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Ogivri

Last reviewed on RxList: 7/11/2019
Ogivri Side Effects Center

Medical Editor: John P. Cunha, DO, FACOEP

Last reviewed on RxList 7/11/2019

Ogivri (trastuzumab-dkst) is a HER2/neu receptor antagonist indicated for the treatment of HER2-overexpressing breast cancer, and the treatment of HER2-overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma. Common side effects of Ogivri include:

Dose of Ogivri depends on the condition being treated. Ogivri may interact with anthracycline. Tell your doctor all medications and supplements you use. Ogivri is not recommended for use during pregnancy; it may harm a fetus. Use effective contraception during treatment with Ogivri and for 7 months following the last dose. It is unknown if Ogivri passes into breast milk. Consult your doctor before breastfeeding.

Our Ogivri (trastuzumab-dkst) for Injection, for Intravenous Use Side Effects Drug 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.

QUESTION

A lump in the breast is almost always cancer. See Answer
Ogivri Professional Information

SIDE EFFECTS

The following adverse reactions are discussed in greater detail in other sections of the label:

  • Cardiomyopathy [see WARNINGS AND PRECAUTIONS]
  • Infusion Reactions [see WARNINGS AND PRECAUTIONS]
  • Embryo-Fetal Toxicity [see WARNINGS AND PRECAUTIONS]
  • Pulmonary Toxicity [see WARNINGS AND PRECAUTIONS]
  • Exacerbation of Chemotherapy-induced Neutropenia [see WARNINGS AND PRECAUTIONS]

The most common adverse reactions in patients receiving trastuzumab products in the adjuvant and metastatic breast cancer setting are fever, nausea, vomiting, infusion reactions, diarrhea, infections, increased cough, headache, fatigue, dyspnea, rash, neutropenia, anemia, and myalgia. Adverse reactions requiring interruption or discontinuation of trastuzumab product treatment include CHF, significant decline in left ventricular cardiac function, severe infusion reactions, and pulmonary toxicity [see DOSAGE AND ADMINISTRATION].

In the metastatic gastric cancer setting, the most common adverse reactions (≥ 10%) that were increased (≥ 5% difference) in patients receiving trastuzumab as compared to patients receiving chemotherapy alone were neutropenia, diarrhea, fatigue, anemia, stomatitis, weight loss, upper respiratory tract infections, fever, thrombocytopenia, mucosal inflammation, nasopharyngitis, and dysgeusia. The most common adverse reactions which resulted in discontinuation of trastuzumab treatment in the absence of disease progression were infection, diarrhea, and febrile neutropenia.

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adjuvant Breast Cancer Studies

The data below reflect exposure to one-year trastuzumab therapy across three randomized, openlabel studies, Studies 1, 2, and 3, with (n = 3678) or without (n = 3363) trastuzumab in the adjuvant treatment of breast cancer.

The data summarized in Table 3 below, from Study 3, reflect exposure to trastuzumab in 1678 patients; the median treatment duration was 51 weeks and median number of infusions was 18. Among the 3386 patients enrolled in the observation and one-year trastuzumab arms of Study 3 at a median duration of follow-up of 12.6 months in the trastuzumab arm, the median age was 49 years (range: 21 to 80 years), 83% of patients were Caucasian, and 13% were Asian.

