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Gemtuzumab Ozogamicin

Class: Antineoplastic Agents
CAS Number: 220578-59-6
Brands: Mylotarg

Warning(s)

Warning: Hepatotoxicity1

See full prescribing information for complete boxed warning.1

Hepatotoxicity, including severe or fatal hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), has been reported in association with the use of gemtuzumab ozogamicin.1

Introduction

Gemtuzumab ozogamicin is an antineoplastic agent.1

Uses for Gemtuzumab Ozogamicin

Gemtuzumab ozogamicin has the following uses:

Gemtuzumab ozogamicin is a CD33-directed antibody-drug conjugate indicated for the treatment of newly diagnosed CD33-positive acute myeloid leukemia (AML) in adults.1

Gemtuzumab ozogamicin also is indicated for the treatment of relapsed or refractory CD33-positive AML in adults and pediatric patients 2 years and older.1

Gemtuzumab Ozogamicin Dosage and Administration

General

Gemtuzumab ozogamicin is available in the following dosage form(s) and strength(s):

For injection: 4.5 mg as a lyophilized cake or powder in a single-dose vial for reconstitution and dilution.1

Dosage

It is essential that the manufacturer's labeling be consulted for more detailed information on dosage and administration of this drug. Dosage summary:

    Newly diagnosed de novo AML (combination regimen):
  • Induction: 3 mg/m2 (up to one 4.5 mg vial) on Days 1, 4, and 7 in combination with daunorubicin and cytarabine. 1

  • Consolidation: 3 mg/m2 (up to one 4.5 mg vial) on Day 1 in combination with daunorubicin and cytarabine.1

    Newly diagnosed AML (single-agent regimen):
  • Induction: 6 mg/m2 on Day 1 and 3 mg/m2 on Day 8.1

  • Continuation: For patients without evidence of disease progression following induction, up to 8 continuation courses of gemtuzumab ozogamicin 2 mg/m2 on Day 1 every 4 weeks.1

    Relapsed or refractory AML (single-agent regimen):
  • 3 mg/m2 (up to one 4.5 mg vial) on Days 1, 4, and 7.1

Premedicate with a corticosteroid, antihistamine, and acetaminophen 1 hour prior to gemtuzumab ozogamicin.1

Cautions for Gemtuzumab Ozogamicin

Contraindications

Hypersensitivity to gemtuzumab ozogamicin or any of its components.1

Warnings/Precautions

Hepatotoxicity, Including Veno-occlusive Liver Disease

Hepatotoxicity, including life-threatening and sometimes fatal hepatic veno-occlusive liver disease (VOD) events, have been reported in patients receiving gemtuzumab ozogamicin as a single agent or as part of a combination chemotherapy regimen.1

In ALFA-0701, VOD events were reported in 6/131 (5%) patients during or following treatment with gemtuzumab ozogamicin, or following later hematopoietic stem cell transplantation (HSCT). The median time from the gemtuzumab ozogamicin dose to onset of VOD was 9 days (range: 2–298 days), with 5 events occurring within 28 days of any dose of gemtuzumab ozogamicin and 1 event occurring greater than 28 days after the last dose of gemtuzumab ozogamicin. Three of the 6 VOD events were fatal. VOD was also reported in 2 patients in the control arm of ALFA-0701 after receiving gemtuzumab ozogamicin as a therapy for relapsed AML. 1

In MyloFrance-1 (gemtuzumab ozogamicin 3 mg/m2On Days 1, 4 and 7), VOD events were reported in none of the 57 patients during or following treatment, or following HSCT after completion of gemtuzumab ozogamicin treatment.1

Based on an analysis across trials, the risk of VOD was higher in adult patients who received higher doses of gemtuzumab ozogamicin as monotherapy, in patients with moderate or severe hepatic impairment prior to receiving gemtuzumab ozogamicin, in patients treated with gemtuzumab ozogamicin after HSCT, and in patients who underwent HSCT after treatment with gemtuzumab ozogamicin. Patients who had moderate/severe hepatic impairment prior to treatment with gemtuzumab ozogamicin were 8.7 times more likely to develop VOD compared to patients without moderate/severe hepatic impairment at baseline. Patients treated with gemtuzumab ozogamicin for relapse after HSCT were 2.6 times more likely to develop VOD compared to patients without prior HSCT. Patients who underwent HSCT following gemtuzumab ozogamicin treatment were 2.9 times more likely to develop VOD after HSCT compared to patients without HSCT following gemtuzumab ozogamicin treatment. Although no relationship was found between VOD and time of HSCT relative to higher gemtuzumab ozogamicin monotherapy doses, the ALFA-0701 study recommended an interval of 2 months between the last dose of gemtuzumab ozogamicin and HSCT. In MyloFrance-1, no patients underwent HSCT within 3.5 months of gemtuzumab ozogamicin therapy. 1

