Delandistrogene moxeparvovec-rokl

Acknowledgment
This article consists of drug labeling information developed under U.S. FDA guidance and excerpted from DailyMed. It was not reviewed by the MedLink Neurology Editorial Board. For the latest FDA-approved information about this drug, visit Drugs@FDA.com.

Highlights

Indications and usage
Delandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl, Elevidys) is an adeno-associated virus vector-based gene therapy indicated in individuals at least 4 years of age:
	• For the treatment of Duchenne muscular dystrophy in patients who are ambulatory and have a confirmed mutation in the DMD gene.
	• For the treatment of Duchenne muscular dystrophy in patients who are nonambulatory and have a confirmed mutation in the DMD gene. The Duchenne muscular dystrophy indication in non-ambulatory patients is approved under accelerated approval based on expression of delandistrogene moxeparvovec micro-dystrophin (noted hereafter as “micro-dystrophin”). Continued approval for this indication may be contingent on verification and description of clinical benefit in a confirmatory trial(s).
Dosage and administration
	• Select patients for treatment with delandistrogene moxeparvovec with anti-AAVrh74 total binding antibody titers <1:400.
	• Recommended dosage: 10 to 70 kg: 1.33 × 10¹⁴ vector genomes (vg) per kg of body weight; 70 kg or greater: 9.31 × 10¹⁵ vg
	• There is limited safety data available in nonambulatory patients weighing 70 kg or greater, who received the maximum dose of delandistrogene moxeparvovec, 9.31 × 10¹⁵ vg, in clinical trials.
	• Postpone in patients with concurrent infections until the infection has resolved.
	• Assess liver function, platelet counts, and troponin-I before delandistrogene moxeparvovec infusion.
	• One day before infusion, initiate a corticosteroid regimen for a minimum of 60 days. Recommend modifying the corticosteroid dose for patients with liver function abnormalities.
	• Administer as an intravenous infusion over 1 to 2 hours. Infuse at a rate of less than 10 mL/kg/hour.
Dosage forms and strengths
	• Delandistrogene moxeparvovec is a suspension for intravenous infusion with a nominal concentration of 1.33 × 1013 vg/mL.
	• Delandistrogene moxeparvovec is provided in a customized kit containing ten to seventy 10 mL single-dose vials, with each kit constituting a dosage unit based on the patient's body weight.
Note: Delandistrogene moxeparvovec-rokl suspension, for intravenous infusion, was first approved by the U.S. FDA in 2024.

Contraindications
Delandistrogene moxeparvovec is contraindicated in patients with any deletion in exon 8 or exon 9 in the DMD gene.
Warnings and precautions
	• Infusion-related reactions. Infusion-related reactions, including hypersensitivity reactions and anaphylaxis, have occurred. Monitor during administration and for at least 3 hours after the end of infusion. If symptoms occur, slow or stop the infusion and give appropriate treatment. Once symptoms resolve, restart infusion at a slower infusion rate. Discontinue infusion for anaphylaxis.
	• Acute serious liver injury. Acute serious liver injury has been observed. Monitor liver function before delandistrogene moxeparvovec infusion, and weekly for the first 3 months after delandistrogene moxeparvovec infusion. Continue monitoring until results are unremarkable. If an acute, serious liver injury is suspected, a consultation with a specialist is recommended.
	• Immune-mediated myositis. Patients with deletions in the DMD gene in exons 1 to 17 and /or exons 59 to 71 may be at risk for severe immune-mediated myositis reaction. Consider additional immunomodulatory treatment (immunosuppressants, eg, calcineurin-inhibitor) in addition to corticosteroids, if symptoms of myositis occur, eg, unexplained increased muscle pain, tenderness, or weakness.
	• Myocarditis. Myocarditis and troponin-I elevations have been observed. Monitor troponin-I before delandistrogene moxeparvovec infusion, and weekly for the first month after delandistrogene moxeparvovec infusion.
	• Pre-existing immunity against AAVrh74. Perform baseline testing for the presence of anti-AAVrh74 total binding antibodies before delandistrogene moxeparvovec administration.
Adverse reactions

To report suspected adverse reactions, contact Sarepta Therapeutics, Inc., at 1-888-SAREPTA (1-888-727-3782) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
See Patient counseling information and medication guide available in the DAILYMED drug label information.

Indications and usage

Delandistrogene moxeparvovec is indicated for the treatment of Duchenne muscular dystrophy in individuals at least 4 years of age:

	• For patients who are ambulatory and have a confirmed mutation in the DMD gene.
	• For patients who are non-ambulatory and have a confirmed mutation in the DMD gene.

The Duchenne muscular dystrophy indication in non-ambulatory patients is approved under accelerated approval based on expression of delandistrogene moxeparvovec micro-dystrophin (noted hereafter as “micro-dystrophin”) in skeletal muscle. Continued approval for this indication may be contingent on verification and description of clinical benefit in a confirmatory trial.

Dosage and administration

For single-dose intravenous infusion only.

Patient selection

Select patients for treatment with delandistrogene moxeparvovec with anti-AAVrh74 total binding antibody titers <1:400. An FDA-authorized test for the detection of anti-AAVrh74 total binding antibodies is not available. Available tests may vary in accuracy and design.

Dose

The recommended dose of delandistrogene moxeparvovec is 1.33 × 1014 vector genomes per kilogram (vg/kg) of body weight (or 10 mL/kg body weight) for patients weighing less than 70 kg or 9.31 × 1015 vg total fixed dose for patients weighing 70 kg or greater. There is limited safety data available in non-ambulatory patients weighing 70 kg or greater, who received the maximum dose of delandistrogene moxeparvovec, 9.31 × 1015 vg, in clinical trials.

For the number of vials required, refer to Table 10.

Calculate the dose as follows:

Delandistrogene moxeparvovec dose (in mL) = patient body weight (rounded to the nearest kilogram) x 10

The multiplication factor 10 represents the per kilogram dose (1.33 × 1014 vg/kg) divided by the amount of vector genome copies per mL of the delandistrogene moxeparvovec suspension (1.33 × 1013 vg/mL).

Number of delandistrogene moxeparvovec vials needed = delandistrogene moxeparvovec dose (in mL) divided by 10.

Example: Calculation of volume needed for a 19.5 kg patient
	19.5 kg rounded to the nearest kilogram = 20 kg
	20 kg × 10 = 200 mL

Number of delandistrogene moxeparvovec vials needed = 200 divided by 10, rounded to the nearest number of vials = 20 vials

Before delandistrogene moxeparvovec infusion:

Due to the increased risk of serious systemic immune response, postpone delandistrogene moxeparvovec in patients with infections until the infection has resolved. Clinical signs or symptoms of infection should not be evident at the time of delandistrogene moxeparvovec administration.

Assess liver function.

Obtain platelet count and troponin-I levels.

Measure baseline anti-AAVrh74 antibody titers using a Total Binding Antibody enzyme-linked immunosorbent assay (ELISA).

