Yervoy 200 MG in 40 ML Injection

Details

Generic Name: IPILIMUMAB

Brand Name: YERVOY

Substance Name(s):
IPILIMUMAB

DRUG INTERACTIONS

7 No formal pharmacokinetic drug interaction studies have been conducted with YERVOY.

OVERDOSAGE

10 There is no information on overdosage with YERVOY.

DESCRIPTION

11 YERVOY (ipilimumab) is a recombinant, human monoclonal antibody that binds to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4).

Ipilimumab is an IgG1 kappa immunoglobulin with an approximate molecular weight of 148 kDa.

Ipilimumab is produced in mammalian (Chinese hamster ovary) cell culture.

YERVOY is a sterile, preservative-free, clear to slightly opalescent, colorless to pale-yellow solution for intravenous infusion, which may contain a small amount of visible translucent-to-white, amorphous ipilimumab particulates.

It is supplied in single-use vials of 50 mg/10 mL and 200 mg/40 mL.

Each milliliter contains 5 mg of ipilimumab and the following inactive ingredients: diethylene triamine pentaacetic acid (DTPA) (0.04 mg), mannitol (10 mg), polysorbate 80 (vegetable origin) (0.1 mg), sodium chloride (5.85 mg), tris hydrochloride (3.15 mg), and Water for Injection, USP at a pH of 7.

CLINICAL STUDIES

14 14.1 Unresectable or Metastatic Melanoma The safety and efficacy of YERVOY were investigated in a randomized (3:1:1), double-blind, double-dummy trial (Trial 1) that included 676 randomized patients with unresectable or metastatic melanoma previously treated with one or more of the following: aldesleukin, dacarbazine, temozolomide, fotemustine, or carboplatin.

Of these 676 patients, 403 were randomized to receive YERVOY at 3 mg/kg in combination with an investigational peptide vaccine with incomplete Freund’s adjuvant (gp100), 137 were randomized to receive YERVOY at 3 mg/kg, and 136 were randomized to receive gp100 as a single agent.

The trial enrolled only patients with HLA-A2*0201 genotype; this HLA genotype facilitates the immune presentation of the investigational peptide vaccine.

The trial excluded patients with active autoimmune disease or those receiving systemic immunosuppression for organ transplantation.

YERVOY/placebo was administered at 3 mg/kg as an intravenous infusion every 3 weeks for 4 doses.

Gp100/placebo was administered at a dose of 2 mg peptide by deep subcutaneous injection every 3 weeks for 4 doses.

Assessment of tumor response was conducted at weeks 12 and 24, and every 3 months thereafter.

Patients with evidence of objective tumor response at 12 or 24 weeks had assessment for confirmation of durability of response at 16 or 28 weeks, respectively.

The major efficacy outcome measure was overall survival (OS) in the YERVOY plus gp100 arm compared to that in the single-agent gp100 arm.

Secondary efficacy outcome measures were OS in the YERVOY plus gp100 arm compared to the YERVOY arm, OS in the YERVOY arm compared to the gp100 arm, best overall response rate (BORR) at week 24 between each of the trial arms, and duration of response.

Of the randomized patients, 61%, 59%, and 54% in the YERVOY plus gp100, YERVOY, and gp100 arms, respectively, were men.

Twenty-nine percent were ≥65 years of age, the median age was 57 years, 71% had M1c stage, 12% had a history of previously treated brain metastasis, 98% had ECOG performance status of 0 and 1, 23% had received aldesleukin, and 38% had elevated LDH level.

Sixty-one percent of patients randomized to either YERVOY-containing arm received all 4 planned doses.

The median duration of follow-up was 8.9 months.

The OS results are shown in Table 7 and Figure 1.

Table 7: Overall Survival Results a Not adjusted for multiple comparisons.

YERVOY n=137 YERVOY+gp100 n=403 gp100 n=136 Hazard Ratio (vs.

gp100) 0.66 0.68 (95% CI) (0.51, 0.87) (0.55, 0.85) p-value p=0.0026a p=0.0004 Hazard Ratio (vs.

YERVOY) 1.04 (95% CI) (0.83, 1.30) Median (months) 10 10 6 (95% CI) (8.0, 13.8) (8.5, 11.5) (5.5, 8.7) Figure 1: Overall Survival The best overall response rate (BORR) as assessed by the investigator was 5.7% (95% CI: 3.7%, 8.4%) in the YERVOY plus gp100 arm, 10.9% (95% CI: 6.3%, 17.4%) in the YERVOY arm, and 1.5% (95% CI: 0.2%, 5.2%) in the gp100 arm.

The median duration of response was 11.5 months in the YERVOY plus gp100 arm and has not been reached in the YERVOY or gp100 arm.

Figure 1 14.2 Adjuvant Treatment of Melanoma The safety and efficacy of YERVOY for the adjuvant treatment of melanoma were investigated in Trial 2, a randomized (1:1), double-blind, placebo-controlled trial in patients with resected Stage IIIA (>1 mm nodal involvement), IIIB, and IIIC (with no in-transit metastases) histologically confirmed cutaneous melanoma.

