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IMLYGIC
(talimogene laherparepvec) for Intralesional Injection
IMLYGIC (talimogene laherparepvec) is a sterile suspension for intralesional injection. IMLYGIC is a live, attenuated HSV-1 that has been genetically modified to express huGM-CSF. The parental virus for IMLYGIC was a primary isolate, which was subsequently altered using recombinant methods to result in gene deletions and insertions.
Each vial contains 1 mL deliverable volume of IMLYGIC at either 1 x 106 (1 million) PFU per mL or 1 x 108 (100 million) PFU per mL concentrations and the following excipients: di-sodium hydrogen phosphate dihydrate (15.4 mg), sodium dihydrogen phosphate dihydrate (2.44 mg), sodium chloride (8.5 mg), myo-inositol (40 mg), sorbitol (20 mg), and water for injection.
The 106 (1 million) PFU per mL vial of IMLYGIC contains a clear to semi-translucent liquid following thaw from its frozen state. The 108 (100 million) PFU per mL vial of IMLYGIC contains a semitranslucent to opaque liquid following thaw from its frozen state. The liquid in each vial may contain white, visible, variously shaped, virus-containing particles.
Each vial of IMLYGIC may also contain residual components of VERO cells including DNA and protein and trace quantities of fetal bovine serum.
The product contains no preservative.
IMLYGIC is a genetically modified oncolytic viral therapy indicated for the local treatment of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery.
IMLYGIC has not been shown to improve overall survival or have an effect on visceral metastases.
For intralesional injection only. Do not administer intravenously.
Administer IMLYGIC by injection into cutaneous, subcutaneous, and/or nodal lesions that are visible, palpable, or detectable by ultrasound guidance.
IMLYGIC is provided in single-use vials of 1 mL each in two different dose strengths:
The total injection volume for each treatment visit should not exceed 4 mL for all injected lesions combined. It may not be possible to inject all lesions at each treatment visit or over the full course of treatment. Previously injected and/or uninjected lesion(s) may be injected at subsequent treatment visits. The initial recommended dose is up to 4 mL of IMLYGIC at a concentration of 106 (1 million) PFU per mL. The recommended dose for subsequent administrations is up to 4 mL of IMLYGIC at a concentration of 108 (100 million) PFU per mL. The recommended dosing schedule for IMLYGIC is shown in Table 1.
Table 1. Recommended Dose and Schedule for IMLYGIC
| Treatment | Treatment Interval | Maximum Injection Volume per Treatment Visit (all lesions combined) | Dose Strength | Prioritization of Lesions to be Injected |
| Initial | – | 4 mL | 106 (1 million) PFU per mL |
|
| Second | 3 weeks after initial treatment | 4 mL | 108 (100 million) PFU per mL |
|
| All subsequent treatments (including reinitiation) | 2 weeks after previous treatment | 4 mL | 108 (100 million) PFU per mL |
|
Use Table 2 to determine the volume of IMLYGIC injection for each lesion.
Table 2. Determination of IMLYGIC Injection Volume Bas ed on Les ion
Size
| Lesion Size (longest dimension) |
Injection Volume |
| > 5 cm | up to 4 mL |
| > 2.5 cm to 5 cm | up to 2 mL |
| > 1.5 cm to 2.5 cm | up to 1 mL |
| > 0.5 cm to 1.5 cm | up to 0.5 mL |
| ≤ 0.5 cm | up to 0.1 mL |
When lesions are clustered together, inject them as a single lesion according to Table 2.
Continue IMLYGIC treatment for at least 6 months unless other treatment is required or until there are no injectable lesions to treat.
Reinitiate IMLYGIC treatment if new unresectable cutaneous, subcutaneous, or nodal lesions appear after a complete response.
Healthcare providers who are immunocompromised or pregnant should not prepare or administer IMLYGIC and should not come into direct contact with the IMLYGIC injection sites, dressings, or body fluids of treated patients [see WARNINGS AND PRECAUTIONS].