Delandistrogene moxeparvovec administration is not recommended in patients with elevated anti-AAVrh74 total binding antibody titers (≥1:400). Re-administration of delandistrogene moxeparvovec is not recommended.

Immune responses to the AAVrh74 vector can occur after administration of delandistrogene moxeparvovec. To reduce the risk associated with an immune response, corticosteroids should be administered starting 1 day before delandistrogene moxeparvovec infusion. Initiate a corticosteroid regimen following the appropriate schedule (see Table 1). This regimen is recommended for a minimum of 60 days after the infusion, unless earlier tapering is clinically indicated. Table 2 includes the recommended corticosteroid regimen dose modification for patients with liver function abnormalities following delandistrogene moxeparvovec infusion. If acute, serious liver injury is suspected, a consultation with a specialist is recommended.

For patients previously taking corticosteroids at baseline, taper off the additional peri-delandistrogene moxeparvovec corticosteroids (back to baseline corticosteroid dose) over 2 weeks, or longer as needed. For patients not previously taking corticosteroids at baseline, taper the added peri-delandistrogene moxeparvovec corticosteroids off (back to no corticosteroids) over 4 weeks, or longer, as needed, and the corticosteroids should not be stopped abruptly.

Table 1. Recommended Pre- and Postinfusion Corticosteroid Dosing

Baseline corticosteroid dosing^a	Peri-delandistrogene moxeparvovec infusion corticosteroid dose (prednisone equivalent) b	Recommended maximum total daily dose (prednisone equivalent)b
Daily or intermittent dose	Start 1 day before infusion: 1 mg/kg/day (and continue baseline dose)	60 mg/day
High dose for 2 days per week	Start 1 day before infusion: 1 mg/kg/day taken on days without high-dose corticosteroid treatment (and continue baseline dose)	60 mg/day
Not on corticosteroids	Start 1 week before infusion: 1.5 mg/kg/day	60 mg/day
^a Patient continues to receive this dose ^b Corticosteroids other than prednisone and prednisolone have not been studied for use as a peri-delandistrogene moxeparvovec infusion corticosteroid

Table 2. Recommended Corticosteroid Regimen Dose Modification for Liver Function Abnormalities Following Delandistrogene Moxeparvovec Infusiona

Peri-delandistrogene moxeparvovec infusion corticosteroid dosing	Modified corticosteroid dose following delandistrogene moxeparvovec infusion (prednisone equivalent)^b	Recommended maximum total daily dose (prednisone equivalent)^b
Baseline + 1 mg/kg/day	Increase to 2 mg/kg/day (and continue baseline dose)	120 mg/day
Baseline + 1 mg/kg/day taken on days without high-dose corticosteroid treatment	Increase to 2 mg/kg/day taken on days without high-dose corticosteroid treatment (and continue baseline dose)	120 mg/day
1.5 mg/kg/day	Increase from 1.5 mg/kg/day to 2.5 mg/kg/day	120 mg/day
^a GGT >= 150 U/L and/or other clinically significant liver function abnormalities (eg, total bilirubin > 2 x ULN) following infusion. For GGT or bilirubin elevations that do not respond to these oral corticosteroid increases, intravenous bolus corticosteroids may be considered. ^b Corticosteroids other than prednisone and prednisolone have not been studied for use as a peri-delandistrogene moxeparvovec infusion corticosteroid.

Preparation

General precautions.

	• Prepare delandistrogene moxeparvovec using aseptic technique.
	• Verify the required dose of delandistrogene moxeparvovec based on the patient's body weight.
	• Confirm that the kit contains a sufficient number of vials to prepare the delandistrogene moxeparvovec infusion for the patient.
	• Visually inspect parenteral drug products for particulate matter and discoloration before administration, whenever suspension and container permit. Delandistrogene moxeparvovec may contain white to off-white particles.

Recommended supplies and materials:

	• 60 mL siliconized polypropylene syringes
	• 21-gauge or smaller stainless steel needles

Preparing delandistrogene moxeparvovec infusion.

Thaw delandistrogene moxeparvovec before use.
	• When thawed in the refrigerator, delandistrogene moxeparvovec vials are stable for up to 14 days in the refrigerator (2°C to 8°C [36º F to 46º F]) when stored in the upright position.
	• Frozen delandistrogene moxeparvovec vials will thaw in approximately 2 hours when placed at room temperature (up to 25°C [77ºF]) when removed from original packaging.
	• Thawed delandistrogene moxeparvovec in vials or syringes is stable for up to 24 hours at room temperature (up to 25°C [77°F]).
Inspect vials to ensure no ice crystals are present before preparation.
When thawed, swirl gently.
	• Do not shake.
	• Do not refreeze.
	• Do not place back in the refrigerator.
Visually inspect each vial of delandistrogene moxeparvovec. Delandistrogene moxeparvovec is a clear, colorless liquid that may have some opalescence. Delandistrogene moxeparvovec may contain white to off-white particles.
	• Do not use if the suspension in the vials is cloudy or discolored.
Remove the plastic flip-off cap from the vials and disinfect the rubber stopper with a sterilizing agent (eg, alcohol wipes).
Withdraw 10 mL of delandistrogene moxeparvovec from each vial provided in the customized delandistrogene moxeparvovec kit (refer to Table 10).
	• Do not use filter needles during preparation of delandistrogene moxeparvovec.
	• Multiple syringes will be required to withdraw the required volume.
	• Remove air from the syringes and cap the syringes.
Maintain syringes at room temperature before and during administration.

Administration

Recommended supplies and materials:

	• Syringe infusion pump
	• 0.2-micron PES* in-line filter with a large surface area. To avoid the risk of occlusions, the use of smaller pediatric in-line filters (eg, less than 10 cm² surface area) is not recommended.
	• PVC* (non-DEHP*) intravenous infusion tubing, and polyurethane catheter
	*PVC = Polyvinyl chloride, DEHP = Di(2-ethylhexyl) phthalate, PES = Polyether sulfone

Administer delandistrogene moxeparvovec as a single-dose intravenous infusion through a peripheral venous catheter:

Delandistrogene moxeparvovec should be administered in a setting where treatment for infusion-related reactions is immediately available. Do not infuse delandistrogene moxeparvovec at a rate of 10 mL/kg/hour or faster.

Consider the application of a topical anesthetic to the infusion site prior to the administration of intravenous insertion.

Recommend inserting a back-up catheter.

