Avelumab

1 INDICATIONS AND USAGE BAVENCIO is a programmed death ligand-1 (PD-L1) blocking antibody indicated for: Merkel Cell Carcinoma (MCC) Adults and pediatric patients 12 years and older with metastatic MCC. ( 1.1 , 14.1 ) Urothelial Carcinoma (UC) Maintenance treatment of patients with locally advanced or metastatic UC that has not progressed with first-line platinum-containing chemotherapy. ( 1.2 , 14.2 ) Patients with locally advanced or metastatic UC who: Have disease progression during or following platinum-containing chemotherapy. ( 1.2 , 14.2 ) Have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. ( 1.2 , 14.2 ) Renal Cell Carcinoma (RCC) First-line treatment, in combination with axitinib, of patients with advanced RCC. ( 1.3 , 14.3 ) 1.1 Metastatic Merkel Cell Carcinoma BAVENCIO (avelumab) is indicated for the treatment of adults and pediatric patients 12 years and older with metastatic Merkel cell carcinoma (MCC) [see Clinical Studies (14.1) ] . 1.2 Locally Advanced or Metastatic Urothelial Carcinoma First-Line Maintenance Treatment of Urothelial Carcinoma BAVENCIO is indicated for the maintenance treatment of patients with locally advanced or metastatic urothelial carcinoma (UC) that has not progressed with first-line platinum-containing chemotherapy [see Clinical Studies (14.2) ] . Previously-treated Urothelial Carcinoma BAVENCIO is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma (UC) who: Have disease progression during or following platinum-containing chemotherapy Have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy [see Clinical Studies (14.2) ]. 1.3 Advanced Renal Cell Carcinoma BAVENCIO in combination with axitinib is indicated for the first-line treatment of patients with advanced renal cell carcinoma (RCC) [see Clinical Studies (14.3) ] .

2 DOSAGE AND ADMINISTRATION Premedicate for the first 4 infusions and subsequently as needed. ( 2.1 ) Merkel Cell Carcinoma : 800 mg every 2 weeks. ( 2.2 ) Urothelial Carcinoma ; 800 mg every 2 weeks. ( 2.3 ) Renal Cell Carcinoma : 800 mg every 2 weeks in combination with axitinib 5 mg orally twice daily. ( 2.4 ) Administer BAVENCIO as an intravenous infusion over 60 minutes. 2.1 Premedication Premedicate patients with an antihistamine and with acetaminophen prior to the first 4 infusions of BAVENCIO. Premedication should be administered for subsequent BAVENCIO doses based upon clinical judgment and presence/severity of prior infusion reactions [see Dosage and Administration (2.5) and Warnings and Precautions (5.2) ]. 2.2 Recommended Dosage for MCC The recommended dosage of BAVENCIO is 800 mg administered as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. 2.3 Recommended Dosage for UC The recommended dosage of BAVENCIO is 800 mg administered as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. 2.4 Recommended Dosage for RCC The recommended dosage of BAVENCIO is 800 mg administered as an intravenous infusion over 60 minutes every 2 weeks in combination with axitinib 5 mg orally taken twice daily (12 hours apart) with or without food until disease progression or unacceptable toxicity. When axitinib is used in combination with BAVENCIO, dose escalation of axitinib above the initial 5 mg dose may be considered at intervals of two weeks or longer. Review the Full Prescribing Information for axitinib prior to initiation. 2.5 Dose Modifications No dose reduction for BAVENCIO is recommended. In general, withhold BAVENCIO for severe (Grade 3) immune-mediated adverse reactions. Permanently discontinue BAVENCIO for life-threatening (Grade 4) immune-mediated adverse reactions, recurrent severe (Grade 3) immune-mediated reactions that require systemic immunosuppressive treatment, or an inability to reduce corticosteroid dose to 10 mg or less of prednisone or equivalent per day within 12 weeks of initiating corticosteroids. Dosage modifications for BAVENCIO for adverse reactions that require management different from these general guidelines are summarized in Table 1. Table 1: Recommended Monotherapy Dosage Modifications for Adverse Reactions Adverse Reaction Severity Based on Common Terminology Criteria for Adverse Events (CTCAE), version 4.03 Dosage Modification ALT = alanine aminotransferase, AST = aspartate aminotransferase, ULN = upper limit normal, SJS = Stevens-Johnson syndrome, TEN = toxic epidermal necrosis, DRESS = drug rash with eosinophilia and systemic symptoms Immune-Mediated Adverse Reactions [see Warnings and Precautions (5.1) ] Pneumonitis Grade 2 Withhold Resume in patients with complete