AFLIBERCEPT C4318H6788N1164O1304S32 (115 kDa-with glycosylation) DB08885 AFLIBERCEPT C4318H6788N1164O1304S32 (115 kDa-with glycosylation) Eylea Regeneron Pharmaceuticals Zaltrap Regeneron Pharmaceuticals CATEGORY Antineoplastic Agents Ophthalmics

DESCRIPTION Aflibercept is a recombinant fusion protein that comprises of two main components: the vascular endothelial growth factor (VEGF) binding portions from the extracellular domains of human VEGF receptors 1 and 2 which is then fused to the Fc portion of human IgG1. Structurally, Aflibercept is a dimeric glycoprotein with a protein molecular weight of 96.9 kilo Daltons (kDa). It contains approximately 15% glycosylation to give a total molecular weight of 115 kDa. All five putative N-glycosylation sites on each polypeptide chain predicted by the primary sequence can be occupied with carbohydrate and exhibit some degree of chain heterogeneity, including heterogeneity in terminal sialic acid residues, except at the single unsialylated site associated with the Fc domain. Aflibercept, as an ophthalmic agent, is used in the treatment of macular edema following Central Retinal Vein Occlusion (CRVO) and neovascular Age-Related Macular Degeneration (AMD). Ziv-aflibercept, under the brand name Zaltrap, was developed as an injection for treatment of metastatic colorectal cancer. FDA approved in November 18, 2011 and EMA approved in November 2012.

INDICATION The opthalmic agent is used for the treatment of neovascular (wet) age-related mascular degeneration (AMD) and macular edema following central retinal vein occulsion (CRVO). The systemic injection, known as ziv-aflibercept, in combination with 5-fluorouracil, leucovorin, irinotecan-(FOLFIRI), is for the treatment of metastatic colorectal cancer that is resistant to or progressed following treatment with oxaliplatin. PHARMACODYNAMICS Compared to other anti-VEGF drugs like bevacizumab and ranibizumab, aflibercept has a higher binding affinity to VEGF-A (Kd = 0.5 pM). MECHANISM OF ACTION Ablibercept is a recombinant fusion protein that acts as a decoy receptor for the ligands, vascular endothelial growth factor-A (VEGF-A) and placental growth factor (PIGF). It prevents these ligands to binding to endothelial receptors, VEGFR-1 and VEGFR-2, to suppress neovascularization and decrease vascular permeability. This ultimately will slow vision loss or the progression of metastatic colorectal cancer.

ABSORPTION In patients with wet AMD and CRVO, the mean peak plasma concentration (Cmax) was 0.02 mcg/mL and 0.05 mcg/mL respectively. These concentrations were reached in 1 to 3 days. Aflibercept did not accumulate when administered as repeated doses intravitreally every 4 weeks. VOLUME OF DISTRIBUTION After intravenous injection of aflibercept, the volume of distribution is 6 L Metabolism Because aflibercept is a protein, it is expected to be broken down via proteolysis into smaller peptides and amino acids. The cytochrome P450 enzyme system is not involved in the metabolism of aflibercept.

Intravitreal HALF-LIFE = 7.13 days in humans Terminal elimination half-life of free aflibercept in plasma was 5 to 6 days after IV injection of 2 - 4 mg/kg dose. CLEARANCE When cancer patients were given 2-9 mg/kg every 2 or 3 week; 1 hour IV infusion of aflibercept the typical estimated clearances were as follows: CL of free aflibercept (CLf) = 0.88 L/day; CL of bound aflibercept (CLf) = 0.19 L/day; Patients clear free aflibercept faster if they had low albumin or high alkaline phosphatase levels. TOXICITY For all intravitreal VEGF inhibitors, there is increased risk of stroke and myocardial infarction. An increase in intraocular pressure may also occur. When used intravenously, most common adverse reactions 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.

AFLIBERCEPT EYLEA (for macular degeneration)  Intravitreal inj AFLIBERCEPT EYLEA (for macular degeneration)  Intravitreal inj. Zaltrap ((ziv‑aflibercept: for colorectal cancer) IV infusion EYLEA (aflibercept) is a recombinant fusion protein consisting of portions of human VEGF receptors 1 and 2 extracellular domains fused to the Fc portion of human IgG1 formulated as an iso-osmotic solution for intravitreal administration. 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. Aflibercept is produced in recombinant Chinese hamster ovary (CHO) cells. Zaltrap (ziv-aflibercept) is a recombinant fusion protein consisting of Vascular Endothelial Growth Factor fused to the Fc portion of human IgG. Zaltrap injection for intravenous infusion is indicated for patients with metastatic colorectal cancer (mCRC).

