Plerixafor Injection (Fresenius Kabi Canada) Product Monograph

INDICATIONS AND CLINICAL USE

Adult

Plerixafor Injection (plerixafor) is indicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells (HSCs) to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma (NHL) and multiple myeloma (MM). Some patients with NHL and MM are able to meet minimal and target HSC collection criteria with G-CSF alone. (See CLINICAL TRIALS)

Plerixafor Injection should only be administered under the supervision of a qualified health professional who is experienced in oncology and/or hematology and in the management of cancer patients undergoing mobilization of hematopoietic stem cells to the peripheral blood. (See DOSAGE AND ADMINISTRATION)

Geriatrics (≥ 65 years of age):

Of the total number of subjects in two placebo-controlled clinical studies of plerixafor, 24% were 65 and over, while 0.8% were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects with normal renal function or mild- moderate renal impairment. In general, care should be taken in dose selection for elderly patients due to the greater frequency of decreased renal function with advanced age. (See WARNINGS AND PRECAUTIONS, Special Populations, Renal Impairment)

Pediatrics (1 to less than 18 years of age):

Plerixafor Injection is indicated in combination with G-CSF to enhance mobilization of hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in children with lymphoma or solid malignant tumors and either:

• low circulating stem cell count on the predicted date of collection after mobilization

  • with G-CSF (with or without chemotherapy), or
• who previously failed to collect sufficient hematopoietic stem cells (see DOSAGE AND ADMINISTRATION).

CONTRAINDICATIONS

• Patients who are hypersensitive to this drug or to any ingredient in the formulation or component of the container. For a complete listing, see the DOSAGE FORMS, COMPOSITION AND PACKAGING section of the Product Monograph.

WARNINGS AND PRECAUTIONS

General

No studies on the effect of plerixafor on the ability to drive and use machines have been conducted. Some patients have experienced dizziness, fatigue or vasovagal reactions (orthostatic hypotension and/or syncope). Appropriate precautions should be taken because of the potential for these reactions. (See ADVERSE REACTIONS)

Carcinogenesis and Mutagenesis

Carcinogenicity studies with plerixafor have not been conducted. (See Part II: Scientific

Information, TOXICOLOGY, Carcinogenesis)

Cardiovascular

Patients with an abnormal ECG with clinically significant rhythm disturbance or other conduction abnormality were excluded from the Phase 3 clinical trials. Arrhythmias are a known risk following citrate anticoagulation and apheresis which induce low Ca/Mg levels and blood volume. In the Phase 3 clinical studies, examination of all clinical cardiovascular adverse events does not identify any rhythm related cardiac safety signals attributable to plerixafor treatment in the populations studied.

Decreases in Blood Pressure: In Phase 3 trials, the incidence of hypotension during mobilization and apheresis was increased in patients receiving plerixafor and G-CSF (3.7

%) as compared to patients receiving placebo and G-CSF (2.4%). In plerixafor oncology and non- oncology clinical studies, 0.8% of subjects experienced vasovagal reactions (orthostatic hypotension and/or syncope) following subcutaneous administration of plerixafor doses ≤ 0.4 mg / kg (see ACTION AND CLINICAL PHARMACOLOGY, Electrocardiography and Hemodynamics). The majority of these events occurred within 1 hour of plerixafor administration. Appropriate precautions should be taken because of the potential for these reactions to occur following treatment with Plerixafor Injection (see WARNINGS AND PRECAUTIONS, General).

Disorders of Atrioventricular Conduction: In a randomized, double-blind, placebo-controlled crossover study in healthy subjects, plerixafor was associated with an asymptomatic shortening of the PR interval (see ACTION AND CLINICAL PHARMACOLOGY, Electrocardiography and Hemodynamics). Caution should be observed in patients with pre-excitation syndromes such as Wolff-Parkinson-White syndrome or Lown-Ganong-Levine syndrome, or atrioventricular nodal rhythm disorders, such as AV junctional rhythms with retrograde activation or ectopic atrial rhythms originating near the AV node.

Myocardial infarctions: In clinical studies, 0.9% of oncology patients experienced myocardial infarctions after HSC mobilization with plerixafor and G-CSF as compared with 0.3% of oncology patients after mobilization with placebo and G-CSF. All events occurred at least 14 days after last plerixafor administration. Two additional oncology patients in the compassionate use program experienced myocardial infarctions following HSC mobilization with plerixafor and G-CSF. One of these events occurred 4 days after last plerixafor administration and the other occurred 67 days after last plerixafor administration.

Hematologic

Leukocytosis: Administration of Plerixafor Injection in conjunction with G-CSF increases circulating leukocytes as well as HSC populations. White blood cell counts should be monitored during Plerixafor Injection use. Clinical judgment should be exercised when administering Plerixafor Injection to patients with peripheral blood neutrophil counts above 50 000 cells/mcL.

Thrombocytopenia: Thrombocytopenia has been observed in patients receiving plerixafor. Platelet counts should be monitored in all patients who receive Plerixafor Injection.

Potential Effect on Spleen Size: Higher absolute and relative spleen weights associated with extramedullary hematopoiesis were observed following prolonged (2 to 4 weeks) daily plerixafor subcutaneous administration in rats at doses approximately 4fold higher than the recommended human dose based on body surface area. The effect of plerixafor on spleen size in patients has not been specifically evaluated in clinical studies. Cases of splenic enlargement and/or rupture have been reported following the administration of plerixafor in conjunction with growth factor G-CSF. Individuals receiving Plerixafor Injection in conjunction with G-CSF who report left upper abdominal pain and/or scapular or shoulder pain should be evaluated for splenic integrity.

Immune

Allergic Reactions: In plerixafor oncology clinical studies, 0.7% of patients experienced mild or moderate systemic reactions within approximately 30 minutes after plerixafor administration. Events included one or more of the following: urticaria (n = 2), periorbital swelling (n =2), dyspnea (n =1), or hypoxia (n =1). Symptoms generally responded to treatments (e.g., antihistamines, corticosteroids, hydration or supplemental oxygen) or resolved spontaneously. Cases of anaphylactic reactions, including anaphylactic shock, have been reported from world-wide post-marketing experience. Appropriate precautions should be taken because of the potential for these reactions.

Psychiatric

An in vitro general receptor screen identified moderate or strong affinity of plerixafor for a number of receptors of the central and/or peripheral nervous systems (CNS and PNS) (see DETAILED PHARMACOLOGY, Safety Pharmacology). In Phase 3 trials, the incidence of psychiatric disorders during mobilization and apheresis was 14.8% in the plerixafor + G-CSF treatment arm and 10.2% in the placebo + G-CSF treatment arm. Insomnia and anxiety were the most common events (see ADVERSE REACTIONS). Related events of insomnia during the same period occurred in 1% of plerixafor -treated patients compared to 0% of placebo-treated patients in the Phase 3 studies. Related events of anxiety occurred in 0.7% of plerixafor -treated patients compared to 0.3% of placebo-treated patients in the Phase 3 studies. Vivid dreams and nightmares have been described in post marketing reports.

Other

Potential for Tumor Cell Mobilization in Lymphoma and Multiple Myeloma Patients:

When Plerixafor Injection is used in conjunction with G-CSF for HSC mobilization in patients with NHL or MM‚ tumor cells may be released from the marrow and subsequently collected in the leukapheresis product. Based on limited laboratory investigations conducted in clinical studies of patients with NHL and MM, an increase in mobilization of tumor cells above that which occurs with G-CSF mobilization alone has not been observed with plerixafor.

The effect of potential reinfusion of tumor cells has not been well studied.

Tumor Cell Mobilization in Leukemia Patients: Plerixafor and G-CSF have been administered to patients with acute myelogenous leukemia and plasma cell leukemia. In some instances, these patients experienced an increase in the number of circulating leukemia cells. For the purpose of HSC mobilization, Plerixafor Injection may cause mobilization of leukemic cells and subsequent contamination of the apheresis product. Therefore, Plerixafor Injection should not be used for HSC mobilization and harvest in patients with leukemia.

Special Populations

Pregnant Women: Plerixafor Injection may cause fetal harm when administered to a pregnant woman. Studies in animals have shown teratogenicity (see TOXICOLOGY). There are no adequate and well-controlled studies in pregnant women using plerixafor. Because CXCR4 plays an essential role in fetal development and plerixafor is a selective antagonist of CXCR4, plerixafor is suggested to cause congenital malformations when administered during pregnancy. The use of Plerixafor Injection is not recommended in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be informed of the potential hazard to the fetus. Advise women of childbearing potential to use effective contraception during treatment.

Nursing Women: It is not known whether plerixafor is excreted in human milk. Because many drugs are excreted in human milk, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatrics (1 to less than 18 years of age): The safety and efficacy of plerixafor in pediatric patients (1 to less than 18 years) were studied in an open-label, multicentre, randomized, controlled clinical study (see ADVERSE REACTIONS; ACTIONS AND CLINICAL PHARMACOLOGY, Pharmacokinetics; CLINICAL TRIALS). No new safety concerns were identified in this study.

Another single site study evaluating plerixafor in young patients (< 6 years of age) was stopped when 9 of 10 planned patients were enrolled, due to the occurrence of nightmares, nyctophobia, and visual hallucinations reported in some patients following the third or fourth dose of plerixafor. Comparable adverse events have not been observed in a larger, randomized, and comparative multiple site pediatric study.

Geriatrics (≥ 65 years of age): In general, care should be taken in dose selection for elderly patients due to the greater frequency of decreased renal function with advanced age. (See Renal Impairment, DOSAGE AND ADMINISTRATION, and ACTION AND CLINICAL PHARMACOLOGY)

Hepatic Impairment: No studies in patients with hepatic impairment have been conducted. Patients with serum alanine transaminase (ALT), aspartate transaminase (AST), and total bilirubin values >2.5 x upper limit of normal were excluded from placebo-controlled clinical studies of plerixafor. Plerixafor is not metabolized by the liver.