or partial resolution (Grade 0 to 1) after corticosteroid taper. Permanently discontinue if no complete or partial resolution within 12 weeks of last dose or inability to reduce prednisone to 10 mg per day or less (or equivalent) within 12 weeks of initiating corticosteroids. Grade 3 or 4 Permanently discontinue Colitis Grade 2 or 3 Withhold Grade 4 Permanently discontinue Hepatitis with no tumor involvement of the liver For liver enzyme elevations in patients treated with combination therapy, see Table 2 AST or ALT increases to more than 3 and up to 8 times ULN or Total bilirubin increases to more than 1.5 and up to 3 times ULN Withhold AST or ALT increases to more than 8 times ULN or Total bilirubin increases to more than 3 times ULN Permanently discontinue Hepatitis with tumor involvement of the liver If AST and ALT are less than or equal to ULN at baseline, withhold or permanently discontinue BAVENCIO based on recommendations for hepatitis where there is no tumor involvement of the liver. Baseline AST or ALT is more than 1 and up to 3 times ULN and increases to more than 5 and up to 10 times ULN or Baseline AST or ALT is more than 3 and up to 5 times ULN and increases to more than 8 and up to 10 times ULN Withhold AST or ALT increases to more than 10 times ULN or Total bilirubin increases to more than 3 times ULN Permanently discontinue Endocrinopathies Grade 3 or 4 Withhold until clinically stable or permanently discontinue depending on severity Nephritis with Renal Dysfunction Grade 2 or 3 increased blood creatinine Withhold Grade 4 increased blood creatinine Permanently discontinue Exfoliative Dermatologic Conditions Suspected SJS, TEN, or DRESS Withhold Confirmed SJS, TEN, or DRESS Permanently discontinue Myocarditis Grade 2, 3 or 4 Permanently discontinue Neurological Toxicities Grade 2 Withhold Grade 3 or 4 Permanently discontinue Other Adverse Reactions Infusion-related reactions [see Warnings and Precautions (5.2) ] Grade 1 or 2 Interrupt or slow the rate of infusion Grade 3 or 4 Permanently discontinue Table 2 presents dosage modifications that are different from those described above in Table 1 for BAVENCIO used as monotherapy or in the Full Prescribing Information for the drug administered in combination. Table 2: Recommended Specific Dosage Modifications for Adverse Reactions for Combination Therapy [see Warnings and Precautions (5.1) ] Treatment Adverse Reaction Severity Based on Common Terminology Criteria for Adverse Events (CTCAE), version 4.03 Dosage Modification BAVENCIO in combination with axitinib Liver enzyme elevations ALT or AST at least 3 times ULN but less than 10 times ULN without concurrent total bilirubin at least 2 times ULN Withhold both BAVENCIO and axitinib until adverse reactions recover to Grades 0-1 Consider corticosteroid therapy Consider rechallenge with BAVENCIO or axitinib or sequential rechallenge with both BAVENCIO and axitinib after recovery Dose reduction according to the axitinib Full Prescribing Information should be considered if rechallenging with axitinib. ALT or AST at least 10 times ULN or more than 3 times ULN with concurrent total bilirubin at least 2 times ULN Permanently discontinue both BAVENCIO and axitinib 2.6 Preparation and Administration Preparation Visually inspect vial for particulate matter and discoloration. BAVENCIO is a clear, colorless to slightly yellow solution. Discard vial if the solution is cloudy, discolored, or contains particulate matter. Withdraw the required volume of BAVENCIO from the vial(s) and inject it into a 250 mL infusion bag containing either 0.9% Sodium Chloride Injection or 0.45% Sodium Chloride Injection. Gently invert the bag to mix the diluted solution and avoid foaming or excessive shearing. Inspect the solution to ensure it is clear, colorless, and free of visible particles. Discard any partially used or empty vials. Storage of diluted BAVENCIO solution Protect from light. Store diluted BAVENCIO solution: At room temperature up to 77°F (25°C) for no more than 4 hours from the time of dilution. Or Under refrigeration at 36°F to 46°F (2°C to 8°C) for no more than 24 hours from the time of dilution. If refrigerated, allow the diluted solution to come to room temperature prior to administration. Do not freeze or shake diluted solution. Administration Administer the diluted solution over 60 minutes through an intravenous line containing a sterile, non-pyrogenic, low protein binding in-line filter (pore size of 0.2 micron). Do not co-administer other drugs through the same intravenous line.