	Flush the intravenous access line with 0.9% Sodium Chloride Injection prior to the delandistrogene moxeparvovec infusion at the same infusion rate.
	Administer delandistrogene moxeparvovec via intravenous infusion using a syringe infusion pump with an in-line 0.2-micron filter at a duration of approximately 1 to 2 hours, or longer at care team discretion, through a peripheral limb vein.
	Infuse at a rate of less than 10 mL/kg/hour.
		• Do not administer delandistrogene moxeparvovec as an intravenous push.
		• Do not infuse delandistrogene moxeparvovec in the same intravenous access line with any other product.
		• Use delandistrogene moxeparvovec within 12 hours after drawing into the syringe. Discard the delandistrogene moxeparvovec-containing syringe(s) if infusion of the drug has not been completed within the 12-hour timeframe.
	In the event of an infusion-related reaction during administration:
		• Slow or stop the infusion based on the patient's clinical presentation.
		• Discontinue infusion for anaphylaxis.
		• Administer treatment as needed to manage infusion-related reaction.
		• Delandistrogene moxeparvovec infusion may be restarted at a lower rate after the infusion-related reaction has resolved at the discretion of the physician, based on the severity of the patient's clinical presentation.
		• If the delandistrogene moxeparvovec infusion needs to be stopped and restarted, delandistrogene moxeparvovec should be infused within 12 hours after drawing into the syringe.
	Flush the intravenous access line with 0.9% Sodium Chloride Injection after the delandistrogene moxeparvovec infusion.
		• Discard unused delandistrogene moxeparvovec.
		• Dispose of the needle and syringe.
	Monitoring post-delandistrogene moxeparvovec administration
		• Assess liver function (clinical exam, GGT, and total bilirubin) weekly for the first 3 months. Continue monitoring if clinically indicated, until results are unremarkable (normal clinical exam, GGT, and total bilirubin levels return to near baseline levels).
		• Obtain platelet counts weekly for the first 2 weeks. Continue monitoring if clinically indicated.
		• Measure troponin-I weekly for the first month. Continue monitoring if clinically indicated.

Dosage forms and strengths

Delandistrogene moxeparvovec is a preservative-free, sterile, clear, colorless liquid that may have some opalescence and may contain white to off-white particles.

Delandistrogene moxeparvovec is a suspension for intravenous infusion with a nominal concentration of 1.33 × 1013 vg/mL.

Delandistrogene moxeparvovec is provided in a customized kit containing ten to seventy 10 mL single-dose vials, with each kit constituting a dosage unit based on the patient's body weight.

The intravenous dosage is determined by patient body weight, with a recommended dose of 1.33 × 1014 vector genomes (vg)/kg for patients weighing 10 to 70 kg, and a maximum of 9.31 × 1015 vg for patients 70 kg or greater.

Contraindications

Delandistrogene moxeparvovec is contraindicated in patients with any deletion in exon 8 and/or exon 9 in the DMD gene.

Warnings and precautions

Infusion-related reactions

Infusion-related reactions, including hypersensitivity reactions and anaphylaxis, have occurred during or up to several hours following delandistrogene moxeparvovec administration. Closely monitor patients during and for at least 3 hours after the end of infusion for signs and symptoms of infusion-related reactions, including tachycardia, tachypnea, lip swelling, difficulty breathing, nasal flaring, urticaria, flushing, lip pruritus, rash, cheilitis, vomiting, nausea, rigors, and pyrexia.

Delandistrogene moxeparvovec should be administered in a setting where treatment for infusion-related reactions is immediately available.

In the event of an infusion-related reaction, administration of delandistrogene moxeparvovec may be slowed or stopped based on the severity of the patient's clinical presentation. Administer treatment as needed to manage infusion-related reactions based on the severity of the patient's signs and symptoms. If the infusion was stopped, delandistrogene moxeparvovec infusion may be restarted at a lower rate once the patient's symptoms have resolved, at the discretion of the physician. Discontinue infusion for anaphylaxis.

Acute serious liver injury

Acute serious liver injury has been observed with delandistrogene moxeparvovec. Administration of delandistrogene moxeparvovec may result in elevations of liver enzymes (eg, GGT, ALT) and total bilirubin, typically seen within 8 weeks.

Patients with preexisting liver impairment, chronic hepatic condition, or acute liver disease (eg, acute hepatic viral infection) may be at higher risk of acute serious liver injury. Postpone delandistrogene moxeparvovec administration in patients with acute liver disease until resolved or controlled. Patients with hepatic impairment, acute liver disease, chronic hepatic condition, or elevated GGT have not been studied in clinical trials with delandistrogene moxeparvovec.

In clinical studies, liver function test increase (including increases in GGT, GLDH, ALT, AST, or total bilirubin) was commonly reported, typically within 8 weeks following delandistrogene moxeparvovec infusion, with the majority of cases being asymptomatic. Cases resolved spontaneously or with systemic corticosteroids and resolved without clinical sequelae within 2 months. No cases of liver failure were reported.

Before delandistrogene moxeparvovec administration, perform liver enzyme test. Monitor liver function (clinical exam, GGT, and total bilirubin) weekly for the first 3 months following delandistrogene moxeparvovec infusion. Continue monitoring if clinically indicated, until results are unremarkable (normal clinical exam, GGT, and total bilirubin levels return to near baseline levels).

Systemic corticosteroid treatment is recommended for patients before and after delandistrogene moxeparvovec infusion. Adjust corticosteroid regimen when indicated. If acute serious liver injury is suspected, a consultation with a specialist is recommended.

Immune-mediated myositis

In clinical trials, immune-mediated myositis has been observed approximately 1 month following delandistrogene moxeparvovec infusion in patients with deletion mutations involving exon 8 or exon 9 in the DMD gene. Symptoms of severe muscle weakness, including dysphagia, dyspnea, and hypophonia, were observed. In a life-threatening case of immune-mediated myositis, symptoms resolved during hospitalization following additional immunomodulatory treatment; muscle strength gradually improved but did not return to baseline level. These immune reactions may be due to a T-cell-based response from the lack of self-tolerance to a specific region encoded by the transgene corresponding to exons 1-17 of the DMD gene.

Limited data are available for delandistrogene moxeparvovec treatment in patients with mutations in the DMD gene in exons 1 to 17 and/or exons 59 to 71. Patients with deletions in these regions may be at risk for a severe immune-mediated myositis reaction. Delandistrogene moxeparvovec is contraindicated in patients with any deletion in exon 8 or exon 9 in the DMD gene due to the increased risk for a severe immune-mediated myositis reaction.

Advise patients to contact a physician immediately if they experience any unexplained increased muscle pain, tenderness, or weakness, including dysphagia, dyspnea, or hypophonia, as these may be symptoms of myositis. Consider additional immunomodulatory treatment (immunosuppressants [eg, calcineurin-inhibitor] in addition to corticosteroids) based on the patient's clinical presentation and medical history if these symptoms occur.

Myocarditis

Acute serious myocarditis and troponin-I elevations have been observed following delandistrogene moxeparvovec infusion in clinical trials.

If a patient experiences myocarditis, those with pre-existing left ventricular ejection fraction impairment may be at higher risk of adverse outcomes. Patients with moderate to severe left ventricular ejection fraction impairment have not been studied in clinical trials with delandistrogene moxeparvovec.

Monitor troponin-I before delandistrogene moxeparvovec infusion and weekly for the first month following infusion. Continue monitoring if clinically indicated. More frequent monitoring may be warranted in the presence of cardiac symptoms, such as chest pain or shortness of breath.

