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Zaltrap Side Effects Center

Medical Editor: Charles Patrick Davis, MD, PhD

Zaltrap (ziv-aflibercept) is a recombinant fusion protein consisting of Vascular Endothelial Growth Factor fused to the Fc portion of human IgG. Zaltrap injection for intravenous infusion is indicated for patients with metastatic colorectal cancer (mCRC). There is no generic available. The most common side effects were diarrhea, stomatitis, fatigue, hypertension, weight loss, loss of appetite, abdominal pain, and headache.

Zaltrap is available in single-use vials in two strengths: 100 mg/4 mL (25 mg/mL) and 200 mg/8 mL (25 mg/mL). Zaltrap is dosed as 4 mg/kg as an intravenous infusion over 1 hour, every 2 weeks. Serious side effects include hemorrhage, GI perforation and compromised wound healing. Based on animal data, Zaltrap may cause fetal harm. Zaltrap should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. It is not known whether Zaltrap is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious side effects in nursing infants, a decision should be made as to whether to discontinue nursing or to discontinue the drugs, taking into account the important of the drug to the mother. The safety and effectiveness of Zaltrap has not been examined in the pediatric population.

Our Zaltrap Center provides a comprehensive view of available drug information on the potential side effects when taking this medication.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What is Prescribing information?

The FDA package insert formatted in easy-to-find categories for health professionals and clinicians.

Zaltrap FDA Prescribing Information: Side Effects
(Adverse Reactions)


The following serious adverse reactions are discussed elsewhere in the labeling:

Clinical Trial Experience

Because clinical trials are conducted under varying designs and in different patient populations, the adverse reaction rates reported in one clinical trial may not be easily compared to those rates reported in another clinical trial, and may not reflect the rates actually observed in clinical practice.

The safety of ZALTRAP in combination with FOLFIRI was evaluated in 1216 previously treated patients with metastatic colorectal cancer (Study 1) who were treated with ZALTRAP 4 mg per kg intravenous (N=611) or placebo (N=605) every two weeks (one cycle) in a randomized (1:1), double-blind, placebo-controlled Phase 3 study. Patients received a median of 9 cycles of ZALTRAP/FOLFIRI or 8 cycles of placebo/FOLFIRI.

The most common adverse reactions (all grades, ≥ 20% incidence) reported at a higher incidence (2% or greater between-arm difference) in the ZALTRAP/FOLFIRI arm , in order of decreasing frequency, were leukopenia, diarrhea, neutropenia, proteinuria, AST increased, stomatitis, fatigue, thrombocytopenia, ALT increased, hypertension, weight decreased, decreased appetite, epistaxis, abdominal pain, dysphonia, serum creatinine increased, and headache (see Table 1).

The most common Grade 3-4 adverse reactions ( ≥ 5%) reported at a higher incidence (2% or greater between-arm difference) in the ZALTRAP/FOLFIRI arm, in order of decreasing frequency, were neutropenia, diarrhea, hypertension, leukopenia, stomatitis, fatigue, proteinuria, and asthenia (see Table 1).

The most frequent adverse reactions leading to permanent discontinuation in ≥ 1% of patients treated with ZALTRAP/FOLFIRI regimen were asthenia/fatigue, infections, diarrhea, dehydration, hypertension, stomatitis, venous thromboembolic events, neutropenia, and proteinuria.

The ZALTRAP dose was reduced and/or omitted in 17% of patients compared to placebo-dose modification in 5% of patients. Cycle delays > 7 days occurred in 60% of patients treated with ZALTRAP/FOLFIRI compared with 43% of patients treated with placebo/FOLFIRI.

The most common adverse reactions and laboratory abnormalities during study treatment in Study 1 where the incidence was ≥ 5% (all grades) in patients receiving ZALTRAP in combination with FOLFIRI and which occurred at ≥ 2% higher frequency in patients treated with ZALTRAP/FOLFIRI compared to placebo/FOLFIRI are shown in Table 1.

