Ziv-aflibercept

Uses

Ziv-aflibercept, in combination with 5-fluorouracil, leucovorin, irinotecan-(FOLFIRI), is used for patients with metastatic colorectal cancer (mCRC) that is resistant to or has progressed following an oxaliplatin-containing regimen.

Ziv-aflibercept is also used to associated treatment for these conditions: Branch Retinal Vein Occlusion With Macular Edema, Central Retinal Vein Occlusion With Macular Edema, Diabetic Macular Edema (DME), Diabetic Retinopathy (DR), Macular Edema, Metastatic Colorectal Cancer (MCRC), Myopic Choroidal Neovascularization, Neovascular Age-Related Macular Degeneration, Wet Age-Related Macular Degeneration

How Ziv-aflibercept works

Ablibercept is a recombinant fusion protein that acts as a decoy receptor for the ligands, vascular endothelial growth factor-A (VEGF-A) and placental growth factor (PIGF). It prevents these ligands to binding to endothelial receptors, VEGFR-1 and VEGFR-2, to suppress neovascularization and decrease vascular permeability. This ultimately will slow vision loss or the progression of metastatic colorectal cancer.

Dosage

Ziv-aflibercept dosage

4 mg/kg as an intravenous infusion over 1 hour every 2 weeks.Do not administer as an intravenous (IV) push or bolus.

Preparation for Administration: Inspect vials visually prior to use. Ziv-aflibercept is a clear, colorless to pale yellow solution. Do not use vial if the solution is discolored or cloudy or if the solution contains particles. Do not re-enter the vial after the initial puncture. Discard any unused portion left in the vial. Withdraw the prescribed dose of Ziv-aflibercept and dilute in 0.9% sodium chloride solution, 5% dextrose solution for injection, to achieve a final concentration of 0.6–8 mg/mL.

Use polyvinyl chloride (PVC) infusion bags containing bis (2-ethylhexyl) phthalate (DEHP) or polyolefin infusion bags. Store diluted Ziv-aflibercept at 2°–8°C for up to 24 hours, or at controlled room temperature 20°–25°C for up to 8 hours. Discard any unused portion left in the infusion bag.

Administration: Administer the diluted Ziv-aflibercept solution as an intravenous infusion over 1 hour through a 0.2 micron polyethersulfone filter. Do not use filters made of polyvinylidene fluoride (PVDF) or nylon. Do not administer as an intravenous (IV) push or bolus. Do not combine Ziv-aflibercept with other drugs in the same infusion bag or intravenous line.

Side Effects

Most common adverse reactions (all grades, ≥20% incidence and at least 2% greater incidence for the Ziv-aflibercept/FOLFIRI regimen) were leukopenia, diarrhea, neutropenia, proteinuria, AST increased, stomatitis, fatigue, thrombocytopenia, ALT increased, hypertension, weight decreased, decreased appetite, epistaxis, abdominal pain, dysphonia, serum creatinine increased, and headache

Toxicity

For all intravitreal VEGF inhibitors, there is increased risk of stroke and myocardial infarction. An increase in intraocular pressure may also occur. When used intravenously, most common adverse reactions were leukopenia, diarrhea, neutropenia, proteinuria, AST increased, stomatitis, fatigue, thrombocytopenia, ALT increased, hypertension, weight decreased, decreased appetite, epistaxis, abdominal pain, dysphonia, serum creatinine increased, and headache.

Precaution

Adverse reactions, sometimes severe and life-threatening or fatal, have been seen in clinical trials with Ziv-aflibercept, including:

• Fistula Formation: Discontinue Ziv-aflibercept if fistula occurs.
• Hypertension: Monitor blood pressure and treat hypertension. Temporarily suspend Ziv-aflibercept if hypertension is not controlled. Discontinue Ziv-aflibercept if hypertensive crisis develops.
• Arterial Thromboembolic Events (ATE) (e.g., transient ischemic attacks, cerebrovascular accident, angina pectoris): Discontinue Ziv-aflibercept if ATE develops.
• Proteinuria: Monitor urine protein. Suspend Ziv-aflibercept when proteinuria ≥ 2 grams per 24 hours. Discontinue Ziv-aflibercept if nephrotic syndrome or thrombotic microangiopathy (TMA) develops.
• Neutropenia and Neutropenic Complications: Delay administration of Ziv-aflibercept/FOLFIRI until neutrophil count is ≥ 1.5 × 109/L.
• Diarrhea and Dehydration: Incidence of severe diarrhea and dehydration is increased. Monitor elderly patients more closely.
• Reversible Posterior Leukoencephalopathy Syndrome (RPLS): Discontinue Ziv-aflibercept.