6 ADVERSE REACTIONS The following clinically significant adverse reactions are described elsewhere in the labeling: Severe and fatal immune-mediated adverse reactions [see Warnings and Precautions (5.1) ] Infusion-related reactions [see Warnings and Precautions (5.2) ] Complications of allogeneic HSCT [see Warnings and Precautions (5.3) ] Major adverse cardiovascular events [see Warnings and Precautions (5.4) ] Most common adverse reactions (≥ 20%) in patients were: MCC : Fatigue, musculoskeletal pain, infusion-related reaction, rash, nausea, constipation, cough, and diarrhea. ( 6.1 ) UC : Maintenance treatment: fatigue, musculoskeletal pain, urinary tract infection, and rash. ( 6.1 ) Previously-treated: fatigue, infusion-related reaction, musculoskeletal pain, nausea, decreased appetite, and urinary tract infection. ( 6.1 ) RCC (with axitinib) : diarrhea, fatigue, hypertension, musculoskeletal pain, nausea, mucositis, palmar-plantar erythrodysesthesia, dysphonia, decreased appetite, hypothyroidism, rash, hepatotoxicity, cough, dyspnea, abdominal pain, and headache. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact EMD Serono at 1-800-283-8088 ext. 5563 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 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 data described in the WARNINGS AND PRECAUTIONS section reflect exposure to BAVENCIO 10 mg/kg intravenously every 2 weeks as a single agent in 1854 patients enrolled in the JAVELIN Merkel 200 and JAVELIN Solid Tumor trials and to BAVENCIO 10 mg/kg intravenously every 2 weeks in combination with axitinib 5 mg orally twice daily in 489 patients enrolled in the JAVELIN Renal 100 and JAVELIN Renal 101 trials. In the BAVENCIO monotherapy population, 25% of patients were exposed for ≥ 6 months and 9% were exposed for ≥ 12 months. The population characteristics of BAVENCIO in combination with axitinib are shown below. When BAVENCIO was used in combination with axitinib, 70% of patients were exposed for ≥ 6 months and 31% were exposed for ≥ 12 months. The following criteria were used to classify an adverse reaction as immune-mediated: onset within 90 days after last dose of BAVENCIO, no spontaneous resolution within 7 days of onset, treatment with corticosteroids or other immunosuppressant or hormone replacement therapy, biopsy consistent with immune-mediated reaction, and no other clear etiology. Metastatic Merkel Cell Carcinoma The safety of BAVENCIO was evaluated in 204 patients enrolled in the JAVELIN Merkel 200 trial with metastatic MCC. Patients received BAVENCIO 10 mg/kg intravenously every 2 weeks or 800 mg intravenously every 2 weeks until disease progression or unacceptable toxicity. The median duration of exposure to BAVENCIO was 4.1 months (range: 2 weeks to 48 months). [see Clinical Studies (14.1) ] . Serious adverse reactions occurred in 52% of patients receiving BAVENCIO. The most frequent serious adverse reactions (≥ 2% of patients) were general physical health deterioration, anemia, abdominal pain, acute kidney injury, sepsis, hyponatremia, and infusion-related reaction. Permanent discontinuation of BAVENCIO due to an adverse reaction occurred in 27% of patients. The most frequent adverse reactions (> 1% of patients) that resulted in permanent discontinuation were infusion-related reaction, anemia, increased ALT, and increased AST. Dosage interruptions of BAVENCIO due to an adverse reaction, excluding temporary interruptions due to infusion-related reactions, occurred in 29% of patients. The most frequent adverse reactions (> 1% of patients) that required dosage interruption were nasopharyngitis, anemia, diarrhea, lung infection, and ALT increased. The most common adverse reactions (≥ 20%) that occurred in patients receiving BAVENCIO were fatigue, musculoskeletal pain, infusion-related reaction, rash, nausea, constipation, cough, and diarrhea. Table 3 and Table 4 summarize the adverse reactions and laboratory abnormalities, respectively, that occurred in patients receiving BAVENCIO. Table 3: Adverse Reactions in ≥ 10% of Patients with Metastatic MCC Receiving BAVENCIO in the JAVELIN Merkel 200 Trial Adverse Reactions BAVENCIO (N=204) All Grades % Grade 3-4 % General Disorders Fatigue Includes fatigue and asthenia. 