Tildrakizumab

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# Overview
Tildrakizumab is a interleukin-23 antagonist that is FDA approved for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.   Common adverse reactions include upper respiratory infections, injection site reactions, and diarrhea.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Tildrakizumab is indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.
- Tildrakizumab is administered by subcutaneous injection. The recommended dose is 100 mg at Weeks 0, 4, and every twelve weeks thereafter. Each syringe contains 1 mL of 100 mg/mL tildrakizumab-asmn.
- Injection: 100 mg/mL solution in a single-dose prefilled syringe. Tildrakizumab is a clear to slightly opalescent, colorless to slightly yellow solution.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding tildrakizumab Off-Label Guideline-Supported Use and Dosage (Adult) in the drug label.

### NonGuideline-Supported Use
There is limited information regarding tildrakizumab Off-Label Non-Guideline-Supported Use and Dosage (Adult) in the drug label.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Tildrakizumab FDA-Labeled Indications and Dosage (Pediatric) in the drug label.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding tildrakizumab Off-Label Guideline-Supported Use and Dosage (Pediatric) in the drug label.

### NonGuideline-Supported Use
There is limited information regarding tildrakizumab Off-Label Non-Guideline-Supported Use and Dosage (Pediatric) in the drug label.

# Contraindications
- Tildrakizumab is contraindicated in patients with a previous serious hypersensitivity reaction to tildrakizumab or to any of the excipients.

# Warnings
- Cases of angioedema and urticaria occurred in tildrakizumab treated subjects in clinical trials. If a serious hypersensitivity reaction occurs, discontinue tildrakizumab immediately and initiate appropriate therapy.
- Tildrakizumab may increase the risk of infection. Although infections were slightly more common in the tildrakizumab group (23%), the difference in frequency of infections between the tildrakizumab group and the placebo group was less than 1% during the placebo-controlled period. However, subjects with active infections or a history of recurrent infections were not included in clinical trials. Upper respiratory infections occurred more frequently in the tildrakizumab group than in the placebo group.
- The rates of serious infections for the tildrakizumab group and the placebo group were 0.3%. Treatment with tildrakizumab should not be initiated in patients with any clinically important active infection until the infection resolves or is adequately treated.
- In patients with a chronic infection or a history of recurrent infection, consider the risks and benefits prior to prescribing tildrakizumab. Instruct patients to seek medical help if signs or symptoms of clinically important chronic or acute infection occur. If a patient develops a clinically important or serious infection or is not responding to standard therapy, monitor the patient closely and consider discontinuation of tildrakizumab until the infection resolves.
- Evaluate patients for tuberculosis (TB) infection prior to initiating treatment with tildrakizumab. Initiate treatment of latent TB prior to administering tildrakizumab. In clinical trials, of 55 subjects with latent TB who were concurrently treated with tildrakizumab and appropriate TB prophylaxis, no subjects developed active TB (during the mean follow-up of 56.5 weeks). One other subject developed TB while receiving tildrakizumab. Monitor patients for signs and symptoms of active TB during and after tildrakizumab treatment. Consider antiTB therapy prior to initiation of tildrakizumab in patients with a past history of latent or active TB in whom an adequate course of treatment cannot be confirmed. Do not administer tildrakizumab to patients with active TB infection.
- Prior to initiating therapy with tildrakizumab, consider completion of all age appropriate immunizations according to current immunization guidelines. Avoid the use of live vaccines in patients treated with tildrakizumab. No data are available on the response to live or inactive vaccines.

# Adverse Reactions

## 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.
- In clinical trials, a total of 1994 subjects with plaque psoriasis were treated with tildrakizumab, of which 1083 subjects were treated with tildrakizumab 100 mg. Of these, 672 subjects were exposed for at least 12 months, 587 for 18 months, and 469 for 24 months.
- Data from three placebo-controlled trials (Trials 1, 2, and 3) in 705 subjects (mean age 46 years, 71% males, 81% white) were pooled to evaluate the safety of tildrakizumab (100 mg administered subcutaneously at Weeks 0 and 4, followed by every 12 weeks ).
- In the placebo-controlled period of Trials 1, 2, and 3 in the 100 mg group, adverse events occurred in 48.2% of subjects in the tildrakizumab group compared to 53.8% of subjects in the placebo group. The rates of serious adverse events were 1.4% in the tildrakizumab group and 1.7% in the placebo group.
- Table 1 summarizes the adverse reactions that occurred at a rate of at least 1% and at a higher rate in the tildrakizumab group than in the placebo group.
- During the placebo-controlled period of Trials 1, 2, and 3, adverse reactions that occurred at rates less than 1% but greater than 0.1% in the tildrakizumab group and at a higher rate than in the placebo group included dizziness and pain in extremity.
Hypersensitivity Reactions
- Cases of angioedema and urticaria occurred in tildrakizumab-treated subjects in clinical trials.
Infections
- Infections were slightly more common in the tildrakizumab group. The difference in frequency of infections between the tildrakizumab group (23%) and the placebo group was less than 1% during the placebo-controlled period. The most common (1%) infections were upper respiratory infections. The rates of severe infections for the tildrakizumab group and the placebo group were 0.3%.
Safety Through Week 52/64
- Through Week 52 (Trials 1 and 3) and Week 64 (Trial 2), no new adverse reactions were identified with tildrakizumab use and the frequency of the adverse reactions was similar to that observed during the placebo-controlled period.
- As with all therapeutic proteins there is the potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence of antibodies to tildrakizumab in the studies described below with the incidences of antibodies in other studies or to other products may be misleading.
- Up to Week 64, approximately 6.5% of subjects treated with tildrakizumab 100 mg developed antibodies to tildrakizumab. Of the subjects who developed antibodies to tildrakizumab, approximately 40% (2.5% of all subjects receiving tildrakizumab) had antibodies that were classified as neutralizing. Development of neutralizing antibodies to tildrakizumab was associated with lower serum tildrakizumab concentrations and reduced efficacy.

