Label: RYBREVANT- amivantamab injection
- NDC Code(s): 57894-501-00, 57894-501-01
- Packager: Janssen Biotech, Inc.
- Category: HUMAN PRESCRIPTION DRUG LABEL
- DEA Schedule: None
- Marketing Status: Biologic Licensing Application
Updated May 24, 2021
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HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use RYBREVANT™ safely and effectively. See full prescribing information for RYBREVANT.
RYBREVANT (amivantamab-vmjw) injection, for intravenous use
Initial U.S. Approval: 2021
INDICATIONS AND USAGE
RYBREVANT is a bispecific EGF receptor-directed and MET receptor-directed antibody indicated for the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations, as detected by an FDA-approved test, whose disease has progressed on or after platinum-based chemotherapy. (1, 2.1)
This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials. (1)
DOSAGE AND ADMINISTRATION
- The recommended dosage of RYBREVANT is based on baseline body weight and administered as an intravenous infusion after dilution. (2.2, 2.5, 2.6)
- Administer premedications as recommended. (2.3)
- Administer via a peripheral line on Week 1 and Week 2. (2.6)
- Administer RYBREVANT weekly for 4 weeks, with the initial dose as a split infusion in Week 1 on Day 1 and Day 2, then administer every 2 weeks thereafter. (2.2)
- Administer diluted RYBREVANT intravenously according to the infusion rates in Table 5. (2.5, 2.6)
Body Weight (at Baseline) Recommended Dose Less than 80 kg 1050 mg (3 vials) Greater than or equal to 80 kg 1400 mg (4 vials)
DOSAGE FORMS AND STRENGTHS
Injection: 350 mg/7 mL (50 mg/mL) solution in a single-dose vial (3)
WARNINGS AND PRECAUTIONS
- Infusion-Related Reactions (IRR): Interrupt infusion at the first sign of IRRs. Reduce infusion rate or permanently discontinue RYBREVANT based on severity. (2.4, 5.1)
- Interstitial Lung Disease (ILD)/Pneumonitis: Monitor for new or worsening symptoms indicative of ILD. Immediately withhold RYBREVANT in patients with suspected ILD/pneumonitis and permanently discontinue if ILD/pneumonitis is confirmed. (2.4, 5.2)
- Dermatologic Adverse Reactions: May cause rash including acneiform dermatitis and toxic epidermal necrolysis. Withhold, dose reduce or permanently discontinue RYBREVANT based on severity. (2.4, 5.3)
- Ocular Toxicity: Promptly refer patients with worsening eye symptoms to an ophthalmologist. Withhold, dose reduce or permanently discontinue RYBREVANT based on severity. (5.4)
- Embryo-Fetal Toxicity: Can cause fetal harm. Advise females of reproductive potential of the potential risk to the fetus and to use effective contraception. (5.5, 8.1, 8.3)
- The most common adverse reactions (≥ 20%) were rash, IRR, paronychia, musculoskeletal pain, dyspnea, nausea, fatigue, edema, stomatitis, cough, constipation, and vomiting. (6.1)
- The most common Grade 3 or 4 laboratory abnormalities (≥ 2%) were decreased lymphocytes, decreased albumin, decreased phosphate, decreased potassium, increased alkaline phosphatase, increased glucose, increased gamma-glutamyl transferase, and decreased sodium. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Janssen Biotech, Inc. at 1-800-JANSSEN (1-800-526-7736) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
USE IN SPECIFIC POPULATIONS
Lactation: Advise not to breastfeed. (8.2)
See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.
Table of Contents
FULL PRESCRIBING INFORMATION: CONTENTS*
- Sections or subsections omitted from the full prescribing information are not listed.
1 INDICATIONS AND USAGE
RYBREVANT is indicated for the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations, as detected by an FDA-approved test [see Dosage and Administration (2.1)], whose disease has progressed on or after platinum-based chemotherapy.
This indication is approved under accelerated approval based on overall response rate and duration of response [see Clinical Studies (14)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.
2 DOSAGE AND ADMINISTRATION
2.1 Patient Selection
Select patients for treatment with RYBREVANT based on the presence of EGFR exon 20 insertion mutations [see Clinical Studies (14.1)]. Information on FDA-approved tests is available at: http://www.fda.gov/CompanionDiagnostics.
2.2 Recommended Dosage
The recommended doses of RYBREVANT, based on baseline body weight, are provided in Table 1. Administer RYBREVANT weekly for 4 weeks, with the initial dose as a split infusion in Week 1 on Day 1 and Day 2, then administer every 2 weeks thereafter until disease progression or unacceptable toxicity. Administer premedications before each RYBREVANT infusion as recommended [see Dosage and Administration (2.3)]. Administer diluted RYBREVANT intravenously according to the infusion rates in Table 5 [see Dosage and Administration (2.5), (2.6)].
