LEBRIKIZUMAB: 78 Adverse Event Reports & Safety Profile

Lebrikizumab-lbkz, an interleukin-13 antagonist, is an immunoglobulin G4 (IgG4) monoclonal antibody that binds to interleukin (IL)-13 and inhibits IL-13 signaling. Lebrikizumab-lbkz is produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology. Lebrikizumab-lbkz has an approximate molecular weight of 145 kDa. EBGLYSS (lebrikizumab-lbkz) injection is a sterile, preservative free, clear to opalescent, colorless to slightly yellow to slightly brown solution for subcutaneous use. EBGLYSS is available as either a 250 mg/2 mL single-dose prefilled pen or a single-dose prefilled syringe with needle shield. The EBGLYSS prefilled pen and prefilled syringe with needle shield are not made with natural rubber latex. Each prefilled pen or prefilled syringe delivers 250 mg lebrikizumab-lbkz in 2 mL solution which also contains glacial acetic acid (1.8 mg), histidine (6.2 mg), polysorbate 20 (0.6 mg), sucrose (119.6 mg) and Water for Injection. The pH is 5.4 – 6.0.

AND USAGE EBGLYSS is indicated for the treatment of adults and pediatric patients 12 years of age and older who weigh at least 40 kg with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. EBGLYSS can be used with or without topical corticosteroids. EBGLYSS ® is an interleukin-13 antagonist indicated for the treatment of adults and pediatric patients 12 years of age and older who weigh at least 40 kg with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. EBGLYSS can be used with or without topical corticosteroids. ( 1 )

AND ADMINISTRATION Prior to EBGLYSS treatment, complete all age-appropriate vaccinations according to current immunization guidelines. ( 2.1 ) The recommended dosage of EBGLYSS is 500 mg (two 250 mg injections) at Week 0 and Week 2, followed by 250 mg (one injection) every 2 weeks until Week 16 or later, when adequate clinical response is achieved. The maintenance dose is EBGLYSS 250 mg every 4 weeks. ( 2.2 ) Administer by subcutaneous injection. ( 2.4 )

2.1 Vaccination Prior to Administration of EBGLYSS Complete all age-appropriate vaccinations according to current immunization guidelines <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.4 )]</span> .

2.2 Recommended Dosage The recommended dosage of EBGLYSS is an initial dose of 500 mg (two 250 mg injections) at Week 0 and Week 2, followed by 250 mg every two weeks until Week 16 or later, when adequate clinical response is achieved. The maintenance dosage is 250 mg every four weeks <span class="opacity-50 text-xs">[see Clinical Studies ( 14.1 )]</span> .

2.3 Concomitant Topical Therapies EBGLYSS can be used with or without topical corticosteroids (TCS). Topical calcineurin inhibitors (TCI) may be used, but reserved for sensitive areas only, such as the face, neck, intertriginous and genital areas.

2.4 Important Administration Instructions EBGLYSS is for subcutaneous administration. EBGLYSS is intended for use under the guidance of a healthcare professional. Provide proper training to patients and/or caregivers on the subcutaneous injection technique of EBGLYSS. Adult patients may self-inject, or caregivers may give EBGLYSS after training in subcutaneous injection technique. For pediatric patients, caregivers may give injections after training in subcutaneous injection technique. Sites for injection include the abdomen, thigh, and back of the upper arm. Administration of EBGLYSS in the back of the upper arm may be performed by a caregiver or healthcare provider. Alternate the injection site with each injection. Do not inject EBGLYSS within 2 inches (5 cm) of the navel or into areas where the skin is tender, bruised, red, hard, or in an area of skin that is affected by atopic dermatitis or skin lesions. It is not necessary to allow EBGLYSS prefilled pen or EBGLYSS prefilled syringe to warm up to room temperature before use. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. EBGLYSS is a clear to opalescent, colorless to slightly yellow to slightly brown solution. Do not use if the liquid contains visible particles, is discolored or cloudy <span class="opacity-50 text-xs">[see Dosage Forms and Strengths ( 3 ), How Supplied/Storage and Handling ( 16 )]</span> . Refer to the Instructions for Use for complete administration instructions with illustrations <span class="opacity-50 text-xs">[see Instructions for Use]</span> .