47 2.9 Infusion-related reaction Includes infusion-related reaction, chills, pyrexia, back pain, hypotension, drug hypersensitivity, dyspnea, flushing and hypersensitivity. 26 0.5 Edema Includes peripheral edema, peripheral swelling, and genital edema. 17 0 Musculoskeletal and Connective Tissue Disorders Musculoskeletal pain Includes musculoskeletal pain, back pain, pain in extremity, myalgia, musculoskeletal pain, and neck pain. 29 1.5 Arthralgia 13 0.5 Skin and Subcutaneous Tissue Disorders Rash Includes rash, erythema, rash maculo-papular, rash pruritic, dermatitis bullous, rash erythematous, and rash macular. 25 0 Pruritus Includes pruritus and pruritus generalized. 16 0.5 Gastrointestinal Disorders Nausea 23 0 Constipation 22 0.5 Diarrhea Includes diarrhea and colitis. 21 1 Abdominal pain Includes abdominal pain, abdominal pain upper, and abdominal pain lower. 16 3.4 Vomiting 12 1 Respiratory, Thoracic and Mediastinal Disorders Cough 22 0 Dyspnea Includes dyspnea and dyspnea exertional. 15 1 Metabolism and Nutrition Disorders Decreased appetite 18 3.4 Decreased weight 16 0.5 Vascular Disorders Hypertension 11 6 Other clinically significant adverse reactions in < 10% of patients receiving BAVENCIO in the JAVELIN Merkel 200 trial were dizziness, headache, transaminase increased, creatine phosphokinase increased, and tubulointerstitial nephritis. Table 4: Laboratory Abnormalities Worsening from Baseline Occurring in ≥ 20% of Patients with Metastatic MCC Receiving BAVENCIO in the JAVELIN Merkel 200 Trial Laboratory Tests Any Grade % Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available (range: 185 to 199 patients). Grade 3-4 % Hematology Lymphocyte count decreased 51 16 Hemoglobin decreased 40 6 Platelet count decreased 23 1.5 Chemistry Aspartate aminotransferase (AST) increased 31 3 Alanine aminotransferase (ALT) increased 22 3.5 Lipase increased 21 5 Locally Advanced or Metastatic Urothelial Carcinoma First-Line Maintenance Treatment of Urothelial Carcinoma The safety of BAVENCIO was evaluated in the JAVELIN Bladder 100 trial where patients received BAVENCIO 10 mg/kg every 2 weeks plus best supportive care (BSC) (N=344) or BSC alone (N=345). Patients with autoimmune diseases or conditions requiring systemic immunosuppression were excluded. In the BAVENCIO plus BSC arm, 47% were exposed to BAVENCIO for > 6 months and 28% were exposed for > 1 year [see Clinical Studies (14.2) ] . The median age of patients treated with BAVENCIO plus BSC was 69 years (range: 37 to 90), 63% of patients were 65 years or older, 76% were male, 67% were White, and the ECOG performance score was 0 (61%) or 1 (39%). A fatal adverse reaction (sepsis) occurred in one (0.3%) patient receiving BAVENCIO plus BSC. Serious adverse reactions occurred in 28% of patients receiving BAVENCIO plus BSC. Serious adverse reactions in ≥ 1% of patients included urinary tract infection (including kidney infection, pyelonephritis, and urosepsis) (6.1%), pain (including abdominal, back, bone, flank, extremity, and pelvic pain) (3.2%), acute kidney injury (1.7%), hematuria (1.5%), sepsis (1.2%), and infusion-related reaction (1.2%). Permanent discontinuation due to an adverse reaction of BAVENCIO plus BSC occurred in 12% of