Gazyvaro 1 g Concentrate for Solution for Infusion: Indications, Dosage, Precautions, Adverse Effects
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Gazyvaro 1 g Concentrate for Solution for Infusion - Product Information

Manufacture: Roche
Country: Great Britain
Condition: B-cell Lymphoma (Burkitt Lymphoma), Chronic Lymphocytic Leukemia, Follicular Lymphoma
Class: Antineoplastic detoxifying agents
Form: Liquid solution, Intravenous (IV)
Ingredients: Obinutuzumab, L-histidine, L-histidine hydrochloride monohydrate, trehalose dihydrate, poloxamer 188, water for injections.

Name of the Medicinal Product

Gazyvaro 1,000 mg concentrate for solution for infusion.

Qualitative and Quantitative Composition

One vial of 40 mL concentrate contains 1,000 mg obinutuzumab, corresponding to a concentration before dilution of 25 mg/mL.

Obinutuzumab is a Type II humanised anti-CD20 monoclonal antibody of the IgG1 subclass derived by humanisation of the parental B-Ly1 mouse antibody and produced in the Chinese Hamster Ovary cell line by recombinant DNA technology.

For the full list of excipients, see section List of Excipients

Pharmaceutical Form

Concentrate for solution for infusion.

Clear, colourless to slightly brownish liquid.

Clinical Particulars

Therapeutic Indications

Chronic Lymphocytic Leukaemia (CLL)

Gazyvaro in combination with chlorambucil is indicated for the treatment of adult patients with previously untreated chronic lymphocytic leukaemia (CLL) and with comorbidities making them unsuitable for full-dose fludarabine based therapy (see section Pharmacodynamic Properties).

Follicular Lymphoma (FL)

Gazyvaro in combination with bendamustine followed by Gazyvaro maintenance is indicated for the treatment of patients with follicular lymphoma (FL) who did not respond or who progressed during or up to 6 months after treatment with rituximab or a rituximab-containing regimen.

Posology and Method of Administration

Gazyvaro should be administered under the close supervision of an experienced physician and in an environment where full resuscitation facilities are immediately available.

Posology

Prophylaxis and premedication for tumour lysis syndrome (TLS)

Patients with a high tumour burden and/or a high circulating lymphocyte count (>25 x 109/L) and/or renal impairment (CrCl <70 mL/min) are considered at risk of TLS and should receive prophylaxis. Prophylaxis should consist of adequate hydration and administration of uricostatics (e.g. allopurinol), or suitable alternative treatment such as urate oxidase (e.g.rasburicase), starting 12-24 hours prior to start of Gazyvaro infusion as per standard practice (see section Special Warnings and Precautions for Use). Patients should continue to receive repeated prophylaxis prior to each subsequent infusion, if deemed appropriate.

Prophylaxis and premedication for infusion related reactions (IRRs)

Premedication to reduce the risk of infusion related reactions is outlined in Table 1 and 2 (see also section Special Warnings and Precautions for Use). Corticosteroid premedication is recommended for patients with FL and mandatory for CLL patients in the first cycle (see Table 1). Premedication for subsequent infusions and other premedication should be administered as described below.

Hypotension, as a symptom of IRRs, may occur during Gazyvaro intravenous infusions. Therefore, withholding ofantihypertensive treatments should be considered for 12 hours prior to and throughout each Gazyvaro infusion and for the first hour after administration (see section Special Warnings and Precautions for Use).

Table 1 Premedication to be administered before Gazyvaro infusion to reduce the risk of infusion related reactions in patients with CLL (see section Special Warnings and Precautions for Use)
Day of treatment
cycle
Patients requiring
premedication
Premedication Administration
Cycle 1:
Day 1
All patients Intravenous corticosteroid1
(mandatory)
Completed at least 1 hour prior
to Gazyvaro infusion
Oral analgesic/anti-pyretic2 At least 30 minutes before
Gazyvaro infusion
Anti-histaminic medicine3
Cycle 1:
Day 2
All patients Intravenous corticosteroid1
(mandatory)
Completed at least 1 hour prior
to Gazyvaro infusion
Oral analgesic/anti-pyretic2 At least 30 minutes before
Gazyvaro infusion
Anti-histaminic medicine3
All subsequent
infusions
Patients with no IRR during
the previous infusion
Oral analgesic/anti-pyretic2 At least 30 minutes before
Gazyvaro infusion
Patients with an IRR (Grade 1
or 2) with the previous
infusion
Oral analgesic/anti-pyretic2
Anti-histaminic medicine3
Patients with a Grade 3 IRR
with the previous infusion OR
Patients with lymphocyte
counts>25*109/L prior to
next treatment
Intravenous corticosteroid1 Completed at least 1 hour prior
to Gazyvaro infusion
Oral analgesic/anti-pyretic2
Anti-histaminic medicine3
At least 30 minutes before
Gazyvaro infusion

1100 mg prednisone/prednisolone or 20 mg dexamethasone or 80 mg methylprednisolone.
Hydrocortisone should not be used as it has not been effective in reducing rates of IRR.
2 e.g. 1,000 mg acetaminophen/paracetamol
3 e.g. 50 mg diphenhydramine

Table 2 Premedication to be administered before Gazyvaro infusion to reduce the risk of infusion related reactions in patients with FL(see section Special Warnings and Precautions for Use)
Day of treatment
cycle
Patients requiring
premedication
Premedication Administration
Cycle 1:
Day 1
All patients Intravenous corticosteroid1
(recommended)
Completed at least 1 hour prior
to Gazyvaro infusion
Oral analgesic/anti-pyretic2 At least 30 minutes before
Gazyvaro infusion
Anti-histaminic medicine3
All subsequent
infusions
Patients with no IRR during
the previous infusion
Oral analgesic/anti-pyretic2 At least 30 minutes before
Gazyvaro infusion
Patients with an IRR (Grade 1
or 2) with the previous
infusion
Oral analgesic/anti-pyretic2
Anti-histaminic medicine3
Patients with a Grade 3 IRR
with the previous infusion OR
Patients with lymphocyte
counts>25 x 109/L prior to
next treatment
Intravenous corticosteroid1 Completed at least 1 hour prior
to Gazyvaro infusion
Oral analgesic/anti-pyretic2
Anti-histaminic medicine3
At least 30 minutes before
Gazyvaro infusion

1100 mg prednisone/prednisolone or 20 mg dexamethasone or 80 mg methylprednisolone.
Hydrocortisone should not be used as it has not been effective in reducing rates of IRR.
2 e.g. 1,000 mg acetaminophen/paracetamol
3 e.g. 50 mg diphenhydramine

Dose
Chronic lymphocytic leukaemia (CLL, in combination with chlorambucil1)

For patients with CLL the recommended dose of Gazyvaro in combination with chlorambucil is shown in Table 3.

Cycle 1

The recommended dose of Gazyvaro in combination with chlorambucil is 1,000 mg administered over Day 1 and Day 2, (or Day 1 continued), and on Day 8 and Day 15 of the first 28 day treatment cycle.

Two infusion bags should be prepared for the infusion on Days 1 and 2 (100 mg for Day 1 and 900 mg for Day 2). If the first bag is completed without modifications of the infusion rate or interruptions, the second bag may be administered on the same day (no dose delay necessary, no repetition of premedication), provided that appropriate time, conditions and medical supervision are available throughout the infusion. If there are any modifications of the infusion rate or interruptions during the first 100 mg the second bag must be administered the following day.

Cycles 2 - 6

The recommended dose of Gazyvaro in combination with chlorambucil is 1,000 mg administered on Day 1 of each cycle.

Table 3 Dose of Gazyvaro to be administered during 6 treatment cycles each of 28 days duration for patients with CLL
Cycle Day of treatment Dose of Gazyvaro
Cycle 1 Day 1 100 mg
Day 2
(or Day 1 continued)
900 mg
Day 8 1,000 mg
Day 15 1,000 mg
Cycles 2-6 Day 1 1,000 mg

1See section Pharmacodynamic Properties for information on chlorambucil dose

Duration of treatment

Six treatment cycles, each of 28 day duration.

Delayed or missed doses

If a planned dose of Gazyvaro is missed, it should be administered as soon as possible; do not wait until the next planned dose. The planned treatment interval for Gazyvaro should be maintained between doses.

Follicular lymphoma (FL)

For patients with FL, the recommended dose of Gazyvaro in combination with bendamustine is shown in Table 4.

Induction (in combination with bendamustine2)
Cycle 1

The recommended dose of Gazyvaro in combination with bendamustine is 1,000 mg administered on Day 1, Day 8 and Day 15 of the first 28 day treatment cycle.

Cycles 2-6

The recommended dose of Gazyvaro in combination with bendamustine is 1,000 mg administered on Day 1 of each 28 day treatment cycle.

