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ALEMTUZUMAB (LEMTRADA™) – Information for Healthcare Professionals

The Multiple Sclerosis Emerging Therapies Collaborative includes the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS), the MS Coalition, the American Academy of Neurology, and the VA Multiple Sclerosis Centers of Excellence East and West.

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What is the medication?
Generic: alemtuzumab
Brand name: Lemtrada™
Has the medication received US Food and Drug Administration (FDA) approval? If so, what are the indications and uses?
Yes. On November 14, 2014, the FDA approved alemtuzumab for treatment of relapsing forms of multiple sclerosis (MS). Because of its safety profile, alemtuzumab should generally be reserved for patients who have had an inadequate response to two or more drugs indicated for the treatment of MS.
What were the findings in the pivotal and supportive trials of this medication?
Two Phase III trials were performed comparing intravenous alemtuzumab with subcutaneous interferon beta-1a (Rebif) 44 mcg tiw. One of these was done in a treatment-naïve MS population, and the other was in MS patients who had breakthrough disease on another disease-modifying therapy (DMT) for MS. Both studies were published in The Lancet on November 24, 2012.

CARE-MS I trial (Cohen JA et al, 2012)
Trial design: This 2-year randomized, rater-blinded trial compared alemtuzumab 12 mg with subcutaneous interferon beta-1a in 581 treatment-naïve MS patients. Patients were 18 to 50 years old, with an Expanded Disability Status Scale (EDSS) of 3.0 or less, who had at least two relapses within the past 2 years, at least one relapse within the past year, and an abnormal brain MRI consistent with MS. Given the very different side-effect profiles and route/frequency of administration of the two drugs, only the neurologic rater was blinded to the treatment assignment.

Results: Relapse rate and 6-month sustained disability progression were the co-primary endpoints for the CARE-MS I study. Relapses were defined as new or worsening neurologic symptoms due to MS occurring in the absence of fever, lasting over 48 hours, occurring after 30 days of neurologic stability, and causing new findings on neurologic examination. A blinded relapse adjudication committee confirmed relapses. In CARE-MS I, there was a 54.9% relative reduction (p<0.001) in the relapse rate in the alemtuzumab arm (0.18) compared with the interferon arm (0.39). Sustained disability progression was defined as an increase in EDSS by 1 point (or 1.5 points if initial EDSS was zero) that persisted for 6 months. Eleven percent of patients on interferon beta-1a had sustained disability progression, while only 8% of patients on alemtuzumab had sustained progression; however, this difference was not statistically significant. The alemtuzumab group had fewer patients with new or enhancing lesions on MRI; this effect was greater in the second year of the study. Patients on alemtuzumab also had less brain volume loss on MRI, and both groups had a slight improvement in the EDSS disability score. Thirty-nine percent of the patients receiving alemtuzumab had freedom from clinical and radiographic disease activity, while only 27% of patients in the interferon arm did.

CARE-MS II trial (Coles AJ et al, 2012)
Trial design: This 2-year randomized, rater-blinded trial compared alemtuzumab 12 mg with subcutaneous interferon beta-1a in 667 MS patients who experienced breakthrough disease after 6 months of being on another DMT (primarily interferon-beta or glatiramer acetate). Patients were between 18 and 55 years of age with an EDSS of 5.0 or lower who had at least two relapses within the past 2 years, at least one relapse within the past year, and an abnormal brain MRI consistent with MS. As above, only the neurologic rater was blinded to treatment assignment due to the very different side-effect profiles and route/frequency of administration of the drugs.

Results: Relapse rate and 6-month sustained disability progression were coprimary endpoints for the CARE-MS II study. Relapses were defined as above and were confirmed by a blinded relapse adjudication committee. In CARE-MS II, there was a 49.4% relative reduction in the relapse rate in the alemtuzumab arm (annual rate of 0.26 vs 0.52, p<0.0001) compared with the interferon arm. Sustained disability progression was defined as an increase of EDSS by 1 point (or 1.5 points if initial EDSS was zero) that persisted for 6 months. The alemtuzumab group had a 42% reduction (p=0.0084) in sustained disability progression compared with the interferon group. The alemtuzumab group had fewer patients with new or enhancing lesions on MRI; this effect was greater in the second year of the study. Measurements of new MRI lesions, gadoliniumenhancing lesions, and brain volume also favored alemtuzumab. The alemtuzumab group had a mild improvement in EDSS, while the interferon group declined somewhat on this scale. More patients in the alemtuzumab arm (32% vs 14%) were free of clinical and radiographic disease activity.