Renal Impairment: Renal impairment was associated with a prolongation of plerixafor half- life and increased exposure due to impaired clearance. Patients with an estimated creatinine clearance (Cl_CR) 20-50 mL/min should have their dose of plerixafor reduced to 0.16 mg/kg/day. Clinical data with this dose adjustment are limited. There are insufficient clinical data to make dosing recommendations for patients with a creatinine clearance <20 mL/min or for patients on dialysis. (See DOSAGE AND ADMINISTRATION; ACTION AND CLINICAL PHARMACOLOGY, Special Populations and Conditions, Renal Insufficiency)

Monitoring and Laboratory Tests

White blood cell and platelet counts should be monitored during Plerixafor Injection use and apheresis. Electrolytes, including calcium and magnesium, should be monitored during Plerixafor Injection use (see ADVERSE REACTIONS, Abnormal Hematologic and Clinical

Chemistry Findings).

ADVERSE REACTIONS

Adverse Drug Reaction Overview

See WARNINGS AND PRECAUTIONS regarding Decreases in Blood Pressure, Disorders of Atrioventricular Conduction, Myocardial Infarctions, Leukocytosis, Thrombocytopenia, Potential Effect on Spleen Size, Allergic Reactions, and Tumor Cell Mobilization in Leukemia Patients.

Safety data for plerixafor in conjunction with G-CSF were obtained from two randomized placebo-controlled studies (301 patients) and 10 uncontrolled studies (242 patients). Patients were primarily treated with plerixafor at daily doses of 0.24 mg / kg by subcutaneous (SC) injection. Median exposure to plerixafor in these studies was 2 days (range 1 to 7 days).

The number of patients in the two treatment groups in the pooled Phase 3 studies changed considerably over the course of the studies, primarily due to the difference in the number who entered the rescue procedure. The Primary Safety Population comprised 301 patients during mobilization and apheresis, 279 from the first dose of ablative chemotherapy until engraftment, and 278 post-engraftment in the plerixafor group; 292 patients during the mobilization and apheresis period and 216 from the start of ablative chemotherapy onwards, in the placebo group.

In the Phase 3 studies, all AEs that occurred from the first dose of G-CSF until 30 days after the last apheresis or until the first dose of ablative chemotherapy, whichever occurred first, were documented. Subsequently, from the first dose of ablative chemotherapy until polymorphonuclear (PMN) engraftment, data were collected only for serious adverse events (SAEs) and AEs that were Grade 3 or greater, except for febrile neutropenia and hemorrhage (data were collected only if Grade 4 or Grade 5) and neutropenia, thrombocytopenia, and anemia (data were collected only if the outcome was death). From the first day following engraftment through the follow-up period, all SAEs up to 6 months post-transplantation or until relapse, whichever occurred first, graft failures that occurred within 12 months post-transplantation, and myelodysplastic syndrome that occurred after 6 months post-transplantation were documented.

The adverse reactions reported in oncology patients who received plerixafor in controlled Phase 3 studies and uncontrolled studies, including a Phase 2 study of plerixafor as monotherapy for HSC mobilization, were similar. No notable differences in the incidence of adverse reactions were observed for oncology patients by disease, age, or sex.

The most common (≥ 10%) adverse events (AEs) reported during HSC mobilization and apheresis in pooled Phase 3 results from patients who received plerixafor in conjunction with G-CSF regardless of causality and more frequent with plerixafor than placebo, were: diarrhea, nausea, fatigue, injection site reactions, headache, arthralgia, dizziness, and vomiting.

Rescue patients: In the Phase 3 studies, 59 patients who had received G-CSF + placebo as their original randomized treatment received a 4-day course of G-CSF followed by G-CSF + plerixafor rescue. The AE profile of these patients was consistent with that of the non-rescue patients.

Clinical Trial Adverse Drug Reactions

Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates.

In the two randomized studies in patients with NHL and MM, a total of 301 patients were treated in the plerixafor and G-CSF group and 292 patients were treated in the placebo and G-CSF group. Patients received daily morning doses of G-CSF 10 micrograms/kg for 4 days prior to the first dose of plerixafor 0.24 mg / kg subcutaneous or placebo and on each morning prior to apheresis.

The majority of AEs were reported during mobilization and apheresis, 96% in patients receiving G-CSF + plerixafor compared to 94% in patients receiving G-CSF + placebo. The majority of AEs were mild or moderate. The incidence of AEs considered related to study treatment was 65% in the plerixafor group and 43% in the placebo group during the period of mobilization and apheresis, and overall.

The adverse events that occurred in ≥ 5% of the pooled Phase 3 patients who received plerixafor regardless of causality and were more frequent with plerixafor than placebo during HSC mobilization and apheresis are shown in Table 1.

Table 1: Adverse Events in ≥ 5% of Non-Hodgkin’s Lymphoma and Multiple Myeloma Patients Receiving Plerixafor and More Frequent than Placebo During HSC Mobilization and Apheresis in Phase 3 Studies

^aGrades based on criteria from the World Health Organization (WHO)

The incidence of anxiety during HSC mobilization and apheresis was 5.3% versus 4.5%, plerixafor versus placebo, respectively.

General disorders and administration site conditions:

Injection site reactions: In the randomized studies, 34% of patients with NHL or MM had mild to moderate injection site reactions at the site of subcutaneous administration of plerixafor. These included erythema, hematoma, hemorrhage, induration, inflammation, irritation, pain, paresthesia, pruritus, rash, swelling, and urticaria. (see Table 1)

Paresthesia was considered an AE related to study treatment in 7% of patients in the plerixafor group and 5.1% of patients in the placebo group in the pooled Phase 3 data.

The majority of SAEs were severe and were considered unrelated to study treatment. The incidence of SAEs in the pooled Phase 3 data (plerixafor versus placebo, respectively) was 112/301 (37.2%) versus 84/292 (28.8%) overall, 13/301 (4.3%) versus 16/292 (5.5%) during mobilization and apheresis, 62/279 (22.2%) versus 44/216 (20.4%) from the start of ablative chemotherapy through engraftment, and 45/278 (16.2%) versus 34/216 (15.7%) post- engraftment.

In the pooled Phase 3 data, the incidence of bacteremia was 6% versus 4.4%, plerixafor versus placebo, respectively. The difference between the 2 groups was largely due to the greater incidence of staphylococcal bacteremia in the plerixafor group (7 patients, versus 0 patients in the placebo group). The incidence of lung infections was 5% versus 3.4%, plerixafor versus placebo, respectively. The incidence of febrile neutropenia was 10.1% versus 6.1%, plerixafor versus placebo, respectively. The majority of events of bacteremia, lung infection, and febrile neutropenia occurred following myeloablative chemotherapy and were considered by the investigator to be unrelated to plerixafor administration.

The incidence, cause, and timing of deaths, as well as the incidence of study or treatment discontinuations due to AEs were similar in both treatment groups. The majority of deaths occurred post-engraftment.

Less Common Clinical Trial Adverse Drug Reactions

Less common AEs occurring more frequently with plerixafor than placebo and considered related to study treatment in ≥ 1% and < 5% of patients during mobilization and apheresis in the randomized trials were as follows:

Allergic Reactions

In plerixafor oncology clinical studies, 0.7% of patients experienced mild or moderate allergic reactions within approximately 30 minutes after plerixafor administration, including one or more of the following: urticaria (n = 2), periorbital swelling (n =2), dyspnea (n =1) or hypoxia (n=1).

Gastrointestinal disorders: abdominal distention, abdominal pain, constipation, dyspepsia, hypoesthesia oral, stomach discomfort

General disorders and administration site conditions: malaise

Musculo-skeletal and connective tissue disorders: musculoskeletal pain

Skin and subcutaneous tissue disorders: erythema, hyperhidrosis

Vasovagal Reactions

In plerixafor oncology and healthy volunteer clinical studies, less than 1% of subjects experienced vasovagal reactions (orthostatic hypotension and/or syncope) following subcutaneous administration of plerixafor doses ≤ 0.24 mg / kg. The majority of these events occurred within 1 hour of plerixafor administration.

Abnormal Hematologic and Clinical Chemistry Findings

Hypokalemia and hypomagnesemia

Hypokalemia (2.3% versus 0.7%, plerixafor versus placebo, respectively) and hypomagnesemia (2% versus 0.3%, plerixafor versus placebo, respectively) were reported as treatment related AEs more frequently with plerixafor than with placebo during mobilization and apheresis in the pooled Phase 3 data. (See WARNINGS AND PRECAUTIONS, Monitoring and Laboratory Tests)

Hyperleukocytosis

In the phase 3 clinical studies, white blood cell counts of 100 000 cells/mcl or greater were observed, on the day prior to or any day of apheresis, in 7% of patients receiving plerixafor and in 1% of patients receiving placebo. No complications or clinical symptoms of leukostasis were observed.

Clinical Trial Adverse Reactions (Pediatrics)

Thirty patients (1 to less than 18 years) with lymphoma or solid tumours were treated with 0.24 mg / kg of plerixafor plus standard mobilization in the stage 2 of an open label, multicenter, randomized, controlled study (see CLINICAL TRIALS). In this study, 23 of 30 (76.7%) patients in the plerixafor arm and 10 of 15 (66.7%) patients in the control arm experienced adverse events.

The most common adverse events (≥10% of patients) in the plerixafor arm were anemia, decreased platelet count, rhinitis, febrile neutropenia, abdominal pain, hypoalbuminemia, diarrhea, vomiting, and pyrexia.

The most common adverse events (> 10% of patients) in the control arm were hypokalemia, increased alanine aminotransferase, febrile neutropenia, vomiting, decreased platelet count, fatigue, nausea, and anemia.

Serious adverse events were reported in 9 of 30 (30%) patients in the plerixafor arm and in 4 of 15 (26.7%) patients in the control arm. The most common treatment-emergent serious adverse events (>2%) in the plerixafor arm were febrile neutropenia, pancytopenia, pyrexia,and bone marrow failure.

