Teclistamab-cqyv
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parth Vikram Singh, MBBS[2]
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Black Box Warning
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CYTOKINE RELEASE SYNDROME and NEUROLOGIC TOXICITY including IMMUNE EFFECTOR CELL-ASSOCIATED NEUROTOXICITY SYNDROME
See full prescribing information for complete Boxed Warning.
Condition Name: (Cytokine release syndrome (CRS), including life-threatening or fatal reactions, can occur in patients receiving TECVAYLI. Initiate treatment with TECVAYLI step-up dosing schedule to reduce risk of CRS. Withhold TECVAYLI until CRS resolves or permanently discontinue based on severity.
Neurologic toxicity, including Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) and serious and life-threatening reactions, can occur in patients receiving TECVAYLI. Monitor patients for signs or symptoms of neurologic toxicity, including ICANS, during treatment. Withhold TECVAYLI until neurologic toxicity resolves or permanently discontinue based on severity. TECVAYLI is available only through a restricted program called the TECVAYLI and TALVEY Risk Evaluation and Mitigation Strategy (REMS). |
Overview
Teclistamab-cqyv is a bispecific B-cell maturation antigen (BCMA) that is FDA approved for the treatment of adult patients with relapsed or refractory multiple myeloma who have received at least four prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody.. There is a Black Box Warning for this drug as shown here. Common adverse reactions include pyrexia, cytokine release syndrome,musculoskeletal pain, injection site reaction, fatigue, upper respiratory tract infection, nausea, headache, pneumonia, and diarrhea.
The most common Grade 3 to 4 laboratory abnormalities (≥20%) are decreased lymphocytes, decreased neutrophils, decreased white blood cells, decreased hemoglobin, and decreased platelets..
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
TECVAYLI is a bispecific B-cell maturation antigen (BCMA)-directed CD3 T-cell engager indicated for the treatment of adult patients with relapsed or refractory multiple myeloma who have received at least four prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody.
This indication is approved under accelerated approval based on response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. Injection
30 mg/3 mL (10 mg/mL) in a single-dose vial. 153 mg/1.7 mL (90 mg/mL) in a single-dose vial.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Teclistamab-cqyv in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Teclistamab-cqyv in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Teclistamab-cqyv FDA-Labeled Indications and Dosage (Pediatric) in the drug label.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Teclistamab-cqyv in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Teclistamab-cqyv in pediatric patients.
Contraindications
None.
Warnings
|
CYTOKINE RELEASE SYNDROME and NEUROLOGIC TOXICITY including IMMUNE EFFECTOR CELL-ASSOCIATED NEUROTOXICITY SYNDROME
See full prescribing information for complete Boxed Warning.
Condition Name: (Cytokine release syndrome (CRS), including life-threatening or fatal reactions, can occur in patients receiving TECVAYLI. Initiate treatment with TECVAYLI step-up dosing schedule to reduce risk of CRS. Withhold TECVAYLI until CRS resolves or permanently discontinue based on severity.
Neurologic toxicity, including Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) and serious and life-threatening reactions, can occur in patients receiving TECVAYLI. Monitor patients for signs or symptoms of neurologic toxicity, including ICANS, during treatment. Withhold TECVAYLI until neurologic toxicity resolves or permanently discontinue based on severity. TECVAYLI is available only through a restricted program called the TECVAYLI and TALVEY Risk Evaluation and Mitigation Strategy (REMS). |
Cytokine Release Syndrome
- TECVAYLI can cause cytokine release syndrome (CRS), including life-threatening or fatal reactions.
- In the clinical trial, CRS occurred in 72% of patients who received TECVAYLI at the recommended dose, with Grade 1 CRS occurring in 50% of patients, Grade 2 in 21%, and Grade 3 in 0.6%. Recurrent CRS occurred in 33% of patients. Most patients experienced CRS following step-up dose 1 (42%), step-up dose 2 (35%), or the initial treatment dose (24%). Less than 3% of patients developed first occurrence of CRS following subsequent doses of TECVAYLI. The median time to onset of CRS was 2 (range: 1 to 6) days after the most recent dose with a median duration of 2 (range: 1 to 9) days.
- Clinical signs and symptoms of CRS included, but were not limited to, fever, hypoxia, chills, hypotension, sinus tachycardia, headache, and elevated liver enzymes (aspartate aminotransferase and alanine aminotransferase elevation).
