Vegzelma

Clinical Value - Phase 1 Study

Study design & objective1

A randomized, double-blind, three-arm, parallel-group, single-dose phase I trial designed to demonstrate the pharmacokinetic equivalence of Vegzelma® vs. EU-approved Avastin and US-licensed Avastin in healthy male subjects.

Overview

Endpoints

Primary pharmacokinetic
endpoints
Secondary pharmacokinetic
endpoints
Secondary safety/
immunogenicity endpoints
AUCinf, AUClast, Cmax Tmax, Vz, λz, t1/2, CL, %AUCext AEs, vital signs, physical examination,
clinical laboratory tests, 12-lead ECG,
immunogenicity
Primary pharmacokinetic
endpoints
AUCinf, AUClast, Cmax
Secondary pharmacokinetic
endpoints
Tmax, Vz, λz, t1/2, CL, %AUCext
Secondary safety/
immunogenicity endpoints
AEs, vital signs, physical examination,
clinical laboratory tests, 12-lead ECG,
immunogenicity

Study demographics

All subjects were Asian males (N=136); the median age (range) of these subjects was 25.0 (19–53) years.
Subject demographics and characteristics were similar across treatment groups.

· Baseline demographics and characteristics
of subjects: safety population
Characteristic Vegzelma® (n=46) EU-approved Avastin (n=47) US-licensed Avastin (n=48)
Age (years)
Mean (SD) 28.5 (8.69) 28.4 (7.59) 26.5 (6.28)
Median (range) 25.0 (19-53) 26.0 (21-52) 25.0 (20-52)
Asian race [n (%)] 46 (100) 47 (100) 48 (100)
Male sex [n (%)] 46 (100) 47 (100) 48 (100)
Height (cm)
Mean (SD) 174.62 (6.589) 174.83 (6.788) 173.14 (4.968)
Median (range) 173.95 (162.6-189.2) 174.40 (161.4-190.9) 173.80 (157.2-182.3)
Weight (kg)
Mean (SD) 69.93 (9.07) 71.01 (9.42) 69.54 (8.14)
Median (range) 69.90 (51.6-88.2) 70.30 (55.7-92.9) 71.30 (52.7-84.4)
Weight [n (%)]
<70 kg 23 (50) 22 (46.8) 23 (47.9)
≥70 kg 23 (50) 25 (53.2) 25 (52.1)
BMI (kg/m2)
Mean (SD) 22.89 (2.310) 23.20 (2.492) 23.17 (2.303)
Median (range) 22.59 (18.0-27.9) 23.36 (19.2-28.7) 23.45 (18.0-28.1)

Pharmacokinetic results

After intravenous administration of a single 5 mg/kg dose of Vegzelma®, EU-approved Avastin, or US-licensed Avastin, similar mean bevacizumab serum concentration–time profiles were observed in each treatment group.

The 90% CIs for the GM ratios of AUC∞, AUClast, and Cmax for Vegzelma®/EU-approved Avastin, Vegzelma®/US-licensed
Avastin, and EU-approved Avastin/US-licensed Avastin comparisons were all within the bioequivalence margin.

· Statistical analysis of the primary pharmacokinetic endpoints (analysis of covariance)

*GM ratios were calculated by back-transforming the difference in LS means calculated using an ANCOVA model with treatment as a fixed effect and body weight assessed on day – 1 (< 70 vs. ≥ 70 kg) and study site as covariates.; †For four subjects (one from the Vegzelma group, one from the EU-approved Avastin group, and two from the
US-licensed Avastin group), AUCinf values were excluded from the statistical analysis because the interval used to calculate λz was < 1.5-fold the estimated half-life.; ‡For five
subjects (one from the Vegzelma group and four from the US-licensed Avastin group), AUClast values were excluded from the statistical analysis because the subjects
withdrew from the study and the last pharmacokinetic samples for these subjects were collected earlier than the planned time (in accordance with the guideline on the
investigation of bioequivalence from the EMA).