Patients were randomized to receive YERVOY 10 mg/kg or placebo as an intravenous infusion every 3 weeks for 4 doses, followed by YERVOY 10 mg/kg or placebo every 12 weeks from Week 24 to Week 156 (3 years) or until documented disease recurrence or unacceptable toxicity.

Enrollment required complete resection of melanoma with full lymphadenectomy within 12 weeks prior to randomization.

Patients with prior therapy for melanoma, autoimmune disease, and prior or concomitant use of immunosuppressive agents were ineligible.

Randomization was stratified by stage according to American Joint Committee on Cancer (AJCC) 2002 classification (Stage IIIA >1 mm nodal involvement, Stage IIIB, Stage IIIC with 1 to 3 involved lymph nodes, and Stage IIIC with ≥4 involved lymph nodes) and by region (North America, Europe, and Australia).

The major efficacy outcome measures were recurrence-free survival (RFS) defined as the time between the date of randomization and the date of first recurrence (local, regional, or distant metastasis) or death, whichever occurs first and assessed by an independent review committee and overall survival.

Tumor assessment was conducted every 12 weeks for the first 3 years then every 24 weeks until distant recurrence.

Among 951 patients enrolled, 475 were randomized to receive YERVOY and 476 to placebo.

Median age was 51 years old (range: 18 to 84), 62% were male, 99% were white, 94% had ECOG performance status of 0.

With regard to disease stage, 20% had Stage IIIA with lymph nodes >1 mm, 44% had Stage IIIB, and 36% had Stage IIIC (with no in-transit metastases).

Other disease characteristics of the trial population were: clinically palpable lymph nodes (58%), 2 or more positive lymph nodes (54%), and ulcerated primary lesions (42%).

The RFS results are in Table 8 and Figure 2.

Based on the observation of 282 deaths at the time of the RFS analysis, the final analysis of overall survival has not occurred (planned at the time of 491 deaths).

Table 8: Efficacy Results in Trial 2 Recurrence-Free Survival YERVOY N=475 Placebo N=476 a Stratified by disease stage.

Number of Events, n (%) Recurrence Death 234 (49%) 220 14 294 (62%) 289 5 Median (months) (95% CI) 26 (19, 39) 17 (13, 22) Hazard Ratio (95% CI) p-value (stratified log-ranka) 0.75 (0.64, 0.90) p<0.002 Figure 2: Recurrence-Free Survival Recurrenc-Free Survival

HOW SUPPLIED

16 /STORAGE AND HANDLING YERVOY is available as follows: Carton Contents NDC One 50 mg vial (5 mg/mL), single-use vial NDC 0003-2327-11 One 200 mg vial (5 mg/mL), single-use vial NDC 0003-2328-22 Store YERVOY under refrigeration at 2°C to 8°C (36°F to 46°F).

Do not freeze.

Protect vials from light.

GERIATRIC USE

8.5 Geriatric Use Of the 511 patients treated with YERVOY in Trial 1, 28% were 65 years and over.

No overall differences in safety or efficacy were reported between the elderly patients (65 years and over) and younger patients (less than 65 years).

Trial 2 did not include sufficient numbers of patients aged 65 years and older to determine whether they respond differently from younger patients.

DOSAGE FORMS AND STRENGTHS

3 Injection: 50 mg/10 mL (5 mg/mL) Injection: 200 mg/40 mL (5 mg/mL) •Injection: 50 mg/10 mL (5 mg/mL) (3) •Injection: 200 mg/40 mL (5 mg/mL) (3)

MECHANISM OF ACTION

12.1 Mechanism of Action CTLA-4 is a negative regulator of T-cell activity.

Ipilimumab is a monoclonal antibody that binds to CTLA-4 and blocks the interaction of CTLA-4 with its ligands, CD80/CD86.

Blockade of CTLA-4 has been shown to augment T-cell activation and proliferation, including the activation and proliferation of tumor infiltrating T-effector cells.

Inhibition of CTLA-4 signaling can also reduce T-regulatory cell function, which may contribute to a general increase in T cell responsiveness, including the anti-tumor immune response.

INDICATIONS AND USAGE

1 YERVOY is a human cytotoxic T-lymphocyte antigen 4 (CTLA-4)-blocking antibody indicated for: •Treatment of unresectable or metastatic melanoma.

(1.1) •Adjuvant treatment of patients with cutaneous melanoma with pathologic involvement of regional lymph nodes of more than 1 mm who have undergone complete resection, including total lymphadenectomy.

(1.2) 1.1 Unresectable or Metastatic Melanoma YERVOY is indicated for the treatment of unresectable or metastatic melanoma [see Clinical Studies (14.1)].

1.2 Adjuvant Treatment of Melanoma YERVOY is indicated for the adjuvant treatment of patients with cutaneous melanoma with pathologic involvement of regional lymph nodes of more than 1 mm who have undergone complete resection, including total lymphadenectomy [see Clinical Studies (14.2)].

PEDIATRIC USE

8.4 Pediatric Use Safety and effectiveness of YERVOY have not been established in pediatric patients.

PREGNANCY

8.1 Pregnancy Risk Summary Based on data from animal studies and its mechanism of action, YERVOY can cause fetal harm when administered to a pregnant woman [see Clinical Pharmacology (12.1)].

