Drug Detail:Lunsumio (Mosunetuzumab-axgb)
Drug Class: Miscellaneous antineoplastics
Highlights of Prescribing Information
LUNSUMIO™ (mosunetuzumab-axgb) injection, for intravenous use
Initial U.S. Approval: 2022
WARNING: CYTOKINE RELEASE SYNDROME
See full prescribing information for complete boxed warning.
Cytokine release syndrome (CRS), including serious or life-threatening reactions, can occur in patients receiving LUNSUMIO. Initiate treatment with the LUNSUMIO step-up dosing schedule to reduce the risk of CRS. Withhold LUNSUMIO until CRS resolves or permanently discontinue based on severity. (2.1, 2.4, 5.1)
Indications and Usage for Lunsumio Injection
LUNSUMIO is a bispecific CD20-directed CD3 T-cell engager indicated for the treatment of adult patients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy.
This indication is approved under accelerated approval based on response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s). (1.1)
Lunsumio Injection Dosage and Administration
- Premedicate to reduce risk of cytokine release syndrome and infusion-related reactions. (2.3, 5.1)
- Administer only as an intravenous infusion. (2.1)
- Recommended dosage:
- Cycle 1 Day 1 – 1 mg
- Cycle 1 Day 8 – 2 mg
- Cycle 1 Day 15 – 60 mg
- Cycle 2 Day 1 – 60 mg
- Cycle 3+ Day 1 – 30 mg
See Full Prescribing Information for instructions on preparation and administration. (2.5)
Dosage Forms and Strengths
Injection:
- 1 mg/mL solution in a single-dose vial. (3)
- 30 mg/30 mL (1 mg/mL) solution in a single-dose vial. (3)
Contraindications
None. (4)
Warnings and Precautions
- Neurologic Toxicity: Can cause serious neurologic toxicity, including Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS). Monitor patients for signs and symptoms of neurologic toxicity during treatment; withhold or permanently discontinue based on severity. (5.2)
- Infections: Can cause serious or fatal infections. Monitor patients for signs and symptoms of infection, including opportunistic infections, and treat as needed. (5.3)
- Cytopenias: Monitor complete blood cell counts during treatment. (5.4)
- Tumor Flare: Can cause serious tumor flare reactions. Monitor patients at risk for complications of tumor flare. (5.5)
- Embryo-Fetal Toxicity: May cause fetal harm. Advise females of reproductive potential of the potential risk to the fetus and to use effective contraception. (5.6, 8.1, 8.3)
Adverse Reactions/Side Effects
The most common adverse reactions (≥ 20%) are cytokine release syndrome, fatigue, rash, pyrexia, and headache.
The most common Grade 3 to 4 laboratory abnormalities (≥ 10%) are decreased lymphocyte count, decreased phosphate, increased glucose, decreased neutrophil count, increased uric acid, decreased white blood cell count, decreased hemoglobin, and decreased platelets. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Genentech at 1-888-835-2555 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
Use In Specific Populations
Lactation: Advise not to breastfeed. (8.2)
See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.
Revised: 12/2022
Related/similar drugs
rituximab, Revlimid, Rituxan, lenalidomide, Ruxience, TruximaFull Prescribing Information
WARNING: CYTOKINE RELEASE SYNDROME
Cytokine release syndrome (CRS), including serious or life-threatening reactions, can occur in patients receiving LUNSUMIO. Initiate treatment with the LUNSUMIO step-up dosing schedule to reduce the risk of CRS. Withhold LUNSUMIO until CRS resolves or permanently discontinue based on severity [see Dosage and Administration (2.1 and 2.4) and Warnings and Precautions (5.1)].
1. Indications and Usage for Lunsumio Injection
1.1 Follicular Lymphoma
LUNSUMIO is indicated for the treatment of adult patients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy.
This indication is approved under accelerated approval based on response rate [see Clinical Studies (14.1)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).
2. Lunsumio Injection Dosage and Administration
2.1 Important Dosing Information
- Administer LUNSUMIO to well-hydrated patients.
- Premedicate before each dose in Cycle 1 and Cycle 2 [see Dosage and Administration (2.2)].
- Administer only as an intravenous infusion through a dedicated infusion line. Do not use an in-line filter to administer LUNSUMIO. Drip chamber filters can be used to administer LUNSUMIO.
- LUNSUMIO should only be administered by a qualified healthcare professional with appropriate medical support to manage severe reactions such as cytokine release syndrome and neurologic toxicity [see Warnings and Precautions (5.1 and 5.2)].