 

What is the mechanism of action and the rationale for the use in MS?
Alemtuzumab is a monoclonal antibody recognizing CD52, which is highly expressed on the surface of certain immune cells (B lymphocytes and T lymphocytes) that are felt to be involved with the pathogenesis of MS. Binding of the antibody to its target causes rapid destruction of the cells expressing CD52, at least those in the vascular compartment; seemingly, this includes destruction of those antireactive lymphocytes that are causing the damage in MS. One study (Jones JL et al 2010) suggests that alemtuzumab may increase the production of neurotrophic factors, perhaps allowing a protective or restorative effect.
What is the delivery route and recommended dosing?
Alemtuzumab is given as an intravenous infusion of 12 mg over at least 4 hours. The initial course is given over 5 consecutive days; the second course is given for 3 consecutive days 1 year later. Subsequent 3-day courses can be given not more frequently than annually for breakthrough disease. The medication can be prescribed only by providers and dispensed by pharmacies enrolled in the Lemtrada REMS (Risk Evaluation and Mitigation Strategy) program. Premedication before the infusions and antiviral prophylaxis are required as described below.
Can this medication be used with other medications?
  • Disease-Modifying Therapies (DMTs):
    No studies using alemtuzumab in combination with other MS DMTs have been published.
  • Other Medications:
    Currently, studies have not identified any specific concerns regarding the use of alemtuzumab with symptomatic medications commonly used in MS patients
How does the expected treatment effect compare with the treatment effect provided by other available medications?
The studies with alemtuzumab demonstrate superiority over subcutaneous interferon beta 1a, which may suggest superiority over other interferon beta formulations, although these studies have not been performed. Other head-to-head studies comparing alemtuzumab with other MS DMTs also have not been performed, so a data-driven comparison regarding the comparative effect of alemtuzumab and other MS DMTs is not possible.
What are the possible short-term side effects? What is the range of severity of side effects, and what are the recommended management strategies?
Over 90% of patients receiving alemtuzumab in the clinical trials experienced infusion reactions – most of which were deemed mild to moderate – typically consisting of skin rash, fever, headache, muscle aches, and temporary reoccurrence of previous neurologic symptoms. More serious but uncommon infusion reactions included anaphylaxis and heart rhythm abnormalities. Pre-infusion treatment typically consisted of highdose intravenous steroids (required for the first three doses of each treatment course), antihistamines such as famotidine (Pepcid) and/or diphenhydramine (Benadryl), and acetaminophen (Tylenol).

Adverse reactions with incidence > 10% and > interferon-beta 1a included rash, headache, pyrexia, nasopharyngitis, nausea, urinary tract infection, fatigue, insomnia, upper-respiratory tract infection, herpes viral infection, urticaria, pruritis, thyroid gland disorders, fungal infection, arthralgia, pain in extremity, back pain, diarrhea, sinusitis, oropharyngeal pain, paresthesia, dizziness, abdominal pain, flushing, and vomiting.

Alemtuzumab causes immediate and significant depletion of a class of immune cells called lymphocytes. It is advised that vaccinations be up-to-date before starting alemtuzumab. Herpes simplex and zoster infections were more common in the patients who received alemtuzumab in the clinical trials, especially soon after the infusions; therefore, an antiviral medication (like valacyclovir) is recommended for at least 2 months following the first infusion of each treatment course (or until CD4+ lymphocyte count is ≥200 cells/mL).
What are the known long-term (morbidity and mortality) health risks?
Because alemtuzumab causes long-lasting immune suppression, a potentially increased risk of infection exists long after the drug is infused. A subset of lymphocytes called T cells takes years to recover after a patient receives alemtuzumab, while B lymphocytes recover more quickly. This perturbation of the immune system can also lead to eventual autoimmune disease and malignancy.