Table 3: Adverse Reactions for Study 3a, All Gradesb

Adverse Reaction One year Trastuzumab
(n = 1678)
Observation
(n = 1708)
Cardiac
Hypertension 64 (4%) 35 (2%)
Dizziness 60 (4%) 29 (2%)
Ejection Fraction Decreased 58 (3.5%) 11 (0.6%)
Palpitations 48 (3%) 12 (0.7%)
Cardiac Arrhythmiasc 40 (3%) 17 (1%)
Cardiac Failure Congestive 30 (2%) 5 (0.3%)
Cardiac Failure 9 (0.5%) 4 (0.2%)
Cardiac Disorder 5 (0.3%) 0 (0%)
Ventricular Dysfunction 4 (0.2%) 0 (0%)
Respiratory Thoracic Mediastinal Disorders
Cough 81 (5%) 34 (2%)
Influenza 70 (4%) 9 (0.5%)
Dyspnea 57 (3%) 26 (2%)
URI 46 (3%) 20 (1%)
Rhinitis 36 (2%) 6 (0.4%)
Pharyngolaryngeal Pain 32 (2%) 8 (0.5%)
Sinusitis 26 (2%) 5 (0.3%)
Epistaxis 25 (2%) 1 (0.06%)
Pulmonary Hypertension 4 (0.2%) 0 (0%)
Interstitial Pneumonitis 4 (0.2%) 0 (0%)
Gastrointestinal Disorders
Diarrhea 123 (7%) 16 (1%)
Nausea 108 (6%) 19 (1%)
Vomiting 58 (3.5%) 10 (0.6%)
Constipation 33 (2%) 17 (1%)
Dyspepsia 30 (2%) 9 (0.5%)
Upper Abdominal Pain 29 (2%) 15 (1%)
Musculoskeletal & Connective Tissue Disorders
Arthralgia 137 (8%) 98 (6%)
Back Pain 91 (5%) 58 (3%)
Myalgia 63 (4%) 17 (1%)
Bone Pain 49 (3%) 26 (2%)
Muscle Spasm 46 (3%) 3 (0.2%)
Nervous System Disorders
Headache 162 (10%) 49 (3%)
Paraesthesia 29 (2%) 11 (0.6%)
Skin & Subcutaneous Tissue Disorders
Rash 70 (4%) 10 (0.6%)
Nail Disorders 43 (2%) 0 (0%)
Pruritus 40 (2%) 10 (0.6%)
General Disorders
Pyrexia 100 (6%) 6 (0.4%)
Edema Peripheral 79 (5%) 37 (2%)
Chills 85 (5%) 0 (0%)
Asthenia 75 (4.5%) 30 (2%)
Influenza-like Illness 40 (2%) 3 (0.2%)
Sudden Death 1 (0.06%) 0 (0%)
Infections
Nasopharyngitis 135 (8%)  
UTI 39 (3%)  
Immune System Disorders
Hypersensitivity 10 (0.6%) 1 (0.06%)
Autoimmune Thyroiditis 4 (0.3%) 0 (0%)
aMedian follow-up duration of 12.6 months in the one-year trastuzumab treatment arm.
bThe incidence of Grade 3 or higher adverse reactions was < 1% in both arms for each listed term.
cHigher level grouping term.

In Study 3, a comparison of 3-weekly trastuzumab treatment for two years versus one year was also performed. The rate of asymptomatic cardiac dysfunction was increased in the 2-year trastuzumab treatment arm (8.1% versus 4.6% in the one-year trastuzumab treatment arm). More patients experienced at least one adverse reaction of Grade 3 or higher in the 2-year trastuzumab treatment arm (20.4%) compared with the one-year trastuzumab treatment arm (16.3%).

The safety data from Studies 1 and 2 were obtained from 3655 patients, of whom 2000 received trastuzumab; the median treatment duration was 51 weeks. The median age was 49 years (range: 24 to 80); 84% of patients were White, 7% Black, 4% Hispanic, and 3% Asian.

In Study 1, only Grade 3 to 5 adverse events, treatment-related Grade 2 events, and Grade 2-5 dyspnea were collected during and for up to 3 months following protocol-specified treatment. The following non-cardiac adverse reactions of Grade 2 to 5 occurred at an incidence of at least 2% greater among patients receiving trastuzumab plus chemotherapy as compared to chemotherapy alone: fatigue (29.5% vs. 22.4%), infection (24.0% vs. 12.8%), hot flashes (17.1% vs. 15.0%), anemia (12.3% vs. 6.7%), dyspnea (11.8% vs. 4.6%), rash/desquamation (10.9% vs. 7.6%), leukopenia (10.5% vs. 8.4%), neutropenia (6.4% vs. 4.3%), headache (6.2% vs. 3.8%), pain (5.5% vs. 3.0%), edema (4.7% vs. 2.7%) and insomnia (4.3% vs. 1.5%). The majority of these events were Grade 2 in severity.

