Leukemias, lymphomas, and other hematologic cancers:
Indications for: KYMRIAH
In patients aged ≤25yrs with B-cell precursor acute lymphoblastic leukemia (ALL) that is refractory or in second or later relapse. In adults with relapsed or refractory large B-cell lymphoma after ≥2 lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma. In adults with relapsed or refractory follicular lymphoma (FL) after ≥2 lines of systemic therapy.
Limitations of Use:
Not for treating primary CNS lymphoma.
Adults and Children:
For autologous and IV use only; confirm patient identity prior to infusion. Premedicate with APAP and diphenhydramine or other H1-antihistamine approx. 30–60mins prior to Kymriah infusion; avoid prophylactic corticosteroids. Infuse IV at rate of 10–20mL/min. ALL: >25yrs: not established. Give lymphodepleting chemotherapy (fludarabine 30mg/m2 IV daily for 4 days + cyclophosphamide 500mg/m2 IV daily for 2 days) 2–14 days prior to Kymriah infusion. ≤25yrs (≤50kg): 0.2–5x106 CAR-positive viable T cells/kg; (>50kg): 0.1–2.5x108 CAR-positive viable T cells. DLBCL and FL: <18yrs: not established. Give lymphodepleting chemotherapy (fludarabine 25mg/m2 IV daily for 3 days + cyclophosphamide 250mg/m2 IV daily for 3 days or bendamustine 90mg/m2 IV daily for 2 days) 2–11 days (DLBCL) or 2–6 days (FL) prior to Kymriah infusion; omit if WBC ≤1x109/L within 1 week prior. ≥18yrs: 0.6–6x108 CAR-positive viable T cells.
Cytokine release syndrome. Neurological toxicities.
Increased risk of severe cytokine release syndrome (CRS) in high pre-infusion tumor burden, uncontrolled or accelerating tumor burden post-lymphodepleting chemotherapy, active infections, and/or inflammatory processes. Delay Kymriah infusion after lymphodepleting chemotherapy if unresolved serious adverse reactions from preceding chemotherapies (eg, pulmonary or cardiac toxicity, hypotension), active uncontrolled infection, active GVHD, or worsening of leukemia burden. Have tocilizumab readily available. Monitor for CRS for ≥4 weeks after treatment; if suspected, manage with supportive care, tocilizumab and/or corticosteroids as indicated (see full labeling). Monitor for neurological events, infection, febrile neutropenia; manage and treat appropriately. Screen for HBV, HCV, and HIV prior to cell collection for manufacturing. Monitor immunoglobulin levels post-treatment; assess newborns of mothers treated with Kymriah. Avoid potential transmission of infectious diseases when handling product. Elderly: not established. Pregnancy: not recommended. Verify pregnancy status prior to starting treatment. Nursing mothers.
CD19-directed genetically modified autologous T cell immunotherapy.
Myeloid growth factors (eg, GM-CSF): not recommended during first 3 weeks post-infusion or until CRS resolved. Live virus vaccines: not recommended for ≥6 weeks prior to lymphodepleting chemotherapy, during Kymriah treatment, and until immune recovery. May yield false (+) results with certain HIV nucleic acid tests.
CRS, hypogammaglobulinemia, infections-pathogen unspecified, pyrexia, decreased appetite, headache, encephalopathy, hypotension, bleeding episodes, tachycardia, nausea, diarrhea, vomiting, viral infections, hypoxia, fatigue, acute kidney injury, edema, cough, delirium, musculoskeletal pain; hypersensitivity reactions, HBV reactivation, neurological events, hemophagocytic lymphohistiocytosis/macrophage activation syndrome, prolonged cytopenias, secondary malignancies (monitor).
To register pregnant patients, call (888) 669-6682.
Generic Drug Availability: