2.1 Dose

The total recommended dose of AUCATZYL is 410 × 106 CD19 chimeric antigen receptor (CAR)-positive viable T cells supplied in three to five infusion bags. Bags are supplied in three color-coded bag configurations (10 × 106, 100 × 106, 300 × 106) for split dose administration.

The treatment regimen consists of a split dose infusion to be administered on Day 1 and Day 10 (± 2 days), see Figure 1 and Figure 3.

• The dosage regimen will be determined by the tumor burden assessed by bone marrow blast percentage from a sample obtained within 7 days prior to the start of lymphodepletion [see Dosing and Administration (2.3,2.4), Figure 1 and Figure 3].
• See the Release for Infusion certificate and Dose Schedule Planner for the actual cell counts and volumes to be infused and to select the appropriate dosage regimen [see Dosage and Administration (2.4,2.4) and Dosage Forms and Strengths (3)].

2.2 Dosage Modification for Adverse Reactions

2.3 Administration

AUCATZYL is for autologous use only. The patient's identity must match the patient identifiers on the AUCATZYL infusion bag. Do not infuse AUCATZYL if the information on the patient-specific label does not match the intended patient.

Preparing the Patient for AUCATZYL Infusion

Bone marrow assessment

• A bone marrow assessment must be available from a sample obtained within 7 days prior to the commencement of the lymphodepleting chemotherapy treatment, see Figure 1.

Figure 1: AUCATZYL Treatment Schedule

• The bone marrow assessment will be used to determine the AUCATZYL dosage regimen based on a Bone Marrow Blast of > 20% or ≤ 20%, see Figure 3.
  • If the bone marrow assessment results are inconclusive:

    -

    Repeat biopsy or aspirate, NOTE a repeat biopsy or aspirate is only possible if lymphodepleting chemotherapy treatment has not started.

    -

    If results remain inconclusive, proceed with the Bone Marrow Blast of > 20% (i.e., administration of the 10 × 106 dose on Day 1) per the AUCATZYL Dose Schedule Planner.

Pretreatment

• Confirm availability of AUCATZYL prior to starting the lymphodepleting chemotherapy treatment.
• Administer the lymphodepleting chemotherapy regimen before infusion of AUCATZYL: fludarabine (FLU) 30 mg/m2/day intravenously (IV) for four days and cyclophosphamide (CY) 500 mg/m2/day IV for two days starting with the first dose of fludarabine. (total dose: FLU 120 mg/m2; CY 1000 mg/m2), see Figure 1. Infuse AUCATZYL 3 days (± 1 days) after completion of lymphodepleting chemotherapy treatment (Day 1), allowing a minimum 48-hour washout.
• Delay AUCATZYL treatment if the patient is experiencing severe intercurrent infection. If the patient requires supplementary oxygen AUCATZYL should only be infused if considered appropriate based on the treating physician's benefit/risk assessment.
  A delay to the second split dose may be required to manage toxicities [see Dosage Modification for Adverse Reactions (2.2) and Warnings and Precautions (5)].

Premedication

• To minimize the risk of an infusion reaction, premedicate with acetaminophen approximately 30 minutes prior to AUCATZYL infusion.
• Avoid prophylactic use of systemic corticosteroids as they may interfere with the activity of AUCATZYL.

Receipt and storage of AUCATZYL

• AUCATZYL is supplied directly to the cellular therapy laboratory associated with the infusion center in the vapor phase of a liquid nitrogen shipper [see How Supplied/Storage and Handling (16)].
  Confirm the patient's identity on the infusion bags with the patient identifiers on the shipper, see Figure 2.

Figure 2: Patient Specific Identifiers

• Keep the infusion bag(s) in the metal cassette(s) and transfer AUCATZYL to the onsite controlled-access vapor phase of liquid nitrogen for storage below minus 150°C until ready for thaw and administration.
  • Time out of the vapor phase liquid nitrogen environment should be kept to an absolute minimum to avoid premature product thaw (recommend not to exceed 90 seconds).

Planning prior to AUCATZYL preparation

• The patient batch specific Release for Infusion certificate and Dose Schedule Planner will be provided in the shipper and via Autolus's Scheduling Portal.
• Confirm the patient identifiers on the Release for Infusion certificate and infusion bags match, see Figure 2.

1. Ensure the patient's bone marrow assessment results are available.

   –

   NOTE: The patient's bone marrow assessment results will be used to select the appropriate dosing regimen based on a Bone Marrow Blast of > 20% or ≤ 20%, see Figure 3.

2. The AUCATZYL Dose Schedule Planner is provided with the Release for Infusion certificate and assists the determination of the appropriate dose regimen to be administered on Day 1 (3 days (±1 days) after the completion of lymphodepleting chemotherapy) and Day 10 (± 2 days). Record the following information on the Dose Schedule Planner:
   1. The blast percentage from the patient's bone marrow assessment.
   2. The AUCATZYL bag serial number(s); number of bag type required for each dose; and the specified volume to administer via syringe (for the 10 × 106 dose, Blue Bag) transcribed from the Release for Infusion certificate.
3. The completion of the AUCATZYL Dose Schedule Planner will guide the treating physician on the number of bags required and preparation of AUCATZYL for the Day 1 and Day 10 (± 2 days) dose, see Figure 3.

Dose Preparation

Do NOT irradiate. Do NOT use a leukodepleting filter.

• Confirm the patient's identity with the patient identifiers on the Release for Infusion certificate. Contact Autolus Inc at 1-855-288-5227 if there are any discrepancies between the labels and the patient identifiers.
• Confirm tocilizumab and emergency equipment are available prior to infusion and during the recovery period.
• Coordinate the timing of AUCATZYL thaw and infusion. Confirm the infusion time in advance and adjust the start time of AUCATZYL thaw such that it will be available for infusion when the patient is ready and will be infused within 60 minutes of thaw.
• Complete the AUCATZYL Dose Schedule Planner, as described above to identify the dose required for Day 1 and Day 10 (± 2 days) administration, see Figure 3.
• Follow the completed AUCATZYL Dose Schedule Planner and refer to the patient batch specific Release for Infusion certificate to verify the bag(s) required for Day 1 or Day 10 (± 2 days) dosing, see Figure 3.

Transfer and Thawing

• Using the completed Dose Schedule Planner for guidance, transfer ONLY the cassette(s)/ infusion bag(s) required for the given dosing day from the onsite vapor phase liquid nitrogen storage to an appropriate transfer vessel (i.e., a vapor phase liquid nitrogen shipper, maintaining a temperature below minus 150°C) for transport to the bag thaw location.
• Transfer the required cassette(s) one by one, confirming the AUCATZYL bag serial numbers and patient identifiers on each infusion bag label, see Figure 2.
• Time out of the vapor phase liquid nitrogen environment should be kept to an absolute minimum to avoid premature product thaw (recommend not to exceed 90 seconds).
• If more than one infusion bag is required on a given dosing day, thaw each infusion bag one at a time; Do NOT remove subsequent bags from the vapor phase liquid nitrogen storage (below minus 150°C) until the infusion of the previous bag is complete.
• AUCATZYL must be continuously monitored during thawing process.
• Leave the AUCATZYL infusion bag in its overwrap, thaw at 37°C using a water bath or dry thaw method until there are no visible frozen clumps left in the infusion bag. Each bag should be gently massaged until the cells have just thawed. Thawing of each infusion bag takes between 2 and 8 minutes. Remove from water bath or thaw device immediately after thawing is complete. Carefully remove the infusion bag from the overwrap taking care to avoid damage to the bag and ports.
• Gently mix the contents of the bag to disperse clumps of cellular material and administer immediately to the patient.
• Do not re-freeze or refrigerate thawed product.

Figure 3: AUCATZYL Dosage and Schedule

* Refer to Release for Infusion Certificate for the exact volume to be administered via syringe. Withdraw ONLY the volume † The 100 × 106 (Orange Bag) and 300 × 106 (Red Bag) doses will be suspended in one or more infusion bags.
Bone Marrow Blast > 20%
Day 1		Day 10 (± 2 days)
10 × 106 Dose administered via syringe*		100 × 106 Dose administered via bag infusion† and 300 × 106 Dose administered via bag infusion†
Bone Marrow Blast ≤ 20%
Day 1		Day 10 (± 2 days)
100 × 106 Dose administered via bag infusion†		10 × 106 Dose administered via syringe* and 300 × 106 Dose administered via bag infusion†

2.4 Infusion Instructions

AUCATZYL is for autologous and intravenous use only.

The patient's identity must match the patient identifiers on the Release for Infusion certificate and infusion bag. Contact Autolus Inc at 1-855-288-5227 if there are any discrepancies between the labels and the patient identifiers.

Dose administration for 10 × 106 CD19 CAR-positive viable T cell Dose (Blue Bag)

Withdrawal of the 10 × 106 dose into the syringe should be carried as follows:

• Prepare and administer AUCATZYL using aseptic technique.
• Gently mix the contents of the bag to disperse clumps of cellular material.
• The volume to be administered for the 10 × 106 dose (Blue Bag) is specified on the Release for Infusion certificate.
• Use the smallest Luer-lock tip syringe necessary (1, 3, 5, or 10 mL) with a Luer-lock bag spike to draw up the volume as specified on the Release for Infusion certificate.

  –

  Do NOT use a leukodepleting filter.

  –

  Do NOT use the syringe to mix the cells, see Figure 4.

Figure 4: Syringe Infusion Guidance for the 10 × 106 Dose (Blue Bag)

Withdraw the volume from the 10 × 106 Dose (Blue Bag) specified on the Release for Infusion certificate using a syringe fitted with a bag spike.	Do not use the syringe to mix the cells	Confirm withdrawal of the exact volume specified on the Release for Infusion certificate for the 10 × 106 Dose (Blue Bag).

• Prime the tubing with normal saline prior to infusion.
• Once AUCATZYL has been drawn into the syringe, verify the volume and administer as an intravenous infusion as soon as possible as a slow push (approximately 0.5mL/minute) through a central venous line (or large peripheral venous access line appropriate for blood products).
• Complete infusion at room temperature within 60 minutes post thaw and flush the tubing line with 60 mL of normal saline.
• Dispose of any unused portion of AUCATZYL (according to local biosafety guidelines).

5.1 Cytokine Release Syndrome

Cytokine Release Syndrome (CRS) occurred following treatment with AUCATZYL. CRS was reported in 75% (75/100) of patients including Grade 3 CRS in 3% of patients.

The median time to onset of CRS was 8 days (range: 1 to 23 days) with a median duration of 5 days (range: 1 to 21 days). Sixty-eight percent of patients (51/75) experienced CRS after the first infusion, but prior to the second infusion of AUCATZYL with a median time to onset of 6 days (range 1 to 10 days). Among patients with CRS, the most common manifestations of CRS included fever (100%), hypotension (35%) and hypoxia (19%) [see Adverse Reactions (6)].

The primary treatment for CRS was tocilizumab (73%; 55/75), with patients also receiving corticosteroids (21%; 16/75).

Prior to administering AUCATZYL, ensure that healthcare providers have immediate access to medications and resuscitative equipment to manage CRS. During and following treatment with AUCATZYL, closely monitor patients for signs and symptoms of CRS daily for at least 14 days at the healthcare facility following the first infusion. Continue to monitor patients for CRS for at least 4 weeks following each infusion with AUCATZYL [see Dosage and Administration (2.1)].

Counsel patients to seek immediate medical attention should signs or symptoms of CRS occur at any time. At the first sign of CRS, immediately evaluate the patient for hospitalization and institute treatment with supportive care based on severity and consider further management per current practice guidelines.

5.2 Neurologic Toxicities

Neurologic toxicities including Immune Effector Cell-associated Neurotoxicity Syndrome (ICANS), which were fatal or life-threatening, occurred following treatment with AUCATZYL. Neurologic toxicities were reported in 64% (64/100) of patients, including Grade ≥ 3 in 12% of patients.