Maintenance

Patients who respond to induction treatment (i.e. the initial 6 treatment cycles) with Gazyvaro in combination with bendamustine or have stable disease should continue to receive Gazyvaro 1,000 mg as single agent maintenance therapy once every 2 months for two years or until disease progression (whichever occurs first)

Table 4 Dose of Gazyvaro to be administered during 6 treatment cycles each of 28 days duration, followed by Gazyvaro maintenance for patients with FL
Cycle Day of treatment Dose of Gazyvaro
Cycle 1 Day 1 1,000 mg
Day 8 1,000 mg
Day 15 1,000 mg
Cycle 2-6 Day 1 1,000 mg
Maintenance Every two months for two years or
until disease progression
(whichever occurs first)
1,000 mg

2See section Pharmacodynamic Properties for information on bendamustine dose

Duration of treatment

Six treatment cycles, each of 28 day duration, followed by maintenance once every two months for two years or until disease progression (whichever occurs first).

Delayed or missed doses

If a planned dose of Gazyvaro is missed, it should be administered as soon as possible; do not wait until the next planned dose. During induction, the planned treatment interval for Gazyvaro should be maintained between doses. During maintenance, maintain the original dosing schedule for subsequent doses.

Dose modifications during treatment (all indications)

No dose reductions of Gazyvaro are recommended.

For management of symptomatic adverse events (including IRRs), see paragraph below (Management of IRRsor section Special Warnings and Precautions for Use).

Special populations

Elderly

No dose adjustment is required in elderly patients (see section Pharmacokinetic Properties).

Renal impairment

No dose adjustment is required in patients with mild to moderate renal impairment (creatinine clearance [CrCl] 30-89 mL/min) (see section Pharmacokinetic Properties). The safety and efficacy of Gazyvaro has not been established in patients with severe renal impairment (CrCl<30 mL/min).

Hepatic impairment

The safety and efficacy of Gazyvaro in patients with impaired hepatic function has not been established. No specific dose recommendations can be made.

Paediatric population

The safety and efficacy of Gazyvaro in children and adolescents aged below 18 years has not been established. No data are available.

Method of administration

Gazyvaro is for intravenous use. It should be given as an intravenous infusion through a dedicated line after dilution (see section Special Precautions for Disposal and Other Handling). Gazyvaro infusions should not be administered as an intravenous push or bolus.

For instructions on dilution of Gazyvaro before administration, see section Special Precautions for Disposal and Other Handling.

Instructions on the rate of infusion are shown in Tables 5-6.

Table 5 Standard infusion rate in the absence of infusion related reactions/hypersensitivity in patients with CLL (in case of infusion related reactions, see “Management of IRRs”)
Cycle Day of treatment Rate of infusion
Cycle 1 Day 1
(100 mg)
Administer at 25 mg/hr over 4 hours. Do not increase the
infusion rate.
Day 2
(or Day 1 continued)
(900 mg)
If no infusion related reaction occurred during the previous
infusion, administer at 50 mg/hr.
The rate of the infusion can be escalated in increments of 50
mg/hr every 30 minutes to a maximum rate of 400 mg/hr.
Day 8
(1,000 mg)
If no infusion related reaction occurred during the prior
infusion, when the final infusion rate was 100 mg/hr or faster,
infusions can be started at a rate of 100 mg/hr and increased
by 100 mg/hr increments every 30 minutes to a maximum of
400 mg/hr.
Day 15
(1,000 mg)
Cycles 2-6 Day 1
(1,000 mg)
Table 6 Standard infusion rates in the absence of infusion related reactions/hypersensitivity in patients with FL (in case of infusion related reactions, see “Management of IRRs”)
Cycle Day of treatment Rate of infusion
Cycle 1 Day 1
(1,000 mg)
Administer at 50 mg/hr. The rate of infusion can be
escalated in 50 mg/hr increments every 30 minutes to a
maximum of 400 mg/hr.
Day 8
(1,000 mg)
If no infusion related reaction occurred during the prior
infusion when the final infusion rate was 100 mg/hr or
faster, infusions can be started at a rate of 100 mg/hr and
increased by 100 mg/hr increments every 30 minutes to a Day 15
maximum of 400 mg/hr.
Day 15
(1,000 mg)
Cycles 2–6 Day 1
(1,000 mg)
Maintenance Every two months for two years or
until disease progression
(whichever occurs first)

Management of IRRs (all indications)

Management of IRRs may require temporary interruption, reduction in the rate of infusion, or treatment discontinuations of Gazyvaro as outlined below (see also section Special Warnings and Precautions for Use).

  • Grade 4 (life threatening): Infusion must be stopped and therapy must be permanently discontinued.
  • Grade 3 (severe): Infusion must be temporarily stopped and symptoms treated. Upon resolution of symptoms, the infusion can be restarted at no more than half the previous rate (the rate being used at the time that the IRR occurred) and, if the patient does not experience any IRR symptoms, the infusion rate escalation can resume at the increments and intervals as appropriate for the treatment dose (see Tables 5 and 6). For CLL patients receiving the Day 1 (Cycle 1) dose split over two days, the Day 1 infusion rate may be increased back up to 25 mg/hr after 1 hour, but not increased further. The infusion must be stopped and therapy permanently discontinued if the patient experiences a second occurrence of a Grade 3 IRR.
  • Grade 1-2 (mild to moderate): The infusion rate must be reduced and symptoms treated. Infusion can be continued upon resolution of symptoms and, if the patient does not experience any IRR symptoms, the infusion rate escalation can resume at the increments and intervals as appropriate for the treatment dose (see Tables 5 and 6). For CLL patients receiving the Day 1 (Cycle 1) dose split over the two days, the Day 1 infusion rate may be increased back up to 25 mg/hr after 1 hour, but not increased further.

Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section List of Excipients

Special Warnings and Precautions for Use

In order to improve the traceability of biological medicinal products, the trade name and batch number of the administered product should be clearly recorded (or stated) in the patient file.

Infusion Related Reactions (IRRs)

The most frequently observed adverse drug reactions (ADRs) in patients receiving Gazyvaro were IRRs, which occurred predominantly during infusion of the first 1,000 mg. IRRs may be related to cytokine release syndrome which has also been reported in Gazyvaro treated patients. In CLL patients who received the combined measures for prevention of IRRs (adequate corticosteroid, oral analgesic/anti-histamine, omission of antihypertensive medicine in the morning of the first infusion, and the Cycle 1 Day 1 dose administered over 2 days) as described in section Posology and Method of Administration, a decreased incidence of IRRs of all grades was observed. The rates of Grade 3-4 IRRs (which were based on a relatively small number of patients) were similar before and after mitigation measures were implemented. Mitigation measures to reduce IRRs should be followed (see section Posology and Method of Administration). The incidence and severity of infusion related symptoms decreased substantially after the first 1,000 mg was infused, with most patients having no IRRs during subsequent administrations of Gazyvaro (see section Undesirable Effects).

In the majority of patients, irrespective of indication, IRRs were mild to moderate and could be managed by the slowing or temporary halting of the first infusion, but severe and life-threatening IRRs requiring symptomatic treatment have also been reported. IRRs may be clinically indistinguishable from immunoglobulin E (IgE) mediated allergic reactions (e.g. anaphylaxis). Patients with a high tumour burden and/or high circulating lymphocyte count in CLL [> 25 x 109/L] may be at increased risk of severe IRRs. Patients with renal impairment (CrCl<50 mL/min) and patients with both Cumulative Illness Rating Scale (CIRS) > 6 and CrCl < 70 mL/min are more at risk of IRRs, including severe IRRs (see section Undesirable Effects).

If the patient experiences an IRR, the infusion should be managed according to the grade of the reaction.For Grade 3 IRRs, the infusion must be temporarily interrupted and appropriate medicine administered to treat the symptoms. For Grade 1-2 IRRs, the infusion must be slowed down and symptoms treated as appropriate. Upon resolution of symptoms, the infusion can be restarted, except following Grade 4 IRRs, at no more than half the previous rate and, if the patient does not experience the same adverse event with the same severity, the infusion rate escalation may resume at the increments and intervals as appropriate for the treatment dose. In CLL patients, if the previous infusion rate was not well tolerated, instructions for the Cycle 1, Day 1 and Day 2 infusion rate should be used for subsequent cycles(see Table 5 in section Posology and Method of Administration).

Patients must not receive further Gazyvaro infusions if they experience:

  • acute life-threatening respiratory symptoms,
  • a Grade 4 (i.e. life threatening) IRR or,
  • a second occurrence of a Grade 3 (prolonged/recurrent) IRR (after resuming the first infusion or during a subsequent infusion).

