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Opdivo

Generic Name: nivolumab
Dosage Form: injection

Medically reviewed by Drugs.com. Last updated on May 1, 2019.

Indications and Usage for Opdivo

Unresectable or Metastatic Melanoma

Opdivo, as a single agent or in combination with ipilimumab, is indicated for the treatment of patients with unresectable or metastatic melanoma.

Adjuvant Treatment of Melanoma

Opdivo is indicated for the adjuvant treatment of patients with melanoma with involvement of lymph nodes or metastatic disease who have undergone complete resection.

Metastatic Non-Small Cell Lung Cancer

Opdivo is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) with progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving Opdivo.

1.4 Small Cell Lung Cancer

Opdivo is indicated for the treatment of patients with metastatic small cell lung cancer (SCLC) with progression after platinum-based chemotherapy and at least one other line of therapy.

This indication is approved under accelerated approval based on overall response rate and duration of response [see Clinical Studies (14.4)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Advanced Renal Cell Carcinoma

Opdivo as a single agent is indicated for the treatment of patients with advanced renal cell carcinoma (RCC) who have received prior anti-angiogenic therapy.
Opdivo, in combination with ipilimumab, is indicated for the treatment of patients with intermediate or poor risk, previously untreated advanced RCC.

Classical Hodgkin Lymphoma

Opdivo is indicated for the treatment of adult patients with classical Hodgkin lymphoma (cHL) that has relapsed or progressed after:

autologous hematopoietic stem cell transplantation (HSCT) and brentuximab vedotin, or
3 or more lines of systemic therapy that includes autologous HSCT.

This indication is approved under accelerated approval based on overall response rate [see Clinical Studies (14.6)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Squamous Cell Carcinoma of the Head and Neck

Opdivo is indicated for the treatment of patients with recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) with disease progression on or after platinum-based therapy.

Urothelial Carcinoma

Opdivo is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma who:

have disease progression during or following platinum-containing chemotherapy
have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

This indication is approved under accelerated approval based on tumor response rate and duration of response [see Clinical Studies (14.8)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Microsatellite Instability-High or Mismatch Repair Deficient Metastatic Colorectal Cancer

Opdivo, as a single agent or in combination with ipilimumab, is indicated for the treatment of adult and pediatric patients 12 years and older with microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer (CRC) that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan.

This indication is approved under accelerated approval based on overall response rate and duration of response [see Clinical Studies (14.9)]. Continued approval for these indications may be contingent upon verification and description of clinical benefit in confirmatory trials.

Hepatocellular Carcinoma

Opdivo is indicated for the treatment of patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib. This indication is approved under accelerated approval based on tumor response rate and durability of response [see Clinical Studies (14.10)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.

Opdivo Dosage and Administration

Recommended Dosage

The recommended dosages of Opdivo as a single agent are presented in Table 1.

Table 1: Recommended Dosages for Opdivo as a Single Agent

Indication

Recommended Opdivo Dosage

Duration of Therapy

Unresectable or metastatic melanoma

240 mg every 2 weeks

(30-minute intravenous infusion)

or

480 mg every 4 weeks

(30-minute intravenous infusion)

Until disease progression or unacceptable toxicity

Metastatic non-small cell lung cancer

Advanced renal cell carcinoma

Classical Hodgkin lymphoma

Squamous cell carcinoma of the head and neck

Urothelial carcinoma

Hepatocellular carcinoma

Adjuvant treatment of melanoma

240 mg every 2 weeks

(30-minute intravenous infusion)

or

480 mg every 4 weeks

(30-minute intravenous infusion)

Until disease recurrence or unacceptable toxicity for up to 1 year

Small cell lung cancer

240 mg every 2 weeks

(30-minute intravenous infusion)

Until disease progression or unacceptable toxicity

Microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer

Adult patients and pediatric patients age 12 years and older and weighing 40 kg or more:

240 mg every 2 weeks

(30-minute intravenous infusion)

or

480 mg every 4 weeks

(30-minute intravenous infusion)

Until disease progression or unacceptable toxicity

Pediatric patients age 12 years and older and weighing less than 40 kg:

3 mg/kg every 2 weeks

(30-minute intravenous infusion)

The recommended dosages of Opdivo in combination with ipilimumab are presented in Table 2. Refer to the ipilimumab Prescribing Information for recommended ipilimumab dosage information.

Table 2: Recommended Dosages of Opdivo in Combination with Ipilimumab

Indication

Recommended Opdivo Dosage

Duration of Therapy

Unresectable or metastatic melanoma

1 mg/kg every 3 weeks

(30-minute intravenous infusion)

with ipilimumab 3 mg/kg intravenously over 90 minutes on the same day

In combination with ipilimumab for a maximum of 4 doses or until unacceptable toxicity, whichever occurs earlier

240 mg every 2 weeks

(30-minute intravenous infusion)

or

480 mg every 4 weeks

(30-minute intravenous infusion)

After completing 4 doses of combination therapy, administer as single agent until disease progression or unacceptable toxicity

Advanced renal cell carcinoma

3 mg/kg every 3 weeks

(30-minute intravenous infusion)

with ipilimumab 1 mg/kg intravenously over 30 minutes on the same day

In combination with ipilimumab
for 4 doses

240 mg every 2 weeks

(30-minute intravenous infusion)

or

480 mg every 4 weeks

(30-minute intravenous infusion)

After completing 4 doses of combination therapy, administer as single agent until disease progression or unacceptable toxicity

Microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer

3 mg/kg every 3 weeks

(30-minute intravenous infusion)

with ipilimumab 1 mg/kg intravenously over 30 minutes on the same day

In combination with ipilimumab
for 4 doses

Adult patients and pediatric patients age 12 years and older and weighing 40 kg or more:

240 mg every 2 weeks

(30-minute intravenous infusion)

or

480 mg every 4 weeks

(30-minute intravenous infusion)

After completing 4 doses of combination therapy, administer as single agent until disease progression or unacceptable toxicity

Pediatric patients age 12 years and older and weighing less than 40 kg:

3 mg/kg every 2 weeks

(30-minute intravenous infusion)

Dose Modifications

Recommendations for Opdivo modifications are provided in Table 3. When Opdivo is administered in combination with ipilimumab, if Opdivo is withheld, ipilimumab should also be withheld. Review the Prescribing Information for ipilimumab for recommended dose modifications.

There are no recommended dose modifications for hypothyroidism or hyperthyroidism.

Interrupt or slow the rate of infusion in patients with mild or moderate infusion-related reactions. Discontinue Opdivo in patients with severe or life-threatening infusion-related reactions.

Table 3: Recommended Dose Modifications for Opdivo
*  Toxicity was graded per National Cancer Institute Common Terminology Criteria for Adverse Events. Version 4.0 (NCI CTCAE v4).
a  Resume treatment when adverse reaction improves to Grade 0 or 1.
b  HCC: hepatocellular carcinoma.
c  Resume treatment when AST/ALT returns to baseline.

Adverse Reaction

Severity*

Dose Modification

Colitis

Grade 2 diarrhea or colitis

Withhold dosea

Grade 3 diarrhea or colitis

Withhold dosea when administered as a single agent

Permanently discontinue when administered with ipilimumab

Grade 4 diarrhea or colitis

Permanently discontinue

Pneumonitis

Grade 2 pneumonitis

Withhold dosea

Grade 3 or 4 pneumonitis

Permanently discontinue

Hepatitis/non-HCCb

Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) more than 3 and up to 5 times the upper limit of normal (ULN) or total bilirubin more than 1.5 and up to 3 times the ULN

Withhold dosea

AST or ALT more than 5 times the ULN or total bilirubin more than 3 times the ULN

Permanently discontinue

Hepatitis/HCCb

If AST/ALT is within normal limits at baseline and increases to more than 3 and up to 5 times the ULN
If AST/ALT is more than 1 and up to 3 times ULN at baseline and increases to more than 5 and up to 10 times the ULN
If AST/ALT is more than 3 and up to 5 times ULN at baseline and increases to more than 8 and up to 10 times the ULN

Withhold dosec

If AST or ALT increases to more than 10 times the ULN or total bilirubin increases to more than 3 times the ULN

Permanently discontinue

Hypophysitis

Grade 2 or 3 hypophysitis

Withhold dosea

Grade 4 hypophysitis

Permanently discontinue

Adrenal Insufficiency

Grade 2 adrenal insufficiency

Withhold dosea

Grade 3 or 4 adrenal insufficiency

Permanently discontinue

Type 1 Diabetes Mellitus

Grade 3 hyperglycemia

Withhold dosea

Grade 4 hyperglycemia

Permanently discontinue

Nephritis and Renal Dysfunction

Serum creatinine more than 1.5 and up to 6 times the ULN

Withhold dosea

Serum creatinine more than 6 times the ULN

Permanently discontinue

Skin

Grade 3 rash or suspected Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN)

Withhold dosea

Grade 4 rash or confirmed SJS or TEN

Permanently discontinue

Encephalitis

New-onset moderate or severe neurologic signs or symptoms

Withhold dosea

Immune-mediated encephalitis

Permanently discontinue

Other

Other Grade 3 adverse reaction
     First occurrence
     Recurrence of same Grade 3 adverse reactions


Withhold dosea
Permanently discontinue

Life-threatening or Grade 4 adverse reaction

Permanently discontinue

Grade 3 myocarditis

Permanently discontinue

Requirement for 10 mg per day or greater prednisone or equivalent for more than 12 weeks

Permanently discontinue

Persistent Grade 2 or 3 adverse reactions lasting 12 weeks or longer

Permanently discontinue

Preparation and Administration

Visually inspect for particulate matter and discoloration. Opdivo is a clear to opalescent, colorless to pale-yellow solution. Discard if cloudy, discolored, or contains extraneous particulate matter other than a few translucent-to-white, proteinaceous particles. Do not shake.

Preparation
Withdraw the required volume of Opdivo and transfer into an intravenous container.
Dilute Opdivo with either 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP to prepare an infusion with a final concentration ranging from 1 mg/mL to 10 mg/mL. The total volume of infusion must not exceed 160 mL.
•     For adult and pediatric patients with body weight ≥40 kg, do not exceed a total volume of infusion of 160 mL.
•     For adult and pediatric patients with body weight <40 kg, do not exceed a total volume of infusion of 4 mL/kg of body weight.
Mix diluted solution by gentle inversion. Do not shake.
Discard partially used vials or empty vials of Opdivo.
The product does not contain a preservative.
After preparation, store the diluted solution either:
•     at room temperature for no more than 8 hours from the time of preparation to end of the infusion. Discard diluted solution if not used within 8 hours from the time of preparation; or
•     under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the time of preparation to end of infusion. Discard diluted solution if not used within 24 hours from the time of preparation.
Do not freeze.
Administration
Administer the infusion over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low protein binding in-line filter (pore size of 0.2 micrometer to 1.2 micrometer).
When administered with ipilimumab, administer Opdivo first followed by ipilimumab on the same day. Use separate infusion bags and filters for each infusion.
Flush the intravenous line at end of infusion.
Do not coadminister other drugs through the same intravenous line.

Dosage Forms and Strengths

Injection: 40 mg/4 mL (10 mg/mL), 100 mg/10 mL (10 mg/mL), and 240 mg/24 mL (10 mg/mL) clear to opalescent, colorless to pale-yellow solution in a single-dose vial.

Contraindications

None.

Warnings and Precautions

Immune-Mediated Pneumonitis

Opdivo can cause immune-mediated pneumonitis, defined as requiring use of corticosteroids and no clear alternate etiology. Fatal cases have been reported.

Monitor patients for signs with radiographic imaging and for symptoms of pneumonitis. Administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents for moderate (Grade 2) or more severe (Grade 3-4) pneumonitis, followed by corticosteroid taper. Permanently discontinue Opdivo for severe (Grade 3) or life-threatening (Grade 4) pneumonitis and withhold Opdivo until resolution for moderate (Grade 2) pneumonitis [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, immune-mediated pneumonitis occurred in 3.1% (61/1994) of patients. The median time to onset of immune-mediated pneumonitis was 3.5 months (range: 1 day to 22.3 months). Immune-mediated pneumonitis led to permanent discontinuation of Opdivo in 1.1% and withholding of Opdivo in 1.3% of patients. Approximately 89% of patients with pneumonitis received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 26 days (range: 1 day to 6 months). Complete resolution of symptoms following corticosteroid taper occurred in 67% of patients. Approximately 8% of patients had recurrence of pneumonitis after re-initiation of Opdivo.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Immune-mediated pneumonitis occurred in 6% (25/407) of patients with melanoma who received Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 1.6 months (range: 24 days to 10.1 months). Immune-mediated pneumonitis led to permanent discontinuation or withholding of Opdivo with ipilimumab in 2.2% and 3.7% of patients, respectively. Approximately 84% of patients with pneumonitis received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 30 days (range: 5 days to 11.8 months). Complete resolution occurred in 68% of patients. Approximately 13% of patients had recurrence of pneumonitis after re-initiation of Opdivo with ipilimumab.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Immune-mediated pneumonitis occurred in 4.4% (24/547) of patients with RCC and 1.7% (2/119) of patients with CRC who received Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset of immune-mediated pneumonitis was 2.6 months (range: 8 days to 9.2 months) in patients with RCC and 1.9 months (range: 27 days to 3 months) in patients with CRC.

Immune-mediated pneumonitis led to permanent discontinuation of Opdivo with ipilimumab in 1.8% of patients with RCC or CRC (n=666) and withholding of Opdivo with ipilimumab in 1.7%. All patients with pneumonitis required systemic corticosteroids, including 92% who received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 19 days (range: 4 days to 3.2 months). Approximately 8% required addition of infliximab to high-dose corticosteroids. Complete resolution of pneumonitis occurred in 81% of patients. Pneumonitis recurred after re-initiation of Opdivo with ipilimumab in one patient with CRC.

Immune-Mediated Colitis

Opdivo can cause immune-mediated colitis, defined as requiring use of corticosteroids with no clear alternate etiology.

Monitor patients for signs and symptoms of colitis. Administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents followed by corticosteroid taper for severe (Grade 3) or life-threatening (Grade 4) colitis. Administer corticosteroids at a dose of 0.5 to 1 mg/kg/day prednisone equivalents followed by corticosteroid taper for moderate (Grade 2) colitis of more than 5 days duration; if worsening or no improvement occurs despite initiation of corticosteroids, increase dose to 1 to 2 mg/kg/day prednisone equivalents.

Withhold Opdivo for moderate or severe (Grade 2 or 3) colitis. Permanently discontinue Opdivo for life-threatening (Grade 4) or for recurrent colitis upon re-initiation of Opdivo [see Dosage and Administration (2.2)].

When administered in combination with ipilimumab, withhold Opdivo and ipilimumab for moderate colitis (Grade 2). Permanently discontinue Opdivo and ipilimumab for severe or life-threatening (Grade 3 or 4) colitis or for recurrent colitis [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, immune-mediated colitis occurred in 2.9% (58/1994) of patients; the median time to onset was 5.3 months (range: 2 days to 20.9 months). Immune-mediated colitis led to permanent discontinuation of Opdivo in 0.7% and withholding of Opdivo in 1% of patients. Approximately 91% of patients with colitis received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 23 days (range: 1 day to 9.3 months). Four patients required addition of infliximab to high-dose corticosteroids. Complete resolution occurred in 74% of patients. Approximately 16% of patients had recurrence of colitis after re-initiation of Opdivo.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Immune-mediated colitis occurred in 26% (107/407) of patients with melanoma who received Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks, including three fatal cases. Median time to onset was 1.6 months (range: 3 days to 15.2 months). Immune-mediated colitis led to permanent discontinuation or withholding of Opdivo with ipilimumab in 16% and 7% of patients, respectively. Approximately 96% of patients with colitis received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 1.1 month (range: 1 day to 12 months). Approximately 23% of patients required addition of infliximab to high-dose corticosteroids. Complete resolution occurred in 75% of patients. Approximately 28% of patients had recurrence of colitis after re-initiation of Opdivo with ipilimumab.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Immune-mediated colitis occurred in 10% (52/547) of patients with RCC and 7% (8/119) of patients with CRC who received Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset of immune-mediated colitis was 1.7 months (range: 2 days to 19.2 months) in patients with RCC and 2.4 months (range: 22 days to 5.2 months) in patients with mCRC.

Immune-mediated colitis led to permanent discontinuation of Opdivo with ipilimumab in 3.2% of patients with RCC or CRC (n=666) and withholding of Opdivo with ipilimumab in 3.9%. All patients with colitis required systemic corticosteroids, including 80% who received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 21 days (range: 1 day to 27 months). Approximately 23% of patients with immune-mediated colitis required addition of infliximab to high-dose corticosteroids. Complete resolution occurred in 88% of patients. Two patients with RCC had recurrence of colitis after re-initiation of Opdivo with ipilimumab.

Immune-Mediated Hepatitis

Opdivo can cause immune-mediated hepatitis, defined as requiring use of corticosteroids and no clear alternate etiology. Monitor patients for abnormal liver tests prior to and periodically during treatment. Administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents followed by corticosteroid taper for severe (Grade 3) or life-threatening (Grade 4) transaminase elevations, with or without concomitant elevation in total bilirubin. Administer corticosteroids at a dose of 0.5 to 1 mg/kg/day prednisone equivalents for moderate (Grade 2) transaminase elevations.

For patients without hepatocellular carcinoma (HCC): withhold Opdivo for moderate (Grade 2) immune-mediated hepatitis and permanently discontinue Opdivo for severe (Grade 3) or life-threatening (Grade 4) immune-mediated hepatitis [see Dosage and Administration (2.2)].

For patients with HCC, permanently discontinue, withhold, or continue Opdivo based on severity of immune-mediated hepatitis and baseline AST and ALT levels as described in Table 3 [see Dosage and Administration (2.2)]. In addition, administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents followed by corticosteroid taper when Opdivo is withheld or discontinued due to immune-mediated hepatitis.

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, immune-mediated hepatitis occurred in 1.8% (35/1994) of patients; the median time to onset was 3.3 months (range: 6 days to 9 months). Immune-mediated hepatitis led to permanent discontinuation of Opdivo in 0.7% and withholding of Opdivo in 1% of patients. All patients with hepatitis received high-dose corticosteroids (at least 40 mg prednisone equivalents) for a median duration of 23 days (range: 1 day to 2 months). Two patients required the addition of mycophenolic acid to high-dose corticosteroids. Complete resolution occurred in 74% of patients. Approximately 29% of patients had recurrence of hepatitis after re-initiation of Opdivo.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Immune-mediated hepatitis occurred in 13% (51/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 2.1 months (range: 15 days to 11 months). Immune-mediated hepatitis led to permanent discontinuation or withholding of Opdivo with ipilimumab in 6% and 5% of patients, respectively. Approximately 92% of patients with hepatitis received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 1.1 month (range: 1 day to 13.2 months). Complete resolution occurred in 75% of patients. Approximately 11% of patients had recurrence of hepatitis after re-initiation of Opdivo with ipilimumab.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Immune-mediated hepatitis occurred in 7% (38/547) of patients with RCC and 8% (10/119) with CRC receiving Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 2 months (range: 14 days to 26.8 months) in patients with RCC and 2.2 months (range: 22 days to 10.5 months) in patients with CRC.

Immune-mediated hepatitis led to permanent discontinuation of Opdivo with ipilimumab in 3.6% of patients with RCC or CRC (n=666) and withholding of Opdivo and ipilimumab in 3.5%. All patients with hepatitis required systemic corticosteroids, including 94% who received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 1 month (range: 1 day to 7 months). Approximately 19% of patients with immune-mediated hepatitis required addition of mycophenolic acid to high-dose corticosteroids. Complete resolution occurred in 83% of patients. No patients had recurrence of hepatitis after re-initiation of Opdivo with ipilimumab.

Immune-Mediated Endocrinopathies

Hypophysitis

Opdivo can cause immune-mediated hypophysitis. Monitor patients for signs and symptoms of hypophysitis. Administer hormone replacement as clinically indicated and corticosteroids at a dose of 1 mg/kg/day prednisone equivalents followed by corticosteroid taper for moderate (Grade 2) or greater hypophysitis. Withhold Opdivo for moderate (Grade 2) or severe (Grade 3). Permanently discontinue Opdivo for life-threatening (Grade 4) hypophysitis [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, hypophysitis occurred in 0.6% (12/1994) of patients; the median time to onset was 4.9 months (range: 1.4 to 11 months). Hypophysitis led to permanent discontinuation of Opdivo in 0.1% and withholding of Opdivo in 0.2% of patients. Approximately 67% of patients with hypophysitis received hormone replacement therapy and 33% received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 14 days (range: 5 to 26 days).

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Hypophysitis occurred in 9% (36/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 2.7 months (range: 27 days to 5.5 months). Hypophysitis led to permanent discontinuation or withholding of Opdivo with ipilimumab in 1.0% and 3.9% of patients, respectively. Approximately 75% of patients with hypophysitis received hormone replacement therapy and 56% received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 19 days (range: 1 day to 2.0 months).

