ENHERTU
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SEE PI & BOXED WARNINGS.
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ENHERTU is approved for the treatment of adult patients with unresectable or metastatic HER2-positive (IHC 3+) solid tumors who have received prior systemic treatment and have no satisfactory alternative treatment options.1
This indication is approved under accelerated approval based on objective response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. Review some of the response data behind this approval below.1
In previously treated HER2+ (IHC 3+) metastatic solid tumors
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Responses with ENHERTU across clinical trials1,2
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Median follow-up was 16 months for metastatic solid tumors, 11.17 months for mNSCLC, and 9.28 months for mCRC.2
This indication is approved under accelerated approval based on objective response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.
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Assessed by ICR based on RECIST v1.1.1
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CI is derived based on the Clopper-Pearson method.1
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c
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Calculated using the Kaplan-Meier technique.1
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+ denotes ongoing response.1
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ENHERTU was granted accelerated approval based on 3 trials. DESTINY-PanTumor02, DESTINY-Lung01, and DESTINY-CRC02 were multicenter clinical trials, which included 192 adults with HER2+ (IHC 3+) unresectable or metastatic solid tumors that progressed after ≥1 prior treatment. Patients were treated with 5.4 mg/kg IV of ENHERTU every 3 weeks until disease progression, death, withdrawal of consent, or unacceptable toxicity. Confirmed ORR was the major efficacy outcome, DOR was an additional efficacy outcome, and both were assessed by ICR using RECIST v1.1.1
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Important Safety Information
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WARNING: INTERSTITIAL LUNG DISEASE and EMBRYO-FETAL TOXICITY
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Interstitial lung disease (ILD) and pneumonitis, including fatal cases, have been reported with ENHERTU. Monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms. Permanently discontinue ENHERTU in all patients with Grade 2 or higher ILD/pneumonitis. Advise patients of the risk and to immediately report symptoms.
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Exposure to ENHERTU during pregnancy can cause embryo-fetal harm. Advise patients of these risks and the need for effective contraception.
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See additional Important Safety Information below.
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In previously treated HER2 (IHC 3+) metastatic solid tumors
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Responses with ENHERTU across tumor types1
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Efficacy was also assessed in 7 patients with rare tumor types: oropharyngeal neoplasm (n=1); vulvar cancer (n=1); extramammary Paget’s disease (n=1); lacrimal gland cancer (n=1); lip and/or oral cavity cancer (n=1); esophageal adenocarcinoma (n=1); esophageal squamous cell carcinoma (n=1).1
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d
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Assessed by ICR based on RECIST v1.1.1
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Median follow-up was 11.17 months for non-small cell lung cancer, 9.28 months for colorectal cancer, and 16 months for metastatic solid tumors.2
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Calculated using the Kaplan-Meier technique.1
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+ denotes ongoing response.1
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ILD and pneumonitis, including Grade 5 cases, have been reported with ENHERTU1,2
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Across pooled studies in solid tumors, ILD occurred in 12% of patients (n=216/1799) treated with ENHERTU at 5.4 mg/kgg
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Fatal outcomes due to ILD and/or pneumonitis occurred in 1% of patients (n=18/1799)
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The majority of ILD cases were Grade 1 or 2 (n=185/216)
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Median time to first onset was 5.5 months (range: 0.9-31.5)
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In clinical trials for ENHERTU in HER2+ (IHC 3+) metastatic solid tumors, ILD occurred in 16% of patients and fatal outcomes due to ILD and/or pneumonitis occurred in 2.3% of patientsh
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Most common adverse reactions with ENHERTU in previously treated HER2+ (IHC 3+) metastatic solid tumors1,h
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The most common (≥20%) adverse reactions, including laboratory abnormalities, were decreased white blood cell count (75%), nausea (69%), decreased hemoglobin (67%), decreased neutrophil count (66%), fatigue (59%), decreased lymphocyte count (58%), decreased platelet count (51%), increased aspartate aminotransferase (45%), increased alanine aminotransferase (44%), increased blood alkaline phosphatase (36%), vomiting (35%), decreased appetite (34%), alopecia (34%), diarrhea (31%), decreased blood potassium (29%), constipation (28%), decreased sodium (22%), stomatitis (20%), and upper respiratory tract infection (20%)
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The pooled safety population reflects exposure to ENHERTU 5.4 mg/kg IV every 3 weeks in 1799 patients in Study DS8201-A-J101 (NCT02564900), DB-01, DB-02, DB-03, DB-04, DL-01, DL-02, DC‑02, and DP-02.1
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h
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Safety was evaluated in 347 adult patients with unresectable or metastatic HER2+ (IHC 3+) solid tumors who received ENHERTU 5.4 mg/kg in DB-01, DP-02, DL-01, and DC-02. Median duration of treatment was 8.3 months (range 0.7, 30.2).1
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Test for HER2 positivity (IHC 3+) in all metastatic solid tumors. Identify patients who may be eligible for treatment with ENHERTU1
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Important Safety Information
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Indication
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ENHERTU is a HER2-directed antibody and topoisomerase inhibitor conjugate indicated for the treatment of adult patients with unresectable or metastatic HER2‑positive (IHC3+) solid tumors who have received prior systemic treatment and have no satisfactory alternative treatment options.
