Cablivi Drug Information

is indicated for the treatment of adult and pediatric patients 12 years of age and older with acquired thrombotic thrombocytopenic purpura (aTTP), in combination with plasma exchange and immunosuppressive therapy. CABLIVI is a von Willebrand factor (vWF)-directed antibody fragment indicated for the treatment of adult and pediatric patients 12 years of age and older with acquired thrombotic thrombocytopenic purpura (aTTP), in combination with plasma exchange and immunosuppressive therapy.

Recommended Dose and Schedules

CABLIVI should be administered upon initiation of plasma exchange therapy. The recommended dose of CABLIVI is as follows: First day of treatment : 11 mg bolus intravenous injection at least 15 minutes prior to plasma exchange followed by an 11 mg subcutaneous injection after completion of plasma exchange on day 1. Subsequent days of treatment during daily plasma exchange : 11 mg subcutaneous injection once daily following plasma exchange. Treatment after plasma exchange period : 11 mg subcutaneous injection once daily continuing for 30 days following the last daily plasma exchange.

If after initial treatment course, sign(s) of persistent underlying disease such as suppressed ADAMTS13 activity levels remain present, treatment may be extended for a maximum of 28 days. Discontinue CABLIVI if the patient experiences more than 2 recurrences of aTTP, while on CABLIVI. Avoid concomitant use of antiplatelet agents or anticoagulants. Missed Dose Administer the first dose of CABLIVI intravenously before the initial plasma exchange.

If the administration of the first intravenous dose of CABLIVI is missed and plasma exchange is already administered, administer the first CABLIVI dose intravenously and administer the next dose subcutaneously on the following day according to the usual dosing schedule. If a dose of CABLIVI is missed during the plasma exchange period, it should be given as soon as possible. If a dose of CABLIVI is missed after the plasma exchange period, it can be administered within 12 hours of the scheduled time of administration.

Beyond 12 hours, the missed dose should be skipped and the next daily dose administered according to the usual dosing schedule.

Discontinuation for Surgery and Other Interventions Withhold

CABLIVI treatment 7 days prior to elective surgery, dental procedures, or other invasive interventions .

Reconstitution and

Administration Instructions The first dose of CABLIVI should be administered by a healthcare provider as a bolus intravenous injection. Administer subsequent doses subcutaneously in the abdomen. Avoid injections around the navel.

Do not administer consecutive injections in the same abdominal quadrant. Adult patients may self-inject, or adult caregivers may inject CABLIVI subcutaneously after proper instruction on the preparation and administration of CABLIVI, including aseptic technique if a healthcare provider determines that it is appropriate. In pediatric patients 12 years of age and older, CABLIVI must be administered by a healthcare provider or an adult caregiver.

If the carton was not stored at room temperature, allow the CABLIVI vial and diluent syringe to reach room temperature by holding them in your hands for 10 seconds. Do not use any other way to warm up the vial and syringe. Reconstitute CABLIVI before administration using the provided syringe containing 1 mL Sterile Water for Injection, USP, to yield an 11 mg/mL single-dose solution.

Using aseptic technique throughout the preparation of the solution, attach the vial adapter to the vial containing CABLIVI. Remove the plastic cap from the syringe and attach it to the vial adapter by twisting it clockwise until it cannot twist any further. Slowly push the syringe plunger down until the syringe is empty. Do not remove the syringe from the vial adapter.

Gently swirl the vial until the cake or powder is completely dissolved. Do not shake. Visually inspect that the reconstituted solution is clear and colorless.

Withdraw all of the clear, colorless reconstituted solution from the vial into the syringe. Label the CABLIVI syringe. Administer the full amount of reconstituted solution.

For the initial intravenous injection, if using an intravenous line, the glass syringe should be connected to a standard Luer lock and flushed with either 0.9% Sodium Chloride Injection, USP, or 5% Dextrose Injection, USP. Use the CABLIVI solution immediately. If not, use CABLIVI within 4 hours after reconstitution when stored in the refrigerator at 2°C to 8°C (36°F to 46°F).

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. TITAN and HERCULES The safety of CABLIVI was evaluated in two placebo-controlled clinical studies (HERCULES, in which 71 patients received CABLIVI; and TITAN, in which 35 patients received CABLIVI). The data described below and in the Warnings and Precautions reflect exposure to CABLIVI during the blinded periods of both studies, which include 106 patients with aTTP who received at least one dose, age 18 to 79 years, of whom 69% were female and 73% were White. The median treatment duration with CABLIVI was 35 days (range 1–77 days). The most frequently reported adverse reactions (>15%) were epistaxis, headache and gingival bleeding.

Seven patients (7%) in the CABLIVI group experienced an adverse reaction leading to study drug discontinuation. None of the adverse reactions leading to discontinuation were observed in more than 1% of patients. Among 106 patients treated with CABLIVI during the TITAN and HERCULES studies, serious bleeding adverse reactions reported in ≥2% patients included epistaxis (4%) and subarachnoid hemorrhage (2%). Adverse reactions that occurred in ≥2% of patients treated with CABLIVI and more frequently than in those treated with placebo across the pooled data from the two trials are summarized in Table 1. Urticaria was seen during plasma exchange.