Pharmacokinetic endpoints Vegzelma® (n=46) EU-approved Avastin (n=47) US-licensed Avastin (n=48)
AUCinf
(day·mg/L)
Mean (SD) 1,751.45 (252.945) 1,683.89 (208.866) 1,792.41 (240.956)
Median (range) 1,720.08 (1,260.0-2,254.7) 1,678.92 (1,140.1–2,122.5) 1,787.43 (1,199.4–2,271.9)
AUClast
(day·mg/L)
Mean (SD) 1,714.28 (237.258) 1,642.17 (193.722) 1,741.84 (227.659)
Median (range) 1,699.81 (1,255.2–2,189.2) 1,643.58 (1,131.5–2,068.2) 1,740.89 (1,164.1–2,239.1)
Cmax (mg/L) Mean (SD) 117.22 (17.756) 114.06 (15.391) 113.09 (17.402)
Median (range) 116 (83.6–173.0) 111 (83.2–148.0) 112 (72.6–155.0)
Tmax (day) Mean (SD) 0.120 (0.0881) 0.117 (0.0820) 0.125 (0.0801)
Median (range) 0.104 (0.06–0.50) 0.104 (0.06–0.33) 0.104 (0.06–0.33)
Vz (L) Mean (SD) 5.352 (1.045) 5.505 (0.705) 5.487 (0.964)
Median (range) 5.311 (3.30–7.42) 5.449 (4.29–6.97) 5.404 (3.45–8.00)
λz (1/day) Mean (SD) 0.039 (0.0081) 0.039 (0.0076) 0.037 (0.0061)
Median (range) 0.037 (0.03–0.06) 0.039 (0.02–0.06) 0.037 (0.03–0.05)
t½ (day) Mean (SD) 18.44 (3.281) 18.28 (3.408) 19.29 (3.245)
Median (range) 18.94 (11.1–24.4) 17.83 (11.5–27.7) 19.00 (14.3–27.6)
CL (L/day) Mean (SD) 0.20 (0.041) 0.21 (0.035) 0.20 (0.033)
Median (range) 0.20 (0.1–0.3) 0.21 (0.2–0.3) 0.19 (0.1–0.3)
%AUCext * Mean (SD) 3.01 (2.665) 2.68 (1.619) 3.59 (2.810)
Median (range) 2.63 (0.4–18.3) 2.12 (0.5–8.8) 3.07 (0.8–18.6)

*Two subjects (one in the Vegzelma® arm and one in the US-licensed Avastin arm) had %AUCext > 10% and were withdrawn (the last pharmacokinetic sampling
timepoints were day 55 and 56, respectively).

Safety profile

Over the course of the study, there were no deaths, TESAEs, or TEAEs leading to discontinuation.

A total of 83 (58.9%) subjects in the safety population reported one or more TEAE during the study (50.0%, 72.3%, and 54.2%
in the Vegzelma®, EU-approved Avastin, and US-licensed Avastin groups, respectively).

· TEAEs by preferred term: safety population
TEAEs, n (%) Vegzelma® (n=46) EU-approved Avastin (n=47) US-licensed Avastin (n=48)
Total number of TEAEs 52 76 75
Subjects with at least one TEAE 23 (50.0) 34 (72.3) 26 (54.2)
Most common TEAEs*
Diarrhea 3 (6.5) 6 (12.8) 4 (8.3)
Nasopharyngitis 4 (8.7) 1 (2.1) 6 (12.5)
Blood creatine phosphokinase increased 3 (6.5) 5 (10.6) 4 (8.3)
C-reactive protein increased 2 (4.3) 5 (10.6) 4 (8.3)
Infusion-related reaction 2 (4.3) 2 (4.3) 4 (8.3)
Troponin I increased 1 (2.2) 3 (6.4) 0
Headache 1 (2.2) 2 (4.3) 3 (6.3)
WBC count decreased 1 (2.2) 0 3 (6.3)
Any TEAE related to study drug† 9 (19.6) 20 (42.6) 16 (33.3)
Most common TEAEs related to study drug†,‡
Diarrhea 3 (6.5) 6 (12.8) 2 (4.2)
C-reactive protein increased 1 (2.2) 4 (8.5) 4 (8.3)
Infusion-related reaction 2 (4.3) 2 (4.3) 4 (8.3)

*TEAEs reported by ≥ 5% subjects in any treatment group; † Considered related (possible, probable, or definite) to study drug by investigator; ‡ TEAEs related to study drug
reported by ≥ 5% subjects in any treatment group

A total of 45 subjects reported TEAEs considered by the investigator to be related to study drug. Of these subjects, 9 (19.6%) were in the Vegzelma®
group, 20 (42.6%) were in the EU-approved Avastin group, and 16 (33.3%) were in the US-licensed Avastin group.

