Summary

• Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
• Neurotoxicity has been reported as an adverse event (AE) in the MonumenTAL-1, MonumenTAL-2, TRIMM-2, and RedirecTT-1 studies.^1-6
• MonumenTAL-1 (MMY1001) is an ongoing, open-label, phase 1/2 study evaluating the efficacy and safety of TALVEY in patients with relapsed or refractory multiple myeloma (RRMM) after ≥3 prior lines of therapy, including a proteasome inhibitor (PI), an immunomodulatory drug, and an anti-CD38 monoclonal antibody.^1,4,7-9
  • Chari et al (2024)¹⁰ published the clinical management of AEs in patients with RRMM treated with TALVEY in the MonumenTAL-1 study. Immune effector cellassociated neurotoxicity syndrome (ICANS) events were reported in the weekly (QW), once every other week (Q2W), and T-cell redirection (TCR) cohorts.
  • Schinke et al (2023)¹ presented the updated efficacy and safety results from the MonumenTAL-1 study at a median follow-up of 18.8 months for the 0.4 mg/kg subcutaneous (SC) QW cohort, 12.7 months for the 0.8 mg/kg SC Q2W cohort, and 14.8 months for the prior TCR–exposed cohort. ICANS events reported in the QW, Q2W, and prior TCR cohorts.
  • Chari et al (2022)¹¹ presented the efficacy and safety of the phase 1/2 portion of the MonumenTAL-1 study. The median follow-up for safety was 11.0 months for the 0.4 mg/kg SC QW cohort and 5.1 months for the 0.8 mg/kg Q2W cohort. ICANS events were reported (measured in phase 2 only) in the QW and Q2W cohorts.
  • Per protocol, neurological toxicities included, but were not limited to, speech disorders, convulsions, and disturbances in consciousness, confusion, disorientation, or coordination, and balance disorders. Management of ICANS has been detailed in Table: MonumenTAL-1 Study Part 3 - Guidelines for the Management of ICANS. Neurotoxicity apart from ICANS were managed per institutional guidelines. Dose delay was required in the event of neurotoxicity.⁷
• MonumenTAL-2 (MMY1004) is an ongoing, phase 1b, multi-arm, open-label study evaluating TALVEY in combination with other anticancer therapies in patients with multiple myeloma (MM). Cohort E is evaluating the safety and efficacy of TALVEY in combination with pomalidomide in 35 patients with RRMM.^6,12 Janssen does not recommend the use of TALVEY in a manner that is inconsistent with the approved labeling.
  • Searle et al (2024)¹³ presented the updated efficacy and safety results of TALVEY in combination with pomalidomide from the MonumenTAL-2 study at a median follow-up of 16.8 months (range, 1.2-25.1). ICANS was reported.
• TRIMM-2 (MMY1002) is an ongoing, phase 1b, multicohort open-label study evaluating the efficacy and safety of DARZALEX FASPRO^® regimens in combination with TECVAYLI^® or TALVEY with or without pomalidomide in patients with RRMM.^2,14,15 Janssen does not recommend the use of TECVAYLI, TALVEY, or DARZALEX FASPRO in a manner that is inconsistent with the approved labeling.
  • Bahlis et al (2024)¹⁵presented the efficacy and safety results of the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO + pomalidomide and TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO + pomalidomide cohorts at a median follow-up of 15.8 months (range, 3.2-37.9) and 17.5 months (range, 0.2-37.7), respectively. ICANS events were reported in both TALVEY + DARZALEX FASPRO + pomalidomide cohorts.
  • Dholaria et al (2023)² presented the updated efficacy and safety results from the TALVEY + DARZALEX FASPRO cohorts at a median follow-up of 16.8 months for the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO cohort and 15.0 months for the TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO cohort. ICANS events were reported in TALVEY + DARZALEX FASPRO cohorts.
• RedirecTT-1 (MMY1003) is an ongoing, open-label, phase 1b/2 study evaluating the safety and efficacy of TALVEY and TECVAYLI in patients with RRMM.^16-18 Janssen does not recommend the use of TALVEY and TECVAYLI in a manner that is inconsistent with the approved labeling.
  • Cohen et al (2024)¹⁸ presented the updated efficacy and safety results in the evaluated cohorts, including in patients with extramedullary disease (EMD) at a median follow-up of 20.3 months for the all-dose levels cohort and 18.2 months (range, 0.7-27.0) for the TALVEY and TECVAYLI recommended phase 2 regimen (RP2R) cohort. ICANS events were reported.
• Other relevant literature has been identified in addition to the data summarized above:
  • Nursing and advance practice practitioner’s considerations for management of ICANS.¹⁹

