Warnings for Tecelra
Included as part of the "PRECAUTIONS" Section
Precautions for Tecelra
Cytokine Release Syndrome
Cytokine release syndrome (CRS), including potentially life-threatening reaction has been observed following administration of TECELRA. CRS occurred in 75% of patients, 2% of whom had Grade ≥ 3 CRS. The median time to onset was 2 days (range: 1 to 5 days) and the median time to resolution was 3 days (range: 1 to 14 days). The most common symptoms were fever (97%), tachycardia (52%), hypotension (30%), nausea/vomiting (21%) and headache (15%) [see ADVERSE REACTIONS]. Management for CRS (including Grade 1) was tocilizumab (55%). Thirteen patients received one dose and five patients received more than one dose. Of the five patients who received more than one dose of tocilizumab, two patients received dexamethasone in addition to tocilizumab.
Ensure that healthcare providers administering TECELRA have immediate access to medications and resuscitative equipment to manage CRS. Ensure patients are euvolemic prior to initiating the infusions.
During and following TECELRA administration, closely monitor patients for signs and symptoms of CRS. Following treatment with TECELRA, monitor patients for at least 7 days at the healthcare facility for CRS. Continue to monitor patients for CRS for at least 4 weeks following treatment with TECELRA. Counsel patients to seek medical attention should signs or symptoms of CRS occur. At the first sign of CRS, immediately evaluate patient for hospitalization and institute treatment with supportive care based on severity and consider further management per current practice guidelines.
Immune Effector Cell-Associated Neurotoxicity Syndrome
Immune Effector Cell-associated Neurotoxicity Syndrome (ICANS) has been observed following administration of TECELRA. One patient (2%) had Grade 1 ICANS. Time to onset was two days and time to resolution was one day. Symptoms included mild mental status changes. Other symptoms may include disorientation to time and place, mild drowsiness, mild inattention. Severe symptoms may include altered level of consciousness, seizures, cerebral edema, impairment of cognitive skills, progressive aphasia, motor weakness.
Ensure that healthcare providers administering TECELRA have immediate access to medications and resuscitative equipment to manage ICANS.
During and following TECELRA administration, closely monitor patients for signs and symptoms of ICANS. Following treatment with TECELRA, monitor patients for at least 7 days at the healthcare facility for ICANS. Continue to monitor patients for ICANS for at least 4 weeks following treatment with TECELRA. Counsel patients to seek medical attention should signs or symptoms of ICANS occur. At the first sign of ICANS, immediately evaluate patients for hospitalization and institute treatment with supportive care based on severity and consider further management per current practice guidelines.
Effect On Ability To Drive And Use Machines
Due to the potential for neurologic events, including dizziness and presyncope, patients receiving TECELRA are at risk for altered or decreased coordination in the 4 weeks following infusion.
Advise patients to refrain from driving and engaging in hazardous occupations or activities, such as operating heavy or potentially dangerous machinery, during this initial period.
Prolonged Severe Cytopenia
Patients may exhibit severe cytopenias, including neutropenia and thrombocytopenia [see ADVERSE REACTIONS].
Patients exhibited anemia, neutropenia, and/or thrombocytopenia for several weeks following lymphodepleting chemotherapy and TECELRA infusion. Patients with Grade ≥ 3 cytopenia not resolved by week 4 included anemia (9%), neutropenia (11%), and thrombocytopenia (5%). The median time to resolution was 7.3 weeks (range: 6.1 to 8.4 weeks) for anemia, 9.3 weeks (range: 6.4 to 12.3 weeks) for neutropenia and 6.3 weeks (range: 6.1 to 6.4 weeks) for thrombocytopenia.
Monitor blood counts after TECELRA infusion. Manage cytopenia with growth factor and blood product transfusion according to local institutional guidelines/clinical practice.
Infections
Infections may occur following lymphodepleting chemotherapy and TECELRA infusion. Infections (all grades) occurred in 32% of patients with synovial sarcoma. Grade 3 or higher infections occurred in 14% of patients.
Do not administer TECELRA to patients with active infections and/or inflammatory disorders.
Monitor patients for signs and symptoms of infection before and after TECELRA infusion and treat patients appropriately.
Febrile neutropenia was observed in patients after TECELRA infusion and may be concurrent with CRS. In the event of febrile neutropenia, evaluate for infection and manage with broad-spectrum antibiotics, fluids and other supportive care, as medically indicated.
Viral reactivation has occurred in patients following treatment with TECELRA. Perform screening for Epstein-Barr Virus, Cytomegalovirus, Hepatitis B Virus, Hepatitis C Virus, Human Immunodeficiency Virus, and any other infectious agents if clinically indicated. Consider antiviral therapy to prevent viral reactivation per local guidelines.