Immunogenicity results

Levels of immunogenicity, as measured by ADA incidence, were low across all groups, with only seven subjects testing
positive for ADAs after study drug administration. No NAbs were detected in any subject who tested positive for ADAs either before or after treatment.

· The positive for ADAs after study drug administration

ADA, anti-drug antibody; AEs, adverse events; ANCOVA, an analysis of covariance; AUC, area under the concentration-time curve; AUClast, AUC from time zero to the last
quantifiable concentration; AUCinf, AUC from time zero to infinity; BMI, body mass index; CI, confidence interval; CL, total body clearance; Cmax, maximum serum
concentration; EMA, European Medicines Agency; EU, European Union; GM, geometric mean; LS, least squares; NAbs, neutralizing antibodies; R, randomization;
SD, standard deviation; TEAE, treatment-emergent adverse event; Tmax, time to Cmax; t1/2, terminal half-life; US, United States; Vz, volume of distribution during the terminal
phase; WBC, white blood cell; λz, terminal elimination rate constant; %AUCext, the percentage of AUCinf obtained by extrapolation.

1. Vegzelma US Prescribing Information (2022).
2. Cho SH, et al. BioDrugs. 2019;33(2):173-181.

IMPORTANT
SAFETY
INFORMATION

WARNINGS AND PRECAUTIONS arrow

Gastrointestinal Perforations and Fistulae: Serious, and sometimes fatal, gastrointestinal perforation occurred at a higher incidence in patients receiving bevacizumab products vs chemotherapy. The incidence ranged from 0.3% to 3% across clinical studies, with the highest incidence in patients with a history of prior pelvic radiation. Serious fistulae ranged from < 1% to 1.8% across clinical studies, with the highest incidence in patients with cervical cancer. Avoid VEGZELMA in patients with ovarian cancer who have evidence of recto-sigmoid involvement by pelvic examination or bowel involvement on CT scan or clinical symptoms of bowel obstruction. Discontinue in patients who develop gastrointestinal perforation, tracheoesophageal fistula, or any Grade 4 fistula. Discontinue in patients with fistula formation involving any internal organ


Surgery and Wound Healing Complications: The incidence of surgery and wound healing complications, including serious and fatal complications, was increased in patients receiving bevacizumab products. In patients who experience wound healing complications during treatment, withhold VEGZELMA until adequate wound healing. Discontinue VEGZELMA in patients who develop necrotizing fasciitis.


Hemorrhage: Severe or fatal hemorrhage occurred up to 5-fold more frequently in patients receiving bevacizumab products vs chemotherapy alone. Discontinue VEGZELMA in patients who develop a Grades 3-4 hemorrhage.


Arterial Thromboembolic Events: Serious, sometimes fatal, arterial thromboembolic events (ATE) occurred at a higher incidence in patients receiving bevacizumab vs chemotherapy. Discontinue VEGZELMA in patients who develop a severe ATE. The safety of reinitiating bevacizumab products after an ATE is resolved is not known.


Venous Thromboembolic Events: An increased risk of venous thromboembolic events (VTE) was observed across clinical studies. Discontinue VEGZELMA in patients with a Grade 4 VTE, including pulmonary embolism.


Hypertension: Severe hypertension occurred at a higher incidence in patients receiving bevacizumab products vs chemotherapy alone. Monitor blood pressure every two to three weeks during treatment with VEGZELMA. Treat with appropriate anti-hypertensive therapy and monitor blood pressure regularly. Discontinue in patients who develop hypertensive crisis or hypertensive encephalopathy.