2.3 Recommended Premedications
Prior to initial infusion of RYBREVANT (Week 1, Days 1 and 2), administer premedication as described in Table 2 to reduce the risk of infusion-related reactions: [see Warnings and Precautions (5.1)]
Table 2: Premedications Medication Dose Route of Administration Dosing Window Prior to RYBREVANT Administration Antihistamine* Diphenhydramine (25 to 50 mg) or equivalent Intravenous 15 to 30 minutes Oral 30 to 60 minutes Antipyretic* Acetaminophen (650 to 1,000 mg) Intravenous 15 to 30 minutes Oral 30 to 60 minutes Glucocorticoid† Dexamethasone (10 mg) or Methylprednisolone (40 mg) or equivalent Intravenous 45 to 60 minutes
Administer both antihistamine and antipyretic prior to all infusions. Glucocorticoid administration required for Week 1, Days 1 and 2 doses only and as necessary for subsequent infusions.
2.4 Dosage Modifications for Adverse Reactions
The recommended RYBREVANT dose reductions for adverse reactions (see Table 4) are listed in Table 3.
Table 3: RYBREVANT Dose Reductions for Adverse Reactions Body Weight at Baseline Initial Dose 1st Dose Reduction 2nd Dose Reduction 3rd Dose Reduction Less than 80 kg 1050 mg 700 mg 350 mg Discontinue RYBREVANT Greater than or equal to 80 kg 1400 mg 1050 mg 700 mg
The recommended RYBREVANT dosage modifications for adverse reactions are provided in Table 4.
Table 4: Recommended RYBREVANT Dosage Modifications for Adverse Reactions Adverse Reaction Severity Dosage Modifications Infusion-related reactions (IRR) [see Warnings and Precautions (5.1)] Grade 1 to 2
- Interrupt RYBREVANT infusion if IRR is suspected and monitor patient until reaction symptoms resolve.
- Resume the infusion at 50% of the infusion rate at which the reaction occurred.
- If there are no additional symptoms after 30 minutes, the infusion rate may be escalated (see Table 5).
- Include corticosteroid with premedications for subsequent dose (see Table 2).
- Interrupt RYBREVANT infusion and administer supportive care medications. Monitor patient until reaction symptoms resolve.
- Resume the infusion at 50% of the infusion rate at which the reaction occurred.
- If there are no additional symptoms after 30 minutes, the infusion rate may be escalated (see Table 5).
- Include corticosteroid with premedications for subsequent dose (see Table 2). For recurrent Grade 3, permanently discontinue RYBREVANT.
- Permanently discontinue RYBREVANT.
Interstitial Lung Disease (ILD)/pneumonitis [see Warnings and Precautions (5.2)]. Any Grade
- Withhold RYBREVANT if ILD/pneumonitis is suspected.
- Permanently discontinue RYBREVANT if ILD/pneumonitis is confirmed.
Dermatologic Adverse Reactions (including dermatitis acneiform, pruritus, dry skin) [see Warnings and Precautions (5.3)] Grade 2
- Initiate supportive care management.
- Reassess after 2 weeks; if rash does not improve, consider dose reduction.
- Withhold RYBREVANT and initiate supportive care management.
- Upon recovery to ≤ Grade 2, resume RYBREVANT at reduced dose.
- If no improvement within 2 weeks, permanently discontinue treatment.
- Permanently discontinue RYBREVANT
Severe bullous, blistering or exfoliating skin conditions (including toxic epidermal necrolysis (TEN)
- Permanently discontinue RYBREVANT.
Other Adverse Reactions [see Adverse Reactions (6.1)] Grade 3
- Withhold RYBREVANT until recovery to ≤ Grade 1 or baseline.
- Resume at the same dose if recovery occurs within 1 week.
- Resume at reduced dose if recovery occurs after 1 week but within 4 weeks.
- Permanently discontinue if recovery does not occur within 4 weeks.
- Withhold RYBREVANT until recovery to ≤Grade 1 or baseline.
- Resume at reduced dose if recovery occurs within 4 weeks.
- Permanently discontinue if recovery does not occur within 4 weeks.
- Permanently discontinue for recurrent Grade 4 reactions.
Dilute and prepare RYBREVANT for intravenous infusion before administration.
- Check that the RYBREVANT solution is colorless to pale yellow. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if discoloration or visible particles are present.
- Determine the dose required (either 1050 mg or 1400 mg) and number of RYBREVANT vials needed based on patient's baseline weight [see Dosage and Administration (2.2)]. Each vial of RYBREVANT contains 350 mg of amivantamab-vmjw.
- Withdraw and then discard a volume of either 5% dextrose solution or 0.9% sodium chloride solution from the 250 mL infusion bag equal to the volume of RYBREVANT to be added (i.e., discard 7 mL diluent from the infusion bag for each RYBREVANT vial). Only use infusion bags made of polyvinylchloride (PVC), polypropylene (PP), polyethylene (PE), or polyolefin blend (PP+PE).
- Withdraw 7 mL of RYBREVANT from each vial and add it to the infusion bag. The final volume in the infusion bag should be 250 mL. Discard any unused portion left in the vial.
- Gently invert the bag to mix the solution. Do not shake.
- Diluted solutions should be administered within 10 hours (including infusion time) at room temperature 59°F to 77°F (15°C to 25°C).