The median time to onset of neurologic toxicities was 10 days (range: 1 to 246 days) with a median duration of 13 days (range: 1 to 904 days). Fifty-five percent of patients (35/64) experienced neurologic toxicities after the first infusion but prior to the second infusion of AUCATZYL with a median time to onset of 6 days (range: 1 to 11 days). Among patients with neurologic toxicities, the most common symptoms (> 5%) included ICANS (38%), headache (34%), encephalopathy (33%, dizziness (22%), tremor (13%), anxiety (9%), insomnia (9%), and delirium (8%) [see Adverse Reactions (6)].

5.3 Prolonged Cytopenias

Patients may exhibit cytopenias including anemia, neutropenia, and thrombocytopenia for several weeks after treatment with lymphodepleting chemotherapy and AUCATZYL. In patients who were responders to AUCATZYL, Grade ≥ 3 cytopenias that persisted beyond Day 30 following AUCATZYL infusion were observed in 71% (29/41) of patients and included neutropenia (66%, 27/41) and thrombocytopenia (54%, 22/41). Grade 3 or higher cytopenias that persisted beyond Day 60 following AUCATZYL infusion was observed in 27% (11/41) of patients and included neutropenia (17%, 7/41) and thrombocytopenia (15%, 6/41). [see Adverse Reactions (6)]. Monitor blood counts after AUCATZYL infusion.

5.4 Infections

Severe, including life-threatening and fatal infections occurred in patients after AUCATZYL infusion. Non-COVID-19 infections of all grades occurred in 67% (67/100) of patients. Grade 3 or higher non-COVID-19 infections occurred in 41% (41/100) of patients [see Adverse Reactions (6)].

AUCATZYL should not be administered to patients with clinically significant active systemic infections. Monitor patients for signs and symptoms of infection before and after AUCATZYL infusion and treat appropriately [see Dosage and Administration (2.2,2.3)]. Administer prophylactic antimicrobials according to local guidelines.

Grade 3 or higher febrile neutropenia was observed in 26% (26/100) of patients after AUCATZYL infusion and may be concurrent with CRS. In the event of febrile neutropenia, evaluate for infection and manage according to treatment guidelines as medically indicated.

Viral reactivation, potentially severe or life-threatening, can occur in patients treated with drugs directed against B cells. There is no experience with manufacturing AUCATZYL for patients with a positive test for human immunodeficiency virus (HIV) or with active hepatitis B virus (HBV) or active hepatitis C virus (HCV). Perform screening for HBV, HCV and HIV in accordance with clinical guidelines before collection of cells for manufacturing.

5.5 Hypogammaglobulinemia

Hypogammaglobulinemia and B-cell aplasia can occur in patients after treatment with AUCATZYL. Hypogammaglobulinemia was reported in 10% (10/100) of patients treated with AUCATZYL including Grade 3 events in 2 patients (2%) [see Adverse Reactions (6)].

Immunoglobulin levels should be monitored after treatment with AUCATZYL and managed per institutional guidelines including infection precautions, antibiotic or antiviral prophylaxis and immunoglobulin replacement.

The safety of immunization with live viral vaccines during or following treatment with AUCATZYL has not been studied. Vaccination with live viral vaccines is not recommended for at least 6 weeks prior to the start of lymphodepleting chemotherapy treatment, during AUCATZYL treatment, and until immune recovery following treatment AUCATZYL.

5.6 Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome

Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS), including fatal and life-threatening reactions occurred after treatment with AUCATZYL. HLH/MAS was reported in 2% (2/100) of patients and included Grade 3 and Grade 4 events with a time of onset at Day 22 and Day 41, respectively. One patient experienced a concurrent ICANS events after AUCATZYL infusion and died due to sepsis with ongoing HLH/MAS that had not resolved [see Adverse Reactions (6)].

Administer treatment for HLH/MAS according to institutional standards.

5.7 Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, may occur due to dimethyl sulfoxide (DMSO), an excipient used in AUCATZYL. Observe patients for hypersensitivity reactions during and after AUCATZYL infusion.

