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Childhood-Onset Idiopathic Nephrotic Syndrome

Childhood-onset idiopathic nephrotic syndrome, or childhood-onset INS, is a rare kidney disease most commonly diagnosed in children 2 to 7 years of age. Loss or altered function of podocytes disrupts the glomerular filtration barrier, leading to proteinuria, hypoalbuminemia, edema, and hyperlipidemia. Most children initially respond to corticosteroids, but 80% to 90% relapse and approximately half develop frequently relapsing or steroid-dependent disease. Repeated and prolonged corticosteroid exposure can contribute to growth impairment, hypertension, and bone disease, supporting the need for steroid-sparing treatment options.

GAZYVA in Childhood-Onset Idiopathic Nephrotic Syndrome

GAZYVA® (obinutuzumab) is indicated to reduce the risk of relapse in adult and pediatric patients 2 years of age and older with frequently relapsing or steroid dependent childhood-onset idiopathic nephrotic syndrome (INS) who are in complete remission. GAZYVA is the first and only FDA-approved treatment for childhood-onset idiopathic nephrotic syndrome.

GAZYVA is a type II, humanized anti-CD20 monoclonal antibody designed to bind to CD20 on pre-B and mature B lymphocytes. It is engineered for higher Fc gamma receptor III binding affinity. Based on preclinical data, GAZYVA has greater direct B-cell death, antibody-dependent cellular cytotoxicity, and antibody-dependent cellular phagocytosis compared with type I anti-CD20 antibodies.

INSHORE Clinical Evidence

INSHORE was a Phase III, randomized, open-label, active-comparator, multicenter study evaluating GAZYVA compared with oral mycophenolate mofetil, or MMF, in patients 2 to 25 years of age with frequently relapsing or steroid-dependent INS. Patients were in complete remission at baseline and at high risk of relapse while steroids were tapered. Compared with MMF, more patients treated with GAZYVA were in complete remission at Week 52 without relapsing after Week 8. There were also fewer total relapses with GAZYVA compared with MMF.

Dosing, Administration, and Safety

GAZYVA is administered as an intravenous infusion according to the approved dosing schedule, with 4 infusions over 6 months for childhood-onset idiopathic nephrotic syndrome. Premedication is required before each infusion. GAZYVA should be administered by a healthcare professional with appropriate medical support to manage severe infusion-related reactions, and blood counts should be monitored regularly.

GAZYVA carries Boxed Warnings for hepatitis B virus reactivation and progressive multifocal leukoencephalopathy. Additional risks include infusion-related reactions, hypersensitivity reactions, tumor lysis syndrome, serious and fatal infections, neutropenia, thrombocytopenia, and disseminated intravascular coagulation. Refer to the full Prescribing Information for complete dosing and safety information. Review additional Important Safety Information, including Boxed Warnings.

Important Safety Information and Indication

Indication

GAZYVA® (obinutuzumab) is indicated to reduce the risk of relapse in adult and pediatric patients 2 years of age and older with frequently relapsing or steroid dependent childhood-onset idiopathic nephrotic syndrome (INS) who are in complete remission.

BOXED WARNINGS: HEPATITIS B VIRUS REACTIVATION AND PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

  • Hepatitis B Virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, can occur in patients receiving CD20-directed cytolytic antibodies, including GAZYVA. Screen all patients for HBV infection before treatment initiation. Monitor HBV-positive patients during and after treatment with GAZYVA. Discontinue GAZYVA and concomitant medications in the event of HBV reactivation
  • Progressive Multifocal Leukoencephalopathy (PML), including fatal PML, can occur in patients receiving GAZYVA

Contraindications

  • GAZYVA is contraindicated in patients with known hypersensitivity reactions (eg, anaphylaxis) to obinutuzumab or to any of the excipients, or serum sickness with prior obinutuzumab use

