Belatacept

Immunosuppressant therapy may affect response to vaccination. Therefore, during treatment with belatacept, vaccinations may be less effective although this has not been studied in clinical trials. The use of live vaccines should be avoided.

Progressive multifocal leukoencephalopathy (PML) is a rare, often rapidly progressive and fatal, opportunistic infection of the CNS that is caused by the John Cunningham (JC) virus. In clinical studies with belatacept, 2 cases of PML were reported in patients receiving belatacept at doses higher than the recommended regimen. In the renal transplant studies of belatacept, one case of PML was reported in a patient who received an IL-2 receptor antagonist, mycophenolate mofetil (MMF) and corticosteroids as concomitant treatment. In the liver transplant study, the patient received MMF and corticosteroids as concomitant treatment. As an increased risk of PML and of other infections has been associated with high levels of overall immunosuppression, the recommended doses of belatacept and concomitant immunosuppressives, including MMF or MPA, should not be exceeded.

Early diagnosis and treatment may mitigate the impact of PML. Physicians should consider PML in the differential diagnosis in patients with new or worsening neurologic, cognitive or behavioural signs or symptoms. PML is usually diagnosed by brain imaging, including magnetic resonance imaging (MRI) or computed tomography (CT) scan, and cerebrospinal fluid (CSF) testing for JC viral DNA by polymerase chain reaction (PCR). When the clinical suspicion for PML is high, brain biopsy should be considered in subjects if the diagnosis of PML cannot be established via CSF PCR and neuroimaging. Consultation with a neurologist is recommended for any suspected or confirmed cases of PML.

If PML is diagnosed, reduction or withdrawal of immunosuppression is recommended taking into account the risk to the graft. Plasmapheresis may accelerate removal of belatacept.

In clinical trials, an increased incidence of graft thrombosis was observed in the post-transplant period in recipients of extended criteria donor allografts. In postmarketing experience in patients with other predisposing risk factors for thrombosis of the renal allograft, renal allograft thrombosis has occurred when the initial dose of anti-thymocyte globulin, as immunosuppressive induction, was coadministered at the same or nearly the same time with the first dose of belatacept.

In the Phase 2 and 3 studies (3 studies), the incidence of PTLD was higher in belatacept-treated patients than in ciclosporin-treated patients. Belatacept-treated transplant recipients who are EBV seronegative are at an increased risk for PTLD compared with those who are EBV positive. EBV serology should be ascertained before starting administration of belatacept. Transplant recipients who are EBV seronegative or serostatus unknown should not receive belatacept.

In addition to EBV seronegative status, other known risk factors for PTLD include cytomegalovirus (CMV) infection and T-cell-depleting therapy, which was more commonly used to treat acute rejection in belatacept-treated patients in Phase 3 clinical studies.

PTLD in belatacept-treated patients most often presented in the central nervous system (CNS). Physicians should consider PTLD in the differential diagnosis in patients with new or worsening neurologic, cognitive or behavioural signs or symptoms.

In addition to PTLD, patients receiving immunosuppressive regimens, including belatacept, are at increased risk of malignancies, including skin cancer. Exposure to sunlight and ultraviolet (UV) light should be limited by wearing protective clothing and using a sunscreen with a high protection factor.

Use of immunosuppressants, including belatacept, can increase susceptibility to infection, including fatal infections, opportunistic infections, tuberculosis, and herpes. CMV prophylaxis is recommended for at least 3 months after transplantation, particularly for patients at increased risk for CMV infection. Pneumocystis pneumonia prophylaxis is recommended for at least 6 months following transplantation.

Tuberculosis was more frequently observed in patients receiving belatacept than ciclosporin in clinical studies. The majority of cases of tuberculosis occurred in patients who currently live or previously lived in countries with a high prevalence of tuberculosis. Patients should be evaluated for tuberculosis and tested for latent infection prior to initiating belatacept. Adequate treatment of latent tuberculosis infection should be instituted prior to belatacept use.

Infusion-related reactions have been reported with belatacept administration in the clinical studies. Patients are not required to be pre-treated to prevent allergic reactions. Special caution should be exercised in patients with a history of allergic reactions to belatacept or to any of the excipients. Anaphylaxis has been reported during post marketing surveillance. If any serious allergic or anaphylactic reaction occurs, belatacept therapy should be discontinued immediately and appropriate therapy initiated.

There are no adequate data from use of belatacept in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to embryonal/foetal development at doses up to 16-fold and 19-fold a human 10 mg/kg dose based on AUC. In a pre- and postnatal development study in rats, limited changes in immune function were observed at 19-fold a human 10 mg/kg dose based on AUC. Belatacept should not be used in pregnant women unless clearly necessary.

