Garadacimab-gxii
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anum Ijaz M.B.B.S., M.D.[2]
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Overview
Garadacimab-gxii is an activated Factor XII (FXIIa) inhibitor (monoclonal antibody) that is FDA approved for the prophylaxis of preventing attacks of hereditary angioedema (HAE) in adult and pediatric patients aged 12 years and older.. Common adverse reactions include are nasopharyngitis and abdominal pain (incidence ≥ 7%)..
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
FDA-labeled Indications
- ANDEMBRY is indicated for prophylaxis to prevent attacks of hereditary angioedema (HAE) in adult and pediatric patients aged 12 years and older.
Recommended Dosage
- The recommended dosage of ANDEMBRY is an initial loading dose of 400 mg (two injections of 200 mg) administered subcutaneously on the first day of treatment followed by a maintenance dosage of 200 mg administered subcutaneously every month.
Missed Dose If a dose of ANDEMBRY is missed, administer the dose as soon as possible.
Dosage Forms and Strengths
Injection: a sterile, preservative-free, slightly opalescent to clear, brownish-yellow to yellow solution available in the following:
- 200 mg/1.2 mL of garadacimab solution in a single-dose prefilled autoinjector.
- 200 mg/1.2 mL (167 mg/mL) of garadacimab solution in a single-dose prefilled syringe with needle safety device.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Garadacimab-gxii in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Garadacimab-gxii in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
FDA-labeled Indications
ANDEMBRY is indicated for prophylaxis to prevent attacks of hereditary angioedema (HAE) in pediatric patients aged 12 years and older.
Dosage
The recommended dosage of ANDEMBRY is an initial loading dose of 400 mg (two injections of 200 mg) administered subcutaneously on the first day of treatment followed by a maintenance dosage of 200 mg administered subcutaneously every month.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Garadacimab-gxii in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Garadacimab-gxii in pediatric patients.
Contraindications
None.
Warnings
None.
Adverse Reactions
Clinical Trials Experience
Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
- The safety of ANDEMBRY reflects the exposure in a total of 164 adult and pediatric patients aged 12 years and older with hereditary angioedema (HAE) from a placebo-controlled study, VANGUARD, and an open-label clinical study.
- Among the 164 patients who received at least one dose of ANDEMBRY 200 mg subcutaneously, 153 (93%) patients were exposed for at least one year. The median duration of ANDEMBRY treatment was 2.6 years.
- The safety data below is based on the 6-month placebo-controlled study (VANGUARD), in which ANDEMBRY 400 mg was administered subcutaneously as a loading dose followed by 200 mg (N=39) every month in patients with HAE.
- Demographics of the patients in this study are summarized in Clinical Studies. The safety of ANDEMBRY was similar across all subgroups of patients, including analysis by age, sex and geographic region.
Specific Adverse Reaction
Injection Site Reactions In VANGUARD and an open-label clinical study, which included 57 patients who rolled over from VANGUARD, 164 patients with HAE received ANDEMBRY 200 mg subcutaneously every month. Injection site reactions (e.g., injection site bruising, injection site erythema, injection site hematoma, injection site pruritus, injection site urticaria) were reported in 23 (14%) patients.
Laboratory Abnormalities'
Prolonged Coagulation Tests (aPTT and PT)'
- In the VANGUARD trial, the incidence of prolonged activated partial thromboplastin time (aPTT), defined as >1.4×ULN, was 3 (8%) patients in the ANDEMBRY group compared to 0 patients in the placebo group.
- Additionally, the incidence of prolonged prothrombin time (PT) or international normalized ratio (INR), defined as >1.3× ULN, was 6 (15%) patients in the ANDEMBRY group compared to 1 (4%) patient in the placebo group.
- None of the increases in aPTT, PT and INR were associated with bleeding events.
Postmarketing Experience
There is limited information regarding Garadacimab-gxii Postmarketing Experience in the drug label.
Drug Interactions
Drug Interference with Laboratory Test
Coagulation Tests
- ANDEMBRY can prolong activated partial thromboplastin time (aPTT) due to an interaction of garadacimab-gxii with the aPTT assay.
