`
`
` These highlights do not include all the information needed to use
`
` TREANDA safely and effectively. See full prescribing information for
`
`TREANDA.
`
`
`
`
`
`
`
` TREANDA® (bendamustine hydrochloride) injection, for intravenous use
`
`
`
`
`TREANDA® (bendamustine hydrochloride) for injection, for intravenous
`
`use
`
`Initial U.S. Approval: 2008
`
`-------------------------INDICATIONS AND USAGE-----------------------------
`
`
`TREANDA is an alkylating drug indicated for treatment of patients with:
`
`
`• Chronic lymphocytic leukemia (CLL). Efficacy relative to first line
`
`
`
`
`
`therapies other than chlorambucil has not been established. (1.1)
`
`
`
`• Indolent B-cell non-Hodgkin lymphoma (NHL) that has progressed during
`
`
`or within six months of treatment with rituximab or a rituximab-containing
`
`
`regimen. (1.2)
`
`--------------------DOSAGE AND ADMINISTRATION----------------------
`
`
`TREANDA is available in two formulations, a solution (TREANDA
`
`
`
`Injection) and a lyophilized powder (TREANDA for Injection). (2.1)
`
`
`
`Do not use TREANDA injection with devices that contain polycarbonate
`
`or acrylonitrile-butadiene-styrene (ABS), including most Closed System
`Transfer Devices (CSTDs). (2.1, 2.4)
`
`
`For CLL:
` • 100 mg/m2 infused intravenously over 30 minutes on Days 1 and 2 of a 28
`
`
`
`
`
` day cycle, up to 6 cycles (2.2)
` For NHL:
`
`
`
` • 120 mg/m2 infused intravenously over 60 minutes on Days 1 and 2 of a 21
`
`
` day cycle, up to 8 cycles (2.3)
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`---------------------DOSAGE FORMS AND STRENGTHS-------------------
`
`
` Injection: 45 mg/0.5 mL or 180 mg/2 mL (90 mg/mL) in a single-dose vial.
`
`
`
`
`
`
`(3)
`
`For Injection: 25 mg or 100 mg lyophilized powder in a single-dose vial for
`
`
`
`
`
`reconstitution. (3)
`
`
`
`
`-----------------------------CONTRAINDICATIONS-----------------------------
`
`TREANDA is contraindicated in patients with a history of a hypersensitivity
`
`
`
`reaction to bendamustine. Reactions have included anaphylaxis and
`
`
`anaphylactoid reactions. (4, 5.3)
`
`
`
`• Anaphylaxis and Infusion Reactions: Severe and anaphylactic reactions
`
`
`have occurred; monitor clinically and discontinue drug for severe reactions.
`
`
`Pre-medicate in subsequent cycles for milder reactions. (5.3)
`
`
`• Tumor Lysis Syndrome: May lead to acute renal failure and death;
`
`
`
`
`
`anticipate and use supportive measures in patients at high risk. (5.4)
`
`
`
`
`• Skin Reactions: Discontinue for severe skin reactions. Cases of SJS,
`
`
`
`DRESS and TEN, some fatal, have been reported. (5.5)
`
`• Hepatotoxicity: Monitor liver chemistry tests prior to and during treatment.
`
`
`(5.6)
`
`• Other Malignancies: Pre-malignant and malignant diseases have been
`
`
`reported. (5.7)
`
`• Extravasation Injury: Take precautions to avoid extravasation, including
`
`
`
`
`monitoring intravenous infusion site during and after administration. (5.8)
`
`
`
`
`• Embryo-Fetal Toxicity: Can cause fetal harm. Advise females of
`
`
`
`
`reproductive potential of the potential risk to a fetus and to use an effective
`
`
`method of contraception. (5.9, 8.1, 8.3)
`
`
`
`
`-------------------------------ADVERSE REACTIONS--------------------------
`
`
`Adverse reactions (frequency >5%) during infusion and within 24 hours
`
`
`
`
`
`
`•
`post-infusion are nausea and fatigue. (6.1)
`
`
`
`• Most common adverse reactions (≥15%) for CLL are anemia,
`
`
`
`
`thrombocytopenia, neutropenia, lymphopenia, leukopenia, pyrexia,
`
`nausea, vomiting. (6.2, 6.3)
`
`• Most common adverse reactions (≥15%) for NHL are lymphopenia,
`
`
`
`leukopenia, anemia, neutropenia, thrombocytopenia, nausea, fatigue,
`
`
`
`vomiting, diarrhea, pyrexia, constipation, anorexia, cough, headache,
`
`weight decreased, dyspnea, rash, and stomatitis.(6.2, 6.3).
`
`
`
`
`
`
`
`
`
`To report SUSPECTED ADVERSE REACTIONS, contact Teva
`
`Pharmaceuticals at 1-888-483-8279 or FDA at 1-800-FDA-1088 or
`
`
`
`www.fda.gov/medwatch.