Studies in rats have shown excretion of belatacept in milk. It is unknown whether belatacept is excreted in human milk. Women should not breast-feed while on treatment with a belatacept-based regimen.

Women of childbearing potential/Contraception in males and

Women of childbearing potential should use effective contraception during treatment with belatacept and up to 8 weeks after the last dose of treatment since the potential risk to embryonic/foetal development is unknown.

Fertility

There are no data on use of belatacept and effect on fertility in humans. In rats, belatacept had no undesirable effects on male or female fertility.

Belatacept has a minor influence on the ability to drive and use machines since it may cause fatigue, malaise and/or nausea. Patients should be instructed that if they experience these symptoms they should avoid potentially hazardous tasks such as driving or operating machines.

Summary of the safety profile

The adverse reaction profile associated with immunosuppressive agents is often difficult to establish due to the underlying disease and the concurrent use of multiple medicinal products.

The most common serious adverse reactions (≥2%) reported with belatacept in both regimens (more intensive [MI] and less intensive [LI]) cumulative up to Year 3 were urinary tract infection, CMV infection, pyrexia, increased blood creatinine, pyelonephritis, diarrhoea, gastroenteritis, graft dysfunction, leukopenia, pneumonia, basal cell carcinoma, anaemia, dehydration.

The most commonly reported adverse reactions (≥20%) among patients treated with both belataceptbased regimens (MI and LI) up to Year 3 are diarrhoea, anaemia, urinary tract infection, peripheral oedema, constipation, hypertension, pyrexia, nausea, graft dysfunction, cough, vomiting, leukopenia, hypophosphataemia, and headache.

Adverse reactions resulting in interruption or discontinuation of belatacept in ≥1% of patients up to Year 3 were renal vein thrombosis and CMV infection.

List of adverse reactions

Presented below, by system organ classification and frequency categories, is the list of adverse reactions with at least a suspected causal relationship, reported in clinical trials cumulatively up to Year 3 and pooled for both belatacept regimens (MI and LI).

The frequency categories are defined as follows: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100). Within each frequency category adverse reactions are presented in order of decreasing seriousness.

Adverse reactions in clinical trials:

Infections and infestations

Very Common: urinary tract infection, upper respiratory infection, cytomegalovirus infection*, bronchitis

Common: sepsis, pneumonia, influenza, gastroenteritis, herpes zoster, sinusitis, herpes simplex, oral candidiasis, pyelonephritis, onychomycosis, BK virus infection, respiratory tract infection, candidiasis, rhinitis, cellulitis, wound infection, localised infection, herpes virus infection, fungal infection, fungal skin infection

Uncommon: progressive multifocal leukoencephalopathy*, cerebral fungal infection, cytomegalovirus (CMV) colitis, polyomavirus-associated nephropathy, genital herpes, staphylococcal infection, endocarditis, tuberculosis*, bronchiectasis, osteomyelitis, strongyloidiasis, blastocystis infection, giardiasis, lymphangitis

Neoplasms, benign, malignant and unspecified (incl cysts and polyps)*

Common: squamous cell carcinoma of skin, basal cell carcinoma, skin papilloma

Uncommon: EBV associated lymphoproliferative disorder**,lung cancer, rectal cancer, breast cancer, sarcoma, kaposi’s sarcoma, prostate cancer, cervix carcinoma, laryngeal cancer, lymphoma, multiple myeloma, transitional cell carcinoma

Blood and lymphatic system disorders

Very Common: anaemia, leukopenia

Common: thrombocytopenia, neutropenia, leukocytosis, polycythaemia, lymphopenia

Uncommon: monocytopenia, pure red cell aplasia, agranulocytosis, haemolysis, hypercoagulation

Immune system disorders

Common: blood immunoglobulin G decreased, blood immunoglobulin M decreased,

Uncommon: hypogammaglobulinaemia, seasonal allergy

Endocrine disorders

Common: cushingoid

Uncommon: adrenal insufficiency

Metabolism and nutrition disorders

Very Common: hypophosphataemia, hypokalaemia, dyslipidaemia, hyperkalaemia, hyperglycaemia, hypocalcaemia

Common: weight increase, diabetes mellitus, dehydration, weight decrease, acidosis, fluid retention, hypercalcaemia, hypoproteinaemia

Uncommon: diabetic ketoacidosis, diabetic foot, alkalosis, decreased appetite, vitamin D deficiency

