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UNITUXIN(dinutuximab)injection

2015-03-30 02:23:59  作者:新特药房  来源:互联网  浏览次数:341  文字大小:【】【】【
简介: 美国FDA批准Unituxin第一个治疗高风险神经母细胞瘤批准日期: 2015年3月10日;公司:United Therapeutics Corporation3月10日,美国FDA批准Unituxin(Dinutuximab)作为一线治疗药物的一部分用于高风险 ...

美国FDA批准Unituxin第一个治疗高风险神经母细胞瘤
批准日期:
2015年3月10日;公司:United Therapeutics Corporation
3月10日,美国FDA批准Unituxin(Dinutuximab)作为一线治疗药物的一部分用于高风险神经母细胞瘤儿科患者,这种一种通常发生在幼儿身上的癌症。
神经母细胞瘤是一种罕见的癌症,它形成于不成熟的神经细胞。这种疾病通常起始于肾上腺,但还可能在腹部、胸部或脊柱附近的神经组织发展。神经母细胞瘤通常发生在五岁以下的儿童身上。
据美国国家癌症研究所提供的信息,神经母细胞瘤在儿童中的发病率大约为十万分之一,男孩中的发病率略高。美国每年预计会有650个神经母细胞瘤新病例被确诊。尽管进行积极治疗,但只有40%到50%的高风险神经母细胞瘤患者有长期生存的机会。
Unituxin是一种抗体,它可以绑定到神经母细胞瘤细胞的表面。Unituxin被批准用作综合治疗方案的一部分,包括手术、化疗及放射治疗,适用于对之前一线多种药物、综合治疗至少达到部分响应的患者。
“Unituxin标志着首款获批专门用于高风险神经母细胞瘤患者治疗的药物,”FDA药品评价与研究中心代谢及肿瘤产品办公室主任、医学博士Richard称。“Unituxin通过提供一种治疗选择满足了一个关键的需求,它可以延长高风险神经母细胞瘤儿童患者的生存期。”
FDA授予了Unituxin优先审评及孤儿药资格。与标准审评相比,优先审评将这款药物申请的审评时间缩短了4个月,优先审评授予那些如果获得批准,将能对严重疾病治疗的安全性及有效性提供明显改善的药物。
孤儿药资格授予那些旨在治疗罕见疾病的药物。对于这次批准,FDA还向United Therapeutics发布了一项罕见儿科疾病审评券,它可授予以后不符合优先审评的一款药物申请优先审评。这是FDA自发起罕见儿科疾病审评券项目以来发布的第二个罕见儿科疾病优先审评,这一项目旨在鼓励用于某些罕见儿科疾病预防及治疗的新型治疗药物的开发。
Unituxin的安全性及有效性在一项由226名患有高风险神经母细胞瘤儿科受试者的试验中得到评价,这些患者的肿瘤在经多药化疗及手术后接受其它大剂量化疗后缩小或消失,他们后来接受骨髓移植支持及放射治疗。
受试者被随机配给一种口服维甲酸药物异维甲酸(RA)或Unituxin与白介素-2、粒细胞巨噬细胞集落刺激因子及RA的合并用药,粒细胞巨噬细胞集落刺激因子被认为可通过刺激免疫系统来增强Unituxin的活性。
治疗后3年,63%的Unituxin合并治疗受试者仍存活,并且肿瘤不再增长或复发,相比之下,仅以RA治疗的受试者只有46%的人达到这一结果。在一项更新的预后分析中,73%的Unituxin合并治疗受试者仍存活,相比之下,仅以RA治疗的受试者只有58%的人达到这一结果。
Unituxin携带一项黑框警告,提醒患者及卫生保健专业人员Unituxin可刺激神经细胞,引起严重疼痛,需要静脉注射麻醉剂进行治疗,还能引起神经损伤及危及生命的输注重反应,包括输液期间或完成后不久出现上呼吸道肿胀、呼吸困难及低血压。Unituxin还可能引起其它严重副作用,包括感染、眼部疾病、电解质异常及骨髓抑制。
Unituxin最常见副作用有剧烈疼痛、发热、低血小板计数、输液反应、低血压、血液盐水平低(低钠血症)、肝酶升高、贫血、呕吐、腹泻、低血钾、毛细管泄漏综合症(特点是大量血浆及其它血液成分从血管泄漏到邻近体腔和肌肉)、抗感染白细胞(中性粒细胞减少和淋巴细胞)数量降低、荨麻疹及低血钙。Unituxin由马里兰州银泉的United Therapeutics上市销售。


HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use UNITUXIN safely and effectively. See Full Prescribing Information for UNITUXIN.
UNITUXIN™ (dinutuximab) injection, for intravenous use
Initial U.S. Approval: 2015
WARNING:
SERIOUS INFUSION REACTIONS AND NEUROPATHY See full prescribing information for complete boxed warning.
Infusion Reactions: Life-threatening infusion adverse reactions occur with Unituxin. Administer required prehydration and premedication. Immediately interrupt for severe infusion reactions and permanently discontinue for anaphylaxis [see Dosage and Administration (2.2, 2.3) and Warnings and Precautions (5.1)].
Neuropathy: Unituxin causes severe neuropathic pain. Administer intravenous opioid prior to, during, and for 2 hours following completion of the Unituxin infusion. Severe peripheral sensory neuropathy ranged from 2% to 9% in patients with neuroblastoma. Severe motor neuropathy was observed in adults. Discontinue for severe unresponsive pain, severe sensory neuropathy, or moderate to severe peripheral motor neuropathy [see Dosage and Administration (2.2, 2.3) and Warnings and Precautions (5.2)].
INDICATIONS AND USAGE
Unituxin is a GD2-binding monoclonal antibody indicated, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and 13-cis-retinoic acid (RA), for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multiagent, multimodality therapy. (1)
DOSAGE AND ADMINISTRATION
17.5 mg/m2/day as a diluted intravenous infusion over 10 to 20 hours for 4 consecutive days for up to 5 cycles. (2.1, 2.4)
DOSAGE FORMS AND STRENGTHS
Injection: 17.5 mg/5 mL (3.5 mg/mL) in a single-use vial. (3)
CONTRAINDICATIONS
History of anaphylaxis to dinutuximab. (4)
WARNINGS AND PRECAUTIONS
Capillary leak syndrome and hypotension: Administer required prehydration and monitor patients closely during treatment. Depending upon severity, manage by interruption, infusion rate reduction, or permanent discontinuation. (5.3, 5.4)
Infection: Interrupt until resolution of systemic infection. (5.5)
Neurological Disorders of the Eye: Interrupt for dilated pupil with sluggish light reflex or other visual disturbances and permanently discontinue for recurrent eye disorders or loss of vision. (5.6)
Bone marrow suppression: Monitor peripheral blood counts during Unituxin therapy. (5.7)
Electrolyte abnormalities: Monitor serum electrolytes closely. (5.8)
Atypical hemolytic uremic syndrome: Permanently discontinue Unituxin and institute supportive management. (5.9)
Embryo-Fetal toxicity: May cause fetal harm. Advise females of reproductive potential of potential risk to a fetus and to use effective contraception. (5.10, 8.1, 8.3)
ADVERSE REACTIONS
The most common adverse drug reactions (≥ 25%) are pain, pyrexia, thrombocytopenia, lymphopenia, infusion reactions, hypotension, hyponatremia, increased alanine aminotransferase, anemia, vomiting, diarrhea, hypokalemia, capillary leak syndrome, neutropenia, urticaria, hypoalbuminemia, increased aspartate aminotransferase, and hypocalcemia. (5, 6.1)
The most common serious adverse reactions (≥ 5%) are infections, infusion reactions, hypokalemia, hypotension, pain, fever, and capillary leak syndrome. (5, 6.1)
To report SUSPECTED ADVERSE REACTIONS, contact United Therapeutics Corp. at 1-866-458-6479 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
See 17 for PATIENT COUNSELING INFORMATION.
Revised: 3/2015
FULL PRESCRIBING INFORMATION: CONTENTS*
1 INDICATIONS AND USAGE
Unituxin (dinutuximab) is indicated, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA), for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multiagent, multimodality therapy [see Clinical Studies (14)].
2 DOSAGE AND ADMINISTRATION
Verify that patients have adequate hematologic, respiratory, hepatic, and renal function prior to initiating each course of Unituxin [see Clinical Studies (14)].
Administer required premedication and hydration prior to initiation of each Unituxin infusion [see Dosage and Administration (2.2)].
2.1 Recommended Dose
The recommended dose of Unituxin is 17.5 mg/m2/day administered as an intravenous infusion over 10 to 20 hours for 4 consecutive days for a maximum of 5 cycles (Tables 1 and 2 ) [see Dosage and Administration (2.4), Clinical Studies (14)].
Initiate at an infusion rate of 0.875 mg/m2/hour for 30 minutes. The infusion rate can be gradually increased as tolerated to a maximum rate of 1.75 mg/m2/hour. Follow dose modification instructions for adverse reactions [see Dosage and Administration (2.3)].
Table 1: Schedule of Unituxin Administration for Cycles 1, 3, and 5

Cycle Day 1 through 3 4 5 6 7 8 through 24*
Cycles 1, 3, and 5 are 24 days in duration.
Unituxin X X X X
Table 2: Schedule of Unituxin Administration for Cycles 2 and 4

Cycle Day 1 through 7 8 9 10 11 12 through 32*
Cycles 2 and 4 are 32 days in duration.
Unituxin X X X X
2.2 Required Pre-treatment and Guidelines for Pain Management
Intravenous Hydration
Administer 0.9% Sodium Chloride Injection, USP 10 mL/kg as an intravenous infusion over one hour just prior to initiating each Unituxin infusion.
Analgesics
Administer morphine sulfate (50 mcg/kg) intravenously immediately prior to initiation of Unituxin and then continue as a morphine sulfate drip at an infusion rate of 20 to 50 mcg/kg/hour during and for two hours following completion of Unituxin.
Administer additional 25 mcg/kg to 50 mcg/kg intravenous doses of morphine sulfate as needed for pain up to once every 2 hours followed by an increase in the morphine sulfate infusion rate in clinically stable patients.
Consider using fentanyl or hydromorphone if morphine sulfate is not tolerated.
If pain is inadequately managed with opioids, consider use of gabapentin or lidocaine in conjunction with intravenous morphine.
Antihistamines and Antipyretics
Administer an antihistamine such as diphenhydramine (0.5 to 1 mg/kg; maximum dose 50 mg) intravenously over 10 to 15 minutes starting 20 minutes prior to initiation of Unituxin and as tolerated every 4 to 6 hours during the Unituxin infusion.
Administer acetaminophen (10 to 15 mg/kg; maximum dose 650 mg) 20 minutes prior to each Unituxin infusion and every 4 to 6 hours as needed for fever or pain. Administer ibuprofen (5 to 10 mg/kg) every 6 hours as needed for control of persistent fever or pain.
2.3 Dosage Modifications
Manage adverse reactions by infusion interruption, infusion rate reduction, dose reduction, or permanent discontinuation of Unituxin (Table 3 and Table 4) [see Warnings and Precautions (5), Adverse Reactions (6), Clinical Studies (14)].
Table 3: Adverse Reactions Requiring Permanent Discontinuation of Unituxin

Grade 3 or 4 anaphylaxis
Grade 3 or 4 serum sickness
Grade 3 pain unresponsive to maximum supportive measures
Grade 4 sensory neuropathy or Grade 3 sensory neuropathy that interferes with daily activities for more than 2 weeks
Grade 2 peripheral motor neuropathy
Subtotal or total vision loss
Grade 4 hyponatremia despite appropriate fluid management
Table 4: Dose Modification for Selected Unituxin Adverse Reactions

