Darzalex
Generic Name: daratumumab
Dosage Form: injection, solution, concentrate
Indications and Usage for Darzalex
Darzalex is indicated:
· in
combination with lenalidomide and dexamethasone, or bortezomib and
dexamethasone, for the treatment of patients with multiple myeloma who have
received at least one prior therapy.
· in
combination with pomalidomide and dexamethasone for the treatment of patients
with multiple myeloma who have received at least two prior therapies including
lenalidomide and a proteasome inhibitor.
·
as monotherapy, for the treatment of patients with multiple myeloma who have
received at least three prior lines of therapy including a proteasome inhibitor
(PI) and an immunomodulatory agent or who are double-refractory to a PI and an
immunomodulatory agent.
Darzalex Dosage and
AdministrationRecommended Dose and Schedule
·
Administer pre-infusion and post-infusion medications [see Dosage and
Administration (2.2)].
·
Administer only as an intravenous infusion after dilution in 0.9% Sodium
Chloride Injection, USP [see Dosage and
Administration (2.4, 2.5)].
·
Darzalex should be administered by a healthcare professional, with immediate
access to emergency equipment and appropriate medical support to manage
infusion reactions if they occur [see Warnings and
Precautions (5.1)].
Monotherapy and Combination Therapy with
Lenalidomide or Pomalidomide and Low-Dose Dexamethasone (4-week cycle regimens)
The recommended dose of Darzalex is 16
mg/kg actual body weight administered as an intravenous infusion according to
the following dosing schedule in Table 1:
|
Table 1: Darzalex dosing schedule for monotherapy and
in combination with lenalidomide or pomalidomide (4-week cycle dosing
regimens)
|
|
Weeks
|
Schedule
|
|
*
First dose of the every-2-week dosing schedule is given
at week 9
†
First dose of the every-4-week dosing schedule is given
at week 25
|
|
Weeks 1 to 8
|
weekly (total of 8 doses)
|
|
Weeks 9 to 24*
|
every two weeks (total of 8 doses)
|
|
Week 25 onwards until disease progression†
|
every four weeks
|
For dosing instructions of combination
agents administered with Darzalex, see Clinical Studies
(14.1, 14.3) and manufacturer's prescribing information.
Combination Therapy with Bortezomib and
Dexamethasone (3-week cycle regimen)
The recommended dose of Darzalex is 16
mg/kg actual body weight administered as an intravenous infusion according to
the following dosing schedule in Table 2:
|
Table 2: Darzalex dosing schedule with bortezomib
(3-week cycle dosing regimen)
|
|
Weeks
|
Schedule
|
|
*
First dose of the every-3-week dosing schedule is given
at week 10
†
First dose of the every-4-week dosing schedule is given
at week 25
|
|
Weeks 1 to 9
|
weekly (total of 9 doses)
|
|
Weeks 10 to 24*
|
every three weeks (total of 5 doses)
|
|
Week 25 onwards until disease progression†
|
every four weeks
|
For dosing instructions of combination
agents administered with Darzalex see Clinical Studies
(14.2) and manufacturer's prescribing information.
Missed Darzalex Doses
If a planned dose of Darzalex is missed,
administer the dose as soon as possible and adjust the dosing schedule
accordingly, maintaining the treatment interval.
Infusion Rates and Management of
Infusion Reactions
Administer Darzalex infusion
intravenously at the infusion rate described below in Table 3. Consider
incremental escalation of the infusion rate only in the absence of infusion
reactions.
|
Table 3: Infusion rates for Darzalex administration
|
|
|
Dilution volume
|
Initial rate (first hour)
|
Rate increment*
|
Maximum rate
|
|
*
Consider incremental escalation of the infusion rate
only in the absence of infusion reactions.
†
Use a dilution volume of 500 mL only if there were no
Grade 1 (mild) or greater infusion reactions during the first 3 hours of the
first infusion. Otherwise, continue to use a dilution volume of 1000 mL and
instructions for the first infusion.
‡
Use a modified initial rate for subsequent infusions
(i.e. third infusion onwards) only if there were no Grade 1 (mild) or greater
infusion reactions during a final infusion rate of ≥100 mL/hr in the first
two infusions. Otherwise, continue to use instructions for the second
infusion.
|
|
First infusion
|
1000 mL
|
50 mL/hour
|
50 mL/hour every hour
|
200 mL/hour
|
|
Second infusion†
|
500 mL
|
50 mL/hour
|
50 mL/hour every hour
|
200 mL/hour
|
|
Subsequent infusions‡
|
500 mL
|
100 mL/hour
|
50 mL/hour every hour
|
200 mL/hour
|
For infusion reactions of any
grade/severity, immediately interrupt the Darzalex infusion and manage
symptoms. Management of infusion reactions may further require reduction in the
rate of infusion, or treatment discontinuation of Darzalex as outlined
below [see Warnings and Precautions (5.1)].
· Grade
1–2 (mild to moderate): Once reaction symptoms resolve, resume the infusion at
no more than half the rate at which the reaction occurred. If the patient does
not experience any further reaction symptoms, infusion rate escalation may
resume at increments and intervals as clinically appropriate up to the maximum
rate of 200 mL/hour (Table 3).
· Grade
3 (severe): Once reaction symptoms resolve, consider restarting the infusion at
no more than half the rate at which the reaction occurred. If the patient does
not experience additional symptoms, resume infusion rate escalation at
increments and intervals as outlined in Table 3. Repeat the procedure above in
the event of recurrence of Grade 3 symptoms. Permanently discontinue Darzalex
upon the third occurrence of a Grade 3 or greater infusion reaction.
·
Grade 4 (life threatening): Permanently discontinue Darzalex treatment.
Recommended Concomitant Medications
Pre-infusion Medication
Administer the following pre-infusion
medications to reduce the risk of infusion reactions to all patients 1–3 hours
prior to every infusion of Darzalex:
·
Corticosteroid (long-acting or intermediate-acting)
Monotherapy:
Methylprednisolone 100 mg, or
equivalent, administered intravenously. Following the second infusion, the dose
of corticosteroid may be reduced (oral or intravenous methylprednisolone 60
mg).
Combination therapy:
Administer 20 mg dexamethasone prior to
every Darzalex infusion [Clinical Studies
(14)].
Dexamethasone is given intravenously
prior to the first Darzalex infusion and oral administration may be considered
prior to subsequent infusions.
·
Antipyretics (oral acetaminophen 650 to 1000 mg)
·
Antihistamine (oral or intravenous diphenhydramine 25 to 50 mg or equivalent).
Post-infusion Medication
Administer post-infusion medication to
reduce the risk of delayed infusion reactions to all patients as follows:
Monotherapy:
Administer oral corticosteroid (20 mg
methylprednisolone or equivalent dose of an intermediate-acting or long-acting
corticosteroid in accordance with local standards) on each of the 2 days
following all Darzalex infusions (beginning the day after the infusion).
Combination therapy:
Consider administering low-dose oral
methylprednisolone (≤ 20 mg) or equivalent, the day after the Darzalex
infusion.
However, if a background
regimen-specific corticosteroid (e.g. dexamethasone) is administered the day
after the Darzalex infusion, additional post-infusion medications may not be
needed [see Clinical Studies (14)].
In addition, for any patients with a
history of chronic obstructive pulmonary disease, consider prescribing
post-infusion medications such as short and long-acting bronchodilators, and
inhaled corticosteroids. Following the first four infusions, if the patient
experiences no major infusion reactions, these additional inhaled post-infusion
medications may be discontinued.
Prophylaxis for Herpes Zoster
Reactivation
Initiate antiviral prophylaxis to
prevent herpes zoster reactivation within 1 week after starting Darzalex and
continue for 3 months following treatment [see Adverse Reactions
(6.1)].
Dose Modifications
No dose reductions of Darzalex are
recommended. Dose delay may be required to allow recovery of blood cell counts
in the event of hematological toxicity [see Warnings and
Precautions (5.3, 5.4)].
For information concerning drugs given in combination with Darzalex, see
manufacturer's prescribing information.
