Cyramza
Generic Name: ramucirumab
Dosage Form: intravenous infusion
WARNING:
HEMORRHAGE, GASTROINTESTINAL PERFORATION, AND IMPAIRED WOUND HEALING
Hemorrhage: Cyramza
increased the risk of hemorrhage and gastrointestinal hemorrhage, including
severe and sometimes fatal hemorrhagic events. Permanently discontinue Cyramza
in patients who experience severe bleeding[see Dosage and Administration (2.3), Warnings and Precautions (5.1)].
Gastrointestinal Perforation: Cyramza can
increase the risk of gastrointestinal perforation, a potentially fatal event.
Permanently discontinue Cyramza in patients who experience a gastrointestinal
perforation [see Dosage and Administration (2.3), Warnings and Precautions (5.5)].
Impaired Wound Healing: Impaired wound
healing can occur with antibodies inhibiting the VEGF pathway. Discontinue
Cyramza therapy in patients with impaired wound healing. Withhold Cyramza prior
to surgery and discontinue Cyramza if a patient develops wound healing
complications [see Dosage and Administration (2.3), Warnings and Precautions (5.6)].
Indications and Usage for CyramzaGastric
Cancer
Cyramza® as a single agent, or in
combination with paclitaxel, is indicated for the treatment of patients with
advanced or metastatic, gastric or gastro-esophageal junction adenocarcinoma
with disease progression on or after prior fluoropyrimidine- or
platinum-containing chemotherapy.
Non-Small
Cell Lung Cancer
Cyramza, in combination with
docetaxel, is indicated for the treatment of patients with metastatic non-small
cell lung cancer (NSCLC) with disease progression on or after platinum-based
chemotherapy.
Patients with EGFR or ALK
genomic tumor aberrations should have disease progression on FDA-approved
therapy for these aberrations prior to receiving Cyramza.
Colorectal
Cancer
Cyramza, in combination with
FOLFIRI (irinotecan, folinic acid, and 5-fluorouracil), is indicated for the
treatment of patients with metastatic colorectal cancer (mCRC) with disease
progression on or after prior therapy with bevacizumab, oxaliplatin, and a
fluoropyrimidine.
Cyramza Dosage and Administration
Do not administer Cyramza as
an intravenous push or bolus.
Recommended
Dose and Schedule
Gastric Cancer
·
The recommended dose of
Cyramza either as a single agent or in combination with weekly paclitaxel is
8 mg/kg every 2 weeks administered as an intravenous infusion over 60
minutes. Continue Cyramza until disease progression or unacceptable toxicity.
·
When given in combination,
administer Cyramza prior to administration of paclitaxel.
Non-Small
Cell Lung Cancer
·
The recommended dose of
Cyramza is 10 mg/kg administered by intravenous infusion over 60 minutes
on day 1 of a 21-day cycle prior to docetaxel infusion. Continue Cyramza until
disease progression or unacceptable toxicity.
Colorectal
Cancer
·
The recommended dose of
Cyramza is 8 mg/kg every 2 weeks administered by intravenous infusion over
60 minutes prior to FOLFIRI administration. Continue Cyramza until disease
progression or unacceptable toxicity.
Premedication
·
Prior to each Cyramza
infusion, premedicate all patients with an intravenous histamine H1antagonist (e.g.,
diphenhydramine hydrochloride).
·
For patients who have
experienced a Grade 1 or 2 infusion-related reaction, also premedicate with
dexamethasone (or equivalent) and acetaminophen prior to each Cyramza
infusion [see Dosage and Administration (2.3)].
Dose
Modifications
Infusion-Related Reactions (IRR)
·
Reduce the infusion rate of
Cyramza by 50% for Grade 1 or 2 IRRs.
·
Permanently discontinue
Cyramza for Grade 3 or 4 IRRs [see Dosage and
Administration (2.2) and Warnings and Precautions (5.4)].
Hypertension
·
Interrupt Cyramza for severe
hypertension until controlled with medical management.
·
Permanently discontinue
Cyramza for severe hypertension that cannot be controlled with antihypertensive
therapy [see Warnings and Precautions (5.3)].
Proteinuria
·
Interrupt Cyramza for urine
protein levels ≥2 g/24 hours. Reinitiate treatment at a reduced dose
(see Table 1) once the urine protein level returns to <2 g/24 hours.
If the protein level ≥2 g/24 hours reoccurs, interrupt Cyramza and reduce
the dose (see Table 1) once the urine protein level returns to <2 g/24 hours.
·
Permanently discontinue
Cyramza for urine protein level >3 g/24 hours or in the setting of
nephrotic syndrome [see Warnings and Precautions (5.9) and Adverse Reactions (6.1)].
Table 1: Cyramza Dose Reductions for
Proteinuria
|
|
Initial Cyramza Dose
|
First Dose Reduction to:
|
Second Dose Reduction to:
|
|
8 mg/kg
|
6 mg/kg
|
5 mg/kg
|
|
10 mg/kg
|
8 mg/kg
|
6 mg/kg
|
Wound Healing Complications
·
Interrupt Cyramza prior to
scheduled surgery until the wound is fully healed [see
Warnings and Precautions (5.6)].
Arterial Thromboembolic Events, Gastrointestinal Perforation, or
Grade 3 or 4 Bleeding
·
Permanently discontinue
Cyramza [see Warnings and Precautions (5.1, 5.2, 5.5)].
For toxicities related to
paclitaxel, docetaxel, or the components of FOLFIRI, refer to the current
prescribing information.
Preparation
for Administration
Inspect vial contents for
particulate matter and discoloration prior to dilution [see Description (11)]. Discard the vial, if
particulate matter or discolorations are identified. Store vials in a
refrigerator at 2°C to 8°C (36°F to 46°F) until time of use. Keep the vial in
the outer carton in order to protect from light.
·
Calculate the dose and the
required volume of Cyramza needed to prepare the infusion solution. Vials
contain either 100 mg/10 mL or 500 mg/50 mL at a
concentration of 10 mg/mL solution of Cyramza.
·
Withdraw the required volume
of Cyramza and further dilute with only 0.9% Sodium Chloride Injection in an
intravenous infusion container to a final volume of 250 mL. Do not use
dextrose containing solutions.
·
Gently invert the container to
ensure adequate mixing.
· DO NOT
FREEZE OR SHAKE the infusion solution.
DO NOT dilute with other solutions or co-infuse with other electrolytes or
medications.
·
Store diluted infusion for no
more than 24 hours at 2°C to 8°C (36°F to 46°F) or 4 hours at room temperature
(below 25°C [77°F]).
·
Discard vial with any unused
portion of Cyramza.
Administration
·
Visually inspect the diluted
solution for particulate matter and discoloration prior to administration. If
particulate matter or discolorations are identified, discard the solution.
·
Administer diluted Cyramza
infusion via infusion pump over 60 minutes through a separate infusion line.
Use of a protein sparing 0.22 micron filter is recommended. Flush the line with
sterile sodium chloride (0.9%) solution for injection at the end of the
infusion.
Dosage Forms and Strengths
Injection:
·
100 mg/10 mL (10 mg
per mL) solution, single-dose vial
·
500 mg/50 mL (10 mg
per mL) solution, single-dose vial
Contraindications
None
Warnings and PrecautionsHemorrhage
Cyramza increased the risk of
hemorrhage and gastrointestinal hemorrhage, including severe and sometimes
fatal hemorrhagic events. In Study 1, the incidence of severe bleeding was 3.4%
for Cyramza and 2.6% for placebo. In Study 2, the incidence of severe bleeding
was 4.3% for Cyramza plus paclitaxel and 2.4% for placebo plus paclitaxel.
Patients with gastric cancer
receiving nonsteroidal anti-inflammatory drugs (NSAIDs) were excluded from
enrollment in Studies 1 and 2; therefore, the risk of gastric hemorrhage in
Cyramza-treated patients with gastric tumors receiving NSAIDs is unknown.
