Pertuzumab

Class: Antineoplastic Agents
VA Class: AN900
Chemical Name: Immunoglobulin G1, anti-(human neu (receptor)) (human-mouse monoclonal 2C4 heavy chain), disulfide with human-mouse monoclonal 2C4 κ-chain, dimer
CAS Number: 380610-27-5
Brands: Perjeta

Introduction

Antineoplastic agent; a recombinant humanized anti-human epidermal growth factor receptor type 2 (anti-HER2/ERBB2) monoclonal antibody.^{1 2 8 13 16}

Uses for Pertuzumab

Breast Cancer

In combination with trastuzumab and docetaxel for the treatment of metastatic breast cancer in patients whose tumors overexpress the HER2 protein and who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease.¹

Efficacy established based on progression-free survival; effect on overall survival not established.^{1 2}

Pertuzumab Dosage and Administration

General

• Because of risk of infusion or hypersensitivity reactions, closely observe patients for 60 minutes after first infusion and for 30 minutes after subsequent infusions.¹ (See Infusion or Hypersensitivity Reactions under Cautions.)

• Consult specialized references for procedures for proper handling (e.g., use of gloves) and disposal of antineoplastics.¹⁸

Restricted Distribution

• Available only through select specialty distributors.³ Contact manufacturer at 800-551-2231 or visit for ordering information.⁴

Administration

IV Administration

For solution compatibility information, see Compatibility under Stability.

Administer by IV infusion.¹ Do not administer by rapid IV injection (e.g., IV push or bolus).¹

Pertuzumab injection must be diluted prior to administration.¹ Use within 24 hours following dilution.¹ (See Storage under Stability.)

Do not mix with any other drug.¹

Dilution

Use aseptic technique since drug product contains no preservative.¹

Dilute appropriate dose in a PVC or non-pvc polyolefin infusion bag containing 250 mL of 0.9% sodium chloride injection; do not dilute in 5% dextrose injection.¹ Mix the diluted solution by gentle inversion; do not shake.¹ Discard any partially used vial.¹

Rate of Administration

Initial dose: Administer over 60 minutes.¹

Subsequent doses: Administer over 30–60 minutes.¹

Dosage

Adults

Breast Cancer

Pertuzumab, Trastuzumab, and Docetaxel for HER2-overexpressing Metastatic Breast Cancer

IV

Initially, pertuzumab 840 mg in combination with trastuzumab 8 mg/kg (administered by IV infusion over 90 minutes) and docetaxel 75 mg/m² (administered by IV infusion), followed every 3 weeks thereafter by pertuzumab 420 mg in combination with trastuzumab 6 mg/kg (administered by IV infusion over 30–90 minutes) and docetaxel 75 or 100 mg/m².¹

If a dose is missed or delayed, and the time between 2 sequential infusions is <6 weeks, administer pertuzumab 420 mg; do not wait until the next scheduled dose.¹ If the time between 2 sequential infusions is ≥6 weeks, administer pertuzumab dose of 840 mg (i.e., same dose as initially used), followed by pertuzumab 420 mg every 3 weeks thereafter.¹

Dosage Modification for Toxicity and Contraindications to Continued Therapy

Dosage reductions not recommended.¹ If toxicities occur, reduce infusion rate or temporarily or permanently discontinue therapy based on causality.¹

Infusion or Hypersensitivity Reactions

If clinically important infusion reactions occur, reduce infusion rate or interrupt infusion and administer appropriate medical therapy.¹

If severe infusion or hypersensitivity reactions occur, immediately discontinue infusion and consider permanent discontinuance of therapy.¹

Monitor patients carefully until signs and symptoms have completely resolved.¹

Left Ventricular Dysfunction

If left ventricular ejection fraction (LVEF) decreases to <40% or to 40–45% with an absolute decrease from baseline of ≥10%, withhold pertuzumab and trastuzumab for at least 3 weeks.¹ (See Left Ventricular Dysfunction under Cautions.)

Reassess LVEF within approximately 3 weeks.¹ If LVEF has recovered to >45% or to 40–45% with an absolute decrease from baseline of <10%, may resume pertuzumab therapy.¹ If LVEF has not improved or has declined further, strongly consider discontinuing pertuzumab and trastuzumab, unless benefits outweigh risks.¹

Consult prescribing information for docetaxel for detailed information on dosage modifications for this drug.¹

Withhold or discontinue pertuzumab if trastuzumab is withheld or discontinued; however, if docetaxel is discontinued, may continue pertuzumab and trastuzumab therapy.¹

Special Populations

Dosage adjustment not necessary based on body weight or baseline albumin concentration.¹ (See Special Populations under Pharmacokinetics.)