- The reagents used in the aPTT laboratory test initiate intrinsic coagulation through the activation of FXII in the contact system, therefore inhibition of plasma FXIIa by ANDEMBRY can prolong aPTT in this assay.
Use in Specific Populations
Pregnancy
Risk Summary
- There are no available data on ANDEMBRY use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage or other adverse maternal or fetal outcomes.
- Monoclonal antibodies such as garadacimab-gxii are transported across the placenta during the third trimester of pregnancy; therefore, potential effects on a fetus are likely to be greater during the third trimester of pregnancy.
- In an embryo-fetal development study in pregnant rabbits, garadacimab-gxii produced no evidence of fetal harm at doses up to approximately 100 times the exposure achieved at the maximum recommended human dose (MRHD) of 200 mg once monthly.
- In a pre- and post-natal development study in rabbits, garadacimab-gxii had no effects on survival, growth, or development of F1 offspring at doses resulting in approximately 76 times the exposure achieved at the MRHD (see Data).
- The estimated background risk of major birth defects and miscarriage for the indicated population(s) is unknown.
- All pregnancies have a background risk of birth defect, loss, or other adverse outcomes.
- In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Data
Animal Data
- In an embryo-fetal development study in pregnant rabbits dosed by the intravenous route every 3 days during the period of organogenesis from gestation days 6 to 18, garadacimab-gxii produced no evidence of fetal harm or maternal toxicity at doses resulting in approximately 100 times the exposure achieved at the MRHD (on an AUC basis with maternal intravenous doses up to 100 mg/kg/dose).
- In a pre- and post-natal development study in rabbits dosed by the intravenous or subcutaneous route once every 5 days from the end of implantation (Gestation Day 7) to postpartum day 38 (end of the lactation period), garadacimab-gxii had no effects on survival, growth, or development of F1 offspring at doses resulting in approximately 76 times the exposure achieved at the MRHD (on an AUC basis with a maternal intravenous dose of 100 mg/kg/dose). There was no evidence of maternal toxicity.
- Garadacimab-gxii crossed the placenta in rabbits. With a maternal dose of 100 mg/kg garadacimab-gxii on gestation day 29, fetal plasma concentrations were 40.8% of maternal concentrations following subcutaneous administration and approximately equivalent following intravenous administration.
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Garadacimab-gxii in women who are pregnant.
Labor and Delivery
There is no FDA guidance on use of Garadacimab-gxii during labor and delivery.
Nursing Mothers
Risk Summary
- There are no data on the presence of garadacimab-gxii or its metabolite in either human or animal milk, the effects on the breastfed infant, or the effects on milk production. Maternal IgG is known to be present in human milk.
- The effects of local gastrointestinal exposure and limited systemic exposure in the breastfed infant to garadacimab-gxii are unknown.
- The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for ANDEMBRY and any potential adverse effects on the breastfed infant from ANDEMBRY or the underlying maternal condition.
Pediatric Use
- The safety and effectiveness of ANDEMBRY for prophylaxis to prevent attacks of HAE have been established in pediatric patients aged 12 years and older.
- Use of ANDEMBRY for this indication is supported by evidence from a total of 6 pediatric patients aged 12 years and older enrolled in VANGUARD who received treatment with ANDEMBRY 400 mg loading dose administered subcutaneously followed by a maintenance dosage of 200 mg subcutaneously every month (n=4) or placebo (n=2).
- Results of the subgroup analysis for pediatric patients aged 12 years and older were consistent with study results for adult patients.
- The safety and effectiveness of ANDEMBRY have not been established in pediatric patients younger than 12 years of age.
Geriatic Use
- Of the total number of ANDEMBRY-treated patients in the clinical study for prophylaxis to prevent attacks of HAE, 6 (9%) were 65 years of age and older.
- No overall differences in safety or effectiveness of ANDEMBRY have been observed between patients 65 years of age and older and younger adult patients.
Gender
There is no FDA guidance on the use of Garadacimab-gxii with respect to specific gender populations.