## Postmarketing Experience
There is limited information regarding Tildrakizumab Postmarketing Experience in the drug label.

# Drug Interactions
- Live Vaccinations
- Avoid use of live vaccines in patients treated with tildrakizumab.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Limited available data with tildrakizumab use in pregnant women are insufficient to inform a drug associated risk of adverse developmental outcomes. Human IgG is known to cross the placental barrier; therefore, tildrakizumab may be transferred from the mother to the fetus. An embryofetal developmental study conducted with tildrakizumab in pregnant monkeys revealed no treatment-related effects to the developing fetus when tildrakizumab was administered subcutaneously during organogenesis to near parturition at doses up to 159 times the maximum recommended human dose (MRHD). When dosing was continued until parturition, a small increase in neonatal death was observed at 59 times the MRHD. The clinical significance of this nonclinical finding is unknown.
- All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
- In an embryofetal developmental study, subcutaneous doses up to 300 mg/kg tildrakizumab were administered to pregnant cynomolgus monkeys once every two weeks during organogenesis to gestation day 118 (22 days from parturition). No maternal or embryofetal toxicities were observed at doses up to 300 mg/kg (159 times the MRHD of 100 mg, based on AUC comparison). Tildrakizumab crossed the placenta in monkeys.
- In a pre- and postnatal developmental study, subcutaneous doses up to 100 mg/kg tildrakizumab were administered to pregnant cynomolgus monkeys once every two weeks from gestation day 50 to parturition. Neonatal deaths occurred in the offspring of one control monkey, two monkeys at 10 mg/kg dose (6 times the MRHD based on AUC comparison), and four monkeys at 100 mg/kg dose (59 times the MRHD based on AUC comparison). The clinical significance of these nonclinical findings is unknown. No tildrakizumab-related adverse effects were noted in the remaining infants from birth through 6 months of age.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Tildrakizumab in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Tildrakizumab during labor and delivery.

### Nursing Mothers
- There are no data on the presence of tildrakizumab in human milk, the effects on the breastfed infant, or the effects on milk production. Human IgG is known to be present in human milk. Tildrakizumab was detected in the milk of monkeys.
- The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for tildrakizumab and any potential adverse effects on the breastfed child from tildrakizumab or from the underlying maternal condition.
- Very low levels of tildrakizumab were detected in breast milk of monkeys in the pre- and postnatal developmental study described in 8.1. The mean tildrakizumab concentrations in milk were approximately 0.09  0.2% of that in serum on postpartum days 28 and 91.

### Pediatric Use
- Safety and effectiveness of tildrakizumab in pediatric patients (<18 years of age) have not been established.

### Geriatic Use
- A total of 1083 subjects were exposed to tildrakizumab 100 mg during Phase 2 and 3 trials. A total of 92 subjects were 65 years or older, and 17 subjects were 75 years or older. Although no differences in safety or efficacy were observed between older and younger subjects, the number of subjects aged 65 and over is not sufficient to determine whether they respond differently from younger subjects.

