INAVO120
The safety of ITOVEBI was evaluated in a randomized, double-blind, placebo-controlled study (INAVO120) in 324 patients with PIK3CA-mutated, HR-positive, HER2-negative, locally advanced or metastatic breast cancer [see Clinical Studies (14.1)].
Patients received either ITOVEBI 9 mg (n=162) or placebo (n=162) with palbociclib and fulvestrant. The median duration of treatment with ITOVEBI was 9 months (range: 0 to 39 months) in the ITOVEBI with palbociclib and fulvestrant arm.
Serious adverse reactions occurred in 24% of patients who received ITOVEBI with palbociclib and fulvestrant. Serious adverse reactions in ≥ 1% of patients included anemia (1.9%), diarrhea (1.2%), and urinary tract infection (1.2%).
Fatal adverse reactions occurred in 3.7% of patients who received ITOVEBI with palbociclib and fulvestrant, including (0.6% each) acute coronary syndrome, cerebral hemorrhage, cerebrovascular accident, COVID-19 infection, and gastrointestinal hemorrhage.
Permanent discontinuation of ITOVEBI due to an adverse reaction occurred in 6% of patients. Adverse reactions which resulted in permanent discontinuation of ITOVEBI included hyperglycemia (1.2%), and (0.6% each) stomatitis, gastric ulcer, intestinal perforation, anal abscess, increased ALT, decreased weight, bone pain, musculoskeletal pain, transitional cell carcinoma, and acute kidney injury.
Dosage interruptions of ITOVEBI due to an adverse reaction occurred in 69% of patients. Adverse reactions which required dosage interruption in ≥ 2% of patients included hyperglycemia (28%), neutropenia (23%), COVID-19 infection (16%), stomatitis (10%), diarrhea (7%), thrombocytopenia (4.9%), anemia (4.3%), upper respiratory tract infection (4.3%), decreased white blood cell count (3.7%), pyrexia (3.1%), nausea (2.5%), and fatigue (2.5%).
Dose reductions of ITOVEBI due to adverse reactions occurred in 14% of patients. Adverse reactions which required dose reduction of ITOVEBI in ≥ 2% of patients were stomatitis (3.7%) and hyperglycemia (2.5%).
The most common (≥ 20%) adverse reactions, including laboratory abnormalities, were decreased neutrophils, decreased hemoglobin, increased fasting glucose, decreased platelets, decreased lymphocytes, stomatitis, diarrhea, decreased calcium, fatigue, decreased potassium, increased creatinine, increased ALT, nausea, decreased sodium, decreased magnesium, rash, decreased appetite, COVID-19 infection, and headache.
Adverse reactions and laboratory abnormalities in INAVO120 are summarized in Table 3 and Table 4, respectively. Patient-reported symptoms are summarized in Table 5.
Table 3: Adverse Reactions (≥ 10% with ≥ 5% [All Grades] or ≥ 2% [Grade 3-4] Higher Incidence in the ITOVEBI Arm) in INAVO120| Adverse Reaction | ITOVEBI + Palbociclib + Fulvestrant N=162 | Placebo + Palbociclib + Fulvestrant N=162 |
|---|
All Grades (%) | Grade 3-4 (%) | All Grades (%) | Grade 3-4 (%) |
|---|
| Gastrointestinal Disorders |
| Stomatitis
| 51 | 6
| 27 | 0 |
| Diarrhea | 48 | 3.7
| 16 | 0 |
| Nausea | 28 | 0.6
| 17 | 0 |
| Vomiting | 15 | 0.6
| 5 | 1.2
|
| General Disorders and Administration Site Conditions |
| Fatigue | 38 | 1.9
| 25 | 1.2
|
| Skin and Subcutaneous Tissue Disorders |
| Rash
| 26 | 0 | 19 | 0 |
| Alopecia | 19 | 0 | 6 | 0 |
| Dry skin
| 13 | 0 | 4.3 | 0 |
| Metabolism and Nutrition Disorders |
| Decreased appetite | 24 | 0 | 9 | 0 |
| Infections and Infestations |
| COVID-19 infection | 23 | 1.9 | 11 | 0.6 |
| Urinary tract infection
| 15 | 1.2
| 9 | 0 |
| Nervous System Disorders |
| Headache
| 22 | 0 | 14 | 0 |
| Investigations |
| Decreased weight | 17 | 3.7
| 0.6 | 0 |
Clinically relevant adverse reactions occurring in < 10% of patients who received ITOVEBI in combination with palbociclib and fulvestrant included abdominal pain, dry eye, dysgeusia, and dyspepsia.