PRODUCT LABELING

• TALVEY (talquetamab-tgvs) [Prescribing Information]. Horsham, PA: Janssen Biotech, Inc.; https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/TALVEY-pi.pdf.
• DARZALEX FASPRO (daratumumab and hyaluronidase-fihj) [Prescribing Information]. Horsham, PA: Janssen Biotech, Inc.; https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/DARZALEX+Faspro-pi.pdf.
• TECVAYLI (teclistamab-cqyv) [Prescribing Information]. Horsham, PA: Janssen Biotech, Inc.; https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/TECVAYLI-pi.pdf.

Clinical Data - Monumental-1 Study

MonumenTAL-1 (MMY1001; NCT03399799, NCT04634552) is a phase 1/2 study of TALVEY in patients with RRMM.^8,9

The study was conducted in 3 parts; the primary objectives are listed below¹:

• Part 1 (phase 1; dose escalation): to characterize the safety of TALVEY and determine the recommended phase 2 dose (RP2Ds) and schedule.
• Part 2 (phase 1; dose expansion): to further characterize the safety of TALVEY at the RP2Ds.
• Part 3 (phase 2): to evaluate the efficacy of TALVEY at the RP2Ds.

Study Design/Methods (Phase 2)

Patients were enrolled into 1 of the following 3 cohorts^1,21:

• TCR naïve: 0.4 mg/kg SC QW, not previously exposed to TCRs such as chimeric antigen receptor T-cell (CAR-T therapy) or bispecific antibody (BsAb; prior B-cell maturation antigen [BCMA] antibody-drug conjugate [ADC] allowed).
• TCR naïve: 0.8 mg/kg SC Q2W, not previously exposed to TCRs (prior BCMA ADC allowed).
• Prior TCR: 0.4 mg/kg SC QW or 0.8 mg/kg SC Q2W, have been previously exposed to TCRs.
  • Among the prior TCR-exposed cohort, patients were divided based on the type of TCR (CAR-T, BsAb or CAR-T and BsAb).
• Key eligibility criteria (Part 3; Phase 2):
  • Measurable MM.²¹
  • ≥3 prior lines of therapy including a PI, an immunomodulatory drug, and an anti-CD38 monoclonal antibody.²¹
  • Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-2.²¹
• Key exclusion criteria (Part 3; Phase 2):
  • Prior grade 3 or higher cytokine release syndrome (CRS; per Lee criteria 2014²²) related to any TCR or any prior G protein-coupled receptor, class C, group 5, member D (GPRC5D)-targeting therapy.⁷
  • Received cumulative dose of corticosteroids equivalent to ≥140 mg of prednisone within 14 days prior to study drug (not including premedication).⁷
• Primary endpoint: overall response rate (ORR).¹
• Key secondary endpoints: duration of response (DOR), progression-free survival (PFS), overall survival, safety, immunogenicity, and pharmacodynamics.¹
• Dosing
  • TALVEY 0.4 mg/kg SC QW and 0.8 mg/kg SC Q2W treatment dose schedule is based on a 28-day cycle.⁷
  • Step-up dosing for 0.4 mg/kg SC QW⁷:
    • Week 1: step-up doses of TALVEY (0.01 mg/kg and 0.06 mg/kg SC).
    • Cycles 1+: TALVEY 0.4 mg/kg SC QW until progressive disease or unacceptable toxicity.
  • Step-up dosing for 0.8 mg/kg SC Q2W⁷:
    • Week 1: step-up doses of TALVEY (0.01 mg/kg, 0.06 mg/kg, and 0.3 mg/kg SC).
    • Cycles 1+: TALVEY 0.8 mg/kg SC Q2W until progressive disease or unacceptable toxicity.
  • Premedications: dexamethasone, acetaminophen, and diphenhydramine were required to be administered for each step-up dose and for the first full treatment dose of TALVEY.⁷
  • Patients were required to be hospitalized for at least 48 hours from the start of the injection for each step-up dose and the first full treatment dose of TALVEY.⁷

Chari et al (2024)¹⁰ published the clinical management of AEs in patients with RRMM treated with TALVEY in the MonumenTAL-1 study. Results specific to ICANS are summarized below.

Results

Safety

• In MonumenTAL-1, ICANS was graded per American Society for Transplantation and Cellular Therapy (ASTCT) criteria, based on the most severe event experienced, including depressed level of consciousness, seizures, motor findings, raised intracranial pressure, intraocular pressure, or cerebral edema, and immune effector cell-associated encephalopathy (ICE) score.
• Median duration of each ICANS event was 7.8-48.5 hours across the 3 cohorts. See Table: MonumenTAL-1 Study: ICANS Events Associated With TALVEY.
• Most ICANS events were grade 1/2 that occurred with step-up doses and the first full dose. Almost all cases of ICANS events were resolved.
• Two patients each in the 0.4 mg/kg QW and 0.8 mg/kg Q2W cohorts required dose modifications due to ICANS.
• In total, 2 patients in the 0.4 mg/kg QW and 1 patient in the 0.8 kg/mg Q2W cohorts discontinued due to ICANS.

Supportive Measures/Management

• Supportive measures given to patients for managing ICANS in MonumenTAL-1 are detailed in Table: MonumenTAL-1 Study: Most Common Supportive Measures and Concomitant Treatments for ICANS Events.
• Corticosteroids are routinely used for grade ≥2 ICANS events. Corticosteroids have been recommended in the MonumenTAL-1 study as first-line therapy for isolated ICANS, while tocilizumab and corticosteroids have been advised for ICANS events occurring concurrently with CRS.
• Grade 1 ICANS events that are expected to resolve quickly with supportive care should be closely monitored, and other potential causes for symptoms should be excluded through diagnostic tests.
• Severe ICANS cases should be treated in a critical care unit and may require airway protection through intubation and neurology consultation.
• Elevating the head, administering hyperosmolar therapy with mannitol or hypertonic saline, and using hyperventilation along with high-dose corticosteroids are recommended for cerebral edema.
• Levetiracetam is advised for primary seizure prophylaxis in patients with a history of seizures or central nervous system (CNS) disease.
• Experience with TALVEY in MonumenTAL-1 suggests that severe ICANS events are rare and can be effectively managed with appropriate and timely intervention.

Schinke et al (2023)¹ presented the updated efficacy and safety results from the phase 2 portion of the MonumenTAL-1 study. Results specific to neurotoxicity are summarized below.

Results

Treatment Disposition

• Overall, 143 patients were included in the 0.4 mg/kg SC QW cohort, 145 patients in the 0.8 mg/kg SC Q2W cohort, and 51 patients in the prior TCR cohort.
• The median duration of follow-up was 18.8 months for the 0.4 mg/kg SC QW cohort, 12.7 months for the 0.8 mg/kg SC Q2W cohort, and 14.8 months for the prior TCR cohort.

Safety

• ICANS was reported (measured in phase 2 only) in 10.7% of patients in the 0.4 mg/kg SC QW cohort, 11.0% in the 0.8 mg/kg SC Q2W cohort, and 2.9% in the prior TCR cohort.

Chari et al (2022)¹¹ presented the efficacy and safety of the phase 1/2 portion of the MonumenTAL-1 study. Results specific to neurotoxicity are summarized below.