- Initiate therapy according to TECVAYLI step-up dosing schedule to reduce risk of CRS.
- Administer pretreatment medications to reduce risk of CRS and monitor patients following administration of TECVAYLI accordingly.
- At the first sign of CRS, immediately evaluate patient for hospitalization. Administer supportive care based on severity and consider further management per current practice guidelines. Withhold or permanently discontinue TECVAYLI based on severity.
- TECVAYLI is available only through a restricted program under a REMS.
Neurologic Toxicity including ICANS
TECVAYLI can cause serious or life-threatening neurologic toxicity, including Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS)
- In the clinical trial, neurologic toxicity occurred in 57% of patients who received TECVAYLI at the recommended dose, with Grade 3 or 4 neurologic toxicity occurring in 2.4% of patients. The most frequent neurologic toxicities were headache (25%), motor dysfunction (16%), sensory neuropathy (15%), and encephalopathy (13%).
- With longer follow-up, Grade 4 seizure and fatal Guillain-Barré syndrome (one patient each) occurred in patients who received TECVAYLI.
In the clinical trial, ICANS was reported in 6% of patients who received TECVAYLI at the recommended dose.
- Recurrent ICANS occurred in 1.8% of patients. Most patients experienced ICANS following step-up dose 1 (1.2%), step-up dose 2 (0.6%), or the initial treatment dose (1.8%). Less than 3% of patients developed first occurrence of ICANS following subsequent doses of TECVAYLI. The median time to onset of ICANS was 4 (range: 2 to 8) days after the most recent dose with a median duration of 3 (range: 1 to 20) days. The most frequent clinical manifestations of ICANS reported were confusional state and dysgraphia. The onset of ICANS can be concurrent with CRS, following resolution of CRS, or in the absence of CRS.
- Monitor patients for signs and symptoms of neurologic toxicity during treatment. At the first sign of neurologic toxicity, including ICANS, immediately evaluate patient and provide supportive therapy based on severity. Withhold or permanently discontinue TECVAYLI based on severity per recommendations and consider further management per current practice guidelines.
- Due to the potential for neurologic toxicity, patients receiving TECVAYLI are at risk of depressed level of consciousness.
- Advise patients to refrain from driving or operating heavy or potentially dangerous machinery during and for 48 hours after completion of TECVAYLI step-up dosing schedule and in the event of new onset of any neurologic toxicity symptoms until neurologic toxicity resolves.
- TECVAYLI is available only through a restricted program under a REMS.
TECVAYLI and TALVEY REMS
- TECVAYLI is available only through a restricted program under a REMS called the TECVAYLI and *TALVEY REMS because of the risks of CRS and neurologic toxicity, including ICANS.
Notable requirements of the TECVAYLI and TALVEY REMS include the following: • Prescribers must be certified with the program by enrolling and completing training. • Prescribers must counsel patients receiving TECVAYLI about the risk of CRS and neurologic toxicity, including ICANS, and provide patients with Patient Wallet Card. • Pharmacies and healthcare settings that dispense TECVAYLI must be certified with the TECVAYLI and TALVEY REMS program and must verify prescribers are certified through the TECVAYLI and TALVEY REMS program. • Wholesalers and distributers must only distribute TECVAYLI to certified pharmacies or healthcare settings. Further information about the TECVAYLI and TALVEY REMS program is available at www.TEC-TALREMS.com or by telephone at 1-855-810-8064.
Hepatotoxicity
- TECVAYLI can cause hepatotoxicity, including fatalities.
- In patients who received TECVAYLI at the recommended dose in the clinical trial, there was one fatal case of hepatic failure.
- Elevated aspartate aminotransferase (AST) occurred in 34% of patients, with Grade 3 or 4 elevations in 1.2%. Elevated alanine aminotransferase (ALT) occurred in 28% of patients, with *Grade 3 or 4 elevations in 1.8%. Elevated total bilirubin occurred in 6% of patients with Grade 3 or 4 elevations in 0.6%. Liver enzyme elevation can occur with or without concurrent CRS.
- Monitor liver enzymes and bilirubin at baseline and during treatment as clinically indicated. Withhold TECVAYLI or consider permanent discontinuation of TECVAYLI based on severity.
