Polivy

Polatuzumab vedotin.

Each vial of powder for concentrate for solution for infusion contains 30 mg or 140 mg of polatuzumab vedotin.
After reconstitution, each mL contains 20 mg of polatuzumab vedotin.
Polatuzumab vedotin is an antibody-drug conjugate composed of the anti-mitotic agent monomethyl auristatin E (MMAE) covalently conjugated to a CD79b-directed monoclonal antibody (recombinant humanized immunoglobulin G1 [IgG1], produced in Chinese Hamster Ovary cells by recombinant DNA technology).
Excipients/Inactive Ingredients: Succinic Acid, Sodium Hydroxide, Sucrose, Polysorbate 20.

Pharmacotherapeutic group: antineoplastic agents; other antineoplastic agents; monoclonal antibodies. ATC code: L01XC37.
Pharmacology: Pharmacodynamics: Mechanism of action: Polatuzumab vedotin is a CD79b-targeted antibody-drug conjugate that preferentially delivers a potent anti-mitotic agent (monomethyl auristatin E, or MMAE) to B-cells, which results in the killing of malignant B-cells. The polatuzumab vedotin molecule consists of MMAE covalently attached to a humanized immunoglobulin G1 (IgG1) monoclonal antibody via a cleavable linker. The monoclonal antibody binds with high affinity and selectivity to CD79b, a cell surface component of the B-cell receptor. CD79b expression is restricted to normal cells within the B-cell lineage (with the exception of plasma cells) and malignant B-cells; it is expressed in > 95% of DLBCL. Upon binding CD79b, polatuzumab vedotin is rapidly internalized and the linker is cleaved by lysosomal proteases to enable intracellular delivery of MMAE. MMAE binds to microtubules and kills dividing cells by inhibiting cell division and inducing apoptosis.
Pharmacodynamic effects: Cardiac electrophysiology: Polatuzumab vedotin did not prolong the mean QTc interval to any clinically relevant extent based on ECG data from two open-label studies in patients with previously treated B-cell malignancies at the recommended dosage.
Clinical efficacy and safety: The efficacy of Polivy plus BR was evaluated in an international, multicenter, open-label study (GO29365) which included a randomized cohort (n=80) and an extension cohort (n=106) of patients with previously treated DLBCL.
Eligible patients were not candidates for autologous hematopoietic stem cell transplant (HSCT) and had relapsed or refractory disease after receiving at least one prior systemic chemotherapy regimen. The study excluded patients with prior allogeneic HSCT, central nervous system lymphoma, transformed follicular lymphoma (FL), and grade 3b FL, significant cardiovascular or pulmonary disease, active infections, AST or alanine transaminase (ALT) >2.5 × ULN or total bilirubin ≥1.5 x ULN, creatinine >1.5 x ULN (or CrCl <40 mL/min) unless due to underlying lymphoma.
Polivy was given intravenously at 1.8 mg/kg administered on Day 2 of Cycle 1 and on Day 1 of Cycles 2-6. Bendamustine was administered at 90 mg/m² intravenously daily on Days 2 and 3 of Cycle 1 and on Days 1 and 2 of Cycles 2-6. Rituximab was administered at 375 mg/m² intravenously on Day 1 of Cycles 1-6.
The primary endpoint of the study was complete response (CR) rate at end of treatment (6-8 weeks after day 1 of cycle 6 or last study treatment) as assessed by independent review committee (IRC). Efficacy results are summarized in Table 1-2 and in Figures 1-3.
Randomized Cohort (n=80): Patients were randomized 1:1 to receive Polivy plus BR or BR alone for six 21-day cycles. Patients were stratified by duration of response to last prior treatment of ≤12 months or >12 months.
Among the 80 patients who were randomized to receive Polivy plus BR (n=40) or BR alone (n = 40) the majority were white (71%) and male (66%). The median age was 69 years (range 30 to 86 years). Sixty-four out of 80 patients (80%) had ECOG performance score (PS) of 0-1 and 14 out of 80 patients (18%) had ECOG PS of 2. The majority of patients (98%) had DLBCL not otherwise specified (NOS). Overall, 48% of patients had activated B-cell (ABC) DLBCL and 40% of patients had germinal center B-cell like (GCB) DLBCL. Primary reasons patients were not candidates for HSCT included age (40%), insufficient response to salvage therapy (26%) and prior transplant failure (20%). The median number of prior therapies was 2 (range: 1-7) with 29% (n=23) receiving one prior therapy, 25% (n=20) receiving 2 prior therapies, and 46% (n=37) receiving 3 or more prior therapies. All except one patient in the pola+BR arm of the randomized Phase II were naïve to bendamustine treatment. 80% of patients had refractory disease. (See Table 1.)

