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Severe and Fatal Immune-Mediated Adverse Reactions

KEYTRUDA is a monoclonal antibody that belongs to a class of drugs that bind to either the programmed death receptor-1 (PD-1) or the programmed death ligand 1 (PD-L1), blocking the PD-1/PD-L1 pathway, thereby removing inhibition of the immune response, potentially breaking peripheral tolerance and inducing immune-mediated adverse reactions. Immune-mediated adverse reactions, which may be severe or fatal,
can occur in any
organ system or tissue, can affect more than one body system simultaneously, and can occur at any time after starting treatment or after discontinuation of treatment. Important immune-mediated adverse reactions listed here may not include all possible severe and fatal immune-mediated adverse reactions.
Monitor patients closely for symptoms and signs that may be clinical manifestations of underlying immune-mediated adverse reactions. Early identification and management are essential to ensure safe use of anti–PD-1/PD-L1 treatments. Evaluate liver enzymes, creatinine, and thyroid function at baseline and periodically during treatment. In cases
of suspected immune-mediated adverse reactions, initiate appropriate workup
to exclude alternative etiologies, including infection. Institute medical management promptly, including specialty consultation as appropriate.
Withhold or permanently discontinue KEYTRUDA depending on severity of the immune-mediated adverse reaction. In general,
if KEYTRUDA requires interruption
or discontinuation, administer systemic corticosteroid therapy (1 to 2 mg/kg/day prednisone or equivalent) until improvement to
Grade 1 or less.
Upon improvement
to Grade 1 or less, initiate corticosteroid taper and continue
to taper over at least
1 month. Consider administration of
other systemic immunosuppressants in patients whose adverse reactions
are not controlled with corticosteroid therapy.

Immune-Mediated Pneumonitis

KEYTRUDA can
cause immune-mediated pneumonitis. The incidence is
higher in patients who have received prior thoracic radiation. Immune-mediated pneumonitis occurred in 3.4% (94/2799) of patients receiving KEYTRUDA, including fatal (0.1%), Grade 4 (0.3%), Grade 3 (0.9%), and Grade 2 (1.3%) reactions. Systemic corticosteroids
were required in
67% (63/94) of patients. Pneumonitis led to permanent discontinuation of KEYTRUDA in
1.3% (36) and withholding in
0.9% (26) of patients. All patients who
were withheld reinitiated KEYTRUDA after symptom improvement; of these, 23% had recurrence. Pneumonitis resolved in 59% of the
94 patients.

Immune-Mediated Colitis

KEYTRUDA can
cause immune-mediated colitis,
which may present with diarrhea. Cytomegalovirus infection/reactivation has been reported
in patients with corticosteroid-refractory immune-mediated colitis.
In cases of corticosteroid-refractory colitis, consider repeating infectious workup to exclude alternative etiologies. Immune-mediated colitis occurred in
1.7% (48/2799) of
patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (1.1%), and Grade 2 (0.4%) reactions. Systemic corticosteroids
were required in
69% (33/48); additional immunosuppressant therapy was required in 4.2% of patients. Colitis led to permanent discontinuation of KEYTRUDA in
0.5% (15) and withholding in
0.5% (13) of patients. All patients who
were withheld reinitiated KEYTRUDA after symptom improvement; of these, 23% had recurrence. Colitis resolved in 85% of the 48 patients.

Hepatotoxicity and Immune-Mediated Hepatitis

KEYTRUDA as a
Single Agent

KEYTRUDA can
cause immune-mediated hepatitis. Immune-mediated hepatitis occurred
in 0.7% (19/2799)
of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.4%),
and Grade 2 (0.1%) reactions. Systemic corticosteroids
were required in
68% (13/19) of patients; additional immunosuppressant therapy was required in 11% of patients. Hepatitis led to permanent discontinuation of KEYTRUDA in
0.2% (6) and withholding in 0.3% (9) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, none had recurrence. Hepatitis resolved
in 79% of the
19 patients.