Infections
- TECVAYLI can cause severe, life-threatening, or fatal infections. In patients who received *TECVAYLI at the recommended dose in the clinical trial, serious infections, including opportunistic infections, occurred in 30% of patients, with Grade 3 or 4 infections in 35%, and fatal infections in 4.2% .
- Monitor patients for signs and symptoms of infection prior to and during treatment with TECVAYLI and treat appropriately. Administer prophylactic antimicrobials according to guidelines.
- Withhold TECVAYLI or consider permanent discontinuation of TECVAYLI based on severity.
- Monitor immunoglobulin levels during treatment with TECVAYLI and treat according to guidelines, including infection precautions and antibiotic or antiviral prophylaxis.
Neutropenia
- TECVAYLI can cause neutropenia and febrile neutropenia. In patients who received TECVAYLI at the recommended dose in the clinical trial, decreased neutrophils occurred in 84% of patients, with Grade 3 or 4 decreased neutrophils in 56%. Febrile neutropenia occurred in 3% of patients.
- Monitor complete blood cell counts at baseline and periodically during treatment and provide *supportive care per local institutional guidelines.
- Monitor patients with neutropenia for signs of infection.
- Withhold TECVAYLI based on severity.
Hypersensitivity and Other Administration Reactions
- TECVAYLI can cause both systemic administration-related reactions and local injection-site reactions.
Systemic Reactions
- In patients who received TECVAYLI at the recommended dose in the clinical trial, 1.2% of patients experienced systemic-administration reactions, which included Grade 1 recurrent pyrexia and Grade 1 swollen tongue.
Local Reactions
- In patients who received TECVAYLI at the recommended dose in the clinical trial, injection-site reactions occurred in 35% of patients with Grade 1 injection-site reactions in 30% and Grade 2 in 4.8%.
- Withhold TECVAYLI or consider permanent discontinuation of TECVAYLI based on severity.
Embryo-Fetal Toxicity
- Based on its mechanism of action, TECVAYLI may cause fetal harm when administered to a pregnant woman.
- Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with TECVAYLI and for 5 months after the last dose.
Adverse Reactions
Clinical Trials Experience
• Cytokine Release Syndrome. • Neurologic Toxicity including ICANS. • Hepatotoxicity. • Infections. • Neutropenia. • Hypersensitivity and Other Administration Reactions.
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.
Relapsed/Refractory Multiple Myeloma
MajesTEC-1
- The safety of TECVAYLI was evaluated in MajesTEC-1. which included adult patients with relapsed or refractory multiple myeloma. Patients received step-up doses of 0.06 mg/kg and 0.3 mg/kg of TECVAYLI followed by TECVAYLI 1.5 mg/kg, subcutaneously once weekly (N=165). Among patients who received TECVAYLI, 47% were exposed for 6 months or longer and 7% were exposed for one year or longer.
The median age of patients who received TECVAYLI was 64 years (range: 33 to 84 years); 58% were male; 81% were White, 13% were Black or African American, and 2% were Asian.
- Serious adverse reactions occurred in 54% of patients who received TECVAYLI. Serious adverse reactions in >2% of patients included pneumonia (15%), cytokine release syndrome (8%), sepsis (6%), general physical health deterioration (6%), COVID-19 (6%), acute kidney injury (4.8%), pyrexia (4.8%), musculoskeletal pain (2.4%), and encephalopathy (2.4%).
- Fatal adverse reactions occurred in 5% of patients who received TECVAYLI, including COVID-19 (1.8%), pneumonia (1.8%), septic shock (0.6%), acute renal failure (0.6%), and hemoperitoneum (0.6%).
- Permanent discontinuation of TECVAYLI due to adverse reactions occurred in 1.2% of patients. Adverse reactions resulting in permanent discontinuation of TECVAYLI included pneumonia (adenoviral and pneumocystis jirovecii pneumonia in the same patient) and hypercalcemia.
- Dosage interruptions of TECVAYLI due to an adverse reaction occurred in 73% of patients. Adverse reactions which required dosage interruption in >5% of patients included neutropenia, pneumonia, pyrexia, cytokine release syndrome, upper respiratory tract infection, and COVID-19.
- The most common adverse reactions (≥20%) were pyrexia, CRS, musculoskeletal pain, injection site reaction, fatigue, upper respiratory tract infection, nausea, headache, pneumonia, and diarrhea. The most common Grade 3 to 4 laboratory abnormalities (≥20%) were decreased lymphocytes, decreased neutrophils, decreased white blood cells, decreased hemoglobin, and decreased platelets.