2.2 Recommended Dosage
The recommended dosage for LUNSUMIO is presented in Table 1.
Administer for 8 cycles, unless patients experience unacceptable toxicity or disease progression.
For patients who achieve a complete response, no further treatment beyond 8 cycles is required. For patients who achieve a partial response or have stable disease in response to treatment with LUNSUMIO after 8 cycles, an additional 9 cycles of treatment (17 cycles total) should be administered, unless a patient experiences unacceptable toxicity or disease progression.
Day of Treatment | Dose of LUNSUMIO | Rate of Infusion | |
---|---|---|---|
Cycle 1 | Day 1 | 1 mg | Administer over a minimum of 4 hours. |
Day 8 | 2 mg | ||
Day 15 | 60 mg | ||
Cycle 2 | Day 1 | 60 mg | Administer over 2 hours if infusions from Cycle 1 were well-tolerated. |
Cycles 3+ | Day 1 | 30 mg |
Last Dose Administered | Time Since the Last Dose Administered | Action for Next Dose(s) |
---|---|---|
|
||
1 mg Cycle 1 Day 1 | 1 to 2 weeks | Administer 2 mg (Cycle 1 Day 8), then resume the planned treatment schedule. |
Greater than 2 weeks | Repeat 1 mg (Cycle 1 Day 1), then administer 2 mg (Cycle 1 Day 8) and resume the planned treatment schedule. | |
2 mg Cycle 1 Day 8 | 1 to 2 weeks | Administer 60 mg (Cycle 1 Day 15), then resume the planned treatment schedule. |
Greater than 2 weeks to less than 6 weeks | Repeat 2 mg (Cycle 1 Day 8), then administer 60 mg (Cycle 1 Day 15) and resume the planned treatment schedule. | |
Greater than or equal to 6 weeks | Repeat 1 mg (Cycle 1 Day 1) and 2 mg (Cycle 1 Day 8), then administer 60 mg (Cycle 1 Day 15) and resume the planned treatment schedule. | |
60 mg Cycle 1 Day 15 | 1 week to less than 6 weeks | Administer 60 mg (Cycle 2 Day 1), then resume the planned treatment schedule. |
Greater than or equal to 6 weeks | Repeat 1 mg (Cycle 2 Day 1) and 2 mg (Cycle 2 Day 8), then administer 60 mg (Cycle 2 Day 15), followed by 30 mg (Cycle 3 Day 1) and then resume the planned treatment schedule. | |
60 mg Cycle 2 Day 1 | 3 weeks to less than 6 weeks | Administer 30 mg (Cycle 3 Day 1), then resume the planned treatment schedule. |
Greater than or equal to 6 weeks | Repeat 1 mg (Cycle 3 Day 1) and 2 mg (Cycle 3 Day 8), then administer 30 mg (Cycle 3 Day 15)*, followed by 30 mg (Cycle 4 Day 1) and then resume the planned treatment schedule. | |
30 mg Cycle 3 onwards | 3 weeks to less than 6 weeks | Administer 30 mg, then resume the planned treatment schedule. |
Greater than or equal to 6 weeks | Repeat 1 mg on Day 1 and 2 mg on Day 8 during the next cycle, then administer 30 mg on Day 15*, followed by 30 mg on Day 1 of subsequent cycles. |
2.3 Recommended Premedication and Prophylactic Medication
Premedication to reduce the risk of cytokine release syndrome and infusion-related reactions are outlined in Table 3 [see Warnings and Precautions (5.1)].
Treatment Cycle | Patients Requiring Premedication | Premedication | Dosage | Administration |
---|---|---|---|---|
Cycle 1 and Cycle 2 | All patients | Corticosteroid | Dexamethasone 20 mg intravenous or methylprednisolone 80 mg intravenous | Complete at least 1 hour prior to infusion |
Antihistamine | Diphenhydramine hydrochloride 50 mg – 100 mg or equivalent oral or intravenous antihistamine | At least 30 minutes prior to infusion | ||
Antipyretic | Oral acetaminophen (500 mg – 1,000 mg) | At least 30 minutes prior to infusion | ||
Cycles 3+ | Patients who experienced any grade CRS with the previous dose | Corticosteroid | Dexamethasone 20 mg intravenous or methylprednisolone 80 mg intravenous | Complete at least 1 hour prior to infusion |
Antihistamine | Diphenhydramine hydrochloride 50 mg – 100 mg or equivalent oral or intravenous antihistamine | At least 30 minutes prior to infusion | ||
Antipyretic | Oral acetaminophen (500 mg – 1,000 mg) | At least 30 minutes prior to infusion |
2.4 Dosage Modifications for Adverse Reactions
See Tables 4 and 5 for the recommended dosage modifications for adverse reactions of CRS and neurologic toxicity, including Immune Effector Cell Associated Neurotoxicity (ICANS). See Table 6 for the recommended dosage modifications for other adverse reactions following administration of LUNSUMIO.