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Overall survival (OS) was an exploratory endpoint which was not type 1 error controlled. The median OS in the Polivy+BR arm was 12.4 months (95% CI: 9.0, NE) vs 4.7 months (95% CI: 3.7, 8.3) in the control arm. The unadjusted estimate for OS HR was 0.42. When accounting for the influence of baseline covariates the OS HR was adjusted to 0.59. Covariates included primary refractory status, number of prior lines of therapy, IPI, and prior stem cell transplant.
Investigator-assessed progression free survival (PFS) was an exploratory endpoint which was not type 1 error controlled. The median PFS in the Polivy+BR arm was 7.6 months (95% CI: 6.0, 17.0) vs 2.0 months (95% CI: 1.5, 3.7) in the control arm. The unadjusted estimate for PFS HR was 0.34.
Immunogenicity: As with all therapeutic proteins, there is the potential for an immune response in patients treated with polatuzumab vedotin. Across all arms (excluding extension cohort) of study GO29365, 8 out of 134 (6.0%) patients tested positive for anti-polatuzumab vedotin antibodies at one or more post-baseline time points. Across seven clinical studies, 14 out of 536 (2.6%) patients tested positive for anti-polatuzumab vedotin antibodies at one or more post-baseline time points. Due to the limited number of anti-polatuzumab vedotin antibody positive patients, no conclusions can be drawn concerning a potential effect of immunogenicity on efficacy or safety.
Immunogenicity assay results are highly dependent on several factors including assay sensitivity and specificity, assay methodology, sample handling, timing of sample collection, concomitant medications and underlying disease. For these reasons, comparison of incidence of antibodies to polatuzumab vedotin with the incidence of antibodies to other products may be misleading. (See Figures 1 and 2.)

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Results of subgroup analyses: Results of subgroup analysis of overall survival were consistent with the results seen in the overall DLBCL population (see Figure 3 as follows).

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Extension cohort (n=106): The median age was 70 years (range 24 to 94 years) 78% of patients were white and 49% were male. The majority of patients (94%) had DLBCL not otherwise specified (NOS). Overall, 48% of patients had ABC DLBCL and 40% of patients had GCB DLBCL. Primary reasons patients were not candidates for HSCT included age (44%), insufficient response to salvage therapy (29%) and prior transplant failure (14%). The median number of prior therapies was 2 (range: 1-7) with 35% (n=37) receiving one prior therapy, 26% (n=27) receiving 2 prior therapies, and 40% (n=42) receiving 3 or more prior therapies. 76% of patients had refractory disease. (See Table 2.)