Infusion-related reactions [see Warnings and Precautions (5.1)]
Mild to moderate adverse reactions such as transient rash, fever, rigors, and localized urticaria that respond promptly to symptomatic treatment
Onset of reaction: Reduce Unituxin infusion rate to 50% of the previous rate and monitor closely.
After resolution: Gradually increase infusion rate up to a maximum rate of 1.75 mg/m2/hour.
Prolonged or severe adverse reactions such as mild bronchospasm without other symptoms, angioedema that does not affect the airway
Onset of reaction: Immediately interrupt Unituxin.
After resolution: If signs and symptoms resolve rapidly, resume Unituxin at 50% of the previous rate and observe closely.
First recurrence: Discontinue Unituxin until the following day.
If symptoms resolve and continued treatment is warranted, premedicate with hydrocortisone 1 mg/kg (maximum dose 50 mg) intravenously and administer Unituxin at a rate of 0.875 mg/m2/hour in an intensive care unit.
Second recurrence: Permanently discontinue Unituxin.
Capillary leak syndrome [see Warnings and Precautions (5.3)]
Moderate to severe but not life-threatening capillary leak syndrome
Onset of reaction: Immediately interrupt Unituxin.
After resolution: Resume Unituxin infusion at 50% of the previous rate.
Life-threatening capillary leak syndrome
Onset of reaction: Discontinue Unituxin for the current cycle.
After resolution: In subsequent cycles, administer Unituxin at 50% of the previous rate.
First recurrence: Permanently discontinue Unituxin.
Hypotension* requiring medical intervention [see Warnings and Precautions (5.4)]
Onset of reaction: Interrupt Unituxin infusion.
After resolution: Resume Unituxin infusion at 50% of the previous rate.
If blood pressure remains stable for at least 2 hours, increase the infusion rate as tolerated up to a maximum rate of 1.75 mg/m2/hour.
Severe systemic infection or sepsis [see Warnings and Precautions (5.5)]
Onset of reaction: Discontinue Unituxin until resolution of infection, and then proceed with subsequent cycles of therapy.
Neurological Disorders of the Eye [see Warnings and Precautions (5.6)]
Onset of reaction: Discontinue Unituxin infusion until resolution.
After resolution: Reduce the Unituxin dose by 50%.
First recurrence or if accompanied by visual impairment: Permanently discontinue Unituxin.
Symptomatic hypotension, systolic blood pressure (SBP) less than lower limit of normal for age, or SBP decreased by more than 15% compared to baseline.
2.4 Instructions for Preparation and Administration
Preparation
Store vials in a refrigerator at 2°C to 8°C (36°F to 46°F). Protect from light by storing in the outer carton. DO NOT FREEZE OR SHAKE vials.
Inspect visually for particulate matter and discoloration prior to administration. Do not administer Unituxin and discard the single-use vial if the solution is cloudy, has pronounced discoloration, or contains particulate matter.
Aseptically withdraw the required volume of Unituxin from the single-use vial and inject into a 100 mL bag of 0.9% Sodium Chloride Injection, USP. Mix by gentle inversion. Do not shake. Discard unused contents of the vial.
Store the diluted Unituxin solution under refrigeration (2°C to 8° C). Initiate infusion within 4 hours of preparation.
Discard diluted Unituxin solution 24 hours after preparation.
Administration
Administer Unituxin as a diluted intravenous infusion only [see Dosage and Administration (2.1)]. Do not administer Unituxin as an intravenous push or bolus.
3 DOSAGE FORMS AND STRENGTHS
Injection: 17.5 mg/5 mL (3.5 mg/mL) solution in a single-use vial.
4 CONTRAINDICATIONS
Unituxin is contraindicated in patients with a history of anaphylaxis to dinutuximab.
5 WARNINGS AND PRECAUTIONS
5.1 Serious Infusion Reactions
Serious infusion reactions requiring urgent intervention including blood pressure support, bronchodilator therapy, corticosteroids, infusion rate reduction, infusion interruption, or permanent discontinuation of Unituxin included facial and upper airway edema, dyspnea, bronchospasm, stridor, urticaria, and hypotension. Infusion reactions generally occurred during or within 24 hours of completing the Unituxin infusion. Due to overlapping signs and symptoms, it was not possible to distinguish between infusion reactions and hypersensitivity reactions in some cases.
In Study 1, Severe (Grade 3 or 4) infusion reactions occurred in 35 (26%) patients in the Unituxin/13-cis-retinoic acid (RA) group compared to 1 (1%) patient receiving RA alone. Severe urticaria occurred in 17 (13%) patients in the Unituxin/RA group but did not occur in the RA group. Serious adverse reactions consistent with anaphylaxis and resulting in permanent discontinuation of Unituxin occurred in 2 (1%) patients in the Unituxin/RA group. Additionally, 1 (0.1%) patient had multiple cardiac arrests and died within 24 hours after having received Unituxin in Study 2.
Prior to each Unituxin dose, administer required intravenous hydration and premedication with antihistamines, analgesics, and antipyretics [see Dosage and Administration (2.2)]. Monitor patients closely for signs and symptoms of infusion reactions during and for at least 4 hours following completion of each Unituxin infusion in a setting where cardiopulmonary resuscitation medication and equipment are available.
