Nivolumab in combination with ipilimumab

On September 30, 2015, the U. S. Food and Drug Administration granted accelerated approval to nivolumab (Opdivo Injection, Bristol-Myers Squibb Company) in combination with ipilimumab for the treatment of patients with BRAF V600 wild-type, unresectable or metastatic melanoma.

Approval was based on demonstration of an increase in the objective response rate (ORR), prolonged response durations, and improvement in progression-free survival (PFS) in an international, multicenter, double-blind, randomized, two-arm, active-controlled trial in patients who were previously untreated for unresectable or metastatic, BRAF V600 wild-type melanoma.

The clinical trial randomized (2:1) 142 patients to receive nivolumab plus ipilimumab (n=95) or ipilimumab plus placebo (n=47). Randomization was stratified by BRAF V600 mutation status based on an FDA-approved test. Patients in the nivolumab plus ipilimumab arm received nivolumab 1 mg/kg and ipilimumab 3 mg/kg intravenously every 3 weeks for four doses, then nivolumab 3 mg/kg every 2 weeks until disease progression or unacceptable toxicity. Patients in the ipilimumab arm received ipilimumab 3 mg/kg and nivolumab-matched placebo intravenously every 3 weeks for four doses followed by placebo. At the time of disease progression, patients on the ipilimumab arm were offered nivolumab 3 mg/kg every 2 weeks.

Of the 109 patients with BRAF V600 wild-type melanoma, the median age was 66 years and ECOG performance score was 0 (84%) or 1 (15%). Forty-six percent had M1c disease and 20% had elevated baseline LDH.

The trial demonstrated a significant improvement in ORR. The ORR was 60% [95% confidence interval (CI): 48, 71] in the nivolumab plus ipilimumab group (n=72) and 11% [95% CI: 3, 25] in the ipilimumab group (n=37), an improvement in ORR of 49% (95% CI: 31, 61; p-value <0.001). Of the 43 patients with an objective response in the nivolumab plus ipilimumab group, 9 patients (21%) with response duration ranging from 3 to 7 months have progressed after response, died, or received subsequent therapy. The remaining 34 patients (79%) had ongoing responses at the time of final analysis; in 14 patients the duration of ongoing responses is at least 6 months but less than 9 months and in 20 patients the duration of ongoing responses is at least 9 months. In addition, there was a significant improvement in PFS for the combination group compared with the ipilimumab group [HR 0.40 (95% CI: 0.22, 0.71); p-value < 0.002] with an estimated median PFS of 8.9 and 4.7 months in the nivolumab plus ipilimumab and ipilimumab groups, respectively.

Among the 140 patients with BRAF V600 wild-type or mutation-positive melanoma who received at least one dose of nivolumab or ipilimumab, serious adverse reactions (62% vs. 39%), adverse reactions leading to permanent discontinuation (43% vs. 11%) or dose delay (47% vs. 22%), and grade 3 or 4 adverse reactions (69% vs. 43%) all occurred more frequently in patients receiving the combination (n= 94) compared with those receiving single-agent ipilimumab (n=46). The most frequent serious adverse reactions in patients receiving the combination were colitis (17%), diarrhea (9%), pyrexia (6%), and pneumonitis (5%). Additional clinically significant immune-mediated adverse reactions included pneumonitis, hepatitis, endocrinopathies, nephritis/renal dysfunction, and rash.

Common adverse reactions (greater than or equal to 20%) in patients receiving nivolumab plus ipilimumab were rash, pruritus, headache, vomiting, and colitis. The most frequent grade 3 and 4 laboratory abnormalities occurring in at least 5% of patients receiving the combination were increased ALT, increased AST, increased lipase, increased amylase, hyponatremia, and lymphopenia.

When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day, every 3 weeks for four doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity.

Full prescribing information is available: http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/125554s002lbl.pdf

Healthcare professionals should report all serious adverse events suspected to be associated with the use of any medicine and device to FDA’s MedWatch Reporting System by completing a form online at http://www.fda.gov/medwatch/report.htm, by faxing (1-800-FDA-0178) or mailing the postage-paid address form provided online, or by telephone (1-800-FDA-1088).