Ziv-aflibercept

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# Black Box Warning

# Overview
Ziv-aflibercept is an antineoplastic agent that is FDA approved for the treatment of patients with metastatic colorectal cancer (mCRC) that is resistant to or has progressed following an oxaliplatin-containing regimen. There is a Black Box Warning for this drug as shown here.  Common adverse reactions include angina,hypertension, pseudoaneurysm,hand-foot syndrome ,hyperpigmentation of skin,impaired wound healing.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Ziv-aflibercept, in combination with 5-fluorouracil, leucovorin, irinotecan-(FOLFIRI), is indicated for patients with metastatic colorectal cancer (mCRC) that is resistant to or has progressed following an oxaliplatin-containing regimen
- Administer Ziv-aflibercept 4 mg per kg as an intravenous (IV) infusion over 1 hour every two weeks. Administer Ziv-aflibercept prior to any component of the FOLFIRI regimen on the day of treatment .
- Continue Ziv-aflibercept until disease progression or unacceptable toxicity.
- Discontinue Ziv-aflibercept for:
- Severe hemorrhage
- Gastrointestinal perforation
- Compromised wound healing
- Fistula formation
- Hypertensive crisis or hypertensive encephalopathy
- Arterial thromboembolic events
- Nephrotic syndrome or thrombotic microangiopathy (TMA)
- Reversible posterior leukoencephalopathy syndrome (RPLS)
- Temporarily suspend Ziv-aflibercept:
- At least 4 weeks prior to elective surgery
- For recurrent or severe hypertension, until controlled. Upon resumption, permanently reduce the Ziv-aflibercept dose to 2 mg per kg
- For proteinuria of 2 grams per 24 hours. Resume when proteinuria is less than 2 grams per 24 hours. For recurrent proteinuria, suspend Ziv-aflibercept until proteinuria is less than 2 grams per 24 hours and then permanently reduce the Ziv-aflibercept dose to 2 mg per kg.
- For toxicities related to irinotecan, 5-fluorouracil (5-FU), or leucovorin, refer to the current respective prescribing information.
- Inspect vials visually prior to use. Ziv-aflibercept is a clear, colorless to pale yellow solution. Do not use vial if the solution is discolored or cloudy or if the solution contains particles.
- Do not re-enter the vial after the initial puncture. Discard any unused portion left in the vial.
- Withdraw the prescribed dose of Ziv-aflibercept and dilute in 0.9% sodium chloride solution, USP or 5% dextrose solution for injection, USP to achieve a final concentration of 0.68 mg/mL.
- Use polyvinyl chloride (PVC) infusion bags containing bis (2-ethylhexyl) phthalate (DEHP) or polyolefin infusion bags.
- Store diluted Ziv-aflibercept at 28C (3646F) for up to 24 hours, or at controlled room temperature 2025C (6877F) for up to 8 hours. Discard any unused portion left in the infusion bag.
- Administer the diluted Ziv-aflibercept solution as an intravenous infusion over 1 hour through a 0.2 micron polyethersulfone filter. Do not use filters made of polyvinylidene fluoride (PVDF) or nylon.
- Do not administer as an intravenous (IV) push or bolus.
- Do not combine Ziv-aflibercept with other drugs in the same infusion bag or intravenous line.
- Administer Ziv-aflibercept using an infusion set made of one of the following materials:
- PVC containing DEHP
- DEHP free PVC containing trioctyl-trimellitate (TOTM)
- polypropylene
- polyethylene lined PVC
- polyurethane

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ziv-aflibercept in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Ziv-aflibercept in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Ziv-aflibercept in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Ziv-aflibercept in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Ziv-aflibercept in pediatric patients.