Preparation for Administration
Darzalex is for single use only.
Prepare the solution for infusion using
aseptic technique as follows:
·
Calculate the dose (mg), total volume (mL) of Darzalex solution required and
the number of Darzalex vials needed based on patient actual body weight.
·
Check that the Darzalex solution is colorless to pale yellow. Do not use if
opaque particles, discoloration or other foreign particles are present.
·
Remove a volume of 0.9% Sodium Chloride Injection, USP from the infusion
bag/container that is equal to the required volume of Darzalex solution.
·
Withdraw the necessary amount of Darzalex solution and dilute to the
appropriate volume by adding to the infusion bag/container containing 0.9%
Sodium Chloride Injection, USP as specified in Table 3 [see Dosage and
Administration (2.1)]. Infusion bags/containers must be made of
either polyvinylchloride (PVC), polypropylene (PP), polyethylene (PE) or
polyolefin blend (PP+PE). Dilute under appropriate aseptic conditions. Discard
any unused portion left in the vial.
·
Gently invert the bag/container to mix the solution. Do not shake.
·
Parenteral drug products should be inspected visually for particulate matter
and discoloration prior to administration, whenever solution and container
permit. The diluted solution may develop very small, translucent to white
proteinaceous particles, as daratumumab is a protein. Do not use if visibly
opaque particles, discoloration or foreign particles are observed.
· Since
Darzalex does not contain a preservative, administer the diluted solution
immediately at room temperature 15°C–25°C (59°F–77°F) and in room light.
Diluted solution may be kept at room temperature for a maximum of 15 hours
(including infusion time).
· If
not used immediately, the diluted solution can be stored prior to
administration for up to 24 hours at refrigerated conditions 2°C – 8°C
(36°F–46°F) and protected from light. Do not freeze.
Administration
·
If stored in the refrigerator, allow the solution to come to room temperature.
Administer the diluted solution by intravenous infusion using an infusion set
fitted with a flow regulator and with an in-line, sterile,
non-pyrogenic, low protein-binding polyethersulfone (PES) filter (pore size
0.22 or 0.2 micrometer). Administration sets must be made of either
polyurethane (PU), polybutadiene (PBD), PVC, PP or PE.
·
Do not store any unused portion of the infusion solution for reuse. Any unused
product or waste material should be disposed of in accordance with local
requirements.
·
Do not infuse Darzalex concomitantly in the same intravenous line with other
agents.
Dosage Forms and Strengths
Darzalex is a colorless to pale yellow,
preservative-free solution available as:
Injection:
·
100 mg/5 mL (20 mg/mL) in a single-dose vial.
·
400 mg/20 mL (20 mg/mL) in a single-dose vial.
Contraindications
None.
Warnings and PrecautionsInfusion
Reactions
Darzalex can cause severe infusion
reactions. Approximately half of all patients experienced a reaction, most
during the first infusion.
Infusion reactions can also occur with
subsequent infusions. Nearly all reactions occurred during infusion or within 4
hours of completing Darzalex. Prior to the introduction of post-infusion
medication in clinical trials, infusion reactions occurred up to 48 hours after
infusion.
Severe reactions have occurred,
including bronchospasm, hypoxia, dyspnea, hypertension, laryngeal edema and
pulmonary edema. Signs and symptoms may include respiratory symptoms, such as
nasal congestion, cough, throat irritation, as well as chills, vomiting and
nausea. Less common symptoms were wheezing, allergic rhinitis, pyrexia, chest
discomfort, pruritus, and hypotension [see Adverse
Reactions (6.1)].
Pre-medicate patients with
antihistamines, antipyretics and corticosteroids. Frequently monitor patients
during the entire infusion. Interrupt Darzalex infusion for reactions of any
severity and institute medical management as needed. Permanently discontinue
Darzalex therapy for life-threatening (Grade 4) reactions. For patients with
Grade 1, 2, or 3 reactions, reduce the infusion rate when re-starting the infusion [see Dosage and
Administration (2.1)].
To reduce the risk of delayed infusion
reactions, administer oral corticosteroids to all patients following Darzalex
infusions [see Dosage and Administration (2.2)]. Patients with a history of
chronic obstructive pulmonary disease may require additional post-infusion
medications to manage respiratory complications. Consider prescribing short-
and long-acting bronchodilators and inhaled corticosteroids for patients with
chronic obstructive pulmonary disease.
Interference with Serological Testing
Daratumumab binds to CD38 on red blood
cells (RBCs) and results in a positive Indirect Antiglobulin Test (Indirect
Coombs test). Daratumumab-mediated positive indirect antiglobulin test may
persist for up to 6 months after the last daratumumab infusion. Daratumumab
bound to RBCs masks detection of antibodies to minor antigens in the patient's serum1 [see References (15)].
The determination of a patient's ABO and Rh blood type are not
impacted [see Drug Interactions (7.1)].
Notify blood transfusion centers of this
interference with serological testing and inform blood banks that a patient has
received Darzalex. Type and screen patients prior to starting Darzalex.
Neutropenia
Darzalex may increase neutropenia
induced by background therapy [see Adverse
Reactions (6.1)].
Monitor complete blood cell counts
periodically during treatment according to manufacturer's prescribing
information for background therapies. Monitor patients with neutropenia for
signs of infection. Darzalex dose delay may be required to allow recovery of
neutrophils. No dose reduction of Darzalex is recommended. Consider supportive
care with growth factors.
Thrombocytopenia
Darzalex may increase thrombocytopenia
induced by background therapy [see Adverse
Reactions (6.1)].
Monitor complete blood cell counts
periodically during treatment according to manufacturer's prescribing
information for background therapies. Darzalex dose delay may be required to
allow recovery of platelets. No dose reduction of Darzalex is recommended.
Consider supportive care with transfusions.
Interference with Determination of
Complete Response
Daratumumab is a human IgG kappa
monoclonal antibody that can be detected on both, the serum protein
electrophoresis (SPE) and immunofixation (IFE)
assays used for the clinical monitoring of endogenous M-protein [see Drug
Interactions (7.1)]. This interference can impact the determination
of complete response and of disease progression in some patients with IgG kappa
myeloma protein.
Adverse Reactions
The following serious adverse reactions
are also described elsewhere in the labeling:
·
Infusion reactions [see Warning and
Precautions (5.1)].
·
Neutropenia [see Warning and
Precautions (5.3)].
·
Thrombocytopenia [see Warning and
Precautions (5.4)].
Adverse Reactions in Clinical Trials
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.
The safety data described below reflects
exposure to Darzalex (16 mg/kg) in 820 patients with multiple myeloma including
526 patients from two Phase 3 active-controlled trials who received Darzalex in
combination with either lenalidomide (DRd, n=283; Study 3) or bortezomib (DVd,
n=243; Study 4) and five open-label, clinical trials in which patients received
Darzalex either in combination with pomalidomide (DPd, n=103; Study 5), in
combination with lenalidomide (n=35), or as monotherapy (n=156).
Combination Treatment with Lenalidomide
Adverse reactions described in Table 4
reflect exposure to Darzalex (DRd arm) for a median treatment duration of 13.1
months (range: 0 to 20.7 months) and median treatment duration of 12.3 months
(range: 0.2 to 20.1 months) for the lenalidomide group (Rd) in Study 3. The
most frequent adverse reactions (≥20%) were infusion reactions, diarrhea,
nausea, fatigue, pyrexia, upper respiratory tract infection, muscle spasms,
cough and dyspnea. The overall incidence of serious adverse reactions was 49%
for the DRd group compared with 42% for the Rd group. Serious adverse reactions
with at least a 2% greater incidence in the DRd arm compared to the Rd arm were
pneumonia (12% vs Rd 10%), upper respiratory tract infection (7% vs Rd 4%),
influenza and pyrexia (DRd 3% vs Rd 1% for each).