In Study 2, data collection was limited to the following investigator-attributed treatment-related adverse reactions: NCI-CTC Grade 4 and 5 hematologic toxicities, Grade 3 to 5 non-hematologic toxicities, selected Grade 2 to 5 toxicities associated with taxanes (myalgia, arthralgias, nail changes, motor neuropathy, sensory neuropathy) and Grade 1 to 5 cardiac toxicities occurring during chemotherapy and/or trastuzumab treatment. The following non-cardiac adverse reactions of Grade 2 to 5 occurred at an incidence of at least 2% greater among patients receiving trastuzumab plus chemotherapy as compared to chemotherapy alone: arthralgia (12.2% vs. 9.1%), nail changes (11.5% vs.6.8%), dyspnea (2.4% vs. 0.2%), and diarrhea (2.2% vs. 0%). The majority of these events were Grade 2 in severity.

Safety data from Study 4 reflect exposure to trastuzumab as part of an adjuvant treatment regimen from 2124 patients receiving at least one dose of study treatment [AC-TH: n = 1068; TCH: n = 1056]. The overall median treatment duration was 54 weeks in both the AC-TH and TCH arms. The median number of infusions was 26 in the AC-TH arm and 30 in the TCH arm, including weekly infusions during the chemotherapy phase and every three week dosing in the monotherapy period. Among these patients, the median age was 49 years (range 22 to 74 years). In Study 4, the toxicity profile was similar to that reported in Studies 1, 2, and 3 with the exception of a low incidence of CHF in the TCH arm.

Metastatic Breast Cancer Studies

The data below reflect exposure to trastuzumab in one randomized, open-label study, Study 5, of chemotherapy with (n = 235) or without (n = 234) trastuzumab in patients with metastatic breast cancer, and one single-arm study (Study 6; n = 222) in patients with metastatic breast cancer. Data in Table 4 are based on Studies 5 and 6.

Among the 464 patients treated in Study 5, the median age was 52 years (range: 25 to 77 years). Eighty-nine percent were White, 5% Black, 1% Asian and 5% other racial/ethnic groups. All patients received 4 mg/kg initial dose of trastuzumab followed by 2 mg/kg weekly. The percentages of patients who received trastuzumab treatment for ≥6 months and ≥12 months were 58% and 9%, respectively.

Among the 352 patients treated in single agent studies (213 patients from Study 6), the median age was 50 years (range 28 to 86 years), 86% were White, 3% were Black, 3% were Asian, and 8% in other racial/ethnic groups. Most of the patients received 4 mg/kg initial dose of trastuzumab followed by 2 mg/kg weekly. The percentages of patients who received trastuzumab treatment for ≥6 months and ≥12 months were 31% and 16%, respectively.

Table 4: Per-Patient Incidence of Adverse Reactions Occurring in ≥5% of Patients in Uncontrolled Studies or at Increased Incidence in the Trastuzumab Arm (Studies 5 and 6)

