pembrolizumab

Medical uses

In the United States, pembrolizumab is indicated for the treatment of melanoma, non-small-cell lung cancer, malignant pleural mesothelioma, head and neck squamous-cell cancer, classical Hodgkin lymphoma, primary mediastinal large B-cell lymphoma, urothelial cancer, microsatellite instability-high or mismatch repair deficient cancer, microsatellite instability-high or mismatch repair deficient colorectal cancer, gastric cancer, esophageal cancer, cervical cancer, hepatocellular carcinoma, biliary tract cancer, Merkel-cell carcinoma, renal cell carcinoma, endometrial carcinoma, tumor mutational burden-high cancer, cutaneous squamous cell carcinoma, and triple-negative breast cancer.

As of 2019, pembrolizumab is used via intravenous infusion to treat inoperable or metastatic melanoma, metastatic non-small cell lung cancer (NSCLC) in certain situations, as a first-line treatment for metastatic bladder cancer in people who cannot receive cisplatin-based chemotherapy and have high levels of PD-L1, as a second-line treatment for head and neck squamous cell carcinoma (HNSCC), after platinum-based chemotherapy, for the treatment of people with refractory classic Hodgkin lymphoma, and recurrent locally advanced or metastatic esophageal squamous cell carcinoma.

For non-small cell lung cancer, pembrolizumab is used in combination with chemotherapy (for all PD-L1, a PD-1 receptor ligand, levels) or by itself as a first-line treatment if the cancer expresses (≥ 1%) PD-L1 and the cancer has no mutations in EGFR or in ALK; if chemotherapy has already been administered, then pembrolizumab can be used as a second-line treatment, but if the cancer has EGFR or ALK mutations, agents targeting those mutations should be used first. Assessment of PD-L1 expression must be conducted with a validated and approved companion diagnostic.

In 2017, the US Food and Drug Administration (FDA) approved pembrolizumab for any unresectable or metastatic solid tumor with certain genetic anomalies (mismatch repair deficiency or microsatellite instability). This was the first time the FDA approved a cancer drug based on tumor genetics rather than tissue type or tumor site; therefore, pembrolizumab is a so-called tissue-agnostic drug.

In the European Union, pembrolizumab is indicated for:

Adverse effects

People have had severe infusion-related reactions to pembrolizumab. There have also been severe immune-related adverse effects including lung inflammation (including fatal cases) and inflammation of endocrine organs that caused inflammation of the pituitary gland, of the thyroid (causing both hypothyroidism and hyperthyroidism in different people), and pancreatitis that caused Type 1 diabetes and diabetic ketoacidosis; some people have had to go on lifelong hormone therapy as a result (e.g. insulin therapy or thyroid hormones). People have also had colon inflammation, liver inflammation, kidney inflammation due to the drug.

The common adverse reactions have been fatigue (24%), rash (19%), itchiness (pruritus) (17%), diarrhea (12%), nausea (11%) and joint pain (arthralgia) (10%).

Other adverse effects occurring in between 1% and 10% of people taking pembrolizumab have included anemia, decreased appetite, headache, dizziness, distortion of the sense of taste, dry eye, high blood pressure, abdominal pain, constipation, dry mouth, severe skin reactions, vitiligo, various kinds of acne, dry skin, eczema, muscle pain, pain in a limb, arthritis, weakness, edema, fever, chills, myasthenia gravis, and flu-like symptoms.

Mechanism of action

Pembrolizumab is a therapeutic antibody that binds to and blocks PD-1 located on lymphocytes. This receptor is generally responsible for preventing the immune system from attacking the body's own tissues; it is a so-called immune checkpoint. Normally, the PD-1 receptor on activated T-cells binds to the PD-L1 or PD-L2 ligands present on normal cells in the body, deactivating any potential cell-mediated immune response against these cells. Many cancers make proteins such as PD-L1 that also bind to the PD-1 receptor, thus shutting down the ability of the body to kill the cancer. Pembrolizumab works by inhibiting lymphocytes' PD-1 receptors, blocking the ligands that would deactivate it and prevent an immune response. This allows the immune system to target and destroy cancer cells, but also blocks a key mechanism preventing the immune system from attacking the body itself. This checkpoint inhibitor function of pembrolizumab thus has immune-dysfunction side effects as a result.

Tumors often have mutations that cause impaired DNA mismatch repair. This in turn often results in microsatellite instability allowing the tumor to generate numerous mutant proteins that could serve as tumor antigens, triggering an immune response against the tumor. By preventing the self-checkpoint system from blocking the T-cells, pembrolizumab appears to facilitate clearance of any such tumor by the immune system.

Pharmacology

Since pembrolizumab is cleared from the circulation through non-specific catabolism, no metabolic drug interactions are expected and no studies were done on routes of elimination. The systemic clearance [rate] is about 0.2 L/day and the terminal half-life is about 25 days.

Chemistry and manufacturing

Pembrolizumab is an immunoglobulin G4, with a variable region against the human PD-1 receptor, a humanized mouse monoclonal [228-L-proline(H10-S>P)]γ4 heavy chain (134-218') disulfide and a humanized mouse monoclonal κ light chain dimer (226-226:229-229)-bisdisulfide.