2.5 Missed Dose If a dose is missed, administer the dose as soon as possible. Thereafter, resume dosing at the regular scheduled time.

EBGLYSS is contraindicated in patients with prior serious hypersensitivity to lebrikizumab-lbkz or any excipients of EBGLYSS [see Warnings and Precautions ( 5.1 )] . Prior serious hypersensitivity to lebrikizumab-lbkz or any excipients in EBGLYSS. ( 4 )

REACTIONS The following adverse reactions are described elsewhere in the labeling: Hypersensitivity [see Warnings and Precautions ( 5.1 )] Conjunctivitis and Keratitis [see Warnings and Precautions ( 5.2 )] Most common (≥1%) adverse reactions are conjunctivitis, injection site reactions, and herpes zoster. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Eli Lilly and Company at 1-800-LillyRx (1-800-545-5979) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying and controlled 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.

Atopic Dermatitis

The safety of EBGLYSS was evaluated across 4 randomized, double-blind, placebo-controlled, multicenter trials in subjects with moderate-to-severe atopic dermatitis including 3 phase 3 trials (ADvocate 1, ADvocate 2, ADhere) and 1 phase 2 dose ranging trial (KGAF). In these 4 trials, mean age was 37 years; 50% of subjects were male; 62% were White, 13% were Black, and 20% were Asian. In terms of co-morbid conditions, in the phase 3 trials, 30% of the subjects had asthma, 50% had allergic rhinitis, 31% had food allergy, and 14% had allergic conjunctivitis at baseline. A total of 891 subjects were treated with EBGLYSS for at least 1 year in the atopic dermatitis development program. ADvocate 1, ADvocate 2, and KGAF compared the safety of EBGLYSS monotherapy to placebo. ADhere compared the safety of EBGLYSS + TCS to placebo + TCS through 16 weeks. All subjects from the phase 3 trials were allowed to enroll in the long-term extension study.

Weeks

0 to 16 Table 1 summarizes the adverse reactions that occurred at a rate of at least 1% in the EBGLYSS 250 mg every 2 weeks monotherapy group, or in the EBGLYSS 250 mg every 2 weeks + TCS group, all at a higher rate than placebo during the first 16 weeks of treatment.

Table

1: Adverse Reactions Occurring in ≥1% of the EBGLYSS Monotherapy Group or the EBGLYSS + TCS Group in the Atopic Dermatitis Trials through Week 16 a Integrated analysis of ADvocate 1, ADvocate 2, and the phase 2 dose finding trial (KGAF) b Analysis of TCS concomitant therapy trial ADhere c EBGLYSS 500 mg at Week 0 and Week 2, followed by 250 mg every two weeks d Conjunctivitis cluster includes conjunctivitis, conjunctivitis allergic, and conjunctivitis bacterial e Injection Site Reactions cluster includes injection site-related: pain, erythema, reaction, discomfort, dermatitis, pruritus, swelling, and rash Adverse Reactions EBGLYSS Monotherapy a EBGLYSS + TCS b EBGLYSS 250 mg Q2W c N = 638 n (%) Placebo N = 338 n (%) EBGLYSS 250 mg Q2W c + TCS N = 145 n (%) Placebo + TCS N = 66 n (%) Conjunctivitis d 61 (10) 10 (3) 7 (5) 0 Injection Site Reactions e 16 (3) 4 (1) 4 (3) 1 (2)

Herpes Zoster

3 (<1) 0 2 (1) 0 In the monotherapy trials (ADvocate 1, ADvocate 2, and KGAF) through Week 16, the proportion of subjects who discontinued treatment due to adverse events was 2.4% in the EBGLYSS 250 mg every 2 weeks group and 1.8% in the placebo group. In the TCS trial (ADhere) through Week 16, the proportion of subjects who discontinued treatment due to adverse events was 2.1% in the EBGLYSS 250 mg every 2 weeks + TCS group and 0% in the placebo + TCS group. The most common adverse reactions leading to discontinuation of EBGLYSS compared to the placebo group were conjunctivitis and keratitis (0.6% vs. 0.3%), and injection site reactions (0.2% vs. 0) in the monotherapy trials; and conjunctivitis (0.7% vs. 0), and injection site reactions (0.7% vs. 0) in the TCS trial.