  Single Agenta
n = 352
Trastuzumab + Paclitaxel
n = 91
Paclitaxel Alone
n = 95
Trastuzumab + ACb
n = 143
ACb Alone
n = 135
Body as a Whole
Pain 47% 61% 62% 57% 42%
Asthenia 42% 62% 57% 54% 55%
Fever 36% 49% 23% 56% 34%
Chills 32% 41% 4% 35% 11%
Headache 26% 36% 28% 44% 31%
Abdominal pain 22% 34% 22% 23% 18%
Back pain 22% 34% 30% 27% 15%
Infection 20% 47% 27% 47% 31%
Flu syndrome 10% 12% 5% 12% 6%
Accidental injury 6% 13% 3% 9% 4%
Allergic reaction 3% 8% 2% 4% 2%
Cardiovascular
Tachycardia 5% 12% 4% 10% 5%
Congestive heart failure 7% 11% 1% 28% 7%
Digestive
Nausea 33% 51% 9% 76% 77%
Diarrhea 25% 45% 29% 45% 26%
Vomiting 23% 37% 28% 53% 49%
Nausea and vomiting 8% 14% 11% 18% 9%
Anorexia 14% 24% 16% 31% 26%
Heme & Lymphatic
Anemia 4% 14% 9% 36% 26%
Leukopenia 3% 24% 17% 52% 34%
Metabolic
Peripheral edema 10% 22% 20% 20% 17%
Edema 8% 10% 8% 11% 5%
Musculoskeletal
Bone pain 7% 24% 18% 7% 7%
Arthralgia 6% 37% 21% 8% 9%
Nervous
Insomnia 14% 25% 13% 29% 15%
Dizziness 13% 22% 24% 24% 18%
Paresthesia 9% 48% 39% 17% 11%
Depression 6% 12% 13% 20% 12%
Peripheral neuritis 2% 23% 16% 2% 2%
Neuropathy 1% 13% 5% 4% 4%
Respiratory
Cough increased 26% 41% 22% 43% 29%
Dyspnea 22% 27% 26% 42% 25%
Rhinitis 14% 22% 5% 22% 16%
Pharyngitis 12% 22% 14% 30% 18%
Sinusitis 9% 21% 7% 13% 6%
Skin
Rash 18% 38% 18% 27% 17%
Herpes simplex 2% 12% 3% 7% 9%
Acne 2% 11% 3% 3% < 1%
Urogenital
Urinary tract infection 5% 18% 14% 13% 7%
aData for Trastuzumab single agent were from 4 studies, including 213 patients from Study 6.
bAnthracycline (doxorubicin or epirubicin) and cyclophosphamide.

Metastatic Gastric Cancer

The data below are based on the exposure of 294 patients to trastuzumab in combination with a fluoropyrimidine (capecitabine or 5-FU) and cisplatin (Study 7). In the trastuzumab plus chemotherapy arm, the initial dose of trastuzumab 8 mg/kg was administered on Day 1 (prior to chemotherapy) followed by 6 mg/kg every 21 days until disease progression. Cisplatin was administered at 80 mg/m² on Day 1 and the fluoropyrimidine was administered as either capecitabine 1000 mg/m² orally twice a day on Days 1 to14 or 5-fluorouracil 800 mg/m²/day as a continuous intravenous infusion Days 1 through 5. Chemotherapy was administered for six 21 day cycles. Median duration of trastuzumab treatment was 21 weeks; median number of trastuzumab infusions administered was eight.

Table 5: Study 7: Per Patient Incidence of Adverse Reactions of All Grades (Incidence ≥ 5% between Arms) or Grade 3/4 (Incidence > 1 % between Arms) and Higher Incidence in Trastuzumab Arm