Dosage Modifications for Cytokine Release Syndrome
Identify cytokine release syndrome (CRS) based on clinical presentation [see Warnings and Precautions (5.1)]. Evaluate for and treat other causes of fever, hypoxia, and hypotension.
If CRS is suspected, withhold LUNSUMIO until CRS resolves, manage according to the recommendations in Table 4 and per current practice guidelines. Administer supportive therapy for CRS, which may include intensive care for severe or life-threatening CRS.
Grade* | Presenting Symptoms | Actions† |
---|---|---|
|
||
Grade 1 | Fever ≥ 100.4°F (38°C)‡ |
|
Grade 2 | Fever ≥ 100.4°F (38°C)‡ with: Hypotension not requiring vasopressors and/or hypoxia requiring low-flow oxygen# by nasal cannula or blow-by. |
|
Recurrent Grade 2 CRS
|
||
Grade 3 | Fever ≥ 100.4°F (38°C)‡ with: Hypotension requiring a vasopressor (with or without vasopressin) and/or hypoxia requiring high flow oxygen# by nasal cannula, face mask, non-rebreather mask, or Venturi mask. |
|
Recurrent Grade 3 CRS
|
||
Grade 4 | Fever ≥ 100.4°F (38°C)‡ with: Hypotension requiring multiple vasopressors (excluding vasopressin) and/or hypoxia requiring oxygen by positive pressure (e.g., CPAP, BiPAP, intubation and mechanical ventilation). |
|
Dosage Modifications for Neurologic Toxicity, including ICANS
Management recommendations for neurologic toxicity, including ICANS, is summarized in Table 5. At the first sign of neurologic toxicity, including ICANS, withhold LUNSUMIO and consider neurology evaluation. Rule out other causes of neurologic symptoms. Provide supportive therapy, which may include intensive care.
Adverse Reaction | Severity*,† | Actions |
---|---|---|
|
||
Neurologic Toxicity*
(Including ICANS†) | Grade 2 |
|
Grade 3 |
|
|
Grade 4 |
|
Adverse Reactions* | Severity* | Actions |
---|---|---|
|
||
Infections [see Warnings and Precautions (5.3)] | Grades 1 – 4 |
|
Neutropenia [see Warnings and Precautions (5.4)] | Absolute neutrophil count less than 0.5 × 109/L |
|
Other Adverse Reactions [see Warnings and Precautions (5.5) and Adverse Reactions (6.1)] | Grade 3 or higher |
|
2.5 Preparation and Administration
Dilution
- 1.
- Withdraw the volume from an infusion bag of 0.9% Sodium Chloride Injection, USP or 0.45% Sodium Chloride Injection, USP equal to the volume of the LUNSUMIO required for the patient's dose and discard. Only use infusion bags made of polyvinyl chloride (PVC) or polyolefin (PO) such as polyethylene (PE) and polypropylene.
- 2.
- Withdraw the required volume of LUNSUMIO from the vial using a sterile needle and syringe and dilute into the infusion bag of 0.9% Sodium Chloride Injection, USP or 0.45% Sodium Chloride Injection, USP according to Table 7. Discard any unused portion left in the vial.
Dose of LUNSUMIO | Volume of LUNSUMIO in 0.9% or 0.45% Sodium Chloride Solution | Size of Infusion Bag |
---|---|---|
1 mg | 1 mL | 50 mL or 100 mL |
2 mg | 2 mL | 50 mL or 100 mL |
60 mg | 60 mL | 100 mL or 250 mL |
30 mg | 30 mL | 50 mL, 100 mL, or 250 mL |
- 3.
- Gently mix the intravenous bag by slowly inverting the bag. Do not shake.
- 4.
- Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if visibly opaque particles, discoloration, or foreign particles are observed.
- 5.
- Apply the peel-off label from the package insert to the infusion bag.
- 6.
- Immediately use diluted LUNSUMIO infusion solution. If not used immediately, the diluted solution can be stored refrigerated at 2°C to 8°C (36°F to 46°F) for up to 24 hours and at ambient temperature 9°C to 30°C (48°F to 86°F) for up to 16 hours. Prior to administration, ensure the infusion solution comes to reach room temperature.
