4.1. Therapeutic indications

TALVEY is indicated as monotherapy for the treatment of adult patients with relapsed and refractory multiple myeloma, who have received at least 3 prior therapies, including an immunomodulatory agent, a proteasome inhibitor, and an anti‑CD38 antibody and have demonstrated disease progression on the last therapy.

4.2. Posology and method of administration

Treatment with TALVEY should be initiated and supervised by physicians experienced in the treatment of multiple myeloma.

TALVEY should be administered by a healthcare professional with adequately‑trained medical personnel and appropriate medical equipment to manage severe reactions, including cytokine release syndrome (CRS) and neurologic toxicity, including immune effector cell‑associated neurotoxicity syndrome (ICANS).

Posology

Pre‑treatment medicinal products should be administered prior to each dose of TALVEY during the step‑up phase (see below).

TALVEY should be administered subcutaneously on a weekly or biweekly (every 2 weeks) dosing schedule according to Table 1. Patients who receive talquetamab according to the 0.4 mg/kg body weight weekly dosing schedule and have attained an adequate clinical response that is confirmed in at least two consecutive disease assessments can be considered for switch to the 0.8 mg/kg body weight biweekly dosing schedule.

Table 1: Recommended TALVEY dose

Dosing schedule

Phase

Day

TALVEY dosea

Weekly dosing schedule

Step‑up phase

Day 1

0.01 mg/kg

Day 3b

0.06 mg/kg

Day 5b

0.4 mg/kg

Treatment phase

Once a week thereafterc

0.4 mg/kg

Biweekly (every 2 weeks) dosing schedule

Step‑up phase

Day 1

0.01 mg/kg

Day 3b

0.06 mg/kg

Day 5b

0.4 mg/kg

Day 7b

0.8 mg/kg

Treatment phase

Once every 2 weeks thereafterc

0.8 mg/kg

a Based on actual body weight and administered subcutaneously.

b Dose may be administered between 2 to 4 days after the previous dose and may be given up to 7 days after the previous dose to allow for resolution of adverse reactions.

c Maintain a minimum of 6 days between weekly doses and a minimum of 12 days between biweekly (every 2 weeks) doses.

Patients should be instructed to remain within proximity of a healthcare facility and monitored for 48 hours after administration of all doses within the TALVEY step‑up phase for signs and symptoms of CRS and ICANS (see section 4.4).

Duration of treatment

Patients should be treated with TALVEY until disease progression or unacceptable toxicity.

Pre‑treatment

The following pre‑treatment medicinal products must be administered 1 to 3 hours before each dose of TALVEY during the step‑up phase to reduce the risk of CRS (see section 4.4).

• Corticosteroid (oral or intravenous dexamethasone 16 mg or equivalent)

• Antihistamine (oral or intravenous diphenhydramine 50 mg or equivalent)

• Antipyretics (oral or intravenous paracetamol 650 mg to 1 000 mg or equivalent)

Pre‑treatment medicinal products should be administered prior to subsequent doses for patients who repeat doses within the TALVEY step‑up phase due to dose delays (see Table 2) or for patients who experienced CRS (see Table 3).

Prevention of infection

Prior to starting treatment with TALVEY, prophylaxis should be considered for the prevention of infections, per local institutional guidelines.

Dose delays

If a dose of TALVEY is delayed, therapy should be restarted based on recommendations in Table 2, and weekly or biweekly dosing should be resumed accordingly (see Posology above). Pre‑treatment medicinal products should be administered prior to restarting TALVEY, and patients should be monitored accordingly.

Table 2: Recommendations for restarting TALVEY after dose delay

Dosing schedule

Last dose administered

Time from last dose administered

TALVEY recommendation*

Weekly dosing schedule

0.01 mg/kg

More than 7 days

Restart at 0.01 mg/kg

0.06 mg/kg

8 to 28 days

Repeat 0.06 mg/kg

More than 28 days

Restart at 0.01 mg/kg

0.4 mg/kg

8 to 35 days

Repeat 0.4 mg/kg

36 to 56 days

Restart at 0.06 mg/kg

More than 56 days

Restart at 0.01 mg/kg

Biweekly

(every 2 weeks) dosing schedule

0.01 mg/kg

More than 7 days

Restart at 0.01 mg/kg

0.06 mg/kg

8 to 28 days

Repeat 0.06 mg/kg

More than 28 days

Restart at 0.01 mg/kg

0.4 mg/kg

8 to 35 days

Repeat 0.4 mg/kg

36 to 56 days

Restart at 0.06 mg/kg

More than 56 days

Restart at 0.01 mg/kg

0.8 mg/kg

14 to 35 days

Repeat 0.8 mg/kg

36 to 56 days

Restart at 0.4 mg/kg

More than 56 days

Restart at 0.01 mg/kg

* Administer pretreatment medicinal products prior to restarting TALVEY. After restarting TALVEY, resume weekly or biweekly (every 2 weeks) dosing accordingly (see section 4.2).

Dose modifications for adverse reactions

Dose delays may be required to manage toxicities related to TALVEY (see section 4.4). See Table 2 for recommendations on restarting TALVEY after a dose delay.