This indication is approved under accelerated approval based on objective response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.
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WARNING: INTERSTITIAL LUNG DISEASE and EMBRYO-FETAL TOXICITY
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Interstitial lung disease (ILD) and pneumonitis, including fatal cases, have been reported with ENHERTU. Monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms. Permanently discontinue ENHERTU in all patients with Grade 2 or higher ILD/pneumonitis. Advise patients of the risk and to immediately report symptoms.
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Exposure to ENHERTU during pregnancy can cause embryo-fetal harm. Advise patients of these risks and the need for effective contraception.
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Contraindications
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None.
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Warnings and Precautions
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Interstitial Lung Disease/ Pneumonitis
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Severe, life-threatening, or fatal interstitial lung disease (ILD), including pneumonitis, can occur in patients treated with ENHERTU. A higher incidence of Grade 1 and 2 ILD/pneumonitis has been observed in patients with moderate renal impairment. Advise patients to immediately report cough, dyspnea, fever, and/or any new or worsening respiratory symptoms. Monitor patients for signs and symptoms of ILD. Promptly investigate evidence of ILD. Evaluate patients with suspected ILD by radiographic imaging. Consider consultation with a pulmonologist. For asymptomatic ILD/pneumonitis (Grade 1), interrupt ENHERTU until resolved to Grade 0, then if resolved in ≤28 days from date of onset, maintain dose. If resolved in >28 days from date of onset, reduce dose one level.
Consider corticosteroid treatment as soon as ILD/pneumonitis is suspected (e.g., ≥0.5 mg/kg/day prednisolone or equivalent). For symptomatic ILD/pneumonitis (Grade 2 or greater), permanently discontinue ENHERTU. Promptly initiate systemic corticosteroid treatment as soon as ILD/pneumonitis is suspected (e.g., ≥1 mg/kg/day prednisolone or equivalent) and continue for at least 14 days followed by gradual taper for at least 4 weeks.
Solid Tumors (IHC3+) and Other Solid Tumors (5.4 mg/kg)
In patients with solid tumors treated with ENHERTU 5.4 mg/kg, ILD occurred in 12% of patients. Median time to first onset was 5.5 months (range: 0.9 to 31.5). Fatal outcomes due to ILD and/or pneumonitis occurred in 1.0% of patients treated with ENHERTU.
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Neutropenia
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Severe neutropenia, including febrile neutropenia, can occur in patients treated with ENHERTU. Monitor complete blood counts prior to initiation of ENHERTU and prior to each dose, and as clinically indicated. For Grade 3 neutropenia (Absolute Neutrophil Count [ANC] <1.0 to 0.5 x 109/L), interrupt ENHERTU until resolved to Grade 2 or less, then maintain dose. For Grade 4 neutropenia (ANC <0.5 x 109/L), interrupt ENHERTU until resolved to Grade 2 or less, then reduce dose by one level. For febrile neutropenia (ANC <1.0 x 109
/L and temperature >38.3° C or a sustained temperature of ≥38° C for more than 1 hour), interrupt ENHERTU until resolved, then reduce dose by one level.
Solid Tumors (IHC3+) and Other Solid Tumors (5.4 mg/kg)
In patients with solid tumors treated with ENHERTU 5.4 mg/kg, a decrease in neutrophil count was reported in 63% of patients. Seventeen percent had Grade 3 or 4 decreased neutrophil count. Median time to first onset of decreased neutrophil count was 22 days (range: 2 to 939). Febrile neutropenia was reported in 1% of patients.