Avoid accidental exposure to IMLYGIC and follow below instructions for preparation, administration, and handling of IMLYGIC:
Table 3. Storage Times for Thawed IMLYGIC Vial at 2° to 8°C (36° to 46°F)
| 106 (1 million) PFU per mL | 108 (100 million) PFU per mL |
| 12 hours | 48 hours |
Follow the steps below to administer IMLYGIC to patients:
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Manufactured by: BioVex, Inc., a subsidiary of Amgen Inc. One Amgen Center Drive Thousand Oaks, California. Revised: March 2017
The most commonly reported adverse drug reactions (≥ 25%) in IMLYGIC-treated patients were fatigue, chills, pyrexia, nausea, influenza-like illness, and injection site pain.
The following adverse reactions are discussed in greater detail in another section of the label:
Because clinical trials are conducted under widely varying 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.
The safety of IMLYGIC was evaluated in 419 patients who received at least 1 dose of either IMLYGIC (n = 292) or subcutaneously administered granulocyte-macrophage colony-stimulating factor (GM-CSF) (n = 127) in an open-label, randomized clinical study of patients with stage IIIB, IIIC, and IV melanoma that was not considered to be surgically resectable [see Clinical Studies]. The median duration of exposure to IMLYGIC was 23 weeks (5.3 months). Twenty-six patients were exposed to IMLYGIC for at least 1 year.
Most adverse reactions reported were mild or moderate in severity and generally resolved within 72 hours. The most common grade 3 or higher adverse reaction was cellulitis [see WARNINGS AND PRECAUTIONS].
Pyrexia, chills, and influenza-like illness can occur any time during IMLYGIC treatment but were more frequent during the first 3 months of treatment.
Table 4 below lists adverse reactions with a 5% or greater incidence in the IMLYGIC arm compared to the GM-CSF arm in the clinical study [see Clinical Studies].
Table 4. Advers e Reactions Reported with At Leas t a 5% Greater Incidence in Patients
Treated with IMLYGIC Compared to GM-CSF
| Adverse Reactions | IMLYGIC (n = 292) |
GM-CSF (n = 127) |
||
| Any Grade n (%) |
Grade 3 n (%) |
Any Grade n (%) |
Grade 3 n (%) |
|
| General disorders and administrationsite conditions | ||||
| Fatigue | 147 (50.3) | 6 (2.1) | 46 (36.2) | 1 (< 1) |
| Chills | 142 (48.6) | 11 (8.7) | ||
| Pyrexia | 125 (42.8) | 11 (8.7) | ||
| Influenza-like illness | 89 (30.5) | 2 (< 1) | 19 (15.0) | |
| Injection site pain | 81 (27.7) | 2 (< 1) | 8 (6.3) | |
| Gastrointestinal dis orders | ||||
| Nausea | 104 (35.6) | 1 (< 1) | 25 (19.7) | |
| Vomiting | 62 (21.2) | 5 (1.7) | 12 (9.5) | |
| Diarrhea | 55 (18.8) | 1 (< 1) | 14 (11.0) | |
| Constipation | 34 (11.6) | 8 (6.3) | 1 (< 1) | |
| Abdominal pain | 26 (8.9) | 2 (< 1) | 3 (2.4) | |
| Musculoskeletal and connectivetissue disorders | ||||
| Myalgia | 51 (17.5) | 1 (< 1) | 7 (5.5) | |
| Arthralgia | 50 (17.1) | 2 (< 1) | 11 (8.7) | |
| Pain in extremity | 48 (16.4) | 4 (1.4) | 12 (9.5) | 1 (< 1) |
| Nervous system disorders | ||||
| Headache | 55 (18.8) | 2 (< 1) | 12 (9.5) | |
| Dizziness | 28 (9.6) | 4 (3.2) | ||
| Respiratory, thoracic, and mediastinal disorders | ||||
| Oropharyngeal pain | 17 (5.8) | 1 (< 1) | ||
| Investigations | ||||
| Weight decreased | 17 (5.8) | 1 (< 1) | 1 (< 1) | |
Other adverse reactions associated with IMLYGIC in the open-label, randomized study include rash, dermatitis, glomerulonephritis, vitiligo, worsening psoriasis, cellulitis, pneumonitis, vasculitis, herpetic keratitis, obstructive airway disorder, plasmacytoma at the injection site, deep vein thrombosis, and oral herpes.