Table 1: Selected Adverse Reactions and Laboratory Findings in Study 1

Primary System Organ Class Preferred Term (%) Placebo/ FOLFIRI
All grades Grades 3-4 All grades Grades 3
Infections and infestations
  Urinary Tract Infection 6% 0.8% 9% 0.8%
Blood and lymphatic system disorders
  Leukopenia 72% 12% 78% 16%
  Neutropenia 57% 30% 67% 37%
  Thrombocytopenia 35% 2% 48% 3%
Metabolism and nutrition disorders
  Decreased Appetite 24% 2% 32% 3%
  Dehydration 3% 1% 9% 4%
Nervous system disorders
  Headache 9% 0.3% 22% 2%
Vascular disorders
  Hypertension 11% 1.5% 41% 19%
Respiratory, thoracic and mediastinal disorders
  Epistaxis 7% 0 28% 0.2%
  Dysphonia 3% 0 25% 0.5%
  Dyspnea 9% 0.8% 12% 0.8%
  Oropharyngeal Pain 3% 0 8% 0.2%
  Rhinorrhea 2% 0 6% 0
Gastrointestinal disorders
  Diarrhea 57% 8% 69% 19%
  Stomatitis 33% 5% 50% 13%
  Abdominal Pain 24% 2% 27% 4%
  Abdominal Pain Upper 8% 1% 11% 1%
  Hemorrhoids 2% 0 6% 0
  Rectal Hemorrhage 2% 0.5% 5% 0.7%
  Proctalgia 2% 0.3% 5% 0.3%
Skin and subcutaneous tissue disorders
  Palmar-Plantar Erythrodysesthesia Syndrome 4% 0.5% 11% 3%
  Skin Hyperpigmentation 3% 0 8% 0
Renal and urinary disorders
  Proteinuria* 41% 1% 62% 8%
  Serum creatinine increased 19% 0.5% 23% 0
General disorders and administration site conditions
  Fatigue 39% 8% 48% 13%
  Asthenia 13% 3% 18% 5%
  AST increased 54% 2% 62% 3%
  ALT increased 39% 2% 50% 3%
  Weight decreased 14% 0.8% 32% 3%
Note: Adverse Reactions are reported using MedDRA version MEDDRA13.1 and graded using NCI CTC version 3.0
* Compilation of clinical and laboratory data

Infections occurred at a higher frequency in patients receiving ZALTRAP/FOLFIRI (46%, all grades; 12%, Grade 3-4) than in patients receiving placebo/FOLFIRI (33%, all grades; 7%, Grade 3-4), including urinary tract infection, nasopharyngitis, upper respiratory tract infection, pneumonia, catheter site infection, and tooth infection.

In patients with mCRC, severe hypersensitivity reactions have been reported with ZALTRAP/FOLFIRI (0.3%) and placebo/FOLFIRI (0.5%).

In patients with mCRC, venous thromboembolic events (VTE), consisting primarily of deep venous thrombosis and pulmonary embolism, occurred in 9% of patients treated with ZALTRAP/FOLFIRI and 7% of patients treated with placebo/FOLFIRI. Grade 3-4 VTE occurred in 8% of patients treated with ZALTRAP/FOLFIRI and in 6% of patients treated with placebo/FOLFIRI. Pulmonary embolism occurred in 5% of patients treated with ZALTRAP/FOLFIRI and 3.4% of patients treated with placebo/FOLFIRI.


As with all therapeutic proteins, there is a potential for immunogenicity. In patients with various cancers across 15 studies, 1.4% (41/2862) of patients tested positive for anti-product antibody (APA) at baseline. The incidence of APA development was 3.1% (53/1687) in patients receiving intravenous ziv-aflibercept and 1.7% (19/1134) in patients receiving placebo. Among patients who tested positive for APA and had sufficient samples for further testing, neutralizing antibodies were detected in 17 of 48 ziv-aflibercept-treated patients and in 2 of 40 patients receiving placebo.

The mean free ziv-aflibercept trough concentrations were lower in patients with positive neutralizing antibodies than in the overall population. The impact of neutralizing antibodies on efficacy and safety could not be assessed based on limited available data.

Immunogenicity data are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to ZALTRAP with the incidence of antibodies to other products may be misleading.

Read the entire FDA prescribing information for Zaltrap (Ziv-Aflibercept Injection for Intravenous Infusion) »


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