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Left Ventricular Dysfunction
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Patients treated with ENHERTU may be at increased risk of developing left ventricular dysfunction. Left ventricular ejection fraction (LVEF) decrease has been observed with anti- HER2 therapies, including ENHERTU. Assess LVEF prior to initiation of ENHERTU and at regular intervals during treatment as clinically indicated. Manage LVEF decrease through treatment interruption. When LVEF is >45% and absolute decrease from baseline is 10-20%, continue treatment with ENHERTU. When LVEF is 40-45% and absolute decrease from baseline is <10%, continue treatment with ENHERTU and repeat LVEF assessment within 3 weeks. When LVEF is 40-45% and absolute decrease from baseline is 10-20%, interrupt ENHERTU and repeat LVEF assessment within 3 weeks. If LVEF has not recovered to
within 10% from baseline, permanently discontinue ENHERTU. If LVEF recovers to within 10% from baseline, resume treatment with ENHERTU at the same dose. When LVEF is <40% or absolute decrease from baseline is >20%, interrupt ENHERTU and repeat LVEF assessment within 3 weeks. If LVEF of <40% or absolute decrease from baseline of >20% is confirmed, permanently discontinue ENHERTU. Permanently discontinue ENHERTU in patients with symptomatic congestive heart failure. Treatment with ENHERTU has not been studied in patients with a history of clinically significant cardiac disease or LVEF <50% prior to initiation of treatment.
Solid Tumors (IHC3+) and Other Solid Tumors (5.4 mg/kg)
In patients with solid tumors treated with ENHERTU 5.4 mg/kg, LVEF decrease was reported in 3.8% of patients, of which 0.6% were Grade 3.
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Embryo-Fetal Toxicity
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ENHERTU can cause fetal harm when administered to a pregnant woman. Advise patients of the potential risks to a fetus. Verify the pregnancy status of females of reproductive potential prior to the initiation of ENHERTU. Advise females of reproductive potential to use effective contraception during treatment and for 7 months after the last dose of ENHERTU. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with ENHERTU and for 4 months after the last dose of ENHERTU.
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Additional Dose Modifications
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Thrombocytopenia
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For Grade 3 thrombocytopenia (platelets <50 to 25 x 109/L) interrupt ENHERTU until resolved to Grade 1 or less, then maintain dose. For Grade 4 thrombocytopenia (platelets <25 x 109/L) interrupt ENHERTU until resolved to Grade 1 or less, then reduce dose by one level.
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Adverse Reactions
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Solid Tumors (IHC3+) and Other Solid Tumors (5.4 mg/kg)
The pooled safety population reflects exposure to ENHERTU 5.4 mg/kg intravenously every 3 weeks in 1799 patients in Study DS8201-A-J101 (NCT02564900), DESTINY‑Breast01, DESTINY-Breast02, DESTINY-Breast03, DESTINY-Breast04, DESTINY-Lung01, DESTINY-Lung02, DESTINY-CRC02, and DESTINY-PanTumor02. Among these patients, 65% were exposed for >6 months and 38% were exposed for >1 year. In this pooled safety population, the most common (≥20%) adverse reactions, including laboratory abnormalities, were nausea (73%), decreased white blood cell count (70%), decreased hemoglobin (66%), decreased neutrophil count (63%), decreased lymphocyte count (58%), fatigue (56%), decreased platelet count (48%), increased aspartate aminotransferase (47%), increased
alanine aminotransferase (43%), vomiting (40%), increased blood alkaline phosphatase (38%), alopecia (34%), constipation (33%), decreased appetite (32%), decreased blood potassium (31%), diarrhea (29%), musculoskeletal pain (24%), and abdominal pain (20%).
HER2-Positive (IHC3+) Unresectable or Metastatic Solid Tumors
The safety of ENHERTU was evaluated in 347 adult patients with unresectable or metastatic HER2-positive (IHC3+) solid tumors who received ENHERTU 5.4 mg/kg intravenously once every 3 weeks in DESTINY-Breast01, DESTINY-PanTumor02, DESTINY-Lung01, and DESTINY-CRC02. The median duration of treatment was 8.3 months (range 0.7 to 30.2).
Serious adverse reactions occurred in 34% of patients receiving ENHERTU.
Serious adverse reactions in >1% of patients who received ENHERTU were sepsis, pneumonia, vomiting, urinary tract infection, abdominal pain, nausea, pneumonitis, pleural effusion, hemorrhage, COVID-19, fatigue, acute kidney injury, anemia, cellulitis, and dyspnea. Fatalities due to adverse reactions occurred in 6.3% of patients including ILD/pneumonitis (2.3%), cardiac arrest (0.6%), COVID-19 (0.6%), and sepsis (0.6%). The following events occurred in one patient each (0.3%): acute kidney injury, cerebrovascular accident, general physical health deterioration, pneumonia, and hemorrhagic shock.