Table 10 summarizes the adverse reactions in MajesTEC-1.
Clinically relevant adverse reactions in <10% of patients who received TECVAYLI included febrile neutropenia, sepsis, ICANS, seizure, Guillain-Barré syndrome, hepatic failure, and new onset or reactivated viral infections (including adenovirus, hepatitis B virus (HBV), cytomegalovirus (CMV), varicella zoster virus (VZV), herpes simplex virus (HSV), and progressive multifocal leukoencephalopathy (PML). Table 11 summarizes laboratory abnormalities in MajesTEC-1.
Postmarketing Experience
There is limited information regarding Teclistamab-cqyv Postmarketing Experience in the drug label.
Drug Interactions
- TECVAYLI causes release of cytokines that may suppress activity of cytochrome P450 (CYP) enzymes, resulting in increased exposure of CYP substrates.
- The highest risk of drug-drug interaction is expected to occur from initiation of TECVAYLI step-up dosing schedule up to 7 days after the first treatment dose and during and after CRS.
- Monitor for toxicity or concentrations of drugs that are CYP substrates where minimal concentration changes may lead to serious adverse reactions.
- Adjust the dose of the concomitant CYP substrate drug as needed.
Use in Specific Populations
Pregnancy
Risk Summary
- Based on the mechanism of action, TECVAYLI may cause fetal harm when administered to a pregnant woman.
- There are no available data on the use of TECVAYLI in pregnant women to evaluate for a drug associated risk.
- No animal reproductive or developmental toxicity studies have been conducted with TECVAYLI. Teclistamab-cqyv causes T-cell activation and cytokine release; immune activation may compromise pregnancy maintenance. *Human immunoglobulin G (IgG) is known to cross the placenta; therefore, teclistamab-cqyv has the potential to be transmitted from the mother to the developing fetus. Advise women of the potential risk to the fetus.
- TECVAYLI is associated with hypogammaglobulinemia, therefore, assessment of immunoglobulin levels in newborns of mothers treated with TECVAYLI should be considered.
- 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
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Teclistamab-cqyv in women who are pregnant.
Labor and Delivery
There is no FDA guidance on use of Teclistamab-cqyv during labor and delivery.
Nursing Mothers
Risk Summary
- There are no data on the presence of teclistamab-cqyv in human milk, the effect on the breastfed child, 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 child to TECVAYLI are unknown.
- Because of the potential for serious adverse reactions in a breastfed child, advise women not to breastfeed during treatment with TECVAYLI and for 5 months after the last dose.
Pediatric Use
The safety and efficacy of TECVAYLI have not been established in pediatric patients.
Geriatic Use
- Of the 165 patients with relapsed or refractory multiple myeloma treated with TECVAYLI in MajesTEC-1 at the recommended dosage, 48% were 65 years of age or older, and 15% were 75 years of age or older.
- No overall differences in safety or effectiveness were observed between patients 65 to 74 years of age compared to younger patients.
- There is an insufficient number of patients 75 years of age or older to assess whether there are differences in safety or effectiveness.
Gender
There is no FDA guidance on the use of Teclistamab-cqyv with respect to specific gender populations.
Race
There is no FDA guidance on the use of Teclistamab-cqyv with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Teclistamab-cqyv in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Teclistamab-cqyv in patients with hepatic impairment.
Females of Reproductive Potential and Males
TECVAYLI may cause fetal harm when administered to a pregnant woman.
Pregnancy Testing
Verify pregnancy status of females of reproductive potential prior to initiating TECVAYLI.
Contraception
Females
Advise females of reproductive potential to use effective contraception during treatment and for 5 months after the last dose of TECVAYLI.
Immunocompromised Patients
There is no FDA guidance one the use of Teclistamab-cqyv in patients who are immunocompromised.
Immunogenicity
- The observed incidence of anti-drug antibodies 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 teclistamab-cqyv or of other teclistamab products.
- During treatment in MajesTEC-1 (up to 27 months), 1/186 (0.5%) of patients treated with subcutaneous TECVAYLI at various dosages developed anti-teclistamab-cqyv antibodies. Because of the low occurrence of anti-drug antibodies, the effect of these antibodies on the pharmacokinetics, pharmacodynamics, safety, and/or effectiveness of teclistamab products is unknown.