Administer the diluted solution [see Dosage and Administration (2.5)] 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 0.2 micrometer) primed with diluent only. Administration sets must be made of either polyurethane (PU), polybutadiene (PBD) PVC, PP, or PE.
Do not infuse RYBREVANT concomitantly in the same intravenous line with other agents.
Administer RYBREVANT via a peripheral line on Week 1 and Week 2 given the high incidence of infusion-related reactions during initial treatment [see Warnings and Precautions (5.1)]. RYBREVANT may be administered via central line for subsequent weeks. For the initial infusion, prepare RYBREVANT as close to administration time as possible to allow for the possibility of extended infusion time in the event of an infusion-related reaction.
Administer RYBREVANT infusion intravenously according to the infusion rates in Table 5.
Table 5: Infusion Rates for RYBREVANT Administration 1050 mg Dose Week Dose
(per 250 mL bag)
Initial Infusion Rate Subsequent Infusion Rate* Week 1 (split dose infusion) Week 1 Day 1 350 mg 50 mL/hr 75 mL/hr Week 1 Day 2 700 mg 50 mL/hr 75 mL/hr Week 2 1050 mg 85 mL/hr Week 3 1050 mg 125 mL/hr Week 4 1050 mg 125 mL/hr Subsequent weeks† 1050 mg 125 mL/hr 1400 mg Dose Week Dose
(per 250 mL bag)
Initial Infusion Rate Subsequent Infusion Rate* Week 1 (split dose infusion) Week 1 Day 1 350 mg 50 mL/hr 75 mL/hr Week 1 Day 2 1050 mg 35 mL/hr 50 mL/hr Week 2 1400 mg 65 mL/hr Week 3 1400 mg 85 mL/hr Week 4 1400 mg 125 mL/hr Subsequent weeks† 1400 mg 125 mL/hr
- 3 DOSAGE FORMS AND STRENGTHS
- 4 CONTRAINDICATIONS
5 WARNINGS AND PRECAUTIONS
5.1 Infusion-Related Reactions
RYBREVANT can cause infusion-related reactions (IRR); signs and symptoms of IRR include dyspnea, flushing, fever, chills, nausea, chest discomfort, hypotension, and vomiting.
Based on the safety population [see Adverse Reactions (6.1)], IRR occurred in 66% of patients treated with RYBREVANT. Among patients receiving treatment on Week 1 Day 1, 65% experienced an IRR, while the incidence of IRR was 3.4% with the Day 2 infusion, 0.4% with the Week 2 infusion, and cumulatively 1.1% with subsequent infusions. Of the reported IRRs, 97% were Grade 1–2, 2.2% were Grade 3, and 0.4% were Grade 4. The median time to onset was 1 hour (range 0.1 to 18 hours) after start of infusion. The incidence of infusion modifications due to IRR was 62% and 1.3% of patients permanently discontinued RYBREVANT due to IRR.
Premedicate with antihistamines, antipyretics, and glucocorticoids and infuse RYBREVANT as recommended [see Dosage and Administration (2.3)]. Administer RYBREVANT via a peripheral line on Week 1 and Week 2 [see Dosage and Administration (2.6)].
Monitor patients for any signs and symptoms of infusion reactions during RYBREVANT infusion in a setting where cardiopulmonary resuscitation medication and equipment are available. Interrupt infusion if IRR is suspected. Reduce the infusion rate or permanently discontinue RYBREVANT based on severity [see Dosage and Administration (2.4)].
5.2 Interstitial Lung Disease/Pneumonitis
RYBREVANT can cause interstitial lung disease (ILD)/pneumonitis. Based on the safety population [see Adverse Reactions (6.1)], ILD/pneumonitis occurred in 3.3% of patients treated with RYBREVANT, with 0.7% of patients experiencing Grade 3 ILD/pneumonitis. Three patients (1%) discontinued RYBREVANT due to ILD/pneumonitis.
Monitor patients for new or worsening symptoms indicative of ILD/pneumonitis (e.g., dyspnea, cough, fever). Immediately withhold RYBREVANT in patients with suspected ILD/pneumonitis and permanently discontinue if ILD/pneumonitis is confirmed [see Dosage and Administration (2.4)].
5.3 Dermatologic Adverse Reactions
RYBREVANT can cause rash (including dermatitis acneiform), pruritus and dry skin. Based on the safety population [see Adverse Reactions (6.1)], rash occurred in 74% of patients treated with RYBREVANT, including Grade 3 rash in 3.3% of patients. The median time to onset of rash was 14 days (range: 1 to 276 days). Rash leading to dose reduction occurred in 5% of patients, and RYBREVANT was permanently discontinued due to rash in 0.7% of patients [see Adverse Reactions (6.1)].
Toxic epidermal necrolysis (TEN) occurred in one patient (0.3%) treated with RYBREVANT.
Instruct patients to limit sun exposure during and for 2 months after treatment with RYBREVANT. Advise patients to wear protective clothing and use broad-spectrum UVA/UVB sunscreen. Alcohol-free emollient cream is recommended for dry skin.