Results

Treatment Disposition

• Overall, 143 patients were included in the 0.4 mg/kg SC QW cohort and 145 patients in the 0.8 mg/kg SC Q2W cohort.
• The median duration of follow-up for safety was 11.0 months (range, 0.5-26.1) for the 0.4 mg/kg SC QW cohort and 5.1 months (range, 0.2-17.9) for the 0.8 mg/kg SC Q2W cohort.

Safety

• The incidence, timing and duration of ICANS events are summarized in the Table: MonumenTAL-1 Study: ICANS Events.
• ICANS was reported (measured in phase 2 only) in 10-11% of patients across RP2D groups.
  • Most ICANS events were grade 1 or 2
  • Across RP2D groups, 7-8% of patients received supportive measures for ICANS, including tocilizumab and corticosteroids.

MonumenTAL-1 Protocol (Part 3) - Description and Management of Neurotoxic Events⁷

• Patients were monitored for neurological toxicities including, but not restricted to, speech disorders, convulsions, and disturbances in consciousness, confusion, disorientation, or coordination, and balance disorders.
• A basic neurologic examination including the ICE Assessment Tool was performed at baseline (within 48 hours prior to administration of TALVEY) at step-up dose 1 and repeated as clinically indicated after the first symptoms of ICANS are suspected until resolution.
• Neurotoxicity that is not assessed as ICANS was managed per institutional guidelines. Patients who experience ICANS grade ≥2 were hospitalized. Hospitalization was also required ≥36 hours prior to the initiation of subsequent 2 doses after grade ≥2 ICANS.
• In case of grade 1, grade 2, or the first occurrence of a grade 3 neurotoxicity event, the next dose was withheld until neurotoxicity is completely resolved.

MonumenTAL-1 Protocol (Part 3) - Discontinuation of Treatment Related to Neurotoxic Events⁷

• Study treatment was discontinued for grade 3 or any grade 4 neurotoxicity, except for the first occurrence of a grade 3 neurotoxicity.

Guidelines for the Management of Raised Intracranial Pressure/Cerebral Edema⁷

• Elevate the head of patient’s bed to an angle of 30 degrees.
• If patient has ommaya reservoir, drain cerebrospinal fluid (CSF) to target opening pressure of <20 mmHg.
• Initiate hyperventilation to achieve target partial pressure of carbon dioxide (PaCO₂) of 28-30 mmHg, but maintain for no longer than 24 hours.
• Consider neurology and/or neurosurgery consultation.
• Use high-dose corticosteroids with methylprednisolone IV 1 g/day.
• Hyperosmolar therapy with either mannitol (20 g/dL solution) or hypertonic saline (3% or 23.4%, as detailed below):
  • Mannitol: initial dose 0.5 to 1 g/kg; maintenance at 0.25 to 1 g/kg every 6 hours while monitoring metabolic profile and serum osmolality every 6 hours. Withhold mannitol if serum osmolality is ≥320 mOsm/kg, or the osmolality gap is ≥40.
  • Hypertonic saline: initial 250 mL of 3% hypertonic saline; maintenance at 5075 mL/hr while monitoring electrolytes every 4 hours, and withhold infusion if serum sodium levels reach ≥155 mEq/L.
  • For patients with imminent herniation: initial 30 mL of 23.4% hypertonic saline; repeat after 15 min, if needed.
• Consider IV anesthetics for burst-suppression pattern on electroencephalography.

MonumenTAL-1 Study Part 3 - Guidelines for the Management of ICANS⁷

MonumenTAL-1 Protocol (Part 3) - Key Prohibited Medications Related to Neurotoxic Events⁷

• Corticosteroids in excess of 10 mg daily of prednisone (or equivalent) for more than 14 days are prohibited, other than for the management of AEs where no other treatment options are available and in consultation with the sponsor.