See Tables 3 and 4 for recommended actions for the management of CRS and ICANS. See Table 6 for recommended dose modifications for other adverse reactions.

Cytokine release syndrome (CRS)

CRS should be identified based on clinical presentation (see section 4.4). Other causes of fever, hypoxia, and hypotension should be evaluated and treated. If CRS is suspected, TALVEY should be withheld until CRS resolves and should be managed according to the recommendations in Table 3. Supportive therapy for CRS should be administered, which may include intensive care for severe or life‑threatening CRS. Laboratory testing should be considered to monitor for disseminated intravascular coagulation (DIC), haematology parameters, as well as pulmonary, cardiac, renal, and hepatic function.

Table 3: Recommendations for management of CRS

CRS Gradea

TALVEY actions

Tocilizumabb

Corticosteroidsc

Grade 1

Temperature ≥ 38°Cd

Withhold TALVEY until CRS resolves.

Administer pre‑treatment medicinal product prior to next dose of TALVEY.

May be considered.

Not applicable

Grade 2

Temperature ≥ 38°Cd with either:

• Hypotension responsive to fluids and not requiring vasopressors, or

• Oxygen requirement of low‑flow nasal cannulae or blow‑by.

Withhold TALVEY until CRS resolves.

Administer pre‑treatment medicinal products prior to next dose of TALVEY.

Monitor patient for 48 hours following the next dose of TALVEY. Instruct patients to remain within proximity of a healthcare facility during monitoring.

Administer tocilizumabc 8 mg/kg intravenously over 1 hour (not to exceed 800 mg).

Repeat tocilizumab every 8 hours as needed, if not responsive to intravenous fluids or increasing supplemental oxygen.

Limit to a maximum of 3 doses in a 24‑hour period; maximum total of 4 doses.

If no improvement within 24 hours of starting tocilizumab, administer methylprednisolone 1 mg/kg intravenously twice daily, or dexamethasone 10 mg intravenously every 6 hours.

Continue corticosteroid use until the event is Grade 1 or less, then taper over 3 days.

Grade 3

Temperature ≥ 38°Cd with either:

• Hypotension requiring one vasopressor, with or without vasopressin, or

• Oxygen requirement of high‑flow nasal cannulae, facemask, non‑rebreather mask, or Venturi mask

Duration < 48 hours

Per Grade 2.

Recurrent or

Duration ≥ 48 hours

Permanently discontinue TALVEY.

Administer tocilizumab 8 mg/kg intravenously over 1 hour (not to exceed 800 mg).

Repeat tocilizumab every 8 hours as needed, if not responsive to intravenous fluids or increasing supplemental oxygen.

Limit to a maximum of 3 doses in a 24‑hour period; maximum total of 4 doses.

If no improvement, administer methylprednisolone 1 mg/kg intravenously twice daily or dexamethasone (e.g., 10 mg intravenously every 6 hours).

Continue corticosteroid use until the event is Grade 1 or less, then taper over 3 days.

Grade 4

Temperature ≥ 38°Cd with either:

• Hypotension requiring multiple vasopressors (excluding vasopressin), or

• oxygen requirement of positive pressure (e.g., continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP], intubation, and mechanical ventilation)

Permanently discontinue TALVEY.

Administer tocilizumab 8 mg/kg intravenously over 1 hour (not to exceed 800 mg).

Repeat tocilizumab every 8 hours as needed, if not responsive to intravenous fluids or increasing supplemental oxygen.

Limit to a maximum of 3 doses in a 24‑hour period; maximum total of 4 doses.

As above or administer methylprednisolone 1 000 mg intravenously per day for 3 days, per physician discretion.

If no improvement or if condition worsens, consider alternate immunosuppressants.c

a Based on ASTCT grading for CRS (Lee et al 2019).

b Refer to tocilizumab prescribing information for details.

c Treat unresponsive CRS per institutional guidelines.

d Attributed to CRS. Fever may not always be present concurrently with hypotension or hypoxia as it may be masked by interventions such as antipyretics or anticytokine therapy (e.g., tocilizumab or corticosteroids).

e Low‑flow nasal cannula is ≤ 6 L/min, and high‑flow nasal cannula is > 6 L/min.

Neurologic toxicity, including ICANS

At the first sign of neurologic toxicity, including ICANS, TALVEY should be withheld and neurology evaluation should be considered. Other causes of neurologic symptoms should be ruled out. Supportive therapy should be provided, which may include intensive care, for severe or life‑threatening ICANS (see section 4.4). Management recommendations for ICANS are summarised in Table 4.

Table 4: Recommendations for management of ICANS

ICANS Gradea, b

Concurrent CRS

No concurrent CRS

Grade 1

ICEc score 7‑9

or depressed level of consciousnessd: awakens spontaneously.

Management of CRS per Table 3.

Monitor neurologic symptoms and consider neurology consultation and evaluation, per physician discretion.

Monitor neurologic symptoms and consider neurology consultation and evaluation, per physician discretion.

Withhold TALVEY until ICANS resolves.

Consider non‑sedating, anti‑seizure medicines (e.g., levetiracetam) for seizure prophylaxis.