If skin reactions develop, start topical corticosteroids and topical and/or oral antibiotics. For Grade 3 reactions, add oral steroids and consider dermatologic consultation. Promptly refer patients presenting with severe rash, atypical appearance or distribution, or lack of improvement within 2 weeks to a dermatologist. Withhold, dose reduce or permanently discontinue RYBREVANT based on severity [see Dosage and Administration (2.4)].
5.4 Ocular Toxicity
RYBREVANT can cause ocular toxicity including keratitis, dry eye symptoms, conjunctival redness, blurred vision, visual impairment, ocular itching, and uveitis. Based on the safety population [see Adverse Reactions (6.1)], keratitis occurred in 0.7% and uveitis occurred in 0.3% of patients treated with RYBREVANT. All events were Grade 1–2. Promptly refer patients presenting with eye symptoms to an ophthalmologist. Withhold, dose reduce or permanently discontinue RYBREVANT based on severity [see Dosage and Administration (2.4)].
5.5 Embryo-Fetal Toxicity
Based on its mechanism of action and findings from animal models, RYBREVANT can cause fetal harm when administered to a pregnant woman. Administration of other EGFR inhibitor molecules to pregnant animals has resulted in an increased incidence of impairment of embryo-fetal development, embryolethality, and abortion. Advise females of reproductive potential of the potential risk to the fetus. Advise female patients of reproductive potential to use effective contraception during treatment and for 3 months after the final dose of RYBREVANT. [see Use in Specific Populations (8.1, 8.3)].
6 ADVERSE REACTIONS
The following adverse reactions are discussed elsewhere in the labeling:
- Infusion-Related Reactions [see Warnings and Precautions (5.1)]
- Interstitial Lung Disease/Pneumonitis [see Warnings and Precautions (5.2)]
- Dermatologic Adverse Reactions [see Warnings and Precautions (5.3)]
- Ocular Toxicity [see Warnings and Precautions (5.4)]
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 population described in the WARNINGS AND PRECAUTIONS reflect exposure to RYBREVANT as a single agent in the CHRYSALIS study in 302 patients with locally advanced or metastatic NSCLC who received a dose of 1050 mg (for patients <80 kg) or 1400 mg (for patients ≥80 kg) once weekly for 4 weeks, then every 2 weeks thereafter. Among 302 patients who received RYBREVANT, 36% were exposed for 6 months or longer and 12% were exposed for greater than one year. In the safety population, the most common (≥ 20%) adverse reactions were rash, infusion-related reaction, paronychia, musculoskeletal pain, dyspnea, nausea, edema, cough, fatigue, stomatitis, constipation, vomiting and pruritus. The most common Grade 3 to 4 laboratory abnormalities (≥ 2%) were decreased lymphocytes, decreased phosphate, decreased albumin, increased glucose, increased gamma glutamyl transferase, decreased sodium, decreased potassium, and increased alkaline phosphatase.
The data described below reflect exposure to RYBREVANT at the recommended dosage in 129 patients with locally advanced or metastatic NSCLC with EGFR exon 20 insertion mutations whose disease had progressed on or after platinum-based chemotherapy. Among patients who received RYBREVANT, 44% were exposed for 6 months or longer and 12% were exposed for greater than one year.
The median age was 62 years (range: 36 to 84 years); 61% were female; 55% were Asian, 35% were White, and 2.3% were Black; and 82% had baseline body weight <80 kg.
Serious adverse reactions occurred in 30% of patients who received RYBREVANT. Serious adverse reactions in ≥ 2% of patients included pulmonary embolism, pneumonitis/ILD, dyspnea, musculoskeletal pain, pneumonia, and muscular weakness. Fatal adverse reactions occurred in 2 patients (1.5%) due to pneumonia and 1 patient (0.8%) due to sudden death.
Permanent discontinuation of RYBREVANT due to an adverse reaction occurred in 11% of patients. Adverse reactions resulting in permanent discontinuation of RYBREVANT in ≥1% of patients were pneumonia, IRR, pneumonitis/ILD, dyspnea, pleural effusion, and rash.
Dose interruptions of RYBREVANT due to an adverse reaction occurred in 78% of patients. Infusion-related reactions (IRR) requiring infusion interruptions occurred in 59% of patients. Adverse reactions requiring dose interruption in ≥5% of patients included dyspnea, nausea, rash, vomiting, fatigue, and diarrhea.
Dose reductions of RYBREVANT due to an adverse reaction occurred in 15% of patients. Adverse reactions requiring dose reductions in ≥ 2% of patients included rash and paronychia.
The most common adverse reactions (≥ 20%) were rash, IRR, paronychia, musculoskeletal pain, dyspnea, nausea, fatigue, edema, stomatitis, cough, constipation, and vomiting. The most common Grade 3 to 4 laboratory abnormalities (≥ 2%) were decreased lymphocytes, decreased albumin, decreased phosphate, decreased potassium, increased glucose, increased alkaline phosphatase, increased gamma-glutamyl transferase, and decreased sodium.
Table 6 summarizes the adverse reactions in CHRYSALIS.