Administration and Monitoring
Administration
Recommended Dosage
For subcutaneous injection only. The recommended dosing schedule for TECVAYLI is provided in Table 1. The recommended dosage of TECVAYLI is step-up doses of 0.06 mg/kg and 0.3 mg/kg followed by 1.5 mg/kg once weekly until disease progression or unacceptable toxicity. In patients who have achieved and maintained a complete response or better for a minimum of 6 months, the dosing frequency may be decreased to 1.5 mg/kg every two weeks until disease progression or unacceptable toxicity. Administer pretreatment medications prior to each dose of the TECVAYLI step-up dosing schedule, which includes step-up dose 1, step-up dose 2, and the first treatment dose as described in Table 1
.
Administer TECVAYLI subcutaneously according to the step-up dosing schedule in Table 1 to reduce the incidence and severity of cytokine release syndrome (CRS). Due to the risk of CRS and neurologic toxicity, including ICANS, patients should be hospitalized for 48 hours after administration of all doses within the TECVAYLI step-up dosing schedule. Refer to Tables 7, 8, and 9 to determine the dosage based on predetermined weight ranges..
Recommended Pretreatment Medications
Administer the following pretreatment medications 1 to 3 hours before each dose of the TECVAYLI step-up dosing schedule, which includes step-up dose 1, step-up dose 2, and the first treatment dose (see TABLE 1), to reduce the risk of CRS. • Corticosteroid (oral or intravenous dexamethasone 16 mg) • Histamine-1 (H1) receptor antagonist (oral or intravenous diphenhydramine 50 mg or equivalent) • Antipyretics (oral or intravenous acetaminophen 650 mg to 1,000 mg or equivalent) Administration of pretreatment medications may be required prior to administration of subsequent doses of TECVAYLI in the following patients: • Patients who repeat doses within the TECVAYLI step-up dosing schedule following a dose delay. • Patients who experienced CRS following the prior dose of TECVAYLI.
Prophylaxis for Herpes Zoster Reactivation
Prior to starting treatment with TECVAYLI, consider initiation of antiviral prophylaxis to prevent herpes zoster reactivation per guidelines.
Restarting TECVAYLI after Dosage Delay
If a dose of TECVAYLI is delayed, restart therapy based on the recommendations in Table 2 and resume the treatment schedule accordingly. .Administer pretreatment medications as indicated in Table 2 .Due to the risk of CRS and neurologic toxicity, including ICANS, patients should be hospitalized for 48 hours after administration of all doses within the TECVAYLI step-up dosing schedule.
Dosage Modifications for Adverse Reactions
Dosage reductions of TECVAYLI are not recommended. Dosage delays may be required to manage toxicities related to TECVAYLI. See TABLES 3, 4, and 5 for recommended actions for adverse reactions of CRS, neurologic toxicity, and ICANS. See TABLE 6 for recommended actions for other adverse reactions following administration of TECVAYLI.
Management of CRS, Neurologic Toxicity and ICANS
Cytokine Release Syndrome (CRS) Management recommendations for CRS are summarized in Table 3.
Identify CRS based on clinical presentation. Evaluate and treat other causes of fever, hypoxia, and hypotension. If CRS is suspected, withhold TECVAYLI until CRS resolves. Manage according to the recommendations in Table 3 and consider further management per current practice guidelines. Administer supportive therapy for CRS, which may include intensive care for severe or life-threatening CRS. Consider laboratory testing to monitor for disseminated intravascular coagulation (DIC), hematology parameters, as well as pulmonary, cardiac, renal, and hepatic function. Neurologic Toxicity and ICANS Management recommendations for neurologic toxicity and ICANS are summarized in Tables 4 and 5. At the first sign of neurologic toxicity, including ICANS, withhold TECVAYLI and consider neurology evaluation. Rule out other causes of neurologic symptoms. Provide supportive therapy, which may include intensive care, for severe or life-threatening neurologic toxicities, including ICANS. Manage ICANS according to the recommendations in Table 5 and consider further management per current practice guidelines.
