Atezolizumab

Revision as of 21:07, 12 January 2017 by Martin Nino (talk | contribs)
Jump to navigation Jump to search

Atezolizumab
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Martin Nino, M.D. [2]

Disclaimer

WikiDoc MAKES NO GUARANTEE OF VALIDITY. WikiDoc is not a professional health care provider, nor is it a suitable replacement for a licensed healthcare provider. WikiDoc is intended to be an educational tool, not a tool for any form of healthcare delivery. The educational content on WikiDoc drug pages is based upon the FDA package insert, National Library of Medicine content and practice guidelines / consensus statements. WikiDoc does not promote the administration of any medication or device that is not consistent with its labeling. Please read our full disclaimer here.

Overview

Atezolizumab is a programmed death-ligand 1 (PD-L1) blocking antibody that is FDA approved for the treatment of elected patients (see below) with locally advanced or metastatic urothelial carcinoma. This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. Atezolizumab is also indicated for the treatment of patients with metastatic non-small cell lung cancer who have disease progression during or following platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving Atezolizumab.. Common adverse reactions include fatigue, decreased appetite, nausea, urinary tract infection, pyrexia, and constipation (≥20%) in patients with locally advanced or metastatic urothelial carcinoma. Most common adverse reactions (≥ 20%) in patients with metastatic non-small cell lung cancer were fatigue, decreased appetite, dyspnea, cough, nausea, musculoskeletal pain, and constipation..

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Indications

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

This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

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

Dosage
  • Recommended Dosing

The recommended dose of Atezolizumab is 1200 mg administered as an intravenous infusion over 60 minutes every 3 weeks until disease progression or unacceptable toxicity. If the first infusion is tolerated, all subsequent infusions may be delivered over 30 minutes. Do not administer Atezolizumab as an intravenous push or bolus.

  • Dose Modifications

No dose reductions of Atezolizumab are recommended.

Withhold Atezolizumab for any of the following:

Atezolizumab may be resumed in patients whose adverse reactions recover to Grade 0–1.

Permanently discontinue Atezolizumab for any of the following:

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Atezolizumab in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Atezolizumab in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Safety and effectiveness have not been established in pediatric patients.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Atezolizumab in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Atezolizumab in pediatric patients.

Contraindications

None

Warnings

Immune-Related Pneumonitis

Immune-mediated pneumonitis or interstitial lung disease, defined as requiring use of corticosteroids and with no clear alternate etiology, occurred in patients receiving Atezolizumab . Monitor patients for signs with radiographic imaging and for symptoms of pneumonitis. Administer steroids at a dose of 1 to 2 mg/kg/day prednisone equivalents for Grade 2 or greater pneumonitis, followed by corticosteroid taper. Withhold Atezolizumab until resolution for Grade 2 pneumonitis. Permanently discontinue Atezolizumab for Grade 3 or 4 pneumonitis.

Across clinical trials, 2.6% (51/1978) of patients developed pneumonitis. Fatal pneumonitis occurred in two patients.

In 523 patients with urothelial carcinoma who received Atezolizumab, pneumonitis occurred in six (1.1%) patients. Of these patients, there was one patient with fatal pneumonitis, one patient with Grade 3, three patients with Grade 2, and one patient with Grade 1 pneumonitis. Atezolizumab was held in all cases and five patients were treated with corticosteroids. Pneumonitis resolved in three patients. The median time to onset was 2.6 months (range: 15 days to 4.2 months). The median duration was 15 days (range: 6 days to 3.1+ months).

In 1027 patients with NSCLC who received Atezolizumab, pneumonitis occurred in 38 (3.7%) patients. Of these patients, there was one patient with fatal pneumonitis, two patients with Grade 4, thirteen patients with Grade 3, eleven patients with Grade 2, and eleven patients with Grade 1 pneumonitis. Atezolizumab was held in 24 patients and 21 patients were treated with corticosteroids. Pneumonitis resolved in 26 of the 38 patients. The median time to onset was 3.3 months (range: 3 days to 18.7 months). The median duration was 1.4 months (range: 0 days to 12.6+ months).

Immune-Related Hepatitis

Immune-mediated hepatitis, defined as requiring use of corticosteroids and with no clear alternate etiology, occurred in patients receiving Atezolizumab treatment. Liver test abnormalities occurred in patients who received Atezolizumab . Monitor patients for signs and symptoms of hepatitis. Monitor AST, ALT, and bilirubin prior to and periodically during treatment with Atezolizumab. Administer corticosteroids at a dose of 1–2 mg/kg/day prednisone equivalents for Grade 2 or greater transaminase elevations, with or without concomitant elevation in total bilirubin, followed by corticosteroid taper. Withhold Atezolizumab for Grade 2 and permanently discontinue Atezolizumab for Grade 3 or 4 immune-mediated hepatitis.