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Hypophysitis occurred in 4.6% (25/547) of patients with RCC and 3.4% (4/119) of patients with CRC receiving Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 2.8 months (range: 1.3 months to 7.3 months) in patients with RCC and 3.7 months (range: 2.8 to 5.5 months) in patients with CRC.

Hypophysitis led to permanent discontinuation or withholding of Opdivo with ipilimumab in 1.2% and 2.6% of patients with RCC or CRC (n=666), respectively. Approximately 72% of patients with hypophysitis received hormone replacement therapy and 55% received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 13 days (range: 1 day to 1.6 months).

Adrenal Insufficiency

Opdivo can cause immune-mediated adrenal insufficiency. Monitor patients for signs and symptoms of adrenal insufficiency. Administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents followed by a corticosteroid taper for severe (Grade 3) or life-threatening (Grade 4) adrenal insufficiency. Withhold Opdivo for moderate (Grade 2) and permanently discontinue Opdivo for severe (Grade 3) or life-threatening (Grade 4) adrenal insufficiency [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, adrenal insufficiency occurred in 1% (20/1994) of patients and the median time to onset was 4.3 months (range: 15 days to 21 months). Adrenal insufficiency led to permanent discontinuation of Opdivo in 0.1% and withholding of Opdivo in 0.5% of patients. Approximately 85% of patients with adrenal insufficiency received hormone replacement therapy and 25% received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 11 days (range: 1 day to 1 month).

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Adrenal insufficiency occurred in 5% (21/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 3.0 months (range: 21 days to 9.4 months). Adrenal insufficiency led to permanent discontinuation or withholding of Opdivo with ipilimumab in 0.5% and 1.7% of patients, respectively. Approximately 57% of patients with adrenal insufficiency received hormone replacement therapy and 33% received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 9 days (range: 1 day to 2.7 months).

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Adrenal insufficiency occurred in 7% (41/547) of patients with RCC and 5.9% (7/119) patients with CRC who received Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 3.4 months (range: 2.0 months to 22.3 months) in RCC and 3.7 months (range: 2.5 to 13.4 months) in CRC.

Adrenal insufficiency led to permanent discontinuation of Opdivo and ipilimumab in 1.2% of patients with RCC or CRC (n=666) and withholding of Opdivo and ipilimumab in 2.6%. Approximately 94% of patients with adrenal insufficiency received hormone replacement therapy and 27% received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 12 days (range: 2 days to 5.6 months).

Hypothyroidism and Hyperthyroidism

Opdivo can cause autoimmune thyroid disorders. Monitor thyroid function prior to and periodically during Opdivo treatment. Administer hormone-replacement therapy for hypothyroidism. Initiate medical management for control of hyperthyroidism. There are no recommended dose adjustments of Opdivo for hypothyroidism or hyperthyroidism.

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, hypothyroidism or thyroiditis resulting in hypothyroidism occurred in 9% (171/1994) of patients; the median time to onset was 2.9 months (range: 1 day to 16.6 months). Approximately 79% of patients with hypothyroidism received levothyroxine and 4% also required corticosteroids. Resolution occurred in 35% of patients.

Hyperthyroidism occurred in 2.7% (54/1994) of patients receiving Opdivo as a single agent; the median time to onset was 1.5 months (range: 1 day to 14.2 months). Approximately 26% of patients with hyperthyroidism received methimazole, 9% received carbimazole, 4% received propylthiouracil, and 9% received corticosteroids. Resolution occurred in 76% of patients.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Hypothyroidism or thyroiditis resulting in hypothyroidism occurred in 22% (89/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 2.1 months (range: 1 day to 10.1 months). Approximately 73% of patients with hypothyroidism or thyroiditis received levothyroxine. Resolution occurred in 45% of patients.

Hyperthyroidism occurred in 8% (34/407) of patients with melanoma who received Opdivo with ipilimumab; the median time to onset was 23 days (range: 3 days to 3.7 months). Approximately 29% of patients with hyperthyroidism received methimazole and 24% received carbimazole. Resolution occurred in 94% of patients.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Hypothyroidism or thyroiditis resulting in hypothyroidism occurred in 22% (119/547) of patients with RCC and 15% (18/119) of patients with CRC who received Opdivo 3 mg/kg and ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 2.2 months (range: 1 day to 21.4 months) in patients with RCC and 2.3 months (range: 22 days to 9.8 months) in patients with CRC. Of the 137 patients with RCC or CRC who developed hypothyroidism, approximately 81% of patients with RCC and 78% with CRC received levothyroxine.

Hyperthyroidism occurred in 12% (66/547) of patients with RCC and 12% (14/119) of patients with CRC who received Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 1.4 months (range: 6 days to 14.2 months) in RCC and 1.1 months (range: 21 days to 5.4 months) in CRC. Of the 80 patients with RCC or CRC who developed hyperthyroidism, approximately 15% received methimazole and 2% received carbimazole.

Type 1 Diabetes Mellitus

Opdivo can cause Type 1 diabetes mellitus. Monitor for hyperglycemia. Withhold Opdivo in cases of severe (Grade 3) hyperglycemia until metabolic control is achieved. Permanently discontinue Opdivo for life-threatening (Grade 4) hyperglycemia [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, diabetes occurred in 0.9% (17/1994) of patients including two cases of diabetic ketoacidosis. Median time to onset was 4.4 months (range: 15 days to 22 months).

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Diabetes occurred in 1.5% (6/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 2.5 months (range: 1.3 to 4.4 months). Opdivo with ipilimumab was withheld in a patient and permanently discontinued in a second patient who developed diabetes.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Diabetes occurred in 2.7% (15/547) of patients with RCC receiving Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks; the median time to onset was 3.2 months (range: 19 days to 16.8 months). Opdivo with ipilimumab was withheld in 33% of patients and permanently discontinued in 20% of patients who developed diabetes.

Immune-Mediated Nephritis and Renal Dysfunction

Opdivo can cause immune-mediated nephritis, defined as renal dysfunction or ≥Grade 2 increased creatinine, requirement for corticosteroids, and no clear alternate etiology. Monitor patients for elevated serum creatinine prior to and periodically during treatment. Administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents followed by corticosteroid taper for life-threatening (Grade 4) increased serum creatinine. Administer corticosteroids at a dose of 0.5 to 1 mg/kg/day prednisone equivalents for moderate (Grade 2) or severe (Grade 3) increased serum creatinine, if worsening or no improvement occurs, increase dose of corticosteroids to 1 to 2 mg/kg/day prednisone equivalents.

Withhold Opdivo for moderate (Grade 2) or severe (Grade 3) increased serum creatinine. Permanently discontinue Opdivo for life-threatening (Grade 4) increased serum creatinine [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, immune-mediated nephritis and renal dysfunction occurred in 1.2% (23/1994) of patients; the median time to onset was 4.6 months (range: 23 days to 12.3 months). Immune-mediated nephritis and renal dysfunction led to permanent discontinuation of Opdivo in 0.3% and withholding of Opdivo in 0.8% of patients. All patients received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 21 days (range: 1 day to 15.4 months). Complete resolution occurred in 48% of patients. No patients had recurrence of nephritis or renal dysfunction after re-initiation of Opdivo.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Immune-mediated nephritis and renal dysfunction occurred in 2.2% (9/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 2.7 months (range: 9 days to 7.9 months). Immune-mediated nephritis and renal dysfunction led to permanent discontinuation or withholding of Opdivo with ipilimumab in 0.7% and 0.5% of patients, respectively. Approximately 67% of patients received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 13.5 days (range: 1 day to 1.1 months). Complete resolution occurred in all patients. Two patients resumed Opdivo with ipilimumab without recurrence of nephritis or renal dysfunction.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Immune-mediated nephritis and renal dysfunction occurred in 4.6% (25/547) of patients with RCC and 1.7% (2/119) of patients with CRC who received Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 3 months (range: 1 day to 13.2 months) among these 27 patients.

Immune-mediated nephritis and renal dysfunction led to permanent discontinuation of Opdivo with ipilimumab in 1.2% of patients with RCC or CRC (n=666) and withholding of Opdivo and ipilimumab in 2.3%. Approximately 78% of patients with immune-mediated nephritis and renal dysfunction received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 17 days (range: 1 day to 6 months). Complete resolution occurred in 63% of patients. One of 16 patients with RCC had recurrence of nephritis or renal dysfunction after re-initiation of Opdivo with ipilimumab.

Immune-Mediated Skin Adverse Reactions

Opdivo can cause immune-mediated rash, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), some cases with fatal outcome. For symptoms or signs of SJS or TEN, withhold Opdivo and refer the patient for specialized care for assessment and treatment. If SJS or TEN is confirmed, permanently discontinue Opdivo [see Dosage and Administration (2.2)].

For immune-mediated rash, administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents followed by a corticosteroid taper for severe (Grade 3) or life-threatening (Grade 4) rash. Withhold Opdivo for severe (Grade 3) rash and permanently discontinue Opdivo for life-threatening (Grade 4) rash.

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, immune-mediated rash occurred in 9% (171/1994) of patients; the median time to onset was 2.8 months (range: <1 day to 25.8 months). Immune-mediated rash led to permanent discontinuation of Opdivo in 0.3% and withholding of Opdivo in 0.8% of patients. Approximately 16% of patients with rash received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 12 days (range: 1 day to 8.9 months) and 85% received topical corticosteroids. Complete resolution occurred in 48% of patients. Recurrence of rash occurred in 1.4% of patients who resumed Opdivo after resolution of rash.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Immune-mediated rash occurred in 22.6% (92/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks. Median time to onset was 18 days (range: 1 day to 9.7 months). Immune-mediated rash led to permanent discontinuation or withholding of Opdivo with ipilimumab in 0.5% and 3.9% of patients, respectively. Approximately 17% of patients with rash received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 14 days (range: 2 days to 4.7 months). Complete resolution occurred in 47% of patients. Approximately 6% of patients who resumed Opdivo and ipilimumab after resolution had recurrence of rash.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Immune-mediated rash occurred in 16% (90/547) of patients with RCC and 14% (17/119) of patients with CRC who received Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks. Median time to onset was 1.5 months (range: 1 day to 20.9 months) in RCC and 26 days (range: 5 days to 9.8 months) in CRC.

Immune-mediated rash led to permanent discontinuation or withholding of Opdivo with ipilimumab in 0.5% of patients with RCC or CRC (n=666) and withholding of Opdivo with ipilimumab in 2.6% of patients. All patients with immune-mediated rash required systemic corticosteroids, including 19% who received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 22 days (range: 1 day to 23 months). Complete resolution occurred in 66% of patients. Immune-mediated rash recurred in approximately 3% (3/98) of patients who resumed Opdivo and ipilimumab.

Immune-Mediated Encephalitis

Opdivo can cause immune-mediated encephalitis with no clear alternate etiology. Evaluation of patients with neurologic symptoms may include, but not be limited to, consultation with a neurologist, brain MRI, and lumbar puncture.

Withhold Opdivo in patients with new-onset moderate to severe neurologic signs or symptoms and evaluate to rule out infectious or other causes of moderate to severe neurologic deterioration. If other etiologies are ruled out, administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents for patients with immune-mediated encephalitis, followed by corticosteroid taper. Permanently discontinue Opdivo for immune-mediated encephalitis [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a single agent, encephalitis occurred in 0.2% (3/1994). Fatal limbic encephalitis occurred in one patient after 7.2 months of exposure despite discontinuation of Opdivo and administration of corticosteroids. In the other two patients, encephalitis occurred post-allogeneic HSCT [see Warnings and Precautions (5.10)].

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Encephalitis occurred in one patient (0.2%) with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks after 1.7 months of exposure.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Encephalitis occurred in one patient (0.2%) with RCC after approximately 4 months of exposure and one patient (0.8%) with CRC after 15 days of exposure. The patient with CRC required infliximab and high-dose corticosteroids (at least 40 mg prednisone equivalents per day).

Other Immune-Mediated Adverse Reactions

Opdivo can cause other clinically significant and potentially fatal immune-mediated adverse reactions. Immune-mediated adverse reactions may occur after discontinuation of Opdivo therapy. For any suspected immune-mediated adverse reactions, exclude other causes. Based on the severity of the adverse reaction, permanently discontinue or withhold Opdivo, administer high-dose corticosteroids, and if appropriate, initiate hormone-replacement therapy. Upon improvement to Grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month. Consider restarting Opdivo after completion of corticosteroid taper based on the severity of the event [see Dosage and Administration (2.2)].

Across clinical trials of Opdivo administered as a single agent or in combination with ipilimumab, the following clinically significant immune-mediated adverse reactions, some with fatal outcome, occurred in <1.0% of patients receiving Opdivo: myocarditis, rhabdomyolysis, myositis, uveitis, iritis, pancreatitis, facial and abducens nerve paresis, demyelination, polymyalgia rheumatica, autoimmune neuropathy, Guillain-Barré syndrome, hypopituitarism, systemic inflammatory response syndrome, gastritis, duodenitis, sarcoidosis, histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis), motor dysfunction, vasculitis, aplastic anemia, pericarditis, and myasthenic syndrome.

If uveitis occurs in combination with other immune-mediated adverse reactions, consider a Vogt-Koyanagi-Harada-like syndrome, which has been observed in patients receiving Opdivo or Opdivo in combination with ipilimumab and may require treatment with systemic steroids to reduce the risk of permanent vision loss.

Infusion-Related Reactions

Opdivo can cause severe infusion-related reactions, which have been reported in <1.0% of patients in clinical trials. Discontinue Opdivo in patients with severe or life-threatening infusion-related reactions. Interrupt or slow the rate of infusion in patients with mild or moderate infusion-related reactions [see Dosage and Administration (2.2)].

Opdivo as a Single Agent

In patients receiving Opdivo as a 60-minute intravenous infusion, infusion-related reactions occurred in 6.4% (127/1994) of patients.

In a trial assessing the pharmacokinetics and safety of a more rapid infusion, in which patients received Opdivo as a 60-minute intravenous infusion or a 30-minute intravenous infusion, infusion-related reactions occurred in 2.2% (8/368) and 2.7% (10/369) of patients, respectively. Additionally, 0.5% (2/368) and 1.4% (5/369) of patients, respectively, experienced adverse reactions within 48 hours of infusion that led to dose delay, permanent discontinuation or withholding of Opdivo.

Opdivo with Ipilimumab

Opdivo 1 mg/kg with Ipilimumab 3 mg/kg

Infusion-related reactions occurred in 2.5% (10/407) of patients with melanoma receiving Opdivo 1 mg/kg with ipilimumab 3 mg/kg every 3 weeks.

Opdivo 3 mg/kg with Ipilimumab 1 mg/kg

Infusion-related reactions occurred in 5.1% (28/547) of patients with RCC and 4.2% (5/119) of patients with CRC receiving Opdivo 3 mg/kg with ipilimumab 1 mg/kg every 3 weeks, respectively.

Complications of Allogeneic Hematopoietic Stem Cell Transplantation

Fatal and other serious complications can occur in patients who receive allogeneic hematopoietic stem cell transplantation (HSCT) before or after being treated with a PD-1 receptor blocking antibody. Transplant-related complications include hyperacute graft-versus-host-disease (GVHD), acute GVHD, chronic GVHD, hepatic veno-occlusive disease (VOD) after reduced intensity conditioning, and steroid-requiring febrile syndrome (without an identified infectious cause) [see Adverse Reactions (6.1)]. These complications may occur despite intervening therapy between PD-1 blockade and allogeneic HSCT.

Follow patients closely for evidence of transplant-related complications and intervene promptly. Consider the benefit versus risks of treatment with a PD-1 receptor blocking antibody prior to or after an allogeneic HSCT.

Embryo-Fetal Toxicity

Based on its mechanism of action and data from animal studies, Opdivo can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of nivolumab to cynomolgus monkeys from the onset of organogenesis through delivery resulted in increased abortion and premature infant death. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with Opdivo and for at least 5 months after the last dose [see Use in Specific Populations (8.1, 8.3)].

Increased Mortality in Patients with Multiple Myeloma when Opdivo Is Added to a Thalidomide Analogue and Dexamethasone

In randomized clinical trials in patients with multiple myeloma, the addition of a PD-1 blocking antibody, including Opdivo, to a thalidomide analogue plus dexamethasone, a use for which no PD-1 or PD-L1 blocking antibody is indicated, resulted in increased mortality. Treatment of patients with multiple myeloma with a PD-1 or PD-L1 blocking antibody in combination with a thalidomide analogue plus dexamethasone is not recommended outside of controlled clinical trials.

Adverse Reactions

The following clinically significant adverse reactions are described elsewhere in the labeling.

Immune-Mediated Pneumonitis [see Warnings and Precautions (5.1)]
Immune-Mediated Colitis [see Warnings and Precautions (5.2)]
Immune-Mediated Hepatitis [see Warnings and Precautions (5.3)]
Immune-Mediated Endocrinopathies [see Warnings and Precautions (5.4)]
Immune-Mediated Nephritis and Renal Dysfunction [see Warnings and Precautions (5.5)]
Immune-Mediated Skin Adverse Reactions [see Warnings and Precautions (5.6)]
Immune-Mediated Encephalitis [see Warnings and Precautions (5.7)]
Other Immune-Mediated Adverse Reactions [see Warnings and Precautions (5.8)]
Infusion-Related Reactions [see Warnings and Precautions (5.9)]
Complications of Allogeneic HSCT [see Warnings and Precautions (5.10)]

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The data in WARNINGS AND PRECAUTIONS reflect exposure to Opdivo as a single agent in 1994 patients enrolled in CHECKMATE-037, CHECKMATE-017, CHECKMATE-057, CHECKMATE-066, CHECKMATE-025, CHECKMATE-067, CHECKMATE-205, CHECKMATE-039 or a single-arm trial in NSCLC (n=117); Opdivo 1 mg/kg with ipilimumab 3 mg/kg in patients enrolled in CHECKMATE-067 (n=313) or another randomized trial (n=94); and Opdivo 3 mg/kg administered with ipilimumab 1 mg/kg (n=666) in patients enrolled in CHECKMATE-214 or CHECKMATE-142.

Unresectable or Metastatic Melanoma

Previously Treated Metastatic Melanoma

The safety of Opdivo was evaluated in CHECKMATE-037, a randomized, open-label trial in 370 patients with unresectable or metastatic melanoma [see Clinical Studies (14.1)]. Patients had documented disease progression following treatment with ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. The trial excluded patients with autoimmune disease, prior ipilimumab-related Grade 4 adverse reactions (except for endocrinopathies) or Grade 3 ipilimumab-related adverse reactions that had not resolved or were inadequately controlled within 12 weeks of the initiating event, patients with a condition requiring chronic systemic treatment with corticosteroids (>10 mg daily prednisone equivalent) or other immunosuppressive medications, a positive test for hepatitis B or C, and a history of HIV. Patients received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks (n=268) or investigator’s choice of chemotherapy (n=102): dacarbazine 1000 mg/m2 intravenously every 3 weeks or carboplatin AUC 6 mg/mL/min and paclitaxel 175 mg/m2 intravenously every 3 weeks. The median duration of exposure was 5.3 months (range: 1 day to 13.8+ months) in Opdivo-treated patients and was 2 months (range: 1 day to 9.6+ months) in chemotherapy-treated patients. In this ongoing trial, 24% of patients received Opdivo for >6 months and 3% of patients received Opdivo for >1 year.

The population characteristics in the Opdivo group and the chemotherapy group were similar: 66% male, median age 59.5 years, 98% White, baseline Eastern Cooperative Oncology Group (ECOG) performance status 0 (59%) or 1 (41%), 74% with M1c stage disease, 73% with cutaneous melanoma, 11% with mucosal melanoma, 73% received two or more prior therapies for advanced or metastatic disease, and 18% had brain metastasis. There were more patients in the Opdivo group with elevated lactate dehydrogenase (LDH) at baseline (51% vs. 38%).

Serious adverse reactions occurred in 41% of patients receiving Opdivo. Opdivo was discontinued for adverse reactions in 9% of patients. Twenty-six percent of patients receiving Opdivo had a dose interruption for an adverse reaction. Grade 3 and 4 adverse reactions occurred in 42% of patients receiving Opdivo. The most frequent Grade 3 and 4 adverse reactions reported in 2% to <5% of patients receiving Opdivo were abdominal pain, hyponatremia, increased aspartate aminotransferase, and increased lipase. The most common adverse reaction (reported in ≥20% of patients) was rash.

Tables 4 and 5 summarize the adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-037.

Table 4: Adverse Reactions Occurring in ≥10% of Opdivo-Treated Patients and at a Higher Incidence than in the Chemotherapy Arm (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-037
Toxicity was graded per NCI CTCAE v4.
a  Includes maculopapular rash, erythematous rash, pruritic rash, follicular rash, macular rash, papular rash, pustular rash, vesicular rash, and acneiform dermatitis.
b  Includes rhinitis, pharyngitis, and nasopharyngitis.