Assess ALT, AST, total bilirubin, and alkaline phosphatase prior to each dose of gemtuzumab ozogamicin. After treatment with gemtuzumab ozogamicin, monitor frequently for signs and symptoms of VOD; these may include elevations in ALT, AST, total bilirubin, hepatomegaly (which may be painful), rapid weight gain, and ascites. Monitoring only total bilirubin may not identify all patients at risk of VOD. For patients who develop abnormal liver tests, more frequent monitoring of liver tests and clinical signs and symptoms of hepatotoxicity is recommended. For patients who proceed to HSCT, monitor liver tests frequently during the post-HSCT period, as appropriate.1

Manage signs or symptoms of hepatic toxicity by dose interruption or discontinuation of gemtuzumab ozogamicin. In patients who experience VOD, discontinue gemtuzumab ozogamicin and treat according to standard medical practice.1

Infusion-Related Reactions (Including Anaphylaxis)

Life-threatening or fatal infusion related-reactions can occur during or within 24 hours following infusion of gemtuzumab ozogamicin. Signs and symptoms of infusion-related reactions may include fever, chills, hypotension, tachycardia, hypoxia and respiratory failure.1

Premedicate prior to gemtuzumab ozogamicin infusion. Monitor vital signs frequently during infusion. Interrupt infusion immediately for patients who develop evidence of infusion reaction, especially dyspnea, bronchospasm, or hypotension. Monitor patients during and for at least 1 hour after the end of the infusion or until signs and symptoms completely resolve. Discontinue use of gemtuzumab ozogamicin in patients who develop signs or symptoms of anaphylaxis, including severe respiratory symptoms or clinically significant hypotension.1

Hemorrhage

Gemtuzumab ozogamicin is myelosuppressive and can cause fatal or life-threatening hemorrhage due to prolonged thrombocytopenia. In ALFA-0701, (gemtuzumab ozogamicin in combination with chemotherapy), all grades and Grade 3–4 bleeding events were reported in 118/131 (90%) and 27/131 (21%) patients, respectively. Fatal bleeding events (including cerebral hematoma, intracranial hematoma, and subdural hematoma) occurred in 4/131 (3%) patients. Thrombocytopenia with platelet counts less than 50,000/mm3 persisting more than 42 days occurred in 19 (19%) patients in the induction phase. The proportion of patients with persistent thrombocytopenia increased with progressive treatment phases and was higher in patients treated with gemtuzumab ozogamicin plus chemotherapy than with chemotherapy alone.1

In AML-19 (gemtuzumab ozogamicin monotherapy at 6 mg/m2 Day 1 and 3 mg/m2 Day 8), all grades and Grade 3 or higher bleeding were reported in 28/111 (25%) and 14/111 (13%) patients, respectively. Fatal bleeding occurred in 1/111 (1%). In MyloFrance-1 (gemtuzumab ozogamicin 3 mg/m2 as monotherapy), Grade 3 bleeding was reported in 4/57 (7%) patients, but no patient experienced Grade 4 hemorrhage. 1

Assess blood counts prior to each dose of gemtuzumab ozogamicin and monitor blood counts frequently after treatment with gemtuzumab ozogamicin until resolution of cytopenias. Monitor patients for signs and symptoms of bleeding during treatment with gemtuzumab ozogamicin. Manage severe bleeding, hemorrhage or persistent thrombocytopenia using dose delay or permanent discontinuation of gemtuzumab ozogamicin, and provide supportive care per standard practice.1

QT Interval Prolongation

QT interval prolongation has been observed in patients treated with other drugs containing calicheamicin. When administering gemtuzumab ozogamicin to patients who have a history of or predisposition for QTc prolongation, who are taking medicinal products that are known to prolong QT interval, and in patients with electrolyte disturbances, obtain electrocardiograms (ECGs) and electrolytes prior to the start of treatment and as needed during administration.1

Use in AML with Adverse-Risk Cytogenetics

In subgroup analyses in ALFA-0701, the addition of gemtuzumab ozogamicin to standard combination chemotherapy did not improve event-free survival in the subgroup of patients having adverse-risk cytogenetics (HR 1.11; 95% CI: 0.63, 1.95). For patients being treated with gemtuzumab ozogamicin in combination with daunorubicin and cytarabine for newly diagnosed de novo AML, when cytogenetics testing results become available consider whether the potential benefit of continuing treatment with gemtuzumab ozogamicin outweighs the risks for the individual patient.1