Table 6: Adverse Reactions (≥ 10%) in Patients with NSCLC with Exon 20 Insertion Mutations Whose Disease Has Progressed on or after Platinum-based Chemotherapy and Received RYBREVANT in CHRYSALIS Adverse Reactions RYBREVANT
All Grades (%) Grades 3 or 4 (%)
- Rash: acne, dermatitis, dermatitis acneiform, eczema, eczema asteatotic, palmar-plantar erythrodysesthesia syndrome, perineal rash, rash, rash erythematous, rash maculo-papular, rash papular, rash vesicular, skin exfoliation, toxic epidermal necrolysis
- Fatigue: asthenia, fatigue
- Edema: eyelid edema, face edema, generalized edema, lip edema, edema, edema peripheral, periorbital edema, peripheral swelling
- Pneumonia: atypical pneumonia, lower respiratory tract infection, pneumonia, pneumonia aspiration, and pulmonary sepsis
- Musculoskeletal pain: arthralgia, arthritis, back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, musculoskeletal pain, myalgia, neck pain, non-cardiac chest pain, pain in extremity, spinal pain
- Dyspnea: dyspnea, dyspnea exertional
- Cough: cough, productive cough, upper airway cough syndrome
- Stomatitis: aphthous ulcer, cheilitis, glossitis, mouth ulceration, mucosal inflammation, pharyngeal inflammation, stomatitis
- Abdominal pain: abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, and epigastric discomfort
- Hemorrhage: epistaxis, gingival bleeding, hematuria, hemoptysis, hemorrhage, mouth hemorrhage, mucosal hemorrhage
- Peripheral neuropathy: hypoesthesia, neuralgia, paresthesia, peripheral sensory neuropathy
- Headache: headache, migraine
Skin and subcutaneous tissue disorders Rash* 84 3.9 Pruritus 18 0 Dry skin 14 0 General disorders and administration site conditions Infusion related reaction 64 3.1 Fatigue† 33 2.3 Edema‡ 27 0.8 Pyrexia 13 0 Infections and infestations Paronychia 50 3.1 Pneumonia§ 10 0.8 Musculoskeletal and connective tissue disorders Musculoskeletal pain¶ 47 0 Respiratory, thoracic and mediastinal disorders Dyspnea# 37 2.3 CoughÞ 25 0 Gastrointestinal disorders Nausea 36 0 Stomatitisß 26 0.8 Constipation 23 0 Vomiting 22 0 Diarrhea 16 3.1 Abdominal Painà 11 0.8 Vascular disorders Hemorrhageè 19 0 Metabolism and nutrition disorders Decreased appetite 15 0 Nervous system disorders Peripheral neuropathyð 13 0 Dizziness 12 0.8 Headacheø 10 0.8
Clinically relevant adverse reactions in <10% of patients who received RYBREVANT included ocular toxicity, ILD/pneumonitis, and toxic epidermal necrolysis (TEN).
Table 7 summarizes the laboratory abnormalities in CHRYSALIS.
Table 7: Select Laboratory Abnormalities (≥ 20%) That Worsened from Baseline in Patients With Metastatic NSCLC with EGFR Exon 20 Insertion Mutations Whose Disease Has Progressed on or After Platinum-based Chemotherapy and Who Received RYBREVANT in CHRYSALIS Laboratory Abnormality RYBREVANT*
Grades 3 or 4
- The denominator used to calculate the rate was 126 based on the number of patients with a baseline value and at least one post-treatment value.
Chemistry Decreased albumin 79 8 Increased glucose 56 4 Increased alkaline phosphatase 53 4.8 Increased creatinine 46 0 Increased alanine aminotransferase 38 1.6 Decreased phosphate 33 8 Increased aspartate aminotransferase 33 0 Decreased magnesium 27 0 Increased gamma-glutamyl transferase 27 4 Decreased sodium 27 4 Decreased potassium 26 6 Hematology Decreased lymphocytes 36 8
As with all therapeutic proteins, there is the potential for immunogenicity. 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 the incidence of antibodies in the studies described below with the incidence of antibodies in other studies or to other amivantamab products may be misleading.
In CHRYSALIS, 3 of the 286 (1%) patients who were treated with RYBREVANT and evaluable for the presence of anti-drug antibodies (ADA), tested positive for treatment-emergent anti-amivantamab-vmjw antibodies (one at 27 days, one at 59 days and one at 168 days after the first dose) with titers of 1:40 or less. There are insufficient data to evaluate the effect of ADA on the pharmacokinetics, safety, or efficacy of RYBREVANT.
8 USE IN SPECIFIC POPULATIONS
Based on the mechanism of action and findings in animal models, RYBREVANT can cause fetal harm when administered to a pregnant woman. There are no available data on the use of RYBREVANT in pregnant women or animal data to assess the risk of RYBREVANT in pregnancy. Disruption or depletion of EGFR in animal models resulted in impairment of embryo-fetal development including effects on placental, lung, cardiac, skin, and neural development. The absence of EGFR or MET signaling has resulted in embryolethality, malformations, and post-natal death in animals (see Data). Advise pregnant women of the potential risk to a fetus.