Patients who have pre-existing cardiac or pulmonary conditions should be monitored carefully throughout the infusion and the post-infusion period. Hypotension may occur during Gazyvaro intravenous infusions. Therefore, withholding of antihypertensive treatments should be considered for 12 hours prior to and throughout each Gazyvaro infusion and for the first hour after administration. Patients at acute risk of hypertensive crisis should be evaluated for the benefits and risks of withholding their anti-hypertensive medicine.

Hypersensitivity reactions including anaphylaxis

Anaphylaxis has been reported in patients treated with Gazyvaro. Hypersensitivity may be difficult to distinguish from IRRs. If a hypersensitivity reaction is suspected during infusion (e.g. symptoms typically occurring after previous exposure and very rarely with the first infusion), the infusion must be stopped and treatment permanently discontinued. Patients with known IgE mediated hypersensitivity to obinutuzumab must not be treated (see section Contraindications).

Tumour lysis syndrome (TLS)

Tumour lysis syndrome (TLS) has been reported with Gazyvaro. Patients who are considered to be at risk of TLS (e.g. patients with a high tumour burden and/or a high circulating lymphocyte count [> 25 x 109/L] and/or renal impairment [CrCl <70 mL/min]) should receive prophylaxis. Prophylaxis should consist of adequate hydration and administration of uricostatics (e.g. allopurinol), or a suitable alternative such as a urate oxidate (e.g. rasburicase) starting 12-24 hours prior to the infusion of Gazyvaro as per standard practice (see section Posology and Method of Administration). All patients considered at risk should be carefully monitored during the initial days of treatment with a special focus on renal function, potassium, and uric acid values. Any additional guidelines according to standard practice should be followed. For treatment of TLS, correct electrolyte abnormalities, monitor renal function and fluid balance, and administer supportive care, including dialysis as indicated.

Neutropenia

Severe and life-threatening neutropenia including febrile neutropenia has been reported during treatment with Gazyvaro. Patients who experience neutropenia should be closely monitored with regular laboratory tests until resolution. If treatment is necessary it should be administered in accordance with local guidelines and the administration of granulocyte-colony stimulating factors (G-CSF) should be considered. Any signs of concomitant infection should be treated as appropriate. Dose delays should be considered in case of severe or life-threatening neutropenia. It is strongly recommended that patients with severe neutropenia lasting more than 1 week receive antimicrobial prophylaxis throughout the treatment period until resolution to Grade 1 or 2. Antiviral and antifungal prophylaxis should also be considered (see section Posology and Method of Administration). Cases of late onset neutropenia (occurring >28 days after the end of treatment) or prolonged neutropenia (lasting more than 28 days after treatment has been completed/stopped) have also been reported. Patients with renal impairment (CrCl < 50 mL/min) are more at risk of neutropenia (see section Undesirable Effects).

Thrombocytopenia

Severe and life-threatening thrombocytopenia including acute thrombocytopenia (occurring within 24 hours after the infusion) has been observed during treatment with Gazyvaro. Patients with renal impairment (CrCl < 50 mL/min) are more at risk of thrombocytopenia (see section Undesirable Effects). Fatal haemorrhagic events have also been reported in Cycle 1 in patients treated with Gazyvaro. A clear relationship between thrombocytopenia and haemorrhagic events has not been established.

Patients should be closely monitored for thrombocytopenia, especially during the first cycle; regular laboratory tests should be performed until the event resolves, and dose delays should be considered in case of severe or life-threatening thrombocytopenia. Transfusion of blood products (i.e. platelet transfusion) according to institutional practice is at the discretion of the treating physician. Use of any concomitant therapies which could possibly worsen thrombocytopenia-related events, such as platelet inhibitors and anticoagulants, should also be taken into consideration, especially during the first cycle.

Worsening of pre-existing cardiac conditions

In patients with underlying cardiac disease, arrhythmias (such as atrial fibrillation and tachyarrhythmia), angina pectoris, acute coronary syndrome, myocardial infarction and heart failure have occurred when treated with Gazyvaro (see section Undesirable Effects). These events may occur as part of an IRR and can be fatal. Therefore patients with a history of cardiac disease should be monitored closely. In addition these patients should be hydrated with caution in order to prevent a potential fluid overload.

Infections

Gazyvaro should not be administered in the presence of an active infection and caution should be exercised when considering the use of Gazyvaro in patients with a history of recurring or chronic infections. Serious bacterial, fungal, and new or reactivated viral infections can occur during and following the completion of Gazyvaro therapy. Fatal infections have been reported. Patients with both CIRS > 6 and CrCl < 70 mL/min are more at risk of infections, including severe infections (see section Undesirable Effects).

Hepatitis B reactivation

Hepatitis B virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, hepatic failure and death, can occur in patients treated with anti-CD20 antibodies including Gazyvaro (see section Undesirable Effects). Hepatitis B virus screening should be performed in all patients before initiation of treatment with Gazyvaro. At a minimum this should include hepatitis B surface antigen (HBsAg) status and hepatitis B core antibody (HBcAb) status. These can be complemented with other appropriate markers as per local guidelines. Patients with active hepatitis B disease should not be treated with Gazyvaro. Patients with positive hepatitis B serology should consult liver disease experts before start of treatment and should be monitored and managed following local medical standards to prevent hepatitis reactivation.

Progressive multifocal leukoencephalopathy (PML)

Progressive multifocal leukoencephalopathy (PML) has been reported in patients treated with Gazyvaro (see section Undesirable Effects). The diagnosis of PML should be considered in any patient presenting with new-onset or changes to pre-existing neurologic manifestations. The symptoms of PML are nonspecific and can vary depending on the affected region of the brain. Motor symptoms with corticospinal tract findings (e.g. muscular weakness, paralysis and sensory disturbances), sensory abnormalities, cerebellar symptoms, and visual field defects are common. Some signs/symptoms regarded as "cortical" (e.g. aphasia or visual-spatial disorientation) may occur. Evaluation of PML includes, but is not limited to, consultation with a neurologist, brain magnetic resonance imaging (MRI), and lumbar puncture (cerebrospinal fluid testing for John Cunningham viral DNA). Therapy with Gazyvaro should be withheld during the investigation of potential PML and permanently discontinued in case of confirmed PML. Discontinuation or reduction of any concomitant chemotherapy or immunosuppressive therapy should also be considered. The patient should be referred to a neurologist for the evaluation and treatment of PML.

Immunisation

The safety of immunisation with live or attenuated viral vaccines following Gazyvaro therapy has not been studied and vaccination with live virus vaccines is not recommended during treatment and until B cell recovery.

Exposure in utero to obinutuzumab and vaccination of infants with live virus vaccines

Due to the potential depletion of B cells in infants of mothers who have been exposed to Gazyvaro during pregnancy, infants should be monitored for B cell depletion and vaccinations with live virus vaccines should be postponed until the infant's B cell count has recovered. The safety and timing of vaccination should be discussed with the infant's physician (see section Fertility, Pregnancy and Lactation).

Interaction With Other Medicinal Products and Other Forms of Interaction

No formal drug-drug interaction studies have been performed, although limited drug-drug interaction sub-studies have been undertaken for Gazyvaro with bendamustine, CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone), FC (fludarabine, cyclophosphamide) and chlorambucil.

A risk for interactions with other concomitantly used medicinal products cannot be excluded.

Pharmacokinetic interactions

Obinutuzumab is not a substrate, inhibitor, or inducer of cytochrome P450 (CYP450), uridine diphosphate glucuronyltransferase (UGT) enzymes and transporters such as P-glycoprotein. Therefore, no pharmacokinetic interaction is expected with drugs known to be metabolised by these enzyme systems.

Co-administration with Gazyvaro had no effect on the pharmacokinetics of bendamustine, FC, chlorambucil or the individual components of CHOP. In addition, there were no apparent effects of bendamustine, FC, chlorambucil or CHOP on the pharmacokinetics of Gazyvaro.

Pharmacodynamic interactions

Vaccination with live virus vaccines is not recommended during treatment and until B cell recovery because of the immunosuppressive effect of obinutuzumab (see section Special Warnings and Precautions for Use).

The combination of obinutuzumab with chlorambucil or bendamustine may increase neutropenia (see section Special Warnings and Precautions for Use).

Fertility, Pregnancy and Lactation

Women of childbearing potential

Women of childbearing potential must use effective contraception during and for 18 months after treatment with Gazyvaro.

Pregnancy

A reproduction study in cynomolgus monkeys showed no evidence of embryofoetal toxicity or teratogenic effects but resulted in a complete depletion of B lymphocytes in offspring. B cell counts returned to normal levels in the offspring, and immunologic function was restored within 6 months of birth. Serum concentrations of obinutuzumab in offspring were similar to those in the mothers on day 28 post-partum. Concentrations in milk on the same day were very low, suggesting that obinutuzumab crosses the placenta (see section Preclinical Safety Data). There are no data from the use of obinutuzumab in pregnant women. Gazyvaro should not be administered to pregnant women unless the possible benefit outweighs the potential risk.