Across clinical trials (n=1978), Grade 3 or 4 elevation occurred in ALT (2.5%), AST (2.3%), and total bilirubin (1.6%).

In patients with urothelial carcinoma (n=523), Grade 3 or 4 elevation occurred in ALT (2.5%), AST (2.5%), and total bilirubin (2.1%). Immune-mediated hepatitis occurred in 1.3% of patients. Of these cases, one patient died from hepatitis, five patients had Grade 3, and one patient had Grade 2 hepatitis. The median time to onset was 1.1 months (range: 0.4 to 7.7 months). Atezolizumab was temporarily interrupted in four patients; none of these patients developed recurrence of hepatitis after resuming Atezolizumab.

In patients with NSCLC, Grade 3 or 4 elevation occurred in ALT (1.4%), AST (1.3%), and total bilirubin (0.6%). Immune-mediated hepatitis occurred in 0.9% (9/1027) of patients. Of these nine patients, one patient had Grade 4, four patients had Grade 3, three patients had Grade 2, and one patient had Grade 1 immune-mediated hepatitis. The median time to onset was 28 days (range: 15 days to 4.2 months). Atezolizumab was temporarily interrupted in seven patients; none of these patients developed recurrence of hepatitis after resuming Atezolizumab.

Immune-Related Colitis

Immune-mediated colitis or diarrhea, defined as requiring use of corticosteroids and with no clear alternate etiology, occurred in patients receiving Atezolizumab. Monitor patients for signs and symptoms of diarrhea or colitis. Withhold treatment with Atezolizumab for Grade 2 diarrhea or colitis. If symptoms persist for longer than 5 days or recur, administer 1–2 mg/kg prednisone or equivalent per day. Withhold treatment with Atezolizumab for Grade 3 diarrhea or colitis. Treat with IV methylprednisolone 1–2 mg/kg per day and convert to oral steroids once the patient has improved. For both Grade 2 and Grade 3 diarrhea or colitis, when symptoms improve to Grade 0 or Grade 1, taper steroids over ≥ 1 month. Resume treatment with Atezolizumab if the event improves to Grade 0 or 1 within 12 weeks and corticosteroids have been reduced to the equivalent of ≤ 10 mg oral prednisone per day. Permanently discontinue Atezolizumab for Grade 4 diarrhea or colitis.

Across clinical trials, colitis or diarrhea occurred in 19.7% (389/1978) of all patients.

In 523 patients with urothelial carcinoma who received Atezolizumab, colitis or diarrhea occurred in 98 (18.7%) patients. Ten patients (1.9%) developed Grade 3 or 4 diarrhea. Four patients (0.8%) had immune-mediated colitis or diarrhea with a median time to onset of 1.7 months (range: 1.1 to 3.1 months). Immune-mediated colitis resolved with corticosteroid administration in three of these patients, while the other patient died without resolution of colitis in the setting of diarrhea-associated renal failure.

In 1027 patients with NSCLC who received Atezolizumab, colitis or diarrhea occurred in 198 (19.3%) patients. Twelve patients (1.2%) developed Grade 3 colitis or diarrhea. Five patients (0.5%) had immune-mediated colitis or diarrhea with a median time to onset of 21 days (range: 12 days to 3.4 months). Of these patients, one had Grade 3, two had Grade 2, and two had Grade 1 immune-mediated colitis or diarrhea. Immune-mediated colitis or diarrhea resolved with corticosteroid administration in four of these patients, while the fifth patient died due to disease progression prior to resolution of colitis.

Immune-Related Endocrinopathies

Immune-related thyroid disorders, adrenal insufficiency, and type 1 diabetes mellitus, including diabetic ketoacidosis, have occurred in patients receiving Atezolizumab. Monitor patients for clinical signs and symptoms of endocrinopathies.

Hypophysitis occurred in 0.2% (1/523) of patients with urothelial cancer receiving Atezolizumab. Monitor for signs and symptoms of hypophysitis. Administer corticosteroids and hormone replacement as clinically indicated. Withhold Atezolizumab for Grade 2 or Grade 3 and permanently discontinue for Grade 4 hypophysitis.