Preparation and Administration
TECVAYLI is intended for subcutaneous use by a healthcare provider only. TECVAYLI should be administered by a healthcare provider with adequate medical personnel and appropriate medical equipment to manage severe reactions, including CRS and ICANS. TECVAYLI is a clear to slightly opalescent, colorless to light yellow solution. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if the solution is discolored, or cloudy, or if foreign particles are present. TECVAYLI 30 mg/3 mL (10 mg/mL) vial and TECVAYLI 153 mg/1.7 mL (90 mg/mL) vial are supplied as ready-to-use solution that do not need dilution prior to administration. Do not combine TECVAYLI vials of different concentrations to achieve treatment dose. Use aseptic technique to prepare and administer TECVAYLI.
Preparation of TECVAYLI
Refer to the following reference tables for the preparation of TECVAYLI. Refer to Tables 7, 8, and 9 below to determine the dosage based on predetermined weight ranges. Use Table 7 to determine total dose, injection volume and number of vials required based on patient's actual body weight for step-up dose 1 using TECVAYLI 30 mg/3 mL (10 mg/mL) vial.
Remove the appropriate strength TECVAYLI vial from refrigerated storage [2°C to 8°C (36°F to 46°F)]. Once removed from refrigerated storage, equilibrate TECVAYLI to ambient temperature [15°C to 30°C (59°F to 86°F)] for at least 15 minutes. Do not warm TECVAYLI in any other way. Once equilibrated, gently swirl the vial for approximately 10 seconds to mix. Do not shake. Withdraw the required injection volume of TECVAYLI from the vial(s) into an appropriately sized syringe using a transfer needle. Each injection volume should not exceed 2 mL. Divide doses requiring greater than 2 mL equally into multiple syringes. TECVAYLI is compatible with stainless steel injection needles and polypropylene or polycarbonate syringe material. Replace the transfer needle with an appropriately sized needle for injection.
Administration of TECVAYLI
Inject the required volume of TECVAYLI into the subcutaneous tissue of the abdomen (preferred injection site). Alternatively, TECVAYLI may be injected into the subcutaneous tissue at other sites (e.g., thigh). If multiple injections are required, TECVAYLI injections should be at least 2 cm apart. Do not inject into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact. Any unused product or waste material should be disposed in accordance with local requirements. Storage If the prepared dosing syringe(s) of TECVAYLI is not used immediately, store syringe(s) at 2°C to 8°C (36°F to 46°F) or at ambient temperature 15°C to 30°C (59°F to 86°F) for a maximum of 20 hours. Discard syringe(s) after 20 hours, if not used.
Monitoring
Due to the risk of CRS and neurologic toxicity, including ICANS, patients should be hospitalized for 48 hours after administration of all doses within the TECVAYLI step-up dosing schedule.
IV Compatibility
There is limited information regarding the compatibility of Teclistamab-cqyv and IV administrations.
Overdosage
There is limited information regarding Teclistamab-cqyv 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 Teclistamab-cqyv Pharmacology in the drug label.
Mechanism of Action
- Teclistamab-cqyv is a bispecific T-cell engaging antibody that binds to the CD3 receptor expressed on the surface of T-cells and B-cell maturation antigen (BCMA) expressed on the surface of multiple myeloma cells and some healthy B-lineage cells.
- In vitro, teclistamab-cqyv activated T-cells, caused the release of various proinflammatory cytokines, and resulted in the lysis of multiple myeloma cells.
Structure
Teclistamab-cqyv, a bispecific B-cell maturation antigen ( BCMA ) -directed CD3 T-cell engager, is a humanized immunoglobulin G4-proline, alanine, alanine ( IgG4-PAA ) antibody. Teclistamab-cqyv is produced in Chinese Hamster Ovary ( CHO ) cells using recombinant DNA technology. Teclistamab-cqyv consists of an anti-BCMA heavy chain and light chain and an anti-CD3 heavy chain and light chain with two interchain disulfide bonds connecting the two arms. The molecular weight of teclistamab-cqyv is approximately 146 kDa. TECVAYLI ® ( teclistamab-cqyv ) injection is a sterile, preservative-free, clear to slightly opalescent, colorless to light yellow solution supplied in a single-dose vial for subcutaneous administration. Each TECVAYLI 3 mL single-dose vial contains 30 mg of teclistamab-cqyv, edetate disodium ( 0.054 mg ) , glacial acetic acid ( 0.72 mg ) , polysorbate 20 ( 1.2 mg ) , sodium acetate ( 2.7 mg ) , sucrose ( 240 mg ) , and Water for Injection, USP. Each TECVAYLI 1.7 mL single-dose vial contains 153 mg of teclistamab-cqyv, edetate disodium ( 0.031 mg ) , glacial acetic acid ( 0.41 mg ) , polysorbate 20 ( 0.68 mg ) , sodium acetate ( 1.5 mg ) , sucrose ( 140 mg ) , and Water for Injection, USP.