### Gender
There is no FDA guidance on the use of Tildrakizumab with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Tildrakizumab with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Tildrakizumab in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Tildrakizumab in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Tildrakizumab in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Tildrakizumab in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Evaluate patients for tuberculosis (TB) infection prior to initiating treatment with tildrakizumab.
- Tildrakizumab should only be administered by a healthcare provider. Administer tildrakizumab subcutaneously. Each pre-filled syringe is for single-dose only. Inject the full amount (1 mL), which provides 100 mg of tildrakizumab per syringe. If a dose is missed, administer the dose as soon as possible. Thereafter, resume dosing at the regularly scheduled interval.
- Before injection, remove tildrakizumab carton from the refrigerator, and let the prefilled syringe (in the tildrakizumab carton with the lid closed) sit at room temperature for 30 minutes. *Follow the instructions on the tildrakizumab carton to remove the prefilled syringe correctly, and remove only when ready to inject. Do not pull off the needle cover until you are ready to inject.
- Inspect tildrakizumab visually for particulate matter and discoloration prior to administration. Tildrakizumab is a clear to slightly opalescent, colorless to slightly yellow solution. Do not use if the liquid contains visible particles or the syringe is damaged. Air bubbles may be present; there is no need to remove them.
- Choose an injection site with clear skin and easy access (such as abdomen, thighs, or upper arm). Do not administer 2 inches around the navel or where the skin is tender, bruised, erythematous, indurated, or affected by psoriasis. Also do not inject into scars, stretch marks, or blood vessels.
- While holding the body of the syringe, pull the needle cover straight off (do not twist) and
discard.
- Inject tildrakizumab subcutaneously as recommended.
- Press down the blue plunger until it can go no further. This activates the safety mechanism that will ensure full retraction of the needle after the injection is given.
- Remove the needle from the skin entirely before letting go of the blue plunger. After the blue plunger is released, the safely lock will draw the needle inside the needle guard.
- Discard of any unused portion. Dispose of used syringe.

### Monitoring
- An improvement in signs and symptoms of moderate-to-severe plaque psoriasis is indicative of efficacy.
- Tuberculosis (TB) screening: Prior to initiation.
- Signs and symptoms of active TB: During and after treatment.

# IV Compatibility
There is limited information regarding the compatibility of Tildrakizumab and IV administrations.

# Overdosage
- In the event of overdosage, monitor the patient for any signs or symptoms of adverse reactions and administer appropriate symptomatic treatment immediately.

# Pharmacology

## Mechanism of Action
- Tildrakizumab is a humanized IgG1/k monoclonal antibody that selectively binds to the p19 subunit of IL-23 and inhibits its interaction with the IL-23 receptor. IL-23 is a naturally occurring cytokine that is involved in inflammatory and immune responses. Tildrakizumab inhibits the release of proinflammatory cytokines and chemokines.

## Structure
There is limited information regarding Tildrakizumab Structure in the drug label.

## Pharmacodynamics
- No formal pharmacodynamics studies have been conducted with tildrakizumab.

## Pharmacokinetics
- Tildrakizumab pharmacokinetics increases proportionally over a dose range from 50 mg to 200 mg (0.5 to 2 times the approved recommended dosage) following subcutaneous administration in subjects with plaque psoriasis. Steady-state concentrations were achieved by Week 16 following subcutaneous administration of tildrakizumab at Weeks 0, 4, and every 12 weeks thereafter. At the 100 mg dose at Week 16, the mean ( SD) steady-state trough concentrations ranged from 1.22  0.94 mcg/mL to 1.47  1.12 mcg/mL. The geometric mean (CV%) steady-state Cmax was 8.1 mcg/mL (34%).
- The absolute bioavailability of tildrakizumab was estimated to be 73-80% following subcutaneous injection. The peak concentration (Cmax) was reached by approximately 6 days.
- The geometric mean (CV%) volume of distribution is 10.8 L (24%).
- The geometric mean (CV%) systemic clearance was 0.32 L/day (38%) and the half-life was approximately 23 days (23%).
Metabolism
- The metabolic pathway of tildrakizumab has not been characterized. As a humanized IgG1/k monoclonal antibody, tildrakizumab is expected to be degraded into small peptides and amino acids via catabolic pathways in a manner similar to endogenous IgG.
- No clinically significant differences in the pharmacokinetics of tildrakizumab were observed based on age (18 years). No specific studies have been conducted to determine the effect of renal or hepatic impairment on the pharmacokinetics of tildrakizumab.
Body Weight
- Tildrakizumab concentrations were lower in subjects with higher body weight.
Cytochrome P450 Substrates
- The AUCinf of dextromethorphan (CYP2D6 substrate) increased by 20% when used concomitantly with tildrakizumab 200 mg (two times the approved recommended dose) administered subcutaneously at Weeks 0 and 4 in subjects with plaque psoriasis. No clinically significant changes in AUCinf of caffeine (CYP1A2 substrate), warfarin (CYP2C9 substrate), omeprazole (CYP2C19 substrate), and midazolam (CYP3A4 substrate) were observed.

## Nonclinical Toxicology
- Animal studies have not been conducted to evaluate the carcinogenic or mutagenic potential of tildrakizumab.
- No effects on fertility parameters were observed in male or female cynomolgus monkeys that were administered tildrakizumab at subcutaneous or intravenous doses up to 140 mg/kg once every two weeks for 3 months (133 or 155 times the MRHD, respectively, based on AUC comparison). The monkeys were not mated to evaluate fertility.