Embryo-Fetal Toxicity

Based on its mechanism of action and findings from animal studies, gemtuzumab ozogamicin can cause embryo-fetal harm when administered to a pregnant woman. In animal studies, gemtuzumab ozogamicin caused embryo-fetal toxicity, starting at a dose that was approximately 0.4 times the exposure in patients at the maximum recommended dose, based on the area under the concentration-time curve (AUC). Advise females of reproductive potential to use effective contraception during treatment with gemtuzumab ozogamicin and for at least 6 months after the final dose of gemtuzumab ozogamicin. Advise males with female partners of reproductive potential to use effective contraception during treatment with gemtuzumab ozogamicin and for at least 3 months after the last dose of gemtuzumab ozogamicin. Apprise pregnant women of the potential risk to the fetus. Advise women to contact their healthcare provider if they become pregnant or if pregnancy is suspected during treatment with gemtuzumab ozogamicin.1

Specific Populations

Pregnancy

Based on its mechanism of action and findings from animal studies, gemtuzumab ozogamicin can cause embryo-fetal harm when administered to a pregnant woman. There are no available data on gemtuzumab ozogamicin use in pregnant women to inform a drug-associated risk of major birth defects and miscarriage. In rat embryo-fetal development studies, gemtuzumab ozogamicin caused embryo-fetal toxicity at maternal systemic exposures that were greater than or equal to 0.4 times the exposure in patients at the maximum recommended dose, based on AUC. If gemtuzumab ozogamicin is used during pregnancy, or if the patient becomes pregnant while taking gemtuzumab ozogamicin, advise the patient of the potential risk to a fetus. Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2–4% and 15–20%, respectively.1

In an embryo-fetal development study in rats, pregnant animals received daily intravenous doses up to 1.2 mg/m2/day gemtuzumab ozogamicin during the period of organogenesis. Embryo-fetal toxicities including fetal growth retardation as evidenced by decreased live fetal weights, incidence of fetal wavy ribs and delayed skeletal ossification were observed at greater than or equal to 0.15 mg/m2/day. Increased embryo-fetal lethality and fetal morphological anomalies (digital malformations, absence of the aortic arch, anomalies in the long bones in the forelimbs, misshapen scapula, absence of a vertebral centrum, and fused sternebrae) were observed at greater than or equal to 0.36 mg/m2/day. All doses with embryo-fetal effects were observed in the presence of maternal toxicity that included decreases in gestational body weight gain, food consumption, and gravid uterine weight. The lowest dose at which embryo-fetal effects were observed in rats (0.15 mg/m2/day) was 0.4 times the exposure in patients at the maximum recommended human dose, based on AUC.1

Lactation

There are no data on the presence of gemtuzumab ozogamicin or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for adverse reactions in breastfed infants, women should not breastfeed during treatment with gemtuzumab ozogamicin and for at least 1 month after the final dose.1

Females and Males of Reproductive Potential

Based on animal studies, gemtuzumab ozogamicin can cause fetal harm when administered to a pregnant woman. Verify the pregnancy status of females of reproductive potential prior to initiating gemtuzumab ozogamicin.1

Advise females of reproductive potential to avoid becoming pregnant while receiving gemtuzumab ozogamicin. Advise females of reproductive potential to use effective contraception during treatment with gemtuzumab ozogamicin and for at least 6 months after the last dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with gemtuzumab ozogamicin and for at least 3 months after the last dose.1

Based on findings in animals, gemtuzumab ozogamicin may impair fertility in females of reproductive potential. Based on findings in animals, gemtuzumab ozogamicin may impair fertility in males of reproductive potential.1

Pediatric Use

The safety and efficacy of gemtuzumab ozogamicin in combination with daunorubicin and cytarabine have not been established in the pediatric patients with newly diagnosed de novo AML. 1

The safety and efficacy of gemtuzumab ozogamicin as a single agent in the pediatric patients with relapsed or refractory AML is supported by a single-arm trial in 29 patients in the following age groups: 1 patient 1 month to less than 2 years old, 13 patients 2 years to less than 12 years old, and 15 patients 12 years to 18 years old. A literature review included an additional 96 patients with ages ranging from 0.2 to 21 years. No differences in efficacy and safety were observed by age.1

Geriatric Use

Use of gemtuzumab ozogamicin in combination with daunorubicin and cytarabine in newly diagnosed adult patients with de novo AML is supported by a randomized, controlled trial that included 50 patients greater than or equal to 65 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. Use of gemtuzumab ozogamicin monotherapy in newly diagnosed adult patients with AML is supported by a randomized controlled trial with 118 patients treated with gemtuzumab ozogamicin. All patients were over the age of 60 years and 65% of patients were above 75 years. No overall differences in effectiveness were observed by age. 1

