Source: European Medicines Agency (EU) Revision Year: 2023 Publisher: AstraZeneca AB, SE-151 85 Södertälje, Sweden
IMJUDO in combination with durvalumab is indicated for the first line treatment of adults with advanced or unresectable hepatocellular carcinoma (HCC).
Treatment must be initiated and supervised by a physician experienced in the treatment of cancer.
The recommended dose of IMJUDO is presented in Table 1. IMJUDO is administered as an intravenous infusion over 1 hour.
Table 1. Recommended dose of IMJUDO:
Indication | Recommended IMJUDO dosage | Duration of Therapy |
---|---|---|
Advanced or unresectable HCC | IMJUDO 300 mga as a single dose administered in combination with durvalumab 1500 mga at Cycle 1/Day 1, followed by durvalumab monotherapy every 4 weeks | Until disease progression or unacceptable toxicity |
a For IMJUDO, HCC patients with a body weight of 40 kg or less must receive weight-based dosing, equivalent to IMJUDO 4 mg/kg until weight is greater than 40 kg. For durvalumab, patients with a body weight of 30 kg or less must receive weight-based dosing, equivalent to durvalumab 20 mg/kg until weight is greater than 30 kg.
Dose escalation or reduction is not recommended during treatment with IMJUDO in combination with durvalumab. Treatment withholding or discontinuation may be required based on individual safety and tolerability.
Guidelines for management of immune-mediated adverse reactions are described in Table 2 (see section 4.4). Refer also to the summary of product characteristics (SmPC) for durvalumab.
Table 2. Treatment modifications and management recommendations for IMJUDO in combination with durvalumab:
Adverse reactions | Severitya | Treatment modification | Corticosteroid treatment unless otherwise specifiedb |
---|---|---|---|
Immune-mediated pneumonitis/interstitial lung disease | Grade 2 | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Grade 3 or 4 | Permanently discontinue | ||
Immune-mediated hepatitis | ALT or AST > 3 - ≤ 5 x ULN or total bilirubin > 1.5 - ≤ 3 x ULN | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
ALT or AST > 5 - ≤ 10 x ULN | Withhold durvalumab and permanently discontinue IMJUDO (where appropriate) | ||
Concurrent ALT or AST > 3 x ULN and total bilirubin > 2 x ULNd | Permanently discontinue | ||
ALT or AST > 10 x ULN or total bilirubin > 3 x ULN | |||
Immune-mediated hepatitis in HCC (or secondary tumour involvement of the liver with abnormal baseline values)e | ALT or AST > 2.5 - ≤ 5 x BLV and ≤ 20 x ULN | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
ALT or AST > 5 – 7 x BLV and ≤ 20 x ULN or concurrent ALT or AST 2.5 – 5 x BLV and ≤ 20 x ULN and total bilirubin > 1.5 - < 2 x ULNd | Withhold durvalumab and permanently discontinue IMJUDO (where appropriate) | ||
ALT or AST > 7 x BLV or > 20 x ULN whichever occurs first or bilirubin > 3 x ULN | Permanently discontinue | ||
Immune-mediated colitis or diarrhoea | Grade 2 | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Grade 3 or 4 | Permanently discontinue | ||
Intestinal perforation of ANY grade | Permanently discontinue | Consult a surgeon immediately if an intestinal perforation is suspected | |
Immune-mediated hyperthyroidism, thyroiditis | Grade 2-4 | Withhold dose until clinically stable | Symptomatic management |
Immune-mediated hypothyroidism | Grade 2-4 | No changes | Initiate thyroid hormone replacement as clinically indicated |
Immune-mediated adrenal insufficiency, hypophysitis/hypopituitarism | Grade 2-4 | Withhold dose until clinically stable | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper and hormone replacement as clinically indicated |
Immune-mediated Type 1 diabetes mellitus | Grade 2-4 | No changes | Initiate treatment with insulin as clinically indicated |
Immune-mediated nephritis | Grade 2 with serum creatinine > 1.5-3 x (ULN or baseline) | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Grade 3 with serum creatinine > 3 x baseline or > 3-6 x ULN; Grade 4 with serum creatinine > 6 x ULN | Permanently discontinue | ||
Immune-mediated rash or dermatitis (including pemphigoid) | Grade 2 for > 1 week or Grade 3 | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Grade 4 | Permanently discontinue | ||
Immune-mediated myocarditis | Grade 2-4 | Permanently discontinue | Initiate 2 to 4 mg/kg/day prednisone or equivalent followed by a taperf |
Immune-mediated myositis/polymyositis | Grade 2 or 3 | Withhold dosec,g | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Grade 4 | Permanently discontinue | ||
Infusion-related reactions | Grade 1 or 2 | Interrupt or slow the rate of infusion | May consider pre- medications for prophylaxis of subsequent infusion reactions |
Grade 3 or 4 | Permanently discontinue | Manage severe infusion-related reactions per institutional standard, appropriate clinical practice guidelines and/or society guidelines | |
Immune-mediated myasthenia gravis | Grade 2-4 | Permanently discontinue | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Immune-mediated encephalitis | Grade 2-4 | Permanently discontinue | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Other immune-mediated adverse reactionsh | Grade 2 or 3 | Withhold dosec | Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper |
Grade 4 | Permanently discontinue | ||
Non-immune-mediated adverse reactions | Grade 2 and 3 | Withhold dose until ≤ Grade 1 or return to baseline | |
Grade 4 | Permanently discontinuei |
a Common Terminology Criteria for Adverse Events, version 4.03. ALT: alanine aminotransferase; AST: aspartate aminotransferase; ULN: upper limit of normal; BLV: baseline value.