patients. Adverse reactions resulting in permanent discontinuation of BAVENCIO in > 1% of patients were myocardial infarction (including acute myocardial infarction and troponin T increased) (1.5%) and infusion-related reaction (1.2%). Dose interruptions due to an adverse reaction, excluding temporary interruptions of BAVENCIO infusions due to infusion-related reactions, occurred in 41% of patients receiving BAVENCIO plus BSC. Adverse reactions leading to interruption of BAVENCIO in > 2% of patients were urinary tract infection (including pyelonephritis) (4.7%) and blood creatinine increased (including acute kidney injury, renal impairment, and renal failure) (3.8%). The most common adverse reactions (≥ 20%) in patients receiving BAVENCIO plus BSC were fatigue, musculoskeletal pain, urinary tract infection, and rash. Thirty-one (9%) patients treated with BAVENCIO plus BSC received an oral prednisone dose equivalent to ≥ 40 mg daily for an immune-mediated adverse reaction [see Warnings and Precautions (5) ] . Table 5 summarizes adverse reactions that occurred in ≥ 10% of patients treated with BAVENCIO plus BSC. Table 5: Adverse Reactions (≥ 10%) of Patients Receiving BAVENCIO plus BSC (JAVELIN Bladder 100 Trial) Adverse Reactions BAVENCIO plus BSC (N=344) BSC (N=345) All Grades % Grade 3-4 % All Grades % Grade 3-4 % General Disorders and Administration Site Conditions Fatigue Fatigue is a composite term that includes fatigue, asthenia and malaise. 35 1.7 13 1.7 Pyrexia 15 0.3 3.5 0 Musculoskeletal and Connective Tissue Disorders Musculoskeletal pain Musculoskeletal pain is a composite term that includes musculoskeletal pain, back pain, myalgia, and neck pain. 24 1.2 15 2.6 Arthralgia 16 0.6 6 0 Skin and Subcutaneous Tissue Disorders Rash Rash is a composite term that includes rash, rash maculo-papular, erythema, dermatitis acneiform, eczema, erythema multiforme, rash erythematous, rash macular, rash papular, rash pruritic, drug eruption and lichen planus. 20 1.2 2.3 0 Pruritus 17 0.3 1.7 0 Infections and Infestations Urinary tract infection Urinary tract infection is a composite term that includes urinary tract infection, urosepsis, cystitis, kidney infection, pyuria, pyelonephritis, bacteriuria, pyelonephritis acute, urinary tract infection bacterial, and Escherichia urinary tract infection. 20 6 11 3.8 Gastrointestinal Disorders Diarrhea 17 0.6 4.9 0.3 Constipation 16 0.6 9.0 0 Nausea 16 0.3 6 0.6 Vomiting 13 1.2 3.5 0.6 Respiratory, Thoracic and Mediastinal Disorders Cough Cough is a composite term that includes cough and productive cough. 14 0.3 4.6 0 Metabolism and Nutrition Disorders Decreased appetite 14 0.3 7 0.6 Endocrine disorders Hypothyroidism 12 0.3 0.6 0 Injury, Poisoning and Procedural Complications Infusion-related reaction 10 0.9 0 0 Patients received pre-medication with an anti-histamine and acetaminophen prior to each infusion. Infusion-related reactions occurred in 10% (Grade 3: 0.9%) of patients treated with BAVENCIO plus BSC. Table 6: Selected Laboratory Abnormalities Worsening from Baseline Occurring in ≥ 10% of Patients Receiving BAVENCIO plus BSC (JAVELIN Bladder 100 Trial) Laboratory Abnormality BAVENCIO plus BSC Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: BAVENCIO plus BSC group (range: 339 to 344 patients) and BSC group (range: 329 to 341 patients). BSC Any Grade % Grade 3-4 % Any Grade % Grade 3-4 % Chemistry Blood triglycerides increased 34 2.1 28 1.2 Alkaline phosphatase increased 30 2.9 20 2.3 Blood sodium decreased 28 6 20 2.6 Lipase increased 25 8 16 6 Aspartate aminotransferase (AST) increased 24 1.7 12 0.9 Blood potassium increased 24 3.8 16 0.9 Alanine aminotransferase (ALT) increased 24 2.6 12 0.6 Blood cholesterol increased 22 1.2 16 0.3 Serum