Grade 2

ICEc score 3‑6

or depressed level of consciousnessd: awakens to voice.

Administer tocilizumab per Table 3 for management of CRS.

If no improvement after starting tocilizumab, administer dexamethasonee 10 mg intravenously every 6 hours if not already taking other corticosteroids. Continue dexamethasone use until resolution to Grade 1 or less, then taper.

Administer dexamethasonee 10 mg intravenously every 6 hours. Continue dexamethasone use until resolution to Grade 1 or less, then taper.

Withhold TALVEY until ICANS resolves.

Consider non‑sedating, anti‑seizure medicines (e.g., levetiracetam) for seizure prophylaxis. Consider neurology consultation and other specialists for further evaluation, as needed.

Monitor patient for 48 hours following the next dose of TALVEY. Instruct patients to remain within proximity of a healthcare facility during monitoring.

Grade 3

ICEc score 0‑2

(If ICE score is 0, but the patient is arousable (e.g., awake with global aphasia) and able to perform assessment)

or depressed level of consciousnessd: awakens only to tactile stimulus,

or seizuresd, either:

• any clinical seizure, focal or generalised, that resolves rapidly, or

• non‑convulsive seizures on electroencephalogram (EEG) that resolve with intervention,

or raised intracranial pressure: focal/local oedema on neuroimagingd.

Administer tocilizumab per Table 3 for management of CRS.

Administer dexamethasonee 10 mg intravenously with the first dose of tocilizumab and repeat dose every 6 hours. Continue dexamethasone use until resolution to Grade 1 or less, then taper.

Administer dexamethasonee 10 mg intravenously every 6 hours. Continue dexamethasone use until resolution to Grade 1 or less, then taper.

Consider non‑sedating, anti‑seizure medicines (e.g., levetiracetam) for seizure prophylaxis. Consider neurology consultation and other specialists for further evaluation, as needed.

First Occurrence:

Withhold TALVEY until ICANS resolves.

Monitor patient for 48 hours following the next dose of TALVEY. Instruct patients to remain within proximity of a healthcare facility during monitoring.

Recurrent:

Permanently discontinue TALVEY.

Grade 4

ICEc score 0

(Patient is unarousable and unable to perform ICE assessment)

or depressed level of consciousnessd either:

• patient is unarousable or requires vigorous or repetitive tactile stimuli to arouse, or

• stupor or coma,

or seizuresd, either:

• life‑threatening prolonged seizure (> 5 minutes), or

• repetitive clinical or electrical seizures without return to baseline in between,

or motor findingsd:

• deep focal motor weakness such as hemiparesis or paraparesis,

or raised intracranial pressure/cerebral oedemad, with signs/symptoms such as:

• diffuse cerebral oedema on neuroimaging, or

• decerebrate or decorticate posturing, or

• cranial nerve VI palsy, or

• papilloedema, or

• Cushing's triad.

Administer tocilizumab per Table 3 for management of CRS.

Administer dexamethasonee 10 mg intravenously and repeat dose every 6 hours. Continue dexamethasone use until resolution to Grade 1 or less, then taper.

Alternatively, consider administration of methylprednisolone 1 000 mg per day intravenously with first dose of tocilizumab, and continue methylprednisolone 1 000 mg per day intravenously for 2 or more days.

Administer dexamethasonee 10 mg intravenously and repeat dose every 6 hours. Continue dexamethasone use until resolution to Grade 1 or less, then taper.

Alternatively, consider administration of methylprednisolone 1 000 mg per day intravenously for 3 days; if improves, then manage as above.

Permanently discontinue TALVEY.

Consider non‑sedating, anti‑seizure medicines (e.g., levetiracetam) for seizure prophylaxis. Consider neurology consultation and other specialists for further evaluation, as needed.

In case of raised intracranial pressure/cerebral oedema, refer to local institutional guidelines for management.

a Management is determined by the most severe event, not attributable to any other cause.

b ASTCT 2019 grading for ICANS.

c If patient is arousable and able to perform Immune Effector Cell‑Associated Encephalopathy (ICE) Assessment, assess: Orientation (oriented to year, month, city, hospital = 4 points); Naming (name 3 objects, e.g., point to clock, pen, button = 3 points); Following Commands (e.g., “show me 2 fingers” or “close your eyes and stick out your tongue” = 1 point); Writing (ability to write a standard sentence = 1 point; and Attention (count backwards from 100 by ten = 1 point). If patient is unarousable and unable to perform ICE Assessment (Grade 4 ICANS) = 0 points.

d Attributable to no other cause.

e All references to dexamethasone administration are dexamethasone or equivalent

Table 5: Recommendations for management of neurologic toxicity (excluding ICANS)

Adverse Reaction

Severitya

Actions

Neurologic Toxicitya (excluding ICANS)

Grade 1

• Withhold TALVEY until neurologic toxicity symptoms resolve or stabilise.b

Grade 2

Grade 3 (First occurrence)

• Withhold TALVEY until neurologic toxicity symptoms improve to Grade 1 or less.b

• Provide supportive therapy.

Grade 3 (Recurrent)

Grade 4

• Permanently discontinue TALVEY.