Thyroid function was assessed routinely only at baseline and the end of the study. Monitor thyroid function prior to and periodically during treatment with Atezolizumab. Asymptomatic patients with abnormal thyroid function tests can receive Atezolizumab. For symptomatic hypothyroidism, withhold Atezolizumab and initiate thyroid hormone replacement as needed. Manage isolated hypothyroidism with replacement therapy and without corticosteroids. For symptomatic hyperthyroidism, withhold Atezolizumab and initiate an anti-thyroid drug as needed. Resume treatment with Atezolizumab when symptoms of hypothyroidism or hyperthyroidism are controlled and thyroid function is improving.

Across clinical trials, hypothyroidism and hyperthyroidism occurred in 3.9% (77/1978) and 1.0% (20/1978) of patients, respectively.

In 523 patients with urothelial carcinoma who received Atezolizumab, hypothyroidism occurred in 2.5% (13/523). One patient had Grade 3 and twelve patients had Grade 1–2 hypothyroidism. The median time to first onset was 5.4 months (range: 21 days to 11.3 months). Thyroid stimulating hormone (TSH) was elevated and above the patient's baseline in 16% (21/131) of patients with a follow-up measurement.

Hyperthyroidism occurred in 0.6% (3/523) of patients with urothelial carcinoma. Of the three urothelial carcinoma patients, one patient had Grade 2 and two patients had Grade 1 hyperthyroidism. The median time to onset was 3.2 months (range: 1.4 to 5.8 months). TSH was decreased and below the patient's baseline in 3.8% (5/131) of patients with a follow-up measurement.

In 1027 patients with NSCLC who received Atezolizumab, hypothyroidism occurred in 4.2% (43/1027). Three patients had Grade 3 and forty patients had Grade 1–2 hypothyroidism. The median time to onset was 4.8 months (range 15 days to 31 months.) TSH was elevated and above the patient's baseline in 17% (54/315) of patients with follow-up measurement.

Hyperthyroidism occurred in 1.1% (11/1027) of patients with NSCLC. Eight patients had Grade 2 and three patients had Grade 1 hyperthyroidism. The median time to onset was 4.9 months (range: 21 days to 31 months). TSH was decreased and below the patient's baseline in 7.6% (24/315) of patients with a follow-up measurement.

Adrenal insufficiency occurred in 0.4% (7/1978) of patients across clinical trials, including two patients with Grade 3, four patients with Grade 2, and one patient with Grade 1. Adrenal insufficiency resolved in two patients.

For symptomatic adrenal insufficiency, withhold Atezolizumab and administer methylprednisolone 1–2 mg/kg per day IV followed by oral prednisone 1–2 mg/kg per day or equivalent once symptoms improve. Start steroid taper when symptoms improve to ≤ Grade 1 and taper steroids over ≥ 1 month. Resume treatment with Atezolizumab if the event improves to ≤ Grade 1 within 12 weeks and corticosteroids have been reduced to the equivalent of ≤ 10 mg oral prednisone per day and the patient is stable on replacement therapy, if required.

New onset diabetes with ketoacidosis has occurred in patients receiving Atezolizumab. Diabetes mellitus without an alternative etiology occurred in one (0.2%) patient with urothelial carcinoma and three (0.3%) patients with NSCLC.

Initiate treatment with insulin for type 1 diabetes mellitus. For ≥ Grade 3 hyperglycemia (fasting glucose >250–500 mg/dL), withhold Atezolizumab. Resume treatment with Atezolizumab when metabolic control is achieved on insulin replacement therapy.

Other Immune-Related Adverse Reactions

Other immune-related adverse reactions including meningoencephalitis, myasthenic syndrome/myasthenia gravis, Guillain-Barré, ocular inflammatory toxicity, and pancreatitis, including increases in serum amylase and lipase levels, have occurred in ≤ 1.0% of patients treated with Atezolizumab.

Monitor patients for clinical signs and symptoms of meningitis or encephalitis. Permanently discontinue Atezolizumab for any grade of meningitis or encephalitis. Treat with IV steroids (1–2 mg/kg/day methylprednisolone or equivalent) and convert to oral steroids (prednisone 60 mg/day or equivalent) once the patient has improved. When symptoms improve to ≤ Grade 1, taper steroids over ≥ 1 month.

Monitor patients for symptoms of motor and sensory neuropathy. Permanently discontinue Atezolizumab for any grade of myasthenic syndrome/myasthenia gravis or Guillain-Barré syndrome. Institute medical intervention as appropriate. Consider initiation of systemic corticosteroids at a dose of 1–2 mg/kg/day prednisone.

