Dosing & Uses
Dosage Forms & Strengths
Available as
- Single vial which contains 2 antibodies coformulated in a 1:1 ratio, OR
- Individual antibody solution in separate vials (supplied separately or in a dose pack)
injection, solution
- Casirivimab/imdevimab (600mg/600mg) per 10mL vial
- Casirivimab 1200mg/10mL vial; 300mg/2.5mL vial
- Imdevimab 1200mg/10mL vial; 300mg/2.5mL vial
COVID-19 (EUA)
Distribution paused
- January 24, 2022: Owing to the high frequency of the omicron variant, bamlanivimab and etesevimab are not currently authorized in any United States region
- In the future, if patients in certain geographic regions are likely to be infected or exposed to a variant that is susceptible to these treatments, then use of these treatments may be authorized in these regions
Treatment
- November 21, 2020: Emergency use authorization (EUA) issued by the FDA for treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults and pediatric patients aged ≥12 years weighing ≥40 kg with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progressing to severe COVID-19 and/or hospitalization
- IV infusion strongly recommended; SC injection is an alternative route of administration when IV infusion is not feasible and would lead to delay in treatment
- IV: Casirivimab 600 mg and imdevimab 600 mg administered together as a single IV infusion; must dilute before IV infusion
- SC: Casirivimab 600 mg and imdevimab 600 mg SC
- Administer as soon as possible after positive viral test for SARS-CoV-2 and within 10 days of symptom onset in patients at high risk for progressing to severe COVID-19 and/or hospitalization
Post-exposure prophylaxis
- August 27,2021: EUA issued by the FDA for postexposure prophylaxis of COVID-19 in adults and pediatric individuals aged ≥12 years weighing ≥40 kg who are at high risk for progression to severe COVID-19, including hospitalization or death, and are:
-
Not fully vaccinated or are not expected to mount an adequate immune response AND
- Were exposed to an infected individual with SARS-CoV-2 consistent with close contact criteria per Centers for Disease Control and Prevention (CDC), OR
- Are at high risk of exposure to an individual infected with SARS-CoV-2 because of occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting (eg, nursing homes, prisons)
- NOTE: Not authorized for preexposure prophylaxis to prevent COVID-19 before being exposed to the SARS-CoV-2 virus – only after exposure
- Initial dose: Casirivimab 600 mg and imdevimab 600 mg administered together as a single IV infusion or SC
-
Repeat dosing
- Consider repeat dosing in individuals with ongoing exposure to SARS-CoV-2 persisting >4 weeks and who are not expected to mount an adequate immune response to complete SARS-CoV-2 vaccination
- After initial dose (above), subsequent repeat dosing: Casirivimab 300 mg and imdevimab 300 mg IV or SC q4Weeks for duration of ongoing exposure
-
Examples of exposure
- Exposure to an individual infected with SARS-CoV-2 consistent with close contact criteria per CDC
- Those with high risk of exposure to an infected individual in same institutional setting (eg, nursing homes, prisons)
Dosage Modifications
Renal impairment
- Not eliminated intact in urine, thus renal impairment is not expected to affect systemic exposure
Hepatic impairment
- Unknown
Dosing Considerations
Circulating SARS-CoV-2 viral variants may be associated with resistance to monoclonal antibodies
Limitations of use
- Benefit of treatment not been observed in patients hospitalized due to COVID-19
- Monoclonal antibodies may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation
-
Not authorized for use in patients
- Who are hospitalized due to COVID-19, OR
- Who require oxygen therapy due to COVID-19, OR
- Who require an increase in baseline oxygen flow rate due to COVID-19 in those on long-term oxygen therapy due to underlying non-COVID-19-related comorbidity, OR
- Who would use as a substitute for vaccination against COVID-19
Patient selection
Other medical conditions or factors (for example, race or ethnicity) may also place individual patients at high risk for progression to severe COVID-19 and authorization of casirivimab and imdevimab under the EUA is not limited to the medical conditions or factors listed below
-
Medical conditions or other factors placing patients at higher risk for progressing to severe COVID-19