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Pharmacokinetics: Antibody-conjugated MMAE (acMMAE) plasma exposure increased dose-proportionally over the 0.1 to 2.4 mg/kg polatuzumab vedotin dose range. After the first 1.8 mg/kg polatuzumab vedotin dose, the acMMAE mean maximum concentration (C_max) was 803 (± 233) ng/mL and the area under the concentration-time curve from time zero to infinity (AUC_inf) was 1860 (± 966) day*ng/mL. Based on the population PK analysis, Cycle 3 acMMAE AUC increased by approximately 30% over cycle 1 AUC, and achieved more than 90% of the Cycle 6 AUC. The terminal half-life at cycle 6 was approximately 12 days (95% CI of 8.1-19.5 days) for acMMAE. Based on population PK analysis, the predicted acMMAE concentration at the end of cycle 6 is approximately 80% of the theoretical steadystate value. Exposures of unconjugated MMAE, the cytotoxic component of polatuzumab vedotin, increased dose proportionally over the 0.1 to 2.4 mg/kg polatuzumab vedotin dose range. MMAE plasma concentrations followed formation rate limited kinetics. After the first 1.8 mg/kg polatuzumab vedotin dose, the Cmax was 6.82 (± 4.73) ng/mL, the time to maximum plasma concentration is approximately 2.5 days, and the terminal half-life is approximately 4 days. Plasma exposures of unconjugated MMAE are < 3% of acMMAE exposures. Based on the population PK analysis there is a decrease of plasma unconjugated MMAE exposure (AUC) after repeated every-three-week dosing.
Based on population pharmacokinetics simulations, a sensitivity analysis predicted exposure to unconjugated MMAE for patients with bodyweight over 100 kg to be increased by 27%.
Absorption: Polivy is administered as an IV infusion. There have been no studies performed with other routes of administration.
Distribution: The population estimate of central volume of distribution for acMMAE was 3.15 L, which approximated plasma volume. In vitro, MMAE is moderately bound (71% - 77%) to human plasma proteins. MMAE does not significantly partition into human red blood cells in vitro; the blood to plasma ratio is 0.79 to 0.98.
In vitro data indicate that MMAE is a P-gp substrate but does not inhibit P-gp at clinically relevant concentrations.
Biotransformation: Polatuzumab vedotin is expected undergo catabolism in patients, resulting in the production of small peptides, amino acids, unconjugated MMAE, and unconjugated MMAE related catabolites. The levels of MMAE metabolites have not been measured in human plasma.
In vitro studies indicate that MMAE is a substrate for CYP 3A4/5 but does not induce major CYP enzymes. MMAE is a weak time-dependent inhibitor of CYP3A4/5 but does not competitively inhibit CYP3A4/5 at clinically relevant concentrations.
MMAE does not inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, or CYP2D6.
Elimination: Based on a population pharmacokinetic analysis, the conjugate (acMMAE) is primarily eliminated by non-specific linear clearance pathway with a value of 0.9 L/day. In vivo studies in rats dosed with polatuzumab vedotin (radiolabel on MMAE) demonstrate that the majority of radioactivity is excreted in feces and the minority of radioactivity is excreted in urine.
Pediatric Population: No studies have been conducted to investigate the pharmacokinetics of Polivy in pediatric patients (<18 years old).
Elderly: Age did not have an effect on the pharmacokinetics of acMMAE and unconjugated MMAE based on a population PK analysis with patients aged 20-89 years. No significant difference was observed in the pharmacokinetics of acMMAE and unconjugated MMAE among patients <65 years of age (n=187) and patients ≥65 years of age (n=273).
Renal impairment: In patients with mild (CrCL 60-89 mL/min, n=161) or moderate (CrCL 30-59 mL/min, n=109) renal impairment, acMMAE and unconjugated MMAE exposures are similar to patients with normal renal function (CrCL ≥ 90 mL/min, n=185), based on a population pharmacokinetic analysis. There are insufficient data to assess the impact of severe renal impairment (CrCL 15-29 mL/min, n=3) on PK. No data are available in patients with end-stage renal disease and/or who are on dialysis.
Hepatic impairment: In patients with mild hepatic impairment [AST >1.0 - 2.5×ULN or ALT >1.0 - 2.5×ULN or total bilirubin >1.0 - 1.5×ULN, n=54], acMMAE exposures are similar whereas unconjugated MMAE AUC are 40% higher compared to patients with normal hepatic function (n=399), based on a population pharmacokinetic analysis.
The safety and efficacy of Polivy in patients with (AST >2.5×ULN, ALT>2.5×ULN or total bilirubin>1.5×ULN) has not been formally studied and these patients are likely to have increased exposure to MMAE. The administration of Polivy in patients with moderate or severe hepatic impairment (total bilirubin greater than 1.5 × ULN) should be avoided.
There are insufficient data to assess the impact of moderate hepatic impairment (total bilirubin >1.5 - 3×ULN, n=2) on PK. No data are available in patients with severe hepatic impairment or liver transplantation.
Toxicology: Preclinical safety data: Systemic toxicity: In both rats and cynomolgus monkeys, the predominant systemic toxicities associated with administration of MMAE and polatuzumab vedotin included reversible bone marrow toxicity and associated peripheral blood cell effects.
Genotoxicity: No dedicated mutagenicity studies have been performed with Polivy. MMAE was not mutagenic in the bacterial reverse mutation assay (Ames test) or the L5178Y mouse lymphoma forward mutation assay.
MMAE was a genotoxic in the rat bone marrow micronucleus study probably through an aneugenic mechanism. This mechanism is consistent with the pharmacological effect of MMAE as a microtubule disrupting agent.
Carcinogenicity: No dedicated carcinogenicity studies have been performed with polatuzumab vedotin and/or MMAE.
Impairment of fertility: No dedicated fertility studies in animals have been performed with Polivy. However, results of the 4-week rat toxicity study indicate the potential for polatuzumab vedotin to impair male reproductive function and fertility. Testicular seminiferous tubule degeneration did not reverse following a 6-week treatment-free period and correlated with decreased testes weight and gross at recovery necropsy of small and/or soft testes in males given ≥ 2 mg/kg.
Reproductive toxicity: No dedicated teratogenicity studies in animals have been performed with Polivy. However, treatment of pregnant rats with MMAE at 0.2 mg/kg caused embryolethality and fetal malformations (including protruding tongue, malrotated limbs, gastroschisis, and agnathia). Systemic exposure (AUC) in rats at a dose of 0.2 mg/kg MMAE is approximately 50% of the AUC in patients who received the recommended dose of 1.8 mg/kg Polivy every 21-days.