IMLYGIC is sensitive to acyclovir. Acyclovir or other antiherpetic viral agents may interfere with the effectiveness of IMLYGIC. No drug interaction studies have been conducted with IMLYGIC.
Included as part of the "PRECAUTIONS" Section
Accidental exposure may lead to transmission of IMLYGIC and herpetic infection. Accidental needle stick and splashback to the eyes have been reported in healthcare providers during preparation and administration of IMLYGIC.
Healthcare providers, close contacts (household members, caregivers, sex partners, or persons sharing the same bed), pregnant women, and newborns should avoid direct contact with injected lesions, dressings, or body fluids of treated patients [see DOSAGE AND ADMINISTRATION]. Healthcare providers who are immunocompromised or pregnant should not prepare or administer IMLYGIC.
Caregivers should wear protective gloves when assisting patients in applying or changing occlusive dressings and observe safety precautions for disposal of used dressings, gloves, and cleaning materials [see DOSAGE AND ADMINISTRATION].
In the event of an accidental exposure to IMLYGIC, exposed individuals should clean the affected area thoroughly with soap and water and/or a disinfectant. If signs or symptoms of herpetic infection develop, the exposed individuals should contact their healthcare provider for appropriate treatment [see Herpetic Infection].
Patients should avoid touching or scratching injection sites or their occlusive dressings, as doing so could lead to inadvertent transfer of IMLYGIC to other areas of the body.
In clinical studies, herpetic infections (including cold sores and herpetic keratitis) have been reported in patients treated with IMLYGIC. Disseminated herpetic infection may also occur in immunocompromised patients [see CONTRAINDICATIONS].
Patients who develop suspicious herpes-like lesions should follow standard hygienic practices to prevent viral transmission. Patients or close contacts with suspected herpetic infections should also contact their healthcare provider to evaluate the lesions. Suspected herpetic lesions should be reported to Amgen at 1-855-IMLYGIC (1-855-465-9442); patients or close contacts have the option of followup testing for further characterization of the infection.
IMLYGIC is sensitive to acyclovir. Acyclovir or other antiviral agents may interfere with the effectiveness of IMLYGIC. Therefore, consider the risks and benefits of IMLYGIC treatment before administering antiviral agents to manage herpetic infection.
Necrosis or ulceration of tumor tissue may occur during IMLYGIC treatment. Cellulitis and systemic bacterial infection have been reported in clinical studies. Careful wound care and infection precautions are recommended, particularly if tissue necrosis results in open wounds.
In clinical studies, impaired healing at the injection site has been reported. IMLYGIC may increase the risk of impaired healing in patients with underlying risk factors (e.g., previous radiation at the injection site or lesions in poorly vascularized areas). One patient had an amputation of a lower extremity 6 months after IMLYGIC injection due to an infected non-healing wound. This wound area had been treated with surgery and radiation prior to IMLYGIC treatment and had previous wound complications.
If there is persistent infection or delayed healing of the injection site(s), consider the risks and benefits of IMLYGIC before continuing treatment with IMLYGIC.
IMLYGIC may result in immune-mediated events. In clinical studies, immune-mediated events, including glomerulonephritis, vasculitis, pneumonitis, worsening psoriasis, and vitiligo have been reported in patients treated with IMLYGIC.
Consider the risks and benefits of IMLYGIC before initiating treatment in patients who have underlying autoimmune disease or before continuing treatment in patients who develop immune-mediated events.
In a clinical study, a plasmacytoma has been reported in proximity to the injection site after administration of IMLYGIC in a patient with smoldering multiple myeloma.
Consider the risks and benefits of IMLYGIC in patients with multiple myeloma or in whom plasmacytoma develops during treatment.
Obstructive airway disorder has been reported following IMLYGIC treatment. Use caution when injecting lesions close to major airways.
Advise patients and/or close contacts to:
Adequate and well-controlled studies with IMLYGIC have not been conducted in pregnant women. No effects on embryo-fetal development have been observed in a study conducted in pregnant mice. The design of the study limits application of the animal data to humans [see Data].