Table 4: Select Laboratory Abnormalities (≥ 10% with a ≥ 2% [All Grades or Grade 3-4] Higher Incidence in the ITOVEBI Arm) in INAVO120| Laboratory Abnormality | ITOVEBI + Palbociclib + Fulvestrant
| Placebo + Palbociclib + Fulvestrant
|
|---|
All Grades (%) | Grade 3-4 (%) | All Grades (%) | Grade 3-4 (%) |
|---|
| ALT = alanine aminotransferase |
| Hematology |
| Neutrophils (total, absolute) decreased | 95 | 82 | 97 | 79 |
| Hemoglobin decreased | 88 | 8
| 85 | 2.5
|
| Platelets decreased | 84 | 16 | 71 | 3.7 |
| Lymphocytes (absolute) decreased | 72 | 9 | 68 | 14 |
| Chemistry |
| Glucose (fasting) increased
| 85 | 12 | 43 | 0 |
| Calcium decreased | 42 | 3.1 | 32 | 3.7 |
| Potassium decreased | 38 | 6 | 21 | 0.6
|
| Creatinine increased | 38 | 1.9
| 30 | 1.2
|
| ALT increased | 34 | 3.1
| 29 | 1.2
|
| Sodium decreased | 28 | 2.5
| 19 | 2.5 |
| Magnesium decreased | 27 | 0.6 | 21 | 0 |
| Lipase (fasting) increased | 16 | 1.4
| 7 | 0 |
In INAVO120, patient-reported symptomatic toxicities (i.e., diarrhea, nausea, vomiting, fatigue, mouth sores, decreased appetite, and rash) were assessed via the Patient-Reported Outcomes – Common Terminology Criteria for Adverse Events (PRO-CTCAE) at baseline, every two weeks through Cycle 3 Day 15, and then Day 1 of every other 28-day cycle until treatment discontinuation.
Completion rates in both arms were > 90% at baseline and > 80% at subsequent time points where > 50% of randomized patients were on treatment.
Table 5: Patient-Reported Symptoms Assessed by PRO-CTCAE in INAVO120| ITOVEBI+P+F = ITOVEBI with palbociclib and fulvestrant arm; Placebo+P+F = placebo with palbociclib and fulvestrant arm. |
| Symptom (Attribute)
| Any Symptom Before Treatment (%)
| Any Worsening on Treatment (%)
| Worsening to Score 3 or 4 (%)
|
ITOVEBI + P + F (N=148)
| Placebo + P + F (N=152)
| ITOVEBI + P + F (N=148)
| Placebo + P + F (N=152)
| ITOVEBI + P + F (N=148)
| Placebo + P + F (N=152)
|
| Diarrhea (frequency), % | 23 | 15 | 78 | 49 | 32 | 8 |
| Nausea (frequency), % | 21 | 21 | 59 | 50 | 20 | 11 |
| Vomiting (frequency), % | 9 | 6 | 35 | 26 | 6 | 3.3 |
| Fatigue (severity), % | 72 | 69 | 72 | 58 | 32 | 22 |
| Mouth sores (severity), % | 11 | 14 | 74 | 52 | 30 | 9 |
| Decreased appetite (severity), % | 38 | 28 | 78 | 55 | 26 | 12 |
| Symptom (Attribute) | Baseline Presence | Post-baseline Presence |
ITOVEBI + P + F (N=148)
| Placebo + P + F (N=152)
| ITOVEBI + P + F (N=148)
| Placebo + P + F (N=152)
|
| Rash (yes), % | 5 | 5 | 50 | 38 |
Patient-reported overall side-effect impact was assessed using the Modified Bother Item (MBI). Patients provided a response to "I am bothered by side effects of treatment," and at baseline the proportion of patients with MBI responses of "not at all" were 70% in the ITOVEBI with palbociclib and fulvestrant arm and 76% in the placebo with palbociclib and fulvestrant arm. At Cycle 2 Day 15, the proportion of patients with MBI responses of "not at all" were 25% in the ITOVEBI with palbociclib and fulvestrant arm and 53% in the placebo with palbociclib and fulvestrant arm. Through 31 cycles of treatment, patients in the ITOVEBI with palbociclib and fulvestrant arm reported more side effect bother compared to the placebo with palbociclib and fulvestrant arm.