Polivy in combination with bendamustine and rituximab is indicated for the treatment of adult patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL) who are not candidates for haematopoietic stem cell transplant.

Polivy must only be administered under the supervision of a healthcare professional experienced in the diagnosis and treatment of cancer patients.
Posology: The recommended dose of Polivy is 1.8 mg/kg, given as an intravenous infusion every 21 days in combination with bendamustine and rituximab for 6 cycles. Polivy, bendamustine and rituximab can be administered in any order on Day 1 of each cycle. When administered with Polivy, the recommended dose of bendamustine is 90 mg/m²/day on Day 1 and Day 2 of each cycle and the recommended dose of rituximab is 375 mg/m² on Day 1 of each cycle. Due to limited clinical experience in patients treated with 1.8 mg/kg Polivy at a total dose >240 mg, it is recommended not to exceed the dose 240 mg/cycle.
If not already premedicated, premedication with an antihistamine and anti-pyretic should be administered to patients prior to Polivy.
Delayed or missed doses: If a planned dose of Polivy is missed, it should be administered as soon as possible and the schedule of administration should be adjusted to maintain a 21-day interval between doses.
Dose modifications: The infusion rate of Polivy should be slowed or interrupted if the patient develops an infusion-related reaction. Polivy should be discontinued immediately and permanently if the patient experiences a life-threatening reaction.
For dose modifications for peripheral neuropathy (see Precautions) see Table 3 as follows.

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For dose modifications for myelosuppression see Table 4.

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For dose modifications for Infusion-related reactions see Table 5.

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Special populations: Elderly: No dose adjustment of Polivy is required in patients ≥ 65 years of age (see Pharmacology: Pharmacokinetics under Actions).
Renal Impairment: No dose adjustment of Polivy is required in patients with creatinine clearance (CrCL) ≥30mL/min. A recommended dose has not been determined for patients with CrCL <30mL/min due to limited data.
Hepatic Impairment: The administration of Polivy in patients with moderate or severe hepatic impairment (total bilirubin greater than 1.5 × upper limit of normal [ULN] should be avoided.
No dose adjustment in the starting dose is required when administering Polivy to patients with mild hepatic impairment (total bilirubin greater than ULN to less than or equal to 1.5 × ULN or aspartate transaminase [AST] greater than ULN).
Paediatric population: The safety and efficacy in children and adolescents (<18 years) has not been established. No data are available.
Method of administration: Polivy is for intravenous use.
The initial dose of Polivy should be administered as a 90-minute intravenous infusion. Patients should be monitored for IRRs/hypersensitivity reactions during the infusion and for at least 90 minutes following completion of the initial dose.
If the prior infusion was well tolerated, the subsequent dose of Polivy may be administered as a 30-minute infusion and patients should be monitored during the infusion and for at least 30 minutes after completion of the infusion.
Polivy must be reconstituted and diluted using aseptic technique under the supervision of a healthcare professional. It should be administered as an intravenous infusion through a dedicated infusion line equipped with a sterile, non-pyrogenic, low-protein binding in-line or add-on filter (0.2 or 0.22 micrometer pore size) and catheter. Polivy must not be administered as intravenous push or bolus.
For instructions on reconstitution and dilution of the medicinal product before administration, see Special Instructions for Use, Handling and Disposal under Cautions for Usage.
Precaution to be taken before manipulating or administering the product: Polivy contains a cytotoxic component which is covalently attached to the monoclonal antibody. Follow applicable proper handling and disposal procedure (see Special Instructions for Use, Handling and Disposal under Cautions for Usage).