Adverse reactions resulted in
discontinuations for 7% (n=19) of patients in the DRd arm versus 8% (n=22) in
the Rd arm.
|
Table 4: Adverse reactions reported in ≥ 10% of
patients and with at least a 5% frequency greater in the DRd arm in Study 3
|
|
|
Adverse Reaction
|
DRd (N=283) %
|
Rd (N=281) %
|
|
|
Any Grade
|
Grade 3
|
Grade 4
|
Any Grade
|
Grade 3
|
Grade 4
|
|
|
Key: D=daratumumab, Rd=lenalidomide-dexamethasone.
|
|
|
*
Infusion reaction includes terms determined by
investigators to be related to infusion, see description of Infusion
Reactions below.
†
upper respiratory tract infection, bronchitis,
sinusitis, respiratory tract infection viral, rhinitis, pharyngitis,
respiratory tract infection, metapneumovirus infection, tracheobronchitis,
viral upper respiratory tract infection, laryngitis, respiratory syncytial
virus infection, staphylococcal pharyngitis, tonsillitis, viral pharyngitis,
acute sinusitis, nasopharyngitis, bronchiolitis, bronchitis viral,
pharyngitis streptococcal, tracheitis, upper respiratory tract infection
bacterial, bronchitis bacterial, epiglottitis, laryngitis viral,
oropharyngeal candidiasis, respiratory moniliasis, viral rhinitis, acute
tonsillitis, rhinovirus infection
‡
cough, productive cough, allergic cough
§
dyspnea, dyspnea exertional
|
|
|
Infusion reactions*
|
48
|
5
|
0
|
0
|
0
|
0
|
|
|
Gastrointestinal disorders
|
|
|
Diarrhea
|
43
|
5
|
0
|
25
|
3
|
0
|
|
|
Nausea
|
24
|
1
|
0
|
14
|
0
|
0
|
|
|
Vomiting
|
17
|
1
|
0
|
5
|
1
|
0
|
|
|
General disorders and administration site conditions
|
|
|
Fatigue
|
35
|
6
|
< 1
|
28
|
2
|
0
|
|
|
Pyrexia
|
20
|
2
|
0
|
11
|
1
|
0
|
|
|
Infections and infestations
|
|
|
Upper respiratory tract infection†
|
65
|
6
|
< 1
|
51
|
4
|
0
|
|
|
Musculoskeletal and connective tissue disorders
|
|
|
Muscle spasms
|
26
|
1
|
0
|
19
|
2
|
0
|
|
|
Nervous system disorders
|
|
|
Headache
|
13
|
0
|
0
|
7
|
0
|
0
|
|
|
Respiratory, thoracic and mediastinal disorders
|
|
|
Cough‡
|
30
|
0
|
0
|
15
|
0
|
0
|
|
|
Dyspnea§
|
21
|
3
|
< 1
|
12
|
1
|
0
|
|
Laboratory abnormalities worsening
during treatment from baseline listed in Table 5.
|
Table 5: Treatment-emergent hematology laboratory
abnormalities in Study 3
|
|
|
|
DRd (N=283) %
|
Rd (N=281) %
|
|
|
Any Grade
|
Grade 3
|
Grade 4
|
All Grades
|
Grade 3
|
Grade 4
|
|
|
Key: D=Daratumumab, Rd=lenalidomide-dexamethasone.
|
|
|
Anemia
|
52
|
13
|
0
|
57
|
19
|
0
|
|
|
Thrombocytopenia
|
73
|
7
|
6
|
67
|
10
|
5
|
|
|
Neutropenia
|
92
|
36
|
17
|
87
|
32
|
8
|
|
|
Lymphopenia
|
95
|
42
|
10
|
87
|
32
|
6
|
|
Combination Treatment with Bortezomib
Adverse reactions described in Table 6
reflect exposure to Darzalex (DVd arm) for a median treatment duration of 6.5
months (range: 0 to 14.8 months) and median treatment duration of 5.2 months
(range: 0.2 to 8.0 months) for the bortezomib group (Vd) in Study 4. The most
frequent adverse reactions (>20%) were infusion reactions, diarrhea,
peripheral edema, upper respiratory tract infection, peripheral sensory
neuropathy, cough and dyspnea. The overall incidence of serious adverse
reactions was 42% for the DVd group compared with 34% for the Vd group. Serious
adverse reactions with at least a 2% greater incidence in the DVd arm compared
to the Vd arm were upper respiratory tract infection (DVd 5% vs Vd 2%),
diarrhea and atrial fibrillation (DVd 2% vs Vd 0% for each).
Adverse reactions resulted in
discontinuations for 7% (n=18) of patients in the DVd arm versus 9% (n=22) in
the Vd arm.
|
Table 6: Adverse reactions reported in ≥ 10% of
patients and with at least a 5% frequency greater in the DVd arm Study 4
|
|
|
Adverse Reaction
|
DVd (N=243) %
|
Vd (N=237) %
|
|
|
Any Grade
|
Grade 3
|
Grade 4
|
Any Grade
|
Grade 3
|
Grade 4
|
|
|
Key: D=daratumumab, Vd=bortezomib-dexamethasone.
|
|
|
*
Infusion reaction includes terms determined by
investigators to be related to infusion, see description of Infusion
Reactions below.
†
edema peripheral, edema, generalized edema, peripheral
swelling
‡
upper respiratory tract infection, bronchitis,
sinusitis, respiratory tract infection viral, rhinitis, pharyngitis,
respiratory tract infection, metapneumovirus infection, tracheobronchitis,
viral upper respiratory tract infection, laryngitis, respiratory syncytial
virus infection, staphylococcal pharyngitis, tonsillitis, viral pharyngitis,
acute sinusitis, nasopharyngitis, bronchiolitis, bronchitis viral,
pharyngitis streptococcal, tracheitis, upper respiratory tract infection
bacterial, bronchitis bacterial, epiglottitis, laryngitis viral, oropharyngeal
candidiasis, respiratory moniliasis, viral rhinitis, acute tonsillitis,
rhinovirus infection
§
cough, productive cough, allergic cough
¶
dyspnea, dyspnea exertional
|
|
|
Infusion reactions*
|
45
|
9
|
0
|
0
|
0
|
0
|
|
|
Gastrointestinal disorders
|
|
|
Diarrhea
|
32
|
3
|
< 1
|
22
|
1
|
0
|
|
|
Vomiting
|
11
|
0
|
0
|
4
|
0
|
0
|
|
|
General disorders and administration site conditions
|
|
|
Edema peripheral†
|
22
|
1
|
0
|
13
|
0
|
0
|
|
|
Pyrexia
|
16
|
1
|
0
|
11
|
1
|
0
|
|
|
Infections and infestations
|
|
|
Upper respiratory tract infection‡
|
44
|
6
|
0
|
30
|
3
|
< 1
|
|
|
Nervous system disorders
|
|
|
Peripheral sensory neuropathy
|
47
|
5
|
0
|
38
|
6
|
< 1
|
|
|
Respiratory, thoracic and mediastinal disorders
|
|
|
Cough§
|
27
|
0
|
0
|
14
|
0
|
0
|
|
|
Dyspnea¶
|
21
|
4
|
0
|
11
|
1
|
0
|
|
Laboratory abnormalities worsening
during treatment are listed in Table 7.
|
Table 7: Treatment-emergent hematology laboratory
abnormalities in Study 4
|
|
|
|
DVd (N=243) %
|
Vd (N=237) %
|
|
|
Any Grade
|
Grade 3
|
Grade 4
|
Any Grade
|
Grade 3
|
Grade 4
|
|
|
Key: D=Daratumumab, Vd=bortezomib-dexamethasone.
|
|
|
Anemia
|
48
|
13
|
0
|
56
|
14
|
0
|
|
|
Thrombocytopenia
|
90
|
28
|
19
|
85
|
22
|
13
|
|
|
Neutropenia
|
58
|
12
|
3
|
40
|
5
|
< 1
|
|
|
Lymphopenia
|
89
|
41
|
7
|
81
|
24
|
3
|
|
Combination Treatment with Pomalidomide
Adverse reactions described in Table 8
reflect exposure to Darzalex, pomalidomide and dexamethasone (DPd) for a median
treatment duration of 6 months (range: 0.03 to 16.9 months) in Study 5. The
most frequent adverse reactions (>20%) were infusion reactions, diarrhea,
constipation, nausea, vomiting, fatigue, pyrexia, upper respiratory tract
infection, muscle spasms, back pain, arthralgia, dizziness, insomnia, cough and
dyspnea. The overall incidence of serious adverse reactions was 49%. Serious
adverse reactions reported in ≥5% patients included pneumonia (7%). Adverse
reactions resulted in discontinuations for 13% of patients.
|
Table 8: Adverse reactions with incidence ≥10% reported
in Study 5
|
|
Body System
|
DPd (N=103)
|
|
Adverse Reaction
|
Any Grade (%)
|
Grade 3 (%)
|
Grade 4 (%)
|
|
Key: D=Daratumumab, Pd=pomalidomide-dexamethasone.
|
|
*
Infusion reaction includes terms determined by
investigators to be related to infusion, see description of Infusion
Reactions below.