The most common treatment-emergent serious adverse events (>2%) in the control arm were febrile neutropenia, abdominal infection, Enterobacter bacteremia, leukopenia, and pulmonary embolism.

No new safety concerns were identified in this study.

Post-marketing Experience

In addition to adverse reactions reported from clinical trials, the following adverse reactions have been reported from worldwide post-marketing experience with plerixafor. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Blood and lymphatic system disorders: Splenomegaly and splenic rupture (see WARNINGS AND PRECAUTIONS, Hematologic).

Immune system disorders: Anaphylactic reactions, including anaphylactic shock (See

WARNINGS AND PRECAUTIONS, Immune, Allergic Reactions).

Psychiatric disorders: abnormal dreams, nightmares.

DRUG INTERACTIONS

Drug-Drug Interactions

Based on in vitro studies, plerixafor is not a substrate, inhibitor, or inducer of human cytochrome P450 enzymes. Formal drug interaction studies have not been conducted. Plerixafor did not act as a substrate or inhibitor of P-glycoprotein in an in vitro study. (See PHARMACOKINETICS)

The effects of co-administration of plerixafor with other drugs that are renally eliminated or are known to affect renal function have not been evaluated in formal drug interaction studies. Since plerixafor is primarily eliminated by the kidneys, co-administration of plerixafor with drugs that reduce renal function or compete for active tubular secretion may increase serum concentrations of plerixafor or the co-administered drug.

In the absence of compatibility studies, Plerixafor Injection should not be mixed with other medicinal products in the same injection.

Drug-Food Interactions

Plerixafor Injection is administered parenterally, and interactions with food and drink are considered unlikely.

Drug-Herb Interactions

No drug-herb interaction studies have been conducted with plerixafor.

Drug-Laboratory Interactions

Plerixafor has not been shown to interfere with any routine clinical laboratory tests.

Drug-Lifestyle Interactions

Some patients have experienced dizziness, fatigue or vasovagal reactions (orthostatic hypotension and/or syncope) with plerixafor treatment which may affect their ability to drive and use machines (see WARNINGS AND PRECAUTIONS, General).

DOSAGE AND ADMINISTRATION

Appropriate management of therapy and complications is only possible when adequate diagnostic and treatment facilities are readily available. (See INDICATIONS AND CLINICAL USE, WARNINGS AND PRECAUTIONS)

Dosing Considerations

Recommended Concomitant Medications

Administer daily morning doses of G-CSF 10 mcg / kg for 4 days prior to the first evening dose of Plerixafor Injection (plerixafor) and on each day prior to apheresis. (See CLINICAL TRIALS)

Dosing in Patients with Renal Impairment

Patients with serum creatinine values >2.2 mg / dL were excluded from the placebo-controlled clinical studies of plerixafor in combination with G-CSF. A total of 60 patients with an estimated creatinine clearance (CrCl) 51-80 mL / min, 11 patients with CrCl 31-50 mL/min, and none with CrCl ≤ 30 mL/min were enrolled and received at least one dose of plerixafor (0.24 mg / kg body weight subcutaneously (SC)).

Dose adjustments are recommended for patients with an estimated CL_CR 20-50 mL / min. (See Recommended Dose and Dosage Adjustment, Dosage Adjustment for Renal Impairment) There are insufficient clinical data to make dosing recommendations for patients with a creatinine clearance <20 mL / min or for patients on dialysis.

Recommended Dose and Dosage Adjustment

• A. Adult Patients

Recommended Dose:

Begin treatment with Plerixafor Injection after the patient has received G-CSF once daily for four days.

The recommended dose of Plerixafor Injection by subcutaneous (SC) injection in the abdominal region is:

• 20 mg fixed dose or 0.24 mg / kg of body weight for patients weighing ≤ 83 kg (see

  ACTION AND CLINICAL PHARMACOLOGY, Pharmacokinetics)

• 0.24 mg / kg of body weight for patients weighing > 83 kg.

Plerixafor Injection should be administered 10 - 11 hours prior to initiation of each apheresis. Plerixafor has been used as a single course for up to 4 consecutive days in two randomized clinical trials.

In clinical studies, plerixafor dose has been calculated based on actual body weight in patients up to 175% of ideal body weight. Plerixafor dose and treatment of patients weighing more than 175% of ideal body weight have not been investigated.

Based on increasing exposure with increasing body weight, the plerixafor dose should not exceed 40 mg/day. (See ACTION AND CLINICAL PHARMACOLOGY, Pharmacokinetics)

Dosage Adjustment for Renal Impairment:

In patients with CL_CR 20-50 mL / min, reduce the dose of Plerixafor Injection to 0.16 mg/kg. This will reduce the increased systemic exposure in these patients when compared to patients with CL_CR >50 mL / min receiving the 0.24 mg / kg dose. In patients with CL_CR ≤50 mL / min, the dose should not exceed 27 mg / day, as the mg / kg-based dosage results in increased plerixafor exposure with increasing body weight (see ACTION AND CLINICAL PHARMACOLOGY, Pharmacokinetics).

Table 2: Recommended Dosage of Plerixafor in Patients with Renal Impairment

The following (Cockroft-Gault) formula may be used to estimate CL_CR:

Males:

Creatinine clearance (mL/min) = weight (kg) X (140 – age in years)

72 X serum creatinine (mg/dL)

Females:

Creatinine clearance (mL/min) = 0.85 X value calculated for males

B. Pediatric Patients (1 to less than 18 years)

Recommended dose

Begin treatment with Plerixafor Injection after the patient has received G-CSF once daily for four days. The recommended dose of Plerixafor Injection is 0.24 mg / kg body weight by subcutaneous (SC) injection in the abdominal region. Plerixafor Injection should be administered 8-12 hours prior to initiation of each apheresis (see ACTION AND CLINICAL PHARMACOLOGY, Pharmacokinetics). Plerixafor has been used as a single course for up to 3 consecutive days in a pediatric clinical trial.

Administration

Vials should be inspected visually for particulate matter and discoloration prior to administration and should not be used if there is particulate matter or if the solution is discolored.

Use the patient’s actual body weight to calculate the volume of Plerixafor Injection to be administered. Each vial delivers 1.2 mL of 20 mg / mL solution, and the volume to be administered to patients should be calculated from the following equation:

0.012 X patient’s actual body weight (in kg) = volume to be administered (in mL)

OVERDOSAGE

Based on limited data at doses above the recommended dose of 0.24 mg / kg subcutaneous and up to 0.48 mg / kg subcutaneous, the frequency of gastrointestinal disorders, vasovagal reactions, orthostatic hypotension, and/or syncope may be higher.

ACTION AND CLINICAL PHARMACOLOGY

Mechanism of Action

Plerixafor is a selective antagonist of the CXCR4 chemokine receptor and blocks binding of its cognate ligand, stromal cell-derived factor-1α (SDF-1α), also known as CXCL12. SDF-1α and CXCR4 are recognized to play key regulatory roles in the trafficking and homing of human HSCs to the marrow compartment. Stem cells express CXCR4 and are known to migrate to the bone marrow through a chemoattractant effect of SDF-1α that is produced locally by bone marrow stromal cells. Once in the marrow, it is postulated that stem cell CXCR4 can act to help “anchor” these cells to the marrow matrix, either directly via SDF-1α or through the induction of other adhesion molecules. Plerixafor-induced leukocytosis and elevations in circulating hematopoietic progenitor cell levels are thought to result from a disruption of CXCR4 binding to its cognate ligand, resulting in the appearance of both mature and pluripotent cells in the

systemic circulation.

CD34+ cells mobilized by plerixafor are functional and capable of engraftment with long-term repopulating capacity.

Pharmacodynamics

Fold increase in peripheral blood CD34+ cell count (cells/mcL) by apheresis day was evaluated in two placebo-controlled clinical studies in patients with lymphoma and MM (Studies 1 and 2, respectively). Fold increase over the 24-hour period from the day prior to the first apheresis to just before the first apheresis is summarized in Table 3. During that 24-hour period, the first dose of plerixafor 0.24 mg / kg or placebo was administered 10-11 hours prior to apheresis.

Table 3: Fold Increase in Peripheral Blood CD34+ Cell Count Following Plerixafor Administration

In pharmacodynamic studies in healthy volunteers of plerixafor, peak mobilization of CD34+ cells was observed from 6 to 9 hours after administration. In pharmacodynamic studies in healthy volunteers of plerixafor in conjunction with G-CSF, a sustained elevation in the peripheral blood CD34+ count was observed from 4 to 18 hours after plerixafor administration with peak response between 10 and 14 hours.

Pharmacokinetics

The pharmacokinetics of plerixafor have been evaluated in lymphoma and MM patients at the clinical dose level of 0.24 mg / kg following pre-treatment with G-CSF (10 mcg / kg once daily for 4 consecutive days).

Table 4: Comparison of Mean Pharmacokinetic Parameters in Healthy Subjects and

Oncology Patients Treated With 0.24 mg / kg Plerixafor With or Without G-CSFa ^a Values are reported as mean ± standard deviation, except T_max is reported as median (min, max).

A population pharmacokinetic analysis showed that the mg/kg-based dosage results in an increased plerixafor exposure (AUC_0-24h) with increasing body weight. There is limited clinical experience with treating patients above 160 mg and therefore the dose should not exceed 40 mg/day for patients with a CL_CR > 50 mL / min and 27 mg / day for patients with a CL_CR 20- 50 mL / min.

In order to compare the pharmacokinetics and pharmacodynamics of plerixafor following 0.24 mg/kg-based and fixed (20 mg) doses, a follow-up trial was conducted in patients with NHL (N=61) who were treated with 0.24 mg / kg or 20 mg of plerixafor. The trial was conducted in patients weighing 70 kg or less (median: 63.7 kg, range of 34.2 to 70 kg). The study population was primarily Asian (91.8%). The fixed 20 mg dose showed 1.43-fold higher exposure (AUC_0-

_10h) than the 0.24 mg / kg dose (Table 5). The fixed 20 mg dose also showed numerically higher response rate (5.2% [60% vs 54.8%] based on the local lab data and 11.7% [63.3% vs 51.6%] based on the central lab data) in attaining the target of ≥ 5 × 10⁶ CD34+ cells/kg than the mg / kg- based dose. The median time to reach ≥ 5 × 10⁶ CD34+ cells/kg was 3 days for both treatment groups, and the safety profile between the groups was similar. Body weight of 83 kg was selected as a cut-off point to transition patients from fixed to weight based dosing (83 kg x 0.24 mg = 19.92 mg / kg).