For mild to moderate infusion reactions such as transient rash, fever, rigors, and localized urticaria that respond promptly to antihistamines or antipyretics, decrease the Unituxin infusion rate and monitor closely. Immediately interrupt or permanently discontinue Unituxin and institute supportive management for severe or prolonged infusion reactions. Permanently discontinue Unituxin and institute supportive management for life-threatening infusion reactions [see Dosage and Administration (2.3)].
5.2 Pain and Peripheral Neuropathy
Pain
In Study 1, 114 (85%) patients treated in the Unituxin/RA group experienced pain despite pre-treatment with analgesics including morphine sulfate infusion. Severe (Grade 3) pain occurred in 68 (51%) patients in the Unituxin/RA group compared to 5 (5%) patients in the RA group. Pain typically occurred during the Unituxin infusion and was most commonly reported as abdominal pain, generalized pain, extremity pain, back pain, neuralgia, musculoskeletal chest pain, and arthralgia.
Premedicate with analgesics including intravenous opioids prior to each dose of Unituxin and continue analgesics until two hours following completion of Unituxin. For severe pain, decrease the Unituxin infusion rate to 0.875 mg/m2/hour. Discontinue Unituxin if pain is not adequately controlled despite infusion rate reduction and institution of maximum supportive measures [see Dosage and Administration (2.3)].
Peripheral Neuropathy
In Study 1, severe (Grade 3) peripheral sensory neuropathy occurred in 2 (1%) patients and severe peripheral motor neuropathy occurred in 2 (1%) patients in the Unituxin/RA group. No patients treated with RA alone experienced severe peripheral neuropathy. The duration and reversibility of peripheral neuropathy occurring in Study 1 was not documented. In Study 3, no patients experienced peripheral motor neuropathy. Among the 9 (9%) patients who experienced peripheral sensory neuropathy of any severity, the median (min, max) duration of peripheral sensory neuropathy was 9 (3, 163) days.
The neuropathic effects of anti-GD2 antibody therapy appear more severe in adult patients compared to pediatric patients. In a study of a related anti-GD2 antibody conducted in 12 adult patients with metastatic melanoma, 2 (13%) patients developed severe motor neuropathy. One patient developed lower extremity weakness and inability to ambulate that persisted for approximately 6 weeks. Another patient developed severe lower extremity weakness resulting in an inability to ambulate without assistance that lasted for approximately 16 weeks and neurogenic bladder that lasted for approximately 3 weeks. Complete resolution of motor neuropathy was not documented in this case.
Permanently discontinue Unituxin in patients with Grade 2 peripheral motor neuropathy, Grade 3 sensory neuropathy that interferes with daily activities for more than 2 weeks, or Grade 4 sensory neuropathy.
5.3 Capillary Leak Syndrome
In Study 1, severe (Grade 3 to 5) capillary leak syndrome occurred in 31 (23%) patients in the Unituxin/RA group and in no patients treated with RA alone. Additionally, capillary leak syndrome was reported as a serious adverse reaction in 9 (6%) patients in the Unituxin/RA group and in no patients treated with RA alone. Immediately interrupt or discontinue Unituxin and institute supportive management in patients with symptomatic or severe capillary leak syndrome [see Dosage and Administration (2.3].
5.4 Hypotension
In Study 1, severe (Grade 3 or 4) hypotension occurred in 22 (16%) patients in the Unituxin/RA group compared to no patients in the RA group.
Prior to each Unituxin infusion, administer required intravenous hydration. Closely monitor blood pressure during Unituxin treatment. Immediately interrupt or discontinue Unituxin and institute supportive management in patients with symptomatic hypotension, systolic blood pressure (SBP) less than lower limit of normal for age, or SBP that is decreased by more than 15% compared to baseline [see Dosage and Administration (2.2, 2.3)].
5.5 Infection
In Study 1, severe (Grade 3 or 4) bacteremia requiring intravenous antibiotics or other urgent intervention occurred in 17 (13%) patients in the Unituxin/RA group compared to 5 (5%) patients treated with RA alone. Sepsis occurred in 24 (18%) patients in the Unituxin/RA group and in 10 (9%) patients in the RA group.
Monitor patients closely for signs and symptoms of systemic infection and temporarily discontinue Unituxin in patients who develop systemic infection until resolution of the infection [see Dosage and Administration (2.3)].
5.6 Neurological Disorders of the Eye
Neurological disorders of the eye experienced by two or more patients treated with Unituxin in Studies 1, 2, or 3 included blurred vision, photophobia, mydriasis, fixed or unequal pupils, optic nerve disorder, eyelid ptosis, and papilledema.
In Study 1, 3 (2%) patients in the Unituxin/RA group experienced blurred vision, compared to no patients in the RA group. Diplopia, mydriasis, and unequal pupillary size occurred in 1 patient each in the Unituxin/RA group, compared to no patients in the RA group. The duration of eye disorders occurring in Study 1 was not documented. In Study 3, eye disorders occurred in 16 (15%) patients, and in 3 (3%) patients resolution of the eye disorder was not documented. Among the cases with documented resolution, the median duration of eye disorders was 4 days (range: 0, 221 days).
Interrupt Unituxin in patients experiencing dilated pupil with sluggish light reflex or other visual disturbances that do not cause visual loss. Upon resolution and if continued treatment with Unituxin is warranted, decrease the Unituxin dose by 50%. Permanently discontinue Unituxin in patients with recurrent signs or symptoms of an eye disorder following dose reduction and in patients who experience loss of vision [see Dosage and Administration (2.3)].