5.8 Secondary Malignancies

Patients treated with AUCATZYL may develop secondary malignancies. T cell malignancies have occurred following treatment of hematologic malignancies with BCMA- and CD19-directed genetically modified autologous T cell immunotherapies. Mature T cell malignancies, including CAR-positive tumors, may present as soon as weeks following infusion, and may include fatal outcomes [see Adverse Reactions (6.3)].

Monitor lifelong for secondary malignancies. In the event that a secondary malignancy occurs, contact Autolus Inc at 1-855-288-5227 for reporting and to obtain instructions on the collection of patient samples for testing.

6.1 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.

The safety of AUCATZYL was evaluated in the FELIX study in which 100 patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL) received AUCATZYL at a median dose of 410 × 106 CD19 CAR-positive viable T cells (range: 10 to 480 × 106 CD19 CAR-positive viable T cells with 90% of patients receiving the recommended dose of 410 × 106 +/- 25%). [see Clinical Studies (14)].

The most common serious adverse reactions of any Grade (incidence ≥ 2%) included infections-pathogen unspecified, febrile neutropenia, ICANS, CRS, fever, bacterial infectious disorders, encephalopathy, fungal infections, hemorrhage, respiratory failure, hypotension, ascites, HLH/MAS, thrombosis and hypoxia.

Nine patients (9%) experienced fatal adverse reactions which included infections (sepsis, pneumonia, peritonitis), ascites, pulmonary embolism, acute respiratory distress syndrome, HLH/MAS and ICANS. Of the 9 patients, five patients who died from infections had pre-existing and ongoing neutropenia prior to receiving bridging therapy, lymphodepletion chemotherapy treatment and/or AUCATZYL.

Table 3 summarizes the adverse reactions (excluding laboratory abnormalities) that occurred in at least 10% of patients. Table 4 presents the most common Grade 3 or 4 laboratory abnormalities, occurring in at least 10% of patients.

Other clinically important adverse reactions that occurred in less than 10% of patients treated with AUCATZYL include the following:

• Cardiac disorders: arrhythmia (5%), palpitations (2%), cardiac failure (1%).
• Endocrine disorders: adrenal insufficiency (2%).
• Eye disorders: visual impairment (2%).
• Gastrointestinal disorders: stomatitis (5%), ascites (4%).
• Immune system disorders: graft versus host disease (4%), HLH/MAS (2%).
• Injury, poisoning and procedural complications: infusion related reaction (2%).
• Nervous system and psychiatric disorders: tremor (8%), motor dysfunction (6%), delirium (5%), seizure (2%).
• Renal disorders: renal impairment (7%).
• Respiratory disorders: respiratory failure (8%), pleural effusion (4%).
• Skin and subcutaneous tissue disorders: skin ulcer (2%).
• Vascular disorders: thrombosis (5%).

6.2 Postmarketing Experience

Because adverse events to marketed products are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to product exposure. The following adverse event has been identified during postmarketing use of BCMA- or CD19-directed genetically modified autologous T cell immunotherapies:

Neoplasms: T cell malignancies.

8.1 Pregnancy

8.2 Lactation

8.3 Females and Males of Reproductive Potential

8.4 Pediatric Use

The safety and efficacy of AUCATZYL have not been established in pediatric patients.

8.5 Geriatric Use

Of the 100 patients treated with AUCATZYL, 20 (20%) were 65 years of age and over. No overall differences in safety or effectiveness were observed between these patients and younger patients.

12.1 Mechanism of Action

AUCATZYL is a CD19-directed genetically modified autologous T cell immunotherapy consisting of the patient's own T cells expressing an anti-CD19 CAR. Engagement of anti-CD19 CAR-positive T cells with CD19 expressed on target cells, such as cancer cells and normal B cells, leads to activation of the anti-CD19 CAR-positive T cells and downstream signaling through the CD3-zeta domain. Proliferation and persistence by the anti-CD19 CAR-positive T cells following activation are enhanced by the presence of the 4-1BB co-stimulatory domain. This binding to CD19 results in anti-tumor activity and killing of CD19-expressing target cells.