Table 5 - Systemic exposure (AUC_0-10h) comparison of fixed and weight based regimens

Absorption: Plerixafor is rapidly absorbed following subcutaneous injection with peak concentrations reached in approximately 30-60 minutes.

Distribution: Plerixafor is moderately bound to human plasma proteins up to 58%. The apparent volume of distribution of plerixafor in humans is 0.3 L / kg, suggesting that plerixafor is largely confined to, but not limited to, the extravascular fluid space.

Metabolism: Plerixafor is not metabolized in vitro using human liver microsomes or human primary hepatocytes and does not exhibit inhibitory activity in vitro towards the major drug metabolizing CYP450 enzymes (1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, and 3A4/5). In in vitro studies with human hepatocytes, plerixafor does not induce CYP1A2, CYP2B6, and CYP3A4 enzymes. These findings suggest that plerixafor has a low potential for involvement in P450-dependent drug-drug interactions.

Excretion: The major route of elimination of plerixafor is urinary. Following a 0.24 mg / kg dose in healthy volunteers with normal renal function, approximately 70% of the dose was excreted in the urine as the parent drug during the first 24 hours following administration. The amount of plerixafor excreted in the feces is not known. The half-life in plasma is 3-5 hours. Plerixafor did not act as a substrate or inhibitor of P-glycoprotein in an in vitro study with MDCKII and MDCKII-MDR1 cell models.

Electrocardiography and Haemodynamics: In a randomized, double-blind, placebo-controlled crossover study, 46 healthy subjects were administered single subcutaneous doses of plerixafor at a therapeutic dose of 0.24 mg / kg or a supratherapeutic dose of 0.4 mg / kg. Peak concentrations for 0.4 mg / kg plerixafor were approximately 1.8-fold higher than the peak concentrations following the 0.24 mg / kg single subcutaneous dose.

There was no treatment-related effect on the QTc interval or QRS duration, indicating no impact in ventricular repolarization, depolarization and conduction, at the plerixafor doses tested.

The PR interval was shortened during the period from 15 min to 12 h post-dosing at both doses of plerixafor, with maximum decreases of mean -9.8 (90% CI -12.3, -7.2) at the 0.24 mg / kg dose and -9.5 (90% CI -12, -6.9) ms at the 0.4 mg / kg dose, both at 2.5 h post-dosing (see WARNINGS AND PRECAUTIONS, Disorders of Atrioventricular Conduction). The PR interval changes were not dose-dependent over the 0.24-0.4 mg / kg dose range studied.

Sitting diastolic blood pressure was decreased from 1 h to 10 h post-dosing with plerixafor 0.24 mg / kg, with a maximum decrease of mean -5.8 (90% CI -8.6, -3) mmHg at 8 h post- dosing. Systolic blood pressure was decreased by mean -3.2 (90% CI -6.4, -0.1) mmHg at this time point.

At the 0.4 mg / kg dose, the maximum decrease in sitting diastolic blood pressure was mean -6.1 (90% CI -9.9, -2.2) mmHg at 1 h post-dosing, whilst the maximum decrease in systolic blood pressure was mean -3.5 (90% CI -6.4, -0.5) mmHg at 2 h post-dosing.

The incidence of syncope was 4.8% for the 0.24 mg / kg dose and 6.7% for the 0.4 mg / kg dose. There were no events of syncope in the placebo arm of this crossover study (see WARNINGS AND PRECAUTIONS, Vasovagal Reactions).

Special Populations and Conditions

Pediatrics: The pharmacokinetics of plerixafor were evaluated at doses of 0.16, 0.24 and 0.32 mg / kg in 27 pediatric patients (2 to less than 18 years) with solid tumors participating in the stage 1 of an open-label, multicenter, randomized study (see CLINICAL TRIALS). Plerixafor exposures (C_max and AUC_0-9h) generally increased with age and with dose over the range of 0.16 to 0.32 mg / kg. At the same weight-based dosing regimen of 240 mcg / kg, plerixafor mean AUC0-9h in pediatric patients aged 2 to < 6 years (1740 ng.h/mL), 6 to <12 years (2270 ng.h / mL), and 12 to <18 years (2600 ng.h / mL) were consistently lower than those in healthy adults (AUC_0-10: 3108 ng.h / mL) and adult patients (AUC_0-10 range: 3035 to 3945 ng.h / mL). However, even with the lower exposure than adults, exposure was sufficient to enhance mobilization of PB CD34+ count in stage 2 of the trial (see CLINICAL TRIALS).

Geriatrics: No specific studies have been conducted to investigate pharmacokinetics in geriatric patients. However, a population pharmacokinetic analysis showed no effect of age on plerixafor pharmacokinetics.

Gender: A population pharmacokinetic analysis showed no effect of gender on plerixafor pharmacokinetics.

Race: Clinical data show similar plerixafor pharmacokinetics for Whites and Blacks, and the effect of other racial/ethnic groups has not been studied.

Hepatic Insufficiency: No specific pharmacokinetics studies have been conducted in hepatically impaired patients.

Renal Insufficiency: Following a single 0.24 mg / kg dose of plerixafor, plerixafor clearance was reduced in subjects with varying degrees of renal dysfunction and was positively correlated with CL_CR. Mean values of AUC0-24 of plerixafor in subjects with CL_CR 51-80 mL / min, CL_CR 31-50 mL / min and CL_CR ≤ 30 mL / min were higher than the exposure observed in healthy subjects with normal renal function (CL_CR >80 mL / min) (Table 6). Renal impairment had no effect on Cmax. (See DOSAGE AND ADMINISTRATION)

Table 6: Human Pharmacokinetic Data for Subjects Enrolled in a Phase I Renal Impairment Study

* Values were based on 24 h urine collection.

A population PK analysis simulated the effect of CL_CR (as determined by the Cockcroft-Gault formula) on plasma clearance of plerixafor. These results support a dose reduction to 0.16 mg / kg in patients with a CL_CR of 20-50 mL / min to reduce the increased exposure in these patients when compared to patients with CL_CR >50 mL / min receiving a 0.24 mg / kg dose of plerixafor.

Tissue accumulation of plerixafor in patients with renal impairment has not been studied.

Genetic Polymorphism: Based on in vitro data, plerixafor is not a substrate, inhibitor or inducer of human cytochrome P450 isozymes, nor is it an in vitro substrate or inhibitor of P-glycoprotein. Therefore, no specific drug metabolism or transporter genetic polymorphism studies have been conducted with plerixafor.

STORAGE AND STABILITY

• Store at 15 °C to 30 °C
• DO NOT USE Plerixafor Injection after the expiration date indicated on the label.
• Each vial of Plerixafor Injection is intended for single use only. Any unused drug remaining after injection must be discarded.

SPECIAL HANDLING INSTRUCTIONS

Plerixafor Injection is supplied as a ready-to-use formulation. The contents of the vial must be transferred to a suitable syringe for subcutaneous administration. Vials should be inspected visually for particulate matter and discoloration prior to administration and should not be used if there is particulate matter or if the solution is discolored.

DOSAGE FORMS, COMPOSITION AND PACKAGING

Plerixafor Injection is supplied as a sterile, preservative-free, clear, colorless to pale yellow, pH neutral, isotonic solution in a single-use 2 mL clear glass (Type I) vial, sealed with a rubber stopper and aluminum seal with a plastic flip-off cap.

Active ingredient: Each 2 mL vial is filled to deliver 1.2 mL of 20 mg / mL solution, containing 24 mg of plerixafor.

Non-medicinal ingredients: Each 1.2 mL contains 5.9 mg sodium chloride in sterile Water for Injection adjusted to a pH of 6 to 7.5 with hydrochloric acid and with sodium hydroxide, if required.

PART II: SCIENTIFIC INFORMATION PHARMACEUTICAL INFORMATION

Drug Substance

Common name: plerixafor

Chemical name: l, 1'-[1,4-phenylenebis (methylene)]-bis-1,4,8,11- tetraazacyclotetradecane

Molecular formula and molecular mass: C₂₈H₅₄N₈; 502.79 g/mol

Structural formula:

N NH H

H N

N

N N H

H HN

N

Physicochemical properties:

Table 7: Physicochemical Properties

CLINICAL TRIALS

ADULT PATIENTS

Study demographics and trial design

Table 8: Summary of patient demographics for clinical trials in specific indication

Trial Design

The efficacy and safety of plerixafor in conjunction with G-CSF in non-Hodgkin’s lymphoma (NHL) patients and multiple myeloma (MM) patients who were eligible for autologous hematopoietic stem cell transplant were evaluated in two placebo-controlled studies (Studies 1 and 2).

On the evening of Day 4 of daily morning doses of G-CSF 10 mcg / kg, the first dose of assigned study treatment, either plerixafor 0.24 mg / kg or placebo was administered. On Day 5, patients received a morning dose of G-CSF 10 mcg / kg and underwent apheresis approximately 10 to 11 hours after the first dose of study treatment (within 60 minutes after administration of G-CSF). Patients continued to receive an evening dose of study treatment followed the next day by a morning dose of G-CSF and apheresis for up to a maximum of 4 aphereses or until the target collection of CD34+ HSCs was achieved.

In both studies, patients who failed to collect ≥ 0.8 x 10⁶ CD34+ cells / kg after 2 days of apheresis or at least 2 x 10⁶ CD34+ cells / kg in 4 or fewer days of apheresis had the option of entering an open-label rescue procedure. After a minimum 7-day rest period, they received another 4-day course of G-CSF followed by a course of plerixafor (0.24 mg / kg) in combination with G-CSF for repeat mobilization.