Posterior Reversible Encephalopathy Syndrome: Posterior reversible encephalopathy syndrome (PRES) was reported in < 0.5% of patients across clinical studies. Discontinue VEGZELMA in patients who develop PRES.


Renal Injury and Proteinuria: The incidence and severity of proteinuria was higher in patients receiving bevacizumab products vs chemotherapy. Nephrotic syndrome occurred in < 1% of patients receiving bevacizumab products across clinical studies, in some instances with fatal outcome. Discontinue VEGZELMA in patients who develop nephrotic syndrome


Infusion-Related Reactions: In clinical studies, infusion-related reactions with the first dose of bevacizumab products occurred in < 3% of patients and severe reactions occurred in 0.4% of patients. Decrease the rate of infusion for mild, clinically insignificant infusion-related reactions. Interrupt the infusion in patients with clinically significant infusion-related reactions and consider resuming at a slower rate following resolution. Discontinue VEGZELMA in patients who develop a severe infusion-related reaction and administer appropriate medical therapy.


Embryo-Fetal Toxicity: Bevacizumab products may cause fetal harm when administered to pregnant women. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with VEGZELMA and for 6 months after the last dose.


Ovarian Failure: The incidence of ovarian failure was 34% vs 2% in premenopausal women receiving bevacizumab with chemotherapy vs chemotherapy alone for adjuvant treatment of a solid tumor. Inform females of reproductive potential of the risk of ovarian failure prior to initiating treatment with VEGZELMA.


Congestive Heart Failure (CHF): VEGZELMA is not indicated for use with anthracycline-based chemotherapy. Discontinue VEGZELMA in patients who develop CHF.


MOST COMMON ADVERSE REACTIONS

The most common adverse reactions observed in patients receiving bevacizumab products as a single agent or in combination with other anti-cancer therapies at a rate >10% were epistaxis, headache, hypertension, rhinitis, proteinuria, taste alteration, dry skin, hemorrhage, lacrimation disorder, back pain, and exfoliative dermatitis.


Across clinical studies, bevacizumab was discontinued in 8% to 22% of patients because of adverse reactions.


ADVERSE REACTIONS BY INDICATION
Metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment
  • Study AVF2107g: Grades 3-4 adverse reactions occurring at higher incidence (≥2%) in patients receiving bevacizumab with IFL (N=392) vs placebo with IFL (N=396) were leukopenia (37% vs 31%), neutropenia (21% vs 14%), diarrhea (34% vs 25%), abdominal pain (8% vs 5%), constipation (4% vs 2%), hypertension (12% vs 2%), deep vein thrombosis (9% vs 5%), intra-abdominal thrombosis (3% vs 1%), syncope (3% vs 1%), asthenia (10% vs 7%), and pain (8% vs 5%)

Metastatic colorectal cancer, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line bevacizumab product-containing regimen
  • Study E3200: Selected Grades 3-5 (non-hematologic) and Grades 4-5 (hematologic) reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with FOLFOX4 (N=521) vs FOLFOX4 alone were fatigue (19% vs 13%), diarrhea (18% vs 13%), sensory neuropathy (17% vs 9%), nausea (12% vs 5%), vomiting (11% vs 4%), dehydration (10% vs 5%), hypertension (9% vs 2%), abdominal pain (8% vs 5%), hemorrhage (5% vs 1%), other neurological (5% vs 3%), ileus (4% vs 1%), and headache (3% vs 0%)

Unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer, in combination with carboplatin and paclitaxel for first-line treatment
  • Study E4599: Grades 3-5 (non-hematologic) and Grades 4-5 (hematologic) adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with paclitaxel and carboplatin (N=422) vs chemotherapy alone were neutropenia (27% vs 17%), fatigue (16% vs 13%), hypertension (8% vs 0.7%), infection without neutropenia (7% vs 3%), venous thromboembolism (5% vs 3%), febrile neutropenia (5% vs 2%), pneumonitis/pulmonary infiltrates (5% vs 3%), infection with Grade 3 or 4 neutropenia (4% vs 2%), hyponatremia (4% vs 1%), headache (3% vs 1%), and proteinuria (3% vs 0%)