# Contraindications
- None

# Warnings
- Patients treated with Ziv-aflibercept have an increased risk of hemorrhage, including severe and sometimes fatal hemorrhagic events. In patients with mCRC, bleeding/hemorrhage (all grades) were reported in 38% of patients treated with Ziv-aflibercept/FOLFIRI compared to 19% of patients treated with placebo/FOLFIRI. Grade 34 hemorrhagic events, including gastrointestinal hemorrhage, hematuria, and post-procedural hemorrhage, were reported in 3% of patients receiving Ziv-aflibercept/FOLFIRI compared with 1% of patients receiving placebo/FOLFIRI. Severe intracranial hemorrhage and pulmonary hemorrhage/hemoptysis including fatal events have also occurred in patients receiving Ziv-aflibercept.
- Monitor patients for signs and symptoms of bleeding. Do not initiate Ziv-aflibercept in patients with severe hemorrhage. Discontinue Ziv-aflibercept in patients who develop severe hemorrhage.
- Gastrointestinal (GI) perforation including fatal GI perforation can occur in patients receiving Ziv-aflibercept. Across three Phase 3 placebo-controlled clinical studies (colorectal, pancreatic, and lung cancer populations), the incidence of GI perforation (all grades) was 0.8% for patients treated with Ziv-aflibercept and 0.3% for patients treated with placebo. Grade 34 GI perforation events occurred in 0.8% of patients treated with Ziv-aflibercept and 0.2% of patients treated with placebo.
- Monitor patients for signs and symptoms of GI perforation. Discontinue Ziv-aflibercept therapy in patients who experience GI perforation .
- Ziv-aflibercept impairs wound healing in animal models .
- Grade 3 compromised wound healing was reported in 2 patients (0.3%) treated with Ziv-aflibercept/FOLFIRI regimen and in none of the patients treated with placebo/FOLFIRI regimen.
- Suspend Ziv-aflibercept for at least 4 weeks prior to elective surgery. Do not resume Ziv-aflibercept for at least 4 weeks following major surgery and until the surgical wound is fully healed. For minor surgery such as central venous access port placement, biopsy, and tooth extraction, Ziv-aflibercept may be initiated/resumed once the surgical wound is fully healed. Discontinue Ziv-aflibercept in patients with compromised wound healing .
- Fistula formation involving gastrointestinal and non-gastrointestinal sites occurs at a higher incidence in patients treated with Ziv-aflibercept. In patients with mCRC, Fistulas (anal, enterovesical, enterocutaneous, colovaginal, intestinal sites) were reported in 9 of 611 patients (1.5%) treated with Ziv-aflibercept/FOLFIRI regimen and 3 of 605 patients (0.5%) treated with placebo/FOLFIRI regimen. Grade 3 GI Fistula formation occurred in 2 patients treated with Ziv-aflibercept (0.3%) and in 1 placebo-treated patient (0.2%).
- Discontinue Ziv-aflibercept therapy in patients who develop Fistula .
- Ziv-aflibercept increases the risk of Grade 34 hypertension. There is no clinical trial experience administering Ziv-aflibercept to patients with NYHA class III or IV heart failure. In patients with mCRC, Grade 3 hypertension (defined as requiring adjustment in existing anti-hypertensive therapy or treatment with more than one drug) was reported in 1.5% of patients treated with placebo/FOLFIRI and 19% of patients treated with Ziv-aflibercept/FOLFIRI. Grade 4 hypertension (Hypertensive crisis) was reported in 1 patient (0.2%) treated with Ziv-aflibercept/FOLFIRI. Among those patients treated with Ziv-aflibercept/FOLFIRI developing Grade 34 hypertension, 54% had onset during the first two cycles of treatment.
- Monitor blood pressure every two weeks or more frequently as clinically indicated during treatment with Ziv-aflibercept. Treat with appropriate anti-hypertensive therapy and continue monitoring blood pressure regularly. Temporarily suspend Ziv-aflibercept in patients with uncontrolled hypertension until controlled, and permanently reduce Ziv-aflibercept dose to 2 mg per kg for subsequent cycles. Discontinue Ziv-aflibercept in patients with Hypertensive crisis or hypertensive encephalopathy .