In case of exposure during pregnancy, depletion of B cells may be expected in infants due to the pharmacological properties of the product. Postponing vaccination with live vaccines should be considered for infants born to mothers who have been exposed to Gazyvaro during pregnancy until the infant's B cell levels are within normal ranges (see section Special Warnings and Precautions for Use).

Breast-feeding

Animal studies have shown secretion of obinutuzumab in breast milk (see section Preclinical Safety Data).

Because human immunoglobulin G (IgG) is secreted in human milk and the potential for absorption and harm to the infant is unknown, women should be advised to discontinue breast-feeding during Gazyvaro therapy and for 18 months after the last dose of Gazyvaro.

Fertility

No specific studies in animals have been performed to evaluate the effect of obinutuzumab on fertility. No adverse effects on male and female reproductive organs were observed in repeat-dose toxicity studies in cynomolgus monkeys (see section Preclinical Safety Data).

Effects on Ability to Drive and Use Machines

Gazyvaro has no or negligible influence on the ability to drive and use machines. IRRs are very common during the first infusion of Gazyvaro, and patients experiencing infusion related symptoms should be advised not to drive or use machines until symptoms abate.

Undesirable Effects

Summary of the safety profile

The adverse drug reactions (ADRs) described in this section were identified during treatment and follow up in the two pivotal clinical studies, BO21004/CLL11, N=781, and GAO4753g, N=396 patients, in previously untreated CLL patients, and indolent Non Hodgkin Lymphoma (iNHL) patients (81.1% of the patients had FL) who had no response to or who progressed during or up to 6 months after treatment with rituximab or a rituximab-containing regimen. These trials investigated Gazyvaro in combination with different chemotherapeutic agents (chlorambucil for CLL, bendamustine for iNHL) and as maintenance monotherapy (in iNHL only). The protocol of study GAO4753g defined patients with iNHL including FL as the study population. Therefore, in order to provide the most comprehensive safety information, the analysis of ADRs presented in the following has been performed on the entire study population (i.e. iNHL).

Table 7 summarises the ADRs that occurred at a higher incidence (difference of ≥2%) in patients with CLL receiving Gazyvaro plus chlorambucil compared with chlorambucil alone or rituximab plus chlorambucil (study BO21004/CLL11) and in patients with iNHL receiving Gazyvaro plus bendamustine, followed by Gazyvaro maintenance in some patients, compared to bendamustine alone (study GAO4753g).

Frequencies are defined as very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare >(≥ 1/10,000 to < 1/1,000) and very rare (< 1/10,000). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Tabulated list of adverse reactions

Table 7 Summary of ADRs reported with a higher incidence (difference of ≥2%) in patients# receiving Gazyvaro + chemotherapy
Frequency All Grades
Gazyvaro + chlorambucil or
Gazyvaro + bendamustine (induction)
followed by Gazyvaro maintenance
Grades 3-5
Gazyvaro + chlorambucil or
Gazyvaro + bendamustine
(induction) followed by Gazyvaro
maintenance
Infections and infestations
Very common Upper respiratory tract infection,
sinusitis
Common Urinary tract infection, nasopharyngitis,
oral herpes, rhinitis, pharyngitis, lung
infection, influenza
Urinary tract infection
Uncommon Nasopharyngitis
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Common Squamous cell carcinoma of skin Squamous cell carcinoma of skin
Blood and lymphatic system disorders
Very common Neutropenia, thrombocytopenia,
anaemia
Neutropenia, thrombocytopenia
Common Leukopenia, lymph node pain Anaemia, leukopenia
Metabolism and nutrition disorders
Common Tumour lysis syndrome, hyperuricaemia Tumour lysis syndrome
Uncommon Hyperuricaemia
Psychiatric disorders
Common Depression
Eye disorders
Common Ocular hyperaemia
Cardiac disorders
Common Atrial fibrillation, cardiac failure
Uncommon Atrial fibrillation
Vascular disorders
Common Hypertension Hypertension
Respiratory, thoracic and mediastinal disorders
Very common Cough
Common Nasal congestion, Rhinorrhoea
Gastrointestinal disorders
Very common Diarrhoea, Constipation
Common Dyspepsia, Colitis, Haemorrhoids Diarrhoea
Skin and subcutaneous tissue disorders
Common Alopecia, pruritus, night sweats,
eczema
Musculoskeletal and connective tissue disorders
Very common Arthralgia
Common Back pain, musculoskeletal chest pain,
pain in extremity, bone pain
Uncommon Arthralgia, back pain, musculoskeletal
chest pain
Renal and Urinary Disorders
Common Dysuria, Urinary incontinence
General disorders and administration site conditions
Very common Pyrexia, Asthenia
Common Chest pain
Uncommon Pyrexia
Investigations
Common White blood cell count decreased,
neutrophil count decreased, weight
increased
White blood cell count decreased,
neutrophil count decreased
Injury, poisoning and procedural complications
Very common Infusion related reactions Infusion related reactions

# with a higher incidence (difference of ≥ 2% between the treatment arms). Only the highest frequency observed in the trials is reported (based on studies BO21004/ previously untreated CLL and GAO4753g/ rituximab refractory iNHL)
No Grade 5 adverse reactions have been observed with a difference of ≥ 2% between the treatment arms

In study GAO4753g, patients in the bendamustine (B) arm received 6 months of induction treatment only, whereas after the induction period, patients in the Gazyvaro plus bendamustine (G+B) arm continued with Gazyvaro maintenance treatment.

During the maintenance period in study GAO4753g, the most common adverse reactions were cough (15%), upper respiratory infections (12%), neutropenia (11%), sinusitis (10%), diarrhea (8%), infusion related reactions (8%), nausea (8%), fatigue (8%), bronchitis (7%), arthralgia (7%), pyrexia (6%), nasopharyngitis (6%), and urinary tract infections (6%). The most common Grade 3-5 adverse reactions were neutropenia (10%), and anaemia, febrile neutropenia, thrombocytopenia, sepsis, upper respiratory tract infection, and urinary tract infection (all at 1%).

The profile of adverse reactions in the subgroup of patients with FL was consistent with the overall iNHL population.

Description of selected adverse reactions

Infusion related reactions (IRRs)

Most frequently reported (≥5%) symptoms associated with an IRR were nausea, fatigue, chills, hypotension, pyrexia, vomiting, dyspnea, flushing, hypertension, headache, tachycardia, dizziness and diarrhoea. Respiratory and cardiac symptoms such as bronchospasm, larynx and throat irritation, wheezing, laryngeal oedema and atrial fibrillation have also been reported (see section Special Warnings and Precautions for Use).

Chronic Lymphocytic Leukaemia

The incidence of IRRs was higher in the Gazyvaro plus chlorambucil arm compared to the rituximab plus chlorambucil arm. The incidence of IRRs was 65% with the infusion of the first 1,000 mg of Gazyvaro (20% of patients experiencing a Grade 3-5 IRR, with no fatal events reported). Overall, 7% of patients experienced an IRR leading to discontinuation of Gazyvaro. The incidence of IRRs with subsequent infusions was 3% with the second 1,000 mg dose and 1% thereafter. No Grade 3-5 IRRs were reported beyond the first 1,000 mg infusions of Cycle 1.

In patients who received the combined measures for prevention of IRRs (adequate corticosteroid, oral analgesic/anti-histamine, omission of antihypertensive medication in the morning of the first infusion and the Cycle 1 Day 1 dose administered over 2 days) as described in section Posology and Method of Administration, decreased incidence of IRRs of all Grade was observed. The rates of Grade 3-4 IRRs (which occurred in relatively few patients) were similar before and after mitigation measures were implemented.

Indolent Non-Hodgkin Lymphoma including Follicular Lymphoma

In Cycle 1, the overall incidence of IRRs was higher in patients with Gazyvaro and bendamustine (G+B) (55%) compared to patients receiving B alone (42%) (with Grade 3-5 IRRs reported in 9% and 2%, respectively and no fatal events reported). In patients receiving G+B, the incidence of IRRs was highest on Day 1 (38%) and gradually decreased on Days 2, 8 and 15 (25%, 7% and 4%, respectively). During Cycle 2, the incidence of IRRs was lower in patients receiving G+B (24%) compared to patients receiving bendamustine (B) alone (32%). The incidence of IRRs in subsequent infusions was comparable in both arms and decreased with each cycle. IRRs were also observed in 8% of patients during the Gazyvaro maintenance period. Overall, 3% of patients experienced an infusion related reaction leading to discontinuation of Gazyvaro.