Advise patients to contact a physician immediately if they experience cardiac symptoms.

Pre-existing immunity against AAVrh74

In AAV-vector-based gene therapies, preexisting anti-AAV antibodies may impede transgene expression at desired therapeutic levels. Following treatment with delandistrogene moxeparvovec, all patients developed anti-AAVrh74 antibodies. Perform baseline testing for the presence of anti-AAVrh74 total binding antibodies before delandistrogene moxeparvovec administration.

Delandistrogene moxeparvovec administration is not recommended in patients with elevated anti-AAVrh74 total binding antibody titers (≥1:400).

Adverse reactions

The most common adverse reactions (incidence ≥ 5%) reported in clinical studies were vomiting, nausea, liver injury, pyrexia, and thrombocytopenia.

The following clinically significant adverse reactions are described elsewhere in the labeling:

	• Infusion-related reactions
	• Acute serious liver injury
	• Immune-mediated myositis
	• Myocarditis

Clinical trials experience

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.

The safety data described in this section reflect exposure to a one-time intravenous infusion of delandistrogene moxeparvovec in 156 male patients with a confirmed mutation of the DMD gene in four clinical studies, including one completed open-label study, one ongoing open-label study, and two studies that included a double-blind, placebo-controlled period. Before delandistrogene moxeparvovec infusion, patients in the delandistrogene moxeparvovec treatment group had a mean age of 6.7 years (range: 3 to 20) and mean weight of 24.6 kg (range: 12.5 to 80.1). 144 patients received the recommended dose of 1.33 × 1014 vg/kg, and 12 received a lower dose. Table 3 below presents adverse reactions from these four clinical studies.

The most common adverse reactions (incidence ≥5%) across all studies are summarized in Table 3.

Adverse reactions were typically seen within the first 2 weeks (nausea, vomiting, thrombocytopenia, pyrexia), or within the first 2 months (immune-mediated myositis, liver injury). Vomiting may occur as early as on the day of the infusion.

Table 3. Adverse Reactions (Incidence ≥5%) Following Treatment with Delandistrogene Moxeparvovec in Clinical Studies

Adverse reactions	Delandistrogene moxeparvovec (N=156)
Vomiting	65%
Nausea	43%
Liver injury^a	40%
Pyrexia	28%
Thrombocytopenia^{b c}	8%
a Includes: AST increased, ALT increased, GGT increased, GLDH increased, GLDH level abnormal, hepatotoxicity, hepatic enzyme increased, hypertransaminasemia, liver function test increased, liver injury, transaminases increased, blood bilirubin increased b Includes: Thrombocytopenia, platelet count decreased c Transient, mild, asymptomatic decrease in platelet counts

In the double-blind, placebo-controlled trial, Study 3 Part 1, patients 4 to 7 years of age (N=125) received either delandistrogene moxeparvovec (N=63) at the recommended dose of 1.33 × 1014 vg/kg or placebo (N=62). Table 4 below presents the most frequent adverse reactions from Study 3 Part 1.

Table 4. Adverse Reactions Occurring in Delandistrogene Moxeparvovec-Treated Patients and At Least Twice More Frequently Than With Placebo in Study 3 Part 1

Adverse reactions	Delandistrogene moxeparvovec (N=63)	Placebo (N=62)
Vomiting	64%	19%
Nausea	40%	13%
Liver injury^a	41%	8%
Pyrexia	32%	24%
Thrombocytopenia^bc	3%	0%
^a Includes: AST increased, ALT increased, GGT increased, GLDH increased, GLDH level abnormal, Hepatotoxicity, Hepatic enzyme increased, Hypertransaminasemia, Liver function test increased, Liver injury, Transaminases increased. ^b Includes: platelet count decreased, thrombocytopenia ^c Transient, mild, asymptomatic decrease in platelet counts

Postmarketing experience

The following adverse reactions have been identified during post-approval use of delandistrogene moxeparvovec. 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.

Immune system disorders. Infusion-related reactions, including hypersensitivity reactions and anaphylaxis, have occurred during or up to several hours following delandistrogene moxeparvovec administration.

Drug interactions

Before initiating the corticosteroid regimen required before delandistrogene moxeparvovec administration, consider the patient's vaccination status. Patients should, if possible, be brought up to date with all immunizations in agreement with current immunization guidelines. Vaccinations should be completed at least 4 weeks before initiation of the corticosteroid regimen.

Use in specific populations

Pregnancy

Risk summary. Delandistrogene moxeparvovec is not intended for use in pregnant women.

In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Lactation

Risk summary. There is no information available on the presence of delandistrogene moxeparvovec in human milk, the effects on the breastfed infant, or the effects on milk production.

Pediatric use

The safety and effectiveness of delandistrogene moxeparvovec for the treatment of Duchenne muscular dystrophy have been established in pediatric patients at least 4 years of age with a confirmed mutation in the DMD gene.

Geriatric use

The safety and efficacy of delandistrogene moxeparvovec in geriatric patients with Duchenne muscular dystrophy have not been studied.

Hepatic impairment

The safety and efficacy of delandistrogene moxeparvovec in patients with hepatic impairment or elevated GGT have not been studied.

Postpone delandistrogene moxeparvovec administration in patients with acute liver disease until resolved or controlled. Treatment with delandistrogene moxeparvovec should be carefully considered in patients with preexisting liver impairment or chronic hepatic viral infection. These patients may be at increased risk of acute serious liver injury.

In clinical trials, liver function test increase was commonly reported in patients following delandistrogene moxeparvovec infusion.

Clinical pharmacology

Mechanism of action

Delandistrogene moxeparvovec is the recombinant gene therapy product that is comprised of a non-replicating, recombinant, adeno-associated virus (AAV) serotype rh74 (AAVrh74) capsid and a single-stranded DNA expression cassette flanked by inverted terminal repeats (ITRs) derived from AAV2. The cassette contains: (1) an MHCK7 gene regulatory component comprising a creatine kinase 7 promoter and an α-myosin heavy chain enhancer, and (2) the DNA transgene encoding the engineered micro-dystrophin protein.

Vector/capsid. Clinical and nonclinical studies have demonstrated AAVrh74 serotype transduction in skeletal muscle cells. Additionally, in nonclinical studies, AAVrh74 serotype transduction has been demonstrated in cardiac and diaphragm muscle cells.

Promoter. The MHCK7 promoter/enhancer drives transgene expression and has been shown in animal models to drive transgenic micro-dystrophin protein expression predominantly in skeletal muscle (including diaphragm) and cardiac muscle. In clinical studies, muscle biopsy analyses have confirmed microdystrophin expression in skeletal muscle.

Transgene. Duchenne muscular dystrophy is caused by a mutation in the DMD gene, resulting in a lack of functional dystrophin protein. Delandistrogene moxeparvovec carries a transgene encoding a micro-dystrophin protein consisting of selected domains of dystrophin expressed in normal muscle cells.