- Arterial thromboembolic events (ATE), including transient ischemic attack, cerebrovascular accident, and angina pectoris, occurred more frequently in patients who have received Ziv-aflibercept. In patients with mCRC, ATE was reported in 2.6% of patients treated with Ziv-aflibercept/FOLFIRI and 1.7% of patients treated with placebo/FOLFIRI. Grade 34 events occurred in 11 patients (1.8%) treated with Ziv-aflibercept/FOLFIRI and 4 patients (0.7%) treated with placebo/FOLFIRI.
- Discontinue Ziv-aflibercept in patients who experience an ATE .
- Severe proteinuria, Nephrotic syndrome, and thrombotic microangiopathy (TMA) occurred more frequently in patients treated with Ziv-aflibercept. In patients with mCRC, proteinuria was reported in 62% patients treated with Ziv-aflibercept/FOLFIRI compared to 41% patients treated with placebo/FOLFIRI. Grade 34 proteinuria occurred in 8% of patients treated with Ziv-aflibercept/FOLFIRI to 1% of patients treated with placebo/FOLFIRI . Nephrotic syndrome occurred in 2 patients (0.5%) treated with Ziv-aflibercept/FOLFIRI compared to none of the patients treated with placebo/FOLFIRI. TMA was reported in 3 of 2258 patients with cancer enrolled across completed studies.
- Monitor proteinuria by urine dipstick analysis and/or urinary protein creatinine ratio (UPCR) for the development or worsening of proteinuria during Ziv-aflibercept therapy. Patients with a dipstick of 2+ for protein or a UPCR greater than 1 should undergo a 24-hour urine collection.
- Suspend Ziv-aflibercept administration for proteinuria 2 grams per 24 hours or more, and resume when proteinuria is less than 2 grams per 24 hours. If recurrent, suspend until proteinuria is less than 2 grams per 24 hours and then permanently reduce the Ziv-aflibercept dose to 2 mg per kg. Discontinue Ziv-aflibercept in patients who develop Nephrotic syndrome or TMA .
- A higher incidence of neutropenic complications (febrile neutropenia and neutropenic infection) occurred in patients receiving Ziv-aflibercept. In patients with mCRC, Grade 34 neutropenia occurred in 37% of patients treated with Ziv-aflibercept/FOLFIRI compared to 30% patients treated with placebo/FOLFIRI . Grade 34 febrile neutropenia occurred in 4% of patients treated with Ziv-aflibercept/FOLFIRI compared to 2% of patients treated with placebo/FOLFIRI. Grade 34 neutropenic infection/sepsis occurred in 1.5% of patients treated with Ziv-aflibercept/FOLFIRI and 1.2% of patients treated with placebo/FOLFIRI.
- Monitor CBC with differential count at baseline and prior to initiation of each cycle of Ziv-aflibercept. Delay Ziv-aflibercept/FOLFIRI until neutrophil count is at or above 1.5  109/L.
- The incidence of severe diarrhea is increased in patients treated with Ziv-aflibercept/FOLFIRI. In patients with mCRC, Grade 34 diarrhea was reported in 19% of patients treated with Ziv-aflibercept/FOLFIRI compared to 8% of patients treated with placebo/FOLFIRI. Grade 34 dehydration was reported in 4% of patients treated with Ziv-aflibercept/FOLFIRI compared to 1% of patients treated with placebo/FOLFIRI . The incidence of diarrhea is increased in patients who are age 65 years or older as compared to patients younger than 65 years of age . Monitor elderly patients closely for diarrhea.
- RPLS (also known as posterior reversible encephalopathy syndrome) was reported in 0.5% of 3795 patients treated with Ziv-aflibercept monotherapy or in combination with chemotherapy.
- Confirm the diagnosis of RPLS with MRI and discontinue Ziv-aflibercept in patients who develop RPLS. Symptoms usually resolve or improve within days, although some patients have experienced ongoing neurologic sequelae or death