In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
If the patient becomes pregnant while taking IMLYGIC, the patient should be apprised of the potential hazards to the fetus and neonate. Women of childbearing potential should be advised to use an effective method of contraception to prevent pregnancy during treatment with IMLYGIC.
If a pregnant woman has an infection with wild-type Herpes Simplex Virus Type 1 (HSV-1) (primary or reactivation), there is potential for the virus to cross the placental barrier and also a risk of transmission during birth due to viral shedding. Infections with wild-type HSV-1 have been associated with serious adverse effects, including multi-organ failure and death, if a fetus or neonate contracts the wild-type herpes infection. While there are no clinical data to date on IMLYGIC infections in pregnant women, herpes infection. While there are no clinical data to date on IMLYGIC infections in pregnant women, there could be a risk to the fetus or neonate if IMLYGIC were to act in the same manner.
Animal Data
No effects on embryo-fetal development were observed when IMLYGIC was intravenously administered during organogenesis to immunocompetent pregnant mice at doses up to 4 x 108 (400 million) PFU per kg (60-fold higher, on a PFU per kg basis, compared to the maximum clinical dose). Levels of IMLYGIC DNA in pooled fetal blood were at or below the assay detection level. Study design limitations included: 1) administration of IMLYGIC expressing human granulocyte-macrophage colony-stimulating factor (huGM-CSF), which is not biologically active in mice; 2) unknown transplacental kinetics of IMLYGIC following intravenous administration in pregnant mice; and 3) unknown significance of IMLYGIC dose extrapolation from animal to human based on body weight.
There is no information regarding the presence of IMLYGIC in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for IMLYGIC and any potential adverse effects on the breastfed infant from IMLYGIC or from the underlying maternal condition.
Because medicinal products can be found in human milk, a decision should be made whether to discontinue nursing or to discontinue IMLYGIC while nursing.
No nonclinical or clinical studies were performed to evaluate the effect of IMLYGIC on fertility.
Safety and effectiveness of IMLYGIC have not been established in pediatric patients.
In clinical studies, no overall differences in safety or efficacy were observed between geriatric patients (≥ 65 years old) and younger patients.
No clinical studies have been conducted to evaluate the effect of renal impairment on the pharmacokinetics of IMLYGIC.
No clinical studies have been conducted to evaluate the effect of hepatic impairment on the pharmacokinetics of IMLYGIC.
There is no clinical experience with an overdose with IMLYGIC. Doses up to 4 mL at dose strength of 108 (100 million) PFU per mL every 2 weeks (maximum cumulative dose of 222.5 x 108 PFU) have been administered in clinical studies, with no evidence of dose-limiting toxicity. The maximum dose of IMLYGIC that can be safely administered has not been determined. In the event of a suspected overdose, the patient should be treated symptomatically and supportive measures instituted as required [see WARNINGS AND PRECAUTIONS].
IMLYGIC is a live, attenuated herpes simplex virus and may cause life-threatening disseminated herpetic infection in patients who are immunocompromised. Do not administer IMLYGIC to immunocompromised patients, including those with a history of primary or acquired immunodeficient states, leukemia, lymphoma, AIDS or other clinical manifestations of infection with human immunodeficiency viruses, and those on immunosuppressive therapy [see Nonclinical Toxicology].
Do not administer IMLYGIC to pregnant patients.
IMLYGIC has been genetically modified to replicate within tumors and to produce the immune stimulatory protein GM-CSF. IMLYGIC causes lysis of tumors, followed by release of tumor-derived antigens, which together with virally derived GM-CSF may promote an antitumor immune response. However, the exact mechanism of action is unknown.
IMLYGIC viral DNA levels in various tissues and secretions were determined using a quantitative polymerase chain reaction (qPCR) assay. Infectious IMLYGIC at the injection sites and at some potential herpetic lesions was also quantified using viral infectivity assays.