• Provide supportive therapy, which may include intensive care.

a Based on National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE), version 4.03.

b See Table 2 for recommendations on restarting TALVEY after dose delays.

Other adverse reactions

The recommended dose modifications for other adverse reactions are provided in Table 6.

Table 6: Recommended dose modifications for other adverse reactions

Adverse reaction

Severity

Dose modification

Serious infections

(see section 4.4)

All Grades

• Do not administer TALVEY step‑up dosing schedule in patients with active infection.

• Withhold TALVEY in the step‑up phase until infection resolves.

Grade 3‑4

• Withhold TALVEY during the treatment phase until infection improves to Grade 2 or better.

Cytopenias

(see section 4.4)

Absolute neutrophil count less than 0.5 × 109/L

• Withhold TALVEY until absolute neutrophil count is 0.5 × 109/L or higher.

Febrile neutropenia

• Withhold TALVEY until absolute neutrophil count is 1.0 × 109/L or higher and fever resolves.

Haemoglobin less than 8 g/dL

• Withhold TALVEY until haemoglobin is 8 g/dL or higher.

Platelet count less than 25 000/µL

Platelet count between 25 000/µL and 50 000/µL with bleeding

• Withhold TALVEY until platelet count is 25 000/µL or higher and no evidence of bleeding.

Oral toxicity, including weight loss

(see section 4.4)

Toxicity not responding to supportive care

Interrupt TALVEY until stabilisation or improvement, and consider restarting on modified schedule as follows:

• If current dose is 0.4 mg/kg every week, change to 0.4 mg/kg every two weeks

• If current dose is 0.8 mg/kg every two weeks, change to 0.8 mg/kg every four weeks

Skin reactions, including nail disorders

(see section 4.4)

Grade 3‑4

• Withhold TALVEY until adverse reaction improves to Grade 1 or baseline.

Other non‑haematologic adverse reactionsa

(see section 4.8)

Grade 3‑4

• Withhold TALVEY until adverse reaction improves to Grade 1 or baseline.

a Based on National Cancer Institute Common Terminology Criteria for Adverse Events (NCI‑CTCAE), Version 4.03.

Special populations

Paediatric population

There is no relevant use of TALVEY in the paediatric population in the treatment of multiple myeloma.

Elderly

No dose adjustment is required (see section 5.2).

Renal impairment

No dose adjustment is recommended for patients with mild or moderate renal impairment (see section 5.2).

Hepatic impairment

No dose adjustment is recommended for patients with mild hepatic impairment (see section 5.2). Limited or no data are available in patients with moderate and severe hepatic impairment.

Method of administration

TALVEY is for subcutaneous use.

The required volume of TALVEY should be injected into the subcutaneous tissue of the abdomen (preferred injection site). Alternatively, TALVEY may be injected into the subcutaneous tissue at other sites (e.g., thigh). If multiple injections are required, TALVEY injections should be at least 2 cm apart.

TALVEY must not be injected into tattoos or scars or areas where the skin is red, bruised, tender, hard or not intact.

For instructions on handling of the medicinal product before administration, see section 6.6.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4. Special warnings and precautions for use

Traceability

In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Cytokine release syndrome (CRS)

CRS, including life‑threatening or fatal reactions, may occur in patients receiving TALVEY (see section 4.8). Clinical signs and symptoms of CRS may include but are not limited to pyrexia, hypotension, chills, hypoxia, headache, tachycardia and elevated transaminases. Potentially life‑threatening complications of CRS may include cardiac dysfunction, acute respiratory distress syndrome, neurologic toxicity, renal and/or hepatic failure, and disseminated intravascular coagulation (DIC).

TALVEY therapy should be initiated with step‑up phase dosing and pre‑treatment medicinal products (corticosteroids, antihistamine, and antipyretics) should be administered prior to each dose of TALVEY during the step‑up phase to reduce the risk of CRS. Patients should be monitored following administration accordingly. In patients who experience CRS following their previous dose, pre‑treatment medicinal products should be administered prior to the next TALVEY dose (see section 4.2).

Subjects who experienced Grade 3 or higher CRS with any previous T cell redirection therapy were excluded from clinical studies. It cannot be excluded that prior severe CRS with chimeric antigen receptor (CAR) T‑cell therapy or other T‑cell engagers might impact on the safety of TALVEY. The potential benefits of treatment should be carefully weighed against the risk of neurologic events, and heightened caution should be exercised when administering TALVEY to these patients.

Patients should be counselled to seek medical attention should signs or symptoms of CRS occur. At the first sign of CRS, patients should be immediately evaluated for hospitalisation and treatment with supportive care, tocilizumab and/or corticosteroids, should be instituted based on severity. The use of myeloid growth factors, particularly granulocyte macrophage‑colony stimulating factor (GM‑CSF), should be avoided during CRS. TALVEY should be withheld until CRS resolves (see section 4.2).

Neurologic toxicity, including ICANS

Serious or life‑threatening neurologic toxicities, including ICANS have occurred following treatment with TALVEY (see section 4.8).

ICANS, including fatal reactions, have occurred following treatment with TALVEY. The onset of ICANS can be concurrent with CRS, following resolution of CRS, or in the absence of CRS. Clinical signs and symptoms of ICANS may include but are not limited to confusional state, depressed level of consciousness, disorientation, somnolence, lethargy, and bradyphrenia.