†
edema, edema peripheral, peripheral swelling.
‡
acute tonsillitis, bronchitis, laryngitis,
nasopharyngitis, pharyngitis, respiratory syncytial virus infection, rhinitis,
sinusitis, tonsillitis, upper respiratory tract infection
§
lung infection, pneumonia, pneumonia aspiration
¶
cough, productive cough, allergic cough
#
dyspnea, dyspnea exertional
|
|
Infusion reactions*
|
50
|
4
|
0
|
|
Gastrointestinal disorders
|
|
Diarrhea
|
38
|
3
|
0
|
|
Constipation
|
33
|
0
|
0
|
|
Nausea
|
30
|
0
|
0
|
|
Vomiting
|
21
|
2
|
0
|
|
General disorders and administration site conditions
|
|
Fatigue
|
50
|
10
|
0
|
|
Pyrexia
|
25
|
1
|
0
|
|
Chills
|
20
|
0
|
0
|
|
Edema peripheral†
|
17
|
4
|
0
|
|
Asthenia
|
15
|
0
|
0
|
|
Non-cardiac chest pain
|
15
|
0
|
0
|
|
Pain
|
11
|
0
|
0
|
|
Infections and infestations
|
|
Upper respiratory tract infection‡
|
50
|
4
|
1
|
|
Pneumonia§
|
15
|
8
|
2
|
|
Metabolism and nutrition disorders
|
|
Hypokalemia
|
16
|
3
|
0
|
|
Hyperglycemia
|
13
|
5
|
1
|
|
Decreased appetite
|
11
|
0
|
0
|
|
Musculoskeletal and connective tissue disorders
|
|
Muscle spasms
|
26
|
1
|
0
|
|
Back pain
|
25
|
6
|
0
|
|
Arthralgia
|
22
|
2
|
0
|
|
Pain in extremity
|
15
|
0
|
0
|
|
Bone pain
|
13
|
4
|
0
|
|
Musculoskeletal chest pain
|
13
|
2
|
0
|
|
Nervous system disorders
|
|
Dizziness
|
21
|
2
|
0
|
|
Tremor
|
19
|
3
|
0
|
|
Headache
|
17
|
0
|
0
|
|
Psychiatric disorders
|
|
Insomnia
|
23
|
2
|
0
|
|
Anxiety
|
13
|
0
|
0
|
|
Respiratory, thoracic and mediastinal disorders
|
|
Cough¶
|
43
|
1
|
0
|
|
Dyspnea#
|
33
|
6
|
1
|
|
Nasal congestion
|
16
|
0
|
0
|
Laboratory abnormalities worsening
during treatment are listed in Table 9.
|
Table 9: Treatment-emergent hematology laboratory
abnormalities in Study 5
|
|
|
DPd (N=103) %
|
|
|
Any Grade
|
Grade 3
|
Grade 4
|
|
Key: D=Daratumumab, Pd=pomalidomide-dexamethasone.
|
|
Anemia
|
57
|
30
|
0
|
|
Thrombocytopenia
|
75
|
10
|
10
|
|
Neutropenia
|
95
|
36
|
46
|
|
Lymphopenia
|
94
|
45
|
26
|
Monotherapy
The safety data reflect exposure to
Darzalex in 156 adult patients with relapsed and refractory multiple myeloma
treated with Darzalex at 16 mg/kg in three open-label, clinical trials. The
median duration of exposure was 3.3 months (range: 0.03 to 20.04 months).
Serious adverse reactions were reported in 51 (33%) patients. The most frequent
serious adverse reactions were pneumonia (6%), general physical health
deterioration (3%), and pyrexia (3%).
Adverse reactions resulted in treatment
delay for 24 (15%) patients, most frequently for infections. Adverse reactions
resulted in discontinuations for 6 (4%) patients.
Adverse reactions occurring in at least
10% of patients are presented in Table 10. Table 11 describes Grade 3–4
laboratory abnormalities reported at a rate of ≥10%.
|
Table 10: Adverse reactions with incidence ≥10% in
patients with multiple myeloma treated with Darzalex 16 mg/kg
|
|
|
|
Darzalex 16 mg/kg
N=156
|
|
|
Incidence (%)
|
|
|
Adverse Reaction
|
Any Grade
|
Grade 3
|
Grade 4
|
|
|
*
Infusion reaction includes terms determined by
investigators to be related to infusion, see below.
†
Pneumonia also includes the terms streptococcal
pneumonia and lobar pneumonia.
|
|
|
Infusion reaction*
|
48
|
3
|
0
|
|
|
General disorders and administration site conditions
|
|
|
Fatigue
|
39
|
2
|
0
|
|
|
Pyrexia
|
21
|
1
|
0
|
|
|
Chills
|
10
|
0
|
0
|
|
|
Respiratory, thoracic and mediastinal disorders
|
|
|
Cough
|
21
|
0
|
0
|
|
|
Nasal congestion
|
17
|
0
|
0
|
|
|
Dyspnea
|
15
|
1
|
0
|
|
|
Musculoskeletal and connective tissue disorders
|
|
|
Back pain
|
23
|
2
|
0
|
|
|
Arthralgia
|
17
|
0
|
0
|
|
|
Pain in extremity
|
15
|
1
|
0
|
|
|
Musculoskeletal chest pain
|
12
|
1
|
0
|
|
|
Infections and infestations
|
|
|
Upper respiratory tract infection
|
20
|
1
|
0
|
|
|
Nasopharyngitis
|
15
|
0
|
0
|
|
|
Pneumonia†
|
11
|
6
|
0
|
|
|
Gastrointestinal disorders
|
|
|
Nausea
|
27
|
0
|
0
|
|
|
Diarrhea
|
16
|
1
|
0
|
|
|
Constipation
|
15
|
0
|
0
|
|
|
Vomiting
|
14
|
0
|
0
|
|
|
Metabolism and nutrition disorders
|
|
|
Decreased appetite
|
15
|
1
|
0
|
|
|
Nervous system disorders
|
|
|
Headache
|
12
|
1
|
0
|
|
|
Vascular disorders
|
|
|
Hypertension
|
10
|
5
|
0
|
|
|
Table 11: Treatment emergent Grade 3–4 laboratory
abnormalities (≥10%)
|
|
|
|
Daratumumab 16 mg/kg (N=156)
|
|
|
All Grade (%)
|
Grade 3 (%)
|
Grade 4 (%)
|
|
|
Anemia
|
45
|
19
|
0
|
|
|
Thrombocytopenia
|
48
|
10
|
8
|
|
|
Neutropenia
|
60
|
17
|
3
|
|
|
Lymphopenia
|
72
|
30
|
10
|
|
|
|
|
|
|
|
|
|
Infusion Reactions
In clinical trials (monotherapy and
combination treatments; N=820) the incidence of any grade infusion reactions
was 46% with the first infusion of Darzalex, 2% with the second infusion, and
3% with subsequent infusions. Less than 1% of patients had a Grade 3 infusion
reaction with second or subsequent infusions.