In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
No animal studies have been conducted to evaluate the effects of amivantamab-vmjw on reproduction and fetal development; however, based on its mechanism of action, RYBREVANT can cause fetal harm or developmental anomalies. In mice, EGFR is critically important in reproductive and developmental processes including blastocyst implantation, placental development, and embryo-fetal/postnatal survival and development. Reduction or elimination of embryo-fetal or maternal EGFR signaling can prevent implantation, can cause embryo-fetal loss during various stages of gestation (through effects on placental development) and can cause developmental anomalies and early death in surviving fetuses. Adverse developmental outcomes were observed in multiple organs in embryos/neonates of mice with disrupted EGFR signaling. Similarly, knock out of MET or its ligand HGF was embryonic lethal due to severe defects in placental development, and fetuses displayed defects in muscle development in multiple organs. Human IgG1 is known to cross the placenta; therefore, amivantamab-vmjw has the potential to be transmitted from the mother to the developing fetus.
There are no data on the presence of amivantamab-vmjw in human milk on milk production, or its effects on the breastfed child. Because of the potential for serious adverse reactions from RYBREVANT in breast-fed infants, advise women not to breast-feed during treatment with RYBREVANT and for 3 months after the final dose.
8.3 Females and Males of Reproductive Potential
RYBREVANT can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)].
Verify pregnancy status of females of reproductive potential prior to initiating RYBREVANT.
8.4 Pediatric Use
The safety and efficacy of RYBREVANT have not been established in pediatric patients.
Amivantamab-vmjw is a low-fucose human immunoglobulin G1-based bispecific antibody directed against the EGF and MET receptors, produced by mammalian cell line (Chinese Hamster Ovary [CHO]) using recombinant DNA technology that has a molecular weight of approximately 148 kDa. RYBREVANT (amivantamab-vmjw) injection for intravenous infusion is a sterile, preservative-free, colorless to pale yellow solution in single-dose vials. The pH is 5.7.
Each RYBREVANT vial contains 350 mg (50 mg/mL) amivantamab-vmjw, EDTA disodium salt dihydrate (0.14 mg), L-histidine (2.3 mg), L-histidine hydrochloride monohydrate (8.6 mg), L-methionine (7 mg), polysorbate 80 (4.2 mg), sucrose (595 mg), and water for injection, USP.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Amivantamab-vmjw is a bispecific antibody that binds to the extracellular domains of EGFR and MET.
In in vitro and in vivo studies amivantamab-vmjw was able to disrupt EGFR and MET signaling functions through blocking ligand binding and, in exon 20 insertion mutation models, degradation of EGFR and MET. The presence of EGFR and MET on the surface of tumor cells also allows for targeting of these cells for destruction by immune effector cells, such as natural killer cells and macrophages, through antibody-dependent cellular cytotoxicity (ADCC) and trogocytosis mechanisms, respectively.
The exposure-response relationship and time-course of pharmacodynamic response of amivantamab-vmjw have not been fully characterized in patients with NSCLC with EGFR exon 20 insertion mutations.
Amivantamab-vmjw exposures increased proportionally over a dosage range from 350 to 1750 mg (0.25 to 1.25 times the maximum approved recommended dosage). Steady state of amivantamab-vmjw concentrations was achieved by the 9th infusion. The accumulation ratio at steady state was 2.4.
The mean (± SD) clearance of amivantamab-vmjw is 360 (± 144) mL/day and the terminal half-life is 11.3 (± 4.53) days.
No clinically meaningful differences in the pharmacokinetics of amivantamab-vmjw were observed based on age (range: 32–87 years), sex, race, creatinine clearance (CLcr 29 to 276 mL/min), or mild hepatic impairment [(total bilirubin ≤ ULN and AST > ULN) or (ULN < total bilirubin ≤ 1.5 times ULN)]. The pharmacokinetics of amivantamab-vmjw have not been studied in patients with severe renal impairment (CLcr 15 to 29 mL/min) or patients with moderate (total bilirubin 1.5 to 3 times ULN) to severe (total bilirubin > 3 times ULN) hepatic impairment.
Increases in body weight increased the volume of distribution and clearance of amivantamab-vmjw. Amivantamab-vmjw exposures are 30–40% lower in patients who weighed ≥ 80 kg compared to patients with body weight < 80 kg at the same dose. Exposures of amivantamab-vmjw were comparable between patients who weighed < 80 kg and received 1050 mg dose and patients who weighed ≥ 80 kg and received 1400 mg dose.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No studies have been performed to assess the potential of amivantamab-vmjw for carcinogenicity or genotoxicity. Fertility studies have not been performed to evaluate the potential effects of amivantamab-vmjw. In 6-week and 3-month repeat-dose toxicology studies in monkeys, there were no notable effects in the male and female reproductive organs.
14 CLINICAL STUDIES
The efficacy of RYBREVANT was evaluated in patients with locally advanced or metastatic NSCLC with EGFR exon 20 insertion mutations in a multicenter, open-label, multi-cohort clinical trial (CHRYSALIS, NCT02609776). The study included patients with locally advanced or metastatic NSCLC with EGFR exon 20 insertion mutations whose disease had progressed on or after platinum-based chemotherapy. Patients with untreated brain metastases and patients with a history of ILD requiring treatment with prolonged steroids or other immunosuppressive agents within the last 2 years were not eligible for the study.