Table 1: Adverse Reactions in ≥2% of Patients Treated with CABLIVI and More Frequent than Placebo During the Blinded Periods of aTTP Studies (HERCULES and TITAN) Adverse Reaction by Body System CABLIVI (N=106) n (%) Placebo (N=110) n (%) Gastrointestinal disorders Gingival bleeding 17 3 Rectal hemorrhage 4 0 Abdominal wall hematoma 3 1 General disorders and administration site conditions Fatigue 16 10 Pyrexia 14 12 Injection site hemorrhage 6 1 Catheter site hemorrhage 6 5 Injection site pruritus 3 0 Musculoskeletal and connective tissue disorders Back pain 7 4 Myalgia 6 2 Nervous system disorders Headache 22 15 Paresthesia 13 11 Renal and urinary disorders Urinary tract infection 6 4 Hematuria 4 3 Reproductive system and breast disorders Vaginal hemorrhage 5 2 Menorrhagia 4 1 Respiratory, thoracic and mediastinal disorders Epistaxis 31 6 Dyspnea 10 5 Skin and subcutaneous tissue disorders Urticaria 15 7 Pediatric Patients The safety of CABLIVI in patients aged ≤18 years with aTTP was evaluated in an observational, retrospective chart review (OBS17325) . The most commonly reported events were epistaxis in 4 (13.3%) patients and tachycardia in 4 (13.3%) patients. One serious bleeding adverse reaction (hemorrhage urinary tract) was reported. The adverse reaction profile in pediatric patients 12 years and older with aTTP was consistent with that in adults.

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of CABLIVI. 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 caplacizumab-yhdp exposure. General disorders and administration site conditions: Injection site reactions including injection site pain, injection site bruising and injection site erythema

Concomitant use of anticoagulants or antiplatelet agents with CABLIVI may increase the risk of bleeding. Monitor closely for bleeding with concomitant use. Concomitant Use of Anticoagulants, Thrombolytic Drugs, Heparin or Antiplatelet Agents Concomitant use of CABLIVI with any anticoagulant, thrombolytic drugs, heparin or antiplatelet agent may increase the risk of bleeding.

Avoid concomitant use when possible. Assess and monitor closely for bleeding with concomitant use .

Pregnancy Risk Summary There are no available data on CABLIVI use in pregnant women to inform a drug-associated risk of major birth defects and miscarriage. However, there are potential risks of hemorrhage in the mother and fetus associated with use of CABLIVI (see Clinical Considerations ). In animal reproduction studies, there was no evidence of adverse developmental outcomes with intramuscular administration of caplacizumab-yhdp during organogenesis in guinea pigs at exposures approximately 30 times the AUC in humans at the recommended subcutaneous injection dose of 11 mg (see Data ). All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. The background rate of major birth defects and miscarriage in the indicated population is unknown.

In the U.S. general population, the estimated background rate of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Clinical Considerations Fetal/neonatal adverse reactions CABLIVI may increase the risk of bleeding in the fetus and neonate. Monitor neonates for bleeding . Maternal adverse reactions All patients receiving CABLIVI, including pregnant women, are at risk for bleeding.

Pregnant women receiving CABLIVI should be carefully monitored for evidence of excessive bleeding . Data Animal data Two separate reproduction studies were conducted in pregnant guinea pigs with administration of caplacizumab-yhdp during the organogenesis period. In an embryo-fetal development study, caplacizumab-yhdp was administered intramuscularly at doses up to 20 mg/kg/day from gestational day (GD) 6 to GD 41 in guinea pigs. No maternal toxicity or adverse developmental outcomes were observed.

In a toxicokinetic study assessing the exposure of caplacizumab-yhdp in the dams and fetuses, caplacizumab-yhdp was administered once daily to female guinea pigs at doses up to 40 mg/kg/day (corresponding to a drug exposure of approximately 30 times the AUC in humans at the recommended dose of 11 mg) by intramuscular injection from GD 6 to GD 41 or GD 61. Exposure to caplacizumab-yhdp was observed in the dams and fetuses, with no effects on embryo-fetal development.

Pediatric Use The safety and effectiveness of CABLIVI in pediatric patients 12 years of age and older with acquired thrombotic thrombocytopenic purpura (aTTP), in combination with plasma exchange and immunosuppressive therapy have been established. Use of CABLIVI for this indication is supported by evidence from an observational, retrospective chart review and pharmacokinetic/pharmacodynamic modeling and simulation data . The safety and effectiveness of CABLIVI in pediatric patients less than 12 years of age have not been established.

is contraindicated in patients with a previous severe hypersensitivity reaction to caplacizumab-yhdp or to any of the excipients. Hypersensitivity reactions have included urticaria . Previous severe hypersensitivity reaction to caplacizumab-yhdp or any of the excipients.

In case of overdose, based on the pharmacological action of CABLIVI, there is the potential for an increased risk of bleeding . Monitor patients for signs and symptoms of bleeding if overdose occurs. Consider the use of von Willebrand factor concentrate to correct hemostasis, if needed.