Secondary Malignancies
Patients treated with TECELRA may develop secondary malignancies or recurrence of their cancer. Monitor for secondary malignancies.
In the event that a secondary malignancy occurs, contact Adaptimmune at 1-855- 24MYADAP (1-855-246-9232) to obtain instructions on patient samples to collect for testing.
Hypersensitivity Reactions
Serious hypersensitivity reactions, including anaphylaxis, may occur due to dimethyl sulfoxide (DMSO) in TECELRA. Observe patients for hypersensitivity reactions during infusion.
Potential For HIV Nucleic Acid Test False-Positive Results
The lentiviral vector used to make TECELRA has limited, short spans of genetic material which are identical to HIV. Therefore, some commercial HIV nucleic acid tests may yield false-positive results in patients who have received TECELRA.
Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Medication Guide).
Discuss the following with the patient:
- Inform patients that there is a chance of manufacturing or delivery failure (approximately 8% in the clinical trial). Therefore, a second manufacture of TECELRA may be attempted.
- Inform patients that additional therapy (other than lymphodepletion) may be necessary before TECELRA manufacturing is completed. This may increase the risk of adverse reactions during the pre-infusion period, which could delay or prevent administration of TECELRA.
- Inform patients that following infusion, it will be necessary to be monitored daily at the healthcare facility for at least 7 days for signs and symptoms of cytokine release syndrome (CRS). Patients must remain within proximity of a healthcare facility for at least 4 weeks following infusion.
- Advise patients to seek immediate medical attention if any of the following occur:
- Cytokine Release Syndrome: inform patients that symptoms may include fever, rigors, fast heartbeat, irregular heartbeat, low blood pressure, lightheadedness or dizziness, shortness of breath, nausea/vomiting, diarrhea, and headache [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS].
- Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS): inform patients that symptoms may include confusion, depressed level of consciousness, delirium, seizures, language difficulty [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS].
- Bone marrow suppression and prolonged severe cytopenias: inform patients that symptoms may include bleeding or bruising, tiredness, shortness of breath, fever, pain, redness for several weeks following lymphodepleting chemotherapy and TECELRA blood counts before and after TECELRA infusion should be periodically monitored [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS].
- Infections: inform patients that they may exhibit signs or symptoms associated with infection, and that past infections can be reactivated following treatment with TECELRA [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS].
Advise patients for the need to:
- Contact Adaptimmune at 1-855-24MYADAP (1-855-246-9232) if they are diagnosed with a secondary malignancy [see WARNINGS AND PRECAUTIONS].
- Refrain from driving or operating heavy or potentially dangerous machines for at least 4 weeks after TECELRA administration [see WARNINGS AND PRECAUTIONS].
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment Of Fertility
No carcinogenicity or genotoxicity studies have been conducted with TECELRA.
A genomic insertion site analysis was performed on TECELRA products from five patients. There was no evidence for preferential integration near genes of concern. No studies have been conducted to evaluate the effects of TECELRA on fertility.
Use In Specific Populations
Pregnancy
Risk Summary
There are no available data with TECELRA use in pregnant women. No animal reproductive and developmental toxicity studies have been conducted with TECELRA to assess whether it can cause fetal harm when administered to a pregnant woman. It is not known if TECELRA has the potential to be transferred to the fetus and cause fetal toxicity. Therefore, TECELRA is not recommended for women who are pregnant, and pregnancy after TECELRA administration should be discussed with the treating physician. Report all pregnancies following treatment with TECELRA to Adaptimmune at 1-855-24MYADAP (1-855-246-9232).
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.
Lactation
Risk Summary
There is no information regarding the presence of TECELRA in human milk, the effect on the breastfed infant, and the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for TECELRA and any potential adverse effects on the breastfed infant from TECELRA or from the underlying maternal condition.
Females And Males Of Reproductive Potential
Pregnancy Testing
Verify pregnancy status of females with reproductive potential prior to starting treatment with TECELRA.
Contraception
here are insufficient exposure data to provide a recommendation concerning duration of contraception following treatment with TECELRA.
Pediatric Use
The safety and effectiveness of TECELRA have not been established in pediatric patients.
Geriatric Use
Of the 44 patients with synovial sarcoma in the SPEARHEAD-1 study that received TECELRA, 6.8% were 65 years of age or older. Clinical studies of TECELRA did not include sufficient numbers of patients aged 65 and over to conclude whether they respond differently from younger patients.