 mg/kg IV every 12 weeks until disease recurrence or unacceptable toxicity, for up to 3 years. In the event of toxicity, doses may be omitted but not delayed. At a median follow-up of 5.3 years, adjuvant treatment with ipilimumab led to a significantly improved median recurrence-free survival (RFS) time (primary endpoint) compared with placebo (27.6 months vs. 17.1 months; hazard ratio (HR) = 0.76; 95% CI, 0.64 to 0.89; p < 0.001) in patients with high-risk stage III melanoma after complete lymph-node dissection in a multinational, randomized, double-blind, placebo-controlled, phase III trial (n = 951; EORTC 18071 trial); the 5-year RFS rate was 40.8% and 30.3%, respectively. Treatment with ipilimumab also resulted in significantly improved 5-year overall survival (65.4% vs. 54.4%; HR = 0.72; 95.1% CI, 0.58 to 0.88; p = 0.001) and metastasis-free survival (48.3% vs. 38.9%; HR = 0.76; 95.8% CI, 0.64 to 0.92; p = 0.002) rates compared with placebo. In this study, patients had stage IIIA melanoma (with at least one metastasis measuring greater than 1 millimeter in the greatest dimension) or stage IIIB or IIIC melanoma with no in-transit metastases and had not received prior systemic therapy.
10 mg/kg IV every 3 weeks.
3 mg/kg IV every 3 weeks.
12 years: 3 mg/kg IV every 3 weeks.1 to 11 years: Safety and efficacy have not been established.
Safety and efficacy have not been established.
Baseline Hepatic ImpairmentMild hepatic impairment (total bilirubin 1 to 1.5X the upper limit of normal (ULN) or AST level greater than ULN): No ipilimumab dosage adjustment is required.Moderate to severe hepatic impairment (total bilirubin greater than 1.5X ULN and any AST level): Ipilimumab has not been evaluated in this patient population; specific guidelines for dosage adjustments in these patients are not available.Treatment-Related HepatotoxicityGrade 2 hepatotoxicity (bilirubin 1.51 to 3X ULN or AST/ALT 3 to 5X ULN): Hold ipilimumab therapy. If hepatotoxicity resolves to grade 0 or 1 in less than 6 weeks and the patient is receiving less than prednisone 7.5 mg/day (or equivalent), resume therapy. If the hepatotoxicity lasts longer than 6 weeks or if the dose of corticosteroid cannot be reduced to the equivalent of prednisone 7.5 mg/day, permanently discontinue therapy.Grade 3 or 4 hepatotoxicity (bilirubin greater than 3X ULN or AST/ALT greater than 5X ULN): Initiate systemic high-dose corticosteroids with prednisone 1 to 2 mg/kg/day (or equivalent) and permanently discontinue ipilimumab therapy. When liver tests show sustained improvement or return to baseline, initiate a taper to last over 1 month. Across the clinical development program, mycophenolate has been administered to patients with persistent severe hepatitis despite high-dose corticosteroids.
Baseline Renal ImpairmentNo ipilimumab dosage adjustment is required in patients with renal impairment. No significant difference in ipilimumab clearance was observed in patients with mild (glomerular filtration rate (GFR), 60 to 90 mL/min/1.73 m2), moderate (GFR, 30 to 60 mL/min/1.73 m2), or severe (GFR, 15 to 30 mL/min/1.73 m2) renal impairment compared with patients with normal renal function (GFR, greater than or equal to 90 mL/min/1.73 m2) in a pharmacokinetic analysis. Treatment-Related NephrotoxicityGrade 2 (SCr 2 to 3 times baseline): Hold ipilimumab therapy. If nephrotoxicity resolves to grade 0 or 1 in less than 6 weeks and the patient is receiving less than prednisone 7.5 mg/day (or equivalent), resume therapy. Permanently discontinue therapy if the toxicity lasts longer than 6 weeks or if the dose of corticosteroid cannot be reduced to the equivalent of prednisone 7.5 mg/day.Grade 3 or 4 (SCr greater than 3X baseline, or SCR greater than 4 mg/dL; hospitalization indicated): Permanently discontinue ipilimumab therapy and initiate systemic high-dose corticosteroids with prednisone 1 to 2 mg/kg/day (or equivalent).
Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit. The ipilimumab solution may have a pale yellow color and may have translucent-to-white, amorphous particles. Discard the ipilimumab vial if the solution is cloudy, if there is pronounced discoloration, or if there is foreign particulate matter.Do not shake ipilimumab.
Preparation:Allow the ipilimumab vials to stand at room temperature for approximately 5 minutes before infusion preparation.Withdraw the required volume of ipilimumab and transfer into an intravenous bag. Discard partially used vials or empty vials of ipilimumab.Dilute with 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP to prepare a diluted solution with a final ipilimumab concentration ranging from 1 to 2 mg/mL. Mix diluted solution by gentle inversion. Do not mix ipilimumab with other medicinal products.Storage: Once diluted, store for no more than 24 hours under refrigeration (2 to 8 degrees C or 36 to 46 degrees F) or at room temperature (20 to 25 degrees C or 68 to 77 degrees F). Intravenous infusion:Administer the diluted infusion over 90 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein-binding, in-line filter. Do not administer as an infusion with other medicinal products.After each infusion, flush the intravenous line with 0.9% Sodium Chloride Injection, USP or 0.5% Dextrose Injection, USP.
YERVOY:- Diluted product is stable and sterile for 24 hours when stored refrigerated or at room temperature- Discard product if it contains particulate matter, is cloudy, or discolored- Discard unused portion. Do not store for later use.- Do not freeze- Protect from light- Refrigerate (between 36 and 46 degrees F)
Severe and fatal immune-mediated enterocolitis has been reported with ipilimumab use; monitor patients for signs and symptoms of enterocolitis (diarrhea, abdominal pain, and mucus or blood in stool) and bowel perforation (peritoneal signs and ileus). An interruption or discontinuation of therapy may be necessary in patients who develop enterocolitis; management includes treatment with antidiarrheal agents, high-dose corticosteroids, or other immunosuppressive agents. Evaluate patients with symptomatic enterocolitis for infection; consider endoscopic evaluation for persistent or severe symptoms. Patients with inflammatory bowel disease such as ulcerative colitis or Crohn's disease may have an increased risk of developing enterocolitis. The time to onset of grade 3 or higher enterocolitis ranged from 1 day to 33.1 months in clinical studies.
Ipilimumab can result in severe and sometimes fatal serious rash or dermatitis, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Monitor patients for signs and symptoms of dermatitis, such as rash and pruritus; unless an alternate etiology has been identified, these should be considered immune-mediated. An interruption or discontinuation of therapy may be necessary, along with treatment with topical or systemic corticosteroids. The median time to onset of moderate, severe, or life-threatening immune-mediated dermatitis was 22 days (range, up to 4 months) in patients who received ipilimumab 3 mg/kg; patients treated with ipilimumab 10 mg/kg developed grade 2 dermatitis in a median of 11 days (range 1 day to 16.6 months) and grade 3 or 4 dermatitis in a median of 14 days (range, 5 days to 11.3 months).
Severe, life-threatening, and sometimes fatal hepatotoxicity has been reported with ipilimumab use, including immune-mediated hepatitis. Evaluate liver function tests (LFTs) and for signs or symptoms of hepatotoxicity prior to each ipilimumab dose. If hepatotoxicity develops, monitor LFTs frequently until resolution; rule out infection or malignancy. An interruption or discontinuation of therapy may be necessary, along with treatment with high-dose corticosteroids. In the clinical development program for ipilimumab, mycophenolate treatment was administered in patients with persistent severe hepatitis despite high-dose corticosteroids. Use ipilimumab with caution in patients with hepatic disease; it has not been evaluated in patients with moderate or severe hepatic impairment. Concomitant treatment with vemurafenib may increase the risk of hepatotoxicity; in a dose-finding trial which was closed due to hepatotoxicity, grade 3 increases in transaminases (with or without concomitant increases in bilirubin) occurred in 6 of 10 patients receiving concomitant ipilimumab and vemurafenib therapy.