It is recombinantly manufactured in Chinese hamster ovary (CHO) cells.

History

Pembrolizumab was invented by scientists at Organon after which they worked with Medical Research Council Technology (which became LifeArc) starting in 2006, to humanize the antibody; Schering-Plough acquired Organon in 2007, and Merck & Co. acquired Schering-Plough two years later. Inventors Gregory Carven, Hans van Eenennaam and Gradus Dulos were recognized as Inventors of the Year by the Intellectual Property Owners Education Foundation in 2016.

The development program for pembrolizumab was seen as high priority at Organon, but low at Schering and later Merck. In early 2010, Merck terminated development and began preparing to out-license it. Later, in 2010, scientists from Bristol Myers Squibb published a paper in The New England Journal of Medicine showing that their checkpoint inhibitor, ipilimumab (Yervoy), had shown strong promise in treating metastatic melanoma and that a second Bristol Myers Squibb checkpoint inhibitor, nivolumab (Opdivo), was also promising. Merck at that time had little commitment or expertise in either oncology or immunotherapy, but understood the opportunity and reacted strongly, reactivating the program and filing its IND by the end of 2010. As one example, Martin Huber was one of the few senior people at Merck with strong experience in lung cancer drug development, but had been promoted to senior management and was no longer involved in product development. He stepped down from his role to lead clinical development of pembrolizumab for lung cancer.

Scientists at the company argued for developing a companion diagnostic and limiting testing of the drug only to patients with biomarkers showing they were likely to respond, and received agreement from management. Some people, including shareholders and analysts, criticized this decision as it limited the potential market size for the drug, while others argued it increased the chances of proving the drug would work and would make clinical trials faster. (The trials would need fewer participants because of the likelihood of greater effect size.) Moving quickly and reducing the risk of failure was essential for catching up with Bristol-Myers Squibb, which had an approximate five year lead over Merck. The phase I study started in early 2011, and Eric Rubin, who was running the melanoma trial, argued for and was able to win expansion of the trial until it reached around 1300 people. This was the largest phase I study ever run in oncology, with the participants roughly divided between melanoma and lung cancer.

In 2013, Merck quietly applied for and won a breakthrough therapy designation for the drug. This regulatory pathway was new at the time and not well understood. One of its advantages is that the US FDA holds more frequent meetings with drug developers, reducing the risk of developers of making mistakes or misunderstandings arising from the differences between regulators' expectations and what the developers want to do. This was Merck's first use of the designation and the reduction in regulatory risk was one of the reasons management was willing to put company resources into development.

Society and culture

Economics

Pembrolizumab was priced at US$150,000 per year when it launched in 2014.

It was added to the Cancer Drugs Fund list of NHS England in November 2022 after a deal with manufacturer Merck Sharp and Dohme, the details of which remain confidential.

Keytruda was the world's top-selling drug in 2024, with $29.5 billion in sales.

Research

In 2015, Merck reported results in thirteen cancer types; much attention was given to early results in head and neck cancer.

As of May 2016, pembrolizumab was in phase IB clinical trials for triple-negative breast cancer (TNBC), gastric cancer, urothelial cancer, and head and neck cancer (all under the "Keynote-012" trial) and in phase II trial for TNBC (the "Keynote-086" trial). At ASCO, in June 2016, Merck reported that the clinical development program was directed to around 30 cancers and that it was running over 270 clinical trials (around 100 in combination with other treatments) and had four registration-enabling studies in process.

Results of a phase III clinical trial in triple-negative breast cancer were reported in October 2019.

Results of a phase II clinical trial in Merkel-cell carcinoma were reported in June 2016.

Results of a clinical trial in people with untreatable metastases arising from various solid tumors were reported in 2017.

A clinical phase III trial in combination with epacadostat, an Indoleamine 2,3-dioxygenase (IDO1) inhibitor to treat melanoma was completed in 2019.

In 2021, researchers reported the results of a five-year follow-up study.

In January 2022, a combination clinical trial of pembrolizumab and NL-201, a de novo protein undergoing a phase I clinical trial in people with advanced, relapsed or refractory solid tumors.

In March 2023, Merck reported the results of NRG-GY018, a phase III clinical trial in people with stage three to four or recurrent endometrial carcinoma.

In 2022, mRNA-4157/V940 drug candidate, a cancer vaccine, was studied alongside pembrolizumab for treatment of skin and pancreatic cancers. mRNA-4157/V940 went on to be granted breakthrough therapy designation by the FDA. In August 2026, Merck and Moderna reported that the Phase 3 INTerpath-001 trial, in which the candidate, by then named intismeran autogene, was given with pembrolizumab as adjuvant treatment to 1,137 patients with completely resected stage IIB–IV melanoma, had met its primary endpoint of recurrence-free survival and its key secondary endpoint of distant metastasis-free survival. The companies did not release hazard ratios, stating that detailed results would be presented at a medical meeting, and overall survival data were not yet mature.