`
`
`--------------------------------DRUG INTERACTIONS----------------------------
`Consider alternative therapies that are not CYP1A2 inducers or inhibitors
`
`
`
`during treatment with TREANDA. (7)
`
`
`
`-------------------------------USE IN SPECIFIC POPULATIONS---------------
`• Lactation: Advise not to breastfeed. (8.2)
`
`
`
`
`• Infertility: May impair fertility. (8.3)
`
`• Renal Impairment: Do not use in patients with creatinine clearance <30
`
`
`
`
`
`mL/min. (8.6)
`
`• Hepatic Impairment: Do not use in patients with total bilirubin 1.5-3 x
`
`
`
`ULN and AST or ALT 2.5-10 x ULN, or total bilirubin >3 x ULN. (8.7)
`
`
`
`
`
`
`See 17 for PATIENT COUNSELING INFORMATION
`
`
`
`
`Revised: 11/2019
`
`
`
`5.9 Embryo-Fetal Toxicity
`
`
`6 ADVERSE REACTIONS
`
`
`6.1 Clinical Trials Experience
`
`
`6.2 Postmarketing Experience
`
`
`7 DRUG INTERACTIONS
`
`
`
`
`
`
`7.1 Effect of Other Drugs on TREANDA
`
`8 USE IN SPECIFIC POPULATIONS
`
`8.1 Pregnancy
`
`
`8.2 Lactation
`
`
`8.3 Males and Females of Reproductive Potential
`
`8.4 Pediatric Use
`
`8.5 Geriatric Use
`
`
`8.6 Renal Impairment
`
`8.7 Hepatic Impairment
`
`
`10 OVERDOSAGE
`
`11 DESCRIPTION
`
`12 CLINICAL PHARMACOLOGY
`
`12.1 Mechanism of Action
`
`12.2 Pharmacodynamics
`
`12.3 Pharmacokinetics
`
`
`_______________________________________________________________________________________________________________________________________
`
`FULL PRESCRIBING INFORMATION: CONTENTS*
`
`1 INDICATIONS AND USAGE
`
`
`1.1 Chronic Lymphocytic Leukemia (CLL)
`
`
`
`1.2 Non-Hodgkin Lymphoma (NHL)
`
`
`2 DOSAGE AND ADMINISTRATION
`
`
`2.1 Selection of TREANDA Formulation to Administer
`
`
`
`2.2 Dosing Instructions for CLL
`
`
`2.3 Dosing Instructions for NHL
`
`
`2.4 Preparation for Intravenous Administration
`
`
`2.5 Admixture Stability
`
`
`3 DOSAGE FORMS AND STRENGTHS
`
`
`4 CONTRAINDICATIONS
`
`
`5 WARNINGS AND PRECAUTIONS
`
`
`5.1 Myelosuppression
`
`
`5.2 Infections
`
`
`5.3 Anaphylaxis and Infusion Reactions
`
`
`5.4 Tumor Lysis Syndrome
`
`
`5.5 Skin Reactions
`
`
`5.6 Hepatotoxicity
`
`
`5.7 Other Malignancies
`
`
`
`5.8 Extravasation Injury
`
`
`
`-------------------------WARNINGS AND PRECAUTIONS--------------------
`
`• Myelosuppression: Delay or reduce dose and restart treatment based on
`
`
`
`
`
`
`ANC and platelet count recovery. (5.1)
`
`• Infections: Monitor for fever and other signs of infection or reactivation of
`
`
`
`
`infections and treat promptly. (5.2)
`
`
`
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`
`
`
`
`
`16 HOW SUPPLIED/STORAGE AND HANDLING
`
`16.1 Safe Handling and Disposal
`
`
`16.2 How Supplied
`
`
`16.3 Storage
`
`
`17 PATIENT COUNSELING INFORMATION
`
`
`
`
`
` 13 NONCLINICAL TOXICOLOGY
`
`
`
` 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
`14 CLINICAL STUDIES
`
`14.1 Chronic Lymphocytic Leukemia (CLL)
`
`
`14.2 Non-Hodgkin Lymphoma (NHL)
`
`
`15 REFERENCES
`
`
`*Sections or subsections omitted from the full prescribing information are not listed.
`
`
`
`
`
` FULL PRESCRIBING INFORMATION
`
` 1 INDICATIONS AND USAGE
`
`
`
` 1.1 Chronic Lymphocytic Leukemia (CLL)
` TREANDA® is indicated for the treatment of patients with chronic lymphocytic leukemia. Efficacy relative to first line
`
`
`therapies other than chlorambucil has not been established.
`
`
`
`1.2 Non-Hodgkin Lymphoma (NHL)
`
`
`
`TREANDA is indicated for the treatment of patients with indolent B-cell non-Hodgkin lymphoma that has progressed
`
`
`during or within six months of treatment with rituximab or a rituximab-containing regimen.