Ipilimumab can result in severe and fatal immune-mediated neuropathies, including Guillain-Barre syndrome. Monitor patients for symptoms of motor or sensory neuropathy, such as unilateral or bilateral weakness, sensory alterations, or paresthesia. An interruption or discontinuation of therapy may be necessary, along with administration of high-dose corticosteroids. In patients receiving adjuvant treatment for melanoma with ipilimumab 10 mg/kg, the time to onset for patients who developed grade 2 to 5 immune-mediated neuropathy ranged from 1.4 to 27.4 months. Cautious use of ipilimumab by patients with pre-existing Guillain-Barre syndrome, peripheral neuropathy, or myasthenia gravis may be warranted.
Ipilimumab can result in severe and life-threatening immune-mediated endocrinopathies. Ipilimumab treatment should be withheld and high-dose corticosteroids initiated in patients with symptomatic endocrinopathies; begin appropriate hormone replacement therapy if necessary. A discontinuation of therapy may be necessary if, after 6 weeks, symptoms are unresolved or corticosteroids are unable to be tapered to less than prednisone 7.5 mg/day (or equivalent). Assess patients for signs and symptoms of endocrinopathy such as hypophysitis, hypopituitarism, adrenal insufficiency (including adrenal crisis), hyperthyroidism, and hypothyroidism; presentation may include fatigue, headache, mental status changes, abdominal pain, unusual bowel habits, hypotension, or other nonspecific symptoms. Evaluate clinical chemistries, adrenocorticotropic hormone (ACTH) level, and thyroid function tests at baseline, before each dose, and as clinically indicated; in a limited number of patients, hypophysitis was diagnosed by imaging studies through pituitary gland enlargement. Unless an alternate etiology has been identified, signs or symptoms of endocrinopathies should be considered immune-related. The median time to onset of moderate to severe endocrinopathy was 2.1 to 2.5 months, ranging up to 4.4 months in patients treated with ipilimumab 3 mg/kg, and from 2 days to 19.3 months in patients receiving 10 mg/kg; some patients required treatment with long-term hormone replacement therapy. Cautious use of ipilimumab may be warranted for patients with thyroid disease or Addison's disease.
Ipilimumab can result in severe and fatal immune-mediated adverse reactions, including immune-mediated nephritis. An interruption or discontinuation of therapy may be necessary, along with treatment with high-dose corticosteroids. Cautious use of ipilimumab by patients with pre-existing renal disease may be warranted.
Ipilimumab can result in severe and fatal immune-mediated adverse reactions, including immune-mediated pancreatitis. An interruption or discontinuation of therapy may be necessary, along with treatment with high-dose corticosteroids. Cautious use of ipilimumab by patients with pre-existing pancreatitis may be warranted.
Ipilimumab can result in severe immune-mediated adverse reactions, including ocular toxicities such as uveitis, iritis, or episcleritis. Permanently discontinue ipilimumab therapy for any ocular toxicity not resolving to grade 1 within 2 weeks of initiating topical therapy, or for any ocular manifestations requiring systemic high-dose corticosteroid therapy. Cautious use of ipilimumab in patients with pre-existing ocular disease may be warranted.
Ipilimumab can result in severe and fatal immune-mediated adverse reactions, including immune-mediated sarcoidosis, myocarditis, arthritis, and polymyalgia rheumatica. An interruption or discontinuation of therapy may be necessary, along with treatment with high-dose corticosteroids. Cautious use of ipilimumab by patients with pre-existing renal disease may be warranted. Cautious use of ipilimumab by patients with rheumatoid arthritis, sarcoidosis, or systemic lupus erythematosus (SLE) may be warranted. Patients with active autoimmune disease were excluded from the clinical development program.
