Dosing and uses of Yervoy (ipilimumab)
Adult dosage forms and strengths
intravenous solution
- 50mg/10mL (5mg/mL)
- 200mg/40mL (5mg/mL)
Malignant Melanoma
Unresectable or metastatic melanoma
- Indicated for treatment of unresectable or metastatic melanoma
- 3 mg/kg IV q3Week for a maximum of 4 doses
- Infuse IV over 90 minutes
- In the event of toxicity, doses may be delayed, but all treatment must be administered within 16 weeks of the first dose
Adjuvant treatment
- Indicated for the adjuvant treatment of patients with cutaneous melanoma with pathologic involvement of regional lymph nodes >1 mm who have undergone complete resection, including total lymphadenectomy
- 10 mg/kg IV q3Week for 4 doses followed by 10 mg/kg q12Week for up to 3 yr
- Infuse IV over 90 minutes
- In the event of toxicity, doses are omitted, not delayed
Dosage modifications
Renal impairment: No dose adjustment required
Hepatic impairment
- Mild (TB >1 to 1.5 x ULN or AST >ULN): No dose adjustment required
- Moderate-to-severe (TB >1.5 x ULN and any AST): Not studied; caution advised
Withhold dosing
- Symptomatic endocrine adverse effects and all other grade 2 adverse effects
- Resume dosing in patients with complete or partial resolution of adverse reactions (grade 0 to 1) and who are receiving <7.5 mg prednisone or equivalent per day
Permanently discontinue
- Endocrine
- Symptomatic reactions lasting ≥6 weeks
- Inability to reduce corticosteroid dose to 7.5 mg prednisone or equivalent per day
- Ophthalmologic
- Grade 2 through 4 reactions that do not improve to grade 1 within 2 weeks while receiving topical therapy
- Grade 2 through 4 reactions requiring systemic treatment
- All other
- Grade 2 reactions lasting ≥6 weeks
- Inability to reduce corticosteroid dose to 7.5 mg prednisone or equivalent per day
- Grade 3 or 4 reactions
Pediatric dosage forms and strengths
Safety and efficacy not established
Geriatric dosage forms and strengths
Malignant Melanoma
No overall differences in safety or efficacy were reported between the elderly patients
Yervoy (ipilimumab) adverse (side) effects
>10%
Dermatitis immune-mediated manifestations (up to 70%)
Fatigue (41%)
Diarrhea (32%)
Pruritus (31%)
Rash (29%)
1-10%
Colitis (8%)
Immune-mediated enterocolitis (7%)
Immune-mediated hepatitis (2%)
Endocrinopathies (1.8%) including adrenal insufficiency, hypogonadism, and hypothyroidism
<1%
Neurologic immune-mediated manifestations (eg, Guillain-Barre, peripheral motor neuropathy)
Ocular immune-mediated manifestations (eg, uveitis, iritis)
Nephrotic immune-mediated manifestations (nephritis)
Pulmonary immune-mediated manifestations (pneumonitis)
Other immune-mediated adverse reactions (<1%) include nephritis, pneumonitis, meningitis, pericarditis, uveitis, iritis, and hemolytic anemia
Meningitis
Pericarditis
Myocarditis
Angiopathy
Temporal arteritis
Vasculitis
Polymyalgia rheumatica
Conjunctivitis
Blepharitis
Episcleritis
Scleritis
Leukocytoclastic vasculitis
Erythema multiforme
Psoriasis
Pancreatitis
Arthritis
Autoimmune thyroiditis
Postmarketing Reports
Skin and subcutaneous tissue disorders: Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
Warnings
Black box warnings
Severe and fatal immune-mediated adverse reactions due to T-cell activation and proliferation may involve any organ system
The most common severe immune-mediated adverse reactions are enterocolitis, hepatitis, dermatitis (including toxic epidermal necrolysis), neuropathy, and endocrinopathy
Other immune-mediated adverse reactions include ocular manifestations include autoimmune central neuropathy (encephalitis), neurosensory hypoacusis, myositis, polymyositis, ocular myositis, and sarcoidosis
These reactions typically manifest during treatment but may occur weeks to months after discontinuation
If severe immune-mediated reactions occur, permanently discontinue and initiate systemic high-dose corticosteroid therapy
Assess signs and symptoms of enterocolitis, dermatitis, neuropathy, and endocrinopathy and evaluate clinical chemistries, including liver function