Race
There is no FDA guidance on the use of Garadacimab-gxii with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Garadacimab-gxii in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Garadacimab-gxii in patients with hepatic impairment.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Garadacimab-gxii in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Garadacimab-gxii in patients who are immunocompromised.
Administration and Monitoring
Administration
Preparation and Administration Instructions for ANDEMBRY Prefilled Autoinjector and Prefilled Syringe with Needle Safety Device
- For subcutaneous use only.
- ANDEMBRY is intended for self-administration or administration by a caregiver. Prior to treatment initiation, train patients/caregivers on proper preparation and subcutaneous (SC) administration technique of ANDEMBRY.
- Prior to administration, remove ANDEMBRY from the refrigerator and allow to sit for 30 minutes at room temperature before use.
- Inspect ANDEMBRY visually for particulate matter and discoloration prior to administration, whenever solution and container permit. ANDEMBRY is a slightly opalescent to clear, brownish-yellow to yellow solution.
- Administer ANDEMBRY subcutaneously into the thigh or abdomen ensuring to stay 1 inch (2 cm) away from the navel. The upper arm can also be used if a caregiver administers the subcutaneous injection.
- Discard the used ANDEMBRY into a sharps disposal container (closed puncture-resistant container).
Monitoring
There is limited information regarding Garadacimab-gxii Monitoring in the drug label.
IV Compatibility
There is limited information regarding the compatibility of Garadacimab-gxii and IV administrations.
Overdosage
There is limited information regarding Garadacimab-gxii 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 Garadacimab-gxii Pharmacology in the drug label.
Mechanism of Action
- Garadacimab-gxii is an inhibitor of activated FXII that binds to the catalytic domain of activated Factor XII (FXIIa and βFXIIa) and inhibits its catalytic activity.
- FXII is the first factor activated in the contact activation pathway and initiates the inflammatory bradykinin-producing kallikrein-kinin system.
- The inhibition of FXIIa decreases the activation of prekallikrein to kallikrein and the generation of bradykinin, which is associated with inflammation and swelling in HAE attacks, thus reducing the cascade of events leading to an HAE attack.
Structure
Garadacimab-gxii, an activated Factor XII (FXIIa) inhibitor, is a recombinant, fully human, monoclonal antibody (IgG4/λ-light chain) produced in Chinese Hamster Ovary (CHO) cells. Based on the amino acid sequence, the molecular weight of garadacimab-gxii is approximately 148 kDa.
Pharmacodynamics
- Garadacimab-gxii concentration-dependent inhibition of FXIIa-mediated kallikrein activity was observed in patients with HAE.
- Inhibition of FXIIa-mediated kallikrein activity was observed after the first dose.
Pharmacokinetics
- The pharmacokinetics of garadacimab-gxii are provided in Table 2 following subcutaneous administration of a single 200 mg dose to healthy volunteers and are presented as mean (SD), unless otherwise specified.
- Specific Populations
No clinically significant differences in the pharmacokinetics of garadacimab-gxii were observed based on age (age range: 12 to 73 years), gender, race, body weight (range: 43 to 153 kg), and mild to moderate renal impairment (eGFR 30 to <90 mL/min/1.73 m2). The effect of severe renal impairment (eGFR <30 mL/min/1.73 m2) on garadacimab-gxii pharmacokinetics is unknown.
Pediatric Patients No clinically significant difference in garadacimab-gxii Cmax and AUCtau was observed between pediatric patients (age range: 12 to 17 years) and adults who received the recommended dosage of garadacimab-gxii (200 mg of garadacimab-gxii once monthly).
Drug Interactions No dedicated drug interaction studies have been conducted in humans.
Immunogenicity
- The observed incidence of anti-drug antibodies (ADA) is highly dependent on the sensitivity and specificity of the assay.
- Differences in assay methods preclude meaningful comparisons of the incidence of anti-drug antibodies in the studies described below with the incidence of anti-drug antibodies in other studies, including those of garadacimab-gxii or other garadacimab products.
- In VANGUARD, 2.6% (1/39) of patients who received garadacimab-gxii tested positive for anti- garadacimab-antibodies during the 6-month treatment period.