Ipilimumab works by T-cell activation and proliferation. Patients receiving systemic immunosuppression for organ transplant were excluded from the clinical development program.
Ipilimumab may cause fetal harm when administered during pregnancy, based on its mechanism of action and data from animal studies. There is little data regarding the effects of ipilimumab exposure in pregnant women. The effects of ipilimumab are likely to be greater during the second and third trimesters of pregnancy. Ipilimumab is an IgG1 kappa immunoglobulin and human IgG1 is known to cross the placental barrier; therefore, ipilimumab may be transmitted from the mother to the developing fetus. Patients with a known or suspected pregnancy should contact their healthcare provider. Advise women who may have been exposed to ipilimumab during pregnancy to contact Bristol-Myers Squibb at 1-800-721-5072. Advise pregnant women of the potential risk to a fetus and to enroll in a Pregnancy Safety Surveillance Study by calling 1-844-593-7869. No treatment-related adverse effects on reproduction were observed in the first two trimesters of pregnancy in pregnant cynomolgus monkeys who received ipilimumab every 3 weeks from the onset of organogenesis in the first trimester through parturition. However, dose-related increases in the rate of abortion, stillbirth, premature delivery (with corresponding lower birth weight), and infant mortality occurred at ipilimumab doses resulting in approximately 2.6 to 7.2 times the human exposure (of 3 mg/kg) administered during the third trimester. Developmental abnormalities including 1 case of unilateral renal agenesis of the left kidney and ureter and 1 case of an imperforate urethra with associated urinary obstruction and subcutaneous scrotal edema were also reported. Mice that were genetically engineered to be heterozygous for the target of ipilimumab, CTLA4 (CTLA4 +/-), appeared healthy and gave birth to healthy CTLA4 +/- heterozygous offspring. These mice produced offspring deficient in CTLA4 (homozygous negative, CTLA-4 -/-), which after appearing healthy at birth, exhibited signs of multi-organ lymphoproliferative disease by 2 weeks of age and died by 3 to 4 weeks of age due to massive lymphoproliferation and multi-organ tissue destruction.
Counsel patients about the reproductive risk and contraception requirements during ipilimumab treatment. Females of reproductive potential should avoid pregnancy and use effective contraception during and for 3 months after the last ipilimumab dose.
It is not known whether ipilimumab is present in human milk. Many drugs are excreted in human milk including antibodies. Due to the potential for serious adverse reactions in nursing infants from ipilimumab, advise women to discontinue breast-feeding during treatment and for 3 months after the final dose.
enterocolitis / Delayed / 5.0-14.0diarrhea / Early / 9.0-10.0elevated hepatic enzymes / Delayed / 0-10.0colitis / Delayed / 3.0-8.0hypopituitarism / Delayed / 1.0-7.4fatigue / Early / 2.3-7.0pruritus / Rapid / 0-2.3rash (unspecified) / Early / 2.0-2.1eosinophilia / Delayed / 0-2.1hyperamylasemia / Delayed / 0-2.0GI perforation / Delayed / 1.0-1.5hyperbilirubinemia / Delayed / 0-1.5pancreatitis / Delayed / 0-1.3erythema multiforme / Delayed / 0-1.0Guillain-Barre syndrome / Delayed / 0-1.0adrenocortical insufficiency / Delayed / 0-1.0meningitis / Delayed / 0.4-1.0acute respiratory distress syndrome (ARDS) / Early / 0-1.0pneumonitis / Delayed / 0.2-1.0pericarditis / Delayed / 0-1.0renal failure (unspecified) / Delayed / 0-1.0hemolytic anemia / Delayed / 0-1.0uveitis / Delayed / 0-1.0vasculitis / Delayed / 0-1.0hearing loss / Delayed / 0-1.0headache / Early / 0-0.8hyperthyroidism / Delayed / 0.2-0.6vomiting / Early / 0-0.4hepatic failure / Delayed / 0.2-0.2hypothyroidism / Delayed / 0-0.2myocarditis / Delayed / 0-0.2nausea / Early / 0-0.2weight loss / Delayed / 0-0.2anorexia / Delayed / 0-0.2ileus / Delayed / Incidence not knowntoxic epidermal necrolysis / Delayed / Incidence not knownStevens-Johnson syndrome / Delayed / Incidence not knownDrug Reaction with Eosinophilia and Systemic Symptoms (DRESS) / Delayed / Incidence not known