Patients should be monitored for signs and symptoms of neurologic toxicities and treated promptly. Patients should be counselled to seek medical attention should signs or symptoms of neurologic toxicities including ICANS occur. At the first sign of neurologic toxicities including ICANS, the patient should be immediately evaluated and supportive care should be provided based on severity. Patients who experience Grade 2 or higher ICANS should be instructed to remain within proximity of a healthcare facility and monitored for signs and symptoms for 48 hours following the next dose of TALVEY.

For ICANS and other neurologic toxicities, TALVEY should be withheld or discontinued based on severity and management recommendations should be followed as indicated in Table 4 (see section 4.2).

There are no data on use of talquetamab in patients with CNS involvement of myeloma or other clinically relevant CNS pathologies as a result of their exclusion from the study due to the potential risk of ICANS.

Due to the potential for ICANS, patients should be instructed to avoid driving or operating machines during the step‑up phase and for 48 hours after completion of the step‑up phase, and in the event of new onset of any neurological symptoms, until symptoms resolve (see section 4.7).

Management of neurologic toxicities

At the first sign of neurologic toxicity, including ICANS, neurology evaluation should be considered. Other causes of neurologic symptoms should be ruled out. TALVEY should be withheld until adverse reaction resolves (see Table 4). Intensive care and supportive therapy should be provided for severe or life‑threatening neurologic toxicities.

Oral toxicity

Oral toxicities, including dysgeusia, dry mouth, dysphagia, and stomatitis occur very commonly following treatment with TALVEY (see section 4.8).

Patients should be monitored for signs and symptoms of oral toxicity. Patients should be counselled to seek medical attention should signs or symptoms of oral toxicity occur, and supportive care should be provided. Supportive care may include saliva stimulating agents, steroid mouth wash, or consultation with a nutritionist. TALVEY should be interrupted or less frequent dosing should be considered (see section 4.2).

Over time, notable weight loss may occur (see section 4.8). Weight change should be monitored regularly during therapy. Clinically significant weight loss should be further evaluated. TALVEY should be interrupted or less frequent dosing should be considered (see section 4.2).

Serious infections

Serious infections, including life‑threatening or fatal infections, have been reported in patients receiving TALVEY (see section 4.8). Patients should be monitored for signs and symptoms of infection prior to and during treatment with TALVEY and treated appropriately. Prophylactic antimicrobials should be administered according to local guidelines. TALVEY should not be administered in patients with active serious infection. TALVEY should be withheld as indicated (see section 4.2). Patients should be instructed to seek medical advice if signs or symptoms suggestive of an infection occur.

Hypogammaglobulinaemia

Hypogammaglobulinaemia has been reported in patients receiving TALVEY (see section 4.8).

Immunoglobulin levels should be monitored during treatment with TALVEY. Intravenous or subcutaneous immunoglobulin therapy was used to treat hypogammaglobulinaemia patients. Patients should be treated according to local institutional guidelines, including infection precautions, antibiotic or antiviral prophylaxis, and administration of immunoglobulin replacement.

Cytopenias

Treatment‑emergent Grade 3 or 4 neutropenia, febrile neutropenia and thrombocytopenia have been observed in patients who received TALVEY. A majority of cytopenias occurred during the first 8 to 10 weeks. Complete blood counts should be monitored at baseline and periodically during treatment. Supportive care should be provided per local institutional guidelines.

Patients with neutropenia should be monitored for signs of infection. TALVEY should be withheld as warranted (see section 4.2).

Skin reactions

TALVEY can cause skin reactions including rash, erythema, palmar-plantar erythrodysesthesia syndrome, as well as nail disorders (see section 4.8). Skin reactions including rash progression should be monitored for early intervention and treatment with corticosteroids. For Grade 3 or higher, or worsening Grade 1 or 2 rashes, oral steroids should also be administered. For non‑rash skin reactions dose modification may be considered (see Table 6).

For skin reactions and nail disorders, TALVEY should be withheld based on severity and institutional guidelines should be followed (see section 4.2).

Vaccines

Immune response to vaccines may be reduced when taking TALVEY. The safety of immunisation with live viral vaccines during or following TALVEY treatment has not been studied. Vaccination with live virus vaccines is not recommended for at least 4 weeks prior to the start of treatment, during treatment, and at least 4 weeks after treatment.

For unexpected exposure during pregnancy, see section 4.6.

Women of child‑bearing potential/contraception

Pregnancy status of females of child‑bearing potential should be verified prior to initiating treatment with TALVEY. Females of reproductive potential should use effective contraception during treatment and for 3 months after the last dose of TALVEY (see section 4.6).

Excipients

Sodium

This medicinal product contains less than 1 mmol (23 mg) sodium per dose, that is to say essentially 'sodium‑free'.

Polysorbate 20

This medicine contains 0.4 mg/mL of polysorbate 20. Polysorbates may cause allergic reactions.

4.5. Interaction with other medicinal products and other forms of interaction

No interaction studies have been performed.