Nonclinical data
Following repeat intratumoral administration in mice, IMLYGIC DNA was primarily detected in the tumor, blood, spleen, lymph node, liver, heart, and kidney. IMLYGIC DNA was not detected in bone marrow, eyes, lachrymal glands, nasal mucosa, or feces. The highest level of IMLYGIC DNA was found in the injected tumor. IMLYGIC DNA was found in the injected tumor through 84 days and in blood samples through 14 days after the last administration of IMLYGIC.
Clinical data
The biodistribution and shedding of intralesionally administered IMLYGIC are being investigated in an ongoing study measuring IMLYGIC DNA and virus in blood, oral mucosa, urine, injection site, and occlusive dressings. In the initial 20 patients with melanoma who received IMLYGIC intralesional injection at a dose and schedule similar to that of the clinical study [see Clinical Studies], available data indicate that IMLYGIC DNA was present in the blood in 17 (85%) patients and in urine of 4 (20%) patients during the study. The peak levels of IMLYGIC DNA in the urine were detected on the day of treatment. Infectious IMLYGIC virus was detected at the site of injection in 3 (15%) patients at a single time point each, and all within the first week after the initial injection. The exterior of the occlusive dressings was positive for IMLYGIC DNA in 14 (70%) patients during the study; however, no infectious virus was detected on the exterior of the occlusive dressing. The number of patients with measurable levels of IMLYGIC DNA on the exterior of occlusive dressings declined over time with no measurable DNA by the third treatment in 13 patients tested.
Repeated intratumoral administration at 2 x 108 (200 million) PFU per kg (30-fold maximum proposed clinical dose, extrapolated based on body weight) did not demonstrate any adverse effects in immunocompetent mice. Severe combined immunodeficient (SCID) mice administered repeat intratumoral injections of IMLYGIC at a dose of 30-fold maximum proposed clinical dose developed systemic viral infection (viral inclusion bodies or necrosis in enteric neurons in the gastrointestinal tract, adrenal gland, skin, pancreatic islet cells, eye, pineal gland, and brain).
The safety and efficacy of intralesional injections of IMLYGIC compared with subcutaneously administered GM-CSF was evaluated in a multicenter, open-label, randomized clinical study in patients with stage IIIB, IIIC, and IV melanoma that was considered to be not surgically resectable. IMLYGIC was injected into cutaneous, subcutaneous, or nodal melanoma lesions and was not injected into visceral lesions. Previous systemic treatment for melanoma was allowed. Patients with active cerebral metastases, bony metastases, extensive visceral disease, primary ocular or mucosal melanoma, evidence of immunosuppression, or receiving treatment with a systemic antiherpetic agent were excluded from the study.
The study included 250 (57%) men and 186 (43%) women. The mean age was 63 (range: 22 to 94) years. Most patients (98%) were white. Seventy percent (70%) of patients had baseline Eastern Cooperative Oncology Group (ECOG) performance status of zero. Seventy percent (70%) of patients had stage IV disease (27% M1a; 21% M1b; and 22% M1c), and 30% had stage III disease. Fifty-three percent (53%) of patients had received prior therapy for melanoma (other than or in addition to surgery, adjuvant therapy, or radiation), and 58% were seropositive for wild-type HSV-1 at baseline.
A total of 436 patients were randomized to receive either IMLYGIC (n = 295) or GM-CSF (n = 141). IMLYGIC was administered by intralesional injection at an initial concentration of 106 (1 million) PFU per mL on Day 1, followed by a concentration of 108 (100 million) PFU per mL on Day 21 and every 2 weeks thereafter, at a dose of up to 4 mL per visit. GM-CSF was administered subcutaneously in 28-day cycles, i.e., 125 µg/m2 daily for 14 days followed by 14 days without GM-CSF administration.
Patients were to be treated for at least 6 months or until there were no injectable lesions. During this period, treatment could continue despite an increase in size in existing lesion(s) and/or development of new lesion(s), unless the patient developed intolerable toxicity or the investigator believed that it was in the best interest of the patient to stop treatment or to be given other therapy for melanoma. After 6 months of treatment, patients were to continue treatment until clinically relevant disease progression (i.e., disease progression associated with a decline in performance status and/or alternative therapy was required in the opinion of the investigator), up to 12 months. Patients experiencing a response at 12 months after the start of treatment could continue treatment for up to an additional 6 months, unless there were no remaining injectable lesions or disease progression. All patients were to be followed for survival status for at least 36 months.
