近日，欧盟委员会批准EMPLICITI(ELOTUZUMAB)INJECTABLE INJECTION以合并用药形式用于多发性骨髓瘤治疗。Empliciti被批准与来那度胺及地塞米松合并用于既往至少接受过一种治疗的患者。这次的批准代表了首个也是唯一在欧盟获批用于多发性骨髓瘤的免疫刺激性抗体。
批准日期：2016年5月18日  公司：百时美施贵宝与艾伯维
EMPLICITI TM（埃罗妥珠单抗 elotuzumab）注射，供静脉使用
首次批准：2015年
作用机制
Elotuzumab是人源化IgG1单克隆抗体，能特异性靶向SLAMF7（信号淋巴细胞激活分子家族成员7）的蛋白质。SLAMF7表达对骨髓瘤细胞的独立细胞遗传学异常。SLAMF7也表达在天然杀伤细胞，浆细胞，并在上分化的细胞的造血谱系内的特定的免疫细胞亚群更低的水平。
Elotuzumab同时通过SLAMF7途径和Fc受体直接激活天然杀伤细胞.Elotuzumab还针对SLAMF7上骨髓瘤细胞，并促进与自然杀伤细胞的相互作用通过抗体依赖的细胞毒性（ADCC）介导骨髓瘤细胞的杀伤。在临床前模型，elotuzumab和来那度胺的组合导致自然杀伤细胞比任一药剂单独的影响更大，并在体外和体内增加的抗肿瘤活性的增强活化。
适应症
EMPLICITI是与来那度胺和地塞米松对患者谁收到一至三个先前治疗多发性骨髓瘤的治疗组合指示的SLAMF7定向免疫刺激性抗体。
用法用量
推荐剂量和用法是10毫克/公斤体重，静脉注射，前两个周期每周一次，之后每2周一次；Elotuzumab输注前用H1阻断剂， H2受体阻断剂，和对乙酰氨基酚以预防不良反应。
来那度胺:25毫克，每天口服，1至21天，每28天重复；
地塞米松给药如下：在Elotuzumab输注周，地塞米松是分剂量来给药，在Elotuzumab输注前 8毫克静脉给药和28毫克口服; 在无Elotuzumab输注周，地塞米松是口服给药40毫克。
病人持续治疗直到疾病恶化或发生不能耐受的毒付作用，
剂型和规格
注射：300毫克或400毫克的单一剂量小瓶用于重构冻干粉末。
禁忌
无。
警告和注意事项
输液反应：
术前用药是必需的。中断EMPLICITI 2或更高级别，并永久停止对严重的输液反应。
感染：
监视发热等感染症状和治疗及时。
第二原发恶性肿瘤（SPM）：SPM的发生率较高，观察患者的临床对照试验与多发性骨髓瘤接收EMPLICITI。
肝毒性：
监测肝功能，并停止EMPLICITI若肝之嫌。
干扰的决心完全反应：EMPLICITI可以用于监测M蛋白检测干扰。这种干扰可能会影响完全反应的决心。
不良反应
最常见的不良反应（20％以上）是疲劳，腹泻，发热，便秘，咳嗽，周围神经病变，鼻咽炎，上呼吸道感染，食欲下降，肺炎。
特殊人群中使用
妊娠：与组合三个药物给药方案胚胎，胚胎毒性。

Empliciti 300 mg and 400 mg powder for concentrate for solution for infusion.
1. Name of the medicinal product
Empliciti 300 mg powder for concentrate for solution for infusion.
Empliciti 400 mg powder for concentrate for solution for infusion.
2. Qualitative and quantitative composition
Empliciti 300 mg powder for concentrate for solution for infusion
Each vial contains 300 mg elotuzumab*.
Empliciti 400 mg powder for concentrate for solution for infusion
Each vial contains 400 mg elotuzumab.
After reconstitution, each mL of concentrate contains 25 mg elotuzumab.
* Elotuzumab is produced in NS0 cells by recombinant DNA technology.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Powder for concentrate for solution for infusion (powder for concentrate).
The powder is white to off white whole or fragmented cake.
4. Clinical particulars
4.1 Therapeutic indications
Empliciti is indicated in combination with lenalidomide and dexamethasone for the treatment of multiple myeloma in adult patients who have received at least one prior therapy (see sections 4.2 and 5.1).
4.2 Posology and method of administration
Elotuzumab therapy should be initiated and supervised by physicians experienced in the treatment of multiple myeloma.
Premedication for prevention of infusion reaction
Patients must be administered with the following premedications 45-90 minutes prior to Empliciti infusion (see section 4.4):
Dexamethasone 8 mg intravenous
H1 blocker: diphenhydramine (25-50 mg orally or intravenous) or equivalent H1 blocker.
H2 blocker: ranitidine (50 mg intravenous or 150 mg orally) or equivalent H2 blocker.
Paracetamol (650-1000 mg orally).
Management of infusion reaction
If a ≥ Grade 2 infusion reaction occurs during Empliciti administration, the infusion must be interrupted. Upon resolution to ≤ Grade 1, Empliciti should be restarted at 0.5 mL/min and may be gradually increased at a rate of 0.5 mL/min every 30 minutes as tolerated to the rate at which the infusion reaction occurred. If there is no recurrence of the infusion reaction, the escalation can be resumed (see Table 2).
In patients who experience an infusion reaction, vital signs should be monitored every 30 minutes for 2 hours after the end of the Empliciti infusion. If the infusion reaction recurs, the Empliciti infusion must be stopped and not restarted on that day (see section 4.4). Very severe infusion reactions (≥ Grade 3) may require permanent discontinuation of Empliciti therapy and emergency treatment.
Posology for administration with lenalidomide and dexamethasone
The dosing schedule is presented in Table 1.
Treatment should continue until disease progression or unacceptable toxicity.
The recommended dose of Empliciti is 10 mg/kg administered intravenously every week (28-day cycle), on days 1, 8, 15, and 22 for the first two cycles and every 2 weeks thereafter on days 1 and 15.
The recommended dose of lenalidomide is 25 mg orally once daily on days 1-21 of repeated 28-day cycles, and at least 2 hours after Empliciti infusion when administered on the same day.
The administration of dexamethasone is as follows:
• On days that Empliciti is administered, dexamethasone should be given as 28 mg orally once daily between 3 and 24 hours before Empliciti plus 8 mg intravenously between 45 and 90 minutes before Empliciti on days 1, 8, 15, and 22 of repeated 28-day cycles.
• On days that Empliciti is not administered but a dose of dexamethasone is scheduled (Days 8 and 22 of cycle 3 and all subsequent cycles), dexamethasone should be given 40 mg orally.
Table 1: Recommended dosing schedule of Empliciti in combination with lenalidomide and dexamethasone

