Lymphir Drug Information

is indicated for the treatment of adult patients with relapsed or refractory Stage I-III cutaneous T-cell lymphoma (CTCL) after at least one prior systemic therapy. LYMPHIR is an IL2-receptor-directed cytotoxin indicated for the treatment of adult patients with relapsed or refractory Stage I-III cutaneous T-cell lymphoma (CTCL) after at least one prior systemic therapy.

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. The pooled safety population described in the WARNINGS AND PRECAUTIONS reflect exposure to LYMPHIR as a single agent in 119 patients with CTCL across 3 clinical trials. Patients received treatment with LYMPHIR as an intravenous infusion at 9 mcg/kg daily from Day 1 through Day 5 of each 21-day cycle until disease progression or unacceptable toxicity.

Among 119 patients who received LYMPHIR the median number of cycles received was 5 (range: 1 to 42), with 13% exposed for 6 months or longer. In this pooled safety population, the most common (≥ 20%) adverse reactions, including laboratory abnormalities, were increased transaminases (70%), albumin decreased (53%), nausea (40%), edema (35%), hemoglobin decreased (34%), fatigue (30%), musculoskeletal pain (26%), rash (23%), chills (22%), constipation (22%), pyrexia (21%), and capillary leak syndrome (20%). Relapsed or Refractory Stage I-III CTCL Study 302 The safety of LYMPHIR was evaluated in Study 302, an open-label, single-arm, multicenter trial that included 69 patients with relapsed or refractory Stage I-III CTCL . Patients received treatment with LYMPHIR 9 mcg/kg daily from Day 1 through Day 5 of each 21-day cycle. Treatment was administered until disease progression or unacceptable toxicity.

The median number of LYMPHIR cycles was 6 (range: 1 to 42). The median age of patients was 64 years (range: 28 to 87 years), 49% were 65 years of age or older, 65% were men, 72% were White, 19% were Black or African American, 1.4% were Asian, and 14% were Hispanic or Latino. Serious adverse reactions occurred in 38% of patients who received LYMPHIR. Serious adverse reactions in > 2% of patients included capillary leak syndrome (10%), infusion-related reaction (9%), sepsis (7%), skin infection (2.9%), pyrexia (2.9%), and rash (2.9%). Permanent discontinuation of LYMPHIR due to an adverse reaction occurred in 12% of patients. Adverse reactions resulting in permanent discontinuation of LYMPHIR included capillary leak syndrome, infusion-related reaction, renal insufficiency, respiratory failure, and sepsis.

Dosage interruptions of LYMPHIR due to an adverse reaction occurred in 38% of patients. Adverse reactions requiring dosage interruption of LYMPHIR included capillary leak syndrome, infusion-related reaction, weight increase, nausea, and tachycardia. Table 3 summarizes the adverse reactions in Study 302. Table 3: Adverse Reactions (≥ 10%) in Patients with Relapsed or Refractory Stage I-III CTCL Who Received LYMPHIR in Study 302 Adverse Reaction LYMPHIR N=69 All Grades (%) Grade 3 or 4 (%) Gastrointestinal disorders Nausea 43 1.4 # Diarrhea 19 0 Vomiting 13 0 Constipation 12 0 General disorders and administration site conditions Fatigue a 38 0 Edema b 33

Chills 27 1.4 Pyrexia 16 1.4 Musculoskeletal and connective tissue disorders Musculoskeletal

pain c 27

Arthralgia 12 0 Nervous system disorders Headache d 25 0 Dizziness 13

0 Mental status changes e 13 0 Injury, poisoning and procedural complications Infusion-related reaction 25 6 Skin and subcutaneous tissue disorders Rash f 23 6 Pruritis 19 6 Vascular disorders Capillary leak syndrome 17 6 Metabolism and nutrition disorders Decreased appetite 13

Eye disorders Blurred vision 13 0 Investigations Weight increased 13 0 Infections

and infestations Skin infection g 13

Renal and urinary disorders Renal insufficiency h 12 2.9 Psychiatric disorders Insomnia

10 0 # Only Grade 3 adverse reaction occurred a Includes fatigue, asthenia, and lethargy b Includes edema, edema peripheral, generalized edema, face edema, swelling face, peripheral swelling c Includes musculoskeletal pain, back pain, neck pain, pain in extremity, myalgia, bone pain d Includes headache, migraine e Includes amnesia, confusional state, delirium, memory impairment, disturbance in attention, somnolence, cognitive disorder f Includes rash, drug eruption, erythema, rash maculo-papular, rash papular, rash pustular, rash pruritic, dermatitis exfoliative generalized, acute generalized exanthematous pustulosis g Includes skin infection, skin bacterial infection, staphylococcal skin infection, impetigo h Includes acute kidney injury, blood creatinine increased Clinically relevant adverse reactions in < 10% of patients who received LYMPHIR included sepsis and peripheral neuropathy. Table 4 summarizes select laboratory abnormalities in Study 302. Table 4: Select Laboratory Abnormalities (≥ 10%) that Worsened from Baseline in Patients with Relapsed or Refractory Stage I-III CTCL who Received LYMPHIR in Study 302 Laboratory Abnormality a,b Any Grade c (%) b Grade 3 or 4 c (%) Chemistry Alanine aminotransferase increased 66 13 Aspartate aminotransferase increased 60

Albumin decreased 43 1.5 Creatine phosphokinase increased d 22 3 Alkaline phosphatase

increased 18 0 Hematology Lymphocyte count decreased 52 20 Hemoglobin decreased 34 1.5 a Graded according to NCI CTCAE version 5.0 b The denominator used to calculate the rate was 67 based on the number of patients with a baseline value and at least one post-treatment value c Percentage of patients with an increase of at least 1 CTCAE grade from baseline to the worst post-baseline value of any grade, or to the worst post-baseline value that is Grade 3 or 4 d The denominator used to calculate the rate was based on 36 patients with a baseline value and at least one post-treatment value. 6. 2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of denileukin diftitox. 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. Thyroid conditions: hyperthyroidism, thyroiditis, thyrotoxicosis, and hypothyroidism.

Pregnancy Risk Summary Based on its mechanism of action, LYMPHIR can cause fetal harm when administered to a pregnant woman. There are no available data on the use of LYMPHIR in pregnant women to evaluate for a drug-associated risk. No animal reproductive and developmental toxicity studies have been conducted with denileukin diftitox.

Denileukin diftitox-cxdl causes depletion of regulatory T lymphocytes (Treg), immune activation, and capillary leak syndrome, compromising pregnancy maintenance. Advise pregnant women of the potential risk to a fetus. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies are 2-4% and 15-20%, respectively.

Pediatric Use Safety and effectiveness of LYMPHIR in pediatric patients have not been established.