In Study 3, the incidence of
severe bleeding was 2.4% for Cyramza plus docetaxel and 2.3% for placebo plus
docetaxel. Patients with NSCLC receiving therapeutic anticoagulation or chronic
therapy with NSAIDS or other anti-platelet therapy other than once daily
aspirin or with radiographic evidence of major airway or blood vessel invasion
or intratumor cavitation were excluded from Study 3; therefore the risk of
pulmonary hemorrhage in these groups of patients is unknown.
In Study 4, the incidence of
severe bleeding was 2.5% for Cyramza plus FOLFIRI and 1.7% for placebo plus
FOLFIRI.
Permanently discontinue
Cyramza in patients who experience severe bleeding [see
Dosage and Administration (2.3)].
Arterial
Thromboembolic Events
Serious, sometimes fatal,
arterial thromboembolic events (ATEs) including myocardial infarction, cardiac
arrest, cerebrovascular accident, and cerebral ischemia occurred in clinical
trials including 1.7% of 236 patients who received Cyramza as a single agent
for gastric cancer in Study 1. Permanently discontinue Cyramza in patients who
experience a severe ATE [see Dosage and
Administration (2.3)].
Hypertension
An increased incidence of
severe hypertension occurred in patients receiving Cyramza as a single agent
(8%) as compared to placebo (3%), in patients receiving Cyramza plus paclitaxel
(15%) as compared to placebo plus paclitaxel (3%), in patients receiving Cyramza
plus docetaxel (6%) as compared to placebo plus docetaxel (2%), and in patients
receiving Cyramza plus FOLFIRI (11%) as compared to placebo plus FOLFIRI (3%).
Control hypertension prior to
initiating treatment with Cyramza. Monitor blood pressure every two weeks or
more frequently as indicated during treatment.
Temporarily suspend Cyramza
for severe hypertension until medically controlled. Permanently discontinue
Cyramza if medically significant hypertension cannot be controlled with
antihypertensive therapy or in patients with hypertensive crisis or
hypertensive encephalopathy [see Dosage and
Administration (2.3)].
Infusion-Related
Reactions
Prior to the institution of
premedication recommendations across clinical trials of Cyramza, IRRs occurred
in 6 out of 37 patients (16%), including two severe events. The majority of
IRRs across trials occurred during or following a first or second Cyramza
infusion. Symptoms of IRRs included rigors/tremors, back pain/spasms, chest
pain and/or tightness, chills, flushing, dyspnea, wheezing, hypoxia, and
paresthesia. In severe cases, symptoms included bronchospasm, supraventricular
tachycardia, and hypotension.
Monitor patients during the
infusion for signs and symptoms of IRRs in a setting with available
resuscitation equipment. Immediately and permanently discontinue Cyramza for
Grade 3 or 4 IRRs [see Dosage and Administration (2.3)].
Gastrointestinal
Perforations
Cyramza is an antiangiogenic
therapy that can increase the risk of gastrointestinal perforation, a
potentially fatal event. Four of 570 patients (0.7%) who received Cyramza as a
single agent in clinical trials experienced gastrointestinal perforation. In
Study 2, the incidence of gastrointestinal perforation was also increased in
patients that received Cyramza plus paclitaxel (1.2%) as compared to patients
receiving placebo plus paclitaxel (0.3%). In Study 3, the incidence of
gastrointestinal perforation was 1% for Cyramza plus docetaxel and 0.3% for
placebo plus docetaxel. In Study 4, the incidence of gastrointestinal
perforation was 1.7% for Cyramza plus FOLFIRI and 0.6% for placebo plus
FOLFIRI. Permanently discontinue Cyramza in patients who experience a
gastrointestinal perforation [see Dosage and
Administration (2.3)].
Impaired
Wound Healing
Impaired wound healing can
occur with antibodies inhibiting the VEGF pathway. Cyramza has not been studied
in patients with serious or non-healing wounds. Cyramza, an antiangiogenic
therapy, has the potential to adversely affect wound healing. Discontinue
Cyramza therapy in patients with impaired wound healing.
Withhold Cyramza prior to
surgery. Resume following the surgical intervention based on clinical judgment
of adequate wound healing. If a patient develops wound healing complications
during therapy, discontinue Cyramza until the wound is fully healed [see Dosage and Administration (2.3)].
Clinical
Deterioration in Patients with Child-Pugh B or C Cirrhosis
Clinical deterioration,
manifested by new onset or worsening encephalopathy, ascites, or hepatorenal
syndrome was reported in patients with Child-Pugh B or C cirrhosis who received
single-agent Cyramza. Use Cyramza in patients with Child-Pugh B or C cirrhosis
only if the potential benefits of treatment are judged to outweigh the risks of
clinical deterioration.
Reversible
Posterior Leukoencephalopathy Syndrome
Reversible Posterior
Leukoencephalopathy Syndrome (RPLS) has been reported with a rate of <0.1%
in clinical studies with Cyramza. Confirm the diagnosis of RPLS with MRI and
discontinue Cyramza in patients who develop RPLS. Symptoms may resolve or
improve within days, although some patients with RPLS can experience ongoing
neurologic sequelae or death.
Proteinuria
Including Nephrotic Syndrome
In Study 4, severe proteinuria
occurred more frequently in patients treated with Cyramza plus FOLFIRI compared
to patients receiving placebo plus FOLFIRI. Severe proteinuria was reported in
3% of patients treated with Cyramza plus FOLFIRI (including 3 cases [0.6%] of
nephrotic syndrome) compared to 0.2% of patients treated with placebo plus
FOLFIRI.
Monitor proteinuria by urine
dipstick and/or urinary protein creatinine ratio for the development of
worsening of proteinuria during Cyramza therapy.
Withhold Cyramza for urine
protein levels that are 2 or more grams over 24 hours. Reinitiate Cyramza at a
reduced dose once the urine protein level returns to less than 2 grams over 24
hours. Permanently discontinue Cyramza for urine protein levels greater than 3
grams over 24 hours or in the setting of nephrotic syndrome [see Dosage and Administration (2.3)].
Thyroid
Dysfunction
Monitor thyroid function
during treatment with Cyramza. In Study 4, the incidence of hypothyroidism reported
as an adverse event was 2.6% in the Cyramza plus FOLFIRI treated patients and
0.9% in the placebo plus FOLFIRI treated patients.
Embryofetal
Toxicity
Based on its mechanism of
action, Cyramza can cause fetal harm when administered to pregnant women.
Animal models link angiogenesis, VEGF and VEGF Receptor 2 (VEGFR2) to critical
aspects of female reproduction, embryofetal development, and postnatal
development. Advise pregnant women of the potential risk to a fetus. Advise
females of reproductive potential to use effective contraception during
treatment with Cyramza and for at least 3 months after the last dose of
Cyramza [see Use in Specific Populations (8.1, 8.3)].
Adverse Reactions
The following adverse drug
reactions are discussed in greater detail in other sections of the label:
·
Hemorrhage [see Dosage and Administration (2.3) and Warnings and Precautions (5.1)].
·
Arterial Thromboembolic
Events [see Dosage and Administration (2.3) and Warnings and Precautions (5.2)].
·
Hypertension [see Dosage and Administration (2.3) and Warnings and Precautions (5.3)].
·
Infusion-Related
Reactions [see Dosage and Administration (2.3) and Warnings and Precautions (5.4)].
·
Gastrointestinal
Perforation [see Dosage and Administration (2.3) and Warnings and Precautions (5.5)].
·
Impaired Wound Healing [see Dosage and Administration (2.3) and Warnings and Precautions (5.6)].
·
Patients with Child-Pugh B or
C Cirrhosis [see Warnings and Precautions (5.7)].
·
Reversible Posterior
Leukoencephalopathy Syndrome [see Warnings and
Precautions (5.8)].
·
Proteinuria Including
Nephrotic Syndrome [see Warnings and Precautions (5.9)].