Eosinophilia

Increased post-baseline blood eosinophils were observed at a higher frequency in EBGLYSS-treated subjects compared to placebo. During the first 16 weeks, eosinophilia (>5000 cells/mcL) was observed in 0.4% in the EBGLYSS-treated subjects and 0% in subjects receiving placebo. Blood eosinophil elevations were generally transient and did not result in discontinuation.

Safety Weeks

16 to 52 Among those EBGLYSS-treated subjects who responded at Week 16 and who were re-randomized in the maintenance period of the monotherapy trials ADvocate 1 and ADvocate 2, a total of 113 and 118 subjects received EBGLYSS 250 mg every 2 weeks or every 4 weeks, respectively. The safety profile of EBGLYSS 250 mg every 4 weeks was generally consistent with EBGLYSS every 2 weeks during Weeks 16 to 52. The safety profile of EBGLYSS during maintenance treatment was generally consistent with the safety profile observed through Week 16.

Specific Adverse Drug Reactions

Conjunctivitis and Keratitis Conjunctivitis was the most frequently reported eye disorder. Most cases of conjunctivitis and keratitis were mild or moderate in severity and recovered or resolved without treatment interruption or discontinuation. During the initial 16-week treatment period of the monotherapy trials, conjunctivitis, including allergic conjunctivitis, was reported by 61 subjects (10%) in the EBGLYSS 250 mg every 2 weeks group and 10 subjects (3%) in the placebo group. In the TCS concomitant therapy trial, conjunctivitis was reported by 7 subjects (5%) in the EBGLYSS 250 mg every 2 weeks + TCS group compared to 0% in the placebo + TCS group. During the 16-week placebo-controlled induction period, 68 subjects reported 73 events of conjunctivitis. All events were nonserious and mild or moderate in severity. Conjunctivitis led to treatment discontinuation in 3 subjects. The exposure adjusted incidence rate of conjunctivitis for subjects treated with EBGLYSS 250 mg every 2 weeks was 30.6 events per 100 patient years through Week 16 (KGAF, ADvocate 1, ADvocate 2, ADhere). During the maintenance treatment period of the monotherapy trials (ADvocate 1 and ADvocate 2) from 16 to 52 weeks, conjunctivitis, including allergic conjunctivitis, was reported by 2 subjects (1.8%) in the EBGLYSS 250 mg every 2 weeks group and 12 subjects (10.1%) in the EBGLYSS 250 mg every 4 weeks group, compared to 5 subjects (8.3%) in the placebo group. During the maintenance treatment period, 14 subjects treated with EBGLYSS reported 18 events of conjunctivitis. All events were mild or moderate in severity. Conjunctivitis led to treatment discontinuation in 2 subjects in the EBGLYSS 250 mg every 4 weeks group. The exposure adjusted incidence rate of conjunctivitis for subjects treated with EBGLYSS 250 mg every 2 weeks was 18.3 events per 100 patient years and for those treated with EBGLYSS 250 mg every 4 weeks was 20.6 events per 100 patient years through Week 52 (ADvocate 1, ADvocate 2, ADhere + the long-term extension study). During the initial 16-week treatment period of the monotherapy trials, keratitis, including atopic and vernal keratoconjunctivitis, was reported by 4 subjects (0.6%) in the EBGLYSS 250 mg every 2 weeks group and 1 subject (0.3%) in the placebo group. In the TCS concomitant therapy trial, vernal keratoconjunctivitis was reported by 1 subject (0.7%) in the EBGLYSS 250 mg every 2 weeks + TCS group, compared to 0% in the placebo + TCS group. All events were nonserious and mild or moderate in severity. Keratitis led to treatment discontinuation in 2 subjects. The exposure adjusted incidence rate of keratitis for subjects treated with EBGLYSS 250 mg every 2 weeks was 2.2 events per 100 patient years through Week 16 (KGAF, ADvocate 1, ADvocate 2, ADhere). During the maintenance treatment period of the monotherapy trials (ADvocate 1 and ADvocate 2) from 16 to 52 weeks, atopic keratoconjunctivitis was reported by 1 subject (0.8%) in the EBGLYSS 250 mg every 4 weeks group, and vernal keratoconjunctivitis was reported by 1 subject (0.9%) in the EBGLYSS 250 mg every 2 weeks group, compared to 0% in the placebo group. One (0.9%) event of severe vernal keratoconjunctivitis in an EBGLYSS 250 mg every 2 weeks subject led to treatment discontinuation. The exposure adjusted incidence rate of keratitis for subjects treated with EBGLYSS 250 mg every 2 weeks was 1.0 event per 100 patient years and for those treated with EBGLYSS 250 mg every 4 weeks was 0.7 events per 100 patient years through Week 52 (ADvocate 1, ADvocate 2, ADhere + the long-term extension study).