The major efficacy outcome was durable response rate (DRR), defined as the percent of patients with complete response (CR) or partial response (PR) maintained continuously for a minimum of 6 months. Tumor responses were determined according to World Health Organization (WHO) response criteria modified to allow patients who developed new lesions or disease progression of existing lesions to continue the treatment and be evaluated later for tumor response.
The DRR was 16.3% in the IMLYGIC arm and 2.1% in the GM-CSF arm in the overall study population. The unadjusted relative risk was 7.6 (95% CI: 2.4, 24.1), with a p-value < 0.0001. The median time to response was 4.1 (range: 1.2 to 16.7) months in the IMLYGIC arm.
There was no statistically significant difference in overall survival (OS) between the IMLYGIC and the GM-CSF arms. The median OS in the overall study population was 22.9 months in the IMLYGIC arm and 19.0 months in the GM-CSF arm (p = 0.116).
IMLYGIC®
(imm-LY-jik)
(talimogene laherparepvec)
Read the Medication Guide before you start treatment with IMLYGIC and before each IMLYGIC treatment. There may be new information. This Medication Guide does not tell you everything about IMLYGIC. Talk with your healthcare provider if you have any questions about treatment with IMLYGIC.
What is IMLYGIC?
IMLYGIC is a prescription medicine used to treat a type of cancer called melanoma when it is on your skin or in your lymph glands. IMLYGIC is a weakened form of Herpes Simplex Virus Type 1, which is commonly called the cold sore virus. Your healthcare provider will inject IMLYGIC directly into your tumor(s).
IMLYGIC may not help you live longer and may not shrink cancer in your organs (for example, lung or liver).
Who should not get IMLYGIC?
You should not get IMLYGIC if you are pregnant or have a weakened immune system (for example, an immune deficiency, blood or bone marrow cancer, steroid use, or HIV/AIDS).
What should I tell my healthcare provider before I get IMLYGIC?
Before getting IMLYGIC, tell your healthcare provider if you:
Tell your healthcare provider about all the medicines you take, including prescription and over-thecounter medicines, vitamins, and herbal supplements. IMLYGIC may affect the way other medicines work and other medicines may affect how IMLYGIC works.
How is IMLYGIC given?
Your healthcare provider will inject IMLYGIC directly into your tumor(s) with a needle and syringe.
You will get a second treatment 3 weeks after the first treatment. After that, you will get treatments every 2 weeks for as long as you have tumor(s). You can get treated for 6 months or longer.
Your healthcare provider will decide which tumor(s) to inject and may not inject every one.
It is important to care for the treatment sites properly so that IMLYGIC does not spread to other people. Your healthcare provider will show you how to do this.
What should I avoid while getting IMLYGIC?
IMLYGIC virus can spread to other areas of your body or to your close contacts (household members, caregivers, sex partners, or persons sharing the same bed).
Do the following to avoid spreading IMLYGIC to other areas of your body or to your close contacts:
What are possible side effects of IMLYGIC?
The most common side effects of IMLYGIC include:
Tell your doctor right away if you get any of these signs and symptoms of herpes infection:
If you think you have a herpes infection, inform your healthcare provider. You or your healthcare provider should call Amgen at 1-855-IMLYGIC (1-855-465-9442) for follow-up testing if needed.
These are not all the possible side effects of IMLYGIC. Your healthcare provider can give you more detailed information. Tell your healthcare provider if you have any side effects that bother you or that do not go away. You may report side effects to FDA at 1-800-FDA-1088.
What are the ingredients in IMLYGIC?
Active ingredient: talimogene laherparepvec
Inactive ingredients: di-sodium hydrogen phosphate dihydrate, sodium dihydrogen phosphate dihydrate, sodium chloride, myo-inositol, sorbitol, and water for injection
This Medication Guide summarizes the most important information about IMLYGIC. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider for information about IMLYGIC that was written for healthcare professionals.