# Adverse Reactions

## Clinical Trials Experience
- The following serious adverse reactions are discussed elsewhere in the labeling:
- hemorrhage
- Gastrointestinal perforation
- Compromised wound healing
- Fistula Formation
- hypertension
- Arterial Thromboembolic Events
- proteinuria
- Neutropenia and Neutropenic Complications
- diarrhea and Dehydration
- Reversible posterior leukoencephalopathy syndrome (RPLS)
- Because clinical trials are conducted under varying designs and in different patient populations, the adverse reaction rates reported in one clinical trial may not be easily compared to those rates reported in another clinical trial, and may not reflect the rates actually observed in clinical practice.
- The safety of Ziv-aflibercept in combination with FOLFIRI was evaluated in 1216 previously treated patients with metastatic colorectal cancer (Study 1) who were treated with Ziv-aflibercept 4 mg per kg intravenous (N=611) or placebo (N=605) every two weeks (one cycle) in a randomized (1:1), double-blind, placebo-controlled Phase 3 study. Patients received a median of 9 cycles of Ziv-aflibercept/FOLFIRI or 8 cycles of placebo/FOLFIRI.
- The most common adverse reactions (all grades, 20% incidence) reported at a higher incidence (2% or greater between-arm difference) in the Ziv-aflibercept/FOLFIRI arm , in order of decreasing frequency, were leukopenia, diarrhea, neutropenia, proteinuria, AST increased, stomatitis, fatigue, thrombocytopenia, ALT increased, hypertension, weight decreased, decreased appetite, epistaxis, abdominal pain, dysphonia, serum creatinine increased, and headache (see TABLE 1).
- The most common Grade 34 adverse reactions (5%) reported at a higher incidence (2% or greater between-arm difference) in the Ziv-aflibercept/FOLFIRI arm, in order of decreasing frequency, were neutropenia, diarrhea, hypertension, leukopenia, stomatitis, fatigue, proteinuria, and asthenia (seeTABLE 1).
- The most frequent adverse reactions leading to permanent discontinuation in 1% of patients treated with Ziv-aflibercept/FOLFIRI regimen were asthenia/fatigue, infections, diarrhea, dehydration, hypertension, stomatitis, venous thromboembolic events, neutropenia, and proteinuria.
- The Ziv-aflibercept dose was reduced and/or omitted in 17% of patients compared to placebo-dose modification in 5% of patients. Cycle delays >7 days occurred in 60% of patients treated with Ziv-aflibercept/FOLFIRI compared with 43% of patients treated with placebo/FOLFIRI.
- The most common adverse reactions and laboratory abnormalities during study treatment in Study 1 where the incidence was 5% (all grades) in patients receiving Ziv-aflibercept in combination with FOLFIRI and which occurred at 2% higher frequency in patients treated with Ziv-aflibercept/FOLFIRI compared to placebo/FOLFIRI are shown in Table 1.
- Infections occurred at a higher frequency in patients receiving Ziv-aflibercept/FOLFIRI (46%, all grades; 12%, Grade 34) than in patients receiving placebo/FOLFIRI (33%, all grades; 7%, Grade 34), including urinary tract infection, nasopharyngitis, upper respiratory tract infection, pneumonia, catheter site infection, and tooth infection.
- In patients with mCRC, severe hypersensitivity reactions have been reported with Ziv-aflibercept/FOLFIRI (0.3%) and placebo/FOLFIRI (0.5%).
- In patients with mCRC, venous thromboembolic events (VTE), consisting primarily of deep venous thrombosis and pulmonary embolism, occurred in 9% of patients treated with Ziv-aflibercept/FOLFIRI and 7% of patients treated with placebo/FOLFIRI. Grade 34 VTE occurred in 8% of patients treated with Ziv-aflibercept/FOLFIRI and in 6% of patients treated with placebo/FOLFIRI. Pulmonary embolism occurred in 5% of patients treated with Ziv-aflibercept/FOLFIRI and 3.4% of patients treated with placebo/FOLFIRI.
- As with all therapeutic proteins, there is a potential for immunogenicity. In patients with various cancers across 15 studies, 1.4% (41/2862) of patients tested positive for anti-product antibody (APA) at baseline. The incidence of APA development was 3.1% (53/1687) in patients receiving intravenous ziv-aflibercept and 1.7% (19/1134) in patients receiving placebo. Among patients who tested positive for APA and had sufficient samples for further testing, neutralizing antibodies were detected in 17 of 48 ziv-aflibercept-treated patients and in 2 of 40 patients receiving placebo.
- The mean free ziv-aflibercept trough concentrations were lower in patients with positive neutralizing antibodies than in the overall population. The impact of neutralizing antibodies on efficacy and safety could not be assessed based on limited available data.
- Immunogenicity data are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to Ziv-aflibercept with the incidence of antibodies to other products may be misleading.