Hepatic Impairment

No specific dosage recommendations at this time.¹ (See Hepatic Impairment under Cautions.)

Renal Impairment

Mild (Cl_cr 60–90 mL/minute) or moderate (Cl_cr 30–60 mL/minute) renal impairment: No dosage adjustment required.¹

Severe renal impairment (Cl_cr <30 mL/minute): No specific dosage recommendations at this time due to limited data.¹ (See Renal Impairment under Cautions.)

Geriatric Patients

No specific dosage recommendations at this time.¹ (See Geriatric Use under Cautions.)

Cautions for Pertuzumab

Contraindications

• Manufacturer states none known.¹

Warnings/Precautions

Warnings

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm.¹ Embryotoxicity and fetotoxicity demonstrated in animals.¹ Oligohydramnios, delayed fetal kidney development, and embryo-fetal death observed following administration of pertuzumab to pregnant cynomolgus monkeys at dosages producing concentrations 2.5–20 times that of human clinical exposure (based on peak plasma concentrations).¹

Embryotoxic and fetotoxic effects likely to be present during all trimesters of pregnancy.¹

Verify pregnancy status prior to initiation of pertuzumab.¹ Advise women of childbearing potential to use effective contraceptive methods during and for 6 months after discontinuance of drug.¹

If used during pregnancy or if patient becomes pregnant during therapy, apprise of potential fetal hazard.¹ (See Pregnancy under Cautions.) Monitor for development of oligohydramnios in patients who become pregnant during therapy; perform appropriate fetal testing if oligohydramnios occurs.¹ Efficacy of IV hydration in the management of oligohydramnios secondary to pertuzumab exposure unknown.¹

Sensitivity Reactions

Infusion or Hypersensitivity Reactions

Infusion reactions, including hypersensitivity and anaphylaxis, reported.¹ Most common infusion reactions reported were pyrexia, chills, fatigue, headache, asthenia, hypersensitivity, vomiting, dysgeusia, and myalgia.¹

Closely observe patients for 60 minutes after first infusion and for 30 minutes after subsequent infusions.¹ If infusion or hypersensitivity reactions occur, may need to reduce infusion rate or temporarily or permanently discontinue therapy.¹ (See Infusion or Hypersensitivity Reactions under Dosage and Administration.)

Other Warnings and Precautions

Left Ventricular Dysfunction

Decreases in LVEF reported with inhibitors of HER2, including pertuzumab.^{1 6 9} In principal efficacy study, pertuzumab not associated with increased incidence of symptomatic left ventricular systolic dysfunction (LVSD, congestive heart failure [CHF]) or decrease in LVEF compared with placebo.^{1 2} Median time to development of LVSD appears to be around cycle 4.⁶

Safety not established in patients with baseline LVEF ≤50%, prior history of CHF, decreases in LVEF to <50% during prior trastuzumab therapy, or conditions that could impair left ventricular function (e.g., uncontrolled hypertension, recent MI, serious cardiac arrhythmia requiring treatment, cumulative prior anthracycline exposure >360 mg/m² of doxorubicin or its equivalent).¹

Risk of LVSD possibly increased in patients who received prior anthracycline therapy or had prior radiation therapy to the chest area.¹

Assess LVEF prior to initiation of therapy and at regular intervals (e.g., every 3 months) during treatment.¹

If substantial decreases in LVEF occur, may need to temporarily or permanently discontinue therapy.¹ (See Left Ventricular Dysfunction under Dosage and Administration.)