Adverse Reaction

Opdivo
(n=268)

Chemotherapy
(n=102)

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

Skin and Subcutaneous Tissue

     Rasha

21

0.4

7

0

     Pruritus

19

0

3.9

0

Respiratory, Thoracic and Mediastinal

     Cough

17

0

6

0

Infections

     Upper respiratory tract infectionb

11

0

2.0

0

General

     Peripheral edema

10

0

5

0

Clinically important adverse reactions in <10% of patients who received Opdivo were:

Cardiac Disorders: ventricular arrhythmia

Eye Disorders: iridocyclitis

General Disorders and Administration Site Conditions: infusion-related reactions

Investigations: increased amylase, increased lipase

Nervous System Disorders: dizziness, peripheral and sensory neuropathy

Skin and Subcutaneous Tissue Disorders: exfoliative dermatitis, erythema multiforme, vitiligo, psoriasis

Table 5: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥10% of Opdivo-Treated Patients and at a Higher Incidence than in the Chemotherapy Arm (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-037

Laboratory Abnormality

Opdivo

Chemotherapy

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

Increased AST

28

2.4

12

1.0

Hyponatremia

25

5

18

1.1

Increased alkaline phosphatase

22

2.4

13

1.1

Increased ALT

16

1.6

5

0

Hyperkalemia

15

2.0

6

0

a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo group (range: 252 to 256 patients) and chemotherapy group (range: 94 to 96 patients).

Previously Untreated Metastatic Melanoma

CHECKMATE-066

The safety of Opdivo was also evaluated in CHECKMATE-066, a randomized, double-blind, active-controlled trial in 411 previously untreated patients with BRAF V600 wild-type unresectable or metastatic melanoma [see Clinical Studies (14.1)]. The trial excluded patients with autoimmune disease and patients requiring chronic systemic treatment with corticosteroids (>10 mg daily prednisone equivalent) or other immunosuppressive medications. Patients received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks (n=206) or dacarbazine 1000 mg/m2 intravenously every 3 weeks (n=205). The median duration of exposure was 6.5 months (range: 1 day to 16.6 months) in Opdivo-treated patients. In this trial, 47% of patients received Opdivo for >6 months and 12% of patients received Opdivo for >1 year.

The trial population characteristics in the Opdivo group and dacarbazine group: 59% male, median age 65 years, 99.5% White, 61% with M1c stage disease, 74% with cutaneous melanoma, 11% with mucosal melanoma, 4% with brain metastasis, and 37% with elevated LDH at baseline. There were more patients in the Opdivo group with ECOG performance status 0 (71% vs. 59%).

Serious adverse reactions occurred in 36% of patients receiving Opdivo. Adverse reactions led to permanent discontinuation of Opdivo in 7% of patients and dose interruption in 26% of patients; no single type of adverse reaction accounted for the majority of Opdivo discontinuations. Grade 3 and 4 adverse reactions occurred in 41% of patients receiving Opdivo.

The most frequent Grade 3 and 4 adverse reactions reported in ≥2% of patients receiving Opdivo were increased gamma-glutamyltransferase (3.9%) and diarrhea (3.4%). The most common adverse reactions (reported in ≥20% of patients and at a higher incidence than in the dacarbazine arm) were fatigue, musculoskeletal pain, rash, and pruritus.

Tables 6 and 7 summarize selected adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-066.

Table 6: Adverse Reactions Occurring in ≥10% of Opdivo-Treated Patients and at a Higher Incidence than in the Dacarbazine Arm (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-066
Toxicity was graded per NCI CTCAE v4.
a  Includes periorbital edema, face edema, generalized edema, gravitational edema, localized edema, peripheral edema, pulmonary edema, and lymphedema.
b  Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, pain in extremity, pain in jaw, and spinal pain.
c  Includes maculopapular rash, erythematous rash, pruritic rash, follicular rash, macular rash, papular rash, pustular rash, vesicular rash, dermatitis, allergic dermatitis, exfoliative dermatitis, acneiform dermatitis, drug eruption, and skin reaction.
d  Includes rhinitis, viral rhinitis, pharyngitis, and nasopharyngitis.

Adverse Reaction

Opdivo
(n=206)

Dacarbazine
(n=205)

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

General

     Fatigue

49

1.9

39

3.4

     Edemaa

12

1.5

4.9

0

Musculoskeletal and Connective Tissue

     Musculoskeletal painb

32

2.9

25

2.4

Skin and Subcutaneous Tissue

     Rashc

28

1.5

12

0

     Pruritus

23

0.5

12

0

     Vitiligo

11

0

0.5

0

     Erythema

10

0

2.9

0

Infections

     Upper respiratory tract infectiond

17

0

6

0

Clinically important adverse reactions in <10% of patients who received Opdivo were:

Nervous System Disorders: peripheral neuropathy

Table 7: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥10% of Opdivo-Treated Patients and at a Higher Incidence than in the Dacarbazine Arm (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-066

Laboratory Abnormality

Opdivo

Dacarbazine

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

Increased ALT

25

3.0

19

0.5

Increased AST

24

3.6

19

0.5

Increased alkaline phosphatase

21

2.6

14

1.6

Increased bilirubin

13

3.1

6

0

a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo group (range: 194 to 197 patients) and dacarbazine group (range: 186 to 193 patients).

CHECKMATE-067

The safety of Opdivo, administered with ipilimumab or as a single agent, was evaluated in CHECKMATE-067, a randomized (1:1:1), double-blind trial in 937 patients with previously untreated, unresectable or metastatic melanoma [see Clinical Studies (14.1)]. The trial excluded patients with autoimmune disease, a medical condition requiring systemic treatment with corticosteroids (more than 10 mg daily prednisone equivalent) or other immunosuppressive medication within 14 days of the start of study therapy, a positive test result for hepatitis B or C, or a history of HIV.

Patients were randomized to receive:

Opdivo 1 mg/kg over 60 minutes with ipilimumab 3 mg/kg by intravenous infusion every 3 weeks for 4 doses followed by Opdivo as a single agent at a dose of 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks (Opdivo and ipilimumab arm; n=313), or
Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks (Opdivo arm; n=313), or
Ipilimumab 3 mg/kg by intravenous infusion every 3 weeks for up to 4 doses (ipilimumab arm; n=311).

The median duration of exposure to Opdivo was 2.8 months (range: 1 day to 36.4 months) for the Opdivo and ipilimumab arm and 6.6 months (range: 1 day to 36.0 months) for the Opdivo arm. In the Opdivo and ipilimumab arm, 39% were exposed to Opdivo for ≥6 months and 30% exposed for >1 year. In the Opdivo arm, 53% were exposed for ≥6 months and 40% for >1 year.

The population characteristics were: 65% male, median age 61 years, 97% White, baseline ECOG performance status 0 (73%) or 1 (27%), 93% with American Joint Committee on Cancer (AJCC) Stage IV disease, 58% with M1c stage disease; 36% with elevated LDH at baseline, 4% with a history of brain metastasis, and 22% had received adjuvant therapy.

Serious adverse reactions (74% and 44%), adverse reactions leading to permanent discontinuation (47% and 18%) or to dosing delays (58% and 36%), and Grade 3 or 4 adverse reactions (72% and 51%) all occurred more frequently in the Opdivo and ipilimumab arm relative to the Opdivo arm.

The most frequent (≥10%) serious adverse reactions in the Opdivo and ipilimumab arm and the Opdivo arm, respectively, were diarrhea (13% and 2.2%), colitis (10% and 1.9%), and pyrexia (10% and 1.0%). The most frequent adverse reactions leading to discontinuation of both drugs in the Opdivo and ipilimumab arm and of Opdivo in the Opdivo arm, respectively, were colitis (10% and 0.6%), diarrhea (8% and 2.2%), increased ALT (4.8% and 1.0%), increased AST (4.5% and 0.6%), and pneumonitis (1.9% and 0.3%).

The most common (≥20%) adverse reactions in the Opdivo and ipilimumab arm were fatigue, diarrhea, rash, nausea, pyrexia, pruritus, musculoskeletal pain, vomiting, decreased appetite, cough, headache, dyspnea, upper respiratory tract infection, arthralgia, and increased transaminases. The most common (≥20%) adverse reactions in the Opdivo arm were fatigue, rash, musculoskeletal pain, diarrhea, nausea, cough, pruritus, upper respiratory tract infection, decreased appetite, headache, constipation, arthralgia, and vomiting.

Tables 8 and 9 summarize the incidence of adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-067.

Table 8: Adverse Reactions Occurring in ≥10% of Patients on the Opdivo and Ipilimumab Arm or the Opdivo Arm and at a Higher Incidence than in the Ipilimumab Arm (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-067
Adverse Reaction Opdivo and Ipilimumab
(n=313)
Opdivo
(n=313)
Ipilimumab
(n=311)
All Grades (%) Grades 3-4 (%) All Grades (%) Grades 3-4 (%) All Grades (%) Grades 3-4 (%)
Toxicity was graded per NCI CTCAE v4.
a  Includes asthenia and fatigue.
b  Includes pustular rash, dermatitis, acneiform dermatitis, allergic dermatitis, atopic dermatitis, bullous dermatitis, exfoliative dermatitis, psoriasiform dermatitis, drug eruption, exfoliative rash, erythematous rash, generalized rash, macular rash, maculopapular rash, morbilliform rash, papular rash, papulosquamous rash, and pruritic rash.
c  Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, pain in extremity, and spinal pain.
d  Includes upper respiratory tract infection, nasopharyngitis, pharyngitis, and rhinitis.
e  Includes hypertension and blood pressure increased.

General

     Fatiguea

62

7

59

1.6

51

4.2

     Pyrexia

40

1.6

16

0

18

0.6

Gastrointestinal

     Diarrhea

54

11

36

5

47

7

     Nausea

44

3.8

30

0.6

31

1.9

     Vomiting

31

3.8

20

1.0

17

1.6

Skin and Subcutaneous Tissue

     Rashb

53

6

40

1.9

42

3.5

     Vitiligo

9

0

10

0.3

5

0

Musculoskeletal and Connective Tissue

     Musculoskeletal painc

32

2.6

42

3.8

36

1.9

     Arthralgia

21

0.3

21

1.0

16

0.3

Metabolism and Nutrition

     Decreased appetite

29

1.9

22

0

24

1.3

Respiratory, Thoracic and Mediastinal

     Cough/productive cough

27

0.3

28

0.6

22

0

     Dyspnea/exertional dyspnea

24

2.9

18

1.3

17

0.6

Infections

     Upper respiratory tract infectiond

23

0

22

0.3

17

0

Endocrine

     Hypothyroidism

19

0.6

11

0

5

0

     Hyperthyroidism

11

1.3

6

0

1

0

Investigations

     Decreased weight

12

0

7

0

7

0.3

Vascular

     Hypertensione

7

2.2

11

5

9

2.3

Clinically important adverse reactions in <10% of patients who received Opdivo with ipilimumab or Opdivo as a single agent were:

Gastrointestinal Disorders: stomatitis, intestinal perforation

Skin and Subcutaneous Tissue Disorders: vitiligo

Musculoskeletal and Connective Tissue Disorders: myopathy, Sjogren’s syndrome, spondyloarthropathy, myositis (including polymyositis)

Nervous System Disorders: neuritis, peroneal nerve palsy

Table 9: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥20% of Patients Treated with Opdivo with Ipilimumab or Single-Agent Opdivo and at a Higher Incidence than in the Ipilimumab Arm (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-067
Laboratory Abnormality Opdivo and Ipilimumab Opdivo Ipilimumab
All Grades (%) Grade 3-4 (%) All Grades (%) Grade 3-4 (%) All Grades (%) Grade 3-4 (%)
a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo and ipilimumab (range: 75 to 297); Opdivo (range: 81 to 306); ipilimumab (range: 61 to 301).

Chemistry

     Increased ALT

55

16

25

3.0

29

2.7

     Hyperglycemia

53

5.3

46

7

26

0

     Increased AST

52

13

29

3.7

29

1.7

     Hyponatremia

45

10

22

3.3

26

7

     Increased lipase

43

22

32

12

24

7

     Increased alkaline phosphatase

41

6

27

2.0

23

2.0

     Hypocalcemia

31

1.1

15

0.7

20

0.7

     Increased amylase

27

10

19

2.7

15

1.6

     Increased creatinine

26

2.7

19

0.7

17

1.3

Hematology

     Anemia

52

2.7

41

2.6

41

6

     Lymphopenia

39

5

41

4.9

29

4.0

Adjuvant Treatment of Melanoma

The safety of Opdivo as a single agent was evaluated in CHECKMATE-238, a randomized (1:1), double-blind trial in 905 patients with completely resected Stage IIIB/C or Stage IV melanoma received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks (n=452) or ipilimumab 10 mg/kg by intravenous infusion every 3 weeks for 4 doses then every 12 weeks beginning at Week 24 for up to 1 year (n=453) [see Clinical Studies (14.2)]. The median duration of exposure was 11.5 months in Opdivo-treated patients and was 2.7 months in ipilimumab-treated patients. In this ongoing trial, 74% of patients received Opdivo for >6 months.

Serious adverse reactions occurred in 18% of Opdivo-treated patients. Study therapy was discontinued for adverse reactions in 9% of Opdivo-treated patients and 42% of ipilimumab-treated patients. Twenty-eight percent of Opdivo-treated patients had at least one omitted dose for an adverse reaction. Grade 3 or 4 adverse reactions occurred in 25% of Opdivo-treated patients.

The most frequent Grade 3 and 4 adverse reactions reported in ≥2% of Opdivo-treated patients were diarrhea and increased lipase and amylase. The most common adverse reactions (at least 20%) were fatigue, diarrhea, rash, musculoskeletal pain, pruritus, headache, nausea, upper respiratory infection, and abdominal pain. The most common immune-mediated adverse reactions were rash (16%), diarrhea/colitis (6%), and hepatitis (3%).

Tables 10 and 11 summarize the adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-238.

Table 10: Adverse Reactions Occurring in ≥10% of Opdivo-Treated Patients - CHECKMATE-238
Adverse Reaction Opdivo
(n=452)
Ipilimumab 10 mg/kg
(n=453)
All Grades (%) Grades 3-4 (%) All Grades (%) Grades 3-4 (%)
Toxicity was graded per NCI CTCAE v4.
a   Includes asthenia.
b    Includes abdominal discomfort, lower abdominal pain, upper abdominal pain, and abdominal tenderness.
c    Includes dermatitis described as acneiform, allergic, bullous, or exfoliative and rash described as generalized, erythematous, macular, papular, maculopapular, pruritic, pustular, vesicular, or butterfly, and drug eruption.
d    Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, spinal pain, and pain in extremity.
e    Includes postural dizziness and vertigo.
f    Includes upper respiratory tract infection including viral respiratory tract infection, lower respiratory tract infection, rhinitis, pharyngitis, and nasopharyngitis.
g    Includes secondary hypothyroidism and autoimmune hypothyroidism.

General

     Fatiguea

57

0.9

55

2.4

Gastrointestinal

     Diarrhea

37

2.4

55

11

     Nausea

23

0.2

28

0

     Abdominal painb

21

0.2

23

0.9

     Constipation

10

0

9

0

Skin and Subcutaneous Tissue

     Rashc

35

1.1

47

5.3

     Pruritus

28

0

37

1.1

Musculoskeletal and Connective Tissue

     Musculoskeletal paind

32

0.4

27

0.4

     Arthralgia

19

0.4

13

0.4

Nervous System

     Headache

23

0.4

31

2.0

     Dizzinesse

11

0

8

0

Infections

     Upper respiratory tract infectionf

22

0

15

0.2

Respiratory, Thoracic and Mediastinal

     Cough/productive cough

19

0

19

0

     Dyspnea/exertional dyspnea

10

0.4

10

0.2

Endocrine

     Hypothyroidismg

12

0.2

7.5

0.4

Table 11: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥10% of Opdivo-Treated Patients - CHECKMATE-238
a   Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo group (range: 400 to 447 patients) and ipilimumab 10 mg/kg group (range: 392 to 443 patients).

Laboratory Abnormality

Opdivo

Ipilimumab 10 mg/kg

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

Hematology

     Lymphopenia

27

0.4

12

0.9

     Anemia

26

0

34

0.5

     Leukopenia

14

0

2.7

0.2

     Neutropenia

13

0

6

0.5

Chemistry

     Increased Lipase

25

7

23

9

     Increased ALT

25

1.8

40

12

     Increased AST

24

1.3

33

9

     Increased Amylase

17

3.3

13

3.1

     Hyponatremia

16

1.1

22

3.2

     Hyperkalemia

12

0.2

9

0.5

     Increased Creatinine

12

0

13

0

     Hypocalcemia

10

0.7

16

0.5

Metastatic Non-Small Cell Lung Cancer

The safety of Opdivo was evaluated in CHECKMATE-017, a randomized open-label, multicenter trial in patients with metastatic squamous NSCLC and progression on or after one prior platinum doublet-based chemotherapy regimen and in CHECKMATE-057, a randomized, open-label, multicenter trial in patients with metastatic non-squamous NSCLC and progression on or after one prior platinum doublet-based chemotherapy regimen [see Clinical Studies (14.3)]. These trials excluded patients with active autoimmune disease, medical conditions requiring systemic immunosuppression, or with symptomatic interstitial lung disease. Patients received Opdivo 3 mg/kg over 60 minutes by intravenous infusion every 2 weeks or docetaxel 75 mg/m2 intravenously every 3 weeks. The median duration of therapy in Opdivo-treated patients in CHECKMATE-017 was 3.3 months (range: 1 day to 21.7+ months) and in CHECKMATE-057 was 2.6 months (range: 0 to 24.0+ months). In CHECKMATE-017, 36% of patients received Opdivo for at least 6 months and 18% of patients received Opdivo for at least 1 year and in CHECKMATE-057, 30% of patients received Opdivo for >6 months and 20% of patients received Opdivo for >1 year.

Across both trials, the median age of Opdivo-treated patients was 61 years (range: 37 to 85); 38% were ≥65 years of age, 61% were male, and 91% were White. Ten percent of patients had brain metastases and ECOG performance status was 0 (26%) or 1 (74%).

In CHECKMATE-057, in the Opdivo arm, seven deaths were due to infection including one case of Pneumocystis jirovecii pneumonia, four were due to pulmonary embolism, and one death was due to limbic encephalitis. Serious adverse reactions occurred in 46% of patients receiving Opdivo. Opdivo was discontinued in 11% of patients and was delayed in 28% of patients for an adverse reaction.

The most frequent serious adverse reactions reported in ≥2% of patients receiving Opdivo were pneumonia, pulmonary embolism, dyspnea, pyrexia, pleural effusion, pneumonitis, and respiratory failure. Across both trials, the most common adverse reactions (≥20%) were fatigue, musculoskeletal pain, cough, dyspnea, and decreased appetite.

Tables 12 and 13 summarize selected adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-057.

Table 12: Adverse Reactions Occurring in ≥10% of Opdivo-Treated Patients and at a Higher Incidence than Docetaxel (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-017 and CHECKMATE-057
Adverse Reaction Opdivo
(n=418)
Docetaxel
(n=397)
All Grades (%) Grades 3-4 (%) All Grades (%) Grades 3-4 (%)
Toxicity was graded per NCI CTCAE v4.

Respiratory, Thoracic and Mediastinal

     Cough

31

0.7

24

0

Metabolism and Nutrition

     Decreased appetite

28

1.4

23

1.5

Skin and Subcutaneous Tissue

     Pruritus

10

0.2

2.0

0

Other clinically important adverse reactions observed in Opdivo-treated patients and which occurred at a similar incidence in docetaxel-treated patients and not listed elsewhere in section 6 include: fatigue/asthenia (48% all Grades, 5% Grade 3-4), musculoskeletal pain (33% all Grades), pleural effusion (4.5% all Grades), pulmonary embolism (3.3% all Grades).

Table 13: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥10% of Opdivo-Treated Patients for all NCI CTCAE Grades and at a Higher Incidence than Docetaxel (Between Arm Difference of ≥5% All Grades or ≥2% Grades 3-4) - CHECKMATE-017 and CHECKMATE-057
a     Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo group (range: 405 to 417 patients) and docetaxel group (range: 372 to 390 patients), except for TSH: Opdivo group n=314 and docetaxel group n=297.
b     Not graded per NCI CTCAE v4.

Opdivo

Docetaxel

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

Chemistry

     Hyponatremia

35

7

34

4.9

     Increased AST

27

1.9

13

0.8

     Increased alkaline phosphatase

26

0.7

18

0.8

     Increased ALT

22

1.7

17

0.5

     Increased creatinine

18

0

12

0.5

     Increased TSHb

14

N/A

6

N/A

Small Cell Lung Cancer

The safety of Opdivo was evaluated in CHECKMATE-032, a multicenter, multi-cohort, open-label, ongoing trial that enrolled 245 patients with SCLC with disease progression after platinum-based chemotherapy [see Clinical Studies (14.4)]. The trial excluded patients with active autoimmune disease, medical conditions requiring systemic immunosuppression, or with symptomatic interstitial lung disease. Patients received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks. The median duration of therapy in Opdivo-treated patients was 1 month (range: 0 to 44.2+ months): 17% of patients received Opdivo for >6 months and 9% of patients received Opdivo for >1 year.