Immune-Mediated Endocrinopathies

Adrenal Insufficiency

KEYTRUDA can
cause primary or secondary adrenal insufficiency. For Grade 2 or higher, initiate symptomatic treatment, including hormone replacement as clinically indicated. Withhold KEYTRUDA depending on
severity. Adrenal insufficiency occurred in 0.8% (22/2799)
of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.3%), and Grade 2 (0.3%) reactions. Systemic corticosteroids
were required in
77% (17/22) of patients; of these,
the majority remained
on systemic corticosteroids. Adrenal insufficiency led to permanent discontinuation of KEYTRUDA in
<0.1% (1) and withholding in 0.3% (8) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement.

Hypophysitis

KEYTRUDA can
cause immune-mediated hypophysitis. Hypophysitis can present with acute symptoms associated with mass effect
such as headache, photophobia, or
visual field defects. Hypophysitis can cause hypopituitarism. Initiate hormone replacement as indicated. Withhold
or permanently discontinue KEYTRUDA depending on severity. Hypophysitis occurred in 0.6% (17/2799) of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.3%),
and Grade 2 (0.2%) reactions. Systemic corticosteroids
were required in
94% (16/17) of patients; of these,
the majority remained on systemic corticosteroids. Hypophysitis led
to permanent discontinuation of KEYTRUDA in
0.1% (4) and withholding in 0.3% (7) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement.

Thyroid Disorders

KEYTRUDA can
cause immune-mediated thyroid disorders. Thyroiditis can present with
or without endocrinopathy. Hypothyroidism can follow hyperthyroidism. Initiate hormone replacement for hypothyroidism or institute medical management of hyperthyroidism as clinically indicated. Withhold or permanently discontinue KEYTRUDA depending on severity. Thyroiditis occurred
in 0.6% (16/2799)
of patients receiving KEYTRUDA, including Grade 2 (0.3%).
None discontinued,
but KEYTRUDA
was withheld in
<0.1% (1) of patients.
Hyperthyroidism occurred in
3.4% (96/2799) of patients receiving KEYTRUDA, including Grade 3 (0.1%) and Grade 2 (0.8%).
It led to permanent discontinuation of KEYTRUDA in
<0.1% (2) and withholding in 0.3% (7) of patients. All
patients who were withheld reinitiated KEYTRUDA after symptom improvement. Hypothyroidism occurred in
8% (237/2799) of
patients receiving KEYTRUDA, including Grade 3 (0.1%) and Grade 2 (6.2%).
It led to permanent discontinuation of KEYTRUDA in
<0.1% (1) and withholding in
0.5% (14) of patients. All patients who
were withheld reinitiated KEYTRUDA after symptom improvement. The majority of patients with hypothyroidism required long-term thyroid hormone replacement.

Type 1 Diabetes
Mellitus (DM), Which
Can Present With
Diabetic Ketoacidosis

Monitor patients for hyperglycemia or other signs and symptoms of diabetes. Initiate treatment with insulin as clinically indicated. Withhold KEYTRUDA depending on severity. Type 1 DM occurred
in 0.2% (6/2799) of patients receiving KEYTRUDA. It led
to permanent discontinuation in <0.1% (1) and withholding of KEYTRUDA in
<0.1% (1) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement.

Immune-Mediated Nephritis With
Renal Dysfunction

KEYTRUDA can
cause immune-mediated nephritis. Immune-mediated nephritis occurred in 0.3% (9/2799)
of patients receiving KEYTRUDA, including Grade 4 (<0.1%), Grade 3 (0.1%), and Grade 2 (0.1%) reactions. Systemic corticosteroids were required in 89% (8/9) of patients. Nephritis led to permanent discontinuation of KEYTRUDA in
0.1% (3) and withholding in 0.1% (3) of patients. All patients who were withheld reinitiated KEYTRUDA after symptom improvement; of these, none had recurrence. Nephritis resolved in 56% of the 9 patients.

Immune-Mediated Dermatologic Adverse Reactions

KEYTRUDA can
cause immune-mediated rash
or dermatitis. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti–PD-1/PD-L1 treatments. Topical emollients and/or topical corticosteroids may be adequate to treat mild to moderate nonexfoliative rashes. Withhold or permanently discontinue KEYTRUDA depending on severity. Immune-mediated dermatologic adverse reactions occurred
in 1.4% (38/2799) of patients receiving KEYTRUDA, including Grade 3 (1%) and Grade 2 (0.1%) reactions. Systemic corticosteroids
were required in
40% (15/38) of patients. These reactions led
to permanent discontinuation in
0.1% (2) and withholding of KEYTRUDA in
0.6% (16) of patients. All patients who
were withheld reinitiated KEYTRUDA after symptom improvement; of these, 6% had recurrence. The reactions resolved in 79% of the
38 patients.