Use of gemtuzumab ozogamicin as single-agent treatment of relapsed or refractory AML is supported by a single-arm trial that included 27 patients 65 years or older. No overall differences in effectiveness were observed between these patients and younger patients. Elderly patients experienced a higher rate of fever and severe or greater infections. 1

Common Adverse Effects

The most common adverse reactions (greater than 15%) were hemorrhage, infection, fever, nausea, vomiting, constipation, headache, increased AST, increased ALT, rash, and mucositis.1

Drug Interactions

Specific Drugs

It is essential that the manufacturer's labeling be consulted for more detailed information on interactions with this drug, including possible dosage adjustments. Interaction highlights:

Please see product labeling for drug interaction information.

Actions

Mechanism of Action

Gemtuzumab ozogamicin is a CD33-directed antibody-drug conjugate (ADC). The antibody portion (hP67.6) recognizes human CD33 antigen. The small molecule, N-acetyl gamma calicheamicin, is a cytotoxic agent that is covalently attached to the antibody via a linker. Nonclinical data suggest that the anticancer activity of gemtuzumab ozogamicin is due to the binding of the ADC to CD33-expressing tumor cells, followed by internalization of the ADC-CD33 complex, and the intracellular release of N-acetyl gamma calicheamicin dimethyl hydrazide via hydrolytic cleavage of the linker. Activation of N-acetyl gamma calicheamicin dimethyl hydrazide induces double-strand DNA breaks, subsequently inducing cell cycle arrest and apoptotic cell death.1

Advice to Patients

Hepatotoxicity, Including Veno-occlusive Liver Disease

Inform patients that liver problems, including severe, life-threatening, or fatal VOD may develop during gemtuzumab ozogamicin treatment. Prior to receiving gemtuzumab ozogamicin, inform patients who previously received, or will receive an HSCT that they may be at increased risk for developing VOD. Inform patients that the risk of developing VOD after an allogeneic HSCT is increased after receiving treatment with gemtuzumab ozogamicin. Inform patients that signs or symptoms of liver toxicity, including rapid weight gain, right upper quadrant pain and tenderness, hepatomegaly, and ascites should be monitored regularly during treatment, but these symptoms may not identify all patients at risk or prevent the complications of liver toxicity. Inform patients that liver problems may require dosing interruption or permanent discontinuation of gemtuzumab ozogamicin. 1

Hemorrhage

Inform patients that decreased platelet counts, which may be life-threatening, may develop during gemtuzumab ozogamicin treatment and that complications associated with decreased platelet counts may include bleeding/hemorrhage events, which may be life-threatening or fatal. Inform patients to report signs and symptoms of bleeding/hemorrhage during treatment with gemtuzumab ozogamicin. Inform patients that severe bleeding/hemorrhage may require dosing interruption or permanent discontinuation of gemtuzumab ozogamicin. 1

Infusion Related Reactions

Advise patients to contact their health care provider if they experience signs and symptoms of infusion related reactions, including symptoms such as fever, chills, rash, or breathing problems.1

Pregnancy and Breastfeeding

Advise men and women of reproductive potential to use effective contraception during gemtuzumab ozogamicin treatment and for at least 3 and 6 months, respectively, after the last dose. Advise women of childbearing potential to avoid becoming pregnant while receiving gemtuzumab ozogamicin. Advise women to contact their healthcare provider if they become pregnant, or if pregnancy is suspected, during treatment with gemtuzumab ozogamicin. Inform the patient of the potential hazard to the fetus. Advise women against breastfeeding while receiving gemtuzumab ozogamicin and for 1 month after the last dose.1

Additional Information

AHFS First Release. For additional information until a more detailed monograph is developed and published, the manufacturer's labeling should be consulted. It is essential that the manufacturer's labeling be consulted for more detailed information on usual uses, dosage and administration, cautions, precautions, contraindications, potential drug interactions, laboratory test interferences, and acute toxicity.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Gemtuzumab Ozogamicin

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for IV infusion

4.5 mg

Mylotarg

Wyeth Pharmaceuticals Inc. a subsidiary of Pfizer Inc.

AHFS Drug Information. © Copyright 2017, Selected Revisions September 25, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

1. Wyeth Pharmaceuticals Inc., a subsidiary of Pfizer Inc. Mylotarg (gemtuzumab ozogamicin) INTRAVENOUS prescribing information. 2017 Sept.

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