`
`
`
`2 DOSAGE AND ADMINISTRATION
`
`2.1 Selection of TREANDA Formulation to Administer
`
`
`TREANDA is available in two formulations, a solution (TREANDA Injection) and a lyophilized powder (TREANDA for
`
`
`
`
`
`Injection).
`
`Do not use TREANDA Injection if you intend to use closed system transfer devices (CSTDs), adapters and syringes
`
`
`
`
`containing polycarbonate or acrylonitrile-butadiene-styrene (ABS) prior to dilution in the infusion bag [see Dosage
`
`
`
`
`and Administration (2.4)].
`
`
`If using a syringe to withdraw and transfer TREANDA Injection from the vial into the infusion bag, only use a
`
`
`
`
`
`polypropylene syringe with a metal needle and polypropylene hub to withdraw and transfer TREANDA Injection
`
`
`into the infusion bag. Polypropylene syringes are translucent in appearance.
`
`
`
`
`TREANDA Injection and the reconstituted TREANDA for Injection have different concentrations of bendamustine
`
`
`
`hydrochloride. The concentration of bendamustine hydrochloride in the solution is 90 mg/mL and the concentration of
`
`
`
`
`bendamustine hydrochloride in the reconstituted solution of lyophilized powder is 5 mg/mL. Do not mix or combine the
`
`
`
`two formulations.
`
`
`TREANDA Injection must be withdrawn and transferred for dilution in a biosafety cabinet (BSC) or containment isolator
`
`
`
`
`using a polypropylene syringe with a metal needle and a polypropylene hub.
`
`
`
`If a CSTD or adapter that contains polycarbonate or ABS is used as supplemental protection prior to dilution1, only use
`
`
`
`
`
`TREANDA for Injection, the lyophilized powder formulation [see How Supplied/Storage and Handling (16.1)].
`
`
`
`2.2 Dosing Instructions for CLL
`
`
`Recommended Dosage:
`
` The recommended dose is 100 mg/m2 administered intravenously over 30 minutes on Days 1 and 2 of a 28-day cycle, up
`
` to 6 cycles.
` Dose Delays, Dose Modifications and Reinitiation of Therapy for CLL:
`
`
`
`
`Delay TREANDA administration in the event of Grade 4 hematologic toxicity or clinically significant ≥ Grade 2 non-
`
`
`
`
`
`hematologic toxicity. Once non-hematologic toxicity has recovered to less than or equal to Grade 1 and/or the blood
`
`
`
`
`
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`counts have improved [Absolute Neutrophil Count (ANC) ≥ 1 x 109/L, platelets ≥ 75 x 109/L], reinitiate TREANDA at the
`
`
`
`
`discretion of the treating physician. In addition, consider dose reduction. [see Warnings and Precautions (5.1)]
`
`
`
`
`
`Dose modifications for hematologic toxicity: for Grade 3 or greater toxicity, reduce the dose to 50 mg/m2 on Days 1 and 2
`
`
`
`of each cycle; if Grade 3 or greater toxicity recurs, reduce the dose to 25 mg/m2 on Days 1 and 2 of each cycle.
`
`
`Dose modifications for non-hematologic toxicity: for clinically significant Grade 3 or greater toxicity, reduce the dose to
`
`
`50 mg/m2 on Days 1 and 2 of each cycle.
`
`
`Consider dose re-escalation in subsequent cycles at the discretion of the treating physician.
`
`
`2.3 Dosing Instructions for NHL
`
`Recommended Dosage:
` The recommended dose is 120 mg/m2 administered intravenously over 60 minutes on Days 1 and 2 of a 21-day cycle, up
`
` to 8 cycles.
` Dose Delays, Dose Modifications and Reinitiation of Therapy for NHL:
`
`
`Delay TREANDA administration in the event of a Grade 4 hematologic toxicity or clinically significant greater than or
`
`
`
`equal to Grade 2 non-hematologic toxicity. Once non-hematologic toxicity has recovered to ≤ Grade 1 and/or the blood
`
`counts have improved [Absolute Neutrophil Count (ANC) ≥ 1 x 109/L, platelets ≥ 75 x 109/L], reinitiate TREANDA at the
`
`
`
`
`
`
`
`
`
`
`discretion of the treating physician. In addition, consider dose reduction. [see Warnings and Precautions (5.1)]
`
`
`
`Dose modifications for hematologic toxicity: for Grade 4 toxicity, reduce the dose to 90 mg/m2 on Days 1 and 2 of each
`
`
`
`cycle; if Grade 4 toxicity recurs, reduce the dose to 60 mg/m2 on Days 1 and 2 of each cycle.
