FDA Approves Expanded Use of Ibrutinib for Chronic GVHD

Ibrutinib, a BTK inhibitor commonly used to treat lymphoma types like chronic lymphocytic leukemia (CLL) and mantle cell lymphoma, has been approved by the United States Food and Drug Administration (FDA) for treatment of adults with chronic graft versus host disease (cGVHD).

Ibrutinib Pills in Hand

GVHD can occur following a stem cell or bone marrow transplant from a related or unrelated donor, also known as an allogeneic transplant. When the immune cells from the graft (donor) are infused into the body of the host (patient), they may recognize the host’s native cells as foreign and try to destroy them. While some cases of GVHD are life threatening, chronic cases tend to generate to more mild symptoms, like dry eyes and mouth, fatigue, and muscle weakness and stiffness.

Ibrutinib becomes the first FDA-approved treatment of cGVHD following clinical trials demonstrating durable safety and effectiveness in patients whose symptoms were resistant to prior corticosteroid treatment administered for immune system suppression.

FDA Approves Subcutaneous Administration of Rituximab for Three Lymphoma Types

On June 22, 2017, the United States Food and Drug Administration (FDA) approved subcutaneous injection of rituximab plus hyaluronidase human for people with follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), and chronic lymphocytic leukemia (CLL). Subcutaneous administration refers to the method of delivering a drug under the skin rather than directly into a vein as performed during intravenous (IV) administration.

insulin injection

Administration of rituximab under the skin tends to take less than 10 minutes, whereas the traditional IV method can last several hours. The technique also allows for fixed dosing, which can reduce preparation time and excess drug waste, and may be more cost effective than IV infusion.

The approved treatment is to be employed only after patients have received at least one cycle of intravenous rituximab.

Approval comes based on the results of a series of clinical trials demonstrating comparable safety and efficacy outcomes across subcutaneous and intravenous administration.

New Immunotherapy Treatment Approved for Children and Adults with Hodgkin Lymphoma

On March 14, 2017, the Food and Drug Administration (FDA) approved pembrolizumab for the treatment of refractory Hodgkin lymphoma in children and adults who have been treated with at least three prior therapies.

Pembrolizumab is a type of immunotherapy called a checkpoint inhibitor. This drug consists of an antibody that binds to programmed death receptor-1 (PD-1), preventing the cancer cells from evading detection by the body’s immune system. Treatment with pembrolizumab allows T-cells (the fighter cells) to mount an immune response against the malignant cells.

Since 2014, Pembrolizumab has been FDA approved for the treatment of unresectable or metastatic melanoma, metastatic non-small-cell lung cancer, and recurrent or metastatic head and neck squamous cell carcinoma. The approval of pembrolizumab for the treatment of relapsed Hodgkin lymphoma was made under the FDA’s accelerated approval process.

This approval was based on data from a clinical trial of pembrolizumab in 210 adult patients with Hodgkin lymphoma who had relapsed or refractory disease after autologous stem cell transplant and/or treatment with brentuximab vedotin.  With a median follow up of 9.4 months, the overall response rate was 69%, including partial responses in 47% and complete responses in 22% of patients. The approval in pediatrics was based on known safety data and extrapolated efficacy based on the adult trial.

The most common adverse events in the trial were fatigue, fever, cough, musculoskeletal pain, diarrhea, and rash. Among 40 pediatric patients with advanced melanoma, PD-L1 positive tumors, or lymphoma, the side effects and overall safety profile was similar to adults.  A “warning and precaution” was added to the label describing the potential complications of graft-versus-host disease (GVHD) in patients undergoing allogeneic stem cell transplant after treatment with pembrolizumab.  Death related to GVHD has occurred and physicians are advised to monitor for hepatic veno-occlusive disease and grade 3-4 acute GVHD including hyperacute GVHD.

The recommended dose of pembrolizumab for patients with Hodgkin lymphoma is 200mg every 3 weeks in adults and 2mg/kg (up to 200mg) every 3 weeks in children.

At the Weill Cornell and NewYork-Presbyterian Lymphoma Program, we offer pembrolizumab as one of many treatment choices available for people with Hodgkin lymphoma.