Derived from recombinant CHO cells DOSAGE (Eyela): 2 mg (0.05 mL or 50 microliters) administered by intravitreal injection every 4 weeks (monthly) for the first 12 weeks (3 months), followed by 2 mg (0.05 mL) via intravitreal injection once every 8 weeks (2 months). Although EYLEA may be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated when EYLEA was dosed every 4 weeks compared to every 8 weeks DOSAGE (Zaltrap): 4 mg per kg as an intravenous (IV) infusion over 1 hour every two weeks. Administer ZALTRAP prior to any component of the FOLFIRI regimen on the day of treatment VIAL DESCRIPTION: EYLEA is a sterile, clear, and colorless to pale yellow solution. EYLEA is supplied as a preservative-free, sterile, aqueous solution in a single-use, glass vial designed to deliver 0.05 mL (50 microliters) of EYLEA (40 mg/mL in 10 mM sodium phosphate, 40 mM sodium chloride, 0.03% polysorbate 20, and 5% sucrose, pH 6.2).

VIAL DESCRIPTION Zaltrap is available in single-use vials in two strengths: 100 mg/4 mL (25 mg/mL) and 200 mg/8 mL (25 mg/mL). Zaltrap is dosed as 4 mg/kg as an intravenous infusion over 1 hour, every 2 weeks. Serious side effects include hemorrhage, GI perforation and compromised wound healing. Based on animal data, Zaltrap may cause fetal harm. Zaltrap should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. It is not known whether Zaltrap is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious side effects in nursing infants, a decision should be made as to whether to discontinue nursing or to discontinue the drugs, taking into account the important of the drug to the mother. The safety and effectiveness of Zaltrap has not been examined in the pediatric population.

ADVERSE REACTION: Eyela: Hives; difficult breathing; swelling of your face, lips, tongue, or throat. Zaltrap: Severe and sometimes fatal hemorrhage, including gastrointestinal (GI) hemorrhage, has been reported in the patients who have received ZALTRAP in combination with FOLFIRI. Monitor patients for signs and symptoms of GI bleeding and other severe bleeding. Do not administer ZALTRAP to patients with severe hemorrhage. GI perforation including fatal GI perforation can occur in patients receiving ZALTRAP. Discontinue ZALTRAP therapy in patients who experience GI perforation. DOSAGE 2 mg (0.05 mL or 50 microliters) administered by intravitreal injection every 4 weeks (monthly) for the first 12 weeks (3 months), followed by 2 mg (0.05 mL) via intravitreal injection once every 8 weeks (2 months). Although EYLEA may be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated when EYLEA was dosed every 4 weeks compared to every 8 weeks

PROTEIN SEQUENCE FOR AFLIBERCEPT SDTGRPFVEMYSEIPEIIHMTEGRELVIPCRVTSPNITVTLKKFPLDTLIPDGKRIIWDSRKGFIISNATYKEIGLLTCEATVNGHLYKTNYLTHRQTNTIIDVVLSPSHGIELSVGEKLVLNCTARTELNVGIDFNWEYPSSKHQHKKLVNRDLKTQSGSEMKKFLSTLTIDGVTRSDQGLYTCAASSGLMTKKNSTFVRVHEKDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSRDELTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPG

PATENTS Country Patent Number Approved Expires (estimated) United States 7306799 2005-03-25 2020-05-23 United States 7531173 2009-05-12 2026-02-02 United States 7374758 2008-05-20 2020-05-23 United States 7608261 2009-10-27 2027-06-14 United States 7070959 2006-07-04 2020-05-23 United States 7374757 2008-05-20 2020-05-23

REFERENCES Eyela http://www.ncbi.nlm.nih.gov/pubmed/25200895 http://www.ncbi.nlm.nih.gov/pubmed/24740170 http://www.ncbi.nlm.nih.gov/pubmed/22354219 http://www.ncbi.nlm.nih.gov/pubmed/23461161 Zaltrap http://www.ncbi.nlm.nih.gov/pubmed/25395483 http://www.ncbi.nlm.nih.gov/pubmed/25394166 http://www.ncbi.nlm.nih.gov/pubmed/25393440 http://www.ncbi.nlm.nih.gov/pubmed/25378900 http://www.ncbi.nlm.nih.gov/pubmed/25378873