The population characteristics were: median age 63 years (range: 29 to 83), 92% White, and 60% male. Baseline ECOG performance status was 0 (30%) or 1 (70%), 94% were former/current smokers, 56% received one prior line of therapy, and 44% received two or more prior lines of therapy.

Serious adverse reactions occurred in 45% of patients. Opdivo was discontinued for adverse reactions in 10% of patients and 25% of patients had at least one dose withheld for an adverse reaction.

The most frequent (≥2%) serious adverse reactions were pneumonia, dyspnea, pneumonitis, pleural effusion, and dehydration. The most common (≥20%) adverse reactions were fatigue, decreased appetite, musculoskeletal pain, dyspnea, nausea, diarrhea, constipation, and cough.

The toxicity profile observed in patients with metastatic SCLC was generally similar to that observed in patients with other solid tumors who received Opdivo as a single agent.

Advanced Renal Cell Carcinoma

Previously Treated Renal Cell Carcinoma

The safety of Opdivo was evaluated in CHECKMATE-025, a randomized open-label trial in 803 patients with advanced RCC who had experienced disease progression during or after at least one anti-angiogenic treatment regimen received Opdivo 3 mg/kg over 60 minutes by intravenous infusion every 2 weeks (n=406) or everolimus 10 mg daily (n=397) [see Clinical Studies (14.5)]. The median duration of treatment was 5.5 months (range: 1 day to 29.6+ months) in Opdivo-treated patients and 3.7 months (range: 6 days to 25.7+ months) in everolimus-treated patients.

Rate of death on treatment or within 30 days of the last dose was 4.7% on the Opdivo arm. Serious adverse reactions occurred in 47% of patients receiving Opdivo. Study therapy was discontinued for adverse reactions in 16% of Opdivo patients. Forty-four percent (44%) of patients receiving Opdivo had a dose interruption for an adverse reaction.

The most frequent serious adverse reactions in at least 2% of patients were: acute kidney injury, pleural effusion, pneumonia, diarrhea, and hypercalcemia. The most common adverse reactions (≥20%) were fatigue, cough, nausea, rash, dyspnea, diarrhea, constipation, decreased appetite, back pain, and arthralgia. The most common laboratory abnormalities which have worsened compared to baseline in ≥30% of patients include increased creatinine, lymphopenia, anemia, increased AST, increased alkaline phosphatase, hyponatremia, increased triglycerides, and hyperkalemia. In addition, among patients with TSH < ULN at baseline, a greater proportion of patients experienced a treatment-emergent elevation of TSH >ULN in the Opdivo group compared to the everolimus group (26% and 14%, respectively).

Tables 14 and 15 summarize adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-025.

Table 14: Adverse Reactions in >15% of Patients Receiving Opdivo - CHECKMATE-025
Toxicity was graded per NCI CTCAE v4.
a  Includes asthenia, decreased activity, fatigue, and malaise.
b  Includes nasopharyngitis, pharyngitis, rhinitis, and viral upper respiratory infection (URI).
c  Includes colitis, enterocolitis, and gastroenteritis.
d  Includes dermatitis, acneiform dermatitis, erythematous rash, generalized rash, macular rash, maculopapular rash, papular rash, pruritic rash, erythema multiforme, and erythema.

Adverse Reaction

Opdivo
(n=406)

Everolimus
(n=397)

Grades 1-4 (%)

Grades 3-4 (%)

Grades 1-4 (%)

Grades 3-4 (%)

Adverse Reaction

98

56

96

62

General

     Fatiguea

56

6

57

7

     Pyrexia

17

0.7

20

0.8

Respiratory, Thoracic and Mediastinal

     Cough/productive cough

34

0

38

0.5

     Dyspnea/exertional dyspnea

27

3.0

31

2.0

     Upper respiratory infectionb

18

0

11

0

Gastrointestinal

     Nausea

28

0.5

29

1

     Diarrheac

25

2.2

32

1.8

     Constipation

23

0.5

18

0.5

     Vomiting

16

0.5

16

0.5

Skin and Subcutaneous Tissue

     Rashd

28

1.5

36

1.0

     Pruritus/generalized pruritus

19

0

14

0

Metabolism and Nutrition

     Decreased appetite

23

1.2

30

1.5

Musculoskeletal and Connective Tissue

     Arthralgia

20

1.0

14

0.5

     Back pain

21

3.4

16

2.8

Other clinically important adverse reactions in CHECKMATE-025 were:

General Disorders and Administration Site Conditions: peripheral edema/edema

Gastrointestinal Disorders: abdominal pain/discomfort

Musculoskeletal and Connective Tissue Disorders: extremity pain, musculoskeletal pain

Nervous System Disorders: headache/migraine, peripheral neuropathy

Investigations: weight decreased

Skin Disorders: palmar-plantar erythrodysesthesia

Table 15: Laboratory Values Worsening from Baselinea Occurring in >15% of Patients on Opdivo - CHECKMATE-025
a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo group (range: 259 to 401 patients) and everolimus group (range: 257 to 376 patients).

Laboratory Abnormality

Opdivo

Everolimus

Grades 1-4 (%)

Grades 3-4 (%)

Grades 1-4 (%)

Grades 3-4 (%)

Hematology

     Lymphopenia

42

6

53

11

     Anemia

39

8

69

16

Chemistry

     Increased creatinine

42

2.0

45

1.6

     Increased AST

33

2.8

39

1.6

     Increased alkaline phosphatase

32

2.3

32

0.8

     Hyponatremia

32

7

26

6

     Hyperkalemia

30

4.0

20

2.1

     Hypocalcemia

23

0.9

26

1.3

     Increased ALT

22

3.2

31

0.8

     Hypercalcemia

19

3.2

6

0.3

Lipids

     Increased triglycerides

32

1.5

67

11

     Increased cholesterol

21

0.3

55

1.4

Previously Untreated Renal Cell Carcinoma

The safety of Opdivo with ipilimumab was evaluated in CHECKMATE-214, a randomized open-label trial in 1082 patients with previously untreated advanced RCC received Opdivo 3 mg/kg over 60 minutes with ipilimumab 1 mg/kg intravenously every 3 weeks for 4 doses followed by Opdivo as a single agent at a dose of 3 mg/kg by intravenous infusion every 2 weeks (n=547) or sunitinib 50 mg orally daily for the first 4 weeks of a 6-week cycle (n=535) [see Clinical Studies (14.5)].The median duration of treatment was 7.9 months (range: 1 day to 21.4+ months) in Opdivo and ipilimumab-treated patients and 7.8 months (range: 1 day to 20.2+ months) in sunitinib-treated patients. In this trial, 57% of patients in the Opdivo and ipilimumab arm were exposed to treatment for >6 months and 38% of patients were exposed to treatment for >1 year.

Serious adverse reactions occurred in 59% of patients receiving Opdivo and ipilimumab. Study therapy was discontinued for adverse reactions in 31% of Opdivo and ipilimumab patients. Fifty-four percent (54%) of patients receiving Opdivo and ipilimumab had a dose interruption for an adverse reaction.

The most frequent serious adverse reactions reported in ≥2% of patients treated with Opdivo and ipilimumab were diarrhea, pyrexia, pneumonia, pneumonitis, hypophysitis, acute kidney injury, dyspnea, adrenal insufficiency, and colitis; in patients treated with sunitinib, they were pneumonia, pleural effusion, and dyspnea. The most common adverse reactions (reported in ≥20% of patients) were fatigue, rash, diarrhea, musculoskeletal pain, pruritus, nausea, cough, pyrexia, arthralgia, and decreased appetite. The most common laboratory abnormalities which have worsened compared to baseline in ≥30% of Opdivo and ipilimumab-treated patients include increased lipase, anemia, increased creatinine, increased ALT, increased AST, hyponatremia, increased amylase, and lymphopenia.

Tables 16 and 17 summarize adverse reactions and laboratory abnormalities, respectively, that occurred in >15% of Opdivo and ipilimumab-treated patients in CHECKMATE-214.

Table 16: Adverse Reactions in >15% of Patients Receiving Opdivo and Ipilimumab - CHECKMATE-214
Toxicity was graded per NCI CTCAE v4.
a     Includes asthenia.
b     Includes peripheral edema, peripheral swelling.
c     Includes dermatitis described as acneiform, bullous, and exfoliative, drug eruption, rash described as exfoliative, erythematous, follicular, generalized, macular, maculopapular, papular, pruritic, and pustular, fixed-drug eruption.
d     Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, pain in extremity, spinal pain.

Adverse Reaction

Opdivo and Ipilimumab
(n=547)

Sunitinib
(n=535)

Grades 1-4 (%)

Grades 3-4 (%)

Grades 1-4 (%)

Grades 3-4 (%)

Adverse Reaction

99

65

99

76

General

     Fatiguea

58

8

69

13

     Pyrexia

25

0.7

17

0.6

     Edemab

16

0.5

17

0.6

Skin and Subcutaneous Tissue

     Rashc

39

3.7

25

1.1

     Pruritus/generalized pruritus

33

0.5

11

0

Gastrointestinal

     Diarrhea

38

4.6

58

6

     Nausea

30

2.0

43

1.5

     Vomiting

20

0.9

28

2.1

     Abdominal pain

19

1.6

24

1.9

     Constipation

17

0.4

18

0

Musculoskeletal and Connective Tissue

     Musculoskeletal paind

37

4.0

40

2.6

     Arthralgia

23

1.3

16

0

Respiratory, Thoracic and Mediastinal

     Cough/productive cough

28

0.2

25

0.4

     Dyspnea/exertional dyspnea

20

2.4

21

2.1

Metabolism and Nutrition

     Decreased appetite

21

1.8

29

0.9

Nervous System

     Headache

19

0.9

23

0.9

Endocrine

     Hypothyroidism

18

0.4

27

0.2

Table 17: Laboratory Values Worsening from Baselinea Occurring in >15% of Patients on Opdivo and Ipilimumab - CHECKMATE-214
a     Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Opdivo and ipilimumab group (range: 490 to 538 patients) and sunitinib group (range: 485 to 523 patients).

Laboratory Abnormality

Opdivo and Ipilimumab

Sunitinib

Grades 1-4 (%)

Grades 3-4 (%)

Grades 1-4 (%)

Grades 3-4 (%)

Chemistry

     Increased lipase

48

20

51

20

     Increased creatinine

42

2.1

46

1.7

     Increased ALT

41

7

44

2.7

     Increased AST

40

4.8

60

2.1

     Increased amylase

39

12

33

7

     Hyponatremia

39

10

36

7

     Increased alkaline phosphatase

29

2.0

32

1.0

     Hyperkalemia

29

2.4

28

2.9

     Hypocalcemia

21

0.4

35

0.6

     Hypomagnesemia

16

0.4

26

1.6

Hematology

     Anemia

43

3.0

64

9

     Lymphopenia

36

5

63

14

In addition, among patients with TSH ≤ULN at baseline, a lower proportion of patients experienced a treatment-emergent elevation of TSH >ULN in the Opdivo and ipilimumab group compared to the sunitinib group (31% and 61%, respectively).

Classical Hodgkin Lymphoma

The safety of Opdivo was evaluated in 266 adult patients with cHL (243 patients in the CHECKMATE-205 and 23 patients in the CHECKMATE-039 trials) [see Clinical Studies (14.6)]. Patients received Opdivo 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression, maximal clinical benefit, or unacceptable toxicity.

The median age was 34 years (range: 18 to 72), 98% of patients had received autologous HSCT, none had received allogeneic HSCT, and 74% had received brentuximab vedotin. The median number of prior systemic regimens was 4 (range: 2 to 15). Patients received a median of 23 doses (cycles) of Opdivo (range: 1 to 48), with a median duration of therapy of 11 months (range: 0 to 23 months).

Eleven patients died from causes other than disease progression: 3 from adverse reactions within 30 days of the last nivolumab dose, 2 from infection 8 to 9 months after completing nivolumab, and 6 from complications of allogeneic HSCT. Serious adverse reactions occurred in 26% of patients. Dose delay for an adverse reaction occurred in 34% of patients. Opdivo was discontinued due to adverse reactions in 7% of patients.

The most frequent serious adverse reactions reported in ≥1% of patients were pneumonia, infusion-related reaction, pyrexia, colitis or diarrhea, pleural effusion, pneumonitis, and rash. The most common adverse reactions (≥20%) among all patients were upper respiratory tract infection, fatigue, cough, diarrhea, pyrexia, musculoskeletal pain, rash, nausea, and pruritus.

Tables 18 and 19 summarize the adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-205 and CHECKMATE-039.

Table 18: Adverse Reactions Occurring in ≥10% of Patients - CHECKMATE-205 and CHECKMATE-039
Toxicity was graded per NCI CTCAE v4.
a   Includes events occurring up to 30 days after last nivolumab dose, regardless of causality. After an immune-mediated adverse reaction, reactions following nivolumab rechallenge were included if they occurred up to 30 days after completing the initial nivolumab course.
b    Includes nasopharyngitis, pharyngitis, rhinitis, and sinusitis.
c    Includes pneumonia bacterial, pneumonia mycoplasmal, pneumocystis jirovecii pneumonia.
d    Includes asthenia.
e    Includes colitis.
f    Includes abdominal discomfort and upper abdominal pain.
g    Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, and pain in extremity.
h    Includes dermatitis, dermatitis acneiform, dermatitis exfoliative, and rash described as macular, papular, maculopapular, pruritic, exfoliative, or acneiform.
i    Includes hyperesthesia, hypoesthesia, paresthesia, dysesthesia, peripheral motor neuropathy, peripheral sensory neuropathy, and polyneuropathy. These numbers are specific to treatment-emergent events.

Adverse Reactiona

Opdivo (n=266)

All Grades (%)

Grades 3-4 (%)

Infections

   Upper respiratory tract infectionb

44

0.8

   Pneumonia/bronchopneumoniac

13

3.8

   Nasal congestion

11

0

General

   Fatigued

39

1.9

   Pyrexia

29

<1

Respiratory, Thoracic and Mediastinal

   Cough/productive cough

36

0

   Dyspnea/exertional dyspnea

15

1.5

Gastrointestinal

   Diarrheae

33

1.5

   Nausea

20

0

   Vomiting

19

<1

   Abdominal painf

16

<1

   Constipation

14

0.4

Musculoskeletal and Connective Tissue

   Musculoskeletal paing

26

1.1

   Arthralgia

16

<1

Skin and Subcutaneous Tissue

   Rashh

24

1.5

   Pruritus

20

0

Nervous System

   Headache

17

<1

   Neuropathy peripherali

12

<1

Injury, Poisoning and Procedural Complications

   Infusion-related reaction

14

<1

Endocrine

   Hypothyroidism/thyroiditis

12

0

Additional information regarding clinically important adverse reactions:

Immune-mediated pneumonitis: In CHECKMATE-205 and CHECKMATE-039, pneumonitis, including interstitial lung disease, occurred in 6.0% (16/266) of patients receiving Opdivo. Immune-mediated pneumonitis occurred in 4.9% (13/266) of patients receiving Opdivo (one Grade 3 and 12 Grade 2). The median time to onset was 4.5 months (range: 5 days to 12 months). All 13 patients received systemic corticosteroids, with resolution in 12. Four patients permanently discontinued Opdivo due to pneumonitis. Eight patients continued Opdivo (three after dose delay), of whom two had recurrence of pneumonitis.

Peripheral neuropathy: Treatment-emergent peripheral neuropathy was reported in 12% (31/266) of all patients receiving Opdivo. Twenty-eight patients (11%) had new-onset peripheral neuropathy and 3 patients had worsening of neuropathy from baseline. The median time to onset was 50 (range: 1 to 309) days.

Complications of allogeneic HSCT after Opdivo: Of 17 patients with cHL from the CHECKMATE-205 and CHECKMATE-039 trials who underwent allogeneic HSCT after treatment with Opdivo, 6 patients (35%) died from transplant-related complications. Five deaths occurred in the setting of severe (Grade 3 to 4) or refractory GVHD. Hyperacute GVHD occurred in 2 patients (12%) and Grade 3 or higher GVHD was reported in 5 patients (29%). Hepatic VOD occurred in 1 patient, who received reduced-intensity conditioned allogeneic HSCT and died of GVHD and multi-organ failure.

Table 19 summarizes laboratory abnormalities in patients with cHL. The most common (≥20%) treatment-emergent laboratory abnormalities included cytopenias, liver function abnormalities, and increased lipase. Other common findings (≥10%) included increased creatinine, electrolyte abnormalities, and increased amylase.

Table 19: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥10% of Patients - CHECKMATE-205 and CHECKMATE-039
a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement: range: 203 to 266 patients.
b  Includes events occurring up to 30 days after last nivolumab dose. After an immune-mediated adverse reaction, reactions following nivolumab rechallenge were included if they occurred within 30 days of completing the initial nivolumab course.
c  In addition, in the safety population, fasting hyperglycemia (all grade 1-2) was reported in 27 of 69 (39%) evaluable patients and fasting hypoglycemia (all grade 1-2) in 11 of 69 (16%).

Laboratory Abnormality

Opdivoa
(n=266)

All Grades (%)b

Grades 3-4 (%)b

Hematology

   Leukopenia

38

4.5

   Neutropenia

37

5

   Thrombocytopenia

37

3.0

   Lymphopenia

32

11

   Anemia

26

2.6

Chemistryc

   Increased AST

33

2.6

   Increased ALT

31

3.4

   Increased lipase

22

9

   Increased alkaline phosphatase

20

1.5

   Hyponatremia

20

1.1

   Hypokalemia

16

1.9

   Increased creatinine

16

<1

   Hypocalcemia

15

<1

   Hyperkalemia

15

1.5

   Hypomagnesemia

14

<1

   Increased amylase

13

1.5

   Increased bilirubin

11

1.5

Squamous Cell Carcinoma of the Head and Neck

The safety of Opdivo was evaluated in CHECKMATE-141, a randomized, active-controlled, open-label, multicenter trial in patients with recurrent or metastatic SCCHN with progression during or within 6 months of receiving prior platinum-based therapy [see Clinical Studies (14.7)].

The trial excluded patients with active autoimmune disease, medical conditions requiring systemic immunosuppression, or recurrent or metastatic carcinoma of the nasopharynx, squamous cell carcinoma of unknown primary histology, salivary gland or non-squamous histologies (e.g., mucosal melanoma). Patients received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks (n=236) or investigator’s choice of either:

cetuximab (n=13), 400 mg/m2 initial dose intravenously followed by 250 mg/m2 weekly, or
methotrexate (n=46) 40 to 60 mg/m2 intravenously weekly, or
docetaxel (n=52) 30 to 40 mg/m2 intravenously weekly.

The median duration of exposure to nivolumab was 1.9 months (range: 1 day to 16.1+ months) in Opdivo-treated patients. In this trial, 18% of patients received Opdivo for >6 months and 2.5% of patients received Opdivo for >1 year.

The median age of all randomized patients was 60 years (range: 28 to 83); 28% of patients in the Opdivo group were ≥65 years of age and 37% in the comparator group were ≥65 years of age, 83% were male and 83% were White, 12% were Asian, and 4% were Black. Baseline ECOG performance status was 0 (20%) or 1 (78%), 45% of patients received only one prior line of systemic therapy, the remaining 55% of patients had two or more prior lines of therapy, and 90% had prior radiation therapy.

Serious adverse reactions occurred in 49% of patients receiving Opdivo. Opdivo was discontinued in 14% of patients and was delayed in 24% of patients for an adverse reaction. Adverse reactions and laboratory abnormalities occurring in patients with SCCHN were generally similar to those occurring in patients with melanoma and NSCLC.

The most frequent serious adverse reactions reported in ≥2% of patients receiving Opdivo were pneumonia, dyspnea, respiratory failure, respiratory tract infection, and sepsis. The most common adverse reactions occurring in ≥10% of Opdivo-treated patients and at a higher incidence than investigator’s choice were cough and dyspnea. The most common laboratory abnormalities occurring in ≥10% of Opdivo-treated patients and at a higher incidence than investigator’s choice were increased alkaline phosphatase, increased amylase, hypercalcemia, hyperkalemia, and increased TSH.

Urothelial Carcinoma

The safety of Opdivo was evaluated in CHECKMATE-275, a single arm trial in which 270 patients with locally advanced or metastatic urothelial carcinoma had disease progression during or following platinum-containing chemotherapy or had disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy [see Clinical Studies (14.8)]. Patients received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. The median duration of treatment was 3.3 months (range: 0 to 13.4+). Forty-six percent (46%) of patients had a dose interruption for an adverse reaction.

Fourteen patients (5.2%) died from causes other than disease progression. This includes 4 patients (1.5%) who died from pneumonitis or cardiovascular failure which was attributed to treatment with Opdivo. Serious adverse reactions occurred in 54% of patients. Opdivo was discontinued for adverse reactions in 17% of patients.