·
Thyroid Dysfunction [see Warnings and Precautions (5.10)].
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.
Gastric
Cancer
Safety data are presented from
two randomized, placebo controlled clinical trials in which patients received
Cyramza: Study 1, a randomized (2:1), double-blind, clinical trial in which 351
patients received either Cyramza 8 mg/kg intravenously every two weeks or
placebo every two weeks and Study 2, a double-blind, randomized (1:1) clinical
trial in which 656 patients received paclitaxel 80 mg/m2 on days 1, 8, and 15 of
each 28-day cycle plus either Cyramza 8 mg/kg intravenously every two
weeks or placebo every two weeks. Both trials excluded patients with Eastern
Cooperative Oncology Group (ECOG) performance status (PS) of 2 or greater,
uncontrolled hypertension, major surgery within 28 days, or patients receiving
chronic anti-platelet therapy other than once daily aspirin. Study 1 excluded
patients with bilirubin ≥1.5 mg/dL and Study 2 excluded patients with bilirubin
>1.5 times the upper limit of normal.
Cyramza Administered as a Single Agent
Among 236 patients who
received Cyramza (safety population) in Study 1, median age was 60 years,
28% were women, 76% were White, and 16% were Asian. Patients in Study 1
received a median of 4 doses of Cyramza; the median duration of exposure was 8
weeks, and 32 (14% of 236) patients received Cyramza for at least six months.
In Study 1, the most common
adverse reactions (all grades) observed in Cyramza-treated patients at a rate
of ≥10% and ≥2% higher than placebo were hypertension and diarrhea. The most
common serious adverse events with Cyramza were anemia (3.8%) and intestinal
obstruction (2.1%). Red blood cell transfusions were given to 11% of Cyramza-treated
patients versus 8.7% of patients who received placebo.
Table 2 provides the frequency and severity of adverse reactions
in Study 1.
Table 2: Adverse Reactions Occurring at
Incidence Rate ≥5% and a ≥2% Difference Between Arms in Patients Receiving
Cyramza in Study 1
|
|
|
|
Adverse Reactions (MedDRA)
System Organ Class
|
Cyramza (8 mg/kg)
N=236
|
Placebo
N=115
|
|
All Grades
(Frequency %)
|
Grade 3-4
(Frequency %)
|
All Grades
(Frequency %)
|
Grade 3-4
(Frequency %)
|
|
Gastrointestinal Disorders
|
|
Diarrhea
|
14
|
1
|
9
|
2
|
|
Metabolism and Nutrition Disorders
|
|
Hyponatremia
|
6
|
3
|
2
|
1
|
|
Nervous System Disorders
|
|
Headache
|
9
|
0
|
3
|
0
|
|
Vascular Disorders
|
|
Hypertension
|
16
|
8
|
8
|
3
|
Clinically relevant adverse
reactions reported in ≥1% and <5% of Cyramza-treated patients in Study 1
were: neutropenia (4.7% Cyramza versus 0.9% placebo), epistaxis (4.7% Cyramza
versus 0.9% placebo), rash (4.2% Cyramza versus 1.7% placebo), intestinal
obstruction (2.1% Cyramza versus 0% placebo), and arterial thromboembolic
events (1.7% Cyramza versus 0% placebo) [see Dosage
and Administration (2.3) and Warnings and Precautions (5.1, 5.2)].
Across clinical trials of
Cyramza administered as a single agent, clinically relevant adverse reactions
(including Grade ≥3) reported in Cyramza-treated patients included proteinuria,
gastrointestinal perforation, and infusion-related reactions.
In Study 1, according to
laboratory assessment, 8% of Cyramza-treated patients developed proteinuria versus
3% of placebo-treated patients. Two patients discontinued Cyramza due to
proteinuria. The rate of gastrointestinal perforation in Study 1 was 0.8% and
the rate of infusion-related reactions was 0.4% [see
Dosage and Administration (2.2, 2.3) and Warnings and Precautions (5.4, 5.5)].
Cyramza Administered in Combination with Paclitaxel
Among 327 patients who
received Cyramza (safety population) in Study 2, median age was 61 years,
31% were women, 63% were White, and 33% were Asian. Patients in Study 2
received a median of 9 doses of Cyramza; the median duration of exposure was 18
weeks, and 93 (28% of 327) patients received Cyramza for at least six months.
In Study 2, the most common
adverse reactions (all grades) observed in patients treated with Cyramza plus
paclitaxel at a rate of ≥30% and ≥2% higher than placebo plus paclitaxel were
fatigue, neutropenia, diarrhea, and epistaxis. The most common serious adverse
events with Cyramza plus paclitaxel were neutropenia (3.7%) and febrile
neutropenia (2.4%); 19% of patients treated with Cyramza plus paclitaxel
received granulocyte colony-stimulating factors. Adverse reactions resulting in
discontinuation of any component of the Cyramza plus paclitaxel combination in
2% or more patients in Study 2 were neutropenia (4%) and thrombocytopenia (3%).
Table 3 provides the frequency and severity of adverse reactions
in Study 2.
Table 3: Adverse Reactions Occurring at
Incidence Rate ≥5% and a ≥2% Difference Between Arms in Patients Receiving
Cyramza plus Paclitaxel in Study 2
|
|
|
Adverse Reactions (MedDRA) System Organ
Class
|
Cyramza plus Paclitaxel
(N=327)
|
Placebo plus Paclitaxel
(N=329)
|
|
|
All Grades
(Frequency %)
|
Grade ≥3 (Frequency %)
|
All Grades
(Frequency %)
|
Grade ≥3 (Frequency %)
|
|
|
Blood and Lymphatic System Disorders
|
|
|
Neutropenia
|
54
|
41
|
31
|
19
|
|
|
Thrombocytopenia
|
13
|
2
|
6
|
2
|
|
|
Gastrointestinal Disorders
|
|
|
Diarrhea
|
32
|
4
|
23
|
2
|
|
|
Gastrointestinal hemorrhage events
|
10
|
4
|
6
|
2
|
|
|
Stomatitis
|
20
|
1
|
7
|
1
|
|
|
General Disorders and Administration Site Disorders
|
|
|
Fatigue/Asthenia
|
57
|
12
|
44
|
6
|
|
|
Peripheral edema
|
25
|
2
|
14
|
1
|
|
|
Metabolism and Nutrition Disorders
|
|
|
Hypoalbuminemia
|
11
|
1
|
5
|
1
|
|
|
Renal and Urinary Disorders
|
|
|
Proteinuria
|
17
|
1
|
6
|
0
|
|
|
Respiratory, Thoracic, and Mediastinal Disorders
|
|
|
Epistaxis
|
31
|
0
|
7
|
0
|
|
|
Vascular Disorder
|
|
|
Hypertension
|
25
|
15
|
6
|
3
|
|
Clinically relevant adverse
reactions reported in ≥1% and <5% of the Cyramza plus paclitaxel treated
patients in Study 2 were sepsis (3.1% Cyramza plus paclitaxel versus 1.8%
placebo plus paclitaxel) and gastrointestinal perforations (1.2% Cyramza plus
paclitaxel versus 0.3% for placebo plus paclitaxel).
Non-Small Cell Lung Cancer
Cyramza Administered in Combination with Docetaxel
Study 3 was a multinational,
randomized, double-blind study conducted in patients with NSCLC with disease
progression on or after one platinum-based therapy for locally advanced or
metastatic disease. Patients received either Cyramza 10 mg/kg intravenously
plus docetaxel 75 mg/m2 intravenously every 3 weeks or placebo plus docetaxel
75 mg/m2 intravenously every 3 weeks. Due to an increased incidence
of neutropenia and febrile neutropenia in patients enrolled in East Asian
sites, Study 3 was amended and 24 patients (11 Cyramza plus docetaxel, 13
placebo plus docetaxel) at East Asian sites received a starting dose of
docetaxel at 60 mg/m2 every 3 weeks.