There is no experience with overdose in human clinical trials. The highest dose tested to date is 2.4 mg/kg administered as an intravenous infusion; it was associated with a higher frequency and severity of PN events. Patients who experience overdose should have immediate interruption of their infusion and be closely monitored.

Polivy is contraindicated in patients with a known hypersensitivity to polatuzumab vedotin or any of the excipients.

Traceability: In order to improve traceability of biological medicinal products, the trade name and the batch number of the administered product should be clearly recorded.
Myelosuppression: Serious and severe neutropenia and febrile neutropenia have been reported in patients treated with Polivy as early as the first cycle of treatment. Prophylactic G-CSF administration was required in the clinical development and should be considered. Grade 3 or 4 thrombocytopenia or anemia can also occur with Polivy. Complete blood counts should be monitored prior to each dose of Polivy. More frequent lab monitoring and/or Polivy delays or discontinuation should be considered in patients with Grade 3 or Grade 4 neutropenia and thrombocytopenia (see Dosage & Administration).
Peripheral Neuropathy (PN): Peripheral neuropathy has been reported in patients treated with Polivy as early as the first cycle of treatment, and the risk increases with sequential doses. Patients with pre-existing peripheral neuropathy may experience worsening of this condition. Peripheral neuropathy reported with Polivy treatment is predominantly sensory peripheral neuropathy; however, motor and sensorimotor peripheral neuropathy have also been reported. Patients should be monitored for symptoms of peripheral neuropathy such as hypoesthesia, hyperesthesia, paresthesia, dysesthesia, neuropathic pain, burning sensation, muscle weakness, or gait disturbance. Patients experiencing new or worsening peripheral neuropathy may require a delay, dose reduction, or discontinuation of Polivy (see Dosage & Administration).
Infections: Serious, life threatening, or fatal infections, including opportunistic infections, such as pneumonia (including Pneumocystis jirovecii and other fungal pneumonia), bacteremia, sepsis, herpes infection, and cytomegalovirus infection have been reported in patients treated with Polivy (see Adverse Reactions). Reactivation of latent infections has been reported. Patients should be closely monitored during treatment for signs of bacterial, fungal, or viral infections and seek medical advice if signs and symptom appear. Anti-infective prophylaxis should be considered throughout treatement with Polivy.
Polivy should not be administered in the presence of an active severe infection. Polivy and any concomitant chemotherapy should be discontinued in patients who develop serious infections.
Human Immunodeficiency Virus (HIV): Polivy has not been evaluated in patients with HIV. With regard to co-administration of CYP3A-inhibitors see Interactions.
Immunization: Live or live-attenuated vaccines should not be given concurrently with the treatment. Studies have not been conducted in patients who recently received live vaccines.
Progressive Multifocal Leukoencephalopathy (PML): PML has been reported with Polivy treatment (see Adverse Reactions). Patients should be monitored closely for new or worsening neurological, cognitive, or behavioral changes suggestive of PML. Polivy and any concomitant chemotherapy should be withheld if PML is suspected and permanently discontinued if the diagnosis is confirmed.
Tumor Lysis Syndrome (TLS): Patients with high tumor burden and rapidly proliferative tumor may be at increased risk of tumor lysis syndrome. Appropriate measures in accordance with local guidelines should be taken prior to treatment with Polivy. Patients should be monitored closely for tumor lysis syndrome during treatment with Polivy.
Infusion-related reactions: Polivy can cause IRRs, including severe cases. Delayed IRRs as late as 24 hours after receiving Polivy have occurred. An antihistamine and antipyretic should be administered prior to the administration of Polivy, and patients should be monitored closely throughout the infusion. If an IRR occurs, the infusion should be interrupted and appropriate medical management should be instituted (see Dosage & Administration).
Fertility: In non-clinical studies, polatuzumab vedotin has resulted in testicular toxicity, and may impair male reproductive function and fertility (see Pharmacology: Toxicology: Preclinical safety data under Actions). Therefore, men being treated with Polivy are advised to have sperm samples preserved and stored before treatment (see Use in Pregnancy & Lactation).
Hepatic Toxicity: Serious cases of hepatic toxicity that were consistent with hepatocellular injury, including elevations of transaminases and/or bilirubin, have occurred in patients treated with Polivy (see Adverse Reactions). Preexisting liver disease, elevated baseline liver enzymes, and concomitant medications may increase the risk. Liver enzymes and bilirubin level should be monitored. (See Special populations under Dosage & Administration and Pharmacology: Pharmacokinetics: Hepatic impairment under Actions.)
Excipients: This medicinal product contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially 'sodium-free'.
Effects on ability to drive and use of machines: Polivy has minor influence on the ability to drive and use machines.
Infusion related reactions, peripheral neuropathy, fatigue, and dizziness may occur during treatment with Polivy (see previous text and Adverse Reactions).
Use in Pregnancy: Embryo-Fetal Toxicity: Based on the mechanism of action and nonclinical studies, Polivy can be harmful to the fetus when administered to a pregnant woman (see Pharmacology: Toxicology: Preclinical safety data under Actions). Pregnant woman should be advised regarding risk to the fetus.
Women of childbearing potential should be advised to use effective contraception during treatment with Polivy and for at least 9 months after the last dose (see Use in Pregnancy & Lactation). Male patients with female partners of childbearing potential should be advised to use effective contraception during treatment with Polivy and for at least 6 months after the last dose (see Use in Pregnancy & Lactation).
Use in the Elderly: Among 173 patients treated with Polivy in Study GO29365, 95 (55%) were ≥65 years of age. Patients aged ≥65 had a numerically higher incidence of serious adverse reactions (64%) than patients aged <65 (53%). Clinical studies of Polivy did not include sufficient numbers of patients aged ≥65 to determine whether they respond differently from younger patients.