Warnings and Precautions

Hepatitis B Virus Reactivation
  • GAZYVA can cause hepatitis B virus (HBV) reactivation. HBV reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, can occur in patients treated with anti-CD20 antibodies, including GAZYVA. HBV reactivation has been reported in patients who are hepatitis B surface antigen (HBsAg) positive and in patients who are HBsAg negative but are hepatitis B core antibody (anti-HBc) positive. Reactivation has also occurred in patients who appear to have resolved hepatitis B infection (ie, HBsAg negative, anti-HBc positive, and hepatitis B surface antibody [anti-HBs] positive)
  • HBV reactivation is defined as an abrupt increase in HBV replication manifesting as a rapid increase in serum HBV DNA level, or detection of HBsAg in a person who was previously HBsAg negative and anti-HBc positive. Reactivation of HBV replication is often followed by hepatitis, ie, increase in transaminase levels and in severe cases, increase in bilirubin levels, liver failure, and death
  • Screen all patients for HBV infection by measuring HBsAg and anti-HBc before initiating treatment with GAZYVA. For patients who show evidence of hepatitis B infection (HBsAg positive [regardless of antibody status] or HBsAg negative but anti-HBc positive), consult healthcare providers with expertise in managing hepatitis B regarding monitoring and consideration for HBV antiviral therapy
  • Monitor patients with evidence of current or prior HBV infection for clinical and laboratory signs of hepatitis or HBV reactivation during and for several months following treatment with GAZYVA
  • In patients who develop reactivation of HBV while receiving GAZYVA, immediately discontinue GAZYVA and any concomitant chemotherapy and institute appropriate treatment. Resumption of GAZYVA in patients whose HBV reactivation resolves should be discussed with healthcare providers with expertise in managing hepatitis B. Insufficient data exist regarding the safety of resuming GAZYVA in patients who develop HBV reactivation
Progressive Multifocal Leukoencephalopathy (PML)
  • John Cunningham (JC) virus infection resulting in PML, which can be fatal, occurred in patients treated with GAZYVA in chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL). Consider the diagnosis of PML in any patient presenting with new onset or changes to, preexisting neurologic manifestations. Evaluation of PML includes, but is not limited to, consultation with a neurologist, brain MRI, and lumbar puncture. Discontinue GAZYVA therapy and consider discontinuation or reduction of any concomitant chemotherapy or immunosuppressive therapy in patients who develop PML
Infusion-Related Reactions
  • GAZYVA can cause severe and life-threatening infusion-related reactions (IRRs)
  • In patients with childhood onset INS, IRRs occurred predominantly during the first infusion of GAZYVA. All IRRs were mild to moderate and could be managed by slowing or temporarily halting the infusion. The most common IRR signs or symptoms reported in the INSHORE study were pyrexia, vomiting and nausea
  • Premedicate patients with acetaminophen, an antihistamine, and a glucocorticoid. Closely monitor patients during the entire infusion. Reduce infusion rate, interrupt infusion, or permanently discontinue GAZYVA for IRRs based on severity. Institute medical management (eg, glucocorticoids, epinephrine, bronchodilators, and/or oxygen) for IRRs as needed
  • For patients with preexisting cardiac or pulmonary conditions, monitor more frequently throughout the infusion and the post-infusion period, since they may be at greater risk of experiencing more severe reactions. Hypotension may occur as part of the IRR to GAZYVA. Consider withholding antihypertensive treatments for 12 hours prior to, during each GAZYVA infusion, and for the first hour after administration until blood pressure is stable. For patients at increased risk of hypertensive crisis, consider the benefits versus the risks of withholding their antihypertensive medication
Hypersensitivity Reactions Including Serum Sickness
  • Hypersensitivity reactions have been reported in patients treated with GAZYVA. Signs of immediate-onset hypersensitivity included dyspnea, bronchospasm, hypotension, urticaria, and tachycardia. Late-onset hypersensitivity diagnosed as serum sickness has also been reported, with symptoms that include chest pain, diffuse arthralgia, and fever. Hypersensitivity reactions may be difficult to clinically distinguish from IRRs. However, hypersensitivity very rarely occurs with the first infusion and, when observed, often occurs after previous exposure
  • If a hypersensitivity reaction is suspected during or after an infusion, stop the infusion and permanently discontinue treatment. GAZYVA is contraindicated in patients with known hypersensitivity reactions to GAZYVA, including serum sickness with prior GAZYVA use
Serious, Including Fatal, Infections
  • Fatal and serious bacterial, fungal, and new or reactivated viral infections can occur during and following GAZYVA therapy
  • In the INSHORE study, the incidence of Grade 3 (severe or medically significant) infections was 11% (5/44) in patients randomized to GAZYVA compared to 5% (2/41) in the mycophenolate mofetil arm. The most frequently reported Grade 3 infection related to study treatment in the GAZYVA arm was pneumonia (2/44 patients, 5%). No Grade 4 or Grade 5 (life-threatening or fatal) infections were reported in either arm