Delandistrogene moxeparvovec micro-dystrophin has been demonstrated to localize to the sarcolemma.

Pharmacodynamics

In 92 patients who received delandistrogene moxeparvovec in clinical studies, micro-dystrophin protein expression from muscle biopsies (gastrocnemius or biceps brachii) was quantified by western blot and localized by immunofluorescence staining (fiber intensity and percentage micro-dystrophin).

Micro-dystrophin expression (expressed as change from baseline) in delandistrogene moxeparvovec-treated patients, as measured by Western blot, was the primary objective of Study 1 and Study 2, and a key secondary objective for Study 3. Muscle biopsies were obtained at baseline before delandistrogene moxeparvovec infusion and at Week 12 after delandistrogene moxeparvovec infusion in all patients. The absolute quantity of micro-dystrophin was measured by western blot assay, adjusted by muscle content, and expressed as a percent of control (levels of wild-type dystrophin in patients without Duchenne muscular dystrophy or Becker muscular dystrophy) in muscle biopsy samples. Study 1 and 2 results of patients receiving 1.33 × 1014 vg/kg delandistrogene moxeparvovec are presented in Table 5.

Table 5. Micro-Dystrophin Expression in Study 1 and Study 2 at Week 12 From Baseline (Western Blot Assay)abc

Western blot (% of micro-dystrophin compared to control)	Study 1 Part 1 (n=6)	Study 1 Part 2 (n=21)	Study 2 Ambulatory (n=40)	Study 2 Non-ambulatory (n=8)
Mean change from baseline (SD)	43.4 (48.6)	40.7 (32.3)	51.0 (47)	40.1 (35.9)
Median change from baseline (Min, Max)	24.3 (1.6, 116.3)	40.8 (0.0, 92.0)	46.9 (1.9, 197.3)	32.7 (1.4, 116.3)
^a All patients received 1.33 x 1014 vg/kg, as measured by ddPCR ^b Change from baseline was statistically significant ^c Adjusted for muscle content. Control was the level of wild-type (normal) dystrophin in normal muscle.

A clear association between Week 12 micro-dystrophin expression and clinical outcome (assessed by change from baseline on the Performance of Upper Limb version 2.0 assessment; Table 7) in non-ambulatory patients has not been established.

In Study 3 Part 1, muscle biopsies were obtained at Week 12 in 31 patients. For the delandistrogene moxeparvovec-treated patients, the mean micro-dystrophin expression at Week 12 was 34.3% (N=17, SD: 41.0%), compared to placebo patients of 0% (N=14, SD: 0%).

Assessment of micro-dystrophin levels can be meaningfully influenced by differences in sample processing, analytical technique, reference materials, and quantitation methodologies. Therefore, valid comparisons of micro-dystrophin measurements obtained from different assays cannot be made.

Pharmacokinetics

Vector distribution and vector shedding.

Nonclinical data. Biodistribution of delandistrogene moxeparvovec was evaluated in tissue samples collected from healthy mice and DMD^mdx mice following intravenous administration in toxicology studies. At 12 weeks following delandistrogene moxeparvovec administration at dose levels of 1.33 ×10¹⁴ to 4.02 ×10¹⁴ vg/kg, vector DNA was detected in all major organs, with the highest quantities detected in the liver, followed by lower levels in the heart, adrenal glands, skeletal muscle, and aorta. Delandistrogene moxeparvovec was also detected at low levels in the spinal cord, sciatic nerve, and gonads (testis). Protein expression of micro-dystrophin was highest in cardiac tissue, exceeding physiologic dystrophin expression levels in healthy mice, with lower levels in the skeletal muscle and diaphragm. In some studies, micro-dystrophin was also detected at low levels in the liver.

Clinical data. Following intravenous administration, delandistrogene moxeparvovec vector genome undergoes distribution via systemic circulation and distributes into target muscle tissues, followed by elimination in the urine and feces. Delandistrogene moxeparvovec biodistribution and tissue transduction are detected in the target muscle tissue groups and quantified in the gastrocnemius or biceps femoris biopsies obtained from patients with mutations in the DMD gene. Evaluation of delandistrogene moxeparvovec vector genome exposure in clinical muscle biopsies at Week 12 post-dose, expressed as copies per nucleus, revealed delandistrogene moxeparvovec drug distribution and transduction with a mean change from baseline of 2.91 and 3.44 copies per nucleus at the recommended dose of 1.33 × 1014 vg/kg for Study 1 and Study 2 Cohort 1, respectively.

In Study 2 Cohorts 1-3, the biodistribution and vector shedding of delandistrogene moxeparvovec in the serum and excreta were quantified, respectively. The mean maximum concentration (Cmax) in the serum was 0.0055 × 1013 copies/mL and 2.78 × 106 copies/mL in the urine, 7.86 × 107 copies/mL in the saliva, and 4.87 × 107 copies/μg in the feces. The median time to achieve maximum concentration (Tmax) was 5.8 hours post-dose in the serum, followed by 6.7 hours, 6.5 hours, and 13 days post-dose in the saliva, urine, and feces, respectively. The median time to achieve first below limit of quantification (BLOQ) sample followed by two consecutive BLOQ samples was 55 days post-dose for serum. The median time to achieve complete elimination as the first below limit of detection (BLOD) sample followed by two consecutive BLOD samples was 49.8 days, 78 days, and 162 days post-dose for saliva, urine, and feces, respectively. The estimated elimination half-life of delandistrogene moxeparvovec vector genome in the serum is approximately 12 hours, and the majority of the drug is expected to be cleared from the serum by 1 week post-dose. In the excreta, the estimated elimination half-life of delandistrogene moxeparvovec vector genome is approximately 40 hours, 55 hours, and 60 hours in the urine, feces, and saliva, respectively. As an AAV-based gene therapy that consists of a protein capsid containing the transgene DNA genome of interest, delandistrogene moxeparvovec capsid proteins are broken down through proteasomal degradation following AAV entry into target cells. As such, delandistrogene moxeparvovec is not likely to exhibit the drug-drug interaction potential mediated by known drug-metabolizing enzymes (cytochrome P450-based) and drug transporters.

Immunogenicity

The observed incidence of anti-AAVrh74 antibodies is highly dependent on the sensitivity and specificity of the assay. Differences in assay methods preclude meaningful comparisons of the incidence of anti-AAVrh74 antibodies in the studies described below with the incidence of anti-AAVrh74 antibodies in other studies.

In delandistrogene moxeparvovec clinical studies, patients were required to have baseline anti-AAVrh74 total binding antibodies of ≤1:400, measured using an investigational total binding antibody enzyme-linked immunosorbent assay (ELISA), and only patients with baseline anti-AAVrh74 total binding antibodies <1:400 were enrolled in those studies. The safety and efficacy of delandistrogene moxeparvovec in patients with elevated anti-AAVrh74 total binding antibody titer (≥1:400) have not been evaluated.