Women of childbearing potential/Contraception in males and females: Women: Women of childbearing potential should be advised to use effective contraception during treatment with polatuzumab vedotin and for at least 9 months after the last dose.
Men: Male patients with female partners of childbearing potential should be advised to use effective contraception during treatment with Polivy and for at least 6 months after the last dose.
Pregnancy: There are no data in pregnant women using Polivy. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). Based on the mechanism of action and nonclinical studies, polatuzumab vedotin can be harmful to the foetus when administered to a pregnant woman. In women of childbearing potential, the pregnancy status shall be checked prior to treatment. Polivy is not recommended during pregnancy and in women of childbearing potential not using contraception unless the potential benefit for the mother outweighs the potential risk to the foetus.
Breast-feeding: It is not known whether polatuzumab vedotin or its metabolites are excreted in human breast milk. A risk for breast-feeding children cannot be excluded. Women should discontinue breast-feeding during treatment with Polivy and for at least 3 months after the last dose.
Fertility: In nonclinical studies, polatuzumab vedotin has resulted in testicular toxicity, and may impair male reproductive function and fertility (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Therefore, men being treated with this medicine are advised to have sperm samples preserved and stored before treatment. Men being treated with Polivy are advised not to father a child during treatment and for up to 6 months following the last dose.

Clinical Trials: Summary of the safety profile: For the clinical development program of Polivy as a whole, an estimated total of 1429 patients have received Polivy. The adverse drug reactions (ADRs) described in this section were identified during treatment and follow-up of previously treated diffuse large B-cell lymphoma (DLBCL) patients (n=151) from the pivotal clinical trial GO29365. This includes run-in phase patients (n=6) and randomized patients (n=39), and extension cohort patients (n=106) who received Polivy in combination with bendamustine and rituximab (BR) compared to randomized patients (n=39) who received BR alone. Patients in the Polivy treatment arm received a median of 5 cycles of treatment while randomized patients in the comparator arm received a median of 3 cycles of treatment.
The most frequently-reported (≥30%) ADRs in patients treated with Polivy in combination with BR were anemia (46.7%), thrombocytopenia (46.7%), neutropenia (46.7%), diarrhea (37.8%), nausea (33.3%) and peripheral neuropathy. Serious adverse events were reported in 55.6% of Polivy plus BR treated patients which included the following that occurred in >5% of patients: febrile neutropenia (9.3%), pyrexia (7.9%), pneumonia (6.6%), and sepsis (6.6%).
The ADR leading to treatment regimen discontinuation in >5% of patients was thrombocytopenia (6.0%).
Tabulated list of ADRs from clinical trials: The ADRs are listed as follows by MedDRA system organ class (SOC) and categories of frequency. The corresponding frequency category for each adverse drug reaction is based on the following convention: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1000), very rare (< 1/10,000). Within each frequency grouping, adverse reactions are presented in the order of decreasing seriousness. (See Table 6.)