In animal reproduction studies, administration of ipilimumab to cynomolgus monkeys from the onset of organogenesis through delivery resulted in higher incidences of abortion, stillbirth, premature delivery (with corresponding lower birth weight), and higher incidences of infant mortality in a dose-related manner (see Data).

The effects of ipilimumab are likely to be greater during the second and third trimesters of pregnancy.

Human IgG1 is known to cross the placental barrier and ipilimumab is an IgG1; therefore, ipilimumab has the potential to be transmitted from the mother to the developing fetus.

There is insufficient human data for YERVOY exposure in pregnant women.

Advise pregnant women of the potential risk to a fetus.

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.

A Pregnancy Safety Surveillance Study has been established to collect information about pregnancies in women who have received YERVOY.

Healthcare providers are encouraged to enroll patients or have their patients enroll directly by calling 1-844-593-7869.

Data Animal Data In a combined study of embryo-fetal and peri-postnatal development, pregnant cynomolgus monkeys received ipilimumab every 3 weeks from the onset of organogenesis in the first trimester through parturition.

No treatment-related adverse effects on reproduction were detected during the first two trimesters of pregnancy.

Beginning in the third trimester, administration of ipilimumab at doses resulting in exposures approximately 2.6 to 7.2 times the human exposure at a dose of 3 mg/kg resulted in dose-related increases in abortion, stillbirth, premature delivery (with corresponding lower birth weight), and an increased incidence of infant mortality.

In addition, developmental abnormalities were identified in the urogenital system of 2 infant monkeys exposed in utero to 30 mg/kg of ipilimumab (7.2 times the AUC in humans at the 3 mg/kg dose).

One female infant monkey had unilateral renal agenesis of the left kidney and ureter, and 1 male infant monkey had an imperforate urethra with associated urinary obstruction and subcutaneous scrotal edema.

Genetically engineered mice heterozygous for CTLA-4 (CTLA-4+/−), the target for ipilimumab, appeared healthy and gave birth to healthy CTLA-4+/− heterozygous offspring.

Mated CTLA-4+/− heterozygous mice also produced offspring deficient in CTLA-4 (homozygous negative, CTLA-4−/−).

The CTLA-4−/− homozygous negative offspring appeared healthy at birth, exhibited signs of multiorgan lymphoproliferative disease by 2 weeks of age, and all died by 3 to 4 weeks of age with massive lymphoproliferation and multiorgan tissue destruction.

BOXED WARNING

WARNING: IMMUNE-MEDIATED ADVERSE REACTIONS YERVOY can result in severe and fatal immune-mediated adverse reactions.

These immune-mediated reactions may involve any organ system; however, the most common severe immune-mediated adverse reactions are enterocolitis, hepatitis, dermatitis (including toxic epidermal necrolysis), neuropathy, and endocrinopathy.

The majority of these immune-mediated reactions initially manifested during treatment; however, a minority occurred weeks to months after discontinuation of YERVOY.

Permanently discontinue YERVOY and initiate systemic high-dose corticosteroid therapy for severe immune-mediated reactions [see Dosage and Administration (2.3) ].

Assess patients for signs and symptoms of enterocolitis, dermatitis, neuropathy, and endocrinopathy, and evaluate clinical chemistries including liver function tests, adrenocorticotropic hormone (ACTH) level, and thyroid function tests, at baseline and before each dose [see Warnings and Precautions (5.1, 5.2, 5.3, 5.4, 5.5)].

WARNING: IMMUNE-MEDIATED ADVERSE REACTIONS See full prescribing information for complete boxed warning.

YERVOY can result in severe and fatal immune-mediated adverse reactions.

The majority of these immune-mediated reactions initially manifested during treatment; however, a minority occurred weeks to months after discontinuation of YERVOY.

Permanently discontinue YERVOY and initiate systemic high-dose corticosteroid therapy for severe immune-mediated reactions.

(2.3) Assess patients for signs and symptoms of enterocolitis, dermatitis, neuropathy, and endocrinopathy and evaluate clinical chemistries including liver function tests, adrenocorticotropic hormone (ACTH) level, and thyroid function tests at baseline and before each dose.

(5.1, 5.2, 5.3, 5.4, 5.5)

WARNING AND CAUTIONS

5 WARNINGS AND PRECAUTIONS YERVOY can result in severe and fatal immune-mediated reactions [see Boxed Warning].

Immune-mediated adverse reactions: Permanently discontinue for severe reactions.

Withhold dose for moderate immune-mediated adverse reactions until return to baseline, improvement to mild severity, or complete resolution, and patient is receiving less than 7.5 mg prednisone or equivalent per day.

Administer systemic high-dose corticosteroids for severe, persistent, or recurring immune-mediated reactions.

(5.1, 5.2, 5.3, 5.4, 5.5) •Immune-mediated hepatitis: Evaluate liver function tests before each dose of YERVOY.