Evaluation of HER2

Assess breast tumors for HER2 overexpression prior to initiation of therapy because safety and efficacy of pertuzumab established only in patients with HER2-overexpressing tumors.¹

Immunohistochemistry (IHC) assays (e.g., Dako Herceptest), which measure overexpression of the HER2 protein, and fluorescent in situ hybridization (FISH) (e.g., Dako HER2 FISH PharmDx), which measures amplification of the HER2 oncogene, are tests most commonly used.^{1 3 5}

In principal efficacy study, patients were required to have disease demonstrating an IHC score of 3+ or a FISH amplification ratio of ≥2.^{1 2} Limited data for patients with FISH-positive tumors that lack HER2 overexpression.¹

Select laboratories with demonstrated proficiency in the specific technology being used; improper assay performance can lead to unreliable results.¹

Specific Populations

Pregnancy

Category D.¹ (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

If used during pregnancy or if patient becomes pregnant while receiving therapy, apprise of potential fetal hazard.¹ Encourage patient to enroll in the MotHER Pregnancy Registry (800-690-6720), and immediately notify Genentech Adverse Event Line (888-835-2555).¹

Lactation

Not known whether pertuzumab is distributed into milk.¹ Discontinue nursing or the drug.¹

Pediatric Use

Safety and efficacy not established.¹

Geriatric Use

No overall differences in safety, efficacy, and pharmacokinetics relative to younger adults.¹

Hepatic Impairment

Pharmacokinetics not studied in patients with hepatic impairment.¹

Renal Impairment

Systemic exposure not altered by mild or moderate renal impairment; no dosage adjustment required.¹ (See Renal Impairment under Dosage and Administration and also see Special Populations under Pharmacokinetics.)

Limited data in patients with severe renal impairment.¹

Common Adverse Effects

Diarrhea,^{1 2} alopecia,^{1 2} neutropenia,^{1 2} nausea,^{1 2} fatigue,^{1 2} rash,^{1 2} peripheral neuropathy.¹

Interactions for Pertuzumab

Specific Drugs

Drug	Interaction	Comments
Docetaxel	Drug interaction not observed1
Trastuzumab	Drug interaction not observed1

Pertuzumab Pharmacokinetics

Absorption

Bioavailability

Steady-state concentrations achieved after first maintenance dose.¹

Special Populations

Age, gender, or ethnicity (Japanese versus non-Japanese): No effects on pertuzumab pharmacokinetics.^{1 12}

Baseline serum albumin concentration or lean body weight: Minor influence on pertuzumab pharmacokinetics.¹ (See Special Populations under Dosage and Administration.)

Mild (Cl_cr of 60–90 mL/minute) or moderate (Cl_cr of 30–60 mL/minute) renal impairment: Systemic exposure is similar to that in patients with normal renal function.¹ (See Renal Impairment under Dosage and Administration.)

Severe renal impairment (Cl_cr <30 mL/minute): Limited data.¹

No relationship between Cl_cr and pertuzumab exposure observed over Cl_cr range of 27–244 mL/minute.¹

Elimination

Half-life

Median half-life: 18 days.¹

Stability

Storage

Parenteral

Injection

2–8°C in original carton to protect from light.¹ Do not freeze or shake.¹

Diluted solution: 2–8°C for up to 24 hours after dilution.¹

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility

Compatible1
Sodium chloride 0.9%
Incompatible1
Dextrose 5% in water

Actions

• Binds specifically to extracellular dimerization domain (subdomain II) of HER2 protein, blocking heterodimerization of HER2 with other ligand-bound members of the HER family (i.e., epidermal growth factor receptor [EGFR]/HER1, HER3, HER4).^{1 2 3}

• Blockade of HER2 heterodimerization (particularly with HER3) results in inhibition of ligand-activated intracellular signaling through 2 major signal pathways, mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K/Akt), potentially causing cell growth arrest and apoptosis, respectively.^{1 2 3 8 13 17}

• Mediates antibody-dependent cell-mediated cytotoxicity (ADCC).^{1 13 16}

• Exhibits complementary mechanisms of action with trastuzumab; therefore, combined use with trastuzumab may result in more comprehensive inhibition of HER2 signaling.^{2 7 13 17}

Advice to Patients

• Risk of fetal harm (e.g., embryo-fetal death, birth defects).¹ Necessity of advising women of childbearing potential to use effective contraceptive methods during and for 6 months after discontinuance of drug.¹ Encourage women who have been exposed to pertuzumab during pregnancy to enroll in the MotHER Pregnancy Registry by contacting 800-690-6720.¹ (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

• Importance of discontinuing breast-feeding during therapy.¹

• Risk of infusion or hypersensitivity reactions.¹

• Risk of decreased LVEF.¹

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.¹

• Importance of informing patients of other important precautionary information.¹ (See Cautions.)

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.

Available only through select specialty distributors.³ Contact manufacturer at 800-551-2231 or visit for ordering information.⁴

Pertuzumab

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection, for IV infusion	30 mg/mL (420 mg)	Perjeta	Genentech