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Description of selected adverse drug reactions from clinical trials: In the Polivy plus BR arm, Grade 3 or higher neutropenia, thrombocytopenia, and anaemia were reported in 40%, 37.8%, and 24.4% of patients, respectively.
Myelosuppression: 4.0% of patients in the Polivy plus BR arm discontinued Polivy due to neutropenia compared to 2.6% of patients in the BR arm who discontinued treatment due to neutropenia. Thrombocytopenia events led to discontinuation of treatment in 7.9% of patients in the Polivy plus BR arms and 5.1% of patients in the BR arm. No patients discontinued treatment due to anemia in either the Polivy plus BR arms or BR arm.
Peripheral Neuropathy (PN): In the Polivy plus BR arms, Grade 1 and 2 PN events were reported in 15.9% and 12.6% of patients, respectively. In the BR arm, Grade 1 and 2 PN events were reported in 2.6% and 5.1% of patients, respectively. One Grade 3 PN event was reported in the Polivy plus BR arms and no Grade 3 PN events were reported in the BR arm. No Grade 4-5 PN events were reported in either the Polivy plus BR arm or BR arm. 2.6% of patients discontinued Polivy treatment due to PN and 2.0% of patients had Polivy dose reduction due to PN. No patients in the BR arm discontinued treatment or had dose reductions due to PN. In the Polivy plus BR arm, the median onset to first event of PN was 1.6 months, and 39.1% of patients with PN events reported event resolution.
Infections: Infections, including pneumonia and other types of infections, were reported in 48.3% of patients in the Polivy plus BR arms and 51.3% of patients in the BR arm. In the Polivy plus BR arms, serious infections were reported in 27.2% of patients and fatal infections were reported in 6.6% of patients. In the BR arm, serious infections were reported in 30.8% of patients and fatal infections were reported in 10.3% of patients. Four patients (2.6%) in the Polivy plus BR arms discontinued treatment due to infection compared to 2 patients (5.1%) of patients in the BR arm.
Progressive Multifocal Leukoencephalopathy (PML): One case of PML, which was fatal, occurred in one patient treated with Polivy plus bendamustine and obinutuzumab. This patient had three prior lines of therapy that included anti-CD20 antibodies.
Hepatic toxicity: In another study, two cases of serious hepatic toxicity (hepatocellular injury and hepatic steatosis) were reported and were reversible.
Gastrointestinal Toxicity: Gastrointestinal toxicity events were reported in 72.8% of patients in the Polivy plus BR arms compared to 66.7% of patients in the BR arm. Most events were Grade 1-2, and Grade 3-4 events were reported in 16.5% of patients in the Polivy plus BR arms compared to 12.9% of patients in the BR arm. The most common gastrointestinal toxicity events were diarrhea and nausea.
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 via the national reporting system.

No dedicated clinical drug-drug interaction studies with Polivy in humans have been conducted.
Drug interactions with co-medications that are CYP3A inhibitors, inducers or substrates and co-medicatins that are P-gp inhibitors: Based on physiological-based pharmacokinetic (PBPK) model simulations of MMAE released from polatuzumab vedotin, strong CYP3A inhibitors and P-gp inhibitors (e.g., ketoconazole) may increase the area under the concentration-time curve (AUC) of unconjugated MMAE by 48%. Caution is advised in case of concomitant treatment with CYP3A inhibitor. Patients receiving concomitant strong CYP3A4 inhibitors (e.g., boceprevir, clarithromycin, cobicistat, indinavir, itraconazole, nefazodone, nelfinavir, posaconazole, ritonavir, saquinavir, telaprevir, telithromycin, voriconazole) should be monitored more closely for signs of toxicities.
Unconjugated MMAE is not predicted to alter the AUC of concomitant drugs that are CYP3A substrates (e.g., midazolam).
Strong CYP3A4 inducers (e.g., rifampicin, carbamazepine, phenobarbital, phenytoin, St John's wort [Hypericum perforatum]) may decrease the exposure of unconjugated MMAE.
Drug interactions of rituximab and bendamustine in combination with polatuzumab vedotin: The pharmacokinetics (PK) of rituximab and bendamustine are not affected by co-administration with Polivy. Concomitant rituximab is associated with increased antibody conjugated MMAE (acMMAE) plasma AUC by 24% and decreased unconjugated MMAE plasma AUC by 37%, based on population PK analysis. No dose adjustment is required.
Bendamustine does not affect acMMAE and unconjugated MMAE plasma AUC.