CLINICAL DATA - Monumental-2 study (Cohort e)

MonumenTAL-2 (MMY1004; ClinicalTrials.gov identifier NCT05050097) is an ongoing, phase 1b, multi-arm, open-label study evaluating TALVEY in combination with other anticancer therapies in patients with MM.^6,12

Cohort E of the MonumenTAL-2 study is evaluating the efficacy and safety of TALVEY in combination with pomalidomide in 35 patients with RRMM.^6,12

Study Design/Methods

• Key eligibility criteria:
  • Measurable MM⁶
  • ≥2 prior lines of treatment including a PI and an immunomodulatory drug⁶
  • ECOG PS of 0-1⁶
  • Prior pomalidomide and prior TCR (CAR-T and BsAb) permitted⁶
  • No prior GPRC5D-targeted therapy⁶
• Primary endpoint: Safety; AEs were assessed per Common Terminology Criteria for Adverse Events (CTCAE) v5.0, except for CRS and ICANS, which were graded per the ASTCT guidelines.⁶
• Key secondary endpoints: ORR (assessed per International Myeloma Working Group [IMWG] 2016 criteria), time to response, DOR, and PFS.⁶
• Dosing⁶
  • TALVEY: 0.4 mg/kg SC QW or 0.8 mg/kg SC Q2W (following step-up dosing)
  • Pomalidomide: 2 mg by mouth (PO) daily, with dose escalation to 4 mg PO daily permitted (starting at cycle 2)

Searle et al (2024)¹³ presented the updated efficacy and safety results of TALVEY in combination with pomalidomide from the MonumenTAL-2 study at a median follow-up of 16.8 months (range, 1.2-25.1). Results specific to CRS are summarized below.

Results

Treatment Disposition

• Overall, 16 patients were included in the TALVEY 0.4 mg/kg QW + pomalidomide cohort and 19 patients were included in the TALVEY 0.8 mg/kg Q2W + pomalidomide cohort.
• Prior treatments included the following: CAR-T therapy (8.6%), BsAb (2.9%), anti-CD38 antibody (74.3%), and pomalidomide (22.9%).

Safety

• ICANS occurred in 3 patients; all events were grade 1 in severity.

CLINICAL DATA - TRIMM-2 STUDY - TALVEY + DArZALEX FASPRO COHORT

TRIMM-2 (MMY1002; clinicaltrials.gov identifier: NCT04108195) is an ongoing, phase 1b, 2-part, multicohort, open-label study evaluating DARZALEX FASPRO regimens in combination with bispecific TCR antibodies with or without pomalidomide in patients with RRMM.^2,14,15

Study Design/Methods

• Key eligibility criteria²:
  • Double refractory to a PI and an immunomodulatory drug or received ≥3 prior lines of treatment (including a PI and an immunomodulatory drug).
  • Treatment with an anti-CD38 monoclonal antibody (>90 days prior allowed) including anti-CD38 refractory patients.
  • Prior BsAb and CAR-T were allowed.
• Key primary endpoints²:
  • Part 1: identify the RP2D for each treatment combination.
  • Part 2: safety and tolerability at the selected RP2D of each treatment combination.
  • Antitumor activity.
• ICANS was graded per ASTCT criteria.

Bahlis et al (2024)¹⁵ presented the efficacy and safety results of the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO + pomalidomide and TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO + pomalidomide cohorts at a median follow-up of 15.8 months (range, 3.2-37.9) and 17.5 months (range, 0.2-37.7), respectively.

Study Design/Methods

• Dosing:
  • TALVEY: 2-3 SUDs before receiving the first full doses of either 0.4 mg/kg SC QW or 0.8 mg/kg SC Q2W.
    • The dose frequency could be reduced from QW to Q2W after cycle 4 if patients achieved partial response (PR) and from Q2W to Q4W after cycle 8 if they achieved very good partial response (VGPR).
  • DARZALEX FASPRO 1800 mg SC: cycles 1-2, QW; cycles 3-6, Q2W; cycles 7+, Q4W.
  • Pomalidomide 2 mg PO: Starting cycle 2. The dosage may be lowered due to hematologic AEs.