5.7 Bone Marrow Suppression
In Study 1, severe (Grade 3 or 4) thrombocytopenia (39% vs. 25%), anemia (34% vs. 16%), neutropenia (34% vs. 13%), and febrile neutropenia (4% vs. 0 patients) occurred more commonly in patients in the Unituxin/RA group compared to patients treated with RA alone. Monitor peripheral blood counts closely during therapy with Unituxin.
5.8 Electrolyte Abnormalities
Electrolyte abnormalities occurring in at least 25% of patients who received Unituxin/RA in Study 1 included hyponatremia, hypokalemia, and hypocalcemia. Severe (Grade 3 or 4) hypokalemia and hyponatremia occurred in 37% and 23% of patients in the Unituxin/RA group respectively compared to 2% and 4% of patients in the RA group. In a study of a related anti-GD2 antibody conducted in 12 adult patients with metastatic melanoma, 2 (13%) patients developed syndrome of inappropriate antidiuretic hormone secretion resulting in severe hyponatremia. Monitor serum electrolytes daily during therapy with Unituxin.
5.9 Atypical Hemolytic Uremic Syndrome
Hemolytic uremic syndrome in the absence of documented infection and resulting in renal insufficiency, electrolyte abnormalities, anemia, and hypertension occurred in two patients enrolled in Study 2 following receipt of the first cycle of dinutuximab. Atypical hemolytic uremic syndrome recurred following rechallenge with Unituxin in one patient. Permanently discontinue Unituxin and institute supportive management for signs of hemolytic uremic syndrome.
5.10 Embryo-Fetal Toxicity
Based on its mechanism of action, Unituxin may cause fetal harm when administered to a pregnant woman. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment, and for two months after the last dose of Unituxin [see Use in Specific Populations (8.1, 8.3) and Clinical Pharmacology (12.1)].
6 ADVERSE REACTIONS
The following adverse reactions are discussed in greater detail in other sections of the labeling:
Serious Infusion Reactions [see Boxed Warning and Warnings and Precautions (5.1)]
Pain and Peripheral Neuropathy [see Boxed Warning and Warnings and Precautions (5.2)]
Capillary Leak Syndrome [see Warnings and Precautions (5.3)]
Hypotension [see Warnings and Precautions (5.4)]
Infection [see Warnings and Precautions (5.5)]
Neurological Disorders of the Eye [see Warnings and Precautions (5.6)]
Bone Marrow Suppression [see Warnings and Precautions (5.7)]
Electrolyte Abnormalities [see Warnings and Precautions (5.8)]
Atypical Hemolytic Uremic Syndrome [see Warnings and Precautions (5.9)]
Embryo-Fetal Toxicity [see Warnings and Precautions (5.10)]
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 rates observed in clinical practice.
The data described below reflect exposure to Unituxin at the recommended dose and schedule in 1021 patients with high-risk neuroblastoma enrolled in an open label, randomized (Study 1) or single arm clinical trials (Study 2 and Study 3). Prior to enrollment, patients received therapy consisting of induction combination chemotherapy, maximum feasible surgical resection, myeloablative consolidation chemotherapy followed by autologous stem cell transplant, and radiation therapy to residual soft tissue disease. Patients received Unituxin in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA). Treatment commenced within 95 days post autologous stem cell transplant in Study 1, within 210 days of autologous stem cell transplant in Study 2, and within 110 days of autologous stem cell transplant in Study 3.
Study 1
In a randomized, open label, multi-center study (Study 1), 134 patients received dinutuximab in combination with GM-CSF, IL-2 and RA (Unituxin/RA group), including 109 randomized patients and 25 patients with biopsy-proven residual disease who were non-randomly assigned to receive dinutuximab. A total of 106 randomized patients received RA alone (RA group) [see Dosage and Administration (2) and Clinical Studies (14)]. Patients had a median age at enrollment of 3.8 years (range: 0.94 to 15.3 years), and were predominantly male (60%) and White (82%). In Study 1, adverse reactions of Grade 3 or greater severity were comprehensively collected, but adverse reactions of Grade 1 or 2 severity were collected sporadically and laboratory data were not comprehensively collected.
Approximately 71% of patients in the Unituxin/RA group and 77% of patients in the RA group completed planned treatment. The most common reason for premature discontinuation of study therapy was adverse reactions in the Unituxin/RA group (19%) and progressive disease (17%) in the RA group.
The most common adverse drug reactions (≥ 25%) in the Unituxin/RA group were pain, pyrexia, thrombocytopenia, lymphopenia, infusion reactions, hypotension, hyponatremia, increased alanine aminotransferase, anemia, vomiting, diarrhea, hypokalemia, capillary leak syndrome, neutropenia, urticaria, hypoalbuminemia, increased aspartate aminotransferase, and hypocalcemia. The most common serious adverse reactions (≥ 5%) in the Unituxin/RA group were infections, infusion reactions, hypokalemia, hypotension, pain, fever, and capillary leak syndrome.
Table 5 lists the adverse reactions reported in at least 10% of patients in the Unituxin/RA group for which there was a between group difference of at least 5% (all grades) or 2% (Grade 3 or greater severity).
Table 5: Selected Adverse Reactions Occurring in at Least 10% of Patients in the Unituxin/RA Group in Study 1 