Following the last apheresis, patients underwent a rest period, then pre-transplant ablative chemotherapy followed by autologous transplantation within 5 weeks after the last apheresis. Transplantation was performed according to standard of care at each study center.

Patients received G-CSF (5 mcg / kg once daily) beginning on the fifth or sixth day after transplantation and continuing until the absolute neutrophil count (ANC) was ≥ 0.5 x 10⁹ / L for 3 days or ≥ 1 x 10⁹ / L for 1 day. Platelet (PLT) engraftment was defined as a PLT count ≥ 20 x 10⁹ / L without transfusion for the preceding 7 days.

Graft durability was assessed at 100 days, 6 months, and 12 months post-transplantation.

The primary objective of Study 1 was to determine if NHL patients mobilized with

G-CSF plus plerixafor 0.24 mg / kg were more likely to achieve a target number of ≥ 5 x 10⁶ CD34+ cells / kg in 4 or fewer days of apheresis than NHL patients mobilized with G-CSF plus placebo. The primary objective of Study 2 was to determine if MM patients mobilized with

G-CSF plus plerixafor 0.24 mg / kg were more likely to achieve a target number of ≥ 6 x 10⁶

CD34+ cells / kg in 2 or fewer days of apheresis than MM patients mobilized with G-CSF plus placebo.

Secondary efficacy objectives common to both studies were to compare the two treatment arms with respect to the number of patients who achieved a minimum of 2 x 10⁶ CD34+ cells / kg (minimum number required for transplantation) in 4 or fewer days of apheresis, the number of days of apheresis required to reach target cell numbers, the time to engraftment of PMNs and PLTs, and the durability of the graft at prespecified times post-transplantation. A secondary objective unique to Study 2 was to compare the two treatment arms with respect to the number of MM patients who achieved the target number of cells in 4 or fewer apheresis days.

Subsequent to the completion of both studies, enrolled patients were asked to participate in observational long-term follow-up with the primary objective of assessing any differences in clinical outcome (progression-free survival [PFS] and overall survival [OS]) in patients treated with at least 1 dose of study treatment (plerixafor or placebo). These patients are to be followed for up to 5 years post-transplantation and the data is not yet mature.

Study demographics

Two hundred and ninety-eight (298) NHL patients were included in the primary efficacy analyses for Study 1. The mean age was 55.1 years (range 29-75) and 57.5 years (range 22-75) in the plerixafor and placebo groups, respectively, and 93% of subjects were Caucasian. Three hundred and two (302) MM patients were included in the primary efficacy analyses for Study 2. The mean age was 58.2 years (range 28-75) and 58.5 years (range 28-75) in the plerixafor and placebo groups, respectively, and 81% of subjects were Caucasian.

In Study 1, 52 NHL patients in the placebo + G-CSF group entered into the open-label rescue procedure. In Study 2, 7 MM patients from the placebo + G-CSF group entered the rescue procedure.

Study results

In Study 1, 59% of NHL patients who were mobilized with plerixafor and G-CSF collected ≥ 5 X 10⁶ CD34+ cells / kg from the peripheral blood in four or fewer apheresis sessions, compared with 20% of patients who were mobilized with placebo and G-CSF (p < 0.001). The achievement of the minimum CD34+ cell collection required for transplantation in 4 or fewer days of apheresis is included in Table 9.

Table 9: Study 1 Efficacy Results - CD34+ Cell Mobilization in NHL Patients (Primary ITT Population)

^ap-value calculated using Pearson’s Chi-Squared test

The number of apheresis days required to achieve ≥ 5 x 10⁶ CD34+ cells / kg are summarized in Table 10. The median number of days to reach ≥ 5 x 10⁶ CD34+ cells / kg was 3 days for the plerixafor group and not evaluable for the placebo group.

Table 10: Study 1 Efficacy Results – Number of Apheresis Days Required to

Achieve ≥ 5 x 10⁶ CD34+ cells / kg in NHL Patients (Primary ITT Population)

^a Patient counts are cumulative across day numbers. Percentages were determined by Kaplan-Meier method.

In Study 2, 72% of MM patients who were mobilized with plerixafor and G-CSF collected

≥ 6 X 10⁶ CD34+ cells / kg from the peripheral blood in two or fewer apheresis sessions, compared with 34% of patients who were mobilized with placebo and G-CSF (p < 0.001). Patients achieving the target and minimum CD34+ cell collections within four or fewer apheresis sessions are presented in Table 11.

Table 11: Study 2 Efficacy Results – CD34+ Cell Mobilization in Multiple Myeloma Patients

^ap-value calculated using Pearson’s Chi-Squared test

The number of apheresis days required to achieve target cell collection are summarized in Table 12. The median number of days to reach ≥ 6 x 10⁶ CD34+ cells / kg was 1 day for the plerixafor group and 4 days for the placebo group.

Table 12: Study 2 Efficacy Results – Number of Apheresis Days Required to Achieve ≥ 6 × 10⁶ CD34+ cells / kg in MM Patients (Primary ITT Population)

^a Patient counts are cumulative across day numbers. Percentages are determined by Kaplan-Meier method.

Rescue patients

In Study 1, 52 NHL patients in the placebo + G-CSF group entered into the rescue procedure with plerixafor and G-CSF. Of these patients, 60% (31 out of 52) mobilized ≥ 2 x10⁶/kg CD34+ cells and had successful engraftment. In Study 2, 7 MM patients in the placebo + G-CSF group entered the rescue procedure, all of whom mobilized ≥ 2 x10⁶/kg CD34+ cells and had successful engraftment.

For transplanted patients in the Phase 3 studies, time to neutrophil engraftment (10-11 days) and platelet engraftment (18-20 days) were similar across the treatment groups.

Based on an adjusted analysis which used laboratory measurements and clinical criteria to assess graft durability, results were similar in both treatment groups, specifically, 128/135 (94.8%) versus 78/82 (95.1%) at 100 days, 120/123 (97.6%) versus 77/78 (98.7%) at 6 months, and 110/112 (98.2%) versus 65/65 (100%) at 12 months in Study 1 and 140/142 (98.6%) versus 133/136 (97.8%) at 100 days, 133/135 (98.5%) versus 125/127 (98.4%) at 6 months, and 127/128 (99.2%) versus 119/120 (99.2%) at 12 months in Study 2, plerixafor versus placebo, respectively.

For transplanted patients, the frequency of graft failure was low in Phase 3 studies, 3 events in plerixafor-treated NHL patients in Study 1 and none in MM patients in Study 2. None of these graft failures were considered by the investigator as related to plerixafor.

Final 5-year PFS and OS data are not yet available. However, OS at 12 months post- transplantation for the primary ITT population was 132/150 (88%) in the plerixafor group and 129/148 (87.2%) in the placebo in Study 1, and 141/148 (95.3%) in the plerixafor group and 148/154 (96.1%) in the placebo group in Study 2.

PEDIATRIC PATIENTS

The table below summarizes the demographic and baseline characteristics data in stage 2 of the pediatric study DFI12860, including the baseline imbalance in peripheral blood CD34+ counts between patient groups that was observed.

Table 13: Summary of the demographic and baseline data for DFI12860 (Stage 2)

The efficacy and safety of plerixafor were evaluated in an open label, multi-center, controlled study in pediatric patients with solid tumors (including neuroblastoma, sarcoma, Ewing sarcoma), or lymphoma who were eligible for autologous hematopoietic stem cell transplantation. Patients with leukemia, persistent high percentage marrow involvement prior to mobilization, or previous stem cell transplantation were excluded. This study consisted of an initial dose escalation study (Stage 1, N=27, age 2 to <18 years) followed by a randomized, comparative study extension (Stage 2, N=45, age 1 to <18 years) at the dose identified as most appropriate in the dose escalation part of the study.

Study patients (N=45) were started on standard mobilization (G-CSF ± chemotherapy as per site standard practice). Upon reaching the trigger point minimum of 7 CD34+ cells / mcL in peripheral blood (PB), patients were randomized 2:1 to either receive 0.24 mg / kg of plerixafor plus standard mobilization (G-CSF plus or minus chemotherapy) or standard mobilization alone. Apheresis was to occur if, on the scheduled day of apheresis, the PB CD34+ count was ≥20 cells/mcL.

The primary efficacy analysis showed that 80% of patients in the plerixafor arm experienced at least a doubling of the PB CD34+ count, observed from the morning of the day preceding the first planned apheresis to the morning prior to apheresis versus 28.6 % of patients in the control arm (p=0.0019).

The table below summarizes the secondary endpoints that relate to mobilization and cell collection:

Table 14: Secondary Endpoints Related to Mobilization and Cell Collection

DETAILED PHARMACOLOGY Nonclinical Pharmacology

The activity of plerixafor at the human CXCR4 receptor was demonstrated in vitro using the CCRF-CEM cell line which endogenously expresses CXCR4. Plerixafor was shown to inhibit SDF-1α ligand binding to CXCR4, and to inhibit SDF-1-mediated calcium flux, G-protein activation, and chemotaxis with IC₅₀ values of 651 ± 37 nM, 572 ± 190 nM, 15.4 ± 4.4 nM, and 51 ± 17 nM respectively. The selectivity of plerixafor’s inhibitory activity was demonstrated in similar studies with cells expressing different chemokine receptors. In these studies plerixafor did not inhibit calcium flux against the following receptors: CXCR1, CXCR2, CXCR3, CCR1, CCR2b, CCR3, CCR4, CCR5, CCR6, CCR7, CCR8, or CCR9. In addition plerixafor did not inhibit the binding of leukotriene B4 (chemoattractant for granulocytes) to its receptor, BLTR., nor did it inhibit binding of SDF-1 to CXCR7, an alternative receptor for SDF-1. The molecular interactions of plerixafor with the CXCR4 chemokine receptor were investigated using receptor site directed mutagenesis studies. Receptor mutagenesis identified Asp171 and Asp262 as being essential for the ability of plerixafor to block the receptor. These studies showed that plerixafor acts on the CXCR4 receptor through binding to the negatively charged amino acids Asp171 and Asp262 with each of its cyclam moieties.

