Written by: Andrew Ruplin, PharmD, Seattle Cancer Care Alliance
The purpose of this PQI is understand the management techniques and interventions when utilizing enfortumab vedotin.
Enfortumab vedotin is a nectin-4 targeting antibody conjugated to the microtubule inhibitor monomethyl auristatin E (MMAE).1 Enfortumab vedotin was granted accelerated approval by the FDA for the treatment of advanced or metastatic urothelial carcinoma in patients who have previously received a programmed death receptor (PD-1) or programmed death receptor (PD-L1) inhibitor, and a platinum-based chemotherapy in the neoadjuvant/adjuvant, locally advanced, or metastatic setting.1 In the pivotal phase II trial, patients were heavily pretreated (50% received ≥3 prior treatments), and the objective response rate was 44%, including 12% complete responses.2 Adverse effects were common, and 54% of patients had a grade ≥ 3 treatment-related adverse event, but these adverse events were manageable and no single grade ≥ 3 adverse event occurred in more than 10% of patients.2 Treatment-related adverse effects led to dose reduction in 32% of patients and discontinuation in 12% of patients.2
Upon order of enfortumab vedotin administration
- Confirm appropriateness of enfortumab vedotin utilizing the EMR
- Review the adverse events Table (#1) on Page 2 with the interventions suggested as needed.
- Review Table (#2) on Page 3 for dose specific adjustments as required
- Drug Interaction Considerations1
- Enfortumab vedotin is metabolized via CYP 3A4, and concomitant use of an antibody-drug conjugate containing MMAE and strong CYP3A4 inhibitors should be considered. Dose adjustment is typically not required.
Table 1: Selected Adverse Events and interventions suggested
|Skin Reactions||54% (any Grade)1||Fragrance-free moisturizers/ointments|
Topical steroids as indicated
Systemic steroids as indicated
|Median time of onset for severe skin reactions was 0.8 months (range 0.2 – 5.3).1|
|Hyperglycemia||11% (any Grade)1 regardless of known hyperglycemia at baseline.|
68% of patients with baseline hyperglycemia did not experience worsening
|Blood glucose test prior to infusion|
(If unable: a basic metabolic panel is possible to use).
Does not need to be fasting.
|BMI and elevated A1c correlated to a higher incidence of Grade 3/4 hyperglycemia.1|
Patients with baseline A1c ≥ 8% were excluded from the trial.1,2
Patients with baseline A1c ≥ 6.5% should be referred to an appropriate provider for glucose management.1
|Ocular Toxicity||Ocular disorders including blurred vision – 46%1|
Dry eye symptoms – 36%1
|Consider prophylactic artificial tears1|
Consider topical ophthalmic steroids after ophthalmic exams1
|Median time to onset for ocular disorders was 1.9 months (range 0.3 – 6.2).1|
|Neuropathy||49% (any Grade).1 |
Peripheral sensory neuropathy was the most common reason for dose reduction.
|Recommend dose reduction as initial strategy|
Consider use of gabapentin/duloxetine
|The median time to onset of Grade ≥ 2 was 3.8 months (range: 0.6 – 9.2).|
At the last follow-up in the trial, 19% had complete resolution and 26% had partial improvement. 76% had resolution or ongoing Grade 1 neuropathy.
|Diarrhea||42% (any Grade)1||Prepare anti-diarrheal medications for patient as needed|
Table 2: Dose Adjustments for Adverse Events1
|Administration||IV infusion over 30 minutes on days 1, 8, 15 of a 28-day cycle until progression or toxicity|
|Starting dose||1.25 mg/kg up to 125 mg*|
|First dose reduction||1 mg/kg up to 100 mg*|
|Second dose reduction||0.75 mg/kg up to 75 mg*|
|Third dose reduction||0.5 mg/kg up to 50 mg*|
|Renal/hepatic dysfunction considerations||No dose adjustment is required for renal dysfunction|
No current studies in moderate to severe hepatic dysfunction – consider avoiding use in this scenario. Mild hepatic dysfunction does not require an upfront dose reduction.
|Adverse Event||Grade/Severity||Dose Modification|
> 250 mg/dL
|Withhold until ≤ 250 mg/dL, then resume at same dose level.|
|Peripheral neuropathy||2||Withhold until Grade ≤ 1, then resume at same dose level. If recurrence, withhold until Grade ≤ 1, then resume and reduce one dose level.|
|≥ 3||Permanently discontinue|
|Skin reactions||3||Withhold until Grade ≤ 1, then resume at same dose level or consider reducing by one dose level|
|4 or recurrent 3||Permanently discontinue|
|Other non-hematologic toxicities||3||Withhold until Grade ≤ 1, then resume at same dose level or consider reducing by one dose level|
|Hematologic toxicity||3 or Grade 2 thrombocytopenia||Withhold until Grade ≤ 1, then resume at same dose level or consider reducing by one dose level|
|4||Withhold until Grade ≤ 1, then resume and reduce one dose level or discontinue treatment|
*Based on actual body weight. Dose is capped for patients ≥100 kg
Patient Centered Activities:
- Advise patients that skin toxicities for enfortumab vedotin are likely to manifest as dry skin, pruritus, and/or maculopapular rash.1
- Severe skin toxicities (10% incidence) included symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), bullous dermatitis, exfoliative dermatitis, and palmar-plantar erythrodysesthesia.1
- Advise patients to self-monitor for peripheral sensory neuropathy and motor neuropathy. Sensory neuropathy (44%) was more common than motor (14%).2
- Enfortumab vedotin has an NCCN emetic risk category of “Moderate” on the day of treatment and patients should receive anti-emetic medications prior to infusion according to institutional standards.3
- Padcev (enfortumab vedotin- ejfv) [Prescribing Information]. Bothell, WA: Seattle Genetics, Inc.; December 2019.
- Rosenberg JE, O’donnell PH, Balar AV, et al. Pivotal Trial of Enfortumab Vedotin in Urothelial Carcinoma After Platinum and Anti-Programmed Death 1/Programmed Death Ligand 1 Therapy. J Clin Oncol. 2019;37(29):2592-2600.
- National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Antiemesis. Version 1.2020. February 19, 2020.