The most frequent serious adverse reactions reported in ≥2% of patients were urinary tract infection, sepsis, diarrhea, small intestine obstruction, and general physical health deterioration. The most common adverse reactions (reported in ≥20% of patients) were fatigue, musculoskeletal pain, nausea, and decreased appetite.

Tables 20 and 21 summarize adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-275.

Table 20: Adverse Reactions Occurring in ≥10% of Patients - CHECKMATE-275
Toxicity was graded per NCI CTCAE v4.
a  Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, pain in extremity and spinal pain.
b  Includes abdominal discomfort, lower and upper abdominal pain.
c  Includes dermatitis, dermatitis acneiform, dermatitis bullous, and rash described as generalized, macular, maculopapular, or pruritic.
d  Includes autoimmune thyroiditis, blood TSH decrease, blood TSH increase, hyperthyroidism, hypothyroidism, thyroiditis, thyroxine decreased, thyroxine free increased, thyroxine increased, tri-iodothyronine free increased, tri-iodothyronine increased.

Adverse Reaction

Opdivo
(n=270)

All Grades (%)

Grades 3-4 (%)

Adverse Reaction

99

51

General

   Asthenia/fatigue/malaise

46

7

   Pyrexia/tumor associated fever

17

0.4

   Edema/peripheral edema/peripheral swelling

13

0.4

Musculoskeletal and Connective Tissue

   Musculoskeletal paina

30

2.6

   Arthralgia

10

0.7

Metabolism and Nutrition

   Decreased appetite

22

2.2

Gastrointestinal

   Nausea

22

0.7

   Diarrhea

17

2.6

   Constipation

16

0.4

   Abdominal painb

13

1.5

   Vomiting

12

1.9

Respiratory, Thoracic and Mediastinal

   Cough/productive cough

18

0

   Dyspnea/exertional dyspnea

14

3.3

Infections

   Urinary tract infection/escherichia/fungal urinary tract infection

17

7

Skin and Subcutaneous Tissue

   Rashc

16

1.5

   Pruritus

12

0

Endocrine

   Thyroid disordersd

15

0

Table 21: Laboratory Abnormalities Worsening from Baseline Occurring in ≥10% of Patients - CHECKMATE-275
a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: range: 84 to 256 patients.

Laboratory Abnormality

Opdivoa

All Grades (%)

Grades 3-4 (%)

Chemistry

   Hyperglycemia

42

2.4

   Hyponatremia

41

11

   Increased creatinine

39

2.0

   Increased alkaline phosphatase

33

5.5

   Hypocalcemia

26

0.8

   Increased AST

24

3.5

   Increased lipase

20

7

   Hyperkalemia

19

1.2

   Increased ALT

18

1.2

   Increased amylase

18

4.4

   Hypomagnesemia

16

0

Hematology

   Lymphopenia

42

9

   Anemia

40

7

   Thrombocytopenia

15

2.4

   Leukopenia

11

0

MSI-H or dMMR Metastatic Colorectal Cancer

The safety of Opdivo administered as a single agent or in combination with ipilimumab was evaluated in CHECKMATE-142, a multicenter, non-randomized, multiple parallel-cohort, open-label trial [see Clinical Studies (14.9)]. In CHECKMATE-142, 74 patients with mCRC received Opdivo 3 mg/kg by intravenous infusion over 60 minutes every 2 weeks until disease progression or until intolerable toxicity and 119 patients with mCRC received Opdivo 3 mg/kg and ipilimumab 1 mg/kg every 3 weeks for 4 doses, then Opdivo 3 mg/kg every 2 weeks until disease progression or until unacceptable toxicity.

Serious adverse reactions occurred in 47% of patients. Opdivo was discontinued in 13% of patients and delayed in 45% of patients for an adverse reaction.

The most frequent serious adverse reactions reported in ≥2% of patients were colitis/diarrhea, hepatic events, abdominal pain, acute kidney injury, pyrexia, and dehydration. The most common adverse reactions (reported in ≥20% of patients) were fatigue, diarrhea, pyrexia, musculoskeletal pain, abdominal pain, pruritus, nausea, rash, decreased appetite, and vomiting.

Tables 22 and 23 summarize adverse reactions and laboratory abnormalities, respectively, in CHECKMATE-142. Based on the design of CHECKMATE-142, the data below cannot be used to identify statistically significant differences between the two cohorts summarized below for any adverse reaction.

Table 22: Adverse Reactions Occurring in ≥10% of Patients - CHECKMATE-142
Toxicity was graded per NCI CTCAE v4.
a  Includes asthenia.
b  Includes peripheral edema and peripheral swelling.
c  Includes upper abdominal pain, lower abdominal pain, and abdominal discomfort.
d  Includes back pain, pain in extremity, myalgia, neck pain, and bone pain.
e  Includes dermatitis, dermatitis acneiform, and rash described as maculo-papular, erythematous, and generalized.
f  Includes nasopharyngitis and rhinitis.

Adverse Reaction

Opdivo
(n=74)

Opdivo and Ipilimumab
(n=119)

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

General

   Fatiguea

54

5

49

6

   Pyrexia

24

0

36

0

   Edemab

12

0

7

0

Gastrointestinal

   Diarrhea

43

2.7

45

3.4

   Abdominal painc

34

2.7

30

5

   Nausea

34

1.4

26

0.8

   Vomiting

28

4.1

20

1.7

   Constipation

20

0

15

0

Musculoskeletal and Connective Tissue

   Musculoskeletal paind

28

1.4

36

3.4

   Arthralgia

19

0

14

0.8

Respiratory, Thoracic and Mediastinal

   Cough

26

0

19

0.8

   Dyspnea

8

1

13

1.7

Skin and Subcutaneous Tissue

   Rashe

23

1.4

25

4.2

   Pruritus

19

0

28

1.7

   Dry Skin

7

0

11

0

Infections

   Upper respiratory tract infectionf

20

0

9

0

Endocrine

   Hyperglycemia

19

2.7

6

1

   Hypothyroidism

5

0

14

0.8

   Hyperthyroidism

4

0

12

0

Nervous System

   Headache

16

0

17

1.7

   Dizziness

14

0

11

0

Metabolism and Nutrition

   Decreased appetite

14

1.4

20

1.7

Psychiatric

   Insomnia

9

0

13

0.8

Investigations

   Weight decreased

8

0

10

0

Clinically important adverse reactions reported in <10% of patients receiving Opdivo with ipilimumab were encephalitis (0.8%), necrotizing myositis (0.8%), and uveitis (0.8%).

Table 23: Laboratory Abnormalities Worsening from Baselinea Occurring in ≥10% of Patients - CHECKMATE-142
a  Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available. Number of evaluable patients ranges from 62 to 71 for the Opdivo cohort and from 87 to 114 for the Opdivo and ipilimumab cohort.

Laboratory Abnormality

Opdivo
(n=74)

Opdivo and Ipilimumab
(n=119)

All Grades (%)

Grades 3-4 (%)

All Grades (%)

Grades 3-4 (%)

Hematology

   Anemia

50

7

42

9

   Lymphopenia

36

7

25

6

   Neutropenia

20

4.3

18

0

   Thrombocytopenia

16

1.4

26

0.9

Chemistry

   Increased alkaline phosphatase

37

2.8

28

5

   Increased lipase

33

19

39

12

   Increased ALT

32

2.8

33

12

   Increased AST

31

1.4

40

12

   Hyponatremia

27

4.3

26

5

   Hypocalcemia

19

0

16

0

   Hypomagnesemia

17

0

18

0

   Increased amylase

16

4.8

36

3.4

   Increased bilirubin

14

4.2

21

5

   Hypokalemia

14

0

15

1.8

   Increased creatinine

12

0

25

3.6

   Hyperkalemia

11

0

23

0.9

Hepatocellular Carcinoma

The safety of Opdivo was evaluated in a 154-patient subgroup of patients with HCC and Child-Pugh A cirrhosis who progressed on or were intolerant to sorafenib enrolled in CHECKMATE-040, a multicenter, open-label trial [see Clinical Studies (14.10)]. Patients were required to have an AST and ALT ≤5 x ULN and total bilirubin of <3 mg/dL. The median duration of exposure to Opdivo was 6 months.

The toxicity profile observed in patients with advanced HCC was generally similar to that observed in patients with other cancers, with the exception of a higher incidence of elevations in transaminases and bilirubin levels. Treatment with Opdivo resulted in treatment-emergent Grade 3 or 4 AST in 27 (18%) patients, Grade 3 or 4 ALT in 16 (11%) patients, and Grade 3 or 4 bilirubin in 11 (7%) patients. Immune-mediated hepatitis requiring systemic corticosteroids occurred in 8 (5%) patients.

Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence of antibodies to Opdivo with the incidences of antibodies to other products may be misleading.

Of the 2085 patients who were treated with Opdivo as a single agent at dose of 3 mg/kg every 2 weeks and evaluable for the presence of anti-nivolumab antibodies, 11% tested positive for treatment-emergent anti-nivolumab antibodies by an electrochemiluminescent (ECL) assay and 0.7% had neutralizing antibodies against nivolumab. There was no evidence of altered pharmacokinetic profile or increased incidence of infusion-related reactions with anti-nivolumab antibody development.

Of the patients who were treated with Opdivo and ipilimumab and evaluable for the presence of anti-nivolumab antibodies, the incidence of anti-nivolumab antibodies was 26% (132/516) with Opdivo 3 mg/kg followed by ipilimumab 1 mg/kg every 3 weeks and 38% (149/394) with Opdivo 1 mg/kg followed by ipilimumab 3 mg/kg every 3 weeks. The incidence of neutralizing antibodies against nivolumab was 0.8% (4/516) with Opdivo 3 mg/kg followed by ipilimumab 1 mg/kg every 3 weeks and 4.6% (18/394) with Opdivo 1 mg/kg followed by ipilimumab 3 mg/kg every 3 weeks.

There was no evidence of increased incidence of infusion-related reactions or effects on efficacy with anti-nivolumab antibody development.

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of Opdivo. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Eye: Vogt-Koyanagi-Harada (VKH) syndrome

Complications of Opdivo Treatment After Allogeneic HSCT: Treatment refractory, severe acute and chronic GVHD

USE IN SPECIFIC POPULATIONS

Pregnancy

Risk Summary

Based on data from animal studies and its mechanism of action [see Clinical Pharmacology (12.1)], Opdivo can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of nivolumab to cynomolgus monkeys from the onset of organogenesis through delivery resulted in increased abortion and premature infant death (see Data). Human IgG4 is known to cross the placental barrier and nivolumab is an immunoglobulin G4 (IgG4); therefore, nivolumab has the potential to be transmitted from the mother to the developing fetus. The effects of Opdivo are likely to be greater during the second and third trimesters of pregnancy. There are no available data on Opdivo use in pregnant women to evaluate a drug-associated risk. Advise pregnant women of the potential risk to a fetus.

The background risk in the U.S. general population of major birth defects is 2% to 4% and of miscarriage is 15% to 20% of clinically recognized pregnancies.

Data

Animal Data

A central function of the PD-1/PD-L1 pathway is to preserve pregnancy by maintaining maternal immune tolerance to the fetus. Blockade of PD-L1 signaling has been shown in murine models of pregnancy to disrupt tolerance to the fetus and to increase fetal loss. The effects of nivolumab on prenatal and postnatal development were evaluated in monkeys that received nivolumab twice weekly from the onset of organogenesis through delivery, at exposure levels of between 9 and 42 times higher than those observed at the clinical dose of 3 mg/kg (based on AUC). Nivolumab administration resulted in a non–dose-related increase in spontaneous abortion and increased neonatal death. Based on its mechanism of action, fetal exposure to nivolumab may increase the risk of developing immune-mediated disorders or altering the normal immune response and immune-mediated disorders have been reported in PD-1 knockout mice. In surviving infants (18 of 32 compared to 11 of 16 vehicle-exposed infants) of cynomolgus monkeys treated with nivolumab, there were no apparent malformations and no effects on neurobehavioral, immunological, or clinical pathology parameters throughout the 6-month postnatal period.

Lactation

Risk Summary

There are no data on the presence of nivolumab in human milk, the effects on the breastfed child, or the effects on milk production. Because of the potential for serious adverse reactions in the breastfed child, advise women not to breastfeed during treatment and for 5 months after the last dose of Opdivo.

Females and Males of Reproductive Potential

Pregnancy Testing

Verify the pregnancy status of females of reproductive potential prior to initiating Opdivo [see Use in Specific Populations (8.1)].

Contraception

Opdivo can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)]. Advise females of reproductive potential to use effective contraception during treatment with Opdivo and for at least 5 months following the last dose.

Pediatric Use

The safety and effectiveness of Opdivo as a single agent and in combination with ipilimumab have been established in pediatric patients age 12 years and older with microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer (mCRC) that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. Use of Opdivo for this indication is supported by evidence from adequate and well-controlled studies of Opdivo in adults with MSI-H or dMMR mCRC with additional population pharmacokinetic data demonstrating that age and body weight had no clinically meaningful effect on the steady-state exposure of nivolumab, that drug exposure is generally similar between adults and pediatric patients age 12 years and older for monoclonal antibodies, and that the course of MSI-H or dMMR mCRC is sufficiently similar in adults and pediatric patients to allow extrapolation of data in adults to pediatric patients [see Dosage and Administration (2.1), Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.9)].

The safety and effectiveness of Opdivo have not been established (1) in pediatric patients <12 years old with MSI-H or dMMR mCRC or (2) in pediatric patients less than 18 years old for the other approved indications [see Indications and Usage (1)].

Geriatric Use

Of the 1359 patients randomized to single-agent Opdivo in CHECKMATE-017, CHECKMATE-057, CHECKMATE-066, CHECKMATE-025, and CHECKMATE-067, 39% were 65 years or older and 9% were 75 years or older. No overall differences in safety or effectiveness were reported between elderly patients and younger patients.

In CHECKMATE-275 (urothelial cancer), 55% of patients were 65 years or older and 14% were 75 years or older. No overall differences in safety or effectiveness were reported between elderly patients and younger patients.

In CHECKMATE-238 (adjuvant treatment of melanoma), 26% of patients were 65 years or older and 3% were 75 years or older. No overall differences in safety or effectiveness were reported between elderly patients and younger patients.

CHECKMATE-037, CHECKMATE-205, CHECKMATE-039, CHECKMATE-141, CHECKMATE-142, CHECKMATE-040, and CHECKMATE-032 did not include sufficient numbers of patients aged 65 years and older to determine whether they respond differently from younger patients.

Of the 314 patients randomized to Opdivo administered with ipilimumab in CHECKMATE-067, 41% were 65 years or older and 11% were 75 years or older. No overall differences in safety or effectiveness were reported between elderly patients and younger patients.

Of the 550 patients randomized to ipilimumab 1 mg/kg administered with Opdivo 3 mg/kg in CHECKMATE-214 (renal cell carcinoma), 38% were 65 years or older and 8% were 75 years or older. No overall difference in safety was reported between elderly patients and younger patients. In elderly patients with intermediate or poor risk, no overall difference in effectiveness was reported.

Opdivo Description

Nivolumab is a programmed death receptor-1 (PD-1) blocking antibody. Nivolumab is an IgG4 kappa immunoglobulin that has a calculated molecular mass of 146 kDa. It is expressed in a recombinant Chinese Hamster Ovary (CHO) cell line.

Opdivo is a sterile, preservative-free, non-pyrogenic, clear to opalescent, colorless to pale-yellow liquid that may contain light (few) particles.

Opdivo (nivolumab) injection for intravenous use is supplied in single-dose vials. Each mL of Opdivo solution contains nivolumab 10 mg, mannitol (30 mg), pentetic acid (0.008 mg), polysorbate 80 (0.2 mg), sodium chloride (2.92 mg), sodium citrate dihydrate (5.88 mg), and Water for Injection, USP. May contain hydrochloric acid and/or sodium hydroxide to adjust pH to 6.

Opdivo - Clinical Pharmacology

Mechanism of Action

Binding of the PD-1 ligands, PD-L1 and PD-L2, to the PD-1 receptor found on T cells, inhibits T-cell proliferation and cytokine production. Upregulation of PD-1 ligands occurs in some tumors and signaling through this pathway can contribute to inhibition of active T-cell immune surveillance of tumors. Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with PD-L1 and PD-L2, releasing PD-1 pathway-mediated inhibition of the immune response, including the anti-tumor immune response. In syngeneic mouse tumor models, blocking PD-1 activity resulted in decreased tumor growth.

Combined nivolumab (anti-PD-1) and ipilimumab (anti-CTLA-4) mediated inhibition results in enhanced T-cell function that is greater than the effects of either antibody alone, and results in improved anti-tumor responses in metastatic melanoma and advanced RCC. In murine syngeneic tumor models, dual blockade of PD-1 and CTLA-4 resulted in increased anti-tumor activity.

Pharmacokinetics

Nivolumab pharmacokinetics (PK) was assessed using a population PK approach for both single-agent Opdivo and Opdivo with ipilimumab. The PK of nivolumab was studied in patients over a dose range of 0.1 mg/kg to 20 mg/kg administered as a single dose or as multiple doses of Opdivo as a 60-minute intravenous infusion every 2 or 3 weeks. The exposure to nivolumab increases dose proportionally over the dose range of 0.1 to 10 mg/kg administered every 2 weeks. The predicted exposure of nivolumab after a 30-minute infusion is comparable to that observed with a 60-minute infusion. Steady-state concentrations of nivolumab were reached by 12 weeks when administered at 3 mg/kg every 2 weeks, and systemic accumulation was 3.7-fold.

Distribution

The geometric mean volume of distribution at steady state (Vss) and coefficient of variation (CV%) is 6.8 L (27.3%).

Elimination

Nivolumab clearance (CL) decreases over time, with a mean maximal reduction from baseline values (CV%) of 24.5% (47.6%) resulting in a geometric mean steady-state clearance (CLss) (CV%) of 8.2 mL/h (53.9%) in patients with metastatic tumors; the decrease in CLss is not considered clinically relevant. Nivolumab clearance does not decrease over time in patients with completely resected melanoma, as the geometric mean population clearance is 24% lower in this patient population compared with patients with metastatic melanoma at steady state.

The geometric mean elimination half-life (t1/2) is 25 days (77.5%).

Specific Populations

The following factors had no clinically important effect on the clearance of nivolumab: age (29 to 87 years), weight (35 to 160 kg), sex, race, baseline LDH, PD-L1 expression, solid tumor type, tumor size, renal impairment (eGFR ≥ 15 mL/min/1.73 m2), and mild (total bilirubin [TB] less than or equal to the ULN and AST greater than ULN or TB greater than 1 to 1.5 times ULN and any AST) or moderate hepatic impairment (TB greater than 1.5 to 3 times ULN and any AST). Nivolumab has not been studied in patients with severe hepatic impairment (TB greater than 3 times ULN and any AST).

Drug Interaction Studies

When Opdivo 1 mg/kg was administered in combination with ipilimumab 3 mg/kg, the CL of nivolumab was increased by 29% and the CL of ipilimumab was unchanged compared to Opdivo administered alone.

When Opdivo 3 mg/kg was administered in combination with ipilimumab 1 mg/kg, the CL of nivolumab and ipilimumab were unchanged.

When administered in combination, the CL of nivolumab increased by 20% in the presence of anti-nivolumab antibodies.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

No studies have been performed to assess the potential of nivolumab for carcinogenicity or genotoxicity. Fertility studies have not been performed with nivolumab. In 1-month and 3-month repeat-dose toxicology studies in monkeys, there were no notable effects in the male and female reproductive organs; however, most animals in these studies were not sexually mature.

Animal Toxicology and/or Pharmacology

In animal models, inhibition of PD-1 signaling increased the severity of some infections and enhanced inflammatory responses. M. tuberculosis–infected PD-1 knockout mice exhibit markedly decreased survival compared with wild-type controls, which correlated with increased bacterial proliferation and inflammatory responses in these animals. PD-1 knockout mice have also shown decreased survival following infection with lymphocytic choriomeningitis virus.

Clinical Studies

Unresectable or Metastatic Melanoma

Previously Treated Metastatic Melanoma

CHECKMATE-037 (NCT01721746) was a multicenter, open-label trial that randomized (2:1) patients with unresectable or metastatic melanoma to receive Opdivo 3 mg/kg intravenously every 2 weeks or investigator’s choice of chemotherapy, either single-agent dacarbazine 1000 mg/m2 intravenously every 3 weeks or the combination of carboplatin AUC 6 intravenously every 3 weeks and paclitaxel 175 mg/m2 intravenously every 3 weeks. Patients were required to have progression of disease on or following ipilimumab treatment and, if BRAF V600 mutation positive, a BRAF inhibitor. The trial excluded patients with autoimmune disease, medical conditions requiring systemic immunosuppression, ocular melanoma, active brain metastasis, or a history of Grade 4 ipilimumab-related adverse reactions (except for endocrinopathies) or Grade 3 ipilimumab-related adverse reactions that had not resolved or were inadequately controlled within 12 weeks of the initiating event. Tumor assessments were conducted 9 weeks after randomization then every 6 weeks for the first year, and every 12 weeks thereafter.