Talquetamab causes release of cytokines (see section 5.1) that may suppress activity of cytochrome P450 (CYP) enzymes, potentially resulting in increased exposure of CYP substrates. The highest risk of drug‑drug interaction is expected to occur from initiation of talquetamab step‑up phase up to 9 days after the first treatment dose and during and after CRS (see section 4.4). Monitor for toxicity or concentrations of medicinal products that are CYP (e.g., CYP2C9, CYP2C19, CYP3A4/5, CYP2D6) substrates where minimal concentration changes may lead to serious adverse reactions. The dose of concomitant CYP (e.g., CYP2C9, CYP2C19, CYP3A4/5, CYP2D6) substrate drugs should be adjusted as needed.

4.6. Fertility, pregnancy and lactation

Women of childbearing potential/Contraception in females

Pregnancy status of females of child‑bearing potential should be verified prior to initiating treatment with TALVEY.

Females of reproductive potential should use effective contraception during treatment and for 3 months after the last dose of TALVEY.

Pregnancy

There are no available data on the use of TALVEY in pregnant women or animal data to assess the risk of TALVEY in pregnancy. Human IgG is known to cross the placenta after the first trimester of pregnancy. Therefore, talquetamab has the potential to be transmitted from the mother to the developing foetus. The effects of TALVEY on the developing foetus are unknown. TALVEY is not recommended for women who are pregnant or for women of childbearing potential not using contraception.

If TALVEY is taken during pregnancy, a reduced immune response to vaccines may be expected in newborns. Consequently, newborn vaccinations with live vaccines such as BCG vaccine should be postponed until 4 weeks.

Breast-feeding

It is not known whether talquetamab is excreted in human milk. Because the potential for serious adverse reactions in breast‑fed infants is unknown for TALVEY, patients should not breast‑feed during treatment with TALVEY and for at least 3 months after the last dose.

Fertility

There are no data on the effect of talquetamab on fertility. Effects of talquetamab on male and female fertility have not been evaluated in animal studies.

4.7. Effects on ability to drive and use machines

TALVEY has major influence on the ability to drive and use machines.

Due to the potential for ICANS, patients receiving TALVEY are at risk of depressed level of consciousness (see section 4.4). Patients should be instructed to avoid driving or operating machines during the step‑up phase and for 48 hours after completion of the step‑up phase (see section 4.2), and in the event of new onset of any neurological symptoms, until symptoms resolve.

4.8. Undesirable effects

Summary of the safety profile

The most frequent adverse reactions were CRS (77%), dysgeusia (72%), hypogammaglobulinaemia (67%), nail disorder (56%), musculoskeletal pain (48%), anaemia (47%), fatigue (43%), weight decreased (40%), skin disorder (37%), rash (39%), dry mouth (36%), neutropenia (35%), pyrexia (33%), xerosis (32%), thrombocytopenia (30%), upper respiratory tract infection (29%), lymphopenia (27%), dysphagia (24%), diarrhoea (25%), pruritus (23%), cough (23%), pain (22%), decreased appetite (22%) and headache (20%).

Serious adverse reactions reported in patients included CRS (13%), pyrexia (5%), ICANS (3.8%), sepsis (3.8%), COVID‑19 (3.2%), bacterial infection (2.4%), pneumonia (2.4%), viral infection (2.4%), neutropenia (2.1%) and pain (2.1%).

The most frequent adverse reactions leading to treatment discontinuation were ICANS (1.1%) and weight decreased (0.9%).

Tabulated list of adverse reactions

The safety of TALVEY was evaluated in 339 adult patients with relapsed or refractory multiple myeloma, including patients treated with TALVEY at the recommended dosing regimen with or without prior T cell redirection therapy in MonumenTAL‑1. The median duration of treatment was 7.4 (range: 0.0 to 32.9) months.

Table 7 summarises adverse reactions reported in patients who received TALVEY. The safety data of TALVEY was also evaluated in the All Treated population (N=501) with no additional adverse reactions identified.

Adverse reactions observed during clinical studies are listed below by frequency category. Frequency categories are defined as follows: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1000 to < 1/100); rare (≥ 1/10 000 to < 1/1 000); very rare (< 1/10 000) and not known (frequency cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Table 7: Adverse reactions in patients with multiple myeloma treated with TALVEY in MonumenTAL‑1 (N=339)

System Organ Class

Adverse Reaction

Frequency

category

Any Grade

(%)

Grade 3 or 4 (%)

Infections and infestations

Bacterial infection*

Very common

40 (12%)

11 (3.2%)

Fungal infection*

Very common

39 (12%)

1 (0.3%)

COVID‑19*#

Very common

63 (19%)

10 (2.9%)

Upper respiratory tract infection*

Very common

98 (29%)

7 (2.1%)

Sepsis*#

Common

15 (4.4%)

14 (4.1%)

Pneumonia*

Common

23 (7%)

11 (3.2%)

Viral infection*

Common

23 (7%)

6 (1.8%)

Blood and lymphatic system disorders

Neutropenia*

Very common

119 (35%)

103 (30%)

Anaemia*

Very common

158 (47%)

99 (29%)

Thrombocytopenia

Very common

101 (30%)

71 (21%)