Across clinical studies evaluating a total of 156 patients, elevated anti-AAVrh74 total binding antibody titers were observed in all patients following a one-time delandistrogene moxeparvovec infusion. Anti-AAVrh74 total binding antibody titers reached at least 1:102,400 in every patient, and the maximum titers exceeded 1:26,214,400 in certain patients. The safety of re-administration of delandistrogene moxeparvovec or any other AAVrh74 vector-based gene therapy in the presence of high anti-AAVrh74 total binding antibody titer has not been evaluated in humans.

Nonclinical toxicology

Carcinogenesis, mutagenesis, and impairment of fertility

No animal studies have been performed to evaluate the effects of delandistrogene moxeparvovec on carcinogenicity, mutagenesis, or impairment of fertility.

Clinical studies

The efficacy of delandistrogene moxeparvovec was evaluated in two double-blind, placebo-controlled studies (Study 1 [NCT 03769116] and Study 3 [WebSite:NCT05096221}{WebURL:https://clinicaltrials.gov/study/05096221}|]) and one open-label study (Study 2 [NCT04626674]) in which a total of 214 male patients with a confirmed disease-causing mutation in the DMD gene were dosed.

Study 1

Study 1 is a completed multi-center study including:

	• Part 1: a 48-week, randomized, double-blind, placebo-controlled period
	• Part 2: a 48-week period that began following completion of Part 1. Patients who received placebo during Part 1 were treated with delandistrogene moxeparvovec, and patients treated with delandistrogene moxeparvovec during Part 1 received placebo.

The study population consisted of male ambulatory patients with Duchenne muscular dystrophy (N=41) aged 4 to 7 years with either a confirmed frameshift mutation, or a premature stop codon mutation between exons 18 to 58 in the DMD gene.

Patients were randomized 1:1 to receive either delandistrogene moxeparvovec (N=20) or placebo (N=21), as a single intravenous infusion via a peripheral limb. Randomization was stratified by age (ie, aged 4 to 5 years vs. aged 6 to 7 years). In the 4- to 5-year-old subgroup, the mean age, mean weight, and mean NSAA total score (range) for the delandistrogene moxeparvovec-treated patients (n=8) were 4.98 years, 20.1 kg, and 20.1 (17 to 23), and for the placebo patients (n=8) were 5.15 years, 19.8 kg, and 20.4 (15 to 24). In the delandistrogene moxeparvovec group, eight patients received 1.33 × 1014 vg/kg of delandistrogene moxeparvovec, and 12 patients received lower doses. Key demographic and baseline characteristics are presented in Table 6.

Table 6. Key Demographic and Baseline Characteristics (Study 1, Part 1)

Characteristic	All (n=41)	Delandistrogene moxeparvovec (n=20)	Placebo (n=21)
Race (%) Asian/Black or African American/White/Other	12/0/73/15	20/0/65/15	5/0/81/14
Ethnicity (%) Hispanic or Latino/Other	12/88	5/95	19/81
Mean age [range] (years)	6.3 [4.3 to 7.9]	6.3 [4.5 to 7.9]	6.2 [4.3 to 7.9]
Mean weight [range] (kg)	22.4 [15.0 to 34.5]	23.3 [18.0 to 34.5]	21.6 [15.0 to 30.0]
Mean NSAA total score [range]	21.2 [13 to 29]	19.8 [13 to 26]	22.6 [15 to 29]
Mean time to rise from floor [range] (seconds)	4.3 [2.7 to 10.4]	5.1 [3.2 to 10.4]	3.6 [2.7 to 4.8]

All patients were on a stable dose of corticosteroids for Duchenne muscular dystrophy for at least 12 weeks prior to delandistrogene moxeparvovec infusion. All randomized patients had baseline anti-AAVrh74 antibody titers <1:400 as determined by an investigational total binding antibody ELISA.

One day prior to treatment with delandistrogene moxeparvovec or placebo, the patient's background dose of corticosteroid for Duchenne muscular dystrophy was increased to at least 1 mg/kg of a corticosteroid (prednisone equivalent) daily and was continued at this level for at least 60 days after the infusion, unless earlier tapering was clinically indicated.

The efficacy outcomes of Study 1 were to evaluate the expression of micro-dystrophin in skeletal muscle and to evaluate the effect of delandistrogene moxeparvovec on the North Star Ambulatory Assessment (NSAA) total score.

Results of micro-dystrophin measured by Western blot are presented in Table 5.

The change in NSAA total score was assessed from baseline to Week 48 after infusion of delandistrogene moxeparvovec or placebo. The difference between the delandistrogene moxeparvovec and placebo groups was not statistically significant (p=0.37). The least squares (LS) mean changes in NSAA total score from baseline to Week 48 was 1.7 (standard error [SE]: 0.6) points for the delandistrogene moxeparvovec group and 0.9 (SE: 0.6) points for the placebo group.

Exploratory subgroup analyses showed that for patients aged 4 to 5 years, the LS mean changes (SE) in NSAA total score from baseline to Week 48 were 4.3 (0.7) points for the delandistrogene moxeparvovec group, and 1.9 (0.7) points for the placebo group, a numerical advantage for delandistrogene moxeparvovec. For patients aged 6 to 7 years, the LS mean changes (SE) in NSAA total score from baseline to Week 48 were -0.2 (0.7) points for the delandistrogene moxeparvovec group and 0.5 (0.7) points for the placebo group, a numerical disadvantage for delandistrogene moxeparvovec.

Study 2

Study 2 is an ongoing, open-label, multi-center study that includes five cohorts of 48 male patients with Duchenne muscular dystrophy.

Patients in cohorts 1, 2, and 3 have a confirmed frameshift, splice site, or premature stop codon mutation anywhere in the DMD gene, whereas patients in cohort 4 included patients with mutations in the DMD gene starting at or after exon 18. All patients in cohort 5 had mutations that partially or fully overlap with exons 1-17 in the DMD gene. Patients received corticosteroids for Duchenne muscular dystrophy before infusion according to Table 1. All patients had baseline anti-AAVrh74 antibody titers ≤1:400 as determined by the investigational total binding antibody ELISA. Patients received a single intravenous infusion of 1.33 × 1014 vg/kg delandistrogene moxeparvovec if they weighed less than 70 kg or 9.31 × 1015 vg/kg total fixed dose if they weighed 70 kg or greater.

Cohorts 1, 2, 4, and 5a enrolled 40 ambulatory patients 3 to 12 years of age, with weights ranging from 12.5 to 50.5 kg, baseline mean NSAA total score of 20.3 (11 to 30), and mean time to rise from floor of 4.7 seconds (2.4 to 9.7). Cohorts 3 and 5b include eight nonambulatory patients, 10 to 20 years of age, with weights ranging from 36.1 to 80.1 kg. Overall key demographics and key baseline characteristics by Cohort are presented in Table 7.