Symptomatic pancreatitis without an alternative etiology occurred in 0.1% (2/1978) of patients across clinical trials. Monitor patients for signs and symptoms of acute pancreatitis. Withhold Atezolizumab for ≥ Grade 3 serum amylase or lipase levels (> 2.0 ULN), or Grade 2 or 3 pancreatitis. Treat with 1–2 mg/kg IV methylprednisolone or equivalent per day. Once symptoms improve, follow with 1–2 mg/kg of oral prednisone or equivalent per day. Resume treatment with Atezolizumab when serum amylase and lipase levels improve to ≤ Grade 1 within 12 weeks or symptoms of pancreatitis have resolved, and corticosteroids have been reduced to ≤ 10 mg oral prednisone or equivalent per day. Permanently discontinue Atezolizumab for Grade 4 or any grade of recurrent pancreatitis.

Infection

Severe infections, including sepsis, herpes encephalitis, and mycobacterial infection leading to retroperitoneal hemorrhage occurred in patients receiving Atezolizumab. Monitor patients for signs and symptoms of infection and treat with antibiotics for suspected or confirmed bacterial infections. Withhold Atezolizumab for ≥ Grade 3 infection.

Across clinical trials, infections occurred in 38.4% (759/1978) of patients.

In 523 patients with urothelial carcinoma who received Atezolizumab, infection occurred in 197 (37.7%) patients. Grade 3 or 4 infection occurred in sixty (11.5%) patients, while three patients died due to infections. Urinary tract infections were the most common cause of Grade 3 or higher infection, occurring in 37 (7.1%) patients.

In Study 3, a randomized trial in patients with NSCLC, infections were more common in patients treated with Atezolizumab(43%) compared with those treated with docetaxel (34%). Grade 3 or 4 infections occurred in 9.2% of patients treated with Atezolizumab compared with 2.2% in patients treated with docetaxel. Two patients (1.4%) treated with Atezolizumab and three patients (2.2%) treated with docetaxel died due to infection. Pneumonia was the most common cause of Grade 3 or higher infection, occurring in 7.7% of patients treated with Atezolizumab.

Infusion-Related Reactions

Severe infusion reactions have occurred in patients in clinical trials of Atezolizumab. Infusion-related reactions occurred in 1.3% (25/1978) of patients across clinical trials, 1.7% (9/523) of patients with urothelial carcinoma, and 1.6% (16/1027) of patients with NSCLC. Interrupt or slow the rate of infusion in patients with mild or moderate infusion reactions. Permanently discontinue Atezolizumab in patients with Grade 3 or 4 infusion reactions.

Embryo-Fetal Toxicity

Based on its mechanism of action, Atezolizumab can cause fetal harm when administered to a pregnant woman. Animal studies have demonstrated that inhibition of the PD-L1/PD-1 pathway can lead to increased risk of immune-related rejection of the developing fetus resulting in fetal death. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, advise the patient of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with Atezolizumab and for at least 5 months after the last dose.

Adverse Reactions

Clinical Trials Experience

The following adverse reactions are discussed in greater detail in other sections of the label:

  • Immune-Related Pneumonitis
  • Immune-Related Hepatitis
  • Immune-Related Colitis
  • Immune-Related Endocrinopathies
  • Other Immune-Related Adverse Reactions
  • Infection
  • Infusion-Related Reactions

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.

Urothelial Carcinoma

The data described in Table 1 reflects exposure to Atezolizumab in Cohort 2 of Study 1. This cohort enrolled 310 patients in a single arm trial with locally advanced or metastatic urothelial carcinoma who had disease progression during or following at least one platinum-containing chemotherapy regimen or who had disease progression within 12 months of treatment with a platinum-containing neoadjuvant or adjuvant chemotherapy regimen. Patients received 1200 mg of Atezolizumab intravenously every 3 weeks until unacceptable toxicity or either radiographic or clinical progression. The median duration of exposure was 12.3 weeks (range: 0.1, 46 weeks).

The most common adverse reactions (≥ 20%) were fatigue (52%), decreased appetite (26%), nausea (25%), urinary tract infection (22%), pyrexia (21%), and constipation (21%). The most common Grade 3–4 adverse reactions (≥ 2%) were urinary tract infection, anemia, fatigue, dehydration, intestinal obstruction, urinary obstruction, hematuria, dyspnea, acute kidney injury, abdominal pain, venous thromboembolism, sepsis, and pneumonia.