Lymphopenia

Very common

91 (27%)

83 (25%)

Leukopenia

Very common

62 (18%)

38 (11%)

Haemorrhage1

Common

27 (8%)

5 (1.5%)

Febrile neutropenia

Common

7 (2.1%)

7 (2.1%)

Immune system disorders

Cytokine release syndrome

Very common

260 (77%)

5 (1.5%)

Hypogammaglobulinaemia2

Very common

227 (67%)

0

Metabolism and nutrition disorders

Decreased appetite

Very common

76 (22%)

4 (1.2%)

Hypokalaemia

Very common

55 (16%)

12 (3.5%)

Hypophosphataemia*

Very common

49 (15%)

21 (6%)

Hypomagnesaemia

Very common

35 (11%)

0

Nervous system disorders

Immune effector cell‑associated neurotoxicity syndrome*

Very common

26 (10%)

6 (2.3%)

Encephalopathy3

Very common

36 (11%)

0

Headache*

Very common

69 (20%)

2 (0.6%)

Motor dysfunction4

Very common

38 (11%)

2 (0.6%)

Dizziness*

Very common

42 (12%)

8 (2.4%)

Sensory neuropathy5

Very common

34 (10%)

0

Respiratory, thoracic and mediastinal disorders

Cough*

Very common

78 (23%)

0

Dyspnoea6#

Very common

39 (12%)

5 (1.5%)

Gastrointestinal disorders

Dysgeusia‡7

Very common

245 (72%)

0

Dry mouth‡

Very common

122 (36%)

0

Dysphagia

Very common

82 (24%)

3 (0.9%)

Diarrhoea

Very common

84 (25%)

4 (1.2%)

Stomatitis8

Very common

67 (20%)

4 (1.2%)

Nausea

Very common

64 (19%)

0

Constipation

Very common

61 (18%)

0

Oral pain*

Very common

42 (12%)

0

Abdominal pain*

Very common

35 (10%)

1 (0.3%)

Vomiting

Very common

34 (10%)

2 (0.6%)

Skin and subcutaneous tissue disorders

Rash*

Very common

132 (39%)

12 (3.5%)

Skin disorder*

Very common

124 (37%)

0

Xerosis9

Very common

109 (32%)

0

Pruritus

Very common

79 (23%)

1 (0.3%)

Nail disorder*

Very common

191 (56%)

0

Palmar-plantar erythrodysesthesia syndrome

Common

31 (9%)

0

Alopecia

Common

30 (9%)

0

Musculoskeletal and connective tissue disorders

Musculoskeletal pain*

Very common

164 (48%)

12 (3.5%)

General disorders and administrate site conditions

Fatigue*

Very common

147 (43%)

12 (3.5%)

Weight decreased

Very common

134 (40%)

11 (3.2%)

Pyrexia*

Very common

113 (33%)

6 (1.8%)

Pain*

Very common

76 (22%)

7 (2.1%)

Oedema10

Very common

59 (17%)

0

Injection site reaction11

Very common

45 (13%)

0

Chills

Very common

39 (12%)

1 (0.3%)

Investigations

Fibrinogen decreased

Very common

52 (15%)

12 (3.5%)

aPTT prolonged

Very common

49 (15%)

0

Transaminase elevation12

Very common

48 (14%)

12 (3.5%)

INR increased

Very common

47 (14%)

1 (0.3%)

Gamma‑glutamyltransferase increased

Very common

36 (11%)

16 (4.7%)

Adverse reactions are coded using MedDRA Version 24.0.

‡ Per CTCAE v4.03, maximum toxicity grade for dysgeusia is 2 and maximum toxicity grade for dry mouth is 3.

* Grouped term

# Contains fatal outcome(s)

1 Haemorrhage includes: Conjunctival haemorrhage, Epistaxis, Haematoma, Haematuria, Lower gastrointestinal haemorrhage, Periorbital haemorrhage, Petechiae, Rectal haemorrhage, Subdural haematoma and Vaginal haemorrhage.

2 Hypogammaglobulinaemia includes: hypogammaglobulinaemia and/or subjects with laboratory IgG levels below 500 mg/dL following treatment with talquetamab.

3 Encephalopathy includes: agitation, amnesia, aphasia, bradyphrenia, confusional state, delirium, disorientation, encephalopathy, hallucination, lethargy, memory impairment, restlessness, sleep disorder and somnolence.

4 Motor dysfunction includes: dysgraphia, dysphonia, gait disturbance, muscle spasms, muscular weakness and tremor.

5 Sensory neuropathy includes: dysaesthesia, hypoaesthesia, hypoaesthesia oral, neuralgia, peripheral sensory neuropathy, sciatica and vestibular neuronitis.

6 Dyspnoea includes: acute respiratory failure, dyspnoea, dyspnoea exertional, respiratory failure and tachypnoea.

7 Dysgeusia includes: ageusia, dysgeusia, hypogeusia and taste disorder.

8 Stomatitis includes: cheilitis, glossitis, glossodynia, mouth ulceration, oral discomfort, oral mucosal erythema, oral pain, stomatitis, swollen tongue, tongue discomfort, tongue erythema, tongue oedema and tongue ulceration.