The most common autoimmunity after alemtuzumab was thyroid autoimmunity, which occurred in about a third of patients receiving the drug in the clinical trial program. This included Graves' disease and autoimmune hypo-/hyperthyroidism and was most common 3 to 4 years after initiating the drug. About 2% of patients who received alemtuzumab in the clinical trials developed an autoimmune platelet disorder (immune thrombocytopenic purpura) that causes easy bruising, spontaneous bleeding, and very low platelet counts (cells involved with clotting). Three tenths of a percent (0.3%) of the patients receiving alemtuzumab for MS developed a serious autoimmune kidney disease that can lead to kidney failure and dialysis if not detected and treated rapidly. Much of the autoimmunity with alemtuzumab occurs years after starting the drug. A recent review (Tuohy OJ et al 2014) of long-term safety in patients treated with alemtuzumab at Cambridge, England, reported secondary autoimmunity in 41/86 subjects (47%) and included some individuals treated with three or more cycles.

Several cases of cancer were identified in patients who received alemtuzumab, including three cases of thyroid cancer, four cases of melanoma, and several cases of lymphoma. Although these numbers are low, it is felt that alemtuzumab may increase the longerterm risk of malignancy.

Pneumonitis occurred in 6 of 1217 (0.5%) alemtuzumab-treated subjects, including hypersensitivity pneumonitis and pneumonitis with fibrosis.
Has the FDA included any black box warnings about this medication?
The following black box warnings are included in the prescribing information:
  1. Lemtrada causes serious, sometimes fatal, autoimmune conditions such as immune thrombocytopenia and antiglomerular basement membrane disease. Monitor complete blood counts with differential, serum creatinine levels, and urinalysis with urine cell counts at periodic intervals for 48 months after the last dose of Lemtrada.
  2. Lemtrada causes serious and life-threatening infusion reactions. Lemtrada must be administered in a setting with appropriate equipment and personnel to manage anaphylaxis or serious infusion reactions. Monitor patients for 2 hours after each infusion. Make patients aware that serious infusion reactions can also occur after the 2-hour monitoring period.
  3. Lemtrada may cause an increased risk of malignancies, including thyroid cancer, melanoma, and lymphoproliferative disorders. Perform baseline and yearly skin exams.
  4. Because of the risk of autoimmunity, infusion reactions, and malignancies, Lemtrada is available only through restricted distribution under a Risk Evaluation Mitigation Strategy (REMS) program.
What training is recommended or required for clinicians or patients before initiating this treatment?
Providers, health care facilities, pharmacies, and patients receiving alemtuzumab must all be registered in an FDA-mandated REMS program that includes education provided by the manufacturer of the drug. See below.
What is the pregnancy rating for this medication, and what is known about possible carcinogenesis, mutagenesis, and impairment of fertility?
Alemtuzumab is pregnancy class C. Animal studies with alemtuzumab do not suggest teratogenicity but suggest an increased rate of fetal death. Autoantibodies may cross the placenta, resulting in fetal and neonatal adverse effects. Women of childbearing potential receiving alemtuzumab are advised to use effective contraception while receiving the drug and for 4 months following the course of treatment. Alemtuzumab has been detected in the milk of lactating mice. It is not known if alemtuzumab is excreted in human milk.
Does this medication interact or interfere with oral contraceptives?
Alemtuzumab is not known to interact with or interfere with oral contraceptives. The recommendation from the manufacturer's drug label is that two forms of birth control be used during treatment to prevent pregnancy.
Has the FDA required a safety-monitoring program?
The FDA has mandated a REMS program to mitigate the risks of autoimmune conditions, infusion reactions, and malignancies associated with alemtuzumab as part of the approval to help ensure informed decisions about safe use of alemtuzumab:
  • Informing patients about the serious risks of autoimmune conditions, infusion reactions, and malignancies associated with alemtuzumab and the need for baseline and periodic monitoring.
  • Informing health care providers about the serious risks of autoimmune conditions, infusion reactions, and malignancies associated with alemtuzumab and the need to counsel patients and the need for baseline and periodic monitoring.
The REMS program will ensure safe use by:
  • Ensuring that only certified prescribers prescribe alemtuzumab.
  • Ensuring that alemtuzumab is dispensed only in approved health care settings by certified pharmacies and certified infusion sites that have on-site access to equipment and personnel trained to manage infusion reactions.
  • Ensuring that only enrolled and authorized patients receive alemtuzumab.
  • Ensuring that certified prescribers submit documentation of periodic monitoring of patients who receive alemtuzumab to identify autoimmune conditions and malignancies.
The REMS program includes a communications plan that includes the following:
  • The manufacturer will send out a letter to health care providers within 60 days of approval, and then again yearly for 3 years, which will address the risks of alemtuzumab treatment and provide details of the REMS program.
  • The manufacturer will ensure that the website www.lemtrada.com will be available and will contain information on the REMS program.
Lemtrada can be administered only by certified programs:
  • Prescribers must be enrolled in the Lemtrada REMS Program to be able to prescribe Lemtrada.
  • Health care facilities and pharmacies must be enrolled in the Lemtrada REMS Program to be able to dispense and/or administer Lemtrada.
  • Patients must be enrolled and authorized in the Lemtrada REMS Program in order to receive Lemtrada.
In order to be certified to administer Lemtrada, a provider must:
  • Review the prescribing information for the drug
  • Review the REMS program by completing and signing the REMS prescriber enrollment form and submitting to the REMS program.
  • Agree to:
    • Inform patients of the risks associated with the need for periodic monitoring and providing each patient with the patient guide and a safety information card.
    • Submit a REMS enrollment form for each patient, with a copy to the patient and to the patient's medical record.
    • Submit a REMS order form for each prescription to the REMS program.
    • Perform required monitoring.
    • Submit the REMS patient authorization and baseline lab form to the REMS program within 30 days prior to the first infusion date.
    • Submit to the REMS program the REMS patient status form 6 months after the first infusion and every 6 months thereafter until 48 months after the completion of the last infusion.
    • Report any adverse events to the manufacturer.
    • Notify the manufacturer if the patient is no longer under the care of the original prescribing provider.
What kind of safety monitoring is recommended (including prescreening, routine checkups, and laboratory tests)?
HPV (human papillomavirus) screening is recommended annually.
  • Complete blood counts with differential, serum creatinine levels, and urinalysis with urine cell counts should be obtained prior to initiation of treatment and at monthly intervals until 48 months after the last infusion.
  • If an individual has not been immunized for varicella zoster virus, antibody testing should be performed (and vaccination performed if appropriate) at least 6 weeks prior to initiating therapy.
  • Thyroid function tests should be obtained prior to the initiation of treatment and every 3 months until 48 months after the last infusion. Monitoring may need to continue past 48 months based on clinical findings of autoimmune conditions in postmarketing studies.
  • Skin examination for melanoma should be performed prior to treatment and yearly thereafter.
  • This medication can be administered only in certified health care settings that have on-site access to equipment and personnel trained to manage infusion reactions, including anaphylaxis and cardiac and respiratory emergencies.
  • Patients should be advised to read the FDA-approved patient labeling (Medication Guide) and instructed to report promptly any symptoms that may be indicative of serious side effects or complications of this medication.
Are there any recommended limits on treatment duration with this medication?
The recommended dosage of alemtuzumab is 12 mg/day administered by intravenous infusion for 5 consecutive days, followed by three consecutive daily infusions 1 year later. There are no known limits on how long this treatment can be continued.
What happens following termination of treatment with this medication?
The effect of treatment on MS disease activity persists long-term: preliminary data suggest that over 80% of subjects who remained in the CARE-MS I and CARE-MS II extension study did not require further doses of alemtuzumab at 3 years. Preliminary data also suggest that the risk of autoimmune side effects from treatment with alemtuzumab appears to be highest between 3 and 4 years after treatment.
What treatment options are available for patients who have been treated with alemtuzumab??
Alemtuzumab treatment is associated with increased rates of certain viral infections and possibly some cancers. How long those increased risks persist after treatment is discontinued and whether the effects are additive with subsequent treatments is not known. Because it is not known whether risks are additive, providers should use caution when switching MS patients who have been treated with alemtuzumab to other immunosuppressive treatments or medications such as natalizumab and dimethyl fumarate that have been associated with progressive multifocal leukoencephalopathy.
What is the washout period?
The effects of treatment are thought to persist for at least 1 to 2 years after the last dose.
How can the provider identify a suboptimal treatment response?
Persistent evidence of inflammatory disease activity (clinical relapses and/or new and/ or gadolinium-enhancing lesions on MRI of brain or spinal cord) could indicate a suboptimal response. Because alemtuzumab is not a cure for MS, clinical judgment is required to determine whether the response is suboptimal.
Is the manufacturer/distributor offering any financial assistance program for patients?
Genzyme MS support program: (1-855-MSOne2One; 1-855-676-6326); www.genzyme.com.