Study 3 excluded patients with
an ECOG PS of 2 or greater, bilirubin greater than the upper limit of normal (ULN),
uncontrolled hypertension, major surgery within 28 days, radiographic evidence
of major airway or blood vessel invasion by cancer, radiographic evidence of
intra-tumor cavitation, or gross hemoptysis within the preceding 2 months, and
patients receiving therapeutic anticoagulation or chronic anti-platelet therapy
other than once daily aspirin. The study also excluded patients whose only
prior treatment for advanced NSCLC was a tyrosine kinase (epidermal growth
factor receptor [EGFR] or anaplastic lymphoma kinase [ALK]) inhibitor.
The data described below
reflect exposure to Cyramza plus docetaxel in 627 patients in Study 3.
Demographics and baseline characteristics were similar between treatment arms.
Median age was 62 years; 67% of patients were men; 84% were White and 12% were
Asian; 33% had ECOG PS 0; 74% had non-squamous histology and 25% had squamous
histology. Patients received a median of 4.5 doses of Cyramza; the median
duration of exposure was 3.5 months, and 195 (31% of 627) patients received
Cyramza for at least six months.
In Study 3, the most common
adverse reactions (all grades) observed in Cyramza plus docetaxel-treated
patients at a rate of ≥30% and ≥2% higher than placebo plus docetaxel were
neutropenia, fatigue/asthenia, and stomatitis/mucosal inflammation. Treatment
discontinuation due to adverse reactions occurred more frequently in Cyramza
plus docetaxel-treated patients (9%) than in placebo plus docetaxel-treated
patients (5%). The most common adverse events leading to treatment discontinuation
of Cyramza were infusion-related reaction (0.5%) and epistaxis (0.3%). For
patients with non-squamous histology, the overall incidence of pulmonary
hemorrhage was 7% and the incidence of ≥Grade 3 pulmonary hemorrhage was 1% for
Cyramza plus docetaxel compared to 6% overall incidence and 1% for ≥Grade 3
pulmonary hemorrhage for placebo plus docetaxel. For patients with squamous
histology, the overall incidence of pulmonary hemorrhage was 10% and the
incidence of ≥Grade 3 pulmonary hemorrhage was 2% for Cyramza plus docetaxel
compared to 12% overall incidence and 2% for ≥Grade 3 pulmonary hemorrhage for
placebo plus docetaxel.
The most common serious
adverse events with Cyramza plus docetaxel were febrile neutropenia (14%),
pneumonia (6%), and neutropenia (5%). The use of granulocyte colony-stimulating
factors was 42% in Cyramza plus docetaxel-treated patients versus 37% in
patients who received placebo plus docetaxel. In patients ≥65 years, there were
18 (8%) deaths on treatment or within 30 days of discontinuation for Cyramza
plus docetaxel and 9 (4%) deaths for placebo plus docetaxel. In patients <65
years, there were 13 (3%) deaths on treatment or within 30 days of
discontinuation for Cyramza plus docetaxel and 26 (6%) deaths for placebo plus
docetaxel.
Table 4 provides the frequency and severity of adverse reactions
in Study 3.
Table 4: Adverse Reactions Occurring at
Incidence Rate ≥5% and a ≥2% Difference Between Arms in Patients Receiving
Cyramza in Study 3
|
|
|
Adverse Reactions (MedDRA)
System Organ Class
|
Cyramza plus docetaxel
(N=627)
|
Placebo plus docetaxel
(N=618)
|
|
|
All Grades
(Frequency %)
|
Grade 3-4
(Frequency %)
|
All Grades
(Frequency %)
|
Grade 3-4
(Frequency %)
|
|
|
Blood and Lymphatic System Disorders
|
|
|
Febrile neutropenia
|
16
|
16
|
10
|
10
|
|
|
Neutropenia
|
55
|
49
|
46
|
40
|
|
|
Thrombocytopenia
|
13
|
3
|
5
|
<1
|
|
|
Gastrointestinal Disorders
|
|
|
Stomatitis/Mucosal inflammation
|
37
|
7
|
19
|
2
|
|
|
Eye Disorders
|
|
|
Lacrimation increased
|
13
|
<1
|
5
|
0
|
|
|
General Disorders and Administration Site Disorders
|
|
|
Fatigue/Asthenia
|
55
|
14
|
50
|
11
|
|
|
Peripheral edema
|
16
|
0
|
9
|
<1
|
|
|
Respiratory, Thoracic, and Mediastinal Disorders
|
|
|
Epistaxis
|
19
|
<1
|
7
|
<1
|
|
|
Vascular Disorders
|
|
|
Hypertension
|
11
|
6
|
5
|
2
|
|
Clinically relevant adverse
drug reactions reported in ≥1% and <5% of the Cyramza plus docetaxel-treated
patients in Study 3 were hyponatremia (4.8% Cyramza plus docetaxel versus 2.4%
for placebo plus docetaxel) and proteinuria (3.3% Cyramza plus docetaxel versus
0.8% placebo plus docetaxel).
Colorectal Cancer
Cyramza Administered in Combination with FOLFIRI
Study 4 was a multinational,
randomized, double-blind study conducted in patients with metastatic colorectal
cancer with disease progression on or after therapy with bevacizumab,
oxaliplatin, and a fluoropyrimidine. Patients received either Cyramza
8 mg/kg intravenously plus FOLFIRI intravenously every 2 weeks or placebo
plus FOLFIRI intravenously every 2 weeks.
Study 4 excluded patients with
an ECOG PS of 2 or greater, uncontrolled hypertension, major surgery within 28
days, and those who experienced any of the following during first-line therapy
with a bevacizumab-containing regimen: an arterial thrombotic/thromboembolic
event; Grade 4 hypertension; Grade 3 proteinuria; a Grade 3-4 bleeding event;
or bowel perforation.
Demographics and baseline
characteristics for the treated population were similar between treatment arms
(n=1057). Median age was 62 years; 57% of patients were men; 76% were White and
20% were Asian; 48% had ECOG PS 0.
The data described in this
section reflect exposure to Cyramza plus FOLFIRI in 529 patients in Study 4.
Patients received a median of 8 doses (range 1-68) of Cyramza; the median
duration of exposure was 4.4 months, and 169 (32% of 529) patients received
Cyramza for at least six months. The most common adverse reactions (all grades)
observed in Cyramza plus FOLFIRI-treated patients at a rate of ≥30% and ≥2%
higher than placebo plus FOLFIRI were diarrhea, neutropenia, decreased
appetite, epistaxis, and stomatitis. Twenty percent of patients treated with
Cyramza plus FOLFIRI received granulocyte colony-stimulating factors. Treatment
discontinuation of any study drug due to adverse reactions occurred more
frequently in Cyramza plus FOLFIRI-treated patients (29%) than in placebo plus
FOLFIRI-treated patients (13%).
The most common adverse
reactions leading to discontinuation of any component of Cyramza plus FOLFIRI
as compared to placebo plus FOLFIRI, were neutropenia (12.5% versus 5.3%) and
thrombocytopenia (4.2% versus 0.8%). The most common adverse reactions leading
to treatment discontinuation of Cyramza were proteinuria (1.5%) and
gastrointestinal perforation (1.7%).
The most common serious
adverse events with Cyramza plus FOLFIRI were diarrhea (3.6%), intestinal
obstruction (3.0%), and febrile neutropenia (2.8%).
Table 5 provides the frequency and severity of adverse reactions
in Study 4.