3. Dosage Forms and Strengths
LUNSUMIO is a sterile, colorless solution available as:
- Injection: 1 mg/mL mosunetuzumab-axgb of solution in a single-dose vial
- Injection: 30 mg/30 mL (1 mg/mL) mosunetuzumab-axgb of solution in a single-dose vial
5. Warnings and Precautions
5.1 Cytokine Release Syndrome
LUNSUMIO can cause cytokine release syndrome (CRS), including serious or life-threatening reactions [see Adverse Reactions (6.1)].
Cytokine release syndrome occurred in 39% of patients who received LUNSUMIO at the recommended dose in the clinical trial, with Grade 1 CRS occurring in 28%, Grade 2 in 15%, Grade 3 in 2%, and Grade 4 in 0.5% of patients. Recurrent CRS occurred in 11% of patients. Most patients experienced CRS following doses of 1 mg on Cycle 1 Day 1 (15%), 2 mg on Cycle 1 Day 8 (5%), and 60 mg on Cycle 1 Day 15 (33%). Five percent of patients experienced CRS after receiving 60 mg on Cycle 2 Day 1 with 1% of patients experiencing CRS following subsequent dosages of LUNSUMIO.
The median time to onset of CRS from the start of administration in Cycle 1 Day 1 was 5 hours (range: 1 hour to 3 days), Cycle 1 Day 8 was 28 hours (range: 5 hours to 3 days), Cycle 1 Day 15 was 25 hours (range: 0.1 hours to 16 days), and Cycle 2 Day 1 was 46 hours (range: 12 hours to 3 days). The median duration of CRS was 3 days (range: 1 to 29 days).
Clinical signs and symptoms of CRS included, but were not limited to, fever, chills, hypotension, tachycardia, hypoxia, and headache. Concurrent neurologic adverse reactions occurred in 6% of patients and included but were not limited to headache, confusional state, and anxiety.
Initiate therapy according to LUNSUMIO step-up dosing schedule to reduce the risk of CRS [see Dosage and Administration (2.3)]. Administer pretreatment medications to reduce the risk of CRS, ensure adequate hydration, and monitor patients following administration of LUNSUMIO accordingly.
At the first sign of CRS, immediately evaluate patients for hospitalization, manage per current practice guidelines and administer supportive care; withhold or permanently discontinue LUNSUMIO based on severity [see Dosage and Administration (2.4)].
Patients who experience CRS (or other adverse reactions that impair consciousness) should be evaluated and advised not to drive and to refrain from operating heavy or potentially dangerous machinery until resolution.
5.2 Neurologic Toxicity
LUNSUMIO can cause serious neurologic toxicity, including Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) [see Adverse Reactions (6.1)].
Neurologic toxicity occurred in 39% of patients who received LUNSUMIO at the recommended dose in the clinical trial, with Grade 3 neurologic toxicity occurring in 3% of patients. The most frequent neurologic toxicities were headache (21%), peripheral neuropathy (13%), dizziness (11%), and mental status changes (6%, including confusional state, disturbance in attention, cognitive disorder, delirium, encephalopathy, and somnolence). ICANS was reported in 1% of patients (Grade 1: 0.5%, Grade 2: 0.5%) who received LUNSUMIO at the recommended dose in the clinical trial.
Coadministration of LUNSUMIO with other products that cause dizziness or mental status changes may increase the risk of neurologic toxicity.
Monitor patients for signs and symptoms of neurologic toxicity during treatment. At the first sign of neurologic toxicity, including ICANS, immediately evaluate the patient, consider neurology evaluation as appropriate, and provide supportive therapy based on severity; withhold or permanently discontinue LUNSUMIO based on severity and follow management recommendations [see Dosage and Administration (2.4)].
Patients who experience neurologic toxicity such as tremors, dizziness, insomnia, severe neurotoxicity, or any other adverse reactions that impair consciousness should be evaluated, including potential neurology evaluation, and patients at increased risk should be advised not to drive and to refrain from operating heavy or potentially dangerous machinery until resolution.
5.3 Infections
LUNSUMIO can cause serious or fatal infections [see Adverse Reactions (6.1)].
Among patients who received LUNSUMIO at the recommended dose in the clinical trial, serious infections, including opportunistic infections, occurred in 17%, with Grade 3 or 4 infections in 14%, and fatal infections in 0.9% of patients. The most common Grade 3 or greater infections were pneumonia, sepsis, and upper respiratory tract infection.