Body System/Adverse Event Trastuzumab + FC
(N = 294) N (%)
FC
(N = 290) N (%)
All Grades Grades 3/4 All Grades Grades 3/4
Investigations
Neutropenia 230 (78) 101 (34) 212 (73) 83 (29)
Hypokalemia 83 (28) 28 (10) 69 (24) 16 (6)
Anemia 81 (28) 36 (12) 61 (21) 30 (10)
Thrombocytopenia 47 (16) 14 (5) 33 (11) 8 (3)
Blood and Lymphatic System Disorders
Febrile Neutropenia - 15 (5) - 8 (3)
Gastrointestinal Disorders
Diarrhea 109 (37) 27 (9) 80 (28) 11 (4)
Stomatitis 72 (24) 2 (1) 43 (15) 6 (2)
Dysphagia 19 (6) 7 (2) 10 (3) 1 (< 1)
Body as a Whole
Fatigue 102 (35) 12 (4) 82 (28) 7 (2)
Fever 54 (18) 3 (1) 36 (12) 0 (0)
Mucosal Inflammation 37(13) 6 (2) 18 (6) 2 (1)
Chills 23 (8) 1 (< 1) 0 (0) 0 (0)
Metabolism and Nutrition Disorders
Weight Decrease 69(23) 6 (2) 40 (14) 7 (2)
Infections and Infestations
Upper Respiratory Tract Infections 56 (19) 0 (0) 29 (10) 0 (0)
Nasopharyngitis 37(13) 0 (0) 17 (6) 0 (0)
Renal and Urinary Disorders
Renal Failure and Impairment 53 (18) 8 (3) 42 (15) 5 (2)
Nervous System Disorders
Dysgeusia 28 (10) 0 (0) 14 (5) 0 (0)

The following subsections provide additional detail regarding adverse reactions observed in clinical trials of adjuvant breast cancer, metastatic breast cancer, metastatic gastric cancer, or post-marketing experience.

Cardiomyopathy

Serial measurement of cardiac function (LVEF) was obtained in clinical trials in the adjuvant treatment of breast cancer. In Study 3, the median duration of follow-up was 12.6 months (12.4 months in the observation arm; 12.6 months in the 1-year trastuzumab arm); and in Studies 1 and 2, 7.9 years in the AC-T arm, 8.3 years in the AC-TH arm. In Studies 1 and 2, 6% of all randomized patients with post-AC LVEF evaluation were not permitted to initiate trastuzumab following completion of AC chemotherapy due to cardiac dysfunction (LVEF < LLN or ≥ 16 point decline in LVEF from baseline to end of AC). Following initiation of trastuzumab therapy, the incidence of new-onset dose-limiting myocardial dysfunction was higher among patients receiving trastuzumab and paclitaxel as compared to those receiving paclitaxel alone in Studies 1 and 2, and in patients receiving one-year trastuzumab monotherapy compared to observation in Study 3 (see Table 6, Figures 1 and 2). The per-patient incidence of new-onset cardiac dysfunction, as measured by LVEF, remained similar when compared to the analysis performed at a median follow-up of 2.0 years in the AC-TH arm. This analysis also showed evidence of reversibility of left ventricular dysfunction, with 64.5% of patients who experienced symptomatic CHF in the AC-TH group being asymptomatic at latest follow-up, and 90.3% having full or partial LVEF recovery.

Table 6a: Per-patient Incidence of New Onset Myocardial Dysfunction (by LVEF) Studies 1, 2, 3 and 4

  LVEF <50% and Absolute Decrease from Baseline Absolute LVEF Decrease
LVEF < 50% ≥ 10% decrease ≥ 16% decrease < 20% and ≥ 10% ≥20%
Studies 1 & 2b,c
AC → TH (n =1856) 23.1% (428) 18.5% (344) 11.2% (208) 37.9% (703) 8.9% (166)
AC → T (n =1170) 11.7% (137) 7.0% (82) 3.0% (35) 22.1% (259) 3.4% (40)
Study 3d
Trastuzumab (n =1678) 8.6% (144) 7.0% (118) 3.8% (64) 22.4% (376) 3.5% (59)
Observation (n =1708) 2.7% (46) 2.0% (35) 1.2% (20) 11.9% (204) 1.2% (21)
Study 4e
TCH(n =1056) 8.5% (90) 5.9% (62) 3.3% (35) 34.5% (364) 6.3% (67)
AC → TH(n =1068) 17% (182) 13.3% (142) 9.8% (105) 44.3% (473) 13.2% (141)
AC → T(n =1050) 9.5% (100) 6.6% (69) 3.3% (35) 34% (357) 5.5% (58)
a For Studies 1, 2 and 3, events are counted from the beginning of trastuzumab treatment. For Study 4, events are counted from the date of randomization.
bStudies 1 and 2 regimens: doxorubicin and cyclophosphamide followed by paclitaxel (AC → T) or paclitaxel plus trastuzumab (AC → TH).
cMedian duration of follow-up for Studies 1 and 2 combined was 8.3 years in the AC → TH arm.
dMedian follow-up duration of 12.6 months in the one-year trastuzumab treatment arm.
e Study 4 regimens: doxorubicin and cyclophosphamide followed by docetaxel (AC → T) or docetaxel plus trastuzumab (AC → TH); docetaxel and carboplatin plus trastuzumab (TCH).