Efficacy was evaluated in a single-arm, non-comparative, planned interim analysis of the first 120 patients who received Opdivo in CHECKMATE-037 and in whom the minimum duration of follow-up was 6 months. The major efficacy outcome measures in this population were confirmed overall response rate (ORR) as measured by blinded independent central review using Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and duration of response.

Among the 120 patients treated with Opdivo, the median age was 58 years (range: 25 to 88), 65% of patients were male, 98% were White, and the ECOG performance score was 0 (58%) or 1 (42%). Disease characteristics were M1c disease (76%), BRAF V600 mutation positive (22%), elevated LDH (56%), history of brain metastases (18%), and two or more prior systemic therapies for metastatic disease (68%).

The ORR was 32% (95% confidence interval [CI]: 23, 41), consisting of 4 complete responses and 34 partial responses in Opdivo-treated patients. Of 38 patients with responses, 87% had ongoing responses with durations ranging from 2.6+ to 10+ months, which included 13 patients with ongoing responses of 6 months or longer.

There were responses in patients with and without BRAF V600 mutation-positive melanoma. A total of 405 patients were randomized and the median duration of OS was 15.7 months (95% CI: 12.9, 19.9) in Opdivo-treated patients compared to 14.4 months (95% CI: 11.7, 18.2) (HR 0.95; 95.54% CI: 0.73, 1.24) in patients assigned to investigator’s choice of treatment. Figure 1 summarizes the OS results.

Figure 1: Overall Survival - CHECKMATE-037*

*   The primary OS analysis was not adjusted to account for subsequent therapies, with 54 (40.6%) patients in the chemotherapy arm subsequently receiving an anti-PD1 treatment. OS may be confounded by dropout, imbalance of subsequent therapies, and differences in baseline factors.

Previously Untreated Metastatic Melanoma

CHECKMATE-066

CHECKMATE-066 (NCT01721772) was a multicenter, double-blind, randomized (1:1) trial in 418 patients with BRAF V600 wild-type unresectable or metastatic melanoma. Patients were randomized to receive either Opdivo 3 mg/kg by intravenous infusion every 2 weeks or dacarbazine 1000 mg/m2 intravenously every 3 weeks until disease progression or unacceptable toxicity. Randomization was stratified by PD-L1 status (≥5% of tumor cell membrane staining by immunohistochemistry vs. <5% or indeterminate result) and M stage (M0/M1a/M1b versus M1c). Key eligibility criteria included histologically confirmed, unresectable or metastatic, cutaneous, mucosal, or acral melanoma; no prior therapy for metastatic disease; completion of prior adjuvant or neoadjuvant therapy at least 6 weeks prior to randomization; ECOG performance status 0 or 1; absence of autoimmune disease; and absence of active brain or leptomeningeal metastases. The trial excluded patients with ocular melanoma. Tumor assessments were conducted 9 weeks after randomization then every 6 weeks for the first year and then every 12 weeks thereafter. The major efficacy outcome measure was overall survival (OS). Additional outcome measures included investigator-assessed progression-free survival (PFS) and ORR per RECIST v1.1.

The trial population characteristics were: median age was 65 years (range: 18 to 87), 59% were male, and 99.5% were White. Disease characteristics were M1c stage disease (61%), cutaneous melanoma (74%), mucosal melanoma (11%), elevated LDH level (37%), PD-L1 ≥5% tumor cell membrane expression (35%), and history of brain metastasis (4%). More patients in the Opdivo arm had an ECOG performance status of 0 (71% vs. 58%).

CHECKMATE-066 demonstrated a statistically significant improvement in OS for the Opdivo arm compared with the dacarbazine arm in an interim analysis based on 47% of the total planned events for OS. At the time of analysis, 88% (63/72) of Opdivo-treated patients had ongoing responses, which included 43 patients with ongoing response of 6 months or longer. Efficacy results are shown in Table 24 and Figure 2.

Table 24: Efficacy Results - CHECKMATE-066
a  Based on a stratified proportional hazards model.
b  Based on stratified log-rank test.
c  p-value is compared with the allocated alpha of 0.0021 for this interim analysis.

Opdivo
(n=210)

Dacarbazine
(n=208)

Overall Survival

     Deaths (%)

50 (24)

96 (46)

     Median, months (95% CI)

Not Reached

10.8 (9.3, 12.1)

     Hazard ratio (95% CI)a

0.42 (0.30, 0.60)

          p-valueb,c

<0.0001

Progression-free Survival

     Disease progression or death (%)

108 (51)

163 (78)

     Median, months (95% CI)

5.1 (3.5, 10.8)

2.2 (2.1, 2.4)

     Hazard ratio (95% CI)a

0.43 (0.34, 0.56)

          p-valueb,c

<0.0001

Overall Response Rate

34%

9%

     (95% CI)

(28, 41)

(5, 13)

     Complete response rate

4%

1%

     Partial response rate

30%

8%

Figure 2: Overall Survival - CHECKMATE-066

CHECKMATE-067

CHECKMATE-067 (NCT01844505) was a multicenter, randomized (1:1:1), double-blind trial in 945 patients with previously untreated, unresectable or metastatic melanoma to one of the following arms: Opdivo and ipilimumab, Opdivo, or ipilimumab. Patients were required to have completed adjuvant or neoadjuvant treatment at least 6 weeks prior to randomization and have no prior treatment with anti-CTLA-4 antibody and no evidence of active brain metastasis, ocular melanoma, autoimmune disease, or medical conditions requiring systemic immunosuppression.

Patients were randomized to receive:

Opdivo 1 mg/kg with ipilimumab 3 mg/kg intravenously every 3 weeks for 4 doses, followed by Opdivo as a single agent at a dose of 3 mg/kg by intravenous infusion every 2 weeks (Opdivo and ipilimumab arm),
Opdivo 3 mg/kg by intravenous infusion every 2 weeks (Opdivo arm), or
Ipilimumab 3 mg/kg intravenously every 3 weeks for 4 doses, followed by placebo every 2 weeks (ipilimumab arm).

Randomization was stratified by PD-L1 expression (≥5% vs. <5% tumor cell membrane expression) as determined by a clinical trial assay, BRAF V600 mutation status, and M stage per the AJCC staging system (M0, M1a, M1b vs. M1c). Tumor assessments were conducted 12 weeks after randomization then every 6 weeks for the first year, and every 12 weeks thereafter. The major efficacy outcome measures were investigator-assessed PFS per RECIST v1.1 and OS. Additional efficacy outcome measures were confirmed ORR and duration of response.

The trial population characteristics were: median age 61 years (range: 18 to 90); 65% male; 97% White; ECOG performance score 0 (73%) or 1 (27%). Disease characteristics were: AJCC Stage IV disease (93%); M1c disease (58%); elevated LDH (36%); history of brain metastases (4%); BRAF V600 mutation-positive melanoma (32%); PD-L1 ≥5% tumor cell membrane expression as determined by the clinical trials assay (46%); and prior adjuvant therapy (22%).

CHECKMATE-067 demonstrated statistically significant improvements in OS and PFS for patients randomized to either Opdivo-containing arm as compared with the ipilimumab arm. The trial was not designed to assess whether adding ipilimumab to Opdivo improves PFS or OS compared to Opdivo as a single agent. Efficacy results are shown in Table 25 and Figure 3.

Table 25: Efficacy Results - CHECKMATE-067
a  OS results are based on final OS analysis with 28 months of minimum follow-up; PFS (co-primary endpoint) and ORR (secondary endpoint) results were based on primary analysis with 9 months of minimum follow-up.
b  Based on a stratified proportional hazards model.
c  Based on stratified log-rank test.
d  If the maximum of the two OS p-values is less than 0.04 (a significance level assigned by the Hochberg procedure), then both p-values are considered significant.
e  p-value is compared with .005 of the allocated alpha for final PFS treatment comparisons.
f  Based on the stratified Cochran-Mantel-Haenszel test.
+  Censored observation

Opdivo and Ipilimumab
(n=314)

Opdivo
(n=316)

Ipilimumab
(n=315)

Overall Survivala

     Deaths (%)

128 (41)

142 (45)

197 (63)

     Hazard ratiob (vs. ipilimumab)
          (95% CI)

0.55
(0.44, 0.69)

0.63
(0.50, 0.78)

     p-valuec,d

<0.0001

<0.0001

Progression-free Survivala

     Disease progression or death

151 (48%)

174 (55%)

234 (74%)

     Median in months (95% CI)

11.5
(8.9, 16.7)

6.9
(4.3, 9.5)

2.9
(2.8, 3.4)

     Hazard ratiob (vs. ipilimumab)
          (95% CI)

0.42
(0.34, 0.51)

0.57
(0.47, 0.69)

          p-valuec,e

<0.0001

<0.0001

Confirmed Overall Response Ratea

50%

40%

14%

          (95% CI)

(44, 55)

(34, 46)

(10, 18)

          p-valuef

<0.0001

<0.0001

     Complete response

8.9%

8.5%

1.9%

     Partial response

41%

31%

12%

Duration of Response

     Proportion ≥6 months in duration

76%

74%

63%

     Range (months)

1.2+ to 15.8+

1.3+ to 14.6+

1.0+ to 13.8+

Figure 3: Overall Survival - CHECKMATE-067

Based on a minimum follow-up of 48 months, the median OS was not reached (95% CI: 38.2, NR) in the Opdivo and ipilimumab arm. The median OS was 36.9 months (95% CI: 28.3, NR) in the Opdivo arm and 19.9 months (95% CI: 16.9, 24.6) in the ipilimumab arm.

Based on a minimum follow-up of 28 months, the median PFS was 11.7 months (95% CI: 8.9, 21.9) in the Opdivo and ipilimumab arm, 6.9 months (95% CI: 4.3, 9.5) in the Opdivo arm, and 2.9 months (95% CI: 2.8, 3.2) in the ipilimumab arm. Based on a minimum follow-up of 28 months, the proportion of responses lasting ≥ 24 months was 55% in the Opdivo and ipilimumab arm, 56% in the Opdivo arm, and 39% in the ipilimumab arm.

Adjuvant Treatment of Melanoma

CHECKMATE-238 (NCT02388906) was a randomized, double-blind trial in 906 patients with completely resected Stage IIIB/C or Stage IV melanoma. Patients were randomized (1:1) to receive Opdivo 3 mg/kg by intravenous infusion every 2 weeks or ipilimumab 10 mg/kg intravenously every 3 weeks for 4 doses then every 12 weeks beginning at Week 24 for up to 1 year. Enrollment required complete resection of melanoma with margins negative for disease within 12 weeks prior to randomization. The trial excluded patients with a history of ocular/uveal melanoma, autoimmune disease, and any condition requiring systemic treatment with either corticosteroids (≥10 mg daily prednisone or equivalent) or other immunosuppressive medications, as well as patients with prior therapy for melanoma except surgery, adjuvant radiotherapy after neurosurgical resection for lesions of the central nervous system, and prior adjuvant interferon completed ≥6 months prior to randomization. Randomization was stratified by PD-L1 status (positive [based on 5% level] vs. negative/indeterminate) and AJCC stage (Stage IIIB/C vs. Stage IV M1a-M1b vs. Stage IV M1c). The major efficacy outcome measure was recurrence-free survival (RFS) defined as the time between the date of randomization and the date of first recurrence (local, regional, or distant metastasis), new primary melanoma, or death, from any cause, whichever occurs first and as assessed by the investigator. Patients underwent imaging for tumor recurrence every 12 weeks for the first 2 years then every 6 months thereafter.

The trial population characteristics were: median age was 55 years (range: 18 to 86), 58% were male, 95% were White, and 90% had an ECOG performance status of 0. Disease characteristics were AJCC Stage IIIB (34%), Stage IIIC (47%), Stage IV (19%), M1a-b (14%), BRAF V600 mutation positive (42%), BRAF wild-type (45%), elevated LDH (8%), PD-L1 ≥5% tumor cell membrane expression determined by clinical trial assay (34%), macroscopic lymph nodes (48%), and tumor ulceration (32%).

CHECKMATE-238 demonstrated a statistically significant improvement in RFS for patients randomized to the Opdivo arm compared with the ipilimumab 10 mg/kg arm. Efficacy results are shown in Table 26 and Figure 4.

Table 26: Efficacy Results - CHECKMATE-238
Opdivo
N=453
Ipilimumab 10 mg/kg
N=453
Recurrence-free Survival
a   Not reached.
b   Based on a stratified proportional hazards model.
c   Based on a stratified log-rank test.
d   p-value is compared with 0.0244 of the allocated alpha for this analysis.

Number of Events, n (%)

154 (34%)

206 (45%)

Median (months)
   (95% CI)

NRa

NRa
(16.56, NRa)

Hazard Ratiob
   (95% CI)
   p-valuec,d

0.65
(0.53, 0.80)
p<0.0001

Figure 4: Recurrence-free Survival - CHECKMATE-238

Metastatic Non-Small Cell Lung Cancer

Second-line Treatment of Metastatic Squamous NSCLC

CHECKMATE-017 (NCT01642004) was a randomized (1:1), open-label trial in 272 patients with metastatic squamous NSCLC who had experienced disease progression during or after one prior platinum doublet-based chemotherapy regimen. Patients received Opdivo 3 mg/kg by intravenous infusion every 2 weeks (n=135) or docetaxel 75 mg/m2 intravenously every 3 weeks (n=137). Randomization was stratified by prior paclitaxel vs. other prior treatment and region (US/Canada vs. Europe vs. Rest of World). This trial included patients regardless of their PD-L1 status. The trial excluded patients with autoimmune disease, medical conditions requiring systemic immunosuppression, symptomatic interstitial lung disease, or untreated brain metastasis. Patients with treated brain metastases were eligible if neurologically returned to baseline at least 2 weeks prior to enrollment, and either off corticosteroids, or on a stable or decreasing dose of <10 mg daily prednisone equivalents. The first tumor assessments were conducted 9 weeks after randomization and continued every 6 weeks thereafter. The major efficacy outcome measure was OS. Additional efficacy outcome measures were investigator-assessed ORR and PFS.

The trial population characteristics were: median age was 63 years (range: 39 to 85) with 44% ≥65 years of age and 11% ≥75 years of age. The majority of patients were White (93%) and male (76%); the majority of patients were enrolled in Europe (57%) with the remainder in US/Canada (32%) and the rest of the world (11%). Baseline ECOG performance status was 0 (24%) or 1 (76%) and 92% were former/current smokers. Baseline disease characteristics of the population as reported by investigators were Stage IIIb (19%), Stage IV (80%), and brain metastases (6%). All patients received prior therapy with a platinum-doublet regimen and 99% of patients had tumors of squamous-cell histology.

The trial demonstrated a statistically significant improvement in OS for patients randomized to Opdivo as compared with docetaxel at the prespecified interim analysis when 199 events were observed (86% of the planned number of events for final analysis). Efficacy results are shown in Table 27 and Figure 5.

Table 27: Efficacy Results - CHECKMATE-017
Opdivo
(n=135)
Docetaxel
(n=137)
a  Based on a stratified proportional hazards model.
b  Based on stratified log-rank test.
c  p-value is compared with .0315 of the allocated alpha for this interim analysis.
d  Based on the stratified Cochran-Mantel-Haenszel test.

Overall Survival

     Deaths (%)

86 (64%)

113 (82%)

     Median (months)
          (95% CI)

9.2
(7.3, 13.3)

6.0
(5.1, 7.3)

     Hazard ratio (95% CI)a

0.59 (0.44, 0.79)

     p-valueb,c

0.0002

Overall Response Rate

27 (20%)

12 (9%)

     (95% CI)

(14, 28)

(5, 15)

     p-valued

0.0083

     Complete response

1 (0.7%)

0

     Median duration of response, months
           (95% CI)

NR
(9.8, NR)

8.4
(3.6, 10.8)

Progression-free Survival

     Disease progression or death (%)

105 (78%)

122 (89%)

     Median (months)

3.5

2.8

     Hazard ratio (95% CI)a

0.62 (0.47, 0.81)

     p-valueb

0.0004

Figure 5: Overall Survival - CHECKMATE-017

Archival tumor specimens were retrospectively evaluated for PD-L1 expression. Across the trial population, 17% of 272 patients had non-quantifiable results. Among the 225 patients with quantifiable results, 47% had PD-L1 negative squamous NSCLC, defined as <1% of tumor cells expressing PD-L1 and 53% had PD-L1 positive squamous NSCLC defined as ≥1% of tumor cells expressing PD-L1. In pre-specified exploratory subgroup analyses, the hazard ratios for survival were 0.58 (95% CI: 0.37, 0.92) in the PD-L1 negative subgroup and 0.69 (95% CI: 0.45, 1.05) in the PD-L1 positive subgroup.

Second-line Treatment of Metastatic Non-Squamous NSCLC

CHECKMATE-057 (NCT01673867) was a randomized (1:1), open-label trial in 582 patients with metastatic non-squamous NSCLC who had experienced disease progression during or after one prior platinum doublet-based chemotherapy regimen. Appropriate prior targeted therapy in patients with known sensitizing EGFR mutation or ALK translocation was allowed. Patients received Opdivo 3 mg/kg by intravenous infusion every 2 weeks (n=292) or docetaxel 75 mg/m2 intravenously every 3 weeks (n=290). Randomization was stratified by prior maintenance therapy (yes vs. no) and number of prior therapies (1 vs. 2). The trial excluded patients with autoimmune disease, medical conditions requiring systemic immunosuppression, symptomatic interstitial lung disease, or untreated brain metastasis. Patients with treated brain metastases were eligible if neurologically stable. The first tumor assessments were conducted 9 weeks after randomization and continued every 6 weeks thereafter. The major efficacy outcome measure was OS. Additional efficacy outcome measures were investigator-assessed ORR and PFS. In addition, prespecified analyses were conducted in subgroups defined by PD-L1 expression.

The trial population characteristics: median age was 62 years (range: 21 to 85) with 42% of patients ≥65 years and 7% of patients ≥75 years. The majority of patients were White (92%) and male (55%); the majority of patients were enrolled in Europe (46%) followed by the US/Canada (37%) and the rest of the world (17%). Baseline ECOG performance status was 0 (31%) or 1 (69%), 79% were former/current smokers, 3.6% had NSCLC with ALK rearrangement, 14% had NSCLC with EGFR mutation, and 12% had previously treated brain metastases. Prior therapy included platinum-doublet regimen (100%) and 40% received maintenance therapy as part of the first-line regimen. Histologic subtypes included adenocarcinoma (93%), large cell (2.4%), and bronchoalveolar (0.9%).

CHECKMATE-057 demonstrated a statistically significant improvement in OS for patients randomized to Opdivo as compared with docetaxel at the prespecified interim analysis when 413 events were observed (93% of the planned number of events for final analysis). Efficacy results are shown in Table 28 and Figure 6.

Table 28: Efficacy Results - CHECKMATE-057
a  Based on a stratified proportional hazards model.
b  Based on stratified log-rank test.
c  p-value is compared with .0408 of the allocated alpha for this interim analysis.
d  Based on the stratified Cochran-Mantel-Haenszel test.

Opdivo
(n=292)

Docetaxel
(n=290)

Overall Survival

     Deaths (%)

190 (65%)

223 (77%)

     Median (months)
          (95% CI)

12.2
(9.7, 15.0)

9.4
(8.0, 10.7)

     Hazard ratio (95% CI)a

0.73 (0.60, 0.89)

     p-valueb,c

0.0015

Overall Response Rate

56 (19%)

36 (12%)

     (95% CI)

(15, 24)

(9, 17)

     p-valued

0.02

     Complete response

4 (1.4%)

1 (0.3%)

Median duration of response (months)
          (95% CI)

17
(8.4, NR)

6
(4.4, 7.0)

Progression-free Survival

     Disease progression or death (%)

234 (80%)

245 (84%)

     Median (months)

2.3

4.2

     Hazard ratio (95% CI)a

0.92 (0.77, 1.11)

     p-valueb

0.39

Figure 6: Overall Survival - CHECKMATE-057

Archival tumor specimens were evaluated for PD-L1 expression following completion of the trial. Across the trial population, 22% of 582 patients had non-quantifiable results. Of the remaining 455 patients, the proportion of patients in retrospectively determined subgroups based on PD-L1 testing using the PD-L1 IHC 28-8 pharmDx assay were: 46% PD-L1 negative, defined as <1% of tumor cells expressing PD-L1 and 54% had PD-L1 expression, defined as ≥1% of tumor cells expressing PD-L1. Among the 246 patients with tumors expressing PD-L1, 26% had ≥1% but <5% tumor cells with positive staining, 7% had ≥5% but <10% tumor cells with positive staining, and 67% had ≥10% tumor cells with positive staining. Figures 7 and 8 summarize the results of prespecified analyses of OS and PFS in subgroups determined by percentage of tumor cells expressing PD-L1.