Table 5: Adverse Reactions Occurring at
Incidence Rate ≥5% and a ≥2% Difference Between Arms in Patients Receiving
Cyramza in Study 4
|
|
a Includes 3 patients with nephrotic
syndrome in the Cyramza plus FOLFIRI treatment group.
|
|
Adverse Reactions (MedDRA)
System Organ Class
|
Cyramza plus FOLFIRI
N=529
|
Placebo plus FOLFIRI
N=528
|
|
All Grades
(Frequency %)
|
Grade ≥3
(Frequency %)
|
All Grades
(Frequency %)
|
Grade ≥3
(Frequency %)
|
|
Blood and Lymphatic System Disorders
|
|
Neutropenia
|
59
|
38
|
46
|
23
|
|
Thrombocytopenia
|
28
|
3
|
14
|
<1
|
|
Gastrointestinal Disorders
|
|
Decreased appetite
|
37
|
2
|
27
|
2
|
|
Diarrhea
|
60
|
11
|
51
|
10
|
|
Gastrointestinal hemorrhage events
|
12
|
2
|
7
|
1
|
|
Stomatitis
|
31
|
4
|
21
|
2
|
|
General Disorders and Administration Site Disorders
|
|
Peripheral edema
|
20
|
<1
|
9
|
0
|
|
Metabolism and Nutrition Disorders
|
|
Hypoalbuminemia
|
6
|
1
|
2
|
0
|
|
Renal and Urinary Disorders
|
|
Proteinuriaa
|
17
|
3
|
5
|
<1
|
|
Respiratory, Thoracic, and Mediastinal Disorders
|
|
Epistaxis
|
33
|
0
|
15
|
0
|
|
Skin and Subcutaneous Tissue Disorders
|
|
Palmar-plantar erythrodysesthesia syndrome
|
13
|
1
|
5
|
<1
|
|
Vascular Disorders
|
|
Hypertension
|
26
|
11
|
9
|
3
|
Clinically relevant adverse
reactions reported in ≥1% and <5% of Cyramza plus FOLFIRI-treated patients
in Study 4 consisted of gastrointestinal perforation (1.7% Cyramza plus FOLFIRI
versus 0.6% for placebo plus FOLFIRI).
Thyroid stimulating hormone
(TSH) levels were evaluated in 224 patients (115 Cyramza plus FOLFIRI-treated patients
and 109 placebo plus FOLFIRI-treated patients) with normal baseline TSH levels.
Patients underwent periodic TSH laboratory assessments until 30 days after the
last dose of study treatment. Increased TSH levels were observed in 53 (46%)
patients treated with Cyramza plus FOLFIRI compared with 4 (4%) patients
treated with placebo plus FOLFIRI.
Immunogenicity
As with all therapeutic
proteins, there is the potential for immunogenicity. In 23 clinical trials,
86/2890 (3.0%) of Cyramza-treated patients tested positive for
treatment-emergent anti-ramucirumab antibodies by an enzyme-linked
immunosorbent assay (ELISA). Neutralizing antibodies were detected in 14 of the
86 patients who tested positive for treatment-emergent anti-ramucirumab
antibodies.
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 incidence
of antibodies to Cyramza with the incidences of antibodies to other products
may be misleading.
Drug Interactions
No pharmacokinetic
interactions were observed between ramucirumab and paclitaxel, between
ramucirumab and docetaxel, or between ramucirumab and irinotecan or its active
metabolite, SN-38 [see Clinical Pharmacology (12.3)].
USE IN SPECIFIC POPULATIONSPregnancy
Risk Summary
Based on its mechanism of
action [see Clinical Pharmacology (12.1)], Cyramza can cause fetal
harm. Animal models link angiogenesis, VEGF and VEGF Receptor 2 (VEGFR2) to
critical aspects of female reproduction, embryofetal development, and postnatal
development. There are no available data on Cyramza use in pregnant women to
inform any drug–associated risks. No animal studies have been conducted to
evaluate the effect of ramucirumab on reproduction and fetal development. The
background risk of major birth defects and miscarriage for the indicated
populations are unknown. In the U.S. general population the estimated
background risk of major birth defects and miscarriage in clinically recognized
pregnancies is 2-4% and 15-20%, respectively. Advise pregnant women of the
potential risk to a fetus.
Data
Animal Data
No animal studies have been
specifically conducted to evaluate the effect of ramucirumab on reproduction
and fetal development. In mice, loss of the VEGFR2 gene resulted in embryofetal
death and these fetuses lacked organized blood vessels and blood islands in the
yolk sac. In other models, VEGFR2 signaling was associated with development and
maintenance of endometrial and placental vascular function, successful
blastocyst implantation, maternal and feto-placental vascular differentiation,
and development during early pregnancy in rodents and non-human primates.
Disruption of VEGF signaling has also been associated with developmental
anomalies including poor development of the cranial region, forelimbs,
forebrain, heart, and blood vessels.
Lactation
Risk Summary
There is no information on the
presence of ramucirumab in human milk, the effects on the breast-fed infant, or
the effects on milk production. Human IgG is present in human milk, but
published data suggest that breast milk antibodies do not enter the neonatal
and infant circulation in substantial amounts. Because of the potential risk
for serious adverse reactions in nursing infants from ramucirumab, advise women
that breastfeeding is not recommended during treatment with Cyramza.
Females and
Males of Reproductive Potential
Contraception
Females
Based on its mechanism of
action, Cyramza can cause fetal harm [see Use in
Specific Populations (8.1)]. Advise females of
reproductive potential to use effective contraception while receiving Cyramza
and for at least 3 months after the last dose of Cyramza.
Infertility
Females
Advise females of reproductive
potential that based on animal data Cyramza may impair fertility [see Nonclinical Toxicology (13.1)].
Pediatric Use
The safety and effectiveness
of Cyramza in pediatric patients have not been established. In animal studies,
effects on epiphyseal growth plates were identified. In cynomolgus monkeys,
anatomical pathology revealed adverse effects on the epiphyseal growth plate
(thickening and osteochondropathy) at all doses tested (5-50 mg/kg).
Ramucirumab exposure at the lowest weekly dose tested in the cynomolgus monkey
was 0.2 times the exposure in humans at the recommended dose of ramucirumab as
a single agent.
Geriatric Use
Of the 563 Cyramza-treated
patients in two randomized gastric cancer clinical studies, 36% were 65 and
over, while 7% were 75 and over. No overall differences in safety or
effectiveness were observed between these subjects and younger subjects. [see Clinical Studies (14.1)]
Of the 1253 patients in Study
3, 455 (36%) were 65 and over and 84 (7%) were 75 and over. Of the 627 patients
who received Cyramza plus docetaxel in Study 3, 237 (38%) were 65 and over,
while 45 (7%) were 75 and over [see Clinical
Studies (14.2)]. In an exploratory subgroup
analysis of Study 3, the hazard ratio for overall survival in patients less
than 65 years old was 0.74 (95% CI: 0.62, 0.87) and in patients 65 years or
older was 1.10 (95% CI: 0.89, 1.36). [see Clinical
Studies (14.2)]
Of the 529 patients who
received Cyramza plus FOLFIRI in Study 4, 209 (40%) were 65 and over, while 51
(10%) were 75 and over. Overall, no differences in safety or effectiveness were
observed between these subjects and younger subjects. [see
Clinical Studies (14.3)]
Renal
Impairment
No dose adjustment is
recommended for patients with renal impairment based on population pharmacokinetic
analysis [see Clinical Pharmacology (12.3)].
Hepatic
Impairment
No dose adjustment is
recommended for patients with mild (total bilirubin within upper limit of
normal [ULN] and aspartate aminotransferase [AST] >ULN, or total bilirubin
>1.0-1.5 times ULN and any AST) or moderate (total bilirubin >1.5-3.0
times ULN and any AST) hepatic impairment based on population pharmacokinetic
analysis. Clinical deterioration was reported in patients with Child-Pugh B or
C cirrhosis who received single-agent Cyramza [see
Warnings and Precautions (5.7) and Clinical Pharmacology (12.3)].
Overdosage
There are no data on overdose
in humans. Cyramza was administered at doses up to 10 mg/kg every two
weeks without reaching a maximum tolerated dose.
Cyramza Description
Cyramza (ramucirumab) is a
recombinant human IgG1 monoclonal antibody that specifically binds to vascular
endothelial growth factor receptor 2. Cyramza has an approximate molecular
weight of 147 kDa. Cyramza is produced in genetically engineered mammalian
NS0 cells.