The median time to onset of a reaction
was 1.4 hours (range: 0.02 to 72.8 hours). The incidence of infusion
modification due to reactions was 42%. Median durations of infusion for the 1st,
2nd and subsequent infusions were 7.0, 4.3, and 3.5 hours respectively.
Severe (Grade 3) infusion reactions
included bronchospasm, dyspnea, laryngeal edema, pulmonary edema, hypoxia, and
hypertension. Other adverse infusion reactions (any Grade, ≥5%) were nasal
congestion, cough, chills, throat irritation, vomiting and nausea.
Herpes Zoster Virus Reactivation
Prophylaxis for Herpes Zoster Virus
reactivation was recommended for patients in some clinical trials of Darzalex.
In monotherapy studies, herpes zoster was reported in 3% of patients. In the
randomized controlled combination therapy studies, herpes zoster was reported
in 2% each in the DRd and Rd groups respectively (Study 3), in 5% versus 3% in
the DVd and Vd groups respectively (Study 4) and in 2% of patients receiving
DPd (Study 5).
Infections
In patients receiving Darzalex
combination therapy, Grade 3 or 4 infections were reported with Darzalex
combinations and background therapies (DVd: 21%, Vd: 19%; DRd: 28%, Rd: 23%;
DPd: 28%). Pneumonia was the most commonly reported severe (Grade 3 or 4)
infection across studies. Discontinuations from treatment were reported in 3%
versus 2% of patients in the DRd and Rd groups respectively, 4% versus 3% of
patients in the DVd and Vd groups respectively and in 5% of patients receiving
DPd. Fatal infections were reported in 0.8% to 2% of patients across studies,
primarily due to pneumonia and sepsis.
Immunogenicity
As with all therapeutic proteins, there
is the potential for immunogenicity. In clinical trials of patients with
multiple myeloma treated with Darzalex as monotherapy or as combination
therapies, none of the 111 evaluable monotherapy patients, and 2 (0.7%) of the
298 combination therapy patients, tested positive for anti-daratumumab
antibodies. One patient administered Darzalex as combination therapy, developed
transient neutralizing antibodies against daratumumab. However, this assay has
limitations in detecting anti-daratumumab antibodies in the presence of high
concentrations of daratumumab; therefore, the incidence of antibody development
might not have been reliably determined.
Immunogenicity data are highly dependent
on the sensitivity and specificity of the test methods used. Additionally, the
observed incidence of a positive result in a test method may be influenced by
several factors, including sample handling, timing of sample collection, drug
interference, concomitant medication and the underlying disease. Therefore,
comparison of the incidence of antibodies to daratumumab with the incidence of
antibodies to other products may be misleading.
Drug InteractionsEffects of Daratumumab
on Laboratory Tests
Interference with Indirect Antiglobulin
Tests (Indirect Coombs Test)
Daratumumab binds to CD38 on RBCs and
interferes with compatibility testing, including antibody screening and cross
matching. Daratumumab interference mitigation methods include treating reagent
RBCs with dithiothreitol (DTT) to disrupt daratumumab binding1 [see References (15)] or
genotyping. Since the Kell blood group system is also sensitive to DTT
treatment, K-negative units should be supplied after ruling out or identifying
alloantibodies using DTT-treated RBCs.
If an emergency transfusion is required,
non-cross-matched ABO/RhD-compatible RBCs can be given per local blood bank
practices.
Interference with Serum Protein
Electrophoresis and Immunofixation Tests
Daratumumab may be detected on serum
protein electrophoresis (SPE) and immunofixation (IFE) assays used for monitoring disease
monoclonal immunoglobulins (M protein). This can lead to false positive SPE andIFEassay
results for patients with IgG kappa myeloma protein impacting initial
assessment of complete responses by International Myeloma Working Group (IMWG)
criteria. In patients with persistent very good partial response, consider
other methods to evaluate the depth of response.
USE IN SPECIFIC POPULATIONSPregnancy
Risk Summary
There are no human data to inform a risk
with use of Darzalex during pregnancy. Animal studies have not been conducted.
However, there are clinical considerations [see Clinical
Considerations]. The estimated background risk of major birth
defects and miscarriage for the indicated population is unknown. In theU.S.general
population, the estimated background risk of major birth defects and
miscarriage in clinically recognized pregnancies is 2–4% and 15–20%,
respectively.
Clinical Considerations
Fetal/Neonatal Adverse Reactions
Immunoglobulin G1 (IgG1) monoclonal
antibodies are transferred across the placenta. Based on its mechanism of
action, Darzalex may cause fetal myeloid or lymphoid-cell depletion and
decreased bone density. Defer administering live vaccines to neonates and
infants exposed to Darzalex in utero until a hematology evaluation is
completed.
Data
Animal Data
Mice that were genetically modified to
eliminate all CD38 expression (CD38 knockout mice) had reduced bone density at
birth that recovered by 5 months of age. In cynomolgus monkeys exposed during
pregnancy to other monoclonal antibodies that affect leukocyte populations,
infant monkeys had a reversible reduction in leukocytes.
Lactation
Risk Summary
There is no information regarding the
presence of daratumumab in human milk, the effects on the breastfed infant, or
the effects on milk production. Human IgG is known to be present in human milk.
Published data suggest that antibodies in breast milk do not enter the neonatal
and infant circulations in substantial amounts.
The developmental and health benefits of
breast-feeding should be considered along with the mother's clinical need for
Darzalex and any potential adverse effects on the breast-fed child from
Darzalex or from the underlying maternal condition.
Females and Males of Reproductive
Potential
Contraception
To avoid exposure to the fetus, women of
reproductive potential should use effective contraception during treatment and
for 3 months after cessation of Darzalex treatment.
Pediatric Use
Safety and effectiveness of Darzalex in
pediatric patients have not been established.
Geriatric Use
Of the 156 patients that received
Darzalex monotherapy at the recommended dose, 45% were 65 years of age or
older, and 10% were 75 years of age or older. Of 664 patients that received
Darzalex with various combination therapies, 41% were 65 to 75 years of age,
and 9% were 75 years of age or older. No overall differences in safety or
effectiveness were observed between these patients and younger
patients [see Clinical Studies (14)].
Overdosage
The dose of Darzalex at which severe
toxicity occurs is not known.
In the event of an overdose, monitor
patients for any signs or symptoms of adverse effects and provide appropriate
supportive treatment.
Darzalex Description
Daratumumab is an immunoglobulin G1
kappa (IgG1κ) human monoclonal antibody against CD38 antigen, produced in a
mammalian cell line (Chinese Hamster Ovary [CHO]) using recombinant DNA
technology. The molecular weight of daratumumab is approximately 148 kDa.
Darzalex is supplied as a colorless to
pale yellow preservative-free solution for intravenous infusion in single-dose
vials. The pH is 5.5. Darzalex must be diluted with 0.9% Sodium Chloride Injection,
USP [see Dosage and Administration (2.4)].
Each Darzalex single-dose 20 mL vial
contains 400 mg daratumumab, glacial acetic acid (3.7 mg), mannitol (510 mg),
polysorbate 20 (8 mg), sodium acetate trihydrate (59.3 mg), sodium chloride
(70.1 mg), and water for injection.
Each Darzalex single-dose 5 mL vial
contains 100 mg daratumumab, glacial acetic acid (0.9 mg), mannitol (127.5 mg),
polysorbate 20 (2 mg), sodium acetate trihydrate (14.8 mg), sodium chloride
(17.5 mg), and water for injection.
Darzalex - Clinical
PharmacologyMechanism of Action
CD38 is a transmembrane glycoprotein (48
kDa) expressed on the surface of hematopoietic cells, including multiple
myeloma and other cell types and tissues and has multiple functions, such as
receptor mediated adhesion, signaling, and modulation of cyclase and hydrolase
activity. Daratumumab is an IgG1κ human monoclonal antibody (mAb) that binds to
CD38 and inhibits the growth of CD38 expressing tumor cells by inducing
apoptosis directly through Fc mediated cross linking as well as by
immune-mediated tumor cell lysis through complement dependent cytotoxicity
(CDC), antibody dependent cell mediated cytotoxicity (ADCC) and antibody
dependent cellular phagocytosis (ADCP). A subset of myeloid derived suppressor
cells (CD38+MDSCs), regulatory T cells (CD38+Tregs) and B cells (CD38+Bregs)
are decreased by daratumumab.