- Older age (eg, ≥65 yr)
- Obesity/overweight (BMI ≥25 kg/m2 [adults]; BMI ≥85th percentile for age/gender based on CDC growth charts [if aged 12-17 yr])
- Pregnancy
- Chronic kidney disease
- Diabetes
- Immunosuppressive disease or immunosuppressive treatment
- Cardiovascular disease (including congenital heart disease) or hypertension
- Chronic lung diseases (eg, COPD, moderate-to-severe asthma, interstitial lung disease, cystic fibrosis, pulmonary hypertension)
- Sickle cell disease
- Neurodevelopmental disorders (eg, cerebral palsy) or other conditions that confer medical complexity (eg, genetic or metabolic syndromes, severe congenital anomalies)
- Having a medical-related technological dependence (eg, tracheostomy, gastrostomy, positive pressure ventilation [not related to COVID 19])
- EUA is not limited to the medical conditions or factors listed above; for additional information on medical conditions and factors associated with increased risk for progression to severe COVID, see the CDC website
Dosage Forms & Strengths
Available as
- Single vial which contains 2 antibodies coformulated in a 1:1 ratio, OR
- Individual antibody solution in separate vials (supplied separately or in a dose pack)
injection, solution
- Casirivimab/imdevimab (600mg/600mg) per 10mL vial
- Casirivimab 1200mg/10mL vial; 300mg/2.5mL vial
- Imdevimab 1200mg/10mL vial; 300mg/2.5mL vial
COVID-19 (EUA)
Distribution paused
- January 24, 2022: Owing to the high frequency of the omicron variant, bamlanivimab and etesevimab are not currently authorized in any United States region
- In the future, if patients in certain geographic regions are likely to be infected or exposed to a variant that is susceptible to these treatments, then use of these treatments may be authorized in these regions
Treatment
- November 21, 2020: Emergency use authorization (EUA) issued by the FDA for treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults and pediatric patients aged ≥12 years weighing ≥40 kg with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progressing to severe COVID-19 and/or hospitalization
- IV infusion strongly recommended; SC injection is an alternative route of administration when IV infusion is not feasible and would lead to delay in treatment
- Casirivimab 600 mg and imdevimab 600 mg administered together as a single IV infusion; must dilute before IV infusion
- SC: Casirivimab 600 mg and imdevimab 600 mg SC
- Administer as soon as possible after positive viral test for SARS-CoV-2 and within 10 days of symptom onset in patients at high risk for progressing to severe COVID-19 and/or hospitalization
Post-exposure prophylaxis
- August 27,2021: EUA issued by the FDA for postexposure prophylaxis of COVID-19 in adults and pediatric individuals aged ≥12 years weighing ≥40 kg who are at high risk for progression to severe COVID-19, including hospitalization or death, and are:
-
Not fully vaccinated or are not expected to mount an adequate immune response AND
- Were exposed to an infected individual with SARS-CoV-2 consistent with close contact criteria per Centers for Disease Control and Prevention (CDC), OR
- Are at high risk of exposure to an individual infected with SARS-CoV-2 because of occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting (eg, nursing homes, prisons)
- NOTE: Not authorized for preexposure prophylaxis to prevent COVID-19 before being exposed to the SARS-CoV-2 virus – only after exposure
- Initial dose: Casirivimab 600 mg and imdevimab 600 mg administered together as a single IV infusion or SC
-
Repeat dosing
- Consider repeat dosing in individuals with ongoing exposure to SARS-CoV-2 persisting >4 weeks and who are not expected to mount an adequate immune response to complete SARS-CoV-2 vaccination
- After initial dose (above), subsequent repeat dosing: Casirivimab 300 mg and imdevimab 300 mg IV or SC q4Weeks for duration of ongoing exposure
-
Examples of exposure
- Exposure to an individual infected with SARS-CoV-2 consistent with close contact criteria per CDC
- Those with high risk of exposure to an infected individual in same institutional setting (eg, nursing homes, prisons)
Dosage Modifications
Renal impairment
- Not eliminated intact in urine, thus renal impairment is not expected to affect systemic exposure
Hepatic impairment
- Unknown
Dosing Considerations