Cycle	28-Day Cycles 1 & 2				28-Day Cycles 3+
Day of Cycle	1	8	15	22	1	8	15	22
Premedication	✓	✓	✓	✓	✓		✓
Empliciti (mg/kg) Intravenous	10	10	10	10	10		10
Lenalidomide (25 mg) Oral	Days 1-21				Days 1-21
Dexamethasone (mg) Oral	28	28	28	28	28	40	28	40
Day of Cycle	1	8	15	22	1	8	15	22

For additional information concerning lenalidomide and dexamethasone, see the corresponding Summary of Product Characteristics.
See Method of administration below for instruction on infusion rates.
Dose delay, interruption, or discontinuation
If the dose of one medicine in the regimen is delayed, interrupted, or discontinued, the treatment with the other medicinal products may continue as scheduled. However, if oral or intravenous dexamethasone is delayed or discontinued, the administration of Empliciti should be based on clinical judgment (e.g. risk of hypersensitivity) (see section 4.4).
Special populations
Paediatric population
There is no relevant use of Empliciti in the paediatric population for the indication of multiple myeloma.
Elderly
No dose adjustment is required for elotuzumab in patients over 65 years of age (see section 5.2). Data on the efficacy and safety of elotuzumab in patients ≥ 85 years of age are very limited.
Renal impairment
No dose adjustment of Empliciti is required for patients with mild (CrCl = 60 - 89 mL/min), moderate (CrCl = 30 - 59 mL/min), severe (CrCl < 30 mL/min) renal impairment or end stage renal disease requiring dialysis (see section 5.2).
Hepatic impairment
No dose adjustment for Empliciti is required for patients with mild hepatic impairment (total bilirubin [TB] ≤ to the upper limit of normal [ULN] and AST > ULN or TB < 1 to 1.5 × ULN and any AST). Empliciti has not been studied in patients with moderate (TB > 1.5 to 3 × ULN and any AST) or severe (TB > 3 × ULN and any AST) hepatic impairment (see section 5.2).
Method of administration
Empliciti is for intravenous use only.
The administration of the reconstituted and diluted solution must be initiated at an infusion rate of 0.5 mL/min. If the infusion is well tolerated the infusion rate may be increased in a stepwise fashion as described in Table 2. The maximum infusion rate should not exceed 5 mL/min.
Table 2: Infusion rate for Empliciti

Cycle 1, Dose 1		Cycle 1, Dose 2		Cycle 1, Dose 3 and 4 and all subsequent Cycles
Time interval	Rate	Time interval	Rate	Rate
0 - 30 min	0.5 mL/min	0 - 30 min	3 mL/min	5 mL/min*
30 - 60 min	1 mL/min	≥ 30 min	4 mL/min*
≥ 60 min	2 mL/min*	-	-