`
`
`
`
`
`
`
`Dose modifications for non-hematologic toxicity: for Grade 3 or greater toxicity, reduce the dose to 90 mg/m2 on Days 1
`
`
`and 2 of each cycle; if Grade 3 or greater toxicity recurs, reduce the dose to 60 mg/m2 on Days 1 and 2 of each cycle.
`
`
`
`
`
`
`
`2.4 Preparation for Intravenous Administration
`
`
`
`
`TREANDA is a cytotoxic drug. Follow applicable special handling and disposal procedures.1
`
`
`
`
`
`TREANDA Injection (45 mg/0.5 mL or 180 mg/2 mL solution)
`
`
`
`TREANDA Injection must be diluted in a biosafety cabinet (BSC) or containment isolator.
`
`
`
`• When preparing and transferring the concentrated TREANDA Injection solution into the infusion bag, do not
`
`
`use devices that contain polycarbonate or ABS. However, after dilution of TREANDA Injection into the
`
`
`
`
`
`
`infusion bag, devices that contain polycarbonate or ABS, including infusion sets, may be used.
`
`
`
`TREANDA Injection contains N,N-dimethylacetamide (DMA), which is incompatible with devices that contain
`
`
`
`
`polycarbonate or ABS. Devices, including CSTDs, adapters, and syringes that contain polycarbonate or ABS have
`
`
`
`
`
`been shown to dissolve when they come in contact with DMA which is present in the product. This incompatibility
`
`
`
`leads to device failure (e.g., leaking, breaking, or operational failure of CSTD components), possible product
`
`
`contamination, and potential serious adverse health consequences to the practitioner, including skin reactions; or to
`
`
`
`the patient, including but not limited to, the risk of small blood vessel blockage if they receive product contaminated
`
`
`
`
`with dissolved ABS or polycarbonate. Devices that are compatible for use in dilution of TREANDA Injection are
`
`available.
`
`
`
`
`
`If using a syringe to withdraw and transfer TREANDA Injection from the vial into the infusion bag, only use a
`
`
`
`polypropylene syringe with a metal needle and a polypropylene hub to withdraw and transfer TREANDA
`
`Injection into the infusion bag.
`
`
`
`
`
`• Each vial of TREANDA Injection is intended for single dose only.
`
`
`• Aseptically withdraw the volume needed for the required dose from the 90 mg/mL solution using a polypropylene
`
`syringe with a metal needle and a polypropylene hub.
`
`Immediately transfer the solution to a 500 mL infusion bag of 0.9% Sodium Chloride Injection, USP (normal saline).
`
`
`
`As an alternative to 0.9% Sodium Chloride Injection, USP (normal saline), a 500 mL infusion bag of 2.5%
`
`
`Dextrose/0.45% Sodium Chloride Injection, USP, may be considered. The resulting final concentration of
`
`
`
`
`bendamustine HCl in the infusion bag should be within 0.2 – 0.7 mg/mL.
`
`
`•
`
`
`•
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`• After dilution of TREANDA Injection into the infusion bag, devices that contain polycarbonate or ABS,
`
`
`
`including infusion sets, may be used.
`
`
`
`
`• Visually inspect the filled syringe and the prepared infusion bag to ensure the lack of visible particulate matter prior to
`
`
`
`
`administration. The admixture should be a clear colorless to yellow solution.
`
`
`Use either 0.9% Sodium Chloride Injection, USP, or 2.5% Dextrose/0.45% Sodium Chloride Injection, USP, for dilution,
`
`as outlined above. No other diluents have been shown to be compatible.
`
`
`TREANDA for Injection (25 mg/vial or 100 mg/vial lyophilized powder)
`If a closed system transfer device or adapter that contains polycarbonate or ABS is to be used as supplemental
`
`
`
`protection during preparation1, only use TREANDA for Injection, the lyophilized formulation.
`
`
`
`
`
`
`
`
`• Each vial of TREANDA for Injection is intended for single-dose only.
` • Aseptically reconstitute each TREANDA for Injection vial as follows:
`
`
`
`
`
` o 25 mg TREANDA for Injection vial: Add 5 mL of only Sterile Water for Injection, USP.
`
`
`o 100 mg TREANDA for Injection vial: Add 20 mL of only Sterile Water for Injection, USP.
`
`
` • Shake well to yield a clear, colorless to a pale yellow solution with a bendamustine HCl concentration of 5 mg/mL.
`
`
`
`
`
`
`
` The lyophilized powder should completely dissolve in 5 minutes. The reconstituted solution must be transferred to the
`
`
` infusion bag within 30 minutes of reconstitution. If particulate matter is observed, the reconstituted product should not
`
`
`
`
`
`be used.