amylase increased 21 5 12 1.8 CPK increased 19 2.4 12 0 Phosphate decreased 19 3.2 15 1.2 Hematology Hemoglobin decreased 28 4.4 18 3.2 White blood cell decreased 20 0.6 10 0 Platelet count decreased 18 0.6 12 0.3 Previously-treated Urothelial Carcinoma The safety of BAVENCIO was evaluated in 242 patients with locally advanced or metastatic UC receiving BAVENCIO at 10 mg/kg every 2 weeks in the UC cohorts of the JAVELIN Solid Tumor trial. Patients received pre-medication with an anti-histamine and acetaminophen prior to each infusion. The median duration of exposure to BAVENCIO was 12 weeks (range: 2 weeks to 92 weeks) [see Clinical Studies (14.2) ] . Fourteen patients (6%) who were treated with BAVENCIO experienced either pneumonitis, respiratory failure, sepsis/urosepsis, cerebrovascular accident, or gastrointestinal adverse events, which led to death. Grade 1-4 serious adverse reactions were reported in 41% of patients. The most frequent serious adverse reactions reported in ≥ 2% of patients were urinary tract infection/urosepsis, abdominal pain, musculoskeletal pain, creatinine increased/renal failure, dehydration, hematuria/urinary tract hemorrhage, intestinal obstruction/small intestine obstruction, and pyrexia. Permanent discontinuation due to an adverse reaction for BAVENCIO occurred in 12% of patients. The adverse reaction that resulted in permanent discontinuation in > 1% of patients was fatigue. Dose interruptions due to an adverse reaction, excluding temporary interruptions due to infusion-related reactions, occurred in 29% of patients receiving BAVENCIO. Adverse reactions leading to interruption of BAVENCIO in > 1% of patients were diarrhea, fatigue, dyspnea, urinary tract infection, and rash. The most common Grade 3 and 4 adverse reactions (≥ 3%) were anemia, fatigue, hyponatremia, hypertension, urinary tract infection, and musculoskeletal pain. The most common adverse reactions (≥ 20%) were fatigue, infusion-related reaction, musculoskeletal pain, nausea, decreased appetite, and urinary tract infection. Eleven (4.5%) patients received an oral prednisone dose equivalent to ≥ 40 mg daily for an immune-mediated adverse reaction [see Warnings and Precautions (5) ]. Advanced Renal Cell Carcinoma The safety of BAVENCIO was evaluated in JAVELIN Renal 101. Patients with autoimmune disease other than type I diabetes mellitus, vitiligo, psoriasis, or thyroid disorders not requiring immunosuppressive treatment were excluded. Patients received BAVENCIO 10 mg/kg every 2 weeks administered in combination with axitinib 5 mg twice daily (N=434) or sunitinib 50 mg once daily for 4 weeks followed by 2 weeks off (N=439). In the BAVENCIO plus axitinib arm, 70% were exposed to BAVENCIO for ≥ 6 months and 29% were exposed for ≥ 1 year in JAVELIN Renal 101 [see Clinical Studies (14.3) ]. The median age of patients treated with BAVENCIO in combination with axitinib was 62 years (range: 29 to 83), 38% of patients were 65 years or older, 71% were male, 75% were White, and the ECOG performance score was 0 (64%) or 1 (36%). Fatal adverse reactions occurred in 1.8% of patients receiving BAVENCIO in combination with axitinib. These included sudden cardiac death (1.2%), stroke (0.2%), myocarditis (0.2%), and necrotizing pancreatitis (0.2%). Serious adverse reactions occurred in 35% of patients receiving BAVENCIO in combination with axitinib. Serious adverse reactions in ≥ 1% of patients included diarrhea (2.5%), dyspnea (1.8%), hepatotoxicity (1.8%), venous thromboembolic disease (1.6%), acute kidney injury (1.4%), and pneumonia (1.2%). Permanent discontinuation due to an adverse reaction of either BAVENCIO or axitinib occurred in 22% of patients: 19% BAVENCIO only, 13% axitinib only, and 8% both