Continue this rate until infusion is completed, approximately 1 hour based on patient weight.
For instructions on reconstitution and dilution of Empliciti before administration, see section 6.6.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
The Summary of Product Characteristics for all medicinal products used in combination with Empliciti must be consulted before starting therapy.
4.4 Special warnings and precautions for use
Infusion reaction
Infusion reactions have been reported in patients receiving elotuzumab (see section 4.8).
Premedication consisting of dexamethasone, H1 blocker, H2 blocker, and paracetamol must be administered prior to Empliciti infusion (see section 4.2 Premedication). The rate of infusion reactions was much higher in patients who were not premedicated.
If any of the symptoms of infusion reaction reach Grade ≥ 2, Empliciti infusion must be interrupted and appropriate medical and supportive measures instituted. Vital signs should be monitored every 30 minutes for 2 hours after the end of the Empliciti infusion. Once the reaction has resolved (symptoms ≤ Grade 1), Empliciti can be restarted at the initial infusion rate of 0.5 mL/min. If symptoms do not recur, the infusion rate may be gradually escalated every 30 minutes to a maximum of 5 mL/min (see section 4.2 Method of administration).
Very severe infusion reactions may require permanent discontinuation of Empliciti therapy and emergency treatment. Patients with mild or moderate infusion reactions may receive Empliciti with a reduced infusion rate and close monitoring (see section 4.2 Method of administration).
Conditions for use of medicinal products used with Empliciti
Empliciti is used in combination with other medicinal products; therefore, the conditions for use applicable to those medicinal products also apply to the combination therapy. The Summary of Product Characteristics for all medicinal products used in combination with Empliciti must be consulted before starting therapy.
Infections
In clinical trials of patients with multiple myeloma, the incidence of all infections, including pneumonia, were higher in patients treated with Empliciti (see section 4.8). Patients should be monitored and infections should be managed with standard treatment.
Second primary malignancies (SPMs)
In a clinical trial of patients with multiple myeloma that compared Empliciti combined with lenalidomide and dexamethasone treatment to lenalidomide and dexamethasone treatment (Study 1), the incidence of SPMs, and specifically of solid tumours and non-melanoma skin cancer, was higher in patient treated with Empliciti (see section 4.8). SPMs are known to be associated with lenalidomide exposure, which was extended in patients treated with Empliciti combined with lenalidomide and dexamethasone vs. lenalidomide and dexamethasone. The rate of haematologic malignancies was the same between the two treatment arms. Patients should be monitored for the development of SPMs.
4.5 Interaction with other medicinal products and other forms of interaction
Pharmacokinetic interaction studies have not been conducted. Empliciti, as a humanised monoclonal antibody, is not expected to be metabolised by cytochrome P450 (CYP) enzymes or other drug metabolising enzymes, inhibition or induction of these enzymes by co-administered medicinal products is not anticipated to affect the pharmacokinetics of Empliciti.
Empliciti may be detected in the serum protein electrophoresis (SPEP) and serum immunofixation assays of myeloma patients and could interfere with correct response classification. The presence of elotuzumab in patient's serum may cause a small peak in the early gamma region on SPEP that is IgGƙ on serum immunofixation. This interference can impact the determination of complete response and possibly relapse from complete response in patients with IgG kappa myeloma protein.
In case of detection of additional peaks on serum immunofixation, the possibility of a biclonal gammopathy should be excluded.
The Summary of Product Characteristics for all medicinal products used in combination with Empliciti must be consulted before starting therapy.
4.6 Fertility, pregnancy and lactation
Woman of childbearing potential/Contraception in the males and females
Empliciti should not be used in women of childbearing potential, unless the clinical condition of the woman requires treatment with elotuzumab. Women of childbearing potential should use effective contraception.
Male patients must use effective contraception measures during and for 180 days following treatment if their partner is pregnant or of childbearing potential and not using effective contraception.
Pregnancy
There is no human experience with elotuzumab during pregnancy. Elotuzumab will be given in combination with lenalidomide, which is contraindicated during pregnancy. No animal data are present regarding the effect on reproductive toxicity because of the lack of an adequate animal model. Empliciti should not be used during pregnancy unless the clinical condition of the woman requires treatment with elotuzumab.
The Summary of Product Characteristics for all medicinal products used in combination with Empliciti must be consulted before starting therapy. When Empliciti is used with lenalidomide there is a risk of foetal harm, including severe life-threatening human birth defects associated with these agents and the need to follow requirements regarding pregnancy avoidance, including testing and contraception. Lenalidomide is present in the blood and sperm of patients receiving the medicine. Refer to the Summary of Product Characteristics for requirements regarding contraception due to presence and transmission in sperm and for additional detail. Patients receiving Empliciti in combination with lenalidomide should adhere to the pregnancy prevention programme of lenalidomide.
Breast-feeding
Elotuzumab is not expected to be excreted into human milk. Elotuzumab will be given in combination with lenalidomide and breast-feeding should be stopped because of the use of lenalidomide.
Fertility
Studies to evaluate the effect of elotuzumab on fertility have not been performed. Thus, the effect of elotuzumab on male and female fertility is unknown.
4.7 Effects on ability to drive and use machines
On the basis of reported adverse reactions, Empliciti is not expected to influence the ability to drive or use machines. Patients experiencing infusion reactions should be advised not to drive and use machines until symptoms abate.
4.8 Undesirable effects
Summary of safety profile
The safety data of elotuzumab have been assessed from a total of 554 patients with multiple myeloma treated with elotuzumab in combination with lenalidomide and dexamethasone (451 patients) or bortezomib and dexamethasone (103 patients) pooled across 6 clinical trials. The majority of adverse reactions were mild to moderate (Grade 1 or 2).
The most serious adverse reaction that may occur during elotuzumab treatment is pneumonia.
The most common adverse reactions (occurring in > 10% of patients) with elotuzumab treatment were infusion related reactions, diarrhoea, herpes zoster, nasopharyngitis, cough, pneumonia, upper respiratory tract infection, lymphopenia and weight decreased.
Tabulated list of adverse reactions
Adverse reactions reported in 554 patients with multiple myeloma who were treated with elotuzumab in 6 clinical trials are presented in Table 3.
These reactions are presented by system organ class and by frequency. Frequencies are defined as: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000); and not known (cannot be estimated from available data).
Table 3: Adverse reactions in patients with multiple myeloma treated with Empliciti