Contraindications
No known contraindications
Cautions
May cause immune-mediated adverse reactions including enterocolitis, hepatitis, dermatitis, neuropathies, endocrinopathies, ocular, and other significant or severe immune-mediated manifestations; may require initiation of systemic corticosteroids at a dose of 1 to 2 mg/kg/day of prednisone or equivalent
Withhold dose for moderate immune-mediated adverse reactions until return to baseline, improvement to mild severity, or complete resolution, and patient is receiving <7.5 mg/day prednisone or equivalent
Administer systemic high-dose corticosteroids for severe, persistent, or recurring immune-mediated reactions
Evaluate liver function tests before each dose; permanently discontinue with Grade 3-4 hepatotoxicity
Monitor thyroid function tests and clinical chemistries prior to each dose
Evaluate at each visit for signs and symptoms of endocrinopathy and institute hormone replacement therapy as needed
Binding antibodies against ipilimumab may develop
Based on its mechanism of action and data from animal studies, can cause fetal harm when administered to a pregnant woman (see Pregnancy); advise females of reproductive potential to use effective contraception during treatment and for 3 months after the last dose of ipilimumaB
Pregnancy and lactation
Pregnancy
Based on data from animal studies and its mechanism of action, can cause fetal harm when administered to a pregnant woman
Advise females of reproductive potential to use effective contraception during treatment and for 3 months after the last dose
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
Animal studies
- 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
- The effects are likely to be greater during the second and third trimesters of pregnancy
Lactation
Unknown whether distributed in human breast milk
Advise women to discontinue nursing during treatment and for 3 months after the final dose
In monkeys, ipilimumab was present in milk
There are no data to assess the effects on milk production
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Yervoy (ipilimumab)
Mechanism of action
Targeted T-cell antibody; recombinant, human cytotoxic T-lymphocyte antigen 4 (CTLA-4) - blocking antibody indicated for unresectable or metastatic melanoma
CTLA-4 is a negative regulator of T-cell activation; ipilimumab 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
Proposed mechanism of action is indirect, possibly through inhibition of CTLA-4 signaling, which can in turn reduce T-regulatory cell function and may contribute to a general increase in T cell responsiveness, including the anti-tumor immune response
IgG1 kappa immunoglobulin with an approximate molecular weight of 148 kd; produced in mammalian (Chinese hamster ovary) cell culture
Pharmacokinetics
Half-Life (terminal): 15.4 days
Vd: 7.21 L (steady-state)
Minimum Plasma Concentration: 19.4 mcg/mL (steady-state)
Clearance: 16.8 mL/hr
Administration
IV Compatibility
0.9% NaCl (normal saline)
Dextrose 5% (D5W)
IV Preparation
Do not shake viaL
Allow the vials to stand at room temperature for ~5 minutes prior to preparation of infusion
Withdraw the required volume and transfer into an intravenous bag
Dilute with 0.9% NaCl (normal saline) or 5% dextrose (D5W) to prepare a diluted solution with a final concentration ranging from 1-2 mg/mL
Mix diluted solution by gentle inversion
IV Administration
Do not mix with, or administer as an infusion with, other medicinal products
Flush the IV line with 0.9% NaCl or D5W after each dose.
Administer diluted solution over 90 minutes through an IV line containing a sterile, nonpyrogenic, low-protein-binding in-line filter
Storage
Unopened vials
- Store refrigerated at 2-8°C (36-46°F)
- Do not freeze
- Protect vials from light
Diluted solution
- Store the diluted solution for no more than 24 hours under refrigeration (2-8°C, 36-46°F) or at room temperature (20-25°C, 68-77°F)
- Discard partially used vials or empty vials