Neutropenia and infections

Chronic Lymphocytic Leukaemia

The incidence of neutropenia was higher in the Gazyvaro plus chlorambucil arm (41%) compared to the rituximab plus chlorambucil arm with the neutropenia resolving spontaneously or with use of granulocyte-colony stimulating factors. The incidence of infection was 38% in the Gazyvaro plus chlorambucil arm and 37% in the rituximab plus chlorambucil arm (with Grade 3-5 events reported in 12% and 14%, respectively and fatal events reported in < 1% in both treatment arms). Cases of prolonged neutropenia (2% in the Gazyvaro plus chlorambucil arm and 4% in the rituximab plus chlorambucil arm) and late onset neutropenia (16% in the Gazyvaro plus chlorambucil arm and 12% in the rituximab plus chlorambucil arm) were also reported (see section Special Warnings and Precautions for Use).

Indolent Non-Hodgkin Lymphoma including Follicular Lymphoma

The incidence of neutropenia was higher in the Gazyvaro plus bendamustine (G+B) arm compared to the bendamustine (B) alone arm (38% and 32%, respectively). The incidence of infection was 65% in the G+B arm and 56% in the B arm (with Grade 3-5 events reported in 18% and 17%, respectively, and fatal events reported in 5 patients (3%) in the G+B and 7 patients (4%) in the B arm).

Cases of prolonged neutropenia (3% in the G+B arm) and late onset neutropenia (7% in the G+B arm) were also reported (See section Special Warnings and Precautions for Use).

Thrombocytopenia

Chronic Lymphocytic Leukaemia

The incidence of thrombocytopenia was higher in the Gazyvaro plus chlorambucil arm (15%) compared to the rituximab plus chlorambucil arm especially during the first cycle. Four percent of patients treated with Gazyvaro plus chlorambucil experienced acute thrombocytopenia (occurring within 24 hours after the Gazyvaro infusion) (see section Special Warnings and Precautions for Use). The overall incidence of haemorrhagic events was similar in the Gazyvaro treated arm and in the rituximab treated arm. The number of fatal haemorrhagic events was balanced between the treatment arms; however, all of the events in patients treated with Gazyvaro were reported in Cycle 1. A clear relationship between thrombocytopenia and haemorrhagic events has not been established.

Indolent Non-Hodgkin Lymphoma including Follicular Lymphoma

The incidence of thrombocytopenia was lower in the Gazyvaro plus bendamustine (G+B) arm (15%) compared to the bendamustine (B) alone arm (24%). The incidence of haemorrhagic events (11% G+B, 10% B) and Grade 3-5 haemorrhagic events (5% G+B, 3%B) was similar in both treatment arms with no fatal events reported.

Special populations

Elderly

Chronic Lymphocytic Leukaemia

In the pivtal study, 46% (156 out of 336) of patients with CLL treated with Gazyvaro plus chlorambucil were 75 years or older (median age was 74 years). These patients experienced more serious adverse events and adverse events leading to death than those patients < 75 years of age.

Indolent Non Hodgkin Lymphoma including Follicular Lymphoma

In the pivotal study in iNHL, 44% (85 out of 194) of patients treated with Gazyvaro plus bendamustine were 65 years or older. No clinically meaningful differences in safety were observed between these patients and younger patients.

Renal impairment

Chronic Lymphocytic Leukaemia

In the CLL11 study, 27% (90 out of 336) of patients treated with Gazyvaro plus chlorambucil had moderate renal impairment (CrCl < 50 mL/min). These patients experienced more serious adverse events and adverse events leading to death than patients with a CrCl ≥50 mL/min (see section Posology and Method of Administration, Special Warnings and Precautions for Use and Pharmacokinetic Properties. Patients with a CrCl < 30 mL/min were excluded from the study (see section Pharmacodynamic Properties).

Indolent Non Hodgkin Lymphoma including Follicular Lymphoma

In the pivotal study in iNHL, a small subset of 8% (15 out of 194) of patients treated with Gazyvaro plus bendamustine, had moderate renal impairment (CrCL < 50 mL/min). These patients experienced more serious adverse events and adverse events leading to death than patients with a CrCl ≥50 mL/min (see section Posology and Method of Administration and Pharmacokinetic Properties). Patients with a CrCl < 40 mL/min were excluded from the study (see section Pharmacodynamic Properties).

Additional safety information from clinical studies experience

Progressive multifocal leukoencephalopathy (PML)

PML has been reported in patients treated with Gazyvaro (see section Special Warnings and Precautions for Use).

Hepatitis B reactivation

Cases of hepatitis B reactivation have been reported in patients treated with Gazyvaro (see section Special Warnings and Precautions for Use).

Gastro-Intestinal Perforation

Cases of gastro-intestinal perforation have been reported in patients receiving Gazyvaro, mainly in NHL.In the pivotal study GAO4753g 1% of patients experienced gastrointestinal perforation.

Worsening of pre-existing cardiac conditions

Cases of arrhythmias (such as atrial fibrillation and tachyarrhythmia), angina pectoris, acute coronary syndrome, myocardial infarction and heart failure have occurred when treated with Gazyvaro (see section Special Warnings and Precautions for Use). These events may occur as part of an IRR and can be fatal.

Laboratory abnormalities

Transient elevation in liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], alkaline phosphatase) has been observed shortly after the first infusion of Gazyvaro.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions (see details below).

Ireland

HPRA Pharmacovigilance
Earlsfort Terrace
IRL - Dublin 2
Tel: +353 1 6764971
Fax: +353 1 6762517
Website: www.hpra.ie
e-mail:medsafety@hpra.ie

Malta

ADR Reporting
Website:www.medicinesauthority.gov.mt/adrportal

United Kingdom

Yellow Card SchemeWebsite:www.mhra.gov.uk/yellowcard

Overdose

No experience with overdose is available from human clinical studies. In clinical studies with Gazyvaro, doses ranging from 50 mg up to and including 2,000 mg per infusion have been administered. The incidence and intensity of adverse reactions reported in these studies did not appear to be dose dependent.

Patients who experience overdose should have immediate interruption or reduction of their infusion and be closely supervised. Consideration should be given to the need for regular monitoring of blood cell count and for increased risk of infections while patients are B cell depleted.

Pharmacological Properties

Pharmacodynamic Properties

Pharmacotherapeutic group: Antineoplastic agents, monoclonal antibodies, ATC code: L01XC15

Mechanism of action

Obinutuzumab is a recombinant monoclonal humanised and glycoengineered Type II anti-CD20 antibody of the IgG1 isotype. It specifically targets the extracellular loop of the CD20 transmembrane antigen on the surface of non-malignant and malignant pre-B and mature B-lymphocytes, but not on haematopoietic stem cells, pro-B-cells, normal plasma cells or other normal tissue. Glycoengineering of the Fc part of obinutuzumab results in higher affinity for FcɣRIII receptors on immune effector cells such as natural killer (NK) cells, macrophages and monocytes as compared to non-glycoengineered antibodies.

In nonclinical studies, obinutuzumab induces direct cell death and mediates antibody dependent cellular cytotoxicity (ADCC) and antibody dependent cellular phagocytosis (ADCP) through recruitment of FcγRIII positive immune effector cells. In addition, in vivo, obinutuzumab mediates a low degree of complement dependent cytotoxicity (CDC). Compared to Type I antibodies, obinutuzumab, a Type II antibody, is characterised by an enhanced direct cell death induction with a concomitant reduction in CDC at an equivalent dose. Obinutuzumab, as a glycoengineered antibody, is characterised by enhanced antibody-dependent cellular cytotoxicity (ADCC) and phagocytosis (ADCP) compared to non-glycoengineered antibodies at an equivalent dose. In animal models obinutuzumab mediates potent B-cell depletion and antitumour efficacy.

In the pivotal clinical study BO21004/CLL11, 91% (40 out of 44) of evaluable patients treated with Gazyvaro were B-cell depleted (defined as CD19+ B cell counts < 0.07 x 109/L) at the end of treatment period and remained depleted during the first 6 months of follow up. Recovery of B-cells was observed within 12-18 months of follow up in 35% (14 out of 40) of patients without progressive disease and 13% (5 out of 40) with progressive disease.

Clinical efficacy and safety

Chronic Lymphocytic Leukaemia

A Phase III international, multicentre, open label, randomised, two-stage, three-arm clinical study (BO21004/CLL11) investigating the efficacy and safety of Gazyvaro plus chlorambucil (GClb) compared to rituximab plus chlorambucil (RClb) or chlorambucil (Clb) alone was conducted in patients with previously untreated chronic lymphocytic leukaemia with comorbidities.