System Organ Class	Adverse reactions	Frequency overall	Grade 3/4 frequency
Infections and infestations	Herpes zostera	Very common	Common
	Nasopharyngitis	Very common	None reported
	Pneumoniab	Very common	Very common
	Upper respiratory tract infection	Very common	Common
Blood and lymphatic system disorders	Lymphopeniac	Very common	Very common
Immune system disorders	Anaphylactic reaction	Uncommon	Uncommon
	Hypersensitivity	Common	Uncommon
Psychiatric disorders	Mood altered	Common	None reported
Nervous system disorders	Headache	Very common	Uncommon
	Hypoaesthesia	Common	Uncommon
Vascular disorders	Deep vein thrombosis	Common	Common
Respiratory, thoracic and mediastinal disorders	Coughd	Very common	Uncommon
	Oropharyngeal pain	Common	None reported
Gastrointestinal disorders	Diarrhoea	Very common	Common
Skin and subcutaneous tissue disorders	Night sweats	Common	None reported
General disorders and administration site conditions	Chest pain	Common	Common
	Fatigue	Very common	Common
	Pyrexia	Very common	Common
Investigations	Weight decreased	Very common	Uncommon
Injury, poisoning and procedural complications	Infusion related reaction	Common	Common

a The term herpes zoster is a grouping of the following terms: herpes zoster, oral herpes, and herpes virus infection.
b The term pneumonia is a grouping of the following terms: pneumonia, atypical pneumonia, bronchopneumonia, lobar pneumonia, bacterial pneumonia, fungal pneumonia, pneumonia influenza, and pneumococcal pneumonia.
c The term lymphopenia includes the following terms: lymphopenia and lymphocyte count decreased.
d The term cough includes the following terms: cough, productive cough, and upper airway cough syndrome.
Exposure-adjusted rates for adverse reactions (all Grades and Grade 3/4) in Study 1, a clinical trial in patients with multiple myeloma comparing Empliciti combined with lenalidomide and dexamethasone treatment (N = 318) to lenalidomide and dexamethasone treatment (N = 317), is shown in Table 4.
Table 4: Exposure-adjusted rates for adverse reactions for Empliciti-treated patients versus lenalidomide and dexamethasone-treated patients [includes multiple occurrences of all treated patients]

Empliciti + Lenalidomide and Dexamethasone N = 318				Lenalidomide and Dexamethasone   N = 317
	All grades		Grade 3/4		All grades		Grade 3/4
Adverse reaction	Event count	Rate (incidence rate/100 patient years)	Event count	Rate (incidence rate/100 patient years)	Event count	Rate (incidence rate/100 patient years)	Event count	Rate (incidence rate/100 patient years)
Diarrhoea	303	59.2	19	3.7	206	49.3	13	3.1
Pyrexia	220	43.0	8	1.6	116	27.7	10	2.4
Fatigue	205	40.0	33	6.4	145	34.7	26	6.2
Cougha	170	33.2	1	0.2	85	20.3	-	-
Nasopharyngitis	151	29.5	-	-	116	27.7	-	-
Upper respiratory tract infection	129	25.2	2	0.4	95	22.7	4	1.0
Lymphopeniab	90	17.6	65	12.7	57	13.6	31	7.4
Headache	88	17.2	1	0.2	40	9.6	1	0.2
Pneumoniac	80	15.6	54	10.5	54	12.9	34	8.1
Herpes zosterd	51	10.0	5	1.0	24	5.7	3	0.7
Oropharyngeal pain	45	8.8	-	-	17	4.1	-	-
Weight decreased	44	8.6	4	0.8	20	4.8	-	-
Night sweats	31	6.1	-	-	12	2.9	-	-
Chest pain	29	5.7	2	0.4	12	2.9	1	0.2
Deep vein thrombosis	26	5.1	18	3.5	12	2.9	7	1.7
Hypoaethesia	25	4.9	1	0.2	12	2.9	-	-
Mood altered	23	4.5	-	-	8	1.9	-	-
Hypersensitivity	10	2.0	-	-	4	1.0	1	0.2