Copayments for Lemtrada are paid by the sponsor for patients who have inadequate insurance coverage and who have qualifying income levels. Appropriate patients may apply for free medication. The sponsor also covers all costs associated with monitoring for those who participate in the Centralized Lab Program offered by Genzyme.
Are there any special considerations with this medication?
Because of potential serious and/or life-threatening short- and long-term side effects of treatment, the use of alemtuzumab is restricted to prescribers certified under the FDA mandated REMS program, to distribution sources also certified under the REMS program, and to infusion centers trained under the same mandate.
COMMENTARY BY TEMPLATE AUTHORS:
The full REMS program is available on the FDA website, www.FDA.gov/Alemtuzumab.
WEB LINKS PROVIDED IN THIS DOCUMENT:
  • FDA prescribing information: http://products.sanofi.us/Lemtrada/Lemtrada.pdf
  • Genzyme: www.genzyme.com
  • Cohen JA, Coles AJ, Arnold DL, Confavreux C, Fox EJ et al. Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis; a randomized controlled phase 3 trial. Lancet 2012 Nov 24; 380(9856):1819-28.
  • Coles AJ, Twyman CL, Arnold DL, Cohen JA, Confavreux C et al. Alemtuzumab for patients with relapsing multiple sclerosis after disease-modifying therapy: a randomized controlled phase 3 trial. Lancet 2012 Noc 24; 380(9856):1829-39.
  • Jones JL, Anderson JM, Phuah CL, Fox EJ, Selmaj K et al. Improvement in disability after alemtuzumab treatment of multiple sclerosis is associated with neuroprotective autoimmunity. Brain 2010 Aug;133 (Pt 8):2232-47.
  • Tuohy O, Costelloe L, Hill-Cawthorne G, Bjormson I, Harding K et al. Alemtuzumab treatment of multiple sclerosis: long-term safety and efficacy. J Neurol Neurosurg Psychiatry 2014 May21; pii: jnnp-2014-307721. doi: 10.1136/jnnp-2014-307721. [Epub ahead of print].
EDITOR:
Rosalind Kalb, PhD

DISCLAIMER:

The Emerging Therapies Collaborative is proud to be a source of information about multiple sclerosis. Our comments are based on published data and expert opinion, but do not represent individual therapeutic recommendations or prescriptions. For specific information and advice, consult your physician.

DISCLOSURES:
Christopher Bever, MD is a co-holder on patent on the use of hematogenous stem cells in neurological diseases. He has received grant support from Department of Veterans Affairs and the National MS Society.

David Jones, MD is a consultant for Biogen Idec, Genzyme, Novartis and Questcor. He has received grant support from the National MS Society.

June Halper, APN-C, MSCN, FAAN, has no disclosures.

Rosalind Kalb, PhD, has no disclosures.
FOR COMPLETE DISCLOSURES AND OTHER INFORMATION:
Please visit our website at http://www.ms-coalition.org/emergingtherapies or email us at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
For additional information, healthcare professionals are invited to email the National MS Society's Professional Resource Center at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
Last Updated on Friday, 30 January 2015 13:25