Recurrent glioblastoma in adults
  • Study EORTC 26101: In the bevacizumab with lomustine arm (N=278), 22% of patients discontinued treatment due to adverse reactions vs 10% of patients in the lomustine arm. In patients receiving bevacizumab with lomustine, the adverse reaction profile was similar to that observed in other approved indications

Metastatic renal cell carcinoma in combination with interferon alfa
  • Study BO17705: Grades 3-5 adverse reactions occurring at a higher incidence (>2%) in patients receiving bevacizumab with interferon alfa (N=337) vs placebo with interferon alfa (N=304) were fatigue (13% vs 8%), asthenia (10% vs 7%), proteinuria (7% vs 0%), hypertension (6% vs 1%; including hypertension and hypertensive crisis), and hemorrhage (3% vs 0.3%; including epistaxis, small intestinal hemorrhage, aneurysm ruptured, gastric ulcer hemorrhage, gingival bleeding, hemoptysis, hemorrhage intracranial, large intestinal hemorrhage, respiratory tract hemorrhage, and traumatic hematoma)

Persistent, recurrent, or metastatic cervical cancer, in combination with paclitaxel and cisplatin, or paclitaxel and topotecan
  • Study GOG-0240: Grades 3-4 adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with chemotherapy (N=218) vs chemotherapy alone (N=222) were abdominal pain (12% vs 10%), hypertension (11% vs 0.5%), thrombosis (8% vs 3%), diarrhea (6% vs 3%), anal fistula (4% vs 0%), proctalgia (3% vs 0%), urinary tract infection (8% vs 6%), cellulitis (3% vs 0.5%), fatigue (14% vs 10%), hypokalemia (7% vs 4%), hyponatremia (4% vs 1%), dehydration (4% vs 0.5%), neutropenia (8% vs 4%), lymphopenia (6% vs 3%), back pain (6% vs 3%), and pelvic pain (6% vs 1%)

Epithelial ovarian, fallopian tube, or primary peritoneal cancer in combination with carboplatin and paclitaxel, followed by VEGZELMA as a single agent, for stage III or IV disease following initial surgical resection
  • Study BO17705: Grades 3-4 adverse reactions occurring at a higher incidence (≥2%) in either of the bevacizumab arms (N=608, N=607) vs control arm (N=602) were fatigue (CPB15+ - 9%, CPB15 - 6%, CPP - 6%), hypertension (CPB15+ - 10%, CPB15 - 6%, CPP - 2%), thrombocytopenia (CPB15+ - 21%, CPB15 - 20%, CPP - 15%), and leukopenia (CPB15+ - 51%, CPB15 - 53%, CPP - 50%)

Epithelial ovarian, fallopian tube, or primary peritoneal cancer in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan for platinum-resistant recurrent disease who received no more than 2 prior chemotherapy regimens
  • Study MO22224: Grades 3-4 adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with chemotherapy (N=179) vs chemotherapy alone (N=181) were hypertension (6.7% vs 1.1%) and palmar-plantar erythrodysaesthesia syndrome (4.5% vs 1.7%)

Epithelial ovarian, fallopian tube, or primary peritoneal cancer in combination with carboplatin and paclitaxel or carboplatin and gemcitabine, followed by VEGZELMA as a single agent, for platinum-sensitive recurrent disease
  • Study AVF4095g: Grades 3-4 adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with chemotherapy (N=247) vs placebo with chemotherapy (N=233) were thrombocytopenia (40% vs 34%), nausea (4% vs 1.3%), fatigue (6% vs 4%), headache (4% vs 0.9%), proteinuria (10% vs 0.4%), dyspnea (4% vs 1.7%), epistaxis (5% vs 0.4%), and hypertension (17% vs 0.9%)

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088. Please see full Prescribing Information for complete information.


1. Vegzelma US Prescribing Information (2022)
This site is intended for US audiences only. Models are used for illustrative purposes only. Not actual patients.
Vegzelma® is a registered trademark of Celltrion, Inc., used under license.
ⓒ Celltrion USA, Inc. 2023 VEG-2306-2405-WS001

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