Pharmacodynamics
Serum concentrations of cytokines (IL-6, IL-10, TNF-α, and IFN-γ) and IL-2R were measured before and after administration of step-up dose 1, step-up dose 2, and the first three treatment doses of TECVAYLI. Increased concentrations of IL-6, IL-10, and IL-2R were observed during this period.
Pharmacokinetics
The C max and AUC tau of teclistamab-cqyv after the first subcutaneous treatment dose increase proportionally over a dosage range of 0.08 mg/kg to 3 mg/kg (0.05 to 2 times the approved recommended treatment dosage). Ninety percent of steady state exposure was achieved after 12 weekly treatment doses. The mean accumulation ratio between the first and 13 th weekly treatment dose of teclistamab-cqyv 1.5 mg/kg was 4.2-fold for C max, 4.1-fold for C trough, and 5.3-fold for AUC tau.
The C max, C trough, and AUC tau of teclistamab-cqyv are presented in Table 12.
Absorption
The mean bioavailability of teclistamab-cqyv was 72% when administered subcutaneously. The median (range) T max of teclistamab-cqyv after the first and 13 th weekly treatment doses were 139 (19 to 168) hours and 72 (24 to 168) hours, respectively.
Distribution
The mean (coefficient of variation [CV]%) volume of distribution of teclistamab-cqyv was 5.63 L (29%).
Elimination
Teclistamab-cqyv clearance decreases over time, with a mean (CV%) maximal reduction from baseline to the 13 th weekly treatment dose of 40.8% (56%). The geometric mean (CV%) clearance is 0.472 L/day (64%) at the 13 thweekly treatment dose. Patients who discontinue teclistamab-cqyv after the 13 thweekly treatment dose are expected to have a 50% reduction from C max in teclistamab-cqyv concentration at a median (5 th to 95 th percentile) time of 15 (7 to 33) days after T max and a 97% reduction from C max in teclistamab-cqyv concentration at a median time of 69 (32 to 163) days after T max.
Specific Populations
The volume of distribution and clearance of teclistamab-cqyv increase with increasing body weight (41 kg to 139 kg).
There were no clinically significant differences in the pharmacokinetics of teclistamab-cqyv based on age (24 to 84 years), sex, race (White, Black or African American), ethnicity (Hispanic/Latino, not Hispanic/Latino), mild or moderate renal impairment (estimated glomerular filtration rate [eGFR] by Modification of Diet in Renal Disease [MDRD] method: 30 to 89 mL/min), or mild hepatic impairment (total bilirubin less than or equal to upper limit of normal [ULN] with AST greater than ULN or total bilirubin greater than 1 to 1.5 times ULN with any AST). The effects of severe renal impairment (eGFR less than 30 mL/min) or moderate to severe hepatic impairment (total bilirubin greater than 1.5 times ULN with any AST) on the pharmacokinetics of teclistamab-cqyv are unknown.
Drug Interaction Studies
No clinical studies evaluating the drug interaction potential of teclistamab-cqyv have been conducted.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
- No carcinogenicity or genotoxicity studies have been conducted with teclistamab-cqyv.
- No studies have been conducted to evaluate the effects of teclistamab-cqyv on fertility.
Clinical Studies
- The efficacy of TECVAYLI was evaluated in patients with relapsed or refractory multiple myeloma in a single-arm, open-label, multi-center study (MajesTEC-1, NCT03145181 [Phase 1] and NCT04557098 [Phase 2]). The study included patients who had previously received at least three prior therapies, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody. The study excluded patients who had stroke, seizure, allogeneic stem cell transplantation within the past 6 months, Eastern Cooperative Oncology Group (ECOG) performance score of 2 or higher, known active CNS involvement or clinical signs of meningeal involvement of multiple myeloma, or active or documented history of autoimmune disease, with the exception of vitiligo, Type 1 diabetes, and prior autoimmune thyroiditis.
- Patients received step-up doses of 0.06 mg/kg and 0.3 mg/kg of TECVAYLI followed by TECVAYLI 1.5 mg/kg subcutaneously once weekly thereafter until disease progression or unacceptable toxicity.