In the efficacy population, EGFR exon 20 insertion mutation status was determined by prospective local testing using tissue (94%) and/or plasma (6%) samples. Of the 81 patients with EGFR exon 20 insertion mutations, plasma samples from 96% of patients were tested retrospectively using Guardant360® CDx. While 76% of patients had an EGFR exon 20 insertion mutation identified in plasma specimen, 20% did not have an EGFR exon 20 insertion mutation identified in plasma specimen, and 3.7% did not have plasma samples for testing.
Patients received RYBREVANT at 1050 mg (for patient baseline body weight < 80 kg) or 1400 mg (for patient baseline body weight ≥80 kg) once weekly for 4 weeks, then every 2 weeks thereafter until disease progression or unacceptable toxicity. The major efficacy outcome measure was overall response rate (ORR) according to Response Evaluation Criteria in Solid Tumors (RECIST v1.1) as evaluated by Blinded Independent Central Review (BICR). An additional efficacy outcome measure was duration of response (DOR) by BICR.
The efficacy population included 81 patients with NSCLC with EGFR exon 20 insertion mutation with measurable disease who were previously treated with platinum-based chemotherapy. The median age was 62 (range: 42 to 84) years, 59% were female; 49% were Asian, 37% were White, 2.5% were Black; 74% had baseline body weight <80 kg; 95% had adenocarcinoma; and 46% had received prior immunotherapy. The median number of prior therapies was 2 (range: 1 to 7). At baseline, 67% had Eastern Cooperative Oncology Group (ECOG) performance status of 1; 53% never smoked; all patients had metastatic disease; and 22% had previously treated brain metastases.
Efficacy results are summarized in Table 8.
Table 8: Efficacy Results for CHRYSALIS Prior Platinum-based Chemotherapy Treated
Based on Kaplan-Meier estimates.
NE=Not Estimable, CI=confidence interval.
Overall Response Rate (95% CI) 40% (29%, 51%) Complete response (CR) 3.7% Partial response (PR) 36% Duration of Response (DOR) Median, months (95% CI), months 11.1 (6.9, NE) Patients with DOR ≥6 months 63%
16 HOW SUPPLIED/STORAGE AND HANDLING
RYBREVANT™ (amivantamab-vmjw) injection is a sterile, preservative-free, colorless to pale yellow solution for intravenous infusion. Each single-dose vial contains 350 mg/7 mL (50 mg/mL) RYBREVANT. Each vial is individually packed in a single carton. (NDC 57894-501-01).
17 PATIENT COUNSELING INFORMATION
Advise the patient to read the FDA-approved patient labeling (Patient Information).
Advise patients that RYBREVANT can cause infusion-related reactions, the majority of which may occur with the first infusion. Advise patients to alert their healthcare provider immediately for any signs or symptoms of infusion-related reactions [see Warnings and Precautions (5.1)].
Interstitial Lung Disease/Pneumonitis
Advise patients of the risks of interstitial lung disease (ILD)/pneumonitis. Advise patients to immediately contact their healthcare provider for new or worsening respiratory symptoms [see Warnings and Precautions (5.2)].
Dermatologic Adverse Reactions
Advise patients of the risk of dermatologic adverse reactions. Advise patients to limit direct sun exposure, to use broad spectrum UVA/UVB sunscreen, and to wear protective clothing during treatment with RYBREVANT [see Warnings and Precautions (5.3)]. Advise patients to apply alcohol free emollient cream to dry skin.
Advise patients of the risk of ocular toxicity. Advise patients to contact their ophthalmologist if they develop eye symptoms and advise discontinuation of contact lenses until symptoms are evaluated [see Warnings and Precautions (5.4)].
Advise patients of the risk of paronychia. Advise patients to contact their healthcare provider for signs or symptoms of paronychia [see Adverse Reactions (6.1)].
Advise females of reproductive potential of the potential risk to a fetus, to use effective contraception during treatment with RYBREVANT and for 3 months after the final dose, and to inform their healthcare provider of a known or suspected pregnancy. [see Warnings and Precautions (5.5), Use in Specific Populations (8.1, 8.3)].
Advise women not to breastfeed during treatment with RYBREVANT and for 3 months after the final dose [see Use in Specific Populations (8.2)].
- SPL UNCLASSIFIED SECTION
Injection, for intravenous use
This Patient Information has been approved by the U.S. Food and Drug Administration. Issued: 05/2021 What is RYBREVANT?
RYBREVANT is a prescription medicine used to treat adults with non-small cell lung cancer (NSCLC) that:
- has spread to other parts of the body (metastatic) or cannot be removed by surgery, and
- has a certain abnormal epidermal growth factor receptor "EGFR" gene(s) and
- whose disease has worsened while on or after chemotherapy that contains platinum.
It is not known if RYBREVANT is safe and effective in children.
Before you receive RYBREVANT, tell your healthcare provider about all of your medical conditions, including if you:
- have a history of lung or breathing problems
- are pregnant or plan to become pregnant. RYBREVANT can harm your unborn baby.
Females who are able to become pregnant:
- Your healthcare provider should do a pregnancy test before you start treatment with RYBREVANT.