Cyramza is a sterile,
preservative-free, clear to slightly opalescent and colorless to slightly
yellow solution for intravenous infusion following dilution and preparation.
Cyramza is supplied at a concentration of 10 mg/mL in either 100 mg
(10 mL) or 500 mg (50 mL) single-dose vials. Cyramza is
formulated in glycine (9.98 mg/mL), histidine (0.65 mg/mL), histidine
monohydrochloride (1.22 mg/mL), polysorbate 80 (0.1 mg/mL), sodium chloride
(4.383 mg/mL), and Water for Injection, USP, pH 6.0.
Cyramza - Clinical PharmacologyMechanism of
Action
Ramucirumab is a vascular
endothelial growth factor receptor 2 antagonist that specifically binds VEGF
Receptor 2 and blocks binding of VEGFR ligands, VEGF-A, VEGF-C, and VEGF-D. As
a result, ramucirumab inhibits ligand-stimulated activation of VEGF Receptor 2,
thereby inhibiting ligand-induced proliferation, and migration of human
endothelial cells. Ramucirumab inhibited angiogenesis in an in vivo animal
model.
Pharmacokinetics
The pharmacokinetic (PK)
characteristics of ramucirumab are similar for patients with gastric cancer,
NSCLC, and mCRC based on a population PK analysis. The mean (% coefficient of
variation [CV%]) clearance for ramucirumab was 0.015 L/hour (30%) and the
mean terminal half-life was 14 days (20%).
Specific Populations
Age, sex, and race had no
clinically meaningful effect on the PK of ramucirumab based on a population PK
analysis.
Renal Impairment: Based
on a population PK analysis, no clinically meaningful differences in the
average concentration of ramucirumab at steady state (Css) were observed in patients
with mild (calculated creatinine clearance [CLcr] 60-89 mL/min, n=687),
moderate (CLcr 30-59 mL/min, n=244) or severe (CLcr 15-29 mL/min, n=6) renal
impairment compared to patients with normal renal function (CLcr ≥90 mL/min,
n=697).
Hepatic Impairment: Based
on a population PK analysis, no clinically meaningful differences in the
average Css of ramucirumab were observed in patients with mild (total
bilirubin within upper limit of normal [ULN] and AST>ULN, or total bilirubin
>1.0-1.5 times ULN and any AST, n=525), or moderate (total bilirubin
>1.5-3.0 times ULN n=23) hepatic impairment compared to patients with normal
hepatic function (total bilirubin and AST ≤ULN, n=1055). No PK data are available
from patients with severe hepatic dysfunction (total bilirubin >3.0 times
ULN and any AST).
Drug Interaction Studies
No clinically meaningful
changes in the exposure of either ramucirumab or its concomitant drugs in the
approved combinations, including paclitaxel, docetaxel, and irinotecan (or its
active metabolite, SN-38), were observed in patients with solid tumors.
Nonclinical ToxicologyCarcinogenesis,
Mutagenesis, Impairment of Fertility
No animal studies have been
performed to test ramucirumab for potential carcinogenicity or genotoxicity.
Inhibition of VEGFR2 signaling
in animal models was shown to result in changes to hormone levels critical for
pregnancy, and, in monkeys, an increased duration of the follicular cycle. In a
39 week animal study, female monkeys treated with ramucirumab showed dose
dependent increases in follicular mineralization of the ovary.
Animal
Toxicology and/or Pharmacology
Adverse effects in the kidney
(glomerulonephritis) occurred in monkeys at doses of 16-50 mg/kg (0.7-5.5
times the exposure in humans at the recommended dose of ramucirumab as a single
agent).
A single dose of ramucirumab
resulting in an exposure approximately 10 times the exposure in humans at the
recommended dose of ramucirumab as a single agent did not significantly impair
wound healing in monkeys using a full-thickness incisional model.
Clinical StudiesGastric
Cancer
Study 1 was a multinational,
randomized, double-blind, multicenter study of Cyramza plus best supportive
care (BSC) versus placebo plus BSC that randomized (2:1) 355 patients with
locally advanced or metastatic gastric cancer (including adenocarcinoma of the
gastro-esophageal junction [GEJ]) who previously received platinum- or
fluoropyrimidine-containing chemotherapy. The major efficacy outcome measure
was overall survival and the supportive efficacy outcome measure was
progression-free survival. Patients were required to have experienced disease
progression either within 4 months after the last dose of first-line therapy
for locally advanced or metastatic disease or within 6 months after the last
dose of adjuvant therapy. Patients were also required to have ECOG PS of 0 or
1. Patients received either an intravenous infusion of Cyramza 8 mg/kg
(n=238) or placebo solution (n=117) every 2 weeks. Randomization was stratified
by weight loss over the prior 3 months (≥10% versus <10%), geographic
region, and location of the primary tumor (gastric versus GEJ).
Demographic and baseline
characteristics were similar between treatment arms. Median age was 60 years;
70% of patients were men; 77% were White, 16% Asian; the ECOG PS was 0 for 28%
of patients and 1 for 72% of patients; 91% of patients had measurable disease;
75% of patients had gastric cancer; and 25% had adenocarcinoma of the GEJ. The
majority of patients (85%) experienced disease progression during or following
first-line therapy for metastatic disease. Prior chemotherapy for gastric
cancer consisted of platinum/fluoropyrimidine combination therapy (81%),
fluoropyrimidine-containing regimens without platinum (15%), and
platinum-containing regimens without fluoropyrimidine (4%). In Study 1,
patients received a median of 4 doses (range 1-34) of Cyramza or a median of 3
doses (range 1-30) of placebo.
Overall survival and
progression-free survival were statistically significantly improved in patients
randomized to receive Cyramza as compared to patients randomized to receive
placebo. Efficacy results are shown in Table 6 and Figure 1.
Table 6: Randomized Trial of Cyramza plus
BSC versus Placebo plus BSC in Gastric Cancer
|
|
Abbreviations: CI = confidence interval
|
|
|
Cyramza
N=238
|
Placebo
N=117
|
|
Overall Survival
|
|
Number of deaths (%)
|
179 (75%)
|
99 (85%)
|
|
Median – months (95% CI)
|
5.2 (4.4, 5.7)
|
3.8 (2.8, 4.7)
|
|
Hazard Ratio (95% CI)
|
0.78 (0.60, 0.998)
|
|
Stratified Log-rank p-value
|
0.047
|
|
Progression-free Survival
|
|
Number of events (%)
|
199 (84%)
|
108 (92%)
|
|
Median – months (95% CI)
|
2.1 (1.5, 2.7)
|
1.3 (1.3, 1.4)
|
|
Hazard Ratio (95% CI)
|
0.48 (0.38, 0.62)
|
|
Stratified Log-rank p-value
|
<0.001
|
Figure 1: Kaplan-Meier Curves of Overall
Survival - Cyramza plus BSC versus Placebo plus BSC in Gastric Cancer
Study 2 was a multinational,
randomized, double-blind study of Cyramza plus paclitaxel versus placebo plus
paclitaxel that randomized (1:1) 665 patients with locally advanced or
metastatic gastric cancer (including adenocarcinoma of the gastro-esophageal
junction) who previously received platinum- and fluoropyrimidine-containing
chemotherapy. Patients were required to have experienced disease progression
during, or within 4 months after the last dose of first-line therapy. Patients
were also required to have ECOG PS of 0 or 1. Randomization was stratified by
geographic region, time to progression from the start of first-line therapy
(<6 months versus ≥6 months) and disease measurability.
Patients were randomized to
receive either Cyramza 8 mg/kg (n=330) or placebo (n=335) as an
intravenous infusion every 2 weeks (on days 1 and 15) of each 28-day cycle.
Patients in both arms received paclitaxel 80 mg/m2 by intravenous infusion
on days 1, 8, and 15 of each 28-day cycle. Prior to administration of each dose
of paclitaxel, patients were required to have adequate hematopoietic and
hepatic function. The paclitaxel dose was permanently reduced in increments of
10 mg/m2 for a maximum of two dose reductions for Grade 4
hematologic toxicity or Grade 3 paclitaxel-related non-hematologic toxicity.
The major efficacy outcome measure was overall survival and the supportive
efficacy outcome measures were progression-free survival and objective response
rate.
Demographics and baseline
characteristics were similar between treatment arms including the following:
Median age was 61 years; 71% of patients were men; 61% were White, 35% Asian;
the ECOG PS was 0 for 39% of patients, 1 for 61% of patients; 78% of patients
had measurable disease; 79% of patients had gastric cancer; and 21% had
adenocarcinoma of the GEJ. Two-thirds of the patients experienced disease
progression while on first-line therapy (67%) and 25% of patients received an
anthracycline in combination with platinum/fluoropyrimidine combination
therapy.
Overall survival,
progression-free survival, and objective response rate were statistically
significantly improved in patients randomized to receive Cyramza plus
paclitaxel compared to patients randomized to receive placebo plus paclitaxel.
Efficacy results are shown in Table 7 and Figure 2.
Table 7: Randomized Trial of Cyramza plus
Paclitaxel versus Placebo plus Paclitaxel in Gastric Cancer
|
|
Abbreviations: CI = confidence interval,
CR = complete response, PR = partial response, CMH = Cochran-Mantel-Haenszel
|
|
|
Cyramza + paclitaxel
N=330
|
Placebo + paclitaxel
N=335
|
|
Overall Survival
|
|
Number of deaths (%)
|
256 (78%)
|
260 (78%)
|
|
Median – months (95% CI)
|
9.6 (8.5, 10.8)
|
7.4 (6.3, 8.4)
|
|
Hazard Ratio (95% CI)
|
0.81 (0.68, 0.96)
|
|
Stratified Log-rank p-value
|
0.017
|
|
Progression-free Survival
|
|
|
Number of events (%)
|
279 (85%)
|
296 (88%)
|
|
Median – months (95% CI)
|
4.4 (4.2, 5.3)
|
2.9 (2.8, 3.0)
|
|
Hazard Ratio (95% CI)
|
0.64 (0.54, 0.75)
|
|
Stratified Log-rank p-value
|
<0.001
|
|
Objective Response Rate (CR + PR)
|
|
|
Rate – percent (95% CI)
|
28 (23, 33)
|
16 (13, 20)
|
|
Stratified CMH p-value
|
<0.001
|
Figure 2: Kaplan-Meier Curves of Overall
Survival - Cyramza plus Paclitaxel versus Placebo plus Paclitaxel in Gastric
Cancer
Non-Small
Cell Lung Cancer
Study 3 was a multinational,
randomized, double-blind, study of Cyramza plus docetaxel versus placebo plus
docetaxel, that randomized (1:1) 1253 patients with NSCLC with disease
progression on or after one platinum-based therapy for locally advanced or
metastatic disease. The major efficacy outcome measure was overall survival and
the supportive efficacy outcome measures were progression-free survival and
objective response rate. Patients were also required to have ECOG PS 0 or 1.
Patients were randomized to receive either Cyramza at 10 mg/kg or placebo
by intravenous infusion, in combination with docetaxel at 75 mg/m2 every 21 days. Sites in
East Asia administered a reduced dose of docetaxel at 60 mg/m2 every 21 days. Patients
who discontinued combination therapy because of an adverse event attributed to
either Cyramza/placebo or docetaxel were permitted to continue monotherapy with
the other treatment component until disease progression or intolerable
toxicity. Randomization was stratified by geographic region, gender, prior
maintenance therapy, and ECOG PS.
Demographics and baseline
characteristics were similar between treatment arms. Median age was 62 years;
67% of patients were men; 82% were White and 13% were Asian; 32% had ECOG PS 0;
73% had nonsquamous histology and 26% had squamous histology. In addition to
platinum chemotherapy (99%), the most common prior therapies were pemetrexed
(38%), gemcitabine (25%), taxane (24%), and bevacizumab (14%). Twenty-two
percent of patients received prior maintenance therapy. Tumor EGFR status was
unknown for the majority of patients (65%). Where tumor EGFR status was known
(n=445), 7.4% were positive for EGFR mutation (n=33). No data were collected
regarding tumor ALK rearrangement status.
Overall survival and
progression-free survival were statistically significantly improved in patients
randomized to receive Cyramza plus docetaxel compared to patients randomized to
receive placebo plus docetaxel. Objective response rate (complete response +
partial response) was 23% (95% CI: 20, 26) for Cyramza plus docetaxel and 14%
(95% CI: 11, 17) for placebo plus docetaxel, p-value of <0.001. Efficacy
results are shown in Table 8 and Figure 3.
Table 8: Randomized Trial of Cyramza plus
Docetaxel versus Placebo plus Docetaxel in NSCLC
|
|
Abbreviations: CI = confidence interval
|
|
|
Cyramza + docetaxel
N=628
|
Placebo + docetaxel
N=625
|
|
Overall Survival
|
|
Number of deaths (%)
|
428 (68%)
|
456 (73%)
|
|
Median – months (95% CI)
|
10.5 (9.5, 11.2)
|
9.1 (8.4, 10.0)
|
|
Hazard Ratio (95% CI)
|
0.86 (0.75, 0.98)
|
|
Stratified Log-rank p-value
|
0.024
|
|
Progression-free Survival
|
|
|
Number of events (%)
|
558 (89%)
|
583 (93%)
|
|
Median – months (95% CI)
|
4.5 (4.2, 5.4)
|
3.0 (2.8, 3.9)
|
|
Hazard Ratio (95% CI)
|
0.76 (0.68, 0.86)
|
|
Stratified Log-rank p-value
|
<0.001
|
Figure 3: Kaplan-Meier Curves of Overall
Survival - Cyramza plus Docetaxel versus Placebo plus Docetaxel in NSCLC
Colorectal
Cancer
Study 4 was a multinational,
randomized, double-blind, study of Cyramza plus FOLFIRI versus placebo plus
FOLFIRI, in patients with mCRC, who had disease progression on or after prior
therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine. Patients were
required to have ECOG PS 0 or 1 and to have disease progression within 6 months
of the last dose of first-line therapy. A total of 1072 patients were
randomized (1:1) to receive either Cyramza (n=536) at 8 mg/kg as an
intravenous infusion or placebo (n=536), in combination with FOLFIRI:
irinotecan 180 mg/m2 administered intravenously over 90 minutes and folinic
acid 400 mg/m2 administered intravenously simultaneously over 120
minutes; followed by 5-fluorouracil 400 mg/m2 intravenous bolus over 2
to 4 minutes; followed by 5-fluorouracil 2400 mg/m2 administered
intravenously by continuous infusion over 46 to 48 hours. Treatment cycles on
both arms were repeated every 2 weeks. Patients who discontinued one or more
components of treatment because of an adverse event were permitted to continue
therapy with the other treatment component(s) until disease progression or
unacceptable toxicity. The major efficacy outcome measure was overall survival
and the supportive efficacy outcome measure was progression-free survival.
Randomization was stratified by geographic region, tumor KRAS status, and time
to disease progression after beginning first-line treatment (<6 months
versus ≥6 months).
Demographic and baseline
characteristics were similar between treatment arms. Median age was 62 years;
57% of patients were men; 76% were White and 20% Asian; 49% had ECOG PS 0; 49%
of patients had KRAS mutant tumors; and 24% of patients had <6 months from
time to disease progression after beginning first-line treatment.
Overall survival and
progression-free survival were statistically significantly improved in patients
randomized to receive Cyramza plus FOLFIRI compared to patients randomized to
receive placebo plus FOLFIRI. The treatment effect was consistent across the
pre-specified stratification factors. Efficacy results are shown in Table
9 and Figure 4.