Prior to enrolment, patients had to have documented CD20+ CLL, and one or both of the following measures of coexisting medical conditions: comorbidity score (CIRS) of greater than 6 or reduced renal function as measured by CrCl <70 mL/min. Patients with inadequate liver function (National Cancer Institute – Common Terminology Criteria for Adverse Events Grade 3 liver function tests (AST, ALT > 5 x ULN for > 2 weeks; bilirubin > 3 x ULN) and renal function (CrCl < 30 mL/min) were excluded. Patients with one or more individual organ/system impairment score of 4 as assessed by the CIRS definition, excluding eyes, ears, nose, throat and larynx organ system, were excluded.

A total of 781 patients were randomized 2:2:1 to receive Gazyvaro plus chlorambucil, rituximab plus chlorambucil or chlorambucil alone. Stage 1a compared Gazyvaro plus chlorambucil to chlorambucil alone in 356 patients and Stage 2 compared Gazyvaro plus chlorambucil to rituximab plus chlorambucil in 663 patients. Efficacy results are summarized in Table 8 and in Figures 1-3.

In the majority of patients, Gazyvaro was given intravenously as a 1,000 mg initial dose administered on Day 1, Day 8 and Day 15 of the first treatment cycle. In order to reduce the rate of infusion related reactions in patients, an amendment was implemented and 140 patients received the first Gazyvaro dose administered over 2 days (Day 1 [100 mg] and Day 2 [900 mg]) (see section 4.2 and 4.4). For each subsequent treatment cycle (Cycles 2 to 6), patients received Gazyvaro 1,000 mg on Day 1 only. Chlorambucil was given orally at 0.5 mg/kg body weight on Day 1 and Day 15 of all treatment cycles (1 to 6).

The demographics data and baseline characteristics were well balanced between the treatment groups. The majority of patients were Caucasian (95%) and male (61%). The median age was 73 years, with 44% being 75 years or older. At baseline, 22% of patients had Binet Stage A, 42% had Binet Stage B and 36% had Binet Stage C.

The median comorbidity score was 8 and 76% of the patients enrolled had a comorbidity score above 6. The median estimated CrCl was 62 mL/min and 66% of all patients had a CrCl < 70 mL/min. Forty-two percent of patients enrolled had both a CrCl < 70 mL/min and a comorbidity score of > 6. Thirty-four percent of patients were enrolled on comorbidity score alone, and 23% of patients were enrolled with only impaired renal function.

TThe most frequently reported coexisting medical conditions (using a cut off of 30% or higher), in the MedDRA body systems are: Vascular disorders (73%), Cardiac disorders (46%), Gastrointestinal disorders (38%), Metabolism and nutrition disorders (40%), Renal and urinary disorders (38%), Musculoskeletal and connective tissue disorders (33%).

Table 8 Summary of efficacy from BO21004/CLL11 study
Stage 1a Stage 2
Chlorambucil
N=118
Gazyvaro +
chlorambucil
N= 238
Rituximab +
chlorambucil
N= 330
Gazyvaro +
chlorambucil
N= 333
22.8 months median observation
time
18.7 months median observation
time
Primary endpoint
Investigator-assessed PFS (PFS-
INV)a
Number (%) of patients with event 96 (81.4%) 93 (39.1%) 199 (60.3%) 104 (31.2%)
Median duration of PFS (months) 11.1 26.7 15.2 26.7
Hazard ratio (95% CI) 0.18 [0.13; 0.24] 0.39 [0.31; 0.49]
p-value (Log-Rank test, stratifiedb) <0.0001 <0.0001
Key secondary endpoints
IRC-assessed PFS (PFS-IRC)a
Number (%) of patients with event 90 (76.3%) 89 (37.4%) 183 (55.5%) 103 (30.9%)
Median duration of PFS (months) 11.2 27.2 14.9 26.7
Hazard ratio (95% CI) 0.19 [0.14; 0.27]
p-value (Log-Rank test, stratifiedb) <0.0001 <0.0001
End of treatment response rate
No. of patients included in the
analysis
118 238 329 333
Responders (%) 37 (31.4%) 184 (77.3%) 214 (65.0%) 261 (78.4%)
Non-responders (%) 81 (68.6%) 54 (22.7%) 115 (35.0%) 72 (21.6%)
Difference in response rate, (95% CI) 45.95 [35.6; 56.3] 13.33 [6.4; 20.3]
p-value (Chi-squared Test) <0.0001 0.0001
No. of complete respondersc (%) 0 (0.0%) 53 (22.3%) 23 (7.0%) 69 (20.7%)
Molecular remission at end of
treatmentd
No. of patients included in the
analysis
90 168 244 239
MRD negativee (%) 0 (0.0%) 45 (26.8% 6 (2.5%) 61 (25.5%)
MRD positivef (%) 90 (100%) 123 (73.2%) 238 (97.5%) 178 (74.5%)
Difference in MRD rates, (95% CI) 26.79 [19.5; 34.1] 23.06 [17.0; 29.1]
Event free survival
No. (%) of patients with event 103 (87.3%) 104 (43.7%) 208 (63.0 %) 118 (35.4 %)
Median time to event (months) 10.8 26.1 14.3 26.1
Hazard ratio (95% CI) 0.19 [0.14; 0.25] 0.43 [0.34; 0.54]
p-value (Log-Rank test, stratifiedb) <0.0001 <0.0001
Time to new anti-leukaemic therapy
No. (%) of patients with event 65 (55.1%) 51 (21.4%) 86 (26.1%) 55 (16.5%)
Median duration of event (months) 14.8 - 30.8 -
Hazard ratio (95% CI) 0.24 [0.16; 0.35] 0.59 [0.42; 0.82]
p-value (Log-Rank test, stratifiedb) <0.0001 <0.0018
Overall survival
No. (%) of patients with event 24 (20.3%) 22 (9.2%) 41 (12.4%) 28 (8.4%)
Median time to event (months) NR NR NR** NR**
Hazard ratio (95% CI) 0.41 [0.23; 0.74] 0.66 [0.41; 1.06] **
p-value (Log-Rank test, stratifiedb) 0.0022 0.0849**

IRC: Independent Review Committee; PFS: progression-free survival; HR: Hazard Ratio; CI: Confidence Intervals, MRD: Minimal Residual Disease

a Defined as the time from randomization to the first occurrence of progression, relapse or death from any cause as assessed by the investigator
b stratified by Binet stage at baseline
c Includes 11 patients in the GClb arm with a complete response with incomplete marrow recovery
d Blood and bone marrow combined
e MRD negativity is defined as a result below 0.0001
f Includes MRD positive patients and patients who progressed or died before the end of treatment
NR = Not reached
Data not yet mature

Overall survival for Stage 1a is presented in Figure 2. Overall survival for Stage 2 will continue to be followed and is not yet mature. Results of the PFS subgroup analysis (i.e. sex, age, Binet stages, CrCl, CIRS score, beta2-microglobulin, IGVH status, chromosomal abnormalities, lymphocyte count at baseline) were consistent with the results seen in the overall Intent-to-Treat population. The risk of disease progression or death was reduced in the GClb arm compared to the RClb arm and Clb arm in all subgroups except in the subgroup of patients with deletion 17p. In the small subgroup of patients with deletion 17p, only a positive trend was observed compared to Clb (HR=0.42, p=0.0892); no benefit was observed compared to RClb. For subgroups, reduction of the risk of disease progression or death ranged from 92% to 58% for GClb versus Clb and 72% to 29% for GClb versus RClb.

Figure 1 Kaplan-Meier curve of Investigator assessed progression-free survival from Stage 1a


Figure 2 Kaplan-Meier curve of overall survival from Stage 1a


Figure 3 Kaplan-Meier curve of investigator assessed progression-free survival from Stage 2


Quality of life

In the QLQC30 and QLQ-CLL-16 questionnaires conducted during the treatment period, no substantial difference in any of the subscales was observed. Data during follow up, especially for the chlorambucil alone arm, is limited. However, no notable differences in quality of life during follow up have been identified to date.

Health-related quality of life assessments, specific to fatigue through treatment period, show no statistically significant difference suggesting that the addition of Gazyvaro to a chlorambucil regimen does not increase the experience of fatigue for patients.

Follicular lymphoma

In a phase III, open label, multicentre, randomized clinical study (GAO4753g (GADOLIN)), 396 patients with iNHL who had no response during treatment or who progressed within 6 months following the last dose of rituximab or a rituximab-containing regimen (including rituximab monotherapy as part of induction or maintenance treatment) were evaluated. Patients were randomized 1:1 to receive either bendamustine (B) alone (n = 202) or Gazyvaro in combination with bendamustine (G+B) (n = 194) for 6 cycles, each of 28 days duration. Patients in the G+B arm who did not have disease progression (i.e. patients with a complete response (CR), partial response (PR) or stable disease (SD)) at the end of induction continued receiving Gazyvaro maintenance once every two months for two years or until disease progression (whichever occurred first). Patients were stratified according to region, iNHL subtype (follicular versus non-follicular), rituximab-refractory type (whether refractory to prior rituximab monotherapy or rituximab in combination with chemotherapy) and the number of prior therapies (≤2 versus >2).