# Clinical Studies
- In two multicenter, randomized, double-blind, placebo-controlled trials (Trial 2  and Trial 3 ), 926 subjects were treated with tildrakizumab 100 mg (N=616) or placebo (N=310). Subjects had a Physician Global Assessment (PGA) score of 3 (moderate) on a 5-point scale of overall disease severity, Psoriasis Area and Severity Index (PASI) score 12, and a minimum body surface area (BSA) involvement of 10%. Subjects with guttate, erythrodermic, or pustular psoriasis were excluded.
- In both trials, subjects were randomized to either placebo or tildrakizumab (100 mg at Week 0, Week 4 and every twelve weeks thereafter ) up to 64 weeks.
- Trials 2 and 3 assessed the changes from baseline to Week 12 in the two co-primary endpoints:
- PASI 75, the proportion of subjects who achieved at least a 75% reduction in the PASI composite score.
- PGA of 0 (cleared) or 1 (minimal), the proportion of subjects with a PGA of 0 or 1 and at least a 2-point improvement.
- Other evaluated outcomes in Trials 2 and 3 included the proportion of subjects who achieved a reduction from baseline in PASI score of at least 90% (PASI 90) and a reduction of 100% in PASI score (PASI 100) at Week 12 and maintenance of efficacy up to Week 64.
- In both trials, subjects in the tildrakizumab 100 mg and placebo treatment groups were predominantly men (69%) and White (80%), with a mean age of 46 years. At baseline, these subjects had a median affected BSA of 27%, a median PASI score of 17.8, and approximately 33% had a PGA score of 4 (marked) or 5 (severe). Approximately 34% had received prior phototherapy, 39% had received prior conventional systemic therapy, and 18% had received prior biologic therapy for the treatment of psoriasis. Approximately 16% of subjects had a history of psoriatic arthritis.
- The results of Trials 2 and 3 are presented in Table 2.
- Examination of age, gender, race, and previous treatment with a biologic did not identify differences in response to tildrakizumab among these subgroups at Week 12.
- In Trial 2, subjects originally randomized to tildrakizumab and who were responders at Week 28 (i.e., PASI 75) were re-randomized to an additional 36 weeks of either maintaining the same dose of tildrakizumab Q12W (every twelve weeks) or placebo.
- At Week 28, 229 (74%) subjects treated with tildrakizumab 100 mg were PASI 75 responders. At Week 64, 84% of subjects who continued on tildrakizumab 100 mg Q12W maintained PASI 75 compared to 22% of subjects who were re-randomized to placebo. In addition, for subjects who were re-randomized and also had a PGA score of 0 or 1 at Week 28, 69% of subjects who continued on tildrakizumab 100 mg Q12W maintained this response (PGA 0 or 1) at Week 64 compared to 14% of subjects who were rerandomized to placebo.
- For PASI 75 responders at Week 28 who were re-randomized to treatment withdrawal (i.e., placebo), the median time to loss of PASI 75 was approximately 20 weeks.
- In addition, for subjects who were re-randomized to placebo and also had a PGA score of 0 or 1 at Week 28, the median time to loss of PGA score of 0 or 1 was approximately 16 weeks.

# How Supplied
- Tildrakizumab Injection is a sterile, preservative-free, clear to slightly opalescent, colorless to slightly yellow solution. Tildrakizumab is supplied as one single-dose prefilled syringe per carton that delivers 1 mL of a 100 mg/mL solution.
- NDC 0006-4241-00
- Each prefilled syringe is equipped with a passive needle guard and a needle cover.

## Storage
- Store refrigerated at 2C to 8C (36F to 46F) in the original carton to protect from light until the time of use. Do not freeze. Do not shake. Tildrakizumab can be kept at room temperature at 25C (77F) for up to 30 days in the original carton to protect from light. Once stored at room temperature, do not place back in the refrigerator. If not used within 30 days, discard tildrakizumab. Do not store tildrakizumab above 25C (77F).

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Advise the patient and/or caregiver to read the FDA-approved patient labeling.
- Instruct patients and/or caregivers to read the Medication Guide before starting tildrakizumab therapy and to reread the Medication Guide each time the prescription is renewed. Advise patients of the potential benefits and risks of tildrakizumab.
- Advise patients to seek immediate medical attention if they experience any symptoms of serious hypersensitivity reactions.
- Instruct patients of the importance of communicating any history of infections to the doctor and contacting their doctor if they develop any symptoms of infection

# Precautions with Alcohol
Alcohol-Tildrakizumab interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.

# Brand Names
- Ilumya

# Look-Alike Drug Names
There is limited information regarding Tildrakizumab Look-Alike Drug Names in the drug label.

# Drug Shortage Status
Drug Shortage

# Price