Table 9: Randomized Trial of Cyramza plus
FOLFIRI versus Placebo plus FOLFIRI in mCRC
|
|
Abbreviations: CI = confidence interval.
|
|
|
Cyramza + FOLFIRI
N=536
|
Placebo + FOLFIRI
N=536
|
|
Overall Survival
|
|
Number of deaths (%)
|
372 (69%)
|
397 (74%)
|
|
Median – months (95% CI)
|
13.3 (12.4, 14.5)
|
11.7 (10.8, 12.7)
|
|
Hazard Ratio (95% CI)
|
0.85 (0.73, 0.98)
|
|
Stratified Log-rank p-value
|
0.023
|
|
Progression-free Survival
|
|
|
Number of events (%)
|
476 (89%)
|
494 (92%)
|
|
Median – months (95% CI)
|
5.7 (5.5, 6.2)
|
4.5 (4.2, 5.4)
|
|
Hazard Ratio (95% CI)
|
0.79 (0.70, 0.90)
|
|
Stratified Log-rank p-value
|
<0.001
|
Figure
4: Kaplan-Meier Curve of Overall Survival - Cyramza plus FOLFIRI versus Placebo
plus FOLFIRI in mCRC
How Supplied/Storage and Handling
How Supplied
Cyramza is supplied in
single-dose vials as a sterile, preservative-free solution.
·
NDC 0002-7669-01
100 mg/10 mL (10 mg/mL), individually packaged in a carton
·
NDC 0002-7678-01
500 mg/50 mL (10 mg/mL), individually packaged in a carton
Storage and
Handling
Store vials in a refrigerator
at 2°C to 8°C (36°F to 46°F) until time of use. Keep the vial in the outer
carton in order to protect from light. DO NOT FREEZE
OR SHAKE the vial.
Patient Counseling Information
· Hemorrhage:
Advise patients that Cyramza can cause severe bleeding. Advise patients to
contact their health care provider for bleeding or symptoms of bleeding
including lightheadedness [see Warnings and
Precautions (5.1)].
· Arterial
thromboembolic events:
Advise patients of an increased risk of an arterial thromboembolic event [see Warnings and Precautions (5.2)].
· Hypertension:
Advise patients to undergo routine blood pressure monitoring and to contact
their health care provider if blood pressure is elevated or if symptoms from
hypertension occur including severe headache, lightheadedness, or neurologic
symptoms [see Warnings and Precautions (5.3)].
· Gastrointestinal
perforations:
Advise patients to notify their health care provider for severe diarrhea,
vomiting, or severe abdominal pain [see Warnings
and Precautions (5.5)].
· Impaired
wound healing:
Advise patients that Cyramza has the potential to impair wound healing.
Instruct patients not to undergo surgery without first discussing this
potential risk with their health care provider [see
Warnings and Precautions (5.6)].
· Pregnancy
and fetal harm:
Advise females of reproductive potential of the potential risk for maintaining
pregnancy, risk to the fetus, and risk to newborn and infant development and to
use effective contraception during Cyramza therapy and for at least 3 months
following the last dose of Cyramza [see Warnings
and Precautions (5.11) and Use in Specific Populations (8.1, 8.3)].
· Lactation:
Advise patients not to breastfeed during Cyramza treatment [see Use in Specific Populations (8.2)].
· Infertility:
Advise females of reproductive potential regarding potential infertility
effects of Cyramza [see Use in Specific Populations
(8.3)].
Revised: March 2017
Eli
Lilly and Company, Indianapolis, IN 46285, USA
US License No. 1891
Copyright © 2014, 2017, Eli Lilly and Company. All rights
reserved.
CYR-0006-USPI-20170323
PACKAGE
LABELING
This section contains a
representative sample of product package labeling. Product may be manufactured
at other manufacturing sites.
PACKAGE
CARTON –Cyramza 100 mg/10 mL single-use vial.
NDC 0002-7669-01
Cyramza®
(ramucirumab)
Injection
100 mg/10 mL
(10 mg/mL)
For Intravenous Infusion Only
Must Dilute Prior to Use
Single-Dose Vial
Discard Unused Portion
Keep Refrigerated
Rx only
www.Cyramza.com
Lilly
CARTON FOR US ORIGIN
CARTON FOR IRELAND ORIGIN
PACKAGE
CARTON – Cyramza 500 mg/50mL single-use vial.
NDC 0002-7678-01
Cyramza®
(ramucirumab)
Injection
500 mg/50 mL
(10 mg/mL)
For Intravenous Infusion Only
Must Dilute Prior to Use
Single-Dose Vial
Discard Unused Portion
Keep Refrigerated
Rx only
www.Cyramza.com
Lilly
CARTON FOR US ORIGIN
CARTON FOR IRELAND ORIGIN
|
Cyramza ramucirumab solution
|
|
Product
Information
|
|
Product Type
|
HUMAN
PRESCRIPTION DRUG LABEL
|
Item Code
(Source)
|
NDC:0002-7669
|
|
Route of
Administration
|
INTRAVENOUS
|
DEA Schedule
|
|
|
|
Active
Ingredient/Active Moiety
|
|
Ingredient
Name
|
Basis of
Strength
|
Strength
|
|
ramucirumab (ramucirumab)
|
ramucirumab
|
10 mg
in 1 mL
|
|
|
Inactive
Ingredients
|
|
Ingredient
Name
|
Strength
|
|
histidine
|
0.65 mg
in 1 mL
|
|
histidine monohydrochloride
|
1.22 mg
in 1 mL
|
|
sodium chloride
|
4.38 mg
in 1 mL
|
|
glycine
|
9.98 mg in 1 mL
|
|
polysorbate 80
|
0.1 mg
in 1 mL
|
|
water
|
|
|
|
|
|
Packaging
|
|
#
|
Item Code
|
Package
Description
|
|
|
1
|
NDC:0002-7669-01
|
1 VIAL,
SINGLE-USE in 1 CARTON
|
|
|
1
|
|
10 mL in 1
VIAL, SINGLE-USE
|
|
|
|
|
|
Marketing Information
|
|
Marketing
Category
|
Application
Number or Monograph Citation
|
Marketing
Start Date
|
Marketing
End Date
|
|
BLA
|
BLA125477
|
04/21/2014
|
|
|
|
Cyramza ramucirumab solution
|
|
Product
Information
|
|
Product Type
|
HUMAN
PRESCRIPTION DRUG LABEL
|
Item Code
(Source)
|
NDC:0002-7678
|
|
Route of
Administration
|
INTRAVENOUS
|
DEA Schedule
|
|
|
|
Active
Ingredient/Active Moiety
|
|
Ingredient
Name
|
Basis of
Strength
|
Strength
|
|
ramucirumab (ramucirumab)
|
ramucirumab
|
10 mg
in 1 mL
|
|
|
Inactive
Ingredients
|
|
Ingredient
Name
|
Strength
|
|
histidine
|
0.65 mg
in 1 mL
|
|
histidine monohydrochloride
|
1.22 mg
in 1 mL
|
|
sodium chloride
|
4.38 mg
in 1 mL
|
|
glycine
|
9.98 mg
in 1 mL
|
|
polysorbate 80
|
0.1 mg
in 1 mL
|
|
water
|
|
|
|
|
|
Packaging
|
|
#
|
Item Code
|
Package
Description
|
|
|
1
|
NDC:0002-7678-01
|
1 VIAL,
SINGLE-USE in 1 CARTON
|
|
|
1
|
|
50 mL in 1
VIAL, SINGLE-USE
|
|
|
|
|
|
Marketing Information
|
|
Marketing
Category
|
Application
Number or Monograph Citation
|
Marketing
Start Date
|
Marketing
End Date
|
|
BLA
|
BLA125477
|
04/21/2014
|
|
|
|
Labeler - Eli Lilly and Company (006421325)
|
Revised:
06/2017
Eli Lilly and Company