  • Do not administer GAZYVA to patients with an active infection. Patients with a history of recurring or chronic infections may be at increased risk of infection. In patients who develop a serious infection while receiving GAZYVA, immediately discontinue GAZYVA and institute appropriate treatment. Consider the risk and benefit of resuming treatment with GAZYVA following resolution of serious infections
Neutropenia
  • Severe and life-threatening neutropenia, including febrile neutropenia, has been reported during treatment with GAZYVA. Monitor patients with Grade 3 to 4 neutropenia frequently with regular laboratory tests until resolution. Anticipate, evaluate, and treat any symptoms or signs of developing infection. Consider dose delays for Grade 3 or 4 neutropenia. Consider administration of granulocyte colony-stimulating factors (GCSFs) in patients with Grade 3 or 4 neutropenia
  • Neutropenia can also be of late onset (occurring more than 28 days after completion of treatment) and/or prolonged (lasting longer than 28 days)
  • Patients with severe and long-lasting (>1 week) neutropenia are strongly recommended to receive antimicrobial prophylaxis until resolution of neutropenia to Grade 1 or 2. Consider antiviral and antifungal prophylaxis
Thrombocytopenia
  • Severe and life-threatening thrombocytopenia has been reported during treatment with GAZYVA in combination with chemotherapy. Fatal hemorrhagic events have been reported in patients with CLL treated with GAZYVA in combination with chemotherapy
  • Monitor patients frequently for thrombocytopenia and hemorrhagic events, and if clinically indicated, evaluate laboratory coagulation parameters. In patients with Grade 3 or 4 thrombocytopenia, monitor platelet counts more frequently until resolution and consider dose delays of GAZYVA and chemotherapy or dose reductions of chemotherapy. Transfusion of blood products (ie, platelet transfusion) may be necessary. Consider withholding concomitant medications that may increase bleeding risk (platelet inhibitors or anticoagulants), especially during the first cycle
Disseminated Intravascular Coagulation (DIC)
  • Fatal and severe DIC has been reported in patients receiving GAZYVA for CLL and NHL. The majority of DIC cases have involved changes in platelets and laboratory coagulation parameters following the first infusion, with spontaneous resolution usually occurring by Day 8. In some cases, DIC was associated with IRRs
  • In patients with suspected DIC, evaluate potential causes and monitor coagulation parameters, platelet counts, and for signs and symptoms of bleeding or thrombosis. Manage according to standard guidelines for DIC. Supportive care, including transfusion of blood products and other medical management, may be necessary
Immunization
  • The safety and efficacy of immunization with live or attenuated viral vaccines during or following GAZYVA therapy have not been studied. Immunization with live virus vaccines is not recommended during treatment with GAZYVA and until B-cell recovery
  • In patients with childhood-onset INS, administer all age-appropriate live vaccines at least 28 days prior to initiation of GAZYVA. Do not administer live virus vaccines during treatment or until B-cell recovery is confirmed. Monitor B-cell counts prior to resuming any live vaccination
Embryo-Fetal Toxicity
  • Based on its mechanism of action and findings in animals, GAZYVA can cause B-cell depletion in infants exposed to obinutuzumab in utero. Advise pregnant women of the potential risk to the fetus. Mothers who have been exposed to GAZYVA during pregnancy should discuss the safety and timing of live virus vaccinations for their infants with their child’s healthcare providers. Advise females of reproductive potential to use effective contraception while receiving GAZYVA and for 6 months after the last dose
Lactation
  • Human IgG is known to be present in human milk. Because of the potential of serious adverse reactions in the breastfed child, advise women not to breastfeed during treatment with GAZYVA and for 6 months after the last dose
Additional Important Safety Information
  • The most common adverse reactions (incidence ≥5%) observed in patients with childhood-onset INS in the GAZYVA arm were upper respiratory tract infection, infusion-related reactions, ear infection, pneumonia, influenza, neutropenia, bronchitis, COVID-19, conjunctivitis, and urinary tract infection
  • The most common serious adverse reactions in the GAZYVA arm were pneumonia (9.1%) and neutropenia (4.5%). No serious adverse reactions were reported for infusion-related reactions, upper respiratory tract infection and bronchitis.

You are encouraged to report side effects to Genentech and the FDA. You may contact Genentech by calling 1-888-835-2555. You may contact the FDA by visiting www.fda.gov/medwatch or calling 1-800-FDA-1088.

Please see the full Prescribing Information for additional Important Safety Information, including BOXED WARNINGS.

    • GAZYVA full Prescribing Information. Genentech, Inc.; 2026.

      GAZYVA full Prescribing Information. Genentech, Inc.; 2026.

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