Adverse Reaction*, Unituxin/RA
(N=134)
RA
(N=106)
All Grades
(%)
Grades 3-4
(%)
All Grades
(%)
Grades 3-4
(%)

Includes adverse reactions that occurred in at least 10% of patients in the Unituxin/RA group with at least a 5% (All Grades) or 2% (Grades 3-5) absolute higher incidence in the Unituxin/RA group compared to the RA group.

Adverse drug reactions were graded using CTCAE version 3.0.

Includes preferred terms abdominal pain, abdominal pain upper, arthralgia, back pain, bladder pain, bone pain, chest pain, facial pain, gingival pain, infusion related reaction, musculoskeletal chest pain, myalgia, neck pain, neuralgia, oropharyngeal pain, pain, pain in extremity, and proctalgia.
Based on investigator reported adverse reactions.
One Grade 5 adverse reaction.
Includes preferred terms gastrointestinal hemorrhage, hematochezia, rectal hemorrhage, hematemesis, upper gastrointestinal hemorrhage, hematuria, hemorrhage urinary tract, renal hemorrhage, epistaxis, respiratory tract hemorrhage, disseminated intravascular coagulation, catheter site hemorrhage, hemorrhage and hematoma.  
Includes preferred terms tachycardia and sinus tachycardia.
General Disorders and Administration Site Conditions
  Pain‡ 85 51 16 6
  Pyrexia 72 40 27 6
  Edema 17 0 0 0
Blood and Lymphatic System Disorders§
  Thrombocytopenia 66 39 43 25
  Lymphopenia§ 62 51 36 20
  Anemia 51 34 22 16
  Neutropenia 39 34 16 13
Immune System Disorders
  Infusion reactions 60 25 9 1
Vascular Disorders
  Hypotension 60 16 3 0
  Capillary leak syndrome 40 23 1 0
  Hemorrhage# 17 6 6 3
  Hypertension 14 2 7 1
Metabolism and Nutrition Disorders
  Hyponatremia§ 58 23 12 4
  Hypokalemia§ 43 37 4 2
  Hypoalbuminemia§ 33 7 3 0
  Hypocalcemia§ 27 7 0 0
  Hypophosphatemia§ 20 8 3 0
  Hyperglycemia§ 18 6 4 1
  Hypertriglyceridemia§ 16 1 11 1
  Decreased appetite 15 10 5 4
  Hypomagnesemia§ 12 2 1 0
Investigations
  Increased alanine aminotransferase§ 56 23 31 3
  Increased aspartate aminotransferase§ 28 10 7 0
  Increased serum creatinine§ 15 2 6 0
  Increased weight 10 0 0 0
Gastrointestinal Disorders
  Vomiting 46 6 19 3
  Diarrhea 43 13 15 1
  Nausea 10 2 3 1
Skin and Subcutaneous Tissue Disorders
  Urticaria 37 13 3 0
Respiratory, Thoracic and Mediastinal Disorders
  Hypoxia 24 12 2 1
Cardiac Disorders
  TachycardiaÞ 19 2 1 0
Infections and Infestations
  Sepsis 18 16 9 9
  Device related infection 16 16 11 11
Renal and Urinary Disorders
  Proteinuria§ 16 0 3 1
Nervous System Disorders
  Peripheral neuropathy 13 3 6 0
Table 6 compares the per-patient incidence of selected adverse reactions occurring during cycles containing dinutuximab in combination with GM-CSF (Cycles 1, 3, and 5) with cycles containing dinutuximab in combination with IL-2 (Cycles 2 and 4).
Table 6: Comparison of Adverse Events by Treatment Cycle in the Unituxin/RA Group in Study 1 

Preferred Term*, All Grades Severe
GM-CSF
N=134
(%)
IL-2‡
N=127
(%)
GM-CSF
N=134
(%)
IL-2‡
N=127
(%)
Abbreviations: GM-CSF: granulocyte-macrophage colony-stimulating factor; IL-2: interleukin-2.
Includes preferred terms with a per-patient incidence of at least 20% in the Unituxin and RA group for either IL-2 or GM-CSF containing cycles.
Adverse drug reactions were graded using CTCAE version 3.0.
Seven patients who received GM-CSF in Cycle 1 discontinued prior to starting Cycle 2.
Includes preferred terms abdominal pain, abdominal pain upper, arthralgia, back pain, bladder pain, bone pain, chest pain, facial pain, gingival pain, infusion related reaction, musculoskeletal chest pain, myalgia, neck pain, neuralgia, oropharyngeal pain, pain, pain in extremity, and proctalgia.
Based on investigator reported adverse reactions.
General Disorders and administration site conditions
  Pyrexia 55 65 10 37
  Pain§ 77 61 43 35
Blood and Lymphatic System Disorders
  Thrombocytopenia 62 61 31 33
  Lymphopenia 54 61 33 50
  Anemia 42 42 21 24
  Neutropenia 25 32 19 28
Immune System Disorders
  Infusion reactions 47 54 10 20
Vascular Disorders
  Hypotension 43 54 5 16
  Capillary leak syndrome 22 36 11 20
Metabolism and Nutrition Disorders
  Hyponatremia 36 55 5 21
  Hypokalemia 26 39 13 33
  Hypoalbuminemia 29 29 3 5
  Hypocalcemia 20 21 2 6
Investigations
  Increased alanine aminotransferase 43 48 15 13
  Aspartate aminotransferase increased 16 21 4 7
Gastrointestinal Disorders
  Diarrhea 31 37 6 13
  Vomiting 33 35 3 2
Skin and Subcutaneous Tissue Disorders
  Urticaria 25 29 7 7
Study 2 and Study 3
Study 2 was a single arm, multicenter expanded access trial that enrolled patients with high-risk neuroblastoma (N=783). The reported adverse event profile of dinutuximab in Study 2 was similar to that observed in Study 1.
Study 3 was a multicenter, single arm safety study of dinutuximab in combination with GM-CSF, IL-2 and RA. In Study 3, adverse events of all CTCAE grades and laboratory data were systematically and comprehensively collected. Of 104 patients enrolled and treated in Study 3, 77% of patients completed study therapy. In general, the adverse reaction profile of dinutuximab observed in Study 3 was similar to that observed in Study 1 and Study 2. The following adverse reactions not previously reported in Study 1 were reported in at least 10% of patients in Study 3: nasal congestion (20%) and wheezing (15%). Table 7 provides the per-patient incidence of laboratory abnormalities in Study 3.
Table 7: Per-Patient Incidence of Selected (≥ 5% Grade 3-4) Laboratory Abnormalities in Study 3 