`
`• Aseptically withdraw the volume needed for the required dose (based on 5 mg/mL concentration) and immediately
`
`
`
`transfer to a 500 mL infusion bag of 0.9% Sodium Chloride Injection, USP (normal saline). As an alternative to 0.9%
`
`
`
`Sodium Chloride Injection, USP (normal saline), a 500 mL infusion bag of 2.5% Dextrose/0.45% Sodium Chloride
`
`
`
`Injection, USP, may be considered. The resulting final concentration of bendamustine HCl in the infusion bag should
`
`
`
`
`be within 0.2 – 0.6 mg/mL. After transferring, thoroughly mix the contents of the infusion bag.
`
`
`
`
`• Visually inspect the filled syringe and the prepared infusion bag to ensure the lack of visible particulate matter prior to
`
`
`
`
`administration. The admixture should be a clear and colorless to slightly yellow solution.
`
`
`Use Sterile Water for Injection, USP, for reconstitution and then either 0.9% Sodium Chloride Injection, USP, or 2.5%
`
`
`
`
`
`Dextrose/0.45% Sodium Chloride Injection, USP, for dilution, as outlined above. No other diluents have been shown to be
`
`
`compatible.
`
`Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration
`whenever solution and container permit. Any unused solution should be discarded according to institutional procedures
`
`
`for antineoplastics.
`
`2.5 Admixture Stability
`
`
`TREANDA Injection and TREANDA for Injection contain no antimicrobial preservative. The admixture should be
`
`
`
`prepared as close as possible to the time of patient administration.
`
`
`
`TREANDA Injection (45 mg/0.5 mL or 180 mg/2 mL solution)
`
`Once diluted with either 0.9% Sodium Chloride Injection, USP, or 2.5% Dextrose/0.45% Sodium Chloride Injection,
`USP, the final admixture is stable for 24 hours stored under refrigerated conditions at 2°-8°C (36°-46°F) or for
`
`
`
`
`
`
`2 hours when stored at room temperature (15°-30°C or 59°-86°F) and room light. Administration of diluted TREANDA
`
`
`
`
`Injection must be completed within this period.
`
`TREANDA for Injection (25 mg/vial or 100 mg/vial lyophilized powder)
`
`Once diluted with either 0.9% Sodium Chloride Injection, USP, or 2.5% Dextrose/0.45% Sodium Chloride Injection,
`USP, the final admixture is stable for 24 hours stored under refrigerated conditions at 2°-8°C (36°-46°F) or for
`
`
`
`
`
`
`
`3 hours when stored at room temperature (15°-30°C or 59°-86°F) and room light. Administration of reconstituted and
`
`
`diluted TREANDA for Injection must be completed within this period.
`
`
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`3 DOSAGE FORMS AND STRENGTHS
`
`• TREANDA Injection: 45 mg/0.5 mL or 180 mg/2 mL as a clear and colorless to yellow ready-to dilute solution in a
`
`
`
`
`
`single-dose vial.
`
`
`• TREANDA for Injection: 25 mg or 100 mg white to off-white lyophilized powder in a single-dose vial for
`
`
`
`
`
`reconstitution.
`
`
`
`
`4 CONTRAINDICATIONS
`
`TREANDA is contraindicated in patients with a known hypersensitivity (e.g., anaphylactic and anaphylactoid reactions)
`
`
`to bendamustine. [see Warnings and Precautions (5.3)]
`
`
`
`5 WARNINGS AND PRECAUTIONS
`
`5.1 Myelosuppression
`
`
`TREANDA caused severe myelosuppression (Grade 3-4) in 98% of patients in the two NHL studies (see Table 4). Three
`
`
`
`patients (2%) died from myelosuppression-related adverse reactions; one each from neutropenic sepsis, diffuse alveolar
`
`
`hemorrhage with Grade 3 thrombocytopenia, and pneumonia from an opportunistic infection (CMV).
`
`
`Monitor complete blood counts, including leukocytes, platelets, hemoglobin (Hgb), and neutrophils frequently. In the
`
`
`clinical trials, blood counts were monitored every week initially. Hematologic nadirs were observed predominantly in the
`
`
`
`
`
`third week of therapy. Myelosuppression may require dose delays and/or subsequent dose reductions if recovery to the
`
`
`recommended values has not occurred by the first day of the next scheduled cycle. Prior to the initiation of the next cycle
`
`
`of therapy, the ANC should be ≥ 1 x 109/L and the platelet count should be ≥ 75 x 109/L. [see Dosage and Administration
`
`
`
`
`
`
`(2.2) and (2.3)]
`5.2 Infections
`
`
`Infection, including pneumonia, sepsis, septic shock, hepatitis and death has occurred in adult and pediatric patients in
`
`
`
`
`clinical trials and in postmarketing reports. Patients with myelosuppression following treatment with TREANDA are more
`
`
`susceptible to infections. Advise patients with myelosuppression following TREANDA treatment to contact a physician if
`
`they have symptoms or signs of infection.