Other Immune-
Mediated Adverse Reactions

The following
clinically significant immune-mediated adverse reactions occurred at an incidence of <1% (unless otherwise noted) in patients who received KEYTRUDA or were reported with the use of other anti–PD-1/PD-L1 treatments. Severe
or fatal cases have been reported for some of these
adverse reactions. Cardiac/Vascular: Myocarditis, pericarditis, vasculitis; Nervous System: Meningitis, encephalitis, myelitis and demyelination, myasthenic
syndrome/myasthenia
gravis (including exacerbation),
Guillain-Barré syndrome, nerve paresis, autoimmune neuropathy; Ocular: Uveitis, iritis and other ocular inflammatory toxicities can occur. Some cases can be associated with retinal detachment. Various grades of visual impairment, including blindness, can occur.
If uveitis occurs in combination with other immune-mediated adverse reactions, consider a
Vogt-Koyanagi-Harada-like syndrome, as this may require treatment with systemic steroids to reduce the risk of permanent vision loss; Gastrointestinal: Pancreatitis, to include increases in serum amylase and lipase levels, gastritis, duodenitis; Musculoskeletal and Connective Tissue: Myositis/polymyositis, rhabdomyolysis (and
associated sequelae, including renal failure), arthritis (1.5%), polymyalgia rheumatica;
Endocrine: Hypoparathyroidism; Hematologic/Immune: Hemolytic anemia, aplastic anemia, hemophagocytic lymphohistiocytosis, systemic inflammatory response syndrome, histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis), sarcoidosis, immune thrombocytopenic purpura, solid organ transplant rejection.

Infusion-Related Reactions

KEYTRUDA can
cause severe or
life-threatening infusion-related reactions, including hypersensitivity
and anaphylaxis, which have been reported in 0.2%
of 2799 patients receiving KEYTRUDA. Monitor for signs and symptoms of
infusion-related reactions. Interrupt
or slow the rate of infusion for Grade 1
or Grade 2 reactions. For Grade 3 or Grade 4 reactions, stop infusion and permanently discontinue KEYTRUDA.

Complications
of Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)

Fatal and other serious complications can occur in patients who receive allogeneic HSCT before or after anti–PD-1/PD-L1 treatments.
Transplant-related complications
include hyperacute graft-versus-host disease (GVHD),
acute and chronic GVHD, hepatic
veno-occlusive disease after reduced intensity conditioning, and steroid-requiring febrile syndrome (without an identified infectious cause). These complications may occur despite intervening therapy between anti–PD-1/PD-L1 treatments and allogeneic HSCT. Follow patients closely for evidence of these complications and intervene promptly. Consider the benefit
vs risks of using anti–PD-1/PD-L1 treatments prior
to or after an allogeneic HSCT.

Increased Mortality
in Patients With Multiple Myeloma

In trials in patients
with multiple myeloma, the addition of KEYTRUDA to a thalidomide analogue plus dexamethasone resulted in increased mortality. Treatment
of these patients with an anti–PD-1/PD-L1 treatment in this combination is not recommended outside of controlled trials.

Embryofetal Toxicity

Based on its mechanism of action, KEYTRUDA can
cause fetal harm when administered to a pregnant woman. Advise women of
this potential risk.
In females of reproductive potential, verify pregnancy
status prior
to initiating KEYTRUDA and advise them to use effective contraception during treatment and for 4 months after the last dose.

Adverse Reactions

The most common adverse reactions for KEYTRUDA (reported in ≥20% of patients) were fatigue, musculoskeletal pain, rash, diarrhea,
pyrexia, cough, decreased appetite, pruritus, dyspnea, constipation,
pain, abdominal pain, nausea, and hypothyroidism.

Lactation

Because of the potential for serious adverse reactions in breastfed children, advise women not to breastfeed during treatment and for
4 months after the
last dose.

Before prescribing KEYTRUDA^®
(pembrolizumab)
please read
the accompanying Prescribing Information.
The Medication Guide also is available.

US-OVC-00633 04/23

Selected Safety Information