On January 26, 2018, the Food and Drug Administration approved lutetium Lu 177 dotatate (LUTATHERA, Advanced Accelerator Applications USA, Inc.) a radiolabeled somatostatin analog, for the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs), including foregut, midgut, and hindgut neuroendocrine tumors in adults.
Approval was based on data from NETTER-1 (NCT01578239), a randomized, multicenter, open-label, active-controlled trial in 229 patients with progressive, well-differentiated, locally advanced/inoperable or metastatic somatostatin receptor-positive midgut carcinoid tumors. Patients were randomized (1:1) to receive either lutetium Lu 177 dotatate (7.4 GBq [200 mCi] every 8 weeks for up to 4 administrations; maximum cumulative dose of 29.6 GBq) with long-acting octreotide (30 mg by intramuscular injection every 4 weeks) or high-dose long-acting octreotide (60 mg by intramuscular injection every 4 weeks). Lutetium Lu 177 dotatate was co-administered with an amino acid solution as a renal protectant. In the US, patients enrolled in NETTER-1 received Aminosyn II 10%, a commercially available solution of amino acids.
The major efficacy outcome measure was progression free survival (PFS) determined by a blinded independent radiology committee using RECIST 1.1. The median PFS was not reached for lutetium Lu 177 dotatate and was 8.5 months in the high-dose long-acting octreotide arm (hazard ratio 0.21; 95% CI: 0.13, 0.32; p<>
The efficacy of lutetium Lu 177 dotatate was also assessed in a subset (n=360) of 1214 patients enrolled in the ERASMUS Medical Center (MC) study with GEP-NET tumors who were assessed according to RECIST criteria. At the ERASMUS MC, lutetium Lu 177 dotatate was initially provided as expanded access under a general peptide receptor radionuclide therapy protocol at a single site in the Netherlands. Lutetium Lu 177 dotatate (7.4 GBq [200 mCi]) was administered every 6 to 13 weeks for up to 4 doses. The ORR was 16% (n=58), including 3 complete responses in this subset of 360 patients with GEP-NETs who were assessed according to RECIST criteria.
In the NETTER-1 study, the most common grade 3-4 adverse reactions occurring with a greater frequency (at least 4%) among patients receiving lutetium Lu 177 dotatate with long-acting octreotide compared to patients receiving high-dose octreotide alone included lymphopenia (44%), increased GGT (20%), vomiting (7%), nausea and elevated AST (5% each), and increased ALT, hyperglycemia, and hypokalemia (4% each). In NETTER-1, with a median follow-up of 24 months, myelodysplastic syndrome was reported in 2.7% of patients receiving lutetium Lu 177 dotatate with long-acting octreotide; no patients receiving high-dose octreotide LAR developed myelodysplastic syndrome.
The recommended dose of lutetium Lu 177 dotatate is 7.4 GBq (200 mCi) as an intravenous infusion over 30 minutes every 8 weeks for a total of 4 doses.
Full prescribing information is available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/208700s000lbl.pdf.
FDA granted priority review for this application and previously granted Orphan Drug designation to lutetium Lu 177 dotatate for treatment of GEP-NETs. A description of FDA expedited programs is in the Guidance for Industry: Expedited Programs for Serious Conditions-Drugs and Biologics, available at: http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm358301.pdf.
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