Circulating SARS-CoV-2 viral variants may be associated with resistance to monoclonal antibodies
Limitations of use
- Benefit of treatment not been observed in patients hospitalized due to COVID-19
- Monoclonal antibodies may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation
-
Not authorized for use in patients
- Who are hospitalized due to COVID-19, OR
- Who require oxygen therapy due to COVID-19, OR
- Who require an increase in baseline oxygen flow rate due to COVID-19 in those on long-term oxygen therapy due to underlying non-COVID-19-related comorbidity, OR
- Who would use as a substitute for vaccination against COVID-19
Patient selection
Other medical conditions or factors (for example, race or ethnicity) may also place individual patients at high risk for progression to severe COVID-19 and authorization of casirivimab and imdevimab under the EUA is not limited to the medical conditions or factors listed below
-
Medical conditions or other factors placing patients at higher risk for progressing to severe COVID-19
- BMI ≥85th percentile for age/gender based on CDC growth charts [if aged 12-17 yr])
- Pregnancy
- Chronic kidney disease
- Diabetes
- Immunosuppressive disease or immunosuppressive treatment
- Cardiovascular disease (including congenital heart disease) or hypertension
- Chronic lung diseases (eg, COPD, moderate-to-severe asthma, interstitial lung disease, cystic fibrosis, pulmonary hypertension)
- Sickle cell disease
- Neurodevelopmental disorders (eg, cerebral palsy) or other conditions that confer medical complexity (eg, genetic or metabolic syndromes, severe congenital anomalies)
- Having a medical-related technological dependence (eg, tracheostomy, gastrostomy, positive pressure ventilation [not related to COVID 19])
- EUA is not limited to the medical conditions or factors listed above; for additional information on medical conditions and factors associated with increased risk for progression to severe COVID, see the CDC website
Adverse Effects
>10%
SC
- Injection site reactions (12%)
1-10%
IV
- Infusion-related reactions (1.5%)
Frequency Not Defined
IV or SC
- Pneumonia
- Hyperglycemia
- Nausea
- Vomiting
- Intestinal obstruction
- Dyspnea
- Anaphylactic reactions
Warnings
Contraindications
None
Cautions
Hypersensitivity
- Potential for serious hypersensitivity reaction, including anaphylaxis
- If signs and symptoms occur, immediately discontinue IV infusion and initiate appropriate medications and/or supportive care
- Infusion-related reactions reported, including fever, chills, nausea, headache, bronchospasm, hypotension, angioedema, throat irritation, rash including urticaria, pruritus, myalgia, dizziness
Severe COVID-19
- Treatment benefit not observed in patients hospitalized due to COVID-19
- Monoclonal antibodies may be associated with worse clinical outcomes when administered to hospitalized patients with COVID-19 requiring high-flow oxygen or mechanical ventilation
-
Therefore, casirivimab and imdevimab are not authorized for use in patients
- who are hospitalized due to COVID-19, OR
- who require oxygen therapy due to COVID-19, OR
- who require an increase in baseline oxygen flow rate due to COVID-19 in those on long-term oxygen therapy due to underlying non-COVID-19-related comorbidity
Viral variants
- Circulating SARS-CoV-2 viral variants may be associated with resistance to monoclonal antibodies
- Prescribing clinicians should consider prevalence of casirivimab/imdevimab resistant variants in their area
- Health care providers should review antiviral resistance information provided by state and local health departments
- Variant proportions circulating in the US can be monitored at the CDC website
Drug interaction overview
- Not renally excreted or metabolized by CYP450 enzymes
- Interactions with concomitant renally excreted drugs or drugs that are CYP450 substrates, inducers, or inhibitors are unlikely
Pregnancy & Lactation
Pregnancy
Insufficient data to evaluate drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes
Use during pregnancy only if the potential benefit outweighs the potential risk for the mother and fetus
Lactation
Data are unknown regarding presence in human or animal milk, effects on breastfed infants, or effects on milk production
Maternal IgG is known to be present in human milk