Psychiatric disorders

Very Common: insomnia, anxiety

Common: depression

Uncommon: abnormal dreams, mood swings, attention deficit/hyperactivity disorder, libido increased

Nervous system disorders

Very Common: headache

Common: tremor, paraesthesia, cerebrovascular accident, dizziness, syncope, lethargy, neuropathy peripheral

Uncommon: encephalitis, Guillain-Barré syndrome*, brain oedema, intracranial pressure increased, encephalopathy, convulsion, hemiparesis, demyelination, facial palsy, dysgeusia, cognitive disorder, memory impairment, migraine, burning sensation, diabetic neuropathy, restless leg syndrome

Eye disorders

Common: cataract, ocular hyperaemia, vision blurred

Uncommon: retinitis, conjunctivitis, eye inflammation, keratitis, photophobia, eyelid oedema

Ear and labyrinth disorders

Common: vertigo, ear pain, tinnitus

Uncommon: hypoacusis

Cardiac disorders

Common: tachycardia, bradycardia, atrial fibrillation, cardiac failure, angina pectoris, left ventricular hypertrophy

Uncommon: acute coronary syndrome, atrioventricular block second degree, aortic valve disease, arrhythmia supraventricular

Vascular disorders

Very Common: hypertension, hypotension

Common: shock, infarction, haematoma, lymphocele, angiopathy, arterial fibrosis

Uncommon: venous thrombosis, arterial thrombosis, thrombophlebitis, arterial stenosis, intermittent claudication, flushing

Respiratory, thoracic and mediastinal disorders

Very Common: dyspnoea, cough

Common: pulmonary oedema, wheezing, hypocapnea, orthopnoea, epistaxis, oropharyngeal pain

Uncommon: acute respiratory distress syndrome, pulmonary hypertension, pneumonitis, haemoptysis, bronchopneumopathy, painful respiration, pleural effusion, sleep apnoea syndrome, dysphonia, oropharyngeal blistering

Gastrointestinal disorders

Very Common: diarrhoea, constipation, nausea, vomiting, abdominal pain

Common: dyspepsia, aphthous stomatitis, abdominal hernia

Uncommon: gastrointestinal disorder, pancreatitis, large intestinal ulcer, melaena, gastroduodenal ulcer, rectal haemorrhage, small intestinal obstruction, cheilitis, gingival hyperplasia, salivary gland pain, faeces discoloured

Hepatobiliary disorders

Common: cytolytic hepatitis, liver function test abnormal

Uncommon: cholelithiasis, hepatic cyst, hepatic steatosis

Skin and subcutaneous tissue disorders

Common: acne, pruritis, alopecia, skin lesion, rash, night sweats, hyperhidrosis

Uncommon: psoriasis, hair growth abnormal, onychoclasis, penile ulceration, swelling face, trichorrhexis

Musculoskeletal and connective tissue disorders

Very Common: arthralgia, back pain, pain in extremity

Common: myalgia, muscular weakness, bone pain, joint swelling, intervertebral disc disorder, joint lock, muscle spasms, osteoarthritis

Uncommon: bone metabolism disorder, osteitis, osteolysis, synovitis

Renal and urinary disorders

Very Common: proteinuria, blood creatinine increased, dysuria, haematuria

Common: renal tubular necrosis, renal vein thrombosis*, renal artery stenosis, glycosuria, hydronephrosis, vesicoureteric reflux, urinary incontinence, urinary retention, nocturia

Uncommon: renal artery thrombosis*, nephritis, nephrosclerosis, renal tubular atrophy, cystitis haemorrhagic, kidney fibrosis

Reproductive system and breast disorders

Uncommon: epididymitis, priapism, cervical dysplasia, breast mass, testicular pain, vulval ulceration, atrophic vulvovaginitis, infertility, scrotal oedema Congenital, familial and genetic disorders

Common: hydrocele

Uncommon: hypophosphatasia

General disorders and administration site conditions

Very Common: oedema peripheral, pyrexia

Common: chest pain, fatigue, malaise, impaired healing Uncommon infusion related reaction*, irritability, fibrosis, inflammation, disease recurrence, feeling hot, ulcer

Investigations

Common: c-reactive protein increased, blood parathyroid hormone increased

Uncommon: pancreatic enzymes increased, troponin increased, electrolyte imbalance, prostate-specific antigen increased, blood uric acid increased, urine output decreased, blood glucose decreased, CD4 lymphocytes decreased

Injury, poisoning and procedural complications

Very Common: graft dysfunction

Common: chronic allograft nephropathy (CAN), incisional hernia

Uncommon: transplant failure, transfusion reaction, wound dehiscence, fracture, tendon rupture, procedural hypotension, procedural hypertension, post-procedural haematoma, procedural pain, procedural headache, contusion

* See section “Description of selected adverse reactions”.
** Includes all events reported over a median of 3.3 years in the Phase 3 studies, and a median of approximately 7 years in the Phase 2 study.