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

# Drug Interactions
- No dedicated drug-drug interaction studies have been conducted for Ziv-aflibercept. No clinically important pharmacokinetic drug-drug interactions were found between ziv-aflibercept and irinotecan/SN-38 or 5-FU, based on cross-study comparisons and population pharmacokinetic analyses.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
- There are no adequate and well-controlled studies with Ziv-aflibercept in pregnant women. Ziv-aflibercept was embryotoxic and teratogenic in rabbits at exposure levels lower than human exposures at the recommended dose, with increased incidences of external, visceral, and skeletal fetal malformations.Ziv-aflibercept should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
- Ziv-aflibercept produced embryo-fetal toxicity when administered every 3 days during organogenesis in pregnant rabbits at all intravenous doses tested,  3 mg per kg. Adverse embryo-fetal effects included increased incidences of postimplantation losses and external (including anasarca, umbilical hernia, diaphragmatic hernia and gastroschisis, cleft palate, ectrodactyly, and atresia), visceral (in the heart, great vessels, and arteries), and skeletal fetal malformations (including fused vertebrae, sternebrae, and ribs; supernumerary arches and ribs, and incomplete ossification). Administration of the 3 mg per kg dose to rabbits resulted in systemic exposure (AUC) that was approximately 30% of the AUC in patients at the recommended dose. The incidence and severity of fetal anomalies increased with increasing dose.
Pregnancy Category (AUS):
- There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of aflibercept in women who are pregnant.

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

### Nursing Mothers
- It is not known whether Ziv-aflibercept is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Ziv-aflibercept, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

### Pediatric Use
- The safety and effectiveness in pediatric patients have not been established

### Geriatic Use
- Of the 611 patients with mCRC, patients treated with Ziv-aflibercept/FOLFIRI, 205 (34%) were 65 years or older, and 33 (5%) were 75 years or older. Elderly patients (65 years of age) experienced higher incidences (5%) of diarrhea, dizziness, asthenia, weight decrease, and dehydration when compared to younger patients. Monitor elderly patients more closely for diarrhea and dehydration
- The effect of Ziv-aflibercept on overall survival was similar in patients <65 years old and 65 years old who received Ziv-aflibercept/FOLFIRI.
- No dose adjustment of Ziv-aflibercept is recommended for patients greater than or equal to 65 years of age.

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

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

### Renal Impairment
- No dedicated clinical studies have been conducted to evaluate the effect of renal impairment on the pharmacokinetics of ziv-aflibercept.
- Based on a population PK analysis with data from 1507 patients, ziv-aflibercept exposure in patients with mild, moderate, and severe renal impairment were similar to those in patients with normal renal function

### Hepatic Impairment
- No dedicated clinical studies have been conducted to evaluate the effect of hepatic impairment on the pharmacokinetics of ziv-aflibercept.
- Based on a population PK analysis with data from 1507 patients, ziv-aflibercept exposure in patients with mild and moderate hepatic impairment were similar to those in patients with normal hepatic function . There are no data available for patients with severe hepatic impairment.

### Females of Reproductive Potential and Males
- Male and female reproductive function and fertility may be compromised during treatment with Ziv-aflibercept, as suggested by findings in monkeys . These animal findings were reversible within 18 weeks after cessation of treatment. Females and males of reproductive potential should use highly effective contraception during and up to a minimum of 3 months after the last dose of treatment.

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

# Administration and Monitoring

### Administration
- Oral
- Intravenous

### Monitoring
There is limited information regarding Monitoring of aflibercept in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of aflibercept in the drug label.

# Overdosage
- There have been no cases of overdose reported with Ziv-aflibercept. There is no information on the safety of Ziv-aflibercept given at doses exceeding 7 mg per kg every 2 weeks or 9 mg per kg every 3 weeks.

# Pharmacology

## Mechanism of Action
- Ziv-aflibercept acts as a soluble receptor that binds to human VEGF-A (equilibrium dissociation constant KD of 0.5 pM for VEGF-A165 and 0.36 pM for VEGF-A121), to human VEGF-B (KD of 1.92 pM), and to human PlGF (KD of 39 pM for PlGF-2). By binding to these endogenous ligands, ziv-aflibercept can inhibit the binding and activation of their cognate receptors. This inhibition can result in decreased neovascularization and decreased vascular permeability.
- In animals, ziv-aflibercept was shown to inhibit the proliferation of endothelial cells, thereby inhibiting the growth of new blood vessels. Ziv-aflibercept inhibited the growth of xenotransplanted colon tumors in mice.