The ability of plerixafor to mobilize HSC and HPC capable of long term engraftment was demonstrated in three species.

The administration of single subcutaneous injection of plerixafor (5 mg / kg) to C3H/HeJ mice induced a rapid and dose-dependent mobilization of HPC to blood with peak mobilization occurring at 1 hour post dosing. Repeat daily dosing (3 days) with plerixafor gave consistent HPC mobilization after each dose, indicating that there was no desensitization with repeated administration. Plerixafor was shown to be a potent HPC mobilizer in other strains of mice where G-CSF is a poor HPC mobilizer, such as DBA/2 and Fanc^-/-. Plerixafor was also shown to augment G-CSF- induced mobilization in DBA/2, C57Bl6 and C3H/HEJ mice. Long-term engraftment in bone marrow was demonstrated using a competitive repopulating assay with CD45⁺ congenic mice. Donor blood cells collected from plerixafor-treated C57B1/6 (CD45.2⁺) mice competed with recipient bone marrow cells for engraftment in lethally irradiated transplant recipient B6.BoyJ (CD45.1⁺) mice. A greater than 8-fold higher chimerism (ratio of donor cells:recipient cells) was observed with plerixafor-mobilized donor cells compared with a saline control. Self-renewal of plerixafor-mobilized HSC was demonstrated using a secondary repopulating assay in which donor cells obtained from the competitively engrafted mice above were re-injected into lethally- irradiated secondary mice. All secondary mice survived with > 50 % engrafted cells of donor origin. The repopulating potential of plerixafor–mobilized human HSC was also evaluated in a NOD/SCID mouse repopulation assay. CD34⁺ blood cells collected during apheresis from healthy human volunteers administered plerixafor, G-CSF, or plerixafor plus G-CSF were able to repopulate the bone marrow of lethally irradiated NOD/SCID mice, as demonstrated by the presence of chimerism (human CD45⁺ cells) in the bone marrow after eight weeks.

The ability of plerixafor to mobilize CD34⁺ stem cells which, following transplantation, result in timely and durable engraftment and reconstitution of the bone marrow has been demonstrated in dogs and monkeys. In these studies, CD34⁺ cells were collected from plerixafor-treated animals by apheresis. Prior to transplantation, the recipient animals received myeloablative total body irradiation followed by infusion of autologous plerixafor-mobilized peripheral blood mononuclear cells. Engraftment was monitored by peripheral blood counts. In dogs, neutrophil and platelet engraftment occurred at medians of 8 and 25 days. In rhesus macaque monkeys, rapid engraftment measured by gene marking was observed within 7- 14 days, with persistent long-term retrovirally marked myeloid and lymphoid cells present up to 32 months after transplantation.

Safety Pharmacology

The effect on the cardiovascular system of subcutaneous administration was evaluated in anesthetized rats at a single dose (20 mg/kg). Similarly to plerixafor after intravenous administration in the rats, there were decreases in mean arterial blood pressure, heart rate, +dP/dt, dP/dt and cardiac output. In addition, a visual inspection of the ECG tracing showed that the P wave became flat, negative or undetectable. Continuous intravenous infusion of plerixafor for 8 hours to conscious dogs delivering plasma steady state levels between 6.4 and 7.4 mcg/ml (significantly higher than the approximate peak plasma level observed in humans at the recommended dose for HSC mobilization, i.e. approximately 1 mcg/ml) showed no treatment-related changes in ECG tracings, heart rate, cardiac function, or blood pressure. Continuous intravenous infusion at a 2-fold higher rate with plasma levels between 10.9 and 14.3 mcg/ml (measured between 3 and 8 hours of infusion) produced an increase in heart rate with associated decrease in PR interval, increased systemic blood pressure and clinical signs of frank toxicity. There were no effects on QRS interval duration or QTc interval.

An in vitro general receptor activity screen showed that plerixafor at a concentration of 5 mcg/ml has moderate or strong binding affinity for a number of different receptors predominantly located on pre-synaptic nerve endings in the CNS and/or the PNS (N-type calcium channel, potassium channel SKCA, histamine H3, acetylcholine muscarinic M1 and M2, adrenergic α1B and α2C, neuropeptide Y/Y1 and glutamate NMDA polyamine receptors). The clinical relevance of these findings is not known.

Nonclinical Pharmacokinetics

Distribution studies conducted with radiolabeled plerixafor in rat following subcutaneous administration demonstrated that plerixafor distributed readily into the majority of tissues evaluated, with the exception of brain, muscle, pancreas, renal fat, salivary gland, spinal cord, and testes tissues. Tissues with the highest radioactivity concentrations were the renal medulla, thymus, epididymis, kidney, renal cortex, and liver. Overall low concentrations (ratio of tissue to plasma of <1) of radioactivity were detected in the brain, muscle, pancreas, renal fat, salivary gland, spinal cord, and testes at up to 4 hours post dose. Elimination of plerixafor from most tissues occurred between 4 and 24 hours, however retention of drug-derived material in bone marrow, cartilage, spleen, liver, and kidney tissues was noted at up to 144 hours post subcutaneous administration. After 168 hours following subcutaneous administration to rat and dog up to 30% of drug-derived material remained in the body. The primary route of elimination of plerixafor in rat and dog is via renal excretion. Following subcutaneious and intravenous administration in rat and dog the majority of the radioactivity (63–72 % of the dose) was excreted in the urine within 48 hours. Elimination in the feces accounted for < 12 % of total radioactivity in rat and dog.

Human Pharmacology

Pharmacodynamics

Plerixafor reversibly and selectively blocks the binding of the CXCR4 chemokine receptor to its cognate ligand SDF-1α. The interruption of the CXCR4/SDF-1α interaction results in the mobilization of bone marrow HSCs to the peripheral blood. A close correlation exists between the number of CD34+ cells, a well-established surrogate marker for HSCs, and the number of colony forming units (which indicate functional HSCs) in peripheral blood HSC collections. Based upon this information, pharmacodynamic activity of plerixafor was assessed by measuring the number of PB CD34+ cells using fluorescence activated cell sorting (FACS) analysis. The pharmacodynamics of plerixafor were also assessed by colony forming units, as a confirmation that CD34+ cell count by FACS analysis was an adequate proxy measure of functional HSCs.

In all studies in both healthy subjects and patients with NHL and MM, the pharmacodynamic effect of plerixafor produces a consistent and marked increase in PB CD34+ cell counts from baseline.

In healthy subjects, the administration of a single dose of plerixafor (0.04 to 0.24 mg / kg) with no G-CSF led to dose-proportional increases from baseline of PB CD34+ cell counts. The pharmacodynamic response to plerixafor 0.24 mg / kg (no G-CSF) in healthy subjects occurs 6 to 10 hours after dosing. The median peak fold-increase was 15.8 over baseline. The pharmacodynamic response to 0.24 mg / kg plerixafor alone was higher than after 0.16 mg / kg plerixafor, yet similar to after 0.32 mg / kg.

The administration of plerixafor to healthy subjects (0.24 mg/kg) in conjunction with G-CSF produced a sustained elevation in the PB CD34+ cell count from 4 to 18 hours after plerixafor administration, with peak response between 10 to 14 hours. Following 4 days of G-CSF, administration of plerixafor (0.16 mg/kg) and G-CSF produced higher peak PB CD34+ cell counts (a 3.8-fold increase over the G-CSF alone baseline) than treatment with either plerixafor (0.16 mg / kg) alone (a 3.2-fold increase over baseline) or G-CSF alone (a 1.2-fold increase over baseline) on the 5^th day.

The pharmacodynamics of plerixafor were also evaluated in oncology patients, either after a single subcutaneous administration or in combination with G-CSF. A single injection of plerixafor alone elicited an increase in PB CD34+ cell counts that was generally less than observed in healthy volunteers.

In combination with G-CSF, patients with MM, in general, had higher responses than patients with NHL in mobilizing CD34+ cells. In the NHL group, patients with higher baseline concentrations of PB CD34+ cell counts (cells / mcL) had better responses than those with lower baseline PB CD34+ cell counts. Plerixafor increased the PB CD34+ count by 3- to 6-fold over the pre-plerixafor dose level after the first injection, which was similar to the 3- to 4-fold increase observed in healthy subjects.

Cumulatively, pharmacodynamic studies showed that in healthy subjects, the plerixafor dose of 0.24 mg / kg elicited a higher and later peak response compared with the 0.16- mg / kg dose. The increase in PB CD34+ cells with plerixafor following 4 days of pre-treatment with G-CSF was higher than with plerixafor or G-CSF alone. When added to a dosing regimen of G-CSF in healthy subjects, 0.16 mg / kg and 0.24 mg / kg plerixafor had similar magnitudes of fold-increases in PB CD34+ cells. In patients with MM and NHL, the 0.24 mg / kg dose with G-CSF elicited a greater response (greater fold-increase in apheresis yields) than the 0.16 mg / kg dose with G-CSF. Based upon the above data and given the difference in response rates of patients with MM and NHL, the recommended dose of plerixafor injection is 0.24 mg / kg body weight by subcutaneous (SC) injection.

Pharmacokinetics

The pharmacokinetics of plerixafor are described under ACTION AND CLINICAL PHARMACOLOGY.

TOXICOLOGY

Single Dose Toxicology

Single intravenous or subcutaneous injection of plerixafor in rats and mice induced a rapid onset (< 2 hour) of transient, but severe, neuromuscular, sedative-like effects (hypoactivity), dyspnea, ventral or lateral recumbency and/or spasms. Complete recovery from most signs occurred within 4 hours following plerixafor administration. In mice, deaths were observed following doses of ≥ 14 mg / kg subcutaneous and ≥ 5 mg / kg Intravenous. In rats, deaths were observed following doses of ≥ 40 mg / kg subcutaneous and ≥ 5 mg / kg Intravenous.