(5.2) •Immune-mediated endocrinopathies: Monitor clinical chemistries, ACTH level, and thyroid function tests prior to each dose.

Evaluate at each visit for signs and symptoms of endocrinopathy.

Institute hormone replacement therapy as needed.

(5.5) •Embryo-fetal toxicity: Can cause fetal harm.

Advise of potential risk to a fetus and use of effective contraception.

(5.7) 5.1 Immune-Mediated Enterocolitis Immune-mediated enterocolitis, including fatal cases, can occur with YERVOY.

Monitor patients for signs and symptoms of enterocolitis (such as diarrhea, abdominal pain, mucus or blood in stool, with or without fever) and of bowel perforation (such as peritoneal signs and ileus).

In symptomatic patients, rule out infectious etiologies and consider endoscopic evaluation for persistent or severe symptoms.

Permanently discontinue YERVOY in patients with severe enterocolitis and initiate systemic corticosteroids at a dose of 1 to 2 mg/kg/day of prednisone or equivalent.

Upon improvement to Grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month.

In clinical trials, rapid corticosteroid tapering resulted in recurrence or worsening symptoms of enterocolitis in some patients.

Consider adding anti-TNF or other immunosuppressant agents for management of immune-mediated enterocolitis unresponsive to systemic corticosteroids within 3 to 5 days or recurring after symptom improvement.

Withhold YERVOY dosing for moderate enterocolitis; administer anti-diarrheal treatment and, if persistent for more than 1 week, initiate systemic corticosteroids at a dose of 0.5 mg/kg/day prednisone or equivalent [see Dosage and Administration (2.3)].

Metastatic Melanoma In patients receiving YERVOY 3 mg/kg in Trial 1, severe, life-threatening, or fatal (diarrhea of 7 or more stools above baseline, fever, ileus, peritoneal signs; Grade 3 to 5) immune-mediated enterocolitis occurred in 34 YERVOY-treated patients (7%), and moderate (diarrhea with up to 6 stools above baseline, abdominal pain, mucus or blood in stool; Grade 2) enterocolitis occurred in 28 YERVOY-treated patients (5%).

Across all YERVOY-treated patients (n=511), 5 patients (1%) developed intestinal perforation, 4 patients (0.8%) died as a result of complications, and 26 patients (5%) were hospitalized for severe enterocolitis.

The median time to onset of Grade 3 to 5 enterocolitis was 1.7 months (range: 11 days to 3.1 months) and for Grade 2 enterocolitis was 1.4 months (range: 2 days to 4.3 months).

Twenty-nine patients (85%) with Grade 3 to 5 enterocolitis were treated with high-dose (≥40 mg prednisone equivalent per day) corticosteroids, with a median dose of 80 mg/day of prednisone or equivalent; the median duration of treatment was 16 days (ranging up to 3.2 months) followed by corticosteroid taper.

Of the 28 patients with moderate enterocolitis, 46% were not treated with systemic corticosteroids, 29% were treated with <40 mg prednisone or equivalent per day for a median duration of 1.2 months, and 25% were treated with high-dose corticosteroids for a median duration of 10 days prior to corticosteroid taper.

Infliximab was administered to 5 (8%) of the 62 patients with moderate, severe, or life-threatening immune-mediated enterocolitis following inadequate response to corticosteroids.

Of the 34 patients with Grade 3 to 5 enterocolitis, 74% experienced complete resolution, 3% experienced improvement to Grade 2 severity, and 24% did not improve.

Among the 28 patients with Grade 2 enterocolitis, 79% experienced complete resolution, 11% improved, and 11% did not improve.

Adjuvant Treatment of Melanoma In patients receiving YERVOY 10 mg/kg in Trial 2, Grade 3 to 5 immune-mediated enterocolitis occurred in 76 patients (16%) and Grade 2 enterocolitis occurred in 68 patients (14%).

Seven patients (1.5%) developed intestinal perforation and 3 patients (0.6%) died as a result of complications [see Adverse Reactions (6.1)].

The median time to onset for Grade 3 to 4 enterocolitis was 1.1 months (range: 1 day to 33.1 months) and for Grade 2 enterocolitis was 1.1 months (range: 1 day to 20.6 months).

Seventy-one patients (95%) with Grade 3 to 4 enterocolitis were treated with systemic corticosteroids.

The median duration of treatment was 4.7 months (ranging up to 52.3 months).

Of the 68 patients with moderate enterocolitis, 51 patients (75%) were treated with systemic corticosteroids with a median duration of treatment of 3.5 months (ranging up to 52.2 months).

Non-corticosteroids immunosuppression, consisting almost exclusively of infliximab, was used to treat 36% of patients with Grade 3 to 4 enterocolitis and 15% of patients with a Grade 2 event.

Of the 75 patients with Grade 3 to 4 immune-mediated enterocolitis, 86% experienced complete resolution, 3% experienced improvement to Grade 1, and 11% did not improve.

Among the 68 patients with Grade 2 enterocolitis, 94% experienced complete resolution, 3% experienced improvement to Grade 1, and 3% did not improve.