`
`
`Patients treated with TREANDA are at risk for reactivation of infections including (but not limited to) hepatitis B,
`
`
`
`cytomegalovirus, Mycobacterium tuberculosis, and herpes zoster. Patients should undergo appropriate measures
`
`
`(including clinical and laboratory monitoring, prophylaxis, and treatment) for infection and infection reactivation prior to
`
`
`
`administration.
`
`5.3 Anaphylaxis and Infusion Reactions
`
`
`Infusion reactions to TREANDA have occurred commonly in clinical trials. Symptoms include fever, chills, pruritus and
`
`
`
`
`rash. In rare instances severe anaphylactic and anaphylactoid reactions have occurred, particularly in the second and
`
`
`
`subsequent cycles of therapy. Monitor clinically and discontinue drug for severe reactions. Ask patients about symptoms
`
`
`
`
`suggestive of infusion reactions after their first cycle of therapy. Patients who experience Grade 3 or worse allergic-type
`
`
`
`
`reactions should not be rechallenged. Consider measures to prevent severe reactions, including antihistamines,
`
`
`antipyretics and corticosteroids in subsequent cycles in patients who have experienced Grade 1 or 2 infusion reactions.
`
`
`Discontinue TREANDA for patients with Grade 4 infusion reactions. Consider discontinuation for Grade 3 infusions
`
`
`
`reactions as clinically appropriate considering individual benefits, risks, and supportive care.
`
`
`5.4 Tumor Lysis Syndrome
`
`
`Tumor lysis syndrome associated with TREANDA treatment has occurred in patients in clinical trials and in
`
`
`
`
`postmarketing reports. The onset tends to be within the first treatment cycle of TREANDA and, without intervention, may
`
`
`
`
`
`
`lead to acute renal failure and death. Preventive measures include vigorous hydration and close monitoring of blood
`
`chemistry, particularly potassium and uric acid levels. Allopurinol has also been used during the beginning of TREANDA
`
`
`therapy. However, there may be an increased risk of severe skin toxicity when TREANDA and allopurinol are
`
`administered concomitantly [see Warnings and Precautions (5.5)].
`
`
`5.5 Skin Reactions
`
`
`Fatal and serious skin reactions have been reported with TREANDA treatment in clinical trials and postmarketing safety
`
`
`
`
`reports, including toxic skin reactions [Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and drug
`
`
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`
`reaction with eosinophilia and systemic symptoms (DRESS)], bullous exanthema, and rash. Events occurred when
`
`
`
`
`TREANDA was given as a single agent and in combination with other anticancer agents or allopurinol.
`
`
`
`
`Where skin reactions occur, they may be progressive and increase in severity with further treatment. Monitor patients with
`
`
`skin reactions closely. If skin reactions are severe or progressive, withhold or discontinue TREANDA.
`5.6 Hepatotoxicity
`
`
`
`
`
`
`
`
`Fatal and serious cases of liver injury have been reported with TREANDA. Combination therapy, progressive disease or
`
`
`
`
`
`reactivation of hepatitis B were confounding factors in some patients [see Warnings and Precautions (5.2)]. Most cases
`
`
`
`were reported within the first three months of starting therapy. Monitor liver chemistry tests prior to and during
`
`bendamustine therapy.
`
`5.7 Other Malignancies
`
`
`
`
`
`
`There are reports of pre-malignant and malignant diseases that have developed in patients who have been treated with
`
`
`
`TREANDA, including myelodysplastic syndrome, myeloproliferative disorders, acute myeloid leukemia and bronchial
`
`
`
`
`
`carcinoma. The association with bendamustine hydrochloride therapy has not been determined.
`
`5.8 Extravasation Injury
`
`
`
`TREANDA extravasations have been reported in postmarketing resulting in hospitalizations from erythema, marked
`
`
`swelling, and pain. Assure good venous access prior to starting TREANDA infusion and monitor the intravenous infusion
`
`
`
`site for redness, swelling, pain, infection, and necrosis during and after administration of TREANDA.
`
`5.9 Embryo-Fetal Toxicity
`
`
`
`
`
`
`Based on findings from animal reproduction studies and the drug’s mechanism of action, TREANDA can cause fetal harm
`
`
`
`
`when administered to a pregnant woman. Single intraperitoneal doses of bendamustine (that approximated the maximum
`
`
`recommended human dose based on body surface area) to pregnant mice and rats during organogenesis caused adverse
`
`
`
`developmental outcomes, including an increase in resorptions, skeletal and visceral malformations, and decreased fetal
`
`
`
`
`
`body weights. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use an
`
`
`
`
`
`effective method of contraception during treatment with TREANDA and for at least 6 months after the final dose. Advise
`
`
`
`
`males with female partners of reproductive potential to use effective contraception during treatment with TREANDA and
`
`
`
`
`for at least 3 months after the final dose [see Use in Specific Populations (8.1, 8.3) and Clinical Pharmacology (12.1)]
`
`
`
`
`6 ADVERSE REACTIONS
`
`
`
`
`The following clinically significant adverse reactions have been associated with TREANDA in clinical trials and are
`
`
`discussed in greater detail in other sections of the label.