Figure 7: Forest Plot: OS Based on PD-L1 Expression - CHECKMATE-057

Figure 8: Forest Plot: PFS Based on PD-L1 Expression - CHECKMATE-057

Small Cell Lung Cancer

CHECKMATE-032 (NCT01928394) was a multicenter, open-label, multi-cohort, ongoing trial evaluating nivolumab as a single agent or in combination with ipilimumab in patients with advanced or metastatic solid tumors. Several cohorts enrolled patients with metastatic small cell lung cancer (SCLC), regardless of PD-L1 tumor status, with disease progression after platinum-based chemotherapy to receive Opdivo 3 mg/kg by intravenous infusion every 2 weeks. The trial excluded patients with autoimmune disease, medical conditions requiring systemic immunosuppression, symptomatic interstitial lung disease, or untreated brain metastasis. Patients with treated brain metastases were eligible if neurologically stable. Tumor assessments were conducted every 6 weeks for the first 24 weeks and every 12 weeks thereafter. The major efficacy outcome measures were ORR and duration of response according to RECIST v1.1 as assessed by Blinded Independent Central Review (BICR).

A total of 109 patients with SCLC who progressed after platinum-based chemotherapy and at least one other prior line of therapy were enrolled. The trial population characteristics were: median age was 64 years (range: 45 to 81) with 45% of patients ≥65 years and 6% of patients ≥75 years. The majority (94%) of the patients were White, <1% were Asian, and 4% were Black; 56% were male. Baseline ECOG performance status was 0 (29%) or 1 (70%), 93% were former/current smokers, 7% had CNS metastases, 94% received two to three prior lines of therapy and 6% received four to five prior lines of therapy. Approximately 65% of patients had platinum-sensitive SCLC, defined as progression ≥90 days after the last dose of platinum-containing therapy.

Efficacy results are shown in Table 29.

Table 29: Efficacy Results - CHECKMATE-032

Opdivo
(n=109)

Overall Response Rate
     (95% CI)
     Complete response
     Partial response

12%
(6.5, 19.5)
0.9%
11%

Duration of Response
      Range (months)
     % with duration ≥6 months
     % with duration ≥12 months
     % with duration ≥18 months

(n=13)
(3.0, 42.1)
77%
62%
39%

Advanced Renal Cell Carcinoma

Previously Treated Renal Cell Carcinoma

CHECKMATE-025 (NCT01668784) was a randomized (1:1), open-label trial in patients with advanced RCC who had experienced disease progression during or after one or two prior anti-angiogenic therapy regimens. Patients had to have a Karnofsky Performance Score (KPS) ≥70% and patients were included regardless of their PD-L1 status. The trial excluded patients with any history of or concurrent brain metastases, prior treatment with an mTOR inhibitor, active autoimmune disease, or medical conditions requiring systemic immunosuppression. Patients were stratified by region, Memorial Sloan Kettering Cancer Center (MSKCC) Risk Group and the number of prior anti-angiogenic therapies. Patients were randomized Opdivo 3 mg/kg by intravenous infusion every 2 weeks (n=410) or everolimus 10 mg orally daily (n=411). The first tumor assessments were conducted 8 weeks after randomization and continued every 8 weeks thereafter for the first year and then every 12 weeks until progression or treatment discontinuation, whichever occurred later. The major efficacy outcome measure was overall survival (OS).

The trial population characteristics were: median age was 62 years (range: 18 to 88) with 40% ≥65 years of age and 9% ≥75 years of age. The majority of patients were male (75%) and White (88%) and 34% and 66% of patients had a baseline KPS of 70% to 80% and 90% to 100%, respectively. The majority of patients (77%) were treated with one prior anti-angiogenic therapy. Patient distribution by MSKCC risk groups was 34% favorable, 47% intermediate, and 19% poor.

The trial demonstrated a statistically significant improvement in OS for patients randomized to Opdivo as compared with everolimus at the prespecified interim analysis when 398 events were observed (70% of the planned number of events for final analysis). OS benefit was observed regardless of PD-L1 expression level. Efficacy results are shown in Table 30 and Figure 9.

Table 30: Efficacy Results - CHECKMATE-025
Opdivo
(n=410)
Everolimus
(n=411)
a  Based on a stratified proportional hazards model.
b  Based on a stratified log-rank test.
c  p-value is compared with .0148 of the allocated alpha for this interim analysis.

Overall Survival

     Deaths (%)

183 (45)

215 (52)

     Median survival in months (95% CI)

25.0 (21.7, NE)

19.6 (17.6, 23.1)

     Hazard ratio (95% CI)a

0.73 (0.60, 0.89)

          p-valueb,c

0.0018

Confirmed Overall Response Rate (95% CI)

21.5% (17.6, 25.8)

3.9% (2.2, 6.2)

     Median duration of response in months (95% CI)

23.0 (12.0, NE)

13.7 (8.3, 21.9)

     Median time to onset of confirmed response in months (min, max)

3.0 (1.4, 13.0)

3.7 (1.5, 11.2)

Figure 9: Overall Survival - CHECKMATE-025

Previously Untreated Renal Cell Carcinoma

CHECKMATE-214 (NCT02231749) was a randomized (1:1), open-label trial in patients with previously untreated advanced RCC. Patients were included regardless of their PD-L1 status. CHECKMATE-214 excluded patients with any history of or concurrent brain metastases, active autoimmune disease, or medical conditions requiring systemic immunosuppression. Patients were stratified by International Metastatic RCC Database Consortium (IMDC) prognostic score and region.

Efficacy was evaluated in intermediate/poor risk patients with at least 1 or more of 6 prognostic risk factors as per the IMDC criteria (less than one year from time of initial renal cell carcinoma diagnosis to randomization, Karnofsky performance status <80%, hemoglobin less than the lower limit of normal, corrected calcium of >10 mg/dL, platelet count greater than the upper limit of normal, and absolute neutrophil count greater than the upper limit of normal).

Patients were randomized to Opdivo 3 mg/kg and ipilimumab 1 mg/kg intravenously every 3 weeks for 4 doses followed by Opdivo 3 mg/kg intravenously every two weeks (n=425), or sunitinib 50 mg orally daily for the first 4 weeks of a 6-week cycle (n=422). Treatment continued until disease progression or unacceptable toxicity.

The trial population characteristics were: median age was 61 years (range: 21 to 85) with 38% ≥65 years of age and 8% ≥75 years of age. The majority of patients were male (73%) and White (87%) and 26% and 74% of patients had a baseline KPS of 70% to 80% and 90% to 100%, respectively.

The major efficacy outcome measures were OS, PFS (independent radiographic review committee [IRRC]-assessed) and confirmed ORR (IRRC-assessed) in intermediate/poor risk patients. In this population, the trial demonstrated statistically significant improvement in OS and ORR for patients randomized to Opdivo and ipilimumab as compared with sunitinib (Table 31 and Figure 10). OS benefit was observed regardless of PD-L1 expression level. The trial did not demonstrate a statistically significant improvement in PFS. Efficacy results are shown in Table 31 and Figure 10.

Table 31: Efficacy Results - CHECKMATE-214
Intermediate/Poor-Risk
Opdivo and Ipilimumab
(n=425)
Sunitinib
(n=422)
a     Based on a stratified proportional hazards model.
b     Based on a stratified log-rank test.
c     p-value is compared to alpha 0.002 in order to achieve statistical significance.
d     Based on the stratified DerSimonian-Laird test.
e     p-value is compared to alpha 0.001 in order to achieve statistical significance.
f     Not Significant at alpha level of 0.009.

Overall Survival

     Deaths (%)

140 (32.9)

188 (44.5)

     Median survival (months)

NE

25.9

     Hazard ratio (99.8% CI)a

0.63 (0.44, 0.89)

     p-valueb,c

<0.0001

Confirmed Objective Response Rate (95% CI)

41.6% (36.9, 46.5)

26.5% (22.4, 31.0)

     p-valued,e

<0.0001

     Complete Response (CR)

40 (9.4)

5 (1.2)

     Partial Response (PR)

137 (32.2)

107 (25.4)

     Median duration of response in months (95% CI)

NE (21.8, NE)

18.2 (14.8, NE)

Progression-free Survival

     Disease progression or death (%)

228 (53.6)

228 (54.0)

     Median (months)

11.6

8.4

     Hazard ratio (99.1% CI)a

0.82 (0.64, 1.05)

     p-valueb

NSf

Figure 10: Overall Survival (Intermediate/Poor Risk Population) - CHECKMATE-214

CHECKMATE-214 also randomized 249 favorable risk patients as per IMDC criteria to Opdivo and ipilimumab (n=125) or to sunitinib (n=124). These patients were not evaluated as part of the efficacy analysis population. OS in favorable risk patients receiving Opdivo and ipilimumab compared to sunitinib has a hazard ratio of 1.45 (95% CI: 0.75, 2.81). The efficacy of Opdivo and ipilimumab in previously untreated renal cell carcinoma with favorable-risk disease has not been established.

Classical Hodgkin Lymphoma

Two studies evaluated the efficacy of Opdivo as a single agent in adult patients with cHL after failure of autologous HSCT.

CHECKMATE-205 (NCT02181738) was a single-arm, open-label, multicenter, multicohort trial in cHL. CHECKMATE-039 (NCT01592370) was an open-label, multicenter, dose escalation trial that included cHL. Both studies included patients regardless of their tumor PD-L1 status and excluded patients with ECOG performance status of 2 or greater, autoimmune disease, symptomatic interstitial lung disease, hepatic transaminases more than 3 times ULN, creatinine clearance <40 mL/min, prior allogeneic HSCT, or chest irradiation within 24 weeks. In addition, both studies required an adjusted diffusion capacity of the lungs for carbon monoxide (DLCO) of over 60% in patients with prior pulmonary toxicity.

Patients received Opdivo 3 mg/kg by intravenous infusion every 2 weeks until disease progression, maximal clinical benefit, or unacceptable toxicity. A cycle consisted of one dose. Dose reduction was not permitted.

Efficacy was evaluated by ORR as determined by an IRRC. Additional outcome measures included duration of response (DOR).

Efficacy was evaluated in 95 patients in CHECKMATE-205 and CHECKMATE-039 combined who had failure of autologous HSCT and post-transplantation brentuximab vedotin. The median age was 37 years (range: 18 to 72). The majority were male (64%) and White (87%). Patients had received a median of 5 prior systemic regimens (range: 2 to 15). They received a median of 27 doses of Opdivo (range: 3 to 48), with a median duration of therapy of 14 months (range: 1 to 23 months). Efficacy results are shown in Table 32.

Table 32: Efficacy in cHL after Autologous HSCT and Post-transplantation Brentuximab Vedotin
a  Per 2007 revised International Working Group criteria.
b  Kaplan-Meier estimate. Among responders, the median follow-up for DOR, measured from the date of first response, was 9.9 months.
c  A + sign indicates a censored value.

CHECKMATE-205 and CHECKMATE-039
(n=95)

Overall Response Rate, n (%)a

      (95% CI)

63 (66%)

(56, 76)

Complete Remission Rate

      (95% CI)

6 (6%)

(2, 13)

Partial Remission Rate

      (95% CI)

57 (60%)

(49, 70)

Duration of Response (months)

      Medianb

      (95% CI)

      Rangec

13.1

(9.5, NE)

0+, 23.1+

Time to Response (months)

      Median

      Range

2.0

0.7, 11.1

Efficacy was also evaluated in 258 patients in CHECKMATE-205 and CHECKMATE-039 combined who had relapsed or progressive cHL after autologous HSCT. The analysis included the group described above. The median age was 34 years (range: 18 to 72). The majority were male (59%) and White (86%). Patients had a median of 4 prior systemic regimens (range: 2 to 15), with 85% having 3 or more prior systemic regimens and 76% having prior brentuximab vedotin. Of the 195 patients having prior brentuximab vedotin, 17% received it only before autologous HSCT, 78% received it only after HSCT, and 5% received it both before and after HSCT. Patients received a median of 21 doses of Opdivo (range: 1 to 48), with a median duration of therapy of 10 months (range: 0 to 23 months). Efficacy results are shown in Table 33.

Table 33: Efficacy in cHL after Autologous HSCT
a  Kaplan-Meier estimate. Among responders, the median follow-up for DOR, measured from the date of first response, was 6.7 months.
b  The estimated median duration of PR was 13.1 months (95% CI, 9.5, NE). The median duration of CR was not reached.

CHECKMATE-205 and CHECKMATE-039
(n=258)

Overall Response Rate, n (%)

      (95% CI)

179 (69%)

(63, 75)

   Complete Remission Rate

      (95% CI)

37 (14%)

(10, 19)

   Partial Remission Rate

      (95% CI)

142 (55%)

(49, 61)

Duration of Response (months)

   Mediana,b

      (95% CI)

   Range

NE

(12.0, NE)

0+, 23.1+

Time to Response (months)

   Median

   Range

2.0

0.7, 11.1

Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck

CHECKMATE-141 (NCT02105636) was a randomized (2:1), active-controlled, open-label trial enrolling patients with metastatic or recurrent SCCHN who had experienced disease progression during or within 6 months of receiving platinum-based therapy administered in either the adjuvant, neo-adjuvant, primary (unresectable locally advanced) or metastatic setting. The trial excluded patients with autoimmune disease, medical conditions requiring immunosuppression, recurrent or metastatic carcinoma of the nasopharynx, squamous cell carcinoma of unknown primary histology, salivary gland or non-squamous histologies (e.g., mucosal melanoma), or untreated brain metastasis. Patients with treated brain metastases were eligible if neurologically stable. Patients were randomized to receive Opdivo 3 mg/kg by intravenous infusion every 2 weeks or investigator’s choice of:

cetuximab 400 mg/m2 initial dose intravenously followed by 250 mg/m2 weekly, or
methotrexate 40 to 60 mg/m2 intravenously weekly, or
docetaxel 30 to 40 mg/m2 intravenously weekly.

Randomization was stratified by prior cetuximab treatment (yes/no). The first tumor assessments were conducted 9 weeks after randomization and continued every 6 weeks thereafter. The major efficacy outcome measure was OS. Additional efficacy outcome measures were PFS and ORR.

A total of 361 patients were randomized; 240 patients to Opdivo and 121 patients to investigator’s choice (45% received docetaxel, 43% received methotrexate, and 12% received cetuximab). The trial population characteristics were: median age was 60 years (range: 28 to 83) with 31% ≥65 years of age, 83% were White, 12% Asian, and 4% were Black, and 83% male. Baseline ECOG performance status was 0 (20%) or 1 (78%), 76% were former/current smokers, 90% had Stage IV disease, 45% of patients received only one prior line of systemic therapy, the remaining 55% received two or more prior lines of systemic therapy, and 25% had HPVp16-positive tumors, 24% had HPV p16-negative tumors, and 51% had unknown status.

The trial demonstrated a statistically significant improvement in OS for patients randomized to Opdivo as compared with investigator’s choice at a pre-specified interim analysis (78% of the planned number of events for final analysis). There were no statistically significant differences between the two arms for PFS (HR=0.89; 95% CI: 0.70, 1.13) or ORR (13.3% [95% CI: 9.3, 18.3] vs. 5.8% [95% CI: 2.4, 11.6] for nivolumab and investigator’s choice, respectively). Efficacy results are shown in Table 34 and Figure 11.

Table 34: Overall Survival - CHECKMATE-141
Opdivo
(n=240)
Investigator’s Choice
(n=121)
a  Based on stratified proportional hazards model.
b  Based on stratified log-rank test.
c  p-value is compared with 0.0227 of the allocated alpha for this interim analysis.

Overall Survival

     Deaths (%)

133 (55%)

85 (70%)

     Median (months)
          (95% CI)

7.5
(5.5, 9.1)

5.1
(4.0, 6.0)

     Hazard ratio (95% CI)a

0.70 (0.53, 0.92)

     p-valueb,c

0.0101

Figure 11: Overall Survival - CHECKMATE-141

Archival tumor specimens were retrospectively evaluated for PD-L1 expression using the PD-L1 IHC 28-8 pharmDx assay. Across the trial population, 28% (101/361) of patients had non-quantifiable results. Among the 260 patients with quantifiable results, 43% (111/260) had PD-L1 negative SCCHN, defined as <1% of tumor cells expressing PD-L1, and 57% (149/260) had PD-L1 positive SCCHN, defined as ≥1% of tumor cells expressing PD-L1. In pre-specified exploratory subgroup analyses, the hazard ratio for survival was 0.89 (95% CI: 0.54, 1.45) with median survivals of 5.7 and 5.8 months for the nivolumab and chemotherapy arms, respectively, in the PD-L1 negative subgroup. The HR for survival was 0.55 (95% CI: 0.36, 0.83) with median survivals of 8.7 and 4.6 months for the nivolumab and chemotherapy arms, respectively, in the PD-L1 positive SCCHN subgroup.

Urothelial Carcinoma

CHECKMATE-275 (NCT02387996) was a single-arm trial in 270 patients with locally advanced or metastatic urothelial carcinoma who had disease progression during or following platinum-containing chemotherapy or who had disease progression within 12 months of treatment with a platinum-containing neoadjuvant or adjuvant chemotherapy regimen. Patients were excluded for active brain or leptomeningeal metastases, active autoimmune disease, medical conditions requiring systemic immunosuppression, and ECOG performance status >1. Patients received Opdivo 3 mg/kg by intravenous infusion every 2 weeks until unacceptable toxicity or either radiographic or clinical progression. Tumor response assessments were conducted every 8 weeks for the first 48 weeks and every 12 weeks thereafter. Major efficacy outcome measures included confirmed ORR as assessed by IRRC using RECIST v1.1 and DOR.

The median age was 66 years (range: 38 to 90), 78% were male, 86% were White. Twenty-seven percent had non-bladder urothelial carcinoma and 84% had visceral metastases. Thirty-four percent of patients had disease progression following prior platinum-containing neoadjuvant or adjuvant therapy. Twenty-nine percent of patients had received ≥2 prior systemic regimens in the metastatic setting. Thirty-six percent of patients received prior cisplatin only, 23% received prior carboplatin only, and 7% were treated with both cisplatin and carboplatin in the metastatic setting. Forty-six percent of patients had an ECOG performance status of 1. Eighteen percent of patients had a hemoglobin <10 g/dL, and twenty-eight percent of patients had liver metastases at baseline. Patients were included regardless of their PD-L1 status.

Tumor specimens were evaluated prospectively using the PD-L1 IHC 28-8 pharmDx assay at a central laboratory and the results were used to define subgroups for pre-specified analyses. Of the 270 patients, 46% were defined as having PD-L1 expression of ≥1% (defined as ≥1% of tumor cells expressing PD-L1). The remaining 54% of patients were classified as having PD-L1 expression of <1% (defined as <1% of tumor cells expressing PD-L1). Confirmed ORR in all patients and the two PD-L1 subgroups are shown in Table 35. Median time to response was 1.9 months (range: 1.6-7.2). In 77 patients who received prior systemic therapy only in the neoadjuvant or adjuvant setting, the ORR was 23.4% (95% CI: 14.5%, 34.4%).

Table 35: Efficacy Results - CHECKMATE-275
a  Estimated from the Kaplan-Meier Curve

All Patients

N=270

PD-L1 <1%

N=146

PD-L1 ≥1%

N=124

Confirmed Overall Response Rate, n (%)

      (95% CI)

53 (19.6%)

(15.1, 24.9)

22 (15.1%)

(9.7, 21.9)

31 (25.0%)

(17.7, 33.6)

   Complete Response Rate

7 (2.6%)

1 (0.7%)

6 (4.8%)

   Partial Response Rate

46 (17.0%)

21 (14.4%)

25 (20.2%)

Median Duration of Responsea (months) (range)

10.3 (1.9+, 12.0+)

7.6 (3.7, 12.0+)

NE (1.9+, 12.0+)

Microsatellite Instability-High or Mismatch Repair Deficient Metastatic Colorectal Cancer

CHECKMATE-142 (NCT02060188) was a multicenter, non-randomized, multiple parallel-cohort, open-label trial conducted in patients with locally determined dMMR or MSI-H metastatic CRC (mCRC) who had disease progression during or after prior treatment with fluoropyrimidine-, oxaliplatin-, or irinotecan-based chemotherapy. Key eligibility criteria were at least one prior line of treatment for metastatic disease, ECOG performance status 0 or 1, and absence of the following: active brain metastases, active autoimmune disease, or medical conditions requiring systemic immunosuppression.

Patients enrolled in the single agent Opdivo MSI-H mCRC cohort received Opdivo 3 mg/kg by intravenous infusion (IV) every 2 weeks. Patients enrolled in the Opdivo and ipilimumab MSI-H mCRC cohort received Opdivo 3 mg/kg and ipilimumab 1 mg/kg intravenously every 3 weeks for 4 doses, followed by Opdivo as a single agent at a dose of 3 mg/kg as intravenous infusion every 2 weeks. Treatment in both cohorts continued until unacceptable toxicity or radiographic progression.

Tumor assessments were conducted every 6 weeks for the first 24 weeks and every 12 weeks thereafter. Efficacy outcome measures included ORR and DOR as assessed by an IRRC using RECIST v1.1.