b Upon improvement to ≤ Grade 1, corticosteroid taper should be initiated and continued over at least 1 month.
Consider increasing dose of corticosteroids and/or using additional systemic immunosuppressants if there is worsening or no improvement.
c After withholding, IMJUDO and/or durvalumab can be resumed within 12 weeks if the adverse reactions improved to ≤ Grade 1 and the corticosteroid dose has been reduced to ≤10 mg prednisone or equivalent per day. IMJUDO and durvalumab should be permanently discontinued for recurrent Grade 3 adverse reactions, as applicable.
d For patients with alternative cause follow the recommendations for AST or ALT increases without concurrent bilirubin elevations.
e If AST and ALT are less than or equal to ULN at baseline in patients with liver involvement, withhold or permanently discontinue durvalumab based on recommendations for hepatitis with no liver involvement.
f If no improvement within 2 to 3 days despite corticosteroids, promptly start additional immunosuppressive therapy. Upon resolution (Grade 0), corticosteroid taper should be initiated and continued over at least 1 month.
g Permanently discontinue IMJUDO and durvalumab if the adverse reaction does not resolve to ≤ Grade 1 within 30 days or if there are signs of respiratory insufficiency.
h Includes immune thrombocytopenia and pancreatitis.
i With the exception of Grade 4 laboratory abnormalities, about which the decision to discontinue treatment should be based on accompanying clinical signs/symptoms and clinical judgment.
For suspected immune-mediated adverse reactions, adequate evaluation should be performed to confirm aetiology or exclude alternate aetiologies.
The safety and efficacy of IMJUDO in children and adolescents below 18 years of age have not been established. No data are available.
No dose adjustment is required for elderly patients (≥65 years of age) (see section 5.2).
No dose adjustment of IMJUDO is recommended in patients with mild or moderate renal impairment. Data from patients with severe renal impairment are too limited to draw conclusions on this population (see section 5.2).
No dose adjustment of IMJUDO is recommended for patients with mild or moderate hepatic impairment. IMJUDO has not been studied in patients with severe hepatic impairment (see section 5.2).
IMJUDO is for intravenous use.
Administer IMJUDO prior to durvalumab on the same day.
IMJUDO and durvalumab are administered as separate intravenous infusions. Refer to the SmPC for durvalumab administration information.
For instructions on dilution of the medicinal product before administration, see section 6.6.
There is no information on overdose with tremelimumab. In case of overdose, patients should be closely monitored for signs or symptoms of adverse reactions, and appropriate symptomatic treatment instituted immediately.
Unopened vial:
4 years at 2°C-8°C.
Diluted solution:
Chemical and physical in-use stability has been demonstrated for up to 28 days at 2°C to 8°C and for up to 48 hours at room temperature (up to 25°C) from the time of preparation.
From a microbiological point of view, the prepared solution for infusion should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C or 12 hours at room temperature (up to 25°C), unless dilution has taken place in controlled and validated aseptic conditions.
Lack of microbial growth in the prepared solution for infusion has been demonstrated for up to 28 days at 2°C to 8°C and for up to 48 hours at room temperature (up to 25°C) from the time of preparation.
Store in a refrigerator (2°C-8°C).
Do not freeze.
Store in the original package in order to protect from light.
For storage conditions after dilution of the medicinal product, see section 6.3.
Two pack sizes of IMJUDO are available:
Not all pack sizes may be marketed.
Preparation of solution:
IMJUDO is supplied as a single-dose vial and does not contain any preservatives, aseptic technique must be observed.
Administration:
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
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