a The term cough includes the following terms: cough, productive cough, and upper airway cough syndrome.
b The term lymphopenia includes the following terms: lymphopenia and lymphocyte count decreased.
c The term pneumonia is a grouping of the following terms: pneumonia, atypical pneumonia, bronchopneumonia, lobar pneumonia, bacterial pneumonia, fungal pneumonia, pneumonia influenza, and pneumococcal pneumonia.
d The term herpes zoster is a grouping of the following terms: herpes zoster, oral herpes, and herpes virus infection.
Description of selected adverse reactions
Infusion reactions
In a clinical trial of patients with multiple myeloma (Study 1), infusion reactions were reported in approximately 10% of premedicated patients treated with Empliciti combined with lenalidomide and dexamethasone (N = 318) (see section 4.4). The rate of mild to moderate infusion reactions was > 50% in patients who were not premedicated. All reports of infusion reaction were ≤ Grade 3. Grade 3 infusion reactions occurred in 1% of patients. The most common symptoms of an infusion reaction included fever, chills, and hypertension. Five percent (5%) of patients required interruption of the administration of Empliciti for a median of 25 minutes due to infusion reaction, and 1% of patients discontinued due to infusion reactions. Of the patients who experienced an infusion reaction, 70% (23/33) had the reaction during the first dose.
Infections
The incidence of infections, including pneumonia, was higher with Empliciti treatment than with control (see section 4.4). In a clinical trial of patients with multiple myeloma (Study 1), infections were reported in 81.4% of patients in the Empliciti combined with lenalidomide and dexamethasone arm (N = 318) and 74.4% in lenalidomide and dexamethasone arm (N = 317). Grade 3-4 infections were noted in 28% and 24.3% of Empliciti combined with lenalidomide and dexamethasone and lenalidomide and dexamethasone treated patients, respectively. Fatal infections were infrequent and were reported in 2.5% of Empliciti combined with lenalidomide and dexamethasone and 2.2% of lenalidomide and dexamethasone treated patients. The incidence of pneumonia was higher in the Empliciti combined with lenalidomide and dexamethasone arm compared to lenalidomide and dexamethasone arm reported at 15.1% vs. 11.7% with a fatal outcome at 0.6% vs. 0%, respectively.
Second Primary Malignancies
The incidence of SPMs was higher with Empliciti treatment than with control (see section 4.4). In a clinical trial of patients with multiple myeloma (Study 1), invasive SPMs have been observed in 6.9% of patients treated with Empliciti combined with lenalidomide and dexamethasone (N = 318) and 4.1% of patients treated with lenalidomide and dexamethasone (N = 317). Second Primary Malignancies are known to be associated with lenalidomide exposure which was extended in patients treated with Empliciti combined with lenalidomide and dexamethasone vs. lenalidomide and dexamethasone. The rate of haematologic malignancies were the same between the two treatment arms (1.6%). Solid tumours were reported in 2.5% and 1.9% of Empliciti combined with lenalidomide and dexamethasone and lenalidomide and dexamethasone treated patients, respectively. Non-melanoma skin cancer was reported in 3.1% and 1.6% of patients treated with Empliciti combined with lenalidomide and dexamethasone and lenalidomide and dexamethasone, respectively.
Deep vein thrombosis
In a clinical trial of patients with multiple myeloma (Study 1), deep vein thromboses were reported in 7.2% of patients treated with Empliciti combined with lenalidomide and dexamethasone (N = 318) and 3.8% of patients treated with lenalidomide and dexamethasone (N = 317). Among, patients treated with aspirin, deep vein thromboses were reported in 4.1% of patients treated with Empliciti combined with lenalidomide and dexamethasone (E-Ld) and 1.4% of patients treated with lenalidomide and dexamethasone (Ld). The rates of deep vein thromboses observed between treatment arms were similar for patients given prophylaxis with low molecular weight heparin (2.2% in both treatment arms), and for patients given vitamin K antagonists the rates were 0% for patients treated with E-Ld and 6.7% for patients treated with Ld.
Immunogenicity
As with all therapeutic proteins, there is a potential for immunogenicity to Empliciti.
Of 390 patients across four clinical studies who were treated with Empliciti and evaluable for the presence of anti-product antibodies, 72 patients (18.5%) tested positive for treatment-emergent anti-product antibodies by an electrochemiluminescent (ECL) assay. Neutralizing antibodies were detected in 19 of 299 patients in Study 1. In the majority of patients, immunogenicity occurred early in treatment and was transient resolving by 2 to 4 months. There was no clear causal evidence of altered pharmacokinetic, efficacy, or toxicity profiles with anti-product antibody development based on the population pharmacokinetic and exposure-response analyses.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions (see details below).
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Fax: +353 1 6762517
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4.9 Overdose
One patient was reported to be overdosed with 23.3 mg/kg of elotuzumab in combination with lenalidomide and dexamethasone. The patient had no symptoms, did not require any treatment for the overdose, and was able to continue on elotuzumab therapy.
In clinical studies, approximately 78 patients were evaluated with elotuzumab at 20 mg/kg without apparent toxic effects.
In case of overdose, patients should be closely monitored for signs or symptoms of adverse reactions, and appropriate symptomatic treatment instituted.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Antineoplastic agents, monoclonal antibodies. ATC code: L01XC23.
Mechanism of action
Elotuzumab is an immunostimulatory humanised, IgG1 monoclonal antibody that specifically targets the SLAMF7 (signaling lymphocyte activation molecule family member 7) protein. SLAMF7 is highly expressed on multiple myeloma cells independent of cytogenetic abnormalities. SLAMF7 is also expressed on natural killer cells, normal plasma cells, and other immune cells including some T cell subsets, monocytes, B cells, and pDCs (plasmacytoid dendritic cells), but is not detected on normal solid tissues or haematopoietic stem cells.
Elotuzumab directly activates natural killer cells through both the SLAMF7 pathway and Fc receptors enhancing anti-myeloma activity in vitro. Elotuzumab also targets SLAMF7 on myeloma cells and facilitates the interaction with natural killer cells to mediate the killing of myeloma cells through antibody-dependent cellular cytotoxicity (ADCC). In nonclinical models, elotuzumab has demonstrated synergistic activity when combined with lenalidomide or bortezomib.
Clinical efficacy and safety
Two randomised, open-label studies were conducted to evaluate the efficacy and safety of Empliciti (elotuzumab) in adult patients with multiple myeloma who have received one or more prior therapies.
Study 1 provided the pivotal data for the indication for Empliciti in combination with lenalidomide and dexamethasone.
Study 1
A randomised, open-label study was conducted to evaluate the efficacy and safety of Empliciti in combination with lenalidomide and dexamethasone in patients with multiple myeloma who have received one to three prior therapies. All patients had documented progression following their most recent therapy. Patients who were refractory to lenalidomide were excluded and 6% of patients had prior lenalidomide treatment. Patients had to recover after transplant for a minimum of 12 weeks from autologous stem cell transplant (SCT), and 16 weeks from allogeneic SCT. Patients with cardiac amyloidosis or plasma cell leukemia were excluded from this study.
Eligible patients were randomised in a 1:1 ratio to receive either Empliciti in combination with lenalidomide and dexamethasone or lenalidomide and dexamethasone. Treatment was administered in 4-week cycles until disease progression or unacceptable toxicity. Elotuzumab 10 mg/kg was administered intravenously each week for the first 2 cycles and every 2 weeks thereafter. Prior to Empliciti infusion, dexamethasone was administered as a divided dose: an oral dose of 28 mg and an intravenous dose of 8 mg. In the control group and on weeks without Empliciti, dexamethasone 40 mg was administered as a single oral dose weekly. Lenalidomide 25 mg was taken orally once daily for the first 3 weeks of each cycle. Assessment of tumour response was conducted every 4 weeks.
A total of 646 patients were randomised to receive treatment: 321 to Empliciti in combination with lenalidomide and dexamethasone and 325 to lenalidomide and dexamethasone.
Demographics and baseline characteristics were well balanced between treatment arms. The median age was 66 years (range 37 to 91); 57% of patients were older than 65 years; 60% of patients were male; Whites comprised 84% of the study population, Asians 10%, and blacks 4%. The International Staging System (ISS) Stage was I in 43%, II in 32% and III in 21% of patients. The high risk cytogenetic categories of del17p and t(4;14) were present in 32% and 9% of patients, respectively. The median number of prior therapies was 2. Thirty-five percent (35%) of patients were refractory (progression during or within 60 days of last therapy) and 65% were relapsed (progression after 60 days of last therapy). Prior therapies included: stem cell transplant (55%), bortezomib (70%) melphalan (65%), thalidomide (48%), and lenalidomide (6%).
The primary endpoints of this study, progression-free survival (PFS), as assessed by hazard ratio, and overall response rate (ORR) were determined based on assessments made by a blinded Independent Review Committee. Efficacy results are presented in Table 5 and Figure 1. The median number of treatment cycles was 19 for the Empliciti arm and 14 for the comparator arm.
Table 5: Efficacy results for Study 1