Monitor patients for signs and symptoms of infection prior to and during treatment with LUNSUMIO and treat appropriately. LUNSUMIO should not be administered in the presence of active infection. Caution should be exercised when considering the use of LUNSUMIO in patients with a history of recurring or chronic infections (e.g., chronic, active Epstein-Barr Virus), with underlying conditions that may predispose to infections or who have had significant prior immunosuppressive treatment. Administer prophylactic antimicrobials according to guidelines.
Withhold LUNSUMIO or consider permanent discontinuation of LUNSUMIO based on severity [see Dosage and Administration (2.4)].
5.4 Cytopenias
LUNSUMIO can cause serious or severe cytopenias, including neutropenia, anemia, and thrombocytopenia [see Adverse Reactions (6.1)].
Among patients who received the recommended dosage in the clinical trial, Grade 3 or 4 decreased neutrophils occurred in 38%, decreased hemoglobin in 19%, and decreased platelets in 12% of patients. Grade 4 decreased neutrophils occurred in 19% and decreased platelets in 5% of patients. Febrile neutropenia occurred in 2%.
Monitor complete blood counts throughout treatment. Based on the severity of cytopenias, temporarily withhold, or permanently discontinue LUNSUMIO. Consider prophylactic granulocyte colony-stimulating factor administration as applicable [see Dosage and Administration (2.4)].
5.5 Tumor Flare
LUNSUMIO can cause serious or severe tumor flare [see Adverse Reactions (6.1)].
Among patients who received LUNSUMIO at the recommended dosage in the clinical trial, tumor flare occurred in 4% of patients. Manifestations included new or worsening pleural effusions, localized pain and swelling at the sites of lymphoma lesions, and tumor inflammation.
Patients with bulky tumors or disease located in close proximity to airways or a vital organ should be monitored closely during initial therapy. Monitor for signs and symptoms of compression or obstruction due to mass effect secondary to tumor flare. If compression or obstruction develops, institute standard treatment of these complications.
5.6 Embryo-Fetal Toxicity
Based on its mechanism of action, LUNSUMIO may cause fetal harm when administered to a pregnant woman. Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with LUNSUMIO and for 3 months after the last dose [see Use in Specific Populations (8.1, 8.3)].
6. Adverse Reactions/Side Effects
The following adverse reactions are described elsewhere in the labeling:
- Cytokine Release Syndrome [see Warnings and Precautions (5.1)]
- Neurologic Toxicity [see Warnings and Precautions (5.2)]
- Infections [see Warnings and Precautions (5.3)]
- Cytopenias [see Warnings and Precautions (5.4)]
- Tumor Flare [see Warnings and Precautions (5.5)]
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The pooled safety population described in the WARNINGS AND PRECAUTIONS reflects exposure to LUNSUMIO as a single agent in GO29781 in 218 patients with hematologic malignancies in an open-label, multicenter, multi-cohort study. Patients received step-up doses of 1 mg on Cycle 1 Day 1 and 2 mg on Cycle 1 Day 8, followed by 60 mg on Cycle 1 Day 15, and 60 mg on Cycle 2 Day 1, then 30 mg every 3 weeks in subsequent cycles. A treatment cycle was 21 days. Among 218 patients who received LUNSUMIO, 52% were exposed for at least 8 cycles and 8% were exposed for 17 cycles.
In this pooled safety population, the most common (≥ 20%) adverse reactions were cytokine release syndrome (39%), fatigue (36%), rash (34%), pyrexia (24%), and headache (21%). The most common Grade 3 to 4 laboratory abnormalities (≥ 10%) were decreased lymphocyte count (92%), decreased phosphate (41%), increased glucose (40%), decreased neutrophil count (38%), increased uric acid (15%), decreased white blood cell count (22%), decreased hemoglobin (19%), and decreased platelets (12%).
Relapsed or Refractory Follicular Lymphoma
GO29781
The safety of LUNSUMIO was evaluated in GO29781, an open-label, multicenter, multi-cohort study which included a cohort of 90 patients with relapsed or refractory follicular lymphoma (FL) [see Clinical Studies (14)]. In this cohort, patients with relapsed or refractory FL were required to have received at least two prior lines of systemic therapy, including an anti-CD20 monoclonal antibody and an alkylating agent. Patients received step-up doses of 1 mg on Cycle 1 Day 1 and 2 mg on Cycle 1 Day 8, followed by 60 mg on Cycle 1 Day 15 and 60 mg on Cycle 2 Day 1, then 30 mg every 3 weeks in subsequent cycles. A treatment cycle was 21 days. The median number of cycles was 8 (range: 1 – 17). In the relapsed or refractory FL cohort, 77% were exposed for at least 8 cycles and 12% were exposed for 17 cycles.