5.2 Immune-Mediated Hepatitis Immune-mediated hepatitis, including fatal cases, can occur with YERVOY.

Monitor liver function tests (hepatic transaminase and bilirubin levels) and assess patients for signs and symptoms of hepatotoxicity before each dose of YERVOY.

In patients with hepatotoxicity, rule out infectious or malignant causes and increase frequency of liver function test monitoring until resolution.

Permanently discontinue YERVOY in patients with Grade 3 to 4 hepatotoxicity and administer systemic corticosteroids at a dose of 1 to 2 mg/kg/day of prednisone or equivalent.

When liver function tests show sustained improvement or return to baseline, initiate corticosteroid tapering and continue to taper over 1 month.

Across the clinical development program for YERVOY, mycophenolate treatment has been administered in patients who have persistent severe hepatitis despite high-dose corticosteroids.

Withhold YERVOY in patients with Grade 2 hepatotoxicity [see Dosage and Administration (2.3) ].

Metastatic Melanoma In patients receiving YERVOY 3 mg/kg in Trial 1, severe, life-threatening, or fatal hepatotoxicity (AST or ALT elevations of more than 5 times the upper limit of normal or total bilirubin elevations more than 3 times the upper limit of normal; Grade 3 to 5) occurred in 8 YERVOY-treated patients (2%), with fatal hepatic failure in 0.2% and hospitalization in 0.4% of YERVOY-treated patients.

An additional 13 patients (2.5%) experienced moderate hepatotoxicity manifested by liver function test abnormalities (AST or ALT elevations of more than 2.5 times but not more than 5 times the upper limit of normal or total bilirubin elevation of more than 1.5 times but not more than 3 times the upper limit of normal; Grade 2).

The underlying pathology was not ascertained in all patients but in some instances included immune-mediated hepatitis.

There were insufficient numbers of patients with biopsy-proven hepatitis to characterize the clinical course of this event.

Adjuvant Treatment of Melanoma In patients receiving YERVOY 10 mg/kg in Trial 2, Grade 3 to 4 immune-mediated hepatitis occurred in 51 patients (11%) and moderate Grade 2 immune-mediated hepatitis occurred in 22 patients (5%).

Liver biopsy performed in 6 patients with Grade 3 to 4 hepatitis showed evidence of toxic or autoimmune hepatitis.

The median time to onset for Grade 3 to 4 hepatitis was 2.0 months (range: 1 day to 4.2 months) and for Grade 2 hepatitis was 1.4 months (range: 13 days to 6.5 months).

Of the 51 patients with Grade 3 to 4 immune-mediated hepatitis, 94% experienced complete resolution, 4% experienced improvement to Grade 1, and 2% did not improve.

Of the 22 patients with Grade 2 immune-mediated hepatitis, 91% experienced complete resolution and 9% did not improve.

Forty-six patients (90%) with Grade 3 to 4 hepatitis were treated with systemic corticosteroids.

The median duration of treatment was 4.4 months (ranging up to 56.1 months).

Sixteen patients (73%) with moderate hepatitis were treated with systemic corticosteroids.

The median duration of treatment was 2.6 months (ranging up to 41.4 months).

Concurrent Administration with Vemurafenib In a dose-finding trial, Grade 3 increases in transaminases with or without concomitant increases in total bilirubin occurred in 6 of 10 patients who received concurrent YERVOY (3 mg/kg) and vemurafenib (960 mg BID or 720 mg BID).

5.3 Immune-Mediated Dermatitis Immune-mediated dermatitis, including fatal cases, can occur with YERVOY.

Monitor patients for signs and symptoms of dermatitis, such as rash and pruritus.

Unless an alternate etiology has been identified, signs or symptoms of dermatitis should be considered immune-mediated.

Permanently discontinue YERVOY in patients with Stevens-Johnson syndrome, toxic epidermal necrolysis, or rash complicated by full thickness dermal ulceration, or necrotic, bullous, or hemorrhagic manifestations.

Administer systemic corticosteroids at a dose of 1 to 2 mg/kg/day of prednisone or equivalent.

When dermatitis is controlled, corticosteroid tapering should occur over a period of at least 1 month.

Withhold YERVOY dosing in patients with moderate to severe signs and symptoms [see Dosage and Administration (2.3) ].

For mild to moderate dermatitis, such as localized rash and pruritus, treat symptomatically.

Administer topical or systemic corticosteroids if there is no improvement of symptoms within 1 week.

Metastatic Melanoma In patients receiving YERVOY 3 mg/kg in Trial 1, severe, life-threatening, or fatal immune-mediated dermatitis (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, or rash complicated by full thickness dermal ulceration, or necrotic, bullous, or hemorrhagic manifestations; Grade 3 to 5) occurred in 13 YERVOY-treated patients (2.5%).

One patient (0.2%) died as a result of toxic epidermal necrolysis and one additional patient required hospitalization for severe dermatitis.

There were 63 patients (12%) with moderate (Grade 2) dermatitis.

The median time to onset of moderate, severe, or life-threatening immune-mediated dermatitis was 22 days and ranged up to 4.0 months from the initiation of YERVOY.