Interaction

No dedicated drug-drug interaction studies have been conducted for Ziv-aflibercept. No clinically important pharmacokinetic drug-drug interactions were found between ziv-aflibercept and irinotecan/SN-38 or 5-FU, based on cross-study comparisons and population pharmacokinetic analyses.

Food Interaction

Volume of Distribution

After intravenous injection of aflibercept, the volume of distribution is 6 L.

Elimination Route

In patients with wet AMD and CRVO, the mean peak plasma concentration (Cmax) was 0.02 mcg/mL and 0.05 mcg/mL respectively. These concentrations were reached in 1 to 3 days. Ziv-aflibercept did not accumulate when administered as repeated doses intravitreally every 4 weeks.

Half Life

Intravitreal half-life= 7.13 days in humans; Terminal elimination half-life of free aflibercept in plasma was 5 to 6 days after IV injection of 2 - 4 mg/kg dose.

Clearance

When cancer patients were given 2-9 mg/kg every 2 or 3 week; 1 hour IV infusion of aflibercept the typical estimated clearances were as follows: CL of free aflibercept (CLf) = 0.88 L/day; CL of bound aflibercept (CLf) = 0.19 L/day; Patients clear free aflibercept faster if they had low albumin or high alkaline phosphatase levels.

Elimination Route

Via kidney and liver

Pregnancy & Breastfeeding use

Pregnancy: Category C. There are no adequate and well-controlled studies with Ziv-aflibercept in pregnant women. Ziv-aflibercept was embryotoxic and teratogenic in rabbits at exposure levels lower than human exposures at the recommended dose, with increased incidences of external, visceral, and skeletal fetal malformations. Ziv-aflibercept should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Lactation: It is not known whether Ziv-aflibercept is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Ziv-aflibercept, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

Females and Males of Reproductive Potential: Use highly effective contraception during and up to a minimum of 3 months after the last dose

Special Warning

Pediatric Use: The safety and effectiveness in pediatric patients have not been established. In a dose-escalation, safety, and tolerability study, 21 patients ages 2 to 21 years (median age 12.9) with solid tumors received Ziv-aflibercept at doses ranging from 2 to 3 mg/kg, IV, every two weeks. The pharmacokinetics of free ziv-aflibercept were evaluated in 8 of these patients (ages 5 to 17 years). The maximum tolerated dose in the study was 2.5 mg/kg, below the dose known to be safe and effective in adults with mCRC.

Geriatric Use: Of the 611 patients with mCRC, patients treated with Ziv-aflibercept/FOLFIRI, 205 (34%) were 65 years or older, and 33 (5%) were 75 years or older. Elderly patients (≥65 years of age) experienced higher incidences (≥5%) of diarrhea, dizziness, asthenia, weight decrease, and dehydration when compared to younger patients. Monitor elderly patients more closely for diarrhea and dehydrationThe effect of Ziv-aflibercept on overall survival was similar in patients <65 years old and ≥65 years old who received Ziv-aflibercept/FOLFIRI. No dose adjustment of Ziv-aflibercept is recommended for patients greater than or equal to 65 years of age.

Hepatic Impairment: No dedicated clinical studies have been conducted to evaluate the effect of hepatic impairment on the pharmacokinetics of ziv-aflibercept. Based on a population PK analysis with data from 1507 patients, ziv-aflibercept exposure in patients with mild and moderate hepatic impairment were similar to those in patients with normal hepatic function. There are no data available for patients with severe hepatic impairment.

Renal Impairment: No dedicated clinical studies have been conducted to evaluate the effect of renal impairment on the pharmacokinetics of ziv-aflibercept. Based on a population PK analysis with data from 1507 patients, ziv-aflibercept exposure in patients with mild, moderate, and severe renal impairment were similar to those in patients with normal renal function [see Clinical Pharmacology.

Females and Males of Reproductive Potential: Male and female reproductive function and fertility may be compromised during treatment with Ziv-aflibercept, as suggested by findings in monkeys [see Nonclinical Toxicology. These animal findings were reversible within 18 weeks after cessation of treatment. Females and males of reproductive potential should use highly effective contraception during and up to a minimum of 3 months after the last dose of treatment.

Acute Overdose

There have been no cases of overdose reported with Ziv-aflibercept. There is no information on the safety of Ziv-aflibercept given at doses exceeding 7 mg per kg every 2 weeks or 9 mg per kg every 3 weeks.

Storage Condition

Store Ziv-aflibercept vials in a refrigerator at 2 to 8° C . Keep the vials in the original outer carton to protect from light.

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