Long-term extension in Study 1 and Study 2

Of the 1209 randomized and transplanted patients in the two Phase 3 studies, 761 patients continued after Year 3 in a long-term extension period for up to an additional 4 years and continued to receive the study drug according to their original treatment assignment. As compared to the results from the initial 3 years, no new adverse reactions or increasing incidence of adverse reactions (listed above from the initial 3-year period) were detected during the 4-year long-term open label extension.

Description of selected adverse reactions

Malignancies and post-transplant lymphoproliferative disease

Year 1 and 3 frequencies of malignancies are shown in Table 1, except for cases of PTLD which are presented at 1 year and >3 years (median days of follow-up were 1,199 days for belatacept MI, 1,206 days for belatacept LI, and 1,139 days for ciclosporin). The Year 3 frequency of malignant neoplasms, excluding non-melanoma skin cancers, was similar in the belatacept LI and ciclosporin groups and higher in the belatacept MI group. PTLD occurred at a higher rate in both belatacept treatment groups versus ciclosporin. Non-melanoma skin cancers occurred less frequently with the belatacept LI regimen than with the ciclosporin or belatacept MI regimens.

Table 1. Malignancies occurring by treatment group (%):

* Median follow-up excluding PTLD for pooled studies is 1,092 days for each treatment group.
** Median follow-up for PTLD for pooled studies is 1,199 days for MI, 1,206 days for LI, and 1,139 days for ciclosporin.

In the 3 studies (one Phase 2 and two Phase 3 studies, Study 1 and Study 2), the cumulative frequency of PTLD was higher in belatacept treated patients at the recommended dosing regimen (LI) (1.3%; 6/472) than in the ciclosporin group (0.6%; 3/476), and was highest in the belatacept MI group (1.7%; 8/477). Nine of 14 cases of PTLD in belatacept-treated patients were located in the CNS; within the observation period, 8 of 14 cases were fatal (6 of the fatal cases involved the CNS). Of the 6 PTLD cases in the LI regimen, 3 involved the CNS and were fatal.

EBV seronegative patients receiving immunosuppressants are at a particularly increased risk for PTLD. In clinical studies, belatacept-treated transplant recipients with EBV seronegative status were at an increased risk for PTLD compared with those who were EBV positive (7.7%; 7/91 versus 0.7%; 6/810, respectively). At the recommended dosing regimen of belatacept there were 404 EBV positive recipients and 4 cases of PTLD occurred (1.0%); 2 of these presented in the CNS.

During the long-term extension period, malignancies (including PTLD) were reported in 10.3%, 8.4%, and 14.7% of patients in the belatacept MI, belatacept LI, and ciclosporin groups, respectively, in Study 1; and in 19.2%, 13.3% and 16.1% of patients in the belatacept MI, belatacept LI, and ciclosporin groups, respectively, in Study 2. Cases of PTLD varied by serostatus. In Study 1, one additional case of PTLD was reported in the ciclosporin group, in a patient who was EBV seropositive at the time of transplant. In Study 2, among patients who were EBV seropositive at the time of transplant, there was one case of PTLD in each of the three treatment groups. Among Study 2 patients who were EBV seronegative at the time of transplant (for whom use of belatacept is not recommended), there were three cases of PTLD in the belatacept LI group, and none in the belatacept MI and ciclosporin groups.

Infections

Year 1 and Year 3 frequencies of infections occurring by treatment group are shown in Table 2. The overall occurrence of tuberculosis infections and non-serious herpes infections were higher for belatacept regimens than for the ciclosporin regimen. The majority of cases of tuberculosis occurred in patients who currently live or previously lived in countries with a high prevalence of tuberculosis. Overall occurrences of polyoma virus infections and fungal infections were numerically lower in the belatacept LI group compared with the belatacept MI and ciclosporin groups.

Within the belatacept clinical program, there were 2 patients diagnosed with PML. One fatal case of PML was reported in a renal transplant recipient treated with belatacept MI regimen, an IL-2 receptor antagonist, MMF, and corticosteroids for 2 years in a Phase 3 trial. The other case of PML was reported in a liver transplant recipient in a Phase 2 trial who received 6 months of treatment with an augmented belatacept MI regimen, MMF at doses higher than the recommended dose and corticosteroids.