The demographic data and baseline characteristics were well balanced (median age 63 years, the majority were Caucasian [88%] and male [58%]). The majority of patients had follicular lymphoma (81%). The median time from initial diagnosis was 3 years and the median number of prior therapies was 2 (range 1 to 10); 44% of patients had received 1 prior therapy and 34% of patients had received 2 prior therapies.

Gazyvaro was given by intravenous infusion as an absolute dose of 1,000 mg on Days 1, 8 and 15 of Cycle 1, on Day 1 of Cycles 2-6, and in patients who did not have disease progression, once every two months for two years or until disease progression (whichever occurs first). Bendamustine was given intravenously on Days 1 and 2 for all treatment cycles (Cycles 1-6) at 90 mg/m2/day when given in combination with Gazyvaro or 120 mg/m2/day when given alone. In patients treated with G+B, 79.4% received all six treatment cycles compared to 66.7% of patients in the B arm.

The primary analysis based on independent Review Committee (IRC) assessment demonstrated a statistically significant - 45% reduction in the risk of disease progression (PD) or death, in patients with iNHL receiving G+B followed by Gazyvaro maintenance, compared with patients receiving bendamustine alone. The reduction in the risk of disease progression or death seen in the iNHL population is driven by the subset of patients with FL.

The majority of the patients in study GAO4753g had follicular lymphoma (FL) (81.1%). Efficacy results in the follicular lymphoma population are shown in Table 9. 11.6% of the patients had marginal zone lymphoma (MZL) and 7.1% had small lymphocytic lymphoma (SLL).

Table 9 Summary of efficacy in FL patients from GAO4753g (GADOLIN) study
Bendamustine
N=166
Gazyvaro +
Bendamustine followed
by Gazyvaro maintenance
N= 155
Median observation time:
20 months
Median observation time:
22 months
Primary Endpoint in FL population
IRC-assessed PFS (PFS-IRC)
Number (%) of patients with event 90 (54.2%) 54(34.8%)
Median duration (months) of PFS (95% CI) 13.8 (11.4, 16.2) NR (22.5,-)
HR (95% CI) 0.48 (0.34, 0.68)
p-value (Log-Rank test, stratified*) <.0001
Secondary Endpoints
Investigator-assessed PFS (PFS-INV)
Number (%) of patients with event 102 (61.4%) 62 (40.0%)
Median duration (months) of PFS (95% CI) 13.7 (11.0, 15.5) 29.2 (17.5,-)
HR (95% CI) 0.48 (0.35, 0.67)
p-value (Log-Rank test, stratified*) <.0001
Best Overall Response (BOR) (IRC-assessed)§
No. of patients included in the analysis 161 153
Responders (%) (CR/PR) 124 (77.0%) 122 (79.7%)
Difference in response rate (95% CI) 2.72 (-6.74, 12.18)
p-value (Cochran-Mantel-Haenszel test) 0.6142
Complete Responders (%) 31 (19.3%) 24 (15.7%)
Partial Responders (%) 93 (57.8%) 98 (64.1%)
Stable Disease (%) 18 (11.2%) 98 (64.1%)
Duration of response (DOR) (IRC-assessed)
No of patients included in the analysis 127 122
No. (%) of patients with event 74 (58.3%) 36 (29.5%)
Median duration (months) of DOR (95% CI) 11.9 (8.8, 13.6) NR (25.4,-)
HR (95% CI) 0.36 (0.24, 0.54)
Overall Survival (not yet mature)
No. (%) of patients with event 36 (21.7%) 25 (16.1%)
Median time to event (months) NR NR
HR (95% CI) 0.71 (0.43, 1.19)
p-value (Log-Rank test, stratified*) 0.1976

IRC: Independent Review Committee; PFS: progression-free survival; HR: Hazard Ratio; CI: Confidence Intervals,

NR = Not Reached
Stratification factors for analysis were refractory type (rituximab monotherapy vs. rituximab + chemotherapy) and prior therapies (≤ 2 vs ≥2). Follicular versus non-follicular was also a stratification factor for the study but is not applicable in the subgroup analysis of patients with follicular lymphoma.
Best response within 12 months of start of treatment

In the non-FL population the HR for IRC-assessed PFS was 0.94 [95% CI: 0.49, 1.90].

No definitive conclusions could be drawn on efficacy in the MZL and SLL sub-populations.

Figure 4 Kaplan-Meier curve of IRC-assessed progression-free survival in patients with follicular lymphoma


Figure 5 Kaplan-Meier curve of overall survival in patients with follicular lymphoma


A post hoc analysis was performed 8 months after the primary analysis data cut. With a median observation time of 24.1 months for follicular lymphoma patients, 48 patients (28.1%) in the B arm and 30 patients (18.3%) in the G+B arm had died. The observed improvement in OS seen with G+B was supported by a stratified HR for OS of 0.62 (95% CI: 0.39, 0.98) in this post hoc analysis. The median overall survival (OS) was not yet reached for either arm. The PFS results in the post hoc analysis are consistent with the primary analysis and its significance is unchanged and the safety profile is consistent with the primary analysis.

Results of subgroup analyses

Results of subgroup analyses were in general consistent with the results seen in the FL population, supporting the robustness of the overall result.

Figure 6 IRC-assessed PFS by patient subgroup in follicular lymphoma*


*pre-specified analyses performed on the ITT population were repeated on the FL population; analysis of double refractory (i.e. unresponsive to or disease progression during or within 6 months of the last dose of an alkylating agent-based regimen) status was exploratory.

Patient-reported Outcomes

Based on the FACT-Lym questionnaire and EQ-5D index scale collected during the treatment and during follow-up periods, health-related quality of life was generally maintained in the pivotal study with no significant difference between the arms. However, in patients with FL the addition of Gazyvaro to bendamustine delayed the time to worsening of health-related quality of life as measured by the FACT-Lym TOI score by 2.2 months (median 5.6 versus 7.8 months for B and G+B respectively HR = 0.83; 95% CI: 0.60, 1.13).

Immunogenicity

Immunogenicity assay results are highly dependent on several factors including assay sensitivity and specificity, assay methodology, assay robustness to quantities of Gazyvaro/antibody in the circulation, sample handling, timing of sample collection, concomitant medicines and underlying disease. For these reasons, comparison of incidence of antibodies to Gazyvaro with the incidence of antibodies to other products may be misleading.

Patients in the pivotal study BO21004/CLL11 were tested at multiple time-points for anti-therapeutic antibodies (ATA) to Gazyvaro. In patients treated with Gazyvaro 8 out of 140 patients in the randomised phase and 2 out of 6 in the run in phase tested positive for ATA at 12 months of follow up. Of these patients, none experienced anaphylactic or hypersensitivity reactions that were considered related to ATA, nor was clinical response affected.

In the iNHL pivotal trial, GAO4753g, two patients in the G+B arm had a positive HAHA (Human Anti-Human Antibody) assessment at baseline and experienced IRRs. No patient developed HAHA to Gazyvaro during or following Gazyvaro treatment.

Paediatric population

The European Medicines Agency has waived the obligation to submit the results of studies with Gazyvaro in all subsets of the paediatric population in Chronic Lymphocytic Leukaemia and follicular lymphoma (see section Posology and Method of Administration for information on paediatric use).

Pharmacokinetic Properties

A population pharmacokinetic (PK) model was developed to analyse the PK data in 469 iNHL, 342 CLL and 130 DLBCL patients from Phase I, Phase II and Phase III studies who received obinutuzumab alone or in combination with chemotherapy.

Absorption

Obinutuzumab is administered intravenously, therefore absorption is not applicable. There have been no studies performed with other routes of administration. From the population PK model, after the Cycle 6 Day 1 infusion in CLL patients, the estimated median Cmax value was 465.7 μg/mL and AUC(τ) value was 8961 μg•d/mL and in iNHL patients the estimated median Cmax value was 539.3 μg/mL and AUC() value was 10956 μg•day/mL.

Distribution

Following intravenous administration, the volume of distribution of the central compartment (2.98 L in patients with CLL and 2.97 in patients with iNHL), approximates serum volume, which indicates distribution is largely restricted to plasma and interstitial fluid.

Biotransformation

The metabolism of obinutuzumab has not been directly studied. Antibodies are mostly cleared by catabolism.