Incompatibilities: Do not mix Polivy with, or administer through the same infusion line, as other medicinal products.
No incompatibilities have been observed between Polivy and IV infusion bags with product contacting materials of polyvinyl chloride (PVC), or polyolefins (PO) such as polyethylene (PE) and polypropylene (PP). In addition, no incompatibilities have been observed with infusion sets or infusion aids with product contacting materials of PVC, PE, polyurethane (PU), polybutadiene (PBD), acrylonitrile butadiene styrene (ABS), polycarbonate (PC), polyetherurethane (PEU), fluorinated ethylene propylene (FEP), or polytetrafluorethylene (PTFE), or with filter membranes composed of polyether sulfone (PES) or polysulfone (PSU).
Special Instructions for Use, Handling and Disposal: Polivy must be reconstituted using sterile water for injection and diluted into an IV infusion bag containing 0.9% sodium chloride, 0.45% sodium chloride, or 5% dextrose by a healthcare professional prior to administration.
Use aseptic technique for reconstitution and dilution of Polivy. Appropriate procedures for the preparation of antineoplastic products should be used.
The reconstituted product contains no preservative and is intended for single-dose usage only. Discard any unused portion.
A dedicated infusion line equipped with a sterile, non-pyrogenic, low-protein binding in-line or add-on filter (0.2 or 0.22 µm pore size) and catheter must be used to administer diluted Polivy.
Reconstitution: 1. Using a sterile syringe, slowly inject 1.8 mL of sterile water for injection into the 30 mg Polivy vial or 7.2 mL of sterile water for injection into the 140 mg Polivy vial to yield a single-dose solution containing 20 mg/mL polatuzumab vedotin. Direct the stream toward the wall of the vial and not directly on the lyophilized cake.
2. Swirl the vial gently until completely dissolved. Do not shake.
3. Inspect the reconstituted solution for discoloration and particulate matter. The reconstituted solution should appear colorless to slightly brown, clear to slightly opalescent, and free of visible particulates. Do not use if the reconstituted solution is discolored, cloudy, or contains visible particulates.
From a microbiological point of view, the reconstituted 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 to 8°C, unless reconstitution has taken place in controlled and validated aseptic conditions.
Chemical and physical in-use stability of the reconstituted solution has been demonstrated for up to 72 hours at 2°C to 8°C and up to 24 hours at room temperature (9°C to 25°C).
Dilution: 1. Polatuzumab vedotin must be diluted to a final concentration of 0.72-2.7 mg/mL in an IV infusion bag with a minimum volume of 50mL containing 0.9% sodium chloride, 0.45% sodium chloride, or 5% dextrose.
2. Determine the volume of 20 mg/mL reconstituted solution needed based on the required dose: (See equation.)

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3. Withdraw the required volume of reconstituted solution from the Polivy vial using a sterile syringe and dilute into the IV infusion bag. Discard any unused portion left in the vial.
4. Gently mix the IV bag by slowly inverting the bag. Do not shake.
5. Inspect the IV bag for particulates and discard if present.
From a microbiological point of view, the prepared solution for infusion should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C, unless dilution has taken place in controlled and validated aseptic conditions. Acceptable chemical and physical stability of the prepared solution for infusion has been demonstrated for the durations listed in Table 7. Discard if storage time exceeds these limits. Do not freeze or expose to direct sunlight. (See Table 7.)

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Avoid transportation of the prepared solution for infusion as agitation stress can result in aggregation. If the prepared solution for infusion will be transported, remove air from the infusion bag and limit transportation to 30 minutes at 9°C to 25°C or 24 hours at 2°C to 8°C. If air is removed, an infusion set with a vented spike is required to ensure accurate dosing during the infusion.
Disposal of unused/expired medicines: The release of pharmaceuticals in the environment should be minimized. Medicines should not be disposed of via wastewater and disposal through household waste should be avoided.
The following points should be strictly adhered to regarding the use and disposal of syringes and other medicinal sharps: Needles and syringes should never be reused.
Place all used needles and syringes into a sharps container (puncture-proof disposable container).
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Vials: Store unopened vials at 2°C to 8°C.
Keep vial in the outer carton in order to protect from light.
Do not freeze. Do not shake.
The reconstituted solution and solution for infusion should not be frozen or exposed to direct sunlight.

Targeted Cancer Therapy

L01FX14 - polatuzumab vedotin ; Belongs to the class of other monoclonal antibodies and antibody drug conjugates. Used in the treatment of cancer.

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