Infections involving the CNS were more frequent in the belatacept MI group (8 cases, including the PML case discussed above; 1.7%) than the belatacept LI (2 cases, 0.4%) and ciclosporin (one case; 0.2%) groups. The most common CNS infection was cryptococcal meningitis.

Table 2. Infections occurring by treatment group (%):

* Median exposure for pooled studies is 1,092 days for each treatment group.

During the long-term extension period, serious infections occurred in 30.3% and 23.5% of patients in the belatacept MI and LI groups, respectively, and in 27.2% of patients in the ciclosporin group in Study 1; and in 35.6% and 38.1% of patients in the belatacept MI and LI groups, respectively, and in 37.9% of patients in the ciclosporin group in Study 2. There was one case of PML reported (Study 1) in the ciclosporin group at 82 months post-transplant (more than 56 days after discontinuing therapy).

Graft thrombosis

In a Phase 3 study in recipients of extended criteria donor (ECD) kidneys (Study 2), graft thrombosis occurred more frequently in the belatacept groups (4.3% and 5.1% for the MI and LI regimens respectively), versus 2.2% for ciclosporin. In another Phase 3 study in recipients of living donor and standard criteria deceased donor kidneys (Study 1), the incidence of graft thrombosis was 2.3% and 0.4% for the MI and LI regimens respectively, versus 1.8% for ciclosporin. In a Phase 2 study, there were 2 cases of graft thrombosis, 1 each in MI and LI (incidence of 1.4% for both) versus 0 in the ciclosporin group. In general, these events occurred early and the majority resulted in graft loss. In postmarketing experience in patients with other predisposing risk factors for thrombosis of the renal allograft, renal allograft thrombosis has been reported when the initial dose of anti-thymocyte globulin was coadministered at the same or nearly the same time with the first dose of belatacept.

Infusion-related reactions

Anaphylaxis has been reported post marketing.

Acute infusion-related reactions (reactions occurring within one hour of infusion) occurred in 5.5% of patients in the belatacept MI group and 4.4% of patients in the belatacept LI group up to Year 3. The most frequently reported acute infusion-related reactions in combined belatacept regimens were hypotension, hypertension, flushing and headache. Most events were not serious, were mild to moderate in intensity, and did not recur. When belatacept was compared to placebo infusions, there were no differences in event rates (placebo infusions were administered at Weeks 6 and 10 of the belatacept LI regimen to blind the MI and LI regimens).

Immunogenicity

Antibodies directed against the belatacept molecule were assessed in 796 kidney transplant recipients (551 of these treated for at least 3 years) in the two Phase 3 studies. An additional 51 patients were treated for an average of 7 years in the long-term extension of a Phase 2 study. Anti-belatacept antibody development was not associated with altered clearance of belatacept.

A total of 45 of 847 patients (5.3%) developed antibodies during treatment with belatacept. In the individual studies, the percentage of patients with antibodies ranged from 4.5% and 5.2% in the Phase 3 studies to 11.8% in the long-term extension of the Phase 2 study. However, immunogenicity rate normalised for duration of exposure was consistent at 2.0 to 2.1 per 100 patient years among the three studies. In 153 patients assessed for antibodies at least 56 days (approximately 7 half-lives) after discontinuation of belatacept, an additional 10 (6.5%) developed antibodies. In general, antibody titers were low, not usually persistent, and often became undetectable with continued treatment.

To assess for the presence of neutralising antibodies, samples from 29 patients with confirmed binding activity to the modified cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) region of the molecule were assessed by an in vitro assay; 8 (27.6%) patients were shown to possess neutralising antibodies. The clinical relevance of such antibodies is unclear.

Autoimmunity

The occurrence of autoimmune events across the core clinical studies was infrequent, occurring at rates of 1.7%, 1.7%, and 1.9% by Year 3 for the MI, LI, and ciclosporin groups respectively. One patient on belatacept MI regimen developed Guillian-Barré syndrome which led to treatment discontinuation and subsequently resolved. Overall, the few reports across clinical studies suggest that prolonged exposure to belatacept does not predispose patients to an increased risk of development of autoimmune events.

During the long-term extension period, autoimmune events occurred in 2.6% and 3.0% of patients in the belatacept MI and LI groups, respectively, and in 3.7% of patients in the ciclosporin group in Study 1; and in 5.8% and 3.5% of patients in the belatacept MI and LI groups, respectively, and in 0% of patients in ciclosporin group in Study 2.