Figure 1: Studies 1 and 2: Cumulative Incidence of Time to First LVEF Decline of ≥ 10 Percentage Points from Baseline and to Below 50% with Death as a Competing Risk Event

Studies 1 and 2: Cumulative Incidence of
Time to First LVEF Decline of ≥ 10 Percentage Points from Baseline
and to Below 50% with Death as a Competing Risk Event - Illustration

Time 0 is initiation of paclitaxel or trastuzumab + paclitaxel therapy.

Figure 2: Study 3: Cumulative Incidence of Time to First LVEF Decline of ≥ 10 Percentage Points from Baseline and to Below 50% with Death as a Competing Risk Event

Study 3: Cumulative Incidence of Time to
First LVEF Decline of ≥ 10 Percentage Points from Baseline and to Below
50% with Death as a Competing Risk Event  - Illustration

Time 0 is the date of randomization.

Figure 3: Study 4: Cumulative Incidence of Time to First LVEF Decline of ≥ 10 Percentage Points from Baseline and to Below 50% with Death as a Competing Risk Event

 Cumulative Incidence of Time to
First LVEF Decline of ≥ 10 Percentage Points from Baseline and to Below
50% with Death as a Competing Risk Event  - Illustration

Time 0 is the date of randomization.

The incidence of treatment emergent congestive heart failure among patients in the metastatic breast cancer trials was classified for severity using the New York Heart Association classification system (I-IV, where IV is the most severe level of cardiac failure) (see Table 2). In the metastatic breast cancer trials, the probability of cardiac dysfunction was highest in patients who received trastuzumab concurrently with anthracyclines.

In Study 7, 5.0% of patients in the trastuzumab plus chemotherapy arm compared to 1.1% of patients in the chemotherapy alone arm had LVEF value below 50% with a ≥ 10% absolute decrease in LVEF from pretreatment values.

Infusion Reactions

During the first infusion with trastuzumab, the symptoms most commonly reported were chills and fever, occurring in approximately 40% of patients in clinical trials. Symptoms were treated with acetaminophen, diphenhydramine, and meperidine (with or without reduction in the rate of trastuzumab infusion); permanent discontinuation of trastuzumab for infusion reactions was required in < 1% of patients. Other signs and/or symptoms may include nausea, vomiting, pain (in some cases at tumor sites), rigors, headache, dizziness, dyspnea, hypotension, elevated blood pressure, rash, and asthenia. Infusion reactions occurred in 21% and 35% of patients, and were severe in 1.4% and 9% of patients, on second or subsequent trastuzumab infusions administered as monotherapy or in combination with chemotherapy, respectively. In the post-marketing setting, severe infusion reactions, including hypersensitivity, anaphylaxis, and angioedema have been reported.

Anemia

In randomized controlled clinical trials, the overall incidence of anemia (30% vs. 21% [Study 5]), of selected NCI-CTC Grade 2 to 5 anemia (12.3% vs. 6.7% [Study 1]), and of anemia requiring transfusions (0.1% vs. 0 patients [Study 2]) were increased in patients receiving trastuzumab and chemotherapy compared with those receiving chemotherapy alone. Following the administration of trastuzumab as a single agent (Study 6), the incidence of NCI-CTC Grade 3 anemia was < 1%. In Study 7 (metastatic gastric cancer), on the trastuzumab containing arm as compared to the chemotherapy alone arm, the overall incidence of anemia was 28% compared to 21% and of NCICTC Grade 3/4 anemia was 12.2% compared to 10.3%.