Seven YERVOY-treated patients (54%) with severe dermatitis received high-dose corticosteroids (median dose 60 mg prednisone/day or equivalent) for up to 3.4 months followed by corticosteroid taper.

Of these 7 patients, 6 had complete resolution; time to resolution ranged up to 3.6 months.

Of the 63 patients with moderate dermatitis, 25 (40%) were treated with systemic corticosteroids (median of 60 mg/day of prednisone or equivalent) for a median of 15 days, 7 (11%) were treated with only topical corticosteroids, and 31 (49%) did not receive systemic or topical corticosteroids.

Forty-four patients (70%) with moderate dermatitis were reported to have complete resolution, 7 (11%) improved to mild (Grade 1) severity, and 12 (19%) had no reported improvement.

Adjuvant Treatment of Melanoma In patients receiving YERVOY 10 mg/kg in Trial 2, Grade 3 to 4 immune-mediated dermatitis occurred in 19 patients (4%).

There were 99 patients (21%) with moderate (Grade 2) dermatitis.

The median time to onset for Grade 3 to 4 dermatitis was 14 days (range: 5 days to 11.3 months) and for Grade 2 dermatitis was 11 days (range: 1 day to 16.6 months).

Sixteen patients (84%) with Grade 3 to 4 dermatitis were treated with systemic corticosteroids for a median of 21 days (ranging up to 49.2 months) resulting in complete resolution of dermatitis within a median time of 4.3 months (range up to 44.4 months).

Of the 3 patients (16%) not treated with systemic or topical corticosteroids, 2 (11%) had complete resolution and 1 had improvement to Grade 1.

Of the 99 patients with Grade 2 dermatitis, 67 (68%) were treated with systemic corticosteroids for a median of 2.6 months, 16 (16%) were treated with only topical corticosteroids and 16 (16%) did not receive systemic or topical corticosteroids.

Seventy-seven patients (78%) had complete resolution, 15 (15%) improved to mild (Grade 1) severity, and 7 (7%) did not improve.

5.4 Immune-Mediated Neuropathies Immune-mediated neuropathies, including fatal cases, can occur with YERVOY.

Monitor for symptoms of motor or sensory neuropathy such as unilateral or bilateral weakness, sensory alterations, or paresthesia.

Permanently discontinue YERVOY in patients with severe neuropathy (interfering with daily activities) such as Guillain-Barré-like syndromes.

Institute medical intervention as appropriate for management of severe neuropathy.

Consider initiation of systemic corticosteroids at a dose of 1 to 2 mg/kg/day prednisone or equivalent for severe neuropathies.

Withhold YERVOY dosing in patients with moderate neuropathy (not interfering with daily activities) [see Dosage and Administration (2.3)].

Metastatic Melanoma In patients receiving YERVOY 3 mg/kg in Trial 1, 1 case of fatal Guillain-Barré syndrome and 1 case of severe (Grade 3) peripheral motor neuropathy were reported.

Across the clinical development program of YERVOY, myasthenia gravis and additional cases of Guillain-Barré syndrome have been reported.

Adjuvant Treatment of Melanoma In patients receiving YERVOY 10 mg/kg in Trial 2, Grade 3 to 5 immune-mediated neuropathy occurred in 8 patients (2%); the sole fatality was due to complications of Guillain-Barré syndrome [see Adverse Reactions (6.1) ].

Moderate Grade 2 immune-mediated neuropathy occurred in 1 patient (0.2%).

The time to onset across the 9 patients with Grade 2 to 5 immune-mediated neuropathy ranged from 1.4 to 27.4 months.

All 8 patients with Grade 3 to 5 neuropathy were treated with systemic corticosteroids (range: 3 days to 38.3 months) and 3 also received tacrolimus.

Four of the 8 patients with Grade 3 to 5 immune-mediated neuropathy experienced complete resolution, 1 improved to Grade 1, and 3 did not improve.

The single patient with Grade 2 immune-mediated neuropathy experienced complete resolution without the use of corticosteroids.

5.5 Immune-Mediated Endocrinopathies Immune-mediated endocrinopathies, including life-threatening cases, can occur with YERVOY.

Monitor patients for clinical signs and symptoms of hypophysitis, adrenal insufficiency (including adrenal crisis), and hyper- or hypothyroidism.

Patients may present with fatigue, headache, mental status changes, abdominal pain, unusual bowel habits, and hypotension, or nonspecific symptoms which may resemble other causes such as brain metastasis or underlying disease.

Unless an alternate etiology has been identified, signs or symptoms of endocrinopathies should be considered immune-mediated.

Monitor clinical chemistries, adrenocorticotropic hormone (ACTH) level, and thyroid function tests at the start of treatment, before each dose, and as clinically indicated based on symptoms.

In a limited number of patients, hypophysitis was diagnosed by imaging studies through enlargement of the pituitary gland.

Withhold YERVOY dosing in symptomatic patients and consider referral to an endocrinologist.

Initiate systemic corticosteroids at a dose of 1 to 2 mg/kg/day of prednisone or equivalent, and initiate appropriate hormone replacement therapy [see Dosage and Administration (2.3) ].