- The development of ADA against garadacimab-gxii did not affect pharmacokinetics (PK), safety, or clinical response.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
- Animal studies have not been conducted to evaluate the carcinogenic or mutagenic potential of garadacimab-gxii.
- Fertility and reproductive performance were unaffected in sexually mature male and female rabbits that received garadacimab-gxii at intravenous doses up to 100 mg/kg once every three days (resulting in exposures in male and female rabbits up to approximately 100 and 80 times the MRHD on an AUC basis).
Clinical Studies
- The efficacy of ANDEMBRY for prophylaxis to prevent hereditary angioedema (HAE) attacks was evaluated in a multicenter, randomized, double-blind, placebo-controlled, parallel-group study (VANGUARD [NCT04656418]) of 6 months duration.
- VANGUARD enrolled a total of 64 adult and pediatric patients 12 years of age and older with Type I or Type II HAE who experienced at least 2 investigator-confirmed HAE attacks over a 2-month period prior to treatment with ANDEMBRY or placebo. Patients were randomized in a 3:2 ratio (ANDEMBRY:placebo) to receive an initial loading dose of ANDEMBRY 400 mg administered subcutaneously followed by a maintenance dose of 200 mg every month, or matched placebo.
- Patients were required to discontinue other prophylactic HAE medications prior to entering the study. All patients were allowed to use on-demand medications for the treatment of HAE attacks during the study.
- The monthly rate of HAE attacks requiring on-demand therapy and the monthly rate of moderate or severe HAE attacks were assessed as secondary endpoints in VANGUARD.
- There was a 91.2% reduction with ANDEMBRY relative to placebo in the monthly rate of HAE attacks requiring on-demand therapy and a 93.6% reduction with ANDEMBRY relative to placebo in the monthly rate of moderate or severe HAE attacks.
- Additional secondary endpoints assessed the proportion of patients with a ≥50%, ≥70%, ≥90%, and 100% (attack-free) reduction in monthly HAE attack rate from the first dose through the end of the 6-month treatment period compared to the 2-month period prior to treatment.
- The proportion of patients with a ≥50%, ≥70%, ≥90%, and 100% reduction was 95%, 92%, 74%, and 62% on ANDEMBRY versus 33%, 17%, 8%, and 0% on placebo, respectively.
How Supplied
- ANDEMBRY (garadacimab-gxii) injection is a ready-to-use, slightly opalescent to clear, brownish-yellow to yellow solution in the following presentations, supplied in single-dose prefilled autoinjector or prefilled syringe with needle safety device.
- Each single-dose prefilled autoinjector or prefilled syringe with needle safety device is supplied in a carton.
Storage
- Do not freeze. Do not shake.
- Keep the prefilled autoinjector and prefilled syringe with needle safety device in the original carton to protect from light.
- Store the prefilled autoinjector and prefilled syringe with needle safety device refrigerated at 36°F to 46°F (2°C - 8°C).
Images
Drug Images
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Package and Label Display Panel
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Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Patient Information and Instructions for Use).
Administration Instructions
- Instruct patients that ANDEMBRY is for subcutaneous use and intended for self-administration or administration by caregiver.
- Instruct patients and/or caregivers on the proper preparation and subcutaneous administration techniques of ANDEMBRY.
- Instruct patients and/or caregivers to administer ANDEMBRY subcutaneously into the upper arm, thigh or abdomen ensuring to stay 1 inch (2 cm) away from the navel.
- Instruct patients or caregivers in proper disposal technique for prefilled autoinjector or prefilled syringe with needle safety device and advise them not to reuse these items.
- Instruct patients to dispose of the prefilled autoinjector or prefilled syringe with needle safety device in a sharps disposal container (closed puncture-resistant container).
Precautions with Alcohol
Alcohol-Garadacimab-gxii interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
Brand Names
There is limited information regarding Garadacimab-gxii Brand Names in the drug label.
Look-Alike Drug Names
There is limited information regarding Garadacimab-gxii Look-Alike Drug Names in the drug label.
Price
References
The contents of this FDA label are provided by the National Library of Medicine.