Laboratory Test* Grade†
All Grades % Grades 3-4 %
ND: not determined
Laboratory abnormalities with a per-patient incidence of at least 20% (all grades) and at least a 5% per-patient incidence of severe (Grade 3 or 4) laboratory abnormalities.
Based on CTCAE version 4.0.
Urinalysis results were reported as positive or negative without assessment of grade.
Hematology
  Anemia 100 46
  Neutropenia 99 63
  Thrombocytopenia 98 49
Chemistry
  Hypoalbuminemia 100 8
  Hypocalcemia 97 7
  Hyponatremia 93 36
  Hyperglycemia 87 6
  Aspartate Aminotransferase Increased 84 8
  Alanine Aminotransferase Increased 83 13
  Hypokalemia 82 41
  Hypophosphatemia 78 6
Urinalysis‡
  Urine protein 66 ND
  Red blood cell casts 38 ND
6.2 Immunogenicity
As with all therapeutic proteins, patients treated with Unituxin may develop anti-drug antibodies. In clinical studies, 52 of 284 (18%) patients from Study 2 and 13 of 103 (13%) patients from Study 3 tested positive for anti-dinutuximab binding antibodies. Neutralizing antibodies were detected in 3.6% of patients who were tested for anti-dinutuximab binding antibodies in Study 2 and Study 3. However, due to the limitations of the assay, the incidence of neutralizing antibodies may not have been reliably determined.
The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence of antibodies to Unituxin with the incidences of antibodies to other products may be misleading.
7 DRUG INTERACTIONS
No drug-drug interaction studies have been conducted with dinutuximab.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
Based on its mechanism of action, Unituxin may cause fetal harm when administered to a pregnant woman [see Clinical Pharmacology (12.1)]. There are no studies in pregnant women and no reproductive studies in animals to inform the drug-associated risk. Monoclonal antibodies are transported across the placenta in a linear fashion as pregnancy progresses, with the largest amount transferred during the third trimester. Advise pregnant women of the potential risk to a fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk in the U.S. general population of major birth defects is 2-4% and of miscarriage is 15-20% of clinically recognized pregnancies.
8.2 Lactation
Risk Summary
There is no information available on the presence of dinutuximab in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. However, human IgG is present in human milk. Because of the potential for serious adverse reactions in a breastfed infant, advise a nursing woman to discontinue breastfeeding during treatment with Unituxin.
8.3 Females and Males of Reproductive Potential
Contraception
Females
Unituxin may cause fetal harm [see Use in Specific Populations (8.1)]. Advise females of reproductive potential to use effective contraception during treatment and for two months after the last dose of Unituxin.
8.4 Pediatric Use
The safety and effectiveness of Unituxin as part of multi-agent, multimodality therapy have been established in pediatric patients with high-risk neuroblastoma based on results of an open-label, randomized (1:1) trial conducted in 226 patients aged 11 months to 15 years (median age 3.8 years) (Study 1). Prior to enrollment, patients achieved at least a partial response to prior first-line therapy for high-risk neuroblastoma consisting of induction combination chemotherapy, maximum feasible surgical resection, myeloablative consolidation chemotherapy followed by autologous stem cell transplant, and received radiation therapy to residual soft tissue disease. Patients randomized to the Unituxin/13-cis-retinoic acid (RA) arm (Unituxin/RA) received up to five cycles of Unituxin in combination with alternating cycles of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-2 (IL-2) plus RA, followed by one cycle of RA alone. Patients randomized to the RA arm received up to six cycles of RA monotherapy. Study 1 demonstrated an improvement in event-free survival and overall survival in patients in the Unituxin/RA arm compared to those in the RA arm [see Adverse Reactions (6), Clinical Pharmacology (12), Clinical Studies (14)].
8.5 Geriatric Use
The safety and effectiveness of Unituxin in geriatric patients have not been established.
8.6 Renal Impairment
Unituxin has not been studied in patients with renal impairment.
8.7 Hepatic Impairment
Unituxin has not been studied in patients with hepatic impairment.
11 DESCRIPTION
Unituxin (dinutuximab) is a chimeric monoclonal antibody composed of murine variable heavy and light chain regions and the human constant region for the heavy chain IgG1 and light chain kappa. Unituxin binds to the glycolipid disialoganglioside (GD2). Dinutuximab is produced in the murine myeloma cell line, SP2/0.
Unituxin is a sterile, preservative-free, clear/colorless to slightly opalescent solution for intravenous infusion. Unituxin is supplied in single-use vials of 17.5 mg/5mL. Each vial contains 3.5 mg/mL of dinutuximab, histidine (20mM), polysorbate 20 (0.05%), sodium chloride (150 mM), and water for injection; hydrochloric acid is added to adjust pH to 6.8.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Dinutuximab binds to the glycolipid GD2. This glycolipid is expressed on neuroblastoma cells and on normal cells of neuroectodermal origin, including the central nervous system and peripheral nerves. Dinutuximab binds to cell surface GD2 and induces cell lysis of GD2-expressing cells through antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC).
12.3 Pharmacokinetics
The pharmacokinetics of dinutuximab was evaluated by a population pharmacokinetic analysis in a clinical study of Unituxin in combination with GM-CSF, IL-2, and RA. In this study, 27 children with high-risk neuroblastoma (age: 3.9±1.9 years) received up to 5 cycles of Unituxin at 17.5 mg/m2/day as an intravenous infusion over 10 to 20 hours for 4 consecutive days every 28 days. The observed maximum plasma dinutuximab concentration (Cmax) was 11.5 mcg/mL [20%, coefficient of variation (CV)]. The mean volume of distribution at steady state (Vdss) was 5.4 L (28%). The clearance was 0.21 L/day (62%) and increased with body size. The terminal half-life was 10 days (56%).
No formal pharmacokinetic studies were conducted in patients with renal or hepatic impairment.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No animal studies have been conducted to evaluate the carcinogenic or mutagenic potential of dinutuximab.
Dedicated studies examining the effects of dinutuximab on fertility in animals have not been conducted. No clear effects on reproductive organs were observed in general toxicology studies conducted in rats.
13.2 Animal Toxicology and/or Pharmacology
Non-clinical studies suggest that dinutuximab-induced neuropathic pain is mediated by binding of the antibody to the GD2 antigen located on the surface of peripheral nerve fibers and myelin and subsequent induction of CDC and ADCC activity.
14 CLINICAL STUDIES
The safety and effectiveness of Unituxin was evaluated in a randomized, open-label, multicenter trial conducted in pediatric patients with high-risk neuroblastoma (Study 1). All patients had received prior therapy consisting of induction combination chemotherapy, maximum feasible surgical resection, myeloablative consolidation chemotherapy followed by autologous stem cell transplant, and radiation therapy to residual soft tissue disease. Patients were randomized between Day 50 and Day 77 post-autologous stem cell transplantation.
Patients were required to have achieved at least a partial response prior to autologous stem cell transplantation, have no evidence of disease progression following completion of front-line multi-modality therapy, have adequate pulmonary function (no dyspnea at rest and peripheral arterial oxygen saturation of at least 94% on room air), adequate hepatic function (total bilirubin < 1.5 × the upper limit of normal and ALT < 5 × the upper limit of normal), adequate cardiac function (shortening fraction of > 30% by echocardiogram, or if shortening fraction abnormal, ejection fraction of 55% by gated radionuclide study), and adequate renal function (glomerular filtration rate at least 70 mL/min/1.73 m2). Patients with systemic infections or a requirement for concomitant systemic corticosteroids or immunosuppressant usage were not eligible for enrollment.
Patients randomized to the Unituxin/RA arm received up to five cycles of dinutuximab (clinical trials material) in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) (Table 8) or interleukin-2 (IL-2) (Table 9) plus 13-cis-retinoic acid (RA), followed by one cycle of RA alone. Patients randomized to the RA arm received six cycles of RA. Dinutuximab was administered at a dose of 17.5 mg/m2/day (equivalent to 25/mg/m2/day of clinical trials material) on four consecutive days. Patients in both treatment arms received six cycles of RA at a dose of 160 mg/m2/day orally (for patients weighing more than 12 kg) or 5.33 mg/kg/day (for patients weighing less than or equal to 12 kg) in two divided doses for 14 consecutive days.
Table 8: Dosage Regimen in the Unituxin