Metastatic Melanoma In patients receiving YERVOY 3 mg/kg in Trial 1, severe to life-threatening immune-mediated endocrinopathies (requiring hospitalization, urgent medical intervention, or interfering with activities of daily living; Grade 3 to 4) occurred in 9 YERVOY-treated patients (1.8%).

All 9 patients had hypopituitarism and some had additional concomitant endocrinopathies such as adrenal insufficiency, hypogonadism, and hypothyroidism.

Six of the 9 patients were hospitalized for severe endocrinopathies.

Moderate endocrinopathy (requiring hormone replacement or medical intervention; Grade 2) occurred in 12 patients (2.3%) and consisted of hypothyroidism, adrenal insufficiency, hypopituitarism, and 1 case each of hyperthyroidism and Cushing’s syndrome.

The median time to onset of moderate to severe immune-mediated endocrinopathy was 2.5 months and ranged up to 4.4 months after the initiation of YERVOY.

Of the 21 patients with moderate to life-threatening endocrinopathy, 17 patients required long-term hormone replacement therapy including, most commonly, adrenal hormones (n=10) and thyroid hormones (n=13).

Adjuvant Treatment of Melanoma In patients receiving YERVOY 10 mg/kg in Trial 2, Grade 3 to 4 immune-mediated endocrinopathies occurred in 39 patients (8%) and Grade 2 immune-mediated endocrinopathies in 93 patients (20%).

Of the 39 patients with Grade 3 to 4 immune-mediated endocrinopathies, 35 patients had hypopituitarism (associated with one or more secondary endocrinopathies, e.g., adrenal insufficiency, hypogonadism, and hypothyroidism), 3 patients had hyperthyroidism, and 1 had primary hypothyroidism.

The median time to onset of Grade 3 to 4 immune-mediated endocrinopathy was 2.2 months (range: 2 days to 8 months).

Twenty-seven of the 39 patients (69%) were hospitalized for immune-mediated endocrinopathies, and 4 patients (10%) were reported to have resolution.

Of the 93 patients with Grade 2 immune-mediated endocrinopathy, 74 had primary hypopituitarism (associated with one or more secondary endocrinopathy, e.g., adrenal insufficiency, hypogonadism, and hypothyroidism), 9 had primary hypothyroidism, 3 had hyperthyroidism, 3 had thyroiditis with hypo- or hyperthyroidism, 2 had hypogonadism, 1 had both hyperthyroidism and hypopituitarism, and 1 subject developed Graves’ ophthalmopathy.

The median time to onset of Grade 2 immune-mediated endocrinopathy was 2.1 months (range: 9 days to 19.3 months), and 20% were reported to have resolution.

One hundred twenty-four patients received systemic corticosteroids as immunosuppression and/or adrenal hormone replacement for Grade 2 to 4 immune-mediated endocrinopathy.

Of these, 42 (34%) were able to discontinue corticosteroids.

Seventy-three patients received thyroid hormones for treatment of Grade 2 to 4 immune-mediated hypothyroidism.

Of these, 14 patients (19%) were able to discontinue thyroid replacement therapy.

5.6 Other Immune-Mediated Adverse Reactions, Including Ocular Manifestations Permanently discontinue YERVOY for clinically significant or severe immune-mediated adverse reactions.

Initiate systemic corticosteroids at a dose of 1 to 2 mg/kg/day prednisone or equivalent for severe immune-mediated adverse reactions.

Administer corticosteroid eye drops to patients who develop uveitis, iritis, or episcleritis.

Permanently discontinue YERVOY for immune-mediated ocular disease that is unresponsive to local immunosuppressive therapy [see Dosage and Administration (2.3) ].

Metastatic Melanoma In Trial 1, the following clinically significant immune-mediated adverse reactions were seen in less than 1% of YERVOY-treated patients: nephritis, pneumonitis, meningitis, pericarditis, uveitis, iritis, and hemolytic anemia.

Adjuvant Treatment of Melanoma In Trial 2, the following clinically significant immune-mediated adverse reactions were seen in less than 1% of YERVOY-treated patients unless specified: eosinophilia (2.1%), pancreatitis (1.3%), meningitis, pneumonitis, sarcoidosis, pericarditis, uveitis, and fatal myocarditis [see Adverse Reactions (6.1)].

Other Clinical Experience Across 21 dose-ranging trials administering YERVOY at doses of 0.1 to 20 mg/kg (n=2478), the following likely immune-mediated adverse reactions were also reported with less than 1% incidence: angiopathy, temporal arteritis, vasculitis, polymyalgia rheumatica, conjunctivitis, blepharitis, episcleritis, scleritis, iritis, leukocytoclastic vasculitis, erythema multiforme, psoriasis, arthritis, autoimmune thyroiditis, neurosensory hypoacusis, autoimmune central neuropathy (encephalitis), myositis, polymyositis, ocular myositis, hemolytic anemia, and nephritis.

5.7 Embryo-fetal Toxicity Based on its mechanism of action and data from animal studies, YERVOY can cause fetal harm when administered to a pregnant woman.

The effects of ipilimumab are likely to be greater during the second and third trimesters of pregnancy.