Pharmacodynamics
NK cells express CD38 and are
susceptible to daratumumab mediated cell lysis. Decreases in absolute counts
and percentages of total NK cells (CD16+CD56+) and activated (CD16+CD56dim) NK
cells in peripheral whole blood and bone marrow were observed with Darzalex
treatment.
Cardiac Electrophysiology
Darzalex as a large protein has a low
likelihood of direct ion channel interactions. There is no evidence from
non-clinical or clinical data to suggest that Darzalex has the potential to
delay ventricular repolarization.
Pharmacokinetics
Over the dose range from 1 to 24 mg/kg
as monotherapy or 1 to 16 mg/kg of Darzalex in combination with other
treatments, increases in area under the concentration-time curve (AUC) were
more than dose-proportional.
Following the recommended dose of 16
mg/kg when Darzalex was administered as monotherapy or in combination therapy,
the mean serum maximal concentration (Cmax) value at the end of weekly dosing,
was approximately 2.7 to 3-fold higher compared to the mean serum
Cmax following the first dose. The mean ± standard deviation (SD) trough
serum concentration (Cmin) at the end of weekly dosing was 573 ± 332 µg/mL when
Darzalex was administered as monotherapy and 502 ± 196 to 607 ± 231 µg/mL when
Darzalex was administered as combination therapy. Daratumumab steady state was
achieved approximately 5 months into the every 4-week dosing period (by the
21st infusion), and the mean ± SD ratio of Cmax at steady-state to
Cmax after the first dose was 1.6 ± 0.5.
Distribution
At the recommended dose of 16 mg/kg, the
mean ± SD central volume of distribution was 4.7 ± 1.3 L when Darzalex was
administered as monotherapy and 4.4 ± 1.5 L when Darzalex was administered as
combination therapy.
Elimination
Daratumumab clearance decreased with
increasing dose and with multiple dosing. At the recommended dose of 16 mg/kg
of Darzalex as monotherapy, the mean ± SD linear clearance was estimated to be
171.4 ± 95.3 mL/day. The mean ± SD estimated terminal half-life associated with
linear clearance was 18 ± 9 days when Darzalex administered as monotherapy and
23 ± 12 days when Darzalex was administered as combination therapy.
Specific Populations
The following population characteristics
have no clinically meaningful effect on the pharmacokinetics of daratumumab in
patients administered Darzalex as monotherapy or as combination therapy: sex,
age (31 to 84 years), mild [total bilirubin 1 to 1.5 times upper limit of
normal (ULN) and any alanine transaminase (ALT)] and moderate (total bilirubin
1.5 to 3 times ULN and any ALT) hepatic impairment, or renal impairment
[Creatinine clearance (CLcr) 15 –89 mL/min]. The effect of severe (total
bilirubin >3 times ULN and any ALT) hepatic impairment is unknown.
Increasing body weight increased the central volume of distribution and
clearance of daratumumab, supporting the body weight-based dosing regimen.
Drug Interactions
Effect of Other Drugs on Daratumumab
The coadministration of lenalidomide,
pomalidomide or bortezomib with Darzalex did not affect the pharmacokinetics of
daratumumab.
Effect of Daratumumab on Other Drugs
The coadministration of Darzalex with
bortezomib did not affect the pharmacokinetics of bortezomib.
Nonclinical ToxicologyCarcinogenesis,
Mutagenesis, Impairment of Fertility
No carcinogenicity or genotoxicity
studies have been conducted with daratumumab. No animal studies have been
performed to evaluate the potential effects of daratumumab on reproduction or
development, or to determine potential effects on fertility in males or
females.
Clinical StudiesCombination Treatment
with Lenalidomide and Dexamethasone
Study 3, an open-label, randomized,
active-controlled Phase 3 trial, compared treatment with Darzalex 16 mg/kg in
combination with lenalidomide and low-dose dexamethasone (DRd) to treatment
with lenalidomide and low-dose dexamethasone (Rd) in patients with multiple
myeloma who had received at least one prior therapy. Lenalidomide (25 mg once
daily orally on Days 1–21 of repeated 28-day [4-week] cycles) was given with
low dose oral or intravenous dexamethasone 40 mg/week (or a reduced dose of 20
mg/week for patients >75 years or body mass index [BMI] <18.5). On
Darzalex infusion days, 20 mg of the dexamethasone dose was given as a
pre-infusion medication and the remainder given the day after the infusion. For
patients on a reduced dexamethasone dose, the entire 20 mg dose was given as a
Darzalex pre-infusion medication. Dose adjustments for lenalidomide and
dexamethasone were applied according to manufacturer's prescribing information.
Treatment was continued in both arms until disease progression or unacceptable
toxicity.
A total of 569 patients were randomized;
286 to the DRd arm and 283 to the Rd arm. The baseline demographic and disease
characteristics were similar between the Darzalex and the control arm. The
median patient age was 65 years (range 34 to 89 years), 11% were ≥75 years, 59%
were male; 69% Caucasian, 18% Asian, and 3% African American. Patients had
received a median of 1 prior line of therapy. Sixty-three percent (63%) of
patients had received prior autologous stem cell transplantation (ASCT). The
majority of patients (86%) received a prior PI, 55% of patients had received a
prior immunomodulatory agent, including 18% of patients who had received prior
lenalidomide; and 44% of patients had received both a prior PI and
immunomodulatory agent. At baseline, 27% of patients were refractory to the
last line of treatment. Eighteen percent (18%) of patients were refractory to a
PI only, and 21% were refractory to bortezomib. Efficacy was evaluated by
progression free survival (PFS) based on International Myeloma Working Group
(IMWG) criteria.
Study 3 demonstrated an improvement in
PFS in the DRd arm as compared to the Rd arm; the median PFS had not been
reached in the DRd arm and was 18.4 months in the Rd arm (hazard ratio
[HR]=0.37; 95% CI: 0.27, 0.52; p<0.0001), representing 63% reduction in the
risk of disease progression or death in patients treated with DRd.
Figure 1: Kaplan-Meier Curve of PFS in
Study 3
Additional efficacy results from Study 3
are presented in Table 12 below.
|
Table 12: Additional efficacy results from Study 3*
|
|
|
DRd (n=286)
|
Rd (n=283)
|
|
DRd = daratumumab- lenalidomide-dexamethasone; Rd =
lenalidomide-dexamethasone
|
|
*
Based on Intent-to-treat population
†
p-value from Cochran Mantel-Haenszel Chi-Squared test.
|
|
Overall response (sCR+CR+VGPR+PR)
|
261 (91.3%)
|
211 (74.6%)
|
|
p-value†
|
<0.0001
|
|
|
Stringent complete response (sCR)
|
51 (17.8%)
|
20 (7.1%)
|
|
Complete response (CR)
|
70 (24.5%)
|
33 (11.7%)
|
|
Very good partial response (VGPR)
|
92 (32.2%)
|
69 (24.4%)
|
|
Partial response (PR)
|
48 (16.8%)
|
89 (31.4%)
|
In responders, the median time to
response was 1 month (range: 0.9 to 13 months) in the DRd group and 1.1 months
(range: 0.9 to 10 months) in the Rd group. The median duration of response had
not been reached in the DRd group (range: 1+ to 19.8+ months) and was 17.4
months (range: 1.4 to 18.5+ months) in the Rd group.
With a median follow-up of 13.5 months,
75 deaths were observed; 30 in the DRd group and 45 in the Rd group.