Repeat Dose Toxicology

The repeat-dose general toxicology has been evaluated after subcutaneous (SC) administration in rats and dogs for up to 4 weeks. This duration of dosing supports clinical administration of plerixafor up to 2 weeks. There are no 6 month studies in rats and 9 month studies in dogs or monkeys that would support chronic clinical studies and/or long term administration in clinical practice.

In repeat dose studies in rats and dogs with once- or twice-daily subcutaneous dosing, severe adverse neuromuscular-like clinical signs were observed within the first 1 to 2 hours post dose and were dose-limiting. At non-lethal doses, daily subcutaneous treatment induced adverse clinical signs similar to those seen in the single dose mouse and rat studies. The onset of these clinical signs occurred within 15 min to 1 hr following subcutaneous plerixafor injection; however, unlike the single dose studies, the signs were generally not seen until after approximately 5 to 8 daily subcutaneous doses of plerixafor had been administered to rats or dogs. Plerixafor was associated with GI clinical signs in dogs (diarrhea, emesis, increased defecation) and neurological signs in dogs and rats (sedation, tremors, spasms, twitching, recumbency and ataxia and mydriasis). There were some minor decreases in body weight gain and food consumption.

Increases in white cell counts (predominantly due to neutrophils), and decreases in serum magnesium and increases in urinary calcium and/or magnesium were noted in both rats and dogs. Histopathology findings of extramedullary hematopoiesis were observed in the liver, spleen and occasionally in other organs of rats and/or dogs. Slightly higher spleen weights were observed in rats. These findings were considered to be an extension of the pharmacological action of plerixafor to mobilize hematopoietic and/or white blood cells and for its affinity to chelate cations.

Compared to control rats, increased injection site reactions were more pronounced at 12 mg / kg BID (24 mg / kg / day) in a 4 week subcutaneous study. At doses of ≥1 mg / kg / day (≥20 mg/m²) plerixafor induced transient increases in heart rates in dogs with decreases in QT interval considered secondary to the effect on heart rate. The No Adverse Effect Dose Level (NOAEL) in 4 week subcutaneous studies were 0.6-1.2 mg / kg / day (3.6-7.2 mg / m²) and 0.25-0.3 mg / kg / day (3.6-7.2 mg / m²) in rats and dogs, respectively. Exposures (AUCs) at these doses were 0.1 to 5 times the clinical exposure. In the rat and dog, the Maximum Tolerated Dose (MTD) was 7.6-24 mg / kg / day (46-144 mg / m²) and 4-8 mg / kg / day (80-160 mg / m²), respectively. At the MTD, exposures (AUCs) are 7 to 18 times the clinical exposure.

Three nonclinical studies have been performed in juvenile animals. In a non-GLP dose range- finding study, plerixafor was administered to juvenile male miniature pigs at single subcutaneous (SC) doses from 1-12 mg / kg or repeat SC doses of 4.75 mg / kg / day for 4 days. In a non-GLP dose range-finding toxicity study and in a GLP toxicity study, plerixafor was administered SC daily to juvenile Sprague-Dawley rats from Postnatal Day (PND)21 to PND50 at 1.5-15 mg / kg / day. The results of the dose range-finding study in juvenile miniature pigs and the range- finding and definitive studies in juvenile rats were similar to those observed in adult mice, rats, and dogs. Clinical signs of lateral recumbence and discomfort were observed in miniature pigs at 8 mg / kg and mortality was seen at 12 mg / kg. Plerixafor produced the expected pharmacologically-mediated leukocytosis in pigs and rats. The organ weight effects observed in rats were considered pharmacologic (thymus) or an adaptive response (extramedullary hematopoiesis in the liver and spleen).

Dose margins in the juvenile rat study at the maximum tolerated dose (MTD) were 18-26-fold higher based on exposure when compared with the recommended clinical pediatric dose in children 2 to less than 18 years of age.

Carcinogenesis

Carcinogenicity studies with plerixafor have not been conducted.

Mutagenesis

Plerixafor was not genotoxic in an in vitro bacterial mutation assay (Ames test in Salmonella), an in vitro chromosomal aberration test using Chinese hamster ovary cells, and an in vivo rat bone marrow micronucleus test in rats after subcutaneous doses up to 25 mg / kg (150 mg / m²).

Impairment of Fertility

The potential effects of plerixafor on male fertility and post-natal development have not been evaluated in non-clinical studies. In studies conducted to measure the distribution of ¹⁴C-plerixafor, there was no evidence of accumulation in testes. The staging of spermatogenesis measured in a 28-day repeat-dose toxicity study in rats revealed no abnormalities considered to be related to plerixafor. There were no plerixafor related histopathological changes in male or female reproductive organs in rats and dogs administered plerixafor daily at doses 24 mg / kg (144 mg / m²; 12 mg / kg BID) and 8 mg / kg (160 mg / m²; 4 mg / kg BID), respectively for up to 4 weeks.

No adverse effects were observed in an investigative female fertility study in rats, even though concentrations of plerixafor in the ovaries were detectable up to the last days of cohabitation.

Reproductive Toxicity

SDF-1α and CXCR4 play major roles in embryo-fetal development. Plerixafor administered during organogenesis has been shown to cause fetal death, increased resorptions, and post- implantation loss, decreased fetal weights, retarded skeletal development and increased fetal abnormalities in rats and rabbits. Fetal abnormalities included cyst at the parietal/frontal bone, anophthalmia, globular heart dilation of the ascending aorta, ringed aorta, cardiac interventricular septal defect, dilation of pulmonary truncus and stenosis of descending aorta, omphalocele, anal atresia, intestinal stenosis, brachdactyly, and acaudia. Animal models also suggest modulation of fetal hematopoiesis, vascularization, and cerebellar development by SDF-1α and CXCR4. The no-observed-adverse-effect-levels (NOAEL) of plerixafor in rats and rabbits (3 mg / kg / day and 0.6 mg / kg / day, respectively) are approximately 2 and 0.8 times the recommended human dose of 0.24 mg / kg / day (8.9 mcg / m² /day). The embryolethal, fetotoxic and teratogenic effects are likely due to the pharmacodynamic mechanism of action of plerixafor.

REFERENCES

1. 1.

   Bensinger W, DiPersio JF, McCarty JM. Improving stem cell mobilization strategies:

   future directions. Bone Marrow Transplant 2009; 43(3): 181-95.

2. 2. Broxmeyer HE, Orschell CM, Clapp DW, Hangoc G, Cooper S, Plett PA et al. Rapid mobilization of murine and human hematopoietic stem and progenitor cells with AMD3100, a CXCR4 antagonist. J Exp Med 2005; 201(8): 1307-18.
3. 3. Calandra G, McCarty J, McGuirk J, Tricot G, Crocker SA, Badel K et al. AMD3100 plus G-CSF can successfully mobilize CD34+ cells from non-Hodgkin's lymphoma, Hodgkin's disease and multiple myeloma patients previously failing mobilization with chemotherapy and/or cytokine treatment: compassionate use data. Bone Marrow Transplant 2008; 41(4): 331-8.
4. 4. Cashen A, Lopez S, Gao F, Calandra G, MacFarland R, Badel K et al. A phase II study of plerixafor (AMD3100) plus G-CSF for autologous hematopoietic progenitor cell mobilization in patients with Hodgkin lymphoma. Biol Blood Marrow Transplant 2008; 14(11): 1253-61.
5. 5. Cashen AF, Nervi B, DiPersio J. AMD3100: CXCR4 antagonist and rapid stem cell- mobilizing agent. Future Oncol 2007; 3(1): 19-27.
6. 6. Choi HY, Yong CS, Yoo BK. Plerixafor for stem cell mobilization in patients with non- Hodgkin's lymphoma and multiple myeloma. Ann Pharmacother 2010; 44(1): 117-26.
7. 7. Costa LJ, Miller AN, Alexander ET, Hogan KR, Shabbir M, Schaub C, Stuart RK., Growth factor and patient-adapted use of plerixafor is superior to CY and growth factor for autologous hematopoietic stem cells mobilization. Bone Marrow Transplant. 2010 Jul 12.
8. 8. Costa LJ, Alexander ET, Hogan KR, Schaub C, Fouts TV, Stuart RK., Development and validation of a decision-making algorithm to guide the use of plerixafor for autologous hematopoietic stem cell mobilization. Bone Marrow Transplant.2010 Apr 12.
9. 9. D'Addio A, Curti A, Worel N, Douglas K, Motta MR, Rizzi S et al. The addition of plerixafor is safe and allows adequate PBSC collection in multiple myeloma and lymphoma patients poor mobilizers after chemotherapy and G-CSF. Bone Marrow Transplant 2010.
10. 10. Devine SM, Flomenberg N, Vesole DH, Liesveld J, Weisdorf D, Badel K et al. Rapid mobilization of CD34+ cells following administration of the CXCR4 antagonist AMD3100 to patients with multiple myeloma and non-Hodgkin's lymphoma. J Clin Oncol 2004; 22(6): 1095-102.
11. 11. DiPersio JF, Micallef IN, Stiff PJ, Bolwell BJ, Maziarz RT, Jacobsen E et al. Phase III prospective randomized double-blind placebo-controlled trial of plerixafor plus granulocyte colony-stimulating factor compared with placebo plus granulocyte colony- stimulating factor for autologous stem-cell mobilization and transplantation for patients with non-Hodgkin's lymphoma. J Clin Oncol 2009; 27(28): 4767-73.
12. 12.

    DiPersio JF, Stadtmauer EA, Nademanee A, Micallef IN, Stiff PJ, Kaufman JL et al.