drugs. The most common adverse reactions (> 1%) resulting in permanent discontinuation of BAVENCIO or the combination were hepatotoxicity (6%) and infusion-related reaction (1.8%). Dose interruptions or reductions due to an adverse reaction, excluding temporary interruptions of BAVENCIO infusions due to infusion-related reactions, occurred in 76% of patients receiving BAVENCIO in combination with axitinib. This includes interruption of BAVENCIO in 50% of patients. Axitinib was interrupted in 66% and dose reduced in 19% of patients. The most common adverse reaction (> 10%) resulting in interruption of BAVENCIO was diarrhea (10%) and the most common adverse reactions resulting in either interruption or dose reduction of axitinib were diarrhea (19%), hypertension (18%), palmar-plantar erythrodysesthesia (18%), and hepatotoxicity (10%). The most common adverse reactions (≥ 20%) in patients receiving BAVENCIO in combination with axitinib were diarrhea, fatigue, hypertension, musculoskeletal pain, nausea, mucositis, palmar-plantar erythrodysesthesia, dysphonia, decreased appetite, hypothyroidism, rash, hepatotoxicity, cough, dyspnea, abdominal pain, and headache. Forty-eight (11%) patients treated with BAVENCIO in combination with axitinib received an oral prednisone dose equivalent to ≥ 40 mg daily for an immune-mediated adverse reaction [see Warnings and Precautions (5) ] . Table 7 summarizes adverse reactions that occurred in ≥ 20% of BAVENCIO in combination with axitinib-treated patients. Table 7: Adverse Reactions (≥ 20%) of Patients Receiving BAVENCIO in Combination with Axitinib (JAVELIN Renal 101 Trial) Adverse Reactions BAVENCIO plus Axitinib (N=434) Sunitinib (N=439) All Grades % Grade 3-4 % All Grades % Grade 3-4 % Gastrointestinal Disorders Diarrhea Diarrhea is a composite term that includes diarrhea, autoimmune colitis, and colitis. 62 8 48 2.7 Nausea 34 1.4 39 1.6 Mucositis Mucositis is a composite term that includes mucosal inflammation and stomatitis. 34 2.8 35 2.1 Hepatotoxicity Hepatotoxicity is a composite term that includes ALT increased, AST increased, autoimmune hepatitis, bilirubin conjugated, bilirubin conjugated increased, blood bilirubin increased, drug-induced liver injury, hepatic enzyme increased, hepatic function abnormal, hepatitis, hepatitis fulminant, hepatocellular injury, hepatotoxicity, hyperbilirubinemia, immune-mediated hepatitis, liver function test increased, liver disorder, liver injury, and transaminases increased. 24 9 18 3.6 Abdominal pain Abdominal pain is a composite term that includes abdominal pain, flank pain, abdominal pain upper, and abdominal pain lower. 22 1.4 19 2.1 General Disorders and Administration Site Conditions Fatigue Fatigue is a composite term that includes fatigue and asthenia. 53 6 54 6 Vascular Disorders Hypertension Hypertension is a composite term that includes hypertension and hypertensive crisis. 50 26 36 17 Musculoskeletal and Connective Tissue Disorders Musculoskeletal pain Musculoskeletal pain is a composite term that includes musculoskeletal pain, musculoskeletal chest pain, myalgia, back pain, bone pain, musculoskeletal discomfort, neck pain, spinal pain, and pain in extremity. 40 3.2 33 2.7 Skin and Subcutaneous Tissue Disorders Palmar-plantar erythrodysesthesia 33 6 34 4 Rash Rash is a composite term that includes rash, rash generalized, rash macular, rash maculo-papular, rash pruritic, rash erythematous, rash papular, and rash pustular. 