12.2 Pharmacodynamics

Serum levels of cytokines such as IL-2, IL-5, IL-6, IL-7, IL-8, IL-10, IL-15, TNF-α, IFN-γ, and granulocyte-macrophage colony-stimulating factors were evaluated pre- and post-AUCATZYL infusion, over 3 months. Peak elevation of plasma cytokines was observed within the first month after infusion and levels returned to baseline by Month 3.

Due to the on-target effect of AUCATZYL, a period of B cell aplasia is expected. B cell aplasia was observed in 93.1% of patients at 3 months and 80.0% at 6 months.

12.3 Pharmacokinetics

The pharmacokinetics (PK) of AUCATZYL were assessed in 90 patients with relapsed or refractory CD19+ B-ALL receiving a median dose of 410 × 106 CD19 CAR-positive viable T cells (range: 10 to 480 × 106 CD19 CAR-positive viable T cells).

Following Day 1 infusion, levels of the AUCATZYL transgene in peripheral blood exhibited an initial rapid expansion. The median time of maximal expansion to peak (Tmax) occurred at Day 14 (range: Day 2-55), demonstrated by a geometric mean peak CAR T concentration (Cmax) of 115,193 copies/µg genomic DNA (gDNA; range, 129-600,000) and a geometric mean area under the curve between Days 0 and 28 (AUC0-28d) of 1,147,631 day*copies/μg DNA (range 179,000-7,230,000 day*copies/μg DNA). A higher expansion was observed in patients with bone marrow blasts >20% compared to patients with bone marrow blast ≤ 20%.

No substantial differences in AUCATZYL expansion were observed between responding (CR/CRi) and non-responding (non- CR/CRi) patients. Furthermore, 75.9% (22/29) of patients who had ongoing remission had ongoing CAR T persistency at the last laboratory assessment, with a maximum observed persistency of 36.5 months.

Patients who received a first split dose of 10 × 106 cells (> 20% blast) demonstrated a higher expansion of CAR T cells (Cmax and AUC0-28d) compared to patients who received a first split dose of 100 × 106 cells (≤ 20% blast). Persistency was not impacted by tumor burden.

Patients who experience CRS had 1.8-fold higher mean bone marrow blast percentage and higher CAR T cell expansion (5.0-fold higher Cmax and 6.8-fold higher AUC0-28d [(geometric mean)]) compared to patients without CRS. Patients who experience ICANS had 1.8-fold higher mean bone marrow blast percentage and higher CAR T cell expansion (3.3-fold higher Cmax and 2.9-fold higher AUC0-28d (geometric mean)) compared to patients without ICANS.

12.4 Immunogenicity

The humoral immunogenicity of AUCATZYL was measured using an assay for the detection of anti-drug antibodies against AUCATZYL. In the FELIX study, 8.7% (11/127) of patients tested positive for anti-CD19 CAR antibodies pre-infusion. Treatment induced anti-CD19 CAR antibodies were detected in 1.6% (2/127) of patients.

The cellular immunogenicity of AUCATZYL was measured using an assay for the detection of T cell responses, measured by the production of interferon gamma (IFNγ) to the full length anti-CD19 CAR. Four percent (3/75) of patients tested positive in the cellular immunogenicity readout (IFNγ) post infusion.

There was no identified clinically significant effect of humoral and cellular immunogenicity on pharmacokinetics, pharmacodynamics, safety, or effectiveness of AUCATZYL.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

No in vivo or in vitro carcinogenicity, mutagenicity or genotoxicity studies have been conducted with AUCATZYL. No studies have been conducted to evaluate the effects of AUCATZYL on fertility.

• Match the identity of the patient with the patient identifiers on the infusion bag upon receipt [see Dosage and Administration (2.3)].
• Store AUCATZYL frozen in the vapor phase of liquid nitrogen (below minus 150ºC) [see Dosage and Administration (Section 2.3)].
• Thaw AUCATZYL prior to infusion [see Dosage and Administration (2.3)].
• Do not re-freeze after thawing.
• Do not irradiate AUCATZYL, as this could lead to inactivation.