Neutropenia

In randomized controlled clinical trials in the adjuvant setting, the incidence of selected NCI-CTC Grade 4 to 5 neutropenia (1.7% vs. 0.8% [Study 2]) and of selected Grade 2 to 5 neutropenia (6.4% vs. 4.3% [Study 1]) were increased in patients receiving trastuzumab and chemotherapy compared with those receiving chemotherapy alone. In a randomized, controlled trial in patients with metastatic breast cancer, the incidences of NCI-CTC Grade 3/4 neutropenia (32% vs. 22%) and of febrile neutropenia (23% vs. 17%) were also increased in patients randomized to trastuzumab in combination with myelosuppressive chemotherapy as compared to chemotherapy alone. In Study 7 (metastatic gastric cancer) on the trastuzumab containing arm as compared to the chemotherapy alone arm, the incidence of NCI-CTC Grade 3/4 neutropenia was 36.8% compared to 28.9%; febrile neutropenia 5.1% compared to 2.8%.

Infection

The overall incidences of infection (46% vs. 30% [Study 5]), of selected NCI-CTC Grade 2 to 5 infection/febrile neutropenia (24.3% vs. 13.4% [Study 1]) and of selected Grade 3 to 5 infection/febrile neutropenia (2.9% vs. 1.4%) [Study 2]) were higher in patients receiving trastuzumab and chemotherapy compared with those receiving chemotherapy alone. The most common site of infections in the adjuvant setting involved the upper respiratory tract, skin, and urinary tract.

In Study 4, the overall incidence of infection was higher with the addition of trastuzumab to AC-T but not to TCH [44% (AC-TH), 37% (TCH), 38% (AC-T)]. The incidences of NCI-CTC Grade 3 to 4 infection were similar [25% (AC-TH), 21% (TCH), 23% (AC-T)] across the three arms.

In a randomized, controlled trial in treatment of metastatic breast cancer, the reported incidence of febrile neutropenia was higher (23% vs. 17%) in patients receiving trastuzumab in combination with myelosuppressive chemotherapy as compared to chemotherapy alone.

Pulmonary Toxicity

Adjuvant Breast Cancer

Among women receiving adjuvant therapy for breast cancer, the incidence of selected NCI-CTC Grade 2 to 5 pulmonary toxicity (14.3% vs. 5.4% [Study 1]) and of selected NCI-CTC Grade 3 to 5 pulmonary toxicity and spontaneous reported Grade 2 dyspnea (3.4 % vs. 0.9% [Study 2]) was higher in patients receiving trastuzumab and chemotherapy compared with chemotherapy alone. The most common pulmonary toxicity was dyspnea (NCI-CTC Grade 2 to 5: 11.8% vs. 4.6% [Study 1]; NCI-CTC Grade 2 to 5: 2.4% vs. 0.2% [Study 2]).

Pneumonitis/pulmonary infiltrates occurred in 0.7% of patients receiving trastuzumab compared with 0.3% of those receiving chemotherapy alone. Fatal respiratory failure occurred in 3 patients receiving trastuzumab, one as a component of multi-organ system failure, as compared to 1 patient receiving chemotherapy alone.

In Study 3, there were 4 cases of interstitial pneumonitis in the one-year trastuzumab treatment arm compared to none in the observation arm at a median follow-up duration of 12.6 months.