Advise pregnant women of the potential risk to a fetus.

Advise females of reproductive potential to use effective contraception during treatment with a YERVOY-containing regimen and for 3 months after the last dose of YERVOY [see Use in Specific Populations (8.1, 8.3)].

INFORMATION FOR PATIENTS

17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Immune-Mediated Adverse Reactions Inform patients of the potential risk of immune-mediated adverse reactions [see Warnings and Precautions (5.1, 5.2, 5.3, 5.4, 5.5, 5.6)].

Embryo-fetal Toxicity Advise female patients that YERVOY can cause fetal harm.

Advise females of reproductive potential to use effective contraception during treatment with YERVOY and for 3 months after the last dose.

Advise female patients to contact their healthcare provider with a known or suspected pregnancy.

Advise females who may have been exposed to YERVOY during pregnancy to contact Bristol-Myers Squibb at 1-800-721-5072 [see Warnings and Precautions (5.1) and Use in Specific Populations (8.1, 8.3)].

Advise patients that there is a Pregnancy Safety Surveillance Study that monitors pregnancy outcomes in women exposed to YERVOY during pregnancy, and they can be enrolled by calling 1-844-593-7869 [see Use in Specific Populations (8.1)].

Lactation Advise women not to breastfeed during treatment with YERVOY and for 3 months after the last dose [see Use in Specific Populations (8.2)].

Manufactured by: Bristol-Myers Squibb Company Princeton, NJ 08543 USA U.S.

License No.

1713 1281558B0

DOSAGE AND ADMINISTRATION

2 •Unresectable or metastatic melanoma: ∘3 mg/kg administered intravenously over 90 minutes every 3 weeks for a total of 4 doses.

(2.1) •Adjuvant melanoma: ∘10 mg/kg administered intravenously over 90 minutes every 3 weeks for 4 doses, followed by 10 mg/kg every 12 weeks for up to 3 years or until documented disease recurrence or unacceptable toxicity.

(2.2) •Permanently discontinue for severe adverse reactions.

(2.3) 2.1 Recommended Dosing for Unresectable or Metastatic Melanoma The recommended dose of YERVOY is 3 mg/kg administered intravenously over 90 minutes every 3 weeks for a maximum of 4 doses.

In the event of toxicity, doses may be delayed, but all treatment must be administered within 16 weeks of the first dose [see Clinical Studies (14.1)].

2.2 Recommended Dosing for Adjuvant Treatment of Melanoma The recommended dose of YERVOY is 10 mg/kg administered intravenously over 90 minutes every 3 weeks for 4 doses followed by 10 mg/kg every 12 weeks for up to 3 years [see Clinical Studies (14.2)].

In the event of toxicity, doses are omitted, not delayed.

2.3 Recommended Dose Modifications Table 1: Recommended Treatment Modifications for Immune-Mediated Adverse Reactions of YERVOY Target/Organ System Adverse Reaction (CTCAE v3) Treatment Modification Endocrine Symptomatic endocrinopathy Withhold YERVOY Resume YERVOY in patients with complete or partial resolution of adverse reactions (Grade 0 to 1) and who are receiving less than 7.5 mg prednisone or equivalent per day.

•Symptomatic reactions lasting 6 weeks or longer •Inability to reduce corticosteroid dose to 7.5 mg prednisone or equivalent per day Permanently discontinue YERVOY Ophthalmologic Grade 2 through 4 reactions •not improving to Grade 1 within 2 weeks while receiving topical therapy or •requiring systemic treatment Permanently discontinue YERVOY All Other Grade 2 Withhold YERVOY Resume YERVOY in patients with complete or partial resolution of adverse reactions (Grade 0 to 1) and who are receiving less than 7.5 mg prednisone or equivalent per day.

•Grade 2 reactions lasting 6 weeks or longer •Inability to reduce corticosteroid dose to 7.5 mg prednisone or equivalent per day •Grade 3 or 4 Permanently discontinue YERVOY 2.4 Preparation and Administration •Do not shake product.

•Inspect parenteral drug products visually for particulate matter and discoloration prior to administration.

Discard vial if solution is cloudy, there is pronounced discoloration (solution may have pale-yellow color), or there is foreign particulate matter other than translucent-to-white, amorphous particles.

Preparation of Solution •Allow the vials to stand at room temperature for approximately 5 minutes prior to preparation of infusion.

•Withdraw the required volume of YERVOY and transfer into an intravenous bag.

•Dilute with 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP to prepare a diluted solution with a final concentration ranging from 1 mg/mL to 2 mg/mL.

Mix diluted solution by gentle inversion.

•Store the diluted solution for no more than 24 hours under refrigeration (2°C to 8°C, 36°F to 46°F) or at room temperature (20°C to 25°C, 68°F to 77°F).

•Discard partially used vials or empty vials of YERVOY.

Administration Instructions •Do not mix YERVOY with, or administer as an infusion with, other medicinal products.

•Flush the intravenous line with 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP after each dose.

•Administer diluted solution over 90 minutes through an intravenous line containing a sterile, non-pyrogenic, low-protein-binding in-line filter.