Table 7. Key Demographic and Baseline Characteristics for Study 2

Characteristics	All (n=48)	Cohort 1 (n=20)	Cohort 2 (n=7)	Cohort 3^a(n=6)	Cohort 4 (n=7)	Cohort 5^a(n=6)	Cohort 5^ba(n=2)
Race (%) Asian/Black or African American/White/Other	8/6/77/8	5/5/75/15	14/0/71/14	0/0/100/0	14/0/86/0	0/33/67/0	50/0/50/0
Ethnicity (%) Hispanic or Latino/Not Hispanic or Latino	15/85	25/75	14/86	0/100	14/86	0/100	0/100
Mean age [range] (years)	7.7 [3.2 to 20.2]	5.8 [4.4 to 7.9]	10.1 [8.0 to 12.1]	15.3 [9.9 to 20.2]	3.5 [3.2 to 3.9]	6.7 [4.7 to 8.6]	13.4 [12.3 to 14.6]
Mean weight [range] (kg)	30.1 [12.5 to 80.1]	21.2 [15.2 to 33.1]	37.1 [28.0 to 50.5]	59.9 [36.1 to 80.1]	15.2 [12.5 to 16.5]	32.1 [19.1 to 47.4]	51.2 [43.4 to 59.0]
Mean NSAA total score [range]	20.3 [11 to 30]	22.1 [18 to 26]	20.7 [17 to 26]	N/A	12.9 [11 to 17]	22.5 [18 to 30]	N/A
Mean time to rise from floor [range] (seconds)	4.7 [2.4 to 9.7]	4.2 [2.4 to 8.2]	5.9 [3.8 to 9.7]	N/A	5.2 [3.8 to 6.7]	4.6 [2.5 to 7.7]	N/A
Mean Performance of Upper Limb v. 2.0 score [range]	30.7 [18 to 42]	NA	38.9 [33 to 42]	22.2 [18 to 31]	NA	NA	27.5 [21 to 34]
^a NSAA and Time to rise from floor were not evaluated in non-ambulatory patients

The efficacy outcome measure of the study was to evaluate the effect of micro-dystrophin expression as measured by Western blot. Results are presented in Table 5.

Study 3

Study 3 is a multi-center, randomized, double-blind, placebo-controlled study in which 125 ambulatory male patients aged 4 to 7 years, with a confirmed frameshift, splice site, premature stop codon, or other disease-causing mutation in the DMD gene starting at or after exon 18, were dosed. Patients with exon 45 (inclusive), or in-frame deletions, in-frame duplications, and variants of uncertain significance (“VUS”), were excluded. Patients received corticosteroids for Duchenne muscular dystrophy before infusion according to Table 1. All patients had baseline anti-AAVrh74 antibody titers <1:400 as determined by the investigational total binding antibody ELISA and received a single intravenous infusion of 1.33 × 1014 vg/kg delandistrogene moxeparvovec. Key demographic and baseline characteristics are presented in Table 8.

The efficacy outcome measure of the study was to evaluate the effect of delandistrogene moxeparvovec on physical function as assessed by the NSAA total score. Key secondary outcome measures were to evaluate expression of micro-dystrophin in skeletal muscle, time to rise from floor, and time of 10-meter walk or run. Additional efficacy outcome measures included time of 100-meter walk or run, and time to ascend four steps. Results of micro-dystrophin measured by Western blot are presented in Table 5.

Table 8. Key Demographic and Baseline Characteristics for Study 3

Characteristic	Delandistrogene moxeparvovec (n=63)	Placebo (n=62)
Race (%) Asian/Black or African American/ White/Multiple/Other/Not Reported	13/0/78/2/3/5	18/3/74/0/2/3
Ethnicity (%) Hispanic or Latino/Not Hispanic or Latino/Not Reported/Unknown	24/75/0/2	13/86/2/0
Mean age [range] (years)	6.0 [4.1 to 7.9]	6.1 [4.0 to 7.9]
Mean weight [range] (kg)	21.3 [13.5 to 38.5]	22.4 [14.4 to 41.6]
Mean NSAA total score [range]	23.10 [14 to 32]	22.82 [15.5 to 30]
Mean time to rise from floor [range] (seconds)	3.52 [1.9 to 5.8]	3.60 [2.3 to 5]
Mean time of 10-meter walk/run [range] (seconds)	4.82 [3.2 to 6.9]	4.92 [3.7 to 7]
Mean time of 100-meter walk/run [range] (seconds)	60.67 [38.0 to 129.2]	63.01 [38.7 to 118.1]
Mean time to ascend four steps [range] (seconds)	3.17 [1.6 to 7.1]	3.37 [1.5 to 7.1]

The change in NSAA total score was assessed from baseline to Week 52 after infusion of delandistrogene moxeparvovec or placebo. The difference between the delandistrogene moxeparvovec (n=63) and placebo groups (n=61) was not statistically significant (p=0.24). The least squares (LS) mean changes in NSAA total score from baseline to Week 52 was 2.57 (95% confidence interval [CI]: 1.80, 3.34) points for the delandistrogene moxeparvovec group and 1.92 (95% CI: 1.14, 2.70) points for the placebo group, with a LS mean difference from placebo of 0.65 (95% CI: -0.45, 1.74). Changes of clinical relevance were noted in three secondary efficacy endpoints, including time to rise from the floor, 10-meter walk or run, and time to ascend four steps.

Table 9. Change from Baseline to Week 52 of Timed Function Tests in Study 3 Part 1

	Delandistrogene moxeparvovec	Placebo	LS Mean Difference from placebo (95% CI)
Time to rise from the floor (seconds)	n=63	n=61	-
LS mean Change (95% CI)	-0.27 (-0.56, 0.02)	0.37 (0.08, 0.67)	-0.64 (-1.06, -0.23)
Time of 10-meter walk/run (seconds)	n=63	n=61	-
LS mean Change (95% CI)	-0.34 (-0.55, -0.14)	0.08 (-0.13, 0.29)	-0.42 (-0.71, -0.13)
Time of 100-meter walk/run (seconds)	n=59	n=57	-
LS mean Change (95% CI)	-6.57 (-10.05, -3.09)	-3.28 (-6.86, 0.29)	-3.29 (-8.28, 1.70)
Time to ascend four steps (seconds)	n=62	n=60	-
LS mean Change (95% CI)	-0.44 (-0.69, -0.20)	-0.08 (-0.33, 0.17)	-0.36 (-0.71, -0.01)

How supplied/storage and handling

How supplied

Delandistrogene moxeparvovec is shipped frozen (≤ -60ºC [-76ºF]) in 10 mL vials.

Delandistrogene moxeparvovec is supplied as a customized kit to meet dosing requirements for each patient. Each kit contains:

	• Ten (10) to seventy (70) single-dose vials of delandistrogene moxeparvovec
	• One alcohol wipe per vial

Each delandistrogene moxeparvovec pack may contain a maximum of two different drug product lots.