`
`
`
`• Myelosuppression [see Warnings and Precautions (5.1)]
` Infections [see Warnings and Precautions (5.2)]
`
`
`
`
`
`•
`
` • Anaphylaxis and Infusion Reactions [see Warnings and Precautions (5.3)]
`
`
` • Tumor Lysis Syndrome [see Warnings and Precautions (5.4)]
`
`
`
`
` • Skin Reactions [see Warnings and Precautions (5.5)]
`
`
`
`
`
` • Hepatotoxicity [see Warnings and Precautions (5.6)]
`
`
`
`
`
` • Other Malignancies [see Warnings and Precautions (5.7)]
`
`
`
`
` • Extravasation Injury [see Warnings and Precautions (5.8)]
`
`
`
`
` 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.
` Chronic Lymphocytic Leukemia
`
`
`
`
`
`
`
`
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`
`
`
`The data described below reflect exposure to TREANDA in 153 patients. TREANDA was studied in an active-controlled,
`
`
`
`
`randomized trial. The population was 45-77 years of age, 63% male, 100% white, and had treatment naïve CLL. All
`
`
`patients started the study at a dose of 100 mg/m2 intravenously over 30 minutes on Days 1 and 2 every 28 days.
`
`
`Adverse reactions were reported according to NCI CTC v.2.0. In the randomized CLL clinical study, non-hematologic
`
`
`
`adverse reactions (any grade) in the TREANDA group that occurred with a frequency greater than 15% were pyrexia
`
`
`
`(24%), nausea (20%), and vomiting (16%).
`
`Other adverse reactions seen frequently in one or more studies included asthenia, fatigue, malaise, and weakness; dry
`
`
`
`
`mouth; somnolence; cough; constipation; headache; mucosal inflammation and stomatitis.
`
`
`Worsening hypertension was reported in 4 patients treated with TREANDA in the randomized CLL clinical study and in
`
`
`
`none treated with chlorambucil. Three of these 4 adverse reactions were described as a hypertensive crisis and were
`
`managed with oral medications and resolved.
`
`The most frequent adverse reactions leading to study withdrawal for patients receiving TREANDA were hypersensitivity
`
`
`
`(2%) and pyrexia (1%).
`
`Table 1 contains the treatment emergent adverse reactions, regardless of attribution, that were reported in ≥ 5% of patients
`
`
`in either treatment group in the randomized CLL clinical study.
`
`
`
`
` Table 1: Non- Hematologic Adverse Reactions Occurring in Randomized CLL Clinical Study in at
`
`
` Least 5% of Patients
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
` Number (%) of patients
`
`
` TREANDA
` Chlorambucil
`(N=153)
`
` (N=143)
`
` Grade 3/4
`
` Grade
`
` All
`Grades
`
` 3/4
`
`
`
`
`
` Body System/ Adverse
`
` Reaction
`
` All
`
` Grades
`
`
`
`
`
`
`121 (79)
`
`
`
`52 (34)
`
`
`
`96 (67)
`
`
`
`
`25 (17)
`
`
`
`
`31 (20)
`
`24 (16)
`
`14 (9)
`
`
`
`
`
`36 (24)
`
`14 (9)
`
`13 (8)
`
`9 (6)
`
`
`
`
`
`
` 7 (5)
`
`
`
`
` 10 (7)
`
` 9 (6)
`
` 5 (3)
`
`
`
`1 (<1)
`
`1 (<1)
`
`2 (1)
`
`
`
`
`
`6 (4)
`
`2 (1)
`
`0
`
`0
`
`
`
`
` 2 (1)
`
`
`
`
` 0
`
`
` 3 (2)
`
` 0
`
`
`
`21 (15)
`
`9 (6)
`
`5 (3)
`
`
`
`
`
`8 (6)
`
`8 (6)
`
`6 (4)
`
`1 (<1)
`
`
`
`
`
` 3 (2)
`
`
`
`
` 12 (8)
`
` 1 (<1)
`
` 7 (5)
`
`
`
`1 (<1)
`
`0
`
`0
`
`
`
`
`
`2 (1)
`
`0
`
`0
`
`0
`
`
`
`
` 0
`
`
`
`
` 0
`
`
` 1 (<1)
`
` 0
`
`
`
` Total number of
`
`
` patients with at least 1
`
` adverse reaction
`
`
`Gastrointestinal
`
`disorders
`
`Nausea
`
`
`Vomiting
`
`
`Diarrhea
`
`
`
`General disorders and
`
`
` administration site