Cycle Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15-24
* GM-CSF: 250 µg/m 2/day, administered by either subcutaneous injection (recommended) or IV infusion administered over 2 hours.
Unituxin: 17.5 mg/m 2/day, administered by diluted IV infusion over 10–20 hours.
‡RA: for >12 kg body weight, 80 mg/m 2 orally twice daily for a total dose of 160 mg/m 2/day; for ≤12 kg body weight, 2.67 mg/kg orally twice daily for a total daily dose of 5.33 mg/kg/day (round dose up to nearest 10 mg).
GM-CSF* X X X X X X X X X X X X X X
Unituxin† X X X X
RA‡
Table 9: Dosage Regimen in the Unituxin/RA

Cycle Day 1 2 3 4 5 6 7 8 9 10 11 12-14 15-28 29-32

IL-2: 3 MIU/m 2/day administered by continuous IV infusion over 96 hours on Days 1-4 and 4.5 MIU/m 2/day on Days 8-11.

Unituxin: 17.5 mg/m 2/day, administered by diluted IV infusion over 10-20 hours.

RA: for >12 kg body weight, 80 mg/m 2 orally twice daily for a total dose of 160 mg/m 2/day; for ≤12 kg body weight, 2.67 mg/kg orally twice daily for a total daily dose of 5.33 mg/kg/day (round dose up to nearest 10 mg).
IL-2* X X X X X X X X
Unituxin† X X X X
RA‡
A total of 226 patients were randomized, 113 patients to each arm. In general, demographic and baseline tumor characteristics were similar across study arms. Across the study population, 60% were male, the median age was 3.8 years and 3% of patients were less than 1.5 years, 82% were White and 7% were Black. The majority (80%) of patients had International Neuroblastoma Staging System Stage 4 disease. Thirty-five percent of patients had a complete response, 43% had a very good partial response, and 23% had a partial response to therapy received prior to autologous stem cell transplant. Forty-six percent of patients had neuroblastoma that was not MYCN-amplified, 36% had tumors with known MYCN-amplification, and MYCN status was unknown or missing in 19% of patients. Forty-three percent of patients had hyperdiploid tumors, 36% had diploid tumors, and DNA ploidy status was unknown or missing in 21% of patients.
The major efficacy outcome measure was investigator-assessed event-free survival (EFS), defined as the time from randomization to the first occurrence of relapse, progressive disease, secondary malignancy, or death. Overall survival (OS) was also evaluated. After observing a numerical improvement in EFS based on the seventh interim analysis, the Data Monitoring Committee recommended termination of accrual. Efficacy results are shown in Table 10.
Table 10: Efficacy Results

Efficacy Parameter Unituxin/ RA arm
n=113
RA arm
n=113
NR = not reached
Compared to the allocated alpha of 0.01 pre-specified for the seventh interim analysis of EFS
Based on an additional three years of follow up after the seventh interim analysis of EFS
EFS No. of Events (%) 33 (29%) 50 (44%)
  Median (95% CI) (years) NR (3.4 ,NR) 1.9 (1.3, NR)
    Hazard Ratio (95% CI) 0.57 (0.37, 0.89)
    p-value (log-rank test)* 0.01
OS† No. of Events (%) 31 (27%) 48 (42%)
  Median (95% CI) (years) NR (7.5,NR) NR (3.9,NR)
    Hazard Ratio (95% CI) 0.58 (0.37,0.91)
The Kaplan-Meier curve of EFS is shown in Figure 1.
16 HOW SUPPLIED / STORAGE AND HANDLING
Unituxin is supplied in a carton containing one 17.5 mg/5 mL (3.5 mg/mL) single-use vial.
NDC 66302-014-01
Store Unituxin vials under refrigeration at 2°C to 8°C until time of use. Do not freeze or shake the vial. Keep the vial in the outer carton in order to protect from light.

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