Empliciti + Lenalidomide/ Dexamethasone N = 321	Lenalidomide/ Dexamethasone N = 325
PFS (ITT)
Hazard Ratio [97.61% CI]	0.68 [0.55, 0.85]
Stratified log-rank test p-valuea	0.0001
1-Year PFS rate (%) [95% CI]	68 [63, 73]	56 [50, 61]
2-Year PFS rate (%) [95% CI]	39 [34, 45]	26 [21, 31]
3-Year PFS rateb (%) [95% CI]	23 [18, 28]	15 [10, 20]
Median PFS in months [95% CI]	18.5 [16.5, 21.4]	14.3 [12.0, 16.0]
Response
Overall Response (ORR)c n (%) [95% CI]	252 (78.5) [73.6, 82.9]	213 (65.5) [60.1, 70.7]
p-valued	0.0002
Complete Response (CR + sCR)e n (%)	14 (4.4)f	24 (7.4)
Very Good Partial Response (VGPR) n (%)	91 (28.3)	67 (20.6)
Partial Response (RR/PR) n (%)	147 (45.8)	122 (37.5)
Combined Responses (CR+sCR+VGPR) n (%)	105 (32.7)	91 (28.0)
Overall Survivalg
Hazard Ratio [95% CI]	0.77 [0.61, 0.97]
Stratified log-rank test p-value	0.0257h
Median OS in months [95% CI]	43.7 [40.34, NE]	39.6 [33.25,NE]

a p-value based on the log-rank test stratified by B2 microglobulins (<3.5 mg/L versus ≥ 3.5 mg/L), number of prior lines of therapy (1 versus 2 or 3), and prior immunomodulatory therapy (no versus prior thalidomide only versus other).
b A pre-specified analysis for 3-year PFS rate was performed based on a minimum follow-up time of 33 months.
c European Group for Blood and Marrow Transplantation (EBMT) criteria.
d p-value based on the Cochran-Mantel-Haenszel chi-square test stratified by B2 microglobulins (<3.5 mg/L versus ≥ 3.5 mg/L), number of prior lines of therapy (1 versus 2 or 3), and prior immunomodulatory therapy (no versus prior thalidomide only versus other).
e Complete response (CR) + stringent complete response (sCR).
f Complete response rates in Empliciti group may be underestimated due to interference of elotuzumab monoclonal antibody with immunofixation assay and serum protein electrophoresis assay.
g A pre-specified interim analysis for OS was performed based on a minimum follow-up time of 35.4 months.
h The interim OS analysis did not meet the protocol-specified early stopping boundary for OS (p ≤ 0.014).
Figure 1: Progression free survival

Improvements observed in PFS were consistent across subsets regardless of age (< 65 versus ≥ 65), risk status, presence or absence of cytogenetic categories del17p or t(4;14), ISS stage, number of prior therapies, prior immunomodulatory exposure, prior bortezomib exposure, relapsed or refractory status or renal function as shown in Table 6.
Table 6: Efficacy results for subsets