ENHERTU was permanently discontinued in 15% of patients, of which ILD/pneumonitis accounted for 10%. Dose interruptions due to adverse reactions occurred in 48% of patients. The most frequent adverse reactions (>2%) associated with dose interruption were decreased neutrophil count, anemia, COVID-19, fatigue, decreased white blood cell count, and ILD/pneumonitis. Dose reductions occurred in 27% of patients treated with ENHERTU. The most frequent adverse reactions (>2%) associated with dose reduction were fatigue, nausea, decreased neutrophil count, ILD/pneumonitis, and diarrhea.
The most common (≥20%) adverse reactions, including laboratory abnormalities, were decreased white blood cell count (75%), nausea (69%), decreased hemoglobin (67%), decreased neutrophil count (66%), fatigue (59%), decreased lymphocyte count (58%), decreased platelet count (51%), increased aspartate aminotransferase (45%), increased alanine aminotransferase (44%), increased blood alkaline phosphatase (36%), vomiting (35%), decreased appetite (34%), alopecia (34%), diarrhea (31%), decreased blood potassium (29%), constipation (28%), decreased sodium (22%), stomatitis (20%), and upper respiratory tract infection (20%).
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Use in Specific Populations
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Pregnancy: ENHERTU can cause fetal harm when administered to a pregnant woman. Advise patients of the potential risks to a fetus. There are clinical considerations if ENHERTU is used in pregnant women, or if a patient becomes pregnant within 7 months after the last dose of ENHERTU.
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Lactation: There are no data regarding the presence of ENHERTU in human milk, the effects on the breastfed child, or the effects on milk production. Because of the potential for serious adverse reactions in a breastfed child, advise women not to breastfeed during treatment with ENHERTU and for 7 months after the last dose.
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Females and Males of Reproductive Potential: Pregnancy testing: Verify pregnancy status of females of reproductive potential prior to initiation of ENHERTU. Contraception: Females: ENHERTU can cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with ENHERTU and for 7 months after the last dose. Males: Advise male patients with female partners of reproductive potential to use effective contraception during treatment with ENHERTU and for 4 months after the last dose. Infertility: ENHERTU may impair male reproductive function and fertility.
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Pediatric Use: Safety and effectiveness of ENHERTU have not been established in pediatric patients.
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Geriatric Use: Of the 192 patients with HER2-positive (IHC 3+) unresectable or metastatic solid tumors treated with ENHERTU 5.4 mg/kg in DESTINY-PanTumor02, DESTINY-Lung01, or DESTINY-CRC02, 39% were 65 years or older and 9% were 75 years or older. No overall differences in efficacy or safety were observed between patients ≥65 years of age compared to younger patients.
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Renal Impairment: A higher incidence of Grade 1 and 2 ILD/pneumonitis has been observed in patients with moderate renal impairment. Monitor patients with moderate renal impairment more frequently. The recommended dosage of ENHERTU has not been established for patients with severe renal impairment (CLcr <30 mL/min).
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Hepatic Impairment: In patients with moderate hepatic impairment, due to potentially increased exposure, closely monitor for increased toxicities related to the topoisomerase inhibitor, DXd. The recommended dosage of ENHERTU has not been established for patients with severe hepatic impairment (total bilirubin >3 times ULN and any AST).
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To report SUSPECTED ADVERSE REACTIONS, contact Daiichi Sankyo, Inc. at 1‑877-437-7763 or FDA at 1-800-FDA-1088 or fda.gov/medwatch.
Please see accompanying full Prescribing Information, including Boxed WARNINGS, and Medication Guide.
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As required by Colorado law, please click here to see the document disclosing pricing information.
As required by Connecticut law, please click here to see the document disclosing pricing information.
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Abbreviations: Cl, confidence interval; CR, complete response; DOR, duration of response; HER2, human epidermal growth factor receptor 2; ICR, independent central review; IHC, immunohistochemistry; ILD, interstitial lung disease; IV, intravenous; mCRC, metastatic colorectal cancer; mDOR, median duration of response; mNSCLC, metastatic non-small cell lung cancer; NA, not available; ORR, objective response rate; PR, partial response; RECIST, Response Evaluation Criteria in Solid Tumors.
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References: 1. ENHERTU. Prescribing Information. Daiichi Sankyo, Inc.; 2024.
2. Data on file. Daiichi Sankyo, Inc. Basking Ridge, NJ.
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For US Healthcare Professionals Only.
To contact us with questions or concerns about a Daiichi Sankyo product,
please call us: 1‑877‑4DS‑PROD (1‑877‑437‑7763).
ENHERTU® is a registered trademark of Daiichi Sankyo Company, Limited.
© 2024 Daiichi Sankyo, Inc. and AstraZeneca. PP-US-ENTA-0126 04/24
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