- You should use effective birth control (contraception) during treatment and for 3 months after your final dose of RYBREVANT.
- Tell your healthcare provider right away if you become pregnant or think you might be pregnant during treatment with RYBREVANT.
- are breastfeeding or plan to breastfeed. It is not known if RYBREVANT passes into your breast milk. Do not breastfeed during treatment and for 3 months after your final dose of RYBREVANT.
How will I receive RYBREVANT?
- RYBREVANT will be given to you by your healthcare provider by intravenous 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 RYBREVANT to help reduce the risk of infusion-related reactions.
- If you miss any appointments, call your healthcare provider as soon as possible to reschedule your appointment.
What should I avoid while receiving RYBREVANT?
RYBREVANT can cause skin reactions. You should limit your time in the sun during and for 2 months after your treatment with RYBREVANT. Wear protective clothing and use sunscreen during treatment with RYBREVANT.
What are the possible side effects of RYBREVANT?
RYBREVANT may cause serious side effects, including:
- infusion-related reactions. Infusion-related reactions are common with RYBREVANT and can be severe or serious. Tell your healthcare provider right away if you get any of the following symptoms during your infusion of RYBREVANT:
- shortness of breath
- chest discomfort
- lung problems. RYBREVANT may cause lung problems that may lead to death. Symptoms may be similar to those symptoms from lung cancer. Tell your healthcare provider right away if you get any new or worsening lung symptoms, including shortness of breath, cough, or fever.
- skin problems. RYBREVANT may cause rash, itching, and dry skin. You may use alcohol-free moisturizing cream for dry skin. Tell your healthcare provider right away if you get any skin reactions. Your healthcare provider may treat you with a medicine(s) or send you to see a skin specialist (dermatologist) if you get skin reactions during treatment with RYBREVANT. See "What should I avoid while receiving RYBREVANT?"
- eye problems. RYBREVANT may cause eye problems. Tell your healthcare provider right away if you get symptoms of eye problems which may include:
- eye pain
- dry eyes
- eye redness
- blurred vision
- changes in vision
- itchy eyes
- excessive tearing
- sensitivity to light
Your healthcare provider may send you to see an eye specialist (ophthalmologist) if you get eye problems during treatment with RYBREVANT. You should not use contact lenses until your eye symptoms are checked by a healthcare provider. The most common side effects of RYBREVANT include:
- infusion-related reactions
- infected skin around the nail
- muscle and joint pain
- shortness of breath
- feeling very tired
- swelling of hands, ankles, feet, face, or all of your body
- sores in the mouth
- changes in certain blood tests
Your healthcare provider may temporarily stop, decrease your dose or completely stop your treatment with RYBREVANT if you have serious side effects.
These are not all of the possible side effects of RYBREVANT.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
General information about safe and effective use of RYBREVANT
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 RYBREVANT that is written for health professionals.
What are the ingredients of RYBREVANT?
Active ingredient: amivantamab-vmjw
Inactive ingredients: EDTA disodium salt dihydrate, L-histidine, L-histidine hydrochloride monohydrate, L-methionine, polysorbate 80, sucrose, and water for injection.
Product of Ireland
Manufactured by: Janssen Biotech, Inc., Horsham, PA 19044.
U.S. License Number 1864
© 2021 Janssen Pharmaceutical Companies
For more information, call Janssen Products, LP at 1-800-526-7736 (1-800-JANSSEN) or go to www.RYBREVANT.com.
- PRINCIPAL DISPLAY PANEL - 7 mL Vial Carton
INGREDIENTS AND APPEARANCE
Product Information Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:57894-501 Route of Administration INTRAVENOUS Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength Amivantamab (UNII: 0JSR7Z0NB6) (Amivantamab - UNII:0JSR7Z0NB6) Amivantamab 350 mg Inactive Ingredients Ingredient Name Strength EDETATE DISODIUM (UNII: 7FLD91C86K) HISTIDINE (UNII: 4QD397987E) HISTIDINE MONOHYDROCHLORIDE MONOHYDRATE (UNII: X573657P6P) METHIONINE (UNII: AE28F7PNPL) POLYSORBATE 20 (UNII: 7T1F30V5YH) sucrose (UNII: C151H8M554) water (UNII: 059QF0KO0R) Product Characteristics Color YELLOW (Colorlous to Pale Yellow) Score Shape Size Flavor Imprint Code Contains Packaging # Item Code Package Description Marketing Start Date Marketing End Date 1 NDC:57894-501-01 1 in 1 CARTON 05/21/2021 1 NDC:57894-501-00 1 in 1 VIAL, SINGLE-USE; Type 0: Not a Combination Product Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date BLA BLA761210 05/21/2021 Labeler - Janssen Biotech, Inc. (099091753) Establishment Name Address ID/FEI Business Operations Janssen Pharmaceutical Sciences Unlimited Company 985639841 API MANUFACTURE(57894-501) , ANALYSIS(57894-501) Establishment Name Address ID/FEI Business Operations Cilag AG 483237103 LABEL(57894-501) , MANUFACTURE(57894-501) , ANALYSIS(57894-501)