Table 6: Efficacy results for subsets
	E-Ld N = 321	Ld N = 325
Subset description	Median PFS (months) [95% CI]	Median PFS (months) [95% CI]	HR [95% CI]
Age
< 65 years	19.4 [15.9, 23.1]	15.7 [11.2, 18.5]	0.74 [0.55, 1.00]
≥ 65 years	18.5 [15.7, 22.2]	12.9 [10.9, 14.9]	0.64 [0.50, 0.82]
Risk factors
High risk	14.8 [9.1, 19.6]	7.2 [5.6, 11.2]	0.63 [0.41, 0.95]
Standard risk	19.4 [16.5, 22.7]	16.4 [13.9, 18.5]	0.75 [0.59, 0.94]
Cytogenetic category
Presence of del17p	19.6 [15.8, NE]	14.9 [10.6, 17.5]	0.65 [0.45, 0.93]
Absence of del17p	18.5 [15.8, 22.1]	13.9 [11.1, 16.4]	0.68 [0.54, 0.86]
Presence of t(4;14)	15.8 [8.4, 18.4]	5.5 [3.1, 10.3]	0.55 [0.32, 0.98]
Absence of t(4;14)	19.6 [17.0, 23.0]	14.9 [12.4, 17.1]	0.68 [0.55, 0.84]
ISS Stage
I	22.2 [17.8, 31.3]	16.4 [14.5, 18.6]	0.61 [0.45, 0.83]
II	15.9 [9.5, 23.1]	12.9 [11.1, 18.5]	0.83 [0.60, 1.16]
III	14.0 [9.3, 17.3]	7.4 [5.6, 11.7]	0.70 [0.48, 1.04]
Prior therapies
Lines of prior therapy = 1	18.5 [15.8, 20.7]	14.5 [10.9, 17.5]	0.71 [0.54, 0.94]
Lines of prior therapy = 2 or 3	18.5 [15.9, 23.9]	14.0 [11.1, 15.7]	0.65 [0.50, 0.85]
Prior thalidomide exposure	18.4 [14.1, 23.1]	12.3 [9.3, 14.9]	0.61 [0.46, 0.80]
No prior immunomodulatory exposure	18.9 [15.8, 22.2]	17.5 [13.0, 20.0]	0.78 [0.59, 1.04]
Prior bortezomib exposure	17.8 [15.8, 20.3]	12.3 [10.2, 14.9]	0.67 [0.53, 0.84]
No prior bortezomib exposure	21.4 [16.6, NE]	17.5 [13.1, 21.3]	0.70 [0.48, 1.00]
Response to therapy
Relapsed	19.4 [16.6, 22.2]	16.6 [13.0, 18.9]	0.75 [0.59, 0.96]
Refractory	16.6 [14.5, 23.3]	10.4 [6.6, 13.3]	0.55 [0.40, 0.76]
Renal function
Baseline CrCl < 60 mL/min	18.5 [14.8, 23.3]	11.7 [7.5, 17.4]	0.56 [0.39, 0.80]
Baseline CrCl ≥ 60 mL/min	18.5 [15.9, 22.2]	14.9 [12.1, 16.7]	0.72 [0.57, 0.90]

The 1-, 2- nd 3-year rates of overall survival for Empliciti in combination with lenalidomide and dexamethasone treatment were 91%, 73%, and 60% respectively, compared with 83%, 69%, and 53% respectively, for lenalidomide and dexamethasone treatment (See Figure 2).
Figure 2: Overall survival

Paediatric population
The European Medicines Agency has waived the obligation to submit the results of studies in all subsets of the paediatric population in treatment of multiple myeloma (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
The pharmacokinetics (PK) of elotuzumab was studied in patients with multiple myeloma.
Absorption
Elotuzumab is dosed via intravenous route and therefore is immediately and completely bioavailable.
Distribution
Mean volume of distribution of elotuzumab ranged from 36 mL/kg to 70 mL/kg (2.3-4.6 L for a typical patient) and was independent from the dose in a dose range of 0.5 mg/kg to 20 mg/kg.
Biotransformation
The metabolic pathway of elotuzumab has not been characterized. As an IgG monoclonal antibody, elotuzumab is expected to be degraded into small peptides and amino acids via catabolic pathways.
Elimination
Following a single dose of 10 mg/kg, the elotuzumab clearance was 13.2 mL/day/kg. Elotuzumab exhibits nonlinear pharmacokinetics with clearance of elotuzumab decreasing from 17.5 to 5.8 mL/day/kg with an increase in dose from 0.5 to 20 mg/kg, suggesting target-mediated clearance, resulting in greater than proportional increases in Area under the Concentration time curve (AUC). Upon discontinuation of elotuzumab in combination with lenalidomide and dexamethasone, concentrations of elotuzumab will decrease to approximately 3% (approximately 97% washout as estimated by 5 half-lives) of the population predicted steady-state maximal serum concentration by 3 months.
Special populations
Based on a population PK analysis using data from 375 patients, the clearance of elotuzumab increased with increasing body weight supporting a weight-based dose. The population PK analysis suggested that the following factors had no clinically important effect on the clearance of elotuzumab: age (37 to 88 years), gender, race, baseline LDH, albumin, renal impairment, and mild hepatic impairment.
Renal impairment
An open-label study evaluated the pharmacokinetics of elotuzumab in combination with lenalidomide and dexamethasone in patients with multiple myeloma with varying degrees of renal impairment (classified using the CrCl values). The effect of renal impairment on the pharmacokinetics of elotuzumab was evaluated in patients with normal renal function (CrCl > 90 mL/min; N = 8), severe renal impairment not requiring dialysis (CrCl <30 mL/min; N = 9), or end-stage renal disease requiring dialysis (CrCl < 30 mL/min; N = 9). No clinically important differences in the pharmacokinetics of elotuzumab were found between patients with severe renal impairment (with and without dialysis) and patients with normal renal function (see section 4.2).
Hepatic impairment
Empliciti is an IgG1 monoclonal antibody, which is principally cleared by catabolism. Thus, hepatic functional impairment is not likely to alter its clearance. The effect of hepatic impairment on the clearance of Empliciti was evaluated by population PK analyses in patients with mild hepatic impairment (total bilirubin [TB] ≤ the upper limit of normal [ULN] and AST > ULN or TB < 1 to 1.5 × ULN and any AST; N = 33). No clinically important differences in the clearance of Empliciti were found between patients with mild hepatic impairment and patients with normal hepatic function. Elotuzumab has not been studied in patients with moderate (TB > 1.5 to 3 × ULN and any AST) or severe hepatic impairment (TB > 3 × ULN and any AST) (see section 4.2).
5.3 Preclinical safety data
Elotuzumab only recognizes human SLAMF7 protein. Because elotuzumab does not recognize non-human forms of SLAMF7 protein, in vivo safety data from animal studies are irrelevant. In the same line, no carcinogenicity data are available for elotuzumab in animals, nor were fertility and embryo-foetal toxicity studies performed. Non-clinical safety information primarily consists of limited in vitro human cell/tissue studies where no safety findings were identified.
6. Pharmaceutical particulars
6.1 List of excipients
Sucrose
Sodium citrate
Citric acid monohydrate
Polysorbate 80
6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3 Shelf life
Unopened vial
3 years.
After reconstitution and dilution
The reconstituted solution should be transferred from the vial into the infusion bag immediately.
Chemical and physical in use stability of the reconstituted and diluted solution has been demonstrated for 24 hours at 2°C - 8°C and protected from light.
From a microbiological point of view, the solution for infusion should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C - 8°C protected from light. Do not freeze the reconstituted or diluted solution. The solution for infusion may be stored for a maximum of 8 hours of the total 24 hours at 20°C − 25°C and room light. This 8-hour period should be inclusive of the product administration period.
6.4 Special precautions for storage
Store in a refrigerator (2°C - 8°C).
Do not freeze.
Store in the original package in order to protect from light.
For storage conditions after reconstitution or dilution of the medicinal product, see section 6.3.
6.5 Nature and contents of container
20 ml Type I glass vial, closed with a grey butyl stopper and sealed with aluminium crimp seal with a polypropylene flip off button, containing either 300 mg or 400 mg elotuzumab. The flip-off seal button colour is ivory for the 300 mg presentation and blue for the 400 mg presentation.
Pack size of 1 vial.
6.6 Special precautions for disposal and other handling
Calculating the dose
Calculate the dose (mg) and determine the number of vials needed for the 10 mg/kg dose based on patient weight. More than one vial of Empliciti may be needed to give the total dose for the patient.
• The total elotuzumab dose in mg = the patient's weight in kg x 10.
Preparing the infusion
Aseptically reconstitute each Empliciti vial with a syringe of adequate size and an 18 gauge or smaller needle as shown in Table 7. A slight back pressure may be experienced during administration of the water for injections, which is considered normal.
Table 7: Reconstitution instructions