The median age of the patients who received LUNSUMIO in the relapsed or refractory FL cohort was 60 years (range: 29 to 90 years), 61% were male, 82% were White, 4% were Black or African American, 9% were Asian, and 8% were Hispanic or Latino.
Serious adverse reactions occurred in 47% of patients who received LUNSUMIO. Serious adverse reactions in ≥ 2% of patients included cytokine release syndrome, infection (including urinary tract infection, sepsis, pneumonia, EBV viremia, and COVID-19), renal insufficiency, pyrexia, and tumor flare.
Permanent discontinuation of LUNSUMIO due to an adverse reaction occurred in 3% of patients. Adverse reactions resulting in permanent discontinuation of LUNSUMIO included cytokine release syndrome and EBV viremia.
Dosage interruptions of LUNSUMIO due to an adverse reaction occurred in 37% of patients. Adverse reactions which required dosage interruption in ≥ 5% of patients included neutropenia, infection, and cytokine release syndrome.
Table 8 summarizes the adverse reactions in patients with relapsed or refractory FL in GO29781.
Adverse Reaction* | LUNSUMIO (N = 90) |
|
---|---|---|
All Grades (%) | Grade 3 or 4 (%) |
|
|
||
Immune system disorders | ||
Cytokine release syndrome | 44 | 2.2 |
General disorders and administration site conditions | ||
Fatigue† | 42 | 0 |
Pyrexia | 29 | 1.1‡ |
Edema§ | 17 | 1.1 |
Chills | 13 | 1.1‡ |
Skin and subcutaneous tissue disorders | ||
Rash¶ | 39 | 4.4‡ |
Pruritus | 21 | 0 |
Dry skin | 16 | 0 |
Skin exfoliation | 10 | 0 |
Nervous system | ||
Headache# | 32 | 1.1‡ |
Peripheral neuropathyÞ | 20 | 0 |
Dizzinessß | 12 | 0 |
Musculoskeletal and connective tissue disorders | ||
Musculoskeletal painà | 28 | 1.1‡ |
Arthralgia | 11 | 0 |
Respiratory, thoracic, and mediastinal disorders | ||
Coughè | 22 | 0 |
Dyspneað | 11 | 1.1‡ |
Gastrointestinal disorders | ||
Diarrhea | 17 | 0 |
Nausea | 17 | 0 |
Abdominal painø | 12 | 1.1‡ |
Infections | ||
Upper respiratory tract infectioný | 14 | 2.2‡ |
Urinary tract infection£ | 10 | 1.1‡ |
Psychiatric disorder | ||
Insomnia | 12 | 0 |
Clinically relevant adverse reactions in < 10% of patients who received LUNSUMIO included pneumonia, sepsis, COVID-19, EBV viremia, mental status changes, tumor lysis syndrome, renal insufficiency, anxiety, motor dysfunction (including ataxia, gait disturbance and tremor), and tumor flare.
Table 9 summarizes the laboratory abnormalities in patients with relapsed or refractory FL in GO29781.
Laboratory Abnormality | LUNSUMIO* | |
---|---|---|
All Grades (%) | Grade 3 or 4 (%) |
|
|
||
Hematology | ||
Lymphocyte count decreased | 100 | 98 |
Hemoglobin decreased | 68 | 12 |
White blood cells decreased | 60 | 13 |
Neutrophils decreased | 58 | 40 |
Platelets decreased | 46 | 10 |
Chemistry | ||
Phosphate decreased | 78 | 46 |
Glucose increased | 42 | 42 |
Aspartate aminotransferase increased | 39 | 4.4 |
Gamma-glutamyl transferase increased | 34 | 9 |
Magnesium decreased | 34 | 0 |
Potassium decreased | 33 | 6 |
Alanine aminotransferase increased | 32 | 7 |
Uric acid increased | 22 | 22 |
8. Use In Specific Populations
8.3 Females and Males of Reproductive Potential
LUNSUMIO may cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)].
8.4 Pediatric Use
The safety and efficacy of LUNSUMIO have not been established in pediatric patients.
8.5 Geriatric Use
Among the 90 patients with relapsed or refractory follicular lymphoma treated with LUNSUMIO, 33% were 65 years of age or older, and 8% were 75 years of age or older. There is an insufficient number of patients 65 years of age or older and 75 years of age or older to assess whether there are differences in safety or effectiveness in patients 65 years of age and older compared to younger adult patients.
11. Lunsumio Injection Description
Mosunetuzumab-axgb is a bispecific CD20-directed CD3 T-cell engager. It is a humanized monoclonal anti-CD20xCD3 T-cell-dependent bispecific antibody of the immunoglobulin G1 (IgG1) isotype. Mosunetuzumab-axgb is produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology. The approximate molecular weight is 146 kDa.
LUNSUMIO (mosunetuzumab-axgb) injection is a sterile, preservative-free, colorless solution for intravenous use.
Each single-dose vial contains a 1 mL solution of mosunetuzumab-axgb (1 mg), acetic acid (0.4 mg), histidine (1.6 mg), methionine (1.5 mg), polysorbate 20 (0.6 mg), sucrose (82.1 mg), and Water for Injection, USP. The pH is 5.8.
Each single-dose vial contains a 30 mL solution of mosunetuzumab-axgb (30 mg), acetic acid (12.8 mg), histidine (46.6 mg), methionine (44.8 mg), polysorbate 20 (18 mg), sucrose (2,462.4 mg), and Water for Injection, USP. The pH is 5.8.
12. Lunsumio Injection - Clinical Pharmacology
12.1 Mechanism of Action
Mosunetuzumab-axgb is a T-cell engaging bispecific antibody that binds to the CD3 receptor expressed on the surface of T-cells and CD20 expressed on the surface of lymphoma cells and some healthy B-lineage cells.
In vitro, mosunetuzumab-axgb activated T-cells, caused the release of proinflammatory cytokines, and induced lysis of B-cells.
12.2 Pharmacodynamics
After administration of the recommended dosage of LUNSUMIO, peripheral B-cell counts decreased to undetectable levels (< 5 cells/microliter) in most patients (92%) by Cycle 2 Day 1 and the depletion was sustained at later cycles including at Cycle 4 and Cycle 8.
LUNSUMIO caused hypogammaglobulinemia (defined as IgG levels < 500 mg/dL). Among 67 patients with baseline IgG levels ≥ 500 mg/dL, 40% had their IgG level decreased to < 500 mg/dL after administration of the recommended dosage of LUNSUMIO.
Plasma concentrations of cytokines (IL-2, IL-6, IL-10, TNF-α, and IFN-γ) were measured, and transient elevation of cytokines were observed at doses of 0.4 mg and above. After administration of the recommended dosage of LUNSUMIO, the highest elevation of cytokines was observed within 24 hours after first dose on Cycle 1 Day 1 and after the first 60 mg dose on Cycle 1 Day 15. The elevated cytokine levels generally returned to baseline prior to the next infusion on Cycle 1 Day 8 and on Cycle 2 Day 1. Limited data is available in subsequent treatment cycles.
12.3 Pharmacokinetics
Mosunetuzumab-axgb PK exposure increased proportionally over a dose range from 0.2 mg to 60 mg (0.007 to 2 times the recommended treatment dosage). PK exposures are summarized for the recommended dosage of LUNSUMIO in Table 10 and Figure 1.
AUC (day∙μg/mL)* | Cmax (μg/mL)* | Ctrough (μg/mL)* | |
---|---|---|---|
|
|||
Cycle 1 (0 ‒ 21 days) | 35.2 (36.6) | 11.1 (36.7) | 2.57 (54.0) |
Cycle 2 (21 ‒ 42 days) | 90.3 (48.5) | 13.6 (37.7) | 1.97 (83.1) |
Steady state† | 52.9 (40.7) | 7.02 (37.9) | 1.29 (59.9) |
Figure 1. Model-Predicted Mosunetuzumab Concentration Time Profile
12.6 Immunogenicity
The observed incidence of anti-drug antibodies is highly dependent on the sensitivity and specificity of the assay. Differences in assay methods preclude meaningful comparisons of the incidence of anti-drug antibodies in the study described below with the incidence of anti-drug antibodies in other studies, including those of mosunetuzumab-axgb.
During treatment in Study GO29781 (up to 12 months) [see Clinical Studies (14)], using an enzyme-linked immunosorbent assay (ELISA), no patients (N = 418) treated with LUNSUMIO developed anti-mosunetuzumab-axgb antibodies. Based on these data, the clinical relevance of anti-mosunetuzumab-axgb antibodies could not be assessed.
13. Nonclinical Toxicology
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No carcinogenicity or genotoxicity studies have been conducted with mosunetuzumab-axgb.
No dedicated studies have been conducted to evaluate the effects of mosunetuzumab-axgb on fertility. No adverse effects on either male or female reproductive organs were identified in a 26-week repeat dose chronic toxicity study in sexually mature cynomolgus monkeys.