9 Xerosis includes: dry eye, dry skin and xerosis.

10 Oedema includes: fluid retention, gingival swelling, hypervolaemia, joint swelling, lip swelling, oedema, oedema peripheral, periorbital oedema, peripheral swelling and swelling.

11 Injection site reaction includes: injection site discomfort, injection site erythema, injection site haemorrhage, injection site inflammation, injection site irritation, injection site plaque, injection site pruritus, injection site rash and injection site reaction.

12 Transaminase elevation includes: alanine aminotransferase increased, aspartate aminotransferase increased, and transaminases increased.

Description of selected adverse reactions

Cytokine release syndrome

In MonumenTAL‑1 (N=339), CRS occurred in 77% of patients. Most events were Grade 1 or 2, with Grade 3 events occurring in 1.5% of patients. Thirty one percent (31%) of patients experienced more than one CRS event. Most events occurred during the step‑up phase following the 0.01 mg/kg dose (29%), the 0.06 mg/kg dose (44%), the 0.3 mg/kg dose (for patients who received biweekly [every 2 weeks] dosing; 33%), or the initial treatment dose (0.4 mg/kg [30%] or 0.8 mg/kg [12%]). Less than 4% of CRS events occurred from week 5 onward; all events were Grade 1. The median time to onset of CRS was 27 hours from the last dose, 91% of events occurred within 48 hours from the last dose, and the median duration was 17 hours. Tocilizumab, corticosteroids and tocilizumab in combination with corticosteroids were used to treat CRS in 39%, 5% and 3.5% of CRS events, respectively. Clinical signs and symptoms of CRS may include but are not limited to pyrexia (76%), hypotension (15%), chills (12%), hypoxia (7%), headache (4.7%), tachycardia (5%) and elevated transaminases (aspartate aminotransferase [1.5%] and alanine aminotransferase [0.9%]).

Neurologic toxicities

In MonumenTAL‑1 (N=339), neurologic toxicity events were reported in 29% of patients receiving TALVEY. Neurologic toxicity events were Grade 1 (17%), Grade 2 (11%), Grade 3 (2.3%) or Grade 4 (0.3%). The most frequently reported neurologic toxicity event was headache (9%).

ICANS were only collected for Phase 2 in MonumenTAL‑1. Of the 265 patients in Phase 2, ICANS occurred in 9.8% (n=26) of patients. Most events were Grade 1 or 2, with Grade 3 and 4 events occurring in 2.3% of patients. The most frequent clinical manifestation of ICANS reported were confusional state (3.8%), disorientation (1.9%), somnolence (1.9%) and depressed level of consciousness (1.9%). Sixty‑eight percent (68%) were concurrent with CRS (during or within 7 days of CRS resolution). Three percent (3%) of patients experienced more than one ICANS event. In addition, one fatal ICANS event was reported in MonumenTAL‑1. Most patients experienced ICANS during the step‑up phase following the 0.01 mg/kg dose, the 0.06 mg/kg dose, or the initial treatment dose (0.4 mg/kg and 0.8 mg/kg) (3% each). The median time to onset of ICANS was 28 hours from the last dose, 68% of events started within 48 hours from the last dose, 32% of events occurred after 48 hours, and the median duration of ICANS was 9 hours.

Oral toxicity

In MonumenTAL‑1 (N=339), 78% of patients had Grade 1 or 2 events, with Grade 3 events occurring in 2% of patients. Oral toxicity events included dysgeusia, dry mouth, dysphagia, and stomatitis were reported.

Serious infections

In MonumenTAL‑1 (N=339), Grade 3 or Grade 4 infections occurred in 19% of patients; fatal infections occurred in 1.5% of patients ‑ COVID‑19 pneumonia, fungal sepsis, infection and septic shock. The most frequently reported (≥ 2%) Grade 3 or 4 infection was pneumonia. Febrile neutropenia was observed in 1% of patients with 1.2% experiencing serious febrile neutropenia. See section 4.4 for monitoring and management guidance.

Hypogammaglobulinaemia

Post baseline IgG values of less than 500 mg/dl consistent with hypogammaglobulinaemia have been reported in 64% of patients treated with talquetamab at the 0.4 mg/kg weekly dose schedule, 66% of patients at the 0.8 mg/kg biweekly dose schedule and in 71% of patients with prior T cell redirection therapy (see section 4.4).

Skin reactions

In MonumenTAL‑1 (N=339), the majority of rash cases were Grade 1 or 2, with Grade 3 events occurring in 3.5% of patients. The median time to onset from the first treatment dose for rash was 22 days. The majority of non‑rash skin toxicities were Grade 1 or 2, with Grade 3 pruritus occurring in 0.3% of patients. Nail disorders occurred in 56% of patients and were Grade 1 or 2. See section 4.4 for management guidance.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms and signs

The maximum tolerated dose of talquetamab has not been determined. In clinical studies, doses of up to 1.2 mg/kg once every 2 weeks and 1.6 mg/kg every month have been administered.

Treatment

In the event of an overdose, the patient should be monitored for any signs or symptoms of adverse effects and appropriate symptomatic treatment should be instituted immediately.