`conditions
`
`Pyrexia
`
`
`Fatigue
`
`
`Asthenia
`
`
`Chills
`
`
`
`Immune system
`
`disorders
`
` Hypersensitivity
`
`
`Infections and
`
`infestations
`
` Nasopharyngitis
`
`
` Infection
`
`
` Herpes simplex
`
`
`
`
`
`
`
`
`
`
`
`Reference ID: 4523349
`
`
`
`
`
`Investigations
`
` Weight decreased
`
`
`
` Metabolism and
`
`nutrition disorders
`
`
`
` Hyperuricemia
`
`Respiratory, thoracic
`
` and mediastinal
` disorders
`
`
`
` Cough
`
` Skin and subcutaneous
`tissue disorders
`
`
`
` Rash
`
`
`Pruritus
`
`
`
`
`
`
` 11 (7)
`
`
`
` 11 (7)
`
`
`
`
`
`
`6 (4)
`
`
`
`
`
`12 (8)
`
` 8 (5)
`
`
` 0
`
`
`
`
` 3 (2)
`
`
`
`
`
`
`1 (<1)
`
`
`
`
`
`4 (3)
`
` 0
`
`
`
` 5 (3)
`
`
`
` 2 (1)
`
`
`
`
`
`
`7 (5)
`
`
`
`
`
`7 (5)
`
` 2 (1)
`
`
` 0
`
`
`
`
` 0
`
`
`
`
`
`
`1 (<1)
`
`
`
`
`
`3 (2)
`
` 0
`
`
`
`
` The Grade 3 and 4 hematology laboratory test values by treatment group in the randomized CLL clinical study are
`
` described in Table 2. These findings confirm the myelosuppressive effects seen in patients treated with TREANDA. Red
`
`
`
`
` blood cell transfusions were administered to 20% of patients receiving TREANDA compared with 6% of patients
`
` receiving chlorambucil.
`
`
`
`
`
`
`
`
`
` Chlorambucil
`
`
` N=141
`
`All Grades
`
`
` n (%)
` 115 (82)
`
`
`Grade 3/4
`
`
` n (%)
`
` 12 (9)
`
` Table 2: Incidence of Hematology Laboratory Abnormalities in
`
`
` Patients Who Received TREANDA or Chlorambucil in the
`
` Randomized CLL Clinical Study
`TREANDA
`
`
`
` N=150
`All Grades
`Grade 3/4
`
`
`
`
` n (%)
` n (%)
` 134 (89)
`
` 20 (13)
`
`
`
`
`
`
`
`
` 116 (77)
`
`
`
` 92 (61)
`
`
`
` 102 (68)
`
`
`
` 113 (75)
`
`
`
` 16 (11)
`
`
`
` 42 (28)
`
`
`
` 70 (47)
`
`
`
` 65 (43)
`
`
`
` 110 (78)
`
`
`
` 26 (18)
`
`
`
` 27 (19)
`
`
`
` 86 (61)
`
`
`
` 14 (10)
`
`
`
` 4 (3)
`
`
`
` 6 (4)
`
`
`
` 30 (21)
`
`
`
`Laboratory
`
` Abnormality
`
` Hemoglobin
`
` Decreased
`
` Platelets
` Decreased
`
` Leukocytes
`
` Decreased
` Lymphocytes
`
` Decreased
`
` Neutrophils
`
` Decreased
`
`
`
`
`
`
`
` In the randomized CLL trial, 34% of patients had bilirubin elevations, some without associated significant elevations in
`
` AST and ALT. Grade 3 or 4 increased bilirubin occurred in 3% of patients. Increases in AST and ALT of Grade 3 or 4
`
`
`
`
` were limited to 1% and 3% of patients, respectively. Patients treated with TREANDA may also have changes in their
`
`
`
`
`
`
`
` creatinine levels. If abnormalities are detected, monitoring of these parameters should be continued to ensure that further
`
`
`
` deterioration does not occur.
`
` Non-Hodgkin Lymphoma
`
`The data described below reflect exposure to TREANDA in 176 patients with indolent B-cell NHL treated in two single-
`
`arm studies. The population was 31-84 years of age, 60% male, and 40% female. The race distribution was 89% White,
`
`
`
`7% Black, 3% Hispanic, 1% other, and <1% Asian. These patients received TREANDA at a dose of 120 mg/m2
`
`
`
`
`intravenously on Days 1 and 2 for up to eight 21-day cycles.
`
`The adverse reactions occurring in at least 5% of the NHL patients, regardless of severity, are shown in Table 3. The most
`
`
`
`common non-hematologic adverse reactions (≥30%) were nausea (75%), fatigue (57%), vomiting (40%), diarrhea (37%)
`
`
`
`
`
`
`and pyrexia (34%). The most common non-hematologic Grade 3 or 4 adverse reactions (≥5