## Structure
- Ziv-aflibercept is a recombinant fusion protein consisting of Vascular Endothelial Growth Factor (VEGF)-binding portions from the extracellular domains of human VEGF Receptors 1 and 2 fused to the Fc portion of the human IgG1. Ziv-aflibercept is produced by recombinant DNA technology in a Chinese hamster ovary (CHO) K-1 mammalian expression system. Ziv-aflibercept is a dimeric glycoprotein with a protein molecular weight of 97 kilodaltons (kDa) and contains glycosylation, constituting an additional 15% of the total molecular mass, resulting in a total molecular weight of 115 kDa.
- Ziv-aflibercept is a sterile, clear, colorless to pale yellow, non-pyrogenic, preservative-free, solution for administration by intravenous infusion. Ziv-aflibercept is supplied in single-use vials of 100 mg per 4 ml and 200 mg per 8 ml formulated as 25 mg/mL ziv-aflibercept in polysorbate 20 (0.1%), sodium chloride (100 mM), sodium citrate (5 mM), sodium phosphate (5 mM), and sucrose (20%), in Water for Injection USP, at a pH of 6.2.

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of aflibercept in the drug label.

## Pharmacokinetics
- Plasma concentrations of free and VEGF-bound ziv-aflibercept were measured using specific enzyme-linked immunosorbent assays (ELISAs). Free ziv-aflibercept concentrations appear to exhibit linear pharmacokinetics in the dose range of 29 mg/kg. Following 4 mg/kg every two weeks intravenous administration of Ziv-aflibercept, the elimination half-life of free ziv-aflibercept was approximately 6 days (range 47 days). Steady state concentrations of free ziv-aflibercept were reached by the second dose. The accumulation ratio for free ziv-aflibercept was approximately 1.2 after administration of 4 mg/kg every two weeks.
- Based on a population pharmacokinetic analysis, age, race, and gender did not have a clinically important effect on the exposure of free ziv-aflibercept. Patients weighing 100 kg had a 29% increase in systemic exposure compared to patients weighing 50 to 100 kg.
- Based on a population pharmacokinetic analysis which included patients with mild (total bilirubin >1.01.5 ULN and any SGOT/AST, n=63) and moderate (total bilirubin >1.53 ULN and any SGOT/AST, n=5) hepatic impairment, there was no effect of total bilirubin, aspartate amino transferase, and alanine amino transferase on the clearance of free ziv-aflibercept. There is no data available for patients with severe hepatic impairment (total bilirubin >3 ULN and any SGOT/AST).
- Based on a population pharmacokinetic analysis which included patients with mild (CLCR 5080 mL/min, n=549), moderate (CLCR 3050 mL/min, n=96), and severe renal impairment (CLCR <30 mL/min, n=5), there was no clinically important effect of creatinine clearance on the clearance of free ziv-aflibercept.
- The effect of 6 mg/kg intravenous Ziv-aflibercept every three weeks on QTc interval was evaluated in 87 patients with solid tumors in a randomized, placebo-controlled study. No large changes in the mean QT interval from baseline (i.e., greater than 20 ms as corrected for placebo) based on Fridericia correction method were detected in the study. However, a small increase in the mean QT interval (i.e., less than 10 ms) cannot be excluded due to limitations of the study design.

## Nonclinical Toxicology
- No studies have been conducted to evaluate carcinogenicity or mutagenicity of ziv-aflibercept.
- Ziv-aflibercept impaired reproductive function and fertility in monkeys. In a 6-month repeat-dose toxicology study in sexually mature monkeys, ziv-aflibercept inhibited ovarian function and follicular development, as evidenced by: decreased ovary weight, decreased amount of luteal tissue, decreased number of maturing follicles, atrophy of uterine endometrium and myometrium, vaginal atrophy, abrogation of progesterone peaks and menstrual bleeding. Alterations in sperm morphology and decreased sperm motility were noted in male monkeys. These effects were observed at all doses tested including the lowest dose tested, 3 mg per kg. Reversibility was observed within 18 weeks after cessation of treatment. Systemic exposure (AUC) with a 3 mg per kg per dose in monkeys was approximately 60% of the AUC in patients at the recommended dose.
- Weekly/every two weeks intravenous administration of ziv-aflibercept to growing young adult (sexually mature) cynomolgus monkeys for up to 6 months resulted in changes in the bone (effects on growth plate and the axial and appendicular skeleton), nasal cavity (atrophy/loss of the septum and/or turbinates), kidney (glomerulopathy with inflammation), ovary (decreased number of maturing follicles, granulosa cells, and/or theca cells), and adrenal gland (decreased vacuolation with inflammation). Most ziv-aflibercept-related findings were noted from the lowest dose tested (3 mg per kg per dose) correlating to 60% of the AUC at the human recommended dose.
- In another study in sexually immature cynomolgus monkeys (treated intravenous for 3 months), similar effects were observed. The skeletal and nasal cavity effects were not reversible after a post-dosing recovery period.
- Repeated administration of ziv-aflibercept resulted in a delay in wound healing in rabbits. In full-thickness excisional and incisional skin wound models, ziv-aflibercept administration reduced fibrous response, neovascularization, epidermal hyperplasia/re-epithelialization, and tensile strength.