Elimination

The clearance of obinutuzumab was approximately 0.11 L/day in CLL patients and 0.08 L/day in iNHL patients with a median elimination t½ of 26.4 days in CLL patients and 36.8 days in iNHL patients. Obinutuzumab elimination comprises two parallel pathways which describe clearance, a linear clearance pathway and a non-linear clearance pathway which changes as a function of time. During the initial treatment, the non-linear time-varying clearance pathway is dominant and is consequently the major clearance pathway. As treatment continues, the impact of this pathway diminishes and the linear clearance pathway predominates. This is indicative of target mediated drug disposition (TMDD), where the initial abundance of CD20 cells causes a rapid removal of obinutuzumab from the circulation. However, once the majority of CD20 cells are bound with obinutuzumab, the impact of TMDD on PK is minimized.

Pharmacokinetic/pharmacodynamic relationship(s)

In the population pharmacokinetic analysis, gender was found to be a covariate which explains some of the inter-patient variability, with a 22% greater steady state clearance (CLss) and a 19% greater volume of distribution (V) in males. However, results from the population analysis have shown that the differences in exposure are not significant (with an estimated median AUC and Cmax in CLL patients of 11282 μg•d/mL and 578.9 μg/mL in females and 8451 μg•d/mL and 432.5 μg/mL in males, respectively at Cycle 6 and AUC and Cmax in iNHL of 13172 μg•d/mL and 635.7 μg/mL in females and 9769 μg•d/mL and 481.3 μg/mL in males, respectively), indicating that there is no need to dose adjust based on gender.

Elderly

The population pharmacokinetic analysis of obinutuzumab showed that age did not affect the pharmacokinetics of obinutuzumab. No significant difference was observed in the pharmacokinetics of obinutuzumab among patients < 65 years (n=375), patients between 65-75 years (n=265) and patients > 75 years (n=171).

Paediatric population

No studies have been conducted to investigate the pharmacokinetics of obinutuzumab in paediatric patients.

Renal impairment

The population pharmacokinetic analysis of obinutuzumab showed that creatinine clearance does not affect pharmacokinetics of obinutuzumab. Pharmacokinetics of obinutuzumab in patients with mild creatinine clearance (CrCl 50-89 mL/min, n=464) or moderate (CrCl 30 to 49 mL/min, n=106) renal impairment were similar to those in patients with normal renal function (CrCl ≥ 90 mL/min, n=383). Pharmacokinetic data in patients with severe renal impairment (CrCl 15-29 mL/min) is limited (n=8), therefore no dose recommendations can be made.

Hepatic impairment

No formal pharmacokinetic study has been conducted in patients with hepatic impairment. 

Preclinical Safety Data

No studies have been performed to establish the carcinogenic potential of obinutuzumab.

No specific studies in animals have been performed to evaluate the effect of obinutuzumab on fertility. In repeat-dose toxicity studies in cynomolgus monkeys obinutuzumab had no adverse effects on male and female reproductive organs.

An enhanced pre and postnatal development (ePPND) toxicity study in pregnant cynomolgus monkeys showed no evidence of teratogenic effects. However, weekly obinutuzumab dosing from post-coitum day 20 to delivery resulted in complete depletion of B cells in infant monkeys at weekly intravenous obinutuzumab doses of 25 and 50 mg/kg (2-5 times the clinical exposure based on Cmax and AUC). Offspring exposure on day 28 post-partum suggests that obinutuzumab can cross the blood-placenta barrier. Concentrations in infant serum on day 28 post-partum were in the range of concentrations in maternal serum, whereas concentrations in milk on the same day were very low (less than 0.5% of the corresponding maternal serum levels) suggesting that exposure of infants must have occurred in utero. The B cell counts returned to normal levels, and immunologic function was restored within 6 months post-partum.

In a 26-week cynomolgus monkey study, hypersensitivity reactions were noted and attributed to the foreign recognition of the humanised antibody in cynomolgus monkeys (0.7-6 times the clinical exposure based on Cmax and AUC at steady state after weekly administration of 5, 25, and 50 mg/kg). Findings included acute anaphylactic or anaphylactoid reactions and an increased prevalence of systemic inflammation and infiltrates consistent with immune-complex mediated hypersensitivity reactions, such as arteritis/periarteritis, glomerulonephritis, and serosal/adventitial inflammation. These reactions led to unscheduled termination of 6/36 animals treated with obinutuzumab during dosing and recovery phases; these changes were partially reversible. No renal toxicity with a causal relationship to obinutuzumab has been observed in humans.

Pharmaceutical Particulars

List of Excipients

  L-histidine
  L-histidine hydrochloride monohydrate
  Trehalose dihydrate
  Poloxamer 188
  Water for injections

Incompatibilities

This medicinal product must not be mixed with other medicinal products except those mentioned in section Special Precautions for Disposal and Other Handling.

Shelf Life

Unopened vial

3 years.

After dilution

After dilution, chemical and physical stability have been demonstrated in sodium chloride 9 mg/mL (0.9%) solution for injection at concentrations of 0.4 mg/mL to 20 mg/mL for 24 hours at 2°C to 8°C followed by 48 hours (including infusion time) at ≤ 30°C.

From a microbiological point of view, the prepared infusion solution 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-8°C, unless dilution has taken place in controlled and validated aseptic conditions.

Special Precautions for Storage

Store in a refrigerator (2°C-8°C).
Do not freeze.
Keep the vial in the outer carton in order to protect from light.
For storage conditions after dilution of the medicinal product, see section Shelf Life.

Nature and Contents of Container

40 mL concentrate in a 50 mL vial (clear Type I glass) with stopper (butyl rubber). Pack size of 1 vial.

Special Precautions for Disposal and Other Handling

Instructions for dilution

Gazyvaro should be prepared by a healthcare professional using aseptic technique. Do not shake the vial.

For CLL cycles 2 – 6 and all FL cycles

Withdraw 40 mL of concentrate from the vial and dilute in polyvinyl chloride (PVC) or non-PVC polyolefin infusion bags containing sodium chloride 9 mg/mL (0.9%) solution for injection.

CLL only – Cycle 1

To ensure differentiation of the two infusion bags for the initial 1,000 mg dose, it is recommended to utilise bags of different sizes to distinguish between the 100 mg dose for Cycle 1 Day 1 and the 900 mg dose for Cycle 1 Day 1 (continued) or Day 2. To prepare the 2 infusion bags, withdraw 40 mL of concentrate from the vial and dilute 4 mL into a 100 mL PVC or non-PVC polyolefin infusion bag and the remaining 36 mL in a 250 mL PVC or non-PVC polyolefin infusion bag containing sodium chloride 9 mg/ml (0.9%) solution for injection. Clearly label each infusion bag. For storage conditions of the infusion bags see section Shelf Life.

Dose of Gazyvaro to be
administered
Required amount of Gazyvaro
concentrate
Size of PVC or non-PVC polyolefin
infusion bag
100 mg 4 mL 100 mL
900 mg 36 mL 250 mL
1000 mg 40 mL 250 mL

Do not use other diluents such as glucose (5%) solution (see section Incompatibilities).

The bag should be gently inverted to mix the solution in order to avoid excessive foaming. The diluted solution should not be shaken or frozen.

Parenteral medicinal products should be inspected visually for particulates and discolouration prior to administration.

No incompatibilities have been observed between Gazyvaro, in concentration ranges from 0.4 mg/mL to 20.0 mg/mL after dilution of Gazyvaro with sodium chloride 9 mg/mL (0.9%) solution for injection, and:

  • PVC, polyethylene (PE), polypropylene or polyolefin bags
  • PVC, polyurethane (PUR) or PE infusion sets
  • optional inline filters with product contact surfaces of polyethersulfone (PES), a 3-way stopcock infusion aid made from polycarbonate (PC), and catheters made from polyetherurethane (PEU).

Disposal

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Marketing Authorisation Holder

Roche Registration Limited
Falcon Way
Shire Park
Welwyn Garden City
AL7 1TW
United Kingdom

Marketing Authorisation Number(s)

EU/1/14/937/001

Date of First Authorisation/Renewal of the Authorisation

23 July 2014

Date of Revision of the Text

sp;13 June 2016

Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.

Company Contact Details

Roche Products Limited
http://www.roche.co.uk

Address
Hexagon Place, 6 Falcon Way, Shire Park, Welwyn Garden City, Hertfordshire, AL7 1TW

Fax
+44 (0)1707 338 297

Medical Information e-mail
medinfo.uk@roche.com

Medical Information Fax
+44 (0)1707 384555

Telephone
+44 (0)1707 366 000

Medical Information Direct Line
+44 (0)800 328 1629

Customer Care direct line
+44 (0)800 731 5711