Three patients (0.9%) who were treated with Atezolizumab experienced either sepsis, pneumonitis, or intestinal obstruction which led to death. Atezolizumab was discontinued for adverse reactions in 3.2% (10/310) of the 310 patients. Sepsis led to discontinuation in 0.6% (2/310) of patients. Adverse reactions leading to interruption of Atezolizumab occurred in 27% of patients; the most common (> 1%) were liver enzyme increase, urinary tract infection, diarrhea, fatigue, confusional state, urinary obstruction, pyrexia, dyspnea, venous thromboembolism, and pneumonitis. Serious adverse reactions occurred in 45% of patients. The most frequent serious adverse reactions (> 2%) were urinary tract infection, hematuria, acute kidney injury, intestinal obstruction, pyrexia, venous thromboembolism, urinary obstruction, pneumonia, dyspnea, abdominal pain, sepsis, and confusional state.

Table 1 summarizes the adverse reactions that occurred in ≥ 10% of patients while Table 2 summarizes Grade 3–4 selected laboratory abnormalities that occurred in ≥ 1% of patients treated with Atezolizumab in Cohort 2 of Study 1.

This image is provided by the National Library of Medicine.

TECENTRIQ: Atezolizumab's Brand name


  • Table 2: Grade 3–4 Laboratory Abnormalities in Patients with Urothelial Carcinoma in Study 1 in ≥ 1% of Patients
This image is provided by the National Library of Medicine.

Postmarketing Experience

There is limited information regarding Atezolizumab Postmarketing Experience in the drug label.

Drug Interactions

There is limited information regarding Atezolizumab Drug Interactions in the drug label.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): There is no FDA guidance on usage of Atezolizumab in women who are pregnant.
Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Atezolizumab in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Atezolizumab during labor and delivery.

Nursing Mothers

There is no FDA guidance on the use of Atezolizumab in women who are nursing.

Pediatric Use

There is no FDA guidance on the use of Atezolizumab in pediatric settings.

Geriatic Use

There is no FDA guidance on the use of Atezolizumab in geriatric settings.

Gender

There is no FDA guidance on the use of Atezolizumab with respect to specific gender populations.

Race

There is no FDA guidance on the use of Atezolizumab with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Atezolizumab in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Atezolizumab in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Atezolizumab in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Atezolizumab in patients who are immunocompromised.

Administration and Monitoring

Administration

There is limited information regarding Atezolizumab Administration in the drug label.

Monitoring

There is limited information regarding Atezolizumab Monitoring in the drug label.

IV Compatibility

There is limited information regarding the compatibility of Atezolizumab and IV administrations.

Overdosage

There is limited information regarding Atezolizumab overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

Pharmacology

There is limited information regarding Atezolizumab Pharmacology in the drug label.

Mechanism of Action

There is limited information regarding Atezolizumab Mechanism of Action in the drug label.

Structure

There is limited information regarding Atezolizumab Structure in the drug label.

Pharmacodynamics

There is limited information regarding Atezolizumab Pharmacodynamics in the drug label.

Pharmacokinetics

There is limited information regarding Atezolizumab Pharmacokinetics in the drug label.

Nonclinical Toxicology

There is limited information regarding Atezolizumab Nonclinical Toxicology in the drug label.

Clinical Studies

There is limited information regarding Atezolizumab Clinical Studies in the drug label.

How Supplied

There is limited information regarding Atezolizumab How Supplied in the drug label.

Storage

There is limited information regarding Atezolizumab Storage in the drug label.

Images

Drug Images

{{#ask: Page Name::Atezolizumab |?Pill Name |?Drug Name |?Pill Ingred |?Pill Imprint |?Pill Dosage |?Pill Color |?Pill Shape |?Pill Size (mm) |?Pill Scoring |?NDC |?Drug Author |format=template |template=DrugPageImages |mainlabel=- |sort=Pill Name }}

Package and Label Display Panel

{{#ask: Label Page::Atezolizumab |?Label Name |format=template |template=DrugLabelImages |mainlabel=- |sort=Label Page }}

Patient Counseling Information

There is limited information regarding Atezolizumab Patient Counseling Information in the drug label.

Precautions with Alcohol

Alcohol-Atezolizumab interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.

Brand Names

There is limited information regarding Atezolizumab Brand Names in the drug label.

Look-Alike Drug Names

There is limited information regarding Atezolizumab Look-Alike Drug Names in the drug label.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

Retrieved from "https://www.wikidoc.org/index.php?title=Atezolizumab&oldid=1282683"