# Clinical Studies
- Study 1 was a randomized, double-blind, placebo-controlled study in patients with metastatic colorectal cancer (mCRC) who are resistant to or have progressed during or within 6 months of receiving oxaliplatin-based combination chemotherapy, with or without prior bevacizumab. A total of 1226 patients were randomized (1:1) to receive either Ziv-aflibercept (N=612; 4 mg per kg as a 1 hour intravenous infusion on day 1) or placebo (N=614), in combination with 5-fluorouracil plus irinotecan . The treatment cycles on both arms were repeated every 2 weeks. Patients were treated until disease progression or unacceptable toxicity. The primary efficacy endpoint was overall survival. Treatment assignment was stratified by the ECOG performance status (0 versus 1 versus 2) and according to prior therapy with bevacizumab (yes or no).
- Demographics characteristics were similar between treatment arms. Of the 1226 patients randomized, the median age was 61 years, 59% were men, 87% were White, 7% were Asian, 3.5% were Black, and 98% had a baseline ECOG performance status (PS) of 0 or 1. Among the 1226 randomized patients, 89% and 90% of patients treated with placebo/FOLFIRI and Ziv-aflibercept/FOLFIRI, respectively, received prior oxaliplatin-based combination chemotherapy in the metastatic/advanced setting. A total of 346 patients (28%) received bevacizumab in combination with the prior oxaliplatin-based treatment.
- Overall efficacy results for the Ziv-aflibercept/FOLFIRI regimen versus the placebo/FOLFIRI regimen are summarized in Figure 1 and Table 2.
- Planned subgroup analyses for overall survival based on stratification factors at randomization yielded an HR of 0.86 (95% CI: 0.68 to 1.1) in patients who received prior bevacizumab and an HR of 0.79 (95% CI: 0.67 to 0.93) in patients without prior bevacizumab exposure.

# How Supplied
- Ziv-aflibercept is supplied in 5 mL and 10 mL vials containing ziv-aflibercept at a concentration of 25 mg/mL.
- NDC 0024-5840-01: carton containing one (1) single-use vial of 100 mg per 4mL (25 mg/mL)
- NDC 0024-5840-03: carton containing three (3) single-use vials of 100 mg per 4 mL (25 mg/mL)
- NDC 0024-5841-01: carton containing one (1) single-use vial of 200 mg per 8 mL (25 mg/mL)
Storage and Handling
- Store Ziv-aflibercept vials in a refrigerator at 2 to 8C (36 to 46F). Keep the vials in the original outer carton to protect from light.

## Storage
There is limited information regarding Ziv-aflibercept Storage in the drug label.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Advise patients:
- That Ziv-aflibercept can cause severe bleeding. Advise patients to contact their health care provider for bleeding or symptoms of bleeding including lightheadedness.
- That Ziv-aflibercept increases the risk of compromised wound healing. Instruct patients not to undergo surgery or procedures (including tooth extractions) without discussing first with their health care provider.
- That Ziv-aflibercept can cause or exacerbate existing hypertension. Advise patients to undergo routine blood pressure monitoring and to contact their health care provider if blood pressure is elevated or if symptoms from hypertension occur including severe headache, lightheadedness, or neurologic symptoms.
- To notify the health care provider of severe diarrhea, vomiting, or severe abdominal pain.
- To notify their health care provider of fever or other signs of infection.
- Of an increased risk of arterial thromboembolic events.
- Of the potential risks to the fetus or neonate using Ziv-aflibercept during pregnancy or nursing and of the need to use highly effective contraception in both males and females during and for at least 3 months following last dose of Ziv-aflibercept therapy. Advise the patient to immediately contact the healthcare provider if they or their partner becomes pregnant during treatment with Ziv-aflibercept.

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

# Brand Names
- Zaltrap

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

# Drug Shortage Status

# Price