Combination Treatment with Bortezomib
and Dexamethasone
Study 4, an open-label, randomized,
active-controlled Phase 3 trial, compared treatment with Darzalex 16 mg/kg in
combination with bortezomib and dexamethasone (DVd), to treatment with
bortezomib and dexamethasone (Vd). Bortezomib was administered by SC injection
or IV infusion at a dose of 1.3 mg/m2 body surface area twice weekly for
two weeks (Days 1, 4, 8, and 11) of repeated 21 day (3-week) treatment cycles,
for a total of 8 cycles. Dexamethasone was administered orally at a dose of 20
mg on Days 1, 2, 4, 5, 8, 9, 11, and 12 of each of the 8 bortezomib cycles (80
mg/week for two out of three weeks of the bortezomib cycle) or a reduced dose
of 20 mg/week for patients >75 years, BMI <18.5, poorly controlled
diabetes mellitus or prior intolerance to steroid therapy. On the days of
Darzalex infusion, 20 mg of the dexamethasone dose was administered as a
pre-infusion medication. For patients on a reduced dexamethasone dose, the
entire 20 mg dose was given as a Darzalex pre-infusion medication. Bortezomib
and dexamethasone were given for 8 three-week cycles in both treatment arms;
whereas Darzalex was given until disease progression. However, dexamethasone 20
mg was continued as a Darzalex pre-infusion medication in the DVd arm. Dose
adjustments for bortezomib and dexamethasone were applied according to
manufacturer's prescribing information.
A total of 498 patients were randomized;
251 to the DVd arm and 247 to the Vd arm. The baseline demographic and disease
characteristics were similar between the Darzalex and the control arm. The
median patient age was 64 years (range 30 to 88 years); 12% were ≥75 years, 57%
were male; 87% Caucasian, 5% Asian and 4% African American. Patients had
received a median of 2 prior lines of therapy and 61% of patients had received
prior autologous stem cell transplantation (ASCT). Sixty-nine percent (69%) of
patients had received a prior PI (66% received bortezomib) and 76% of patients
received an immunomodulatory agent (42% received lenalidomide). At baseline,
32% of patients were refractory to the last line of treatment and the
proportions of patients refractory to any specific prior therapy were in
general well balanced between the treatment groups. Thirty-three percent (33%)
of patients were refractory to an immunomodulatory agent only, with 24%
patients in the DVd arm and 33% of patients in the Vd arm respectively
refractory to lenalidomide. Efficacy was evaluated by progression free survival
(PFS) based on International Myeloma Working Group (IMWG) criteria.
Study 4 demonstrated an improvement in
PFS in the DVd arm as compared to the Vd arm; the median PFS had not been
reached in the DVd arm and was 7.2 months in the Vd arm (HR [95% CI]: 0.39
[0.28, 0.53]; p-value < 0.0001), representing a 61% reduction in the risk of
disease progression or death for patients treated with DVd versus Vd.
Figure 2: Kaplan-Meier Curve of PFS in
Study 4
Additional efficacy results from Study 4
are presented in Table 13 below.
|
Table 13: Additional efficacy results from Study 4*
|
|
|
DVd (n=251)
|
Vd (n=247)
|
|
DVd = daratumumab- bortezomib-dexamethasone; Vd =
bortezomib-dexamethasone
|
|
*
Based on Intent-to-treat population
†
p-value from Cochran Mantel-Haenszel Chi-Squared test.
|
|
Overall response (sCR+CR+VGPR+PR)
|
199 (79.3%)
|
148 (59.9%)
|
|
P-value†
|
<0.0001
|
|
|
Stringent complete response (sCR)
|
11 (4.4%)
|
5 (2.0%)
|
|
Complete response (CR)
|
35 (13.9%)
|
16 (6.5%)
|
|
Very good partial response (VGPR)
|
96 (38.2%)
|
47 (19.0%)
|
|
Partial response (PR)
|
57 (22.7%)
|
80 (32.4%)
|
In responders, the median time to
response was 0.8 months (range: 0.7 to 4 months) in the DVd group and 1.5
months (range: 0.7 to 5 months) in the Vd group. The median duration of
response had not been reached in the DVd group (range: 1.4+ to 14.1+ months)
and was 7.9 months (1.4+ to 12+ months) in the Vd group.
With a median follow-up of 7.4 months,
65 deaths were observed; 29 in the DVd group and 36 in the Vd group were
observed.
Combination Treatment with Pomalidomide
and Dexamethasone
Study 5 was an open-label trial in which
103 patients with multiple myeloma who had received a prior PI and an
immunomodulatory agent, received 16 mg/kg Darzalex in combination with
pomalidomide and low-dose dexamethasone until disease progression. Pomalidomide
(4 mg once daily orally on Days 1-21 of repeated 28-day [4-week] cycles) was
given with low dose oral or intravenous dexamethasone 40 mg/ week (reduced dose
of 20 mg/week for patients >75 years or body mass index [BMI] <18.5). On
Darzalex infusion days, 20 mg of the dexamethasone dose was given as a
pre-infusion medication and the remainder given the day after the infusion. For
patients on a reduced dexamethasone dose, the entire 20 mg dose was given as a
Darzalex pre-infusion medication.
The median patient age was 64 years
(range: 35 to 86 years) with 8% of patients ≥75 years of age. Patients in the
study had received a median of 4 prior lines of therapy. Seventy-four percent
(74%) of patients had received prior ASCT. Ninety-eight percent (98%) of
patients received prior bortezomib treatment, and 33% of patients received
prior carfilzomib. All patients received prior lenalidomide treatment, with 98%
of patients previously treated with the combination of bortezomib and
lenalidomide. Eighty nine percent (89%) of patients were refractory to
lenalidomide and 71% refractory to bortezomib; 64% of patients were refractory
to bortezomib and lenalidomide.
Efficacy results were based on overall
response rate as determined by Independent Review Committee using IMWG criteria
(see Table 14).
|
Table 14: Efficacy results for Study 5
|
|
|
N=103
|
|
ORR = sCR+CR+VGPR+PR
CI=Confidence Interval
|
|
Overall response rate (ORR)
95% CI (%)
|
61 (59.2%)
(49.1, 68.8)
|
|
Stringent complete response (sCR)
|
8 (7.8%)
|
|
Complete response (CR)
|
6 (5.8%)
|
|
Very good partial response (VGPR)
|
29 (28.2%)
|
|
Partial response (PR)
|
18 (17.5%)
|
The median time to response was 1 month
(range: 0.9 to 2.8 months). The median duration of response was 13.6 months
(range: 0.9+ to 14.6+ months).
Monotherapy
Study 1, was an open-label trial
evaluating Darzalex monotherapy in patients with relapsed or refractory
multiple myeloma who had received at least 3 prior lines of therapy including a
proteasome inhibitor and an immunomodulatory agent or who were
double-refractory to a proteasome inhibitor and an immunomodulatory agent. In
106 patients, Darzalex 16 mg/kg was administered with pre- and post-infusion
medication. Treatment continued until unacceptable toxicity or disease
progression.
The median patient age was 63.5 years
(range: 31 to 84 years), 49% were male and 79% were Caucasian. Patients had
received a median of 5 prior lines of therapy. Eighty percent of patients had
received prior autologous stem cell transplantation (ASCT). Prior therapies
included bortezomib (99%), lenalidomide (99%), pomalidomide (63%) and
carfilzomib (50%). At baseline, 97% of patients were refractory to the last
line of treatment, 95% were refractory to both, a proteasome inhibitor (PI) and
immunomodulatory agent, and 77% were refractory to alkylating agents.
Efficacy results were based on overall
response rate as determined by the Independent Review Committee assessment
using IMWG criteria (see Table 15).
|
Table 15: Efficacy results for Study 1
|
|
|
N=106
|
|
ORR = sCR+CR+VGPR+PR
CI = confidence interval
|
|
Overall response rate (ORR)
95% CI (%)
|
31 (29.2%)
(20.8, 38.9)
|
|
Stringent complete response (sCR)
|
3 (2.8%)
|
|
Complete response (CR)
|
0
|
|
Very good partial response (VGPR)
|
10 (9.4%)
|
|
Partial response (PR)
|
18 (17.0%)
|
The median time to response was 1 month
(range: 0.9 to 5.6 months). The median duration of response was 7.4 months
(range: 1.2 to 13.1+ months).
Study 2 was an open-label dose
escalation trial evaluating Darzalex monotherapy in patients with relapsed or
refractory multiple myeloma who had received at least 2 different cytoreductive
therapies. In 42 patients, Darzalex 16 mg/kg was administered with pre- and
post-infusion medication. Treatment continued until unacceptable toxicity or
disease progression.
The median patient age was 64 years
(range: 44 to 76 years), 64% were male and 76% were Caucasian. Patients in the
study had received a median of 4 prior lines of therapy. Seventy-four percent
of patients had received prior ASCT. Prior therapies included bortezomib
(100%), lenalidomide (95%), pomalidomide (36%) and carfilzomib (19%). At
baseline, 76% of patients were refractory to the last line of treatment, 64% of
patients were refractory to both, a PI and an immunomodulatory agent, and 60%
of patients were refractory to alkylating agents.
Overall response rate was 36% (95% CI:
21.6, 52.0%) with 1 CR and 3 VGPR. The median time to response was 1 month
(range: 0.5 to 3.2 months). The median duration of response was not estimable
(range: 2.2 to 13.1+ months).
REFERENCES
1. Chapuy, CI, RT
Nicholson, MD Aguad, et al., 2015, Resolving the daratumumab interference with
blood compatibility testing, Transfusion, 55:1545–1554 (accessible at
http://onlinelibrary.wiley.com/doi/10.1111/trf.13069/epdf).
How Supplied/Storage and HandlingHow
Supplied
Darzalex is a colorless to pale yellow,
preservative-free solution for intravenous infusion supplied as:
NDC 57894-502-05 contains one 100 mg/5
mL single-dose vial
NDC 57894-502-20 contains one 400 mg/20
mL single-dose vial
Storage and Stability
Store in a refrigerator at 2ºC to 8ºC
(36ºF to 46ºF).
Do not freeze or shake. Protect from
light. This product contains no preservative.
Patient Counseling Information
Advise the patient to read the
FDA-approved patient labeling (Patient Information).
Infusion Reactions
Advise patients to seek immediate
medical attention for any of the following signs and symptoms of infusion
reactions:
·
itchy, runny or blocked nose; chills, nausea, throat irritation, cough,
headache, shortness of breath or difficulty breathing [see Warnings and
Precautions (5.1) and Adverse
Reactions (6.1)].
Neutropenia
·
Advise patients that if they have a fever, they should contact their healthcare
professional [see Warnings and
Precautions (5.3) and Adverse
Reactions (6.1)].
Thrombocytopenia
·
Advise patients to inform their healthcare professional if they notice signs of
bruising or bleeding [see Warnings and
Precautions (5.4) and Adverse
Reactions (6.1)].
Interference with Laboratory Tests
Advise patients to inform healthcare
providers including blood transfusion centers/personnel that they are taking
Darzalex, in the event of a planned transfusion [see Warnings and
Precautions (5.2) and Drug
Interactions (7.1)].
Advise patients that Darzalex can affect
the results of some tests used to determine complete response in some patients
and additional tests may be needed to evaluate response [see Warnings and
Precautions (5.5) and Drug
Interactions (7.1)].
Manufactured by:
Janssen Biotech, Inc.
Horsham,PA19044
U.S.License
Number 1864
© Janssen Biotech, Inc., 2015
|
PATIENT INFORMATION
Darzalex® (Dar'-zah-lex)
(daratumumab)
injection, for intravenous use
|
|
This Patient Information has been approved by the U.S.
Food and Drug Administration.
|
Revised: June/2017
|
|
What is Darzalex?
Darzalex is a prescription medicine used to treat
multiple myeloma:
· In combination with the medicines lenalidomide and
dexamethasone, or bortezomib and dexamethasone, in people who have
received at least one prior medicine to treat multiple myeloma.
· In combination with the medicines pomalidomide and dexamethasone
in people who have received at least two prior medicines to treat multiple
myeloma, including lenalidomide and a proteasome inhibitor.
· Alone in people who have received at least three prior
medicines to treat multiple myeloma, including a proteasome inhibitor and an
immunomodulatory agent, or did not respond to a proteasome
inhibitor and an immunomodulatory agent.
It is not known if Darzalex is safe and effective in
children.
|
|
Before you receive Darzalex, tell your healthcare
provider about all of your medical conditions, including if you:
· have a history of breathing problems
· have had shingles (herpes zoster)
· are pregnant or plan to become pregnant. Darzalex may
harm your unborn baby.
Females who are able to become pregnant should use an
effective method of birth control during treatment and for at least 3 months
after your final dose of Darzalex. Talk to your healthcare provider about
birth control methods that you can use during this time.
· are breastfeeding or plan to breastfeed. It is not
known if Darzalex passes into your breast milk.
Tell your healthcare provider about all the medicines
you take, including prescription and
over-the-counter medicines, vitamins, and herbal supplements.
|
|
How will I receive Darzalex?
· Darzalex may be given alone or together with other
medicines used to treat multiple myeloma.
· Darzalex will be given to you by intravenous (IV)
infusion into your vein.
· Your healthcare provider will decide the time between
doses as well as how many treatments you will receive.
· Your healthcare provider will give you medicines before
each dose of Darzalex and on the first day after each dose of Darzalex to
help reduce the risk of infusion reactions.
· If you miss any appointments, call your healthcare
provider as soon as possible to reschedule your appointment.
|
|
What are the possible side effects of Darzalex?
Darzalex may cause serious reactions, including:
· Infusion reactions. Infusion reactions are common
with Darzalex and can be severe. Your healthcare provider may
temporarily stop your infusion or completely stop treatment with Darzalex if
you have infusion reactions. Tell your healthcare provider right away if you
get any of the following symptoms:
|
|
|
· shortness of breath or trouble breathing
· dizziness or lightheadedness (hypotension)
· cough
· wheezing
|
· throat tightness
· runny or stuffy nose
· headache
· itching
|
· nausea
· vomiting
· chills
· fever
|
|
· Changes in blood tests. Darzalex can affect the
results of blood tests to match your blood type. These changes can last for
up to 6 months after your final dose of Darzalex. Your healthcare provider
will do blood tests to match your blood type before you start treatment with
Darzalex. Tell all of your healthcare providers that you are being
treated with Darzalex before receiving blood transfusions.
· Decreases in blood cell counts. Darzalex can
decrease white blood cell counts which help fight infections and blood cells
called platelets which help to clot blood. Tell your healthcare provider if
you develop fever or have signs of bruising or bleeding.
The most common side effects of Darzalex include:
|
|
· tiredness
· nausea
· diarrhea
· shortness of breath
|
· fever
· cough
· muscle spasms
· back pain
|
· cold-like symptoms (upper respiratory infection)
· nerve damage causing tingling, numbness or pain
· swollen hands ankles or feet
|
|
Tell your healthcare provider if you have any side
effect that bothers you or that does not go away.
These are not all the possible side effects of
Darzalex. Call your doctor for medical advice about side effects. You may
report side effects to FDA at 1-800-FDA-1088.
|
|
General information about the safe and effective use of
Darzalex
Medicines are sometimes prescribed for purposes other
than those listed in a Patient Information leaflet. You can ask your
healthcare provider or pharmacist for information about Darzalex that is
written for health professionals.
|
|
What are the ingredients in Darzalex?
Active ingredient: daratumumab
Inactive ingredients: glacial
acetic acid, mannitol, polysorbate 20, sodium acetate trihydrate, sodium
chloride, and water for injection
Manufactured by: Janssen Biotech, Inc.,Horsham,PA19044U.S.License Number 1864
For more information, call 1-800-526-7736 or go to
www.Darzalex.com.
|
PRINCIPAL DISPLAY PANEL - 100 mg/5 mL
Vial Carton
NDC 57894-502-05
Rx only
Darzalex®
(daratumumab)
Injection
100 mg/5 mL
(20 mg/mL)
For Intravenous Infusion Only
Dilute Before Use
Single-Dose Only. Discard Unused
Portion
janssen