Metastatic Breast Cancer

Among women receiving trastuzumab for treatment of metastatic breast cancer, the incidence of pulmonary toxicity was also increased. Pulmonary adverse events have been reported in the postmarketing experience as part of the symptom complex of infusion reactions. Pulmonary events include bronchospasm, hypoxia, dyspnea, pulmonary infiltrates, pleural effusions, noncardiogenic pulmonary edema, and acute respiratory distress syndrome. For a detailed description, see WARNINGS AND PRECAUTIONS.

Thrombosis/Embolism

In 4 randomized, controlled clinical trials, the incidence of thrombotic adverse events was higher in patients receiving trastuzumab and chemotherapy compared to chemotherapy alone in three studies (2.6% vs. 1.5% [Study 1], 2.5% and 3.7% vs. 2.2% [Study 4] and 2.1% vs. 0% [Study 5]).

Diarrhea

Among women receiving adjuvant therapy for breast cancer, the incidence of NCI-CTC Grade 2 to 5 diarrhea (6.7% vs. 5.4% [Study 1]) and of NCI-CTC Grade 3 to 5 diarrhea (2.2% vs. 0% [Study 2]), and of Grade 1 to 4 diarrhea (7% vs. 1% [Study 3; one-year trastuzumab treatment at 12.6 months median duration of follow-up]) were higher in patients receiving trastuzumab as compared to controls. In Study 4, the incidence of Grade 3 to 4 diarrhea was higher [5.7% ACTH, 5.5% TCH vs. 3.0% AC-T] and of Grade 1 to 4 was higher [51% AC-TH, 63% TCH vs. 43% AC-T] among women receiving trastuzumab. Of patients receiving trastuzumab as a single agent for the treatment of metastatic breast cancer, 25% experienced diarrhea. An increased incidence of diarrhea was observed in patients receiving trastuzumab in combination with chemotherapy for treatment of metastatic breast cancer.

Renal Toxicity

In Study 7 (metastatic gastric cancer) on the trastuzumab-containing arm as compared to the chemotherapy alone arm the incidence of renal impairment was 18% compared to 14.5%. Severe (Grade 3/4) renal failure was 2.7% on the trastuzumab-containing arm compared to 1.7% on the chemotherapy only arm. Treatment discontinuation for renal insufficiency/failure was 2% on the trastuzumab-containing arm and 0.3% on the chemotherapy only arm.

In the post-marketing setting, rare cases of nephrotic syndrome with pathologic evidence of glomerulopathy have been reported. The time to onset ranged from 4 months to approximately 18 months from initiation of trastuzumab therapy. Pathologic findings included membranous glomerulonephritis, focal glomerulosclerosis, and fibrillary glomerulonephritis. Complications included volume overload and congestive heart failure.

Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and the specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies in the studies described below with the incidence of antibodies in other studies or to other trastuzumab products may be misleading.

Among 903 women with metastatic breast cancer, human anti-human antibody (HAHA) to trastuzumab was detected in one patient using an enzyme-linked immunosorbent assay (ELISA). This patient did not experience an allergic reaction. Samples for assessment of HAHA were not collected in studies of adjuvant breast cancer.

Post-Marketing Experience

The following adverse reactions have been identified during post-approval use of trastuzumab. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

  • Infusion reaction [see WARNINGS AND PRECAUTIONS]
  • Oligohydramnios or oligohydramnios sequence, including pulmonary hypoplasia, skeletal abnormalities, and neonatal death [see WARNINGS AND PRECAUTIONS]
  • Glomerulopathy [see ADVERSE REACTIONS]
  • Immune thrombocytopenia
  • Tumor lysis syndrome (TLS): Cases of possible TLS have been reported in patients treated with trastuzumab products. Patients with significant tumor burden (e.g. bulky metastases) may be at a higher risk. Patients could present with hyperuricemia, hyperphosphatemia, and acute renal failure which may represent possible TLS. Providers should consider additional monitoring and/or treatment as clinically indicated.

Read the entire FDA prescribing information for Ogivri (Trastuzumab-Dkst Injection, for Intravenous Use)

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