Pharmacological properties : תכונות פרמקולוגיות

Pharmacodynamic Properties

5.1   Pharmacodynamic properties

Pharmacotherapeutic group: antineoplastic agents, monoclonal antibodies and antibody drug conjugates, ATC code: L01FX15


Mechanism of action
Belantamab mafodotin is a humanised IgG1κ monoclonal antibody conjugated with a cytotoxic agent, maleimidocaproyl monomethyl auristatin F (mcMMAF). Belantamab mafodotin binds to cell surface BCMA and is rapidly internalised. Once inside the tumour cell, the cytotoxic agent is released disrupting the microtubule network, leading to cell cycle arrest and apoptosis. The antibody enhances recruitment and activation of immune effector cells, killing tumour cells by antibody-dependent cellular cytotoxicity and phagocytosis. Apoptosis induced by belantamab mafodotin is accompanied by markers of immunogenic cell death, which may contribute to an adaptive immune response to tumour cells.

Pharmacodynamic effects

Cardiac Electrophysiology
Based on exposure-QTc analysis, belantamab mafodotin had no meaningful QTc prolongation (>10 ms) at the recommended dose of 2.5 mg/kg once every 3 weeks.

Immunogenicity

In clinical studies in patients with multiple myeloma, <1% of patients (2/274) tested positive for anti- belantamab mafodotin antibodies after receiving belantamab mafodotin. One of the two patients tested positive for neutralising anti-belantamab mafodotin antibodies.

Clinical efficacy

Study 205678 was an open-label, two arm, Phase II, multicentre study which evaluated belantamab mafodotin as monotherapy in patients with multiple myeloma who had relapsed following treatment with at least 3 prior therapies, and who were refractory to an immunomodulatory agent, a proteasome inhibitor and an anti-CD38 antibody alone or in combination. Patients were included if they had undergone autologous stem cell transplant or were considered transplant ineligible and had measurable disease by International Myeloma Working Group (IMWG) criteria.

Patients were randomised to receive 2.5 mg/kg (N=97) or 3.4 mg/kg (N=99) belantamab mafodotin by intravenous infusion every 3 weeks until disease progression or unacceptable toxicity (see Table 4).
The data presented below is from the 2.5 mg/kg cohort who received the recommended therapeutic dose based on overall benefit risk assessment (see section 4. 2).

Table 4: Baseline demographics and disease characteristics
Baseline Characteristics                                 2.5 mg/kg
(N=97)
Age                         Median (range)              65.0 (39-85)
Interquartile range             60-70
Gender                      Male                          51 (53%)
Female                        46 (47%)
ECOG at baseline            0/1                          33%, 50%,
2                                17%
ISS stage at screening      II                            33 (34%)
III                           42 (43%)
Cytogenetics risk           High risk*                    26 (27%)
Number of prior lines       Median                            7
Range                           (3-21)
Duration of exposure        Median                         9 weeks
Range                           (2-75)
Treatment cycles            Median                            3
Range                           (1-17)
ECOG = Eastern Cooperative Oncology Group Performance Status

ISS= International Staging System
*High risk cytogenetic factors [positive for t (4;14), t (14;16), and 17p13del] 
The primary endpoint was overall response rate as evaluated by an Independent Review Committee (IRC) based on the IMWG Uniform Response Criteria for Multiple Myeloma. Table 5 provides the results of study 205678.

Table 5. Efficacy of BLENREP in patients with multiple myeloma in study 205678 2.5 mg/kg
Clinical response
(N = 97)
Overall response rate (ORR), % (97.5% CI)                           32% (22, 44) Stringent complete response (sCR), n (%)                            2 (2%) Complete response (CR), n (%)                                       5 (5%) Very good partial response (VGPR), n (%)                          11 (11%) Partial response (PR), n (%)                                      13 (13%) Clinical benefit rate (CBR)*, % (95% CI)                          36% (26.6, 46.5) Median duration of response in months (95% CI)                 11 (4.2 to Not reached) Probability of Maintaining Response at 12 Months (95% CI)     0.50 (0.29, 0.68) Median time to response in months (95% CI)                      1.5 (1.0, 2.1) Median time to best response in months (95% CI)                 2.2 (1.5, 3.6) Median overall survival (OS) in months (95% CI)               13.7 (9.9 to Not reached) Survival probability at 12 Months (95% CI)                    0.57 (0.46, 0.66) *CBR: sCR+CR+VGPR+PR+Minimal response

Paediatric population

The European Medicines Agency has waived the obligation to submit the results of studies with BLENREP in all subsets of the paediatric population in multiple myeloma (see section 4.2 for information on paediatric use).

This medicinal product has been authorised under a so-called ‘conditional approval’ scheme. This means that further evidence on this medicinal product is awaited.

The European Medicines Agency will review new information on this medicinal product at least every year and this SmPC will be updated as necessary.

Pharmacokinetic Properties

5.2   Pharmacokinetic properties

Absorption
Maximum concentration for belantamab mafodotin occurred at or shortly after the end of infusion while cys-mcMMAF concentrations peaked ~24 hours after dosing. Geometric mean belantamab mafodotin Cmax and AUC(0-tau) concentrations were 43 mcg/mL and 4,666 mcg.h/mL, respectively.
Geometric mean cys-mcMMAF Cmax and AUC(0-168h) concentrations were 0.90 ng/mL and 84 ng.h/mL, respectively.

Distribution

The mean steady-state volume of distribution of belantamab mafodotin was 10.8 L.
Biotransformation

The monoclonal antibody portion of belantamab mafodotin is expected to undergo proteolysis to small peptides and individual amino acids by ubiquitous proteolytic enzymes. Cys-mcMMAF had limited metabolic clearance in human hepatic S9 fraction incubation studies.


Drug interactions
In vitro studies demonstrated that cys-mcMMAF is a substrate of organic anion transporting polypeptide (OATP)1B1 and OATP1B3, multidrug resistance-associated protein (MRP)1, MRP2, MRP3, bile salt export pump (BSEP), and a possible substrate of P-glycoprotein (P-gp).

Elimination

Belantamab mafodotin was cleared slowly with total plasma clearance of 0.92 L/day and a terminal phase half-life of 12 days. Over time, clearance was reduced by 28% to 0.67 L/day with an elimination half-life of 14 days. Predose cys-mcMMAF concentrations at each dose were typically below the limit of quantification (0.05 ng/mL).

In an animal study, approximately 83% of the radioactive dose of cys-mcMMAF was excreted in the faeces; urinary excretion (approximately 13%) was a minor route; intact cys-mcMMAF was detected in human urine, with no evidence of other MMAF-related metabolites.

Linearity/non-linearity

Belantamab mafodotin exhibits dose-proportional pharmacokinetics over the recommended dose range with a reduction in clearance over time.

Special populations

Elderly patients (≥65 years old)
No formal studies have been conducted in elderly patients. Age was not a significant covariate in population pharmacokinetic analyses.

Renal impairment
No formal studies have been conducted in patients with renal impairment. Renal function was not a significant covariate in population pharmacokinetic analyses that included patients with normal renal function and mild or moderate renal impairment.

Hepatic impairment
No formal studies have been conducted in patients with hepatic impairment. Hepatic function was not a significant covariate in population pharmacokinetic analyses that included patients with normal hepatic function or mild hepatic impairment.

Body weight
Body weight was a significant covariate in population pharmacokinetic analyses. Belantamab mafodotin Ctau was predicted to be +10% at a body weight of 100 kg (+20% for 130 kg) and -10% at a body weight of 55 kg (-20% for 40 kg) compared to the typical patient (75 kg).