25 0.9 16 0.5 Respiratory, Thoracic and Mediastinal Disorders Dysphonia 31 0.5 3.2 0 Dyspnea Dyspnea is a composite term that includes dyspnea, dyspnea exertional and dyspnea at rest. 23 3 16 1.8 Cough 23 0.2 19 0 Metabolism and Nutrition Disorders Decreased appetite 26 2.1 29 0.9 Endocrine Disorders Hypothyroidism 25 0.2 14 0.2 Nervous System Disorders Headache 21 0.2 16 0.2 Other clinically important adverse reactions that occurred in less than 20% of patients in JAVELIN Renal 101 included arthralgia, weight decreased, and chills. Patients received pre-medication with an anti-histamine and acetaminophen prior to each infusion. Infusion-related reactions occurred in 12% (Grade 3: 1.6%; no Grade 4) of patients treated with BAVENCIO in combination with axitinib. Table 8 summarizes selected laboratory abnormalities that occurred in ≥ 20% of BAVENCIO in combination with axitinib-treated patients. Table 8: Selected Laboratory Abnormalities Worsening from Baseline Occurring in ≥ 20% of Patients Receiving BAVENCIO in Combination with Axitinib (JAVELIN Renal 101 Trial) Laboratory Abnormality BAVENCIO plus Axitinib Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: BAVENCIO in combination with axitinib group (range: 413 to 428 patients) and sunitinib group (range: 405 to 433 patients). Sunitinib Any Grade % Grade 3-4 % Any Grade % Grade 3-4 % Chemistry Blood triglycerides increased 71 13 48 5 Blood creatinine increased 62 2.3 68 1.4 Blood cholesterol increased 57 1.9 22 0.7 Alanine aminotransferase increased (ALT) 50 9 46 3.2 Aspartate aminotransferase increased (AST) 47 7 57 3.2 Blood sodium decreased 38 9 37 10 Lipase increased 37 14 25 7 Blood potassium increased 35 3 28 3.9 Blood bilirubin increased 21 1.4 23 1.4 Hematology Platelet count decreased 27 0.7 80 15 Hemoglobin decreased 21 2.1 65 8 6.2 Postmarketing Experience The following adverse reactions have been identified during postapproval use of BAVENCIO. 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. Blood and lymphatic system disorders: neutropenia Hepatobiliary disorders : sclerosing cholangitis

12.3 Pharmacokinetics The pharmacokinetics (PK) of avelumab as a single agent was characterized in patients who received BAVENCIO at doses ranging from 1 to 20 mg/kg every 2 weeks (0.1 to 2 times of the approved recommended dosage). The exposure of avelumab increased dose-proportionally from 10 to 20 mg/kg every 2 weeks. Steady-state concentrations of avelumab were reached after approximately 4 to 6 weeks (2 to 3 cycles) and the systemic accumulation was 1.25-fold. Distribution The mean volume of distribution at steady state after patients received a dose of 10 mg/kg was 4.7 L (coefficient of variation (% CV) of 44%). Elimination The primary elimination mechanism of avelumab is proteolytic degradation. The total systemic clearance (% CV) was 0.59 L/day (25%) and the terminal half-life (% CV) was 6.1 days (92%) in patients who received a dose of 10 mg/kg every 2 weeks. Avelumab clearance decreased over time in patients with MCC, with a mean maximal reduction (CV%) from baseline value of approximately 32% (36%), which is not considered clinically important. A change of avelumab clearance over time was not observed in patients with UC or with RCC. Specific Populations No clinically meaningful differences in pharmacokinetics were observed in the clearance of avelumab based on age; body weight; sex; race; PD-L1 status; tumor burden; mild to severe renal impairment (calculated creatinine clearance of 89 to 15 mL/min, as estimated by the Cockcroft-Gault formula), and mild or moderate hepatic impairment (bilirubin less than or equal to 3 times ULN). The effect of severe hepatic impairment (bilirubin greater than 3 times ULN) on the pharmacokinetics of avelumab is unknown. Drug Interactions BAVENCIO with axitinib: Avelumab PK was assessed following administration of BAVENCIO in combination with axitinib. There are no clinically meaningful differences in exposure of avelumab when administered in combination with axitinib.