The efficacy population included 110 patients. The median age was 66 (range: 33 to 82) years with 16% of patients 75 years of age or older; 56% were male; 91% were White, 5% were Black or African American, 3% were Asian. The International Staging System (ISS) at study entry was Stage I in 50%, Stage II in 38%, and Stage III in 12% of patients. High-risk cytogenetics (presence of del(17p), t(4;14) and t(14;16)) were present in 25% of patients. Seventeen percent of patients had extramedullary plasmacytomas. Patients with prior BCMA-targeted therapy were not included in the efficacy population.
- The median number of prior lines of therapy was 5 (range: 2 to 14); 78% of patients had received at least 4 prior lines of therapy. Eighty-one percent of patients received prior stem cell transplantation. All patients had received prior therapy with a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody, and 76% were triple-class refractory (refractory to a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody).
Efficacy was established based on overall response rate (ORR) as determined by the Independent Review Committee (IRC) assessment using International Myeloma Working Group (IMWG) 2016 criteria (see TABLE 13). The median time to first response was 1.2 months (range: 0.2 to 5.5 months). With a median follow-up of 7.4 months among responders, the estimated duration of response (DOR) rate was 90.6% (95% CI: 80.3%, 95.7%) at 6 months and 66.5% (95% CI: 38.8%, 83.9%) at 9 months.
How Supplied
TECVAYLI ® (teclistamab-cqyv) injection is a sterile, preservative-free, clear to slightly opalescent, colorless to light yellow solution supplied as follows:
One 30 mg/3 mL (10 mg/mL) single-dose vial in a carton: NDC: 57894-449-01 One 153 mg/1.7 mL (90 mg/mL) single-dose vial in a carton: NDC: 57894-450-01
Storage
Store refrigerated at 2°C to 8°C (36°F to 46°F) in the original carton to protect from light.
Do not freeze.
Images
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Patient Counseling Information
====Cytokine Release Syndrome (CRS====) Discuss the signs and symptoms associated with CRS, including fever, hypoxia, chills, hypotension, sinus tachycardia, headache, and elevated liver enzymes. Advise patients to immediately contact their healthcare provider if they experience any signs or symptoms of CRS. Advise patients that they will be hospitalized for 48 hours after administration of all doses within the TECVAYLI step-up dosing schedule.
Neurologic Toxicity including ICANS
Discuss the signs and symptoms associated with neurologic toxicity, including ICANS, including headache, confusion, dysgraphia, motor dysfunction, neuropathy, or encephalopathy. Advise patients to immediately contact their healthcare provider if they experience any signs or symptoms of neurologic toxicity. Advise patients to refrain from driving or operating heavy or potentially dangerous machinery during and for 48 hours after completion of TECVAYLI step-up dosing schedule and in the event of new onset of any neurologic toxicity symptoms until neurologic toxicity resolves.
TECVAYLI and TALVEY REMS
TECVAYLI is available only through a restricted program called TECVAYLI and TALVEY REMS. Inform patients that they will be given a Patient Wallet Card that they should carry with them at all times and show to all of their healthcare providers. This card describes signs and symptoms of CRS and neurologic toxicity which, if experienced, should prompt the patient to immediately seek medical attention.
Hepatotoxicity
Advise patients that liver enzyme elevations may occur and that they should report symptoms that may indicate liver toxicity, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice
Infections
Discuss the signs and symptoms of infection
Neutropenia
Discuss the signs and symptoms associated with neutropenia and febrile neutropenia.
Hypersensitivity and Other Administration Reactions
Advise patients to immediately seek medical attention for any signs and symptoms of systemic administration-related reactions. Advise patients that local injection-site reactions may occur and to report any severe reactions.
Embryo-Fetal Toxicity
Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Advise females of reproductive potential to inform their healthcare provider if they are pregnant or become pregnant. Advise females of reproductive potential to use effective contraception during treatment with TECVAYLI and for 5 months after the last dose.
Lactation
Advise women not to breastfeed during treatment with TECVAYLI and for 5 months after the last dose.
Precautions with Alcohol
Alcohol-Teclistamab-cqyv interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
Brand Names
TECVAYLI
Look-Alike Drug Names
There is limited information regarding Teclistamab-cqyv 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.