A total of 74 patients were enrolled in the single-agent MSI-H mCRC Opdivo cohort. The median age was 53 years (range: 26 to 79) with 23% ≥65 years of age and 5% ≥75 years of age, 59% were male and 88% were White. Baseline ECOG performance status was 0 (43%), 1 (55%), or 3 (1.4%) and 36% were reported to have Lynch Syndrome. Across the 74 patients, 72% received prior treatment with a fluoropyrimidine, oxaliplatin, and irinotecan; 7%, 30%, 28%, 19%, and 16% received 0, 1, 2, 3, or ≥4 prior lines of therapy for metastatic disease, respectively, and 42% of patients had received an anti-EGFR antibody.

A total of 119 patients were enrolled in the Opdivo and ipilimumab MSI-H mCRC cohort. The median age was 58 years (range: 21 to 88), with 32% ≥65 years of age and 9% ≥75 years of age; 59% were male and 92% were White. Baseline ECOG performance status was 0 (45%) and 1 (55%), and 29% were reported to have Lynch Syndrome. Across the 119 patients, 69% had received prior treatment with a fluoropyrimidine, oxaliplatin, and irinotecan; 10%, 40%, 24%, and 15% received 1, 2, 3, or ≥4 prior lines of therapy for metastatic disease, respectively, and 29% had received an anti-EGFR antibody.

Efficacy results for each of these single-arm cohorts are shown in Table 36.

Table 36: Efficacy Results - CHECKMATE-142
a  Estimated using the Clopper-Pearson method.
b  In the monotherapy cohort, 55% of the 20 patients with ongoing responses were followed for <12 months from the date of onset of response. In the combination cohort, 78% of the 51 patients with ongoing responses were followed for <12 months from the date of onset of response.

Opdivo
MSI-H/dMMR Cohort

Opdivo and Ipilimumab
MSI-H/dMMR Cohort

All Patients
(n=74)

Prior Treatment
(Fluoropyrimidine, Oxaliplatin, and Irinotecan)
(n=53)

All Patients
(n=119)

Prior Treatment
(Fluoropyrimidine, Oxaliplatin, and Irinotecan)
(n=82)

IRRC Overall Response Rate; n (%)

24 (32%)

15 (28%)

58 (49%)

38 (46%)

     (95% CI)a

(22, 44)

(17, 42)

(39, 58)

(35, 58)

     Complete Response (%)

2 (2.7%)

1 (1.9%)

5 (4.2%)

3 (3.7%)

     Partial Response (%)

22 (30%)

14 (26%)

53 (45%)

35 (43%)

Duration of Response

     Proportion with ≥6 months response duration

63%

67%

83%

89%

     Proportion with ≥12b months response duration

38%

40%

19%

21%

Hepatocellular Carcinoma

The efficacy of Opdivo was evaluated in a 154-patient subgroup of CHECKMATE-040 (NCT01658878), a multicenter, open-label trial conducted in patients with hepatocellular carcinoma (HCC) who progressed on or were intolerant to sorafenib. Additional eligibility criteria included histologic confirmation of HCC and Child-Pugh Class A. The trial excluded patients with active autoimmune disease, brain metastasis, a history of hepatic encephalopathy, clinically significant ascites, infection with HIV, or active co-infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) or HBV and hepatitis D virus (HDV); however, patients with only active HBV or HCV were eligible. Patients received Opdivo 3 mg/kg by intravenous infusion every 2 weeks. Tumor assessments were conducted every 6 weeks for 48 weeks and every 12 weeks thereafter. The major efficacy outcome measure was confirmed overall response rate, as assessed by BICR using RECIST v1.1 and modified RECIST (mRECIST) for HCC. Duration of response was also assessed.

The trial population characteristics were: median age was 63 years (range: 19 to 81), 77% were male, and 46% were White. Across the population, 31% had active HBV infection, 21% had active HCV infection, and 49% had no evidence of active HBV or HCV. The etiology for HCC was alcoholic liver disease in 18% and non-alcoholic liver disease in 6.5% of patients. Baseline ECOG performance status was 0 (65%) or 1 (35%). Child-Pugh class and score was A5 for 68%, A6 for 31%, and B7 for 1% of patients. Seventy-one percent (71%) of patients had extrahepatic spread, 29% had macrovascular invasion, and 37% had alfa-fetoprotein (AFP) levels ≥400 µg/L. Prior treatment history included surgical resection (66%), radiotherapy (24%), or locoregional treatment (58%). All patients had received prior sorafenib, of whom 36 (23%) were unable to tolerate sorafenib; 19% of patients had received 2 or more prior systemic therapies.

Efficacy results are shown in Table 37.

Table 37: Efficacy Results - CHECKMATE-040
a  Overall response rate confirmed by BICR.
b  Confidence interval is based on the Clopper and Pearson method.

Opdivo
(n=154)

Overall Response Ratea, n (%), RECIST v1.1

22 (14.3%)

          (95% CI)b

(9.2, 20.8)

     Complete response

3 (1.9%)

     Partial response

19 (12.3%)

Duration of Response, RECIST v1.1

(n=22)

     Range (months)

(3.2, 38.2+)

     % with duration ≥6 months

91%

     % with duration ≥12 months

55%

Overall Response Ratea, n (%), mRECIST

28 (18.2%)

          (95% CI)b

(12.4, 25.2)

      Complete response

5 (3.2%)

      Partial response

23 (14.9%)

How Supplied/Storage and Handling

Opdivo® (nivolumab) Injection is available as follows:

Carton Contents NDC

40 mg/4 mL single-dose vial

0003-3772-11

100 mg/10 mL single-dose vial

0003-3774-12

240 mg/24 mL single-dose vial

0003-3734-13

Store under refrigeration at 2°C to 8°C (36°F to 46°F). Protect from light by storing in the original package until time of use. Do not freeze or shake.

Patient Counseling Information

Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Immune-Mediated Adverse Reactions

Inform patients of the risk of immune-mediated adverse reactions that may require corticosteroid treatment and withholding or discontinuation of Opdivo, including:

Pneumonitis: Advise patients to contact their healthcare provider immediately for any new or worsening cough, chest pain, or shortness of breath [see Warnings and Precautions (5.1)].
Colitis: Advise patients to contact their healthcare provider immediately for diarrhea or severe abdominal pain [see Warnings and Precautions (5.2)].
Hepatitis: Advise patients to contact their healthcare provider immediately for jaundice, severe nausea or vomiting, pain on the right side of abdomen, lethargy, or easy bruising or bleeding [see Warnings and Precautions (5.3)].
Endocrinopathies: Advise patients to contact their healthcare provider immediately for signs or symptoms of hypophysitis, adrenal insufficiency, hypothyroidism, hyperthyroidism, and diabetes mellitus [see Warnings and Precautions (5.4)].
Nephritis and Renal Dysfunction: Advise patients to contact their healthcare provider immediately for signs or symptoms of nephritis including decreased urine output, blood in urine, swelling in ankles, loss of appetite, and any other symptoms of renal dysfunction [see Warnings and Precautions (5.5)].
Skin Adverse Reactions: Advise patients to contact their healthcare provider immediately for rash [see Warnings and Precautions (5.6)].
Encephalitis: Advise patients to contact their healthcare provider immediately for neurological signs or symptoms of encephalitis [see Warnings and Precautions (5.7)].

Infusion-Related Reactions

Advise patients of the potential risk of infusion-related reactions [see Warnings and Precautions (5.9)].

Complications of Allogeneic HSCT

Advise patients of potential risk of post-transplant complications [see Warnings and Precautions (5.10)].

Embryo-Fetal Toxicity

Advise females of reproductive potential of the potential risk to a fetus and to inform their healthcare provider of a known or suspected pregnancy [see Warnings and Precautions (5.11), Use in Specific Populations (8.1)].
Advise females of reproductive potential to use effective contraception during treatment with Opdivo and for at least 5 months following the last dose [see Use in Specific Populations (8.3)].

Lactation

Advise women not to breastfeed during treatment with Opdivo and for 5 months after the last dose [see Use in Specific Populations (8.2)].

Manufactured by:
Bristol-Myers Squibb Company
Princeton, NJ 08543 USA
U.S. License No. 1713

MEDICATION GUIDE

Opdivo® (op-DEE-voh)
(nivolumab)
Injection

Read this Medication Guide before you start receiving Opdivo and before each infusion. There may be new information. If your healthcare provider prescribes Opdivo in combination with ipilimumab (YERVOY®), also read the Medication Guide that comes with ipilimumab. This Medication Guide does not take the place of talking with your healthcare provider about your medical condition or your treatment.

What is the most important information I should know about Opdivo?

Opdivo is a medicine that may treat certain cancers by working with your immune system. Opdivo can cause your immune system to attack normal organs and tissues in any area of your body and can affect the way they work. These problems can sometimes become serious or life-threatening and can lead to death. These problems may happen anytime during treatment or even after your treatment has ended. Some of these problems may happen more often when Opdivo is used in combination with ipilimumab.

Call or see your healthcare provider right away if you develop any symptoms of the following problems or these symptoms get worse:

Lung problems (pneumonitis). Symptoms of pneumonitis may include:

new or worsening cough
chest pain
shortness of breath

Intestinal problems (colitis) that can lead to tears or holes in your intestine. Signs and symptoms of colitis may include:

diarrhea (loose stools) or more bowel movements than usual
blood in your stools or dark, tarry, sticky stools
severe stomach-area (abdomen) pain or tenderness

Liver problems (hepatitis). Signs and symptoms of hepatitis may include:

yellowing of your skin or the whites of your eyes
severe nausea or vomiting
pain on the right side of your stomach area (abdomen)
drowsiness
dark urine (tea colored)
bleeding or bruising more easily than normal
feeling less hungry than usual
decreased energy

Hormone gland problems (especially the thyroid, pituitary, adrenal glands, and pancreas). Signs and symptoms that your hormone glands are not working properly may include:

headaches that will not go away or unusual headaches
extreme tiredness
weight gain or weight loss
dizziness or fainting
changes in mood or behavior, such as decreased sex drive, irritability, or forgetfulness
hair loss
feeling cold
constipation
voice gets deeper
excessive thirst or lots of urine

Kidney problems, including nephritis and kidney failure. Signs of kidney problems may include:

decrease in the amount of urine
blood in your urine
swelling in your ankles
loss of appetite

Skin Problems. Signs of these problems may include:

rash
itching
skin blistering
ulcers in mouth or other mucous membranes

Inflammation of the brain (encephalitis). Signs and symptoms of encephalitis may include:

headache
fever
tiredness or weakness
confusion
memory problems
sleepiness
seeing or hearing things that are not really there (hallucinations)
seizures
stiff neck

Problems in other organs. Signs of these problems may include:

changes in eyesight
severe or persistent muscle or joint pains
severe muscle weakness
chest pain

Getting medical treatment right away may keep these problems from becoming more serious.

Your healthcare provider will check you for these problems during treatment with Opdivo. Your healthcare provider may treat you with corticosteroid or hormone replacement medicines. Your healthcare provider may also need to delay or completely stop treatment with Opdivo, if you have severe side effects.

What is Opdivo?

Opdivo is a prescription medicine used to treat:

people with a type of skin cancer called melanoma:
o
Opdivo may be used alone or in combination with ipilimumab to treat melanoma that has spread or cannot be removed by surgery (advanced melanoma), or
o
Opdivo may be used alone to help prevent melanoma from coming back after it and lymph nodes that contain cancer have been removed by surgery.
people with a type of advanced stage lung cancer (called non-small cell lung cancer).
Opdivo may be used when your lung cancer:
o
has spread or grown, and
o
you have tried chemotherapy that contains platinum, and it did not work or is no longer working.
 
If your tumor has an abnormal EGFR or ALK gene, you should have also tried an FDA-approved therapy for tumors with these abnormal genes, and it did not work or is no longer working.
people with a type of lung cancer called small cell lung cancer.
Opdivo may be used when your lung cancer:
o
has spread or grown, and
o
you have tried at least two different types of chemotherapy, including one that contains platinum, and it did not work or is no longer working.
people with kidney cancer (renal cell carcinoma).
o
Opdivo may be used alone when your cancer has spread or grown after treatment with other cancer medicines.
o
Opdivo may be used in combination with ipilimumab in certain people when their cancer has spread.
adults with a type of blood cancer called classical Hodgkin lymphoma.
Opdivo may be used if:
o
your cancer has come back or spread after a type of stem cell transplant that uses your own stem cells (autologous), and
o
you used the drug brentuximab vedotin (Adcetris®) before or after your stem cell transplant, or
o
you received at least 3 kinds of treatment including a stem cell transplant that uses your own stem cells (autologous).
people with head and neck cancer (squamous cell carcinoma)
Opdivo may be used when your head and neck cancer:
o
has come back or spread, and
o
you have tried chemotherapy that contains platinum and it did not work or is no longer working.
people with bladder cancer (urothelial carcinoma).
Opdivo may be used when your bladder cancer:
o
has spread or grown, and
o
you have tried chemotherapy that contains platinum, and it did not work or is no longer working.
adults and children 12 years of age and older, with a type of colon or rectal cancer (colorectal cancer)
Opdivo may be used alone or in combination with ipilimumab when your colon or rectal cancer:
o
has spread to other parts of the body (metastatic),
o
is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR), and
o
you have tried treatment with a fluoropyrimidine, oxaliplatin, and irinotecan, and it did not work or is no longer working.
people with liver cancer (hepatocellular carcinoma)
o
Opdivo may be used after you have received treatment with sorafenib (Nexavar®).

It is not known if Opdivo is safe and effective when used alone:

in children younger than 12 years of age with MSI-H or dMMR metastatic colorectal cancer, or
in children younger than 18 years of age for the treatment of any other cancers.

What should I tell my healthcare provider before receiving Opdivo?

Before you receive Opdivo, tell your healthcare provider if you:

have immune system problems such as Crohn’s disease, ulcerative colitis, or lupus
have had an organ transplant
have lung or breathing problems
have liver problems
have any other medical conditions
are pregnant or plan to become pregnant. Opdivo can harm your unborn baby.
o
Females who are able to become pregnant should use an effective method of birth control during and for at least 5 months after the last dose of Opdivo. Talk to your healthcare provider about birth control methods that you can use during this time.
o
Tell your healthcare provider right away if you become pregnant during treatment with Opdivo.
are breastfeeding or plan to breastfeed. It is not known if Opdivo passes into your breast milk. Do not breastfeed during treatment with Opdivo.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

Know the medicines you take. Keep a list of them to show your healthcare providers and pharmacist when you get a new medicine.

How will I receive Opdivo?

Your healthcare provider will give you Opdivo into your vein through an intravenous (IV) line over 30 minutes.
Opdivo is usually given every 2 weeks or 4 weeks depending on the dose you are receiving.
When used in combination with ipilimumab, Opdivo is usually given every 3 weeks, for a total of 4 doses. Ipilimumab will be given on the same day. After that, Opdivo will be given alone every 2 weeks or 4 weeks depending on the dose you are receiving.
Your healthcare provider will decide how many treatments you need.
Your healthcare provider will do blood tests to check you for side effects.
If you miss any appointments, call your healthcare provider as soon as possible to reschedule your appointment.

What are the possible side effects of Opdivo?

Opdivo can cause serious side effects, including:

See “What is the most important information I should know about Opdivo?”
Severe infusion reactions. Tell your doctor or nurse right away if you get these symptoms during an infusion of Opdivo:
o
chills or shaking
o
itching or rash
o
flushing
o
difficulty breathing
o
dizziness
o
fever
o
feeling like passing out
Complications of stem cell transplant that uses donor stem cells (allogeneic). These complications can be severe and can lead to death. Your healthcare provider will monitor you for signs of complications if you have an allogeneic stem cell transplant.

The most common side effects of Opdivo when used alone include:

feeling tired
rash
pain in muscles, bones, and joints
itchy skin
diarrhea
nausea
weakness
cough
vomiting
shortness of breath
constipation
decreased appetite
back pain
upper respiratory tract infection
fever
headache
abdominal pain

The most common side effects of Opdivo when used in combination with ipilimumab include:

feeling tired
rash
diarrhea
nausea
fever
pain in muscles, bones, and joints
upper respiratory tract infection
itching
abdominal pain
vomiting
cough
decreased appetite
shortness of breath

These are not all the possible side effects of Opdivo.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

General information about the safe and effective use of Opdivo.

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. If you would like more information about Opdivo, talk with your healthcare provider. You can ask your healthcare provider for information about Opdivo that is written for health professionals.

What are the ingredients in Opdivo?

Active ingredient: nivolumab

Inactive ingredients: mannitol, pentetic acid, polysorbate 80, sodium chloride, sodium citrate dihydrate, and Water for Injection. May contain hydrochloric acid and/or sodium hydroxide.

Manufactured by: Bristol-Myers Squibb Company, Princeton, NJ 08543 USA U.S. License No. 1713

Opdivo® and YERVOY® are trademarks of Bristol-Myers Squibb Company. Other brands listed are the trademarks of their respective owners.

For more information, call 1-855-673-4861 or go to www.Opdivo.com.

This Medication Guide has been approved by the U.S. Food and Drug Administration.

Revised: March 2019

Opdivo 40 mg/4 mL Representative Packaging

See How Supplied section for a complete list of available packages of Opdivo.

NDC 0003-3772-11
Rx only

Opdivo®
(nivolumab)
injection

40 mg/4 mL
(10 mg/mL)

For intravenous Infusion Only
Single-dose vial; Discard unused portion.
Please provide enclosed Medication Guide to the patient.

Bristol-Myers Squibb

Opdivo 100 mg/10 mL Representative Packaging

NDC 0003-3774-12
Rx only

Opdivo®
(nivolumab)
injection

100 mg/10 mL
(10 mg/mL)

For Intravenous Infusion Only
Single-dose vial; Discard unused portion.
Please provide enclosed Medication Guide to the patient.

Bristol-Myers Squibb

Opdivo 240 mg/24 mL Representative Packaging

NDC 0003-3734-13
Rx only

Opdivo®
(nivolumab)
injection

240 mg/24 mL
(10 mg/mL)

For Intravenous Infusion Only
Single-dose vial; Discard unused portion.
Please provide enclosed Medication Guide to the patient.

Bristol-Myers Squibb

Opdivo 
nivolumab injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0003-3772
Route of Administration INTRAVENOUS DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NIVOLUMAB (NIVOLUMAB) NIVOLUMAB 10 mg  in 1 mL
Inactive Ingredients
Ingredient Name Strength
MANNITOL 30 mg  in 1 mL
PENTETIC ACID 0.008 mg  in 1 mL
POLYSORBATE 80 0.2 mg  in 1 mL
SODIUM CHLORIDE 2.92 mg  in 1 mL
TRISODIUM CITRATE DIHYDRATE 5.88 mg  in 1 mL
WATER  
HYDROCHLORIC ACID  
SODIUM HYDROXIDE  
Packaging
# Item Code Package Description
1 NDC:0003-3772-11 1 VIAL, SINGLE-DOSE in 1 CARTON
1 4 mL in 1 VIAL, SINGLE-DOSE
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
BLA BLA125554 12/22/2014
Opdivo 
nivolumab injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0003-3774
Route of Administration INTRAVENOUS DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NIVOLUMAB (NIVOLUMAB) NIVOLUMAB 10 mg  in 1 mL
Inactive Ingredients
Ingredient Name Strength
MANNITOL 30 mg  in 1 mL
PENTETIC ACID 0.008 mg  in 1 mL
POLYSORBATE 80 0.2 mg  in 1 mL
SODIUM CHLORIDE 2.92 mg  in 1 mL
TRISODIUM CITRATE DIHYDRATE 5.88 mg  in 1 mL
WATER  
HYDROCHLORIC ACID  
SODIUM HYDROXIDE  
Packaging
# Item Code Package Description
1 NDC:0003-3774-12 1 VIAL, SINGLE-DOSE in 1 CARTON
1 10 mL in 1 VIAL, SINGLE-DOSE
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
BLA BLA125554 12/22/2014
Opdivo 
nivolumab injection
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0003-3734
Route of Administration INTRAVENOUS DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NIVOLUMAB (NIVOLUMAB) NIVOLUMAB 10 mg  in 1 mL
Inactive Ingredients
Ingredient Name Strength
MANNITOL 30 mg  in 1 mL
PENTETIC ACID 0.008 mg  in 1 mL
POLYSORBATE 80 0.2 mg  in 1 mL
SODIUM CHLORIDE 2.92 mg  in 1 mL
TRISODIUM CITRATE DIHYDRATE 5.88 mg  in 1 mL
WATER  
HYDROCHLORIC ACID  
SODIUM HYDROXIDE  
Packaging
# Item Code Package Description
1 NDC:0003-3734-13 1 VIAL, SINGLE-DOSE in 1 CARTON
1 24 mL in 1 VIAL, SINGLE-DOSE
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
BLA BLA125554 12/08/2017
Labeler - E.R. Squibb & Sons, L.L.C. (011550092)
 
E.R. Squibb & Sons, L.L.C.
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