antibody formation / Delayed / 1.1-4.9psoriasis / Delayed / 0-1.0myasthenia / Delayed / 0-1.0iritis / Delayed / 0-1.0blepharitis / Early / 0-1.0ocular inflammation / Early / 0-1.0conjunctivitis / Delayed / 0-1.0encephalopathy / Delayed / 0-1.0esophagitis / Delayed / 0-1.0infusion-related reactions / Rapid / 0-1.0Cushing's syndrome / Delayed / 0-0.2hepatitis / Delayed / Incidence not knownskin ulcer / Delayed / Incidence not knownbullous rash / Early / Incidence not knownperipheral neuropathy / Delayed / Incidence not knownhypophysitis / Delayed / Incidence not known
insomnia / Early / 0-10.0urticaria / Rapid / 0-2.0abdominal pain / Early / Incidence not knownfever / Early / Incidence not knownparesthesias / Delayed / Incidence not knownweakness / Early / Incidence not known
Clozapine: (Major) It is unclear if concurrent use of other drugs known to cause neutropenia (e.g., antineoplastic agents) increases the risk or severity of clozapine-induced neutropenia. Because there is no strong rationale for avoiding clozapine in patients treated with these drugs, consider increased absolute neutrophil count (ANC) monitoring and consult the treating oncologist. Vemurafenib: (Moderate) Concurrent use of vemurafenib and ipilimumab led to elevated transaminase levels in the majority of patients with BRAF V600-mutation positive melanoma in a small dose finding study; this study was closed due to adverse hepatic effects. Grade 3 elevated transaminase levels occurred in 6 of 10 patients who received combination therapy with vemurafenib (960 mg or 720 mg PO twice daily) plus ipilimumab (3 mg/kg IV every 3 weeks) in a phase I dose finding study; grade 2 or 3 elevated total bilirubin levels were reported in 2 patients in this study.
Ipilimumab is a recombinant, human monoclonal antibody that binds to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and blocks the interaction of CTLA-4 with its ligands CD80/CD86. Blockade of CTLA-4 augments T-cell activation and proliferation, including tumor infiltrating T-effector cells. The inhibition of CTLA-4 signaling may cause a decrease in T-cell regulatory function resulting in an increase in T-cell antitumor responsiveness.
Ipilimumab is administered intravenously. The pharmacokinetic parameters of ipilimumab were studied in 785 patients with unresectable or metastatic melanoma who received doses of 0.3, 3, or 10 mg/kg once every 3 weeks for 4 doses; the pharmacokinetics of ipilimumab are linear over this dose range. Upon repeated dosing of ipilimumab every 3 weeks, ipilimumab clearance was found to be time-invariant and minimal systemic accumulation (1.5-fold or less) was observed. Steady state concentration was reached by the third dose. In a population pharmacokinetic analysis, the terminal half-life was 15.4 days (coefficient of variance (CV), 34%) and the systemic clearance was 16.8 mL/hour (CV, 38%).
In a pharmacokinetic study, peak concentration, trough concentration (Cmin), and area under the curve of ipilimumab were found to be dose proportional within the dose range examined; steady-state concentrations were reached by the third dose. The mean ipilimumab Cmin achieved at steady-state with the 3 mg/kg regimen was 19.4 mcg/mL; the mean Cmin at 10 mg/kg was 58.1 mcg/mL.