14. Clinical Studies
The efficacy of LUNSUMIO was evaluated in an open-label, multicenter, multi-cohort study (GO29781, NCT02500407) in patients with relapsed or refractory follicular lymphoma (FL) who had received at least two prior therapies, including an anti-CD20 monoclonal antibody and an alkylating agent. The study excluded patients with active infections, history of autoimmune disease, prior allogeneic transplant, or any history of CNS lymphoma or CNS disorders.
Patients received step-up doses of 1 mg on Cycle 1 Day 1 and 2 mg on Cycle 1 Day 8, followed by 60 mg on Cycle 1 Day 15, and 60 mg on Cycle 2 Day 1, then 30 mg every 3 weeks in subsequent cycles. A treatment cycle was 21 days. LUNSUMIO was administered for 8 cycles unless patients experienced progressive disease or unacceptable toxicity. After 8 cycles, patients with a complete response discontinued therapy; patients with a partial response or stable disease continued treatment up to 17 cycles, unless patients experienced progressive disease or unacceptable toxicity.
Among the 90 patients with relapsed or refractory FL, the median age was 60 years (range: 29 to 90 years), 33% were 65 years of age or older, 61% were male, 82% were White, 9% were Asian, 4% were Black or African American, and 8% were Hispanic or Latino. A total of 77% of patients had Stage III-IV disease, 34% had bulky disease, and all patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. The median number of prior therapies was 3 (range: 2 to 10), with 38% receiving 2 prior therapies, 31% receiving 3 prior therapies, and 31% receiving more than 3 prior therapies.
Seventy-nine percent of patients were refractory to prior anti-CD20 monoclonal antibody therapy, 53% were refractory to both anti-CD20 monoclonal antibody and alkylator therapy, 9% received prior rituximab plus lenalidomide therapy, 21% received prior autologous stem cell transplant, and 3% received prior CAR T therapy. Fifty-two percent of patients had progression of disease within 24 months of first systemic therapy.
Efficacy was established on the basis of objective response rate (ORR) and duration of response (DOR) as assessed by an independent review facility according to standard criteria for NHL (Cheson 2007). The median follow-up for DOR was 14.9 months. The efficacy results are summarized in Table 11.
Response | LUNSUMIO N = 90 |
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CI = confidence interval; NR = not reached | |
|
|
Objective response rate (ORR), n (%) | 72 (80) |
(95% CI) | (70, 88) |
Complete response rate (CR), n (%) | 54 (60) |
(95% CI) | (49, 70) |
Partial response rate (PR), n (%) | 18 (20) |
(95% CI) | (12, 30) |
Duration of Response (DOR) | N = 72 |
Median DOR*,†, months (95% CI) | 22.8 (10, NR) |
Rate of Continued Response† | |
At 12 months, % | 62 |
(95% CI) | (50, 74) |
At 18 months, % | 57 |
(95% CI) | (44, 70) |
The median time to first response was 1.4 months (range: 1.1 to 8.9).
16. How is Lunsumio Injection supplied
LUNSUMIO (mosunetuzumab-axgb) injection is a sterile, colorless, preservative-free solution supplied as follows:
- One 1 mg/mL single-dose vial in a carton (NDC 50242-159-01)
- One 30 mg/30 mL (1 mg/mL) single-dose vial in a carton (NDC 50242-142-01).
17. Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Medication Guide).
LUNSUMIO
mosunetuzumab concentrate |
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LUNSUMIO
mosunetuzumab concentrate |
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Labeler - Genentech, Inc. (080129000) |
Establishment | |||
Name | Address | ID/FEI | Business Operations |
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Genentech, Inc. | 080129000 | ANALYSIS(50242-142, 50242-159) , MANUFACTURE(50242-142, 50242-159) , API MANUFACTURE(50242-142, 50242-159) |
Establishment | |||
Name | Address | ID/FEI | Business Operations |
---|---|---|---|
Roche Diagnostics GmbH | 315028860 | ANALYSIS(50242-142, 50242-159) |
Establishment | |||
Name | Address | ID/FEI | Business Operations |
---|---|---|---|
Roche Diagnostics GmbH | 323105205 | ANALYSIS(50242-142, 50242-159) |
Establishment | |||
Name | Address | ID/FEI | Business Operations |
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F. Hoffmann-La Roche Ltd | 485244961 | LABEL(50242-142, 50242-159) , PACK(50242-142, 50242-159) |
Establishment | |||
Name | Address | ID/FEI | Business Operations |
---|---|---|---|
Genentech, Inc. | 146373191 | ANALYSIS(50242-142, 50242-159) |