The total number of vials in each kit corresponds to the dosing requirement for the individual patient, based on the patient's body weight, and is specified on the package. Each kit includes a specified number of delandistrogene moxeparvovec vials (with a minimum of 10 vials for a patient with 10.0 to 10.4 kg bodyweight range, and a maximum of 70 vials for a patient with a bodyweight of 69.5 kg and above).

Kit sizes and National Drug Codes (NDC) are provided in Table 10.

Table 10. Delandistrogene Moxeparvovec Multivial Kits

Patient weight (kg)	Total vials per kit	Total dose volume per kit (mL)	NDC number
10.0 – 10.4	10	100	60923-501-10
10.5 – 11.4	11	110	60923-502-11
11.5 – 12.4	12	120	60923-503-12
12.5 – 13.4	13	130	60923-504-13
13.5 – 14.4	14	140	60923-505-14
14.5 – 15.4	15	150	60923-506-15
15.5 – 16.4	16	160	60923-507-16
16.5 – 17.4	17	170	60923-508-17
17.5 – 18.4	18	180	60923-509-18
18.5 – 19.4	19	190	60923-510-19
19.5 – 20.4	20	200	60923-511-20
20.5 – 21.4	21	210	60923-512-21
21.5 – 22.4	22	220	60923-513-22
22.5 – 23.4	23	230	60923-514-23
23.5 – 24.4	24	240	60923-515-24
24.5 – 25.4	25	250	60923-516-25
25.5 – 26.4	26	260	60923-517-26
26.5 – 27.4	27	270	60923-518-27
27.5 – 28.4	28	280	60923-519-28
28.5 – 29.4	29	290	60923-520-29
29.5 – 30.4	30	300	60923-521-30
30.5 – 31.4	31	310	60923-522-31
31.5 – 32.4	32	320	60923-523-32
32.5 – 33.4	33	330	60923-524-33
33.5 – 34.4	34	340	60923-525-34
34.5 – 35.4	35	350	60923-526-35
35.5 – 36.4	36	360	60923-527-36
36.5 – 37.4	37	370	60923-528-37
37.5 – 38.4	38	380	60923-529-38
38.5 – 39.4	39	390	60923-530-39
39.5 – 40.4	40	400	60923-531-40
40.5 – 41.4	41	410	60923-532-41
41.5 – 42.4	42	420	60923-533-42
42.5 – 43.4	43	430	60923-534-43
43.5 – 44.4	44	440	60923-535-44
44.5 – 45.4	45	450	60923-536-45
45.5 – 46.4	46	460	60923-537-46
46.5 – 47.4	47	470	60923-538-47
47.5 – 48.4	48	480	60923-539-48
48.5 – 49.4	49	490	60923-540-49
49.5 – 50.4	50	500	60923-541-50
50.5 – 51.4	51	510	60923-542-51
51.5 – 52.4	52	520	60923-543-52
52.5 – 53.4	53	530	60923-544-53
53.5 – 54.4	54	540	60923-545-54
54.5 – 55.4	55	550	60923-546-55
55.5 – 56.4	56	560	60923-547-56
56.5 – 57.4	57	570	60923-548-57
57.5 – 58.4	58	580	60923-549-58
58.5 – 59.4	59	590	60923-550-59
59.5 – 60.4	60	600	60923-551-60
60.5 – 61.4	61	610	60923-552-61
61.5 – 62.4	62	620	60923-553-62
62.5 – 63.4	63	630	60923-554-63
63.5 – 64.4	64	640	60923-555-64
64.5 – 65.4	65	650	60923-556-65
65.5 – 66.4	66	660	60923-557-66
66.5 – 67.4	67	670	60923-558-67
67.5 – 68.4	68	680	60923-559-68
68.5 – 69.4	69	690	60923-560-69
69.5 and above	70	700	60923-561-70

A 10 mL single-dose vial carton for delandistrogene moxeparvovec (NDC 60923-562-01) is not sold individually.

Storage and handling

	• Delandistrogene moxeparvovec is shipped and delivered at ≤ −60ºC [−76ºF].
	• Delandistrogene moxeparvovec can be refrigerated for up to 14 days when stored at 2°C to 8°C (36º F to 46º F) in the upright position.
	• Do not refreeze.
	• Do not shake.
	• Do not place back in the refrigerator once brought to room temperature.
	• Follow local guidelines on handling of biological waste.

Patient counseling information

Inform patients or caregivers that:
	• Infusion-related reactions, including hypersensitivity and anaphylaxis, have occurred during and after delandistrogene moxeparvovec infusion. Possible symptoms of infusion-related reactions are fast heart rate, fast breathing, swollen lips, being short of breath, nostrils widening, hives, red and blotchy skin, itchy or inflamed lips, rash, vomiting, nausea, chills, and fever. Contact a healthcare provider immediately if the patient experiences such a reaction.
	• Delandistrogene moxeparvovec can increase certain liver enzyme levels and cause acute serious liver injury. Patients will receive oral corticosteroid medication before and after infusion with delandistrogene moxeparvovec. Weekly blood tests will be required to monitor liver enzyme levels for 3 months after treatment. Contact a healthcare provider immediately if the patient's skin or whites of the eyes appear yellowish, or if the patient misses a dose of corticosteroid or vomits it up.
	• Immune-mediated myositis (an immune response affecting muscles) was observed in patients with a deletion mutation in the DMD gene that is contraindicated. Contact a physician immediately if the patient experiences any unexplained increased muscle pain, tenderness, or weakness, including difficulty swallowing, difficulty breathing, or difficulty speaking, as these may be symptoms of myositis.
	• Myocarditis (inflammation of the heart) has been observed within days following delandistrogene moxeparvovec infusion. Weekly monitoring of troponin-I for the first month after treatment is required. Contact a healthcare provider immediately if the patient begins to experience chest pain and/or shortness of breath.
	• Patient's immunizations should be up to date with current immunization guidelines prior to initiation of the corticosteroid regimen required before delandistrogene moxeparvovec infusion. Vaccinations should be completed at least 4 weeks before initiation of the corticosteroid regimen.
	• Due to the concomitant administration of corticosteroids, an infection (eg, cold, flu, gastroenteritis, otitis media, bronchiolitis, etc.) before or after delandistrogene moxeparvovec infusion could lead to more serious complications. Contact a healthcare provider immediately if symptoms suggestive of infection are observed (eg, coughing, wheezing, sneezing, runny nose, sore throat, or fever).
	• Vector shedding of delandistrogene moxeparvovec occurs primarily through body waste. Practice proper hand hygiene, such as hand washing, when coming into direct contact with patient body waste. Place potentially contaminated materials that may have the patient's bodily fluids/waste in a sealable bag and dispose in regular trash. These precautions should be followed for 1 month after delandistrogene moxeparvovec infusion.

Medication guide

See the Medication guide section of the DAILYMED drug label information.

Acknowledgement

This article was excerpted from U.S. FDA Drug Labeling information available on the DailyMed website.