Injection Site Reactions

Injection site reactions were reported by 3% of the EBGLYSS group and 1% of the placebo group in the first 16 weeks of the monotherapy trials. Incidence of injection site reactions declined with continued treatment. Most events were mild or moderate and recovered without treatment discontinuation.

AND PRECAUTIONS Hypersensitivity: Hypersensitivity reactions including angioedema and urticaria, have occurred after administration of EBGLYSS. Discontinue EBGLYSS in the event of a serious hypersensitivity reaction. ( 5.1 ) Conjunctivitis and Keratitis: Report new onset or worsening eye symptoms to a healthcare provider. ( 5.2 ) Parasitic (Helminth) Infections: Treat patients with pre-existing helminth infections before initiating EBGLYSS. If patients become infected while receiving EBGLYSS and do not respond to anti-helminth treatment, discontinue treatment with EBGLYSS until the infection resolves. ( 5.3 ) Vaccinations: Avoid use of live vaccines during treatment with EBGLYSS. ( 5.4 )

5.1 Hypersensitivity Hypersensitivity reactions, including angioedema and urticaria, have been reported with use of EBGLYSS. If a serious hypersensitivity reaction occurs, discontinue EBGLYSS and institute appropriate therapy.

5.2 Conjunctivitis and Keratitis Conjunctivitis and keratitis adverse reactions have been reported in clinical trials. Conjunctivitis and keratitis occurred more frequently in atopic dermatitis subjects who received EBGLYSS compared to those who received placebo. Conjunctivitis was the most frequently reported eye disorder. Most subjects with conjunctivitis or keratitis recovered during the treatment period <span class="opacity-50 text-xs">[see Adverse Reactions ( 6.1 )]</span> . Advise patients to report new onset or worsening eye symptoms to their healthcare provider.

5.3 Parasitic (Helminth)

Infections

Patients with known helminth infections were excluded from participation in clinical studies. It is unknown if EBGLYSS will influence the immune response against helminth infections by inhibiting IL-13 signaling. Treat patients with pre-existing helminth infections before initiating treatment with EBGLYSS. If patients become infected while receiving EBGLYSS and do not respond to antihelminth treatment, discontinue treatment with EBGLYSS until the infection resolves.

5.4 Vaccinations EBGLYSS may alter a patient’s immunity and increase the risk of infection following administration of live vaccines. Prior to therapy with EBGLYSS, complete all age-appropriate vaccinations according to current immunization guidelines. Avoid use of live vaccines immediately prior to or during treatment with EBGLYSS. No data are available on the response to live vaccines.