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Casirivimab (IgG1-kappa) and imdevimab (IgG1-lambda) are recombinant human mAbs, which are unmodified in the Fc regions
The mAbs bind to nonoverlapping epitopes of the spike protein receptor binding domain (RBD) of SARS-CoV-2, and thereby block binding to the human ACE2 receptor
Administration
IV Compatibilities
0.9% NaCl
Preparation
IV
Casirivimab and imdevimab IV solution are each supplied in individual single-dose vials and must be diluted before administration
Remove vials from refrigerated storage and allow to equilibrate to room temperature for ~20 minutes before preparation
Do not expose to direct heat; do not shake vials
Inspect for particulate matter and discoloration; solution should appear clear to slightly opalescent and colorless to pale yellow
Obtain prefilled IV bag containing 50 mL, 100 mL, 150 mL, or 250 mL of 0.9% NaCl
-
Coformulated vial
- 600 mg/600 mg dose: Add 10 mL into 0.9% NaCl infusion bag
- 300 mg/300 mg dose: Add 5 mL into 0.9% NaCl infusion bag
-
Individual vials
- 600 mg/600 mg dose: Add casirivimab 5 mL and imdevimab 5 mL from each respective vial using separate syringes and inject all 10 mL into 0.9% NaCl infusion bag
- 300 mg/300 mg dose: Add casirivimab 2.5 mL and imdevimab 2.5 mL from each respective vial using separate syringes and inject all 5 mL into 0.9% NaCl infusion bag
Discard any product remaining in the vial
Gently invert infusion bag by hand ~10 times to mix; do not shake
This product is preservative-free and therefore, diluted infusion solution should be administered immediately; refrigerate if not administered immediately administration is not possible
SC
Remove vial(s) from refrigerated storage and allow to equilibrate to room temperature for ~20 minutes before preparation
Do not expose to direct heat
Do not shake the vials
-
Coformulated vial
- 600 mg/600 mg dose: Withdraw 2.5 mL solution per syringe into 4 separate syringes
- 300 mg/300 mg dose: Withdraw 2.5 mL solution per syringe into 2 separate syringes
-
Individual vials
- 600 mg/600 mg dose: Withdraw casirivimab 2.5 mL per syringe into 2 separate syringes and then imdevimab 2.5 mL per syringe into 2 more separate syringes (total 4 syringes)
- 300 mg/300 mg dose: Withdraw casirivimab 2.5 mL into 1 syringes and then imdevimab 2.5 mL into 1 more separate syringes (total 2 syringes)
Replace the 21-gauge transfer needle with a 25-gauge or 27-gauge needle for SC injection
IV Administration
If refrigerated, allow diluted solution to equilibrate to room temperature for ~30 minutes before infusing
Infuse by PVC infusion set containing 0.20/0.22-micron in-line polyethersulfone (PES) filter
Attach infusion set to IV bag and prime infusion set
Maximum infusion rate
-
600 mg/600 mg dose
- 50-mL bag: 180 mL/hr (minimum time: 20 min)
- 100-mL bag: 310 mL/hr (minimum time: 23 min)
- 150-mL bag: 310 mL/hr (minimum time: 33 min)
- 250-mL bag: 310 mL/hr (minimum time: 52 min)
-
300 mg/300 mg dose
- 50-mL bag: 165 mL/hr (minimum time: 20 min)
- 100-mL bag: 310 mL/hr (minimum time: 20 min)
- 150-mL bag: 310 mL/hr (minimum time: 30 min)
- 250-mL bag: 310 mL/hr (minimum time: 49 min)
Flush line after infusion completed to ensure entire dose delivered
Discard unused product
Monitor during infusion and observe patients for at least 1 hr after infusion completed
SC Administration
Administer the 4 prepared SC injections consecutively, each at different injection sites, into thigh, back of upper arm, or abdomen, except for 2 inches (5 cm) around the navel; avoid waistline
Use different quadrants of abdomen or upper thighs or back of upper arms to space apart each 2.5 mL SC injection
DO NOT inject into skin that is tender, damaged, bruised, or scarred
Clinically monitor patients after injections and observe for at least 1 hr
Storage
Preservative-free product
Unopened vials
- Refrigerate unopened vials at 2-8ºC (36-46ºF) in original carton to protect from light
- Do not freeze, shake, or expose to direct light
Diluted solution
- Refrigerate at 2-8ºC (36-46ºF) for no more than 36 hr OR
- Store at room temperature up to 25ºC (77ºF) for no more than 4 hr
- These storage times include infusion time
Prepared SC syringes
Refrigerate at 2-8ºC (36-46ºF) for no more than 4 hr OR
Store at room temperature up to 25ºC (77ºF) for no more than 4 hr
If refrigerated, allow the syringes to equilibrate to room temperature for ~20 minutes before administration