Results

Treatment Disposition

• Overall, 18 patients were included in the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO + pomalidomide cohort and 59 patients were included in the TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO + pomalidomide cohort.
• The median duration of follow-up was 15.8 months (range, 3.2-37.9) for the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO + pomalidomide cohort and 17.5 months (range, 0.2-37.7) for the TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO + pomalidomide cohort.

Safety

• ICANS was reported in 3 patients and all events occurred in the TALVEY 0.8 mg/kg Q2W DARZALEX FASPRO + pomalidomide cohort. One grade 4 ICANS event led to treatment discontinuation.

Dholaria et al (2023)² presented the updated results of the TRIMM-2 study. Results specific to neurotoxicity reported in patients receiving TALVEY + DARZALEX FASPRO are summarized below.

Study Design/Methods

• Dosing:
  • TALVEY: 1-3 SUDs within 1 week before receiving the full doses of either 0.4 mg/kg SC QW or 0.8 mg/kg SC Q2W.
    • The dose frequency of TALVEY could be reduced from QW to Q2W after 4 cycles if patients achieved PR and further from Q2W to Q4W after 8 cycles if they achieved VGPR.
  • DARZALEX FASPRO 1800 mg SC: cycles 1-2, QW; cycles 3-6, Q2W; cycles 7+, Q4W.

Results

Treatment Disposition

• Overall, 14 patients were included in the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO 1800 mg Q4W cohort and 51 patients in the TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO 1800 mg Q4W cohort.
• The median duration of follow-up was 16.8 months (range, 1.9-31.0) for the TALVEY 0.4 mg/kg QW + DARZALEX FASPRO 1800 mg Q4W cohort and 15.0 months (range, 1.0-23.3) for the TALVEY 0.8 mg/kg Q2W + DARZALEX FASPRO 1800 mg Q4W cohort.

Safety

• In both the cohorts combined, ICANS was reported in 4.6% of patients, all of which were of grade 1/2 and resolved in 1-2 days.

CLINICAL DATA - REDIRECTT-1 STUDY - TALVEY + tecvayli COHORT

RedirecTT-1 (MMY1003; clinicaltrials.gov identifier: NCT04586426) is an ongoing, open-label, phase 1b/2 study evaluating the safety and effectiveness of the combination of TALVEY + TECVAYLI in patients with RRMM.^16-18

Study Design/Methods

• Key inclusion criteria: relapsed or refractory or intolerant to established therapies including the last line of therapy; prior exposure to a PI, an immunomodulatory drug, and an anti-CD38 monoclonal antibody.¹⁸
• Primary endpoints: safety, identify RP2R(s) and schedule.¹⁸
• Dosing: eligible patients received varying dose levels of TALVEY and TECVAYLI to determine the RP2R dose and schedule of the combination.¹⁸
  • All dose levels: Five varying dose levels of TALVEY and TECVAYLI.
  • RP2R: TALVEY 0.8 mg/kg SC Q2W plus TECVAYLI 3.0 mg/kg SC Q2W.

Cohen et al (2024)¹⁸ presented the updated safety and efficacy results for the all dose levels cohort and the TALVEY and TECVAYLI RP2R cohort in the RedirecTT-1 study, including patients with EMD.

Results

Treatment Disposition

• Overall, 94 patients were included in the all dose levels cohort and 44 patients were in the RP2R cohort.
• The median duration of follow-up was 20.3 months for the all dose levels cohort and 18.2 months (range, 0.7-27.0) for the RP2R cohort.

Safety

• ICANS events occurred in 3 patients (3.2%); including 1 grade 3 ICANS event; 2 events were concurrent with CRS. All ICANS events occurred during SUD.
• The median time to onset of ICANS was 2-2.5 days; the median duration of ICANS was 3 days. All events recovered.

Literature Search

A literature search of MEDLINE^®, Embase^®, BIOSIS Previews^®, and Derwent Drug File databases (and/or other resources, including internal/external databases) was conducted on 14 November 2024.