Strength	Amount of water for injections, required for reconstitution	Final volume of reconstituted Empliciti in the vial (including volume displaced by the solid cake)	Post-reconstitution concentration
300 mg vial	13.0 mL	13.6 mL	25 mg/mL
400 mg vial	17.0 mL	17.6 mL	25 mg/mL

• Hold the vial upright and swirl the solution by rotating the vial to dissolve the lyophilised cake. Then invert the vial a few times in order to dissolve any powder that may be present on top of the vial or the stopper. Avoid vigorous agitation, DO NOT SHAKE. The lyophilised powder should dissolve in less than 10 minutes.
• After the remaining solids are completely dissolved, allow the reconstituted solution to stand for 5 to 10 minutes. The reconstituted solution is colourless to slightly yellow, and clear to very opalescent. Empliciti should be inspected visually for particulate matter and discolouration prior to administration. Discard the solution if any particulate matter or discolouration is observed.
• Once the reconstitution is completed, withdraw the necessary volume for the calculated dose from each vial, up to a maximum of 16 mL from 400 mg vial and 12 mL from 300 mg vial. Dilute the reconstituted solution with 230 mL of either sodium chloride 9 mg/mL (0.9%) solution for injection or 5% glucose injection, into an infusion bag made of polyvinyl chloride or polyolefin. The volume of sodium chloride 9 mg/mL (0.9%) solution for injection or 5% glucose injection should be adjusted so as not to exceed 5 mL/kg of patient weight at any given dose of Empliciti.
Administration
The entire Empliciti infusion should be administered with an infusion set and a sterile, non-pyrogenic, low-protein-binding filter (with a pore size of 0.2-1.2 µm) using an automated infusion pump.
Empliciti infusion is compatible with:
• PVC and polyolefin containers
• PVC infusion sets
• polyethersulfone and nylon in-line filters with pore sizes of 0.2 μm to 1.2 μm.
Empliciti should be initiated at an infusion rate of 0.5 mL/min. If well tolerated, the infusion rate may be increased stepwise as described in Table 2 (see section 4.2 Method of administration). The maximum infusion rate should not exceed 5 mL/min.
The Empliciti infusion solution should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C − 8°C protected from light. Do not freeze the reconstituted or diluted solution. The solution for infusion may be stored for a maximum of 8 hours of the total 24 hours at 20°C − 25°C and room light. This 8-hour period should be inclusive of the product administration period.
Disposal
Do not store any unused portion of the infusion solution for reuse. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. Marketing authorisation holder
Bristol-Myers Squibb Pharma EEIG
Uxbridge Business Park
Sanderson Road
Uxbridge UB8 1DH
United Kingdom
8. Marketing authorisation number(s)
EU/1/16/1088/001-002
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation: 11 May 2016
10. Date of revision of the text
11 May 2016
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.