    • Plerixafor and G-CSF versus placebo and G-CSF to mobilize hematopoietic stem cells for autologous stem cell transplantation in patients with multiple myeloma. Blood 2009; 113(23): 5720-6.
13. 13. Duarte RF, Shaw BE, Marin P, Kottaridis P, Ortiz M, Morante C et al. Plerixafor plus granulocyte CSF can mobilize hematopoietic stem cells from multiple myeloma and lymphoma patients failing previous mobilization attempts: EU compassionate use data. Bone Marrow Transplant 2010.
14. 14. Flomenberg N, Devine SM, Dipersio JF, Liesveld JL, McCarty JM, Rowley SD et al. The use of AMD3100 plus G-CSF for autologous hematopoietic progenitor cell mobilization is superior to G-CSF alone. Blood 2005; 106(5): 1867-74.
15. 15. Flomenberg N, DiPersio J, Calandra G. Role of CXCR4 chemokine receptor blockade using AMD3100 for mobilization of autologous hematopoietic progenitor cells. Acta Haematol 2005; 114(4): 198-205.
16. 16. Fruehauf S, Ehninger G, Hubel K, Topaly J, Goldschmidt H, Ho AD et al. Mobilization of peripheral blood stem cells for autologous transplant in non-Hodgkin's lymphoma and multiple myeloma patients by plerixafor and G-CSF and detection of tumor cell mobilization by PCR in multiple myeloma patients. Bone Marrow Transplant 2010; 45(2): 269-75.
17. 17. Fruehauf S, Seeger T, Maier P, Li L, Weinhardt S, Laufs S et al. The CXCR4 antagonist AMD3100 releases a subset of G-CSF-primed peripheral blood progenitor cells with specific gene expression characteristics. Exp Hematol 2006; 34(8): 1052-9.
18. 18. Fruehauf S, Veldwijk MR, Seeger T, Schubert M, Laufs S, Topaly J et al. A combination of granulocyte-colony-stimulating factor (G-CSF) and plerixafor mobilizes more primitive peripheral blood progenitor cells than G-CSF alone: results of a European phase II study. Cytotherapy 2009; 11(8): 992-1001.
19. 19. Gazitt Y, Freytes CO, Akay C, Badel K, Calandra G. Improved mobilization of peripheral blood CD34+ cells and dendritic cells by AMD3100 plus granulocyte-colony- stimulating factor in non-Hodgkin's lymphoma patients. Stem Cells Dev 2007; 16(4):657-66.
20. 20. Gertz MA, Wolf RC, Micallef IN, Gastineau DA. Clinical impact and resource utilization after stem cell mobilization failure in patients with multiple myeloma and lymphoma. Bone Marrow Transplant. 2010 Sep;45(9):1396-403.
21. 21. Giralt S, Stadtmauer EA, Harousseau JL, Palumbo A, Bensinger W, Comenzo RL et al. International myeloma working group (IMWG) consensus statement and guidelines regarding the current status of stem cell collection and high-dose therapy for multiple myeloma and the role of plerixafor (AMD 3100). Leukemia 2009; 23(10): 1904-12.
22. 22. Hess DA, Bonde J, Craft TP, Wirthlin L, Hohm S, Lahey R et al. Human progenitor cells rapidly mobilized by AMD3100 repopulate NOD/SCID mice with increased frequency in comparison to cells from the same donor mobilized by granulocyte colony stimulating factor. Biol Blood Marrow Transplant 2007; 13(4): 398-411.
23. 23.

    Holtan SG, Porrata LF, Micallef IN, Padley DJ, Inwards DJ, Ansell SA et al. AMD3100 affects autograft lymphocyte collection and progression-free survival after autologous

    • stem cell transplantation in non-Hodgkin lymphoma. Clin Lymphoma Myeloma 2007; 7(4): 315-8.
24. 24. Hubel K, Liles WC, Broxmeyer HE, Rodger E, Wood B, Cooper S et al. Leukocytosis and Mobilization of CD34+ Hematopoietic Progenitor Cells by AMD3100, a CXCR4 Antagonist. Support Cancer Ther 2004; 1(3): 165-72.
25. 25. Jagasia MH, Savani BN, Neff A, Dixon S, Chen H, Pickard AS., . Outcome, toxicity profile and cost analysis of autologous stem cell mobilization. Bone Marrow Transplant 2010 Nov 1.
26. 26. Jin P, Wang E, Ren J, Childs R, Shin JW, Khuu H et al. Differentiation of two types of mobilized peripheral blood stem cells by microRNA and cDNA expression analysis. J Transl Med 2008; 6: 39.
27. 27. Lack NA, Green B, Dale DC, Calandra GB, Lee H, MacFarland RT et al. A pharmacokinetic-pharmacodynamic model for the mobilization of CD34+ hematopoietic progenitor cells by AMD3100. Clin Pharmacol Ther 2005; 77(5): 427-36.
28. 28. Liles WC, Broxmeyer HE, Rodger E, Wood B, Hubel K, Cooper S et al. Mobilization of hematopoietic progenitor cells in healthy volunteers by AMD3100, a CXCR4 antagonist. Blood 2003; 102(8): 2728-30.
29. 29. Liles WC, Rodger E, Broxmeyer HE, Dehner C, Badel K, Calandra G et al. Augmented mobilization and collection of CD34+ hematopoietic cells from normal human volunteers stimulated with granulocyte-colony-stimulating factor by single-dose administration of AMD3100, a CXCR4 antagonist. Transfusion 2005; 45(3): 295-300.
30. 30. MacFarland R, Hard ML, Scarborough R, Badel K, Calandra G. A pharmacokinetic study of plerixafor in subjects with varying degrees of renal impairment. Biol Blood Marrow Transplant 2010; 16(1): 95-101.
31. 31. Micallef IN, Ho AD, Klein LM, Marulkar S, Gandhi PJ, McSweeney PA. Plerixafor (MOZOBIL) for stem cell mobilization in patients with multiple myeloma previously treated with lenalidomide. Bone Marrow Transplant 2010.
32. 32. Micallef IN, Stiff PJ, DiPersio JF, Maziarz RT, McCarty JM, Bridger G et al. Successful stem cell remobilization using plerixafor (mozobil) plus granulocyte colony-stimulating factor in patients with non-hodgkin lymphoma: results from the plerixafor NHL phase 3 study rescue protocol. Biol Blood Marrow Transplant 2009; 15(12): 1578-86.
33. 33. Montgomery M, Cottler-Fox M. Mobilization and collection of autologous hematopoietic progenitor/stem cells. Clin Adv Hematol Oncol 2007; 5(2): 127-36.
34. 34. Perseghin P, Terruzzi E, Dassi M, Baldini V, Parma M, Coluccia P et al. Management of poor peripheral blood stem cell mobilization: incidence, predictive factors, alternative strategies and outcome. A retrospective analysis on 2177 patients from three major Italian institutions. Transfus Apher Sci 2009; 41(1): 33-7.
35. 35. Pusic I, DiPersio JF. Update on clinical experience with AMD3100, an SDF-1/CXCL12- CXCR4 inhibitor, in mobilization of hematopoietic stem and progenitor cells. Curr Opin Hematol 2010; 17(4): 319-26.
36. 36.

    Pusic I, Jiang SY, Landua S, Uy GL, Rettig MP, Cashen AF et al. Impact of

    • mobilization and remobilization strategies on achieving sufficient stem cell yields for autologous transplantation. Biol Blood Marrow Transplant 2008; 14(9): 1045-56.
37. 37. Rettig MP, Ramirez P, Nervi B, DiPersio JF. CXCR4 and mobilization of hematopoietic precursors. Methods Enzymol 2009; 460: 57-90.
38. 38. Rosenbeck LL, Srivastava S, Kiel PJ. Peripheral blood stem cell mobilization tactics. Ann Pharmacother 2010; 44(1): 107-16.
39. 39. Shaughnessy P, Islas-Ohlmayer M, Murphy J, Hougham M, Macpherson J, Winkler K et al. Cost and Clinical Analysis of Autologous Hematopoietic Stem Cell Mobilization with G-CSF and Plerixafor compared to G-CSF and Cyclophosphamide. Biol Blood Marrow Transplant 2010.
40. 40. Stewart DA, Smith C, MacFarland R, Calandra G. Pharmacokinetics and pharmacodynamics of plerixafor in patients with non-Hodgkin lymphoma and multiple myeloma. Biol Blood Marrow Transplant 2009; 15(1): 39-46.
41. 41. Stiff P, Micallef I, McCarthy P, Magalhaes-Silverman M, Weisdorf D, Territo M et al. Treatment with plerixafor in non-Hodgkin's lymphoma and multiple myeloma patients to increase the number of peripheral blood stem cells when given a mobilizing regimen of G-CSF: implications for the heavily pretreated patient. Biol Blood Marrow Transplant 2009; 15(2): 249-56.
42. 42. Taubert I, Safrich R, Zepeda-Moreno A, Hellwig I,Eckstein V, Bruckner T, HO A & Wuchter P, Characterization of hematopoietic stem cell subsets from patients with multiple myeloma after mobilization with plerixafor. Cytotherapy, 2010; Early Online,1–8.
43. 43. Tricot G, Cottler-Fox MH, Calandra G. Safety and efficacy assessment of plerixafor in patients with multiple myeloma proven or predicted to be poor mobilizers, including assessment of tumor cell mobilization. Bone Marrow Transplant 2010; 45(1): 63-8.
44. 44. Uy GL, Rettig MP, Cashen AF. Plerixafor, a CXCR4 antagonist for the mobilization of hematopoietic stem cells. Expert Opin Biol Ther 2008; 8(11): 1797-804.
45. 45. Wagstaff AJ. Plerixafor: in patients with non-Hodgkin's lymphoma or multiple myeloma. Drugs 2009; 69(3): 319-26.
46. 46. Worel N, Rosskopf K, Neumeister P, Kasparu H, Nachbaur D, Russ G et al. Plerixafor and granulocyte-colony-stimulating factor (G-CSF) in patients with lymphoma and multiple myeloma previously failing mobilization with G-CSF with or without chemotherapy for autologous hematopoietic stem cell mobilization: the Austrian experience on a named patient program. Transfusion 2010.
47. 47. Neupogen (filgrastim) Product Monograph. Amgen Canada Inc 2010.
48. 48. MOZOBIL, Sanofi-aventis Canada Inc. Product Monograph. Control Number 213345. Date of Revision: January 09, 2019